there is a question of tuberculosis. In the city of Baltimore the same assistance is offered by the local board. Thus the country practitioner stands upon the same level with his city brother as regards these necessary diagnostic measures. Such opportunities he should not neglect to utilize.

In any suspected epidemic of cholera, of yellow fever, of plague, of typhoid fever, of cerebro-spinal meningitis the State Board of Health is ever ready to furnish the necessary expert investigators and to offer every assistance.

What have been the first results of the advances of late years in our knowledge of the nature, especially, of the infectious diseases, and of the discovery of improved diagnostic methods? The answer is obvious. The knowledge of the nature of an infectious disease, and of the manner in which the poisonous agent enters the body, have been followed in many instances by the discovery of methods of destroying these agents or preventing their entry into and their dissemination in the organism, while early diagnosis, with the recognition of the first cases, has given us the key to successful prophylaxis. We possess today, for instance, knowledge which should enable us in an ideally-governed State to recognize at the outbreak and largely prevent the spread of diphtheria, typhoid fever, malarial fever, yellow fever, cholera, plague, tuberculosis. Moreover, with regard to one of the most terrible of the scourges of mankind, diphtheria, we have at hand an almost certain means of cure if the disease but be recognized at a sufficiently early period. Why, then, does tuberculosis exist, widespread? Why does typhoid fever carry off every year hundreds of the flower of our country? Why does malaria in some localities wear out, debilitate, and render incapable for work and a prey to disease valuable members of the community?

Is this the fault of our governors and legislators? Not at all. It is because we live in a state of society which is still far from ideal-in a community in which everyone is, to a greater or less extent, working for himself, with little intelligent responsibility for the general good. It is because we still lack a large measure of the attributes of true civilization. With the barbarous and untutored savage in the African jungle every word and every act are determined by the impulse of the moment, by that familiar instinct which impels us all to follow the path of least resistance. His simple mind is incapable of grasping the idea of the practical advantages of truth and loyalty and justice, much less of any religious or moral obligation. And in his more or less guileless desire to make his own pathway smooth by obliging his civilized neighbor when it is convenient, and knocking him in the head when that seems the simplest way to comfort, he inevitably entangles himself in a snare which brings about his own destruction. The idea of the necessity of the practice of truth and justice with our neighbor, of charitable and loyal co-operation with our fellows, as the basis on which we may assure for ourselves the safest and happiest form of government is an idea which is acquired only by

many centuries of bitter experience. And while the more intelligent part of most Christian communities of today, either through faith or reason, or both, profess to accept these principles with regard to the conduct of life and society, the philosopher from another planet would, I fear, be amazed should he attempt to compare individual profession with collective practice.

The degree to which a community is capable of disinterested co-operation for the promotion of the general welfare is a good measure of its grade of civilization. Should one, however, apply such a test to the manner in which the medical profession and the general public in this country deal with affairs of public health I fear that his first sentiment might not be one of encouragement. When we meet in our practice with a suspected case of diphtheria our first thought is too apt to be, "What a nuisance! If this case be reported, the house will be posted; there will be no end of trouble for the family"-who are at the same time urging us to say nothing for the present, and will take it sorely amiss if we notify the Board of Health. What a temptation, if the symptoms be mild, to take every precaution and let it pass, or, if there be doubt, to take no measures at the moment, and not to alarm the family until we are perfectly sure of the nature of the case; and in either instance delay may mean, through the ignorance or carelessness of the family, the beginning of an epidemic.

If, again, it be a case of typhoid fever, how often do we begin the necessary precautions at the very onset, at the time when we nervous; if we insist upon the proper precautions, she will immediately understand what is in our mind. She "will die if she suspects it is typhoid fever." The business of the hotel will be ruined if anyone fancies this possibility. The neighborhood will be discredited. There is a good chance, after all, that it may amount to nothing. One waits, therefore, until, after a week or two, a positive Widal test or the natural course of circumstances determines the diagnosis, and during this week or two the mother has, perhaps, acquired the disease by direct contagion, or contamination of food or water supply may have started an epidemic in the house or neighborhood.

In a Southern city, in the summer, a few cases of fever occur of a puzzling or uncertain nature. Are they perhaps dengue? What if they should be yellow fever? But, no; that is not likely. We have had no serious yellow fever for years, and the condition of the city is now so much better than it was. Might it not be safer to notify the Health Department at once of these uncertain and slightly suspicious cases and adopt all precautions? Of course, if one were but sure. But, then, think of the results if the cases be innocent, after all, and yet our suspicions become public-a shotgun quarantine, the business of the city at a standstill, and with its gradual resumption a certain inevitable permanent loss to the advantage of the rival community. Suppose, even, that time should show it to be yellow fever; it would be early enough to take action then. Five or six years ago there were a few cases which the

Health Department said were yellow fever, and yet there was no general epidemic. And then, to be sure, there were many among us who believed and stated with assurance that these cases were not yellow fever at all, but only estivo-autumnal malaria. After all, that suspicion was born only of over-conscientiousness. It would be folly to upset the whole State on such mere fancy. And from two to three weeks later there is a sudden outburst of new cases, some of which are fatal, and but too clearly the dreaded enemybut it is already too late, and, despite intelligent and vigorous action by local and national authorities, there is an epidemic of thousands of cases, with the loss of hundreds of valuable lives.

The only daughter of the family is brought to you with evident tuberculosis. The parents realize that there is no hope; they can ill afford to take her away, and they know it is useless; but "Above all, Doctor, don't tell her what it is. She does not suspect it, and it will kill her if she has any idea of it." But it is of importance to her to know the truth that she may follow that course of life which is best for herself and safest for those about her. "No, no," you are assured, "you don't know her sensitive nature. To tell her will be to put an end to all hope. The family understand; they will take all precautions, they will teach them to her in such a way that she may not suspect," and the delicate, sensitive girl sits shivering by the stove and takes patent medicines, and slowly dies, and the precautions are not carried out, and next year her only brother, the hope of the family, follows close on her heels.

