The learned author says: "Hitherto medicine has been able to effect little for the cure of confirmed phthisis, although there can be no doubt that attacks are warded off and that life is prolonged by change of air, regimen, and the judicious administration of remedies."

In the same vol. Dr. Farr found (according to the then returns) that of 30,878 males alive in the metropolis at the age of twenty, 2779 died in the subsequent ten years, and of these no less than 1438 by phthisis. The danger of dying by phthisis in the ten years he expressed by the fraction 047; thus of the 1000 alive at the beginning of any year of age from 20 to 30, about 47 die in the year following; from the age of 30 to 40 nearly 5*3 in 1000 die; and from the age of 40 to 50 the danger from Consumption is greatest, for 6.6 in 1000 men die of the disease ann. The mort. from the malady increases 1.75 p.c. annually-19 p.c. every 10 years of life-from the age of 20 to 50.

It was shown that the death-rate from C. and other diseases of the respiratory organs was 782 in towns, against 522 in country districts, to each 100,000 living.

Finally, we are told, "The lives of consumptive persons, although shorter, are regulated by laws as constant as those which are observed in persons dying of other diseases," and admitting that the applicant (for ins.) will ultimately die of C.-but is not at the moment labouring under the disease-"he need not be deprived of the advantages of ins.: for his chance of living can be determined and the risk calculated." Then from a T. prepared for the purpose of showing the mort. of various diseases, and which we give under DISEASED LIVES, Dr. Farr deduced the following:

In 1842 there was read before the Brit. Asso. at its Meeting at Manchester, a paper by Mr. D. Noble, Surgeon, Manchester, On the Influence of the Factory System on the Development of Pulmonary Consumption. The author says:

I propose in the present paper to examine, in the first place, to what extent the positive results obtained by the Reg.-Gen. confirm the idea that C. is more frequent in this manufacturing town of Manchester than in other places; these results I shall compare with corresponding ones gathered from other large towns, where little or no manufacturing prevails; and I shall then subjoin some statistical data obtained by myself from an examination, in conjunction with Mr. Ner Gardiner, the Sup.-Reg. of the district, of the reg. books of the township of Manchester, for a period of 3 yearsdata which will contribute in some degree to satisfy the inquiry as to the proportion which the cases of C. occurring in this place, amongst persons of various pursuits, bear to those happening to the factory pop.

The writer proceeds to state that he draws his numerical comparisons from 3rd Rep. of Reg.-Gen., but on comparing the results with the preceding Rep. there is a "remarkable accordance in all the main results." According to the Census of 1831, the number of families resident in Manchester was 49,392; while the families in Essex were 62,403. The deaths regis. in Manchester in 1839 from C. were 1454. The deaths in Essex same year from same cause, 1201, or 250 less in the larger pop. This, he admits, taken by itself, furnishes a decided evidence of the prevalence of the disease in the former district; but then he points out that that is a town district compared with a country or rural district, and that therefore many material causes differ. He then proceeds to compare Manchester and Salford with West Derby, a district of Liverpool, wherein the deaths from C. in the same year were 1762 in a smaller pop. He next takes Birmingham, where the result is slightly more favourable than in Manchester. Lond. furnishes a smaller proportion of deaths from C. in relation to its pop. than either of the places named. He proceeds:

These numerical statements, of unquestionable authenticity, drawn from the national records, of the causes of death in various parts of the kingdom, supply, certainly, no corroboration of the views that have been set forth of the extraordinary prevalence of C. in the manufacturing districts, as compared with other districts free from manufactories. Manchester and Salford seem, on the whole, rather more exempt from the disease than some other places; decidedly more so than Liverpool; but in comparison with the agricultural districts, and the metropolis, more subject to its prevalence. It is a remarkable fact however that, the metropolis excepted, Manchester has fewer deaths from C., in proportion to the whole number of deaths, than any of the other districts above instanced; and contrasted with the metropolis in this respect, the ratio is the same. So far we look in vain for evidence of the baleful influence of the factory system in developing and causing the increase of the disease in question.

Further investigations led him to believe that the factory pop. did not furnish any undue proportion of the deaths from C. in Manchester.

