c c<< **«>< «ms« ,;< cccc< - < r \ «s:<: r - < * at? «..«: <: .5 c ^<-3tsjs&Mat<-' ocro c« ch all hope to enjoy, the State has an interest that all should reach maturity, and then labor and contribute to the common strength and wealth as long as possible. * Calculated from the National Life Tables. Norway. — " Norges omcielle Statistik, Folkmcengdens Bevosgelse," 1856-65, p. 217. Sweden.—" Sveriges Officiela Statistik, Befolknings Statistik," 1856-60, p. 75. England.—" English Life Table No. 3, p. 24. Dr. Farr in Registrar-General's Re- port, 1864." Hanover. — " Bevolkerung und den Lebensdauer," 1846. Ta. B. xxvii. Ireland. — Census of Ireland, 1844, p. lxxx, &c. United States. — L. W. Meech — Life Table Males, in Insurance Report, Mass., 1868, p. ciii. 340 STATE BOARD OF HEALTH. [Jan. In this economical view, man may be considered as a pro- ductive machine, which creates property or sustenance for itself and the Commonwealth. Then a child that is born is but a vital machine begun. But it is powerless and ineffect- ive, and must be built up and developed and grown and trained for work. This is a perilous and doubtful process of twenty years. It seems, by table on page 339, that in Norway, the most favored country, 25 per cent, perish in the forming period. In the United States, 35 per cent, of the males, and in Ireland, 51 per cent., fail to reach maturity. In Norway, only 34 per cent. ; United States, 24 per cent. ; and in Ire- land, less than 9 per cent, enjoy the full period of working years. In the ideal state, every twenty years expended in the development of manhood and womanhood, results in the completion of a matured laborer. But in the actual ex- perience of the world, a varied portion of this expenditure is lost by death in this period. In the production of dead machinery, the cost of all that are broken in the making is charged to the cost of those which are completed, and the prudent manufacturer charges all that he expends on the failures to those that succeed, as a proper part of the cost. Thus, if two fail, when half finished, for every one that is completed, the cost of the finished one is doubled ; and this increase of cost is in proportion to the expenditure which has been made or lost on those that broke down in the process. So in estimating the cost of raising children to manhood, it is necessary to include the number of years that have been lived by those that fell by the way, with the years of those that pass successfully through the period of development. With this view, the following table has been prepared to show the number of years that were lived by children and youth under twenty, for every 1,000 that reached the fulness of maturity : — * * Calculated from the Life Tables. 1874.] STATE BOARD OF HEALTH. 341 COUNTRY. Years spent under 20. Per cent. Loss. Norway, . 2,142 7.1 Sweden, . 2,182 9.1 England,. 2,192 9.6 America, . 2,233 11.16 United States, . 2,251 12.55 France, . 2,327 16.35 Ireland, . 2,514 25.70 As the great majority of those who were lost died in infancy and early childhood, the sum of the years that they had lived was small compared with that of those who passed safely through the whole period. But yet there is a great difference in this respect in these several countries. The loss iu Ireland was 120 per cent, greater in the first year, 75 per ceut. in the first five years, and 120 per cent, greater in the period of growth, than in Norway. Financial Yiew t . Beside the pain, anguish and sorrow caused by these early deaths, they deeply concern the State as a matter of political economy. Simply as a vital productive machine, a child at any age is worth the cost that has been expended on him for his support and development. The cost of the support and training of children is widely various, from that which sustains bare animal life, to the lavish luxury of the opulent; but taking the lowest estimate for the laboring population, it, on an average, costs not less than fifty dollars a year. Then a child of ten is worth $500; and at maturity $1,000, and the death of either of these is so much loss to the Commonwealth. Both English and German political economists calculate the value of man at all ages, from childhood to old age, and come to similar conclusions from very different bases. Death of Children and Youth in Massachusetts By the Thirtieth Report of Mortality of Massachusetts, page 146, we find that in the seven years, ending with 1871, 342 STATE BOARD OF HEALTH. [Jan. 81,029 died under twenty in the State. Their ages are all given in years to the fifth, and in quinquennial periods, from five to twenty. With these facts and the life table, it appears that the whole sum of their lives amounted to 292,762 years, which, at $50 a year, had cost $14,638,100. This sum had been paid from the estates, income or earnings of their fami- lies, and diminished to that extent the income or the capital of the Commonwealth. This sum, invested in the life of these 81,029 children and youth, was lost in the course of seven years, and so much, or an annual average of $2,109,157, was lost to the State by premature death. The blessing which these perishing children were to their families in their shortened lives, cannot be measured nor told in any language ; the heart alone knows the jo} r at their ap- pearing and the agonizing sorrow at their early departure. But the Commonwealth only knows these as the promise of usefulness which was not and never can be fulfilled. Working Years. The life tables of the several nations show that all fall short of their ideal in various degrees. The average duration of effectiveness enjoyed by the people, between twenty and sev- enty was,* in — Norway, . . . . . 39.61 years. Sweden, . . . . . 38.10 United States, males, . . . 37.46 Hanover, . . . . . 35.81 England, 35.55 France, 32.84 Ireland, . . . . . 28.88 Thus the productive efficiency fell short of its fulness 20.78 per cent, in Norway, 23.7 per cent, in Sweden, 25.08 per cent, in the United States, 28.38 per cent, in Germany, 28.9 per cent, in England, 34.3 per cent, in France, and 42.24 per cent, in Ireland. * Calculated from Life Tables. 1874.] STATE BOAED OF HEALTH. 343 Death in Working Peeiod in Massachusetts. In Massachusetts, during the seven years, 1865 to 1871, 72,727 died in their working period. In the fulness of health and completeness of life, they would have had opportunity of laboring for themselves, their families and the public, in all 3,606,350 years, but the total of their labors amounted only to 1,681,125 years, leaving a loss of 1,925,224 by their premature death. This was an average annual loss of 276,461 years of service and cooperation. Thus it appears that in Massachusetts, one of the most favored States of this country and of the world, those who died within seven years had con- tributed to the public support less lhan half, 46.07 per cent., of what is done in the best conditions of life. Sickness. Nor is this loss by early death all that the Commonwealth suffers in diminution of productive power in their period presumably devoted to profitable labor. Even while men and women live they are subject to sickness, which lays a heavy tax on their strength and effectiveness. No exact account has been yet taken of the amount of sick- ness in this country. But the experience and investigations of other nations enable us to approximate this matter. In Great Britain there are many organizations under various forms and names, as Benefit Societies, etc., which include many hundred thousand members of all ages. A prominent purpose of their association is to support each other, when deprived of the power of labor by sickness. For this pur- pose, each member makes certain contributions weekly or monthly to a common fund, and in return receives a certain weekly amount, varied according to the contribution or other circumstances, when sick or otherwise disabled from labor. The treasurer takes account and makes record of the time and duration of the sickness or disability, with other facts, as age, sex, disease, the occupation of the applicant, etc. By this means a full record is made of all the sickness and inju- ries of a very large portion of the men, women and children in every part and in all the employments of the kingdom. The government, wishing to measure the productive power 344 STATE BOARD OF HEALTH. [Jan. of the people, gathered these records, made through many years, and placed them in the hands of the best investigators and calculators to analyze and combine them and show the proportion and amount of sickness that fell on males and females, children and adults in every age from childhood to the last years of life, and in the various occupations and con- ditions of society. The results of these labors are published in the Parliamentary Reports on Benefit Societies. Finlaison, Neison, Ansel, Macullagh and other statisticians have writ- ten very instructively on this subject. Thus the amount of sickness and the proportions of time lost in consequence of sickness or disability at each age is shown as it existed through many years, and is the basis of expectation for people in like conditions and circumstances. It is not to be sup- posed that every individual will have just his quota of sick- ness in every year, nor is it said that this has been each one's experience. But these are the averages of all. American Health Assurance Companies. Some years ago there were several Health Assurance Com- panies in operation in this country, offering for certain pre- miums, varied according to age and circumstances, to be paid at fixed periods, to pay out certain amounts a week, whenever the assured should be sick. For want of any record or knowl- edge of the experience of the people in this country, they assumed the British rates as their guide in fixing the amounts that should be paid in as premiums and returned in time of sickness. On this basis they adjusted the rate of premium and relief in such a manner as they supposed would leave the companies a reasonable profit. But unfortunately, in the re- sult, there was not only no profit, but a loss, and the compa- nies were compelled to close their offices and cease to insure. The premiums paid in were insufficient for the allowances promised in the time of sickness. The demands were greater than they had calculated ; there was more sickness than the British records showed as their experience in England and Scotland. It is safe, then, to assume that the amount of sickness or disability is, at least, as great in the United States as it is in Great Britain, and the rates found in the British reports may 1874.] STATE BOARD OF HEALTH. 345 be used as a means to determine or approximate the amount of sickness in Massachusetts among the people of the work- ing age, 20 to 70. At the last census, in 1870, there were 796,252 of this class in this State. The British rates of sickness for each sex, at each age, are given by Finlaison,* in days for the males, and in weeks and fractions of a week, by Neison,| for the females. Applying these several rates, in each of the quinquennial periods from 20 to 70, to the population of Massachusetts in 1870, it appears that there was in that year among the people of the working productive age a total amount of 24,553 years and eight months sickness or disability, when so much oppor- tunity for labor was lost to our people. This is not all the loss of labor and production by means of sickness. These rates are from records of the treasurers of the benefit societies of the periods during which they paid money in aid of the sick members. Their rules allow no payment for periods short of a full week. It is presumed that for a disablement of a period less than a week the mem- bers can take care of themselves, and will need no aid from the society. The records, then, do not include the manifold lesser ailments that are frequently occurring, — colds, headache, temporary rheumatism, slight injuries, toothache, — which sus- pend the power of labor for one, two or more days, yet less than a week, and therefore not recorded. Beside these there are many slight ailments that are insufficient to confine one to the house, or even keep him from his workshop, yet im- pair his energy and lessen the effectiveness of his exertions. There is another and remarkable exception to the fulness of the reports of sickness. The government report says that in this analysis, "nothing but sickness, in the true sense of the word, — that is, sickness incapacitating from labor, and requiring constant medical treatment, and of limited duration, as contra-distinguished from chronic ailment, and mere decreptitude, — was considered to be sickness ; for instance, slight paralysis, blindness, mental disorder or senile infirmity * Parliamentary Report on Sickness in the Friendly Societies, August 16, 1853, p. xxvii. f Contributions to Vital Statistics, p. 410. 44 346 STATE BOARD OF HEALTH. [Jan. cannot, it was thought, be fairly classed with the sickness commonly prostrating the workman, and for relief under the ministrations of which he seeks the aid of a benefit- club."