Cyclopædia of Political Science, Political Economy, and the Political History of the United States
SANITARY SYSTEM. I. Public Health. The administrative organization of the sanitary regimen, in Europe, may be divided into three distinct systems: the French system, the English system and the German system. Other states adopt one or the other of these systems, with some modifications.
—1. The French System. This is characterized by the institution of collective authorities, under the name of councils of public health, and by the purely consultative powers with which they are invested. The right of execution belongs to the prefect, who is president ex officio of these councils. From the time of the new organization of police in the city of Paris, in 1667, the first magistrate charged with this administration, De La Reynie, formed a commission of physicians to consult upon a question relative to the making of bread. The opinions were found to be so diverse that he appealed to the faculty of medicine, which, at that time, embraced the entire medical body. In this assembly the disagreement was no less, and a commission, composed this time of six physicians and six "notable and expert" citizens, had to decide the question. Afterward, recourse was had again, more than once, to the advice of this commission, and, toward the end of the last century, the state of the sanitary police of the capital of France was relatively superior, and it filled with enthusiasm J. P. Frank, who may be considered as the founder of scientific hygiene. "I found there," he exclaimed, "a model of those courageous applications of heroic remedies, which will never escape criticism in certain German provinces. For many centuries the enlightened vigilance of the magistrates of this immense city has descended to the slightest details, and an eminently salutary (segensvoll) order of things confirms the value of most of the prescriptions which have their origin there."
—The royal society of medicine was religiously faithful to that part of its duties, the usefulness of its work, in the domain of public health, extended far beyond the precincts of Paris, and has outlived the existence itself of the illustrious company. Whoever has had to treat any subject of hygiene, notably of endemics or epidemics, appreciates with real gratitude, in the memoirs of the society published from 1779 to 1790, the instructive developments of its programmes and the wealth of material it has bequeathed to students.
—M. Dubois, prefect of police, took up these excellent traditions, when, by a decree dated the 18th Messidor, year VIII. (July 6, 1802), he established a board of health, composed of four paid members. Since then, this board, consulted as to all questions relating to public health, has seen the number and importance of the affairs submitted to its deliberation increase in proportion as Paris has increased. Its organization was fixed by the decree of the prefect of police of Dec. 24, 1832, somewhat modified in 1838 and 1844. The decree of Dec. 15, 1851, only confirmed the existing institution. The powers of this board extend only over Paris, but there are, in each of the arrondissements of the city of Paris and in those of Sceaux and Saint Denis, health commissions; with less extensive powers.
—The example given by the capital was slowly enough followed by the administrations of the principal cities of France. From 1822 to 1832, Lyons, Marseilles, Lille, Nantes. Troyes, Rouen, Bordeaux, Toulouse and Versailles were provided with boards of health. In 1836 the government thought of a general and definitive organization of the sanitary régime in France. The academy of medicine joined eagerly in this effort with a long and remarkable report by Dr. Marc; but these projects were not realized. They were revived by the revolution of February. In the midst of the ardent aspirations for the well-being of the masses, which agitated this epoch, public health could not be forgotten. A plan was drawn up under the direction of M. Tourret, then minister of agriculture and commerce, and became the decree of Dec. 18, 1848. This act applied only to the departments; it organized commissions of health in each department, arrondissement and canton, composed of physicians, apothecaries, architects and other specialists. Their powers extended over the healthfulness of the public highways, houses, workshops, schools, etc.; over the slaughterhouses, factories and other industrial establishments, the nuisances of all kinds, dangerous animals, cemeteries, epidemic and endemic diseases, as well as over epizoötics. Their powers also extended to the surveillance of the quality of the foods, beverages, condiments and medicines of commerce. The decree mentions also many other points; but, as they seem to be entirely neglected, we may pass them over in silence. In fact, the occupation of the boards of health consists chiefly, as M. Tardieu admits, in examining demands for the licensing, removing or abolishing dangerous, unhealthy or incommodious establishments, governed by the decrees of Oct. 15, 1810, and Dec. 31, 1866. The committees find at times useful auxiliaries in the physicians of epidemics and the cantonal physicians. The first, established since May 2, 1805, in each arrondissement, must, at the first request which they receive from the subprefect, go to the localities in which an epidemic has broken out, examine into the circumstances of the situation, the habits of the people, etc., which might have caused it to originate or which favor it, and prescribe the measures proper to arrest its progress, as well as the method of treatment. The cantonal physicians date from April 13, 1835, and are as yet in only a certain number of departments.
