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ON THE LAWS OF MORTALITY AND SICKNESS OF THE LABOURING CLASSES OF ENGLAND.
329 about five-eighths of an inch in diameter, and was composed of uric acid and urate of ammonia, the former constituting the nucleus, with a slight incrustation of phosphates upon its surface. 22ncl.-Says she has nothing whatever to complain of.Runs about the ward,and parses urine in a natural manner; urine
in
some
of these
cases.
A stone which
can
be detected without
difficulty may be very readily seized and crushed, with nearly if not quite as little disturbance to the bladder as that occasioned by the efforts commonly employed in dilating the neck, in grasping the calculus with the forceps, and in forcibly extracting it through the passage. In neither case does there appear to be any objection to the use of chloroform for the purpose of subhe’tlthy. 2.5th.-Perfectly free from any symptom, except a slight duing the pain of the operation. When there is reason to believe thitthe nucleus of the stone consists of some foreign degree of incontinence during sleep ; none at any other time. September 23rd.-Quite well. For two or three nights after body which can neither be crushed nor removed by means of last report she did not wholly retain her urine, but since that the lithotrite, other means must be resorted to, and these will time she has been perfectly free from that or any other symp- generally be determined by the nature of the individual case. Neither can any absolute rule be laid down as to the method of tom of urinary complaint. The foregoing case suggests one or two points of remark in dealing with a stone in relation to its size. Probably there relation to the practical management of calculus in the female are not many calculi of purely natural origin sufficiently large to render incisions absolutely necessary, more especially as the bladder, which appear to me to be important:The methods which have commonly been adopted for the larger formations are more commonly phosphatic in their comextraction of stone in the cases of adult females (and our position, and consequently extremely friable, often possessing a recorded experience of any other age, as before mentioned, is consistency little more firm than that of mortar. Nevertheless, exceedingly small) are-dilatation of the urethra and neck of there are doubtless a few which are not amenable to the grasp the bladder alone; dilatation in combination with incisions ; of the lithotrite. and incisions of various kinds, usually commencing in the On the whole, then, I am anxious that we should recognise urethra, and adequate to permit the passage of the stone. fully the advantages of a method which promises to accomplish Against all of these the very serious objection of a resultingI the end in view without entailing on the patient the subsequent incontinence of urine is confessedly held to lie. There is no evil of urinary incontinence. If lithotrity is admitted to be an question at all amongst practical surgeons as to the occurrence operation of superior efficiency and safety in many cases of of this infirmity in a certain, and probably not very small, calculus in the male subject, liable as it is to become the proportion of cases so operated on. Hence it has been proposed occasion of serious contingencies, arising from his sexual forto substitute the employment of the lithotrite for these pro- mation, it must surely be, d fortiori, a more desirable procedures, although, judging from published reports, it does not ceeding than the operation by the knife, or three-bladed seem by any means to be very commonly resorted to. At the dilator, in a very large proportion of those cases which are same time, the only objection urged against it, as far as I have presented in the female. been able to learn, is a degree of difficulty, arising from the Wimpole-street, Cavendish-square, 1851. alleged inability on the part of the bladder, on account of the shortness of the urethra, to retain a quantity of fluid sufficient for the purpose of the lithotritist. The objection, if valid, ON THE certainly presents an obstacle to the successful issue of the of operation in one point view; but on the other hand, it should LAWS OF MORTALITY AND SICKNESS OF not be forgotten that for obvious reasons the manipulation of THE LABOURING CLASSES OF ENGLAND.
more easy iu the female than in the male bladder. Owing to the shortness and extensibility of the urethra in the former case, a far greater freedom of motion is permitted to the instrument, both in regard of the direction of which the axis of the shaft is capable, and in the general character of the movements themselves, which are not retarded or modified by close contact and friction with the walls of a long urethral canal, as in the male. Consequently a smaller expenditure of time, as a rule, will be necessary for the performance of the operation under these more favourable conditions. But further, I conceive that it would be by no means impossible to exercise a degree of pressure around the external meatus of the urethra, either by the fingers of the left hand or by some other means, which should be sufficient to prevent the Indeed, whenever an expulsive effort was escape of fluid. made by my patient, as did occasionally happen, I found no difficulty in retaining the fluid, by applying the left thumb and finger to the urethral orifice, and compressing it temporarily around the shaft of the lithotrite. But this occurrence in her case was, I believe, due to the fact that I had employed rather more distending force, by means of the sponge tent, than was really necessary. The introduction of one, instead of two tents, would probably have been sufficient to permit the introduction cf the lithotrite with ease, but having had no previous experience of their effect upon a child’s urethra, it was not possible to foresee this. Of course, in operating for the ordinary cases of adults, dilatation of the urethra would be unnecessary as a preliminary step; on the contrary, it is not improbable that the objection just alluded to as lying against the use of
the lithotrite is
BY THOMAS ROWE
EDMONDS, ESQ.,
ACTUARY TO THE LEGAL AND GENERAL LIFE ASSURANCE SOCIETY.