There is no danger to others; tuberculosis is not contagious; these cases have not been reported, and perhaps the final cause of death was "pneumonia." And a year later the infected house poisons another innocent and unsuspecting family.

This is the path of least resistance, this is the natural course followed by our ingenuous savage, the way along which we find ourselves ever inclined to follow, and the result is, in the end, the same-calamity.

But little by little, laboriously through ages, humanity is learning the value and necessity of co-operation, of social and political regulation and restraint, of the necessity of the sacrifice of many individual liberties for the welfare of the whole; and while, as a rule, experience-cruel, personal experience-alone teaches the masses, yet it is perhaps true that today the public is as intelligent and as capable of profiting by the experience of others and by the researches and advice of the competent student as it ever has been in times past. The thoughtful element of the medical profession, and happily many of the public, have come to realize that dissipated individual effort cannot suffice to protect the community as it should be protected, that such protection can only be afforded by the labors of properly constituted boards of health, supported by the united efforts of the medical profession. And this is, I sincerely believe, our most important public duty as physicians: thorough, cordial, intelligent support of and co-operation with our central boards of health.

What does such co-operation imply?

1. We should use our influence in every way to bring it about that the board itself should consist of disinterested men who are trained to or specially fitted for the essentially scientific duties of such a body. In times past there have been many men whose training has not particularly fitted them for such positions-busy general practitioners, who have yet developed into faithful and efficient health officers. There are many such in the country today. All honor to them! But with modern educational opportunities there should be no difficulty in the State and in our larger cities in finding men whose training especially qualifies them for this work. What boards of health have been in the past and still are in many localities where the appointments are made as rewards for political service or as gifts to friends it is needless to point out. And how extraordinary it is to think that individuals, a part of whom at least, are gifted with some powers of reason, should place the protection of the public health in the hands of men who have no more training in and no more idea of those measures of sanitary science which insure the safety of the public than an able seaman might have of the government of the engines of an ocean steamer.

A few days ago, in a French journal, I came across the following words, attributed to Socrates: "It is a remarkable fact that those who wish to become skilled on the lyre or on the flute, in riding or in any such exercise, work ceaselessly and undergo fatigue and suffering to learn their trade, while our great politicians who wish to govern us, fancy that they become suddenly capable of everything as it were by instinct, without study or preparation." The quotation is inexact, but the observation is singularly applicable to modern conditions.

But if the Athenian held that the art of politics could not be taught, it was not so with regard to the other arts or sciences. "When we are met together," says Socrates, "in the assembly, and the matter in hand relates to building, the builders are summoned as advisers; when a question of shipbuilding, then the shipbuilders, and the like of other arts which they think capable of being taught and learned. And if some person offers to give them advice who is not supposed by them to have any skill in the art, even though he be good-looking and rich and noble, they do not listen to him, but laugh at him and hoot him until he is either clamored down and retires of himself, or, if he persist, he is dragged away or put out by the constables at the command of the prytanes. This is their way of behaving about the arts which have professors."*

The medical profession should be the first to realize the fact that the members of boards of health should be chosen with all the care and discrimination that would be exercised in the selection of a professor in a university. That such appointments should be allowed to fall into the slough of party politics, that members of

*Plato, Protagoras: "The Dialogues of Plato," translated by Jowett, Oxford, 8vo, 1871, I, 124.

the medical profession, without any of the necessary special training, should put themselves forward as applicants for such offices, should be abhorrent to our whole body.

This State is fortunate in possessing a Board of Health which may well be an object of pride to all. It is a competent, disinterested, eminently efficient body. It is a board in which we may trust and confide, to support which loyally we owe it to ourselves and patients.

2. The first and most essential evidence of confidence in a board of health is the faithful and immediate reporting of all cases of communicable disease. The only way to protect the public and ourselves is to record all contagious diseases, not only when we positively recognize them, but when we suspect their existence; to take cultures from every case suggesting diphtheria; to have examinations of the sputa made whenever we fear the presence of tuberculosis; to send to the department specimens of blood wherever there is a question of typhoid or malarial fever, to notify or confer with the Health Board concerning every case in which one suspects measles, whooping-cough, scarlet fever, chicken-pox or smallpox, yellow fever or plague.

We should remember that it is the first doubtful case that counts, that nearly every epidemic can be nipped in the bud, while it takes often but a fearfully short time to gain a growth which overwhelms us.

3. We should assist our boards of health in every way in carrying out proper methods of prophylaxis. What this means in yellow fever where the methods of protection are so simple and efficacious, need not be emphasized. It would have been simple enough at the outset to prevent the present epidemic by that intelligent co-operation between physician and board of health which is of such vital importance to our welfare.

One of the most serious problems with which we have to deal is in connection with typhoid fever. Here, indeed, a great field lies before us. If every instance of this omnipresent reproach to civilization were promptly recognized or suspected and reported to the authorities, the excreta carefully and systematically disinfected, and proper precautions taken by the nurses and attendants, the disease might be eradicated from our midst. Every case of typhoid fever in which the dejecta and urine are not disinfected is a menace to the community. Boards of health should distribute among the medical profession careful directions as to the proper measures of protection, and these should be carried out in every suspicious case. But more than this, we should ourselves, in our dealings with the public, use our influence constantly to bring about improvement in the sanitary conditions, in the measures which should be adopted against flies, in the proper construction and protection of outhouses, in the control of the water supply. These are questions in which boards of health may be of the greatest assistance, but where much of the burden falls upon us individually. No one of us can tell what neglected case of typhoid