SUMMARY REPORT OF THE BOARD.

To His Excellency, SHELBY M. CULLOM, Governor:

SIR: A considerable portion of the Fifth Annual Report of the STATE BOARD OF HEALTH has been in type for some months; but various causes have combined to delay its publication until the present time. Among these was the necessity for condensing the vast mass of data, collected by the Secretary, concerning the SmallPox Epidemic of 1880-82, and concerning Vaccination in Illinoistwo related subjects which have occupied a large share of the attention of the BOARD since the winter of 1880-81. To have published this information as at first proposed, with details and tables in extenso for each county, would have swollen the volume far beyond any admissible limit. Some 400 octavo pages of tabular statements and abstracts concerning the vaccination of school-children alone-of which specimens are given on pages 387-390, inclusive, would have been necessary to give what has finally been condensed into about 60 pages, in much more accessible form. An immense amount of work has thus been done in the preparation, not only of these 60 pages, but of much other matter, and which work does not show in the completed volume, but the extent of which may be inferred from this illustration.

It is hoped, however, that some amend is made for this delay in the character of the Report now presented. So far as the BOARD is aware, no epidemic in this country has been so widely and intelligently observed, and so faithfully recorded, as the Small-Pox Epidemic of 1880-82 in Illinois. Nearly 500 individuals, embracing attending physicians, and municipal, town and county officers, have contributed, each in his proper capacity, to the information furnished as to the introduction of the contagion, its mode and extent of propagation, the measures resorted to for its suppression and their result, the cost, actual and constructive, and other noteworthy features. In like manner, the vaccinal history of 304,586 public-school children-based upon physicians' certificates of vaccination-has been furnished by over 8,000 teachers; 493 physicians have reported the results in 187,223 vaccinations at all ages; and the vaccinal status of 18,708 inmates of public institutions, private and parochial schools, colleges, academies, etc., has also been given-making an aggregate of 510,517 individual vaccinations and revaccinations, concerning which the details of results with different kinds of virus,

at given ages and in each sex; of the individual experience of vaccinating physicians; of the relative merits of humanized and of bovine virus; of noteworthy complications and results; of vaccinal and post-vaccinal erysipelas, and alleged disasters; and other matters of interest, are given in something over one hundred pages of the Appendix.

Small-pox invaded 77 out of the 102 counties of the State during its epidemic prevalence, causing an aggregate of 8,856 cases and 2,973 deaths, and involving a cost of nearly four and a half millions. of dollars, exclusive of the value of human life lost and the disabled condition of many of the survivors. As early as March, 1881, when the disease had appeared at less than half a dozen points in the State outside of Chicago, the BOARD issued its first circular, calling attention to the indications of a wide-spread epidemic, and urging the necessity of vaccination and revaccination as the only means of security. Little heed was paid to this first warning, and the fact that only seven new localities were infected during July, August and September, still further diminished its effect. Study of the situation, however, and past experience confirmed the view first taken; and in November of that year the BOARD issued an order providing for the vaccination of all public-school children before the 1st of January, 1882, and supplemented this by efforts to secure the vaccinal protection of different classes of the community, through circulars, orders and instructions, addressed to State, county, township and municipal authorities, corporation officers, superintendents, managers and other employers. These efforts were finally attended with such success that, on the 24th of January, 1882, the Secretary was able to say, "I doubt if the people of any other State of equal age are as well protected against small-pox as those of Illinois at the present time";* and the degree of vaccinal protection thus secured, (mainly within sixty days), coupled with a general familiarity with the BOARD's instructions as to the methods of dealing with an outbreak, warranted the prediction then made, to-wit: That the epidemic, although more widely spread than at any previous time, was practically under control. As a matter of history it is now known that this was the culminating point of the epidemic, and within twenty days after the various agencies set in operation by the BOARD had fairly begun to act, there was a decline of nearly 59 per cent. in the number of cases, whereas the average reduction, from the highest point reached in other epidemics for 32 years previous, had been only a little over 15 per cent. As is elsewhere shown, this implies a constructive saving of 320 lives, 1,517 cases, and over two and three-quarter millions of dollars.+

In the hundred and fifty-odd pages devoted to this subject, will be found a succinct history of the inception and progress of the epidemic in Illinois; the measures employed for its suppression; the details of local outbreaks; and the lessons taught by a study of the vast mass of facts and figures contributed by numerous observers in all parts of the State. Forming a portion of this section of the Report is a paper demonstrating the connection of unpro

* See summary of the situation, pages 213-214 of Appendix.

