Part 3

I have already referred (p. 10, _ante_) to a curious outbreak of scarlet fever following on a dinner-party at South Kensington, and it may be here mentioned that a report of the occurrence having found its way, with more or less inaccuracy, into some of the papers, a good deal of alarm was created, and an impression got abroad that the disease was very prevalent in Kensington, his impression was not confined to the immediate locality, and the effect of it was to cause a considerable exodus of the wealthier classes at a prematurely early period of the “season,” as well as more or less consequent injury to trade. Some suspicions connected with the state of the Knightsbridge Barracks and the health of the soldiers’ families, including those that lived outside, added fuel to the fire, if indeed they did not kindle it. I had no reason, myself, to suspect any extensive prevalence of scarlet fever, for I knew that the deaths though rather above the average were still few in the aggregate, and I was aware, after repeated enquiry, that the cases under treatment at the three charitable dispensaries and by the five district Poor Law Medical Officers were astonishingly few. In fact, on several occasions when enquiry was made, it turned out that only one or two, or at the most three cases, were under the care of the Medical Officers, although they have many thousand cases of sickness among the poorest classes under their care during the year. I also ascertained from many medical men that they had very few cases under their care, most of them none at all. I stated these facts in my June report, but as the alarm was really great I thought it well to address a circular letter to the two hundred and fifty medical men whose names appear in the Medical Directory as residents in Kensington, asking for information and stating all I knew as to the actual dimensions of the epidemic, if it could be so called, and the comparative abeyance of scarlet fever in dispensary and parochial practice. To this letter I had fewer than fifty replies, including those that were _viva voce_. As I had asked for positive information only, it is probable that many of those who did not favor me with any reply were silent for the best of reasons, viz., that they had nothing to communicate. Of those gentlemen to whose courtesy I am indebted for their replies only six had any cases under treatment. The testimony of all my correspondents excepting two was unanimous in this—that the disease generally assumed a mild form, and the correctness of this view was supported by the fact that although adults formed a large proportion of the cases, the few deaths that occurred were those of young children. The exceptions referred to went to prove the rule. The first-named was a group of seven cases in one house of a person in good circumstances, in which it was subsequently discovered that the cistern was not only in untrapped connection with the drains but was also in a disgusting condition of filthiness, to which cause my informant attributed the outbreak. This fact, however, may perhaps with greater probability be the explanation of the severity of the disease, and the sharp _sequelœ_ in all the cases. There were no deaths. In the second group of cases, eleven in number, occurring in three families of 21 persons occupying rooms in two small houses in a street at Notting Hill, there were five deaths, but, as I stated in my July report the causes of the severity and the fatality of the outbreak were to be found in the circumstances of the people and in their dwellings, “The fatality of the disease,” I remarked, “has been great in proportion to the number of cases . . . and this I attribute to the want of proper accommodation, etc., for the sick, the spread of the disease being the direct and necessary result of the retention for home treatment of first cases. It is practically impossible to isolate the patients in the crowded houses of the poor, and the parents are generally unwilling to allow their children to be removed to the hospital, the prejudice against which, however rarely survives actual experience.” In the same report I alluded to the concealment of cases, and to the fact that the registration of a death is oftentimes the first clue to the existence of the disease, and the information then comes too late for practical, i.e., _preventive_ purposes. It is obvious, also, after repeated experience that some of the poor who can ill afford to pay a doctor, employ the services of private medical men for fear that if they applied for Parish relief the sick child, or children, will be sent to the hospital. Private practice, is, under such circumstances, conducted under great disadvantages, for the payment of the small fees with which the medical man is content in such cases, deprives the poor of the means of purchasing those comforts, not to say necessaries, of the sick chamber, on which, _inter alia_, recovery so largely depends. It is heart-breaking to see the wan faces of little sick children in their miserable rooms, especially when the contrast is mentally made between the condition prevailing “at home,” and the well-ordered hospital, with its staff of doctors and nurses, and all requisites for every stage of illness and convalescence. Another case that came under my notice in the course of the enquiry may be mentioned. The child was attended by a non-qualified practitioner; the parents, however, believing him to be a duly qualified medical man, for how should a poor ignorant Irish labourer know the difference between “Doctors”?

