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 1837-1 
 
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 THE PROGRESS 
 
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 PREVENTIVE MEDICINE 
 
 DURING 
 
 THE VICTORIAN ERA. 
 
 Being the Inaugrtral Address delivered before the Epiderniological 
 Society of London, Session 1887-88. 
 
 BY 
 
 R. THORNE THORNE, M.B.LoND., RR.C.P.LoND., 
 
 ASSISTANT MEDICAL OFFICER TO H.M. LOCAL GOVERNMENT BOARD ; 
 
 PRESIDENT OF THE EPIDEMIOLOGICAL SOCIETY OF LONDON; 
 LECTURER ON PUBLIC HEALTH TO THE MEDICAL SCHOOL OF ST. BARTHOLOMEW'S HOSPITAL | 
 
 EXAMINER IN PUBLIC HEALTH 
 
 TO THE UNIVERSITIES OF OXFORD AND LONDON AND TO THE CONJOINT BOARD 
 OF THE ROYAL COLLEGES OF PHYSICIANS AND SURGEONS, LONDON. 
 
 LONDON : 
 SHAW & SONS, FETTER LANE, E.G. 
 
 1888.
 
 CONTENTS. 
 
 INTRODUCTORY . . . 1 
 
 i. SMALL-POX . . .5 
 
 ii. TYPHUS FEVER . . . .14 
 
 in. ENTERIC FEVER . . . .22 
 
 iv. SCARLATINA . . . .30 
 
 v. DIPHTHERIA . . . .37 
 
 vi. PHTHISIS . . . .46 
 
 vii. CHOLERA . . . .53 
 
 CONCLUSION 61
 
 ON THE PROGRESS OF PEEVENTIVE MEDICINE 
 DURING THE VICTORIAN ERA. 
 
 BY E. THOENE THOENE, M.B.LoND., F.E.C.P., 
 
 Of H.M. Local Government Board, President of the Epidemiological 
 Society of London. 
 
 HER MAJESTY THE QUEEN ascended the throne on June 20th, 
 1837. She has now reigned for fifty years, and there are 
 but few phases of the great and all but unhindered progress 
 which has been so marked a feature of the Victorian Era 
 that have had a greater effect for good upon her people than 
 that which has had to do with the improvements affecting 
 public health. Review of the advance thus made in all its 
 branches would cover too large a field for me to deal with in 
 this address, but I shall venture to lay before you some 
 account of that progress, in so far as it has been identified 
 with the development of Preventive Medicine and Epide- 
 miology in this kingdom; feeling sure of your interest in an 
 endeavour to place on record, in this Jubilee year, soms 
 account of a movement which, whilst it has effected a saving 
 of life, and a prevention of disease on a scale the magnitude 
 of which it would be difficult to define, has done so much to 
 elevate the condition of man, and to bring health and hap- 
 piness to an untold number of British homes. 
 
 In the year of the Queen's accession one of the greatest 
 hindrances to progress in the prevention of disease was 
 
 B
 
 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 [ removed by the passing of the Act for the Civil Eegistration 
 | of Deaths, as well as of births and marriages. There had, 
 indeed, been some partial registration of deaths since the date 
 of Queen Elizabeth; the London weekly Bills of Mortality, first 
 commenced in 1593, had been uninterruptedly continued from 
 1603 to 1831; but the system gradually became less rather than 
 more efficient. Even before 1593 certain records had been 
 kept which chronicled the periodic devastations of this country 
 by famines and epidemics ; black death, sweating sickness, 
 and plague being prominent amongst the latter. Later 
 on came other records, medical and historical, supplying 
 information, more or less inexact and incomplete, as to 
 large and often sustained mortalities from small-pox, scarlet 
 fever, influenza, and what appeared to be typhus and diph- 
 theria, as well as from other allied epidemic diseases. The 
 last of these epidemics was due to cholera, which made 
 its first appearance in the United Kingdom in October 1831, 
 and from which, in the following year, many thousands 
 perished. But no registration of the causes of death existed 
 at the time, and hence, although 52,547 cholera deaths were 
 heard of from various sources as having occurred in the 
 United Kingdom during that epidemic, yet the actual extent 
 of cholera fatality remained unknown. Such statistical in- 
 formation as was available up to 1837 was all but useless for 
 scientific purposes ; death-rates were calculated on no certain 
 data, and their significance was correspondingly open to ques- 
 tion. The first requisite to a proper understanding of the 
 etiology of disease was wanting, and epidemics were looked 
 upon as enveloped in inscrutable mystery, and as far beyond 
 human control. 
 
 But, in 1837, better machinery for the compilation of vital 
 statistics was provided ; and when Dr. William Farr entered 
 the office of the Eegistrar-General of England, in 1839, those 
 first steps were taken to secure such classification and grouping
 
 DURING THE VICTORIAN ERA. 3 
 
 of deaths from various causes and in various localities, on sex, 
 age, and condition of life, as have so largely contributed " to 
 demonstrate the principal springs" of health and mortality. 
 For no class of diseases was this more needed than as regards 
 that group which appeared in the form of epidemics ; concern- 
 ing which, as Dr. Farr tells us, man could only " whisper of 
 telluric and meteoric influences" unless, indeed, some "comet 
 was at hand to account for the phenomena". There was, in 
 short, the grossest ignorance as to the group of so-called 
 epidemic, endemic, and contagious diseases, the prevalence of 
 which had formed epochs of chronology, affected the stability 
 of cities, states, and governments, and brought wide-spread 
 misery to communities and individuals. 
 
 The first publication of Abstracts of Deaths began to throw 
 some light on the behaviour of epidemics, and the records 
 indicated that, with a population which in 1831 had num- 
 bered some fourteen millions in England and Wales, infectious 
 diseases were causing large mortalities. Thus, in the ten 
 quarters from July 1st, 1837, to December 31st, 1839, we 
 can trace the march of an epidemic of small-pox which 
 destroyed at least 30,819 persons in England and Wales ; 
 and it became evident, from the facts learned as to the 
 incidence of the disease, that the rate of mortality increased 
 with the density of the population, and that the extension 
 of the infection was differently disturbed by the protection 
 which some persons derived from vaccination, and by the 
 artificial diffusion of the malady which accompanied the prac- 
 tice of small-pox inoculation. In 1840 scarlet fever was the 
 reigning epidemic, the deaths from this cause having steadily 
 increased from 5,802 in 1838 to 19,816. Diarrhoea, dysentery, 
 and so-called cholera formed a group which was also causing a 
 large mortality, and the distribution of the three affections 
 was such as to make it in practice difficult to draw a line 
 between them and those forms of diarrhceal disease which 
 
 B 2
 
 4 ON THE PKOGRESS OF PREVENTIVE MEDICINE 
 
 assumed epidemic characters. Attention was also, in 1840-41, 
 attracted to the heavy mortality from " typhus", a term under 
 which all the fatal attacks of continued fever were at that 
 time registered. Already, the dothinenteria of Louis, the 
 enteric fever of our day, was referred to in British statistical 
 returns as in all probability different from typhus, though there 
 is good reason for believing that at that date much of our 
 " fever" mortality was in reality due to true typhus. Thus, 
 in 1841, the excess of the " typhus" death-rate in towns over 
 that obtaining in the country was 56 per cent. This fact, 
 indeed, led to a further examination of the difference in the 
 general death-rate of towns and country districts, and it was 
 found that, whereas the annual mortality per cent, of popula- 
 tion was 1'8 in country districts, it was as high as 2'6 in town 
 districts ; and in 1841 the Eegistrar-General pointed out that, 
 whereas the mean duration of life in Surrey was 45 years, it 
 was not more than 37 in the metropolis, and only 26 in 
 Liverpool. Pulmonary consumption was also now ascertained 
 to be one of the diseases which exhibited a striking excess 
 in the case of town life. In fact, the general mortality was 
 found to be increased 44 per cent, by the then condition of 
 English towns and cities, and much that led to this excess of 
 death was rightly held to be capable of remedy. 
 
 Some account of the principal diseases which I have thus 
 incidentally referred to, namely, small-pox, typhus, enteric 
 fever, scarlatina, diphtheria, phthisis, and cholera, will, in the 
 main, suffice for the purpose of illustrating the progress 
 which I am desirous of recording. They are typical of that 
 group of diseases which is amenable to the control of pre- 
 ventive medicine and to public health measures ; they hold 
 a prominent place in the history of scientific and epidemic- 
 logical research during the period under consideration ; and I 
 propose briefly to review the course of each of them during 
 the past fifty years.
 
 DURING THE VICTORIAN ERA. 
 
 I. SMALL-POX. 
 
 Jenner's great discovery of vaccination a process by 
 which man can be protected against small-pox without him- 
 self becoming, as had been the case in variolous inoculation, 
 a source of danger to others was made known to the world 
 towards the close of last century, but it was not until 1840 
 that the first Vaccination Act was passed which inaugurated 
 the system of public vaccination, under which "all persons" 
 could claim to be vaccinated at the public cost, and which 
 has been the means of saving so great an amount of life in 
 this country. It was also reserved for this era to extend and 
 elaborate that system by the Acts of 1853, 1858, 1867, and 
 1871, and to promote and superintend the execution of those 
 Acts by a department of the Government and by local 
 officers. The diminution of small-pox occurring in sequence 
 to these measures may be judged of by the following state- 
 ment : During the period 1838-42, towards the end of which 
 the advantages of the Act of 1840 were in operation, the rate 
 of mortality from small-pox in England and Wales was 57'2 
 per 100,000 living; by the end of 1849 it had fallen to 
 29'7, and during the period 1850-54 to 27'4. It was at this 
 time that the Vaccination Act of 1853 came into operation. 
 That Act embodied the principle of making vaccination com- 
 pulsory on all infants within a few months of birth ; and the 
 Epideiniological Society, in a report which was printed by 
 order of Parliament, and laid before the House of Commons, 
 assisted in securing the adoption of this new departure, which 
 has so largely contributed to the prevention of death from 
 a loathsome disease. During the course of the three next 
 quinquennial periods the small-pox rate fell further to 19'8, 
 19-0, and 144 per 100,000 respectively ; the latter portion of 
 the last period, namely, that for 1865-69, being in part in-
 
 6 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 fluenced by the operation of the provisions embodied in the 
 comprehensive Act of 1867. 
 
 So far, the operation of vaccination performed in one way 
 or another could be credited with a success without parallel 
 in the history of preventive medicine. But during the next 
 five years 1870-74 the small-pox rate rose to 42 -7 per 
 100,000 ; and although it again fell as low as 8'3 during the 
 period 1875-79, and to 6'5 for 1880-84, yet the sudden 
 leap upwards in 1870 afforded incontestable proof that the 
 practice of vaccination, as it was then largely carried out in 
 this country, had not secured for the inhabitants generally 
 that extent of immunity from small-pox which had been 
 hoped for ; and it became evident that there was yet much 
 to learn as to the circumstances under which an operation 
 apparently so simple, and yet so dependent for its full effi- 
 ciency on the observance of important details, could best be 
 carried out. 
 
 One principal point elicited as the result of the epidemic 
 1870-72 was, that a large proportion of the deaths from small- 
 pox had occurred amongst persons over 15 years of age who 
 were stated to have been vaccinated; and examination of the 
 returns went to show that a large amount of imperfect and 
 insufficient vaccination had been practised at a period when 
 the then adult population had, as infants, been submitted to 
 that process. 
 
 Other considerations were also raised by that epidemic. 
 Small-pox, both in this country and abroad, was ascertained 
 to have been of a malignancy heretofore unknown to the 
 present generation, and it was assumed by some that a pro- 
 cess of vaccination which had been sufficient to protect against 
 fatal small-pox of the ordinary virulence had failed in the 
 presence of an infection of exceptional potency such as that 
 which had been imported under the circumstances of the 
 Franco-German war.
 
 DURING THE VICTORIAN ERA. 7 
 
 How far such theory of an exceptional potency of infection 
 can be held to account for the results that ensued, may be 
 open to doubt. But other possible explanations merit atten- 
 tion. Thus, there is the surmise of a special receptivity on 
 the part of those attacked. The protection which vaccination 
 had afforded against small-pox in this country had been 
 steadily, and to an increasing extent, given to infants during 
 several generations, and together with its extension there had 
 been a gradual failing of that power of resistance to attack 
 which is believed to be inherited by the offspring of parents 
 who have themselves suffered from a specific infectious fever, 
 in much the same way as the transmission of physical qualities 
 takes place. And in this way it has been explained that, 
 just as measles in 1875 wrought such havoc amongst the 
 inhabitants of the Fiji Islands who had had no opportunity 
 of acquiring any immunity against the natural force of the 
 poison by reason of heredity, so small-pox, under the cir- 
 cumstances of 1871, broke in upon the descendants of a people 
 who, by reason of vaccination, had had no opportunity for 
 transmitting to their children such resistance to attack from 
 small-pox as had formerly been brought about by attacks of 
 the same disease in their ancestry. 
 
 And again. When vaccination was first made gratuitous, 
 many adults must then have resorted to it for the first time, 
 and thus people acquired the protection attaching to a primary 
 vaccination at an age which gave them a practical immunity 
 against small-pox for the remainder of their lives. But as 
 years passed on, primary vaccination during infancy became 
 more and more general, and long intervals of time often 
 elapsed between the performance of that operation and 
 exposure to the poison of small-pox. The bearing of these 
 and kindred considerations upon the epidemic of 1871-72 
 led to the belief that we were not yet fully acquainted with
 
 8 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 all the circumstances under which the full effect of vaccination 
 in its conflict with small-pox could be acquired. 
 
 At this stage, Dr. Buchanan, medical officer to H.M. Local 
 Government Board, commenced an investigation into the 
 influence of vaccination as a protective against small-pox, 
 the results of which are embodied in a series of reports 
 which form some of the most important chapters in the 
 history of this subject, and are characteristic of the labours 
 by which progress in this department of the science of pre- 
 ventive medicine has been advanced during recent years. 
 
