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Notwithstandin- all that has been said and written in this country upon sanitary subjects during the last thirty years, it must be confessed, more especially since the publication of the important work which heads our list, that the knowledge of our sanitary condition as a people is still most indefinite, and that still less defined is our knowledge of the measures best adapted to correct the causes of disease and death which are daily and hourly diminishing the efficiency, as well as curtailing the lives, of English men, women, and children, spreading among them not only physical pain and want, but moral perversion also. It is impossible to go over the publications to which we call attention, and not to feel how much
public health. Hitherto, sanitary efforts have been for the most part temporary and spasmodic; an alarm of cholera, or an outbreak of fever in some town or village, has roused the people or the authorities into a sanitary activity, often too great an activity, for the time being; but the cause of alarm disappears, and with it the reforms to which it had given momentary impulse; the old nuisances accumulate, and the people return to their old habits, little thinking, that though cholera or fever with their striking effects have gone, the same predisposing causes are still working, with as certain if less palpable power to sap the constitutions of themselves and of their children, and that convulsions, with the whole train of nervous diseases, pulmonary affections, with consumption at their head, are doing far more deadly work among them. That every casual malady, every epidemic of influenza,* every child-hed ailment, every accident, is liable to be rendered more severe, perhaps fatal, by these influences. Just so did our forefathers five centuries ago. They well knew that filth, impure air and water, were productive of disease, and when the black death of the fourteenth, the sweating sickness of the fifteenth, and the plague of the seventeenth centuries had done their fearful work, then, as now, were sanitary precautions taken, and many if not all the measures of this our nineteenth century resorted to, to be, like them, abandoned, or allowed to slumber, as soon as the present fear had passed away, and the remembrance of the horrors become dimmed.
We speak now of the country at large, for the lessons of the past have not been entirely thrown away, and thinking men, chiefly, justice compels us to say, belonging to the medical profession, have ever kept urging the adoption of a proper sanitary system, extended to every city and town, to every village and district of the kingdom. That their urging has availed somewhat, the list of works which heads this article testifies.
Wc learn much from the ' Reports' of the recently appointed " Medical Officers of Health;" but by far the most comprehensive and valuable exposition of the "sanitary condition of the people of England," is that of Dr. Headlam Greenhow, most valuable in itself, and rendered still more so by the introduction added to it by Mr. Simon, the well-known medical officer of the General Board of Health.
Dr. Greenhow's 'Papers,' and Mr. Simon's 'Report,' offer a stand-point from which we may regard the present state of sanitary science; they direct our attention, in the first place, to what we know of the causes of disease and mortality, and in the second, to how far and by what means that disease and mortality are to be prevented. The first of these questions will fully occupy the present article, the latter we reserve for future consideration.
We find that we are as yet but on the threshold of the science of hygiene, and Mr. Simon points out that special attention is required to some of the conclusions of Dr. Grcenhow's 'Papers'
"Because in the new light which they afford, the sanitary state of the people of England almost imperatively claims to be reconsidered as a whole, and because of the valuable evidence presented of how very much remains to be done in great part of England before the limits of practical preventability will be even distantly approached.' (p. 3.)
practice in the matter of
• Dr. Greenhowss Papers, p. 103.
Further on, Dr. Greenhow himself tells us—
"That before sanitary science can make any further progress, it would be necessary to investigate the causes of excessive disease and mortality in a more analytical manner than has heretofore been done, for without a more precise and accurate acquaintance with their cause, it would be impossible to employ the most certain means of prevention against the diseases which so largely aggravate the death-rates of certain districts." (p. 132.)
