Comparative Mortality of Great Capitals.
Our recent alarm at the appearance and progress of the cholera in London may have drawn the attention of many who had before been accustomed to pass them by with indifference, to those columns in the papers in which the reports of the Registrar-General on the state of the public health are from time to time recorded. But we are perhaps hardly yet sufficiently awake to the importance and interest of the statistics there contained, any more than to the value of the short and, at first sight, rather unintelligible tables which embody, day after day, the meteorological phenomenon collected in London from so many different points on our own coast and those of adjacent countries. These last statistics have an interest which does not yet belong to those which relate to the public health, in that they embrace reports from so many distinct places which can be compared together. We, of course, only publish our own statistics of health, disease, births, and deaths; and we have not yet seen our way to the information that might be gathered by a comparison of our own condition in these respects with that of others under similar circumstances. The interest and value of such a comparison is obvious enough; and some of the results which might be hoped from it, if it were systematically and scientifically made, may be guessed at by the perusal of a thin volume of less than two hundred pages, lately published in Paris by M. Vacher, [Footnote 136] which at first sight may seem not to promise very much except to professional readers, but from which we shall take the liberty of drawing a few facts which certainly seem worthy of the attention of the more general public.
[Footnote 136: Etude Médicale et Statistique sur la Mortalité à Paris, à Londres, à Vienne et à New-York en 1865. D'aprés les Documens officiels, avec une Carte Météorologique et Mortuaire. Par le docteur L. Vacher. Paris: F. Savy, 1866.]
Canning once said, in answer to some one who alleged "a well-known fact" against him, that there was but one thing more fallacious than a fact, and that was a figure. We must all be ready to allow that the results which we see embodied so neatly in a set of figures in statistical tables are, after all, but approaches to the truth; and they are not put forward as anything more. Still, there is often a wonderful accuracy about the average results given by statistical inquiries; and it is obvious that when the result of one calculation is confirmed by that of another independent of the former, or when one uniform result is given by a continued series of inquiries, or when there is a very decided preponderance on one side of a comparison, such as cannot be accounted for by chance, it would be absurd to refuse to assent to conclusions thus obtained. With this single preliminary remark, let us proceed to some of the facts collected for us by M. Vacher.
He begins by giving due credit to this country for having taken the lead in the publication of the kind of statistics with which he has to deal. The reports of the Registrar-General are all that he can desire. New York and Vienna have followed, more or less fully, the example set in London. It has also been copied in St. Petersburg, as far as the registration of deaths is concerned; and it is hoped that a weekly publication of the results will soon be made in that city. Paris joined the movement at the end of 1864 or the beginning of 1865. There is, however, some difference of system. The chief point is, that in England the medical man who attends a sick person reports the cause of death; in Paris there are certain official physicians, vérificateurs des décès, and these, instead of the attending physician, assign the cause. The superiority of the English system seems to be acknowledged. M. Vacher's book is founded on the reports thus produced.
His first business is, of course, to settle approximately the population of the four capitals with whose statistics he deals—a matter of considerable difficulty, even with all the results of the census before him. He calculates the number of the inhabitants of Paris in 1865 at 1,863,000; those of London were 3,028,600; those of Vienna, 560,000; and those of New York, 1,025,000, (in 1864.) At the present rate of increase, Paris will double its population in 32 years, London in 40, Vienna in 44, and New York in 13½. On the other hand, this increase is not to be set down to the excess of births over deaths, which in London, in 20 years before 1861, was only 328,189—about a third of the actual increase, (35 per cent.) In a similar period, the births exceed the deaths in Paris by only 13 (and a fraction) per cent of the whole increase. Immigration has therefore the largest share in the increase of the population. A flow is continually setting in from the country to the town in the age in which we live, and it enriches the largest towns, and the capitals especially. New York, receiving annually so many immigrants from Europe, is, of course, beyond the others in its gains from this source. Paris has undergone great vicissitudes as to the number of its inhabitants. In 1762, the population seems to have been about 600,000. It fell off immensely during the Revolution; even in 1800 it was only 547,756. From 1790 to 1810 the number of deaths exceeded the number of births. Since that time the proportion has been reversed, except in years of great epidemics.