THE mortality, according to age, of the general population of England in all localities, was first satisfactorily determined for the period of seven years ending with the year 1844. The observations and results were published by the Registrar-General in the year 1849; and in the following year I was allowed the opportunity of exhibiting in THE LANCET (vol. i. 1850, pp. 297, 330) the principal results in new combinations, with my conclusions therefrom. The knowledge thus ’obtained of the mortality of the general population (with distinction of town from country districts) is valuable for testing the correctness of independent observations made on the mortality of classes of the labouring population, such as are contained in ’’ Friendly Societies," whose mortality and sickness it is now proposed to
discuss. Within the last few years a very great addition has been made to the previously existing small stock of observations on the mortality and sickness experienced by members of Friendly Societies. In THE LANCET of April, 1839, (vol. i., p. 185,) was published an observation made by me on the members of a metropolitan benefit society, in which observation was comprehended the deaths and sickness, distributed according to age over 30,000 years of life. At that time there existed only two similar observations; one of these was contained in the report of the Highland Society, and embraced 85,000 years of life: crushing instruments might be overcome, if not entirely, at the other was made by Mr. Ansell, and embraced 25,000 years least to a considerable extent, by employing them of larger of life. Since the time mentioned, we have had large additions size than those which are adapted to the male; in short, by made to this department of knowledge from three sources, to taking care always to use such as will adequately fill or slightly the extent of two and a half-millions of years of life observed. The first of these additions is due to Mr. Neison, and embraces distend the urethra of the patient. I am inclined to think that there are not many cases of more than one million years of life observed during the five .calculus in the female to which the lithotrite would not be years ending with 1840. The next addition proceeded from a preferable to any operation by dilatation or incision. Its ap- very large friendly society, called the " Manchester Unity of plicability to children has been shown by the case just reported, Odd Fellows," and embraced about 600,000 years of life, the first, I believe, on record, in which it has been successfully observed during the three years ending with 1848; this obser- resorted to, if not the first in which it has been employed. In vation having been made by the corresponding-secretary of - adults a certain amount of irritability, or mucous discharge from that society, Mr. Ratcliffe. The third and last addition to the bladder, should not necessarily contra-indicate an attempt to this department of knowledge has been made by authority of extract the calculus by crushing, because of the peculiar fa- the British Government, the results having been published cilities, already referred to, which the female passages offer to within the last half-year. Mr. Finlaison, junr., has been emthe operator. I cannot but think that the unhealthy condition ployed to make this observation, which extends over the five nd embraces about 800,000 years of so described is apt to be regarded with unnecessary apprehension years ending with 1850
I
330 This last observation, like that of Mr. Neison, is founded by Mr. 1BTeison and Mr. Finlaison as unavailable, through official returns, which all registered Friendly Societies are obvious defects arising from negligence, wilful or otherwise. residue of the returns containing no required by Act of Parliament to make once every five years. As regards the The three observations on Friendly Societies made respect- obvious defects, the results which they indicate cannot be ively by Mr. Neison, Mr. Ratcliffe, and Mr. Finlaison, jun., yield entitled to much confidence, unless they are consistent with each its specific law of mortality and sickness. The three laws one another, and corroborated by other observations founded of mortality obtained are in accordance with the general law, upon facts better attested. It is fortunate for thepublic that which in all other observations regulates, in adult life, the there exists such an extensive and well-authenticated observaincrease of mortality according to age. The general law is tion as that of MR. Ratcliffe, with which can be compared the this-that the rate of mortality increases, from puberty to the observations of Mr. Neison and Mr. Finlaison. From his posiage of about 53 years, at the rate of 3 per cent. (’02991) for tion in connexion with the " Manchester Unity," we have, in every advance of one year in age; and after that age, increases Mr. Ratcliffe, responsibility for facts as well as conclusions; at the rate of 8 per cent. (’07969) for each year of age until the whilst Mr. Neison and Mr. Finlaison are responsible for arithend of life. There exist innumerable specific laws of mortality, metical conclusions only, founded upon alleged facts, whose appropriate to particular masses of population, but all these correctness they had no power of testing. There is another way of treating the discrepancies mentioned, specific laws differ from each other only in two characteristic the particular age at which which is, to assume that the statements of all three observers points,-one characteristic being the period of " florescence " terminates and the period of are of equal weight, and that the true statement is the mean "senescence" begins, and the other being the absolute mor- of all three statements. This plan of proceeding is found highly successful, as will be seen on inspection of Table III. tality at any specified age. Previously to the publication of the three observations now It will there be perceived that the results of the combined under consideration, there existed grounds for believing that, observations can be closely represented by assuming the age of in adult life, the increase according to age in the amount or 48 years to be the point of separation of the period of " floresduration of sickness suffered in each year of life was regulated cence" from that of "senescence," for mortality as well by the same two numbers which regulate the increase of mor- as for sickness. Out of twenty-four points of comparison of tality in the periods of "florescence"" and " senescence" re- sickness and mortality, at decennial intervals of age, there spectively. In the year 1832, I published Sickness Tables, will be seen 23 points of agreement, whilst the only point of founded upon such unity of law. The present three observa- divergence (which is in " city" mortality between the ages of tions confirm the view then acted upon, and may be said to 65 and 65 years) is a specialty hereafter explained, in which establish the fact of identity between the constants of mortality all three observations agree in departing from the theoretical and the constants of sickness. There is, however, a remark- numbers. In the " Manchester Unity," at ages