—The organization of the Comité consultatif d'hygiène publique de France was regulated by the decrees dated Aug. 10, 1848, Oct. 23, 1856, and Nov. 5, 1869. It is composed of physicians, a chemist, an engineer of roads and bridges or of mines, an architect, and various functionaries. The province of the committee extends to quarantines and to the service of the sanitary physicians established in the orient; to the measures to be taken to prevent and combat epidemics; to the improvement of the thermal establishments, and to means of rendering the use of them more accessible to invalids who are poor.
—The law of April 13, 1850, also instituted, besides, "in each commune where the municipal council shall have declared it necessary," commissions of unhealthy houses, furnished with the power necessary to bring about the purification of such houses.
—The academy of medicine is the completion of the aggregate of the institutions with which we have to deal here. It encourages by honorary rewards the study of epidemics, centralizes the results which this study produces, and presents annually, in its learned memoirs, a tableau of the diseases which have prevailed in the different parts of France. The care of propagating vaccine, and the centralization of the observations made in the establishments of thermal or mineral waters, are also confided to it.
—Italy, Belgium and Spain follow, in their sanitary system, the way of the French. But it would be departing from the truth to place these countries in the same line. In the middle ages, Italy had already preceded other countries on this road, and to-day it still occupies an honorable rank among countries which give their attention to public health.
—2. The English System. Intelligent provisions relative to the construction and maintenance of public highways, dams and sewers; regulations concerning unhealthy trades and the construction of houses, dating from the reigns of Henry VIII. and Queen Elizabeth, had fallen into disuse. Under George IV. a law declared that each person had the right to remove objects which were "to the annoyance of all the king's subjects," and "of doing one's self justice." Then it was necessary to bring long and expensive lawsuits, which were very much disapproved of by everybody. And yet there was the appearance of a sanitary police. It was confided to local juries; their organization and the services which could be expected from them may be inferred from the following example. In a district frequently ravaged by contagious fevers "of the gravest kind," the jury was composed of twelve members, of whom six were toll-keepers, one or two cheesemongers, three or four tailors or drapers, one mason, one house builder, and no physician. No one, they acknowledged themselves, knew anything of the business in hand, except how to examine weights and measures; and without the fortuitous presence of the builder, they would neither have understood. nor been able to do anything of, what was incumbent upon them.
—Such was the situation when the invasion of the cholera brought to an end this too long continued security. The tribute paid by England to the scourge was great. In one year alone she lost 70,000 individuals, of whom 30,000 were adults. This was 10,000 more men than the wars of 1800 to 1815 had cost her. And this was not all. In presence of these hecatombs, it was recalled that other epidemic diseases, almost unknown elsewhere, subjected, at all times, the English populations to a regular diminution, and it had to be acknowledged that those wealthy cities and those sunny stretches of country were as if poisoned by murderous miasmas; that those majestic rivers, the pride of the country, carried death in their corrupt waters; that the royal residences and even the interior of the palaces were filled with dangers. As soon as these cries of alarm were heard, England looked the enemy in the face, and understood that, to conquer it, radical measures were necessary.
—From 1848 new laws paved the way for a general healthfulness by means of the drainage of the marshes, the streets and the houses, as well as the establishment of aqueducts and sewers. This vast undertaking was confided to a general board of health, furnished with great executive authority and powers proportioned to the difficulties of the enterprise. In the special interest of the new sanitary police, the entire country was divided, by geological basins, into districts wholly independent of the administrative arrangements of the parishes, etc.; physicians were charged with the medical care of the poor, who were, moreover, visited and aided by a great number of relief officers—This organization appears to have been only partially successful, especially outside of the capital; complaint was made of the multiplicity of laws and authorities, one charged with the poor, another with the sewers, others still with unhealthy houses, etc. A law of 1872 (Aug. 10, 35 & 36 Victoria, chap. lxxix.; see also the sanitary act of 1866) concentrates this service in the hands, either of the municipality in the cities, or of poor boards. All power is given them to take the necessary measures and to levy taxes, to appoint and pay physicians, and to have charge of the execution of measures of sanitary police. The sanitary service comes within the functions of the board of local government, which causes its execution to be seen to by inspectors appointed for that purpose.
—3. The German System. The principle of cantonal physicians, official guardians of the public health, and expert physicians attached to the courts, charged with visiting the poor gratuitously, is everywhere in force. A hierarchy, similar to that of the administrations, binds them to a medical college forming part of the provincial authority. At the top of the pyramid is a superior committee. This system does not seem, however, to be sufficiently efficacious, at least as regards epidemics, for in 1872, the government appointed a commission to devise the organization of a service embracing all Germany, public health being within the functions of the federal government.
