COLUMBIA LIBRARIES Ul-f&nc HEALTH SC1ENCES_STANDARD Hyn0041904 RECAP Columbia ^ntbersitp \ in ttje Citj) of i^eto gorfe College of ^lipgiciang anti ^urgeonsf Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/publichygiene01blai A PARK LAKE, FORMERLY A MALARIAL SWAMP OF NO VALUE THE SHALLOW LAKE SHOWN IS CHOKED WITH WEEDS AND IS INSANITARY A PROPERLY CONSTRUCTED ARTIFICIAL LAKE STOCKED WITH FISH AND FOWL PUBLIC HYGIENE BY THOS. S. BLAIR, M.D. Neurologist Harrisburgh, Pennsylvania, Hospital, Author "A Practitioner's Handbook of Materia Medica," "A Practitioner's Handbook of Modern Medical Treatment," etc. ASSISTED BY NUMEROUS CONTRIBUTORS IN TWO VOLUMES. VOLUME I With 158 illustrations RICHARD G. BADGER BOSTON Copyright 1911 by RICHARD G. BADGER Entered at Stationers' Hall All rights reserved THE GORHAM PRESS, Boston, U. S. A. THIS BOOK IS DEDICATED TO THE MEMORY OF THE NOBLE PHYSICIANS AND MARTYRS WHO LAID DOWN THEIR LIVES IN THE CAUSE OF SANITATION THAT THE MANY WHO PROFIT BY THEIR DISCOVERIES MIGHT LIVE PREFACE The proceedings of the annual conferences of state and territorial health officers with the United States Public Health and Marine-Hospital Service have developed so many points of friendly difference regarding various sanitary procedures that the present author has been led to institute a per- sonal investigation of public hygiene from the standpoint of a seasoned gen- eral practitioner of medicine and w^hich investigation embraces a wide area of this country. The decision has been reached that public hygiene has developed too much as a specialty and needs the tempering conclusions of the whole body of the medical profession. Such conclusions must result from a careful comparison of laboratory and clinical data and no one class of men are so fully qualified to weigh them as is the class to whom this volume is especially addressed. But in order to do so the family doctor must inform himself not only upon the pathological and clinical aspects of the work, but also upon the socio- logic, legal, and engineering factors involved. The effort is here made to present reliable data upon the present very creditable development of this important subject, and in doing so the author poses more as an editor than as an original writer and has endeavored to judicially weigh the evidence at hand upon a basis of real accomplishment rather than upon that of a propa- ganda. Where especial information is needed that is foreign to the work of the clinician, the special worker and the various organizations identified with health administration have very courteously supplied the deficiencies. A listof contributors will be found following this explanatory foreword. To them and to a large number of others interviewed, the author acknowl- edges a great debt of obligation. Largely fathered by the Harrisburg Academy of Medicine, the extensive library of that institution and several of its Fellows have aided me in the preparation of this book. A great work in preventive medicine faces the rank and file of the phy- sicians, a work singularly appealing to the representative people in many walks of life. Never before have the great American public so fully joined hands with the doctor. In deference to them and in recognition of their creditable and proper concern, this medical book aims to present what the intelligent laymen are doing and offers for their study much that is of joint interest to them and to the physicians. The work in public hygiene cannot be effectively done without the inteUigent and enthusiastic efforts of my colleagues; neither can we do it all. The trio involved consists of the public health adminis- tration, the medical profession, and the great American public. vi HYGIENE Doubtless the author has made some mistakes herein, but the hope is expressed that they be viewed kindly since, so far as ascertained, this is the first eflFort to present a work from this especial point of view in the great domain of public health. The illustrations were largely made or collected by the author during trips of inspection. The largely academic and the merely literary have been merged in the definite seen or heard upon the spot or de- rived from original sources, and the work must be judged accordingly. It is the very earnest hope of the writer that the splendid class of men with whom professional affiliations identify me may study this and other works upon our public obligations and join forces with the earnest sanitarians of the boards of health, for, let me assure you, they need us. June 1, 1910. T. S. B. CONTRIBUTORS TO THE WORK David S. Funk, A.B., M.D. Physician, Interne Department, Harrtsburg Hospital. W. E. Wright, M.D. Formerly Resident Physician, Bay View Asylum, Baltimore; Resident Clinical Royal Asylum, Edinburgh; Late First Assistant, Pennsylvania State Hospital; Neurologist, Harrisburg City Hospital. W. Blair Stewart, A.M., M.D. Formerly Instructor in Medico Chirurgical College, Philadelphia; Member Visiting Staff, Atlantic City Hospital, etc. Charles S. Rebuck, M.D. Medical Inspector, Public Schools; Assistant Surgeon, Ear, Nose, and Throat Department, Harrisburg Hospital. John Uri Lloyd, Phar. M., Cincinnati, Ohio. J. B. McAlister, A.m., M.D. Chairman, Committee on Legislation, Pennsylvania State Medical Society; Physician Interne Department, Harrisburg Hospital. J. Horace McFarland President, American Civic Association. J. Wesley Ellenberger, M.D. Assistant Chief Physician, Pennsylvania Department of Health Tuber- culosis Dispensary Work. J. J. Taylor, M.D. Editor, Medical Council, Philadelphia. Harvey F. Smith, Ph.B., M.D. Dispensary Surgeon, Harrisburg Hospital H. C. FoLGER, Jr. Standard Oil Company, New York City. Clarence R. Phillips, M.D. Pathologist; Assistant Physician Pennsylvania Department of Health Tuberculosis Dispensary, No. 13. William G. Snow Heating and Ventilating Engineer (Boston); Past President, American Society of Heating and Ventilating Engineers; Former Lecturer on Heat- ing and Ventilation, Universtiy of Pennsylvania and Massachusetts Institute of Technology. J. Harvey Miller, M.D. Formerly Physician Soldiers' Home, Dayton, Ohio; Physician Dis- pensary Department, Harrisburg Hospital. Frank Hedley, Esq. Vice-president and General Manager, Interborough Rapid Transit Company, New York. Samuel H. Orwing, A.M., LL.B. COLLABORATORS A Committee of Fellows of the HarrishurgAcademy of Medicine, J. Walter Park, M.D., David S. Funk, A.B., M.D., J. W. Ellenberger, M.D. Allen S. Graham, A.B. Gas Engineer, United Gas and Improvement Company. A. M. Cleland. General Passenger Agent, Northern Pacific Railway Company. A. M, Kepple. Superintendent, The Washington Terminal Company. A. W. GiBBS. General Superintendent, Motive Power, P. R. R. C. C Lacey. Marine Superintendent Great Northern Steamship Company. J. W. Price. Chief Engineer, Atlantic City Sewerage Company. Management, The Red Star Line. Chemical Department, H. J. Heinz Company. Management, Waldorf-Astoria Hotel. Jos. H. Appel, The Wanamaker Store. W. Murrie, Hershey Chocolate Company. Thos. a. Curry, The Larkin Company. These gentlemen have supplied technical and commercial information essential to the preparation of the volume. THE FOLLOWING INDIVIDUALS AND ORGANIZATIONS have supplied data, reprints, photographs, etc., or have delegated assistants to aid the editor; or have otherwise actively promoted the undertaking: The Surgeons General of the Army, Navy, and the Public Health and Marine Hospital Service, United States. Bureau of Chemistry, United States Department of Agriculture, Dr. H. W. Wiley, Chief. U. S. Bureau of Animal Industry. United States Department of Internal Affairs. United States Post Office Department. The Public Health Service, Philippine Islands and Canal Zone. United States Immigration Station, Ellis Island, New York Harbor. Dr. C. C. Grieve, U. S. N., Sitka, Alaska. Maj. Chas. Lynch, Medical Corps, United States Army, Washington, D. C . Secretary and Editor, The Association of Military Surgeons of the United States. Thomas Darlington, M.D., New York City. Late Commissioner of Health, New York City Department of Health. Wm. C. Woodward, M.D., Washington, D. C. Health Officer, District of Columbia. A. H. Doty, M.D. Health Officer, Port of New York. Office, Commissioner of Corrections, Neiu York City. State Departments and Boards of Health. Of nearly all of the States and Territories of the United States. Many Local and City Boards of Health. The Laboratory of Hygiene, University of Pennsylvania. Colorado State Bureau of Mines. Pennsylvania Department of Mines. Thos. R. Crowder, M.D., Superintendent of Sanitation, The Pullman Company, Chicago. Chas. B. Dudley, Ph.D., Lately Chemist P. R.R., Altoona, Pa. California Board of State Harbor Commissioners. Wm. Blair, M.D., Ann Arbor, Mich. S. M. Shoemaker, Eccleston, Md. Wm. Jennings, Esq., President Harrisburg Board of Public Works. Paul A. Hartman, M.D., Dauphin County Inspector, Pennsylvania De- partment of Health. Harold R. Jauss, Harrisburg, Pa. Many Park Boards, Manufacturers, Railroads, Municipal Officers, etc. CONTENTS PREFACE LIST OF CONTRIBUTORS Chapter I THE FAMILY VS. THE COMMUNITY 1-7 Provisional quarantine and its limitations — The necessity of state regulation — Reporting infectious diseases — Local regulation of — Urgency of special cases — Rural and isolated cases — Doubtful cases — Mild forms — How far the attending physician should rely upon his own diagnosis — State and other experts — How should quarantined families be main- tained ? — Paucity of laws regulating this matter — When is it safe for the bread-winner of quarantined families to work ? — The duties of con- sultants — Concealed cases and those employing no physician. Chapter II HOTELS, LODGING HOUSES AND PUBLIC BUILDINGS . . 8-37 Introductory — The common law as it influences the question — Some consideration of the laws and regulations governing hotels and lodging houses — Quarantine in hotels and public buildings — The problem of the modern fiat and apartment house — Summer and resort hotels — The privileges that may be safely allowed to isolate a case in a hotel or public building without quarantine of the entire building — Transients and vital statistics — An Example of a sanitary hotel — Specifications for public buildings — Office buildings and infectious cases therein — The large commercial buildings and their sanitation — Fire hazard and sanitation — An example — Stores — Markets — Barber shops — Laundries — Churches and schools — Opera houses — Industrial establishments — Hygiene and disinfection of large buildings — Some examples. Chapter III SCHOOL INSPECTION AND COLLEGE SANITATION . . 38-57 A practical presentation of the duties of the school medical inspector and the school nurse in both the large and the small city — Exclusion of infec- tious cases — The tuberculous teacher — Defectives and degenerates — Sani- tation of buildings — The tobacco problem — The hygiene of athletic sports — Sexual and venereal instruction for young men in college — College training in sanitation — Nurses' training schools. Chapter IV PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE 58-78 The bad record of the past as regards jails — Some present bad conditions — Signs of improvement — Specializing in correction — Plans tending toward a more rational treatment of crime and criminals — Some instances of correct practice — Disease in prisons — The special hygiene of large prisons • — Of smaller prisons — The tramp question — Juvenile offenders — The HYGIENE medical service of prisons — Infectious diseases — Some general con- siderations. The Police — Their service to the public — Police ambulances — The police matron — The sanitary police — The place of the police in suppress- ing vice — Police instruction in first aid — Their future. Insanity and its care in the broader aspects of prevention, the sanitation of institutions and the general care of perversions and moral conditions due to insanity. Chapter V MATERNITIES 79-92 Introductory — Early maternities — Social considerations — Modem institutions — Objections urged — Illegal maternities — Laws regulating all institutions and with especial reference to the statutes of Ohio — Ethical, professional, and religious considerations. Chapter VI PLACES OF AMUSEMENT AND OF DISSIPATION . . 92-114 Opera houses especially in time of epidemic — Actors and actresses with infectious diseases — Small amusement halls, rinks, and dance halls — Clubs and infectious diseases — The hygiene of liquor and narcotic addiction — Prostitution and what the general practitioner can do to miti- gate its evils — Our duty to inmates in behalf of public safety — The necessity for adequate treatment of venereal diseases — So-called " cer- tificates of health." Parks and their sanitation — Forest reservations — Mountain lands — Salt marshes — Mosquitoes in same — Closing natural waterways — Artifi- cial lakes and ponds — Municipal parks — Parking of public grounds — School grounds — Pubhc playgrounds — Amusement parks — Expositions. Seaside Resorts and their sanitation — Boards of health in — Quaran- tine and isolation as applied at Atlantic City — Food supply — Sewerage — Garbage — Mosquitoes and flies — Water supply — Bathing estab- lishments — Hospitals — The death rate. Chapter VII SLUMS AND TOWN NUISANCES ...... 115-126 Building laws and the slums — What we should and may expect of owners, tenants, and the authorities — Inadequate laws in many places — Manure and factory refuse — The smoke evil — Stagnant water — Public dumps — Dirty vacant lots — Weeds — Offensive manufacturing and mine refuse — Other nuisances — Rats, fleas, and bubonic plague. Chapter VIII SPECIAL RURAL HYGIENE AND SANITATION . . . 127-156 Watersheds and rural water supply — Ice supply and ice ponds — Infected wells — Springs — Cisterns — Hauled water — Tanks and piped water — Barnyard drainage — Sewage — Vaults — Fertilizers — Sick and dead animals. TABLE OF CONTENTS Milk Supply and the many questions involved therein — Cheese, meat, and milk ptomaines — Butter and butter substitutes — Creameries. Dressed Meats and federal inspection — Poultry — Eggs — Food pre- servatives and dyestufFs — Fish and game meats. Insecticides upon food — Poisonous plants and their eradication — Insect pests — Sanitation in sending produce to market — Summer camps — Rural resorts. Chapter IX STATE DEPARTMENTS AND BOARDS OF HEALTH . 157-251 Introductory remarks — An outline of their legal basis in the states and territories — The legal powers and limitations of state boards of health — The importance of keeping up with the regulations in force in one's own state — What obhgations rest upon the general practitioner — The vaccination problem — Reports expected of physicians — Vital statistics — Local representatives of state organizations — Their relationship to local health boards — Misunderstandings and disputes and how to avoid them — The charity and emergency work of state boards and how the physician can co- operate therein. Roster of States, territories and dependencies of the United States, giving an account of the organization and work therein — Where to secure bulletins and regulations — Analysis and conclusions. Chapter X A PROPOSED FEDERAL BUREAU OF HEALTH . . . 216-220 What the government at Washington is now doing — What it might do — Objections to a national department but little to a bureau — What such a bureau could do for the general good of medicine and sanitation — The importance of international hygiene as shown in Cuba and the Canal Zone — What the army and navy could do for public health — The hygiene of interstate and international commerce. Chapter XI LOCAL BOARDS OF HEALTH AND SANITARY OFFICERS 221-250 Introductory remarks — The maze of laws and regulations — The neces- sity of informing one's self regarding local regulations — The relationship that should exist between the officials and the physicians — The mistake of shifting all authority from local to state officials — City bacteriologists and chemists — Routine duties of the health officer discussed under several headings. City Boards as a separate problem. The Washington and New York city departments of health. Chapter XII ARMY AND NAVY SANITATION; OR — HYGIENE OF CAMPS 251-274 Introduction — Organization — Recruits — Hygiene in peace — In war — In battle. HYGIENE Camps — Water supply — Rations — Disposal of excreta — Housing — Transmissable diseases — Typhoid — Malaria — Diarrhoeas — Bubonic plague — Venereal diseases — Other infections — Special tropical dis- eases — Clothing — Marches — The canteen. Special Naval Regulations — To enter medical service of — Medical school of — Duties of medical officers — Enlistment — Sanitary regulations — Quarantine — Insanity in Navy. Public Health and Marine Hospital Service, a general survey of its functions and the work it has done. Other Camps — Contractor's labor camps — Camps in time of public dis- aster — The lessons the general practitioner can learn from the army and navy. Chapter XIII THE CORONER AND THE PHYSICIAN 275-277 A discussion of his statuts in law — The importance of the physician knowing the powers of the Coroner — What a physician can expect of a coroner — What a coroner can expect of a physician — What cases to report to the coroner — Final remarks. Chapter XIV QUARANTINE 278-294 Definitions — Maritime — Port regulations — Inspection — Ports of entry — Quarantining of vessels — Requirements at quarantine — Regula- tions concerning cholera, yellow fever, smallpox, typhus fever, leprosy, and plague — Canadian and Mexican frontiers — Disinfection — Interstate quar- antine — Maritime quarantine maintained on lakes, gulf, and rivers — Inland quarantine. The States — Survey and tables of the quarantine regulations in force in the various states and territories. Chapter XV INFECTIOUS DISEASES 295-310 Introductory remarks — Tables giving incubation, mode of onset, occur- rence of eruption, character of eruption, fading or disappearance of erup- tion, duration of illness, character of other symptoms and phenomena, mode of contagion, and period of contagion. Methods in use by physicians to protect themselves, their families, their patients, and the public. PLATE ILLUSTRATIONS Volume I A Park Lake, Formerly a Malarial Swamp, a Shallow Lake Choked with Weeds — A Properly Constructed Artificial Lake frontispiece GPP. PAGE A Filthy Stream in a Large City 4 Two Insanitary Alleys 4 Parking Concealing a Coal Pit 14 Ideal Apartment Houses 14 A Street of Apartment Houses, New York City 14 Surgeon's Room, Waldorf-Astoria 1 l8 Elevator Entrance to Rest Room 1 l8 New Union Depot, Washington, D. C. 2 22 Heating and Power Plant, under a Paved Area 22 Public Building Marooned 22 Model Sanitary Office Building 3 j4 Central Skylighted Court of Above ^ 34 Large Office, Administration Building 3 , , _ 35 Reading Room for Employees ^ 36 University of Michigan Gymnasium 48 School Nurse at Work 4 48 Medical College, Anatomical Laboratory 48 Cell Corridor, "The Tombs" Prison 62 Portion of the Kitchen 62 Part of Yard 62 Police Automobile Ambulance Service 68 Automobile 68 Michigan State Psychopathic Hospital, Ann Arbor 5 76 Portion of "The Tombs" Prison, New York City 76 Lying-in Hospital, New York City 6 82 Harrlsburg Park Views — Lily Pond Water Works Park 92 Automatic Sanitary Spill- Way at Dam, Wildwood Park 92 Riverside Parkway 92 Botanical Garden, Washington ^ lOo House of Public Comfort lOO Park Museum, Fairmount Park lOO Young Athlete's Paradise 108 Where the Unfortunate Often Sleep 108 Bear's Den, Zoological Garden, Philadelphia 108 Sewerage Plant, Atlantic City 8 II2 Locker Room, Sanitary Bath House ^ 1 12 Ideal Rural Water Supply 132 Uncontaminated Stream Supply 132 Farm Spring Effectively Protected 132 Ideal Dairy Conditions ^ 140 Pumping River Coal 156 Abandoned Canal 156 Machine for Drilling Deep Wells 156 Michigan Laboratory of Hygiene 212 Medical Missionary Work in the Tropics 10 212 Municipal Crematorium, District of Columbia 1^ 228 Smallpox Hospital, at Above H 228 Public Comfort Station, Washington, D.C. H 240 Reception Hospital, Department of Health, New York City 4 250 Scarlet Fever Building * 250 PLATE ILLUSTRATIONS OPP. PAGE Administration Building ^ ^ 2C0 Dressing Station and First Aid Work, Camp Tacoma 12 256 Camp of Instruction and Provisional Tent Hospital 12 264 Another Portion, same Camp 12 264 Field Hospital and Ambulance Company 12 264 Marine Hospital Sanatorium, Fort Stanton, New Mexico 13 274 Boat Landing, Offices, and Laboratory — Quarantine Station, Staten Island 282 Savannah Quarantine Station 14 292 Cape Fear Quarantine Station 14^ 292 Two Views Municipal Hospital, Atlantic City 9 292 TEXT ILLUSTRATIONS Volume I PAGE Dark Prison of the Old and Insanitary Type 60 A Farm Filter j^i Rider and Ericsson Hot Air Pumping Engines 134 Plan for House Drainage 136 Revision, from Illustrations in the Typhoid Issue of the Virginia Health Bulletin 137 A Few Common or Dangerous Weeds 153 From the Mud Taken from a Mountain Brook 155 Your Turn Next 207 How High is the Wall in Your Town 207 The Hemisphere of our Health Work 208 Public Comfort Station, Washington, D. C 241 ACKNOWLEDGMENT The author and publisher wish to express their thanks to those through whose courtesy, as indicated below, many of these illustrations are used. 1 Management, Waldorf-Astoria Hotel. 2 From Steel Engraving, The Washington Terminal Company. 3 The Larkin Company. * Department of Health, New York City. 5 William Blair, M.D., Ann Arbor. ^ Lying In Hospital, New York. 7 J. A. Kepple, Harrisburg, Pa. 8 W. Blair Stewart, A.M., M.D., Atlantic City, 9 S. M. Shoemaker, Eccleston, Maryland. 10 J. S. Grant, M.D., Ningpo, China. 11 Wm. C. Woodward, M.D., Health Officer, District of Columbia. 12 United States War Department. 13 P. M. Carrington, Surgeon, United States Public Health and Marine Hospital Sen-ice. 14 United States Public Health and Marine Hospital Service. Other photographs and drawings by the author. PUBLIC HYGIENE Chapter I THE FAMILY VERSUS THE COMMUNITY* IT is perhaps no exaggeration to say that in no other period of history has the prevention of disease occupied so large a place in the thoughts of every intelligent community as obtains at this present day. Organiza- tions of intelligent men and women exist in all of the large centers of popula- tion whose sole aim and purpose is the conservation of the public health. Their time and means are freely given to the end that their fellows, of every class and condition, may not only be nursed back to health when they fall ill, but that their wellbeing may also be preserved by a healthful environment, and pure and wholesome food, in order to limit disease they may contract, avoid unnecessary ailments, and prolong their lives to their families and society. No man is or can be " a law unto himself," but is, in a large sense, his brother's keeper. Individualism must be submerged in order that every human unit in every place have a community of interest with every other. The early recognition and isolation of communicable disease is the first step in this splendid movement; the discovery of its cause and its complete eradication, the next one. So brilliant have been recent achievements along this line as to constitute an epoch in the world's medical history. Nor is this the end, but rather only the beginning; for it is entirely fair to assume that prophylaxis will prevail so successfully as to be the crowning glory of the twentieth century. All men love liberty, but they love life more. It happens as a logical sequence that, when life is at stake, it may be necessary to curtail liberty in order to safeguard or preserve existence. The medical men of long ago recognized the fact of the transmission of certain diseases, but the medium of contagion was a fruitful theme for discussion and dissension. Our own Oliver Wendell Holmes and Semmelweis, of Vienna, both taught that puerperal fever was communicable, but the pro- fession at large was slow to accept the dictum and the disease continued to reap its harvest. So likewise was yellow fever known to be contagious, but it remained for Reed, Lazear, Carroll, and Agramonte to demonstrate how it became so. It would be impossible to estimate the far-reaching results for good that such discoveries have brought to pass in presenting convincingly to the intelligent lay mind the value of medical research work. The endorsement by laymen of the various men and means necessary to effective sanitation has been accomplished by such definite demonstra- tions as are these. The doubt and distrust of empiricism have given way to the co-operation and confidence engendered by demonstrated science. Among the modern measures none is of more vital importance than is the early establishment of quarantine. Centuries before the Christian era attempts were made along this line with the hope of staying the ravages of certain dreaded diseases, the Hebrews and their attempted isolation of leprosy being a striking case in point. *By David S. Funk, A.B., M.D. 2 HYGIENE Provisional quarantine and its limitations. — While the maintenance of a legal quarantine is to be preferred under most circumstances, yet occasions arise in which such quarantine either cannot exist or cannot be enforced. The special article upon Seaside Resorts, in Chapter VI, is an instance in point. Aside from such instances where business policy is the dominating factor, there are areas of the country destitute of any public sanitary admin- istration. Nevada has been without health boards, and whole counties in the interiors of some Southern states have not been organized effectively. In remote lumber camps, in some of the turpentine camps of the South, and in contractors' labor camps in unsettled regions, as well as in the gold fields of Alaska, quarantine is largely a matter which devolves upon the physicians in charge. The United States navigation laws place certain sanitary respon- sibility upon the masters of vessels, who usually provide sick bays and author- ize the surgeon of the ship to maintain a quarantine. Surgeons employed in camps and by corporations have large discretion in matters of quarantine. Yet all such quarantine measures are only provisional and imperfect. A lawyer who is admitted to the bar is considered an officer of the court. In the same sense, a physician who is licensed to practice has a legal status in his state that surely warrants him in protecting the community in case of danger from disease. In the Journal of the American Medical Association, for November 20, 1909, appeared an article upon epidemic anterior polio- myelitis in Minnesota, and in which it is stated that over fifty epidemics of this disease have been reported. This is not one of the reportable diseases in Pennsylvania, yet, were I to encounter it here, my provisional quarantine of the case would doubtless be upheld by the department of health if upon investigation my diagnosis were confirmed. In a sense all quarantine by attending physicians is merely provisional, and we should confess to a feeling of relief that the state takes up the work for us and endeavors to make effec- tive the necessary protective measures so liable to bring an unsupported physician into unpleasant conflicts. It is where the state does not impose an adequate quarantine that the physician is in the greater difficulty and sustains the greatest responsibility. In reporting a case of smallpox to the board of health my legal status is the same as when I " pull " a fire alarm box; a false alarm alone makes me re- sponsible. Possibly a case of contagion is not so easy of diagnosis as is a fire, but the diagnosis or discovery of both are equally important to the commun- ity. But if I discover a small fire in the midst of the wilderness it is my responsibility to isolate and to limit it by any and all means within my power. Inasmuch as the general good health of any community is its very best asset, it is incumbent upon the commonwealth to inaugurate such measures as seem to its citizens to be necessary to prevent the invasion of disease, and to permit localities so situated as to be geographically liable to unusual danger, to institute special regulations, such as have been found necessary by New Orleans to keep out yellow fever, and by San Francisco to protect the Occident from the oriental bubonic plague. As the " Sovereign States " are now looking to the federal government to do its share in interstate and inter- THE FAMILY vs. THE COMMUNITY 3 national sanitation, so they also expect every man to do his duty. Any citizen with a flag may nail it to the pole or take possession of an unexplored region in the name of his government; so any physician can raise the yellow flag of quarantine pending the arrival of the health officer. And it is his human and professional duty to take the initiative where the circumstances are such as to preclude adequate official service. Reporting infectious diseases. — As will be noted in the latter portion of the chapter upon quarantine, all of the organized states require attending physicians to report certain communicable diseases or be subject to certain penalties for their neglect. This is a decided step in advance of the condi- tions which obtained only a few years ago, when the state had little expressed voice in the matter, and when the limited authority was all vested in the boards of county commissioners or directors of the poor. It is only necessary to note this former state of affairs to fully appreciate the utter lack of S}'Stem resulting from such proceduie as compared with that which exacts of the physician in charge a prompt and full report to the proper authorities of such cases of infectious disease as may come under his care. The general dissemi- nation of knowledge upon all matters the laity require in order to appreciate the operation of and necessity for public health administration, is rapidly converting them to approval of measures formerly misunderstood and some- times resisted. Hence, reporting is becoming a less disagreeable duty to the physician. Reporting infectious diseases aims at two objects, the first being the protection of the public, and the second the collection of vital statistics. The first object is the more immediate one, yet it is to be feared physicians do not fully appreciate the value of the second one. Publicity is the modern cure for many evils; among them disease looms large and its existence should be made a subject of common knowledge to the end that precautionary measures may be early instituted of such a char- acter as will aff^ord the maximum of protection with the minimum of incon- venience. To accomplish this, organization is essential and boards of health a necessity. To be effective, they must be vested with due legal authority. Vital statistics are impossible without professional reports giving the data necessary to the making up of the mortality rate and the number and character of infectious cases. But reports accomplish more than this; that is to say the presence, in a more or less continued way or endemicall}^, of communicable diseases is prima facie evidence of unpardonable supineness or even lack of intelligence upon the part of some one. Provided physicians make proper and prompt reports, the fault cannot be theirs, but rather that of the community or of its authorities. As a striking illustration, one need but recall the very insanitary condition of Havana and Santiago under Span- ish rule and involving a frightful mortality from yellow fever and other infec- tious diseases. Nor were our own military camps in the United States during the Spanish American War very much better so far as relates to the mortality from typhoid fever. Our later more favorable reports from our tropical service aie due to measures outlined in the chapter in this book upon military hygiene, and emphasize the fact that eternal vigilance is the price of sanitary 4 HYGIENE success. Vital statistics suggested the reforms in camp life and are as neces- sary in civil affairs, for a city is but a permanent camp. Indeed, the intelli- gence of a community can be somewhat gauged by its care or its lack of care in the collection of vital statistics. Urgency of special cases. — While the usual reports are alv?ays desirable, especial urgency occurs in the case of invasions of smallpox, cholera, yellow fever, bubonic plague, and other rapidly disseminated infections. Many epidemics have resulted from tardy reports, and it is essential that the tele- phone and telegraph be used and are none too rapid for reports in urgent cases or in those of marked danger. Some states require such reports. Rural and isolated cases. — Special risks and dangers attend these classes of contagious disease. Their isolated environment are calculated to beget upon the part of the family and the medical attendant a disinclination to hew strictly to the line in the many little details essential to the prevention of dis- ease dissemination. The comparatively recent epidemic of typhoid at Ply- mouth, Pennsylvania, brings forcibly to mind the terrible amount of harm which may result from a single case of this disease when disinfection of the excreta has been neglected. Watersheds are thus contaminate and entire villages and towns are brought face to face with serious epidemics. The milk supply has frequently been the means of one case of scarlet fever result- ing in a severe epidemic, and London, Philadelphia, and other large cities have furnished striking instances. Viewed in the light of dreadful experiences, one can readil}- appreciate the rather larger responsibility of the physician in attendance upon the rural or isolated case than obtams with the city physician who may have at his beck and call all the machineiy of a well-organized and fully equipped board of health. With the latter upon the reporting of the case come certain restrictions which will probably prevent further spread of the disease, whereas in the case of the former physician the fight is single handed and with probably greater precautions necessary. Wells, cesspools, streams, schools, dairies, and other factors may all devolve upon him, and it behooves the country practitioner to be Ytvy circumspect in his management of all cases of communicable disease, and he must be politic in enforcing proper hygienic practice to prevent a widespread epidemic being due partially to his own lack of care and education of his families and the community. Doubtful cases. — In the irregular cases of the eruptive fevers, it is fre- quently a matter of no little difficulty to make an early diagnosis. In all such cases there can be but one proper line of conduct for the attending phy- sician, viz., isolate the patient from the very first, since it is better to slightly inconvenience the family than to subject the community to danger. One need not report the case until after he is able to make a diagnosis unless an undue period of doubt justifies calling a consultant or an experienced medical health officer. Mild forms. — The seeming mildness of any form of communicable dis- ease should not have any weight whatever against the advisability of quar- antine providing the attending physician has just ground for suspecting the real nature of the case. These are the very cases, however, that are well *• ^■^4^•l:i. '/^ w ^r-rr x^^^^ ^mr \^^!^^ «»► •w\ 'i-. A FILTHY STREAM IN A LARGE CITY Such Streams are a difficult problem. Much effort and money has been expended upon this one, but it is still insanitary. One side of this alley faces the This alley is not in a large city, rear of large stores and hotels; the and instances land greed on one side other side, stables and saloons. and tuberculosis on the other side. THE FAMILY vs. THE COMMUNITY 5 calculated to make him very unpopular with the involved families, since they do not understand the danger of mild cases engendering the most virulent type of the disease in other individuals. Nor has the medical attendant done anything like his full duty to himself, the family, or the community, until after he has taken the time to fully explain the absolute necessity of main- taining quarantine over communicable disease without regard to the apparent mildness of the attack. The more intelligent element of society is quick to understand the import of quarantine, but the less informed must be edu- cated along such lines by the rank and file of general practitioners. This requires patience and that the doctor tactfully controvert preconceived ideas and prejudices that are very natural. Neither health officers nor physicians in attendance upon cases can afford to be arbitrary or dictatorial to persons who feel that their rights are being involved without due process. It is here that the physician can do an excellent educational work that will greatly aid the health boards. How far the attending physician should rely upon his o%vn diagnosis. — In the matter of communicable disease it is of the utmost importance that a correct diagnosis be made at the earliest possible moment. This is so uni- versally conceded that it would seem scarcely necessary to make mention of it here. But when one recalls that errors of the most serious nature and fraught with very unpleasant consequences have arisen in the past and are still arising in most unexpected quarters, it would seem that a word along this line might be admissible. So long as smallpox is mistaken for " Cuban itch," and fatal cases of diphtheritic croup for " tonsillitis with suffocation," and appendicitis for typhoid fever, it would seem that some general practitioners may at least have their limitations He should not be too hasty in forming an opinion in a case, a similar one of which he may never have seen. Errors in diagnosis are bound to occur, but so long as disease is of a nature which is not communicable, the community is not endangered and no great harm may be done. With infectious diseases the clinical features may be so plain as to make early diagnosis easy; but the onset of the disease may follow an irregular or unusual type and perhaps one never previously seen by the medical attendant, or new to his locality and requiring a bacteriological examination to determine its real character. Especially in seaport towns into which the germs of diseases from remote sections are extremely likely to be imported, despite efficient quarantine regulations, is the general practitioner apt to encounter these irregular or little seen diseases. Naturally, his duty is to notify the quarantine officer instead of depending solely upon his own diagnosis. And in any event, it behooves the medical attendant to recognize his limitations and to avail himself of such expert counsel as is almost always available, especially since nearly all state boards of health make it their care to supply laboratory and other diagnostic aids. How should quarantined families be maintained? — A family under rigid quarantine may be entirely deprived thereby of its bread-winning capacity. It happens not infrequently that the maintenance of such persons becomes a matter of serious concern. At first blush, it might seem that a legal regula- 6 HYGIENE tion which deprives the bread-winner of exercising that function, while phy- sically able and willing to do so, should reimburse him, at least in part, for the loss of time and money entailed. The fallacy of such logic becomes at once apparent, however, when it is borne in mind that these same restrictions which now apply to him and are protecting his neighbors and fellow workmen, may have safeguarded himself and his family in the past and stand ready to do so again in the future. Quarantine so limits the spread of communicable disease that the time and wages lost are a small item compared to the general conservation of health and industrial activity gained thereby. If this is true to society at large it is equally true to its units. The state of Maine makes certain legal provision for the support of families under quarantine, but the states at large have not admitted the legality of this especial claim. The paucity of laius regulating this matter makes it questionable as to whether the state should be asked to contribute to one class of individual or family poverty when all other classes come under the supervision and become the charge of counties or municipalities. As to the maintenance of a quarantined family, two points are to be considered: first, the urgent need of the family; second, the element of quarantine itself. It is always to be borne in mind that quarantine calls attention in a forcible way to the needs of the families so involved, and both city and rural hearts respond to the call so readily that there is but little real occasion for real suffering or deprivation made necessary by reason of the fact that the com- munity at large is being protected by quarantine regulation. It is rare indeed but that the families find coming to their support such redress as the exigencies of the case would seem to demand. Some well-organized plan to relieve the immediate necessity of the de- serving poor when taken down by illness of whatsoever kind is needed in every considerable community, rural or urban. That is to say, the deserving poor merit the charity of the community at all times, but more especially when they become ill; not so much because the illness may be of a character which requires the enforcement of quarantine regulations, but because they are poor. When IS it safe for the bread-winner of quarantined families to work? — This question cannot be answered offhand. In Chapter II there is some discussion of the matter as applies to apartment houses, while the chapters upon local boards of health, quarantine, disinfection, etc., all throw light upon the subject. The duties of consultants is a touchy matter, discussed in the chapter upon local boards, and need not be entered into here, although allied to this subject. Concealed cases and those employing no physician. — It is certainly a regrettable fact that an occasional physician so far forgets the real significance of his high calling as to be a party to an attempt at concealment of communi- cable disease. The motive for such concealment is nearly always the same, and aims no higher than the obtaining of a certain though surely very ques- tionable popularity with the family in which the disease may happen to occur. There are to be found in almost any community a few people who are selfish THE FAMILY vs. THE COMMUNITY 7 and inconsiderate enough to insist that they shall be exempt from the restric- tions of quarantine, and they hold out to the medical attendant all manner of bribes and inducements, to the end that he may fall into line with their way of thinking. Failing in this, they threaten the attendant with immediate dis- missal, and frequently do actually dismiss him, presuming usually to be able to secure the services of a physician who will have a conscience sufficiently pliable to totally ignore his predecessor's diagnosis and thus ingratiate him- self into the good graces of the family in question. With such physicians, diphtheria is never anything worse than " sore throat " or " tonsillitis," and scarlet fever becomes " rose rash " or an " erythematous rash," or some other high-sounding name. Of course men of this stamp are very largely in the minority, but they are to be found and they sometimes crop up in most unexpected quarters. In those instances in which the physician is dismissed from the case because of his making a diagnosis which means quarantine, the remedy is easy of application. It simply requires that the physician first called in the case report the matter to the health authorities, who will make the proper investigation. In such events the physician should avoid controversy, simply reporting that in his opinion a certain communicable disease exists, and ever bearing in mind the possibility of error upon his own part. In the absence of an organized board of health and more especially in those cases where the attendant first called is willing to stoop to concealment, or where no physician is employed, the problem becomes very much more complex and more difficult of solution. Mild cases of scarlet fever are par- ticularly prone to be a source of contagion because of no physician having been called, unless, perchance, scarlatinal nephritis or some other complica- tion arises late in the disease and is accompanied by symptoms which alarm the parents. Every general practitioner can recall cases of this kind. As to the laity, the correction of this evil must be left largely to the cul- tivation of a higher ethical point of view as regards their sanitary and other duties toward their neighbor. To this end, the family medical adviser can accomplish much by taking a high point of vantage as regards all sorts of deception or subterfuge and leading his patients up to it as a civic and per- sonal duty. He who stands upon this height should beckon the weaker brother, and probably the best way to maintain sanitary virtue is through joining with and maintaining the high ideals characterizing medical societies. The free commingling of the medical men of every community and their combining to accomplish the things looking tOAvard their betterment will have as an end resultant the sanitary betterment of the whole community and the elimination of abuses such as have been described. Add to this, publicity, the modern panacea for most abuses, and they will cease to exist. The old Hippocratic Oath was good. It made good and honorable men alone seek the sacred trust of family doctor. But that oath must to-day be extended. No longer are we interested only in " our families." We now know that " God has made of one family all men who dwell upon the face of the whole earth," and to them all must we preach the gospel of sanitation and right living. Chapter II HOTELS, LODGING HOUSES, PUBLIC BUILDINGS Introductory. — The common law as it influences the question — Some consid- eration of the laws and regulations governing hotels and lodging houses — Quarantine in hotels and public buildings — The problem of the modern flat and apartment house. Summer and resort hotels — The privileges that may be safely allowed to isolate a case in a hotel or public building, without quarantine of the entire building — Transients and vital statistics — An example of a sanitary hotel — Specifications for public build- ings — Ofiice buildings and infectious cases therein — The large commercial buildings and their sanitation — Fire hazard and sanitation — An example — Stores — Markets — Barber shops- — Laundries — Churches and schools — Opera houses — Industrial establishments — Hygiene and disinfection of large buildings — Some examples. " /I MAN'S house is his castle," and for a long time it was regarded /~\ as no one's affair what went on therein. House waste, disagreeable things, and undesirable inmates were simply turned into the street. The house was surrounded with a high wall and one was safe therein from all except the robber and the visitations of offended gods or the " dispositions of Divine Providence." But one went abroad at his peril and carried a lantern and side arms and avoided unclean streets by taking carriage or a horse. And the " tavern " or " hostlery " was equally a refuge for the stranger and the wayfarer so long as he paid for his entertainment. But the home of the few has been invaded by the sanitarian, and the temporary abode of the many cannot claim immunity. The law reaches far to-day. Let us see how far it can influence a hotel. How far the common law is concerned with the question can be better answered by a lawyer, and we present here the views of Samuel H. Orwig, Esq. The Constitution of the United States provides that the people shall be secure in their persons, houses, papers, and possessions from unreasonable search and seizures. The cases in which the health authorities, either at common law or by statute, may quarantine private dwellings, are confined exclusively to cases of pestilence or contagious disease. The persons quarantined are entitled to the care and protection necessary for their welfare and safety, and the neglect to provide for their necessities pending the quarantine would subject the party guilty of gross neglect to action at law either civil or criminal. The legal rights of an owner of a dwelling house when his tenant is quarantined are necessarily limited by the facts and circumstances in each case. The landlord is subject to the like restraint, as are all other persons, so far as may be necessary to protect the public health. It is self-evident that he would not be permitted to break the quarantine. His legal rights to col- lect rents or recover possession may be in abeyance and would be restrained so far, and so far only, as the welfare of the public generally and the afflicted in quarantine would seem to require; and it would be safe to assume that the HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 9 courts would excuse an excessive exercise of authority to quarantine, in cases where there is great peril to the public health. It is the nature of the disease that warrants the quarantine and not the character of the place in which the infected person or persons may be. A hospital for contagious diseases is in itself always in quarantine. The proprietor of a hotel or lodging house, like the owner of a dwelling,, may suffer inconvenience and perhaps loss by reason of quarantine. His legal rights may be in abeyance for the time being and must be measured finally by the same general rules that govern in the case of a dwell- ing house. If the removal of a lodger or a guest at a hotel to a hospital would secure the public from the danger of contagion, it would seem to be the better course to pursue rather than to bar the doors of a public house. How far the constituted authorities charged with the duty of protecting the public health have acted within their limits in any particular case, or may have exceeded them, may be submitted to a court of law and then and there be determined in the light of all the facts and conditions in the case. The inconvenience and loss necessarily resulting from quarantine may or may not entitle the person or persons who suffer such inconvenience or loss to redress at law. The courts will not interfere with the legitimate use of the police power. Thus it appears that the common law gives pretty full latitude for the regulation and sanitation of the class of buildings this chapter is considering- We have been to some care to examine the building regulations of several cities, and find that such structures as theaters and hospitals are very ade- quately provided for, while there are in most cities very inadequate regula- tions as regards the construction of hotels. Unfortunately hotels are apt to be like Topsy, " jess grow up," and be metamorphosed from some other structure and have wings added and appropriate adjoining buildings, until the city awakes to the fact that it has a big hotel that is a fire trap. Here in my own city we wished to enlarge a hospital by adding a new wing, and we were obliged to change plans and spend several thousand dol- lars additional in order to conform to city regulations. For instance, the laundry floor is based upon such heavy iron girders that, were a track laid over it, it would be safe to run a loaded trolley car across it. But since that was built two hotels have gone up that look beautiful, but are very inflammable. And our building laws are based upon those of one of our largest cities. If it is necessary to make a hospital practically fireproof certainly the same need exists for a hotel. In the May, 1909, issue of the Pacific Monthly, the following statement is made about fires in the United States: Week after week we average up three theaters, three public hal]s,*twelve churches,, ten schools, two hospitals, two asylums, two colleges, six apartment houses, twenty-six hotels, three department stores, two jails, one hundred and forty flat houses, and about sixteen hundred homes destroyed by fire. 10 HYGIENE Note the large number of hotels and flat houses in the list. Municipali- ties have been slow to exact proper building laws in this country, and it is amazing how fire will swirl through block after block of our showy American cities. In Europe they do these things better. The buildings are not erected there with the idea of tearing them down in a few years. A little further in this chapter details of construction will be given, but here it is proper to say why so many hotels and lodging houses burn. Two main sources of origin of fire are the kitchen and the heating plant. The kitchens of hotels are nearly always too small and too many wooden closets are built right around the ranges. There is a tendency to keep coffee boilers, cereal steamers, and hot water boilers going all night, and they are often heated by gas and the flames more or less exposed. Grease boiling over or being spilled is an added danger, and matches are seldom properly cared for in hotel kitchens. Several states provide for the inspection of hotels and lodging houses, but Illinois has one of the fullest laws, and we will here refer to some of its main features. Instead of having some separate board, the state board of health is given supervision. The statute requires that not less than four hundred cubic feet of air space be provided for every occupant of the sleeping apartments, and the placing of the beds and proper ventilation is defined. Records and annual statements are required of the proprietors, and the in- spectors of the board can order and enforce necessary sanitary rules. Florida has the most stringent rules. The state board inspects, and charges two dollars and issues a certificate of having successfully passed inspection. In an uninspected hotel, if a guest becomes ill from insanitary conditions, he can bring suit against the hotel for damages. Refusal of the proprietor to abate insanitary conditions may result in fine or imprisonment. Maine and some other states have regulations requiring the disinfection of a room after its occupancy by a tuberculous case. The department of health of the city of Chicago has a list of about two thousand restaurants to inspect, and it finds difficulty in bringing all up to standard. So many are conducted by very poor people that it is a hardship to them to provide proper facilities. By means of subterfuge or by posing as a patron, the editor has seen behind the counters and into the kitchens of Chinese, Italian, and other foreign restaurants. The worst ones I have seen were run by Greeks and Italians, while the Chinese were comparativel)^ clean. It has been an amaze- ment to me to find in Philadelphia and other large cities basements and cellars used by restaurants for the storage and preparation of food in states almost beyond description. Especially was I amazed to find an awful state of plumbing supposedly " inspected." There is an abuse in the hotel business that needs attention. Some of the courts are very slow to give licenses for saloons, but are ready enough to grant them to hotels. So the man who wishes to run a saloon opens a " hotel " in a little fifteen by thirty building, with hardly room enough to house the saloon and his family, and with not the remotest idea of ever HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 11 taking more than the legally required number of guests. These places rob the bars of the real hotels and make the profits so small that it is hard to exact of the hotel the facilities it should have. It is surprising how many hotels are just barely existing, and what small profits are made by many large establishments. It is simple justice for the courts to refuse to issue so many licenses. If the state sells a license, it should protect the holder from ruinous competition. It is the poor fellow who is " down and out " who is most liable to steal a loaf of bread, and it is the saloon keeper who makes a bare livingwho is most apt to keep a dirty place and sell dirtv liquor. Itwould largely advance the sanitation of hotels if the lower strata of them were forced out of business by the courts refusing to grant licenses to any but the real enterprises conducted along right lines. It is claimed that it is hard to make a financial success of a hotel unless it has a bar. If that be true, it is surely the duty of the courts to distribute licenses in such a way that the public would be served in a cleanly and well-ordered manner, and that can be done only by a paying business. It is well to remember that the hotels have first contact with the great world outside, and they can bring epidemic to us or we can go to summer hotels ourselves and bring home typhoid fever. It is a matter of great public importance to keep our hotels up to a high standard of excellence. All communities should have hotels of which they can be proud, and they should do all they can to promote the tone and the legitimate business of these places; then we shall have sanitary hotels. A physician in general practice learns something of the woes of the hotel keeper. It seems that a large portion of the public regard a hotel as a place where they have an especial dispensation to do as they please. Intem- perance and various indiscretions are more the fault of the guests than of the proprietor, nine times out often. It is very hard to secure and to retain good hotel help, and many of the irregularities and insanitary conditions found in hotels are due to careless and incompetent help. As to the food served, that is discussed in the chapter upon pure food and drugs. Lodging houses are more apt to become insanitary than are hotels, and the conditions found in the lodging houses where foreign laborers are housed is often frightful and is contrary to good health and good morals. The worst conditions of that character that have come to my attention exist in the small places employing foreign labor in the mining and steel works. One cannot hold the authorities too much to blame for these conditions, since an inspec- tion and cleaning up improves the state of affairs for about a week, and then they gravitate back to the old ways. These foreigners want to send all the money possible back to the " old country," and they seem content to live like swine here in order to get a little saved to live upon in Europe after their return. Unfortunately, many of these foreign lodging houses are situated just beyond the line of the municipality, and the building and sanitary regu- lations do not reach them. My suggestions would be: first, adopt the plan being tried in the South, of enacting a state law extending the authority of all municipal health boards 12 HYGIENE and officers for one mile beyond the corporate limits; second, place a placard upon the door of every room occupied as sleeping quarters, stating how many persons are permitted to occupy the apartment, and fining the proprietor for allowing an excess number to occupy said rooms; third, extend the municipal garbage regulations to cover these places and charge a small sum for the service; fourth, in case of over twenty unmarried adult occupants in one house there should be a janitor provided, and he should be acceptable to the sanitary authorities, and be required to report to them; fifth, storage of rags, paper, junk, or any other material apt to be insanitary should be prohibited in these buildings; sixth, allow no licenses for the sale of intoxicants within these buildings and grant no " club " licenses therein. In addition to these suggestions, as so many of these people are mem- bers of the Roman Catholic Church, much can be accomplished by the sani- tary authorities asking for the co-operation of the Church in the districts involved. The bishops and priests of many cities have given substantial aid in furtherance of such plans. Lodging houses for working girls are very often conducted in a very careless manner. The Young Women's Christian Associations are pro- viding quarters for many girls, but they cannot reach all. Their work might well be extended to include a co-operation with the sanitary authorities and the anti-vice leagues in providing safe and sanitary lodging for the army of young women employed in stores and factories and separated from all home influences. Places like Mills's Hotels for men are needed for women. The wages of most of the women workers should be placed upon a more equitable basis, and then their living quarters would soon be improved by themselves. Quarantine in hotels and public buildings. — What Mr. Orwig has stated in this chapter nearly covers the subject. Doubtless a hotel can be fully quarantined, and such measures have been placed in force when smallpox or scarlet fever was present and the hotel building a small one. However, the regulations of the District of Columbia are safe guides in sanitation gen- erally. The following is quoted from the last edition: If such premises be a hospital, asylum, hotel, or apartment house said placards or warning signs may, in the discretion of said health officer, be placed in a conspicuous position or positions within said premises, at such place or places as said heahh officer may determine. . . . That whenever any person in said District is an inmate of any premises occupied by three or more families, or of any tenement house, hotel, or apartment house, and is suffering from any contagious disease, and cannot, in the opinion of said health officer, be properly isolated in such premises, tenement house, lodging house, hotel, or apartment house, said person shall be removed as expeditiously as possible, under direction of said health officer, to the public hospital or to such other place, satisfactory to said officer, provided by and at the expense of said person, his parents or guardians; if such person cannot, in the opinion of said health officer, be removed as aforesaid without endangering his life, said health officer may cause such persons in the vicinity to be removed as are in danger of contracting the disease. Any person suffering from any contagious disease, and requiring to be treated at public expense, may, at the discretion of said health officer, be removed to the public hospital for treatment. HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 13 All hospitals and dispensaries in the District of Columbia are required to provide isolation wards or rooms. The public are not so fortunate in most places. In my city we have a " Sanitary Hospital," and it is opened only when smallpox or a serious epidemic of some other communicable disease occurs. Recently we had leprosy there. Such a hospital is not expensive to build and the cost of maintenance is not very great. State boards can demand of a community that they provide quarters for smallpox and other cases, and it is a serious emergency for a city or county to face these demands when they have made no provision for housing such cases. Our building is comfortable and good nursing and medical attendance is supplied, but the public seem to fear " the smallpox hospital " as, here, all cases must go there and no provision is made for classifying the cases socially or providing espe- cial accommodations. Cities following the plan we have adopted could well allow the well-to-do patient to provide private pay supervision, as in the District of Columbia. Hotels, hospitals, and public buildings, inclusive of apartment houses, are put to manifest loss and inconvenience when the municipality provides no place to which cases of communicable disease can be removed, and it impresses me that all places populous enough to have large hotel interests should make adequate provision in the way indicated. See the arti- cle upon Seaside Resorts, in Chapter VI. " Homes," asylums, and charitable institutions should provide an isola- tion ward or rooms, especially if children are housed in the building. Board- ing schools and colleges would save themselves great inconvenience and pos- sibly large losses, by having such an isolation ward or cottage. And yet this matter is much neglected, even at quarantine stations. Philadelphia re- cently docked a vessel filled with steerage passengers who had been exposed to smallpox on board, and yet the city and even the federal authorities there had no place large enough to detain so large a body of people. General hospitals frequently have cases of communicable disease de- velop therein, and there is a flurry at once as to what to do. Most general hospitals are not prepared for such contingencies. From what observation I have been able to make, it impresses me as best to erect a separate building for such isolation. I was visiting a hospital where a case of bubonic plague was brought in. Fortunately, it had an isolation building, and no excitement occurred either among the patients or in the community. Unfortunately for us, Harrisburg hospitals do not have sufficiently large grounds to erect such buildings. The annexed letter will show what we have to do when cases develop in the wards. Harrisburg Hospital Harrisburg, Pa., March 9, 1909. Thomas S. Blair, M.D., Dear Sir: As? you know, epidemics of scarlet fever and measles are running their courses in the Harrisburg Hospital. Subject to the approval of the State Depart- ment of Health, the second and third floors of the new Ward and Dispensary Building have been placed under quarantine. Patients who have been stricken with ihe diseases and patients who have been exposed are in the quarantined wards. 14 HYGIENE For the present the old male medical ward will be used for new female patients, and the old surgical ward for new m.ale patients. The private rooms are also available. Please do not admit any except accident cases or cases which require immediate attention and cannot be cared for at home. Please assure any paiients who can wait that we will admit them as soon as our quarantine shall be raised. We have taken vigorous measures, and we hope to be successful in stamping out the diseases promptly. Please discharge any patients under your care who can be cared for at home. The conditions imposed by the health department are as follows: private room patients may be discharged after antiseptic baths and after their clothes have been disinfected; ward patients may be discharged if they are immune from either of the diseases to which they have been exposed by reason of having had a previous attack of the disease. Some patients have been exposed to both diseases. These cannot be discharged unless they have had both scarlet fever and measles. We will depend on you to discharge any patients you may have, if they can possibly be cared for at home, and can stand being moved. We wish to have as much room as possible for new patients. Yours very sincerely, Henry B. McCormick, President Board of Aianagers, Harrishurg Hospital In the event of a case of smallpox or other dangerous communicable disease being discovered in a public building, closing the building during fumigation is necessary and the fumigation should be thorough. In this city, churches, schools, the mayor's office and the state library have all been closed for fumigation when any public danger was apprehended. Physi- cians' offices should come under the same category. The chapter upon dis- infection gives full directions for disinfection of small houses. Flats and apartment houses. — Much that has been said applies to this subdivision. In Paris and other European cities the question of the sanita- tion of apartments has been well worked out. The concierge and the gen- darmes are different quantities altogether from the American janitor and police. In France and Germany one expects to have his home supervised, but the American resents that sort of thing. Much can be done by having stringent building laws regulating the erection of flat, apartment, and tene- ment houses. Some of these buildings are so sumptuous that every possible sanitary advantage is supplied as a matter of course. Good tenements or " model tenements," as some merely good tenements are called, usually house a desirable class of people, and there is very little trouble as regards their sanitation. Ordinary prudence should demand that the owners of these buildings provide an isolation room or rooms. When an apartment house is provided with safe facilities for the isolated care of communicable disease, the occupants do not become alarmed and vacate the premises. The nurse or caretaker of the patient should live in the isolation quarters. When the house is of the character that will attract tenants capable of paying a trained nurse, this plan works out very well, but with people apt to nurse the members of their families, it does not do so well. Ordinary tenements so frequently are found in the slums that their sani- tation would naturally come under the chapter upon slums and town nuisances PARKING CONCEALING A THREE THOUSAND TON COAL PIT (behind bov) IDEAL APARTMENT HOUSES. Light, air, and a park for a front yard A STREET OF APARTMENT HOUSES, NEW YORK CITY HOTELS, LODGING HOUSES, PUBLIC BUILDINGS IS (q. v.). I am almost tempted to call the sanitation of this class of building " the attempted sanitation," but presume there are in existence " tenement houses " that are sanitary. I have never been so fortunate as to have seen one. Perhaps I may some day, but doubt very much if it is possible to house a large number of ignorant people under one roof and keep the place as it should be kept, unless it be a jail, a hospital, or an institution conducted by intelligent people. Even then, it is hard enough. I have interested myself somewhat in religious and charitable w^ork among the class of people who herd together. Herding together is a different thing from living together. Ignorant and careless people always herd. They always have done so and I presume they ever will. It takes a considerable degree of education and some considerable amount of sanitary and ethical sense as well for a large body of people to live together. Witness the army camps of all history, the religious communities of the middle ages, the puebloes and Aztec village buildings of the Southwest, and the various trials at digging canals. In this day, when we recognize the causes of tuberculosis and typhoid, it seems but one step further to realize that the " tenement house " of the past must go. It does not belong to the twentieth century, and cannot be made to fit in with the general scheme of things as advocated to-day. So long as people are kept in reeking wrecks and rotten rows, neither religion nor charity is able to reach any large number of them. As a nation we have no right to keep human beings in quarters not fit for cattle. AH municipalities should absolutely condemn such shacks as one sees in the slums. If they have not laws to do so they should promptly get them. Summer and resort hotels. — Under the last heading, " Rural Resorts," in Chapter VIII, the work being done by the New York board is described. While the final revision of this chapter was in progress, a later report came to hand showing that the work of the board has already been effective in many places. It is largely ignorance and thoughtlessness that is responsible for insanitary hotels and resorts. However, it is not all to be covered so charitably. If one goes out in a rowboat on Lake , so the report states, and looks out for the intakes and sewer outlets, he will want to filter the water he drinks there. There are places in the ( ) Islands no better. The ice supply of some of these hotels is of a dubious character, being privately cut from places not inspected at all. All of the state boards should issue a cir- cular of information for hotels. The privileges that may he safely allowed.- — The legal phases of this ques- tion have been discussed, but there are some medical ones that should have separate consideration. Probably a perfect quarantine has never existed. Little leaks will occur. When it comes to a partial quarantine of a building, these little leaks are apt to be numerous. As regards hotels, it is by far the safest plan to remove an infectious case from the building. If the case is isolated and treated in the building, every effort should be made to secure a trained nurse, even if the proprietor has to board her free. From the business point of view, if from no other, it will pay. It would be well to cut out the annunciator from the infected rooms because the servants like to get extra 16 HYGIENE fees and are very liable to connive with the patient or his indiscreet friends and various articles are spirited into and out of the rooms. Needless to say, they are not disinfected. The bar should be instructed to send nothing to the rooms without orders from the physician. The chambermaid is another loose cog in the mechanism, and she is apt to do even more harm than the " bell hop," because she is apt to be longer in the rooms and become con- taminated with dust, and she is more liable to handle clothing. The hotel laundry should not mingle the linen from these rooms with any other. Chil- dren in the building are apt to stray in, as is also tabby and the poodle, and they must all be watched. No one but the doctor should determine what things may be safely done. Conditions vary and the list of safe things varies in every concrete case. In general, hotels are a poor place to practice isolation. Apartment houses are a little safer, since the individual apartment is more like an individual home. Architects, in planning the better class of homes, nearly always make provision for an especially constructed suite of rooms for the reception of ill persons. Such rooms should be found in apart- ment houses, but even if they are not found, it is a comparatively easy matter to isolate a flat or suite of apartments. If there is not a private bath, great care must be exercised. Also cold-storage apartments for the use of several tenants should not be used to store anything that has been in the sickroom. The trunk room is a source of danger, and the physician should lay down stringent rules concerning the matter. There is often a pharmacy in the building and the patient sends there for ices and soda. Glasses and all uten- sils should be sterilized before returning them. Apartment houses with a common dining hall often send bottled milk to the sickroom. Such bottles should be sterilized before returning. Newspapers and magazines entering the rooms must not be loaned, but should be burned after reading. Send the cat or dog away and keep them away. Sending out suits to be pressed, sending out letters with children in the building, hanging blankets and clothing on a balcony where children play, sending down soiled clothing and dishes in the dumb waiter or elevator, sending waste paper and cigar stubs from the patient to the cellar to be burned when the janitor gets ready, these, and many other little matters should be watched. Cases in " tenement houses " spread unless the city sends a responsible party there with power to act. I never knew quarantine without a guard to amount to anything in a tenement. Perhaps others have had a more fortu- nate experience. I always try to keep my eyes open, and yet I have been in the room with smallpox cases, in a dark tenement, and did not know until afterwards that they were there. Allow no privileges at all in a tenement. The only safe way is to put the job right up to the authorities. Transients and vital statistics. — I have reported tuberculous cases that have remained in this city for a few days and then removed to some other place where it is likely they were also reported. Or, I may report a case, and it soon turns up at the tuberculosis dispensary or a hospital. This shows the necessity of giving the full name and address in all reports. With some physicians a large portion of their cases are transients. At my clinic I HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 17 report foreigners with unpronounceable names, and few of them stay here for a year. Many of them are doubtless reported from the next stopping place. I would suggest that all reports of chronic communicable disease state whether or not they are transient residents. In the general hospital here we treat many cases of typhoid that do not originate here. It is hardly fair to the city records for these cases to appear therein. Transients in hotels and lodging houses come under the same category. An Example of a Sanitary Hotel It is rather difficult to convey concrete teachings without a specific example, and this applies to sanitation with greater force than to most other subjects. There are so many sanitary hotels in this country that I found some difficulty in selecting one that appeared to me could be ethically used for our present purpose. Within the last few years several very modern and thoroughly sanitary hotels have been bidding for the patronage of wealthy people, and what I can see about them appears ideal, except that they have not been in operation long enough to have worked out fully a few problems older and probably more old-fashioned institutions have solved. It takes a steady and well-paying patronage to provide some things discriminating people now demand. Sanitary appliances are well in their way, but sanitary administration is better. Usually the place having call for the latter will install the former. Wishing to avoid any appearance of commercialism I have selected as an instance of sanitary hotel administration a hotel known to every one, and so much a part of the public life of New York city to remove any suspicion of any effort upon its part to secure free advertising or any commercialism or favoritism upon my part. The management of the Waldorf-Astoria has kindly supplied the fol- lowing data, and in presenting it I wish it understood that the description will fit, in essentials, many other good hotels. On the other hand, I know many expensive hotels that need to copy the example I give, and it is to be hoped that the instance will prompt physicians who read this to demand sanitation in all hotels. Plumbing. — The Waldorf-Astoria has upwards of one thousand bathrooms, which of necessity require a great deal of attention in the way of maintaining cleanli- ness, and keeping the marble slabs, base, and tiling, as well as the bathtubs themselves, and the nickel trimming polished. The expense of this is considerable, the plumbing feature costing about ;^20,000 or more per annum. All of the fixtures are of course thoroughly disinfected and the sewerage promptly disposed of. The hot water supply is ample at all hours of the day and night. All of the fixtures are " open work," thus insuring perfect cleanliness and freedom from the slightest accumulation of filth. In addition to the constant attention given the bathrooms by the help, they are regularly inspected by the floor authorities and the mechanical force. PTater Supply. — All water supply used in the hotel is carefully filtered. The consumption is about sixty-eight thousand cubic feet per day. rent 1 1 at I on. — There are in operation eighty-three motors, which distribute pure air to the different parts of the hotel. The motors vary in size from 5 H.P. to 125 H.P. 18 HYGIENE The intake air is brought from the top of the building and the exhaust is exhausted also at the top of the building. All intake air is screened and cooled by means of water while in transmission through the building, until it reaches its final destination. Heating. — The consumption of coal is about seventy tons per day. Ice plant. — The hotel manufactures and uses for ordinary purposes twenty tons of ice per day. In addition to this quantitj- the cold storage departments throughout the hotel consume about twenty-five tons additional, which is also manufactured in the hotel. The restaurants use between twelve and thirteen hundred carafes per day. Electricity and elevators. — The hotel generates all of the electric current required therein for a total number of thirty-eight thousand incandescent lamps, the electric grill in use in the South Cafe, and the special electrical appliances throughout the hotel. There are thirty-three elevators, of which about half the number are electric, the balance being hydraulic. Laundry. — The laundry turns out an average of seventy-five thousand pieces a day. Silver. — The silver department connected with the hotel repairs and replates an average of two hundred and fifty pieces per day, at a total cost of about $25,000 per annum. Fire pumps. — There are four fire pumps with a combined capacity of 3,433 gallons per minute, or 4,943,520 gallons per day. There are in addition between six and seven thousand fire appliances throughout the hotel. Cleaning. — This is largely done by pneumatic processes, while hangings and mattresses are sunned when of a character not injured thereby. Antiseptics are freely used in the routine cleaning of certain portions of the buildings and contents. Garbage disposal. — The garbage is kept in a room isolated from all food depart- ments of the hotel, and is removed every night. The removal is by private contract. The room in question is equipped with brine pipes, and the garbage is frozen in order to prevent decomposition. This garbage room is never used for any other purpose. Cooking. — All cooking is done in the basement and odors disposed of by means of air ducts supplied with exhaust fans which convey the air to the roof of the building. The kitchen is also supplied with fresh-air inlet ducts, equipped with supply fans. The kitchen floors are of marble and cement, and are scrubbed after each meal. Ample toilet and washroom facilities are provided for the kitchen help. No tuberculous help is employed. Food and drink. — Quality is the very best that can be procured regardless of cost. Various refrigerators at different temperatures for meats, butter, and eggs, fruit, vegetables, wines, liquors, etc., are cooled by private ice plant. Milk in cans is kept standing in iced-water tanks in a room used only for that purpose. Milk is bottled on the premises in another room which has been approved by the board of health of New York city. The entire milk supply is in charge of one man and is not accessible to any other employee. Certified milk in bottles is at all times available, and any particular brand or mark is supplied upon request. Ice cream is made on the premises with the most modern equipment in a perfectly sani- tary space with fresh outside air. All machines, cans, etc., are kept clean by a man employed for that purpose. Material used is the best, and all cream is sterilized. All wines, liquors, groceries, and other goods bought in original packages are required to conform with the pure food law. Oysters are purchased only from firms whose beds have been inspected and licensed by the board of health of New York city. " Inspected meat " is used, with the following exceptions. Baby lamb, suckling pigs, milk-fed poultry, prize mutton, and such specialties are sometimes procured surgeon's room, WALDORF-ASTORIA HOTEL ELEVATOR ENTRANCE TO REST ROOM FOR GUESTS WHO ARE ILL HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 19 from the private country estate of the proprietor and from some of the prominent " show farms " in the vicinity of the city. Inspection. — The hotel is inspected hourly from basement to roof night and day. There are five Nevp York city special officers in civilian dress in the service of the hotel, and betvi^een the hours of 6 a.m. and 1 a.m. two of these men are on duty on the main floor in each watch, four in all. The fifth man is assigned to see that order is pre- served on the upper floors. These five men have exactly the powers and authority vested in the regular police officers of the city of New York, and under agreement of employment with each of the help have the right to enter the rooms of employees at any time. In addition to these special officers there are eight night watchmen who report for duty at 7 o'clock p.m. These men are stationed on the diff'erent floors and keep a continuous watch throughout the night, reporting every hour to the main office, where their reports are recorded in a book kept for that purpose, and which is signed by them. Their duty ends at 6 o'clock a.m., at which time the day force reports for duty and takes charge for the day. The city assigns a number of uniformed police officers around the building whose duty it is to keep the sidewalks clear. In addition a mounted officer is stationed at the corner of Fifth Avenue and Thirty-third Street, and another at the corner of Fifth Avenue and Thirty-fourth Street. When special events take place in the hotel the city assigns extra officers because of the large number of people who attend these functions. Infection. — In cases of infectious diseases occurring in a hotel the law provides that the board of health be notified, and every means must be taken to isolate the patient. After the patient has recovered, the health officers take charge of fumigating and disinfecting the rooms and furnishings. Sanitary rules and employees. — The cooks are provided with clean white aprons and jackets every day, the kitchen girls with white aprons twice a day, AH other kitchen help are required to present themselves for duty every day with clean, washable jackets and trousers. Ample washroom facilities are provided, and uncleanliness of person or habits is not tolerated. Waiters are required to be clean shaven, to have their hair neatly combed and their hands and finger nails must be clean. They are inspected by the captains before being allowed to go on duty. Medical aid. — The medical department is in charge of a prominent physician who has a number of competent assistants, one or more of whom is immediately available at all hours of the day or night. A fully equipped surgeon's room is main- tained on the premises, where emergency cases can be attended to and ordinary opera- tions performed. This room is used by the medical staff" every day from 11 to 12 o'clock noon, for the purpose of giving medical aid to any of the hotel employees who require same. A system of health reports is kept in the assistant manager's office, supplied by the clerks in charge of each floor, who report daily the cases of illness, the name of the doctor in charge, nurse, if any, and the condition of the patient. All ailing guests are visited daily by a representative of the management to see that nothing is left undone to add to their comfort. Tobacco. — No smoking is allowed among employees while on duty. Animals. — Dogs are the only animals which the hotel is called upon to care for, and for these a kennel is provided in the basement, where every sanitary precaution is taken, and a competent man employed to care for the same. They are fed at regular intervals and in accordance with their general disposition and breed. 20 HYGIENE Automohiles. — All automobiles belonging to guests are sent to adjacent garages. The management also procures chauffeurs for guests desiring same, and furnishes copies of the municipal rules and regulations governing automobiling to out of town guests. Rules for guests, as to hygiene, etc., about the hotel. — The hotel is extremely solicitous of the health of its guests, and indefatigable in its attentions to those who are ill. Cases of illness of the guests are reported to the manager promptly, and assistance promptly extended, such as hot-water bottles, etc., kept on every floor. A physician is constantly in the house to attend to any emergency, or the guest can have his own physician or a specialist promptly summoned. Accidents are promptly attended to, whether to guests or employees, the hotel maintaining a room fitted up as a hospital operating room, with the latest apparatus. Major operations are occa- sionally performed in the patient's own room, the management preparing the room by removal of superfluous furniture, curtains, etc., and surgeons of national reputation have expressed themselves as satisfied that the patient's surroundings were as satis- factory as at a hospital especially designed for the purpose; while the room service is maintained better than in most of the hospital private pavilions, nurses being the best obtainable from the graduates from the best hospitals. Special attention is given to the preparation of nourishing broths or dainty dishes for the sick, by the chef. Among the great advantages to convalescents are the solariums on the roof in winter and the roof garden in summer. Public Buildings Specifications for public buildings. — The building regulations of many cities practically supply specifications in many particulars. Michigan and a few other states have allowed their state boards of health to define sanitary specifications for state buildings. While what is said in Chapter XX con- cerning heating, lighting, ventilation, plumbing, etc., applies here, yet cer- tain specifications particularly apply to large and public buildings. The fol- lowing is largely based upon the Michigan specifications. Heating Direct method not suitable since an insufficient supply of fresh air is obtained for rooms housing many persons. The " direct-indirect " method is unreliable, especially during high winds. The indirect method is preferable to both of the others. The " fan " method requires skilled help, but it is recommended for large assembly halls, laboratories, and some factories. Automatic temperature regulation is recommended. This is usually accomplished with electrical devices or by bypasses in the heating or ven- tilating pipes. Air supply should be taken from outside the building and be conveyed to the indirect radiators through air-tight metallic tubes made of galvanized sheet iron. The radiators should be in rooms with cement floors, with well- screened windows and tight doors. The rooms should be frequently cleaned and should not be used for storage. Brick flues may be used, but wooden construction is not recommended. HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 21 Fresh-air registers should not be placed in the floors of public buildings since dirt, sputum, and dust get into them. They should be not less than six feet above the floor and be placed in the wall. It is well to cover them with wire mesh to prevent persons from placing dirt and small objects in them. Vitiated-air registers should not be placed in the floor, as the air has to make two square turns in order to escape to the vertical flues. They should be in the walls and at the floor level. Summer ventilation is best accom- plished by open windows. If vitiated-air registers are placed in the ceiling, they interfere with the heating in the winter time. Vertical ventilating flues should not be placed in outside walls, since they chill to such an extent in cold weather as to reverse the draft. They are best placed in inside walls opposite windows. Ventilating flues should be suflEiciently large to effect changes of air equal to thirty-three and one third cubic feet per minute for each person, and fifty feet for each person in a hospital ward. In climates subject to great change, or where the difference between outside and inside temperature exceeds twenty-five degrees, it is well to place dampers in the flues, since the current is accelerated in cold weather, and the flues need to be partly shut off. The velocity of air in flues, in feet per minute, due to natural draft, with a difference of twenty-five degrees between the temperature of the outdoor air and of that in the flues. Height of flue in feet .... 10 20 30 40 50 70 90 125 Velocity of air 171 243 297 342 384 456 516 603 In practice it is well to allow a deduction of fifty per cent from this theoretical data, to provide for friction, turns in piping, and changes in direction. Determine the usual number of persons to occupy the room and the height of the vitiated-air flue, then divide the total amount of air which must be removed from the room every minute by the velocity shown for the given height of the flue. The quotient is the necessary area of the flue in square feet. To allow for space taken by the grills, the face plates of registers should have one third more area than the vertical flues. Improper methods of disposing of vitiated air are: (a) passing the vitiated air to the basement before it enters the main ventilating flue. To make this plan a success requires either a fire or a fan at the base of the flue, and this is expensive and apt to be neglected. The use of a fan is apt to bring the air from a basement, and such air is either dead or defiled, (b) Con- necting the vitiated-air flues of two or more rooms together or with a common ventilator in the attic, makes it necessary to have too many angles in the pipes or flues, resulting in cross-drafts, and the irregularities of weather con- ditions would interfere with the action of some of the flues, (c) Discharging vitiated air into the attic results in deranging the whole system of ventilation during the prevalence of high winds, (d) Openings from several rooms into a common vertical flue establishes cross-currents, and when the wind is high the leeward side nearly always fails to act. (e) Connecting many flues 22 HYGIENE with a main ventilating chamber in and running parallel to the ridge, without a cross partition in the ridge ventilator between each flue, is another plan deranged by winds, (f) If each vitiated-air flue is not extended through the roof, a few flues may be combined into one stack, but it is not well to limit the number of stacks on account of conserving architectural beauty. Conducting cool air from a hallway in a public building to be rewarmed results in a deterioration of the air supply, and the dust of a hallway (possibly infected) would be constantly agitated and would be distributed throughout the entire building. When a heating and ventilation system is made only partial, and drafts up the stairs and through transoms is depended upon, the whole scheme is apt to be deranged and be wasteful in the long run. (Read section by Mr. Snow, in Chapter XX.) Sewerage Read the section upon plumbing in Chapter XX. Public buildings demand emphasis upon certain features. Stoneware pipes should not be used under buildings. " Extra heavy" iron pipes, with caulked lead joints, must be used for sewers inside of and for a distance of a few feet outside of a public building. It is not advisable to connect tile subsoil drains with the sewer, as the subsoil is liable to contamination by sewage, and traps between the subsoil drains and the sewer are liable to become dry and allow the sewer gas to enter the building. Subsoil drains should discharge into a land drain, a ditch, a watercourse, or into a porous piece of land at some distance from the building. It is not advised to directly connect private sewers with the public sewer on account of sewer gas from the public sewer. A self-cleaning main trap should be placed in the sewer of the building, with fresh air and inspection openings at the grade and vertical soil and waste pipes extending above the roof, as described in Chapter XX. When several buildings of an institution are connected with a common private sewer, one main trap and air inlet may serve the purpose if well placed. No sewer should be ventilated through a down spout or rain conductor. Fresh-air openings and sewer inlets should not be close to the building. Catch basins and manholes are great filth an^esters, and only one catch basin should be erected for one building. A group of buildings may also get along very well with but one, if the residents or inmates are prevented from throwing all manner of filth and trash into the sewer. These devices should be as far from the buildings as is practicable. If there is a good ventilated main trap, and soil pipes are extended above the roof of all buildings, these devices may be covered with a metal lid instead of with grating. Soil and waste pipes should not be placed within ventilating flues, as gas may escape and proper repair is almost impossible. Bell traps are not approved for public buildings by the sanitary authori- ties because they have very shallow water seals and are unsealed at the fre- XEW LXlOX DEPOT, \\'ASlIIX(JTOX, D.C. A LARGE HEATING AND POWER PLANT UNDER A PAVED AREA A PUBLIC BUILDING MAROONED. PHILADELPHIA CITY HALL HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 23 quent intervals when it is necessary to raise the covers. The Michigan board says they " should be relegated to the scrap heap at the earliest opportunity." When toilet rooms are placed in a basement the ceiling above should be impervious to air, and staircases should not open from them directly to the floor above. Water closets should never be placed in a room unless it have at least one window opening to the outside air. When the clean-out pipe of a water tank serves also as the overflow and is trapped below the tank, unless the tank overflows frequently, evaporation lowers the seal and allows the escape of gas. The overflow of a rain-water cistern should be trapped, but in a dry season evaporation may break that seal too. Consequently, these waste and overflow pipes should not discharge directly into sewers. The same can be said as to waste pipes from refrigera- tors. Some boards disapprove of the T fitting for the branches in the horizon- tal sewer, and recommend a T-Y or a Y fitting and one eighth bend. By- passes for septic tanks are condemned, as is also the discharge of sludge from the tank. Office buildings and infectious cases therein. — Probably there is no more sanitary building than is the modern concrete and iron office building. However, in their construction several things should be remembered from the sanitary point of viev/. The architect should first Idarn the depth of the existing sewer and its capacity and present load. These huge concrete build- ings require deep foundations. I have seen a foundation go down twenty feet below the sub-basement and be twenty-two feet wide at the base. The sub-basement of such a building may be below the level of the existing sewer, or the sewer may be too small to serve the demands made upon it. It is very frequently the case that an entirely new sewer may be needed, and instances of office buildings smelling of sewer gas may be due to the owner refusing to make adequate sewer arrangement. The base of the elevator shaft may be even below the floor of the sub-basement, especially if an " air cushion " safety elevator is used. The pit for such a shaft should be absolutely water- proof, as water collecting or seeping into such a pit becomes very foul and may contaminate the air of a large portion of the building. No sweepings or other filth should be allowed in this pit, and it should be frequently cleaned. The practice of dropping the elevator just to show how well the air cushion works should be abandoned. While it may not break the eggs therein, it surely does raise a dreadful cloud of dust that permeates more or less nearly the whole building. Large vaults are often constructed in public buildings and especially in banking houses. They should be based upon concrete, but it is often noticed that the floor and interior of these vaults become damp and unhealthy. If the concrete base is topped with slate, no moisture can reach the floor. An electric fan should be kept going in the vault to provide ventilation. Large office buildings are usually erected upon very valuable land and the heating plant of the building and the coal and ashes must be all in the cellar. The ideal way to heat them is from a central station steam-heating plant. With 24 HYGIENE such heating I have some experience. The steam pipe is run in from the street and the volume of steam admitted into the system is controlled by a valve and lever arm upon which are placed adjustable weights. The radia- tors may be arranged most any way demanded so there is a good return cir- culation of the condensation which is trapped off into the sewer. (See Chapter XX.) Little attention is required for such a system. It may be kept uniform by an electric thermostat, a spring-driven mechanism turning the steam on and off. This must be kept wound and the battery cells charged, the trap must be watched that it does not blow out its seal, and the radiators must be watched that they do not fill up with air or water. One must give about five minutes a day to regulating and caring for such an installation. It is a sani- tary way to heat an office building. Generators or boilers in the cellar may or may not be sanitary depending upon the man in charge. Wetting down hot ashes and handling dry ones in such a manner as to avoid vitiating the air of the building is something of an art. If some of the gentlemen with luxurious offices went to the cellar of some of the office buildings, they would find that " Mike " kept his little realm according to his own code of sanitation. It is the undergound parts of these places that need better sanitation. Hand rails, door knobs, and other parts of the inside construction handled by the public should be of a character readily cleansed and of material not injured by antiseptic solutions. Plumbing should be ideal, since so many persons spend so many hours in these buildings. (See Chapter XX and the portion of this chapter devoted to specifications.) Lighting is an important matter. I have an office building in mind where the architect made the mistake of placing the angled skylight at the north side of the building when he could just as well face it south, where he would have secured more light. He also provided no court or area, since the owner would not sacrifice the space, calculating that he would have more offices to rent if he omitted an area. The consequence is that one half of the building is constantly idle, and the tenants remaining are awaiting vacancies in office buildings provided with good daylight. The time has come that dark offices will not rent, for business men are going in for sanitary surroundings. It will pay the owners of office buildings to provide a room for the espe- cial use of women and where they may eat lunches, A smoking and lunch room for the men and a dark room for the use of architects and others who do photographic work, a rest room for persons who become ill, and a small office for a public stenographer and notary and a few volumes therein of re- ference and information needed in offices. The general hygiene of office buildings will be considered at the end of this chapter. Infectious cases in office buildings should be removed and the room subject to the contagium should be disinfected and closed from the public until after prolonged ventilation. It should be the especial care of the sanitary authorities to trace up the case and disinfect any of the rooms or offices re- quiring it. Office buildings have their own weaknesses from the sanitary point of view, as so many exposed papers of value are difficult of disinfection HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 25 and the books cannot be destroyed. The office cat should be banished. Adding machines, typewriters, and other office appliances are not readily disinfected. It is surpiising how much dirt accumulates upon the keys and other portions of machinery coming in contact with the fingers. Careful cleaning with ammonia will remove finger marks, but care should be used not to spoil the paint. Telephone receivers and transmitters, speaking tubes, various recording and time mechanisms, and numerous small articles apt to be handled by the sick man, should all be washed with anti- septic solutions. "The large commercial buildings and their sanitation. — This class of structures are subject to the general rules, but different trades and lines of business require of the sanitary official a large degree of initiative in deciding what to do in specific instances. Fortunately, most of the persons visiting these buildings do not remain long enough to leave behind them any danger- ous elements of disease except sputum. The laws governing the erection of buildings in certain cities provide specifically as to the specifications of this class of buildings. The points cov- ered by law refer largel)/ to the thickness of walls and the method of their con- struction, piers, and other supports, floors and the weight to be placed upon them, roof construction, when metal construction must be used, the placing of fire escapes, the width of stairways, and the other factors tending to reduce the fire risk and make exit safe. Plumbing and other city regulations apply to them, and the general trend of these laws are excellent. However, the building experts are a little apt to lay the emphasis upon height, to the exclu- sion of other equally important matters. Reference was made under hotels to the fact that they may be more carelessly constructed in Harrisburg than may a hospital. Strange to say, the matter is decided by height and that is a relic of the time when elevators and fire escapes were almost unknown and the element of mere height was more of a potential danger than it is to-day. How- ever, our law upon certain buildings says: Section IS. Every building hereafter erected to be used as a hotel or a school- house, the height of which exceeds sixty feet, and every building hereafter erected or altered to be used as a hospital, asylum, or institution for the treatment of persons, the height of which exceeds forty-five feet, and every other building, the height of which exceeds seventy-five feet, except grain elevators and buildings for which specifi- cations and plans have been heretofore submitted to and approved by the proper authorities, shall be built fireproof, etc. That allows a hotel to be a fire trap provided it is 59 feet and 11 inches high, and the temptation is to build them no higher. A department store may be 74 feet and 11 inches high and be a tinder box. But a hospital 45 feet high must be what a hotel or a department store should be even if only 30 feet in height. The regulations of most of the eastern cities are on a par with this, just because of precedent and the effort to make old laws fit new conditions. Boards of health need to take up such matters and secure modern provisions. Commercial buildings are a difficult proposition as to fire hazard, and everything is made to bend to the reduction of that hazard. What is regarded 26 HYGIENE as mere sanitation is apt to be pushed aside. The great fire in Bahimore started in a store, and as soon as the roof fell in the brands started fires in- numerable. I have seen many stores burn, and it impresses me that the building laws are queerly drawn as regards them. If a big store full of goods takes fire, the interior is usually gutted, despite all the fire department can do. If the automatic sprinkler system were compulsory few of these fires would get beyond control. As it impresses me, commercial and more particularly mercantile establishments and warehouses should be housed in buildings with very strong walls not liable to be thrown down by fire, but the most impor- tant matter appears to me to be the fact that the roof is almost always the weak place, falls in, and then things go with a " whoof." Strong walls with a roof made of metal and clay tiling would keep together even if rendered use- less by fire. The important thing is, it would not be so liable to spread. I -was taken through an " absolutely fireproof " department store in Pittsburg, and next week saw it simply melt and crumble to a twisted mass of metal and lime. The facts were, that a fire in adjoining buildings was so hot that it caused expansion of the metal in the big store, and the building wrecked itself and its fine marble was baked to lime. The progress of the fire was stopped by an ordinary brick wall. Theaters make bad fires, as the laws require that the roof over the stage be so arranged that burning a hempen twine opens a skylight. The idea is to dispose of heat, smoke, and gases, so as to save the audience, and that is all well enough, but I saw a theater burn after midnight and it surely was " whoof " two minutes after the fire reached the stage. I noticed brands next morning a mile and a quarter away, and only a snow saved millions of dollars' loss. It seems to me that stores and theaters could be so constructed that great columns of fire need never twist out of them and start a cyclone of the devas- tating element. A brick wall will stand fire better than will the structural iron frame veneered over with stone and filled in between with brick. Heavy brick walls with the iron inside do not throw themselves down when heated. Neither does concrete. The so-called " slow burning " floors are all that is necessary so far as saving life is concerned. We could save im- mensely in cost of construction if we abandoned the idea that our American methods really made a building fireproof, and if we would simply think for a moment we would see that the greater part of the blaze results from the inflam- mable merchandise in stock. No amount of fireproofing will prevent goods from burning. The important point to my mind is, that // we did not waste so much money in structural fads there would be something left to make better provision for safety and for sanitation. In the South and in parts of the West commercial buildings are built altogether too much of wood, and fires are common. Grain elevators are made so immensely large as to hold quantities of grain we can ill aff^ord to lose, and every year we read of them going up in smoke. If a war came on and the enemy wanted to cripple us most efi'ectually, he would fire about a HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 2T hundred grain elevators and let us go hungry. It is a mystery to me why they are built as they are. As a fine illustration of construction, the new Wanamaker store in Phila- delphia favorably impressed me, and investigation convinced me that sanita- tion was further advanced there than in the majority of our larger mercantile establishments. I asked Mr. Joseph H. Appel of the store to furnish me with the sanitary data of the establishment. His paper upon the subject follows: The sanitary system of the Wanamaker store in Philadelphia consists in main- taining an adequate number of hygienically clean toilet rooms (containing washbasins, toilets, urinals, sinks, wastes, etc.), a supply of filtered water (cooled for drinking purposes), a splendid ventilating system, proper methods of cleaning and dusting the store, judicious use of disinfectants, and instruction of the employes in the observance of hygienic rules. The sanitary provision made in regard to toilet rooms, both for employees and customers, begins with the construction of these rooms. The toilet rooms are large,, well-ventilated compartments, the floors and partitions of which are marble, and the walls and ceilings marble and plaster. Natural ventilation is assisted by suction pipes which exhaust vitiated air. The floors, walls, and partitions are cleaned, and the toilets themselves are cleaned with antiseptic solutions many times a day. The toilets are of the most modern type, and very frequent flushings do not depend on the individual using them. Attendants who are constantly present see to it that this high degree of cleanliness is maintained. Stationary washstands, soap, and towels are supplied in each room. Number of toilet rooms and washbasins: EMPLOYEES Closets Men 54 Women 70 CUSTOMERS Men 31 Women 99 Ventilation. — The ventilating system of the basement, the basement mezzanine,, and the sub-basement, consists of air being removed by suction, while fresh air, which is washed pure, is pumped in, the air being completely changed every six minutes. The construction of the building, with the light shaft in the center, together with high ceilings and high and wide windows, permits a free and natural ventilation above these floors. The heating plant being entirely separate from the building is a factor in keeping the air clean and fresh. Thoroughly filtered water is supplied at frequent and convenient localities through- out the store. The water used for drinking purposes is cooled by refrigeration, and is in constant circulation through the pipes. The employees are instructed regarding personal and general cleanliness by means of literature placed in their hands by the management of the store. The medical director, who has charge of the general health, hygiene, and sani- tation of the employees, spends one half of each day in the store. inals Washbasins 34 45 47 21 15 61 28 HYGIENE Questions of sanitation and hygiene are presented each day, and individuals are instructed and advised. In addition to this, physical instruction is given by highly competent instructors and drill masters. The drills of the cadets (boys and girls) of the battalion, the outdoor life of the boys in camp, of the girls in camp, the field sports and athletic teams, are all im- portant factors in the high hygienic standard attained among the employees. Stores especially need regulation, since so many of them are found in slum districts and are no better than their surroundings. With many kinds of merchandise sanitation is not affected, but foods are a vital matter. The Ladies' Home Journal started a crusade against dirty groceries. The editor should inspect some of the stores conducted by foreigners. The reader can imagine the conditions. However, some of the most exclusive and elaborately finished confectionery stores in the country refuse to place their goods under glass or screens because, as explained to me by the proprietor of one of them, " Our wealthy patrons would think we feared they might help themselves free to an occasional bon-bon." I watched awhile and found the " wealthy patrons " were fully able to help themselves while fondly imagining the pro- prietor would not even it up on the semi-annual bill. The District of Colum- bia provides as follows, to protect food from contamination: Section 14. Every manager of a store, market, dairy, cafe, lunch room, or any other place in the District of Columbia, where a food or a beverage or confectionery or any similar article is manufactured or prepared for sale, stored for sale, offered for sale, or sold, shall cause it to be screened effectually, or effectually protected by power- driven fan or fans, so as to prevent flies and other insects from obtaining access to such food, beverage, confectionery, or other article, and shall keep such food, beverage, confectionery, or other article free from flies and other insects at all times. Any person violating the provisions of this regulation shall, upon conviction thereof, be punished by a fine of not more than twenty-five dollars for each and every such offense. This regulation shall take effect from and after the expiration of thirty days immediately following the date of its promulgation. Official copy furnished health department. By order: WM. TINDALL, Secretary Officially published in the Washington Herald, April 16, 1908. Market houses are a specialty here in Pennsylvania, and they are a wonder of wonders to Western friends I take especial pride in astonishing, for it takes a great deal to astonish the Westerner. But the Pennyslvania markets are a wonder, for we people eat everything ever heard of and then some we only know about ourselves. How the pure food laws would classify some of the " Dutch dishes " we buy " made aretty " is a mystery to me. So far as I can see, the pure food people never try, and yet our markets in the larger cities provide better produce than one is able to buy in the small towns adjacent to the farms. It must be good to sell at market, and what will not sell is peddled through the country and villages. People living in the small towns come here to market. Short weight and measure are common in the markets, as well as forestalling, but the produce is nearly always good. I HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 29 have seen markets in the South and they are fairly good, but have a less va- riety to sell and are not so well housed. In very few instances have I seen any effort to screen food exposed for sale in market houses. The stalls are not as clean as they should be, and the places are usually crowded, as the effort is made to place as many stalls in a small building as can possibly be accommo- dated. Most cities need legislation concerning their markets. It is unnecessary to enter at length into the vending of food here, as the chapter upon pure food and drugs covers the subject. Also, the hygiene of such commercial buildings will be covered under the last heading in this present chapter. Two classes of establishments may well be considered here, the barber shop, so commonly found in hotels, and the laundry. I have taken occasion to ask barbers their opinion of legislation governing their work, and all to whom I have spoken are either opposed, are ignorant of the dangers, or are indifferent to the matter. Barber shops. — Ever since 1903 Utah has had a board of examiners for barbers, consisting of tvv^o barbers and one physician, and the act is very full in its requirements, one section of which is here reproduced. Section 10. How certificate obtained. — Any person desiring to obtain a certifi- cate of registration under this act shall make application to said board therefor, and shall pay to the treasurer of said board an examination fee of five dollars, and shall present himself at the next regular meeting of the board for the examination of appli- cants, whereupon said board shall proceed to examine such person; and being satis- fied that he is above the age of sixteen years, of good, moral character, free from contagious or infectious diseases, that he had either studied the occupation for one year as an apprentice under a qualified practicing barber, or that he has studied the occupation in a barber school or schools as defined by this act for one year, or has practiced the occupation in another state for at least one year, and is possessed of a requisite skill in said occupation to properly perform all the duties thereof, including his ability in the preparation of tools, shaving, hair cutting, and all the duties and services incident thereto, his name shall then be entered by the board in the register hereinafter provided for, and a certificate of registration shall be issued to him authorizing him to practice said occupation in cities of the first and second class in this state; Provided, that whenever it appears that the applicant has acquired his knowledge of said occu- pation in a barber school, the board may subject him to an examination and withhold from him a certificate if it shall thus appear that he is not qualified to practice the said occupation. Licenses may be revoked upon conviction of crime, habitual drunk- enness, gross immorality, incompetence, and violation of the provisions of the law. Several other states have legislated upon the subject and, where well tried out, the barbers of the better class seem to approve the law. Some barbers in states having no laws upon the subject are reported as practically observing the usual requirements of such laws. The weak point in the sanitation of a barber shop is the strop upon which the razor is sharpened. There is no effective method for sterilizing these leather strops. 