 At the outset of this inquiry it became evident that vacci- 
 nation had led to a vast saving of life during infancy and 
 childhood. Examining into the mortality from small-pox in 
 children under ten years of age in London, Dr. Buchanan 
 ascertained that this mortality "among the unvaccinated was 
 about a hundredfold the mortality from small-pox among 
 the vaccinated" ;* and that if in the year 1881, which was 
 then under consideration, the small-pox mortality amongst 
 the vaccinated children had been at the same rate as amongst 
 the unvaccinated, London would during that one year have 
 been confronted with 12,000 more deaths from small -pox 
 than actually occurred. This saving of 12,000 young lives 
 in one twelve months was effected by the current vaccination 
 available ; but it was further shown that "the power of a 
 thorough vaccination to protect against death from small-pox 
 is at least ten times greater than the power of much that 
 passes for vaccination"; and that as regards the children dying 
 in London of small-pox within some ten years of alleged vac- 
 cination, the mortality in this class obtaining "private" 
 vaccination was more than twice as great as in the class 
 seeking vaccination at the hands of public officials, who 
 are under the requirement to perform the operation accord- 
 
 * Report of the Medical Officer of the Local Government Board for 
 1881. [C. 3337. I.]
 
 DURING THE VICTORIAN ERA. U 
 
 ing to a recognised standard of efficiency. In short, vaccina- 
 tion had not failed to prevent death from small-pox during 
 the early period of life, except in so far as the application of 
 the prophylactic had been imperfect. 
 
 In one sense the failure, at that date, to apprehend the 
 need for such vaccination as we have now learnt gives the 
 highest form of protection against small-pox is not to be 
 wondered at. The extraordinary and continuous decline in 
 small-pox mortality during the quinquennial periods already 
 referred to, from a rate of 57'2 per 100,000 in 1838-42 to 144 
 in 1865-69, which had followed on the extension of the system 
 of public vaccination, was enough to lead to an undue exalta- 
 tion of the influence of vaccination as such; and it required the 
 subsequent rise to 427 per 100,000 during the period 1870-74 
 to convince those who were engaged in the study of prevent- 
 ive medicine that there was more to be learnt about vacci- 
 nation before its full protective value could be enjoyed by 
 the public. Much of the needed information has already 
 been obtained. Thus, whilst no difference can be found in 
 the protective value of lymph, whether taken direct from the 
 calf or after it has passed through the human subject, it is 
 known that the full effect of the operation of vaccination can 
 only be secured by careful selection of the lymph used, and 
 by the performance of the operation in such a way as to 
 secure at some four or five points of insertion well-foveated 
 scars, which shall, in the aggregate, cover at least half a 
 square inch of surface. And, further, it is becoming more 
 and more evident that the protective value of even an effi- 
 cient vaccination is not always so enduring as many had, at 
 first, been inclined to think ; that its full effects are not un- 
 frequently limited to a comparatively short term of years ; 
 and that, for the retention of its full protection, it calls tor 
 repetition, especially in the young, probably within not less 
 than ten years of the first operation.
 
 10 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 Tliis conclusion may to a large extent be drawn from the 
 results of Dr. Buchanan's investigations, and it is promi- 
 nently brought out by the statistics published in the recent 
 report of the Vaccination Committee of the Epiderniological 
 Society, and which go to indicate the need for an even earlier 
 repetition of vaccination.* From that report we learn that, 
 during the first five years of life, when liability to death from 
 small-pox is at its highest, the influence of recent vaccination, 
 efficient in point of foveation, number, and total area of the 
 resulting scars, is pre-eminent in its protective power against 
 fatal attack ; that, indeed, at all ages up to twenty years 
 " small-pox patients having ' good' vaccination at the date 
 of their attack, "die, according to their age, from /$ to /$ 
 only the extent of unvaccinated patients at corresponding 
 ages." The value of an efficient vaccination is thus strik- 
 ingly indicated. 
 
 But if the power of vaccination as such, and without 
 proper regard to quality and frequency of its application, has 
 in the past been somewhat over-estimated, there is steadily 
 accumulating evidence that the proper use of this extra- 
 ordinary prophylactic has a potency which borders on the 
 marvellous. Some who profess that they do not believe in 
 its influence for good would allege that the all but uninter- 
 rupted diminution in small-pox mortality which has followed 
 on the extension of vaccination has been brought about by an 
 improvement, synchronously effected, in the general sanitary 
 circumstances to which the population have year by year 
 been exposed. But, under the same circumstances of treat- 
 ment, unvaccinated small-pox patients die nowadays at the 
 same, if not at a higher, rate than they died before the dis- 
 covery of vaccination, while vaccinated small-pox patients die 
 at a rate varying between one-fifth and one-fortieth of the 
 
 * Report of the Vaccination Committee. Transactions of the Epidemic- 
 logical Society, vol. v, Session 1885-86.
 
 DURING THE VICTORIAN ERA. 11 
 
 rate of the unvaccinated ; the difference between the one-fifth 
 and the one-fortieth being determined by the degree of vacci- 
 nation.* 
 
 Comparison of the results of exposure in hospital to the 
 infection of typhus on the one hand, and of small-pox on the 
 other, are of especial interest in this connection. In the 
 London Fever Hospital there were, during the ten years 
 1861-70 the latest period during which typhus was received 
 into that institution no less than 179 attacks, and 42 deaths 
 from typhus amongst the nurses and staff of the hospital ; 
 whereas, according to the recent report of the Vaccination 
 Committee of the Epidemiological Society, out of a total of 
 734 nurses and attendants in the three small-pox hospitals of 
 the Metropolitan Asylums Board, whence complete informa- 
 tion was procurable, not a single re-vaccinated person took 
 small-pox. Of these 734 members of the staff, 79 (mostly 
 former patients) had recently suffered from small-pox ; of the 
 remainder, 645 were re-vaccinated before entering on their 
 duties ; and 10 were, for one and another reason, not re- 
 vaccinated. Every one of the latter contracted small-pox, 
 
 * An unknown essayist, writing in The World, No. 127, 5th June 1755, 
 supplies important information as to the deadly character of small-pox 
 uncontrolled by any such protective as vaccination; and he, for the 
 purposes indicated in his essay, contrasts it with the same disease as 
 modified by inoculation. He states that, prior to the introduction of small- 
 pox inoculation, London, thanks to the fatal ravages of small-pox, was 
 tolerably roomy ; people preferred to stay at home in the provinces rather 
 than come to London and catch the disease. ... " But now, thanks to 
 inoculation, this danger has disappeared, and London is most incon- 
 veniently crowded." ... " This inconvenience has, in a great measure, 
 been hitherto prevented by the proper number of people who were daily 
 removed by the small-pox in the natural way, one at least in seven dying, 
 to the great ease and convenience of the survivors, whereas, since inocu- 
 lation has prevailed, all hopes of thinning our people in this way are at 
 an end, not above one in three hundred being taken off, to the great in- 
 cumbrance of society."
 
 12 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 whereas not one of the 645 re-vaccinated persons suffered 
 from the disease. 
 
 Or again. During 1882 fourteen nurses were engaged at 
 the Newcastle-upon-Tyne infectious hospital in attendance on 
 cases of typhus. Of these, nine contracted the disease, and two 
 died. In an adjacent pavilion nine other nurses were in at- 
 tendance on small-pox patients. Of the nine, all but one, who 
 had recently had small-pox, were re- vaccinated before coming 
 on duty. None of these contracted small-pox, but one of them 
 did catch typhus. So, also, during the same year, the Medical 
 Officer of Health of Gateshead reported that " every nurse 
 who has been more than a fortnight in the typhus wards has 
 suffered from typhus ; on the other hand, the only officers 
 who took small-pox were two kitchen girls whom I neglected 
 to vaccinate." 
 
 In each of these three groups of cases the two sets of 
 nurses and attendants were drawn from the same class ; 
 they were fed alike, and subjected to the same sanitary cir- 
 cumstances. They differed in one respect only. One group 
 of persons were fully exposed to the poison of small-pox, and 
 being vaccinated they escaped ; the others, unprotected by 
 any prophylactic against the poison of typhus, suffered heavily, 
 either by disease or death, from the infection to which they 
 were exposed. 
 
 But evidence as to the value of re-vaccination is no longer 
 limited to experiences such as I have referred to, for the 
 story of an experiment on a gigantic scale is to be found in the 
 report of the German Vaccination Commission.* There we 
 find that, since the establishment of compulsory re-vaccination 
 at the age of twelve years, " in Germany, as a whole, small- 
 pox has diminished to a degree never before known, so far 
 as any records reach"; whereas "in all neighbouring 
 
 * On the German Vaccination Commission. Transactions of the 
 Epidemiological Society, vol. v, 1885-86.
 
 DURING THE VICTORIAN ERA. 13 
 
 
 
 countries small-pox is, as usual, still very prevalent " ; 
 " that the German large cities suffer scarcely at all from 
 small -pox, which continues to demand its victims in all large 
 foreign cities" ; that " the German army is almost free 
 from small-pox, while other armies still suffer severely"; 
 and, lastly, that "not a single death from small-pox has 
 occurred in the Prussian army since 1874", whereas both 
 the neighbouring "Austrian and French armies still show 
 considerable losses in this respect." 
 
 Reference to the knowledge recently acquired as to small- 
 pox would be incomplete were I not to advert to the 
 disturbing influence which the establishment of hospitals 
 for the isolation of that disease has had upon the incidence 
 and mortality from small-pox in the metropolis and in other 
 towns. The investigations of Mr. W. H. Power into this 
 matter are well known. They have been submitted to the 
 consideration of a Eoyal Commission, and the whole subject 
 has been further dealt with in Dr. Buchanan's recent reports 
 on the proceedings of the Medical Department of the Local 
 Government Board.* It is now generally admitted that aggre- 
 gations of small-pox patients do cause an increase of small- 
 pox in their neighbourhoods ; and Mr. Power's contention 
 that a hypothesis of the conveyance of the contagium through 
 the general atmosphere can alone explain the circumstances 
 of the diffusion, now meets with the almost unanimous sup- 
 port of competent scientific judges. 
 
 Advance in our knowledge of the natural history of small- 
 pox, of its more obscure methods of diffusion, and of the 
 circumstances under which the full protective effects of vacci- 
 nation are to be acquired against this terrible scourge, has 
 
 * Reports of the Medical Officer of the Local Government Board : On 
 the Use and Influence of Hospitals for Infectious Diseases, 1 882 [C. 3290]j 
 Annual Report for 1884 [C. 4156]; Annual Report for 1885 [C. 4844 I] ; 
 and Annual Report for 1886 [C. 5171].
 
 14 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 characterised the past fifty years ; and although the record 
 of a steadily diminishing small-pox death-rate was at one 
 point marred by the circumstances of the period 1870-72, 
 yet even that experience will have tended to a useful end, 
 if only the striking lessons it has taught are but applied to 
 the further control of this eminently preventable disease. 
 
 II. TYPHUS FZVEK. 
 
 Eeview of Typhus, and of the influence of sanitary 
 measures upon it in this country, are greatly hindered by the 
 circumstance that it was not until 1869 that the different 
 forms of continued fever were separated in the mortality 
 returns of the Eegistrar-General. But there is abundant 
 evidence to show that typhus was widely prevalent during 
 the earlier portion of the half -century we are considering, in 
 many of our large cities, where poverty, over-crowding, and 
 the resulting depressing influences were at work. In 1837 
 the disease was prevalent in several parts of the United 
 Kingdom. In the period 1846-48 a typhus epidemic of 
 terrible magnitude followed on an extensive failure of the 
 potato crop in Ireland, which had brought about a vast amount 
 of wretchedness and famine; and from Ireland the disease was 
 imported into and spread in several of the large cities of 
 England. About this date typhus was first discriminated in 
 hospital returns from relapsing and from enteric fever ; and 
 the epidemic prevalence of the disease in London in 1848 is 
 shown from the fact that 786 cases of typhus came under 
 treatment in the London Fever Hospital during that year. 
 In 1856 the typhus admissions into the London Fever Hos- 
 pital reached 1,062. Another epidemic commenced in 
 Ireland in 1861, and in the following year the disease was 
 again widely prevalent in London. Indeed, the records of 
 the London Fever Hospital show that during the period
 
 DURING THE VICTORIAN ERA. 15 
 
 1862-70 a long-continued prevalence of typhus was main- 
 tained, the admissions being 14,589 in all. 
 
 Since 1869 there has been an almost continuous decrease of 
 typhus deaths in England, the fatal attacks falling from 4,281 
 in that year to 318 in 1885 ; the corresponding rates per 
 thousand living being 019 and O'Ol. And, in seeking the 
 causes of this vast improvement, some reference to the 
 incidence of the disease in London and Liverpool may be 
 opportune. The conditions that bring about epidemic typhus 
 are now but too well known. The disease is essentially asso- 
 ciated with over-crowding and destitution; the depressing 
 influence resulting from those circumstances being amongst 
 the most powerful of its predisposing causes. Both in London 
 and in Liverpool its prevalences have been mainly on those 
 localities where houses have been so densely massed together 
 on area as to preclude free movement of air about them, and 
 where there has been such overcrowding of persons in dwell- 
 ings as has ensured the fouling of the air within them by 
 the concentrated emanations of living bodies. The incidence 
 of the disease has also been essentially on the pauper and 
 badly housed elements of the community. 
 
 In London there were 716 typhus deaths in 1869 ; but 
 since that date this mortality has undergone rapid and 
 almost continuous decrease, until in 1885 there were only 28 
 such deaths ; the decrease in the rate per thousand living 
 during the same period having been from - 23 to O'Ol. But 
 even these death-rates do not tell the whole story of the dis- 
 appearance of this disease; for of the deaths which have 
 in recent years been attributed to typhus in the metropolis, 
 the majority have not been true instances of that disease. 
 
