%\xt s>hattudi guditue. 
1892. 
THE 
PREVENTION OF DISEASE 
IN 
MASSACHUSETTS. 
J. F. ALLEYNE ADAMS, M.D. 
OF PITTSFIELD, MASS. 
Read before the Massachusetts Medical Society, June 7, 1892. 
BOSTON: 
DAVID CLAPP & SON, PRINTERS, 115 HIGH ST. 
1 8 9 2. THE PRETENTION OF DISEASE IN 
MASSACHUSETTS. 
Mr. President and Fellows 
of the Massachusetts Medical Society : 
The professional life of the founder of the Shattuck fund 
extended over the first half of the present century. Pre- 
ventive medicine, as a science and an ai't, had in the United 
States as yet taken no root; but, in the prophetic minds 
of the medical thinkers of that time, the seed was germina- 
ting which was in the next generation to put forth the 
tender leaf, and in our day to grow into a goodly tree. 
Science and philanthropy united in teaching these wise 
medical fathers that to prevent disease is even better than 
to cure it; and in the front rank of these scientific philan- 
thropists was Dr. George Cheyne Shattuck. In selecting 
therefore for this paper a title relating to the prevention of 
disease, choice has been made of one of his favorite themes. 
In confining it within the geographical limits of the Com- 
monwealth of Massachusetts, respect is had to the patriotic 
preference expressed in the terms of his bequest. 
To what extent is it possible to prevent disease in this 
Commonwealth? What has been accomplished in this 
direction, and what more remains to be done? What are 
the special needs which to-day are calling for concerted 
action on the part of the medical profession? In asking 
your attention to a consideration of these questions, I feel 
confident of a sympathetic hearing; for the subject is one 
in which the Massachusetts Medical Society has not only a 
lively interest but a peculiar title of proprietorship. It 
cannot be wholly relegated to health officials and special 4 
THE PRETENTION OF DISEASE 
associations, for it is the medical practitioners, as a body, 
who give vitality to the work. It is the Doctors who, in 
their daily intercourse with the people, are educating them 
in sanitary matters, it is the Doctors who have been in- 
strumental in the enactment of sanitary legislation, and it 
is the Doctors who stand behind the health authorities with 
ever ready help. The Massachusetts Medical Society is 
imbued with a true missionary spirit. Its members gladly 
spend themselves in this cause, which not only brings no 
pecuniary return, but even threatens to deprive them of a 
livelihood. Its efforts for the prevention of disease began 
before any official action was inaugurated. To us as a 
Society belongs much of the credit for what has been done, 
and upon us largely rests the responsibility for its effective 
continuance. 
It is well known that Massachusetts was the first State 
in the Union to establish a State Board of Health, and that 
the founder of the Board was a distinguished member of this 
Society. It was Dr. Bowditch’s writings on sanitary sub- 
jects and his personal influence upon public men which 
brought this Board into being ; and it was he who, as its 
first President, gave it a successful start in its useful career. 
Since our last meeting, this great and noble-hearted man 
has passed from among us ; and profound grief for his loss 
is the dominating sentiment of this occasion. How can we 
better do honor to his memory than by occupying ourselves 
for a time with one of the departments of medicine in which 
he was a pre-eminent leader? 
During the twenty-two years which have elapsed since 
the establishment of the State Board of Health, our State 
has enjoyed the benefit of systematic sanitary work, the 
great scope and thoroughness of which is known to those 
who have watched its operations or read its series of Annual 
Reports. Investigations of the utmost practical value have 
been carried on, and with the aid of local Boards of Health IN MASSACHUSETTS. 
5 
a vigorous warfare has been waged against the causes of 
disease, with a special view to the prevention and suppres- 
sion of epidemics. An interesting sketch of the work of 
the Board was given by its President, Dr. Walcott, in the 
Annual Address before this Society in 1889. 
Now,' after twenty-two years of this excellent work, we 
are justified in inquiring as to the results, and even in 
confidently looking for such results in the statistics of 
mortality. Although it would not be fair to judge this 
work wholly by statistics, yet there is no other test which 
has the merit of accuracy. The trustworthiness of the 
Massachusetts Registration Reports is generally conceded, 
our State being no less distinguised among the others in 
this respect than in that of priority of sanitary legislation. 
Nowhere, therefore, in the United States are the conditions 
so favorable for estimating the value of public health meas- 
ures as in this State of Massachusetts. 
In inquiring what change has taken place in the death 
rate of our State, are we not justified in expecting to find 
a material decline? For my own part, I had hoped to 
discover quite a handsome reduction. Imagine, then, my 
surprise and disappointment at finding that the death rate 
of Massachusetts has remained practically unchanged. The 
average for the past 40 years has been 19.35 per 1,000, 
while for 1890 it was 19.44, a trifling increase. Dividing 
this period of 40 years into decades, we find the average 
death rates for each decade to be 18.24, 19.43, 19.81 and 
19.59. Thus there was a slight increase in the death rate 
which reached its maximum in the third period. The aver- 
age for the fourth decade was slightly less than the third, 
and yet was higher than either the first or second. The 
best that can be said is that the upward tendency was 
arrested about 1884, since which time there has been a 
slight irregular downward tendency. 
But, unsatisfactory as this showing is, we must not be 6 
THE PREVENTION OF DISEASE 
hasty to conclude that nothing has been accomplished and 
that the movement for the prevention of disease has proved 
a dismal failure. Let us rather analyze the death-rate, to 
ascertain whether there are any special directions in which 
an improvement can be discovered. My own studies in 
this direction have proved profoundly interesting, and have 
resulted in the discovery that the mortality from certain 
diseases is decreasing while that from others is increasing, 
the gain and the loss so nearly balancing each other as to 
produce but little impression upon the general death rate. 
In order not to weary you with statistics, I have prepared 
diagrams which show at a glance the comparative mortality 
fx'oxn twelve principal diseases or classes of disease during 
the forty-one years from 1850 to 1890. 
