disposed, is the following:--first, as heretofore, the weekly list would
contain all places needing investigation on the ground of such deaths
and illness as are usually associated with preventable causes, in order
that any sanitary defects may at once be remedied in them; secondly, in
each week there would fall due a certain number of sanitary works
(relating to house-drainage, water-supply, and the like) for which you
would have previously issued orders requiring them to be completed
within a stated time, and on the satisfactory execution of these it will
be the Inspectors duty to examine and certify; thirdly, in each district
I would have a certain rota of visitation, according to the badness of
the spot and its known liability to fall into filthy and unwholesome
condition, requiring one set of houses to be seen weekly, another set
fortnightly, another monthly, another quarterly, and so on--a rota,
varying from time to time with the changing circumstances of each
locality; and, out of this rota, each week would supply a stated number
of cases for inquiry, to which I should occasionally add certain of
those establishments in which offensive occupations are pursued. Thus,
in the large number of weekly visits which I suppose the Inspector to
make, there would be a certain proportion of that more elaborate kind
which involves an examination of the entire house; another proportion,
made for the sole purpose of seeing that previous orders have been
executed; another proportion, repeated at fixed intervals, simply to
ascertain that houses, once cleansed and repaired, are not relapsing
into filth, nor their works becoming inefficient.
By utilising, on some such plan as this, the increased staff which you
have appointed for the purpose, and by giving to its execution my
continual superintendence, I trust to be able, from time to time, to
certify you that the City becomes better and better capable of resisting
epidemic invasion.[85] From such statements as I have set before you, on
the local affinities of disease--not of Cholera alone, but of typhus and
its kindred, you will be prepared to expect increased sanitary
advantage, from this more systematic suppression of the causes of death:
and I believe you will not be disappointed. Whether the anticipated
pestilence rage in our metropolis or not, you will be combating, day by
day, the influence of other malignant diseases. Whenever it may be in my
power to tell you generally of the City, that the dwellings of the poor
are no longer crowded and stifling; nor their walls mouldy; nor their
yards and cellars unpaved and sodden; nor their water-supply defective;
nor their drainage stinking; nor their atmosphere hurt by neighbouring
nuisances; then, gentlemen, whether Cholera test your success or not,
surely you will have contributed much to conquer more habitual enemies.
For whatever there may be specific and exceptional in the production of
Cholera, at least it touches no healthy spot: the local conditions
which welcome its occasional presence are, in its absence, hour by hour,
the workers of other death; and in rendering a locality secure against
the one, you will also have made it less vulnerable by the others.
[85] I may take this opportunity of mentioning that, during the last
few months, the increased sanitary staff has been worked with very
great advantage.--J. S., May, 1854.
As a last suggestion in this part of my subject, there are two steps
which I would recommend to your Hon. Court, as likely to assist the
labours of your officers, and to bring a large quantity of important
information before you:--first (according to a plan adopted here in the
last epidemic) that printed notices should be posted in every
back-street, court and alley of the City, and should be renewed once a
month, advising the careful maintenance of cleanliness in all houses,
and inviting all persons who are aggrieved by any nuisance, or by any
neglect of scavengers and dustmen, or by any defect of water-supply,
forthwith to make complaint at your Office, or to the Inspector of the
district, whose name and address might be subjoined; secondly, that a
circular letter should be written to all persons in parochial authority,
also to other clergy, to heads of visiting societies and the like,
begging them to communicate with your officers on every occasion when
any local uncleanliness or nuisance may come within their knowledge.
* * * * *
3. Finally, gentlemen--in the probable anticipation that next year
Cholera will prevail in London with at least its former severity, it may
be claimed of my office, that I should say something with respect to
personal precautions for avoidance of the disease. While most willing to
place at your disposal any useful results of my practical experience in
the matter, I cannot but feel the great difficulty of making general
suggestions in a form really capable of particular application.