* It is manifest, then, that very much of the disability that prevents work and causes loss of production is not in the record, and that much of the actual loss, by impaired health and energy, fails to be noticed in the calculation, and is there- fore not included in the rates herein quoted from the British reports. There is another consideration. These friendly societies, being practically health insurance companies, must sustain themselves, and make their payments out of constant and sufficient assessments. They are not charitable institutions, except so far as the recipient of charity and aid has already paid that which he asks. None but those who can make the regular payments are admitted ; and none are retained, except as long as they comply with the conditions of unfailing contributions. Hence the poorest, the idle, the profligate, the intemperate, those who earn but little, or who spend their earnings in drinking, are excluded, or, if admitted, are dropped from the roll. These are the classes who have the most sickness. The same rule would exclude many feeble lives, — persons suffering from hereditary disease or chronic ailments, — consumption, asthma, epilepsy, — who either never had health sufficient to become contributors, or fail to ask for admission before they became so impaired. From all these causes and conditions, a large portion of the disabilities of the people does not appear on their records, and the rates which are found on the tables, on which these societies base this class of their operations, and on which our health assurance companies endeavored to carry on their work, do not signify the whole extent of the disabilities, either there or here. It is estimated by the English observations and calculations that for every death there are two constantly sick ; that is, 730 days' sickness and disability for every death. It appears, then, that in Massachusetts, in 1870, there was a loss in the effective period equal to 276,461 years by prema- * Pari, paper, August 12th, 1853. 1874.] STATE BOAKD OF HEALTH. 347 ture death, and 24,553 years by sickness, making 301,014 years' loss of force on productive power in a single year. There was the same proportionate loss in the previous year, and there is no reason to hope that it will not be the same in ratio of the numbers of the living for years to come, unless some happy change shall come over the sanitary habits and condition of our people. Comparison of Periods of Development and Labor. If there were no deaths in this period of growth, — if none fell in the process of development, and none in the effective period, — then every twenty years expended in the early stage would produce a mature man or woman, and be followed by fifty working years. But, as already seen, much time is expended on those that are lost in the period of growth, and the period of labor is shortened by the deaths between 20 and 70. Having the number that are lost in the maturing period, and the number of years that they have lived, and also the number that die in the effective stage, and the dura- tion of their labors, it is easy to draw a comparison between them, and show the cost, in years, of creating and maturing human power, and the return which it makes in labor in compensation. By this double measurement of life, in its incompleteness and in its fulness, it is found that for every 1,000 years expended in the developing period, upon all that are born, both those who die and those w 7 ho survive the period from birth to 20, the consequent laboring and productive years are, — In Norway . 1,881 years.* Sweden, . 1,749 " England, . 1,688 " Hanover, 1,686 « United States, males, 1,664 " France (1806), 1,398 " Ireland (1841), 1,148 " It costs less to develop a man in Norway than in any other * Calculated from Life Tables. 348 STATE BOARD OF HEALTH. [Jan. country. It was shown in the article on Infant Mortality,* that a larger proportion of infants survived their first year in Norway than elsewhere, and these children, when grown, have the greatest power of endurance that the records of life and death reveal. Comparing those people who are thus endowed with persistent vitality with those of the opposite ex- treme, — the Irish at home, — it is seen that a thousand years spent in the growing period produce 63 per cent, more of working life among the Scandinavians than among the Celts. In this respect the Norwegians are 13 per cent, more favored than the Americans, and the Americans 44 per cent, more favored than the people of Ireland. The World's Work done between Twenty and Seventy. In this period of life, — twenty to seventy, — shortened as it is by premature death and weakened by sickness, all the work of the world is planned, directed and performed. This age gives to the nation its physical and mental power, its wisdom, and its effectiveness. It directs the affairs, public and private. It earns the income, produces the sustenance, and creates the wealth. Nearly all the property, capital and value in the world are created by human power in this period. Nature and Man Partners in Creation of Wealth. In this work — the creation of wealth — nature and man are joint partners and cooperate together. Nature contributes the material, man gives it value by putting it in such form, combinations and position as to make it available. The con- tributions of nature are worthless as they lie in her hands ; but they have a prospective value, in proportion as they can be manufactured, by the power and skill of man. The earth, air and water produce vegetation (tree, herb and fruit) , but these are useless, and nearly worthless, to the world until the human hand shall convert them and fit them for use. In the simplest matter of property, the tree standing in the forest has a small price. In Massachusetts, in various places, it is sold from fifty cents to two dollars a cord. The wood- man cuts it down and divides it into parts fit for transporta- * Massachusetts Fourth Report Board of Health,.1873, p. 193. 1874.] STATE BOARD OF HEALTH. 349 tion, and thus adds 50 to 100 per cent, to its value. The teamster carries it, on his sled or his wagon, to market, and thereby increases its value from $5 to $10 a cord ; the wood- sawyer then divides it into portions fit for burning, and then it is worth $7 to $12 a cord. Of all this value nature con- tributes but a small proportion, and the brain and muscle of man gives the rest. This disproportion of contribution is increased in the production of other forms of wooden merchan- dise. The fine woods — mahogony, rosewood, black walnut-— are found in distant forests, some, in the tropics, of difficult access. They are brought within the reach of mechanical art by ships, railroads and horses ; then they are wrought into furniture,' musical instruments and ornaments, with skill and force of handicraft; and when, at last, they appear in forms of chairs, bureaus," pianofortes, flutes, articles of graceful adornment, etc., they have a value in the market, compared with which its worth in the living forest is an almost inappre- ciable trifle. The metals in their manifold forms constitute a very large part of the world's pecuniary capital. Nature furnishes the original raw material of these in the ores of the earth. The ore of iron is often deep in the recesses of the ground, inac- cessible except through pits and shafts, which must be made by the power of human labor, digging through the loose earth and blasting through rocks. The ore is removed with great labor from its bed and brought to the surface of the earth, submitted to the process of metallurgy, and at length is made into bars for the smith's and the manufacturer's use. Finally, through the process of the shop and the factory, it is converted into articles of hardware, locks, nails, wheels, machinery, etc. In all these processes human skill and labor add so much to the value of the material, that what originally had hardly a price has become a small fortune. The " New American Cyclopedia" (IX. , 589) , says, a bar of iron worth $5 is worth $10.50 in horseshoes, $55 in needles, $3,285 in pen-knife blades, $29,480 in shirt buttons. In this property of $29,480 the iron represents only $5 and labor $29,475. And carrying the analysis of value farther back to the ore in its buried place in the earth before the soil had been removed from the surface, or the strata of rock blown 350 STATE BOARD OF HEALTH. [Jan. and broken from about it, or even a road had been made from civilization to the ore-bed, it is manifest that human labor has given most of the value of the iron bar, and a few cents, more probably a few mills, would represent the total value of the ore in its original position. Then these few mills' worth of the natural ore is but the nucleus around which the labor of man may gather value a hundred fold, thousand fold, ten thousand fold ; and this is the proportion that the joint partners — nature and man — contribute to the capital finally vested in the merchandise of iron and steel. Buildings. The capital in buildings, dwellings, shops, factories, and of many other kinds, which is one of the great elements of the world's wealth, — these, like others herein mentioned, are the handiwork of man. Nature gave the lumber in the living tree, in the remote for- est; the marble, granite, sandstone; the lime for the mortar in the subterranean, and, in large portion, distant quarries ; the brick in the clay-pit ; the iron for the nails, screws, hinges, locks, etc. ; the copper, tin, lead and zinc, in the original ore in the earth ; the elements of the paints also in their raw and uncompounded state, before the mind of man had devised a way to reach them, or the hand of man had lifted a shovel, spade or pick-axe to take possession of them. It is plain that in this great property, as elsewhere, the analysis of the origin of value shows that it is nearly all the result of human labor, — the work of the hand guided by the brain. ' * Effective Population in 1855, 1865 and 1870. In this State the numbers of the effective population were, — In 1855, 626,476* 1865, 709,542* 1870, 828,448| Who did, or presumptively could, by their labor, contribute to the income and capital of the Commonwealth. * State Census, 1855 and I860, t National Census. 1874.] STATE BOARD OF HEALTH. 351 Productions and Valuation of Massachusetts. In Massachusetts the total valuation of the taxable property was,* — In 1865, . . . . . $996,841,901 1870, 1,417,127,376 1872, 1,696*599,966 The productions of industry, agricultural and mechanical, — In 1855, were .... $295,820,681f 1865, " . . . . 517,240,613 All these statements are but approximations to the truth. The valuation includes only the taxable property, and omits that which was not taxable. These exceptions are large. They include all public property, belonging to the State, counties and towns, public buildings, roads, streets, and United States bonds. These would swell the valuation to a much larger amount. But it is sufficient for the purpose to say that there was a cap- ital in the State amounting, in 1865, to $991,841,906 in the care of 709,542 people of the working age, and in 1870 there was a capital of $1,417,127,376 in the care of 828,448 people to use and utilize it, and that in 1865 these people produced or put in condition of use $517,000,000 worth of property. This was an average of $729 for each one between the ages of twenty and seventy. These amounts of production include both the estimated value of the raw material used *n»the cost of labor in the production, in the total value of the articles when they passed out of the hand of the manufacturers. In this way some articles are valued more than once, as the leather, which is valued and included in the productions of the tannery, passes into the hands of the ^oemaker and har- ness-maker and is again included in the production of shoes and harness factories. So also paper re-appears in publishers' productions; hinges, nails, screws, doors, sashes, blinds, etc., in the value of buildings ; cloth in clothing. * State Reports : Taxation, Property, etc. t State Reports, 1855-1865. 352 STATE BOARD OF HEALTH. [Jan. It is impossible, from the returns, to make corrections for this repetition, although the separate town reports and the county summaries give the values of the materials used, leav- ing it to be inferred that the remainder of the production is to be accredited to labor, rents and interest, yet this is generally for individual articles, of which in this respect no summary is given. In some manufactories the cost of the new material is large in comparison with that of labor. The material of clothing costs Goods made, Boot aud shoe stock, Goods made, Woollen stock, Goods made, $11,000,000 17,000,000 35,000,000 53,000,000 35,000,000 52,000,000 In some others, the cost of material was about half the value of goods made, and others the labor was the main cost of the whole. In farming the production is given with no cost of material. For want of an exact statement it may be safe to give $300,- 000,000 as the approximate amount of labor expended in the productions of these $517,000,000 in 1865. But it must be further considered that this includes only the labor expended on visible articles of vegetation or manu- facture. Even in these employments there are many occu- pied whose labor sends no products nor wares to market. The repairs of buildings employ many carpenters, masons and painters. The repairs of vehicles and harnesses gives occupation to many coach and harness makers. Jobbing blacksmiths, tinmen and many other mechanics render great service to the community, which does not enter these records. There are manifold mechanic shops which are not establish- ments, and are not included in the report. No note is taken of tailors, dress-makers who go from house to house, nor of personal and household service, the men and women of all- work ; the cook, the washerwoman, the hostler, the day la- borer, the stone-wall builder, nor of the laborers on public works, railroads, highways, streets, building making and repairing; nor of all the earnings of hotels, boarding-houses, 1874.] STATE BOAKD OF HEALTH. 