Since blessings brighten as they take their flight, it may be difficult to realize how much of our present happiness and comfort depend upon the constantly abiding benefactions brought about by the progress of Sanitary Science in the present cycle. The proper care of the body and the prevention of disease, rather than its cure, have occupied the minds of men from the dawn of history. Moses is the author of a well-digested code of hygiene, and erudite scholars can find hints of the proper conservation of health in the Egyptian papyri. Hippocrates wrote about the prevention as well as the cure of disease; indeed, all along the course of time the master minds of medicine attempted the solution of many of the problems of Sanitary Science as eagerly as they sought for the elixir vitæ or for the universal solvent. Notwithstanding all this, one can truthfully say that sanitation could not be fairly termed Sanitary Science until its rules of procedure began to be formulated with more or less exactness upon careful experiment and accurately recorded observation. Sanitary science, as such, could not begin to be until pathology (a knowledge of the morbid processes of disease) and etiology (a study of the causation of disease) had builded upon a scientific foundation. Before this all deductions were from experience, and had no other reason than the seeming helpfulness of the procedure; after this, as fast as the facts were demonstrated, deductions were made that determined a procedure which would of a certainty accomplish the purpose. In the olden times, during an epidemic of a contagious disease, tar barrels were burned in the streets,—and not without some benefit. At the present, the room, with its contents, can be disinfected with a certainty of destroying every atom of contagion.

This difference must be kept in mind when comparing the old with the new, and the true reason of the great advance be recognized as due to the spirit of scientific investigation, which began in the latter part of the last century with the employment of instruments of precision in research, and which has developed so wonderfully up to the present that the experimental psychologist measures the minute portion of time it takes to form a thought. At the same time, it must be kept in mind that the sciences which furnish sanitary science much of its material are progressing and, because progressing, changing; that the conditions desired to be removed are prevailing, and the necessity of overcoming them urgent. Not in every case has the sanitarian fully demonstrated and laid down scientifically accurate data on which to base his method of procedure. Hence it happens that even now sanitary empiricism must needs be mingled with sanitary science, and the mingling is sometimes as much of a motley as the dress of the court fool of the Middle Ages.

Since sanitary science had its origin during the present century, it will be helpful to assign a definite period for its birth. Not that any one would have the temerity to dogmatically assert that the science came into being at a fixed date, but rather to fix a period of time when the conditions working through the ages were so shaped that, perforce, the problems of sanitation would thereafter be treated more in a scientific and less in an empirical method than before. This time is associated with the beginning of the reign of Queen Victoria of England, since the first Act of Parliament for the registration of births, marriages, and deaths was passed in 1837, and the beginning made of accurately gathering information which is to the sanitarian what the pulse is to the physician. With his fingers on this tell-tale of the flow of the heart-blood of the nation, he is enabled to determine whether disease is above or below the normal, the character of the disease that abounds, and its whereabouts. Knowing where to find any disease in excess, he can study the conditions and surroundings, comparing them with other places, whether afflicted in like manner or, more favored, free from the disease. By means of these vital statistics he can compare year with year, and tell with a degree of exactness heretofore impossible whether any disease is increasing or decreasing; he can lay his returns by the side of the figures of the meteorologist and learn if the weather has any influence on the death-rate; he can follow the results of his efforts to improve the condition of the people and vindicate his expenditure of the public money by pointing to the reduced mortality rate. It may seem to be a gruesome task for every physician in the land to send to the proper official a notice of each death and of each patient suffering from a disease apt to be communicated to some one else; and almost ghoulish for the officer to sit at his desk, day after day, and catalogue and tabulate these returns. But it is only a modern version of the old riddle of Samson, out of the bitter came forth the sweet; for without this, much of the progress of sanitary science would be well-nigh impossible.