30 HYGIENE The regulations governing shops vary somewhat, but those of the District of Columbia are as full as any that have come into my hands. They are here reproduced : Executive Office Commissioners of the District of Columbia Washington, May 28, 1906 Ordered: That the health ordinances of the District of Columbia be, and they are hereby, amended by adding thereto the following: Regulations for the control of barber shops in the District of Columbia. 1. Every manager of a barber shop that is in operation at the time of the pro- mulgation of these regulations shall, on or before September 1, 1906, register his full name and the location of said shop in a book to be kept in the health office for that purpose; and every manager of a barber shop that is first opened for business after the promulgation of these regulations shall within five days after the opening of said shop register in like manner. In event of a change in the manager or in the location of any barber shop aforesaid, the manager of said shop shall call at the health office within five days after such change takes place and make a corresponding entry in the register. 2. The owner and the manager of any barbershop, and each of them, shall equip said shop and keep said shop equipped with running hot and cold water and with all such appliances, furnishings, and materials as may be necessary to enable persons em- ployed in and about said shop to com.ply with the requirements of these regulations. 3. No owner and no manager of a barber shop shall knowingly permit any person suffering from a communicable skin disease or from a venereal disease to act as a barber in said shop. 4. No person who to his own knowledge is suffering from a communicable disease or from a venereal disease shall act as a barber. 5. Every manager of a barber shop shall keep said shop and all furniture, tools, appliances, and other equipments used therein at all times in a cleanly condition. 6. Every manager of a barber shop shall cause all combs, hair brushes, hair dusters, and analogous articles to be washed thoroughly at frequent intervals, and to be kept clean at all times, and shall cause all mugs, shaving brushes, razors, shears, scissors, clippers, and tweezers to be sterilized from time to time as hereinafter provided. 7. No barber shall use for the service of any customer a comb, hairbrush, hair duster or any analogous article that is not thoroughly clean, nor any mug, shaving brush, razor, shears, scissors, clippers, or tweezers that are not thoroughly clean, or that have not been sterilized since last used. 8. Every barber immediately after using a mug, shaving brush, razor, scissors, shears, clippers, or tweezers for the service of any person, shall sterilize the same by immersing them in boiling water for not less than a minute or, in the case of razors, scissors, shears, and tweezers, by immersing them for not less than ten minutes in a five per cent aqueous solution of carbolic acid, or in alcohol of a strength not less than sixty-five per cent. 9. No barber shall use for the service of a customer any towel or wash cloth that has not been boiled and laundered since last used. 10. Every barber shall cleanse his hands thoroughly immediately before serving each customer. HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 31 11.^ No barber shall, to stop the flow of blood, use alum or other material unless the same be used as a powder or liquid, and applied on a clean towel or in a similar manner. 12. No barber shall use a powder pufF, a sponge, or a finger bowl for or in the service of a customer. 13. No barber shall permit any person to use the head rest of any barber's chair under his control until after the head rest had been covered with a towel that has been washed since having been used before, or by clean, new paper. 14. No barber shall shave any person when the surface to be shaved is inflamed or broken out, or contains pus, unless such person be provided with a cup and lather brush for his individual use. 15. No barber shall undertake to treat any disease of the skin. 16. No person shall use a barber shop as a dormitory, nor shall any owner or any manager of a barber shop permit said shop to be so used. 17. Any person violating any of the provisions of these regulations shall, upon conviction thereof, be fined not more than twenty-five dollars, 18. The owner and the manager of any barber shop, and each of them, shall keep a copy of these regulations, to be furnished by the health officer, posted in said shop for the information and guidance of persons working or employed therein. 19. The word " barber " as used in these regulations means any person who shaves or trims the beard, or cuts or dresses the hair of any other person for pay, and includes " barbers' apprentices " and shop boys. The word " manager " means any person having for the time being control of the premises and of persons working or employed therein. By order: WILLIAM TINDALL, Secretary Officially published in the Washington Times, June 1, 1906. Laundries. — Establishments with modern machinery are usually in a fair sanitary condition. The buildings in which some of them do business are far from sanitary, and the constant exposure to steam is not conducive to health in the operatives. So far as the patron is concerned his linen usually comes back quite sterile, since the washer is run at practically boiling tem- perature, the mangle or hand iron is very hot, and the methods of drying are usually by centrifugal machine or by superheated steam or drying closet kept very clean. The danger is from laundries doing hand work. The Chinese laundries vary much according to the character of the patronage. The average Chinaman " aims to please " and is very quick to respond to demands necessary to achieve the American dollar. The " wash lady " is the real offender and not always by choice. These women work hard for a living and often must, perforce of untoward environment, do their washing and drying in places wretched enough and not conducive to sanitary laundry work. However, so long as no contagious disease exists upon the premises, the danger is slight. There should be a registration of these small laundries as per the following: 32 HYGIENE Commissioners of the District of Columbia HEALTH DEPARTMENT Regulation Requiring the Registration of Laundries That every person who commonly launders for pay on the premises which he or she occupies, the clothing, or the sheets, pillow cases, table cloths, napkins, or other similar articles, belonging to any other person or persons, shall report that fact to the health officer in writing within thirty days after this regulation takes effect, giving his or her name and the location of his or her premises, and the number of person or families living independently of one another whom he or she serves, if less than ten in number; and thereafter every person laundering as aforesaid shall report in like manner his or her name, and the location of his or her premises, and the number of persons or families whom he or she serves, within five days after the beginning of his or her occupancy of such premises and the use thereof for the purposes aforesaid. Any person violating any of the provisions of this regulation shall, upon conviction thereof, be punished by a fine of not more than twenty-five dollars. Order of Commissioners of July 22, 1908, as amended by order of August 7, 1908 Churches and schools. — Chapter III, upon " Schools and Colleges," as well as Chapter XVIII, upon " Disinfection," give so much data upon school sanitation that little need be said upon the matter here. The construction of school buildings is being carefully studied, and the death by fire of a large number of children in a school building has stimulated the matter of school safety. Stairs and exits of proper construction and a constantly used fire drill will almost always prevent loss of life except by explosion. Too many school buildings have wooden ceilings and construction so full of cracks and joints that adequate disinfection is almost impossible. Every schoolroom should be provided with artificial light for use during cloudy weather. Need- less to say, the plumbing and the drinking vessels should be above reproach. The specifications in the earlier portion of this chapter and the plumbing regulations appearing in Chapter XX, as well as the remarks upon the hygiene of large buildings near the close of this chapter, all apply to schools. It was not so very long ago that the peculiar warped ideas of the then dominant theology stood directly in the way of church sanitation, but men and ideas of larger caliber have banished the prejudice against heating a church, properly furnishing them, and the use of unfermented wine and individual cups at the sacrament. It is now generally recognized that churches and Sabbath schools may spread contagion, and they are rapidly coming under regulation. However, the church schools (probably excepting parochial schools) are not sufficiently careful to exclude children from families under quarantine. I know very well that children with whooping cough and the milder infectious diseases often are not excluded. Church officials are not wholly to blame, as they may not be notified of disease in their families. There should be a space in report cards giving the names of the day and Sabbath schools attended by the patient and members of the household involved in the report. Superintendents of all Sabbath schools should be HOTELS, LODGING HOUSES, PUBLIC BUILDINGS ^3 notified of such cases by the local health board. In some places this is done. Churches are very hard to disinfect. The size and height of the auditorium and the many openings for ventilation and ceiling lights, as well as the large number of Bibles and hymn books in racks, all make the practical difficulties very great. Formaldehyde generators have been used, but they do not liber- ate the gas fast enough to attain sufficient concentration before most of it escapes. Probably the best method consists in filling the building v^ith steam and then touching off^ at once a dozen milk pails charged according to direc- tions for the formalin-permanganate method described in Chapter XVIII. The persons emptying the formalin upon the permanganate must have a pre- arranged signal for that act and must leave the room on the run. Sufficient chemicals to do a thorough job cost quite a sum, and the gas is liable to escape so soon that additional precautions should be taken, consisting of an elaborate cleaning with bichloride solution. Books had better be taken into a small room, strung upon cords or wires, and subjected to full formalin per- manganate disinfection. In a small and tight room the gas will not escape so readily. Opera houses. — The writer has been looking for an opera house or theater that is ideal, from the hygienic point of view, and has not found it thus far. Many theaters are all right from the standpoint of the audience, but the actor has a different story to tell. The larger cities have building laws requiring theaters and opera houses to be of fireproof construction and with fireproof division walls, doors, properties, curtain, stairways, and all scenery that can be made so. These regulations call for fire escapes of the best pattern, and every precaution to empty the building of smoke and to prevent the spread of fire is defined in the rules. Lighting and ventilation is regulated and automatic sprinklers must be freely installed at all points of danger. Some smaller cities, like Harrisburg, have copied these regulations verbatim et llteratum, and because land does not cost so much have erected theaters in advance of the run of the large city playhouses. Aside from defec- tive ventilation and drafts the audience is safe and comfortable in buildings constructed along these modern lines unless there are three tiers above the main floor, when the upper tiers become too warm for comfort and often the air is vitiated near the ceiling. Little could be added to better provide for the safety of the audience In the new opera houses of the cities with adequate building laws that are enforced. But many theaters are presenting their attractions in old buildings patched up to cover the letter of the law. Some of the more celebrated theaters in our larger cities are gilded shells. It is time the public refused to patronize these places. Procure a copy of the building laws of your city, and you will probably be amazed at the require- ments that are gradually allowed to become dead letters. However, matters theatrical are improving, and It will not be many years before the poorly constructed houses will be a thing of the past. Actors and small amusement halls are considered in Chapter VI, but It is incumbent upon me here to say that the dressing rooms and accommoda- 34 HYGIENE tions for the talent employed in the large theaters is almost if not quite uni- versally inadequate and insanitary. These quarters are adequate for a small company, but when a grand opera company or a spectacular attraction or a comic opera with a large chorus tries to make up for their acts, with twenty or thirty people to a room, it is no wonder if an occasional actor forgets the amenities of civilized society and acts outside as he is compelled to do in his dressing room. Putting the whole menagerie into one cage is about as edi- fying to them as it is to ladies and gentlemen who happen to be theatrical people to be jammed together in a way the lower animals would resent. I practiced medicine for eight years next door to a theater, and can assure my readers that the rank and file of theatrical talent are ladies and gentlemen compelled to fight hard against the common impression of their depravity, and hustled along and crowded regardless of the sensitive feelings outraged daily by what they have to endure to hold their jobs. They need to apply union rules and demand that they be given better accommodations and enforce it by refusing to act in any new opera house failing to supply them. Industrial establishments. — This class of buildings might well be dis- cussed here, but as Chapter XXII, upon " Public Works and Corporations," treats of so many industries and occupation diseases, the whole may just as well be grouped together in the later chapter. Hygiene and disinfection of large buddings. — Disinfection is included here merely to afford opportunity to refer to the chapter upon disinfection, the one upon schools and colleges, that upon local boards of health, and the heading " Churches and Schools " in this chapter. Full data regarding disinfection can be found in these places. As to the hygiene of large buildings, we will not repeat here the data given in discussing schools, colleges, hospitals, sanitoria, hotels, penal in- stitutions, etc. Some general rules onl} will be given as a mere index. All premises must be drained, cisterns and water containers screened, proper lighting and ventilation supplied, good water secured, be swept daily when few persons are in the building, dusted ditto, floor scrubbed once a week, signs must be posted prohibiting spitting except into cuspidors cleaned daily and containing six ounces disinfecting solution when in use. All plumbing must be good and kept clean. Tuberculous employees must be given work not bringing them into intimate contact with others. Windows should be screened, especially in hospitals. No burlap, cocoa matting, or sacking cloth may be used for floor covering, as they cannot be adequately disinfected. Hospitals should disinfect rooms regularly every three months and immediately after the recovery of infectious diseases. AU stairs, corridors, etc., should be scrubbed with antiseptic solution every few days or scrubbed after sprinkling with a solution. Toilet rooms should be scrubbed daily. Hotels and restaurants should take especial care of the ice box or re- frigerator; they should be kept free from rats, garbage should be carefully handled, and a grease trap should be provided. A MODEL SANITARY OFFICE BUILDING Exterior and central skylighted court, The Larkin Co., Administration, Building, Buffalo, N. Y. HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 35 Finally, nearly everything in this book applies to the hygiene of some kind of public building or to the comfort and wellbeing of the inmates. A Sanitary Office Building While the present writer has found many large office buildings models in arrangement and kept scrupulously clean, the reverse is niore common than might be anticipated. In the larger cities and in offices largely visited by the public, as well as in large corporation offices, conditions are usually good, but in isolated places or those closed to the public there is less incentive to erect and to properly maintain modern and sanitary construction and appli- ances. Nevertheless, I have visited so many creditable office buildings that I was at a loss to select one to illustrate the points already outlined as neces- sary for hygienic office work. While in Buffalo, N. Y., I found opportunity to visit the Larkin Company's factories, a series of large structures, with fifty acres of floor space, and where I mistakenly supposed they made nothing but soap. Across the street therefrom I noted a tall, massive building in the midst of a pretty lawn. I confess it never occurred to me that it might be an office made after twentieth-century plans, but such it was. The Larkin Company claims it is the finest and most complete private office building in the world. Certainly it is by far the most sanitary one it has ever been my pleasure to study, and next to the new office building of the Capitol at Wash- ington the most up to date structure I have found filled with desks. By courtesy of the Larkin Company, the following description and illustrations are given. It is true there are public or governmental office buildings with a much more ornate interior, but I commend for imitation the sanitary features of the Larkin offices. The Larkin Company has paid particular attention to housing its employees in healthful, pleasant surroundings. The administration building has capacity for eighteen hundred workers. Viewed from the outside, the building is massive and austere; the interior is in direct contrast. It is light in color and restful in effect. A great, skylighted central court extends upward from the first floor to the roof. It admits an abundance of daylight to all parts of the five floors. The windows are hermetically sealed with double glass, so that smoke, dust, and noise are excluded. Fresh air is drawn in at the roof, forced to the basement, and washed by passing through a sheet of water sprays which remove ninety-eight per cent of the dirt, dust, and impurities. The spraying reduces the temperatures of the air in the summer. In the winter the air is heated. Then it is circulated throughout the building and exhausted from beneath the great skylight. The building is absolutely fireproof. Window frames, desks, chairs, and filing cabinets are of metal. The flooring and stairways are of a fireproof composition known as magnesite. As much attention was given to providing an office that could be kept clean and sanitary as to providing a place in which business could be trans- acted conveniently. Wherever possible, partitions are free of the floor; the toilet closets and their enclosures are arranged so, and with few horizontal joints anywhere in which dirt may lodge. The metal lockers and metal desks have metal bases that touch the floor at intervals only. The chairs are swung free of the floor onto the desk legs. 36 HYGIENE The main building contains five floors (six, including the basement). Four floors and part of the basement are given over to business. The top floor contains assembly hall, kitchens, and the restaurant in which the employees are fed at cost prices. The roof is a recreation ground with conservatories and tiled promenade. An annex to the main structure contains rest rooms, lounging rooms, toilet and bathrooms, and quarters for the trained nurse who is on duty at every business session. Employees have the privilege of consulting the nurse and using the rest rooms when indisposed. Those who are unable to report for work are visited, and those who need help receive it. The Larkin Company administers its welfare work on the plan of helping those who help themselves; it does not essay to be a father and a mother to its employees. An educational offer makes it possible for any employee who is a student in a public class of instruction to be reimbursed for tuition and expenses by attaining a standing of seventy-five per cent or more in work, and ninety per cent or more in attendance. The company also refunds to employees the cost of books purchased and twice read, of which the purchasers write brief synopses which show thorough reading. The business sessions are from 8 to 12 and 1 to 5 daily, with Saturday half holidays from June to September. A department for employees' savings that pa)'s five per cent interest, compounded quarterly, is maintained for the employees, and there is a sick benefit association in which membership is voluntary. The New Union Station, Washington, D. C. The Union Station is situated at the northern edge of the Capitol Hill terrace, the natural terrace having been artificially extended to the north prior to the erection of the edifice. A large plaza occupies the space south of the station, the foundation of which is higher, and the building itself is at a considerable distance from any structure in this section of the city. By reason of this elevation and the surrounding open space, the air is less vitiated and breezes from all directions are more frequent than could otherwise occur in the heart of the city. A high vaulted arcade occupies to a considerable elevation three sides of the main structure, the great concourse (the largest in the world) which might be considered an exaggerated arcade occupies the remaining side at the north. The north side of the concourse is open at all times. This arrange- ment of arcades permits the free circulation of air in all directions. The high vaulted main waiting room occupies to a great extent the cen- tral part of the main structure, communicating by numerous large doorways and windows with the concourse and with the east and south arcades. The method of heating this room is unique. The air is drawn in near the main entrance through two large shafts, and passes between the sides of a series of vertical heated pipes, then through a large mesh cylinder revolving above a vat of w^ater, which submerges the lower portion of the cylinder; dust and other particles floating in the air are thus caught, and the air cleaned to this extent passes from the cylinder to another chamber w-here it is superheated and forced into the main waiting room through registers at either extremity of each bench. LARGE OFFICE, LARKIN CO., ADMINISTRATION BUILDING READING ROOM FOR EMPLOYEES; EIGHTEEN HUNDRED IN THE OFFICES Many firms are doing welfare work such as this HOTELS, LODGING HOUSES, PUBLIC BUILDINGS 37 An unusually large number of doors and windows assist in the ventilation of the building, which process is completed by numerous air shafts which extend from the main floor to a distance above the roof; a fan operates near the top of each shaft. These air shafts and fans are found to be of particular value, especially in improving the ventilation of the restaurants and kitchen. All offices are cleaned by the vacuum process, and the cars, toilet rooms, cuspidors, and other vessels about the station are disinfected. The shops and roundhouses are at a great distance from the station, which is used only for passenger service; no freight trains pass near or stop at the edifice. The system of plumbing and sewerage meets the most advanced sanitary requirements. Chapter III SCHOOL INSPECTION AND COLLEGE SANITATION* A practical presentation of the duties of the school medical inspector and the school nurse in both the large and the small city — Exclusion of infectious cases, the tuberculous teacher, defectives and degenerates, and other problems — Sanitation of buildings — The tobacco problem — The hygiene of athletic sports — Sexual and venereal instruction for young men in college — College training in sanitation — Nurses' training schools. MEDICAL inspection of school children, while comparatively an innovation, is nov^ permanently established in over two hundred cities throughout the United States, and will probably soon be compulsory in most states. It comprises three distinct objects, viz. (1) the recognition and isolation of all pupils affected with any communicable disease. This is accomplished by daily examination. (2) Routine examination for the pur- pose of detecting any deficiencies that may retard the pupil in school work or hinder proper physical growth. (3) Examination of the schools as to hy- giene and sanitary condition of the premises. Two working systems of medical inspection are made use of; one in which all three previously named elements are employed and another in which, while all are kept in view, only the second or routine examination is properly carried into effect, the others being reached only incidentally. The ideal system is naturally the first, where all objects are attained, but this is possible only in a large city or where the health officers are willing to incur the necessary expense. An attempt will be made to formulate a correct working plan for the two systems, taking that adapted for the smaller city first. One physician, devoting from one to two hours each school day and as- sisted by one nurse, can take care of from six to eight thousand pupils during an ordinary school year. The work may be done more thoroughly and very much better results may be attained by having two nurses. So many requests have come to our school board for sets of the blanks used here that the entire set is reproduced at the end of this section. Suffice it to say that these blanks were not devised until after those in use in many cities were studied, and they have only recently reached their perfected form after due trial of varying features. They have proven very satisfactory. The office work of school inspection should be done at the general offices of the school board, so that records, names, and addresses are available. The nurse will then prepare cards for a special schoolroom, filling Form M, 1 — 1. This makes a permanent record of data, as shown by the card, and usually cards are prepared for every pupil in the building. In making the initial examination one of two methods may be used, the first to have all of the pupils in a building examined in one vacant room in groups of six, or to examine in the individual schoolrooms. After trying both *By Chas. S. Rebuck, M.D., and the Editor. SCHOOL INSPECTION AND COLLEGE SANITATION 39 methods, the latter plan has been found preferable here. The examiner should stand with his back to a window and at twenty feet distance is placed the card for eye tests. Be sure the distance is measured. All pupils above the first year use Snellin's E Card. Smaller children use a number card, such as is used for the illiterate. Examinations of the mouth and throat make individual wooden tongue depressors imperative, and the teachers must be instructed to have them promptly destroyed. Towels must also be sup- plied for the examiner. The nurse calls out, from the previously prepared cards, the names of the children in order, and they pass before the examiner, who notes quickly the state of nutrition, the condition of the cervical glands, any deformity of limbs or spine, skin eruptions upon exposed portions of the body, and any characteristic abnormality. Then with the wooden tongue depressor the conditions of the teeth and throat are noted, as well as the tonsils and the presence or absence of post-nasal discharges. This is fol- lowed by an examination of the heart and lungs, superficially noting all cases except those presenting valvular lesions or lung troubles of moment. With the child's back to the window the vision is tested, each eye being tested separately by holding a card over the other. Much time can be saved by having the teacher point to the letters upon the eye card. If the child can see distinctly all the characters or letters in the |^ and |^ line with each eye, and there is no visible strabismus, vision is considered normal. Finally the acuteness of hearing is tested by having the child close the eyes and testing each ear separately by holding a watch at a distance of about three feet. Any defect found is called to the nurse by its proper number according to the following code. She enters the numbers and date upon the record card. CODE 1 Malnutrition 11 Defective Hearing 2 Enl. Car. Glands 12 Def. Nasal Breathing 3 Chorea 13 Teeth Defective 4 Cardiac Disease 14 Defor. Palate 5 Pulmon. Disease 15 Hyper. Tonsils 6 Skin Disease 16 Adenoids 7 Defective Spine 17 Mentality 8 Defective Chest 18 Spec. Infec. Disease 9 Defective Extrem. 19 Defec. Speech 10 Defective Vision After some experience, from thirty to fifty children may be examined in one hour. After retiring from the room the nurse records upon a blank form already noted the clinical data elicited, as well as filling the " Room Report." From this list she prepares the recommendation card to parent or guardian (Form Ml — 3) and the physician's reply post card (Ml — 9). These are both given the same serial number and mailed in a sealed envelope. To the writer's mind, the most important feature of medical inspection is the " follow up " system, without which real good will be seldom accom- plished. Whenever the physician's reply card is not received within two 40 HYGIENE weeks from the date of mailing, a nurse will visit that home, explain the need of proper treatment and urge the same. If among the very poor, the igno- rant, or the foreign population, she will administer treatment to minor skin affections, or for matters of greater difficulty take the child to a hospital dis- pensary. This personal visitation is productive of much good, and at the same time she is often able to instruct the family in many points of personal hygiene and sanitation. In a city of from thirty thousand to sixty thousand population, two nurses and one inspector are able to pretty thoroughly cover the ground as to routine examinations during a school year. However, in this system the primal object of medical inspection is lost sight of to a large extent; that is, the daily visitation for the detection of communicable disease. An ideal system amply comprehensive to cover the needs of medical in- spection could be maintained by using one physician for about fifteen hundred pupils, employing the same cards and follow up plan. Form Ml — 2 is used in any event when contagion exists. Each inspector would visit the build- ings assigned to him at a definite, prearranged time every day. At that hour the teachers would have sent to a vacant room all cases having been absent more than a day and returning without a doctor's certificate, all cases com- plaining of not feehng well, and all suspects, who would then be examined and suspects or communicable cases excluded. This would require probably twenty minutes at each of his buildings, and the remainder of his time would be devoted to the line of work already described, and which greater time would allow him to do more thoroughly. The following rules will be found helpful where daily inspections are made: INSTRUCTIONS TO MEDICAL INSPECTORS OF PUBLIC SCHOOLS 1. The pupils to be inspected will be referred to the inspectors by the principal for two reasons; A. Those who have been absent one or more days. B. Those in the school whom the teacher may suspect to be suffering from communicable diseases. These two classes must be kept separate in the reports. 2. The inspection is to be made with reference to communicable diseases only, and pupils are to be excluded for the following diseases: Scarlet Fever Chicken-pox Diphtheria Whooping-cough Tonsillitis Pediculosis Measles Ring Worm Roetheln Impetigo Mumps Scabies Smallpox or other communicable diseases of the skin and scalp, and communicable diseases of the eye. SCHOOL INSPECTION AND COLLEGE SANITATION 41 3. In making throat examinations, the wooden tongue depressors supplied must be used to the exclusion of all other depressors. EACH TONGUE DEPRES- SOR MUST BE USED ONCE ONLY. Aseptic methods must be employed in all examinations. 4. Whenever a child is excluded, brief but sufficient reason therefor must be written on the exclusion card. 5. Medical inspectors will use their own judgment about the acceptance of family physician's certificates. You have the right to ignore them if such action is justified by your personal investigation of a case at school. 6. The PRINCIPAL excludes children from school, the inspector RECOM- MENDS to the principal exclusions when justified, the principal acts accordingly. Do your utmost to maintain harmony and co-operation with principals. 7. Be sure and give exclusion cards in every instance, so parents will be notified. 8. Remember you have no jurisdiction as inspector beyond the threshold of the public schools of your district. DO NOT examine pupils at your office or any place outside of the public schools. The following are the regulations in use by the writer in the exclusion of communicable cases. SANITARY REGULATIONS The following Sections of the Rules and Regulations of the School District of the city of Harrisburg, Pa., give information concerning the Sanitary Regulations governing the schools of the city. These Regulations were adopted by the Board of School Directors, September 7, 1906. D. D. HAMMELBAUGH, Secretary Section 233. No pupil or teacher afl^ected with any contagious or infectious disease, or directly exposed to the same, shall be allowed to attend schools. Section 234. The following diseases are classified as contagious or infectious, in the intention of the preceding section: Cholera, smallpox (variola or varioloid), scarlet fever, scarlet rash, typhus fever, yellow fever, relapsing fever, diphtheria (diphtheritic croup), leprosy, epidemic cerebro spinal meningitis (spotted fever), whooping cough, measles, German measles, mumps, and chicken pox. Section 235. Pupils or teachers sufi^ering with or residing in families having cholera, smallpox, scarlet fever, scarlet rash, typhus fever, yellow fever, relapsing fever, diphtheria, or leprosy, shall be excluded from school for a period of thirty days following the discharge by removal or recovery of the person last afflicted in said house or family, and the thorough disinfection of the premises; and all such children or teachers, before being permitted to attend or return to school, shall furnish to the principal a certificate signed by the medical attendant of said children or persons, and countersigned by an officer of the sanitary department, setting forth that the thirty days mentioned in this section have fully expired. Section 236. Pupils and teachers suffering with whooping cough, measles, Ger- man measles, mumps, or chicken pox, shall be excluded from school until recovery; those residing in families having any of the diseases named in this section, but who may not have contracted said disease, shall be excluded from school for a period of twenty-one days after the first onset of the disease in the house or family; and all such 42 HYGIENE children or teachers, before returning to school, shall furnish to the principal a cer- tificate signed by a physician, or, in cases where no physician has been in attendance, by an authorized health officer, setting forth that the above provision has been complied with, and that proper precautions have been taken for the prevention of the spread of the disease. Section 237. Pupils and teachers suffering with or residing in families having epidemic cerebro spinal meningitis (spotted fever) shall be allowed to return to school only upon the certificate of attending physician setting forth recovery of the individual, and that all proper precautions have been taken for the prevention of the spread of the disease. Section 238. Children affected with tonsillitis, pediculosis capitis (head lice), pediculosis corporis (body lice), and all forms of contagious skin or eye diseases, such as scabies (itch), impetigo contagiosa, favus, tinea circinata (ring worm), erysipelas, trachoma, and acute contagious conjunctivitis (pink eye), shall be excluded from school until recovery as certified to by a physician. This section applies only to per- sons actually affected, and not to other persons living in the household or family. Section 239. Teachers are directed to insist upon cleanliness and neatness in personal appearance of pupils, and those who are wilfully and habitually negligent in this respect may be sent home with an explanation to the parents or guardian of the cause of dismissal, and admission may be refused until'they are suitably prepared for school. Section 232. No pupil shall be received into any school except upon a certificate signed by a physician setting forth that such child has been successfully vaccinated, or has previously had smallpox. Some differences of opinion exist as to the line of demarcation between the duties of inspectors and nurses. The nurse is of inestimable value in the Work, and of the two probably, by her personal contact with parents, does the greater work. In administration she must be under the inspector. In brief her work consists of clerical duties, visiting the schools with the inspectors, home visiting, instructing parents how to carry out certain lines of treatment, treating certain skin diseases, and teaching personal hygiene and household sanitation. As the prevention and cure of tuberculosis is rapidly coming to the front, so the proper disposition of tubercular teachers and pupils must be met. Many school boards, like ours here with a teacher's retirement fund, now require a physical examination of all applicants for the position of teacher, more or less along the line of life insurance examinations. Our blank here is reproduced and is similar to that used elsewhere. Naturally this examina- tion precludes a tubercular teacher beginning the work. If cases develop among the force, so long as the case is incipient and curable and the teacher will adhere to rigid rules as to expectoration, the use of paper napkins, etc., the sufferer is not dismissed, but given leave of absence, if practicable, so as to enter a sanitorium. Careless teachers or scholars suffering from incipient tuberculosis are excluded from the schools. While in many states no legal warrant is given for excluding the tubercular, a little tact will bring it about, as a rule. A problem of increasing importance in the larger cities is that of the care of mentally deficient children. Probably one per cent of city public school SCHOOL INSPECTION AND COLLEGE SANITATION 43 pupils are defective or degenerate. In many instances this is due to some physical defect, such as adenoids, or to improper environment, and when these are corrected the child soon becomes normal. But in many instances it is purely a mental defect. It has been demonstrated that a majority of these children improve markedly under proper care and training and later lead useful lives. This requires special schools, with teachers who have been scientifically trained in their work. As will be observed, the set of blanks now presented are very largely self explanatory, and their reproduction gives in graphic form what would take many pages for me to present didactically. These forms are adapted to most places, but boroughs should not be discouraged, since a creditable work can be done along very simple lines, while highly elaborated systems may require a greater number of reports. I wish to say, in closing, that the work is interesting, has justified itself by results in Harrisburg,and seems to be appreciated by the patrons of the schools. Relatively speaking, the cost is insignificant. PHYSICAL RECORD Name Nationality Parent (Guardian) Building. Treatment Date of Age Grade Code Number of any Advised Examination Defect Found (Yes or No) CODE 1 Malnutrition. 2 Enl. Cer. Glands. 3 Chorea. 4 Cardiac Disease. 5 Pulmon. Disease. 6 Skin Disease. 7 Defective Spine. 8 Defective Chest. 9 De- fective Extrem. 10 Defective Vision. 11 Defective Hearing. 12 Def. Nasal Breathing. 13 Teeth Defective. 14 Defor. Palate. 15 Hyper. Tonsils. 16 Ade- noids. 17 Mentality. 18 Spec. Infec. Disease. 19 Defec. Speech. Obverse Physical Record This card must be filed by teacher and transferred with pupil through succeeding grades. Address of Parent REMARKS Reverse Physical Record 44 HYGIENE Date is ordered to discontinue attendance at the School Building, until he or she presents to the principal a certificate from a physician, showing him or her to be free from any con- tagious or infectious disease, and that no danger of contagion exists at home. Reason Medical Inspector This notice does NOT exclude this child from school. No Date A physical examination seems to show that has. For his or her future welfare and proper progress in school work, you should consult your family physician as to proper treatment; or, if unable to pay, take the child to a Hospital Dispensary. Medical Inspector TAKE THIS CARD WITH YOU TO THE FAMILY PHYSICIAN Form M 1—4 ROOM REPORT of Pupils Having Some Defect Building Grade Teacher Treatment NAME Date Advised Case No. REMARKS (Yes or No) Form M 1—5 DAILY AND MONTHLY REPORT OF MEDICAL INSPECTOR No. Date BUILDING Routine No. No. Special Total No. Exam. Re-exam. Exam. Exam, No. Contagious or Infectious No. Showing No. Requiring No. Defective No. Excluded Diseases some Defect Medical Attention Conditions found Medical Inspector Obverse Report of Medical Inspector SCHOOL INSPECTION AND COLLEGE SANITATION 45 Summary from to. Total No. routine examinations re-examinations special examined contagious or infectious diseases showing some defect requiring medical attention excluded defective conditions found Defects for which treatment has been recommended Malnutrition Enl. cervical glands Chorea Cardiac disease Pulmonary disease Skin disease Defective spine Defective chest Defective extremities Defective vision Defective hearing Defective nasal breathing . Teeth requiring attention.. Deformed palate Hyper, tonsils Adenoids Deficient mentality Specific infectious disease. Defective speech No. reporting treatment during month. Condition for which Treatment has been instituted REMARKS Reverse Report of Medical Inspector Form M 1—6 DAILY AND MONTHLY REPORT OF SCHOOL NURSE Date Buildings Visited No. Homes Visited No. Children Attended in Homes No. Calls Made No. Attended in School No. taken to Dispensary or Hospital Obverse Report of School Nurse School Nurse 46 HYGIENE Summary from to. Total No. schools visited " " homes visited " " children attended in homes " " calls made " " attended in school " " taken to Dispensary or Hospital Class of Cases Visited in Homes Time^devoted to clerical work Malnutrition " " " inspection .. Enl. cervical glands " " " visiting Chorea Total time Cardiac disease Pulmonary disease REMARKS Skin disease Defective spine Defective chest Defective extremities Defective vision Defective hearing Defective nasal breathing Teeth requiring attention Deformed palate Hyper, tonsils Adenoids Deficient mentality Specific infectious disease Defective speech Reverse Report'^of^School Nursk Form M 1—7 INSTRUCTIONS TO TEACHERS Prior to the examination of scholars the nurse will furnish a blank form, on which shall be written the names of all pupils in the room. Any child who appears to be backward in school work, or shows signs of physical deficiency, such as mouth breathing, poor vision, defective hearing, foul breath, or any skin eruption, shall be given a slip of paper, to be handed to inspector, with its name, and the nature of the defect stated thereon. These slips must NOT be given to children until time of examination. Medical Inspector SCHOOL INSPECTION AND COLLEGE SANITATION 47 Form M 1—8 THE FOLLOWING METHOD OF TREATMENT FOR KILLING LICE AND NITS IS RECOMMENDED Wet the hair thoroughly with crude petroleum, of which half a pint may be ob- tained at a drug store. Keep it wet for three hours; then wash the whole head with warm water and soap. Repeat this process on three successive days. The nits may then be removed by combing the hair very carefully with a fine-toothed comb wet with vinegar. Repeat the combing for several days until no more nits can be found. To make the treatment easier and the more thorough, the hair may be cut short, if there is no objecvion. All persons in a family are likely to be affected, and should also be treated as above. Brushes and combs should be cleansed by putting them in boiling water for a few minutes. TAKE THIS CARD TO YOUR PHYSICIAN No. The physician consulted will kindly sign and forward this card after examining child. I have this day examined and have. advised treatment. Respectfully, Date DAILY MEMORANDUM FOR MEDICAL INSPECTOR Date School No. routine examinations No. re-examinations No. special examinations No. contagious diseases No. showing some defect No. requiring medical attention No. defective conditions No. excluded Remarks: 48 HYGIENE DAILY MEMORANDUM FOR SCHOOL NURSE Date School visited _ No. homes visited „ No. children attended in homes No. calls made No. attended in school _ No. taken to dispensary _ _ _. Time devoted to clerical work Time devoted to inspection _ _ Time devoted to visiting Remarks: REPORT OF MEDICAL EXAMINER ON APPLICANT FOR POSITION AS TEACHER 1 . Name in full _ Date of birth „ 2. Family History: Living Dead Age Age Cause of Death Father Father's father Father's mother ...„ „ Mother Mother's father Mother's mother Brothers _ _ Sisters 3. State what serious illness, if any, you have have had during the past ten years .? 4. Name your medical attendant, May the school board refer to him ? 5. To what extent do you use alcoholic drinks To what extent do you use tobacco, and in what form .'' The foregoing answers are full, complete, and true. Date Applicant UNIVERSITY OF MICHIGAN GYMNASIUM SCHOOL NURSE AT WORK, NEW YORK CITY A MEDICAL COLLEGE ANATOMICAL LABORATORY Properly separated from other departments SCHOOL INSPECTION AND COLLEGE SANITATION 49 6. Weight _„. Height Girth of chest at full expiration „ _ Girth of chest at full inspiration _ — _ _ 7. Frequency of pulse „ - - Frequency of respiration _ 8. Is there any evidence of disease of _ Brain or nervous system _ - Heart or lungs - - — Sromach or abdominal organs „ Rheumatism - _ - 9. Vision : Right eye „ — .. Left eye ....„ Hearing : Right ear Left ear _ (Snellin'sTest Type to be used in testing vision; the closed vpatch in testing hearing.) 10. Has applicant been successfully vaccinated ? 11. Urinalysis: Color _ _ - — Reaction „ _ _ _ — - Specific gravity — - Sugar _ _ Albumen „ _ - 12. Do you advise the acceptance of the applicant ? _ — The preceding answers and examination of _ _ _ — _ are correct to the best of my knowledge Date „...„ Medical Examiner Sanitation of buildings. — In Chapters II and XX the construction and sanitation of buildings is fully discussed, while the chapters upon Disinfection and Quarantine relate much of importance in this connection. School build- ings have especial need for frequent disinfection. The drinking cup is of sanitary importance in the school. Several plans have been suggested tor avoiding the dangers of promiscuous use of the same cup. Here in Hams- burg we are installing drinking founts made like the sanitary scuttle butts of the United States navy. They are very satisfactory where municipal water plants exist. In rural districts individual cups are advised and can be kept in the child's desk. Paper or paraffined cups are satisfactory, but the total cost of supplying them is considerable of an item. The same must be said of paper napkins or towels. Every teacher should be charged with the task of instructing scholars to refrain from kissing, sucking pencils or pens, or passing them around, trading chewing gum, eating apples or confectionery that have been in the mouths of other children, and should any insanitary habits or customs arise among the 50 HYGIENE scholars the teacher should tactfully take the matter in hand. City school children are often restricted in their playgrounds. (See the remarks upon playgrounds under " Parks " in the chapter upon " Places of Amusement and Dissipation.") The accommodations for toilet purposes at rural schoolhouses are often abominable. In the chapter upon " Rural Hygiene " a proper arrangement is pictured and described. This is a matter of the very greatest importance in the country. Especially is this true in view of the fact that hookworm disease is kept up in whole communities from the defective sanitation at rural schoolhouses. This disease is really a fearful scourge in the South and readers should study this disease and the means of its dissemination most carefully. See the index of this book for several references thereto, and it is also shown in a drawing in the Appendix. Marion Hamilton Carter has written a splendid paper upon hookworm disease, and it is found in the October, 1909, number of McClure's Magazine, under the caption: "The Vampire of the South." From it I quote: On a plantation in South Carolina sixty hands were employed, all infected with hookworms, several of them in severe degree, and all from the same obvious cause — no sanitary convenience. In another state, thirty per cent of all the rural school- houses were without closets, — in some entire counties no rural schools had any, — and the soil for a radius of one hundred and fifty feet about each of these schools was infested with hookworm ova and larvae. Superficial examination of the school chil- dren in one district showed seventy to eighty per cent of them infected, many of them very badly. These school percentages are about three times those of the adult and twice those of the non-school going population in the regions from which the schools draw, the school, as a hotbed of infection, being nearly double in potency the one- horse farm. There are asserted to be two million cases of hookworm infection in the United States, and its history is that the negroes brought it from Africa, are relatively immune to it themselves, although eighty per cent of Southern negroes are asserted to have the disease, and are disseminating it among the whites, to whom no degree of immunity has been established. At all events it is a dreadful scourge in several states, and dirty communities along the Mason and Dixon line are liable to outbreaks, and it may even come further North. I have seen what wretched toilet accommodations are com- mon, not only in the South, but also in portions of the North in and about rural schoolhouses. Every physician who is in country practice should look into the matter in his own district. I used to practice in the country and know how hard it is to wake up some rural school boards, but keeping ever- lastingly at it even brings them to time. Academies and colleges are often housed in most insanitary buildings, and especial attention should be called to overcrowding in colleges. Most of these institutions are hampered for room, and two students are housed where one should be, especially in the dormitories. Nowadays the public schools are so well looked after where there are adequate boards of health, that it is time to turn to some of the colleges and SCHOOL INSPECTION AND COLLEGE SANITATION 51 compel them to tear out a lot of antiquated old plumbing and other sanitary abominations. A good place to begin is at the medical colleges. The aver- age medical institution houses several dead bodies " in pickle " and in process of dissection, beside numerous animals for experiment, and an odoriferous chemical laboratory, all under the same roof with lecture rooms and some- times a public dispensary. Such a conglomeration should not be permitted. The anatomical and pathological laboratories should be compelled by law to be separately housed. The tobacco problem. — Some reference is made to this in the chapter upon pure food and drugs. It is commonly agreed that tobacco is dangerous to the growing youth, and the data is so extensive and the series of com- parative tests so numerous that we can regard the matter as settled. There- fore, school boards have a perfect right to prohibit its use, and states to enact laws against the sale of tobacco to young persons. Also it is very generally agreed that the American cigarette is responsible for much of harm. The majority of men who smoke will decry the use of the cigarette, and a large proportion of cigarette users themselves frankly admit their possibilities for harm. The use of the pipe and cigar by grown men is regarded in a some- what different light. While many able scientists strenuously oppose this latter use of the drug, the majority of men of all shades of opinion in other things look upon the use of the pipe and cigar by adult males as a pastime and mild habit of small moment with the aggregate of men, but deleterious in the case of a small minority. Just what is the scientific point of view is hard to define, since there is but little agreement as regards the points most at issue. From an examination of fourteen brands of smoking tobacco I was forced to the conclusion that there is much adulteration and very probably a degree oi harmful adulteration sufficient to make it very difficult to judge of the questions at issue until after the chemists and others have determined very definitely the degree and character of deleterious adulteration in smoking tobaccos. It is alleged that certain intoxicating weeds are used to adulterate tobacco in the United States. If this be true, it is difficult to say how much harm comes from the tobacco and how much from the adulterant. Further- more, it is a matter of some considerable importance to determine these things specifically and without prejudice. The hygiene of athletic sports. — Upon my desk lies a pile of reprints upon certain phases of athletic sport. Some of them dwell upon the dangers and others upon the advantages to be derived. The place of physical training in a school system has never been accurately defined. That it has a place does not admit of doubt. So has Greek. How much of a place either one should occupy in the affairs of any specific young man can best be deter- mined by his personal equation, his balance as to mentality upon one side and the physical ego upon the other, his environment and its influence upon him, and his own personal taste in the matter. It is like diet: " One man's meat is another man's poison." No set rules can be made. Systems must be flexible and differing schools as to the glorification of or debasements 52 HYGIENE of the flesh must learn to be amiable with one another's pet theories or de- lusions. Both the Samson and the Saint may live long and be happy, each in his way. Probably athletics is too much indulged while in college and too much neglected after one is out. If the French one learns in the classroom be kept up in after years, it is a real advantage; so with athletics and the use made of it after school days have merged into those of business. Our English and Canadian friends can teach us a bit about such things. Parks are not meant merely for the youth; they are the playgrounds of the people. Some day some good citizen and wise man will invent some good outdoor American game suited for the average adult and one that does not require a uniform. Athletic sports in college should be regarded as a part of the serious work there to rationally build up a healthy body that should stay healthy so long as the mind is active enough to demand muscular activity. To keep up mental exercise is regarded as necessary all through life, but we do not feel the same way about the body. One is just as necessary as is the other. Sexual and venereal instruction. — The trouble with this whole matter has been that no one seems to want to discover what is proper and normal in this phase of life. We have theories, pretty or nasty, according to the way one chooses to look at them, and we fit in the facts to the theory, while the other chap with a different view is standing at the end of our house of cards ready to push it over so soon as he decides to make a new shuffle to fit his theory. The whole maze of sex question literary pyrotechnics that have risen like rockets and come down like sticks the last few years have left nothing but smoke behind. The sexual problem never became a problem until man begun to speak in whispers about it. Neither did clothes. It is the trim- mings of both that have made most of the trouble. Men and women should fit into the general scheme of things here just like they did from the beginning of time. Leave them more to their own natural instincts and morality will be as natural as is love and usually the mating will be for life. While it is certainly not the thing for the small child, puberty should mark the time of supplying the information nature rules is due. College should advance the information to a more scientific status and the pathology of sexual force may be clearly defined. The average college student wants to be clean. Most physicians have no sympathy with the view that young men are all naturally unmoral. The history of the race does not read that way. After all, there are but two ways to live the sexual life: that of the orient, with its polygamy and debasement of woman, and thatofthe Occident, with legal wedlock and woman elevated. You cannot mix the two. The nations who tried it in the past went down to oblivion. The same rule would apply to us. Instructing young men upon the matter should not consist of explanations of the many forms of legalized vice and prostitution, but rather telling them of the inexorable laws of nature and the laws of the land. There need be nothing mystical about the matter, and we can well omit the wretched and sordid details of the experiments with pathologic love that man has been fool enough to try out in certain communities and by means of certain cults. SCHOOL INSPECTION AND COLLEGE SANITATION 53 College traininv in sanitation. — Within the last few months several American colleges and universities have announced courses preparing the graduate more or less fully for public health work and administration. Among the first to do so was Cornell. Regarding the work there the Twenty- ninth Annual Report of the New York State Department of Health gave a syllabus of the lectures, the main subjects of which are reproduced, and com- mented upon the course, as will be immediately quoted. It must be explained, however, that these comments were made before other colleges followed the example of Cornell. Doubtless many institutions will soon offer very thor- ough training along the lines indicated in the rather tentative courses thus far announced. SCHOOL OF SANITARY SCIENCE AND PUBLIC HEALTH If the public health is to be properly safeguarded we must have men rightly taught and trained to do the work. We need to-day expert sanitarians. They must be men so instructed that they have gained that comprehensive grasp that gives a mastery of the broader economic and social problems of our modern and complex life. As so forcibly and clearly stated by Dr. Ditman, such men should not only be able to cure but should be able to prevent disease; should be familiar with methods of public health administration which bear on the purity of food and water supplies, dangerous occupations and the occurrence of epidemics; they should know thoroughly such sociological questions as concern the habits of the people and the evils of tene- ment house existence. Many other matters should come within their province. They should know the work of the various charitable organizations, be conversant with the different phases of educational questions, and be able to at all times carry on a continual campaign of education on sanitation among the people. The need of such men is painfully apparent, and there are few to be found. It must be stated, although not very gratifying to our pride, that there is at present no place in these United States where such training as that described above may be obtained. Other countries have outstripped us in the work, seeing clearly the absolute necessity of putting trained men in charge of the public health. In England, for example, since 1892, in any country district or combination of districts, no one could be appointed medical officer of health unless he were a full graduate of medicine and registered as a holder of a diploma from some university body giving instruction in sanitary science, public health, or state medicine. This act demanded special training, and created a trained body of medical state officers. The urgent need of some place where such special training and teaching could be given caused the department of health, with the cordial co-operation of the authori- ties of Cornell University, to establish at that institution a fairly complete course in sanitary science and public health. Its success was marked from the first lecture. The interest taken by the students was unmistakable, and at times the large hall was unable to accommodate all who came. Since the inauguration of this course the movement has spread, and in several institutions and colleges similar courses of instruction are given. The experiment, if it could be so termed at Cornell, has demonstrated that a school of sanitary science and public health is an imperative necessity, and it is the plain duty of the state to provide such a school. A very modest amount of money would establish at Cornell in a permanent way a school of state medicine that would return promptly a thousand fold its cost. 54 HYGIENE The subjects covered at Cornell were (1908) as follows: Public health administration. Town planning. Problems of life and health in industry. The relation of the state to the health of rural communities. The influence of the action of the laws of heredity upon public health. Social problems in their relation to the public health. The public health law. The various aspects of vital statistics. Prophylaxis as a public asset. Insanity and public health. Voluntary organization in public health work. Bacteriology and comparative epidemiology. Disinfection in its relation to public health. Cancer in its relation to public health. Food adulterations and their detec- tion. Effect of dairy processes on pathogenic bacteria and their transmission to human beings. Dairy hygiene. The need of more attention to health in the public schools. Statistics relating to early tuberculosis. Waste of wealth in New York from preventable illness and death. Local quarantine measures. Relation of alcohol to the public health. Insects and the trans- mission of disease. The medical side of the negro problem. The history of therapeutics. The value of animal wastes in agricultural processes. The betterment of agricultural conditions. Transmission and prevention of some infectious diseases. Immunity. The law of nuisances and its relation to public health. Sanitary science. Water filtration. Water purification. Principles of sewage purification. Sewage disposal. Limnology. Occu- pational diseases and their prevention. Modern housing. Heating and ventilation. Agricultural economics. General municipal sanitation. Nurses' Training Schools. — There need be very little apprehension about the trained nurse. There are so many grades of work for the nurses to do that most of the objections raised against them apply to but a portion of the guild, and varying grades of nurses are needed for differing lines of work. Certainly it is not to be wondered at that the really trained nurses want to raise distinctions between themselves and those who are notadequately trained for surgical and difficult work, but who are admittedly useful in illness not requiring so many detailed attentions upon the part of the nurse. Many states have laws regulating the registration of trained nurses and providing for boards and examiners, but ver}' few state boards of health have undertaken to define what a nurse must know. The state of Iowa is an ex- ception in this regard, and it may not be amiss to reproduce these require- iments of the Iowa State Board of Health. NOTICE TO SUPERINTENDENTS OF TRAINING SCHOOLS In accordance with the provisions of Chapter 139, Acts of the Thirty-second General Assembly, the Iowa State Board of Health has formulated and adopted the following schedule of minimum requirements for training schools and admission thereto. This schedule will ake effect and be in force on and after February 1, 1908. After February 1, 1908, no training school will be regarded as in good standing by the Iowa State Board of Health, unless such school conforms to the minimum require- ments herein prescribed; nor will the graduates of such institutions receiving their diplomas subsequent to February 1, 1908, be admitted to examination as applicants for a state certificate of registration. SCHOOL INSPECTION AND COLLEGE SANITATION 55 CONDITIONS FOR ADMISSION TO TRAINING SCHOOLS All applicants for admission to training schools for registered nurses must file credentials as follows: 1st. Satisfactory evidence of good moral character. 2d. A certificate showing completion of grammar school course (after July 1, 1910, a high school course will be required), or in the absence of such certificate the applicant shall pass a satisfactory examination equivalent thereto, such examination to be conducted under the supervision of the principal of an accredited high school. An applicant failing in one or more branches in such examination may be conditioned for one year, at which time such deficiency must be removed. REQUIREMENTS FOR TRAINING SCHOOLS To obtain recognition by this board, training schools shall conform to the following requirements: 1st. They shall require their matriculates to comply with the preliminary re- quirements prescribed by this board, and keep an accurate record of each student's credentials. 2d. The training schools must be connected with a general or state hospital (or sanitorium) having not less than twenty-five beds, and the number of beds must be at least twice the number of students in the school, depending on the character of the hospital facilities, with private or ward practice. SPECIAL OR STATE HOSPITAL TRAINING SCHOOLS Graduates of training schools connected with a special or state hospital will be admitted to examination by this board, only upon satisfactory evidence of having completed a course of six months' instruction in the general hospital of a training school of recognized standing with this board. Said course may be taken during the last six months preceding graduation, or within one year subsequent thereto. BRANCHES TO BE TAUGHT The following branches must be taught by all training schools. (1) Elementary Anatomy. (2) Elementary Physiology. (3) Elementary Bacteriology and Pa- thology. (4) Elementary Materia Medica and Elementary Toxicology. (5) Ele- mentary Hygiene. (6) Dietetics, Domestic Science, and Food Values. (7) Practical Nursing. (8) Surgical Nursing, including Gynecology, and the eye and ear. (9) Medical Nursing, including nervous diseases and contagious diseases. (10) Nursing in children's diseases. (11) Obstetrical Nursing and practical experience in at least six cases. (12) Chemistry and Urinary Analysis, (13) Medical Jurisprudence. (14) Nursing of diseases peculiar to men for men. Note. — The state examination will include also the rules and regulations of the Iowa State Board of Health relating to infectious and contagious diseases and quarantine. PERIOD OF TRAINING The period of instruction in the training school shall be not less than two (2) full years (three (3) years being recommended). Training schools having a three years' course, and wishing to send pupils outside the hospital in private cases, may pursue 56 HYGIENE this practice only during the student's senior year; but said outside work shall not exceed three months of the course. Training schools having only a two (2) years' course will not be accorded this privilege unless they extend the course to three (3) years. After July 1, 1910, no training school will be in good standing with this board which does not require a three (3) years' course of study. It is earnestly recommended that all training schools forthwith adopt a three (3) year course. SCHEDULE OF SUBJECTS The following schedute of subjects, together with the number of hours to be taught in each branch, is recommended by the board; a rearrangement of the several branches, however, may be made to meet local conditions: FIRST YEAR Anatomy 15 hours Hydrotherapy 5 Practical nursing, including massage 40 Physiology . 15 Hygiene 5 Domestic science (including dietetics and cookery, — food values) 20 Chemistry and urinary analysis 5 Physical culture 10 El. bacteriology and pathology 10 125 hours SECOND YEAR Medical nursing, including nervous diseases, contagious diseases, and the Rules and Regulations of the Iowa State Board of Health relating to infectious diseases and quarantine 36 hours Practical nursing 18 j Children's diseases 15 Obstetrical nursing and obstetrics 10 Materia medica and toxicology 10 Surgical nursing, including eye and ear and gynecology 30 Preparation of food for sick 20 Nursing ethics 3 142 hours THIRD YEAR Medical nursing, including nervous diseases and contagious diseases 20 hours Surgical nursing, including eye and ear and gynecology 20 Electro-therapeutics 5 Medical jurisprudence 5 Nursing ethics 3 Review 50 Emergencies 15 118 hours SCHOOL INSPECTION AND COLLEGE SANITATION 57 Training schools maintaining only a two-year course must arrange their schedule so as to cover the work outlined in the foregoing requirements. The foregoing rules were adopted by the Iowa State Board of Health on January 22, 1908, and are in full force and effect on and after February 1, 1908. (Attest:) Louis A. Thomas, (Signed:) J. H. Sams, Secretary President One reads much of the nurses knowing too much about therapeutics. I instruct a class of nurses in materia medica and therapeutics and find it hard to drill the subject into them and they complain of the difficulties. Therefore, it does not appear to me that they are very apt to undertake the administration of any but emergency remedies. It is in such drugs and anti- septics that I give most drill. The trained nurse has hardly gotten her bearings as yet, but it does not appear to me that the outlook is at all bad. Certainly they have a well- defined place, not only in the care of patients, but also in certain matters of public health. Chapter IV PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE The bad record of the past as regards jails — Some present bad conditions. Signs of improvement — Speciahzing in correction — Plans tending toward a more rational treatment of crime and criminals — Some instances of correct practice — Disease in prisons — The special hygiene of large prisons — Of smaller prisons — The tramp question — Juvenile offenders — The medical service of prisons — Infectious ■diseases — Some general considerations. The Police. — Their services to the public — Police ambulances — The police matron — The sanitary police — Their place in suppressing vice — Police instruction in first aid — Their future. Insanity and its care in the broader aspects of prevention, the hygiene of insti- tutions and the general care of perversions and moral conditions due to insanity. AND this conjuration and mighty magic that worked so great a transformation when the most ingenious punishments had failed of effect is the new spirit that is beginning to appear in the conduct of our prisons. Prisons are terrible things, and of rather more than doubtful utility; and yet I know of nothing that gives one stronger hope than to contemplate their history. How long ago were men thrown into such frightful dungeons as the cells under the canals at Venice ? How long ago were the days of branding and ear-splitting ? When did lashing at the cart tail cease, and those mad processions of Tyburn ? How long ago was the Bastile merely a type of a hundred European prisons, no better and no worse ? How many thousand wretches actually rotted away in such filthy dens ? How about prison fever and the death rate that used to be appalling when prisons were unventilated and without a pretense at sanitation ? How about the prison hulks that not so very long ago cursed the harbors of England \ How about the system of transporting felons over seas, which lasted until almost the present genera- tion ? How about the sickening and hellish horrors of Botany Bay and Norfolk Island ? What was written of Newgate sixty years ago ? What were the English prisons like in the days of Charles Reade ? And so we come up the long trail of mani- fold horrors, cruelties, and barbarisms, burnings, manglings, beatings, from the dungeons of France before the Revolution, past the American commonwealth that still maintains the whipping post, to the decency, cleanliness, and human impulses -displayed at Fort Leavenworth or Joliet, up at last to a prison system like that of New Zealand that has no thought of breaking the fallen man's spirits nor of exacting retribution, but only of restoring him whole to his due place among his fellowmen. Along this road, in spite of the survival of some of the vilest prisons in the world, and in spite of the unspeakable horrors of the Southern convict camp, we make •progress. Not very swift, but still progress. This quotation is from a series of articles by Charles Edw^ard Russell, upon American prisons, and is running in Hampton's Magazine, beginning in the number for September, 1909. To Mr. Russell and other able writers I am indebted for some of the data used in this chapter, v^^hile the rest is from my own observation and the photographs used were taken by myself. Prison reform is a large subject, and it would give me much pleasure to detail what has been done by the large-hearted people who have awakened PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE 59 to the cry of the prisoner. My observation and reading have convinced me of two things. The first can be illustrated by giving the reply of an able judge when asked why his sentences were usually for such short terms; he said, " Most prisons punish a man beyond what the law designs." This has been literally true and is true of many of them to-day. Certain it is that the passing of sentence ends the jurisdiction of the court and the convicted man passes from the scrutiny of a learned profession and an able court to the care of a set of officials who may be merciful and just, but who in the past seldom were either and may yet be selected by political considerations in which neither mercy nor justice have a part. But this is a day of publicity, and the cloister and solitary dungeon have no part in modern civilization. Whether the end be religion or punishment, it is contrary to human nature and divine requirements that man be shut up alone to his own thoughts and the morbid introspection that ferments in the darkness and turns to acid all the sweetness that God placed in the human mind and heart. And this leads to the second thing, and that is that public policy has ever been largely dominated by the preconceived ideas man forms of divine policy. The frightful theological nightmares of the past were responsible for much of law that was cruel and for much of war that was hell. Read history, and my statement needs no comment. A theological course taught me that the original Greek and Hebrew Scriptures have been so warped and twisted in the course of ages and eccle- siastical wrangling in trying to frighten men into the faith, that the legalistic idea of God and His dealings with men have darkened the light of the gospel, and the humanitarianism of Jesus Christ has been kept In the background, until men who were not ecclesiastics were forced to accept either rationalism or to restudy the ancient Scriptures in the light of modern scholarship. This has been done, and is the most hopeful aspect of Christianity to-day. Prob- ably an awakening in many things was due for this age, but it is certainly significant that a better understanding of God is leading men to a better understanding of each other. The horrors of war, the blaming of disease upon Divine Providence, racial antagonism, human slavery, the degradation of woman, enslaving our fellows with alcohol and degrading drug habits, and the cruelties of prison life are all things that men are coming to see in a new light bred of true perspective and the light of a cleansed religion. We doc- tors are apt to feel aggrieved when religions invade the field of therapy. Let us give to religion the proportion of credit due In preparing men's minds for better conditions In all things inclusive of preventive medicine. The bad jails of the past. — The saddest sight I have ever seen, next to the great disaster at Johnstown after the excitement was over, or a railroad wreck in which I saw people burning to death, was at a big penitentiary of the old political type and in which the poor victims of the brutal contract system were kept at work with rifles always pointing at them. That punishment by brutal flogging, by confinement in absolute darkness, by strangling with the fiendish " water cure," by being strung up in the " bullrings," the elec- 60 HYGIENE A dark prison of the old and insanitary type trie torture of the " hummingbird " and other more refined but not less barbarous means need not be denied by officials in the face of overwhelming proof of the fact. The disreputable old dungeon shown on this page was a fair type of what the average state penitentiary was like not so many years ago. In fact, some of them look like it now. In dark prisons like this sanitation is almost unknown in any but the old prison sense. Men are packed away like sardines and doomed to all but certain tuberculosis. The literature and the affidavits in proof of such cruelty is so extensive that we need not harrow the reader's soul by reproducing it here. Fortu- nately, most of that sort of thing is done within this country, although there are prisons in which it is stated that such measures survive. I have no per- sonal knowledge of any such places existing now, although there is reason to PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE 61 believe that there must be at least some truth in statements discharged pri- soners make about present cruelty. In taking occasion to interview gentlemen identified with corrections, I find them alert to advances made. Many of them are broad gauge gentle- men and do not think, as some persons state, that " the prison reform cranks are wild-eyed fanatics." As a matter of fact, some of the latter are better informed about prison management than are the class of wardens who never see anything of prisons except their own institutions. On the other hand, the reform people do number among them some very theoretical persons who do not realize what a tough proposition is the confirmed criminal. Signs of unprovement. — These are almost universal. The federal gov- ernment has probably been in the fore in the matter. " The Turn of the Balance," by Brand Whitlock, tells what has been, and the balance is turning in the right direction. No longer does the official who has informed himself by study of conditions and by travel, consider it well to " break the spirit of the prisoner " ; he does not consider that brutality really ever reformed any man; that the medieval idea of revenge is creditable to a state; that stripes upon clothing removes the leopard's stripes; that lock-step discipline is of any value; that shaving the head improves the conduct of a felon, or that the convict leasing system has one redeeming feature. We wish we had the space to give details as to actual results from the newer ideas in correction. It is a fact, that with the great majority of prisoners the new methods result in better discipline in the prison, vastly less disease and a very greatly increased proportion of men and women whose reform is testified to by the fact that they have no future criminal history. They leave the prison better citizens than when they entered. This can be said of very few under the old system. Un- fortunately, it must be admitted that there is a certain proportion of hardened criminal upon whom the new system seems to be wasted. It is strange how one sees the good and bad side by side. The state of Kansas has a penitentiary that is said by Mr. Russell to be a disgrace to the state, and it also has within its borders the Fort Leavenworth Federal Peni- tentiary, one of the most humane in the world and a model in its way. Miss Kate Barnard, the State Commissioner of Charities of Oklahoma, is a won- derful instance of what a woman can do in public life. I have read her biography, and it should be an inspiration to every woman who enters public work. She has shown up the bad penitentiary in Kansas in a way to make one's blood run cold. If you don't believe her, ask Oklahoma. She is a power out there and the state is proud of her. The warden at Fort Leavenworth, Maj. R. W. McClaughry, believes that outdoor work is the solution of most of the prison problems. The convicts there, and there are some very bad ones, erected nearly everything upon the place and the plans were such that sanitation was first of all. Mr. Russell says of this prison: You may probably observe here that a great increase of mental and moral, as well as of physical health is found to follow outdoor work for convicts. At Fort Leavenworth the men that work out of doors give practically no trouble. Fifty 62 HYGIENE convicts often work on the farm in charge of only two guards, and no attempt at escape has been reported in this squad. This reminds me that in New Zealand I have seen forty convicts working in the woods many miles from the prison and guarded by one keeper, armed with a walking stick. None of them ever seemed to want to run away. It must be wise to theorize about the necessity for force, guns, and spirit breakers, or we should not have so much of such arguing; but as a matter of practice, good will, decency, and kindness seem much more effective in keeping men in order. Later in his argument he says: Fort Leavenworth is not cursed with politics; therefore it can be operated by men that understand penolog}', and have higher ideals than to get and keep a " job." Stripes are abolished, the convicts wear an attractive dark gray uniform. Corporal punish- ment is unknown. The food is good, sufficient, and well cooked. The kitchens are marvelous places, where cooking is done with steam in great polished copper caldrons. Meals are served bv colored waiters wearing neat white aprons and white caps; fresh air and light abound. Dishes, table, and floor are clean, guards decent, and convicts regarded as human beings. Which seems to be much the best way. To hasten on, Joliet, Stillwater, and other prisons in Minnesota, Canon City, Michigan City, the prisons of New York state, those of Michigan, of Massachusetts, and isolated ones all over the country, are tr}'ing the newer ideas in correction and the results are good. A volume could be written upon the subject, but it is to be hoped that prison physicians who may read this paper will interest themselves in the subject and study the matter in a de- tailed way impossible here, and will use their influence to better conditions where defective. Specializing in correction. — Any one who takes the trouble to secure and study the prison reports of the states and cities will know that the prison work of this countr}' is rapidly becoming a highly specialized profession, and that many earnest people are developing the different lines of penal and reform work. The subject is too large to discuss here, but the work along special reform lines is not only most interesting, but promises in time to render the prison population of the country a smaller proportion of the whole. Rational treatment of the criminal element. — This is a question for the social settlement worker, the sociologist, the criminologist, the church and the sanitarian. All should work together tow^ard a solution. Magazine articles galore treat the subject from varying points of view. We should read these articles. The race question enters in very largely and the people of differing nationality must be handled differently. The prevention of crime will bring better results, perhaps, than does the punishment of the criminal. We spend large sums in preventive medicine and find it pays. Wh)' not pre- vent crime ? How about the liquor problem ? What of immorality r What influence does the amusements of the people have upon the crime question ? The church has long been struggling along with the question, and that the churches are doing a good work does not admit of doubt. Is the church alone strong enough to stem the tide ? If not, who or what should help and what part in the general work should the church occupy ? The doctors are surely getting together and are doing what work in crime prevention relates n H ?s ffi H M O H ^ O o PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE 63 to insanitary conditions. The state helps the doctor to do his work; should it help the persons identified with the other factors of the problem ? If not, why not ? The engineer has dropped some academic theories and is now serving sanitation and is improving housing and industrial conditions; the doctors are dropping sectarianism and are largely working together for the good of the public at large; the sociologist goes more to the slums now than to lec- tures; the criminologist is dropping the theories of past years and is doing a large work in reform; it is now up to the different churches to drop the foolish dogmas to which no one will listen and join hands with the rest of us in a great work. Some instances of correct practice. — There could be many given, but because of the prominence of New York city I will describe a few of the things to be seen there, confining my remarks mainly to the sanitary points of interest. I had the pleasure of meeting the Hon. John J. Barry, Com- missioner of Corrections of New York city, at his ofltice, and he afforded me every opportunity to inspect any or all penal institutions under his jurisdic- tion. It would unduly fill pages to describe all I saw, but one cannot but realize what a complex subject is prison administration when you see the mass of detail incident to such work, and talk with the many people who are trying to bring about better conditions among the criminal element in a large city. As I understand it, the public and legislative bodies must be edu- cated in matters of prison reform before appropriations commensurate to the needs of the work will be forthcoming. A vast deal of newspaper criticism of prisons has a basis in insufficient appropriations. If there is excuse anywhere for crowding and for dark quarters justify- ing the term heading this section, it is in a " city prison," the official name of this institution. Situated at Fourth Avenue and Central Street, the ground covered is very valuable. Yet there is a prison yard of considerable size, a small section being shown in the photograph. It is clean and orderly, and the prisoners take exercise therein daily. Mr. Wm. Flynn, the warden, told me there were usually nearly five hundred prisoners in the cells, and they were orderly as a rule and gave very little trouble. Parts of the buildings are dark, but the average prison in small towns is not so well lighted as is this one, due to the large windows, as shown in the outside view of a portion of the building. Prisoners are carefully classified and the employes are of a better class than one finds in the average prison. Female prisoners are officered exclusively by matrons. The construction is good. There is no chance for vermin to be har- bored for any length of time, as the cells are models of sanitary construction and the iron beds and cell fixtures are regularly scrubbed. The cells have better plumbing than has the average house, and ward shower baths are supplied. I saw no rubbish about the place, or no place needing paint or reconstruction. The sewers are flushed out with fire hose every day, and there was absolutely no suggestion of " the prison smell." The religious care of the prisoners is excellent. 64 HYGIENE The electric lighting is good and every cell has its light. Little hospital care is needed, seriously sick prisoners being removed to a proper hospital outside. The food interested me and I found that it v^as good and w^ell cooked. The kitchens were models of cleanliness. The foods are furnished by strict specification and no inferior or insanitary food is accepted. There are some pretty hard-looking prisoners received, and under the barbarous rule of some prisons there would be all kinds of trouble with them. While I was there visitors were coming and going, and I intercepted two or three coming out and quizzed them about what they thought of conditions inside. The replies evaded everything about the prison and they seemed to have little interest or care about the prison or the wellfare of their friends inside, but they all took occasion to narrate improbable hard-luck tales and want the authori- ties or myself or any one to give them money or supplies and " do it quick." All over the East Side one finds the uppermost thought to be to get something. A very large portion of the prisoners in this institution wanted to get something and the only function of the city administration, in the eyes of these people, is to give them something. The women are the worst of all, and it is no wonder their men get into trouble. The American spirit of get, get, get is not confined to high life. The recent structural troubles with " The Tombs " are due to the foundations of an adjoining building slipping, due, probably, to the excavations for the subway. Blackweir s Island, once a place for political contractors to exploit at the expense of the poor, is now a very interesting place to visit. The wretched penitentiary of the past is going, and the new is taking the place as fast as the old can be torn down. Plans are under way whereby the island will be turned into one of the best and most beautiful hospital reservations in the world. There will be three zones, one will be a metropolitan hospital dis- trict, another for the insane, and the third for city hospitals. The penal in- stitutions will be removed to Riker's Island and other places. The New York Penitentiary is still at the old place, but the prisoners are kept busy largely at work for the improvements under way, and the conditions are such as to justify the contention of Leavenworth, that work is the best thing for the prisoner. It may be some years before the penitentiary is wholly removed. The report shows that the work is largely outside labor. The workhouse is another institution really in quite a sanitary condition, considering the fact that some of the buildings are old. Plumbing and all sanitary arrangements are good, and this institution is another instance justifying the contention in favor of work. The medical and surgical service is excellent, and one can- not but feel that the petty criminals have here an excellent schooling. A detailed study of these institutions would be interesting and the range of work done by the prisoners is remarkable. The new penitentiary on Riker's Island will be a model institution with industrial and school features, placing it in the front rank, and it will cost several million dollars. Note the grouping of the buildings, and that the light that will reach the various portions of the place will make it cheerful. The location is ideal and the plans call for PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE 65 sanitary arrangements and such surroundings as will make the place a penal health resort to which to transfer prisoners in bad physical condition. The various district prisons and the city reformatory complete a system of corrections admirably striving to bring to pass the best of recent thought in prison reform. In it all I have been impressed with the fact that education and healthful work amid sanitary surroundings remove the bad elements of prison life. It is true that the element of punishment is not lacking, but it is so reasonably administered even with the worst element of people that it will be an object lesson to the old-time jailor to visit New York city and get a permit to see the workings of the various prisons. He will see some things not yet ideal, but if he visits the office of the commissioner and studies the plans of the department he will see that deficiencies are being corrected as fast as the funds can be secured. Disease in prisons. — In the old institutions there is more disease than there should be. Much of it could be prevented. Many persons who reach the prison are wrecked with alcohol and disease, and prison life is good or bad for them according to the degree of sanitation and humanitarianism of the prison and its administration. In a modern institution, many of these phy- sical wrecks end their terms better physically and in ever}' other way than they were upon entrance. The special hygiene of large prisons. — Tuberculosis is the special prob- lem here. Fortunately, there is usually more capable administrators in the large institution than in the small one. Sometimes three is a difficulty in providing sufficient work for the large number of inmates. Some states limit the amount of work by statute. Probably these laws were well meant when enacted, but it is better to leave such matters to the prison management than to legislate concerning them. Of smaller prisons. — Some of the small penitentiaries and the county jails are abominations. No one seems to take sufficient interest in them to awaken the public to the conditions. Sheriffs and wardens are so often selected from the small fry politicians that decorate the county seat that the prison " job " is a rew^ard for political sers'ices and no real work or interest is expected. One cannot blame these officials, but it is time the tax payers of the country took enough interest in the prisons to select better men. One sees much of criticism of the city politician, but for absolute littleness and petty graft commend me to the political contingent in the average county seat where politics is one sided. Many physicians could do their counties a real service by making unexpected visits to the wretched jails usually found and then give them a well-deserved write up in the local paper. The tramp question. — Several years ago I took a short tour with a college graduate who had turned " bum." It is strictly within the truth when I say we had a really good time, and I would enjoy repeating the experience. That should not be the case. We have ourselves to blame for the tramp nuisance. People seem to be afraid of them and feed them for fear they will set the barns on fire. Enforced hard work is the main solution and rural police is 66 HYGIENE the second. Surely the boarding of tramps in jail is an injustice to the tax payer. On the other hand, some honest men who want work go upon the road. We need officials who can differentiate. I am in favor of a tramp's gallery and Bertillon measurements, as well as a record of the whole " pro- fesh." The chronic vagabond thus traced should be imprisoned and made to work hard at some form of productive labor and turned out with small wages for his work. Then, if he is picked up again, he should be put at disagreeable work upon a smaller wage. He is an anomaly and a nuisance, and it is time he be eliminated from the round of comfortable jails he selects. Juvenile offenders. — I pity these little chaps. They are more smned against than sinning. Drink, immorality, and criminality among parents is the real basis for most of the youngsters going wrong. " Original sin " is mostly copied and " innate depravity " is not so uni- versal as most persons imagine. Give the youngster a chance. People who make bad parents should no more complain when the society to protect children from cruelty takes them away than when a similar society takes away the horse they beat and starve. Children are of more value than are horses. The medical service of prisons. — There is but one point I care to make here, and that is that the medical service of a prison should be a sanitary service as well. The prison doctor should have legal power to super\"ise the sanitation of the prison. The advantages are so obvious that little discus- sion is needed. In many prisons this is done and it works out well, provided the doctor studies sanitation. Infectious diseases. — The following from the statutes of Virginia covers the main points to be observed. It is not usually considered wise for a prison to risk contagion within its walls unless the grounds are large and a proper isolation hospital can be maintained: Section 1743a. Quarantine for convicts in the penitentiary and prisoners in the jails in case of any contagious or infectious diseases. It shall be lawful for the governor of the commonwealth of Virginia, upon the application of the superintendent of the penitentiary, when requested in writing so to do by the physician at said institution, to have removed from said penitentiary any felon or prisoner serving a term of imprisonment who has contracted any such con- tagious or infectious disease dangerous to the public health to some place to be desig- nated bv the said governor, and when any such prisoner is so removed he shall be safely kept and treated for said disease, and as soon as he recovers his health, be returned by said superintendent to said penitentiary-, unless the term of his imprison- ment has expired during his quarantine, in which event he shall be discharged, but not until all danger of his spreading contagion has passed. (2) The judges of the county and corporation courts of the commonwealth are likewise authorized and empowered to have removed from the jails of their respective counties and cities, upon the application of the keeper of the jail, when requested so to do in writing by the physician doing the practice at the jail in question, all felons or prisoners serving terms of imprisonment in said jail, and all persons who may be confined in said jail and awaiting trial, who have contracted any such contagious or infectious diseases dangerous to the public health, to some place designated by the judge of the county or corporation court, as the case may be, wherein it exists, and PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE 67 when said prisoners are so removed they shall be safely kept, and receive proper care and attention, including medical treatment, and as soon as they are restored to health they shall be returned to the jail from whence they were moved, unless the term of those who have been convicted of any offense should expire during the time of their quarantine, in which event they shall be discharged, but not until all danger of their spreading contagion has passed. All expenses incurred under and bv reason of this act shall, as to prisoners taken from the penitentiary, be borne by the state, and as to persons taken from the jails of counties and corporations, be paid by the respective cities and counties. (1895-96, p. 193.) General considerations. — There is a tendency to raise the labor union question when proposals are made to introduce workshops into prisons. From some little study of the matter, it impresses me that the labor unions have not been as antagonistic to the matter as have the contractors who desire to keep up the abominable prison leasing system. While prison re- form is important we should not swing so far toward reform as to forget the fact that the malefactor desers'es proper punishment. No matter what point of view one takes as regards the punishment of crime, there is no excuse for insanitary conditions or cruelty in any institution. Their services to the public are constantly enlarging and, as with the army and navy, the work in peace is of greater moment than is that connected with war and disorder. These branches of governmental service are more for the prevention of war and crime than to fight battles and make arrests. With- out depreciating their services in the latter and important fields of action, the armv, the navy, and the police are doing a very important service to the country in preventing various woes inclusive of disease. Read the chapter upon army and navy hygiene, and it will be seen what a great work Is being done for sanitation by these national policemen. Local police can be utilized in much the same way. While police duties do not as yet embrace much aside from the maintenance of order, the larger duties are gradually creeping in by the addition of special police, such as sanitary and ambulance police. It is a tedious task to simply patrol a beat with an occasional arrest for excitement, and I believe many officers would welcome duties of a more varied character. Also it stands to reason that if higher duties are exacted, a higher class of men would enter the work. Recent magazine articles impress one with the idea that the rank and file of city police would be men of correct deportment and without " graft," or other failings attributed to them if they could be removed from under the dominion of crooked politicians and busi- ness interests, not altogether legitimate. Of such matters I know nothing, but am inclined to the view that some magazine articles are a bit perfervid. Police ambulances. — One reads of neglect and cruelty in connection with the police ambulance system. Possibly some cases reported are true, but I have seen so much good done and so many lives saved by the service that the good overwhelms the alleged bad features. Photographs are shown of our Harrisburg service, which uses automobile ambulances. They ride easy, are rapid, and make a very quick response to a call. It is a difficult thing to diagnose and treat a case upon the street or in a rapid ambulance. 