+ See Cost of the Epidemic, pages 218-220, ibid.

tected immigrants with the origin and continuance of small-pox epidemics; and urging the sanitary surveillance of immigrant travel from the port of arrival to the point of ultimate destination; such surveillance to consist of repeated inspections, vaccination of the unprotected, systematic observation of suspicions sickness, prompt isolation of discovered small-pox or other contagious disease, and enforcement of the necessary measures to prevent its further spreadthe system to be under the control of, and the expense to be borne. by, the National Government.

From June to December, 1882, such a system was in operation in the area of country between the Canadian frontier and the port of Baltimore, and extending westward to the Mississippi river. It was inaugurated by the National Board of Health, as a result of the Small-Pox Conference, held in Chicago in June, 1831, at the instance of this BOARD; and the Secretary of the BOARD acted as Supervising Inspector of the Western District, embracing the States of Indiana, Illinois and Missouri. An aggregate of 115,057 immigrants, arriving in the District during the seven months, were inspected, and 21,618 were here vaccinated or revaccinated, in addition to 28,408 vaccinated or revaccinated by the Eastern inspectors. In other words, 47 per cent. of all immigrants landed in this country during the year 1882-and the vast majority direct from smallpox localities in Europe-were susceptible to the disease, capable of conveying the contagion into the communities among which they might settle, and of becoming its victims themselves. Including Chicago, there had been 57 separate importations of small-pox into Illinois by immigrants during the seven months preceding the inauguration of this Service. With one solitary exception, early in June, there was no further immigrant introduction of the disease into the State during the succeeding seven months--although many cases were discovered in transit and removed from the trains direct to hospital, in every instance without further spread of the disease. The same results were obtained throughout the rest of the Northwest, only one other outbreak from immigrants being reported -namely, in Minnesota-during the month of August.

Want of means compelled the National Board to order the service discontinued on the 15th of December; but, in the hope that Congress would make the necessary appropriation for its further maintenance, the inspectors were induced to remain on duty until the close of the year. Congress has, however, failed to make any provision for such a system in the future, notwithstanding its demonstrated value. The Secretary of this BOARD visited Washington twice in the interest of the Service, and appeared before the House and Senate committees to explain its details and benefits, not only to Illinois and the Northwest, but to the entire country; urging that its operation, or some equivalent, was indispensable to the exclusion of imported contagion in the absence of a uniform administration of maritime and boundary quarantines. Alike in the prevention of the spread of yellow fever or Asiatic cholera from one State to another, as in the exclusion of small-pox, an authority independent of State lines, but co-operating with, and aiding State and local health organizations is essential to the perfection of the sanitary defense of the Nation. A summary of his argument is given

in the report of the proceedings of the Sanitary Council of the Mississippi Valley, pages 526-28 of the Appendix. The BOARD has formally memorialized Congress to the same effect, and has sought to interest the Illinois Senators and Representatives in the matter, feeling assured that, whatever the specific agency employed-whether the National Board of Health, or the medical departments of the Government-the only adequate authority is the National authority, as the only proper support is the National Treasury. This BOARD is firmly convinced that, sooner or later, the United States Government must not only assume plenary control of exterior quarantine, but also provide for a permanent system of co-operation with State and local governments in the administration of inter-State quarantine in order, on the one hand, to prevent the introduction of exotic epidemic diseases-small-pox, yellow fever and cholera-and, on the other, to prevent their spread from State to State, along the great intra-national highways of travel and commerce.