above 53 years, the able discrepancy between the three observations as to the particular age at which the period of florescence is divided mortality (shown in Table 1.) is 15 per cent. greater than the This. from the period of senescence. In the three observations on mortality of the total male population of England. mortality, and the three observations on sickness, the limiting higher relative mortality is such as mighthave been anticipated age is either at 53 years or at 46 years. According to Mr. from this society, containing less than the average proportion Finlaison’s observation, the limit dividing the two periods is at of members resident in rural districts, and more than thethe age of 53 years, both for mortality and sickness; accord- average proportion of members resident in town and city dising to Mr. Ratcliffe’s observation, the line of separation is at tricts. According, however, to the observations of Mr. Neison the age of 46 years, both for mortality and sickness; but, and Mr. Finlaison, at ages above 53 years the mortality in. according to Mr. Neison’s observation, the limits of division Friendly Societies (containing the due proportion of rural for mortality and sickness are different, that for mortality town and city members) is 20 per cent. less than the mortality being at 53 years, and that for sickness being at 46 years of of the total male population of England. This is an unexpected age. This difference of seven years in the position of the limit result, which is open to doubt, more especially from the fact dividing the period of florescence from that of senescence occa- that there is a discrepancy in the statements of sickness at the sions a difference of 40 per cent. in the relative mortality or same ages, respectively made by Mr. Neison and Mr. Finlaison, relative sickness at ages above 53 years compared with ages which discrepancy, when converted into its proportional amount below 46 years. For example, assuming (as is not far from of deaths, would be just sufficient to make up the suspected the truth) the mortality and sickness stated by all three deficiency of 20 per cent. The sickness suffered, at ages exobservers to be equal at ages below 46 years, it will ensue, from ceeding 53 years, is 40 per cent. greater accordingto Mr. the difference in the position of the limitsjust mentioned, that Neison than it was according to Mr. Finlaison. The alleged at any specified’age above 53 years, the mortality observed by mortality being equal in the two cases, it would follow that Mr. Ratcliffe is 40 per cent. greater than the mortality observed the sickness of a population can be greatly increased without by Mr. Neison and Mr. Finlaison, and that the sickness the deaths being simultaneously increased-a conclusion opposed observed by Mr. Ratcliffe is equal to that observed by Mr. to all experience. It is nearly certain that the extra 40 per Neison, but 40 per cent. greater than the sickness observed by cent. of sickness observed by Mr. Neison represents the lifeMr. Finlaison. time of all superannuated members, which life-time is altogether The discrepanciesjust mentioned are of such magnitude as excluded from his observation by Mr. Finlaison. If one-half to detract considerably from the value of the results of all three of all superannuation time be true sickness, Mr. Nelson’s obserobservations at any age exceeding 53 years. In order to vation, as compared with Mr. Finlaison’s, will contain an extract a useful result from the apparently contradictory obser- extra 20 per cent. of true sickness, without any extra per vations, it is necessary to devise some principle of reconciliation centage of deaths. If, however, an addition to the deaths (for which will explain the inconsistencies. Such a principle is omissions in the returns) be made proportionate to the extra found in the assumption, that one particular class of facts has per centage of the true sickness observed by Mr. Neison, the been treated in three different ways by the three observers, resulting mortalities of all three observations will be in harmony whether designedly or not. The class referred to, is that of with each other, and conformable to expectation. It is also to be remarked, that if the mortality of members of members retired on the Superannuation or Sick-Pension List. It appears highly probable that Mr. Ratcliffe, in his obser- Friendly Societies is influenced by " selection," as is probably vation, has treated all on this list as sick, and added their the fact, there will be additional reason for doubting the truth deaths to the general amount of deaths. On the other hand, of the statement in question; for the statement of Mr. Neison it appears highly probable that Mr. Finlaison has treated and Mr. Finlaison is, that in Friendly Societies the mortality nearly the whole of this class as pensioners in good health, and in the period of florescence, as well as in the period of senescence, removed them from observation, whether as regards sickness is 20 per cent. less than that of the total male population of * To reconcile the third observation with the two England of the same age. The former part of this statement is or mortality. just mentioned, it is necessary to assume that Mr. Neison has probably true; but the latter part is inconsistent with the designedly reckoned all superannuation time as sick time, and former part, and the known ordinary effects of selection of that he has unavoidably omitted the deaths of the same class good lives from the general mass. In Friendly Societies the of members, because they were omitted in the returns from great majority of members are admitted below the age of 35years, so that the effect of selection (being limited to about 15 Friendly Societies submitted to him. It may be useful here to remark, that Friendly Societies in years from admission) does not extend to the period of age exgeneral make these returns very reluctantly, and are careless ceeding 53 years. Assuming the reduction of 20 per cent. in as to their correctness or completeness. A very large propor- the mortality during the period of florescence to be caused by tion of the total returns from these societies has been rejected " selection," there ought to be no difference, in the period of * The interpretation here suggested of "Sickness" has been conui-med by senescence, between the mortality of members of Friendly Mr. Finlaison in the second part of his Official Report since published. Societies and the mortality of the classes from which the mem-
life. on
adopted
331 TABLE I.
SHOWING, for Quinque7z?zial Intervals of Age, the Rates of Mortality and Sickness experienced by Members of Friendly Societies, according to three several observations; with which are compared the Results from flve Theoretical Tables, one of which. represents the Annual Mortality of the Total Male Population of England, according to the latest Obserzations.
TABLE II.
SHOWING, for Decennial hzterzals of Age, the Rates of Mortality observed amongst the Members of Friendly Societies resident in Rural, Town, and City Districts ; with which are compared the Mortality of the whole and of parts of the Male Population of England.
TABLE
II.-(Continued.)