In these diagrams, the vertical lines correspond to the 
number of years, and each horizontal line represents one 
death to 10,000 of population. Each of the irregular lines, 
or curves, therefore, indicates the number of deaths from a 
specified disease, in each year, to evei'y 10,000 of popu- 
lation for that year. 
In the preparation of these statistics, I am indebted for 
much valuable aid to Dr. S. W. Abbott, Secretary of the 
State Board of Health. 
An examination of these several curves shows that five 
of them have a decided downvvax'd tendency. These are 
Small-Pox, 
Scarlet-Fever, 
Measles, 
Typhoid-Fever, 
Consumption. 
Observing these in detail, we find that Small-Pox de- 
clined irregularly from 1850, recurring in epidemics about 
once in five years, the epidemics lasting two to three 
years, until 1872-73, when a great epidemic which extend- IN MASSACHUSETTS. 
7 
Ed all over the country caused the heaviest mortality on 
record in this State, the number of deaths in 1872 arnount- 
to 1029, and in 1873 to (5(58. The following year they had 
fallen to 26, since which time they have steadily tapered off 
until 1886, when not a single death occurred from this 
cause. In 1890 there was but one death. 
/Scarlet-Fever and Measles have both decreased in each 
decade since 1850, the epidemic waves showing a receding 
tide. For /Scarlet-Fever there was but little difference be- 
tween the average of the first and second decades ; the third 
showed a marked decrease, and the fourth the sharpest de- 
cline of all. Measles, however, owing to the severe epi- 
demic of 1859, made the greatest fall in the second decade, 
since which time the mortality has been low and declining. 
Typhoid-Fever increased in the second decade, the max- 
imum being reached in 1865, since when the fall has been 
decided, though undulating. 
The fall in the death rate from Consumption is very 
striking, each decade showing a decrease since 1850. The 
decline was the most marked in the second decade, and has 
been comparatively steady since 1860. 
The curve for Diphtheria and Croup shows two great 
epidemics, reaching their height in 1863 and 1876, the 
third decade having the heighest average. Since 18(6 
there has been a fall, well marked but not great, so that the 
average for the last decade, though lower than the third, is 
still a trifle higher than the second, and almost double that 
of the first. 
The Diarrhoeal Diseases exhibit a mortality greater 
than any of those yet mentioned, except Consumption. The 
list includes Cholera Infantum, to which are attributed more 
than half of the deaths, Dysentery, Diarrhoea, Cholera 
Morbus and Enteritis. The mortality from these is seen 
to be irregular. The highest average was reached in the 
third decade, which was however but little above the second. 8 
THE PREVENTION OF DISEASE 
The fourth is lower than the second or third, but still a 
little higher than the first. The highest point was reached 
in 1872. A more favorable showing could be made by 
selecting Cholera Infantum and Dysentery ; but the figures 
are liable to be so largely affected by uncertainties of diag- 
nosis and nomenclature that it has seemed best to consider 
the diarrhoeal diseases only as a whole. 
If we now examine the curves for Bronchitis and Pneu- 
monia, Diseases of the Brain, Heart and Kidneys, and for 
Cancer, we find one observation to be true of them all, 
namely, that they have all increased in mortality, and that 
each of them has increased in each decade since 1850. 
The most remarkable increase is shown in the case of 
Bronchitis and Pneumonia, the death rate from which was 
more than three times as great in the last decade as in the 
first. This increase has been enough to slightly more than 
compensate for the decline in Consumption. The query, 
therefore, which naturally presents itself, is whether we 
have not here, again, to deal with a question of diagnosis 
rather than of fact. Very likely we have, to a certain ex- 
tent ; but an examination of the ages at which the deaths 
occurred will convince us that this is not the only explana- 
tion. Thus we find that Ist, the increase of Bronchitis is 
largest during the first two years of life, and next largest 
after the age of fifty, these being the ages when Consumption 
is least fatal; and 2d, that if we add together the total 
deaths from Consumption, Bronchitis and Pneumonia for 
the several age periods, for the two years 18(il and 1890, 
we find an increase of these aggregated lung-diseases under 
the age of five years and between the ages of forty and fifty ; 
but a decrease between five and forty, and over fifty. The 
most marked decrease is between the ages of fifteen and 
thirty. As the gain therefore is greatest at the ages most 
prone to Consumption, we may safely conclude that there 
is an actual falling off in the mortality from this disease. IN MASSACHUSETTS. 
9 
The increase in the mortality from diseases of the Brain, 
Heart and Kidneys, and from Cancer, is very remarkable. 
Diseases of the brain have increased two-fold, those of the 
heart three-fold and cancer nearly three-fold, while diseases 
of the kidneys and dropsy, taken together, have increased 
about 50 per cent. This means, of course, in proportion 
to the population. The actual increase has been twice as 
much, the population of the State having doubled in the 
forty years. 
Thus we may provisionally classify diseases in two groups, 
those which are decreasing and those which are increasing. 
O O 
Let us now inquire what other features characterize these 
two groups. 
In the first place we observe that all of the decreasing 
diseases except consumption, belong to the zymotic class. 
Even consumption it is hardly possible, at the present day, 
to exclude from this group, though the nosologists still re- 
tain it among the constitutional diseases. Now, these same 
zymotic diseases are the very ones which are most amen- 
able to preventive measures, and against which these meas- 
ures have been chiefly directed. 
Small-pox has been vigorously fought by vaccination, 
quarantine, inspection of imported rags, isolation of cases 
and disinfection. The result is one of the greatest triumphs 
of sanitary science, for this disease, once so frightful in its 
ravages, is for the present practically stamped out. 
Scarlet-Fever and Measles have been combated by 
isolation and disinfection, and by the protection of school 
children by forbidding the attendance at school of any chil- 
dren liable to convey the infection. 
