Part 27

Perhaps in no manufacturing community is human life, in large classes of men, so shortened or accompanied with such an amount of suffering or wretchedness as in this town, in connection with certain staple manufactures. Were the legislature to interfere and enforce the correction of the evils, by a system of ventilation, which is neither difficult nor expensive to put in operation, the duties of this officer, if directed to the superintendence of this system, would save numerous lives and prevent an incalculable amount of misery. At present, in consequence of these evils, a majority of the artisans is killed off from twenty-five to thirty-five years of age, and numbers annually leaving widows and children in great destitution, and, in most cases, dependent on the parish. The evils are not inseparably connected with the occupation; they admit of redress. An officer of health, by maintaining the system of ventilation in efficient operation, would save numerous lives, would create a better tone of mind among the artisans—for wretchedness is closely allied with ignorance and immorality—would diminish the high rate of mortality amongst the young under five years of age—left by the premature death of the parent unprovided for, and lastly, would greatly relieve the parish funds. The officer, having the power to remove at once any case of fever from a densely populated locality, as well as to enforce measures of prevention, such as the removal of accumulated filth, stagnant pools of water, or the correction of any other local circumstances, would perform duties which would redound considerably to the advantage of the community.

§ 214. In confirmation of the views of the benefits derivable to medical science from such arrangements as those proposed, § 211, various instances might be adduced besides the last cited, § 213, and that already given in the General Report, p. 355, of the discoveries made, on an examination of 1000 cases, by M. Louis, on the nature of consumption, now generally recognized as presenting facts at variance with all ancient and previous modern opinions: but in respect of the views there stated, as to the great public importance of well-ascertained medical statistics, I submit the high confirmation derivable from the following statement contained in the recently published outlines of pathology and practice of medicine, by Dr. W. Pulteney Alison, fellow and late president of the College of Physicians at Edinburgh, and professor of the practice of medicine in the University of Edinburgh:—

“The living body,” he observes, “assumes, in many cases, different kinds of diseased action, varying remarkably in different periods of life, without any apparent or known cause; but in the greater number of cases it is generally believed that certain circumstances in the situation or condition of patients, before diseases appear, can be assigned with confidence as their causes. The efficacy of these, however, is seldom established in any other way than simply by the observation that persons known to be exposed to their influence become afflicted with certain diseases in a proportion very much greater than those who are not known to be so exposed.

“This kind of evidence is in many _individual_ cases very liable to fallacy, in consequence of the great variety of the circumstances capable of affecting health, in which individuals are placed, and of the difficulty of varying these so as to obtain such observations, in the way of induction or exclusion, as shall be decisive as to the efficacy of each. Hence the importance of the observations intended to illustrate this matter being as extensively multiplied as possible; and hence also the peculiar value, with a view to the investigation of the causes of diseases, of observations made on large and organized bodies of men, as in the experience of military and naval practitioners. All the circumstances of the whole number of men whose diseases are there observed, are in many respects exactly alike; they are accurately known to the observer, and are indeed often to a certain degree at his disposal; they are often suddenly changed, and when changed as to one portion of the individuals under observation, they are often unchanged as to another; and therefore the conditions necessary to obtaining an _experimentum crucis_ as to the efficacy of an alleged cause of disease are more frequently in the power of such an observer than of one who is conversant only with civil life.

“But when the necessary precautions as to the multiplication of facts, and the exclusion of circumstances foreign to the result in question, are observed, the efficacy of the remote causes of disease may often be determined _statistically_, and with absolute certainty; and the knowledge thus acquired as leading directly to the _prevention_ of disease, is often of the greatest importance, especially with a view to regulations of medical police. And if the human race be destined, in future ages, to possess greater wisdom and happiness in this state of existence than at present, the value of this knowledge may be expected to increase in the progress of time; because there are many diseases which the experience of ages has brought only partially within the power of medicine, but the causes of which are known, and under certain circumstances may be avoided; and the conditions necessary for avoiding them are in a great measure in the power of _communities_, though at present beyond the power of many of the individuals composing these.

“There are, indeed, various cases, of frequent occurrence, in which the study of the remote causes of disease is as practically important as anything that can be learnt as to their history, or the effects of remedies upon them. This is particularly true of epidemic diseases, and of diseases to which a tendency is given by irremediable constitutional infirmities.”

