PUBLIC HEALTH SERVICE IN 
THE UNITED STATES 
BY 
Walter Wyman, A. M., M. D. 
Surgeon-General IT. 8. Marine Hospital Service. 
Reprint from the Cleveland Journal of Medicine 
February, 1897 PUBLIC HEALTH SERVICE IN THE UNITED STATES 
BY WALTER WYMAN, A. M., M. D. 
Surgeon-General U. S. Marine Hospital Service 
MR. PRESIDENT and Gentlemen of the Cleveland Medical Society: 
In April last a note was received from the Minister of Belgium 
at Washington, asking for certain information concerning the 
health service of the United States, and inclosing the following specific 
inquiries: 
1st. What are the attributes of the National Board of Health at Wash- 
ington? 
2d. Are there any general laws for the whole Union relative to the 
prevention of epidemic diseases, formulating a uniform plan to be followed 
by the states? Or do the federal states remain absolutely independent in 
this matter? 
3d. Do quarantine doctors belong to a federal ministry, or are they 
simply officers taken (relevant) from the federal states having maritime 
ports? 
4th. Is there any difference-and if so, what is it?-between "Naval 
Hospitals" and "Hospitals of the Marine Hospital Service?" 
5th. Are there any general sanitary regulations applicable to the 
whole Union concerning contagious diseases of animals, and established 
not only in regard to exportation, but also with regard to the development 
of agriculture and interstate commerce? 
6th. Are there any general regulations for the whole Union relative 
to commerce, manufactures and the adulteration of food commodities? 
7th. What are the relations existing between the sanitary or medical 
officers of the Union and those of the different federal states? 
The following are the replies sent to these inquiries: 
1st. "What are the attributes of the National Board of Health at 
Washington?" 
There is no National Board of Health so called. A National Board 
of Health was created by act of Congress, approved March 3, 1879. An- 
other act was approved June 2, 1879, clothing the Board with certain quar- 
antine powers, but this last act was limited to a period of four years, at 
the expiration of which time Congress declined to renew it. The National 
Board of Health, therefore, had an active existence from 1879 to 1883. 
The act establishing the Board, March 3, 1879, remained upon the statute 
books until February 15, 1893, when it was formally repealed by Congress, 
An address delivered before the Cleveland Medical Society of Cleveland, Ohio, December 18,1896 2 
but the operations of the Board were confined to the four years above men- 
tioned-1879 to 1883. The principal functions of the National Board of 
Health are now administered by the Marine Hospital Service, whose duties 
will be enumerated in another portion of this report. 
2d. "Are there any general laws for the whole Union relative to the 
prevention of epidemic diseases, formulating a uniform plan to be followed 
by the states, or do the federal states remain absolutely independent in this 
matter?" 
The act of Congress approved February 15, 1893, provides for the for- 
mulating of uniform regulations to be observed by all state and local quar- 
antine authorities in preventing the introduction from foreign countries of 
epidemic diseases, and for preventing the spread of epidemic diseases from 
one state or territory into another. The regulations are promulgated by the 
Secretary of the Treasury, and the Surgeon-General of the Marine Hospital 
Service is charged, under the direction of the Secretary, with the perform- 
ance of all the duties in respect to quarantine, and quarantine regulations^ 
which are provided for by said act. The law further provides that if the 
states or municipalities shall fail or refuse to execute the quarantine regula- 
tions, the President shall appoint a proper person to execute them. 
3d. "Do quarantine doctors belong to a federal ministry, or are they 
simply officers taken from the federal states having quarantine ports?" 
There are two classes of quarantine physicians. First, those commis- 
sioned by the national (federal) government; second, those commissioned 
by state governments. The quarantine physicians employed by the national 
government are the medical officers of the Marine Hospital Service. The 
national government has the conduct of twelve fully equipped quarantine 
stations, and maintains, moreover, quarantine inspection at seven ports. 
At the remaining quarantine stations of the United States quarantine phy- 
sicians are appointed by state or municipal authority. These latter, how- 
ever, are all subject to inspection by the Marine Hospital Service. 
4th. "Is there any difference-if so, what is it?-between naval hos- 
pitals and hospitals of the Marine Hospital Service?" 
Yes. Naval hospitals are hospitals provided by the national govern- 
ment exclusively for the treatment of sailors belonging to the United States 
navy, while marine hospitals are administered by the Marine Hospital 
Service, a bureau of the treasury department, for the treatment of seamen 
employed in the merchant marine of the United States. 
5th. "Are there any general sanitary regulations applicable to the 
whole Union, concerning contagious diseases of animals, and established 
not only in regard to exportation, but also with regard to the development 
of agriculture and interstate commerce?" 
The Bureau of Animal Industry in the Department of Agriculture 
makes investigations as to the existence of contagious pleuropneumonia and 
other dangerous communicable diseases of live-stock; superintends the 3 
measures for their extirpation, makes original investigations as to the nature 
and prevention of such diseases, and reports on the condition and means 
of improving the animal industries of the country. It also has charge of 
the inspection of import and expert animals, of the inspection of vessels 
for the transportation of export cattle, and of the quarantine stations for 
imported neat cattle; supervises the interstate movement of cattle, and in- 
spects live-stock and their products slaughtered for home consumption. 
6th. "Are there any general regulations for the whole Union relative 
to commerce, manufactures, and the adulteration of food commodities?" 
There are many general regulations for the whole Union relative to 
commerce. The interstate quarantine regulations, promulgated under the 
act of February 15, 1893, are based upon the constitutional right of the 
national government to regulate commerce. Practically, it may be said 
that there are no national health regulations concerning the adulteration 
of food commodities, or concerning manufactures. These matters are sub- 
jects of careful legislation by the different state governments. 
7th. "What are the relations existing between the sanitary or medical 
officers of the Union and those of the different states?" 
The relations between the national and local quarantine authorities have 
been explained in answer to previous questions. Each state has its own 
health laws and organization, and each city its own health board; and,'in 
general, it may be said that municipal and domestic sanitation is left en- 
tirely to the state or local health authorities without interference by the 
national government. 1 quote an editorial of the New York Times, of Au- 
gust 2, 1893, showing the general sentiment concerning the proper relation 
between the national and state governments in the matter of public health: 
The sanitary condition of cities and towns, and the control of the in- 
fluences which affect the health of the people are matters that come very 
distinctly within the police power of the States. Regulations and restric- 
tions for the protection of the public health can be best established and 
administered by State and local authorities, and the nearer their adminis- 
tration comes to the people affected the better. The subject may be neg- 
lected in some States, or they may be slow in appreciating its importance 
and providing for the sanitary well-being of their people, but that fact does, 
not impair their authority or transfer it elsewhere. They may be dilatory 
or negligent in many things that the national government cannot look after 
for them. 