For the prevention of Typhoid Fever every effort has 
been made to ensure the purity of drinking water, the im- 
provement of sewerage and local cleanliness. The thorough 
and systematic work of the State Board of Health in rela- 
tion to the water supply and sewerage of the State is of 10 
THE PREVENTION OF DISEASE 
inestimable value, both present and prospective, and is 
worthy of our grateful recognition. 
The decline in the mortality from these four diseases, 
small-pox, scarlet fever, measles and typhoid fever, has been 
so marked during the past twenty years, since the establish- 
ment of the State Board of Health and the generally in- 
creased attention to sanitary measures, that it is impossible 
to avoid the conclusion that these facts stand to each other 
in the relation of cause and effect, and that to our sanitary 
laws and their careful execution may be attributed the fall- 
ing off of the death rate from these diseases. 
That the same notable decrease is not found in the case 
of the diarrhoeal diseases and of diphtheria and croup is dis- 
appointing, and yet it is satisfactory to find that, though the 
improvement is less, it is not insignificant, and that it has 
been continuous for periods of fourteen and eighteen years 
respectively. The great difficulty in the case of diphtheria 
is its virulent contagiousness and persistent infectiousness, 
facts which have been very strongly presented by Dr. S. W. 
Abbott, in his recent admirable paper on "Diphtheria in 
Massachusetts”; but which, as yet, appear to be inade- 
quately understood by the public. The causes of the 
diarrhoeal diseases are difficult to reach, the controllable 
factor of local or general filthiness being influenced power- 
fully by the uncontrollable factor of intense summer heat; 
while a third factor, namely bacteria in milk, is liable to 
elude the most active vigilance. But all of these problems 
are receiving the careful attention of the sanitary authorities, 
and their satisfactory solution may be hopefully expected. 
The zymotic diseases as a class have diminished from 
474 to each 100,000, in 1870, when the State Board of 
Health began its work, to 360 to each 100,000 in 1890. 
This is equivalent to a saving of over 2500 lives in 1890, 
and is a result of which the Board and every citizen may 
well feel proud. IN MASSACHUSETTS. 
11 
How far the decrease of Consumption may be attributed 
to sanitation is a question not readily answered. The 
agencies likely to affect this disease have been the better 
ventilation of school-houses, factories and public halls, the 
improvement of tenement houses, the drainage of wet cel- 
lars, and the weeding out of tuberculous cows. While 
some good results from these agencies are to be expected, 
yet they are wholly insufficient, and are not likely to have 
caused the very marked decline which the statistics show. 
One important fact which must not be overlooked is the 
removal from the State of great numbers of consumptives 
to more favorable climates where, if they die, their deaths 
are not charged to the State of Massachusetts. 
While thus we find that all of the diseases which are 
decreasing are those against which the efforts of the sanitary 
authorities have been actively directed, the converse fact is 
equally striking, namely, that the increasing diseases are 
either not amenable to public preventive measures, or have 
not yet been subjected to such measures. No official method 
of preventing diseases of the brain, heart, lungs or kidneys, 
or of cancer, has yet been discovered, and in the present 
state of science we cannot expect the Health Boards to con- 
trol them in any way whatever. The increase of these 
diseases cannot therefore be attributed to any lack of 
efficiency on the part of the health officers, nor is there any 
just debit to offset the 2500 lives a year which we have just 
placed to their credit. 
The second General feature which characterizes these two 
groups of diseases is this ; that the diminishing diseases are 
chiefly those of early life, while the increasing diseases are 
those of later life. 
Of the deaths from measles in 1890, nearly all were 
under ten years of age, and more than half under two years. 
From scarlet fever and diphtheria the maximum mortality 
was between five and ten yeai’S ; and nearly all of the deaths 12 
THE PREVENTION OF DISEASE 
occurred from the former under fifteen years, and from the 
latter under thirty years. From the diarrhceal diseases, more 
than 83 per cent, occurred under five years. Typhoid 
fever and consumption are especially diseases of early adult 
life, and both attain their highest mortality between the 
ages of twenty and thirty. In striking contrast with these 
are the increasing diseases. Diseases of the heart are most 
fatal between the ages of fifty and eighty ; brain diseases 
between seventy and eighty, and kidney diseases and cancer 
between sixty and seventy. As regards pneumonia, although 
the first year of life is the most fatal, yet one half of the 
deaths occur after the age of forty, and the most fatal period 
after the first year is between the ages of sixty and seventy. 
At this point it is necessary to inquire what relation this 
excessive mortality at the later ages bears to the number of 
persons living at those ages. The census of 1880 shows 
that the population of Massachusetts embraced in that year 
a larger percentage of persons over sixty years of age than 
any other of the United States with the exception of Maine, 
New Hampshire, Vermont and Connecticut. It also in- 
cluded a smaller proportion under five years of age than any 
other State with five exceptions. Moreover, the population 
under fifteen years is decreasing, and over fifty is increasing. 
Yet neither of these facts will explain the decrease of 
mortality in early and the increase in later life ; for when 
we compare the deaths at given ages with the number of 
persons living at those ages, we find a decrease at all ages be- 
low forty, and an increase at all ages above forty. The de- 
crease is greatest between five and thirty, and the increase 
grows greater and greater in each ten years from forty upward. 
The natural effect of this condition is to increase the num- 
ber of persons living to middle age, but to i-educe the pro- 
portion of very old people. The effect upon the average 
duration of life has been to increase this average in the last 
forty years from 27.07 years to 34.13 years, a gain of over IN MASSACHUSETTS. 
13 
seven years ; a remarkable fact when taken in connection 
with the unchanged death rate and the increased mortality 
of old age. This gain, therefore, belongs wholly to early 
life, and shows that children have now a better chance than 
forty years ago of living to maturity, and of passing safely 
through the producing and reproductive age. The change 
is therefore in that direction which is, beyond all others, of 
material value to the Commonwealth. 
