add R S / 
IN 
STATE MEDICINE AND PUBLIC HYGIENE 
UKPORK THK 
AMERICAN MEDICAL ASSOCIATION, JUNE 6, 1878. 
BY 
J. L. CABELL, M.A., M.l)., LL.D., 
UNIVERSITY OF VIBGINIA. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1 8 7 8. ADDRESS 
IN 
STATE MEDICINE AND PUBLIC HYGIENE 
BEFORE THE 
AMERICAN MEDICAL ASSOCIATION, JUNE 6, 1878. 
BY 
J. L. CABELL, M.A., M.D., LL.D., 
UNIVERSITY OF VIRGINIA. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1 8 7 8. ADDRESS IN STATE MEDICINE AND PUBLIC 
HYGIENE. 
Inasmuch as a special ordinance of the Association makes it 
the duty of your Permanent Secretary to report annually the 
names of States where boards of health exist, and also of those 
which decline to establish them ; said report to form a part of the 
annual proceedings of the Association, I am thereby relieved of 
this portion of my duty in relation to the advances in State Me- 
dicine during the past year. I cannot, however, forego the op- 
portunity of saying that the establishment of a general board of 
health is the indispensable initial measure of any systematic effort 
to inaugurate State Medicine in any of the States of the Federal 
Union. What has been accomplished in this direction during 
the past year will be reported by the Secretary in conformity 
with the requirements of the ordinance to which I have alluded. 
What may be effected towards the protection of the health of 
communities by judicious sanitary legislation conceived and sub- 
sequently carried into execution by the sanitary advisers of the 
State is strikingly exhibited in the result of an obstinate contest 
of the butchers of Boston with the State Board of Health, a con- 
test which continued for five or six years, but which finally ter- 
minated in a complete triumph for the board by the abatement 
of a nuisance of great magnitude and of an extremely dangerous 
character, affecting the populous town of Brighton, which there- 
after became a salubrious and agreeable place of residence. Dr. 
Bowditch, President of the Board, has stated that it required a 
“thirty years’ war” before the legislature of Massachusetts was 
conquered, but in view of what has been effected by his board, 
assuredly the fruits of this victory have amply compensated for 
all the labor expended in the protracted contest, and the lesson 
is one by which others may profit. 4 
ADDRESS IN 
The first step taken by the newly created board was to address 
a circular letter to the civic authorities of every city and town, 
to every member of the legislature, and to every physician and 
clergyman in the commonwealth, inviting their sympathy and 
co-operation, and especially soliciting the nomination of “a me- 
dical correspondent in every town to whom they could apply for 
local information,” some physician possessing the confidence of 
the local community who would be willing for the public good 
to report to the board facts relating to disease occurring within 
the jurisdiction of his town. I cite this fact, which as relating to 
voluntary services of private individuals may at first view seem 
to have but little bearing upon the question of State Medicine, 
not only because such services, solicited by the official sanitary 
advisers of the State, were designed to be in aid of the newly in- 
augurated system of State Medicine, but also and chiefly because 
it serves to exemplify one of the ways in which the ground may 
be prepared for State action. 
It was, doubtless, foreseen by these earnest pioneers in the 
work of inaugurating State Medicine in America, that legislation 
was little likely to go ahead of popular opinion and consent, or 
to be of much practical utility if it were thus pressed forward, 
and they, therefore, recognized the importance of directing the 
attention of the citizens to well-authenticated and significant facts 
collected in their respective communities by physicians in whom 
they could confide. Then, it was hoped, the demand for sanitary 
legislation would come up from the people themselves. 
Now, as to the value of sanitation in general in increasing the 
salubrity of localities and diminishing the death-rate, some very 
remarkable illustrations recently stated in a public address by 
that eminent lay sanitarian, Mr. Edwin Chadwick, may be cited 
here as an exponent of the latest “ advances and discoveries” 
in the practical applications of sanitary science. This address 
“On the Present Position of Sanitary Science, for its Future 
Practical Advancement,” was delivered by Mr. Chadwick as Pre- 
sident of the Health Section of the British Social Science Asso- 
ciation, at Aberdeen, September 13, 1877, and contains many 
striking and suggestive facts which, so far as I know, have not 
been published elsewhere. He has successfully shown that a 
Norma of Sanitation for the infantile stages of life may be estab- 
lished with factors that go to the prevention of an annual excess 
of upwards of 50,000 deaths in the school stages of life, in England STATE MEDICINE AND PUBLIC HYGIENE. 
5 
and Wales. The details of this statement are so interesting and 
important as to justify the recital somewhat in extenso. 
“ In 1838 there fell to the direct administration of our Poor Law Board, of 
which I was secretary, two large institutions for the care of destitute orphan 
children, which suffered severely from passing epidemics of typhus fever. In one, 
at Norwood, containing 700 children, there was a severe outburst of typhus fever, 
by which more than one-third were attacked and more than thirty (30) were 
killed. The general declaration of medical men at the time was, that the mor- 
tality was occasioned by deficient food. But the food was better and more 
abundant than the food of the independent wage classes. I got the case ex- 
amined by the late Dr. Neill Arnott, who was a specialist in one element of sani- 
tation, viz., ventilation. He pronounced the main evil to be not deficiency of 
food, but deficiency of pure air, and the remedy was the constant removal of pu- 
trefying matter by good drainage, and of foul air by ventilation. This was adopted, 
with the result of a reduction of the death-rate by about one-third. Next 
followed the production of clean skins, by regular head to foot ablutions with 
tepid water ; and this was followed by the reduction of about another third of the 
ordinary death-rates. Other improvements in detail have followed chiefly in phy- 
sical training. As sanitary improvement has advanced in these institutions 
there have been fewer inmates of the sick wards, to the extent that not one- 
fourth of the beds provided for sickness are now actually occupied. The par- 
ticular institution first attacked, and now eight other large orphan institutions, 
district asylums, are in fact children’s hospitals, where numbers are received 
only to die. All the inmates as a class are of the most wretched type of children, 
all weakly and susceptible to disease; but of those who come without marked 
disease, there is now an almost absolute immunity from the children’s epidemics. 
Oases of typhus, at one time scarcely ever absent, have not been seen there for 
several years. The mean death-rates in these institutions have been steadily 
reduced to about 3 in 1000, that is to say, nearly one-fouth of the general 
death-rate of children of the school ages, including the children of the well-to- 
do classes of the 'population. It was recently stated, as evidencing the success 
of the “ boarding-out” system, that the deaths had not exceeded 2 per cent.; and 
this may be taken as an average children’s death-rate for the cottage, that is to 
say, 20 per 1000, as against 3 per 1000 in the district orphan institution, with 
little variation in the separate institutions. Medical officei’s in charge of them, 
but who are in private practice, have repeatedly expressed to me their astonish- 
ment at these results of sanitation as surprising and wonderful to them. I was 
lately present at a prize given to agricultural laborers by Lord Shaftesbury, where 
one prizeman was a shepherd, who, out of 100 lambs he had reared, had only 
lost one. Such emulation may well be directed to the preservation of human 
life in infancy. On a visit to one of these orphan institutions, I told the govern- 
ess that the Queen of the Belgians had offered a gold medal to whichever mana- 
ger of such institutions should rear the greatest number of infants, and I asked 
the governess whether she would compete in conservancy of life against that 
shepherd with his lambs. She proudly declared that she would do more than 
that, and with the infants of the ages under her care she really has done more.” 
Mr. Chadwick adds the very significant and suggestive fact that 6 
ADDRESS IN 
the schools in which such remarkable results have been obtained, 
are “ on the half time principle, introduced with the Factory Acts 
as preventive of the physical injury done by over-sedentary work 
in the long time schools, and that by a better adjustment of the 
book teaching to the children’s mental powers of receptivity, and 
by the freshening up of the faculties by brisk gymnastic exercises 
and the military drill, these children, though naturally of an in- 
ferior mental type, are got well through the three R’s in less 
than four years as against seven in the common elementary 
schools, and at half their cost for teaching power; and with the 
economical outcome, that the efficiency of three is imparted to 
two for industrial occupations.” 
lie then proceeds to show that an equally favorable norma 
of sanitation may be attained for the adult stages of life of the 
ages of the prison populations, men being taken from the ranks, 
where the death-rates were 17 per 1000, and put into prisons 
where the death-rates were only 3 in 1000, and that these results 
were obtained by very rudimentary means and are evidently 
susceptible of further advances. 
Adverting to the decimation by reason of insanitary adminis- 
tration of the first army sent by England to the Crimea, and the 
saving of the second army as a result of the sanitary measures 
instituted by a special Royal Commission sent out for the pur- 
pose, that army returning in a better condition of health than 
the army at home, Mr. Chadwick comments upon the failure of 
the government to recognize by suitable rewards the services of 
the able men who had accomplished such a saving of valuable 
lives. “It marks,” he says, “the antipathy, or at least the 
apathy, with which sanitation has to contend—of which other 
large examples may be adduced — that whilst every official 
through whose misfeasance the first army was lost was decorated, 
not one of those through whose sanitary science the second army 
was declared to have been saved received then or since the 
slightest notice for the achievement.” 
After citing statistical records to show the extremely satisfac- 
tory results of sanitation in the British army and navy, the 
Indian army, for example, of which the death-rate, according to 
the report of a Rojml Commission of Inquiry as late as 1859, 
had since the first occupation of the country oscillated around 
69 in 1000, having now a death-rate of only 17.48 per 1000, Mr. 
