3^4 



NATURE 



[August 20, 1891 



will indicate how much remains to be done. Did time permit, 

 I might illustrate the progress of preventive medicine by con- 

 trasting the state of England with its population of more than 

 29,000,000 during the Victorian with the England of the 

 Elizabethan age with its 4,000,000. I might remind you of the 

 frightful epidemics which had devastated the land, in the forms 

 of black death, sweating sickness, plague, petechial typhus, 

 eruptive fevers, small-pox, influenza, and other diseases, such 

 as leprosy, scurvy, malarial fever, dysentery, &c., of the 

 wretched mode of living, bad and insufficient food, filthy 

 dwellings, and ill built towns and villages, with a country un- 

 cultivated and covered with marshes and stagnant water (ac- 

 cording to Defoe, one-fifteenth part of England consisted of 

 standing lakes, stagnant water, and moist places, the land unre- 

 claimed, and with the chill damp of marsh fever pervading all). 

 The homes of the people were wooden or mud houses, small 

 and dirty, without drainage or ventilation, the floors of earth 

 covered with straw or rushes, which remained saturated with 

 filth and emitting noxious miasmata. The streets were narrow 

 and unpaved, with no drains but stagnant gutters and open cess- 

 pools, while the food was principally salted meat with little or 

 no vegetable. To this may be added a large amount of intem- 

 perance and debauchery. As it is, I can only just allude to 

 them. In such conditions disease found a congenial nidus, and 

 by a process of evolution assumed the various epidemic forms 

 which proved so destructive to life. Some of these have gone, 

 let us hope never to return, and the conditions which fostered if 

 they did not cause them have gone also. Can we venture to 

 hope that it will be the same with those that remain ? Our im- 

 munity during the last diffusion of cholera gives some ground for 

 thinking it may be so, if, indeed, the Legislature and popular 

 intelligence should be of accord on the subject. 



If we turn to the present, we find that great improvements 

 have gradually been made in the mode of living ; the houses are 

 better constructed, the drainage and ventilation are more com- 

 plete, the land is better cultivated, and the subsoil better 

 drained ; marsh fever and dysentery, at one period so rife, are 

 unknown, and leprosy hns long since disappeared. The death- 

 rate is considerably reduced, and theexpectancy of life enhanced. 

 Water is purer, food is more varied and nutritious, clothing is 

 better adapted to the climate, the noxious character of many 

 occupations has been mitigated, and the mental, moral, and 

 physical aspects of the people altogether improved ; education is 

 general, a better form of government prevails, and the social 

 conditions are far in advance of what they have been ; but still 

 the state of our cities shows that improvement is demanded, 

 and one object of this Congress is to point out why and how 

 this may be effected, not only in this country but throughout the 

 world. 



If we inquire into the effects of certain well-known diseases, 

 we find that they are less severe in their incidence, if not less 

 frequent in their recurrence. With regard to small-pox, since 

 the passing of the first Vaccination Act in 1840, the death- 

 rate has diminished from 57*2 to 6"5 per 100,000 for 1880-84, 

 though for the five years 1870-74 it was 427, thus showing that 

 there was still much to be learnt about vaccination. Enteric 

 fever was not separated from typhus fever before 1869, but since 

 then the death-rate has decreased from 0*39 to 0-17 per 1000, 

 and it has been shown that this improvement was synchro- 

 nous in different parts of England with the construction of proper 

 drains. The diminution in the death-rate from typhus fever is 

 quite as striking, and this also is shown to have run parallel with 

 improved sanitation in more than one large town. The death- 

 rate from scarlatina fluctuated between 97 and 72 per 100,000 

 between the years 1851 and 1880, and though it has 

 diminished considerably of late years (17 per 100,000 in 

 1886), a corresponding increase in the death-rate from 

 diphtheria has taken place ; this may be due in part to 

 a better differentiation of the two diseases. In 1858 

 it was reported that phthisis killed annually more than 50,000 

 people ; the death-rate from this disease has not decreased very 

 much for England and Wales, but it has done so in some large 

 towns, notably in Liverpool ; and Dr. Buchanan and Dr. Bow- 

 ditch of Massachusetts both showed a striking parallelism 

 between the diminution of the death-rate from this cause and 

 the drying of the soil resulting from the construction of sewerage 

 works. Cholera first appeared in England in 183 1, and there 

 were epidemics of it in 1848-49, 1853-54, and 1865-66, but the 

 number of deaths diminished each time it appeared, and though 

 it has been present since, it has never reached the height of an 



NO. I 1 38, VOL. 44] 



epidemic. This is fairly attributable to local sanitary rather 

 than to coercive measures. Preventable disease still kills yearly 

 about 125,000, and, considering the large number of cases for 

 every death, it has been calculated that 78^ millions of days of 

 labour are lost annually, which means ;^7, 750,000 per annum ; 

 this does not include the days lost by the exhaustion so often 

 induced by the still too numerous unhealthy houses of the poor. 

