Part 9

Possibly it may occur to you that these comparisons are devoid of practical application--that it is unreasonable to suppose we can mitigate our London death-rate to the likeness of a selected country mortality--that the circumstances of the two populations are essentially and unalterably dissimilar--that the advantages of the one cannot be given to the other--that the traditional ‘threescore years and ten’ of human life are allotted only to rustic existence--that the right of participating in the higher civilisation of the metropolis, or of trading in its larger market, is not too dearly purchased by the tax of half or a third of one’s fair expectation of life.

On general grounds I should not hesitate to combat this objection, and should feel sure of convincing you of its invalidity. I should argue (as indeed I have already argued here) that the main conditions which constitute the unhealthiness of towns are definite, palpable, removable evils; that dense over-crowding of a population--that intricate ramification of courts and alleys, excluding light and air--that defective drainage--that the products of organic decomposition--that contaminated water and a stinking atmosphere, are distinct causes of disease and death; that each admits of being definitely estimated in its numerical proportion to the total mortality which it contributes to cause; that each is susceptible of abatement or removal, which will at once be followed by diminution of its alleged effects on the health of the population. Likewise, I should argue, that if there indeed exist, attached to a metropolitan residence, some really unavoidable and necessary disadvantages to life (a point which however I am not prepared to concede) there are likewise, as respects the poor, some peculiar advantages to counterbalance those evils; that in urban communities the operations of charitable relief are largest and least remitting; that the resources of medicine for curing what cannot be prevented are likewise readiest and most effective.

On all these general grounds I should be prepared to maintain that a lowness of mortality which has been attained in any considerable rustic population, may be attained by an urban population, if only the removable evils be removed, if only the practicable good be made practical.

Surely too, above all, I would maintain this possibility in respect of our capital--the treasury as she is of all means for progress in civilisation, the stronghold of all applicable knowledge. Let but the wealth, the science, the energy, and the benevolence of the metropolis deal with removable causes of death as they have dealt with subjects infinitely more difficult, infinitely less promising, and certainly of not greater importance; and few competent persons will doubt that the mortality of London might speedily be reduced to the level of any district-mortality yet recorded by the Registrar-General.

There may be those in your Hon. Court who will hesitate to accept for themselves the firm conviction which I entertain on this subject; or who, at least, will withhold their assent from the line of argument which I have advanced. To them, what I have now to state may be more conclusive than any other consideration: viz., during the year on which I am reporting, there was one sub-district of the City of London Union--one comprising from twelve to thirteen thousand inhabitants, in which (after including a due proportion of deaths which had occurred in the union-workhouse at Mile-end) the mortality stood only at 15 in the thousand; one in which, if those extramural deaths had been excluded, the local death-rate for the year would have been only 13·32.[33]

[33] These figures require some correction for decrease of population in the sub-district referred to: the death-rate, inclusive of workhouse mortality, was nearly 16, and exclusive of that mortality, nearly 14 _per_ thousand.--J. S., 1854.

For an illustration of low and enviable death-rates, I need then no longer appeal to Northumberland, or to our south-eastern counties--though, no doubt, their septennial periods of low mortality are valuable corroborations of any inference which could be drawn from our more restricted experience;--but I may point to the last year’s death-rate in the north-west sub-district of the City of London Union as one of rare excellence, and may content myself with wishing that that partial rate might become universal for the City, and might be the permanent expression of its average mortality.

A detailed consideration of our sickness and mortality during the last year suggests to me a few other remarks, which may, I think, be of practical utility to your Hon. Court.

First, as regards the ages at which death occurs; the respective proportions of _timely_ and _untimely_ deaths may, generally speaking, be inferred from the local death-rates. In general terms, we know a high death-rate indicates that many die before their time--indicates that a proportion of the population, more or less considerable, instead of reaching old age, becomes prematurely blighted and extinguished. In order to illustrate this subject to you more exactly, I append a table in which the deaths of the last two years are classified according to the ages at which they occurred. Of 3763 persons whose deaths are recorded in my last Report, 1243 died under the age of five years: of 2752 deaths registered in the present year, 1032 belong to the same early period of life.

