Part 3

Before my first enlistment in the service of public health, others had fought this great cause with rare courage and devotion; establishing its main principles in a manner to require no corroboration, and to admit little immediate increase. The true patriarchs of the cause in this country are the present working members of the General Board of Health. The constitution of my city appointment is quite independent of this Board; but I should be acting an unworthy part if I refrained from acknowledging, that, in innumerable instances, I have gathered most valuable knowledge from the Board’s official publications, and that, in personal intercourse with its members and officers, I have had abundant reason to be grateful for information invariably given with that frank kindness which belongs to brotherhood in science, and to sympathy for common objects.

I must likewise acknowledge constant obligations to the courtesy of the Registrar-General, and express with how much pleasure and instruction I have studied the works of his inestimable office. Especially I would offer my tribute of respect to Dr. Farr’s learning and industry, as well as to that capacity for generalisation which the world has long recognised in his eloquent and thoughtful writings.

And, though this be not the place to boast of private friendships, I may venture to say that there are few topics relating to sanitary medicine that I have not enjoyed the advantage of discussing with men who have given genius, inquiry, and reflection to their development.

Thank God! the number of persons capable of apprehending the cause, and ready to take interest in its promotion, is now daily on the increase. If some minister of Public Health could take his seat in the House of Commons--some minister knowing his subject and feeling it, I believe he would find no lack of sympathy and co-operation. The world abounds with admirable wishes and intentions, that vaguely miscarry for want of guidance. How many men can get no farther in their psalm of life than the question, _in quo corriget_. To such--not masters of the subject, but willing and eager to be its servants, an official leader might be everything: for in great causes like this, where the scandal of continued wrong burns in each man’s conscience, the instincts of justice thirst for satisfaction. What can we do or give--how shall we speak or vote, to lessen these dreadful miseries of sanitary neglect--is, at this moment, I believe, the fervent inquiry of innumerable minds, waiting, as it were for the word of command, to act.

How much of this generous earnestness towards the cause exists in society--how much desire to grasp any reasonable opportunity of good has lately happened to fall under my notice. Last winter, when the signs of the times were making us fear that Cholera would presently again be epidemic in London, it was remembered that, in the greater part of the metropolis, nothing whatever had been done since the last invasion to give immunity against the returning disease. It was remembered--too late, how indescribably dreadful a thing is the epidemic prevalence of sudden death. And the poor were thought of--in their unprotectedness, their filth, their ignorance. Among the persons thus aroused, was a gentleman whom I reluctantly leave unnamed; saying of him only, that, from a distinguished position in official life, he had retired to literary enjoyments, amid which he bears the imputation of many unacknowledged writings which charm and instruct the public. When the rumours of the pestilence began, he too heard and read and became aghast. The notion that ‘in a skilful, helpful, Christian country nothing should be done’ against these impending dangers--that the poor should be left ‘defenceless, huddled together in some dismal district, not more helpful than women’--was felt by him, he wrote, ‘deeply as a disgrace;’ and he pleaded that, ‘on a great and pressing occasion, it remains for the thoughtful, the rich, and the benevolent, to try and do these needful things for the people.’[11] Let us, he urged, endeavour to meet this shameful reproach; let us combine voluntary charitable assistance for extemporaneous sanitary measures, rapid, though partial; let us get a hundred thousand pounds and do what we can in aid of local authorities in the poorest districts--in Bethnal Green, in Shoreditch. Eventually this plan was abandoned, at least for the time. There was argued against it, that prompt legislation might do more good, with less exoneration of local responsibility. Whether rightly or wrongly, the latter view was acted on; and in accordance with it, the gentleman first adverted to (waving his own hopes and wishes in the matter) took active part in framing suggestions,[12] which Lord Palmerston had expressed himself willing to accept, for modifying the laws of Nuisance and Disease-Prevention to a form more suitable for the apprehended emergency. But, in the meantime, what had happened? The author of the plan, as it were at a moment’s notice, had seemed to draw round himself half the intellectual and moral strength of the metropolis. Himself setting aside the literary ambition of his life, he found others ready to meet him with their several self-sacrifices. Over-worked men of science and of business, who afford no time to relaxation; favourites of society, who might have been suspected of mere shuddering at distasteful subjects; men of high laborious rank in Church and State; poets; heads of professions; minds that guide the tastes and morals of the country, or feed its imagination; not least, the invalid from his distant wintering-place; men, in short, immersed in all kinds and grades of occupation, were either bodily present at the deliberations referred to, or were writing about the plan in terms of warm interest, anxious to promote whatever usefulness could be shown them. About the means there was discussion--about the object, none; nor lukewarmness. All were competing, by gifts of time and labour, to snatch some opportunity of serving this neglected cause.

