The War Against Disease

[The author of this paper is instructor in sanitary bacteriology in the Massachusetts Institute of Technology. — THE EDITORS.]

THE cure of disease was variously attempted in the remotest ages of which we have any record, but its prevention is a strictly modern phenomenon. Until a somewhat recent period many devout persons sincerely believed plagues and pestilences to be “a merciful provision on the part of Providence to lessen the burthen of a poor man’s family, ” and consequently held that it must be “impious and profane to wrest out of the hands of the Almighty these divine dispensations.” A disproportionate emphasis on certain Pauline doctrines had produced utter contempt for the body and all its ills.

Science, nevertheless, has made nothing clearer than the fact that the moral and intellectual life are intimately bound up with the physical, and that from a sound and normal body wise thoughts and right actions are far more likely to proceed than from the deranged mechanism of the defective or the degenerate. It becomes then as essential to fight against physical poverty and disease as against their correlatives in the moral sphere. Disraeli expressed the sentiments of thoughtful public men upon the importance of this function of the state when he uttered these memorable words: “The public health is the foundation on which repose the happiness of the people and the power of a country. The care of the public health is the first duty of a statesman.”

The devoted work of the medical profession in the conflict against these evils has been lately supplemented by that of trained specialists, sanitary engineers, epidemiologists, and bacteriologists. Day by day the fight is being waged, and always with more and more honorable results. While the power of the man behind the gun to destroy human life has been multiplied by civilization, the power of the man behind the microscope to prolong it has increased in far greater proportion. Bad news however travels fastest; and the destroyer still occupies in the public eye a larger place than the preserver. It is therefore profitable at times to take a brief survey of the progress of science in its relation to the public health, — to read as it were the bulletins from the seat of this Holy War.

The very completeness of the victory has in some cases obscured the formidable nature of the foe. Immunity from certain diseases is accepted, like the sunshine, without thought, by a generation which has not felt their incidence; and this condition has its dangerous side, for it leads often to a neglect of the precautions necessary to retain the advantages won. Smallpox, for example, has been so held in check by vaccination that its horror is forgotten, and the number of thoughtless and misguided persons who are to-day unvaccinated is a serious menace to the public health. Two hundred years ago every one had smallpox, first or last, as children have the measles to-day, those who escaped in one epidemic being almost sure to sicken in the next. From palace to hovel none were safe but those who had gone through the disease and recovered. Sir John Simon, in the History and Practice of Vaccination, quotes the experience of certain royal families, typical of the conditions which prevailed. William III. of England, for instance, lost by smallpox his father and his mother; his wife, Mary; his uncle, the Duke of Gloucester, and his cousins, the eldest son and the youngest daughter of James II. ; he himself barely survived his own attack, with a constitution damaged for life. The only check to these terrible epidemics was the fact that a large portion of the population at any given time was protected by a previous attack. When introduced among isolated peoples which had not acquired this protection, the effects were appalling, as in Iceland, where, in 1707,18,000 persons out of a population of 50,000 are said to have perished, or in Mexico, where three and a half millions of people were suddenly smitten down, the epidemic, according to Prescott, “sweeping over the land like fire over the prairies . . . leaving its path strewn with the dead bodies of the natives, who (in the strong language of a contemporary) perished in heaps like cattle stricken with the murrain. ”

