Part 32

I am very far from considering that these arrangements have been perfect. Circumstances beyond my control have prevented me from constructing as complete an organisation as I could wish; and the fact that your Inspectors are very largely employed in other duties, has perhaps occasionally given some hurry and imperfection to their share of the work. Still, such as it is, this system has been the means of considerable advantage; and I am glad to be able to claim for your Hon. Court the distinction of being first in the metropolis to have established an arrangement for the systematic sanitary visitation of the dwellings of the poor. In relation to this subject, I beg to inform your Hon. Court that your Inspectors have discharged, with much zeal, intelligence, and industry, the duties which you authorised me to impose on them.

During the last few weeks it has become obvious to your Hon. Court that the duties of this department of your service have grown to such dimensions as to necessitate some increase of your staff; and acting on this opinion, mainly with a view to render more complete your sanitary supervision of the City, you have just appointed two additional Inspectors of Nuisances. In making this appointment, you have determined not to restrict any two or three Inspectors exclusively to the business of house-inspection, but to allot the joint duties, sanitary and surveying, equally among their number: parting the area of the City into six, instead of four, Inspectors’ districts; so that each Inspector shall give a certain proportion of time to the duties which he has to fulfil under your Surveyor’s direction, and another certain proportion to those in which he will be engaged under the direction of your Officer of Health. It is only some experience of this arrangement that can decide whether it will be the most effectual for your purpose; but in the mean time I have studied so to dispose the industry of your increased staff, under the arrangement you have ordered, as to obtain the most systematic and efficient discharge of those duties which you have desired me to superintend.

Reckoning that each Inspector, if he fulfilled no other duty, could report on the condition of about fifty houses per diem, I presume that henceforth, in each of your five more important districts, from one hundred to one hundred and twenty houses can be visited weekly by the Inspector, without encroaching on the time required for his other duties.

The general plan, on which I would propose that this force should be 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. 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.

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.

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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. 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.

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.

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.

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