Reports Relating to the Sanitary Condition of the City of London

Beyond these general cautions, there is yet one which requires very particular mention.

In respect of the commencement and predispositions of the disease, it is now well known—first, that in this country it habitually begins with diarrhœa of a painless and apparently trivial character; secondly, that diarrhœa, however produced, is, of all known personal conditions, the one most likely to invite an attack of Cholera at times when that disease is epidemic; thirdly, that during the prevalence of Cholera, side by side with it in a district, there is always a vast amount of epidemic diarrhœa, apparently constituting slighter degrees or earlier stages of the same disease; that this condition is just as amenable to treatment as the confirmed collapse of Cholera is utterly the opposite; and—since we can never say how incurable a few hours may render this insidious symptom, that its immediate arrest is a consideration of vital importance.

Precautions against causing diarrhœa to oneself by errors of diet will vary somewhat with different individuals. Every person of ordinary discretion knows the habits of his own body, and can be tolerably confident, within certain limits of food, that he gives himself no occasion of sickness. He remembers articles of diet, which his neighbour perhaps may innocently indulge in, but which to himself are the occasion of inward disorder—of purging or vomiting, ‘bilious attack’ or nettle rash, headache, nightmare, or some other inconvenience. This knowledge fixes the limits which it primarily behoves him to regard; taking such food only into his body as experience has shown best to agree with it; and adhering to this course, without panic as to particular accustomed articles, and without abrupt discontinuance of old harmless habits. Apart from personal peculiarities, the chief dangers of diet appear to lie as follows: first, in those excesses of meat and drink, which (especially under circumstances of fatigue) occasion sickness to the stomach, or an increased labour of digestion; secondly, in taking food, solid or fluid, which is midway in some process of chemical transition—half-fermented beer and wine, water containing organic matters, meat and game and venison no longer fresh and not completely cooked, fish and shell-fish, in any state but the most perfect freshness, fruit or vegetables long-gathered or badly kept, and the like; thirdly, in a profusion of cold sour drink; fourthly, in partaking largely of those articles of diet which habitually, or by reason of imperfect cooking, pass unchanged through the intestinal canal; and fifthly, in the indiscreet use of purgative medicines, or in taking any article of diet which is likely to produce the same effect.

In short, if care be taken under all these heads to avoid occasions of intestinal disturbance; if the diet, while generous, be simple and strictly temperate; if regular hours be given to sleep, to meals, to industry, to recreation; if a fair proportion of out-door exercise be taken; if damp and extremes of temperature be guarded against; and all practical pains be given to avoid the sources of bodily and mental depression; the danger will certainly be reduced to its minimum; and whatever effects the epidemic may happen to produce can be readily recognised and boldly encountered.

Should these effects arise in their customary form of diarrhœa, it is of absolute urgent necessity that immediate medical treatment be resorted to: and so important for the safety of life is the recognition of this symptom in the earliest stage of its occurrence, that no unwonted action of the bowels should pass unobserved.

The public constantly asks to be informed of some drug, or combination of drugs, to which under these circumstances they may have immediate recourse. But after very careful consideration of this subject, after hearing arguments on both sides, and reading those prescriptions which have been recommended for adoption, I venture to express my opinion that the safest course for the public, in regard of this threatened disease, will be to follow the same principle as guides them in their ordinary seizures of illness, and to obtain as quickly as possible the aid of their customary medical advisers. There is an invincible aptitude in the public to misapply all precautionary medicines within their reach; often superstitiously to treat them as charms, under the protection of which they may neglect temperance of diet and all other solicitude for health; often ignorantly to employ them in cases for which their use is forbidden; often, at the instigation of panic, to abuse them by preposterous and hurtful excess. Nervous and uneducated persons, instead of employing their astringent dose simply to stop any undue action from the bowels, would be apt, as the danger neared them, to make it an habitual dram in order to anticipate any such action; and the frequent after-necessity for purgative medicine, thus created, would constitute the very danger they desire to avoid. Recognising, therefore, at its full value, the importance of immediately treating, in every case, the first phenomena of epidemic diarrhœa, I must yet doubt whether the conditions of medical science and general education are such as to justify the promulgation of general formulæ so liable to extensive abuse.

