144 



SCIENCE. 



[Vol. XVIII. No. 449 



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 im- 

 pressed with the influence of certain conditions in producing dis- 

 ease, and thus it was forced upon the public conscience that some- 

 thing must be done; and when philantliropists like John Howard 

 devoted life and property to the amelioration of such awful con- 

 ditions as existed, — e.g., in our jails, 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 operation and partially obviated these evil conditions. But it 

 was not before the middle of this century that any scientific prog- 

 ress was made; it was when Chad wick, Parkes, and others ini- 

 tiated the work by which they liave earned the lasting gratitude 

 of the human race that preventive medicine became a distinct 

 branch of medical science. 



The sanitary condition of towns and communities is not depen- 

 dent on the views or exertions of individuals 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 v?hich deal with 

 questions concerning the public healtli. Indeed, were all the pro- 

 visions 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 require- 

 ments 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 acknowl- 

 edge, 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 aflfected 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 something about them we do not yet grasp is equally 

 true, but it is as surely the cage that local sanitation is the preven- 

 tive 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 per- 

 fection, the sanitary administration of every district in the country 

 is intrusted to the care of duly qualified health officers — -a systeni 

 from which excellent results have already accrued, and from 

 which better still may be anticipated. The records of the past 

 fifty years prove the influence exerted by sanitary measures on 

 vital statistics. The first reliable tables from which expectancy 

 of life may be derived show that in 1838 to 1854 it was, for males 

 39.91 years, for females 41.85 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 increases 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 gain- 

 ing 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 sani- 

 tation tells, and are not subject to quite the same conditions as 

 men, so that their expectancy of life is greater than by the old 

 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 the past times with the present ; 

 whether they be equally significant for other countries I cannot 

 say, but these, at all events, sufficiently prove the point in ques- 

 tion: 1660-79, 80 per 1,000; 1681-90,43.1; 1746-55, 85.5; 1846-55, 

 24.9; 1866-70, 32.4; 1870-75, 30.9; 1875-80, 20.0; 1880-85, 19.3; 

 1885-88, 18.7; 1889, 17.85. In some parts of England, where the 

 main object is the recovery or maintenance of health, the death- 

 rate is down to 9 per 1,000, while in others, where the main 

 object is manufacture and money-making, it is as high as 30 per 

 1,000. 



Nowhere, I think, have the beneficial results of sanitary work 

 been better illustrated than in India during the past thirty years. 

 A royal commission was appointed after the Crimean war to in- 

 quire 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 conditions of existence being well known, reliable 

 information was accessible. It was ascertained that up to that 

 time the annual death-rate over a long period had stood at 69 per 

 1,000. 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 death rate, and the annual reports of the sanitary commis- 

 sioners to the government of India gave the rates as, in 1886, 15.18 

 per 1,000; 1887, 14.20; 1888, 14.84. During some years it has been 

 even lower, down to 10 per 1,000, while the general efficiency of 

 the troops has increased. As to native soldiers with whom the 

 European troops may be compared, I find that the death-rate was, 

 in 1886, 13.27 per' 1,000; 1887, 11.68; 1888, 12.84. Famine, 

 cholera, and other epidemic visitations, in some years disturb the 

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

 living, as in the case of prisoners in the jails, it is somewhat higher. 

 In the Indian jails, for example, it was, in 1886, 31.85 per 1,000; 

 1887, 34.15; 1888, 35.57. 



On the whole, all this indicates improvement, and as regards 

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

 many disturbing causes, the figures are neither so easily obtained 

 nor so reliable. The comparatively large mortality is due to neg- 

 lect of the common sanitary laws, added to extremes of climate 

 which favor 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 govern- 

 ment, at no small cost, to give effect to sanitary laws. There can 

 be little doubt that the results, so far, are good, that disease gen- 

 erally 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 that, large as may 

 appear the death-i-ate from cholera in Inrlia (i e , in 1888, 1.99 per 

 1,000 for the European army, and 1.35 for the civil population), it 

 is small compared with that of fevers, which caused in 1889, 4.48 

 per 1,000 in the European army and 17.09 in the civU population; 

 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 

 must have this for its basis. A certain empirical knowledge may 

 be useful as a guide, but no real advance can be expected without 

 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 

 ah'eady well known, whilst under its guidance the reproach of 

 uncertainty which attaches to medicine as a science is disappear- 

 ing. Recent advances in phjsiology, 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 indi- 