When it comes to dealing with contagious diseases brought from other 
countries the matter takes a different aspect. The enforcement of measures 
for preventing their introduction at our seaports or over our borders neces- 
sarily involves interference with foreign commerce. Vessels have to be de- 
tained, inspected, and disinfected, and passengers and merchandise have to 
be subject to regulations that concern the people and the interests of the 
country, regardless of State lines. National jurisdiction has here an appro- 
priate field and is alone adequate to its requirements. Quarantine regula- 
tions affecting communication with foreign countries should be national and: 4 
national only. The same principle may apply in some degree to protection 
against the transmission of infectious diseases from one State to another 
through the agencies employed in interstate traffic, as interference with those 
agencies pertains to the regulation of commerce between the several States. 
But there is seldom any occasion for interference in the case of infections 
originating in this country. 
There might be a useful function for a national board of health in the 
collection and diffusion of statistics and information relating to matters that 
concern the public health, and in consulting and advising with State and 
local authorities. But no power or jurisdiction could be exercised by such 
a board, by whatever name it might be called, over those authorities, and it 
could in no way deal practically with internal sanitation. 
MARINE HOSPITAL SERVICE 
The function of the Marine Hospital Service may be seen by an enu- 
meration of the various duties of its officers, as follows: 
1. The management of hospitals and relief stations for the care of 
sick and disabled seamen of the merchant marine of the United States, over 
50,000 seamen being treated annually. 
2. The active management of twelve national quarantine stations, in- 
cluding the steam vessels belonging thereto. These national quarantine 
stations, particularly in the South, are the refuge stations for neighboring 
local quarantines, and for a large number of years have done the greater 
part of the actual cleansing and disinfecting of infected vessels. In the last 
fifteen years their hospitals have, with but few exceptions, received and 
cared for all the yellow-fever patients taken from vessels entering United 
States ports. 
3. Inspection of local quarantines, under the act of February 15, 1893. 
4. Investigation of reported cases of epidemic disease, including bac- 
teriologic examinations and local sanitary conditions. 
5. The suppression of epidemic diseases and enforcement of the inter- 
state quarantine regulations. 
6. The collection and dissemination of mortality statistics and sanitary 
information. 
7. Scientific investigation into the causes of disease. 
8. The examination of pilots for color-blindness. 
9. Physical examination of keepers and crews of the life-saving sta- 
tions; professional examination of their claims on account of disability and 
their treatment in hospital. 
10. Physical examination and treatment of the officers and crews of 
the Revenue-Cutter Service, both prior and subsequent to enlistment, and 
medical and surgical service under special detail on revenue cutters engaged 
in Arctic cruising, or on other long voyages. 
11. Physical examination of immigrants under the law excluding those 
afflicted with contagious disease. 
12. Service in the office of consuls at foreign ports to assure the accu- 
racv of bills of health given to vessels. 
13. Miscellaneous duties imposed from time to time by the Treasury 
Department. 5 
QUARANTINE LAW THE FOUNDATION OF NATIONAL PUBLIC 
HEALTH SERVICE 
From the above it will be seen that the foundation of a national public 
health service, as it has heretofore existed in the United States, and as it 
exists today, is in quarantine law. The act of June 2, 1879, investing the 
National Board of Health with certain quarantine powers, and making 
quarantine appropriation, was limited to four years' operation, and was not 
re-enacted. The act of March 3, 1879, establishing the board, defined its 
duties to be those pertaining to quarantine and to obtain information and 
to advise upon all matters affecting the public health, but in the Sundry 
Civil Act for the fiscal year ended June 30, 1883, Congress specially re- 
stricted the duties and investigations of the board to cholera, small-pox and 
yellow fever. 
ADVANCE IN SCIENTIFIC QUARANTINE 
Comparing the present quarantine law of February 15, 1893, with the 
quarantine law to be operated by the National Board of Health, it may be 
said That the present one is by far more powerful and efficient. The quar- 
antine service of the United States is today almost strictly national, and, not- 
withstanding local sentiment in certain states to the contrary, the time is 
near when all quarantine administration will be strictly national. The de- 
velopment of a public health service out of quarantine seems to be a natural 
sequence, particularly, when the scientific and progressive character of mod- 
ern quarantine is considered. Quarantine is today as much in advance of 
the original quarantine established in Venice at the beginning of the fifteenth 
century as is the practice of medicine in advance of that date. The colonies 
of America established quarantine before the Union was established, and 
it was a more rational quarantine than the Venetian. More recently the 
States and municipalities established quarantine laws and practice which 
were in advance of those of the colonies, but while their regulations were 
undoubtedly effective to a degree, in barring pestilential disease, many of 
the State and local quarantines degenerated into political institutions and 
became, as some of them still are, quarantines chiefly for political preference 
and for revenue. Some of the members of this Society may recall the 
number of quarantine conventions which were held before and subsequent 
to the civil war, to bring about uniformity of quarantine procedures between 
the several States, and may also recall the futility of these efforts. For 
years the cry had been for uniformity in quarantine practice, but no relief 
from the dangers of lack of uniformity was obtained until the passage of 
the act of February 15, 1893. Under this act there are maritime quaran- 
tine regulations for the whole United States, as well as interstate quaran- 
tine regulations, all of which, by the terms of the law, must be uniform in 
their operation so far as minimum requirements are concerned; but there 6 
is nothing in the law to prevent useless and expensive requirements in addi- 
tion to those of the Treasury Department. With a strictly national quar- 
antine service these useless embargos upon commerce may be removed, 
and, as said before, the trend of public sentiment and of legislation is to that 
end. But scientific quarantine does not stop here. Earnest efforts to pro- 
tect the United States from the invasion of foreign pestilence have demon- 
strated the necessity of so great watchfulness, such great expense, such a 
handicapping of commerce, that inquiry is now being urged by those directly 
interested, with regard to the conditions which give rise to our annual 
fears and necessitate these expenditures, and restrictions upon commerce. 