“The child died at the end of the second week, and the existence of scarlet fever in the house became known to us only on the registration of the death: too late, in fact, for the mischief was done. The two rooms occupied by this family contained seven persons, viz., the parents and five children. Successively the father and two more children fell sick, and were removed to the hospital, where they are all doing well. The rooms and clothing were disinfected, and the mother and two remaining children were reluctantly compelled to leave the house; but no sooner had they done so than the elder child fell sick, and was sent to the hospital. The mother and her infant are at present well. The day following the burial of the deceased child another family of nine persons left the house. They have been traced, and two children found to be ill. They are tolerably well isolated, however, and seem likely to do well. I am trying, nevertheless, for the sake of the rest of the family, to have them removed. The lessons taught by this story are too obvious to need recapitulation; I will only observe, therefore, what the facts have strongly suggested to my own mind, viz., that among the many requirements in sanitary legislation, none is more needed than power to provide quarantine for the apparently healthy members of poor families in which infectious disease has broken out.”

The other cases that have occurred up to the present time are too few, and otherwise offer nothing to call for special notice. All the fatal cases occurred in streets wholly occupied by the poorer classes. But, as I observed in my report,—

“A principal source of danger in the future lies in the carelessness or ignorance which leads to the premature exposure of convalescents, to which cause several cases have been referred by my correspondents. A case of this kind occurred a short time ago. I ascertained that a boy, who had been ill only a few days and whose skin was actively peeling, had not only, by inadvertence, attended at the waiting room of a public dispensary, but had also been to one of the largest and most crowded of our parochial schools, while other members of the same family, and out of the same room, had been in the other departments of the same school, which moreover I found on inspection to be in a very unsanitary condition. I am doing what I can to prevent the recurrence of such a case by putting the teachers of schools on their guard; and, mindful of the steps which the School Board for London took, on our suggestion last year, with a view to prevent the spread of the malady through the medium of Board Schools, I addressed the Clerk to the Board lately, stating the facts as they are known in this parish, and urging a repetition of the precautions adopted last year; and I have had the satisfaction of receiving a communication from that gentleman to the effect that ‘the notices on the subject of scarlet fever, issued to the respective teachers in the autumn of last year, will be re-issued to the teachers by the time the various schools commence their work, after the summer holidays.’”

Before concluding my remarks on this subject, I may mention that I availed myself of the opportunity afforded by sending the circular letter to medical men to place in their hands the “Suggestions for preventing the spread of infectious diseases,” and other sanitary notices, pointing out that copies were always available for the use of their patients; asking their co-operation in aid of the efforts which it is at all times my duty to make, with a view to arrest the spread of infectious diseases, urging the importance of isolation of the sick, and the propriety of sending patients to the hospital when the home accommodation does not allow of isolation; offering the services of your sanitary staff in all such cases, and explaining the arrangements made for the disinfection of clothing, etc., in the absence of a public disinfecting chamber. It, of course, remains to be seen to what extent the epidemic will grow, and judging by past experience the disease may during this year and the next be expected to prove fatal above the average, but come what may I have the satisfaction of knowing that no means have been spared, or will be, which it is in the power of your Vestry to adopt with a view to arrest its progress.

_Diphtheria_.—This disease was the cause of 26 deaths (Town, 24; Brompton, 2), an increase of 15 over 1873—entirely in the Town sub-district. The deaths under five years were 14.

_Whooping Cough_.—The mortality from this complaint was 45, in the Town sub-district 36, and in Brompton 9. The deaths under five were 44.