353 of professional men, of teachers. These occupy no small por- tion of the people, who create value in their respective ways. Their earnings are not, and cannot well be, stated in the form of this report; but if added, they would very greatly swell the gross amount, and carry it with the earnings therein indi- cated up to the full $517,000,000 given. Eelation of Laboe and Capital. All this capital, $991,000,000 in 1865 and $1,696,000,000 in 1872, in Massachusetts, is intrusted to the care of the effect- ive classes, who utilize it, and produce the value already stated, earning thereby sufficient for the sustenance of themselves and their families, and to increase the capital of the Common- wealth over $400,000,000 in the five years, 1865 to 1870, and $279,592,590 in the two years next following, 1870 to 1872. The production by human agency is very great in propor- tion to the capital, and both production and capital increase rapidly. In the ten years, 1855 to 1865, the production increased 75 per cent. In the ten years, 1861 to 1871, the value in- creased 73.79 per cent, and in the five years, 1865 to 1870, this increase was 42 per cent. The amount of production accomplished by those within the laboring period, abridged and burdened with sickness and disability, indicate the amount of vitality, health and strength enjoyed by them between early maturity and the beginning of old age. Moral Aspects of Health. In this paper, thus far, account has been taken only of the productive power of the people, and this is measured by the length of the effective period which they enjoy, and their financial results. These are the only facts in this connection which are recorded and given to the world. They are the only reliable means of comparing the ideal and desirable life with the actual experience. They are the facts on which states and governments necessarily rely when they estimate their own worth and power, and when they compare them- selves with each other. Man's physical energy and power of creating property, as thus described, although the most necessary element in his 45 354 STATE BOAKD OF HEALTH. [Jan. earthly being, is not the whole of human life. But in this connection, with its gains and its losses, it may be taken as an indication of the proportion of comfort and happiness that is enjoyed or lost through his other and higher elements con- nected with the intellectual and moral nature. The pleas- ure of mental and spiritual culture, of domestic and social affections, — all that elevate man above the earth, — are not to be measured by the financial scale ; but they are measured by their opportunity and duration, which are the same for them as for labor. All of man's enjoyments, both physical and spiritual, in this life, are multiplied by lengthened years and diminished by premature death. It is natural for all men and women of sound mind to hope to possess a fulness of life, and to retain their strength to the last years of old age. Man is a religious being. Eesignation to the will of the Creator is a prominent element of his spiritual nature. He accepts the conditions of life, — seemingly established beyond power or expectation of change, — and he looks for death, at any moment, from the first, when infancy dawned, to the last, when a century or more of years shall have passed over him here. When his friends are taken from him, he submits to the unalterable decree with mingled sorrow for the loss and thankfulness that so much had been granted. Nevertheless, all hope for length of days, for complete development and maturity, and for the full opportunity of labor in their strength, and for deferred and protracted old age, and that they may, at length, lay themselves down to rest after having done all of life's work, and enjoyed all of life's blessings, that earth can afford. Interest of the Government in Health. It is manifest, then, that the first and largest interest of the State lies in this great agency of human power, — the health of the people. Herein is all its strength. This creates and manages all its wealth, and the chief responsibility of the gov- ernment is to protect it and, if possible, to enlarge it and make it more and more productive. But here the govern- ment, the representative of the State, very naturally asks what it can do in this matter. There is apparently no way nor op- 1874.] STATE BOAED OF HEALTH. 355 portunity for its interference. It would gladly prohibit fevers and all other diseases, if it would have any effect. It pro- hibits theft and murder, and is generally obeyed. But here it feels powerless. It cannot prevent the attack of sickness, nor resist its destructive force. It cannot arrest the hand of death, nor prolong human life by any act of legislation. All this is in the hands of a higher power, whose messenger is disease, and whose agent is death. What and where, then, is the responsibility of the State for the health of its mem- bers? Whatever may be the interest in, or sympathy with, the suffering and the sorrowful, when health fails or life is taken away, it is powerless before the causes, and, with the mourning people, must bow in submission to the fiat of the inevitable. There is a double error in this reasoning. First, life is not a fixed quantity to which it must come, and beyond which it cannot pass ; second, the body politic, both in this and in rtner countries, sometimes directly and sometimes uncon- sciously, has interfered in this matter, and life has thereby been expanded, strengthened and prolonged. The laws and conditions of life, in all its manifestations, — in vegetable, in. animal, in man, — are determined, and cannot be changed ; but the circumstances which surround life, and the measure of conformity to the appointed conditions, are infi- nitely various, and the degree to which life is developed and sustained is in accordance with them. Agkicultuke. For ages, one of the greatest studies of mankind has been to know exactly the laws which nature has established for the life of vegetables, plants, grains, fruits, roots, and of animals, cattle, sheep, fowls, and to learn and adapt the uecessary cir- cumstances to these requirements. So far as people have been successful in this search, and faithful to their knowledge, they have developed a larger life in this field of culture. Hence we have better, stronger and more useful cattle, larger and more nutritious grains and fruits for human sustenance, and better and richer herbs and grass for the support of domestic animals. The original apple, as offered by nature to man- kind, was the small, sour, bitter crab of the forest, unpleasant, 356 STATE BOARD OF HEALTH. [Jan. indigestible, innutritious. By diligent and intelligent culture, it has grown to be hundreds of delicious and nutritious vari- eties. The pear, the peach, the plum, grapes and berries, have had a similar development from beginnings as humble and un- promising. Potatoes, beets, parsnips, beans and manifold other garden vegetables, have a similar history from small originals, through gradually increasing expansion, to their present richness and worth in the scale of nutrients. Fowls, sheep, swine, cattle, — all the varieties of animals which man has taken under his care in their present state, — have advanced as much from their primitive condition as the vegetables. One hundred and sixty years ago, in 1710, Dr. Davenant, a writer on political economy, estimated that the average weight of dressed cattle did not exceed 370 lbs., and that of sheep 2S lbs. In 1795, a committee of parliament stated that these animals had increased one-fourth in weight and size within fifty years. In 1846, McCulloch stated that, "at present the average weight of cattle is estimated at or about 800 lbs., and that of sheep at or about 80 lbs." "The weight of these animals has a good deal more than doubled in a little more than a century." * Whenever it has suited the purposes of man, and he has used the appropriate means, the strength of horses and cattle, and all their available qualities, have been increased, and they have become more and more useful to the world. Thus, agriculture and horticulture, in all their varieties, are neither more nor less than the culture of the living principle in some of its forms, the adaptation of circumstances, and supplies to the necessities of each beast, fowl and insect, each plant, grain and leaf, and giving them their appropriate means and opportunities of growth. Increase of Human Lite. Man, himself, has happily followed in the same path of im- provement. By better adaptation of means, circumstances and habits, his life has been expanded, his strength increased, and his days on earth prolonged. By the improvements in agriculture and in vegetable and animal life, he has obtained * Account of the British Empire, II., p. 515. 1874.] STATE BOARD OF HEALTH. 357 better and more constant food, and is therefore better nour- ished. By the improvements in the arts, he is better clothed and housed, better protected from the elements. The prog- ress of civilization is best manifested in the progress of vital- ity. There is less sickness, and that which visits humanity is less destructive than in former ages. The records of these most important facts are unfortunately few ;«yet these all concur in their testimony to the increase of man's longevity. In ancient Rome, in the period two hundred to five hundred years after the Christian era, the average duration of life in the most favored class was thirty years.* In the present century, the average longevity of persons of the same class is fifty years. The records of life and death in Geneva, in Switzerland, for the last three hundred years, are more complete than any others now known. These show that the expectation of life from birth, or the average longevity, was — 21.21 years 25.67 " 33.62 " 39.69 « 40.68 " in the 16th century. 17th " 18th " from 1801 to 1833. 1814 to 1833. In the 16th century, 25.92 per cent, of the children died in their first year. In the 19th century, the deaths at this age were reduced to 15.12 per cent. In the 16th century, 61.11 per cent., and in the present century only 33 per cent., perished before they reached ma- turity at twenty. In the first period, 3.08 per cent, passed their threescore and ten years, and in the latter 17.94 per cent, had that length of life. As large proportion now- live to seventy as lived to forty- three, three hundred years ago.f * Ulpianns quoted in Pandectas Justiniani, Lib. 35. Tit. 2. Ad legem Falcidiam. f Mallet in Annales D' Hygiene, XVII., 169. 358 STATE BOAKD OF HEALTH. [Jan. British Tontines. In 1693, the British government borrowed money by sell- ing annuities on lives from infancy upwards, on the basis of the average longevity of the people of that century. The treasury received the price and paid the annuities regularly as long as the annuitants lived. The contract was satisfactory to both parties. The government obtained the money at a reasonable cost, and the annuitants received their principal and a fair interest, and no more. Ninety-seven years later, in 1790, Mr. Pitt issued another tontine or scale of annuities, on the basis of the same expecta- tion of life as in the tontine of the previous century. These latter annuitants lived so much longer than their predecessor, that it proved to be a very costly loan for the government. It was found that while 10,000 of each sex, in the first company of annuitants, died under the age of twenty- eight, only 5,772 males and 6,416 females in the second com- pany died at the same age, one hundred years later. The annuitants of 1693 enjoyed an average life of twenty-six years and six months. Those of 1790 lived thirty-three years and nine months after they were thirty years old. Within the century, included in this history, the longevity of this class of people increased twenty years.* • In Sweden the expectation of life at birth was thirty-five years and three months from 1755 to 1775. It was forty-three years and five months from 1841 to 1855. The average deaths were one in 36.2 of the living from 1746 to 1767, and one in 47.3 from 1842 to 1855. f In France, of 1,000 born, the survivors to twenty, in 1781, were 458 ;J in 1806 they were 558, and in 1861, 628. § One million births in 1746 would support a constant population of 35,938,543, and in 1865 39,815,520. || Moreau de Jonnes, says, "The improvements in nutrition among the people of * Dr. Southward Smith, in Trans. Brit. Social Science Assoc, 1857, p. f Befolknings Statistik, 1851-55. J Buffon's Works, II., 515. § Legoyt Mouvement de la Population, 1861-65, p. xci. || Ibid., p. xcii. 1874.] STATE BOAED OF HEALTH. 359 France have reduced the mortality one moitie. The mor- tality was one in 25 in 1782, and one in 43 in 1861 to 1865.