THE EVOLUTION AND SIGNIFICANCE OF THE
MODERN PUBLIC HEALTH CAMPAIGN

AN ADDRESS
DELIVERED UNDER THE AUSPICES OF THE
GAMMA ALPHA FRATERNITY
OF YALE UNIVERSITY
 
PUBLISHED UNDER THE AUSPICES OF THE
YALE SCHOOL OF MEDICINE
ON THE FOUNDATION ESTABLISHED IN MEMORY OF
WILLIAM CHAUNCEY WILLIAMS, M.D.,
OF THE CLASS OF 1822, YALE MEDICAL SCHOOL,
AND OF
WILLIAM COOK WILLIAMS, M.D.,
OF THE CLASS OF 1850, YALE MEDICAL SCHOOL
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THE . pie
. EVOLUTION AND SIGNIFICANCE
OF THE
MODERN PUBLIC HEALTH
CAMPAIGN.

By C.-E. A. WINSLOW, Dz.P.H.

“
PROFESSOR OF PUBLIC HEALTH, YALE SCHOOL OF MEDICINE

 

NEW HAVEN

YALE UNIVERSITY PRESS
LONDON + HUMPHREY MILFORD + OXFORD UNIVERSITY PRESS

MCMXXIII JG LL
COPYRIGHT 1923 BY YALE UNIVERSITY PRESS

PRINTED IN THE UNITED STATES OF AMERICA

 
THE WILLIAMS MEMORIAL PUBLICATION FUND

THE present volume is the sixth work published by the Yale Uni-
versity Press on the Williams Memorial Publication Fund. This
Foundation was established June 15, 1916, by a gift made to Yale
University by George C. F. Williams, M.D., of Hartford, a mem-
ber of the Class of 1878, Yale School of Medicine, where three
generations of his family studied—his father, William Cook Wil-
liams, M.D., in the Class of 1850, and his grandfather, William
Chauncey Williams, M.D., in the Class of 1822.

DIHI0L
 
Chapter IL
Chapter II.
Chapter III.
Chapter 1V.
Chapter V.

CONTENTS

The Dark Ages of Public Health .
The Great Sanitary Awakening .

Pasteur and the Scientific Bases of Prevention .

The Golden Age of Bacteriology .
The New Public Health

12
28
34
49
 

dat

~

-

 

 

 
CHAPTER I

THE DARK AGES OF PUBLIC HEALTH

HE motto “Non scholae sed vitae discimus’” is pe-

euliarly pertinent to a discussion of the origins and

development of the public health movement which
has come to play so large a part in the community activities
of the present day. Public health is not a concrete intellec-
tual discipline, but a field of social activity. It includes ap-
plications of chemistry and bacteriology, of engineering and
statistics, of physiology and pathology and epidemiology,
and in some measure of sociology, and it builds upon these
basic sciences a comprehensive program of community
service.

Public health, in such a sense as this is something very
new in the history of the human race. The ideal of control-
ling the forces of nature for the uses and the purposes of
man must have glimmered in the mind of every seeker of
causation since our ancestors painted the cave frescoes of
Dordogne. Yet to the mind of the average man the concep-
tion that life and death are not merely dispensations of

1 Tnseribed above the rostrum of Lampson Lyceum, Yale University, where
the address upon which this book is based was first delivered.

2 The author has elsewhere attempted to define public health in the following
terms,—which will make clear the scope of the movement whose development we
shall attempt to trace./‘‘ Public health is the science and the art of preventing
disease, prolonging life, and promoting physical health and efficiency through
organized gommunity efforts for the sanitation of the environment, the control |
of community infections, the education of the individual in principles of .
personal hygiene, the orghinization of medical and nursing service for the early
diagnosis and preventive treatment of disease, and the development of the
social machinery which will ensure to every individual in the community a
standard of living adequate for the maintenance of health.”” The Untilled

Fields of Public Health, 1920, Science, N. 8., Vol. 51, p. 23; also Modern
Medicine, Vol. 2, p. 183.
2 Ph BBL OF PUBLIC HEALTH

: die phovitimad ‘but lie within the control of the human
mind and the human will has only become familiar within a
period of a hundred years,—to use the striking figure which
James Harvey Robinson has suggested,—in the last three
or four lines of the last page of a three-hundred-page book,
which should chronicle the complete history of the human
race.

Visions there are, of fragments of the public health ideal,
first flushes of a dawn which was not to break for centuries
therdafter. In ancient Greece, for example, the pursuit of
personal hygiene was developed ‘‘for the first time in his-
tory, and in a scope and degree never again approached.’’
“They undertook universal training of boys (in some
phratries of girls also), with a view to the harmonious de-
velopment of all the physical faculties and to the attainment
of the greatest measure of strength, dexterity and self-con-
fidence, of physical perfection and beauty. The system was
founded upon daily exercise from earliest youth to ripe
manhood, under the supervision of experienced and prac-
ticed leaders, who not only strove to make it viable and
successful, but were capable of intelligent specialization, ex-
acting from each physical entity the highest possible accom-
plishment, with constant reference to general vigor. The
teacher of gymnastics became the professional ‘gymnast,’
who strove to comprehend the normal functions of the body,
vying with the medical fraternity, who again studied the
value of gymnastics for a healthy physique and took from
its storehouse of anatomic-physiologic knowledge the plumb
line for estimating the possibilities of each individual. With
the aid of general dietetics, the physicians deduced the
norms for the application of gymnastics to the prevention
of bodily ills and as an auxiliary in the treatment of general
or organic disorders. Under this beneficent rivalry between
professional gymnast and physician, gymnastics itself be-
came a scientific system of physical exercise and invigora-
tion, of hygiene of movement and occupation, such as we
DARK AGES 3

today, with the aid of modern technique and instrumental
precision, are intent upon creating anew.

“With this central endeavor of Hellenism, physical in-
vigoration by daily gymnastic exercise, the rest of personal
hygiene was in great measure associated, viz., care of the
skin by washing and bathing, by swimming and massage;
physical cleanliness, including care of the hair and clothing;
as well as regulation of diet, rest and sleep, and of the
sexual life.””®

As personal hygiene flowered in Greece, so public sanita-
tion reached a brilliant development in ancient Rome, The
office of Aedile was established in 494 s.c. ¢‘To this period,”
says Mommsen,* there ‘‘probably belong in great measure
the enactments under which the four aediles divided the city |
into four police districts, and made provision for the dis-
charge of their equally important and difficult functions ;—
for the efficient repair of the network of drains small and
large by which Rome was pervaded, as well as of the public
buildings and places; for the proper cleansing and paving
of the streets; for preventing the nuisances of ruinous
buildings, dangerous animals, or foul smells; for the remov-
ing of waggons from the highway except during the hours
of evening and night, and generally for the keeping open of
the communication; for the uninterrupted supply of the
market of the capital with good and cheap grain; for the
destruction of unsound goods, and the suppression of false

weights and measures; and for the special oversight of -

baths, taverns, and houses of bad fame.’” Not only were pav-
ing and drainage, sewerage and scavenging well provided
for. There were excellent building regulations and strict
laws in regard to pollution of water supplies; and the law
of servetus amply covered the contentious problem of pri-

3 Sudhoff, K. The Hygienic Idea and Its Manifestations in World History.
To by F. J. Stockman, Annals of Medical History, 1917, New York, Vol. I,

4 Mommsen, Theodor. The History of Rome, Vol. III, p. 84 (Book II,
Chap. 8). :

be
4 EVOLUTION OF PUBLIC HEALTH

vate nuisances. Later, under Imperial Rome, Vitruvius dis-
played an excellent knowledge of many of the sanitary
features of building construction and Frontinus® has given
us a survey of the waterworks which supplied the popula-
tion of the seven hills, as full of sound engineering knowl-
edge as of the spirit of high-minded public service.

Yet these were but transitory gleams of social intel-
ligence, to be quenched in the intellectual darkness of
medieval Europe. The decay of hygiene and sanitation at
this period was associated with a very positive and definite
reaction from the personal luxury and the pomp of state-
hood of Pagan Rome, which to the mind of the Early Church
were symbols of the moral and spiritual corruption which
accompanied them. ‘The body no doubt had been the spoilt
child of imperial Rome, and a frequent fate of spoilt chil-
dren was now to come to it in the form of neglect and hu-
miliation. In reaction from the Roman thermae, associated
as in memory they were with the whole fabric of Roman
luxury, bodily cleanliness fell out of favour, and a cult of
bodily uncleanliness began ; while also, in reaction from the
Roman sumptuosities of food and clothing, the most meagre
diet and the poorest dress were deemed the fittest for all
men to adopt.”’® In the words of St. Jerome’ ‘Does your
skin roughen without baths? Who is once washed in Christ
needs not to wash again.”’

If, however, hygiene and sanitation were neglected in the
Middle Ages there was one phase of public health which
grim necessity forced upon the attention of the rulers of the
period,—the control of epidemic disease. The development
of the practice of isolation in medieval times constitutes in-
deed the third great foreshadowing of the modern public
health movement. Its foundation goes straight back to the
01d Testament, for it was the Jews who first grasped the

5 Herschel, C. Frontinus and the Water Supply of Rome. Boston, 1899. :

6 Simon, J. English Sanitary Institutions. London, 1890.
7 Ep. XIV.
$

DARK AGES 5

importance of contagion and laid down in the thirteenth and
following chapters of Leviticus the elements of a sound sys-
tem of isolation and quarantine. The spread of leprosy from
Egypt, which began to affect Northern Europe in the sixth
century, was greatly accelerated by the Crusades: and as
Sudhoff says, ‘‘Enlightened princes of the Church, moved
by the increasing misery of the people, on the strength of the
sacerdotal code of the Old Testament, undertook the task of
interfering; the shepherdess of the medieval peoples knew
her duty.”” The Council of Lyons in 583 first attempted to

restrict the free migration of lepers and through the times

of Rotharius and Charlemagne the process was rigorously
carried forward. Heine, paraphrasing an old chronicle, says
of the wretched victims of this disease, ‘‘living corpses, they
wandered to and fro, muffled from head to foot; a hood

drawn over the face, and carrying in the hand a bell, the

Lazarus-bell, as it was called, through which they were to
give timely warning of their approach.’’

The incidence of leprosy reached its height in Northern
Europe in the thirteenth century; but it was met by a de-
termined and vigorous campaign which culminated in the
leprosy decretals of the third Lateran Council in 1179. Iso-

lation camps or leprosaria were established everywhere, |

their numbers ranging in the thousands; and according to
the somewhat partial views of Father Walsh many of these
leprosaria were places of cheer and comfort akin to the
tuberculosis sanatoria of the present day. The method of
isolation was, as we now know, peculiarly adapted to a
malady of the mild contagiousness of leprosy. It was trium-
phantly successful and by the end of the sixteenth century
the disease died out from Northern Europe.

A second great battle was fought by the Princes and the  -

Bishops against bubonic plague, beginning just when fhe’

incidence of leprosy was on the decline. In 1374 Venice

denied entrance to. the city of infected or suspected ships,

travelers or freight; in 1377 Ragusa rejected all travelers
6 EVOLUTION OF PUBLIC HEALTH

from plague districts who had not sojourned for a month
at one of two designated points without developing the dis-
ease; in 1383 Marseilles erected her first quarantine sta-
tion, at which, after rigid inspection of the vessels, all
travelers from stricken or suspicious ships were detained
for forty days, and cargoes, ships and rigging exposed to
elaborate processes of disinfection and to the influence of
air and sunshine.®* Unfortunately, since the rodent popula-
tion of the ships generally escaped attention, quarantine
proved less effective here than in the case of leprosy.

The development of isolation and quarantine in medieval
times was in a very real sense a form of preventive medi-
cine. Yet as a community activity it had in it more of the
nature of therapeusis than of prophylaxis; it was a feverish
attempt to deal with an immediate and existing danger,
rather than an example of the forethought which guards
against remotely anticipated evils. The Middle Ages gave
no. thought to the underlying hygienic or sanitary factors
which might favor the development of disease. It was natu-
ral that the classical world with its love for comfort and for
beauty should promote hygiene and sanitation. It was
equally inevitable that the medieval churchman, with eyes
fixed on another and a better world, should pay scant atten-
tion to the deeper causes of mere earthly ills.

It is in any case certain that the peoples of Europe |
emerged from the Middle Ages and came down to very mod-
ern times with no general comprehension of any one of the
principles of public health, save the single procedure of iso-
lation and quarantine. The sanitary conditions of the good
old days when lords and gentlemen ruffled in silks and laces
were appalling to the modern mind; and called forth more
or less ineffective efforts at reform even on the part of
contemporary authority. In France, in 1350, King John II
established the first Sanitary Police in an ordinance which

8 See Eager, J. M. The Early History of Quarantine. Yellow Fever Institute
Bulletin No. 12, Public Health and Marine Hospital Service, Washington, 1903,
DARK AGES 7

provided that hogs should not be kept in cities; that streets
should be cleansed, and the offal removed; that butchers
‘should not sell meat more than two days old in winter, and
one and a half in summer; and that fish should be sold the
same day they were caught. In England, as early as 1297,
we find legal regulations requiring every man to keep clean
the front of his own tenement. The pollution of the Thames
began to receive official attention in 1345. In 1357 a Royal
Order, addressed to the Mayor and Sheriffs, tells how the
king, Edward III, passing along the river, had ‘‘beheld
dung and laystalls and other filth accumulated in divers
places in the said city upon the bank of the said river’’ and
had ‘also perceived the fumes and other abominable
stenches arising therefrom; from the corruption of which,
if tolerated, great peril, as well to the persons dwelling
within the said city as to the nobles and others passing along
the river, will it is feared arise, unless indeed some fitting
remedy be speedily provided for the same.’”” In the Court
Rolls of Stratford-on-Avon in 1552 is found an entry that
Shakespeare’s father was fined for depositing filth in a
public street, and he was disciplined again in 1558, for not
keeping his gutters clean.