The City of London appears peculiarly fatal to infant life. Reference to the Registrar-General’s last septennial record shows that of every 1000 male children under five years of age within the City of London (aggregately) nearly 113 die in each year; and the portion of this rate which is deduced from the East and West London Unions is as high as 119 in the thousand. In the subjoined table,[34] which illustrates some points of comparative mortality, I have endeavoured to show the extreme and disproportionate amount of this pressure on infant life. In referring (for instance, in regard of the City of London Union) to the last three columns of that table, you will observe that the mortality of children at the age stated, during the septennial period, was 1/2·66 of the entire mortality, although their class numerically constituted only 1/11·09 of the entire population; so that they died at more than four times (4·17) the rate which would have fallen to them as simple participators in the average mortality of their district. The actual infant mortality of the past year holds the same proportion to the general mortality as in the Registrar-General’s septennial period, being 1/2·66 of the whole.

[34]

+--------------+---------+--------+----------+----------+-----------+ | Places. | General | Death- | Out of | Out of | By what | | | death- | rate | entire | entire | multiple | | | rate | _per_ | living | mortality| is the | | | _per_ |thousand|population| what | mortality | | | thousand| _per | what |proportion|of children| | | _per | annum_ |proportion| occurs | under five| | | annum_. |of male | is under | under | years in | | | |children|five years|five years| excess of | | | | under | of age? | of age? |the average| | | | five | | | mortality | | | | years | | | of all | | | | of age.| | | ages? | +--------------+---------+--------+----------+----------+-----------+ |City of London| | | | | | |Union | 21 | 101 | 1/11·09 | 1/2·66 | 4·17 | |E. and W. Lon-| | | | | | |don Union | 26¾ | 101 | 1/9·02 | 1/2·24 | 4·02 | |Metropolis | 25 | 93 | 1/8·45 | 1/2·45 | 3·45 | |Holborn | 26 | 115 | 1/8·98 | 1/2·20 | 4·08 | |St. Giles | 27 | 122 | 1/9·85 | 1/2·24 | 4·39 | |St. Martin | 24 | 120 | 1/10·64 | 1/2·42 | 4·39 | |Bristol | 29 | 107 | 1/8·73 | 1/2·53 | 3·45 | |Liverpool | 33 | 143 | 1/7·35 | 1/1·91 | 3·85 | |Lancashire | 26¾ | 102 | 1/7·19 | 1/2·02 | 3·56 | |Surrey | 18 | 48 | 1/7·98 | 1/3·22 | 2·48 | |South-east | | | | | | |divn. of | | | | | | |England | 19 | 52 | 1/7·76 | 1/3·03 | 2·56 | |Glendale } | | | | | | |Bellingham } | 14 | 28 | 1/10·32 | 1/3·99 | 2·58 | |Haltwhistle } | | | | | | +--------------+---------+--------+----------+----------+-----------+

Lest any undue importance should be ascribed to the influence of bad or inappropriate articles of diet in producing this large infant mortality, I may inform you that the rate of death is highest during that very early period of life when the child depends for nourishment on its mother; so that, of a thousand male children in the first year of life there die within the district of the City of London Union 242; within that of the East and West London Unions, 276.

The causes which thus decimate the young population of London are the common conditions of district unhealthiness--the conditions which it lies within the scope of sanitary legislation to amend. But, inasmuch as the few days of these wretched children are passed mainly within doors, so their high mortality constitutes the readiest and least fallacious evidence of the unwholesomeness of the dwellings in which they die: and hence I am acquainted with no correcter material for estimating the sanitary condition of a district than is afforded by the death-rate of its infant population.

Secondly, with regard to the alleged _particular causes of death_; I have extracted from our general registry, and have grouped in a separate table, those cases of death from acute disease which seem peculiarly due to physical causes affecting large numbers of persons.

