course, will soon demand special forms of training. Whether apprenticeship in public health service will provide the chief means of preparation or whether schools of public health will assume this function is a question for thoughtful consideration.

may

In an attempt to outline the chief lines of future development it be well to enumerate the different types of public health functionaries for whom training will have to be provided. These fall into a number of fairly well defined groups: 1. Public health administrators, men with fundamental and thorough training who are capable of serving as federal functionaries, and as state, city and county health officers. 2. Laboratory men who have had sufficient contact with field work to be thoroughly intelligent about their duties. In this group may be included also statisticians whose training in public health enables them to interpret with some intelligence the data with which they deal, and to estimate with reasonable accuracy the coefficient of corruption and the mean of mendacity by which vital statistics are so largely vitiated. 3. Administrative specialists, who, with a background of general training, have become proficient as epidemiologists, authorities in tuberculosis or specialists in venereal diseases. 4. Sanitary engineers who deal with engineering problems not merely from a physical but from a biologic point of view. 5. School medical officers who are more than practitioners and see the health of the school in its wide relations to community life on the one hand, and to individual efficiency on the other. 6. Specialists in public health education and publicity who combine with accurate knowledge the capacity to apply practically the principles of individual and group psychology. 7. Public health nursese with special training and aptitude for the important duties which more and more will devolve on them. These nurses will be differentiated, for example, into the city nurse, the town nurse and the rural nurse. 8. Sanitary inspectors of many kinds, the artisans of the public health service, who nevertheless require a training which will enable them to do their work intelligently and with satisfaction both to themselves and to the commiunity. Doubtless as time goes on the types enumerated above will be still further differentiated, and new functionaries will be added to the list. A system of public health education must consciously take into account the functions to be performed and adapt its methods to the indicated kinds of training required.

A word may be said here about the sanitary engineer. It is sometimes assumed that engineering training with special reference to water supplies, sewage disposal, etc., best fits a man for public health administration. This is far from being true. The sanitary engineer is a specialist whose expert services are essential. But he has not the background of biologic training, the intimate knowledge of infectious diseases, or the mastery of medicine which enables him to assume the general oversight of a municipal or state public health organization. The sanitary engineer is a necessary member but not the responsible head of a modern mechanism of social medicine.

The underlying idea of successful technical training is that it should be in the hands of men thoroughly familiar with the profession

involved and completely imbued with its point of view and spirit. This means that no successful course for specialized training can be made by the mere grouping of existing courses and the printing of these in a single catalogue. Business training in American universities affords an illustration in point. Colleges of commerce were created over night. Courses in economics, business law, modern languages, commercial geography, banking, insurance, etc., were grouped into a new curriculum and offered to an admiring public. The failure of these early attempts was inevitable. The courses were taught not by men who were familiar with the actual problems of business, but by instructors whose training and interests were of a wholly different tradition. The recent progress in schools of business administration has been due to the introduction of new types of teachers who, by practical contact with business organizations, have trained themselves for efficient service. The best schools are being brought into close and sympathetic connection with the business world.

This principle applies to public health training in a most obvious way. Laboratory courses, public hygiene courses, and instruction in law, economics and sociology will be of little value unless they are all dominated by public health ideals and are constantly realted to public health problems. It is for this reason that the new school at Johns Hopkins University will be in a position to create from the outset the right atmosphere, by securing men who represent public health training, spirit and ideals, and who will inspire in their academic collegues that intelligent co-operation so essential to a unified and successful course of technical training. In order to insure this unified, purposeful kind of organization the agency for the teaching of public health must have reasonable autonomy. It will not do to make the new curriculum a mere by-product of medical education or subject to its sole control. There should be a special administrative board and a director imbued with the ideals of preventive medicine. Only under such conditions. can a public health teaching organization gain the requisite authority. co-ordinated efficiency and professional spirit.

The conditions for admission to a public health course will require careful consideration. There is an advatage in making the degree of Doctor of Medicine a prerequisite. This degree received from a medical school of the first class guarantees sound training and maturity. Moreover, it gives a public health officer a sense of security and independence, for he feels that he can fall back on the practice of his profession if he proves unadapted to the public career. On the other hand, there is a little danger that a man may gain too much of the physician's individualistic philosophy and therapeutic bent, give too much time to unnecessary medical and surgical technic, and for the very reason that he may take up the practice of his profession, lack the devotion of the person who has committed himself almost irrevocably to a career of service under public auspices. It is althogether likely that requirements will be so modified as to permit a student of medicine, after his first two years to substitute in the second two years a good deal of public health work for the clinical courses of the regular medical curriculum. It is undesirable, however, for men who are being trained for the

highest positions in preventive medicine to have less than the full equivalent of a four year medical course with two years of graduate work.

