to be hoped at increasingly long intervals of time, it is the accepted duty of the Secretary of War to keep up the discipline and efficiency of the army at all times. "The fighting time for which a Secretary of Health and his organization would have to prepare is daily and continuously. It would be with him as if an invading enemy were constantly to be met, and every year a great battle was to be fought."* At the present time civilization is fighting these battles all over the world, and for the most part losing them, as in that unobstructed invasion of Great Britain in 1832, by cholera, which proved so destructive of life and property, and also as, during last summer, yellow fever found free admission to our principal southern port without inspection or quarantine. That fever, once admitted, found in the accumulated filth of city, town, and country, such an abundant material for the reception and development of its poison-germs as to defy all prevention or remedy. The consequent loss of life is counted by thousands, the loss of property by millions of dollars; the desolation of households, the consequent suffering, etc., cannot be measured or counted. Cholera has of late years repeatedly visited the ports of Great Britain, and sanitary regulation has restricted it to the infected vessels. Sanitary science claims that the due enforcement of its laws, thorough, rigid quarantine and other precautions, can prevent the importation of any epidemic disease, or limit its ravages, and thus avert such fearful waste of life and property.

Having given the accepted definitions of the science of State Preventive Medicine, and a brief sketch of its rise and progress, we are brought to the questions, What are the specific duties it prescribes? What loss has been sustained by their neglect? What has it already done? What more does it propose to do? and What are its reasonable possibilities in the future?

We have seen that this science was ancient in its inception, and, though long dormant, has of late begun to obtain due recognition of its momentous importance, ranking among its numerous friends and advocates an increasing number of eminent statesmen, scientists, and philanthropists, and in all civilized countries moreover winning to its cordial support many who, from an honest misapprehension of its character and aim, were for a time indifferent or opposed. It now comes before us, claiming the power to prevent disease, prolong the duration of human life, and, in its ultimate reach, to increase the well-being and happiness of the nations. This it seeks to do

* Dr. Farr.

by giving a higher aim and efficiency to the powers of civilization through the removal or diminution of evils which now deteriorate the race or hinder its progress.

The duties it prescribes are well defined in the succinct language of the Act creating this Board:

"The said State Board of Health shall take cognizance of the interests of health and life among the people of this State; they shall make sanitary investigations and inquire respecting the causes of disease, and especially of epidemics, the sources of mortality, and the effects of localities, employments, conditions, ingesta, habits and other circumstances upon the public health; and they shall collect such information in respect to these matters as may be useful in the discharge of their duties, and contribute to the promotion of health and the security of life in this State; they shall cause to be made by their Secretary, or by a Committee of the Board, inspections at such times as they may deem best, and whenever directed by the Governor or the Legislature, of all public hospitals, prisons, asylums, or other public institutions, in regard to the location, drainage, or water supply, disposal of excreta, heating and ventilation, and other circumstances in any way affecting the health of their inmates, and shall also suggest such remedies as they may consider suitable for the removal of all conditions detrimental to health."

These duties are also marked out by Cameron as " mainly to procure supplies of pure water, to prevent the pollution of air and water by foul liquids, gases, vapors, and dirt of all kinds; to prevent over-crowding of dwellings, to see that the houses of the laboring classes are in perfectly tenantable order, to check the sale of adulterated, diseased, or otherwise unsound food, to cleanse the streets and roads, to prevent the spread of contagious diseases, to bury the poor, to provide burial places for rich and poor, and to disinfect and to provide dwellings for artisans." The German code is still more minute and comprehensive.

It is meant furthermore, that the best knowledge bearing upon the illustrations and teachings of this science, and upon the legis lative action necessary for its furtherance, shall be published in a plain and economic manner, and be freely distributed throughout the community, in order that the people may be educated in respect to the nature and causation of diseases, the means of prevention, and generally the danger of ignorance, neglect, or disobedience of the laws of hygiene." This diffusion of

knowledge is truly the first and gravest duty of all; other measures following in due course the right discharge of this primary duty. In the words of an eminent English statesman,* "No sanitary improvement worth the name will be effective, whatever acts you pass, or whatever powers you confer upon public officers, unless you can create an intelligent interest in the matter among the people at large. The State may issue directions, municipal authorities may execute to the best of their power, inspectors may travel about, medical authorities may draw up reports, but you cannot make a population cleanly or healthy against their will, or without their intelligent coöperation. . . This is why, of the two, sanitary instruction is even more important than sanitary legislation." At this time, when so many schemes of reform and philanthropy (falsely so-called), are dinned into the public ear, any new claim, urged not only on the people but on the government of the State for adoption and support, should of right be submitted to the sharpest scrutiny, and to the rigid requirement of satisfactory evidence.

