Duty of the State in Public 
Health. 
BY 
F. B. STEPHENSON. A. M., M. D., 
u. s. JJavy, 
MEMBRE TITULAIRK DE LA SOCIAtA d’ANTHROPOLOGIE 
DE PARIS. 
BErKINTED FROM 
STtje Neto Torfe IrUetiical 
for June 25, 1887. Reprinted from the New York Medical Journal 
for June 25, 1887. 
DUTY OF THE STATE IN PUBLIC HEALTH.* 
By F. B. STEPHENSON, A. M., M. D., U. S. Navy, 
MBMBRE TITULAiEeT DE LA SOCIETE D’ANTHROPOLOGIE DE PARIS. 
Although the original f of a part of this paper was writ- 
ten having especially in view the people and government of 
Italy, it is hoped that what follows may be of interest to 
the economists of America. 
The great innovations—those which should be very ad- 
vantageous to humanity—are, more than others, opposed 
from the first, objections being sometimes strong enough to 
arrest them for years, occasionally for centuries. This may 
be brought about through malevolence, or by the mere dis- 
like of anything new. In medicine, particularly, obstacles to 
free progress of the truth appear to be more numerous than 
in any other branch of science.J One of the greatest diffi- 
culties with which surgery has to struggle is represented by 
some of the most malignant diseases well known. These 
attack persons who have recently undergone some opera- 
* Read before the United States Naval Medical Society, April 7, 
1887. 
f “ La Risponsabilita del Governo nella Salute Publica,” by Pro- 
fessor 0. Ruata (“ Estratto dalla Gazzetta degli Ospedali”). 
J The history of pseudo schools of medicine and of patent reme- 
dies may be studied for illustrations. 2 
DUTY OF THE STATE IN PUBLIC HEALTH. 
tion, occurring in a frequency disproportionate to the grav- 
ity of the cases. Many instances of this kind took place un- 
der the old regime. The mortality records of some former 
hospitals are dire enough. With the now recognized pre- 
cautions of asepsis a surgeon may approach in confidence 
the most formidable operations, most if not all of which 
would be impossible without them. Pyaemia and septicae- 
mia from such sources are now known only (or should be) 
from descriptions given of them.* 
It is calculated! that in Italy, during the year 1883, 
eighteen thousand women died in partu—that is, in the 
flower of their age. Other losses would indirectly flow 
from this, first to individuals and families, ultimately to the 
state. Puerperal fever has been produced by experiments 
on animals, through injection of the septic discharges. Our 
author makes the surprising statement that, even in this age 
of enlightenment, many Italian midwives, and some physi- 
cians, too, forbid lying-in women to be washed or have linen 
changed for quite a number of days after labor. During 
the same year there were about sixty-two thousand deaths 
from other contagious diseases. We read that five thousand 
deaths annually arc caused by diarrhoea and dysentery, ow- 
ing, doubtless, to bad local hygienic conditions, as seen by 
Professor Ruata. The modes of transmission of disease- 
germs in typhoid fever, and the ease with which it may be 
prevented, are referred to. Many cases, foci of infection, 
pass unperceived, probably through ignorance; such ought 
to be noticed by medical officers, whose special business it 
should be to look after them. Tuberculous phthisis J is con- 
*“Tutti questi avvelenamenti del sangue, cosi comum altri volti, 
sono ormai scomparsi, e non e molto tempo che un giovane medico in- 
glese mi diceva ch’ egli non conosceva che cosa fosse piemia o settice- 
mia se non dalle descrizioni che i trattati ne famo.”—C. Ruata. 
f Official statistics published by the Italian Government. 
f Lions have phthisis and elephants Bright’s disease.—Gerard. DUTY OF THE STATE IN PUBLIC HEALTH. 
3 
sidered to be infectious and preventible ; reference is made 
to the good results one may expect from applying antisep- 
tics to the lungs by inhalation. The breath of individuals 
may spread the disease ; milk from tuberculous cows * may 
cause it in those otherwise healthy. 
Professor Ruata refers briefly to cholera and the bacil- 
lus f of Koch, with the remark, “What practical utility re- 
sults? Little, if any.” 
Thus much, as illustrations, for the multitudes that died. 
