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SECTION ON STATE MEDICINE Dr. J. M. McComas Elk City, Oklahoma When one examines closely into the history of state medicine and sanitary science he is very soon impressed with the fact that progress seems to be constantly evident. Authorities tell us that in the sixteenth century the average life covered a period of eighteen or twenty years. In the eighteenth century it had been lengthened to approximately thirty years and today the span of human life is about forty years. Since the year 1880 man's average life has been extended by nearly six years. For such splendid humanitarian and economic benefits progress in state medicine and sanitary science is beyond doubt, directly responsible.

The year that has elapsed since last we met has, I think, been marked by unusual interest throughout our country in the problems of public health. This interest has been manifested by legislators, by medical men and best of all by the people at large. The great majority of medical men have in the past quarter century been unremitting in their ardent zeal for better measures concerning public hygiene and sanitation. Legislators have shown but intermittent interest in such questions and the people up to seven years ago were scarcely more than lukewarm in matters pertaining to their health as communities in need of sanitary regulations.

And while still today there is much to be desired, very much in the matter of public interest in health regulation and

state medicine, nevertheless, the signs of the times are hopeful. There seems to be a general and increasing appreciation of the fact among all classes of society that on state medicine depends the happiness of our people and our national success. Not the hordes of barbarians but the degeneracy of her citizens caused the fall of Rome.

There are several facts pointing to better things and still greater progress in public health measures. Notice first, the wide prevalence of the agitation for a national department of Public Health with a medical man at its head who should have a seat in the President's cabinet. With greater or less completeness all political parties of any claim to national importance incorporated into their platforms last summer a plank favoring such a step. Surely. the pressure of public opinion is strong when political parties are practically uniform in proclaiming the need for a reform not usually carried into the political arena. President Taft has recently declared himself emphatically in favor of a National Board of Health though he has not committed himself as to what he believes should be its composition and its status. Medical societies and medical journals have recently waxed eloquent and forceful in their arguments in behalf of a National Board with extensive powers. Incidentally I may say that those same journals have at the same time brought out clearly the highly commendable work done by the present federal organization known as the Public Health and Marine Hospital Service. See, for instance the New York Medical Journal, volume 88 (1908) page 1,024, where is an excellent article by Dr. C. E. Wood.

Public hygiene has become a kind of social quest. An excellent campaign of education stressing the importance of official sanitary work is being carried on by

such societies as the Public Health Defense League, the American Public Health Association and the American Association for the Advancement of Science which through its committee of One Hundred is doing and has been doing for three years noble service in a strenuous warfare against tuberculosis. Professor Irving Fisher of Yale University, at the head of this committee, has made his voice heard far and wide in the plea for proper treatment of consumptives.

One reason for the recent awakening of the people to the great merits of state medicine and sanitary science has been the growing realization of the economic value to the country of a general raising of the average health. Professor Fisher and others have calculated in dollars and cents what preventable illness means to the country. Newholme has estimated the economic burden of sicknes in startling concreteness. He postulates nine days of average illness per year. At this rate two million years of life are lost each twenfth month. Estimating wages at one dollar per day and all other expenses at one dollar a day, a loss of $1.144.000.000 a year is registered by illness. Could days of illness. be cut down one-third, nearly five hundred million dollars would be saved. Higgins has estimated that six hundred million dollars are now spent on criminality in the United States. If the criminality is largely the product of social environment, such as overcrowding, alcoholism, etc., measures which would decrease this only fractionally are worthy of consideration.

At the last conference of the governors at the White House, Dr. George M. Kober in a speech on "Conservation of Life and Health by Improved Water Supply." showed that the decrease in the "vital assets" of of the country through typhoid fever in one year is more than $350,000,000. The death rate from typhoid being frequently

directly traceable to polluted water, the purification of the city water of Albany by means of filtration plants was accomplished and this reduced the death rate from one hundred to twenty-six in one hundred thousand inhabitants. This Dr. Kober calculated was equivalent to a real increase of $350,000 per year in the "vital assets" of the city.

In view of the wide heralding of such facts by organized societies and by medical and lay journals, we cannot wonder greatly at the increasing popular interest in the needs of public health regulation. Rather do we note such an awakening with approval and much satisfaction.

Besides noting progress in our observation of state medical and sanitary science, one is impressed with the growing need of specialists in this branch of medical work. The three medical specialties of the future, due to the new importance of state control of health, probably will be curative medicine, supervision of personal hygiene and the direction of public hygiene. The problems of sanitation, it has been said, are essentially as attractive as those of curative medicine and effective public recognition seems the one thing at present withheld. But it seems to me that the time will surely come when physicians will, by special courses of study in medical colleges, qualify as experts in public sanitation and public hygiene. Preventative medicine is assuredly of as much value as remedial medicine. After all there can be no absolute distinction between personal and public hygiene. A physician's services are surely as valuable to a man in showing him how to maintain good health and prevent disease as in making him whole when disease fastens itself upon him. Popular opinion might not support this statement, but men of medical training doubtless uniformly believe it. The knowledge of matters of health among the masses should be of far

greater extent than the early smattering of health laws obtained in school days. The trained physician is needed always to advise and instruct.

Another phase of the question of public health is suggested in the truth that all general advancement in this direction is conditioned absolutely upon law, upon sanitary legislation. And laws that are passed should first of all be wise, and secondly should be, not persuasive, but compulsory. Wise laws! How we long for them in every line of activity! The usual complaint from which we suffer in this respect is not entirely the indifference of legislators to matters of state medicine and public health, but more frequently it is hasty and ill-advised medical legislation of which we physicians must complain. In many states sanitary measures are passed by state law makers without previously consulting, either at all or sufficiently, competent medical advisers. Legal men are good advisers in many or most matters of proposed legislation but they cannot possibly render the service that physicians and scientific men can in regard to legislation affecting state medicine. Nor can legislators afford to listen to quacks and visionaries when the health of the people is in question Two much crude, half digested and even nefarious legislation attributable to one cause or another, has been passed in nearly every state legislature.

As to th eneed of sanitary legislation being made compulsory, evidence is overwhelmingly in support of such a contention. Written law, with stringent penalties atatched, is necessary if state medicine is to be practical. As Dr. Samuel G. Dixon said before the American Medical Association, "The great majority of men are not wise enough to submit themselves to requirements of sanitary laws or righteous enough to be willing to exercise self-denial and repress cravings of avarice to save others from sickness and contagion." We