Indeed, nothing strikes the mind more on the perusal of these papers, than the vast amount of work to be done before we can arrive at an accurate opinion respecting causes, and how very unstable are many of the foundations on which rest present opinions and theories. One in point: It has almost been received as an established fact, that the immense mortality of soldiers stationed in this country, and especially of the Foot Guards in London, from pulmonary disease, was due to overcrowding and other causes, which occasioned them to breathe all night and almost all day an impure air. "The soldier sleeps in a fetid and unwholesome atmosphere, the habitual breathing of which, though producing, for the most part, no direct immediate effects, probably lays the seeds of that pulmonary disease which is so fatal in the British army."* At the recent meeting of the British Association, Mr. Neison read a paper,f tending to disprove the fact assumed, that pulmonary disease does arise from such a cause, and that we must look for its great prevalence and mortality among the troops elsewhere. How far Mr. Neison sustains his point remains to be seen, but the fact of its being mooted by so high an authority is strongly illustrative of the present unsettled state of sanitary science. Moreover, the point is one of special interest here, Dr. Greenhow attaching the greatest importance to the pulmonary death-rates of the various districts as indicative of their general sanitary state. It may be remarked that the term "death-rite" belongs peculiarly to the science of sanitation, having taken its origin from reports on health; and now, the death-rate of a town or district is the dial-plate of its sanitary working. The entire death-rate, however, gives but a rough idea of the causes which are at work to cut short human life; it requires to be analysed, and the results classified and tabulated, not in one, but in various combinations, as we see done in Dr. Greenhow's 'Papers,' before it yields the novel and valuable information which can be extracted from it. Certain diseases, certain localities, certain occupations, difference in sex or age, all have their own special death-rates, which must be compared one with another, and must be brought into contrast and comparison with contingent circumstances and influences. For convenience, throughout Mr. Simon's 'Report,' and Dr. Greenhow's 'Papers,' the number 100,000 has been adopted as the standard of comparison for the various death-rates; this standard being adhered to even when the population of a town or district does not nearly reach it, the ratios being calculated proportionally.
Mr. Simon opens hit Report by distinguishing from the 628 registration districts into which England » divided, sixty-four districts which, compared with the others, present the best sanitary condition. In these sixty-four districts, with a combined population of one million, the annual death-rate runs from 1500 to 1700 per 100,000; the average death-rate for England at large being 2226, rising in some notorious districtsto 3100, 3300, or even 3600. Disregarding for the present the latter high rates, we may well ask the question why, if in some districts but from 15 to 17 persons die per 1000 annually, in others the mortality rises to 22 or more per 1000?
Moreover, although a mortality of from 1500 to 1700 is taken as a sanitary standard, it is so simply for the reason that it is, for the present, with one small exception, the best we can get; we have amongst us no model community to furnish us with, if we may so call it, a model death-rate. The exception alluded
• Ileal* of the English Soldier, Sanitary Review, April, 1858.
to is that of the distant and isolated Faroe Islands. In this small community the largest proportion of deaths occurs in the decenniad between eighty and nmety years of age, the death-rate being as low as 1250. Of this rate, which is the lowest we can find, Mr. Simon makes great use, constituting it, as it were, the key-note of our entire subject. Albeit, it is more than doubtful whether, even in this case, anything like sanitary order prevails. Mr. Robert Chambers, in his 'Tracings of Iceland and the Faroe Islands,' tells us that "round nearly every house is a black and fetid sewer," the houses themselves being "small and stifling," and the adjacent rill defiled with "washings of clothes and eviscerations of fish." Well may it be asked, if we have this low mortality amid all these fosterers of disease, what might we not have under a better system? Verily we have not yet found our lowest death-rate. Nevertheless, what we have will serve our purpose for the time.
As above stated, a mortality of 1500 per 100,000 is the highest sanitary status to be found in the English registration districts; for an isolated community, with certain conditions favourable to health and longevity, the mortality falls as low as 1250, leaving between the two lowest death-rates a margin of 250. This mortality of 250 Mr. Simon assumes is due to non-preventable causes of disease and death—that is to say, causes which cannot, at present, at least, be prevented from operating upon us as a large community, but which are escaped by people so limited in number and so isolated as the Faroe Islanders. The non-preventable causes of premature death are enumerated as congenital and hereditary influence; contagions of small-pox, hooping-cough, measles, and scarlatina; privation, accidental injuries and violence, vice and intemperance. Passing the lowest English death-rate of 1500, or at most 1700, all mortality in excess of these numbers we are to consider as preventable, and as due to
"Diseases of which the very essence is filth; diseases which have no local habitation except where putrefiable air or putrefiable water furnishes means for their rise and propagation; diseases against which there may be found a complete security in the cultivation of public and private cleanliness." (p. 9.)