Chadwick argues that it is perfectly practicable to obtain favor- 7 
STATE MEDICINE AND PUBLIC HYGIENE. 
able normas of sanitation by local or private effort for the pro- 
tection of civic populations. Thus in the blocks of model dwell- 
ings in London erected by voluntary associations the death-rates 
range separately from 14 to 17 per 1000, which is an important 
advance on the general death-rate of 23 in 1000. But the real 
gain is far greater than is indicated by this comparison with the 
average death-rate of a large city. The comparison should 
rather be made with the death-rate of the ordinary dwellings 
occupied by the wage classes, which is very far above the gen- 
eral average. 
Similar testimony is borne by Dr. Russell, medical officer of 
health of the city of Glasgow, who states that “ in the large 
model lodging-houses of the corporation a case of fever is the 
greatest rarity and never spreads. In the common lodging- 
houses belonging to private individuals we have fever oftener, 
but there again it never spreads; that is to say, as it does in the 
defective houses of the wage classes.” Adverting to Mr. Chad- 
wick’s norma of sanitation in prisons, Dr. Russell is convinced 
that if he had perfect command over all the Irish in Glasgow, as 
the governor of a prison, he could reduce the death rate fully 
one-half in five years, or in less time than that. 
On a full survey of all the facts obtained from recent returns. 
Mr. Chadwick feels warranted in affirming, that by vigorous and 
thorough sanitation the general death-rate of London might be 
reduced from 22 to at most 17 per 1000, and that of the provin- 
cial cities in the manufacturing districts in yet greater pro- 
portion.1 
Equally significant examples of the beneficial results of sani- 
tation in general might be cited to an indefinite extent, but these 
may suffice. Special sanitary reforms require a previous knowl- 
edge of the special nuisances to be abated, and this knowledge is 
obtained or verified by mortality and sickness statistics. One of 
the early measures to be inaugurated by a State Board of Health 
relates to a proper and effective system for the collection of 
statistics of disease and death throughout the entire State, a 
measure which is obviously impracticable otherwise than under 
the sanction and authority of the State. Registration of deaths 
1 Mr. Chadwick concluded the Address referred to in the text, by a valuable 
summary of the chief results obtained of the progress of the power of sanitation, 
which is reprinted in The Sanilurian, of New York, of June, 1878. 8 
ADDRESS IN 
and of the causes of death, inestimable as such registration may 
be, will not, however, answer all the requirements of Preventive 
Medicine. By means of mortuary statistics we may make the 
disasters of the past available as monitors to warn and instruct 
us as to the means of averting their recurrence in the future, but 
they are gathered too slowly to avail for contemporaneous pro 
tection. It is only by the registration of current diseases that 
we can hope to secure the application of prompt and efficient 
measures in the interest of special sanitation. Moreover, it is 
not exclusively, nor even, perhaps, mainly the mortal diseases 
which entail affliction and pecuniary loss upon the individual 
citizens and constitute a heavy burden on the State, for many 
diseases which seldom or never prove fatal do vet rob life both 
of its joy and its usefulness, and effectually destroy its working 
and productive energies. It is, therefore, of the first importance 
to have an accurate record of existing disease as early as possi- 
ble afLer its appearance in any locality in which it is desired to 
establish the most favorable norma of sanitation. 
A general and complete registration of diseases has not yet 
been found practicable in Great Britain, or in any of the States 
of our Union. A praiseworthy attempt to inaugurate a plan of 
reporting the prevalent diseases of the State was made by the 
State Board of Health of Massachusetts in 1875, in conformity 
with the suggestions of Dr. F. W. Draper. It was hoped that by 
the voluntary co-operation of a large number of regularly edu- 
cated, intelligent medical men, whose field of practice was so 
distributed as to enable them in the aggregate to give a compre- 
hensive and accurate weekly conspectus of the diseases prevalent 
in the entire State, to obtain a sufficient number of returns each 
week to admit of useful generalizations. In the 8th Annual 
Report it is stated that a little more than one-half the number 
who agreed to co-operate sent in their reports each week from 
about ninety out of the three hundred and forty one cities and 
towns of the State. Unfortunately, too, for comparison, the 
physicians not reporting were not the same from week to week. 
A similar experiment is now in progress in Michigan under 
the auspices of the State Board of Health, with what degree of 
success we are not yet informed. 
Dr. B. W. Richardson referring, in an Address delivered be- 
fore the Sanitary Institute of Great Britain, July 5th, 1877, to an 
effort he had made many years ago to carry out a plan of regis- 9 
STATE MEDICINE AND PUBLIC HYGIENE. 
tering the diseases of the Kingdom, states that in a short time 
fifty medical observers were sending in returns of epidemic dis- 
eases, to which his plan at that time was limited, from as many 
stations, which could easily have been increased to any extent. 
It was during this period that the first account of the invasion 
of England by diphtheria was contained in the returns from the 
district of Canterbury. “This disease first appeared in the little 
village of Ash, and was called the Ash fever. The first facts of 
a new disease were thus recorded on the spot which,” says Dr. 
Richardson “is something even as a matter of history. How 
such a fact, reported at once to a central government authority, 
might be dealt with ; how promptly a central authority so advised 
might act in arresting a fatal epidemic at its origin, and what 
national service is rendered thereby,” it is not difficult to con- 
ceive He then urges the importance of pressing this scheme for 
the registration of disease on the government, and thinks that 
the Sanitary Institute may greatly assist the work by lending its 
mind to the best means of collecting the facts on which the weekly 
reports of disease will have to be based. 
It appears from the concurrent testimony of all who have in- 
quired into the subject that the registrations of deaths in the 
several States of this Union, and consequently of the whole 
country, is extremely defective. Even in Massachusetts under a 
system closely similar to that which in England has reached so 
high a degree of perfection, the State Board of Health has recently 
reported very glaring defects, and Dr. Henry B. Baker, the able 
and earnest Secretary of the State Board of Health of Michigan, 
has declared that “no method has yet been found, or at least 
acted upon, whereby the actual death-rate can be positively 
ascertained for the United States, or, so far as he knows, of any 
single State.” 
Now, here is a crying evil for which legislation is urgently 
needed. If it be “not too much to say that modern sanitary 
science owes its existence to the registration of deaths and their 
causes, and the localization thereby of insanitary conditions,” the 
importance of complete and accurate records can scarcely be ex- 
aggerated, for death returns are, in default of yet more general 
sickness returns, the basis of all sanitary statistics. It can be so 
easily shown by the irresistible logic of statistics that no amount 
of taxation likely to be called for for sanitary improvements can 
be half as burdensome to a community as the losses entailed by 10 
ADDRESS IN 
preventable sickness, and that consequently the outlay required 
for sanitation is the most remunerative investment which a com- 
munity of ta'x-payers could possibly make.1 
Let us, therefore, not relax our efforts until in all the States 
of the Union, we shall have obtained results equal to those re- 
alized in Great Britain by the Public Health Act of 1875, which 
Dr. Richardson characterizes as “splendidly comprehensive.”2 
Notwithstanding her pre-eminence in matters of State Medicine 
the leading sanitarians of that great Empire are never weary in 
their efforts to popularize the knowledge of sanitary principles 
and practice, an example which, I rejoice to know, is cltfifcly 
followed bv those zealous pioneers in the cause of sanitary im- 
provement who started the scheme of an American Public Health 
Association and have done so much to impart interest to its 
annual meetings. 
In view of the actual and prospective success of such systematic 
sanitation in England, some writers in that country seem to ap- 
prehend an overplus of population and to entertain doubts 
whether there was not more harm than good in such success in 
sanitary work. “ Medical science,” says Mr. Grey, “ is mitigating 
1 “The total annual loss and cost occasioned by illness from zymotic diseases 
in this country (England), if it fell upon the wage class alone, would amount 
annually to more than £2,500,000. Then there was the loss from imperfect re- 
coveries, such as eye-diseases following measles, blindness following zymotic 
diseases. If such evils were to fall for the first time upon a community paying 
heed to sanitary regulations, scarcely any effort would be thought too great for 
their removal. It was only the deadening influence of habit, which enables so 
many among ourselves to regard them with comparative indifference. It would 
be too much to say that all zymotic diseases could be removed by proper legisla- 
tion and adequate care ; but past experience was distinctly in favor of the pro- 
position.”— R. Brudeuell Carter, “ On the Present Possibilities of Sanitary Legis- 
lation,” Sanitary Record of October 12, 1867. 
2 In giving a rapid summary of the beneficent provisioiPof the Act, Dr. Rich- 
ardson specifies “ the constitution of sanitary authorities throughout the Kingdom ; 
the power it invested in those authorities to appoint learned medical others of 
health, the provisions it made for securing to each locality better sewerage, free- 
dom from nuisances, improved water supply, regulation of cellar-dwellings, 
governance over offensive trades and removal of unsound foods ; the provisions for 
prevention of spread of infection, and for the erection of hospitals and mortuaries ; 
and the provisions for the regulation of streets and highways, lighting of streets, 
establishment of pleasure-grounds and regulation of slaughter-houses; these as 
well as the general provisions for the carrying out of the Act, were, in his opinion, 
most commendable as practical plans by the working of which the nation may be 
tempered into a saniiary mould of thought and character.”—Nature, July 5, 
1877, p. 185. STATE MEDICINE AND PUBLIC HYGIENE. 
