REPORT ON CHOLERA IN ENGLAND: 1848-49.*
ALTDoncin not free from an unavoidable minuteness of statistical details in regard to the localities of the cholera in England, and the various facts connected with the age, sex, and probable conditions of the patients, this Report is one of the ablest of Mr. Farr's productions. It brings together with great clearness and skill the medical and hygienic facts connected with the disease, and
applies them with sound judgment; it sketches the history, probable origin, and general concomitants of cholera ; pass-
ing beyond and above the nominal subject of cholera in Eng- land, it investigates the general laws of health and the phy- sical and mental qualities both of man and other animals, so far as locality, air, earth, and water, may be presumed to influ- ence them ; from this survey it not only offers practical hints for individual self-management and conduct in the choice of habita- tions, but adduces reasons, which may be called historical, touch- ing the decline of empires and one of the means of averting their fall. There is, of course, not the slightest trace of politics in the report; but it is impossible to read its facts as to the effects of bad drainage or total absence of drainage, the want of hygienic pre- cautions owing to the insufficiency of sanitary laws, the manner in which two great elements of existence, air and water, are corrupted from these causes—reducing the vigour of life, and facilitating the spread of pestilence among the people—without calling to mind what boastful hygienic promises were made by the late Ministry when Sanitary Reform was a question, and how coolly that ques- tion was dropped when it ceased to answer an interested purpose. The basis of the Report is the registration-returns. By means of the extensive and thoroughly organized system of registrars and deputy registrars, "the name, sex, age, and occupation of every
person who dies in England, as well as the time, place, and cause of death, are registered." In special cases, remarks are made by
the registrar or medical man; in such an invasion as cholera, the officers are expected if not directed to add these notes wherever the case requires them. By these arrangements, every case of every
variety of cholera and diarrhoea is recorded in its salient facts, and very often with its particulars. " When the epidemic was over, it appeared desirable to give a complete abstract of the facts. Accordingly, a list of every ease of death from cholera and diarrhoea in 1849 was transcribed from the Registration volumes." "The whole forms a large mass of manuscript, which contains the parti- culars of 72,180 deaths. Upon inquiry it was found that the list of persona
who died of the two diseases would fill a thick octavo volume of about 2500 pages. Three courses were open : (1) to publish those facts simply ; (2) to publish the tabular abstracts in detail; or (3) to publish the abstracts and the salient facts relating to each locality in a condensed form. The publica- tion of the cases in detail would have been attended with several advantages: it would have enabled the medical men of the country to study the particu- lar facts in their respective districts, surrounded by the circumstances which affect and modify the mortality ; and the publication of an extended tabular summary of the daily deaths in each of the 2189 sub-districts of the country would also have possessed interest. As the work on either plan would, how- ever, have been exceedingly voluminous, the third course was adopted : in the mean time, the manuscript list of the 72,180 cases, and the extended tabu- lar abstracts, are preserved among the records of the General Register Office, and will always be accessible to the local inquirer, as well as to the general student of this great and extraordinary epidemic."
The arrangement of these facts in the volume before us is con- tained in ten tables, filling with the notes attached to them three hundred pages, and exhibiting various statistics of the cholera in England for the years 1848 and 1849. There are the deaths of each sex, with their proportionate numbers to the popu- lation of 1841 in all England, and its forty-eight registration sub- divisions. Other tables represent the ages, and again the duration of the attacks. The deaths day by day throughout 1849 are displayed, and the same features of the disease in greater detail in London, the counties, and the divisional districts. In short, the tables with their accompanying notes give as full and clear an exhibition of the statistics of the subject as it was possible to do in the space, and reflect great credit both on the judicious plans of the author and on the efficiency of his assistants.
The merit and general attraction of the work, however, lie much less in the tables than in the report itself. This not only applies the materials as well as the further information in possession of the office to the ostensible subject of cholera in England in 1848-49. It travels into the whole question of pestilence and public health, as connected with those obvious hygienic precautions over which the state can exercise influence ; bringing varied medical acquire- ments and philosophical thought to bear upon the subject. It runs over the history of plagues in England ; investigates the general rates of mortality at different ages and different places ; traces the Asiatic and European course of cholera till its arrival in this coun- try, and, after briefly noticing previous visitations, proceeds to point attention to the most striking facts connected with the last visitation ; exhausting the subject in various aspects, not only as respects sites, age, sex, duration, but the influences of the weather, the season of the year, &c. These topics are followed by more important and still more generally interesting matter. The pro bable cause of cholera itself is investigated; as well as the causes of its varying mortality in London, with respect to water supply, elevation of soil, density of population, and wealth and poverty, so far as they can be estimated from general statistics. The different theories that have been broached in connexion with the origin and propagation of pestilence are next discussed ; and the report closes
• Report on the Mortality of Cholera in England: 1848-49. Printed by Clown for her Majesty's Stationery °Mee.
with a broad and comprehensive essay on the fatality-of low places to health, life, and race. Surveying the regions in which ague and remittent fever, yellow fever and plague, are most prevalent and moat fatal, Mr. Farr finds that, like cholera, they are most noxious on low marsh lands, along low-lying coasts, and at the deltas of rivers. He looks at horses, cattle, &c., and finds the breeds of flat moist lands heavy probably in flesh, but sluggish, inert, and spiritless, whilst those produced in hilly or mountainous countries are active, vigorous, alert, and spirited. It is the same, he finds, with man : and the final conclusion he draws is that health and safety are to be found in high, dry, and purely- watered places ; that the choice of sites for many towns, dictated for the most part by gainful objects, slowly saps the vigour of the inhabitants, and finally depreciates the race ; that in founding new towns, especially in colonies, more regard should be paid to per- manent health and less to immediate lucre in the selection of sites ; that in existing towns the evil should be remedied as much as pos- sible by drainage, sufplies of pure water and other hygienic pre- cautions, and where, as at London, good sites for building abound in the vicinity, even artisans should sleep out of town ; for the additional cost, in these days of cheap locomotion, would be amply made up to them in greater health and vigour.
