Commissioners of Health, a majority of whom are required to be graduates of legally constituted medical colleges, and of not less than seven years' practice of their profession in the State.

The State Board of Health of Indiana, under its most recent form of organization, as established by Act of the General Assembly, approved March 7, 1881, is composed of five members, four of whom are appointed by the Governor, which four elect a fifth, who is required to be a physician, to act as secretary. In fact, the other four are also physicians.

The State Board of Health of Colorado, now three years old, is composed entirely of physicians, all regular graduates. There is also a State Board of Medical Examiners, which, like that of Illinois, comprises homœopathic and eclectic members, who consult harmoniously as to who shall be guardians of the public health, if they cannot harmonize in the sick-room.

The State Board of Health of Iowa, organized May 5, 1880, has nine members, seven of whom are physicians, one a civil engineer, and the other the Attorney-General of the State.

The State Board of Health of New York dates from May 18, 1880, and consists of nine members, three appointed by the Governor and Senate, three designated by the Governor from the Health Commissioners in cities, and three ex officio members; namely, the Health Officer of New York, the Superintendent of State Survey, and the Attorney-General of the State.

In contradistinction to what may be termed the Massachusetts plan is that of Alabama, where the State Medical Association is constituted the State Board of Health, county medical societies in like manner being empowered to act as health boards in the several counties.

In North Carolina the State Medical Society was in 1876 empowered to choose from its active members, by ballot, six members, and the Governor to appoint three other persons (one of whom was required to be a civil engineer), who were to constitute the North Carolina Board of Health.

In South Carolina, by the provisions of the Act of the General Assembly, approved December 23, 1878, the State Medical Association, together with the Attorney-General and Comptroller-General of the State, became the State Board of Health, from which body seven members are elected every seven years, who, together with the State officers mentioned,

comprise an Executive Committee to serve in the intervals of the meetings of the Board.

There are now but nine States which have not established Boards of Health, namely, Florida, Kansas, Maine, Missouri, Nebraska, Nevada, Ohio, Pennsylvania, and Vermont ; some of these from their age in the Union, and others from their wealth, population, and political prominence, having nothing to plead in extenuation of their neglect.

State Medicine as a department of public administration is still in the inchoate stage; but we have reaped enough from the sparsely sown field in this country to know that only energetic, zealous workers are required to produce an abundant harvest. The original Massachusetts plan of State Board organization ought to be imitated by those States in which such boards are yet to be formed as more practical and effective than the State Medical Society plan, which seems to be popular in the South. State societies are too cumbersome for profitable work. The wide range of their subjects of discussion distributes their efforts as objectionably as the health, lunacy and charity combination of the present Massachusetts scheme, and they are actually compelled to delegate their duties to an executive committee, which practically usurps all their prerogatives. Except where political greed devours every principle of propriety, the appointment of medical men as members of these Boards is recognized by law or admitted in actual practice. Of the eleven members of the National Board, of whom only the three appointees from the Army, Navy and Marine Hospital Service are required to be medical officers, all but one-the Solicitor-General representing the Department of Justice-are physicians,—one of them a well-known practitioner of homeopathy, but, withal, a zealous sanitarian, in hearty accord with his colleagues and joint member on important special committees with Professors Cabell and Johnston, and those other veterans of this Association, Henry I. Bowditch and Stephen Smith.

The administrators of the public health have enough to do in the legitimate direction of endeavoring to prevent the occurrence of disease, without undertaking to control eleemosynary institutions for the relief of the poor, sick, impotent or insane. Hence, I propose to discountenance the introduction into this Section of questions which do not directly concern the prevention of disease by the exhibition of the authority of the State,

involving incidentally (1) the neutral territory on which medical men meet with lawyers and law-makers, and consequently justifying the discussion of the subject of medical evidence, to which sufficient reference has been already made; and (2) the question of the State's support, control or regulation of medical education and the license of medical practitioners. There is one collateral field of inquiry in our Section, intimately related with preventive medicine, which is properly exciting widespread interest. Medical men are generally agreed that some provision should be made for the systematic collection and compilation of vital statistics, but a national registry of births, deaths and marriages has been the most that has been contemplated. Mortality returns are, however, of far less value to the public sanitarian than accurate morbility exhibits, covering a period of years. As an instance, the city of Washington has a death rate of 23.372 per thousand, of which only 1.616 are ascribed to intermittent, remittent, typho-malarial and malarial fevers; and on this plausible statement, a specious but fictitious theory of the salubrity of the city has gone abroad, and is seriously interfering with the legislation which has been urged in the interest of the public health of the community. The medical officers of the Navy on duty in Washington are required to make an accurate return to the Bureau of Medicine and Surgery of every case of disease treated by them; and these returns collated by the Surgeon-General of the Navy, and recently presented by him before the Congressional Committee on the reclamation of the Potomac Flats, indicate among all the cases of disease treated at the Naval Hospital, Navy Yard, Receiving Ship and other vessels in the harbor, Marine Barracks, Naval Dispensary, and at officers' residences, a total of eighteen per centum of malarial affections distributed over the city, the proportion among officers and their families alone, excluding the public establishments, being as high as twenty-five per centum of cases and twenty-three per centum of the individuals, subject to treatment. Until every practitioner of medicine is required to make a similar classified return of the sick, no idea of the actual insanitary condition of a locality can be obtained. The handsome maps issued by the Health Officer of Washington exhibit only deaths from typhoid, phthisis, malarial, diarrheal or other diseases, but the cases that do not die are a necessary factor in the estimate of prevailing disease. The excellent chart

