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number killed in battle and dying from wounds. That was at a time when the causes, the ways of spreading and the means of preventing camp diseases were unknown. In the Spanish-American war the number of deaths from diseases was more than five times the number resulting from bullets. The greatest disgrace is that over 2000 of these did not occur in an active campaign, but in the training camps at home, where the sanitary conditions could have been and should have been controlled. Most of these deaths were due to diseases that are well understood and entirely preventable. The fault was not with the medical department of the regular army, but the primary cause of this enormous mortality was the method of making appointments to responsible positions purely for political reasons and not because of fitness for the position.
Contrast with this the conditions in the Philippine, where, notwithstanding the climate and inability to control sanitary conditions in an active campaign, the mortality from disease for the year 1899 did not exceed the number killed and dying from wounds. Or, contrast the condition of the British army in South Africa, where, up to March 1, 1900, the number of deaths from disease was less than one-half of those killed in battle and less than one-eighth of those wounded.
Without offering any apologies for the mismanagement of our army in the summer of 1898, let me call your attention to the high mortality from typhoid fever constantly occurring among us at home. There probably occur annually in the United States from 25,000 to 30,000 death from typhoid fever, probably representing nearly 200,000 cases of this disease. In Philadelphia alone, with a little over 1,000,000 population, there were 7985 cases of typhoid fever in 1899. An English writer has said: "For every case of typhoid fever somebody ought to be hung." Would it not be well for the good people and "yellow journals" who strained so hard at this comparative gnat in the form of mortality rate in our army two summers ago, to concern themselves more about swallowing a camel in the shape of the inexcusably high mortality rate from typhoid fever at home? It is difficult to understand how a people that felt so indignant at the loss of life on the Maine will tolerate such loss of life from causes that can be prevented. The fault is
ours; the way is clear; the certain means of prevention is at hand; it only needs to be supplied.
The achievements of modern sanitary science are numerous and striking. The great reduction of mortality resulting from a pure water supply and from a good sewerage system has been experienced by so many cities and towns throughout the country that every one is familiar with it, and these two matters have become corner stones in the foundation of public sanitation.
As a result of cleanliness enforced by Americans, the mortality of Santiago de Cuba for 1899 was but 30 per cent. of the average annual mortality rate for the three years preceding, notwithstanding an inadequate water supply and the absence of a sewerage system. The mortality of Havana for 1899 was but 44 per cent. of the average for the three years before that time, even without a sewerage system.
However, it is not only in cities that have been so indescribably filthy as these were under Spanish control that great improvements have been made. In New York City, where sanitary matters have always received due attention, there has been a reduction of 25 per cent. in the death rate from 1887 to 1897, without any single great public improvement, such as a purer water supply or better sewerage system. This improvement has resulted chiefly from the thorough and scientific methods used in the recognition, notification and isolation of contagious diseases and the disinfection after their occurrence. Other cities have adopted her methods with the same benefits. This movement has extended so rapidly that at present New York, Boston, Chicago and Philadelphia have medical inspectors of schools to prevent the spread of contagious diseases through the publie schools.
Does anyone think the people are not in favor of sanitary improvements? The popular vote in Pittsburg for a pure water supply; the vote in Philadelphia to provide means for purifying the water, and the vote of the property holders in New Orleans for a public sewerage system all indicate that the people are in favor of such improvements, even though they are expensive. It is indeed a sad thing to see the metropolis of the South only taking such action because the recurrence of epidemics affects her commerce. Human life can not be valued in terms of dollars and cents. But it is a
still sadder thing to see other cities, like Galveston, equally bad off from a sanitary standpoint, failing to profit by her unfortunate experience.
I hope that each one of you graduating in medicine today will consider it a duty you owe to the State that has given you a free education to lend your best efforts to the cause of public medicine, to the prevention of disease.
As physicians you should keep out of politics, but if the important position of health officer or of membership of a board of health should come to you, do not shirk the responsibility merely because the duties of the position may not have been properly performed in the past. You are fitted for such work, and we want capable, strong and fearless men for such positions, and not mere figureheads, who know nothing of sanitation, and often care even less.
