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 EUBUCiiSALTH 
 
State Boards of Health, 
 
 THEIR OBJECT AND USE. ETC. 
 
 ..T.rOR -^ 
 
 KXTRACT8, SHOWING THE ' ' 
 
 VIEWS OF PRACTICAL WORKERS AND EMINENT SANITARIANS. 
 
 ISSUED BY OKDEE OF THB 
 
 INDIANA STATE BOARD OF HEALTH. 
 
 THAD. M./STEVENS, M. D., 
 Secretary h'nU JUxecutive^jJicer. 
 
 INDIANAPOLIS: 
 
 W.M. n. BUKFiiKO, PRINTEn, LITHOGRAPHJER AMD BIN OKU 
 
fubiic Health lib." 
 

 PUBUC 
 HEALTH 
 LIBRARY 
 
 OPINIONS OF SANITARIANS. 
 
 The first State Board of Health in the United States was that 
 of Massachusetts, established in 1869. Since that date, twenty- 
 six States have established health organizations. By an act, ap- 
 proved March 7, 1881, a State Board was established in Indiana, 
 and since that date, there has been fully organized in every 
 eounty of the State, except one, a County Health Board; also, 
 city and town boards in each incorporated city and town of 
 the State. 
 
 Such organization necessarily entails some expense, and 
 places upon physicians and others certain duties, for the per- 
 formance of which they do not receive what would appear to 
 be adequate pay. 
 
 It is the duty of those engaged in such work, or taking an 
 interest therein, to inform those who seek information relative 
 to the value of such work, and to show the need and good 
 policy of keeping up the added expense to the State and in- 
 creased labor that devolves upon the physicians and others. 
 
 "We here present the views of many who have for years been 
 engaged in such work, and give, also, the recorded result, so 
 that all may easily judge of its value and need. 
 
 The introduction of any new system is generally met with 
 more or less opposition, and it was not to be expected that the 
 establishment of a State Board of Health would be an excep- 
 tion. It is gratifying to know that this opposition has been 
 less than was anticipated. The cause of opposition may be 
 said to be founded on a misapprehension or ignorance of the 
 object of the law and the aims of the Board. 
 
 It may be well to state that the chief aim of the law is, first, 
 to collect facts and then to disseminate correct sanitary infor- 
 
 ivi833990 
 
matioii among tlie people. Wliatcvcr tends to increase tlie 
 knowledge of the medical profession, tends to increase the 
 Bufety and health of the people. It i^- due the medical profes- 
 sion to say that its members have generally been eager to seek 
 all information that promises any beneficial knowledge, and the 
 si'.iiitary and vital facts, gathered by the State and local Boards, 
 will furnish data from which we shall be able to. arrive at cor- 
 rect conclusions, as to tlie causes and means of prevention of 
 many diseases. 
 
 The graveyards of the State are full of those w1io have fallen 
 victims to their own lack of knowledge, or their own careless- 
 ness. It is within the bounds of truth to say that two-thirds 
 of the children that die annually, iii Indianapolis or other cities 
 of the State, might have been rescued from death, had their 
 parents possessed the information which should be within the 
 reach of all. Not by means of any "Domestic* Medicine," or 
 "Every Man His Own I'hysician" book, but by well authenti- 
 cated and practical facts, placed before the people in a reliable- 
 shape, so that they should be warned as to the dangers that 
 can be avoided, as the red flag, warns of small-pox or the 
 signal light, of the locomotive. Such disseminated intelligence 
 would furnish the means of avoiding the danger. 
 
 Take that disease so common among children, viz : Whooping 
 cough — parents look upon it as one of the necessar}' ills that 
 must fall upon all children, and regard it as being without 
 danger to the child, and in many cases hail its appearance with 
 a kind of semi-delight. It is true, there is comparatively little 
 danger in the disease, if proper care is taken of the child, and 
 this care must be exercised by the parents, and not by the 
 medical attendant, if there be one. The truth must be made 
 known to the people. Scarlet fever is justly regarded with 
 dread, yet whooping cough has annually, in Indiana, carried to 
 the grave more victims than scarlet fever, and while the Board 
 has at present no means of knowing the exact facts in every 
 case, yet the information it has, justifies it in saying that in 
 nearly all cases of death from whooping cough during the past 
 nine months, the fact that death ensued was due to want ot 
 proper care of the child by its parent or nurse, especially at a 
 time when the patient is supposed to be convalescent. 
 
 Diphtheria is another of those diseases that has caused fearful 
 
ravages among children. Statistics, gathered by the Board, show 
 that certain diseases are prevalent with this class of the popula- 
 tion. This is not always from anything in their occupation or 
 surroundings. The causes for the frequency of death must often 
 he sought for elsewhere. A study of the tables compiled by the 
 State Board, that will appear in the annual report, will show 
 that bronchitis and pneumonia are particularly noticeable for the 
 fatal ending in cases of children, and this frequently is, in a 
 large degree, due to a want of proper preventive measures. 
 
 Farmers and their families will, in winter, attend p'atherins^s 
 of various kinds in small and ill-ve7itii;ited school houses- or 
 churches; stoves are made red hot, and, from the steaming at- 
 mosphere, they go forth into the chilling air — ride home through 
 the cold without properly protecting themselves. 
 
 In the city, those who attend such assemblages go, at least, 
 provided with* wraps to protect themselves against such sudden 
 changes, and the result is, they are less liable to those forms of 
 disease. 
 
 It is safe to say that one hundred persons are annually killed 
 upon and by railroads of the State, and that, of tlie whole num- 
 ber, less than a score are employes of the railroad, while the 
 other persons are those who have no business in the place where 
 they meet their death. It is only bringing such facts to the 
 minds of the people that they can be made to realize their 
 danger. They hear of isolated cases of railroad injuries, but 
 it is the figures in the aggregate that impress them. 
 
 In accidents, of one kind and another, fully five hundred 
 persons, annually, in Indiana, meet their death, and, in nine 
 cases out of ten, carelessness somewhere is the cause. 
 
 It may be asked, why the State should engage in the work? 
 The State is directly interested in the life and health of every 
 citizen. The longer lived and healthier its citizens, the stronger 
 and wealthier the State becomes. 
 
 As to vaccination, the policy of compulsory vaccination has 
 been very much questioned, and the silly objection that such a 
 system interferes with the rights of the citizen, has been made. 
 Every citizen owes some obligation to the community where he 
 lives, and while he may have an abstract right to deal with his 
 own life, he has no right to endanger the life or health of an- 
 other. 
 
G 
 
 Vaccination is not alone to preBcrvc one from the disease, 
 but also to prevent him from aiding in its dissemination among 
 liis fclIow.H. 
 
 The prevention of disease is the accumulation of wealth botli 
 to the individual and the State. The knowledge how to j)reventy 
 is based upon ihtal and sanitary statistics. 
 
 The diseases that are of the most importance in a sanitary 
 point of view belong to the class Zymotic (ferments). We may 
 mention, as prominent among these, the following, viz: Small- 
 pox, diphtheria, ncarlct fever, chicken-pox, wliooping cough, 
 typhoid and typhus fever, puerperal fever, croup, cerebro-spinal 
 meningitis and cholera, dysentery, consumption and acute lung 
 affections might be added. 
 
 Xow let us see what some of the most eminent "and practical 
 sanitarians sa}' as to the influence upon human health and com- 
 fort the work of State and local health organizations exert, and 
 as to the value of vital and sanitary statistics. We give the 
 following extracts: 
 
 PuiJLic Economy of Sanitary xVIea-^lires. 
 
 We are fast coming to understand that the prevention of dis- 
 ease means wealth and prosperity, and that, aside from those 
 high and sacred considerations which move the heart of man 
 to alleviate the sutterings and obstruct the evils that afflict his 
 fellow-man, there is a sharp pecuniary side to your efforts, 
 which, as true citizens of Chicago, we are not at liberty to 
 overlook. 
 
 I read in o)ie of your interesting re])orts that the small-pox 
 scourge of 1871-72, cost the city of Pliiladelphia over twenty- 
 one million dollars. The facts given, I think, warrant the 
 conclusion. This was manifested in diminished travel and 
 shrunken commerce. Nor is this all; for it appears that this 
 great sum might have been saved, to say nothing of the lives 
 lost and the suffering endured. We rejoice this year in a most 
 bountiful crop; but thei'c are other sources of wealth, quite as 
 visible and more certain than corn ami wheat, that do not 
 attract our attention. 
 
 Our city has been in commotion for thirty days about the 
 truly serious loss of four or five million dollars by our savings 
 
banks, but we probably annually lose a much greater sum in, 
 and inclitference to, sanitary means, and without excitement 
 and almost without protest. 
 
 There is not within the limits of Chicago a business unin- 
 jured, a palatial residence or a cottage, the value of Avhich is 
 not diminished by the pestilent odors that sweep over the city. 
 Yet men, busy with their own afiairs, who pass for sagacious, 
 far-seeing men, act as though it were no concern of theirs — no 
 concern of theirs as to the drainage of houses two blocks away; 
 no concern of theirs whether the air, common to all, becomes 
 polluted; but typhoid and scarlet fever among their loved ones 
 at home utter a mournful denial of these assertions. And thus 
 you will prove that the widest traffic, the most permanent pros- 
 perity, and the largest security for the home are founded on 
 the truth that man is his brother's keeper. 
 