332 bers have been selected. It may be useful here to remark, that four healthiest Registrar’s divisions, which comprehend onea reduction through selection of 20 per cent. in the mortality third part of the total population of England. It may also be for the period orfloieseence is equivalent in appearance to a seen, on comparing together the first and last columns of Table retrogression of four years in the limit at which the period of II., that the least mortality observed between the ages of 35 senescence commences. If, as is the fact, this limit in the total and 65 years, is one-third part only of the greatest mortality male population of England is at the age of 53 years, the corre- observed in England at the same interval of age,-the least sponding position of this limit in Friendly Societies affected by mortality being that of agricultural labourers, observed by Mr. . selection in the degree mentioned would be at the age of 49 Neison. The true range of mortality is, however, considerably years. greater than the observed range of 1 to 3. For it is nearly In the three several observations, the members are dis- certain that, in all towns of great magnitude, there exist twotributed into three classes, according to their residence in large classes, occupying the extremes of good and bad health,. "Rural," "Town," or "City" Districts; and the rates of one of which suffers a mortality one-third less, and the other a. mortality and sickness at different ages are separately stated mortality one-third greater, than the average mortality of the for each class. Thegeneral result of all the observations, is, whole population of the town. Whence we are justified in that the mortality of the town is 25 per cent. greater than the concluding that, in the least healthy class of large towns of mortality of the rural districts; and the mortality of the city England, there exists a considerable portion of the population 25 per cant. greater than that of the town districts. In Mr. suffering a mortality four times as great as that which has been Ratcliff’s observation, the mortality of the aggregate popula- observed to exist in a class formed by selection from agricultural tion is greater than the mortality of his town population; but labourers. in Mr. Neison’s and Mr. Finlaison’s observations, the mortality All three observers, in their statements of " city" mortality of the aggregate is considerably less than that of their town at ages above 55 years, agree in presenting a similar anomaly. population. These variations are accidental, and arise from the According to all three statements, city mortality is considerably absence of any settled principle regulating the distribution of greater than town mortality at all ages under 55 years, whilst the members into the three classes. Mr. Ratcliffe has dis- at ages above 55 years, the relation is reversed, though in a less tributed his numbers equally amongst the three classes of rural, degree. On inspection, however, of the three last columns of town, and cityresidents; and has formed his rural class from Table II., exhibiting the rates of mortality according to age of residents of townships or parishes whose total population is less three classes of the largest towns of England, arranged accordthan 5000 of all ages and both sexes. Mr. Neison (who has ing to their degrees of healthiness, there will be found no such been followed by Mr. Finlaison) has distributed his numbers, anomalous appearance. It will there be seen, that at ages above 55 years, the unhealthiness of either class of towns is as so that the rural, town, and city residents are in the proportions (nearly) of 4, 2, and 1 respectively; and Mr. Finlaison (with strongly indicated by increased mortality, as it is at ages below Mr. Neison probably) has formed his rural class from residents 55 years. There is thus no countenance afforded to the paradox in townships or parishes whose total population is less than presented by Messrs. Neison, Finlaison, and Ratcliffe, that as 3000. Instead of these classifications, without any apparent the unhealthiness of large towns increased, the mortality of the principle, it appears to me that the preferable course would population at ages above 55 years, proportionally diminished. The anomalous appearance in question is probably attributablehave been, to comprehend in the "town" class about one-half of the total numbers, and so to haveadjusted the limits of to the mixing together in one observation of classes resident in magnitude of the places designated as " towns" as to render cities, whose mortalities are widely different. All three obthe mortality of the class resident in towns coincident in servers have formed their " city’’class out of residents in large amount with the mortality of the aggregate population observed. towns whose mortalities, for their total populations, differed Having thus fixed the intermediate "town class," the two from one another as much as 50 per cent. as already stated. extremes of rural and city classes would be simultaneously In the case of such combination of two classes differing greatly fixed. I acted upon the opinion now expressed, in forming a in mortality, the result exhibited at the early ages will be the system of Theoretical Life Tables, which I published twenty- mean of the rates of mortality for the healthy and the untwo years ago. I divided the population into three classes, healthy parts of the population. At the higher ages, however, of mortality the designations, the rate of mortality belonging to the healthier portion of the and gave to the three degrees " Mean," and " City." The names of the two population will alone appear, by reason of the previous extincextreme classes were indicative of extreme rarity or extreme tion by death of the portion subject to the higher of the two density of population; the intermediate term was used to rates of mortality. The error arising from defective classificaindicate, either a population of mean density, or the aggregate tion is much greater in city than it is in town or rural populapopulation independent of density. tions ; but it can never be altogether avoided. In deducing the Both Mr. Neison and Mr. Finlaison have, in their observations, mortality of the total population of England, a defect of the made an important subdivision of the residents of rural districts nature alluded to must exist through the difficulty of forming into two classes, whose mortalities differ from one another in classes of people whose mortalities are nearly on an equality. as great a degree as the mortality of town districts differs from The mortality of a combination of correctly constituted classes that of rural districts in general. One of these two subdivisions will never increase according to age, so rapidly as the mortality is a class consisting chiefly of agricultural labourers, the other of the classes observed separately would increase. In the total subdivision is a class consisting of the residue of all residents male population of England, the line which apparently divides in rural districts. According to both observations, the mor- the period of florescence from that of senescence is at the age tality of agricultural labourers is less than the mortality of the of 53 years. It is not improbable that the true line of division residue of the rural class in the proportion of 4 to 5, which is for the separate classes is at 51 years of age, the difference of the relation of rural to town, and of town to city mortality. two years being the effect of the combination of various classes. Attempts have been made to subdivide the " town" and the whose amalgamation is necessarily imperfect. "city" members of Friendly Societies into classes suffering (To be continued.) similarly well marked different degrees of mortality, but, apparently, hitherto without success. This failure of the investigation, so far as regards town and city districts, affords, however, no ground for doubting, what is evidently the fact, A CASE OF GREAT HYPERTROPHY OF THE that the range of mortality between classes occupying the exHEART. tremes of good health and bad health is much greater in city BY WILLIAM SEDGWICK, ESQ., M.R.C.S. & L.S.A., than it is in rural districts. LATE SURGEON TO THE NORTH DISTRICT OF ST. MARYLEBONE. The mortality experienced by members of Friendly Societies " resident in City" Districts, according to the observations of THE following case has been selected for publication from a. Messrs. Neison, Finlaison, and Ratcliffe, approaches nearly to the mortality of the male population of large towns of England large number of cases of heart disease that have come under of the healthiest class, such as York, Sunderland, Plymouth, my notice, as a striking instance of the great size this organ (See Table II., hereunto annexed, and THE may attain at a comparatively early age. It is probably, for Brighton, &c. LANCET, vol. i. 1850, p. 330.) The result has been obtained the age of the patient, the largest heart of which there is any by combining together the members of Friendly Societies definite record. The circumstances attending the death of the resident in large towns, of the first, second, and third degrees patient will be found to possess peculiar interest, as tending toof health. Liverpool and Manchester represent large towns prove that the heart, " by the simple vehemence of its action,’ or cities of the third or lowest degree of health in England; does not kill, the immediate cause of death in this case being the mortality of these large towns being 50 per cent. greater at inflammatory softening of the brain, passing into suppuration, most ages than that of the healthiest class of large towns just which is not an unfrequent effect of dilated hypertrophy of the mentioned, and 100 per cent. greater than the mortality of the left side of the heart.