Such sporadic attempts at reform appear to have accom-

plished little in the way of immediate results. In a famous | 7

letter of Erasmus to Dr. Francis, the physician of Cardinal
Wolsey,’ the state of the English household of the sixteenth
century was described in the following terms. ‘As to the
floors, they are usually made with clay covered with rushes
that grew in the fens, which are so slightly removed now
and then, that the lower part remains sometimes for twenty
years together, and in it a collection of spittle, vomit, urine
of dogs and men, beer, scraps of fish and other filthinesses
not to be named.”’

Regarding the state of the waterways, we have Pope’s

9 The Negotiations of Thomas Woolsey, p. 18.
8 EVOLUTION OF PUBLIC HEALTH

testimony in the Dunciad, written early in the eighteenth
century,—

To where Fleet Ditch with disemboguing stream
Rolls the large tribute of dead dogs to Thames,

The King of Dykes, than whom no slime of mud

‘With deeper sable blots the silver flood.

One hundred years later, conditions were still not much
improved. In the epoch-making report on the Sanitary Con-
dition of the Labouring Population of England presented
by the Poor Law Commissioners in 1842 we read the fol-
lowing:

In the parish of Modbury, many of the dwellings of the poor are
arranged round narrow courts having no other opening to the main
street than a narrow covered passage. In these courts there are
several occupants, each of whom has accumulated a heap. In some
cases, each of these heaps is piled up separately in the court, with
a general receptacle in the middle for the drainage. In others a pit
is dug in the middle of the court for the general use of all the occu-
pants. In some the whole courts up to the very doors of the houses
are covered with filth. Around this mass, the cottages of the resi-
dents are arranged, having no back outlet, no back windows, or
other means of ventilation. The windows and doors of the houses
open and look towards this mass; and all the air supplied to the
inmates is obtained through these doors and windows. The residents
I learnt were very frequently subject to fever, and were always re-
garded as the first to be affected by any epidemic disease.

Conditions in the large cities were no better. Even in
London a public water supply was available only in certain
districts and was turned on only at certain hours of the day.
In 1847 in a distriet, typical of the poorer quarters of the
city, ‘“‘the supply was very bad; it was an intermittent
supply from the water company, it was distributed in courts
by stand-pipes on intermittent days. The fatigue of fetching
it was so great that they only used it for purposes which
they deemed of absolute necessity, such as cooking; they
DARK AGES 3

rarely bestowed much of it on their own clothes or persons.
I remember it well, as a fact, that the water, from being
kept so long, and absorbing the impurities of these places,
smelt very bad. I know it to be a fact that the water for all
domestic purposes was pumped into many of the houses
from the parts of the river where the most abominable im-
purities abounded.”

In the summers of 1858 and 1859 the Thames stank so

badly as to rise ‘‘to the height of an historic event. Even

ancient fable failed to furnish figures adequate to convey
a conception of its thrice-Augean foulness. For many weeks
the atmosphere of Parliamentary committee-rooms was
only rendered barely tolerable by the suspension before
every window of blinds saturated with chloride of lime, and
by the lavish use of this and other disinfectants. More than
once, in spite of similar precautions, the law courts were
suddenly broken up by an insupportable invasion of the
noxious vapor. The river steamers lost their accustomed
traffic, and travellers pressed for time often made a circuit
of many miles rather than cross one of the city bridges.

“For months together, the topic almost monopolized the
public prints. Day after day, week after week, the Tumes
teemed with letters filled with complaint, prophetic of
calamity or suggesting remedies. Here and there, a more
than commonly passionate appeal showed how intensely
the evil was felt by those who were condemned to dwell on
the Stygian banks. At home and abroad, the state of the
chief river was felt to be a national reproach. India is in
revolt and the Thames stinkSy were the two great facts
coupled together by a distingdished foreign writer, to mark
the climax of a national humiliation.’’"*

Nor was London unique in its_appalling conditions of |

sanitary neglect. Here are a few citations which indicate

10 First Report of the Metropolitan Sanitary Commission, Liondon, 1848.
11 Budd, W. Typhoid Fever, Its Nature, Mode of Spreading and Prevention.
London, 1873.

|
10 EVOLUTION OF PUBLIC HEALTH

the state of our own metropolitan city of New York as late
as 1865." Of the Sixth Ward an inspector says, ‘‘Domestic
garbage and filth of every kind is thrown into the streets,
covering their surface, filling the gutters, obstructing the
sewer culverts, and sending forth perennial emanations
which must generate pestiferous disease. In winter the
filth and garbage, etc., accumulate in the streets to the depth
sometimes of two or three feet.”” In the Thirteenth Ward
‘the streets are generally in a filthy and unwholesome con-
dition; especially in front of the tenant houses, from which
the garbage and slops are, to a great extent, thrown into the
streets, where they putrefy, rendering the air offensive to
the smell and deleterious to health. The refuse of the bed-
rooms of those sick with typhoid and scarlet fevers and
smallpox is frequently thrown into the streets, there to
contaminate the air, and, no doubt, aid in the spread of those
pestilential diseases.’’ In the Sixteenth Ward the privies
““form one of the chief features of insalubrity. Nearly all
of them are too small in size and too few in number, and
without ventilation or seat-covers. About twelve were found
full to the floor timbers or within one foot of them. Tn some
cases the doors were found locked securely, and on procur-
ing the key and inspecting the privy, such masses of human
excrements were found on the seats and floors as would
justify the locking of the door to protect unwary persons
from injury,” It was estimated that 18,000 persons were
living in cellars in New York at this time; and in the Fourth
Ward many of these cellar dwellings were below high-water
mark. ‘“At high tide the water often wells up through the
floors, submerging them to a considerable depth. In very
many cases the vaults of privies are situated on the same
or a higher level, and their contents frequently ooze through
the walls into the occupied apartments beside them.’’ In
two weeks’ time the inspectors in this survey found over

12 Report of the Council of Hygiene and Public Health of the Citizens Asso-
ciation of New York upon the Sanitary Condition of the City. New York, 1865.
DARK AGES 11

1200 cases of smallpox and over 2000 cases of typhus fever.
In a single tenement house on Mulberry Street, with a tran-
sient population of about 320 persons, there had been 240
cases of fever and 60 deaths in a period of four years.
R CHAPTER II

THE GREAT SANITARY AWAKENING

: Vi serious concerted effort to remedy such condi-
tions as have been described in the previous chap-
ter—an effort which formed the real starting point

of the modern public health campaign—was essentially a
product of the first half of the nineteenth century. Its roots

| struck down into the dawning social consciousness of 1800;

| and its full flowering came about 1850.

» There were two major tendencies dominant in the life of
Europe a hundred years ago which were jointly responsible
for the birth of the public health movement,—the develop-
ment of the scientific spirit and the growth of a new motive
of humanitarianism,—both tendencies quite new in the his-
tory of the human race. The spirit of science made it pos-
sible for the first time to grasp clearly and confidently the
possibility of a practical amelioration of the conditions of
existence; and the humanitarian ideal compelled vigorous
efforts to accomplish such an amelioration in the interest
of that portion of the human race which had hitherto
labored under an accepted curse of misery and suffering.

“In the preface to one of his volumes of essays, Lord

Morley speaks of the eighteenth century as the scientific

' Renaissance. Such it undoubtedly was, for it was in this
century and especially in its latter half, that chemistry,
geology, botany, zoology and physics began to make deep
impression on the learned world, while astronomy and

«

13 Tt was at the end of the eighteenth century that Malthus remarked that
‘Diseases have generally been considered as the inevitable inflictions of Provi-
dence.’’
SANITARY AWAKENING 13

mathematics ventured upon bolder and more far reaching
generalizations than they had ever before made.’’** Black,
Cavendish, Priestley and Lavoisier in chemistry, Franklin,
Galvani and Volta in physics, Hutton in geology, Buffon,
Linnaeus, Bonnet and Spallanzani in biology, Haller and
the Hunters in anatomy, the Bernoullis, Euler, Lagrange,
Laplace and the Herschels in mathematics and astronomy,
laid the foundation for much of the later progress of mod-
ern science. Even in the field of public health there were at
this time substantial and concrete advances, particularly in
England, which had a very direct connection with the de-
velopments of the next half-century. For example, the pub-
lication in 1720 by Dr. Richard Mead, the foremost English
physician of his time (of whom Dr. Johnson said that he
““lived more in the broad sunlight of life than almost any
man’’) of a book entitled 4 Short Discourse concerning
Pestilential Contagion and the Methods to be Used to Pre-
went It, had an influence which may be estimated by the fact
that the work passed through seven editions in a year. More
or less successful attempts to ventilate the British House of
Commons by Sir Christopher Wren and later by Desagu-
liers attracted wide attention to the problems of air-condi-
tioning. An admirably precise study of the causative factors

in a particular disease was presented before the London / —

College of Physicians in 1767 by Sir George Baker on The
Endemial Colic of Devonshire. Of this disease, character-,

ized by colic and palsy, the Exeter hospital alone had add ~—

mitted an average of nearly sixty cases a year. A Plymouth
physician reported it ‘‘so vastly common that there was
scarce a family amongst the lower rank of people that had
it not, and he often saw five or six lying ill of it in the same

.house.”” Dr. Baker demonstrated that the ¢‘Devonshire
colic’? was simply plumbism, due to the general use of cider
made and stored in vessels containing lead.

14 Sedgwick, W. T., and Tyler, H. W. 4 Short History of Science. New York,
1017.
14 EVOLUTION OF PUBLIC HEALTH

An enormous impetus was given to the subject of per-
sonal hygiene, and particularly to the prevention of scurvy,
by the remarkable achievement of Captain Cook in complet-
ing a voyage of three years and eighteen days in H. M. S.
Resolution with a loss by disease of only one man out of a
crew of 118. The chief points in his regimen were as fol-
lows: ‘““proper provision of food, which was made to in-
clude rob of lemons and oranges, sourkraut, sugar, portable
soup or broth, and malt for making sweetwort; avoidance
of too long watches; dry shifts when wet; insistence on
keeping persons and hammocks clean ; insistence on keeping
ship clean and dry; ventilation by wind-sail and by frequent
use of portable fire at bottom of well; great care for fresh
water to be renewed at every opportunity; and for fresh
provisions, animal and vegetable, whenever possible.”’ Cap-
tain Cook was awarded the Copley Medal of the Royal So-
ciety for this achievement in 1776, though he was at that
time absent on his last voyage ; while in 1796, thanks to this
demonstration and the painstaking efforts of Doctors James
Lind and Gilbert Blane, the use of lemon-juice as a pre-
ventive of scurvy was made compulsory in the British Navy.

Finally, the medical history of the century was crowned
in 1798 by the announcement of the discovery of vaccination

_by Edward Jenner. It is difficult for us today to realize the
burden once imposed upon mankind by ‘‘the continued
raging of that pitiless plague,’”’ smallpox. In the circle of
William the Third, to cite one illustrious instance, his father
and mother died of smallpox, as did Mary, his wife, his
uncle, the Duke of Gloucester, and two of his cousins ; while
he himself barely survived an attack. The practice of inocu-
lation, introduced into England in 1717 by the vivacious
Lady Mary Wortley Montagu, wife of the British Am-
bassador to Constantinople, had served only in slight degree
to mitigate such terrors. When Jenner suggested his method
of vaccination the general acceptance of the older practice
made it possible to test the new procedure without delay by
SANITARY AWAKENING 15

direct experiments upon the human subject. In the years
1799-1801, over 3000 persons were first vaccinated and then
inoculated with true smallpox under Woodville’s direction
at the London Small-pox Hospital with the demonstration
of complete protection in every instance.” We may fairly
say that no single procedure in the whole field of medical
science rests upon such a complete basis of experimental
evidence and that none was ever introduced which has
proved a greater boon to the human race.

In our present task of considering the public health cam-
paign, primarily as a social movement, the development of

the humanitarian spirit in the eighteenth century is a factor) |,

quite as important as the progress of natural science. The
fire of French liberalism, which flamed out in the French
Revolution, and was never quite extinguished by the con-
gress of Vienna, had been carried by the mordant pen of
Voltaire to every country on the continent of Europe. In
England, immune against the excesses of both revolution
and reaction, the same seeds were sprouting. On the emo-
tional side, the preaching of the Wesleys contributed to
their development ;'® while the intellectual basis for the
liberalism of the early nineteenth century was being laid by
Jeremy Bentham and by Adam Smith. Taine says of the
English of this period, ‘‘They have succeeded; Bakewell
transforms and reforms their cattle; Arthur Young their
agriculture; Howard their prisons; Arkwright and Watt
their industry; Adam Smith their political economy; Ben-
tham their penal law; Locke, Hutcheson, Ferguson, Joseph
Butler, Reid, Stewart, Price, their psychology and their
morality. They have purified their private manners, they
now purify their public manners. They have settled their

15 Simon, Sir John. History and Practice of Vaccination. In Public Health
Reports. London, 1887, Vol. I.

16 It is of some interest to note that in 1747 John Wesley made a more direct
contribution to the cause of health by the publication of a book entitled

Primitive Physick: or an Easy and Natural Method of Curing Most Diseases,
which contained an excellent set of rules for personal hygiene.
16 EVOLUTION OF PUBLIC HEALTH

government, they have confirmed themselves in their reli-
gion. Johnson is able to say with truth, that no nation in the
world better tills its soil and its mind. There is none so rich,
so free, so well nourished, where public and private efforts
are directed with such assiduity, energy and ability towards
the improvement of public and private condition.’
| The first phase of the humanitarian movement which
_, exerted a direct and immediate influence upon the public
‘ health was the campaign for prison reform, imperishably
associated with the name of John Howard. When Howard
was appointed Sheriff of Bedfordshire in 1773, he dis-
covered that the keepers of the gaols within his jurisdiction
received no salary but were remunerated entirely by the
fees of the prisoners and that many prisoners who had long
paid the original debt for which they were incarcerated re-
mained in durance because they could not pay the charges
of the gaoler. In order to obtain precedents for the estab-
lishment of a salary system Howard set out, at his own per-
sonal expense, to inspect the gaols in other counties and
finally on the continent of Europe. He failed to find the
precedent which he desired; but he discovered instead the
most deplorably unsanitary conditions, to the amelioration
of which he devoted himself, with absorbing energy. He
found in many of the prisons no water supply, no ventila-
tion, no means of disposing of excreta. His clothes became
so impregnated with the gaol smell that he was forced to
travel on horseback and his note books had to be fumigated
before he could use them. He was often overpowered by
the nature of the effluvia and had to sustain himself by the
use of a smelling bottle. He was in the most imminent danger
of typhus, which ran riot among the prisoners. As Simon
says, ‘‘in the mere matter of benevolence, Howard as much
took the eighteenth century by surprise as Francis of Assisi
did the thirteenth; and Dante and Giotto, had they been

17 Taine, H. A. History of English Literature. Trans. by H. van Lann. Lon-
don (undated), Vol. II.
SANITARY AWAKENING 17

here, might have celebrated his espousals with Pestilence
as they did his predecessor’s with Poverty.”’

