Address ox State Medtcixe. 
Delivered before the American Medical Association at the Forty-fourth 
Annual Meeting, held at Milwaukee, June, 1893. 
BY 
WALTER WYMAN, A.M., M.D. 
SUPERVISING SURGEON GENERAL OF UNITED STATES MARINE HOSPITAL 
SERVICE. 
Reprinted from "The Journal of the American Medical Association," 
July 1 and 8,1893. 
CHICAGO: 
Journal of the American Medical Association. 
1893. ADDRESS ON STATE MEDICINE. 
BY WALTER WYMAN, A.M., M.D., 
SUPERVISING SURGEON GENERAL OF UNITED STATES MARINE HOSPITAL 
SERVICE. 
THE EXTINCTION OF CONTAGIOUS DISEASES. 
Mr. President, Ladies and Gentlemen:-Is the idea 
utopian or has the time come in the history of the 
world when it should be considered a rational thought, 
worthy of serious contemplation? When a standard 
so lofty as this should be raised, and around it 
gather physicians, sanitarians and philanthropists 
fully determined upon a great struggle and animated 
by a reasonable confidence in .ultimate success? 
Concerning the great epidemic diseases, encourage- 
ment may be found both by a reasoning from anal- 
ogy, in the study of their respective histories, and 
in the contemplation of modern knowledge and 
methods. 
The history of the world shows us that whole 
races of men and other animals have become extinct. 
Why should not races of microbes become extinct? 
And certain diseases that once ravished the earth in 
epidemic form have so lost their inherent strength or 
have been so controlled in the latter part of the 
• nineteenth century as to warrant the belief that their 
histories are closed, or fast closing. The plague of 
Athens and the plague of the second century are un- 2 
known at the present time; and the terrible black 
death of the fourteenth century it is unreasonable to 
suppose can ever again sweep from the face of the 
earth 25,000,000 of its inhabitants within a century. 
The terrible bubonic plague since the introduction 
of quarantine, crude though the first quarantines 
were, has gradually receded from Europe, its last ap- 
pearance on European soil being in 1878 when the 
Russian government by means of military cordons 
and destruction of infected villages by fire succeeded 
in stamping it out. Though it still occurs in Asia it 
may never again obtain a serious foothold in Europe 
because of more perfect quarantine and improved san- 
itation. 
With regard to yellow fever the great period of Us 
history was from 1732 to 1805. Formerly it was of 
common occurrence in Europe, the ports of Spain in 
particular suffering severely between 1801 and 1825, 
but there has been no disastrous epidemic of this 
disease in Europe since that of Lisbon in 1857, thir- 
ty-six years ago. 
Its earlier history in this country includes invasion 
not only of the South, but of parts as far north as 
Pennsylvania, New Jersey, New York and even New 
Hampshire. But to-day, though constant vigilance 
against its introduction is necessary, it has practi- 
cally vanished from the ports of the United States. 
Formerly epidemics of this disease were so fre- 
quent in the city of New Orleans that the belief be- 
came quite prevalent that it was natural to the soil, 
but under the excellent quarantine service, and the 
modern quarantine appliances of the Louisiana State 
Board of Health, there is now a record of fourteen 
years' exemption from this dreaded pestilence. The 
last epidemic in the United States was that in Flor- 
ida in 1888, when, by reason of intelligent restraints, 
it was prevented from spreading to other States. 
Since that date an efficient State Board of Health for 3 
Florida has been established, and under its vigorous 
management the disease has been barred out. Even 
in the West Indies some ports formerly affected 
are now exempt and with careful sanitation and 
sanitary engineering all might be freed, and this 
dread disease become as certainly a matter of 
history only, as the African slave trade with which 
it was intimately associated. In South America, Rio 
Janeiro is its principal breeding place, but the dis- 
ease was unknown there until 1849. Why should it 
not again become unknown? 
Since the discovery of vaccination by Jenner in 
1796 small-pox, though still a stubborn foe, no longer 
devastates without restraint. It is now simply a 
matter of choice whether one shall be made abso- 
lutely proof against this disease, and the good effects 
of a compulsory law regarding vaccination are seen 
in the statistics of Prussia, in which country for six 
years prior to the enforcement of vaccination the 
deaths from small-pox averaged 85 per 100,000 of the 
inhabitants, while from 1875 to 1886, after the law 
came into force, the yearly average was but 2 per 
100,000. 
Typhus fever flourishes to-day in certain parts of 
Mexico, and is occasionally reported from the old 
world. It is always a menace where large numbers 
of people are crowded together with unsanitary 
surroundings. But it has no permanent lodgment 
in the United States, and the energetic and success- 
ful measures instituted by the Board of Health of 
New York during the past winter to suppress this 
disease, although it appeared in a section of the city 
more densely populated than that of any other city 
in the world, is a striking example of what may be 
accomplished by proper law, energetic execution and 
scientific disinfection. 