 "Wirt Dexter, Esq. 
 A. P. H. A. Beport, Vol IV. 
 
 Possible Future Achievements in Hygiene. 
 
 Let us now inquire what are some of the possible achieve- 
 ments of hygienic science and art in the future, and the best 
 means for their accomplishment. 
 
 One of the most promising fields of labor for the hygienist 
 is, it seems to me, in the still further prevention of sickness 
 and deaths from miasmatic causes. 
 
 Referring to our vital statistics for 1871, we learn that the 
 probable number of deaths in the State, as corrected by the 
 compiler, was 18,094, and that of these 4,832, or about 27 per 
 cent., were believed to have been caused by miasmatic diseases. 
 Certainly this number should be largely increased, for there 
 were reported as deaths from pneumonia, 482 ; or, when " cor- 
 rected " by multiplying by 1.86, 800. Of these we may add to 
 our former number of deaths from miasmatic causes at least 
 500, as surely due to miasmatic causes as any others, and we 
 have our list swelled to 5,332 from these causes in a single year. 
 
 As many persons can better appreciate the loss to the State 
 by preventable deaths when the value of the years of "eftective 
 
8 
 
 life" lost by thorn i.s put into dollars and conU, let uh, for a, 
 moment try, approximately, to estimate the real money loss to 
 the State by these miasmatic causes. 
 
 The last sickness of tlie 5,332 persons who die from these 
 causes, including loss of time, must have cost on an average $50 
 for each person, and the funeral expenses must have been, on 
 an average, §25 for each one, giving a cost — actually a loss — 
 to the State of ^399,900. 
 
 Now, as these causes of death are accounted by all hygicnists 
 as preventable, it is safe to say that a large number of these 
 persons died prematurely. Let us suppose, then, that these 
 persons died sooner than they otherwise would by an average 
 of ten years, and that one-half of -those years thus lost might 
 be said to be years of '' eiiective life." 
 
 The State then loses, annually, 26,660 years of "effective life,"' 
 which can not be estimated at less than >?150 per year, giving a 
 money loss of $3,999,000. 
 
 English observers and statisticians have estimated that for 
 every death two persons are constantly sick. 
 
 Thus for every death from the same causes under cousidera- 
 tion, it is probable there are two years of sickness from the 
 same causes in other persons in this State, or 10,664 years of 
 sickness from miasmatic causes in the year 1871. Counting 
 one-half of these years of sickness as in the "effective period" 
 of life, we have their money value, §150 per year, §799,800, 
 which is really so much loss to the State. 
 
 Nor is this all ; for the cost of these 10,664 years of sickness, 
 in medical attendance, nursing and loss of time of parents and 
 friends can not be estimated at less than an average of §200 per 
 year, thus entailing another loss to the State of §2,132,800. 
 Here, theu, is the approximate money loss to the State from 
 these preventable causes of sickness and death : 
 
 Sickness and funeral expenses of those dead from 
 
 these causes, 5,332 §399,900 
 
 Loss of effective years of labor bv these premature 
 
 deaths, 26,660 '... • 3,999,000 
 
 Loss of effective years of labor from sickness of 
 
 others, 5,332 years 799,800 
 
 Loss in cost of 10,664 years of sickness 2,132,800 
 
 Total loss to the State §7,331,500 
 
9 
 
 That probably one-half of all this loss may be saved to the 
 State is, I think, apparent from the foUowine^ and other con- 
 siderations: 
 
 Dr. Edward Jarvis, in a paper contributed to the State Board 
 of Health of Massachusetts, on "Political Economy of Health," 
 very concisely remarks that "the cftective power of a nation is 
 in the number of its people in sustaining period" {i. e., between 
 the ages of twenty and seventy), "and in the proportion these 
 bear to the dependent classes." 
 
 "Collective personal gain is public gain, and aggregate per- 
 sonal loss is, to the same extent, the suffering of the com- 
 munity." 
 
 " The S.tate thus has an interest not only in the prosperity, but 
 also in the health and strength and eiiective power of each one 
 of its members." 
 
 Whatever has, in the history of the race, and especially in 
 the history of civilization, intended to add to the efficient power 
 of individuals of the various nations, is really embraced in 
 hygienic science and art. Their's are the better adaptations 
 of means, circumstances, and habits, by which man's' life has 
 been expanded and his strength increased; their's the various 
 improvements in agriculture, in vegetable and animal life, by 
 which man has obtained better and more constant food; their's, 
 too, the wonderful and manifold improvements in the arts, by 
 w^hich man is better clothed and housed. 
 
 The gradual increase in the length of human life since the 
 commencement of the Christian era, is the result, and really 
 marks the progress of the benignant rule of the goddess Hygea. 
 
 In the third century, the average duration of life among the 
 most favored classes in ancient Rome was thirty years. In the 
 present century, the average longevity ot persons of the same 
 class is fifty years, or an increase since the third century of 67 
 per cent. There can, I think, be no doubt that in "the lower 
 classes the increased longevity is still more striking. 
 
 II, O. HiTcncocK, M. I). 
 MicUyan Ecport, 1876. 
 
10 
 
 Responsibilitv of Board? of Health. 
 
 While the responsibilities of Boards of Plealth in cities and 
 villages are proportionately greater than in the townships, yet 
 the importance of organization and careful attention to the 
 sanitary conditio)is of tlie town must not be underrated. Epi- 
 demics sometimes sweep through a farming community, which 
 might easily have been prevented by prompt action on the part 
 of the Board of Health, had immediate notice of the first case 
 been given to them. Nuisances in the shape of stagnant pools 
 of water or undraincd marshes often exist in the township, 
 which are fruitful sources of disease to the inhabitants, and 
 should be abated in the manner prcrvided by law. All Boards 
 of Health should, therefore, ascertain whether any cause of dis- 
 ease exists within their jurisdiction, and if there is reason to 
 apprehend that any source of sickness may possibly arise from 
 the action or neglect of any person, the Board should establish 
 such regulations, and take such measures as they may think 
 necessary to prevent the same. 
 
 Hon. Leroy Parker. 
 
 Michigan Report, 1870. 
 
 The statute now gives the State Board of Health only direct- 
 ory or advisory power. Practical experience has demonstrated 
 the necessity for giving the rules and orders of the State Board 
 mandatory power, with statutory force and effect. 
 
 Contingencies have arisen, and will arise, where local influ- 
 ences prevent the operation of the health laws for the protec- 
 tion of the people. Authority should rest somewhere in such 
 cases, to secure to communities the full benefit of the law, and 
 no where could it be vested with more impartial judgment than 
 with the State Board of Health, composed, as it is, of repre- 
 sentatives from difiorent parts of the State. 
 
 Emergencies often exist requiring prompt and immediate ac- 
 tion to })rotecf the public health. Boards of Health should, 
 therefore, iiave the power to restrain persons from maintaining 
 a nuisance until a hearing can be had before a court. Such is 
 the law in Massachusetts, and the Supreme Court of that State 
 has confirmed the action of Boards of Health under the statute 
 granting such powers. 
 
 loica Report y 1881. 
 
11 
 
 Work of Health Boards. 
 
 As regards villages, the case is worse than in cities. Out of 
 152 incorporated villages, an annual report for the year ending 
 September 30, 1874, has been received from only nine clerks. 
 There seems to be a greater degree of indifference to all laws 
 and measures for promoting the public health in villages, than 
 in either cities or townships; and this is particularly unfortu- 
 nate, because it is in just such places that so much can be done 
 in the way of preventing sickness and death. It is in villages- 
 that water supply is peculiarly liable to be contaminated, and 
 the inhabitants to be decimated in consequence, though such 
 diseases as diarrhea, dysentery and typhoid fever. It is in vil- 
 lages that the ordinary contagious diseases spread with such 
 facility and rapidity, through the free communication of chil- 
 dren. It is in villages that that fearful disease, cerebro-spinal 
 meningitis, or spotted fever, most frequently causes the greatest 
 destruction of life. If every village had an actual and active 
 Board of Health, how much might be done to search out and 
 remove some of these causes of sickness and death which now 
 strike down hundreds from the village population of this State 
 in every year. 
 
 It is possible that some part of this apparent inditterence 
 really comes from comparative ignorance of the subject, both 
 as regards the possibility of preventing sickness and death 
 through sanitary work, and of the duties of village councils aa 
 local Boards of Health. In fact, it is not reasonable to expect 
 that members of village councils, elected to perform the various 
 duties of the office, should always be fully acquainted with the 
 latest teachings of sanitary science. 
 
 Michigan Report, 1874. 
 
 Vital Statistics. 
 
 The comparative success which has attended the eiibrts to 
 secure these returns of vital statistics, is shown by their steady 
 increase, while the per capita expenditure is not as great as 
 when there was no attempt at classification or study. It is 
 only as to the returns of birtlis that our methods do not seem 
 to be perfected. So far as vital study is concerned, we are able 
 
12 
 
 from those obtained, and from the deaths under one year of 
 age, to compute allowauces. But it woukl be better if the re- 
 turns themselves were more complete. As it is, tliey are several 
 thousand in advance of those under the last system, beside8 
 being accompanied with details of value in vitnl study. Until 
 our governing authorities, an\i especially those of our cities, 
 come to know that proper sanitary care and policy requires that 
 the number of young children he known, in order to limit and 
 protect from disease, tliey will ho insensibly contributing to 
 the general death rate. 
 