Nearly all these fears and precautions are rendered necessary by but two 
diseases-cholera and yellow fever. Without these, maritime quarantine 
would be but an inspection service, with occasional disinfection for typhus 
fever, plague, etc., and its restriction upon commerce would be practically 
nil. Therefore, a question engaging the public mind today- is whether it 
would not be cheaper and safer, and prevent our annual perturbation of 
mind, if these two diseases were attacked in their habitats. Quarantine 
authorities are beginning to demand that conditions which favor the con- 
tinuous propagation of cholera at its home in India should be removed; 
that its conveyance from India by pilgrims to Mecca and from Mecca to 
Egypt and the northern coast of Africa, and to the continent of Europe, 
should be prevented. And the same inquiry is being made with regard to 
yellow fever upon the western continent. 
PROTEST AGAINST YELEOW FEVER PORTS 
At the meeting of the American Public Health Association, held in 
Buffalo last October, the following resolutions were adopted: 
"Whereas, Yellow fever is believed to be the most subtle and dangerous 
of all epidemic diseases, and 
"Whereas, It is ordinarily conveyed into one country from an infected 
seaport of another, and 
"Whereas, The continued and persistent presence of this disease in 
any seaport is believed to be unnecessary, and may be prevented by proper 
engineering and other sanitary measures; therefore, 
"Resolved, 1st-That it is the duty of every government possessing 
seaports thus infected to institute such engineering and other sanitary 
measures as will remove this menace to the seaports of other nations; and 
"Resolved, 2d-That it is the duty of all governments continuously 
threatened with invasion of yellow fever from a seaport in which the disease 
is allowed to persist, to make such representations to the government in 
possession of the offending seaport as will induce it to adopt the sanitary 
measures necessary to remove this obstruction to commercial intercourse 
and menace to human life. 
"Resolved, That a copy of these resolutions be transmitted to the execu 
tives of the several governments represented in this association." 7 
I quote from an address delivered by myself last month before the 
Pan-American Medical Association in Mexico, touching up this very live 
subj ect: 
"I know of no more necessary campaign upon which to enter than 
one calling for a concentration of forces against yellow fever in the western 
hemisphere. Cholera no longer inspires its old-time dread. It is now an 
unmasked enemy, requiring only vigilance, skill and pecuniary resources to 
overcome it. A lapse in any of these may give it headway, but with these 
three particulars carefully observed, the conquest of this enemy as soon as 
it appears is a certainty. The same cannot be said of yellow fever. Its 
entity is unknown. 
"Our duty with regard to it includes (1) an investigation into its exact 
nature and cause, and (2) an insistence upon sanitary engineering and other 
sanitary measures which will remove it. 
"With regard to scientific investigation, it is hoped that the Congress 
of the United States will be induced at its next session to initiate a plan 
providing for continuous labor in this direction." 
YELLOW FEVER INVASION OF THE UNITED STATES 
Our knowledge of yellow fever is incomplete, but enough is known 
of the causes which propagate it to enable us to take necessary action to 
suppress it wherever evident. We know that it is a filth-disease, and that, 
where permitted to permanently exist, it is an evidence of a want of proper 
care on the part of public administration. Moreover, it is a disease pre- 
eminently of seaports. In the annual report of the Marine Hospital Service 
for 1895 is a table showing the years in which yellow fever has visited the 
seaport cities of the United States. From 1800 to 1896 there have been only 
nine years in which the United States has not been visited by yellow fever. 
Twenty-three visitations, it is proven, came from Havana; twelve were from 
Cuba (exact port unknown). Since 1862 there have been twenty-six inva- 
sions. The source of nineteen of these is positively known, viz.: sixteen 
from Havana, two from Cuba, one from Honduras. 
Since 1893 there has been no yellow fever in the United States, and 
the records show that the disease, although frequently imported*, has never 
become a fixed habitant of our shores. The same cannot be said of Vera 
Cruz, Havana, Santiago, Rio or Santos, and history shows that if one of 
these ports becomes free from the disease it is subject to re-infection from 
the others. 
HAVANA A GREAT AND CONSTANT MENACE 
As remarked previously, it is desirable to concentrate our efforts upon 
■one disease-yellow fever. But we may go further and say that it is desir- 
able to still further concentrate them upon one port. It is obvious that the 
chief offending port on the western continent is Havana. So greatly was I 
impressed by this fact while compiling the table showing the sources of 
infection of yellow fever brought to the United States, that it seemed to be a 8 
duty to prepare the following letter, to be used in the nature of a protest 
by the proper authorities. Following is the letter: 
"Washington, D. C., December 4, 1895. 
"The Honorable, the Secretary of the Treasury. 
"Sir:-I have the honor to submit for your consideration the following 
statements relating to the island of Cuba and its chief port, Havana, and the 
jeopardizing relation which the latter in particular constantly bears to the 
United States by reason of insanitary but remediable conditions, causing it 
to be a focus of the infection of yellow feyer-the most subtle and dangerous 
of all the epidemic diseases and one which annually threatens the lives and 
property of a large portion of the United States. 
"I transmit herewith a table which I have caused to be prepared for 
the annual report of the Marine Hospital Service for 1895, showing the 
years in which yellow fever has visited the cities of the United States, the 
cities visited and the source of the infection. It will be seen from the table that 
during the present century, from 1800 to 1894, there have been but seven 
years in which yellow fever has not visited the United States. The source 
of the infection is known in only forty-one of the eighty-seven years; in 
twelve of these forty-one years the source of infection is given as simply 
the West Indies, which may or may not mean the island of Cuba, but in 
twenty-three of the years the source is given definitely as Havana. Taking 
a more limited period-namely, between 1862 and 1894-our shores have 
been infected with yellow fever twenty-six different years. The source of 
the infection is known for nineteen, and of these nineteen yearly visitations 
sixteen have been traced definitely to Havana. The records further show 
that in some years a number of places in the United States have been in- 
fected independently of one another from Havana, as, for example, in 1862, 
Key West, Florida, and Wilmington, N. C.; in 1871, Cedar Keys, Tampa 
and New Orleans; and in 1873, New Orleans and Pensacola. The last 
epidemic of yellow fever in this country-namely, in Brunswick, 1893- 
was brought on vessels from Havana, and the last great epidemic-namely, 
in 1878-is traceable to the same source. The epidemic of 1878 invaded 
132 towns of the United States and caused a mortality of 15,934 persons, 
and the pecuniary loss to this country has been stated at the lowest estimate 
as $100,000,000 in gold. The disease is not indigenous to our soil, but is 
always imported. So great is the danger of its introduction from Cuba and 
Havana that it has become a trite saying among sanitary officers that the 
only absolute safety lies in non-intercourse. 
