MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA. SESSION OF 1877. ADDRESS IN HYGIENE. PROPOSED ACT TO CREATE A STATE BOARD OE HEALTH. REPORT OF PHILADELPHIA COUNTY MEDICAL SOCIETY. DIAGNOSIS OF PSOAS ABSCESS. BENJAMIN LEE, A.M.,M.D. PHILADELPHIA: COLLINS, PRINTER, 7 05 JAYNE STREET. 1877. MEDICAL SOCIETY OP THE STATE OF PENNSYLVANIA. SESSION OF 1877. ADDRESS IN HYGIENE. PROPOSED ACT TO CREATE A STATE BOARD OE HEALTH. REPORT OF PHILADELPHIA COUNTY MEDICAL SOCIETY. DIAGNOSIS OF PSOAS ABSCESS. BENJAMIN LEE, PHILADELPHIA: COLLINS, PRINTER, 70 5 JAYNE STREET 1877. THE ADDRESS IN HYGIENE. It has been greatly the fashion during the past ten years, both in England and in this country, to stigmatize the heir apparent to the British throne, the wearer of the prince’s feather, as, to say the least, an altogether useless appendage to the national government. From such an opinion I humbly beg leave to dissent. I desire to express my conviction, that H. II. H. the Prince of Wales stands first among living men, not alone in his own noble realm, but in the civilized world, as a benefactor to humanity. Not as a mighty hunter, bearding the monarch of Bengalese forests in his native jungle from the safe elevation of a second story, or braving the peril of that deadly viper of Ceylon, the tic prolonga; not as a munificent Telemachus on his travels, bestowing largesses with princely hand on those who can well afford to return them with interest; not even as a philanthropist acting as chairman at a charity-dinner, would I urge his claim to this proud—this most enviable—distinction. I would rather ask you for a moment to contemplate him as a fever-stricken patient on his uneasy couch at Sandringham. I would call your attention to the hushed and mournful group outside the gates of the lodge, awaiting with such intense eagerness the posting of the frequent bulletin announcing that this life, which has suddenly become so dear to the nation that all its past errors are forgotten, is still spared. I would ask you to remember that this anxious assemblage is but a representation in miniature of the whole English people, hanging, by towns, by cities and by hamlets, on the hourly revelations of the telegraph : nay, that even distant continents, and, above all, this English-born and Eng- lish-speaking continent»of ours, throb hour by hour to the electric pulse that beats almost in unison with that of the royal sufferer— and then, when the long suspense is over, and cautious science dares to give the glad prophetic word of hope, to follow with me the steps of those sagacious physicians, who, believing their duty but 4 half done when they had met and vanquished the grim destroyer, by patient, pains-taking, jHjrsonal investigation, assured themselves of the causa teterrima, the lurking poison which had worked this strange infection in the Prince’s blood, and you will begin to appre- ciate what a powerful instrument for good this Prince has been. Sanitarians might have gone on preaching, and writing, and toiling, and striving, aye, and laying down their own lives (for noble Anstie’s death stands not alone as that of a martyr to sanitary science)—all this they might have done for half a century without producing ns profound an impression, without inducing as general a belief in the deadly properties of sewer gas and polluted water, as resulted from the illness of that one man. Now all England believes that typhoid fever at least may be produced by drinking water contaminated by sewage or sewage gas. Nor hus the lesson been lost u|k>ii our own country. Everywhere physicians are more on the alert to protect the sound as well as to heal the sick. Everywhere earnest, intelli- gent, and educated investigators are applying themselves to im- prove the sanitary conditions of our homes, and eradicate the hidden roots of pestilence and death. And an impulse of this kind, originating in an “experimentum in corpore” nubili, carried out in all its details to its legitimate conclusions, was greatly needed: for State Medicine, like many another tree whose leaves are for the healing of the nations, is a plant of recent growth. Sanitary legislation in England goes no further back than the Public Health Act of 1848, for although it is true that local authorities had made efforts, here and there, to improve the health conditions of their communities, and had even obtained par- liamentary enactments to enable them to suppress particular nui- sances, still no action had been taken looking toward a general sanitary supervision of the United Kingdom, or indicating that the government appreciated in the least degree the responsibility which rested upon it as the guardian of the life and health of its subjects.' As is the case with all legislation on this subject in free countries, the first law erred greatly on the side of laxity and timidity. It was permissive and suggestive rather than mandatory. The dread of trespassing on the rights of individuals led the legislators to hesitate to confer on the boards which they created, and the ofllcers whom they commissioned, the powers necessary to enforce the reform 1 The “ Factory Health and Morale Act," 42 George III,, paeaed in 1802, might be cited as an exception to this statement, but it was, although of general appli- cation, really local in its practical bearings, and designed to meet the crying evils existing in one or two great manufacturing towns. 5 measures which they urged and the necessity for which they at length became fully convinced of. This led to more positive legis- lation seven years later, under the title of the “ Nuisances Removal Act,” under the auspices of which, the health officers were enabled to sweep away many obnoxious establishments and remedy many abuses. Three years after this, the passage of the “ Local Government Act,” conferring increased powers on the authorities of towns and shires for the suppression of noxious industries,and the improvement of drainage, sewage, and domestic architecture, gave a new impulse to sanitary reform, bringing it more directly home to the people. An experience of the benefits to be derived from a systematic following up of the regulations suggested by the general health authorities, of careful study and investigation of the laws governing the distribu- tion of disease in large communities and over large tracts of country, prepared the public mind for the passage in 1866 of the “ Sanitary Act,” by means of which a much more thorough organization of sanitary administration was effected, and the central authorities were brought into more direct relation with local bodies and individual officials. Under this act much good work was done, many import- ant problems either solved or greatly elucidated, and as a substan- tial result, the annual death-rate very diminished in some parts of the kingdom—in certain large cities to a wonderful extent. Time, however, revealed defects in its practical working so serious, that further legislation* w*as urged by those most thoroughly ac- quainted with the subject, and this took shape in the “ Public Health Act of 1872.” Each of these separate enactments is still in force, save where it has been reinforced or superseded by the provisions of a subsequent act. It is of course greatly to be desired that they should all be collected and sifted, and, together with various minor and local laws which have accumulated under them and in pursuance of their requirements, put into a compact and solid shape, which will make them both more manageable and effective at home, and especially more useful as guides for those who are prosecuting similar labors at an earlier stage in other countries. It will be seen then that this great body of wise and discriminating laws on this important subject, with all the laborious and pains-taking observation and investigation, all the tedious and difficult statistical calculation, all the thankless and hard-fought battles w ith ignorance, prejudice, greed and self-interest, and finally all the notable victories gained and immense benefits conferred—all this has been the work of a single generation, and that but just passing off the stage of life. There is certainly a world of encouragement in this fact, for all those 6 who have felt disheartened at the slow propress which sanitary ideas are making in the minds of our people and government. If we turn from Old England to New England (matrit pulchrm filia, pulchrior) we shall find, in the history of the State Board of Health of Massachusetts, a source of even greater consolation. Its brief existence of seven years has been an uninterrupted succession of triumphs in favor of the health, happiness, and prolonged life of the inhabitants of that State. To such an extent is this true, that a learned jurist and careful statistician, a member of the legislature of that State, has pronounced the opinion, based upon careful calcu- lations, that in single villages the saving in money—not in life, not in health, not in happiness, or any such mere sentimental advantages, but in actual cash—in consequence of the existence and action of this board, amounted to more in a single }'ear than all the expenditures of the board for the entire State. We may not unprofltably take u hurried glance at their work, especially as the circumstances sur- rounding them, forms of State and local government, and charac- teristics of population, have many points in common with our own, making the problems which they have successfully solved much the same in form as well as in fact that our sanitary authorities will find themselves compelled to grapple with. The act establishing a State Board of Health in Massachusetts was passed June 21, 1869, and went into effect immediately. All of the liberal professions, with commerce, science, and literature, have been represented in its membership. There has been nothing one- sided, partisan, or bigoted, either in its constitution or its action. It began its work by sending out a circular explanatory of the then existing condition of the health laws of the State, what they author- ized. what they prevented, and what amount of actuul power they conferred on health officers. And now mark the wisdom which characterized the distribution of this circular. It was sent not only to mayors of cities, not only to members of the legislature, not only to physicians, but to every selectman of every town, and every clergyman throughout the commonwealth. In this way public en- lightenment at once commenced, and a public sentiment was created which sustained and even stimulated the reformatory zeal of the local authorities. The Declaration of lnde|>endence, which may almost be considered as a part of the constitutional law of the United States, guarantees to every individual certain inalienable rights—life, liberty, and the pursuit of happiness. The Board rightly argued that among these was included the inherent right of every citizen “ to the enjoyment of pure and uncontaminated air, and water, and soil,” and that it is the duty of the State to see that 7 no one should be allowed to trespass on this right, whether from negligence, from greed of gain, or even from ignorance. The abridgment of the rights or license of the individual for the sake of protecting the rights of the community is the very foundation stone of civilized life. Civil organization cannot exist without it. The people recognize this fact in reference to certain agencies which are dangerous to life and health, but strangely ignore it in reference to other agencies which are infinitely more destructive. Thus we prohibit the merchant from exercising his right of barter and sale and storage in the matter of explosives. He is. not allowed to keep any considerable quantity of gunpowder or nitro-glycerine within certain limits, or within a certain distance from an inhabited house. This is right and proper. But if a powder magazine had exploded in every street of Philadelphia on the first day of January, 1872, this calamity, frightful as it would have been, would not have caused as many deaths, would not have produced as much suffering, would not have inflicted as great pecuniary loss, as did the great epidemic of variola which was then raging. Thousands of lives, tens of thousands of maimed, disfigured, or invalided persons, millions of money; such was the cost of this explosion. A single pustule of smallpox virus, contains more powerful elements of destruction than a fifty pound can of nitro-glycerine; yet the one a man may retain in his house without the slightest remonstrance from the law, while the whole neighborhood would be up in arms against him for keeping the other, and the authorities would at once compel its removal. * A few years since, a flood of fire poured through the streets of a section of the city of Philadelphia. Men were headed off by rivers of liquid flame, and perished in frightful agony in full sight .of their fellows, powerless to rescue them—home after home melted and crisped and tottered to ruin before the blazing torrent spent itself. Public sentiment was greatly outraged, as well it might be, that so dangerous an industry as the refining and storing of petroleum should have been permitted in the heart of a populous city, and legislation was quickly invoked to banish it to the rural districts. But the citizens of Philadelphia are daily pouring down their throats a fluid which, in the course of a single month, burns up in the horrid torture of fever more victims from among them than the Southwark fire destroyed, and yet men go on pursuing industries which pollute the purity of the city’s water-supply, and the law is powerless to remove those industries. Why is public opinion so thoroughly aroused on the one question, so completely dormant on the other? Simply because in the one case it.is instructed, 8 in the other it is ignorant. It can trace the connection between a shattered corpse and an exploded powder keg; it is beginning dimly to do so between a bloated corpse and an empty whiskey bottle; but it utterly fails to do so between an emaciated fever smitten corpse and a glass of cold water. Hence the absolute necessity, if we would have •efficient administration of sanitary laws, for the instruction of the people in the simplest of the princi- ples of hygiene. We must create a sound and sensitive public sentiment in favor of the preservation and protection of the public health. And, at this foundation-stone the Massachusetts Hoard began its labors. Hut the Hoard was itself in need of instruction as to the sanitary conditions of the various centres of population throughout its juris- diction. This it sought by issuing a circular to the selectmen or health ofllcers of every town, requesting that some trustworthy physician should be recommended for appointment by the Board as its medical correspondent in that town. From the returns of these correspondents the Hoard was enabled at once to ascertain the existence, character and proportions of any epidemic that might occur. Preliminary measures having thus been satisfactorily taken, the Board felt itself to be sufficiently well understood and sup- ported by the public to enable it to attack sj»ecific evils. It first measured its strength with the fifty slaughter houses in the Brighton suburb of Boston, which, with their adjuncts, bone- boiling, fat-trying, refuse-rendering, etc., contaminated the air for miles around with foul odors and pernicious vapors. Tift' butchers of course made a strong fight, but persistence, wise management, and education carried the day; so that at the end of six years the Hoard was able to congratulate the citizens that this task was ended, and “a whole town rendered an agreeable and salubrious place of residence; while, at the same time, it had within its limits, though somewhat remote from its residences, an admirably conducted abattoir, which need never be a source of offence, and which was capable of supplying with meat all the inhabitants of the metro- politan district.” And the best of it is that none are more pleased with the new arrangement than the butchers themselves. The battle having thus been won by the State Hoard, the duty of main- taining the conquered rights was intruded to the local authorities, and the care of the abattoir transferred by legislative enactment to the City Hoard of Health. Similar action was successfully taken in regard to nuisances of this kind in other suburl* and towns, and “ such excellent results followed the frequent visits of ins|>ectioii to the large slaughtering 9 establishments, that the Board recommended to the Legislature, in their sixth and seventh annual reports, that some provisions should be rtiade by law providing for a regular inspection of all such works hereafter.” The sarutary condition of the homes of the poor early attracted their attention, and in spite of “ the utter indifference to the subject in