August 20. 1891] 



NA TURE 



365 



human race that preventive medicine became a distinct branch 

 of medical science. The sanitary condition of towns and com- 

 munities is not dependent on the views or exertions of indi- 

 viduals alone, for they are and have been for the last fifty years 

 largely cared for by the Legislature, and a variety of Acts have 

 been passed which deal with questions concerning the public 

 health ; indeed, were all the provisions enforced, little would 

 remain to be desired on the part of the executive Government, 

 but as many of them are permissive, not compulsory, the 

 benefit is less complete than it might be. The old difficulty 

 of prejudice combined with ignorance still too often stands 

 in the way, and, despite evidence which on any other 

 subject would be conclusive, the most obvious sanitary re- 

 quirements are often ignored or neglected. Many thousands 

 of lives have been saved by the Sanitary Acts now in force ; 

 but there is little doubt that more thorough organization under 

 State control, as under a Minister of Public Health, would 

 have most beneficial results, and would save a great many 

 more. We must acknowledge, however, that we are much 

 indebted to the action of the Local Government Board, under 

 whose able administration the most crying evils are gradually 

 being rectified. Through the wise precautions enacted by it 

 against the importation and diffusion of epidemic disease, when 

 other parts of Europe were affected by cholera, this country 

 escaped, or so nearly so as to suggest that it was to sanitary 

 measures we owed our immunity. That there is something in 

 the nature of epidemics which brings them under the dominion 

 of a common law as to their extension seems certain ; that there 

 is much about them we do not yet grasp is equally true, but it 

 is as surely the case that local sanitation is the preventive 

 remedy as it is that coercive measures to arrest their progress 

 are unavailing. 



Under the improved system of sanitary administration which 

 now obtains, and is gradually developing to a greater state of 

 perfection, the sanitary administration of every district in the 

 country is intrusted to the care of duly qualified health officers — 

 a system from which excellent result-; have already accrued, 

 and from which better still may be anticipated. The records of 

 the past fifty years prove the influence exerted by sanitary mea- 

 sures on vital statistics. The first reliable tables from which the 

 expectancy of life may be derived show that in 1838 to 1854 it 

 was for males 39 91 years, for females 4 1 '85 years ; by the tables 

 of 1871 to 1880 it had increased to 41 "35 for males and 44'66 

 for females. It is shown also that the expectation of life in- 

 creases every year up to the fourth year, and decreases after that 

 age. For males up to nineteen years it is higher by the last 

 tables, but after that age it is higher by the old table ; for 

 females it is greater by the new table up to forty-five, but after 

 that age it is less. The improved sanitation saves more 

 children's lives, but the conditions of gaining a living are harder 

 than they were at the time of the first table, which accounts for 

 the expectancy of life for adult men being less. Women remain 

 more at home, where the better sanitation tells, and are not 

 subject to quite the same conditions as men, so that their 

 expectancy of life is greater than by the oM tables up to the age 

 of forty-five. A further proof of the effects of sanitary work is 

 a decreased death-rate. Let us compare the death-rates of 

 England during past limes with the present ; whether they be 

 equally significant for other countries I cannot say, but these, 

 at all events, sufficiently prove the point in question : — 



In some parts of England, where the main object is the re- 

 covery or maintenance of health, the death-rate is down to 9 per 

 1000, while in others, where the main object is manufacture and 

 money-making, it is as high as 30 per looo. Nowhere, I think, 

 have the beneficial resulisof sanitary work been better illustrated 

 than in India during the past thirty years. A Royal Commission 

 was appointed after the Crimean war to inquire into the sanitary 

 condition of the British Army, and this in 1859 was extended to 

 India. The European army was the special subject of it, but the 

 native troops were referred to incidentally. Here the inquiry had 

 to deal with a large body of men, concerning whom, their con- 

 ditions of existence being well known, reliable information was 



NO. 1138, VOL. 44] 



accessible. It was ascertained that up to that time the annual 

 death-rate over a long period had stood at 69 per lOOO. The 

 inquiry resulted in certain changes and improvements in the 

 housing, clothing, food, and occupation of the soldier. Since 

 those have been carried out there has been a steady decline in 

 the dearh-rate, and the annual reports of the Sanitary Com- 

 missioners to the Government of India give the rates as : in 

 1886, 15 'iS per 1000; 1887, 14-20 per 1000 ; 1888, 14-84 per 

 1000. During some years it has been even lower, down to 

 10 per 1000, whilst the general efficiency of the troops has in- 

 creased. It is not easy to estimate the money equivalent of this, 

 but if we take the rough standard which values each soldier at 

 ;^ioo, a simple calculation will show how great is the gain, and 

 who can estimate the value of lives saved and suffering avoided ? 