Of the four capitals with which M. Vacher deals, Vienna, the smallest, had the largest proportion of deaths in 1865. In Vienna the proportion was 1 to 31 of the inhabitants; in Paris, notwithstanding the ravages of the cholera in October—causing 6591 deaths (nearly an eighth of the whole)—it was 1 to 36; in New York, 1 to 40; in London, 1 to 41. In Paris, London, and New York, the death rate has diminished in its proportion to the population for some time past. In Paris, in the three decades of years from 1830 to 1860, it fell successively from 1 to 31, to 1 to 34, and then to 1 to 38. There has been the same improvement in the other two cities. In New York, fifteen years ago, the rate of deaths was 1 to 22—nearly twice as high as at present. We do not see any statement in M. Vacher's pages as to the case of Vienna. He attributes the improvement in Paris to some extent to the great public works and measures for securing the health of the population which have marked the second empire; but much more, it would seem, to the better management of the hospitals. In Paris and Vienna a much larger proportion of the inhabitants die in hospitals than in New York and London; and, as far as we are concerned, M. Vacher includes workhouses and asylums of all kinds under the general name of hospitals. He finds, on comparing some scanty statistics of the last century with the facts of the present, that in old times the number of deaths in hospitals was far greater in proportion to the cases admitted than now; and he thinks that, in Paris at least, this almost explains the improvement in the death-rate. In New York the same improvement may have had many causes, but it is remarkably coincident as to time with the magnificent changes made, at an immense cost, in the water supply of that city. From some meteorological tables compiled with great care by M. Vacher, we gather the rather surprising result that the variations of temperature during the year, which have considerable influence on the death-rate, are greatest at Vienna, (nearly 27°,) next at New York, (25°,) much lower in Paris (17°,) and lowest of all in London, (15°.)
One of the most interesting questions at the present time on this subject is that of the water supply. M. Vacher begins with a cordial tribute to the Romans on this head. The magnificent aqueducts by which the city of Rome was supplied date from the time of the early republic, though the emperors increased their number. At an early point of their history, therefore, the Romans were wise and liberal enough to dispense with the waters of the Tiber for drinking. They carried their system everywhere when they became the masters of the world; in France, in Spain, and in Italy many aqueducts can still be traced which were their work. We may be quite certain that if Britain were now a Roman province, the Thames water companies would never be allowed to supply water except for the streets, and great aqueducts would long since have brought us the pure water of Bala Lake or Windermere. Thanks to the popes, modern Rome though not so profusely supplied as in imperial times, is still very far in advance of all other cities in the world in this respect. [Footnote 137] M. Vacher reckons the water supply in ancient Rome as 1492 litres a day for each inhabitant; in modern Rome it is 1040; in New York, 159; in Vienna. 134; [Footnote 138] in Paris, according to the new system, 109; in London, 132. But no city seems to have its houses so well supplied as London; in Rome a great quantity of water is wasted, being left to run away from the fountains, while the houses are not conveniently provided with water. We suppose that our old friend the house-cistern, against which we have heard so many complaints lately, is not an essential feature in our system of house supply.
[Footnote 137: M. Vacher attributes the salubrity of Rome—for, considering its position, it enjoys remarkable salubrity—to the abundance and good quality of its water. Lancisi, who practiced there as a physician in the last century, accounts for the longevity of its inhabitants in the same way. At all events, remarks M. Vacher, "il est impossible de n'étre pas frappé de ce fait, que les historiens ne mentionnent pas un seul example de peste à Rome, et qu'au moyen age et dans les temps modernes elle a constainment échappé aux atteintes de la pests et du choléra, qui ont sévi à plusteurs reprises en Italie." But Rome has certainly been visited by the cholera more than once, and the rest of the statement is surely contrary to history.]
[Footnote 138: This statement is, however, an anticipation. The municipality of the Vienna has undertaken some immense works in order to improve the water supply, at a cost of 16,000,000 florins. The works are not yet completed: but M. Vacher gives the quantity of water for each inhabitant which they are expected to furnish. Hitherto the city has been supplied, it would seem, partly from the Danube, partly by wells. The new supply will be drawn from three different sources among the neighboring mountains.]
