men.

Mr. Whitman is a determined fighter, and, with Mr. Mitchell as Mayor, would make up a team that could bring order out of the chaos in the Police Department, if such a task is possible of human achievement.

The mildness and never-failing courtesy of George McAneny have led some men, to their sorrow, to conclude that he was "easy." Idealist and philosopher as he is, he is by no means a dreamer, and his ideals are those of a practical man who knows the world and human nature. During most of the fortythree years of his life Mr. McAneny has had his nose near the municipal grindstone, and his hobby is city government. As a New York newspaper man during some of the years when city politics were at their worst, and later as President of the City Club when they weren't a great deal better, he had acquired, when he took office as President of Manhattan in 1909, a vast knowledge of what not to do as well as the fund of theories that made him suspected by the " man on the street." A friend of the Borough President's has given me this impartial and illuminating estimate of the man : is a mild idealist, but no theorist. philosophy is that of sunshine and light. He hates blue and purple, and likes pink, red, and yellow. Clean, intelligent, effective up to the limits of his physical strength, he makes a good municipal housekeeper and would make an ideal general equilibrator for any administration." In National politics Mr. McAneny is an independent Democrat.

McAneny His social

For the other important city officesnamely, those that confer membership in the Board of Estimate, the body that virtually holds the city's purse-strings-the Fusion nominators have selected William A. Prendergast for Comptroller; and for the Presidencies of the Boroughs of Manhattan, Brooklyn, the Bronx, Queens, and Richmond they have chosen, respectively, Marcus M. Marks, Lewis H. Pounds, Douglas Mathewson, Robert W. Higbie, and George Cromwell.

Mr. Prendergast, who is the present Comptroller, is a Progressive whose aptitude for finance was first evidenced in public office when he was Register of Kings County. He has written much on commercial subjects, and his work, "Credit and Its Uses," is considered an authority. He nominated Timothy L. Woodruff for Lieutenant-Governor in 1896, seconded the nomination of Charles E. Hughes for Governor in 1906, and has himself run for Congress.

Of the others, Mr. Marks and Mr. Higbie, both Republicans, have had little political experience. Mr. Marks is a retired manufacturer with a penchant for arbitrationboth international and industrial, but especially the latter. He has served as a mediator and abitrator in numerous labor disturbances, and was a member of the Industrial Peace Committee of Nine appointed by President Roosevelt, as well as of Governor Hughes's Immigration Commission; but whether his experience as a peacemaker will avail him anything as a member of the Board of Estimate remains to be seen. Mr. Higbie, a merchant who has served as President of the Queens County Chamber of Commerce, has never held public office, although he was a member of the executive committee of the Inter-State Commerce Commission Law Convention which was active in getting through the Hepburn Bill regulating railway rates. Mr. Mathewson is a Republican lawyer who was noted for his independence as a member of the State Assembly some years ago. He has also been Assistant Corporation Counsel, and, as First Deputy Comptroller since 1909, has made a record for efficiency and devotion to duty. Another lawyer on the ticket is Lewis H. Pounds, who showed his willingness to subordinate his own fortunes to the interest of the public when he declined the Republican nomination for Borough President. of Brooklyn in 1909 to avoid cutting into the support of the Fusion candidate, Judge Steers. He was put in the place of the man for whom he had stepped aside when President Steers resigned a month ago. Mr. Cromwell is running for a position that has been his for some time, he having been President of Richmond since the Borough was created in 1898.

The item in the Fusion programme most indicative of the trend of city government in the United States to-day is the provision to clothe the Board of Estimate with powers to be shorn from the Board of Aldermen. This is the last step in a process that has been going on since the Board of Estimate was formed in 1871, and is analogous to the gradual centralization of power in other cities during recent years, culminating in government by commission. Although the average New Yorker is unaware of it, it is a fact that his city is to-day virtually commission governed. Almost the entire power of the city in fiscal matters lies with this Board, which has been called "New York's unique contribution to municipal government." This body

is composed of the Mayor, Comptroller, and President of the Board of Aldermen, with three votes each; the Presidents of the Boroughs of Manhattan and Brooklyn, each with two votes; and the Presidents of the Bronx, Queens, and Richmond, with one vote apiece. At present the only power of the Aldermen over the city's money is to reduce items in the budget proposed by the Board of Estimate they may neither increase items nor insert new ones. Any such reductions, too, are subject to the Mayor's veto, and in that event the Aldermen can gain their point only by a three-quarters vote. If this remnant of former puissance is taken from the Aldermen and given to the Board of Estimate, the government of New York City will be carried on by a commission of eight men, of whom three can control a majority of votes.

