Part 24

3. In the third table all the deaths of the last three years are enumerated in a form which may enable you to compare one year with another, and one sub-district with another, in respect of their several contributions to the total mortality.

This information is now included in the Quinquennial Synopsis, Appendix, No. II.

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4. In the fourth table are classified, according to the ages at which they occurred, 9476 deaths of the last three years. This table is arranged in a manner to display its results--(1) for each year separately, and (2) for each Union separately, in order that you may observe what local or annual differences have obtained as to the ages of chief mortality. You will notice that in 3469 instances, nearly three-eighths of the whole, death has befallen children under five years old. Children at this age constitute about a tenth part of the population of the City. They accordingly die at about four times the rate which would fall to them as equal participators in the average mortality of the district. The next table will throw some light on this disproportionate excess of infant deaths.

Now embodied in Table VIII.

In the remaining number (17) the particulars of age and residence could not be correctly ascertained.

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5. In it an enumeration is made of such deaths, during the last three years, as have arisen in consequence of acute disease partially or entirely preventable. They amount to 3923--more than two-fifths of the entire mortality of the period.

Appendix, No. IX. includes this Table.

I would especially beg the attention of your Hon. Court to the particulars set forth in the successive columns of this table.

The first column shows 391 deaths by fever; and of these, without hesitation, I would speak as entirely preventable. Under favourable sanitary conditions fever is unknown. The deaths arising from it befall for the most part persons in the prime of life, whose premature removal, in the midst of their vigour and usefulness, is not only a direct weakening of society, but is also, in respect of orphanage and widowhood, a frequent source to the public of indirect detriment and expense.

In the second column, swelled by the epidemic visitation of 1849, you will find 902 deaths referred to Asiatic Cholera, and to other kindred diseases. Comparatively few cases of the kind have occurred since Michaelmas, 1849; an overwhelming majority belonged to the summer quarter then terminating, when the Metropolis generally was suffering from the presence of Cholera. I have already had occasion to show you that this frightful pestilence belongs only to localities which, by their general epidemic mortality, have previously been stigmatised as unhealthy; that, over districts otherwise healthy, it migrates without striking a blow; that it may, therefore, with confidence be spoken of as a disease proportionate to removable causes--in other words, as a preventable disease.

I cannot pass over these two columns, without begging you to observe what perhaps may be novel to you. If, instead of reckoning the cholera-deaths as belonging solely to the one year in which they happened, you reckon them as belonging to the whole term of years which elapsed between the two visitations of the epidemic, and distribute them equally over that period, so as to form an average--say for fifteen years, you cannot fail to notice how largely, in the long run, the destruction by fever (which is always here) surpasses the fatality of that Eastern disease; so much so, that the average annual mortality by the latter probably does not amount to half the fatality of the former.

Nor must it be lost sight of, that if the deaths by typhus double in number those produced by cholera, the list of persons attacked by the former disease, and thereby for a long while incapacitated and suffering, is immeasurably beyond this proportion. Two or three times the number of deaths by cholera would give you the number of seizures, and enable you to estimate all the direct mischief caused by it; while, in regard of typhus, probably for one death there are twenty cases of protracted illness, tardy convalescence, and injured constitution. Not only are the deaths double in number, but each of them indicates an infinitely larger amount of sickness and suffering not immediately productive of death.

The frightful suddenness of the rarer disease, and the condensation of its epidemic fatality into some single year, give it more apparent importance than belongs to the familiar name of typhus; but I can assure your Hon. Court, that if a large amount of preventable death, and a still larger amount of preventable misery, be strong arguments for sanitary improvement and activity, those arguments are more abundantly derivable from the constant pressure of fever and its kindred maladies, than from the sharper but infrequent visitations of the foreign pestilence.

In the third column of this table come deaths by scarlatina. Of these, perhaps a certain proportion would occur even under favourable circumstances; for, whatever may have been the original derivation of the disease, it is impossible to doubt that the severity of its attack mainly depends on conditions peculiar to the person of the patient, and that no perfection of external circumstances will ensure mildness of infection. But on the other hand it is certain, that, under attacks of the disease at first equally malignant, adequate ventilation with pure air will enable one patient to wrestle successfully against the poison, while another, less favourably circumstanced, will rapidly sink beneath its influence; and hence I have no hesitation in assuring you, in respect of the 213 deaths registered under this head, that a majority would have been avoided under improved domestic arrangements.

In the fourth column, you will read of 91 deaths by small pox. Your judgment will not be a harsh one, if you assume that 90 of these were the result of criminal negligence. Under the present administration of the Poor Laws, vaccination is not only accessible to all members of the community, but is literally pressed on the acceptance of the poor. Those stupid prejudices, which for some years retarded the universal adoption of Jenner’s great discovery, have now died away; the neglect of vaccination must be regarded as the omission of a recognised and imperative duty. Deaths of children, arising in this parental neglect, ought to be considered in the same light as if they arose in the neglect to feed or to clothe; and I am disposed to believe, that the readiest way of bringing this view of the case before those uneducated classes, where the omission usually arises, would be to procure Coroner’s inquests every year in respect of some half dozen or more instances where the evidence of neglect might happen to be glaring.