FEVER.—_Typhus_, was fatal in 9 cases, all in the Town sub-district. The number in the previous year was 6—all likewise in the Town.

_Enteric Fever_.—The registered deaths from this disease were 28—viz., 19 in the Town and 9 in Brompton. The numbers in 1873 were 19 and 8 respectively. The term _Typhoid_ is often employed to designate this disease, and leads to error in the tabulation of the mortality returns. I have good reason to believe that some of the cases returned by the Registrar-General as _typhoid fever_ were not cases of _enteric fever_, the word _typhoid_ having been employed in medical certificates of the cause of death to describe a condition of the patient in the last stages of fatal illness of a nature entirely distinct from _enteric fever_.

_Simple continued fever_ caused 15 deaths (8 under five years), viz., 11 in the Town sub-district and 4 in Brompton. The deaths in 1873 were 7 and I respectively in the two districts.

_Diarrhœa_ was less fatal than in 1873, the deaths being in that year 145, and in 1874 only 112. The annual average number in ten years was 111, without allowances for increase of population. The deaths last year in the two sub-districts were 90 and 22; in the previous year 121 and 24. The large majority of fatal cases occurred in infancy, viz., 100 under one year and 8 between one and five. Above 65 years of age the deaths were 4. At intermediate ages there was no death. The principal mortality was experienced in the warm summer weather, viz., in July 38, and in August 31. Five deaths from _Cholera_ were registered, viz., 3 in the Town and 2 in Brompton.

OTHER ZYMOTIC DISEASES.—_Croup_ was the cause of 26 deaths, 25 under five years, and all save one in the Town sub-district. The deaths in the previous year were 20.

_Erysipelas_ caused 21 deaths, viz., 13 and 8 in the Town and Brompton respectively. The deaths in 1873 were 24.

PUERPERAL MORTALITY.—Some difficulty is experienced in procuring a correct record of the deaths arising out of or connected with childbed, owing to the fact that reference to the previous occurrence of childbirth is sometimes omitted in the medical certificate of the cause of death. Some of the deaths, therefore, registered as Peritonitis, Pyæmia, Erysipelas, and even under less suggestive headings, may have been connected with the puerperal state. The deaths actually ascribed to childbed diseases were 24, other 14 being set down to the various accidents incident to that critical period. These numbers together represent a mortality somewhat below one per cent. (0.87) on the births registered. Dr. Matthews Duncan, the successor of Sir James Simpson at the University of Edinburgh, has promulgated an opinion that the true average mortality of the puerperal state is one per cent., _i.e._, one death in every hundred confinements; an estimate which a practitioner in this parish, who has a most extensive midwifery practice, tells me coincides with his personal experience. The causes of death as registered were:—_Puerperal fever_, 4; _Puerperal peritonitis_, 9; _Pyæmia_, 5; _Septicæmia_, 1; _Metritis_, 4; _Pelvic cellulitis_, 1. Eighteen of the deaths occurred in the Town sub-district, the mortality being pretty evenly spread over the parish, and none of the cases being traceable to contagion. They occurred in the four quarters respectively as follows—9, 6, 5, and 4. The ages at death were: 20–30 years, 18; 30–40 years, 4; 40 years and upwards, 2.

_Syphilis_ nominally caused 12 deaths—a number we may well believe below the actual mortality from this Protean disease.

CONSTITUTIONAL DISEASES.—_Cancer_ was the cause of 67 deaths, viz., 51 in the Town and 16 in Brompton. Fifty-four of the deaths took place between the ages of 45 and 75.

THE TUBERCULAR DISEASES caused 408 deaths, viz., 325 in the Town and 73 in Brompton. _Scrofula_ was the registered disease in 27 cases, _Tabes mesenterica_ in 53, _Phthisis_ in 245, and _Hydrocephalus_ or _Meningitis_ in 82 cases. The numbers of deaths in the several quarters were—1st, 113; 2nd, 104; 3rd, 88; and 4th, 103:—216 in the winter and 192 in the summer quarters. One hundred and fifty-seven of the deaths were those of children under the age of five years. This mortality is exclusive of those brain affections, _Convulsions_, &c., and those diseases called developmental which, under the names of _Atrophy_ and _Premature birth_, are nearly allied to the tubercular diseases specially so-called.

