if

same year rheumatic fever and rheumatism of the heart were responsible for a death-rate of 104 per million; endocarditis and pericarditis, which in a vast preponderance of cases are caused by rheumatism, causing a death-rate of 329 per million; while tubercular diseases caused a death-rate of 3,145 per million (phthisis being responsible for 1,468 of this); and bronchitis and pneumonia caused a death-rate of 3,192 per million. Of the zymotic diseases a death-rate of 716 per million was caused by measles and whooping-cough collectively, of 325 per million by influenza, and of 954 per million by diarrhoea. None of these is included in the scope of compulsory notification of infectious diseases as practised in the majority of districts, and although it may be doubted whether any immediate practical benefit would arise from such notification, the improved knowledge of their natural history and causation, which would gradually accumulate, must in the end prepare the way for more effective preventive measures. At present, with the possible exception of summer diarrhoea, it may be said of these diseases that the sanitary measures already adopted in this country have produced but little, any, effect. If we omit these diseases, there remains a deathrate of 1,170 per million due to infectious diseases, the spread of which has been seriously combatted by sanitary authorities. The total annihilation of these diseases would only have reduced the general death-rate, in 1893, from 1917 to 18 per 1,000; while the annihilation of tubercular diseases, which is much more within the range of possibility, and may in fact be accomplished, like the already secured annihilation of the closely allied disease leprosy as an endemic disease in this country, would have reduced the general death-rate in 1893 from 1917 to 16.02 per 1,000. The mortality really caused by rheumatism is immensely understated by the 433 per million officially ascribed to rheumatic fever, endocarditis, and pericarditis. It is not improbable that this disease will ere long come into the list of actively preventible diseases. A very large amount of bronchitis and pueumonia is caused by improper conditions of housing or of work; and there is little doubt that a large saving might be effected under this head. Alcoholism figures low in the official returns, 73 deaths per million being ascribed to this cause in 1893; and even if we add the death-rate of 121 per million caused by cirrhosis of the liver (an almost solely alcoholic disease), the official returns give a very incomplete notion of the immense mortality due to this preventible cause. These instances by no means exhaust the list which might be given to illustrate the fact that preventive medicine is concerned with all the diseases to which flesh is heir, the only condition beyond its possible scope being old age.

Proposals.

Accurate knowledge of sickness, of its degree of incidence in relation to sex, age, occupation, housing, locality-in fact of all the conditions under which it is originated-must, however, precede rational preventive measures. Hence it is necessary that the following measures should be adopted :

1. All cases of sickness occurring among the parochial poor in each district should be periodically reported to the medical officer of health, and tabulated statements concerning them forwarded to a central office in London, in which such statistics, along with those from other sources, should be analysed, summarised, and published.

Schedules might easily be arranged similar to those in force in Christiania or Berlin, in which a weekly return of the new cases of sickness among the poor could be made by the Poor-Law medical officer with a minimum of trouble. The cases in the workhouse infirmaries and in industrial schools should be similarly scheduled. Care would be required to prevent the same cases from being entered more than once. It may be mentioned that it has since 1879 been incumbent on all district and workhouse medical officers, and upon medical officers of district schools appointed since that date, to furnish the medical officers of health with returns of pauper sickness and deaths; but as the chief object of these returns appears to have been the notification of infectious diseases, the returns have been in most places allowed to lapse, and have not, I believe, been used for general statistical purposes.

2. All cases of sickness, whether out-patients or in-patients, at hospitals (general and special) and at public dispensaries should be reported weekly to the medical officer of health, and by him forwarded to the central office in London, to be there treated like the pauper statistics. The hospitals and dispensaries of this country are supported by subscriptions or bequests, and they owe it to the State to furnish the fullest particulars which the latter may require. Every public institution for the treatment of the sick should, I maintain, be required to give to the medical officer of health a weekly statement of the number of new inpatients and out-patients treated during the week, specifying the age, sex and nature of the illness of patients; also a quarterly or annual statement of the total cases, and the number of days spent by each patient in the hospital. The statistics of large general hospitals, especially those to which medical schools are attached, are of great value, the diagnosis and certification being exceptionally accurate. I have recently shown that the statistics of the chief metropolitan hospitals give a faithful index of the

yearly incidence of rheumatic fever in London, and the same must be true for many other diseases. It will hardly be credited that several of the large metropolitan hospitals, as University College, London, and Guy's Hospitals, have either very imperfect or no tabulated statistics of annual cases of sickness. At the Edinburgh infirmary such records were only commenced in 1889, while in other hospitals in various parts of the country accurate statistics have been kept for a long series of years, as at Aberdeen, Glasgow, York, Bradford, Brighton, and many other places.

It should be made obligatory on the managing bodies of all general and special hospitals, and all public dispensaries, to keep accurate entries of all cases treated at these institutions, and to report on special schedules these cases to the medical officer of health at stated intervals. What has been done in Germany can be done here; and as they followed our lead in respect of registration of deaths, it is for us now to follow them in registration of hospital and other forms of sickness.