There are deaths by cholera, epidemic diarrhœa, and dysentery, of which during the biennial period we have had nearly 900; by fever, of which we have had 284; by erysipelas and puerperal fever, of which we have had 84; by small-pox, of which we have had 50; and cases of this sort partake of the nature of deaths by violence, not only because they are abrupt and untimely, but because they are _avoidable_. If in the instances which I have specified it were possible to make inquiry into the antecedent circumstances of the dead, you would find irrefragable evidence that life was lost in each individual instance by the operation of removable causes--by the foolhardy neglect of some familiar precaution, or by the obstinate retention of some notorious ill. The death of a child by small-pox would in most instances call for a verdict of ‘homicide by omission’ against the parent who had neglected daily opportunities of giving it immunity from that disease by the simple process of vaccination; the death of an adult by typhus would commonly justify still stronger condemnation (though with more difficulty of fixing and proportioning the particular responsibility) against those who ignore the duties of property, and who knowingly let, for the occupation of the poor, dwellings unfit even for brute tenants, dwellings absolutely incompatible with health. In addition to the diseases which I have named, there are others which owe their chief malignity and numerical largeness of fatality, though not their existence, to local and removable causes. The proportionate mortality from scarlatina, measles, and hooping-cough, is greatest when the general death-rate is greatest. Under similar circumstances, too, we find among the infant population a frequency and fatality of other diseases, not commonly accounted specific, which warrant us in considering them to be mainly of endemic and avoidable origin. Such are the hydrocephalus and convulsions, the diarrhœa, bronchitis, and pneumonia of infants; often indeed referred to the irritation of teething, but prevailing in different localities with so marked a proportion to the causes of other endemic disease that we may be sure of their partial and considerable dependence on those local and obviable causes. I dwell on this aspect of the subject, and particularly invite the attention of your Hon. Court to the table[35] which illustrates it, because it is in respect of these diseases that your exertions have already effected valuable improvements for the health of the City, and because the future registry of such cases will attest year by year the further progress of your sanitary reforms. In examining this index of preventable deaths you will notice that those from fever are fewer by 29 _per cent._ in the year just terminated than in the previous twelve months; that those from scarlatina are 75 _per cent._ fewer; those from infantile zymotic disorders nearly 40 _per cent._ fewer; those from erysipelas and puerperal fever 9 _per cent._ fewer. Small-pox, it is true, is doubled; but the prevention of this disease rests, out of your jurisdiction, in the exercise of individual discretion. Under the item of infantile diarrhœa (included in the tenth column) there is likewise an increase of nearly a third;[36] an exception probably dependent on the fact that, during last year, many deaths which might have swelled this column were (on account of the then prevalent influence) catalogued under the head of epidemic diarrhœa or cholera.

[35] _Appendix_, No. IX.

[36] In the column referred to, this is concealed by the marked diminution, during the present year, of other disorders classed with infantile diarrhœa. Their reduction maintains the total of that column (notwithstanding the difference of diarrhœa) considerably less for this year than for last.

I should be misleading your Hon. Court, and practising a deception which next year’s registry would expose, if I pretended that the striking difference between the two years’ several totals of preventable deaths (a difference which, leaving cholera out of the question, probably amounts to a diminution of 30 _per cent._ on the sum of last year) had resulted wholly, or even chiefly, from sanitary improvement, and could be interpreted as the evidence of permanent physical changes around the dwellings of our poorer population. I guard you against this impression now, because, however satisfactory it might be as a momentary belief, it would lead to subsequent disappointment; and any future rise in the proportion of these deaths would induce the erroneous, but disheartening, supposition that your later sanitary steps had been less successful than the first. In all these matters, and especially in analysing the details of a death-registry, it is requisite (as I have already stated) to deal with cycles of many years. Periods of pestilence are habitually followed by periods of diminished mortality: partly because population is diminished, and especially that share of the population which suffers most from obviable causes of disease; partly because the great alarm of death has induced vigilance and precaution, public and private, against the occasions and beginnings of illness. And, beyond both these circumstances, there are others which we cannot analyse or explain, though we have scientific certainty of their operation; circumstances which seem to ensure a comparative quiescence of the ordinary causes of zymotic disease during those periods which next succeed the prevalence of certain fatal epidemics.[37]

[37] For the professional reader I may here throw out a hint--referring to the doctrine of epidemic disease stated in the Fifth Annual Report, that this apparent healthiness of districts after certain epidemic invasions probably bears relation to a temporary exhaustion of their zymotic atmosphere under the action of a specific ferment, and is in some respects analogous to that immunity from an infected fever which belongs to an individual who has recently suffered its attack. See also page 235.--J. S., 1854.

Nevertheless, that the sanitary condition of the City has undergone considerable improvement within the last two years is a fact which no one can gainsay; and that a considerable share of the mitigation in mortality arises from this improvement cannot reasonably be questioned. If even a third of the mitigation in question, if a reduction of ten _per cent._ on the preventable mortality of the City, may be inferred from the materials which I lay before you, it is indeed matter for the utmost congratulation; and a continuance of the same reduction year by year, perpetuated (as doubtlessly it may be) by a continuance of the same exertions, would soon raise the City of London above all fear of comparison, on the ground of healthiness, with urban or suburban populations.

Thirdly, I would beg the attention of your Hon. Court to those very important _local differences_ of death-rate which may be deduced from a study of our death-register. I have already had the pleasure of citing to you the low rate of mortality which has prevailed during the last year in the north-west sub-district of the City of London Union. The rate of death in the north division of the West London Union was nearly double that proportion; and between these extreme terms of disparity there were many intermediate degrees.