Village,"
in
some
of these
cases.
A stone which
can
be detected without
difficulty may be very readily seized and crushed, with nearly if not quite as little disturbance to the bladder as that occasioned by the efforts commonly employed in dilating the neck, in grasping the calculus with the forceps, and in forcibly extracting it through the passage. In neither case does there appear to be any objection to the use of chloroform for the purpose of subhe’tlthy. 2.5th.-Perfectly free from any symptom, except a slight duing the pain of the operation. When there is reason to believe thitthe nucleus of the stone consists of some foreign degree of incontinence during sleep ; none at any other time. September 23rd.-Quite well. For two or three nights after body which can neither be crushed nor removed by means of last report she did not wholly retain her urine, but since that the lithotrite, other means must be resorted to, and these will time she has been perfectly free from that or any other symp- generally be determined by the nature of the individual case. Neither can any absolute rule be laid down as to the method of tom of urinary complaint. The foregoing case suggests one or two points of remark in dealing with a stone in relation to its size. Probably there relation to the practical management of calculus in the female are not many calculi of purely natural origin sufficiently large to render incisions absolutely necessary, more especially as the bladder, which appear to me to be important:The methods which have commonly been adopted for the larger formations are more commonly phosphatic in their comextraction of stone in the cases of adult females (and our position, and consequently extremely friable, often possessing a recorded experience of any other age, as before mentioned, is consistency little more firm than that of mortar. Nevertheless, exceedingly small) are-dilatation of the urethra and neck of there are doubtless a few which are not amenable to the grasp the bladder alone; dilatation in combination with incisions ; of the lithotrite. and incisions of various kinds, usually commencing in the On the whole, then, I am anxious that we should recognise urethra, and adequate to permit the passage of the stone. fully the advantages of a method which promises to accomplish Against all of these the very serious objection of a resultingI the end in view without entailing on the patient the subsequent incontinence of urine is confessedly held to lie. There is no evil of urinary incontinence. If lithotrity is admitted to be an question at all amongst practical surgeons as to the occurrence operation of superior efficiency and safety in many cases of of this infirmity in a certain, and probably not very small, calculus in the male subject, liable as it is to become the proportion of cases so operated on. Hence it has been proposed occasion of serious contingencies, arising from his sexual forto substitute the employment of the lithotrite for these pro- mation, it must surely be, d fortiori, a more desirable procedures, although, judging from published reports, it does not ceeding than the operation by the knife, or three-bladed seem by any means to be very commonly resorted to. At the dilator, in a very large proportion of those cases which are same time, the only objection urged against it, as far as I have presented in the female. been able to learn, is a degree of difficulty, arising from the Wimpole-street, Cavendish-square, 1851. alleged inability on the part of the bladder, on account of the shortness of the urethra, to retain a quantity of fluid sufficient for the purpose of the lithotritist. The objection, if valid, ON THE certainly presents an obstacle to the successful issue of the of operation in one point view; but on the other hand, it should LAWS OF MORTALITY AND SICKNESS OF not be forgotten that for obvious reasons the manipulation of THE LABOURING CLASSES OF ENGLAND.
more easy iu the female than in the male bladder. Owing to the shortness and extensibility of the urethra in the former case, a far greater freedom of motion is permitted to the instrument, both in regard of the direction of which the axis of the shaft is capable, and in the general character of the movements themselves, which are not retarded or modified by close contact and friction with the walls of a long urethral canal, as in the male. Consequently a smaller expenditure of time, as a rule, will be necessary for the performance of the operation under these more favourable conditions. But further, I conceive that it would be by no means impossible to exercise a degree of pressure around the external meatus of the urethra, either by the fingers of the left hand or by some other means, which should be sufficient to prevent the Indeed, whenever an expulsive effort was escape of fluid. made by my patient, as did occasionally happen, I found no difficulty in retaining the fluid, by applying the left thumb and finger to the urethral orifice, and compressing it temporarily around the shaft of the lithotrite. But this occurrence in her case was, I believe, due to the fact that I had employed rather more distending force, by means of the sponge tent, than was really necessary. The introduction of one, instead of two tents, would probably have been sufficient to permit the introduction cf the lithotrite with ease, but having had no previous experience of their effect upon a child’s urethra, it was not possible to foresee this. Of course, in operating for the ordinary cases of adults, dilatation of the urethra would be unnecessary as a preliminary step; on the contrary, it is not improbable that the objection just alluded to as lying against the use of
the lithotrite is
BY THOMAS ROWE
EDMONDS, ESQ.,
ACTUARY TO THE LEGAL AND GENERAL LIFE ASSURANCE SOCIETY.