Dr. Richardson says: "I want strongly to enforce that it is the section of the nation which Dr. Farr classes as the domestic-the women-on whom full sanitary light requires first to fall. Health in the home is health everywhere; elsewhere it has no abiding place. I have been brought indeed by experience to the conclusion that the whole future progress of the sanitary movement rests for per manent and executive support on the women of the country. When as a physician I enter a house where there is a contagious disease, I am, of course, primarily impressed by the type of the disease and the age, strength, and condition of the sick person. From the observations made on these points I form a judgment of the possible course and termination of the disease, and at one time I should have thought such observations sufficient. Now I know them to be but partly sufficient. A glance at the appointments and arrangements and managements of the house is now necessary to make perfect the judgment. By this glance is detected what aid the physician may expect in keeping the sick in a condition most favorable for escape from death; and by this is also detected what are the chances that the affection will be confined to

* Lord Derby.

Address on the

Future of Sanitary Science,” before the Sanitary Institute of Great Britain, July, 1877.

one sufferer or distributed to many.

As a rule to which there are the rarest exceptions, the character of the judgment is hereupon dependent on the character of the presiding genius of the home, on the woman who rules over that small domain. The men of the house come and go; know little of the ins and outs of anything domestic; are guided by what they are told, and are practically of no assistance whatever. The women are conversant with every nook of the dwelling, from basement to roof; and on their knowledge, wisdom, and skill the physician rests his hopes. How important, then, how vital that they shall learn, as a part of their earliest duties, the choicest sanitary code."

As a timely illustration of the correctness of this judgment, I may be permitted to state, on the authority of Dr. Bowditch of Boston, that the movement which resulted in the establishment in Massachusetts of the first Board of Health in the United States, originated with a lady of Pittsfield, (Mrs. Thomas F. Plunkett,) who had been intimately connected with the Maplewood Seminary in that town at the time of the well-known outbreak of typhoid fever in that institution, and was an intelligent observer of those violations of sanitary law which led to such disastrous and fatal results.

In fairly measuring what sanitary science has done and can do. for the people, we are to take into consideration all those powers, values, and indeed sympathies, which are the real vital elements of the State, and which must exist in due proportion to make the best whole. We are also to take the right estimate of another element of public or State property, whose full measure of worth political economists have only of late been ready to admit, the money value of each healthy life, acknowledging the soundness of that axiom of finance as well as of political economy, that public health is public wealth.

In their best conditions, air, water, food, clothing, house construction, drainage, and more indirectly soil and climate, each with individual importance and mutual relation, are positive factors of the best health assurance. This is demonstrated by that which is the ultimate standard and measurement of sanitary results,—the diminished death-rate, that diminution being in due proportion to those best conditions. In further illustration of these measurements, let us compare the sanitary condition of the people of England in the last century with that of the present time; the utter neglect, then, of drainage, sewerage, and ventilation, of purity and plenty of air

and water, of personal cleanliness, of the removal of filth accumulations, with badly-constructed dwellings, poor and insufficient food and clothing, all leading to their natural results in the frequent recurrence of zymotic (epidemic and contagious) diseases, and the unrestrained prevalence of all other forms, with a corresponding death-rate of about 1 in 23, against about 1 in 40 at the present time; the death-rate being at all times the most reliable floodmark of diseased conditions.

To-day, by the establishment of government boards, and the employment of able and learned men as the inspectors, "full," as Dr. Bowditch says, "of the enthusiasm and accuracy of modern science, England has made an immense stride towards having a perfect system of sanitary guardianship of the realm." The reports of her unrivalled system of statistical investigations enable us to measure with a good degree of precision what State Preventive Medicine has already accomplished there. In all the conditions above specified, especially in regard to the removal of filth, as in the recognition of the fact that the germs of vice, as well as of disease, are developed from filth, extraordinary advances have been made. Epidemics and contagious diseases have either been prevented or kept within narrow limits; some diseases have disappeared, and the frequency and fatality of others have been largely diminished. Consequently the general death-rate has fallen to a much lower figure. Of course, these conditions are not universally regarded; in many locations are found overcrowded dwellings, an abundance of filth and vice, and the neglect or defiance of all sanitary law, and consequently in such places there is no diminution, but an increase of sickness and of the death-rate, the difference in the latter between the most healthy district and the least in the same city, varying sometimes from twelve to fifty or even sixty in 1,000. Mr. Chadwick* says: "We have gained the power of reducing the sickness and death-rate of the old cities by one-third; of the death-rate in the old settled country districts to 16 or 17 in 1,000; . . . in the new districts, with complete systems of watersupply, drainage, etc., to less than one-half, or a mean rate of 10 to 1,000, and of sickness in due proportion in both; . . . in prisons and other places under sanitary control, and in the large collection of indigent and dependent children in schools and insti

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* Paper read before the British Social Science Association in 1877, on the chief results of the progress of Sanitation.