Part 25
“In the Glasgow Fever Hospital there occurred 81 deaths from eruptive typhus in individuals whose habits were ascertained, and 34 of these were reported as intemperate, 19 a little intemperate, and 28 temperate. In Dr. Craigie’s table of the deaths in 31 fever cases that occurred in the Edinburgh Royal Infirmary, there were 15 stated to be irregular or dissipated; only two regular; the habits of the remainder are not stated.
“It is also a singular fact, which has been noticed by several writers, that fever is more fatal among the higher than among the lower classes. Dr. Braken states, in reference to the fever which prevailed at Waterford during the years 1817–18–19, that ‘it would be difficult to adjust the rates of mortality in the upper classes, but it seems probable that one-fourth, or perhaps one-third of all those persons who were attacked with fever fell victims to its power.’
“Drs. Barker and Cheyne, in their historical account of the Irish epidemic, state that, ‘in every part of the country, fever was reported to have been much more fatal amongst the upper than the lower classes.’ To what is this difference of mortality, so generally remarked by experienced hospital physicians, to be attributed, and which in Ireland seemed to be very remarkable, namely, in the lower classes about one in twenty-three cases, and in the upper classes one in three or four generally, but in other places about one in seven? Can the difference in the mode of living account for this anomaly? as the first live very much on potatoes, while the others use a larger or smaller proportion of animal food; and the lower classes almost everywhere in this country use less animal food and stimulating dishes than those who are more wealthy and in a higher sphere of society.”
In remarking on the supposed influence of fear and the depressing passions in producing fever, _Dr. Davidson_, however, remarks:—
“The influence of fear and the depressing passions has also been considered as very powerful in predisposing persons to be affected with typhus contagion. There can be no doubt that fear has a tendency to produce a temporary depression of the physical powers; but, as has been already shown, there is no proof that persons of a naturally spare or weak habit of body, who are generally very sensitive, are more liable to fever than those of an ordinary constitution; this opinion must also be considered hypothetical. Indeed the facts, as far as our inquiries have enabled us to judge, seem to prove that the apprehension of fever, more particularly when it is not epidemic, is very rarely felt until the person is actually seized with the disease; for some cannot recollect of a single circumstance by which they could be exposed to contagion; and a considerable number of those who had undoubtedly been exposed to it were only made aware of the fact when it had been elicited by cross-examination. We are quite aware that cases may be brought forward of sensitive individuals who have been seized with fever soon after visiting a person labouring under the disease; but as this fact can be opposed with at least an equal number of persons who were destitute of fear, and yet caught it after an exposure to contagion, no conclusion whatever can be drawn from them. It must be observed, however, that though there is no proof that persons who are naturally weak in body or of a sensitive disposition are more susceptible of fever than those who are naturally vigorous and robust, yet that, during famine or commercial distress, poverty, by depressing the mind and lowering the physical status from insufficient aliment, does powerfully predispose a community to become affected with fever. This has been already shown in a former part of the essay, and has been again alluded to in order that the distinction might be made between an individual of naturally weak mental and physical stamina, and one who has been reduced to that state by deficient nutriment.”
There appears to be little evidence on one side or the other in support of this last hypothesis, other than such as that cited from Dr. Davidson himself; but it is to be observed that the wet or bad seasons, which suspend agricultural industry and much labour in the towns, is usually of a character of itself to predispose to disease, if not to produce it; and that it does propagate it amongst all classes, high and low, in proportion to their exposure to it. It appears to be highly probable that the privation attendant on the stoppage of work, by diminishing the means for the purchase of fuel, of soap, &c., and in various ways by inducing lax habits of life, may increase the amount of exposure to and loss from the all-pervading cause.
The preponderant evidence given on this subject by the great majority of the medical officers in England who are accustomed to visit the labouring classes in their own dwellings, is however of the tenor of the following from the medical officer of the Whitechapel union acting in Spitalfields parish.
_Mr. Byles_, the medical officer of the Whitechapel union:—
“What is the number of cases you have had to visit during the year 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.