The act adopted in Great Britain has been modified and improved upon since then, and in the United States many of our cities and some of our States have been engaged in a similar effort. As yet we have no central bureau or collecting office for the nation; nor is this necessary, if each State would do its duty, or, at least, the general government in that event need only tabulate the returns of each of the States. The effort is now making, under the auspices of the American Public Health Association, to secure a uniform method of registration in all offices collecting vital statistics, by which the same name will be given to the same disease and the same facts recorded in each return made. This will cause a little confusion at first in those offices where statistics have been tabulated for a number of years, but the advantage will be so great as to fully repay any inconvenience at the first. If we desire to obtain the full benefits from the advance of sanitary science, we must see to it that in every State there is an efficient bureau of vital statistics, whether under the supervision of the State Board of Health or some other department of the State. The absence of such a bureau reflects upon the intelligence of the people or the integrity of the law-making power.

Are there tangible results to warrant so sweeping an assertion? is a fair question, since at the time of the preparation of the census of 1890 New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, and Delaware were the only States collecting vital statistics, and since then but Maine and Michigan have been added. Before quoting figures, it must be premised that even now the returns only approximate accuracy; they were much more inaccurate at the first, and before the general registration was undertaken most of the statements are merely estimates, after the fashion of the geographer who gives the number of inhabitants in China, where a census never has been taken. It may happen that the benefits are not as great as the figures seem to show, but after making all allowance there is great improvement.

The “Encyclopædia Britannica” asserts that two centuries ago the mortality of London was 80 per 1000, while now it is but a little over 20. In 1841, out of every 100,000 people in England, 30,000 would have died before reaching the age of 10, and one half would have died before they were 40 years old; in the decennium 1881–90, before 30,000 would have died out of each 100,000 some would have lived to be 17, and some would have lived to be 55 before one half of the number had departed into the unknown and the hereafter.

The figures of the statistician must be quoted again and again in the progress of the article, as no more tangible evidence can be given of the benefits resulting from improved methods of sanitation. Very early a coincidence was observed between the uncleanly and the death-rate. Neighborhoods where little or no care was taken to remove the refuse, where there were foul drains and a deficient water supply, were found to be the abodes of special forms of disease,—so much so, that these diseases soon received the name of “filth diseases.” Acting upon the suggestion, the gospel of cleanliness was preached and its practice enforced. There was a “redding up” in its eventuality as thorough as the cleansing of Santiago de Cuba in recent days. It did not take long to discover that decaying organic matter in some way was the offending body, and that this contaminated the water supply. Wells were condemned and public water supplies installed; means were sought to enable the cleansing to be constantly carried on, and sewers for house drainage followed or accompanied the water supply. In proportion as this has been thoroughly done has the death-rate from certain diseases diminished. During the last century the European armies were decimated by fever (typhus or relapsing) to such a degree that the work of the fell destroyer at Santiago was trifling in comparison. On into the present century, the great scourge of Great Britain was these same two fevers; so much so, that “the fever” meant the dread jail or typhus fever. It was imported into this country, and epidemics of “ship fever” were of frequent occurrence. Thus, as late as 1846, it was estimated that in Dublin alone there were 40,000 cases of fever, with a total in Ireland of 1,000,000 cases. There were 10,000 deaths in Liverpool, a city especially prone to the disease; while in Edinburgh one person out of every nine of the population was attacked, and one out of every eight of the sick died. Turning from this account to the medical returns of the war for the Union, there were reported only 1723 cases, with 572 deaths, to the office of the Surgeon General, and even these a very competent authority after careful investigation decided not to be instances of true typhus. Or turn to civil practice: the disease is found so seldom with us that it is not necessary to assign to it a column along with the other diseases in publishing the mortality returns by our health authorities. The deaths from fever in London during October, November, and December, 1898, were but 296. London has an estimated population of 4,504,766, and the “fever” in the report included typhoid, simple and ill-defined forms of fever, as well as typhus. This makes a death-rate of but 0.26 per 1000.