M. Vacher gives the following conclusions as to the sanitary effect of good and abundant water. He tells us that inorganic substances contained in water are comparatively innocuous to the health of those who drink it; on the other hand, great injury is caused by the presence of organic matter. The best water in Paris—that of the springs on the north—contains nine times as much of calcareous salts as the water of the Seine; but it is justly preferred for drinking purposes. On the other hand, M. Vacher quotes the testimony of M. Bouchut, a professor at the Ecole de Médecine, for the fact that he noticed the frequency of epidemic diarrhoea during the summer months in the Quartier de Sèvres and that it had been almost stopped in cases where the doctors had ordered the water of the Seine to be no longer used, and had substituted for it water from the artesian well of Grenelle. He adds his own experience at the Lycée Napoleon, which is supplied from the reservoir of the Pantheon, which receives its water from the Seine and the aqueduct d' Arcueil. He had known as many as fifteen students at once ill of diarrhoea, and the disease was stopped by the "alcoholization of all the water." [Footnote 139]
[Footnote 139: P, 106. M. Vacher here cites the Indian case quoted by Mr. Farre in is cholera report. The natives in India drink boiled water as a preventative against cholera; and it has been found that out of a great number in the family of a single proprietor in Calcutta, all of whom took this precaution, not a single person had been attacked even in the worst times of the prevalence of cholera. But Dr. Frank has disapproved at least the universality of this fact.]
As regards cholera, the proof is even more striking than that lately furnished in the case of London by the great and almost exclusive ravages of that disease in the eastern districts. Mortality by cholera seems ordinarily, as M. Vacher tells us, to follow the laws of general mortality, that is, it prevails most in those districts which are ordinarily the most unhealthy. But the one element of good or bad water supply seems to be enough to counterbalance the influence of the other causes which affect the comparative mortality of districts. For instance, difference of elevation is supposed to be one of these causes. Mr. Farre tells us that the mortality of a district is in inverse proportion to the elevation: that in nineteen high districts the proportion of deaths by cholera was as 33 to 10,000; in the same number of low districts, as 100 to 10,000. This law, however, is not enough, nor is it free from exception. Sometimes places loftily situated are attacked and lower places are spared. The elevation of Montmartre is almost equal to that of Belleville; but Montmartre had last year 3.6 cholera cases to 1000, Belleville only 1.1. Again, a rich quarter has ordinarily immense advantages over a poor quarter. The mean mortality by cholera in the poorer arrondissements of Paris was almost three times as great as that in the rich arrondissements. The reason is obvious: the poor work hard, have insufficient food, and are crowded together in discomfort and want; the rich are well fed, not overworked, well and healthily housed. Yet there was one arrondissement of Paris, and that one of the very poorest, which in the three first visitations of cholera (1832, 1849, 1854) had actually the lowest proportion of deaths by cholera of all these districts. In 1865, it had barely more deaths than the very richest of all, that of the Opéra, which headed the list on that occasion as the most lightly visited. This arrondissement was Belleville. Another cause of comparatively greater mortality is density of population; but here again we are met by the fact that this fortunate Belleville is very densely populated. The nature of the soil is another. M. Vacher mentions a number of departments in the centre of France which have never yet been attacked by cholera. They are those which consist of a huge granitic mass, like an island in the midst of the more recent formations around them. Nevertheless, though this will explain much, and though Belleville has an advantage in this respect over many of the arrondissements of Paris, still it has the same geological formation as Montmartre, which had three times as many deaths (in proportion) from cholera. In short, there is no way left of accounting for its comparative exemption, except that which we have already mentioned, the superior character of the water consumed by its inhabitants. The argument certainly seems as complete as it can possibly be, and we know that it has been strongly confirmed by our own late experience. Let us hope that no time may be lost in acting on the lesson which we have received.
We pass over some interesting statements on the meteorological phenomena which were observed during the prevalence of the cholera last year in Paris. [Footnote 140]
[Footnote 140: M. Vacher here tells a story of his endeavor to make some ozonometrical observations in the Paris hospitals, which were prohibited by the Directeur de l'Assistance publique—an officer of whom M. Vacher is continually complaining on the ground that they would frighten the patients. He remarks that on one occasion when travelling in the pontifical states, some gendarmes found in his possession a psychrometer and an aneroid barometer, and thought they were weapons of destruction. He would have been arrested but for M. Matteucci, then Director of Police. He complains bitterly of the comparative want of enlightenment in the "administration" of his own country. But no hospital would have allowed his experiments.]