* A similar diminution of death and prolongation of life has been granted to other nations in the progress of civilization. The marked effect of the improvements in life is seen in the increased proportion that reach maturity, and of the effective population between twenty and seventy. The dependent class is thereby diminished and the sustaining class is increased. According to the Genevan record, the average working period has increased from eight years and five months to twenty-two years and eleven months within three hundred years, and con- sequently old age is postponed. Those who were formerly old at fifty and decrepit at sixty, are now old at seventy and decrepit at eighty, f From these facts, it is plain that life, in many forms and manifestations, and probably in all, can be expanded in vigor, intensity and duration under favorable' influences. For this purpose, it is only necessary that the circumstances amidst which, and the conditions in which, any form of life is placed, should be brought into harmony with the law appointed for its being. By this means the intelligent world has been and is now continually adding to the vitality of the vegetable and animal kingdom, as far as they are brought under their control. Man has increased his own life, also, in as far as he has con- formed his self-management to the requirements of the vital law. Beyond the pale of man's intelligent aid, life is apparently stationary. So far as human observation has gone, the wild, uncultivated plants, the trees of the forest, the grass of the meadows, the flowers of the untouched wilderness, the fishes of the sea, the birds of the air, insects, reptiles, wild beasts of the desert, left to their own instincts, are no larger nor stronger ; they have no more vital force or longevity than in the beginning of their race on earth. * Peuples d l'Antiquite. f Calculated from Mallet in Annales D'Hvgiene, XVII. 360 STATE BOARD OF HEALTH. [Jan. Influence and Power of the Government in Agriculture. In most, if not all, civilized nations, the government, which is the concentrated wisdom of the people, has taken an espe- cial interest in agriculture, and lent its aid in the promotion of its prosperity. In Massachusetts it has encouraged the forma- tion and efficiency of agricultural societies, through which it has wielded great influence on the improvement of the pro- ductions of the farm and garden. The legislature makes annual appropriations, amounting to nearly thirty-four thou- sand dollars in this and the previous year. Nearly eighteen thousand dollars is given to the various agricultural societies, and is distributed by them in premiums for excellence in cult- ure and productions of the field and garden, etc. Board of Agriculture. A board of agriculture is established by the State, composed of the best agricultural talent and accomplishment in the Commonwealth. They have a secretary, a man of large power and acquirement, w T holly devoted to the work of his vocation. They have rooms in the state house, where is gathered a library of the best books, pamphlets and journals relating to farming, both American and foreign. These are offered freely for public use, and all who will, are invited to come and read or consult them. Agricultural Societies. There are thirty-one agricultural societies in Massachusetts, • in which probably every town is represented by some or many of its farmers. At their meetings and exhibitions, the best agricultural wisdom of their several districts is brought forth. The best plans of cultivation that have been suggested, ma- tured and tried on the farms, even in the obscurest corner, are there brought forth and the results exhibited. Specimens of the best products of the earth in every variety, grains, fruits, roots, whether grown for man or beast, are presented. These show what intelligence, skill and faithfulness can ac- complish in the development and expansion of animal and vegetable life ; and the methods used for these purposes are 1874.] STATE BOARD OF HEALTH. 361 described for the instruction of all. Thus the knowledge and experience of each is made the common property of the whole community. The best agricultural and horticultural lights are placed on the hill-top, so that all cultivators may be guided by them. Co-OPEKATION OF COLLATEKAL SCIENCES. The government enlists the cooperation of men of learning, scholars in all collateral sciences, philosophers, naturalists, botanists, chemists, mineralogists, geologists, ornithologists and entomologists. These investigate the nature and habits of plants, the character and re'ations of soils, the composition and power of manures, natural and artificial, and other ele- ments of vegetable nutrition, and their relation to the quantity and quality of crops. The habits of insects injurious to vege- tation, and of birds that are favorable to it, and the physiolog- ical character and pathological dangers of domestic animals, are all subjects of these scientific inquiries. Reports of great value to the agricultural interest are made on them, and mani- fold other topics connected with the cultivation of the earth. Some of these reports are printed by the State in separate volumes. Others, with essays on every variety of topics use- ful to the farmer, the discussions of the agricultural board, and the gatherings they draw in various parts of the State, and the reports of the agricultural societies are collected and published in annual volumes by the secretary, and distributed at the cost of the public treasury freely and gratuitously among the people. JThus the State has, in manifold ways, obtained the aid of the science of her scholars, and the practical wisdom of her culti- vators, to teach the best way of creating the largest life in plants and animals. The people have profited thereby. A marked effect has been produced on the public mind. Routine farming disappears ; thought, system and improvement take its place, under this liberal and sagacious leadership and encour- agement of the government. In this work the legislature and people have gone hand in hand, mind with mind, heart with heart, to effect their common purpose. Agricultural newspapers have sprung up in every part of the land. They find their way into a large part of the 46 362 STATE BOARD OF HEALTH. [Jan. farmers' houses ; they offer another and very wide opportunity for writers and experimental cultivators to teach their lessons. Those who take these papers profit by their instructions, and apply them to their daily practice. They learn, not for them- selves alone, but diffuse these blessings to their neighbors, so that few or none can avoid the light and influence of these journals. Farmers' clubs are formed in many towns, and hold earnest and profitable meetings. They are excellent schools of mutual instruction on the manifold topics connected with their voca- tion. These and other instrumentalities for the agricultural edu- cation of the people, here and elsewhere, have had so much influence that this interest has become a ruling power in the civilized world. It forms public opinion; it controls the habits and sensibilities of cultivators, so that they aim to de- velop and sustain the best animal and vegetable life, and feel ashamed of meagre cattle or unskilfully managed fields. Human Life Expansible as in Animals. Human life is subject to the same condition as the life of beasts that work for man, as that of the animals and vege- tables that supply him with food. The vital laws are equally determined in all living beings. Each has its own appointed requirements, and its vitality and power are in proportion to its opportunity to fulfil them. Intelligence of these laws, and conformity to them, produce the same effect in all, whether man, beast or plant. By means of this regard to the laws of their being, the vital energy of cattle, fruits, etc., is developed and sustained in high, perhaps in the highest, degree. But for the want of this regard, human vitality is incompletely developed and imperfectly sustained. Few of our cattle die in immaturity ; but many of .our children sink in this stage of their being. Man suffers more from sickness, in all his stages, than his animals, for whose health and protection he faithfully provides. A larger proportion of his race than of his horses perish in the middle and active periods of life, and a smaller proportion reach their fulness of years and die of old age. 1874.] STATE BOARD OF HEALTH. 363 Can Government Aid in Improving Human Liee? Is there room here in this field of human life for govern- mental cooperation as well as in the agricultural field of vege- table and animal life? It is powerful there. It is not power- less, and need not be ineffective, here. The power of the government is threefold, and is exerted in a triple way. It is mandatory, and says, thou shalt and thou shalt not. It is permissive, and grants privileges. It is advisory, instructive and encouraging. It teaches the people their best interests, and points the way of gaining them. By the second of these methods it has aided in the advance- ment of agriculture, — it grants money. But mainly in the third method has it done this great work. By all the three methods it has wrought its work in educa- tion. It has ordered a certain amount of schooling, in ratio of the population and the due facilities of houses, teachers, books, etc. It permits the people to raise more money and obtain for their children a higher and more liberal education. In the third method the government instructs, leads and persuades the people. By the board of education, the nor- mal schools, teachers' institutes; by enlisting the aid of the talent and learning of scholars, who can write and speak; by the reports in which are condensed the wisdom and experi- ence of the teachers throughout the State, — by all these and other means the State has created such popular sentiment, that the people, in all the towns and districts, demand and support schools of high order, in which every child may be taught and fitted for usefulness in the world. Yital Legislation. The government of Massachusetts has been accustomed, from its early periods, to take cognizance of public health, and has endeavored to protect the people from some of the causes of injury. The law offers some protection against contagious diseases, small-pox, etc., and also against nuis- ances, offensive trades, etc. In some degree it proposes to regulate tenement-houses ; it endeavors to save children from 364 STATE BOARD OF HEALTH. [Jan. the exhaustive effect of over-labor in factories ; it authorizes hoards of health to abate nuisances of wet and foul lands, etc. ; and, lastly, in the creation of the State Board of Health, and endowing it with ample authority, it has taken large and very wise steps in this direction. All these show that the govern- ment recognizes its interest in, and responsibility for, the health and working power of the people, and its determination to lend its authority for their promotion. So far, these laws have had some effect in some places, but they are ineffective in others. There are manifold sanitary evils yet to be abated. The work ass r gned to the Board of Health has been prosecuted with great energy, and, as far as it has been able to go, with signal success. But ages must elapse before the single hand, authorised by the law, can accomplish the herculean task assigned to it, and required by public necessities. The field of human life is everywhere spread about us, and the harvest of tares and weeds is ready for the sickle, 'but the laborers appointed, though skilful and diligent, are very few. European Sanitary Legislation. Some of the European governments watch over the health of their people with jealous and anxious care, and endeavor to surround it with all the safeguards that modern science can suggest. They find many sanitary evils, which are the growth of ages, that have come down from the periods of barbarism. These are rooted in the habits and conditions of the people, — in the physical condition of the earth, — in the structure of cities, — in the locations of towns and dwellings. They seem to be an almost inseparable element in the social organism. The British parliament are singularly alive to this work, and have ordered many inquiries as to the health of the people ; and, led by the reports of their sanitary officers and commis- sions, many laws have been enacted for the benefit of public health. In the annual lists of laws that are passed, these are very prominent : — 1839. Metropolitan improvement act. 1840. Chimney-sweepers act. Bakehouse regulation act. Print-works regulation act. 1874.] STATE BOARD OF HEALTH. 