year which terminated at Michaelmas last; showing the deaths, as they
have occurred, male and female, during each quarter of the year, in the
several districts and sub-districts of the City; and including at the
foot of each column, a statement of the year’s death-rate _per_ thousand
of the living in each such district and sub-district.
[61] _Appendix_, No. V. The calculated death-rates are omitted from
this, as from the other annual tables:--the quinquennial rates (App.
No. II.) giving more useful results.--J. S., 1854.
You will observe that, during the 52 weeks, dated from September 29th,
1850, to September 27th, 1851, there have died of the population under
your charge 2978 persons; giving, for the City aggregately, a rate of
nearly 23 deaths for every thousand living persons.
The rate of last year was little over 21 _per_ thousand.
In my last Annual Report I suggested that the death-rate then prevailing
was probably (from temporary circumstances) more favourable than the
true average of the City; that it corresponded to the period of recovery
from severe epidemic influences; that it seemed exceptional; and that
you might be prepared for this year’s mortality showing again a tendency
to increase.
Such has been the case; and it illustrates the necessity of appealing to
cyclical averages for correct intelligence as to the healthiness of a
population. To my mind the increased mortality of this year does not
indicate any deterioration of the City in respect of sanitary matters
under your control; it shows merely that the death-rate, which must be
considered our present average for the City, is in truth higher than
that which favourable circumstances, foreign to your jurisdiction, last
year permitted us to attain.
Looking to the total mortality of the last three years (the period for
which I have had the honour of serving your Commission), I find that
9493 deaths have taken place; which, the mean population of the time
being 129,922, gives an average rate of 24·35 deaths _per_ thousand _per
annum_. This accords very nearly with a death-rate (24·36) deduced from
the septennial period 1838-44, during which (according to the
Registrar-General) 22,127 deaths occurred in a population estimated at
129,739.[62]
[62] Since 1841, when the Census gave these figures, the limits of the
West London Union have been slightly altered. The Inner Temple and
Barnard’s Inn have been added to it, while part of St. Sepulchre’s
parish has been taken away.
Assuming our City mortality to be accurately represented by these
averages, I need not inform your Hon. Court that such a death-rate is
unduly high. I have already, in previous Reports, laid before you the
materials for measuring its excess,--materials which seem to show that
our existing death-rate is nearly the double of that which better
circumstances have elsewhere rendered attainable.[63]
[63] The death-rate to which I particularly refer in the text, and
which I cited in my last year’s report, is that of a large district in
Northumberland, numbering 27,628 inhabitants, where, during the seven
years 1838-44, the mortality was at the rate of only 14 _per_ thousand
_per annum_; and even in this comparatively low proportion a very
distinct share might still be called preventable deaths.
It is not to the City alone of metropolitan districts that this high
mortality belongs. Unhappily it affects the entire Metropolis; and we
may find other towns in England, and still more on the Continent, where
the death-rate is higher than under your jurisdiction. Yet your Hon.
Court will not doubt that the standard to be adopted for your estimate
of healthiness ought to be the lowest known death-rate; that every
avoidable death represents an evil to society; and that, if a mortality
of 12, or 13, or 14 _per_ thousand _per annum_ can be reached for one
mixed population, there is ample room for discontent among any other
population, which finds itself doomed to perish at double the rate of
the first.
* * * * *
3. In the third table[64] 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.
[64] This information is now included in the Quinquennial Synopsis,
_Appendix_, No. II.
* * * * *
4. In the fourth table[65] are classified, according to the ages at
which they occurred, 9476[66] 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.
[65] Now embodied in Table VIII.
[66] In the remaining number (17) the particulars of age and residence
could not be correctly ascertained.
* * * * *
5. In it[67] 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.
[67] _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.
Considering all these causes, and the needless waste of life occasioned
by them, I can have little doubt that as much might be done by
individuals, under the influence of improved education, to lessen the
mortality from chronic disease, as by sanitary legislation to stay the
sources of epidemic death. And regarding both classes of disease
together--those, on the one hand, which are of endemic origin (arising
in imperfect drainage, in defective water-supply, in ill-devised
arrangement of buildings, in offensive and injurious trades, in the
putrefaction of burial-grounds, and the like) and those classes, on the
other, which arise in the circumstances of individual life, I can have
no hesitation in estimating their joint operation at a moiety of our
total death-rate, or in renewing an assertion of my last years’ Report,
‘if the deliberate promises of Science be not an empty delusion, it is
practicable to reduce human mortality within your jurisdiction to the
half of its present average prevalence.’
To revert, however, to your more special branch of the subject,--I have
thought the present a convenient time for indicating to you the pressure
of preventable death, arising in acute disease, because of the great
addition which you have recently gained to your powers for enforcing
prevention.
