A glance at the accompanying table will show how very unequal are the birth-rates of different towns. There are many reasons why the birth-rate should vary, not only in different countries, from race, climate, &c., but also in the same country, and in different years, from the varied conditions under which the inhabitants live, and from moral, economical, or physiological causes, quite apart from the salubrity of towns or the healthiness of inhabitants. It depends. especially upon the number of marriages, and this again upon the proportion of individuals who are of marriageable ages, upon the condition of trade, the plenty or scarcity of the necessaries of life. A large birth-rate almost always leads to a large death-rate, and since many of these deaths do not necessarily occur in consequence of the bad health of the parents, or of defective physical sanitary arrangements, it is impossible justly to compare places which are unequal in the relative proportions of births to population.* 2. The English Life Tables were constructed originally by Dr. Farr, to represent both the mean age of the living of any population and the mean time which, according to past experience, an existing generation will live. If the data upon which these tables are constructed were reliable, the expectation of life, at the different ages which they portray, would probably be the best possible measure of the health of a population, and might be used for purposes of comparison. Unfortunately their basis is affected, though in a less degree than are the ordinary death-rates, by the same disturbing causes which have just been mentioned. Mr. Rumsey has recently pointed out the insufficient nature of the statistics upon which they are founded, and the errors they are liable to contain owing to the various degrees of reproductiveness of different portions of the population, and especially to the continual migration of young adults from rural districts to cities and towns. I have already remarked that the sources of fallacy which have now been noted, have been frequently recognized by Dr. Farr in his reports to the Registrar-General, and it is by means of the admirable statistics which accompany the census that we have been able to ascertain in many cases the extent to which his results are affected by them. Still, the discovery of such errors does not render the rates of mortality more trustworthy as measures of the health of populations. Many and serious errors, also, have been committed by those who have neglected the caution of Dr. Farr, whilst them Manchester men of business, their families and servants. The annual death-rate (average of 8 years, 1856-64) of Altrincham is 21.3 per 1,000, of Bowdon, 12 per 1,000, and their respective birth-rates are, Altrincham 36, Bowdon 19.5. "On some of the some and W. Royston. Numerical Tests of the Health of Towns," by A. Ran- "On the Value of Life Tables," by H. W. Rumsey. Manchester Statistical Society. they have grasped at, and have applied indiscriminately, the apparently ready means presented to them for estimating the healthiness of a population, the salubrity of a place, or the value of sanitary measures. It is not necessary now, to enlarge on this part of the subject, for when it is considered how large a proportion of the preventable mortality of our towns arises, not from defects in the sanitary arrangements in the places themselves, but from evil habits, and neglect of themselves and their children on the part of the inhabitants, it becomes evident at once that no safe conclusion can be drawn from these recorded death-rates, either as to the healthiness of places, or the healthfulness of their inhabitants. There is, in truth, no royal road to knowledge of this description: it can only be attained by painful inquiry into the respective effects of all the morbific agencies which are so actively at work in large towns, or wherever human beings are crowded together in "poverty, hunger, and dirt." It will probably be long before a thoroughly trustworthy measure of the relative health of different portions of the population can be obtained. In addition to the information now secured, it will be necessary to record in the registers of death the duration of each person's residence in the respective localities, and then the healthrate of each place must be deduced by long and careful investigation of these records. When we turn to the second branch of the inquiry conducted by the Registrar General, namely, the investigation into the causes of death, we obtain no more satisfactory results. The causes of death, or rather the names of the diseases which are supposed to have immediately preceded the deaths, recorded in the Registrar's returns, are grouped under the heads of a carefully framed classification of diseases. I have no wish, at the present time, to criticize this arrangement; the nosological tables have been greatly improved since they were first brought out, and they are now apparently constructed with a view of obtaining some idea of the true causes of death, the various injurious conditions which have led to the diseases finally entered on the certificates of death. The defects in these records are to be found, not in the arrangement of the statistical tables, but in the data upon which these are founded. However perfect the grouping of diseases in separate classes and orders, the tables will be of little value if the diseases which they include have been imperfectly observed or wrongly entered. Unfortunately the evidence given by these statistics cannot be relied upon for several reasons. In the first place, the returns of certified deaths are very incomplete the registration of deaths is still not compulsory; it is left to all the uncertainty of voluntary service-and, in consequence, a very large proportion of deaths are not certified at all. It has been calculated by Dr. Farr, that in 17 per cent. of the total number of deaths registered in England and Wales no clue is given to the cause of death; and in some districts it is stated, upon good authority,* that the proportion of uncertified deaths is more than 70 per cent. 2. The certificates of the causes of death are often erroneous, either purposely, from carelessness, or from ignorance. Without a proper inspection of the body of the deceased it is sometimes impossible to state with any degree of probability the immediate cause of death. There is a strong prejudice amongst many people against post-mortem examinations, and, moreover, few medical men have either time or inclination to make them: this in itself would be a serious hindrance to obtaining correct returns; not only, however, is this a most common defect, but, in some instances, certificates are signed by medical men when they have not seen the case before death, and sometimes even when they have not seen the deceased either during the illness or after death. Thus it often happens that a mere guess at the cause of death, whether probable or improbable, is allowed to take its place in what ought to be a record of well attested and well observed facts. Again, many persons are attended upon by ignorant or unqualified practitioners, who are utterly unable to give a correct statement of the causes of death. The temptations also to make deliberately false returns are often very great. It is well known that ambiguous statements of the causes of death or of the duration of the illness are occasionally made by qualified medical men, in order to escape troublesome inquiries on the part either of friends or of insurance societies. There is, indeed, at present little or no security against directly fraudulent entries on the register, and it is believed that not a few crimes are allowed to pass undetected from the want of a proper supervision of certificates. So long, also, as still-births, or those alleged to be such, are left unrecorded, there will at least be strong grounds for suspicion that many cases of infanticide escape without notice or punishment. Many of these defects would probably be greatly reduced in number by the adoption of Dr. Farr's suggestion for the appointment of a Registration Medical Officer in each Superintendent Registrar's district, and it is greatly to be desired that this Association should urge upon the Secretary of State for the Home Department the necessity that exists for the appointment of such af officer.