68 HYGIENE and it is to be expected that mistakes will be made where differential diagnosis is difficult or involved. The so-called " ambulance chaser " needs to be met with a club when he reaches the hospital. There is no occasion for phy- sicians upon the staff of a hospital to give them any information or privi- leges beyond what is legally necessary. The better plan is for the hospital surgeon to take no interest or part for or against the persons making claims or wishing to settle them, as such matters need not come within the province of the medical man at all. Also the favoring of certain hospitals for political reasons is beneath contempt. The proper fitting of a police ambulance depends upon local conditions. The police matron. — Women understand women's nature far better than do men. Many unfortunate girls and women are arrested who conceal facts mitigating or extenuating their offenses. A police matron can ferret this out and can often do better by the case by getting her into some retreat or institution instead of into prison. The peculiar psychology of crime need not be discussed here, but the simple fact remains that women police officers are needed just as are female detectives. Proper consideration of sex makes the matron necessary. Incidentally, these matrons do a great deal of good in a quiet way and of which the public never hears. Certain sanitary matters properly come under their care. The sanitary police. — These men, when properly trained and of due ability, are not only useful, but may become highly necessary to enforce sani- tary regulations and quarantine. They should be taught the details regard- ing disinfection, since so much public disinfection is a mere farce through the ignorance of those entrusted with the work. Their place in suppressing vice. — Gen. Theodore A. Bingham, former Police Commissioner of New York city, said, in an article in Hampton's Magazine (September, 1909) : The social evil "can be controlled ; not licensed, but segregated so as to be reduced to a minimum. Prostitution, at present scarcely restricted at all in New York, but rampant on the lower East Side and in the * Tenderloin,' demands quarantining just as do yellow fever and smallpox. Given full authority to grapple with this scourge, regarding which decent citizens of the community are as ignorant as children, a zealous police commissioner can restrict it to specific districts and, with the aid of the health department, keep it under absolute control. Not only would this reduce by one half the fearful ravages of disease, but it would greatly reduce the dangers to which the youth of the city are now exposed through the presence of well- appearing, immoral women even in the most exclusive apartment-house neighborhoods. " Beyond enforcing segregation the police are powerless to act, espe- cially when this vicious and appalling evil renders such rich returns to poli- ticians for their own profit and for corrupting the police." Police instruction in -first aid should be given in every city, and also to firemen in the paid service. The policeman is frequently the first man avail- able, especially at night. I have found the officers to whom I have lectured very much interested. Germany makes a general public factotum of the POLICE AUTOMOBILE AMBULANCE SERVICE PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE 69 policeman, and we will come to the same thing in this country eventually. I have great faith in the future sanitary value of the police department. Hospitals for the Insane* Much can be said upon a subject which carries with it such vital inter- ests, not only to those confined in these institutions, but to the community at large. What new ideas can be brought forth ? It is easy to see faults and to criticise, but is it equally as easy to supply the necessary remedy for those evils with which we find fault ? The subject of this chapter leads the reader to infer that the author has mastered this difficult question, and in the short space allotted to him would point out clearly to them the duties of those good men at the head of these important institutions, in the perform- ance of their work. The duties of these institutions as regards the observ- ance of laws of public hygiene and health are already well known. Knowing our duty, and possessing the ability to perform it correctly, does not always follow each other. Of course it is the duty of each and every public hospital to see that its inmates are properly protected from influences that will impair their general health, and at the same time it is their duty to protect the public from any infection which may arise in such places. But is the great difficulty of such an action on the part of the officials generally reasonably considered ? I am speaking of the hospitals for the insane. One of the most trying of all public positions is that of superintendent to one of these state institutions. A great field indeed for good work, but one's reward must be looked for in the great hereafter, because I have never known it to appear during the lifetime of any present incumbent. In case a patient receives a black eye, loses an overcoat or a pair of sleeve buttons, makes his escape, or hangs himself, the officer in charge is considered the one to blame. Or should the condition of patients be such that visits from friends or relatives would do him any injury, such a refusal to have his friends see him would be proof positive in the minds of those receiving this denial, that there was some other motive for the refusal. They would think that the patient had been abused, or is being punished in some way, and the officer is bringing this point forward as a good excuse to shield himself for that which seems sure is an evil act on his part. Now if these officers are meeting with obstacles like this daily in the administration of their duties, what would be the result if the public were refused admission entirely to this or that person ? He is in quarantine, there is an infectious disease; that quarantine in the minds of a great many means a dark cell. If the super- stition and prejudice against hospitals for the insane could be removed, it would be one of the greatest benefits to that unfortunate class of people who lose their minds and have to be committed. It would mean hospital treat- ment of insanity in its incipiency. A thing we do not see now, and the super- stition which lurks in the mind of every one who has relatives in hospitals, viz. that these people were subject to neglect and abuse, would be removed; and it would add as much comfort to those at home as it would give benefit to that most unfortunate class of people who are inmates of these institutions. *ByW. E.Wright, M.D. 70 HYGIENE Infection does not always originate in hospitals. For the most part patients in these institutions are cleaner, better housed, and better fed than they ever were before their admission. But on visiting days great crowds of the curious swarm through the wards, in the most part a class of people who have no interest in the study of insanity or the conditions of the insane, but who are idle and curious. They stare with astonishment at the homelike appearance of the wards, and the sane manner and appearance of the inmates, they giggle, shy off, and appear to assume fear of attack, but at the same time are disappointed, and their appetites for the sight of suffering and general disorder they had hoped to see is not satisfied. Why should not these curious people, who come in many instances from the slums of our towns and cities, bring in contagion ? In the times of great commercial prosperity it is almost impossible to keep efficient employees in these institutions, and it is equally impossible to employ new ones who are efficient. During this period the officers are forced to employ a class that are in many respects themselves degeneiate. They could not succeed in getting such employment, if the institutions were not in destitute circumstances as regards employees. These people come from unknown districts, are themselves dirty and unkept, and are put in wards to have charge of clean patients. They are liable to bring all kinds of infection with them. It is from this particular source that vermin is introduced into public hospitals, and when this pest once gets a lodging, every one who has had hospital experience knows how difficult a matter it is to get clean of it. And is not this an infection ? With the exception of tuberculosis, it has been my experience that the various infectious diseases, when developed in hospitals for the insane, are more frequently carried there from without than it has been that the infection arises within the institution itself. A case of diphtheria in a patient may be traced to the employment of a new nurse who comes from a home recently infected. A case of scarlet fever develops when an attendant goes to a friend's house in the city, though he knows it is placarded. A case of typhoid fever develops from food brought by relatives from a home where there is a case of the disease. There are really so many minor ways by which infection can reach the inside of a public hospital, that I think much weight should be given to its importance, and especially should promiscuous visiting to these wards be carefully guarded against. The state of Pennsylvania has many large institutions built with a specific purpose of giving care and maintenance to the insane. These institutions are given the name " hospital." In addition to these there is provided an insti- tution for those unfortunates who are no longer considered curable, and thus are not amenable to hospital care. These people, if they are able-bodied, and capable of self-support at ordinary labor, are committed to this specific institution, which is given the name " asylum." It is necessary that a person shall have been insane one year, and that he or she be able-bodied and capa- ble of working, in order to be eligible to a residence in this asylum. When I interpret the definition of hospital and that of as}'lum, the meaning of the PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE 71 terms is a widely different one. A hospital would naturally be a place where the acutely sick are cared for; an asylum is a place for safe keeping and pro- tection. Now when we consider the fact that in those institutions the state calls " hospital " not more than five per cent (and this probably is too high) of their number are considered curable, and the vast number of patients there are merely crowded together in wards which have barred windows and locked doors, in their overcrowded conditions, two patients occupying a space origi- nally built for one, the corridors or day halls are crowded with poor, demented people who much prefer lying on the floor in some dark corner of the room to occupying comfortable seats at an open window, and who are necessarily breathing a polluted atmosphere constantly, the only change in the monotony of the life of these individuals is a visit to the dining room, and then to a large dormitory to sleep at night; perhaps once or twice a day in good weather the most trustworthy of these patients will be taken out for a walk about the grounds for an hour or more. When we consider the environment, and the mental condition of this class of people, which would be the better term for such an institution — hospital or asylum ? It seems to me that asylum fits in with the description admirably, and yet Pennsylvania had five such chronic institutions when the place near Wernersville was built, and to designate it from the others known as hospitals, was called Asylum for the Chronic Insane. This has always appeared very unfortunate to me, when the fact was con- sidered that this great commonwealth was already the possessor of five institutions which were then caring for the chronic insane, had this idea only been reversed, and instead of another chronic insane colony, a hospital in its truest sense been constructed where acute cases could have been received and properly studied and treated. Then, after a stated period, say a year, there should be found no benefit, and the case declared an unfavorable one, let such a case then be transferred to one of the chronic asylums already in existence. With a colony of fifteen hundred or more people crowded together under unsanitary conditions, it is but natural to expect infection to crop out at vari- ous intervals. As I have already pointed out, the inmates of these institu- tions are living in an atmosphere depressing, both mentally and physically, their vitality is lowered by disease, and their resistive forces are also greatly diminished, making them shining marks when exposure is brought about. In institutions of this kind the only way to prevent a spreading of the infection is a prompt and proper isolation of the case. When there has been no thought, and no provision made for such an emergency, it taxes the ingenuity of those in charge to meet it, when they make a discovery of a case of scarlet fever or diphtheria in a ward with seventy or one hundred patients. The first diflficulty is the fact that in these overcrowded places every bed is occupied, the patient probably has been a mild case, and was sleeping in a dormitory with twenty-five or more patients. It is now necessary to get him in a single room. There is no single room available. The room for isolation must be large enough to accommodate an attendant also, because the patient cannot be left alone. The room must be in a secluded part of the ward, because 72 HYGIENE other patients must be protected; there must be water closet and bath facili- ties; also an arrangement must be made for his meals to be served, and the proper disinfection of dishes and bed clothing, etc. After making a half dozen or more changes, and inconveniencing that number or more persons, and making them more or less uncomfortable, such a case of infection is generally taken care of in a room on the ward, or in a part of the building which to the mind of the officer serves as the best facilities at hand for such an isolation. In the majority of cases it is not ideal. The next day in another ward, per- haps, you will find a case of diphtheria. This time the subject of the disease is a violent and treacherous patient. Maybe he cannot be trusted in a room with other patients, and the room which he occupies must have guards on the windows and inside shutters to protect him from his own violence,— what is to be done with this case ? He cannot be left in the ward, because he occupies a room — say about the center — where every other occupant comes in close contact many times each day. It is the same old hardship, some one else has to give up his room, — but where is the last patient to sleep ? You will say at once, " In the room of the patient who has just been moved " ; but this cannot be done, because this room has to be fumigated. " Well, why not fumigate it ? " Because it may be late in the evening when such a case is discovered, and there is no time for the proper fumigation and ventila- tion in order to have it ready for the patient to sleep in that night. All such questions are constantly arising, and have to be promptly met in institutions for the insane. It is one of the most trying problems a physician has to deal with, and could be simplified so readily by establishing a ward or building for the isolation of such infectious cases. In every institution for the insane there should be an isolation ward, or hospital for contagious and infectious cases, arranged with diet kitchen, sterilizing room, bath, and comfortable quarters for those who have to nurse such cases. Special sterilizers in laundry for the care of bedding and clothing, etc., should also be provided. In these institutions the appearances of infectious diseases are more to be feared than the outbursts of violence among the inmates. A typhoid case, if not properly protected, may be the nucleus for an epidemic. Typhoid fever is, as we all know, a water-borne disease, but there are other means of carrying the infection. The germ is generally introduced through the ailmentary tract. I have known more than one case in a public institution to have originated by taking food brought them by their relatives when there had been a recent case of typhoid in the home of that individual. These visitors are admitted to the various public institutions to see their relatives on special days in each week. They always feel it is their duty to take the sick some- thing to eat, and the patients generally expect them to do so. It is out of the question for the superintendent in charge of such an institution to make an inspection of each of these individual parties, and ask regarding contagious diseases in their homes. Even if such a plan were feasible, the parties would not always give correct statements regarding them. Their lack of knowledge and appreciation of the importance of the subject makes them careless, and they would enter a denial, if they thought by doing so they would be able to PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE 73 gain permission to see the patient. I mention this as a source of infection that is hard to guard against, but it is an important one, and must be given careful study as to what measures could best be applied to prevent it. But apart from the outside danger of carrying infection to the inmates of these institutions, there are the conditions in these places in particular which I have already mentioned, and which seem to me to be a hotbed for the development of such infection as tuberculosis. How does the health officer recommend that these tuberculosis-favoring conditions should be met in an insane hospital ? In the first place let me picture the conditions as I have seen them, and tried to meet them for a period of a dozen years or more. Old buildings, poorly ventilated, badly heated, very little sunshine, capacity overcrowded forty per cent, inmates majority are chronic, demented,' restless, untidy, irritable, and very careless in their habits. A great many prefer to lie on the floor in some corner of the room, their faces turned to the wall, and become irritable when they are asked to sit in a comfortable chair near an open window. Some of these people, if not watched constantly, will remain in the chair but a few minutes before they return to their old positions on the floor in the corner of the room. These people are breathing bad air constantly, seldom getting in the sun, all the exercise they get is going to and from the ward to the dining room, and the dormitory to sleep. Is anything more potent for the predisposition to the development of tuberculosis than the life of an individual with such en- vironments r These people do develop the disease with alarming frequency. They are weak to begin with, their mental condition is that of a chronic dis- ease, their resistive force is lowered, their circulation is poor, and their diges- tion is bad. I believe if the tuberculin test Vv^ere made upon all the patients in the disturbed and overcrowded wards of our state ond county institutions which care for the insane, that there would be a positive reaction in at least twenty per cent of the cases. These cases in their various stages are mingling with the other inmates daily. In the advanced cases, or those that have been recognized, there is some attempt at isolation for those of mild mental dis- turbance. If they are not violent, or if they are too feeble to do physical damage to others, they are placed in an infirmary ward, or such room with more sunlight and better ventilation than they had when they developed the disease. These patients have always been careless in their habits, they ex- pectorate promiscuously, and they cannot be taught, or will not, the habits of hygiene, which I mentioned in the beginning of this subject. In my mind they are far more dangerous individuals even in this bedridden and exhausted state than they were when in the strength of their mania and muscular bodies they were inclined to assault others. These patients expectorate over their bedding and the floor about their beds. Often in an irritable mood their weapon of defense is to expectorate in the face of an attendant who wishes to change their clothing or administer some aid. These are dangerous problems which the medical officers of these institutions have to deal with constantly. The peculiar nature of these individuals under their care makes it a major problem in comparison with the conditions which are met by the general practitioner and the various dispensary physicians throughout the 74 HYGIENE state. They are dealing with chronic mental conditions, in the majority of cases incurable, together with a dreaded physical malady, the hygiene and prophylaxis of which depends in great part upon the individual himself. These subjects now under discussion pay no attention whatever to such methods, and cannot be taught to do so. I know there has been written a great deal recently concerning the tent life of the tubercular insane. Pho- tographs illustrating the work of attending physicians in various state institu- tions in New York have been displayed, for which the authors should receive due credit. Only the very mild cases could receive the benefit of this outdoor arrangement, and the violent case, with his resistive tendencies, was still locked up in the ward with the other inmates, who were forced to come, if not in direct contact with him, were compelled to breathe the same atmosphere, which may have possibly been made dangerous by his filthy habits and care- less expectoration. In the past few years Pennsylvania must be given credit for efforts in the better housing of the insane. The old buildings, badly ventilated and poorly heated, which were referred to a moment ago, have been, by the persistent efforts of a worthy superintendent and a determined board of trustees, torn down. Only two are now left. In the place of these old buildings have been constructed modern fireproof buildings on the cottage plan, which not only insure a better classification of the inmates, but give them more comfortable apartments with cheerful surroundings, good light, plenty of sunshine, suc- cessful ventilation, and good heating. The plan, when completed, will be a pride to the state and a monument to the memory of those good officers who for years have fought the hardest obstacles and reverses in order to carry out their plans. The overcrowding in some of the departments here, however, continues, and the tubercular insane are still there. It may be with these improved environments the percentage of tubercular cases in future years will be lowered, but the means of isolating such cases, and those of other infections, has not been provided. The same condition of affairs exists in every hospital in our state. I have reference to a hospital building for isolating the infectious diseases. To sum up, then, the duty of every institution housing the insane when infectious diseases make their appearance is, first, to establish isolation and disinfection. Quarantine regulations as provided by the state board of health should be closely observed. The hospital should be properly screened against the infection from insects, such as flies, mosquitoes, roaches, rats, etc. To carry out these plans properly, every such institution should be provided with the proper isolation ward or building, which is distinct from the rest of the buildings, and should be used for no other purpose. With such a pro- vision in every institution there would be fewer instances in which the second, the third, or in a particular instance one hundred and fifty cases follow the first infection. Notes by the Editor. — The preceding very excellent paper by my colleague in the neurologic work in Harrisburg Hospital tends to confirm my views that the average insane person does not receive the kind of treatment best adapted to cure. His point PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE 75 is well taken that the average institution is an asylum and is not a hospital. In the first section of this chapter upon penal institutions it will be observed that the old ideas of prisons were a place to shut up people away from society, but that the new idea is to so train the prisoner as to return him again to society and industrial usefulness. It will not be long, in my view of the case, when the same progressive ideals will abolish the present type of asylums for the insane, and that establishments similar to the Craig Epileptic Colony of Sonyea will be opened for the treatment of insane people presenting some reasonable promise of cure or improvement. A movement in this direction has been initiated by the establishment of psy- chopathic hospitals. It was my pleasure to inspect the one at Ann Arbor, Michigan, and a photograph of the building accompanies these remarks. The following printed matter is taken from the first biennial report of the hospital, and from an editorial in the August, 1909, Pennsylvania Medical Journal. The state of Michigan has the creditable position in the history of psychiatry in America of being the first to establish a university hospital for the care and treatment of mental diseases, and of providing adequate facilities for the instruction of medical students of the university regarding insanity. The achievement of this hospital is almost entirely due to the late Dr. William J. Herdman. . . . As a result of his in- terest and initiative there was passed by the Michigan State Legislature in 1901 (Act 161, Public Acts of 1901) an act to provide for the construction and equipping of a psychopathic ward upon the hospital grounds of the University of Michigan, and to appropriate the sum of ^50,000 therefor. It must be borne in mind that there were no precedents to follow in drafting a comprehensive set of provisions for the organization and administration of a new hospital. The problem was to establish an institution of the type desired in the usual state organization for the care of the insane. It was essential that there should be harmonious co-operation with the asylums of the state, and at the same time the new hospital should be an integral part of the University Medical School. . . . Patients may be admitted to the psychopathic hospital by any of the following procedures: I. Any judge of probate may commit any insane person to the psychopathic hospital whom the director regards as a suitable patient for the hospital. II. A person may be sent to the psychopathic hospital as an observation patient for a period not longer than thirty-five days for any of the following reasons: 1. When the judge of probate may have doubt as to whether the person is insane and desires such data as could be furnished by an observation under such conditions as the psychopathic hospital can furnish. 2. When the mental condition of the person is associated with complicating physical disease which may be benefited by treatment by the physicians and surgeons of the general hospitals of the university. 3. When the judge of probate regards a decree of insanity as inadvisable as when the disease will be of such short duration as to recover within the period of thirty- five days. . . . The patients who come to the hospital are afflicted with different forms of mental diseases. Some are noisy and restless, some are depressed and apprehensive, and some bedridden from serious disease of the nervous system. Others come for relief from abnormal mental states which are not classed as insanities. These conditions are commonly known as psychopathic states, and it is these that this hospital can do most for. Such persons have various hysterical manifestations, severe forms of nervous prostration, or are troubled with fears of one kind or another that make their lives miserable. It is obvious that such a variety of conditions as these just mentioned need different arrangements for treatment. 76 HYGIENE The considerable number of patients seeking treatment for various psychopathic conditions, and who are not insane, must be cared for apart from those who are insane. It is not an uncommon occurrence for patients of this class who come to the hospital, to refuse to remain when they learn that they cannot be given accommodations apart from those who are insane. The few of these patients who are brave enough to come into the hospital under ihe conditions which now exist are greatly benefited by the treatment. However, i^ is always apparen. chat they would do better if they could be kept from contact with those who are insane. If this were possible, many others who could be benefited would enter the hospital. . . . In addition to its duties to its patients the psychopathic hospital is a part of the state's educational system, and will have a part in the training of the future physicians who will have the care and early treatment of those mentally disturbed throughout the state. Since the opening of the hospital, students of the medical department of the state university have enjoyed opportunities for the studying of mental diseases not possible elsewhere. Clinical lectures on insanity have been given each week to senior medical students. The results of such practical instruction must be apparent to all. ... STATE PSYCHOPATHIC HOSPITAL AT UNIVERSITY OF MICHIGAN The first biennial report of this institution, of which Dr. Albert M. Barrett is medical director, has just been issued and contains much of general interest. The passages found on a preceding page are abstracted from the report. Two hundred and thirty-nine patients were admitted into the hospital from its opening until June 30, 1908. These cases have been analyzed in the most interesting and instructive way by Dr. Barrett. The Kreplin classification is largely adopted. The relative frequency of the various psychoses will be seen by the following per- centages which Dr. Barrett gives: Mania depressive, 17.1; dementia praecox, 16.7; alcoholic insanity, 5; general paralysis, 7.9; hysteria, 8.4. Smaller groups include melancholia, paranoia, senile dementia, imbecility, cerebral syphilis, Huntingdon's chorea, etc. The psychopathic hospital at Albany, N. Y., and the psychopathic ward in con- nection with the St. Francis Hospital in Pittsburg have for some years been doing excellent work; now this larger and broader experiment of a state psychopathic hospital in intimate connection with a university will be watched with greatest in- terest. This hospital aims to bring not only " insanity," but conditions allied more or less closely to it under the same careful supervision, observation, and treatment as are now afforded persons sick from what are called physical diseases. Johns Hopkins University is preparing to build a psychopathic clinic which is made possible by a large fund given by Mr. Phipps. Dr. Adolph Meyer, who has been selected for the head of the proposed clinic in Baltimore, is at work studying out plans for it. Doubtless when this building is completed there will be incorporated in it all or most of what is best and most advanced in psychiatry. Altogether it would seem that the way has now been opened for psychopathic hospitals in connection with universities and with other hos- pitals in large cities where medical men, trained in this particular branch of internal medicine, can be secured. — D. This movement is bound to grow, and will result in the early treatment of mental diseases, a consummation that will save to the state and to society much more than will the new hospitals cost. The colony and industrial treatment of less encouraging cases will also reduce the cost of looking after these people. I have been reading with interest two old books, " Mental Hygiene," by I. Ray, ^'1 . MICHIGAN STATE PSYCHOPATHIC HOSPITAL AT ANN ARBOR PORTION OF THE "tOMBS" PRISON, NEW YORK CITY PENAL INSTITUTIONS AND HOSPITALS FOR THE INSANE 77 M.D. (1863), and " The Use of the Body in Relation to the Mind," by Geo. Moore, M.D. (1847). The first book is purely scientific, while the second one includes the spiritual and religious phases. And now if the reader turns to the chapter upon epidemics and reads there about the dancing mania of the middle ages, and realizes that various cults and alleged religions of to-day are really succeeding in engrafting a sort of mania upon their deluded followers that may eventuate as disastrously as did the middle ages cults, he will come to realize that these old books by physicians should have been taken more seriously, and that we owe it to our own age to study and teach a sane view of the influence of mental impressions upon bodily functions and diseases. In other words, we need to study not merely how to treat incipient insanity, but we must learn how to prevent such disasters as well. But the subject is too big to pursue here. Just permit me to say that the clergy Vv'ill not add much of value to our knowledge unless they abandon present methods, and both clergymen and medical men can learn much by a study of some of the old literature written before every writer felt that his chief task consisted in assailing or explaining Eddyism. History does that. What we need to do is to begin over again and view the question in the wide attitude of sociology and what we may call mental sanitation. The following editorial appeared in the Medical Council for November, 1909: DREAMLAND AND INSANITY The most pleasant of dreams are those that relate to ourselves, and the most dangerous that we are greater than our fellows. Joseph, of biblical lore, tried the latter and won out, and he has had many imitators who lost their all. The worst mundane loss is our reason, but few realize how serious a matter it is to even have it impaired. We have just had related to us a distressing case of insanity in which the un- fortunate man imagined he possessed occult power, and that his enemies were hypno- tists. In going through his eff'ects it was found that he was a " graduate " of a corre- spondence school of magnetic healing, and was accredited with wonderful healing virtue. Another " diploma " declared he was a made-by-mail hypnotist and capable of manifold stunts of entertaining and healing. Numerous kinds of new thoughts and cooked-over occultism, commercialized esoteric specialties, spiritualism up to date, oriental mysticism and all that line of flubdub were represented in a miserable lot of well-thumbed magazines and booklets, most of which endeavored to assail medicine and medical men. We had no idea that so many swindlers were fishing for suckers with such ancient bait, but when we realize that vanity is inversely strengthened as intelligence is weak- ened, we can see millions in it for the mail-order character builders who promise " to develop latent forces and a strong personal magnetism guaranteed to make any man or woman successful in anything undertaken." Unfortunately, learning to read does not breed sense, and there are millions of readers whose superstitions are only increased by reading the superstitions of others. Superstition breeds supernaturalism and it, in turn, superegotism, and the ignorant class who are fleeced by these esoteric fakers are the most superlative egotists in the world. Implant this upon an already weakened mind and disaster follows. When the world sobers up from its present worshiping at the shrine of the cults that range from the ignorant mail-order hypnotist to clerical mentalopathy, but are at bottom the same thing assorted for different minds, there will be a trail of wrecked minds and crowded asylums. 78 HYGIENE " The saving grace of common sense " is as necessary for the mind as is the grace of religion for the soul. We physicians have been saving bodies; let us realize that we can save minds as v^ell. Prevention is the cry in nearly all diseases. Let us start a propaganda to aid in the prevention of mental diseases. Better far prevent them than to hold religious clinics and experiment with all the ancient quackery ever devised or^the making of fools out of idiots. Chapter V MATERNITIES* Introductory — Early maternities — Social considerations — Modern institutions — Objections urged — Illegal maternities — Laws regulating all institutions and with especial reference to the statutes of Ohio — Ethical, professional, and religious considerations. AMONG the instincts or primary impulses of mankind a very important one is that which leads to the propagation of the race. It presents more of the complicated problems of developing civilization than perha ps do all others combined. Among these important problems are to be found the question of the care of the mother during her period of gestation and labor, and the care of the children until they reach an age at which is it thought proper to let them undertake their own maintenance, largely depending upon the stage of progress in the arts and sciences which has been reached by the community in which they are born and reared. The ideal condition of mankind would be one in which all families, each consisting of one father and one mother, enjoy a sufficient income to enable them to maintain a comfortable home. One has but to take a cursory view of the different nations of the world, or even to look around him in his own community, to realize how frequently these conditions are imperfectly enjoyed or wanting altogether. Many homes are not properly equipped for the care of the parturient woman, and many women who find themselves in the con- dition of impending motherhood have no home at all. In no respect is the progress of civilization more marked than in the development of institutions for the proper care of those who are not able to care for themselves. Among the last to be considered in the development of such public institutions have been those providing for the wants and necessities of indigent mothers, either married or single. The earlier maternities were established solely for the purpose of pro- viding a place where poor but respectable married women could be properly taken care of during their accouchement. The reasons for restricting the services of such an institution to respectable married women have been so strongly expressed by the founders of The British Lying-in Hospital for Married Women, established in London, in 1747, that we quote from the prospectus issued by them, as follows: Poverty is an object of pity; sickness and poverty united seem to comprehend all the natural evils of life. But, as it is not the case of every sick person to be dis- tressed in circumstances, so there are not many persons, thus distressed, whose calamity it is to be frequently or periodically ajfflicted with sickness; whereas, most women that marry bear children, and those who work for their subsistence, are, for a considerable part of their lives, annually disqualified for labor; at other times their labor is but a bare support. During the latter part of their pregnancy, and the time of their lying-in, *By J. J. Taylor, M. D. 80 HYGIENE the needy family is wholly taken up in attendance upon them, and the joys, natural at such a season, are suppressed by the wants which surround them. Or, if they be destitute of this attendance, how great is the hazard that the helpless mother, or the child, or perhaps both, may, by their deaths, become melancholy instances of the evils of real poverty. They [the governors] allow, that every fellow creature in distress is an object of compassion, even though that distress is ever so apparently the consequence of their vices. Nevertheless, as members of society, they think they should not be justified, without the sanction of the legislature, in receiving such objects: First, because the legislature has considered the persons in question as criminal; has rendered them liable to punishments, and has declared their offspring illegitimate; on purpose, no doubt, to discourage the vices of individuals, and thereby preserve the good order of the whole. Secondly, because bastard children gain a settlement in the parish where they are born; they think therefore they should be an act of injustice to the parish, in which the hospital is situated, in bringing upon it the incumbrance of these children, which, in a course of years, might accumulate to a very great number. To prevent the like incumbrance upon the parish (as all other children, whose parents' settlements are not known, obtain a settlement in the parish where they are born) it has been the custom, before admission of the patient, to require an affidavit of the time and place of her marriage, and of the place of settlement of the husband or wife, in order that the parish might be enabled, should there be occasion, to pass the children to that place of settlement. Similar to this is an institution established in Philadelphia in 1837, by Dr. Jonas Preston, bearing the name of the Preston Retreat. His purpose is well expressed in the following extract from his last will and testament. It has long been my opinion that there ought to be a lying-in hospital in the city of Philadelphia for indigent married women of good character, distinct and uncon- nected with any other hospital, where they may be received and provided with proper obstetric aid for their delivery, and with suitable attendance and comforts during the period of weakness and susceptibility which ensues, continuing ordinarily about four weeks. I have no doubt that there is often much suffering and loss of life in such cases from the effects of ignorance and destitution, and I think an establishment for affording the required assistance well deserves a place among the numerous charities which attest the Christian philanthropy that characterizes Philadelphia. Under this con- viction, and to contribute what may be in my power to supply the want, with a firm belief that our Blessed Lord will cause the work to prosper, so that the needy shall not always be forgotten, nor the expectations of the poor perish forever, I do hereby give, devise, and bequeath, etc. The Preston Retreat exists to-day as one of the model institutions of the kind in the w^orld, although not one of the largest. A class of institutions v^hich breathe more truly the spirit of Christian charity are those which open their doors to married women and unfortunate single women alike. A fine example of such an institution is the Maternity Hospital of Philadelphia. The spirit of this special work is excellently shown by the following extracts from their proceedings : " The object of this hospital as set forth in its charter is the care, nurture, and maintenance of destitute women, married or single, during childbirth MATERNITIES 81 or whilst suffering from diseases peculiar to their sex; of children born of their bodies, either whilst in the care of the corporation or surrendered to it after birth; the providing for the spiritual and temporal welfare of such women and children either within or outside of the institution, as well as the care and boarding of women and children for compensation." Most of the founders had been previously connected with the obstetrical staff of the Philadelphia Hospital, and all were familiar with the fact that not infrequently young unmarried girls were found in the obstetrical ward, where they had gone to be delivered of their illegitimate children. As these girls, often mere children, were neither vicious nor depraved, it seemed cruel to compel them to be exposed to the degrading effects of the associations and the publicity which must necessarily follow a prolonged residence in a city alms- house. As a careful search among the then existing institutions revealed the fact that there was no place in the city of Philadelphia, or the state of Pennsyl- vania, outside of the county almshouse, where an unmarried woman could be taken care of during the period of her confinement, it was then determined to create such an institution. From the very beginning the work of the institution was the subject of heated controversy. By many well-meaning persons it was contended that the mere fact that such a refuge was known to exist would tend to increase the amount of illegitimacy and even act as an incentive to vice. Many indignant protests were sent to the board, and individual pressure, as well as public opposition, was brought to bear upon the members. Fully convinced, how- ever, of the real necessity for such a charity, and trusting to the ultimate triumph of broader and more humane views, the founders of the hospital persisted in their labors and the struggle for existence began. Since the admission of the first patient in 1873, 9,693 applications for admission have been made, and 3,288 women have been confined in the hospital. Of these, 36 died, a mortality from all causes of 1.1 per cent. The justice of their position is further argued in the following quotation from the thirty-fifth annual report: The commission of sin must be prevented, the weakness of the frail girl or woman strengthened, the saving of poor girls "subjected to the influence of man's examples and the teachings of evilly disposed persons," leading to vice, poverty, or crime, effected through the instrumentalities of institutions like the Maternity Hospital. The continued operations of our hospital prove the necessity of its existence, as a place of refuge for those who seek admission to its portals, where they find not only physical help, careful nursing, and nurture, but loving counsel, moral uplifting, and honest effort to help them physically, mentally, and morally. We cannot too often repeat that we do not offer shelter as an extenuation of the sin committed, that we do not encourage evildoers, but we do have the compassion and pity to attempt the strengthening of the weak, the care of the helpless, the pro- tection of the suffering, and the reform of the sinner. With all the efforts being made to reform the delinquent, the convicted criminal, and to substitute for the law of re- venge and vindictiveness the law of love, should we hesitate to evidence that love for the poor girl, in the extremity of her suffering, and for the helpless babe, surely not responsible for the error which has brought it into existence? God helping us, we 82 HYGIENE purpose to continue our work, not only as efficiently as we have done it in the past, but even more efficiently, more effectively, and to that end we invite the helpful co- operation of the charitable and benevolent public. Our statistical report is both sad and satisfactory. Sad to find a little mother of twelve years, another of fourteen, four of fifteen, seven of sixteen, twelve of seventeen, thirty-one of eighteen, nineteen of nineteen, and eleven of twenty, making eighty-six, or more than fifty per cent of our patients who became mothers during their minority; satisfactory, that out of a hundred and sixty-eight patients delivered since October 1, 1907, only one died from a septic cause and none from a non-septic. We quote these reasons in full as being the best expression of the argu- ment that could be given. One of the greatest institutions of this kind is the Lying-in Hospital of the city of New^ York. This institution was established in 1798 by the Society of the Lying-in Hospital of New York City, at the instance of Dr. David Hosack. Its magnificent building is one of the best equipped maternity hospitals in the world. It cares for more cases than any other institution of the kind in America. The general purpose of all these maternity hospitals is primarily to supply facilities for the comfort and safety of poor women during their period of confinement. Incidental to this, however, they supply, by their perfect organization and equipment, the means by which the most advanced ideas in the science and art of obstetrics may be put into practice and still further developed. Thus they have been the means of advancing the practice of obstetrics and of reducing very greatly the mortality from the various acci- dents and diseases incident to motherhood. The various problems relating to the care of the woman's health previous to confinement, and the causes and prevention of eclampsia, puerperal infection, and the various other dangers of the confinement period, can all be worked out most systematically and thoroughly in such an institution, where the conditions can be the best for all patients and where a thorough study of each case may be made. The results of these studies advance the practice of obstetrics in private as well as hospital work. Also, they supply the means of instruction to thousands of phy- sicians, medical students, and student nurses. A large part of the work of these institutions consists in the attendance upon parturient women in their own homes by students and visiting physicians from the maternities. Nurses are also supplied in a similar manner to the patients in their own homes. In the period before our knowledge of sepsis as the cause of puerperal fever, lying-in hospitals had some very sad experiences. These diseases, once getting established in a large institution, made it a veritable pesthole. The following facts will give some idea of the troubles which these institutions went through. In 1875 the International Congress of Physicians at Brussels resolved: Large lying-in hospitals ought to be abolished. They ought to be replaced by small institutions with separate rooms. There ought to be a house for occasional use in the neighborhood of the estab- lishment, having an entirely different administration and different physicians. All this was to avoid puerperal sepsis. .!\ m ,,•*#■•* llP" ^^SSi:»««*"""r^ THE LYING-IN HOSPITAL, SECOND AVENUE, 17TH AND 18TH STREETS, STUYVESANT SQUARE, NEW YORK MATERNITIES 83 In 1856Tarnier, of Paris, made elaborate investigations (aroused by the high mortality rate in the Paris Maternity Hospital), and he found mortality in private houses, 1 in 322; mortality in maternal hospitals 1 in 19; Le Fort (Des Maternites, Paris, 1866, 1, p. 84), estimating statistics for nearly two million confinements, found deaths in hospitals, 1 in 29; deaths outside of hospitals, 1 in 212. Matthews Duncan ("Mortality of Childbed and Maternity Hospitals," Edinburgh, 1871), seriously called these figures in question and said: "With our great registering machinery all at work, we cannot find out what is the mortality of childbed in London." Henry J. Garrigues, M.D., of New York (Trans. Amer. Gyn. Society, 1877), says (p. 600): " If we leave out the exceptional results of prominent obstetricians, in wealthy practice, we obtain one in one hundred, as repre- senting the mortality connected with childbed in large cities, outside of the hospitals." He admits larger figures for hospitals, but thinks cleanliness and antisepsis would much modify the figures, and concludes: " Lying-in hospitals with a number of yearly confinements not exceed- ing a thousand are not to be feared, when they are properly managed." These figures show the mortality caused largely by " child-bed fever," as it was then called, but which is now known as puerperal sepsis. Since the profession has accepted the facts taught by Semmuelweis and Oliver Wendell Holmes, regarding the contagious character of this disease, and since later the principles of antisepsis and asepsis have been properly established, the conditions have been reversed, and the mortality in maternities is less than in private practice. In the maternities all obstetric procedures are con- ducted under the strictest aseptic conditions and infection is so rare as to be almost a thing of the past. The maternities thus far considered are of a public character conducted for a purely philanthropic purpose and of undoubted legal existence and practice. However, it may readily be seen that the private care of women in confinement is a matter which easily lends itself to commercial exploitation. Many establishments for this purpose have been conducted, the most of which have not been for a legitimate purpose. After more or less experience of the various points that may arise in the conducting of such establishments the states have generally enacted stringent laws regulating the establishment, conduct, and inspection of such enterprises. From the different state laws we select those of the state of Ohio as in our opinion most thoroughly cover- ing the requirements of the subject. LAWS OF OHIO REGARDING MATERNITY BOARDING HOUSES AND LYING-IN HOSPITALS 10 regulate the establishment, maintenance, and inspection of maternity boarding houses and lying-in hospitals Section 1. [Definition of maternity boarding house or lying-in hospital; nurses.\ Whoever for hire, gain, or reward, receives, cares for, or treats within a period of six months, more than one woman during pregnancy, or during or after delivery, except women related by blood or marriage; or whoever for hire, gain, or reward has in his custody or control at any one time two or more infants under the age of two years, 84 HYGIENE unattended by parents or guardians, for the purpose of providing them with care, food, and lodging, except infants related to him by blood or marriage, shall be deemed to maintain a maternity boarding house or lying-in hospital. Provided, however, that nothing herein shall be construed to prevent a nurse from practicing her profession under the care of a physician in the home of a patient, or in a regular hospital other than a lying-in hospital. [O. L., v. 99, p. 13.] Sec. 2. [Licenses; what contained in license; limit of number; inspection.] The state board of health shall have the power to grant licenses to maintain maternity boarding houses and lying-in hospitals. Every application therefor shall first be ap- proved by the board of health of the city, village, or township in which such maternity boarding house or lying-in hospital is to be maintained. Such license shall be granted for a term not exceeding one year, shall state the name of the licensee, the particular premises in which the business may be carried on, the number of women and infants that may be boarded, treated, or maintained there at any one time, and, if required by the board of health of the city,village, or township in which such maternity boarding house or lying-in hospital is located, it shall be posted in a conspicuous place on the licensed premises. No greater number of women and infants shall be kept at one time on the premises than is authorized by the license, and no women or infants shall be kept in a building or place not designated in the license. A record of license issued shall be kept by the state board of health, v/hich shall forthwith give notice to the board of health of the city, village, or township in which the licensee resides of the granting of such license and of the terms thereof. The state board of health and the board of health of cities, villages, or townships shall annually, and may, at any time visit and inspect or designate a person to visit and inspect premises so licensed. [O. L., V. 99, p. 13.] Sec. 3. [Revocation of license.] The state board of health may revoke such license in its discretion where any provision of this act is violated, or in any case where in the opinion of the state board of health such maternity boarding house or lying-in hospital is being maintained without regard to the health, comfort, or morality of the inmates thereof, or without due regard to sanitation and hygiene. The state board of health shall note such revocation upon the face of the record thereof and shall give written notice of such revocation to the licensee by delivering the notice to him in person or by leaving it on the licensed premises, and shall forthwith notify the board of health of such city, village, or township in which such maternity boarding house or lying-in hospital is situated. [O. L., v. 99, p. 14.] Sec. 4. [Reporting births.] Every birth which takes place in such maternity boarding house or lying-in hospital shall be attended by a legally qualified physician, who shall forthwith reportthefact of such birth to the board of health of the city, village, or township in which such maternity boarding house or lying-in hospital is located. [O. L., v. 99, p. 14.] Sec. 5. [Records to be kept; adopting children.] Every person holding such license shall keep a record in a form to be prescribed by the state board of health wherein he shall enter the name and address of the physician who attended at any birth which may take place in such house or hospital, or any infant who may be sick, and the name, age, and sex of all children born on the premises or brought thereto, and also the name and age of every child who is given out, adopted, or taken away to or by any person, together with the name and residence of the peison so adopting or taking away such children; and within twenty-four hours after such child is given ovit or taken away, shall cause a correct copy of the record relating thereto to be sent to the board of health of the city, village, or township wherein such house or hospital is located. [O. L., V. 99 p. 14.] MATERNITIES 85 Sec. 6. [Notice in case of death; coroner's inquest; when necessary.] Every person licensed as aforesaid shall, immediately after the death of any inmate of such boarding house or lying-in hospital, whether a woman or an infant born therein or brought thereto, cause notice thereof to be given to the board of health of the city, village, or township in which such house or hospital is located, and such board of health shall immediately call the coroner of the county in which said person died to hold an inquest on the body of such person, unless a certificate under the hand of a legally qualified physician is produced to said board of health by the licensee that such physician had personally attended and examined the person so dying, and also specify- ing the cause of death, and said board of health is satisfied that there is no ground for holding an inquest. [O. L., v. 99, p. 14.] Sec. 7. [State board of health to furnish books for records.] Every license shall be entitled to receive gratuitously from the state board of health a book of forms for the registration and record of persons received into such home or hospital. The book shall contain a printed copy of this act. [O. L., v. 99, p. IS.] Sec. 8. [Inspection.] It shall be lawful for the officers and authorized agents of the state board of health and the boards of health of the cities, villages, or townships in which such licensed premises are located to inspect such house or hospital at any time and examine every part thereof, and to call for and examine the records which are required to be kept by the provisions of this act, and to inquire into all matters concern- ing such house or hospital and the inmates thereof, and it shall be the duty of the licensee to give all reasonable information to such persons making the inspection, and to afford them every reasonable facility for viewing and inspecting the premises and seeing the inmates thereof. [O. L., v. 99, p. 15.] Sec. 9. [Adoption of children.] No child under two years of age, whether inmate of such house or hospital, or born therein or brought thereto, or otherwise, shall be given out for adoption, except by and with the consent of a charitable organi- zation, society, or institution having the care of children under its control duly in- corporated under the laws of the state of Ohio or juvenile court. [O. L., v. 99, p. 15.] Sec. 10. [Placing child for hire, gain, or reward.] No parent or guardian shall give to any person an infant under two years of age for the purpose of placing it for hire, p;ain, or reward under the permanent care and control of another person; and no person, for hire, gain, or reward shall receive such infant for the purpose of placing it under the permanent care and control of another. The provisions of this section shall not apply to any charitable organization, society, or institution, incorporated under the laws of the state of Ohio, or any of the officers or agents thereof. [O. L., V. 99, p. 15.] Sec. 11. [Secrecy of records!] No officer or authorized agent of the state board of health or the boards of health of the cities, villages, or townships where such licensed homes or hospitals are located, or any keeper of such house or hospital, shall divulge or disclose the contents of the records, or any of the particulars entered therein, except upon inquiry before a court of law, or at a coroner's inquest or before some other com- petent tribunal, or, in the case of such officer or authorized agent or keeper of such house or hospital for the information of the state board of health or the board of health of the city, village, or township in which said house or hospital is located. [O. L., V. 99, p. 15.] Sec. 12. [Offering inducements^ It shall be unlawful for any person licensed as herein provided to advertise that he will adopt children, or to hold out inducements to parents to part with their offspring; and when such children are transferred by their parents, or are given out for adoption to other persons, such transfer shall be with the 86 HYGIENE knowledge and consent of a charitable organization, society, or institution, duly in- corporated under the laws of the state of Ohio, or juvenile court. [O. L., v. 99, p. 16.] Sec. 13. [License.] No person shall maintain a maternity boarding house or lying-in hospital, as defined in Section 1 of this act, unless licensed thereto by the state board of health. [O. L., v. 99, p. 16.] Sec. 14. [Relationship.] In any prosecution under the provisions of this act, a defendant who relies for defense upon the relationship of any said women or infants to himself, shall have the burden of proof thereof. [O. L., v. 99, p. 16.] Sec. is. [Penalty.] Any person who shall violate any of the provisions of this act shall be guilty of a disdemeanor, and upon conviction thereof, shall be punished by a fine of not more than three hundred (^300.00) dollars, or by imprisonment for not more than one year, or both. [O. L., v. 99, p. 16.] In all of our large cities there are many of these private maternities, mostly devoted to caring for single women who have been unfortunate and whose relatives or friends are able to pay for their maintenance and care during the period of gestation. We have visited and inspected a number of such establishments of the better class. A typical establishment of this kind is conducted in the following manner: Patients are usually directed to the establishment by their family phy- sician or lawyer. They are received in the house, usually before their con- dition of pregnancy is manifest to the casual observer, maintain their resi- dence there until after their confinement and they are sufficiently well to return home. A uniform charge is made covering all cost of board and services. When the child is born, the mother is not allowed to see it, so as not to become in any way sentimentally attached to it. It is separately cared for until called for by some family who wishes to adopt it. Statements made to the writer by physicians in charge of these institutions indicate that there are more applications from respectable families for these infants than they are able to supply. They also state that they follow up the infants and assure themselves that they are properly cared for. The mother returns to her home after her recovery, and her acquaintances are not aware of the trouble through which she has passed. As nearly all of the cases are first offenses in which a trusting young girl has been led astray, this method of treating them enables them to resume their place in the society of their home community. The physicians who have followed them up state that they almost invariably lead a correct life thereafter, having been thoroughly frightened and warned by their bitter experience. In contrast to this is the practice of some other institutions which require the young mother to nurse her child and take it with her when she leaves the institution. This, it will be seen, is, to say the least, no better for the child, while it fastens upon the young mother the burden which requires almost superhuman efforts to bear. The vast majority of young women so treated lead a miserable existence either as a misanthropic recluse or in a life of prostitution. MATERNITIES 87 Thus far we have dealt with maternities of an absolutely legal char- acter and doing a legitimate work. Unfortunately there are institutions which are without legal existence and are devoted to criminal practices — abortion and infanticide. As it is a matter for the department of justice of each city to ferret out such places and terminate their existence, there seems to us to be no special advantage in entering fully into a discussion of them in this connection. In the report of the society of the Lying-in Hospital of the city of New York we find the following table of the wages per week of the husbands of the patients treated therein: ;^2.00 3 3.00 41 4.00 102 5.00 292 6.00 475 7.00 453 8.00 709 9.00 401 10.00 877 11 .00 90 12.00 530 13.00 78 14.00 99 15.00 145 Over ^15 81 Among the occupations of the husbands we find that those connected with the tailoring trade far outnumber all the other occupations put together. These workers, not being properly organized, are subject to the inflexible laws of supply and demand of labor, and hence the most distressing sweat- shop conditions prevail. Some interesting points picked up while investigating these institutions: Almost invariably the victim despises the man who is the father of her child, and prefers honest, independent work to a prospect of marrying him. Only an appeal to a consideration of her child's welfare leads her to favorably consider it. The youngest patient of which we have record is twelve years of age, the oldest a shy and respectable spinster of forty — her first and only ofFense, for which she felt deep humiliation. Many of the cases of seduction have occurred entirely within the family — in two or three cases the father, and in several cases the brother being the author of the trouble. In this connection it is well to note that boys and girls in the family should not be allowed to sleep together after they reach the age of observation. It seems that the brother in law is a most dangerous associate. He is 88 HYGIENE allowed greater familiarity than other men, and the relationship not being a blood tie, he carries the same magnetism or sexual influence as other men not in the family. From observation in many cases, and statistics of many in- stitutions, it may be established that the brother in law should not be allowed any more familiarity than other men. Cousins are a grade better than brothers in law as the authors of young girls' downfall. Parents should be very chary of sending their young daughters to the city to earn their living. If such a step becomes absolutely necessary, then they should see that the daughter is properly established in a respectable home with favorable surroundings and has an opportunity to form suitable church or other social connections. Parents should instruct their sons just as thoroughly as they do their daughters in sexual morality. To neglect this is to tacitly acknowledge that, while they care for the virtue of their own daughters, they are indifferent to that of their neighbors' daughters. Mothers should thoroughly instruct their daughters not to allow any affectionate fondling in their associations with young men. Where these principles are most strictly followed cases of seduction are rare. Incidental to the study of maternities comes the consideration of the care, support, and education of infants and children that, for various reasons, are left without the protection which parents could give them in their homes. In our various cities the foundling hospitals, which take care of infants and other very young children, and the children's aid societies, which take charge of older children, are doing a noble work for these homeless ones. These institutions incidentally perform a greater service for society at large than they do for these homeless waifs. These children exist under every con- dition which .would favor their growing up as vagrants and criminals to be a burden and menace to society. We shall see, in what follows, that, instead of this, they are brought up to a higher standard of physical, mental, and moral training than is the average child in its parents' home. We will take as an example the New York Foundling Hospital. In a niche above its doorway a marble statue of a woman holds a little child close to her breast. Beneath her, through a swinging door that has not been locked for forty years, women pass in to the Foundling Hospital with their babies in their arms, and come out with their arms empty. A single white cradle in the entr}^ of a bare reception room receives and rescues nearly two thousand babies a year. Two thousand men and women are the number of a village community. Here in the home of deserted children are the things which are eternal, — the tears, the laughter, and the joys. " It is the little children we must save," one of the matrons said. " We keep them from privation, from cruelty, even fi'om death — the little baby nobody wants. We are just trying to give them their chance. We hope to preserve the mothers from greater sin, from the life of the streets, from the doors of prison, but it is the babies that count. We must save our babies." The foundling hospitals in our big cities are charity's efforts to play the MATERNITIES 89 part of universal motherhood, to care for the children who are thrown on her mercy, and who wiU help make her future. The room where the mothers relinquish their babies is called the saddest place in New York. There is nothing in the receiving room but the little cradle, and no one in sight. A matron is alwaj'S in waiting nearby. She never forces a mother to confession, but if possible persuades her to tell her why she wishes to desert her child, and perhaps influences her not to give it up, but to begin life over again. A mother must understand that the choice is with her — the matron may give the mother ten or fifteen minutes in which to decide — but the choice is final. There are six hundred indoor babies being cared for inside the New York City Foundling Home. It is necessary to board on the outside twelve hundred more. Seven thousand four hundred and twenty-four little found- lings have been looked after in the past two years, and there are relatively as many in Boston, in Chicago, in Philadelphia — in every large city of America, In Europe there are an even greater number of foundling babies. The European states take charge of the deserted waifs, but the mother is only per- mitted to bring her child to an entrance way, ring a bell, and give it into the arms of the attendant who opens the door — and go away without a word. These foundling hospitals and children's aid societies care for the children in the best possible manner until a suitable home is found, where they are placed by adoption. Not only infants that are born under unfor- tunate circumstances, but children whose parents die or desert them, are taken care of by these institutions. Many are adopted by child-loving people who go to the institution to select them for that purpose. Otherwise, at stated intervals they are sent to the rural districts of our country, mainly West and South, where they readily find excellent homes. There are always more families applying for children than there are children in these institutions to supply the demand. The first question that arises in the mind of the average over-prudent person is, " Are not these children the offspring of desolute or degenerate parents, likely to grow up into undesirable men and women ? " In answer to that, the experience has been almost universally just the opposite. En- vironment conquers heredity. The Children's Aid Society of New York City, for example, follows up its children until they are nineteen years of age, learning of their condition and progress once or twice a year. We give some quotations from the fifty-sixth annual report (1908) of this institution. The sympathy of all the world goes out to the orphans, and the doors of countless homes are open to them. We have but to make it known that a little child needs a mother, and our desks are heaped with letters from good people who wish to take the little one into their families on trial for adoption, promising the same tender care, the same education, the same opportunities in life as to their very own. The supply of suitable orphans is so much less than the demand, we often wonder how the orphan asylums compete with the family home, especially if we consider the cost. The expense of placing a child in a selected family in the country is thirty-eight dollars. Compare it with the cost of maintaining a child in an orphanage and compare also the advantages of family life with the institution. All are kept under the supervision of -90 HYGIENE •our agents until nineteen years of age, and our records show in detail their develop- ment. Countless romances lie hidden in these records. The heroine of the latest, a child deserted by her parents, was taken West in the private car of her new foster father, with a trained nurse to secure her from childish ills while traveling to her new Jiome. Surely a modern adaptation of Cinderella and her fairy coach! NOTEWORTHY CAREERS Most of our wards have become farmers or farmers' wives. Of the others we know of the following careers: Governor of a state 1 Members of state legislatures 7 Governor of a territory 1 County commissioners 3 Members of Congress 2 Judge 1 Sheriffs 2 Bankers 27 District attorneys 2 Merchants 22 City attorney 1 High school principals 4 Business clerks 460 Superintendent of schools 2 Tawyers 34 Civil engineers 3 Physicians 17 Clergymen 24 Postmasters 9 College professors 2 Railroad officials 5 County treasurer 1 Railroad men 36 Artists 2 Real estate agents 10 County recorders 2 Journalists 15 County auditors 3 Teachers 82 Clerk of U. S. Senate 1 School principals 3 From careful analysis of the records of all the children it is estimated that eighty- seven per cent are doing well, eight per cent were returned to New York, two per cent died, one quarter of one per cent committed petty crimes and were arrested, and two and three quarters per cent left their homes and disappeared. An example of the startling change that comes in the lives of these children is seen in the following true story: The S children were devoid of all moral and religious training, and were like wild creatures when brought to us in 1893. The parents were of low type, the father brutal and immoral, and at time of surrendering them to the society the mother said it was to protect them from the father who was about to be prosecuted for assault. What subsequently became of S is not known, but the mother " married " the man D , who proved to be of the same type as S . Thus her only hope in life has been in her three children. Her letters of inquiry about them have been incessant and most sympathetic, and always contained small slips of fresh cut flowers. Finally her long cherished desire to see the children once more induced her to visit them in their Western homes. On her return she called at our office, saying she had just returned from a visit to Nebraska where the society found homes for the three children about fifteen years ago. She found them all well and of fine physique, and as happy as can be — the two boys are strong, manly fellows. C is still in Nebraska, farming at twenty-five dollars a month. He has his own horses and implements, and considerable money saved, and probably soon will have a farm of his own. MATERNITIES 91 O is a college man and expects to be a doctor. He is a splendid fellow^ president of two local societies and one of the most popular young men in his com- munity. R was married in January, and is living in Oklahoma, her husband being a relative of her foster mother, who brought her up. He is said to be a fine, ambitious young man, and already worth about ;^47,000. All three children have developed splendidly physically, and have had a good Christian training. All grew up in churches of different denominations, with the result that C is now an Evangelist, O a Methodist, and R a Baptist. The mother was greatly overjoyed at her experience in the West, and said she could not believe her own eyes at the sight of her three children of the present day, and, although a very poor woman, she " feels as proud as a millionaire." Chapter VI PLACES OF AMUSEMENT AND OF DISSIPATION* Opera houses, especially in time of epidemic — Actors and actresses with in- fectious diseases — Small amusement halls, rinks, and dance halls — Clubs and in- fectious diseases — The hygiene of liquor and narcotic addiction — Prostitution and what the general practitioner can do to mitigate its evils — Our duty to inmates in behalf of public safety — ^The necessity for adequate treatment of venereal diseases — So-called " certificates of health." The sanitation of parks. — iForest reservations — Mountain land — Salt marshes — Mosquitoes in same — Closing natural waterways — Artificial lakes and ponds — - Municipal parks — Parking of public grounds — School grounds — Public playgrounds Amusement parks — Expositions. The sanitation of seaside resorts. — Boards of health — Quarantine and isolation as applied at Atlantic City — Food supply — Sewerage — Garbage — Mosquitoes and flies — Water supply — Bathing establishments — Hospitals — -The death rate. yPERA houses, especially in time of epidemic. — In Chapter II some reference to the construction of opera houses serves what might be here said upon the subject. Some of the states wisely require that the main floor of such structures be at or near the street level. This prevents having business places under the opera house and allows for the construction of a firm stage and dressing rooms with adequate plumbing. The ventilation of theaters presents some difficulties, but mechanical ventilation engineers can readily solve them. All theaters of any size should be fireproof or at least " slow burning." In timie of serious epidemic it has been customary for the civil or the health authorities to close the opera houses and other places of public gather- ing for a short tim.e and to fumigate and disinfect well before opening to the public again, and even then there are restrictions as to the patronage. The wisdom of such a course is not debatable. The boards of health usually look after the matters concerning the opera houses, but in small places having no capable board it morally devolves upon the physicians to exact of all places of amusement proper care in sanitary matters, but to do so with tact and by sensible argument. The hangings and wood construction that are inflammable and that harbor disease germs should be done away with and there should be some adequate regulations as to ventilation, clean floors, and expectoration. Several years ago I sent to our local isolation hospital five smallpox cases who had contracted the disease from a man seated in the vicinity, and who had, as one of the patients described him, " bumps all over his forehead." Audience rooms are apt to be overheated and be charged with the products of respiration, thus reducing the power of resistance to infection. In an afflic- tion like smallpox the period of incubation is relatively short and the onset intense and we can readily trace the source of infection; but in diseases like *By J. Harvey Miller, M.D. J, ^' / / / / 1 1 I I I ,1 i^rrrr^^ SOME HARRISiU KG PARK VIEWS LILY POND AT THE WATER WORKS PARK AUTOMATIC SANITARY SPILL-WAY AT DAM, WILDWOOD PARK THE RIVERSIDE PARKWAY PLACES OF AMUSEMENT AND DISSIPATION 93 tuberculosis the period of incubation of which is more uncertain and the onset less decided it is harder to trace, but it is believed that many infections result in public gatherings of various kinds. Whilst meager Phthisis gives a silent blow; Her stroaks are sure but her advances slow. No loud alarms nor fierce assaults are shown; She starves the fortress first, then takes the town. — Garth's Dispensary, 1699, The advances in professional and lay education in sanitary matters is no- where better shovv^n than in the toilet accessories of theaters and other public buildings and open freely to all patrons. The "penny in the slot" devices for vending toilet paper, paraffined drinking cups, and antiseptic paper aprons for commode use are to be commended. In the chapter upon public build- ings the regular and thorough disinfection of public buildings is dwelt upon. The rules there laid down apply with the greatest of force to theaters and other places of public gathering. Methods of disinfection are described in the chapter devoted to that subject. The fact that actors and actresses come into contact with the hotel people, the employees of theaters, and with persons upon the trains makes it very necessary to carefully isolate them upon the first suspicion of communicable disease. This is so well done that very little trouble has occurred with stage people so far as the dissemination of disease is concerned. There was a time when actresses were charged with disseminating venereal diseases, but the higher class of people now required to interpret the different roles and the advanced salaries paid have placed the profession upon a higher level. Be- side that, managers have found that nights of revelr}' and excess militate against the good work demanded by the critics and the public. The chorus is better paid than are the rank and file of clerks and factory operatives and have less incentive to evil habits. Women naturally shrink from the illicit, and inadequate pay is the greatest factor leading them to such lives. It is my observation that large stores are more responsible for such matters than are the well-managed theatrical concerns. Furthermore, in all my reading I have not encountered a single case wherein epidemics were traced to theatrical people. Small amusement halls, rinks, and dance halls. — The sanitary faults of these places are vastly greater than usually inhere to the larger halls. Poor construction, deficient cubic capacity, and inadequate arrangements for fire exits and ventilation are common conditions. Some states have rigid laws upon the subject. The recent explosion of moving picture films in Pittsburg and in which a score or more of persons were seriously hurt, accentuates the dangers of the small hall in which they are exhibited. Only under the most stringent regulations is it wise to license these places. The larger theaters have adequate room for their proper care and storage as well as exhibition. With a complete change in personnel and good ventilation hourly, the ex- posure to infection is strikingly reduced in these places. It is the long play 94 HYGIENE that keeps the hall closed up tight until conditions become bad. Dr. Willis Cummings contributed to the May, 1909, Medical Council an article upon the remedial influence of good shows of this character or of other nature that re- laxes the mind and are restful. He says: It would pay an enterprising manager to have a well-furnished, well-organized, and artistically equipped place at which quiet and not brazen music might be heard, where the highest grade of pictures the state of the art could produce would be shown, where an admission would be charged that would exclude undesirables, thus fur- nishing rest and pleasure. Such a description presupposes good sanitary surroundings and the enforcement of rules regarding expectoration, etc. The floors of all rinks and dance halls should be dust free and be frequently gone over with a proper floor dressing. Patrons from homes under quarantine are sometimes found in these places, and it is well for the authorities to be upon their guard. Con- tagion is readily carried from the clasping of hands by the skaters, " the right hand across " of the quadrille or the whirl of the waltz or two-step; the patrons being in more danger than when seated side by side in an audience room. The average temperature of a rink or dance hall should not be above 60 degrees F. and the ventilation should be especially well regulated. The moral aspect of the small amusement place is probably not so bad as some persons imagine. Where liquor is sold in them the case is apt to be worse than where it is excluded. Clubs and infectious diseases. — There are clubs and clubs; the rich man has his, the middle classes have theirs, and the very low down have them too. That " booze " is the magic cement holding together the membership of many clubs in all classes, no one can doubt. True, we have the " Thursday " or some other club among the gentler sex, we have the mite society, and other church organizations, as well as various mutual admiration clubs to aid good causes. These bind people into reputable membership, but the sanitary dangers are forgotten. Syphilis, tuberculosis, and other communicable diseases are no respecters of person or social standing. There should be greater care in these clubs as to promiscuous kissing among the women, the use of a common drinking cup, and the dangers imperilling all gatherings of people. Clubs having dormitories should as promptly report infectious dis- ease as is possible because of the added danger to a wider circle than in the home. The hygiene of liquor and narcotic addiction. — In the chapter upon pure food and drugs the purity of liquors is discussed. When a man steps up to the bar in a public saloon, he is apt to rub elbows with the scum of the earth. Neither race nor color is debarred; the man with the broken down syphilitic nose, the one with a horrible ozena, the old sore with an iodoform dressing, the fellow who has tobacco stains on his chin, all these and others no less desirable as companions are there with you. The fellow with a chancred lip may have had his ale from the same glass you are now holding in your hand, — true, it might have had a slight rinsing in cold or luke-warm water just prior PLACES OF AMUSEMENT AND DISSIPATION 95 to your using it and allowed to drain imperfectly by being inverted upon a brass or wooden drain. The most insanitary drinking vessel of them all is the tin cup, supposed to hold a ten-cent quantity of beer or porter. There is frequently a circle of rust near the rim from which the liquor is drunk, a fit hiding place for infection. The " stein " with its rough surface and at times its pewter top cannot be as readily cleansed as is the drinking glass by a per- functory rinsing. From my own experience I know that a large percentage of bartenders are syphilitic and I also know that many have chronic gonor- rhoea, with acute exacerbations, one attack subsiding to give place to another. They do not exercise the necessary care in washing their hands after having dressed an open sore or readjusted a d-a-b-d. In many cases they themselves are heavy " customers " of the goods supplied at the bar, they handle all drinking vessels and drink from many, and, with an imperfect cleansing of them, pass them out to the trade. The old sawdust spitting box and the large earthenware spittoon are still seen in country taverns and very low down saloons. The brass rod usually covered with verdigris and running along the upper and outer edge of the bar is rapidly disappearing. The up to date bar fixtures are at least to some extent sanitary. The highly polished hardwood floor is more easily kept clean. The slate trough upon the floor immediately in front of the bar for use as a cuspidor and a receptacle for the froth that some men insist upon blowing off^ their mug of beer is cer- tainly an improvement upon the old sawdust box. U -^^ ^^i'^^s^^ M The next group of gentlemen stepping up to the bar might ask for whiskey. The bartender touches the bottle while placing it upon the bar, the men in their order pouring the quantity they desire also handled the bottle, and it is again placed upon the shelf back of the bar, to be passed around again and again — being handled and rehandled by unclean hands, by syphilitic hands, by tuberculous hands, by hands with surgical dressings upon them and at times with gonorrheal pus. The outside of the bottle is never cleansed, in fact the paper label " Trimble," " Mount Vernon," or what not, must do service so long as it is readable, so that the bottle can be filled and refilled by some dollar and a half blend from a barrel in the cellar after the lights are out. Hotelkeepers are frequently very kind-hearted men, and will keep in their employ individuals who are actually too ill to work. In my own voting precinct a hotel man allowed a bartender to continue in employment until he became bedfast from pulmonary tuberculosis. Worse than the dining-room waiter's towel suspended from the waist is the towel we find suspended from the bar in a drinking place. I have seen it used by the man with mustache and beard to wipe these appendages upon and have also seen it used to wipe hands upon by the individual just return- ing from the urinal. Very few hotels pass you your glass of beer as it was my pleasure to drink it at the Hoffman House, each individual glass being upon a tray and with clean napkin accompanying same. The time is not far distant when the public will demand sanitary drinking places and in which the uten- sils will all be sterilized by boiling water and the barkeeper alone be allowed 96 HYGIENE to handle spirit bottles and have a clean napkin wrapped about his hand when he does so. Clean paper napkins should be served with drinks. The coils of piping through which beer and porter flow should be in- spected by the health authorities, and they should require that the water- propelled beer pump should be surrounded by fresh and clean air. The cellar air may be very contaminated and the pump should be placed where this is impossible. The moral evils of excessive drinking need not be dvv'elt upon here; they are only too apparent to all. It is certainly to be hoped that some rational solution of the evils that have crept into the business of dispensing alcoholic liquors should be arrived at and that they will be of such a character as to be acceptable to the reasonable man both in and out of the business. Personal hygiene is not involved in this book. There is no hygiene of narcotic addiction, except to keep away from narcotics. As illustrative of the extent to which drugs may enslave a man, the following news item is partially reproduced: Special dispatch to The Patriot. Lewistown, Sept. 27. In S , who says he hails from Philadelphia, local phy- sicians saw a dope fiend who by long odds is the worst ever. S informed Dr. W. H. Sweigert, from whom he obtained an old hypodermic needle, that his average is one hundred and twenty grains of morphine and sixty grains of cocaine daily. When induced to remove his clothes his entire body was found to be a mass of punctures incident to the jab of the needle. From the base of his collar bone to the ankle joints his skin surface looked as if a crude attempt had been made at tattooing. There were thousands of little punctures, more than a score of these having created sores as large as a quarter dollar. The man is traveling along the Pennsylvania railroad right of way, and the patrol- men have had a busy season keeping him away from the tracks. Last night he visited a lonely watch box in the heart of the Lewistown Narrows, crying like a child. The watchman found that his needle had become clogged, and he was unable to get any of the dope into his system. As soon as the defect was remedied he gave himself a shot and ran, laughing like a school boy, in the direction of Mifflin. The editor takes the liberty of interpolating at this point certain observations upon the subject from a national point of view. Careful study of the temperance problem justifies the statement that the consumption of spirits is not keeping pace with that of beer and other malt liquors. The adulteration of the first class is so notorious that the consumer is becoming afraid of them. Furthermore, the large employers object to their men becoming intoxicated and their stand is having a most healthy influence. Beer is a city drink and must be iced, and the poor of the cities are using it in preference to the spirits that cost more and do not impress them as having a food value. The city saloon business is really in a pretty bad way, and the profits of the average saloon are not large. There has been a great rivalry among the brewers to control saloons, and that has been using or tying up their capital and obliging them to enter into politics to keep up their end of the transaction. So long as the country was full of small breweries conducted by men of small business ability, this ruinous competition continued, and is somewhat in evidence to-day. But breweries are combining and the bad business management characterizing them in the past is giving way to a rational handlingof their interests by men well trained PLACES OF AMUSEMENT AND DISSIPATION 97 in modern business methods. In addition to this, the people who now own the brew- eries are of a very much higher grade than was the case thirty years ago. All this tends to the elimination of ruinous competition and the brewery ownership of in- sanitary saloons and low dives. It is reasonable to expect an improvement in the saloon business within a very few years. It is already apparent, and temperance people like myself can afford to refrain from hysterics and can help along in the general uplift that is influencing the saloon business in a perfectly natural way aside from legislation and political parties. One of the best things I know of in the way of saloon reform is the high license law depending upon population as to the location of saloons. Massachusetts and Pennsylvania have such laws, and thev work well. Here in Harris- burg, a place with a very large drinking population, there is a section of the city boasting a population of 30,000, and it has not one saloon or hotel license. I live in a central ward and there is not a license in it. There are plenty of places to get a drink, but we district such things here. Local option is a big factor, provided the unit rule prevails. A ward or a town- ship, or even a borough may vote for local option and enforce it, but it is very doubtful if any large city in the Union is in position to absolutely exclude liquor. There is no one plan suitable for the whole country, and it is doubtful if there is a plan suitable for even all portions of a large state. I have been in a position to learn that religious considerations do not influence even the majority of church members when license or no license stands in the way of their business interests. Temperance in politics has cut a sorry figure. Social matters influence the liquor question very slightly. It is racial and business affairs that dominate in the question aside from personal appetite. Making good Americans of our foreign contingent will advance temperance but not prohibition. Business generally is amenable to law. Why should the liquor business be an exception ? If the courts, the sanitary ofiicer, and the trade organizations domi- nate a bakery to its advantage and the welfare of the community, it is but a step to the saloon, and the saloon must yield to the power of public opinion and reform itself. I would be in favor of giving the liquor interests reasonable time to correct abuses and get in badly invested money, but after the expiration of such a time there is no reason that can be advanced by them for a continuance of their present wretched methods. The saloon has no more right to violate law than has the doctor, and, at the last analysis, most of the worst features of the liquor business are the direct result of violation of law already upon the statute books. Prostitution and what the general practitioner can do to mitigate its evils. — Webster defines prostitution as the " act or practice of prostituting or offer- ing the body to an indiscriminate intercourse with men. " When v\^e consider prostitution and the evils resulting therefrom or the possibility of doing away with it entirely, " it is a condition and not a theory that confronts us." The moralist may dream of the day when prostitution will be banished from the earth; but the practical man, the one who does more but dreams less, will con- sider conditions as they exist, and instead of attemptingthe impossible thing — a complete upheaval of the social sin — he will simply do what little he can either as an individual or as a member of a society organized for the purpose, to mitigate the present evils. That prostitution dates from early times is evident from Bible history. " Do not prostitute thy daughter." Lev. xix. 29. The middle West of our country seems to have taken the most rational stand upon this problem. I have read with much interest " Social Hygiene vs. The Sexual Plagues," 98 HYGIENE issued by the Indiana State Board of Health, and designed to teach the public the dangers of venereal disease. Literature of this kind, in simple language, yet thoroughly scientific and containing reliable statistics, must be productive of much good. Our youth should knov^ the dangers of prostitution, and they should be informed by parent, physician, priest, minister, and teacher as well as by proper literature. Dr. Morrow^ (Jour. A. M. A., March 4, 1905) urged upon the Department of Health of New York city the sending out of circulars of warning regarding venereal infection, but was refused lest such information " might offend the moral susceptibilities of the community." Boys and girls should not be allowed to reach maturity without such warning, and it would come with especial force from a board of health. Then, if they offend, they do not do so ignorantly. In my experience it is not the young man who is most responsible for prostitution, but rather the older married men — usually the father of several children and the husband of a wife whose every thought is for the comfort of the family. Man is by nature a polygamist. Were it possible for every man to be true to the woman he calls wife, there would be few prostitutes. The single man might have heard something of " sex necessity," or idle curiosity might lead him to a house of ill fame, but his visits are few and far between compared with the nights spent in revelry and lewdness by the married men. Radical measures to limit prostitution are useless, for, when unduly oppressed, the traffic seeks cover and practices clandestinely in the midst of respectability to the aggravation of morals and ill health. Properly regulated, there is a natural tendency for prostitutes to segregate. In early days they were burned at the stake, drowned, scourged, and tortured in divers ways. Were all the prostitutes to be deported their ranks would soon be recruited, as the poly- gamous instinct in man demands a supply. At the forty-fourth annual session of the Ohio Eclectic State Medical Association, Jerome D. Dodge, M.D., read a paper upon " The Medical Profession and Purity," from which I quote: In so far as the enlightenment of the general public is concerned, the subject (purity of the sex life) has been strangely neglected, through a shameful prudery, until evils of gigantic proportion have resulted. The times are ripe for purity organi- zations. The psychological period has come when they can do a great and necessary work in reforming our local and national life. The youth of the land must be taught the dignity and the true meaning of the pow- ers of the sex life, its purpose, its proper care, and its dangers. They must be taught not only thou shalt not, but, the why not. At a stated meeting of the Pennsylvania Society for the Prevention of Social Diseases, November 6, 1908, the important question was considered, " Have our women and girls a right to the facts regarding social disease ? It was discussed from several standpoints and the concensus of opinion was affirmative and those qualified to speak and write were urged to do so. The New York State Journal of Medicine, in a recent issue, said, under the title, " Idle Wives, Unmated Men, and the Venereal Peril " : PLACES OF AMUSEMENT AND DISSIPATION 99 We have drifted away from the happy old habit of thinking of the wife as an help- meet, to the habit of treating her as a luxury to be maintained at a certain necessary expense, just as one's yacht must be maintained. This is the state in which many young men think a wife wants to live, and few young men can afford to maintain a luxurious appurtenance of this sort. Marriage is postponed. The roaming about of unmated men, seeking who may devour them, is far too prevalent and a great cause of the venereal peril. An editorial in the Medical Era of February, 1909, says: The most popular movement of the day is the one looking to the suppression of vice. People have banded together for the avowed purpose of throttling all manner of vice, their most aggressive efforts being directed against immoral sex relations. Their methods insist upon a sudden upheaval of a complex social system whose growth has been a matter of many centuries. Among the means chosen to bring about a healthier moral tone has been the closing or attempted closing of houses of ill fame. In other words, the old cancer was rooted up, cut into a dozen pieces, and scattered, full of contamination, in every direction, a new nidus of horror and infection taking growth wherever a section of the parent body landed. What a feeling of horror would possess the people were an organization to advocate the elimination of smallpox by razing the pest house. General Bingham, of New York city, has recently said: It is high time for thoughtful people in this country to wake up to the fact that law breaking in our greater cities is to an appalling extent a safe and profitable occupation, and that one reason for this condition of affairs is the superfluity of laws, many of which are placed upon the statute books and among the ordinances not to be enforced, but to be used as weapons of blackmail and graft. There are laws making it a crime to rent a house for prostitution, and there are laws making it a disdemeanor to be a proprietress or an inmate of a house of ill fame. These laws had better be repealed than to be used, as we have known them to be as a weapon for personal jealousy or political revenge, or their enforcement threatened for the purpose of blackmail and graft. Theodore Roosevelt, in The Outlook, March 20, 1909, says: Socialism intends to do away with both prostitution and marriage, which he (M. Gabriel Deville, a French socialist) regards as equally wicked, his method of doing away with prostitution being to make unchastity universal. Prof. Carl Pearson, a leading English socialist, states their position exactly: The sex relation of the future will not be regarded as a union for the birth of children, but as the closest form of friendship between man and woman. . . . Aside from its thoroughly repulsive character, it ought not to be necessary to point out that the condition of affairs aimed at would in actual practice bring about the destruction of the race. An important article in the Medical Council for May, 1909, by Theodore Schroeder, member of the New York and Utah bars, gives a wealth of his- toric data proving that the early polygamy of the Morman Church did not prevent or even seriously limit prostitution. The medical profession should try to bring about the prophecy of Des- cartes: " If it is possible to perfect mankind, the means of doing so will be found In the medical sciences." He should also consider what James Foster 100 HYGIENE Scott has said: " Every individual who is possessed of the strongly character- istic attributes of manhood must belong either to the side which is in favor of purity, or to the faction which practices and advocates sensuality. After the advent of puberty a neutral or indifferent attitude is impossible." The general practitioner of loose morals can do nothing; but he who is known to be on the side of purity can do much both by precept and by example. The medical societies could do much. Knowledge from such a source would command the respect of all. Physicians already instruct a very large number of people, but usually not until they come to them as victims of dis- ease. Dodge has said : " Occasions arise and do arise upon which the general practitioner can warn and admonish; and he has the right to make the occa- sion if he sees fit." None are better qualified to speak concerning the ills of prostitution than is he. If there ever be adequate legislation concerning prostitution, the knowledge possessed by the general practitioner must be a factor in framing such laws and ordinances. Our duty to inmates on behalf of public safety. — Prostitution fills its ranks principally from the poor and ignorant classes. We should inform them of their dangers. There should be a medical society and health board circular to hand to them. Social purity societies should be formed in every populous center, and the physicians should be active therein. To illustrate what edu- cation along a particular line will do, I have had a number of patients come to me recently who had read circulars sent out by the anti-tuberculosis societies, and who inquired if they had the new disease called tuberculosis. When called to attend inmates we should not only give them adequate treatment, but should warn them to keep in seclusion. We frequently see gross lesions of syphillis and gonorrhoea among prostitutes, and are powerless to prevent their spreading the diseases. Recently I prescribed for a woman from whose body there emanated the odor of putrid flesh, who had a series of syphilitic ulcers, and who was regularly " seeing company." She said to me, in answer to my question, " Why not, when nobody complained ? " Venereal diseases must be well treated, and if so are curable. In a prostitute? No! She cannot remain a prostitute and follow up the hygienic and medical measures requisite for cure. Young men who come to us with their first venereal infection should be frankly and kindly treated, and we should gain their confidence. Make yourself his best friend. Be gentle in your admonition; put all friendliness and sincerity of heart in your advice for future conduct; above all cure him, cure him right, to stay cured. So-called " certificates of health." — Much to my shame, I have written them. Having practiced medicine for the past nine years in a semi-tenderloin district, some of my early experiences took me among the " painted dames," and upon one of my first visits I saw tacked upon the wall a prescription blank of one of our most distinguished and reputable practitioners and upon which was written, " I have this day (date) carefully examined and find her free from venereal disease." Signed, M.D. I had never seen any writing of the kind before, but have seen many since, all A BOTANICAL GARDEN, WASHINGTON. PhotO, J. A. Kepplc HOUSE OF PUBLIC COMFORT. A ncccssary sanitary adjunct to parks- A PARK MUSEUM. _ Memorial Hal],"Tairmount Park, Philadelphia PLACES OF AMUSEMENT AND DISSIPATION 101 worded about the same, both from this and other honorable practitioners, members of various medical societies. I have written and signed the same kind of certificate. Upon one occasion I attempted to be truthful and worded my certificate as follows: " This certifies that I have made a careful examination of the genitals and surrounding structures of and find no evidence of vene- real disease." This certificate was returned to my office for explanation and elucidation. It is absolutely impossible by any medical supervision to guarantee the health of a woman leading a life of vice. Any partial advantages of such supervision are more than compensated by the increase of libertinism engendered by a false sense of security, so that it actually results in increased disease among men. Such are the conclusions of Dr. Chaufleury and others who have enjoyed a large field of observation: Then gently scan your brother Man, Still gentler sister Woman; Though they may gang a kemin wrang, To step aside is human: One point must still be greatly dark, The moving why they do it; And just as lamely can ye mark How far perhaps they rue it. Who made the heart, 'tis He alone Decidedly can try us. He knows each chord, its various tone. Each spring its various bias; Then at the balance let's be mute. We never can adjust it; What's done we partly may compute. But know not what's resisted. — Robert Burns Sanitation of Parks* Forest reservations. — This is a matter of greater economic than of hygienic interest. Ex-President Roosevelt and others gave a great impetus to the important subject of forest conservation and the colleges have been taking up the matter. Yale University grants the degree of Master of For- estry after a two years' post-graduate course. Harvard practically parallels this course in its Graduate School of Applied Science. The University of Michigan has a Forest School giving a post-graduate degree of Master of Science in Forestry. Numerous undergraduate courses are given in the various colleges and agricultural schools, in all, over twenty institutions offering good courses, while many others give partial lecture courses. Twenty- *By the Editor, 102 HYGIENE seven of the states have state forest officers and most of these departments will supply literature to any interested person. The American Forestry Association and the Society of American Foresters, both of Washington, have published interesting literature, while thirty-two state organizations have thus far been formed to promote the interest of forest conservation and reser- vation. The present writer sees many practical difficulties in the path of the con- servators of our forests in this unduly commercialized country. Some efforts fail because of forest fires in adjacent unguarded property. It is very hard to get the owners of the forests to take any effective precautions against fire. The hardest physical labor I have ever done was fighting forest fire. Persons who have never faced such fires can have little conception of how fierce and destructive they are. There are great areas in this country that are not worth a dollar per acre because they are covered with the stumps and wreckage of oft-repeated fires. They are no good as timber land and clearing them for the plow costs more than the game is worth. The only use made of them is to occasionally set up a movable turpentine still therein. With intelligent handling, most of this land would eventuate in valuable timber areas, but there is absolutely no hope of this coming to pass unless the state governments do the work. Some of the railroads are doing good work in growing locust trees for ties, but they have their discouragements because wanton persons destroy so many of the young trees and forest fire impends in any dry season. It has been suggested that the states purchase large areas and enter the field of scientific forestry, and the suggestion is a good one. It has also been recommended that the states make use of these areas in protecting watersheds, housing consumptives, supplying free summer camps for all classes of invalids and persons desiring a cheap and hygienic outing, and developing great natural parks. This plan would supply places of amusement to great num- bers of people, hygienic labor to many others, and the revivifying influences of the forest to many who would be benefited thereby. The advantages of the plan are so obvious to physicians as to require little comment upon my part. However, it particularly impresses me that the present methods of caring for tuberculous persons involve so much expense as to necessarily limit the charity of the states and municipalities to but a small proportion of the total number of cases. Were the states to undertake forestry upon a large scale, many of the incipient cases could engage in productive labor in the forests and perhaps be sufficiently restored as to comfortably live and labor in these reserves for many years. Mountain lands. — The Adirondacks have a great reputation as a health- giving area. This is largely because they have been exploited and their ad- vantages developed. In many parts of this country are mountain regions capable of being made quite as charming and as hygienic as is this justly celebrated region. Mountains are great conservators of moisture and they supply the head waters of many a mighty river. With good roads to these mountains and pipe lines from them, the mountain dwellers and the valley residents would both be benefited. Mountains are great watersheds and PLACES OF AMUSEMENT AND DISSIPATION 103 the time is coming when the states will be obliged to exercise a greater super- vision over them. As places of amusement they are much abused and the indiscriminate defilement of head waters by careless campers should be stopped. Boards of health should be especially careful as to typhoid cases occurring in elevated regions. Hay fever sufferers would appreciate moun- tain regions under such supervision as would render them suitable for resi- dence by sufferers with this ailment. (See " Rural Resorts," in the chapter upon " Rural Hygiene.") Salt marshes. — This may seem a strange heading under parks. But persons who have been about the Jersey resorts know what a factor of dis- comfort the peculiar mosquito of these regions may become. While the pro- fession is well informed concerning the species of mosquitoes disseminating malarial and yellow fevers, they are not so well instructed concerning the salt water mosquito. Dr. A. H. Doty, health officer, port of New York, and located at Staten Island, has done much original work upon the life history and the methods of successful destruction of the salt water mosquito. I went to see the doctor and the ditches upon the island and found that he has succeeded in practically exterminating this species of insect from the drained region. By the courtesy of Dr. Doty, the following extracts are reproduced from reprints with which he furnished me, derived from Reports of the American Public Health Asso- ciation and the American Journal of the Medical Sciences. To obtain success in our efforts to exterminate the mosquito we must be familiar with the manner in which it is propagated, its habits, etc. First, we must understand that all varieties of the mosquito propagate only in water. The importance of this lies in the fact that it gives us definite information regarding the character of their breeding places. Thus far investigation has shown that all mosquitoes, with the exception of the sollicitans, deposit their eggs on the surface of the water. These develop into larvae, commonly known as "wigglers," and then into pupae, which are subsequently transformed into the winged insects. From the deposit of the eggs to the development of the winged insect only twelve to twenty-five days elapse, depending on the variety of mosquito. The longest period is, as a rule, required for the development of the anopheles or malarial mosquito. Until recently it has been the general belief that mosquitoes deposit their eggs only upon the surface of the water. The investigation of Dr. John B. Smith, State Entomologist of New Jersey, and the investigation under my direction have satisfactorily demonstrated the fact that the sollicitans, when free to act, deposit its eggs on the ground in the salt marshes along the coast, although in captivity this mosquito may deposit its eggs on water, glass, cotton, or on almost any- thing with which it comes in contact. However, even in captivity, it will be found that, if earth from salt marshes be placed in cages containing the sollicitans, it will preferably deposit its eggs on this material ; however, the development of the eggs does not take place until the earth is covered with water. In the salt marshes this is supplied by the frequent floodings, which form both small and large collections of water; many of these remain sufficiently long for the development of the winged insect. Therefore, while the eggs of the sollicitans are deposited on the earth in salt marshes, their development into the winged insects depends upon the presence of water in the same manner required by other varieties of the mosquito. 104 HYGIENE Culex sollicttans. — The belief thac no mosquito will breed in salt water is erron- eous, inasmuch as the culex sollicttans will breed in no other place. Therefore, while we suffer the annoyance which the bite of the sollicitans inflicts, i^ may be of some com- fort to know that they will not breed inland or away from salt marshes. The statement just made regarding the sollicitans has been corroborated by careful investigation and experimental work which I have conducted during the past five years. During this period specimens of water containing larvse taken from all kinds of receptacles about dwelling houses, ground depressions, etc., either in close proximity or some distance removed from salt-water swamps, were placed in large glass receptacles, covered with netting, and allowed to remain until the winged insects were developed, but in no in- stance did the sollicttans develop from these larvae. A number of times larvae have been taken from inland drains, the immediate vicinity of which was thickly infested with the sollicttans, but the larvae always developed into the culex pungens, or " in- land " mosquito, and no sollicttans were ever found. The result of these observa- tions gradually directed attention to the salt marshes along the coast as the seat of propagation of the sollicttans. Here in the pockets, or ground depressions containing salt water, the larvae of this variety were found in enormous numbers; this was proven by placing the water containing larvae in large glass jars covered with netting. When the winged insects appeared they were in every instance found to be the sollicitans, and no other variety. A series of experiments which followed consisted in the transfer of earth from these swamps to the laboratory, where k was placed in large glass jars covered with netting. In these were confined the sollicitans. Soon after their cap- tivity eggs were found deposited on the earth. After the release of the mosquitoes the earth upon which the eggs had been deposited was kept intact and allowed to remain for various periods, in some instances for four months. In some of the tests the earth was kept moist; in others it was allowed to dry, but in no instance was there any fur- ther development of the eggs until the earth was covered with water; then, within twelve hours afterward, the larvae appeared. Other experiments consisted in placing earth from salt water warshes in wire cages also containing water in glass jars. The sollicttans in the cages preferably deposited their eggs on the earth rather than on the water. The results to which I have referred are in harmony with those obtained by Dr. John B. Smith, to whom credit is due for exceedingly valuable work in connection with this variety of mosquito. As a result of these investigations it is reasonable to assume that the culex solli- cttans breeds only in salt-water swamps, and that their eggs are deposited upon the earth and remain without further change until covered with water, when the develop- ment of the winged insect rapidly follows. It is also reasonable to assume that the first crop of the sollicitans, which appears in the spring or early summer, is due to the hibernation of the eggs of this insect, which are deposited on the ground late in the fall, but do not develop until the warm weather of the following year appears, and the swamps are more or less covered with water. On the other hand, it is equally certain that the culex pungens, or " inland " mos- quito, is perpetuated by the hibernation of the winged insect itself, and not by its eggs. It is a frequent occurrence in sections where this variety of the mosquito breeds to find a few of them about the house during the winter months. When the warm weather appears the survivors become active and deposit their eggs in receptacles containing water. It is not impossible that a few larvae of this variety may hibernate during the winter, as in some instances they have been detected in ice, warmed, and brought to life. However, I have never known of one which survived more than a short time, and I am quite certain that they do not play an important part in perpetuating their species. The statement which I have just made relative to the perpetuation of the culex pungens PLACES OF AMUSEMENT AND DISSIPATION 105 may, I believe, be also applied to the anopheles and stegomyias, although regarding the latter variety I do not speak from personal experience. There is good reason to believe that the stegomyia, or yellow-fever mosquito, like the culex pungens, prefers to breed in contaminated water. Extermination of the Mosquito Careful investigation of the mosquito has shown that the various types of this insect differ in their method of propagation, habits, etc. It is very necessary that we should be familiar with this fact, inasmuch as the means by which the mosquito may be exterminated depend largely upon the variety with which we have to deal. The importance of our present knowledge regarding the culex sollicitans will be better appreciated by those who live along the Altantic coast, and who are constantly subjected to the annoyance of this variety of the mosquito during the warm weather. It is a well-known fact that the enormous number oi sollicitans present has seriously interfered with the development of certain sections along the Atlantic coast. Before its breeding place was definitely known efforts to prevent its propagation were confined to the same means which are used to exterminate the culex pungens, anopheles, and stegomyia, such as the care of inland ground depressions, cisterns, rain-water barrels, and other receptacles. We now know that such methods as these are practically use- less in the extermination of the sollicitans, and it is only by the proper drainage of salt- water swamp lands along the coast that the propagation ofthis variety can be prevented. The use of oil in the extermination of this variety of mosquito even as a temporary measure is but of little or no value. Although the sollicitans deposits its eggs on the ground in the swamps, they cannot develop without water, and, if accumulations of surface water be prevented by drainage, propagation ceases. This has already been successfully demonstrated in some of the New Jersey salt-water swamps, which were impassable and thickly infested with mosquitoes. These have recently been ditched and drained, and this year are producing crops of hay, which are harvested with mowing machines. Furthermore, the mosquito has practically disappeared in the sections thus treated. Work of a similar character is now in progress along the Staten Island coast, and it is confidently expected that next year will prove the success of this work. For a full description of the methods of ditching, etc., used by Dr. Doty, see his paper in the May, 1908, issue of the New York State Journal of Medi- cine. This same subject is referred to in what is said concerning docks and harbors, in Chapter XXIII. What is said above is a matter of vital interest to the seaside dweller and to municipalities maintaining parks along the shore. From what I saw at Staten Island, it impresses me that the reclaimed land from the salt marshes would be of a value almost if not quite repaying the cost of ditching and drainage. Even lands failing to mature the ordinary crops will readily grow profitable crops of the salt hay used for packing purposes. As to salt water mosquitoes, it is asserted that in the Philippines one variety of them do carry malaria. Closing natural waterways. — This subject is suggested by the preceding one. State boards of health have been given this right when the sanitary necessities of the case demanded such measures. But to close a navigable waterway is another matter. However, in the celebrated Blackbird Creek 106 HYGIENE case, of Delaware, the supreme court upheld the right of a state to close a creek for sanitary reasons. There can be no question but that insanitary es- tuaries and creeks can be closed. If, however, the waterway drains a large area of storm water, it may not be practicable to close it up and the question arises as to the engineering possibility of installing a large drain in the place of the stream. This cannot be answered oflFhand. Every case must be judged upon its own merits, but a few things must not be forgotten. It is very easy for an engineer to base his plans or estimates upon an average flow. This is not safe, even if it is cheap. Another point is that a closed sewer needs a greater gradient than does an open stream, since the latter has an initial velocity and the suction action of the fall below, whereas a sewer has little chance for an initial velocity and often discharges against resistance. Conse- quently, the sewer is apt to silt up. Park boards will be apt to involve them- selves in needless expense by attempting to close natural waterways or turn open drains into closed ones. The thing to do is to prevent contamination and then the open drain may not be objectionable. Jrttficial lakes and ponds. — This usually involves a dam so constructed as to detain the flow of a small stream. Several factors must be considered. First, the engineering features must be made safe. A dam is always a poten- tial source of danger and every foot added to the height increases that danger. The possible engineering features are so many that I will touch upon but a few. It is always wise to estimate the safe sanitary size or area of the lake upon the minimum flow. Great Salt Lake and the Dead Sea are instances of bodies of water receiving some considerable amount of water, but discharging none. In other words, evaporation and seepage disposes of the whole available supply. Fortunately, they are filled with salt and do not become ofi^ensive. Not so with some artificial lakes I know. A photograph of a lake filled up with weeds is given elsewhere, and it will also serve to illustrate this subject. The dam construction of the lake is excellent and the general engineering features good, but the several persons who laid it out probably did not know the minimum flow of the stream supplying it. In consequence, the area of the porous bottom and the surface area of the water dispose of practically the whole supply received in this very dry summer, and when I took the photo- graph the air was reeking with the odor of dead frogs. Were the photo- graph taken in the early spring, it would show a beautiful stretch of water. Engineers make the same mistake in the construction of power dams and mil- lions of dollars are tied up in immense concrete dams that will never yield divi- dends, because the minimum flow of the stream measures the safe maximum load the dynamos may be expected to carry when the company is under con- tracts that run by the year. That is bad enough, but to endanger the health of a city is even worse. Engineers are about as liable to make mistakes as are physicians, and they differ among each other nearly as much when it comes to debatable questions. Never employ a cock-sure park engineer. He will dilate upon "the certitude of any profession based upon mathematics, the only exact science." So far as that goes, so is vital statistics based upon mathematics. I understood that the city where this lake is located sent for a celebrated PLACES OF AMUSEMENT AND DISSIPATION 107 landscape gardener from New England. He advised pulling up the weeds and raising the height of the dam, but pond weeds in the North and ever so much further South are two sorts of propositions. I have seen pond weeds in the South that a mule could not pull and pond lilies up North that the current is apt to uproot. The right way to improve that lake is to dredge out the central third of it to a minimum of six feet depth and deposit the earth v\^here its shallow sides are now filled with water plants. These lakes in parks are a great source of trouble and many are insanitary. The whole idea seems to be to beautify the park, and the two mistakes are made of attempting too great an area and making the lake shallow, so that it is safe for children. The latter plan almost invariably results in the lake filling up with water vegetation. If the excavation is well treated with crude coal oil before the water is let in, the weeds are killed for the time at least. Once they are established, pulling them up does little appreciable good. Some places use a sort of drag saw to cut the vegetation, but it grows right up again. All such lakes should be well stocked with mosquito-eating fish. Parking waste lands and swamps costs money out of all proportion to the results, but if sanitation is conserved and the city gets the land for nothing, it may be worth the outlay. Other things being equal, it is better to pay for good park land that is capable of development with a reasonable outlay. Swamps are a dismal proposition to undertake in any line of development. City water fronts are a neglected possibility in the way of parkways. Harrisburg is developing a very beautiful water front parkway, nearly two miles in length. The sanitary advantages of the city controlling the water front are manifold. i3 Municipal parks. — From the side of sanitation there is but little to say. All over this country parks are being elaborated and a large number of very well-informed park boards exist, whose experience justifies the large amount of literature emanating from them principally as individuals. The present writer has made a partial survey of this literature and finds the subject so large that we can but suggest that interested persons should not depend upon a work upon public hygiene for general information about parks. However, the writer must be pardoned if he suggests that some of this literature is stilted and theoretical. There are one-sided persons in every department of literature. It is well for us never to forget that public parks are for the public; that driveways far from the city but built at city expense do not supply the legitimate place of a public park, since only the small por- tion of the public owning horses and carriages and automobiles get to even see them; that " keep off the grass " signs can be very much overdone and are but little seen in the really model parks of the land; that as trolley cars are the vehicle of the great mass of people, it is folly to exclude them from parks at a distance from the city or to exclude cars from adjoining places while such an important park as Fairmount Park in Philadelphia has a trolley line built to its more interesting portions; that the pretty plans upon paper are not matters of " plenary inspiration " and usually need considerable toning down; that the maintenance of a park is expensiveand is just as im- portant as is its original laying out; that policing of parks is imperative; that a 108 HYGIENE plant that works well in a certain latitude and with a certain kind of soil may fail dismally under other circumstances; that even park boards cannot change the natural habitat of plants and trees, and that the old-fashioned gardener of the neighborhood may be in position to give more true expert advice than can the expensive expert from a distance; and that the politician seldom knows much about any trees except the " plum tree." From the sanitary point of view, what has been said under other headings applies here, but there is an especial danger in parks that the local boards of health should regulate, and that is that children recovering from long illnesses and sometimes from infectious diseases are frequently taken to parks and come into contact with healthy children. Tuberculous cases should also be watched that they do not expectorate upon park property. Parking of public grounds. — A photograph herein shows hov/ a formerly unsightly waterworks grounds may be made a thing of beauty and of health, it is but one instance of many that I might give showing how the factories and public buildings of the country are being made centers of fine parks that are object lessons to the community and that indirectly influence the people to better things in beauty and in hygiene. However, the matter can be overdone. School grounds have been parked in many places to such an extent that the children had no place for their sports and games. It is vastly more important that a base ball diamond be laid out for the boys than that the flower beds be used to teach botany. Nearly all city schools have too con- tracted grounds, and it would be well to use some of the park funds to pur- chase property contiguous to the school buildings and tear them down to give space to the children and their games. School grounds should be kept open, under proper supervision, for the use of the children during the summer vacations. Public playgrounds are a good investment, but they should be playgrounds rather than places to exploit the ideas of the apostles of beauty and various phases of alleged teaching. We illustrate one in Harrisburg that is placed upon an island surrounded with shallow water. The park board employs a physical culture professor there and allows all this part of the state to have their sports there. The intercollegiate track meet and high school athletics and all the contests upon land and water that so delight the hearts of young America keep enthusiasm and noise there at high pressure. It costs very little to keep it up compared to the good it does, and there is not a flower- bed upon the place. There are tennis courts, bathing facilities, a fine run- ning track, and everything needed in the way of athletic appliances, and the only disadvantage is two cents' bridge toll for the otherwise free use of the island. Another playground is adapted to smaller children and has swings, a shallow wading pond, arrangements for games, etc. Railroad parking is to be commended. Some roads spend considerable sums in beautifying their various grounds and sodding theii embankments. Some of the most intelUgent park work I have seen is done by railroad companies. Amusement parks. — Were we to have written this a few years ago, there would have been much to say in condemnation. As it is, the writer is just back from seeing Coney Island, Luna Park at Washington, Electric Park at THE YOUNG ATHLETE S PARADISE WHERE THE UNFORTUNATE IN NEW YORK SO OFTEN SLEEP bears' den, zoological GARDEN, PHILADELPHIA PLACES OF AMUSEMENT AND DISSIPATION 109 Baltimore, and other presumably rather dizzy resorts. While a clergyman would see much oi" Sabbath desecration, and which lam inclined to condemn as well, and the student of ethnology could see many problems suggested by the crowds, there is little of gross violation of sanitation to be found in these places. Smaller places, where local boards of health have gone to sleep, are just as bad as ever. It is a matter purely in the hands ct the sanitary authori- ties and we could tell some of them about places of which they should know themselves. Out in one of the great lakes there used to be an island resort rightly described as " a little hell." It was closed long ago. The editor tried to find the worst parts of it and failed dismally in locating anything that he could really say was bad from any point of view. The trouble was he was not known, and was spotted because he was in conversation with a policeman who located him as a " squealer." But if the reader thinks that sort of pro- tected vice is out of style everywhere he is sadly mistaken. From an ad- mittedly superficial observation of such places we can suggest no real remedy except the general diffusion of religious and moral teaching and the enforce- ment of law. As it impresses me, no man with the instincts of a gentleman can be anything but disgusted at such places. If he has not such instincts, he will usually find some way to gratify the base and animal instincts that usurp the place of the manhood he has lost. Such resorts as cater to such people are usually controlled by that coterie that are the hybrid children of debased politics upon one side and the worst saloon element upon the other. Not that all politics is bad or that all saloons are vile, for that would be an unwarranted generalization, but the combination of politics and liquor is wholly debased and its institutions the worst enemies of the national man- hood and womanhood. The editor lived in Pittsburg at the time a reform mayor tried to clean up the city and enforce the Sabbath laws. He meant well, but he did more harm than good. Driving certain things to cover does not abolish them. Certain cities to-day are congratulating themselves that they have suppressed vice. Let their officials visit some of the small amusement parks and beer gardens outside the city limits, and they will see what they will see. If they should visit a place we know of they would be apt to see the chief of police in citizens' clothing and accompanied by bad characters he should arrest for known violation of law. We do not drink beer or anything intoxicating, but have made it our care to see things before writing about them, and it is a shame how the outskirts of some of our cities are made the refuge of the worst element living in the cities, and that moral and sanitary matters are neglected where the neglect is doing most harm. In some places boards of health have jurisdiction for one mile beyond the corporate limits. Were that the case everywhere and the same power given to police, much could be done to rectify the conditions of which we speak. But where the police and the saloons are manipulated by the same wires, the case is hopeless unless a miracle happens, the city voter becoming really aroused. As to what we have not seen at Coney Island and other re- sorts, we have simply to say that careful citizens miss seeing a host of things and we may not be an exception, but the outward moral no HYGIENE conditions of parks and resorts seem to keep equal pace with their sanitary conditions. At this moment an automobile chemical engine dashed past the house. That means it is not worth while to see where the fire is for it will probably be extinguished within five minutes. We have learned to suppress physical fire in its incipiency and the devices for physical safety are innumerable, but the same old moral abuses go on from year to year and only vary in their phases. As to this one, park boards over the country should take the matter up in the interest of decent parks. It would be well for the trolley and excur- sion boat people to co-operate and the boards of health to do their part as well. Expositions. — In closing this section of places of amusement, we beg to reproduce an editorial appearing in the Medical Council a couple of years ago. An Exposition Menace Quite a contention has arisen between Major Charles E. Woodruff, chief surgeon of the United Sta' es Army camp at the Jamestown Exposition, and Dr. R. L. Payne, medi- cal director of the exposition. They are both most excellent gentlemen, one taking the rigid army sanitation point of view and the other the more easy-going attitude of the civilian. From a non-biased review of their several contentions, in the Military Surgeon of December, 1907, as well as our own superficial observation of other expositions, it has forcibly impressed us that the waterways of a natural and artificial order, the im- perfect drinking water and sewage systems, the filthy camps of Indians and even less civilized peoples, the presence of numerous animals, the flimsy hotels and restaurants, the moral turpitude of the " outside attractions," the poor quality of the food, lax management, the camps of laborers, crowded conveyances, the dust and the com- mingling of so many people in close quarters — all tend toward making an exposition a mosL unsanitary place to visit. We have no doubt at all that Major Woodruff is correct in his statements that to keep his camp free of typhoid, admittedly present in many places in the vicinity, was an almost herculean task, but we also have no doubt that Dr. Payne and gentlemen holding similar positions in previous expositions were very distinctly " up against " a hard task. Sanitary regulations are more readily enforced in a military camp than in the cosmopolitan and motley crew of hunters for easy money holding the concessions in and about the great exposition. The whole matter has a very serious and threatening aspect to the trained sanitarian. The average physician who has not been brought into frequent contact with army camps has really li-tle conception of the dangers ever lurking there, and of the elaborate precautions taken to prevent illness. No exposition can, in the nature of the case, be made as safe as is an army camp. Now that so much money has been lost in great expositions, we hope they will be abandoned in future or limited in scope and camp features. The people of Norfolk are entitled to more praise than was given them by the newspapers. It is a thriving city, containing hosts of en.