In 1843 Dr. Wm. A. Guy read before the Statistical So. a paper: Contributions to a

Knowledge of the Influence of Employments upon Health. The materials upon which the paper was based were obtained from the Regis. of the out-patients of King's College Hospital. The details are of considerable interest, but we must content ourselves here with the following summary of the results deduced, as set forth by the learned author of the paper:

1. In females the ratio of cases of pulmonary C. to those of all other diseases is highest in those following sedentary employments; less in those having mixed in-door occupations; and least of all in those employed out of doors. The highest ratio occurs in the case of females whose habits of life are irregular.

2. In men the ratio of cases of pulmonary C. to those of all other diseases is somewhat higher in those following in-door occupations than in those working in the open air.

3. The ratio of cases of pulmonary C. to those of all other diseases, in the case of men following indoor employments, varies inversely as the amount of exertion, being highest where there is least exertion, and lowest in employments requiring strong exercise.

4. Neither a constrained posture, nor exposure in a high temperature, nor a moist atmosphere, appears to have any marked effect in promoting pulmonary C.

5. The ratio of cases of pulmonary C. to those of all other diseases is highest in the case of men whose employments expose them to the inhalation of dust, there being in persons so employed 2 cases of C. for less than 3 of all other diseases.

6. The ratio is also high in the case of persons exposed to habits of intemperance, there being 2 cases of pulmonary C. to 5 of all other diseases.

7. The age at which pulmonary C. makes its attack varies with the employment, being earlier in those Occupations characterized by a high ratio of consumptive cases. Thus it is earlier in those following in-door occupations than in those employed in the open air, and in those using little exertion than in those using much. It also occurs very early in those exposed to the temptation of intemperance, and in those whose occupations lead them to the inhalation of dust.

In a further paper by the same author on the same subject, which also appears in vol. vi. of the Statistical Journ., there occurs the following passage:

How many thousand unnecessary victims pulmonary C. claims year by year it is impossible to ascertain; whether this chronic plague is more or less destructive than the kindred pestilence which is constantly snatching away so many of our adult pop. must remain a subject of conjecture; but of this there can be no reasonable doubt, that in add. to those who might have escaped C. and reached at least the borders of old age, a large proportion of all who die of that disease, die much earlier than they would if they had been placed in more favourable circumstances. As each unnecessary death from C. represents the loss, after a slow and lingering illness, of one of those who form the real strength of society, so the death of each father of a family, at an age when those who depend upon him for support are most helpless, is the source of an amount of private suffering and privation, and oftentimes of expense to the public, which is much more readily conceived than estimated. To complete the calculation of the cost to society in this one disease alone, which results from unwholesome influences admitting of removal, it would be necessary to add the hereditary taint transmitted from the consumptive parent, and ready at fitting season to cut short the life of the child after he, in his turn, has bequeathed the same sad legacy to his offspring. Thus it happens that the seeds of disease are more thickly sown with each new generation, and a race of men famed for strength and vigour is doomed to slow but sure degeneracy.

In 1844 Dr. Guy presented to the Statis. So., A Third Contribution to a Knowledge of the Influence of Employments upon Health. The returns now presented were mainly deduced from the Reports of the Reg.-Gen., and the immediate object of the author was to ascertain whether the several classes of society-the gentry, tradesmen, and working men -were equally liable to pulmonary C.? "The answer to this question will lead to a consideration of the causes of the unequal prevalence of the disease among the three classes; and this will suggest a further inquiry as to the actual amount of pulmonary C. in this country, and will originate an attempt to determine the actual waste of human life due to this cause." The following T. embodies the main results arrived at:

The ratios of death from Consumption follow the same order as the average age at death, being lowest where the average age is highest, and the reverse. Thus the average age at death of the class of gentlemen is 58 61, and the ratio of deaths from C. is 1 to 5; in the case of the tradesmen the average age is 48'84, and the ratio of deaths from C. 1 to 260; while in the class of artizans the average age is 48'06, and the proportion of deaths from C. 1 to 2 29.