"This subject is by no means a new one. Attention has frequently 
been called in the reports of the Marine Hospital Service to Havana as a 
constant menace to the health of the United States, and the subject was one 
of exhaustive inquiry by the United States Yellow Fever Commission, whose 
report may be found in the annual report of the National Board of Health 
for 1880. I quote from this report as follows: 
"Page 78-'Cuba, as its prosperity and commerce increased, has be- 
come the greatest nursery and camping ground of one of man's most ruth- 
less destroyers. Itself most seriously afflicted, it annually disseminates to 
other lands, as from a central hell, disease and death.' 
"Page 104-'Cuba makes no such efforts to limit the spread of yellow 
fever as have apparently proved successful in Martinique and others of the 9 
West Indies. * * * Our present knowledge justifies the hope that, if the 
periods when this tendency to die out was very manifest were utilized in 
efforts for protection, even Havana might be freed from the poison of yellow 
fever and require a fresh importation for the renewal of the disease.' 
"The harbor of Havana is a cesspool which for years has received the 
drainage of the city, and is virtually a cul-de-sac, with no means of its being 
scoured by the tides or fresh-water streams. The wharves on the Havana 
side of the harbor are notorious as foci of infection. An examination of the 
records of the quarantine stations on the South Atlantic and gulf coasts for 
the year 1894 shows that there were eleven cases of yellow fever taken from 
six vessels arriving at the Dry Tortugas quarantine station. All of these 
vessels came from the wharves in Havana. In the year previous, 1893, at 
Ship Island, there were five vessels which arrived at the quarantine station 
having had eight cases of yellow fever on board, and all these yellow fever 
vessels lay at the wharves in Havana, with the exception of one, which lay 
very near a vessel which had been at Tallapiedra wharf, and was infected 
with yellow fever. Two of these wharves-namely, the Tallapiedra and the 
San Jose-are particularly dangerous. Under this latter empties the sewer 
from the military hospital, where the yellow fever patients of the army are 
treated. It has been said that no vessel has ever been tied to this wharf with 
a non-immune crew on board without yellow fever appearing among them. 
So well known is it as a danger point that it is called "dead man's hole" 
by ships' captains, and so great is the danger of being obliged to tie up 
to it that captains of American vessels have been known to pay for the 
privilege of discharging cargos in the open bay on,lighters, the payment 
being made by deduction from freight charges, amounting frequently to 
$200 or $300. Captains of American vessels have frequently asserted that 
the United States government should not allow vessels to go to this wharf. 
The personal danger to the American seamen is increased by reason of the 
fact that the law compels him to remain on his vessel, even though tied to 
Tallapiedra wharf in "dead man's hole." 
"A description of the sanitary imperfections of Havana may be found in 
the annual reports of the Marine Hospital Service and in the report of the 
United States Yellow Fever Commission, previously referred to. I have 
made an inquiry as to whether any improvements in the conditions have 
been made in recent years, and the reports received show there have not 
been. Sanitary Inspector Burgess reports that, while a new water-supply 
has been provided for Havana, there has been no sewerage to correspond. 
He states that the few sewers are badly made of pervious material, so uneven 
in their course and so leaky that the city would be better off without them. 
It is already being reported that many houses, as also the city generally, 
are damper than before the new supply of water, and, naturally, this must 
obtain and increase until some appropriate drainage system is constructed. 
"The furnishing of a new supply of water to a city before providing an 
extra amount of drainage, is sometimes called by sanitarians 'the cart before 
the horse' procedure. The danger is actually increased by the increased 
supply of water. The dread caused by this condition of affairs in Cuba, 
and particularly in Havana, is illustrated by a concise review of the quaran- 
tine regulations deemed necessary by local and state, as well as by the 
national quarantine authorities. Between May and November every vessel 
from Havana, and most other Cuban ports, arriving at any port in the 10 
United States between Norfolk, Va., and Brownsville, Texas, whether yellow 
fever has been aboard the vessel or not, is required to discharge ballast at 
quarantine, to have its hold washed and filled with fumes of sulphur, all 
the dunnage of the crew and baggage of passengers placed in steam disin- 
fecting chambers, and after completion of disinfection the vessel is then 
held from three to five days before being allowed to entir port. 
"Some exception is made to the above with regard to iron steam vessels 
bringing passengers, but other specific and stringent requirements are added. 
Moreover, the regulations forbid absolutely persons not immune to yellow 
fever to come to Florida from Cuba during this period. By an immune 
person is meant one who has had yellow fever, or who has resided in a yellow 
fever locality a period of ten years. This rule, therefore, excludes children 
under ten years of age, and, notwithstanding that efforts have been made 
to abrogate this regulation, no health officer dares venture to recommend 
its abrogation. To carry out this regulation the United States is obliged 
to maintain two inspectors in Havana in order to give the proper certificates 
to passengers leaving that port for the United States. All the above entails, 
in addition to responsibility, large expense. 
"I wish, as a sanitary officer, having in view the safety of the United 
States from visitations of yellow fever, to protest against these conditions 
so strikingly in contrast with the sanitary enlightenment of the age, and so 
threatening to the commerce and lives of the people of other countries, and 
particularly our own. I have respectfully to request that the matter be 
brought to the attention of the Department of State. 
• "Respectfully yours, 
(Signed) Walter Wyman, 
Supervising Surgeon-General, M. H. S." 
NECESSITY OF PUBLIC SENTIMENT 
There are other seaports habitually infected with yellow fever, but it is 
believed if we will concentrate our energies first upon one, and that one 
of the most dangerous, we may have greater hope of improving the present 
conditions; and actual results once obtained will furnish a precedent to aid 
in effecting like changes in other ports. To this end we must awaken public 
sentiment-a sentiment that will cause the people to appeal to their respect- 
ive governments. 
The time has come when we should submit no longer to this annual 
trepidation concerning yellow fever and when the restrictions to commerce 
caused by infected seaports should be removed. And we should not fail to 
impress upon others their responsibility with regard to this public sentiment. 
In fact, we may claim as physicians and sanitarians that our work has so far 
progressed that it is the duty of others to take it up and press it to more 
practical results. 
The dangers have been demonstrated, the causes have been made 
known, the methods to be adopted have been pointed out. Now, gentle- 
men of the Exchange, of the Legislature, and you who are skilled in diplo- 
macy, it is time for you to bear a hand. Join your efforts with ours that 11 
commerce may be free, unobstructed by sanitary restraints, and this disease 
be eliminated from the friendly intercourse of nations. If now, through 
the higher demands of quarantine and in the interest of commerce, sanita- 
tion of seaport cities and of localities which breed disease is enforced, a good 
beginning will be made toward the sanitation of all cities. 