M. Vacher rather contradicts current opinion by some remarks he has made as to the relation of cholera to other diseases. Sydenham has remarked that when several epidemic diseases are rife during the same season, one of them usually absorbs to itself, as it were, the bulk of the mortality, diminishing the influence of the rest even below the ordinary level. Thus in the year of the great plague in London, just two centuries ago, the smallpox was fatal to only thirty-eight persons, its average being about eleven hundred. However, the general fact is now questioned. In October last, though 4653 persons were carried off by cholera, the mortality by other diseases in Paris was greater than in any other month of the year. Yet October is usually one of the most healthy of all the months; and the epidemic maladies which ordinarily rage during the autumn—typhoid fever, small-pox, diphtheria, croup, whooping-cough, erysipelas, and puerperal fever—were prevalent to an extraordinary degree. It is curious also that there was an unusual number of children born dead.
The most destructive of all ordinary complaints is undoubtedly consumption. At Vienna it actually causes 25 per cent of the deaths, at Paris 16 per cent, at London nearly 12 per cent, at New York 14 per cent. It is more frequent in women than men; it is twice as destructive in poor quarters as in rich quarters; the age which suffers most from it is between 25 and 40. The difference between the sexes M. Vacher attributes to the more confined and retired life led by women. If observations in Paris are to be taken as enough to furnish a general conclusion, it would appear that more consumptive patients die in the spring than in the autumn. Here again a common opinion is overthrown. The most destructive months are March, April, and May: the least destructive are September, October, and November. We believe that in this country the fewest consumptive patients die in winter, and the most in summer. M. Vacher also attacks the notion that maritime climates are the best for consumptive cases. New York is situated on the sea, but it loses as many by consumption as London; and in the maritime counties of Kent, Sussex, Hampshire, Dorset, and Devonshire, the deaths by consumption are as 1 in 7 of the whole; while in the Midland counties of Warwickshire, Buckinghamshire, Worcestershire, and Oxfordshire, they are as 1 in 9. "Les phthisiques qu'on envoie à Nice et à Cannes, ou même sur les bords du Nil, sur la foi d'un passage de Celse, y meurent comme ceux qui restent sous le ciel natal. Ceux-la, seuls en reviennent guéris, chez qui le mal n'était pas sans ressources et qui auraient guéri partout ailleurs," (p. 129.) We must remember, however, that if such patients are sent to the seaside, and die there, they raise the death-rate there unfairly. M. Vacher insists that the guiding principle in selecting a place for the residence of a consumptive patient should be the absence of great variations in the temperature rather than the actual number of deaths by the disease. Consumption, he says, is unknown in Iceland; but that is not a reason for sending a consumptive patient to that island. As to New York, we have already quoted his observation as to the variableness of the temperature there, notwithstanding its maritime position.
Although we have already stated the results of a general comparison of the mortality in the four capitals—results very favorable to the salubrity of London—it may be interesting to our readers to learn the state of the case with regard to particular classes of disease. In most cases, of course, we have the list in actual numbers: our comparative immunity is only evident when the great excess of our population is considered. In zymotic diseases we have little more than a majority of a thousand over Paris; but then we must remember that in the year of which M. Vacher speaks between 5000 and 6000 persons in Paris died of cholera. This, therefore, would seem to be one of the classes of disease as to which we are really worst off. As to constitutional diseases, consumption, cancer, scrofula, gout, rheumatism, and others, Paris exceeds us in proportion; and it is the same with diseases of the nervous system. From diseases of the heart we lose between two and three times as many as the Parisians; this proportion, therefore, is greatly against us. On the other hand, in diseases of the digestive organs, Paris, notwithstanding its inferior population, exceeded London by a hundred deaths in the last year. London, however, regains a sad preeminence when we come to diseases of the respiratory organs, asthma, bronchitis, influenza, and the like: Paris losing between 7000 and 8000 a year against our 12,500. It is in the commoner diseases that the worst features of London mortality in 1865 were found. Typhoid was nearly three times as fatal last year in London as in Paris; measles four times as fatal; scarlatina not far short of twenty times; whooping-cough more than thirteen times. As the population of London is to that of Paris as five to three, it is clear to how great an extent the balance was against us. It was probably an accident. These diseases prevail very generally for a time, and then retire: and we have lately been visited by a period of their prevalence.