If the analysis of functions indicated in an earlier paragraph is valid, it would suggest that courses of different length and different. requirements will be prescribed for the several groups. It is quite conceivable, therefore, that curriculums may vary in length from two or four to eight years beyond graduation from high school. The earlier limit might apply to nurses and inspectors, while the latter would have reference to the health executive who assumes responsibility for a large administrative unit. Appropriate certificates and degrees will doubtless be worked out and given, as in the case of other designations, a standardized value, so that the holding of these forms of recognition will be directly related to the securing of positions, promotion, etc., in public health organizations.

Lack of time and my obvious incompetence afford good grounds for not attempting any detailed discussion of curriculums. One or two suggestions may be made in passing: 1. The fundamental public health background should be provided for all specialized functionaries. The unity of the profession, the proper team play, and efficiency can be secured only as each individual sees his special task in the wider relationships of the general theory of preventive medicine and of public health purposes. 2. The practical field work must be done under supervision, and must be carefully checked and reported. There is a good deal of so-called practical work done in connection with educational institutions, but this is likely to be of little significance because it is not made a vital part of the curriculum as a whole. The cooperation with public health agencies, therefore, will have to be worked out in a definite and precise fashion. It is possible also that it will turn out to be wise not to confer the highest degree until a candidate has demonstraated for at least a year his ability to render satisfactory service in connection with some regular agency of public health. This test would correspond to the one year's internship which medical education regards as essential for the completion of a course of thorough general training.

Ordinary laboratory facilities and supplies, in the case of a school of public health, should be supplemented by a statistical laboratory with its proper equipment; by a special public health library and museum, with exhibits of all kinds bearing on public health problems; by a collection of slides and films; by equipment, models, etc., illustrating various phases of sanitary engineering, water supplies, filtration plants, sewage disposal, housing and the like, and by exhibits of public health publicity material, charts, posters, placards, newspaper articles and advertisements. Obviously all the devices for administrative purposes, record cards, blanks, filing systems, etc., would form a part of the illustrative material at the disposal of every public health school.

The social sciences will receive more emphasis. Courses in vital statistics, the history of public health work, in the social philosophy which underlies modern collective undertakings, the economic side of public health, the growth of administrative law in its relation to pre

ventive medicine, and the problems of poverty and of dealing with dependent, defective and delinquent groups will receive increasing attention. This will have a specially important bearing on giving not only the public health point of view but also the attitude toward modern society which is necessary for devoted and loyal public service.

It is to be hoped that some system of fellowship aid may be made available to encourage promising men and women of limited means to enter the profession. It is possible that, in connection with these schools, endowments may be secured for fellowships of this kind. It is also to be expected that subordinate positions in public health departments will be open to students in schools of public health so that these persons may at the same time support themselves and turn their work to account as a part of the training which they are receiving. In many places, arrangements of this kind have been made. It is reasonable to look forward to an extension of this plan. Fellowships might also be made useful in encouraging small communities to engage full-time health officers. Graduates with stipends for a year might in this way find openings, and after demonstrating convincingly the possibilities of modern health administration, might be given permanent positions, wholly sustained by local appropriations.

The outlook for public health in the United States is encouraging. There is an increasing recognition of its economic and social importance as well as its bearing on individual happiness. The new sense of nationality which is being forced on us will accustom us more and more to taking the general rather than the individual point of view. We shall be driven to co-operate and to undertake public services on a new basis. It is, therefore, a time when the subject of training public health officers is peculiarly significant. It is to be hoped that the work will be developed not through institutional and local ambition, but with the welfare of the whole country in view.

It seems clear that not every university which has a medical school can provide a full course of public health training. It is desirable, therefore, that a few centers be recognized, and that for the higher types of training these centers be given the ample funds which are necessary for the right sort of education. This does not mean that in many places courses for public health nurses and inspectors may not be profitably introduced, or that in still others laboratory men may not be trained at least up to a certain point. Standards and ideals, however, should be set by a few institutions which have the resources which will enable them to establish genuine schools well equipped, properly manned, dominated by authoritative leaders, inspired by the public health point of view, and working in close fruitful relations with the public health agencies of the community, the state and the nation. The University of Minnesota.

FUMIGATION.*

. BY F. ADAMS, M. D., D. P. II.

Acting Director of Laboratories and Epidemiologist, Department of Public Health, Toronto, Canada.

Our knowledge of the contagious diseases has increased, particularly in regard to the ways in which they are spread, and our conceptions of what is genuinely important and what is relatively unimportant in the matter of prevention have undergone radical changes.

1885. Diseases.

SCARLET FEVER, DIPHTHERIA, MUMPS, MEASLES, INFLUENZA, WHOOPING COUGH, COMMON COLDS.

SCARLET FEVER, DIPHTHERIA, MUMPS, MEASLES, INFLUENZA, WHOOPING COUGH,

*This is in part, an article appearing in The Public Health Journal of Toronto, Canada, in March, 1917.