11 
suffering and achieving some success in its warfare against dis- 
ease; but at the same time it enables the diseased to live. It 
reduces the aggregate mortality by sanitary improvements and 
precautions; but those whom it saves from dying prematurely, 
it preserves to propagate useless and imperfect lives.” 
Dr. Ransome in quoting this remark gives an overwhelming 
answer from Mr. Grey’s own point of view. “It appears,” he 
says, “to be forgotten that most of the evils that we deplore in 
our town populations, the disease and feebleness from which they 
suffer are the direct outcome of the unhealthy circumstances in 
which they live. If the conditions of existence in towns continue 
as they now are, if the fever nests, the breeding places of scrofula 
and consumption, the temptations to intemperance and vice, are 
left unchecked to do their malignant work, then indeed we may 
certainly look for deterioration of race, but sanitarians will not 
be responsible for the result.”1 
In the last volume of the Transactions of this Association, an 
excellent paper on the “Relation of Heredity to Race Degenera- 
tion and Improvement,” by Dr. Black, of Ohio, contains the re- 
cords of a number of typical instances of recovery or reversion 
from inherited to disease, when the conditions favorable 
to such reversion to the normal state have been faithfully and 
skilfully carried out. 
Then, as to the Malthusian fallacy, a sufficient refutation had 
been given by Dr. Wm. Farr, who, from his masterly deductions 
1 Never was man more belied than Malthas is by his new-found friends. 
He never, like them, proposed to rest satisfied with a high rate of mortality, and 
to look calmly on while this modern massacre of innocents was taking place, for 
he says “ a decrease of mortality at all ages is what we ought chiefly to aim at.” 
And again “ a young person saved from death is more likely to contribute to the 
creation of resources than another birth. It is a great loss of labor and food to 
begin over again.” 
But all the preventive checks named by him, except the prudential check, 
must inevitably lead to a great deterioration of race. The checks that he never 
really sanctioned, but with which our friends are apparently afraid to interfere, 
pestilence, unwholesome trades, misery, and vice, all these necessarily lower the 
standard of life and endanger the future well-being of the nation. The prudential 
check to population would, of course, be a splendid invention, if it could be pru- 
dently regulated, or if individual judgment could be trusted. It is still a question 
how far restrictions upon marriage can be imposed by the State without harm ; 
but if the matter be left to individuals, as Galton has shown, only the improvident 
will breed and the race will infallibly become of a lower type.”—Dr. A. Ransome, 
“On the Present Position of State Medicine in Great Britain,” Public Health, 
August 24, 1877. 12 
ADDRESS IN 
drawn from the vital statistics of England, concluded that “the 
great source of the misery of mankind is not their numbers, but 
their imperfections, and the want of control over the conditions 
in which they live.” In like manner Dr. Nathan Allen, of Massa- 
chusetts, in a series of admirable papers published during the 
last few years, has conclusively shown that the decrease of the 
native element of the population of New England cannot be due 
to the causes usually assigned for such an effect, since these 
causes have scarcely occurred, and if they had occurred, would 
have operated on the foreign as well as the native elements of 
the population. He gives good reasons for believing that the 
effect is to be explained by a gradual change in the physical 
organization in both sexes, “in the case of the males in giving 
up manual labor, physical exercise, and out-door work generally, 
for lighter employment in the shop and business that taxes the 
brain far more than other parts of the body. In the case of 
females giving up housework and employment which make a 
severe demand upon the muscles, in giving more attention to 
mental pursuits, to the fashions of the day, to the artificial habits 
of society and what may be called the luxuries of modern civili- 
zation. These and other causes, commencing in early life, have 
served to impair not only the strength or stamina of the constitu- 
tion, but to change the harmony or balance of the organization ; that 
is, instead of having a good development of the muscles and lym- 
phatic temperament, we have a great predominance of nerve 
tissue, so that the constant demands of the brain are far greater 
than the physical system as a whole can bear.” 
The evidences of an advance in Public Hygiene with reference 
to the maintenance of the purity of the air within and around 
dwellings consist not so much in the discovery of new facts or 
principles, as in more careful, exact, and honest methods of sani- 
tary engineering, in conformity with well-known laws of sanitary 
science. It can scarcely need to be said that one of the most 
fruitful sources of impurity of the air around dwellings and con- 
sequently of the air within dwellings, since the latter is constantly 
being replaced by the former, is the damp condition of the ground, 
which however well drained of subsoil water at first is liable to 
subsequent contamination with liquid filth whether arising from 
PUBLIC HYGIENE. STATE MEDICINE AND PUBLIC HYGIENE. 
13 
slops thrown upon the surface of yards and gardens, or from the 
dejections of animals. A soil well aerated by proper under- 
drainage would, in a measure at least, oxidize the organic matters 
and mitigate the generation of malaria. It would not, however, 
be safe to rely upon this to disinfect the excrement-sodden soil 
in the streets of cities, and it becomes an important problem of 
sanitary engineering howto protect the atmosphere of cities from 
this source of contamination. This end will probably be secured 
by the best asphalt pavements, such as have been largely used 
in some of the cities of Europe, and have been successfully in- 
troduced into some parts of Brooklyn, and on the principal ave- 
nues of the national metropolis. In addition to the other valuable 
qualities of firmness, noiselessness, durability, with facility of re- 
moval when necessary for laying water or gas pipes, and equal 
facility in repairing the breaches thus made, their non-combus- 
tibility, and finally their comparative cheapness, they are also 
clean and impervious. No water or filth can penetrate them, and 
they are easily cleaned at less expense than any other pavement. 
A necessary condition, however, of the beneficial action of im- 
pervious pavements, is the absolute freedom of the subsoil from 
the sewage contamination which might arise from defective sewers 
or from percolation of the contents of cesspools. The late Dr. 
Parkes, in his report on hygiene for 1873, suggested that a pecu- 
liarity of house construction in Munich, which may have an in- 
fluence in drawing air from great depths, might furnish a solution 
of the facts observed in that city by Pettenkofer and others re- 
specting the relation between ground-water and the prevalence 
of typhoid. 
“The houses in Munich have cesspools beneath them, which 
are emptied by a hose and steam-engine from time to time. The 
cesspools are, in many instances, not cemented; and Wolfsteiner 
mentions that he resides in a large house with many other inhabi- 
tants, and calculates that yearly thirty five tons pass into the 
cesspool under the house; yet in twenty years hardly twenty- 
five tons have been removed ; so that in twenty years six hun- 
dred and seventy-five tons of excrement have soaked into the 
ground. Now in Munich the warm houses help to draw the 
cesspool air into the rooms, and as the streets are beautifully 
paved, and no gas can escape through them, the cesspools and 
houses must be the only ventilating shafts for the soil air.” 14 
ADDRESS IX 
In this connection may be mentioned a proposition made by a 
writer in the Annales d'Hygiene for watering the streets of cities 
which are paved with pulverizable material, as also walks in 
parks and gardens, with a solution of the chloride of calcium in 
lieu of simple water. This is stated to be economical as well as 
wholesome, because the first cost is not high, and one watering 
will last five or six days, while simple water has to be re-applied 
several times a day in the long, hot days of summer. The appli- 
cation of this process to garden-walks has the incidental advan- 
tage of arresting the growth of grass, and thus of saving the cost 
of the usual method of keeping the walks free from grass. The 
editor of the Annales d'Hygiene states that this method has been 
tried with success. 
Dr. Frankland has recently investigated the conditions under 
which organic germs pass from sewage into air, and by means of 
decisive experiments has demonstrated the fact that the breaking 
up of minute gas bubbles resulting from fermentation or putre- 
faction is a cause of the suspension of solid organic particles in 
the air. If, therefore, through the stagnation of sewage, or 
constructive defects which allow the retention of excrementitious 
matters for several days in a sewer, putrefaction sets in, then 
gases are generated, and the dispersion into the air of zymotic 
germs is very probable. It is, therefore, of the greatest import- 
ance that foul liquids should pass rapidly and freely through 
drainage-pipes and sewers, so as to secure their discharge before 
putrefaction sets in. 
It has been known for some years that green wall-papers de- 
teriorate to a hurtful and even dangerous extent the atmosphere 
of sleeping rooms by reason of the arsenical salts with which 
they are colored. It now appears, according to a statement in 
the Sanitary Record of March 15, 1877, that paper-stainers have 
found it an unusually profitable practice to use arsenic in even 
the palest white drawing-room papers, especially those which 
have an enamelled ground. 
In the Sahitary Record for April 13, 1877, Mr. Baldwin 
Latham discussed the importance of hydro-geological surveys 
from a sanitary point of view ; and later in the year, namely, on 
the 5th of October, read a paper on the same subject before the 
Sanitary Institute of Great Britain, at Leamington. He cited 
several instances in which a knowledge of the direction of the 
underground current, as determined by the geological formation, STATE MEDICINE AND PUBLIC HYGIENE. 
15 
would have prevented contamination of wells by appropriate 
location of cesspools. In view of numerous specifications given 
by him it is evident that the assignment of a minimum “pro- 
tective distance” of four or five hundred yards from a cemetery 
gives no guarantee of safety if the well should be below the con- 
taminating source as to the direction of the subterranean flow. 
