1841 as a medical officer?—I think the number of cases I have had to
visit during each year since the commencement of the Union has been
upwards of 2,000 cases of various disease, of which 1,400 were cases
out of the workhouse.
“Has the present winter been unhealthy?—I do not think it has; there
has been an increase of fever cases during the last month. The number
of cases is, however, still below the average of 1838.
“Is there not, however, unusual distress in your district,
comprehending Spitalfields and a portion of Whitechapel?—Yes, there
is: I believe that more than half the looms are out of work.
“Do you not find that fever attacks in greatest number those who are
out of work?—On the contrary, the greatest number of the cases of
fever we have are those who fall ill during the time they are in
employment. I think they are more attacked when in work, when the
windows are closed, and there is no ventilation. Many of them are
obliged to work with closed windows, to keep out the moist air, and
prevent the dust blowing upon their work. When they are out of work,
they are more out of doors looking after work, more in the open air,
and that very exercise may be the means of keeping them in health.
This observation applies to the weavers. I find that they have
generally less fever when they are out of work. The reverse, I think,
holds as respects out-door labourers, such as those who work at the
docks. When they are out of work, they stand about waiting in the
cold, and when cold, they generally take cheap gin, and no food: they
catch cold, and on going to their close filthy habitations, their cold
is apt to generate fever.
“There was an unusual amount of fever prevalent in Spitalfields and
Whitechapel, was there not, in the year 1838?—Yes, there was; in the
proportion, perhaps, of more than two to one of the present amount. My
last account for the year ending Lady-day, 1842, was about 250 fever
cases; it has been as high as 800.
“Did it prevail proportionately amongst the weavers?—Yes, I believe it
did.
“Was there any marked or unusual distress at that period?—Not that I
remember.
“Do you find in the course of your experience that the diminution of
food is followed by fever?—Not as a general cause, I should say. If
these two persons, casually exposed to the contagion of fever, the one
in full vigour, and with a full stomach, the other with an empty
stomach, the person with the empty stomach would be the most obnoxious
to its influence. In my experience, however, intemperance is a much
more frequent antecedent to fever than destitution or want of food.
“Have you ever observed that habits of intemperance are created by
distress of mind?—Such cases may occur, but I have not observed them,
and I think it does not operate as a general cause.
“What are the chief remedies which your experience in this district
would lead you to recommend for the prevention of fever and contagious
diseases?—The promotion of cleanly habits amongst the poor; the
promotion of sewerage and drainage; having proper supplies of water
laid on in the houses; the removal of privies from improper
situations. I could point out in our neighbourhood many houses, and
some courts, that ought to be pulled down as wholly unfit for human
habitation.
“What is the personal state of the labouring classes in your
district?—Generally extremely filthy. I have said that I could almost
smell from what street a man came who came to my surgery: I do not
think the poor themselves are conscious of it, but the smell to other
persons must be extremely offensive. I certainly think that the want
of personal cleanliness, and of cleanliness in their rooms, and the
prevalence of fever, stand in the relation of cause and effect.
“Your colleague has pointed out that the want of proper and convenient
supplies of water is an antecedent to the filth and the fever. Does
your experience enable you to concur with him?—My experience entirely
agrees with his on that point.”
The late _Dr. Cowan_, of Glasgow, and the great majority of the medical
officers, assign the foremost place to these physical agencies as
antecedents to fever.
The medical controversy as to the causes of fever; as to whether it is
caused by filth and vitiated atmosphere, or whether the state of the
atmosphere is a predisposing cause to the reception of the fever, or the
means of propagating that disease, which has really some other superior,
independent, or specific cause, does not appear to be one that for
practical purposes need be considered, except that its effect is
prejudicial in diverting attention from the practical means of
prevention.
_Dr. Bancroft_, one of the controversialists cited by Dr. Davidson,
observes,—
“That fever often exists in them” (gaols) “cannot be denied; but this
circumstance can afford no evidence of its being generated therein,
any more than the multiplication of vermin in such places could
demonstrate the spontaneous generation of these and other insects by
the nastiness which favours the deposition and hatching of their
eggs.”
Taking the controversy at this point, and admitting the force of this
statement, the decision upon it will not alter the practical value of
cleanliness, or of its protective effects in prevention, whether it
remove an original or only a predisposing cause.
