bacteriological examinations. Dr. A. may make a diagnosis of Diphtheria; Dr. B. may say the case is not Diphtheria. The State Board of Health can be appealed to, to settle the dispute beyond all controversy. The people of the State have a perfect right to demand that a diagnosis shall be confirmed by the State Board of Health before their homes are quarantined. Of course, it is not right for the State Board to enter into competition with the physicians, if the latter is perfectly capable of making his own microscopical and bacteriological examinations, but the vast majority of doctors are neither capable of making these delicate tests, nor have they the time or the apparatus; and therefore the State supplies this deficiency, to the great benefit of the people of the State at large.

DR. BENJAMIN LEE, Philadelphia, Pa.: In my State, as in Minnesota, the State Board of Health has the power of domestic quarantine. We are compelled to use it constantly from the fact that outside of our incorporated cities and boroughs, no such thing as a Local Board of Health exists. Of course this condition of affairs is a very unfortunate one, as you can readily see what an immense area is left without any local sanitary protection.

In cases where Boards of Health exist, we are often called upon to settle disputes as to diagnoses. If a Board of Health appeals to us for this purpose, we say : "We will send you an inspector to decide the diagnosis, but you must pay for his services; the State Board can not do this for you gratuitously." We say to the Local Boards in the many small towns where they have no means of making bacteriological tests, for so much a year according to your population, we will furnish you a report, as a rule within twenty-four hours from the time the specimen is received, determining the character of the disease.

Many towns avail themselves of this privilege. We also offer individual physicians throughout the State the same facilities for a fixed charge for each test.

PROF. W. H. BREWER, New Haven, Conn. In the State of Connecticut every town has a Local Board of Health operating under a State law. There are 168 towns in the State, and there is no town so small that it has not its Local Board of Health; and if it does not of itself appoint a Health Officer, then the State Board can appoint a man and name his salary. That is about the only absolute power the State Board of Health in Connecticut has.

We

have the general and advisory oversight of all the Local Town Boards.

DR. GARDNER T. SWARTS, Providence, R. I.: Does each town have its own laboratory for bacteriological examination?

PROF. W. H. BREWER, Connecticut: There are not more than two or three towns in the State which have bacteriological laboratories. Many of the towns employ the laboratory at New Haven which is run in connection with the Yale Medical College.

DR. HENRY B. BAKER, Michigan: It seems to me that where State Boards of Health do so much for the Local Boards in the way of settling diagnoses that it prevents a proper development of the health service throughout the State. In Michigan the State has a complete laboratory for bacteriological examinations. This laboratory is in charge of a skilled director, with competent assistants, but it goes no farther. If examinations are wanted they must be paid for; that is, the cost must be paid. I believe with Dr. Wingate, of Wisconsin, my next neighbor on the west, that it is hardly the function of the State Board of Health to make a business of supplying diagnoses. In Michigan we have many local bacteriologists who are doing this work and who would not have entered upon it if the State had occupied the field; for instance, in the city of Kalamazoo, they have a city bacteriologist who is right on the ground. Physicians can have their diagnoses confirmed very promptly. I think the same is true of the city of Detroit, but I consider the centralizing of this business in the hands of the State Board of Health a mistake.

DR. H. M. BRACKEN, Minneapolis, Minn. : I do not think the State Board of Health should enter into competition with local physicians who may be doing bacteriological work, but there are many localities in which there is no competent bacteriologist. Before enforcing quarantine against any infectious disease the Local Health Board should have the diagnosis confirmed, if possible, bacteriologically, and it should have the right to appeal to the State Board of Health for the confirmation of such diagnosis.

DR. GARDNER D. SWARTS, Providence, R. I. : I agree in a measure with what Dr. Bracken has said. Certainly we should not pronounce the quarantine until the diagnosis is assured. Who shall confirm the diagnosis? I doubt if there is one physician in this room who considers him

self a skilled bacteriologist. Not one physician in a hundred can afford to own and maintain a complete bacteriological laboratory, and if he could afford it he would not have the time to make his examinations properly. I think it devolves upon the Local Board and upon the State Board to confirm diagnoses. This is the one feasible way to control epidemics.

THURSDAY MORNING, AUG. 19, 1897.

PROPOSED BY HENRY B. BAKER, M. D., MICHIGAN.

"HOW FAR SHOULD MANDATORY MEASURES GO IN DEALING WITH (a) MEASLES, (b) WHOOPING-COUGH, (c) LEPROSY, (d) TUBERCULOSIS?"

REMARKS, IN OPENING THE DISCUSSION, BY HENRY B. BAKER, LANSING, MICH.