 Wc lind in the State no tendency to resist a law which has 
 its foundations in a decent care of human life. It is not of- 
 ficious for the State, in the case of a marriage, to claim that it 
 have the recorded evidence thereof, with such appended facta 
 as, in the judgment of those who have made the civic care of 
 population a study, are deemed desirable. As to births, the 
 trouble arises from negligence and delay rather than from intent. 
 Some at first were disposed to question the right which a State 
 has to enforce a duty without compensation. This duty has 
 been imposed by a law on the statute book for thirty years, and 
 the principle is acknowledged in many cases, where lawyers, 
 who are apt to protect their own legal rights, are required to 
 perform services for which no direct pay is provided. It would 
 be easy to show that incidental benefits accrue to medical men 
 from all laws that look to this kiiul of guardianship over such 
 vital conditions of population, as they Vjear relation to. 
 
 As to deaths, the common sentiment is that the death and 
 the cause of death of every person should be authenticated. 
 
 In most of the returns of death there is evident carefulness 
 of diagnosis, or a note showing some doubt or com^Jication 
 which is recognized. We invite the attention of all students 
 of statistics to the data already on hand, as showing how in- 
 formatory these records are, if, for instance, any one physician 
 is dispoi-ed to abound in "general debility,'' "cancer of liver," 
 "pyaemia or septicaemia" (without locality,) "congestive or 
 gastric liver" or other doubtful term, the return itself comes to 
 bo eliminated and either is (Iroi)ped from the vital tabulation 
 or looses its significance in the multitude of numbers. 
 
 K. M. Hunt, M. D. 
 
 Aac Jirscy Rrport, l^'ol. 
 
13 
 
 Until accurate registration of vital statistics is thorougVily 
 carried out by each State, it obviously will be impossible to 
 have an efficient system of State Preventive Medicine. What 
 we have said of the States may be applied to the United States. 
 I cite the following fact as illustrative of these remarks : I 
 was desirous of learning whether we had proof from reliable 
 statistics that a man lives longer now than he did a century 
 ago. This is believed to be true, i-f we may judge from past 
 history, whcrefrom it seems that the duration of life has been 
 steadily augmenting with advancing civilization. To get ac- 
 curate data, I consulted some noted experts in the community, 
 but I have not been able to get satisfactory replies. JSTot one 
 of them could refer me to printed vital statistics ^jroyj/?^ the 
 fact for these United States. 
 
 Public Hyrjiene by Henry L. Bowditch. 
 
 The Registration of Vital Statistics in the United States. 
 
 Abstract of a Paper Read be/are the General Sefsirm of (he American Social Sciejicc 
 Association, by Dr. Elisha iiams. 
 
 The ceilsus enumeration of the population ought to be abso- 
 lutely accurate and complete; but the method of enumeration 
 is so essentially faulty, that, as respects the poll of the living 
 inhabitants, even the total columns are equivocal, w^hile all the 
 distributive grouping is untrustworthy. The essential vicious- 
 ness of each successive census will remain unremedied until 
 the methods of enumeration are made exact; until all the facts 
 relating to births, marriages and deaths, and the causes of death, 
 are currently registered as public records in every county and 
 State. Vital statistics comprise the account current of the 
 State with the lives of the inhabitants. The registration of 
 these statistics is a duty rendered to the State, and is to be 
 maintained by ways and means which the State alone can pro- 
 vide. But Wiiercver a State has so provided the methods and 
 means for the performance of the duties of vital registration, 
 the people must comply with alacrity to the requirements of 
 the registry laws. Birth records should be so complete as to 
 establish and perpetuate the identity of individuals, and such 
 other facts should be secured in respect to both the child and 
 
14 
 
 its parents as the law may require. Vital ^^tatisticiau8 are al- 
 ready fully agreed on the elements of good birth records. The 
 claim, both of the State and the infant, as to the record of its 
 birth, is imperative, and allows no optional delay beyond the 
 reasonable time necessary for certifying and tilling the record 
 for public registration. Claiming such a right, the State can 
 not do less than define the duties and obligations it imposes on 
 the several persons interested, who can not justifiably postpone 
 the certification of a detailed and complete record. In cases of 
 illnjitimatc children^ as much information as possible should be ob- 
 tained, 2)arlicularly as to the occupation and nationality of each 
 parent. Such records, made with faithfulness, will subserve the 
 interest of statistical and biographical science. Faithful regis- 
 tration of still-births should be secured by judiciously regulating official 
 returns and the suitable interment of the remains. The interests of 
 morality, as well as of science, demand this record. All records of 
 ■marriage should be registered as soon as verified. The law sub- 
 mitted is in harmony with the statutes of Massachusetts, Con- 
 necticut, Rhode Island and Illinois. Amendments of existinsf 
 statutes may be readily etfected in the States which need mere- 
 ly to give harmony and efficiency to existing laws, while in 
 States which have only cumbrous and inefficient statutes relat- 
 ing to marriage registration, the adoption of an entirely new 
 system, under new laws, will be more practicable than amend- 
 ments. The epitomized anthropological history of a life, a 
 faithful certificate concerning time, place and social condi- 
 tions of each death scene, and medical facts in regard to 
 causes of death will ever impart to records all the real import- 
 ance which family. State and olficers of health will justly claim. 
 All events and causes of mortality should be followed back un- 
 til the question may be answered, "IIow may human life hence- 
 forth be guarded against the causes of sickness, injury, and 
 premature deatli?" 
 
 As it is the chief object of this report to suggest the argu- 
 ments and i)lans by which uniformity and completeness should 
 be given to the registration of vital statistics, we shall proceed 
 directly to this purpose in all we submit in regard to records 
 and registration. Certain essential conditions should be kept 
 in view in devising the plan of the greatest practical utility 
 and completeness in the records. These may be enumerated 
 
15 
 
 as a complete registration of birth in every community; com- 
 plete registration of marriage, the records of which shall be 
 comprehensive. This branch of registry provides a basis of 
 correct information concerning the foundation of families. 
 The statute should provide for thorough and scientific verifi- 
 cation of violent and unknown causes and circumstances of 
 death, and effectual provision for specially verifying the fact, 
 and the attendant circumstances of deaths. The entire matter 
 of records and registration of mortality should be placed under 
 the supervision of expert sanitary officers or boards of health. 
 
 extract from proceedings of a conference of yital 
 Statisticians, 1880. 
 
 Dr. Thompson, President State Board of Health of Kentuekr/y 
 says: "We have had but little experience in Kentucky, except 
 in a few localities, in gathering these statistics. I am very 
 confident that the large cities of the West, including Cincin- 
 nati, St. Louis, Louisville and Chicago, do not obtain perfect 
 returns, much less States at large. It is impossible to give 
 anything approximating a correct death list except through 
 physicians. And yet some physicians think you are inquiring 
 into their private affairs when you require that they shall state 
 the causes of death of their patients. The parents and guard- 
 ians also think the causes of death of friends concern only 
 themselves. In Kentucky we are endeavoring to compel the 
 physicians to make the certificate under oath. It would take 
 years to educate the public to make these returns, but we can 
 educate the physicians much sooner, and I think that the whole 
 duty must be put upon them. It is true that it is for the bene- 
 fit of the people, but it is also for the information of the profes- 
 sion, and hence, in my opinion, no dead body should be buried 
 without the certificate of the physician. It is perfectly clear to 
 me that in the rural districts it will be impossible ever to gain 
 anything that will be satisfactory, except through the pro- 
 fession." 
 
 Dr. Lindsley, Health Officer, New Haven, Conn.: The law al- 
 lowed every town to elect a Registrar, but in failure of such 
 election the Town Clerk was to be Registrar. Wherever he 
 
was Kegistrar, very little iuterest was taken in th6 matter of 
 these certitieates, and frequently he would make collections of 
 them but once a year. TJut. where a l^egistrar was elected, 
 he took a personal interest in it, and the collections and records 
 were far more accurate than otherwise. At the present time 
 we have a law by which, in all tlie cities of the State, a hi/rial 
 perrnit h required. That has been since the organization of 
 the State Board of Health, two years ago. I believe that it 
 has operated so far very well, and the records numerically are 
 almost perfect. I know that it is so in New Haven. I do not 
 know of a single instance where a body has been buried with- 
 out a permit. I believe that the physicians are the proper y»ar- 
 ties to look after these matter!}, and that we can educate the 
 profession to the practice of giving them. 
 
 Dr. Clerncuui: We have an undei'taker's certificate and also 
 a physician's certificate on the same blank. I think in Phila- 
 delphia the undertakers are registered, and an inspector is de- 
 tailed for the purpose of going around among them at certain 
 times to see that they are attending to their duties in returning- 
 these certificates. The certificate from the cemetery is entirely 
 a different thing. It is not on the same blank. If it is found 
 that those certificates do not coincide, the matter would be in- 
 quired into, and if anything is wrong, a fine of $25 will be im- 
 posed all around. One has been enforced within a month. 
 The certificate is returned by the undertaker. 
 
 Ijr Thompson: In Kentucky, there are no registrars, but we 
 have City Clerks, and it is a finable offence for the undertakers 
 to bury any one without authority from the city to difj the (jrave. 
 The City Clerk can not give the authority until he receives tlic 
 certificate of the physician. The family have to get that from 
 the doctor. It is generally made the duty of the head of the 
 family to carry that certiiicate to the physician wherever his 
 place of business is, and I understand it works well. 
 