LOCAL DISEASES.—The diseases of the nervous system were fatal in 256 cases, viz., 199 in the Town and 57 in Brompton. Eighty-five of the deaths occurred under five years of age. _Apoplexy_ was fatal in 64 cases, _Paralysis_ in 47, _Epilepsy_ in 13, _Convulsions_ in 59, and _Brain disease_ in 62. Apoplexy and Paralysis are diseases of old age; Convulsions, as a rule, of infancy. The deaths from this order of diseases were very equally spread over the whole year, the quarterly numbers being 66, 63, 61, and 66 respectively

THE DISEASES OF THE ORGANS OF CIRCULATION caused 149 deaths, viz., in the Town district 115, and in Brompton 34. Nine only of these deaths occurred under the age of five years. _Pericarditis_ was the registered cause in 5 cases, _Aneurism_ in 7, and “_Heart disease_” in the remainder, 137.

DISEASES OF THE RESPIRATORY ORGANS.—The deaths from this important order of diseases were 554, viz., 462 in the Town sub-district, and 92 in Brompton. Under five years of age the deaths were 244. The mortality from these affections is greatly influenced by season, more deaths occurring in winter than in summer, and a higher mortality prevailing in proportion as the winter is severe. These facts are illustrated by the subjoined figures, which show the mortality to have been in the four quarters of the year respectively 189, 80, 58, and 227. Thus in the winter quarters the deaths were 416, and in the summer quarters only 138. The deaths in the summer quarters of 1874 were seven less than in 1873; but there was an excess of 78 in the winter quarters of the former year, due to the long-continued cold weather that prevailed in the latter months. The several diseases of this order were the registered causes of death as follows:—_Laryngitis_ 6, _Bronchitis_ 300, _Pleurisy_ 10, _Pneumonia_ 176, _Asthma_ 12, and _Lung disease_ 41. The increased fatality of Bronchitis and Pneumonia helps to explain the higher mortality of 1874 as compared with 1873.

DISEASES OF THE DIGESTIVE ORGANS were fatal in 118 cases (18 under five years), viz., 93 in the Town and 25 in Brompton. They include _Enteritis_ 19, _Peritonitis_ 20, and _Liver disease_ 37.

DISEASES OF THE URINARY ORGANS were fatal in 51 cases, including _Kidney disease_ 12, _Blight’s disease_ 22; _Cystitis_ 7, and _Diabetes_ 5.

DISEASES OF THE ORGANS OF GENERATION caused 7 deaths, 6 of them registered as _Uterus disease_, &c. These deaths are exclusive of malignant affections of the organs included under the head of Cancer.

THE DISEASES OF CHILDREN were fatal in 75 cases, including _Premature birth_ 46, _Teething_ 25, and _Malformations_ 4.

THE DISEASES OF ADULTS include 14 deaths returned as _Child-birth_, these deaths being irrespective of those already alluded to under the head of Puerperal Fever.

DISEASES OF OLD PEOPLE (so described) were returned under the head of _Old Age_ as the cause of 94 deaths.

DISEASES OF NUTRITION, viz., _Atrophy_ and _Debility_, were the cause of 163 deaths, all under five years of age, (153 in the first year of life) viz., 143 in the Town sub-district and 20 in Brompton.

VIOLENT DEATHS, 48 in number, were registered, including 10 due to _fractures and contusions_, 17 (all under one year) to _suffocation_, and four to _drowning_.

CAUSES NOT SPECIFIED OR ILL-DEFINED.—Twenty deaths registered came under this description.

DEATHS IN PUBLIC INSTITUTIONS.