the public mind,” and the unwillingness of politicians to inaugurate any movement, which owing to ignorance or prejudice would incur opposition and risk their tenure of office, they at length succeeded in obtaining a charter for a company, “whose object should be the building and hiring of suitable tenements for the poor.” When it was found impossible to induce city councils to undertake needed reforms, the Board carried its cause directly to the source of power, the citizens in mass-meeting assembled, and were invariably sustained the ballot. Each annual report has contained papers of great value, founded on original investigations by physicians appointed for the purpose, of subjects connected with the causation and prevention of disease, such as milk-, water- and food-supplies, trichiniasis, foot and mouth disease, river pollution, wall-paper poisoning, sewage disposal, alcoholic beverages, ventila- tion of school-houses, and so on. Ten thousand eight hundred of these reports are now printed for distribution each year, and in addi- tion to this, large editions of elementary instructive papers have been sown broadcast among the people. “Such has been, the written history in the barest abstract of the State Boaixl of Health of Massa- chusetts. Its unrecorded work can, of course, never be given to the public. It would be impossible to estimate the actual amount of public sanitary work which has, oftentimes unconsciously, owed its origin” to its wise counsels. “ In many cases hotly disputed questions of local importance have been quietly settled, and often- times even a threatened litigation has been avoided by an appeal to the Board, whose unbiased opinion has always been freely given when asked for.” We see then that its work has been mainly one of instruction. It has thrown out its feelers into every remotest nook and hamlet of the State. It has found out who could be relied on as intelligent agents, to keep it informed as to the sanitary con- dition of the inhabitants, and at the same time to diffuse among them such simple and practical information as they could both readily appreciate and easily apply. It has made use of every ordi- nary channel for the conveyance of knowledge to the public; the secular as well as the medical press, the clergyman as well as the physician, the forum and pulpit as well as the medical society. It has taken pains that the intelligence which it communicated should be at first hand—should possess the freshness, the sparkle, the enthu- 10 siasm, the reliability and the innate force, of persona! observation made upon the spot, dealing with facts which all to whom they came could verify. And in this way it lias commanded a respectful hear- ing for itself, and that hearing has brought conviction. It has carefully avoided conflict with local health authorities when that was possible; and when the honesty and purity of its intentions became manifest, that generally was possible. Work that it has begun and carried to a successful issue, it has turned over, so soon as they would undertake to carry it on in good faith, to the local authorities to perpetuate. It is always ready to counsel, never hasty to interfere. And to-day, throughout the whole common- wealth, there is entire accord between the health boards,committees, and otlicers of every town and city, ami the general board. I do not know how 1 could have presented to you in any more forcible way the subject which I desired to illustrate in this pajier, namely, the “ End and Scope of a State Hoard of Health,” than in this simple recital of the progress of sanitary legislation in the two most highly civilized populations of the old and the new world. Their evils are our evils, their difficulties will be our difficulties, and in the light of their experience we must meet them. It will not lie out of place, however, to refer to a few of the great problems which a general sanitary establishment, sustained by the weight of the State Government, can alone successfully co|>e w ith and which must early engage its attention. The first question which I would allude to in this view of the matter, is the harmonizing of the sanitary interests' of different but contiguous or otherwise related sections. It often hap|>ens that the sanitary undertakings of one city prove to be most insanitary in their results in regard to another city. The towns and cities which line the Schuylkill, for example, each most meritoriously washes itself in that limpid stream, and so far as it alone is concerned, does well; but unhappy Philadelphia, with the typhoid virus creeping through her veins with ever-increasing malignity, shudders as she unwillingly drinks their defiled washings, lienee the necessity for the consideration in a broad, generous spirit of the difficult problem of the u pollution of rivers,” and the determination of methods whereby one community may improve its own health conditions without impairing those of a neighbor. An admirable pa|>er will tie found in the Transactions of the American Public Health Associa- tion for 1875, by General Kgbert L. Viele, showing how tens of thousands of dollars have been squandered in a comparatively small district of the State of New Jersey, drained by the Passaic and Hackensack Rivers, and thickly set with large towns, in the almost 11 vain attempt to dispose in some satisfactory way of their sewage, from the fact that there has been no intelligent concert of action among different centres of population, and hence the efforts of one have been often completely thwarted by the operations of another in the same praiseworthy direction. Next, in an immense territory like our own, larger than that of many a nation of Europe, with its great diversity of surface and lofty mountain ranges, the question of drainage becomes one of paramount importance—in what directions tbe water shed shall be encouraged and in what diverted, and to what extent private cor- porations are to be allowed to jeopardize the health of large sections of the country by obstructing watercourses for the purposes of manufacture or navigation. Much interesting matter on this point is to be found in the reports of county societies, scattered through the volumes of the Transactions of this Society. The history of the so-called uDrowned Lands'’’ in Orange County, New York, and Sussex County, New Jersey, as given by Prof. Cook, State Geolo- gist, of New Jersey, before the Am. Pub. Health Association at its Baltimore Meeting, is also full of interest in this connection. The fact that so large a portion of our State is still in a wild, uncultivated condition, gives great opportunities for sanitary engi- neering on a large scale, and for preventing in this way the evils which so often follow in the train of a blind and disconnected occu- pation and cultivation of a territory. Especially in the matter of protection of forests is interference needed here. A wise discrimi- nation may be used in determining what forests act as natural barricades against the force of devastating winds, and should, there- fore, be untouched, and what ones interfere with the proper circula- tion of the atmosphere, and may, therefore, with safet)r be removed. The agency of forests in maintaining a permanent average rainfall throughout the year and thus preventing both drought and destruc- tive floods, cannot be gainsaid, and merits careful attention. But especially with a growing population is an opportunity offered for an immense amount of prospective sanitation to be accomplished in supervising the laying out of new towns. No town should be allowed to take the simplest corporate form, without laying before the health authorities of the State a carefully prepared plan of its hygienic provisions. Inquiry should be made into the character of the soil on wrhich it is proposed to found it, the quality and quantity of its water supply, the width of its streets, its projected sewage, whether its lines of sewage are easy and take advantage of natural watercourses, and are adapted also to assist in the drainage of the natural surface water, its regulations in regard to habitations, as 12 to space allowed to each, and space allowed in each, to height of rooms and to ventilation. All these are points which should not, in our day, be left to settle themselves haphazard ns emergencies arise, or as the streets of New York were originally laid out by the meanderings of meditative cows going to and from their pasture, but should, by a wise prevision, l>e arranged beforehand, and evils thus be easily and wholly averted, which when once the}' have become established, prove so diillcult of reined)'. The relations of the country to the city ns a purveyor must also be considered. The supply of fresh vegetables and pure milk to large communities is of the utmost importance, and should be infallibly insured. The transportation of live stock for food requires to be very carefully watched and regulated, both that none but healthy and therefore wholesome meat may lie exposed for sale, and that infectious and epidemic diseases may not l>e introduced among our native stock from other localities. Thus it will be seen, even from this hasty and bald summary, that, entirely apart from its function as an adviser and coadjutor of established local health l>oards and otllcers, an immense amount of independent and heretofore neglected work is waiting to be entered upon by a State Hoard of Hculth, work of the utmost importance for the future as well as the present well-being of our Common- wealth. In view of the fact that a bill for the establishment of such a board has been twice defeated in our Legislature (although at the last session it passed the Senate), I have ventured to draw up an act, which may avoid some of the features which rendered the others objectionable, and which, with the weighty indorsement of this So- ciety, would, I trust, have a fair chance of success. Extract from the Minutee. “Resolved, That this Society gives its official endorsement to the proposed bill introduced at the close of the Address in Hygiene, for the creation of a State Hoard of Health in this Commonwealth. “Iiesoloed, That the Committee on State Hoard of Health be instructed to present it through the appropriate committee to the Legislature at its next session.” AN ACT To create a State Board of Health, to provide for the registration of vital statistics, and to assign certain duties to local boards of health and health officers in this Commonwealth. Section 1. Be it enacted, by the Senate and House of Representa- tives of the Commonwealth of Pennsylvania in General Assembly met, and it is hereby enacted by the authority of the same, That the Governor, with the advice and consent of the Senate, shall, as soon as possible after the passage of this act, appoint six persons, five of whom shall be physicians, in the State, of good standing and of not less than ten years’ professional experience, and one of whom shall be a civil engineer of not less than ten years’ professional ex- perience, who, together with the Secretary of Internal Affairs, the Superintendent of Public Instruction, and the President of the Board of Health of the City of Philadelphia, shall constitute a board of health for the State, which board shall be denominated the u State Board of Health of Pennsylvania.” Of the six persons first ap- pointed, two shall serve for two years, two for four years, and two for six years from the first day of July next following their confir- mation, and the Governor shall hereafter biennially appoint, by and with the advice and consent of the Senate, two persons of the same professions as those whose terms of service have just expired, to be members of said State Board of Health, to hold their offices for six years from the first day of July next following their confirma- tion and until their successors are appointed, excepting the secretary, who shall continue in office as hereinafter provided; but any member may be reappointed. Any vacancy occurring in said board during a recess of the Legislature shall be filled by the Governor until the next regular session of the same. Section 2. As soon as possible after the appointment of the first six persons as aforesaid, they shall meet (on the call of the Secretary of Internal Affairs) in the office of the Secretary of the Common- wealth, and shall proceed under the direction of the latter officer to determine by lot which of them shall serve for the respective terms of two, four, and six years. Immediately before entering upon the duties of the office they shall, together with the President of the Board of Health of the City of Philadelphia, take the oath pre- 14 scribed for State ofllcers by the Constitution of the State, and shall file the same in the ofllce of the Secretary of the Commonwealth, who, upon receiving the said oath of ofllce, shall issue to each a cer- tificate of appointment for his respective term of office determined as aforesaid, upon receiving which they shall possess and exercise the powers and perform the duties of said board as defined in this act. Immediately after having taken the oath of office, they shall meet with the Secretary of Internal Affairs ami the Superintendent of Public Instruction, ami organize by electing one of said board, not already an officer of the State, to lie president, and by appointing a proper person, who shall be a physician of good standing, and of not less than ten years’ professional experience, to be secretary of said board. The president shall be elected annually. The secretary shall hold his appointment until removed by the appointment of a suc- cessor or otherwise, and shall be executive officer of said board, and shall receive an annual salary not to exceed three thousand dollars, which shall be paid him in the same manner that the salaries of other State officers are paid; and such necessary expenses as the Auditor General shall audit, on the presentation of an itemized account with vouchers annexed and the certificate of the board, shall be ullowed him. Xo member of the l»oard except the secretary shall, ns such, receive any salary, but the actual travelling and other expenses of any member, while engaged in the duties of the board, shall be allowed and paid, on presentation of an itemized account as afore- said. The board may elect one of its own members secretary, in which case the vacancy thus created shall be filled by the Governor in the same manner as a vacancy caused in any other way. Skction 3. The secretary shall keep a record of the transactions of the board ; shall have the custody of all books, papers, documents, and other property belonging to the board, which may be deposited in his office; shall, so far as practicable, communicate with other State boards of health, and with the local boards of health within this State; shall keep and file all reports received from such boards, and all correspondence of the office api>ertaining to the business of the board. He shall, so far as possible, aid in obtaining contribu- tions to the library and museum of the board. He shall prepare blank forms of returns, and such instructions as may be necessary, and forward them to the clerks of the several boards of health throughout the State. He shall collect information concerning vital statistics, knowledge respecting diseases, and all useful information on the subject of hygiene, and through an annual report, and other- wise, as the board may direct, shall disseminate such information among the people. 