I speak of course with particular reference to the metropolis. In remote rural districts it may often be desirable that discreet and intelligent persons—the Clergy, for instance, should obtain from their medical neighbours some astringent preparation to which—in the very rare event of real emergency, temporary recourse might be had: but—for so hazardous a condition of disease, I must repeat as a general rule, that no nostrum, even in the best-intentioned hands of ignorance, can supply the place of medical discrimination.

During the acute prevalence of the epidemic in any particular locality, it becomes of great importance to bring the uneducated classes of society, as far as possible, under systematic medical care; in the absence of which they are likely to neglect all premonitions of the disease, and thus to incur much unnecessary danger. To fulfil this object as regards the poor, express provision has been made by the Law: and it might be well for other classes, under similar exposure to attack, to consider how far they could arrange for their households a similar plan of protection.

Under any Order in Council which brings into action the extraordinary powers of the Nuisances Removal Act, the General Board of Health has authority to enjoin on all Boards of Guardians throughout the country, that they provide, for ‘persons afflicted by or threatened with’ the disease, such medical aid as may be required: and the actual working of this has been that, on all occasions of epidemic Cholera prevailing in particular localities, the General Board of Health has called on the local Boards of Guardians to establish systematic house-to-house visitation, for discovering and treating among the poor all premonitory symptoms of the disease.

In the too probable event of its becoming necessary next year to establish this system of medical organisation in parts of the metropolis, I have no reason to doubt that a requisition to the above effect will be addressed to the Guardians of the City poor; and, in this anticipation, I think it desirable to bring, in conclusion, one more point under notice of your Hon. Court. During the former invasion, the Guardians within the City of London resisted the requisitions of the General Board of Health; and the first fourteen weeks of the epidemic consequently passed without the establishment of any visitational system for arresting its progress. In the fifteenth week, however, the Corporation of the City undertook the unperformed duty, not legally devolving on them, and requested me to make arrangements for the purpose of its execution. With the assistance of the several Medical Officers of the City Unions, I immediately organised the requisite staff, and from that moment to the close of the epidemic there continued under my superintendence a systematic visitation of the poor, with beneficial, though tardy and imperfect, results.

Recalling these incidents to the recollection of your Hon. Court, I would beg to observe that no similar endeavour can fully succeed, except as a system—well considered beforehand, and adjusted to the various circumstances which may require its application. Uncertainties of responsibility and conflicts of jurisdiction would inevitably occasion a sacrifice of life; and therefore, before the time when Cholera is likely to become epidemic, it should be definitively settled who is to undertake this organisation. Your Commission can have no jurisdiction in the matter; and the interference of the Corporation would be only at its own option. The legal responsibility rests solely with the Boards of Guardians: and it seems to me indispensable that, before the time for action arrives, the Corporation should determine its intentions; in order that the Boards of Guardians, if again called upon to organise arrangements of the kind in question, may know distinctly—either that the Corporation has relieved them of their task, or that there rests on them the undivided obligation of providing for the crisis.

III. Gentlemen, in concluding this report, I will not attempt to disguise from you that it has been written under feelings of considerable apprehension; and I am fully conscious that, in thus expressing myself, I am liable to the imputation of raising unnecessary alarm.

If the possible mischief to be wrought by epidemic Cholera lay in some fixed inflexible fate, whatever opinion or knowledge I might hold on the subject of its return, silence would be better than speech; and I could gladly refrain from vexing the public ear by gloomy forebodings of an inevitable future.

But from this supposition the case differs diametrically: and the people of England are not like timid cattle, capable, only when blindfold, of confronting danger. It belongs to their race—it belongs to their dignity of manhood, to take deliberate cognisance of their foes, and not lightly to cede the victory. A people that has fought the greatest battles—not of arms alone, but of genius and skilful toil, is little likely to be scared at the necessity of meeting large danger by appropriate devices of science. A people that has inaugurated railways—that has spanned the Menai Strait and reared the Crystal Palace, can hardly fear the enterprise of draining poison from its infected towns. A people that has freed its foreign slaves at twenty millions’ ransom, will never let its home population perish, for cheapness sake, in the ignominious ferment of their filth.