Had sanitary science no other trophy, its votaries could still boast of the great benefits to humanity brought about by their labors. This is but one of many; thus, scurvy, the great bane of the navy, is now a disease that few physicians have the misfortune to see, or patients to endure. Then that disease somewhat akin to typhus, and until within the memory of the fathers confounded with it, hence called typhoid fever, is likewise fast disappearing, more rapidly in cities than in rural communities however. The suppression of typhoid proceeds with equal step with the introduction of a public water supply in our towns, the adoption of the proper means to furnish this water unpolluted, and the proper removal of domestic waste through sewers, whose contents are so treated as to work no harm after they escape. Notwithstanding these great triumphs, if boasting is permissible, the sanitarian’s boast is rather that his science, which had its beginning, as we have seen, at the time when there was a great awakening of the national conscience in British politics for “the larger sympathy of man with man,” has broadened with the years of its growth; has endeavored to care for one’s brother so that his blood would not cry up from the ground; so that, after forty or fifty years had passed, a distinguished sanitarian could write with literal accuracy: “Whatever can cause, or help to cause, discomfort, pain, sickness, death, vice, or crime—and whatever has a tendency to avert or destroy, or diminish such cases—are matters of interest to the sanitarian; and the powers of science and the arts, great as they are, are taxed to the uttermost to afford even an approximate solution of the problems with which he is concerned.”1 And the crowning glory of the science to-day is the care it bestows upon the weak, the ignorant, and the helpless; the efforts it makes to ameliorate every undesirable condition of society.

It would be misleading to infer that all of these benefits have been brought about solely through the collection of vital statistics, although much of it would have been difficult without the knowledge furnished by these statistics. Workers in almost every branch of pure science have contributed to the progress,—the physicist, the meteorologist, the chemist, and by no means the least, the biologist. Indeed, with the more recent investigations, the culture tube of the biologist has almost revolutionized medicine and all that pertains to it.

Sanitary science seeks to accomplish two ends; it purposes to prevent disease and to promote public health. If it seeks to prevent disease, after the fashion of the oft-quoted cook-book, it must first secure the disease, or what is essentially the same thing, know what causes it. If the cause be known, and we can conquer the cause, we can prevent the disease. Thus a disease known as trichinæ spiralis, from the name of the parasite invading the body and causing sickness and death, is caused by eating pork infected by the trichinæ. We can certainly prevent trichinæ in persons by forbidding pork; but we also know that the trichinæ do not occur in all pork, and that their presence can be detected by the microscope. If, then, a sample from every slaughtered pig is submitted to the microscopist, the infected pork can be discovered. This is done in our large packing establishments, especially for that pork which is to be exported. Again, a thorough cooking will kill the trichinæ, even if present. Only the grossest carelessness, consequently, can account for a case of trichinæ, and, indeed, it is a very rarely occurring disease. This illustrates the importance of a knowledge of the cause of the disease, to enable one to devise a method for preventing it. In the study of disease causes, the biologist has been very successful during the past few years, and a number of our communicable diseases are demonstrated to be caused by the growth and development of bacteria. From this demonstration in the case of some, a general hypothesis has been formulated, which is useful as a working hypothesis, but by no means safe to call a theory as yet. This hypothesis is that all of our communicable diseases are caused by living organisms originating in one person and conveyed to another, where they begin to grow, to reproduce their kind and to perform their life functions. Hence all communicating diseases are infectious. Some of these infectious diseases, like measles or smallpox, are capable of direct communication from one person to another, rendering them contagious; others, like typhoid fever and cholera, are not contagious in this sense of the word. This is a very excellent distinction to make in the use of these much abused words.

The biologist has rendered sanitary science great service not only in discovering the causes of certain diseases, but also by aiding to determine the nature of the disease in any outbreak. It makes a vast difference if a given case is one of true diphtheria or not, or of Asiatic cholera or not, and often the symptoms alone are not conclusive. Here the biologist comes to our aid, as is seen so often in cases of supposed diphtheria. A portion of the throat secretion is sent him under such precautions that no bacteria from the outside can possibly contaminate. With this secretion he stabs or inoculates a jelly composition which he has placed in a test-tube, stuffs a wad of absorbent cotton in the mouth of his tube and puts it in a warm chamber or incubator. If there are any microbes present, they will begin to grow, and the expert biologist can tell the bacteria from its manner of growth as readily as the gardener can distinguish between his radishes and lettuce when they sprout in the spring, and in this way is able to report the nature of the germs. If he is in doubt, he carries his cultivation further and employs other tests to prove his observation.