-erprising and cultured citizens, who sacrificed much upon an exposition having many admirable features, but the defects inherent in all such under- takings were accentuated in a semi-tropical region. We are much inclined to fear that the civilian physician has many lessons to leam from the modern army sanitarian, and we believe any future exposition should have army officers or men of army training in charge of its sanitation. PLACES OF AMUSEMENT AND DISSIPATION 111 The Sanitation of Seaside Resorts* The sanitar}' problems of seaside resorts are materially influenced by the great fluctuation of permanent and transient population at different seasons of the year. When one considers an increase of from one hundred to five hundred per cent in summer, and with people coming from all parts of the world, a proper sanitary administration of public affairs presents some unique questions. The permanent population living in cottages and flats is treated the same as in any town or city; but the great summer rush into hotels, boarding houses, and cottages necessarily brings with it sanitary dangers that demand radical handling. Boards of health. — To rigidly enforce sanitary laws an efficient board of health entirely divorced from politics is an absolute necessity. It should comprise in its membership representatives of the medical profession and of the hotel and business interests, all being good representative property owners, whose main aim shall be to protect visitors as well as home popu- lation. When one considers a single hotel accommodating at one time a village of twelve hundred people, it is necessary to have most rigid sanitation and thorough systematic inspection at frequent intervals. In fact, the man- agement of the house should establish his own sanitary corps upon such a thorough basis that no routine problems in his place should demand outside interference. Every successful seaside hotel adopts this principle, and many penalize their help for any neglect of sanitary law. The problem of handling contagious and infectious diseases in these seashore hotels demands the utmost secrecy, as the outbreak of one case, publicly announced to the guests, usually causes a panic and exodus that is financially detrimental to the hotel interests and also makes possible a general spread of diseases. It is decidedly impolitic to quarantine a whole hotel in midseason, unless the exposure has been so flagrant and general as to absolutely demand it. Immediate, early reports of every case of illness to the management must be demanded, and every case of real or suspected contagion should be removed at once to the municipal hospital (if there is one in the resort), or, if not, then to a proper house of detention and treatment. A thorough, systematic fumigation, reno- vation, and cleaning must always follow before the rooms are thrown open to other guests. Every seaside hotel should demand vaccination or a certificate of recent successful vaccination from ever} employee. This is mandatory of employees in every large hotel in Atlantic City. Unless complied with no one can remain upon or be added to the hotel staff. Years of trial in Atlantic City have shown this method of quarantine and reports to be absolutely safe, and where properly enforced none will suffer. It is also unwise to placard houses in seaside resorts for contagion, as the moral effect upon transient population is bad and tends to drive thousands home without cause. The panicky condition of the public at large is well illustrated by out- breaks of variola, yellow fever, and other contagious diseases, when they migrate by the thousands to our seaside and other resorts. At these times *By W. Blair Stewart, A.M., M.D. 112 HYGIENE too great sanitary restrictions cannot be administered, and every hotel pro- prietor should be especially cautioned to watch closely for and immediately report every suspicious case. Here, as in all towns and cities, the board of health should insist upon thorough quarantine, and it can be accomplished in resorts, as well without as with the usual placard. Variola should always be removed to the municipal hospital or held under special officer quarantine. Systematic renovation and fumigation should be demanded of every hotel at the close of or before the opening of a new season. The problems of food supply differ little from the interior, except that the clam and oyster supply needs the greatest regulation. Residents and dealers too often dredge their supply from the sewage -infected waters, or, what is of equal importance, fatten their oysters on half fresh water and half sewage- infected sea water mixed together. Where the waters are infected too rigid laws cannot be enforced in regard to this question. The board of health of Atlantic City does not allow the delivery, sale, or use of oysters or clams taken from or fattened in the waters within five miles of the resort. As a still further pre- caution the leading hotels do not serve oysters in any form on their regular menu during July and August. Sewerage. — Most seaside resorts pump their sewage without sedimenta- tion directl}- into the ocean or the large tide-water thoroughfares, acting upon the principle that the dilution is so great and the antiseptic qualities of sea water so decided that no harm results. While this may be true to a limited degree, the time will come when it will prove a decided unsanitary measure. Evidences of this are noticeable in some resorts where, during certain tides, considerable excrement and foreign materials wash upon the beach. Some system of sedimentation or purification should be adopted by every resort to provide against future trouble. Open filter beds in Atlantic City proved to be so much of a nuisance that they were abandoned years ago. The handling of seaside sewage resolves itself into a pumping system, such as must be adopted in any flat country. The strain here is the pumping a reduced quan- tity in winter and a vastly increased amount in summer and yet so arrange things that local insanitary conditions do not arise. This is successfully done. Garbage. — The sj^stem of towing garbage miles to sea in scows is to be discouraged. Cooking of garbage is also a nuisance, as it will not be done without unpleasant odors. Incineration seems to be most satisfactory here. Many hotels can burn their own garbage in special range racks to great advantage as to heat-saving and eliminating the visits of the too often insani- tary garbage carts. (See Chapter II in regard to hotel sanitation in general; Chapter XXII upon the sewage and garbage questions and the chapters upon quarantine and boards of health.) Mosquitoes and Flies. — The mosquito is best banished from the seaside resorts by filling all lowlands, draining all meadows and destro)ing every breeding point possible. The proper and persistent crusade against filth and open manure heaps will soon abolish the fly nuisance, as has been done by many resorts. (Read details upon the salt water mosquito under " Parks," in Chapter VI.) Water supply. — Where a proper artesian supply is available, large hotels /COr SEWERAGE PLANT, ATLANTIC CITY There is no odor resulting from the process here used LOCKER ROOM. SANITARY BATHHOUSE, ATLANTIC CITY PLACES OF AMUSEMENT AND DISSIPATION 113 drive their own wells, fitted with absolutely impervious casings, and deliver for use to their guests water that has never been exposed to the air, light, or any possibility of outside contamination. In fact, many shore resorts supply artesian water to the entire community during the greater part of the year and a mixed artesian and stream water in summer. As another sanitary measure, some hotels deliver artesian water, from their own system, through pipes coiled through a refrigerating chamber and connected to each room, thus giving a cold, potable, pure water instead of water iced with a dubious source of supply, as is most commonly done. Bathing establishments. — With from one to five thousand people bathing from one establishment in one day, the same suit often used several times, and a common towel supply, we have a great source of possible communication of scabies, favus, syphilis, gonorrhoea, eye troubles, and all forms of communi- cable maladies. These places should come under strictest supervision and a general campaign of education and inspection established. The modern up to date bathing establishment must be sanitary in its surroundings, most scrupulously cleaned, ventilated, and drained. Floors should be of tile or smooth concrete, there should be proper rooms for dressing and toilet pur- poses, and a system of thorough steaming, washing, and drying to supply perfectly clean suits and towels for each person. The spirit of competition has fortunately supplied these necessities in spite of neglectful boards of health. Many of these bath houses refuse service to those known to have or who are suspected of having contagious maladies. Every bathing estab- lishment should be made to conform to the strictest sanitary laws and should be allowed to conduct business only upon a permit given by the authority of a strict board of health. Hospitals. — The day of treating contagious diseases in hotels and cot- tages is practically past, and every seaside resort must have its own municipal hospital conducted upon such lines as will conform to the needs of the poor as well as those of the most fastidious. A hospital for the treatment of general infectious troubles of less danger is a necessity as well. Added to such pro- vision, Atlantic City has established a fully equipped central hospital tent and two auxiliary tents upon the beach front bathing grounds, where hundreds of cases are given first aid treatment and many cases of communicable disease are first recognized and recommended for proper treatment. Three physi- cians of proper standing are in charge during bathing hours in the regular season. They also report to the proper authorities all unhygienic conditions coming under their notice and often receive complaints of insanitary states needing correction. Every seaside resort with a large bathing contingent can well copy this method as a protection and sanitary beach front necessity. Death rate. — The seaside resorts are the most healthy in the world as regards permanent population, and the proper death rate is among the lowest. Records of state boards of health do not show this to be the fact, as their statis- tics are based upon deaths among permanent population and transients as a unit. The latter outnumber the former two or three to one, since thousands of invalids, convalescents, and incurables are sent here either to recover or to die, and a due proportion accomplish the latter outcome. It is not fair to 114 HYGIENE any resort to take the death rate of other places and add it to its own and publish it to the world at large as representing the true conditions present. A fair death rate cannot be computed upon a basis of 40,000 permanent popula- tion when the deaths occur among over 200,000 visitors as well. Chapter VII SLUMS AND TOWN NUISANCES* Building laws and the slums — What we should and may expect of owners, tenants, and the authorities — Inadequate laws in many places — Manure and factory refuse — The smoke evil — Sewers — Stagnant water and mosquitoes — Public dumps — Garbage disposal — Dirty vacant lots — Weeds — Offensive manufacturing and mine refuse — Rats and bubonic plague. THE ideal community would have neither slums nor nuisances, and in consequence its expense for the adm.Inistration of justice, for charities, and for the correction of social disorders veould be at a minimum. This ideal community would provide the highest possible personal efficiency, and I take it that such is the effort of all modern philanthropic and sanitary work. When we shall have realized that all unnecessary illness, all loss of opportunity for gainful work, all restraint from industry by judicial or other means, and the cost of all effort to relieve distress, make up a sum which bears in the last analysis upon every member of the community, we shall begin to see that the slum is a heavy expense to the better portions of the com- munity, and that nuisances concern everybody. Building laws and the slums. — So long as no restraint is placed upon the cupidity of the incidental possessor of a portion of the earth's surface, on the one hand, and upon the foolishness of the unfortunate or careless, on the other hand, slums will exist. It is well understood that a definite relation exists between healthful conditions and the number of cubic feet of indoor space allowed for each individual in a dwelling. But this understanding does not always assume legal shape or have bearing upon the builder or the owner of real estate, who calculates his possible income regardless of the future effect on humanity. One of the first things needful in bringing about a state of public senti- ment which will produce proper building laws, and then enforce them, is the understanding that a man who so uses property in his hands as to damage his neighbor now or in the future is working evil and wrong, and is not deserving of public respect. Not unfrequently men of really good intent, whose lives are beyond reproach, for the most part, are among the most inveterate offend- ers in respect to the contraction of space in which a human being may be expected to exist. I have in mind a Sunday school superintendent who has but recently erected two dwellings and a store on a piece of ground of eight feet front by some hundred feet in depth. Another, occupying an important position in a strong church, is extending his operations into the open country in such fashion as to prevent any possibility of sunlight or fresh air getting into the habitations he causes to be erected. Another who seeks public honor is selling habitations built upon lots 14 by 85 feet on land bought by the acre. When, as I have above suggested, it is understood that such men as these are blood guilty, and when they are looked down upon because of their cupid- *By J. Horace McFarland, President American Civic Association. 116 HYGIENE ity, selfishness, and disregard to the public health, then proper laws will be possible but unnecessary. Meanwhile, it is important that any thoughtful community should safeguard itself by an insistence upon the enactment of such laws as shall provide against the evils of the slum. It should not be understood that only the large cities, with their much talked of " tenements," are offenders in this respect. Many of the smaller cities, especially in eastern Pennsylvania, are fully as wrong in this respect as are the larger and more congested cities; indeed, they are worse, for in the larger places attention has been called and there are building regulations and a considerable oversight of housing conditions. In the smaller places, on the contrary, the tenement is simply laid on its side in the shape of monotonous blocks, with conditions which rapidly become as offensive as the worst high tenements in the larger cities. A noted writer on the national health has recently observed that the shelter of our houses is responsible for much of the sickness which the medical profession combats. He has urged that a point of view be taken under which shelter shall be incidental and the outdoors shall be brought indoors as much as possible. Two primary points may therefore be set down as necessary to be considered in respect to building laws in the efficient community. The first is that a certain adequate space shall be provided for each individual, and the number of individuals permitted to live in any structure erected shall be proportioned to that space. The second is that such buildings shall be so arranged with respect to the access of light and air as to make it possible to bring the outdoors indoors. I do not conceive that it is necessary in this connection for me to give figures, but merely that it is important to suggest the underlying principle, from which details may readily be worked out. Another of the ways in which cupidity and carelessness combine to create slums where there should be only healthy, sightly, and pleasant conditions, is that connected with building in blocks, in which, as a matter of fact, there are but four walls and a roof, the intervening lath and plaster, or single brick partitions, being merely impervious to light, and not to sound, odors, or con- versation. Obviously, there can be no proper family life amid the promis- cuous conditions which prevail where the odors of cooking go from end to end, in the accursed dwellings under discussion, where the least noise is trans- mitted through the several partitions, and where sleep is made troubled or impossible because the person in the dwelling making the latest noise at night controls the situation, in connection with the one who rises earliest in the morning. The model building law, therefore, should not only provide in respect to the number of cubic feet allowed for each individual, and in respect to the admission of light and air, but should, as well, provide against the block, w^ith its flimsy partitions. The experience of those who have erected model homes, in England, particularly, and to a certain small extent in America, goes to show that it is entirely practicable to put up separate buildings of low cost, but giving the advantages of privacy, light, air, and adequate space to the workers housed in them. SLUMS AND TOWN NUISANCES 117 In any community undertaking to put in legal form proper regulations covering the erection of dwellings, there will be opposition from those whose interests are against the public welfare. Those who believe that individual efficiency is at the bottom of national prosperity will need to fight hard for such laws as will make it impracticable to continue slums. In addition to the items above mentioned, drainage, water supply, the street surface, the side- walk, trees, contiguous playgrounds for that recreation absolutely necessary to the healthy human animal, and arrangements for the removal of human wastes, must all be taken into account. It may fairly be said that we have a right to expect of the owner of a property that he shall not undertake to put upon it dwellings which will pro- duce citizens who must be cared for by his fellow citizens through ill health, or immorality resulting from ill health. It is also reasonable to expect that the constituted authorities of the town will be willing to enact and enforce building laws which reduce to a minimum the burden arising from ill health and immorality. It is no less right to insist that the tenants of such buildings as would be erected under the conditions above described shall use them with respect and decency. One of the discouraging things connected with the model tene- ments of New York, for instance, has been the tendency of more or less ignorant tenants to destroy the very things which made for decency and good health. The story of the Italian woman who found it more convenient to keep her supply of kitchen coal in the bathtub than to use that white enam- elled receptacle for the proper purposes, is familiar to all. The tenant must be educated in this matter, and if he has been, as is very frequently the case, the result of generations of carelessness, it is going to be quite a job to get him to see the right and to do the right. What, for instance, could be expected of the children who have grown up in the coal mining slums of Pennsylvania, under the shameful conditions there provided by wealthy owners, if these children should suddenly be given access to a properly fitted dwelling house ? The responsibility in this case returns to the wicked owners of the property, who have fostered a system in which humanity is educated downward and returned as nearly as possible to barbarism. Manure and factory refuses. — The time was when, under the prevailing idea that all that was necessary was to get rid of wastes in any easy way, the housewife deposited the ashes resulting from her use of coal in the nearest highway, and the factory dumped its refuse in convenient places, taking ac- count only of the way in which such refuse might interfere with its own opera- tions in respect to access to its premises. This referred primarily to solid refuse, and not to liquid refuse, which was, without the least thought of objec- tion, turned into the nearest water course. I have said the time was when these methods of disposing of refuse were considered proper. I should say that, so far as factory refuse is concerned, the time yet is when, for the most part, refuse is simply gotten out of the way, without consideration of the neighbor. The housewife, to be sure, may no longer throw potato parings into the alley, or ashes into the street, but the manufacturer can, and does, distribute his refuse without much reference 118 HYGIENE to his neighbor, taking refuge under the plea of the importance of his industry. From the standpoint of public hygiene, the main objection to the thought- less disposition of stable refuse, here mentioned as manure, is the long-time unnoted fact that the common house fly finds its most favorable breeding place in manure, particularly horse manure. Since it has been discovered that the house fly is an efficient disseminator of disease germs, and not a scavenger doing good work, the disposition of manure becomes distinctly of importance. Upon the theory previously indicated, that no man has a right to injure his neighbor by any of his own acts, manures of all sorts should be so cared for as to be completely inoffensive, either from odor or as breeding places for insects. If kept in tightly closed and well-screened pits, and if hauled away from stables in cities at frequent intervals, and if these stables are in them- selves kept clean, there should be little difficulty. If, on the contrary, there is neglect of the simple sanitary necessity of preventing the breeding of injurious insects, by reason of neglect to safeguard the handling of manures, then a serious and distinctly dangerous nuisance results. It has some bearing on the subject to be able to say that modern agri- culturists insist that manures may properly be disposed of without being subjected to the process of rotting, long supposed to be necessary; that is, they may be promptly put on the soil, to return to it a portion of the fertility extracted through the processes of growth, nutrition, and defecation. As to factory refuses there can be no proper question as to the necessity for insisting that they be so cared for as not to interfere with the lives, the health, or, indeed, the comfort of a populace. This view has been legally sustained, particularly in one notable case, decided in a Pittsburgh court by Judge Ewing, when, after a long endeavor, the citizens of the Pittsburgh district known as Oakland succeeded in securing an injunction order upon the Jones & Laughlin Steel Co., restraining it from ematting clouds of ore dust which made life intolerable. The legal view was put forth that it was not equitable for the offending corporation to so conduct its manufacture as to interfere with the health and comfort of the surrounding populace, and that it must provide means for avoiding such offense. This would seem to point the way clearly to proper procedure in respect to factory refuse, whether it be emitted through the air, deposited on the ground, or permitted to flow into a water course by the usual drainage means. Latterly the disposition of health authorities ever}'where is to insist that water courses, said to belong to all the people, shall not be polluted by some of the people whether by house sewage or factory drainage. There is another side to disposition of factory refuse, not always taken up. Great heaps of slag or waste from any manufacture, disposed in careless fashion and destroying all vegetation, introduces depressing ugliness into the landscape, and to that extent interfere not only with comfort, but, indeed, with health, and so with efficiency. It is certainly a proper view, and will, I insist, shortly become a completely legal view, that manufacturers must so arrange their processes and methods as not to interfere with the light, air, comfort, or health of their neighbors, be those neighbors their own workmen, living nearby, or others related merely as fellow-citizens. SLUMS AND TOWN NUISANCES 119 The positive nuisances, including flies, mosquitoes, poles and wires, billboards, smoke, unnecessary industrial noises. — The house fly is discussed elsewhere in this volume, as also is the mosquito. Both are properly classed as positive nuisances; both are known to be preventable, and the presence of both or either in any considerable numbers is disgraceful in any civilized communit). As a disseminator of typhoid and other diseases, and especially as con- nected with its influence on infant mortalit)' in hot weather, the house fly is a deadly and desperate menace. The investigations of the Merchants' Asso- ciation of New York have shown that the infant death rate in that great city follows closely the rise of the number of house flies. As the flies increase the babies die, as the flies die the babies live; in my part of the subject under discussion I need, I think, only insist that a sane view of public hygiene will draw the distinction as to the impoitance of lives. If it is more important to have the babies of a community live than to have plenty of house flies, the latter must be killed, or, rather, prevented from breeding. The house fly, it is well known, breeds only in filth, particularly in horse manure, as has above been suggested. The removal of filth and the proper handling of horse manure will soon eliminate this dangerous nuisance. The mosquito is known in its various species to be the host and dissemi- nator of malarial diseases, and in certain localities of yellow fever and other germ diseases. It is known also to breed only in stagnant water, and its presence in any community is an evidence of sanitary neglect. The success which has followed energetic endeavor to free from mosquitoes — both malarial and ordinary' — certain localities on Long Island and in New Jersey shows that a ny community can be rid of this buzzing nuisance. It is not amiss to mention that of the thirty odd species of mosquito known to exist in the Eastern states, but one or two fly to any considerable distance. Breeding places may therefore best be looked for immediately about the premises aflfected. A hoof print, a choked roof gutter or rain spout, a discarded tin can, or any little puddle may, in a week or two in hot weather, aff^ord breeding opportunity to a horde of off^ensive mosquitoes. To screen the house is an excellent method of defense, but a better method is to prevent the breeding of the mosquito by drying up the stagnant pools, wherever they may be found, in which he loves to generate, or by covering with a thin film of petroleum the water-holding vessels which cannot be otherwise treated, thus killing the wigglers as they rise to the surface to breathe, and hy generally seeing to it that the necessary conditions for mosquito life are not provided. It is a mistake to insist that trees or shrubbery aff^ord breeding places for mosquitoes. This is in no case true, but it is true that when mosquitoes have been bred somewhere through the provision of the necessary stagnant water, the trees and shrubs afi^ord comfortable lurking places for them. I class electric poles and wires as among the positive nuisances of town life. They obstruct the view, and while their relation to hygiene is only that which comes about as one considers that they interfere with ultimate effi- ciency, yet their removal gives so much greater freedom, atmosphere, and 120 HYGIENE beauty to our community, streets, and roadways, that they may properly be classed as nuisances. The increasing price of timber, and the fact that the maintenance of an overhead wire line is far more expensive than the maintenance of an under- ground line, tend to decrease this nuisance. It is believed that in the course of time main lines of wire throughout the country, as well as in populous communities, will be put under ground, effecting a great improvement in conditions generally, as well as a vast economy in maintenance. The billboard is classed as a positive nuisance for several reasons. As erected in most of the smaller communities, without adequate supervision, it tends to afford places for the depositing of filth behind its outer surface, and in many cases affords convenient opportunity for lawless persons to commit other nuisances. Where billboards must be permitted there should be a positive regulation that they be maintained at not less than two feet from the surface of the ground on which they stand, and that the owner of the property on which they are maintained be charged with the duty of keeping the ground back of them absolutely free from anything offensive to the senses. Billboards are a nuisance also because they tend to education in vulgar- ity, in bad form, in incongruous coloring, and, in general, toward the very opposite to that which makes for efficiency. The restfulness of natural scenery is recognized. No one has ever insinuated that when the landscape is substituted by a " billboard scape " restfulness is present at all. Who has not seen the traveler turn his weary eyes from the once restful landscape to the inside of the car in which he was traveling because of the assaults upon his optic nerves, created by a succession of staring announcements of whisk- eys, corsets, phonographs, tobacco, and nostrums ? Billboards are a positive nuisance also because they are a positive waste. Tests are shown that the effectiveness of billboards as a means of advertising is very low. Inasmuch as it is impossible for advertisers to trace results, those who erect billboards secure their continuance mainly by an appeal to improbable advantages. It is believed that before a great while the courts will class billboards as nuisances under the common law, and that they will either be abolished, for the most part, or restricted to definite localities, to definite sizes, and to less offensiveness. In the city of Cincinnati the new building code restricts them to not exceeding twelve feet in height or thirty feet in length, and provides a definite interval between two billboards. They are compelled also to keep at least two feet from the ground and to keep back at least ten feet from the street line of any property on which they may be erected. In Kansas City residents may secure the condemnation of billboards right in any district, with compensation by the city to owners of property under consideration, so that billboards may be completely eliminated. Efforts are being made in many cities and states to tax the billboards, and thus to diminish their in- trusions. Smoke is unquestionably one of the greatest of the positive nuisances. It is just as unquestionably one of the least necessary of these positive nui- sances. Nearly all the black smoke emitted over our communities is com- SLUMS AND TOWN NUISANCES 121 posed of unconsumed carbon, unreplaceable, and having a very distinct relation to our vanishing coal supply. It would seem to be no more right for the manufacturer to deposit his carbon, carelessly emitted through the stack over his boiler furnace, upon the persons, clothing, and goods of his neighbor than it is for the housewife to deposit her ashes, which are the result of her combustion of carbon, on the sidewalk or in the street. Statistics show that vast damage in a material way results from the emission of black smoke. Something more than two hundred million dollars a year is the economic waste In the United States, according to a recent report made by a section of the Federal Geological Survey. From the hygienic standpoint, black smoke is certainly a nuisance and a damage. It clogs the human air passages and the lungs, and is known to decrease life and to have an injurious effect in many disorders. The emission of black smoke is totally unnecessar}'. Vv ith the provision of a proper furnace any sort of coal may be burned without black smoke. It is not necessary that the details of proper combustion shall be here dis- cussed, but it may be briefly noted that the main essential for proper combus- tion is the provision of ample space between the fire and the boiler, or other surface to be heated, in which the gases resulting from the burning of the coal may be fully consumed before they strike the colder surface of the boiler or other object above, and are thus condensed into form to be emitted as black smoke. There are numberless devices on the market, many of which are effi- cient, but no device works in the absence of intelligent attention by the fire- man, himself usually the worst paid and most carelessly treated employee in any manufacturing plant. Communities should prepare to enforce reasonably restrictive laws against the emission of black smoke, providing an inspector to see that manu- facturers obey the law, and proposing progressive penalties, under which it will be most expensive for manufacturers to persist in creating this nuisance. It is known that any grade of coal burned in a suitably constructed fur- nace will give a far greater degree of its latent force to the use of the manu- facturer than if improperly burned. There is therefore hope that good sense will supervene, especially in connection with reasonably restrictive laws, to bring about the practical abolition of wasteful black smoke. The use of electric power, generated in large volumes under conditions which make the emission of smoke notably uneconomical, or generated from water power, will obviously tend to reduce the emission of smoke in com- munities, and the eventual electrification of railroads may be expected to solve the most difficult part of the smoke problem. Unquestionably unnecessary industrial noises have a distinct relation to the health of the people, and thus come into proper consideration in a volume devoted to modern hygiene. I refer under this designation to the passing of trolley cars with what are technically known as " flat wheels," or with ill- adjusted machinery, making a frightful racket; to the continuance of cobble- stone or Belgian block street paving, over which heavy teams, loaded with carelessly packed noise-producing wares, are driven by shouting and often profane teamsters; to the unnecessary ringing of bells and blowing of whis- 122 HYGIENE ties; to the reducible noise met with contiguous to great factories; and, in short, to all other forms of waste and friction which produce racket, clangor, and nerve-distracting sounds. There is evidence easily obtainable to showthat any normal human being works with greater efficiency amid surroundings of reasonable quietude. Leaving out of consideration for the moment the effect of these industrial noises on persons ill or in a subnormal condition,! insist that unnecessary and avoidable noises directly reduce the working efficiency of every human being exposed to them, and that for that reason, if for no other, they should be comhatted, reduced, and, as far as possible, eliminated. I believe that the prevailing racket characteristic of American cities can be reduced fully seventy-five per cent, with an added increase in efficiency due to the resulting peace which will far more than compensate for the cost involved. It is admitted that sound sleep is necessary if the tired worker is to be restored to efficiency. Sound sleep is impossible if the local authorities permit rackety trolley cars to pound through the streets without respect to the noise created, at all hours of the night, ringing their exciting gongs at frequent intervals, sometimes in accordance with city regulations, but without real necessity. That these noises are reducible ought to be evident to an} one who reflects on the difference between the automobile of to-day, so noiseless as to give no signal of its approach, except when its noise-producing device is operated, as compared with the unpleasant racket characterizing the auto- mobile of but a few years ago. If noise can be eliminated from the auto- mobile, a mechanism operated on indifferent and miscellaneous roads, it can certainly be eliminated from trolley cars, whose mechanism operates on rail- ways, which surely can be made smooth, and ought to be. The other mechanical noises referred to, connected with paving, teaming, and factory work, can certainly be removed almost entirely by proper atten- tion, and such removal should be insisted upon as a necessary adjunct to wholesome life. The blowing of whistles is a barbarous survival of the day when there were no clocks. Any manufacturer can, at slight expense, install electric gongs about his premises, which will give signals for commencing and stop- ping work without alarming the neighborhood. Particularly does this sug- gestion apply in the cases still existing in which whistles are used in the small hours of the morning to arouse those unfortunates who must take up their labors at early hours. It is obviously unfair to awaken an entire neighbor- hood in order that a score or more of workers may be caused to disregard the easily obtainable alarm clock. An unnecessary noise has been above alluded to in the explosive gong of the trolley car, which, as I have before said, is sometimes by municipal ordi- nance operated at every street crossing. To substitute sharp vigilance on the part of the motorman would be to relieve the community from this unneces- sary addition to its preventable noises. The operations of railroads produce many avoidable noises. Whistling can be, and in some American communities is, reduced to a minimum, being done only for necessary signalling purposes and in cases of danger. SLUMS AND TOWN NUISANCES 123 There is a class of noises not connected with industrial life, for the con- tinuance of which there is absolutely no excuse. I refer particularly to the periodic celebration of the national holiday, through the explosion of fire- works, guns, and pistols. From every standpoint this misuse of the national holiday is wrong. That it has annually caused a great sacrifice in life, property, and in addition caused many accidents, does not seem yet to have impressed the public as to the futility of this form of showing patriotism. But it is believed that eventually a " safe and sane Fourth " will prevail in the United States, to the comfort of many, particularly those who may be at that time so unfortunate as to be confined in hospitals or their homes by illness. The whole matter may be summed up in the statement that every avoid- able noise of a distracting character is unhygienic and wrong, and in the properly conducted city such noises will be suppressed or reduced. Sewers, sewage disposal and purif cation. — This subject relates only remotely to that of the chapter. The absence of sewers undoubtedly creates a nuisance, and therefore I may briefly insist that a proper, modern, well- designed and successfully operated system for removing the wastes of human life is essential in any decent community. Just what that method is to be must be determined in each individual instance. It is no longer considered right to dispose of these human wastes by turning them into a convenient water course, as I have before observed, and therefore, in addition to such division of liquid wastes as will keep house sewage distinct from storm water and street drainage, there needs to be taken up in any community some adequate system of sewage disposal and possibly of purification. The subject may properly be dismissed for consideration in a more com- pletely technical way by reiterating the statement that no community has the right to thrust the unsanitary result of the wastes of its own life either upon its own citizens or upon the citizens of another community. Stagnant water. — The main reason for disposing of stagnant water is that it is in it that the mosquito breeds. A secondary reason is that a pond or puddle of stagnant water seems inevitably to attract tin cans and refuse which tends to become much more unsanitary than the water itself. A general misconception exists in regard to stagnant water with a green scum. This scum is plant life, and is not unwholesome in itself; indeed, it frequently takes up through the process of nature impurities in the water^ which are thus turned through nature's economics to what may be a useful purpose. Unquestionably stagnant water should usually be drained. Where it cannot be conveniently drained a thin film of a mineral oil will at least prevent the breeding of mosquitoes. Public dumps. — These seem to be necessary in modern community eco- nomics. They also seem to be usually unsanitary, and they tend continu- ously to become public nuisances. Where the dumping is, as is often ideally proposed, of clean ashes only, there can be no harm done and no nuisance created. When, however, a disgusting odor comes from a dump upon which supposedly nothing but clean ashes have been placed, obviously somebody has gone wrong. In practice dumps are always odorous, and should have^ 124 HYGIENE for that reason, sharp attention. Where there is a garbage collection system, and especially where there is some attempt to economically recover value from house wastes deposited in garbage cans, it is certainly practicable to reduce the dump to its lowest oftensiveness. This can be accomplished by rigid inspec- tion, following a proper basic contract or set of rules, under w^hich offensive conditions bring immediate and automatic punishment in the way of penalties or fines. The depositing of loose papers, boxes, and the like on public dumps intended for clean ashes only creates a nuisance, not necessarily unsanitary, but none the less annoying. There is no reason for the continuance of any such nuisance. As to the success of garbage reduction operations I cannot speak with assurance. Thev exist in many places, and their existence is generally r^bvious to the entire neighborhood because of their failure to maintain the scentless condition upon which they usually secure entrance to that neighborhood. That there is material of money value in the wastes of life which are collected as garbage, and which tend to get on public dumps, is known. In New York and in other large cities considerable revenue is received from attention to this class of substances. The burning of loose refuse under boilers to create power is successfully practiced in New York, where one large bridge is lighted entirely from loose garbage consumed in this fashion. The whole subject of public dumps and garbage handling is at this writing not at all in a settled and definite condition. There is much dis- cussion and experimientation, and there will eventually ensue a sanitary result. The disposition of factory and manufacturing refuse has been above alluded to. It has a relation to dumps, however. In localities where it is desirable to fill in low places, clean factory refuse is certainly usable to advan- tage. There should never be any offensive manufacturing refuse dumped anywhere, for under the construction I assume as the basis of this chapter, no manufacturer has the right to ask his neighbor to suffer from or take care of the results of his industry or carelessness. The dumping of mine refuse on the banks of streams or its washing into water courses is receiving considerable attention. In connection with our vanishing coal supply this frequently combustible refuse will diminish, as it becomes necessary and desirable to utilize it for the unconsumed carbon it contains. Meanwhile it is not improper to assume the position common to other details of this subject, that the mine owner has no more right than any other citizen to reduce the pleasantness and efficiency of the lives of his em- ployees and his neighbors by depositing his refuse where it will act to that result than any other citizen has to do the same things. Dirty backyards and vacant lots. — Unquestionably filth in backyards and in vacant lots is a potent means of continuing the slum and creating a town nuisance. Under the American idea of the sacredness of private prop- erty the disposition to allow the individual to do what he pleases on his own premises has given rise to filthy conditions. With the modern conception of the responsibility of the individual to his fellows, and under the broad scope of the police power of the community, it is certainly practicable to prohibit SLUMS AND TOWN NUISANCES 125 the collection of filth or material of an unsanitar}- nature close to human habi- tations, and to have it removed at the cost of the offender, where it has been deposited. A little attention en the side to the promoting knowledge of the desira- bility of the use of plants, fiowei's, and trees in back}ards sufficiently open to the sun and air for their growth will often entirely remove the trouble from unpleasant backjards. Any movem.ent in a town which will stimulate the pride ot the citizen in his own surroundings and about his own hom.e will help amazingly in eliminating the dirty backyard. There exist in many communi- ties societies distributing free or at a nominal price seeds of flowers and vege- tables, for the successful growth of which premiums are offered. Particularly in Cleveland, Ohio, the long pursuit of this plan has been effective in almost eliminating the unpleasant backyard. Dirty vacant lots should be eliminated under the police power of the community by requiring the owner of them to make his premises sanitary and sightly. It may be that he cannot be legally forced to make them sightly, for as yet the police power does not protect the eye. It is certain that he can be compelled to keep them sanitary. Therefore, when a vacant lot becomes a dumping ground for refuse, slyly placed there by citizens who know better, the municipal authorities should take action to either catch the offenders in the act or force the owner of the lot to himself protect his own property. In some communities much good has resulted from a movement to place vacant lots, upon which vegetables might be grown, at the disposition of men out of work or of men who could so use spare time. There immediately en- sues good order and pleasant experience, as well as a real addition to the wealth of the community, not only in the value of the products raised, but in the knowledge obtained and in the economics promoted. Frequently, therefore, the suggestion that vacant lots may thus be availed of will work a removal of what may be a distinct nuisance. Where vacant lots are used to harbor billboards the observations pre- viously made in respect to this outbreaking nuisance may be taken into account. I urge the consideration of the fact that in such an event as the erection of a billboard on a vacant lot it shall be construed by assessors as liable for taxes, and that it may no longer be considered a vacant lot, inasmuch as a structure has been erected on it, properly subject to taxation supervision and the necessity for preserving sanitary conditions. Such a public sentiment in the community as will force the assessors and health authorities to thus look after the billboards will eliminate some of them and certainly promote the public welfare in several obvious ways. Conclusion. — In discussing this whole problem of slums and town nuisances I have, as will be observed, considered the matter from a rather broad humanitarian standpoint, avoiding, for the most part, definite direc- tions, and trying to state as well as I may the determining principles which relate the subject under discussion to public hygiene. I do not believe the cause of public health can be advanced in any way so well as in bringing about a feeling that every man is responsible, not only for his own acts, but for the influence of those acts upon his neighbors, whether that influence arises 126 HYGIENE through noises he makes, through smoke or refuse he puts upon his neighbors, through unsanitary conditions he creates, through land greed or the erection of improper dwellings, or through any other act which makes less wholesome, happy, and therefore efficient, the lives of his fellow-citizens. Notes. — In addition to the matters discussed by Mr. McFarland, sewers, the fly nuisance, mosquitoes as carriers of infection, weeds, factory wastes, the garbage pro- blem, and other town nuisances are discussed in several other chapters. (See the gen- eral index.) Mr. McFarland has asked the editor to say something about bubonic plague and the town nuisances contributing to its spread. The extensive spread of the disease during the last few years has led to a large volume of literature upon the subject and what I have to say will be very brief In the 1908 Weekly Public Health Reports appears a paper prepared by direc- tion of che Surgeon-General and that shows the total number of countries infected since 1894 to be 51, and with a dreadful mortality, India in 1907 having 1,400,000 cases and 1,200,000 deaths. The personal prophylaxis being rigid quarantine and the avoidance of contact with rats, dogs, and other flea-carrying animals, ground squirrels, etc. It is stated that coal oil best protects against the fleas. Quarantine against rats is an important matter and vessels must anchor at least a third of a mile from port if considered infected. Sulphur fumigation is used aboard for the destruc- tion of rats and bacteria. Cities and houses infected require most elaborate disinfection and such measures as will render them rat proof. This is accomplished principally by cement or concrete construction of walls and portions near to the ground. All sources of food for the rats must be cut off except such as is poisoned and set for them. This involves very care- ful garbage collection and destruction. In California, ground squirrels are known to have caused nearly all of the recent cases, and it is possible that other squirrels carry the disease. In view of this, it appears unwise to harbor squirrels in parks or to eat their flesh in sections known to be infected. The squirrel readily domesticates. From the adjoining parks these animals are spreading all over this city and they frequently enter yards and even houses here. This is a potential danger when the least infection exists. Outgoing quarantine involves the disinfection of all clothing, rags, etc., and the utmost care in receiving and loading vessels and cars. Wharves should be provided with rat funnels and proper fenders, and the gangways should be elevated six feet above the wharves at night. Sewers should be especially watched and placed in the best possible condition in order to prevent their harboring rats. Trapping and poisoning rats has been reduced to a science in San Francisco and other infected places. The large nineteen-inch French wire cage trap is preferred, but must be made of heavy wires. The best places to set them are slaughter houses, meat markets, chicken houses, cellars, and near to the garbage cans. Traps must also be set in the sewers and the habits of the rodents must be studied to secure the best results. The bait may be one of many substances rats like, but are not likely to obtain where the rat trap is set. A female ra. within the trap is likely to attract males and the young. Kill the rats where live ones cannot hear them squeal and burn out the trap before setting again. Rats may be poisoned by arsenic, phosphorus paste, and car- bonate of baryta. In the city of San Francisco it is estimated that 800,000 rats have been trapped and poisoned since 1907. Chapter VIII SPECIAL RURAL HYGIENE AND SANITATION* Watersheds and rural water supply — Ice supply and ice ponds — Infected wells — Spring — Cisterns — Hauled water — Tanks and piped water — Barnyard drainage — Sewage — Vaults -^- Fertilizers — Sick and dead animals ^ — Milk supply and the many questions involved therein — Cheese, meat, and milk ptomaines — Butter and butter substitutes — Creameries — Dressed meats and federal inspection — Poultry — Eggs — Food preservatives and dyestufFs — Fish and game meats — Insecticides upon food — Poisonous plants and their eradication — Insect pests — Sanitation in sending produce to market — Summer camps — Rural resorts. AS means of communication increase and the country settles up, the special problems of rural and urban hygiene disappear and the work of state medicine is making one question of the whole. There is no just reason for considering the farmer as peculiar or possessed of special privileges or immunities; nor is it right to create distinctions between urban and rural dwellers or establish lines of procedure, in sanitation, apply- ing exclusively to one or the other class. But there are matters of detail and environment and practical points in the farmer's busmess that demand consideration the same as any other business or industry. A full treatise upon rural hygiene would demand a volume of itself, but it may be said that nearly every chapter of this present book bears directly upon some phase of the problem facing the ruralist, and what will be said herein will treat of the special sanitary measures from a practical point of view and from that of one who used to be " a country doctor." Watersheds and rural water supply. — Although the general question of water supply is treated of in Chapter XXII, some data must be given here in order to understand the importance of a watershed. Rain water is nearly chemically pure, except for impurities in the air carried down by the first portion of the rainfall. These impurities vary greatly and may contain con- siderable organic and bacterial matter, but, taken as a whole, the total pre- cipitation is quite pure at the moment it falls upon the earth. But such soft water is a rapid solvent, and not only carries into solution many of the chemi- cal substances in the soil and the rock strata, but by virtue of its contained oxygen gas and ammonia, it acts chemically and produces hydrates and ox- ides. In the earth it takes up carbonic acid, and that in turn produces other chemical changes. In sandy soil there is very little carbonic acid. There is no substantial ground for the view that melted snowwater, from clean regions, is more impure than is rainwater. For these reasons much ground water is not fit for domestic use, aside from later contamination. Arid plains, alkaline deserts, country underlaid with sulphides, arsenic, and other toxic minerals, gas, and oil, and even some kinds of limestone, all yield water either partially or wholly unfit for use. *Prepared from numerous reports and investigations of agricultural, dairying, and government organizations and departments. 128 HYGIENE Settlers in new country should carefully examine into the water supply. Sulphur waters should be used cautiously, as they are reputed to cause exotoses in cattle and other diseases of bone in man. Calculi may be caused by limestone waters, while goitre may arise from the constant use of mag- nesian and sedimentous waters. All this goes to show the importance of the watershed from a chemical point of view. I would advise farmers to be care- ful about signing oil and gas leases covering their farms, since the sinking of wells may result in striking salt water, which is pumped or runs over the land, thus permanently ruining the soil. Natural organic impurities need not occasion much alarm. Nature maintains a balance and, except in marshy and tropical lowlands, these impurities are not especially dangerous. Country spring water contains little organic impurities, few bacteria, and a mere trace of albuminoid am- monia. Dead organic matter does not markedly influence the health, but its presence (as shown by the permanganate test) may be a valuable indication of the presence of pollution. Hence, until water is shown to contain no dangerous impurities, it is a safe rule to suspect all water containing much organic matter. There is a vast difference between natural organic impuri- ties and organic pollution. Even the fact that a water contains many bacteria does not indicate marked danger unless it is some specific and pathogenic bacterial contamination. Very deep wells usually yield pure water, but not always. My neighbor. Dr. Harvey B. Bashore, says truly, in his book, " The Sanitation of a Country House " : A spring, like many other things in this world, is just as good as its surroundings. If it happens to be situated on an uninhabited and uncultivated upland it will likely yield a pure water, and if near enough and constant enough may furnish the most available supply, especially if it is at such an elevation that it can be used by a gravity system. Since springs are only overflows of the ground water, their condition is dependent on the geological character of the strata through which the water passes. In a region in which the strata have been upturned and broken there may be a seepage of pollu- tion from places little suspected, unless one is thoroughly conversant with the place. In a limestone region, on account of the many underground seams and tunnels which transmit wacer with great facility, without the filtering properties of the soil, pollution and infection may travel for miles. Therefore, these small streams and springs are the most liable to danger- ous contamination, and none should be used for a water supply until after it is followed up to its source and its watershed well examined. It is these small watersheds that are of the greatest importance to the farmer and contami- nation is not diluted largely by them. One case of typhoid on such a shed may infect a whole neighborhood. Watersheds on a larger scale interest the whole country and are quite a problem. Too big a problem for any one short of the state itself. Chapter IX discusses this matter, while specific contamination of waterways and public supply is adequately presented under appropriate headings. Undoubt- edly the best way to be prepared for the emergencies arising from contamina- tion of the watersheds is for the state to prepare maps from sanitary surveys SPECIAL RURAL HYGIENE 129 and from the geologic data, of every waterway in the state and of every build- ing upon the watersheds. This has been done by some of the states, and data accompany the maps, giving the number of inhabitants in every house and the average number of animals kept upon every farm. These surveys and maps enable the state board of health to intelligently use the typhoid and other reports coming in, and, through their local agents, protect the watershed in- volved at once and most effectively. It even goes further than that. These maps enable the department to intelligently judge the situation. Suppose the case is smallpox; the map may show that the tenant conducts a dairy and at once his route is gone over and exposed persons vaccinated. Or it may be typhoid fever; and proper disinfectants are left and full directions given for sterilizing the dejecta. Also, persons living along the streams that may have already been contaminated are warned to boil the water and any waterworks drawing their supply from that shed are inspected and warned. Thus, a small matter in an isolated locality may become the great concern of the state. To physicians it may be said that their duty imperatively demands that they promptly report all infectious diseases, so that this machinery may be set in motion. The large watersheds, of course, involve rivers, and they flow through all kinds of country. Mountain regions cause little contamination, while valleys and plains may do so to a serious degree. To one who has never studied such problems the amount of literature and reports issued about the Croton watershed, from which New York city is supplied, would, if he saw them all, be a revelation, and the sums of money spent would stagger him. And this is hut one of the important watersheds. A detailed study of the host of problems involved in caring for an important watershed would tire my readers, and we will leave to the engineers and pro- fessional sanitarians their detailed treatment. A few salient features demand some words. River water is usually rich in bacteria, but the important matter is to keep out typhoid bacilli, the com- mon colon bacillus, and all kinds of sewage. Lakes and slow-flowing streams are natural sedimentation basins, and such matters as coal, culm, sand, clay, mica particles, and mud settle out. But in a rapid-flowing stream they do not. One of the sights that astonish visitors to Harrisburg is seeing the coal fleet at work pumping coal out of the Susquehanna River. At times of freshet, when this river carries twice as much water as does Niagara Falls, millions of tons of coal culm is carried down stream from the distant mines. At every eddy or swirl of the water, the heavier particles of coal drop to the bottom of the river and pile up in heaps. Then, after the water falls from ten to twenty feet, this coal is pumped up to a screen and carried away in flatboats. A few years ago, before the city installed a filter plant, the finer particles of coal made the water so foul that it was absolutely undrinkable at times, and it is no exaggeration to say that laundry work had to go un- done. To-day the filter gives sparkling water at these times of freshet. Now that was our local question; other communities have theirs, — and the rivers carry nearly every abomination ever heard of, much of which cannot be successfully filtered out. 130 HYGIENE It is a big problem for the state to control corporate contamination of waterways because it is an equally big question for coal and mineral mining companies to devise ways for the disposition of dirt, waste, and tailings. Iron works use immense quantities of water and so do certain refineries, dye houses, chemical works, pulp and paper works, strawboard mills and hosts of other industries. A look at the Schuylkill River at Philadelphia or the Chicago drainage canal makes one a pessimist about river water supply. Neverthe- less there are rivers and rivers. Some must be inevitably contaminated, and it would be slow suicide to use them for a municipal supply. Thus far the states do not discriminate between streams (on paper), but they must do so in fact. This " gets on the nerves " of rural dwellers and small towns. The Susquehanna River must be used for a water supply, and the cities up the state do not see why they should be required to install sewage disposal plants to keep from poisoning Harrisburg any more than Harrisburg can see why she should do the same thing to keep from poisoning the towns down the river, and the farmer can't see why his hogpens should not be allowed anywhere upon the banks of the stream. It does seem hard to let the big trust ruin a stream and fine the man who runs a one-inch sewer into another one, and it does seem hard to we heavily taxed towns to build bonded disposal plants that do not do us one particle of good. It seems to be hard for us and good for " the other fellow," but remember the chaps up stream. As a matter of fact, legislatures are considering the question of the state building or helping to build these disposal plants and they will doubtless consider in time helping the farmer to meet his obligations to public hygiene. It is not right to expect a three thousand dollar farm to build a two thousand dollar retaining wall in order to protect a watershed, nor can municipalities do the state's work in protecting the dwellers of the rural districts. All this will finally devolve upon the state. There are certain things we cannot do and be within the limit of safety. If a watershed supports a population of over one hundred per square kilo- meter, the surface water is so liable to contamination that we run a grave risk, despite all care, if we collect and use that water without adequate and well- supervised filtration. The whole subject of filtration is presented in another chapter. If the agitation for reforesting the watersheds results in anything practical, a long step will have been taken to conserve, not only the forests, but public health as well. Another thing we cannot do is to prevent the dis- tribution of fertilizers over watersheds. Probably there is little danger from commercial fertilizers, but there needs to be some supervision of barnyard manure and of night soil. It has impressed me, but it is not definitely proven, that the micro-organisms in manure convert the organic chemicals therein into inorganic forms. If this be true, there is but little danger to be apprehended if the manure is allowed to stand in heaps for some time before being spread upon the land. As this is common practice, nothing need be done beyond what is already the rule. A question of both urban and rural interest is that of self-purification of streams. Certainly sedimentation and oxidation both combine to bring this about. The first process is favored by a sluggish current, while a shallow SPECIAL RURAL HYGIENE 131 and swiftly flowing stream churns up the water and aerates it effectively. Most streams have reaches of both kinds, and surely do much toward their own cleansing. Furthermore, clay and aluminum sulphate in the water act as coagulants and precipitate many impurities, while algae, infusoria, and micro-organisms convert organic matter into inorganic. However, the vitally important matter of killing the putrefactive and pathogenic bacteria is not accomplished by these natural methods or is but imperfectly accom- plished. Rural water supply demands extreme care, since the usual supply is from a very limited source and any contamination cannot be adequately diluted. Organic impurities from marshes and graveyards are to be sedu- lously avoided, and running brooks should be explored throughout their entire length and extent of watershed before they are used as a supply. Algae or diatoms, especially of yolvox, uroglena, and anabena, develop a disagreeable odor and taste in water infected with them, but they are not dangerous to health, although far from pleasant. One grain of copper sul- phate to fifty gallons of water will effectually kill these growths. As they grow only in the light, covering an infected spring will prevent the formation of the green scum. Eggs of parasites such as round worm and due to hog excrement, the ankylostoma duodenale and the organisms of amebic dysen- tery may all be found in a rural water supply. A Farm Filter It is composed of a water-tight trough divided into four compartments. The one most distant from the barrel is half filled with gravel, powdered charcoal, and clean sand, as shown; the second one is left empty; the third one is two thirds filled with gravel, charcoal, and sand; the fourth one is empty. The heavy marks in partitions indicate rows of half-inch augur holes across par- titions at levels marked. Il is a good filter when kept clean and constantly filled to capacity. It is the old Cutbush filter formerly used in the United States Navy. Domestic filters are often needed on the farm, and there are several types dealers sell in the smaller cities. The trifling little strainers amount to fittle, but those made of double soft earthenware containers and the stone cylinder 132 HYGIENE filters are effective and safe. The latter type cannot be used without plumb- ing connection to an elevated source of supply. Domestic filters with soft materials, sand, charcoal, etc., are hard to keep clean and pure. Methods other than filtration may be used to purify water. Farmers understand the process used to aerate milk, and they know how fully it may dispose of disagreeable odor and taste. The same thing is true of water. Pouring water repeatedly through a wire sieve removes hydrogen sulphide and other gases as well as dissolved organic matters. Boiling water kills most fungi and bacteria, lessens organic matter, and removes most carbo- nates, iron salts, and sulphides. The addition of about six grains of alum to the gallon of water will co- agulate suspended matter and precipitate it. The alum process is largely used in municipal filtration plants and the amount needed is determined daily. In domestic use, six grains per gallon is merely approximate, but is safe. As a matter of fact, if the water is boiled first, and the alum added before it cools down very much, the precipitation is hastened. Do not add to boiling water. If water is boiled and the alum added when it cools down to about 100 degrees F., then filtered through a stone or earthernware filter and finally aerated, it is remarkable how much it is improved. Ice supply and ice ponds. — Researches conducted by the State Board of Health of Massachusetts showed that there were eighty-one per cent as many bacteria in the snow ice as in the waters from which it formed; ten per cent as many in all other ice, and two per cent as many in the clear ice. P. Sacerdote has proven that the bacteria abound in the center or opaque portion of masses of ice, while the outer and clear portion is much more free of them. W.^H. Park found no bacilli living at the end of twenty-two weeks in ice frozen from water containing before freezing2,560,410t}phoid bacilli percubic centimeter. All this goes to prove that recently frozen ice may be as dangerous as is the waterway or pond from which it is cut, but that the cutting of ice long frozen or its storage for a few months before it reaches the consumer mark- edly reduces the dangers. In a recent report of the Massachusetts State Board of Health I observe that they demand a careful inspection of the watersheds of ice ponds, and grant permits to cut ice only after approval in specific cases. This protects the public. They commonly exact that snow ice and the first inch of clear ice be rejected. I have carefully observed the harvesting of ice in the northern states, and am convinced that the ice there is not only safer, from its long refrigeration, but is more scientifically handled and housed than is the case in more south- erly states, where the supply is precarious and must be quickly harvested. Artificial ice is better for the milder regions. Rural dwellers with small pri- vate ice houses will do well to apply to the health authorities for an inspection before cutting ice from any pond or stream at all liable to contamination. Infected wells are a source of much illness in rural districts. Artesian wells pierce geological basins and their water is pure, but most so-called artesian wells are actually not so at all. In many districts an artesian well is a geological impossibility, and the wells known as artesian are merely deep AN IDEAL RURAL WATER SUPPLY AN UNCONTAMINATED STREAM SUPPLY A FARM SPRING RUDELY BUT EFFECTIVELY PROTECTED FROM CATTLE SPECIAL RURAL HYGIENE 133 Wells, and some of these deep wells are most impure. A false sense of security is often engendered by the lies of the well driller. No man should risk the expenditure of several hundred dollars in sinking a deep well until after he has had expert advice as to geologic and sanitary conditions. Needless to say, sinking wells near to barnyards or vaults is dangerous. Graveyards are especially liable to infect deep wells. In my former country practice I have been actually discharged for daring to ascribe typhoid to bad wells infected by neighboring cases, and some of these same people drank the water despite my warning, and died of typhoid fever. Such fatuous conduct is a mystery to me, but I know it is common. When a neighbor of mine closed a condemned well he was threatened with suit b}- several aggrieved users, simply because the water was colder than the city supply and these people wanted to save the cost of ice. The following is from the Virginia Health Bulletin, published by the Virginia Department of Health: The location of the well is of the greatest importance. It should be as far as possible from the house, barn, and privy. If possible the surface of the ground about the well should be a lircle higher than the surrounding soil, so that any surface washings may be carried away from the top of the well. The ground about the top should be well sodded in grass. This not only adds to the attractiveness of the well, but it takes care of a great deal of water that would otherwise have to stand in pools about the well. If the stock have i:o be watered from the well there should be a pipe leading to a stock trough not less than twenty feet away, so that the stock need no; come up to the well itself. A well to be safe should be not less than twenty feet deep. Thai: is to say, twenty feet from the surface of the ground to the top of the water. It should go well through the surface soil, preferably through a layer of clay. The lining should be of brick or stone laid in cement. Any lining that allows water to seep through i: above the surface of the water may lead to infection. The space between the casing and the surrounding soil should be filled with sand or earth. The top of the well should be raised from the ground about a foot, and set on a cement or masonr}- coping that goes at least three feet below the surface of the ground. Over the top should be laid a solid, double tongue and groove flooring tha. is absolutely waterproof. This is essential. Most wells are polluted by material that falls in or is washed in from the top, and not by seepage through the soil. On the well top there should be put a good pump, carefully set so as to exclude leakage from around its base. If the pump cannot be used there should be an auto- matic tipping bucket. The well bucket should not be handled with the hands. Many wells have been infected by handling the bucket with soiled hands and then letting it back into the well, the filth being then washed off into the well. Below the spout there should be a trough with a pipe leading some distance away so that the waste water may be carried away from the well. A well constructed in the manner described above will almost always furnish a water that is perfectly safe, and the saving of sickness and trouble will many times over- pay for the expense and care involved. Springs. — A bubbling spring rising out of clean soil is an almost ideal supply, but even such a spring may be and often is contaminated. It is always well to wall in the spring with stone or concrete and lay sod or gravel around it upon ground graded away from the spring. Algae are prevented by 134 HYGIENE roofing over the spring. No dirt or rubbish should be allowed to remain near by. If the spring is on a sidehill, it is well to terrace above it or build a diverting retaining wall. 1 Cisterns are a poor investment in a city, but in rural districts afford soft water for the laundry work and sometimes fair water for culinary purposes. Much that is said about wells applies equally to cisterns. No masonry should be laid with lime mortar, cement being preferable. It is well to taper the bottom so the cistern can be readily cleansed. In a sandy soil it is almost impossible to build any but a tapering one, as the earth falls in when exca- vating. Use good cement for the inside dressing. All cisterns should be ventilated, but the openings should be covered with wire mesh to exclude mosquitoes and flies. If one keeps pigeons on the farm, it is hard to prevent their fouling the roof supplying the cistern. Spouting should be carefully looked after and all accumulations removed at regular intervals. A sagging spout may hold water and breed mosquitoes that are carried down to the cistern with the next rain. Rider and Ericsson Hot Air Pumping Engines The farmer who wants a pump that works every day will do well to install some type of hot air engine. The pump can be made suitable for any situation, and the furnace is made to suit various kinds of fuel. There is no climbing a tower with such an outfit and neither will it blow down, like a tower, nor blow up like a gasolene engine. Hauled water loses its gases and is made more palatable for drinking if aerated. Containers had best be regular tank wagons, but casks with good covers and well-charred inside do very well. If stored in barrels they should be well covered and be frequently cleaned, and when emptv, exposed to the sun until dry. Do not use denatured alcohol barrels. Tanks a^id piped water. — While very well for fire protection, water in elevated tanks usually tastes very flat. The common wind engine or wind SPECIAL RURAL HYGIENE 135 mill may pump a sufficient supply, but a hydraulic ram or a small gasoline or hot-air engine is not dependent upon the uncertain factor of varying winds or lack of them. If a hill is near at hand, it is better to erect a concrete or cement tank on its side or summit and deep enough in the earth to keep the water cool in summer. A protected reservoir like that is less apt to freeze in winter than is an exposed tank. It pays any modern farm to build and main- tain a really good system. Piping and plumbing generally is considered in Chapter XX, and the same principles apply on the farm as do elsewhere. It does not pay to install poor work and a competent plumber should be employed. Barnyard drainage. — It is hard to define rules for the entire country. In the East we have the expensive and wasteful " bank barn," and stable manure and the straw stack are piled in the barnyard. In the West there is a tendency to spend less money in barn construction and to erect a series of smaller buildings each for its own purpose. This latter is the better plan. It is well to have the stock housed apart, and the question of drainage is a simpler one. Manure pits are not only more sanitary than is the open heap, but they cause a real saving of valuable fertilizing material. In New Jersey and other truck-raising districts the stable manure is so disposed that the liquid portion is caught and is used upon certain growing vegetation. By this plan there is no barnyard drainage except surface water, which presents no sanitary problems. In the bank barnyard the soggy dungheap oozes a trail of wasteful abomination most of the time and always so after a rain. Nothing but condemnation can be written of this plan and it contaminates thousands of small streams. The proper way to provide for barnyard drainage is to have none. Down spouts from buildings should never be allowed to empty near to the dungheap, but the water should be directed away from the building and grounds. It takes very little piping to do this. It seems very strange that while an Ohio farmer will buy miles of subsoil drain pipe, most of our Penn- sylvania farmers cannot be induced to purchase two hundred feet of terra- cotta sewer pipe. If manure heaps are covered and no rain water allowed to run into them, little liquid drains from them, especially if the soiled straw bedding is piled up with the manure. It is well to run a drain from the stalls to carry away urine, and when a manure pit is well placed the urine can be run into it. Where trucking is done it will pay to catch the drip in a tank wagon and use it upon certain crops. In addition to this, flies are one of the farm nuisances, and it is well known that they breed in stable manure. If the manure is kept in covered pits and screened at the openings, the generation of flies is very much reduced. Various chemicals have been used upon manure to prevent the development of flies, but the matter is hardly worked out to a satisfactory basis nor the influence of these chemicals upon crops sufficiently determined. Sewage. — This question, as it relates to cities, is discussed elsewhere, and much that is said applies to the farm as well. It is certainly desirable that the farm be possessed of a water supply under pressure. When so sup- plied the plumbing may be of the same general type of city installation. 136 HYGIENE State boards of health generally are coming to the conclusion that the pollu- tion of streams by sewage must cease, and this will apply to the farmer as well as to the city dweller. The old cesspool is an abomination, but what is known as a " sink " may be used in some locations where rock strata allow seepage into harmless areas not close to wells or residences. In a sandy soil these sinks should be prohibited entirely. Where they may be permitted it is well to excavate to some depth and at some distance from the house. After rock is reached, drill into it as far as the hand drill will go and load the hole with two or three sticks of dynamite and fill in over it dry earth to the top. The explosion of deeply placed dynamite rends the rock strata to some depth and provides drainage. House drainage may be run into this sink through piping protected by a screen to keep out large masses that might obstruct the drain. This plan is far from ideal, but may be used in the absence of a better one. A better plan is to pipe the sewage to a settling tank which connects (a few feet above its bottom) with an automatically siphoned flush tank discharging the material into irrigating gutters placed in a convenient field. By this plan the sewage is macerated and discharged at intervals upon the soil, which quickly absorbs the liquid. In summer it is well to occasionally fork over or spread lime upon the area receiving the drainage. The plan of construction is here sketched. (See, also, "Plumbing," in Chapter XX, and "Sewage Dis- posal," in Chapter XXII.) Plan for Home Drainage This plan shows the principle but not the details, which must be left to a plumber who is intelligent and can work out the scheme according to the fall and other varying conditions. These tanks may also be discharged into sub- surface irrigation systems laid near the surface with open-jointed drain tiles. Garbage on the farm should be kept in covered galvanized iron cans and either fed to the hogs daily or buried in the earth twice a week. i \ ^ Vaults. — Some method for the disposition of human excrement is neces- sary to civilization, but the farmer usually selects the worst possible method. Except where sewers are installed, dry ashes or dried earth should always be SPECIAL RURAL HYGIENE 137 mixed with the dejecta. Very simple appliances are required, and the details vary only in accordance with the size and location of the closet. An outside dry closet should not be over one hundred and fifty feet from the house, nor closer than one hundred feet. Place it on the opposite side from the well and see that it is comfortable and well roofed. Keep a divided barrel (one sawed through the middle, and so not too high for a child to reach) filled with dry earth or ashes inside and provide a scoop holding a pint, to apply the ashes. The accompanying pen drawing shows how an outside closet should not be constructed and also how the same wretched building may be " revised." The box receiver figured is to be tightly constructed and placed some little distance above the ground. It should be frequently hauled away and a few inches of earth or ashes placed in it before it is replaced. The construction should be such as to exclude flies as far as is possible, wire screening being used where necessary. In the summer more earth should be used than is necessary in cold weather. The attention to a dry closet is annoying to some persons, but the advantages far outweigh the trouble and much sickness may be prevented. T^^h^^U Revision Adapted from illustrations in the typhoid issue of the Virginia Health Bulletin. Fertilizers. — The handling of barnyard manure has been discussed already, but it remains to be said that some sanitarians advecate its removal to the fields whenever a wagon load accumulates and it is claimed that its nitrogen content is saved by this method. The contention has been made that commercial fertilizers may contaminate a watershed, but no tangible data has come to my attention confirming this view. Sick and dead animals. — Many animals become sick through unhealthy surroundings. Every horse should have fifteen hundred cubic feet of air space, good ventilation and light in his stall, and clean surroundings. Cattle are peculiarly liable to tuberculosis, and the " fresh air propaganda " should be extended to them as well as to mankind. In the appendix at the end of this volume the diseases of animals communicable to man are duly con- 138 HYGIENE sidered. The burial of dead animals should be carefully conducted, espe- cially if they have died of anthrax or other virulent disease. Always bury them deeply and cover the carcass with lime. Animals sick with contagious disease should be isolated at once and rigid quarantine maintained. In most of the states there are proper departments to look after these problems and cases of contagious disease among animals must be duly reported in some states. Milk supply and the many questions involved. — The general problem of milk supply is so extensive and involves so much that we will here limit our discussion to the hygiene of the matter and especially as it involves the farmer and the dairy. Probably the best brochure upon the whole question is a seven hundred and fifty page bulletin (No. 41), issued by the United States Public Health and Marine Hospital Service, and entitled "Milk and its Rela- tion to the Public Health." To it and to the reports of the various state health boards (notably New Jersey and Massachusetts), I am indebted for much of the data herein. That infected milk causes much illness is so well known as to require no discussion, but it is not so generally understood that it is responsible for serious epidemics, especially marked by an explosive onset, and a whole milk route may be involved. Furthermore, milk long kept without proper refrigeration is a good culture medium and even when mixed with other milk will pro- liferate pathogenic bacilli as readily as will warm dough generate yeast cells. Typhoid fever, scarlet fever, diphtheria, tuberculosis, anthrax, and other diseases are so spread and an immense amount of literature exists giving details of epidemics so produced.* Sources of contamination are many — the chronic bacillus carrier, the milker who fails to wash his hands or does not clean his finger nails, milkers nursing contagious disease, the tuberculous milker, the one who moistens his hands with saliva, or who wears dirty clothing; filthy cows and dirty stables, stable and barnyard dust; milk pails not properly scalded, or from infected surroundings becoming contaminated; defective water supply; non-sterilized milk coolers; cans not properly scalded and aired; infection received at the distributing dairy from opening and mixing contents of cans, tasting the milk with a spoon carried from can to mouth and then to another can; careless bottling and at the creamery. According to the law of averages, about one person in every three hun- dred, in each year, has typhoid fever in this country, dairymen contracting their quota. This being true, it is to be expected that twenty-five cases ol typhoid per year will occur at dairy farms supplying a city the size of Wash- ington, D. C. The potential danger in such a normal situation is so great *Let me refer to a few authorities: E. Hart, Trans. Inter. Med. Cong. Lond., 1897, 1, 1167, 1229, and 1292. V. C. Vaughan in several Reports, Mich. St. Bd. of Health. W. H. Powers, Rep. Local Govt. Board, Lond., 1885, p. 73. J. S. Fulton, Jour. Hyg., Camb., 1901, 1, p. 422. Ninth An. Rep., Bd. of Health, Montclair, N. J., 1903. The writings of Busey and Kober, Dist. of Col. Health Of. Rep., 1895, etc. SPECIAL RURAL HYGIENE 139 that no amount of care devoted to the milk supply can be regarded as ex- cessive. We know that bacteria exist in all milk, but it is important to keep down the bacterial count to as low a proportion as is possible. Lactic acid fer- mentation will normally occur, and when the vessels are so full that air is excluded and the milk is warm, butyric acid will follow the lactic acid. Pu- trefactive fermentation is not apt to occur, except in alkaline milk, and such milk as well as the ropy, slimy, soapy, and bitter milks must be destroyed at once and the containers thoroughly scalded or even boiled. If milking is done in a cleanly manner, kept clean and promptly cooled, and then kept cool, there is little proliferation of bacteria except by over-long keeping. Prevention is all important. All herds should be regularly inspected by a state veterinarian or one appointed locally. It is especially necessary to exclude tuberculosis. The state of New Jersey has a very good general law upon the subject, very wisely leaving the details largely to the officials. The statute is here reproduced. (Approved May 16, 1893 — Gen. Stat., p. 53.) 1. That the local board of health of any city of this state shall by ordinance require, from time to time, a registry of all cattle kept within the limits of said city, which registry shall state the place of keeping, the number in each case kept, and the number of these intended, or used, as milch cows; and it shall be the duty of the owner of any such cattle to make registry thereof at the time, place, and in the manner that the board of health of said city may direct, under a penalty not exceeding fifty dollars for any neglect of the same; provided, that no such registry shall be made by any board of health until after the examination of the stables and place in which said cattle are kept, and until it is known to the satisfaction of said board rhat they are in good sani- tary condition. 2. That whenever any local board of health of any city shall have reason to suspect the existence of any contagious disease among cattle, or such as may be a risk or danger to the food or milk supply, or whenever they may deem it necessary, in order to prevent the occurrence of such risk or danger, they shall order the inspection of all cattle that are kept or intended for meat or milk production, by a competent veteri- narian chosen by them, and may for such inspection require so much payment for such service as may be necessary for the expenses attending such inspection; it being, how- ever, provided, that in no case shall the amount charged exceed fifty cents a head per year for dairies often cows or under, and for all dairies above ten cows, twenty-five cents per head per year; provided further, that no charge shall be made against any one keeping a single cow for family use. 3. That whenever any local board of health, or any veterinary inspector appointed by said board shall find or suspect any disease in any cow, or in any herd of milk-pro- ducing cattle, which may prove harmful to the meat or milk supply, the state board of health and the state dairy commissioner shall be notified, and it shall be the duty of the dairy commissioner to investigate the same, and he shall prohibit the sale or use of the milk from any such milch cow, but he, or the owner of said milch cow, mav ask, through the state board of health, a report from some veterinarian appointed by the state board of health as to whether, or how long, it will be necessary to continue the prohibition of the use of said milk, and the dairy commissioner or the state board of health may pro- hibit the use of said milk or of meat of any animal declared by a veterinarian of the state board to be unfit for use. 140 HYGIENE In addition to this, the state board prohibits the transportation or sale of milk from rural districts whenever, in the opinion of the authorities, any danger exists. Under watersheds, sufficient was said about the water supply, but dairy farms should especially heed the warnings and should supply a full amount of running water. It is impossible to keep large amounts of milk clean by water carried to the dairy in buckets. Cow stables must be built in such manner that they are dry and well lighted. Ceilings and side walls should be smooth and dust tight, and never less than six hundred to eight hundred cubic feet of air space should be allowed for each cow. Horses should have even more than that. The floors must be graded to carry off water and urine, and the manure should be re- moved every day. Every cow stable should be provided with a suitable place for washing the hands and for putting on suitable garments for milking. Cows should be kept clean by being curried or brushed every day and they should have exercise in clean places and a dry and dust-free bedded stall at night. The hair on the flanks, tail, and udder should be clipped at intervals. Before each milking the udder and teats should be washed with tepid water and the parts dried. Milk is handled in so many ways that the only safety is absolute cleanli- ness clear through the process, and the exclusion of flies, poultry, and sick people. It is imperative to keep the milk cool and to avoid dust and vessels having wide openings exposed to the air. Some of the milking machines are to be commended. From a comparison of statistics available I find that approximately three times as many bottle-fed babies die the first year of life as do breast- nursed children. The crime of the American unwilling or selfish mother cries to high heaven for vengeance. A bottle-fed babe consumes about five hundred quarts of milk during its first year and, despite all possible care, cow's milk is not a suitable diet for such young children, nor can it be made so. It requires unremitting care upon the part of the dairyman to market milk that is not absolutely dangerous for young children. As a physician who has seen many promising babes perish from their mothers being so fatuous (to use too mild a term) as to refuse a well-functionating breast, I honestly believe the authorities should make provision for two kinds of milk. The first kind should be safe and clean and suitable for adults; the second kind should be produced by ideal herds under ideal conditions, and it should be sold at double the ordinary price. No parent, where such milk is procurable, should be allowed to feed any other to a babe under two years of age. If foolish par- ents (and the father is often to blame) insist upon the bottle, they deserve to pay the difference in price. Poor people would not pay the difference and the result would be a far larger proportion of breast-fed children. I know very well, from actual experience, what a proposition the dairy is facing to- day in trying to aid mothers in doing what nature never intended should be done, and I also know that to keep all the milk up to the proper standard for bottle-fed babes is so expensive that there is no profit in the dairy business at the prices adults like to pay for milk, I also know that three fourths of city IDEAL DAIRY CONDITIONS AT BURNSIDE, ECCLESTON, MD. S. M. SHOEMAKER, PROPRIETOR SPECIAL RURAL HYGIENE 141 mothers who declare they cannot nurse their babes are not telling the exact truth. It is a matter of style largely. In Norway nearly all mothers nurse their babes. In Wurtemberg nearly all mothers refuse the breast. Chemical standards for the control of the sale of milk are becoming com- mon. I figured out an average of requirement, based upon the laws of thirty- three states, and find — for milk, the requirements average 12.1 per cent total solids; 8.77 per cent solids not fat; 3.12 per cent fat. The rather arbitrary determination of these standards is shown by the fact that subtracting the second figure from the first one gives 3.23 per cent instead of 3.12 per cent. This comes from eliminating fractions. Possibly it is close enough for prac- tical purposes. There is a movement on foot to set aside these state standards and substitute those of the federal government, which require 3.25 percent fat and 8.5 per cent solids not fat. From some considerable experience in estimating the amount of butter fat in milk, I can say that I have found less than 3 per cent of fat in whole milk from a mixed stall-fed herd in February and March, and I know the milk was not diluted. It impresses me that the requirements should be more flexible, taking into account the season of the year. I have seen men fined in court for selling milk below the state standard in February, and had every reason to believe that they sold milk just as re- ceived from the cow. We should have standards, but there is so much varia- tion in milk that a mere deficiency of a point or two in butter fat should not subject one to a fine in the absence of other factors tending to prove adultera- tion or dilution. As regards adulteration with chalk, calves' brains, etc., that sort of thing is largely of the past. Dilution is quite common. There is absolutely no excuse for adding preservatives to milk commonly offered for sale. Campers and those traveling may find occasion to do so. It is illegal to sell milk containing these substances in many of the states. Borax, boric acid, benzoic acid, and sodium bicarbonate have been used, but formaldehyde, under fanciful names such as " Freezine," is more commonly employed. Such practices are absolutely bad. " Certified milk " was originated by the Fairfield Dairy Co. and the plan has been copied by about thirty commissions over the country aiming to market milk for clinical purposes and for the feeding of infants. The detailed plans and requirements of these commissions are most elaborate and are given in a paper by Dr. John W. Kerr, of the Public Health and Marine Hospital Service, and published by the service. It is aimed to accomplish the following : First. An absence of large numbers of micro-organisms and the entire freedom of the milk from pathogenic varieties. Second. Unvarying resistance to early fermentative changes in the milk, so that it may be kept under ordinary conditions without extraordinary care. Third. A constant nutritive value of known chemical composition and a uniform relation between the percentage constituents of fat, proteid, and carbohydrate. Legal contracts are entered into by the commissions and the dairymen, and ideal conditions are enforced. The proposed legal recognition of " cer- tified milk " would bring about the plan I suggested of selling two grades of 142 HYGIENE milk. The question of infant feeding is of great importance, but need not be discussed here; nor is it necessary to say much about pasteurizing milk. Suffice it to say that such milk prepared for infants should be used within twenty-four hours. The process is highly useful in the preparation of cream for butter-making. However, pasteurizing milk will not improve its char- acter one particle when it is defective or deteriorated, and should be applied only to fresh and good milk. By reason of the fact that pasteurization kills the non-sporulating lactic acid bacilli in milk, such milk does not sour, but putrefies and becomes utterly unfit for use. The consumer has his responsibilities as well as the dairy. Refrigera- tors and milk vessels must be kept clean. Milk had better be kept in the bottles in which it comes. Placing coins and milk tickets in pitchers is very apt to infect the milk. -A Cheese, meat, and milk ptomaines. — I was working under Vaughan when he discovered tyrotoxicon, one of the milk and cheese ptomaines. In his laboratory the chemical data worked out was most interesting, but need not be considered here. As a sanitary matter, these ptomaines are produced in milk and milk products kept or worked in filthy surroundings. Theoretically, they may be generated from very slight infections, but practically they are seld om found except when the milk, cheese, or ice cream is very badly handled. Good milk may produce ptomaines when the consumer stores it in a filthy ice box. From the standpoint of sanitation, the danger from ptomaines is a threatened penalty for carelessness or filthiness. In the book, " Ptomaines and Leucomaines," by Vaughan and Novy, the points are made that milk should be aerated and chilled promptly after milking, and they instance many cases of poisoning by tyrotoxicon in which one single defect or a few very slight ones produced the conditions favoring the generation of ferments. Very unfortunately, some milk or milk products may taste and smell normal in every essential particular, and yet give rise to dangerous poisoning. Mussels and shellfish, sausages, cured meats, canned foods, and especially canned fish and meats, and some " fresh " meats, and especially liver, may all de- velop ptomaines. When traced up, these foods show putrefactive changes. I nearly lost my life from eating liver one very hot day. It was kept over for two days and, while nothing abnormal was noted at first, it soon developed a frightful odor. Butter and butter substitutes. — From the sanitar}^ standpoint, butter should be good if the rules defined under milk and those to be given under creameries are fully observed. The process of churning and the working of butter present practical difficulties making the production of a uniform butter somewhat difficult, but a clean butter is seldom unwholesome, even though the flavor leaves something to be desired. Garlic and other plants may taint butter and too much coloring may be undesirable, but carrots, annetto, and turmeric may be safely used. More or less objectionable butter color has been used by some makers. There is a great outcry against oleomargarine and butterine, and there is evidence that much of these products have, in the past, been made of bad materials. So far as I can judge, the objections to these products, when made of good materials, are not very valid so far as SPECIAL RURAL HYGIENE 143 hygiene is concerned. Certainly there aie many persons who consider good oleomargarine a tasteful and nutiitious food. Creameries. — The general rules applying to milk are equall) valid as applied to creameries. The State Board of Health of New Jersey enforces such excellent rules that they are here reproduced as a model worthy of gen- eral application: RULES GOVERNING THE CONSTRUCTION AND OPERATION OF CREAMERIES 1. The site of the creamery building must be dry, and the surroundings free from all refuse accumulations. Creamery buildings must not be located near any stable, chicken yard, hog pen, or slaughter house, and no open privy vault or other receptacle for filth allowed near said buildings. If cesspools are necessary, they must be screened to prevent the entrance and exit of flies. Waste fluids from creamery premises must be conducted through subsurface drains and finally disposed of in a manner which will not create a nuisance. 2. If the creamery is provided with a cellar, this apartment must be well lighted and ventilated, and kept scrupulously clean and dry. 3. The floors of all rooms in which milk is handled must be covered with asphalt or other mater'al impervious to water, and the surfaces graded to permit qu ck escape of waste fluids into a properly constructed drain. 4. No room in any creamery which is used for receiving, handling, or bottling milk shall be used for any other purpose. 5. All creamery rooms in which milk is stored, handled, or exposed must be screened to prevent the entrance of insects. 6. All vats must be provided with removable covers of a pattern approved by the state board of healch, and all vats must be kept covered when milk is contained in them. 7. The milk should, when practicable, be elevated when it is received and before it is transferred from the dairymen's cans to receptacles provided by the cream- ery, to a sufficient height to permit it to flow by gravity through open channels to the separator, cooling apparatus, cans, bottles, etc. If pumps and closed pipes are used in conveying milk, they must be so constructed that every portion of their interior surfaces will be accessible for cleaning. All pipes used for this purpose must have an internal diamxeter of at least two inches, and must be made up of short lengths. All pipes, separators, coolers, and other machinery used for handling milk must be taken apart daily, and all surfaces which come in contact with milk must be thoroughly cleaned and sterilized. 8. Every creamery should be equipped with a steam sterilizing chamber, large enough to receive all cans, bottles, and utensils used in handling milk, and all such con- tainers and utensils, after thorough washing, should be exposed to live steam at a tem- perature of 240° F. for not less than thirty minutes before use. 9. No measuring rod or other instrument should be put into milk unless such rod or instrument has been sterilized before use. 10. The water used in creameries must be pure, wholesome, and abundant in quantity. 11. Every portion of the creamery building and premises must be kept clean and free from dust, cobwebs, and accumulations. 12. Creamery employees must be cleanly in their habits; their outside garments should be white and clean, and warm water, soap, and clean towels must be provided to permit convenient washing of their hands. 144 HYGIENE 13. The temperature of milk intended for sale or shipment must not be above 50° F. 14. All milk, at the time it is received at the creamery, should be at or below^ a temperature of 60°F. 15. Cats, dogs, fowls, or other domestic animals must not be kept or allovi^ed in or about creamery buildings. 16. Each creamery owner or manager must send to the chief of the division of creameries and dairies, when requested so to do, a statement, giving the name and address of every person supplying milk to said creamery, the quantity of milk sent by each person, the amount of milk shipped or delivered from the creamery, the names and addresses of the persons to whom such milk is shipped or delivered, and such other matter relating to the management and operation of such creamery as may be requested by said chief of the division of creameries and dairies. 