Howard presented his exhaustive findings, in prosaic but
overwhelmingly convincing form, to the House of Commons
in 1774. He received the official thanks of Parliament and
Thad the greater satisfaction of seeing passed forthwith a
bill for the abolition of the fee system of paying gaolers
and another for the betterment of the sanitary condition of
prisons. Prisons were to be whitewashed yearly, regularly
washed and ventilated ; rooms were to be set apart for the
sick, hot and cold water baths provided and in cases of
necessity clothes were to be lent to prisoners; surgeons and
apothecaries were to be appointed. Very moderate steps
forward; yet they not only set in motion the whole modern
movement for prison reform but formed the thin end of the
wedge in introducing into the mind of the British public the
fundamental conceptions of sanitation.

The next of the great movements which added its force
to the stream of sanitary reform was the campaign for the
protection of the industrial workers of England which is
associated with the name of Antony Ashley Cooper, sev-
enth Earl of Shaftesbury, as the reform of the prisons is
identified with that of Howard. The improvements in textile
machinery introduced by Hargreaves, Arkwright, Cromp-
ton, Cartwright and Millar between 1767 and 1785, and
above all the introduction of steam power, first applied to
factory uses in the latter year, brought about the Industrial
Revolution, which in one century changed the social and
economic life of mankind more radically than it had pre-
viously changed in the entire period of recorded history.
With the resulting demand for labor there grew up a system
of apprentice slavery, so revolting in its details as to be
almost unimaginable in the England which was reforming
prisons and abolishing the African slave trade. Pauper
children were indentured in gangs to the eager factory-
owners, certain of the contracts providing that with every
18 EVOLUTION OF PUBLIC HEALTH

thirty normal children the Poor-Law authorities should be
relieved of one idiot! The apprentices worked for sixteen
hours a day, frequently with irons riveted upon their ankles
to prevent a possible escape. Mrs. Browning has pictured
their hopeless fate in The Cry of the Children.

For, all day, the wheels are droning, turning,—
Their wind comes in our faces,—

Till our hearts turn,—our heads with pss burning,
And the walls turn in their places.

Turns the sky in the high window blank and reeling,
Turns the long light that drops adown the wall,
Turn the black flies that crawl along the ceiling,

All are turning, all the day, and we with all.

And all day, the iron wheels are droning,

And sometimes we could pray,

“0 ye wheels’’ (breaking out in a mad moaning)
“Stop! be silent for today !”’

Under the insanitary conditions which surrounded these
wretched children, both in the factory and in the bar-
racks (where they slept by relays in filthy beds which were
. never allowed to cool), it is small wonder that epidemic dis-
ease raged as in a hotbed of contagion. The first impetus
toward, reform was in fact no altruistic one but was in-
spired by the spread of disease from these apprentice fever-
nests to the general population of Manchester. Dr. Thomas
Percival was asked to report to the justices of Lancashire
on this problem as early as 1784. Parliamentary action was
taken by the passing of the first British Factory Act (intro-
duced by Sir Robert Peel) in 1802. It was a very mild
measure, providing (much as in the first prison legislation)
for the use of whitewash in factories, for proper clothing,
feeding and instruction of apprentices, for the reduction of
working hours to twelve and for the abolition of night-work
of children. Again, a seemingly unimpressive measure; but
it established the far-reaching principle of the right and
duty of the state to interfere under certain conditions be-
SANITARY AWAKENING 19

tween employer and employed; and it was the beginning of
the long series of the British Factory Acts, which were to
prove of such far-reaching social significance. Lord Ashley,
as he then was, took up this cause in 1833 and secured before
the end of the year the passage of the most comprehensive
Factory Act which had been contemplated up to that time.
The Ten Hours Bill of 1847, and the Factory Consolidation |
Act of 1878, were perhaps the two other outstanding land-
marks on the long road which led at last to a rounded and
reasonably complete system of protection for the health of
the industrial worker.

‘We may pass now to the third and most significant of the |

S0Ci0- sanitary movements of the early nineteenth century,
to the campaign initiated by Sir Edwin Chadwick and Sir
John Simon which constituted the movement rightly known
as the great sanitary awakening. It is these two men who
are in a very real sense the fathers of the modern public
health campaign. They were true pioneers, of the type of
which Paracelsus speaks,

Tis in the advance of individual minds

That the slow crowd should ground their expectation
Eventually to follow; as the sea

‘Waits ages in its bed till some one wave

Out of the multitudinous mass, extends

The empire of the whole, some feet perhaps,

Over the strip of sand which could confine

Its fellows so long time; thenceforth the rest,

Even to the meanest, hurry in at once,

And so much is clear gained.

Edwin Chadwick (1800-1890) was a lawyer and a keen
student of social problems. In 1838 he was serving as Secre-|
tary of the Poor Law Commission and the connection be-
tween poverty and disease, as well as the preventability of
much of this disease, was forced upon his attention. For the
first time in the history of England he employed physicians
to study systematically the sanitary conditions which might
20 EVOLUTION OF PUBLIC HEALTH

contribute to ill-health, and a resulting report by Dr. South-
wood Smith ‘“on some of the physical causes of sickness and
mortality to which the poor are particularly exposed, and
which are capable of removal by sanitary regulations’’ is
one of the classics of sanitation. Dr. Smith had already (in
1835) published a popular work on preventive medicine
under the title Philosophy of Health; and he was intimately
“associated with Chadwick in all his later work.'®

When Queen Victoria ascended the throne in 1837, the
dawning knowledge of public health science ‘‘was virtually
unrecognized by the Legislature. The Statute-Book con-
tained no general law of sanitary intention, except (so far
as this deserves to be ¢éunted an exception) the Act pro-
viding for Quarantine: under which well-intentioned but
futile Act, the Lords of the Council were supposed to be al-
ways on the lookout for transmarine dangers of pestilence,
and could make pretence of resisting such dangers. Against
smallpox, Parliament used annually to vote 2000 pounds
to support a National Vaccine Board which had a few vac-
cinating-stations in London, and furnished the public with
vaccine lymph! Outside those two matters, the Central Gov-
ernment had nothing to say in regard to the Public Health,
and Local Authorities had but the most indefinite relation
to it 2219

The movement begun in so characteristically practical
and English a fashion by Chadwick, was destined to change
all this. The studies of 1838 led in 1842 to a three-volume re-

18 Chadwick was a close friend of Bentham’s and lived in his house for a
time. It is ‘‘noteworthy that Dr. Smith also was in intimate relations with
Jeremy Bentham during his later years. When Bentham, in the memorable
bequest by which he hoped to correet the then popular prejudice against dis-
section, directed that his own dead body should be publicly dissected and lec-
tured over in a place of medical teaching, he appointed Dr. Smith his legatee
for the purpose; and Dr. Smith accordingly, on the 9th of June, 1832, de-
livered an address over Bentham’s dissected body in Messrs. Grainger’s Ana-
tomical Theatre, Webb Street, Southwark: an address, which has been for
the most part reproduced by Sir John Bowring in the last volume of his edition

of Bentham’s works.”’
19 Simon, Sir John, English Sanitary Institutions. London, 1890.
SANITARY AWAKENING 21

port of the Poor Law Commissioners to Parliament, The
synoptical volume on the Sanitary Condition of the Labour-
ing Population of Great Britain was the work of Chadwick
himself and its clear and forceful exposition of the insani-
tary conditions which existed in all parts of England, of the
burden of sickness and poverty resulting therefrom, and
of the necessity for the construction of sanitary works,
produced a profound impression. It is said that 10,000
copies of it were distributed (an enormous circulation for
the time) ; and in 1843 its influence led to the appointment of
a special Royal Commission on the health of large towns
and populous districts. The reports of this Health of Towns
Commission in 1844 and 1845 initiated the movement for
water supply and sewage disposal throughout the world.

./In 1848 a General Board of Health was constituted, of
which the appointive members were Chadwick, Smith and
Lord Ashley. This board in its original form lasted only six
years, however, and it was in large measure the despotic
and overbearing methods of Chadwick which led to its un-
timely end. Simon in writing of the leader, to whom he
looked with such deep admiration, pays deserved tribute to
“his rare abilities as an initiative investigator in matters of
social pathology,’ and ‘‘his absolute rectitude of intention
toward the public in every line of conduct which he fol-
lowed.”’ He acknowledges Chadwick’s weakness, however,
in a passage which may be commended to the serious con-
sideration of all reformers. ‘‘ He perhaps did not sufficiently
recognize that the case was one in which deliberate national
consents had to be obtained, and in which therefore no real,
no permanent success could be won except in proportion as
* the people and their representative bodies should have made
way in a necessarily gradual process of education. He could
not advisedly have thought it possible to snatch his verdict,
and to revolutionize national habits by surprise; but he
probably hoped to achieve in a few years the results which
not ten times his few years could see achieved ; and where on
22 EVOLUTION OF PUBLIC HEALTH

all sides were hanging back, his ardour seemed ready to
undertake the work of all.”’

Simon himself (1816-1904) was free from these failings;
and no one man perhaps so well typifies the ideal qualities
of a preacher of the gospel of health. The first Medical Offi-
| cer of Health in England was appointed in the person of
Dr. W. H. Duncan by the Town Council of Liverpool in
1847. In October of the next year the City of London fol-
lowed suit and, fortunately for the future of sanitary
science, the Corporation elected to the post John Simon,
then a young lecturer on pathology at Kings College. The
statutory duties of the new officer were ‘To inspect and re-
port periodically upon the sanatory condition of the city, to
ascertain the existence of diseases, more especially epi-
demies increasing the rates of mortality, and to point out
the existence of any nuisance or other local causes which are
likely to originate and maintain such diseases and injuri-
ously effect the health of the inhabitants of the city, and to
take cognizance of the fact of the existence of any conta-
gious or epidemic disease, and to point out the most effica-
cious mode of checking or preventing the spread of such
disease, and also to point out the most efficient modes for
the ventilation of churches, chapels, schools, lodging houses,
and other public edifices within the city, and to perform any
other duties of a like nature.’’ :

It is delightful to read in Simon’s book on English Sani-
tary Institutions, of the enthusiasm with which he attacked
his new task. The death returns of the City Registrars were
made on Monday morning and on Monday afternoon they
were placed at Simon’s disposal through the courtesy of
the Registrar General as he says ‘‘in a way which enabled
me to complete my use of them during the evening, so that
on the Tuesday mornings when the weekly courts of the
City Commission were held, I was ready with all needful
particulars as to the deaths which had befallen the city
population during the previous week, and with my scheme
SANITARY AWAKENING 23

of such local inquiries as were to be made in consequence.”’

John Simon did far more than to clean up the municipal
area under his care. He was an excellent administrator but
he was even greater as a teacher. In his annual and quar-
terly reports he ‘aimed at such generalizations as could be
popularly understood and popularly applied with regard
to the causes of death and to the proportion in which dis-
eases more or less preventable were killing within the city
and in its respective districts.”” These reports ‘‘had an
extraordinary circulation through the medium of the daily
press, and were received by the public with every possible
indulgence and favor.’’

In 1855, after serving as Medical Officer for the City of
London for seven years, Simon was called to the newly
created office of Central Medical Officer to the General
Board of Health. He held essentially the same position for
twenty-one years during various administrative changes,
the position being for a time under the Privy Council and
later attached to the Local Government Board.

The results of Simon’s activities between 1855 and 1876
were, first of all, a notable advance in filling what he called

the ‘‘huge legislative vacuum’’ in matters of public health

by the passage of a series of laws of which the great Sani- |

tary Act of 1866 is perhaps the most notable. He describes
the general result of these legislative advances in his elev-
enth report (for 1868), as follows: ‘“‘It would, I think, be
difficult to overestimate, in one most important point of
view, the progress which during the last few years has been
made in sanitary legislation. The principles now affirmed in
our statute book are such as, if carried into full effect, would
soon reduce to quite an insignificant amount our present

“very large proportions of preventable disease . .". Large

powers have been given to local authorities, and obligation

expressly imposed on them, as regards their respective dis-!

tricts, to suppress all kinds of nuisance and to provide all
such works and establishments as the public health pri-
24 EVOLUTION OF PUBLIC HEALTH

marily requires; while auxiliary powers have been given
for more or less optional exercise in matters deemed of less

than primary importance to health . . . The State . . . has
interfered between parent and child . . . between employer
and employed . . . between vendor and purchaser; has put

restrictions on the sale and purchase of poisons; has pro-
hibited in certain cases certain commercial supplies of
water; and has made it a public offence to sell adulterated
food or drink, or medicine, or to offer for sale any meat
unfit for human food . . . Its care for the treatment of dis-
ease has not been unconditionally limited to treating at the
public expense such sickness as may accompany destitu-
tion; it has provided that in any sort of epidemic emer-
gency, organized medical assistance, not peculiarly for
paupers, may be required of local authorities; and in the
same spirit requires that vaccination at the public cost shall
be given gratuitously to every claimant.’’