Yet it cannot but be regretted that the enlightened force of the
professional opinion should sustain any diminution from an apparent want
of unanimity on so important a question as the necessity of removing
these causes, whether original or predisposing: that, for example,
whilst the fleets were ravaged by fever and disease, men of high
standing should have occupied the attention of the public with
speculations on contagion, and infection from the gaols as the original
cause, and diverted attention from the means of prevention, cleansing
and ventilation, the means by which, as will hereafter be shown, the
pestilence was ultimately banished. The main error of those who have
ascribed fever to destitution, appears to have been in adopting too
hastily as evidence of the fact of destitution, such _primâ facie_
appearances as are noticed by Dr. Scott Alison, an error which
non-professional experience may correct. In more than one instance
where, in a district in which the demand for labour was still great, and
the wages high, benevolent gentlemen have propounded similar doctrines,
which, being at variance with the known state of the labour-market, I
have requested that the names of these fever cases might be given, that
their antecedent circumstances might be examined, and the accuracy of
the conclusions tested, by officers of experience in such
investigations; but I think it right to state the names or means of
inquiry have never been forthcoming. In general, medical practitioners
and benevolent individuals are extremely liable to deceive themselves
and to deceive others, by what they call the evidence of their own eyes.
The occurrence of severe destitution is denied as a general cause of
fever, not as a consequence. The evidence shows that the best means of
preventing the consequent destitution are those which prevent the
attacks of fever and other epidemics upon all classes of the community.
By an extract from a report of the late Dr. Currie, of Liverpool, given
in the Appendix, it will be seen that at the time he wrote, 1797, when
only 9500 of the population are reported to have lived in cellars, the
proportion of fever cases was nearly the same as at present, when the
cellar population has risen to 40,000; the disease has been almost as
constant as the surrounding physical circumstances of bad ventilation,
filth, and damp then pointed out as removable, and the disease has
continued in every period of the prosperity of the town in its progress
from a population of 77,000 to 223,000 in 1841. So the late Dr. Ferriar,
of Manchester, when writing between 30 and 40 years ago, of the state of
the population in periods of great prosperity, especially for hand-loom
weaving, described the effect of the bad economy of the habitations much
as they were described in the year 1829 by Dr. Kay, and as they are
described in 1840 by Dr. Baron Howard. _Dr. Ferriar_, when he wrote to
warn the labouring classes as to the choice of their dwellings, stated
that—
“The custom of inhabiting cellars also tends to promote both the
origin and preservation of febrile infection. But even in them the
action of filth and confined air is always apparent when fevers arise.
I have often observed that the cellar of a fever patient was to be
known by a shattered pane, patched with paper or stuffed with rags,
and by every external sign of complete dirtiness.”
The false opinions as to destitution being the general cause of fever,
and as to its propagation, have had extensively the disastrous effect of
preventing efforts being made for the removal of the circumstances which
are proved to be followed by a diminution of the pestilence.
The opinion of the majority of the medical officers of the unions in
England on this topic, acting in districts in every condition, might be
expressed in the terms used by _Dr. Davidson_:—
“It has already been shown that filth and deficient ventilation tend
much to spread the contagion of typhus, being almost constant
concomitants; and that while it generally affects the whole members,
or the large proportion of a family among the lower orders, it rarely
spreads in this manner among the better classes of society, who attend
more to cleanliness and ventilation. It is quite obvious that an
amelioration of the physical condition of the lower orders, in these
particulars, would, in proportion as this was effected, diminish their
chances of catching the contagion, which would not only operate in
lessening directly its diffusion, but by reducing the number of its
sources, must tend to lessen the actual quantity of this principle
that might be generated in a given time.
“But can this amelioration be effected to any appreciable extent; or,
if effected, could it be maintained for any length of time? We fear
that little permanent amelioration could be effected without a
legislative enactment; for though our philanthropists are very active
in their charities during the prevalence of an epidemic, it no sooner
subsides than they relapse into a comparative quiescence, and our
working population into their former habits of filth and intemperance.
And the evil will continue to assail us so long as our cities contain
so many narrow and filthy lanes, so long as the houses situated there
are little better than dens or hovels, so long as dunghills and other
nuisances are allowed to accumulate in their vicinity, so long as
these hovels are crowded with inmates, and so long as there is so much
poverty and destitution. Why, then, should we not have a legislative
enactment that would level these hovels to the ground—that would
regulate the width of every street—that would regulate the ventilation
of every dwelling-house—that would prevent the lodging-houses of the
poor from being crowded with human beings, and that would provide for
their destitution? It may be said that this would interfere too much
with the liberty of the subject, and no doubt it would be vehemently
opposed by many interested persons. In place, however, of being an
infringement on the liberty of the subject, it might rather be
designated an attempt to prevent the improper liberties of the
subject; for what right, moral or constitutional, has any man to form
streets, construct houses, and crowd them with human beings, so as to
deteriorate health and shorten life, because he finds it profitable to
do so? As well ought the law to tolerate the sale of unwholesome food
because it might be profitable to the retailer of it.”
