II
Previous to the fifth decade of the last century it was only very rarely that the prevalence of disease, or any subject connected with the health of the community, received recognition by Parliament.
In 1840 the Medical Society of London, in a petition to Parliament, called attention to the increase of smallpox, and to its preventability by vaccination, and to the imperfect means of vaccination throughout the country.
The mortality from this—“one of the greatest pests that ever afflicted humanity”[26]—was very great. In one city in the south of England no less than 500 persons had died of it in one year. In London in 1839 upwards of 1,000 had died of it.
And Parliament, after an unusual amount of discussion, passed an Act[27] for extending the practice of vaccination, and enacted that Boards of Guardians might contract with their Medical Officers or other medical practitioners “for the vaccination of all persons resident in their Union or Parish.”
And at the same time “inoculation” or “otherwise producing smallpox” was made penal—to the extent of one month’s imprisonment.
In 1846 there was a sudden display of Parliamentary energy in health matters.
The total want of baths and wash-houses for the poorer classes of the people in the towns was brought under the notice of the Legislature, and, as it was deemed “desirable for the health, comfort, and welfare of the inhabitants of towns, &c., to encourage the establishment therein of baths, wash-houses, and open bathing places,” an Act was passed giving power to the Parochial Authorities to establish such institutions and to borrow money for the purpose.[28]
Their provision would have tended to an increased degree of cleanliness among the people, and consequently an improved sanitary condition, but it was long before many of these institutions were established, the local authorities being slow in availing themselves of the facilities thus offered, and this piece of legislation—like every other of the sort—being purely permissive or facilitatory.
And in the same year Parliament so far awakened to the fact that certain causes of disease were removable, that in a preamble to an Act[29] it acknowledged that it was “highly expedient for the purposes of preserving the health of Her Majesty’s subjects that better provision should be made for the removal of certain nuisances likely to promote or increase disease.”
The better provision made by the Act did not amount to much. There were two forms of insanitary evil to be combated: one the chronic insanitary condition of the masses of the people, the other the invasion of the country by some exceptional or unusual epidemic disease.
As to the former, authority was given to certain public officers, on receipt of a certificate of two medical men, to complain of the existence of certain nuisances. The Justices before whom the case was heard might order the abatement of the nuisance; and if the order were not obeyed, the parties complaining might enter upon the necessary cleansing of such dwelling, and the cost of the same might be imposed on the owner or occupier.
In London, the power of complaint was vested in the officers of those petty local bodies which have already been described, and, in their default, in the Boards of Guardians.
Ludicrous, truly, was the idea that the countless thousands of nuisances existing in London could be remedied, or even temporarily abated, by so cumbrous, dilatory, and complicated a procedure as the complaint of an individual backed by the certificate (which would have to be paid for) of two doctors to the officer of a more or less hostile and self-interested local body, who might or might not bring the complaint before the Justices, whose decision, even if it were in favour of the complainant, could only effect a reform so far as the precise nuisance complained of was concerned, and that only temporarily, for were the nuisance renewed the whole procedure would have to be gone through again.
Yet this was the “better provision” propounded and enacted by Parliament in 1846 for the regeneration of the sanitary condition of the great masses of the people of London. Nor was it even intended to be permanently available, for the Act was only to be in force for two years.
The dreadful nemesis for such dense inappreciation by Parliament of its obligations to the community was, unfortunately, soon to fall heavily upon the unhappy people of the metropolis. Thousands of miles away in Hindoostan, Asiatic cholera of a deadly type had been playing havoc with the people of the country. Thence it was slowly but steadily moving westward; so much so that the desirability of making some preparations for defence against its invasion of England became apparent; and in 1847 a Royal Commission was appointed to “inquire whether any, and what, special means might be requisite for the improvement of the health of the metropolis, with regard more especially to the better house, street, and land drainage, … the better supply of water for domestic use, &c., &c., &c.”
One important conclusion was at once forced upon the Commissioners, namely, that the great and vital task of making adequate provision for the sewerage of London could not be accomplished so long as it was entrusted to several bodies, each with a district of its own.