THE mortality, according to age, of the general population of England in all localities, was first satisfactorily determined for the period of seven years ending with the year 1844. The observations and results were published by the Registrar-General in the year 1849; and in the following year I was allowed the opportunity of exhibiting in THE LANCET (vol. i. 1850, pp. 297, 330) the principal results in new combinations, with my conclusions therefrom. The knowledge thus ’obtained of the mortality of the general population (with distinction of town from country districts) is valuable for testing the correctness of independent observations made on the mortality of classes of the labouring population, such as are contained in ’’ Friendly Societies," whose mortality and sickness it is now proposed to
discuss. Within the last few years a very great addition has been made to the previously existing small stock of observations on the mortality and sickness experienced by members of Friendly Societies. In THE LANCET of April, 1839, (vol. i., p. 185,) was published an observation made by me on the members of a metropolitan benefit society, in which observation was comprehended the deaths and sickness, distributed according to age over 30,000 years of life. At that time there existed only two similar observations; one of these was contained in the report of the Highland Society, and embraced 85,000 years of life: crushing instruments might be overcome, if not entirely, at the other was made by Mr. Ansell, and embraced 25,000 years least to a considerable extent, by employing them of larger of life. Since the time mentioned, we have had large additions size than those which are adapted to the male; in short, by made to this department of knowledge from three sources, to taking care always to use such as will adequately fill or slightly the extent of two and a half-millions of years of life observed. The first of these additions is due to Mr. Neison, and embraces distend the urethra of the patient. I am inclined to think that there are not many cases of more than one million years of life observed during the five .calculus in the female to which the lithotrite would not be years ending with 1840. The next addition proceeded from a preferable to any operation by dilatation or incision. Its ap- very large friendly society, called the " Manchester Unity of plicability to children has been shown by the case just reported, Odd Fellows," and embraced about 600,000 years of life, the first, I believe, on record, in which it has been successfully observed during the three years ending with 1848; this obser- resorted to, if not the first in which it has been employed. In vation having been made by the corresponding-secretary of - adults a certain amount of irritability, or mucous discharge from that society, Mr. Ratcliffe. The third and last addition to the bladder, should not necessarily contra-indicate an attempt to this department of knowledge has been made by authority of extract the calculus by crushing, because of the peculiar fa- the British Government, the results having been published cilities, already referred to, which the female passages offer to within the last half-year. Mr. Finlaison, junr., has been emthe operator. I cannot but think that the unhealthy condition ployed to make this observation, which extends over the five nd embraces about 800,000 years of so described is apt to be regarded with unnecessary apprehension years ending with 1850
I
330 This last observation, like that of Mr. Neison, is founded by Mr. 1BTeison and Mr. Finlaison as unavailable, through official returns, which all registered Friendly Societies are obvious defects arising from negligence, wilful or otherwise. residue of the returns containing no required by Act of Parliament to make once every five years. As regards the The three observations on Friendly Societies made respect- obvious defects, the results which they indicate cannot be ively by Mr. Neison, Mr. Ratcliffe, and Mr. Finlaison, jun., yield entitled to much confidence, unless they are consistent with each its specific law of mortality and sickness. The three laws one another, and corroborated by other observations founded of mortality obtained are in accordance with the general law, upon facts better attested. It is fortunate for thepublic that which in all other observations regulates, in adult life, the there exists such an extensive and well-authenticated observaincrease of mortality according to age. The general law is tion as that of MR. Ratcliffe, with which can be compared the this-that the rate of mortality increases, from puberty to the observations of Mr. Neison and Mr. Finlaison. From his posiage of about 53 years, at the rate of 3 per cent. (’02991) for tion in connexion with the " Manchester Unity," we have, in every advance of one year in age; and after that age, increases Mr. Ratcliffe, responsibility for facts as well as conclusions; at the rate of 8 per cent. (’07969) for each year of age until the whilst Mr. Neison and Mr. Finlaison are responsible for arithend of life. There exist innumerable specific laws of mortality, metical conclusions only, founded upon alleged facts, whose appropriate to particular masses of population, but all these correctness they had no power of testing. There is another way of treating the discrepancies mentioned, specific laws differ from each other only in two characteristic the particular age at which which is, to assume that the statements of all three observers points,-one characteristic being the period of " florescence " terminates and the period of are of equal weight, and that the true statement is the mean "senescence" begins, and the other being the absolute mor- of all three statements. This plan of proceeding is found highly successful, as will be seen on inspection of Table III. tality at any specified age. Previously to the publication of the three observations now It will there be perceived that the results of the combined under consideration, there existed grounds for believing that, observations can be closely represented by assuming the age of in adult life, the increase according to age in the amount or 48 years to be the point of separation of the period of " floresduration of sickness suffered in each year of life was regulated cence" from that of "senescence," for mortality as well by the same two numbers which regulate the increase of mor- as for sickness. Out of twenty-four points of comparison of tality in the periods of "florescence"" and " senescence" re- sickness and mortality, at decennial intervals of age, there spectively. In the year 1832, I published Sickness Tables, will be seen 23 points of agreement, whilst the only point of founded upon such unity of law. The present three observa- divergence (which is in " city" mortality between the ages of tions confirm the view then acted upon, and may be said to 65 and 65 years) is a specialty hereafter explained, in which establish the fact of identity between the constants of mortality all three observations agree in departing from the theoretical and the constants of sickness. There is, however, a remark- numbers. In the " Manchester Unity," at ages