But what has been the effect on those who have indeed es- 
caped with their lives? “The expense of sickness, time 
lost from work,J deterioration of health, misery, desolation 
—malediction on society I ” How much more destruction 
of life and happiness is due to these causes than to war and 
other violence ! And what does the government do against 
them ? Drugs are shown to be powerless to cure any of 
the infectious diseases.* Our author says: “ I have no 
hope to ever be able to cure them by such means. This is 
my hypothesis, but sustained by facts that leave no doubt 
* Epidemics of pleuro-pneumonia and epizootic furnish examples of 
loss among the lower animals, to say nothing of inconvenience and dan- 
ger therefrom to man; as, for instance, ailments due to impure meat 
and milk. 
f Vide “ Microbes,” by E. L. Trouessart, in Appletons’ “ Interna- 
tional Scientific Series.” 
“ Aucune de ces vibrions ou de ces bacteries ne peut etre consideree 
comme caracteristique de telle ou telle maladie ou comme la produisant. 
On ne les trouve pas dans les liquides des animaux vivants et sains.” 
J. Pelletan, “ Le microscope.” 
| “ En France, la maladie, avec ses chomages et ses frais, emporte 
708 millions des francs chaque annee.” Congres d’hygiene a la Haye, 
aout, 1884; conference de M. Rochard sur “La valeur economique de 
la vie humaine,” “ Jour, de med. et de chir. prat.,” Sept., 1884, p. 386. 
w This idea is worth consideration by those who believe with Hah- 
nemann that “ drugs are the real curative agents ” of disease. 4 
DUTY OF THE STATE IN PUBLIC HEALTH. 
of its correctness.” The difficulty of destroying the Acarus 
scabiei (so easy of access, relatively) is compared with that 
of even reaching the alleged peccant microbes, which, we 
are told, have more vital resistance than the itch-insect. 
How, then, is it possible to come at and kill these germs in 
the blood and tissue without great harm to health ? “ Spe- 
cific treatment of disease seems to be unreasonable.” * We 
know that in these and like kinds of sickness there is a 
question of poisoning merely, and that it is within our 
power—the power of the government—to stop infection. 
We have police for crimes, why not for the detection and 
annihilation of such poisons, far more dangerous and de- 
structive certainly than many an open foe ? Every citizen 
has a right to expect that the state should guarantee his life 
against these terrible enemies, from which he can not be 
made safe unless by the intervention of a force able to ab- 
solutely impede their progress. We can, by barricading 
our houses, guard ourselves from thieves and murderers, but 
for these diseases we have no means of defense save those 
that the central authority should give ; its responsibility in 
such things is so great as not to admit of any half-way 
measures. Deaths from these sources, and the consequences 
thereof, are to be laid at the door of the general govern- 
ment in its duty to public health. Public health is made 
up of the health of individuals. The need of enforced legal 
sanitation is apparent, nay, urgent I Why not apply Lis- 
terism (asepsis), which consists not only in mere pharmacal 
antiseptics, but in the use of all the means within the power 
of society to prevent the formation of nests (nidus) or 
centers of disease that may become poisonous to persons 
* Is not the supposed cure in such cases due entirely to the physi o 
logical action of the drug, rather than to any specific effect against the 
cause of disease ? DUTY OF THE STATE IN PUBLIC HEALTH. 
5 
about? Formerly epidemics were rare because means of in- 
tercourse were few. 
Places of public resort or of private gathering may be 
points of diffusion.* Have we not an example of this in 
the epidemic of small-pox in Montreal, Canada, during 1885, 
where the disease was evidently spread by processions in 
the streets and the crowds in churches, seeking aid through 
ceremonial and prayer? 
What is the duty of the government in such a condition 
of popular intelligence ? The government’s most productive 
act is to educate in the widest sense; that is, to show the 
people how to best use their own abilities in accordance 
with the laws of nature about them, from which, indeed, 
human life is not free. Why are there these sixty-two 
thousand deaths from contagious diseases? Why allow one 
person or family to poison another without restraint ? Why 
is disease communicated in churches, theatres, hotels, rail- 
way-trains, and so forth ? 
Isolation of original cases and the endeavor to stamp 
out the disease in the start f would prove to be much more 
effective than the usual quarantine or sanitary cordon, 
which are, ordinarily, difficult of application and imperfect 
in result. England escaped cholera (1883) through the 
very prompt attention of her sanitary officials to the first 
imported cases, infection being thus hindered. The history 
* “ Pensai che il focolajo d’infezione comune fosse la chiesa, dove 
tutti accorevano, e che la pia madre che lasciava per pochi istanti il suo 
bambino ammalato per recarsi al tempio a pregare il Signore per la 
salvezza del figlio, seminasse in quel luogo stesso la morte per qualche 
altro.”—C. Ruata. 