accompanying the report of Dr. C. W. Chancellor, Secretary of the State Board of Health of Maryland, on the endemic of diphtheria at Frederick City, Maryland, during 1881 and 1882, exhibits the location of every case of the disease, the fatal appearing as centers of clusters of greater or less size, the vicinity of all to grave-yards, slaughter-houses, tan-yards, skin-dressing establishments, glue and soap-factories, being also shown.

As a further illustration of the worthlessness of mortality returns as evidence of prevailing disease, I may be permitted to refer to the popular ignorance and incredulity—not confined to laymen-respecting venereal disease. Eighteen deaths in a total of 4,207 are attributed to the enthetic class, and of these, ten are reported as congenital, leaving five white males and three male negroes as the measure of the amount of these diseases prevailing in the District of Columbia, with its population of 177,638, and in the face of a police return of 726 prostitutes arrested for various offenses against decency, in a city where this class is remarkable for its decorum. Now as very careful estimates, based upon naval, military and marine hospital returns, and statistics of public charitable institutions in the great cities, render it probable that there are not less than seven thousand cases of venereal origin in this one city; and as many of these are in a condition of communicability to innocent women and children, it is a pertinent inquiry whether any table of vital statistics is of real value to those concerned in the public health, which does not represent these facts clearly, unmistakably and prominently. It is premature to expect the public to believe that they are in danger, or legislators, who spring from the ranks of that public, to frame protective laws, until they see demonstrated in figures that the venomous brood of small-pox, diphtheria, scarlet fever and yellow fever has a dread sister in venereal disease,-whose victims are not, like those of diphtheria, quickly carried to the grave-yard, but linger on earth, suffering a living death. Once recognized that the pestilential air of the sewer causes the most dread form of zymotic disease, and forthwith Health Boards are sustained in ferreting out the obnoxious sewers. Glue factories, fertilizing depots, and other noisome stenches, find ready advocates for their abolition; but the prude's handkerchief goes to the eyes when a bawdy house is suggested as an inodorous focus of

disease, which will surely invade some pure household to defile a chaste wife, or by accident men, women, and children guiltless of wrong-doing; and the Health Officer, who would and should ascertain the number and location of every one of these disease-breeding spots, is compelled to forego this legitimate inquiry of his office, and perform his work with the incompleteness of the author who professes to teach physiology and omits all reference to the generative function, and portrays men and women to boys and girls with suggestive anatomical omissions, which stimulate them to surreptitious independent investigation. Certainly it is of very little consequence to him to know that 1,035 marriages have been reported, examined, recorded, and put on file. Whatever its interest to the social economist, it has very little bearing on sanitation, which would rather know something definite about the irregular as well as the regular congress of the sexes.

The statistics of disease are what the sanitarian demands as a necessary preliminary to his efforts at prevention, and this Section can engage in no more appropriate labor than to devise a practicable scheme for their accurate compilation. In some States a return of cases of so-called "diseases dangerous to health" is required, but the number and names on the list vary according to locality. In North Carolina they are defined to be small-pox, scarlet fever, diphtheria, cholera, and yellow fever. In Indiana all these but yellow fever are included, and typhoid fever, typhus fever, measles, whooping cough, and cerebro-spinal fever added. Another list includes all these except whooping-cough and cerebro-spinal fever, for which it substitutes puerperal fever; but even the fullest list in use is incomplete, for the catalogue of ills to which flesh is heir, which are communicable, may be extended to at least twentyfive, all more or less dangerous to health; those additional to the ones already mentioned being erysipelas, mumps, varicella, rotheln, influenza, relapsing fever, dengue, farcy, grease, glanders, gonorrhoea, syphilis, hydrophobia, and the plague,—a formidable array capable of still further extension, according to Richardson, if pyæmia, hospital gangrene, sloughing phagedana, malignant pustule, carbuncle, malarial fever, croup, catarrh, and choleraie diarrhoea, are included, and which, if not communicable in the ordinary sense, are indubitably dangerous to health, and ought to be carefully enumerated and recorded. To these, Italian VOL. XXXIII.-20.