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with inland places, even such as Macclesfield, with only 493 persons per square mile, and indeed with many other places.
We might here pass on to review what we learn from Dr. Greenhow of the influence of density of population generally on pulmonary death-rates, but we cannot omit an interesting and valuable comparison between the manufacturing districts of Cheshire, Lancashire, and the West Riding, and the midland manufacturing counties of Leicester and Nottingham. In the first three the factory system prevails, in the last two more work is done by the operatives at their own homes. In the first three the pulmonary death-rate is larger than in the last two, in which, however, as in Cheshire, the female death loss is the larger; it should be remarked, however, that in Cheshire, which offers fair ground of comparison, the rate is higher for both sexes. It might be fair to conclude that the factory system, as it works at present, is more prejudicial to life, as far as pulmonary disease is concerned, than where work is done at home. It may be so, but many contingent circumstances, only to be brought out by minute inquiry, must be taken into consideration.
The fact seems to come out strikingly in these investigations, that one marked indubitable cause of pulmonary disease, and especially of phthisis, is the inhalation of fine hard dust. This seems to be the case in Warwickshire, especially where the metallic manufactures are of a kind to give rise to such dust, more than where the work is of a coarser description; we have observed the same fact where fine pottery is made; it is well known in the hardware manufactures of Yorkshire, and the mortality of miners where the ore lies in dry sandstone is said to be from the same cause. On the other hand, where the dust inhaled is of a soft character, as in woollen, flax, and cotton factories, asthma and chronic bronchitis are more prevalent. Pulmonary consumption, it is true, is also prevalent, but it must be a question whether this may not be the result of the deterioration of the constitution generally under the influence of the manufacturing system, as much as the consequence of the direct irritation of the lungs; at least the increased pulmonary death-rates in those places where females are engaged in industrial employments— such as lace-making and straw-bonnet making—where no dust is evolved, tend to support the proposition. Thus, whilst investigating the effect of manufactures as productive of pulmonary disease, it should not be lost sight of, that if in some cases the disease undoubtedly commences in the lungs; possibly, probably in others, as in the factory operatives, it has its origin in the constitution. There can be no doubt that, as expressed by Mr. Simon,
"In proportion as the male and female populations arc severally attracted to indoor branches of industry, in such proportion, other things being equal, their respective deathrates by phthisis are increased." (p. 28.)
In the lace-making districts just alluded to, the female death-loss seems always to exceed the male.
"The pulmonary death-rate is usually excessive in towns where both males and females are largely employed in the manufacture of textile fabrics, but the difference in the mortality of the sexes is rarely great." (p. 34.)
The woollen districts have a somewhat lower mortality than the cotton and silk, the disease excited seems rather of the form of chronic bronchitis and asthma.
The pulmonary mortality of the cotton districts is decidedly high, Manchester, as we might expect, having the greatest loss. The difference in the death-rates, however, of males and females, is slight, both being largely engaged in the industrial occupations of the place. This is remarkable in comparison with Liverpool, which, with a higher mortality still, does not show it so much in its female population, who are not engaged in any special employment. Preston stands next to Manchester in pulmonary insalubrity, higher than Chorlton and Salford, and yet the people are much less thick upon the ground than iu the latter places, and the proportion of agricultural labourers is higher, but the paupers, as in Saffron Waldon, are more numerous.
It is difficult to pass over a page of the elaborate and industriously compiled work before us, without finding matter for comment or extract. Space confines us to a selection of the most striking observations and marked exceptional facts. Of the latter, Saffron Waldon, just mentioned, is an instance. Of the hundred and five districts under investigation, it has the highest pulmonary death-rate; and the only probable reason to be assigned is, that it has the greatest amount of pauperism. Another exception we find in Hendon, near London, a purely agricultural district, yet presenting an exceptionally high pulmonary death loss. The most probable reason for this adduced by Dr. Greenhow, is, that it is a great hay growing district, the labourers being for the most part employed as hay cutters, carters, &c., and exposed continually to the fine grit or dust thrown off from the hay. It may here be added, that one probable cause of high phthisical death-rate, especially in hamlets, is the intermarriage of the people. In our own experience, at least, it is not uncommon to find villages in England composed of families of which a large proportion bear not only the same name, but the same stamp of family resemblance, and the same tendency to disease, especially of a scrofulous character.