■f Disease in cattle, fowls, etc., may also be cut short by isolation 
and proper care in the beginning. This is done to some extent in 
America at present, but there is yet need of officials duly informed, so 
that infectious cases may be recognized without delay from ignorance. 6 
DUTY OF THE STATE IN PUBLIC HEALTH. 
of cholera in Naples shows how neglect may allow conta- 
gion, and a wise use of energy stop it. The inconvenience 
and difficulty of isolation have been objected. But which 
is the worse trouble, such temporary interference, or a ravag- 
ing epidemic? Shall the benefits of commerce, the profits 
of present trade, be held of more value than the great prac- 
tical and future good of saving alive adult citizens ? * 
With one properly qualified and authorized agent (the 
strong arm of the law duly sustaining him) to a certain 
number of inhabitants, epidemics might be avoided through 
separation (isolation) of the first single cases. When the 
disease occurred elsewhere, the health officer of that district 
should be there to thwart its progress.f Our Italian con- 
frere thinks that it would not be hard to obtain the requisite 
number of fit medical men for this purpose, at least in his 
country ; such physicians could also attend the poor. One 
great advantage of appointing for this work might 
be the giving to the populace right ideas on hygiene. 
Laws and regulation exist cui bono? An enlightened 
public opinion only can bring about a thorough carrying 
out of the most perfect legal plans,* and this public opinion 
must be made through knowledge, instruction, education ! 
The following remark applies particularly, perhaps, to the 
smaller officials of some European countries, yet the “ mus- 
* For the action, in this connection, of those in control of Egypt 
during 1883, we refer to “ Cholera,” by J. A. S. Grant (Bey), M. D., in 
the “New York Medical Journal” for February 27, 1886. 
f Isolation of cases of infectious diseases is yet so imperfect in the 
United States that, during the year 1886, there was a discussion before 
the Massachusetts Medical Society as to the means of getting better 
results therefrom. 
| Using “doctor” in the sense also of the original Latin — “a 
teacher.” 
* Witness the power of religious and of race prejudice to nullify 
law, DUTY OF THE STATE IN PUBLIC HEALTH. 
7 
tard-seed ” of truth may be found for use in the New World : 
“ In the eyes of the local authorities, a fine road or a monu- 
ment to those who died from such diseases is of more im- 
portance than good drinking-water for the people — the 
people in whose health and prosperity consists the welfare 
of the state.” 
An organized body of capable sanitary officials, under 
the central direction of a board of public health, would be 
a most beneficent institution among many of which this 
age may wisely be proud.* 
The public health is endangered in a peculiarly insidious 
way by adulteration of food and drink.f 
A healthy population or people—healthy in body and in 
mind—is the strength and riches of a nation. As a matter 
of wise conservation, the government or commonwealth 
should protect the ignorant from disease; the ignorant in 
such cases are not, necessarily, in the lowest rank of social 
life. Security—physical, hygienic, and mental—is better 
than material wealth. Natural liberty of the individual 
should not prevent the State giving medical assistance. 
In all schemes of government aid the question is not as 
to the effect upon highly cultured or ideal men, but as to 
what, profitably to ail, can be done for men in general, 
what may be expected from people as they are.J We can 
* For an interesting, vivid, and impressive presentation of some im- 
portant details of this question (touching Italy), see “ Cholera, and the 
Duties of Governments and Countries during Epidemics,” by Professor 
E. Albanese, Palermo, in the “ New York Medical Journal ” of Janu- 
ary 8, 1887. 
f See “ Modern Adulteration in Foods and their Relation to Dis- 
ease,” by E. H. Bartley, M. D., in the “New York Medical Journal” 
for July 17, 1886. 
| In the by-laws of the International Workingmen’s Association 
(1864) it is stated that the association recognizes “truth, right, and 
morality as the basis of their conduct toward one another and their 8 
DUTY OF THE STATE IN PUBLIC HEALTH. 
not deal with them as we would with figures on a slate.* 
Reasoning, to be of value, must give deductions from ob- 
served facts of nature (including human nature), verified by 
general experience. 
It is written of a renowned Russian general: “ He list- 
ened to all told him, and gave the requisite orders without 
seeming to take any interest in what was said, though, in 
fact, alive to every tone and every change of expression in 
the speaker.” To do otherwise than treat men and things as 
they are would be as futile as to expect anything real from 
Napoleon’s plan for the government of his Europe made 
peaceful by conquest. An economist, besides educating 
himself, has much to observe. 
The great influence of the Government appears in the 
following testimony by Malthus in 1827: “The Govern- 
ment of Ireland has, upon the whole, . . . tended to de- 
grade the general mass of the people, and consequently to 
prevent them from looking forward and acquiring habits of 
prudence.” Another phase is presented by R. B. Brough : 
“ To the institution of aristocracy in this country (England) 
is mainly attributable all the political injustice, and more 
especially the groveling moral debasement we have to de- 
plore.” Malthus further says: “If the Government would 
remove hindrances to agriculture, and spread knowledge 
about it,f it would do more for the population of the coun- 
try than by establishing five hundred foundling hospitals.” 