But it is not only as public sanitarians that opportunities are opened to you. Every physician can do much in his private practice toward the prevention of disease. Dr. Holmes once humorously said: "Physicians desire for their patients great longevity, with frequent illness." It is entirely unnecessary to attempt to refute these suggestions before this audience. The question is, however, often asked, Why should a physician, who makes his living by treating the sick, use his knowledge of hygiene in the prevention of disease? Even from a purely business standpoint it is to his advantage to do so. The time is past when intelligent people are satisfied to have the physician call, prescribe his medicine and then leave. They want to know something of the nature and the cause of the disease, the way in which it was most probably contracted, and, if preventable, the means of preventing its spread. If the physician does not give this information he may soon find himself supplanted by some one else who will.
But there is a higher moral reason why every true physician will practice preventive medicine on all occasions, whether it is of any pecuniary benefit to him or not. It is the duty of the physician to save life, to lessen and prevent suffering whenever and wherever he can, and if any one of you have no higher motive in the practice of medicine than the money to be gained you had better give it up right now.
If the public water supply is polluted, you should tell your patients
how it may be rendered free from danger. If the board of health or the health officer in the community in which you live should not pay proper attention to the isolation of contagious diseases and disinfection after the occurrence, that does not excuse the attending physician for any neglect of the minutest detail in these matters. In limiting the spread of consumption the attending physician can accomplish far more in instructing the patient how to prevent its communication to others than can be done by the public health officials. Regarding personal hygiene, such, for example, as the evils of over-cating and over-working, which are so common at present, the people can only be educated by their private physicians. Indeed, as educators of the people in matters concerning the public health of the community, as well as the health of the individual, the physician and the public press are the most potent factors. I sincerely trust you will not regard dosing your patients as your only duty and that you will pay due attention to the prevention of disease. Time does not permit me to address any words especially to the graduates in pharmacy and to the graduates of the school of nursing. No one appreciates more than the physician what valuable allies he has in the nurse and the skilled pharmacist. Indeed, it often happens that the nurse in an emergency or by faithful devotion to duty, contributes more than the doctor to saving the life of the patient. Perhaps the highest compliment that could be paid to the pharmacist in recognition of the dignity and efficiency of his profession is seen in the way most of the State examining boards of this country have within the past decade required all candidates for registration to be graduates of a school of pharmacy.
It does not matter to the true soldier in what branch of the service he fights; he is content to know that he is performing his duty to the best of his ability wherever he may be stationed. You are all today enlisting in a noble cause and I may say one final word of advice which will apply to all, wherever you may serve: Be in earnest in your work and always, under all circumstances, do your full duty. Be true to your profession; be true to your alma mater; be true to the community and State in which you live, and
"This above all; to thine own self be true,
THE SUMMER SCHOOL MOVEMENT.
[An address delivered at the opening of the Summer Session of 1900 by Dr. Geo. P. Garrison.]
The summer school is now well established in America, and is doubtless a permanent institution. It is past the stage in which its friends need to rally in order to keep it alive, or its enemies can expect to destroy it by the most energetic attacks. The attitude of wisdom towards it, therefore, can be neither that of hostility nor neglect. Since it has come to stay, we are all interested in ascertaining its possibilities, both good and evil, and in getting from it the best obtainable results. So it is my intention to discuss briefly the influences which have given it existence and determined its function, and those which it exerts in turn upon our education 1 and social system.
Unquestionably the summer school has sprung from the stress of modern life, and its rapid growth affords significant evidence of the increasing intensity of this stress. There is much to be done, and the time is short; and, while every advance in civilization adds to the task of the individual, the span of human existence remains practically the same. The most direct and evident way to redress the balance is to encroach on the resting-time. And so we see the teacher who has spent nine months of the year in the constant and exhausting labors of his profession giving also, either as instructor or as student, the whole, or at least the major part, of his precious vacation to such work as that which we begin here today. It would not be right to characterize the tendency which in so doing he obeys as entirely healthful. One of its more extreme and worse effects is the increase of nervous ills, of insanity, and of suicide, which may be taken as a rough measure of the progress of social evolution. The spirit of the age is as insatiable as the daughters of the horse-leech. It cries out eternally for more strength and skill and endurance; him that cannot respond it punishes with failure, and on him that pushes his efforts to do so too far beyond the limits of his ability it lays the penalty of collapse. It has given us the summer school. How shall we estimate the gift?