17. Each creamery owner or manager must report immediately by telegraph to the state board of health, Trenton, N. J., any case or suspected case of typhoid fever, scarlet fever, diphtheria, or tuberculosis occurring amongthe employees of the creamery or their families, or among the persons supplying milk to the creamery or their families. The manager of the creamery must at all times make diligent effort, by inquiry or otherwise, to ascertain whether or not any case or suspected case of any of the above- mentioned diseases exists among any of the aforesaid persons. Failure to obey this rule will result in the immediate revocation of the license issued to that creamery. 18. No person suffering with typhoid fever, scarlet fever, diphtheria, or tubercu- losis shall be employed in or permitted to enter any creamery in this state. Score cards. — During the last five years a large number of inspections of dairy and creamery premises have been made by the state board of health for the purpose of ascertaining the conditions existing on such premises and securing improvement in them. A satisfactory method of recording the results of such investigations and of comparing the conditions of different premises has been found to be one involving the use of score cards The cards at present in use in this state for scoring dairies and creameries are substantially the same as those adopted by the department of health of the city of New York. These forms are given below. These particular form have been adopted because a large proportion of the milk produced in this state goes to the New York market, and it was therefore believed that the advantage accruing from uniformity in the records of this board and those of the New York Health Department would more than ou weigh certain disadvantages which these forms possess. No Score allowed per cent BOARD OF HEALTH OF THE STATE OF NEW JERSEY Dairy Inspection Division of Creameries and Dairies 1 Inspection No Time a.m., p.m. Date 190 2 Tenant P. O. Address 3 Township County 4 Owner Party Interviewed 5 Milk retailed at By whom 6 Address Since 7 Is shipped, to whom Address 8 Distance of farm from creamery Occupied farm since 9 No of cows Breed No. Milking Quarts milk produced SPECIAL RURAL HYGIENE 145 10 All persons in the households of those engaged in producing or handling milk are free from all infectious disease 1 1 Date and nature of last case on farm 12 A sample of the water-supply on this farm numbered taken for analysis 190 .... and found to be 13 Size of cow barn, length. . . .feet. Width feet. Height of ceiling STABLE Perfect Allow 14 Cow stable is located on eleva'ed ground wiih no stagnant water, hogpen, or privy within 100 fee 1 15 Floors are constructed of concrete or some non- absorbent material 1 16 Floors are properly graded and water-tight 2 17 Drops are constructed of concrete, stone, or some non-absorbent material 2 18 Drops are water-tight 2 19 Feeding troughs, platforms, or cribs are well lighted and clean 1 20 Ceiling is constructed of and is tight and dust-proof 2 21 Ceiling is free from hanging straw, dirt, or cobwebs . . 1 22 Number of windows total square feet which is sufficient 2 23 Window panes are washed and kept clean 1 24 Ventilation consists of which is sufficient 3, fair 1, insufficient 0. ... 3 25 Air space is cubic feet per cow which is sufficient (600 and over — 3) (500 to 600 — 2) (400 to 500 — 1) (under 400 — 0) 3 26 Interior of stable painted or whitewashed on which is satisfactory 2, fair 1, never 2 27 Walls and ledges are free from dirt, dust, manure, or cob- webs 2 28 Floors and premises are free from dirt, rubbish, or decayed animal or vegetable matter 1 29 Cowbeds are clean 1 30 Live stock, other than cows, are excluded from rooms in which milch cows are kept 2 31 There is direct opening from barn into silo or grain pit ... . 1 32 Bedding used is clean, dry, and absorbent 1 33 Separate building is provided for cows when sick 1 34 Separate quarters are provided for cows when calving. ... 1 35 Manure is removed daily to at least 200 feet from the bam ( ft.) 2 id Manure pile is .... so located that the cows cannot get at it 1 37 Liquid matter is absorbed and removed daily and allowed to overflow and saturate ground under or around cow barn 2 38 Running water supply for washing stables is located within building 1 39 Dairy rules of the Department of Health are .... posted 1 146 HYGIENE COW YARD Perfect Allow 40 Cowyard is properly graded and drained 1 41 Cowyard is clean, dry, and free from manure 2 COWS 42 Cows have been examined by Veterinarian Dale 190 . . Report was 3 43 Cows have been tested by tubercuHn, and all tuberculous cows removed 5 44 Cows are all in good flesh and condition at time of in- spection 2 45 Cows are all free from clinging manure and dirt. (No. dirty ) 4 46 Long hairs are kept short on belly, flanks, udder, and tail 1 47 Udder and teats of cows are. . . .thoroughly cleaned before milking 2 48 All feed is of good quality and all grain and coarse fodders are free from dirt and mould 1 49 Distillery waste or any substance in a state of fermentation or putrefaction is fed 1 50 Water supply for cows is ... . unpolluted and plentiful 2 MILKERS AND MILKING 51 Attendants are in good physical condition 1 52 Special milking suits are used 1 53 Clothing of milkers is clean 1 54 Hands of milkers are washed clean before milking 1 55 Milking is done with dry hands 2 56 Fore milk or first few streams from each teat is discarded 2 57 Milk is strained at and in clean atmosphere 1 58 Milk strainer is clean 1 59 Milk is cooled to below 50°F. within two hours after milk- ing and kept below SO°F. until delivered to the creamery 60 Milk from cows within 15 days before or 5 days after parturition is discarded 1 UTENSILS 61 Milk pails have all seams soldered flush 1 62 Milk pails are of the small mouth design, top opening not exceeding 8 inches in diameter. Diameter 2 63 Milk pails are rinsed with cold water immediately aftei using and washed clean with hot water and washing solution . . 2 64 Drying racks are provided to expose milk pails to the sun. . 1 SPECIAL RURAL HYGIENE 147 MILK HOUSE Perfect Allow 65 Milk house is located on elevated ground with no hogpen, manure pile, or privy within 100 feet 1 66 Milk house has direct communication with. .. .building. . . 1 67 Milk house has sufficient light and ventilation 1 68 Floor is. . . .properly graded and water-tight 1 69 Milk house is. . . .free from dirt, rubbish, and all material not used in the handling and storage of milk 1 70 Milk house has running or still supply of pure, clean water 1 71 Ice is used for cooling milk and is cut from 1 WATER 72 Water supply for utensils is from a located feet deep and apparently is pure, wholesome and uncontaminated 5 73 Is protected against flood or surface drainage 2 74 There is privy or cesspool within 250 feet ( feci;) of source of water supply 2 75 There is stable, barnyard, or pile of manure or other source of contamination within 200 feet ( feet) of source of water supply , 100 Inspector. BOARD OF HEALTH OF THE STATE OF NEW JERSEY Division of Creameries and Dairies Creamery Report License No Score Allowed No Inspection No Date Time a.m. p.m Location County Owner Address Manager Address Number of employees All persons engaged in handling milk are free from infectious disease. Number of patrons Quantity of milk received daily Qts. Average butter fat test for dairies at present Milk train leaves daily at a.m., p.m. On Railroad Branch Method of Pasteurizing Machine used Cream is made by hand-skimming, separating Butter, cheese, condensed milk, casein, ice cream or milk sugar are made on the premises Board of health rules are posted. Source of ice supply 148 HYGIENE SHIPMENTS TO CUSTOMERS Name Address Cans /Cases Mi"k. Cans /Cases Cream. Name Address Cans /Cases Milk. Cans /Cases Cream. Name Address Cans /Cases Milk. Cans /Cases Cream. Name Address Cans /Cases Milk. Cans /Cases Cream, Name Address Cans /Cases Milk. Cans /Cases Cream. Perfect Score Allow 1 Premises surrounding creamery are clean 2 2 Receiving room is partitioned off from main milk room 2 3 Weigh vacS and storage tanks are covered when in use ... 4 4 M Ik-handling room is used exclusively for handling mi!k 1 5 I-s separate from where cans are washed 1 6 Is separate from where engine or boiler is located 1 7 Is well lighted by windows 2 8 All odors and steam are carried to the outside air 3 9 Walls and ceiling are sheathed and dust tight 2 10 Are painted with some light-colored paint 1 11 All ledges are clean and free from dust and dirt 2 12 Floors are free from dirt, rubbish, or pools of drainage. . . 2 13 Are made of concrete, stone, or some non-absorbent material . . 5 14 Are water tight 2 15 Are so graded that all drainage is discharged at one or more points 2 16 Strainers in floor are at least 6 inches in diameter 1 17 Space beneath creamery is dry 3 18 Is free from waste or rubbish 1 19 Drains are of earthenware or iron 2 20 Are watertight 2 21 Are continuous from the floor level to point of disposal. . .. 2 22 Are protected against freezing 1 23 Drainage is satisfactorily disposed of 5 24 Milk pumps and pipes for milk can be readily taken apart 1 25 Are thoroughly cleaned daily 2 26 All steam and water pipes are painted and clean 1 27 Milk vats are in good repair 1 28 All tin joints are soldered flush 1 29 Are thoroughly cleaned daily 2 30 Milk cans are washed with hot water and washing solution 2 3 1 Are rinsed out with clean water 1 32 Are exposed to live steam for at least two minutes 2 SPECIAL RURAL HYGIENE 149 Perfect Al- score lowed 33 All milk is protected from dust, dirt, and flies while in pools 2 34 Is protected while in mixing vats or over aerators 2 35 Is received at a temperature not above 60°F 3 36 Is kept below 50° while held or handled on premises 2 37 Cooling tanks are water tight 1 38 Are made of some non-absorbent material 1 39 Are supplied daily with clean water or filled with clean ice, 1 40 Water supply is ample for all the needs of the creamery 5 41 Water supply is apparently free from all contamination and is from 10 42 Storage tank for water is cleaned regularly 1 43 Is covered or protected from dirt 1 44 Attendants are cleanly in their habits 2 45 Garments worn by such employees are clean 2 46 Privy, water closet, earth closet, tight vault is satisfac- torily located 2 47 Is in a cleanly condition 1 48 Spitting or smoking in any part of the building is )^^i allowed 1 49 Domestic animals are allowed in creamery 1 Remarks 100 .Inspector. Dressed meats and federal inspection. — This is a matter of international importance, and yet great variation exists in the requirements of different governments. The principal difference is due to the fact that some countries allow the locally diseased animals to be sold after the diseased portion is removed. In Germany and some other lands this meat must be sold as second grade and with the warning that it must be very thoroughly cooked. Unfortunately, most countries sell locally diseased meat (of course removing pathologic tissues) without any classification or warning. In the United States the federal government makes most elaborate inspection of all meats for export. I have watched this process and it im- presses me as ideal and the inspectors highly skilled in their work. Such inspection is so detailed that a description of the whole process would exceed our present limits. Such carcasses as become merchandise in interstate commerce are well inspected, but the states must legislate for themselves. Many of them have not done so and the great mass of meat sold in this coun- try is not subject to any kind of public supervision. Many cities have local ordinances regulating slaughter houses and abbattoirs. Such ordinances should require the erection and use by all butchers of a public slaughter house under professional supervision and inspection of animals and carcasses. All private houses should be abolished. As to rural and unskilled inspection, it may be said that it is difficult to 150 HYGIENE estimate the condition of an animal before slaughter, unless it has some de- veloped disease. In the Appendix of this book there is an article upon the diseases of animals transmissible to man. After an animal is killed it may- be examined as follows: Note the nature of the fat as well as its amount. It should be firm and not deep yellow in color nor show points where blood has exuded, but its appearance is influenced by the food and by the age of the animal. The flesh should have no unpleasant odor and should be fairly dry, and a purple or livid appearance is suspicious. The bone-marrow of the hind legs remains solid for one day at least after slaughter, and if it is found soft and have lost its rosy red color, it is probable the animal was diseased. Carefully examine the internal organs for tumors, tubercles, and suppuration and a low power glass (twenty-five to fifty diameters) will assist in such ex- amination and reveal any parasites present. Poultry. — The common practice of allowing poultry about the dairy- should be done away with, as they carry infection upon their feet and foul the surroundings. Pigeons should not be kept upon dairy farms using cistern water, since they foul the roof from which the water comes. Diseased poultry may often be cured, but when I raised several hundred chickens at a time, I found it paid to cut the head off of a sick bird and to bury the body and cover it withvlime. I knew then that it was quarantined thoroughly. In the thirty-ninth annual report of the Massachusetts State Board of Health, very elaborate and detailed researches appear relating to poultry kept in cold storage. The conclusions reached were so definite and of such value that they are reproduced here: GENERAL CONCLUSIONS 1. Poultry kept at temperatures ranging from -f" 5° to — 14° F. undergoes no decomposition as a result of bacterial activity. 2. Freezing destroys the red and some of the white blood corpuscles. 3. Freezing temperatures as low as — 14° F. destroy a large percentage of the bacteria present, but do not affect the more resistant ones. 4. When the tissues are thawed, they become moistened by the melting ice crys- tals, and in this condition bacterial growth is facilitated and decomposition of the tissues and contents of the cells is promoted. 5. In the drawn chickens placed in cold storage aerobic conditions prevailed throughout the pleuro-peritoneal cavities. The undrawn chickens showed much smaller numbers of bacteria in the pleuro-peritoneal cavities. On account of the closed cavity, partial anaerobic conditions prevailed in these birds. In decomposing meats, putrefactive aerobic bacteria may possibly produce the primary stages and prepare the way for anaerobes which possibly control the inter- mediate stages of decomposition. By the combined action of bo^h, decay is brought about, but it is probably finished by aerobic bacteria. From these facts it appears that, given the aerobic conditions and the larger numbers of bacteria growing on the moist surfaces and tissues of a thawed drawn chicken, decomposition will proceed at a more rapid rate than with an undrawn one containing fewer bacteria existing under partial anaerobic conditions. 6. In freshly killed, unfrozen drawn chickens, the surfaces and tissues become dry within a very short time, and although aerobic conditions prevail, the bacteria cannot grow because of lack of moisture. SPECIAL RURAL HYGIENE 151 7. In freshly kiiled, unfrozen, and undrawn chickens, on account of the closed pleuro-peritoneal cavivies there is no drying of the tissues and surfaces, and facultative aerobic and anaerobic bacteria from the intestines rapidly cause decomposition. 8. By the removal of the viscera without the spilling of the contents of the ali- mentary tract decomposition can be prevented absolutely. The operation requires about two minutes. 9. Briefly stated, decomposition depends largely upon the presence of moisture in the tissues, for moisture is absolutely essential to bacterial growth. In freshly killed birds, ordinarily or properly drawn, the surfaces quickly become dry. In cold- storage birds, no matter how they are drawn, the tissues will be moist, because of the melting of the crystals of ice. If properly drawn, there would be but few bacteria present capable of causing decomposition. Eggs. — There are many shiftless farmers and hosts of city people who rarely taste a really first-class egg. " Just eggs " and " cooking eggs " are common enough, and they should never be used raw or but partly cooked. It is dijB&cult to estimate how much illness may or may not be caused by non- negotiable eggs, but it is certain that good ones are safer and to be preferred. I found that it paid to keep fine birds and to house and feed them well. It is impossible for mongrel hens living upon the dungheap to lay good eggs, and only a long-sufFering public being kept in ignorance of what really eggs are like prevents an outcry against the wretched conditions so commonly existing. There is Httle excuse, apart from the desire for gain, to pack eggs for any length of time. They are markedly inferior in every way and there is some question as to their healthfulness. If hens are warmly housed and fed upon warm food on cold mornings, they lay fairly well through the winter. It is claimed that avian tuberculosis in hens may cause the eggs to contain bacilli, but I have seen no definite proof of the claim. Eggs may be safely kept in cold storage for some time. Food preservatives and dyestuffs. — Chapter XXI discusses this question pretty thoroughly and there is occasion to say but little here. The fanciful names given to such substances sold to farmers creates the impression that they are original and safe substances. As a matter of fact, they are all com- posed of substances outlawed in many of the states and many are prohibited in interstate commerce. Fish and game meats. — The sale of these products out of season is illegal in many states, and in a few states the sale of some of them is altogether prohibited. The clandestine sale of these perishable meats results in much of it being kept too long and sold when tainted. I believe these prohibitory laws are against public policy and are unfair to the owner of rural property. They are devised at the behest of professional hunters and " sportsmen," a class who are an unmitigated nuisance to the farmer. No amount of foolish legislation, like protecting bear, will prevent the farmer from killing bear that raid his property. If rabbits are girdling a farmer's trees he is apt to kill them in season or out of season. I do not advocate breaking law, but the farmer and the sanitarian should be considered before the selfish " sports- man " when fish and game laws are drawn. It is the height of folly to allow the killing of game in inaccessible regions by persons having no facilities to 152 HYGIENE properly ship it to market, and yet prevent the residents who are in position to take sanitary care of the meat from kilUng more than one or two animals in a season. The result is that the game reaching market is often unfit to eat. Insecticides upon food. — The free use of Paris green and of powdered hellebore may lead to the consumer being poisoned, but actual instances are so rare that the danger is not at all imminent. Tobacco stems, lime, sulphur, land plaster, coal oil emulsion, and other rather safe substances, are more generally used, and Paris green very rarely except upon potatoes, which, being a root crop, are not reached by the chemical. Ordinary care will prevent any danger from insecticides. Poisonous plants and their eradication. — Too few trees and too many weeds are a common condition upon the farm. Trees die too young and weeds live too long. If you think your trees will not respond to kindly treat- ment and live to a green old age, read " The Tree Doctor," by John Davey, of Kent, Ohio, and be convinced. It would amaze an Ohio or New York farmer to see the weeds of the South. They grow there as if they meant to " stay put," and they usually do stay. Mere weeds usually do little harm except to crowd out other more useful vegetation, but so many species are poisonous or do harm to cattle and horses that the farmer should know con- siderable of botany. Weeds should not be allowed to choke up the margins of streams and ponds, as they not only are apt to decay and produce offensive conditions, but they also prevent the natural enemies of mosquitoes from reach- ing them. Rag weed and golden-rod along public roads induce hay fever in many susceptible persons and should be removed. Some varieties of wind- flower poison cattle and even so common a plant as starwort may do the same thing. Crawford has shown that certain plants take up barium from the soil in quantities sufficient to produce " loco " in animals. Different regions have their special plant problems. The following is clipped from a news- paper: Waco, Texas., May 9. — The alarming destruction of Texas trees through the agency of the poisonous mistletoe has induced M. B. Davis, secretary of the Texas Audubon Society, to sound a warning to those interested in trees to destroy the mis- tletoe before it in turn denudes the state of its forests. "Every municipality in Texas is afflicted with the pest, and it has been stated by an authority that the life of a tree when thoroughly inoculated with the mistletoe poison will terminate in about seven years," says Mr. Davis. " It is carried from one tree to another by certain birds feeding on the berries, and wherever it finds lodgment on trees susceptible to its deadly parasitic growth its blight proves fatal in time, unless heroic treatment is applied. At this season, while the evergreen parasite is clearly discernible upon the bare boughs, the work should be done. " The Texas mistletoe (phoradendron flavencens) differs materially from its kindred parasite evergreen of Europe (viscum album), which is kept in check in the old world, but cultivated to some extent for winter decoration. The variety in the cotton states is far more pernicious and must be wholly exterminated or the trees will all perish from its baleful blight. Any one may observe from car windows that entire forests are being killed by mistletoe. " It is a beautiful, but horrible, parasite, and can be destroyed finally only by cutting off the entire bough on which its growth appears. The hackberry, which is SPECIAL RURAL HYGIENE 153 popular in cities as a shade tree, is one of the favorites of these poisonous parasites, and in nearly every city in this state where hackberry trees have been planted about twenty-five per cent of them have already died from mistletoe poison." Many other plants have a host. A familiar instance is the wheat rust known as Puccinia gra minis, which has its cluster-cup stage on the leaves of barberry in June. The spores are carried by the wind to the wheat. Ergot or smut on rye and corn is quite poisonous and should be removed when found. It must be used for some time for spurred rye or corn to cause OULdAM/^HA A Few Common or Dangerous Weeds Anemone is poisonous to cattle. Celandine is an irritant poison externally. Capsella is a nuisance in pastures and is apt to harm the kidneys of cattle. Dulcamara is a narcotic poison. Conium is a dangerous poison. Agaricus is the poisonous mushroom. serious symptoms. Vetch should not be used as food, as it induces symptoms similar to those produced by the castor be^n. Pellagra is a disease of some importance in parts of the South and it is caused by damaged Indian corn or corn cut when immature or stored in damp and bad surroundings. Many 154 HYGIENE fungi and mildews cause disease under certain circumstances. The " dry rot " fungus causes immense damage to timber. Mushrooms must be care- fully identified before they are eaten. As a matter of fact, they possess very little food value. This whole class of plants are hard to eradicate, and the best that can be done is to practice clean farming and to look after the forest growth and to drain bogs. Weeds are legion; common ones being the thistles, wire and wild grasses, burs, ticks, dodder, wild mustard, burdock, chicory, cockle, daisies, dandelion, dock, nettles, narcotic herbs, pigweed, plantain, purslane, ragweed, capsella, sorrel, and many species escaped from cultivation. Good cultivation mark- edly reduces the number of weeds, while others must be pulled up after a long rain or grubbed out. A few, like the artichoke, are destroyed by hogs rooting for the tubers. Garhc and other plants eaten by cattle, and that taint the milk, are difficult of eradication. Some berries, such as those of phytolacca or poke, attract children and should be watched and the youngsters taught the danger. Monkshood and other ranunculaceae will readily kill cattle. Poison ivy should be pulled down and burned. Toxic plants are so numerous that our space precludes a full description. Coal oil will kill some of them, but care and cultivation is the main reliance and also planting clean seed will largely prevent new pests from gaining a foothold. Be careful of new flowers, I had great difficulty getting rid of the Japanese lantern plant and a rapid growing morning glory. It is probably of greater importance to eradicate poisonous weeds than is com- monly thought to be the case, but the main danger is upon the dairy farm. Insect pests require little discussion here. Mosquitoes are considered in other chapters. We do not have the tsete fly m this country, but blow flies, cheese mites, the bee moth that spoils the honey in the interior of hives, mites and worms infesting grain and beans, worms infesting fruit, and many other species are more or less of a menace to health and lead to industrial losses. The agricultural bureaus and the state entomological departments give detailed direction for the destruction of these pests. Sanitation in sending produce to market. — This is largely a matter of good roads, good transportation, and a ready market. The farmer and trucker are blamed for many things for which they are not responsible. I have seen commission houses in the large cities seriously neglect the produce in their hands and, when the market was bad from their own point of view, sell wilted and decayed vegetables and fruit that was received in good order. The granges and farmers' organizations could do a real service to sanitation by bringing some of these foreign produce dealers to book. They should not be permitted to store good truck and hold it for a rise and sell their share then and dump the other half off" the dock. So called " gluts " are largely fictitious or are produced by car famines. It is hard for the small shipper to get proper icing facilities, and the large shipper owns his own cars and icing stations, gets to market first because they can send a man with the train to prevent side- tracking, and can undersell the small owner. Fortunately conditions are improving. The Interstate Commerce Commission is forbidding freight rebates, the railroads are providing better cars, the public is demanding better SPECIAL RURAL HYGIENE 155 produce, the sanitary authorities are being more strict, the pure food laws are stopping the excessive use of agents to prevent decay, and the commission merchants are objecting to the Italian and other careless merchants bringing the business into disrepute. One great factor to produce better market con- ditions is the very great extension of trolley service. Milk and perishable freight is gathered up and delivered expeditiously by this service. Free rural mail delivery and the use of the telephone are placing the farmer in touch with the market. But if any one thinks there is not room for improvement, let him watch the freight yards and terminals, the docks and wharves, and the commission houses. However, there is no occasion for pessimism. All that is needed is publicity, as in the exposure of stockyard conditions and " em- balmed meat," and whatever abuses still exist will soon come to an end. Summer camps. — The sanitation of large camps is considered in Chapter XII. Small camps are peculiarly liable to enteric and malarial fevers, and the precautions to be observed are in the direction of water supply, the avoid- ance of mosquitoes and the disposal of waste as covered under different headings in this book. Camp meetings, as formerly conducted, had few sanitary arrangements, but the modern assemblies and chautauquasare usu- ally well conducted, although the cottages are built unnecessarily close to- gether. OECAYINC- From the Mud taken from a Mountain Brook Rural resorts. — The Twenty-eighth Annual Report of the New York State Department of Health reports a condition of affairs paralleled in many other states. The following is from the report: SANITARY CONDITION OF SUMMER RESORTS This investigation comprises a series of visits or inspections of summer hotels in the state. On one railroad line alone are o be found nearly two thousand boarding houses or hotels, the capacity of which is not far from fifty thousand people. A large number of these are under the superv sion of the health officer of the village or town where they happen to be located. Bm mountain camps, farm boarding houses, and even large hotels in the mountains are often beyond vhe reach of regular health officers, 156 HYGIENE even if a small community felt justified in assuming such control and attendant expense. It would appear, therefore, that if the large number of summer recreation seekers are to be pro- ected in health while at summer hotels, the protection must come from the state authorities. The conditions in existence at present have been found to be revolting in the extreme. In several cases drinking water was taken from a shallow well, surrounded by privies and cesspools. In a number of cases the sewer of the hotel discharged into the same pond or lake from which the water supply for the house was taken, and only a few feet away. In one hotel, indeed, the two pipes were laid in the same trench to save expense. In about seventy-five per cent of the places inspected, the conditions were not seriously bad, but in the other twenty-five per cent the condi- tions called for immediate remedy. Owmg to lack of adequate engineering assistance this investigation was onlv par- tially completed. The information that was secured, however, was at once utilized, and notices were sent to all offending parties that the sanitary conditions must be remedied before the opening of the next season. In addition to these notices, con- siderable advice was given as to the nature, extent of the improvement, and in some cases the type and arrangement of disposal plants, that would meet the requirements of this department. The results of this investigation show so clearly the danger that lies in the unsani- tary conditions surrounding many summer resorts and the importance of protecting this growing population of pleasure and health seekers, that it is important that this work be continued and extended in the future. f. ^ » t*r^>«V'^ ■— " ^ Til If '^/i*^Lm •l^ PUMPING RIVER COAL TWENTY MILES BELOW THE MINES THE ABANDONED CANAL. A RURAL PERIL MACHINE FOR DRILLING DEEP WELLS Chapter IX STATE DEPARTMENTS AND BOARDS OF HEALTH* Introductory remarks. — An outline of their legal basis in the states and terri- tories — The legal powers and limitations of state departments — The importance of keeping up with the regulations in force in one's own state — What obligations rest upon the general practitioner — The vaccination problem — Reports expected of phy- sicians — Vi'al statistics — Local represen- atives of state organizations — ^Their rela- tionship to local health boards — Misunderstandings and disputes and how to avoid them — The charity and emergency work of state departments and how the physi- cian can co-operate therein — A brief outline of their status in the various states — Where to secure bulletins of the laws and regulations of the states. He can hoist a yellow flag over a center of civilization and turn it into a desert ; he can hoist a Red Cross in the desert and turn it into a center of civilization. If he judges it necessary to the success of any operation in which he is interested he can halt a twenty thousand ton liner with her mails, in midocean, till he has finished that operation. He can forbid any ship to enter any port in the world; he can tie up the traffic of any port in the world without notice given. He can order houses, streets, whole quarters of cities to be pulled down or burned up, and if his patients object to the prescription he can count on the armed co-operation of the nearest troops to see that his orders are obeyed. — Rudyard Ktpling. ONE of the first questions recorded in history was, " Am I my brother's keeper ? " From thirty centuries ago, the physician has answered it in the affirmative. True, he construed the word brother in the singular. To-day, he gives it a plural significance. The world of fiction is rich in pictures of the erstwhile conventional doctor, full of mystery and sympathy, but obsessed with the vast diflTerence between the doctor and the layman and an exalted impression of his own prerogative. To him the relationship between his patient and himself was so sacred that public interest was a matter apart and none of his concern. In these days we may forget some of the finer attributes so fully possessed by him, and we cannot but admire the rugged commonsense of our medical ancestors. But a new era has dawned upon the world. Nations are being drawn together, and the means of communication are so extended that the old and careless ways are dangerous, and society is forced to look after the health of its units in order to preserve the whole fabric. It is the old saying over again, " like priest, like people " ; only it is the doctor this time, and not the priest. It is very easy for the physician to complacently assume that the profession leads the people, but it would be difficult to prove it; the rather is it easy to show that nearly all medical advance parallels that of other fields of endeavor *Prepared from the reports and other literature of every state board in the United States and in the territories. Legal data by Samuel H. Orwig, A.M., LL.B. 158 HYGIENE and the branches of pure science. Dogma and empiricism can be evolved in a cloister or at the desk, but the modern tendency of medicine has been to apply the data derived by experimentation and the conclusions of the biologist, physicist, and chemist. Colonization enterprises, large engineering works, the extension of trade, the development of the tropics, foreign missionary effort, the aggression of war and " the white man's burden " are factors that created international medicine. We have been insular here. " States' rights " have taken pre- cedence of national obligations. If we want to be a world power we must take our national part in the world. We look to a nation and not to one of its provinces or departments, and the nations look to our federal government and not to the states. But the government at Washington looks to the states. Federal obliga- tions regarding sanitation have been largely diverted to places under military control; but the various bureaus are establishing connections with state work, and such things as the Interstate Commerce Commission and the Pure Food and Drug Act are rapidly extending the national interest in what is of im- portance in matters of health and sanitation. A national department or bureau of health will doubtless be established, and the states will very sud- denly become aware of the demands this department will make. Many of the states have anticipated these demands and are elaborating state medicine in a very efficient manner. It is inevitable that all of the states will come to regard themselves as simple units in a national scheme of sanitation. The writer is old enough in the profession to belong to the old order of things, when we studied under preceptors and expected to find" laudable pus " and other disagreeable things considered as inevitable. Men like myself can have little sympathy with the idea advanced in England that the time will soon be that the doctor will wear a state uniform and live upon a state salary. Such ideas rudely wrench all that we hold dear in the profession. An experienced man is also liable to resent interference with his work, espe- cially when it comes from some very young official. But it is well for us to remember that the old order has departed and that we must get new marching orders or be left in the rear by the younger men. It is also well to bear in mind that the health authorities have their own troubles and are limited by very definite laws. Very few heads of departments are inclined to exact the unreasonable. They are sharply restricted in their work. So long as the American system of national and state financial appropriation is vested in popular legislative bodies, just so long v/ill the more or less creditable politi- cian dominate even health boards, to some extent. But the politician is improving. There is a general uplift in the air, and the things that might justly be subject to criticism in the work of some of the state health boards are being eliminated. I am sure that the excel- lent gentlemen at the heads of these boards over the country are doing the very best they can and often under very trying circumstances. They regret just as much as does any practicing physician, that the exigencies of politics and the newness of the work are responsible for the fact that some incom- petent men are upon their payrolls. They also think that it is a pity that so STATE DEPARTMENTS — BOARDS OF HEALTH 159 many incompetent men are practicing medicine and failing to appreciate the fact that no man, in any line of work, may legally carry on his business unless he makes all proper effort to protect the public from whatever dangers or perils are incident to that business. Weak human nature is responsible for practically all of the friction with the profession and the public that has been engendered in the work of quali- fied sanitary authorities. After this function of the nation and the state is fully understood, and the newness of it all wears off, there will be little trouble. Poor officials will be eliminated, and the whole machine will run more smoothly. It is incumbent upon all physicians to be patient and uphold all proper and honest effort upon the part of the state to improve the health of its citizens. It is true we should insist upon our own proper prerogatives, but we should not do so rashly. If the mass of the profession display the proper spirit, the officials will not limit our own initiative within our own field of effort. It is very easy for the departments and the profession to cultivate cordial and harmonious relations, and that should always be done. One way to do so is for the physicians to make an effort to get real practicing doctors and not mere theorists upon these boards. Such officials better understand the situation confronting us. Salus Populi Suprema Lex Every well-organized government has the inherent right to protect the health and provide for the safety and welfare of its people. This inherent right is tantamount to a duty of the sovereign power to the public under its jurisdiction. The authority to enforce this obligation is vested in what is termed " the police power," and originally and inherently belongs in the United States of America to the states and not to the federal government, save in exceptional cases. In the absence of statutory regulations, or acts of assembly, the common law affords sufficient authority to enforce what measures may be necessary to protect the health of the community, and to indict in the courts offenders against necessary orders from constituted authority. By reason of the innumerable occasions of offense against necessary sanitary measures, whether excited by malice, gain, an indifference to the welfare of others, or by ignorance upon the part of the offender, it is diffi- cult to set the limits within which the police power may be exercised. Happily for the inhabitants of most of the states of the American Union, this police power, so far as it relates to the public health, is defined and limited by statutes which, for the time, appear to define the limits and pro- vide more specifically and certainly for the protection of the public health and the welfare of the people, and to avoid arbitrary and unjust action. But even these statutes, as experience has shown, not infrequently need revision, amendment, and judicial interpretation. " The police power " is a broad and comprehensive one, by which the rights of an individual, both as to his liberty and his enjoyment of property, 160 HYGIENE may be curtailed in the interest of the public welfare. When laws enacted by virtue of an exercise of the police power interfere with the citizen's liberty or rights of property, they can only be justified on the grounds that they, in some manner, secure the comfort, safety, or welfare of society. To quarantine persons is to keep them, when suspected of having them- selves contracted or been exposed to an infectious or contagious disease in another person, out of the community, or to confine them to a given place therein, thus preventing intercourse between them and the people generally. The general law warrants such quarantine, but in order to make it effective enabling acts must be passed designating through what officers and under what conditions quarantine may be enforced. The relationship of the medical profession and the police power of the state, cit}, borough, or other governmental unit, when defined by legislative enactment, must be determined in every instance by the words of the statute, subject (as in other cases) to judicial interpretation. Having thus considered the legal competence of the state to ordain and execute sanitary legislation, it is of interest to inquire to what extent it is prac- ticable and wise to execute these prerogatives. This can be best answered by telling what has been done by the authorities of the several commonwealths of the Union. We will do so at large, since it would require a volume itself to narrate the multitudinous activities in detail. As to the ultimate extent of state medicine, we should not care to hazard a guess. Piobably the degree of wisdom actuating the officials having in charge this important work will be the determining factor in public support. Without popular interest and support no such work can survive in this country. This fact is a guarantee of discreet and conservative management, and it is more than probable that the United States will witness within its several commonwealths the greatest official sanitary and public health measures ever undertaken in the world. The United States Government does not undertake to officially guide the states in the enactment of legislation rendering operative the state police power in the enforcement of sanitary measures, but the various bureaus and the Public Health and Marine Hospital Service and its hygienic laboratory at Washington are co-operating with the state authorities in elaborating the details of legislation and administration necessary for the practical conduct of an efficient state work. As has been said, an act of assembly is necessary to the carrying out of an effective state work. In such states as have legis- lated upon the subject some variation is apparent, but the underlying power of each state varies but little in capacity. Therefore, the possible limits of actual work are nearly similar. Based upon no one state, we will consider the question of how far the state is actually enforcing sanitary legislation to-day. The state takes the view that there must be an executive at the head of any department; and it makes it the duty of the state commissioner of health (some states use a different title) to protect the health of the citizenship and alien residents of the commonwealth, but the details incident thereto are vested largely in his own discretion. This makes him a very powerful official. Some of the states provide for an advisory board of physicians and lay- STATE DEPARTMENTS — BOARDS OF HEALTH 161 men trained in sanitation or its engineering features, and there are various provisions for the co-operation of the legal and executive officers of the state. In states with seaports the national and state quarantine regulations must not conflict with merely local measures, and this requires especial provision. States bordering upon foreign countries have their own problems to work out as regards quarantine. To facilitate practical administration, most state departments are divided into divisions, having each its head. The number of these subordinate offices is determined by the range of work undertaken by the state department. This will be touched upon later. A field organiza- tion is usually effected or arrangements made for local co-operation with the central organization, A well-organized department is in constant touch with the whole state and its work and problems. This is usually all provided for by special enactment. Anything regarded as a nuisance or inimical to health or life within the commonwealth comes under the dominion of the department. Any state can give the officials of the health department the right to enter, examine, and survey any and all places so offending and to order the abatement of the fault and to enforce the order and assess costs. Most state departments possess all of or a portion of these powers. Some states grant the right of forcible entry and impose penalties upon violators of department orders and with interference with the duties of the department or of its agents in the discharge of their duties. Vital statistics and the work of physicians, mid- wives, nurses, and undertakers, with reference to vital statistics and the re- porting of infectious diseases, all come under the departments or a division to which it assigns this work. In some states local registrars are appointed to look after vital statistics in a county or district. As many as one thousand such registrars exist in some states. A few legislatures have given the state department the right to revoke or modify local regulations or ordinances when they appear to be contrary to public policy as regards sanitation outside their own district or territory, Except in so far as the state waterways are involved or in time of epidemic, such powets are seldom invoked and some persons call in question the wis- dom of such enactment. However, it is often so imperative that something be done in time of epidemic, that it is considered legal to vest large discre- tionary powers in a state health department. There is always the protection of the courts for persons who feel aggrieved or injured, and it is not likely that a department will forget this fact and do harsh things, except when they are necessary. Sheriffs, constables, and police officers may be required by a state de- partment to make arrests, help maintain quarantine, or do any act devolving upon them under the law. Nearly all state departments have a division of medical inspection with many sanitary agents scattered over the state. This phase of work is dis- cussed in Chapter XI of this book, and need not be entered into here. Vital statistics will also be discussed later in this present chapter. A sanitary engineering division is really essential to a state department. The work of sanitary engineers is touched upon under several chapters in this 162 HYGIENE book. Here we are interested in the legal powers of such a division. All states have large rights over their waterways, and this gives state health departments a large measure of control over municipal or corporate water- works and sewage systems. There is no doubt but that the state does have the right to control such matters to a large degree. There is a tendency to object to government by commission, but this can hardly be classed under that category, especially as the work of the division is largely of a helpful rather than a prohibitory nature. All corporations are subject to state laws or regulations, and water com- panies must obey the sanitary laws and build and equip their plants under state supervision, provided the state so exacts. A larger question is involved in maintaining a clean watershed, and much care and tact is required upon the part of the state to maintain these sheds as they should be kept. The engineering division does this work in part and it has large powers that are seldom invoked in full. As ideal conditions cost so much, the carrying out of some orders cannot be borne by individuals and the state cannot undertake it all at once. The state can demand that sewage, not already so discharging, must be kept out of streams or waterways. Some states make the claim that extending an existing sewer system gives the state department the right to demand that such extension forfeits the right to discharge any sewage from the old system into the streams. Cases exist where the state department has ordered a municipality to make changes in its system of sewers of so costly a nature as to require the bonding of the municipality beyond its debt capacity. In such event the courts must review the matter and the engineering division must be patient, since two laws must not be brought into conflict. In all such cases or in others where an injustice would be done by the state in rigidly enforcing the law, conferences with those involved usually result in a certain extension of time for the completion of changes deemed necessary for sanitary reasons. Legislatures are also asked to make appro- priations of state funds to do such things as cannot be completed by the municipalities. It goes without saying that state departments of health may legally under- take certain charity work, such as the free distribution of diphtheria anti- toxin (see Chapter XVI) and tuberculosis dispensaries being maintained for the free treatment of the poor. (See Chapter XIX.) The importance of keeping up unth the regulations in force in one's own state. — It should never be forgotten that a state department of health con- stitutes an expansion of the medical prerogative and the work of the medical profession. Lawyers are so accustomed to look to the courts that they all finally become officers of the court. That is what admission to the bar really means. The courts and the administration of justice are ingrained parts of the lawyer's existence. Physicians have, as a class, avoided politics and have felt little public obligation. Their opinion has not been sought in matters they have avoided and the profession has lost caste, to some extent, by reason of our isolation. But this day is passing, and we cannot afford to fold our hands and " view with alarm " the publicity that is beginning to beset the work of the doctor. Let us learn from our friends of the legal STATE DEPARTMENTS — BOARDS OF HEALTH 163 profession and realize that we should hold the same relationship to the sani- tary authorities as do the lawyers to the courts. We should be officers of the state so far as public health is concerned. We should not dominate the health departments, but we should hold ourselves in readiness to aid in their work. In this view of the case, if it ever prevails, rests one of the great hopes of state medicine and the greatest opportunity of the medical profession to serve the public. But ignorant loyalty to a cult, a religion, a ruler, a cause, or a department of health, never accomplished much of permanent value. In- telligent service alone avails to save a nation or a cause, and equally is it true that intelligent service is necessary to preserve the health and wellbeing of any people. Hence, our proper course is very clear. " Ignorance of the law excuses no man," and particularly is it true that ignorance of the laws governing his own environment and calling are inexcusable. One trade and business after the other have been subjected to regulation and legal supervision, and, while there has been some friction, the ultimate result has been to improve the condition of every legitimate interest involved. Such things as would not stand the light of day have suffered and have deserved to suffer. Whatever there may be of weakness in the theories and practice of medicine must give way to the intelligence of the twentieth century, and what- ever there is of strength and usefulness must have the protection and aid of the public and of public law. We need fear nothing from the operation of health department legisla- tion, but it imposes a responsibility upon us. This we should not evade. We will be short-sighted if we attempt to do so. " No man liveth to himself and no man dieth to himself," and the day is long since set in the mist of superstition in which the physician could afford to try so monastic a role in life. We owe it to our fellows in the profession that has honored us, to honor the laws that help us individually to honor the profession. This is no " vicious cycle," but the good one akin to — " Better fifty years of Europe than a cycle of Cathay." We are living in the best fifty years, or let us hope so. At the end of this chapter will be found such data as is necessary for some general understanding of conditions in one's own state. There is a bulky publication issued covering all the legislation and rulings of the several state departments, but three months after issuance it begins to need revision. Hence, it is quite impossible for us here to attempt an analysis of the state regulations in detail. The members of the profession who are actively in- terested in the practical working out of the problems involved in state medi- cine should study the matter at first hand, and in the offices and field work of such state departments as they may find access to and are near at hand. As to the general practitioner of medicine, it is his duty to carefully read the cir- culars sent to him by the department of his own state, or to send for new ones if he has neglected the matter in the past. Especially is it necessary for him to find out the definite laws and regulations to which he is subject. If he thinks any of these laws or regulations are unjust or oppressive, let him take up the matter in his local medical society and compare notes with his fellows. Perhaps he may see the wisdom of the law as expressed by the discussion, or 164 HYGIENE some better plan may be presented that the department will be glad to hear about. Such discussions are very interesting when the local health officials take a part and narrate some of their experiences. It is well to bear in mind that the various state departments issue new rulings at intervals and they should be carefully studied. What obligations rest upon the general practitioner. — These obligations are of two kinds, legal and moral. Roughly stated, the legal obligation is to protect the public by obeying the laws provided for this purpose. In detail we cannot adequately discuss the matter in our limited space. Suffice it to say that the general practitioner must meet the situation differently in city and in country practice. It is not intended by state departments to set aside proper local regulation, but rather to supplement such measures. In conse- quence one usually finds that the cities carry out most of the detail so far as the individual physician is concerned. In a city one reports to the city health officials (in most states), while in a rural locality some county represen- tative may represent the state department or said department may supply proper blanks for direct reports. It is well to remember that the law is no respecter of persons, and that prominence in the community or social position does not render a family or an individual immune to the quarantine and other regulations of the sani- tary or health departments. The physician has no right to make such dis- tinctions. Furthermore, neglect to report infectious disease may render the family or its responsible head equally guilty before the law with the physician. All courts exact of a physician that he possess the average degree of skill and learning found among the doctors of his district. As regards the matters we are discussing, all physicians are expected to so inform themselves as to be able to diagnose the infectious diseases common to their locality. Let me commend a study of Chapter XV. In case one is not able to arrive at a diagnosis, it is his duty to call a consultant or to report the matter to the proper authorities. It does not compromise a physician in the least to admit ignorance of some disease. The writer has never seen a case of yellow fever. Am I in a position to diagnose a case ? Here in Harrisburg we have filtered water and almost no typhoid fever. In course of time we may have physi- cians of several years' practice and yet have never treated a case of this disease. Will they be able to diagnose typhoid ? It would be strange if we did not have some dishonest men in the medi- cal profession. Unfortunately, these men are called in to reverse the diag- noses of honest men called into families who wish to resist quarantine. It is always disagreeable when this occurs, and all of us have lost families by obeying the law. Usually we are helpless except to keep track of these cases and these alleged doctors and report the facts to the local medical society. Where the case is dangerous or the facts seem to warrant it, we can report such differences to the health authorities and let them decide the matter. If the local board is made up of ordinary politicians, and the alleged doctor has *' a pull," we may just as well save ourselves the trouble, for nothing will be done except to discredit the honest man. But honest differences in opinion occur. In the midst of writing the last paragraph, I was called to a village STATE DEPARTMENTS — BOARDS OF HEALTH 165 in an adjoining county in which several cases exist of both measles and scarlet fever, and it is hard to differentiate between them. In some houses both dis- eases have appeared. Measles is quarantined for twenty-one days and scarlet fever for thirty days (in that county) and the residents are angry at physicians who impose the longer quarantine or who report second cases in the same house and thus extend the time limit. I realized that the local phy- sicians are facing a disagreeable situation. In other chapters the details of local regulation will be discussed. One thing much neglected by physicians and yet expected by the state is some understanding of diseases transmitted by animals to man. Bubonic plague, anthrax, actinomycosis, glanders, hydrophobia, trichiniasis, foot and mouth disease, and others, are readily transmitted to man and are a real menace. In the appendix of this book they are given some description. Moral obligations are too well understood to need discussion here. The vaccination problem. — The national government undertakes, through the Public Health and Marine Hospital Service, the supervision of vaccine production necessary to ensure its safety from contamination and impurities. Persons in the federal service are subject to the regulations of the department in which they are employed, and must submit to vaccination when required. The states face a different problem. A general compulsory vaccination law similar to that of Germany could not be enforced in most communities in the United States, Any state exercises authority over its schools and can enact a law making school attendance obligatory and requir- ing the vaccination of all who attend. Some states have done this and the general results have been good. However, there has arisen certain conflict in some states, and the law in such cases has failed of complete enforcement. Probably the provisions of some of these laws is a little harsh, but the matter is being carefully studied and objectionable features are being eliminated. There is no doubt that the opponents of vaccination exaggerate the degree of objection to the school laws. The school and health bureau records of Phila- delphia show that less than fifty children out of two hundred thousand remain out of school because of parental opposition to vaccination. In case of great peril from epidemics of smallpox, the state authorities have little trouble in inducing the great majority of people to be vaccinated. Chapters III and XVI discuss the vaccination question in detail. Reports expected of physicians. — Nearly all cities maintain a board or bureau of health or sanitation, the official names varying greatly. In order to facilitate the conduct of quarantine and other measures, most departments of health in the various states require the physician to report infectious dis- ease to the cit} board, and it, in turn, transmits the data to the state depart- ment. Most cities provide blank reports and proper postage for such re- turns. The following is a fair example of a city report: CITY OF SANITARY DEPARTMENT Report of communicable disease; of one or more cases in one family. This report must be made within twenty-four hours by a physician. 166 HYGIENE Notice. — The following is an extract from the Act of Assembly approved . (Then follows the extract.) Or it may be quotations from city legislation. A list of reportable diseases may be given. Disease Date of first symptoms Name of patient Sex Age Residence of patient No. of persons in family, ; male, ages, ; £,.... ages . . . Others exposed ? Name and address of attending physician Date Some cities require the physician to telephone or send messenger in case of smallpox or where the health of the community is seriously endangered. There is some conflict in regard to the very common requirement to report within twenty-four hours. It may be construed as twenty-four hours after first seeing the case or twenty-four hours after diagnosis. The language should be specific and should make allowance for the delay required in typhoid and other cases one cannot always diagnose at the first visit. There is a danger of too great haste in diagnosing and reporting a case, since follicular tonsil- litis may be mistaken for diphtheria, malarial fever for typhoid, etc. Young physidans should be especially careful in this regard, as they are less apt to have seen many cases of some of the infectious diseases. In rural districts or in the absence of a health board the report is made to a health officer designated by the state authorities and notice of whose appoint- ment is sent to the physicians of the district. The following data, or some- thing very similar, appears upon the notification cards: DISEASES TO BE Commonwealth of REPORTED DEPARTMENT OF PUBLIC HEALTH ' Actinomycosis 19. . Anthrax Bubonic plague Patient Nativity Cerebrospinal Age Sex Color Occupation meningitis Chickenpox Address Cholera Diphtheria County Township Epidemic dysentery Erysipelas Disease Date of onset German measles Glanders Name of householder Hydrophobia Leprosy Occupation of householder Malarial fever Measles Number of school children School Mumps Pneumonia (True) M.D. Puerperal fever Relapsing fever Address Scarlet fever STATE DEPARTMENTS — BOARDS OF HEALTH 167 Smallpox Reports of smallpox cases should be telephoned or telegraphed Tetanus to the County Medical Inspector. Trachoma Trichiniasis By order of M.D. Tuberculosis Typhoid fever Commissioner of Public Health. Typhus fever Whooping cough N.B. — Mail this Card Promptly. Yellow fever Some states do not include so extended a list of diseases, nor are all re- portable diseases quarantined. One must consult the regulations of his own state to be guided in this matter. But wherever the physician lives, the gen- eral principle rules that he should promptly report all cases as required by his home officials. Cities may or may not require the reporting of further data and the event of the recovery of the patient. In most of them, there are so many sanitary authorities that such reports are made by them, or the length of quarantine automatically terminates and the sanitary officer fumigates and disinfects the premises and removes the placard. In rural sections the de- partment is notified of the termination of the case by sending in a report similar to this: Commonwealth of DEPARTMENT OF PUBLIC HEALTH To Health Officer living at in (Patient) ffully recovered Twp., has -| or from I^died (disease) Please disinfect and release from quarantine and isolation. M.D. Address Date Note: Physicians will please note rooms which should be disinfected The writer has examined the blank reports from many cities and states, and submits the above as based upon those of Pennsylvania and its cities, and as, in his judgment, being so well adapted to the work as to merit reproduc- tion and as serving as a guide for districts and states not satisfied with their own forms. But, where medical health officers are employed, shorter blanks serve every purpose. (See Chapter XI.) The twenty-four hour limit for report should, in my opinion, be defined as to its exact meaning, by a footnote. 168 HYGIENE Vital statistics have never interested the general practitioner very greatly, and most of us lag somev^hat in reporting the cases of minor infection, such as whooping cough and mumps. We are inclined to argue that as these cases are not quarantined (they are in Pennsylvania), why should we go to the trouble to report them. Probably a monthly report of some of these matters might relieve the physician somewhat, but it is questionable if it would result in more full reports. The safer plan is for the physician to assume that he knows only one locality and is ignorant of conditions elsewhere, and the state authorities may very badly need data from all sources in order to determine their course of action in regard to some threatening disease. Measles may be very mild in one section and be a fatal scourge in another section. This is a disease commonly neglected, and that should be always reported. I have seen an epidemic of whooping cough develop many fatal cases. This matter is important and physicians assume too much when they denounce the laws regarding the collection of vital statistics. And the public is at fault very often. We have many Pennsylvania German people in this district, and they see no reason for sending for a physician in a case of minor infection or what they choose to regard as such. In my own families I often am asked for school permits after a child has recovered from measles or some other disease and in which no physician was called to see the case and of which I have no knowledge until after the recovery. For these and other reasons vital statistics in this region are apt to be very far short of the real facts. It is the duty of the physicians and of the public to make an effort to improve upon the past in this regard. Physicians who are legally registered are state officers in regard to the reporting of births, deaths, and disease. They should feel both the honor and the responsibility that devolves upon them therein. In reporting births, much may be at stake years after, since these reports are permanent records and constitute legal proof in some actions at law. One should be careful to supply correct data and be upon his guard as to writing into a certificate the name of the alleged father in case of an illegitimate birth. There is a tendency upon the part of some authorities to demand the reporting of all miscarriages and abortions. There is no doubt that such demand is fair from a legal point of view, and the physician is protected in certain cases; but there are unfortunate incidents in so many good families that it would be outrageous to make public their shame. If reports of such cases are demanded, it is incumbent upon the authorities to preserve inviolate all such data. This is nearly impossible, especially in states where registrars get this data and where the reports are made matters of public record. I have known in- stances where a report of such a case would have resulted in the physician being either thrashed or shot. The Bertillon system of disease classification has been adopted in many states, in an effort to make uniform the vital statistics of the different states and countries. Physicians can assist in this work by filling out death cer- tificates in an intelligent manner and avoiding indefinite or vague terms or disease names. Such terms as " heart failure " and those indicative of a mere symptom should not be used. By comparing the census returns with STATE DEPARTMENTS — BOARDS OF HEALTH 169 the vital statistics, much very valuable data and conclusions are elicited. This object is defeated unless the reports are approximately accurate. This is equally true of the reports of marriages by clergymen and magistrates and the reports of the midwives and undertakers. As illustrative of the importance of carefully gathered vital statistics, permit me to quote from the message of the governor of Pennsylvania to the legislature of 1897: The need of a suitable system of registration of vital statistics is also being con- stantly brought to the attention of the health authorities. In an enlightened com- munity there live but few people of mature age whose birth, marriage, or death does not at some time become a matter for the cognizance and consideration of legal author- ities. The attainment of majority with its rights and duties, the fact and date of wed- lock, the inheritance or conveyance of property, parentage, and nationality, place, date and cause of death and interment, and many other questions of sociologic, eco- nomic, and even historical character often assume much importance with reference to many of our citizens. In the absence of a state system of registration many of the citizens are deprived of their legal rights or are enabled to deprive their fellows of their legal rights. The deeds of the murderer and abortionist or the suicide can be easily concealed from human view until decomposition has obliterated all evidence of the crime. Local representatives of state organizations. — The duties of these gentle- men are defined in another chapter in more detail than is necessary here. In order for the state to fully prosecute its work, it is essential that it be repre- sented by trained men who have a proper executive over them, and thus the " team work " so essential for any definite results is quickly attained. Time means much in state medicine and it requires " minute men " to carry into effect the orders of the state officials just as much as it requires trained firemen to fight our fires. Their relationship to local health hoards. — This is largely advisory, and to do the disagreeable things that must be done but that the cousins and the uncles and the aunts (as well as the patients and the political friends) of the local men ptoceed to make too hot for him to do. It is the same old question of the use of local militia to quell a local riot. It takes state police or soldiers from elsewhere to maintain order. Sickness is a strange influence mixed with superstition and fanaticism, in the minds of so many, that it is all but impos- sible to make othei"wise normal people take a sane view of the problem. The folly of the clergy in trying to meet the inroads of alleged " Christian Science " and other mystical cults is an illustration of the tendency of this hystero- strenuous age. All this makes it hard to keep people from deliberately run- ning their heads against a stone wall. The laws make it a misdemeanor to attempt suicide by fast means, and the authorities must not allow people to do the same thing by slower methods. Some one must be responsible, and in this instance it is the local representative of state medicine. It must be remembered that these men are the friends of all who obey the laws, and that is the duty of every good citizen. Misunderstandings and disputes and how to avoid them. — Lack of knowl- edge and misinterpretation of men and things are responsible for most dis- 170 HYGIENE putes. The practical administration of the sanitary laws is like the admin- istration of all other law, in that it first interests itself in what the lawyers call " the people." But with sanitation, it really is the people and not the side upon which the district attorney is alligned, although he is often dragged into a side against his will. There being no greed for money back of sanitation and the enforcing of sanitary laws, the " people " have an unprejudiced case every time and it is well for obstructionists to remember that fact. On the other hand, most legal processes are in no hurry, and can be removed to another jurisdiction or postponed or appealed to a higher court, or a demurrer entered or a cross suit instituted or settled out of court, or one of several kinds of writs issued and no end of" circumlocution office " red tape twisted over and around the whole proceeding. People are used to that sort of thing and would probably be quite unhappy without it; at least the lawyers would be, but when it comes to the enforcement of sanitary matters these " sacred traditions " and " inalienable rights " do not count and the physi- cian cannot get half as much fun out of this kind of law as does the rest of people out of theirs. Probably this is too bad, but our spoiling the lawyer's pet way of doing business with powdered wig and mourning robes is no worse than his ripping out the darling foibles of the medical profession. At all events, things are destined to be done differently and with less friction. However, it would not hurt the sanitary authorities to be as considerate as is possible under the circumstances and to refrain from using " the big stick." Many questions of practical administration are not in a hurry and both sides should be patient. Sanitary legislation is rather new, and it will take some time for the people and even for the profession to understand and to intelli- gently co-operate with the gentlemen who have given these matters detailed and highly specialized study. One way to make the doctors better under- stand the situation is for the sanitary officers to seek opportunities to address the medical societies. Sometimes it is hard for others to fully appreciate the difficulties of the general practitioner. It is equally hard for him to com- prehend the trials of the sanitarian. Strict adherence to the code of medical ethics should be imposed upon both sides. The charity and emergency work. — Several states are undertaking such work. Tuberculosis dispensaries and sanitoria are being established and are doing a great work that is fully entered into in a separate chapter. Permit me to refer the reader to it and to the many publications so fully describing this important work. Statistics are said to he dry reading and a mere statistical narration of the work of the various states would not interest the general practitioner. In order to avoid this and make the following portion of this chapter of real and live interest, I have written to every state hoard of health in the United States asking for copies of their latest literature. The response has heen most generous and I have made a careful study of the large mass of interesting reports and other official puhlications of the hoards. By personal travel and from federal reports, I have added to this data and helieve the suhject, as presented in an informal manner, will he of interest and convey much information to the reader. Please do not omit reading this portion of the chapter, hut take with me a STATE DEPARTMENTS — BOARDS OF HEALTH 171 survey of our great country and learn the lesson that YOUR SECTION is not the only one doing a splendid work in state medicine. Health officers can well afford to read the details of a survey made, from their standpoint, by an amateur hut unbiassed observer, and permit me to say to them that, from my standpoint, all hoards have some weak points and all have strong ones. So have health officers. It is not my province to point out the weak places, but to provide a narration by which one can read between the lines to find his own deficiency and FROM the lines may find a cure. Alabama The Medical Association of the State of Alabama issues from Montgom- ery a quite elaborate annual publication inclusive of its annual proceedings and the health work of the state. There is a state commission of public health, but the work is conducted partially under the auspices of the medical association. From the reports, I gather that an adequate work is being con- ducted, and it is to the credit of the medical men of the state that their society takes so active a part therein. In no other state is the health work so intimately related to the medical society, although it was formerly common in the South to conduct state sani- tation along this line. Alaska Dr. C. C. Grieve, of Sitka, writes that Alaska has no territorial health officers or sanitary organization, but that the incorporated towns, such as Juneau, have local regulations and some have boards of health. Arizona The Territorial Board of Health is composed of the governor, the attor- ney-general, and the superintendent of public health. It is empowered to make rules, and the legislative assembly has enacted into laws a full code of requirements governing state, county, and city sanitation. An examination of these laws shows that they are in advance of those of many of the states. The territory is now preparing to establish a system of vital statistics similar to the Pennsylvania division of vital statistics. Reports are rendered bi- ennially, and they reveal a considerable degree of efficiency in the Arizona work. The board issues a quarterly bulletin with the suggestive motto: " Sanitation and strict quarantine pays big interest on the investment," and the publication seems to be a most practical one. Here is an extract: GLOBE'S TYPHOID RECORD FOR TWO YEARS Globe has a health officer who is interested in his work, who is a sanitarian and who does things. In the spring of this year he instituted a clean-up of the entire city — 172 HYGIENE streets, alleys, and yards — warned the public of the danger of flies and filth and for ten days had eleven men and two teams at work gathering up and removing the rubbish. The city is kept clean by rigid inspection, regular removal of garbage, rubbish, and manure, and by regulations prohibiting the throwing of "dodgers" and other paper about the streets. Covered receptacles for rubbish are provided by the city along the main street. The county team was employed and some work was done by the prison- ers during the clean-up. Dr. Fox's salary was increased from ^50 per month to ;^100. Aside from this the entire expense of the clean-up was about ;$500. Here are the results: Male Adult Female Adults Children Total Cases Deaths Cases Deaths Cases Deaths Cases Deaths 1907 . 83 9 8 8 25 1 116 12 1908 , . 13 1 1 1 5 1 19 3 Saving ... 70 8 7 1 20 97 9 Seventy men at ;^3.00 per day for forty-five days (it is usually figured at sixty days) represents a saving of i^9,4S0.00 Expenses (medical attendance, medicines, nursing, necessary appli- ances) for ninety-seven patients at ;^75 7,275 . 00 A total saving of ;^16,725 .00 Sixteen thousand seven hundred and twenty-five dollars gained! The joy of living in a clean town, the freedom from noisome odors and from un- sightly rubbish, the absence of worry — any one of these is worth the five hundred dollars. And this takes no account of the nine lives saved , the value of which it is difl&cult to compute. Talk about copper mines! Why this has them faded to a frazzle! Arizona must meet the tuberculosis problem owing to the fact that so many sufferers take advantage of its climate. I figured from one of the quarterly reports of vital statistics that thirty-six per cent of the mortality was due to this disease. Flies and insects, dust, heat, adobe houses, and other matters,come before them. The board is meeting its obligations to sanitation very creditably. Arkansas The state board of health was organized in 1881, and conducts its work from Little Rock. The ordinances of the state provide for the necessary lines of public sanitation, and for the organization of local boards. California The officers of the state board of health are located at Sacramento, and the general work and that of the Bureau of Vital Statistics are there per- STATE DEPARTMENTS — BOARDS OF HEALTH 173 formed, while the State Hygienic Laboratory and the State Food and Drug Laboratory are at the University of CaHfornia, at Berkeley. The political code contains acts covering practically all of the necessary regulations, an excellent feature being that the exact powers of the state and local boards are clearly outlined and defined. Emergencies are well met by allowing cities and counties to levy a special tax not exceeding one fourth of one per cent when such a tax is needed for quarantine and other sanitary purposes. There is a good vaccination law and the 1909 act providing for the sanitation of food-producing establishments is almost ideal. The gov- ernor has recently signed it. The food and drug act is ahead of most state legislation upon the subject. In general, the California laws are admirable. California has been blamed with concealing bubonic plague. I have never been there, but have read California literature as well as that from other sources. It impresses me that some of the criticism was most unjust. There was a tendency upon the part of the business interests to resent the aggressive action of the Public Health and Marine Hospital Service, but the health authorities of the state, pressed by political and business interests as they were, maintained a pretty correct attitude so soon as they realized the situation. There were individuals who concealed cases, it is true, but the state authorities cannot be so blamed. The recent publications of the Public Health and Marine Hospital Service go into details concerning the activities of the California authorities and tell some of the difficulties, such as sewers deflected by the earthquake. Oakland alone spent ^65,000 upon plague measures. The fact remains that a prompt and eflFective work was done and California deserves some of the credit and only part of the blame. The following is 1909 legislation passed by the California Legislature: The people of the state of California, represented in senate and assembly, do enact as follows: [Section 1.] It shall be and is hereby declared to be the duty of every person, firm, co-partnership, company, and corporation, owning, leasing, occupying, possessing or having charge of or dominion over, any land, place, building, structure, wharf, pier, dock, vessel, orwater craft, which is infested with [rats, mice, gophers, or ground squir- rels, or] as soon as the presence of the same shall come to his, their, or its knowledge, at once to proceed and to continue in good faith to endeavor to exterminate and destroy such rodents, by poisoning, trapping, and other appropriate means. [Sec 2.] The state board of health and inspectors appointed by such board, and local health officers and inspectors appointed for the purpose, as hereinafter provided, shall have authority, and shall be permitted to enter into and upon any and all lands, places, buildings, structures, wharves, piers, docks, vessels, and water craft, for the purpose of ascertaining whether the same are infested with such rodents and whether the requirements of this act as to the extermination and destruction thereof are being complied with; provided, however, that no building occupied as a dwelling, hotel, or rooming house, shall be entered for such purpose, except between the hours of nine o'clock in the forenoon and five o'clock in the afternoon of any day. [Sec 3.] The board of supervisors of each county and the city council or other governing body of each city and county, city and town, whenever it may by resolution determine that it is necessary for the preservation of the public health or to prevent the spread of contagious or infectious disease, communicable to mankind, or when 174 HYGIENE such board shall so determine that it is necessary to prevent great and irreparable damage to crops or other property, may appropriate moneys for the purchase of, and may purchase poison, traps, and other materials for the purpose of extermina- ing and destroying such rodents, in such county, city and county, city or town, and may employ and pay inspectors, who shall have authority to and shall prosecute such work of ex- termination and destruction, under the direction of such board, or of the local health officer, or board of health, on both private and public property, in such county, city and county, city or town. [Sec. 4.] Whenever any person, firm, co-partnership, company, or corporation, owning, leasing, occupying, possessing or having charge of or dominion over, any land, place, building, structure, wharf, pier, dock, vessel, or water craft, which is infested with such rodents, shall fail, neglect, or refuse to proceed and to continue to endeavor to exterminate and destroy such rodents, as herein required, it shall be the duty of the state board of health, its inspectors and the local board of health and health officer, at once to cause such nuisance to be abated by exterminating and destroying such rodents. The expense thereof shall be a charge against the county, city and county, city or town, wherein the work is done, and the board of supervisors or other governing body shall allow and pay the same. Thereupon, the clerk of such board shall file in the office of the county recorder a notice of such payment, claiming a lien on such property for the amount of such payment. Any and all sums so paid by such county, city and county, city or town, shall be a lien on the property on which said nuisance shall have been abated, and may be recovered in an action against such property, which action to foreclose such lien shall be brought, within ninety days after such pay- ment, and be prosecuted by the district, city or town attorney, in the name of such county, city and county, city or town, and for its benefit. When the property is sold, enough of the proceeds shall be paid into the treasury of such county, city and county, city or town, to satisfy such lien and the costs, and the overplus, if any there be, shall be paid to the owner of the property, if known, and if not known shall be paid into court for the use of such owner when ascertained. When it appears from the com- plaint in such action that the property on which such liens is to be foreclosed is likely to be removed from the jurisdiction of the court, the court may appoint a receiver to take possession of the property and hold the same while the action may be pending or until the defendant shall execute and file a bond, with sufficient suredes, conditioned for the payment of any judgment that may be recovered against him in the action and all costs. [Sec. 5.] Any violation of the provisions of this act shall be deemed a mis- demeanor and shall be punishable as such. Canal Zone By direction of Col. W. C. Gorgas, U. S. A., chief sanitary officer, with headquarters at Ancon, C. Z., a most interesting package of documents was sent to me. It seems strange for the United States to have sanitary regula- tions printed in four languages, and to be a party to such a decree as is the following : DECREE NUMBER 33 OF 1905 (Of 18th February) Approving Sanitary Regulations The President of the Republic of Panama, in the exercise of his attributes, and CONSIDERING That in accordance with Article VII of the Treaty of 18th November, 1903, for STATE DEPARTMENTS — BOARDS OF HEALTH 175 the opening of a maritime canal across the isthmus, the United States of America are charged with the regulation of the sanitary conditions in the cities of Panama and Colon;" .... etc. Then follow the decrees. Enacted in Panama on the 18th day of February, 1905. (Sgd.) M. Amador Guerrero The secretary of government and foreign relations, (Sgd.) Santiago de la Guardia. The decrees are those of the redoubtable Colonel Gorgas and would make the people " back in the states " think something had happened. It is five dollars (gold) fine to breed " v^^igglers " on your property, and if the mayor does not impose the fine, he is fined from five to one hundred gold dollars. All manner of sew^age and other regulations are imposed and a blanket " nui- sance " section reads: Whatever is dangerous to human life or health, whatever building, or part or cellar thereof, is overcrowded or not provided with adequate means of ingress and egress, or is not sufficiently ventilated, drained, lighted or cleaned, and whatever ren- ders soil, air, water, or food impure or unwholesome, are declared to be nuisances and illegal. What would a New York or Chicago lawyer think if that were a national law and imposed upon all of the states ? In Colon and Panama even a phy- sician (to say nothing of a clergyman) may not visit any of the quarantined diseases, except chickenpox, without a permit. And the tropics used to be considered " slow." And when we come to read the annual reports, we see what this highly specialized system does. In one of them Colonel Gorgas said : " The working efficiency of our force, as far as loss from sickness is con- cerned, is as good as that of a similar force anywhere in the United States, and better than that of either our army or navy." For details, permit me to refer to the following papers by Colonel Gorgas : " Mosquito Work in Havana." Medical Record, July 10, 1902. " Sanitary Conditions," etc., in Canal Zone. Medical Record, Feb. 4, 1905. " Sanitary Work on the Isthmus," etc. Med. Record, May 18, 1907. " Sanitation of the Canal Zone." Medical Record, Feb. 15, 1908. " Method of the Spread of Yellow Fever." Medical Record, June 27, 1908. " Destroying Mosquitoes." Washington, Gov- ernment Printing Office, 1904. In all history there has never been such an object lesson in practical sani- tation. Considering the former conditions, and then the present ones, it makes a good health officer dream of the time when public opinion has been trained to such a point in this country that a benevolent government will be allowed to adequately enforce the laws necessary to make our own record show that sin and filth are our worst enemies and that we can do even better than the Canal Zone. The good old Uncle Samuel makes the " kids " obey but allows his grown children to do much as they please. Colorado The state board of health of this state has offices in the capitol building at Denver, is well organized, has an energetic food division, does laboratory 176 HYGIENE work, employs capable inspectors, and conducts several lines of work. For eight years the board has published a bulletin containing much interesting data. The counties are duly organized and the vital statistics are reported by registrars. The work is effective, but is along the same lines outlined in the work of others of the states of the mid-west and presents few points of difference requiring description in detail. Connecticut The business of the state board of health is transacted from the office of the secretary in New Haven. The statutes of the state bearing upon public health and safety are highly elaborated and are the gradual accretion of an old state with varied interests. These acts extend from that concerning the " secret delivery of a bastard," enacted in 1808, up to legislation concerning osteopathy of recent date; and they embrace everything of interest to health or safety in between these dates. A feature that commends the laws of Connecticut is that they seem to be especially devised to protect the individual citizen more than to regulate every- thing under the sun and provide salaries for politicians to do what local author- ities would do better than some hybrid commission or half-cooked " expert." Another good thing about their laws is that they are not drawn in the interest of the brewers and distillers, and the prescribing of and adulteration of liquors is fully regulated. This state does not forget to look after child labor and to regulate the so-called " clubs " that are making drunkards of our young men in so many places. In other words, the humanities are not forgotten by this old state. I do not mean to criticise the boards in younger states, but do feel that some of them would do well to remember that health demands something more than mere material science, and after they have developed essentials, make a study of the legislation of states whose health departments have been in operation long enough for people and officials to come to some mutual understanding of what is needed. This board issues very good bulletins, and its publications give one an excellent impression of their work, Delaware The state board of health has offices at Wilmington and a pathological and bacteriological laboratory at Delaware College. This is not a very power- ful board, the law making the organization of local boards obligatory and giving them considerable control in local affairs. However, the state board exercises a general supervision, and, in case of local neglect, has power to act. As to nuisances, complaint must be made in writing, but the statutes define nuisances very well and the powers of relief are adequate. Quarantine, vital statistics, water supply regulation, etc, are provided for by proper laws. Twice a year the executive officer makes a tour of the state and the tone of the literature issued is exceedingly temperate and gives one the impression that the officials and the physicians in Delaware are working in harmony. STATE DEPARTMENTS — BOARDS OF HEALTH 177 The legislature appropriates a rather small sum for the maintenance of the work, but provides for additional sums to be expended in case of serious epidemic. The regulations under which the work of the state and local boards are done are well drawn and are very reasonable. District of Columbia The commissioners of the District of Columbia have charge of the health work, but delegate it to the health officer, who has a small army of assistants under him. They put into effect as elaborate a code as is found anywhere in the country. The district regulations are also those of the city of Wash- ington, and as that matter is discussed and the regulations given in some detail under the heading of the special problem of cities in the chapter on local boards of health, it is unnecessary to repeat the data here. The work is almost a model in its plan and works out well in practice. Florida The revised statutes of the state of Florida provide adequate regulations for the enforcement of rigid quarantine in time of epidemic, and for fairly detailed conduct of all matters involved in sanitation. The state board of health employs a medical state health officer, who is given full powers, subject to the approval of the board. For the support of the detailed work of the board, a state tax of one half mill is assessed upon the property of the state and the governor is authorized to expend additional sums necessary in time of epidemic. Railroads and vessels, nuisances, hotels and boarding houses, and domes- tic animals are subjects of stringent rules, ever keeping in mind the danger from yellow fever, the large number of tourists coming into the state, and the danger (in a warm climate) of animal infections. The .State Bureau of Vital Statistics conducts its work under very good regulations, and the part of the practitioner of medicine in making reports for quarantine and statistics is fully outlined and the penalties for neglect thereof may be made quite heavy. ^s) The counties are fairly well organized and are under the supervision of the state board. The rules and regulations are very rigid as regards vacci- nation, shipping, filth, and nuisances, and they are doubtless very necessary in so warm a climate. ^ The organization is not a very large one, but judging from its printed regulations it is fully alive to its responsibilities, and from its office at Jackson- ville keeps a very tight rein upon affairs in the thickly populated portions of the state, but does not expect so much from the weaker counties. Georgia In a letter from Dr. H. F. Harris, secretary of the Georgia State Board of Health and director of the laboratories, it appears that Georgia is beginning, 178 HYGIENE in a veiy scientific way, what promises to be a splendid work. The letter itself best gives the data. It is as follows : My Dear Doctor: In reply to your letter I would say that the work being done by our state board of health is almost entirely of a scientific character. We have a well-equipped laboratory where examinations are made for bacteria and parasites that produce disease, and the results promptly reported to the physician sending the specimen, all of which is free of cost. We have a well-equipped laboratory for the Pasteur preventive treatment of rabies, — there having been treated here between three and four hundred cases during the last year; if the patients desire it or are too poor to stand the expense of a trip to this city, the virus is prepared daily and forwarded to the victim's physician, who does the in- oculating. We also prepare diphtheria antitoxin, — the method of Gibson for concentrating the same being employed. ^-3 We also make tuberculins, malleins, etc. All of this is furnished free of cost to the patient. The law creating our board directs that we keep a record of vital statistics, but under existing conditions this is utterly out of the question, and we have made no attempt to comply with this requirement. At best such figures are more or less unreliable, and where no local boards of health exist no real idea can be secured as to matters of this kind. Only the larger cities in this state have boards of health, and the counties are without them almost without exception. Very cordially yours, H. F. Harris, Secretary. The difficulty Dr. Harris notes with regard to vital statistics is reflected in the correspondence with other states. From my own observation, a divi- sion of vital statistics, to be at all effective, requires dozens of clerks and is so expensive to maintain to a point of efficiency that it is hardly justified for a state to expend much money upon such work if in doing so other work is curtailed. If the finances of the state warrant the expenditure of sufficient money, the work may be made highly useful. Guam The following is an editorial cut from The Journal of the American Medical Association for September 11, 1909. It is a statement of remarkable conditions in Guam: POSSIBILITIES OF MODERN PREVENTIVE MEDICINE It has been asserted that if the knowledge of the transmission of disease which we already possess could be fully utilized it would be possible — without the dis- covery of a single new fact — to increase materially the average span of human life and immeasurably to diminish human distress. Sanitarians have often longed for an opportunity to prove the truth of this in a community where the necessary authority and facilities could be provided and thus to show what modern preventive medicine is capable of accomplishing. It seems that in the Island of Guam many of the con- ditions of such a medical Utopia can be found. STATE DEPARTMENTS — BOARDS OF HEALTH 179 This island, which is solely a naval station, has a native population of 11,636 and a foreign population of 398, about one half of which is made up of the naval forces. The government is a sort of beneficent autocracy entirely in the hands of naval officers, and all affairs relating to health and sanitation are administered by naval medical offi- cers. There are no other physicians in the colony, and so these officers are charged with the care of the sick. Hospital accommodations are ample and, by means of dressing stations and clinics, relief is extended in all parts of the island. There is provision in segregated colonies for all cases of leprosy and gangosa and a small sepa- rate hospital for other communicable diseases. A medical officer detailed as patho- logist of the station is engaged in investigating the nature and causes of the diseases peculiar to Guam. Such a rare centralization of medical research, sanitary admin- istration and the care of all classes of the sick makes conditions almost ideal for a prac- tical demonstration in preventive medicine. The fact that more than three fourths of the native population of the island is concentrated in a large town where overcrowd- ing is extreme and that Guam is afflicted with the usual endemic diseases and with general worm infection simply makes the results of the experiment of so much more interest and value. In the July issue of the United States Naval Medical Bulletin one may read what has been accomplished in the short period of American occupation. The reports of the medical officers for 1907 and 1908 are full of interest and should be read in detail by all those interested in tropical sanitation, but the results of the splendid work which has been done are sufficiently well shown by the death rate of 24.3 per 1,000. Some idea of what such a rate means in the tropics may be gained from comparison with the mortality in tropical cities which have long been under the control of European governments, and from the fact that Guam's death rate is exceeded in not a few cities in the United States. Twenty per cent of the deaths in Guam are caused by guha, an epidemic respiratory disease peculiar to the Ladrone and Caroline Islands. The death rate from all other causes was 19.9. In many countries in Europe such a rate as this would be considered remarkably low at the present time, and there are many communities in the most favored parts of this country which have not yet been able to attain it. The results achieved in the Canal Zone have set a standard for tropical sanitation, but the presence there of a large temporary population within an age period having normally a very low death rate renders comparison with other tropical com- munities less significant than in the case of Guam, In Guam it is planned to replace the water supply by means of wells with one from an uncontaminated source and to extend the sewer system. With such means of con- trolling infection from intestinal parasites it is likely that the vital statistics of this in- significant Pacific isle will assume an importance li;tle dreamed of by those who under- took its sanitation as part of the day's work. It is a strange commentary on our progress in matters relating to the public health that we must go to the edges of the civilized world for examples of what can be done in the control of disease, but if the true lesson of the splendid victories which have been won in Guam, the Canal Zone and our other tropical possessions is ever fully grasped by those who make and administer the laws in our own country the end of the present sacrifice of human lives from preventable causes will be in sight, Hawaii The work is under the supervision of the United States Public Health and Marine Hospital Service, Dr, L. E. Gofer in charge. It is outlined in the 1908 Report of the Surgeon General of the Service, pages 117 to 124, and 180 HYGIENE is done in the thorough manner just described under Guam, and as indicated in the discussion of the service in Chapter XII. Idaho The Idaho State Board of Health has an officer at Boise. The health laws are brief, but provide adequately for all of the state regulations and offi- cials necessary for reports of infectious disease and vital statistics. Local boards are required and are given much latitude as to local requirements. A step in advance of some other and older boards is the required reporting of ophthalmia neonatorum. A note in large type, says : The state board has deemed it prudent in order to stamp out smallpox which is so prevalent in our midst, to insist upon as strict a quarantine of chickenpox as of the former disease, thereby avoiding the confusion heretofore incident to the difficulties of diagnosis between chickenpox and varioloid. Illinois The state board of health is well organized and with the office and laboratcxy at Springfield. There is an executive officer, a legal department, a department of vital statistics, a water surve}', a department of lodging house inspection, state examiners of embalmers and a laboratory staff. There is a state food commissioner and a vigorous prosecution of the evils of bad dairies and adulterated and misbranded food is in progress. The board of health distributes antitoxin and is doing practically all of the lines of work devolving upon a state board. The city of Chicago has such an efficient department of health that it constitutes an aid to the state organization. a^ The circulars issued upon the various contagious diseases are among the best I have seen and cannot fail to be of value, and the one upon the care of the baby is to be especially commended. The Monthly Bulletin is one of the best issued by any state. The issue for 1908, if bound, would make a fair- sized volume. Illinois was one of the first states of the Union to establish a state board of health, and it is a rather powerful board. While the law under which it operates is not very specific, yet it is sweeping in the latitude given under the " police power." The board is making an energetic fight against tuberculosis. Indiana In Chapter XI the basis of the Indiana work is discussed and the remarks there made may be of interest in connection with what is here said. One only needs to go through the literature issued by the State Board of Health at Indianapolis, to see that the state is to be congratulated upon its efficient work. The laws are so detailed that space precludes a full discussion and probably the best I can do is to quote from a letter written to me by the secretary of the board: STATE DEPARTMENTS — BOARDS OF HEALTH 181 Your letter received. In this mail we send you a copy of our Book of Instruc- tions to Health Officers, also one of our envelope packages, which illustrates somewhat the work we are doing. We now have a new health law which wi.l take the place of the one you will find printed on page 59. It will not go into effect until May and we cannot furnish you a copy of it at the present time. The vital statistics law on page 64 and the Quarantine Law on page 67, are still in force. The Pure Food Law also is enforced by the state board of health. It has a special department for this work, with ample laboratories, fully equipped. With the package find a copy of our Pure Food Law and the rules of the state board of health. The legislature, just adjourned, passed an anti-stream pollution law, enforcement of which depends upon the state board of health. It also passed a law concerning the sanitation of food-producing establishmenf;, a copy of which is enclosed. Another law requires the testing of cattle with tuberculine, and provides for the paying for of all cattle tested, found not to be diseased, if slaughtered. The state board of health constantly carries on a campaign of education in Hygiene and Sanitary Science. This is done through the distribution of circulars, correspondence, press articles, and visits to cities. Our Tuberculosis Exhibit is con- stantly traveling over the state. Illustrated lectures upon the " Cure and Prevention of Tuberculosis," and also upon the prevention of other diseases. We have two lec- turers connected with the board. '■' A good hygienic work which is being done in this state is carried on by the Indiana Social Hygiene Society. It has a special lecturer who appears wherever called for, and talks upon the sexual plagues. The society also distributes literature. You will find a copy of the pamphlet which they dis.:ribute, which is published by the Indiana State Board of Health, in the envelope package which is sent to you. Very truly yours, J. N. HURTY, Secretary. The Book of Instructions to Health Officers impresses me as the best pamphlet of its sort that has come to my notice, and I wish to call attention to the model city and tov^n health ordinances recommended in this pamphlet. If the Indiana Board had never done anything else, it could still be com- mended for issuing the health circular entitled " Social Hygiene vs. The Sexual Plagues." This is far and away the very best little book upon the subject I have ever read and is referred to in detail elsewhere in this book. Indian Territory (See Oklahoma) Iowa The state board of health is located at Des Moines and is organized upon a strict legal basis of administration, its orders having the effect of law. Local boards are held strictly to account by it and must organize and per- form their duties. The regulations provide full quarantine protection, and tuberculous persons are excluded from many occupations. The regulations, if obeyed to the letter, could be made pretty harsh upon the private physician. The directions given for disinfection and the care of infectious diseases are admirable and the statutes regulating water supply are to be commended. Iowa is one of a small group of states to place under the state board of health the inspection of illuminating and miner's oil. 182 HYGIENE The state veterinarian co-operates with the United States Bureau of Animal Industry and so far as I am capable of judging the matter, the regu- lations under which he works are among the best in the countr}. The board has charge of the examination and licensure of physicians, nurses, embalmers, osteopaths, etc. The board wisely employs a civil engineer, a chemist, and a force of workers in the state laboratory. The state board of medical examiners have laid down a schedule of minimum requirements for the equipment of a medical college and it impresses me as a step in the right direction. Kansas At Topeka the state board of health has its office. There are ten mem- bers, inclusive of the president, the secretary, and editor. An advisory board consists of an engineer, a skilled sanitarian, a food analyst, a drug analyst, a bacteriologist, and a statistician. The scientific work is done at the State University, at Lawrence, and at the Agricultural College, at Manhattan. The law creating the board is adequate for the conduct of an effective service, although not very extended. Quarantine, vital statistics, and sani- tary service are duly provided. County boards are composed of the county commissioners and a physician appointed by them. The rules and regulations of the board are quite stringent and cover a wide field. As instances: stagnant ponds are not allowed in the state, de- leterious substances from factories may not be discharged into any stream, stables are fully regulated, school vaccination is absolute, cases of gonorrhoea are regulated to some extent, and no person with syphilis may be served in a barbershop. Free and extended laboratory service is rendered to physicans and health officers, research work and tests of food and drug products are carried out, and a steady war is waged against tuberculosis. The board publishes a good monthly bulletin. Kentucky " We want a league, offensive and defensive, with every wellwisher of Kentucky and her people," is the motto of this active and well-organized board. The executive office is at Bowling Green. The law creating the state and local boards of health is well drawn, and provides for the usual lines of work in a very harmonious and reasonable way as regards others interested, but there are two features that merit atten- tion. First, the common carriers and other corporations are more fully regulated than is the case in most of the Southern states; second, the laws are enforced. As evidence of this, it is interesting to read over the court decisions affirming the legality of the regulations. Health officers lacking judicial pre- cedents should write to Dr. J. N. McCormack, of Bowling Green, for a copy of the Kentucky decisions. It is to be feared that very prolix laws and regu- STATE DEPARTMENTS — BOARDS OF HEALTH 183 lations lead to more or less laxity as regards enforcement, and the shorter codes of the states actively enforcing them are to be preferred. The Kentucky Board issues an excellent series of bulletins upon the pre- vention of disease, including one upon ophthalmia neonatorum, and from it I quote the following: As soon as the child is born the eyes should be carefully cleansed with a saturated solution of boracic acid, wiped dry with a little absorbent cotton, the lids carefully opened and one or two drops of a two per cent solution of nitrate of silver dropped into the conjunctival sac. This application should neither be neutralized with a salt solution nor be repeated. Louisiana One of the most elaborate and interesting reports that have come into my hands is the last biennial report of the Louisiana State Board of Health. The m.ere fact that the index to the report takes sixty-one closely printed pages is enough for one to realize that it v^ould take a long article to detail all of the activities of this busy board. Suffice it to say that nearly every line of sanitation is undertaken and that the matter of mosquito control is more fully developed than anywhere else in the United States. The board has a big project on hand, as any one can see by a visit to this gulf coast state. Large tracts of the state are populated by colored people who are hard to educate up to the standard in hygiene, and the energetic campaign of education is very necessary. There is a close co-operation be- tween the board and the physicians of the state. Maritime quarantine and the contact with the republics of South and Central America make it necessary for the board to be very closely identified with the Public Health and Marine Hospital Service of the federal government. Louisiana maintains excellent laboratories, and is undertaking a most energetic campaign against impure and adulterated food and drugs. Few states in the Union have so full a code of regulations governing this important matter. Permit me to call attention to the excellent financial management of the affairs of this board. There are some first-class men paid fair salaries, but I do not know of another state that can show so much actual work done per dollar. At all events, there are very few states to equal the record. The work of this board is referred to in other chapters of this book. The offices are in New Orleans. Maine The state board of health has its office at Augusta and, judging from its voluminous literature, is doing an effective work under rather inadequate laws. The 1909 Legislature is adding to these statutes and the board expects its posi- tion to be very much strengthened thereby. However, the laws as they have been provide very well for the organization of local boards and for adequate quarantine, etc. The State Laboratory of Hygiene provides good diagnostic facilities and conducts several lines of work. The Maine Sanatorium is doing effective 184 HYGIENE tuberculosis work, and the state is aroused by numerous publications upon tuberculosis. The bulletin of the board has devoted three full issues to this important work. The circulars upon the several infectious diseases issued by this board are most excellent, one especially instructive being upon tuberculosis in cattle and another valuable one upon infant feeding. The new legislation aims to make persons infected with tuberculosis take proper precautions to prevent the infection of others; to provide free anti- toxin in diphtheria; to provide for the support of families under quarantine and to add to existing regulations. The earnest literature of the board impresses the reader that the old state of Maine is not behindhand in the work of public sanitation. Maryland The business of the state board of health is transacted from the office of the secretary, 8 and 10 South Street, Baltimore. The annual reports of the board are interesting to those devoting attention to vital statistics, since they are very complete in this regard. Any one who has been much in the state of Maryland cannot but be impressed with the large number of charitable institutions and the insanitary conditions prevailing in some of the munici- palities. Both of these factors give the board a lot of work to do. The laws under which they operate, aside from provision for the usual matters of public hygiene, designate several kinds of laboratory work, a vaccine agency, rules against sweatshops, the suppression of opium traffic, the hours of labor for children, as well as other regulations concerning minors, vagrants, and tramps under regulation, the care of inebriates and other things showing the large- heartedness of the Southern people. The geography of the state is such as to cut it into two parts, and there are so many bays and estuaries with sewage carried back and forth by tidal influences or sluggish flow that the sanitary problems are immense. However, the laws cover about all of the several lines of sanitation and inspection, but county and smaller town reports show that the board must overcome much local inertia in order to be effective in some districts. By a comparison with conditions I noted some years ago they are doing well. The more recently enacted laws include a very rigid vaccination act which practically amounts to compulsory vaccination, new pure food requirements, strengthening the local boards, providing for the registration of tuberculosis etc, A novel and really impressive plan of treating the danger from tuber- culosis takes the attending physician into the state service as provided in Section III of the act, as here quoted : Section III. It shall be the duty of the local board of health to transmit to the physician reporting any case of pulmonary or larv'ngeal tuberculosis a printed report after the manner and form to be prepared and authorized by the state board of health naming such procedures and precautions as in the opinion of the state board of health are necessary or desirable to be taken on the premises of the said tuberculous case, and it shall be the duty of the state board of health to print and keep on hand STATE DEPARTMENTS — BOARDS OF HEALTH 185 sufficient number of such report blanks and to furnish the same in sufficient number to any local board of health upon due requisition of the latter. Upon receipt of the blank report the physician shall fill, sign, and date the same and return to the local board of health without delay, provided that if the attending physician is unwilling or unable to undertake the procedure and precautions specified he shall so state upon his report blank, the duties herein prescribed shall then devolve upon the local board of health. Upon receipt of this report the local board of health shall carefully examine the same, and if satisfied that the attending physician shall have taken all necessary and desirable precautions to insure the safety of all persons living in the house or apartments occupied by the consumptive and to insure the safety of the people of the state of Maryland, the said local board of health shall issue an order on the state board of health in favor of the attending physician for the sum of one dollar and fifry cents ($1.50) to be paid by the state board of health out of a fund hereinafter provided. If the precautions taken by the attending physician are in the opinion of the local board of health not such as will remove all reasonable danger or probability of danger to the persons occupying the said house or apartment the local board of health shall return to the attending physician the report blank with a letter specifying the additional precautions which they shall require him to take, and the said attending physician shall immediately take the addi- tional precautions specified and shall record and return the same on the original blank to the local board of health. It shall further be the duty of the local board of health to transmit to the physician reporting any case of pulmonary or laryngeal tuberculosis a printed requisition which shall be prepared by the state board of health and issued in sufficient number to any local board of heahh upon due requisition of the latter. Upon this requisition blank shall be named the materials kept on hand by the local board of health for the prevention of the spread of the disease, and it shall be the duty of the state board of health to purchase such supplies as it may deem necessary from the fund hereinafter provided, and to supply them to any local board of health upon the requi- sition of the latter. Any physician may return a duly signed requisition to the local board of health for such of the specified materials and in such amount as he may deem necessary in preventing the spread of the disease, and all local boards of health shall honor as far as possible a requisition signed by the attending physician in such case. It shall be the duty of every local board of health to transmit to every physician report- ing any case of pulmonary or laryngeal tuberculosis or to the persons reported as suffering from this disease, provided the latter have no attending physician, a circular of information prepared and printed by the state board of health and which shall be furnished in sufficient quantity to every local board of health on due requisition of the latter. This circular of information shall inform the consumptive of the best methods of cure of his disease and of the precautions necessary to avoid transmitting the dis- ease to others. The importance of this plan is such that we reproduce portions of the letter and blank sent to the attending physician, the latter to be filled by him. As will be observed, this plan preserves inviolate the secrets of the family, places the family physician in charge of what a health officer usually does, and pays the physician $1.50 for his trouble. It seems to me to be an effective step toward taking the family doctor into partnership with the state. Dear Doctor: Acknowledging and thanking you for your report just received ( ) we hand you herewivh an inspection blank. Assuming that you are attending this patient we ask you that you will obtain a package of the prophylactic supplies which the state furnishes, take it with you to the house, instruct the patient 186 HYGIENE and at least one responsible member of the household in the use of the supplies and give such instruccions as the report blank suggests with such other advice as your own judgment approves. Return to us a complete report of your observations and the instructions which you have given, and for the service we will pay ;^1.S0. Physicians living in Baltimore can obtain supplies, in person or by an author- ized messenger, at the office of the state board of health on any week day between the hours of nine and four. Physicians living outside Baltimore will be supplied by the health officer for the county, town, or district. Supplies will not be issued for any unregistered case. Very truly yours, Secretary. N.B. — Money appropriated by the state for the restriction of tuberculosis cannot be properly expended for non-infectious cases. The sputum must be examined and must show the presence of tubercle bacilli. N.B. — There are three places on the blank where your name must appear, all on the fourth page. Sign your name to Part III, the requisition for supplies. Write your name twice where the abbreviation Dr. occurs under the headline Endorsements. N. B. — Physicians are expected to perform these services in their private char- acter as family advisers, and to avoid unnecessary show of official intervention. This does not mean that individuals are at liberty to disregard the advice of the physician. STATE BOARD OF HEALTH OF MARYLAND State of Maryland, County of , Town of REPORT UPON A CASE OF TUBERCULOSIS Part I Name of patient Address : Town Maryland Age of patient years, months. Male or female ? Married, single, or widowed ? White or colored ? Birthplace ? Birthplace of father ? Birthplace of mother .? Occupation Underline the definite occupation in which the patient is engaged. In returning the occupation of a man, do not use such indefinite terms as " laborer," " tailor," " mill hand," " carpenter," " painter." If an unskilled laborer, state accurately the sort of labor usually performed. The United States Census recognizes four separate classes of carpenters, eleven classes of tailors, four classes of painters, and it is necessary for us to conform to such a standard. In returning the occupations of women, it should be noted that tuberculous women abandon their occupations much earlier than men. Specify the occupation of a woman at the time the disease became apparent. The term " housework " should not be used, as it includes several distinct occupations, namely, housewives (and other unpaid mem- bers of the family), housekeepers (salaried), domestic servants on wages (cooks, laundresses, waitresses, nurses, chambermaids, ladies' maids, etc.) Always make a distinction between gainful and unpaid occupations. A space is left after occupation for the return of unpaid occupations, such as housewives, students, school children, etc. STATE DEPARTMENTS — BOARDS OF HEALTH 187 Is the patient now engaged in the original occupation ? Is the earning power as good as ever ? If working irregularly or at reduced wages, how long ? If totally unable to work, how long ? If totally disabled, is the patient confined to bed ? If there has been consumption in the family history, mark in the list below those who were affected. Brother Father's mother Sister Mother's mother Father Husband Mother Wife Father's father Son Mother's father Daughter Other cases in the house now or formerly ? If the patient has had children, how many are living ? Dead .? Are there infants or young children in the house ? If the patien^ is a mother, does she nurse an infant ? Does the patient habitually kiss other persons on the mouth ? Does the patient use dishes, tableware, pipes, clothing, handkerchiefs, or towels in common with other persons ? Does the patient prepare the food of the family ? DISPOSAL OF SPUTUM Does the patient spit upon ihe floor, walls, hearth, or furniture ? Does the patient spit into a spitioon used by other persons .? Does patient spit into a handkerchief.? Does patient spit into a paper napkin ? Does patient, spit into a paper sputum cup .'' Into a china, glass, or metal sputum cup ? Is water, or carbolic acid, or any disinfectant used in the sputum cup ? FINAL DISPOSAL OF SPUTUM Is the sputum burned .? Is it thrown into a water closet or into a sewer } . . . Is it thrown upon the ground, or ini.o surface drain or gutter ? Is it thrown away with garbage, ashes, or other refuse .'' Are patient's handkerchiefs put in wash with other clothing .? Are patient's handkerchiefs disinfected before being laundered } CONDITION OF THE ROOM Is the room suitable in size, ventilation and lighting for a tuberculous person ? Are the hangings, floor coverings and furniture such as admit of proper prophylaxis L . How are the walls finished (rough plaster, smooth plaster, wainscoted, papered, painted) .? Are the walls and furniture ever wiped off with a disinfectant solution ? Is the room swept and dusted in the ordinary way with broom and feather duster ?. . . . Are the floors ever washed with a disinfectant } How many other persons occupy the patient's bedroom ? Does any one share the patient's bed ? Is the patient's bedroom used as a kitchen .? As a dining room ? Do children play on the floor of the bedroom .'' Do you find any other conditions which in your opinion may be sources of danger to those on the premises, or to the public ? In order to expend state funds for tuberculosis the tubercle bacillus mus. be found. This sheet should not be filled until the bacillus has been found and the supplies re- ceived and their use demonstrated. 