 In considering the circumstances under which the blot of 
 our metropolitan typhus record has been so largely effaced, I 
 would call to mind some of the conditions which affected 
 the housing of the people during the earlier part of
 
 16 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 the past half-century. Writing in 1849, Sir John Simon, 
 KC.B. (then Mr. Simon), drew public attention to the exist- 
 ence of localities within the City of London which were so 
 irremediably bad that no mere provision of wholesome water- 
 supply and drainage could bring healthiness to their inha- 
 bitants. These localities exhibited complicated turnings, 
 narrow inlets, close parallels of houses, and high barriers pre- 
 venting light and movement of air. Them were " courts and 
 alleys hemmed in on all sides by higher houses, having no 
 possibility of any current of air, and (worst of all) sometimes 
 so constructed back-to-back as to forbid the advantage of 
 double windows or of back doors, and thus to render the 
 house as perfectly a cul-de-sac out of the court, as the court 
 is a cul-de-sac out of the next thoroughfare."* The inherent 
 vice of these houses was the lack of means for through- 
 ventilation, and amidst it all there was " a dense population 
 of human beings with an atmosphere hardly respirable from 
 its closeness and pollution." "Typhus", it is added, "prevails 
 there .... not as an occasional visitor, but as a habitual 
 pestilence." Passing on to 1865, Mr. Simon, then medical 
 officer of the Privy Council, in dealing with the question of 
 the house accommodation for the poorer classes in towns and 
 cities, generally adverts again to the sources and distribution 
 of metropolitan typhus, and in his report he condemns 
 especially the then " tenement-houses", the evils of which 
 combined to constitute " one monstrous form of nuisance", 
 where overcrowding reached a proportion that "no obtainable 
 quantity of ventilation" could keep the air of the dwelling 
 free from hurtful contamination, and where the houses, large 
 but densely peopled, were " often without a span of court- 
 yard, either front or back", and where the influence was so 
 degrading, that to children " born under its curse" it must 
 
 * John Simon, Public Health Reports, vol. i, p. 57. London, J. and A. 
 Churchill.
 
 DURING THE VICTORIAN ERA. 17 
 
 often have been "a very baptism into infamy". At this date 
 some 2,000 cases of typhus were annually received into the 
 London Fever Hospital; the subjects of this preventable fever 
 beinglargely derived from localities such ashave been indicated. 
 
 But great changes as regards the circumstances of the 
 housing of the poor and working-classes of London were 
 already in progress ; and, since then, most of the old 
 typhus-haunts have been demolished. Great thoroughfares, 
 bringing with them light and air, have been cut through 
 dense aggregations of houses ; courts and alleys have been 
 opened out, their exposure to the public gaze often leading 
 to their being altogether swept away ; and a vast number of 
 unhealthy dwellings have been demolished. Healthy dwell- 
 ings have also replaced the unhealthy ones ; and a large ex- 
 penditure of money has been incurred in attaining these 
 objects. 
 
 I have not found it possible so to arrange the various 
 proceedings that have been taken in this direction as to trace 
 their influence, in point of time, upon the reduction of the 
 London typhus mortality ; but I would note that between 
 1856 and 1887 a sum of over 14 millions sterling has been 
 devoted by the Metropolitan Board of Works to measures 
 tending almost exclusively to the destruction of unwholesome 
 house property, and to the opening up of wide thoroughfares 
 and breathing spaces in crowded parts of the metropolis. 
 And this sum does not include over two millions spent on 
 the Thames Embankments ; neither does it take any account 
 of outlay in the erection of wholesome dwellings to replace 
 unwholesome ones this latter work having been almost alto- 
 gether undertaken by bodies and individuals having no 
 access to the public purse. Thus, the Company of which 
 Sir Sydney Waterlow is Chairman has, during the past 
 twenty-five years, provided model-dwellings for 25,000 
 persons; some 440,000 has been spent within the City 
 
 c
 
 18 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 precincts in artizans' and labourers' dwellings, and such 
 bodies as the Artizans' and Labourers' and General Dwellings 
 Company, and the Peabody Trustees, have laboured in the 
 same direction. Indeed, an intimate relation must be ad- 
 mitted to exist between these efforts and the disappearance 
 of London typhus. 
 
 The same inference may be drawn from the circumstances 
 of typhus in Liverpool, though the data are somewhat different. 
 In 1840 no less than 40,000 of the inhabitants of that city 
 lived in cellars " dens into which sunlight never penetrated, 
 and vile-smelling" ; and it was well asserted that from such 
 dwellings no amount of disinfection could banish typhus ; 
 whereas, on the other hand, the so-called " open courts" 
 remained on the whole healthy, and this even in districts 
 " smitten with fever". In 1843 it was found that no less 
 than 55,534 of the inhabitants lived in courts nearly one- 
 third of which were closed at one end, so that no through- 
 ventilation was possible ; and such preliminary measures as 
 were adopted, or in contemplation, for dealing with this 
 serious condition received a fatal check when, in 1847-49, an 
 already densely over-crowded city had to face the great im- 
 migration of a destitute population seeking to escape the 
 miseries of the Irish Famine. Writing in 1866, Mr. Simon 
 refers to a munificent beginning of work, for the purchase 
 and destruction of dwellings " unfit for habitation" in Liver- 
 pool, where 100,000 was then being devoted to this purpose. 
 But the work to be performed was a gigantic one ; and, 
 judged by the needs of that city, the progress was but slow. 
 In 1882 Dr. Stopford Taylor reported that there still re- 
 mained, in illegal occupation, 945 cellars in streets, and 165 
 in courts ; and, even as recently as 1884, Mr. E. T. Stephens, 
 a member of the Liverpool Town Council, in his evidence 
 before the Eoyal Commission on the Housing of the Working 
 Classes, referred to a report made in 1865, in which the then
 
 DURING THE VICTORIAN ERA. 19 
 
 Medical Officer of Health spoke of an overcrowded group of 
 streets in which the fever mortality was between two and 
 three times as great as for the borough generally ; and the 
 witness added, " I can see no substantial improvement in 
 the character of those streets since the date of that 
 report" twenty years ago. He further stated that 
 there remained between 15,000 and 16,000 unsanitary 
 dwellings in Liverpool. Another witness said that no less 
 than " 70,000 persons" in the borough still needed "healthful 
 dwellings". And in the same year, Dr. Stopford Taylor, in 
 dealing with the conditions of Liverpool typhus, recorded a 
 number of instances which emphasise every phase of that 
 misery which attaches to this disease in its relation to 
 destitution amongst a people living under aggravated con- 
 ditions of overcrowding and aerial filth. 
 The following are typical illustrations : 
 
 " Margaret Carroll, age 11, 9 The Bower, 9 Court, Gore Street. The 
 child has been about fourteen days ill. She lies on rags, in a state of 
 great filth. The house is almost bare of furniture, and the people appear 
 to be destitute. There are two or three other starved-looking children, 
 and the mother wears only a single garment. The father, a strong, able- 
 bodied man, tremulous with drink, volunteers the opinion that the child 
 is suffering from want of food, and not from fever. He also states that 
 he has been drinking hard for the last fourteen days, and considers that 
 drink is more easily got than food." 
 
 " Matilda Crosby, aged 35, I/] 3 Eaton Street. The poor creature in 
 this filthy and abominable court has been five or six days ill. The room 
 is so dark as to necessitate the use of wax matches to examine the 
 patient. The room is foul and filthy, almost bare of furniture, and the 
 other inmates are clothed with rags. Two or three half-naked children 
 bear evidence of chronic starvation." 
 
 " Melaney, 6/1 Hughson Street. The intense foetor of the room in 
 which the sick people lay necessitated waiting outside until the window 
 was opened. The occupants of the bed, which is about 3 feet by 6, were 
 five in number, and all exceptionally filthy. The mother is a fish-hawker, 
 and the fish were in a basket under the bed. The family appeared to be 
 suffering from chronic starvation, and two members had fever. The 
 upper rooms of the house were sub-let." 
 
 " Lizzie Thompson, aged five, 7/2 Eankiu Street. The child has been 
 sick about nine days. There is another child, aged about four years, who 
 
 c 2
 
 20 OX THE PROGRESS OF PREVENTIVE MEDICINE 
 
 has recently been ill, and is now convalescent. The mother states that 
 during the last two weeks the income of the family has been 4s. 6d. per 
 week, and they have no other money nor relief. Her face bears the 
 imprint of chronic starvation, and the surroundings confirm her story." 
 
 " Mumford, 1/13 Upper Frederick Street. Three persons, viz., tho 
 father and two children, are sick in this house, which is miserably 
 furnished, filthy, and foul-smelling from the dirty skins and clothing of 
 the inmates. The mother states that for seventeen weeks the income of 
 the family, derived from the earnings of the father, has been 7*. per 
 week. In reply to the inquiry as to how they were living, the mother 
 replied, with some emphasis, ' they were not living, but starving.' " 
 
 But, gradually, a number of these conditions have been 
 ameliorated, and within recent years even more substantial 
 efforts have been made to cope with them. Amongst these 
 I would mention the provision of healthy homes by the 
 Liverpool Labourers' Dwellings Company, Limited ; and the 
 fact that, under a Sanitary Amendment Act of 1864, there 
 had been expended up to the close of last year, and for the 
 purposes in question, a sum of nearly 199,000 ; and an 
 expenditure of 141,000 for works under Cross's Act, in 
 the demolition of crowded areas and in the erection of 
 wholesome dwellings. The precise effect of these several 
 measures on the diminution of typhus cannot be traced, 
 for it was not until 1877 that typhus became a separate 
 entry in the borough records. But it deserves notice that, 
 whereas in 1877 there were 204 such deaths, they fell to 96 
 in 1880 ; and though during the three years 1881-83 typhus 
 again became prevalent, and caused 1,030 deaths ; this was 
 followed by a marked diminution and a record of only 71 fatal 
 attacks in 1885, and of 45 in 1886; this latter being the lowest 
 number ever yet recorded in any one year. 
 
 At this stage allow me to recall the fact that, as far back 
 as 1849, Mr. Simon referred to back-to-back houses in con- 
 nection with typhus. And he by no means stands alone in con- 
 demning the vicious system of so constructing dwellings as 
 to deprive them once for all of means of through-ventilation.
 
 DURING THE VICTORIAN ERA. 21 
 
 Confining my remarks on this point to two sources of infor- 
 mation which have been prominent in connection with typhus 
 prevalences, I would quote the opinion of the experienced 
 Health Officers of Glasgow and of Liverpool. In his evidence 
 before the recent Royal Commission on the Housing of the 
 Working Classes, Dr. Russell declared that " these back- to- 
 back houses are the curse of Glasgow". In Liverpool they 
 have been described by successive officers as " blind houses"; 
 " houses only open to the front"; " houses back-to-back, and 
 only one room deep"; or, more recently still, as " straight-up" 
 houses. And they are never mentioned except in terms of 
 reprobation, as violating the first principles of health, and 
 as having a marked connection with the persistence of 
 typhus. 
 
 Having regard to facts such as these, the Local Govern- 
 ment Board have embodied in their model code of bye-laws 
 as to new buildings, clauses requiring that every new 
 domestic building shall have, both to the front and to the rear, 
 a defined minimum amount of open space ; and the Board 
 make it a practice to refuse confirmation of such codes as 
 do not embody this principle. And the Royal Commission 
 of 1884 have also made a recommendation to the effect 
 that a similar requirement should be enforced, even under 
 the difficulties of the metropolis, where the cost of building- 
 land is so excessive. 
 
 Thousands of lives have been sacrificed to the greed and 
 ignorance under which houses have been aggregated together 
 iu disregard of the requirements of health. Millions have 
 been spent in endeavouring to undo the mischief wrought 
 by past generations in this respect; and if we consider alone 
 the relation of typhus to that uncleanliness of air which 
 results from the concentrated emanations of human bodies, we 
 have abundant ground for demanding that a check shall be 
 placed on all who, for one motive or another, would interfere
 
 22 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 with that free movement of air around our future dwellings 
 which is so essentially necessary for the prevention of 
 disease. 
 
 III. ENTERIC FEVER. 
 
 During the early part of the half-century we are consider- 
 ing, many able workers were engaged in research which had 
 for its object to determine whether the " fever" mortality of this 
 country was due to one or more distinct and separate diseases. 
 English, French, and German pathologists had alike noticed 
 the special lesions which we now know to be pathognomonic of 
 enteric fever ; and in Glasgow the fact was early recognised 
 that two altogether different eruptions were met with in the 
 " fever" wards. Much the same conclusions were being ar- 
 rived at in the United States. In this country, where both 
 typhus and enteric fever were commonly prevailing side by 
 side, it was not until 1 840 that it was made clear that the rose- 
 spot eruption and the intestinal lesion of Peyer's patches were 
 characteristic of enteric fever, and incompatible with true 
 typhus. In that year the late Dr. A. P. Stewart, in a 
 masterly description, indicated the more prominent differ- 
 ences between the two fevers, declaring that their characters 
 were "so marked as to defy misconception". Besides which, 
 he went so far as to point out that there were differences in 
 the circumstances under which the two diseases occurred. 
 
 But this doctrine of the non-identity of the two diseases 
 was by no means universally accepted, and it remained for 
 Sir William Jenuer, as the result of his researches, published 
 between 1849 and 1853, to clear up all further doubt on the 
 subject. And he did more. He showed conclusively that the 
 two diseases by no means necessarily prevailed together; that 
 the one did not communicate the other; and, above all things, 
 lie made it clear that they depended on different causes.
 
 DUKING THE VICTOKIAN ERA. 23 
 
 Accurate observation of the symptoms, natural history, 
 and pathology of disease has ever been at the foundation of 
 progress in preventive as in curative medicine ; but there pro- 
 bably never was an occasion when so much depended on 
 correct diagnosis as when these two diseases were once for all 
 dissociated from each other. So long as one " fever" was 
 alone recognised, the fatality which on the one hand attached 
 to our jails, camps, and city tenements, where misery and 
 excessive crowding obtained, was confused with that which, 
 on the other hand, occurred alike in the mansions of the 
 wealthy to which sewer-air had by ill-contrived arrange- 
 ments been laid on and in scattered rural districts, where the 
 need for the proper disposal of excreta was not yet recog- 
 nised. This confusion of the two diseases barred the way to 
 progress in preventive medicine; for the causation of that 
 which seemed but one disease, and which yet appeared under 
 such widely differing circumstances, long defied detection. 
 But, when once the distinction was made, the road was 
 clear. The remedy needed for the prevention of the one 
 disease had little or nothing in common with that for which 
 the other called; and whilst the removal of conditions favour- 
 ing that form of filth which comes of an air laden with the 
 accumulated emanations of a crowded and destitute people 
 rid our towns of typhus, it was found necessary, for the pre- 
 vention of enteric fever, to cope with the varying circumstances 
 under which poisoning by means of the excreta of populations 
 could operate, either through water and food consumed, or 
 through air breathed. Medical science having once indicated 
 the directions in which remedial measures were needed, the 
 work of prevention could be intelligently pushed forward ; and 
 I may truly say that its rapid advance, and the widespread 
 benefits resulting from it, have been largely due to the 
 impulse given by the skilfully discovered differentiation of 
 these two continued fevers.
 