PUBLIC HEALTH SERVICE-DEVELOPED GRADUALLY, OR ESTABLISHED 
DE NOVO? CONSTITUTIONAL CONSIDERATIONS 
The sequence of public health service upon quarantine laws and regula- 
tions will be illustrated further on, but, turning for the moment from this 
consideration, it will be convenient here to discuss the possibility or wisdom 
of establishing de novo a public health service, not developed gradually. It 
will be found that many of our legislators believe there are limitations to 
the exercise of health prerogatives by the national government, claiming 
that these limitations have their corresponding privileges in the rights and 
constitutions of the several states. The provisions of the constitution of 
the United States relative to this matter are contained in Section VIII, para- 
graphs 1 and 3, which I quote as follows: 
"Section VIII. The Congress shall have power- 
Par. 1. To lay and collect taxes, duties, imposts and excises, to pay 
the debts and provide for the common defense and general welfare of the 
United States; but all duties, imposts and excises shall be uniform through- 
out the United States. 
Par. 3. To regulate commerce with foreign nations and among the 
several states, and with the Indian tribes." 
A strict constructionist will inform you that the powers of the national 
government, pertaining to the public health, are restricted to paragraph 3, 
which gives the right of Congress to regulate commerce, and, in regulating 
commerce, Congress may so regulate it as to prevent its being a carrier of 
disease. Others will claim that under the general welfare clause, in para- 
graph 1, Congress has the right to legislate for the public health. But the 
strict constructionists reply that this general welfare clause means to pro- 
vide for the general welfare, in accordance with the subsequent paragraphs 
of the same Section, or as elsewhere specified. 
Let us assume, however, that the liberal construction is correct, and 
that under the constitution an absolute health service, with rights and 
powers in states and municipalities, may be established. Even then the 
most natural organization would appear to be by a division of labor accord- 
ing to states. Considering the vast territory covered by this government, 
the different conditions existing in its various portions so widely separated 
by degrees of latitude and longitude, it would be necessary for any sanitary 
authority to divide its work into sections, represented preferably by the 
several states, and the organization would be practically the same as at 
present. 12 
Again, admitting the right of Congress to establish a service of this 
character, with full powers over states and municipalities, with regard to 
municipal and domestic sanitation, involving all details, as house-drainage 
plumbing, methods of sewerage and disposal of garbage, water-supply, ven- 
tilation of dwellings, school houses and other public buildings, examination 
of milk supply, food and drugs, disposal of the dead, disinfection of dwellings 
after the ordinary contagious diseases, such as scarlet fever, measles and 
diphtheria; placarding of houses containing contagious diseases, and so 
forth-would it be desirable for the national government to have such 
authority? Would it be cheerfully yielded by state and municipal officers, 
or by the people? And what would be the effect upon our people other 
than to cultivate a weak leaning upon the national government in all these 
matters? 
STATE BOARD OF HEALTH 
The sanitary welfare of this country is dependent, primarily, upon the 
development and perfection of the State boards of health. While quaran- 
tine is, properly speaking, a national matter, domestic sanitation is a State 
matter. There should be, and is, a State pride in the development of sani- 
tation, and a self-reliance; an unwillingness to surrender functions, or call 
for aid from the general government, excepting after clearest convictions of 
propriety or necessity. As each State has its own militia, its own educa- 
tional system, its own laws regarding marriage, its own judiciary, so also 
it should consider the control of health matters affecting its individual citi- 
zens, as one of its functions, as important as any of the others which go to 
make up its autonomy. And it may be remarked that the same cordial and 
cooperative relations which the States should bear to the U. S. government 
should exist between the State and its municipalities. 
There has been a remarkable growth of State and municipal health or- 
ganizations within the last twelve years, both in number and in power. Of 
the forty-five states, thirty-eight have now State boards of health. 
These State boards annually meet in national conference for the ex- 
change of information concerning all public-health matters within their 
respective territories, and their transactions are published. True, greater 
uniformity of state health laws and regulations is desirable with regard to 
morbidity and mortuary statistics, registration of births, suppression of dis- 
ease, practice of medicine, and so forth, but there is no greater variance in 
these matters than with regard to many others. 
PUBLIC HEALTH SERVICE UNDER EXISTING LAWS AND ORGANIZATIONS 
Now, with the States and municipalities allowed to attend to their own 
domestic sanitation, let us see what has been done, and what may be done 
by the national government in the interest of the public health under existing 
laws and organization. I have always contended that the Marine Hospital 13 
Service, even when considered solely in the light of its original function- 
the care of sick and disabled seamen-is a very important element in public 
health work. The name itself now conveys no adequate idea of its scope; 
but the Service is very nearly a century old, and its functions have been 
added to from time to time by Congress to such an extent that it is a some- 
what laborious and tiresome task to enumerate all that it is doing. But, 
in its original restricted capacity, it has by careful selection of its officers, and 
appointment only after rigid examination, and its entire removal from polit- 
ical influence, established a corps of medical men, under strict discipline, 
divorced from local influences and made familiar, to a degree unusual among 
medical men, with correct business habits and the systematic-methods upon 
which is dependent the success of all large organizations and of government 
itself. It treats annually 53,000 sick and disabled seamen in twenty-one 
marine hospitals and dispensaries and at eighty-six relief stations, and has an 
annual fund of between. $500,000 and $600,000 for its support. In connec- 
tion with the hygienic condition of these hospitals, and the scientific treat- 
ment of the diseases therein, legally the Service is entitled to make investi- 
gations, which, though primarily intended for the benefit of the sailor, actually 
are more far-reaching in their effect. I will instance the hygienic laboratory 
of this Service, which was established in 1887, in connection with the marine 
hospital for the port of New York, and afterwards removed to Washington. 
There are much finer laboratories, so far as building and conveniences are 
concerned, but it is doubtful whether any laboratory in the United States is 
more completely equipped. The most recent scientific appliances are pro- 
vided for this laboratory and paid, with occasional exception, from the 
Marine Hospital fund. 
Among the investigations legally charged to this fund may be men- 
tioned the work of the Service in connection with diphtheria. An officer of 
the Service was detailed to go abroad for the purpose of familiarizing him- 
self with serum-therapy, and coincidently the antitoxin discovery being 
made known, he immediately familiarized himself, under the direct instruc- 
tion of Roux and Martin, with all the details, and was among the first, if not 
the first, to give a succinct account in this country of the methods of pre- 
paring antitoxin and its use in the treatment of diphtheria. The horse, still 
in service in the laboratory stable was the second animal to be thus inocu- 
lated in this country, the first being one inoculated under the auspices of the 
Board of Health of New York city. All this was done out of the 
Marine Hospital fund, and the antitoxin obtained was distributed to the 
marine hospitals of the United States, while the method was published in 
the Abstract of Sanitary Reports. 
