out the country. They wish it to be clearly understood, that of the papers transmitted for their revision, it will be optional with the individuals making the several communications, to determine whether their names shall or shall not be made known to the public. They do not anticipate many instances in which it will be necessary for them to exercise the rejecting power placed in their hands; but should it ever happen that they find themselves obliged to perform this painful duty, the papers meeting their disapproval will, whenever required, be returned to their authors.

Having thus alluded to the materials of which the proposed work is to be framed, it seems proper to say a few words on the part to be taken by the Board in their compilation and preparation for the press, it will appear evident that some power of alteration as well as selection must pe placed in their hands; but this power, it is both their wish and determination to use as sparingly as possible. From the communications received, they will set apart and arrange for publication, without alteration, all papers appearing to contain important doctrinal views and interesting practical details and observations; this will generally be done without minute reference to judiciousnsss of manner, or peculiar niceties of style, as occasion may seem to require; they will preface each class of essays on any particular disorder, with such remarks as their own longer experience, or various returns from the different establishments under their control may point out to them as bearing upon the subjects under discussion. In addition to these prefatory remarks, short notes may now and then be interspersed at the foot of the page elucidatory of the text, and communicating such information as may prove generally interesting to the profession, or such recent medical intelligence, as although known to their brethren in Europe, may, from distance and the difficulty of procuring English publications at remote stations, still have failed to reach the great body of the medical staff in this country. To each separate volume the Board may likewise prefix an introductory discourse, comprehending a historical sketch of the health of the various corps and departments of the army, and of the civil establishments under their superintendence, during the past year, and illustrative of the causes and effects of any sudden or marked changes; any increase or diminution of sickness, that may have occurred during the period under review. The whole to be followed by a series of tables or returns, showing the strength of each corps; the number of its sick and casualities, and the complaints most prevalent amidst it, and affording to the profession in general data, on which to form accurate conclusions regarding the nature and fatality of the diseases usually encountered in Indian climates.

The Board need hardly say, that in a work, one main object of which is to excite a free spirit of enquiry and discussion, they cannot consider that it falls within their province to censure harshly any portions of individual essays, that may, in their judgment, contain assumptions erroneous in theory or practice, to constitute themselves absolute judges of the merits of questions at issue; or to assume authority, to dictate precise rules, or lay down positive laws, for the guidance of the Medical Staff in the treatment of diseases. They will, in all cases, consider it to be their duty to refrain from taking part in professional disputes, and from betraying such a bias to particular theories or opinions, as might tend to restrain those under their authority, from the open expression of their sentiments; and, if they ever interfere in the points under discussion it will be from the more gratifying motive of holding up to general approbation, instances of rare ingenuity, or of laudable industry.

The great and numerous advantages to be gained by the prosperous issue of the undertaking now on foot, are so clear and evident, that the Board feel perswaded they need make use of no further arguments to secure to it your concurrence and hearty co-operation. Its immediate effects, it is hoped, will be to excite a spirit of honourable emulation, that may call forth the talent and energy which have till now lain nearly dormant: to give a strong impulse of activity,

and to communicate to all parts of the Service a feeling of consent and mutual respect, and an ardent desire for the improvement of professional pursuits. Looking a little further, we may venture to predict, that ere the lapse of many years, a large mass of valuable information will, by its means, be placed before the public, and this country be thus relieved from the reproach under which she has long lain, of having failed to contribute her part to the advancement of science, and the lessening of disease and human misery.

Such communications as you may please to make in furtherance of the foregoing statement you will have the goodness to address, in the usual form, to this office.

I have the honor to be,

Sir, &c. &c.

SECRETARY, MED. BOARD.

THE

Medico-Chirurgical Review,

No. LXXXII.

[No. 42 of a Decennial Series.]

JULY 1, TO OCTOBER 1, 1844.

FIRST REPORt of the CoMMISSIONERS FOR INQUIRING INTO THE STATE OF LARGE TOWNS AND POPULOUS DISTRICTS. Presented to both Houses of Parliament by Command of Her Majesty.

