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tion of cases that outbreaks due to infected milk or the infection of a common water supply can be recognized and proper remedies applied or that typhoid-bacillus carriers can be traced and controlled.

Scarlet fever is another common disease in which the need for the notification of cases is universally understood. Every case of this disease comes from some preexisting case. No community would expect and no health department would attempt to control this disease in the absence of the notification of the cases that were occurring. The same is true of plague, yellow fever, and cholera. There are many other diseases, however, in which the importance of the reporting of cases has not been generally appreciated, but in which the necessity is just as great if they are to be prevented. The necessity for notification exists in all preventable diseases. Their causes or methods of spread may be different and the measures necessary to prevent them may vary, but the notification of the occurrence of cases is essential in all for their successful control. The health department can not prevent the spread of diseases of the existence of which in the community it is unaware.

For purposes of public health administration, cases of the communicable diseases may be divided into four groups, namely: First, the well-marked cases: second, the mild, concealed cases; third, the mild unrecognized cases; and, fourth, the well, or apparently well, carriers. To prevent the spread of these diseases control of all four groups is necessary. The control of only the first group by quarantine or other means, a practice by no means uncommon, is of little value in preventing the spread of these diseases, as the well-marked cases usually come less in contact with others than do the cases of the other groups, and are likely, therefore, to be less potent factors in spreading infection. The well-marked cases are presumably usually reported. The mild cases should also be reported. The notification of the cases in the first two groups should enable a well-organized health department to discover most of those in the other two by a careful study of the conditions under which the reported cases occur. To find the unrecognized cases and carriers, to which is largely due the spread of the communicable diseases, is a prime duty of the health officer. The accomplishment of this requires intelligence and watchfulness and will be possible in proportion to the completeness with which the recognized cases are reported.

But the health department of a city, township, or county needs to know not only of the occurrence and prevalence of disease in its own jurisdiction, but also of the prevalence of disease in neighboring cities, towns, and counties, so that it may be informed of the possibility of the introduction of disease from other communities. The prevalence of infectious diseases in every city and county has an important bearing on the welfare of every other city and county in a State. In a

well-organized State, therefore, the local health authorities keep the State health department currently informed of the prevalence of disease in their respective jurisdictions, that the information may be made available to the various local authorities and that the State department, acting in its broader field as the agent and representative of all localities and all the people, may perform its proper functions in the prevention and control of disease. Without the information of the prevalence and geographic distribution of disease obtaineble in this way the State health department will remain in ignorance of the sanitary condition of the State, and, because of this lack of knowledge, will be unable to perform its proper functions and will therefore constituie a health department largely in name only.

In addition, a State health department needs for the proper performance of its functions a knowledge of the prevalence of disease more extensive than that of its own State. It needs to know of the prevalence of disease in neighboring States and even in those more remote. It is as necessary that one State should know of the prevalence of disease in other States as that a city should know of the prevalence of disease in surrounding communities. Therefore, to complete the usefulness of the health organization it is important that the States report to some national agency the occurrence of disease in their various jurisdictions, that the information may be made available to the several States, and that the national health service, acting as the representative of all the States, may, when occasion arises, perform those functions with which it has been intrusted and for which it has been made responsible. A resolution providing for reports of this kind by the States for the purpose of making available current information of the prevalence and geographic distribution of the notifiable diseases was adopted in June, 1912, by the State and Territorial health authorities in conference with the United States Public Health Service. 1

Thus, it is apparent that the notification of cases of the preventable and controllable diseases is the only satisfactory foundation upon which public health work--local, State, or national--can be builded. There is no other foundation upon which work that will yield a proper return for the amount expended can rest , nor is there likely to be for a long time to come. Public health work based upon the knowledge furnished by the notification of cases is not only the only rational and effective work, but is the only one that gives results commensurate with the outlay and effort made.

A discussion of either public health organization or the notification of disease-morbidity reports—would be incomplete without a consideration of the relation of the practicing physician to the subject. The person responsible in most cases for the reporting to the

1 See Public Health Reports, Vol. XXVII, No. 23, June 7, 1912, p. 895.

proper authorities of the occurrence of cases of the notifiable diseases is necessarily the practicing physician who first comes in contact with such cases. The practicing physician constitutes the picket of the health organization, the sentinel who must give the first notice of the presence of disease and upon whom rests the responsibility of discovering and reporting new cases as they occur. The practicing physician, therefore, constitutes in reality an essential part of any plan of health administration.

The physician is engaged in a work which places him in a position of especial and peculiar responsibility to the community, a work which carries with it moral and usually statutory obligations, upon the proper fulfillment of which depends to a large degree the ability of the health department to perform its functions. The requiring of those desiring to practice to pass an examination and to be duly licensed and registered is a partial recognition of this, and presumably such licenses are given on the assumption that the recipient will comply with the requirements imposed upon physicians by law, among which is invariably the duty of reporting cases of certain diseases coming to his knowledge. The physician who does not comply with such statutes not only places himself in the class of those who violate the law, but shows himself indifferent to his moral obligations as they affect the welfare of the community. It would be well to give more definite recognition to the relationship the physician holds to the health department and to the community. Such recognition would undoubtedly be agreeable to physicians and bring them into closer cooperation with the health authorities in whose jurisdictions they practice.