The Japanese have recently illustrated how a dis- 
ease, commonly thought to be infectious, may be 4 
eliminated by scientific investigation and the appli- 
cation of a proper remedy. Prior to 1884, beriberi 
was the scourge of the Japanese navy. During a 
period of six years prior to 1884 there were 9,516 
cases reported, while for a second period of six years, 
from 1884 to 1889 inclusive, there were but 765 
cases, of which 718 occurred in 1884, which was the 
year in which the remedy, relating to a change in the 
character of the food furnished, was applied. In 
1887 there was not a single case reported in the entire 
navy of 9,000 men ; and the New York Medical Record 
aptly remarks that "this is one of the great victo- 
ries of science, and lends good grounds to the hope 
that beriberi may before long become a rare or even 
unknown disease in the Mikado's dominions." 
With regard to cholera, which is still an ever 
threatening menace, the history of the past few years 
has demonstrated most clearly its relation to filth 
and to contaminated food and water, both of which 
conditions require only the peculiar energy and love 
of cleanliness characteristic of the Anglo-Saxon race. 
In recent years the superior sanitation of England 
and the more perfect quarantine surveillance of the 
United States have served to protect these two na- 
tions from this exotic disease. 
One possible agency in the elimination of these 
diseases, still young as a science but not without 
promise, is protective inoculation. Whatever opinion 
may be held of Freire's inoculations for yellow fever 
and Kitisato's and Haffkine's inoculations for chol- 
era, the investigations of these and other bacteriolo- 
gists in this particular field warrant the hope that 
results will be attained equal in efficiency to vaccina- 
tion for variola. But be this as it may, the nature 
of these diseases is now so well known that they no 
longer strike terror in the hearts of those whose duty 
it is to meet and combat them, and never before has 
human agency had within its grasp the weapons 5 
known to be efficient in preventing their spread. The 
terra incognitas no longer exists, and we have but to 
provide ourselves with the weapons, and manifest 
the energy to wield them, to combat successfully 
these microbic armies hostile to human life. As to 
the United States the time is at hand when we may 
expect that no more shall cholera, typhus, yellow 
fever or small-pox prevail in epidemic form. Never 
before have our ports been provided, as now, with 
protective armaments; the ordnance, so to speak, of 
sanitary defense. The great power of steam has been 
invoked, and along the coast from Portland, Maine, 
to Port Townsend, Washington, where ten years ago 
not a single port was provided with a steam disin- 
fecting chamber, there are now twenty-three ports 
with steam chambers in actual operation or in course 
of construction. These ports are : Portland, Boston,. 
New York, Sandy Hook, Delaware Breakwater, Reedy 
Island in the Delaware River, Cape Charles, Balti- 
more, Wilmington, N. C., Savannah, Blackbeard 
Island, Ga., Charleston, Dry Tortugas, Key West, 
Mullet Keys, Pensacola, Mobile, Chandeleur Islands, 
New Orleans, Galveston, San Diego, San Francisco 
and Port Townsend; of these ten are national quar- 
antine stations. 
In support of the quarantine plants are laws both 
national and State, that are sufficient; but should 
perchance contagion pass this line, it meets with 
forces ready to prevent its spread. State boards of 
health have increased in number and in power. 
There are now thirty-seven, and at their recent-con- 
ference in New York City, the reports revealed not 
only their zeal and activity, but an increase in the 
legal power and pecuniary resources of many, brought 
about by their own efforts within the past year. In 
States that have no board of health, or for other 
reasons fail to execute such regulations as are neces- 
sary to prevent the spread of epidemic disease into 6 
adjoining States, the government, in the interest of 
all, under the act of Congress of February 15, 1893, 
must undertake*to enforce them. 
QUARANTINE LAW AND REGULATION. 
It will be germane to the subject and may be of 
particular interest at this time, to give a resume of 
the measures which have been taken by the national 
government under the act referred to. This act, ap- 
proved February 15, 1893, is entitled "An Act grant- 
ing additional quarantine powers and imposing 
additional duties upon the Marine Hospital Service." 
Stripped of its legal verbiage it provides, first, that 
no vessel shall enter a port of the United States from 
a foreign port without a bill, of health, signed by the 
United States consul, or a medical officer of the 
United States government; and provides a penalty 
of.$5,000 to be imposed on any vessel coming into 
American waters without such bill of health. Fur- 
thermore, the vessel shall not be admitted to entry 
except in accordance with other provisions of the 
act, and with such regulations of State and municipal 
authorities as may be made consistently therewith ; 
and before being permitted to enter or discharge 
its cargo or land its passengers a certificate must be 
obtained from the health officer at the quarantine 
station, certifying that the rules and regulations 
have in all respects been complied with, both on his 
part and on the part of said vessel and its master. 