 24 ON THE PROGRESS OF PREVENTIVE MEDICINE. 
 
 It was not until 1869 that enteric fever and simple con- 
 tinued fever were separated, for the purpose of death regis- 
 tration, from the general body of " fever" deaths. From 
 that date the records concerning them are distinct ; but 
 in any reference to them before 1870 they must be dealt with 
 collectively.* In 1869, the number of fatal attacks from 
 enteric and simple continued fever in England and Wales 
 was 13,967, and in the years that immediately followed but 
 little diminution is to be observed in their fatality. During 
 the five years 1876-80 the average annual number of deaths 
 had fallen to 8,657, and in the period 1881-85 and this 
 notwithstanding a steady increase in population it had fallen 
 to 6,671. Or, comparing the annual death-rate per thousand 
 living in 1869 and in 1885, I find that they were 0'39 and 
 0'17 respectively in the case of enteric fever, whilst for simple 
 continued fever they were 0'24 and 0'02 respectively a suffi- 
 ciently marked decrease in both cases. 
 
 Before the period for which these comparisons can be 
 made, it had been shown, by means of reports and otherwise, 
 how urgently our towns and cities stood in need of proper 
 means of drainage and water-supply. In 1849, Mr. Simon 
 pointed out, as regards the City of London, how often a cess- 
 pool was to be found "actually within the four walls of the 
 inhabited house ; the latter reared over it, as a bell-glass 
 over the beak of a retort, receiving and sucking up inces- 
 santly the unspeakable abomination of its volatile contents" ; 
 and it is notorious how generally wells were resorted to 
 which were sunk in a filth-laden soil, and how even public 
 water-services were so contrived as to give a minimum sup- 
 ply with the maximum amount of trouble, and often with a 
 
 * With reference to the interpretation to be put on the term " simple 
 continued fever", see Dr. LongstafTs paper in the Proceedings of the 
 Epidemiological Society, New Series, vol. iv, on ' The Seasonal Preva- 
 lence of Continued Fevers in London."
 
 DUE1NG THE VICTORIAN EKA. 25 
 
 large share of danger. These and kindred matters were 
 shown to be prevailing on a wide scale during the period in 
 which the General Board of Health instituted its long series J 
 of public inquiries. And, again, after Mr. Simon had for 
 nine years held office as medical officer to H.M.'s Privy 
 Council, he still found it necessary continuously to advise 
 1st, that, by appropriate structural works, all the excremental 
 produce of the population shall be so promptly and so 
 thoroughly removed that the inhabited place, in its air and 
 soil, shall be absolutely without fcecal impurities ; and, 2nd, 
 that the water-supply of the population shall be derived from 
 such sources, and conveyed in such channels, that its conta- 
 mination by excrement is impossible.* And, as regards 
 enteric fever, he went on to show by reference to Dr. Bu- 
 chanan's well-known report on the results gained in various 
 parts of England, by works designed to promote public 
 health how remarkable had been its diminution since the 
 execution of efficient sanitary works. To quote a few ex- 
 amples only. Comparison between the enteric fever annual 
 death-rate per 10,000 people living after the execution of 
 such works, with that for periods which had preceded them, 
 showed that there had been a fall at Merthyr Tydvil from 
 211 to 8, at Croydon from 15 to 5, at Ely from lOf to 
 4^, at Penrith from 10 to 4^, and at Stratford from 12^ to 4. 
 In the meantime another great advance had been made. 
 Although it had long been an accepted doctrine that filth 
 was in some way related to the production of disease, yet but 
 little was known, during the earlier part of the present reign, 
 of the actual means by which conditions of filth affected 
 health; and many of the works which had been carried out, 
 and which had led to results such as I have referred to, 
 \vere primarily adopted for the prevention of nuisance, 
 
 * Ninth Report of the Medical Officer of the Privy Council, 1866.
 
 26 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 But it had now come to be regarded as the result of etio- 
 logical research that the great potency of filth for mischief 
 lay in the fact that it formed a nidus for the multiplication 
 and spread of definite and specific contagia of disease ; and it 
 is largely to the apprehension of this important principle 
 that the vast expenditure for sanitary works which has 
 characterised the past quarter of a century has been due. 
 
 But even in places where works aiming at the safe disposal 
 of the solid and liquid refuse of populations, and at the 
 provision of wholesome water-services, had been carried 
 out, periodic, and at times large, outbreaks of enteric fever 
 still recurred, and it remained for those engaged in epidemio- 
 logical research to discover those more obscure channels 
 through which the infection of this fever was at times con- 
 veyed to man. 
 
 In May 1858, Dr. Michael W. Taylor wrote a paper in 
 the Edinburgh Medical Journal on " The Infection of Fever 
 by Ingesta", in which he suggested that an outbreak of what 
 we know now to have been enteric fever was due to specific 
 contamination of milk, derived from a dairy where the 
 disease prevailed. This report received but little publicity. 
 It was followed in 1870 by a report from Dr. Ballard, then 
 Medical Officer of Health for Islington, who had succeeded in 
 tracing a prevalence of the same fever to the distribution of a 
 particular milk-service. Within less than a semicircle of a 
 quarter of a mile radius, 168 cases of that disease occurred 
 within ten weeks, and the occurrence could not be explained 
 by any of the ordinarily recognised means with which the 
 spread of that disease was then known to be associated. 
 Gradually a suspicion arose that there was some connection 
 between the outbreak and the use of milk from a certain dairy ; 
 but the idea was still a novel one, and it was only after further 
 exhaustive investigation that Dr. Ballard was at last in a posi- 
 tion to demonstrate that connection as the true explanation of
 
 DURING THE VICTORIAN ERA. 27 
 
 the disease. Out of 140 families supplied from the dairy in 
 question, there were no fewer than 70 attacks, with 30 deaths, 
 the disease picking out, as it were, its victims from the homes 
 of the dairy customers living widely apart, in different streets 
 and squares, and showing a marked incidence on large con- 
 sumers of milk. And, finally, it was ascertained that water 
 from a tank in direct communication with some old drains 
 had been used for dairy purposes. The report in which Dr. 
 Ballard announced the discovery he had made was, at the time, 
 characterised as a masterpiece of medical logic, and it is 
 worthy of being remembered on such an occasion as this as 
 forming one of the most striking and important episodes in 
 the history of preventive medicine in its application to 
 enteric fever and other infectious diseases. 
 
 In 1873 there followed the admirable report by Mr. 
 Netten Eadcliffe and Mr. W. H. Power, on a wide-spread 
 epidemic of the same disease in West London. It was 
 traced to the use of milk from a large London dairy, and 
 the ultimate conclusions arrived at made it practically a 
 certainty that the milk in question was " infected with 
 enteric fever material", and that at the particular farm from 
 which it was derived the water used " for dairy purposes 
 contained excremental matters from a patient suffering from 
 enteric fever immediately before and at the time of the 
 outbreak." 
 
 Numerous instances of the same sort were gradually 
 brought to light, and there were soon strong indications to 
 show that milk formed a specially favourable vehicle for the 
 propagation and distribution of the contagion of this and of 
 other diseases. Outbreaks of enteric fever have since, in the 
 same way, been traced to the use of cream ; and, later on, the 
 occurrence of infectious diseases as the result of the use of ice 
 and iced creams prepared with materials containing the specific
 
 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 poison of disease, went to prove that the process of freezing 
 did not suffice for the destruction of the contagia in question. 
 
 And, more recently, the frequent occurrence in this country 
 of enteric fever in connection with milk-supplies has led ob- 
 servers to consider how far it is possible that this affection 
 may have a starting-point in some bovine disease; whilst 
 Dr. James F. Allen, Medical Officer of Health to the Corpora- 
 tion of Pietermaritzburg, has gone so far as to contend that his 
 South African experiences warrant him in the conclusion 
 that there is a disease in cows and calves allied to that of 
 enteric fever in man, and he holds that there are strong 
 grounds for believing that enteric fever may be produced in 
 man by means of milk from cows suffering from the corre- 
 sponding bovine disease. The subject is an important one, 
 and it is sure to receive the careful consideration of epide- 
 miologists. 
 
 In the meantime a new channel for the dissemination of 
 enteric fever had been discovered. In 1873, Dr. Blaxall, 
 during the course of an inquiry into an outbreak of enteric 
 fever at Sherborne, had found that, during intermissions in 
 a public water-service, foul matters had facilities for getting 
 into water-mains ; and' in the following year Dr. Buchanan 
 was able to show conclusively that a localised spread of 
 enteric fever in Caius College, Cambridge,* had been mainly 
 due to the suction of specifically contaminated air and other 
 matters into the water-pipes of a particular portion of the 
 college during intermissions in the water-service, and to the 
 subsequent mingling of this air with the water used for 
 drinking purposes. And late in the same year I had occasion 
 to trace an epidemic of the same disease in Lewes to a pre- 
 cisely similar cause. In this instance a wide-spread diffusion 
 of the disease took place, and no less than 486 attacks, with 
 
 * Report of the Medical Officer of the Privy Council and Local 
 Government Board. New Series, No. II, 1874.
 
 DUUING THE VICTORIAN ERA. 21) 
 
 some 40 deaths, resulted before the mischief could be checked 
 by the substitution of a constant for an intermitting water- 
 service. Since that date the conditions under which inter- 
 mitting water-services become dangerous to the public health 
 have been very generally recognised, and, as a consequence 
 of investigations such as I have referred to, additional 
 measures for the prevention of enteric fever have become 
 practicable. 
 
 Year by year evidence was accumulating to show how 
 great was the potency for mischief of even minute portions 
 of the specifically diseased evacuations of enteric fever 
 patients when such matter was placed under circumstances 
 favourable to its multiplication and its communication to man. 
 One of the most striking instances of this potency occurred 
 in the epidemic of enteric fever which I had to investigate, 
 in 1879, in the wide area over which the Caterham Water 
 Company distributed their supply.* In that case 352 cases 
 of enteric fever took place at Caterham, Eedhill, and certain 
 intervening places, some 200 of the earlier cases being traced 
 directly to the use, during a particular fortnight, of water 
 derived from a deep well, in which a man suffering from that 
 disease had been employed, under circumstances which left 
 no possible doubt that his excreta had got access to the well- 
 water. In this case it was estimated that, after all possi- 
 bility of further pollution had come to an end, no less than 
 1,861,000 gallons of water had been pumped from the well 
 during the fortnight in question; and Dr. Buchanan, in 
 dealing, in his annual report for 1881,^ with the question 
 of the amount of specific pollution which might suffice to 
 render a potable water dangerous, showed that, in this case, 
 
 * Annual Report of the Medical Officer of the Local Government 
 Board for the year 1879. [C. 2681 I], 1880. 
 
 f Annual Eeport of the Medical Officer of the Local Government 
 Board for the year 1881. [C. 3337 I], 1882.
 
 30 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 the water could have contained no such amount as one 
 grain of excremental matter per gallon ; and he brought for- 
 ward considerations tending to prove that an amount of speci- 
 fically polluting matter so infinitesimal in quantity as to be 
 altogether beyond detection by chemical analysis was fully 
 potent for mischief. 
 
 It may, indeed, now be claimed as one of the most settled 
 principles of preventive medicine that all excremental 
 filth, irrespective of its quantity, must be regarded as 
 potentially noxious to man ; and that, for the prevention 
 of such a disease as enteric fever, " the one essential is 
 cleanliness." Measures based on this principle have already 
 done much to diminish the amount of sickness and death 
 which were formerly the result of enteric fever. But much 
 still remains to be done, and it will be the duty of epi- 
 demiologists to continue the study of the etiology of this 
 disease, and the detailed history of its occurrences, with a 
 view of learning whether there are not still undiscovered 
 means by which its contagium becomes communicated to man. 
 
 IV. SCARLATINA. 
 
 Scarlatina is a disease the mortality from which in 
 England and Wales has, from time to time, exhibited very 
 extensive fluctuations. The first decennial summary of the 
 Eegistrar-General showed that during 1851-60 the deaths 
 at all ages from this disease amounted to 88 per 100,000 
 living ; in the next decennial period, 1861-70, the rate had 
 risen to 97 ; but during the ten years 1871-80 there was a 
 substantial diminution, the rate standing at only 72. Since 
 1878, when the rate was 75 per 100,000, it has fallen year 
 by year without interruption, until, in 1886, it was in the 
 proportion of only 17 per 100,000 living. There is, perhaps, 
 no disease concerning which it can be said with less cer-
 
 DURING THE VICTORIAN ERA. 31 
 
 tainty that diminutions year by year in its fatality foretell a 
 permanent lessening in its prevalence than is the case in 
 regard of scarlatina. Not only do different outbreaks vary 
 very greatly as regards mortality, but the epidemic preva- 
 lences tend to occur in cycles ; and an abatement extending 
 over a few years has been known to be followed by a wide 
 and fatal diffusion of the infection. And not only so, but the 
 more recent diminution in the amount of fatal scarlatina may 
 be in noteworthy part matter of diagnosis ; thus, whereas 
 many deaths which are now registered as due to diphtheria 
 were formerly returned under the heading of scarlatina, or 
 scarlet fever, the difference between the two diseases is year 
 by year becoming more recognised, and the fatal attacks are 
 not confused under one name to the extent that was formerly 
 the case. . , 
 
 But, after making every allowance, there remains the im- 
 portant fact, that ever since the decennial period 1861-70 
 there has been a very general and fairly steady diminution 
 in the fatality of scarlatina in this country, until, in 1885, 
 the rate of death from that cause was less than a quarter of 
 that which formerly prevailed ; and it is impossible not to 
 regard so long-continued and marked an abatement as an 
 indication that some of the means conducing to the spread 
 of this very fatal fever have been materially restricted. 
 