It is difficult to institute any comparison between the 
statistics of Massachusetts and those of other portions of the 
United States, partly because the compilation of the vital 
statistics of the census of 1890 is not }?et completed, and 
again because the superior accuracy of the Massachusetts 
registration gives our State an excessive death rate as com- 
pared with other States, which is more apparent than real. 
But when the new census is completed, we may expect 
results of great value, worked out under the skillful super- 
vision of Dr. John S. Billings. One observation however 
may here be made, which is that the diseases which are here 
decreasing are those which in 1880 were in Massachusetts 
below the average for the United States, and those which 
are increasing were, in that year, well above that average ; 
showing that these disease-tendencies are, at least in their 
excessive manifestation, peculiar to our own section of the 
country. 
In order that we may have a more definite basis for com- 
parison, let us refer briefly to the vital statistics for England 
and Wales. From 1850 to 1880 the death rate of Massa- 
chusetts was almost invariably lower than that of England 
and Wales, but since 1880 the rates have been almost 
identical, the death rate over there having showed a pretty 
steady decline since 1875, and now having crept a little 
below ours. 
An examination of the causes of death in England and 
Wales shows a very similar state of things to that which 14 
THE PREVENTION OF DISEASE 
exists in Massachusetts, namely, that the zymotic diseases 
and consumption are decreasing, while there is a decided 
increase in acute diseases of the lungs and in diseases of the 
heart, kidneys and cancer. The chief exceptions are the 
following : diphtheria, which decreased in earlier years, 
while it was increasing in Massachusetts, has since 1880 
been on the increase in England and Wales. The decrease 
in small-pox has not been so remarkable as in Massachusetts. 
The mortality from diseases of the brain in England and 
Wales shows no marked increase, but still is much higher 
than in Massachusetts, where the increase has been very 
rapid. 
In regard to the actual mortality, the chief differences 
between Massachusetts and England and Wales are these ; 
we have a larger proportion of deaths from diphtheria, 
diarrhoeal diseases, fever and consumption, while England 
and Wales have a larger proportion from small-pox, 
measles, scarlet-fever, acute lung diseases, diseases of the 
brain, heart and kidneys, and from cancer. 
For the data for these comparisons I am indebted to 
Longstaff’s "Studies in Statistics,” a book which might 
c* o 
appropriately have been entitled "Arithmetic made Interest- 
ing.” It was not till after my examination of the Massa- 
chusetts statistics that this delightful volume came into my 
hands, and I was much interested to find so strong a general 
correspondence between the disease tendencies of these two 
widely separated communities, a correspondence indicating 
the presence of similar social forces. Concerning the de- 
crease in the zymotic diseases, Longstaff says (p. 235) : 
"It seems impossible to dissociate this great saving of life 
from the operation of the Public Health Acts, and more 
especially the indirect results of this as shown in the pro- 
ceedings of such bodies as the Sanitary Institute, the ex- 
hibition of sanitary appliances under various auspices, and 
other proofs that public attention has been drawn to these 
matters. The fall in the death rate from fever is without IN MASSACHUSETTS. 
15 
doubt the great triumph of the sanitary reformers. Typhus 
has been driven out from place after place by measures 
taken to check over-crowding and want of ventilation until 
it now lingers only in the lowest quarters of a few large 
towns. Things are not perfect yet, far from it; but they 
were once much worse, and that not so long ago.” 
"Things are not perfect yet.” These words used by Mr. 
Longstaff concerning his own country are equally true in 
Massachusetts, where more than 8,000 persons died in 1890 
from the zymotic diseases alone. If 8,000 lives are de- 
stroyed in a single year by preventable diseases, surely 
prevention has not yet done its perfect work. We must 
remember also that the baleful influence of the zymotic 
diseases cannot be measui’ed by their mortality alone ; for 
many who recover from them are left with weakened con- 
stitutions or with some organic affection which impairs their 
usefulness and shortens their lives. Such are diseases of 
the kidneys resulting from scarlet-fever, of the lungs from 
measles, and of the heart from diphtheria. The results thus 
far accomplished, however, are substantial and encouraging, 
and a sufficient vindication of our sanitary laws and the 
mode of their enforcement. The indications for the future 
are that these efforts must be no whit relaxed, but must, on 
the contrary, be increasingly strenuous. To relax them at 
any point would entail direful consequences. The conta- 
gious and infectious diseases are like fire which must be 
fought unceasingly until it is extinguished. Left to itself 
it will burn until the inflammable material is all consumed. 
With all that has been done, we have seen how small are 
the results in some very important directions. Small-pox 
is the only disease which can be said to be almost extin- 
guished ; and yet the smouldering spark of even a single case 
of small-pox is sufficient, with the least removal of the 
agencies which hold it in check, to flash up into the blaze 
of a desolating epidemic. Even in our present immunity 16 
THE PREVENTION OF DISEASE 
lurks a future danger; for the further we get away from an 
epidemic and a scare, the larger will be the proportion of 
persons unprotected by vaccination. 
Our aim should be the ultimate extinction of all germ- 
diseases ; but when this will be accomplished I do not 
venture to predict. The condition most favorable for such 
a happy result would be an isolated community holding 
absolutely no intercourse with the rest of the world. Here 
a war of extermination against all disease germs might be 
Q “ o 
successfully waged, supposing such an isolated people to be 
possessed of the requisite intelligence or to find life suffi- 
ciently interesting to care for its preservation. But Mas- 
sachusetts is not thus isolated, nor is it possible in this age 
that such a condition should anywhere obtain. Emigration, 
trade and travel cause a constant intermingling of peoples. 
Quarantine, to be sure, acts as a check upon the importa- 
tion of disease from abroad ; but evidences of the impotency 
of quarantine are alarmingly frequent, and interstate quaran- 
tine is impossible- Our State might be free from zymotic 
diseases today, and yet by tomorrow a full assortment of 
them might be brought within our borders. Herein lies 
the great obstacle to the stamping-out process ; and it is 
therefore safe to say, if pressed for a prediction, that the 
epidemic diseases cannot be eradicated from Massachusetts 
until they are likewise eradicated from every part of the 
world. That such a time may come we may venture to 
hope. Whether or not we believe in it as a practical pos- 
ibillty, we should be satisfied with no lower ideal. 