—Holland, Russia, Sweden and Denmark have organized their sanitary institutions after the German system.
—II. Endemics and Epidemics; Contagious Diseases; Quarantines. The diseases which have a right to the attention of the legislator and of the administration constitute three classes. They are: endemic, epidemic and contagious diseases. Endemic diseases arise from the conditions of the configuration of a country, from its meteorology, from the geological structure of its soil, from the distribution of its waters and their qualities, from its vegetation and all its products, from the food of its inhabitants, from their mode of life, from their case or their poverty. The number of affections of this order is large, if one considers them in all the zones of the globe. Here it is sufficient to cite the most prominent examples in certain climates: cretinism, with the endemic goitre, intermittent fevers, pellegra, etc. When we consider that the goitre and cretinism constitute a veritable physical and moral degeneration of man; that it is fatally propagated by heredity; that on the territory of France live more than 100,000 of these unfortunates, and that the number of them is still more considerable in Switzerland, Piedmont, Austria, etc; that the endemic intermittent fevers, in their various pernicious forms, very often carry death in their train, and when they are of an intense degree, keep entire populations in an habitual state of debility, incapacity for labor, and sunk in profound poverty, we must admit that the ravages produced by this category of evils outweigh every other danger which can temporarily threaten public health.
—Fortunately, the state can do much to improve this state of things. The drainage and cultivation of the marshes, the planting of the downs, irrigating canals, drainage practiced on a sufficient scale, are sure means of producing healthfulness. A government must not even recoil before the removal of a small population, when it is absolutely impossible to modify the topography of the localities which it inhabits, as may happen in certain narrow valleys, and mountain gorges, seats of cretinism. These great public works necessitate, it is true, very considerable expense. But public interest counsels these productive expenses as much as humanity commands them.
—Any disease which attacks simultaneously in a place a more or less considerable number of individuals, is called an epidemic. Strictly speaking, we should not have to cite examples here, for we would have to pass in review almost all the immense repertory of medical practice. We see even epidemics of erysipelas and of brain fever; as, on the other hand, we observe isolated cases of affections which we are most used to regard as being of an epidemic character, such as small-pox, cholera, etc. Epidemics belong to those cases in which society finds the compensation of the sacrifices it has undergone to increase the well-being and strength of its members even in the lowest ranks. The evil is always so much the more formidable and is so much the more extensive as it encounters the less resistance; and where can this resistance be found except in the vital energy of those who are exposed to the attacks of disease? Moreover, hygienic and healthful measures, hastily improvised when an epidemic is imminent or has already broken out, present the double inconvenience of being particularly expensive and of a very limited efficacy.
—A contagious disease is one which can be transmitted, by the contact of an individual who is already affected by it, to one or more other individuals predisposed to catch it. This definition differs essentially, we see, from the one we gave in the preceding paragraph; it establishes a well-defined line of demarcation between the two classes of diseases. There exist undoubtedly contagious diseases which are never epidemic, just as there are important epidemics into which the element of contagion never enters; for these latter, the question is only one of isolation, sequestration, quarantine.
—Antiquity, although it was acquainted with very terrible epidemics, opposed to them only a stoical courage and a few measures of general hygiene. In the middle ages only, at the same time that the frequency and violence of the "pests" took a frightful development, did efforts of direct defense against them begin to be taken. The terror which they inspired was extreme, the weapons with which they were fought were often barbarous. Society saw itself powerless to attack the evil in its source, by transforming the physical state of Europe and improving the material and moral existence of its people. It conceived the idea of closing access to its cities to the enemy, and of hemming it in, like a conflagration, when it had once penetrated there. The disease considered especially contagious, leprosy, had its permanent quarantines. Veritable centres of an unclean and crowded population, the settlements of lepers soon became themselves, by hereditary propagation, more surely than by contagion, immense centres of infection, which that heartless time ended by recognizing only one way of opposition, the funeral pile and the stake, its last argument in hygiene, as it was in politics and theology.
—The Italian republics sought, from the second half of the fourteenth century, in quarantines a means of protection against the invasion of pestilential diseases, although the greater part of these diseases, far from being the real eastern plague, were not even contagious. Milan possessed a lazaretto with nearly 500 rooms. Having at that time the monopoly of the trade with the Levant, Venice instituted, in 1403, the first maritime quarantine; Genoa followed this example in 1467. The regulations designed for these institutions were drawn up with Draconian severity, and the traces of them have been very slowly effaced. Scarcely a century ago, shipwrecked men, who were supposed to come from a port where an epidemic prevailed, were driven from the shores of Holland with cannon, and in our day we have seen pitiless instructions given to the troops who, on the frontiers of Poland and Russia, formed the sanitary cordon against the cholera. Despite a permanent sanitary cordon, maintained, from 1728, by Austria upon all its eastern frontier, its provinces were ravaged by the plague in 1738, and from 1755 to 1757.