“Everything,” they said, “pointed to the necessity of operations being superintended by one competent body”; and they declared that it was expedient that a Commission for the entire drainage of the whole of the metropolis should be appointed with a special view to such measures, and with aid to carry them out.
This report was followed in the ensuing year (1848) by an Act of Parliament[30] abolishing the various Commissions of Sewers (except those of the City), and creating in their stead one executive body whose members were to be appointed by the Crown.
Wide powers were given to this central body: among them that no house was to be built or re-built without proper drains, and without proper sanitary conveniences, and that if houses built before the passing of the Act were not properly drained, the Commissioners might order the work to be done.
The Metropolitan Commissioners of Sewers were duly appointed, and they divided the area over which they had jurisdiction into seven separate sub-districts, with a Commission for each.
The creation of this body constitutes a great landmark in the sanitary evolution of London, for it was the first recognition by Parliament of the great principle of the unity of London; of the necessity—at least so far as regarded one matter—for one central governing authority for the numerous populations, and bodies, and districts which were becoming welded together into one mighty town and one vast community.
It is true, the recognition extended only to this one matter, and that the Central Board was to be a Board nominated by the Crown, and without any vestige of representation upon it, but none the less it was a forward step towards a sounder and wiser system of government than that which had hitherto prevailed.
That the new body failed to prove equal to the task imposed upon it was due as well to the constituent members thereof as to the imperfections of the machinery devised by the Act. Its failure, however, in no way controverted the soundness of the great principle thus, for the first time, recognised by Parliament.
The evidence given before the Royal Commissioners brought into view the enormous area of filth and limitless insanitation in London: it displayed some of the principal sources of the excessive amount of disease and premature mortality; and to some extent it elucidated the principles and demonstrated the practicability of large measures of prevention. And it also disclosed the regrettable fact that since the epidemic of cholera in 1832 there had been little or no improvement in the sanitary condition of many parts of the metropolis—indeed, in most parts of it the evils were wider spread and acuter in form, whilst, owing to the increase of population, the numbers affected were vastly larger.
All the while the Commissioners were sitting, the evil seeds of insanitation were producing a tremendous crop, and events actually occurring at the moment emphasised the crying need for some means of grappling with the intolerable existing evils. The whole class of zymotic diseases—diseases which constitute the true gauge of the healthiness or unhealthiness of a community—received a rapid and immense development.[31] From 9,600 deaths from such diseases in 1846, the number increased to 14,000 in 1847; and in this latter year the metropolis was visited by two epidemics which rendered the mortality of the last quarter of the year higher than that of any other quarter of any year since the new system of registration of deaths had been commenced.[32] Typhus fever produced fourfold its ordinary mortality—other diseases showed a similar increase—and towards the end of November influenza broke out and spread so suddenly and to such an extent that within five or six weeks it attacked no less than 500,000 persons out of 2,100,000—the then population of London. Altogether the excess of mortality in 1847 over 1845 was very close upon 50,000 persons.
The attitude of Parliament and of successive Governments about this period, as regarded the insanitary condition of the masses of the inhabitants of London, is now almost incomprehensible. The plea of ignorance cannot be urged in exculpation, for their own Blue Books and official returns were there to inform them. Moreover, the existence of similar evils throughout the country, where they were on a very much smaller scale, was recognised both by the Government and Parliament.
Lord Morpeth, a member of the Cabinet, speaking in 1848 in the House of Commons, said[33]:—
“It is far from any temporary evil, any transient visitant, against which our legislation is now called upon to provide. It is the abiding host of disease, the endemic and not the epidemic pestilence, the permanent overhanging mist of infection, the annual slaughter doubling in its ravages our bloodiest fields of conflict, that we are now summoned to grapple with.”
Yet they resolutely shut their eyes to the huge mass of misery and fearful waste of life which was going on at their very doors, and all around them. This was proved beyond controversy by their action in 1848. In that year the Government introduced into Parliament a measure which was, in effect, a comprehensive sanitary code, and which, if duly enforced, was capable of conferring vast benefit on the community at large.