No better proof could be furnished of the dread in which this disease was held than the general adoption of the practice of inoculation, introduced into England from the East by Lady Mary Wortley Montagu in 1717. In the remote ages of antiquity the Brahmins had realized that the only immunity from smallpox lay in a previous attack; and they had discovered that the inoculation of smallpox matter directly under the skin of a person in good physical condition gave him the true disease but in a milder form. Taken in this way, the malady proved fatal only to one in a hundred, or, under the most favorable circumstances, to one in three hundred, and rather than run the risk of virulent smallpox which might supervene when the constitution was weak and unable to resist it, those who could meet the cost of the operation preferred to take their chance with this lighter disease at a time when the vitality had been reënforced by special diet and preliminary treatment. The effect on the inoculated was excellent; they obtained immunity from smallpox with only one fiftieth of the deaths which would have followed from the malady in its usual form ; but the disadvantage of the treatment lay in the fact that it spread contagion among the public at large, for an inoculated person could give the disease in its most virulent form to any one with whom he came in contact. “The confession that must be made is mortifying to a professional man, for, according to such records as we possess, it appears that in spite of all medical exertion, the mortality of smallpox had progressively augmented. It has been made evident by calculations from the Bills of Mortality of the City of London, renowned for medical science, that at the beginning of the eighteenth century about one fourteenth of the inhabitants died of the smallpox, and during the last thirty years of that century, when the practice in smallpox was highly improved, the mortality of this disease had augmented to one tenth.” 1 Medicine, according to Sir John Simon, in the volume quoted above, was “baffled and helpless. For after times —— for millions of our race — the continued raging of that pitiless plague. A drearier picture could scarcely have saddened mankind.”

Medical skill and sanitary science were then of no avail; until, in 1798, a village doctor, Edward Jenner, suggested the practice of vaccination, which seemed at the middle of the last century to be “the greatest physical good ever yet given by science to the world. ” It had long been observed among the dairy folk of Gloucestershire that a mild eruptive disease of cattle, known as cowpox, could be communicated to human beings, and that those thus affected were protected from subsequent attacks of smallpox. Jenner conceived the idea of applying this preventive inoculation with the cowpox, on a larger scale; he tested its efficacy by careful experiments, and finally succeeded in convincing scientific men and the intelligent public that the dread disease could at last be conquered. All over the civilized world the new prophylactic was eagerly adopted, and everywhere it was followed by an abrupt decline in the smallpox death rate. In the city of Berlin, for example, 3422 in every million of the population died of smallpox per annum, during the period 1781-1805, before the introduction of vaccination; from 1810 to 1850 the average number of yearly deaths was 176. In Sweden the yearly death rate from 1774 to 1801 was 2050; from 1810 to 1850 it was 158. Actual experiments confirmed these statistical results in an even more striking manner. At the London Smallpox Hospital, within the two years 1799-1801, 7500 persons were vaccinated, and about one half of them were subsequently inoculated with actual smallpox matter in the manner previously practiced. In not one case did the virus produce any effect; and it was thus proved with certainty that a fresh vaccination, successfully performed, is an absolute preventive of the smallpox. Even after some years have elapsed, when the protective effect of vaccination has been weakened, so that the disease may be contracted in a small number of cases, it will yet occur only in a mild form. Thus in London, during the ten years 1891-1900, 125 persons who had been vaccinated at some time in their lives took smallpox and none died; while 672 unvaccinated persons contracted the disease, and among these there were 153 deaths. Since the time of Jenner it has year by year become more certain that we have in vaccination a sure and perfect means of fighting smallpox. Germany has realized this, and by the enforcement of the most rigid system of vaccination in the world reduced its smallpox death rate for 1895—99 to less than one in two millions of the population. England and America suffer from smallpox more than Germany, because a portion of the community is allowed to neglect this simple prophylactic.

How and why vaccination prevented a subsequent attack of smallpox, the early observers were quite ignorant, and it was not until the latter part of the last century that the researches of Pasteur threw a flood of light upon the subject. The great French savant, founder of the sciences of bacteriology and preventive medicine, proved in the first place that certain epidemic diseases are due to minute living organisms, plants and animals, and that for each definite disease there is a specific micro-organism. This was the great fundamental fact. Later it became evident that these microscopic parasites cause disease by chemical poisons which they secrete, called toxins. In many cases the microorganisms, if grown in culture-tubes outside the body, will produce the same toxins; after being separated from the living germs these substances will excite all the symptoms of the disease when injected into an animal body. The body at the beginning of an attack of fever is not however passive. Its cells react against the poisons introduced, and a struggle ensues, the end of which is life or death, the fighting being purposeful and definite. The body cells secrete a specific chemical body that either tends to destroy the invading bacteria or has the power of neutralizing and rendering harmless the toxins formed by them; this antidote to the poisonous toxin we call the anti-toxin. When a man recovers from an attack of smallpox, it is because his anti-toxins have proved too strong for the toxins of the disease, and his after immunity, it seems probable, is due to the persistence within his body of the anti-toxins once produced.