The biologist has also rendered great aid to sanitary science in discovering many other species of bacteria that are helpful to man. Our polluted waters could not be purified, our air could not be cleared from foul odors, nor the proper decomposition of organic matters go on, without the aid of bacteria. These little vegetable growths, while working much harm upon humanity, contribute far more to their comfort, well-being, and happiness than they do to their ill. Possibly no better illustrations can be given of the value of bacteriology to sanitary science, and the great progress it has brought about, than to contrast a cholera outbreak of a few years ago with one occurring more recently; or to point to the efficacy of purifying water by the assistance of bacteria. Another disease, pulmonary consumption, may also be noticed, but the triumph here is not so marked as yet.

The first outbreak of cholera in the United States occurred in 1832. In one special hospital in New York city, 2030 patients were received in the nine weeks from July 1 to September 1, and of these 850 died. An eye-witness, who was personally known to the writer, one not given to exaggeration, said that the state of dread and alarm had been increasing until, when the disease first made its appearance in New York, fully one half of the population had left the city, many of the physicians fleeing with the rest. There was no efficient health department, and no organized system for the protection of the public health. This gentleman was a city missionary, and, in the performance of his duties, visited many of the houses. He mentioned visiting one of these on a morning when the fifteenth body had been carried out. It was the time of the rumble of the dead cart and the indiscriminate burial in public trenches. Contrast the horrors of this scene with the last attempt of cholera to invade the United States, in 1893, when, notwithstanding its presence at the quarantine station in New York harbor, and the actual presence of a few well-authenticated cases in the city itself, not one of these cases proved a focus for the spread of the disease.

The opinion that water in some way acts as a conveyer of disease can be generalized after a very little observation. To explain how it does this is a problem that was attempted to be solved by the chemist. He added vastly to our knowledge, but it was not until the biologist showed the presence of the disease-producing bacteria in water that a full explanation was possible. But the biologist has done more: it has been found, and notably in the very complete series of experiments carried on by the Massachusetts Board of Health, that even an effluent of a sewer, if filtered through a bed of sand, is purified to such an extent that the filtrate is a perfectly safe water to drink. The dangerous organic matter disappears, and ninety-eight per cent of the bacteria is removed. And it is pleasing to note, when one has so much to say of the dangers of bacteria, that the purification is entirely brought about by the action of bacteria working for the good of man. A sand filter bed does not purify water properly until it has been in operation for a few days, when the top of the bed is covered with a slime in which the bacteria act upon the organic matter in the water and purify it. The fact of the purification was known before the manner in which it was done was understood; and in those cities where the authorities have acted upon this knowledge and have purified their water supply, the influence upon the death-rate of typhoid fever is almost as marked as those already quoted for typhus fever, while the scourge of cholera has been almost entirely removed from their borders, as many an instance during the late outbreak in Europe could illustrate. It does not contribute to our self-esteem to know that most of the water supplies so filtered are to be found abroad. There is not enough of “practical politics” in filter beds to charm the traditional alderman of our cities.

It is now clearly proven that a species of bacteria is uniformly present in pulmonary consumption. This bacillus is to be found in the material coughed up by those who are ill with that disease. It has considerable tenacity of life; the expectorated material can be dried, pulverized into dust, and carried about on the wind; should the bacteria so dried and carried find a proper soil, they can grow and reproduce the disease. Fortunately, a combination of circumstances is required for the contraction of this disease, or it would be far more prevalent than it is. Notwithstanding, it already claims more victims than any other single disease. What has sanitary science done for its repression? It is attempting, in a tentative way, to obtain a registration of those who are consumptives, in order to teach them to avoid being possible sources of infection; to disinfect the discharges carrying the bacteria, and at times the rooms occupied by the consumptives. In Rome, for example, the services of the public disinfectors are asked for as eagerly for the room occupied by a consumptive as for one that had been used by a person suffering from diphtheria. In New York city, where the department of health has been exercising an oversight and care over the consumptives, there has been a constantly diminishing death-rate from all tubercular diseases from 1886, when the rate was 4.42, to 1897, when it was 2.85, with the single exception of 1894, which was lower than 1895. It is too soon to predict the result, but the proper care of consumptives promises much to check the ravages of the disease.