Describing the provisions of the Bill, Lord Morpeth said:—
“It will be imperative upon the local administrative bodies to hold meetings for the transaction of business; to appoint a surveyor; to appoint an inspector of nuisances; to make public sewers; to substitute sufficient sewers in case old ones be discontinued; to require owners or occupiers to provide house-drains; to cleanse and water streets; to appoint or contract with scavengers to cleanse, cover, or fill up offensive ditches; … to provide sufficient supply of water for drainage, public and private, and for domestic use.
“The permissive powers to be granted to the local administrative bodies … include the power to make house-drains upon default of owner or occupier, to make bye-laws with respect to the removal of filth, to whitewash and purify houses after notice … to require that certain furnaces be made to consume their own smoke … to provide places for public recreation, to purchase and maintain waterworks.”
The Bill, which was duly passed and became an Act, in fact provided means for coping with many of the sorest dangers, it curbed some of the powers for evil which so many persons had such little scruple in exercising; it provided methods for bringing to punishment at least some of the evil-doers who hitherto had gone scot free; and it held out some prospects of the diminution of the huge death rate and still huger sick rate.
Though a somewhat similar Bill, introduced in 1847, and which was withdrawn, had included the metropolis, this Act did not apply to the metropolis. Its application was limited to the rest of England and Wales. London—the capital of the kingdom—was, it was said, “reserved for a separate Bill.” “The separate Bill,” however, did not make its appearance. The subtle, all-pervading influence of vested rights was too powerful for any such reform to be attempted.[34] And so, the Government and Parliament, deliberately excluding the metropolis from this beneficial legislation, left untouched the centre and main emporium of disease, and left the people of London exposed on all sides to the merciless onslaught of the direst diseases which can afflict mankind.
Cholera, however, the only power able to awe the Government, was now so close at hand that some special provision had to be devised for the protection of the public health. Parliament, this time not excluding the metropolis, re-enacted the trumpery “Nuisance Removal and Diseases Prevention Act” of 1846, with some slight enlargements, and one important addition, namely, authority for the appointment by the Privy Council of a General Board of Health, which might issue directions and regulations for the prevention of epidemic and contagious disease.
Upon this slender thread Londoners were left dependent for such measures as might afford them some protection against the impending epidemic. No other help was at hand. Nor was there much time for help to be organised or preparations made, for cholera had reached Egypt and Constantinople, and by June, 1848, had crept forward to St. Petersburg. Isolated suspicious cases occurred in London in the summer of 1848,[35] then an undoubted case in Southwark on the 22nd of September, and then more undoubted cases, and the disease had secured a footing. As the winter approached it died down and ceased, having carried off some 468 victims.
The Privy Council had appointed a General Board of Health, and early in November the Board issued regulations directing the Guardians to take the necessary measures for the cleansing of houses, the abatement of nuisances, and generally for the removal of all matters injurious to health. To direct is one thing, to get obeyed is another, and with some few exceptions, these directions were disregarded. Partly, the fault was Parliament’s.
The Act, by naming various local authorities, had created a divided power, and consequently a divided responsibility, which resulted in inaction, neglect, delay, and loss of life; and though the General Board of Health might require the Boards of Guardians and other local bodies to put the regulations into force, they had no power to compel them to do so, and in default of such power the General Board of Health was almost helpless.
The cessation of the disease proved to be only temporary. Scarcely was 1849 entered on than the epidemic broke out again, steadily gathering momentum as the summer went on.
In Bethnal Green there was an outbreak in the night—sudden and panic-striking—“consternation and alarm were spread abroad—the hurried passing and re-passing of messengers, and the wailing of relatives, filled the streets with confusion and woe, and impressed all with a deep sense of awful calamity.”
And the epidemic spread and spread until in one week in September (1849) the deaths from it amounted to 2,026.[36]
Were the full facts known, the mortality was doubtless far higher.
And then the epidemic began rapidly to abate, and by the end of the year had ceased, having slain some 14,600 victims.[37]
Numerous and important were the lessons inculcated by this disastrous epidemic. It afforded the most definite evidence that had yet been obtained of the influence upon health of local conditions and pre-disposing causes.
It showed that in the most violent and extensive outbreaks of the pestilence its virulence was invariably confined to circumscribed localities. It showed that the habitat of cholera and the habitat of fever were one and the same.