This recalls the outbreak of typhoid fever at Lausan, near Basil, 
in Switzerland, a few years ago, when it was proved by positive 
experiments that the contaminating material was carried two 
miles under a hill to a village on the opposite side, this village 
being on the direct line of flow of the subterranean water, and at 
a lower grade.1 
The now well-known influence of dampness of soil in causing 
consumption, as demonstrated by Buchanan in England, and 
Bowditch in America, makes it a matter of the first importance 
to select suitable ground for dwelling-houses. When in towns 
and cities such a selection is precluded by the necessity of occu- 
pying a definite spot, and the retentiveness of a stiff clay soil 
does not admit of effectual underground drainage, it is held by 
the best sanitary architects that dwellings should be constructed 
without cellars, and be well raised above the ground, with a free 
ventilation between the surface and the ground-floor of the house. 
As to other sanitary requirements in connection with dwell- 
ings I need say no more than that the greatest trouble relates not 
so much to the want of a clear conception of what is required as 
to the practical difficulties of execution. They are questions of 
1 “In conducting a hydro-geological survey it should be thoroughly borne in 
mind that though, as a rule, water underground follows the natural inclination 
of the surface of the district, often there are exceptions to this iule. There are, 
also, circumstances which may modify the flow of water; such, for example, as 
the abstraction of a large volume of water at a particular point by pumping from 
a well, which well would become the centre for a drainage-area, extending, in all 
probability, for a considerable distance from the well; or in some flat districts the 
elevation of the water-line of a river in time of flcod, may reverse the direction of 
the flow of the underground water, unless, as is the case with some wells which are 
known to be tidal, the volume of water flowing to the river is very large. It is 
scarcely possible in a town where there are so many points for pollution, to so locate 
a surface-well as not to be affected by some of them. The use of the water from 
surface-wells within a town ought, therefore, to be prohibited for domestic pur- 
poses. It is rather singular that, while measures are being adopted for the 
prevention of the pollution of streams flowing on the surface, and which, by the 
way, have never been traced to be the cause of disease, no one has thought of the 
great evils that have resulted and will result from the pollution of the under- 
ground sources of the water-supply.”—Baldwin Latham, loc. cit. 16 
ADDRESS IN 
architectural and sanitary engineering rather than of scientific 
principles. All concede the great importance of thorough venti- 
lation of sewers and soil-pipes, but sanitary engineers still differ 
widely as to the safest and most effective means of accomplishing 
this object. 
I am not aware that any real progress has been made towards 
a definite solution of the great sanitary problem of the purifica- 
tion and final disposal of sewage, since the elaborate reports of 
Dr. 0. F. Folsom, Secretary of the State Board of Health of Massa- 
chusetts, in the 7th and 8th Annual Reports of the Board. From 
these exhaustive reports it appears that purification by the oxi- 
dizing influence of a porous soil is the only process which gives 
satisfactory results, and that these results may be almost complete 
if the operation be well conducted. 
The common practice in America of discharging the sewage 
of cities and towns into the nearest river or running water will 
not long be tolerated where other populations are dependent 
wholly or in part on such streams for their water-supply. 
Massachusetts has already followed the example of Great Britain 
in legislating against the pollution of rivers. 
HOW TO PREVENT THE SPREAD OP CONTAGIOUS DISEASES. 
It is needless to say that there are almost insuperable difficul- 
ties in the way of stamping out the infectious diseases which yet 
are theoretically preventable. In addition to the obstacles arising 
from false ideas of economy intensified by ignorance and sloth, 
we have to encounter yet graver difficulties in the fact that 
nearly all the infectious diseases are subject to epidemic as well 
as local influences, and though the latter are amenable to sanita- 
tion, we know too little of the laws which govern the former to 
be able to attack them with much probability of success. And 
yet the very remarkable manner in which they recur at some- 
what regular periods may and should serve to aid us in our 
efforts to prevent their spread. Dr. Ransome, of Manchester, 
England, has presented some striking illustrations of the cycles 
of recurrence of the epidemics of zymotic diseases; diseases 
which bv their very class name might be supposed to depend 
exclusively on local causes. In a lecture delivered by this 
gentleman before the National Health Society, in May, 1877, lie 
exhibited diagrams representing graphically cycles that have STATE MEDICINE AND PUBLIC HYGIENE. 
17 
been observed for upwards of a century by smallpox, scarlet 
lever, and measles. They displayed in a remarkable manner the 
tendency of these diseases to recur in certain definite periods, 
and they showed moreover the difference between the course 
followed in densely peopled England and in the sparse population 
of Sweden. The period of recurrence for smallpox appears to 
have been six or seven years, that for measles five or six years, 
and scarlet fever has a greater wave-length of fifteen to twenty 
years, with lesser undulations of about five years. The sudden 
interference with the cyclical period of smallpox brought about 
by vaccination is clearly shown, so that Dr. Ransome is inclined 
to think that to point to these diagrams would be a sufficient 
answer to any anti-vaccinationist who presumes to doubt the 
efficacy of this means to arrest the spread of this horrible disease. 
“ We ought,” he says, “always to be on our guard against these 
disorders, but a knowledge of the curve that they usually follow 
ought to assist us in preparing to deal effectually with them at 
their periods of greatest prevalence.” 
lie also considers as suggestive and instructive the curious 
fact that those epidemics which chiefly affect certain organs of 
the body are most common at the season of the year when other 
non-specific affections of those organs are prevalent and in places 
most favorable to those diseases. Thus, whooping-cough and 
measles generally attain their highest prevalence as epidemics 
in the winter and spring when bronchitis and other affectiops of 
the air passages abound. Scarlet fever nearly always spreads 
most rapidly in autumn, and occasionally in the spring, and at 
both these seasons relaxed and ulcerated throats are most com- 
mon. And so for cholera and enteric fever, of which the maxi- 
mum rate of prevalence is in summer and autumn respectively, 
in accordance with an observation of Murchison that “circum- 
scribed epidemics, or the ordinary autumnal increase of fever, 
are often preceded by a great increase of diarrhoea.” “ It may 
be,” as suggested by Dr. Ransome, “that the weakness of par- 
ticular organs affords an opportunity for the entrance of the epi- 
demic poison which has an elective affinity for those organs, and 
we may be able to meet and to ward off attacks of epidemics by 
paying especial attention to the prevention of diseases that weaken 
or predispose those organs to attack.” Dr. I. Sinclair Holden, in 
a paper read at the Congress of the Sanitary Institute of Great 
Britain, at Leamington last October aimed to show that careful 18 
ADDRESS IN' 
investigation could usually discover the rule of law under all the 
apparent irregularity and caprice of contagion. He referred par- 
ticularly to scarlatina, which had been mainly studied in connec- 
tion with severe cases. The mild cases, always the most infectious, 
were not so closely scrutinized and kept under sanitary super- 
vision. Whenever an outbreak occurred a mild case was at the 
bottom of it, whereas where isolated cases cropped up and led 
to no other cases, they were sure to be severe cases. The rationale 
given was that the mild cases shed an almost invisible poison- 
dust from the skin, and were let loose on society in this stage, and 
because they were never really ill, little restraint was maintained. 
Hence the importance of converting the dry scaly dust into a 
moist controllable form, by frequent rubbing of the whole body, 
as soon as the faintest rash appeared, with oil or lard, this in- 
junction being most imperative in the class of mild cases. 
Two members of this Association, who have won honorable 
distinction by their zealous devotion to sanitary studies, have 
recently placed on record their apparently successful experience 
in attempts to control zymotic disease by prophylactic treatment. 
Dr. Ezra M. Hunt, my immediate predecessor as Chairman of the 
Section of State Medicine and Public Hygiene, has published 
two interesting and suggestive articles in the Medical Record of 
New York for Sept. 22 and Dec. 8, 1877, on the prevention of 
scarlet fever and diphtheria by individual sanitation ; Dr. L. D. 
Waterman, of Indianapolis, in a short article in the Practitioner 
of London, for March of the current year, states that his use of 
sulphurous acid administered on antizymotic principles has been 
strikingly successful. 
Dr. E. J. Syson, a medical officer of health, in a well written 
paper on the “Antiseptic Treatment of Zymotic Diseases,” read 
before the Hunfi§ Medical Society and published in Public Health 
for Nov. 9, 1877, puts in a strong claim for antiseptic medicine, 
and states that in 1866, he supposed himself to have discovered 
that it was impossible to vaccinate where the patient was tho- 
roughly under the influence of arsenic, which induced him sub- 
sequently to see how far arsenic would exercise antagonistic in- 
fluence to smallpox. In three cases the results quite confirmed 
his anticipations. Yet more decisive results were obtained by 
the use of the same agent, both as a curative and a prophylactic, 
in cases of rinderpest. 
