T lIE 
NATIONAL BOARD OE HEALTH 
AND 
NATIONAL QUARANTINE. 
BY 
JOHN S. BILLINGS, M.D., 
SURGEON U. S. ARMY. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA,: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1 880. THE NATIONAL BOARD OF HEALTH, AND 
NATIONAL QUARANTINE. 
It has seemed good to the chairman of this Section that there 
should be presented to it, at this meeting, an account of the ori- 
gin and organization of the National Board of Health, in order 
that some account of this new medical departure shall form a 
part of the records of this body, so that Macaulay’s New 
Zealander will be able to prepare a full report on the subject, if 
he can only obtain a complete set of the “Transactions of the 
American Medical Association.” 
I have acceded to the request that I should prepare this paper, 
with some misgivings; but attempts to excuse myself have 
proved fruitless, and I can only say that I have done the best I 
could, with the very limited time at my disposal. 
That some form of a central sanitary organization must sooner 
or later be created by the United States, has long been foreseen 
by those who have given attention to such matters; but it is 
only within the last ten years that the discussions on this sub- 
ject have taken any definite form. In saying this, it is not 
meant to asseit that definite proposals for a national quarantine 
system have not been of a much older date. But a national 
quarantine system is by no means the equivalent of a national 
health organization,and the two will be considered as quite dis- 
tinct in this paper. Each has had its partisans and opponents— 
the one being in some cases arrayed against the other; and, in 
order to understand some of the controversies which have arisen 
with regard to the National Board of Health, it is essential to 
know that those in favor of such a board, may or may not favor 
a national quarantine; while some of those most prominent in 
urging the creation ot a national quarantine, have not onlv not 4 
NATIONAL BOARD OF HEALTH 
desired the organization of a National Board of Health, but 
have most strenuously opposed it. For more than eighty years, 
and in spite of repeated failures, attempts have from time to 
time been made to induce Congress to place under some depart- 
ment of the government the contro' or supervision of the quar- 
antine systems of the several ports of the United States. The 
immediate cause of these attempts has usually been the occur- 
rence—in some part of the country—of an epidemic of cholera 
or yellow fever, believed to be due to importation from abroad. 
The arguments in favor of a national quarantine system are 
well known. The various local systems of our several national 
maritime ports are not uniform as to time, carefulness of inspec- 
tion, or methods of treating infected ships; nor are the great 
majority of such ports either willing or able to meet the heavy 
expense of a really efficient quarantine system, which shall per- 
mit vessels to return to commerce with no more delay than is 
necessary to secure their proper inspection and thorough cleans- 
ing. If any port fails to keep up such a system, it to a great 
extent destroys the value of the quarantines of other ports, and 
of other places. Hence, the interior of Alabama has been infected 
through Florida ports; and Arkansas, Mississippi, and Tenn- 
essee are to a great extent dependent for safety upon what Hew 
Orleans may choose to do, and have suffered severely in conse- 
quence. The prevailing ideas, with regard to the powers of the 
general government, in this respect, may be briefly stated as fol- 
lows ; 
The United States, by virtue of the control which the consti- 
tution gives it over commerce with foreign nations, and between 
States, has the right to prevent ships coming from a foreign coun- 
try or from another State, from entering any port, unless they 
have complied with such regulations as it may prescribe. In 
like manner, it has the right to prevent any conveyance, person, 
or thing from passing from one State into another, unless such 
passage be made in accordance with the rules which it may 
establish. It cannot, however, undertake to interfere with con- 
veyances or persons going from one part of a State to another 
place in the same State. Whether it has a right to compel a 
State or city to admit a conveyance or person coming from foreign 
countries or other States, is a question upon which there is more 
difference of opinion among jurists; but at present the decided 
majority are of the opinion that it has no such right, and nearly AND NATIONAL QUARANTINE. 
5 
all those who think that it does possess such power are of opin- 
ion that it would be inexpedient to exercise it. 
As it is not proposed in this paper to give any account of the 
various efforts to secure a national quarantine system, except in 
so far as these have immediate relation to the origin of the pre- 
sent National Board of Health, it is sufficient to merely allude 
to the proceedings of the quarantine conventions held in 
1859-1860, as containing some interesting and valuable discus- 
sions on this subject. 
Let us now turn to the subject of a national health organiza- 
tion properly so called. 
In 1869 the fact that such a department of the Government 
would soon become necessary, together with its probable needs, 
were used as arguments before Congressional committees in favor 
of the formation of a large medical library in Washington, and 
the commencement of a complete collection of sanitary reports 
and statistics; and in the spring of 1870, in connection with re- 
ports to the Secretary of the Treasury upon the reorganization 
of the Marine Hospital service, the relations of a department of 
public health to the several medical departments of the Gov- 
ernment were briefly discussed. 
The first published scheme for such a department was the bill 
prepared by Dr. C. C. Cox in 1871. This bill as introduced into 
the Senate, in December, 1872, together with the report of Dr. 
Cox upon the necessity for a national sanitary bureau, will be 
found in the first volume of the reports of the American Public 
Health Association. 