Pasteur showed also that cultures of micro-organisms might be artificially weakened or “ attenuated ” so that they could cause only a very mild attack of disease, not sufficient to be dangerous to the patient, but enough to stimulate his body cells to the production of antitoxin which would protect him against subsequent exposure to the virulent malady. This is what happens in vaccination, for we believe that the cowpox is simply smallpox, modified by being communicated to the cow. In the passage through the bovine body the germ has become so weakened that it can excite merely the most trifling derangement of the functions of the human body while conferring the protective effect of a severe attack of the original disease.

One method of securing protection is then to inoculate with weakened germs, which cause the formation of anti-toxins within the body itself. In some cases the process may be carried a step further, by causing the anti-toxins to be secreted in the body of an animal, drawing them off with the blood, and injecting them ready formed into the human system. In the case of at least one disease, diphtheria, the work of the German, Behring, and the Frenchman, Roux, has brought this process to perfection. At numerous public and private establishments, in this country and in Europe, carefully chosen horses are now kept to be injected with successively increasing doses of diphtheria toxin, prepared as described above by cultivating the germs in laboratory tubes. The first dose is sufficient to cause a slight rise of temperature and indisposition; gradually larger and larger amounts are used as the animal becomes more and more insusceptible, till finally a dose, one thousandth of which would prove fatal to a normal horse, is borne without discomfort. The blood of the animal is then rich in anti-toxin, and a portion of it is drawn off, the serum being separated, and purified by filtration. Injected into the blood of a sick child gasping in the clutches of diphtheria the straw-colored liquid works what seems a miracle, recovery being almost certain if it is administered at the beginning of the disease. The general death rate from diphtheria has been reduced to a third of what it was by this process.

The theory of the specificity of diseases did not alone lead to such methods of preventive medicine as fortify the system against the attacks of those micro-organisms which have already entered, or may in the future enter it. Sanitary engineers and public health authorities learned also the importance of proper systems of water supply and sewage disposal in controlling the spread of disease germs in the environment before they have a chance to reach the human body at all. What we now know to be the great water-borne disease, typhoid fever, was thirty years ago a scourge whose origin was shrouded in mystery. Most English sanitary authorities were “ anti - contagionists, ” and held firmly to the “pythogenic theory ” that the typhoid poison was generated spontaneously in the earth or in heaps of decomposing filth. Dr. William Budd, to whom more than to any other individual is due the overthrow of these erroneous ideas, wrote as follows in 1873: “There are few things which concern the people of this country more deeply than to know the exact truth touching the mode in which this fatal fever is disseminated amongst them. Every year on an average — take the United Kingdom through — some 15,000 or more of their number perish prematurely by it; a population equal to that of a considerable city every year swept into the grave. . . . As nine or ten recover for every one who dies, 140,000 persons, or more, must every year pass through its protracted miseries.” Yet, as Dr. Budd believed, this was “a perfectly preventable plague.” It was his privilege to show, what is accepted by all sanitarians to-day, first, that every case of typhoid fever arises by direct or indirect contact with a previous case of the same disease, and, second, that “the contagious element by which it is mainly propagated is contained in the specific discharges from the diseased intestine.” The “contagious element, ” or the germ of typhoid fever, enters the body in every case with some article of food or drink contaminated by an earlier victim. Under unclean conditions the infection may be communicated directly to the food by the fingers of a person who has been in attendance upon the sufferer ; in this case the disease is said to be actively contagious, Sometimes the carriers of the pestilence may be flies which have passed from the unsavory places they affect to a neighboring dinner-table. Usually, however, typhoid fever is transmitted in a more roundabout fashion; by such vehicles as water, milk, and raw shellfish.