15 Section 4. The said board shall meet at least every three months’ and may also hold special meetings as frequently as the proper and efficient discharge of its duties shall require the same to be held, in the Capitol at Harrisburg (unless otherwise ordered), and the rules or by-laws shall provide for the giving of proper and timely notice of all such meetings to every member of the board. The Secretaiy of Internal Affairs shall provide and furnish such apart- ments and stationery as said board of health shall require in the discharge of its duties. A majority of the members of said board shall at any regular called or adjourned meeting organize and con- stitute a quorum for the transaction of business. Section 5. The State Board of Health shall have the general supervision of the interests of the health and life of the citizens of this State. They shall especially study the vital statistics of this State, and endeavor to make intelligent and profitable use of the collected records of deaths and of sickness among the people; they shall make sanitary investigations and inquiries respecting the causes of disease, and especially of epidemics ; the causes of mortalit}r, and the effects of localities, employments, conditions, ingesta, habits, and circumstances on the health of the people. They shall, when required by the governor or the legislature, and at such other times as they deem it best, institute inspections of public institutions throughout the State, and advise officers of the State, county, or local govern- ment, in regard to the location, drainage, water supply, disposal of excreta, heating and ventilation of such public institutions or build- ings. They shall from time to time recommend standard works on the subject of hygiene for the use of the schools of the State. Section 6. It shall be the duty of the State Board of Health to have the general supervision of the State system of registration of births, marriages, and deaths, to prepare the necessary methods and forms for obtaining and preserving such records, and to insure the faithful registration of the same in the several counties and in the central bureau of vital statistics at the capitol of the State. The said Board of Health shall recommend such forms and amendments of law as shall be deemed to be necessary for the thorough organiza- tion and efficiency of the registration of vital statistics throughout the State. The Secretary of said Board of Health shall be the superintendent of registration of vital statistics. As supervised by the said Board, the clerical duties and safe-keeping of the bureau of vital statistics thus created shall be provided for by the Secretary of Internal Affairs, who shall also provide and furnish such apart- ments and stationery as said Board shall require in the discharge of such duties at the capital of the State. 16 Section 7. It shall be the duty of all health officers and l»onrds of health in the State to communicate to said State Hoard of Health copies of all their reports and publications, also such sanitary infor- mation as may be useful, and said Hoard shall promptly cause all proper information in its possession to be sent to the local hea fth authorities of any city, village, or town in the State which may request the same, and shall add thereto Ruch useful suggestions as the experience of said Hoard may supply. And said Hoard is authorized to require reports and information (at such times, and of such facts, and generally of such nature and extent, relating to the safety of life and promotion of health, as its by-laws or rules may provide) from all public dispensaries, hospitals, asylums, infirmaries, prisons and schools, and from the managers, principals and ofllcers thereof, and from all other public institutions, their ofllcers ami managers, and from the proprietors, managers, lessees and occu- pants of all places of public resort in the State; but such reports and information shall only be required concerning matters or par- ticulars in resj)ect of which it may in its opinion need information for the proper discharge of its duties. Said Hoard shall, when requested by public authorities, or when they deem it best, advise officers of the State, county, or local government in regard to sani- tary drainage, and the location, drainage, ventilation, and sanitary provisions of an}* public institution, building, or public place. Section 8. It shall be the duty of the State Hoard to give all information that may be reasonably requested concerning any threatened danger to the public health to the health officer of the port of Philadelphia, quarantine physician and all other sanitary authorities in the State, who shall give the like information to said Hoard; and said Hoard and said officer, said quarantine physician and said sanitary' authorities, shall so far as legal and practicable co-operate together to prevent the spread of disease ami for the protection of life and the promotion of health within the sphere of their respective duties. Section 9. Said Hoard may from time to time engage suitable persons to render sanitary service and to make or supervise practical and scientific investigations and examinations requiring ex{>ert skill, and to prepare plans and reports relative thereto; and it is hereby made the duty of all boards, officers and agents having the control, charge or custody of any public structure, work, ground or erection, or of any plan, description, outlines, drawings or charts thereof, or relating thereto, made, kept, or controlled under any public authority, to permit and facilitate the examination and inspection, and the making of copies of the same by any officer or person by said Hoard 17 authorized ; and the members of said Board and such other officer or person as may at any time be by said Board authorized, may, without fee or hindrance, enter, examine, and survey all grounds, erections, vehicles, structures, apartments, buildings and places; but*no more than five thousand dollars in any one year shall be expended for such special sanitary service. Section 10. It shall be the duty of said Board, on or before the first Monday of December in each year, to make a report in writing to the Governor of this State upon the sanitary condition and pros- pects of the State, and such report shall set forth the action of the said Board and of its officers and agents and the names thereof for the past year, and may contain other useful information, and shall suggest any further legislative action or precaution deemed proper for the better protection of life and health, and the annual report of said Board shall also contain a detailed statement of the State Treasurer of all money paid out by or on account of said Board, and a detailed statement of the manner of its expenditure during the year last past, but its total expenditures shall not exceed the sum of eight thousand dollars in any one year. Section 11. The sum of eight thousand dollars ($8000) is hereby appropriated from the treasury for the purposes of this act, and the expenditures properly incurred by the authority of said Board and verified by affidavit, subject, however, to the limitations hereinbefore imposed, and shall be paid by the treasurer upon the warrant of the Auditof General. Section 12. This act shall take effect immediately, and all acts or parts of acts inconsistent herewith shall be and are hereby repealed. REPORT OF THE COMMITTEE ON METEOROLOGY AND EPIDEMICS OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY. The Meteorology of the year 1816 was exceptional. The ele- ments appeared to vie with each other in making the Centennial year of American national existence memorable in its natural pheno- mena as well as in its historic associations. Unseasonable mildness followed by gales of terrific violence, heat unparalleled in duration and degree balanced by cold both protracted and severe, consti- tuted a sequence as remarkable from a scientific point of view as it was prejudicial to health and promotive of a high rate of mortality. The December previous had been normal in temperature, but charac- terized by dampness and fog. The new year opened with the same peculiarities; but, as it progressed, the atmosphere became dryer, the sky clearer and the temperature higher, so that the month of January showed the very unusual monthly mean of 40.64° Fahr., 11.19° higher than that of January, 1815, and about 4° above the norm. The rainfall was very slight, amounting only to 1.63 inches, there having been but nine days on which rain or snow fell. This unusual continuance of fair and mild weather in mid-winter was noticeable as affording an opportunity, quite uninterrupted, of pro- secuting work on the buildings and grounds of the International Exhibition, and it was owing to this that the preparations were in such a state of forwardness when the opening day arrived. Although, several considerable falls of temperature and storms of tremendous violence, one at the beginning and one at the middle of the month,, took place in February, the monthly mean temperature was still high—31.21°, as compared with 29.51° in the previous year. In reference to the cause of this abnormally high thermometer, the Chief Signal Officer of the U. S. says in his Annual Report for 1816, “In general, it would seem, that during the present winter exten- sive areas of cold air have pressed outward from the northern and interior portions of the eastern and western continents, but owing to preponderating extent and influence of the former continent,, the air over the Atlantic has been pushed westward, so that there has 20 been a tendency towards higher pressures and moister, warmer air in the Southern ami Atlantic States.” March was more nearly normal in its meteorology than the two preceding months; cold and blustering, trying alike to the temper and the health; dust-storms alternating with pelting rains, heavy snows, and northeasterly gales, a temperature a fraction below that of January; nothing, in short, to l>c said in its favor so far as its immediate effect on health and comfort was concerned. Its rain- fall was great, and, added to that of February, amounted to eleven inches. During all these three months there were but seventeen days on which the mean temj>crature was below 32°, five in January, eight in February, and four in March, while the year before there were no less than forty-two such days during the corresponding period. April, May, and June were clear, dry, and delightful; although by the latter part of the last-named month a tendency to a steadily maintained high thermometer began to manifest itself, a foreshadow- ing of what the Centennial summer was to Ik?. The mean tempera- ture was above 81° in ten days during this month, and its monthly mean was 78.35°. And now followed a period of scorching, wither- ing, wilting, deadly heat, which, as it had no parallel in this portion of the habitable globe in the experience of living man, so will it remain forever branded into the memory of every one who endured its torture. It was memorable alike for its intensity, the wide ex- tent of the earth’s surface involved, and its long duration. On this continent, from Maine to Texas, from the Atlantic to the Pacific, the dog-star raged. For weeks together the mercury ranged above 90°, not rarely touching 100°, and on the 9th day of July reached 102°, the highest point attained for tw'enty-fivc years. The mean temperature of this day was 93J°. In Kurope, although the thermometer did not stand as high as here, the unusual character of the summer was not less marked. Numerous cases of sunstroke took place in the streets of London. A senator of France was prostrated by the heat in the legislative balls. Forty laborers died from the effects of heat in Seville. The streets of Madrid were absolutelj' empty during the heat of the day. Berlin, and many other Euro|Han capitals, were visited by a similar wave of caloric. One singular evidence of the protracted high temperature of the summer was the intense vitality and rapid increase of insect life, especially of a parasitic character. Domestic animals, particularly dogs, were infested with fleas to a most har- assing extent, and no amount of washing sufficed to free them of these torments. Careful housewives were driven to distraction by 21 the hosts of cimices lectularii, which, appearing out of every crack and crevice, swarmed in frightful numbers over their snowy sheets, driving sleep from the pillow, and defying all efforts at their extermi- nation. Flour and meal “bred worms” to an unprecedented extent. Biscuit and crackers were infested with the weevil. The specimens of grains, plants, and seeds which were sent to the International Exhibition from other countries developed animal life to such a degree that a committee of entomologists were appointed by the Academy of Natural Sciences to inquire into the character and number of the insects so introduced. These facts are mentioned as having a possible bearing on one theory of “causation of epidemics.” No attempt has been made to account for this remarkable dis- turbance of temperature equilibrium, but it is evident that the cause must have been one of very general operation, and, probably, extraneous to our atmosphere. It is at least a significant fact, in this connection that, as reported in “Nature” for June 22, 1876, “ According to the photographs taken daily at Montmartre by M. Janssen, no spots had been noticed on the sun up to that date since March 25th.” Not until late in the month of August was there any decided and continuous relief from this fierce outpouring of the solar rays. There were altogether forty-five days whose mean temperature was above 81°, the last one being the first day of September. The early summer was comparatively dry, but during August heavy falls of rain fook place, amounting in the course of the month to 8.09 inches, considerably more than for any other month in the year, and nearly one-fifth of the entire annual rainfall. The autumn months presented no unusual features, but December ushered in a period of severe and protracted cold. The mean temperature of the month was 28.70°, and ranged below the freezing point on twenty-one days. There were several storms of rain and sleet, but little snow, so that the earth in the country and the streets in the city were glazed with ice for weeks together. Notwithstanding this great reduction of temperature at the close of the year the annual means was 1.67° above the average for twenty-five years. The rain- fall, force of vapor, and relative humidity, were all somewhat less than usual for the year. To determine what effect these remarkable meteorological conditions had upon the health of the city, we turn now to Mortuary Tables Nos. 1 and 2, in which we have recorded the number of deaths assignable to certain of the more important diseases, such especially as are liable to be affected by atmospheric fluctuations in temperature and moisture, as well as the total 'num- ber of deaths occuring in each month. 22 MORTUARY TABLK NO. 1. January 1879. 1,344 1878. 1,402 February . 1,392 1,373 March . . 1,843 1,918 April . 1,377 1,336 May 1,393 1,662 June 1,769 1,441 July . 1,744 2,523 August. 1,926 1,525 September 1,175 MN October 1,165 1,565 November 1,092 1,242 December 1,580 1,242 Total 17,805 18,892 Deaths for each month in 1875 and 1876. Hut in order to compare the mortality of thin year intelligently with that of former years, we must first determine the population of the city. The census taken under the direction of Mayor Stokley in April gave a population of 817,448. This included, of course, the large number of (arsons brought to Philadelphia in connection with the preparations for the International Exhibition, but was exclusive of the host of visitors who poured into the city all through the six subsequent months, nnd who contributed their quota, although a small one in proportion to (heir numbers, to its mortality. The number of individual visitors your committee esti- mate at about two ami a half million. But it must l>e remem- bered that a considerable pro(>ortion of these lived within a few hours of the city, and did not even pass the night here, while even those w hose homes were distant, if they found themselves threat- ened with serious illness, would, in the majority of cases, at once start on their homeward journey, and thus would not add to the death list of the city if the attack proved fatal. Your committee cannot but think then that the population of 900,000 assumed by the medical director of the Exhibition (whose circulars will be found in the appendix) as a basis for estimating the comparative mortality of this and the other great cities of the world, is an exaggeration. Our normal rate of growth would have entitled us to an estimate of 825,000 up to the middle of the year, and if we allow 25,000 more on account of temporary residents, we shall be claiming all that we have a right to on this score. We assume then for the year an average population of 850,000. This is nearly 50,000 more than the population estimated for 1875, an increase of 23 one-sixteentli or six and a quarter per cent. Had the same general conditions then prevailed as in the previous year, our mortality should have been that of 1875 increased by this ratio, which would have made it 18,932. In point of fact, it was 18,892, or 40 less, while the atmospheric conditions were incomparably worse. The death-rate of the city for a considerable number of years has aver- aged 22.68 per 1000, or 44.15 persons living to one death. That of 1876 was 22.21 per 1000, or 45.02 persons living to one death. The actual mortality of our neighboring city of New York for the same year was 29,152, a death-rate of 27.23 per thousand, or 36.72 per- sons living to one death. In comparing the two years month b}r month, we find that the actual mortality was less in 1876 than in 1875, in five months, viz., February, April, June, August, and De- cember; that it was less than the allowable increase of six and a quarter per cent, in two months, viz., January and March; and that it exceeded the allowable increase in five months, viz., May, July, September, October, and November. It is not until May, therefore, that we notice any departure from our customary low