[11] I quote from a pamphlet printed by him for private circulation. It was entitled ‘_Health-Fund for London; some Thoughts for next Summer: by Friends in Council_.’

[12] These have since been laid before the House of Lords, on the motion, I think, of Lord Harrowby, who took much interest in the subject.

Such--to return to my text--such, I am deeply assured, would be the spirit which a minister of Public Health would find abundantly on his side in Parliamentary discussion, and in the Press. There is no attachment to the incongruities I have sketched as belonging to our abortion of a sanitary system. Still less is there any want of feeling for the poor--any reluctance to raise their state and better their circumstances--any unconsciousness that these things are great solemn duties. On the contrary, everywhere there is the conviction that _something_ must be done; everywhere a waiting for authority to say _what_. But, the trumpet giving an uncertain sound, who can prepare himself to battle? Knowledge, and method, and comprehensiveness, are wanted--the precise, definite, categorical impulses of a Parliamentary leader, who can recognise principles and stick to them.

And for such a minister, what a career! It would be idleness to speak of the blessings he could diffuse, the anguish he could relieve, the gratitude and glory he could earn. A heathen can tell him this. _Homines enim ad Deos nullâ re propius accedunt quam salutem hominibus dando. Nihil habet nec fortuna tua majus quam ut possis, nec natura tua melius quam ut velis, conservare quam plurimos._

Upper Grosvenor Street, May 15th, 1854.

REPORTS RELATING TO THE SANITARY CONDITION OF THE CITY OF LONDON.

FIRST ANNUAL REPORT.

TO THE HON. THE COMMISSIONERS OF SEWERS OF THE CITY OF LONDON.

_November 6th, 1849._

GENTLEMEN,

During the 52 weeks dating from October 1st, 1848, to September 29th, 1849, there died of the population of the City of London 3763 persons.

The rate of mortality, estimated from these _data_ for a population of 125,500, would be about the proportion of 30 deaths to every thousand living persons.[13]

[13] The Census of 1851, compared with that of 1841, would lead me to believe that in 1848-9 the population of the City must have been about 129,000. With this correction, the death-rate would have been about 29·16 _per_ thousand.--J. S., 1854.

The lowest suburban mortality recorded in the fifth volume of the Registrar-General’s Reports, for the year then under estimation, gave a rate of 11 in the thousand; and we might perhaps be justified in adopting that rate as a _minimum_ for the purpose of sanitary comparison.

According to this standard (undoubtedly a very superior one) it would appear that, during the last year, death has prevailed in the City of London with nearly three times its recognised _minimum_ of severity.

But, to avoid all sources of fallacy, I will allow a very ample margin to this estimate; I will take 15 per thousand as a fair standard of mortality, and will assume that last year’s deaths in the City have amounted to only double their normal proportion.

Probably no one contends that the lower rate of mortality, as illustrated at Dulwich or Sydenham, indicates an over-healthy condition of the locality to which it refers. Probably no one argues that human life, in those healthier districts, is prolonged beyond enviable limits. Surely, on the contrary, every one who can measure the large amount of misery and destitution which results from a high rate of mortality, will think it most desirable that, by every means within the scope of sanitary science, exertion should be made to reduce the higher rate to the level of the lower.

Therefore, Gentlemen, I venture to assure myself, that I shall but have anticipated the wishes of this Hon. Court, in preparing for your consideration a statement of those circumstances, which apparently conspire to determine the larger mortality of the City of London.

* * * * *

In order to prevent any misapprehension of my remarks, I think it well to observe that, in commenting on this mortality, I purposely avoid instituting any comparison between it and the mortality of those urban districts which immediately adjoin us: for the object of my comparison is not to illustrate how, by similar or worse circumstances, an equally great mortality may have been procured elsewhere; but rather to suggest how, by other and better sanitary arrangements here, our present high mortality may be diminished.

Indeed, while I speak of the causes of that high mortality which distinguishes the City of London from the healthier sub-districts I have cited, it will be obvious that many of my observations do not apply to the City of London exclusively, but admit of equal application to various other central districts of the metropolis;--relating, in fact, generally to the characteristic evils of all urban residences.

With those other districts I have nothing to do; but I wish it to be understood, that in describing the City as healthy or unhealthy, I am not comparing it with Holborn, or Whitechapel, or Bermondsey, or other urban localities, where--whatever the relative badness of the places, the scale of comparison would be essentially vicious, and the results of comparison worthless. It is my object to test the salubrity of the City by comparison with a superior standard, in order that some definite aim may appear, towards which to direct the endeavours of sanitary improvement.