—In France, up to the year 1822, there existed no sanitary law, although Marseilles, in obedience to the wants which its relations with the east created, had for a long time developed the institutions bequeathed by previous centuries, and had evolved from its old captains of health the magistracy of sanitary supervision no less independent than they. The invasion of the yellow fever into Catalonia soon brought about the promulgation of a law, dated March 3, 1822, followed by a royal ordinance of Aug. 7 of the same year. The precision with which, in 1830, it was believed the advance of the cholera could be followed from the delta of the Ganges to the centre of Europe, revived with new force the hope that the progress of diseases considered to be communicable might be arrested The experiment was not fortunate for the contagionist doctrines, which had been previously shaken so far as the yellow fever and the plague were concerned. Legislation had to undergo modifications, which were formulated by the royal ordinance of Aug. 17, 1847 (which instituted European sanitary physicians in the Levant), a decree of Aug. 10, 1849, and a decree of Dec. 24, 1850. Then France took an initiative, the happy influence of which must be acknowledged. She was the instigator of an international sanitary conference, formed by the various powers which have joint interests in the Mediterranean. In 1850 there assembled at Paris delegates from France, Austria, the Two Sicilies, Spain, the Roman States, Greece, Portugal, Russia, Sardinia, Tuscany and Turkey, who, after thorough discussion, decided on a project for an international convention and for sanitary international regulations. England was also represented at this congress, but she did not sign the convention which was the result of it. Adopting the advice of her general board of health, she renounced all organization intended to keep away from her shores the cholera, the plague and the yellow fever. Neither in France nor elsewhere did people dare to break, in so radical a manner, with deep-rooted ideas and apprehensions. But the new code has freed commerce from a great part of the shackles and the injury which were becoming more onerous in proportion as the circle of communications between nations enlarged.
—The imperial decree promulgating this international convention bears date May 27, 1853; the decree relative to its being put into execution is dated June 4 of the same year, and was followed by detailed instructions. After having declared that this act applied especially to the plague, the yellow fever and the cholera, the convention sets forth in principle that besides any healthy port has the right to fortify itself against a ship having on board persons affected by a disease reputed contagious, such as typhus fever and malignant small-pox. It maintains the foul bill and the clean bill: the former, for the proven presence of the disease in the country from which the ship comes, the latter, for the attested absence of all contagious disease. Every ship arriving with a foul bill shall be declared in quarantine. The latter is divided into quarantine of observation and close or rigorous quarantine. In what concerns the plague, the minimum of the quarantine is fixed at ten full days, and the maximum at fifteen. For the yellow fever, the minimum is five days and the maximum seven; for the cholera, the quarantine of observation is five full days, including the time of the voyage.
—For merchandise, three categories have been established, and they must be treated according to the class to which they belong. The execution of the prescriptions is confided to sanitary authorities, who are everywhere organized upon uniform bases. The director of health, taken when possible from the medical body, is the head of the active service. A council, composed of local scientific elements, watches over the interests of the public health, exercises a general surveillance over the sanitary service, gives advice as to the measures to be taken in case of invasion, and controls its execution.
—Besides the provisions common and applicable to all the countries signing the convention, Turkey in Europe and Turkey in Asia, as well as Egypt, are the object of particular provisions, intended to prevent the development of the plague, to stop this disease when it exists, to give notice of it, and to oppose its introduction into other countries. To this end a superior board of health has been established at Constantinople, and a sanitary board at Alexandria; foreign delegates, who must as much as possible be specialists, form a part of these boards.
—This organization is completed by the development of the institution of sanitary physicians, established in 1847, who are divided into two classes: central physicians and ordinary physicians. Appointed by the contracting powers, they preserve their independence of the local authorities, and are dependent only on the governments which appointed them. Their functions consist in studying, in its relation to public health, the country where they are, its climate, its diseases and all the conditions attached thereto, as well as the measures taken to combat these diseases; to inform the central physician of the arrondissement or district (a central physician resides at Constantinople, Smyrna, Beyrouth and Alexandria), and the local consular body and the local authorities, of everything which has to do with the general health.
—Finally, physicians, commissioned by the minister of agriculture and commerce, are shipped upon the steamers, which are the most active intermediaries between France and the Levant. These men are there, as so many posts of observation, whence they must signal the slightest suspicious disease which may arise during the voyage.
M. BORCHARD, D. M. P.
Return to top