The prospect of seeing tried out in a city of 5,000,000 inhabitants an experiment hitherto confined to much smaller communities, and the spectacle of a body of citizens striving to throw off permanently the shackles of partisanship, are the two great features that lend National interest to the bloodless revolution called "Fusion."

GREGORY MASON.

[This article will be followed next week by an account of Tammany Hall and its corrupting influence on New York City government. This account has been written, at the request of The Outlook, by Everett P. Wheeler, Esq., a leading member of the New York Bar, and a loyal, active, and influential Democrat in National politics.-THE EDITORS.]

T

HERE are certain diseases which it would easily be possible for medical skill, clothed with sufficient authority, to banish utterly from any community within a brief time. If we were to set up in each city or State a competent medical dictator, with authority to enforce regulations and restrictions that past discoveries have suggested, he could quickly put an end to typhoid fever and malaria, and reduce diphtheria and scarlet fever to a point where they would cause as little concern as does smallpox in most of our cities at the present time.

Within the past few years we have seen something of this very sort accomplished at Panama, which has been transformed, under the sanitary rule of Colonel Gorgas, from a spot in which it was deemed impossible for white men to work or to live for any length of time, to a district which compares favorably in its health record with any other portion of the United States.

While it is true that under what may be designated as ideal conditions of medical control it would be possible to reduce and in some directions practically to eliminate mortality and morbidity from the common forms of contagious and communicable disease, it is equally true that these diseases continue to exact their toll of sickness and death in all parts of the country at a rate that is still relatively large. If we turn to the statistics of three familiar contagious diseases, diphtheria, scarlet fever, and measles, we find that in 1910 there were 71,238 cases of these diseases in New York and 25,038 in Chicago. There are many smaller cities that would show far higher rates proportionately to their populations.

NOT WHOLLY A MEDICAL PROBLEM

This is but another way of saying that the control and eradication of disease is not wholly a medical problem. It is almost equally a social problem. So long as the

general public prefers to submit to the suffering and loss imposed by controllable diseases, medical skill cannot lift the burden. But the medical profession can devise means of extending the degree of control exercised over contagious and communicable disease. It can impress upon the public mind the advantage and the necessity of isolating and limiting such diseases so far as is possible under existing conditions. And this is a public service which is being performed with increasing thoroughness and effect by medical men through their various organizations.

The problem of dealing with contagious diseases is not a simple one. This is true especially in large and crowded cities. The majority of cases of measles, diphtheria, and scarlet fever, for example, occur among children. Even in schools where medical inspection is provided these diseases often go unrecognized in the early stages and until the opportunity to prevent the spread of contagion has passed. Ignorance and indifference frequently vitiate attempts at effective home quarantine. There are still parents who cling to the senseless belief that measles and scarlet fever are inevitable ills and that the sooner their children have had them and are through with them the better.

CYCLES OF CONTAGION

Contagious diseases, at least the commoner ones which are here dealt with, come and go in waves or cycles, recurring more or less regularly. Measles and scarlet fever appear usually at the same time of year and run in parallel waves. A high wave of measles is accompanied by a high wave of scarlet fever. The receding tides are likewise simultaneous and parallel, although the amplitude of the measles wave is usually much larger than that of scarlet fever. Diphtheria fluctuates less from year to year than the other two. It has a longer season, beginning usually in August or September and slackening only in May or June. It never becomes so suddenly acute as measles and scarlet fever, but its greatest prevalence falls during the months of their heavy incidence.

This synchronous occurrence of the high and low points in the prevalence of the commoner contagious diseases adds to the difficulty of effective control. On account of the difficulties attending the enforcement of rigid home quarantine, it is recognized that hospital treatment is the best method of checking the spread of infection. The mainte

nance of hospital facilities for diseases that may supply hundreds of cases in March and only tens in July presents some special problems. If hospital equipment is provided to care for the number of cases presented when an epidemic is at its height, most of its beds will stand empty during a good part of the year. This in itself is no great calamity, but, whether patients are many or few, the cost of maintenance, the overhead charges, the expense of the medical and nursing staff, must go on. The demands upon the exchequer of the average city are such that public officials are not likely to agree to the expenditure of funds for hospitals unless they are reasonably well filled at most times. There are many unusual items of expense connected with the maintenance of hospitals for contagious diseases, including the necessity of separate pavilions and separate working staffs for each disease treated.

