EFFECT OF SANITARY WORKS ON THE GENERAL Annual Death-RATE AND ON THE MORTALITY FROM TYPHOID FEVER AND PHTHISIS.*

* Compiled from the Ninth Report of the Medical Officer of the Privy Council, 1866.

again, that nothing is so costly in all ways as disease, and that nothing is so remunerative as the outlay that augments health, and in doing so augments the amount and value of the work done."

Again, as Dr. Lyon Playfair says "The record of deaths only registers, as it were, the wrecks which strew the shore, but it gives no account of the vessels which were tossed in the billows of sickness, stranded and maimed as they often are by the effects of recurrent storms."

At present we have no means of arriving at an accurate estimate of the amount of sickness in a community, and although this information would prove of the greatest interest and value, it is doubtful whether it can ever be obtained. It may be taken for granted, however, that a high death-rate means a high sickrate, and that the one bears a fairly constant ratio to the other.

So far, we have considered the effect that improved sanitation has had on the death-rate of the community as a whole. We will now go a step farther, and consider the death-rate, and, consequently, also the health-rate, as influenced by condition and surroundings.

The first point that strikes one is the great difference between the death-rate of rural as compared with urban districts. Take Staffordshire, for example, and we find that the average rural annual death-rate is 16-2 per thousand of the population, as compared with 18.8, the urban rate. It is true that the age and sex constitution, which greatly influences the deathrate, differs, as a rule, in urban and rural districts; but the advantage, so far as this is concerned, is certainly in favour of towns with their large industrial populations containing a greater proportion of young adults, among whom, other things being equal, the death-rate is low.

Among the conditions that influence the death-rate, to occupation must be given an important place, and, without going too fully into the question, the following table shows in a striking manner how this operates, particularly in the case of two classes of disease-viz., phthisis and diseases of the respiratory organs :

COMPARATIVE MORTALITY OF MALES IN CERTAIN DUST-INHALING OCCUPATIONS FROM PHTHISIS AND DISEASES OF THE RESPIRATORY

We must not stop to discuss the process by which these trades exercise their baneful effects; why in a given number of coal miners only 126 deaths occur from phthisis, whereas, among a corresponding number of Cornish miners, 690 deaths occur from that disease-more than five times as many-the figures are given merely to show that occupation does influence the deathrate, and to a very large extent. In recent years much has been done in the case of some of these trades, as well as in others, to diminish this wholesale sacrifice of life, but much still remains to be done, as apparently our present legislators are aware. The responsibility is a serious one; for the prostration of the bread-winner of a family for months, by an illness which in the end proves fatal, must involve an amount of misery, poverty, and distress beyond conception.

Certain of these trades operate injuriously upon those engaged

in them by reason of their nature, but, on the other hand, there are some trades which need not cause injury, provided they are carried on under conditions less unfavourable to health than is frequently the case.

The two following tables give the mortality in Glasgow in 1885 from all causes, as well as from certain classes of disease that are especially liable to be influenced, both as regards prevalence and fatality, by insanitary surroundings. Of course the conditions of life in other respects of the occupants of small, as compared with large houses, are not comparable, but apart from this, there can be no doubt that cleanliness of the atmosphere, as affected by density of population, is an all-important factor in the result:

GLASGOW, 1885.

INCIDENCE OF ANNUAL DEATH-RATE PER 100,000 ON POPULATION INHABITING HOUSES OF

OVERCROWDING AND DEATH IN A GROUP OF TEN FAMILIES OF FIFTY PERSONS IN HOUSES OF

To put it shortly, nearly two and a-half times the number of people die from all causes who live in houses of one and two rooms, as compared with those who live in houses with five rooms and upwards; and in the case of zymotic diseases three times, lung diseases four times, and diseases of nutrition in children five times the number die in the small, as compared with the large houses.

In the second table, the same point is exemplified in a different manner. Both these Tables deserve careful study; the figures they contain are taken from a large district, and, therefore, the operation of chance is less likely to invalidate the conclusions one may draw from them.

As already pointed out, from such statistics one is not justified in attributing the excessive mortality entirely to overcrowding. The conditions of life as regards occupation, food, and general surroundings have an important bearing on the question, as well as the fact that the population living in houses of five rooms and upwards includes domestic servants, a class in which, by reason of sex and age, the mortality is low.

The following table, although compiled on different lines, illustrates the same point, and is not open to the same objection. In this case, owing to the character of the localities selected, the inhabitants of each may fairly be compared with each other as regards condition and surroundings, so that any difference in the rate of mortality may be attributed to the one circumstance in which the localities differ-viz., the proportion in each of backto-back houses, and, as this feature, in its result (by reason of less possibility of free ventilation), corresponds to overcrowding, to that cause must the difference in the mortality be attributed.*

The foregoing tables of statistics have been introduced, in the first place, to show that already some good has resulted from sanitation, and, therefore, inspectors need not be discouraged if they fail to see any immediate result from their work, and, in the second place, to demonstrate that much still remains to be done. Neither need we be discouraged if from some temporary cause the satisfactory decline in the death rate, as shown in the Table on page 3, should be interrupted, as indeed might have

*The two following papers will be read with profit by those who are interested in the housing of the working-classes:-1. The Vital Statistics of Peabody Buildings and other Artisans and Labourers' Block Dwellings. By A. Newsholme, M.D., D.P.H. (read before the Royal Statistical Society, Feb. 17, 1891). 2. Model Dwellings in London and Overcrowding on Space. By Louis C. Parkes, M.D., D.P.H. (read before the Sanitary Institute, Feb. 11, 1891).