This bill provided for the establishment, under the direction 
of the Department of the Interior, of a national sanitary bureau 
with a chief executive officer to be known as the commissioner 
of such bureau. His duties, which are specified at great length 
in the bill, may be summed up as being to collect information 
on all matters connected with sanitary science, and to report 
on the same from time to time. He was to appoint whatever 
additional officers might be required, including chief clerk, 
chemists, experts, etc. etc. 
There was a general feeling among sanitarians that this bill 
was not opportune, that the circumstances were such that it 
would lead to purely political appointments, and that the result 
would be upon the whole prejudicial to the cause of public 
hygiene. It, therefore, received little or no cordial support. 6 
NATIONAL BOARD OF HEALTH 
The American Public Health Association did not recommend 
its passage, and it was practically pigeon-holed in the Congres- 
sional committee to which it was referred. 
The yellow fever epidemic in 1873 resulted in the introduc- 
tion, by Hon. Mr. Bromberg, M. C. of Alabama, of a bill for a 
national quarantine, which bill was based mainly on the recom- 
mendations of Dr. Harvey Brown, U. S. A., who had in 1872 
made a report on quarantine on the Southern and Gulf coasts, 
in which he strongly urged the importance of a national system. 
During the winter of 1873-74 several conferences were held 
at Washington on the subject of a national health bureau and 
a national quarantine system. 
The discussions at these conferences made it clear that there 
were two distinct parties; the first represented by Mr. Brom- 
berg’s bill, which was to prevent the importation of contagious 
and infectious diseases into the United States—in other words, 
to secure quarantine alone. For this purpose the surgeon-gene- 
ral of the army, the surgeon-general of the navy, and the super- 
vising surgeon-general of marine hospitals were to constitute a 
board, whose duty it should be to prepare quarantine regulations 
which were to be enforced by an officer from one of these ser- 
vices to be detailed for that purpose. 
The other party urged that the utility of such a board would 
be comparatively small, and its existence probably brief. They 
desired that its scope should be made much wider, somewhat 
like that of the national sanitary bureau proposed by Dr. Cox, 
although they did not approve the placing such a bureau at that 
time under the control of any one man—-in other words, pre- 
ferred a board to a commissioner. 
The size of this board, the manner of selecting its members, 
its precise duties, and the amount which should be allowed for 
its support, were all subjects upon which it was found hard to 
reconcile the opposing views. 
Mr. Bromberg’s bill passed the House and failed in the Senate, 
not so much because of any active opposition as because of a re- 
quest made by Mr. Thurman, that it should be passed over to 
give time for reflection, and his statement of the difficulties of 
the question is worth quoting. He said; “ Every seaboard 
State, and I believe every State bordering on either of the great 
lakes, has its police and quarantine regulations for the preserva- 
tion of its people against any danger of vessels coming into port AND NATIONAL QUARANTINE. 
7 
with persons having infections diseases ; and those health regu- 
lations have been decided by the Supreme Court to be within 
lawful competency of the States to enact. If that is the case, 
there is a little trouble in knowing how the United States is to 
interfere. If the States have authority to make these regula- 
tions, and the United States has like authority, it is very easy 
to see what a conflict of jurisdiction might arise between the 
officers of the one and the officers of the other. If, on the 
other hand, the whole matter belongs to the States, then it 
ought to be left to them; but if it is one of those cases of con- 
current jurisdiction until Congress shall act, then the effect of 
the action of Congress would be to oust the State jurisdiction. 
It is a question of very great consequence, and I see that the 
committee in reporting the bill had felt that, and therefore pro- 
vided that the regulations to be made under this act shall not 
interfere with the regulations of the several States. But it 
seems to me that there is very great difficulty in that, for the 
health regulations of the States are different one from the other. 
The health regulations of Massachusetts are, perhaps, different 
from those of New York, and both of them different from those 
of South Carolina, or of Georgia, or of Louisiana. How this 
board is to make any general regulations that will be effective, 
and not interfere with the State regulations, I do not clearly 
perceive.” 
For a time this was the end of proposals for national quaran- 
tine legislation. 
Meanwhile, both in this Association and in the American 
Public Health Association, the subject of a National Board of 
Health, properly so-called, continued to be discussed, and in 
1875, Hr, H. I. Bowditch, of Boston, acting as chairman of the 
section of State Medicine and Public Hygiene, delivered an ad- 
dress before the Association, upon a future health council of the 
Nation, in which he began by the very emphatic declaration 
that, in his opinion, any attempt to establish a national council 
until there were State boards of health in every State, would 
not only be premature, but positively prejudicial to the very ob- 
ject which we all wish to gain. 
In this address, which will be found in Yol. 26 of our Trans- 
actions, after alluding to the preceding action of the Society on 
this subject, commencing in 1871, by the resolutions of Hr. 
Logan, he gave a summary of the prevailing opinions among 8 
NATIONAL BOARD OF HEALTH 
his correspondents in the various States and Territories. Ot 
seventeen of these, only two advised immediate action looking 
to the establishment of such a department. 