This bill of health and the quarantine certificate are 
to be delivered to the collector of customs. 
The secretary of the treasury is directed to make 
rules and regulations to be observed by vessels at 
ports of departure and on the voyage, and the pres- 
ident may detail a medical officer of the government 
to serve in the office of the consul at any foreign 
port for the purpose of making the necessary inspec- 
tion of vessels, to see that the regulations are com- 7 
plied with, to sign the bills of health and to furnish 
information. 
Consular officers are required to be notified by the 
secretary of the treasury of the regulations made 
with regard to vessels, cargoes, passengers and 
crew at ports of departure and on the voyage; and 
of the regulations also to be observed in the inspec- 
tion and treatment of vessels on arrival at ports of 
destination .in the United States. The supervising 
surgeon general of the marine hospital service is 
required to examine the quarantine regulations of 
all State and municipal boards of health, and at 
ports or places which are found to have no quaran- 
tine regulations under State or municipal authority, 
where such regulations are, in the opinion of the 
secretary of the treasury, necessary, and at ports or 
places where State or municipal regulations exist, 
which, in the opinion of the secretary are not effi- 
cient, the secretary is empowered to make additional 
rules which after being promulgated, are to be en- 
forced by the sanitary authorities of the States and 
municipalities if they will undertake to execute and 
enforce them, but if said authorities refuse or fail, 
the president shall adopt such measures as are nec- 
essary to their enforcement. 
The law further specifies that it shall be the duty 
of the supervising surgeon general of the marine 
hospital service, under the direction of the secretary 
of the treasury to perform all the duties in respect 
to quarantine and quarantine regulations which are 
provided for by this act. 
It further provides that information shall be 
obtained of the sanitary condition of foreign ports 
and places through the consular officers of the 
United States; that weekly reports shall be obtained 
of the sanitary conditions of ports and places within 
the United States, and for the collection of such 
other information affecting climatic and other con- 8 
ditions of the public health as may be pertinent. 
Weekly extracts of the consular and other sanitary 
reports are to be prepared and published, and trans- 
mitted to the collectors of customs, State and muni- 
cipal health officers and other sanitarians. The law 
further permits the secretary of the treasury to 
remand an infected vessel from any port, which is 
not provided with proper facilities, to the nearest 
national or other quarantine station, and after treat- 
ment at a national quarantine station, with a certifi- 
cate furnished by the United States quarantine offi- 
cer, a vessel shall be admitted to entry at any port 
of the United States named in the certificate. But 
at ports where sufficient quarantine provision has 
been made by State or local authorities, the secre- 
tary of the treasury may direct vessels bound to 
said ports to undergo quarantine at said State or 
local station. 
An important section of this act is that which 
gives the president the right to prohibit in whole or 
in part the introduction of persons and property 
from such countries or places as he shall designate, 
and for such period of time as he may deem neces- 
sary, whenever by reason of existence of cholera or 
other infectious or contagious disease in a foreign 
country there is serious danger of the introduction 
of the same into the United States, despite the 
quarantine defenses. 
Provision is also made that if a State wishes to sur- 
render the use of its quarantine buildings and dis- 
infecting apparatus to the United States, the secre- 
tary of the treasury is authorized to receive them and 
pay a reasonable compensation to the State for their 
use. 
The first step under this new law was the framing 
of regulations for vessels at foreign ports. To assist 
in this duty a board of medical officers of the marine 
hospital service was convened, and the regulations 9 
framed were approved by the secretary of the treas- 
ury February 24, and duly promulgated. These 
regulations prescribe the form of the bill of health; 
the definition of an infected port; what vessels shall 
be inspected before the bill of health is granted ; the 
time and method of making the inspection, with all 
necessary details for the enforcement of cleanliness 
and perfect sanitation including disinfection, and 
relating both to the vessel itself and the cargo, crew 
and the passengers, both steerage and cabin. In 
ports infected with cholera, passengers of the cabin 
class must produce evidence as to abode during the 
four days immediately preceding embarkation, and 
if necessary they and their baggage may be detained 
and the baggage subjected to such disinfection as is 
necessary. Steerage passengers in a cholera infected 
port, or from a cholera infected place must be 
detained five days under medical observation, and 
their personal effects and baggage must be disinfec- 
ted by steam. The regulations further forbid the 
shipment of certain articles of bedding and clothing 
from an infected port, also certain articles of mer- 
chandise, such as old rags, old jute and old gunny, 
during the prevalence of an epidemic and for thirty 
days after it has been officially declared at an end. 