above 53 years, the able discrepancy between the three observations as to the particular age at which the period of florescence is divided mortality (shown in Table 1.) is 15 per cent. greater than the This. from the period of senescence. In the three observations on mortality of the total male population of England. mortality, and the three observations on sickness, the limiting higher relative mortality is such as mighthave been anticipated age is either at 53 years or at 46 years. According to Mr. from this society, containing less than the average proportion Finlaison’s observation, the limit dividing the two periods is at of members resident in rural districts, and more than thethe age of 53 years, both for mortality and sickness; accord- average proportion of members resident in town and city dising to Mr. Ratcliffe’s observation, the line of separation is at tricts. According, however, to the observations of Mr. Neison the age of 46 years, both for mortality and sickness; but, and Mr. Finlaison, at ages above 53 years the mortality in. according to Mr. Neison’s observation, the limits of division Friendly Societies (containing the due proportion of rural for mortality and sickness are different, that for mortality town and city members) is 20 per cent. less than the mortality being at 53 years, and that for sickness being at 46 years of of the total male population of England. This is an unexpected age. This difference of seven years in the position of the limit result, which is open to doubt, more especially from the fact dividing the period of florescence from that of senescence occa- that there is a discrepancy in the statements of sickness at the sions a difference of 40 per cent. in the relative mortality or same ages, respectively made by Mr. Neison and Mr. Finlaison, relative sickness at ages above 53 years compared with ages which discrepancy, when converted into its proportional amount below 46 years. For example, assuming (as is not far from of deaths, would be just sufficient to make up the suspected the truth) the mortality and sickness stated by all three deficiency of 20 per cent. The sickness suffered, at ages exobservers to be equal at ages below 46 years, it will ensue, from ceeding 53 years, is 40 per cent. greater accordingto Mr. the difference in the position of the limitsjust mentioned, that Neison than it was according to Mr. Finlaison. The alleged at any specified’age above 53 years, the mortality observed by mortality being equal in the two cases, it would follow that Mr. Ratcliffe is 40 per cent. greater than the mortality observed the sickness of a population can be greatly increased without by Mr. Neison and Mr. Finlaison, and that the sickness the deaths being simultaneously increased-a conclusion opposed observed by Mr. Ratcliffe is equal to that observed by Mr. to all experience. It is nearly certain that the extra 40 per Neison, but 40 per cent. greater than the sickness observed by cent. of sickness observed by Mr. Neison represents the lifeMr. Finlaison. time of all superannuated members, which life-time is altogether The discrepanciesjust mentioned are of such magnitude as excluded from his observation by Mr. Finlaison. If one-half to detract considerably from the value of the results of all three of all superannuation time be true sickness, Mr. Nelson’s obserobservations at any age exceeding 53 years. In order to vation, as compared with Mr. Finlaison’s, will contain an extract a useful result from the apparently contradictory obser- extra 20 per cent. of true sickness, without any extra per vations, it is necessary to devise some principle of reconciliation centage of deaths. If, however, an addition to the deaths (for which will explain the inconsistencies. Such a principle is omissions in the returns) be made proportionate to the extra found in the assumption, that one particular class of facts has per centage of the true sickness observed by Mr. Neison, the been treated in three different ways by the three observers, resulting mortalities of all three observations will be in harmony whether designedly or not. The class referred to, is that of with each other, and conformable to expectation. It is also to be remarked, that if the mortality of members of members retired on the Superannuation or Sick-Pension List. It appears highly probable that Mr. Ratcliffe, in his obser- Friendly Societies is influenced by " selection," as is probably vation, has treated all on this list as sick, and added their the fact, there will be additional reason for doubting the truth deaths to the general amount of deaths. On the other hand, of the statement in question; for the statement of Mr. Neison it appears highly probable that Mr. Finlaison has treated and Mr. Finlaison is, that in Friendly Societies the mortality nearly the whole of this class as pensioners in good health, and in the period of florescence, as well as in the period of senescence, removed them from observation, whether as regards sickness is 20 per cent. less than that of the total male population of * To reconcile the third observation with the two England of the same age. The former part of this statement is or mortality. just mentioned, it is necessary to assume that Mr. Neison has probably true; but the latter part is inconsistent with the designedly reckoned all superannuation time as sick time, and former part, and the known ordinary effects of selection of that he has unavoidably omitted the deaths of the same class good lives from the general mass. In Friendly Societies the of members, because they were omitted in the returns from great majority of members are admitted below the age of 35years, so that the effect of selection (being limited to about 15 Friendly Societies submitted to him. It may be useful here to remark, that Friendly Societies in years from admission) does not extend to the period of age exgeneral make these returns very reluctantly, and are careless ceeding 53 years. Assuming the reduction of 20 per cent. in as to their correctness or completeness. A very large propor- the mortality during the period of florescence to be caused by tion of the total returns from these societies has been rejected " selection," there ought to be no difference, in the period of * The interpretation here suggested of "Sickness" has been conui-med by senescence, between the mortality of members of Friendly Mr. Finlaison in the second part of his Official Report since published. Societies and the mortality of the classes from which the mem-
life. on
adopted
331 TABLE I.
SHOWING, for Quinque7z?zial Intervals of Age, the Rates of Mortality and Sickness experienced by Members of Friendly Societies, according to three several observations; with which are compared the Results from flve Theoretical Tables, one of which. represents the Annual Mortality of the Total Male Population of England, according to the latest Obserzations.
TABLE II.
SHOWING, for Decennial hzterzals of Age, the Rates of Mortality observed amongst the Members of Friendly Societies resident in Rural, Town, and City Districts ; with which are compared the Mortality of the whole and of parts of the Male Population of England.
TABLE
II.-(Continued.)