He then proposed a plan for a national health organization 
derived mainly from that sketched many years ago by Jeremy 
Bentham. The essential features of this plan were, first, a Sec- 
retary of Health, who should be a member of the Cabinet, and 
have control of all health matters in the nation, including the 
medical departments of the Army, Navy, and medical libraries 
and museums belonging to the country, etc.; second, a healtlj 
council, composed of one representative from each State, and 
four representatives at large, to be selected by this Association. 
This council was to have advisory powers simply, and to re- 
commend investigations of various kinds to the Secretary. 
The prevailing opinion in the Association and among the 
medical profession, continued to be that the time had not come 
for urging the establishment of any form of national health 
organization ; that there was great danger that if it were created 
the appointments would be made for political reasons, and that 
it was better to encourage the formation of State and local boards 
of health and wait until the people were educated up to seeing the 
importance and usefulness of such institutions. 
In 1878 the quarantine question again came to the front, and 
a law was enacted by Congress making it the duty of consular 
officers to inform the chief of the Marine Hospital Service of 
the date of departure and port of destination of any vessels leav- 
ing any foreign port where contagious or infectious diseases 
exist, for any port in the United States. 
The Surgeon-General of the Marine Hospital Service was 
charged with the execution of this act, with framing quaran- 
tine rules and regulations under it, and with issuing weekly 
bulletins of information collected by him. 
No funds, however, were appropriated for the purpose, and a 
proviso was inserted to the effect that his rules and regulations 
should not interfere with those of any State or local system— 
the result being that the law was practically a dead letter. 
Close upon this came the yellow fever epidemic of 1878, the 
formation, at the expense of Mrs. Elizabeth Thompson, of a 
commission to investigate this epidemic ; and the discussions by 
the American Public Health Association, in the latter part of 
November of that year, of so much of the report of this com- AND NATIONAL QUARANTINE. 
9 
mission as was then prepared. The resolutions adopted the 
Association at the close of the discussion may be taken as re- 
presenting the prevailing opinions of the time among sanita- 
rians, and three of these I will quote:— 
“3. That it is the duty of the general government to aid in the 
establishment of a practical and proper quarantine by all means 
in its power.” 
“ 5. That it is the duty of the general government to invite 
foreign nations to co-operate with it in the establishment of 
uniform and effective international quarantine regulations.” 
“6. That whatever may be the practical value of quarantine, 
there is no doubt of the importance and value of internal sani- 
tary measures in the prevention or modification of epidemic 
yellow fever, and that this Association strongly urges upon 
State and municipal authorities the great amount of responsi- 
bility which rests upon them on this account at times when no 
disease is prevalent or threatening.” 
As soon as Congress met in the following December, special 
committees on epidemic diseases were formed in both House and 
Senate, and the fact that such committees were found necessary 
is sufficient evidence of the slight attention which had been 
previously given to the subject of public health by Congress. 
A second yellow fever commission, composed of members of 
the House of Representatives, Senators, and physicians, includ- 
ing those who had been engaged on the work of the previous 
commission, was created, and proceeded to visit those places 
where the epidemic had prevailed, and to collect the opinions of 
the physicians of those localities as to the causes of the spread 
of the disease, and the best methods of preventing it. 
Before the report of the commission was complete, several 
bills relative to quarantine were introduced, of which the one 
presented by Senator Lamar, of Mississippi, may be taken as 
a type. This bill created a department of public health, abol- 
ished the office of Supervising Surgeon-General of the Marine 
Hospital Service, and provided for the appointment of a Direc- 
tor-General of Health, to be in charge of the department, and 
also of the Marine Hospital Service, who was to make and en- 
force all quarantine measures and regulations for the prevention 
of epidemic diseases, or to limit their spread. He was to receive 
a salary of $7500 per annum, and only to be removed from office 
upon a hearing before the Chief Justice of the United States. 10 
NATIONAL BOARD OF HEALTH 
The proposal to thus confer almost autocratic power upon a 
single man met with very general disapproval among sanitari- 
ans and medical men throughout the country. 
In January, 1879, the executive and advisory committees of 
the American Public Health Association issued a memorandum 
upon the legislation then pending in Congress relative to the 
public health, in which objection was made to any national 
legislation upon quarantine until more information should be 
obtained. 
It was recommended that Congress should at once provide for 
the organization of a national health commission, whose duty it 
should be to report to Congress, at the next session, a plan for 
a permanent national public health organization to take charge 
of any investigations into the causes and means of prevention 
of yellow fever, or other epidemic disease, which might be refer- 
red to it by Congress, and that said commission should not be 
burdened with any administrative duties not connected with 
the investigation referred to, nor should it be dependent upon 
or connected with any existing bureau or department of the 
government. 
It was urged that the future of public hygiene in this coun- 
try depends mainly upon the proper organization of State and 
local boards of health, and upon such recognition of their import- 
ance and utility by the people and their legislators, that the 
necessary means and powers shall be granted to them to enable 
them to properly perform their duties; that the general govern- 
ment can do much to stimulate and encourage the formation of 
such boards; and that an important part of the duty of the national 
health commission would be to point out what can best be done 
to forward this object. “Such boards can do good work, not 
only for their own locality, but for the nation ; and, if the nation 
will pay for this work, it will be most cheerfully done, especi- 
ally if a proper central health organization be arrived at with 
which they can co-operate, as we hope and believe will be the 
case, if the plan suggested be carried out.” 
