norance, not on the part of the people alone, but also of the health authorities. Small towns have been subjected to great loss of life by outbreaks of diphtheria. In one week fifty deaths have

occurred in a place of two or three thousand inhabitants without causing much consternation outside the immediate locality, and without any action on the part of the government officials, who are so solicitous regarding the coast quarantine.

Serious outbreaks of typhoid fever are constantly occurring as the result of a polluted water supply. This occurs from year to year without any apparent concern on the part of the community affected. Another danger to which the public is exposed, particularly the infantile portion of it, is the milk of tuberculous cattle. When it is considered to what extent milk is relied upon as the sole nourishment of children, the gravity of this danger cannot be over-estimated, particularly as we know this disease to be very common among cattle, frequently involving 10 to 50 per cent. of an entire herd. Although bacteriological work has confirmed the danger from this source, but little effort outside of the large cities has been made to protect the consumers. The loss of life in the United States from yellow fever is absolutely insignificant compared with the deaths resulting from causes just enumerated. If it is necessary for the protection of the people, that the government should assume direct control of health matters at the coast, it is equally if not more important that it should take direct charge of the health of those living in the interior.

The recent outbreak of yellow fever in New Orleans and other Southern towns has been of a particularly mild character. The mortality has not exceeded 13 per cent., which is extremely low. At no time in New Orleans has the disease passed beyond the control of the efficient Health Department, the officers of which deserve praise for the energetic manner in which the emergency has been met. This much, however, cannot be said of the methods for protection employed by the health officials of some of the smaller Southern towns invaded by yellow fever. The want of harmony which has here prevailed, and the absurd and unnecessary rules enforced, have been followed by an irreparable injury to business, and it is not a surprise that the business community should demand some change which would prevent a repetition of the experiences which have followed the recent outbreak. This, however, is not the first time that this disease has

invaded the South, and although the lesson each time has been severe, it is rapidly forgotten; otherwise, the construction of proper sewers and clean streets would be demanded. This, I am sorry to say, is not the case, nor is the importance of such measures fully appreciated. If Southern citizens and legislators, who are now clamoring for a change in the administration of the quarantine service, would expend the same energy in securing appropriations for the construction of proper sewerage systems, and means of securing good sanitary conditions, the danger from yellow fever would be reduced to the minimum, and the fear of this disease, which now prevents the proper execution of sensible health ordinances, would doubtless soon be a thing of the past.

It is evident that the substitution of a national quarantine system for the present one is not the remedy for the evil complained of. It is not sufficiently comprehensive. Therefore, the question arises, what change can be made which will best protect the public of this country against the danger and annoyance from infectious disease both at the coast and in the interior? I believe that the consensus of opinion of those who are best able to decide this matter is that the establishment of a National Bureau of Health offers the best solution of the problem. This bureau should be sufficiently distinct and separate from any other body in order that it may not be embarrassed in its work. Its functions should be to co-operate with State and municipal authorities, and to see that certain general health laws applicable to both the coast and interior are enforced. This body should assume direct control only on invitation or when the State or municipal officers are unable by reason of lack of funds, etc., to perform the work. This would insure a uniformity of action without interfering with the rights of the State or municipality, and would in a measure be educational. It has been suggested that this work be placed in the hands of the Marine Hospital Service; this suggestion, however, is not seriously entertained by many who are fully conversant with the subject.

The Marine Hospital Service, which is a branch of the Treasury Department, and under the control of a Supervising SurgeonGeneral, was created for the relief of disabled American seamen. For this purpose hospitals, laboratories, etc., have been equipped in different parts of the United States. The character of this work demands the highest respect, and it would seem that, with

the facilities now at hand for the investigation of disease, ample employment could be furnished the medical officers of this service, particularly as scurvy, beriberi, and other like maladies which affect seamen are not as yet well understood. It is certain that the Marine Hospital Service is not properly constructed for the management of a national bureau of health in addition to its own work. It is so considered by the American Public Health Association and other medical bodies.

There is a matter to be considered which is of great importance, and which has a distinct bearing on this question. I refer to the proper education of medical men in this line of work. The majority of graduates of medical colleges leave these institutions without having seen a single case of any quarantinable disease; they know practically nothing of disinfection or disinfectants, or the care of infected ships or houses Therefore, when they have been brought face to face with these conditions, they are frequently powerless to act. This is only too soon recognized by the public, and a want of confidence in a health officer of this kind is naturally followed by such excesses as shotgun quarantines, etc. That the necessity for this education is appreciated by the profession is evident from the fact that a special course in the study of infectious disease and sanitation will probably soon be added to the curriculum of the different medical colleges.