 And to those who are engaged in the study and practice of 
 that branch of medicine which has prevention for its main 
 object, the fact is the more satisfactory, because it must 
 be admitted, with respect to scarlatina, that the great saving 
 of life indicated in the statistics quoted has, in the main, 
 been brought about by epidemiological research, and by the 
 resulting intelligent apprehension on the part of the public of 
 the methods by which the specific contagion of this disease 
 may be multiplied and is communicated to man. Scarlatina 
 has no such relation to works of water-supply and drainage
 
 32 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 as have those other preventable diseases of which enteric 
 fever is a type, and such effective action as has been taken 
 to check its ravages has been based on a growing scientific 
 knowledge of the etiology of the disease. 
 
 Up to a comparatively recent date all the more generally 
 adopted means of prevention were in one way or another 
 included within such processes as had to do with the isola- 
 tion of the sick from the healthy, and the disinfection or 
 destruction of such articles as were known to act as vehicles 
 for the infection. And it may be recorded with satisfaction 
 that, apart from such measures as are now adopted by 
 private individuals, many public bodies have come to regard 
 it as a duty to take such action as lies in their power to 
 stay the diffusion of this disease. Thus, several hundreds of 
 the Sanitary Authorities of England and Wales have pro- 
 vided their districts with isolation hospitals, and with means 
 of disinfection; and measures have been initiated under the 
 auspices of the Education Department of the Privy Council 
 with a view of staying the dissemination of infection through 
 the agency of elementary schools. 
 
 But a record of some of the principal phases by which 
 our knowledge of scarlatina has from time to time been 
 added to will go to show that, stage by stage, \ve have had 
 to deal with newly discovered conditions favouring the 
 spread of the infection conditions lying beyond the limits 
 of the ordinarily recognised means of personal intercom- 
 munication ; and, also, that we have now arrived at a critical 
 point in the natural history of this disease a point at which 
 it is evident that we shall, in the future, have largely to 
 rely on the skilled co-operation of those who devote them- 
 selves to the study of disease in the lower animals. 
 
 I believe that Dr. Michael W. Taylor, of Penrith, was the 
 first to record an occurrence of scarlatina in connection with 
 a milk-service. He did so in August 1870 ; the history
 
 DURING THE VICTORIAN ERA. 33 
 
 which he gave being that of a prevalance of the .disease in 
 Penrith, where the customers of a certain dairy were so 
 largely attacked that " there was only one house containing 
 children, which continued intercourse with the dairy to the 
 end, that escaped the hurtful influence." It was ascertained 
 that an attack of scarlatina at the dairy had preceded the 
 general outbreak ; that the dairyman's wife, who was nurs- 
 ing her sick child, at times milked the cows ; that the milk 
 was brought from the byre into the infected dwelling before 
 it was given out for sale ; and that a large proportion of those 
 attacked could have had no communication with the dairy 
 except as the result of the consumption of the milk issued 
 from it. Gradually similar experiences were recorded by 
 other observers, and sixteen instances in which scarlatina 
 is believed to have followed on the distribution of special 
 milk-services were brought under the notice of the Inter- 
 national Medical Congress of London in 1881 ; the evidence 
 implicating the milk being, in a majority of instances, of the 
 most convincing character. 
 
 It thus became a gradually accepted doctrine that scarla- 
 tina could be, and largely was, communicated through the 
 agency of milk, and in a majority of instances there was 
 recorded the belief that the specific contamination of the 
 milk had been directly derived from some antecedent 
 case in the human subject. But there remained a certain 
 proportion of cases in which this means of contamination 
 could not be traced; and when, in 1882, Mr. W. H. Power 
 reported on a scarlatina outbreak which had coincided with 
 the distribution of a special milk-service in certain districts of 
 London,* he expressed himself as satisfied "that it was 
 practically out of the question that the milk had become in- 
 fected in any of the commonly believed ways that require a 
 
 * Eeport of the Medical Officer of the Local Government Board for 
 1 882. [ C .3778 I ] , 1883. 
 
 D
 
 34 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 human subject as the source of infection." And, further, he 
 brought forward a series of facts, which went to show that 
 many of the circumstances connected with milk outbreaks of 
 scarlatina generally accorded rather with some cow-condi- 
 tion than with the theory of milk-infection through any 
 human agency. And he formulated certain positive indica- 
 tions as to the nature of the relation between infectivity of 
 milk and ailment of cows, " indications which arise as soon 
 as there is seen to be probability that the milk", in a given 
 case, " was infected when it left the animal." These views 
 received support, from the circumstance that Dr. Klein, ex- 
 perimenting, in view of these considerations, with human 
 scarlatinal material, was able to transmit to the cow a distinct 
 disorder, and to further transmit it from the cow to other 
 animals. 
 
 So matters remained until 1885, when a wide distribution 
 of scarlatina in Marylebone and other London districts was 
 traced to several separate milk-services, derived from a 
 Hendon farm, under circumstances that induced the Local 
 Government Board to instruct Mr. W. H. Power to investigate 
 and report upon the subject. The conclusions which were 
 arrived at were not long since brought under the considera- 
 tion of the Epidemiological Society, and they are calculated 
 to have a most important influence on the future of sanitary 
 medicine as applied to the prevention of this disease, which 
 still annually destroys some 10,000 to 12,000 lives in England 
 and Wales. 
 
 Mr. Power's report* demands the careful and detailed 
 study of all who are interested in the etiology of scarla- 
 tina; but on this occasion I can only refer to its more 
 salient features. The several prevalences of scarlatina were 
 conclusively shown to have been brought about by the use 
 
 * Beport of the Medical Officer of the Local Government Board for 
 1885. [C. 4844-1], 1886.
 
 DURING THE VICTORIAN ERA. 35 
 
 of the milk from the Hendon farm ; it was quite impossible 
 to connect the means by which the milk had received its 
 infection with any pre-existing scarlatina in the human 
 subject ; and it was clear that it was the milk of certain 
 cows and of those cows only that had to do with the 
 diffusion of the disease. 
 
 During the course of his 1882 inquiry Mr. Power had ex- 
 pressed the belief that there existed grounds for associating 
 the infection of the milk with some parturient condition in 
 the cow ; and in the 1885 epidemic the scarlatina was found 
 to be related, in point of time, to the arrival at the implicated 
 farm of three recently calved cows, and to the use of their 
 milk whilst they were suffering from an ailment at first 
 sight unimportant, but which turned out to be a specific 
 contagious and transmissible disease, which had followed on 
 the process of calving.* And, further, when inoculation 
 was made into calves, either directly from the diseased pro- 
 ducts of the affected cows, or by means of sub-cultures of 
 micro-organisms connected with these substances, a disease 
 was produced which, to quote Dr. Buchanan, had " unmis- 
 takable affinities in its local phenomena with the Hendon cow 
 disease, and in its constitutional manifestations with scarlatina 
 in the human subject." The cow disease was ascertained by 
 Dr. Klein to be characterised by the presence of a definite 
 micro-organism in the affected tissues ; and both the blood 
 and tissues of ordinary human scarlatina have been found to 
 exhibit organisms identical in their morphological characters 
 and pathological properties with those which had been found 
 in the case of the Hendon cow. 
 
 Summarising the information available on this subject, 
 Dr. Buchanan, in his last report, states as follows : " 1. The 
 disease in man and in the cow alike is characterised by 
 
 * Annual Report of the Medical Officer of the Local Government 
 Board for 1886. TC. 5171], 1887. 
 
 D 2
 
 36 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 closely similar anatomical features. 2. From the diseased 
 tissues and organs of man and cow alike the same micro- 
 coccus can be separated, and artificial sub-cultures be made 
 from it. 3. These sub-cultures, no matter whether esta- 
 blished from man or cow, have the property, when inoculated 
 into calves, of producing every manifestation of the Hendon 
 disease, except sores on the teats and udders no doubt for 
 the reason that the milk apparatus is not yet developed in 
 calves. 4. But and this I have from Dr. Klein's later 
 observations while this report is in preparation the sub- 
 cultures made from human scarlatina and inoculated into 
 recently calved cows can produce in those cows, along with 
 other manifestations of the Hendon disease, the characteristic 
 ulcers on the teats ; ulcers identical in character with those 
 observed at the Hendon farm. 5. The sub-cultures, 
 established either from the human or the cow disease, have 
 an identical property of producing in various rodents a 
 disease similar in its pathological manifestations to the 
 Hendon disease of cows and scarlatina in the human subject, 
 6. Calves fed on sub-cultures established from human 
 scarlatina obtain the Hendon disease. 7. Children fed on 
 milk from cows suffering under the Hendon disease obtain 
 
 scarlatina The above combine, I think, to form 
 
 a mass of evidence to show that the Hendon disease is a 
 form, occurring in the cow, of the very disease that we call 
 scarlatina when it occurs in the human subject." 
 
 Here, indeed, we have a chain of circumstances linked 
 together with the scientific accuracy which is typical of 
 that form of research which has, at various stages, led to 
 the identification of disease in man with definite micro- 
 organisms, and which forcibly calls to mind the keen 
 forethought of those who in the early days of the Epidemio- 
 logical Society laid it down as a leading principle that its 
 " objects" should include " a knowledge of epizootics, or
 
 DURING THE VICTORIAN EJRA. 37 
 
 epidemic diseases among the lower animals, whether contem- 
 poraneous or not with such diseases in the human family." 
 
 V. DIPHTHERIA. 
 
 Diphtheria is so often regarded as having certain affinities 
 with scarlatina, that some consideration of its history may 
 appropriately be included in this place ; besides which, it 
 is a disease which has the more interest for us because such 
 study as it has received in this country has been carried 
 out during the Victorian Era. 
 
 Diphtheria is known to have been epidemic on the conti- 
 nent of Europe during the 16th and 17th centuries; and, 
 according to Sir John Simon, it was prevalent in England 
 during the two middle quarters of the past century, there 
 being also, later on, record of certain small local epidemics. 
 But it was not until the summer of 1855 that the disease 
 received 'much notice in this country. At that date an 
 extensive epidemic . prevailed in Boulogne, many English 
 residing there being .attacked. In September of the same 
 year it was recognised at Launceston, Cornwall. In July 
 1856 it appeared in Lincolnshire ; in 1857 and 1858 it was 
 manifested, in many parts of England ; and from that date 
 it has been an almost continuous and, generally speaking, 
 an increasing caiise of death amongst us. 
 
 In 1859 the disease was made the subject of a somewhat 
 extensive inquiry by the Medical Department of the Privy 
 Council; it was regarded as distinct from scarlatina, 
 prevailing mainly, but by no means exclusively, in places 
 either marshy or otherwise damp, and on cold, wet clay soils ; 
 it was distinguished by certain characteristic neuroses ; 
 and, though no definite connection could at that date be 
 traced between the disease and any affection of the lower 
 animals, it was reported by Dr. Greenhow to have been
 
 38 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 found prevailing simultaneously with certain forms of 
 disease affecting the mouth, lips, nose, etc., of certain lower 
 animals, such as cattle and horses. 
 
 The etiology of the disease was, subsequently to that date, 
 matter of frequent inquiry, such investigation as was made 
 being, however, largely limited to single outbreaks. But, 
 in 1880, Dr. Airy was instructed by the Local Government 
 Board to make a somewhat comprehensive inquiry into the 
 circumstances of new appearances of the disease in various 
 parts of England and Wales, and some of the conclusions at 
 which he arrived are as follows. 
 
 Whilst admitting that the disease was largely spread 
 from person to person, especially amongst the young, Dr. 
 Airy was much struck by the failure, in a great majority of 
 the cases investigated, to trace any cause to which the 
 several outbreaks could with any probability be ascribed ; 
 a failure which could hardly have occurred if it were the case 
 that communication, direct or indirect, with previous human 
 diphtheria were a necessary or, even a habitual condition of 
 a new outbreak of the disease ; and he, in this connection, 
 recalls the opinion of Dr. Burdon Sanderson, who, in 1859, 
 reported that "the circumstances were frequently such as 
 to shut out even the possibility of personal communication." 
 Bearing upon this point, it is also noteworthy that diphtheria 
 operates more frequently in sparsely populated country districts 
 than it does in densely populated towns, where the facilities 
 for intercommunication are at their greatest. Dr. Airy 
 further reported that he had found appearances of the disease 
 to be far more frequent in October than in any other month ; 
 that it had prevailed more frequently on clayey than on sandy 
 soils ; that it had a preferential incidence on families that 
 had shown liability to throat-affections ; and, taking note 
 of the whole of the circumstances which had come under 
 his notice, together with the discoveries of Oertel and Hiiter,
 
 DURING THE VICTORIAN ERA. 39 
 
 he held that nothing short of a living organism capable of 
 infecting milk and air, and of being transmitted by means of 
 wind currents, could fully account for all that he had met with. 
 
 In many respects Dr. Airy's inferences were confirmatory 
 of those of previous observers ; and, amongst other things, he 
 gives some support to the views which I brought under the 
 notice of the Epidemiological Society in 1878, and in which I 
 endeavoured to show, from the history of diphtheria, that 
 there were grounds for believing that certain infectious 
 diseases were not exclusively self-propagating, but did at 
 times arise independently of antecedent cases in the human 
 subject. The following are the passages in which I especially 
 dealt with this subject. 
 