Again, the class of gentry presents a smaller proportional number of deaths under 30 and 40 than either of the other classes. It is also well worthy of obs. that the per-centage proportion of deaths from C. under 30 and 40 is higher in the class of tradesmen than in that of the artizan and labourer, although the ratio of cases of C. is greater in the latter class. This is doubtless accounted for by the fact already estab., that the strong exertion which a considerable portion of the labouring class employed within doors use in their occupations, and the large number employed out of doors, has the effect of retarding the attack of pulmonary C. The tradesman, it will be seen, occupies the intermediate place between the in-door and the out-door labourer, between the artizan using little exertion and the artizan using much exertion.

Another point attracts attention in T. IV. [the table just given], viz. the great proportion of deaths from C. occurring in the class of gentry from 15 to 20 years of age. Does not this show that the liability to the disease is greater in this class than in the two others; and does it not tend to strengthen the position, that the excess of the deaths from C. in the other classes is due to the unfavourable circumstances in which they are placed?

The ratio of deaths from C. in the class of gentry, low as it is, would have been still lower if the medical men who are included in it were omitted. The number of cases of pulmonary C. occurring

in members of that profession is very remarkable, and it is a subject of regret with the author that they were not made a separate class.

The author then proceeds to estimate the number of cases of pulmonary C. occurring ann. in the metropolis, and in E. and W. In the former he found them to be 5560 -or about one-eighth of the deaths of all ages, and rather less than one-fourth of the deaths above 15 years of age. In E. and W. he found the deaths to be about 36,000 p.a., "being rather less than one-ninth of the mort. from all causes at all ages, and in less than 6 of the total deaths occurring above 15 years of age." This estimate, which was less than the returns in R. of the Reg.-Gen., Dr. Guy considered to be only an approximation.

Many of the points treated of by Dr. Guy will be more particularly mentioned under OCCUPATION, Influence of.

In 1844 Dr. Guy completed a laborious investigation into the health of letterpress printers and of others following in-door occupations. He says:-"This inquiry taught me that a great saving might be confidently looked for in an unexpected quarter.' That out of 36,000 deaths a year in E. and W., which he attributed to true pulmonary C., 5000 might be saved by increased space and improved ventilation in ships, workshops, and factories; that among men doing the same work under the same roof, the liability to C. was determined by the space; and that this might be narrowed to a point at which men would die as fast as by some contagious malady; so that here, as in Italy, C. might seem to pass from one person to another.

In 1845 the deaths of males in Lond. from C. were 3624, of whom 2599 were above 20 years of age; and of these latter 213 p.c. were between 41 and 50 inclusive, 10'6 p.c. between 51 and 60, and 4·2 p.c. above 60; that is, 36 p.c. in all after 40, and even 15 p.c. after 50. These, it has been remarked, are large proportions, especially if compared with the existing total pop. above those ages, which is, of course, considerably less than at earlier periods of life.

In 1847 Dr. James Begbie, Medical Examiner for the Scottish Widows' Fund, pub. in the Monthly Journ. of Medical Science, an account of causes of death in that so. for the first 30 years of its existence. Subsequent reports have been pub. by the same learned authority; and we shall speak of the general and combined results of these obs. under other dates: especially under 1868. The total deaths up to the close of 1845 had been 642, of which 72, or about 11 p.c., arose from C.

CASES OF PHTHISIS.

In the first 20 years' mort. experience of the Clergy Mut., founded 1829, the deaths from C. bore rather a large proportion to the entire deaths of the So. We are told, in the medical hist. of the So., that the 16 phthisical cases represent a total of 104 years 8 months of life, which only gives an average duration of 61⁄2 years to each pol. "The average of 23 cases is substantially the same. It is not uninteresting to extract these deaths from the general T., and place side by side the duration of the policy and the age at death.

One only of these deaths occurred below 30; 9 between 30 and 40; 5 between 40 and 50; one at the end of the sixth decennial period.

In the year 1850, Dr. Farr tells us, "The deaths from phthisis (consumption) were fewer than usual (46,614), but amounted to more than the deaths from any other disease, and to I in 8, or 13 p.c., of the deaths from all causes. To every 1000 of the pop. 2.6 die every year of C."