ALVAH H. DOTY.

III.

THE recent epidemic of yellow fever in the South has fully demonstrated that State and municipal health authorities are inadequate to prevent the entrance and spread of infectious and contagious diseases, and has emphasized the necessity of national action in dealing with cholera, yellow fever, smallpox and the plague. So far, the most efficient means of preventing the entrance and spread of these exotic diseases is unquestionably the enforcement of strict, scientific quarantine and sanitary regulations.

The numerous conflicting and, in many instances, ridiculous quarantine regulations, formulated by State, county, and muni

cipal authorities, and enforced oftentimes by excited and inexperienced men, aided in some cases by the shotgun, during the epidemic of yellow fever which has just prevailed in the Gulf States; the utter disregard of commercial and railway interests, and in the end the complete failure to arrest the passage of the contagion from town to town and from State to State, form a telling object lesson, which must convince the staunchest supporter of State autonomy that the Federal government should take entire and complete control of quarantine in these several diseases.

Illustrations of confusion and conflict of sanitary and quarantine regulations during the recent epidemic were to be found everywhere in the territory involved. Unreasonable quarantine restrictions were imposed. One State quarantined against another State, and one town against another town. One or two small villages in Alabama and Mississippi quarantined even against the world. Travel was interfered with or wholly suspended; commerce was paralyzed throughout Alabama, Missiзsippi, Louisiana, and Texas, and greatly hampered in all contiguous States; while the movement of railway trains in these States was either entirely forbidden or limited. The United States mails were stopped and more than once destroyed by local authorities. The requirements of State and local boards of health for disinfection were in many instances as absurd as they were incompatible with each other, and the absence of uniformity in regulations imposed unjust hardships upon the travelling public and the railways interested. The loss to the country must be estimated by millions of dollars. The South was on the very threshold of prosperity; crops were abundant in yield, manufactories were opening up, and new life and hope were ready to enter. In the presence of this happy condition, a single case of yellow fever was introduced, and the disease was allowed to spread, producing a panic among the people, destroying commerce and traffic, and affecting injuriously every enterprise in the section. State and municipal authorities found themselves unable to cope with the disease or to stamp it out, because they lacked experience and the machinery for effective quarantine and for the enforcement of sanitary rules and regulations.

The very inception of exotic epidemic disease in this country

is of national concern. The appearance of a single case of yellow fever in Galveston affects Boston, and, like leaven in the commercial mass, its influence extends to every centre of trade and manufacture in the country. As epidemic diseases when existing in this country are factors in interstate commerce, Congress has the constitutional right to enact laws governing the same.*

The act of Congress approved February 15, 1893, provides for limited quarantine rules and regulations, under the direction of the Secretary of the Treasury and the Supervising SurgeonGeneral of the Marine Hospital Service. Rules and regulations were formulated by the Surgeon-General, assisted by an advisory board of the Marine Hospital Service (the members of which were all experts or had had large experience in quarantine matters), and these were promulgated by the Bureau. The powers of the President and the Secretary of the Treasury are not broad enough to meet the exigencies of the case. It is made the duty of the Supervising Surgeon-General, under the direction of the Secretary of the Treasury, to "co-operate with and aid State and municipal boards of health in the execution and enforcement of the rules and regulations of such and in the execution and enforcement of the rules and regulations made by the Secretary of the Treasury; . but if the State or municipal authorities fail or refuse to enforce said rules and regulations, the President shall execute and enforce the same." It is, therefore, plain that the Marine Hospital Service cannot intervene in an early effort to stamp out infectious or contagious diseases, unless the local authorities fail or refuse to act, and State and municipal pride too often prevent local authorities from asking for Federal aid until the disease has made progress in spreading. And the fact must not be lost sight of that quite often local health officers are not sufficiently acquainted with the symptoms of epidemic diseases to be able to make prompt and correct diagnoses. There is also danger of concealment of epidemic diseases by local physicians and health officers in order to save their friends and patients from the inconvenience of quarantine stations and detention camps, and to protect the local interests of towns and States. Discrimination by State and municipal officers in control of * See Section VIII., paragraph 3, U. S. Constitution.