Having had the honour to be associated with the late Dr. Cowan of Glasgow, Dr. Alison, and some other gentlemen, in a committee to consider of the means of obtaining a system of mortuary registration for Scotland, and having conversed with many qualified persons who have also paid much attention to the subject, I may state confidently that the exposition above given of the advantages derivable to the public service from the improvement of vital statistics would meet with extensive concurrence, independently of the very high sanction conferred by any expression of an opinion on such a subject from Dr. Alison. The towns where the greatest mortality prevails present precisely the opportunities so highly appreciated, of observations on large and organized bodies of men, § 213, often as similar in the chief circumstances which govern their condition, as the classes presented to the observation of medical officers in the army or in the navy.

Lord Bacon observes, in his suggestions for an inquiry into the causes of death—“And this inquiry, we hope, might redound to a general good, if physicians would but exert themselves and raise their minds above the sordid considerations of cure; not deriving their honour from the necessities of mankind, but becoming ministers to the Divine power and goodness both in prolonging and restoring the life of man; especially as this may be effected by safe, commodious, and not illiberal means, though hitherto unattempted. And certainly it would be an earnest of Divine favour if, whilst we are journeying to the land of promise, our garments, those frail bodies of ours, were not greatly to wear out in the wilderness of this world.” It would accord with his great views that adequate public provision and arrangement should be made to enable physicians to render the services desired. From the earliest time to the present, when the subject of sanitary evil and desecration of grave-yards was brought before the public by the long-continued exertions of Mr. Walker, members of the medical profession have made the most strenuous exertions and sacrifices for the attainment of such objects.

It is submitted that, in whatsoever place a proper system of the verification and registration of the fact and cause of death has not been introduced, as in Ireland and Scotland, and in all populous and increasing districts, that the appointment of an officer of health, having charge and regulations of all interments, would be the most economical as well as the most efficient mode of introducing it: in every place it must be a measure of paramount importance.

§ 215. As an instance of the incompatibility of such duties as those of the proposed officer of public health, with service in connexion with any existing local administrative body, it may be mentioned that every local Board in such a town as Sheffield would comprehend some of the chief householders, who would most probably be the chief manufacturers and employers of the class of workmen, and that even the official connexion would to such minds as the workmen expose him to suspicion, and diminish his influence, for the effectuation of any voluntary changes of practice. On other grounds, such as the absence of qualification in such Boards to give superior directions; and such grounds as those specified in p. 322 and p. 349 and 350 of the General Report, it is submitted that the functions of the officer of health would be the best exercised, independently of any other local administrative body. He would, in an independent capacity, be the most powerful auxiliary of any well-intended and zealous administration of local works, and as his functions must bring him at once to the chief spots where the consequences of neglects and omissions would be often manifest in fatal events, he would, as an independent and yet responsible officer, exercise an extensive influence and an efficient check on behalf of the public at large.

§ 216. Every efficient measure of improvement of the sanitary condition of the population, must be in its mere pecuniary results a measure of a large economy (§ 80). Physicians and medical officers are of opinion that all the ordinary and extraordinary duties specified, and even more, may be done by an officer of health with the same average expenditure of time (taking one case with another), that occurs to a physician in visiting a patient, examining the case, writing out a prescription and giving instructions to attendants. I shall be able to show that it may be accomplished at a charge no greater than that now paid by the labouring classes to one of their body as a steward or officer of their burial clubs who is required to inspect and identify the body of a deceased member.

_Proximate Estimate of the comparative Expense of Interments under arrangements for National Cemeteries._

Having shown the chief desiderata in respect to the improvement of the practice of interment, and the means of protecting the public health, I proceed to submit the substance of the information collected as to the means of obtaining them.

§ 217. In submitting for consideration a proximate estimate of the extent to which it is practicable to carry that reduction of the expense of interments, which is so important to the middle and lower classes, the expense of interments of gentry and persons of the middle class of life is taken at double the amount at which persons of great experience in providing for the interment of large numbers have estimated they may be executed for without any reduction of the essentials to a decent solemnity.

§ 218. The estimate takes the existing scale of burial fees of the parish of St. James, Westminster, as fees to be continued, which would, if received in a fee fund, not only provide compensation for vested interests, but go far to provide the expense of new services.