More important even than these legislative enactments
was the influence of Simon as a molder of public opinign.
The root of the matter as he saw it was that average Eng-
land had not ‘“‘reached any high standard of sensibility to
dirt. Against accumulated obvious masses of filth, against
extreme atrocities of stench, local protests, no doubt, are
pretty commonly to be heard, and, at moments when there is
panic about disease, may often rise to considerable warmth
of indignation, but in regard of the less riotous forms of
uncleanliness far too much insensibility is widely shown.”
The remedy for this state of affairs was education of which
he says ‘“over great territories of social evil, adjacent to
the field of our merely medical work, we seem to see on all
sides, just as in our own province, the common pervasion of
one deep want; the want of riper national education. Edu-
cation in the full sense of the word, is the one far-reaching
true reformer, for which in all domains the sufferers have
to work and hope.”’

Simon’s own work was necessarily largely concerned with
SANITARY AWAKENING 25

the remedy of those grosser evils of obvious filth which |

favor the spread of epidemic disease; but he was far-sighted

enough to glimpse the deeper prevention of the present day, |

which aims at building up vital resistance through the per-
sonal conduct of life. ‘‘Long before our modern codes of
public sanitary law had begun to shape themselves, elabo-

rate counsels of personal hygiene had become current in the |

world; counsels, as to the ways and habits of life which
would most conduce to healthful longevity; counsels, above
all, for moderation in life,—the rule of not too much; and
those counsels for personal self-government, enforced from
age to age by the evergrowing common experience of man-
kind, are not now to be deemed superfluous because boards
of local government have arisen. In relation to their union,
and to the many personal influences which are hereditary,—
in relation to work and repose and recreation for mind and
body,—in relation to the charge of infancy, and to proper
differences of regimen for the different after periods of
life,—there are hygienic rules, perhaps not less important
to mankind than the rules which constitute local authori-
ties.”’

I have dwelt thus at length upon the work of the early
English sanitarians, even to ignoring such great continental

pioneers as Johann Peter Frank (1745-1821) and Max von |
Pettenkofer (1818-1901) because the impulse of the ‘‘great |

“sanitary awakening’’ actually came to us in this country
from Lo “and not from Vienna or Munich. It would be
. a fascinating task to trace out the influence of Frank upon
the development of state medicine in Germany and Scan-
dinavia and Russia but the limitations of our time forbid.
So far as the United States is concerned, the public health
movement began with the Report of the Massachusetts
Sanitary Commission in 1850, a document which drew its
inspiration directly from Chadwick and Simon.

* This report, drafted by Lemuel Shattuck, nearly three- \
26 EVOLUTION OF PUBLIC HEALTH

quarters of a century ago,” is worthy to rank with the best

productions of English sanitary statesmanship,—I am not -

quite certain that for breadth and clarity of prophetic
vision it is not the most remarkable document in the history
of public health. Like Chadwick, Lemuel Shattuck was not a
medical man but a statistician and a student of social prob-
lems. In the Plan for a Sanitary Survey of the State, which
forms the essential part of the report, he not only recom- °
mends the establishment of a system of sanitary police, with
state and local health departments, and careful collection
and analysis of vital statistics but outlines a complete health ,
program, including sanitation,—of towns and of buildings,
—studies on the health of school children, special investiga-
tion of tuberculosis, control of alcoholism, supervision of
mental disease by boards of health, systematic study of
immigration, the formation of local sanitary associations
for collecting and diffusing information relative to health,
the erection of model tenements and public bathing and
wash-houses, the control of the smoke nuisance, food adul-
teration and the exploitation of nostrums, the better educa-
tion of nurses, the teaching of preventive medicine as a
part of the medical curriculum, the preaching of health from
the pulpit, the keeping of family records of illness and
routine physical examination! Shattuck was far ahead of
/ his time; but his ideas slowly germinated and led in 1869
to the establishment in Massachusetts of the first State
Board of Health. Once this beginning was made the idea
spread rapidly, for when Connecticut established its Board
in 1878 there were already sixteen others in existence.
Meanwhile a similar impetus was given to the develop-
ment of nfunicipal health administration by the sanitary
survey of New York City, to which reference has been made
in a preceding paragraph.** At this time the famous Citizens

20 Most easily accessible in Vol. T of State Sanitation by G. C. Whipple,
Cambridge, 1917.
21 See page 10, footnote 12.
SANITARY AWAKENING 27

Association under the leadership of Peter Cooper was fight-
ing the Tweed ring and in 1864 the attempt was made to
secure a health organization for the city in place of the
highly corrupt and inefficient force of the City Inspector,
then in sole charge of sanitary supervision. On the failure
of this effort a sanitary survey of the city was instituted
under the direction of Dr. Stephen Smith (later first presi-
dent of the American Public Health Association, who died
at the age of ninety-nine a year ago). The startling revela-
tions of this survey formed the basis for a purposeful
political campaign which early in 1866 led to the triumphant
passage of the Metropolitan Health Law, whose far-reach-
ing and drastic provisions as drawn by Mr. Dorman B.
Eaton formed a basis for the sweeping powers later con-
ferred upon departments of health throughout the United
States.”

22 This story is fascinatingly told in The City That Was by Stephen Smith.
New York, 1911.
CHAPTER III

PASTEUR AND THE SCIENTIFIC BASES

OF PREVENTION

Y 1870 the sanitary awakening had begun to bear
fruit on both sides of the Atlantic. The first chapter
of the public health movement was practically com-

plete. Its vision, however, except for the long dreams of
Simon or of Shattuck, was limited to the problem of en-
vironmental sanitation. The Royal Sanitary Commission in
its report of 1871 summarized the fundamental health essen-
tials under the following eleven heads, a sufficiently meager
program from the standpoint of the present day; even
though it represents a vast advance over the ideals of 1838:

1.

wo 3

9.

10.
11.

The supply of wholesome and sufficient water for drinking
and washing.
The prevention of the pollution of water.

. The provision of sewerage and utilization of sewage.

. The regulation of streets, highways, and new buildings.

. The healthiness of dwellings.

. The removal of nuisances and refuse and consumption of

smoke.

. The inspection of food.
. The suppression of causes of disease and regulations in case

of epidemics.

The provision for the burial of the dead without injury to the
living.

The regulation of markets, ete., public lighting of towns.
The registration of death and sickness.

Furthermore it must be remembered that even the sanita-
tion of this period was entirely devoid of any sound scien-
PASTEUR 29

tific basis. Hippocrates had attributed epidemic disease pri-
marily to miasmatic conditions and was believed to have
controlled the plague of Athens by lighting fires as an at-
mospherie corrective. Thueydides is the first writer to enun-
ciate the doctrine of contagion and from his time on the
conception was never wholly lost. It was consistently subor-
dinated, however, to the miasmatic theory. Thus Lucretius
in De rerum natura does speak of ‘‘seeds’ ‘‘that bring
disease and death’’; but he devotes 200 lines to atmospheric
and other influences. Infection by contact air and fomites
is recognized in the verses of the School of Salerno and
Boccaccio in the introduction to the Decameron (1350)
writes, ‘‘The disease by being communicated from the sick
to the well, seemed daily to get ahead and to rage the more,
as fire will do by laying on fresh combustibles. Nor was it
given by conversing only, or coming near the sick, but even
by touching their clothes, or anything that they had
touched.”

By far the most illustrious medieval proponent of the doc-
trine of contagion was Hieronymus Fracastorius (1478-
1553). In his essay De Contagionibus (1546) he speaks of
the “‘seminaria’’ of contagion, which have a power to mul-
tiply and propagate their like. They are transmitted by di-
rect contact (which he compares to the spoiling of fruits by
mutual apposition), by fomites (which he compares to the
déposit of soot on a smoky wall) and by atmospheric trans-
fer (which he illustrates by the glance of the basilisk).**

It is easy to read into such speculations far more of mod-
ern scientific knowledge than a just criticism warrants. The
spoiling of fruit was a flash of inspiration but the glance
of the basilisk was an analogy equally satisfying to the
contemporaries of Fracastorius. There was no consistent
comprehension of the seminaria of contagion as concrete
physical entities, still less as living organisms. The broad

23 Singer, C. and D. The Scientific Position of Girolamo Fracastoro. Annals
of Medical History, New York, 1917, Vol. I, p. 1.
30 EVOLUTION OF PUBLIC HEALTH

conception of contagion gained general acceptance so far
as diseases like smallpox were concerned, but it was defi-
nitely repudiated in favor of the Hippocratic miasms as re-
gards what came to be known as the filth-diseases. The
Metropolitan Sanitary Commission®* devotes pages to dem-
onstrating how erroneous is the idea that cholera may be
contagious; while Pettenkofer,* in order to explain the ob-
vious epidemiological differences between cholera on the
one hand and such diseases as smallpox on the other, as-
sumes that although the virus of cholera must be present in
the dejecta of cholera patients it only causes disease after
decomposition in a suitable organic soil. To diseases of this
class (particularly typhoid) the eminent English physician,
Sir Charles Murchison, gave the name ‘‘pythogenic fe-
ver,””?® defining it in a later work as®” ‘‘an endemic disease
generated and propagated by certain forms of decomposing
organic matter.”” As late as 1873* he says of pythogenic
fever that ¢‘it may be generated independently of a previous
case by fermentation of faecal, and perhaps other, forms
of organic matter’’; and that ‘‘it may be communicated by
the sick to persons in health, but even then the poison is not,
like that of smallpox given off from the body in a virulent
form, but is developed by the decomposition of the excreta
after their discharge.’’

At this very time, however, an ardent and tenacious little
French chemist in the dingy laboratories of the Ecole
Normale was at work along a line that was to clear up once
and for all time these puzzling problems, and to open the
second chapter in the history of public health.

Louis Pasteur was born in the cottage of a humble tanner
at Dole in 1822, when Chadwick was a young man of twenty-

24 See page 9, footnote 10.

25 Pettenkofer, M. Untersuchungen und Beobachtungen iiber die Verbreit-
ungsart der Cholera. Munich, 1855.

26 In a footnote to a paper read before the Royal Medical and Chirurgical

Society of London, April 27, 1858 (Trans. 1858, p. 221).
27 Murchison, Charles. The Continued Fevers. Second edition. London, 1873.
PASTEUR 31

two years old and Simon a child of six. During the period
of the Health of Towns Commission and the Metropolitan
Sanitary Commission (the late forties) he was beginning
his work on the relation between chemical composition and
crystalline form among the tartrates,—as what we would
call today a physical chemist. Fortunately the peculiar
properties of amyl alcohol as it appeared in certain fer-
mentations aroused his curiosity as to the true mechanism
of the process of fermentation itself and set his feet upon
the path which was to lead straight onward to the germ
theory of disease.” The doctrine that fermentation was a
purely chemical disintegration, held almost complete sway
in the middle of the nineteenth century; but in a brilliant
series of investigations which began in 1858 and were pur-
sued intermittently for nearly twenty years Pasteur dem-
onstrated that the process of fermentation was due to mi-
crobes, that each particular fermentation was caused by a
particular kind of microbe, and that these microbes them-
selves were produced only by biogenesis and were not
spontaneously generated.” This was no easy task. It was
necessary to combat the dominant influence of Liebig, who
stoutly contended that fermentation was a purely chemical
process incited by the oxygen of the air. It was necessary
to open flasks of putrescible liquids out on the Mer de Glace
and show that the pure air of the high Alps free from mi-
crobic life would not cause putrefaction; but at last the
biological nature of such decompositions was demonstrated
beyond possibility of doubt.

In 1865 (at about the middle of Simon’s period of service
with the Local Government Board) Pasteur was called from

28 The logical dévelopment of Pasteur’s researches is admirably traced in
Pasteur, The History of a Mind, by Emile Duclaux, translated by E. F. Smith
and Florence Hedges. Philadelphia, London, 1920.

29 As specially outstanding contributions of Pasteur’s to this special prob-
lem, see Annales de Chimie et de Physique, Series III, 1858, Vol. 52, p. 404,
Comptes rendus de 1’ Académie des Sciences, 1858, Vol. 47, pp. 224 and 1011;

1860, Vol. 50, pp. 303 and 849; 1860, Vol. 51, pp. 348 and 675; Etudes sur le
Vin, Paris, 1866, and Etudes sur la Biere, Paris, 1876.
32 EVOLUTION OF PUBLIC HEALTH

his laboratory to undertake—very unwillingly—a study of
the strange disease of silkworms which was threatening the
ruin of the silk industry of France. His microscope showed
in the bodies of the affected worms corpuscles very like
the microbes of spoiled wine and beer. While of course reec-
ognizing the fact of contagion, Pasteur himself resisted for
nearly two years the idea that these corpuscles were the
causative agents of the disease. By 1867, however, he had
definitely reached the parasitic hypothesis and by 1870 he
had shown how the serious economic problem of silkworm
disease could be practically controlled, essentially by the

| application of the principle of isolation and quarantine.®

From fermentation to silkworm disease was a long but a
natural step. (Even Fracastorius spoke of disease as a
putrefaction.) From silkworm disease to the contagious
maladies of the higher animals was a short and inevitable
one. Already Iister had applied the general theories of
Pasteur to antiseptic surgery and Davaine to the etiology
of anthrax; in 1877 Pasteur himself, and Robert Koch,
simultaneously and independently, demonstrated beyond
doubt that the germ of anthrax is actually the cause of this
disease, by cultivating it in pure cultures and artificially in-
fecting animals by their use.” Finally by his studies on the
chicken cholera (1880), on anthrax (1882) and on rabies

(1884), Pasteur succeeded in producing artificial immunity

against mierobic diseases by the attenuation of the specific
viruses concerned.” In a quarter of a century, and by the
labors of one man, the mystery which for time immemorial

‘had shrouded the plagues and pestilences was rent away,

~N

and there was established on the one hand the science of

30 See particularly Comptes rendus de 1’Académie des Sciences, 1866, Vol.
63, pp. 126 and 897; 1867, Vol. 64, pp. 835 and 1113. Also Etudes sur la Maladie
des vers a soie. Paris. 1870.