One of the charms connected with the great results indicated is the simplicity of the methods employed to bring them about. While complex schemes and elaborate machinery may be necessary whenever the amount of service to be rendered requires organization and division of labor to properly accomplish the desired results, the principles are such that they can be executed in the smallest hamlet, and with the very crudest paraphernalia. The two great weapons of the sanitarian in fighting disease are isolation and disinfection. Dr. Henry M. Baker, the efficient secretary of the State Board of Health of Michigan, has for years collected and tabulated the results of the observing and non-observing of these precautions in his State. He has a happy faculty for graphically presenting the results. One of his diagrams is presented here and needs no explanation. In very few of these outbreaks could there have been any municipal disinfecting plant or isolating hospital.

Isolation and disinfection—but the old quarantine and fumigation under new names! Who of us has not sympathized with the traveler of the earlier days in the Levant, when he was condemned to days and weeks of detention in the barren lazaretto? And even at so comparatively recent a date as the pilgrimage recorded by Mark Twain in his “Innocents Abroad,” he states that the Italians found it more to their convenience to fumigate travelers than to wash themselves. How very different is a modern quarantine station, such as may be found near any of our more important ports on the Atlantic coast. If the health officer of the port finds a contagious disease upon board, he immediately removes the sick to the hospital, and keeps the well under supervision long enough to see if the disease has been communicated to any. He may keep them on shipboard; but more likely, if the ship must be disinfected, he removes them to the detention station, safely separated from the hospital. The steerage has been crowded, and there is need of disinfection of their persons and clothing. Under proper supervision, each is required to take a bath, for which abundant facilities are furnished; and while this is doing their clothing has been placed in the steam disinfecting apparatus, a partial vacuum secured, superheated steam introduced, the clothing thoroughly disinfected, a partial vacuum again produced, whereby the contents are rapidly dried, and they are ready to be put on again by the time the bath is completed. The luggage is treated in the same way, while the cargo is probably treated to a sulphur fumigation,—the sulphur being burned in furnaces and the fumes carried to all parts of the cargo through lines of hose. In the course of a very few days, at least, all but the sick can proceed on their journey without any risk of conveying the disease.

Everything that has thus far been chronicled regarding the progress of sanitary science has related to the diminution of the death-rate and the prevention of disease. After all, is this worthy the telling? When one learns “how the other half lives,” or, with more restricted knowledge, realizes to a degree the intensity of the remark of a young Hebrew, replying to a command of a police officer to clean up, as related in “The Workers” by Professor Wykoff: “You tell us we’ve got to keep clean,” he answered in broken English, lifting his voice to a shout above the clatter of machines; “what time have we to keep clean, when it’s all we can do to get bread? Don’t talk to us about disease; it’s bread we’re after, bread!”

Is it worthy of boasting that sanitary science is only increasing the hardships and adding to the number of mouths to be fed, without opening up new ways to earn one’s bread? Even if it be so decided, and all the claims of progress thus far made be declared wanting, there still remains much worthy of praise. Sanitary science strives not only to prevent disease, but also to promote health, and its progress is fully as marked in its efforts at promotion as in those of prevention, although we do not possess the cold figures of even imperfect vital statistics to demonstrate the proposition.

It must be kept in mind that sanitary science is wider than sanitation in its technical sense. One would not care to assert that philanthropic effort and sweet charity are resultants of the development of sanitary science,—very few care to assert an evident untruth. But the influence of this study has been widespread and beneficial. The whole round of social science is also permeated with the truths demonstrated by the sanitarian, and is likewise deeply indebted to its teachings. Our field broadens greatly as we view it, just as one who has been traveling through a vale of surpassing grandeur, because of the mountain barriers on either side, finds himself confronted by a park whose beauty is enhanced by its variety as well as its extent, bounded, it is true, by the same mountains, but merely a hazy definition of the distant horizon.

