Part 17

Nor must it be lost sight of, that if the _deaths_ by typhus double in number those produced by cholera, the list of _persons attacked_ by the former disease, and thereby for a long while incapacitated and suffering, is immeasurably beyond this proportion. Two or three times the number of deaths by cholera would give you the number of seizures, and enable you to estimate all the direct mischief caused by it; while, in regard of typhus, probably for one death there are twenty cases of protracted illness, tardy convalescence, and injured constitution. Not only are the deaths double in number, but each of them indicates an infinitely larger amount of sickness and suffering not immediately productive of death.

The frightful suddenness of the rarer disease, and the condensation of its epidemic fatality into some single year, give it more apparent importance than belongs to the familiar name of typhus; but I can assure your Hon. Court, that if a large amount of preventable death, and a still larger amount of preventable misery, be strong arguments for sanitary improvement and activity, those arguments are more abundantly derivable from the constant pressure of fever and its kindred maladies, than from the sharper but infrequent visitations of the foreign pestilence.

In the third column of this table come deaths by scarlatina. Of these, perhaps a certain proportion would occur even under favourable circumstances; for, whatever may have been the original derivation of the disease, it is impossible to doubt that the severity of its attack mainly depends on conditions peculiar to the person of the patient, and that no perfection of external circumstances will ensure mildness of infection. But on the other hand it is certain, that, under attacks of the disease at first equally malignant, adequate ventilation with pure air will enable one patient to wrestle successfully against the poison, while another, less favourably circumstanced, will rapidly sink beneath its influence; and hence I have no hesitation in assuring you, in respect of the 213 deaths registered under this head, that a majority would have been avoided under improved domestic arrangements.

In the fourth column, you will read of 91 deaths by small pox. Your judgment will not be a harsh one, if you assume that 90 of these were the result of criminal negligence. Under the present administration of the Poor Laws, vaccination is not only accessible to all members of the community, but is literally pressed on the acceptance of the poor. Those stupid prejudices, which for some years retarded the universal adoption of Jenner’s great discovery, have now died away; the neglect of vaccination must be regarded as the omission of a recognised and imperative duty. Deaths of children, arising in this parental neglect, ought to be considered in the same light as if they arose in the neglect to feed or to clothe; and I am disposed to believe, that the readiest way of bringing this view of the case before those uneducated classes, where the omission usually arises, would be to procure Coroner’s inquests every year in respect of some half dozen or more instances where the evidence of neglect might happen to be glaring.

In the fifth column of the table stand recorded a hundred deaths by the poison of erysipelas, in one form or another; arising sometimes spontaneously, sometimes in connection with the child-bearing state, sometimes in sequel of accidental lesions and surgical operations.

My daily experience as a Surgeon--especially as a Hospital-Surgeon, enables me confidently to speak of these diseases as an artificial product of unhealthy exterior conditions. The contrasting results of surgical operations in town and in country--of operations undertaken amid pur-ventilation, in spacious cleanly rooms and dry localities, with those undertaken under opposite circumstances (in the dwellings of the poor for instance, or wherever else amid damp, dirt, and over-crowding), and the similar experience which exists as to the origination of puerperal fever, would be quite conclusive as to the fact, that of the 101 deaths under this head, a large majority might have been prevented.

Next, in the sixth, seventh and eighth columns, stand deaths arising in the chief acute diseases of infancy, those to which the disproportionate mortality of infants is mainly due. Many careful statistical observations, as well as personal experience, convince me that the immense fatality recorded under this head, is, to a very great extent, due to obviable causes.

To bring this matter distinctly before you, I must take, as a standard of comparison, some district where the general death-rate is sufficiently low to distinguish it as eminently healthy; and in such an one you will notice a marked diminution, not only (of course) in the _number_ of infant deaths, but likewise in their _proportion_ to the total mortality.

Such a district is that of the combined parishes of Glendale, Bellingham and Haltwhistle, in the county of Northumberland. In it the general death-rate is 14; in the East and West London Unions of the City of London, the general death-rate is 26·73. In the former district, children under five constituting more than an eighth of the population (1/7·6), their deaths form about a quarter of the whole mortality; while in the latter district, where the children are in smaller proportion--namely about 1/9 of the population, their deaths are not much less than half (1/2·21) of the whole mortality. Thus, in the healthier district they die at less than double the average rate for all ages; in the unhealthier, at more than four times that average.