The possible importance of the last article of diet in conveying the infection was first made evident by an epidemic among the students of Wesleyan University at Middletown, Conn., in 1894, studied in great detail by Professor H. W. Conn. The oysters which did the damage in this case were grown in a bed at Fair Haven, within three hundred feet of the sewer outlet from a house containing two cases of typhoid fever. They were served at three fraternity banquets on the night of October 12. The students present did not live at other times together, and between the three menus there was no common bond, not general to the town at large, except the oysters. Two weeks later, the period typhoid fever takes to develop in the system, one in every four of the students who had been at the banquets sickened with the disease. Among twenty-nine guests from other cities, Wesleyan alumni and members from Yale, who ate the Fair Haven oysters six additional cases of typhoid fever developed, while four other fraternities which held initiation suppers on the same night, but with no raw oysters or oysters from another source, had no cases of the disease.

Of the typhoid epidemics traced to milk, one of the most typical was that at Springfield, Mass., where, in July and August of 1892, one hundred and fifty cases occurred, concentrated in one of the most beautiful suburban districts of that city. The investigation showed that the path of the pestilence was coincident with the route of a certain milkman. It was next found that a portion of his product was derived from a farm where several cases of typhoid fever had occurred during the preceding summer. Shortly before the outbreak of the epidemic, the discharges from the patients were spread upon a tobacco field. Manure from this field, carried on the boots of the farm hands, was obvious about, and in, a well near by. On the bottom of this well, and submerged, — in leaky cans, —stood the milk to be cooled before it was sent to Springfield. The chain of evidence was thus complete.

Water epidemics have been still more numerous and of more serious dimensions. At Lowell, Mass.,for example, in 1890-91, nearly 1000 cases of typhoid fever were due to the pollution by four mill operatives of a little brook at North Chelmsford which emptied into the public water supply. In this year, as to a lesser extent in other years, the Lowell epidemic was followed by a secondary one in Lawrence, whose citizens drank from the river still further below. The public at last realized that these supplies from a polluted river, installed fifteen years before with the approval of the best sanitarians, furnished an ideal condition for the widest distribution of the agents of disease. In Lawrence a filter was constructed in 1893 to purify the water by passage through a layer of sand, and the deaths from typhoid fever, averaging fiftythree a year during the period 1887-92, fell to fourteen a year from 1894 to 1899. In Lowell the abandonment of the river water for that obtained from a system of driven wells caused a similar decline in the death rate.

Nothing is clearer from the facts than that typhoid fever is indeed a perfectly preventable plague. Indeed it has been said by one zealous sanitarian that “for every case of typhoid fever some one should be hanged. ” Yet great cities in the United States, Pittsburg, Philadelphia, even Washington, have not ceased to furnish their citizens with polluted river water containing the germs of this deadly disease. Year after year the early months are marked in Philadelphia by an outbreak of typhoid fever due solely to the washing of infectious material into the stream by the spring floods, — the same phenomenon which used to occur in Newark and Chicago, the same phenomenon which still occurs in Paris. Between 1890 and 1898, there died from typhoid fever an annual average of over 175 persons in Washington, of over 200 persons in Pittsburg, and of over 475 persons in Philadelphia, nearly 8000 men and women perishing of this preventable plague in those three cities during nine years. Allowing for all other possible causes it is certain that more than half of them were condemned to death solely by the corruption or the incapacity of those municipal officials who permitted the continuance of the existing water supplies.