 Dr. liauch, Secretary State Board of Health, of Illinois: There 
 is no trouble in Illinois; but the undertakers are not the par- 
 ties who are made to make the returns. The medical men are 
 the parlies responsible. The certificates are, as a general rule, 
 brought to the office of registration by undertakers, who are 
 puni-hable by fine, as are cemetery keepers and physicians, for 
 neglect of duty. "With regard to the persons who should make 
 
17 
 
 these returns, I would ask the question : Ought uot this re- 
 sponsibilitj^ to be divided? In Illinois, the duty rests entirely 
 on the medical men. Recently the question of fee has been 
 raised. Before that was raised there was no trouble at all. I 
 think it is the duty of the medical men to make these returns. 
 They can do it better than any one else. It does not I'cquire a 
 great deal of time and trouble to obtain what is required. 
 
 Dr. Thompson: We have no -difficulty in Kentucky in get- 
 ting all tlie information in regard to the certificate. The pen- 
 alty imposed on the sexton of the cemetery takes the difficult}^ 
 entirely ofl" our hands. They are not allowed to bury any body 
 without a permit from the Health Department, and the Health 
 Department will not grant certificates unless they are signed 
 according to the ordinance. 
 
 Dr. Ames, of 3Iassac.huse.tts : The bulk of the discussion seems 
 to be upon the registration of cities, as might naturally be sup- 
 posed. But there is a hroad field in the country districts. The 
 trouble with the country districts is that they arc sparsely settled, and , 
 a physician is called over a large territory, and unless he attends 
 to the certificate at the moment of death he may not be able to 
 attend to it for some time afterward. 
 
 If there could be some one to vise the return of the house- 
 holder, who makes the primary return ; if some officer of the 
 town could vise it — and I believe something of that kind might 
 be done — registration laws might be passed so as to secure every- 
 where completeness of the return, where now no law could be 
 passed. And I commend that feature of it to the attention of 
 the committee, as one which must everywhere be met, and ones,/ 
 which ought to be met intelligently, and at the same time re- 
 gistration be efi^ected. 
 
 Dr. White, of New Orleans : These duties in New Orleans 
 are managed as follows: The Board of Health passed -iin ordi- 
 nance stating that no body shall be buried in any part of the 
 city, or removed from the city, without a permit from that 
 oflice. That permit is based on the certificate of a physician. 
 It is considered the business of the family to furnish the cer- 
 tificate, but the doctor signs it. There is no difficulty of the 
 working of that matter in New Orleans. No dead body can 
 be removed from the city without a permit from the Board of 
 Health, and a fine can be levied on the railroads for carrying 
 2— Bd. H. 
 
18 
 
 out bodies without permits. The cliargo for the burial permit 
 is, I think, tifty cents. The money for tliese permits goes into 
 the treasury of the Board of Jleaith. 
 Vital Sfofi.^tic.s, by J. D. Plavlui, 31. D. 
 
 Thus far, the State Board of Health has organized and set 
 in motion the system of registration and vital statistics, and if 
 this system seems to be complicated, it is because numerous 
 laws relating to the matter — and all in operation — have to be 
 co-ordinated as to secure the action of local authorises as well 
 as insure an efficient supervision and complete rec;ord8 at the 
 State IJureau of Registry. -i 
 
 I)y this ceaseless survey, description, comparison and map- 
 ping of the courses of disease, and the varying rates and causes 
 of mortality in more than a thousand registration districts, the 
 whole State will derive practical results far more useful than 
 any merely immeral summaries that would only record the 
 total losses by death, and the gains by birth, and the establish- 
 ment of families by marriage. The purpose to render this 
 branch of work directly tributary to public interests is well 
 formed and now seems attainable. The State Board of Health 
 has recognized the practical relations of this branch of its 
 work, as dciined by a sanitary statesman of England, who lias 
 emphasized his estimation of it l)y saying : " Considered phys- 
 ically, the main object of correct civil registration of births, 
 deaths and marriages, is to aid in disclosing the causes of dis- 
 eases. Considered legally, the object is to provide the means 
 of tracing descent and proving personal identity. And con- 
 sidered }»olitically, it is to assist the government in arriving at 
 correct conclusions in regard-to measures of internal economy, 
 etc." Completeness, accuracy, and the requisite attestation of 
 such records should be fully attained under the system of vital 
 statisti(^s in tlie State of New York. 
 
 K. IIakkis, M. B. 
 
 New York Reports, ISSO. 
 
19 
 
 Work of Health Boards. 
 
 For several years I have been comparing the results of the 
 work of municipal Health Officers, as contrasted v?-ith that of 
 municipal Boards of Health, both in this country and Europe. 
 I find that, in the great majority of cases, the single officer 
 succeeds better than the Board. Where the Health Officer sys- 
 tem fails it is often because the officer attempts to continue to 
 practice his profession and perform his sanitary duties. It is 
 not desirable that a Health Officer should be a practitioner of 
 medicine; for, if he is, he can hardly avoid the distrust and 
 dislike of his fellow-physicians, if he does his duty; nor can 
 he be expected to be as severe on the nuisances of his wealthy 
 and influential patients as on those of others. 
 
 J. S. Billings, M. D. 
 A. P. H. A., Vol. VI. 
 
 Sanitation. 
 
 "One of the first great objects of sanitary organization," to 
 use the language of a distinguished sanitarian, "is to watch the 
 death rate; to watch it not only over a city or parish, but in 
 detail; to watch it from mouth to month, and even from week 
 to week; to watch it as att'ected by difi'erent diseases, and par- 
 ticularly what are termed epidemic diseases, and such diseases 
 as we believe to be, in a great degree, preventable; and this 
 done, to make known the results from time to time to those 
 who are chiefly concerned in sanitary evils, so as eftectually to 
 bring home to the dwellers in darkness, ignorance and disease, 
 the immense significance of the facts taught by these figures." 
 
 At the beginning of the fourth century, Paris is said to have 
 "lost her population at the rate of 50 in every 1,000 annually, 
 and notwithstanding the great increase of her population up 
 to the time of the late war, her death rate was then only about 
 28 in 1,000. At the close of the sixteenth century, the aver- 
 age duration of life was about twenty-one years; in 1833 it was 
 forty-five years and five mouths." 
 
 Under the influence of improved sanitary measures, wher- 
 
20 
 
 ever they have ]>eeii strictly enforced and intelligently con- 
 ducted, the ref<ults, though lar from what it is yet hoped to at- 
 tain, arc even more gratifying. In England, after the adoption 
 of measures for the improvement of cities, "in nineteen towns 
 the annual mortality, which had heon 28 in 1,000 for years pre- 
 vious to the improvement, fell to 21 in 1,000." 
 
 In Liverpool, the rate of mortality was reduced from 38.4 in 
 1,000 to 20 in 1,000. In five towns, according to Latham on 
 Sanitary Engineering, " the saving of life =i= * * averaged 
 25 per cent.; while in the two diseases, typhoid fever and con- 
 sumption, tlie average reduction was 55 and 25 per cent., re- 
 spectively." 
 
 It is further sliown b}' Dr. Gqo. Buchanan that, by the intro- 
 duction of sewerage, drainage, and water supply into twenty- 
 five cities and towns, possessing an aggregate population of 
 593,736, "the average of the death rate per 10,000 for the 
 ditiferent places, liad decreased as follows: From all causes 
 from 247.55 to 219.87; from typhoid fever, from 13.34 to 7.8; 
 from diarrhea, from 8.45 to 7.66 ; from pulmonary consump- 
 tion, from 33.44 to 27.3; among infants under one year, from 
 55.65 to 50." 
 
 One additional example, drawn from the sanitary records of 
 England, where hygienic measures for the prevention of dis- 
 ease have been longest and most elficiently pursued, may be de- 
 duced from the testimony of Dr. Buchanan in the ninth report 
 to the Privy Council, showing that in twenty-five towns where 
 a system of sewerage liad been introduced, in nine of these 
 the number of deaths was diminished over 50 per cent., and 
 in ten others from 33 to 50 per cent., the average reduction be- 
 ing about 45 per cent. 
 
 Even in the United States, wliere sanitary supervision has 
 been only partly and recently introduced, during the last twenty 
 years, up to and including 1870, the percentage of deaths to the 
 population had decreased from 1.39 in l,p00 to 1.28 in 1,000. 
 According to Dr. Henry B. Baker, the efficient Superintendent 
 of Vital Statistics of Michigan, the death rate in that State had 
 been decreased at each census. In 1850 it was 1.14; in 1860, 
 .99; in 1876, .94 i»er cent., effecting a saving, in a single year, 
 of 2,317 lives, and, if we regard its financial aspect, a total of 
 ^1,899,940. 
 
21 
 
 St. Louis, from one of the most unhealthy, has been raised 
 to one of the healthiest cities of the United States; and such 
 has been the gratifying result of the general attention paid to 
 the improvement of cities, and the removal or destruction ot 
 the recognized causes of disease, that it has been laid down as 
 a rule, that any excess over 14 deaths in 1,000 of population, 
 is unnecessary, and the result of known hygienic laws. That 
 such result can be attained is a legitimate conclusion from what 
 has already been achieved, as in St. Louis, just mentioned, 
 where the death rate for 1875 was only 14.46 per 1,000. 
 