rate of mor- tality. That of March was high as it always is, the highest excepting that of July, claiming 1918 victims, of whom about 800 were sacri- ficed to phthisis pulmonalis and acute pulmonary affections. This we always look for. But how shall we account for the excess of May? Your committee are inclined to attribute it to the intense excitement attendant upon the opening of the Exhibition and the immediate influx of visitors and increase of population. MORTUARY TABLE No. 2, Deaths from certain of the more important diseases, occurring in each month in 1876 S! ►“5 & crished from it during the season was 1173, a larger numl>er than ever liefore recorded with one exception, that of 1872, also a year of excessive and protracted heat. The closeness with which the mortality from this disease follows fluctuations of temperature, and the certainty with which it makes its appearance as soon as the requisite degree of beat is persistently maintained, seem to point this out as the sole essential factor in its production, and to indicate that the initial lesion is not in the alimentary canal, the result of improper alimentation, but in the nervous sj’stem. If this be so, it is evident that our thera|>cutic efforts should be addressed not to checking intestinal flux or modi- fying mucous secretion, but to diminishing bodily temperature, re- storing tone to the brain and spinal coni, and acting secondarily on the alimentary canal through the medium of the vaso-motor nerves It is an eloquent commentary on the abundance and wholesome- ness of the food supply of the city, that even with the immense and sudden increase of consumers, diarrlnea, dysentery, and cholera-mor- bus, usually aggravated by continued high temperature, prevailed to a less extent than the year before, and to a very slight extent as com- pared with their prevalence in other cities. Mild cases of intesti- nal disturbance were of course frequent, but these three diseases together are accountable for a mortality of only 2G2 for the entire year, and of these deaths 102 were among children ladow 5 years of age, only 80 occurring in individuals between the ages of twenty and sixty, while 70 took place above the latter age. This singling out of the extremes of life shows clearly that the heat was responsi- ble for the greater part of these affections. Of the excess of the mortality of this year over the previous one, amounting to 1087, nearly one-half occurred in early infancy, during the first twelve months of existence, and one-tenth, or 107, are set 25 down to old age. With the return of cold weather, phthisis began again to assert its lethal pre-eminence, having by the end of the year accomplished a death-roll of 2676, an increase of 317 over the pre- vious year, and by far the largest ever reached in this city. Acute diseases of the air-passages did not again reach the level of the opening of the year, the latter part of the winter being the time of their greatest prevalence. We have thus accounted for the increased mortality of the year satisfactorily by a consideration of those affections which are pecu- liarly under the influence of meteofological forces and without refer- ence to that important class of diseases which may prevail as— Epidemics.—Here we shall find that our gains and losses very nearly balance one another. We are at once enabled to strike off a grand total of 704 for Scarlet Fever. This disease began to lose its malignancy as the warm season came on, and by September had almost disappeared, the deaths for that month having been but five, nor did it again assume a threatening aspect. Diphtheria shows an increase over the already alarming figure of the year before of 52, but this increase is more apparent than real, for its alter ego, Croup, shows a corresponding decrease of 42 ; and as these affections are very similarly affected by atmospheric conditions, and were both prevalent in an epidemic degree, the infer- ence is not strained that the difference was one of nomenclature rather than of pathology, indicating a growing conviction on the part of the profession that croupal affections are essentially diph- theritic. These two diseases combined were the cause of death in 1094 cases, of whom only 21 were adults. The number of fatal cases in January was 124; it fell to 32 in July, and, with returning cold weather, gradually rose again to 99 in December. It is mortifying to be compelled to record that, notwithstanding the fearful lesson of the epidemic of 1871-72, notwithstanding the warning of the previous year in a slowly but steadily increasing mor- tality in our own city, notwithstanding the knowledge of the preva- lence of the disease as an epidemic in various parts of Europe, so lax are our sanitary laws, so powerless are our health authorities that this disease has again stolen a march on them, and intrenched itself firmly within our walls. A death-roll of 407 from this loathsome but entirely unnecessary pest, in a single year, may well afford food for reflection if not for indignation. In connection with this subject we rejoice to be able to say that a measure which was urged upon the authorities by this committee as long ago as the winter of 1871-72 has now been adopted, and that Philadelphia, after having existed for two hundred years (for she will 26 oelebrate her bi-centenninl only five j'ears henoe), and having a popu- lation of more than three-quarters of a million inhabitants, is at length supplied with a disinfecting station, at which clothing or furniture which has been exposed to contagion can Ik; thoroughly purified. This is a reform greatly needed, of the utmost value especially in regard to the spread of the scarlet fever and small|K)x, and it is greatly to be desired that the public should appreciate the importance of availing themselves of this new facility for their self-protection. The building, which is in the shape of an annex to the Municipal Hospital, owes its existence to the persistent efforts of Dr. Welch, the efficient physician of the hospital, and of the active medical members of the Hoard of Health, Drs. Ashurst and Ford, who them- selves drew the plans and superintended the erection of the building. It must be said that, in the event of a wide-spread epidemic, this single station would be altogether inadequate to the needs of the city. But it is confidently hoped that its utility will be so self- demonstrating as to result in the establishment of several agencies at points convenient to the different sections of the immense area included within the city limits. Whooping-cough and Measles were both mild, the former caus- ing 88 and the latter 53 deaths. The same immunity of the colored race from the last-named disease, at least in a fatal form, as has been adverted to in former reports, is still noteworthy. Cerebro-Spinal Meningitis, now thoroughly domesticated with us, carried off* about an average number, 85; of whom 68 were minors and 53 females. Malarial Fevers of all kinds prevailed to but a trifling extent; but Typhoid Fever was unquestionably present to a greater degree than in any year since 1865, the number of deaths from it amounting to 761. This is the more noticeable from the fact that the previous year showed a decided falling off" in the mortality from this disease. Indeed, j’our committee took occasion to congratulate the Society on this auspicious diminution, and to assign us its probable cause certain engineering operations calculated to improve the purity of our drinking water. To what are we to attribute this very con- siderable increase? Must we ascribe it to some purely local cause, or are we at liberty to connect it in any way with the meteorology of the year? As liearing closely upon this question, your com- mittee ask leave to quote a foreign authority treating of the existence of the same disease in a Kuropean capital, and to call attention to the fact that the fluctuations of the fever liear the same relation to those of temperature and moisture in his record that they are found 27 to do in our own experience. We quote, from the London Lancet of Jan. 13, 1817, a sketch of the recent epidemic of typhoid fever in Paris, by Dr. Bourdon, Physician to “ La Charity Hospital.” He says: “If we investigate the atmospheric conditions, which might be regarded as constituting the causes of this epidemic, it will be found that, in the months antecedent to the outbreak, the rainfall was below the average proper to this period of the year—that there had been in fact a great drought. The temperature rose as usual, and remained moderate for some time. On the 9th of June, how- ever, it suddenly increased, and continued excessively high until the 17th of August. On the 18th of August it fell considerably, and the rains began. In September the drought had passed away; 69 millimetres (2.76 inches) of rain fell. “The exacerbation of the disease distinctly coincided with the dryness and heat, and we may notice that the paroxysm is marked much more by the excess of the mortality than by the number of patients. It diminished with the cessation of the heat and dryness. The most severe cases occurred in August. The number of cases continued to augment subsequently to this period, but the relative mortality underwent a sudden reduction. “ Etiology.—The first question then is, Are we to regard these ex- ceptional atmospheric conditions as the cause of the epidemic? No doubt can be entertained that the lowering of the bed of water in the subsoil exposed a whole series of putrid foci, and that the exces- sively high temperature was well adapted to induce fermentation, and at the same time to favor the diffusion of the effluvia produced by causing an unusual amount of evaporation. May we not then attribute to the miasmata so developed the leading part in the genesis of the typhoid fever? Whatsoever may have been the influ- ence of this cause on the outbreak of the disease in August, the epidemic which had diminished during September and the beginning of October, burst forth with renewed intensity towards the middle of this month and continued to rage till November, so that the mor- tality which had fallen to 163 in October rose to 929 in November.” The highest mortality was 39 per cent. 28 MORTUARY TABLE No. 3. Typhoid Mortality of 1876 compared with that of 1875, and Typhoid Death-rate of 1876 compared with the average Typhoid l)eath-rate for ten yean. WA*D. Population. 1878. General Mortality. Typhoid. Mortality. Typhoid Ileal ha to 10,000 of popu- lation. 1873. 1870. 1873. 1876. Average. 1876. 1st . 38,794 896 914 18 32 4.12 8.24 21 . 28,242 729 640 15 21 4 55 7.43 3d . 20,255 463 462 11 11 4.01 6.43 4th . 20,545 629 656 13 16 6.03 7.78 5th . 18,972 450 4(4 8 17 4.27 8.96 6th . 12.i'7" 264 212 8 10 2.99 8.28 7th . 83,067 733 817 11 26 6.19 7.86 8th . 23,868 440 447 7 19 3.54 7.96 9th . 15,915 296 279 4 15 3.76 9.42 10th . 24,786 486 457 7 28 3.75 ILM Uth . 14,345 394 377 5 16 4.90 11.14 12th . 15,394 306 304 8 11 5.15 7.14 13th . 20,027 353 354 10 10 3.84 4.99 14th . 23,385 403 480 9 27 5.30 11.54 15th . 48,472 955 1,103 8 45 4.03 9.28 16th . 18,903 396 436 7 15 6.11 7.93 17th . 21.279 554 481 11 22 6. 10.33 18th . 28,286 680 706 28 39 6.58 13.79 19th and 31*t 69,499 1,713 1,713 74 81 7.44 11.65 20th and 29th 75,828 1,500 1,838 47 46 4.11 6.31 21nt . 18,097 402 393 4 7 4.28 :i *; 22d . 28,482 501 491 13 17 2.97 5.96 23d . 25,299 470 399 23 18 2.82 7.15 24th . 51,310 711 899 15 44 3.72 8.57 25th . 28,648 541 726 6 24 3.40 8.34 26th and 30th 56,842 1,132 1,782 21 41 3.39 7.21 27th . 22,457 1,017 1,226 15 32 5.11 14.24 28th . 24,381 392 473 13 8 5.09 3.24 Total . : • 17,805 18,892 419 761 It will be seen by reference to our tables, that our own outbreak begau a little earlier and continued a little longer before the inter- mission, just as our heated term did; but that the same abatement in the autumn and the same exacerbation in the early winter were observable here as there. Berlin at the same time suffered from a very serious outbreak of the same disease. Other American cities found the purity of their water supply seriously impaired by the heat and drought. A writer in the Sanitarian of Februarj', 1877, says of the Croton water in New York: “ So impure was it after a severe rainfall in July and August of the present (past) season that the press of the city devoted entire pages to complaints and to discussions of the subject. One of the most remarkable facts noted was, that while the rainfall was greater in the former month than in any other July since 1873, 29 the Croton supply was impure, and had a foul odor, not only through the entire month, but through the preceding one.” And yet, such is the force of local prejudice, that men could actually be found fatuous enough to bottle up this reeking fluid and bring it on to Philadelphia in order that they might not be com- pelled to drink the Schuylkill water. The report of the Maryland State Board of Health, by Dr. E. Lloyd Howard, mentions the occurrence in Baltimore last summer of an explosion of typho-malarial fever which cost the city fifty-nine lives, a large amount of suffering, and over eight thousand dollars. It was to be expected, then, that Philadelphia, having a water supply, it must be admitted, not above suspicion—to the impurities of which, indeed, these reports have not failed to allude in terms of strong reprobation and urgent warning for the past six years—and having already a fixed typhoid death-rate of somewhat more than one per diem, should, under the combined aggravation of drought and excessive heat, have this death-rate greatly increased. That of Paris was trebled by these causes, as has been shown. That of Philadelphia was not doubled. We escaped, therefore, quite as well as we had any right to expect, and do not need to look further for an explanation of this augmented mortality. But in order to deter- mine to what extent impurities in the Schuylkill may perhaps have been responsible, it will be of considerable importance to observe the localities in which the greatest increase occurred. Your committee last year determined with approximate accuracy the fever haunts of the city as indicated by the record of ten years. If the returns for the year under discussion correspond closely with the distribution thus determined, we may conclude that conditions already existing were simply intensified by the heat and drought. But if there are marked discrepancies, it becomes a matter of consequence to inquire into the meaning of these discrepancies. The first point which impresses us in glancing over our table of ward returns is the much more uniform dissemination of the disease throughout the entire city. Instead of confining itself to the Delaware front and certain densely crowded and notoriously insanitary sections, as heretofore, it has existed to an alarming extent in every quarter, and in some of the healthiest districts. The second is, that its increase in specified sections bears no relation to the general in- crease of mortality. The third—that while in the regions recog- nized as its favorite abodes, it manifests about such a rate of increase as the growth of population, and the unfavorable atmo- spheric conditions of the year would warrant us in anticipating, in portions of the city which have usually been comparatively free 30 from its ravages, it has far exceeded this rate. Tho first of these propositions is too much a matter of personal experience with every one present to need detailed proof. Of the second, the following are instances: The deaths from all causes in the Second Ward fell off from 729 in 1875 to 640 in 1876, while the deaths from typhoid increased from 15 to 21 ; the deaths from all causes in the Fifth Ward we're slightly reduced, those from typhoid were more than doubled ; a decided reduction of general mortality in the Ninth and Tenth Wards accompanied a nearly fourfold increase of typhoid, ami in the Eleventh Ward a more than threefold. On the other hand, in the Twenty-eighth Ward the death-rate increased from 392 to 473, and the typhoid deaths fell from 13 to 8. The only other ward in which there were fewer deaths from typhoid than in 1875 was the Twenty-third, where they were reduced from 23 to 18, while at the same time the general mortality diminished in nearly the same ratio. An addition of 338 to the whole number of deaths in the Twentieth (including the Twenty-ninth) Ward, comprised only one additional typhoid death. We may note in passing, however, singular coincidences of stationary death-rates in respect to both general and sj>ecific causes. In the Third Ward the mortality was practically identical in the two years, 463 and 462, and the typhoid mortality was also identical, 11 in both years. The same was true of the Thirteenth, in which the figures were 353 and 354 for the former, and 10 in both for the latter; and approximately of tho Nineteenth (including the Thirty-first), when the mortality was 1713 in !