188 HYGIENE PART II (To be filled afiier supplies have been received on requisition) PRECAUTIONS TAKEN AND ORDERED Is the room in such a condition as to require formaldehyde fumigation before other prophylactic steps are taken ? Have you delivered the supplies received upon the above requisition and demonstrated their use ? If the patient has an infant, have you advised her of the danger of nursing it ? Have you advised the patient not to kiss any one on the mouth ? Have you instructed the patient when coughing to hold a handkerchief or napkin before the face ? Have you ordered that the patient shall have for exclusive personal use all utensils and articles vphich come into contact with the mouth ? Have you forbidden the use by others of the patient's utensils or wearing apparel ? Have you ordered the disinfection of wash clothing before being laundered ? If the patient prepares or handles food for the family, have you given careful instruc- tions how to avoid contaminating the food ? Have you instructed the patient to carefully avoid contaminating the hands and to wash and disinfect them frequently, especially when performing any household duty ? Haf e you instructed the patient and at least one other responsible member of the house- hold concerning the disinfection of hands, utensils, and the accidental contamina- tion of surroundings ? Have you ordered every accidental contamination with sputum to be disinfected immediately ? Have you forbidden expectoration anywhere except into proper receptacles ? Have you ordered the sputum cups burned after use not exceeding forty-eight hours ?. . Have you directed the use of paper napkins and waterproof pocket when the patient is away from home ? Have you ordered the paper napkins burned daily ? Have you forbidden the throwing of sputum upon the ground, or in surface drains or gutters ? Have you forbidden throwing sputum away with garbage, ashes, or refuse ? Do the patient's circumstances admit of special furnishings and arrangement of room ? If so, have you made any of the following recommendations: Removal of heavy curtains ? Use of sash curtains or other curtains of wash material ? Removal of carpets ? Useof rugs, preferably of cotton or other washable material ? Removal of large and unnecessary pieces of furniture, especially such as inter- fere with thorough cleansing of the room ? Have you ordered the walls, floors, and furniture wiped oflF once a week with a cloth wet with disinfecting solution ? Have you forbidden dry sweeping and dusting in the patient's room ? Have you advised against the patient's sleeping with any other person ? Is it practicable to have no other person to sleep in the room ? Have you advised against preparing or serving food in the patient's room ? Have you advised that children should not be allowed to play on the floor of the patient's room ? STATE DEPARTMENTS — BOARDS OF HEALTH 189 PART HI Requisition for Supplies I hereby make application for the following supplies to be used in preventing the spread of tuberculosis on the premises of , a consumptive. 75 Sputum Cups. 1 lb. of Liquid Disinfectant. 2 Waterproof Bags. 200 Japanese Paper Napkins. 1 Cup Holder. (Signed) M.D. Note. Supplies will not be issued for more than three months. The above list in- cludes all the supplies which can be issued to one patient at one time. ENDORSEMENTS (^1.50) has been issued upon the state board of health. 1. The requisition for supplies made by Dr OF Secretary or Executive Board of Health of •••;•. •• is approved, and the same have been 3. I am unwilling or unable to take the issued. precautions specified in this circular and hereby turn the case over to the board of health for its action. Secretary or Executive Board of Health M.D. of Attending Physician 2. The precautions taken and ordered by Dr Note. — The last endorsemen; is only OF made by the attending physician when he is unable or unwilling to provide for the - safety of those occupying the premises have been sufficient to insure the safety of with the consumptive. When this en- every one occupying the premises men- dorsement is made by the physician all tioned in this report, and are approved, of his duties devolve upon the local board and an order for one dollar and fifty cents of health. INSTRUCTIONS TO THE TOWN OR COUNTY BOARD OF HEALTH 1. The law requires all details of information concerning cases of tuberculosis to be held confidential. No matter how fully the general public may be informed concerning any case, official discussion must be confined to the local health officer, the state board of health, the attending physician, and the infected household. 2. As soon as the name of the attending physician is received, you will forward to him the four-page circular issued to you with instructions to fill Part I, and the blank requisition for supplies (Part III). When the circular is returned to you properly executed, you will return it to the attending physician with one quarter's supply of prophylactic material, and endorse your issue on the back of the blank. 190 HYGIENE 3. When the blank is returned to you with Part II executed, you will determine whether or not all necessary and desirable precautions have been taken. If you find these satisfactory, you will issue an order on the state board of health for one dollar and fifty cents (^l.SO), in favor of the attending physician. If not, you will order the additional precautions necessary. 4. You will transmit to the attending physician (or to the patient, if he have no physician), a Circular of Information for those suffering from pulmonary diseases, prepared and printed by the state board of health. INSTRUCTIONS TO ATTENDING PHYSICIANS 1. On receipt of this circular you will fill Part I, which is a statement of conditions as you find them, and Part III, which is a requisition for three months' supplies, and mail to the local board of health. 2. The circular with the endorsement of your requisition will be returned to you with one quarter's supplies by the local board of health. 3. You will then state upon Part III what precautions you have taken and ordered, and what use you have made of the prophylactic supplies. 4. If these are satisfactory, the local board of health will issue an order, in your favor, upon the state board of health for one dollar and fifty cents (;J$1.50). Massachusetts The state board of health has its office in the State House at Boston. An examination of its report and literature impresses me that it is doing a solid work in a conservative but effective way. The usual regulations for quarantine and vital statistics prevail, and state inspectors of health are appointed who work under the supervision of the state board. The statutes provide for fifteen of these inspectors upon an adequate salary, and the business exigencies of the state are such that these men are practically factory inspectors as well. In no other state do I find so great attention given to the matter of factory and workshop sanitation. The reports upon this matter are so valuable that they are utilized elsewhere in this book and need not be further discussed here. The cattle bureau operates under rigid inspection rules, and dairies throughout the state are inspected. Even dairies in adjoining states that send their products into Massachusetts must be inspected by Massachusetts officials regardless of state lines. The 1908 report of these inspections show that the New England states have much to do in improving dairy conditions. Food and drug inspection takes the time of several officials and the reports are quite interesting. The Massachusetts State Sanatorium at Rutland, the first state insti- tution of its kind in this country, cares for tuberculous cases, as do also the state institutions at North Reading, Lakeville, and at Westfield. The build- ings are not yet all completed. Michigan The office of the state board of health is at Lansing. The secretary writes as follows : STATE DEPARTMENTS — BOARDS OF HEALTH 191 Your favor of the 13th at hand, and in reply thereto, let me say that to give you a full idea of the Michigan plan of carrying on public health work, I am sending you, under separate cover, a copy of our public health laws, a copy of our quarterly publication, " Public Health," last issued, a copy of our last monthly bulletin " Pub- lic Health," also of our various blanks and our teachers' edition containing instructions for the restriction and prevention of contagious diseases. The power of this state board is advisory only, having in connection with it a bacteriological and chemical laboratory for the free use of health officials throughout the state. When a case of communicable disease occurs in a community, the physician is required by law to report (also the householder is required to report) the case to the local health officer. The health officer is required by law to investigate and take the necessary restrictive measures, and report to the state board of health. Upon receipt of report we send out contagious disease pamphlets for distribution among families and neighbors, or where they will do the most good, the local health officer attending to the distribution of same. Four times a year we supply the teachers and others with our quarterly issue " Public Healch," which we attempt to make readable and instructive on broader lines of public health. The monthly bulletin, " Public Health," is a current summary of disease condi- tions throughout the state, issued for the benefit of health officials and physicians. These publications are among the most elaborate issued by any of the boards, and to them we are indebted for considerable data used in the body of this book. The state university at Ann Arbor does much research w^ork for the board in its laboratory of hygiene. It was in that university laboratory that the editor of this volume received his start in the study of the problems of hygiene over twenty years ago, and Michigan at that time was in advance of most of the more eastern states in research work. It has told upon the state and I have observed since, in that state, that the general public well support the work. The laws under which the board bperate are drawn with special care and impress me as fair to the physician and as elastic enough to provide for con- tingencies ever arising in health administration. They do what all states should do, designate definitely how local boards of health should organize and conduct their work, and they define nuisances in a manner saving the officers a world of trouble. The university maintains a Pasteur laboratory for the treatment of hydro- phobia and the board sends cases there. Michigan is conducting an aggres- sive campaign against tuberculosis and has a psychopathic hospital at the university for the reception of mild cases of insanity. This latter is one of the later but most humanitarian phases of state medicine and should be copied by other states. Minnesota The Aiinnesota State Board of Health has offices in the capitol building at St. Paul. New regulation is pending, but it is principally additional to an already elaborate code. The law provides for the appointment of a board of" nine members, learned in sanitary science," but the work is largely under 192 HYGIENE the supervision of the secretary and executive officer. With the approval of the attorney general the board may promulgate rules and regulations not in conflict with any statutes or the charter or ordinances of a city of the first class. These regulations have the effect of laws. The board has adequate regulations regarding sewage, cemeteries, hos- pitals, water supply, contagious disease, vaccination, vital statistics, inter- state carriers, nuisances, and food inspection. Legislation passed in 1907 provided good county organization and most excellent regulation of vital statistics reports and their collaboration. The regulations are very carefully worked out in detail, following the lines of other states. An arrangement to secure vaccination without the fea- tures objected to in many places commends itself. It is as follows: VACCINATION 16. Following an exposure of smallpox every individual who cannot show evi- dence of a recent successful vaccination or a recent attack of smallpox must be vacci- nated (within three (3) days of che first exposure) or placed under the same isolation restrictions as smallpox patients. If smallpox prevails in a community or if the disease appears in a school, all un- vaccinated teachers and pupils must be excluded from school for a period of three weeks unless vaccinated within three (3) days of first exposure. Failing to comply with this requirement, the school must be closed for a period of three weeks. If smallpox appears in any class in any college in Minnesota, all unvaccinated teachers and students in the class must be excluded from recitations for a period of three weeks unless vaccinated within three (3) days of first exposure. Failing to com- ply with this requirement, the classes attended by such teachers or students must be discontinued for a period of three weeks. Scarlet fever is quarantined for three weeks or longer, depending upon whether or not desquamation is complete. This is a very reasonable provi- sion. Laboratory findings in diphtheria are not accepted except from a laboratory approved by the board. There is a provisional quarantine for suspicious cases and the laboratory findings figure largely in determining the diagnosis. The board has a laboratory of its own. When a house is plac- arded for measles, all children therein must remain away from school except those who have previously had measles. The following very wise provision is made as regards typhoid fever: 53. Whenever typhoid fever prevails in a locality the local board of health shall immediately appoint a competent inspector, or inspectors, to patrol the city, village, or district involved. Such inspector or inspectors shall report to the local board of health all water closets, privies, vaults, and cesspools which are not fly-proof, with screened doors and windows; and all vaults and cesspools which are not water-tight, dark, and fly-proof The local board of health shall thereupon enter its proper order in the premises to the end that all such water closets and privies shall be made fly-proof and all such vaults and cesspools water-tight, dark, and fly-proof. 54. Any drinking water supply shown to be a positive or probable source of dis- ease shall be condemned either by the local board of health or by the Minnesota State Board of Health, and when so condemned, shall nor be used again as a drinking water supply until declared safe by the condemning party. STATE DEPARTMENTS — BOARDS OF HEALTH 193 Minn. There are many excellent features in the practical conduct of the work of the Minnesota Board largely due to the reasonableness of its regulations. I wish to refer in detail to the advanced position this board takes toward the suppression of tuberculosis, by reproducing a few of its blanks: REPORT OF A CASE OF TUBERCULOSIS Name Age Sex Color Residence County of (Township, Village, or City.) Occupation Married, Single, Widowed. (See Special Sheet for list of Occupa- tions.) In returning the occupation of a man, do not use indefinite terms. In returning the occupation of a woman remember that tuberculous women aban- don their occupations much earlier than do tuberculous men. The occupation to be named is of the patient at the time the disease appeared. In naming occupation, be guided by the list furnished. If pulmonary form: Coughing, how long ? Expectorating \ (Yes or no) Stage of disease } How long tuberculous ? Have tubercle bacilli been demonstrated as present ? (Yes or No.) If so. When .? By Whom .? Filled out by of Date of report 190 .... (Return this to the Minnesota State Board of Health at St. Paul, Minnesota) (Cross out all except proper answer.) Nationality Birthplace Lungs, Lymph Glands, Perito- neum, Intestines, Genito Urinary Tract, Meninges, Skin, Bones. (Cross out all of the above except the proper answer.) Location of Lesions Minn. By Dr. REPORT OF A CASE OF TUBERCULOSIS of 19. Name of patient Age Residence Birthplace (Township, Village, or City.) Birthplace of Father Birthplace of Mother Male or Female Married, Single, or Widowed Occupation White, Colored, Indian Is the patient now engaged in the original occupation .? Is the earning power of the patient as good as ever ^ If working irregularly or at reduced wages, how long ? If totally unable to work, how long .? If totally disabled, is the patient confined to bed .^ If there has been consumption in the family, mark in the list below those who were affected. Father Mother Brother Daughter Father's father Mother's father Sister Wife Father's mother Mother's mother Son Husband 194 HYGIENE Have there been or are there now other cases in the house ? If patient is a parent, how many children are living ? Dead ? Are there infants or young children in the house ? How many ? If the patient is a mother, is she nursing an infant ? Does the patient habitually kiss other persons on the mouth ? Does the patient use dishes, tableware, handkerchiefs, towels, clothing, pipes, etc., in common with other persons ? Does the patient prepare the food for the family ? DISPOSAL OF SPUTUM Does the patient spit upon the floor, walls, hearth, or furniture ? Does the patient spit into a spittoon used by other persons ? Does the patient spit into a handkerchief? Does the patient spit into a paper napkin ? Does the patient spit into a paper sputum cup ? Does the patient spit into a china, glass, or metal sputum cup ? If so, which ? Is water, carbolic acid, or any disinfectant used in the sputum cap ? FINAL DISPOSAL OF SPUTUM Is the sputum burned ? Is it thrown into a water close- or into a sewer ? Is it thrown upon the ground, or in"o a surface drain or gutter ? Is it thrown away with garbage, ashes, or other refuse ? Are the patient's handkerchiefs put into the wash with other clothing ? Are the patient's handkerchiefs disinfected before being laundered ? CONDITION OF THE ROOM Is the room suitable in size, ventilating, and lighting, for a tuberculous person ? Arethehangings, floor coverings, or furniture such as to admit of proper disinfection ?. . How are the walls finished (rough plaster, smooth plaster, wainscoted, papered painted) ? Are the walls and furniture ever wiped off" with a disinfecting solution ? , Is the room swept and dusted in the ordinary way with broom and duster ? Is the floor ever washed with a disinfecting solution ? How many persons occupy the patient's bedroom ? Does any one share the patient's bed ? Is the patient's bedroom used as a kitchen ? Asa dining room ? Do children play on the floor of patient's bedroom ? Do you find any other conditions in the patient's room which in your opinion may be a source of danger to those on the premises, or to the public ? (To be sent to a Physician one month after a prophylactic outfit has been fur- nished him for a tuberculous patient.) RELATING TO PRECAUTIONS TAKEN IN THE CARE OF THE TUBERCULOUS Return this to the Secretary of the Minnesota State Board of Health, St. Paul, Minn. 19 Name of patient Age Residence (Township, Village, or City.) Was the room of the pacient in such condition as to require formaldehyde disinfection before other prophylactic steps were taken f STATE DEPARTMENTS — BOARDS OF HEALTH 195 If the patient is a nursing mother with an infant, have you advised her of the danger of nursing it ? Have you advised the patient not to kiss any one on the mouth ? Have you instructed the patient to hold a handkerchief or napkin before the face when coughing ? Have you given directions for the patient to have for exclusive personal use all utensils and articles which come in contact with the mouth ? Have you forbidden the use by others of the patient's utensils or wearing apparel ?. . . . Have you ordered the disinfection of washable clothing before the same is laundered ?. . If the patient prepares or handles food for the family, have you given careful instruc- tions how to avoid contaminating the food ? Have you instructed the panent to wash and disinfect the hands frequently, especially when performing any household duties, and how to avoid contaminating the hands ? Have you instructed the patient, and at least oneother responsiblememberof thehouse- hold, concerning the disinfection of the hands and utensils, and the accidental contamination of surroundings ? Have you ordered that every accidental contamination with sputum be disinfected immediately ? Have you forbidden the patient to expectorate anywhere except into proper receptacles ? Have you ordered that the soiled sputum cups be burned after use not exceeding forty-eight hours ? Have you directed the use of paper napkins and waterproof pockets for the soiled napkins when the patient is away from home ? Have you ordered that the soiled paper napkins be burned daily ? Have you forbidden the throwing of sputum upon the ground or into surface drains or gutters ? Have you forbidden the throwing away of sputum with garbage, ashes, or refuse ?. . . . Do the patient's circumstances adm.it of special furnishings and the proper arrange- ments of the sickroom ? If so, have you made the following recommendations ? The removal of heavy curtains ? The use of sash curtains or other curtains of washable material ? The removal of carpets ? The use of rugs, preferably of cotton or other washable material ? The removal of large and unnecessary pieces of furniture, especially such as inter- fere with the thorough cleansing of the room ? Have you ordered the walls, floors, and furniture wiped off once a week with a cloth wet with a disinfecting solution ? Have you forbidden dry sweeping and dusting in the patient's room ? Have you advised against the patient's sleeping with any other person ? Is it possible to have the patient sleep alone in a room ? Have you advised against preparing food for or serving food to other persons in the patient's room ? Have you advised that children should not be allowed to play on the floor of the patient's room ? Mississippi The Mississippi State Board of Health has offices at Jackson. This state is a party to the " Quarantine Rules and Regulations of the South 196 HYGIENE Atlantic and Gulf Coast States," and which are directed against yellow fever and all kinds of infected shipping and freight as well as passengers arriving from infected ports or districts. Elaborate regulations as to inspection and disinfection are outlined and the whole work is supervised by an inspector employed by the United States Marine Hospital Service. Aside from this, the state has regulations of its own similar to those of other states, but which are brief and to the point. It lays especial emphasis upon cholera and yellow fever and some of the requirements as to burial, funerals, the relays of guards, the passage of trains, etc., are so gruesome as to emphasize the terrors of this scourge. The mosquito dissemination theory will modify some of the features of such quarantine. The board employs a state lecturer to visit all of the towns of the state and they are preparing a full set of bulletins for circulation among the people. The state is doing a good work and is organizing the counties. Missouri The state board of health does not have a central office at the state capitol, but the secretary of the board, Dr. J. A. B. Adcock, Warrensburg, receives the reports and issues the very excellent bulletin as a quarterly entered as second-class mail matter. The board numbers seven members, five of whom must be physicians. All of the present board are medical gentlemen. The board operates under a brief but workable code of laws and is author- ized to take such measures as circumstances may demand, is required to take cognizance of diseases among domestic animals, and acts as a state board of medical examiners. County boards are composed of the iudges of the county courts and one physician, selected by them, for each county. These boards are subsidiary to the state board and they operate under brief but effective rules governing quarantine, sanitation, and school regulations. There is a state bacterio- logist and a Missouri State Sanitarium for tubercular cases. Montana The department of public health is located at Helena, the membership being composed of the governor, the attorney general, four physicians, n d a veterinarian. The laws under which the board operates have been recently amended. Nebraska The state board of health is composed of the governor, the attorney gen- eral, the superintendent of public instruction, a board of secretaries, and a state health inspector. The office is at Lincoln. The law under which the board conducts its work is so framed as to give great recognition to local boards when they properly perform their functions, but also to give the state authority to safeguard the health of delinquent com- STATE DEPARTMENTS — BOARDS OF HEALTH 197 munities. The quarantine regulations are up to the standard of the most advanced practice, and inspection of schools, vital statistics, and other de- partments of state hygiene are provided for in a carefully drawn code of laws and regulations. Nevada The Nevada State Board of Medical Examiners, through its secretary, who is also secretary of the board of health, has endeavored to secure a proper recognition for their work but with little success. The secretary writes: " I am sorry to say this state is doing nothing along the lines you mention. I endeavored to get some legislation and appropriation for above purposes at the session of the legislature that ends to-morrow, but was not successful. In sackcloth and ashes." Nevada is a young state and the secretary is an earnest man and it will probably not be long until this state will swing into line. New Hampshire The state board of health has its offices in the State House at Concord and is allied with the board of commissioners of lunacy, the department of vital statistics, and the state laboratory of hygiene. This state has snug and workable sanitary laws and rigid ones concerning food and drugs. The local boards are well organized, nuisances are well defined, quarantine regulations are adequate, swamp lands come under state care, building and improvement measures are provided, and the physicians are paid small fees for vital statistics reports. The state maintains a tuberculosis sanatorium and the board publishes a very good sanitary bulletin, as well as other literature for the information of health officers and the public. The laboratory of hygiene conducts a high grade of research work and the board is making a most careful investigation of the water supplies of the state. Food, drug, and liquor inspection is developed to an extent in New Hamp- shire equalled by very few other states. They are doing a fearless and effective work commented upon in other portions of this book, and that need not be fully discussed here. Suffice it to say that the federal government accepts as authoritative the work of this laboratory and it is permitted especial privileges in the federal courts. New Jersey In Chapter XI detailed reference is made to the excellent provisions of this state board of health as regards the training of local health officers, a plan every state should copy. The public health laws are so detailed as to render an abstract of them too lengthy for these pages. In general it can be said that they have been brought more fully up to date than are the codes of most of the eastern states. 198 HYGIENE Section VI provides: " That every physician in this state making official reports to the state board of health through the bureau of vital statistics shall be entitled to receive by mail, from the treasurer of the state, a copy of the annual report of the state board of health and of the bureau of vital statistics." In addition to this, every physician making reports receives a semi- annual remittance for his trouble. The splendid sanitary inspection service provides the foUov^ing books for study : " Principles of Sanitary Science," by W. T. Sedgwick, published by McMillan & Co., price, ;^3. " Practical Hygiene," by Charles Harrington, published by Lea Bros. & Co., price, $4.25. "Manual of Hygiene and Sanitation," by Seneca Egbert, pub- lished 'by Lea Bros. & Co., price, $2.25. " Clean Milk," by S. D. Belcher, pub- lished by the Hardy Publishing Company, price, $1. Circulars of the board of health of the state of New Jersey will be sent upon request. Partial provision is made for placing inspectors who have passed the examination under civil service rules. The series of circulars issued are of a reasonable and scientific tone and calculated to impress a layman. An ex- cellent tuberculosis campaign is in progress. By revision the food and drug laws of the state have been brought into conformity with federal regulations. The officers of the board are at Trenton, as is also the well-equipped state laboratory of hygiene. A good provision of the laboratory is the host of repositories for mailing cases scattered all over the state and thus facilitating reports. New Mexico The New Mexico Board of Health and Medical Examiners is composed of seven physicians, the office of the secretary being at Santa Fe. This grow- ing state has been attending to sanitary matters arising, but the laws under which the board operates are inadequate and are undergoing revision looking toward an effective and up to date service. New York As is to be expected, New York maintains an elaborate department of health with a commissioner and divisions of sanitary engineering, laboratory work, vital statistics, communicable diseases, publicity and education, a con- sulting staff and a tuberculosis advisory board. The offices are at Albany. The department conducts the work common to all states, but is espe- cially marked by its energetic tuberculosis work, the school of sanitar}' science and public health maintained at Cornell University, and the many lines of research work conducted and which would take much space to detail. The protection of the public water supply is a serious problem in a densely popu- lated region and this department is giving much attention to the matter largely aided by the division of sanitary engineering, a vital part of a state department and one in which so many states are weak. As yet pure food work is not ver}' largely undertaken, but plans are being made for an aggressive campaign Vital statistics and quarantine are looked after in a very well-organized way. The department maintains an antitoxin laboratory and distributes a large amount every year. There is also a cancer laboratory. STATE DEPARTMENTS — BOARDS OF HEALTH 199 Systematic effort is made to train the many local health officers, and a circulating library is maintained for their use. The local boards over the state seem to be doing good work. The department issues a monthly bulletin and many circulars promoting popular sanitary education. (See the final section of Chapter XI for a discussion of the work in New York city.) North Carolina The business of the board is conducted from the office of the secretary in Raleigh. The quarantine regulations are brief, but seem to me to be well drawn, and the regulations concerning local boards are adequate. The state laboratory of hygiene is evidently doing a good work, and pro- vides facilities for the physicians of the state in the many directions under- taken by such laboratories. North Dakota The work of the state board of health is conducted from the office of the secretary, Dr. J. Grassick, Grand Forks. The revised statutes of the state apply to superintendents of county boards, health officers of cities, and town- ship supervisors. These men are responsible for the enforcement of a well- devised code of laws that includes school vaccination, the non-employment of tuberculous teachers, adequate quarantine, provisional quarantine in sus- picious cases, the regulation of milk supply, vital statistics reports, and reports twice weekly by attending physicians of the progress of infectious cases in their practice. The bureau of vital statistics is under a state registrar and many local deputies, and quite a complete code of laws and full reports guarantee a useful state work in this important division. There are twelve hundred local regis- trars and about seventy health officers in the state. The board publishes an excellent monthly bulletin. As illustrative of feeling in what the East regards as the West, an extract is given from its pages: North Dakota has now reached that stage in its development when it must take its place alongside of the older states in everything that pertains to its material pro- gress. It is no longer on the western border of civilization, but right in the center of the most enlightened section of our country. Its soil has been so productive that it has earned the title of " the breadbasket of the world." Its institutions of learning are turning out scholars that are winning laure's when pitted against the graduates of eastern schools. Our citizenship is of as high a grade, morally, intellectually, and physically as that of any sia. e in the Union; and it only remains for us to fill in some of the gaps to make us a model of statehood. One of the most important institutions of any state is that of the department of public health. In the conservation of the health of our people lies the chief factor for our economic and material progress. We have in a measure escaped some of the sanitary problems that confront older states, but we have now approached that stage in our development where they can no longer be overlooked. 200 HYGIENE O HIO The state board of health conducts its business through the office of the secretary at Columbus. An engineering division is maintained and good laboratory service is provided. The dairy and food commissioner has charge of the food problem and the laws he is charged to enforce are drawn along modern lines. The laws regarding nuisances might be copied to the advan- tage of some other states. Particularly commendable is the law prohibiting the reception of the tuberculous in county infirmaries or " poorhouses " and requiring either sepa- rate buildings to be erected upon the infirmary grounds or the erection of a separate institution by the commissioners of every county not otherwise pro- vided with a suitable tuberculosis hospital for the reception of charity cases. Proper provision is made for the organization of local boards of health and for the regulation of corporate sanitation. The board has widely circulated a very good series of circulars upon the various contagious diseases and has issued a very practical pamphlet upon " Disinfection and Disinfectants." Oklahoma The state commissioner of health has his office at Shawnee, from which is handled an adequate work along several lines, inclusive of food, dairy, and drug inspection, the regulation of hotels, etc. Indian Territory became a part of Oklahoma when that state was created, but the Indians are still largely under the control of the Department of the Interior. The report of the commissioner to the five civilized tribes to the Secretary of the Interior (1908) reveals that the m.aterial interests and edu- cation of the Indians is being much more fully looked after than is thought to be the case by some advocates of reform in the Indian service. The re- ports of the governor of Oklahoma show an efficiency in health work in the state, but that insane and other institutional buildings are needed. The last official map of Oklahoma shows the immense strides taken by this state during the last few years. Oregon The state board of health consists of seven physicians, one of whom is the state health officer. A bacteriologist is employed and the office is in Room 422, Marquam Building, Portland. The legislation is brief, but confers fairly full powers upon the board, which has issued rules covering quarantine, school vaccination, vital statistics, dairy inspection, and many other lines of state sanitation. The counties are organized and are under the state regulations. The board issues a bi-monthly bulletin of general interest. Pennsylvania The state department of health is housed in the state capitol building at Harrisburg, and has the most elaborate set of offices of any health board in the STATE DEPARTMENTS — BOARDS OF HEALTH 201 United States and probably the largest force of employees. The law under which it operates is the most far-reaching one ever enacted, and the legisla- ture has conferred very unusual powers upon the commissioner, who is probably the most powerful officer in the state. Section VHI reads: It shall be the duty of the commissioner of health to protect the health of the people of the state, and to determine and employ the most efficient and practical means for the prevention and suppression of disease. An order of the department has the effect of law, the agents of the de- partment have right of entry, and certain ones of arrest, and Section 16 of the law provides: Any person who violates any order or regulation of the department of health, or who resists or interferes with anyofficeror agent thereof in the performance of his duties .... shall be deemed guilty of a misdemeanor, and shall upon conviction thereof be punished by a fine of not more than ;^100, or by imprisonment not exceeding one month, or both." The department has absolute power over nuisances and can order munici- palities, local boards, corporations, physicians, and others to put its regula- tions into effect as: The commissioner of health is furthermore empowered to revoke or modify any order, regulation, by-law, or ordinance passed by any local board of health if he thinks it will work injury to the public health outside the territory over which the local board has control. He may also issue warrants to any sheriff, constable, or policeman for the arrest of those who disobey quarantine orders or the department's regulations, and he may subpoena witnesses. The commissioner's salary is ;^10,000 a year. The work is carried on under divisions of medical inspection, sanitary engineering, vital statistics, morbidity statistics, antitoxin distribution, and subsidiary organization. There is a very large office and clerical force, 1,153 local registrars, 730 health officers, 67 county medical inspectors, a varying but large force in the engineering work, 108 tuberculosis dispen- saries with staffs of physicians and nurses, a laboratory maintained at the Universityof Pennsylvania, and a total force aggregating over three thousand persons upon salaries or per-diem fees. The last legislature appropriated ^3,000,000 for the next two years' work, inclusive of antituberculosis hospitals, but not covering any work along pure- food lines, which is under the dairy and food commissioner, nor veterinary sanitation, which comes under the agricultural department. The law also imposes large expense upon city and other local boards. The engineering division of the department is the best in the United States. The division of vital statistics is highly elaborated and requires a great deal of physicians in practice in the state, but does not remunerate them for services involved. The reports expected cover a wide field, inclusive of malaria and all other infections, and the rules governing physicians are of a rigid character. Local boards are subsidiary to the state organization. The free distri- bution of antitoxin is upon a liberal scale and antituberculosis work is elab- orately organized. 202 HYGIENE There is an immense work to do in Pennsylvania, owing to the large foreign element in the population, and whole sections populated with a semi- Americanized class of persons densely ignorant so far as sanitation is con- cerned. In the past many local boards were mere political ornaments, and it is a big proposition to awaken the state to a sense of its dangers and its needs. In the larger cities a good work has been done for years past, and the new department of health has done little to modify their work except to require them to report to Harrisburg. Some very skilled men are employed by the department and a very aggressive work is being done under an organization differing radically from those of most other states. Time only will tell just what legal provisions will best suit state work, but Pennsylvania is tr}-ing an ambitious experiment, thus far with success. But it is very expensive and many states could not afford so large an outlay. Philippine Islands The bureau of health for the Philippine Islands is a model of organiza- tion, working under regulations more advanced than are those of most of the states in the Federal Union. Sanitation is made one of the first cares of the ?dministration, and the printed regulations kindly sent to me are too extensive to be detailed here. They are referred to in some of the chapters of this book. Medical, dental, and pharmaceutical practice are all regulated very rigidly; pharmacists being more restricted than in the states, although Chinese pharmacists may sell their wares to the Chinese. Especially to be commended is the admirable anti-opium law and the humane and sanitary administration of prisons. We have due occasion to be proud of the record being made by our federal sanitation of the tropics. The appended letter is self explanatory: The government of the Philippine Islands has established a bureau of health under the charge of a director of health, and all local health officers of the Philippine Island not only report to the bureau of health, but are directly subject to the orders of the director of health. Both the director of health and the assistant director of health are passed assistant surgeons of the United States Public Health and Marine Hospital Service. The bureau of health is one of the largest and most important bureaus of the government of the Philippine Islands and handles an annual appropriation of about ^700,000, United States currency. This does not include the local appropriations for health work, which amount to about ^100,000, United States currency for all purposes. There is maintained a bureau of science, which also deals largely with health matters, especially in the preparation of serums and vaccines, and in research work on its own account and for the bureau of health. I shall be pleased to assist you further in any way in which I can be of service. Very respectfully, Victor G. Heiser, Passed Assistant Surgeon, U. S. P. H. and M. H. S., Director of Health. Executive Bureau, Manila, P. I., April 26, 1909, to the Bureau of Insular Affairs. STATE DEPARTMENTS — BOARDS OF HEALTH 203 Puerto Rico Sanitation is under the charge of the United States Public Health and Marine Hospital Service, described in Chapter XH (q.v.). The work is in charge of Dr. M. H. Foster of the service, and is discussed in detail in various reports of the service. The principal problems to be met are maritime quar- antine and hookv^orm disease. Rhode Island This state maintains a good system of registration of vital statistics and, I am told, is manned by good men doing a good work. The secretary has favored me with the following account of the work: In reply to your inquiry concerning the work of the state board of health I will state that we have no circulars which explain all the work, but our line of investigai ion inc'udes the investigation of water and sewage supplies throughout the state; spring waters and ice supplies; the examination of diphtheria cultures; the free distribution of diphtheria antitoxin; examination of sputum and free distribution of spit cups for tuberculosis (the latter to the extent of fifty thousand last year); the education of people on the subject of tuberculosis by means of a tuberculosis exhibit, lectures, litera- ture, etc.; and the examination for Widal reaction. The advice in reference to water supplies and filtration works and general advice in reference to control of contagious diseases. Quarantine is maintained only slightly on the maritime division by the cities of Newport and Providence. Our foreign connections are very slight, being mostly the Cape Verde Islands. Yours truly, Gardner T. Swarts, Secretary. South Carolina The secretary and state health officer of the state board of health writes me that the laws governing the board are being codified, and that several im- portant acts have been recently passed, bringing their work up to date. The last compilation, 1901, I have examined, and the laws are a good founda- tion for an excellent code. The board is publishing an excellent series of pamphlets upon communicable disease, for general distribution. South Dakota The office of the superintendent and ex-officio secretary is at Tyndall, from which place the business of the state board of health is conducted. It would be unfair to enter into much detail with regard to the work of this board, since they are at work revising their rules. The rules and regulations published in May, 1908, are brief, but indicate that the board is well organized for necessary work. A noticeable feature of their rules is that a definite quarantine period is not set as to days or weeks. Sometimes I feel that such a 204 HYGIENE latitude as South Dakota allows is wise. For instance, I have under my care at present a very mild case of " scarlet rash " and desquamation was over remarkably soon and the child hardly ill at all. Yet the business place where the patient is must be quarantined for forty days, despite the fact that all danger is over before so long a period. On the other hand, I have had patients who should be quarantined for fifty days or more. The rules re- ferred to are here appended : Diphtheria — For the patient: Isolation for fourteen (14) days after recovery and disinfection of premises. For persons associated with or in the house with the patient: Quarantine until after death or recovery of the patient and disinfection of the premises. Scarlet Fever — Isolation of the patient and quarantine of children associated with or in the house with the patient for ten (10) days after complete desquamation or scaling of patient and disinfection of the premises. Smallpox — For the patient: Isolation until after all crusts or scales have fallen off and the disinfection of the premises. For exposed persons: Vaccination at once. Cholera and Yellow Fever — For the patient: Isolation until after complete recovery and disinfection of premises. For exposed persons: Quarantine for five (5) days from date of last exposure. Typhus Fever — For the patient: Isolation until after complete recovery and dis- infection of the premises. For exposed persons: Quarantine for twenty-one (21) days from the date of last exposure. Tennessee The motto of this state board of health is, " Public Health is Public Wealth," and yet there are few states with such wideawake health officials that appropriate so little of the public wealth for the public health. The biennial report of this board is one of the best published in the country and is an instructive volume of about five hundred pages, and yet the state appro- priation for two years' work was only ^21,800, and but ^12,510 was actually used, and that covered pure food work in addition. Pennsylvania appro- priates two hundred and forty times as much, and pays its commissioner a larger salary than the whole Tennessee appropriation. All I can say is, that I cannot see how Tennessee does it. " Sweet are the uses of adversity." As nearly as I can figure out the problem, Tennessee has a pretty sensible code of laws and makes the county and municipal boards of health attend to things and gives them the necessary power to enforce their orders even for a mile beyond the municipal limits. The state health officers seem to be self- sacrificing men, the pure food and drug inspector, for instance, using his own building and purchasing his own equipment for the work, and personally col- lecting and analyzing five hundred and seventeen samples collected from all over the state, and all on |! 1,9 50 expenditure for two years. The women's clubs, the schools, the railroads, and numerous organizations are carrying on an aggressive antituberculosis work. The watersheds of the state are being plotted, the public institutions are under sanitary inspection the water supply is being carefully supervised, every county is organized, the medical societies are active in sanitary work, schools are being looked after and the regulations of the state board are fully up to date. The state is a STATE DEPARTMENTS — BOARDS OF HEALTH 205 splendid instance of how much can be donewith little money when enthusiastic men are at work. I take off my hat to the Tennessee Board of Health. Texas The department of public health and vital statistics has its office at Austin. The last biennial report of the energetic state health officer shows that the work is divided into four departments, sanitation, vital statistics, pure food, and quarantine. Each branch seems to be very active and two hundred and eighteen of the two hundred and twenty-eight counties are organized as well as a large number of the two hundred and sixty-eight incorporated cities and towns. Some of the state departments in small eastern states would get a congested chill if they had so many counties to look after. Texas is a wonder- ful state and the department must look after the northern diseases as well as the tropical yellow fever through its " flying squadrons " that go gunning for the elusive mosquito in the south of the state and bury frozen cattle in the north. The department is doing a good thing in promoting a uniform muni- cipal sanitary code. The state follows the uniform maritime quarantine regulations of the gulf states, and has a good working arrangement with the Mexican health officials and the Public Health and Marine Hospital Service charged with maritime and border quarantine. The quarantine regulations and vital statistics reports are reasonable and, considering the size of the state, seem to be fairly effective. Many lines of work are being undertaken, but probably the most individual advance is the exceedingly good regulations governing the sanitation of public buildings, railway coaches, and sleeping cars. The Texas Anti-Tuberculosis Association is working in conjunction with the state department, and issues excellent folders for public instruction. Utah The Utah State Board of Health transacts its business from the office of the f ecretary and state registrar of vital statistics at Salt Lake City. The board has a revised edition of its health laws in press, but the edition of 1904 shows that Utah has a board organized along modern lines. Since that date, the legislature has provided for a very full registration of vital statistics much upon the Pennsylvania plan, the improvement of quarantine and disinfection rules, and the reporting of tuberculosis. The rules cover even gonorrhoea and syphilis, although they are not mandatory as to reporting them. The state laws require full county and municipal organization and specify many things, such as plumbing inspection, the abatement of specified nuisances, food in- spection, etc., that are required of local authorities. Nuisances are well defined, animal diseases are regulated, corporations are regulated, and many things done not found in the codes of older states. 206 HYGIENE Strange to isay, the legislature passed, over the governor's veto, " An act to prevent compulsory vaccination and to prevent vaccination being made a condition precedent to entering the public schools of Utah." Utah has a state chemist, a dairy and food commissioner under rules paralleling those of the federal statute, a state board of barbers v^ho enforce sanitation, and a rigid pharmacy law. Proprietors of drug stores are respon- sible for the quality and purity of all but package goods and the U. S. P. is the basis of purity. Substitution is punishable and the sale of poisons is strictly regulated. The board has issued some excellent circulars. Vermont It is quite a task to go through the literature supplied by the Vermont State Board of Health, as it is so voluminous. The offices are at Concord and an old state like this gradually develops the several lines of sanitation very much in detail. The regulations of this board are well tested and cover so much ground that we will refer to the work of this state in the several chapters rather than attempt to give details here. The state is well organized and the regulations are of a practical char- acter. The circulars upon contagious disease and the other public literature is excellent. The bulletin is issued quarterly and shows that the state labora- tory of hygiene is doing research and practical work of a high order and that the work of the state is well manned. Virginia Since July, 1908, Virginia has had a department of health under the guidance of a commissioner of health. In consequence, most of the laws and regulations are new and along modern lines. The board consists of twelve members and the commissioner must be a trained man. He has charge of the laboratory and public lectures and demonstrations, and is backed by fairly large appropriations and a good code of laws and regulations. In the counties, the medical societies recommend three physicians for health officers. The regulations under which local boards do their work are thoroughly up to date and embrace everything liable to be needed to enforce sanitary measures of all kinds. The execution of the pure food law is incumbent upon the dair}- and food commissioners of the department of agriculture and immigration. The pure food laws of the state are elaborate and the problems involved are studied much in detail. An aggressive campaign against tuberculosis is being waged and a state sanitarium is to be established. Diphtheria antitoxin is supplied at a very much reduced rate and standard fumigating outfits are supplied at cost. Laboratory examinations are made free of cost and a good work is being done. STATE DEPARTMENTS — BOARDS OF HEALTH 207 There is one great weakness and that is the lack of adequate provision for the collection and tabulation of vital statistics. The Virginia Health Bulletin, entered as second-class matter, is one of the best publications of its kind and employs an artist with a very vivid imagination, as witness the following reproductions: Tour Turn Nextf How High is the Wall in Tour Townt Washington The state board of health and bureau of vital statistics has offices at Seattle and is operating under brief but well-drawn laws, fortified by legal tests and opinions of the attorney general. The recently adjourned legislature 208 HYGIENE has added some very good features in the Hne of epidemiological work. The laws for county boards and the collection of vital statistics are the bases for excellent service in these directions. The bacteriological laboratory has been called to do a great deal of diagnostic work, especially as regards typhoid, diphtheria, and bubonic plague. Some interesting data are given in the last biennial report upon Kohlen-oxide gas fumigation and other means for dis- posing of infected rats. The sanitary engineer of the board is urging the absolute exclusion of sewage from the waterways of the state. West Virginia This state has the offices of its board at Wheeling and is organized for the usual lines of work, and its law provides for county and municipal organi- zations. The Hemisphere of Oub Health Work Wisconsin The state board of health and department of vital statistics is located at Madison. This board is organized to carry out the general purposes of state work, but emphasis is laid upon its functions as advisory to the local boards. In this it differs from some other boards that desire to centralize power in themselves and make the local boards quite subservient to them. In giving practical application to this basis of work, the local boards are unusually well organized and the regulations controlling them are so admirable that some space is given to them in Chapter XL The state board retains the right to promulgate rules that are binding in STATE DEPARTMENTS — BOARDS OF HEALTH 209 effect and have the force of law and make uniform the administration of local boards. The rules of quarantine and matters in general regulated by the sanitary authorities, are fairly rigid. A most excellent addition to the code was made in 1907, and provides that when a council fails to appoint a local board of health the state board will make such appointments and charge up the expense to the village, borough, or city. There are rigid rules as to tuber- cular cases in cars and conveyances and conductors on trains have the power of constables to enforce health regulations. A state laboratory is maintained, but accepts specimens only from health officers, and it does not undertake to make diagnoses except as may be needed in the work of public hygiene and sanitation. Wyoming The state board of health does not report anything except meager pro- visions for state medicine, but a private letter received from Cheyenne informs me that the secretary of the board has his work very much at heart. Conclusions Having reviewed the work of the states, it may not be amiss to draw some conclusions. The reader will have observed that we discussed the general features of state medicine upon the basis of the more recent forms of organi- zation such as that of Pennsylvania. This is not meant in disparagement of other states. In fact, one would be blind to many things were he to fail to recognize the fact that this more recent form of powerful organization is, as yet, in an experimental stage and may need modification. It may strike a Northern man as strange that the South was the first to recognize adequately the need for state quarantine. Yellow fever did that for the South and I well remember the time when Northern people were free with criticism of the South for the alleged cruelties of its quarantine regulations. In that day, the Southern states left the details of quarantine to the medical societies to a degree unheard of now, except as to the remnants of the old rules, still in force in some ofthe Southern states, Alabama being an example. It worked out fairly well, and I am not quite sure but that the medical profession and the medical societies are unduly neglected in the present administration of sani- tary affairs. The New England states are among the oldest as settlements and as state sanitarians, and I believe we have considerable to learn from them. A review of their literature gives one the impression that the laws there in force are well tried and fit the people well. The humanities are well worked out there and both the New England states and the Southern states seem to be more actually in contact with the masses of the people and their needs than are the states with a more modern code. As a matter of fact, some of these states issue literature more calculated to reach the people and be read by them than is that printed by some of the states with greater legal powers for their boards. Such states as Maine, Vermont, Virginia, and Louisiana issue ideal literature for public education along sanitary lines, and one cannot but feel 210 HYGIENE that they realize that it is difficult to effectively legislate ahead of public opinion. Candor compels the admission that one sees some strange contrasts in the South. I was down in a certain Southern state a few days ago and noted how particular they were to watch the " jim crow cars " and how filthy the white man's smoking cars were. Furthermore, the Northern passengers were the more offended by contact with colored persons. It also looked funny to see signs on every corner prohibiting expectoration when the streets and open gutters were a reeking abomination. Even in the District of Col- umbia, where the regulations are ideal, I have recently seen conditions that were far from ideal. But when I contrast Southern conditions of the present with what used to be there, I feel that they are making greater progress in sanitation than are some Northern towns and states I could name. The doctors in the South are a whole-souled set of good fellows and would not sub- mit to the starchy legislation of some of the Northern cities. The health officer soon learns that he must be a good fellow too, or there is a change of admin- istration. And, after all, a mere general practitioner like myself is a little inclined to the view that the Southern people do some things with a regard to human nature that is wise in the long run and that brings results. And it might also strike a Northern man as strange that the Southern boards have some splendid laboratories and are working out the scientific end of sanitation in a way some Northern states might very profitably copy. Some of our most talented investigators are in the South and it is to be noted that the therapeutic nihilist is " persona non grata " down there where they are apt to need real doctors and need them quickly. The doctor is really respected in Dixie Land. In Chapter XI, I took occasion to draw a contrast between the states of Indiana and Wisconsin as regards some of the legal phases of the work. Wisconsin and Michigan are states having advisory powers, and yet a modern form of organization. I know something about those states and particu- larly Michigan, There you will find the state board conducting one of the most effective lines of popular education in the United States. The Michigan bulletins are a model and the authorities realize that popular support is imperative, and it keeps the board keyed up to a sense of the due proportion of things. It would be manifestly unfair for me to criticise the work of any board with which I was not intimately familiar, and I am absolutely not in position to condemn the form of organization of the small coterie of boards claiming practically legislative functions, but one can see advantages in the other form, and I feel justified in directing attention to Wisconsin and Michi- gan as affording illustrations of the fact that it is not essential to vest large special powers in a state board of health to enable it to do a splendid work. In relation to this, permit me to call attention to the following from the Journal of the American Medical Association, May 1, 1909: THE WORK OF BOARDS OF HEALTH Dr. George A. Soper, in the Popular Science Monthly, March, 1909, considers the powers and relations of boards of health from a popular viewpoint. He notes the com- bination of legislative, executive, and, sometimes, judicial powers granted to such STATE DEPARTMENTS — BOARDS OF HEALTH 211 boards, and while admitting that extensive authority may have been necessary in the emergencies created by epidemic diseases, he questions whether it would not be wise, in view of the extension of the field of operation of health authorities, to limit their powers. Another anomaly in our system is that the highest health authority is the state to which the municipalities are related, but there is no national health board to correlate the action of the various states. The duties of boards of health may be defined as the collection of vital statistics, the suppression of communicable diseases, the abatement of nuisances, and the edu- cation of the people in health matters. It may properly be asked what are to be con- sidered nuisances. There is danger that the health board may occupy itself with in- conveniences of a semi-esthetic nature to the neglect of matters of more serious im- portance in relation to health. Dr. Soper says: " There is something incongruous about a board of health conducting a crusade against smoke and noise, and at the same time allowing the streets to be filthy with dirt and dust and offensive with accumulations of fermenting garbage. Again, a great deal of the attention of health boards is occupied with alleged private nuisances which affect comfort, but not health. The history of every city is a record of more and more strict regulations to minimize the unpleasant as well as the insanitary conditions of household life." In the sanitary education of the public the important aid given by the press is recognized, but it is to be regretted that the opportunities for systematic school instruc- tion on these subjects are still to a large extent lacking. " In the campaign of sanitary education which is going on it is a deplorable fact that the universities and colleges of the United States are singularly backward. With a few notable exceptions, there is scarcely a school for higher education in the United States where a competent knowl- edge of hygiene can be obtained. In spite of the fact that many of the largest and most prominent universities have had severe experiences with typhoid, they have been exceedingly slow in providing proper facilities for the teaching of hygiene. One of the greatest needs of to-day is the want of competent teaching for health officers, physi- cians, engineers, and others who may wish to obtain a complete and practical knowl- edge of their profession. In the absence of suitable facilities for the education of health officers the United States is decidedly behind European countries." The propriety of the extension of the activity of health boards into the realm of esthetics may be questioned, but they have been granted ample power. The standards of public health and municipal hygiene are continually growing higher. " First and foremost among the defects and needs of public health administration," says Soper, " must be placed the want of adequate knowledge of the principles and practices of public health work on the part of officials having jurisdiction. It is a deplorable fact that special professional qualifications are not as a rule required of health officers in the United States. " If there is any department of municipal government that should be taken out of politics and put on a high plane of professional efficiency it is public health work. Generally in the United States appointment on a public health board means a thank- less and gratuitous service performed for the sake of the small honor which is supposed to go with it. Where a salary is connected with the position the office is too often a reward of political work rather than of professional merit. Dr. Soper is slightly in error, as Cornell, Pennsylvania, and Michigan Universities give such a training as he commends, and I have heard that some other institutions do so as well. In general, he raises some questions worthy of consideration. His statement as to politics dominating health boards is 212 HYGIENE rather sweeping, but true of many of them, and especially of local boards. We will discuss that later, but first want to state a side he failed to touch upon and that the physicians of the land are apt to forget. And that raises the whole question as regards boards with large powers (" legislative, executive, and sometimes judicial ") and as are instanced in Indiana and Pennsylvania. While it is remarkable that the United States government has lived and expanded so well under a constitution adopted away back in 1787, and but slightly amended since, yet the fact remains that many good citizens have felt that the federal power is too limited to ade- quately meet the exigencies of modern governmental communication and treaty obligations as well as to provide for certain common necessities as re- gards traffic between the states and other domestic questions growing out of modern conditions. As it is brought home to us doctors, we must realize that there would be no federal government unless it had been preceded by several sovereign states finding such a governmental clearing house necessary. Even so, there can be no federal department of health without the demand for it by organizations within the states needing it for a common ground of union and exchange. The very fact that there is not a federal power adequate to the accomplishment of the work of national sanitation has made it necessary for the states to initiate functions that, judicially considered, do not really be- long to the individual states. Naturally, the states arrived at differing conclusions and devised varying plans. And it is well that they did so even as it is well that they put into effect differing divorce laws. It is better to try an experiment with one state than with the whole nation. As it is, all kinds of health organizations have been tried out in practice and Invaluable data is collecting to assist the federal power to wisely initiate a national work in due time. Indiana and Pennsyl- vania are trying the plan of a centralized board. Naturally, the Indiana and Pennsylvania officials are delighted with the success they have achieved, but the fact remains that no certain judicial basis yet exists for regarding this plan as ideal for the whole United States nor yet even for Indiana and Pennsylvania. That it is a harmonious and rational plan cannot admit of doubt, but that it is exactly adapted to the genius of all forms of American law and American government cannot be determined until after it is under fire and passes the scrutiny of American courts and proves itself acceptable to the American people and, may I add, the rank and file of the American med- ical profession. It is an exceedingly difficult matter to make any law flexible enough to cover the extremes of condition demanded by insanitary conditions. From a widespread pestilence, constituting a national disaster, to the regulation of little matters of petty detail in sanitation, is a long stretch for any law to cover. When the nation is not in position to step in and do the things for which a trained force may be necessary any hour, it is imperative that the states delegate to some one the authority to meet the emergency. But a legislature cannot pass a law giving a certain authority one day and with- holding it the next day. Consequently, in order to be ready, some of the MICHIGAN LABORATORY OF HYGIENE MEDICAL MISSIONARY WORK IN THE TROPICS STATE DEPARTMENTS — BOARDS OF HEALTH 213 boards have powers necessary in time of peril, but that might become op- pressive under other circumstances. In the federal government there are the co-ordinate branches of legisla- tive, executive, and judiciary. In time of emergency the executive officer (the president) may fill in the breach until Congress can meet or until the courts can pass upon the matter. In the absence of emergency he v^ould run the risk of impeachment if he undertook to exceed the necessary authority. Apply this same reasoning to state boards of health, and it is not difficult to draw some conclusions that are applicable to the case in hand. While these objections to a centralized board may be considered as academic, the plan of meeting objection by making the governor and the attorney general consulting members of the board or securing their sanction to measures, is also academic. Many able publicists consider it as unsafe to get far away from the authority of the courts in anything, and they claim that the courts are the greatest conservators of our liberties. W hile that may all be true enough, yet we know that courts are very finite indeed and look quite as ridiculous to doctors sometimes as the doctors look to the learned court. Neither understands the other and the plan of placing sanitary measures under the review of the court would result in a large mortality before anything was done. The law, as administered by our sluggish courts, is utterly inadequate to meet the sanitary necesssities of the twentieth century. Consequently, something had to be done and the most natural thing to do was to do just what the government has done in constructing the Panama Canal, turn from the civilian to the soldier. That is just what has happened in sanitation. It is in the armies and navies that many of these questions have been worked out and the most effective federal work is that done by the Public Health and Marine Hospital Service. Next to it, comes the surgeon general's office, and it impresses me that food and drug work and other lines of federal sanitation will ultimately be under a semi-military regime. It is almost neces- sary that it should be so and we may just as well face that fact now as after awhile. Despite any objections we may urge and whether we like it or no, the signs of the times are that a disciplined sanitary service absolutely divorced from politics must be maintained by every respectable government. If the civil code does not provide for it, so much the worse for the civil code and musty legal precedent. The medical profession is getting rid of empiricism and convention and if the American legal profession does not wake up to the times and follow the example, so that necessary legal decisions can be reached vastly quicker than they are to-day, the great twentieth century will roll on without consulting them very much and find a new wa} of doing things. The sanitarians have already found it and the new way is here to stay. This is not said to detract from the courts, but the courts are too slow to meet the emergencies of epi- demics and other sanitary problems. When a federal department of health get under headway and after it has shaken off the barnacles of bureau poli- ticians that will hedge it about at first, it is likely that the objections to the 214 HYGIENE centralized form of state department will be removed and the powers of the boards will be limited and their plans and administration harmonized. Meanwhile, we must be patient. It is probably true enough, as Dr. Soper intimated, that the centralized boards are given too much power. But the practical fact remains that state sanitation was in so bad a way throughout most of the states that something radical was imperative, and we must not view the question in the light of old English legal precedent and quibble over trifles in the face of death and disease. I do not pretend to be a lawyer, but I have talked with many of them over this matter, and have yet to find one that can view the question in the larger aspects demanded. I have no doubt there are many such men in the profession and the sanitarians will align themselves with them and the very involved questions of sanitary administra- tion will be well worked out. Meanwhile, let no state or no board conclude it has the only right and proper plan. Furthermore, it becomes state health officials to be a little modest in the routine use of power conferred upon them, for the sole purpose of meeting emergencies for the public good. Undue display of power simply aids the adversaries of sanitation. As things are at present, boards like those of Indiana and Pennsylvania have taken pretty advanced ground, and possibly their position may not be wholly tenable. On the other hand, it would not seem to be wise to take away their power to act in emergency. They might be more advisory in their functions as regards their relations with counties and municipalities and be more subject to legal review. Certainly, they have been doing a good work, and any criticism attaching to the plan under which they operate has very little force when applied to what they have actually done, and that is the record by which they stand or fall. Western legislatures seem to be in a hurry to get through with sanitary legislation, but exceedingly willing to do those tangible things required for adequate quarantine and public instruction. The campaigns of education and the codes of law in the Western states are up to date, but there is a little neglect of such matters as are found in the older states so far as relates to factory inspection, industrial sanitation, and what may be called the humani- ties. This will correct itself and all that is needed is simple addition to their already excellent laws. I cannot but admire the Western horror of slums and outside of a few of the larger cities, one finds few slums in the West. Here in the East, hosts of towns where land is cheap have abominable alleys teeming with shanties, wretchedly poor people and tuberculosis. There is no excuse except that of greed for such conditions. An up to date Western town seldom allows such conditions and the West is right. People live more outdoors in the West and build better houses, placed further apart than does the average Eastern town. Consequently, sanitation is a somewhat easier task, except in the foreign colonies not yet Americanized. An examination of the litera- ture of the Western boards convinces the reader that the West is doing a thoroughly efficient work in public sanitation. As to Dr. Soper's charge that politics is too much of a factor, my obser- vation is that the higher officials in health administration are as clean and altruistic a body of men as one will find anywhere and are a credit to the STATE DEPARTMENTS — BOARDS OF HEALTH 215 country. Unfortunately, state boards of health are obliged to go to legis- latures and the political powers that be for the necessary appropriations. It is unnecessary to enter into details, but the end result is that many subsidiary appointments are dominated by the more or less creditable politician. It is unfair to charge this against the state boards, for I am quite assured that no body of men are more opposed to political meddling than are the health offi- cials of the states. As a matter of fact, they seldom have any voice in the appointment of local boards. As to political conditions in city and tov^nship and other local boards, the general practitioner of medicine is in position to judge for himself and I do not care to discuss it here except to say that condi- tions are improving. There is one unfortunate condition that should be corrected. Profes- sional sanitarians gravitate so easily into a class feeling and take an attitude apart from their fellows in practice, while the latter class are just as apt to regard the former with a certain degree of suspicion and distrust. This is absolutely unwarranted upon both sides. In collecting data for this book, I have been surprised to find how little the state boards knew about each other and how little real knowledge of their work exists among the officials in Wash- ington. We need to get acquainted with each other and inaugurate a " get together campaign " for the good of all concerned. Finally, after my investigations of state boards, I can truthfully say that I am proud of my country and of the grand work being done by so many states, north, east, south, and west, under the twining flags, " old glory " and the red cross. Chapter X A PROPOSED FEDERAL BUREAU OF HEALTH* What the Government at Washington is now doing — What it might do — What such a bureau or department of health might do for the general good of medicine and sanitation — The importance of international hygiene as shown in Cuba and the Canal Zone — The Army and Navy and public health — The hygiene of interstate and international commerce. THE health of our people is now recognized to be largely a responsibility of the municipality, state, or nation, the individual is so often powerless to protect himself against his neighbors and his environments. Ever}'- body'shealth is nobody's business. The question of the preservation of public health has become each year more important. The length of life is increasing wherever sanitary science and preventive medicine are applied. Thisis illus- trated by the case in India, where nothing is done and the average has not increased above twenty-three and a half years, and in Prussia the home of preventive medicine where the average life is forty-seven and is still lengthen- ing. " From data collected it is found that fifteen years at least could be at once added to the average human life by applying the science of preventing disease. More than half of this additional life would come from the pre- vention of tuberculosis, typhoid fever, and five other diseases, the prevention of which could be accomplished by pure air, pure water, and pure milk." As a nation we have no comprehensive health organization. No mem- ber of the Cabinet of the President of the United States has any direct respon- sibility for the health and life of our people, which is so much more important than mere property interests. " The health of our pigs has representation in the Cabinet, but not our children." Our only federal guardianship is vested in the United States Public Health and Marine Hospital Service, under the control of the Treasury Department. What particular interest the Treas- ury Department can have in the public health is hard to conceive. What we need is a national bureau of health. We are the only great civilized nation without such a department. Several branches of the government have to do more or less with matters of public health, and are doing excellent work. The Department of Agriculture must pass judgment on foods, drugs, and medicine. The Bureau of Vital Statistics is under the Department of Com- merce and Labor. The Public Health and Marine Hospital Serv'ice is under the Secretary of the Treasury, who is the chief medical officer of the United States. The Department of Interior has charge of the National Elemosy- nary Institutions, all of them public health agencies. They are all doing good work, but they are inadequate, scattered, and unorganized, and in that degree are inefficient. The movement abroad now is to take the several bureaus, exercising health functions that are now scattered through the Treasury, Interior, and Agriculture Departments, and centralize them all in one department of *By J. B. McAlister, A.M., M.D. PROPOSED FEDERAL BUREAU OF HEALTH 217 health, which would be of service worthy of the nation. There is a wide- spread and growing movement throughout the United States for the creation of this new department. The campaign for the establishment of a national bureau of public health has been carried on by the Committee of One Hundred of the American Association for the Advancement of Science, and recom- mended by the American Medical Association as long ago as 1871; and at intervals during the succeeding years it has been a live subject before this asso- ciation. At present the movement seems to be making towards success. First the Ohio republican platform of 1908, and later the platform of both parties in the national campaign declared for a national public health department. President Taft in his message at the opening of Congress, December 7, 1909, says, " There seems to be no reason why all the bureaus and offices in the general government, which have to do with the public health or the subjects akin thereto should not be united in a bureau to be called the Bureau of Public Health." In a recent speech. President Taft also says: " How near this movement will come to accomplishing the complete purpose of its promoters only the national health can tell. Certainly the economy of the union of all health agencies of the national government in one bureau or department is wise." Former President Roosevelt gave this movement his cordial support. Professor Russel H. Chittenden, who strongly supports the movement, says, "The purpose of our movement is of course not merely the establishment of a national bureau of health. That step itself is merely a means to an end. The end is the elevation of the health of the American people." Such a department of health at Washington, with the power and wealth of the government back of it, with laboratories the equal of any in the world, and with a corps of research workers, the peers of any in the world, engaged continually in searching out the cause and prevention of disease, would make it equal to any function of the government. There would be a bureau of vital statistics, which in this country is an infant science. Yet it is the very basis of any attempt to better the general health. It would gather data as to the location and cause of all sickness and every death in the United States, and would tabulate and disseminate the knowledge thus obtained with a view of preventing other sickness and death. Only fifteen states, representing forty-eight per cent of our population, records all deaths and forbids burial without a legal permit giving the cause of death and other details. In some states there is no such thing as general registration of births, school attendance, factory employment, etc. " It is curious to note that Uruguay in its official report of statistics regrets its inability to draw satisfactory conclusions from the United States of America, because the nation has not yet attained to any scientific method of treating the subject." A national department of health could remove this reproach, and without accurately compiled statistics sani- tary calculations will be mere guesswork. With such a department preventive diseases could be still further pre- vented to the incalculable benefit of the people. Suppose the power of the government was exerted to check the ravages of tuberculosis in the United States. One hundred and fifty thousand persons die annually of tuberculosis, 218 HYGIENE three fourths of which could be avoided. The movement against this disease is now world wide in extent, by private societies and municipalities, and a few state governments; but with the guide of the government, in a campaign of education and sanitation, who can imagine the results that would accrue ? Now, consider the poison in water supplies, and the prevalence of typhoid fever, due to the almost total lack of sanitary supervision over streams that are sources of water supplies. Even though certain states do their duty many streams are interstate in their course, making the pollution of the stream a national problem. Of what avail to police one side of a stream if you do not control both sides and the source as well. Lake Champlain, for instance, is protected on the New York side and contaminated on the Vermont shore. It took an epidemic of typhoid fever to teach Ithaca and Scranton that they must not drink filth. Any state can prohibit the pollution of water sup- plies in its borders, but cannot prevent other states emptying its sewerage into streams which may be a water supply in another state. The indifference of our people to the pollution of our rivers has made it urgent that their supervision should be the duty of a federal department of health. The national government should enact suitable legislation providing against pollution of the interstate streams. The federal government should provide for more investigation in health matters and the education of the public concerning preventable disease. If diseases are preventable, why are they not prevented ? Some one has said, " For every death from typhoid fever, some one should be hung." So the public should be aroused to hold public health officials responsible for health conditions. A federal health bureau could co-operate with state and muni- cipal authorities in checking epidemics, in the enforcement of pure food laws and meat inspection; the education of the people in both public and private hygiene; encourage medical investigation and establish a national medical practice act to raise the standard of medicine to the welfare of the people; and improve the efficiency of our state and national health services. " A poultry raiser or a cattleman or a farmer can secure scientific information to guide him in his selection of fowl or stock or seed, by applying to the government at Washington; but information on how to raise children has up to this time been neglected by our government." We have three bodies in the national line of defense against disease, the Public Health and Marine Hospital Service, the Medical Corps of the Army and Navy. The first protects our quarantines, excludes emigrants with infectious disease, and assists in epidemics when called upon. It assisted New Orleans to eliminate yellow fever and San Francisco to rid itself of the bubonic plague. Each year it treats fifty thousand seamen, and maintains a large number of hospital relief stations and conducts a well-equipped hygienic laboratory. The work of the army medical corps in our insular possessions and in the Canal Zone is only an example of the efficiency of a national bureau, with the power of the government back of it. The sanitary reforms introduced into Cuba stand out as noble monuments to the American Medical Corps. In Havana, the hotbed of insanitary conditions, with yellow fever epidemic for PROPOSED FEDERAL BUREAU OF HEALTH 219 two centuries, the introduction of modern sanitary measures reduced the death rate of disease, except yellow fever. General sanitary measures had no effect upon yellow fever until acting upon the theory that the stegomyia mos- quito was the only means of transmitting yellow fever and measures were taken for the destruction of the mosquito was yellow fever eradicated. When the American army took charge of the health department of Havana the death rate was 21,223 per year. When it relinquished authority the death rate was 5,720 per year. Smallpox occurring epidemic annually is now as rare as in an American city. The army stamped out yellow fever in its greatest stronghold and has demonstrated a system by which yellow fever can certainly be con- trolled without interference to commerce and untold financial loss to both Havana and the United States, as formerly. "It has been estimated that the yellow fever epidemic of 1878 invaded 132 towns, caused a mortality of 15,954 persons, and that the pecuniary loss in this country was not less than ^100,- 000,000 in gold.— Dr. Walter Wyman." The work of sanitation in the Canal Zone is equally brilliant. The efficient work of Colonel Gorgas has rendered the isthmus a safe place of habi- tation. The yellow fever has been effectually stamped out and malaria reduced to a minimum. Health conditions compare favorably to those which obtain in this country, among a similar body of men, and the death rate among the women and children of the families of these men about the same as in this country. Careful hygiene and systematic sanitation as enforced by our army has stripped the once greatly dreaded isthmus of Panama of its terrors and rendered it perfectly safe for residence and occupation. It is as much the function of the national government to protect its people from disease as from foreign invasion or criminals. " It is bad economy to leave this work mainly to the weak and spasmodic efforts of charity or to the philanthropy of the physicians." The national government should exercise at least three public health functions: First, investigation; second, dissemination of information; third, administration. It should remove the reproach that more pains are taken to protect the health of our cattle than of human beings. It should provide more and greater laboratories for research in preventive medicine and public hygiene. Provision should also be made for better and more universal vital statistics, without which it is impossible to know the exact condition in epidemics or, in general, the sanitary or insanitary conditions in any part of the country. It should aim, as should state and municipal legislation, to procure adequate registration of births, statistics of which are at present lacking throughout the United States. The national government should prevent transportation of disease from state to state in the same way as it now provides for quarantine and the protection of the nation from importation of disease by foreign emigrants. It should provide for the dissemination of information in regard to the prevention of tuberculosis and other diseases, the dangers of impure air, impure foods, impure milk, imperfect sanitation, ventilation, etc., just as now the Department of Agriculture supplies specific information to the farmer in respect to raising crops or live stock, so should one of the departments devoted principally to health and education be able to provide every health officer, school teacher, employer, physician, and private family with specific information in regard to public, domestic, and personal hygiene. 220 HYGIENE People in this country are going to have such a department of health. It is closest to the happiness and prosperity of the people, and when the public is once educated to the capabilities of modern sanitation and that the warfare against disease, like the warfare against a human foe, can best be conducted by the general government' they will wonder that this country has so long deferred this important department. Bibliography, Medical Sociology, Warbasse. Military Surgeon, November, 1908, Rucker. Report on National Vitality, July, 1909. Chapter XI LOCAL BOARDS OF HEALTH, COUNTY, AND SANITARY OFFICERS Introductory remarks — The maze of laws and regulations with reference to them — Their duties — The necessity of informing oneself regarding local regula- tions — The relationship that should exist between these officials and the physician — The mistake of shifting all local sanitation away from local to state authorities — City bacteriologists and chemists and their usefulness to the physician and public — The separate problems of cities, /NTRODUCTORT REMARKS. It has been claimed that in general society the " upper crust " and the " lower crust " are those most subject to criticism. Certainly in sanitation the upper crust of federal aid is nearly absent, since there is no United States department of health, as is ad- vocated in the chapter immediately preceding this one, and the lower crust has to do with the subject of our present study. Between these two but imperfectly worked out factors in sanitation stand the splendidly organized state boards of health. It is strange that above and below the state organiza- tions in the nation on the one hand, and in the smaller units of our government on the other, lie the weak points in public hygiene. Our republican form of government is partly responsible for this condition, and what I will call bene- volent centralization will alone cure this ill of the body politico-sanitary. By benevolent centralization is meant such construction of the Constitu- tion and the statutes as will permit such desirable reforms as uniform divorce laws, uniform pure-food laws, uniform registration of physicians, uniform excise laws, uniform regulations as regards interstate carriers and waterways, and of such other matters as are of interest to the whole people. In order to bring this about, it is necessary for the federal government to define some standard, as it has in the matter of pure food and drugs, and then for the sovereign states to legislate according to the scheme outlined. As regards local boards of health and the medical and other sanitary officers appointed by them, it may be said that it requires a certain degree of training to produce an efficient sanitary officer of any grade, and an efficient administration of affairs to render his work effective to the betterment of conditions. It is quite natural that the older cities and states should have established sanitary regulations under bureaus still doing effective work, and it is to be expected that the authorities will be very slow in changing satisfactory con- ditions. Before the states organized boards or departments of health, many of the cities had efficient organizations duly operating under state or city charters. It would probably be unwise for the state to interfere too much with the work of such local boards. And yet, notwithstanding the fact that the city of New Orleans and the state of Louisiana maintained for many years a well-equipped Mississippi River quarantine station, an unbroken line of United States Supreme Court decisions affirming the right of a state to main- 222 HYGIENE tain quarantine as a part of the police powers guaranteed the separate states by the federal Constitution and incidentally to collect quarantine inspection fees; that the statutes of the state give the state board exclusive control of maritime quarantine, and several other legal factors unnecessar)' for our argu- ment, yet the Mallory-Williams bill passed by Congress resulted in the state selling to the United States Public Health and Marine Hospital Service the existing plants and abdicating to the service a large part of the work and privi- leges previously done so well by the state. The sale was in the line of progress and uniformity in the matter of gulf-states maritime quarantine. If Loui- siana submitted to this matter and yielded her manifest legal rights, other states can as well afford to emulate her example. Furthermore, counties and municipalities can afford to yield local regulations for the benefits of uniform- ity with other counties and municipalities. The end result of this sort of thing will be beneficial and tend toward the improvement of the service. Were I to give here the regulations of all of the states bearing upon local health officials, this chapter would be extended beyond all limits; but it may be profitable to select a few widely separated states and partially define their regulations. This will help us to reach some just conclusion as to the proper method of organization and of administration of local boards of health. The statutes of Connecticut provide that: " The judges of the superior court shall appoint for each county a health officer. The person so appointed shall be an attorney at law, residing in the county for which he shall be appointed." The statute outlines his duties and confers upon him the proper powers inclusive of those of a grand juror and a prosecuting officer. This county officer appoints town health officers who must be learned in medicine and sanitary science. The regulations adopted by the towns must be approved by the state board of health. Cities and boroughs have health officers appointed by the mayors and wardens, and confirmed by councils. Circular 110 of the New Jersey State Board of Health, says, quoting the law: (Approved April 8, 1903 — P. L. 1903, p. 453.) 1. To the end that local boards of health may be enabled to secure the services of capable health officers and trained sanitary inspectors, the board of health of the state of New Jersey is hereby authorized to cause examinations to be made by such persons, and at such times and places as it may appoint, and under such rules and regulations as it may adopt, for the purpose of determining the qualifications of appli- cants for license as health officers and sanitary inspectors; every such examination shall be in such subjects and conducted in such manner as the board of health of the state of New Jersey shall direct, and every applicant whose examination shall be ap- proved by said state board shall receive a license as health officer or sanitary inspector as hereinafter provided. 2. Said state board shall issue four classes of licenses, to wit, health officers' licenses, sanitary inspectors' licenses of the first class, sanitary inspectors' licenses of the second class, and sanitary inspectors' licenses of the third class; every person whose examination as an applicant for a health officers' license is approved shall be entitled to receive such license, and every person whose examination as an applicant BOARDS OF HEALTH AND SANITARY OFFICERS 223 for a sanitary inspectors' license of the first class, the second class, or the third class, is approved shall be entitled to receive a sanitary inspectors' license of the first class, the second class, or the third class, according to the approval of his examination. 3. Any person licensed as a health officer shall be eligible to appointment as such oflGcer by any local board of health in this state, and when so appointed shall, during the term of his appointment, and subject to the superior authority of such local board, be its general agent for the enforcement of its ordinances and the sanitary laws of this state within the territorial jurisdiction of such local board. 