A still better method of district-comparison, is to arrange in a series the death-rates prevailing in several localities for persons _over five years of age_, and side by side with this column, another for the death-rates of children _under five years of age_. The first column will of course indicate very well the relative sanitary conditions of the districts; but the differences between them will be expressed far more clearly, and, as it were, in a magnified form, in the column of infantine death-rates. Thus, for instance--to repeat the comparison just instituted between the Northumberland and the London district; the death-rate for all ages over five is about 12 in the former district, and nearly 15 in the latter; a difference quite sufficient to establish the inequality of their sanitary conditions. But, how much more strongly is this disparity expressed in the comparison of the infantine death-rates--26·5 for the healthier district, 107·57 for the unhealthier one!

Nothing can be more conclusive than the evidence afforded by statistics, as to the dependence of high infantine mortality on the general causes of endemic unhealthiness. My own observation within the City gives complete confirmation to this view, showing me that the diseases specified in my table (diarrhœa, bronchitis and pneumonia, hooping-cough, croup and measles, hydrocephalus and convulsions) however various in nature they may seem, and however apt you may be to dissociate their occurrence from the thought of local causation, yet unquestionably multiply their victims, in proportion to the otherwise demonstrable unhealthiness of a place, owe most of their fatality to local causes, and may, therefore, to a great extent he disarmed of their malignity.

The last column gives the total of those which have preceded it, and shows, out of 9493 deaths, 3923, all from acute disease, in intimate dependence on local and obviable causes. It will be a moderate computation with respect to these deaths, if we estimate that two-thirds of them might have been hindered.

And yet it is not only by _acute_ disorders, that preventable death succeeds in ravaging the population. If we turn to the examination of _chronic_ ailments producing death, we may quickly recognise many indications of their preventability, and may satisfy ourselves that here also the general mortality might be very largely reduced.

Look, for instance, at the whole immense class of scrofulous diseases, including pulmonary consumption, a class probably causing, directly or indirectly, at least a quarter of our entire mortality; and consider the vast influence which circumstances exert over its development.

Of such circumstances some lie within your control, and affect masses of the people; but the more special causes of chronic disease lie rather out of your jurisdiction, and the option of avoiding them is a matter of individual will. Vicious habits and indiscretion; a life too indolent, or too laborious; poverty and privation; vicissitudes of weather and temperature; intemperance in diet; unwholesome and adulterated food; and, not least, inappropriate marriages tending to perpetuate particular kinds of disease; these words may suggest to you, briefly, that there are many influences, within the sphere of private life, by which the aggregate death-rate of a population is largely enhanced, but the control of which, if attainable, lies almost entirely at the discretion of the classes subject to their operation.

Considering all these causes, and the needless waste of life occasioned by them, I can have little doubt that as much might be done by individuals, under the influence of improved education, to lessen the mortality from chronic disease, as by sanitary legislation to stay the sources of epidemic death. And regarding both classes of disease together--those, on the one hand, which are of endemic origin (arising in imperfect drainage, in defective water-supply, in ill-devised arrangement of buildings, in offensive and injurious trades, in the putrefaction of burial-grounds, and the like) and those classes, on the other, which arise in the circumstances of individual life, I can have no hesitation in estimating their joint operation at a moiety of our total death-rate, or in renewing an assertion of my last years’ Report, ‘if the deliberate promises of Science be not an empty delusion, it is practicable to reduce human mortality within your jurisdiction to the half of its present average prevalence.’

To revert, however, to your more special branch of the subject,--I have thought the present a convenient time for indicating to you the pressure of preventable death, arising in acute disease, because of the great addition which you have recently gained to your powers for enforcing prevention.

That an average death-rate of nearly 25 _per_ thousand _per annum_ prevails in the City; that three-eighths of your mortality consists in a premature extinction of infant life; that fatal disease, in more than two-fifths of its visitations, is of a kind which operates endemically and preventably;--these are the facts to which I have appealed, as my evidence of the need for sanitary activity and perseverance.

On other occasions I have endeavoured to set before you what are those agencies hostile to life, which affect the masses of an urban population; and during the last three years your Hon. Court has shown its recognition of these causes, and has devoted attention to the means of counteracting them by appropriate sanitary measures.

In too many instances, the powers first given you by the Legislature were inadequate to this great purpose. But now, armed with the further authority of your new Act of Parliament, you enjoy such means for sanitary improvement as have never yet been possessed by any Corporation in the country; such means as, judiciously wielded, cannot but produce the greatest advantage to persons living under your jurisdiction.

As you are only now entering on the exercise of these powers, it may be convenient that I should submit to you a brief account of them, and I gladly turn from contemplating the spectacle of preventable death, to analyse the means of prevention now vested in you by the Legislature.