In the construction of dwellings, for example, the small, low ceiled rooms, whose earthen or stone floors were covered with rushes seldom removed, the absorbers of whatever might fall upon the floor; the unpaved, unswept, and unsewered street; the domestic water supply but a well into which filters the water from the adjoining cesspool,—these and many similar destroyers of health and comfort can no longer be found among nations classed as enlightened in our school geographies. Even the improvements of half a century ago—the tenements improvised out of the deserted mansions of the well-to-do, with the additions built on the rear of the lot to increase the density of the population and the rent of the owner (as well as the death-rate), are disappearing, and in their places we find dwellings capable of furnishing air and light to all of the residents.

Then, in the matter of streets, how much more attention is now given to small parks! When about the middle of the century interest in public parks was revived, the efforts of the various cities were directed to the securing of large tracts of ground and beautifying them in every way. They were open to every one, it is true, but too often too far removed to be of use to the submerging tenth. Now, while not adorning these with one garland less, the effort is making to break up the congestion of the crowded districts by breathing spaces, to the comfort and vigor of those who must make the surrounding houses their homes. The streets, too, no longer paved with the unsightly cobble-stones, are made noiseless with the asphalt paving and, what is more to the purpose, can be easily cleansed by flushing. When practical business, and not practical politics, prevails in the municipality, there is no opportunity for the household refuse to accumulate, although no longer rushes are available to receive it, for it is regularly and promptly removed.

The exigencies of trade compelled our government to establish its bureau for the inspection of meat. The necessity of an inspection of foodstuffs for export demonstrates the possibility of adulteration for the home market. While, possibly, the ingenuity of the sophisticator has more than kept pace with the keenness of the inspector, the health of the people has been maintained, their comfort promoted, and their resources husbanded by the inspections carried on by the various city and state boards of health.

The welfare of the people at home, in their dwellings and at their tables, does not limit the efforts of the sanitarian. He takes cognizance of the daily toil, the ceaseless grind, to win one’s daily bread. He recognizes that some callings are dangerous or annoying to the people, and devises methods to overcome this, or failing in this, insists that such occupations must be carried on remote from the dwelling-place of man. Others, he finds, bring danger to those who are employed. This may not be an inherent danger, but one acquired by our crowding of operatives, or in other ways not securing to them proper comfort; and factory inspectors are at work to reduce these dangers to a minimum, and to prevent child labor as well—giving to youth, as far as cessation from overmuch toil can give, an opportunity to develop into physical manhood or womanhood. The sanitarian insists upon proper ventilation in mines, and tries to devise the means to remove the danger from those trades that ordinarily are inherently dangerous.

The sanitarian seeks to aid in the amenities and relaxations of life as well. The playgrounds for children, the athletic grounds by the riverside at Boston, recreation piers in New York, are examples of this. And all of these are comparatively recent efforts, adding to the catalogue of achievements during the century. It was the arch-enemy who, in the poem of antiquity, said: “All that a man hath will he give for his life.” But he made the remark after much observation, and to Jehovah, unto whom even he would not dare to lie; and the rolling years since the Hebrew epic was first written have only added testimony to the truth of the assertion. In these later days, when the rule and plummet are everywhere applied, where the scientist delves and classifies to seek the cosmos in the apparent chaos, there was evolved out of self-seeking for life a higher and better quest,—a search for those things which make for the health of all. This search has widened, until many a broad savannah has been trodden, many a mountain scaled and wilderness explored. With its ever extending view, new responsibilities and greater cares have been thrust upon those who are endeavoring to rule in this domain. A community, a nation, is but a unit. Let one part suffer, and all are in pain; let one but decay, and rot is imminent everywhere. There can be no true social progress, no real stability of government, no national prosperity worthy the name, unless the environment of each individual permits the enjoyment of personal health, if he individually observes but the ordinary care of self. And whatever else of progress for sanitary science may be granted or denied as belonging to our century, the crowning claim of all, which cannot be taken from her, is that, along with the ideas embodied in commonweal and commonwealth, she has added the other of equal dignity and worth—Public Health.