81 Koch. (Cohn’s) Beitrdge zur Biologie der Pflanzen, 1877, Vol. 2, p. 277.
Pasteur. Comptes rendus de 1’ Académie des Sciences, 1877, Vol. ‘84, p. 900.

32 Comptes rendus de 1’Académie des Sciences, 1880, Vol. 90, pp. 239, 952
and 1030; 1880, Vol. 91, p. 86; 1881, Vol. 92, pp. 209, 429, 666, 1378; 1881,
Vol. 92, p. 1259.
PASTEUR 33

bacteriology which was to make it possible to check the
spread of mierobic invaders and on the other the science of
immunology which opened the way for building up specific
resistance against their ravages. Almost as important as
his direct and concrete contributions was the spirit of pa-
tient critical investigation which Pasteur impressed upon
the medical science of later times. He taught us, in the
words of his address at the opening of the Pasteur Institute,
to “worship the spirit of criticism. If reduced to itself, it
is not an awakener of ideas or a stimulant to great things,
but, without it, everything is fallible; it always has the last
word. What I am now asking you, and what you will ask of
your pupils later on, is what is most difficult to an inventor.
It is indeed a hard task, when you believe you have found
an important scientific fact and are feverishly anxious to
publish it, to constrain yourself for days, weeks, years
sometimes, to fight with yourself, to try and ruin your own
experiments and only to proclaim your discovery after hav-
ing exhausted all contrary hypotheses. But when, after so
many efforts, you have at last arrived at a certainty, your)
joy is one of the greatest which can be felt by a human /
soul.”’

"That joy he himself tasted in the fullest measure. Before
his death in 1895 he saw his discoveries acclaimed through-
out the civilized world and the scope of their influence
widening with every passing year. The germ of tuberculosis
was described in a classic contribution® by Koch in 1882;
the causative organism of cholera in 1883 and those of diph. |
theria and typhoid fever in 1884. From that time, progress
in the unmasking of our microscopic foes has gone steadily
forward to the recent studies of Noguchi on yellow fever,
of Wolbach on typhus, of Olitsky and Gates on influenza.
The newer research involves the use of novel culture media; ||
but in principle it is but a repetition of the experiments so
painstakingly planned in the Ecole Normale fifty years ago.

33 Koch, Berliner klinische Wochenschrift. 1882, Vol. 19, p. 221.
CHAPTER IV

THE GOLDEN AGE OF BACTERIOLOGY

HE new knowledge which came flooding in as a re-
sult of the researches of Pasteur was very quickly

brought from France and Germany to America. The
first work in bacteriology in the United States was appar-
ently that of T. J. Burrill at the University of Illinois in the
seventies. Surgeon-General Sternberg in Washington,
W. H. Welch at Johns Hopkins, T. Mitchell Prudden at the
College of Physicians and Surgeons in New York, D. E.
Salmon of the Bureau of Animal Industry, Henry Formad
and A. C. Abbott in Philadelphia were other pioneers who
began to teach or to write on bacteriology before 1885.%
From the practical public health standpoint there were
two centers of dissemination for the young science of bac-
teriology which proved of peculiar importance in their in-
fluence upon the public health. The first of these was the co-
operative work of the State Board of Health and the
Massachusetts Institute of Technology in Boston. Even be-
fore the days of bacteriology, Professor William Ripley
Nichols had in 1870 begun a notable series of researches on
the sanitary chemistry of water supplies. With him was
associated Ellen H. Richards, pioneer student of the hy-
giene of the home and zealous protagonist of Euthenics
which her Alma Mater, Vassar, is just now planning to
recognize in its curriculum. The Massachusetts State Board
of Health was reorganized in 1886, with the purpose of de-
veloping control over ¢‘the Purity of Inland Waters’’ and in

34 Bergey, D. H. Early Instructors in Bacteriology in the United States.
Aournal of Bacteriology, Vol. 2, 1917, p. 595.
GOLDEN AGE OF BACTERIOLOGY 35

1887 the Lawrence Experiment Station was established for
research in regard to water and sewage problems, with Pro-
fessor T. M. Drown as Consulting Chemist and Professor
W. T. Sedgwick as Consulting Biologist. This co-operation
between the state and the Institute of Technology led on
the one hand (at Lawrence) to the basic discoveries which
underlie the whole modern art of sewage treatment, and on
the other (at Technology) to the development under Sedg-
wick’s direction of the earliest training school for sani-
tarians in the United States. It was Sedgwick who lighted
the torch for such leaders as Hazen, Fuller, Jordan and
Whipple. He became the most influential figure of his time
in the teaching of public health and hundreds of men and
women, of whom the writer is one, owe to him the direction
and the inspiration of their careers.

The other center at which bacteriology was developed to
a point of peculiar influence and importance was in the
Health Department of New York City. A state hygienic
laboratory had been established at Ann Arbor in the winter
of 1887-1888 and the first municipal public health laboratory
was opened in Providence in 1888. In Massachusetts, Michi-
gan and Rhode Island, the emphasis had, however, been
chiefly on the sanitary rather than the medical aspects of
the subject. It was now becoming apparent that the dis-
coveries which were being made in the laboratories of
Europe held rich promise of usefulness in the more direct
control of communicable disease. The great epidemic of
cholera at Hamburg was at its height and a number of ships
from that port were detained at quarantine in New York
harbor. Dr. Hermann M. Biggs, who as General Medical
Officer of the New York City Department, and from 1914 to
1923 as Commissioner of Health of New York State,—suc-
. cessively built up two of the outstanding health organiza-
tions on this continent, was then Pathologist to the City
Department. He suggested the application of bacteriologi-
cal methods for the detection of cholera cases among the
36 EVOLUTION OF PUBLIC HEALTH

immigrants, and was fortunate enough to secure the serv-
ices of Dr. Kl. K. Dunham, a young pathologist just returned
from a study of the methods in use in Hamburg. In 1892 a
Division of Bacteriology and Disinfection was formally
established in the Department and in the next year Dr.
W. H. Park began his connection with the laboratories, of
which he is now the head, by introducing the new technique
for the bacteriological diagnosis of diphtheria. In 1894 the
examination of the sputum of suspected cases of tubercu-
losis was begun and an appropriation made for the manu-
facture of diphtheria-antitoxin, then produced in a small
way by Behring and Aaronsen in Germany and by Roux in
Paris.

From this time onward the laboratory has become the
scientific foundation of the public health campaign in Amer-
ica, developed to a point perhaps unequalled in any other
country. The activities of the chemist and the bacteriologist
are basic in the control of water supplies and milk supplies
and food supplies, in the diagnosis of disease and in the
preparation of sera and vaccines. They impart throughout
the whole range of the work of the health department the
rigorous spirit of science, the results of laboratory study
being directly applied on a vast and practical scale to the
population under the administrative control of the depart-
ment. It is truly inspiring to see laboratories maintained at
public expense not only performing the routine function of
disease control, but, as in the case of the Massachusetts
State Laboratory, the New York State Laboratory (under
Dr. A. B. Wadsworth) and the New York City Laboratory
(under Dr. Park), carrying on independent researches of
the highest grade and making first-rate contributions to the
fundamental principles of science.

The two decades between 1890 and 1910 formed in a
sense the golden age of public health. The germ theory was
now thoroughly established and its applications went for-
ward by leaps and bounds. No previous period of twenty
GOLDEN AGE OF BACTERIOLOGY 37

years had ever seen equal progress in the application of
sanitary science and it is-doubtful if any similar period in
the future will ever witness quite such phenomenal achieve-
ments.

The first result of the new science of bacteriology was to
make precise and definite the shotgun methods of the em-
pirical sanitation and the empirical isolation of an earlier
day. The pythogenic theory, erroneous though it was, had
yielded substantial results because, as has been said, ‘filth
if not the mother, is at least the nurse of disease.”” Yet a
scientific comprehension of the real elements of contagion
made possible advances of a far-reaching kind, as may be
illustrated by tracing its influence upon the control of the
three great groups of diseases, spread respectively by water
supplies, by insects and by direct contact.

Before the days of steam, water supplies for large cities
must necessarily be brought in from distant mountain re-
gions by gravity as in the aqueduct systems of ancient
Rome; and such supplies were likely to be of reasonably
good sanitary quality. With the introduction of steam
pumping (London, 1761), supplies were more and more
freely taken from rivers in the immediate vicinity of the
cities themselves in the comfortable belief that ‘‘running
water purifies itself’’ and that water which looked clear and
tasted fresh was likely to be safe for potable purposes. It
is true that filtration had been introduced by James Simp-
son for the London water supply as early as 1829. Its pur-
pose however was primarily an esthetic improvement in
the appearance of the otherwise turbid waters. With the
introduction of the solid culture method of Koch and its
application to the enumeration of bacteria by P. F. Frank-
land, it became evident that these filters were removing bac-
teria as well as visible impurities. The cholera epidemic-at
Hamburg in 1892, in which the neighboring town of Altona
was effectively protected by filtration, furnished convincing
epidemiological evidence of the value of the process. The
38 EVOLUTION OF PUBLIC HEALTH

epidemic of typhoid fever at Lowell and Lawrence in 1890-
1891 and the subsequent construction of the Lawrence filter
in 1893 and of the Albany filter in 1899 led to a rapid popu-
larization of the English or slow-sand filter in this country.*
For the treatment of clay-bearing waters, however, this
process proved to be both costly and inefficient. The Ameri-
can, or rapid-mechanical filter, in which the filtering effect
is increased by the addition of a chemical coagulant, with
corresponding acceleration of the rate of filtration, was
gradually developed to meet this need. First regarded with
suspicion as a patented process (adapted particularly for
use in purifying water for paper mills), the mechanical
filter gained acceptance as a standard procedure for the
treatment of turbid municipal supplies after the investiga-
tions of KE. B. Weston at Providence in 1893-1894 and of
G. W. Fuller at Louisville in 1895-1896 and at Cincinnati in
1898. After this, developments were rapid. In 1880 only
about 30,000 people in cities of over 2500 population in the
United States were supplied with filtered water; by 1890
the number had risen to 310,000; by 1900 to 1,860,000, by
1910 to 10,805,000, and by 1920, to over 20,000,000. In 1908
the introduction of the practice of disinfecting water sup-
plies with hypochlorite of lime (later to be replaced by
liquid chlorine) at the Chicago Stockyards and at Jersey
City, N. J., added enormously to the ease with which pro-
tection may be secured against water-borne disease. Many
other factors than improvement in water supplies have
contributed to the reduction of the typhoid death-rate. Yet
it is of interest in this connection to note that out of a group
of thirty-five large American cities every one had in 1898-
1908 a typhoid death-rate of over 15 per 100,000 and seven-
teen out of the thirty-five had a rate of 30 or more. In 1917
1919 only two of the same cities had a rate over 15 and oy
one a rate over 30.

35 The first sand filter was built by J. P. Kirkwood at Poughkeepsie, N. Y.,
in 1872 but the process did not acquire any general popularity until after 1890.

/
GOLDEN AGE OF BACTERIOLOGY 39

The development of knowledge in regard to the insect-
borne diseases was even more far-reaching in its influence
than that of water supply sanitation. It did not, like the
latter, derive directly from an application of bacteriology,
since the most typical insect-borne parasites are Protozoa;
yet it was clearly made possible by the fundamental view-
points of the germ theory of disease. As far back as 1889
Smith and Kilbourne demonstrated the dissemination of
Texas fever of cattle by the tick; but it was ten years later
that the solution of the mystery of malaria attracted world-
wide attention to the insect enemies of man.

It is most interesting to look at a standard medical ref-
erence book of thirty years ago® and see how many
facts had been observed in regard to the bad-air disease
(mal-aria) and yet how puzzling and mysterious was the
general picture which it presented. ‘An earth-born poi-
son’’; evolved from marshes ‘‘when the water level is
lowered and the saturated soil is exposed to the drying in-
fluence of a high temperature’’; frequently resulting from
“the disturbance of soil that has long been fallow’’; as in
the construction of the fortifications of Paris under Louis
Philippe; ‘‘freely generated at the bases of mountain
ranges in tropical climates’’; ‘it drifts along plains to a
considerable distance from its source, when aided by winds
sufficiently strong to propel, but not to dispel it’’; and ‘‘un-
der the influence of currents of heated air it can ascend in
dangerous concentration, far above its source.”” In 1897
Ronald Ross demonstrated the parasite of bird malaria in
the stomach of the mosquito. In 1898 Grassi and Bignami
in Italy identified the microbe of human malaria in the
Anopheles mosquito; and the mystery of drifting miasms
generated by moist soils was explained by the agency of a
mosquito-carrier bred in stagnant water. Malaria remains
one of the major health problems of the world. Osler has
said that ‘‘if a census were taken among the world’s

—

36 See for example Quain’s Standard Dictionary of Medicine, 1894 edition.
40 EVOLUTION OF PUBLIC HEALTH

workers on disease, the judgment to be based on the damage
to health and direct mortality the votes would be given to
malaria as the greatest single destroyer of the human race.”’
Its control is, however, now wholly within éur grasp.

Next came the most dramatic episode in the whole history
of public health, the conquest of yellow fever. Between the
years 1702 and 1800 this terrible disease had appeared in
the United States thirty-five times and between 1800 and
1879 it visited this country every year with but two excep-
tions. In 1793 a tenth of the population of Philadelphia are
said to have perished from its ravages. Matthew Carey in
his vivid account of this epidemic says, ‘‘it is not probable
that London, at the last stage of the plague, exhibited
stronger marks of terror than were to be seen in Philadel-
phia from the 24th or 25th of August till pretty late in
September.’

For over a century more the etiology of this disease re-
mained obscure and as late as 1898 the United States
Marine Hospital Service in an official bulletin stated that
‘‘while yellow fever is a communicable disease, it is not
contagious in the ordinary acceptation of the term, but is
spread by the infection of places and articles of bedding,
clothing and furniture. . . . One has not to contend with an
organism or germ which may be taken into the body with
food or drinks but with an almost inexplicable poison so
insidious in its approach and entrance that no trace is left
behind.”’