Recent legislation in France, offering a premium for the 
fellow-men, without respect to color, creed, or nationality. ... No 
rights without duties, no duties without rights.” 
* However this may be in theory, we dare say that few men have 
capabilities of mind so unlimited as to be able to base anything prac- 
tical thereon at present. “ Le plus grand instrument de 1’homme est 
1’homme.” 
f This idea might be fruitfully applied to the life of modern Greece. DUTY OF THE STATE IN PUBLIC HEALTH. 
9 
seventh child, is quite opposed to the views of this philoso- 
pher as to the wisest way of increasing the population, and 
thus conducing to national prosperity. Population increases 
when means of sustenance increase. Removals give space 
for new-comers, from marriages becoming possible. 
The cause of poverty ? Poverty exists wherever two 
persons try to live on the food (everything necessary) na- 
ture has designed for one—accidents apart. Whose fault 
brings two beings into the world where one only can find 
perfect life ? 
The effect of character on actions and of actions on 
character are of great economic importance. The clear 
consciousness of personal responsibility is the soul and cen- 
ter of every healthy advance. Enlightened self-interest is 
a wise and potent motive in social betterment. “ The lan- 
guage of experience owes much of its meaning to the in- 
terpreter.” The ways, more or less direct, in which gen- 
eral knowledge aids in procuring and retaining physical 
well-being are very many; oftentimes they are not easy to 
find. A learned and strong guide is most valuable. Ad- 
vice, teaching, example are better than positive aid, which 
has often caused feelings of dependence and selfishness an- 
tagonistic to the desired individual development. The hope 
and effort to improve their condition are fruitful in all 
classes, but most frequent and constant in the grades above 
the wretchedly poor. As an example, where there is evi- 
dent ignorance, the people should be taught how best to 
utilize waste of unoccupied lands.* 
The man who commits the crime may not be the most 
guilty, but he who causes or, being able to dispel, permits 
the darkness of ignorance. “ Man shall not live by bread 
alone, but by every word that proceedeth out of the mouth 
* See “ Russians of To-Day,” chap, ii, on the condition of the lower 
classes. 10 
DUTY OF THE STATE IN PUBLIC HEALTH. 
of God ”—that is, being interpreted, by the highest wis- 
dom. Much disease and years of misery might be avoided 
if some judicious forethought—sometimes called worldly 
wisdom or common sense—were used in forming marriages 
and in the conduct of life afterward, especially in regard to 
offspring. Truth is weakened by any addition of error. 
A wise government will care for the temporarily weak 
and needy portions of the community, they being on that 
account not less essential to public welfare than those who 
are able to provide for themselves in all things. 
One important duty of the state is to require registra- 
tion of deaths, with satisfactory evidence that it is due to 
natural causes—that is, not from crime.* The result of 
such action tends to educate the people so as to procure for 
the community at large physicians worthy of confidence, as 
is now attempted by the examination of men for the public 
service. 
Whether laws (so easily and widely evaded) to regulate 
the practice of medicine that reduce good and bad to the 
same low level are a benefit, is a question upon which legis- 
lators may well bestow serious thought. Would it not be 
better to instruct the people so that they might judge with 
reason ? Education for the raising of man’s physical and 
mental condition “ is rarely absolute, but relative, and should 
be conducted in language used by ordinary, clear-thinking 
men.” Thorough informing of the people in regard to the 
laws that control mental and moral being (if, indeed, they 
are not identical) is needful in order to complete the work 
of customary education. Does not the highest education 
find its best use in making wise laws for social rule? The 
more freedom citizens have, so much the more profound 
must be their knowledge—knowledge of things concerning 
* Billings, “Medicine in the United States,” 1886. DUTY OF THE STATE IN PUBLIC HEALTH, 
11 
both body and mind—to prevent liberty becoming license 
and to attain the best results possible.* 
Although some of the ideas herein presented may seem 
to have little relation to public health, the philosophic stu- 
dent knows that remote causes are often of greater influ- 
ence than the proximate, usually deemed most important by 
the vulgus. 
* An outline of this broad education is given in the address of 
Carroll D. Wright, President of the American Social Science Associa- 
tion, under title, “ Popular Instruction in Social Science.” See Boston 
“Evening Transcript,” September 7, 1886. REASONS WHY 
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