† * Report of the Committee appointed by the Manchester Statistical Society to inquire into the defects of the system of registration of deaths. † I venture to append to this paper a form of Memorial which has already been forwarded to the Home Office by the Manchester and Salford Sanitary Association. "The following address, signed by about 100 of the most influential citizens and merchants, humbly showeth,-That the registration of the cause of death under the provisions of the existing Registration Act not being compulsory, is, in our opinion, very imperfectly performed. The certificates given are often those of unqualified medical practitioners, whilst in a large number of instances no certificate of death is obtained. That, in consequence 3. The usefulness of these returns is also much lessened by the fact that as they are at present published, they do not indicate either the time or the place at which the fatal diseases have originated; and thus they render no assistance in determining the surrounding conditions which have immediately preceded or accompanied the outbreak of any disorder. They throw little or no light upon the predisposing or exciting causes of disease. Owing to this fact, even a weekly return of deaths in any place is comparatively useless; it scarcely serves as a warning against an epidemic unless this is rapidly fatal in its effects, and it gives no clue to the atmospheric or other conditions which favour or produce it. The elaborate meteorological tables which are appended to the metropolitan returns, however much they may advance physical science, are of little use in discovering the causes of disease. Much might probably be done to improve these records of the causes of death, but I believe that before long it will be found necessary to collect returns, not only of deaths, but also of some diseases as they arise. In this way only can we hope to learn the exact place and time at which these diseases have arisen, and trace the fluctuations in their prevalence. If a regular and systematic registration of disease, such as that proposed by the British Medical Association, were to be combined with the record of deaths, we * of such imperfect registration, the reports of the Registrar-General are, to a great extent, useless as scientific records, and comparatively valueless as a basis for legislation for sanitary purposes. That, as a further consequence of such imperfect registration, and also through the absence from the Registration Act of any provision for the registration of still-births, no adequate means exist for preventing the concealment of crimes of violence, especially in the case of young infants. That the inquiry held in the Coroner's court, from the want of medical evidence, is too often little better than a mere form. That there is in many parts of the kingdom a total want of efficient sanitary supervision, and that in consequence thereof the causes of disease are not duly brought under the notice of the local authorities, and it is only reasonable to believe that many deaths thus occur which, with proper care, might have been prevented. That to remedy these defects there ought, as your memorialists believe to be, in all parts of the kingdom, skilled persons appointed as officers of health, whose function it should be to examine the body of every person, the cause of whose death has not been duly certified by a qualified medical practitioner; and also to examine the body of every infant alleged to have been still-born, the fact of whose still-birth has not been duly certified by a qualified medical practitioner; and also to attend as Assessors to the Coroner at every Coroner's inquest; and further to make themselves acquainted with the nature and causes of any diseases extensively prevalent, or whose prevalence is to be feared, and report to the local authorities or to the Government; and to give such advice as they may think necessary with reference to the steps to be taken for the prevention of such diseases; and generally to perform the duties of Medical Officers of Health. And your memorialists humbly submit that such officers ought not to be removable by the local authorities, nor be allowed to engage in the ordinary duties of medical practice. Your memorialists therefore humbly suggest that the matters above referred to may receive such consideration as their importance seems to demand; and, that with a view to legislation on the subject, such inquiries may be made, and such steps taken, as may appear best calculated to aid in attaining the ends proposed." * See "British Medical Journal," August 25th, 1866, p. 229. might at least hope to add greatly to our now very limited knowledge of epidemic disease. At present also the return of deaths only, gives no measure of the extent to which a disease has spread; it only shows its intensity. Even partial returns of new cases of an epidemic disease at the time of their occurrence would both be useful as a warning to the public and would indicate the degree of its prevalence. In concluding this brief review of some of the defects of the present system of registration of deaths I must express my regret that my task should have been one of fault-finding only. It would have been a much more congenial labour had I been requested to point out the many services which have already been rendered to the country by the Registrar-General and his coadjutors. But this was not in my brief, and I can now only say that I have endeavoured to speak in no captious spirit, but solely in the hope that by the discussion of this subject by the Association a still more useful and complete system of registration may be inaugurated. RECREATION OF THE WORKING CLASSES.* In what Form and to what Extent is it desirable that the Public should provide Means for the Recreation of the Working Classes? - By WILLIAM HARDWICKE, M.D., Medical Officer of Health for the Parish of Paddington. THER HE practical interest taken by the public in this matter has been sufficiently manifest. Many plans have been suggested and readily adopted. At one time mechanics' institutions were thought to be what was most desirable; co-operative associations, building societies, and industrial partnerships are encouraged, to economize the savings of workmen, and to teach habits of thrift; societies have been formed for the promotion of early closing and Saturday halfholidays; of late working men's clubs have been founded, and are become the newest philanthrophic fashion, whilst, as supplementary and complementary to these, a vigorous crusade has been made. against public-houses by temperance societies, and men who believe that by regulating the licensing system, and making more difficult the means of procuring intoxicating liquors, people will abandon their drinking habits, and betake themselves to a less deleterious method of enjoyment. It is found, however, that whatever success may have severally attended these attempts, something additional is needed, acceptable to those for whose benefit it is designed, as well as to those by whom it is proposed. *For Abstracts and Discussion, see p. 552. |