Two years later, early in the year 1900, a commission of
army officers was appointed to study the disease in Havana
as a result of a number of cases which had occurred in the.
American army of occupation. The Chairman of the Com-
mission was Walter Reed, and his associates were James
Carroll, Jesse W. Lazear, and Aristides Agramonte. At the
very beginning, the investigators turned their attention to

37 Carey, M. A Short Account of the Malignant Fever lately Prevalent in
Philadelphia. Philadelphia, 1793.
GOLDEN AGE OF BACTERIOLOGY 41

the mosquito as a possible agent in the transmission of the
disease. Dr. Carlos J. Finlay of Havana had suggested the)
mosquito theory of yellow fever very convincingly in 1881,
though without experimental proof, and the discoveries
of Manson and Ross and Grassi and Bignami had recently
demonstrated a similar origin for malaria. Reed and his
colleagues were fortunate in thus beginning almost at once
with a correct hypothesis.

The lower animals were not known to suffer from yellow
fever, so that experiments upon human subjects were essen-
tial. In the words of Dr. Kelly’s life of Major Reed, ‘‘after
careful consideration, the Commission reached the conclu-
sion that the results, if positive, would be of sufficient serv-
ice to humanity to justify the procedure, provided, of
course, that each individual subjected to experiment was
fully informed of the risks he ran, and gave his free consent.
The members of the Commission, however, agreed that it
was their duty to run the risk involved themselves, before
submitting anyone else to it.”’

The first successful experiment was made with Dr. Car-
roll, who allowed himself to be bitten on August 27 by a
mosquito which had previously bitten four yellow fever
patients. Four days later he was taken sick and for three
days his life hung in the balance. Both he and Private W. H.
Dean, the second case produced experimentally in the same
way, recovered. Dr. Lazear, however, who came down with
the disease, not as a result of the experimental inoculations
to which he also had submitted, but from an accidental bite,
was less fortunate than his colleagues, for a week later he
died, after several days of delirium.

An experimental station, named ‘‘Camp Lazear’’ after
this first martyred member of the party, was established in
the open country; and to the lasting honor of the United
States Army, volunteer subjects for the experiments from
among the troops were always in excess of the demand.
Private John R. Kissinger and John J. Moran, a civilian
42 EVOLUTION OF PUBLIC HEALTH

employee, were the first to volunteer ‘‘solely in the interest
of humanity and the cause of science,” their only stipula-
tion being that they should receive no pecuniary reward.

The result of the experiments carried out at Camp
Lazear proved beyond peradventure that yellow fever was
transmitted by the bite of a certain mosquito, 4édes calo-
pus, and in no other way, for non-immunes who lived for
twenty days in a small, ill-ventilated room, in which was
piled clothing and bedding, loathsome with the discharges
of yellow fever patients, all escaped infection, so long as
they were protected from the bites of mosquitoes.

On the memorial tablet to Lazear in the Johns Hopkins
Hospital is the inscription: ‘With more than the courage
of the soldier, he risked and lost his life to show how a
fearful pestilence is communicated, and how its ravages
may be prevented.’’ The same risk was freely taken by each
member of the party from major to private. The result of
their devotion is indicated in two of Reed’s letters to his
wife, ‘‘six months ago, when we landed on this island, abso-
lutely nothing was known concerning the propagation and
spread of yellow fever—it was all an unfathomable mys-
tery—but today the curtain has been drawn’’; and later, on
New Year’s Eve—‘ ‘only ten minutes more of the old cen-
tury remain. Here have I been sitting reading that most
wonderful book, ‘La Roche on Yellow Fever,” written in
1853. Forty-seven years later it has been permitted to me
and my assistants to lift the impenetrable veil that has
"surrounded the causation of this most wonderful, dreadful
pest of humanity and to put it on a rational and scientific
basis. I thank God that this has been accomplished during
the latter days of the old century. May its cure be brought
out in the early days of the new.”’

The practical result of this discovery was immediate and
striking. In the half-century or so for which we have rec-
ords, yellow fever had killed an average of 750 persons a
year in the City of Havana. The sanitary reforms intro-
GOLDEN AGE OF BACTERIOLOGY 43

duced by the American army of occupation which produced
good results in reducing typhoid and smallpox had been
powerless against yellow fever because its cause was as yet
a mystery. Following immediately on the experiments at
Camp Lazear, on February 15,1901, a campaign was begun |
on the new lines indicated, by screening the rooms occupied
by yellow fever patients and destroying all mosquitoes in
the neighborhood. As a result there were six deaths in the
City of Havana during the year 1901 as against 305 in the
preceding year, and although sporadic cases have been in-
troduced from other localities, yellow fever has never again
established itself in Havana. The scourge of centuries was
wiped out in a single year.

It was the demonstration of yellow fever control at
Havana which, four years later, made possible the building
of the Panama Canal;2 and throughout the Torrid Zone
has opened up the Tropics for the occupancy of the white
race. During the last few years the International Health
Board has actively embarked upon the aggressive warfare
of extermination against yellow fever outlined by the late
General Gorgas. At Guayaquil, once the chief endemic cen-
ter of this disease, it has been eradicated. During 1921,
Honduras, Nicaragua, Ecuador and Costa Rica were im-
mune from the disease; Guatemala and Salvador had no
cases later than February; by July, Peru, and by Novem-
ber, British Honduras, were free of infection. The complete
eradication of yellow fever from the earth is within the
bounds of our vision.

While the mosquito-borne diseases were thus passing un-
der control, the two great pandemic scourges of medieval
times, bubonic plague and typhus fever were also yielding
up their secrets. The germ of plague was discovered by
Yersin in 1894 soon after this disease began its most recent

38 For an enlightening estimate of the significance of this feat by a layman
see C. F. Adams, Proceedings of the Massachusetts Historical Society for May,

1911.
6
\ ok d

4°
44 EVOLUTION OF PUBLIC HEALTH

spread from the marmot hunters of Manchuria to China
and to India. During the next ten years evidence showing
that this chronic disease of rodents is normally spread from
rat to rat and from rat to man by the agency of the flea
continued to accumulate ; and in 1898-1899 the researches of
the Indian Plague Commission completed the demonstra-
tion. The present pandemic of plague killed six million peo-
ple in India and has spread to the chief seaports of every
important country in the world. The ground squirrels of
California have become infected; but everywhere except in
India the disease has been held in check by an organized
campaign against its rodent hosts.

The part played by the louse in the spread of typhus fever
was revealed by Nicolle and his associates in 1909. By a
simple routine of cleansing the person and the clothing
“‘camp-fever,’’ which decimated the troops of Napoleon and
of so many captains before him, was effectively controlled
during the great war; and when it burst forth in decivilized
Revolutionary Russia it was held in check at the Polish
frontier by the co-operative efforts of the Polish govern-
ment and the Anti-Epidemic Commission of the League of
Nations.

The eradication of the communicable diseases which are
spread by water and by insects is today solely a problem
of economics and administration. The battle with the third

“group, of contact-borne diseases, has not gone quite so well,
| —because there are still serious gaps in our armamenta-
‘rium of knowledge. Two broad fundamental principles,
however, which underlie the isolation of these maladies,
emerged from the various investigations of the period be-
tween 1890 and 1910. In the first place it was made clear
that microbic parasites (like the human dependents in
great men’s houses for whom the word was first coined by
the Greeks) were adapted to an artificial existence and had,
through evolution, lost the ability to maintain themselves in
the world outside. They died out very rapidly when removed
GOLDEN AGE OF BACTERIOLOGY 45

from the rich warm fluids of the human body. The proba-
bility of transmission by air, dust and fomites became pro-
gressively less important; and the conclusion was estab-
lished that the prompt transfer of infective material from
one human being to another is the primary essential for the
dissemination of communicable disease.

On the other hand the investigations which followed upon
Koch’s studies of typhoid at Trier® made it clear that the
human source of infection need not be himself actively suf-
fering from disease. In typhoid, cholera, diphtheria, ma-
laria, epidemic cerebro-spinal meningitis, pneumonia and
epidemic anterior poliomyelitis the important part played
by the carrier revealed wholly unsuspected problems in
epidemiology.

A landmark in the history of public health in America
was the appearance in 1910 of Dr. Charles V. Chapin’s
clear and convincing book on The Sources and Modes of
Infection. Regarded at first as alarmingly radical, this pres-
entation of the new facts was so incontrovertible that it
rapidly led to the abandonment of terminal fumigation and
to emphasis on the search for carriers, the quarantine of
contacts and the prompt isolation of early cases of disease,
which are the distinguishing characteristics of present-day
practice. Where the causative organisms can be detected or
where the period of communicability and avenues of infec-

tion have been determined the modern methods of ‘“con-
current epidemiology’’*® are beginning to yield results of
substantial importance. In the case of scarlet fever, even |

though its etiology is unknown, isolation has fortunately
proved successful. On the other hand we have been in the

anterior poliomyelitis (on account of the lack of any praec-

39 Koch, R. Die Bekimpfung des Typhus. Berlin, 1903. The carrier state had
been noted in many diseases before this time but the work at Trier gave a
powerful stimulus to investigation.

40 See Hill, H. W. The New Public Health, Minneapolis, 1913, for definition
and discussion of this term,

I

past practically helpless to check the spread of epidemic
46 EVOLUTION OF PUBLIC HEALTH

ticable method of detecting carriers) or of influenza. The
brilliant researches of Olitsky and Gates* at the Rockefeller
Institute at last promise to reveal the secrets of this great-
est of pandemic pestilences.

We must now return for a moment to the quiet but fervent
little figure, standing before the tribune of the Paris
Academy of Sciences, more than fifty years ago, and con-
futing conservative antagonists with ever new experimental
facts; for this figure still stands as an inspiring spirit by
the side of every student of the problems of disease in every
laboratory of the world. Pasteur not only showed us how
to discover our microbic foes and shut them out from the
citadel of the human body but he also found the way to arm
the living cells with new power to destroy the parasites
even after they gain entrance to its tissues.

The artificial control of immunity was known to the an-
cients in the practice of mithridatism by which resistance
to poisons was gained by the taking of small doses. The
Moors are said to have practiced a rough sort of vaccina-
tion for the protection of cattle against pleuropneumonia.
Jenner’s discovery had given the world the beneficent boon
of vaccination against smallpox. It was Pasteur’s studies
on chicken cholera and anthrax in the early eighties which
first established the conception of attenuation and vaccina-
tion on a generalized scientific basis; and his success in
preparing anti-rabic virus was the earliest victory over
human disease*? attained by producing a vaceine,—not
empirically suggested but produced by a definite and de-
liberate process of purposeful experimentation.

This line of research produced results quite as important
as those which followed upon the primary demonstration of
the germ theory of disease. Limitation of space forbids even

41 See Jour. Bap. Med., 1921, Vol. XXXTIT, 125, 361, 373 and 713; 1921,
Vol. XXXIV, 1; 1922, Vol. XXXV, 1, 553, 813; 1922, Vol. XXXVI, 685.

Also Science, N. 8. 1923, Vol. LVII, 159.
42 See page 32, footnote 32.
GOLDEN AGE OF BACTERIOLOGY 47

a reference to the theoretical aspects of this subject, to the
demonstration of the role of the phagocytes in immunity
by Metchnikoff, to the complex and fascinating problems
which underlie the production and reactions of antitoxins
and agglutinins, precipitins and opsonins. Here we can only
recall the outstanding practical results achieved. The pro-
duction of active immunization by a vaccine prepared from
attenuated or killed parasites or parasitic extracts was
accomplished for rabies by Pasteur in 1884, for cholera by
Haffkine in 1895, for typhoid fever by Pfeiffer and Kolle in
1896 and by Wright in 1897, for plague by Haffkine in 1906,
‘to name only a few of the most universal of such vaccines
and a few of the investigators who have perfected methods
for their application. The creation of passive immunity by
the injection of serum constituents from an animal, itself
rendered actively immune,—of special value for treatment
rather than prophylaxis,—began with the work of Behring
and Kitasato on diphtheria and tetanus in 1890; was ap-
plied to plague by Yersin, Calmette and Borrel in 1895, to
epidemic cerebro-spinal meningitis by Kolle and Wasser-
mann and by Jochmann in 1906 and by Flexner in 1907, to
pneumonia by Neufeld and Hindel in 1909 and by Dochez
and Gillespie and by Cole in 1913, to yellow fever by No-
guchi within the past two years. ¥ o
Of these discoveries, the most far-reaching in importance |’
‘are those which relate to typhoid fever and to diphtheria.
Inoculation against typhoid should, without doubt, become
a practice as universal as Jennerian vaccination; and ty-
phoid fever will disappear as a cause of death when this
practice becomes the rule. Against diphtheria we have a
truly remarkable set of weapons, more complete perhaps
than in the case of any other single disease. We detect cases
and carriers by a simple bacteriological examination; we
determine the presence of natural immunity by the Schick
test; we produce temporary passive immunity in those in-
fected by the use of antitoxin; and we produce permanent
48 EVOLUTION OF PUBLIC HEALTH

active immunity by the use of toxin-antitoxin mixture.
Diphtheria can be abolished from the roll of Azrael’s min-
isters at any moment, when these defensive measures are
applied upon a really comprehensive scale.

Along this general line of vaccine and serum therapy
there will, I think, be won some of the most signal victories
of the coming generation. We already have a serum for one
form of pneumonia which is full of practical promise; and
such studies as those which my colleague, Professor Blake,
is now conducting on the production of immunity against
measles are likely to bear rich fruits in a field where the
harvest of preventive medicine has so far been a meager
one.
CHAPTER V

THE NEW PUBLIC HEALTH

Sir William Osler describes his undertaking as ‘‘an

aeroplane flight over the progress of medicine through
the ages.’”’ Lacking the spreading wings of Sir William's
inspiration, we have attempted, as it were in a modest ob-
servation balloon, to glimpse a few of the highest mountain
peaks which stand out in the history of public health. We
have charted in cursory fashion the first two distinctive
phases into which the development of the public health
movement is divided,—the period of empirical environ-T
mental sanitation, which extended from 1840 to 1890,—and *
the period of scientific control of communicable disease by
the applications of bacteriology, which dominated the field
between 1890 and 1910. We must now turn for a few brief
moments to the characteristics of the last decade, charac-
teristics so outstanding and so different from all that went
before, as to constitute a wholly new chapter in the history
of preventive medicine.