MEASLES.-I believe such measures should extend-1. To compulsory notification, by the householder, of every case not already reported by a physician; compulsory notification by the physician of every case, and possibly nominal compensation, say ten cents for each such report. On this point of compensation to physician, I am not sure that it is necessary. It is so provided in the Michigan law. Dr. Rohé, in an able paper on this subject, says: "The report of deaths and contagious diseases should be considered by the physician as a high public duty; one that he alone can satisfactorily perform, and for which he should scorn to ask or receive compensation."

"A Connecticut court has declared that 'it is universally understood to be one of the implied and necessary conditions upon which men enter into society and form governments, that sacrifices must sometimes be required of individuals for the general benefit of the community, for which they have no rightful claim to specific compensation.' (Bradley v. N. Y. & N. H. R. R. Co., 21 Conn. 306.) "* Notification is useful:

(a) To enable the local health officer to promptly act for the restriction of the disease.

(b) To serve as a starting point for the supplying of

*Proceedings of Public Health Conference, Baltimore, Md., Feb. 17 and 18, 1897, Pp. 24-25.

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facts for compilation, in order to learn the facts needed for intelligent dealing with the subject.

(c) To enable the local health officer to notify the State Board of Health, to receive from the State Board of Health leaflets of instructions how to restrict the disease, and to distribute such leaflets liberally to the neighbors of infected premises.

Relative to Measles, and to any other disease concerning which the people, generally, are not convinced of the importance of restricting the disease, the most important work by health authorities is the education of the people, as to the extent of the danger from the disease, the fact that the disease may be restricted, and as to the great gain in life, health, and money values by the restriction of the disease. Compulsory notification is essential as a starting point for any systematic work. And that should certainly be enforced, and educational work should be pushed to the

utmost.

2. I believe mandatory measures should extend to the prompt isolation of every infected person and thing; and to their disinfection before coming in contact with healthy persons. But for the restriction of any disease, the action. by the people themselves is as important as the action by the health officials. Unless the co-operation of the people can be had, isolation of infected persons can not be enforced. In Michigan, the law specifying the duties of health officers makes it their duty to order the isolation of every sick and infected person, unless the Local Board of Health directs the health officer differently. The Local Board of Health is supposed to be able to judge of the public sentiment in its locality, and whether restrictive measures can or can not be enforced. Local Boards, however, sometimes begin their efforts out of the order of best sequence. In the city of Detroit, recently, there has been a marked instance of an unsuccessful effort at the forcible restriction of Measles, unsuccessful because the forcible restriction was commenced before the people had been educated as to the importance of restricting Measles.

As regards Measles, and in fact every communicable disease the restriction of which is to be commenced in any locality, the first effort should be for the education of the people as to the necessity for action.

I believe it is a general law that people can not be taught on any subject except they first have their interest awakened. When there is no threatening danger of a dis

ease people can not be taught relative to it. When there is immediate danger they can be taught. These facts in sociology supply the reason why the first mandatory requirement is for compulsory notification of the occurrence of Measles in order that advantage may be taken of the knowledge of its occurrence to educate the neighbors of the infected persons and premises.

I believe the best plan is for the State Board of Health to supply the educational data and statements, and for the local health officers to distribute such data and statements. As fast as communities are sufficiently educated to cooperate for the restriction of Measles, or any other disease, the restriction of that disease should be enforced by the compulsory isolation of all infected persons and things and their complete disinfection before permitting their unrestricted movement.

WHOOPING-COUGH.-Precisely the same remarks made retative to Measles may properly be made relative to Whooping-cough.

LEPROSY.-In Michigan and in most of the States of this Union, there is no case of Leprosy, and in my opinion the danger of the introduction of Leprosy in those States is so small that the disease may almost be disregarded. The education of the people relative to Leprosy has already been accomplished in most States. It is generally recognized as a dangerous communicable disease. Therefore, in most States, nothing stands in the way of the approved methods of restricting such a disease, namely isolation of infected persons and things, and their disinfection before permitting unrestricted movement.

In any State or Province in which there is Leprosy and in which the necessity for restrictive measures in Leprosy is not generally recognized, I believe it is the imperative duty of the State or Provincial Board of Health immediately to take such action as shall tend to create an intelligent public sentiment which shall make it possible to limit the disease to the present generation, or at least to a restricted area.

In my judgment, mandatory measures should extend to (1) compulsory notification by the householder and by the physician, (2) isolation of every infected person, and (3) disinfection of every possibly infected thing.

TUBERCULOSIS.-What I have said relative to the education of the people concerning Measles, I wish to have con