INADEQUATE HOSPITAL FACILITIES

The practical working out of these conditions in most cities is that the provision of hospitals for the treatment of contagious diseases is altogether inadequate. When an epidemic develops, the hospitals are overcrowded, sometimes to the bursting point. Such congestion operates to defeat their usefulness. Overcrowding and lack of air space lead to cross-infection. Insufficient medical and nursing attendance work havoc among the patients. The mortality rates become much higher than the corresponding rates among patients treated in their homes. lack of ample and modern provision for contagious disease hospitals in many American cities has led to the strong prejudice that exists against these "pest-houses," as they are popularly and sometimes accurately named.

The

In a previous article reference has been made to the work done by the New York Academy of Medicine in helping to solve some of the public health problems of the city. One of the first subjects to which the Public Health, Hospital, and Budget Committee of the Academy turned its attention upon its organization early in 1911 was a study of the contagious disease situation in New York. It was found that there were too few hospitals for the needs of the city, and that their capacity was sorely overtaxed during epidemics. The long ambulance rides required in conveying patients to the hospitals, amounting in some instances to eighteen miles, were exhausting and in some cases fatal. As a

result of its investigations, the Committee made a large number of recommendations covering the erection of new hospitals, besides details of construction and administration, quarantine and sanitary regulations, nursing, medical care, and after care.

One of the peculiar difficulties attending the handling of contagious diseases was illustrated when the city authorities, following out the suggestions of the Committee, provided for the erection of new contagious disease hospitals in two boroughs of the city where such facilities were greatly needed. Owners of property adjoining the sites selected immediately protested on the ground that property values would be depreciated because of the popular prejudice against living in the neighborhood of such institutions. The Committee thereupon issued an address pointing out that a hospital for diphtheria, measles, and scarlet fever when properly administered is not a danger to a neighborhood. Undoubtedly, however, a much more sustained effort at popular education in this matter is necessary to eradicate the mediaval notion that the contagion of these diseases is somehow carried about in the air and that the vicinity of a hospital devoted to them necessarily must be a dangerous locality.

PROBLEM OF THE BLACK PLAGUE

While the danger from failure to control such diseases as have been mentioned is generally appreciated, and failure to adopt adequate measures of protection is due usually to practical financial difficulties, there are other more dangerous and insidious diseases against which society has remained virtually unprotected because of ignorance regarding them and because of false notions of modesty which have stood in the way of attempts to dispel this ignorance. Unquestionably it is primarily because of the efforts of physicians to find some means of checking the frightful ravages of this class of diseases that the public is gradually awakening to the importance of this subject and is being brought to the determination to put an end to damaged goods, in the eugenic sense of the term.

There is plenty of evidence to prove that it is high time to grapple with this problem and that its solution will require public support and co-operation in enforcing such measures as may be suggested by the experience of the medical profession. The most serious fact about these diseases, which poison the blood, destroy mental faculties, and bring

a vast train of physical and social ills in their wake, is that their worst effects fall upon the innocent. The hospitals for children are full of venereal affections; half of the existing blindness is due to them; their victims fill not only hospitals and dispensaries, but also lunatic asylums and correctional and charitable institutions.

Over thirteen per cent of all cases admitted to the New York State insane asylums in 1911 were cases of general paresis, an incurable disease of the brain due to syphilis. The care of these patients alone costs the State a million dollars a year. In the city of Philadelphia the cases of paresis, tabes, and cerebro-spinal syphilis admitted to the neurological wards form fifteen per cent of the admissions. From twenty to thirty per cent of the patients in our general hospitals suffer from one form or another of these diseases.

In January, 1913, a circular letter was sent by the Department of Health of New York to every physician in the city, asking him to give the number of cases of venereal disease that he had treated during 1912. The 1,500 physicians who replied, out of a total of 8,000, reported a total number of cases amounting to 42,659. This of course is only a fraction of the number of cases treated in private practice. To form an estimate of the extent of this form of disease one would have to add the large numbers treated in hospitals and dispensaries, and there would still be left a very large number of cases that receive no treatment at all or that receive it at the hands of druggists or of quacks.