THE HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST. At this important institution 131 persons died, viz., 80 males and 51 females. All the deaths, with the exception of eight, were due to that hitherto incurable malady phthisis, or as it is popularly known, consumption. Five deaths were caused by heart disease, one by aneurism, and two by lung disease. The deaths in the four quarters respectively were 26, 30, 30, and 45. Six only of the deaths properly belong to the parish. Seventy-five of the deceased came from other parishes in London and the suburbs, and 50 from other than metropolitan counties. If the truth were known, it is not improbable that some few deaths from phthisis outside the hospital properly belong to other districts, the patients having come to town for medical treatment attracted by the fame of the institution, and being attended as out-patients.

ST. JOSEPH’S HOUSE.—This large charitable establishment of the Roman Catholics, situated in Portobello Road, Notting Hill, is not classed as a public institution, although its inmates (about 200) are drawn from all parts. The deaths last year numbered 36—males 21 and females 15—all above 60 years of age, and due to the more common diseases of senility, as Brain disease 8, Lung and Heart disease 16, Cancer 3, Intestinal diseases 3, “Old Age” 2, other diseases 4.

THE PARISH INFIRMARY.—At this large and important hospital there were 221 deaths, viz., in the four quarters respectively 61, 40, 44, and 76; males 117, females 104. The deaths included 37 of infants under one year of age, and 86 of persons above 60 years of age, viz., between 60 and 70, 36; 70–80, 38; 80–90, 11; at 97, 1. Inquests were held in three cases, the verdicts returned being (1) “Sudden, apoplexy, natural causes,” (2) “Fall from a window, accidental,” (3) “Fall from a ladder, accidental.”

The causes of death may be summarised thus:—

Brain disease, Apoplexy, Paralysis, &c. 26 Lung diseases 37 Heart disease 7 Scrofulous or Tuberculous diseases, Phthisis, &c. 41 Wasting diseases, Debility, &c., of Children 21 Atelectasis (Imperfect expansion of lungs at birth) 5 Cancer 8 Enteric fever 2 Measles 4 Diarrhœa 3 Intestinal diseases, &c. 13 Kidney disease 4 Uterine diseases 2 Ulcer 3 Childbirth, &c. 3 Violent 2. Privation 1. 3 Old Age 23 Various 16 Total 221

INQUESTS.

A large proportion of deaths form the subject of enquiry in the Coroner’s Court. Last year the number was 172, viz., 152 in the Town sub-district and 20 in Brompton, equal to 6.4 per cent. of the total deaths. One hundred of the subjects of enquiry were below the age of five years, 80 being less than a year old, mostly in fact infants of a few hours, days, or weeks. Forty-eight inquests were held on persons between the ages of 5 and 60, and 24 on persons above the age of 60. The great majority of the deaths were due to disease. Thus of the 99 sudden deaths the causes of death as found by _post mortem_ examination (and _post mortem_ examinations were made in 154 out of the total of 172 cases) were as follows:—

Brain, Diseases of the 13 Apoplexy 11 Lungs, Diseases of the 24 Heart „ „ 20 Scrofula 4 Convulsions 4 Spasm of the Glottis 7 Diarrhœa 3 Diphtheria 2 Syphilis 2 Premature birth and infantile debility 3 Visceral diseases (of Liver, Kidneys, &c.) 3 “Fever” 1; Thrush 1; “Sudden” 1 3 Total 99

Various diseases were specified in other six cases in which the deaths were not returned as “sudden.” Death was found to be caused by disease in many of the cases in which the deceased were “found dead,” either in bed or otherwise, viz., from

Lungs, Diseases of the 6 Heart „ „ 6 Convulsions 4 Brain, Diseases of the, 2; Apoplexy 1 3 Laryngitis 1; Spasm of the Glottis 1; Scrofula 1 3 “Found Dead,” &c. 4 Total 26

The accidental and violent deaths were caused as follows:—