Deaths from cholera took place in the very same streets, and houses, and rooms, which had been again and again visited by fever; and rooms were pointed out where some of the poor people had recovered from fever in the spring to fall victims to cholera in the summer.
As it was tersely summed up by one of the most active and capable medical officers of the Board of Health:—
“We find but one cause of so much sickness, suffering and death—the prolific parent of all this diversified offspring—‘filth.’
“It is in filth, in decomposing organic matter, that the main causes of epidemic diseases are to be sought out—filthy alleys, filthy houses, filthy air, filthy water, and filthy persons.”
What the General Board of Health could do, it did, as was indeed to be expected from such sanitary enthusiasts as Lord Ashley, Dr. Southwood Smith, and Mr. Edwin Chadwick, but the local authorities were dilatory, lukewarm, or actually hostile, and their proceedings, where anything was done, were altogether inadequate for insuring those prompt, comprehensive, and vigorous measures so urgently demanded in the presence of a great and destructive epidemic such as malignant cholera.
The system of house-to-house visitation was essential for the discovery and checking of the disease, but, wrote the Board, “nothing effective was done or attempted in the metropolis. We repeatedly and earnestly urged upon the Boards of Guardians the importance to the saving of life of making immediate arrangements for special measures of prevention, but our representations were made in vain.
“The local authorities could not be induced to carry into effect the preventive measures we proposed.”
Several unions and parishes, among whom were some of the most wealthy and populous, positively refused to comply with the directions of the Board.
In the case of Bethnal Green, just described, the Board issued a “Special Order.” But even under these urgent circumstances “the Board of Guardians appointed no medical officer for five days, they provided no nurses, they established no hospital, they opened no dispensary, they appointed one inspector of nuisances instead of two, and they made no provision for extensive and effectual lime-washing.”
The explanation of the inaction and hostility of the local authorities lay in the fact that the various measures prescribed by the Act interfered with private interests, and especially with interests which were largely represented on the Boards of Guardians. Among the members of those boards there was often “an antagonistic power” at work which prevented proper attention being paid to the sanitary condition of the localities of the poor. In many instances, owners of small houses and cottage property, to which class of dwellings the provisions of the Act more particularly applied, were themselves members of such boards, and when this was not the case, they exerted an influence not the less powerful because it was indirect. This interest often conspired to impede efficient sanitary measures.[38]
Local interests also operated, the apprehension being that if active and really efficient measures were adopted the trade of the neighbourhood would suffer.
In one instance—an instructive one—where the epidemic had extensively prevailed among the poor, its existence was denied, and house-visitation resisted, till, after considerable delay and loss of life, a number of shopkeepers were attacked by the disease, and then, all opposition ceased.
The evidence of the unfitness of the local authorities charged with the administration of the Act for the duties imposed upon them was overwhelming. The unfortunate position was accentuated and intensified by the fact that the General Board of Health had no power either of compelling the local authorities to do their duty or of itself acting in default of their neglect; and the absence of this first essential of effective administration hampered and crippled its action.
The Board summed up its experience of this great visitation of 1848–9:—
“The evidence shows that where combined sanitary arrangements have been carried into effect the outbreak of the pestilence has been sometimes averted; that where not prevented, its course has been gradually arrested.
“That where material improvements have been made in the condition of the dwellings of the labouring classes, there has been an entire exemption from the disease, and where minor improvements were made, the attacks have been less severe and less extensive.
“That with reference to the measure of prevention, the immunity from the disease has been in proportion to the extent to which those measures have been carried into effect systematically and promptly.”
By the end of the year the epidemic was practically over. And then the usual thing took place.
It is described a few months later by Dr. Grainger, who wrote:—
“In many of the most densely populated districts the inspectors of nuisances have been dismissed, the cleansing operations have been relaxed, and there is too much reason to apprehend that the courts and alleys will lapse back again into their accustomed filth, … that houses proved by the evidence of medical officers, inspectors, and local authorities to be unfit for human habitation will long continue to remain ‘pest-houses,’ spreading disease around; and that, in the midst of these tolerated and accumulated evils, the industrious classes will continue as heretofore to be decimated by fever, or, should it again break out, by cholera.”[39]