Therefore, gentlemen, advisedly I state the danger as it seems to me. England has again become subject to a plague, the recurrence of which—or the duration—or the malignity, no human being can predict.

But, if I state the danger, so likewise, to the best of my belief, I state the remedy and defence. Colossal statistics concur with the results of detailed inspection, to refer this disease, in common with many others that scourge our population, distinctly and infallibly, to the working of local causes—of causes susceptible of removal—of causes which it devolves on our Legislature to remove.

The exemption we seek is worth a heavy purchase. My thoughts turn involuntarily to the epidemics of former centuries, to their frequent returns and immense fatality. I reflect on the Plague, and how it influenced the average death-rate of London; how in 1593 it doubled it, in 1603 trebled it, in 1625 quadrupled it: and how (after a less considerable visitation in 1636) it actually multiplied the mortality sevenfold in the tremendous epidemic of ‘65. The ravages of that pestilence are best appreciated in the fact, that we esteem the Great Fire of London a cheap equivalent for their arrest; looking to that eventful conflagration of the metropolis with gratitude, rather than horror, because of the mightier evils that were extinguished with its flames.

To so frightful a development as this, Cholera, by many degrees, has not attained; but, ignorant as we are of its laws and resources, we dare not surmise, at any renewed invasion, what increment of severity it may have won. In the simple fact, that our country has again become subject to pestilential epidemics, there lies an amount of threat only to be measured by those who are conversant, by history or experience, with the possible developments of such disease.

Therefore, gentlemen, having the deepest assurance that these unexplored possibilities of evil may be foreclosed by appropriate means, I should ill deserve your confidence if I shrank from setting before you—however ungracious the task—my deliberate estimate of the peril.

It pertains to my local office to tell you of local cures; and this I have sought to do. I have suggested that, by active superintendence of all houses within your jurisdiction, there may be suppressed in detail those several causes of the disease which arise in individual neglect; that, by elaborate care as to the cleanliness of pavements, markets, docks, and sewers, something may be done towards the mitigation of more general causes; that, by a well-organised system of medical visitation, very much may be effected towards encountering attacks of the disease, while still amenable to treatment:—that these, with similar precautions, are therefore to be recommended.

And not for a moment would I seem to depreciate such measures, palliative only, and partial though they be. By their judicious application, from Aldgate to the Temple, life may possibly be saved to some hundreds; to children that are fondly loved, to parents that are the stay of numbers.

But against the full significance of any epidemic, I am bound to tell you that these are but poor substitutes for protection. To render them effectual, even in their narrow sphere of operation, there must be great vigilance and great expenditure; a weary vigilance and a disproportionate expenditure, because chiefly given to defeat in detail what should have been prevented in principle. And be done what may, in this palliative spirit, the sources of the disease are substantially unstayed: for the faults, to which its metropolitan prevalence is due, consist not simply in a number of individual mismanagements, but include a common and radical mal-construction as their chief.

No city, so far as Science may be trusted, can deserve immunity from epidemic disease, except by making absolute cleanliness the first law of its existence; such cleanliness, I mean, as consists in the perfect adaptation of drainage, water-supply, scavenage, and ventilation, to the purposes they should respectively fulfil; such cleanliness, as consists in carrying away by these means, inoffensively, all refuse materials of life—gaseous, solid, or fluid, from the person, the house, the factory, or the thoroughfare, so soon as possible after their formation, and with as near an approach, as their several natures allow, to one continuous current of removal.

To realise for London this conception of how a city should cleanse itself may involve, no doubt, the perfection of numberless details. Yet, most of all, it would pre-suppose a comprehensive organisation of plan and method: not alone for that intramural unity of system which is needful for all the works, as most for those of drainage and water-supply; but, equally, to harmonise these works with other extramural arrangements for utilising to the country the boundless wealth of metropolitan refuse—for distributing to the uses of agriculture what is then rescued from the character of filth—for requiting to the fields in gifts for vegetation, what they have rendered to the town in food for man.