In 11 years prior to Oct., 1850, there occurred in the Royal Infirmary of Edin. 852 cases of death, recognized as cases of C., among the male patients. Of these 715 were above 20 years of age. Of the latter, 17.8 p. c. were between 41 and 50, 5'6 p.c. between

Duration of Policy.

Age at death.

Years.

Months.

Years.

Months.

I

30

5

9

36

4522786

51 and 60, and 2.4 p.c. above 60: that is, 25.8 p. c. in all were above 40, and 8 p.c. above 50. The deaths from the same cause in both sexes yielded almost entirely the same results. Of 698 deaths, 611 were above 20; and of these 17 p.c. were between 41 and 50, 5'5 p.c. between 51 and 60; and 2'3 p.c. above 60: that is, 248 in all were above 40, and 7.8 p.c. above 50.

In the 14th R. of Reg.-Gen.-returns for 1851-Dr. Farr tells us :

The respiratory organs were affected by diseases which were fatal in 48,759 cases: 17,294 of bronchitis, 22,001 of pneumonia, and 4896 of asthma. This aggregate constitutes 12.55 in 100 of the specified deaths, or nearly the same proportion of the total deaths as the deaths by diseases of the nervous system. If phthisis (consumption), which, however, is a disease that affects the intestines as well as the lungs, is added to the diseases of this order, it doubles the aggregate: for the deaths from that disease are as numerous as the deaths from all the diseases of the respiratory organs. 25 in 100 deaths are caused by C., and by the diseases of the respiratory organs.

Dr. Guy prepared the following T., showing the deaths from C. in 1000 males and 1000 females of the pop. of E. and W. and of Lond. respectively, living in 1851, at decennial ages:

66

In the 15th R. of Reg.-Gen.-returns of 1852-Dr. Farr says: Consumption is the greatest, the most constant, and the most dreadful of the diseases that afflict mankind. It is the cause of nearly half the deaths that happen between the ages of 15 and 35 years, and during one year was fatal in 50,594 cases!"

In 1853 there was pub. An Investigation of the Deaths in the Standard Life Assu. Co., by Prof. Robert Christison, M.D., etc., etc. The results of this investigation extended over the 5 years ending 1850. Of 293 deaths during that period 29 were referred to C., which the learned author says is, "of all single diseases, the most important in relation to life assu.' "" The deaths from this cause were 10 p.c. of the whole, and "the proportion would evidently have been greater, certainly not under 12 p.c., were it not for the unusual add. to the mort. of the quinquennium from epidemic fever and malignant cholera." On the 29 lives 32 pol. had been granted:

The number of years which the assured lives survived acceptance conjunctly is 159 on the 32 assu. The conjunct expec. of life was 947 years. Hence each individual outlived acceptance 5 years as an average, instead of fully 29-that is, a sixth part only of his expec. of life. Only one attained so much as two-thirds of his expectation term; 2 others outlived a third part, but did not reach one-half of it; and 3 others approached the third of it; but the rest were far behind. It follows that Consumption must be principally fatal at early periods of assurance life; and, accordingly, of the 29 deaths, I fell between 20 and 30, 16 between 30 and 40, 4 between 40 and 50, 6 between 50 and 60, and 2 after 60. Hence 17 deaths took place under 40 years of age, and no fewer than 21 under 50. It is easy to see from these particulars how serious a source of loss Consumption has proved. It is of moment, therefore, to inquire whether the loss can be lessened for the future.

In this view he enters into a detailed scrutiny of the causes of death from C. We can only note a few of the many interesting features he discusses :

In the first place, there can be no doubt that much greater loss has been saved by the vigilance of the directors and their officers in avoiding consumptive risks. From the mort. returns of Lond. in 1845, it appears that 9629 males above 30 years of age died of all diseases, and 1689 of Consumptionthat is 17p.c. Therefore, if it be fair to assume that a great proportion of assurances are effected by males above 30, and also that the prevalence of C. in Lond. corresponds pretty nearly with its general prevalence among persons who effect assu. throughout the U.K. at large, it will follow that the 293 deaths from all causes, during the experience of this Co. for 5 years, would have comprised 51 deaths from C., instead of 29, under a lax system of admission. This points to a material amount of protection effected by the former principles which guided the directors in the selection of lives.