Similar inequalities of mortality were observable in last year’s record. In the healthiest sub-district of the City the year’s death-rate was about 22 in the thousand; while in the worst it stood above 41; and for the whole West London Union exceeded 38.[38]

[38] I have here availed myself of the corrections given in the note of page 6.

Mainly and essentially these local differences of mortality depend on the proportion in which _preventable deaths_ enter into the total; the differences, however partial, depending on the operation within certain districts, of removable deleterious influences which do not exist in certain other districts.

In classifying for your consideration the deaths which, during the last two years, have depended on epidemic, endemic, and infectious diseases, I have thought it desirable to distribute them according to the municipal divisions of the City. Strongly believing, as I have endeavoured to express, that this class of deaths is for the main part preventable, I have thought it would interest the representatives of the several Wards, and would more directly enlist their sympathies for sanitary progress, if I could enable them at a glance to recognise the ratio in which their respective constituencies contribute to this annual death-roll. I have included in the table, under eight different heads, all those acute diseases which depend in an important degree on local causation, either for their existence or for their fatality. It will be obvious, even to the unprofessional reader, that local causes are not of equal prevalence in respect of all the diseases there tabulated. Some (as fever and cholera) would not be known at all under perfect sanitary arrangements; others (as scarlatina, measles, and hooping-cough) would be far less malignant in their attacks; others (as those classified in the tenth and twelfth columns) would no doubt exist under the most perfect physical circumstances, but would probably prevail in numbers quite inconsiderable as compared with those actually observed.

On consulting this table[39], it will be observed that in _Cordwainers_’ Ward, during the last year, not a single death occurred from the causes referred to, and in the preceding year of epidemic visitation, only five; that in _Cornhill_ Ward there have been only two such deaths in each of these years; that in _Coleman-street_ they have been 66; in _Queenhithe_, 59; in _Portsoken_, 143; in _Aldersgate Within_, 30; in _Aldersgate Without_, 179; in _Cripplegate Within_, 80; in _Cripplegate Without_, 299; in _Bishopsgate Within_, 60; in _Bishopsgate Without_, 329; in _Farringdon Within_, 153; in _Farringdon Without_, 845.

[39] Page 167.

I am unable to state with accuracy, in these several instances, what proportion subsists between the preventable mortality and the number of living persons, for I have no means of ascertaining precisely the population of the separate Wards; and without this knowledge it is impossible to arrange them in a scale of comparative healthiness. I need hardly remind your Hon. Court that the Wards differ very considerably in their magnitude; so that the largest majority of cases occurring in one Ward (as in Farringdon Without) must not unconditionally be taken to imply that the Ward, _in proportion to its population_, suffers more deaths than one in which the apparent number is less considerable. In the table to which these remarks refer, I have endeavoured to give you the means of comparing (at least approximatively) the healthiness of your several departments, by entering against the name of each Ward the number of holdings for which it stands assessed to your rate. This entry, with some trifling modifications specified in the table, may be taken to express the number of houses contained in each Ward of the City: thus it furnishes indirectly the means for estimating the local population.

It will be noticed, that the more glaring inequalities which I have adduced are in some degree due to the epidemic of last year, which did not press uniformly on all parts of the City. It may, however, likewise be observed, that the chief operation of that epidemic was to exaggerate, but not importantly to misrepresent, the features of each locality; that the habitual sanitary proportions of districts to each other were for the most part preserved; that (with a qualification to which I shall presently revert) the Wards numbering fewest deaths last year numbered also fewest this year.

In my last Report, when the cholera had scarcely subsided, when men’s minds were full of apprehension on the subject, and when it seemed only too possible that, with the recurrence of autumn, we might again suffer from its invasion, I was unwilling to dwell too pointedly on the wonderful pertinacity with which that disease fixes itself on particular localities, and tends to re-appear in them on each new occasion of its rise. Believing that no extemporaneous measures could counteract these local preferences of the epidemic, I refrained from a course which would have produced no good result (unless indeed it had depopulated certain spots of the City), and which might have caused unavailing and hurtful alarm. Now, however, I think it right to tell you that the local predilections of this dreadful disease are so marked and so obstinate, that we may almost certainly predict in what parts of the metropolis it would tend to arise on any renewed visitation. We may anticipate that at any such time its latent power of destruction will kindle again in the districts, the streets, the houses, perhaps even in the very rooms, where it recently prevailed, _unless the determining local conditions shall previously have been annulled_.