365 1840. Dyeing-works regulation act. Passengers act. 1841. • Vaccination act. 1843. Vaccination act. 1846. Fever in Ireland act. Baths and wash-houses act. Nuisance removal act. 1847. Towns improvement act. Baths and wash-houses act. 1843. Health of towns act. 1849. Nuisance removal and disease prevention act. 1850. General board of health act. 1851. Interment act. Lodging-houses act. 1852. Smoke nuisance prevention, in London, act. General board of health act. Vaccination extension act. Eegistration of births, marriages and deaths, in Scotland, act. Public health act. Nuisance removal and disease prevention act. 1854 and 1855. Burial-grounds, iu Scotland, act. Public health, supplemental act. Burial grounds, in Ireland, act. 1856. Nuisance removal act. Smoke nuisance abatement act. 1862. Eegistration of births, marriages and deaths, in Ireland, act. Vaccination, Ireland. Vaccination, Scotland. Drainage, in London, act. Nuisance removal act. It is manifest from these titles, taken from the lists of a few years, that the British government take a very deep interest in sanitary matters, and are willing to make great efforts in their behalf. The Improvement of Towns in England. The most important and effective legislation in this direction inclndes the several laws, both general and special, authorizing the local governments to drain certain wet districts in the country, and to make improvements in the cities. Under the authority of these laws, many towns widened streets and lanes, opened courts, made sewers, paved highways, removed families from cellars, destroyed unfit habitations, swept and washed the filthy pavement, cleared away the micldensteacls or col- lections of animal excretion and refuse ; they filled low and muddy places, and made these streets and neighborhoods dry, 366 STATE BOARD OF HEALTH. [Jan. clean, airy and healthful, — consequently sickness diminished, the rate of mortality was reduced, the average age at death was increased. The people were stronger, more active, buoyant and cheerful ; they earned a better sustenance ; the numbers of paupers, both in and out of the workhouses, were lessened, and the poor-rates were less burdensome. The records of very many of these improvements, in vari- ous towns, together with the rates of mortality for series of years before they were made and after they were completed, are published, and show that there was good reason for be- ginning them, and that great increase of health and life fol- lowed them. In nineteen towns the annual mortality, which had been 28 in 1,000 living for years previous to the improvements, fell to 21 in 1,000 for the years afterward. In these towns the average annual deaths were 3,276 less after than before the cleansing of these places. So many lives were yearly saved.* In Macclesfield the average longevity was increased 20 per cent, by these means, j In Liverpool the rate of mortality was 38.4 in 1,000 before the authorities made the sanitary changes in the streets, cellars and other dwellings, and 26 in 1,000 afterward. Latham, in his admirable treatise on. " Sanitary Engineer- ing " (p. 10) , quotes the results of the improvements in twelve towns, of which the following are the most prominent : — Deaths in 1,000. 1 Eeductioxs— per cext. Saving of Life- TOWNS. Before After Improve- Improve- per cent. Typhoid Consump- ment. ment. Fever. tion. Cardiff, .... 33.2 22.6 32 40 17 Croydon, 23.7 18.6 22 63 17 Merthyr, .... 33.2 26.2 18 60 11 Newport, 31.8 21.6 32 36 32 Salisbury, 27.5 21.9 20 75 49 These sanitary improvements, in these and in many other towns, were universally followed by such increase of health * Cowper in Social Science Transactions, 1859, p. 113. f John May in Trans. Social Science, 1857, p. 403. 1874.] STATE BOAKD OF HEALTH. 367 and strength, and such reduction of mortality, that Mr. Chad- wick, formerly secretary of the National Board of Health, says that a sanitary " engineer ought to contract for the reduc- tion of the sickness and death-rate, in such a city as Glasgow, by at least one-third for a penny a head of the entire popula- tion." * The same good results followed the draining of coun- try districts, in some of which the annual deaths were reduced from 2.6 to 2.1 per cent, of the population. The whole of this experience in many cities and districts, in Great Britain, abundantly proves that the way is open in this sanitary field for the interference of the government, and the reward, in the increase of life and strength, is very great and sure. The sanitary dangers in the country are due, in great meas- ure, to natural causes, wet and marshy ground, unhealthy dwelling sites, etc. But in the cities they are mostly due to the faults of the people, to bad engineering, bad arrangement of streets and courts, and worse habits of the inhabitants of the foul districts,. and to the neglect of the local authorities. As, in all the civilized world, cities constitute so # large and increasing element of the nation, and as there is a tendency of the poor, ignorant and careless to crowd together in the pestiferous centres, it is the duty as well as the interest of the government to exe.cise an unceasing vigilance to prevent the establishment of such unhealthy conditions of street, court and house. And, if unhappily they already exist, the necessity is imperative that the authorities redeem the people at once from their destructive power. Geowth of Cities. Here in the United States, as elsewhere, is a constant tendency of population to gather in dense masses. The cities absorb the young and middle-aged from the country, and grow at its vital cost. In Massachusetts towns with 10,000 and more inhabitants heel 6.8 per cent, of the whole population of the State in 1800, 22 per cent, in 1840, and 48.7 per cent. in 1870. f The rate of increase of population of the cities and of the rest or country part of the State was : — * Social Science Transactions, 1866, p. 580. t Calculated from the census. 368 STATE BOAED OF HEALTH. [Jan. Cities. Country. 1800 to 1820, . 18.7 per cent. 4.4 per cent.* 1820 to 1840, 110.9 " 20.4 1840 to 1860, 109. " 45. Mortality or City and Country. The cities not only grow at the cost of the country, but they exhaust human life more rapidly. Sickness is more preva- lent and fatal in the dense than in scattered populations. In England, among the same numbers of people living in the towns than in the rural districts, the deaths were many more from every class of diseases except two in the towns than in the country (from the class of zymotic diseases supposed in great proportion to be due to removable causes). They were nearly twice as many in the dense as they were in the scat- tered population. The proportion of deaths from old age, which are significant of health and longevity, were 37.7 per cent, greater in the country than in the great towns. Of the whole ninety-five causes of death specified in the Eegistrar- General's Keport, only fourteen, and these among the least destructive, were more prevalent in the country. From the whole number of diseases the deaths were 40 per cent, more in town than in country, or as often as 100 died in the rural districts 140 died among the people of the cities, f Tables in the sixteenth and supplement to the twenty-fifth reports of the registrar-general show the ratio of deaths in each of the six hundred and twenty-three registration districts and the density of the population, for twenty years. It is seen from these, that the death-rate keeps almost constant pace with the increasing density. In the most crowded dis- tricts, where 250 live on one acre of ground, one in eighteen died ; and in the country, where there were twenty to thirty- eight acres to a person, the death-rate was one in sixty-two. J Similar statements are made in the thirty-four annual reports of mortality. The report of Mr. Chadwick on the sanitary condition of the laboring classes in 1842, the report of the health of towns * Calculated from the census. t Condensed from Registrar-General's English Reports. % Supplement to Registrar-General's 25th Report, p. xxxviii. 1874.] STATE BOARD OF HEALTH. 369 commission in 1844, the reports of the Board of Health, — all confirm the statement that vital force is developed in a lower degree, and sustained in less vigor, and that life is shorter in the city than in the country. Both British and French army authorities state that a much larger proportion of the recruits for the army were rejected for want of strength, constitution or sufficient height anions: those enlisted in the towns than among those that came from the country. A lower physical vital power generally characterized the civic population of Great Britain and in the foul spots the depression was very great, sickness was abundant and life very short. American Cities. These pestiferous centres of disease and death are not peculiar to the old cities of Europe. We have them here in this newer country. The board of health discovered and revealed them in New York. Dr. Draper found them in Bos- ton, and even in some of the little cities of Massachusetts, that within a generation were open country villages. These need the vigorous arm of the law to purify them and make them fit for the residence of healthy and strong men and women. Government should Prevent the Creation of* Un- healthy Districts. The law now authorizes and commands the boards of health to make these reforms, at any pecuniary cost, for human life and strength are not to be weighed in the same scale with money. If the government can reform the unhealthy districts, remove their causes of sickness, open them to the fresh breezes of air, — if it can overcome these destructive influences after they are established, it can prevent them. If the law can upturn old and corrupted districts, and lay them out anew, favorably for health, it can lay them out according to this plan, when the fields are open, before the population gathers upon them. The health of towns commission appended to their great and valuable report, a series of propositions for the plan of all new cities, and the extension of all old cities. They required that all these should be laid out, measured, graded, 47 370 STATE BOARD OF HEALTH. [Jau. by a sanitary engineer, with strict reference to the health and power of the people that dwell on them. It would be a blessing to every city, and economy to the body politic, to make these conditions a necessary element in the organic law of every prospective city ; to require that its whole plan of streets, lanes, courts, and open grounds be made by such a sanitary engineer, and be ever afterward under his control. This would prevent the growth of those centres of disease and death, and those condensed hives of feeble popu- lation that now infest the old cities, and cost the municipalities so much to improve. This is legislation in the right direc- tion, and at the right time, where it will be most effectual. It offers to humanity protection against its sanitary foe before it appear^ and disarms it of power to do injury. The Law should make Steeets Safe for Dwellers as well as for travellers. The law already takes the streets under its care so far as to make them safe for the passage of travellers, teams and merchandise. It makes the municipalities responsible for all damage that may befall man, beast, wagon or freight, from defect in the pavement or hole in the highway. If the law can secure safe passage for travellers, carriages," merchandise in the thoroughfares, and make the towns liable for any damage to limb of man or beast, or to vehicle or freight from holes or obstacles in the highway, it may, with better grace, make the municipality liable for all suffering, fevers, dysenteries, withering of life and strength of the inhabitants, caused by pestilential emanations from the filthy pavement or sloughs in the passage-way. If the town be required to make the street wide and open enough for the passage of carts that bring coal and provisions, it may with more advantage to the families and the public, be required to make them sufficiently broad and permeable for the fresh air to reach and bring health and vigor to the dwellers on the border. The suffering, the loss of power from diseases which the exhalations from the uncleaned ground of these slums generate in the families that live in the houses near to them, are far greater, and cause more loss of time and productive 1874.] STATE BOARD OF HEALTH. 