 As to native soldiers with whom the European troops may be 

 compared, I find that the death-rate was: in 1886, 1327 per 

 1000; 1887, ii'68per 1000; 1S88, 12-84 per 1000. Famine, 

 cholera, and other epidemic visitations in some years disturb the 

 regularity of the death-rate ; under less favourable conditions of 

 living, as in the case of prisoners in the gaols, it is somewhat 

 higher. In the Indian gaols, for example, it was : in 1886, 

 31 85 per 1000; 1887, 34-15 per 1000; 1888, 35*57 per 1000. 



On the whole, all this indicates improvement,' and as re:jards 

 the civil population progress also is being made ; but here, from 

 so many disturbing causes, the figures are neither so easily ob- 

 tained nor so reliable. The comparatively large mortality is 

 due to neglect of the common sanitary laws added to extremes 

 of climate, which favour the incidence and diffusion of epidemic 

 disease, and intensify it when it has once appeared. A Sanitary 

 Department has existed in India since 1866, and every effort is 

 made by Government, at no small cost, to give effect to sanitary 

 laws ; there can be little doubt that the results, so far, are good, 

 that disease generally is diminishing, and that life is of longer 

 duration. An important result of the observations of the able 

 medical officers of the Sanitary Service of India has been to 

 show that cholera is to be prevented or diminished by sanitary 

 proceedings alone, and that all coercive measures of quarantine or 

 forcible isolation are futile and hurtful. Here I may say 1 hat, large 

 as may appear the death-rate from cholera in India [i.e. in 1888, 

 I "99 per looo for the European armyand 1-35 for the civil popula- 

 tion), it issmall compared with that of fevers, which caused in 1889 

 4-48 per 1000 in the European army and 17 09 in the civil popu- 

 lation ; but there is every reason to believe that these also are 

 becoming less fatal under the influence of sanitary measures. In 

 preventive as in curative medicine, knowledge of causation is 

 essential. It is obvious that any rational system of proceeding 

 mu't have this for its basis. A certain empirical knowledge may 

 be useful as a guide, but no real advance can be expected with- 

 out the exactitude which results from careful scientific observation 

 and induction ; the spirit of experimental research, however, is 

 now dominant, and progress is inevitable. How much we owe 

 to it is already well known, whilst under its guidance the reproach 

 of uncertainty which attaches to medicine as a science is dis- 

 appearing. Recent advances in physiology, chemistry, histology, 

 and pharmacology, have done much to throw light on the nature 

 and causes of, and also on the means of preventing or of dealing 

 with, disease. It is impossible to exaggerate the value of the 

 scientific researches which have led to antiseptic methods of 

 preventing the morbific action of micro organic life, whether the 

 toxic effects produced by them, or those induced autogenetically 

 in the individual. Theory has here been closely followed by its 

 practical application in prevention and treatment of disease, 

 whilst the study of bacteriology, which is of such remarkable 

 pre-eminence at the present time, is opening out sources from 

 which may flow results of incalculable importance in their 

 bearing on life and health. That the conclusi ms arrived at are 

 always to be depended on I doubt, and it seems that scientific 

 zeal may perhaps sometimes outrun discretion. That it might 

 be wiser to postpone generalization has, I think, been more than 

 once apparent, whilst the expediency of further investigation 

 before arriving at conclusions which may subsequently prove to 

 be erroneous should not be lost sight of ; but it has probably 



' " It i.i to be noticed with regret that during the last five years there has 

 been a tendency to revert to a higher death-rate and percentage of sickness. 

 Let us hope this will prove only transitory ; the attention of sanitary au- 

 th'irities both at home and in India is an.\iously directed towards there- 

 moval of whatever may be the cause of it. It is shown both by the vital 

 statistics and the history of the chief diseases that there is in India an 

 enormous amount of preventable sickness and death," but "that the local^ 

 insanitary conditions or local disease causes are well known and wides[>read." 

 —A. S. C.'s Reports for 1889. 