But if epidemics cannot be kept out, we may reasonably 
hope to keep them in; and here is the true principle which 
should guide our efforts. Every city and town should see 
to it that no epidemic disease is allowed to spread beyond 
the first case, and on no account to pass beyond its borders. 
This is already the aim of the Boards of Health; but in 
order to achieve success, these Boards must be aided by an IN MASSACHUSETTS. 
17 
intelligent public, and especially must they have the active 
and watchful co-operation of the whole medical profession. 
There is one particular direction in which, it seems to 
me, that we Doctors can, at this time, render material 
service in this cause; and that is by making a concerted 
effort to secure the general adoption of disinfection by steam. 
The modes of disinfection now in use after a case of infec- 
tious disease are very diverse, and seldom sufficient. If 
the germs do happen to get destroyed, it is apt to he at the 
cost of a ruinous destruction of property. Especially is 
there no thorough and convenient way of disinfecting mat- 
tresses, pillows and carpets. What is needed is a receptacle 
of sufficient size in which these may be placed and subjected 
to a moist heat in the form of steam under pressure. By a 
pressure often pounds, a temperature of 230° F. is obtained, 
a continuance of which for fifteen minutes is found to be 
sufficient. Dry heat requires a much longer exposure, at 
least two hours, and even then is not certain. Superheated 
steam, which is practically dry heat, has been tried and 
found wanting. But steam under pressure can be kept at 
a sufficient temperature and forced into the centre of any 
porous material, with the result that every germ becomes 
thoroughly cooked. Various forms of apparatus for this 
purpose are made in France, England, Germany and 
Holland. They have not yet come into general use in 
this country, though this method is employed, in some 
form, in most of our large hospitals. It has also been 
adopted, within two or three years, at the quarantine stations 
at New Orleans and Charleston. At New Orleans super- 
heated steam had previously been tried on a large scale, but 
abandoned. The disinfecting oven made by Geneste, 
Herscher & Co., of Paris, is very complete, and may be 
taken as the type of this form of apparatus. This consists 
of a sheet iron cylinder, sheathed with wood to prevent 
radiation, with a door at each end fastened by clamps. 18 
THE PREVENTION OF DISEASE 
Within the cylinder, above and below, are coils of steam 
pipe for the preliminary heating of the chamber, to prevent 
condensation. Another pipe pierced with small holes 
traverses the side of the cylinder and admits the steam to 
its interior. The articles to be disinfected are placed in a 
carriage or rack which runs upon a track into the oven. 
After the doors are fastened a dry heat is first obtained by 
admitting steam to the coils of pipe. Steam is then ad- 
mitted directly into the cylinder and the air allowed to 
escape. Then the outlet is closed and the pressure of steam 
kept up for about five minutes. The steam is then per- 
mitted to escape, and admitted a second time. By this 
intermittent action, the most complete penetration of the 
articles under treatment is secured. Even the heart of a 
mattress becomes as hot as its surface. These ovens are 
made both stationary and portable. The stationary form 
is built into a wall in such a way that the opposite ends 
open from separated rooms, whereby any mixing of infected 
and disinfected articles is avoided. These ovens are from 
7 feet to 7£ feet in length, by 3 feet 8 inches to 4 feet 4 
inches in diameter. The portable apparatus is smaller, has 
a door only at one end, and with its upright boiler strongly 
resembles a steam fire engine. This weighs 2400 kilo- 
grammes (5291 lbs.), is drawn by a pair of horses, and 
costs in Paris $1,340. The stationary form costs $9BO to 
$1282, according to size. These are extensively adopted 
in France, and are under municipal control, being placed 
free of cost at the service of the public. 
The steam disinfector of Washington Lyon of London is 
similar in principle, but is made with a double casing in- 
stead of the steam coils. It is also oval in form and is only 
made stationary. I see no reason why disinfectors of this 
type should not be made in our own country, and cheaper 
than they could be imported. If every town in Massa- 
chusetts, or at least the larger ones, owned such a disin- IN MASSACHUSETTS. 
19 
fector, the arrest of epidemics would become a much easier 
matter then it is at present. If the portable form were 
adopted, it could be sent to neighboring towns or villages. 
If the stationary form, the articles to be disinfected would 
be packed in bundles or bags and conveyed in a special 
wagon to the disinfecting station. 
Let us all make a business of calling the attention of the 
authorities and the public to this matter. 
The reduction of the mortality from consumption is one 
of the greatest of sanitary needs ; for this is, in our climate, 
the most destructive of all diseases. Great as has been the 
apparent decline in the last forty years, it still holds its place 
at the head of the list, having caused in lb9(J 5791 deaths. 
Moreover, its mortality being greatest in the most active 
period of life—that of young manhood and womanhood— 
the loss to the community is peculiarly heavy. In Massa- 
chusetts the mortality from this disease is greater in the 
eastern than in the western counties, and is greater in the 
cities than in the country. Our Irish population suffer 
more severely than any other class, and the large propor- 
tion of this nationality in our population is one cause of our 
high death rate from consumption. 
The discovery of the tubercle bacillus adds consumption 
to the list of germ diseases, and indicates modes of preven- 
tion from which we are justified in expecting great results. 