371 energy, than all that comes from injuries caused by physical imperfections in the street, lane and court. Interests of Human Life should hold Peecedence in all Legislation. In as far as human life is more important than all financial interests, arid even in the financial view, the creative power of human force is more valuable than all created capital, this cardinal interest of the people, individually and collect- ively, should take precedence of all other provisions, in all legislation. Every law, grant, or privilege from the legisla- ture should have this invariable condition : that human health, strength or comfort should, in no manner or degree, be im- paired or vitiated thereby. When the legislature grants the right to build a dam, and flow the waters of streams and ponds, the grantee is held responsible for all the damage that may be caused thereby to land's, crops and other mills. All this is well, for these may be compensated in money ; but besides this, he should be held responsible that no damage shall be caused to human life and comfort by the changes in the condition of the waters. This cannot be compensated by money. Factory Villages. Beside the large masses of population that are gathered in cities, there is a great tendency, promoted by civilization and increasing wealth and industry, to gather people in compact villages for manufacturing purposes. For the conveni- ence of access, and to save time, they live as near as pos- sible to the place of their occupation. Hence the dwellings of the operatives and the boarding-houses are often closely crowded in narrow streets, lanes and courts, and near to the water, sometimes on damp ground ; and, to euable the work- folk to live at as little cost as possible, these dwellings, in both village and city, are made to contain many lodgers, with little breathing-space. In Mr. Chad wick's report on the sanitary condition of the laboring classes, he states that though the operatives suffered sometimes from the close and impure air of factories and shops, they suffered more from the closeness of their homes, and 372 STATE BOARD OF HEALTH. [Jan. the impurities of air and ground in and around them. Some manufacturers take extraordinary pains to make their facto- ries, and the dwellings and boarding-houses of their operatives, airy, healthful and invigorating. The Pacific Mills, of Law- rence, Mass., offer a noteworthy example of this sanitary arrangement, and find good return in the small amount of sickness and loss of time among their people. The silk factory at South Manchester, Connecticut, in which about a thousand people are employed, is situated in an open field of about five hundred acres. The halls, the rooms of the great factories and the shops are large, open, well ventilated, and lighted. Everything about them is enlivening and cheer- ful. The dwellings of the operatives who have families, and the boarding-houses of the others, are spread about on the lawns, separated from each other, with open grounds all around them. Everything is comfortable and attractive and tends to promote vigor and working power. The proprietors find that their benevolent and sagacious provision for the health and happiness of their work-people is well rewarded in their more constant strength, clearer brain, and more con- trollable and effective muscles. They do more and better work ; consequently, all connected with the establishment are more prosperous ; the company make larger profits ; the men and women earn more money ; and all add more to the income and capital of the State. The English laws offer many securities for the health and safety of the operatives in factories, and vigilant, ubiquitous inspectors watch closely for the sure fulfilment of these regu- lations. .The law of Massachusetts defends children from suffering from too early employment and excess of work in their tender years in these establishments, lest they be blighted in childhood and grow up to feeble and ineffective manhood ^Vcc* and womanhood, and unprofitable members of the Common- wealth. The same humanity and public interest demand that the State protect these working-people, both young and old, at their homes, from the wasting influence of bad, damp, un- healthful locations and surroundings, from foul and pestilential streets and grounds, from noxious emanations sent forth from decaying material and artificial accumulation of waste matter. 1874.] STATE BOARD OF HEALTH. 373 Such sanitary provision should be made a necessary element of every law that incorporates manufacturing establishments. It should be made to reach and govern all collections of peo- ple, whether in city, town or village, whether for business, labor or dwelling purposes. In this way the State would take the first step to insure that every plan, enterprise and movement shall be begun and conducted without needless cost of human health and force, and without depreciation of the productive power of the people. In this way all legislation would hold first in consideration the Commonwealth's greatest interest, — the power of the people to create value and capital. Legislative Sanitary Committee. Our legislature always has various committees, consisting of men selected for their special intelligence, to watch over the several classes of public interest and see that they suffer no damage, and, more than this, to see that they derive the most advantage from the parental wisdom, care and power of the government. There are committees on education agricult- ure, manufactures, banks, insurance, finance, fisheries, rail- roads, mercantile affairs, towns, etc. The New York legislature adds to these a committee on public health. Such a committee, here and elsewhere, would find plentiful occupation in watching the effect of all laws on human health and productive force, in searching for causes of injury and the means of their removal or amelioration, and in providing securities for the future. Manner op Legislative Action. As a drowning man, or a child falling into the fire, demands help, prompt and energetic in proportion to the imminence and degree of the peril, so some sanitary dangers demand the immediate and efficient interference of the law, only to be measured by the importance of the matter that is at risk. When a person tampers with human life by adulterating food, or knowingly and selfishly offers to sell unwholesome articles of diet ; when he reduces milk with, water or adulterates it with foreign matter, and thus deprives children and adults of their due nutriment, or impairs their stomachs with indigesti- 374 STATE BOARD OF HEALTH. [Jan. ble mixtures ; when men thus selfishly sacrifice the health and strength of others for their own gain, the law should hold this as a crime, as when one robs another of his property, or impairs his life and power with deadly weapons, and relax none of its severity until the destructive practice is overcome and the people assured of safety whenever they purchase milk or other provisions in the market or elsewhere. In all cases where life and health are in question, the arm of the government should be used with sufficient force to pro- tect them. A few years ago there was a very large establish- ment for boiling dead horses in the neighborhood of Boston. The flesh, with swill brought out of the city, was given to several hundred hogs in a piggery on the grounds. The odors from the processes and the hogs were very offensive to the neighborhood and injurious to their health. The town board of health remonstrated without effect. They complained to the grand jury. The proprietor was indicted for keeping a nuisance. The case was manifest and could not be denied. But he knew the mildness of the .law and the limit of the penalty. Weighing this against the profits of the business, he let the case go by default, paid the fine, and continued the work as before. It was more profitable to disobey than to regard the law. The law should not be thus set at defiance nor be bought off. It should never, in these questions of human health, be for the interest of the offender to persevere in his injurious practices. Fields of Sanitary Legislation. There are many fields for culture and operation in this broad sanitary region. They are as various as the habits and experiences of the people. The interests of health require unceasing vigilance of individuals in their self-management, and of the government in its watch over the conditions and influence that may affect them for good or evil. Nutrition. Animal life is maintained by a constant change of particles in the living body. We eat and drink two, three or four pounds of solid and liquid food in a day, and yet, after reach- ing maturity our weight is not materially increased. We 1874.] STATE BOARD OF HEALTH. 375 take into our bodies about a thousand pounds, half a ton, in a year, and yet at the end weigh no more than at the beginning. Our food, or whatever proportion of it is soluble in the digestive organs, is converted into nutriment of the blood, and whatever proportion of this is fitted for its ultimate purpose, is converted into flesh of various kinds in the several textures of the living body. The atoms of digested food thus become parts of the muscles, skin, fat, stomach, lungs, brain, nerves, bones, etc. When deposited in their new places, they are endued with the principle of life and with the peculiar and specific living powers of the organ or part to which it is attached ; in the muscles they contract, in the nerves they feel, in the brain they perceive, in the skin they receive impres- sions. In their several positions and connections they act and serve the purposes of life for a short period, and then they die, and are removed by an appropriate apparatus from their positions and other and new particles are brought to take their places, to live and work for a while and then give their places to their successors. After the}'' die they are carried out of the system through the lungs, the skin, the kidneys and bowels. As much thus goes out as comes into the living body. We are continually passing through a change in our internal structure. We are daily, hourly, momently dying, particle by particle, and as continually revived with the freshness of new life. This is nutrition. For this, new and appropriate materials in form of food must be constantly supplied. Food and Cookery. For this renewal of our bodies we ourselves provide the material, — dead flesh, meats, fowl, fish, bread, vegetables, fruit, etc. Nature takes what we offer her, digests it, if it be digestible, and converts it into flesh if it be nutritious. But nature is not indifferent as to the kind and condition of the material that is offered. The stomach will not digest all things alike. The nutritive organs cannot convert all matters into living flesh. The raw material, the food, must be selected in exact accordance with the powers of digestion and its fitness to be converted into flesh. It must be prepared and cooked 376 STATE BOARD OF HEALTH. [Jan. in such a manner that the delicate organs of digestion and nutrition can use it for its intended purpose. This work of the purveyor and the cook, the selection and preparation of our food, requires more intelligence of its pur- poses and means of accomplishing them, more consideration, careful judgment and discipline, than any process submitted to human supervision. If the food be appropriately selected and suitably cooked, it is easily digested, and converted first into blood and lastly into flesh, then the body is well nourished and made strong. The eater enjoys a feeling of buoyancy and energy. He has possession of all his faculties, and is ready to apply them to effect his purposes. He thinks clearly. His muscles are ready for labor. His stomach does its work quickly, easily, and he is unconscious of its operations. But if the food be misadaptecl, if it be prepared in a manner unsuited to the stomach's power and the wants of nutrition, the eater suffers in various ways and degrees. He may have pains and oppression. The digestive powers may absorb an undue proportion of the nervous energy, and make him feel dull and heavy. His brain may be indisposed to action, and unable to carry on the mental operations. He is therefore more or less unfitted for labor or business, or the food may fail to supply the new atoms of flesh, in due proportion, and then the body is not renewed in the fulness of life, the mus- cles are not strengthened, the man is not refreshed. Much disease and disability, much distress and great loss of working power both in body and in mind, and even premature death, are brought upon us in consequence of the misadaptations by the provider and unfitting preparations of the cook. These, the provider and the cook, are our life-makers. We are in their hands, to make us what they can or will, — strong or weak, buoyant or depressed, active or sleepy, clear, bright, quick-witted, or dull and torpid, No office has such control over human power and effectiveness as that of # the housekeeper and the cook. There is none to which the Com- monwealth is indebted for so much of its energy. An office that wields so much power can be filled only by persons of high intelligence, appropriate culture and thorough 1874.] STATE BOAED OF HEALTH. 377 discipline. No office offers so wide and rich a field for the exercise of talent and scientific acquirement. No other posi- tion offers the opportunity for mind, heart and hand to pro- duce such large and desirable results. It is both a public and private misfortune that this office is not so considered and esteemed ; that the intelligent do not seek it, and the ambi- tious avoid it, and that consequently it is given up to the lower grades of intellect and culture. In the social and domestic organization of the civilized world, the men do the work and business abroad. They are farmers, mechanics, laborers, merchants, etc. The women are the housekeepers and provide and prepare the materials of life, or appoint those who do this in their stead, and be- come responsible in their office for the nutrition and thereby for the health and power of the family. The woman is not, by nature, a housekeeper or cook; nor is the man, by nature, made a farmer, mechanic or trader. But each has the capacity to learn the principles and details of the art or occupation which he or she may elect to. pursue. The man fits himself in youth for his future sphere of busi- ness, and takes the responsibility of its management only at maturity, after he has strengthened himself with knowledge and discipline for its burdens, otherwise he fails in his attempt. The woman often defers her preparation for her office as housekeeper until she assumes the responsibility, and some- times she accepts it while yet immature, undisciplined and unformed in character. If outward circumstances favor, she finds some other person to bear the most important part of her responsibility of providing and preparing the family nutrition. Generally this is performed by a deputy of the lower order of intelligence, who has no rational nor clear idea of the duty she undertakes or of the sanitary consequences of her operations. As a natural consequence of intrusting this all-important matter of human nutrition to such inadequate agencies, the preparations of food are often uncertain and unfitting for their purpose, and it is but a chance that they are adapted to the powers