>oth years, and the typhoid mortality only increased from 74 to 81. The examples which illustrate the second are equally pertinent to the third proposition. The increase from 15 to 44 deaths from this .affection in the Twenty-fourth Ward, in which the Centennial buildings were situ- ated, does not surprise us. Its suddenly doubled population, its hastily erected dwellings, with their imperfect and often deficient sewerage, its immense areas of undrained land, often lying under stagnant water, and of newly upturned soil, all would lead to the anticipation of such an outbreak. but what shall we say of the Ninth, Tenth, and Fifteenth, contiguous wards, lying along the Schuylkill, every vantage in point of location, drainage, architecture, and (M)pulation, comprehending within their limits the residences of our wealthi- est citizens, and heretofore exhibiting the lowest death-rate from typhoid of any of the built-up parts of the city? Why does the Tenth suddenly advance from its average typhoid death-rate of 3.75 to 10,000 i>ersons living to one of 11.89, higher than that of the 31 Nineteenth, which is 11.65? We fear there can be but one answer to this question. The only factor in the production of this affection, so far as we know with positive assurance, which could have been materially increased either in quantity or efficiency, was infectious material in the drinking water, and the drinking water of all this section comes from Fairmount dam. The fact is a significant one that the increase was most marked in the Fifteenth Ward, jumping from eight up to forty-five, when we remember that this ward is principally supplied by the Spring Garden Water Works, which draw their supply from a point in the river acknowledged to be seriously contaminated by sewage. The drainage of a number of breweries into the river at a point above the dam is instanced. All the other conditions of this section— drainage, sewerage, cleanliness, food supply, etc., were as usual, and we cannot, therefore, look to them for an explanation. The intense heat, the long drought, the increasing population along the river banks, and especially the disturbance of the bottom of the stream by the immensely increased steam navigation during the summer, are sufficient to account for a decided increase in the morbific- material held in suspension in the water, without the supposition that the excrementitious sewage of the Exhibition grounds reached it in any appreciable quantity. But our report would, notwithstanding, not be complete without a reference to the so-called “ Centennial Sickness,” the fame of which certain sensational sheets, never friendly to the great enter- prise, took care to spread far and wide throughout the country. As seen in Philadelphians, independently of typhoid fever, it almost invariably assumed the diarrhoeal type, and wras very amen- able to treatment. In many instances each visit to the Exhibition was followed by an attack of looseness of the bowels, accompanied or not by nausea, which usually passed off in a day without further care than attention to the diet. After reading carefully all the authentic reports from medical observers which have appeared upon this subject, however, your committee are of the opinion that this affection was not one but many diseases—in one case simple diarrhoea, in another pure de- bility, in a third true typhoid, in a fourth typho-malarial fever, and so on—and that in a large proportion the visit to the Exhibition was but the spai’k which kindled morbific fuel already piled up in the system. They attribute their existence, beyond the obvious and sufficient causes of fatigue, exposure, excitement, and improper diet, to a poisonous condition of the atmosphere, in the buildings and about 32 the grounds of the Exhibition, owing, in the first plnce, to crowd- poisoning,—the emanations from such immense congregations of human beings, so closely packed together, vitiating the air beyond the power of any system of ventilation to purify it, especially when intense heat is stimulating the sudoriparous glands to the last degree of activity—even the open air becoming on some occasions notice* ably impure from this cause; and, in the second, to imperfect drainage and the want of proper sanitary precautions during the years of preparation. The chairman of this committee took occa- sion at three different times to call the attention of the Medical Director to evils of this nature, and has reason to believe that they were rectified in those particular instances. Hut the committee cannot but feel that the mistake of the Commission was, that it inaugurated and carried out this great undertaking, involving the lives and health of millions of their fellows, without appointing a single officer whose duty it was to superintend its engineering o|>cra- tions in the interests of public health—a sanitarian as such. It was not until the end of Novem!>er, 1875, that the accomplished Medical Director received his appointment, when too late to make any alteration in architectural or engineering sanitary arrangements; nor did his authority extend beyond the organization and control of a bureau of medical relief. The admirable efficiency of this service, and the dignified and unobtrusive manner in which its delicate duties were j»erfonned, must not be passed by in silence, but cannot atone for the previous culpable neglect of the Commission in this regard. It is not probable that any very large amount of fecal pollution reached the Schuylkill from the Exhibition grounds, but the impure condition of the atmosphere at many points, and esj>ccially in Lans- downe ravine where so many resorted to listen to the music of the bands, to rest and to lunch, was but too palpable to the sense of smell. While fully recognizing then the glaring defects in the sanitary provisions of the Exhibition, your committee felt that it was due both to Philadelphia and to the Commission, to point out the fnet that, on the other hand, a certain amount of mortality was inevi- table among the large numbers who thronged the city and the industrial palaces, and that the fact of a death occurring after a visit to the u Centennial,” was by no means a proof that the visit was the cause of the death. A careful estimate was, therefore, made of this inevitable mortality and published in one of the daily papers the early part of the present year, “in order to remove as far as possible any uncomfortable impression which might still 33 linger in the minds of those who had personal knowledge of cases of illness supposed to have been contracted there.” The problem proposed was this :— What number of deaths and what amount of sickness might have been naturally looked for among those who visited the International Exhibition from a distance? The factors of the problem were, first, the whole number of visitors; secondly, the normal dea‘th-rate for the United States, averaged for large and small towns and the country; and, thirdly, modifying cir- cumstances. It was considered that the 8,400,000 paid admissions indicated, making all due allowance for those from this city, a total of visitors from a distance of 2,300,000. Let us now endeavor to arrive at the nominal death-rate for such a host in a corresponding period of time. The death-rates of our gi’eat cities for the jrear 18t4, which was a favorable one in respect to public health, were as follows per thousand of living population: Yew York, 27.61; Philadelphia, 19.54; Brooklyn, 24.46; St. Louis, 16.27; Chicago, 20.31; Balti- more, 21.14 ; Boston, 23.60 ; Buffalo, 18.46 ; the highest being those of Charleston, S. C., 38.96, and Savannah, 35.38. Of exceptionally healthy small cities we may cite Syracuse, 15.20 ; Toledo, 10.90 ; (?) Hartford, 12.86, and Springfield, 111., 12.23, the average health of which is probably even better than that of country villages and rural districts. From these data we are justified in assuming for the entire country a death-rate of 18 per 1000, which means that of eveiy thousand persons living during a year, eighteen must inevi- tably die before the expiration of the year. (In this calculation we have not included the excessive mortality of the Southern cities, presumably the result of epidemic influences of an unusual charac- ter.) So much for the second factor. Third, the “modifying circumstances” to be taken into account are, first, incremental, viz , the season of the year, the unusual character of that season, and the prejudicial modes of life of the great majority of the visitors; secondly, largely subtrahendal, namely, the time of life at which most of them had arrived. First, incremental: It is a well-known fact, that during the summer months the mortality in all of our large cities invariably increases. During the past summer, owing to the exceptionally high temperature which pre- vailed (the average for July having been more than six degrees higher than that for the same month of last year), the increase was greater than usual. That of Yew York ran up to the alarming figure of 48.12, and of Brooklyn to 42.10, being 20 above the 34 annual average of the former, anil 17 above for the latter city. In commenting on anil accounting for this terrible mortality, that excel- lent journal, the Sanitarian, published in New York, says: The “heated term” is also found to seriously at feet the Croton; it Iwing the same term as the grazing, when the Croton’s tributary streams, with unprotected banks, traverse luxuriant meadows; when summer resorts distribute their sewage; when the “cattle upon a thousand hills” gently sloping to streams made picturesque by the revelling of geese and ducks, and sw ine cooling themselves in the margins— all permitted—make the water smell “ loud” and taste “ sapid.” Farther on, the same article speaks of the necessity for “ holding our breaths and biting our tongues lest we smell and taste the de- composing organic matter in the Croton.” The impure condition of the drinking water,-however, not peculiar to the city just men- tioned, is but one of numerous causes which render an American summer dangerous to human health and destructive to human life. We shall l>e extremely moderate if we allow 3 per 1000 additional on account of the season and as many more on account of the |>ecu- liarly fatal character of the season. Add to this the fact that the vast crowds visiting the Centennial arrived in the city worn out with travel and loss of sleep, endured excessive fatigue while here, exposed themselves rashly both to midday sun and evening damps, ate much indigestible and promiscuous food at unaccustomed hours, often going fasting when their systems were in an exhausted condi- tion—and all this under a cerebral pressure of intense excitement— and we have established another factor of increment at least equal in value to either of the other two. Our annual death-rate for this exceptionally trying |>eriod would thus advance from 18 to 27 per 1000, a little less than that of New York at all seasons. This is to be reduced one-half on account of infants and invalids not attending, which gives a death-rate of 13.50 per annum. That this is probably below the mark is indicated by the fact that the annual death-rate of the New York police force, a Ixsly of picked men at the age of greatest exjjectation of life, living under a strict regime and generally favorable hygienic conditions, is 15 per 1000. It still remains to be determined what length of time wc are to cover in our calculation. For, although all the Centennial visitors were living from the commencement of the Exhibition, and although large numbers of them arrived here with the seeds of disease in their systems, still we are not at liberty to bring them into the question until they passed the gates. A careful estimate of the admissions at different periods, leads to the conclusion that ten weeks will be an allowance erring upon the safe side. Now the rate which we have adopted for a year gives us 35 a rate of 2.6 for ten weeks. In other words: It was written in the inevitable decrees of Providence, more inexorable than the “ law of the Medes and Persians which altereth not,” that of every ten thousand of the eager multitudes who, month after month, were pressing onward with such glad anticipations to this wondrous con- course of earth’s peoples and exhibit of their products, at least twenty-six should step quickly down from the thronged and glittering palaces of Art and Industry into the silent chambers of the tomb. The Centennial Commissioners, able, sagacious, far-seeing, and provi- dent as they have proved themselves in many respects, had no power to stay this edict—could confer no brief immunity from nature’s laws. Recurring to our totals, we find that it was only natural, there- fore, to expect that up to the eleventh day of December, one month after the close of the Exhibition, six thousand deaths should have taken place among our returning guests, representing probably sixty thousand cases of illness of greater or less severity. It is natural also to expect that a certain proportion of these cases should have been typhoid fever. If we allow only .03 per cent., this will give us about one hundred and eighty deaths from this affection strictly, or in the neighborhood of two thousand cases. It is not surprising, therefore, that we should hear of a Centen- nial fever. Allow us, in conclusion, to present a typical case of this disease which came to the notice of a member of the committee: A family came on from a small town in Connecticut, and took rooms in a new hotel, hastily run up, just outside the Exhibition grounds. They visited the latter faithfully and conscientiously, as New Englanders will, remaining for about a week. The party was a large one, of all ages. Soon after their return home, it was reported that one of the children of the family was very ill with typho-malarial or gastric fever—unmistakable evidences of the insanitary conditions prevailing in West Philadelphia—but for an additional fact, which was afterwards learned, namely, that this child was the only member of the famity which did not go to Philadelphia at all, but remained at home in the salubrious air of its native town. The others all escaped. Not denying, then, that the sanitary administration of the Ex- hibition was open to severe criticism, 3'our committee wish to call attention to the fact that it was entirely unjust to expect, as seems to have been expected, that a visit to the Centennial should ensure the visitor a temporary immortality. BENJAMIN LEE, Chairman, A. D. HALL, R. BURNS. H. Y. EVANS, II. LEAMAN. 36 if Si ? r * ? < s ST CtJWfSK s.; s • gS [: *: *: I ' *f • ' : F5.?i e :»8tJ !|W Sl?|: ?b ?: : S 5.: • »i*: • i • • : *: : : ?: : : ,: : • • • • 22®“ 5; »• * * * •» ■ B * >5 : : £.: : b- • : • • • • • • • • • # ■» -stj f; ir=4* 5* 1 •* M m ?! = JT ?? >• 5. ; • S* !t t If f M * er 2 / ■ ► on B ssSssSSi 3SSsisa.2«?6 1s«3Ki3 1 Matos. *2i=S=S*SrS ” ! ” S “ t “ # 5 i i ” - 5 K v !j l! £ Female*. a*5 g28Sls = = i2-§A8S: S-SlSBIsj: 1 Boy*. !« « % ’/ 2 'i ‘i L" © i » 3 i i » > 8 » > 8 « — “ £ £ iS5 fl Olrl*. 8 = 1 SSiSsSstfSS: §.sr w • * « 8 K = Under 1 year. klttt SS2£*»w®*“’ S': S83S38 2 1 to 2 yearn. ~ » £5t13!2*S8S-2-«« • MMU 8: «i'lii 23 i M l* MM «- 2 to A yearn. MO ft t; T m — t 8-«28£ A to 10 yearn. O' • 9* *- <0 Id »a-i — g | 10 to 15 year*. M 8*: *.: 8S«** M MWOim T. '/ -. - — W Cl■ J > : *8 *» • a •-' / 8 = 3 I 15 to 20 yearn. 20 to 30 yearn. 8 I = 5«> 8 5 o>« — I a-** * = - ,i £ .4 • 4. 3 3 8 3 30 to 40 yearn 40 to 50 year*. id a t8u* ! u-s i A0 to 00 yearn. 8. SSSSa 8*1 ,« : .4 « - 00 to 70 yearn. V s8 !«S*: 38-.* * — •> 8 u 70 to 80 year*. 5« Sm«* o» OP 9» • •■* 4- * • • O : : -: C 80 to 90 year*. •4 *4 - 3 90 to 100 year*. • 5 100 to 110 year*. j _j IS i 5 3$$3s8S8 li i muh ?ints *89 ; w 2SS6SS 2S*3cii»t »«>mS kB»8s3 3 Ad nil*. Minora. I Total. U 8 • M *- V Ii M Sms*uS< People of color eSI* 8!tS|g*88«3'3*?s!«SsslSSsg 1 United Slate* as <5 8 V14 i* 8 5 — » V £ a «j — “ 8 8 S 3 »*Mwt i# Foreign. » 9$ SC»;Sh ii* — Soit)S« « a Uuknowu. MORTUARY TABLK No. 4. Death* from certain of the. more important disease*, tabulated in reference to Age, Color, and Nativity. 37 MORTUARY TABLE No. 5. Record of Causes of Death in the City of Philadelphia, from January 1, 1876, to January 1, 1877. (Abridged from the Tables of Dr. William H. Ford, Secretary of the Board of Health.) CAUSES OF DEATH. Total. '3 | Females. Boys. s | Under 1 year. 1 to 2 years. 2 to 5 years. Adults. Minors. People of color. United States. is* s» Foreign. 3. a o a X a A li. Causes 18,892 9848 9044 4964 4372 4551 1491 1590 9556 9,336 1027 14,022 3938 932 Specified Causes 18,812 9809 9003 4940 4358 4521 1488 1589 9514 9,298 1020 13,967 3917 928 Classes. I.—Zymotic diseases 4,761 2472 2289 1883 1729 1263 617 940 1149 3,612 177 4,199 463 99 II.