The influence of the occupation of mining upon the health and life is full of interest, as well as most important to this country of coal and iron. The facts connected with it are significant. The employment is generally carried on in salubrious country districts. In lead mining, which seems unusually pernicious, the differences in the pulmonary death-rate are well marked, and correspond pretty nearly with the proportion of men engaged in the pursuit. The district of Alston, the most exclusively lead mining district in England, is specially noticed. Situated in a most salubrious country district, the pulmonary death-rate exceeds that of Liverpool; and this excess is almost entirely due to the adult male mortality, the mortality of the infant population of Alston being immensely below that of Liverpool. Alston has more widows, proportionally, than any other place in the kingdom. Moreover, the female death-rate from phthisis is also high, although none of the sex are engaged in mining. This may be due to acquired hereditary tendency, presenting us with another of those influences which complicate the calculations. Tin and copper mining both seem to increase the pulmonary death loss among those engaged; the latter, as in the case of Redruth, gives a male mortality considerably in excess of the average. Coal mining, on tbe other hand, does not appear to affect its workers in the same way. Easington and Houghtonle-Spring, both purely coal districts, have comparatively low pulmonary death loss. An exception, nevertheless, meets us in the Welsh coal mining districts, which, as well as the slate-quarrying district of Carnarvon, have a high pulmonary death loss. So little explicable, too, is the cause, that Dr. Greenhow is fain to fall back upon the question of race as a predisponent, especially as this mortality prevails likewise among the females, who do not engage in the staple occupations.
Passing from the consideration of the effect of industrial employment upon the general pulmonary death-rate, to the effect of density of population, we find very indefinite results. The discrepant example of Hull in comparison with other towns, has already been noticed. As a rule, the greatest mortality appears to prevail in urban, and consequently crowded, districts, but to this there are many exceptions, which Dr. Greenhow thus endeavours to explain:—
"It is indeed certain that the mode usually adopted, of measuring the aggregate distribution of the population by the number of persons on a square mile or acre, fails to afford a true estimate of density in a sanitary sense. Some town districts have a considerable portion of outlying country district attached to them, while the density having been calculated for the entire district, of course diminishes the average number of persons on a given space, and yet the urban portion may be very densely populated. Other places, where the labouring classes chietly dwell in separate cottages, may present a smaller superficial density of population, and yet, from deficiency of space within the dwellings, their inhabitants may suffer from all the worst evils of an over-crowded population." (p. 42.)
Contrasting the discrepant pulmonary death-rates and population-densities of Hull, Macclesfield, and Huddersfield, we meet the following most important remarks:—
"For these three towns there is an entire absence of definite relations between the proportion of deaths from this particular class of diseases, and the more or less urban character of the several places. Let it not be supposed that I desire altogether to ignore the urban element in the causation of pulmonary affections. I am fully sensible its influence is considerable, and have already said it is always evident; but we must look to other causes as at least largely auxiliary to town influences in the production of the very remarkable diversities which have just been enumerated." (p. 45.)
In the Report on the ' Sanitary State of Clerkenwell,' by Dr Griffiths, one of the Medical Officers of Health in the metropolis, we find some observations which bear upon the above. After giving a "mortality table," showing the number of persons living, to one death in the districts of the metropolis, he adds:
"Here we find that Hamp3tead, with its pure atmosphere, its beautiful trees and fields, its open gravelly soil, its great elevation, and its population of only five persons an acre, has the same mortality as the city of London, with its atmosphere of smoke, its population of 128 persons to the acre," &c., ,fcc. (p. 24.)
The investigations before us entirely disprove any supposed immunity of the southern districts of England from pulmonary disease, at least as compared with the northern parts of the kingdom. The fact, however, that chest affections are less frequent and fatal in the keen air of Northumberland and Durham, than in the more relaxing atmosphere of Devon or Hampshire, would have been thought more remarkable a few years ago. The hygienics of consumption, especially, are not what they were.
Contagious diseases, however important, do not occupy as prominent a place in the present inquiries as they do in most death reports, for although they claim a not inconsiderable proportion of the mortality as their own—97 in every thousand deaths in England and Wales—they "are not the principal causes of high deathrates." (p. 130.) Small-pox is chiefly remarkable for the irregularity in its prevalence, and, consequently, in the mortality from the disease; this is just what we might expect as the result of the uncertain and ill-regulated system of vaccination as practised at present in England. Measles and scarlet fever are marked by the absence of definite relations between their mortality and tho general death-rate. Measles tend to greater fatality in places where the pulmonary death-rate is high, and even joined with scarlet fever and hooping cough, have nearly double the mortality in the crowded north-western districts that they have in the comparatively thinly-peopled south and south-east of England. Doubtless the facile transmission of contagious disease amid a thickly-planted population contributes much to its prevalence and mortality, but there can be little doubt, as suggested by Mr. Simon,* that a general weakness of constitution, con joined with defective sanitary arrangements, "greatly aggravates the fatality of the infectious diseases in question."