Fortunately these conditions are exceptional ; and in most cities of the United States typhoid fever is a steadily diminishing factor in the death rate. Eventually a clear knowledge of the mode in which any disease is transmitted must lead to practical methods for restraining it, while without such knowledge preventive measures can have but meagre success. So malaria for years furnished an insoluble problem for sanitarians. Moisture seemed somehow to aid in its spread, and digging up of the soil, even for so beneficent a purpose as the introduction of sewerage systems, appeared to favor it. How, no one could say, until a very few years ago the researches of Celli and Grassi in Italy, and of Manson and Ross in British India, cleared up the matter. The parasite of malaria passes some stages of its life in the body of a species of mosquito, and by the bite of this insect it is transmitted from person to person. Damp places favor the breeding of mosquitoes. Italian laborers engaged in excavating bring the parasites in their systems from their native homes, and these parasites are carried by the insects to healthy natives of the neighborhood. Digging up of the streets does not introduce malaria when it is done by gangs of Scandinavians ; pools of water when covered with a film of oil so that mosquito larvæ cannot breed in them are no longer dangerous. These malaria researches have also thrown light on another scourge of the tropics, yellow fever; and the credit for this triumph of sanitation rests with three devoted surgeons of the United States Army, Drs. Reed, Carroll, and Agramonte. Placed in charge of the city of Havana during the temporary guardianship of the United States, they found that yellow fever had been endemic there for over two hundred years. During the period 1856—1900 this disease caused an average of 751 deaths a year. General sanitary improvements had produced little effect in 1900 until the brilliant investigators above mentioned showed that yellow fever, like malaria, was transmitted by the bite of a mosquito, though of another species. March 1, 1901, an active campaign of extermination was begun against this insect. The result was that between that date and February 15, 1902, only six deaths occurred from yellow fever; and since September 28, 1901, not a case has originated in the city. The terror of the region for centuries has been wiped out in a single year.

Knowledge of the diseases mentioned above, of smallpox, diphtheria, typhoid fever, and yellow fever, has made such progress that they are already controlled within narrow limits, while their practical extermination must come with the lapse of time and the progress of popular education. In other directions,however, the fight is just beginning. There are in particular two great classes of disease which come under this head, being preventable but as yet not prevented, the tubercular diseases and the diarrhœal diseases of children. Of tuberculosis, the “white plague,” it was said fifteen years ago, “about one fourth of all deaths occurring in the human being during adult life is caused by it, and nearly one half of the entire population at some time in life acquires it. ” Coming most frequently just at the wageearning period, the path of this insidious malady was marked by poverty and destitution as well as by sickness and bereavement. Striking with terrible persistence at the members of certain families and the inhabitants of certain dwellings, its supposed hereditary character cast a shadow of despair even beyond the zone of its actual incidence.

In 1882 the German bacteriologist, Robert Koch, proved that the cause of tuberculosis was a microscopic plant, a minute bacillus, now known to have affinities with the moulds. As in all other communicable diseases the presence of the specific germ is an absolute condition. Although the offspring of a consumptive family may inherit a constitution easily susceptible to the disease, he cannot inherit the disease itself, and with proper sanitary and hygienic precautions need never fear it. Even when tuberculosis has begun, the outlook is by no means discouraging, for the experience of the last quarter of a century has shown that the “fresh air treatment,” with proper diet, clothing, and habits of life, always ameliorates and often abolishes the malady. If taken at a sufficiently early period, consumption is emphatically a curable disease.

Improvement in general sanitary conditions, greater cleanliness, better ventilation, and more adequate housing of the poor have therefore led to a very material decrease in the death rate from tuberculosis. The establishment of special sanatoria for phthisical patients has proved of the highest value. It is necessary however to go deeper than this, to strike at the root of the trouble, the original source of infection, contained almost exclusively in the sputum of tuberculous patients, richly loaded with the germs of the disease. Directly transmitted by kissing or by the fine particles of moisture cast into the air in fits of coughing, still oftener dried and blown about as particles of dust, it is the material which sows the seed for the harvest of death. Cut off this source of infection, and tuberculosis will follow the great epidemics of smallpox and bubonic plague into the pages of history.