Added to the duties of this Service have been the establishment and 
maintenance of twelve national quarantine stations, in the perfection of 
which our knowledge with regard to appliances for scientific disinfection 14 
has been greatly increased. An annual appropriation of $137,000 is made 
for the maintenance of these stations. In addition to this, Congress has 
placed upon the Marine Hospital Service the execution of the national quar- 
antine law, with its provision for maritime and interstate quarantine regula- 
tions, and for the collection and publication of sanitary reports and statistics. 
Again, in emergency, the Marine Hospital Service has the expenditure 
of the epidemic fund, from which from time to time, either by direction of 
Congress or by interpretation of the law, special investigations have been 
and are being made, relating particularly to the prevalence, the causes for 
dissemination, and the nature of cholera, yellow fever and small-pox. 
I know of no better way of illustrating what may be done in the matter 
of public health under the present laws, and with the increased agency of 
the Marine Hospital Service, than by giving, as briefly as possible, a sum- 
mary of the work of the Service during the past year. The summary, which 
has not yet appeared in print, is now going through the press. 
OPERATIONS OF THE MARINE HOSPITAL SERVICE FOR THE FISCAL YEAR 
ended June 30. 1896, with certain additional transactions 
TO NOVEMBER 1, 1896 
During the fiscal year ended June 30, 1896, 53,804 patients were treated, 
12,954 in hospital, and 40,850 at the several hospital dispensaries. Aid was 
given to certain other branches of the government service, as follows: To 
the life-saving service by examination of 1297 keepers and surfmen as to 
their physical qualifications, of which number twelve were rejected, and by 
the examination of applicants for appointment as surfmen, of which number 
sixty-three were rejected on account of physical defects. Eleven hundred 
and three pilots were examined with regard to their ability to distinguish 
color, fifty-eight of whom were rejected on account of color blindness. I 
will add that since 1880 every pilot employed on a merchant vessel of the 
United States, whether on the ocean, lakes or rivers, has been examined for 
color-blindness by an officer of the Service. 
. At all the chief ports of entry medical officers have been attached to the 
immigration service for the purpose of medical inspection of arriving immi- 
grants. This is irrespective of quarantine, and is with a view of excluding all 
immigrants with contagious or loathsome disease in accordance with the 
immigration law. 
Five hundred and eighty-two seamen were examined prior to enlist- 
ment in the revenue-cutter service, and twenty-seven rejected. Ten boards 
of officers were convened during the fiscal year for the physical examination 
of officers and seamen of the revenue-cutters. 
Public Health Service, 1896 
Under the head of Public Health Service, the annual report for 1896 
contains the history for the year of the four principal epidemic diseases, 
cholera, yellow fever, small-pox and plague. 
Cholera was violently epidemic in Egypt, and the chief concern was lest 15 
it should be carried to the several Mediterranean ports of Europe, particu- 
larly Naples, from which port came, during the past season, a large pro- 
portion of the immigration to the United States. Arrangements were 
made for prompt notification should the disease appear in Naples; and by 
appropriate action through the State Department, a rigid observance was 
enforced at Alexandria of the treasury regulation prohibiting the shipment 
of rags from cholera-infected ports to the United States. Attention is called 
to the responsibility resting upon the government having territorial juris- 
diction in the countries where cholera finds its breeding-place, and in the 
countries subjected to the incursion of this disease through Mohammedan 
pilgrimages; and by contributed articles the methods are shown by which 
the spread of this disease may be prevented and its prevalence in its breed- 
ing-places be greatly diminished. 
Yellow Fever 
Under this heading are included reports from the sanitary inspector at 
Rio de Janeiro, giving the history of the disease in that city, the cause of 
its continuance,, and showing its ravages particularly among newly-arrived 
immigrants. The statistical tables shows the continued prevalence of the 
disease in Cuba, and the constant danger of its extension to the neighboring 
shores of the United States, particularly from Havana, as set forth at length 
in a special report. 
Small-Pox 
Small-pox is reported as having prevailed in twenty-two States, the 
point of greatest focal activity being the State of Louisiana, where, in New 
Orleans, it assumed an epidemic form, there being to August 1, 1896, 952 
cases and 256 deaths since the first of November last. The epidemic came 
to an end in the early fall. The Marine Hospital Bureau was called upon 
to assist in the suppression of this disease, particularly in Arkansas, where, 
in Crittenton County, a camp was established and other measures taken to 
prevent the extension of the pest to neighboring states; and in Key West, 
Fla., where the State health officer was aided in his efforts by the detail of 
an experienced medical officer of the Marine Hospital Service, who, under 
direction from the Bureau, established and maintained a detention camp. 
Aid was also rendered to New Orleans, Mobile and Apalachicola by the 
general vaccination of the crews of all steamers arriving at those ports. 
National Quarantine Administration-Foreign 
In the enforcement of the quarantine regulations of the Treasury De- 
partment in foreign ports, sanitary inspectors of the Marine Hospital Service 
were maintained throughout the year at Havana, Santiago de Cuba, Pana- 
ma, Rio de Janeiro and Yokohama, and during a portion of the year at 
Honolulu. A full report from the sanitary inspector at Havana gives in 
detail the extreme care exercised to prevent yellow fever being carried to 16 
the United States. Special precautions were taken with regard to bag- 
gage, even during the winter months, the baggage of passengers bound for 
Florida being critically examined, and if considered at all dangerous, 
stamped with a label, which called for disinfection at the port of arrival. 
Several complaints having been received concerning the incomplete 
information furnished by the consular bills of health, instructions were issued 
through the State Department to consular officers, calling their attention 
to the deficiencies and enjoining upon them a strict compliance with all 
details of the regulations. 
Reports from two United States consuls, one at Havre, France, and 
the other at Kobe, Japan, are published in full as illustrating the value of 
intelligent observance of the quarantine regulations of the Treasury De- 
partment, which are to be enforced in foreign ports immediately on the ap- 
pearance of epidemic disease. 
Administration of the Treasury Quarantine Regulations at Quarantine 
Ports of the United States 
In the enforcement of the quarantine regulations in United States ports 
there were thirty-four fines imposed upon vessels entering without the con- 
sular bill of health required by the act of February 15, 1893. 