Dr. Greenhow commences his inquiries by the selection of one hundred and five registration districts, which should "comprise a variety of healthy and of unhealthy places, each of them distinguished by its positive character, or some peculiarity in the industrial employment of its inhabitants." (p. 19.) Next he selects the diseases to be investigated, and in this our author appears to have taken a sufficiently extensive field for an initiatory inquiry; so extensive, indeed, that he considers " the entire subject as barely opened " by the present investigation. The period selected includes the seven years 1848-54, the census of 1851 occurring midway; this length of time being deemed sufficient "to obviate the fluctuations that are liable to occur from year to year."
The diseases investigated are arranged in ten groups :—
"A. Pulmonary affections, including phthisis.
B. Contagious diseases, including small-pox, measles, scarlatina, and hooping-cough.
C. Alvine flux, including diarrhoea, dysentery, and cholera.
D. Typhus and erysipelas.
E. Croup, influenza, and ague.
G. Nervous diseases of children, including convulsions, hydrocephalus, and teething.
H. Apoplexy and paralysis.
I. Rheumatic fever and rheumatism.
"Pulmonary diseases, alvine flux, and the nervous diseases of children, are the classes of disease which are, both absolutely and relatively, the chief causes of high death-rates . . . . It is to the investigation of their origin that sanitary inquiries may most advantageously be directed. It is from devising and adopting measures for the removal of their causes, that we may most confidently hope for an amelioration in the public health. Any measures that should be successfully adopted for diminishing the mortality produced by these diseases, would undoubtedly diminish that from other diseases likewise. Certain of the contagious diseases, although their amount might be undiminished, would at least fall with diminished intensity upon a healthier population; and the same would probably hold true of other diseases likewise." (p. 131.)
If these opinions are correct—and we see no reason to donbt them—they must have a very important bearing upon the question of sanitary reform, and the measures to be adopted.
The class of pulmonary diseases is first brought under notice; and the most prominent fact which appears is the absence of "uniform relation between the male and female death-rates,"—the male-rate exceeding the female in the proportion of 100 to 94 in the country generally. In three of the registration districts, however, this is reversed. In these three divisions, the Eastern Counties, the South Midland Counties, and the North Midland Counties, few males are engaged in manufactures, but the number engaged in agriculture considerably exceeds the average. On the other hand, a good proportion of the adult females are engaged in industrial manufacturing pursuits, these being chiefly conducted at their own homes. Albeit, the three districts in question contrast favourably in the matter of health generally with the other districts of the kingdom, we have now got the fact that, in three healthy districts, with a general pulmonary death-rate not excessive, the female-rate, reversing the usual order, exceeds the male, the exception occurring coincident with the difference in industrial pursuit above alluded to. Mark, however, the following:—Buckinghamshire, Hertfordshire, and Bedfordshire, with almost the same number of adult males engaged in agriculture as Lincolnshire, have a pulmonary death-rate one fourth larger than the latter county. Cambridgeshire, though with an agricultural element second only, and that in very slight degree, to Lincolnshire, and with scarcely any manufacturing element at all, has a pulmonary death-rate proportionally larger, not only than Lincolnshire, but larger than that of any of the counties mentioned.