 " In isolated districts, and in houses situated at times 
 many miles away from other habitations, and in some 
 instances lying in lonely spots among mountain ranges, 
 where a visit to or a visit from the nearest town or village 
 would be a circumstance too important to be forgotten, I 
 have met with instances of what appeared to me to be 
 nothing more than a simple inflammation of the throat, at 
 times so trivial that it has passed all but unnoticed, and yet 
 it has led, by transmission through other persons, to cases 
 of well-marked and severe diphtheria. The first attacks 
 have often happened in children whose former movements 
 could apparently be traced with the strictest accuracy; 
 they have occurred under circumstances which did not 
 appear to admit of previous infection ; and it has been 
 difficult to interpret their occurrence except on the suppo- 
 sition that in some way they have arisen independently of 
 prior cases. With regard also to the well-marked attacks of 
 diphtheria to which they seemed to give rise, all other 
 sources of infection could be excluded with a degree of 
 certainty rarely to be met with. And as to those first 
 affected, whose cases appeared to be earliest in a series
 
 40 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 which led up to attacks of well-marked diphtheria, it has 
 more than once happened that they were children in whom 
 so-called ' sore-throat' was a common affection, and whose 
 fauces, when examined, exhibited a loss of tissue indicative of 
 former throat-attacks." 
 
 "I have stated that instances such as these have been 
 met with in connection with outbreaks of diphtheria, and 
 it may therefore be inferred that the early cases were merely 
 mild attacks of that disease, the poison of which had been 
 received in some unascertained method ; but every one of 
 these instances occurred in persons living miles away from 
 the apparently very limited infected localities, which in 
 some cases were mere hamlets, and this source of error 
 seemed to be one which could unquestionably be excluded. 
 And, during the same investigations, I have noticed the fact 
 that, over an area of some miles around the district in which 
 genuine diphtheria was prevailing, there existed, prior to, 
 as well as during, the diphtheria epidemic, numerous 
 instances of sore-throats which, so far as an examination 
 of the patients was concerned, in every way resembled the 
 early cases above referred to, and yet which gave no indica- 
 tion of being infectious ; sore-throat being, in fact, in the 
 surrounding district a prevailing ailment. And I have 
 hardly been able to refrain from drawing the conclusion 
 that conditions very similar to those under which genuine 
 diphtheria was epidemic in a limited district obtained, and 
 had obtained, before genuine diphtheria was anywhere seen, 
 over a wide area around the immediately infected locality ; 
 and that these conditions, leading to a somewhat general 
 predisposition to simple and apparently non-infectious sore- 
 throat, had, further, probably under somewhat modified 
 circumstances, tended at certain points to produce an affec- 
 tion capable of putting on the property of infectiveness,
 
 DURING THE VICTORIAN ERA. 41 
 
 which thus lead to the transmission of the disease in a 
 distinctly communicable form to others."* 
 
 " If this be a correct interpretation of the circumstances 
 related, it would appear to indicate the possible occurrence 
 of what may perhaps be looked upon as the progressive 
 development of the property of infectiveness. And if the 
 contagia of the acute specific diseases do as has been 
 suggested by more than one observer belong to the vegetable 
 world, I knew no grounds for refusing to believe that 
 organisms capable of producing a minor and an uncom- 
 municable disease in particular stages of their growth may, 
 in other stages of their growth, or in the course of their 
 subsequent development, become capable of producing a 
 major disease communicable from person to person; the 
 affair being essentially one of soil. This is not at all a 
 question of the development of a living organism out of 
 matter independently of antecedent lite, but merely the 
 production, by means of a process of evolution, of that which 
 gives to an already existing organism that property by which 
 it becomes infective a property which it may perhaps lose 
 directly it is deprived of the circumstances which favoured 
 its development, in much the same way as special charac- 
 teristics may be artificially developed in higher plant-life, 
 and be as easily lost again." 
 
 Since I wrote the above, in 1878, circumstances have 
 arisen which will make it necessary in the future, in seeking 
 for antecedent infection, to look to the possibility of such 
 infection being derived from the lower animals. But, apart 
 from such consideration, additional evidence has, I think, 
 been forthcoming in favour of the opinion that the contagium 
 
 * In this connection Dr. Gresswell's paper on "Diphtheria and its 
 Liability to Recrudescence" deserves study. (See Transactions of the 
 Epidemiological Society, vol. v, 1885-86.)
 
 42 ON THE PEOGEESS OF PEEVENTIVE MEDICINE 
 
 of diphtheria is often characterised by a want of stability 
 when compared with that of other contagia, such as small- 
 pox, and that it does affect the human subject in a form 
 which is capable both of progressive development and of 
 relapse in point of type, according to the circumstances of 
 its surroundings.* 
 
 But whilst diphtheria may be regarded as not necessarily 
 dependent in its origin on an antecedent human case of the 
 same affection, yet its epidemic spread is largely due to 
 personal intercommunication, and this especially amongst 
 children between the ages of 3 and 12 years : an age inci- 
 dence that necessarily involves the question of attendance 
 at elementary schools. Numerous investigations have been 
 made, which show the marked influence of school attend- 
 ance and of age as a cause of diphtheria spread. In an 
 outbreak on which I reported to the Local Government 
 Board early in 1877, and in which no less than 170 
 diphtheria attacks had occurred in a population of 3,309 
 living at Great Coggeshall in Essex, 7*1 per cent, of 
 the children between 0-15 years were attacked; between 
 0-3 years the attacks were at the rate of 4*0 per cent. ; 
 from 3-12 years they were 8'4 per cent. ; and from 12-15 
 years 4'8 per cent. ; the incidence of the disease upon 
 children from 3 to 12 years being about 50 per cent, greater 
 upon those known to have attended school than upon the 
 remainder.-f- Much the same incidence of diphtheria on 
 school-going children of the ages specified has been noted 
 
 * In his Morton Lecture, delivered before the Eoyal College of 
 Surgeons on Nov. 11, 1887, Sir James Paget, in referring to the re- 
 semblances between innocent and cancerous tumours, and to the 
 examples of intermediate forms occupying the space between the two 
 extremes, refers to this "gradation" as affecting "all groups of diseases". 
 His remarks on this point deserve study in this connection. 
 
 t Dr. Downes's " Contributions to Diphtheria", in The Practitioner, 
 vols. xxxi and xxxii, are of great interest in this connection.
 
 DUKING THE VICTORIAN ERA. 43 
 
 * 
 
 elsewhere ; and at times school attendance has appeared to 
 have constituted a very important factor in the recrudescence 
 of the disease, and in imparting to it special characteristics. 
 Mr. W. H. Power's report, in 1882, on an epidemic in 
 Pirbright is very instructive from this point of view.* 
 
 "On four successive occasions while the village school 
 was open, well-marked diphtheria occurred among the 
 scholars . . . . ; and this although the school premises were 
 free from recognisable sanitary defect; and although the 
 school was not, after its first closure, reopened until the 
 disease had seemed extinct in the parish, and careful 
 measures of disinfection had been used." But, beyond this, 
 the reopening of the school appeared on each of four occasions 
 to be responsible for giving a serious quality to the resulting 
 diphtheria, and this although the assembling of the children 
 only took place some weeks after the disease had apparently 
 subsided, and when skilled investigation, subsequently 
 carried out, could only detect the existence of certain 
 neuroses amongst convalescents and a few attacks of so-called 
 " colds". On each occasion, and "with startling suddenness", 
 multiple cases of diphtheria, and fatal diphtheria, promptly 
 occurred, and this without the intervention except perhaps 
 at one period of cases of intermediate gravity. Indeed, there 
 are grounds for believing that the aggregation together of cases 
 of diphtheria and of allied throat-affections under circum- 
 stances such as those obtaining in elementary schools 
 constitutes one of the conditions under which a form of 
 disease of particular potency for spread and for death may 
 be, so to speak, manufactured. 
 
 And, as far back as 1878, during an epidemic of diphtheria 
 in North London, Mr. Power connected the incidence of the 
 disease with the distribution of a certain milk-supply ; and 
 
 * Eeport of the Medical Officer of the Local Government Board for 
 1882. [C. 3778 I], 1883.
 
 44 ON THE PKOGRESS OF PREVENTIVE MEDICINE 
 
 * 
 
 this under circumstances which raised the question whether 
 the cow herself might not have been concerned in the infec- 
 tion of the milk. 
 
 In 1883, again, evidence that may be regarded as con- 
 clusive was forthcoming to show that diphtheria was capable 
 of being brought about by the distribution of milk from a 
 particular dairy; and in referring to two such outbreaks, 
 investigated respectively by Mr. Power at Hendon and Dr. 
 Parsons at Devonport, in 1883, Dr. Buchanan says, in his 
 report for that year, that " at Hendon it was difficult to refuse 
 this explanation of the facts, since the milk at the very time 
 it was operative for harm . . . exhibited a peculiar ropi- 
 ness and unpleasant taste, which caused some of its habitual 
 customers to return it to the dairy; and for these phenomena 
 no condition about the dairy or its utensils could be regarded 
 as responsible." Here it was again foreshadowed that diph- 
 theria in man might have relation to some disease in the 
 cow ; and it is well at this stage to recall the fact that 
 different observers had, even before this date, expressed 
 suspicion that the contagium of the disease might be due to 
 conditions affecting the brute creation, and that others had 
 associated it with fungoid growths of a vegetable character. 
 
 Amongst the latest developments of these views I would call 
 attention to several reports. First, there is one presented 
 by Dr. Simpson to the Local Government Board in 1885, on 
 diphtheria in and about Shaftesbury. In it he refers 
 especially to an outbreak, in three successive Novembers, 
 in an old, dilapidated house, standing in a water-logged 
 soil, where the walls of the ground and upper floors were 
 found to be wet and covered with moulds, and the woodwork 
 rotten. " There could scarcely", he adds, " be a more favour- 
 able soil for the growth of lower forms of vegetable life."* 
 
 * See also a paper by Dr. Michael W. Taylor, in Transactions of the 
 Epidemioloyical Society, Session 1886-87.
 
 DURING THE VICTORIAN ERA. 45 
 
 Next, there is the contribution by Dr. George Turner on his 
 experiences of diphtheria, especially in its relation to the 
 lower animals, embodied in Dr. Buchanan's report for 1886. 
 And, lastly, in the same volume, that by Mr. Power on 
 diphtheria at York Town and Camberley. In this latter 
 case the outbreak was ascertained to have been due to milk 
 which had clearly received its infectiveness before it left 
 the farm where it was produced ; but the incidence of the 
 disease on the better class of consumers, as compared with 
 the cottagers and trades-folk, was as 29*3 to 6'2 ; and, it 
 having been ascertained that this excess of disease was 
 brought about apart from the use of cream, it became 
 apparent that the amount of milk consumed, involving, as 
 it did, inter alia, differences of number of opportunities for 
 infection, had been all-important in bringing about this 
 result. And, again, the better-class people stored their milk, 
 and did not, like the other class, use it directly after pur- 
 chase ; and thus an opportunity was given in the former 
 case for the development and multiplication of any infective 
 material present in it, and so of giving to the milk a superior 
 ability to convey infection. 
 
 In this case there was a complete absence of evidence 
 as to infection of the milk directly by human agency, or 
 owing to unwholesome conditions at the farm ; but, as regards 
 disease in the cow, it could only be stated that the outbreak 
 had been related in point of time to the process of calving 
 and " cleansing" in two of the cows belonging to the dairy- 
 farm, and to the existence in another cow of a " scab or 
 crust", not unlike those which at a later stage of their malady 
 had been observed to replace ulcers on the udders of certain 
 Hendon cows referred to in connection with scarlatina. 
 
 The etiology of diphtheria is thus still involved in con- 
 siderable obscurity. By some the disease is regarded as 
 having distinct alliance with scarlatina, there being no
 
 46 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 clearly defined boundary-line dividing affections which, in 
 their more marked forms, present obvious differentiating 
 characteristics ; and the views which were expressed by 
 Dr. Franklin Parsons, in the paper which he read before 
 the Epidemiological Society during the Session 1883-84, 
 are worthy of careful consideration in this connection. It 
 is also interesting to note that, whilst in the three quin- 
 quennial periods ending 1885 there was a diminution 
 in the scarlatina death-rate for England and Wales, 
 there was a coincident increase for that of diphtheria. 
 Thus, for the periods 1871-75, 1876-80, and 1881-85, the 
 scarlatina death-rate per 100,000 living in England and 
 Wales was 75'8, 67'9, and 43'4 respectively, whereas the 
 corresponding diphtheria rates were 12'1, 12'2, and 15*6. 
 
 How far this may be a question of nomenclature brought 
 about as the result of improved diagnosis it is difficult to 
 say ; but there can be but little doubt that, quite apart from 
 any such consideration, there is evidence to show that, for some 
 cause or another, diphtheria has, during recent years, exhibited 
 a tendency to increase, and to acquire a more permanent 
 stability of type amongst us. Yet there is reason for some 
 confidence that the study devoted to the etiology of the 
 disease, especially during recent years, has tended towards the 
 ultimate discovery of those measures by means of which a 
 substantial check may before long be put upon the increasing 
 fatality of diphtheria. 
 
 VI. PHTHISIS. 
 
 I believe that the first comprehensive report relating to 
 the prevention of pulmonary phthisis which was made during 
 the present reign was that which Dr. Greenhow prepared, in 
 1858, and which was submitted by Mr. Simon to the 
 President of the General Board of Health. In addressing 
 the President, Mr. Simon stated that "pulmonary
 
 DUKING THE VICTORIAN ERA. 47 
 
 affections, including phthisis, cause very nearly a quarter 
 of the annual mortality of England. Every 100,000 of our 
 population yields on an average 552 annual victims to this 
 deadly class of disorder." He also expressed the opinion 
 that pulmonary phthisis then killed, on an average, in 
 England more than 50,000 persons a year, in addition to 
 some 8,000 others, whose deaths were set down to such causes 
 as scrofula and tabes mesenterica ; and he urged the need 
 for further study of this disease and its causes, not alone 
 because of its cruel mortality, but because of the tendency of 
 tubercular disease to transmit itself from parent to child ; 
 and he added, that " whatever tends to increase tubercular 
 disease among the adult members of a population must be 
 regarded as assuredly tending to produce a progressive 
 degeneration of race." 
 