Several circular letters containing amendments to and instructions con- 
cerning the regulations, were issued, including the following subjects, 
namely: Notification to be given to State health authorities of the interior, 
of the departure of immigrants arrived upon vessels upon which contagious 
disease has appeared: Relapsing fever made a quarantinable disease: 
Quarantine order requiring at national quarantine stations the disinfection 
of vessels from suspected latitudes unless specially authorized by the Bureau 
to give pratique without disinfection: Request made of all State and local 
quarantines to send weekly reports to the Bureau for publication in the 
weekly edition of the Public Health Reports, which are transmitted to all 
quarantine stations, concerning trespass on quarantine anchorage, upon 
the boarding of vessels by unauthorized persons before inspection; and 
upon the right to forcible detention of persons in quarantine. The report 
also gives an account of special measures to prevent the introduction of 
yellow fever into Key West through Cuban refugees or returning filibusters; 
also the measures taken to secure the co-operation of the Canadian authori- 
ties in enforcing the disinfection of baggage of all Chinese immigrants 
arriving at ports on the Pacific coast. Included also are contributed articles 
by experienced quarantine officers of the Service upon the details connected 
with the management of national quarantine stations, and the interpretation 
of the quarantine regulations. 
Included, also, are reports in detail from each of the twelve national 
quarantine stations, showing the operation of each station during the year. 
Also full reports of the inspection of each of the State and local quarantine 
stations and ports of entry throughout the whole coast of the United States, 
from Maine to Washington,by seven medical officers, to each of whom a 
district was assigned. 
Relations with State and Local Quarantine Authorities 
The relations of the Marine Hospital Service with the State and local 
authorities have been of an amicable character, although a number' of 
differences of opinion have naturally arisen relative to respective rights and 17 
propriety of procedure. The local authorities, almost without exception, 
have given their hearty cooperation to the Bureau. At Portland, Maine, 
the authorities request the government to take possession of the station. 
At Baltimore, by reason of representations made, the quarantine inspection 
service is now maintained throughout the year, instead of, as formerly, 
through the summer and fall months only. At Key West, a steam disin- 
fecting chamber has been provided, as required by the Treasury Regula- 
tions, the attention of the authorities having been called to the necessity of 
this provision. At Apalachicola, a sanitary inspector of the Marine Hos- 
pital Service was appointed during the winter months to make the necessary 
inspection of vessels, the local quarantine having been discontinued, and 
later the regulation requiring disinfection of vessels from ports infected with 
yellow fever has been enforced by directing the collector of customs to re- 
fuse entry to vessels from said ports, unless provided with the certificates 
of discharge from a fully-equipped quarantine station. It was found that 
an attempt was made to disinfect vessels without the proper appliances. 
The support of the Bureau was given to the State health officer of 
Florida in his controversy with the city council of Key West at the time 
small-pox was epidemic in that city, and pecuniary assistance was rendered 
the same officer by the establishment and maintenance of a camp for the 
detention of those who had been exposed to the disease. 
The relations of the Marine Hospital Bureau and its representative in 
New Orleans with the president and quarantine officers of the Board of 
Health of Louisiana are amicable, but the Board of Health, as shown in the 
report, objects to federal surveillance as required by the act of Congress of 
February 15, 1893. 
At San Francisco, while the quarantine station on Angel Island has 
always been under the management of the Marine Flospital Service, the 
boarding and inspecting of vessels has until recently been carried on by 
the local quarantine officer. Congress, during the last session, made ap- 
propriation for placing the boarding vessel belonging to the Marine Hospital 
Service in commission, and accordingly the Service is now performing the 
full quarantine function at this port. Some objection was made at first on 
the part of the San Francisco Board of Health, but subsequently the same 
Board transmitted a special request to the Secretary of the Treasury to the 
effect that the collector of customs be directed to require the quarantine 
certificate of the national quarantine officer before admitting vessels to entry. 
The portion of the report devoted to the quarantine service terminates 
with a special paper, showing the necessity of a strictly national quarantine 
service. 
Division of Sanitary Reports and Statistics 
The editing of the Public Health Reports, issued weekly by the Bureau, 
has been conducted in this division. A table of mortality statistics for the 
calendar year 1895 is presented, based upon replies to a circular letter ad- 
dressed to all cities and towns in the United States having a population, 
according to the census of 1890, of 1,000 or more. Three thousand, seven 
hundred and fifteen of these circular letters were sent out, and 1,715 replies 
received. From these replies the table of mortality statistics of 1,461 cities 
and towns has been prepared. An inquiry has been begun by circular letter 
with a view to ascertaining the laws and regulations at present in force in 
the different states and municipalities to prevent the spread of tuberculosis. 18 
Hygienic Laboratory 
In the hygienic laboratory investigations have been continued with 
regard to diphtheria antitoxin; the etiology, pathology and prophylaxis of 
pneumonia; and concerning vaccinia and the serum therapy of small-pox. 
Other subjects of investigation in the laboratory have been: the water- 
supply of Washington, D. C.; enteric and malarial fevers; the disinfection 
of the mails, bank-notes, library and school-books; the sanitary condition 
and disinfection of railway coaches; and a new disinfecting agent, formal- 
dehyd gas, by the use of which the process of all disinfection promises to 
become simplified. 
Other public-health measures conducted by the Service have been an 
inquiry by circular letter concerning the water-supply and disposal of sewage 
and garbage of the cities and towns of the United States, the bacteriological 
study of the water-supply of San Francisco, and a consideration of the 
prevalence and prevention of the spread of tuberculosis. 
The closing portion of the report gives a brief description of the health 
service of the United States as it now exists, and resolutions passed by cer- 
tain medical and sanitary associations relative to the enlarging the scope 
and facilities of the present organization. 
WATER POLLUTION 
Among other matters now engaging the attention of the Bureau may 
be mentioned the subject of the pollution of water-supplies, when such pol- 
lution affects, or threatens to affect, the sanitary conditon of the people of 
more than one State. A bill providing for a commission for an investiga- 
tion of this character has been introduced in Congress, and the following 
are extracts from an official report showing its necessity: 
Official Report 
The importance of investigating the pollution of the water-courses and 
other water-supplies which are of necessity utilized for drinking purposes,, 
cannot be questioned when we consider the enormous number of cases of 
illness and death which are annually caused by waters which are polluted 
with sewage and garbage. As time goes on, the situation becomes more 
and more complex, and is fraught with greater danger by reason of the 
increase in population and the dependence upon streams as the source of 
water-supply. 
