September ii, 1891.] 



SCIENCE. 



143 



of ignorance and superstition to its present well-established foun- 

 dation on a scientific basis. It is of happy augury for mankind 

 that the subject of public health is now fairly grasped by popular 

 sentiment, and that, though ignorance, opposition, and vested in- 

 terests still contest the ground, progress is sure, and the light of 

 science is illuminating the dark places. It is now better appre- 

 ciated than it ever has been, that the causes which induce disease 

 and shorten life are greatly under our own control, and that we 

 have it in our power to restrain and diminish them, and to remove 

 that which has been called " the self-imposed curSe of dying be- 

 fore the prime of life." 



It is, indeed, only recently that the resources of medical science 

 have been specially devoted to the prevention as distinguished 

 from the cure of disease, and how far successfully I hope in a few 

 words to show, whilst I trust the proceedings of the various sec- 

 tions of this congress will indicate how much remains to be done. 

 Did time permit, I might illustrate the progress of preventive 

 medicine by contrasting the state of England with its population 

 of more than 29,000,000 during the Victorian age with the 

 England of the Ehzabethan 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 sick- 

 ness, plague, petechial typhus, eruptive fevers, small-pox, influ- 

 enza, and other diseases, such as leprosy, scurvy, malarial fever, 

 dysentery, etc., of the wretched mode of living, bad and insuffi- 

 cient food, filthy dwellings, and ill-built towns and villages, with 

 a country uncultivated and covered with marshes and stagnant 

 water (according to Defoe, one-fifteenth part of England consisted 

 of standing lakes, stagnant water, and moist places, the land un- 

 reclaimed, 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 nan'ow and un- 

 paved, with no drains but stagnant gutters and open cesspools, 

 while the food was principally salted meat with little or no vege- 

 tables. To this may he added a large amount of intemperance 

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

 such conditions disease found a continual 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 immunity 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 iniprovements have 

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

 constructed, the drainage and ventilation are more complete, the 

 land is better cultivated, and the subsoil better di-ained ; marsh- 

 fever and dysentery, at one period so rife, are unknown, and lep- 

 rosy has long since disappeared. The death-rate is considerably 

 reduced, and the expectancy 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, moi-al, and physical aspects of the 

 people altogether improved; education is general, a better form 

 of government prevails, and the social conditions are far in ad- 

 vance of what they have been; but still the state of our cities 

 shows that improvement is demanded, and one object of this con- 

 gress 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-S4, though for the five years 

 1870-74 it was 42.7, 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 de- 

 creased from 0.39 to 0.17 per 1,000, and it has been shown that 

 this improvement was synchronous 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 73 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 ruuch for England and 

 Wales, but it has done so in some large towns, notaMy in Liver- 

 pool; and Dr. Buchanan and Dr. Bowditch of Massachusetts both 

 showed a striking parallelism between the diminution of the 

 death-rate from this cause and the di-ying of the soil resulting 

 from the construction of sewerage works. 



Cholera first appeared in England in 1831, and there were epi- 

 demics 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 epidemic. 

 This is fairly attributable to local sanitary i-ather than to coercive 

 measures. Preventable disease still kills yearly about 125,000. 

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

 the death-rate is still higher and the expectance of life lower than 

 it should be. and though we have got rid of the terrible plagues 

 of the middle ages, yet in this ceutury, now closing, other epi- 

 demics have made their appearance. Cholera has four times vis- 

 ited 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 equal to that of the 

 plague. 



Much has been done, and a great deal of it in what has been 

 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 zyuiotic 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 malt," jet 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 conditions which give rise to zymotic '.iisease, 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 va- 

 rious occupations, 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 ex- 

 haustion 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 inevitable 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 precaution 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 stimu- 

 lants and narcotics, and the evil consequences which may result 

 therefrom, is also a subject worthy of consideration. 



The possible deleterious influence of mistaken notions of educa- 

 tion, as evinced in the over-pressure which is exercised upon the 

 young, the predominance of examinations, their increasing mul- 

 tiplication and severity, and the encouragement of the idea that 

 they are the best test of knovvledge, 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 