All rags at all times are to be disinfected before 
shipment to the United States. 
Under the law these regulations are to be enforced 
at foreign ports, either by United States consuls, or 
by medical officers of the United States government, 
when said medical officers have been detailed by the 
president for that purpose. 
An examination of the records shows that the 
chief ports of embarkation of the immigrants most 
liable to bring contagion are as follows: 
Southampton, Liverpool, Hamburg, Bremen, Rot- 
terdam, Amsterdam, Antwerp, Havre, Marseilles, 
Genoa and Naples. Accordingly a medical officer 10 
of the marine hospital service has been detailed by 
the president to serve in the office of the consul at 
each of the ports named. These officers have all 
had experience with ships, and with but two excep- 
tions have had actual quarantine experience. They 
have been at their respective stations now for a 
period of two months, and their reports show both 
the necessity of their presence and the good results, 
of their activity. This is a new departure in quar- 
antine-quarantining in foreign lands-and the ulti- 
mate result may be looked for with great interest. 
Whatever the result may be, certain it is that the 
presence of these officers in European ports has. 
diminished in a great degree the danger of introduc- 
tion of cholera and other diseases from those ports. 
Their relations in one or two instances with the for- 
eign governments were in danger of being strainedr 
but this danger has been averted both by their tact 
and good judgment, and because of the all powerful 
United States law, which practically says to foreign 
officials that should they object to the official acts 
of these officers, the alternative is the refusal of the 
bill of health and the cutting off of all commerce 
between their ports and the United States. 
For securing uniformity of action among these 
medical officers, and that the bureau may be in- 
formed as to any special difficulties in enforcing the 
regulations, an inspecting medical officer is now 
under detail, visiting each of these ports for the pur- 
pose named. 
To aid these medical officers and the consuls in 
the performance of their duty a letter of instruction 
has been issued by the State department, addressed 
particularly to United States consuls at interior 
places in Europe and Asia, directing that when mer- 
chandise or immigrants are about to leave or have 
left, any section within their respective consulates 
where cholera prevails, they shall notify by telegraph 11 
the United States consul or medical officer at the 
seaport selected for embarkation that the officer may 
be prepared to enforce the detention and disinfection 
required. 
On May 4 a circular was issued to consuls and 
medical officers, requiring all baggage of immigrants 
coming from any port to the United States to bear a 
label certifying to either inspection or disinfection. 
Furthermore, each immigrant is to be furnished with 
an inspection card giving his name, last residence, 
name of ship, port and date of departure and a refer- 
ence number relating to the manifest which is 
required by the immigration regulations, and in which 
is contained much information regarding each immi- 
grant. This card is to bear the stamp of the consulate. 
It is also to be stamped or punched at the quarantine 
at the port of arrival, and again at the immigration 
depot, and it is to be held by the immigrant until he 
reaches his point of destination. These inspection 
tickets, and the labels upon the baggage will furnish 
to the health officers of the interior States informa- 
tion which they have much desired with regard to 
immigrants coming within their borders. These 
provisions also insure care and accuracy on the part 
of medical officers and particularly on the part of 
United States consuls at ports where immigrants do 
not usually embark for the United States, but which 
may be sought by them in the hope of avoiding the 
enforcement of the stringent rules at ports where 
medical officers have been stationed. 
For the vessel on the voyage certain rules have 
been promulgated relating to inspection and sanita- 
tion, isolation of the sick and requiring a clinical 
history by the ship surgeon of all cases of sickness 
to be delivered to the quarantine officer at the port 
of arrival. 
Having thus detailed the precautionary measures 
set in operation abroad, I will now narrate briefly 12 
those which have been taken on this side of the 
Atlantic. 
First I may refer to the danger which, for some 
time, seemed to be imminent by reason of immigra- 
tion through Canada. The Canadian laws do not 
provide for the inspection and sanitation of ships 
and passengers at foreign ports, and it was feared on 
this account, there would be a large deflection of 
immigration to Canada. But owing to the public 
spirited policy of the Canadian government, and the 
energy and efficiency of the chief quarantine officer, 
Dr. Montozambert, the danger of introduction of 
cholera through Canada has been reduced to the 
lowest possible degree short of prohibition of immi- 
gration. All immigration into Canada is now via 
the St. Lawrence river. Forty miles below Quebec 
is statoned the Grosse Isle quarantine station, with 
perfect apparatus for scientific disinfection and 
accommodations for the sick and suspects. This 
station is reserved for infected vessels. Further up 
the river at Quebec, is the Louise Embankment, 
where is located a complete disinfecting plant; while 
at Point Levis, directly opposite, is located another. 
