is to prevent its entrance nine times out of ten; but this is well worth striving for. If yellow fever depends on local sanitary conditions, there is little hope that these will be done away with in many of our Southern cities and towns for years to come. By properly constituted and intelligent State and local boards, stimulated and aided by the national board, no doubt much may be done to prevent the origin, and limit the spread of this disease, and if the co-operation of other powers of the intertropical Atlantic can be obtained, its field may be restricted within very narrow limits.

Under existing laws, and in the prevailing state of public opinion, it is a necessity that the national board should give special attention to quarantine matters, and much the greater part of the funds under its control have been granted for that purpose only. But in common with all intelligent sanitarians and physicians the board sees clearly enough that its most important fields of usefulness lie in other directions, and it has done enough already in those fields to make it probable that hereafter this country will not be without some central sanitary organization irrespective of the question of a national quarantine system.

That this organization will remain permanently in the form of the present National Board of Health is improbable. The tendency just now is towards the plan sketched by Dr. Bowditch, involving a representation of all State boards in a general council, with a single executive officer to be chosen by the council; but there are many practical difficulties in the way of this plan. To make it effectual, concurrent legislation on the part of the several States and of the United States will be necessary, and a very extensive educational process must be gone through with before such legislation can be secured; and it seems to me that one of the first steps in this process is to show what the sanitary condition of our cities, towns, and villages actually is, which is to be effected by a uniform system of vital statistics and by sanitary surveys.

In conclusion, permit me to repeat what I have elsewhere said. in this connection:

"In sanitary matters no single man, city, State, or nation can protect itself, except by non-intercourse, and not always even by that. To get the best results with the least cost and interference with freedom, we must help one another; but this help

must be given, received, and regulated on business principles, 'because it will pay,' and not be considered as sentimental charity, which will sooner or later be grudgingly bestowed and unthankfully received. We want our citizens and cities, counties, and States to take care of themselves in sanitary as in other matters as far as possible; but there should be some power competent to interfere in the exceptional cases in which selfishness, ignorance, or terror leads either to danger of pestilence or obstruction of commerce. This power, however, cannot be established arbitrarily, or in advance of sufficient education of the business portion of the community to create a powerful public opinion to support it. Whether it is possible to supply this education otherwise than through the lessons which epidemics themselves give is the problem which the sanitarians of this country are at present practically trying to solve."

1 International Review, Jan. 1880, p. 49.

THE DEATH-RATE OF THE RICH AND POOR.

BY CHARLES ROBERT DRYSDALE, M.D.,

LONDON, ENGLAND.

IT has for many years appeared to me, whilst acting as medical officer to various London charities, that a vast deal of the sickness and death of the poorer classes is almost entirely due to the unfortunate position in which many of them are placed with respect to food, dwellings, clothing, and other requisites of healthy existence. In newer countries, like the Western States of the American Union, and in our Australian colonies, where the climate is suitable for the constitution of races of European, and, for the most part, of British origin, I presume, if I may judge from the statistics of New Zealand and Victoria, Australia, that poverty is not wide-spread, and hence that it does not greatly influence the death-rate, as it does in London.

I have no doubt that the same observation has been very frequently made by all medical men who have seen much of the poorest classes; but, in my opinion, there has, up to this time, been too little of accurate statistics collected to enable the medical world to see, what I am now inclined to believe is the case, that poverty, caused by low wages, is in all old and civilized countries by far the most important cause of premature death, and the main obstacle to all sanitary improvements.

It is doubtless quite true that, during the past three or four centuries, a very great advance has been made in lowering the death-rate in European states, a statement which will be amply verified, when it is known that in the town of Geneva, in the sixteenth century, the probability of life, or the age to which half of the population born lived, did not exceed 5 years, whilst the mean life was 18 years. In the eighteenth century these figures had risen to 27 years for the probability of life, whilst the mean of life had advanced to 32 years. England has had a similar history of a rapid fall in the death-rate during the VOL. XXXI.-30

earlier decades of this century; but it must be confessed, that for the last thirty or forty years there has been no very perceptible fall in the mortality, and this in the face of the fact, that at no previous period in the history of the nation has there been such an amount of capital, labor, and intelligence expended on the drainage and purification of our cities.

Let me take London as a sample. With all the advances recently made in this wonderfully healthy city, we find that the death-rate was 22.2 per 1000 in 1856, 22.3 in 1876, and about 23 per 1000 in 1877 (Vacher). And if we turn to all England, we see, as Dr. Fergus pointed out at the Cork meeting of the British Medical Association, that the death-rate of England and Wales was identically the same, namely, 22.35 per 1000 in each of the decades 1841-50, 1851-60, and 1861-70.

The point that I shall endeavor to insist upon and elucidate is, that the grand cause of the non-improvement of our mortality resides in the mass of indigence, which is now, as it always must have been, the main cause of premature death, in all settled and civilized states.

M. Villermé, the distinguished Parisian physician, and several of his able collaborateurs, in the Journal d'Hygiène Publique, have contributed some valuable facts to this argument. Thus, in France, it has been observed that persons between the age of 40 and 45 die, if in easy circumstances, in the proportion of 8.3 per 1000, whilst if poor they died at the rate of 18.7; that is two and a half as many poor as rich died at these found, too, that in Paris there died between the years 1817 and ages. It was 1836, 1 inhabitant in 15 in the 12th arrondissement, which, as those of us who have studied in the Quartier Latin know, is peopled in great part by the poor, whilst but 1 death in 65 took place in the 2d arrondissement, chiefly inhabited by the richer classes.

M. Joseph Garnier, of Paris, mentions that in 1857 the mean life in certain quarters in Manchester was only 17 years, whilst that of other quarters of that most unhygienic city was then 42 years: and Villermé found, some thirty years ago, that the probable life of the infant of a weaver at Mulhouse was so low as only 13, whilst that of the child of the manufacturing class of that city was 26 years.

The venerable Mr. Edwin Chadwick, late chief officer of the first general Board of Health in England, kindly gave me, in