The prevention of this dread disease depends then upon so slight a matter as the reception of tuberculous sputum in special vessels of which the contents can be burned or otherwise disinfected. Yet many Boards of Health after spending thousands of dollars on the inspection of defective plumbing, to which it is doubtful if a single death has ever been conclusively traced, make no specific efforts to secure the intelligent coöperation of the public in this most vital matter. In the city of New York, indeed, a splendid campaign has been conducted against tuberculosis with significant results ; as early as 1893 a definite movement was begun under the inspiration of Dr. H. M. Biggs, the pathologist of the board. Public institutions were required, and practicing physicians were requested, to report cases of this disease, just as had long been done with the more acute infectious disorders. Cases occurring in tenement houses, boarding-houses, and hotels were to be visited by inspectors for the purpose of giving instruction in the proper care of the infective material. Premises occupied by tuberculous patients, when vacated by death or removal, were to be renovated, and clothing, bedding, etc., disinfected. Finally, a laboratory was established for bacteriological diagnosis of the disease by sputum examinations.

The departure involved in the inclusion of tuberculosis among the “notifiable diseases ” met with the strongest opposition from a large section of the medical profession. Nevertheless Dr. Biggs persisted in the struggle with what he has justly called “ the most fatal disease with which we have to deal, ” one that “from both an economic and sanitary standpoint is of vastly greater importance than any other infectious disease. ” Gradually his labors and those of his colleagues bore fruit. Knowledge of the true nature of phthisis has spread, even among the poorest class of the population, and the inspectors now find that in nearly half the cases visited for the first time more or less efficient precautions are being taken to prevent dissemination. The mortality from tubercular diseases in New York decreased more than thirty-five per cent between 1886 and 1900.

Much however remains to be done. In 1898 consumption caused more than one tenth of all the deaths in the six largest cities of the United States, about twelve per cent in Philadelphia and New York, and nearly twelve and a half per cent in Boston. Using the illustration of Vaughan, we may say that of the 75, - 000,000 people living to-day in the United States, eight or nine millions will die of tuberculosis, “unless something is done to prevent it.” Whether or not anything shall be done to prevent it depends upon the extent to which knowledge of these facts can be disseminated in the community.

Human life has been strikingly compared to the burning of a candle. The flame, as it first catches, flutters feebly so that the least breath will quench it; and again when burned almost to the socket it flickers and easily goes out. Thus the body which in middle life may bear the severest shocks of sickness and privation, in infancy and in old age succumbs to but slightly unfavorable conditions. The extinction of life at the end of its natural cycle, after the course has been finished, and the allotted work has been done, can scarcely be regretted, but the lives cut off before they are well begun are an absolute loss to the community, of the extent of which most of us have little conception. In many of the large cities of this country one fifth of all the children born die before reaching one year of age. Dr. S. W. Abbott, Secretary of the Massachusetts State Board of Health, has shown that in his state the ratio of deaths under one year to 1000 births between 1881 and 1890 was 160 for the whole community, and 175 for the cities alone. There is no single question, political or economic, which ought to be of such vital concern to enlightened public men as this tremendous sacrifice of life.

A certain proportion of these deaths is due to inherent weakness and the accidents of childbirth. By far the greater number of them however fall under three heads, the communicable diseases, tuberculosis, diphtheria, etc., which we have seen may be prevented, the respiratory diseases, pneumonia and bronchitis for example, which result from undue exposure, and the so - called “summer diseases, ” cholera infantum and enteritis, caused by an improper food supply. The most important factors are the diseases of this last class, which in Massachusetts account for about one third of the total infantile death rate.