A single death from C. in a proposer's family is not considered of itself a reason for rejection. Nevertheless, the preceding summary shows the necessity of caution even in that case. Four of the deaths present this flaw in the family; and most prob. it existed in several of the others, for in 12 I find either no family hist., or at least no statement of the causes of death of deceased members.

An evident bar to acceptance in cases of the kind is the occurrence of suspicious symptoms of pulmonary disease in the proposer himself earlier in life. This is an objection which can seldom be set aside. One case only presenting it occurs in the list now under consideration. Accepted at 31, when his life seemed to be a fair one, he made another proposal 7 years afterwards, which was accepted, although he had sustained severe inflammatory catarrh two years before.

General delicacy, a state of health described as "tolerably good," or "pretty good," or "not robust," a great liability to "slight common colds," or "rheumatic pains," or "bilious complaints," a pulse habitually frequent-are all suspicious circumstances in one whose family has suffered at all from C. Among these particulars, I would call attention especially to a liability to indigestion as a serious ground of doubt, when even only one member of a family has been cut off by C. It is no unusual obs. in medical practice that C. is preceded by such liability. Either frequent indigestion favours the development of C. in the predisposed, by further impairing a previously doubtful constitution, or simply the two liabilities may be each the direct result of the same constitutional defect. But there can be no doubt of their connexion.

It appears that the Directors of the Standard had, during the latter portion of the period under review, resolved to decline any life where 2 or more of the proposer's immediate family were ascertained to have suffered from Consumption. Dr. Christison says hereon:

Since adopting the general rule,

the directors have repeatedly had to consider whether the rule might be safely departed from in special cases, under favourable conditions. The exp. of the Co. supplies satisfactory information in regard to one of these conditions, viz. the advanced age of the proposer. According to some late notices on medical statistics of L. assu., the notion long generally entertained that, subsequent to adult age, the proportion of deaths from Consumption diminishes with the advance of life, and becomes very small after 45 or 50, is not borne out by facts, and is therefore an unsafe principle to follow, in regulating the acceptance of proposals of assu.

This position the learned author proceeds to combat, and he quotes the statistics we have already given regarding the deaths of males in Lond. from C. in 1845 and also of

:

the patients in the Royal Infirmary of Edin. down to 1850, in support of this position. He continues:

I am not acquainted with any pub. data which will supply available information on this point. But the experience of the Standard L. Assu. Co. during the last 5 years-too limited, it is true, to yield absolute results-is satisfactory so far as it goes. Thus among lives accepted under the age of 40, 104 have died of all diseases, and 19 of these from Consumption-that is, 18 27 p.c. But among lives accepted after 40, of which 187 have been cut off by diseases of all kinds, only to have been cut off by C., or 5'2 p.c. Of lives accepted after 50, 122 have died, and only 3 of C., or 2'43 p.c. Of lives assu. above 55, 85 have died, and only 1 of C., or 12 p.c. And among lives accepted after 60, 53 have died, without a single death from C. These remarkable results certainly go to show that whatever may be the frequency of C. in the general pop, after middle life, it becomes progressively a less frequent proportional cause of death among lives accepted for assu. at a later and later period of life that the risk from it is not great after 40, very small after 50, and quite insignificant after 55— that, therefore, great and increasing facilities must exist for escaping consumptive risks proposed after middle age-and that greater stringency than is now observed by the directors in accepting lives after that period of life is scarcely required so far as the fear of C. is concerned.

Reviewing the occupations of those who had died, he did not consider they pointed to any "useful information for an assu. co." Among the sedentary trades and professions there were 5 shopkeepers, a tailor, a mercantile clerk, an engraver, a law agent, an accountant, a barrister, and a director of Chancery; among those of average activity, a broker, a merchant, a wine merchant, and a flax merchant; among the active occupations, a canal overseer, a bank porter, a surgeon, a farmer, an innkeeper, 5 country gentlemen, and 3 ladies.