The diseases which are carried by water are cholera, typhoid fever, dys- 
entery, diarrheal diseases, malarial fever, and, exceptionally, diphtheria, 
glanders and anthrax. 
With regard to cholera, its frequent spread through the infection of 
rivers furnishing the water-supply of cities has been demonstrated in nearly 
all European countries. With regard to the other diseases mentioned, the 
literature upon the subject shows that they were carried by streams con- 
veying the specific infection of each disease, but the exact distance to which 
the specific infection of each disease may be carried has not been determined, 
nor the exact relation that the sewage bears to the spread of the disease. The 
quantity of sewage which may render the water of any particular stream 
unhealthful; the amount of dilution of the sewage, or other treatment thereof, 
necessary to prevent the lethal contamination of a particular stream; and 
the effect of sewage pollution upon the seasonal prevalence of disease, are 
as yet undetermined problems in the United States. It cannot be questioned 19 
at this day that sewage pollution of a water-supply is responsible for the 
majority of the diseases above mentioned. 
With regard to typhoid fever, no subject is attracting the attention of 
the sanitarians of the United States more widely at present than its spread 
through polluted water-supply. The prevalence of typhoid fever throughout 
the United States during the past year has been very marked. During the 
calendar year 1895 the reports received at the Marine Hospital Bureau 
show that, of the cities and towns making report to the Bureau, located on 
the Mississippi river, with a total population of 1,260,143 (census 1890), 
there were 490 deaths from typhoid fever, and an estimated number of 
4,900 cases; that of similar cities and towns on the Ohio river, aggregating 
a population of 1,141,527, there were 1,980 deaths reported, with an esti- 
mated number of 19,800 cases, or in a total population of 2,401,670 of cities 
reporting on the Ohio and Mississippi rivers, there were 2,470 deaths and an 
estimated number of 24,700 cases. 
On the great lakes the cities of the United States reporting to the 
Marine Hospital Bureau in 1895, aggregating a population of 2,625,775, 
reported 188 deaths, with an estimated number of 1,880 cases. It should 
be remarked that two of the great cities on the lakes (Chicago and Buffalo), 
aggregating a population of 1,420,000, are not included in the above statis- 
tics. These cities failed to send in 1895 the weekly reports from which these 
statistics are compiled, but in the annual reports for the previous year there 
were 592 deaths reported, indicating 5,920 cases. Adding these cases and 
deaths to the totals above, it would give an annual total of 780 deaths and 
7,800 cases of typhoid fever in the cities of the United States on the great 
lakes, aggregating a population of 4,045,755. 
From the above statistics it is estimated that every year there are no 
fewer than 45,000 deaths caused by typhoid fever alone throughout the 
United States, not to speak of diarrheal diseases, which latter will augment 
the above number by half, and, based upon an estimated mortality of ten 
percent, it is within reason to assume a yearly prevalence of 450,000 cases 
of this disease. To what extent the prevalence of typhoid fever is due to 
the infection of the rivers and lakes from which cities take their water-supply 
will be one of the subjects for the investigation. The carrying of this disease 
from one city or town to another by means of water-courses has been defi- 
nitely proved both abroad and in the United States, and the presumption is 
strong that in the Ohio river, taken as an example, which is the sewer and 
at the same time the source of water-supply for nearly all the cities located 
upon its banks, this and other diseases are annually disseminated thereby, 
and it is one of the prime objects of this bill to determine this point accu- 
rately. i 
There are a number of other streams, such as the Mississippi, Merrimac, 
Connecticut, Potomac, Missouri, the Red River, the Red River of the North, 
the Columbia and Wabash rivers, the cities on which in different states show 
a marked prevalence of typhoid fever. 
In the event of cholera obtaining a lodgment in the United States this 
accurate knowledge would be of the utmost importance, for while the con- 
veyance of this disease by water-courses has been demonstrated in Euro- 
pean countries, the conditions relating to the amount of sewage, the length of 
the water-courses, and so forth, are so different in the United States as to 
absolutely require specific investigation. In other words the conclusions 20 
to be drawn from experiments in foreign countries are not sufficient for the 
needs of this country. 
This subject has long been one of inquiry in England, and the investi- 
gations made and conclusions reached have been of inestimable value to a 
great majority of the cities and towns which were compelled to depend upon 
streams for their water-supply. The same action has also been taken by 
the sanitary authorities of France and Germany with equal benefit to their 
people. 
In the United States it is impossible for one State bordering upon a 
river, even by most stringent laws, to protect the health of its citizens, 
because it has no jurisdiction over others. As our urban populations are 
rapidly increasing and the question of supplying this great number of people 
with a sufficient supply of potable water is becoming more important, it 
behooves our government to give aid to this by at least pointing out some 
efficient remedy for this great disturber of the life and happiness of our 
people. I am informed that fourteen State boards of health, the National 
Conference of State Boards of Health, and the American Public Health 
Association have passed resolutions urging an investigation of this character. 
TUBERCULOSIS 
Tuberculosis is also receiving the attention of the Bureau by an effort 
to establish an arid region sanitarium for the care of the tuberculous patients 
of the Marine Hospital Service, thus relieving the hospitals of these con- 
tagious diseases and preventing their infecting the forecastles and other 
places occupied by the crews of vessels. Car sanitation, previously referred 
to, is another measure in the same direction. 
The bill introduced into the House of Representatives by Representa- 
tive Burton, of Cleveland, and which has been endorsed by the Chamber of 
Commerce of this city, "To provide for the medical inspection of emigrants 
at ports of debarkation," is one with which I am in thorough sympathy, and 
will aid to the extent of my ability. 
I have not in the foregoing pages suggested what additional legislation 
is necessary or desirable to be engrafted upon that already existing, nor 
have I anywhere stated that there should be or should not be a department 
of public health, or a bureau of public health. These are matters for fur- 
ther consideration, and which I would not wish to treat of on the present 
occasion. I have endeavored simply to place various facts before you which 
I have never seen set forth in consecutive detail, and I do not pretend even 
to have exhausted this branch of the subject, though I fear the same may 
not be said with regard to your patience. 
In conclusion, Mr. President and gentlemen of the Society, and mem- 
bers of the Chamber of Commerce, who have honored me with your pres- 
ence, permit me to express my grateful appreciation of the honor conferred 
by the invitation sent me, and to thank you for your courteous attention. It 
is a privilege and a pleasure to address a society whose members have shown 
such active and patriotic interest in matters relating to the medical profession 
and to public health, in a city whose representative business men manifest a 
like interest and cordial cooperation with the medical profession.