 Another fact encouraging to those engaged in the work of 
 sanitary reform is that so forcibly alluded to by Dorman B. 
 Eaton, LL. D., in a discourse delivered in 1875, that as the 
 health of communities increases, crime diminishes. In Glas- 
 gow, while the death rate fell, between 1869 and 1873, from 34 
 in 1,000 to 29.09 per 1,000, the whole number of crimes were 
 reduced from 10,899 to 7,876; 1867 to 1873, of thefts alone 
 there was a reduction of from 1,192 to 264. . 
 
 These facts are rapidly forcing themselves upon the observa- 
 tion of the public. The}' have attracted the attention of Legis- 
 latures and State authorities everywhere, and their legitimate 
 result has been the creation of State Boards of Health in nearly 
 one-third of the States of the Union. 
 
 F. M. Hatch, M. D., Sec'y. 
 
 Report of State Board of Health of California, 1877. 
 
 Vaccination. 
 
 As a rule, one successful vaccination in childhood protects 
 until about fourteen or sixteen years of age. If, however, there 
 be epidemics of small-pox near, or the danger of exposure great, 
 the process may be repeated oftener, as there can no harm re- 
 sult, as no effect will be produced if the person be already pro- 
 tected by the previous operation. One trial, however, in face 
 of danger, is not conclusive, and care should be taken that the 
 operation be thoroughly performed. 
 
 In England, the small-pox death rate has decreased one-half 
 since the introduction of compulsory vaccination. In many 
 
22 
 
 cities wlierc periodical inspection of all the schools, and house 
 to house visitation, with free, though not compulsory, vaccina- 
 tion takes place, often the disease is hardly known unless im- 
 ported, and then nevt-r becomes extensively prevalent, but is at 
 once stamped out. 
 
 The number of persons efficiently vaccinated or successfully 
 revaccinated, that are attacked even during an epidemic, is very 
 small; and where the vaccination has been imperfect the dis- 
 ease is usually greatly modified in severity. 
 
 When successful vaccination and revaccination has been done, 
 the i)roportion of deaths to attacks is but one-seventieth part 
 of that in unvaccinated persons. By universal revaccination, 
 sniali-pox has been stamped out of the army and navy. Ex- 
 p,erience here shows that one successful revaccination in an 
 adult is sufficient. (England). 
 
 ConnccHcuf Beport, 1879. 
 
 How TO l^KDrcE THK Deatu Kate. 
 
 There are reported in the vital statistics for 1871, 75 deatha 
 as having occurred from small-pox; or, when "corrected" by 
 multiplying by 1.86, 130 deaths. 
 
 Compulsory vaccination, carefully carried out by faithful and 
 vigilant local Boards of Health in every city, village, and 
 township of the State, together with more complete isolation 
 of every case of variola and varioloid, under t'ne present sta- 
 tutes of the State on this subject, would, without doubt, reduce 
 the mortality from this cause to a very small per cent, of what 
 it now is. 
 
 Can any one doul)t that the same may be true in respect to 
 tfie (596 (or, as corrected, 1,294) cases of deatli from scaHatina? 
 
 It seems a late day to point out the danger of its contagion, 
 and the absolute necessity of complete isolation for the [)reven- 
 tion of the spread of this disease so fearfully latal among chil- 
 dren. There has grown up a feeling in the public mind as 
 productive of evil as it is devoid of truth, that scarlatina is one of 
 the inevitable children's diseases, and, although often extreme- 
 ly dangerous to life, it must be submitted to, and, on the whole^ 
 the sooner the children have the disease the better. 
 
23 
 
 If the same care of isolation, too, were used in cases of 
 measles, diphtheria and whooping cough, the fatality from 
 these diseases would be largely reduced. And what is true of 
 these last named diseases is, for far stronger reasons, true of 
 typhus and typhoid fevers. Let all public and private nuis- 
 ances be abated, and all private and public rooms be well ven- 
 tilated, and we shall have recorded but very few original cases 
 of typhus or typhoid fevers; and let these few be strictly and 
 comi)letely isolated, and no other would follow. 
 
 H. O. Hitchcock, M. D. 
 
 Michigan Hepori, 1876. 
 
 I. — Small-pox a Prevkntable Dlseask, 
 
 It has long been known that small-pox can be prevented or 
 modified by vaccination. It is now^ believed that a wide-spread 
 epidemic of the disease can be attributed only to an equally 
 wide-spread ignorance or willfulness concerning small-pox and 
 its prevention by vaccination. No intelligent person need have 
 small-pox. 
 
 II, — Why Vaccinate? 
 
 Because unmodified small-pox is so deadly a (iisease, and so 
 often disfigures and enfeebles those who recover, and because 
 by traveling or by travelers, by articles received in the mail or 
 from stores or shops, or in various other ways, any one at any 
 time may, without knowing it, be exposed to small-pox, it be- 
 comes important, so far as possible without injury to health, to 
 render every person incapable of taking the disease. This may 
 be done so perfectly by vaccination and revaccination with 
 genuine bovine vaccine virus, that no question of ordinary ex- 
 pense or trouble should be allowed for a day to prevent the 
 careful vaccination of every man, woman, and child in Michi- 
 gan, and the revaccination of every one who has not been vac- 
 cinated within five years. It is well established that those who 
 have been properly vaccinated are far less likely to take small- 
 pox if exposed to it, and that the very few who have been pro- 
 
24 
 
 pcrly viifc'liiated, and have siiiall-pox, liavo it in a much milder 
 form and are much less distigured hy it than tho.se who have 
 not been thus vaccinated. 
 
 In Sweden the average numl)er of deaths in each year 'from 
 small-pox per one million inhabitants was: 
 
 Before the introduction of vaccination (1774-1801) 1,973 
 
 During the period of optional vaccination (1802-181G) 479 
 
 During the period of obligatory vaccination (1817-1877).... 189 
 
 Vaccination was introduced in England near the beginning 
 of the present century, and since 1853 compulsory vaccination 
 has been attempted. In England the number of deaths in each 
 year from small-pox per one million inha])itants was: 
 
 At the close of the last century. ...<. 3,000 
 
 ' From 1841 to 1853 (average) 304 
 
 From 1854 to 1863 (average) 171 
 
 In the Bavarian army revacci nation has been compulsory 
 since 1843. From that date till 1857 not even a single case of 
 unmodified small-pox occurred, nor a single death fi\)m small- 
 pox. 
 
 During forty-two yeai's of duty, Dr. Marson, physician of 
 tlie London Small-pox Hospital, has never observed a single 
 case ot small-pox in the officers and employe;? of the hospital, 
 who are revaccinated when they enter the service, and who 
 are constantly exposed to the infection. 
 
 "Out of more than 10,000 children vaccinated at Brussels 
 with animal lymph, from 1865 to 1870, and who went through 
 the terrible epidemic of small-pox which, in 1870 and 1871, 
 frightened the world, not a single one was, to my knowledge, 
 reported as being attacked by the disease. The same inmiu- 
 nity was shared by those, a much larger number, whom I had 
 revaccinated, and who, at the same time, were living in epi- 
 demic centers." — Dr. Warlemont, of Brussels, in North Carolina 
 Medical Jonrnal, January, 1880, Vol. V., p. 2. 
 
 III. — Who Should be Vaccix.\ted. 
 
 Every])()dy, old and young, for his own interest, and that he 
 may not become a breeding place for the distribution of small- 
 pox to others, should seek that protection from small-pox 
 which is altbrded by vaccination alone. 
 
'lb 
 IV. — Who Should not be Vaccinated. 
 
 Unless exposure to small-pox is believed to have taken place, 
 or likely to take place, teething children, pregnant women, 
 persons suflering with measles, scarlet fever, erysipelas, or 
 susceptible to and recently exposed to one of these diseases, 
 persons suffering with skin disease or eruption, and in general, 
 feeble persons not in good healtl^, should not be vaccinated. 
 In all cases in which there is any doubt as to the propriety of 
 vaccinating or postponing vaccination, the judgment of a good 
 physician should be taken. The restriction as to vaccinating 
 teething children, makes it important that children should be * 
 vaccinated before the teething process has begun, because small- 
 pox is very much more dangerous than vaccination. Small-jiox 
 is exceedingly dangerous to pregnant women. 
 
 Reasons for preferring bovine virus to humanized virus may 
 be given as follows : (1) By the use of the bovine virus there 
 is secured a more perfect or typical development of the vaccine 
 disease; and hence, it may fairly be inferred, a greater protec- 
 tion against small-pox. (2) With the bovine virus an*d with a 
 clean lancet, and with clean surroundings, there is no danger 
 of communicating syphilis. (3) The bovine virus is far more 
 effective than the humanized virus in re vaccination; and where 
 the humanized virus fails, and the bovine virus works, it is 
 probable that there was susceptibility to small-pox which the 
 humanized virus did not remove, but which has been removed 
 by the bovine virus. (4) Greater care can be taken in the prop- 
 agation of bovine virus, a greater supply can be always at 
 command, and always, but especially in time of urgent danger 
 from small-pox, people can have a better guarantee that they 
 are vaccinated with genuine and pure vaccine virus. 
 
 Michigan Report, 1881. 
 