A few weeks later the Congressional Yellow Fever Commis- 
sion presented its conclusions, recommending quarantine, and 
the formation of a chief health authority at Washington to 
supervise it. The result of this was the reporting of a bill by 
Senator Harris, of Tennessee, chairman of the Senate Committee AND NATIONAL QUARANTINE. 
11 
on Epidemics, which bill created a bureau of public health, hav- 
ing no duties other than those relating to quarantine. 
It also created the office of Director-General of Health, who 
was also to have charge of the Marine Hospital Service; but in 
connection with him there was to be established a board of 
health, to consist of seven members, to be appointed by the Pre- 
sident, and of the Surgeon-General of the Army and Navy, 
respectively. The Director-General of Health was to be ex officio 
president of the board. 
This board was to frame rules and regulations for quarantine, 
and in case the health officer at any port appointed by local 
authority refused to adopt and observe these rules and regula- 
tions, or in the opinion of the board of health neglected or failed 
to do so, then the Secretary of the Treasury was to appoint a 
health officer of the United States for such port to carry out 
such rules. 
This bill was quite as objectionable to the great majority of 
sanitarians as the Lamar bill, and met with so much opposition, 
both from this quarter and from those especially interested in 
State rights, that although it passed the Senate it was defeated 
in the House. 
In the mean time, Mr. McGowan, of Michigan, after consulta- 
tion with some sanitarians, introduced a bill just at the close of 
the session to establish a national board of health, and although 
this was strongly opposed by the Surgeon-General of the Marine 
Hospital Service up to the very last moment, it passed both 
House and Senate in the final hours of the session and became 
a law. 
This act created a National Board of Health, to consist of seven 
members appointed by the President, one medical officer of the 
army, one medical officer of the navy, one medical officer of the 
Marine Hospital Service, and one officer from the Department 
of Justice. 
The duties of the board were to obtain information upon all 
matters affecting the public health, and to advise the several 
departments of the Government, the executives of the several 
States, and the commissioners of the District of Columbia, 
on all questions submitted by them, or whenever in the opinion 
of the board such advice may tend to the preservation and im- 
provement of the public health. It was also directed in con- 
junction with the National Academy of Sciences to report to 12 
NATIONAL BOARD OF HEALTH 
Congress a plan for a national public health organization, giving 
special attention to the subject of quarantine, and consult with 
the principal sanitary organizations and sanitarians of the seve- 
ral States of the United States with regard to the matter. 
Under this act the present National Board of Health was for- 
mally organized on the 2d of April, 1879. 
In the mean time Congress had convened in extra session, and 
the representatives from the Southwest had insisted upon the 
necessity for national quarantine. 
Accordingly, an act was passed, approved June 2d, to prevent 
the introduction of contagious and infectious diseases into the 
United States—in other words, a National Quarantine Act. 
Besides its quarantine features, however, this act authorized 
the board to publish a weekly bulletin of the information and 
vital statistics collected by it, and made it the duty of our con- 
sular officers to furnish weekly reports as to the health of their 
stations. 
The operations of the board under what may be called its 
constituting act are not as well known as they should be, which 
is in part due to the fact that the board has not been able to 
obtain authority to print the full report of the investigations 
which have been made under its directions, and of its operations 
in an educational point of view. The most important of these 
have been;— 
Ist. The inquiry as to the best form of a national sanitary 
organization. 
2d. An investigation into yellow fever in Cuba. 
3d. The making prominent, both by precept and example, of 
the importance of sanitary surveys, with instructions as to 
methods. 
4th. Investigation on water and air analysis, on the operation 
of sewers, on food and drug adulterations, on diphtheria, on 
disinfectants, etc. 
Time is wanting to give any details of this work, but I must 
allude to the conclusions as to the best form of a national sani- 
tary organization for this country. After conferences and cor- 
respondence with the principal sanitary organizations and sani- 
tarians of the country, and with a number of our most prominent 
scientific men as represented in the National Academy of Sci- 
ence, the opinion was found to be almost unanimous that for 
the present the existing form of the National Board of Health AND NATIONAL QUARANTINE. 
13 
is as good as any, and that no change in it should be made until 
the desirability for such a change becomes much more apparent 
than it now is. 
In accordance with the law which created it, the board, in 
conjunction with the National Academy, advised Congress to 
this effect, recommending that for the present no change be 
made in the plan of organization of the board ; that it should 
continue the special investigations already commenced; and that, 
in addition to these, investigations should be undertaken by it 
or under its direction, upon the subjects of cholera, malaria, 
typhoid and typho-malarial fevers, diphtheria, and eerebro-spinal 
meningitis, and that it should also carry on sanitary surveys of 
places remarkably unhealthy or liable to become so. 