THE subject of the Report before us is the wide spread existence of removable causes of disease, and the best mode of securing their removal.

That prevention is better than cure is in no case so true as in that of medicine. Great as is the utility of efficiently treating disease-the preservation of health is greater still. The cure of a disease, as it is called, is often the partial removal only of an existing evil-its prevention is its complete avoidance. It rarely happens that the subject of severe sickness, however complete may be his apparent recovery, escapes without some permanent injury to his constitution, which either lowers the standard of his health, and adds, practically, years to his constitutional age, or, at least, renders him more prone than he would otherwise be to subsequent attacks of the like or analogous disorders.*

Then again, how often does it happen that complete recovery is not the issue of the best directed remedial treatment. Not rarely death claims his victim before his naturally appointed time, and still more frequently the occurrence of a severe attack is but the commencement of a series of tormenting and protracted sufferings. By the prevention of disease, then, not only is immediate risk and pain, and anxiety avoided, but permanent injury prevented, and unquestionably a large addition made both to the duration and the desirableness of existence.

Until a comparatively recent period this most important subject,-attention to the general health of the community-had met with but little attention either from the profession or the public. What is everyone's business, is no one's business, and this has been no exception. Our knowledge, even of the exciting causes of particular diseases, is in a very unsatisfactory state, that of the remote and predisposing causes, of the reasons for the prevalence of particular classes of disease among certain portions of the population, is still more imperfect. The contrast between our ignorance on these subjects and the advanced state of our knowledge in pathology and practical medicine and surgery is very remarkable. Nor is it surprising. Knowledge on the latter subjects is required for our ordinary business; by it is our road to fame and fortune, and by its employment we earn our daily bread. For the other sort of knowledge there is

This is so well known that many insurance offices will not accept the lives of those who have been previous sufferers from any serious disease, and all make it an important object of enquiry in estimating the risk of each particular life. No. LXXXII. Y

little demand, and consequently but a small supply. For without in the least insinuating that the members of our noble profession are habitually actuated by merely mercenary motives, they, like other men, pay but little attention to that, which, however valuable, is not useful to themselves; and a subject of such extent and difficulty as that of the nature and mode of removal, of removable causes of disease, will never be thoroughly understood, and still less will such information be widely diffused, until a number of men are engaged in acquiring and employing the knowledge as a profession. That not being the case, we ought rather to be surprised that our knowledge is so extensive as we find it, than that it is so confined as we confess it to be.

The Commissioners, whose Report we are examining, were appointed by Her Majesty's Letters Patent, dated may 9th, 1843, "to inquire into the present state of large towns and populous districts in England and Wales, with reference to the matters hereunder specified :

:

"The causes of disease among the inhabitants.

"The best means of promoting and securing the public health under the operation of the laws and regulations now in force, and the usages at present pre→ vailing with regard to

"The drainage of lands;

"The erection, drainage, and ventilation of buildings;

"And the supply of water in such towns and districts, whether for purposes of health, or for the better protection of property from fire, and—

"How far the public health and the condition of the poorer classes of this realm, and the salubrity and safety of their dwellings, may be promoted by the amendment of such laws, regulations and usages."-Report, p. vii.

The Report, with its evidence and appendices, appears in the form of a large blue book, of more than seven hundred pages. It is clear that we cannot present even an outline of so vast a mass of matter, and all that we shall attempt is to abstract enough to establish the following points. First-the wide diffusion and vast importance of the evils to be remedied. Secondly-that the causes of the evils are removeable. Thirdly-that the cost of their removal would impose no inordinate burden upon those who would have to bear the expense of, as well as receive, the benefit to be conferred.

1st. The wide Diffusion and Extent of the Evil to be remedied.