 Conditions of Good Sanitary Administration. 
 
 But the arguments that sickness and death, as they occur, are 
 providentially inevitable, and that pestilence and famine are 
 pre-ordained messengers of God's wisdom and wrath, before 
 which we must dismiss our reason — that our precautions against 
 
26 
 
 them lire viiin iioutings of oiir wisdom in tlie face of Divine 
 Providence — sire so nearly monopolized by illiterate grandma- 
 mas and snju'rannuated bigots, as to be elements of precantion 
 hardly wortliy of notice in our sanitary condition on earth. 
 Tiiongh Dr. Lyon IMayfair, now a professor at Edinburgh, 
 says that in his day Scotcli professors dared not preach such 
 heretical doctrines, and it is not very long since an English 
 comjjany was refused the lil>erty of deepening the channel of 
 the (Juadaiquiver, because, it was argued, that if God had in- 
 tended the river to be navigated. He would bave made it navi- 
 giildc. 
 
 It is, I think, safe to say that London and Paris lost more 
 lives needlessly, both by the plague and by the cholera, in ten 
 weeks, than either of them have so lost during the last twenty 
 years. Bordeaux, then one of the filthiest towns in Europe, 
 lost 18,000 out of 40,00 of its people in a few weeks. The 
 plague remained longest in Naples, which was perhaps the 
 worst ventilated and worst drained of the large cities of Eu- 
 rope. 
 
 There is nothing better settled in regard to life and health 
 than that such diseases as cholera, yellow fever, small-pox, ty- 
 phus and typhoid fever, can be in great measure kept away by 
 good sanitary administration, the cost and loss of which is in- 
 finitesimal compared with what these diseases would cause. 
 They have been, by such means, so far kept out of New York, 
 that for ten years they have caused less aggregate loss and cost, 
 I presume, than either the toothache or the mumps. Cholera 
 came live times to English ports in 1873, and twenty-eight died 
 of it on one foreign ship in London, and yet such were the pre- 
 cautions that not a single Englishman took the disease. In 
 the city of Bombay, with its population of 650,000, made up 
 of all the races of Europe and Asia, and situated in a region 
 where plagues and leprosies and choleras, have through all his- 
 toric time reaped their greatest harvests of death; where, in 
 1820, 150,000 persons died from one of these scourges in a few 
 weeks, and the average death-rate had always been alarmingly 
 high; in such a city, within a few years, good sanitary admin- 
 istration, introduced from England, has, by enforcing drainage, 
 ventilation, adecpiate air-space, by having good w^ater and 
 wholesome food and general cleanliness, accomplished result-s 
 
* 27 
 
 which are marvelous. The death-rate of Bombay, in 1873 — 
 only about an average year — was only slightly over 24 to a 
 thousand of its people; and Dr. Harris says its death-rate in 
 1874, was 23.9 to the thousand, being a lower rate than that of 
 Vienna, or Berlin, or I^ew York, or Baltimore, or Richmond. 
 Analogous results have been secured in Calcutta and Ilong 
 Kong. 
 
 _ Professor Lyon Playfair says the death-rate of London from 
 1660 to 1679, was not less than 80 out of every thousand each 
 year. About the latter date better sanitary precaution began 
 to be applied in that city, and especially since 1848, they have 
 been largely and continually improved. Much the same has 
 been ilia sanitary history of Paris. The wonderful results are 
 that these two largest are among the healthiest, and the very 
 cleanest of the great cities of the world. If N'ew York, or 
 . Philadelphia, or Chicago, or St. Louis* or Cincinnati, or Balti- 
 more, was as cleanly and well paved as either Paris or London, 
 the ratio of crime, poverty, death, and taxes, would go down, 
 their pride, population, and productive industry, would go np, 
 and reupblican institutions would be crowned with a new 
 honor. The average death-rate of London for the past ten 
 years has been only 24 to the thousand annually. In 1874, 
 with its 3,400,700 people, the death-rate was only 22.04 to the 
 thousand. The average death-rate of all England, for the ten 
 years last past, has been 22.04 to her thousand, which is prob- 
 ably lower than in this country; so that good sanitary admin- 
 istration has brought down the death-rate of the two largest 
 cities in the world, and the largest city of India, nearly to that 
 of the general death-rate of two of the most healthy countries 
 of the globe peopled by the most vigorous and enlightened 
 of the race of men. 
 
 Taking the records of 1873, and rejecting fractious, the 
 death-rates per thousand of population per year in some of the 
 principal European and American cities w^ere as follows: Lon- 
 don, 22, and New York, 29; Liverpool, 25, and Philadelphia^ 
 19 ; Glasgow, 28, and Richmond, 33; Edinburgh, 21, and Balti- 
 more, 24; Berlin, 27, and Cincinnati, 22; Birmingham, 25, and 
 Savannah, 43; Dresden, 34, and New Orleans, 37; Munich, 45, 
 and Valparaiso (a very unclean city), 64. It will be observed 
 that the average death-rate in American cities is higher than 
 
28 * 
 
 111 England, tliougli, perhaps, not higher than in German cities, 
 where public health in cities has, until very recently, been neg- 
 lected. 
 
 Our city death-rate among children under one year of age 
 is much higher than in English cities. 
 
 The high relative death-rates of Munich and Dresden, have 
 caused measures to be taken on a large scale for improving 
 their drainage, water supply, and ventilation; and v^ery soon 
 weniay be sure the rate will go down. The comparative low 
 rate of Liverpool has been secured by the most vigorous 
 administration, which within a few years has produced results 
 which every observing traveler has noticed. 
 
 Interesting results of sanitary administration in smaller 
 cities and villages might be drawn indefinitely from Eng- 
 lish experience, and it is in that country that such administra- 
 tion has been carried f(5rward with the most thoroughness. I. 
 give these examples from the report ot the medical officer to 
 J'arliament, made in 1867, relating to villages of from' 5,000 to 
 2,000 inhabitants. It comprises the health statistics for ten 
 ^'cars before the sanitary reform, with tliose of the ten years fol- 
 lowing them. 
 
 In Cardiff, wliere typhoid fever and diarrhoeal diseases had 
 prevailed, the former subsided in the ratio of 17 to 10, and 
 the latter in that of 17 to 4; while the aggregate death-rate ot 
 the place fell 35 per cent. In Salisbury the death-rate fell 20 
 per cent, and typhoid ferver and diarrhoea subsided in the rates 
 of 14 to 4. Consumption subsided in Salisbury, 40 per cent.; 
 in Ely, 47 percent.; in Rugby, 43 per cent.; in Bouberg, 41 
 per cent. ; in Worthing, 36 per cent. ; in Newcastle, 32 per cent. 
 
 If anybody consoles himself with the thought that we need 
 no such work in this country, let him read the first report (made 
 in 1873) of the State Board of Health of Minnesota — that fresh 
 young paradise of health to which so many go to be cured. In 
 that report we are told that, in 1871, forty per cent, of all 
 <leaths in the State occurred among children not over one year 
 of age; that more deaths are attril)uted to typhoid fever than 
 to any other disease; that 3,000 persons are (constantly, as I 
 understand) sick of that long-lingering, exhausting complaint; 
 that the average age of those thus carried away is twenty-five 
 years; that there is the least of such sickness in two larger 
 
29 
 
 cities wlicre there is most cleanliness; ami the chief cause, of 
 this disease th^ report declares to be "filth Avhich accumulatfes 
 about us, contaminating the air we breathe and tlie water we 
 drink; that there is in most of the large towns a criminal want 
 of attention to the construction of sewers and the removal of 
 the contents of privies.'"' Xow, Minnesota is not, relatively, 
 an unhealthy State, nor conspicuously in such sad sanitary con- 
 dition. But what shall we say of a people, with such a record, 
 ^which refuses to vote more than $250 per year to its Board of 
 Health; or of Virginia, refusing to vote a dollar for its State 
 Board of Health, while seeking immigrants from England in 
 presence of a death-rate in Richmond a third higher than that 
 of London in 1873, and higher than that of Bombay in 1874 ! 
 And such facts as to the death-rate of young children under one 
 year of age lose none of their painful interest when we read in 
 the English medical report of 1873, that in about one-Seventh 
 part of England the death-rate among children is only from 
 eight to twelve per cent, of the entire deaths, and that in no 
 district is that ratio higher than thirty per cent. ; that is less than 
 one- half that of Minnesota. 
 
 As we leave this part of the subject, let us remember that a 
 small reduction of a death-rate means a large reduction of dis- 
 abling sickness — exemption from pain and anxiety in cases 
 innumerable, and the value of which no money can measure — 
 and an improved physical tone and capacity for study, work and 
 happiness equally incommensurable. 
 