It was also advised that the Board should take steps to secure 
as far as possible throughout the country, uniformity in the 
methods of collecting and reporting vital statistics; and that to 
this end it should call a convention of representatives of the 
United States, State and local authorities especially engaged in 
the collecting and reporting such statistics, with a view to se- 
curing agreement upon this subject. 
This recommendation has been carried out, and the convention 
met at Washington on the 6th and 7th of May last. It adopted 
provisionally the nomenclature of the Royal College of Physi- 
cians of London, and appointed a committee to confer with the 
College, and more especially with its committee, which, it is 
supposed, is now engaged in the decennial revision of said no- 
menclature, with the view of obtaining, if possible, for all Eng- 
lish speaking people, a uniform system. You are all aware of 
the attempts made by this Association, a few years ago, to make 
an improvement upon this nomenclature of the Royal College 
of Physicians, and of the fact that the whole matter was finally 
tabled and led to nothing. 
The proposition which is now made by the Rational Board of 
Health and by the convention called by it, is to adopt provision- 
ally this nomenclature, as far as it goes ; leaving every one when 
he meets with a case which is not fairly represented in this list, 
to select such name as may seem good to him; and to endeavor 
to co operate with the college in revising and making addi- 
tions to the nomenclature to correspond with the additions of 
modern pathology, and ultimately to organize some form of 14 
NATIONAL BOARD OF HEALTH 
standing committee for this country, which shall join with the 
college in revisions at stated periods. 
It is very desirable that this Association should interest itself 
in this matter, and should appoint a committee to co-operate 
and advise in the revision proposed, and I would suggest that a 
resolution should be reported from this Section to the Associa- 
tion for the appointment of a committee for the purpose of co- 
operating with the two committees above referred to, and with 
the National Board of Health, in regard to these matters. 
The convention also took steps to secure uniformity in the 
forms of certificates of births, deaths, and marriages, and in 
the methods of recording and tabulating these, which in due 
time will probably lead to improvements in the vital statistics 
of the country. 
The preliminary report of the Havana Yellow Fever Com- 
mission is, no doubt, familiar to all. The most important part 
of this work was to destroy a large number of unfounded theo- 
ries, and to clear the ground for future work in definite directions, 
such, for instance, as has been pointed out by Hr, Woodward in 
his report on the Histological Pathology of Yellow Fever, pub- 
lished by the board as Supplement Ho. 4 to the Bulletin, 
Advancement in this direction can only be hoped for from spe- 
cially trained observers, and the board proposes to take steps to 
have at least one observer properly fitted for this purpose to 
continue the research. In the mean time researches are now 
being made by the aid of photomicrography in Hew Orleans 
with regard to suspended matters and minute organisms in the 
air of that city and the marshes of the vicinity, and these pho- 
tographs will be compared with other photographs, collected in 
like manner, if the fever appears at that point or vicinity. 
The investigation into the flow of sewers, made at the request 
of the board, by Col. Geo, E, Waring, has already had the im- 
portant practical result of leading the authorities of Memphis 
to accept the system of sewerage which was within their means 
as adequate to the wants of the city, instead of a system which 
would have cost nearly five times as much. The investigation 
now in progress as to the best methods of determining both quan- 
titatively and qualitatively organic matters in the air under the 
direction of Prof. Remsen, of the Johns Plopkins University, is 
also one from which in the future important results may be 
hoped for. AND NATIONAL QUARANTINE. 
15 
Tims far the work has mainly been in the nature of criticism 
showing the unreliability of methods of analysis heretofore 
used. During the coming year it is proposed by the board to 
undertake investigation into diphtheria and malaria, and more 
especially into the pernicious forms of malaria, and those accom- 
panied by hemorrhages. 
Prof. H. C. Wood, of Philadelphia, is now engaged in a series 
of experiments to determine the possibility of communicating 
diphtheria to animals. 
In all such investigations it should be remembered that nega- 
tive results, when based upon a sufficient number of carefully 
conducted experiments by scientific observers, have in them- 
selves a positive value, and limit the field to which future in- 
vestigators may profitably apply their efforts. 
Let us now review briefly the National Quarantine System, 
as established by the act of June 2, 1879, and the results which 
have been obtained by it. This act provides that no vessel 
coming from any foreign port where contagious or infectious 
disease exists shall be allowed to enter any port in the United 
States unless she has a certificate or bill of health signed by the 
consular officer of the United States at the port of departure. 
The National Board of Health is to make rules which, when 
approved by the President, will govern the forms and condition 
of giving such a certificate. The law left it to the national 
board to determine what should be considered as contagious or 
infectious diseases. Evidently, if these terms were used in their 
medical sense, there would be very few ports in the world which 
would not come under this law. The board, however, has de- 
cided that the only diseases which for the purposes of the act 
are to be recognized as contagious or infectious, are cholera, 
yellow fever, plague, small-pox, and relapsing and typhus fevers. 
The intent of this part of the act was to cooler great power 
on the board, but it failed in its object for two reasons. 