* * * * *

1. In regard of _public drainage or sewerage_, the first and most elementary condition of endemic health, I need hardly tell you that within the City, your powers are absolute. You have entire and sole responsibility for the construction and maintenance of sewers, for their cleaning or flushing, and for the prevention of noxious effluvia from their innumerable gully-holes.

* * * * *

2. In the all-important particular of _house-drainage_, your authority is sufficient for every purpose. You can order the complete abolition of cesspools; the construction of drainage in any premises within fifty feet of a sewer; its repair, cleansing, or renewal, whenever it may be disordered: and not only can you order these works to be done, but--failing the owner’s compliance with your notice, you can devolve the performance of his duty on your own workmen, and can recover your expenses from the recusant.

* * * * *

3. In regard of _water-supply to houses_ your powers are equally cogent, though the unsatisfactory condition of the water-trade continues a serious obstacle to their effective employment. You have authority here, as with house-drainage, to order the construction of all necessary apparatus, and to enforce the fulfilment of your order.

Under both these heads, you possess a power hitherto but imperfectly used, the complete and constant exercise of which I would strongly recommend to your Hon. Court. In all those clauses of your Acts of Parliament, which relate to private works of house-drainage and water-supply, there occurs a very important phrase:--such works shall be constructed ‘to the satisfaction of the Commissioners.’ Now, of private works effected under the authority of your Act, during the last three years, a certain, not inconsiderable, share proves inoperative and bad. The mere overflowing of a water-butt (and in numberless instances this is the arrangement evasively adopted under your orders) can never suffice for the effectual cleansing of house-drains. I need scarcely inform you that an obstructed drain and choked privy, wherever they occur, are equivalent to a cesspool; shedding abroad the same effluvia, and producing the same deadly results. No gain is gotten to the wholesomeness of a house, by substituting for its former cesspool an equally offensive and inoperative drain. To my knowledge, much of the drainage done during the last three years is liable to this risk; and it appears to me indispensable that you should exert direct supervision against so serious an evil.

I would recommend to your Hon. Court that, in issuing orders for the construction of drainage and water-supply, you should require a full specification to be delivered you of the works about to be undertaken, and should distinctly decide as to their sufficiency; or by a still simpler process, that you should fix and determine a certain standard of combined works; a model plan, in short, for house-drainage, privies, and water-supply, and should direct your Inspectors to certify to you the sufficiency of only such works as may accurately correspond to this design.

I cannot but regard it as a grave calamity, that the general supply of water to the City remains beyond your control, in the hands of irresponsible traders; for its imperfect adaptation to the requirements of the public constitutes the largest sanitary evil of the day.

* * * * *

4. You have entire control over the _pavement of every public way_ within the City, for its construction, maintenance, and cleansing; and in this respect you exercise a power of great sanitary value. The preservation of cleanliness along the whole extended surface of the City, including its many hundred courts and alleys, is indeed a branch of your functions which can hardly be over-estimated for its importance; and the fines which you have the power of levying from your contractors, whenever the scavenging is neglected, are useful securities for the general performance of their duties.

It lies within your power to order, wherever you may think fit, the employment of the hose and jet for the purpose of surface-cleansing in courts and alleys: and, I may add, that the advantages of this most effective sanitary process have been highly appreciated where you have directed its application.

In some of the poorer localities, complaints have arisen in a matter relating to the pavements, where you are not able to afford the complainants effectual relief: viz., with respect to certain inhabitants throwing refuse and offensive matters from the houses into the public way, so that nuisance is created. I have already suggested to your Hon. Court, and I beg leave here to repeat, that in the 41st clause of the City Police Act, provision is made for the prevention of this particular offence, and that your four Inspectors are manifestly unable to relieve the Police Force of their legal responsibility in the matter.

* * * * *

5. Your powers for enforcing the wholesome _cleanliness of private premises_ are equally considerable. You can order the removal of offensive matter, the purification and whitewashing of premises, and the abatement of any nuisance arising in conditions of filth. In case of need, as shown by a medical certificate, you can summon the offender before your Court; and (under your new Act) you can punish with a heavy fine any repetition of the nuisance against which your order has once been issued.

* * * * *

6. So long as _slaughter-houses_ are tolerated within the City (and it is to be hoped this may not be long) you have power to regulate their use, according to your discretion, with a view to their cleanliness and better management; and in case of disobedience to your orders, you have power to enforce the temporary suspension of slaughtering. Your new Act renders illegal any slaughtering in cellars, or any keeping of cattle there: and it prohibits that offensive exposure of putrescent hides, which has so often been complained of in the vicinity of Leadenhall Market.