4. Any person licensed as a sanitary inspector of the first class shall be eligible to appointment as such inspector by any local board of health in this state; any person licensed as a sanitary inspector of the second class shall be eligible to appointment as such inspector by any local board of health in any municipality in this state, not being a city; any person licensed as a sanitary inspector of the third class shall be eligible to appointment as such inspector by any local board of health in any township of this state; the title " sanitary inspector," as used in this act, shall be understood to apply to every officer appointed by a local board of health to aid in the enforcement of the sanitary laws of this state, or the rules, regulations, and ordinances of such local board, excepting health officers and persons performing merely clerical duties in the office of such local board; any sanitary inspector so appointed shall be the agent of the local board appointing him for the performance of such services as such local board, or any health officer under the authority of such local board shall assign unto him. 5. No local board of health shall, on or after the first day of January, nineteen hundred and five, appoint any person as health officer who is not the holder of a health officers' license granted as in this act above prescribed, or as sanitary inspector, who is not the holder of a sanitary inspectors' license of the class hereinabove prescribed for the municipality or township within which the appointing local board shall have jurisdiction; provided, however, that nothing in this act shall prevent any local board of health from continuing in office any person now filling the office of health officer or sanitary inspector for such local board. There are about four hundred and seventy sanitary districts in the state and many of them have not conformed to the law, but the number is increasing as capable inspectors are found. Local boards are general throughout the state, and the tendency, under the guidance of the active state board, is to place local sanitation in skilled hands. The District of Columbia has abolished the board of health, and in Sec- tion 9 of the laws and regulations provides that the commissioners of the district may employ a health officer and skilled inspectors. And, as more fully described in Chapter IX, the system works out excellently. From my limited observation in Washington, I am impressed with the manifest advan- tages of employing local officials who are skilled in the legal, medical, chemi- cal, and engineering features of sanitation. In Kentucky it is the duty of the state board of health to appoint three physicians in each county, who, together with the county judge and one per- son elected by the fiscal court of each county, shall constitute a local or county board of health. They have power to appoint health officers and do all the acts devolving upon such officers. Cities and boroughs delegate the appoint- ments to councils. The Indiana State Board of Health is illustrative of a class of energetic boards not very sharply limited by legislation as to details. The attorney 224 HYGIENE general of the state says: " The rules established by the state board of health have the force of statutes, and a law authorizing their adoption is constitu- tional." Under such powers the county boards are regulated very distinctly by the executive officers of the state board, and the county health officer is really an employee of the state board. The city, borough, and township officers are responsible to the state board, and the numerous deputies appointed are used to help the work of an elaborate and complicated mechanism of a rather militant but certainly effective character. Before discussing this matter, permit me to refer to the state board of health of Wisconsin. This board has issued a pamphlet upon " The Powers and Duties of Local Boards of Health." From it I clip the following: FUNCTIONS OF THE STATE BOARD OF HEALTH It is frequently understood that the state board of health has greater powers than the law provides. In a decision of the supreme court of this state, wherein the power to make rules relating to vaccination was considered invalid, the court said: "The state board of health is a creation of the statute, and has only such powers as the statute confers. It has no common law powers. .... The powers of the state board of health, though quite general in terms, must be held to be limited to the enforcement of some, statute relating to some particular condition or emergency in respect to public health; and, although they are to be fairly and liberally construed, yet the statute does not, either expressly or by fair implication, authorize the board to enact a rule or regulation which would have the force of a law changing the statute in relation to the admission and the right of pupils of a proper school age to attend the public schools. The state board of health has no legislative power properly so called, and none could be delegated to it. It is purely an administrative body It cannot be doubted but that under proper general provisions of law in relation to the prevention and suppres- sion of dangerous contagious diseases, authority may be conferred by the legislature upon the state board of health, or local boards, to make reasonable rules and regula- tions for the carrying into effect such general provisions which will be valid and may be enforced accordingly. The making of such rules and regulations is an admin- istrative function, and not a legislative power As to the matter of inspections authorized by Section 1409b (S. & B. A. S.) to ascertain the presence of the intro- duction of Asiatic cholera, or other dangerous and contagious diseases, and the power conferred upon the inspector to enter any building, vessel, railway car, etc., as well as the quarantine authorized by Section 1409b (S. & B. A. S.), the power of the state board of health to make proper rules and regulations to effectuate the general purposes thus declared would seem to be free from doubt." It would appear by this decision that the state board of health can make rules and regulations pertaining to the carrying into effect of any law passed by the legislature. It also has general powers pertaining to quarantine in the state, but other than this its principal functions are advisoiy to local boards of health and local authorities. It is the function of the state board of health to see that all local boards of health are duly and legally organized, and that the health officers of those boards make proper reports and returns to the state board of health. It is also incumbent upon the state board to investigate any outbreaks of contagious diseases in the state; and, when requested, or when it is deemed advisable, to investigate the sanitary conditions of pubHc buildings, sewerage disposal, water supplies, and to advise local authorities relative to the sanitary construction and management of the same; also to study the vital statistics of the state BOARDS OF HEALTH AND SANITARY OFFICERS 225 as far as possible, and to publish and issue such information to the public as in the judgment of the board seems proper and necessary for the best interests and welfare of the public health. Here are two very different types of board, and it is a question in my mind as to which is the better system. I have observed the working out of both forms of administration. The Indiana plan works smoothly after a time, but not at first. Centralizing power is certain to offend some of the local men whose wings are clipped. There is also a tendency (in some states) to take the matter into politics and to load up the state with a lot of worse than worth- less appointments and to employ an army of unnecessary clerks urged by the political coterie. Also friction and jealousies arise and foolish things are done by parties feeling aggrieved and by young and inexperienced officers who feel their prerogative and are readily ruffled by trifles. After a time, provided the executive officer is tactful and is politically clean, the incompetent men are weeded out of the service, the field personelle " team work " improves, the profession comes to recognize the valuable service being rendered, the fossilized old " boards " give way to real sanita- rians, and the general public apprehends what the state board is trying to do. It is doubtless true that the ultimate form of sanitary administration will be largely along these lines, but with the state boards secondary to the federal one and the local boards uniform and vastly more effective than they are at present. On the other hand, the Wisconsin plan has an element of safety, even though it may be less efficient. What is called " government by commission " is rapidly becoming a nuisance. We have about thirty-five commissions in Pennsylvania all helping our legislature and courts to be lazy, and all costing the state a lot of money. It is not always safe to limit the judiciary and the legislative bodies by delegating their powers to commissions or even to health authorities. It may work excellently with the health authorities so long as good and upright men hold the power, but we have no guarantee that the other type may never hold the office. Legislatures may readily empower state boards to do all that is done in Indiana, and the orders of the board are legal and its powers very great, but only the future will determine whether or no it is wise for a legislature to do so, or if it would be better for the board to be subject to regular supervision by the courts and to possess no inherent common law powers. No one individual can pass adequate judgment upon this matter, but it impresses me that the issue will result in a form of compromise method. Meanwhile, it is incum- bent upon the profession and the public to obey the laws as they are. As the issue influences local boards, there is a great tendency in human nature to value individual privilege, and local boards may feel aggrieved when some one is set over them. But the fact that they value their privileges is no guarantee at all that they will attend to their work. Most local boards need a boss. The whole question must be looked at from the standpoint of public policy, and if somewhat rigid methods get trained sanitary service for the public, the profession must put up with inconveniences. In the long run, capable local boards will be given all authority they need. 226 HYGIENE Wisconsin provides for local organization as follows : ORGANIZATION OF LOCAL BOARDS OF HEALTH Chapter 57, laws of 1898, hoards of health, their officers, powers^ and duties. Sec- tion 1411: The town board, village board, and common council of every town, village, and city shall, within thirty days after each annual election, organize as a board of health, or appoint wholly or partially from its own members, a suitable number of competent persons who shall organize as a board of health for such town, village, or city. The officers of such board shall include a chairman, a clerk, and a health officer, who shall be ex-officio a member of such board and its executive officer; all such officers shall be elected by the board immediately after its organization. Every board of health as thus constituted shall exercise all the powers and perform all the duties prescribed in this chapter within the limits of the town, village, or city of which they are such officers. Every health officer so appointed shall be, whenever practicable, a reputable physician; he shall hold office during the pleasure of such board and until the qualifi- cation of his successor; if a vacancy occurs in his office the board of health shall imme- diately fill the same by an election. The foregoing provisions shall not apply to any city or village in which a board of health and a health officer are provided for by the charter thereof; but every such board, whether organized under the provisions of this section or otherwise, shall, immediately after each annual or other organization, report to the secretary of the state board of health the names, post-office addresses, and o^ccupations of the officers thereof, and make such report whenever a new health officer is chosen. Every board of health may take such measures and make such rules and regulations as they may deem most effectual for the preservation of the public health. They may appoint as many persons to aid them in the execution of their powers and duties as they think proper, regulate the fees and charges of every person so employed by them, and fix the salary of the health officer, examine into all nuisances, source of filth, and causesof sicknesses, and make such rules and regulations respecting the same as they may judge necessary for the public health and safety of the inhabitants. Note. — Board's Powers. A statute which gives a board of health " all the powers necessary and proper for the preservation of the public health and the preven- tion of the spreading of malignant diseases," and makes it the duty of such board " to examine into all nuisances, sources of filth injurious to the public health, and cause to be removed all filth found within the town which in their judgment shall endanger the health of the inhabitants," gives express power to decide what is filth; and if a board merely errs in judgment there can be no redress given a party who complains of its acts. Raymond vs. Fish, 51 Conn., 80. The board's determination of questions of discretion and judgment in the dis- charge of its duties is in the nature of a judicial decision and within the scope of the powers conferred, and for the purposes for which the determination is required to be made, it is conclusive. It is not to be impeached or set aside for error or mistake of judgment, nor to be reviewed in the light of new or additional facts. The officers or board to whom such determination is confided, and all those employed to carry it into effect or who may have occasion to act upon it, are protected by it and may safely rely upon its validity for their defense. Salem vs. Eastern Ry. Co., 98 Mass., 431. In the regulations following, any possible deficiencies in the powers of the state board are largely imposed upon the local ones. BOARDS OF HEALTH AND SANITARY OFFICERS 227 The Illinois State Board of Health issues a pamphlet, " Public Health Laws of Illinois and Sanitary Memoranda," that contains such admirable drafts of model local board of health laws, that persons in doubt as to what should be required should read this publication. The Illinois county and township boards are organized as follows: Section 116. How created — powers and duties. — The board of county com- missioners in counties not under township organization, and the supervisor, assessor, and town clerk of every town in counties under township organization, shall constitute a board of health, and, on the breaking out of any dangerously communicable diseases in their county or town, or in the immediate vicinity thereof, it shall be their duty to make and enforce such rules and regulations tending to check the spread of the disease within the limits of such county or town as may be necessary; and for this purpose they shall have power to quarantine any house or houses or place where any infected person may be, and cause notices of warning to be put thereon, and to require the disinfec- tion of the house or place: Provided, that nothing in this Act shall apply to any terri- tory lying within the corporate limits of any incorporated city or village: Provided, further, that in case the board of health in any county not under township organization, or of any township in counties under township organization shall fail, refuse, or neglect to promptly take the necessary measures to preserve the public health, or in case any such board of health shall refuse or neglect to carry out the rules and regulations of the state board of health, that thereupon the state board of health may discharge such duties and collect from the county or township, as the case may he, the reasonable costs, charges, and expenses incurred thereby. The Iowa State Board of Health makes no elaborate provision for local boards, mayors, and councils of towns and cities and clerks of townships attending to the duties and employing such physicians as they see fit. They must appoint a health officer and certain regulations of the state board must be adopted verbatim. Kansas makes the following provision for local boards : 6662. Local boards. Section 7. The county commissioners of the several counties of this state shall act as local boards of health for their respective counties. Each local board thus created shall elect a physician, preference being given to adepts in sanitary science, who shall be ex officio a member of said local board and the health officer of the same. He shall hold his office during the pleasure of the board, but may be removed for just cause at any regular meeting of the same by a majority of the mem- bers voting therefor, on which motion he shall not vote. The local boards of health hereby created shall not supersede or in any way interfere with such boards established by municipal regulations in any of the counties of this state; but all local boards of health of this state, created by this act, or existing by authority of municipal law, shall be governed by the provisions of this act. The territorial board of health of Arizona make very complete provision for local boards, the gist of the regulations being as follows: COUNTY BOARDS OF HEALTH Section 6. There are hereby established county boards of health, composed of a president, a vice-president, and a superintendent. The chairman of the board of supervisors in each county shall be ex officio president of the county board and the 228 HYGIENE district attorney of such county shall be ex officio vice-president of such board. The board of supervisors shall appoint a superintendent of public health for the county, who shall be a practicing physician within the county. Section 9. The several county boards of health shall have power within their respective counties, outside of the corporate limits of cities having a city board of health, subject to the supervisory control of the territorial board of health and the superintendent of public health, to do and perform all the things mentioned in sub- divisions 3, 4, 5, 6, 7, and 8 of Section 4. All expenses actually and necessarily in- curred by the county board of health in carrying out the provisions of this article shall be audited by the board and certified to the county supervisors, and shall be paid the same as other county expenses are paid. Section 10. The county superintendent of health shall have charge of and super- intend, subject to the approval of the board of which he is a member, and the super- visory control of the territorial board of health and the superintendent of public health. A survey of the field, viewed historically, shows that the gulf coast and the large cities have found it most incumbent upon them to provide for local health boards. In these sections the boards have been gradually brought up to a point of efficiency. One of the most elaborate organizations is in New Orleans. Ports and port cities have been compelled to organize an effective force. Until recently the interior Southern states have been remiss'', but they are now organizing along quite modem lines, although much territory is not fully complying with the new and somewhat untried state laws. In the old eastern section of the country- there are a host of alleged local boards of health not at all in sympathy with the new order of things being adopted by most of the Eastern and Middle states. The state boards are handi- capped by a lot of old charters giving these local boards a legal standing. Some of them are reorganizing, as requested by the state boards, but some parsimonious counties are very remiss, and it is difficult for the state boards to get them in line. The large eastern and central cities have efficient organi- zations. In theAVest, commendable advance is being made. There are few old charters and the country is newer, and hence it is comparatively easy to organize effectively. In many states these matters have been well adjusted. As to the form of law advisable it would not be fair for me to discriminate. My opinion would be of little value. Conditions vary and communities have different problems and differing kinds of people with which to deal. Only a few things do I care to outline. The first one is that politics is the bane of local health boards. It impresses me that when the appointment of the members of these boards is vested with the courts, politics can be largely avoided. Allow me also to commend the feature of the Kentucky law giving the medical societies a voice in the matter. New Jersey has a splendid provision in requiring inspectors to be trained and to pass an examination for license. One of the urgent needs is for trained men. Better fewer laws and better men. A trained man will give good service under poor laws, but an ignorant official must have ever}^thing in print to get him to do one half of the necessan' work. It must not be forgotten that the state health departments may be called upon to meet frightful emergencies. Therefore it is well to confer large pow- ^.■ MUNICIPAL CREMATORIUM, DISTRICT OF COLUMBIA Here are burned all dead bodies of paupers SMALLPOX HOSPITAL, DISTRICT OF COLUMBIA BOARDS OF HEALTH AND SANITARY OFFICERS 229 ers upon them. They must be able to declare a sort of martial law, as it were, but martial law is not declared for a mere street fight. Neither should the extreme powers of the state health boards be used in the ordinary course of affairs. A policeman may deal with the first and a health officer with the other. It is poor policy to call out the militia when the sheriff can control the situation, and it is equally poor policy to call out the state board when the affair is of purely local import. Any county would be remiss if it did not have a sheriff and district attorney, and it is equally remiss if it does not have a local health board capable of handling ordinary matters of local sanitation. As there are grades of courts and attorneys general as well as district attor- neys, so there are grades of health officers, and each should constitute a part of one chain and act as co-ordinate parts of one harmonious whole. In general we practitioners of medicine can well leave to the trained sani- tarian the details of organization of local boards. The whole matter is a specialty, being very carefully studied out by as able and honest a class of men as we have in the land, and it is not at all likely that they will perpetuate any mistakes definitely shown to exist in the present system. Duties of local boards. — Upon the appointment of a local board, it is incumbent upon them to organize as provided by law. Whatever views one may hold upon abstract questions of law, it is the duty of every officer under the law to yield implicit obedience to the statutes governing his appointment and the conduct of his office, and to govern his individual conduct by such orders as may emanate from the constituted authorities superior to him. Members of boards of health, either lay or professional, should realize that their appointment is no joke or merely for the community to "put on a front." The health laws are meant to be enforced just as much as are other laws. Supposedly dead laws are like supposedly dead wires, they may get crossed in time of storm and woe betide the luckless individual who picks them up. Dead wires should be connected up or taken down; so with dead laws. The academic attitude has no place in sanitation. One may scoff at therapeutics and medical theories to his heart's content, if he is so minded, but disease, sin, and dirt won't rub out and must be reckoned with as positive entities. A mere altruist or academic theorist is a nuisance upon a health board, to be dealt with by them as are other nuisances. The first duty of a member of a board is to fully inform himself upon the law; not what he thinks the laws should be but what they are. Then he should realize that it is " up to him " to enforce the laws. But the interpretation of the law may present difficulties in certain specific instances. Let no layman arrogate to himself judicial decision or ruling. That is for the courts and the constituted officers of the courts or those speci- fically charged with the execution of the law. I say specifically charged. In regard to the health laws, states differ in this regard, and all local boards should be sure of their ground. Every local board should have competent legal advice. Local boards must have some definite attitude toward physicians. There are two relations to be maintained; first, that toward the physicians who are entrusted with the medical part of the work of public sanitation; second, 230 HYGIENE that toward the private practitioner of medicine. The attitude toward the first class should be the same as that assumed with the lawyer or the chemist employed in public health work. Each man is assumed to be an expert in his special line of endeavor. If he is not willing to became expert, release him from an irksome task and get a man who takes a real interest in his work. There are lazy lawyers and lazy doctors and they have no place in public health work. Local boards have some difficulty in securing physicians who understand the practical side of the work. The mere fact that a man holds a medical diploma does not signify that he is a sanitary expert any more than it indicates that he is an experienced surgeon. But any properly educated and earnest physician can become a good sanitarian, provided he has some know- ledge of modern laboratory methods and a fair understanding of chemistry. Physicians who do not possess such knowledge should not be appointed upon health boards. The political doctor may or may not become a good health officer, but the ratio is about 16 to 1 and generally " politics doth make cowards of us all." If politics must be a factor, it should not be mixed in with the medical end of affairs. Unless a physician possesses a fair share of spunk and executive ability, he makes a poor health officer, and if he goes into the work for the money he can get out of it and for nothing else, the sooner he is dropped the better for the service. On the other hand, a medical man who is woTth having is worth paying all that his skilled services are worth to the community. Only a well-paid line of work will secure and hold good men, and the state has no more right to free medical than to free legal services. As to practicing physicians, there is a lot of temper wasted by them and by health officers in contact with them, that may just as well be saved. Both sides are often in the wrong. It must not be forgotten that " great bodies move slowly," and that the medical profession has long enjoyed certain immunities and has its conventions and precedents. It is not to be ex- pected that men graduating many years ago will immediately apprehend the point of view of younger men fresh from the schools. Many capable phy- sicians are not informed concerning the sanitary advances and necessities of the day, and cannot see the need for many of the regulations imposed upon them. If the state undertook to regulate the legal ills of the citizens 2nd expected the lawyers to report to some board all cases of infectious conten- tion and epidemic litigation in order that the board should pour the oil of peace over the wounds and cut the law} er out of the job, these gentlemen would mob the legislature. And yet it would be a pretty good thing for the state to do and would save an immense sum to the citizens and to the state. Possibly it may be undertaken some day and will result in a host of lawyers having very little to do and yet assist (free of cost) in destroying their own business. That is exactly what the state is asking the doctors to do and the state is right. " What is sauce for the goose is sauce for the gander." Human nature is the same in both professions, and in both of these lines of work there is plenty of necessary work to do for a limited number of able men. There are many good lawyers who believe that their chief function is to prevent litigation, just as there are many good doctors who think that their chief function is to prevent disease. Ultimately an enlightened public BOARDS OF HEALTH AND SANITARY OFFICERS 231 conscience will demand that both lawyers and doctors who do not feel that way should not be allowed to practice, and the public will be right. But " ultimately " may be a long time coming, and the fact remains that all professions are full (" in this present evil age ") of men who have none but a business conscience and cannot rise above sordid impulses. We all cry " grafter! " but take good care of our own little graft that we dignify with some better name. We cannot blame some men because they cannot see beyond their own noses. A few centuries ago some well-meaning and righteous men devised systems of theology rejected in this more humanitarian age, and yet we find academic but well-meaning ecclesiastics who are dread- fully worried because the rest of humanity have refused to stand still. It takes a public conscience to make the individual one see straight. The same people who think local option the only righteous way may have had grand- fathers who owned distilleries, and those old distillers may have prayed more fervently than do their descendants. The public conscience is the practical outcome of the old saying: " The voice of the people is the voice of God." Certainly, the people are demanding that better conditions as relates to dis- ease must prevail, or they will hold the medical profession responsible. And the people are right. Woe betide the profession, or any part of it, that fails to heed the " signs of the times." Nevertheless, health officers must be patient with the men who cannot see their way. Funerals bring lots of good things to pass and they are the only thing that will accomplish some reforms. Ideas die more slowly than do men, and the mummies of some dead ideas are often long kept on ex- hibition, but the public ultimately demands new sights and " the mills of the gods" gradually grind new grist. I know it is aggravating to have to put up with the illogical opposition of touchy doctors, but then the health officer himself may have some little pet delusion of his own. And sometimes the doctor is right. To this very day the health laws of some of the Southern states do not nam.e the mosquito in connection with yellow fever, and thereby hangs a tale. Years ago some " fool doctors " dared to claim that this gentle bird carried the fever and that such regulations as the following were not effective: MEASURES TO BE TAKEN IN A TOWN OR LOCALITY WHICH MAY NOT REQUIRE QUARANTINE 16. If an inspection shows that the disease be certainly confined to a few houses and all persons who have been exposed to possible infection are known, and these houses and people be isolated under observation, the remainder of the town need not be quarantined; should either of these conditions fail the town shall be quarantined. 20. When practicable in towns which do not require quarantine the patient shall be removed to hospital or other quarters little liable to infection, and so situated as to involve a minimum of danger if infected. 21. If the patient cannot be removed all proper precautions must be taken to prevent contamination of his premises. 22. Those immune to yellow fever and furnishing evidence to that effect satis- 232 HYGIENE factory to the health officer in charge may be given free pratique after disinfection of effects. 23. Non-immunes may be permitted to go to places incapable of infection, to remain there during the period of incubation, but their baggage must be disinfected before leaving. 24. Non-immunes not going to such places shall be isolated under observation in non-infected quarters, so situated as if fever develops among them there shall be as little danger as possible of conveying infection; their effects being disinfected upon isolation. 25. Such persons as are isolated under observation on account of exposure to yellov? fever shall be so isolated for a period of not less than ten days from the last possible time of exposure to infection. They shall be inspected once daily. 26. Premises occupied or having been occupied by a case sick with yellow fever shall be treated as infected, and be under sanitary control, and such neighboring prem- ises as are close enough for their inmates to receive infection from the above, shall also, with their inmates, be under sanitary control. And much more to like effect, even to recommending depopulating the town as rapidly as possible. It sounds funny now, but I remember the time when it did not sound funny, and when the whole North was frightened over the " yellow Jack." AncJ yet even some of our most noted living sanitarians waxed wroth and indignantly denied the possibility of the despised mosquito being the agent of dissemination. And they had two earthquakes out in San Francisco; one shook down buildings and the other nearly blew up the Public Health and Marine Hospital Service because the service listened to other " fool doctors " who had noticed that bubonic plague killed rats and that rats had fleas. Things and language looked blue out there for a time, and the local health authorities "went up into the air " so high they have not all come down yet. Some one has said that " dogmatism is puppyism grown up." Perhaps! At all events even health officers should study history before they denounce the " fool doctors." A certain amount of conservatism and humility does not hurt any of us. Our sins are very largely the sins of our age and time, and the doctors, take them all and all, are as good as this age deserves. But a better age is coming and better doctors will come with it, as well as trained local health authorities who will master the gentle art of making an ally of the doctor. The first contact of the doctor with the health officer usually is in the form of the medical report of infectious disease occurring in his practice. Un- fortunately very many health boards fail to realize that the doctor has limited time, and cannot afford to employ a clerk to make the free reports exacted of him. These blanks are often unnecessarily long and even duplicate data reported by the health officer. The result of these long blanks is that the phy- sician frequently fails to report minor diseases at all. Some child may be brought to my office and the cough prescribed for develops into whooping cough and must be duly reported. When it comes to filling out the blank report I find that I must give the full name, the age, the number of persons in the family, their ages and sex, others exposed, etc. Half the time I have never BOARDS OF HEALTH AND SANITARY OFFICERS 233 seen the persons before, and they are two miles away when I fill out the blank. It is true that I should look fully into these matters as I go along, but when one gets small fees and must push right along to make a fair living he does not have uppermost in his mind the free reports he is expected to make. It impresses me that the doctor should either be paid for making the reports, or they should be of a very brief nature and take little of his time to fill. The mere name of the patient, with the address, name of disease, and date of onset, will give the health officer all he needs to make his first visit. This officer should be a physician, even if some of the local physicians do not like another doctor going to verify their diagnoses. A medical health officer is in as good or better position to report to the authorities the necessary data than is the attending physician. The better class of families hesitate to give proper data to an officer, other than a physician, and they instinctively realize that he will be more considerate and less harsh than the man they regard as a policeman is apt to be. Of course there are harsh doctors and gentle police- men, but it is well to be considerate of the people. I have known quarantine officers who were not fit to quarantine self-respecting cattle. They were ap- pointed by a corrupt political machine. Such men are not capable to fill the office, and it is an outrage to inflict them upon the community. As an illustration of the kind of reports local health officers should make, I have asked the Michigan State Department of Health for copies of their blanks to reproduce. The following are a part of the excellent set sent to me. I can recommend them as model blanks and as serving the purpose much better than would those commonly filled out by the attending physician. FIRST REPORT OF EACH CASE OF DIPHTHERIA, SCARLET FEVER, MEASLES, WHOOPING-COUGH, SMALLPOX To be mailed to the secretary of the state board of health, Lansing, Michigan, as soon as the health officer knows of there being in any household within his jurisdiction a first or subsequent case. To the Secretary: Sir: — There has come to my knowledge a case of in the household of who resides in the of , County of State of Michigan. The name of the person sick is a taken sick with this disease on the day of 190 Has the infected house been conspicuously placarded ? Has the person sick with this disease been ordered isolated.? Have all per- sons exposed to the disease been ordered isolated ? For how long ? Note : Signature Health Officer of. 190 I have blanks like this. 234 HYGIENE FINAL HOUSEHOLD REPORT RELATIVE TO DIPHTHERIA, SCARLET FEVER, MEASLES, WHOOPING COUGH This blank is to be filled out by the health officer when the last case in a household has recovered or died. Please Make a Full Report 190 To the Secretary of the State Board of Health, Lansing, Michigan: 1. The name of the disease about which this report is made is 2. All cases included in this report occurred in the household of who resides in the of County of State of Michigan. 3. How was this disease first introduced into this household ? 4. The disease in this household began 190 . . . . , ended 190 . . 5. Number of cases occurring in this household were. . . .Number of deaths were. . . . 6. Were the instructions of the State Health Department, as contained in the pamph- let on the restriction and prevention of this disease, promptly carried out relative to: (a) Thorough isolation of those sick or infected .'' (b) Conspicuous placarding of the premises .'' (c) Disinfection of discharges from mouth, nose, and throat .? (d) Disinfection of discharges from bowels and kidneys ^ "^(e) Disinfection of all bedding, clothing, etc., used by the patients and attendants ? (f) Disinfection of the house and contents ^ In cases of diphtheria: 7. How many persons sick with diphtheria were treated with antitoxin .? 8. On how many persons exposed to but not yet sick with diphtheria was antitoxin used ? 9. Of the persons exposed to diphtheria and treated with antitoxin, how many after- wards had diphtheria ? Remarks : Signature , Mich. Health Officer of. FIRST REPORT OF A CASE OF TYPHOID FEVER [To be mailed to the secretary of the state board of health, Lansing, Mich., as soon as the health officer knows of a case being present in his jurisdiction.] To the Secretary: Sir — There has come to my knowledge a case of Typhoid Fever in the of County of State of Michigan. The name of the person sick is , a about years old, who was taken sick with this disease on the day of , 190 . . , and which case was reported to me 190 . . . Suspected source of infection is Have instructions been given to disinfect the discharges from the body of the patient } Has the person sick with this disease been ordered isolated 1 BOARDS OF HEALTH AND SANITARY OFFICERS 235 How many cases are now present in your jurisdiction ? Remarks : Signature Health Officer of 190 I have blanks like this. FINAL REPORT RELATIVE TO A CASE OF TYPHOID FEVER [This blank is to be filled out by the health officer and returned immediately after the patient has recovered or died.] Please Make a Full Report 190. To the Secretary of the State Board of Health, Lansing, Mich.: 1. The case reported occurred in the of County of , State of Michigan 2. The name of the patient was 3. The age of the person was years. The sex 4. The case was taken sick , 190 .. and died , 190 . or recovered 190 . . 5. The disease was contracted in the following manner 6. From what source was the water for domestic purposes obtained .? 7. Was the water boiled during the entire period of sickness of this patient ? 8. Were flies excluded from the sickroom .'' 9. Were the instructions laid down by this department, as contained in the pamphlet on typhoid fever, promptly carried out relative to: (a) Isolation of the patient ? (b) Conspicuous placarding of the premises ? (c) Disinfection of the discharges ? (d) Disinfection of all bedding, clothing, etc., soiled by the patient f (e) Disinfection of the sickroom ? (f) Disinfection of the privy ? Signature ' Mich. Health Officer of CONSUMPTION, PNEUMONIA, MENINGITIS First Special Report [To be mailed to the secretary of the Michigan Department of Health, Lansing, Mich., as soon as the health officer knows of a case being present in his jurisdiction.] To the Secretary: Sir — There has come to my knowledge a case of in the of County of State of Michigan. The name of the person sick is a ; years old. Color Married or single Occupation Taken sick on the day of , 190 . . In what part of the body is the disease located .? 236 HYGIENE The number of cases now present in this same family is Has instruction been given regarding the destruction or disinfection of the sputa before it has been allowed to become dry ? Signature Health Officer of 190 I have blanks like this. SPECIAL FINAL REPORT RELATIVE TO A CASE OF PNEUMONIA [This blank is to be filled out by the health officer and returned after the case has recovered or died.] Please Make Full Report , 190.. To the Secretary: 1. The case reported occurred in the of County of , State of Michigan. 2. The name of the patient was 3. Age Years; Sex ; Color ; Married ; Occupation 4. The case was taken sick , 190 . . and died , 190 . . or recovered , 190 . . 5. *^ Was there recently a previous case of pneumonia in this household ? If so, when ? , 190. . 6. Can this case be traced to a former case of pneumonia ? 7. What sickness or other predisposing influence preceded this case ? 8. Were the instructions laid down by this depart ment, as contained in the pamphlet on pneumonia, promptly carried out, relative to: (a) Isolation of patient ? (b) Disinfection of the sputa f (c) Disinfection of all bedding, clothing, etc., soiled by this patient's sputa ? (d) Disinfection of the sick room ? Signature Mich. Health Officer of FINAL REPORT RELATIVE TO A CASE OF CONSUMPTION (TUBERCULOSIS) [This blank to be filled out by the health officer and returned after the case has recovered or died.] Please Make Full Report 190.. To the Secretary of the State Board of Health, Lansing, Michigan: 1. The case included in this report occurred in the of County of State of Michigan. 2. The name of this consumptive person was 3. The age of the person was years. The sex Color Married The occupation 4. The case was taken sick , 190 . . , and died 190 . . or recovered , 190 . . 5. In what part of the body was the disease located ? BOARDS OF HEALTH AND SANITARY OFFICERS 237 6. Was this patient a coughing consumptive ? 7. Was the sputa examined for the Bacillus tuberculosis ? With what result ?. . 8. Had or has the patient any relative or associate vpho has been or is sick with consumption ? If so, who ? When ? 9. Can you trace this case to a former case of consumption or tuberculosis ? 10. Can you trace any other case of consumption or tuberculosis to this case ? 11. Were the instructions laid down by this department, as contained in the pamphlet on tuberculosis, promptly carried out, relative to: (a) Disinfection of the sputa ? (b) Disinfection of all bedding, clothing, etc., soiled by sputa or bowel discharges ? (c) Disinfection of the bowel discharges ? (d) Disinfection of the rooms occupied by the patient ? Signature Mich. Health Officer of Other reports. — Having indulged in this little preachment, we come to the specific duties of the health officer. Our argument will assume that he Is a physician, and he certainly should be, and the argument must be general, since conditions vary widely. The fact that a telephonic report is legal and is urged in the case of smallpox and other severe diseases justifies my contention that other less serious diseases may well be reported in very simple manner. The main thing is to tell where the patient is and to put the doctor on record as to the diagnosis. In our consideration of these matters we can well ignore the members of the board other than the health officer, since he does most of the real field work. Having received the report, the health officer need not call into question the correctness of the diagnosis of the attending physician, but must quaran- tine at once. When two attending doctors disagree a third one may be called and the diagnosis be determined by the majority, but quarantine may be maintained until such time as the health officer may feel certain that the patient assuredly does not have the disease in question. Furthermore, some states very properly expect a health officer to investigate any suspicious cases not reported. To do so effectively requires that the officer be a physician. At this point let me quote from the Wisconsin regulations : As a matter of course, if the health officer be a physician his duty of investigating the causes of and circumstances attendant upon the appearance of any disease must not be construed as giving any authority to interfere with the rights of the regular medical attendant of the case, and great caution must be exercised lest a conflict be brought about in the performance of such a duty. In making an investigation there should be the most cordial co-operation^and understanding between the health officer and medical attendant. In case of epidemic, emergency reports may be exacted of the health officer. Most health officers have weekly or monthly reports to render, and the regular inspection reports upon the many lines of work often undertaken, as well as reports of supplies and expenditures, all tend to make the word *' report " a tender spot with him. 238 HYGIENE The up to date health officer is a very busy man and must report along so many lines that it would not be profitable for us to take up here the details of so much clerical work. Suffice it to say that if vital statistics can be cor- rectly collected and if health department records are to amount to much, the trained health officer is the only man whose reports will bring about the benefits that should accrue to science from the expensive and elaborate work of the authorities. All local records are collated by the state boards and these should be, in turn, by a national one. The inspection of hotels and public buildings is commonly a part of his work. It is given a separate chapter in this book. School inspection may be delegated to the health officer, but is becoming a special line of work. (See Chapter III.) Penal institutions and hospitals are also given a separate chapter, although the health officer may have certain duties to perform with reference to them. Maternities, places of amusement and dissipation^ slums, and town nuisances, camps, tuberculosis sanitaria, food and drug inspection, corporation property, and many other subjects more or less connected with the work of the health officer are given full discussion in chapters devoted to them. Diagnosis is often a function of the health officer. Permit me to refer to Chapter XV upon infectious diseases and to Chapter XXIV upon laboratory methods. Vaccination and serum therapy is discussed in Chapter XVI upon im- munity. No data need be given here. Quarantine is of such importance that it has a full chapter upon the subject. In addition it is necessary for the health officer to be fully informed as to the regulations governing his own state and district. Disinfection is so important a subject to the health officer that he should have a special outfit for the work. The general subject of disinfection is taken up in Chapter XVIII. Most state boards provide a uniform for the health officer to use when disinfecting a room or building. The general pattern is that of a loose union garment made of duck or other washable material. A cloaked hood is worn upon the head and rubber shoes or boots and a pair of rubber gloves complete the outfit. A special formaldehyde and permanganate bucket is advised by most boards. The following directions are from the Illinois regulations: The only apparatus required is a large open vessel, protected by some non- conductive material to prevent the loss of heat from within. An ordinary milk-pail set into a pulp or wooden bucket will answer every purpose, although a special con- tainer devised for physicians and health officers will be found of considerable advan- tage. This container or generator consists of a simply constructed tin can with broad, flaring top. Its full height is fifteen and one half inches, the height from the bottom to the flaring top being about eight inches. The lower or round section is ten inches in diameter, while the flaring top is seventeen and one half inches in diameter at its top. The container is made of a good quality of bright tin, is supplied with a double bottom, with one fourth inch air space between the two layers, and is entirely covered on its sides and bottom with asbestos paper. The asbestos paper and double bottom serve effectively to retain the heat which is generated by the vigorous chemical reaction BOARDS OF HEALTH AND SANITARY OFFICERS 239 occurring within and which is essential to the complete production and liberation of the gas. This special container can be made by any tinner of ordinary intelligence and costs but a few dollars. Rural health officers should read Chapter VIII, which also covers the question of milk inspection and the sanitation of dairies and creameries. The relationship to the coroner is given in Chapter XIII. Epidemics are discussed in Chapter XVII. Funerals and the regulations concerning dead bodies are sometimes matters of local legislation. The chapter upon disinfection touches upon the question, and those upon the coroner and upon corporations give some atten- tion to the matter. The supplying of nurses demands appropriation?, and the health officer should be guided by the instructions of the board. A study of the several chapters to which attention has been called will give a health officer a good idea of his general duties, but the necessity of in- forming oneself regarding local regulations remains and should not be ne- glected. Probably enough was said earlier in this chapter to emphasize the necessity of adhering strictly to the law. It must be remembered by the health officer especially, that he takes an oath to uphold the laws and regu- lations. Personally I detest military methods and routine, but I know per- fectly well that they are an absolute necessit) in many of the relations of life and even in the sanitary service. I have no right to let my personal dislikes make me break the laws or interfere with discipline. I know that there are hosts of good soldiers who dislike the discipline and routine most heartily and yet these same men obey every order. The health officer should never question necessary regulations. But he has a place in creating or changing merely local regulations. The relationship to the physician has been discussed to some extent, but a word must be s^id as to sectarian physicians. The laws of the states provide for boards of examiners before whom all physicians who desire to practice in the state must come. All who pass the board, regardless of school, are equal before the law. It is not incumbent upon a health officer to raise any questions as to the school or the special therapeutics of the physician. Frcin the sani- tary standpoint all schools think about alike, and the question of sectarian medicine need not enter into the account. Occasionally extremists of some schools will raise questions well answered by merely referring to the statutes and the regulations. Attenuated vaccine virus given internallv is advocated by a mere handful of men. In the meaning of most acts or statutes such administration is not vaccination, and no evidence can be had of whether or no it " takes " or becomes effective. Hence, the officials will not accept such vaccination. The question of death certificates is one for the coroner in many cases. Whether an osteopath or a Christian Scientist can give a death certificate depends wholly upon the laws under which he may practice. They vary in different states. The question of obstetric reports is locally regu- lated nearly ever}'where and is discussed in other portions of this book. " Nuisances " might be the subject for a really humorous essay, and I felt tempted to try my hand at it since the differing laws and conceptions of 240 HYGIENE what constitutes a *' nuisance " are as hard to put together as a jigsaw puzzle. They range all the way from dead animals in Kansas wells to crowing roosters in the District of Columbia, and embrace almost everything in between. First, find your alleged nuisance and then report it to the president of the board of health. He will, in turn, report it to the third assistant district attorney. In due time it comes to the ears (or nose) of the district attorney, who refers it to the city solicitor. He decides that action may be brought. The president of the board decides that no funds exist for the bringing of the action, and calls it to the attention of the grand jury. They orate about it, but decide that it is in the city and therefore not within the province of a county, and it gets to city councils. They refer it to their legal adviser who finds the ordinance upon nuisances defective. They make a new ordinance, but the old health officer has died meanwhile and the formerly rich owner of the property harboring the nuisance has lost his money. Meanwhile again, a raw policeman who has a hard fist and knows how to swear, has not bothered about technicalities and ripped it out on sight and promised to " make it hot " for the owner if the nuisance is repeated. Health officers need the "big stick " in abating some nuisances. Joking aside, what I have said very nearly covers the ground. The fact that the health officer considers any given thing or condition a nuisance does not legally make it so. The law is exceedingly potent in conserving the rights of property and very slow in abrogating or denying any of those rights. Whether rightly or wrongly, courts are actuated largely by precedents and the common law in determining equities and disabilities not defined by statute or ordinance, and juries are not inclined to take from an individual anything demanded by the state unless the state pays two or three prices therefor. In- junctions are easy to get and hard to dissolve, and some recalcitrant offender against sanitation can hang up a health officer almost indefinitely when it comes to matters involving property. Juries go more by the witnesses or evidence than they do by the court and the law. For instance, the health officer declares an infected vault a nuisance and orders its removal. The owner does not comply with the order and the board of health enters a com- plaint before a court. The medical evidence is clear to a medical man, but not to a jury or a judge. The attorney for the defence brings a number of witnesses having vaults of their own, and none of them know of any person being injured in his comfort or in the enjoyment of his estate by reason of the vault in question. It is only by virtue of the police power that the state can control certain nuisances involving property. Wells, slaughter houses, offensive manufac- turing, a stagnant mill pond, stored manure, swine near to a schoolhouse, a saloon adjoining a church, a private sewer, and many other things may be declared nuisances when a bill in chancery is filed and a judicial decision is reached, but the chances are that if they seriously injure some man's business or property interests, the courts will fail to decide in favor of the health officer or the board of health. On the principle that due notice of intention constitutes a certain legal bar to prevent a man investing money in projects apt to be later declared FIRST FLOOR PLAN PUBLIC COMFORT STATION, WASHINGTON, D. C. BOARDS OF HEALTH AND SANITARY OFFICERS 241 Public Comfort Station, IVashington, D. C. 242 HYGIENE nuisances, it is good policy for local boards of health to define regulations gov- erning certain industries and occupations liable to produce nuisances and to declare the intention to ask for legislation from councils preventing certain things after some date announced. (See Appendix.) Local responsibility is not sufficiently apprehended by many counties and cities. It is not the intention of the state boards to take things out of local hands, any more than it is the desire of the state school department to abolish local boards of directors. Bacteriologists and chemists are employed by many of the state boards and by the larger cities. The health officer should make use of these experts rather than to rely upon his own tests. It is not very practical for one man to keep up a bacterial incubator and fresh culture media and all the more or less perishable reagents and stains needed in modern laboratory work. If he undertakes to do so he is apt to neglect the field or clerical work. Ideals are often hard of attainment but should be indulged more or less. The special medical inspector of Louisiana divides his work under the follow- ing headings: A. Educational: Hygienic Institute work. B. Convention work. V C. Office work. D. Legislative work. E. Field work. This active officer held over one hundred institutes in schools and other public buildings, and expounded the mosquito control idea and other sanitary measures all over the state. Certain social features, as a barbecue, helped along. Chautauquan lectures were given and conventions of health officers were held, and all this stimulated the local health officers to do the office and field work more effectively. A very important duty of the health officer is to educate the physicians. Publicity and education are the two main factors that have made modern sanitation possible. It is natural for the doctor to be so taken up with his cares that he fails to appreciate his duty to the public in the matter of sani- tation, and yet if he is approached in a fraternal spirit and the health officer places in his hands some of the excellent literature issued by the boards he may become an enthusiastic supporter of every sensible measure. Health officers should welcome opportunities to address medical societies. The separate problem of cities. — Some of the cities have been long organ- ized and the reports of their health bureaus indicate a large degree of effi- ciency. The large eastern cities have elaborate departments and abundant regulations. The articles of the civil code relating to sanitation in the city of New Orleans take up one hundred and seventy large pages. The bureau of health of Philadelphia undertakes an elaborate work similar to that of sev- eral other cities in the East. Baltimore has been remiss, but in going through the district ravaged by fire a few years ago I found as up to date and sanitar}' business blocks as one will find in any part of the country and the city is putting in a most complete sewage system. It and San Fiancisco are illustrations of what a great disaster will do to stimulate a city to better things, and give the BOARDS OF HEALTH AND SANITARY OFFICERS 243 sanitarians a chance to do things the previous inertia would never allov/. Even China Town in the latter city is growing up from the ashes a thing of beauty and cleanliness. I was recently in Cleveland and find it a fair illus- tration of the good work being done by cities of its class all over the land. My own little city is rapidly becoming a model of cleanliness and has gone about the matter in a very scientific way. Chicago and all of the cities along the great lakes are fully awake. The commissioner of the department of health of the city of Chicago showed the Western spirit when he said, in the Bulletin Chicago School of Sanitary Instruction, for February 20, 1909, speaking of annual reports: " Essays on sanitary questions are buried when placed in an annual report. . . . They should be published in widely circu- lated periodicals, and should come to the eye of sanitarians when warm." So the Chicago board publishes them weekly and has a school to train its men. In general, the cities are doing an excellent work. It is necessary to end this chapter with some exemplifications of local regulations. It was with difficulty that I could select cities for illustration, since so many have excellent health laws. But because it is the national capi- tal I will outline the regulations of the District of Columbia and the city of Washington and of New York city, the largest city department. Additional reasons for using Washington as an illustration are that the city is under civil service regulation and the laws are not twisted by the politician, and they especially serve our purpose, since they are for the whole district and embrace semi-rural as well as metropolitan practice. No effort will be made to define the statutes, but to give an alphabetical list of subjects, followed by a plain statement of the regulations governing them.. The whole will serve as suggestive to other municipalities desiring changes in their regulations. However, it must not be forgotten that con- stitutional reasons may exist in any specific state rendering some of the Washington regulations beyond the reach of the state. No regulations should be drawn without legal advice. Advertismg of legal notices, such as the abatement of nuisances and the provision of water and sewer service, is provided in case party or his agent cannot be found. Ailanthus trees, which emit a disagreeable smell, are legally declared nuisances and may not be planted. Alleys may be closed, opened, straightened, or divided among the owners of abutting property, according to facts as ascertained and the requirements of public health. Refuse may not be deposited in alleys. Provision is made requiring further building upon alleys to be so placed as to widen the alley, the idea being that all alleys will become narrow streets with adequate sidewalks in time. Anatomical material is provided from the almshouse, etc., under a defined ordi- nance. Animals may not run at large. Animals sick with contagious disease may be quarantined or killed. Dead animals may not be deposited in the waterways, the streets or sewers, and must be disposed of as directed by the health officer. Owners of dead animals must give notice to health board within eight hours. Bodies must be removed in covered wagons by the contractor who collects garbage. Domestic ani- mals may not run at large and may be subject to license or quarantine. Cattle may 244 HYGIENE be driven only upon certain streets. All manner of inspection of diseased animals and the flesh of those killed for food is made. Diseased cattle prohibited in dairy stables. Unlicensed animals impounded. Anthrax in animals under quarantine regulations and milk from infected animals may not be sold. Antidote must be printed upon poison labels. Anti-Narcotic Law, very rigid provisions inclusive of prescriptions fornarcotics to addicts. Antitoxin, sale and purity under rigid regulation. Apartment house quarantine may apply to but a part of building, Areaways must be drained. Ashes collected, sifted, or disposed of according to regulation. Barbers and shops regulated in every way tending to prevent the patron from infection. Bathing beaches strictly regulated. Births reported under regulations to make vital statistics accurate. Blacksmith shops regulated as to location, etc. Boarding houses regulated as to contagious diseases, sanitation, and quality of food, etc. Boards for condemnation of insanitary buildings, for dental, medical,'and phar- maceutical examination, for medical supervision, and for the manufacture of serums, viru'ses, etc. Bones — boiling, burning, transporting, and storage regulated. Bread regulated as to baking, adulteration, etc. Building laws, detailed, and buildings inspected. Bureau of Animal Industry has many regulations. Burial requires permit and cemeteries regulated. Butter — making of and sale regulated. Standards required. Candy is made and sold under adequate protection to buyer. Carpets and rugs may be cleaned only in designated manners and places. Cars a nuisance if kept standing in city loaded with manure or^other^ofFensive matter. Spitting in cars prohibited. Cattle regulated in every way. Cellars may not be used as dairies. Cemeteries under strict control. Cesspools nearly prohibited and, where allowed, must conform to strict regulation. Chemicals, vending and peddling regulated. Cisterns may not be left uncovered. Combustibles sold and stored under regulation. Condemnation of insanitary buildings provided for. Contagious diseases reported, quarantined, etc. Convenience stations provided and regulated. Cremation regulated. Dairies regulated in every way. Dead bodies — adequate regulation. Deaths registered and reported. Disinfection at public cost. Disinterment only on permit or by order of coroner or court. Dispensaries must have an isolation room. Docks may not deposit refuse in river. Dogs taxed and many provisions concerning. BOARDS OF HEALTH AND SANITARY OFFICERS . 245 Drainage applied not only to sewers, but to lots, parks, dairy farms, and area ways. Drivers — liability of defined. Drug addicts restrained as to sale of narcotics. Drug adulteration — provisions practically those of Food and Drug Act. Dumps — public, provided for and regulated. Dust may be a nuisance when so declared. Must be kept in check. Dye water must not be run upon streets or alleys. Eating houses specifically regulated. Embalming under permit and regulations. Excavations regulated and dangerous ones protected. Excreta disposal only according to regulation. Expectoration regulated. Prohibited cars and pavement. Explosives — partial prohibition. Factory inspection, regulation, etc., extensive requirements. Fish markets regulated. Foods — requirements practically those of Pure Food and Drug Act. Fowls — May not run at large, noisy fowls a nuisance in thickly populated dis- trict, prohibited in dairy stable, sale regulated. Fruit — sale of regulated, unlawful to deposit on streets orstreams, receptacles on streets for fruit skins, etc. Game — season defined, sale regulated, game warden provided. Garbage collection by contract. Garbage receptacles of specified kind and size. Gases — illuminating, factory, sewer, etc., regulated. Goats not allowed at large, prohibited in dairy stables. Grading with offensive substances prohibited. Graves — many requirements. Gristmills only in certain locations. Groceries — inspected. Gutters — provisions for cleaning. Harbor regulation act. Health department vehicles have right of way. Health officer — duties defined. Hides sold and handled under regulation. Hogs — inspection, keeping, feeding, slaughtering, etc., regulated. Homoeopathic pharmacies defined and regulated by board. Horses and stables regulated. Horses not permitted in dairy stables. Not allowed to run at large. Hospitals inspected and under regulation. Hotels inspected and must be sanitary. Impersonation of health inspectors illegal. Infected premises may not be rented until disinfected. Insecticides — sale regulated. Inspections of varied character. Many inspectors. Irrigation — subsoil sewage disposal in suburbs. Isolation regulations for contagious diseases. "Jails — sanitary regulations for. Labels must tell the truth. Lands and tenements — several ordinances regarding. Nuisances of. Licenses of various kinds provided for. Liquors come under Food and Drug Act. 246 HYGIENE Live stock — inspection provided. Lodging houses regulated in sanitary directions. Manure — kept in pits, transportation regulated. Marine products — inspection provided. Measures — a sealer appointed. Medical inspectors for schools, etc. Medical supervisors attending to the distribution of anatomical material, etc. Medicines — Pure Food and Drug Act applying. Midwives registered and practice regulated. Milk — all proper regulation of dairies and sale of milk, etc. Morgue regulations. Narcotics — sale regulated and limited. Night soil disposition under regulation. Noises — loud and unnecessary noises prohibited. Nuisances — Many defined and abatement of provided for. Nurses — registered and practice regulated. Odors — certain ones declared nuisances. Oil business regulated. Offal and offensive matter — regulated disposition of. Outhouses to be kept clean and wholesome. Overcrowding of buildings prohibited. Paper — may not be thrown upon streets. Circus paper to be removed. Parrots — noisy ones not permitted in city. Permits — many kinds required. Pharmacopoeia (U. S.) official in city regulations. Pharmacy must be licensed. Physicians must report as required. Testimony privileged. Pigeons — permit to keep live. Plumbing inspector working under detailed regulations. Police regulations — many apply to sanitation. Poisons — sale of strictly regulated. Poundmaster with specified duties. Prescriptions — writing and compounding of regulated. Privy — many regulations. Public assemblage regulated in time of epidemic, etc. Public conveyances regulated. Public schools — medical inspection of. Push carts licensed. Quarantine regulations very full. Rags dealt in and stored under limitations. Railroads — many requirements. Refuse disposal provided. Rendering establishments regulated. Reservoirs — sanitary regulation of. Saloons come under food and drink regulations. Schools — many regulations. Sewers — an extensive list of regulations. Slaughter houses carefully regulated. Smoke nuisance regulated and partly suppressed. Spitting prohibited. Spring — unlawful to defile. BOARDS OF HEALTH AND SANITARY OFFICERS 247 Stables — many provisions for sanitation of Stalls and stands must be kept clean. Stores must be hygienic. Street cleaning under rigid rules. Swill — use regulated. Tenements — under inspection and sanitary rules. Undertakers registered and under code of rules. Urinals — sanitary requirements. Vaccination provided for. Vegetables sold and conveyed under regulation. Vehicles licensed and under sanitary rules. Ventilation subject to inspection. Veterinary practice regulated. Vital statistics carefully collected. Water supply — an elaborate code of rules. Water closets must be properly constructed and maintained. Weeds must be removed. Wharf inspection provided. What is here given is little more than an index of the more important regulations of the city and district, but will serve as a list of the many phases of sanitation of direct interest to the public health officer. Other places have still other problems as, for instance, the mosquito work in the gulf coast cities. The Washington list may be of interest to gentlemen who feel their own city regulations to be inadequate. Municipalities wishing copies of the regula- tions of any city will find them easy to secure if they let it be known why they are wanted. The New York City Department oj Health. — Having discussed the health organization of the District of Columbia and the city of Washington, with the maze of regulations and detailed specifications incident to that type of health administration, we will take up quite a differently organized department of health and use it to point the moral the present writer takes the liberty of de- riving from the mixed state of affairs resulting in the United States in a host of very defective local health boards. This, in many respects the most impor- tant health unit, is usually so inadequate in its organization as to be entirely echpsed by the state boards having jurisdiction over it and its work. As has been shown, the fault lies mostly with the communities and their local boards. In our argument in favor of better local boards, we bespeak for them a greater legal latitude. Some local boards have been born with so much legal rope that they have hung themselves; some have had so much power thrust upon them that they got drunk; others have achieved power. To this latter class belongs the New York City Department of Health, an organization that has done well and made a name for itself for the same reason that the man who makes his own money spends it more wisely than does his neighbor who inherits a fortune. The government of New York city costs, according to General Theodore Bingham, ^200,000,000 a year, or one third as much as the expenses of con- ducting the entire federal government. Of this sum $156,545,148 is raised by direct taxation, the balance being accrued bonded indebtedness. 248 HYGIENE One and one half per cent for health administration is a very modest allowance, and is very much less than is the percentage allowance of many states and cities for the same purpose. At an assessment of twenty mills, that means less than one third mill for health insurance, and yet in New York city that totals about $3,000,000 per year or twice as much as is received by the Pennsylvania Department of Health for its work all over the state. But there is a big work to do in Greater New York, it takes big men to do this work, and it is done in a big way. Like such things generally, it is done economically, and, possibly aside from federal administration, I have not personally seen anj^where else so much accomplished, dollar for dollar, in city administration. There are few regulations. That should delight the soul of President Taft, who thinks we make too many laws. Of course the New York depart- ment is based upon law, but it is in such a hurr}' to keep up with its work that its regulations practically are: " We expect every man to do his duty," and the commissioner sees to it that the rule is obeyed. He is given very full powers, subject to revision by the courts. As Dr. Thomas Darlington, the present able commissioner, is a man of judicial temperament, as well as an energetic officer, the people of New Y'ork city know by experience that an order from his office stands very remote chances of being held up by a court. That New York city has health laws that are enforced is witnessed by the fact that nine to ten thousand convictions for their violation is a common yearly record, and as much as twelve thousand tons of bad foodstuffs have been destroyed in the same inters^al; but mere regulations are more a matter of routine orders than of the printed page. It is a fact that there are boards of health in certain portions of the United States operating under regulations adopted before formaldehyde fumigation was in use, before mosquitoes were known to disseminate yellow fever, and long before bubonic plague touched our shores. It does seem that in these days of rapid advance it is a mistake to handicap sanitary work with regulations apt to be defective before the ink is dr}'. While law is necessary for the basis of any sanitary organization, it is practically impossible for a state board of health to adopt regulations czvry'mg more weight than mere suggestion. Rural districts and the cities of different class cannot do good work under the same common specifications; yet it is attempted in several states. There is no lack of eminent sanitarians who, while they uphold a state law governing all sanitation within the state, yet uphold local autonomy in many matters. From my own pretty widely spread observation, I find that trained men can make better regulations than can be made for them, but where the local health board is selected regardless of training specifically fitting them for the work, it is necessary for the state board to provide specifi- cations or go into the communities and do the work themselves. New York city is a brilliant example of the fact that the health unit (the local board) needs trained men and few regulations rather than one brilliant man presidingover the state board and wearing his soul out in the effort to keep a lot of incompe- tent appointees up to the standard of what a real health officer should be. BOARDS OF HEALTH AND SANITARY OFFICERS 249 The New York Department Annual Reports are very elaborate and the details of their work far too extended to justify taking space here to present a descriptive article. Their literature presents so much of practical admin- istration and original research that the data is frequently used in the various chapters of this present book. But it is our present purpose to refer to some general principles proper to this chapter upon local boards of health, and par- ticularly as relating to the city problem. Firstof all, writers of fiction and near-fiction have exploited New York city with an eye to literary effect rather than telling the truth. There has to be a goat and New York serv^es the purpose. As a matter of fact, the town is no better and no worse than are hosts of small cities more obscure, and New York has no copyright upon crooked politics, low dives, immorality, frenzied finance, or talent. It has both the vices and the virtues of the big. As is to be ex- pected, the sanitary problem is a very big one. The town is the greatest for- eign missionary station in the world and is the greatest teacher of sanitary decency in this country. They begin with the foreigner there in the rough and send him over the rest of the country better trained in sanitation than are most of the foreign residents of righteous interior towns whose residents go to New York for a fling and find the stage and slums there cleaner than they are at home. I made a sanitary tour of the densely crowded " East Side," and it is apparent that rigid sanitary policing of the district is imperative. One can- not temporize with those people, and I found them more afraid of the sanitary ofiicer than they are of the police magistrate. And the sanitary conditions are far better than the majority of the country will believe. It is to the credit of the department that moral conditions are improving there in direct pro- portion as sanitation has been advanced. In the chapter upon the sanitation of corporate establishments, the point is made that the states placing factory inspection and pure food work under the boards of health are securing better results than where separate boards or departments do the work. New York city is a good example. It patterns somewhat after the New England states in its factory inspection. Nowhere else, not even in Washington, do I find such efficient administration of the food laws. In both cities I have banqueted in the cheapest restaurants I could find, and I do not know of any place of five thousand people where one can get so much clean and healthy food for fifteen cents as is served in New York city. Cleveland, Ohio, is a close second, I wish to commend the series of municipal and health department hos- pitals of New York city. The reports show that their maintenance is an expensive matter, but that is probably balanced by the actual isolation of communicable disease difficult or even impossible of attainment by other means. Quarantine is only a relative term, and, under the present social and industrial conditions, the family doctor and the local board of health cannot make it a positive one. The division of laboratories has arrived at the same conclusion as has the United States Public Health and Marine Hospital Service, that original research is a function of the public health administration. No amount of 250 HYGIENE enthusiasm or propagandism will take the place of research, \\niile the public will follow a medical agitator for a time, any agitation not based upon well-ascertained fact will soon become " a nine days' wonder," and fall by the wayside. I find it very difficult to impress some of my anti-tuberculosis friends with the idea that it is not well to go faster than the laboratory can keep up with, nor to proclaim as facts those things not definitely determined by research. In the chapter upon " Army and Navy Hygiene " the opinion is expressed that the final type of health administration will probably be of a semi-military character, and that such organization has a great advantage in that the poli- tician cannot spoil it. New York is but one of several cities in which this ten- dency is already showing. Probably they do not realize it, but a person coming from a smaller city notes it at once and just as he does of the police. My opinion may not weigh much in the matter, but I favor such development as likely not only to furnish better service to the public, but also to promote harmony between the health administration and the general practitioner of medicine. When a local physician whose activities have been more political than medical is placed in charge of the health work, and, in a sense, is placed over a number of physicians who may know more of sanitation than he does, the result is seldom satisfactory. A man trained in the work and wearing a military uniform commands respect at once. Not as a matter of financial data, but simply as an impression, I am in- clined to the belief that the clerical force in New York city accomplishes more than is the case in most health bureaus. Probably the clerical work is simplified, but it impressed me that vital statistics there are adequately col- lected and recorded with a small force. This is a matter of importance, as the expense involved is preventing many of the states from undertaking this work as it should be done for proper scientific registration. The day has gone, I hope never to return, when a doctor may be a mere palliator, prescriber, and pathologist. He needs to be a sociologist, a sani- tarian, and a scientist. Until he becomes all of this, he will not take his full place in the world. The same applies to a health board. The board we are considering realizes this fact. Can I say anything better of its work ? A last word. — It may not be amiss to say in ending this section, that it has been prepared from two standpoints; first, that of the general practitioner rather than that of the professional sanitarian; second, from a 77ational point of view instead of that natural to me as a citizen of an Inland eastern town. Therefore, the health officer should not let me tincture his ideas with anything contrary to the regulations he is under oath to follow in his own state, and the general practitioner who may not have read state medicine extensively should not think this brief chapter exhaustively covers the subject. However, it does not hurt the health officer to read the Ideas of a private practitioner, and it will benefit the general run of physicians to secure copies of their local and state regulations and study them carefully. RECEPTION HOSPITAL, DEPARTMENT OF HEALTH, NEW YORK CITY SCARLET FEVER BUILDING, DEPARTMENT OF HEALTH, NEW YORK CITY ADMINISTRATION BUILDING, DEPARTMENT OF HEALTH, NEW YORK CITY Chapter XII ARMY AND NAVY SANITATION — HYGIENE OF CAMPS Introductory — Organization — Recruits — Hygiene in peace — In war — In battle — Camps — Water supply — Rations — Disposal of excreta-housing — Transmissible diseases — Typhoid fever — Malaria — Diarrhoeas — Bubonic plague — Venereal diseases — Other in- fections — Tropical diseases — Clothing — Marches — The canteen. Special Naval Regulations — To enter medical service of — Medical school of — Duties of medical officers — Enlistment — Sanitary regulations — Quarantine — .Insanity in navy. Public Health and Marine Hospital Service — A general survey of its functions and the work it has done — Other camps — Contractors' labor camps — Camps in time of public disaster — The lessons the general practitioner can learn from the army and navy. /NTRODUCTORr — Surgeon Sheldon G. Evans, of the United States Navy, has well said {The Military Surgeon, October, 1908): " Far be it from me to detract from the dignity of the position of a medical officer in any honorable service; but I am one of the old style medical men who look upon the title of doctor of medicine as the highest in the gift of any university or college, and upon the practice of medicine, the healing of the sick, succoring the helpless, and relieving the sufferings of overburdened humanity as the noblest profession under God's blue canopy, and this all ought to admit as the first and most important duty of a medical man in any or either service. To be a doctor first and a medical officer afterwards." The present writer views the matters involved in this chapter from the standpoint of the general practitioner of medicine. While not an army or navy man, considerable observation of army camps and some little contact with the naval establishment, added to extensive reading of books and jour- nals devoted to such matters, has interested me in the problems of army and navy sanitation sufficiently to have formed some very definite opinions. They are given for what they are worth. lam well aware that the whole problem involves a specialty thoroughly elaborated by many men and many governments, and yet there is a sufficient degree of unrest noted among medical officers of the different establishments to indicate that the general reorganization of things medical and surgical going on all over the world is being reflected in the armies and navies of the world as well. This is especially the case since the war between Russia and Japan and in which the value of sanitation was strikingly manifested. It would be far from me to take an attitude antagonistic to our excellent military organization in the United States, and yet our best soldiers realize that the American temperament is such as to allow an initiative and latitude to our soldiers not deemed wise by the older organizations in Europe. If this is true of the officers devoting their attention to field work and tactics, it is equally true of the medical officer. The past few years have shown that medical men may be safely given command in civil affairs relating to the 252 HYGIENE public health. City sanitation was never efficient in the time when the medi- cal health officer had no power to enforce his orders except by tedious appeal to the authorities who were usually entirely ignorant of sanitary necessities. If there was one especial reason why sanitation was effective in the Japanese army it was because the medical officer of a certain grade had the same power of command as did the equivalent officer in the ranks. With all deference to West Point and Annapolis, the academic point of view and tradition have no place in modern sanitation, either in military or in civil affairs. When we take into consideration that the history of armies makes apparent that disease kills more soldiers than do bullets and weapons, sanitation becomes a subject of at least equal importance to tactics. It is fair to assume that the medical branch of any service is one of the most im- portant of its varied features, and is manned by men the equal in training of the gentlemen with whom they come into contact. On the other hand, there are so many advantages connected with mili- tary forms of administration that Europe has injected a certain amount of military method and discipline into many forms of public service. We have an illustration in Pennsylvania. For many years a large force of coal and iron police were kept in service by the corporations so liable to suffer destruc- tion of property by riot or by strike. This large force has been disbanded and has been succeeded by state constabulary. About two hundred of these mounted police are kept constantly in the field and are probably the most effective police organization in the United States, largely because they are under military discipline, and in constant training. In the chapter upon state boards of health, I have taken occasion to predict the ultimate semi- military organization of these necessary establishments. We are cursed with crooked politics in our states, and about the only way to free sanitation from its blighting influence is to ally it with something with which the poli- tician cannot deal. If my view be correct, military ideals and ideas are a coming horizon for the sanitarian, and army and navy sanitation is a study worthy the attention of every doctor. In our present consideration, it is impossible to give any adequate con- ception of army and navy methods by merely repeating the sanitary regula- tions issued by the surgeons general. We must be permitted to cover a slightly wider field. One is at once confronted by the army claim that they have the most difficult task because of taking conditions as they find them instead of living upon a well-constructed vessel. On the other hand, the navy man says his work is done in a community vastly overcrowded, and that to keep the occupants of a ship from being swept off by epidemic is more diffi- cult than upon land where camps can be spread out or moved. I have taken occasion to carefully study the instructions for medical officers issued by both branches of the service, and shall give more attention to the navy literature because it covers a somewhat wider field and embraces most of what is given in the army as well as other conditions with which the army does not have to deal. As to which branch of the service presents the greatest of difficulty in sanitation, I do not pretend to know. This book being written for civil rather than for military readers, a host ARMY AND NAVY SANITATION 253 of administrative matters of military interest will be wholly omitted; hence, the writer deliberately lays himself open to the charge, just from the military point of view, of omitting one of the most important branches of the subject. However, there are some things in military red, white, and blue tape that do not seem so impressive to the average citizen as they do to the military officer, and I will take occasion to define, under the next heading, some adminis- trative heresy that I see cropping out of the pages of The Military Surgeon at intervals and that seems to be " sapping the faith " of some of the brightest men in the service. The chapter will end with a discussion of the Public Health and Marine Hospital Service. Organization. — There is a chapter in this book devoted to a discussion of a proposed national department of health. The military branch of the gov- ernment prefers that such a department be upon a military basis. With this suggestion the present writer agrees. As things are, the army, the navy, and the Public Health and Marine Hospital Service have each their medical organization. They each have hospitals sometimes almost side by side (as in Boston), their equipment differs, whereas there is little adequate reason why it should, there is a duplication of recruiting stations and many store- houses and administrative buildings, some branches have too many medical men, while some other branch has too few and they do not interchange, a vast deal of clerical work is done under the three organizations that a " trust " would eliminate in short order; there are separate medical schools conducted that would be better combined into one; there is a vast deal of professional dry rot resulting from a medical man being assigned to a post where he has Httle to do but render routine reports, and this cannot be helped under the present inflexible system, and the divided system does not permit of the medical department having its own transportation and commis- sary. Such are the reasons advanced in favor of a union of the different divi- sions of the government medical service. I have talked with the men who favor the present organization and they strenuously oppose any such changes as are suggested, raising a host of small objections that to my mere civilian mind did not appear very weighty. However, unless a department of health were established along military lines, or maritime quarantine be placed exclusively in federal hands (which is not apt to be done for a long time), uniting the three branches of the medical service would result in a considerable number of medical officers losing their commissions. Establishing a federal department would obviate this loss to many very excellent physicians. Recruits. — This matter will be sufficiently discussed under the heading " Enlistment " when we discuss the navy regulations. Hygiene in -peace. — With the regular army, this is upon a very satisfac- tory basis, the troops being seasoned and the ration regular. The commands are not very large, and the camps are changed sufficiently often to prevent trouble. Troops in garrison are little of a sanitary problem in these days, except when the garrison is too near to certain diversions for which soldiers have a weakness. National guards of the various states go into practice en- campment annually and some degree of sickness occurs among the men because they are not inured to camp life. The sanitary problem in time of 254 HYGIENE peace is so similar to that of times of war that separate discussion is hardly demanded, except to say that the reports are of such a character as to indicate the necessity for care in preventing the spread of venereal diseases. Hygiene in war. — This subject will be limited to a discussion of hygiene in the field, and need not take up barracks, the hygiene of which is largely that of a hotel or large lodging house, only administered in a military manner. In the field routine reports and records should be simplified, except those relating to the injuries and illnesses occurring. It is the duty of the medical officer to make the command the best fighting unit he can, and he must do this by preserving the health of each and every individual. He should not give all of his attention to the large features; he must look after the individual as well. It is very necessary that the general stafFand the medical department be as one and that medical supplies be abundant and the stores of such a char- acter as to restore the sick and wounded to the lines as soon as is consistent with good work and humanitarianism. In modern war, the number of wounded is often one fourth of the whole command, but the number of serious wounds is diminishing, owing to long-distance fighting. Modern warfare has accentuated the benefit to be deiived from the use of first aid dressings supplied to the soldiers themselves, and it is a matter of hygiene in that it reduces the number of septic wounds. Field organiza- tion is a matter of great importance, and its discussion would involve so much space that I would recommend interested physicians to write to the surgeon general for a copyof the "Medical Department Manual." He will not be likely to supply copies at random, however. This really admirable volume gives a very clear idea of what may be expected of the medical officer under all con- ditions. I am very much inclined to indulge the personal view that the medi- cal officer is justified in specializing. Sanitation is of constant use, but sur- gery of only occasional need. Even in time of war many surgeons get really little experience in surgery. It seems to me that the major surgery could usually be well left to the surgeons of special experience and training. The diseases with which the military surgeon has to do will be discussed pre- sently. Very fortunately, hard campaigning and fighting do not induce com- municable diseases. Col. Valery Havard, Assistant Surgeon General, U. S. A., is reported to have said in an address : Until recent years all sanitary work in our camps was done under the immediate supervision of the quartermaster's department. Medical officers were simply per- mitted to make recommendations which were more or less heeded. There was, there- fore, a divided responsibility which bred indifference and prevented the attainment of the best results, ll has, at last, been realized that military hygiene is specialized knowledge and that medical officers are best fitted to direct and supervise its applica- tion. Hence came the sanitary organization of some of our latest camps, where the whole business of sanitation, conception, and execution was entrusted to the medical department, and, as we know, with the happiest results. The quartermaster's depart- ment was simply called upon to furnish the material and hire the necessary laborers. In my opinion, it would be a still further advance if the medical department controlled all the sanitary material and personnel. This control would be for the best interest of the service, and we may confidently soon expect to obtain it. ARMY AND NAVY SANITATION 255 Thus we see how the medical officer must become a practical adminis- trator. It takes a really big man to fill the bill acceptably. In addition to this, he must be prepared to instruct the men in sanitation. Another duty in wartime is for him to instruct the medical officers of the state militia and the volunteers always raised in time of war. The appointment of these men is upon altogether too loose a basis. With all deference to the general practitioner of medicine, he is seldom prepared to attempt the sani- tation of a camp. The contract surgeons and the medical officers of state troops may be most excellent physicians and surgeons, but that does not make them capable sanitarians by any manner of means. I enjoyed much opportunity to observe how the mixed system worked during the Spanish- American war. There was fault upon both sides. It is not necessary here to go into details, but the fact is that certain regulations that failed to appeal to the civilian doctors were necessary for the service. The kits of surgical instruments and the chests of drugs cannot be varied to suit the individual ideas of all. The regular army medical officer attains a specialized knowledge of the drugs regularly supplied, and gets along with them very well. Not so some of the physicians suddenly called upon to serve in an army camp. But some of the " regulars " can shake up a chest in the dark and tell just what is there and the " vagaries " of some of the " civilian " doctors got upon their nerves. I remember a rather pompous medical officer, as inefficient as he was pompous, throw several kinds of patent elliptical fits over the fact that a really distinguished civilian doctor in the command had in his chest a few drugs not upon the list. A little fraternal co-operation would have avoided much friction. It would be an excellent thing for all of the physicians of military age to familiarize themselves with the general principles of military and naval hygiene. There is no lack of text-books and " The Military Surgeon," edited in Washington, D. C, will afford a sort of correspondence course in the subject. And that is not all that is necessary. Every state owes it to its citizens who may be called to the colors, that a body of medical officers be trained, not only in the theory and details of military hygiene, but in the administra- tion of the matter. Things were thoroughly bad in the Spanish-American war, and we may just as well admit the fact. I saw enough myself to con- vince me that the best of family doctors positively is no/ worth while as a mili- tary sanitarian. Just what should be done I confess I do not know, but am inclined to believe that the state boards of health and the state militia should get together and devise a way to put In training certain physicians in the several communities, in order to meet the possible emergencies of the situa- tion confronting the nation in time of war. I am aware that there are cer- tain organizations endeavoring to train men to meet emergencies in time of disaster, but the results are hard to judge. My view is that every state should train the men selected strictly along federal army methods, so as to have an absolute uniformity. The medical officers of the state militia get a slight training, but they are seldom selected with any regard to their efficiency as sanitarians. Some day this nation will pay an awful price for its neglect of 256 HYGIENE military matters, and especially for its neglect of military training for its medi- cal officers. There is a lot of talk about the sovereign rights of the states, but very little about the sovereign duties. All manner of sanitary matters are being taken up by the states, and there is a great opportunity offered, in co-operation v^ith a semi-military federal department of health, of making the medical officers in the state organizations men of similar training and resource. In my view of the matter, that is w^hat we will have to come to ultimately, and it will result in better service, more economical administra- tion, a very badly needed separation from politics, a uniformity over the country, and sanitar}^ preparedness in time of war. Hygiene in battle. — Probably one who has never seen a real battle should say nothing under this heading. But I have talked with those who have seen much fighting and find it difficult to induce them to write anything except for miUtary publications. What they have told me leads me to the belief that hygiene in battle is one of the things sanitarians may dream over but never attain. From my reading, I find that the most effective sanitary pre- caution our government has undertaken for use upon the firing line is the supplying of first aid packets to the soldier. An examination of this packet shows it to be most admirable, as it is contained in a metal box encased in a canvas cover and fastened to the cartridge belt. Doubtless it has saved many lives and the men need not be hastened to the rear so fast. Another precau- tion is to see that their water supply carried into battle is good. The Japan- ese navy always have their men bathe and put on clean clothing before going into action. This would be harder to do with land foices. Naval writers tell of the difficult position of the medical department during action. Such fights are very apt to be one-sided affairs. The fortunate shot or the heaviest gun or the well-placed mine or torpedo will render a vessel impossible, from the surgical status, in short order, while the winning vessel may hardly be hurt and things go on like they do during target practice. Persons who have seen a vessel with a short complement of men, but partially supplied with stores and coal, and most of the machinery covered, have little idea what a crowded place a vessel is when stripped for action. The difficulties are immense. Camps It is the camp that tests the efficiency of the sanitary service. Well do I remember my childish sorrow when my maimed and sick relatives from the war between the states would tell us of their hardships in the camps. Sani- tation was a largely untried experiment in those days, and the wonder is that things were no worse. Any one who looks over the medical and surgical history of that war will give large honors to the splendid men who served in its hospitals and upon the field. There are even creditable records of the sanitary efforts made and the hospitals and hospital vessels were an honor to their time. But when one visits the G. A. R. camps of to-day and notes the comments of the old soldiers upon the modern appliances they there see, one finds that they place more reliance upon hardy manhood than they do upon modern invention. Down in the Canal Zone certain negro laborers n 2 o o C ^ > ^ 5 3 n ARMY AND NAVY SANITATION 257 were housed in well-ventilated and properly screened buildings, and they had a large mortality record because they were used to sleeping in huts reeking with filth and dead air. They contracted colds and pneumonia in good buildings. It is much the same when you take an Indian from his tepee or an Eskimo from his hut. The sanitary administration of Cuba is much con- cerned over yellow fever, because the immune is becoming more rare, and the population is more susceptible to the infection from year to year. Our own American young men seem to contract typhoid too readily. All this suggests a weak spot in sanitation vastly accentuated in the army camp. One of the best things that can happen to a camp, from the sanitary point of view, is to have the enemy near. This makes it necessary to scatter the brigades and to present an extended front. Such camp formation is to be commended at all times. Water supply. — I have seen a regular piped supply laid through military camps. Usually this is impossible, but the expense may be fully justified in many instances. There need be no extended discussion of this matter here, since water supply is fully covered in other portions of this book. But the especial features of a camp supply will be very briefly outlined. The medical officer should always examine all new sources of supply, but it is not to be expected that he can make a good bacteriological examination in the field. Condemned water should never be used, but it takes severe penalties some- times to prevent the soldier from taking the risk. Sterilization by boiling is the main reliance in the preparation of water for the soldier. This matter became really automatic in the Japanese army, since the universal drink was tea. Sterilizing large quantities of water presents many difficulties in the field, but they are not insurmountable. The Forbes sterilizer is largely in use in our army, and the latest pattern supplies sterilized cold water. If water be raised to 176 degrees F. and be maintained there for a short time, the pathogenic bacteria liable to contaminate water are killed and the water does not taste so flat as does boiled water and less fuel is required in the pro- cess. Apparatus requiring special fuel is not suited for field use. Where ten gallons of rhineral oil can be procured every day, water can be sterilized for three thousand troops in an oil-operated apparatus. There are many practical difficulties in transporting and operating regularly any sort of sterilizer. There are many filters in use by various armies, the Darnell outfit being the one most in use in our army. For a full description of this filter see The Military Surgeon, for April, 1908. This apparatus, packed, weighs three hundred and ninety pounds, has a maximum capacity of four hundred gal- lons of filtered water per hour, uses alum and soda as precipitants, imparts little if any taste to the water, makes the water perfectly clear, and removes as high as ninety-nine per cent of all bacteria, in actual service. Water may be purified by chemicals, chlorine, bromine, hydrochloric acid, and potassium permanganate being used at various times. All of these methods are academic and are spoken of here merely because they are still found in books upon military hygiene. In practical use they are far from satisfactory. The precipitation process using alum and other chemicals is discussed in Chapter XXII. 258 HYGIENE Considerable attention has been called to methods of water purification by ozone. Superior results have been claimed for the method under certain circumstances. Some years ago I devised an apparatus designed to produce quantities of ozone and conducted some experiments vi^ith it. At first I felt some enthusiasm over the matter, but finally found that the reactions pro- duced v^ith ozone varied so remarkably under varying conditions not appar- ently according with the range of practicability that I was compelled to admit that ozone is not an agent upon which we can rely and that its real uses are very limited, except when made upon a large scale. Unless some means are found to produce ozone uniformly and of uniform characteristics, I do not believe it will be a real factor in the purification of water for camps. Com- mercial ozone plants are practical. (See Chapter XXII.) Rations. — A large amount of study has been given to the army ration and it is upon a scientific basis. But as this is not a book upon dietetics, there is no occasion to enter upon a discussion of the matter in this connection. The hygiene is partly covered in the chapter upon " Pure Food and Drugs." But aside from that and matters of quality carefully scanned by the govern- ment, it is important to watch the cook. I have personally seen military camps where I would be afraid to eat a meal. They were not camps of regu- lar soldiers. The commissary of every command must be under the constant scrutiny of a capable officer. There is very little occasion for complaint because of the food itself in any kind of command to-day, but there may be carelessness in any of them unless under constant inspection. Keeping food clean, away from dust, cool, dry, free of insects and worms, careful cooking, clean serving, proper disposal of garbage, and above all absolutely screening from flies, are all very necessary in the camp and upon the march. The sub- ject is too large to be entered into at length here and special books should be consulted by interested persons. The army regulations are adequate and could well be followed by camps not connected with the regular army. As to flies, permit me to incorporate here for the benefit of persons who may be compelled to live in a camp, a circular issued by the Chicago Depart- ment of Health and circulated principally among house dwellers. It applies with peculiar force to camps in some of its specifications: Don't allow flies in your house. Don't permit them near your food — especially milk. Don't buy foodstufi^s where flies are tolerated. Don't eat where flies have access to the food. Flies are the most dangerous insects known to man. Flies are the filthiest of all vermin. They are born in filth, live on filth, and carry filth around with them. They are maggots before they are flies. Flies are known to be carriers of millions of death-dealing disease germs. They leave some of these germs wherever they alight. Flies may infect the food you eat. They come to your kitchen or to your dining table, fresh from the privy vault, from the garbage box, from the manure pile, from the cuspidor, from decaying animal or vegetable matter, or from the contagious sickroom with this sort of filth on their feet and in their bodies, and they deposit it on your food, and you do swallow filth from privy vaults, etc., if you eat food that has come in contact with flies. ARMY AND NAVY SANITATION 259 Flies may infect you with tuberculosis, typhoid fever, scarlet fever, diphtheria, and other infectious diseases. They have the habit of feasting on tuberculosis sputum and other discharges of those sick with these diseases, and then go direct to your food, to your drink, to the lips of your sleeping child, or perhaps to a small open wound on your hands or face. When germs are deposited in milk they multiply very fast; therefore, milk should never be exposed to flies. What to do to Get Rid of Flies Screen your windows and doors. Do it early before flytime and keep screens up until snow falls. Screen all food, especially milk. Do not eat food that has been in contact with flies. Screen the baby's bed and keep flies away from the baby's bottle, the baby's food, and the baby's " comforter." Keep flies away from the sick, especially those ill with typhoid fever, scarlet fever, diphtheria, and tuberculosis. Screen the patient's bed. Kill every fly that enters the sickroom. Immediately disinfect and dispose of all discharges. Catch the flies as fast as they appear. Use liquid poisons, sticky fly papers, and traps. Place either of these fly poisons in shallow dishes throughout the house: (a) Two teaspoonfuls of formaldehyde to a pint of water, or (b) One dram of bichromate of potash dissolved in two ounces of water, sweetened with plenty of sugar. To quickly clear rooms of flies, burn pyrethrum powder or blow powdered black flag into the air of the room with a powder blower. This causes flies to fall to the floor in stunned condition. They must then be gathered up and destroyed. Eliminate the Breeding Places of Flies Sprinkle chloride of lime or kerosene over contents of privy vaults and garbage boxes. Keep garbage receptacles tightly covered, clean the cans every day, the boxes every week. Keep the ground around garbage boxes clean. I Sprinkle chloride of lime over manure piles, old paper, old straw, and other refuse of like nature. Keep manure in screened pit or vault if possible. Manure should be removed at least every week. Pour kerosene into the drains. Keep sewerage system in good order, repair all leaks immediately. Clean cuspidors every day. Keep five per cent solution of carbolic acid in them all the time. Get rid of sawdust boxes used as cuspidors — destroy them — they're insanitary. Don't allow dirt to accumulate in corners, behind doors, back of radiators, under stoves, etc. Allow no decaying matter of any sort to accumulate on or near your premises. Flies in the home indicate a careless housekeeper. Remember: No dirt — no flies. If there is a nuisance in the neighborhood notify the department of health, city of Chicago. It is cheap to condemn and destroy all doubtful food in the camp and to keep a supervision over food sold to soldiers by merchants and restaurants contiguous to the camp. Disposal of excreta. — Pit latrines will do for camps of a few days, but 260 HYGIENE they must be so constructed as to exclude flies absolutely, the dejecta must be so placed as to be readily sterilized without removal, and soiled parts must not be too valuable to burn. The best device for brief use of which I have knowledge was invented by Capt. F. A. Herrick, of the Ohio National Guard. Circular holes were sunk by means of post hole augers and widened at the bottom with bars or other devices. They were sunk upon hillsides and in light soil, so they would not fill with water. Galvanized iron cylinders were fitted into these holes and over them were erected metal bowls and wooden seats with covers automatically closing. Cheap disinfectant solutions were siphoned into the latrine at frequent inten-^als. Once each day the holes were burned out with paper saturated in coal oil. When breaking camp, lime is thrown in and the holes filled. In camps used for long periods, the McCall incinerator is almost ideal. It is most too elaborate to fully describe without diagrams, but can be seen in so many camps of United States troops or at the factory at Huntington, Tenn., that interested persons can readily become familiar with its workings. Private parties can procure them of the factory. In many camps the men are required to wash their hands in an antiseptic solution when leaving the latrine or incinerator. In view of the fact that urine may carry typhoid bacilli, care must be exercised to prevent urination, ex- cept at the latrine. Garbage may be buried, but the safest and best way is to burn it at once. An experienced camp cook can burn so much of it that it is little of a separate problem. Housing can best be studied from the regulations and upon the field. So many kinds of construction are used in the army and so many forms of tents are issued that our present space precludes a study of the matter. I could not attempt to give an adequate idea of the subject in the few pages at command. See special works. Transmissible diseases. — These are the same in military as in civil life and the treatment calls for no special comment here, except to say that the military physician is largely limited to the supply table in the selection of his drugs. This supply table has been much called in question by contract physicians who feel that the patient needs what he has been accustomed to use. There is truth upon both sides, but the field difficulties are so great that one should not criticise the medical service of the United States without seeing for himself the difficulties of the situation. As a matter of fact, the mortality records of the army and navy do not make it appear that the welfare of the sick soldiers and sailors is being jeopardized by a limited drug list. Upon requisition, properly vised, a medical officer can usually get most any drug he may need. I have at my hand " Hygienic Laboratory Bulletin, No. 49," being a " Digest of Comments on the Pharmacopoeia of the United States of America," and issued by the Government Printing Office in 1909. It is an answer to the medical critics of the senice, and shows conclusively that the service is keeping abreast of therapeutic advance. The present writer is inclined toward school liberality and very frankly uses and advocates certain drugs of eclectic and homoeopathic origin, yet he cannot see how a government can recognize three pharmacopoeias, and, until the schools unite in pharmaceutical matters, there is no hope of the army and ARMY AND NAVY SANITATION 261 navy using any but defined preparations. I can in private practice do so, but would not think of attempting it in my hospital service, as matters would be sadly mixed in short order. Therefore, were I in the medical service of the army, I would not think of making any experiments. A short experience substituting in the Indian service some years ago made it very plain to me that a supply table is very necessary. Furthermore, observation has con- vinced me that the men in the medical service know their business. Typhoid fever has a very high mortality rate in the field and every effort is made to prevent it. From my observation of this disease in camp I believe that the appearance of the disease therein should spell marching orders within forty-eight hours. If it occurs in a national guard camp of short duration, the camp site better be changed the next year. Malaria is well controlled, now that we know how it is disseminated, and there is comparatively little of a problem presented to the medical officer practically familiar with mosquito extermination. Cases may well be transferred to base hospitals. Diar- rhoeas are usually preventable, but must be carefully differentiated from typhoid. The bacillus coli communis is responsible for many cases, and the remedy is obvious. Bubonic plague is prevented by methods described for the extermination of rats in the chapter upon Slums and Town Nuisances, and need not be repeated here. Venereal diseases are common in all armies and navies. The navy of japan admits that 27.75 per cent of all admissions are for venereal diseases, and some persons say that England and the United States show even a worse record. I have read a large amount of learned matter as to how to suppress venereal diseases in the army and navy, but have found few real suggestions. Any one who visits ports and keeps his eyes open will see just why. Camps are bad or fair in this regard, according to the degree of latitude allowed by the officers. Certain things are so deeply ingrained in human nature that even military officers are inclined to wink at them. Perhaps sometime there will be a different sentiment among soldiers and sailors, and something can be done to prevent venereal abuses. That time has not yet come. That soldiers and sailors, or in fact any class of segregated men, will ever accord with the point of view of the " purists " as to the " amiable vices " is very improbable. Certainly most of us think men should, but the fact is they never did accord with this view. See the chapter upon Places of Amusement and Dissipation. Other infections are of importance among soldiers and sailors. Measles has been a serious m.enace in camps and surgical erysipelas was formerly a serious matter. Mumps sometimes assumes a threatening aspect in camps. Tropical diseases were never so studied as they have been by the Ame can army. Osier's "Modern Medicine" will acquaint the reader so well with the wonderful advances along this line that it is quite unnecessary to discuss the subject here. Unfortunately, yellow fever, pellagra, and bubonic plague have reached our shores. Cholera is a menace possible with us, while cattle diseases seem to be coming to us from foreign shores. The victory over yellow fever and malaria in Panama and Cuba and of the hookworm disease in Puerto Rico are largely instances of the scientific attainment and courage of the army medical man. And within our own country at home the record of 262 HYGIENE the same kind of men in preserving us from bubonic plague is an earnest of the good an army can do. Our military establishment does not exist solely to fight our battles. I wish that it were possible for the rank and file of phy- sicians to receive the literature of our government departments and especially of those having to do with medicine. As an author and medical librarian I have these publications at command, and they have made me proud of my country; but any physician can get them at cost by addressing the Superintendent of Documents, Government Printing Office, Washington, D. C. And it seems to me that the military physician who has accomplished so much in the prevention of tropical diseases might be a good man to inves- tigate the unconquered diseases of temperate climes. Clothing. — This subject will be touched upon in considering the naval regulations. There has been a wonderful change in military uniforms within the last few years, all tending toward greater practicability and sanitary use- fulness. Persons desiring details can consult the regulations governing the matter. Marches. — Did you ever march in the ranks ? There is very little poetry in it and it is exceedingly exhausting work. And yet it is necessary work. The mobile army is usually the one to win the victory. To my mind, the march could be rendered more easy. There are military men who claim that the " martial bearing " or " ramrod attitude " is not good for health. While this sort of thing and many other fancy postures of the drill manual look pretty and are supposed to make a soldier, I fail utterly in seeing any real utility in that sort of thing and think it time to stop using the soldier's strength preparing for parade drill and indulging in what the women regard as heroics. With all deference to the ladies, they are not needed about mili- tary camps and show good taste in remaining away unless they come to work in time of war or to nurse sick men. I speak advisedly in the matter and think it time that the regulations about camp visiting generally be made more stringent. At all events, removing the spectacular and the appeal to gallantry would puncture a lot of dress drill or " dress parade," as it is justly called. What the soldier needs to learn is how to take care of himself and make it dangerous for the enemy. Fancy uniforms have largely gone and fancy postures and drills should follow. As a matter of fact, they are going. " Tell it not in Gath," but I have really seen soldiers upon the march walking along just like any easy-going pedestrian. The martial bearing need not be abolished, but a sensible officer will suspend as much of it as the regulations will permit. Peary's march to the pole should be an object lesson to the army. The long practice marches recently indulged by certain commands have nothing to commend them, but a sensible and regular system of practice marches strictly within the capacity of the men should be highly beneficial. The canteen. — Dr. Anita Newcomb McGee, formerly acting assistant surgeon, United States Army, conducted an elaborate investigation of the canteen and reported in a very scientific and unbiased way her conclusions. Her statements impress me as the most temperate and well advised of any- thing I have encountered upon the subject. Permit me to state her postulates without the data substantiating them. ARMY AND NAVY SANITATION 263 1. There has been somewhat less drunkenness in the army since the canteen was abolished than there was in the years when it flourished. 