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is to be restrained. We not long ago had the opportunity of inspecting certain model dwellings erected on the most improved plans and with the most philanthropic intentions, in the midst of a most degraded quarter of a great manufacturing town. Philanthropy had become wearied of the persistent struggle required to regulate the debased habits of the occupiers; the Municipality had not put the building under such supervision as was needed; and there, before the stone of which the block of building was constructed had lost its freshness, the different tenements, the appurtenances, and the surroundings had fallen into a state of squalor and unwholesomeness which rivalled the miserable dwellings in the vicinity. Again, we have recently seen in the environs of the metropolis, streets of admirably planned and commodious new cottages, erected for a single family, systematically let in occupation to two families, and undergoing a process of deterioration, under the double occupation, which will quickly bring the buildings to a state of deplorable foulness and unwholesomeness, and will require the most energetic action of the sanitary authority to remedy. Let us avoid the terms "minor" and "major" in dealing with the different agencies we already possess, or which we hope to possess, for the improvement of the condition of the dwellings of the poor. But at the same time we agree with the committee of the Sanitary Organisation Society, that it is proper to concentrate our energies in order to obtain such additional powers to this end as have been proved to be necessary.
THE AUGMENTED MORTALITY OF THE TEN
It is very probable that not a few persons whose attention may have been arrested by the Return of Deaths for the decennial period 1861-70, the general results of which were briefly stated in the last number of the Practitioner, will have been puzzled to account for the increased mortality there shown as compared with the previous decennial period, 1851-60. It is true that the increase of the rate of mortality during the
last decennial period has been slight (2,242 as compared with 2,217 per 100,000 population), and that for practical purposes the mortality may be regarded as having been stationary; but nevertheless there is an increase, and an explanation may well be asked how it has come to pass that the large amount of sanitary work done during the period under consideration should apparently have been productive of no result upon the general mortality of the kingdom, and that the large sums of money expended on such work have seemingly yielded no return in life and health. This explanation is not difficult. The result does not in the least make doubtful either the value of or the necessity for sanitary work. It simply means that such work has been as yet but partially carried out, and that it has only sufficed to keep the general mortality for some years virtually stationary. This conclusion may excite surprise among those who have little familiarity with the details of the subject. It is no doubt difficult to believe that all the energetic work on sanitary matters of the last twenty-five years should have had so meagre a result. Yet such we believe to be the fact. That work has indeed been chiefly limited to large town populations, and even to a few only of these; and until the passing of the Public Health Act 1872, it was not possible (such being the imperfect state of the law) to carry out in any great degree like work in small towns and rural districts. It is not too much to say that in the great mass of villages, the majority of small towns, and not a few large towns, no real improvement in their sanitary condition has taken place during the past quarter of a century; and in some towns and villages the sanitary condition has even steadily deteriorated. Nay, during this period, from the defective state of the law, it may be said broadly, that in almost all the new centres of population which have been created in connection with mines and manufactures, the worst sanitary evils of the older centres have been reproduced; and these newest places, which might have and ought to have set examples of sanitary order and propriety, have rivalled the older and least-cared-for places in all that was objectionable and unwholesome.
An instructive illustration of the little progress which thorough sanitary work has to the present time made in this country,
may be obtained from the official inquiry which was carried out by Dr. Buchanan, for the Medical Department of the Privy Council in 1865 and 1866, "On the results which have hitherto been gained in various parts of England by works and regulations designed to promote the Public Health." (Ninth Report of the Medical Officer of the Privy Council.) This inquiry related to twenty-five towns with an aggregate population of more than 600,000 persons; and in several of these towns sanitary improvements had been too recently carried out to exercise any marked effect upon the mortality. The small number of places included in Dr. Buchanan's inquiry, it is to be inferred, arose from the paucity of towns which, having regard to the state of sanitary work in them, admitted of such an inquiry. Indeed, Dr. Buchanan says that "the towns were chosen, after consultation with the Local Government Act Office, as being places where structural works had been most thoroughly done and had been longest in operation, and were not chosen for any previously ascertained improvement in the health. They are believed to represent a considerable majority of the towns in England that are available for the purposes of the inquiry." And Mr. Simon, commenting on Dr. Buchanan's inquiry, observes: "It was essential that the inquiry should not be prematurely made; and it was not till two years ago that I felt myself entitled to hope that the undertaking could be free from such reproach."
If we insist upon this point of the comparatively small extent, in respect to numbers of towns and villages, to which sanitary works have as yet been carried out in England, it is because we are anxious to impress upon our readers the necessity for correction of the common misapprehension which exists upon the subject. No doubt that the sanitary work which has been done here contrasts very favourably in amount with what may have been done in other countries; but it is very far indeed from being as considerable and as general as is needed. We do not in the least degree desire to under-rate the work which has been done. We know well its magnitude; and we also know the enormous difficulties which have had to be overcome in carrying out sanitary works, and which still impede their progress. But it is important that we should not form a false estimate of the amount of what has been done, and so anticipate
from it results as respects the general health of the kingdom which this amount is not calculated to yield.
It is a perfectly proper assumption that the effects of sanitary work should be shown in a diminution of the general rate of mortality; that, in fact, the general rate of mortality may be taken as a gauge of the wholesomeness or unwholesomeness of a place. The evidence supplied by Dr. Buchanan from his inquiry is conclusive on this point, while at the same time it furnishes the fullest confirmation of the value of sanitary works. We quote the results obtained by Dr. Buchanan :
On the results of his inquiry as to reduction of total mortality, Dr. Buchanan remarks:
"In the great majority of the twenty-five towns there has been distinct reduction of the total death-rate. In nine of them, having an aggregate population of 204,641, this reduction has amounted to about a fifth part of the previous rate of death. In eleven other towns the fall in the death-rate has been less considerable. In three or four towns (including one that has
scarcely finished its works) the rate has been stationary, and one shows an increase in the rate of mortality since the period when the works designed for its improvement were executed.
"Some of the reasons for the position of towns in the above list readily occur. Thus, at the head of the list with chief reduction of mortality are towns where the previous death-rate was most excessive, as in Cardiff, Newport, Merthyr, where it had exceeded 300 in the 10,000 yearly; and, secondly, towns where, along with sanitary improvements, notable change in the social or industrial conditions of the population has taken place; of this the chief examples are Croydon and Macclesfield. At the other end of the list appear towns that cannot yet have got the full fruit of their sanitary work, as Bristol and Penzance; or that had previously a death-rate close upon the necessary annual rate, as Cheltenham, Rugby, Worthing, and Chelmsford. These considerations require to be kept plainly in view if a judgment of the relative value of sanitary measures in various towns is to be obtained."
Of Chelmsford, Dr. Buchanan writes:-"While very much has been done for the improvement of the town, there is to each sort of work some drawback from complete efficiency."
These details (and very much besides in Dr. Buchanan's report), while demonstrating the value of works carried out for the promotion of public health, serve to confirm the interpretation that we have put upon the augmented mortality of the last decennial period. This augmented mortality in no wise militates against the efficacy of sanitary works, but is simply an indication that such works have not yet become so common in the kingdom as to reduce the general death-rate.
ERRATA. Two misprints occurred in the article on "Quixotic Pathology" in the last number of the Practitioner, the author having been unable to correct the press. Last line but one, p. 464, for "severe and fatal miasmas," read “ and fatal invasions." Second paragraph, seventh line, p. 467, for "so far as is known, ten cases occurred," read "so far as is known, no cases occurred."