a female mosquito of the Anopheles species and by it be transferred to man. It is claimed that in parts of the United States today malaria reduces the working strength of the people 50 per cent. Sir Ronald Ross of the Liverpool School of Tropical Medicine is quoted as saying that one-half of the people of Greece have suffered genuine injury from malaria, while Dr. W. H. S. Jones feels that malaria in no small way caused the downfall of ancient Greece and Rome. Continued warfare on the mosquito therefore will give us the victory over both malaria and yellow fever.

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The work done at Havana and at Panama is a striking proof of man's growing control and of its value. The Panama Canal was made possible by the growth of our knowledge of disease. No one can speak with greater authority on this than Dr. Gorgas. Before 1901 "Havana had yearly from 300 to 500 deaths from malaria, rising as high in 1898 as 1,900 deaths. Since 1901 there has been a steady decrease in the malarial death rate until the last year of the table, 1912, when there were only four deaths." By 1912 malaria had become as completely extinguished in Havana as had yellow fever in 1902.❞ 14 In 1906, at Panama 821 out of every 1000 were admitted to hospitals for malaria, in 1913 only 76 per 1000. Of the general situation at Panama he says: We had an average of 900 men sick every day. For the year this would give us 328,900 days of sickness, and for the ten years 3,285,000 days of sickness. If our rate had been 300 per 1000, a very moderate figure compared with what it was under the French, we should have had 11,700 sick every day. For the year this would have

66

14 GORGAS, W. C. Sanitation in Panama, pp. 73, 74. 15 Ibid., p. 275.

15

given us 4,270,500 days of sickness and for the ten years 42,705,000, a saving of 39,420,000 days of sickness during this period." This is equal to a saving in cash of $329,420,000.

"During the ten years of construction, we lost by death seventeen out of every thousand of our employees each year. That is, from the whole force of 39,000 men, 663 died each year, and for the whole construction period we lost 6,630 men. If sanitary conditions had remained as they had been previous to 1904, and we had lost as did the French, two hundred of our employees out of each one thousand on the work, we should have lost 7,800 men each year, and 78,000 during the whole construction period." 16 This means that 71,370 lives were saved.

Perhaps the greatest conflict of medical history is that now waged against tuberculosis, which today causes over one-tenth of the deaths in our land. This disease is important not merely because of the death rate (being responsible for some 130,000 lives annually) but because of its long, lingering character, imposing a terrific burden upon families and communities alike, and costing some $200,000,000 annually in our own country. Cures for tuberculosis are today unknown, yet the newer knowledge has enabled us to cut down the death rate perhaps 50 per cent in the last twenty-five years. Once regarded as fatal to every sufferer, we now know that if proper care is provided in the earlier stages of the disease, recovery may be expected in perhaps the majority of the cases. an authority than Dr. Earl Mayo has declared: members of the medical profession were given a free hand to deal with this disease, backed by adequate provision for the care of existing cases, tuberculosis could be prac16 GORGAS, W. C. o. c., p. 280.

No less

"If the

tically stamped out within a single generation." 17 The fight against this disease involves its extermination among cattle likewise, for these valuable animals are unfortunately attacked by it. Probably the best organized social agency of the day is the anti-tuberculosis movement.

For a long time typhus and typhoid-both filth diseases were not distinguished. The rôle of the former is now usually insignificant, but recent frightful outbreaks in Servia and Armenia make us realize that it is only suppressed by maintaining high standards.

Deaths per 10,000 from Typhus and Typhoid

Typhoid fever, the cause of the death of 30,000 Americans a year, did not play an important rôle till the middle of the nineteenth century, when the many epidemics became noticeable. It is spread only through the waste products of the body and carried by milk, water, or flies to other persons. If these waste products are sterilized there can be no spread. Hence the bill of $212,000,000 annually paid by Americans is wholly unnecessary if present knowledge is utilized. Europe is ahead of us. Thirty-three of its largest cities with a population of 31,500,000 have recently averaged only 6.5 deaths to every 100,000, while twenty-five of our cities with 20,000,000 inhabitants are averaging 25 per 100,000. Aside from this attack on the disease, we are now reducing its ravages by inoculation. In 1898 in the Seventh Army Corps at Jacksonville, Florida (some 10,759 men), there were 4,422 cases of typhoid with 248 deaths. In the 1912 17 MAYO, E. In The Outlook, Dec. 7, 1912.

maneuvers at San Antonio, Texas, among 12,801 soldiers there was only one case, which however resulted fatally.

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During the Spanish War there were 20,738 cases of typhoid and 1480 deaths; nearly one-fifth of the entire army had the disease. It caused over 86 per cent of the entire mortality of that war. In some regiments as many as 400 men out of 1300 fell ill with it. . . . From June 1908 to 1909, when the vaccination was purely voluntary and the army was not in the field, proportionately sixteen times as many unvaccinated soldiers fell ill with the disease as compared with the vaccinated." 18 In the British garrison in India formerly from 300 to 600 died yearly of typhoid before vaccination was introduced. In 1913 less than 20 died. Among 8,754 inoculated British soldiers in India there were recently 16 cases with no deaths, while 7,376 uninoculated showed 68 cases with 14 deaths. The French have produced similar results in Africa. Contrast the Franco-Prussian War, when typhoid was responsible for nearly 60 per cent of the mortality among the German troops, with the Russo-Japanese War when for the first time in history disease played second rôle to death in battle.

Diphtheria still kills about as many as typhoid, and these chiefly young children, but its share in the death rate has been greatly decreased since the discovery of antitoxin in 1892 by Behring and can be still further reduced when better provision is made for prompt attention. The death rate from diphtheria in New York City is now about one-fifth of the average rate before the introduction of antitoxin. In 19 of the large cities of Europe and North America with a combined population of nearly 23,000,000, the deaths from diphtheria were 66.9 per 18 KEEN, W. W. o. c., p. 259.

The

100,000 in 1890; 32.7 in 1900, and 19 in 1905. mortality of 7.9 per 10,000 of population in 1894 was reduced to 1.9 by 1905.

With reference to other diseases, the present prospect is less encouraging. Pneumonia contests with tuberculosis for a place at the head of the causes of death, while cancer stands seventh and is apparently increasing. While we are making little headway against pneumonia,

DEATHS FROM TUBERCULOSIS AND CANCER

the fact that it attacks people of advanced years and the intemperate makes it perhaps less significant. It results fatally in from 20 per cent to 30 per cent of the cases. The germs are probably present in 20 per cent of healthy normal people all the time. Cancer is giving us growing The use of the knife in the early stages plus perhaps treatment by radium, offers the only hope at

concern.