Alvine flux includes diarrhoea, dysentery, and cholera. With respect to the second of these it may be asked, whether the "dysentery" we see so frequently reported, is true dysentery with ulcerative inflammation of the colon, or whether it is not, in many cases, simply aggravated diarrhoea? There is perhaps a little vagueness in the use of the term. The connexion between alvine fluxes and impurities of every kind, impure air, water, and food, is too fully established to require much comment. Specific influence is often, doubtless, it may be always a co-originator; but filth, if not the sole parent, is at ieast the foster-mother of these diseases. Apart from the direct influence of impurities, the mortality from alvine
• p. 29.
flux in various districts and towns, seems little amenable to any rule we at present know. Generally speaking, where diarrhoea has been prevalent, there cholera has likewise prevailed; but to this there are many exceptions. Birmingham, Nottingham, Leicester, have a high diarrhoeal death-rate, but have been remarkably exempt from cholera. Gateshead and Abergavenny reverse the fact.
Cholera was of course most fatal at the epidemic periods of 1849, 1853-54. In a few districts, as London, Newcastle-on-Tyne, and Gateshead, it prevailed severely at both periods, but was much less fatal at the latter than the former visitation. Plymouth, Bradford, and Wolverhampton, are examples of this fact. A few districts in which it had been severe at the former visitation, entirely escaped at the latter period; this was remarkably the case with Tynemouth. In the cholera visitation of 1848-49, that town suffered severely, losing 463 out of its population of 64,248; warned by this, active sanitary measures were adopted, and when, in 1852, cholera was again epidemic, those exertions were redoubled. 1853 saw Newcastle and Gateshead suffering "from the most terrible outbreak of cholera yet experienced in England;" whilst Tynemouth, eight miles lower down the river, was exempt, although numerous cases of diarrhoea plainly showed that over it the choleraic influence extended, but found no congenial soil.
Dr. Barclay, Medical Officer of Health for Chelsea, tells us that "the average level of this extensive parish is but a few feet above high-water mark, but that the district of Kensal, with the advantage of at least fifty feet higher elevation than the rest of the parish, and an 'open airy situation,' has a death-rate from epidemic disease, principally diarrhoea, nearly double that of any other district in the parish; w hilst, excluding epidemic disease, it is actually the healthiest of the Chelsea districts. Inefficient drainage, faecal fermentation, and the impregnation of the atmosphere with unwholesome emanations from foul drains, ditches, and cesspools," are the words in which Dr. Barclay describes the Kensal sanitary arrangements. After such a description we cease to wonder at the death-rate, and accept it as the natural consequence of the evils described. The people breathe an atmosphere laden with impurity, and die of epidemic disease. Not less certainly do they die if they drink a water saturated with sewage.
We are indebted to Dr. Lankester, Officer of Health to the Westminster district,* for the full exposition he gives in his Report, and for the abundant testimony he adduces to support his exposition, of the injurious effect arising from the u3eof the " surface-well waters" of London, containing as they do organic matters "of precisely the same nature as those found in rivers which are the receptacles of house sewage" (p. 16), and saline matters, common salt, ammonia, the phosphates, nitric acid, ,fcc., all indicative of animal excretion. Carbonic acid is largely present in these surface waters, and from the pleasant drinking qualities it imparts to them, actually makes the most impure waters the most popular, and the most dangerous. Did space permit, w-e would gladly cite some of Dr. Lankester's proof-cases, but for these we must refer to the pamphlet itself. We must, too, content ourselves with the simple acknowledgment of the labours of the late Dr. Snow in connexion with this very subject, the propagation, if not the origination of disease, by polluted drinking water. He may at times have pushed his facts and his deductions too far, but he was, unquestionably, the prime mover of inquiry in this direction. Dr. Liddle, Officer of Health to the Whitechapel district, has the following (p. 13): "In a street at Salford containing ninety houses, 25 deaths from cholera occurred in thirty of these houses, the inhabitants of which drank water from a well into which a sewer had leaked; in the remaining sixty houses, where pure water was drunk, there were 11 cases of diarrhoea only, and no deaths."