All immigrants, whether from infected or non-infec- 
ted countries and though coming on«non-infected 
vessels are obliged to undergo inspection at one of 
these two points, and all their baggage is disinfected 
by steam, the containers being washed with a solution 
of mercury. The disinfection is not one in name; 
but is thorough and complete. The Canadian gov- 
ernment has very courteously assented to allow rep- 
resentatives of the marine hospital service, two in 
number, to be stationed at Quebec for the purpose of 
inspecting the disinfection and labeling the baggage 
and giving certificates to immigrants bound for the 
United States. 
It was feared at one time that Halifax would be a 
point of danger during the present season. Halifax 13 
is the winter port of entry for Canada, and it was 
proposed to continue the landing of immigrants 
there through the summer, but the steamship agents 
were informed that the quarantine plant at Halifax 
is insufficient; and therefore immigrants arriving 
there and seeking entrance into the United States 
through Canada would be subjected at the border to 
every possible delay through inspection and disin- 
fection by the United States officers, or perhaps be 
turned back into Canada. Assurances were there- 
upon given that no immigrants will be carried to 
Halifax. 
Thus it would seem that protection against the 
introduction of cholera through Canada is as com- 
plete as it can be made. 
With regard to the quarantine and maritime ports 
in the United States it will be remembered that the 
new law provided that an examination should be 
made of all State and local regulations, and if any 
were found insufficient, the secretary of the treasury 
should make additional ones. In accordance with 
this provision, a request was sent to all quarantine 
authorities to transmit their rules and regulations 
to the marine hospital bureau. A general response 
followed, and after examination it was evident that 
to determine upon the sufficiency of all, a minimum 
standard must be established embodying what should 
be required of every quarantine station in the United 
States. 
A uniform quarantine code for the maritime ports 
of the United States has long been the desire of 
quarantine and sanitary officers, and heretofore all 
attempts have been futile. 
A board of officers of the marine hospital service 
was summoned to prepare a code. After the rules 
and regulations had been prepared and before 
adjournment of the board, a conference was called of 
the quarantine officers of the Atlantic and Gulf 14 
coasts representing the cities and ports of Portland, 
Boston, Providence, New Haven, New York, New 
Jersey, Philadelphia, Wilmington, Del., Baltimore, 
Norfolk, Wilmington, N. C., Charleston, Savannah, 
Florida, Mobile, New Orleans and Texas. 
This conference was called to order the 16th of 
March and remained in session two days, the first 
day being devoted to a consideration of the rules 
which had been prepared, and discussion thereof, 
with the understanding that there would be no vote. 
The second day the rules were again read seriatim, 
discussed and voted upon. After adjournment of 
the conference, the board continued its labors pay- 
ing special attention to the views expressed in the 
conference. The rules thus perfected were then pro- 
mulgated by the secretary of the treasury, April 4, 
and a letter enclosing them was sent to each mari- 
time quarantine officer, calling attention to the law 
and to the fact that these were minimum require- 
ments and requesting an expression of willingness 
and ability to execute them. Satisfactory responses 
have been received from all ports. These regulations 
relate first, to inspection of vessels, stating what ves- 
sels shall be inspected, the time of inspection, and 
the method of making it. They define the quaran- 
tinable diseases; and declare under what circum- 
stances vessels shall be placed in quarantine. They 
relate also to the treatment in quarantine, particu- 
larly of vessels infected with cholera and yellow 
fever, and the time of detention and care of the pas- 
sengers arriving on such vessels. Special regula- 
tions exist with regard to rags; also with regard to 
vessels suspected only of being infected with yellow 
fever. 
As a further protective measure with reference to 
cholera it may be stated that on the appearance of 
this disease in any maritime port, a system of immi- 
grant train inspection will be at once set in opera- 15 
tion, medical inspectors to accompany each train 
from that port into the interior and provision made 
for the removal and care of the sick en route. 
FOREIGN. 
But while we have thus erected our sanitary forti- 
fication upon the coasts and have provided the means 
for internal warfare against epidemic disease, our 
duty is not yet accomplished. The danger of the 
attack should be eliminated. The sense of the Amer- 
ican people should be aroused to an indignant pro- 
test against the approach of these diseases from 
other lands. Not one of them is indigenous. Chol- 
era comes from India and Arabia, yellow fever from 
Havana and other ports of Cuba, and from Central 
and South America; typhus fever comes from Rus- 
sia and occasionally from Germany. It is time that 
a vigorous protest should be made to the govern- 
ments of the countries where these diseases flourish. 