2. The difference in amount of alcoholism during the canteen years (before 1898), and that during the post canteen years is so slight as to show in conjunction with other facts that the presence or absence of the canteen has a decidedly minor eflTect on drunkenness in comparison with other influences. 3. There was an enormous increase in venereal diseases in 1899, coincident with tropical service; there was no increase in the United States in the four years following the abolition of the canteen, as compared with the two years preceding it. In the Philippine Islands there was an absolutely regular increase from 1896 to 1903. 4. The increase of saloons outside army posts, which was so generally predicted to follow an anti-canteen law, did not occur at all. 5. Desertions, court-martials, etc., are due to so many causes I have not con- sidered them worthy of thorough analysis, but so far as I examined, I could find no pro-canteen evidence. 6. The statement that " The army from the lowest rank up is (1907) practically unanimous in its desire to have the canteen re-established " is an opinion, the proof of which I could not obtain. 7. Quite apart from the canteen, the subject of drunkenness and immorality in the army demands attention. International medical statistics show that the admission rates of alcoholism, for gonorrhoea, and (British Army excepted) for syphilis, " were much higher than in any other army." (Surgeon General's Report, 1907, pages 23 and 26; for 1906, pages 22 and 24.) 8. Conclusions: It is evident that I have only scratched the surface of a mine of actual fact. But the great difi^erence shown to exist in the different arms of the service leads me to the belief that if army officers would make a careful study of the facts much could be done to reduce the amount of alcoholism, and it is for this reason that I have yielded to repeated urgings to set forth the main facts which I have learned, I have become convinced that the prohibition sentiment of the country makes the restoration of the canteen impossible. The sooner we forget it and adopt other methods for diminishing alcoholism, the better it will be for the army. It is significant that many officers do not agree with Dr. McGee. Per- haps the clubs they frequent keep up a canteen sentiment, and what is good for them should be good for their men. The American officer is always " generous to a fault." Special Naval Regulations A physician who knows how to operate a lathe or run an engine is just as much impressed with the mechanical features of a modern warship as he is with the sanitary regulations. From some examination of examples of the navies of several nations, I confess to a disappointment in the former features. Altogether too much is attempted within a limited space, and the whole impressive ensemble is that of a machine shop needing a visit from the factory inspector. With wireless equipment, submarine features, and the ever growing addition of mechanical devices, the whole jumble leads one to speculate as to how much of it will have to be cast overboard when stripping for action so as to leave room to man the guns. It is like a house so full of 264 HYGIENE junk as to leave no adequate room for the people, or a factory so crowded with machines and workmen as to scarce give one room to turn around or get fresh air. To the mechanic there is a dangerous proximity of diverse ele- ments and too much heavy machinery for successful handling within the space at command. A mere boat builder cannot but regard the overweighted and top-heavy warship as a sort of monstrosity. The man apt to be shot at fears more from splinters and broken machinery and internal explosions than he does from the projectiles of the enemy. In modern construction too much depends upon maintaining structural integrity. There are too few units and too much mechanism. It is like two hundred trolley cars depending upon one power plant; slip a belt and the whole line is tied up. Some day (or more likely some night) half a dozen such leviathans will be annihilated by one cruiser and a fleet of submarines, and then the world will cease building the over-developed typical battleship of to-day. But from the sanitary point of view there are features to commend. There are no timbers to rot out and no inaccessible places for filthy bilge water to collect ; a man with an electric light and paint pot can get anywhere, even between the double bottoms; there are few places to harbor vermin or mosquitoes, rats are readily controlled upon such vessels, they are easy of disinfection, the sick bays in peace are ideal, the plumbing and sanitary fea- tures are beyond criticism, there is a most careful inspection of provisions, and there is an abundance of hot water and live steam for sanitary purposes. Simplify the naval fight and reduce the range of work required of a vessel, so as to reduce machinery, fittings, and weight of superstructure, and there could hardly be a better health resort than a naval fighting machine in time of peace. Aboard a warship one finds ideal care as to foods. Meats are in cold storage and are not allowed to be even hung up to thaw, but must be placed in cold water for this purpose; vegetables and fruits are most carefully washed before peeling; vegetables eaten raw are first subjected to a heat of one hundred and forty to one hundred and sixty degrees if from an oriental country, where human excrement is used as fertilizer an inch is cut oflF the ends of bananas, and endless trouble is taken with the water used for all purposes. This is but an illustration of the care exercised. Even the coal bought is inquired into as to the health of the region from which it came, so that cholera and other pathogenic germs may not come aboard. What is said here is a mere indication of the naval problems. Doubt- less many persons will desire to pursue the matter further. Dr. P. M. Rixey, Surgeon General, United States Navy, informs me by letter that the latest book upon the subject, as it relates to the United States, is one by Medical Inspector J. D. Gatewood, U. S. N., entitled " Naval Hygiene," and published by Blakiston & Co., Philadelphia. Dr. Gatewood is one of the most able officers in the service and his book is very authoritative. This work covers the broad principles involved, and is a scholarly presentation of the matter in its many bearings. The book called " Instructions for Medical Officers of the United States Navy " is a one hundred and fifty page volume (1909 edition) issued to medical officers of the navy. It would pay any phy- Hligi; *-«**: art-i^isw-iiftin^sa^s-- -?c»»» CAMP OF INSTRUCTION AND PROVISIONAL TENT HOSPITAL FORT RILEY, KANSAS ANOTHER PORTION OF THE SAME CAMP FIELD HOSPITAL NO. 8 AND AMBULANCE COMPANY, SAME CAMP Courtesy U. S. War Department ARMY AND NAVY SANITATION 265 sician to read it, provided it is attainable. From it most of the following data is derived, as I do not feel justified in the expression of any but the official views as regards specific regulations. Criticism of structure is another matter. If you want some pessimistic reading look up the reports of medical officers aboard vessels badly injured or destroyed in action during the naval fights of the last fifteen years. The United States Navy cannot aflTord to largely de- part from conventional models until there is a general international agree- ment that the structural defects of the present t}pe of vessels be eliminated. While such matters are not settled and the advocates of the present types are so sensitive to criticism, it is not fair to quote naval men upon the matter, but I am informed that most of the " navy muckraking " is based upon data from constructors here and abroad. Certain it is that vessels out of commis- sion and practically abandoned by the navy are often so spick and span in ap- pearance that I cannot help but feel there is something wrong in a type that is so soon cast upon the scrap heap. War vessels have been made much longer than have automobiles. I have just been looking at 1910 models up about Columbus Circle, and can find very little change in the new cars. The sales- men tell me they are so near perfected that little change is advisable in new models. But when I went over to the navy yards the mechanics were in a ferment wondering what would happen next year to make obsolete the types of this year. Down in the Washington navy yards I found them remaking certain mechanism that had never been used long enough to get limbered up. One day when aboard a warship the bandmaster left the vessel and a medical officer laughingly recounted to me the ideas the first man entertained as to musical technic and the extreme professional views he held relative to music and the great difficulty in rendering " the soul " of the composition. The medical officer had just been telling me something of how different naval sanitation was from any other, and how long it took for an intelligent man to imbibe the highly specialized technic involved. It reminded me of my own experience. For eight years I had charge of a very busy and well-equipped X-ray laboratory and made it a point to meet the operators over the country who were publishing results I never secured, and explaining how the usual operator did not succeed in doing these remarkable stunts with the ray because of defective technic. I found most of these enthusiasts had a different technic. I never published my results with the ray; they were too mottled. And I have noticed that the naval medical officer of some years' experience is a very modest gentleman and can tell of seveial things he does not con- sider immutably settled. A mere observer like myself cannot judge between differing naval points of view, so will content myself now with a resume of matters contained in the book of instructions before referred to. The very first page has to do with appropriations, and that very clearly proves that the regulations are up to date. And if any one thinks that the money is all spent in getting ready to fight, he is mistaken, for, as with the army, the navy does a host of things in time of peace that are of positive use to the country. Croakers please take notice. Our navy pays a host of me- chanics and constructors, keeps up a coast survey, good museums and labora- tories, and adds a large increment to the sum total of useful human knowl- 266 HYGIENE edge, maintains hospitals, buries the dead, pubhshes much valuable data, gives instruction along sanitary and other lines, conducts original investiga- tions, looks after certain insane persons, patronizes a host of industries, and does many things with money that render a good return to the country if it never fires another shot. To enter medical service of navy. — The applicant must be a citizen of the United States, be of good moral character, be between twenty-one and thirty years of age, and pass a nine days' examination, guaranteeing his physical and professional fitness to enter the service, and that he possesses a good general education. The examinations are rigid but practical, and what I have learned of them make me believe that they are more rational and reasonable than are a good many medical state board examinations. Pro- motion is earned only after later and additional examinations, and which works to keep the medical officers up to date and studious. Navy medical school. — This school gives a course of instruction lasting five months of each year and serves as a post-graduate school of instruction for naval medical officers, and covers such subjects as are of value in increas- ing their efficiency. Duties of the medical officer. — He gives the crew weekly instruction in first aid and personal and general hygiene. The boys get plenty of good advice as to the use of intoxicants, the care of venereal diseases, etc., and are taught how to take care of themselves under all circumstances. Asepsis is well drilled into the men and tuberculous cases on board are given especial instruction. The medical officer also takes part in the drills and keeps the men up to efficiency in the medical features of fire drill, collision drill, rescue drill, and clearing ship for action. There are additional duties at recruiting rendezvous, at hospitals, in hospital ships, and certain board duties. Of course he attends the sick and looks after the sanitation of his station. There are numerous regulations regarding the hospital corps, nurses, hos- pital ships, and many other duties not specifically relating to sanitation, and which need not be discussed here. Enlistment. — The examination of the recruit is such an elaborate affair that it would take pages to outline the matter, let alone give any adequate digest of the methods and requirements. I note that persons given to intoxi- cation are now rejected. Added to the elaborate examination, identification records and finger prints are made and preserved of all enlisted men. Sanitary regulations. — These regulations provide for detailed re- ports and designate a number of duties very obvious in their necessity, such as ship ventilation, etc., and covering hygiene such as is necessary everywhere. The work especially pertaining to shipboard is as follows: Distilled water must be used for drinking and culinery purposes and harbor water may not be used upon the decks where sewage enters the harbor, or where epidemic disease, such as cholera, prevails. There are regular rules as to temperature and weather conditions decisive of the kind and weight of clothing to be worn and the use of awnings, etc. Bathing over the ship's side is allowed when the water is at 70 degrees F. Infected ports are to be avoided, and when duty calls the vessel there elaborate precautions are taken. Anchorage ARMY AND NAVY SANITATION 267 at such ports is selected to windward and the shore Hberty is Hmited or abolished during the stay of the vessel. Mail is watched or disinfected and the medical officer is empowered to do whatever seems necessary for safety. In the tropics the crew is rested during the middle of the day, awnings are freely used, mosquito nets are in constant service, clothing is changed when a man gets wet from rain, the sun is carefully avoided, and especial care is taken of the food supply. Contagious or infectious diseases aboard are very carefully isolated, and the care taken is similar to that outlined in other chapters of this book, only the navy inclines toward the use of sulphur fumigation and steam sterilization more than do health boards. The scuttle-butt cup is kept submerged in a formalin solution (1-2500) when not in use, but especially constructed scuttle- butts are coming into use that very much reduce the danger of infection being conveyed by drinking at a common supply. Landing parties are under sanitary regulations similar to those described in the earlier sections of this chapter, only the regulations are imperative, and such matters as sterilizing the water are not merely suggested; they are directed absolutely. Insects are carefully avoided and unnecessary exposure of the men to the sun, rain, and dew are prohibited, whether the drills are held or not. Camp sites are not used twice unless absolutely unavoidable. " Under no circumstances should the men be allowed to sleep in wet clothing," and they are shielded from the sun, are not allowed to go with bare feet, meals must be served warm, no one may be overworked, and the whole list of regulations impress one with the good sense and humanitarianism of the orders. Hospitals, shore stations, navy yards, newly commissioned ships, and all other property are under constant regulation too complex to outline in detail here. Careful sanitary observations and reports of all places visited outside the continental limits of the United States are required, and are sent to the Bureau of Medicine and Surgery. Quarantine. — The chapter upon quarantine covers the matter and little need be said here. The following diseases are quarantinable: (a) Cholera, period of incubation, five days. (b) Yellow fever, period of incubation, five or six days. (c) Smallpox, period of incubation, fourteen days. (d) Typhus fever, period of incubation, twelve days. (e) Plague, period of incubation, seven days. (f) Leprosy. If in an alien, not permitted to land. If a citizen, the case is dealt with according to the state laws of the port of entry. This list can well be commended to the attention of sanitary officials wanting to quarantine a very extended list of minor diseases. With certain exemptions, vessels of the navy entering port are subject to quarantine in- spection the same as are other vessels. Disinfection is along lines outlined in the chapter upon disinfection. In that chapter will be found two photo- graphs of disinfecting apparatus. Both of them were taken by myself aboard a vessel at the Staten Island Quarantine Station. As indicated 268 HYGIENE before, sulphur disinfection is very largely depended upon in the navy. Spaces containing machinery are first arranged so that metal parts may be coated with vaseline. Fabrics are removed, from the apartments and the effort is made to reach rats and vermin. I find that formaldehyde is not very much in favor in the navy. It is not depended upon at all for the holds of vessels and has the disadvantage of not killing vermin. It has slight penetration. It is used largely for fabrics and in apparatus such as is illustrated in Chapter XVIII. The autoclave under pressure is used, formalin and calcium chloride being used, and the gas being evolved under a pressure of not less than forty-five pounds. The autoclave method combined with sustained dry heat (60 degrees C. for one hour) is used in sterilizing some articles and in disinfecting baggage. Chemi- cal disinfectants are used as in general sanitary practice, the regulations specifying details. For the destruction of mosquitoes, the following methods are used: (a) Sulphur dioxide. A strength of one per cent of dry gas is very efficient. (b) By burning pyrethrum. Use two pounds for every one thousand cubic feet of space, allowing an exposure of four or five hours. After using pyrethrum sweep up the stupefied mosquitoes and burn them. (c) By vapors from a mixture of equal parts of camphor and phenol, using about five ounces for each one thousand cubic feet of space. Put camphor and phenol in evaporating dish, and heat with moderate alcohol flame. A fine white cloud of vapor is evolved. Inhalation of this vapor should be avoided. If inhaled smoky urine results. Insanity. — There is a government hospital for the insane in the District of Columbia. That institution and the Mendocino State Hospital of Cali- fornia receive the cases under regulations, copies of which can be procured from the Bureau of Medicine and Surgery. And now to return to my own humble expression of opinion. Navies generally are taking an increased interest in the humanities. The Geneva Convention marked the end of wholesale barbarity in navies. I have no word of criticism for the past, but the world moves on and there is a growing tendency in armies and navies to retire the old saying, " War is hell." That killing and maiming will continue is to be expected in the nature of the case, but warfare is becoming a far more humanitarian international game and civil and revolutionary war is becoming less possible and probable from the necessity for procuring expensive and elaborate equipment as well as specially trained men in many lines. Any one who takes the trouble to read the articles of the convention and their further elaboration at the Hague Peace Conference cannot but be impressed with the humanitarian advances in warfare, and a physician will realize the great emphasis laid upon camp and ship hygiene and the especial prerogative and liberties accorded to the medical service in time of battle. Hospital ships are becoming a factor of great importance, and the litera- ture is extensive. While not purely a matter of hygiene, the subject interests physicians. Dr. J. C. Wise, of the United States Navy, contributed a very good article to the December, 1907, number of The Military Surgeon. The a. a- ? O H ^ O O R o tj- CO O 2! v^ CO O Chapter XIII THE CORONER AND THE PHYSICIAN A discussion of his status in law — The importance of the physician knowing the powers of the coroner in his own county or city — What a physician can expect of a coroner — What a coroner can expect of a physician — What cases to report to the coroner — Final remarks. OLD English law provides for and defines the duties of the coroner, and most of the states of the American Union have followed the general principles long since laid down. Some cities enact special legislation regulating his office, especially where the limits of the city and the county are the same. These city laws differ somewhat and may provide for deputies, coroner's physicians, and a force of detectives. Such a law is in force in Philadelphia and doubtless cities desiring copies of the law can obtain the same from the office there or wherever special legislation has been enacted. In general a coroner is a county official, and has power to subpoena witnesses, take evidence, make arrests, and do other things not necessary to discuss here. He is a very powerful official and bears a certain relationship to the sheriff and is, in most places, the only man who may arrest the sheriff, unless the latter official be taken in the commission of crime. Where the cause of a death is not certainly and legally determined, it is the duty of a coroner to make an inquiry into the facts surrounding the death. If in his inquiry he finds full evidence clearly determining the matter, he may issue a death certificate. Such disposition is frequently made of the case since many suicides are so apparent, and many deaths come suddenly in persons known to be suffering from vital diseases and the end come without medical atten- dance. In such cases the coroner is the only person who may issue a death certificate and the same is accepted by the health authorities for record. Where the facts are not such as in his judgment warrants the issuance of a death certificate or to define liability for the death, he may impanel a jury of citizens who view the body to make it assured that the party is dead, to make such inquiries as may be necessary to establish the identity of the deceased, to define the cause of death and sometimes to determine liability therefor. The general principles of evidence are rigidly applied and the findings of a coroner's jury may warrant arrest and the presentation of the evidence to the grand jury and finally to the court. These all involve so much of a legal nature that persons desiring information should look for the same in legal works, the books upon medical evidence, toxicology, and medical jurisprudence, inclusive of the many points involved in the making of a post mortem examination. The matters at issue do not concern our present inquiry, but there is a dearth of authoritative literature upon the duties of the coroner's office. The importance of the physician knowing the powers of the coroner in his own county or city. — In law the word of the physician actually in personal 276 HYGIENE attendance upon a person who is ill and who may die is accepted as com- petent evidence as to the cause of death; but there are distinct exceptions every physician must bear in mind. Death by violence (homicidal or acci- dental), by poison, by suicide, by neglect, from unknown cause, or without legal medical attendance, must be reported to the coroner. Were not this the case, not only would criminals be apt to escape punishment for their crimes, but the record of death would be so ill defined as to give trouble in many directions. The sanitary authorities are charged with the recording of all deaths and such record must stand legal tests. When the physician is not in actual position to give legal weight to his death certificate, he should not issue one. Therefore, this book is not in position to define the obligation of the physicians to the coroner's office. Every physician should make it his care to learn the requirements in his own district. The only safe general rule is for the physician to take no risks. If he has not personally examined within twenty-four hours, in the capacity of attending physician, the person who has died and knows that said living person was suffering from a disease liable to be soon fatal, he better call the attention of the coroner to the death. While some reports may be unnecessary, it is better to err upon the safe side than upon the other. What a physician can expect of a coroner. — First of all, he can expect the coroner to absolve him from liability in case of sudden death and in which he may be present and gossip may connect his name in an unpleasant manner. It is a common occurrence for a reputable physician to be called to a woman flooding to death from a criminal operation, or to the deathbed of a person who has been feloniously assaulted, or who has endeavored to commit suicide. When we find ourselves in such unpleasant circumstances, it is wise to send for a consulting physician and for the coroner, and his inquiry will soon absolve the innocent physician. A physician who is a party to the con- cealment of crime is particeps criminis, just like anyone else. Professional secrecy does not involve our compromising our own liberty or innocence. It is the duty of the coroner to make as prompt response as he can to the call of the physician. Post mortem changes may soon take place and delay may defeat the ends of justice. In the rare cases in which sudden death may be charged to a surgical operation or to an anaesthetic, the surgeon cannot insist upon a post mortem examination for his own protection, but the coroner can do it for him and very probably relieve him of all blame. Where con- tagious disease has been concealed and the death involves the necessary pre- cautions, the physician can save all controversy with the family and the sani- tary authorities by calling the coroner. Besides all this, there are occasional cases of conflict between physicians or between the physician and the real or pretended relatives of the deceased, and that may involve one in quite a deli- cate position. In such cases, the coroner is always our best friend. There is no occasion for the physician to fear the coroner, provided he has done his duty, and is not helping some one to pull chestnuts out of the fire. The phy- sicians as a class can expect the coroner to aid in procuring evidence against THE CORONER AND THE PHYSICIAN 277 malpractitioners, and the health authorities can expect his aid in keeping the most difficult class of vital statistics. What a coroner can expect of a physician. — Briefly, he can expect a full and frank statement of everything he knows that may help in arriving at a just verdict in any and all cases. He can direct a physician to make an examination of a body, perform a post mortem examination, or make chemical analyses. He may also call upon a physician as a witness in ordinary or as an expert. A coroner need not be a physician, but may, when specific city legislation permits, employ a regular physician and, in any event, give war- rants upon the county commissioners for such medical services as may be really necessary. The notifications of deaths by the physician is mandatory. When the physician has notified the coroner of a death, only the latter may issue the death certificate, unless he directs the physician to do so. What cases to report to the coroner. — This depends somewhat upon local regulations. Sheriffs must have the coroner issue the death certificate in cases of legal execution. Common carriers must notify him of corpses found along their right of way, or of persons dying suddenly upon their property, as well as those killed by accident. Reports need not necessarily come from a physician, but he must report any sudden deaths in his practice unless the case has been ill of a disease liable to cause death at any time, or complica- tions arise in a less dangerous disease. If the physician is sure of the cause of death and has attended the party within twenty-four hours, he need not report, save in exceptional cases. Deaths by violence, poison, suicide, or neglect, or of persons not known, must be reported. Final remarks. — The coroner does not take any part in public hy- giene, except in the making of death reports, and in the suppression of crimes that incidentally touch upon the larger questions of public hygiene in its sociologic side. The neglect of infants, so that they die, the criminal care- lessness of persons and corporations, abortions, and infanticide and other questions regarding human life are within his province. Chapter XIV QUARANTINE* Definitions — Maritime — Port regulations — Inspection — Ports of entry — Quarantining of vessels — Requirements at quarantine — Regulations concerning cholera, yellow fever, smallpox, typhus fever, leprosy, and plague — Canadian and Mexican frontiers -^ Disinfection — Interstate quarantine — Maritime quarantine maintained on lakes, gulf, and rivers — Inland quarantine • — Quarantine in the various states. THE word quarantine is derived from quaranta, meaning forty, and was first applied to the period of detention as practiced against plague in Marseilles in the fourteenth century. Quarantine may be subdivided into maritime, interstate, state, muni- cipal, and house quarantine, depending upon the extent of territory that is involved in the application of the measure. Maritime quarantine relates to the measures enforced by the national and state governments to prevent the entrance of infected persons, ships, or merchandise. These measures are applied at ports of entry and along lines of communication by land with such ports. Interstate quarantine relates to the measures which are employed by the national and state governments to prevent the transmission of infection from one state to another through infected persons, merchandise, or public conveyances. These measures are applied in such a way as to prevent the transportation of the infection from the infected area to areas that are free from the infection. State quarantine relates to the measures adopted by a state government to prevent the introduction of infectious persons or merchandise into the state along the ordinary routes of travel. Municipal quarantine relates to the measures adopted by a municipality to prevent the entrance of infected persons into the town, and consists in in- hibiting all intercourse with the infected area. House quarantine relates to those measures which are applied to limit the infection to certain houses, and consists in inhibiting intercourse between the occupants of the house and those living outside its walls. Maritime Quarantine The machinery employed by the national government in enforcing quar- antine consists of inspection stations at all important ports of entry where ships are detained, and their passengers, crews, and merchandise inspected and isolated in case they do not show a clean bill of health. At these inspection stations the government maintains boarding vessels manned by experts who inspect the vessels and enforce the quarantine measures. Here quarters are provided for the treatment of the sick and for the isolation of the well persons *Edited from data secured from the Laboratory of Hygiene, University of Pennsylvania. QUARANTINE 279 until they are found to be free from infection. Appliances are also provided for the disinfection of the vessels and their cargoes. The appliances for dis- infection include arrangements for the mechanical cleansing of vessels and for the use of steam, formaldehyde, sulphur dioxide, and disinfecting solutions as may be indicated by the nature of the infection. Regulations at Ports of Departure The quarantinable diseases are cholera, yellow fever, smallpox, typhus fever, leprosy, and plague. Vessels coming from foreign ports must show a clean bill of health with regard to these diseases, which bill of health is issued by the resident consular officer of the port of departure. Masters of vessels departing from any foreign port, or from any port in the possessions or other dependencies of the United States for a port in the United States or its possessions or other dependencies, must obtain a bill of health, in duplicate, signed by the proper officer or officers of the United States as provided for by law. Vessels plying between Canadian ports on the St. Croix River, the St. Lawrence River, the St. Clair River, and adjacent ports of the United States on the same waters;also vessels plying between Canadian ports on the follow- ing named lakes, viz., Ontario, Erie, St. Clair, Huron, Superior, Rainy Lake, Lake of the Woods, and Lake Champlain, and ports of the United States; also vessels plying between Mexican ports on the Rio Grande River and adjacent ports in the United States, are exempt from the foreign regulations. During the prevalence of any of the quarantinable diseases at the foreign port of departure, vessels above referred to are required to obtain from the consular officer of the United States, or from the medical officer of the United States, when such officer has been detailed by the President for this purpose, a bill of health, or a supplemental bill of health, in duplicate, in the form prescribed by the Secretary of the Treasury. The officer issuing the bill of health shall satisfy himself, by inspection if necessary, that the conditions certified to therein are true, and is authorized in accordance with the law to withhold the bill of health or the supplemental bill of health until he is satisfied that the vessel, the passengers, the crew, and the cargo have complied with all the quarantine laws and regulations of the United States. Inspection is Required of (a) All vessels from ports at which cholera, yellow fever, or plague pre- vails, or at which smallpox or typhus fever prevails in epidemic form. (b) All vessels carrying steerage passengers; but need only include the inspection of such passengers and their living apartments, if sailing from a healthy port. Inspection of the vessel is such an examination of the vessel, cargo, pas- sengers, crew, personal effects of same, including examination of manifests and other papers, food and water supply, the ascertainment of its regulations with the above, the manner of loading and possibilities of invasion by small 280 HYGIENE animals as will enable the inspecting officer to determine if these regulations have been complied with. The officer making the inspection will preserve in his office a record of each inspection made and of each immunity certificate given; a copy of each certificate of disinfection and of each bill of health issued. A weekly report of the transactions of his office shall be forwarded to the surgeon-general at Washington, D. C. Regulations at Ports of Entry The national government maintains quarantine and inspection stations at the following places: Portland, Me.; Boston, Mass.; New York, N. Y. ; Perth Amboy, N. J.; Delaware Breakwater, and Reedy Island, Del.; Alex- andria, and Cape Charles, Va.; Cape Fear, Newbern, and Washington, N. C; Charleston, Georgetown, Beaufort, and Port Royal, S. C; South Atlantic, and Savannah, Ga.; Cumberland Sound, St. John's River, Biscayne Bay, Knight's Key, Key West, Punta Rossa, Bocagrande, Tampa Bay, Port Ingles, Cedar Keys, St. George's Sound, and Pensacola, Fla.; Fort Morgan, Ala.; Gulf Quarantine, Miss.; New Orleans, La.; San Francisco, San Diego, San Pedro, Port Los Angeles, Santa Barbara, Port Hartford, and Eureka, Cal., Casco Bay, Newport, Florence, and Columbia River, Ore.; Port Townsend and Port Angeles, Wash.; Dutch Harbor and Nome, Alaska. Every vessel subject to quarantine inspection, enteringa port of the United States, its possessions or dependencies, shall be considered in quarantine until given free pratique. Such vessels shall fly a yellow flag at the foremost head from sunrise to sunset, and shall observe all the other requirements of vessels actually quarantined. Vessels arriving at ports of the United States under the following condi- tions shall be inspected by a quarantine officer prior to entry: (a) All vessels from foreign ports except those coming from Canadian and Mexican ports, (b) Any vessel with sickness on board, (c) Vessels from domestic ports where cholera, plague, or yellow fever prevails, or where smallpox or typhus fever prevail in epidemic form, (d) Vessels from ports suspected of infection with yellow fever, having entered a port north of the southern boundary of Maryland without disinfection, shall be subjected to a second inspection before entering any ports south of said latitude during the quarantine season of such port. Inspection at Ports of Entry The inspection of vessels required by these regulations shall be made between sunrise and sunset, except in case of vessels in distress. In making the inspection of a vessel, the bill of health and clincial record of all cases treated during the voyage, crew and passengers' lists and mani- fests, and, when necessary, the ship's log shall be examined. The crew and passengers shall be mustered and examined and compared with the lists and manifests and any discrepancies investigated. QUARANTINE 281 After arrival at a quarantine station of a vessel carrying immigrants, and upon w^hich there has appeared during the last voyage a case of cholera, smallpox, typhus fever, or plague, and after quarantine measures provided by regulations of the treasury department have been enforced and the vessels given free pratique, the facts are transmitted by the quarantine officer to the commissioner of immigration at the port of arrival, who transmits, by mail or telegraph, to the state health authorities of the several states, to which immigrants from said vessel are destined, the date of departure, route, num- ber of immigrants, and the point of destination in the respective states of the immigrants from said vessel, together with the statement that said immi- grants are from a vessel which has been subject to quarantine by reason of infectious disease, naming the disease. This information is furnished to state health officers for the purpose of enabling them to maintain such sur- veillance over the arriving immigrants as they may deem necessary. When a vessel arriving at quarantine has on board any of the communi- cable but unquarantinable diseases, the quarantine officer shall promptly inform the local health authorities of the existence of such disease aboard and shall make every effort to furnish such notification in ample time, if possible, to permit of the case being seen by the local authorities before discharge from the vessel. Quarantining of Vessels Vessels arriving under the following conditions shall be placed in quar- antine: (a) With quarantinable disease on board or having had such disease on board during the voyage. (b) Any vessel which the quarantine officer considers infected. (c) If arriving at a port south of the southern boundary of Maryland in the season of close quarantine. May 1 to November 1, directly or via a northern port, from a tropical American port, unless said port is known to be free from yellow fever. (d) In the case of vessels arriving at a northern port without sickness on board from ports where yellow fever prevails, the personnel shall be detained under observation at quarantine to complete five days from the port of departure. (e) Towboats and other vessels having had communication with vessels subject to quarantine shall themselves be quarantined if they have been ex- posed to infection. Vessels arriving under the following conditions need not be quarantined: (a) Vessels from yellow fever ports bound for ports in the United States north of the southern boundary of Maryland, with good sanitary condition and history, having had no sickness on boaid at ports of departure, en route or on arrival, provided they have been five days from last infected or suspected port. (b) Vessels engaged in the fruit trade may be admitted to entry without detention, provided that they have complied in all respects with the special rules and regulations made by the secretary of the treasury with regard to vessels engaged in said trade. 282 HYGIENE Requirements at Quarantine No direct communication shall be allowed between any vessel in quar- antine and any person or place outside and no communication whatever between quarantine or any other vessel in quarantine and any person or place outside, except under the supervision of the quarantine officer. Pilots will be detained in quarantine a sufficient time to cover the period of incubation of the disease for which the vessel is quarantined, if, in the opinion of the quarantine officer, such pilots have been exposed to infection. No presumably infected ballast shall be allowed to leave the quarantine station until disinfected. After a vessel has been rendered free from infection, it may be furnished with a fresh crew and released from quarantine, while all or part of the per- sonnel is detained. The persons detained shall be inspected by the physician twice daily, and be under his constant surveillance, and no intercourse will be allowed between different groups while in quarantine. In any group in which communicable disease appears, the sick will be immediately isolated in hospital, and the remaining persons in the group and their effects appropriately treated and then removed to other quarters, if possible, and the compartments disinfected. No convalescent shall be discharged from quarantine until after a suffi- cient time has elapsed to insure his freedom from infection, and this is to be determined by bacteriologic examination where possible. The body of no person dead of quarantinable disease shall be allowed to pass through quarantine until one year has elapsed since death. Such bodies must be transported in hermetically sealed coffins, the outsides of which have been carefully disinfected. In the case of the bodies of such persons as may have died on the voyage or upon arrival at quarantine, cremation should be resorted to if practicable and consented to; if not, the body should be wrapped without preliminary washing in a sheet saturated with a solution of bichloride of mercury 1 to 500 and buried, surrounded by caustic lime. The quarantine officer shall report to the collector of customs any ves- sel which arrives without the bill of health herein before prescribed. Special Regulations on Account of Cholera For the purpose of these regulations five days shall be considered as the period of incubation of cholera. If the vessel carry persons from cholera-infected ports or places, a bacteriologic examination should be made of any cases of diarrhea to exclude cholera before granting pratique. If cholera has appeared on board, remove all passengers from the vessel and all of the crew, save those necessary to care for her, and the sick are placed in hospital. Those especially suspected are carefully isolated, and the remainder are BOAT LANDING, OFFICES, AND LABORATCJKV, QUARANTINE STATION AT STATEN ISLAND, PORT OF NEW YORK QUARANTINE 283 segregated into small groups. Those believed to be especially capable of conveying infection must not enter the place of detention until they are bathed and furnished w^ith non-infected clothing; nor shall any material capable of conveying infection be taken into the place of detention, especially food and water. The water and food supply must be strictly guarded to prevent con- tamination, and issued to each group separately. No fruit or uncooked vegetables shall be permitted. The greatest care must be exercised to prevent the spread of the infection through the agency of flies or other insects. The dejecta from all persons in quarantine on account of cholera shall be disinfected before final disposition. The baggage or effects of passengers and crew that may have been ex- posed to infection must be disinfected. Articles of cargo which have been exposed to infection and are liable to convey the same must be disinfected. Living apartments and their contents and such other portions of the vessel as have been exposed to infection must be disinfected. Water ballast taken on at a cholera-infected port should be discharged at sea, or if discharged in fresh or brackish water, must be previously disinfected. Vessels arriving with water ballast presumably infected must return to sea under guard in order to discharge such ballast. If practicable, the tanks should be disinfected before being flushed, and refilled with sea water. Special Regulations on Account of Yellow Fever For the purpose of these regulations, five days shall be considered as the period of incubation of yellow fever. Where practicable the sick are removed to hospital, and all persons not required for the care of the vessel are also removed and isolated. The per- sonnel of the vessel shall be detained five days from completion of disinfection, or if they have been removed before disinfection of the vessel, their detention shall begin from last possible exposure to infection. In stations south of the southern boundary of Maryland detention must be extended to six days. If the vessel has in all respects complied with the quarantine regula- tions to be observed at foreign ports in such cases, and has been disinfected under the supervision of an accredited medical officer of the United States at the port of departure, she may, upon arrival at her port of destination in the United States, with good sanitary history and in good condition, be subject to the following treatment: (a) If arriving in five days or less, she may be admitted to pratique with- out disinfection or further detention than is necessary to complete the five days. (b) If arriving after five and within ten days, she may be immediately fumigated and admitted without detention. (c) If arriving after a longer voyage than ten days, she shall be treated as if she had not been subjected to any previous treatment. Passenger traffic without detention may be allowed during the close quarantine season, May 1 to November 1, from ports infected with yellow 284 HYGIENE fever to ports in the United States south of the southern boundary of Mary- land, under the following conditions: (a) Vessels to be of iron or the best class of wooden vessels, and to be cleaned immediately prior to taking on passengers. The officer issuing the bill of health to these vessels shall withhold the same if the vessel is not in first-class sanitary condition and complying in every respect with the condi- tions. (b) The vessel must lie at approved moorings in the open harbor; must not approach the wharves, nor must the crew be allowed ashore at the port of departure. Every possible precaution must be taken to prevent the ingress of mosquitoes, and to provide for the destruction of these should they find ingress. All passengers and crew must be immune to yellow fever, and so certified by the United States medical officer. The evidence of immunity which may be accepted by the sanitary inspector is: First, proof of previous attack of yellow fever; second, proof of continued residence in an endemic focus of yellow fever for ten years. Special Regulations on Account of Smallpox For the purpose of these regulations, fourteen days shall be considered as the period of incubation of smallpox. On all vessels arriving with smallpox on board, or having had small- pox on board during the voyage, any of the personnel who have been exposed to the infection of the disease must be vaccinated or detained in quarantine not less than fourteen days, unless they show satisfactory evidence of recent successful vaccination or of having had smallpox. Vessels arriving with smallpox on board which has been properly iso- lated and other sufficient precautions taken to prevent the spread of the dis- ease need not be quarantined further than the removal of the sick, the disin- fection of all compartments, baggage, and objects that have been exposed to the liability of infection, as well as the vaccination of the personnel. On vessels arriving with smallpox on board and where the proper iso- lation and other precautions have not been taken, all those whom the quar- antine officer believes to have been exposed to the infection will be detained unless they have had smallpox or unless they show satisfactory signs of having been properly vaccinated within one year. Living compartments and their contents or any other pait of the vessel exposed to the infection must be disinfected. The baggage and effects of passengers and crew that have been exposed to infection must be disinfected. Special Regulations on Account of Typhus Fever For the purpose of these regulations twelve days shall be considered as the period of incubation of typhus fever. Vessels in otherwise good sanitary condition, but having typhus fever on board which has been properly isolated, need not be quarantined further than the removal of the sick, and disinfection of the compaitments and their con- tents exposed to infection. QUARANTINE 285 If the case has not been isolated, or the disease has spread on board from person to person, the vessel will be quarantined, the sick removed, and those w^ho have been exposed to the infection detained under observation. Vessels in bad sanitary condition, on which the disease has appeared, will be quarantined until thoroughly cleaned and disinfected throughout; the sick will be cared for at isolated hospitals, and those exposed to the infec- tion detained under observation. The baggage and effects of passengers and crew that have been exposed to the infection must be disinfected. Living compartments and their con- tents, or any other parts of the vessel exposed to infection must be disinfected. Special Regulations on Account of Leprosy Vessels arriving at quarantine with leprosy on board shall not be granted pratique until the leper with his or her baggage has been removed from the vessel to the quarantine station. No alien leper shall be landed. If the leper is an alien passenger and the vessel is from a foreign port, action will be taken as provided by the immigration laws and regulations of the United States. If the leper is an alien and a member of the crew and the vessel is irom a foreign port, said leper shall be detained at the quarantine at the vessel's expense until taken aboard by the same vessel when outward bound. Such case of leprosy should be promptly reported to the collector of customs at the port of arrival of the vessel, and the collector shall exact a bond from the vessel for the reshipment of the said alien leper upon the departure of the vessel. Special Regulations on Account of Plague For the purpose of these regulations seven days shall be considered as the period of incubation of plague. In those actually exposed to the infection of plague the administration of antipest serum is regarded as a valuable prophylactic measure; for the pre- vention of the introduction of plague into a community liable to the intro- duction of plague through commercial intercourse, immunization by Haff- kine's prophylactic is to be recommended. Vessels infected with plague, or suspected of such infection, should be anchored at a sufficient distance from the shore or other vessels, to prevent the escape of rats by swimming. In inspecting vessels from plague-infected ports, or vessels with plague on board at port of departure, en route or on arrival, the personnel of the vessel should be examined with special reference to the glandular regions, cervical, axillary, and inguinal, and for such examination as much clothing should be removed as may interfere with the thoroughness of the process. When possible, females should be examined by female inspectors. In the inspection of vessels for plague, special attention must be directed to the discovery of cases of a mild type or of the pneumonic form of the disease. Suspected or doubtful cases should be subjected to bacteriologic examination before the vessel is released. 286 HYGIENE On all plague-infected vessels any of the personnel of such vessels who, in the opinion of the quarantine officer, are infected or have been exposed to infection, shall be bathed and body, clothing, and hand baggage disinfected. Nothing shall be thrown overboard from the vessel, not even deck sweep- ings. Such material shall be burned in the furnaces of a steamer, or in a place specially designated, but not in the galley. Special precautions must be taken against rats, mice, ants, flies, fleas, and other animals, on account of the danger of the infection of the disease being spread through their agency. As soon as practicable, there shall be a preliminary disinfection with sulphur dioxide for the purpose of killing rats and vermin, before further dis- infecting processes are applied to the vessel and her cargo. The killing of any escaping rats shall be provided for by a water guard in small boats, and no person with abrasions or open sores should be employed in the handling of the vessel or her cargo. The vessel shall be submitted to a simultaneous disinfection in all parts with sulphur dioxide to insure the destruction of rats and vermin. The rats shall be subsequently gathered and burned, due precautions being taken not to touch them with the bare hands, and the places where found disinfected with a germicidal solution; and the quarantine officer shall insure himself that the vessel is free of rats and vermin before granting free pratique. Canadian and Mexican Frontiers When practicable, alien immigrants arriving at Canadian or Mexican ports destined for the United States shall be inspected at the Canadian or Mexican port of arrival by the United States consular or medical officer, and be subjected to the same sanitary restrictions as are called for by the rules and regulations governing United States ports. Inspection cards will be issued by the consular or United States medical officer at the Canadian or Mexican port of arrival to all such alien immigrants, and labels affixed to their baggage, as is required at foreign ports in the case of those coming direct to any port of the United States. If any person be found suffering from a quarantinable disease, or be presumably infected, he shall be denied entry or shall be kept under quaran- tine observation so long as danger of conveying the infection exists. Any baggage or other effects believed to be infected shall be refused entry unless disinfected in accordance with these regulations. Persons coming from localities where cholera is prevailing shall not be allowed entry until after five days have elapsed since last presumable exposure to infection, and their baggage disinfected. During the quarantine season persons not positively identified as immune to yellow fever, coming from places where yellow fever prevails, will not be permitted to enter until they have been away from said localities five full days. Persons coming from localities where smallpox is prevailing shall not be allowed entry without vaccination, unless they are protected by a previous attack of the disease or a recent successful vaccination. The baggage of persons from such localities shall be disinfected. QUARANTINE 287 Persons coming from localities where typhus fever prevails in epidemic form shall not be allowed entry until twelve days have elapsed since their last possible exposure to infection and the disinfection of their baggage. Persons coming from localities where plague is prevailing shall not be allowed entry until seven days have elapsed since their last possible exposure to infection and the disinfection of their baggage. No common carrier which is infected, or suspected of being infected, shall be allowed to enter the United States until after such measures have been taken as will render it safe. Articles or merchandise, personal effects, etc., which are presumably infected, shall not be allowed entry into the United States until after dis- infection. Rags gathered and baled in Canada, accompanied by affidavits that the ports or places where collected or handled were free from quarantinable disease for thirty days prior to shipment, may be admitted to entry; but rags from foreign ports shipped through Canada shall not be admitted to entry unless they are accompanied by a certificate of a United States consul or medical officer of the United States that they have been disinfected, or until after they have been unbaled and disinfected at the port of arrival. Where not otherwise specifically stated, the rules and regulations for maritime quarantine shall be applied at stations on the Canadian and Mexican frontiers; and the methods of disinfections shall be those prescribed in these regulations. Application of Disinfectants in Quarantine Work Holds of iron vessels, empty, shall be disinfected by either: (a) Sulphur dioxide generated by burning sulphur five pounds per one thousand cubic feet of air space, or liberated from ten pounds of liquid sulphur dioxide, sufficient moisture being present in both cases; time of exposure, twenty-four hours: (b) Washing with a solution of bichloride of mercury, 1 : 1000. Holds of wooden vessels, empty, shall be disinfected by: (a) Sulphur dioxide in the manner prescribed above, followed by (b) Washing with a solution of bichloride of mercury. In the case of all vessels, both iron and wooden, when treated for yellow fever or plague infection, the first process shall be a preliminary fumigation by sulphur dioxide in the manner previously stated, in order to insure the destruction of mosquitoes, rats, and other vermin. Holds of cargo vessels, when cargo cannot be removed, shall be disin- fected in so far as possible by sulphur dioxide not less than four per cent per volume strength, and where possible this should be generated from a furnace to minimize danger of fire in cargo: Living apartments, cabins, and forecastles of vessels shall be disinfected by one or more of the following methods : (a) Sulphur dioxide, the destructive action of the gas on property being borne in mind. (b) Formaldehyde gas. 288 HYGIENE (c) Washing with solution of bichloride of mercury, 1: 1000, or five per cent solution of formaline, or five per cent solution of carbolic acid, preference being given to carbolic acid for application to polished v^oods, bright metals, and other objects injured by metallic salts. The forecastle, steerage, and other living apartments in bad sanitary condition must be disinfected by method (a), followed by method (c). Mattresses, pillows, and heavy fabrics are to be disinfected by: (a) Boiling. (b) Flowing steam, i.e. steam not under pressure. (c) Steam under pressure. (d) Steam in a special apparatus with vacuum attachment. Clothing, fabrics, textiles, curtains, hangings, etc., may be treated by either of the above methods from (a) to (d) inclusive, as circumstances may demand, or by formaldehyde gas or sulphur dioxide where the article is of a character which will not be damaged by sulphur dioxide. Articles injured by steam, such as leather, furs, skins, rubber, trunks, valises, hats and caps, bound books, silks, and fine woolens should not be dis- infected by steam. Such articles should be disinfected by formaldehyde gas or by any of the agents allowed in these regulations which may be applicable thereto. Those which will be injured by wetting should be disinfected by a gaseous agent. Clothing, textile, and baggage, clean and in good condition, but suspected of infection, can be efficiently and least injuriously disinfected by formalde- hyde gas. Textiles which are soiled with the discharges of the sick or presumably are deeply infected, must be disinfected by: (a) Boiling. (b) Steam. (c) Immersion in one of the germicidal solutions. Cooking and eating utensils are always to be disinfected by immersion in boiling water or by steam. Interstate Quarantine An act of Congress, passed March 27, 1890, provides that whenever it shall be made to appear to the satisfaction of the President, that cholera, yellow fever, smallpox, or plague exists in any state or territory or in the District of Columbia, and that there is danger of the spread of such disease into other states, territories, or the District of Columbia, he is hereby author- ized to cause the Secretary of the Treasury to promulgate such rules and regulations as in his judgment may be necessary to prevent the spread of such disease from one state or territory into another, or from any state or territory into the District of Columbia, or from the District of Columbia into any state or territory, and to employ such regulations to prevent the spread of such disease. The said rules and regulations shall be prepared by the supervising surgeon general of the Marine Hospital Service, under the direction of the Secretary of the Treasury. The following rules and regulations have been made: QUARANTINE 289 Interstate Quarantine Regulations Article I Quarantinable Diseases (1) For the purposes of these regulations the quarantineable diseases are cholera (cholerine), yellow fever, smallpox, typhus fever, leprosy, and plague. Article II Notification (1) State and municipal health officers should immediately notify the supervising surgeon general of the United States Marine Hospital Service by telegraph or by letter of the existence of any of the above-mentioned quar- antinable diseases in their respective states or localities. Article III General Regulations (1) Persons suffering from a quarantinable disease shall be isolated until no longer capable of transmitting the disease to others. Persons exposed to the infection of a quarantinable disease shall be isolated, under observation, for such a period of time as may be necessary to demonstrate their freedom from the disease. All articles pertaining to such persons, liable to convey infection, shall be disinfected as hereinafter provided. (2) The apartments occupied by persons suffering from quarantinable disease, and adjoining apartments when deemed infected, together with articles therein, shall be disinfected upon the termination of the disease. (3) Communication shall not be held with the above-named persons and apartments, except under the direction of a duly qualified officer. (4) All cases of quarantinable disease, and all cases suspected of belong- ing to this class, shall be at once reported by the physician in attendance to the proper authorities. (5) No common carrier shall accept for transportation any person suffer- ing with a quarantinable disease, nor any infected article of clothing, bedding, or personal property. The body of any person who has died of a quarantinable disease shall not be transported, save in hermetically sealed coffins, and by order of the state or local health officer. (6) In the event of the prevalence of smallpox, all persons exposed to the infection, who are not protected by vaccination or a previous attack of the disease, shall be at once vaccinated or isolated for a period of fourteen days. (7) During the prevalence of cholera all the dejecta of cholera patients shall be at once disinfected as hereinafter provided, to prevent possible con- tamination of the food and water supply. 290 HYGIENE Article IV Yellow Fever In addition to the foregoing regulations contained in Article III the fol- lowing special provisions are made with regard to the prevention of the intro- duction and spread of yellow fever: (1) Localities infected with yellow fever, and localities contiguous thereto, should be depopulated as rapidly and as completely as possible, so far as the same can be safely done; persons from non-infected localities and who have not been exposed to infection being allowed to leave without detention. Those who have been exposed, or who come from infected localities, shall be required to undergo a period of detention and observation of ten days from the date of last exposure in a camp of probation or other designated place. Clothing and other articles capable of conveying infection shall not be transported to non-infected localities without disinfection. (2) Persons who have been exposed may be permitted to proceed without detention to localities incapable of becoming infected and whose authorities are willing to receive them, and after arrangements have been perfected to the satisfaction of the proper health officer, for the detention in said localities for a period often days. (3) The suspects who are isolated under the provisions of paragraph 1, Article III, shall be kept free from all possibility of infection. (4) So far as possible, the sick should be removed to a central location for treatment. (5) Buildings in which yellow fever has occurred and localities believed to be infected with said disease must be disinfected as thoroughly as possible. (6) As soon as the disease becomes epidemic the railroad trains carrying persons allowed to depart from a city or place infected with yellow fever shall be under medical supervision. (7) Common carriers from the infected districts, or believed to be carry- ing persons and effects capable of conveying infection, shall be subject to a sanitary inspection, and such persons and effects shall not be allowed to pro- ceed, except as provided for by paragraph 2. (8) At the close of an epidemic the houses where sickness has occurred, and the contents of the same, and houses and contents that are presumably infected, shall be disinfected as hereinafter prescribed. Special Regulations to Prevent the Spread of Plague in the United States During the existence of plague at any point in the United States the surgeon general of the Marine Hospital Service is authorized to forbid the sale or donation of transporation by common carrier to Asiatics or other races particularly liable to the disease. No common carrier shall accept for transportation any person suffering with plague or any article infected therewith, nor shall common carriers QUARANTINE 291 accept for transportation any class of persons who may be designated by the surgeon general of the Marine Hospital Service as being likely to convey the risk of plague contagion to other communities, and said common carriers shall be subject to inspection. The body of any person w^ho has died of plague shall not be transported except in a hermetically sealed coffin and by consent of the local health officer, in addition to the local representatives of the Marine Hospital Service. Wherever possible, such bodies should be cremated. Maritime Quarantine Maintained by States Bordering on the Atlantic and Pacific Oceans, the Gulf of Mexico, the Mississippi and Ohio Rivers, and the Great Lakes The national government has taken over the regulation of foreign inter- course at most of the ports of entry, especially along the southern borders where there is danger of the importation of yellow fever, though at several important ports the local authorities still exercise the quarantine function under the supervision of the United States Marine Hospital Service, notably at Boston, New York, and Baltimore. Although until recently the state of Louisiana maintained four quarantine stations on the lower portion of the Mississippi River, these stations have now been given over to the complete control of the United States. The following states still maintain inspection and quarantine at ports of entry: California, Connecticut, Delaware, Georgia, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, Ohio, Oregon, Pennsylvania, and Texas. Inland Quarantine Inland quarantine, or the application of quarantine measures by state and local boards of health to inland territory, especially the maintenance of quarantine by one state against neighboring states, is provided for in the laws of the following states: California, Connecticut, Georgia, Indiana, Illinois, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Penn- sylvania, Tennessee, Virginia, West Virginia, and Wyoming. Distrirution of Quarantine Powers in the Various States The administration of public health affairs in cities, towns, and in the rural districts in the various states differs broadly; no two states agreeing altogether in the manner in which quarantine powers are distributed. In some of the states the power of enforcing quarantine is largely or wholly centralized in the state board of health, the local authorities being merely the agents of the state board. The following states belong in this class: Kansas, Louisiana, Mississippi, New Mexico, South Carolina, Ten- nessee, Texas, Vermont, Washington, Wyoming (absolute). 292 HYGIENE In most of the states the quarantine powers are conferred upon the local health authorities, usually with the proviso that the rules and regulations promulgated by the state board of health be observed in the administration of public health affairs; the state boards in most instances having the power to supersede the local authorities, and to assume full control of affairs in case the regulations are not properly carried into effect: Arizona, California, Connecticut, Delaware, Illinois, Indiana, Iowa, Kentucky, Maine, Mary- land, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Jersey, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Utah, Vermont, Virginia, Washing- ton, West Virginia, and Wisconsin. In some of the states the local health authorities have an almost inde- pendent existence and have the quarantine powers conferred upon them. This is true in more or less degree of the following state laws : Colorado, Georgia, New Hampshire, and North Carolina. It is difficult to satisfac- torily classify several of the states in this respect. The following states have county boards of health, besides the local boards of health of cities and towns, to v/hich are delegated the power of administering quarantine regulations: Arizona, California, Colorado, Con- necticut, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Miss- issippi, Missouri, North Carolina, Oklahoma, Oregon, Tennessee, Utah, Virginia, West Virginia. The following states have township boards of health in addition to the boards of health of cities and to which is delegated the power of enforcing quarantine in the rural districts: Illinois, Iowa, Michigan, Minnesota, New Jersey, Oklahoma, and Pennsylvania. The following states have local boards of health in incorporated cities and towns whose duty it is to administer the public affairs of the municipality: Arizona, California, Colorado, Connecticut, Delaware, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massa- chusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, Ohio, Oklahoma, Oregon, Penn- sylvania, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, and West Virginia. The following states have the power of inspecting and isolating infected persons and merchandise in transit to or through the state on public con- veyances: Connecticut, Georgia, Illinois, Kansas, Kentucky, Louisiana, Maine, Maryland, Michigan, Mississippi, New Hampshire, New Mexico, Ohio, Oklahoma, Pennsylvania, Tennessee, Virginia, and Wyoming. Disease against which Quarantine is Imposed All the states whose laws I have been able to examine, impose quarantine against smallpox, scarlet fever, and diphtheria, except in Arizona, where no diseases are specified, and in New Mexico and West Virginia, where small- pox is the one disease specified. n J" It ^ 1 r fer b^ 1 Prl is ¥' mSg i QUARANTINE 293 The following states quarantine against Asiatic cholera: California, Connecticut, Delaware, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Michigan, Mississippi, Missouri, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Vermont, Virginia, Washington, Wisconsin, and Wyoming. The following states quarantine against yellow fever: CaUfornia, Con- necticut, Delaware, Georgia, Illinois, Indiana, Kentucky, Louisiana, Miss- issippi, Missouri, Nebraska, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Tennessee, Texas, Vermont, Virginia, Washington, Wisconsin, and Wyoming. The following states quarantine against typhus fever: California, Delaware, Georgia, Indiana, Louisiana, Maine, Missouri, Nebraska, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Texas, Vermont, Virginia, Washington, Wisconsin, and Wyoming. The following states quarantine against bubonic plague: California, Delaware, Indiana, Iowa, Louisiana, Maine, Missouri, New Jersey, Ohio, Oklahoma, Oregon, Pennsylvania, Texas, Virginia, Washington, Wisconsin, and Wyoming. The following states quarantine against measles: California, Indiana, Iowa (placard), Kentucky, Louisiana, Maryland, Minnesota, Missouri, Montana, New Hampshire (reportable), New York, North Dakota, Ohio (optional), Oklahoma, Pennsylvania, Tennessee, Utah, Vermont (modified), Wisconsin, and Wyoming (modified). The following states require all cases of typhoid fever to be reported : California, Illinois, Indiana, Iowa, Louisiana, Minnesota, Nebraska, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Tennessee, Texas, Vermont, and Washington. The following states quarantine against leprosy: California, Indiana, Iowa, Louisiana, Missouri, Nebraska, New Jersey, Oklahoma, Pennsylvania, Texas, Washington, and Wyoming. The following states quarantine cases of epidemic cerebro-spinal menm- gitis : California (reportable), Iowa, Kansas, Louisiana, Minnesota, Nebraska, New York, Oklahoma, Pennsylvania, Tennessee, Texas, Vermont, Wiscon- sin, and Wyoming (modified). The following states require all cases of tuberculosis (pulmonary), to be reported: California, Indiana, Iowa, Louisiana, Minnesota, Nebraska, New Hampshire, New York, Pennsylvania, Texas, and Vermont. The following states require notification or quarantine of all cases of whooping cough: California (reportable), Indiana, Iowa (placard), Mary- land, Missouri, Nebraska (placard). North Dakota, Ohio (optional), Okla- homa (placard), Pennsylvania (modified), Tennessee, Utah, Vermont (modi- fied), Wisconsin, and Wyoming (modified). The following states require all cases of mumps to be reported : Cali- fornia, Iowa (placard), Maryland, Oklahoma (placard), Pennsylvania, Ten- nessee, and Vermont (modified). The following states require all cases of chickenpox to be reported: 294 HYGIENE California, Indiana, Iowa (placard), Nebraska (placard), Maryland, Ohio (optional), Oklahoma (placard), Pennsylvania, Tennessee, and Vermont (modified quarantine). The following states require all cases of German measles to be reported: Pennsylvania (modified quarantine), Tennessee, Vermont (modified quar- antine). The following states require all cases of epidemic dysentery to be re- ported: California, Louisiana, Pennsylvania, and Texas. The following states require cases of dengue to be reported: California, Louisiana, Mississippi, and Texas. The following states require the reporting and quarantining of cases of membranous croup: CaHfornia, Delaware, Georgia, Iowa, Kentucky, Missouri, New Hampshire, New Jersey, Ohio, Oklahoma, Oregon, Penn- sylvania, Vermont, Wisconsin, and Wyoming. The following states require all cases of anthrax to be reported : Cali- fornia, Louisiana, Pennsylvania, and Texas. The following require the reporting of glanders: California, Louisiana, and Pennsylvania. The following require the reporting of cases of pneumonia: California, Iowa, Louisiana, and Pennsylvania. In addition to the foregoing, the following diseases must be reported in different states: Tetanus and trachoma in Pennsylvania and California. Trichinosis in Pennsylvania and New Jersey. Relapsing fever in Pennsyl- vania and Louisiana. Puerpural fever in Pennsylvania, Nebraska, and Iowa, Actinomycosis in Pennsylvania. Hydrophobia in Louisiana. Oph- thalmia neonatorum in Nebraska and New York. Uncinariasis in Cali- fornia. Erysipelas in Pennsylvania. Cuban or Manilla itch in Pennsyl- vania and California. Anterior poliomyelitis in Minnesota. Chapter XV INFECTIOUS DISEASES* Introductory remarks — Tables giving incubation, mode of onset, occurrence of eruption, character of eruption, fading or disappearance of eruption, duration of illness, character of other symptoms and phenomena, mode of contagion and period of contagion — Methods in use by physicians to protect themselves, their families, and their patients. THE tables and other forms of data herein are based upon the recorded opinions of the leading authorities, and are as accurate as the circum- stances render possible. But it must not be forgotten that there is oftimes a wide variation in opinion, and that disease expression varies in different epidemics. Therefore the data cannot be aught but compara- tive and suggestive. Very naturally various state boards of health lay down differing standards and the present writer does not know of any better way at present than for physicians to be guided by the instructions issued by the au- thorities in his own state. Various diseases of animals communicable to man are omitted here because considered under a special heading in the appendix. Period of Incubation Mode of Onset Time of Eruption Character Eruption Disappearance of Eruption Duration of illness Character other Symptoms Mode of contagion Period of Contagion Bubonic Plague Average, three to four days. Certain individ- ual cases, six to eight days, (Greisinger.) Usually sudden with severe chiU and fever and soon followed by severe systematic intoxi- cation due to the plague bacteria. No characteristic eruption. In certain cases, hemorrhages in skin and mucous membranes first week of disease. When present, small hemorrhages as above, especially digestive, bronchial, and urethral tracts. No regular course. Five to thirty days. Cases longer usually fatal and due to mixed infection, staph, c-strep. c. Enlargement lymph glands in inguinal, axil- lary, and popliteal regions and elsewhere. Often suppurate. Symp. cardiac poison from toxins. From bronchial secretions, pus from buboes, carriers usual ones, and rats, mice, fleas, ground squirrels, and possibly other vermin. Ten days after the cessation of all symptoms. (International Sanitary Conference at Venice.) *By Harvey F. Smith, Ph.B., M.D. 296 HYGIENE Period of Incubation Mode of Onset Time of Eruption Character of Eruption Disappearance of Eruption Duration of Illness Other Symptoms Mode of Contagion Period of Contagion Note Period Incubation Mode of Onset Time of Eruption Character of Eruption Disappearance of Eruption Duration Illness Other Symptoms Mode of Contagion Period of Contagion Cerebro-spinal Meningitis Not definitely known. Probably three or four days. No prodromal symptom. Repeated chiUs, vomiting, and severe pain in head and back usher in disease. Irregular. Herpes labialis frequently appear between third and sixth days. No characteristic eruption. Herpes facialis in many cases. Frequently vaso-motor dis- turbances cause an erythema of skin or a pur- puric rash. No regular time or manner. Death in from fifty to eighty per cent of cases, in from eight hours to two weeks. In case of recovery, convalescence is very prolonged. Marked rigidity muscles back and neck, inflam- matory exudate causes various pressure symp- toms; cranial and spinal nerves involved. From the patient and especially the bronchial and nasal secretions, infected clothing and other articles, from a third person. During entire illness. The epidemic form of this disease has not oc- curred in every section of this country and some physicians have never seen a case. Per- mit me to sound a note of special warning re- garding this quickly fatal disease. Chickenpox Usually ten to fourteen days. Slight fever, vesicular eruption. Vomiting and convulsions in severe cases. Appears within first twenty-four hours. Discrete, superficial, umbilicated vesicles. Ap- pear in crops three to five days. Later, con- tents vesicles become milky and sero-purulent. Brown crusts form on vesicles, which fall off in one week. Seldom scars ; perhaps two or three. Usually one to two weeks. Very moderate fever two to four days. No constitutional symptoms of any moment. From exfoliation of crusts on body and pos- sibly from respiratory passages. Direct con- tact not necessary. Until last crusts are off. INFECTIOUS DISEASES 297 Cholera (Asiatic) Period of Incubation Mode of Onset Eruption Duration lUness Other Symptom? Mode of Contagion Period of Contagion A few hours to five days. Mild cases (Cholerine) diarrhoea ten to twenty stools per day. Vomiting — muscular and ab- dominal cramps. Cholera gravis — develop- ment more rapid, greater prostration, tem- perature subnormal. None. Death may occur several hours after onset. Mild cases recover one to two weeks. Con- valescence may be four months. Spas, contrac. muscles calves — distorted facial expression — cyanosis — sunken eyes — Stools are large, watery, painless, frequent (so called rice water) — persistent vomiting — — secondary infection common. Caused by a variety of comma b. propagated chiefly by contaminated water. Carried by water and culinary articles, foods, travelers, etc. Hard to define. United States navy requires bacteriological examination in some cases. Health officers rely largely upon freedom from diarrhoea. Bacilli may live long time. Diphtheria Period of Incubation Mode of Onset Eruption ' Duration of Illness Other Symptoms Period of Contagion Mode of Contagion Average from two to eight days. Chill, malaise, moderate fever, painful and difficult deglutition, red and congested fauces. None. Indefinite; depends upon type of infection and use or neglect of serum therapy. If used within first thirty-six hours in adequate dose, recovery may occur as early as three days. The gray-white membrane on fauces within first twenty-four hours, enlargement of the lymph glands under angle of jaw; heart, kid- ney, and nerve complications. From beginning of symptoms until two weeks after all membrane has disappeared. Some persons carry the germs in throat for an inde- terminate period, except that swab cultures may determine freedom therefrom. From person to person; indirectly from third person; from infected fomites for long period. 298 HYGIENE Erysipelas Period of Incubation Mode of Onset Time of Eruption Character of Eruption Disappearance of Eruption Duration of Illness Other Symptoms Mode of Contagion Period of Contagion Period of Incubation Mode of Onset Time of Eruption Character of Eruption Disappearance of Eruption Duration of Illness Other Symptoms Mode of Contagion Period of Contagion Period of Incubation Mode of Onset Eruption From fifteen hours to three days. Chill, fever, red and painful spot on part affected, commonly the nose. Within first twenty-four hours. Bright red, swollen, indurated, sharply circum- scribed; spreading by irregular continuity; in severe cases covered with vesicles, pustules, or crusts. Begins in three to five days, gradually losing redness and swelling; vesicles, etc., dry and scale. Simple, eight to nine days; severe and ambu- latory, two weeks to two months. Depend upon the point of entrance of the strep- tococci and resisting power of individual at time. Relapses a common phenomenon. From patient, third person, or infected objects. From time of onset until all symptoms dis- appear. German Measles Seventeen to twenty-one days. Except slight fever, prodromal symptoms ab- sent. First day. Begins upon face, spreads rapidly over entire body, varies in color from a very bright red to pale red, is usually macular. Disappears rapidly. Usually the face is clear by time extremities are involved. Slight desquamation. Three to five days. Moderate enlargement of the superficial cervi- cal lymph glands. Person to person, infected articles. From onset to cessation of desquamation. Malarial Fever About fourteen days, varying somewhat with organism and Its habitat. Sensation of lassitude, headache, feeling of chilliness increasing to a typical chill, tem- perature then rises abruptly to 104 to 105° F. Varies according to climate, type, etc. None. INFECTIOUS DISEASES 299 Duration of Illness Other Symptoms Mode of Contagion. Period of Contagion Depends upon treatment and environment. May last for months. Chron. mal. tox. lasts several years. Vary widely with stage of disease and variety of infection. Cerebral and nervous symptoms are common in severe forms. Congestive chill may be quickly fatal. From the anopheles species of mosquito. In the Phihppines there is said to be a species of salt-water mosquito that carries infection. All seasons of year, especially spring and summer. Period of Incubation Mode of Onset Time of Eruption Character of Eruption Disappearance Eruption Duration of Illness Other Symptoms Mode of Contagion Period of Contagion Period of Incubation Mode of Onset Eruption Duration of Illness Other Symptoms Mode of Contagion Period of Contagion Measles Nine to eleven days. Fever, coryza, catarrhal condition conjunctiva and upper bronchial tubes. Fourth day. First on face; spreads rapidly over body. Small bluish-red slightly raised macules ar- ranged in crescentric groups. Fading begins in three to five days. Desqua- mates in small flakes. Average, twelve to fourteen days. Koplik's spots, marked respiratory catarrh. Contact with previous case. From onset to cessation desquamation. Pro- dromal stage very infectious. Mumps From two to three weeks. Mild constitutional symptoms two or three days, gradual swelling parotid glands. None. Ordinarily eight to fourteen days. Parotid swollen and painful three to five days. Orchitis most frequent complication. Usually from person to person; may be car- ried by third person and fomites. Begins even before glandular enlargement and lasts through convalescence (Falkenheim). Where orchitis exists, it is diflRcult to say when period ends, as has thus far not been definitely determined. 300 HYGIENE Pneumonia (True) Period of Incubation Mode of Onset Eruption Duration of Illness Other Symptoms Mode of Contagion Period of Incubation Mode of Onset Eruption Duration of lUness Other Symptoms Mode of Contagion Period of Contagion Notes Period of Incubation Mode of Onset Time of Eruption Not known, probably very short. Severe chill, often lasting several hours, sharp chest pains, rapid rise of temperature (104-5). None. Typical variety at least ten days, but range is from one to four vi^eeks. Dyspnea, rapid respiration, cough and "rusty" sputum, flushed face, cyanosed lips, delirium, labored heart action. Not definitely known — ■ diplococcus pneu- monia of Frankel accepted by most investi- gators. It lives normally in oral cavity. Ex- posure to cold or trauma probably active ex- citing causes. Puerperal Fever Cannot be stated. Depends upon the infec- tive agent. May be streptococci, staphy- lococci, gonococci, bac. coli com., or one of many others. Varies widely from the sudden eclamptic con- vulsion to a relighted pelvic cellulitis. Usu- ally symptoms of a septic fever. No characteristic eruption. From few hours to several weeks. Compli- cations may prolong case for months. Septic endometritis, vaginitis, metritis, metro- lymphangitis, salpingitis, peritonitis, pyemia, phlegmasia alba dolens, etc. Unclean midwifery, other infections, such as erysipelas carried by medical attendant; from diphtheria, scarlet fever, or other contagion to which woman is exposed, occasionally infec- tion through air, etc. Varies. Pennsylvania requires reporting of cases of " Puerperal Fever," but the term is really hard to definitely define, since so many infec- tions are so known. See the text-books. Scarlet Fever One to seven days. ChiU, fever, vomiting, sore throat, rapid pulse, sometimes convulsions. Second day. INFECTIOUS DISEASES 301 Character of Eruption Disappearance of Eruption Duration of Illness Other Symptoms Mode of Contagion Period of Contagion Period of Incubation Mode of Onset Time of Eruption Character of Eruption Disappearance of Eruption Duration of lUness Other Symptoms Mode of Contagion Period of Contagion Period of Incubation Mode of Onset Eruption Duration of Illness Other Symptoms A deep red, punctiform rash, uniform, begin- ning on face and neck, spreading rapidly over body. At end of third or fourth day rash begins to fade, followed by scaly desquamation. Varies with character of infection, usually ten to fifteen days. Desquamation sometimes continues for many weeks. Pharyngitis, follicular tonsillitis, enlarged cer- vica glands, " Strawberry tongue," nephri- tis, otitis media, lymph, suppurations. From previous case, infected fomites or milk. Onset to end desquamation. Smallpox About twelve days. Fever, chill, vomiting, pain in head and back. Third or fourth day. Small red papules on face, hands, forearms, neck, and trunk, and increasing in numbers. They become vesicles and (three days later) pustules. Where close together they coalesce and skin edematous. In three or four days pustules dry up, crusts form, produce odor, fall off in one week, leav- ing scar. Four to six weeks. Secondary fever ten days after primary symp- toms. Severity varies, depending upon infec- tion and number of pustules. Many compli- cations. From patient, infected fomites, flies. The in- fectious agent very tenacious and may be car- ried long distances. Third parties carry. From onset until after the last scab has been removed. Tetanus Two thirds of aU cases develop during the second or third week following infection. Begins with stiffness of muscles of mastication and of the neck. None. From a few days to several weeks. General muscular rigidity, opisthotonos, tris- mus, risus sardonicus, extreme hyperaesthesia, mind is clear. 302 HYGIENE Mode of contagion Period of Incubation Mode of Onset Time of Eruption Character of Eruption Disappearance of Eruption Duration of Illness Other Symptoms Mode of Contagion Period of Contagion Period of Incubation Mode of Onset Time of Eruption Character of Eruption Disappearance of Eruption Duration of Illness Other Symptoms Mode of Contagion Period of Contagion Tetanus bacillus always enters through an external wound. Puerperal tetanus caused by infected water. Typhoid Fever From eight to fourteen days; sometimes twenty-three days. Gradual onset. Symptoms of general malaise, gradual rise of temperature, headache, epis- taxis. Seventh to tenth day. Small, red spots, somewhat raised; disappear completely under pressure, found more fre- quently on upper abdomen, also on chest and back, occur in repeated crops. No definite time or manner. From four to six weeks. Regular daily remissions of temperature, tym- panites, intestinal hemorrhage and perforation, nervous symptoms. By way of the gastro-intestinal canal, in food and water. Directly from stool or urine of patient. Flies. During entire illness. Also waterways may be contaminated by stools for a long time and some persons are " typhoid carriers." Typhus Fever About nine days. Yery suddenly with chill, rapid rise in tem- perature, extreme prostration. Third to seventh day; average, fourth or fifth day. Red macules size of pinhead, beginning on shoulders and flanks and flexor surfaces, fore- arms, become hemorrhagic in a few days; dark red subcuticular mottling of skin follows. Begins to fade in five to seven days; petechial eruption persists into convalescence. Crisis comes about end of second week, after which convalescence is rapid. Continuous high temperature (104-106), pro- found nervous disturbances and prostration. From patient directly, infected bedding, and clothing highly dangerous, germ not yet iso- lated. During entire iUness. INFECTIOUS DISEASES 303 Period of Incubation Mode of Onset Eruption Duration of Illness Other Symptoms Period of Contagion Whooping Cough Seven to twenty-one days. Symptoms bronchial cold, one week, then con- vulsions, cough. None. Six to twelve weeks. Paroxysmal cough followed by " whoop." Bronchial complications. Sometimes resem- bles pneumonia in some features. Sometimes nervous and eye symptoms. From the very earliest symptoms until the end of the disease. Period of Incubation Mode of Onset Time of Eruption Character of Eruption Disappearance of Eruption Duration of Illness Other Symptoms Yellow Fever From one to seven days. General muscular pains, sudden chill, head- ache, facial congestion, temperature 103 to 105. No regular eruption; jaundice fourth to sev- enth day. Occasionally erj'thema, urticaria, or even pus- tules. Usually petachial to jaundiced skin. Most marked in third stage. After seventh day. Varies greatly. The average is four days to one week in cases that recover. Has three stages. There is persistent vomit- ing, finally becoming " black vomit " from mucous membrane hemorrhages. Jaundice is apt to be marked and the third stage is marked by kidney and liver complications often ending in serious mixed infections of a secondary character. Infection carried by the mosquito, stegomyia fasciata. Infection also directly from blood of patient during first four days of disease. No infection carried by fomites. Methods in use by physicians to protect themselves, their families, their patients, and the public. — This heading involves so much said in other portions of this book that we will here make reference to the portions involved and present brief data from the literature of several of the state boards of health. A study of any recent work upon practice of medicine answers any question arising, and it is not necessary to give such data here except such as relate specifically to public health and state medicine. Quarantine is considered in a separate chapter to which we refer while sidelights are thrown upon the subject in Chapters I, II, III, IV, IX, XI, XVI XVII, and XIX. Mode of Contagion 304 HYGIENE Disinfection is fully treated, for our present purpose, in the special chap- ter upon the subject. Actinomycosis is discussed in the Appendix, under the heading, " Dis- eases of animals communicable to man." Anthrax is found in the same paper. Bubonic Plague is considered in Chapter VII and in Chapter IX under California. For other references see the general index. Cerebrospinal Meningitis. — The especial precautions are to destroy sputum and all secretions from the nose and mouth. Especial care should be exercised to wash the hands in an antiseptic solution before leaving the house. The writer has been in contact with the epidemic form of this disease, and cannot be too positive upon the necessity of isolation and disinfection in this form of the affection. Chickenpox. — This disease is frequently reported when the real trouble is smallpox. Adults seldom have chickenpox and a pustular eruption in a person over twelve years of age looks suspicious, especially if papular and becoming vesicular. Children with chickenpox must be kept from school and infected clothing must be destroyed or disinfected as in more severe diseases. Cholera is seldom encountered in this country, and in case of epidemic it is weU to follow all advice given by the health boards. Cholera Infantum or acute milk infection and Cholera Morbus are well considered in the follow- ing, from the Indiana State Board of Health: PRECAUTIONS AGAINST CHOLERA MORBUS, SUMMER DIARRHOEA, AND DYSENTERY All of these well-known diseases occur principally during the summer and autumn. Cholera morbus is caused by improper food and sudden chilling of the body after exposure to great heat. Certain substances will produce it in certain persons, such, for instance, as veal or shell fish, and all dishes cooked with milk, such as rice pudding, cream puffs, and even ice cream, when they are kept too long. Ripe and overripe fruit, especially if taken with large draughts of ice water, will also cause it; but sound, ripe fruit is a natural food in hot weather, and wholesome. Avoid becoming chilled during sleep. In a climate as changeable as ours, a light blanket should always be at hand, to be drawn up in case it suddenly becomes cold during the night. Persistent summer diarrhoea is sometimes caused by malaria or impure water. The conditions liable to contaminate air and water should be carefully sought out and remedied. Water can be rendered safe by boiling. As dysentery is often epidemic, it is wise to consider every case as a possible source of danger to others, and to disinfect the discharges with the greatest care. HOW TO REAR A HEALTHY BABY Leaflet issued by the Wakefield (Eng.) Sanitary Aid Society Food. If the mother's milk is good and plentiful, the child should have no other food whatever until seven months old. If the mother has not enough milk, cow's milk should be given in addition to it, but not in place of it; the two milks will not disagree. While suckling, the mother should take plain and wholesome food; stimulants are not necessary, and spirits are distinctly harmful. INFECTIOUS DISEASES 305 Times of feeding. — For the first month the baby should be fed regularly every two hours by day and every four hours by night. In the second month, feed every two and a half hours by day; in the third month, every three hours by day and twice during the night. Gradually increase the interval between the feeds, so that at seven months old the child is fed once every four hours by day and once in the night, if awake. On no account must a baby be put to the breast every time it cries; it may be crying for some other reason than hunger. Look at the clock, and // it is not feeding time, do not feed it; a teaspoonful or two of clean cold water will often comfort it. Fretfulness, stomach ache, and sickness are caused if an infant is fed irregularly or too frequently. Bottle feeding. — If there is not enough mother's milk, the diet must be supple- mented by fresh unskimmed cow's milk. A bottle prepared as follows should then take the place of one or more feeds at the breast. All milk used for children should be well scalded by placing in a clean jar and keeping on the fire in a saucepan of boiling water for twenty minutes. Do this as soon as the milk comes to the house. Then put the jar in a cool place, and keep it covered. The following are the proper amounts for each feed: For an infant a week old use one tablespoonful of this milk, two tablespoonfuls of water or barley water, and a small lump of sugar. Gradually increase the quantities so that by the fourth week each feed consists of two tablespoonfuls of milk to three and a half of water, with a lump of sugar. By the third month use three teaspoonfuls of milk and three of water. From three to six months old the child should have eight to twelve tablespoonfuls in each bottle, of which not more than two or three are water. From eight months onward the child should be able to digest pure milk, scalded and sweetened, and should have one and a half pints a day. If the infant is having no mother's milk, the cow's milk should be enriched, if possible, by adding a teaspoonful of fresh dairy cream to the milk for each bottle before scalding. Do not use the cream sold in jars, as it may have chemicals added to make it keep, which would be hurtful to a baby. When the right quantity of milk, water, cream, and sugar has been mixed, the food should be warmed and placed in a perfectly clean bottle. Use an old-fashioned " boat bottle " with a teat that can be turned inside out for cleaning. Tube bottles are dangerous. Directly after each feed cleanse the bottle and teat thoroughly, and place them in clean, cold water until wanted again. If a child does not take all the food, what is left should not be kept. Never give milk that is not quite fresh to any child. Weaning. — As a rule a child should be gradually weaned at the eighth month. Suckling beyond this time is most injurious to mother and child, and it is untrue that the mother will not become pregnant while she is suckling. Take care that the baby has plenty of cow's milk after weaning; a healthy weaned child of nine months old needs at least one and a half pints of good scalded milk a day. By the time the child has four teeth it may have its milk thickened with baked flour, rusks, toasted bread, or the prepared infant's foods. On no account give any sort of bread food before the teeth are through, as the infant cannot digest it, and convulsions may be caused. Watch over the child's feeding carefully. Do not give it " just what we have ourselves." Do not let the other children give it " little bits." When a child is ten months old it may have milk pudding, bread, and milk, por- ridge, egg, or a little broth, but still give it plenty of milk. Train it to regular meal times, and to eat and drink slowly. 306 HYGIENE Never give the baby tea or coffee. Children would be much sturdier if given warm milk instead of tea or coffee till four years old. The following things are also harmful for little children: Beer, spirits, wine, new bread, currants, unripe fruit, pickles, salads, soothing syrups, or teething powders. The use of the two last undermine the health of many children. No medicine should be given except by doctor's advice. A baby's clothing should be clean and warm, but not tight about the body. A baby should be washed all over every day with warm water and soap. Also, night and morning, fix a piece of clean rag firmly round the finger, dip into clean water, and thoroughly wash the gums and roof of thechild's mouth. Burn the rag. You are strongly advised not to use a comforter* It is often the cause oi thrush and other troubles. A baby should be taken out whenever possible if the weather is fine. Babies need pure fresh air — indoors and outdoors — -even more than grown people; those who have the most of it will be the least liable to bronchitis and will sleep the best. An infant should have a separate cot, and not stay in the mother's bed during the night. A healthy baby should gain four to six ounces in weight every week. If it suffers from diarrhoea or indigestion, in spite of every care, take it to a doctor without delay. The care of infant life is a subject of vast economic importance and justifies a separate chapter in this book. Maternities are considered in Chapter V, but lack of space precludes a general consideration of infant feed- ing and hygiene. The editor is led to this decision, because nearly all recent works upon children's diseases discuss the matter more fully than is possible here. Furthermore, boards of health everywhere are issuing pamphlets upon the subject. Milk is considered in Chapter VIII. Diarrhoea and Dysentery are usually caused by impure water or milk, and precautions similar to those for typhoid are advised, but need not be so stringent. Epidemic dysentery must be watched with the utmost of care. Boiling the water and disinfecting the discharges are necessary in this whole class of affections. Diphtheria. — In the chapter upon epidemics reference is made to this disease and shght discussion is found in several other sections of this book. See the general index. Especial care is necessary to act promptly in immun- izing with antitoxin. See the chapter upon immunity. Practically every state has issued special bulletins upon this disease, but the " Special Diph- theria Number, Bulletin of the State Board of Health of Maine," is especially good. It is a disease so familiar to the general practitioner that a full dis- cussion is not necessary here. Erysipelas requires that all persons about the patient be very careful of the secretions and the hnen soiled by the patient or the dressings removed from him. Clothing and bed linen should be disinfected very carefuUy. German measles demands the same precautions as does measles, only this is usually a milder disease. Glanders. — See diseases of animals in the Appendix. Gonorrhcea. — See what Dr. Miller writes in Chapter VI. Hydrophobia. — See the chapter upon Immunity. *A comforter is a rubber nipple or other article for the baby to keep in its mouth- Keep everything out of the baby's mouth except pure food and pure water. INFECTIOUS DISEASES 307 Leprosy. — This disease is seldom seen by our American practitioners. Cases should be segregated, in the opinion of most authorities. Malarial fevers. — See the chapter upon epidemics and the several places where mosquitoes are discussed, as per index. Measles. — Among other things, the special bulletin upon this disease issued by the Maryland Board says: Often, when the rash of measles disappears, the skin peels off in small flakes or scales. It is not positively known that this shed skin is infectious, but it is suspected. Therefore when removing clothing from the patient's body, keep the inside inward, and roll the clothing up so as to prevent the scales from being scattered about. Simi- larly in changing bed linen; don't pull it off the bed. Roll it up, body side inward. These things may be wadded up tightly and put into a clean pillow slip, or else rolled into paper parcels, after which they may be carried safely down stairs and put directly into a wash boiler and boiled. Paper bags are convenient and safe receptacles for such infected articles as you have to carry to the kitchen fire. The bags are cheap enough to burn. The things used by the patient in taking food or medicine should always be disinfected before being taken out of the room, and before being used again. At- tendants must wash the hands whenever leaving the bedside and should never leave the room without washing the hands, and if possible the outer dress should be changed. In moving about the house care should be taken not to loiter about or come into contact with other persons any more than can be avoided. Remember that the in- fectious material practically all comes out of the patient's mouth and nose, so that if you keep your hands and clothing free from these discharges you will be pretty safe. When Can the Patient Come Back into the Family Circle ? When the doctor says that recovery is complete, after the body has been bathed, and clean clothing put on. If cough still persists, the same care should be kept up, since the patient may spread the disease through coughing. A patient recovering from measles will have delicate lungs for a rather long time, and must not associate with or be fondled by another person who may have lung trouble. Few diseases pro- vide a more favorable chance for consumption to develop than does measles. %■' After measles the eyes are sometimes weak for a considerable time, and children of school-going age should not be taxed heavily with lessons, particularly at night. Altogether measles lays a good foundation for later ill health, and a child should be watched carefully for some time after his attack is apparently over. Mumps. — Children should not be admitted to school until at least one week after the disappearance of all symptoms. Ophthalmia neonatorum. — The Nebraska Board directs as follows: Rule 29. The disease ophthalmia neonatorum, prevalent only among newborn infants, is one of the most fruitful sources of blindness. All things considered, where there is the least suspicion of the prevalence of any gonorrhoeal infection, or a muco- purulent discharge from the vagina during birth, the attending physician shall take precautionary measures at once to prevent this fearful disease. This consists in the instillation of two drops of a two per cent solution of nitrate of silver in the eyes of the newborn child, after thoroughly cleansing the eyelids, then parting them and intro- ducing the drug. When there is reason to suspect gonorrhoeal contagion, this must be repeated the second day. While the instillation of the silver solution may cause hyperaemia it disappears in a few days, and the enormous value of this treatment far outweighs the few accidents which have occurred after its use. It is the duty of phy- sicians, nurses, and directors of public charities to disseminate among the poorer 308 HYGIENE classes a knowledge of the dangers of this disease and the necessity of prompt treat- ment. Disinfection of the clothing of the patient, and burning of all cloths, etc., is essential, as there is great danger of contamination. Pediculosis. — Directions are given in Chapter III. Pneumonia. — Only a small class of cases is definitely proven to be con- tagious, although many authorities claim that all cases are liable to be more or less dangerous. Puerperal fever. — The Nebraska Board says: Puerperal fever is a fearfully fatal disease. Hence every attendant upon cases of labor should by the use of antiseptic measures sedulously guard against the occur- rence of the disease. The hands, and all instruments and appliances, should be care- fully disinfected, and all discharges subject to decomposition should be promptly re- moved and buried or destroyed. The only way to avoid this terrible disease is for every practitioner to recognize his personal responsibility in the care of his patient, and he who does not is guilty of criminal negligence. Relapsing fever. — Similar to most infections of its character. Ring worm. — Exclude children from school until cured. Scabies. — Same as ring vi^orm. Better burn clothing. Scarlet fever. — The Connecticut Board issues a splendid bulletin upon this disease and among other things, directs: Precautionary Directions The room. — When a person is attacked with scarlet fever, place him in a room by himself, the larger the better, and by preference in the top of the house. Before his admission remove all unnecessary articles from the room. Carpets, woolen curtains, and upholstered furniture are especially liable to become infected. The nursing. — Not more than one or two attendants should occupy the room to nurse the sick person. The nurse should wear no clothing which would be injured by washing. Children especially should not be allowed to enter the room. The contagion is contained in all the excretions of the patient, and in the bran-like scales of the outer skin that are shed so freely in convalescence. The matters that come from the head, throat, nose, and skin are especially contagious. It is an important point to deal with the contagion at its source and act promptly, under all circumstances. Delay gives opportunity for its diffusion. House flies and other insects, by access to the vessels containing excreta, may carry it about. Cats and dogs should be rigidly excluded. Drying may convert it into dust to float in the air. Destroy the infection at the point of origin, if possible. It is possible. The excreta should be received in vessels containing a quart of Solution No. 1 for each discharge, and should be left in the vessel at least an hour before throwing into privy vault or water closet. The vomited matters and sputum should be received in vessels containing the like solution. Or milk of lime, Solution No. 4, may be used and mixed intimately with the ex- creta until it is strongly alkaline (tested by litmus paper). All linen and cotton articles used about the patient should be at once immersed in a wooden tub containing two fluid ounces of Solution No. 3 to each gallon of water, and left in soak not less than two hours, or in a solution of carbolic acid, § iii to a gallon, for four hours. They should then be sent to the laundry and boiled. Under no circumstances should the sheets or underclothing he carried from the room dry, and care should be taken not to shake off the brannv scales to infect other articles. INFECTIOUS DISEASES 309 N. B. — Solutions No. 2 and 3 should not be placed in metal receptacles. Only a wooden tub or earthen crock is suitable for these solutions. Solution 1 is bichloride. — See " Disinfection." Solution 2 is bichloride and perm. pot. Solution 3 is bichloride, weak. Solution 4 is milk of lime. Outer garments of wool or silk, and similar articles which would be injured by immersing in a disinfecting solution or by boiling, should be exposed for two hours to dry heat 230 degrees F., or fumigated with burning sulphur or formaldehyde gas. Any articles of clothing or bedding taken from the room before disinfecting should be tied up in a sheet saturated with Solution No. 3. Dust and dirt must be removed by damp cloths, as sweeping and dusting are prohibited. These cloths should be at once thrown into the solution or into the fire. Books, toys, and articles used to amuse the patient when convalescent are best disposed of by burning them in the room. Under no circumstances should toys be borrowed to return nor used by the well. Physicians, nurses, and others who come in contact with the disease may convey the poison to persons at a distance. No children should be allowed to go to school from the house, nor allowed to play with others that have not had the disease. As a rule the cases where the child is not confined to bed oftenest spread infection, as little care is excised for prevention. When fully convalescent the patient should receive a warm bath in carbolized water, or carbolic soap may be used. When peeling has entirely ceased and no rough- ness of skin remains there is little if any danger to be apprehended of conveying the disease. It is difficult to fix any definite period when there is no longer any danger of conveying the disease, as the types and varieties are so numerous, and of all grades of severity. From a wide experience of treating the disease, the average period of six weeks has been stated; the more cautious give eight weeks as the proper period before a child should attend school and mingle freely with others. As the sequels of scarlet fever are so severe, this period is not oppressive, and in fact is demanded by the best interests of the public. All persons recovering from scarlet fever should be considered dangerous, and therefore should not attend school, church, or any public assembly, or use any public conveyance, so long as the skin is peeling off, or the eyes are sore or symptoms of dropsy exist. Inunction during the " peeling process " is useful in preventing infection. The body, head, and limbs should be thoroughly anointed with vaseline, camphorated oil, or similar substance, as the attending physician may direct, should he think it proper to use them. And the entire surface of the body should receive occasional ablutions with solu- tions of chlorinated soda (Labaracque's solution) diluted with one part to twenty of water. The dishes used in the sick room should be washed separately, first in Solution No. 1, then in hot water. For many purposes linen or cotton rags are useful instead of handkerchiefs, etc., especially when the throat symptoms are present. After use they should be at once burned, together with all fragments and refuse. Perfect cleanliness should be enjoined, especially if the attendant is obliged to mingle with other people. As the hands are very liable to be infected from the neces- sary care of the patient, a disinfecting solution (chlorinated soda, one part to ten of water) should be used. After the use of the disinfecting solution the hands should be 310 HYGIENE washed with plain soap and water. The disinfectant solution should be also provided for the physician's use on leaving the room. The above precautions and isolation are always necessary in the mild as well as the severe forms to prevent the spread of the disease. In the sickroom free ventilation and cleanliness are essential aids to disinfection. In case of death the body should be wrapped in a sheet saturated with sixty grains of corrosive sublimate and two tablespoonfuls of common salt in a gallon of hot water; or six ounces of pure carbolic acid in a gallon of hot water; and if to be carried out of town must also be enclosed in an air-tight coffin, hermetically sealed. Funerals of those dead from scarlet fever should always be strictly private. The bodies should never be exposed to view. Smallpox. — See the chapters upon Epidemics and Immunity. Syphilis. — See Chapter VL Tetanus. — The Michigan Board says: The tetanus germ exists and thrives in the incrustation or dust of filth; and a wound from a rusty nail, or from a powder explosion, as from fireworks, etc., permits this dust so laden with tetanus germs to enter the abrasion of the skin, and, sealed in this excellent medium, the tetanus germ becomes prolific, causing the death of the human being within a short time. Prompt medical treatment and the administration of prophylactics are absolutely necessary for the saving of life. A pamphlet bearing on the especial relation of tetanus to Fourth of July celebration with improper fire- works has been issued by the state department of health, and copies of the same will be mailed free upon request. Also see chapter upon Immunity. Trachoma. — See section upon inspection of immigrants (index), and works upon eye diseases. Trichiniasis. — See Appendix and section upon meats in Chapter VIII. Tuberculosis. — See Chapter XIX and index for other references. Typhoid fever. — See Chapter XII and index for other references. Typhus fever. — Same as typhoid. Whooping cough. — Exclude child from school or other public places and maintain a mild or modified quarantine. Yellow fever. — Referred to in several places. See general index. Note. — Every physidian should secure copies of the regulations of his own state, county, or city, and be governed by them. V"^,*-^- X