 Dr. Blayfair says, if England could be relieved of 125,000 
 needless deaths, ann'ually, she would also be relieved of 4,200,000 
 cases of sickness; but he does not tell us of how many hun- 
 dreds of millions of indigestions and headaches. Many strik- 
 ing illustrations of the truths herein set forth might be drawn 
 from the sanitary administration of this country, but the limits 
 of this paper forbid, and my selections might awaken jealousy. 
 The beniiicent results attained in the city of New York, how- 
 ever, are conspicuous. Beginning in 1866, when political doc- 
 tors and ignorant and mercenary partisans were the health 
 officers, the good work of sanitary reform, then placed and since 
 continued in the hands of men of benevolence, science and 
 wisdom, has produced fruits in the presence of which a great 
 metropolis and a whole nation may well be proud and take- 
 
30 
 
 courage. Contagions and epidemics have been disarmed and 
 averted; noxious occupations and deadly nuisances without 
 numi)er, besides more than two liundred slaughter-houses, have 
 been removed. Cellars, garrets and tenement houses, more fatal 
 than a decree of Herod to infantile life, have, on a vast scale, 
 been cleansed and ventilated; and the rate of mortality, the 
 security and the general comforts, especially of humble life, 
 have been increased; the best registry of vital statistics in this 
 country has been established, and last, but not least, an appre- ^ 
 ciative and inspiring public sentiment, which welcomes good 
 sanitary administration as a public blessing, and has extended 
 over the Union, has been there developed. 
 
 Dorman'B. Eaton, LL. D. 
 A. P. H. ^l.s.v. Reports, Vol. 11. 
 
 Homes fok the People. 
 
 In the year 1857, the annual death-rate for the rural districts 
 of England and Wales was 17 per 1,000 of the population, the 
 aggregate 9,750,000 people distributed over 350,000,000 acres, 
 giving nearly 36 acres to each person; during the same year 
 the i^ortality in towns and cities among a population aggregat- 
 ing 8,250,000, located on lands amounting in all to 2,150,00 J 
 acres, or rather less than 4 persons to one acre, was 25 per 1,000, 
 or, on the total number from overcrowding, alone, an aggre- 
 gate of <j8,000 preventable deaths per annum. The same law 
 of an increasing death-rate, resultant from overcrowding was 
 illustrated during the cholera year, 1854, in the same countries. 
 There were 134 districts in which the population averaged 915 
 persons to the square mile; 404 districts in which the density 
 of the populatii)n was only 225 to the square mile, and 85 dis- 
 tricts in which there were only 122 persons to the square mile. 
 The death-rate from cholera was nil in the 85 districts sparsely 
 peopled, 7 in the 10,000 where the population was 22.5 to the 
 square mile, and more than nine times that number, or 65 in 
 10,000, in the more densely peopled districts. The bearing of 
 such figures can hardly be questioned. 
 
 We do not, from these startling results, arrive at the conclu- 
 sion that city life is per se destructive to vitality. There are 
 
31 
 
 already abundant statistics to render any such idea impossible 
 for the well-informed mind, and whenever the tables of mor- 
 talities for cities shall be compiled oi> ph)ns adapted to show 
 the health and life rates obtaining in different localities more 
 and less favored by position, by construction, and ventilation of 
 buildings, by area of breathing room, by efficient sewerage 
 and by meteorological conditions, we shall find a much more 
 effective reply to such a conclusion. 
 
 • Some of the best results recorded as to vitality are found in 
 towns, and may be illustrated by a few figures submitted to 
 the Social Science Association by Mr. Michael, the Mayor of 
 Swansea, Wales. That gentleman caused the vital statistics 
 of Swansea to be divided according to the respective densities 
 of population, and he found the A division, resident in super- 
 ior houses apart from each other or standing on their own 
 grounds, subject to a mortality of only 11 in the 1,000 per an- 
 num, while the C division suffered a mortality of 36, or nearly 
 3 J times the minimum, and the intermediate density lost 20 in 
 the 1 ,000, or 9 more than the A division. 
 
 It is claimed by some writers that the human race would be 
 extinguished in less than two centuries if confined to large 
 cities; but, manifestly, that would depend upon the conditions 
 by which they were surrounded, as the Swansea A division 
 compares favorably with suburban vitality, and there is no 
 reason known among men why every man, woman and child 
 should not have a never-failing supply of pure air. 
 
 London shows an aggregate of 10,000 deaths per annum in 
 excess of births, but there are parts of London that are as fa- 
 vorable to longevity as those occupied by the A. division at 
 Swansea; and in the worst cities, hygienically considered, 
 length of life is found dependent upon individual action in a 
 very great degree. For very many centuries the Jews were 
 systematically persecuted by governments, and people all over 
 Europe, condemned to live in particular quarters in all the 
 principal- cities, and robbed without scruple by the ruling class, 
 if they were so ill-advised as to make a show of comfort or 
 wealth. Under such, and manifold other disadvantages, they 
 adhered more or less strictly to the rules of life with reference 
 to personal purification laid down for them of old time, and we 
 find them leading the whole human race to-day in the essen- 
 
82 
 
 tiuls ol" vitality. I'rus.siiui stuti.stics show that the mortality per 
 year among 100,000 Jews is less hy 800 tlian the deaths in the 
 same time among the same nnmher of Christians ; the numhers 
 being 2,161 Jews to 2,961 Christians; and in dvery particular 
 the chosen people manifest greater powers of endurance. A 
 few results obtained from 100,000 on each side, will show how 
 complete amd advantageous is the contrast ^ivoring the Jews. 
 There were among the Christians 143 still-births; among the 
 Jews, 89; a difference of 54 to our disadvantage. It might be* 
 supposed that the decreased number of still-births would be off- 
 set by a larger average of weakness in the offspring of Israel, 
 but preciselv the reverse is the fact, as only 453 children of that 
 race die under one year, while 697, or more than 50 per cent, 
 above tlie Jewish average, die in the lirst year out of the aggre- 
 gate of Christian births. In the four years next ensuing, 386 
 Jewisli children die, the offspring of Christians, already much 
 smaller in number, still heading the death-rate by nearly 25 per 
 cent., the number being 477. From five years old to fourteen, 
 151 children of the Jewish children fall out of the ranks, and 
 one-third more, or 202 Christian children die. From that age 
 until twenty-five, the Jews lose 125, the Christians 155. 
 
 During the twenty years ending at forty-five, there is a loss 
 among the Jews of 231, and among the Christians of 334, or 
 103 in excess. So marked was the exemption of the Jews from 
 the plagues that decimated all nations during the middle ages, 
 that they were charged with having poisoned wells and springs, 
 and only active interference on the part of the authorities pre- 
 vented a general massacre of the cleanliest people on the con- 
 tinent. 
 
 These illustrations show the potency of their modes of lire in 
 warding oft' maladies, as well as sustain the proposition that 
 men ma}' make city life conduce to comfort and longevity by 
 wisely controlling circumstances. Men need not fall victims to 
 epidemics, although surrounded b}" evil conditions, unless they 
 allow their physical systems to become weakened and their 
 minds to sink into demoralization. 
 
 Town life is not necessarily more brief nor less healthful than 
 life in the country. The conditions of longevity can be filled 
 in one location as well as the other. 
 
 Wisconsin Report. 
 
 1 
 
33 
 
 The first annual report of the Indiana State Board of 
 Health will shortly be issued. The statistical portion of that 
 report will embrace returns of births, marriages, deaths, and 
 diseases dangerous to public health, as received from Health 
 Officers up to September 80, 1882. We give here the following 
 extract from the forthcoming report: 
 
 There is an opinion held by many that, while sanitary rules 
 are needed to be enforced in cities, and for this purpose City 
 Boards of Health are needed, or are at least allowable, in the 
 country there is no necessity for any such rules or organizations. 
 In the country it is held that the air is pure, and the water 
 uncontaminated, that the ill effects of over-crowding are not 
 known, and that preventable sickness is comparatively un- 
 known outside of the crowded cities. 
 
 If we attempt to reason with those holding such views, we 
 are met with a general denial, and the advancement of certain 
 ideas derived from the poetical view of the case, the "tangled 
 wildwood," the "nectar that Jupiter sips," and the "free and 
 pure country air,'* is quoted as proof of the fact that the coun- 
 try keeps itself pure, and that such condition is sustained by 
 the unaided laws of nature. Man is not called upon, while in 
 the country, to exert any care as regards his surroundings; to 
 be in the country is to be where health abounds, etc. 
 
 Certainly, this view is all wrong. While the curses accom- 
 panying over-crowding are found in cities, still, as in other 
 cases, such ills have compensating blessings. Men are found in 
 such places exerting themselves, and providing means for the 
 removal of that which would cause sickness, and finally drive 
 them from that location, and in consequence of such care the 
 centers of population are often less afflicted with preventable 
 forms of disease than are the rural districts, for in the latter, a 
 " trnst in Providence" system prevails — an apathy born of 
 ignorance and sloth, and kept up by false teaching and penu- 
 riousness, permits that which destroys to remain, and prevents 
 the needed protective influences from being exerted. 
 
 To sustain our position we refer to the accompanying tables: 
 
 3— Ed. H. 
 
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88 
 
 Table X gives by State, and eaeb i;ounry, total deaths from 
 all causes. The deaths from each of the ten causes iu each 
 county. Also tlie per cent, of the mortality from each cause 
 of death, to the total mortality iu the several counties. 
 
 All such causes of death are in a great degree preventable. 
 A study of the tables will, we think, show tliat these prevent- 
 able diseases exist in a greater degree in the rural districts and 
 scattered population than iu those counties where the popula- 
 tion is more concentrated; whereas, with proper attention and 
 such care as Boards of Healtli exert, both by mandatory en- 
 forcement of proper rules and educational functions. 
 
 Scarcely any deaths should occur in these counties from the 
 causes mentioned. 
 