Every nation should be held responsible for any con- 
ditions within its border or within its dependencies 
which tend to propagate epidemic disease that may 
be carried to other nations with which it expects to 
maintain a friendly commerce. 
Is it too much to expect that the fons et origo of 
cholera in India shall be eliminated? But before 
discussing cholera in its home, consider a moment 
one of the chief means by which itfindsegress there- 
from. I refer to the religious pilgrimages. 
In Mesopotamia are four Shiah shrines, the most 
sacred, Karbala, being the place of pilgrimage for 
large numbers of Shiahs from both India and Persia. 
Thousands of bodies from India and Persia and 
other countries where the Shiah faith exists, are 
brought here by the pilgrims for interment. The 
place is one vast burial ground and cholera raging is 
carried back to their respective countries by the pil- 
grims. 16 
In Mesopotamia also is the holy city of Islam 
where the Mohammedan sect known as the Chitty 
send their dead for burial. In 1889 cholera was im- 
ported there from Bombay in the clothing surround- 
ing the dead sent from Bombay for interment. Be- 
sides Karbala and Islam in Mesopotamia, Hurdwar 
in India, and Mecca and Medina in Arabia, are 
great foci for the development of epidemics which 
diverge therefrom in every direction. 
In 1890 there arrived by the sea at Jedda and 
Yembo, the seaports of Mecca and Medina in the Red 
Sea 43,000 pilgrims, of whom 28,000 only returned ; 
the balance representing the victims of cholera. 
Why should the whole civilized world be allowed 
to suffer through the constant dread of invasion, or 
invasion itself of cholera, on account of the religious 
fanaticism of the Mohammedans of the East? Why 
should the civilized nations of the world continue to 
look complacently upon these pilgrimages to Mecca 
with their horrible accompaniments of constant dis- 
ease and death? Death while en route to the shrine 
at Mecca is welcomed by all true followers of the 
prophet as a certain passport to eternal bliss ! So 
long as this religious theory affects themselves alone, 
it might be viewed with complaisance, but when it 
involves the health and the lives of thousands of 
others to whom such a thought is a very absurdity, 
it is the right as well as the duty of those others to 
protest. This subject has no longer a faraway as- 
pect. Steam has brought us into closer connection 
with Mohammedism. All nations are incomparably 
nearer to one another than twenty-five years ago, and 
the welfare of the most distant places on the face of 
the earth has now a direct bearing upon our own 
health and lives. The Mohammedan pilgrimages are 
a subject for international arbitrament. 
What pressure can be brought to bear upon the 
Turkish or other government, to strip these pilgrim- 17 
ages of their disease bearing features, is a subject for 
immediate consideration, but one that will require 
careful study on the part of those versed in diplo- 
matic relations. But when it is remembered that 
the vessels which carry these pilgrims, and upon 
which this disease breaks out, are owned by other 
nations it would seem entirely practicable to estab- 
lish restrictive measures. I know that some of Eng- 
land's-vessels carry these pilgrims, as well as vessels 
of other nations. Are not these vessels, therefore, 
and the governments under whose flags they sail 
responsible in great part for the spread of this hor- 
rible plague? 
Again, with regard to the harbors of the West In- 
dies and South America, yearly menacing our coast 
-should not some pressure be brought on their gov- 
ernments to place them in sanitary condition? Ask 
of the men who, year by year, stand upon the quar- 
antine piers of our southern cities and greet the ves- 
sels as they come from these infected ports, who re- 
move to hospital the crew or passengers stricken with 
yellow fever, who clean and disinfect the ships, and 
whose minds in addition to the bodily activity 
required are strained from May until November lest 
through some chance oversight of their own, the ter- 
rible contagion of yellow fever may pass their out- 
port and strike the coast of the United States. Despite 
the exemption of the last few years yellow fever is the 
prevailing thought throughout the south during this 
period. The quarantine officers, the physicians, the 
commercial men and the daily press are on the qui 
vive, watchful, anxious. Why? Because, forsooth, our 
neighbors are content to live with an indifference to 
sanitation, life and health unknown within our bor- 
ders. 