* * * * *

Starting, then, from our Registrars’ Returns, I invite you to inquire with me, how it has come to pass that within the City of London there have died in the last year twice as many persons as it seems necessary that there should die; and whence has arisen the apparent anomaly, that here--in the very focus of civilization, where the resources of curative medicine are greatest, and all the appliances of charitable relief most effectual, still, notwithstanding these advantages, there has passed away irrevocably during the year so undue a proportion of human life.

Let it not be imagined that the word _cholera_ is a sufficient answer to these questions, or that its mention can supersede the necessity for sanitary investigation. Let it, on the contrary, be observed that the epidemic which has visited us, extends its ravages only to localities previously and otherwise hostile to life; so that, while all regions of the globe in succession are shadowed by its dark transit, the healthiest districts of each region remain utterly unharmed in presence of the pestilence. Compare, for instance, the cholera mortality in a healthy suburban sub-district with that of an unhealthy urban one. Dulwich and the parish of St. Ann’s, Blackfriars, in the City of London, are probably nearly equal in population: in the former, there was not a single death from cholera; in the latter, the deaths from this cause alone were at the rate of twenty-five to every thousand of the population. Dulwich is one of the healthiest sub-districts within the bills of mortality; St. Ann’s belongs to one of the unhealthiest sub-districts of the City of London; and the cholera visited each in proportion to its ordinary healthiness.

Such is the general rule; and accordingly I would suggest to you that the presence of epidemic cholera, instead of serving to explain away the local inequalities of mortality, does, in fact, only constitute a most important additional testimony to the salubrity or insalubrity of a district, and renders more evident any disparity of condition which may previously have been overlooked. The frightful phenomenon of a periodic pestilence belongs only to defective sanitary arrangements; and, in comparing one local death-rate with another, it is requisite to remember that, in addition to the ordinary redundance of deaths which marks an unhealthy district, there is a tendency from time to time to the recurrence of epidemic pestilence, which visits all unhealthy districts disproportionately, and renders their annual excess of mortality still more egregious and glaring.

* * * * *

As materials which may aid you to estimate the sanitary defects of the City, I subjoin two tables[14] illustrating the relative mortality of the several sub-districts. The first of these tables indicates numerically the local distribution of the year’s deaths, and gives their proportion to the population of each district and sub-district. The second relates particularly to the last quarter, and illustrates the pressure of the epidemic. The two together furnish a synoptical view of the several rates of mortality, as calculated for the entire City, for the Unions separately, for the sub-districts separately; and for the last quarter of the year separately. In the tedious process of constructing these tables, I have been careful to avoid every source of inaccuracy, and believe that they present you with a true measure of the health of the City during the past year.

[14] I have not reprinted these tables quite as here described. The local distribution of the 3763 deaths of the year is given in the Appendix, No. III.; and the sub-district death-rates of the year, as nearly as I can get them, in a note overleaf, page 6. The high mortality of this summer quarter (in which 1395 persons died) will be best appreciated by the reader in referring to Appendix, No. XIV.; where it can be compared with the mortality of similar periods of time in the four other years there accounted for.--J. S., 1854.

From these comparative tables it will be observed, that the high mortality of the population does not affect the entire City equally; that, in some of its portions, the rate of death approaches the _minimum_ standard much more nearly than in others; that in those districts where the general rate is best, the temporary aggravation from epidemic causes has likewise been least; and that our aggregate City rate, either for ordinary times or for a period of epidemic disease, is compounded from the joint result of several very different proportions. Reference to the Registrar-General’s tables will enable any one to see that the ordinary rate of mortality for the West London Union is a fourth higher than the rate for the City of London Union, while the rate for the East London Union bears a still higher proportion; and these very different rates are, as it were, merged in the one aggregate rate, struck for the whole City, as comprising the three unions referred to. It will be obvious, therefore, that many parts of the City are much healthier than this aggregate rate would signify, while others are much unhealthier. In regard of last year, for instance, the aggregate rate of mortality was (as I have stated) 30 per thousand of the general population of the City: but if this rate be analysed by examination of the sub-district mortality, it will be seen that in one sub-district the rate of death stood nearly as low as 20; that in another sub-district of the same union it rose to 36, and in a third sub-district (of another union) to within a small fraction of 40.[15]

[15] On account of changes of population shown by the subsequent Census, these figures would require correction. The death-rates _per_ thousand in the several sub-districts were probably about as follows, viz.:--