The progress of scientific thought and of social move-
ments is of course never marked by sharp discontinuity.
Ideas and practices overlap each other, as in the succession
of groups of plants and animals through geologic time. We
shall best understand the motives which animate present-
day public health by going back a little and considering the
development of some of its chief constituent movements,
particularly that of the campaign against tuberculosis, the
first and in some respects the most typical expression of a
new technique in dealing with the problems of disease.

| N the introduction to his fascinating Silliman lectures,
50 EVOLUTION OF PUBLIC HEALTH

Sanitation, isolation, vaccine and serum therapy, pro-
vided the complete machinery necessary for controlling
many of the acute communieable diseases; but with the pro-
gressive conquest of so many of the plagues and pestilences
of medieval times it became clear that the major problem
of tuberculosis required other methods for its solution. En-
vironmental sanitation will help in the control of industrial
dusts and other atmospheric conditions which form con-
tributory factors in the incidence of this disease. The isola-
tion of the careless consumptive will help to reduce mass
infection and in particular will protect children against an
invasion too heavy for their powers of resistance to endure.
Yet in the face of a germ, so widespread that in urban com-
munities at least 90 per cent of the adult population has
already been to some extent infected, it was obvious that
such measures would carry us but a short distance along
the road to adequate control.

The first real note of hope came in 1859 when Brehmer in
Silesia published a series of articles in which he maintained
that a regulated life in the open air would enable the tuber-
culosis patient to effect his own cure in a fair proportion
of cases. Yet, as Dr. Edward L. Trudeau said, in an address
before the Henry Phipps Institute in 1903, ‘The medical
profession took little interest in the disease known as con-
sumption, and the general public knew little about it except,
perhaps, that it was thought to be always inherited and was
considered almost invariably fatal. . . . There were a few
homes for consumptives in existence, but no institution was
presumptuous enough to announce that its object in taking

sthese patients was anything beyond affording them a place
where they might die. . . . In the consumption hospitals in
existence the administration of anodyne cough mixtures,
and the keeping of the wards at a given temperature were
the only attempts at treatment, and in order to meet the
latter condition and prevent the patients from taking cold
the windows were generally kept tightly closed. ”’
THE NEW PUBLIC HEALTH 51

This was the general attitude of the public and the medi-
cal profession when Trudeau, as a young physician, pre-
sumably destined to die of tuberculosis, went to the Adiron-
dacks in 1873—encouraged by Dr. Alfred Loomis, but in
defiance of the gloomy prognostications of most of his medi-
cal friends—to brave the severity of the northern winter
in a settlement of a sawmill, and a half-dozen guides, forty-
two miles from a railroad or another medical man. The
improvement which he experienced and his meditations on
the views of Brehmer finally led to the establishment of the
Adirondack Cottage Sanatorium at Saranac Lake in 1884.
‘“The first cottage consisted of one room, heated by a wood
stove and lighted by a kerosene lamp. It accommodated two
patients and cost about $350. It was furnished with a small
covered piazza, where,”” Dr. Trudeau says, ‘‘after much per-
sistence and eloquence I persuaded my first two patients to
sit most of the day at rest. This was, as far as I know, the
first attempt in America at applying the sanitarium rest
and open-air method according to Brehmer’s and Dett-
weiler’s teachings, and from this humble beginning the
institution gradually and steadily developed until it has
become a small village and the principles of treatment upon
which it was founded have gained general acceptance over
the entire land.”

Sanatorium treatment formed the cornerstone of the |
modern campaign for the conflict with the ‘“captain of the
hosts of death.’” It was essential, however, that it should be
supplemented by the organization of dispensaries for early
diagnosis and the supervision of the ambulant case (first
organized by Philip at Edinburgh in 1887); by measures
for the visitation of home cases and their instruction in’
sanitary and hygienic principles (introduced by Osler at
Baltimore in 1899 and as the ‘‘visites domiciliaires’’ by
Calmette at Lille in 1901) ; by systematic examination and
hygienic care of contacts (of which the Oeuvre Grancher

formed a pioneer exemplar); and by organized follow-up / =
52 EVOLUTION OF PUBLIC HEALTH

and after care for the arrested case.** Above all, however,
as soon as the fact became clearly recognized that tuber-
culosis could be cured by a properly regulated regimen of
fresh air, food, exercise and rest, the need was evident for
a campaign of popular education to acquaint the public with
the good tidings. The first Society for the Prevention of
Tuberculosis was organized by Dr. Flick in Philadelphia in
1892. The problem was being actively discussed in New
York at that time and in 1894 under the inspiration of Dr.
“Biggs the New York Department of Health adopted the
first comprehensive plan for dealing with this disease put
in force anywhere in the world. It involved, as fundamental,
the compulsory notification of cases by public institutions
and voluntary notification of private cases, the provision of
laboratory facilities for diagnosis and a system of medical
inspection and cleansing and disinfection. First of all, how-
ever, it set ‘‘an educational campaign through the use of
specially prepared circulars of information designed to
reach different classes of the population (one of which was
printed in many different languages) and also the utiliza-
tion of the public press and lectures for the dissemination
of popular information.”’

The Tuberculosis Committee of the Charity Organization
Society of New York was formed in 1902, the National
Association for the Study and Prevention of Tuberculosis
in 1904. The first tuberculosis exhibition in the United
States was opened at Baltimore in January, 1904. The re-
cent developments of this movement with its associations,
its lectures, its Red Cross Seal campaigns, are familiar to
us all. The anti-tuberculosis movement from the first was
animated by a new idea, the idea of bringing hygienic knowl-
edge right to the individual in his home or in his shop; and
it developed a new machinery, a new system of organization
for bringing about this end. Since January, 1905, anti-tuber-

43 For interesting details, particularly in regard to the Edinburgh system,
see The Control and Eradication of Tuberculosis. Edinburgh and London, 1911.

®.
THE NEW PUBLIC HEALTH 53

culosis organizations have increased from 24 to 1285, sana-
toria, hospitals and day camps from 115 to 746, dispensaries
from 19 to 595. In accomplishing this task the medical and
sanitary experts, and the social workers, not only pointed
the way to a conquest of tuberculosis, but set in motion
forces which are revolutionizing the campaign for public
health in every field. The dominant motive in the present-
day public health campaign is the education of the in-
dividual in the practices of personal hygiene. The discovery
of popular education as an instrument in preventive medi-
cine, made by the pioneers in the tuberculosis movement,
has proved almost as far-reaching in its results as the dis-
covery of the germ theory of disease thirty years before.

The history of the movement for the control of infant
mortality shows the development of exactly the same tend-
encies. The pioneer attempts at a systematic improvement
in infant feeding and infant hygiene in general were made
by Koplik at New York in 1889, by Herrgott at Naney in
1890, by Variot and by Budin at Paris, in 1892 and 1893,
respectively.* In spite of Koplik’s priority this was essen-
tially a French movement, since it was the influence of
Variot and Budin and its application by Dufour in Nor-
mandy and by Morel de Villiers in the village of Villiers le ,
Duc*® which convinced the world of the importance of such
activities.
- Koplik, Herrgott and Budin all emphasized the impor- |
tance of breast feeding (echoing the still powerful voice of |
Rousseau in Emile) and Budin called his center a ‘‘con-
sultation des nourissons.’” Variot, however, laid chief stress
on the distribution of pure cows’ milk and this conception a

44 Koplik. The History of the First Milk Depot or Gouttes de Lait with Eo.
Consultations in America. Jour. A. M. A., Oct. 31, 1914, p. 1574.

45 See Armand-Delille, P. Jour. 4. M. A., July 27, 1918, p. 240; also Van
Ingen, P. 4. P. H. A. Jubilee Historical Volume, A Half Century of Public
Health, N. Y., 1921, p. 290; also Shaw, H. L. K. Proc. 12th Annual Meeting,

Amer. Child Hygiene Association, 1921, p. 25.
46 See Broadbent, B. Mother and Child, Vol. 2, Nov., 1921, p. 483.

8
54 EVOLUTION OF PUBLIC HEALTH

(embodied in the phrase ‘‘Gouttes de lait’ by Dufour)
dominated our practice for ten years, rather than the more
fundamental viewpoint of Budin. We were chiefly concerned
with the helpful, but one-sided, attempt to improve artificial
milk supplies, while the central features of the problem,
the child and the mother, were ignored. When, however, the
first American Conference for the Prevention of Infant
Mortality was held at New Haven in 1909, it was surprising
to see how experience from every organization dealing with
the problem had focused on a single point. Man after man
said, in effect, that he had come to feel that the success of
a station could be gauged not by the quarts of milk dis-
tributed, but by the number of nursing mothers under ip-
struction. The movement for the reduction of infant mor-
tality in America became at that meeting, consciously and
definitely, an educational one, and its prime task is today
recognized, as clearly as in the case of tuberculosis, to be
the task of carrying sanitary and hygienic knowledge into
the indivi home.

Among the outstanding landmarks in the history of the
child hygiene movement in the United States may be men-
tioned the establishment of a Division of Child Hygiene in
the New York City Health Department in 1908 and in the
New York State Department in 1914; the creation of the
Federal Children’s Bureau in 1912 and the passage of the
/ Sheppard-Towner Act for Federal aid to local infant wel-
fare work in 1922; the formation of the National Child
Health Council in 1920 and the amalgamation of the two
pre-existing voluntary organizations ty form the American
Child Health Association in 1922.

The work of the infant welfare station has been extended
backward to include pre-natal clinics and forward to keep
under observation all children up to the school age; but
in essence it remains as it was conceived by Budin, a center
for the dissemination of hygienic information and for: the
expert supervision of the health of mothers and children.
THE NEW PUBLIC HEALTH 55

Throughout the world, in Russia and Czechoslovakia, in
Roumania, in New Zealand, there gather every week groups
of mothers bringing their babies to such centers for ex-
amination and advice.

Bauiies fun 1g Seuioie of U6 TAG ern campaign

pre-eminent _amone all the causes of preventable disease
and death as the two greatest scourges, from the abatement
of which the largest results for humanity are to be attained.
In each case the fight must be won, not by the construction
of public works, but by the conduct of the individual life.
The same thing is true with regard to the spread of the
acute contagia, the burden of venereal disease, the obscure
ill effects of defective eyes and ears and teeth, and a dozen
other problems which in greater or lesser degree concern
the public health. In every one of these cases the results
we are striving for can only be reached by spreading a clear
knowledge of the ways in which disease spreads, and the
ways in which it is prevented, among the mothers who bring
up the babies and the men who pay rent in the tenements .
and work in the stores and factories.

With the growth of this conception of education as the
dominant motive in the public health campaign, there came
the need for new machinery through which such education.
could be accomplished. An elaborate technique of health)
bulletins, health news services, health lecture bureaus and =~
institutes, health cinemas, health exhibits, and health radio-
grams has been created to meet this need. These instru-
ments are all of assistance in their twofold object, of secur-
ing popular support for the community health program, and
of bringing into contact with health clinics of various types
the individuals who are in need of their services. Mass
methods of this kind form, however, only a first step toward-,
the goal which is in view. Personal hygiene is after all a
very personal matter. The kingdom of health, like the King-
dom of God, is within you. It was essential to utilize some
I

56 EVOLUTION OF PUBLIC HEALTH

more direct and more individual agency to carry the gospel
of health to the individual in the form adapted to that par-
ticular individual’s needs; and in the person of the public
health nurse has been found the ideal agent for carrying
the message to Gareia.

District, or visiting, nursing, first revived on a modern
secular basis by William Rathbone at Liverpool in 1859,*
was introduced into America in 1877 by the Woman’s Board
of the New York City Mission, followed by Dr. Adler’s So-
ciety for Kthical Culture in the following year. The first
Nursing Association organized directly for this purpose,
was established in Boston in 1886. Its name was the In-
structive District Nursing Association; and from this time
on we find the teaching of hygiene as a recognized objective
for the district nurse, along with the care of the sick in their
homes. School nursing was begun in London in 1892 and in-

troduced into America by Miss Wald in New York in 1902. |

Tuberculosis nursing was introduced under Dr. Osler’s
influence at Baltimore in 1903. Infant welfare nursing and
industrial nursing, too, developed for a time as independent
specialties ; until a reaction set in against undue specializa-
tion and there was formulated the modern ideal of a com-
munity nurse, serving a population of not over 2000 per-
sons, caring for the sick in their homes on a visiting nursing
plan and becoming the teacher of health par excellence, a
sort of community mother but armed with the expert knowl-
edge which few mothers can possess. The public health
nurse has become in very truth a central figure in the mod-
ern health campaign. We have 11,000 such nurses in the
United States today and we need at least 50,000. Recent
attempts to set forth an ideal plan for community health
organization allot one-third of the total health budget to
the nursing service. In this particular field the United

47 For a truly admirable historical discussion of public health nursing, see

The Evolution of Public Health Nursing by Annie M. Brainard, Philadelphia
and London, 1922,
THE NEW PUBLIC HEALTH a7

States has been an unquestioned pioneer; and we can echo
with pride Dr. Welch’s statement that America has made at
least two unique contributions to the cause of public health,
—the Panama Canal and the public health nurse.