How far the construction of London has proceeded on the recognition of such objects, or how far the advantages of such a plan have been realised, it could only be a mockery to ask. Our metropolis, by successive accretions, has covered mile after mile of land. Each new addition has been made with scarcely more reference to the legitimate necessities of life, than if it had clustered there by crystallisation. With no scientific forecast to plan the whole, with little but chance and cheapness to shape the parts, our desultory architecture has eclipsed the conditions of health. Draining up-hill or down-hill, as the case might be, and running their aqueducts at random from chalk-quarries or river-mud; or ponding sewage in their cellars, and digging beside it for water; blocking-up the inlets of freshness and, equally, the outlets of nuisance; constructing sewers to struggle with the Thames—now to pollute its ebb, now to be obstructed by its flow; the builders of many generations have accumulated sanitary errors in so intricate a system, that their apprehension and their cure seem equally remote.

Therefore—by reason of causes, ramified through the whole metropolis and deep-rooted in its soil, which bind all parts together in one common endurance of their effects—therefore cannot epidemic disease be conquered by any exertions or by any amelioration, short of the complete and comprehensive cure. Against the danger we dread, no shelter is to be found in petty reforms and patchwork legislation. Not to inspectorships of nuisances, but to the large mind of State-Policy, one must look for a real emancipation from this threatening plague.

A child’s intellect can appreciate the wild absurdity of seeking at Peru what here runs to waste beneath our pavements,—of ripening only epidemic disease with what might augment the food of the people—of waiting, like our ancestors, to expiate the neglected divinity of water in some bitter purgation by fire.

But it needs the grasp of political mastership, not uninformed by Science, to convert to practical application these obvious elements of knowledge; to recognise a national object irrelevant to the interests of party; to lift an universal requirement from the sphere of professional jealousies, and to found in immutable principles the sanitary legislation of a people.

APPENDIX OF TABLES
ILLUSTRATING THE
SANITARY CONDITION OF THE CITY OF LONDON.

No. I. Area and Population of the several Districts and Sub-districts of the City of London.

No. II.—Quinquennial Synopsis of City Mortality, with Death-rates calculated per Thousand on the Population of 1851.

NOTE TO TABLE No. II.

In calculating the Death-Rates given in the last lines of this Table, I have proceeded as follows:—

First, I have counted all Workhouse-Population and Workhouse-Deaths as forming part of the aggregate population and aggregate mortality of that Union to which the particular workhouse legally belongs.

Next, I have distributed among the several sub-districts the population and the mortality of their Union Workhouses, in the ratio of the general sub-district population; so as to prevent the high Workhouse-Mortality from telling unjustly against that sub-district in which the Workhouse happens to have been erected.

Thus, for instance, the East London Union has its male Workhouse placed in the territory of the West London Union; but I have reckoned it as belonging to the East London Union, in respect both of its population and its deaths. Similarly, the City of London Union has its Workhouse situate at Bow; but, not the less, I have considered its 794 inmates and 526 deaths as belonging to the population and the mortality of our central Union.

Thus again for the sub-district death-rates—for instance, in the two sub-districts of the East London Union: reckoning the Workhouse-Population not as exclusively due either to Cripplegate or to St. Botolph, but as furnished by these sub-districts jointly, in the ratio of their populations, I have distributed 576 between them in the proportion, 23,435 : 20,582. The Workhouse-Deaths of the period (802) have been similarly distributed; and the rates, given in the last line of the table, are finally deduced from a comparison of these sums, viz:—

23,435 + 306.66 : 2458 + 426.991 :: 1000 : 121.515, which divided by 5 (to show an annual, instead of a quinquennial, result) gives 24.30 as the annual death-rate for St. Botolph; and, in like manner, 20,582 + 269.33 : 2483 + 375.008 gives 137.065 as the quinquennial, and 27.41 as the annual death-rate per thousand for the sub-district of Cripplegate.

Hospital Deaths have been distributed, as far as possible, according to the previous residence of the patients. Thus the north sub-district of the West London Union, in which St. Bartholomew’s Hospital is situated, is made to retain only its just proportion of deaths. On the same principle I have reckoned to the death-lists of other sub-districts those cases in which I could ascertain that the residents of such sub-districts had gone to die either in St. Bartholomew’s, or in other Metropolitan Hospitals.

No. III.—First Annual Enumeration of Deaths, relating to the Fifty-two Weeks dating from October 1st, 1848, to September 29th, 1849.