We have almost proved enough; but an instance quoted by Mr. Simon is so stronglymarked, partakes so much, as he expresses it, of the nature of a gigantio experiment, that we cannot avoid quoting it in his own words. It occurred during two epidemiosiin the southern districts of London :—
* Second Annual Report .
"These districts (comprising nearly a fifth of the population of the Metropolis) have been notorious for the great severity with which cholera has visited them .... Throughout these districts, during the epidemics of 1853-4, there were distributed two different qualities of water; so that one large population was drinking a tolerably good water, another large population an exceedingly foul water; while in all other respects these two populations (being intermixed in the same districts, and even in the same streets of the?e districts) were living under precisely similar social and sanitary circumstances. And when, at the end of the epidemic period, the death-rates of these populations were compared, it was found that the cholera mortality in the houses supplied by the bad water had been three and a half times as great as in the houses supplied by the better water. This proof of the fatal influence of foul water was rendered still stronger by reference to what had occurred in the epidemic of 1848-9. For on that occasion the circumstances of the two populations were to some extent reversed. That company which, during the later epidemic, gave the bettor water, had given during the earlier epidemic even a worse water than its rival's; and the population supplied by it had at that time suffered a proportionate cholera mortality. So that the consequence of an improvement made by this water company in the interval between the two epidemics was, that whereas, in the epidemic of 1848-9 there had died 1925 of their tenants, there died in the epidemic of 1853-4 only 611; while among the tenants of the rival company (whose supply between the two epidemics had been worse instead of better) the deaths, which in 1848-9 were 2880, had in 1853-4 increased to 3476. And when these numbers are made proportionate to the populations or tenantries concerned in the two periods respectively, it is found that the cholera death-rates per 10,000 tenants of the companies were about as follows:— for those who in 1848-9 drank the worse water, 125; for their neighbours, who in the same epidemic drank a water somewhat less impure, 118; for those who in 1853-4 drank the worst water which had been supplied, 130; for those who in this epidemic drank a comparatively clear water, 37. The quality of water which (as is illustrated in the first three of these numbers) has produced such fatal results in the metropolis, causing two-thirds of the cholera deaths in those parts of London which have most severely suffered from the disease, has been riverwater polluted by town-drainage—water pumped from the Thames within range of the sewage of London—water which, according to the concurrent testimony of chemical and microscopical observers, was abundantly charged with matters in course of putrefactive change." (Mr. Simon's "Eeport," p. 14.)
From diarrhceal to febrile disease the transition is natural as short; at least, typhoid fever, with its diarrhceal tendency, gives us the link which connects two species—we might almost, botanically speaking, call them "varieties"—of disease, having the same origin, filth, polluted water, privation; the last, perhaps, more a predisponent than an actual cause. It is remarkable how, in " sanitary reports," we find the above causes and their effects, fever (typhoid) and diarrhoea, associated. Dr. Letheby, in his report on " Sewage and Sewer Gases,'' gives the somewhat notorious case of Croydon, where, in consequence of a new but badly constructed system of drainage, very shortly there was produced " an alarming outbreak of fever, diarrhoea and dysentery;" adding, that Dr. Carpenter, of Croydon, informs him, "that even now he can tell where the pipes are stopped by the occurrence of diarrhoea or fever in the houses through which the foul gases are forced." In one respect, as justly remarked by Dr. Barnes in his report on St. Leonard's, Shoreditch, typhoid fever " is a better test of the sanitary state of a town than diarrhoea;" it is "more strictly dependent upon local conditions," and "is less influenced by season and atmospheric changes." The distinctions between typhoid and typhus fevers are not generally, that is popularly, known, and for this reason Mr. Simon has felt compelled to treat them as "a single form of disease," as they appear in the registration returns. This necessity is unfortunate, as tending to confound a contagious disease with one almost* non-contagious, and in many respects different both as to origin and diffusion, circumstances which can scarcely fail to introduce an element of fallacy into deductions drawn from the returns of disease under the head of " fever."
* Not long rfnee the " almost" would have been omitted by us; but cirenmstances which have occurred undor our notice In a serious outhreak of typhoid fever, have led us to doubt at least the absolute non-contagiousness of the disease. Dr. Barnes seems to hold it as "no doubt true that typhoid fever is occasionally communicated by contagions' (Report, p. 8); and Dr. Acland, in his pamphlet on Fever in Agricultural Districts, considers the fact proved.