Overcrowding, intemperance, poverty, and the heat of summer no doubt contribute to the high mortality from intestinal diseases among young children. These conditions are bound up with another, and the one of prime importance, the character of the milk consumed. In the city of Berlin, with probably the best system of vital statistics in the world, the method of feeding each infant is reported, and the records prove with mathematical exactitude what has been everywhere a matter of common observation. Milk, as it flows from the glands of a healthy mammal, is warm, sweet, and practically germ free. It is delivered to consumers in a city as an acid, fermenting fluid, containing countless myriads of bacteria, many of them actively poisonous to the delicate system of a young child. It is then not surprising to find that while the death rate under one month, among children fed at the breast, was nineteen, in Berlin, in 1896, the corresponding figure for those fed on animal milk was 111, and for those fed on various milk substitutes, 308. Furthermore the Berlin statistics show with great clearness that it is not simply cow’s milk, but decaying cow’s milk, which is at fault. Among children fed at the breast there were from two to three deaths a day during the whole year. In the animal milk class, the deaths for 1897 numbered thirteen a day during the nine cooler months, and thirty-three a day during the summer, when the germs which enter the milk are most rapidly multiplied.

If this slaughter of the innocents is due to the bacteria in milk, the problem for the sanitarian is to exclude or destroy these micro - organisms. Much may be done in the former direction, by thorough supervision of dairies, to insure cleanliness in the production and handling of the milk, care in its cooling, and promptness in its delivery. The price paid for milk is however too low to support model dairies, and milk produced under strictly sanitary conditions will probably always be out of the reach of the poor in the larger cities. The destruction of the germs is a far more simple matter than their exclusion. Heating to a temperature of 160° F. for twenty minutes kills so large a proportion of the bacteria present as to render the milk entirely innocuous, while there is no evidence that its digestibility is seriously impaired by the process. It cannot be too often repeated that “uncooked milk is an unsafe food; ” 2 dangerous because from the conditions of its production it is particularly exposed to contamination, because it furnishes an ideal medium for the multiplication of the bacteria which gain access to it, and because its color and opacity conceal the dirt which it contains, and give to it a delusive appearance of purity.

What progress may be made toward a solution of this problem has been shown in the city of Buffalo, where the Health Commissioner, Dr. Ernest Wende, has especially devoted himself to diminishing the infant mortality. His first step was to institute a rigid supervision of the milk supply, and the second and more important one was to begin a propaganda of education by distributing circulars of information on the care of infants to every family in which a birth had been reported. The results of this work form a sufficient answer to those who doubt the possibility of educating the public upon such matters. Dr. Wende reports that a “continuous and marked decrease of infant mortality dates from the time these circulars were first distributed.” In 1890 there were 2305 deaths of children under five years in Buffalo; in 1898, although the total population had increased more than one third, there were only 1570 deaths among children at that age. This number should have been doubled if the rate of 1890 had been maintained. Sanitary science then had saved the lives of 1500 children in that city during one year.

Each disease must be fought after its own kind. For smallpox, vaccination; for diphtheria, anti-toxin inoculation; for typhoid fever, the protection of food supplies; for yellow fever, the destruction of mosquitoes; for tuberculosis, the disinfection of sputum; for cholera infantum, the cooking of milk. Absurdly simple, many of these remedies appear; but with a thorough knowledge of the micro-parasites of any disease and the mode in which they gain access to the body, their exclusion will always be theoretically a simple matter. Our knowledge is unfortunately far in advance of our practice. Diseases which have been clearly shown to be preventable continue to slaughter their thousands year by year. While it is well therefore to push on and occupy new fields, it is still more essential to see that the ground already covered has been surely won. Won it must be, not by investigators or even by medical practitioners, but by a community in which the knowledge of sanitary science is generally diffused. Health is the normal condition of the human mechanism, while disease and premature death are in large part unnecessary. They are to be overcome, however, not by an abrogation of the intellectual faculty, but by its exercise. Those only who seek ardently to discover, and implicitly to obey, the inexorable laws of nature will survive in the struggle for existence, to round out their sum of years, and to benefit their kind.

C.-E. A. Winslow.

  1. Moore. History of Smallpox.
  2. W. T. Sedgwick. Principles of Sanitary Science and the Public Health. New York : The Macmillan Co. 1902.