332 bers have been selected. It may be useful here to remark, that four healthiest Registrar’s divisions, which comprehend onea reduction through selection of 20 per cent. in the mortality third part of the total population of England. It may also be for the period orfloieseence is equivalent in appearance to a seen, on comparing together the first and last columns of Table retrogression of four years in the limit at which the period of II., that the least mortality observed between the ages of 35 senescence commences. If, as is the fact, this limit in the total and 65 years, is one-third part only of the greatest mortality male population of England is at the age of 53 years, the corre- observed in England at the same interval of age,-the least sponding position of this limit in Friendly Societies affected by mortality being that of agricultural labourers, observed by Mr. . selection in the degree mentioned would be at the age of 49 Neison. The true range of mortality is, however, considerably years. greater than the observed range of 1 to 3. For it is nearly In the three several observations, the members are dis- certain that, in all towns of great magnitude, there exist twotributed into three classes, according to their residence in large classes, occupying the extremes of good and bad health,. "Rural," "Town," or "City" Districts; and the rates of one of which suffers a mortality one-third less, and the other a. mortality and sickness at different ages are separately stated mortality one-third greater, than the average mortality of the for each class. Thegeneral result of all the observations, is, whole population of the town. Whence we are justified in that the mortality of the town is 25 per cent. greater than the concluding that, in the least healthy class of large towns of mortality of the rural districts; and the mortality of the city England, there exists a considerable portion of the population 25 per cant. greater than that of the town districts. In Mr. suffering a mortality four times as great as that which has been Ratcliff’s observation, the mortality of the aggregate popula- observed to exist in a class formed by selection from agricultural tion is greater than the mortality of his town population; but labourers. in Mr. Neison’s and Mr. Finlaison’s observations, the mortality All three observers, in their statements of " city" mortality of the aggregate is considerably less than that of their town at ages above 55 years, agree in presenting a similar anomaly. population. These variations are accidental, and arise from the According to all three statements, city mortality is considerably absence of any settled principle regulating the distribution of greater than town mortality at all ages under 55 years, whilst the members into the three classes. Mr. Ratcliffe has dis- at ages above 55 years, the relation is reversed, though in a less tributed his numbers equally amongst the three classes of rural, degree. On inspection, however, of the three last columns of town, and cityresidents; and has formed his rural class from Table II., exhibiting the rates of mortality according to age of residents of townships or parishes whose total population is less three classes of the largest towns of England, arranged accordthan 5000 of all ages and both sexes. Mr. Neison (who has ing to their degrees of healthiness, there will be found no such been followed by Mr. Finlaison) has distributed his numbers, anomalous appearance. It will there be seen, that at ages above 55 years, the unhealthiness of either class of towns is as so that the rural, town, and city residents are in the proportions (nearly) of 4, 2, and 1 respectively; and Mr. Finlaison (with strongly indicated by increased mortality, as it is at ages below Mr. Neison probably) has formed his rural class from residents 55 years. There is thus no countenance afforded to the paradox in townships or parishes whose total population is less than presented by Messrs. Neison, Finlaison, and Ratcliffe, that as 3000. Instead of these classifications, without any apparent the unhealthiness of large towns increased, the mortality of the principle, it appears to me that the preferable course would population at ages above 55 years, proportionally diminished. The anomalous appearance in question is probably attributablehave been, to comprehend in the "town" class about one-half of the total numbers, and so to haveadjusted the limits of to the mixing together in one observation of classes resident in magnitude of the places designated as " towns" as to render cities, whose mortalities are widely different. All three obthe mortality of the class resident in towns coincident in servers have formed their " city’’class out of residents in large amount with the mortality of the aggregate population observed. towns whose mortalities, for their total populations, differed Having thus fixed the intermediate "town class," the two from one another as much as 50 per cent. as already stated. extremes of rural and city classes would be simultaneously In the case of such combination of two classes differing greatly fixed. I acted upon the opinion now expressed, in forming a in mortality, the result exhibited at the early ages will be the system of Theoretical Life Tables, which I published twenty- mean of the rates of mortality for the healthy and the untwo years ago. I divided the population into three classes, healthy parts of the population. At the higher ages, however, of mortality the designations, the rate of mortality belonging to the healthier portion of the and gave to the three degrees " Mean," and " City." The names of the two population will alone appear, by reason of the previous extincextreme classes were indicative of extreme rarity or extreme tion by death of the portion subject to the higher of the two density of population; the intermediate term was used to rates of mortality. The error arising from defective classificaindicate, either a population of mean density, or the aggregate tion is much greater in city than it is in town or rural populapopulation independent of density. tions ; but it can never be altogether avoided. In deducing the Both Mr. Neison and Mr. Finlaison have, in their observations, mortality of the total population of England, a defect of the made an important subdivision of the residents of rural districts nature alluded to must exist through the difficulty of forming into two classes, whose mortalities differ from one another in classes of people whose mortalities are nearly on an equality. as great a degree as the mortality of town districts differs from The mortality of a combination of correctly constituted classes that of rural districts in general. One of these two subdivisions will never increase according to age, so rapidly as the mortality is a class consisting chiefly of agricultural labourers, the other of the classes observed separately would increase. In the total subdivision is a class consisting of the residue of all residents male population of England, the line which apparently divides in rural districts. According to both observations, the mor- the period of florescence from that of senescence is at the age tality of agricultural labourers is less than the mortality of the of 53 years. It is not improbable that the true line of division residue of the rural class in the proportion of 4 to 5, which is for the separate classes is at 51 years of age, the difference of the relation of rural to town, and of town to city mortality. two years being the effect of the combination of various classes. Attempts have been made to subdivide the " town" and the whose amalgamation is necessarily imperfect. "city" members of Friendly Societies into classes suffering (To be continued.) similarly well marked different degrees of mortality, but, apparently, hitherto without success. This failure of the investigation, so far as regards town and city districts, affords, however, no ground for doubting, what is evidently the fact, A CASE OF GREAT HYPERTROPHY OF THE that the range of mortality between classes occupying the exHEART. tremes of good health and bad health is much greater in city BY WILLIAM SEDGWICK, ESQ., M.R.C.S. & L.S.A., than it is in rural districts. LATE SURGEON TO THE NORTH DISTRICT OF ST. MARYLEBONE. The mortality experienced by members of Friendly Societies " resident in City" Districts, according to the observations of THE following case has been selected for publication from a. Messrs. Neison, Finlaison, and Ratcliffe, approaches nearly to the mortality of the male population of large towns of England large number of cases of heart disease that have come under of the healthiest class, such as York, Sunderland, Plymouth, my notice, as a striking instance of the great size this organ (See Table II., hereunto annexed, and THE may attain at a comparatively early age. It is probably, for Brighton, &c. LANCET, vol. i. 1850, p. 330.) The result has been obtained the age of the patient, the largest heart of which there is any by combining together the members of Friendly Societies definite record. The circumstances attending the death of the resident in large towns, of the first, second, and third degrees patient will be found to possess peculiar interest, as tending toof health. Liverpool and Manchester represent large towns prove that the heart, " by the simple vehemence of its action,’ or cities of the third or lowest degree of health in England; does not kill, the immediate cause of death in this case being the mortality of these large towns being 50 per cent. greater at inflammatory softening of the brain, passing into suppuration, most ages than that of the healthiest class of large towns just which is not an unfrequent effect of dilated hypertrophy of the mentioned, and 100 per cent. greater than the mortality of the left side of the heart.
Village,"