In connection with the extermination of the source 
of epidemic disease should be mentioned the recent 
brochure of Dr. J. Telyafus, of Tiflis, Russia, who has 18 
expressed his views upon the means of strangling 
cholera in its Indian home and thus freeing Europe 
and America from the constant menace of its period- 
ical excursions. I quote from a recent review: 
"Dr. Telyafus takes this exception to the opinion 
that any attempt to exterminate the germs of cholera 
in Indian is utopian. He states that it has been 
stamped out in the Nile delta, and that similar, or 
more energetic measures, would be equally effectual 
on the banks of the Ganges. Formerly the fellaheen 
of Egypt interred their dead on the banks of the 
river Nile, and the bodies were then washed out into 
the stream during the annual overflow of the river, 
and were carried down to spread disease throughout 
the delta. Since an end has been put to this custom, 
the plague no longer harasses the country. While 
it would be difficult, if not impossible, to restrain 
the natives of India from casting their dead into the 
waters of the sacred Ganges, it might be possible to 
compel them to cremate their dead and throw the 
ashes, if they will, on the border of the river. Drain- 
age and the planting of the eucalyptus tree, while an 
enormous undertaking, is one, in the opinion of Dr. 
Telyafus, not impossible ; similar work having been 
already accomplished with profitable results in 
Algiers." 
•THE EFFECT OF IMMIGRATION ON THE PUBLIC HEALTH. 
A most important subject for consideration at the 
present time is the effect of immigration on the pub- 
lic health. So far as epidemic disease is concerned it 
is superfluous to call attention to the menace thereof 
accompanying immigration ; and the measures taken 
to meet thio danger, and the one held in reserve, 
prohibition, have already been described. 
Concerning the other contagious diseases, not ordi- 
marily epidemic, there is no doubt also of the in- 19 
creased liability thereto in the United States from 
this same cause. 
Recently a cablegram was received from the medi- 
cal officer detailed at Naples that nine ships would 
leave within ten days, carrying 11,000 immigrants. 
They are arriving at New York now at the rate of 
15,000 a week-each week a new city's population 
grafted on the nation ! 
Thia wonderful movement of the earth's inhabi- 
tants during this latter part of the nineteenth cen- 
tury presents many phenomena of striking interest 
to the sociologist, and many problems to the sani- 
tarian. 
Where do they come from, why do they come, and 
■what is their ultimate condition? From the stand- 
point of the sanitary officer it is difficult at this 
time to see aught but danger in this movement, or to 
have any other wish than that it might be stopped. 
But if we may rise above our present fears and 
consider the subject from a very broad standpoint 
which commands an international as well as a na- 
tional or local view, we may see in this movement a 
blessing to humanity not only political and intel- 
lectual, but physical as well. 
Pressed out from their narrow confines, these peo- 
ple in swift moving columns and in swift moving 
ships are landed on our coast; they separate, and are 
almost lost to view in our vast expanse of territory. 
Forced out of overpopulated districts either by a 
Russian decree or by their own appreciation of their 
unfortunate surroundings, they seek the United States 
as a land of promise, and in their broader surround- 
ings and breathing the political life of a government 
of the people by the people, a broader and more 
intelligent manhood must be theirs. 
First impressions are lasting, and the opportunity 
therefore is great to impress upon this large and 
constant addition to our citizenship a profound 20 
regard for the laws of public health in their new 
homes. 
At the foreign port of departure the immigrant 
to-day receives his first sanitary impression of the 
new world as he presents himself for scrutiny by the 
medical officer of the United States government be- 
fore being permitted to board his ship. 
Again must he pass a quarantine officer at the port 
of arrival, and once more at the immigration station 
be closely and individually scanned or catechised by 
the medical inspector. 
How can he fail to be impressed, to some degree 
at least, with the importance attached to health in 
the United States? 
On arriving at his destination in the State chosen 
for his permanent home, he is the better prepared to 
accept such restraint or obligations of a sanitary 
nature as may be imposed by a local or State board 
of health. 
There is opportunity, therefore, for each board of 
health to build up within the borders of the State a 
tolerance and respect for sanitary laws. 
Nor is the effect upon the overpopulated districts 
in Europe to be lost sight of. Surely the relief in 
some communities must be obvious. 
Moreover, statistics prove that thousands of immi- 
grants revisit their homes. The sanitary teachings 
of the new world go with them and can not be with- 
out effect. 
We can not forget, however, that while the physi- 
cal condition of the immigrant is improved, and the 
sanitary condition of the locality he has left, the 
same can not be said of our own domain and people, 
and greater stringency both in the laws and their 
execution is demanded. 
THE NON-EPIDEMIC CONTAGIOUS DISEASES. 
Of the contagious diseases not ordinarily epidemic 21 
in character, but which are actually the more de- 
structive to human life (as diphtheria, scarlet fever, 
typhoid fever, measles and tuberculosis), it may be 
said that with the exception of one (tuberculosis), 
the means of preventing their spread is so plain that 
it is within the power of every community to accom- 
plish it. 