 The investigation which was made at that time went to 
 show, amongst other things, that " in proportion as the male 
 and female populations are severally attracted to indoor 
 branches of industry, in such proportion, other things being 
 equal, their respective death-rates by phthisis are in- 
 creased"; that imprisonment and barrack-life, under the then 
 circumstances, exerted a considerable influence in inducing 
 the disease ; that inadequate ventilation, both in and about 
 dwellings, was a factor in the disease ; and that high phthisis 
 death-rates were associated with certain branches of in- 
 dustry, in which sustained irritation of the air-passages was 
 brought about, as, for example, by the diffusion in the 
 atmosphere of the work-places of particles of materials used 
 in the manufacturing processes, and in which the operatives 
 were exposed to marked vicissitudes of temperature. 
 
 This inquiry was continued under Mr. Simon, after he 
 was appointed medical officer to the Privy Council ; and in 
 his 3rd and 4th annual reports he published the details of an 
 investigation, the result of which had for its object to elicit
 
 48 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 the influence of certain branches of industry on the produc- 
 tion of phthisis. The summary of this inquiry, as set out in 
 the 4th report, refers to the following as some of the more 
 important influences at work in producing the excess of 
 disease and death in question. 
 
 In the first place, and generally affecting most of the 
 callings and pursuits, the unwholesomeness of work-rooms, 
 through want of ventilation, stood out prominently this evil 
 obtaining " from the humblest cottage industry even up to 
 the highest development of our factory system". Adding to 
 the mischievous results of this lack of ventilation were con- 
 ditions such as the vitiated products of combustion 
 following on the use of artificial light ; the methods of 
 heating, other than by open fire-places ; and the failure to 
 rid the air of injurious dust and other matters. Another 
 cause of phthisis was found to be the sedentary nature of 
 many employments, and often the constrained bodily 
 posture. Numerous details in connection with various 
 methods of manufacture were cited in support of these 
 views, and a number of remedial suggestions were made, 
 which have since been widely acted upon, with a result of 
 substantially diminishing the risk of pulmonary phthisis in a 
 large number of callings. 
 
 I have already referred, in connection with enteric fever, to 
 an inquiry which was made by Dr. Buchanan in 1865-66, 
 under the instructions of the Privy Council Office, and by 
 which it was sought to ascertain what had been the results 
 obtained by local authorities, who had, by means of such 
 works as water-supply and sewerage, sought to improve the 
 public health within their jurisdiction. One main purpose 
 of the inquiry was, " that the then Central Public Health 
 Authority should fulfil one of the principal duties expected of 
 it by making new local experiences conducive to general 
 enlightenment" ; and this object was, in one important
 
 DURING THE VICTORIAN ERA. 49 
 
 respect, attained in an altogether unexpected direction. 
 That the prosecution of such works as have been referred to 
 should have led to a diminution in the general death-rate, as 
 well as in that for certain of the infectious fevers and allied 
 diseases which are known to be intimately associated with 
 pollution of air, soil, and water, was indeed to be anticipated ; 
 but as the inquiry progressed it became obvious that an 
 influence had been exercised by such works on the amount of 
 mortality from pulmonary phthisis ; and in the end it became 
 clear that " the drying of soil", which had, in most cases, 
 accompanied the laying of main sewers in the improved 
 towns, " had led to the diminution, more or less considerable, 
 of phthisis mortality."* 
 
 Some brief summary of the results of Dr. Buchanan's 
 inquiry, in so far as it relates to phthisis, will be of interest. 
 Amongst the towns visited there were many in which a 
 striking diminution had taken place in the phthisis mortality ; 
 that diminution being not only, at times, the largest amend- 
 ment discovered, but it had taken place at a period 
 which must necessarily have preceded, by some years, 
 the accomplishment of such objects as the construction of 
 proper house-drains, the abolition of cesspools, etc. Indeed, 
 it was quite evident that any mere improvement in the 
 methods of dealing with excreta and refuse, both solid and 
 liquid, the bringing in of new water-supplies, and a host 
 of other conditions that were considered, bore no necessary 
 relation to the improvement effected. But a distinct 
 etiological connection was established between local damp- 
 ness of soil and phthisis. Where drying of soil had resulted 
 from works of sewerage, there the phthisis mortality had under- 
 gone diminution ; where no such drying of soil had as yet been 
 brought about, there no improvement as to phthisis had been 
 
 * Ninth Report of the Medical Officer of the Privy Council, with 
 Appendix, 1866. 
 
 E
 
 50 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 effected ; and not only so, but the amount of reduction in the 
 phthisis mortality appeared largely dependent on the extent 
 to which permanent drying of soil had been brought about. 
 The results recorded, as regards Leicester and Chelmsford, 
 afford crucial proof of these contentions. In the case of 
 Leicester, we have a town " in the main situated on a saucer 
 of loam, principally stiff clay", and formerly having an 
 undrained subsoil and " a wet surface". In these circum- 
 stances it had, for a series of years before the execution of 
 any sanitary works, a mortality from phthisis amounting to 
 43^ per 10,000 living ; during six years, in which 30 miles 
 of sewers were constructed, the rate fell to 25^ ; though, after 
 the completion of the sanitary works, it rose again to 29^; the 
 comparatively small rise during the third period here referred 
 to corresponding, doubtless, with a damper state of subsoil 
 than that which obtained during the period when the works 
 were in actual progress, and when the stiff clay was inter- 
 sected with deep trenches for the reception of the sewers. 
 Chelmsford, on the other hand, lies at the confluence of the 
 rivers Chelmar and Cann ; the town being situated on a 
 gentle incline on a bed of gravel, some 15 to 30 feet in depth, 
 overlying the London clay. In 1853 works of sewerage and 
 water-supply were commenced. During the ten years preced- 
 ing that date there had been a death-rate from phthisis of 32 
 per 10,000 ; whilst the works were in execution a time 
 when certain wells were dried the rate exhibited a slight 
 fall to 301 ; but the rate for a period of eleven years after 
 their completion practically reverted to its previous state, 
 and is recorded as amounting to 32 per 10,000. In the 
 case of Chelmsford the sewers are deep and the soil is porous; 
 and it is under these circumstances that drying of soil is 
 most likely to take place. But, half a mile below the town, 
 on the river Chelmar, stands a mill having flood-gates, with 
 which the mill-owners alone have a right to deal ; by means
 
 DURING THE VICTORIAN ERA. 51 
 
 of these the subsoil water of Chelmsford is artificially kept 
 up, and, at the date of the report, fogs prevailed in the 
 meadows ; and the town was, in winter, surrounded on 
 more than one side by marshy lakes. Both Leicester 
 and Chelmsford thus teach the same lesson, although the 
 data are altogether different. At the close of his inquiry 
 Dr. Buchanan learned that Dr. Bowditch, during the course 
 of an inquiry as to the causes of consumption in Massachu- 
 setts, had come to conclusions similar to his own ; and 
 it is needless to add that the circumstance of two observers 
 having, independently of each other, arrived at precisely similar 
 results gives additional importance to the discovery made.* 
 The discovery was, indeed, of the utmost value. It 
 afforded indications as to the prevention of phthisis which 
 it soon became impossible to ignore ; and we see some of 
 their developments both in the efforts made, by works of 
 drainage and otherwise, to reduce the level of the sub-soil 
 water of towns and villages, and in those codes of bye-laws 
 which require that the ground surface of every domestic 
 building shall be covered with a layer of cement concrete, 
 and that a damp-course shall always be so placed in the 
 
 * I am aware that, in his sixth report (1879) on the Combined Sanitary 
 District of West Sussex, Dr. Charles Kelly, basing his views on certain 
 experiences derived from that rural area, has expressed a doubt as to the 
 correctness of these conclusions. He states that the phthisis death-rate 
 had been "distinctly lowered" in that district "in recent years", " while 
 very little, if any, change has taken place during the same period in the 
 drainage of the soil." Without entering into any criticism of some of 
 the statistical data brought forward by Dr. Kelly in support of his views, 
 I would here merely note, 1st, that the large amount of agricultural 
 drainage which had then already been effected throughout the kingdom 
 would be expected to have produced a very similar result in rural dis- 
 tricts to that brought about by sanitary drainage in towns ; and, 2nd, 
 that Dr. Kelly offers no explanation of the definite and striking relation 
 shown by Dr. Buchanan to have existed between the amount of diminu- 
 tion of phthisis death and the extent and permanence of the lowering of 
 sub-soil water. 
 
 E 2
 
 52 
 
 ON THE PROGKESS OF PREVENTIVE MEDICINE 
 
 walls of such buildings as to be beneath the level of the 
 lowest timbers. The value attaching to residence at high 
 altitudes, and in a dry atmosphere, also receives significant 
 explanation as the result of Dr. Buchanan's inquiry. In- 
 deed, it may be asserted that, on the lines indicated by the 
 results of the several inquiries to which I have adverted, 
 vast improvements have been going on, which have influ- 
 enced health and life in town and village, factory, workshop, 
 and home, to a degree that has already materially diminished 
 the production of pulmonary consumption, both in this country 
 and in many parts of the world. 
 
 Unfortunately, confusion between pulmonary phthisis and 
 other diseases of the respiratory organs has not, even at this 
 date, been eliminated from our mortality returns ; and com- 
 parative statistics as to these several diseases are further 
 vitiated by reason of changes in nomenclature which have 
 followed on improved diagnosis. But, at the same time, 
 some indication of the improvement I have referred to may 
 reasonably be assumed to underlie the figures included in 
 the following table, which shows the annual mortality per 
 million from " phthisis" at all ages, and at certain typical 
 ages in both sexes during the last three decennia. 
 
 PHTHISIS IN ENGLAND AND WALES. 
 
 
 AH Ages. 
 
 15- 
 
 20 
 
 25 
 
 35 
 
 1851-60... 
 
 .... 2679 
 
 2961 
 
 4181 
 
 4317 
 
 4091 
 
 1861-70... 
 
 2475 
 
 2651 
 
 3928 
 
 4243 
 
 4020 
 
 1871-80... 
 
 2116 
 
 2036 
 
 3117 
 
 3619 
 
 3745 
 
 
 
 
 
 
 
 I cannot quit this subject without making some reference 
 to the investigations which are being made in this country, 
 in Germany, in the United States, and elsewhere, as to the 
 etiological relationship of bovine and human tuberculosis ; 
 and to the allegations of some observers, that bovine tuber-
 
 DURING THE VICTORIAN ERA. 53 
 
 culosis may be communicated to man as the result of the use 
 of milk of cows suffering from that disease, and even that 
 human tuberculosis has a source in the use for food of the 
 flesh of tuberculous animals. So far, the propriety of accepting 
 the probability of such transmission of this infective disease 
 appears to depend materially on the question of the identity 
 of bovine and human tuberculosis, as to which different 
 views are entertained. But the fact that the milk of tuber- 
 culous cows has, apart from certain complications, not yet 
 been found to contain tubercle bacilli, alone forms a ground 
 for suspending judgment on this important point. 
 
 VII. CHOLERA. 
 
 The history of cholera in this country is very intimately 
 associated with the story of progress in the department of 
 public health and of sanitary medicine. As already stated, 
 the first appearance of cholera in England was in 1831-32, 
 before the commencement of the Victorian era. The disease 
 reached this country by way of the Baltic,first attacking several 
 of our eastern ports in the autumn of 1831, and becoming 
 widely diffused in the following year. Unfortunately, no 
 accurate information is available as to the extent of its 
 ravages. But that invasion led to an important movement 
 in the direction of sanitary reform, and of legislation to 
 effect that object ; such legislation being largely based upon 
 the skilled observations of those who had recorded the 
 circumstances under which cholera had prevailed in this 
 country. 
 
 The second great visitation of cholera occurred in 1849. 
 On the occasion of this epidemic, cholera, after having 
 extended its destructive course over the eastern part of 
 Europe, penetrated into Prussia, Hamburg, and Holland, 
 and, in September 1848, crossed the German Ocean, and
 
 54 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 broke out ill several towns in Scotland and England. 
 At first the progress of the disease was slow and irregular ; 
 the total deaths in England numbering 988 from the 
 date of its first appearance, in 1848, to the end of March 
 1849. But between June and the middle of September 
 of that year there was a rapid increase, after which 
 the disease gradually declined, and finally ceased in 
 December. In all, the fatal attacks during 1849 numbered 
 53,293, in addition to 18,887 diarrhoea deaths; and, from 
 the literature in which the epidemic is recorded, it is 
 evident that there was recognition at this date of the cir- 
 cumstance that its spread was largely facilitated by 'con- 
 ditions of filth, affecting air, soil, and water. In the words 
 of the Eoyal Sanitary Commission, 1869 : " The reports then 
 made by the medical officers who had been established 
 .... clearly traced the most fatal ravages of the epidemic 
 to the crowded alleys of large old towns, impure air and 
 water, and foul streams." And whilst the diffusion of the 
 disease was largely dependent on human intercommunication, 
 direct or indirect, it was found to differ in its mode of spread 
 from such affections as typhus and small-pox. 
 
 In August 1853 cholera appeared again in London ; in 
 September it was widely prevalent in Newcastle, Gateshead, 
 and other places in Great Britain ; and in the following year, 
 1854, England suffered from a third great epidemic of this 
 disease. Cholera in this country had again followed on an 
 epidemic spreading from Russia, through Norway, Sweden, 
 and Denmark, and the Baltic ports of Germany, from whence 
 it was communicated to this country. 
 
 In the metropolis the disease was maintained during 
 September, and in the months of October, November, and 
 December 1853 the fatal attacks were 335, 288, and 43 re- 
 spectively. From January to June 1854 only occasional 
 deaths took place ; but during the last three days of July no
 
 DURING THE VICTORIAN ERA. 55 
 
 less than 138 fatal attacks occurred. From this latter date 
 there was a rapid rise in the amount of cholera and diarrhoea 
 fatality. The epidemic spread in various parts of the king- 
 dom, and by the close of the year the total deaths from cholera 
 in England and Wales had numbered 20,097. 
 