+-------------+------------------------------ EAST LONDON UNION.|W. L. UNION. | CITY OF LONDON UNION. ---------+--------+------+------+-----+-----+------+-----+----- St. |Cripple-|North.|South.|S. W.|N. W.|South.|S. E.|N. E. Botolph. | gate. | | | | | | | ---------+--------+------+------+-----+-----+------+-----+----- 26½ | 32 | 34 | 41 | 38 | 22 | 24 | 21⅔ | 22 ---------+--------+------+------+-----+-----+------+-----+-----

J. S., 1854.

If it were possible to furnish you with statistics derived from a still smaller sub-division of each district, these points would be infinitely more manifest. In some limited localities of the City you would probably find an approximation to the average mortality of suburban districts; while in other spots, if they were isolated for your contemplation, you would see houses, courts, and streets where the habitual proportion of deaths is far beyond the heaviest pestilence-rate known for any metropolitan district aggregately--localities, indeed, where the habitual rate of death is more appalling than any which such averages can enable you to conceive.

These facts are quite unquestionable, and I have felt it my duty to bring them under your notice as pointedly and impressively as I can; feeling assured, as I do, that so soon as you are cognisant of them, every motive of humanity, no less than of economical prudence, must engage you to investigate with me, whether or not there may lie within your reach any adoptable measures for lessening this large expenditure of human life, and for relieving its attendant misery. It is, therefore, with the deepest feeling of responsibility that I proceed to fulfil the main object of my First Annual Report, by tracing these effects to their causes, and by explaining to you, from a year’s observation and experience, what seem to me the chief influences prevailing against life within the City of London.

* * * * *

My remarks for this purpose will fall under the following heads, viz.:--

I. Defective house-drainage;

II. Incomplete and insufficient water-supply;

III. Offensive or injurious trades and occupations;

IV. Intramural burials;

V. Houses insusceptible of ventilation, and absolutely unfit for habitation;

VI. The personal habits of the lowest classes, and the influence of destitution in increasing their mortality.

In treating of these topics, I shall not pretend to bring before you all the details on which my opinions are founded, or to enumerate under each head those infinite individual instances which require sanitary correction. It is my wish at this time to submit to you only such general considerations as may show you the largeness of the subject, its various ramifications, and its pressing importance; and it is my hope that these considerations may suffice to convince you of the necessity which exists in the City of London for some effective and permanent sanitary organisation.

HOUSE-DRAINAGE.

I. It is not in my power to lay before you any numerical statement of the proportion of drained to undrained houses. From such information as I possess, I may venture to speak of imperfect house-drainage as having been a general evil in all the poorer districts of the City; and the latest intelligence on the subject leads me to consider this great evil as but very partially removed. So far as I can calculate from very imperfect materials, I should conjecture that some thousands of houses within the City still have cesspools connected with them. It requires little medical knowledge to understand that animals will scarcely thrive in an atmosphere of their own decomposing excrements; yet such, strictly and literally speaking, is the air which a very large proportion of the inhabitants of the City are condemned to breathe. Sometimes, happily for the inmates, the cesspool in which their ordure accumulates, lies at some small distance from the basement-area of the house, occupying the subsoil of an adjoining yard, or if the privy be a public one, of some open space exterior to the private premises. But in a very large number of cases, it lies actually within the four walls of the inhabited house; the latter reared over it, as a bell-glass over the beak of a retort, receiving and sucking up incessantly the unspeakable abomination of its volatile contents. In some such instances, where the basement story of the house is tenanted, the cesspool lies--perhaps merely boarded over--close beneath the feet of a family of human beings, whom it surrounds uninterruptedly, whether they wake or sleep, with its fetid pollution and poison.

Now, here is a removable cause of death. These gases, which so many thousands of persons are daily inhaling, do not, it is true, in their diluted condition, suddenly extinguish life; but, though different in concentration, they are identically the same in nature with that confined sewer-gas which, on a recent occasion, at Pimlico, killed those who were exposed to it with the rapidity of a lightning stroke. In their diluted state, as they rise from so many cesspools, and taint the atmosphere of so many houses, they form a climate the most congenial for the multiplication of epidemic disorders, and operate beyond all known influences of their class in impairing the chances of life.

It may be taken as an axiom for the purposes of sanitary improvement, that every individual cesspool is hurtful to its vicinage; and it may hence be inferred how great an injury is done to the public health by their existence in such numbers, that parts of the City might be described as having a cesspool-city excavated beneath it.

I beg most earnestly to press on the consideration of your Hon. Court, the extreme importance of proceeding with all convenient speed to alter this very faulty construction, and to substitute for it an arrangement compatible with the health of the population.