DURING the year the usual quarterly meetings have been held, the January and October meetings in Springfield, and the April and July meetings in Chicago. Owing to the pressure of details connected with the small-pox epidemic, the January meeting was adjourned, after a prolonged session, on the 19th, at Springfield, to Chicago, where a two days' session was held in March. At the April meeting the annual examination of non-graduate candidates for licenses to practice was held, resulting in the passing of six out of a class of sixteen. The schedule of questions submitted at this examination will be found in the abstract of proceedings of the April meeting.

While conforming to the letter of the law, which prescribes that examinations shall be of an elementary and practical character, the spirit of the entire act is believed to be fulfilled by exacting, from year to year, a stricter test of the candidate's qualifications as a practitioner. Hence, it will be found, by comparing this schedule with those of earlier years, that a higher standard of qualifications is now deemed necessary to obtain a certificate. This accords with the improvement in medical education generally, and is simple justice to the medical colleges and the public. It is not conceived by the BOARD that the provisions of the Medical-Practice Act, whereby non-graduates may obtain licenses or certificates, were intended to furnish a cheap and easy entrance to the practice of medicine in the State; nor to deprive the public of the attainments and qualifications which are best acquired by attendance upon the full curriculum of study at a properly-equipped college, with the necessary clinical facilities for hospital and dispensary practice. In accordance with this view, the successful candidates at the BOARD examinations of recent years would have been awarded diplomas at any medical college in the country, with, probably, only two or three exceptions. As a matter of fact, the great majority of those who obtain certificates by examination subsequently do graduate from some reputable college, in accordance with the recommendation of the BOARD; and from this, among other causes, the proportion of non-graduates to graduates in Illinois has been reversed since the passage of the Act; so that now, instead of there being an excess

of the former over the latter, the proportion is less than one nongraduate to five graduates-a reduction of from 3,800 non-graduates at the time when the law went into effect, to about 650 at the close of 1882.

The BOARD has recommended, not only to its licentiates upon examination, but also to non-graduate practitioners exempt by the ten years' prior-practice clause, that they attend lectures and procure diplomas from legally-chartered medical institutions in good standing, if for no other reason than that there is an increasing demand by the public for the higher qualifications of such institutions in applicants for places of public trust and profit, as well as in general practice.

CERTIFICATES, authorizing the practice of medicine and surgery in Illinois, have been issued to 473 physicians during the year, being 57 less than in the preceding year. Of these 450 were based upon diplomas of reputable modical colleges; 17 upon length of practice in the State prior to the passage of the Medical-Practice Act; and 6 upon result of examination.

Licenses to practice midwifery have been issued to 62 midwives; 36 based upon certificates, diplomas or licenses (mainly foreign); 13 on term of practice in the State; and 13 after examination by the BOARD.

There have been, in all, 7,034 certificates to physicians, and 732 licenses to midwives-or a total of 7,766 certificates and licenses issued since the organization of the BOARD in July, 1877.

Applications for physician's certificates were refused in 143 cases during the year, for some one of the following causes: Presenting diplomas of institutions not recognized by the BOARD as in good standing; unsatisfactory personal or professional antecedents, habits or associations, warranting the charge of unprofessional and dishonorable conduct; intent to practice in an unprofessional and dishonorable manner-as by claiming to cure incurable maladies, to possess unusual skill, experience or facilities, and similar claims involving deceit and fraud upon the public.

One certificate was revoked on evidence that it had been fraudulently obtained upon a stolen diploma;* and three others on proved charges of unprofessional and dishonorable conduct. One certificate, previously revoked by the BOARD, was restored upon receiving guarantee of intention to refrain from the objectionable practices which had caused its revocation.

A number of charges against practitioners (43 during the year) have been investigated by the full BOARD: but, in the majority of instances, these cases are satisfactorily disposed of by the Secretary without being pushed to a formal investigation. Reports, verbal or written, are made of such cases to the BOARD at its meetings; but, unless some important interest is to be subserved, no publicity is given to them. Generally, a letter calling attention to the offense charged is sufficient to secure its correction or abandonment of the

* See Henry A. Luder's case, page xl.