Dr. E. B. Baxter, whose experimental studies of certain dis- 19 
STATE MEDICINE AND PUBLIC HYGIENE. 
infectants as recorded in the Report of the Medical Officer of the 
Privy Council and Local Government Board for 1875, fully 
warranted his announcing some positive and some negative con- 
clusions of more or less value, has quite recently expounded his 
latest views on the “Theoretical Aspects of Disinfection” in a 
paper read to the Society of the Medical Officers of Health. He 
justly, in my opinion, regards the evidence of the causal relation 
of septic microzymes to putrefactive changes to be now too strong 
to be disputed, which could not have been affirmed with certainty 
so late as three years ago. While abstaining from dogmatic 
assertions as to the completeness of the proof of the parasitic 
theory of communicable disease and as to the vegetable nature of 
contagium particles, he yet recognized certain analogies between 
these contagia and the septic microzymes, and adds that, “if it 
could be empirically ascertained that both stood in much the 
same quantitative relation to certain destructive chemical agencies, 
one might provisionally accept the generalization that germicidal 
was a measure of disinfectant power.” The results of his first 
indirect experiments were not encouraging; the germs of septic 
microzymes appeared far more susceptible than the contagia to 
the operation of destructive agencies. The microzymes had all 
been held in Cohn’s solution, which was neutral in reaction, 
whereas the virulent liquids are mostly alkaline, charged with 
albuminous principles and saline ingredients. The more nearly 
the medium containing the infective particles was made to ap- 
proach the type of pure water, the more easy became the task of 
disinfection : on the other hand, by suspending septic microzymes 
in albuminous and highly alkaline liquids, they became less 
amenable to germicidal influence. Then germicidal power might 
be taken as a measure of disinfectant power provided full allow- 
ance be made for the protective influence of media.1 Holding 
that what might be called the “intrinsic” resistance of contagia 
to destructive agencies was insignificant in comparison with that 
conferred upon them by their media, and remembering their ten- 
1 According to recent researches of Dr. Anders referred to by Dr. Sanderson in 
his lectures on “ the Infective Processes of Disease,” delivered in the early part 
of the current year, in the Theatre of the University of London, “ it was shown 
conclusively that doses of chlorine and salicylic acid which were more than suf- 
ficient to destroy, and actually did destroy, the vitality of the living organisms 
present, left the virulence of the liquid unimpaired.”—British Medical Journal, 
Jan. 5,1878. 20 
ADDRESS IN 
dency to elude our efforts by becoming scattered, it seemed that 
the success of the operation in any given case must depend upon 
the knowledge (1), of the media in which the infective particles 
were contained; (2) of the laws which governed their dissemina- 
tion or propagation. 
This paper was followed at the same meeting by one “On the 
Practical Aspects of Disinfection,” by Dr. Seaton, in which it 
was shown that for bedding and clothing dry heat was the only 
disinfectant to whose action such articles could be conveniently 
subjected. Dr. Seaton described a self-regulating apparatus of Dr. 
Kansome, which consisted of a chamber heated by gas to a tempera- 
ture of about 250° F. Should this be exceeded, a fusible plug 
was melted and shut off the gas. Some blankets and quilting 
from the Infectious Diseases Hospital were exhibited, which had 
been in use for three years, and had been baked over thirty times 
without apparent injury. 
If, then, the contagia were propagated only by continuous de- 
velopment, whether in the infected organism or in the excretions, 
in accordance with Budd’s theory in regard to the contagium of 
typhoid fever, the outlook would, indeed, as suggested by Mr. 
Baxter, “be very hopeful, and we might even anticipate an ap- 
proach to the perfect fulfilment of the work of disinfection, by 
subjecting all matters immediately after their removal from the 
affected person, and before any dilution or admixture, to the full 
influence of one or other among the destructive agencies at our 
com mand.” 
This result is feasible, and ought to be realized in the case of 
smallpox, scarlatina, and possibly some other zymotic affections, 
but, unhappily, this is not the case, as, I believe, with typhoid 
and some others. That typhoid fever—I will not say may be 
generated spontaneously, for I believe it to depend on a living 
contagium, and I do not believe in the possibility of a spontaneous 
generation of living organisms—but that it may appear in a given 
place otherwise than by direct, i. e. recent, importation by either 
persons or fornites has, I think, been placed beyond question.1 
In some of these cases it would appear that the contagia may be 
1 It would surely be unwarrantable to say that a case of typhoid had origi- 
nated spontaneously, that is, that the eontagiuin had originated de novo in the 
spot where it was manifested, until every possible channel by which it might 
have been introduced from without, either at or near the time, or at some not 
very distant epoch, had been excluded. STATE MEDICINE AND PUBLIC HYGIENE. 
21 
wafted in clouds of definite width over long distances, giving rise 
to true wide-spreading epidemics, while in others there is reason to 
believe that germs long buried may be disinterred and be awakened 
into activity by upturning of the soil. It is obvious that in such 
cases artificial disinfection would be for the most part practically 
inoperative. For such modes of approach we can only oppose 
to the morbific agent such defensive measures as cleanliness, 
good ventilation, drainage, the use of uncontaminated water, 
wholesome food, and a brave cheerfulness of spirits. 
ON THE THEORY OF CONTAGIUM VIVUM. 
No other subject within the scope of sanitary inquiry has ex- 
cited greater interest during the past year than that which is con- 
nected with the investigation of the nature of the contagious 
material of the infectious fevers. The doctrine of a contagium 
vivurn has been recently assailed with earnestness and vigor by 
that able and zealous sanitarian Dr. W. B. Richardson. Never- 
theless, that doctrine has been steadily gaining ground, not only 
in the increasing number of its avowed adherents, but still more 
in the variety and significance of the analogies by which it is 
sustained. 
It will be remembered that a little more than a year ago Dr. 
Burdon Sanderson who still holds fast to the doctrine of living 
contagia, seemed to give up the germ theory, in that he denied 
to contagium the attribute of structure in the anatomical sense, 
and maintained that “so far as the morphologist is concerned, 
germs have quietly gone out of court, and given place to things 
which are ultra-microscopical, to molecular aggregates, of which 
all that we can say is, that they occupy the border-land between 
living and non-living things.” I have elsewhere commented upon 
the weakness of the argument implied by this statement, as really 
resting upon no other basis than the limits of microscopic demon- 
stration, and I cited the admission of its author that “after all 
contagium resembles an organism much more than it resembles 
a chemical body, for its characteristic behavior is such as, if it 
had structure, would prove it to be living. What, he asks, is 
more characteristic of living protoplasm than that while main- 
taining its own integritj' it alters the surrounding medium?” 
Assuming that the matter of contagium is identical with the 
“ germinal matter” of bacteria, Dr. Sanderson endeavors to fortify 22 
ADDRESS IN' 
his position as to the absence of morphological characters by ad- 
verting to the fact that this germinal matter resists destructive 
influences which are fatal to the adult bacteria. Prof. Tyndall 
has shown that this argument is utterly without validity. He 
adverts, in a paper published in the proceedings of the Royal 
Society of June 21, 1877, to the well-known fact that the con- 
tagium of splenic fever appears under two forms, one of which 
is fugitive and readily destroyed, the other persistent and de- 
stroyed with difficulty. It had been shown by Koch, and also 
by Cohn, that the fugitive contagium is the fully developed or- 
ganism of Bacillus anthracis, while the persistent contagium is the 
spore of that organism. So likewise the observations of Dallinger 
and Drysdale establish a great difference between the death tem- 
peratures of adult monads and monad germs. With a magnifying 
power of 5000 diameters these gentlemen demonstrated the pro- 
duction of spores by adult organisms some of which organisms 
did not exceed the of an inch. The young spores were 
watched through to the adult condition, and it was found that 
while a temperature of 140° F. was sufficient to cause the death of 
the adults, the spores were able to grow even after having been 
heated to 300° F. for ten minutes. “ Can it be philosophical,” 
asks Mr. Dallinger, “ with the life history of bacteria still un- 
known, to assume it is a different method of propagation?” 
Then as to the ultra-microscopical minuteness of the contagious 
particles. Prof. Tyndall argues with pertinency and force that be- 
tween the microscopic limit and the true molecular limit there is 
room for infinite permutations and combinations, and he invokes 
the uniformity of nature to sustain his position that “a particle, 
whether great or small, which when sown produces a plant, is 
proved thereby to be the germ of that plant,” certainly as defen- 
sible and rational a position as that of Dr. Sanderson that a 
particle, however fruitful it may be, ceases to be a germ and 
“dwindles to a molecular aggregate” when it becomes ultra- 
microscopical. 
As to the bearing of this discussion on the question of the germ 
theory, after saying that, “in order that any particle may be 
rightly termed a disease germ, two things must be proved con- 
cerning it, namely: first, that it is a living organism; secondly, 
that, if it finds its way into the body of a healthy human being, or 
of an animal, it will produce the disease of which it is the germ,” 
Dr. Sanderson, replying to Prof. Tyndall, in the Proceedings of the STATE MEDICINE AND PUBLIC HYGIENE. 
23 
Royal Society, No. 184, Nov. 22, 1877, contends that there is 
only one disease affecting the higher animals in respect of which 
anything of this kind has been proved, namely, splenic fever of 
cattle; in other words, there is but one disease in which the ex- 
istence of a disease germ has been positively established. Now, 
comparing such a germ with the germinal particles under dis- 
cussion, he thinks there is but little analogy between them, in- 
asmuch as the latter are not known to be organized, and, he adds, 
“they have no power of producing disease, for it has been proved 
by experiment that ordinary bacteria may be introduced into the 
circulating blood of healthy animals in considerable quantities 
without producing any disturbance of health.” 
This last statement of the innocuousness of ordinary bacteria 
may be conceded, but it is certainly somewhat irrelevant in this 
connection. Cohn has successfully maintained that there are 
numerous species and varieties of microzymes, and it is surely 
illogical to infer the absence of morbific qualities in all from the 
demonstrated inuocuousness of one or more of the species. In 
splenic fever, as we have seen and as Dr. Sandersou admits, we 
have positive evidence of the causal connection between the 
presence of Bacillus anthracis in the blood of the infected ani- 
mal and the phenomena of the fever. The inference that there 
may be a similar cause in other infectious fevers, where ocular 
proof has not yet been given, is supported bv numerous and very 
striking analogies, the force of which cannot be weakened by Dr. 