The first is that it was accompanied by a proviso that no 
vessel should be subject to the penalties imposed by the act un- 
less the rules prepared by the national board, and approved by 
the President, should have been officially promulgated at the 
port of departure at least ten days before her sailing, buch 
official promulgation, however, cannot be made without* the 
consent of the authorities of the place, and in Cuba this con- 
sent was refused. 16 
NATIONAL BOARD OF HEALTH 
The second cause of failure of this part of the act was due to 
the fact that to render a vessel liable to its penalties it was 
necessary to prove in court that contagious or infectious disease 
actually existed at the port at the precise date of sailing of the 
vessel—which proof usually could not be furnished. 
In view of these failures the board, in conjunction with the 
National Academy, recommended additional legislation to the 
effect that all vessels coming from ports lying between certain 
parallels of latitude shall be required to furnish the certificate 
or bill of health, just referred to, irrespective of the existence 
of contagious or infectious diseases in such ports, or of the offi- 
cial promulgation of the rules of the board in such ports. 
It also advised legislation to authorize the President of the 
United States to call an International Sanitary Conference, to 
which the several Powers having jurisdictions of ports likely 
to be intected with yellow fever should be invited to send dele- 
gates for the purpose of securing an international system of 
notification as to the actual sanitary condition of ports and 
places under the jurisdiction of such Powers, and of vessels 
sailing therefrom. 
The object of the conference was thus limited, instead of 
making it to secure an international system of quarantine, for 
the reason that the United States could not undertake to enforce 
any international system of quarantine, properly so called, since 
to do this it must override State and local legislation on this 
subject, and guarantee that vessels should be allowed to enter 
any port in this country irrespective of its quarantine laws. 
This recommendation of the board has become a law, the 
word cholera being inserted in addition to yellow fever, and it 
is to be hoped that this conference will lead to very important 
practical results. 
This act of June 2d also directed the board to aid State and 
local boards of health in carrying out their quarantine regula- 
tions, and provided funds for this purpose. If the quarantine 
rules of the local boards are not sufficient, the national board 
may make additional rules, which, when approved by the Presi- 
dent, must be enforced by the sanitary authorities of the States, 
or else the President may detail an officer to do it for them. 
This, however, does not give the board the slightest power to- 
wards what may lie called forcing intercourse. 
That is to say, after all its rules have been complied with, it AND NATIONAL QUARANTINE. 
17 
has not power to assure to any vessel, steamboat, or train of 
cars, that it will be allowed entrance to any given port or place, 
since the local authorities of such port or place may enforce ad- 
ditional rules, even to non-intercourse, at their discretion. 
It is probably unnecessary to remind you of the operations of 
the hoard under this act during the last summer. Through the 
assistance given by it to the State boards of health of Tennes- 
see, Arkansas, Mississippi, Louisiana, and Illinois, and in a less 
degree to Texas, there is no doubt that the progress of the epi- 
demic last summer was greatly restricted, and that commercial 
intercourse was kept up under circumstances which, in the ab- 
sence of such aid, wmuld have prevented travel and traffic to a 
great extent. 
I will only allude here to the effects of the work of the board 
on the traffic of the Illinois Central Railroad, a note on which 
will be found in the Bulletin, of May 15th. From this it 
appears that the tonnage received and forwarded by that road 
at Cairo, 111., for the last six months of 1878 and of 1879, 
was respectively 267,411,200 and 867,869,800 tons ; forwarded, 
87,300,600 and 129,833,800 tons. 
The great difference in favor of 1879 is more than can be 
ascribed to increase of trade, and is largely due to the different 
quarantine regulations in force. In 1878, there was practically 
an exclusion of everything from the South, while under the in- 
spection system of 1879 only dangerous articles were excluded. 
Dr. Rauch, the Secretary of the Illinois State Board of Health, 
reporting this, says that “ this result could not have been 
reached without the co-operation of the National Board of 
Health, and the utmost exertions and repeated assurances of its 
inspector, as to precautions along the Mississippi River, were 
required to allay the fears of the local authorities.” As it was, 
though not a single case of yellow fever occurred in Illinois in 
1879, one-third of the people of Cairo were ready for immediate 
flight from July to September. The statement of tonnage be- 
ing for one railroad alone, which pays to the State seven per 
cent, of its net earnings, the amount gained by increase of trade 
was many times greater than the whole expenditure for sanitary 
purposes. 
After an experience of one season under this quarantine act, 
the board, in conjunction with the Rational Academy of 
Sciences, and in accordance with law', advised “that the Ra- 18 
NATIONAL BOARD OF HEALTH 
tional Board of Health, or, in the interval of its sessions in sea- 
sons of emergency, the executive committee, shall be charged 
with the duty ot reporting to the President when any given 
city or locality is considered to be dangerously infected with 
contagious or infectious disease ; and that upon the official pub- 
lication by the President of such report, the transportation of 
goods or persons from the place thus proclaimed as dangerously* 
infected, into other States, shall be forbidden under penalties to 
be imposed under the jurisdiction of the United States Courts, 
unless such transportation is carried on in accordance with rules 
and regulations approved by the National Board of Health.” 
The object of this recommendation was to induce local au- 
thorities to refrain from declaring quarantine, often unnecessa- 
by fixing the responsibility of declaring when such quar- 
antine was necessary upon the National Board and the President. 