We have hitherto spoken only of diseases; but M. Vacher's researches extend to the comparative frequency of deaths of other kinds. In suicides, New York has the best account to give, Paris the worst. To speak roughly, London has twice as many suicides as New York, Vienna twice as many as London, Paris more than twice as many as Vienna—in comparison, that is, with the total number of deaths of all kinds. The actual numbers stand thus: Paris 716, London 267, Vienna 813, New York 36. For the last nine years there has been little change in the number in London; in New York it has diminished, in Paris it has increased, having more than doubled itself since 1839. The two years, 1848 and 1830, which were marked by revolutionary movements, were also marked by a diminution in the number of suicides. The relative proportion of suicides increases with age; that is, it is four times as frequent with people above 70 as with people between 20 and 30. Paris has for a long time been noted as a city in which there were more suicides than any other. More than eighty years ago, Mercier noted this, and attributed it to the rage for speculation. Other writers have since attempted to find a reason for it in the prevalence of democratic ideas. We suppose that both democratic ideas and speculation are not unknown in New York, yet that city (and indeed the State itself) is remarkably free from suicides, and a great number of those that occur are said to be of Europeans.
But if Paris bears the palm in self-slaughter, no city can vie with London in slaughter of another kind. Violent deaths are nearly three times as frequent in London as in Paris. As many as 2241 persons were slain in London last year; as many, that is, as would be enough for the number of the killed in a sanguinary battle: 328 were burnt, 405 were suffocated, (this probably includes children overlaid by their mothers,) 40 were poisoned, 767 disposed of by "fractures and contusions," 232 were killed by carriage accidents; leaving 469 to be laid to the account of other accidents. In the other three capitals the proportion of deaths by accidents to the whole number of deaths ranges from under one per cent to under two per cent; in London it is just three per cent. Finally, London had 132 murders to give an account of in 1865, Paris had 10, and New York only 5.
We are sorry that the last fact which we glean from M. Vacher's interesting tables must be one rather disparaging to the great Transatlantic city which we have last named. Disparaging, that is, positively rather than comparatively; and we fear that, if the statistics which we are now to quote do not reveal a terrible state of things in London also, it is because on this head our admirable system of registration has given M. Vacher no assistance at all. "Quant à la ville de Londres," he says, "il m'a été impossible d'arriver à connaitre le chiffre de ses mort-nés. Le Bulletin des Naissances et des Morts ne donne d'ailleurs aucun renseignement à ce sujet." He expresses his opinion that, if the numbers were given, London would have quite as bad a tale to tell as Paris or New York. But the figures in these cities are sufficiently startling. In Paris the children "born dead" are to the whole number of deaths as one to ten; in New York as one to fifteen; in Vienna they are as one to twenty-three. Twenty years ago, the Préfet of the Seine addressed a circular to the maires of Paris, in which he drew their attention to the great number of these children, and pointed out that it was natural to conclude that their deaths were too often the result of crime. In New York similar complaints have been made, and we are significantly told that full reports cannot be obtained on the subject. As to London, we find a large number of deaths, 1400 or 1500 a year, set down to "premature birth and debility." We fear it would be quite impossible to give an account of the number of births which are prevented—contrary to the laws of God and man alike. We need hardly do more than allude to the frightful increase of infanticide, on which Dr. Lankester has lately spoken so strongly. Mr. Humble's Essay on the subject in Mr. Orby Shipley's volume contains some very startling statistics. There are as many as 12,000 women in London to whom this crime may be imputed. "In other words," says Mr. Humble, "one in every thirty women (I presume, between fifteen and forty-five) is a murderess." We must hope that there is exaggeration about this; but if it were one in every thirty thousand, it would be bad enough—a state of things calling down the judgments of heaven on the land.
The Anglican writer to whom we have just alluded speaks with some apparent prejudice against the most obvious remedy for infanticide—the establishment of foundling hospitals, perfectly free. There may be some objections to these institutions, but we must confess that, in the face of the facts on which we are commenting, they seem to us rather like arguments against life-boats because they may encourage oversecurity in exposure to the dangers of the sea. If Mr. Humble will read, or read again, Dr. Burke Ryan's Essay on Infanticide, which gained the Fothergillian prize medal some time ago, and in which the fact seems to be proved that the crime is more common in England than anywhere else, he will perhaps see reason to conclude, from the French statistics there adduced, that foundling hospitals are more effectual in preventing this abominable evil than anything else that has ever been devised.