From the eminently local prevalence of the poison, it may be inferred
that, for all whose circumstances allow an option in the matter, the
first and most important precaution would consist in avoiding those
localities where the epidemic is active. Our knowledge of the subject
enables us confidently to say that, if in one spot the chance of being
attacked by Cholera is as 1 to 100, in another it becomes 1 to 50, in a
third 1 to 5, in a fourth almost an equal chance whether to be attacked
or not. Nothing is gained towards security by the mere act of leaving
our metropolitan area, if one resorts to some other place where the
system of drainage is equally vicious, or where--as at our nearest
bathing-place, the beach is made almost as offensive by sewage as here
the river-banks.[86] From earlier statements in my Report, it will be
obvious to you that the eligible sites of residence are those which
stand high and dry, with clean effectual drainage of their soils and
houses, conveying all organic refuse beyond range of the local
atmosphere.
[86] Unless the sanitary improvement of Brighton be soon set about in
earnest, the reputation for healthiness, which established its
prosperity, will undergo a very sensible reverse. The natural
advantages of the place are now almost neutralised by the evil
adverted to in the text, and by other filthinesses of the kind.--J.
S., 1854.
I will not pass this part of the subject without admitting that the
course here suggested might involve a considerable desertion of
particular localities, and a transient injury to their commerce. This
unavoidable result of proclaiming the laws of the disease, I must regret
in regard of its personal bearings. But the facts of the case are
all-important for the public; and sanitary improvement will perhaps
move more quickly in the country, when it is known that the pecuniary
prosperity of places may suffer from their reputation for endemic
disease.
In case of Cholera prevailing with severity in spots containing a dense
poor population, great assistance would be given to medical and sanitary
measures, if a number of empty unlet houses, healthily situated, were at
the disposal of the authorities; into which, under proper regulations,
they might induce certain of the poorest families to migrate for a time,
as to places of refuge, till the disease should have subsided about
their original dwellings.
For persons, whose circumstances or duties retain them unavoidably in
the midst of those suffering districts where the poison is most active,
the best counsel I can offer--even if at first hearing it seem
vague--is, that they should be vigilant as to preserving the greatest
possible soundness and vigour of general health; keeping the body, so
far as may be, undisturbed by extremes of heat and cold, undepressed by
long confinement, unfluttered by violent passions, unexhausted by
physical or mental fatigue, untried by any excess or any privation;
taking for diet a sufficiency of fit and nutritive food, rather in
generous measure than otherwise, but far from the confines of
intemperance; and giving meanwhile a prompt attention and cure to
whatever accidental ailments may arise.
Such, in general language, are our best fortifications against the
poison. It may be well, however, to add that in our metropolitan
climate--perhaps everywhere else--the human frame tends to require some
periodical aid from medicine. It may be the excitement and labour of
London; it may be its atmosphere; it may be native peculiarity: but
thus the fact stands--that there are few persons who do not at intervals
require the re-establishing effects of what is called _tonic_ treatment.
Probably three-fourths of the prescriptions we write are aimed at this
mere tendency to depression in the human body, as manifested in one form
or another. Now, as a man, going on some distant voyage of exploration,
submits his chronometer to a last intelligent scrutiny, before he
exposes it to the ordeal of other climates, so, in this matter of
frequenting infected districts, men will do prudently, before they pass
into perils which may test their powers of resistance, to see that they
carry about with them no enfeeblement or disrepair which a short
submission to medical discipline could effectually remove. For with
epidemic poisons generally, and in a marked degree with Asiatic Cholera,
it seems that all states of languor, depression, and debility enhance
the risk of infection.[87]
[87] For my medical readers, I may suggest that perhaps the daily use
of _sulphate of quinine_, in small doses, during the height of the
epidemic, would seem to deserve trial as a prophylactic; subject, of
course, to what each practitioner is best able to estimate--of
personal peculiarity in the patient, forbidding the use of this
drug.--J. S., 1854.
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.