It was never intended to give the board more power, since it 
already has the power, with the approval of the President, to 
prescribe the minimum of precaution which shall be taken by 
any State against an infected place in another State. 
When introduced as a bill in the Senate by Senator Harris, 
of lennessee, opposition was made to it on the ground that it 
would interfere with State rights, and would confer a dangerous 
power on the national authorities. This opposition came mainly 
from medical men, whose solicitude lest local self-government 
should be interfered with seems to have been much greater than 
that of business men or politicians. 
In a sanitary point of view it is unimportant, and the ques- 
tion is one that can best be left to business men to settle. 
.As regalds maritime quarantine, it is proposed by the board 
to aid the poits of the South Atlantic and Gulf coasts, in a more 
systematic manner than heretofore, by the establishment of three 
or four relief stations for infected ships, to which vessels can be 
sent from the various Southern ports when found to be infected 
and to require treatment. These several ports, then, need only 
incur the expenses of a proper inspecting station and inspecting 
officer, while the stations established by the National Board of 
Health at Sapelo Sound, Hampton Poads, Ship Island, and per- 
haps at Galveston, can serve as general hospitals, so to speak, 
for the benefit of the numerous small ports which cannot afford 
the expense of constructing and maintaining a large station. 
A complete quarantine station can hardly be established at a AND NATIONAL QUARANTINE. 
19 
cost of much less than $50,000, and to maintain it would re- 
quire an annual expenditure of from SIO,OOO to $15,000 at least. 
Such a station has been compared to a fort. It may not be 
needed for several years, but when it is required it may in a 
single season save many times the expenses of its construction 
and maintenance. It is, however, hopeless to expect that the 
smaller Southern ports can each establish and maintain such 
stations, and it is just here that the aid of the national govern- 
ment can be most profitably extended. 
Let us now consider some of the objections to the National 
Board of Health, and the practical difficulties which lie in its 
way. 
In the first place, wre have seen that its creation was in one 
sense premature. Forced into existence in an emergency, it was 
only to be expected that as soon as this emergency had passed it 
would find itself without the support of an educated public 
opinion, and upon such an opinion alone, under our form 
of government, can such an organization securely rest. The 
education of our people, however, sometimes goes on very 
rapidly, and this has undoubtedly been the case in regard to 
sanitary matters within the last eighteen months, to an extent 
which probably no sanitarian had anticipated. Although com- 
paratively few as yet understand the organization or powers ot 
the board, or have any clear idea of what it has done or is try- 
ing to do, still there are a large number of physicians and scien- 
tific men who have become more or less interested in its opera- 
tions and publications, and who would now prefer to see it 
improved rather than abolished. It was fortunately so com- 
posed that its members could hardly be suspected of political 
or personal motives; and although by a few persons it has been 
charged with grasping for power, it is tolerably well understood 
that this charge has no foundation, and that its main objects have 
been to promote original investigations, to collect information 
as to the condition of the public health, and to stimulate the 
formation of State and local boards of health, which should 
have as much real unquestionable authority as possible, and to 
aid them in their work in all possible ways. 
It has also been fortunate for the board that it has had com- 
paratively little patronage to dispense, and that it has so man- 
aged that the greater portion of this patronage has been made 
upon the recommendations of State or local boards of health ; as 
it is, the pressure uponjt for appointments to the half a dozen 20 
NATIONAL BOARD OF HEALTH 
clerkships and the ten or fifteen inspectorships it has thought 
proper to create, has made it some enemies among disappointed 
candidates and their friends. 
The principal objections, however, to the National Board of 
Health and to the system of quarantine inspections and relief 
stations which it has proposed to inaugurate, are made on the 
ground of expense. These objections, as urged in the daily press, 
and by members of Congress, may be stated as follows: 
I. Every port or State ought to take care of itself, and furnish 
the means for doing it. The Northern States and cities do this, 
and do not desire any help from the general government. Why 
do not Southern ports and cities do the same ? and why should 
the whole country be taxed to pay their local expenses? 
The answer to this is that, as a matter of fact, they do not do 
it; that they probably cannot do it ; and that the evil results of 
such failure affect not them only, but the whole country. The 
interest on the money which, during the last fifteen years has 
been raised by. voluntary contributions in the North to aid South- 
ern communities affected with yellow fever, would more than 
pay the expenses of the system of prevention which is proposed. 
The second objection is this: Granting the utility of the 
preventive means proposed, and also that in the interests of 
commerce and of the national revenue, as well as of humanity, 
it is wise for the United States to furnish the means, cannot 
these means be supplied without creating a National Board of 
Health to control them ? A board is a cumbrous and costly insti- 
tution, and although its members may be scientific, that rather 
makes it improbable that they should be good business men, or 
possess executive ability? 
The reply is that the national board was not created to dis- 
burse funds for quarantine, but to do much more difficult and 
important work, as I have tried to explain in this paper. But 
having such a board, it seems more proper to refer to it such 
work, connected with quarantine, as the general government may 
undertake than to send such work to some other bureau. This, 
however, is a mere detail as to executive work; the point is 
that the board has other work to do, and that its utility does 
not depend solely or even mainly on its quarantine work. 