Hitherto, our efforts have been directed to the overcoming 
7 o 
of hereditary tendencies and the improvement of the environ- 
ment ; now it appears that there is one element in the 
environment more dangerous than all others, and this is the 
venomous little bacillus. That consumption is both conta- 
gious and infectious can no longer be doubted. Instances 
of evident contagion have come under my own observation ; 
and doubtless many members of this Society could report 
similar cases. How else can we account for the phenome- 
non which is frequently presented to us of several brothers 20 
THE PREVENTION OF DISEASE 
and sisters in a family dropping off, one by one, from this 
disease, with no hereditary tendency and no unsanitary 
surroundings? And what can we say of those cases where 
a healthy young person suddenly breaks down with con- 
sumption shortly after nursing or paying a loving visit to a 
consumptive friend? Hereditary predisposition exists in 
not over 30 per cent, of all cases, and this is probably an 
excessive estimate. Of the deaths in Massachusetts there- 
fore, in 1890, 70 per cent., or 4,053, had no consumptive 
antecedents. Without contagion, this is a puzzling fact, 
but granting contagion the mystery is removed. 
That the bacilli which swarm in phthisical sputa are ca- 
pable of conveying the disease to a healthy person, whether 
in the fresh or dry state, is now so positively determined 
that it becomes the duty of all medical men to explain the 
matter to their patients and their patients’ families, and to 
insist upon such precautions as tend to prevent the spread 
of the disease. These precautions may be summed up in a 
few simple rules such as these : 
1. Let all sputa be carefully collected and destroyed by 
fire. 
2. Let sputa never be deposited on handkerchiefs, car- 
pets, floors, or any other place where it may dry and be- 
come mingled with the atmosphere. 
3. Never drink from the same glass with a consumptive. 
These rules are equally applicable to pneumonia and per- 
haps also to bronchitis. It will therefore be best to call 
them, not rules for consumptives, but for all persons who 
cough and expectorate. This will save the patient from 
the shock of a positive and perhaps too hasty diagnosis. 
4. Never kiss a consumptive upon the mouth. 
The investigations concerning tuberculosis in cattle show 
how carefully we must watch the milk supply of our pa- 
tients, and especially since Dr. Ernst has demonstrated 
that a cow tuberculous in any part may yield tuberculous IN MASSACHUSETTS. 
21 
milk. This fact also emphasizes the importance of forbid- 
ding a consumptive mother to nurse her offspring. 
Boards of Health have already begun to publish rules 
such as the foregoing; but in order that they should be so 
generally and intelligently followed as to produce any posi- 
tive results, it is necessary that physicians should persistently 
teach the public of their necessity. 
Having thus hopefully and even confidently placed con- 
sumption among the preventible diseases, why are not the 
acute lung affections entitled to the same distinction? We 
know that they have their specific germs, and we believe in 
their communicability ; and though our knowledge of the 
natural history of these germs is as yet very limited, their 
very existence opens up possibilities of future jirevention, 
and should lead us to add them, at least experimentally, to 
the preventible class. 
Having now broadened out the boundaries of the preven- 
tible diseases to extreme and perhaps you will say unwarran- 
table limits, let us see for what portion of the mortality 
these are accountable. 
For the five years ending in 1890 the zymotic diseases 
caused 18 per cent, of all the deaths. Consumption and the 
other tubercular affections caused very nearly the same 
proportion, namely 17 per cent., while pneumonia and 
bronchitis were responsible for 11 per cent. These amount 
in the aggregate to 46 per cent., or not quite half of the 
total deaths. Of what, then, is the other half of the death 
rate composed? For one thing, it includes old age, to 
which are attributed 4£ per cent, of all deaths. The rate 
to the population has remained practically unchanged in 
forty years, being from eight to ten to 10,000. But this 
is not a disease. On the contary, a death from old age, 
since it implies living to old age, is the greatest triumph of 
human vitality ; and the ultima thule of preventive medicine 
is to render old age common, hereditary and even con- 22 
THE PREVENTION OF DISEASE 
tagious. We may therefore exclude old age from the list 
of non-preventible diseases, and the same may be said of 
violence, which causes 4 per cent, of all the deaths. 
This will leave as a remainder about 45 per cent, of all 
deaths. More than half of this number is made up of dis- 
eases of the brain, heart, kidneys, and of cancer, and the 
balance comprises the diseases of the digestive organs, in- 
cluding the liver, of the organs of generation and locomo- 
tion, of the developmental diseases, and disorders of nutri- 
tion. It is among these, or a portion of them, that the 
great increase in mortality is taking place. How to arrest 
this mortality is one of the most important medical prob- 
lems of the day, and one which it behooves the medical 
profession to set itself resolutely to solving. 
We have seen that these increasing diseases are largely 
those of the latter part of life, or at ages above forty. In 
some respects the loss to the community is somewhat less of 
persons of this age than of the same number of persons be- 
tween twenty and forty, which is the age of production and 
of re-production. These older men and women have reared 
their families and have passed the age of greatest strength 
and activity; but they are possessed of something which we 
cannot spare, namely, the experience and wisdom which 
belong to ripe maturity. Many and many a brilliant leader 
of men in politics, literature or the professions, is cut down 
in what should be the prime of life, between 40 and 60, 
when he ought to have lived to 70 or 80 to give the world 
the benefit of those well seasoned powers which had but 
just attained their full development. 
These diseases of later life are largely of the degenerative 
type, the disintegration of tissues in one organ or another. 
Our great Poet Doctor has sung to us of chaises which 
"break down but never wear out,” and therein has typified 
the human vehicle, which, like a chaise, has "always some- 
where a weakest spot.” How shall these weak spots be IN MASSACHUSETTS. 
23 
made strong? How can the human chaise be made to run 
"a hundred years to a day,” or even keep in good repair 
for three-score years and ten? How, in short, can the lon«- 
life and perennial youth of the writer of the "One Hoss 
Shay” be made less exceptional among men? 
Before attempting to answer these questions, it is neces- 
sary to inquire what are the causes which contribute to the 
increase in the diseases of later life. These, it seems to 
me, can be grouped under two general heads, of which 
the first is that this is the natural tendency of an advanc- 
ing, but still imperfect civilization. 