—Constitutional diseases 4,194 2063 2131 678 640 698 202 120 2876 1,318 307 2,911 1036 247 III.—Local diseases 7.300 3910 3390 1782 1519 1722 606 489 3999 3,301 421 5,206 1749 345 IV.—Developmental diseases .... 1,913 f 96 1047 46S 407 788 51 14 1068 875 87 1,307 161 V.—Violent deaths 691 507 187 153 77 80 15 27 464 230 35 399 215 80 Orders. I.—1. Miasmatic diseases 4,627 2372 2255 1846 1714 1228 612 937 1067 3,560 173 4,123 433 71 2. Enthetic diseases 31 23 8 19 6 16 3 1 7 24 1 26 1 4 3. Dietic diseases So 61 21 7 4 4 1 1 74 11 3 32 29 94 4. Parasitic diseases 18 13 5 12 5 15 ] 1 ] 17 II.—1. Diathetic diseases .600 195 .305 24 28 10 4 15 448 52 26 273 189 38 2. Tubercular diseases 3,694 1868 1826 654 612 6S8 198 105 242S 1,266 281 2,638 847 209 III.—1. Diseases of nervous sys- tern 2,952 1641 1311 925 783 970 327 241 1244 1,708 141 2,291 549 112 2. Diseases of organs of cir- dilation 867 452 415 75 69 33 6 17 723 144 67 535 278 54 3. Diseases ot respiratory organs 1,945 1029 916 498 459 47 S 209 168 9S8 957 150 1,413 448 S4 4. Diseases of digestive or- gaus 1,055 535 520 231 176 231 61 47 648 407 37 706 323 20 5. Diseases ot urinary organs 370 223 147 40 25 4 3 14 305 65 18 194 113 63 6. Diseases of generative or- 72 3 69 1 2 09 0 42 26 7. Diseases of organs of loco- 24 18 6 8 2 14 10 14 8 8. Diseases of integument- ary system 15 9 6 4 3 6 1 8 7 1 11 4 IV.—1. Developmental diseases of children 158 86 72 S6 72 141 16 1 15S 158 2. Developmental diseases of 33 33 4 29 21 _ 3. Developmentaldiseasesof 599 210 389 2G1 4. Diseasesof nutrition .... 1,153 600 553 3«2 331 647 35 13 440 713 61 867 174 112 V.—1. 1 Accident or negligence .. 525 398 127 124 62 48 11 26 339 186 23 300 159 66 22 20 2 4 2 14 60 48 14 1 i 58 6. Violent deaths (not 7 4 3 Causes not specified or ill- defined 80 39 41 24 14 30 4 1 42 38 7 55 21 4 Class I.—Zymotic diseases 4,761 2472 2289 1883 1729 1263 617 940 1149 3,612 177 4,199 463 99 I.—Order 1. Miasmatic diseases 4,627 2372 2255 1840 1714 1228 612 937 1067 3,560 173 4,123 433 71 Smallpox 4u9 231 175 143 136 59 35 102 130 279 26 48 Measles 63 31 22 31 20 14 13 21 2 51 52 Scarlet fever 328 179 149 176 147 18 39 170 5 323 2 323 5 1 For want of definite information, some causes of death are placed uDder this order that properly belong under Order No. 4. 8 Order 2 comprises violent deaths in battle, and Is therefore omitted. 38 MORTUARY TABLK No. 5.—Continued. ta Nativity CAUSES OP DEATH. t c a 8 K U • c 8 K ffi i K i t l 7* i m * i s * K •9 ■ 2 2 3 m I i = x a f” X u - w < a. b Efa b Clarr I. Order 1.—Continu'd. 22 70S 310 308 330 380 33 118 312 is 800 701 7 • •• II 7 8 7 7 1 3 8 1 14 1 13 1 l 386 204 182 |0S iso 38 73 21H 3 383 4 392 • 4 ,SH 37 31 37 31 47 27 12 8S 2 89 27 12 13 2 8 19 9 .... 10 7 1 77.1 pH) 371 143 139 3 12 32 489 281 29 538 192 23 84 49 33 21 13 26 3 3 49 30 1 83 1.1 6 Al 34 3 40 3 3 33 10 2 0 6 3 9 4 3 4 i 3 1 1 1 1 2 2 3 1 78 43 S3 19 8 14 7 2 31 27 4 4.1 23 10 140 70 79 38 38 49 18 8 71 74 loo 38 13 IS 20 13 8 3 8 1 1 24 11 1 20 13 • •• 1173 834 339 634 33). 80.1 232 24 1173 8 4 1172 1 13 8 7 1 1 1 1 1.3 2 2 0 3 l 31 13 18 3 3 3 23 8 23 8 3.1 21 3 6 8 41 12 1 37 13 l Orvl.ro-aptnal niealogltlR... 83 32 3 31 37 18 10 16 17 68 2 70 3 1 43 22 23 11 3 3 3 7 29 10 2 20 13 3 23 8 13 3 4 2 1 18 7 1 13 7 i 2 1 23 | 1 1 1 7 1 2 I.—Order 2. Embetic . 31 8 18 6 18 3 1 24 1 26 1 4 27 19 8 14 0 10 3 1 7 2» 23 4 4 4 4 4 1 3 1 I.—Order 3. Dietle dliw>RROR 83 84 21 7 4 4 1 1 74 11 3 32 29 24 20 13 7 7 4 4 1 1 0 11 2 13 3 2 Alcoholism \ ( lutemp«rauc« ... 31 14 63 1 19 21 22 A 12 A 13 | 1 1 17 18 Tbro i Is 13 12 3 13 1 1 1 17 1 8 Clam II.—CoaRtilatloaal dl*MR*a 4,194 2083 2131 678 640 699 202 120 2878 1316 307 2,911 1036 247 II.—Order 1. Diathetic dla*>*i<«« 300 193 sai 24 28 10 4 13 448 32 2*1 273 189 38 4 1 4 4 120 38 73 10 13 3 2 108 *3 11 67 40 2 22 13 * 4 3 2 2 13 7 18 3 1 Cancer 310 107 *09 4 4 2 1 302 8 12 lit 138 31 2 2 1 2 2 Qau«reae 24 13 11 3 3 2 1 3 18 8 3 13 3 4 Leacocylbcmia 9 3 4 1 3 1 1 3 4 0 3 II.—Order2. TaberealardUcaM-. 3,894 1888 1828 634 612 688 198 103 21-28 1268 281 2,638 647 2»9 42 28 18 21 !< II s 8 12 to 1 as 3 3 811 431 380 421 .131 300 131 .18 .14 719 49 783 24 2 Dhthiaia pultaoaalla 2,877 1289 1388 113 209 26 19 19 2311 322 210 1.817 318 202 H ydrocepbaluR 184 lot 82 97 39 81 40 21 8 138 " loo 2 2 Clarr III.—Local dlaeaaea 7.300 3910 3390 1782 1319 1722 808 489 3990 3301 421 5,206 1749 343 HI.—Ordrr 1 XerroOR dlaeRRCR.. 1932 1841 1311 9V> 783 970 .127 241 1244 1708 141 2,201 319 112 4H| 272 218. 229 1st 1.17 loo 08 .... T-’ 2<> 430 31 7 )|jr«|i(|s 18 8 9 1 2 2 10 o .... lo 8 273 138 IS3 7 8 3 2 3 280 13 10 112 lit 17 303 148 130 14 10 3 2 ’ 8 291 24 12 101 91 23 10 3 7 1 0 1 1 .1 4 1 'r-*J ■ A 3 2 2 1 2 3 3 34 19 13 8 3 1 23 0 2 SO 4 10 89 4 ISO 414 43! 379 370 131 78 81 611 88 640 41 13 34 41 13 28 II 27 17 37 4 41 9 443 261 | 184 142 131 148 61 39 172 273 10 3ti 62 18 | 1 4 4 4 ■"•.I 9 • 3 2 7 2 4 5 130 99 31 9 9 11 2 2 112 1» 3 102 9 41 81. 9 Brain d!•»*•«, etc 291 184 127 33 49 48 24 13 189 201 76 >« 39 MORTUARY TABLE No. 5. — Continued. CAUSES OF DEATH. Total. V X s © X S Boys. Girls. | Under 1 year. | 1 to 2 years. j 2 to 5 years. 3 'TS < Minors. j People of color. Nativity. United StAtes. | Foreign. j Unknown. III.—Order 2. Diseases of organs of circulation 867 452 415 75 69 33 6 17 723 144 67 535 278 54 Pericariditis 106 46 60 17 16 2 5 73 33 6 78 22 6 20 16 4 20 3 8 8 4 21 8 13 3 1 18 3 1 14 6 1 Hypertrophy of heart 71 37 34 7 6 1 2 58 13 11 48 22 1 9 4 1 S 1 4 5 Heart disease, etc 640 341 299 50 44 31 5 9 546 94 46 383 215 42 III.—Order 3. Diseases of respi- ratory organs 1,945 1029 916 498 459 47S 209 168 988 957 150 1,413 418 84 Laryngitis 67 41 26 30 20 16 12 15 17 50 1 57 10 363 180 183 140 135 181 61 30 88 275 38 310 43 10 Pleurisy 89 55 34 12 10 6 2 5 67 22 8 45 35 9 Pneumonia 1,082 564 518 238 228 19S 108 94 616 466 80 768 263 51 Asthma 50 26 24 3 2 3 1 45 5 3 20 25 5 Lung disease, etc 294 163 131 75 64 74 26 23 155 139 20 213 72 9 III.—Order 4. Diseases of diges- tive organs 1,055 535 520 231 176 231 61 47 648 407 37 706 323 26 Pharyngitis 14 9 5 8 5 2 8 1 13 1 13 1 Gastritis 17 9 8 3 3 i 3 11 6 12 5 Enteritis 431 213 218 146 115 160 48 26 170 261 12 342 85 4 Peritonitis 133 52 81 12 7 4 1 114 19 7 77 53 3 38 10 28 2 5 3 31 7 5 19 IS 1 Ulceration of intestines 25 13 12 3 4 3 18 7 15 7 3 Hernia 28 14 14 3 2 1 25 3 2 20 7 1 47 28 19 15 6 17 26 21 2 30 15 2 23 13 10 8 4 9 11 12 17 6 8 2 (j 8 i 4 4 i 1 i i Stomach disease, etc 22 11 11 2 5 6 1 15 7 i 15 6 1 Disease of intestines, etc.... 32 16 16 l 5 7 1 2 20 12 22 10 Hepatitis 73 39 34 6 6 7 3 1 61 12 2 38 33 2 Jaundice 28 19 9 10 5 13 . v . . 1 13 15 19 8 1 131 82 49 4 6 5 2 121 10 4 5S 65 8 4 4 2 2 • 2 2 4 III.—Order 5. Diseases of urinary organs 370 223 147 40 25 4 3 14 305 65 IS 194 113 63 Nephritis 35 19 16 7 5 1 1 3 23 12 1 21 5 9 5 3 2 1 1 3 2 4 1 186 103 83 15 13 7 15S 28 15 88 60 38 19 9 10 i 2 1 16 3 12 6 1 30 23 7 3 1 1 26 4 18 9 3 Kidney disease, etc 95 66 29 13 3 2 2 3 79 16 2 51 32 12 III.—Order 6. Diseases of organs 72 3 69 1 2 69 3 6 42 26 4 7 7 7 1 3 3 1 65 3 62 1 2 62 3 5 39 23 3 III.—Order 7. Diseases of organs 24 18 6 8 2 1 14 10 1 14 8 2 Synovitis (arthritis) 2 2 1 1 1 1 1 22 16 6 7 2 1 9 i 13 8 1 III.—Order 8. Diseases of integu- mentary system 15 9 6 4 3 6 1 8 7 1 11 4 . . • Phlegmon 11 7 4 2 * 3 1 7 4 8 3 4 2 2 1 3 1 3 1 3 1 Class IV. — Developmental dis- eases 1,943 896 1047 468 407 788 51 14 1068 875 87 1,307 47f 161 IV.—Order 1. Developmental dis- 158 86 72 S6 72 141 16 1 158 4 158 102 55 47 55 47 96 1 102 3 102 11 5 11 11 11 17 10 7 10 7 17 17 17 Teething 2 15 13 15 13 17 11 28 1 28 40 MORTUARY TABLK No. 5.—Continued. CAUSES or DEATH. i i ■ i & 1 i i H u •o m U i K N § K •O 2 N i < i m m i Z * 1 Nat ii Ivlty f fiN | -UM^*0 IV.—Orphk 3. Developmental dta- 33 S3 4 29 4 21 9 3 1 1 1 I Childbirth 3 3 32 4 28 4 2 2o 9 3 IV.—Orkiir 3. Developmental die- im 210 3*'. .... 090 20 •j.ii 292 46 009 210 389 099 •jo 261 292 46 IV.—Ordkr 4. Dieoa-e* of nutrl- lion 1,103 600 003 382 331 647 31 13 4 40 713 61 867 174 112 Atrophy Rod debility 1,103 6U0 003 382 331 647 30 13 444) 713 61 867 174 112 Clam V.—Violent death* an 4 007 187 103 77 80 10 27 464 230 30 399 210 80 V.—Oriirr 1. Accident or negll- genre or. 398 127 124 62 48 11 26 339 186 23 3no 109 66 31 22 fl 3 2» 1 » 16 4 ii 11 0 6 0 1 7 4 Burn* and >cald* 68 23 40 12 24 3 4 13 32 36 6 02 10 i I’oloon 18 11 7 2 3 1 1 2 13 0 1 12 6 Drowning 111 99 12 30 4 2 1 72 39 7 06 22 33 Suffocation 286 M 04 67 31 42 8 11 188 98 7 164 94 28 22 2o 2 4 2 18 4 4 14 0 3 22 20 4 2 18 4 4 14 A 3 60 46 14 I 1 08 2 20 27 4 j7 17 4 21 11 ft 2 H 4 1 11 i 0 6 1 6 4 2 6 4 2 18 HI 2 1 17 1 6 11 1 3 1 2 3 3 V.—Oru»h 6 Violent death*(not 7 4 3 7 1 1 3 3 Canoe* not epeclfled o* 111- defined 80 39 41 24 14 30 4 1 42 38 7 00 21 4 41 1876. MONTHS. Thermometer. Iiain or melted snow. Clouds. Relative humidity. Maximum. Minimum. Mean daily range. Means. No. of days it fell. Amount Clear. Cloudy. Means of sky covered. j Maximum. Minimum. Means. 7 A.M. 2 P.M. 9 P. M. Monthly. | or less covered. 1 I More than | j covered. 7 A. M. 9 P. M. Monthly. 7 A. M. 2 P. M. 9 P. M. Monthly o o o o o O days inches days days p.C. p c. p.C. p. ot. p.C. p.c. p.c. p.c. p.c. p.ct. January, 69 18 8.01 37.44 44.77 39.73 40.64 9 1.63 9 22 63 67 52 60.5 93 17 68 48 62 59.4 February, 62 13 6.06 33.52 40.98 37.14 37.21 16 4.35 9 20 60 65 53 59.5 93 13 68 46 65 59.5 March, 69 16 6.59 36.13 44.28 40.06 40.16 12 6.65 9 22 60 66 52 59.3 93 17 66 43 62 57.3 April, 74 33 5.27 47.33 58.88 51.02 52.41 11 1.95 10 20 47 67 42 52.0 84 7 60 34 51 46.8 May, 87 37 6.24 59.10 71.21 63.21 64.51 10 3.79 9 22 57 64 47 56.1 88 21 65 45 63 57.6 June, 96 56 3.53 73.43 84.78 76-85 78.35 11 1.69 9 21 51 63 38 50.7 86 24 71 45 67 61.0 July, 102 65 3.09 78.98 88.66 81.87 83.17 11 4.54 8 - 23 39 63 45 49.0 85 30 65 42 62 56 5 August, 94 60 2.94 74.05 83.94 77.85 78.61 7 1.37 12 19 58 64 26 49.4 87 22 70 48 64 60.5 September, 90 52 3.87 64.17 72.07 67.28 67.84 18 8.09 6 24 68 69 56 64.3 89 28 72 56 68 65.4 October, 74 34 5.50 50.02 59.60 54.43 54.68 9 1.03 9 22 53 53 50 52.2 94 21 66 47 64 59.1 November, 76 27 4.48 46.02 51.87 48.22 48.70 13 5.50 5 25 68 69 58 65.2 100 30 70 59 69 66.2 December, 54 6 6.33 26.34 31.29 28.47 28.70 11 2.36 11 20 60 63 48 56.7 90 19 67 53 67 62.1 Annual max min total total sum sum max min means, 102 6 5.16 52.21 61.03 55.51 56.25 138 42.95 106 260 ' 57 64 47 56.3 100 7 67 47 64 59.3 Winter, 69 12 6.55 35.26 42.16 38.36 38.59 39 8.90 25 66 65 69 58 64.1 93 13 68 51 65 61.5 Spring, 87 16 6.03 47.52 58.12 51.43 52.36 33 12.39 28 64 55 66 47 55.8 93 7 62 41 59 53.9 Summer, 102 56 3.19 75.48 85.79 78.86 80.05 29 7.60 29 63 50 63 36 49.7 87 22 69 45 64 59.3 Autumn, 90 27 4.62 53.40 61.18 56.64 57.07 40 14.62 20 71 63 64 55 60.6 100 21 69 54 67 63.6 Means for max min an’ual an’ual an’ual an’ual max min 25 years, 102 —9 5.45 50.26 59.80 53.67 54.58 126 46.74 110 256 60 61 46 55.7 100 7 73 55 70 66.3 , METEOROLOGICAL TABLE No. 1. A General Abstract of the Meteorological Observations made at Philadelphia, Pa., during the year 1870. By James A. Kirkpatrick, A.M. Latitude 39° N. Longitude 75° 11£' W. from Greenwich. Barometer fount 55£ feet above mean tide in the Delaware River. The thermometer was highest, 102°, on the 9th of July. The warmest day was July 9th. Mean temperature 93^°. “ lowest, 6°, “ “ 10th of December. “ coldest “ “ Dec. 9th and 10. “ “ 16°. It will be seen that the maximum temperature, 1020, on the 9th of July was the highest for twenty-five years. 42 Fore* of vapor. Wind*. Barometer reduced to 32° Fahrenheit. 1876. Mesa*. S Mean*. MONTHS. a a j| * a a * si < *» M (6 M flu « Monthly. Monthly Kesullant. e “• 6* K a 0 a H ■ a a a a i £ • a a a M M ◄ *» M flu n M flu a> K 5 a a inch inch inch inch incli inch direction from times inches inches inch inches inches inches i uches January, .472 .046 .166 .171 .169 .169 8. 71° 53’ W. 30 547 29.491 .245 30.099 30.063 30.092 30.085 February, March, .406 .028 .142 .125 .154 .140 N. 39 34 W. 207 30.895 29.297 .265 30.099 30.059 30.065 30.074 .4 1 .035 .153 .136 .169 .153 N. 73 33 W. 308 30.448 29.185 .282 29.991 29.969 29.972 29.977 April, .542 .031 .192 .177 .202 .190 N. 63 26 W. 279 30.439 29.523 .165 29.975 29.912 29.941 29.943 May, .714 .091 .346 .359 .384 .363 8. 60 31 W. 184 30.376 29.679 .133 30.018 29.983 29.989 29.997 June, .867 .221 .596 .546 .621 .588 8. 38 6 W. 423 30.159 29.660 .065 29.967 29.936 29.932 29.945 July, .911 .284 .660 .573 .677 .636 N. 88 34 W. 258 80.S14 29.719 .092 29.962 29.925 29.928 29.938 August, .906 .188 .603 .557 .620 .593 N. 52 7 W. 72 30.173 29.760 .076 30.026 29.996 29.999 30.007 September, .775 .224 .438 .438 .463 .446 N. 30 15 W. 100 30.210 29.630 .142 29.951 29 917 29.925 29.931 October, .555 . .088 .253 .254 .289 .265 8. 79 S3 W. 315 30.374 29.565 .162 29.978 29.931 29.958 29.956 November, .507 .085 .232 .237 .244 .238 N. 34 34 W. 355 30.319 29.510 .153 29.937 28.889 29.904 29.910 l>eceml*er. .216 .027 .099 .093 .111 .101 N. 58 31 W. 3h0 :ocn obtained. A steam disinfecting chamber, such ns that proposed by Dr. Ksse, and in use in Berlin, has its advantages where steam is already in use. In the apparatus determined upon the heat is obtained from a cast-iron cockle situated in a cellar immediately under the hot-air chamber. The building is constructed of stone, pointed, and is one story high with a basement. It contains on one floor a bath-room, suj>- plied with hot and cold water, six feet by eight feet, communicating with a dressing-room, eight feet by ten feet; a fumigating chaml>er, six feet by eleven feet; and a hot-air chamber, eight feet by eleven feet. The fumigating chamber is made perfectly tight, so as to completely confine the gases liberated for the purposes of disinfec- tion. The articles to be purified are suspended, and exposed to the fumes of burning sulphur, or other gases, for hours, the length of time being regulated by the character of the substances submitted to the process. The hot-air chamber is eight feet wide and eleven feet long, and eight feet to the spring of the arch. The interior wall is built of brick, arched at the top, and is nine inches in thickness. Between it and the outside wall is an air space for the object of economizing the heat. The door is made of wrought-iron set in a cast-iron frame, so that the chamber is perfectly lire-proof. The furnace is placed in a chamber immediately under the floor, which is laid in tiles of stone, supported on an iron frame-work. The heated air passes directly through an adjustable grating near the centre of the floor, over which a soapstone screen is placed to protect the clothing from the direct rays of heat. The smoke flue passes around the chamber under the floor before entering the chimney. At the top of the chamber there is an owning provided with a valve for the es- cape of air into a shaft leading into the chimney. Cold air is admitted from below into the space around the furnace. Valves control the openings for entrance and exit of air, which can be managed without entering the chamber. The thermometer can be examined from the bath-room through a slit in the wall, covered by glass. A temperature of 280 degrees Fahrenheit can be maintained for any length of time. A tem|>erature of 344 degrees Fahrenheit has been reached; but above 250 degrees there is danget of scorch- ing the clothing, and there is no necessity for a higher degree of heat. “ The temperature at which infectious matter is rendered inert has lately been a subject of keen controversy, chiefly in relation to the temperature at which the vitality of living genus and minute 45 infusorial creatures is destroyed. The late Dr. Henry, of Manches- ter, demonstrated experimentally that the vitality of vaccine matter is destroyed at a temperature of 140 degrees Fahrenheit, and that the virus of scarlet fever is inert after being exposed to a heat 204 degrees Fahrenheit; but some of the lower organisms appear to be more tenacious of life, for, according to Dr. Crace Calvert, the com- mon vibrio will bear a temperature of nearly 300 degrees, and his black vibrio, which appears to be a very salamander of animalcules, is not killed by a heat of less than 400 degrees Fahrenheit. After a long investigation, however, before the des Sciences of Paris, it was unanimously agreed by all parties to the controversy of spontaneous genesis, that none of the lower organisms or their germs would resist in air a temperature of 130 degrees C. (= 266 degrees Fahrenheit), and in liquid a temperature of 110 degrees C. ( = 230 degrees Fahrenheit). This, indeed, was the temperature fixed by Pasteur himself, although many of the members thought that 100 degrees C. (=212 degrees Fahrenheit) was sufficiently high to destroy all vitality. In most cases, in fact, a temperature of 180 degrees Fahrenheit is sufficient to destroy infusorial life, for that will coagulate albumen, of which they are made. Assuming, however, that it is desirable to use as high a temperature as possible for disinfection, it is important to know what is the effect of heat on textile fabrics. Up to a temperature of 250 degrees Fahrenheit most of these fabrics are unchanged, unless the exposure is main- tained for many hours, when they become discolored and slightly brittle. Above this temperature the change is more marked, and with a dry heat of 300 degrees Fahrenheit cotton fabrics are slightly charred, and, therefore, spoiled. At 400 degrees they become dark brown, and crumble into powder when rubbed. At 500 degrees gaseous hydrocarbons are produced, and at 600 degrees all vegetable and animal tissues are converted into charcoal, with the evolution of empyreumatic oil and gas. It would seem, therefore, that, for practical purposes, a heat of 250 degrees, aided by a jet of steam, for the purpose of diffusing the temperature and helping its action, may be safely applied to textile fabrics.”1 In using the chamber, care must be taken that none of the articles are in contact with the walls or floor. Small articles are placed upon a wire grating; matti*esses and more bulky articles are sus- pended from the ceiling by means of clips composed of iron rods. The introduction of the disinfecting apparatus supplies a want that has long been a source of embarrassment. Not only is such an establishment needed for the proper treatment of the clothing of * The Right Use of Disinfectants, by Dr. H. Letheby, London. 