I have said above that the creation of the board was prema- 
ture, in one sense; I mean by this that our legislators, when 
they created the board, did it for quarantine purposes, and not AND NATIONAL QUARANTINE. 
21 
for the true purposes of a sanitary board, and they measure its 
utility solely with reference to its power to prevent the entrance 
or spread of contagious or infectious disease. The very title of 
the act which created it is misleading. It is called “An Act 
to prevent the introduction of infectious and contagious diseases 
into the United States, and to establish a National Board of 
Health but a very slight examination of this act will show that 
it has nothing to do with preventing the introduction of infec- 
tious and contagious diseases, or, in other words, with quarantine. 
I have elsewhere expressed the opinion that the remedy for 
the evils connected with local quarantines, as they have hereto- 
fore been managed, is “the education of the people until they 
shall know what amount of restriction is really necessary to in- 
sure safety, and it seems, on the whole, expedient that the cost 
of this education should be borne the general government. 
It follows, therefore, that the United States should for a time 
bear a much larger proportion of the expenses of a quarantine 
system than it will need to do when the States and municipali- 
ties are equally well informed as to their duties, and as to their 
true interests.” 
What shall we say as to the future of this National Board of 
Health ? For a premature birth, the infant seems healthy and 
lively, but it would be rash to make any prophecies as to its 
immediate future, since this depends so largely upon the con- 
tingencies of the next few months. 
There still prevails over a large section of the country, and in 
the minds of many of our legislators, the idea that the main 
purpose and use of the board is to prevent the entrance of 
yellow fever into this country, and that, if yellow fever does ap- 
pear here, it shows that the board is useless. Until this idea is 
changed, and the public obtains a much broader conception of 
the field of labor of a national health organization, the very 
existence of the board hangs upon a slender thread, for until 
we know much more of the nature of the cause of yellow fever 
and its methods of propagation than we now know, it is prob- 
able that this disease will continue to appear whether we have 
a national board or not. If it depends exclusively on importa- 
tion, it will at times pass any quarantine system which now 
exists in this country, or which is likely to exist for a long 
time. 
All that any system can effect with our present knowledge 22 
NATIONAL BOARD OF HEALTH 
is to prevent its entrance nine times out of ten ; but this is well 
worth striving for. If yellow fever depends on local sanitary 
conditions, there is littld hope that these will be done away 
with in many ot our Southern cities and towns for years 
to come. By properly constituted and intelligent State and 
local boards, stimulated and aided bjT the national board, no 
doubt much may be done to prevent the origin, and limit the 
spread of this disease, and if the co-operation of other powers 
of the intertropical Atlantic can be obtained, its field may be 
restricted within very narrow limits. 
Under existing laws, and in the prevailing state of public 
opinion, it is a necessity that the national board should give 
special attention to quarantine matters, and much the greater 
part of the funds under its control have been granted for that 
purpose only. But in common with all intelligent sanitarians 
and physicians the board sees clearly enough that its most im- 
portant fields of usefulness lie in other directions, and it has 
done enough already in those fields to make it probable that 
hereafter this country will not be without some central sanitary 
organization irrespective of the question of a national quaran- 
tine system. 
lhat this organization will remain permanently in the form 
of the present National Board of Health is improbable. The 
tendency just now is towards the plan sketched by Dr. Bow- 
ditch, involving a representation of all State boards in a general 
council,'with a single executive officer to be chosen by the 
council; but there are many practical difficulties in the way of 
this plan, lo make it effectual, concurrent legislation on the 
part of the several States and of the United States will be neces- 
sary, and a very extensive educational process must be gone 
through with before such legislation can be secured; and it 
seems to me that one of the first steps in this process is to show 
what the sanitary condition of our cities, towns, and villages 
actually is, which is to be effected by a uniform system of vital 
statistics and by sanitary surveys. 
In conclusion, permit me to repeat what I have elsewhere said 
in this connection;— 
“In sanitary matters no single man, city, State, or nation can 
protect itself, except by non-intercourse, and not always even by 
that. To get the best results with the least cost and interfer- 
ence with freedom, we must help one another; but this help AND NATIONAL QUARANTINE. 
23 
must be given, received, and regulated on business principles, 
because it will pay, and not be considered as sentimental 
charity, which will sooner or later be grudgingly bestowed and 
unthankfully received. We want our citizens and cities, coun- 
ties, and States to take care of themselves in sanitary as in other 
matters as tar as possible ; but there should be some power com- 
petent to interfere in the exceptional cases in which selfishness, 
ignorance, or terror leads either to danger of pestilence or ob- 
struction of commerce. This power, however, cannot be estab- 
lished arbitrarily, or in advance of sufficient education of the 
business portion of the community to create a powerful public 
opinion to support it. Whether it is possible to supply this 
education otherwise than through the lessons which epidemics 
themselves give is the problem which the sanitarians of this 
country are at present practically trying to solve.”1 
1 International Review, Jan. 1880, p. 49.