In the fifth column of the table stand recorded a hundred deaths by the poison of erysipelas, in one form or another; arising sometimes spontaneously, sometimes in connection with the child-bearing state, sometimes in sequel of accidental lesions and surgical operations.

My daily experience as a Surgeon--especially as a Hospital-Surgeon, enables me confidently to speak of these diseases as an artificial product of unhealthy exterior conditions. The contrasting results of surgical operations in town and in country--of operations undertaken amid pur-ventilation, in spacious cleanly rooms and dry localities, with those undertaken under opposite circumstances (in the dwellings of the poor for instance, or wherever else amid damp, dirt, and over-crowding), and the similar experience which exists as to the origination of puerperal fever, would be quite conclusive as to the fact, that of the 101 deaths under this head, a large majority might have been prevented.

Next, in the sixth, seventh and eighth columns, stand deaths arising in the chief acute diseases of infancy, those to which the disproportionate mortality of infants is mainly due. Many careful statistical observations, as well as personal experience, convince me that the immense fatality recorded under this head, is, to a very great extent, due to obviable causes.

To bring this matter distinctly before you, I must take, as a standard of comparison, some district where the general death-rate is sufficiently low to distinguish it as eminently healthy; and in such an one you will notice a marked diminution, not only (of course) in the number of infant deaths, but likewise in their proportion to the total mortality.

Such a district is that of the combined parishes of Glendale, Bellingham and Haltwhistle, in the county of Northumberland. In it the general death-rate is 14; in the East and West London Unions of the City of London, the general death-rate is 26·73. In the former district, children under five constituting more than an eighth of the population (1/7·6), their deaths form about a quarter of the whole mortality; while in the latter district, where the children are in smaller proportion--namely about 1/9 of the population, their deaths are not much less than half (1/2·21) of the whole mortality. Thus, in the healthier district they die at less than double the average rate for all ages; in the unhealthier, at more than four times that average.

A still better method of district-comparison, is to arrange in a series the death-rates prevailing in several localities for persons over five years of age, and side by side with this column, another for the death-rates of children under five years of age. The first column will of course indicate very well the relative sanitary conditions of the districts; but the differences between them will be expressed far more clearly, and, as it were, in a magnified form, in the column of infantine death-rates. Thus, for instance--to repeat the comparison just instituted between the Northumberland and the London district; the death-rate for all ages over five is about 12 in the former district, and nearly 15 in the latter; a difference quite sufficient to establish the inequality of their sanitary conditions. But, how much more strongly is this disparity expressed in the comparison of the infantine death-rates--26·5 for the healthier district, 107·57 for the unhealthier one!

Nothing can be more conclusive than the evidence afforded by statistics, as to the dependence of high infantine mortality on the general causes of endemic unhealthiness. My own observation within the City gives complete confirmation to this view, showing me that the diseases specified in my table (diarrhœa, bronchitis and pneumonia, hooping-cough, croup and measles, hydrocephalus and convulsions) however various in nature they may seem, and however apt you may be to dissociate their occurrence from the thought of local causation, yet unquestionably multiply their victims, in proportion to the otherwise demonstrable unhealthiness of a place, owe most of their fatality to local causes, and may, therefore, to a great extent he disarmed of their malignity.

The last column gives the total of those which have preceded it, and shows, out of 9493 deaths, 3923, all from acute disease, in intimate dependence on local and obviable causes. It will be a moderate computation with respect to these deaths, if we estimate that two-thirds of them might have been hindered.

And yet it is not only by acute disorders, that preventable death succeeds in ravaging the population. If we turn to the examination of chronic ailments producing death, we may quickly recognise many indications of their preventability, and may satisfy ourselves that here also the general mortality might be very largely reduced.

Look, for instance, at the whole immense class of scrofulous diseases, including pulmonary consumption, a class probably causing, directly or indirectly, at least a quarter of our entire mortality; and consider the vast influence which circumstances exert over its development.

Of such circumstances some lie within your control, and affect masses of the people; but the more special causes of chronic disease lie rather out of your jurisdiction, and the option of avoiding them is a matter of individual will. Vicious habits and indiscretion; a life too indolent, or too laborious; poverty and privation; vicissitudes of weather and temperature; intemperance in diet; unwholesome and adulterated food; and, not least, inappropriate marriages tending to perpetuate particular kinds of disease; these words may suggest to you, briefly, that there are many influences, within the sphere of private life, by which the aggregate death-rate of a population is largely enhanced, but the control of which, if attainable, lies almost entirely at the discretion of the classes subject to their operation.