 Towns, villages, and houses are still built in an insanitary way ; 

 the death-rate is still higher and the expectancy of life lower 

 than it should be, and though we have got rid of the terrible 

 plagues of the middle ages, yet in this century, now closing, 

 other epidemics have made their appearance : cholera has four 

 times visited us ; fevers, eruptive diseases, and diphtheria 

 have prevailed ; influenza has appeared several times, even 

 recently, and after leaving us last year, only to return with 

 renewed virulence, caused in the United States a mortality 

 almost equa to that of the plague. Much has been done, 

 and a great deal of it in what is called the pre-sanitary age, 

 but much remains to be effected. Let us hope that the 

 future may be more prolific of improvement than the past ; 

 international philanthropy seems to say it shall be so. That 

 we can exterminate zymotic disease altogether is not to be 

 expected, but there cannot be a doubt that we may diminish its 

 incidence, and though we may never be able to reach the " fons 

 et origo mali," yet we can make the soil upon which its seed is 

 sown so inhospitable as to render it sterile. The scope and objects 

 of preventive medicine are not limited to the removing of condi- 

 tions which give rise to zymotic disease, nor even of those which 

 compromise otherwise the physical welfare of mankind, but should 

 extend as well to a consideration of the best means of controlling 

 or obviating those which, attending the strain and struggle 

 for existence, involve over-competition in various occupa- 

 tions, whether political, professional, or mercantile, by which 

 wealth or fame is acquired or even a bare livelihood is obtained, 

 and under the pressure of which so many succumb, if not from 

 complete mental alienation, from breakdown and exhaustion of 

 the nervous system, which give rise to many forms of neurotic 

 disease and add largely to the numbers of those laid aside and 

 rendered unfitted to take their due share in the natural and in- 

 evitable struggle for existence. Or I might point to the 

 recrudescence of those psychical phenomena manifested by 

 the so-called hypnotism or Braidism, morbid conditions arising 

 out of the influence of one mind upon another ; this is a subject 

 which demands not only further investigation, but great precau- 

 tion as to its application, and claims-' the watchful notice of 

 preventive medicine on account of the dangerous consequences 

 which may ensue from it. 



Again, the abuse of alcohol, opium, chloral, and other 

 stimulants and narcotics, and the evil consequences which may 

 result therefrom, is also a subject worthy of consideration, and 

 will, no doubt, receive it in a communication which is to be 

 brought before this Section. 



The possible deleterious influence of mistaken notions of 

 education, as evinced in the over-pressure which is exercised 

 upon the young, the predominance of examinations, their in- 

 creasing multiplication and severity, and the encouragement of 

 the idea that they are the best test of knowledge, whilst true 

 mental culture is in danger of being neglected, and physical 

 training, if not ignored, left so much to individual inclination — - 

 this is another subject which demands the jealous scrutiny of 

 preventive medicine, whose duty it is to safeguard the human 

 race from all avoidable causes of either physical or mental 

 disease. 



Though preventive medicine in some form has been 

 practised since the days of Moses, yet it has received but 

 little recognition until a comparatively recent period ; when 

 science developed and observation extended, medical men 

 and others became impressed with the influence of certain 

 conditions in producing disease, and thus it was forced 

 upon the public conscience that something must be done ; 

 and when philanthropists like John Howard devoted life 

 and property to the amelioration of such awful conditions as 

 existed — e.g. in our gaols, where the prisoners not only died of 

 putrid fever, the result of ochletic causes, but actually infected 

 the judges before whom they came reeking with the contagion of 

 the prisons— rude sanitary measures gradually came into opera- 

 tion and partially obviated these evil conditions, but it was not 

 before the middle of this century that any scientific progress was 

 made ; it was when Chadwick, Parkes, and others initiated the 

 work by which they have earned the lasting gratitude of the 