Sanderson so unuecessarily reminding us that there is no proof, 
that is, no positive ocular demonstration, of the actual presence 
and operation of such a cause. Let him point out errors, if there 
be any, in the alleged analogies. Otherwise we are entitled to 
rely upon them as constituting valid data for a legitimate pro- 
visional theory. 
Dr. Sanderson is himself fully aware that, however innocuous 
the germs of ordinary bacteria may be, there are other particulate 
bodies which, having derived infectiveness from some particular 
source of miasm or contagion, impart a very definite morbific 
action to air or water.1 
1 Dr. Burdon Sandersou, alluding, in his recent lectures “On the Infective 
Processes of Disease,” to its having been suggested that he had changed his views 
of late as to the necessity of the agency of septic organisms in producing infec 
tious virus, declared with emphasis that he still believes that “ to the chemical 
processes which give rise to the production of infective products, these minute 24 
ADDRESS IN 
He moreover denies with emphasis that any experiments of 
Bastian or others have proved the possibility of spontaneous 
generation, citing his own experiments and those of Samuelson, 
Pfluger, and Prof. Tyndall in opposition to the inconclusive ones 
cf Dr. Bastian. It was shown by the former gentleman, as it had 
been shown several years ago by the late Dr. Jeffries Wyman, 
that an extension of the time during which the boiling tempera- 
ture was maintained, or a slight elevation of the temperature 
above the boiling point, would in all cases completely sterilize 
any organic infusion. More recently Prof. Tyndall has thrown 
a flood of light on the cause of the diversity of results obtained 
by different persons, or by the same party at different times, in 
attempts to sterilize organic infusions. 1 have already alluded 
to the trustworthy observations of Dallinger and Drysdale on the 
remarkable difference between adult monads and their demon- 
strable spores in respect of the power of resisting heat. It oc- 
curred to Prof. Tyndall that, as, doubtless, a similar difference 
existed between the finished organism and the germinal particles 
in the case of bacteria, so too the power of extreme resistance ex- 
hibited by the germ would probably be greatly lessened the nearer 
the germ is to its final sensitive condition. Seeds soften before and 
during germination, and, assuming that this takes place in the 
germinal particles as preparatory to their development into the 
mature organisms, Prof. Tyndall determined to apply a crucial 
test. “ An infusion infected with the most powerfully resistant 
germs, but otherwise protected against the floating matters of the 
air, is gradually raised to the boiling point. Such germs as had 
reached the soft and plastic state immediately preceding the de- 
velopment into bacteria would thus be destroyed. The infusion 
is then put aside in a warm room for ten or twelve hours. If for 
organisms are not only accessory, but necessary. I have always maintained that 
the facts we already possess relating to the development of organisms belonging 
to the same group as bacteria, in association wstlr pathological processes, are 
such as to make it impossible to doubt that such organisms exercise an important 
part in these processes; but, as regards the theory that the common air we 
breathe is constantly charged with infective organized particles, apart from and 
without reference to its having previously come in contact with any specific source of 
contagion ; and that when a wound goes wrong, it does so because these ordinary 
air particles find their way into it, I have never neglected any opportunity of 
saying, that, to the best of my judgment, such a theory is based on what I ven- 
ture to think the misapplication of an analogy, than on the direct observation of 
what actually goes on in the wound itself.”—British Medical Journal, December 
22, 1877. ' 25 
STATE MEDICINE AND PUBLIC HYGIENE. 
twenty, we might have the liquid charged with well developed 
bacteria. To anticipate this, at the end of ten or twelve hours 
we raise the infusion a second time to the boiling temperature, 
which as before will all the germs then approaching their 
final development. The infusion is again put aside for ten or 
twelve hours, and the process of heating is repeated. By this 
method of discontinuous and repeated applications of heat we kill 
the germs in their order of resistance and finally kill the last of 
them, by a temperature no higher than that of boiling water at 
the ordinary pressure, and maintained for only a few minutes at 
a time. “No infusion,” says Prof. Tyndall, “can withstand this 
process if it is repeated a sufficient number of times. He applied 
it to infusions of a great variety of substances, including those 
most tenacious of life. Not one of them bore the ordeal. These 
results were clearly foreseen before they were realized, so that 
the germ theory fulfils the test of every true theory, that test 
being the power of prevision.” 
The attack of Dr. "Richardson on the germ theory of disease is 
far more uncompromising, his views being in direct opposition to 
the idea of there being a living and self-multiplying contagium. 
He contends that the poisons of the various communicable 
diseases are modified secretions, and thus, though products of living 
organs, are not themselves living, but really dead matter, and 
that different diseases are caused by secretions of different glands. 
These views relative to the glandular origin of contagious dis- 
eases were first promulgated in 1867, and, with the single excep- 
tion relating to his alleged success in isolating the poison of septic 
matter which he regards as a type of the contagia of all the com- 
municable diseases, I believe that his twenty or more propositions 
asserted in his recent address as President of the Sanitary Con- 
gress at Leamington, have failed to meet with acceptance either 
on the part of the general medical public or of special investi- 
gators in the same of pathological inquiry. 
Dr. Burdon Sanderson has shown, by his experiments on the 
propagation of infective inflammations, that, in cases of putrid 
intoxication caused by the injection of septic matter from which 
the septic organisms have been previously separated, if the dose 
be not so large as to kill the animal in a few' hours, there is 
usually a rapid recovery, the septic poison not having the slightest 
tendency to multiply in the infected body, provided that the access 
of microzymes be excluded. This presents a most remarkable 26 
ADDRESS IN 
contrast with the effects of the introduction of the contagia of the 
zymotic diseases, and the difference is full of significance. In 
like manner the observations of Dr. Satterthwaite in concert with 
Prof. Edward Curtis, as reported in the paper read by the first 
named gentleman before the International Medical Congress in 
Philadelphia, had reference chiefly to the poisonous matter of 
putrid infusions, and only showed what Burdon Sanderson had 
already established, that this matter capable of producing intense 
sepsis is a chemical and not a living substance. Nevertheless, 
the latter has established another fact on equally incontestable 
experimental evidence, namely, that this chemical poison is the 
product of bacterial activity and cannot be otherwise manufac- 
tured. The error of the germ-crazy folks, if error there be, con- 
sists, according to him, “ not in stating that bacteria are of patho- 
logical importance, but in asserting that because A produces B, 
and B produces C, therefore C cannot be produced unless A is 
present. It would be erroneous to say that the yeast plant is the 
agent in the production of the evils of intemperance, and it is a 
mistake to say that bacteria are the agents in the production of 
septicaemia, but just as, if there were no yeast plant there would 
be no drunkenness, so, if there were no bacteria there would be 
no septicaemia.”1 
1 “ The septic poison we have seen to be an exclusive product of bacterial de- 
velopment, a product whicli bacteria are capable of manufacturing from unorgan- 
ized and perfectly harmless material, a product which, although incapable of 
passing through certain kinds of filters, is soluble in the ordinary sense. Patho- 
logically, we have seen that it does not act the part of a specific•contagium ; that 
in order to the production of its morbific effects, a sufficient quantity must be in- 
troduced into the circulation ; and further, that the intensity of the effect is pro- 
portionate to the quantity introduced ; so that if the amount be not too great, the 
tendency is to a favorable, not to a fatal termination. But every one knows that 
there occur from time to time in clinical experience instances of a sort of septi- 
caemia of a more virulent kind ; cases for example of septic peritonitis, in which 
the quantity of the agent required to produce the fatal result is not measured by 
drops or grains, but (if one may so express one’s self), in homoeopathic doses; cases 
in which we at once recognize that we have to do, not with a poison of which the 
effect is determined by its quantity, but with a ferment of which the destruc- 
tiveness to life is chiefly dependent on the rapidity of its development.” 
The inevitably fatal result of these malignant forms of septicaemia preceded by 
“ diffuse suppurative infiltration of the cellular tissue” (pyaemia) surrounding 
the gateway of access by which the poison was introduced, and by delirium and 
collapse, “being partiy, perhaps, due to the direct influence of the specific con- 
tagium, but principally to the enormous deve'opment in the organism of the ordi- 
nary septic poison.”—Burdon Sanderson, Lectures on the Infective Processes of 
Disease, British Medical Journal, Feb. 9, 1878. 27 
STATE MEDICINE AND PUBLIC HYGIENE. 
While thus recognizing the fact that in simple septicaemia the 
microzymes are not the direct agents which produce the patho- 
logical results, we may justly enter a protest against the graver 
error of those who “maintain, in the face of all the experimental 
investigations relating to the subject during the last few years, 
that these organisms are without pathological significance.” As 
Dr. Sanderson pertinently and justly remarks, “ if these infinitely 
minute organisms are present in very intensely infective inflam- 
mation, we may be quite sure that they stand in important rela- 
tion to the morbid process.” He has further shown that bacteria 
grown in Pasteur’s cultivating liquid, there being no putrid 
albuminoid matter present, are for the first crop inert, but event- 
ually a product is obtained which possesses all the virulence of 
putrescent animal or vegetable infusions, a possible explanation 
being that the liquid becomes charged with the excretions of the 
bacteria or with the products of the decomposition of dead 
bacteria.1 
Now, as to the doctrine of a specific contagium vivum for each 
of the specific fevers, I think it a sufficient answer to most of the 
objections urged against this doctrine to remark that, however 
plausible some of these objections may appear, they are at once 
refuted by the conceded positive demonstration of such a conta- 
gium in a single case, namely, splenic fever. Koch, having ascer- 
tained that the Bacillus anthracis produces spores when grown in 
the cultivating liquid, proceeded to test the pathogenic activity 
of rods and spores as thus produced. The inoculations of either 
rods or spores into a small incision in the skin of a mouse pro- 
duced splenic fever in every instance. If the tested material 
caused no development of rods and spores in the incubator, it 
failed to produce splenic fever by inoculation. “ Proof,” says Dr. 