That an average death-rate of nearly 25 _per_ thousand _per annum_
prevails in the City; that three-eighths of your mortality consists in a
premature extinction of infant life; that fatal disease, in more than
two-fifths of its visitations, is of a kind which operates endemically
and preventably;--these are the facts to which I have appealed, as my
evidence of the need for sanitary activity and perseverance.
On other occasions I have endeavoured to set before you what are those
agencies hostile to life, which affect the masses of an urban
population; and during the last three years your Hon. Court has shown
its recognition of these causes, and has devoted attention to the means
of counteracting them by appropriate sanitary measures.
In too many instances, the powers first given you by the Legislature
were inadequate to this great purpose. But now, armed with the further
authority of your new Act of Parliament, you enjoy such means for
sanitary improvement as have never yet been possessed by any Corporation
in the country; such means as, judiciously wielded, cannot but produce
the greatest advantage to persons living under your jurisdiction.
As you are only now entering on the exercise of these powers, it may be
convenient that I should submit to you a brief account of them, and I
gladly turn from contemplating the spectacle of preventable death, to
analyse the means of prevention now vested in you by the Legislature.
* * * * *
1. In regard of _public drainage or sewerage_, the first and most
elementary condition of endemic health, I need hardly tell you that
within the City, your powers are absolute. You have entire and sole
responsibility for the construction and maintenance of sewers, for their
cleaning or flushing, and for the prevention of noxious effluvia from
their innumerable gully-holes.
* * * * *
2. In the all-important particular of _house-drainage_, your authority
is sufficient for every purpose. You can order the complete abolition of
cesspools; the construction of drainage in any premises within fifty
feet of a sewer; its repair, cleansing, or renewal, whenever it may be
disordered: and not only can you order these works to be done,
but--failing the owner’s compliance with your notice, you can devolve
the performance of his duty on your own workmen, and can recover your
expenses from the recusant.
* * * * *
3. In regard of _water-supply to houses_ your powers are equally cogent,
though the unsatisfactory condition of the water-trade continues a
serious obstacle to their effective employment. You have authority here,
as with house-drainage, to order the construction of all necessary
apparatus, and to enforce the fulfilment of your order.
Under both these heads, you possess a power hitherto but imperfectly
used, the complete and constant exercise of which I would strongly
recommend to your Hon. Court. In all those clauses of your Acts of
Parliament, which relate to private works of house-drainage and
water-supply, there occurs a very important phrase:--such works shall be
constructed ‘to the satisfaction of the Commissioners.’ Now, of private
works effected under the authority of your Act, during the last three
years, a certain, not inconsiderable, share proves inoperative and bad.
The mere overflowing of a water-butt (and in numberless instances this
is the arrangement evasively adopted under your orders) can never
suffice for the effectual cleansing of house-drains. I need scarcely
inform you that an obstructed drain and choked privy, wherever they
occur, are equivalent to a cesspool; shedding abroad the same effluvia,
and producing the same deadly results. No gain is gotten to the
wholesomeness of a house, by substituting for its former cesspool an
equally offensive and inoperative drain. To my knowledge, much of the
drainage done during the last three years is liable to this risk; and it
appears to me indispensable that you should exert direct supervision
against so serious an evil.
I would recommend to your Hon. Court that, in issuing orders for the
construction of drainage and water-supply, you should require a full
specification to be delivered you of the works about to be undertaken,
and should distinctly decide as to their sufficiency; or by a still
simpler process, that you should fix and determine a certain standard of
combined works; a model plan, in short, for house-drainage, privies, and
water-supply, and should direct your Inspectors to certify to you the
sufficiency of only such works as may accurately correspond to this
design.
I cannot but regard it as a grave calamity, that the general supply of
water to the City remains beyond your control, in the hands of
irresponsible traders; for its imperfect adaptation to the requirements
of the public constitutes the largest sanitary evil of the day.
* * * * *
4. You have entire control over the _pavement of every public way_
within the City, for its construction, maintenance, and cleansing; and
in this respect you exercise a power of great sanitary value. The
preservation of cleanliness along the whole extended surface of the
City, including its many hundred courts and alleys, is indeed a branch
of your functions which can hardly be over-estimated for its importance;
and the fines which you have the power of levying from your
contractors, whenever the scavenging is neglected, are useful securities
for the general performance of their duties.
It lies within your power to order, wherever you may think fit, the
employment of the hose and jet for the purpose of surface-cleansing in
courts and alleys: and, I may add, that the advantages of this most
effective sanitary process have been highly appreciated where you have
directed its application.