In comparing the effects of the diseases of men with those 
of the lower animals, we find a marked difference. Ani- 
mals, like men, are not born equally vigorous, and in the 
struggle for food and against enemies the weaker are soon 
weeded out. These also more readily fall a prey to diseases, 
which are chiefly of the zymotic type, and since they receive 
no care from their kind, they cannot obtain food, and neces- 
sarily die. It is therefore the strong and healthy only 
who reach maturity and become the parents of the next 
generation. This is "natural selection,” or "the survival 
of the fittest.” Moreover, the lower animals, being guided 
by instinct, naturally tend to adapt themselves to their 
environment. Without knowing why, they select such 
food as is most suitable for them, and adopt such habits as 
are best for their physical well-being. 
But with man, and especially civilized man, the circum- 
stances are changed. The law of the survival of the fittest 
is still in force, but is modified in its action by the fact 
that man is governed by will and not by instinct, and also 
possesses intellectual and moral faculties whereby the selfish 
and cruel propensities of the brutes are, or may be, over- 
come. By these qualities the physical character of the race 
is affected in several ways. The delicate children receive 
the most tender care and are often enabled to grow to 24 
THE PREVENTION OF DISEASE 
maturity and procreate children of their own. Diseased 
persons are cared for in homes or hospitals and not allowed 
to starve, as the brutes are ; but those who have recovered 
from disease are often, if not usually, left with some impair- 
ment of structure or function which is then liable to be 
transmitted to the next generation. Again, as it is a 
matter of choice with men " what they shall eat, what they 
shall drink and wherewithal they shall be clothed,” they 
may and frequently do choose such a mode of life as is in- 
compatible with integrity of structure, however perfect 
originally. Man’s freedom of action leads him more nat- 
urally to self-indulgence than to self-restraint, and self- 
indulgence leads inevitably to physical degeneracy. Savage 
man very nearly resembles the brutes, as regards natural 
selection, but the tendency of civilization is not to the 
survival of the fittest physically, but to the preservation of 
impaired lives, the impairment of healthy lives, the heredi- 
tary transmission of weaknesses of structure, and conse- 
quently to the development of a race in which perfect 
health is almost unknown, and tendencies to disease are an 
universal heritage. With these tendencies we all haye to 
contend. They are the structural weaknesses with which 
we are born, and which, though they may not show them- 
selves for years, are ever ready to yield to some special 
strain which a perfect structure would successfully resist. 
To these are added mental and moral inherited defects, 
weakness of will or overmastering desires, which cannot 
fail to influence the physical development. 
The fundamental reason for this state of society seems to 
be that man is still in a transition state. He is neither a 
brute nor lias he yet become a perfect man. The brute is 
well equipped for life with an unerring instinct. Man has 
endowments which are capable of rendering him far better 
service, namely, a will, an intellect and a conscience. If 
this machinery were perfect (and in the ideal man it must IN MASSACHUSETTS. 
25 
be perfect), man would emancipate himself from all the ills 
which now enslave him, and disease would vanish from the 
earth. But thus far, a perfect co-ordination between the 
will, the reasoning power and the conscience is seldom 
found ; and the age when it shall become so constant as to 
acquire the force of an hereditary racial characteristic must 
be regarded as extremely remote. 
The conclusion is here forced upon us that a high physi- 
cal condition of the race is impossible without a high moral 
condition, with the self-restraint which this implies; and 
hence that even for the physical uplifting of the race, science 
requires the aid of religion. 
The second general cause which appears to contribute to 
the increase of the diseases of mature or advancing is 
, c? o 
the rapid growth of cities. It is in cities that the de- 
generative tendencies of civilization are strongest. The 
environment is more artificial, and therefore the strusale 
for existence is more desperate than under the more natural 
conditions of rural life. To the conditions which exist in 
the worst part of a great city the term " necessarily fatal 
environment” has been not inaptly applied. In London, a 
native of the city, of the third generation, among the lowest 
classes, is practically unknown. If one is occasionally dis- 
covered, he is found to be a wretched creature, stunted in 
body and mind, though probably the descendant of vigorous 
grand-parents who came from the rural districts to seek 
their fortunes in the great city. This does not apply, how- 
ever, to those city families whose means enable them to live 
in comfort and to spend a portion of the year in the country ; 
and yet there are certain influences which affect all classes. 
The endless excitement of city life, the furious competition, 
the desperate struggle which all are making, some for 
wealth or position, and others for the bare necessities of life 
—these are fruitful sources of disease which affect both rich 
and poor. 26 
THE PREVENTION OF DISEASE 
Associated with a life of great mental excitement, is a 
general insufficiency of muscular exercise. This leads to a 
general prevalence of dyspepsia and lithasmia, which we 
know to be the under-lying causes of many organic diseases. 
The excessive use of alcoholic stimulants also, which is 
most common in cities, is one of the most fruitful causes of 
disease. In London it was estimated by a committee of 
the Harveian Society that alcohol is responsible, directly or 
indirectly, for 14 per cent, of all deaths. 
In Massachusetts we must lay our plans with special 
reference to the city environment, for our State is approach- 
ing the condition of a mere group of cities. By the census 
of 1890 it has 70 per cent, of urban population, being a 
larger proportion than any other State in the Union except 
Rhode Island. Though our State is one of the smallest, 
being 44th in respect of area, it is the seventh in population 
and the second in density. The increase of population 
during the last decade has been greater than that of any 
State east of the Mississippi, with four exceptions. More- 
over, this increase has almost all been in the cities, and some 
of the smaller towns are actually dwindling. 
A third cause which may contribute to the increase in the 
diseases of later life is the influence of the late war. A 
great number of our most vigorous young men were killed 
or died in the service, and of the survivors a large propor- 
tion were shattered in health, while of those who did not 
enlist, many were prevented from doing so by physical 
disability. Our veterans are now mostly between the ages 
of forty-five and sixty-five, and it is evident that the average 
vigor of men at these ages must be less than it would have 
been but for the destructive effects of the war upon the 
young men of thirty years ago. The death-rate for veterans 
is, according to Dr. Billings, slightly higher than the aver- 
age for men of corresponding age, while the health of living 
veterans is below the average standard. But just how far IN MASSACHUSETTS. 