Again, in Nottinghamshire the female pulmonary death loss exceeds the male almost as much as it does in Bedfordshire; whilst the proportion of women employed in manufactures is only half as many, and materially less than the number in Buckinghamshire, which county Nottinghamshire also approximates in the proportion of its male and female pulmonary death-rates. Dr. Greenhow's remarks upon the foregoing are:—
"Here, then, is a case which seems at variance with the conclusions that appeared to spring so evidently from the facts previously recorded. No explanation of the fact is to be gathered from the evidence, so far as it has hitherto been considered. Probably the discrepancy will be explained when the subject shall have been more fully investigated." (p. 29.)
And a little further on :—
"Thus, although there does appear to be some general relation between the comparative death loss of different counties from pulmonary affections, and the closer or more diffused aggregation of their inhabitants, the per-centage of urban population, and the nature of the prevailing industrial employment, this relation is neither constant nor exact." (p. 29.)
sWell may it be elsewhere observed, that "the causes which modify public health are of a complicated nature, and still require much investigation." "When large districts and more numerous populations are taken as subjects of comparison, their very extent and diversity offer various sources of fallacy and confusion; and we are thrown back upon more circumscribed inquiries for more accurate deductions."
In Staffordshire the male occupations are of a very mixed character, including the manufacture of earthenware, the female employments also taking up three and a half per cent, for this branch of industry, and nine per cent, in manufacturing pursuits generally. The general pulmonary death-rate is above the average of England and Wales; moreover, the difference between the male and female death-rate is small. In a subsequent observation it is shown that the chief pulmonary (phthisical) mortality among the earthenware workers appears to arise from the fabrication of a particular kind of fine pottery, attended with evolution of fine dust.
Illustrative of the difficulty of forming definite conclusions from the inquiries already made, we come at a more advanced stage of the Papers, upon a curious anomaly connected with the pottery district death-rate. Wolstanton and Stokeupon-Trent are closely adjacent to one another, the former being much the most thinly populated, and having fewer adults, either male or female, engaged in the earthenware manufactures; yet Wolstanton has a higher pulmonary death-rate than Stoke: "the question could only be satisfactorily solved by a careful investigation of this subject in the pottery district." (p. 73.)
Again, the North-Western Registration Division includes the counties of Lancashire and Cheshire, with the West Riding of Yorkshire, in fact, "the great manufacturing centre of England." Comparing the male pulmonary death-rate of the above with that of England and Wales, and with that of the three agricultural counties of Lincoln, Hereford, and Cambridge, we find it considerably in excess, as may be seen in the following selection from Table VII. of the work before us:—
Name of pulmonary affec
Connty. tions per 100,000
sWest Riding 577
England and Wales 569
In the above table Cheshire contrasts rather favourably with England and Wales, but the contrast is only favourable as regards the male sex, for the mean pulmonary mortality of both sexes is higher in Cheshire than in the country generally.
Lancashire shows the highest pulmonary mortality, higher than the West Riding, and yet in the latter a larger proportion of males are engaged in manufacturmg industry than in the former,—a sufficient proof, perhaps, that some other cause, in addition to manufacturing employment, is at work to produce the mortality. Lancashire contains Liverpool, and
"The mortality from pulmonary disease is higher in Liverpool than in any other district to which this investigation has extended. The pulmonary mortality of Lancashire is therefore in some measure augmented by the high pulmonary death loss of Liverpool; and the high pulmonary death loss of Liverpool is not at all attributable to the employment of its inhabitants in manufactures, but must be ascribed to some other cause not apparent at present." (p. 32.)
If we look at the density of the population of Liverpool as compared with that of other towns and cities in the kingdom—for example, Liverpool having 34,000 persons to the square mile, while London has little more than 19,000—we can scarcely wonder that Liverpool has not only a very high general death-rate, but we are also ready to connect its high pulmonary death loss with the same cause; justly, perhaps, in some degree, but we cannot altogether, when we find a few pages further on that Hull, with a population of 13,750 per square mile, contrasts favourably as regards pulmonary death-rate with Ipswich, which has but 2493 persons per square mile; and with Gravesend, which has but 6908 in the same space, both sea-port towns; and that the same favourable comparison holds good