PUBLIC CO-OPERATION NECESSARY The causes of these diseases are well known, as are also the methods of early diagnosis and the remedies that can be applied effectively in their earlier stages. Upon the medical side society is well equipped to resist the spread of this frightful scourge. But it is true of these diseases to a greater extent than of almost any others that medical skill alone is unable to deal effectively with the situation. The physician cannot compel treatment, nor can he prevent the spread of the contagion. Only education and rigid social discipline, combined with adequate therapeutic and prophylactic measures, can check the spread of these ravaging diseases. The public and the medical profession must work together in order to check and, finally, to conquer them.

In an effort to devise more effective methods of dealing with diseases of this class the Public Health, Hospital, and Budget Committee of the New York Academy of Medicine has turned its attention to an important agency which is valuable also in dealing with many other forms of disease, but which is usually hampered by lack of resources and facilities. This is the dispensary or outpatient clinic. With an equal expenditure of time and effort the well-equipped dispensary can deal with a far greater number of those cases which it is fitted to treat than can a hospital, and it reaches many cases that never would come under hospital care. According to official statistics more than 3,500,000 treatments were given in the dispensaries of the city of New York in 1911. This, of course, is the count of treatments, not of patients. Many patients come many times. Even with this qualification, however, the figures are instructive as showing the vast tide of illness and misery that flows unceasingly upon the one hundred odd dispensaries of the city, the amount of gratuitous service that the attending physicians render, and the important place that the dispensary occupies in the general scheme of public health work.

IMPORTANCE OF THE DISPENSARY

In view of the vast field that it is called upon to cover and the importance of its work, it is a curious fact that the dispensary is looked upon almost invariably by boards of managers as the Cinderella of the hospital household. It is scarcely ever cared for properly, is seldom well equipped, and is almost always expected to be self-supporting. Apparently not much faith is placed in the efficacy of the medical treatment provided by the dispensary, and slight recognition is given to its great possibilities in preventive medicine and in the public health movement. It is relatively easy to raise money for a hospital, but it is difficult to raise it for a dispensary, despite the greater social importance of the out-patient department. The hospital deals with cases of disease when they are in full swing; the dispensary deals with them in incipient stages, when they lend themselves much more readily to successful treatment and cure. Then, also, the dispensary has a great function to perform in advising and guiding patients with chronic diseases who either cannot be admitted to hospitals, or, if admitted, are likely to become pauperized,

hospitalized, and helpless. Dispensary work becomes still more efficient and socialized where it reaches out to the homes of patients through a social service department, which brings patients back for treatment and thereby prevents the waste of the physicians' efforts, which supplies facts helpful to establishing correct diagnoses, and does educational work looking to the conservation of health and the prevention of disease among the dispensary's constituency. Wherever dispensary work is treated conscientiously along such lines as these its benefits soon become manifest. From this brief outline of the field of the dispensary it may readily be seen that it is especially adapted to dealing with those diseases which menace society particularly because, either from ignorance or fear of exposure on the part of their victims, they do not receive private medical treatment or come under hospital care until they have reached advanced stages, having been transmitted possibly to many other persons in the interim. In any comprehensive plan for dealing with diseases of this class the dispensary should fill a very important rôle.

In the effort to increase the efficiency of this branch of the public health service the Public Health, Hospital, and Budget Committee of the Academy was instrumental in bringing about the formation of the Associated Out-Patient Clinics of New York, with the fourfold aim of co-ordinating the work of the existing dispensaries and out-patient clinics, of eliminating “rounders" and other undeserving applicants, of promoting proper standards of treatment, and of securing economy and efficiency in management. Most of the important general dispensaries of Manhattan, all of those connected with teaching institutions, the municipal dispensaries, and many special dispensaries, have joined the Association. In the short period of its existence many important measures have been adopted and changes have been inaugurated which will go a long way toward the betterment of existing conditions. The Association should prove valuable in helping to impress upon medical authorities, city officials, and the general public the importance of this branch of public health endeavor.

A PUBLIC HEALTH CLEARING-HOUSE

Another field in which the Academy's Committee has been active has been in bringing about a concentration of effort among agencies devoted to the promotion of public