 In this table there is included in the estimate of total mor- 
 tality from all causes, 710 still-birth>2. The estinuited per cent, 
 of mortality for the State from the ten specitied causes to tlie 
 total mortality is exclusive of Porter, Cass, Wells and Starke 
 counties, the Health 01ii(;ers of those counties having made 
 no report. 
 
 We liud the mortality from those ten causes to be 4,149 — 
 nearly one-half of the total deaths in the State, if we exclude 
 still-births. This is a bad showing, even if we estimate that 
 one-half of such deaths might be [»re vented. We also find 
 that the death-rate for these ten causes to the total mortality 
 iu nine counties having the most concentrated population is 
 below 40 per cent., while in twenty-nine counties, altogether 
 agricultural, with population less concentrated, the death-rate 
 exceeds 40 per cent. Such fact ought at once to settle the ques- 
 tion as to the need of some means being used in the rural dis- 
 tricts to prevent deaths from such preventable causes. If we 
 consider separately each of these ten causes of death, w*e find 
 that in the counties given to agriculture, and where the popu- 
 lation is most scattered, the death-rate from nearly all these 
 preventable causes exceed that which is found to exist in coun- 
 ties with population more concentrated. 
 
 The per cent, of deaths from Diphtheria iu seven counties of 
 scattered population, designated as (a,) average 0.53 per cent.; 
 in seven counties of concentrated jtopulation, designated as (A), 
 it averaged 1.57 per cent. Deaths from whooping cough in 
 seven counties [a] averages 3.oM, in seven counties {h) 1.41. 
 
89 
 
 Deaths from scarlet fever in seven counties (a) averaged 4.4<i 
 per cent.; in seven counties (/>) 1.41 per cent. 
 
 Deaths from typhoid fever in seven counties (a) 3.20 per 
 cent.; in seven counties (6) 3.20 per cent. Deaths from spot- 
 ted fever in seven counties (a) average 4.11 per cent.; in seven 
 counties (6) 1.71. Deaths from pneumonia and bronchitis 
 (acute hmg affections) in seven counties (a), 25.60 per cent.; in 
 seven counties (b), 7.66 per cent. Deaths from consumption in 
 seven counties (a) a verage 17.7 4_per cent.: in spi'^i. r.^.-..^j-:-- /'^ 
 
 jB:E<,:EiJ^rrJ^. 
 
 On pac^e BS, lines 11, 12 and 13, should read as follows: 
 a Both by mandatory enforcement of proper rules and edu- 
 cational functions, scarcely any deaths should occur n. these 
 counties from the causes mentioned. 
 
 „._^^v. v.pun iTie lemaie portion of the population, 810 females 
 dying, to 531 males. 
 
 *In table XI is given the deaths from each of the ten causes, 
 by ages, and the total number of deaths from each cause. W 
 notice that 404 deaths occurred from these ten cause? diy^g 
 the first year of life, a greater number than occurred!/*^ ^ny 
 other year. This preponderance in number is chie^ ^'^'e to 
 an increase of deaths from whooping cough, spin9^^^'''"'^'Jgi- 
 tis, pneumonia and bronchitis. Dividing the age/\ "* P^nods 
 
 of ten 3'ears, we find the greatest mortality in^ 
 — 1,100; the next greatest number of death 
 agoa of 25 and 30 — 833. 
 
 No death from whooping cougu 
 
 first 
 
 pei-iod 
 
 between the 
 
 the 
 
 age of 18 
 
 o deaths from scarlet fever, 8 from dipUna, and 39 from 
 small-pox occurred after that age, while lOjaths from wlioop- 
 ing cough, 64 from scarlet fever, 153 frorfiphtheria, and 47 
 from small-pox occurred before the agd^l8. Of the 480 
 
 / 
 
 *Table omitted here. 
 
88 
 
 Tablo X gives by State, and each I'ounty, total deaths from 
 all causes. The deaths from each of the ten causes iu each 
 county. Also tlie pur cent, of the mortality from each cause 
 of death, to the total mortality iu the several counties. 
 
 All such causes of death arc in a great degree preventable. 
 A study of tlie tables will, we tliink, show that these pi'cvent- 
 able diseases exist in a greater degree iu the rural districts aud 
 scattered population than in those counties where the popula- 
 tion is more concentrated; whereas, with proper attention and 
 such care as Boards of Health exert, bntl. Ki' i>,...^ri.nf.^ 
 
 riiat the death-rate for these ten causes to the total mortality 
 iu nine counties having the most concentrated population is 
 below 40 per cent., while in twenty-nine counties, altogether 
 agricultural, with population less concentrated, the death-rate 
 exceeds 4U per cent. Such fact ought at once to settle the ques- 
 tion as to tile need of some means being used, in the rui'al dis- 
 tricts to prevent deaths from such preventable causes. If we 
 consider separately each of these ten causes of death, we find 
 that in the counties given to agriculture, and w here the popu- 
 lation is most scattered, the death-rate from nearly all these 
 preventable causes exceed that which is found to exist in coun- 
 ties witli population more concentrated. 
 
 The per cent, of deaths from Diphtheria iu seven counties of 
 scattered population, designated as (a,) average fi.o3 per cent.; 
 in seven counties of concentrated population, designated as (A), 
 it averaged 1.57 per cent. Deaths from whooping cough in 
 seven counties {a) averages ii.oV, in seven counties {b) 1.41. 
 
89 
 
 Deaths from scarlet fever in seven counties (n) averaged 4.4B 
 per cent.; in seven counties (/?) 1.41 per cent. 
 
 Deaths from typhoid fever in seven counties {a) 3.20 per 
 cent.; in seven counties (6) 3.20 per cent. Deaths from spot- 
 ted fever in seven counties (a) average 4.11 per cent.; in seven 
 counties (h) 1.71. Deaths from pneumonia and bronchitis 
 (acute hiug affections) in seven counties («), 25.60 per cent.; in 
 seven counties (6), 7.66 per cent. Deaths from consumption in 
 seven c©unties (a) average 17.74 per cent.; in seven counties (6) 
 12.21 per cent. Deaths from casualties in seven counties (a) 
 average 7.09; in seven counties (6), 4.75 per cent. 
 
 *If we examine tableXII that gives deaths by occupation, we 
 find that, as, reported, about one-half of the deaths from these 
 ten causes occurred among those we must class as farmers. In 
 this classification we must place one-half of those returned as 
 laborers, housekeepers, housewives, domestics, and those placed 
 as not reported. 
 
 Out of the 228 deaths from casualties, 80 were classed as 
 farmers; of the 840 deaths from pneumonia and bronchitis, 439 
 were of the class farmers; of the 340 deaths from typhoid 
 fever, 169 were farmers. Of deaths by consumption, 334 were 
 of the tarmer class. This cause of death showed its greatest 
 efi:ect upon the female portion of the population, 810 females 
 dying, to 531 males. 
 
 *In table XI is given the deaths from each of the ten causes, 
 by ages, and the total number of deaths from each cause. "W 
 notice that 404 deaths occurred from these ten causes du 
 the first year of life, a greJiter number than occurred iri any 
 other year. This preponderance in number is chie^r due to 
 an increase of deaths from whooping cough, spina^neningi- 
 tis, pneumonia and bronchitis. Dividing the ages into periods 
 of ten years, we tiiid the greatest mortality in tbp first period 
 — 1,100: the next greatest number of deaths j^between the 
 agoa nf 25 and 30— 833. 
 
 No death from whooping cougn occurs :,/jj# the age of 18 
 5 deaths from scarlet fever, 8 from dipXtrftria, and 39 from 
 small-pox occurred after that age, while lO^ftaths from whoop- 
 ing cough, 64 from scarlet fever, 153 from diphtheria, and 47 
 from small-pox occurred before the age :>f 18. Of the 480 
 
 ♦Table omitted here. 
 
 / 
 
40 
 
 (leathii from typhoid tcver, the majority occurred hetwecn the 
 ages of teji and -jO; from this cause the deaths of maU>s and 
 females are ahout ecjual in numher. Of deaths from spotted 
 fever, there were '2'jU; a majority (135) occurred hefore the age 
 of 10 years. More deaths occurred from consumption than 
 from an\- other of tlie ten rauses (1.841), and next to this, 
 })n(MinK)nia (1,094). I'nenmonia and hnmchitis. comhined, 
 shf)\v 1,286 deaths. 
 
 Ol" broncliitis, a majority of dcatlis (105) occurred ix'fore the 
 age of live years. The great(;st age at which death occurred 
 was 107 years. Two returns at this age, one a mahi, the cause 
 of death not being ohl age, but pneumonia, and one a female, 
 death from old age. There have been 102 deaths returned and 
 no ages given. Age is an important item in these statistics, 
 and sliould be returned in all cases. Deaths from early old 
 age generally have some additional reason for their apY)earance. 
 and care should be taken in returning facts in such cases. 
 Deaths of those under live years of age numl)er 21.19 per 
 cent, of the whole. 
 
 It can not fail to strike the attention that more deaths occur 
 from whooping cough than from scarlet fever. This is thought 
 to be rather a harndess disease, at least considered inevitable, 
 and the sooner the child has it the better, no care is taken of the 
 sufferer, acute <]isease of the lungs follows, and death is often 
 tlii^ result. The people need to be educated upon this subject, 
 .ind taught that proper care by pai-ents and nurses will prevent 
 a V^rge proportion of deaths from this cause. 
 
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