While therapeusis is an indispensable antagonist 
to these -diseases, their subjugation will be accom- 
plished only by a triple alliance of law, organization 
and disinfection. Gradually the laws are spreading 
throughout the United States and municipalities, 
requiring notification, placards, disinfection and con- 
struction of special hospitals. Within a year even 
the White House has been placarded for scarlet fever, 
furnishing notable illustration of cheerful compli- 
ance with the law which may well be considered by 
those who would oppose it. 
Sanitary plumbing and architecture, purity of 
water supply, proper disposal of sewerage and gar- 
bage, all are prominent subjects of town and munici- 
pal concern, and any community found indifferent 
thereto should be held up to public condemnation. 
All sanitary organizations should be modeled after 
our national and State governments, embracing the 
three heads-legislative, executive and judicial. The 
framing of laws requires a skill and training apart 
from that required for their execution, and they ac- 
complish their object more effectively when executed 
by others than those who make them, and back of 
them a wise judiciary preserves a just balance be- 
tween the individual and the public. 
Valuable adjuvants from time to time in municipal 
sanitation are the voluntary organizations called into 
existence by some particular threatening danger or 
by official laxity. 
The most recent organization of this nature, formed 
because of the possible advent of cholera, and one 22 
which may be taken as an excellent model, is the 
Sanitary League of Washington, a full description of 
which will be found in the abstract of sanitary 
reports of this date. 
DISINFECTION. 
But with regard to the destruction of these domes- 
tic contagious diseases the keynote of success appears 
to be disinfection, and while the germicidal proper- 
ties of the several disinfectants are known, still much 
depends upon their mechanical application-upon 
the mechanical devices for their distribution. 
As stated by Dr. Cyen Edson, health commissioner 
of New York, whose experience in municipal and 
house sanitation is probably unsurpassed, the great 
difficulty in practical disinfection is in eliminating 
the personal equation; that is, on account of the 
carelessness or ignorance of individuals to whom are 
intrusted the actual work, their failure to compre- 
hend its principles and to care for details, it is often 
inefficient. 
Now this personal equation may be eliminated 
provided a mechanical device is found by means of 
which there shall be obtained a diffusion and pene- 
tration of the disinfecting gas equal to that of the 
germs of the disease. 
Recently attention has been called to two new 
forms of disinfectants, which with especial mechanical 
devices promise to be among the most potent instru- 
ments in our sanitary armamentarium. 
The first of these is a recent discovery produced 
by the action of an electric current, electrolyzing sea 
water. 
Doubtless all the details concerning this agent will 
be published by its inventor in New York, but at 
present I can only say that the resultant solution 
contains germicidal and deodorizing properties of a 
remarkably high degree, while the cost is immeasur- 23 
ably lower than that of any known disinfectant per- 
mitting the application. 
The second disinfectant is the anhydrous liquid 
sulphur dioxide. True, this has been known for 
several years, and experiments demonstrating its 
utility were made in the laboratory of the marine 
hospital at New York five years ago. But no device 
for its practical use has been offered till within a 
month, and it is but recently that placing it in the 
market for sanitary purposes has been seriously 
considered. 
This liquid dioxide, confined in copper carboys of 
from fifteen to 200 pounds weight, may be easily 
transported, and simply by liberation will throw off 
the sulphurous acid gas, filling either a small room 
or the hold of a vessel with any required per cent. 
A simple apparatus for carrying the gas cylinder 
from place to place, which at the same time can be 
used for weighing the gas liberated, has been recently 
devised by Passed Assistant Surgeon Kinyoun, and 
may be seen in the marine hospital exhibit in the 
government building at the Columbian Exposition. 
The present difficulty with regard to this disin- 
fectant is that its manufacture is a secret process, 
and the first cost of a plant large enough to supply 
the demand would be great. But it has been sug- 
gested that the general government might appropri- 
ately meet these two difficulties, and in doing so 
would confer a great benefit upon the country, for it 
could then furnish to local health authorities any 
amount of the agent in question, and at a cost that 
would permit its free use. 
The object of the present paper will have been 
accomplished if it but serves to awaken interest in 
the possibilities suggested by its title. 
Says Dr. D. B. St. John Roosa in the May number 
of the magazine: " Many of the illnesses that are 
thought to be special dispensations from Providence 24 
occur only because of the neglect of personal care. 
" The time will probably come, however, when the 
human race will everywhere, with only exceptional 
instances, live out its life. It is perfectly possible 
to conceive of the domination of human intellect 
and human force being so universal as to abolish 
accidental deaths." 
The day of this deliverance seems yet far off. We 
may not even claim to see the morning's rosy hue, 
but surely we may discern its first gray dawn and 
rouse to effort. The struggle is worthy of man's 
greatest powers, and even while striving we shall add 
great motive power to the upward progress of man 
toward his final destiny - whatever that destiny 
may be.