of the stomach or the necessities of the living organ- ism. Hence the common and very apt and descriptive con- gratulatory remark of the housekeeper, that " she had good 48 378 STATE BOARD OF HEALTH. [Jan. • luck with her bread," or the apologetic statement that "she was unlucky with her cake." A second, but necessary, consequence of the imperfect in- telligence as to the responsibilities of the kitchen is, that the family is sometimes oppressed by the labor of digestion and imperfectly nourished, and the final result is, that not unfre- quently they are not strengthened for work nor fitted for business, and then their efficiency is impaired and their product- ive energy is reduced. Nutrition of Domestic Animals. Our domestic animals are, and have been, more favored than their owners in respect to nutrition. Public attention is continually called to consider the best methods and means of strengthening and fatting them or fitting them for their intended purposes. So many are carefully studying their wants and the means of supplying them, — so much has been written in books, magazines, newspapers, in society reports and state reports, — such clear, philosophical and practical essays on these topics have been spread abroad by the agents of the government, — that most farmers are familiar with the best way of feeding their horses and oxenro develop their greatest . strength for work, their cows to produce the best quality or largest quantity of milk, their cattle and swine to produce the most flesh on their frames, — that, with all these aids, failure in these matters is very rare, while lean, weak, dyspeptic men and women and children are common. Purpose of Food not Generally Understood or Re- garded. Beside the inadequate nutritive supply for human necessities, there is a frequent lack of intelligence as to the real purposes of eating and the means of completely fulfilling them, and a general contentment with whatever may be offered from the kitchen. The eater's ideal of good food generally corresponds with the caterer's. Although good, digestible, nutritious bread is far from being universal (and it very generally falls short of the best standards in these respects), most people have the very comfortable belief that, at their own homes, 1874.] STATE BOARD OF HEALTH. 379 they have good bread, and pity their neighbors who are not so highly favored. There, is aj'go a very common sort of heroism or physiolog- ical stoicism in regard to eating. People often say, with self- complacency, that they can always eat whatever is set before them. They seem to think it unmanly or unwomanly to complain of their food. Not denying that they have special appetites, which they may indulge when suitable occasion may invite, yet to be particular Qg to their diet, and to give trou- ble to others on this account, appears to them to savor of selfishness and meanness. Their only principle is to fill the stomach with anything that is handy. Thus, while they feed their beasts and fowls, each for a specific purpose, — strength- ening, fattening, milking, eggs, — they feed themselves and their families according to the accidental convenience of the purveyor and the cook. A generous traveller, driving his own team, in cool weather, stops at a wayside inn, at noon, for rest and refreshment. He first cares for his beast. He sees that the horse is unharnessed, rubbed dry with straw, housed and blanketed. He directs the hostler to give first a little water and plentiful hay, and when the animal shall be sufficiently cooled and rested, to add grain and more water. Having done this, he goes into the house and takes such food as can be obtained, without much trouble to the family. A farmer in Massachusetts, of high intelligence in all the varieties of his vocation, watched all his animals unceasingly. He was familiar with their temperaments, habits and apparent wants, and fed them according to these idiosjmcrasies and his purposes concerning them. His working and fattening cattle and milch cows had different food, to promote their different ends. To one horse he gave oats, to another corn, and to a third meal with cut hay, because each worked better with the special kinds of food. He discriminated among his fattening pigs, and gave some potatoes and others meal, because they throve better with these respective diets. Nothing in these matters among his animals escaped his notice or was neglected by his judicious care. One day, meeting his physician accidentally, in the after- noon, and appearing to be in pain, he was asked as to the 380 STATE BOARD OF HEALTH. [Jan. cause. He said that, for many months, he had felt great dis- tress and oppression for two, three or more hours after dinner, so that he was almost unfitted for work, and a*!w**nclay this was very severe, so that he usually lost the whole afternoon. He had the same in the morning after breakfast, but it was less severe. The physician inquired minutely as to the farmer's diet, and learned that the only constant article was brown bread (rye and Indian) , which he always ate freely at dinner and sparingly at breakfast, and *©onday he had Indian pud- ding. Hence arose his trouble. The Indian meal, which is ordinarily very healthy and digestible food, was not digested in consequence of some temporary weakness of his stomach. It fermented, turned acid, and gas w T as evolved, and produced distress and general depression. Following the physician's advice, he discontinued this bread and pudding, and had no more pain or debility, but was able to labor without inter- ruption or discomfort. This careful observer of his cattle and fowls, who ministered to each one's necessities, had not thought to watch himself, nor had he suspected that there would be any connection between his food and his suffering and weakness. He is an extreme illustration of the mental habits of a large part of the community as to their own nutrition and power and those of the beasts that they care for. Financial Estimate or the Office of the Cook. The price, in money, in the general market, or the financial value of any service, is a good indication of the world's esti- mate of its importance. Less is given to those who prepare our food than for most other service. The wages of a cook are much lower than those of the maker of our garments. The groom that feeds the horses is paid twice as much as the one w T ho feeds the family. The carpenter and the bricklayer, who build our houses, are paid as much for the work of a day as the women that build our bodies for the work of a week. According to the natural law, the character of the supply rises and falls in accordance with the estimate that is put upon it, and the reward that is paid for it, in this as in other occu- pations. The talent that can rise high avoids the food labo- 1874.] STATE BOARD OF HEALTH. 381 ratoiy, where it is meagrely paid, and goes to the clothes laboratory, where it is paid generously. The cook of little education and skill in her vocation, finds small inducement of better appreciation or higher wages to cultivate her talents and become accomplished in her art, as men and women in other employments, where respect and reward follow step by step closely upon improvements in taste and workmanship. Government Aid. Here it may be asked, What can the government do in this matter ? Shall it write a book on diet and cookery for the people? It has caused this to be done for domestic animals. The interesting and instructive State Agricultural Reports are bespread with admirable essays on the food, its material and preparation, for cattle of various kinds and purposes, — work- ing, milch, fattening ; and also for swine and fowls. The writers prove the excellence of their teachings in the results of their practice in the production of flesh, strength, milk, etc., and in the increase of vitality. One teacher, in the re- port of 1872, after describing minutely the material and the manner of the preparation of the food, said that "he had this year raised one hundred chickens without one case of sick- ness." * He does not say there were no deaths in his flock. But if there were no sickness none could be lost from this cause. Through all these annual volumes, issued by the State, we find these receipts, directions for the healthful nutrition of animal life, written by the agents appointed by the govern- ment or enlisted in the work by its influence. And although these sagacious and profitable teachers have given their lessons of wisdom for so many years, still they are not satisfied with the progress they have made. They are untiring in their investigations and teachings. Every volume is freshly laden with new wisdom, new instruction, as to the means and manner of nourishing animal life. By the use of similar agencies and instrumentalities, the government can begin, and in course of time accomplish, as large a work in respect to the people, as it has in respect to the cattle. It can create such a public sentiment that those who * Page 300. 382 STATE BOARD OF HEALTH. [Jan. have the care of human nutrition, whether in themselves or in others, will be as eager as the farmers to learn the principles and practice of their vocation, and feel as responsible for the fulness and duration of life in men, women and children as the managers of domestic animals for the health and power of the beings under their charge. Insanity. Among the many interruptions to human effort and pro- ductive power caused by ill-health, insanity, which includes a wide range of mental disorders, stands prominent by its frequency and persistence. Under appropriate influences, insanity is among the most curable of grave diseases. If the persons who are attacked with this disorder are as promptly cared for as others wdien attacked with fever, dysentery, pneumonia, etc., 80 or 90 per cent, can be restored to health and usefulness. But if neglected, the disease tends rapidly to fix itself upon the brain, and becomes more and more difficult to be removed. If allowed to remain one year, the chance of restoration is materially diminished. In two years this hope is reduced more than half; and after five years' duration few are restored, and even then it is due to some unexpected turn of the disease rather than the result of heal- ing remedies. Not only is the chance of recovery lessened by delay of attention, but the time required for cure is greatly increased. The period of the healing power varies with many circum- stances and conditions, from a few days or weeks to many years. The average in the several hospitals in this country ranged from ten months and five days in the longest, to five months and three days in the shortest. In the Worcester Hospital it was 23.8 weeks, in the Northampton, 30 weeks, and in the McLean Asylum, 22 weeks ; the differences being due, in great measure, to the earlier or later attention to the cases by the friends. Under the power of this disease, the sufferer not only ceases to be a worker and to contribute to his own support and that of his family and the State, but he is a positive burden, for the cost of his sustenance and the care necessary for him in his wayward impulsiveness and uncertainty 18.74.]- STATE BOAED OF HEALTH. 383 of conduct. He always requires supervision and guardian- ship. Some are violent, a few are dangerous, many, perhaps most, *nust be confined, or under the watch of discreet and faithful attendants. This is necessary for their own security and comfort, or the safety of the community. In the most favorable condition, the cost for care and sus- tenance of the insane is greater than that of the sound in mind, and with most, the expense is very much greater. Although insanity unfits its subjects for mingling with, and taking part and lot in the interests of, the world, it is not immediately destructive to life. Some lunatics live five, some ten, others live fifteen, and a few live forty and fifty years, while suffering from their mental malady. Mr. John LeCapelain, actuary of the Albion Life-insurance Company, in London, calculated the average longevity of the insane at the several periods of life, and determined the number of years that they would live after any age from twenty, thirty, forty, etc. This life-table of the insane in England compared with the life-table of the sane people, shows how much life is lost by uncureel insanity. The following table includes the mean number of years that the insane and the sane in England will live after speei- fied ages, according to the LeCflpelain Table and that of the English Life-Table by Dr. Farr :— Years of After-life from Ages. Males. Females. AGE. Sane.* Insane.f Sane.* Insane.f 20, . 30, '. . 40, 50, . . . . ' . 