In 1853, also, Dr. Begbie pub. in the Monthly Fourn. of Medical Science, a second Report on the causes of death among the assured in the Scottish Widows' Fund, during the period 1846-52 inclusive. Out of 690 deaths in the septennium, 42 only, or about 6 p.c. of the total mort., were from C. "A small proportion, certainly (says the Doctor), considering that Consumption, according to the T. of the Reg.-Gen., annually accounts for 20 per cent. of the total deaths of England and Wales, or nearly 4 annually out of 1000 living." Again:

This gratifying result in the experience of the so. is no doubt due to the care and caution exercised by the board in the selection of lives as far as possible free from consumptive taint; and chiefly to the rejection, as ineligible, of all the younger applicants for assu. in whose immediate family tubercular disease has unequivocally manifested itself. The effect of this procedure is clearly shown by a reference to the tabular view of the deaths by decennial periods in the two reports. In the former, exhibiting the experience of the so. during the earlier years, when the same minute attention was not paid to family hist., we find 35 deaths recorded between 30 and 40-the most fatal period of C. in L. assu. bus. in the latter we find only 12, out of a larger general mort., from the same cause at the same period. It may possibly occur to some that this marked difference may be accounted for in another manner, and that under the head of disease of the lungs, or under that of bronchitis, or other pulmonary affection, many of the deaths which ought to have been returned as C. ought to have been included. In reply to this, it can be stated that the number of deaths from disease of the lungs, not of tubercular origin, is actually smaller on this than on the former occasion; and that though there is in our present T. a considerable increase of death under the head of bronchitis (which might have been expected from the greater prevalence of the disease of late years), still the deaths during the consumptive period are few in number-7 only before 50, and 29 after that age, 15 being upwards of 70-a fact which goes far to prove that these were not cases of C., and could not have been borrowed to diminish its mort.

In the 16th R. of Reg.-Gen.-returns for 1853-Dr. Farr tells us: "Consumption is more fatal than any other single disease in England; and 54,918 deaths are referred to that head. The deaths from this cause were 46,614 in 1850, and have since that year increased progressively without any very evident reason.

The lowest number of deaths from C. for a million of inhabitants of Lond. for any one of the 15 years from 1840 to 1854 inclusive was 2645, and the highest 3941; and the fluctuation is very slight. The figures in 3 consecutive years were as follows: 1849, 2777; 1850, 2645; 1851, 2970. "If then (says Dr. Guy) any one were to assert that this disease is contagious, which is tantamount to saying that it may be epidemic, the figures I have quoted would in themselves furnish an answer in the negative. They are suggestive of a domestic disease, influenced, as is bronchitis, by the seasons and the weather."-Public Health, 1870.

In the 17th R. of Reg.-Gen.-returns for 1854-Dr. Farr says:

There is no ground for belief that Consumption is more fatal in England than it is on the Continent; or that it can be at all characterized as peculiarly an English disease; still it is a disease which deserves to be carefully studied in England, with a view both to its prevention and cure. Within the last eight years the disease appears to have declined to some extent; for the deaths by phthisis were 53,317 in 1847, and 51,284 in 1854. Some may be inclined to see in this evidence of the efficacy of the modern modes of treatment; but it will be well to wait before coming to a definite conclusion for more obs. And the increase of deaths by bronchitis from 16,499 to 20,062 in the same period, with the gradual diffusion of diagnostic skill, must be taken into account.

Mr. Haviland, in his Climate, Weather, and Disease, 1855, has an interesting chap. on the subject of Phthisis :

In England we learn from the statistical returns that the spring is the most fatal to C. patients, whether male or female; but with regard to the other seasons there is considerable variability. For instance, suppose we take the seasons of 1838 in the order of their fatality to males, they would stand thus: spring, 1137; winter, 1048; summer, 968; autumn, 904. To females-spring, 972; summer, 937; winter, 896; autumn, 825. Then again, although the spring invariably takes the lead, the other seasons change places with each other from year to year; and what is remarkable, this inconsistency does not seem to be dependent upon temperature, as we shall presently see. In the returns for 1853, 6

VOL. II.