But the professional experience and weight of professional testimony on
this subject is not confined to this country. In a report prepared under
the superintendence of a commission of the Royal Academy of Medicine at
Paris,[16] appointed to investigate the epidemics prevalent in France,
similar general conclusions are announced upon similar evidence adduced,
of which we select the following instance:—
“If an example,” says the report, “be necessary to justify this
placing of circumstances as cause and effect, we shall find one in the
terrible epidemic which desolated the commune of Prades, in the
department of Ariège, at the end of the year 1838. Out of 750 healthy
and vigorous inhabitants of this commune 310 were attacked with the
disease, and 95 died, thus the deaths were 1 in every 3¼ cases. The
cause of this epidemic, violent and sudden in its nature, and which
broke out in all points at once, is not less evident. It proceeded
from a sewer, the receptacle of all the water from the neighbourhood,
and of the filth which the water brought with it, and of the dead
animals of the district. The hot, damp weather which preceded it no
doubt augmented the activity of this focus of infection. The first
persons attacked were the women employed in washing linen in this
pestiferous pool, and the labourers working in the neighbourhood of
it. This terrible epidemic recurred three times, which the invalids in
their simplicity attributed to the influence of the moon, but which
mainly depended upon the wind at certain periods passing over the
infected pool, and bringing the miasma in the direction of their
dwellings. If for want of sufficient description it is not possible to
prove completely the similarity of the epidemic at Prades with the
typhus fever, yet it may be inferred from the symptoms, viz. that when
the skin was broken deep sores were formed, and that serous abscesses
showed themselves in the lymphatic ganglions, that this disease was
very similar to the ancient putrid and malignant fevers formerly
described by authors, and which are entirely replaced in our
_nosology_ by the typhoid affection. The physicians of Ariège, in
order to prove that the disease was not _contagious_, and to re-assure
the inhabitants, lay in the beds from which the invalids had been
removed.”
Adverting to the local reports they have received, the Commissioners
state—“These reports have awakened in us the sad conviction that many
localities are quite devoid of even the most simple ideas on public
health; the inhabitants live surrounded by marshes, drains, stagnant
pools, manure heaps, without having the slightest idea of the dangers
they are incurring. Indeed, many of them blindly speculate in these
heaps of infection, increasing the manure which is to enrich their
fields at the expense of their health, and often of their lives.”
The Commissioners observe,—“Most of the improvements in public health
have been brought about through the experience and science united in our
large cities; so much so that now epidemics often come to us from the
rural districts. These epidemics are generally much less fatal than
formerly, but are still very prevalent even in the wealthiest and the
most civilized departments. It would be an important problem to solve,
what are the causes which produce these epidemics in the agricultural as
well as in the manufacturing counties, as in ancient Normandy and
Picardy. One cause is certainly the unhealthiness of the houses. The
inhabitants of these districts are, in general, well fed, well clothed,
but ill lodged. We are surprised to find in the midst of a fertile plain
wide districts covered with luxuriant vegetation, villages buried in the
ground, _smothered_ with large trees, and cottages constructed without
any art or plan, and almost entirely without windows.” The Commissioners
state, further,—“If you wish to have a robust and healthy people, you
must have a care for their physical education, their houses, and their
modes of living. Do not allow generation after generation to be
depressed under the evil effects of recurring epidemics, which must
eventually ruin the strongest constitutions, as is seen to be the case
in marshy and ill-drained districts, where fevers, _goitres_, and
scrofulas constantly prevail.”
In another report made on the proceedings of the Conseil de Salubrité,
the diseases prevalent amongst the population in the towns is adverted
to:—“We must be like the men so well painted by the Psalmist, to reject
such evidence—_eyes have they, and see not_. How shall we explain, or
rather to what shall we attribute the difference that is remarked
between the mortality of one quarter and that of another quarter of the
same town; of one street and that of another street of the same quarter
or of the same village; or, lastly, the difference that is observed in
this respect between the houses of the same street and those houses
which are completely isolated? Misery, it is replied to us, is the
cause. Yes, without doubt, misery is a powerful cause; but it is so
especially when it is driven back into the most insalubrious quarters,
streets, and houses; when it lives habitually in the midst of filth and
dirt, that is to say, in the midst of an infected atmosphere; and when
there is no misery, or when it exists in the same degree in the
quarters, in the villages, in the streets, and in the houses with which
the comparison is made; and, stronger still, when poverty is met with
precisely there where there is the least mortality; in what is to be
found the cause of this difference, if it is not in the insalubrity of
the dwelling-places?”
The report on the local epidemics concludes by earnestly recommending to
the government—“That sanitary measures be adopted by means of which the
constitution of the people may be renewed, and their longevity
increased. If this recommendation be fulfilled, we may then hope to see
the condition of some of the departments ameliorated, in which now the
population is so degenerated that the men seem to diminish in size each
time they are measured for the conscriptions.”