§ 219. To the estimate of the expenses of interment is superadded a fee to defray the expenses of medical officers of a board of public health. The reduction of that great source of waste and expense, the payment of two or three stages of profits, for materials, &c. of funerals (by placing them under general arrangements), would admit of this charge, which is really a means to a still greater economy, the economy of health and life, and consequently of the number of funerals themselves. Objection to these charges would scarcely have place where the pecuniary economy is immediate. The medical service proposed may be procured to the working classes (supposing it were necessary to charge the expense on the funeral) at all distances, for the same sum as that which they now pay to the unlearned inspectors, officers of their clubs, for inspection within short distances, namely, 2_s._ 6_d._ It is declared by competent witnesses, that a respectable officer of public health, a physician, performing such services as those described, would be welcomed in most families on such a charge as 10_s._ 6_d._ for the middle classes, and 1_l._ 1_s._ for the higher classes, charged as a part of the reduced funeral expenses.

_Estimated Scale of Charges for Interments in the Metropolis, inclusive of Compensations; the payment for the purchase of new Cemeteries; and new Establishment Charges._

────────────────────────┬────────────┬────────────┬──────────── │ │ Proposed │ Scale of │ │ Charge for │Expense for │ Existing │ Officer of │Undertaker’s │Burial Dues.│ Health and │ Materials │ │Registration│ and │ │ of Death. │ Services. │ │ │ ────────────────────────┼────────────┼────────────┼──────────── │£. _s._ _d._│£. _s._ _d._│£. _s._ _d._ │ │ │ Gentry {Adults │ 10 10 0│ 1 0 0│ 21 0 0 {Children│ 5 5 0│ 1 0 0│ 3 10 0 │ │ │ 1st Class {Adults │ 2 10 0│ 0 10 0│ 10 10 0 Tradesmen {Children│ 1 5 0│ 0 10 0│ 2 10 0 │ │ │ 2nd Class }Adults │ 1 12 9│ 0 6 3│ 6 0 0 Tradesmen }Children│ 0 16 9│ 0 6 3│ 1 12 6 (Undescribed) } │ │ │ │ │ │ Artisans {Adults │ 0 15 6│ 0 2 6│ 1 10 0 {Children│ 0 8 9│ 0 2 6│ 0 15 0 │ │ │ Paupers {Adults │ }│ │ {Children│ }│ │ │ │ │ Totals

─────────────────────────────────────────────────────────────── ────────────────────────┬───────────────┬────────────┬──────┬────────── │ │ │Annual│ Total │ │ Total │Number│estimated │Charge for New │ estimated │ of │Expense of │Cemeteries and │ Scale of │Cases │Interments │Establishments.│ Expense of │ of │ to each │ │ Burials. │ each │Class per │ │ │Class.│ annum. ────────────────────────┼───────────────┼────────────┼──────┼────────── │ £. _s._ _d._ │£. _s._ _d._│ │ £ │ │ │ │ Gentry {Adults │ 6 0 0│ 38 10 0│ 1,724│ 66,374 {Children│ 4 5 0│ 14 0 0│ 529│ 7,406 │ │ │ │ 1st Class {Adults │ 3 0 0│ 16 10 0│ 3,979│ 65,655 Tradesmen {Children│ 2 0 0│ 6 5 0│ 3,703│ 23,144 │ │ │ │ 2nd Class }Adults │ 1 10 0│ 9 9 0│ 2,996│ 28,312 Tradesmen }Children│ 0 10 0│ 3 5 6│ 2,761│ 9,042 (Undescribed) } │ │ │ │ │ │ │ │ Artisans {Adults │ 0 2 0│ 2 10 0│12,045│ 30,113 {Children│ 0 1 9│ 1 8 0│13,885│ 19,439 │ │ │ │ Paupers {Adults │ │ 0 13 0│ 3,655│ 2,376 {Children│ │ │ │ —————— │ │ │ │ Totals │ 251,861 │ ——————— Or an annual saving on the estimated total expense of the │ interments and parochial charges for the whole metropolis │ 374,743 ───────────────────────────────────────────────────────────────────────

§ 220. In this estimate the expense of the funerals of the classes “undescribed” in the mortuary registries may be taken as representing the second or third class of tradesmen. In the estimate of the expense of funerals of persons of the first class, no account is taken for a long cavalcade of mourning coaches; but those who are conversant with the details agree that several may be supplied, with a full retinue of hired mourners, and the expense be yet kept below one-half the present amount of charges. A confident opinion is expressed that interments might be performed, under general arrangements, with all the advantages specified, and full compensation be given, at a rate of between 5_l._ and 6_l._ each funeral, instead of about 15_l._, the present average.