Eoberts, “ could go no further ; the infection absolutely followed 
the specific organism ; it came with it, it went with it. These 
observations were repeated with the strictest precautions at the 
Physiological Institute at Breslau, under the eyes of Prof. Cohn 
1 Concurrently with this acquisition of a toxic quality by the liquid, there is a 
marked difference in the appearance of the first and the subsequent crops of bac- 
teria, “the former consisting mostly of rods (becteria proper), the latter of sphe- 
roids or micrococci. They differ not only in form, but also in the fact that, whereas 
the rods are endowed with great mobility and appear to act independently, as if 
each had a consciousness of its own, the latter are held together in masses by 
interstitial substance (gloea) and usually form a scum or pellicle on the surface 
of the liquid.”—Bunion Sanderson, British Medical Journal, Jan. 5, 1878. 28 
ADDRESS IN 
and other competent observers, who fully corroborated their ex- 
actness.” 
The proof is likewise nearly complete in the case of relapsing 
fever. It is now generally known that the discovery by Dr. 
Obermeier of Berlin of minute spiral organisms in the blood of 
patients suffering from relapsing fever has been fully confirmed 
by late observers. An elaborate monograph on this subject by 
Dr. Ileydenreich of St. Petersburg is quoted by Dr. Roberts in 
his Address in Medicine before the British Medical Association in 
August, 1877. It is based on 46 cases which were studied with 
the most minute care, the blood being examined and the tempe- 
rature being observed from two to six times each day. Altogether 
over a thousand examinations of the blood were made. Now the 
spiral organisms are found during the paroxysms, they dis- 
appear at the crisis and are absent during the apyrexial periods. 
The fever is easily communicated to a healthy person by inocu- 
lation with the blood of a patient suffering from the disease, but 
the blood is only infective during the paroxysms when it con- 
tains the organisms, but not at the crisis nor during the apyrexial 
periods when they are absent. None of the fluids or secretions 
of the body except the blood are infective, all of which seems 
to show that the virus is associated with the spiralla. 
The fact that the organism lives in the blood in this fever 
furnishes thus a perfectly satisfactory explanation of the absence 
of local lesions which distinguishes it from the eruptive fevers. 
It does not so satisfactorily explain another distinctive peculiarity, 
namely, the lack of a protective influence of a first attack against 
a recurrence of the disease, although it is urged by Maolagan 
that it is reasonable to believe that a permanent impression may 
be more readily produced on a formed and stable organ than on 
a constantly changing fluid like the blood, and that a contagium 
which finds its second factor in an individual organ or tissue is, 
therefore, more likely to produce a permanent impression than 
one which finds its second factor in the circulating fluid. 
These facts, relating to splenic and relapsing fevers as furnish- 
ing a positive demonstration of the doctrine of contagium vivum 
in its application to those particular diseases, sweep away the ob- 
jections urged by Dr. Richardson and others against that doctrine 
in general, and leave us free to accept general analogies as legiti. 
mate data for making a provisional assumption of a similar con- STATE MEDICINE AND PUBLIC HYGIENE. 
29 
tagium in the case of other infectious fevers in which disease- 
producing organisms have not yet been detected.1 
The theory which ascribes the phenomena of the infectious 
fevers to the agency of living parasites had floated before men’s 
minds in a vague way for many centuries. It was not, however, 
until about the middle of the present century that there had 
been observed a sufficient body of appropriate facts to entitle it 
to be ranked as a legitimate hypothesis, when Henle, in Germany, 
Dr. J. K. Mitchell, in Philadelphia, and a Dr. Cowdell, in Eng- 
land, nearly about the same time, and quite independently of 
each other, promulgated very pronounced opinions on the sub- 
ject, and defended them with an imposing array of striking facts 
and ingenious and plausible arguments. Liebermeister says of 
Ilenle, that he elaborated the theory of a contagium vivum in 
1853, with as much modesty as thoroughness, though even as 
early as 1840 he had maintained it with convincing logic. 
Dr. Mitchell’s lectures on the Cryptogamous Origin of Malarious 
and Epidemic Fevers, delivered at the Jefferson Medical College 
during the session of 1846-47, and subsequently published in 
compliance with the request of the class, attracted general atten- 
tion and elicited strong expressions of commendation from dis- 
tinguished members of the profession, especially from the late 
Dr. Daniel Drake, then engaged in the preparation of his great 
work “On the Diseases of the Interior Valley of North America.” 
About a year later, and apparently without any knowledge of 
Dr. Mitchell’s essay, Dr. Charles Cowdell, of London, published 
a “Disquisition on Pestilential Cholera: being an attempt to ex- 
plain its phenomena, nature, cause, prevention, and treatment, 
by reference to an extrinsic fungous origin.” A contemporary 
critic in the British and Foreign Medico-Chirurgical Review, in a 
commendatory notice of Dr. Cowdell’s book, advised him to ex- 
tend his hypothesis to all epidemics, suggesting that “he would, 
perhaps, find yellow fever and the plague still more to his pur- 
pose than cholera.” It was not, however, until after the publica- 
1 “In an argument of this kind it is of capital importance to get hold of an 
authentic instance, because it is more than probable—looking to the general 
analogy between them—that all infective diseases conform in some fashion to 
one fundamental type. If septic bacteria are the cause of septicaemia, if the spi- 
ralla are the cause of relapsing fever, if the bacillus anthracis is the cause of 
spleuic fever—the inference is almost irresistible that other analogous organisms 
are the cause of other infective inflammations and other specific fevers.”—Dr. 
Wm. Roberts, Medical Times and Gazette, August 11, 1877. 30 
ADDRESS IN 
tion of Pasteur’s researches on fermentation and putrefaction, 
within the past twenty years, that the germ theory, previously 
regarded as at most a plausible conjecture, began to be treated 
as a serious pathological doctrine, being warmly advocated by 
leading minds in the profession, though as earnestly opposed by 
others of equal standing and authority. The subsequent dis- 
covery of specific organisms in the blood and tissues of animals 
suffering from splenic fever, and in the blood of human beings 
affected with relapsing fever, gave an immense impulse to the 
spread of this doctrine, which now counts among its adherents 
many of the leading minds of the profession, and which is sup- 
ported by analogies of great variety and significance. The latest 
systematic exposition of these analogies which I have seen is 
given by Dr. Roberts, of Manchester, in an admirable address 
before the British Medical Association, held in that city in 
August of last year. This address has been published in extenso 
in the British Medical Journal, and in the Medical Times and 
Gazette, of London, August 11, 1877, and contains, besides a 
summary of previous observations by others, some original ex- 
periments of the author himself. The object of some of these 
experiments was to indicate a curious resemblance between the 
action of yeast and the phenomena of a contagious fever, and of 
others to confirm the conclusions of Pasteur and Tyndall, that 
organic matter has no inherent power of generating bacteria, 
and no inherent power of passing into decomposition, but that 
bacteria are the actual agents of decomposition, and that they owe 
their origin exclusively to parent germs derived from the sur- 
rounding media. In addition to the experiments relating to this 
latter point he further fortifies his conclusions by an argument 
based upon a striking generalization which is, I believe, at least 
in this application of the fact, original with himself. “Sapro- 
phytes,” under which general designation he includes all the 
organisms associated with the decomposition and decay of organic 
matter, “are,” he says, “as is well known, destitute of chloro- 
phyll, and like all such plants, they are unable to assimilate car- 
bonic acid. They obtain their carbon exclusively from more 
complex compounds which have been prepared for them by pre- 
existing living beings.” This, of course, was a familiarly known 
fact, but Dr. Roberts has sagaciously drawn the conclusion that 
it is manifestly impossible that the primordial forms of life could 
have belonged to this group ; “for if we throw ourselves back in STATE MEDICINE AND PUBLIC HYGIENE. 
31 
imagination to that remote era when life first appeared on the 
globe, we should find ourselves in a purely inorganic world— 
amid conditions in which saprophytes could not possibly live nor 
obtain nourishment. The special function of the saprophytes in 
the order of nature is to destroy, not to create organic matter; 
and they constitute, not the first, but the last link in the biologi- 
cal chain. For if we regard the order of life as it now proceeds 
on the earth’s surface, we may describe it as beginning with the 
chlorophyll body, and ending with the saprophyte. The chloro- 
phyll body is the only known form of protoplasm which obtains 
all its nutriment from inorganic sources If ever I should 
be privileged to witness an abiogenic birth, I should certainly not 
expect to see a saprophyte; I should rather expect to see a speck 
of protoplasm slowly formed, without definite shape or dimen- 
sions, and nourishing itself, like the chlorophyll body, on a 
purely mineral diet. The more one reflects on this subject, the 
more clearly does it appear that the spontaneous origin of sapro- 
phytes is impossible. Speaking as an evolutionist, I should 
rather infer that saprophytes were a late development, probably 
a degradation from some algal forms which had found their 
profit in feeding on waste organic matter, and which gradually 
lost their chlorophyll through want of use, and with it their 
power of feeding on an exclusively mineral diet.” 