46 SECTION THROUGH 0ISINFECTIN6 ANO FURNACE CHAMBERS BUILT BY A. W. RAND. DISINFECTING ANNEX TO MUNICIPAL HOSPITAL, PHILA. COAL CELLAR SMOKE FLUE FURNACE CHAMBER CELLAR PLAN DISINFECTING CHAMBER 8 X II BATH ROOM 6X8 TIRST STORY PLAN DRESSING ROOM 6 X 10 DAVIS E SUPPLEE, ARCHITECT. CHEMICAL ROOM 6 X II MAIN BUILDING 47 patients, and articles in use at the hospital, which cannot be tho- roughly disinfected bjr the ordinary process of washing, but it is also of great service in the management of clothing, beds, bedding, etc., sent to the hospital for the express purpose of disinfection. Heretofore it has been necessary to burn many articles which might otherwise have been preserved and returned. To prevent the spreading of contagion, the patients, before leaving the hospital, are compelled to take a bath, and are then supplied with non-infected clothing. As a public health measure it is important that greater facilities for disinfecting articles of clothing, etc., be provided for citizens, and for this object one or more disinfecting chambers should be es- tablished in other parts of the city. The charges could be regulated so as simply to cover the expense, or the work might be done gra- tuitously, for the same reason that vaccination is offered to the people free of charge. United States Centennial Commission. APPENDIX B. International Exhibition, 187H, Philadelphia. Bureau of Medical Service. Owing to the very large number of persons who contemplate a visit to Philadelphia during the coming summer, it seems important that the utmost publicity should be given to the facts bearing on the sanitary condition of the city. The following statistics, which have been obtained from the most authentic sources accessible, represent the mortality in some of the chief cities of the world during the past four or five years:— Number of years. Average population. Average total mortality. Average death-rate per thousand. Vienna . . . . , 5 648,560 20,424 31.42 New York .... 5 994,458 29,601 29.93 Berlin 4 950,000 28,420 29.91 London 5 3,284,488 76,741 23.33 Paris 4 1,851,792 42,724 23.06 Philadelphia.... 5 744,831 16,573 22.27 While thus showing an average rate of mortality more favorable than that found in any other city containing over 500,000 inhabi- tants, Philadelphia has recently (1874) attained a degree of health- fulness almost unparalleled, viz., with a population at that time of 775,000, the number of deaths was but 14,966, giving a death-rate of only 19.3 per thousand. These very favorable results are largely due to the abundant and cheap water-supply, and to the opportuni- ties given, even to the poorest citizens, for the enjoyment of pure 48 country air in the great Fairmount Park, which contains 2091 acres. The extent to which this is valued by the citizens may la* inferred from the fact that during the year 1875 the Park was visited by over eleven million persons. The most powerful influence of all, however, is the absence of that overcrowding of the population, which is the most fruitful source of sickness and death in many quarters of nearly all other large cities. This will be more clearly comprehended when it is remembered that the 817,488 inhabitants of Philadelphia are spread over an area of square miles, which are traversed by more than one thousand miles of streets and roads; and that tin* city contains, in addition to other kinds of buildings, 143,000 dwelling- houses occupied by families—a number exceeding by over 40,000 that of any other city in America. The climate of Philadelphia is also, on the whole, a favorable one, although presenting man}' of the ]>eculinritie8 common to inland localities. The mean annual temperature of the last ten years is 53.73° Fahrenheit; the average annual rainfall is about forty-five inches. The following table exhibits the mean temperature of each month for the past ten years, showing that the range is far less extreme than is found in many other less favorably situated localities:— Mean Temperature ( Fahrenheit) of each month during the patt ten yean. January .... 82.72° F. February . . . .88.12 “ March . . . . 80.16 “ April .... 58.30 ** May 68.24 “ June 73.54 “ July 78.74° F* August .... 75.02 “ September . . . 67.72 “ October .... 50.03 ** November . . . 48.84 ** December . . . 88.02 “ It is thus seen tliat only during the months of June, July, and August does the menu temperature rise to a high point. During this period there are very rarely any prevailing epidemic diseases; and the chief mortality occurs among children, es|iecially among the poorer classes. The health of Philadelphia at present is unusually good. Timely efforts have been made to secure an abundant water-supply to meet the great increase in the demand which must be expected this summer as compared with previous years. Constant watchfulness will be exercised by the authorities to maintain cleanliness, and to avoid or remove every possible cause of disease. Within the Exhibition grounds a rigid sanitary inspection will be maintained, under the control of the Bureau of Medical Service; and thus a guarantee will be afforded that no cause of infection or dis* ease will be allowed to occur through neglect of this importanlduty. The object of this circular has been to call attention to the unusual sanitary advantages of Philadelphia, and to the preparations which have been made to insure the highest possible degree of healthful- ness during the approaching Exhibition season. It is proposed to issue at certain intervals other circulars, announcing in an official and accurate manner the sanitary condition of the city, so that entire security may be felt by all who desire to visit the Centennial International Exhibition. WILLIAM PEPPER, M.D , 15th April, 1876. Medical Director. International Exhibition, 1876, Philadelphia. Bureau of Medical Service. In a former circular issued from this Department, the exception- ably favorable position which is occupied by Philadelphia, in com- parison with the other great cities of the world (i. e., cities contain- ing over 500,000 inhabitants), in regard to its sanitary advantages and average rate of mortality, was shown by carefully prepared statistics. In anticipation of the unusally large number of visitors who would be present in the city during the continuance of the International Exhibition, great efforts were made by the municipal authorities, as well as by those in charge of the Exhibition grounds, to obviate every cause of disease. The details of these arrangements will be published in the official reports of the various departments, which will appear after the close of the Exhibition. It is owing to their thoroughness that, despite the very severe and prolonged heat of June and July, and the vast number of unaccli- mated strangers constantly present in Philadelphia since the 10th of May, the general health of the city has been remarkably favor- able. With the exception of the four weeks ending July 22, the range of temperature for the past five months has been about the average. Thus, for the entire period of 20 weeks since May 10, the mean daily temperature has been 71.30° F., while the average for the same months during the past ten years has been 71.82° F. The mean temperature of the four weeks referred to (ending July 22), on the other hand, was 80°, 83°, 83°, and 81° respectively, giving an average for the month of 81.75° against 75.5° F., the mean tempera- ture of the corresponding period of the previous year. The following table, showing the relative mortality of Philadel- phia and some of the larger American and European cities, has been prepared with strict care from the official records. The periods selected for comparison correspond as closely as possible. It will be seen, on careful examination, that the past season has not been an unfavnrnlVIp nnp 49 50 CITIES. Estimated Population. Xo. of week* Included and dal* In 1878. Average mortality per week, from Typhoid Fever and Diarrhmal Affection*. Average mortality per week, from Zymotic Dl*ea- aee. Average mortality per week, from all rauaea. Annnal death-rate per 1010, daring week from Ty- phoid Fever and Diarrhtcal Affec- tion*. Annnal death-rate per 1000, daring week from Zy- motic Diaenaea. Annual death-rate per 1000, during week from all cauae*. LOXDOX. 3,254, -.MO 1873. 98 wwki Including lb* quarter euding June 19, and that ending Sept. 98 100.4 391 1487.4 1 88 .63 33.40 PHILADELPHIA. 900,000 90 week*, from week end- ing M»y 13, to week ending Sept 33, 1878 S3.8 119 408.4 4.84 6 47 33 48 CHICAGO. 490,000 17 week*, from week end- ing May 13, to week ending Sept. 9. 43 SO 198 844 91 34.37 BOSTO*. 349,000 18 week*, from week end- ing May 13, to week ending Sept. 9, 1878. 36.7 37.4 181 4.44 873 34.48 BALTIMORE. M0,000 19 week*, from week end- ing Mar 13, to week eoding Sept. 18. 1878. 48.9 481 173 M 891 837 24.80 PARIS. 1,831,799 34 week*. Including the quarter ending Jane93and Sept. 34. 1874. 84 896 1.74 39.16 BROOKLYX. 308,933 19 week*, from week end- ing May 13. to week ending Sept 33. 1878. 74.7 114 963 7.74 11.81 3891 HW TORE. 1,004,238 19 week a, from May IS, to Sept. 18 174.9 989 839.7 8.43 1874 30 73 BKKL1X. 930,000 M week*. Including Ibe quarter eoding June 30 and Sept. 30, 1873. 901 698 10 S3 • 34.33 51 It will be further observed that, as in the table published in the former circular, Philadelphia occupies an exceptionably favorable position. With the exception of London, whose rate of mortality is nearly identical, Philadelphia presents a considerably lower rate than any other of the great cities, while, in comparison with its nearest neighbors, New York and Brooklyn, its superiority is both striking and suggestive. In calculating the rate of mortality in Philadelphia during the past twenty weeks, the population has been estimated at 900,000. Those who have carefully studied the movement of its population, expect, however, that in consequence of the large influx of visitors, this estimate is below rather than above the mean daily population. It must further be borne in mind that, while a considerable portion of its more favored classes were as usual absent from Philadelphia during the summer months, the lower classes, among whom the mortality is always greater at this season of year, were largely rein- forced. If, in addition to this, it is considered that a comparatively large amount of sickness might have been expected among the vast throngs of unacclimated visitors reaching the city after long and hurried journeys, and exposed to excitement and excessive fatigue, the full significance of the remarkable table above given, will, it is hoped, be appreciated by all. As one of the most important factors in the maintenance of public health is the purity of the water sup- ply, it is with great satisfaction that we learn from the official report furnished by Dr. Charles M. Cresson, the distinguished ana- lytical chemist, that the purity of the water supplied from the Schuylkill River to the Exposition grounds and the neighborhood, is fully up to the standard of the past four years. As the summer months, during which time alone any fears could be entertained for the development of wide-spread disease, have passed with such gratifying results, it is not premature to express the feeling of thankfulness and congratulation, that during this important year, Philadelphia has been favored with the same ex- ceptionally low rate of mortality she has so long enjoyed. WILLIAM PEPPER, Medical Director. THE DIAGNOSIS OF PSOAS ABSCESS. The case which I am about to relate, while sufficiently important in itself to merit rehearsal, as indicating the value of mechanical treatment in cases where a lesion of the spine is suspected, derives its importance, in- the connection in which I introduce it, from the fact that up to the day on which I saw the patient, when I found him with a well-developed psoas abscess, none of the numerous physicians who had examined him had suspected its existence. As the diagnosis presented no difficulty to me, it occurred to me at the time that I should perhaps not be presuming if I should briefly place before the profession the modes by which I arrived at my conclusion. History.—I was called to the Girard House on Sunday* Feb. 28, 1875, to see the son of Mr. E. W. H., a resident of an interior town in this State. He was a well-developed, sturdy, thick-set boy of ten years; but pale, and with a countenance indicating past suffering and present anxiety. His parents were both living; the mother in good health, the father a sufferer from neuralgia and nocturnal pains in the tibia, probably periosteal in their seat. He had one brother and two sisters, all of whom were in fair health. When four years old he was attacked with whooping-cough, which he had very severely. From this time forward his parents noticed an alteration in his gait and carriage. He w*as awkward in his movements, and Could not run like other children. At two different times he had attacks of severe pain lasting for several days, originating in the left side and shoulder and extending around to the spine. The three physicians who saw him during these illnesses were unable to assign any cause for the paroxysms. In August, 1874, nine months before I saw him, he had met with a very severe fall from a hay-mow. The distance was almost fourteen feet, but the fall was somewhat broken by striking some steps on the way. The brunt of the blow was 2 THE DIAGNOSIS OF PSOAS ABSCESS. borne by the left ischium. The pain was severe at the time, and although he endeavored to make light of it, as boys will, he has since confessed to me that he was stiff lor a considerable length of time from its effects. Within a month after, he was attacked with acute pain in the left side of the abdomen, in the region of the descending colon. The agony was so intense that he was held on the lap for a week, the only relief being from strong pressure with the hand over the seat of pain. This pressure was kept up day and night. His sufferings continued for nearly three weeks; and it was six weeks before he was able to walk. When he did so, his gait was more awkward and his movements more constrained than ever. The family physician was inclined, from the seat of the pain, to ascribe it to inflammation of the colon, ami based his treatment on that suppo- sition. “ From time to time,” writes his father, “ he was seen by a great many physicians and many of them thought him incurable.” Matters went on in this way until about a month before, when it was noticed that his spine was curve* 1 to one side. His father then determined to bring him to Philadelphia for advice. He had been seen the day previous to m3' visit by a highly respectable surgeon, who pronounced the bo}f to lx* suffering from a trilling muscular contraction, and advised his father to take him home and let him run in the iields, and use Indian clubs and dumlvlxlls, promising that the dillioiilty w’ould wear off of itself with exercise and fresh air. Notwithstanding the entire absence of pain at this time, and the fact that the patient had a good appetite, and appeared well nourished, I was unable, even at the first glance, to take so favor- able a view of the case. And just here I desire to “embrace the occasion,” as our clerical friends sa}', to preach a short sermon on the danger of underrating the significance of muscular contraction. In m3' opinion, and it baa been arrived at, not without extended ob- servation and careful reflection, there is no such thing us a “trifling muscular contraction.” Persistent contraction of a muscle is always a serious matter. It means mischief. Mischief, sometimes, it is true, simpl3’ in its own substance, in the sha]>e of phlegmonous inflammation, when it will not be long in making its true nature apparent; but oftener—in the vast majorit3'of cases—mischief in an different and often distant organ—of which it is merely the reflection, and to the thoughtful observer, the index. It is the index, first, of obscure disease in the joints. Long before the attention of parents or sicians is called to the hip in the early stage of coxnlgia, the watchful hamstrings and gastrocnemius begin to contract aud, by slightly flexing the knee and elevating the heel, produce the peculiar limp which we have all of us learned to look THE DIAGNOSIS OP PSOAS ABSCESS. 