In discussing the developments of public health during
the last two decades we have so far emphasized one par-
ticular tendency, the empliasis which has been laid on the
education of the individual in the principles of healthy liv-
ing. There is a second tendency of this period which is
equally characteristic and equally far-reaching in its ny

fluence,—the use of the physician as a real force in preven \3
{ v7
tion, by the organization of machinery for the medical | |

examination of well persons or of those in the early and in-

cipient stages of disease. The two lines of attack are indeed
inevitably inter-related. Education in personal hygiene, if
it is to be intensively adapted to the individual, must be
based on medical diagnosis. The tuberculosis dispensary |
and the infant welfare station have done more than express
"the educational emphasis of the modern public health cam-
paign; they have suggested a wholly new relation between
the physician and the patient.

We can most easily realize what this new relation
means, and how momentous a revolution it invites, by con-
sidering the development of still another of the many cur- :
rents which together fuse into the public health movement
as a whole,—the growth of a systematic plan for the medi-
cal supervision of school children.

The city of Dresden instituted tests for the vision of
school children in 1867. Sweden probably appointed the
first true school physicians in 1868. Russia provided for
‘medical inspection in 1871 and Austria in 1873; but the
system, in its full modern sense, was really introduced at
Brussels in 1874 and at Paris in 1879." The idea spread

48 See article on Medical Inspection of Schools, Cyclopedia of Education.
Macmillan Company, N. Y., 1918, Vol. IV, p. 182.

ih

vt
58 EVOLUTION OF PUBLIC HEALTH

rapidly, particularly in Germany, and was brought to the
United States in effective form by Boston in 1894.* This
action was inspired by an epidemic of diphtheria which had
occurred in the schools and the primary duty of the physi-
cians was to detect communicable disease, in other words, to
exercise the conventional police power of the health depart-
ment, to protect one child against another. If the proposal
had been made thirty years ago to establish school clinics
for the treatment of non-contagious physical defects it
would probably have been hailed as a highly dangerous
form of paternalism.

Yet the logic of the situation proved irresistible. When
the physicians actually began to examine the children in
the schools, they found scores suffering from defective
teeth, from defective vision, from defective hearing, from
enlarged tonsils, and adenoids, for every one that was the
victim of acute communicable disease. They devoted more
and more attention to the problem of assisting each in-
dividual child to reach his highest possibilities of physical
welfare. The school nurse was introduced in 1902 to carry
the message of hygiene into the home and to secure the
prompt treatment of the physical defects discovered by the
school physician. Finally, when it appeared that for many
children, ready to avail themselves of treatment, treatment
facilities were lacking, the school clinic came into the pie-
ture. For the school child, at least, it was recognized as
sound public policy to make sure that, so far as possible,
remediable defects and diseases shall be found and reme-
died, and to provide at the public expense whatever medical
services were needed to facilitate that end.

JHygienic instruction, plus the organization of medical
service for the detection and the early treatment of incipient
disease,—these are the twin motives of the modern public
health campaign. Sometimes one and sometimes the other

49 New York had appointed a single medical school officer in 1892. See
reference to Van Ingen, page 53, footnote 45.
THE NEW PUBLIC HEALTH 59

may be dominant. Thus the active development of medical
inspection of school children during the first fifteen years
of this century led to a realization of the importance of
malnutrition as a factor in lowered vitality; and thence to
the active development of nutrition clinics and the remark-
able campaign of popular health education inaugurated by
the Child Health Organization in 1918. In the main, the twa
forces of education and medical service are mutually com-
plementary and inseparable. They dominate every one of
the major health programs of the present day.

Among these special programs we must, even in the /

briefest survey, add to those already cited the campaign | "

against venereal disease, in which the United States has
played the part of a pioneer. It is true that it was Fournier
in France who first launched a concerted effort, medical,
social and educational, against the Black Plague of syphilis
and gonorrhea in 1900, when the French Society of Sani-
tary and Moral Prophylaxis was founded. The movement
first gained its real impetus, however, in America under the
inspiring leadership of Prince A. Morrow, who organized
a Society for Sanitary and Moral Prophylaxis in this coun-
try in 1905. The discovery of the causative organism of
syphilis in 1905, the development of the Wassermann reac-
tion in 1907, the preparation of salvarsan in 1910, gave the
necessary scientific basis for the movement; but it was the
stand taken by the American Army and Navy during the
world war, which brought it to real and effective maturity.
For the first time in the history of the world, military and
naval authority was frankly and definitely bent, not only
toward the treatment of venereal disease but toward its
prevention, by firm and vigorous endorsement of masculine
continence. Tt is probable that since the beginning of time
there has never been a cleaner group of young men than
the American Expeditionary Force; and the reflex effect
upon the civilian campaign against venereal disease was so
great that I am convinced America has gained in this one
60 EVOLUTION OF PUBLIC HEALTH

direction more lives than it lost through the destruction
wrought by German shot and shell.

Another sector of the public health campaign which re-
ceived enormous stimulus from the experiences of the war
is that which deals with Mental Hygiene, a field which
promises to prove of widening importance with every pass-
ing year. Everyone is today familiar with the dramatic ex-
perience of Clifford Beers, who on his discharge from a hos-
pital for the insane in 1903 set himself to reform for ever
the abominable abuses which surrounded the attitude of
society toward mental disease; in 1908 he published the re-
vealing story of his experiences under the title 4 Mind that
Found Itself, the book which was to prove the Uncle Tom’s
Cabin of the movement which is freeing the insane from
the shackles forged by ignorance and fear; in the same
year he founded the Connecticut Society for Mental Hy-
giene and in the following year, 1909, the National Commit-
tee for Mental Hygiene and thus launched another new
movement in preventive medicine. As a result of less than
fifteen years of activity there has been realized a progress
which is truly phenomenal in the humanizing of the institu-
tional care of mental disease, in the organization of mental
clinics and psychiatric social service, in the development of
community programs for the discovery and care of mental
disease and defect and above all in the creation of a popular
attitude toward mental disorders which considers them, no
longer as things shameful and mysterious, but as phe-
nomena no less natural and no less controllable than dis-
orders which affect other bodily tissues. The application of
the modern conceptions of Psychiatry saved thousands of
cases of so-called “shell shock?’ among the members of the
American Expeditionary Force ; and the publicity thus
gained for its principles has gone far to establish it as a
highly potent factor in the social and industrial life of the
future.

It is needless to dwell at length upon similar movements
THE NEW PUBLIC HEALTH 61

directed at the control of other groups of diseases, such as
are exemplified by the American Society for the Control of ye
Cancer (founded in 1913)*° and the Association for the,
Prevention and Relief of Heart Disease of New York City,
organized in 1915.°* It is, however, important to point out
that the programs of these organizations, dealing as they
do with the degenerative diseases of adult life, aim to bring
within the range of preventive medicine diseases which the
health worker of 1900 would have unhesitatingly classed
as non-controllable. The possible field of public health is
thus extended so that it is almost co-extensive with the
range of physical liability.

Such programs involve a corresponding expansion of the
application of medical services for the early diagnosis of
disease, and call for a complete reconsideration of the fune-
tion of the physician in modern community life. The con-
trol of the degenerative diseases requires nothing less than
the systematic medical examination of presumably normal |
individuals, not merely of mothers and infants, of school
children and tuberculous suspects, but of as large a section
as possible of the entire population over forty-five years of
age. It seems logically inevitable that such an application
. of medical knowledge shall, in some fashion, be provided, if
medical science is to yield the high service of which it is
capable, and which it can by no possibility render so long
as it is limited to the alleviation of the symptoms of archi-
tecturally completed disease. :

Yet it is probable that, before medicine becomes truly
preventive, there must be a radical alteration in the basis | *
of payment for medical service. It is extremely unlikely
that the average individual will ever resort to his physician
until he experiences compelling symptoms of disease if the

50 Powers, Charles A. The Work of the American Society for the Control of
Cancer, Medical Record, Feb. 5, 1921, p. 211, and Osborne, Frank J., American
Society for the Control of Cancer, Modern Medicine, April 1921, p. 215.

51 First report, Association for the Prevention and Relief of Heart Disease,
New York, 1921.
EIR
i Th
62 EVOLUTION OF PUBLIC HEALTH
incurring of an immediate financial obligation is specifically
involved. The maintenance of physical health will surely
call for the provision of some. social machinery superior to
the happy-go-lucky methods of the past. How the desired
end can be attained is the major problem before the physi-
cians and the public health profession of the present day.

Compulsory health insurance is one panacea which has
been strenuously advocated’ for the solution of this prob-
lem. As introduced by Bismarck in Germany in 1885 and by
Lloyd George in England in-1912 health insurance had two
main objectives, the distribution of the financial burden of
sickness and the provision of medical care not otherwise
available. The first of these aims is a problem for the econo-
mist, not the sanitarian; it is the second with which we are
concerned at the present moment.

When we attempt to determine whether compulsory
health insurance, as actually operated abroad, has in fact
tended to realize the essential aim of making medicine pre-
ventive, we are met by sharp difference of opinion. A sec-
tion of English official medicine is enthusiastic as to the
results attained. Sir Arthur Newsholme, the late chief medi-
cal officer of the local government board is certain that
these results are inadequate.” The evidence in favor of the
latter view seems on the whole the weightier. The conclusion
of a recent American critic, Gerald Morgan,* would seem to
be justified that ‘‘in no state system of insurance, taken as
a whole, have both adequate cash benefits and adequate
medical treatment actually been provided, chiefly on account
of the inability or unwillingness of the contributors to meet
the expense; that this expense is likely to increase, because
the cost of medical treatment has advanced, and is still ad-
vancing, faster than wages; and that insurance medical

52 See American Labor Legislation Review, Vol. VI, No. 2, June, 1916, and
Vol. XI, No. 3, Sept., 1921.

53 Newsholme, Arthur. Public Health and Insurance. Baltimore, 1920.

54 Morgan, Gerald. Public Relief of Sickness. New York, 1922,
THE NEW PUBLIC HEALTH 63

practice, by the very nature of the bargain, contains a
strong incentive to hurried and careless work.”” .". . “What
a state system of health insurance does is to recognize
legally, and to perpetuate under the name of medical benefit,
a system of medical treatment by which the great majority
of general practitioners are obliged to contract to be paid
in direct proportion to the speed with which they diagnose
and treat the ailments of patients, and in inverse proportion
to care and deliberation.”

If this estimate be justified, we can scarcely avoid Mor-
gan’s further conclusion that it is wiser to handle the prob-
lem of financial relief through sickness insurance but to
omit medical benefits from the insurance scheme and trust
for the solution of the provision of preventive medical care’
to the gradual expansion of hospital and dispensary and
nursing service under public or private auspices. The sub-
sidies granted for local health enterprises in Great Britain®
and the plan for health center development advocated by
Dr. Biggs in New York State™ are excellent examples of the
latter line of action. The evolution of such community health
services will require the utmost exercise of sanitary states-
manship in order that the standards of medical practice and
the legitimate interests of the medical profession may be
adequately safeguarded. The steps that have so far been
taken along this line in England and in the United States
seem however to be distinetly promising and to encourage
us to go forward step by step, in the tentative and experi-
mental fashion which is characteristic of British and Ameri-
can social progress.

Whatever may be the best ultimate solution of these
complex problems it is clear that it can be found only
through patient and earnest and dispassionate adventure

55 See Newsholme, footnote 53, page 62, and Newman, George, An Outline of
the Practice of Preventive Medicine, British Ministry of Health, H M. S.
Stationery Office, London, 1919.

56 See Morgan, footnote 54, page 62. A law embodying this general prin-
ciple was enacted in New York State in 1923.
64 EVOLUTION OF PUBLIC HEALTH

on the part of the medical profession. Preventive medicine
must come, as a reality and not a pious phrase, through a
fundamental change in the attitude of the physician and
through a fundamental change in the attitude of the medical
school where he is trained. Tt is to a new generation of medi-
cal students, imbued with a new spirit of prevention, that we
look forward with hope for the future. At Yale we con-
ceive it to be our special duty and our special opportunity
to make this new spirit prevail; and we believe that in the
working of such a revolution our medical school can make
its most unique contribution to the cause of human progress.

Surely no more inspiring appeal can echo in our hearts
than the appeal to carry forward this great movement,
whose historical outlines we have sought to trace, To state
that the death rate of New York City has been reduced from
25 per 1000 in 1890 to 13 per 1000 in 1920 may perhaps leave
one unmoved; but think for a moment what such statistics
mean in terms of human life and human happiness. Today
in that great city there are 201 death beds every twenty-
four hours. If the death rate of thirty years ago were still
in force there would be 384,—a saving of 183 lives with each
revolution of the earth. If death be the wage of sanitary sin,
nearly one half the debt has been remitted in a period of
thirty years.

Or take a larger field. In the Registration Area of the
United States, the reduction in the death rate from four
diseases only, typhoid fever, tuberculosis, diphtheria and
the diarrheal diseases of infancy® between 1900 and 1920
amounts to a saving of 230,000 lives a year, 230,000 men,
women and children for the year 1920 alive and well who
would be in their graves under the dispensation of a brief
twenty years ago; more than 230,000 more for 1921, and
still more for 1922, and on so far forward as our civiliza-

57 Rates per 100,000: typhoid fever, 1900, 35.9, 1920, 7.8; diphtheria, 1900,

43.3, 1920, 15.3; diarrhea and enteritis, 1900, 133.2, 1920, 44.0; tuberculosis,
1900, 201.9, 1920, 114.2.
THE NEW PUBLIC HEALTH 65

tion shall endure. If we had but the gift of second sight to
transmute abstract figures into flesh and blood, so that as  ~
we walk along the street we could say ‘‘That man would be
dead of typhoid fever,”” ‘That woman would have suc-
cumbed to tuberculosis,’”’ ‘“That rosy infant would be in
its coffin,”’—then only should we have a faint conception
of the meaning of the silent victories of public health. For
such achievements we may thank God and take courage for
the future, bearing on our banners that eternal phrase of

Cicero;™ “In no single thing do men approach the (Gods) (ris
more nearly, than in the giving of safety to mankind.”

58 ¢‘ Homines enim ad Deos, nulla re propius accedunt, quam salutem homini-
bus dando.’’ Cicero, Pro. Q. Ligario XII, 38.
 
 

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