* * * * *

7. In close connection with the regulation of slaughter-houses, your new Act gives you authority in a matter hitherto quite foreign to your jurisdiction, but where your vigilance may no doubt be exercised with great advantage to the public health. You are authorised to _appoint Inspectors of slaughter-houses and of meat_; and these officers are required to inspect shops, markets, and slaughter-houses, and to seize and destroy any meat which may appear to them unsound or unwholesome. A further clause of very extensive application enables you to deal generally with all cases, where _unwholesome provisions_ are exposed for sale; and this clause is so constructed as to include and render penal all those _fraudulent adulterations of food_ which render it detrimental to health.

* * * * *

8. You are invested with important authority against _such trades and occupations as are offensive or injurious_ to their neighbourhood. Under your former Act, you can subject to penalties any person who shall ‘roast or burn, boil, distil, or otherwise decompose any root, drug, or other article or thing, in any house or building, and thereby cause offensive or injurious smells or vapours to be emitted therefrom, so as to become a common nuisance;’ and the same Act also gave you a very inoperative clause against such nuisance-causing manufactories as might begin to work in the City after the commencement of that Act.

Your new law enacts that everything practicable shall be done for the suppression of all nuisances arising in manufactures and the like:--that, after the first of January next, every furnace used in the City shall be such as to consume its own smoke; and that whatever trade or business may occasion noxious or offensive effluvia, or otherwise annoy the inhabitants of its neighbourhood, shall be required to employ, to your satisfaction, the best known means for preventing or counteracting such annoyance.

* * * * *

9. You have certain powers, to which I adverted in my former Report, as likely to come into activity whenever the injurious practice of intramural burial might cease; powers, namely, relating to the _disposal of dead bodies_ in certain specified cases: and under your new Act, you have acquired some further authority (likewise only to be exercised after that cessation, and with the consent of the Bishop of London) to _appropriate the disused burial-grounds_ for purposes of improvement. At the time of my last Report I looked ‘forward to the complete discontinuance of burial within your territory as a matter for warm congratulation among all who are interested in the cause of sanitary improvement;’ and it is with proportionate disappointment and regret, that I have now to report to you that the Order in Council, which was to have closed all metropolitan burial grounds, has never yet been issued; and that negociations, conducted by the General Board of Health for the purchase of a sufficient extramural cemetery, were suddenly arrested at the close of the last session of Parliament. Your powers in relation to these matters remain of course meanwhile inoperative.[68]

[68] In the Parliamentary Session of 1852, the Interments Act of 1850, which had remained inoperative, was repealed under a new ‘Act to amend the Laws concerning the Burial of the Dead in the Metropolis,’ which became law July 1st, 1852. Under this Act, the powers, alluded to in a later part of this volume, were given to the Commissioners of Sewers of the City of London as a Burial Board for the City.--J. S., 1854.

* * * * *

10. The most important additions made to your power relate to the _dwellings of the poor_, and are embodied chiefly in the tenth section of your new Act. The definition of ‘lodging-house’ given in this clause is so extensive, and the power of regulation conceded to you is so unconditional (where once the necessity for your interference is shown) that your Hon. Court can now exert your authority for every legitimate object, in respect of all the poorer houses in the City.[69] The definition is, that ‘the expression _common lodging-house_ shall, for the purposes of this Act, mean any house, not being a licensed victualling house, let, or any part of which is let, at a daily or weekly rent not exceeding the rate of three shillings and sixpence per week; or in which persons are harboured or lodged for hire for a single night, or for less than a week at one time; or in which any room let for hire is occupied by more than one family at one time.’ And your powers are to the following effect:--Wherever over-crowding has taken place unwholesomely or indecently--wherever undue illness has prevailed--wherever from any one of several causes the house is unfit for occupation, you can require its _immediate registration_; you can then _make such rules_ as you think fit for the _maintenance of decency and health_; and you can enforce conformity to those regulations with appropriate penalties.

[69] Circumstances, which need not here be detailed, have led to disappointment in the working of this clause, and have shown, to my great regret, that I over-estimated the benefits it was capable of conferring.--J. S., 1854.

The terms of the clause throw on your Medical Officer the responsibility of initiating these proceedings; and his task in the matter will be one of anxiety and arduousness. In most other clauses of your Acts of Parliament, an alternative is allowed as to your taking the opinion ‘of the Officer of Health, or of any two duly qualified Medical Practitioners:’ but in this clause you are expressly restricted to the certificate of your Officer of Health.