3 upon as almost pathognomonic of that treacherous disease. Con- tractions about the knee alone lead ns to look for strumous disease in that joint, although it may have been entirely free from either pain or swelling. It is the index, secondly, of a cause of irritation in the course of a nerve trunk, or at its origin, or at its point of exit from the spinal foramen; or of disease, whether functional or organic, of the spinal cord, or even of the brain itself. It would be foreign to my purpose here to indicate the differentiation of the symptoms of these various phases of contraction of nervous origin. I will simply call attention to that very common form which goes under the misnomer of “ muscular rheumatism,” and for which, of late years, the more descriptive and non-commital name of myalgia has been proposed, and, still further to narrow it down, to that localiza- tion of it to which we assign the designation of stiff-neck in slighter, and torticollis or wry neck in severer cases. I believe that in all cases of obstinate torticollis, unless where the muscular tissue has itself been involved in injury or inflammation tending to suppura- tion, the lesion is in the spinal cord or in the nerve-trunk just after emission. In many cases I have been able to trace it back to a direct injury to the cervical spine, which had been forgotten by both parents and patient; in other cases, the connection of cause and effect had been so evident that they could not but notice it themselves. In the milder form I am strongly of the opinion that it depends upon a disturbance of the circulation of the spinal cord, dne to general exhaustion of the system. The local condition may be one of anaemia or of hypersemia, but the systemic condition is one of depression—and one of its most frequent causes is too much brain work or anxiety, often accompanied with loss of sleep. It is, therefore, if this view be correct, in no sense to be trifled with. Much the same cause operates lower down in the spinal column to produce lateral curvature. And how common is it in the early stage of this disease for the physician to slight the fears of the anxious mother; saying: “ Oh, it’s a trifle; let it alone; give her plenty of fresh air and exercise, and she’ll outgrow it.” I have rarely been consulted in a case of idiopathic lateral curvature, no matter how great the deformity, which had not gone through this experience. A British Review recently contained a superficial and rather ill- natured critique on a number of works on deformities, in which it took occasion to contrast in a very unfavorable light those physi- cians who are inclined to resort to the early use of mechanical appli- ances in such cases, with the “ high-toned practitioner” who says, in his grand, off-hand manner, “ My dear madam, there’s absolutely nothing the matter with your daughter. Take her to the country; 4 let her ride on horseback every day; make her tako a walk l>cforo breakfast, and drink plenty of milk”—with other well-meant plati- tudes—pockets his two guineas, and “ hears nothing more of the case.” It is true, he hears nothing moro of it, but the orthopanlist may, and too often does. For, after months or years of weary, pain- fid effort to follow out the prescribed regime, the unfortunate girl, now grown perhaps to womanhood, comes to bog him, if possible, to save from absolute wreck a form that might have been preserved a model of womanly beauty. Let us not, therefore, I urge, as we value our reputations as skilful diagnosticians, slight a muscular contrac- tion. Muscles don’t contract without a cause—a provocation. Sock out that cause. Determine that provocation. Let no nerve, Joint, or organ, which, by direct or by reflex influence, could possibly Imj implicated in its production go unexamined. When we have sub- jected all these possible sources to a rigid scrutiny, anil found them unoffending, then, and not until then, may we wisely venture to pronounce a contraction “trifling.” In the case of disease of the vertebra', it will be observed we have an opportunity for both sources of muscular irritation to come into play, namely, the articular and the nervous. But to return to our case. Condition.—When I entered the room the patient was lying dressed upon the bed. I observed, first, that he rose with gfeat difficulty, turning on to the side before attempting to sit up, and holding his shoulders quite stiff. I requested him to walk with his clothing still on, and found that he stooped forward considerably, keeping the knees bent, the heels flat on the floor, the left toe pointed in, and the buttocks much projected posteriorly, especially on the left side. He complained of no pain on walking, and could even step down heavily with either or both feet without apprehension. There was a tendency to rest the left hand on the knee of that side. 1 now directed him to strip, and examined him first standing. I found that when he straightened out the right leg the left foot was ruised from the floor, the hip being much and the knee slightly flexed. The spine was curved forward deeply in the lumbar region as in lordosis, but without any projection higher up. It also curved to the right, throwing the shoulders toward the left, and depressing that of the left side. I now made him sit down, when presto! every particle of spinal curvature vanished, and in place of the lordosis there was the slightest possible bulging of the lumbar spine backwards, and a certain degree of rigidity in the probulgcnt tract. It was evident, therefore, that the contraction producing the antero-lateral curvature was not in the muscles of the dorsum of the spine and trunk, but in those which flex the thigh on the pelvis, or nice eertta. THE DIAGNOSIS OP PSOAS AKSOKSS. THE DIAGNOSIS OF PSOAS ABSCESS. 5 Now the muscles which are concerned in the production of this movement are, on the one hand, the proper flexors of the thigh, whose contraction, plus certain other features, would indicate dis- ease of the hip-joint; or, on the other, the psoas with the iliacus, whose contraction, usually that of the former only, would point to an irritation of that muscle by inflammation and suppuration, either originating in itself or in the contiguous vertebrae, or by transmitted nervous action caused by such vertebral disease. I decided against the existence of hip disease, first, from the position of the limb; the heel was not raised in standing or walking ; the toes were turned in; and the trunk was flexed on the thigh, rather than the thigh upon the trunk; in other words, he bent the body forward rather than drew the limb up: secondly, from the absence, all through the case, of the characteristic starting pains at night, of flattening of the nates, of swelling about the joint, of pain in the knee, and of tender- ness on pressure directly behind the head of the bone or upwards from the foot. There was also freedom of motion of the hip-joint within limits. The contraction was, therefore, located in the psoas muscle. I did not need to go further for my own conviction. In fact, the history of the case—whooping-cough of severe grade, fol- lowed by rigid and awkward carriage with disinclination to run— had, in itself, almost decided me from the outset. But it was neces- sary to give the father, if possible, some more definite and palpable proof of the nature of the disease, as I believed it to exist. It was important to determine whether suppuration had actually taken place, and, if so, to what extent. I therefore caused the patient to lie down on the floor on the flat of his back. On making careful pressure with the points of the fingers directly above the ramus of the pubes on each side of the abdomen, I found that while on the right side my fingers descended at once over the edge of the pelvic brim into the fossa, on the left side they met with a firmly resistent surface about level with the brim, and that I was obliged to follow up this surface for a couple of inches before I could penetrate at all into the abdominal excavation. This tumor was smooth and even, elastic—under firm pressure presenting a sense of deep-seated fluc- tuation—and rounding off gradually at its upper end. The presence of abscess of the left psoas muscle was therefore fully demonstrated. I expressed the opinion that it originated in disease of the spine, caused immediately by the severe fall alluded to, but primarily by the succussion of the vertebrae and cartilages years before by the paroxysms of whooping-cough; and that treatment should, there- fore, be directed, not to the contacted muscle and limb, but to the spine. This view of the case was immediately accepted. I caused 6 T FT E DIAGNOSIS OF PSOAS AB8CESS. a spinal splint to l>c made which I applied five day" later, a matter of no little difficulty, owing to the excessive incurvation of the spine in standing and its excurvation in sitting. Ho at once, however, expressed himself as more comfortable, and his countenance betrayed less anxiety. I also supplied him with a spinal swing and a trapeze or hand swing, having instructed him in their use in my orthopedic gymnasium, and furnished written directions as to time and manner of exercising with them at home. He left the city in ten days, and I soon learned from his father that the accuracy of my diagnosis was called in question by the physicians who had seen him at home and in Heading. One reason especially urged for doubting it, was that when the boy was lying on his back, he could stretch out l>oth legs straight side by side. And this is so simple a difficulty, and yet so often proves a stumb- ling block, that I may be pardoned for calling your attention for a moment more particularly to its rationale. In making any ex- amination involving measurements of the skeleton, contractions, joint diseases, etc., always make it a point to place the patient on a hard surface, either a table, the floor, or a very firm couch,, never a feather-bed. Now, if the question is of hip-disease or psoas abscess, in other words, of anchylosis, fibrinous or muscular, of the hip-joint, slip one hand under the small of the bark—the patient lying supine, with the limbs stretched out ns straight as possible —and with the other slowly flex the sound limb. The pressure of the body upon the hand underneath it will continue absolutely unchanged. Repeat the experiment on the suspected limb, and if cither of these conditions exist, you will at once begin to feel the spine pressing more heavily upon the hand, and this pressure will increase the higher the leg is lifted. This test will often convince the examiner in a case of hip-disease in its early stage, when every diagnostic point is of importance, that the free motion which he appears at first to get through the diseased joint, in reality takes place through that of the opposite side, being transmitted through the pelvis. The affected limb, therefore, lies straight beside its fellow, because the lumbar spine has yielded to the weight of the thigh, arching upwards and tilting the |>elvis forwards. 1 corre- sponded both with the attending physician and with I)r. Cleaver, of Reading,giving the reasons for my opinion; and before the abscess made its way to the surface or passed outside the abdominal cavity, had the satisfaction of demonstrating its existence to them sepa- rately, at my office, on the person of the patient. I bad warned the father at the first interview, that although a j)Moa» abscess was sometimes absorbed under the employment of efficient THE DIAGNOSIS OP PSOAS ABSCESS. 7 support to the diseased spine, I could not promise any such result, and that in this instance, the pus would probably work its way down into the thigh and come to the surface in its upper third. I was not surprised, therefore, to have the bo}r brought down again, about the middle of November, nine months later, and to And a well-defined tense tumor of considerable size below Poupart’s ligament. This I aspirated on the 29th of November, assisted by Dr. Atkinson, Passed Assistant Surgeon Siegfried, and Assistant Surgeon Boyd, IT. S. N., Dr. Atkinson administering the anaesthetic. Owing to the excessive nervousness of the patient, I resorted to the expedient of putting him into a profound sleep with chloral hydrate before administering the ether, a first attempt to anaesthetize him having entirely failed. The aspiration was only partially successful owing to the shreds of necrosed tissue which continually blocked the needle, but about five ounces of unhealthy pus were removed through a wall of about an inch in thickness, and an injection of salicylic acid and iodine thrown in, in the hope of setting up a healthy action in the cavity. In this I was entirely disappointed. The pus soon began to re- accumulate and the swelling was by the end of a week larger than before. At the end of the second week the pus made its way the track of the needle and the abscess soon discharged freely. It' was dressed with a salicylic ointment, a poultice sprinkled with a salicylic lotion being occasionally used, and the whole carefully covered from the air with cotton wadding sprinkled with the same, and oil-silk smeared with salicylic oil. At the same time the Messrs. Wyeth made for me a salicylate of quinia, which he took in six-grain doses two or three times a day. The tendency of the opening to close -was obviated by the use of lint tents stiffened with salicylic cerate rolled into a small cylinder and introduced to the depth of about two inches. Hectic soon set in with night sweats, entire loss of appetite and excessive despondency. As his room at the La Pierre House was dark, gloomy, and very small, overlooking a narrow court, I had him removed to a private boarding-house, where he could have the benefit of sunshine and fresh air, and homely diet, and he soon began to improve. On the fourteenth of January, a month after the spontaneous discharge of the abscess, he left for home greatly improved. Under the efficient care of Dr. L3dle, of Philipsburg, with whom I corresponded in consultation, this im- provement continued with slight interruptions. During all this time he was never, day or night, without his spinal splint, which was the source of the greatest possible relief from pain in the back and leg. As soon as the abscess ceased to be a source of anxiety, I recommenced the systematic use of suspension, adding to his other 8 TII K DIAQNOSIS OF PSOAS ABHCR8B. apparatus the wheel-crutch, which was of much service in enabling him to regain the use of his limb. The first of May he again came to the city ami spent two weeks in my house, during which massage and movements of the limb were cautiously employed, but the con- traction was still very great and the abscess discharging somewhat. By the 10th of June “lie began to walk a little without the wheel- crutch, went out riding every day, and could sit up straight in a chair.” June 20th, his father writes, “ Dick can walk up and down stairs without assistanceand Septemlier l,“llis leg has healed up, his buck has grown very strong and quite straight, and he is only the least particle lame. We can hardly realize that it is the same Dick. He still uses all of his swings regularly.” He continued to improve without further interruption. His father writes, May 16, 1877, “ I wish very much that you could see Dick. He is now stronger than he ever was, in perfect health; his back entirely straight; never complains of the least pain, weakness, or soreness; takes the most violent exercise, and joins in the roughest kind of play. We were alwaj’s very careful to follow out your in- structions to the letter and to have him use his swings regularly.” This result I consider sulliciently bears out the statement with which this paper opened, that the case possesses an intrinsic interest as indicating the value of mechanical treatment, aud especially, I may add, of suspension in spinal atfectious. 1503 Spruce Street, Philadelphia, Juke 11, 1877.