27 
this cause may affect the death-rate, I am unable to deter- 
mine. A comparison of the male and female mortality has 
given only negative results. Ihe death-rate for males was 
higher than for females in 1892 ; but so it was also in 1860, 
and the ratio between them for these two years is almost 
exactly the same. It was, in 1860, for males 19.2, and 
for females 18.2 ; while in 1890 it was for males 20, and 
for females 18.9. An examination of the comparative mor- 
tality from diseases of the brain, heart and kidneys in the 
two sexes, shows that while these are all somewhat more 
fatal among men than women, the ratio between the sexes 
was very nearly the same in 1890 as in 1860.1 
These observations upon the causes of the increasing 
diseases are intended as suggestions only, and not as a com- 
plete enumeration of those causes. The subject is one 
which needs further investigation, and I commend it to this 
Society as one of the most serious and urgent of medical 
problems. Among the causes mentioned there are a few 
which stand out conspicuously, and seem to demand our 
especial attention. These are : 
1. The general prevalence of digestive disturbances, 
due in part to a diet generally too rich in albuminoids and in 
part to a weakness of digestion caused by lack of exercise 
and mental strain. From these result lithasmia and dis- 
orders of the liver, with Bright’s disease as one of the remote 
effects, while they constitute an important factor in the 
causation of diseases of the heart and brain. 
2. A lack of general vigor due to insufficient exercise, 
resulting from sedentary occupations, cheap modes of con- 
1 The number of deaths from unknown causes is, through increased accuracy 
of registration, decreasing year by year, and this of course increases the number 
from known causes. The deaths from unknown causes in 1871 were 1290, and 
in 1890—515. The difference between these figures is 775, and allowing for 
increase of population would be 916, and if this number of deaths had been 
correctly returned in 1871, we might now find a less marked increase in some of 
the diseases. But the increase in diseases of the brain, heart, kidneys and cancer 
alone is four times this amount, and therefore the increase cannot be accounted 
for by increased accuracy of the returns. 28 
THE PREVENTION OF DISEASE 
veyance, and a climate which, during half the year, makes 
out-door exercise unattractive. 
3. The excitement and anxiety which pervade all occu- 
pations at the present day, when men must wear themselves 
out in trying to keep pace with the mad rush of this age of 
steam, electricity and desperate competition. 
4. The intemperate use of alcoholic stimulants, than 
which no other cause of disease is so potent and destructive. 
This is an old enemy ; and yet one whose assaults are ever 
new. 
In applying preventive measures of these diseases, it is 
evident that the campaign must be largely educational. 
Frugal living, self-restraint and tranquillity of mind cannot 
be enforced by act of legislature, while even the legal sup- 
pression of intemperance has not yet been accomplished. 
The work must chiefly be done by medical men in their daily 
intercourse with their patients. Anticipating the dangers 
with which they are threatened, and helping each to so 
order the course of his life as to pass through these dangers 
unscathed, constitutes the highest and the most difficult 
branch of preventive medicine. Though a branch which we 
all are practising, it is capable of broader development and 
demands more persistent application. 
There are, however, certain ways in which much benefit 
may be reaped from measures of a public character. 
Two of these relate to the public schools. One consists 
in an increased attention to instruction in hygiene, and the 
other to the general introduction into the schools of physical 
training, and in giving this a conspicuous place in the 
curriculum. The absence of such training has, in the past, 
been the greatest defect in our school system. That this 
defect is already being remedied in Boston and elsewhere is 
a most hopeful sign ; and we, as physicians and humani- 
tarians, can render the public inestimable service by using 
our influence to have such instruction introduced into the IN MASSACHUSETTS. 
29 
schools of every city and town of the State. This should 
be a systematic course of gymnastic drill, extending through 
every grade of school, from the lowest to the highest, pre- 
ference being given to the Swedish system, or something of 
like nature ; and should be under the direction of specially 
trained instructors. Facilities for the training of such 
teachers already exist in Boston, and it would take but very 
few years to built up such a system of physical training 
that the graduates of our schools would be possessed of a 
sound bodily development which would give them a better 
chance for a long and useful life than thay now have, while 
this would in no way hinder, but, on the contrary, would 
greatly help, their intellectual development. 
As a result of this inquiry into the practical effects of 
sanitation in the State of Massachusetts, we have found that 
these effects are not only tangible but brilliant, and consti- 
tute veritable triumphs of preventive medicine. But, on 
the other hand, we have found that with these triumphs we 
must not rest satisfied ; for, while the hostile army of disease 
has been weakened in one part, it has gathered strength in 
another, and our partial victory is offset by severe reverses. 
The zymotic diseases, against which our sanitary army 
now chiefly directs its attack, cause but a paltry 18 per cent, 
of all deaths. In twenty years they have suffered a reduc- 
tion of 30 per cent. ; and supposing it were possible to keep 
up this rate of decrease by arithmetical progression, they 
would, in fifty years more, be reduced to zero. But, even 
if this extraordinary thing should happen, and the present 
increase of the local diseases should continued unchecked, 
the year 1940 would find us with a still undiminished death- 
rate. 
We cannot longer, therefore, confine our efforts to the 
£3 7 
suppression of this small minority of diseases, but must plan 
a new campaign against the greater foe. Here new and 30 
THE PREVENTION OF DISEASE. 
even greater difficulties confront us. for we have to contend 
with causes remote, complex and intangible ; but to seek 
out and attack these causes is a duty which we now see to 
be imperative, and the forces of preventive medicine must 
be brought to bear upon them with new weapons and new 
modes of warfare. The Boards of Health cannot do this 
alone, but the whole medical profession must be the attack- 
ing army. May we all do good and valiant service against 
these treacherous foes which are sapping the vitality of our 
race and retarding the evolution of the perfected type of 
manhood.