The question of hospitals would not be complete without reference to the special hospitals now established in most towns and districts of England for the isolation and treatment of infectious diseases. Many important problems as to the intensity of different epidemics, the relative fatality of cases occurring in different districts, the influence of "hospitalism" on the character of each disease, &c., might be solved by accurate comparative statistics for the great fever hospitals throughout the country. At present there are statistical reports for such hospitals in the annual reports of some medical officers of health, of very varying comprehensiveness and value. What is required is that these should be formed on a uniform basis, and that the statistics from different hospitals should be analysed and published at a central office in London.

It is but fair to mention here the extremely valuable reports of the statistical committee of the Metropolitan Asylums Board. The year 1894 was the ninth year of issue of this report, which is in some respects a model for others.

We may also mention here the statistics in the same report as to lunacy and imbecility in the asylums and schools of the Board, which it ought to be practicable to compare with those of other similar establishments throughout the country.

The lunatic asylums for each county form another field for collective investigation, which can only be fully utilised by analysis and tabulation of statistics at a central office.

3. All Friendly Societies, and all sickness insurance societies of every description should be required to furnish weekly or monthly returns of the number of new cases of sickness in their experience, classified according to a specified schedule, and a yearly statement

of the total number of subscribing members, classified according

to age.

Such Friendly Societies are already under some degree of control as regards their financial condition, and there is no reason why accurate statistics of sickness should not be required in the interest of the community. These would furnish a very valuable means of estimating the relative amount of yearly sickness at different ages in the industrial classes, the relative incidence of special diseases at certain ages and in special occupations, and so on. Such statistics would be much more trustworthy, if properly collated, than can be any mortality statistics for different occupations. They would throw a flood of light on the healthiness or the reverse of various industries, and would

open the way for valuable preventive measures.10

4. An attempt should be made to obtain accurate returns of sickness in the great industries. This can only be gradually secured. Two factors are necessary in order that industrial sickness may he estimated for comparative purposes: (a) An accurate return of the number of men employed in each industry; and (b) a similarly accurate return of the cases and causes of sickness, each classified according to age. Some important steps have been taken in this direction in the Factory and Workshops Act, 1895, which comes into operation on the 1st January of next year. By sec. 34 it is required that—

The occupier of every factory and workshop shall, on or before the 1st day of March in every year, send to the inspector of the district on behalf of the Secretary of State a correct return specifying, with respect to the year ending on the preceding 31st day of December, the number of persons employed in the factory or workshop, with such particulars as to the age and sex of the persons employed as the Secretary of State may direct, and in default of complying with this section shall be liable to a fine not exceeding 10l.

There is, however, no provision requiring a general notification of sickness among the employés, although this would be quite practicable. The only approach to it are the enactments contained in sec. 20 and sec. 29.

1 It is true that at present there is great discrepancy in the administration of Friendly Societies and in the amount of sickness which their experience shows, in persons of corresponding ages. The data from these societies would consequently require to be judiciously employed for many years to come. The proposed collation and tabulation and publication of the experience of these societies would, however, probably form the first step in the direction of securing more uniform administration of sick relief in different localities.

Sec. 20 states that

(1.) Every occupier of a factory or workshop shall keep a register of accidents, and shall enter therein every accident occurring in the factory or workshop of which notice is required by the Factory Acts, within one week after the occurrence of the accident, and this register shall be at all times open to inspection by the inspector and the certifying surgeon for the district.

(2.) If any occupier of a factory or workshop makes default in complying with the requirements of this section, he shall be liable on summary conviction to a penalty not exceeding Iol.

This enactment will doubtless be of great value in determining the relative liability to accidents of different industries, and the directions in which additional regulations and restrictions are required.

Sec. 29 requires that-

(1.) Every medical practitioner attending on or called in to visit a patient whom he believes to be suffering from lead, phosphorus, or arsenical poisoning, or anthrax, contracted in any factory or workshop, shall (unless the notice required by this section has been previously sent) send to the Chief Inspector of Factories at the Home Office, London, a notice stating the name and full postal address of the patient and the disease from which in the opinion of the medical practitioner the patient is suffering, and shall be entitled in respect of every notice sent in pursuance of this section, to a fee of 28. 6d., to be paid as part of the expenses incurred by the Secretary of State in the execution of the principal Act. (2.) If any medical practitioner, when required by this section to send a notice, fails forthwith to send the same, he shall be liable to a fine not exceeding 408.

(3.) Written notice of every case of lead, phosphorus, or arsenical poisoning, or anthrax, occurring in a factory or workshop, shall forthwith be sent to the inspector and to the certifying surgeon for the district; and the provisions of the Factory Acts with respect to accidents shall apply to any such case in like manner as to any such accident as is in those sections mentioned.

(4.) The Secretary of State may by order made in accordance with sec. 65 of the principal Act apply the provisions of this section to any other disease occurring in a factory or a workshop, and thereupon this section and the provisions referred to therein shall apply accordingly.