Evidence on the mismanagement of expenditure in respect to supplies of
food, on mismanagement also in respect to clothing and fuel by the
labouring classes, might be added to complete the view of the principal
causes of disease prevalent amongst them, but these do not come within
the immediate scope of the present inquiry, which has been directed
chiefly to the investigation of the evils affecting their sanitary
condition, that come within the recognized provinces of legislation or
local administration.
The information on the means for the prevention of epidemic disease
arising in the common lodging-houses maintained for the accommodation of
trampers and vagrants, might also have been considered in connexion with
the subject of the effects of overcrowding and filth which they strongly
exemplify; but it appeared most convenient to consider them apart, from
the exposition of what may be termed the indigenous evils that afflict
the settled inhabitants of the labouring class.
I would now submit for consideration, 1st, the total expense of the
present state of things, so far as a proximate view of it can be
obtained, on the health, strength, and life of the lower classes of the
population. 2d, a proximate view of the pecuniary expense of such
partial remedies as are at present applied or applicable to alleviate
the consequences of these preventable diseases.
IV.—COMPARATIVE CHANCES OF LIFE IN DIFFERENT CLASSES OF THE COMMUNITY.
Very dangerous errors arise from statistical returns and insurance
tables of the mean chances of life made up from gross returns of the
mortality prevalent amongst large classes, who differ widely in their
circumstances. Thus we find, on inquiry into the sanitary condition of
the population of different districts, that the average chances of life
of the people of one class in one street will be 15 years, and of
another class in a street immediately adjacent, 60 years. In one
district of the same town I find, on the examination of the registries,
the mortality only 1 out of every 57 of the population; and in another
district 1 out of every 28 dies annually. A return of the average or the
mean of the chances of life, or the proportions of death in either
instance, would and does lead to very dangerous errors, and amongst
others to serious misapprehensions as to the condition of the inferior
districts, and to false inferences as to the proper rates of insurance.
With the view of arriving at some estimate of the comparative extent of
the operation of the chief causes of sickness and mortality proved to be
prevalent, amidst the different classes of society, in the towns where
the sanitary inquiries have been made; I have obtained the following
returns from the clerks of the several unions acting as superintendent
registrars. These returns have, as far as practicable, been corrected by
particular local inquiry, and are submitted as the best approximations
that can readily be obtained. In all districts, and especially in the
manufacturing districts, there is some migration of labourers which
would, for the obtainment of perfect accuracy as to the chances of life
in particular localities, have rendered necessary an examination of
every individual case enumerated. This extent of labour has been
considered unnecessary. In the returns from single towns, the numbers of
deaths of persons of the first class are too small not to be affected by
accidental disturbances, but when large numbers of the like class are
taken, the uniform operation of the like circumstances are shown in the
like results. It is at present a general defect of the important head of
information, “the occupation of the deceased,” that the deaths of
masters are not carefully distinguished from the deaths of journeymen.
So far as this error prevails, it will tend to raise the apparent
chances of life amongst the labouring classes. In some instances the
occupations of the deceased, or of the parents of the deceased, in the
case of children, are not described in the registries. With these and
possibly with other defects that may have escaped notice, these returns
will be received as corroborative of the reports of the medical officers
and physicians who have attended and observed many of the individual
cases themselves, though not enumerated by them. Had the mortality
prevalent amongst workpeople of particular trades and their families
been taken, instead of the mean chances of persons of all occupations
deriving subsistence from weekly wages, the case of classes with still
lower chances would have been presented; but these would have appeared
to suggest particular remedies. Such returns of the effects of common
evils were therefore taken as appeared applicable to the consideration
of common or general means of prevention.
One of the first returns obtained is from _Dr. Barham_, as to the
different rates of mortality in Truro:—
“The information derived from the registers of deaths and sickness has
been arranged in a series of tables.[17] The first gives a return of
the condition in life, average ages, and the causes of death, with
respect to all who died in Truro from July 1st, 1837, to December
31st, 1840. The occupation of the deceased not being stated in the
register, except in the case of adult males, the condition of others
has been inferred in the majority of cases from that of the parent or
husband, in many from my own knowledge of the parties, and in others
from the place of abode or other collateral evidence. Altogether I am
confident that the statement is not materially erroneous.”
The sum of these several returns was as follows:—
No. of TRURO. Average
Deaths. Age of
Deceased.
33 Professional persons or gentry, and their families 40 years.
138 Persons engaged in trade, or similarly circumstanced,
and their families 33
447 Labourers, artisans, and others similarly
circumstanced, and their families 28
In Derby the proportions appear to be as exhibited in the following
table:—
No. of DERBY. Average
Deaths. Age of
Deceased.
10 Professional persons or gentry 49 years.
125 Tradesmen 38
752 Labourers and artisans 21