The citizen also should cooperate with the health department. The individual who objects to complying with the requirements regarding the notification of disease when they apply to himself or his household can not expect his neighbors or associates to report the cases in their families. The moral obligation of the individual to his neighbors and the community is such that he should make the same effort to protect them from his illnesses as he expects them to make to protect him. The health officer needs the assistance of the people at least to the extent of complying with the health laws, and the requirements for the notification of sickness are among those to which especial attention should be paid. The health officer is the servant of the community. He is the one employed by the people to look after their health interests, taken in the aggregate. It is no more rational to employ a health officer and then not give him every facility and assistance for accomplishing the things for which he has been employed than it would be to hire a gardener and then not supply him with tools.

As the local health department expects to have cases of the notifiable diseases reported to it by physicians, so it should give every assistance to the State health department by keeping the State department informed of the sanitary status and occurrence of disease in its local jurisdiction. If there is law or regulation requiring the city, town, or county authorities to notify the State, this is sufficient reason. In the absence of law, however, the importance of the matter, and the fact that both State and local health departments are working for a common end, is sufficient reason why the local authorities should give all possible assistance to the State, and especially should report the occurrence of the preventable diseases in so far as it has the information. No city can be so large nor its health department so efficient that it is relieved of this obligation. The larger the city and the better equipped its health department the greater the obligation to the State, just as the more influential and prominent the citizen the greater his obligations to the community. The local health department that does not cooperate with the State authorities has but little moral right to expect the citizens within its jurisdiction to render to it any assistance beyond that insisted upon by the courts or inspired by fear of fines or imprisonment. The local health department and its jurisdiction are to the State department what the individual and his household are to the local department.

On the other hand, the State, too, in so far as the control and prevention of disease is concerned, is but a unit. Disease is no more a respecter of State boundaries than it is of those of counties or municipalities. It ignores such boundaries established by man. What the household is to the municipality, and the city and county to the State, the State is to the Nation.

With the several States alone responsible under the Constitution for the sanitary conditions and public health administration within their respective boundaries in so far as these do not affect the welfare of other States, and with a large part of this responsibility in many instances delegated by the States to local authorities, a comprehensive plan of public health administration will need to be one of cooperation. Within the States it will need to be one of cooperation of the local authorities acting with and through the State health departments, and for the Nation a cooperation of the State health authorities with the Federal Public Health Service.

USE OF FINGER BOWLS.

AN OBJECTIONABLE CUSTOM AS SOMETIMES PRACTICED.

A Note by C. H. LAVINDER, Surgeon, United States Public Health Service. A recent bulletin of the service (Public Health Bulletin No. 57) reviews the subjects of common drinking cups and roller towels, and gives the laws relating thereto. Neither in this bulletin nor elsewhere have I ever seen any reference to an abuse which it seems to me is of little less importance than the common drinking cup, and the dangers from which are of quite a similar character. This is the use of the common finger bowl.

It seems to be customary even in high-class restaurants to have in use about half a dozen finger bowls, more or less, and these do service for many patrons. The water in them seems to be changed at rare intervals and entirely in the discretion of the waiter. Occasionally one will see the old water poured out and fresh poured in, but far more frequently even this is not done. I presume the bowls must be taken out and washed occasionally. Now, when one considers that many persons in using these bowls wash not only their fingers but their lips as well, it would seem that the conditions of the common drinking cup are different only in degree. Moreover with the finger bowl it is not only the question of using a common bowl but often common water also.

Since I first noticed in some hotels and restaurants this disgusting manner of serving these convenient accessories of a table service, I have taken some pains to learn how widespread such a thing might be, and my observations lead me to the belief that it is very common indeed. I am inclined to think that the common finger bowl should be classed with the common drinking cup, as an offense of the same character, but possibly less in degree.

HOOKWORM DISEASE.

PROPORTION OF MALES TO FEMALES IN THE AMERICAN HOOKWORM (NECATOR

AMERICANUS), BASED ON 13,080 WORMS FROM 102 CASES. By C8. WARDELL STILES, Professor of Zoology, and W. L. ALTMAN, Assistant, Hygienic Laboratory,

United States Public Health Service. The point was raised by Leichtenstern in 1885 that by counting the male and female hookworms passed by a patient and drawing the proportion, the clinician has a practical clue to the completeness or incompleteness of the cure effected. This point was based upon the premises that the males and the females are present in relatively fairly constant proportion and that the males are more difficult to expel than are the females.

Read at the XV International Congress on Hygiene and Demography, Washington, September, 1912.

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