60, 70, 39.48 32.76 26.06 19.54 13.53 8.45 21.31 20.64 17.65 13.53 11.91 9.15 40.29 33.81 27.34 20.75 14.34 9.02 28.66 26.33 21.53 17.67 12.51 .8.87 * English Life-Table, 1864, Dr. Wm. Farr, p. cli. t Mr. John LeCopelain's letter. It is seen from this table, that men twenty years old becom- ing insane, will have an average life of 21.31 years, if not restored to health. During this period, their families and the 384 STATE BOARD OF HEALTH. [Jan. Commonwealth not only will lose their services and contribu- tion to their income, but they will be obliged to support them, at even greater cost than if they were in good mental health. On the contrary, if they be restored, they will have an average life of 39.48 years, during which they may labor for their own and their families' support, and add to the public income and capital. Cost of Restoring the Insane, The cost, of supporting the patients in the three state lunatic hospitals of Massachusetts, was about four dollars ($4) a week, in the last reported year. The average time required for restoration is twenty-six weeks. Thus the average cost of restoring an insane person in our state hospitals is one hundred and four dollars, and a patient restored to health goes forth to the world. He has then an average life of 39.48 years before him, to labor for himself and the body politic. As merely a common laborer he can earn, at least, thirteen dollars a month, or one hundred and fifty- six dollars a year, beside his sustenance. If then he be not restored, he remains an unproductive bur- den on the private or the public estate of the Commonwealth, a consumer of his part or other people's earnings for 21.31 years. At the lowest estimate, for the poorest and cheapest, this cost of board, clothing, care and rent for a lunatic, is three dollars a week, or one hundred and fifty-six dollars a year, which must be paid out of his own or family's estate, or the general treasury, weekly, monthly or yearly. On the other hand, if he be restored to health, he will contribute as much yearly or weekly to the general income of the Commonwealth. Here are the means of comparing the advantages and dis- advantages of properly caring for and healing the insane and of neglecting them. On one side is the cost of supporting a lunatic in the hos- pital for twenty-six weeks, the average period of cure, at four dollars a week — one hundred and four dollars in all. Even if we add for the cost of rent or interest on the value of the hospital, house and lands, etc., thirty dollars for each patient for his six months' occupancy, the whole average cost 1874.] STATE BOARD OF HEALTH. 385 amounts to one hundred and thirty-four dollars for the ex- pense of restoring a man from being a profitless burden and making him a profitable cooperator in the community. On the other side, if not restored, the community, or its members or its estates, becomes responsible for the payment of his board and support for 21.31 years at the lowest rate of one hundred and fifty-six dollars a year, and also loses his earnings of the same amount for 39.48 years. These two annually recurring sums, each of one hundred and fifty-six dollars, are practical annuities ; one, for the lunatic's support, must be paid by the State or its members for 21.31 years ; and the other, the earnings which he would have gained for 39.48 years, is lost to the same parties. At five per cent, interest of money the annuity of the earn- ings, one hundred and fifty-six dollars for 39.48 years, can he bought of an annuity company for twenty-six hundred and sixty-five dollars and thirty-seven cents ($2,665.37). This is the present commercial value of a laborer twenty years old. The annuity of the cost of the support of the uncurecl luna- tic for 21.31 years can be bought for twenty-one hundred and forty-one dollars ($2,141). An annuity company will con- tract to pay this sum for this period for this amount. This is the present worth of the obligation resting upon the State or its people for the support of a neglected lunatic, beginning in his twenty-first year. The costs and the profits of healing lunacy may then be compared in the cases of laborers becoming insane at twenty years of age. Gain, present value of his future labor, $2,665 37 Present value of the cost of his support if not healed, . . . . 2,121 00 Total saved and gained, . . . $4,786 37 Cost of healing, 134 00 Net gain, $4,652 37 On an average, a lunatic twenty years old, allowed to remain unhealed, entails a loss of $4,786 to the body politic and a gain of $4,652 if restored to health. 49 386 • STATE BOARD OF HEALTH. [Jan. If the patient be older, with a lesser duration of life before him, whether insane or restored to health, the cost and the loss will be proportiouably less. In the foregoing calculation no regard is paid to the ten or twenty per cent., who, from the nature of their malady, can- not be healed ; upon whom all hospital skill and efforts will be expended in vain. These must be supported in the period when the trial of remedy is made, either in the hospital or at home, and the cost in the institution is but little if any more than it is elsewhere. And considering the great burden of a lunatic in domestic life, the care and anxiety, the interruption to business, the lessened labor and production caused by his presence, it is safe to say, that the average cost of supporting and caring for the insane in private families is as great as it is in the state hospitals. The example quoted above is that of a common laborer, without skill, trade or profession, who earns thirteen dollars a month beside board, and whose board is three dollars a week. Mechanics, merchants, proprietary farmers, profes- sional men, etc., earn much more, if in health, and live at greater cost, if mentally diseased. They are worth more, the loss is much greater if their malady be not relieved, and the gain greater if they are restored. Economical Practice in some States, Several of the Western States, looking upon insanity in this economical light, and believing that for the good of the com- monwealth as well as for the sake of humanity, every men- tally diseased citizen should be restored to health and useful- ness, at any cost, open their hospitals gratuitously and bid all their families to send their lunatic members to be cured with the least loss of time or productive power. They find the double advantage that a much larger propor- tion t>f these patients are sent in the early and curable stage of their disease, and a larger proportion are restored, and con- sequently a smaller proportion are left in permanent lunacy, a life-long burden on the public or private property of the com- monwealth. 1874.] STATE BOARD OF HEALTH. 387 Burden of Insanity in Massachusetts. When the insane of Massachusetts were enumerated in 1854 there were 2,630 in the State. Of these 2,007 were American, and 625 were foreigners. Eight hundred and twenty-four, or 41 per cent, of the Americans and 16 or 2.5 per cent of the foreigners, had never had opportunity of healing in a hospital. If the proportion of the insane to the sane population con- tinued to be as large, there were 3,194 in 1870, and there are still more at the present time. In 1854 there were 2,018 or 76 per cent, incurable, 435 or 16 per cent, were curable, and nothing was learned of the pros- pects of 179. The incurables were those who had not been in any hospital, those who were not sent until their malady was immovably fixed, and lastly, those who had had an appropriate trial of the healing process, but whose disease was incurable from the beginning. Some of those, who, in 1854, had never been in a hospital, were diseased past cure before the Worcester hospital was opened, in 1833. Most of these probably have passed away, and that class is reduced. A larger proportion of lunatics are now sent to hospitals, and more of these are sent in the early stages of their disorder. Still, many are kept back until their day of healing is past. Of the 1,019 admitted last year into the state hospitals, 489 had been diseased a year, and 391 two years or more. The great majority of the last must remain insane for life. There is no record to show whether any, or how many, were deprived of all opportunity of treatment in the state hospitals. According to the last reports there were 1,006 paupers and 298 paying patients belonging to Massachusetts in these establishments. Adding the lunatics in the McLean Asylum, the asylum at Tewksbury, and the receptacle at Ips- wich, there were 468 independent patients and 1,533 pauper patients in the institutions of this State. Beside these, the overseers of the poor reported 442 others in almshouses, etc., making 1,975 reported pauper insane in the State. It appears, then, that this class of patients are sufficiently well provided for. 388 STATE BOARD OF HEALTH. [Jan. But the 468 independent patients under care indicate either that the self-sustaining families en'oy a remarkable immunity from mental disease, or, more probably, that but a small pro- portion of their lunatics are sent to the hospitals and a large proportion retained at their homes. As the self-sustaining families are as anxious that their insane relatives should be restored as the poor, it is worth while to inquire why so many of the latter class and so few of the former are found in the hospitals. The established charge in the state hospitals for private patients is five dollars ($5) a week, and more when circum- stances permit. A large proportion of the independent families, in this and all civilized States, earn a comfortable living only, and have no surplus. By diligence and good discipline of economy they have sufficient for all their common wants, and no more. To them the payment of two hundred and # sixty dollars a year, for the support of a member in a hospital, is nearly or quite impossible, and certainly a burden painful to be borne, and especially if that diseased member be one of the heads, who creates or administers the income. This class embraces professional men, — especially clergymen and teachers, — small farmers, mechanics, journeymen, small traders, etc., who constitute no small proportion of the people, to whom, or, at least, to many of whom, the state hospitals are practically closed by their inability to pay the appointed charge for board and care.* From the e and other causes, we have, in Massachusetts, about 3,300 lunatics, who are and must be supported at an average expense of three dollars a week, at least, for each, or $514,800 a year for all. Add to this the loss of their earnings, and the whole cost of the burden of insanity approaches a million dollars annually in Massachusetts. * Three unmarried sisters sustain themselves and, in great part, their aged parents, by their personal labor; one taught school, one is a book-keeper, and one a sales- woman in a store. Three years ago one of them became insane. They applied to one of the state "hospitals for admission, stating their pecuniary condition. They re- ceived answer, that the patient could be received for five or ten dollars a week. They could not spare five hundred and sixty dollars a year, nor even two hundred and fifty. They could not call themselves paupers and apply to the overseers of the poor. The patient was not sent. She is now insane for life. 1874.] STATE BOARD OF HEALTH. 389 Constant Recurrence of Insanity. The causes of insanity are many and various. They inhere in the constitutions of some. They are connected with many physical disorders and forms of vital depression. They grow out of perversions, excesses, abuses of the mental, moral and bodily powers, especially the appetites and lower passions. These vary in different periods, and with different people, yet in any population their united destructive force is about the same from year to year. The number of patients admitted to the hospitals, within any year, may be assumed to represent as many new cases of the disease. For although in the last year, and in the preced- ing year, many of the lunatics received had been diseased one, two, five, ten and more years, they left behind as many, who w 7 ill be presented to the hospitals when their maladies shall have been standing as long. Taking thus the annual admissions into the hospitals of Massachusetts as representa- tives of the number attacked, there was an annual average of 953 new cases in the last six years, or one in 1,508 of our peo- ple were stricken down with insanity in each year. The pro- portions to the population were singularly regular in these six years, — 1867 to 1872, — being severally one in 1,546, 1,486, 1,533, 1,350, 1,389 and 1,357. There was a similar regu- larity through many preceding years. During the war the proportion was less. The opening of each new hospital increased it. What has been will be, in the same conditions, unless our personal habits and exposures and our social customs change. A similar proportion of our people will annually become insane. And unless more effective influences be used to induce their friends to use the proper means of healing, or to draw them into the hospitals in the early and curable stage of their malady, a like proportion will be kept at home until their dis- ease is fixed beyond hope of removal, or deprived entirely of the opportunity of being restored, and be life-long burdens on the body politic. With this experience of the past, with this great and increasing burden on the income and capital of the people, considering how small the cost of restoration and how large 390 STATE BOARD OF HEALTH. [Jan.'74. the cost of neglect, it is good economy' for the State to open its hospitals freely to every lunatic, and even compel every one to use these or other appropriate means for healing, and allow none to remain permanently insane except the small residuum whose mental disorders are, in their nature, incura- ble. Humanity as well as economy still further demands that the government lend its intelligence and its influence to discover the causes of mental disorder, and to lead the people from those paths of error and those pitfalls that have hitherto destroyed so many among them. jz. < < ■ c: ^Ops -_<:<> ,- CC <£LO tC