Upon this point we may be very brief. The wide diffusion of the evil of excessive unhealthiness of towns is established by the fact, that out of 40 of the largest towns in England, four only have a rate of mortality not exceeding that of the average of the country; which average is itself raised by this excessive, and, as we shall shortly try to prove, artificially high mortality. The mortality of healthy districts is about two per cent. Eight only of the forty towns above alluded to have a rate of mortality less than two and a half per cent. while five have a rate exceeding three per cent.; and in one, Liverpool, the mortality has been three and a half per cent. In other words, while in a healthy district twenty out of a thousand inhabitants die annually, and the average duration of life is more than forty years, in five of these large towns thirty or more out of every thousand perish in the same time, and the average duration of their lives is reduced by one third of its natural period. It requires no argument to prove the incalculable importance of measures tending to diminish this fearful sacrifice of life, to alleviate the injury by which it is accompanied, and to extend to its natural term the period of existence for vast multitudes of our fellow creatures. We will, however, present another illustration. In the fifth Report of the Registrar-General, at page 400, a table is published which well deserves attentive study. It is too long for extract, we must content ourselves with giving some of the results. It is an abstract of the deaths registered in the year 1841, in the districts of 25 towns, in the Metropolis, and in Cornwall, Devonshire, Dorset

shire, Somersetshire, Wiltshire, Essex, Gloucestershire (except Bristol and Clifton), Herefordshire, Norfolk (except Norwich), Suffolk, Sussex, and Westmorland. The population of the Metropolitan and town districts was, in 1841, rather more than three and a half millions (3,759,186), that of the rural districts was rather less (3,440,501). The disproportion in the number of deaths, however, far exceeded this small disproportion in the amount of population, being 96,999 in the town districts, and only 65,575 in the rural districts, being a difference of 31,424. In other columns the comparison is made of the mortality among exactly equal civic and rural populations. The calculation is made of the number of deaths from all causes occurring in 1841, among a population of 1,000,000 of both town and country districts: of the former 25,803, of the latter 19,060 died in the year 1841. For reasons into which we will not at present stop to enquire, the mortality in towns appears to have been less in 1841 than usual; and in the average of the four years 1838-39-40 and 41, 27,073 died annually in each million in the town districts, while 19,300 only died in each million in the country districts.

We are now in a condition to form an estimate, though still an imperfect one, of the vast extent of the evil for which we must seek a remedy. If it really be, as many believe it is, quite possible by proper sanatory precautions, to reduce the mortality of towns to the same rate as that of the country districts, it follows that we have it in our power to diminish the number of deaths in the four millions of large town population by more than thirty thousand a year. But the benefit of improved sanatory precautions, though most urgently required in large towns, will not be confined to them. All parts of the country will participate, and we may estimate the number of lives which may probably be annually saved, at a number considerably exceeding that which we have named.

It is with difficulty that the mind receives the idea of numbers larger than it is accustomed to deal with. A population of thirty thousand is that of a considerable town, such for instance as Derby, Lancaster, or York. Let us imagine one of these towns to pour forth all its inhabitants; let every dweller from cellar to garret appear; let every street, every alley, give up its living horde; let all, male and female, of every age, from the new-born babe to the octogenarian tottering on the brink of the grave, join in the vast crowd, to give us some slight idea of the enormous multitude which we represent by the words THIRTY THOUSAND LIVING SOULS. And yet this number, vast as it is, is but a part of those who, in all human probability, might be annually saved by proper attention to the circumstances necessary for healthful existence.

But this vast unnecessary loss of life, together with the melancholy amount of suffering by which it is preceded, is a part only of the evil resulting from faulty sanatory arrangements. Each of these unnecessary deaths represents a family unnecessarily bereaved. Early orphanage with all its risks, premature widowhood with all its privations, are not among the least of the evils it is within our power to lessen. Again, it is probable that sickness and mortality have a pretty constant ratio to each other, and that by the same means by which we diminish fatal disease, we shall in like proportion lessen that which is not destructive of life. If so, we may calculate upon a diminution of physical and mental suffering beyond that already indicated. According to the experience of the

* That this ratio is nearly constant is probable, but by no means certain. Any difference, however, there may be, is likely to be in favour of our argument. It is certain that many cases run their course, whether for recovery or death, with greater rapidity in country constitutions, and such cases will tend to diminish the ratio of sickness to mortality in the country. It is probable, however, that the ratio is sufficiently constant for the substantial correctness of the argument in the text.