§ 221. On the eight chief cemeteries opened in the metropolis by private companies, and comprising about 260 acres, or considerably more than the space occupied by all the parochial and private burial grounds whatever, a capital of about 400,000_l._ has been invested. The expenses of litigation and of procuring Acts of Parliament, and purchasing grounds, must have been excessively heavy; and it appears probable that, for an amount not much greater or not exceeding it by more than one-fifth, superior national cemeteries, with houses of reception and appropriate chapels, may be formed on the present scale of expenditure of these companies, and in a style commensurate with what is due to the metropolis of the empire. If the charge of the purchase of the land and the structural arrangements be spread over 30 years, and the payment of the money charged, with interest, on the burials of persons of the higher and middle classes, the amount might be included in the total charges for funerals above estimated for the several classes, which charges, though so much below the amount at present usually paid, are yet higher than asserted to be necessary by respectable tradesmen, ready to verify their assertions by sureties to supply the materials and service of an equal or of a better description for the public than that which they now obtain. If the charges of the new cemeteries and establishments at such rates as those suggested were taken as substitutes for the existing rates of charge for graves, the new rates would be for the middle and higher classes greatly below the charges usually found in undertakers’ bills and executors’ accounts. If those new expenses were levied in the shape of a poll tax, or as burial dues, a sum of about 5_d._ per head per annum (exclusive of the expense of collection) would suffice in the metropolis to repay the principal and interest of purchase-money in 30 years, and also to defray the annual establishment charges.

§ 222. The establishment charges of the existing eight principal cemeteries amount, it is stated, to about 7500_l._ per annum. I believe, that by appropriate arrangements of a public establishment a far more efficient service might be obtained for national cemeteries for the same money. Assuming that the greatest solemnity and the highest cathedral service is due to funerals, four full choirs of 20 choristers and four organists to lead them might be obtained for less than 10,000_l._ per annum for four national cemeteries to meet the wishes of those who desire a service of the highest solemnity. The lowest aggregate charge for the separate establishments of parochial and suburban burial grounds, if only on the scale of that of St. Martin’s-in-the-Fields, must be at the least 25,000_l._, and would probably extend to 30,000_l._ or 40,000_l._ per annum. Such an amount in connexion with national cemeteries would suffice to maintain, in addition to the superior religious establishments above described, a superior description of intermediate houses of reception for the dead, with houses and offices for the residence of the officers of public health in care of them: it would beyond that suffice to provide the means for accommodation, on a large scale, for the reception and treatment of all persons labouring under infectious diseases. It might also suffice for the establishment of public baths, in which the metropolis is also deficient.

§ 223. The number of the officers of health requisite for the due execution of the service could only be determined by experience; but, judging from analogous experience, a much smaller staff than on the first view might be expected would suffice for the performance of all the duties specified, if their whole time were devoted to them. Medical officers of dispensaries, within their districts, visit, examine, and treat twenty or thirty cases per diem; physicians in full practice, and driving to distant parts of the town, on the average (which includes cases of short visits of a few minutes and cases where a long attendance would be required), visit about three cases in the hour. This appears to be the best analogous experience. On this experience, and considering that it would be good economy to provide each officer with a one-horse vehicle, he may be expected to visit fifteen cases a-day, one day with the other, out of the daily number of deaths. The two public medical departments, the navy and the army, have rendered the highest, if not the only, public service in the prevention of disease—the navy medical department especially; which service it has been enabled to achieve from having the subjects of its care under the most complete control. The scale of remuneration to these officers, who, whatever diploma they may possess, are required to undergo, and do undergo, a special re-examination, is taken for estimating the expense. There are various grounds that, at all events at the outset, and for their superior responsibility, this class of officers should be selected. The proposed staff would be as follows:—

Per Annum. £. _s._ _d._ An inspector of public health, of the rank of an inspector-general of hospitals in the army, or of 657 0 0 fleets in the navy, at full pay of 1_l._ 16_s._ per diem, at the rate given after ten years’ service

A deputy inspector-general, at the rate of the army 438 0 0 full pay of 1_l._ 4_s._ per diem

Eight inspectors of public health, of the rank of staff surgeon, at the rate of the army full pay of 19_s._ 2,774 0 0 per diem

Two supernumeraries, of the pay of regimental surgeons, 547 10 0 at the rate of the army pay of 15_s._ per diem