 Dr. Snow was amongst the earliest contributors to the 
 etiology of cholera in this country. He had previously dealt 
 with the epidemics of 1832 and 1849, in connection with the 
 theory of water-pollution. As regards the 1832 epidemic, 
 he had maintained that its exceptional incidence, in certain 
 localities, was in large part due to the polluted water in 
 use in London, whether derived from wells liable to 
 receive cesspool soakage or from the sewage-contaminated 
 Thames. Between 1832 and 1849 cesspools had been largely 
 abolished, but water-closets, the contents of which passed 
 into the Thames, had replaced them, with the result of 
 bringing about a state of river impurity far exceeding that of 
 1832. And during the 1849 epidemic the parts of the metro- 
 polis most heavily visited were those within the area of the 
 Lambeth and the Southwark and Vauxhall Water Companies 
 on the south side of the river, their supply being then the 
 worst of all those derived from the Thames. The "contami- 
 nation of pump-water" was also ascertained to have been asso- 
 ciated with the spread of the disease. And now again, in 1854, 
 Dr. Snow pointed to the proof which the incidence of cholera 
 afforded " of the powerful influence which the drinking-water 
 containing the sewage of a town exerts over the spread of 
 cholera". Between 1849 and 1854 important changes had 
 taken place, m the water-supply of the metropolis. The 
 Lambeth Company had sought a supply higher up the river, 
 and, to quote Mr. Simon,* that Company was now "furnishing 
 as good a water as any distributed in London" ; while its 
 
 * Eeport addressed to the President of the General Board of Health 
 in May 1856, by the Medical Officer of the Board.
 
 56 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 southern colleague, the Southwark and Vauxhall Company, 
 " was purveying perhaps the filthiest stuff ever drunk by a 
 civilised community". Here were materials for comparison, 
 and the result was as follows: On a population of 166,906 
 persons living in houses supplied by the Lambeth Company, 
 the cholera deaths were at the rate of 37 to every 10,000 
 living; whereas, on 268,171 persons supplied by the Southwark 
 and Vauxhall Company, they were at the rate of 130 per 
 10,000. " The population drinking dirty water accordingly 
 appears to have suffered 3| times as much mortality as the 
 population drinking other water." 
 
 It was during this epidemic that the circumstances occurred 
 which have made the pump in Broad Street, Golden Square, 
 historic in the annals of English cholera. According to Dr. 
 Snow,* 89 cholera deaths were registered in three sub-districts 
 in the week ending September 2nd, 1854; 79 of these occurring 
 in the two last days of that week, and "nearly all" in persons 
 residing within a short distance of that pump. Indeed, 
 " except among the persons who had been in the habit of 
 drinking of the .... pump-well", there had been no par- 
 ticular outbreak or increase of cholera in that part of London. 
 It was a celebrated pump. " The water was used for mixing 
 with spirits in all the public-houses around. It was used 
 likewise at dining-rooms and coffee-shops .... it was also 
 used at various little shops" in the making of sherbet. And 
 amongst occasional consumers of it, some living at a distance 
 from the pump, numerous fatal attacks occurred ; whilst, on 
 the other hand, the disease was markedly absent from several 
 large groups of people living in the immediate neighbour- 
 hood, in institutions or other places having a different water- 
 supply. 
 
 But it also became recognised that polluted water was by 
 uo means the sole cause of cholera spread. Dr. Greenhow, 
 
 * Snow, On Cholera, 1855. London, John Churchill
 
 DURING THE VICTORIAN ERA. 57 
 
 in reporting to the General Board of Health, pointed out 
 that the mortality had also "generally borne a direct 
 ratio to the amount of atmospheric contamination"; and 
 although some of the channels by which the poison operated 
 in its various wanderings still remained undiscovered, yet 
 observers, such as Mr. Simon, detected the operation of 
 " specific influences", with capability for propagation, such as 
 is exhibited by " ferments", in the presence of conditions of 
 filth affecting air, soil, and water. 
 
 It was as a sequel to this epidemic that the need for a 
 medical adviser to the State was recognised by the appoint- 
 ment of Mr. Simon as Medical Officer to the General Board 
 of Health. 
 
 The fourth cholera epidemic from which this country has 
 suffered took place in 1866. As on the occasions of the 
 former epidemics, the disease manifested itself in the year 
 immediately preceding its wide diffusion. But it entered 
 this country by an altogether different route. Early in 1865 
 cholera was causing an appalling mortality amongst the 
 Mecca pilgrims, and from Mecca it was diffused into Egypt, 
 and thence along the lines of steam-boat communication 
 between Alexandria on the one hand, and the Levant and 
 Southern Europe on the other ; extension subsequently 
 taking place in a more northward direction. Ultimately 
 the disease manifested itself in Southampton, on more than 
 one occasion, during the month of July 1865 ; this extension 
 being probably connected with arrivals from Alexandria, 
 Malta, and Gibraltar ; and being the first occasion in which 
 cholera had entered the kingdom by way of our southern coast. 
 After these preliminary warnings, a definite outbreak, in- 
 volving some sixty persons, took place in Southampton 
 during September-November; and cases also occurred at 
 other places, such as Weymouth, Portland, Dorchester, and 
 at Theydon Bois in Essex.
 
 58 ON THE PKOGRESS OF PREVENTIVE MEDICINE 
 
 Towards the close of April 1866, a trader arrived at Bristol 
 from Rotterdam sick of the disease ; in May, German and 
 Dutch emigrants had conveyed the infection to Liverpool. 
 Birkenhead and Swansea were next attacked. In June the 
 Poonah arrived at Southampton with the disease on board ; arid 
 England was evidently developing cholera at various points. 
 Then came the invasion of London, the first death being 
 returned from Poplar on July 18th,* after which the disease 
 spread rapidly. The story of this epidemic has been told 
 in detail by the late Mr. Netten Radcliffe, who also, as the 
 result of a laborious inquiry, came to the conclusion that 
 the exceptional incidence of the disease in the eastern 
 districts of London was the result of the distribution by 
 the East London Water Company of a polluted water, which 
 had " in it a power of direct infectiveness for those who 
 drank it". During the course of 1866 the cholera deaths 
 amounted to 14,378 in England as a whole ; 5,548 of these 
 occurring in London. 
 
 The circumstances of the 1866 epidemic acted as a 
 great stimulus to epidemiologists in various parts of 
 Europe to study afresh the conditions under which cholera 
 prevailed, and to obtain a knowledge of the right principles 
 of defence against it; the practical sanitary experiences 
 gained in England being especially supplemented by the 
 labours of distinguished German pathologists, who, at that 
 date, sought for the essential cause in some fungoid growth. 
 In this country it had been conclusively shown that the laws 
 of cholera contagion bore a striking resemblance to those 
 relating to enteric fever, and that, to quote the words of Mr. 
 Simon, " excrement-sodden earth, excrement-reeking air, 
 excrement-tainted water, these are for us the causes of 
 cholera." 
 
 * Reports of the Medical Officer of the Privy Council for 1865 and 
 1866.
 
 DUKING THE VICTORIAN ERA. 
 
 59 
 
 But though this lesson had been brought home more 
 convincingly than ever, it was not a new one; and for many 
 years past a movement often but too slow had been on 
 foot towards the removal of those conditions of filth which 
 had been found to be essential to the diffusion of the cholera 
 infection. And we have a right to assume that it was 
 largely owing to these labours that the power of the disease 
 for harm had become less and less during its last three 
 visitations. This result is shown in the following table : 
 
 CHOLERA MORTALITY. 
 
 
 EjfGLAlfD AND WALES. 
 
 LONDOW. 
 
 Date. 
 
 Total Deaths. 
 
 Deaths per 
 10,000 living. 
 
 Total Deaths. 
 
 Deaths per 
 10,000 living. 
 
 1849 
 
 53,293 
 
 30 
 
 13,565 
 
 51 
 
 1854 
 
 20,097 
 
 11 
 
 10,684 
 
 43 
 
 1866 
 
 14,378 
 
 7 
 
 5,548 
 
 18 
 
 Since 1866, cholera, though more than once brought to 
 our shores as during the European epidemics of 1871-74 
 and 1884-87 has never succeeded in establishing itself in our 
 midst, a result which is no doubt due to the steady removal 
 from amongst the people of those insanitary conditions which 
 are essential to its epidemic spread, and to the increasing 
 security afforded by those measures of imperial and local sani- 
 tary administration by which it is sought to diminish sickness 
 and mortality from all preventable diseases, including cholera. 
 
 The beneficial results which have ensued in regard to the 
 saving of life from cholera have, in no small measure, been 
 due to the fortunate abandonment by this country of all en- 
 deavours to keep cholera away from her shores by a system 
 of quarantine. I recently brought under the notice of the Epi- 
 demiological Society the attitude we have finally adopted in 
 this matter, in a record of the Proceedings of the International
 
 60 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 Sanitary Conference of Kome, 1885, which I had the honour of 
 attending as one of the delegates of Her Majesty's Govern- 
 ment.* It is one of distinct opposition to the entanglement 
 of this country by means of a delusive system, offered anew 
 under the plea that another reduction should be effected in 
 the duration of a detention which, even under its most stringent 
 forms, had been mainly characterised by ever-repeated failure ; 
 and I would now only refer to a summary of the grounds on 
 which I justified this opposition when dealing with this subject 
 at the meeting of the British Medical Association in 1887. I 
 concluded by observing that " the system of quarantine has 
 again and again shown itself to be impotent for good, and, 
 being so, its vexatious and inhuman characteristics stand out 
 the more prominently. Above all, it has a blighting effect 
 upon sanitary progress. So long as Governments tell their 
 peoples that a line shall be drawn around them across which 
 disease shall not pass, so long will those peoples be reluctant 
 to spend their money on the promotion of true measures of 
 prevention. The quarantining countries are essentially those 
 which cholera invades. Taken as a group they are those where 
 true sanitary progress is at its lowest ebb ; and, with the ex- 
 perience we have before us, I would, in conclusion, ask, much 
 in the words I used at the Borne Conference : Is it likely 
 that this nation will sacrifice her well-tried system of preven- 
 tion for a restriction of five days' quarantine ?" 
 
 I cannot close this subject without referring to one note- 
 worthy contribution to the etiology of cholera, which has 
 recently been made by Dr. W. J. Simpson,f Health Officer 
 for Calcutta. An outbreak of cholera having occurred on 
 
 * Transactions of the Epidemiological Society, vol. v, New Series. 
 Session 1885-86. 
 
 t Report on the Health of the town of Calcutta, for the first quarter 
 of 1887.
 
 DURING THE VICTORIAN ERA. 61 
 
 board the Ardenclutha, which was moored in the river, he 
 succeeded by a process of elimination in at last tracing the 
 disease to the use of a certain milk-supply. Fourteen of the 
 crew who had not partaken of this milk remained altogether 
 free from sickness ; whereas, of ten who had drunk it, nine, or 
 ninety per cent., sickened, four with fatal cholera, and five 
 with " diarrhoea" ; the one who escaped having only drunk a 
 "thimbleful". The milk-supply being stopped, all sickness 
 was stayed. In this case the milk which was procured from 
 a distance, namely, from Howrah, on the other side of the river 
 Hooghly, and had been brought on board by a native was 
 admittedly and somewhat copiously diluted with the contents 
 of a tank polluted with cholera excreta. Cases of cholera 
 occurred amongst the natives using the tank water directly 
 after the contamination took place, and this localised outbreak 
 at Howrah was simultaneous with that on board the Arden- 
 clutha. This is, I believe, the only case on record in which 
 milk has been definitely ascertained to have served as a 
 vehicle for cholera transmission. 
 
 I am deeply conscious of the shortcomings of this record. 
 The time at my disposal has of necessity placed limits on its 
 completeness, and has compelled me to omit all but the most 
 cursory reference to labours and discoveries which are calcu- 
 lated to exercise a most important influence on public health 
 in the future, and which are identified with the names of 
 many with whom we have been and still are associated. One 
 such omission will, I am glad to say, speedily be supplied by 
 Dr. Klein, who will shortly bring before us the subject of 
 " The Infectious Diseases common to Man and the Lower 
 Animals". We have also in prospect a communication which
 
 62 ON THE PROGRESS OF PREVENTIVE MEDICINE 
 
 will bring our information as to the relation of micro- 
 organisms to preventable disease up to current date. 
 
 The complete story of the progress of sanitary medicine 
 during the memorable period under discussion would carry us 
 far beyond such bounds as I have had to place upon myself. 
 It extends to the saving of human life, as the result of 
 advancing knowledge, in every quarter of the globe ; and 
 those whom I address, having, during the best years of their 
 lives, devoted singular gifts to epidemiological research in 
 every portion of this great Empire, may well remember with 
 satisfaction how our Society has been the repository of 
 learning that has so largely tended to the lessening of 
 death, which has been so distinguishing a characteristic of the 
 past half-century. 
 
 If we need any fresh incentive to our labours we have 
 but to compare the terrible death-roll of the past with that 
 diminished mortality which has gone hand-in-hand with the 
 scientific application of the principles of sanitary medicine 
 to the circumstances under which we live. And when we 
 look at the recent advances in our knowledge of the intimate 
 nature of infection, and of the still hidden, but yet far- 
 reaching, influences of disease, we are further stimulated to 
 enter into friendly rivalry with those to whom the laurels 
 of the past have so deservedly fallen. 
 
 It has, indeed, been contended that there are limits 
 beyond which the saving of human life is not consistent 
 with the public welfare, and that the present tendency is 
 towards an undue multiplication of the human race, and to 
 a corresponding increase of poverty and misery. But I venture 
 to assert that, so long as the work we are engaged in goes, 
 as it has gone hitherto, to the lessening of death, so long 
 must it ensure the diminution of sickness, and a correspond- 
 ing promotion of a higher vitality, and a greater capacity for 
 remunerative work amongst the living.
 
 DURING THE VICTOKIAN EEA. 63 
 
 And our determination to continue in a labour so full of 
 promise will have the more binding force as we recall the 
 progress which has marked a reign on which we, in common 
 with the great British world, look back to-day with feelings 
 of pride and loyal affection. 
 
 LONDON: 
 WHITING AND COMPANY, PABDINIA STHBKT, LINCOLN'S INK FIELDS.
 
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