It has been shown, both by those who affirm and those who 
deny the doctrine of a contagium vivum, that there is no constant 
and easily recognizable distinction between septic organisms 
which produce the poison of putrid fever and the common bac- 
teria of putrefaction, and it is affirmed by Cohn that the bacillus 
anthracis, the deadly contagium of splenic fever, is identical in 
form and development with the bacillus subtilis, a harmless sapro- 
phyte, the only difference he could detect being that the rods of 
the former were motionless, while those of the latter exhibit 
movements. The same authority has shown that the so-called 
spirillum of relapsing fever is really a spirochaete, a genus distin- 
guished from spirillum by exhibiting in addition to serpentine 
movements, by which they are enabled to change their place, an 
undulation passing along their whole length which has never 
been observed in spirillum. He has further shown that the re- 
lapsing fever species (S. Obermeieri) is almost, if not quite, identi- 
cal in form and botanical character with the Spirochaete plicatilis 32 
ADDRESS IN 
of Ehrenberg, a species found in dirty water, from which it is 
conceivable that it may be taken into the human system.1 
Those who find in such facts as these evidence of the falsity of 
the germ theory commit therefore an obvious fallacy, inasmuch 
as the apparent identity in anatomical characters may be consis- 
tent with a complete diversity in pathogenic properties, whether 
this difference depends upon a peculiar state of the system giving 
rise to a pathological infectivity as a necessary factor in the pro- 
duction of the disease in addition to the circulation of the living 
contagium, or whether it depends upon changes in the nature of 
the organisms analogous to those which are observed in both the 
animal and vegetable kingdoms in connection with the develop- 
ment of permanent varieties. This latter hypothesis is suggested 
by Dr. Roberts, who at least makes it clear that it rests upon the 
assumption of a vera causa which is also appropriate to the effect 
which it is invoked to explain. “ If,” he says, “contagia are 
organisms, they must necessarily possess the fundamental ten- 
dencies and attributes of all organized beings. Among the most 
important of these attributes is the capacity for “ Variation ” or 
“Sporting.” This capacity is an essential link in the theory of 
evolution ; and Darwin brings forward strong grounds for the 
belief that variation in plants and animals is not the result of 
chance or caprice, but is the definite effect of definite (though 
often quite obscure) causes. I see no more difficulty in be- 
lieving that the bacillus anthracis is a sport of the bacillus subtilis, 
than in believing, as all botanists tell us, that the bitter almond 
is a sport from the sweet almond—the one a bland, innocuous 
fruit, and the other containing the elements of a deadly poison.2 
1 Abstract of Recent Researches into the History of Bacteria: made by and 
under the direction of Prof. Cohn, of Breslau. By P. Jeffrey Bell, in Microscopical 
Journal, July, 1870. 
2 “The laws of variation seem to apply in a curiously exact manner to many of 
the phenomena of contagious diseases. One of these laws is the tendency' of a 
variation, once produced, to become permanent and to be transmitted ever after 
with perfect exactness from parent to offspring. Another and controlling law is 
the tendency of a variation, after persisting a certain time, to revert once more 
(under altered conditions) to the original type. The sporting of the nectarine 
from the peach is known to many horticulturists. A peach-tree, after producing 
thousands and thousands of peach-buds, will, as a rare event, and at rare inter- 
vals, produce a bud and branch which ever after bear only nectarines; and con- 
versely, a nectarine at long intervals, and as a rare event, will produce a branch 
which bears only peaches ever after. Does not this remind us of the occasional 
apparent sporting of diphtheria from scarlet fever ? My friend, Dr. Rausome, STATE MEDICINE AND PUBLIC HYGIENE. 
33 
“Cholera suddenly breaks out in some remote district in India 
and spreads from that centre over half the globe. In three or 
four seasons the epidemic dies away and ceases altogether from 
among men. A few years later it reappears and spreads again, 
and disappears as before. Does not this look as if the cholera 
virus were an occasional sport from some Indian saprophyte, 
which by variation has acquired a parasitic habit, and having 
run through countless generations, either dies out or reverts again 
to its original type ? Similarly, typhoid fever might be explained 
as due to a variation from some common saprophyte of our stag- 
nant pools or sewers, which, under certain conditions of its own 
surroundings, or certain conditions within the human body, ac- 
quires a parasitic habit. Having acquired this habit, it becomes 
a contagious virus, which is transmitted with its new habit through 
a certain number of generations; but finally, these conditions 
ceasing, it reverts again to its original non-parasitic type.” How 
admirably this ingenious theory reconciles the observations of 
Murchison and others on the occasional pythogenic origin of 
typhoid fever with the doctrine of a contagium vivum and harmo- 
nizes them with the deductions of Budd as to the continuous 
development of this fever, it is needless to insist. 
When we thus find innumerable analogies between the phe- 
who has paid so much attention to the laws governing the spread of epidemics, 
relates the following instance: A general outbreak of scarlet fever occurred at a 
large public school. One of the masters, who took the infection, exhibited diph- 
theritic patches on the throat. This patient was sent to his own home in Bowden. 
Six days after his arrival his mother was attacked, not with scarlet fever, but 
with diphtheria ; though there were no cases of diphtheria at the time, neither at 
the school nor at Bowden.” 
“ Complex cases of mingled scarlet fever and diphtheria are sometimes seen. 
Similarly the peach tree will occasionally, among a multitude of ordinary fruit, 
produce a fruit of which one-half has the peach character, and the other half the 
nectarine character.” 
“ In regard to some contagia, such as smallpox and scarlet fever, it might be 
said that the variation was a very rare one, but also a very prominent one, with 
little or no tendency to reversion ; while others, like erysipelas and typhoid fever, 
were frequent sports, with a more decided tendency to a reversion to the original 
type. In regard to som; pathogenic organisms, it might be assumed that the 
parent type had disappeared, and the parasitic variety only remained, just as the 
wild parents of many of our cultivated flowers and vegetables have disappeared 
leaving behind them only their altered descen iants.”—Dr. W. Roberts, loc. cit. 
llow aptly does this view explain what used to he called the “epidemic con- 
stitution,” and the hybrid forms and sub-varieties of eruptive and other fevers, 
such as some of the varieties of typho-malarial fever, and the occasional blend- 
ing or else alternations of allied types. 34 
ADDRESS IN- 
nomena of the contagious fevers, and those connected with the 
development and life of certain low organisms, analogies so nu- 
merous and so close that every peculiarity in the manifestation 
of the fevers as to the mode of development and spreading will 
be found to be susceptible of interpretation in terms of the doc- 
trine of a contagium vivum;, and many of them not susceptible of 
any other explanation, and that, moreover, a positive demonstra- 
tion has, it is universally conceded, been given in the case of 
splenic fever, not to insist upon the almost equally conclusive 
proof in the case of relapsing fever and septicaemia, nor upon the 
apparently conclusive demonstration, given by Chauveau and 
subsequently confirmed by Sanderson and by Braidwood and 
Vaclier, that the contagium of vaccinia and variola consists of 
transparent vesicles, first recognized by Lionel Beale, not ex- 
ceeding according to Sanderson the 5<r inch in diameter, it 
does appear to me that a very strong case has been made out in 
proof of the general doctrine in question.1 
Those who are prone to reiterate the assertion that no positive 
demonstration has been given of a living contagium in the case 
of typhoid, typhus, or the malarial fevers, and who seem to take 
for granted that until such demonstration has been given, it is 
more logical to doubt, if not to deny, the possibility of such a 
mode of causation, than to hold it as a provisional hypothesis, 
forget that ocular demonstration may be absolutely precluded by 
reason of an ultra-microscopical minuteness of the particles, that, 
moreover, between the microscopic and molecular limits there s 
space for countless gradations of beings, and that after all infer- 
ential proof may be quite as conclusive as sensible demonstration, 
in some cases, indeed, much more so, the liability to commit 
logical fallacies in the one case being balanced, or more than 
balanced by possible errors of interpretation in the other. What 
would be thought of the scientist who would doubt, not to say 
deny, the truth of the undulatory theory of light on the ground 
that the supposed elastic medium, whose motions are believed to 
constitute the light of the Universe, is itself invisible, impalpable 
and absolutely imponderable, that we cannot demonstrate its pre- 
sence nor know anything of its essential nature? The assumption 
of its existence, suggested by observed analogies between many of 
the phenomena of light and the known effects of the undulations 
1 British and Foreign Medico-Chirurgical Review, Oct. 1877, p. 393. STATE MEDICINE AND PUBLIC HYGIENE. 
35 
of ponderable fluids, not only furnishes a satisfactory explanation 
of all the previously known facts, but has enabled competent 
philosophers to predict and thus to discover other more recondite 
phenomena which had eluded direct observation. No proof 
could be stronger than this. In like manner the extension of the 
doctrine of contagium vivum from infectious fevers in which 
positive ocular demonstration of its presence has been given to 
others of the same class, in regard to which ocular demonstration 
may be precluded presumably by reason of the extreme minute- 
ness of the particles, is fully justified by the uniformity of Nature. 
The doctrine in question thus fulfils every test of a legitimate 
scientific theory. It assigns a cause which as we have seen is 
true and appropriate to the effects to be explained, while the 
facility of its application to the solution of all the phenomena of 
the infective fevers shows it to be also adequate in extent.