The application of Mr. Farr's opinions on these larger subjects to the state of things around us is the most interesting feature of the volume. It is possible, indeed, that Mr. Farr, like some other modern writers, may ascribe too much to hygienic means, or at least allow too little for moral evils, bad constitutions, and perhaps poverty. It is probable that the deductions from the statistics may require correction, for causes that are occult, or which cannot be embraced in returns. It may be true that though some of the evils admit of remedy by public authority, the public mind, at least the sluggish and interested part of it, would interpose ob- stacles to their removal ; and that even if opinion were more en- lightened, we might have to wait for the advent to power of a genius like Pericles or Cmsar or Augustus. There is no doubt, however, that much of the hygienic evil is clearly proved to exist, and as clearly admits of remedy. Bad water, for example, is one of the most frequent causes of disease ; in the opinion of the Hin- does it is the immediate cause of cholera and remittent fever. In London the mortality from cholera varied in a most remarkable degree according to the water-company from which the district was supplied. Other causes doubtless were at work besides the purity of water, but the operation is too uniform to deny to it a consider- able degree of importance. "The Thames collects the waters of 616ff square miles of country, extend- ing from the Cotswold Hills in Gloucestershire to the Eastern coast ; and the great body of this water flows and reflows through London in tides, which carry the matter below London Bridge, a mile and a half above Battersea Bridge twice a day, and ascend as high as Teddington. The contents of the greater part of the drains, sinks, and water-closets of this vast city, and of the 2,360,000 people on its sides, are discharged through the sewers into its waters ; which, scarcely sullied by the primitive inhabitants, have now lost all their clearness and purity. The dark, turbid, dirty waters from half- stagnant sewers, are agitated by the tides, but are not purified until they reach the sea.
"London derives its supply of water for washing, cleansing, cooking, and drinking, to a small extent from wells ; eighteen districts have supplies from the river Amwell, and from the Lea, a tidal tributary of the Thames ; two districts from the Ravensbourne ; and eighteen districts from the Thames, at five points of its course. The water is generally pumped by steam-power into water-butts or reservoirs in the houses, at intervals of one, two, or three days. As the water is of very different degrees of impurity, it will now be right to state the fatality of cholera in the several water districts of London, arranged under the companies by which the water is furnished.
"Grand Junction Company.—The waters of the Thames at Kew chiefly supply the sub-districts of Paddington, Hanover Square, and May Fair, and the greater part of the district of St. James, Westminster. The mortality from cholera was at the rate of 8 in'10,000 inhabitants.
" West _Middlesex Company.—The waters of the Thames at Hammer- smith supply Marylebone and a small part of Hampstead. The mortality from cholera was at the rate of 17 in 10,000 inhabitants inliarylebone. In Hampstead the mortality was 8 in 10,000.
" Chelsea Water Company.—The waters of the Thames at Battersea, much below Battersea Bridge and below the Chelsea Hospital, supply the Belgrave sub-district of St. George, Hanover Square, and the districts of Chelsea and Westminster. The mortality from cholera was at the mean rate of 47 in 10,000 inhabitants ; in the Belgrave sub-district the deaths from cholera were 28, in Chelsea 46, in Westminster 68 in 10,000 inhabitants. " Southwark Water Company.—The waters of the Thames at Battersea, still lower down the river, supply the districts of Wandsworth, St. Olave, and Bermondsey. The mortality from cholera was at the rate of 147 in 10,000. In Wandsworth the mortality was 100, in St. Olave 181, in Ber- mondsey 161, in 10,000.
"Lambeth Water Company and Southwark Water Company.—The waters of the Thames between Waterloo Bridge and the Hungerford Sus- pension Bridge, supply parts of the districts of Lambeth, St. Saviour, St. George, Southwark, Newington, and Camberwell; the other parts of these districts being supplied from Battersea by the Southwark Company. The mortality from cholera was at the rate of 136 in 10,000. In the district of Lambeth the mortality was 120, St. Saviour 153, St. George Southwark 164, Newington 144, Camberwell 97, in 10,000. " Southwark and East Kent Water Companies.—Rotherhithe is supplied with water partly by the Thames at Battersea and by the Ravenebourne, and partly from ditches and wells, into some of which the drains and cess- pools soak. The mortality from cholera was at the rate of 205 in 10,000 in- habitants.
" East London Water Company.—The Lea supplies the districts of Pop- lar, Stepney, Bethnal Green, SL George's-in-the-East, and Whitechapel with water. The mortality from cholera was at the rate of 63 in 10,000 inhabit- ants ; and 71, 47, 90, 42, and 64, in each of the five districts.
" New liver Water Company.—The Amwell and the Lea supply Islingz ton, St. Luke, Clerkenwell, London City, West London, East London, Hol- born, St. Giles, the Strand, St. Martin-in-the-Fields. The mean mortality from cholera was at the rate of 41 in 10,000 inhabitants ; the mortality was least in Clerkenwell (19), near the head reservoir; greatest (96) in West London, on the edge of the Thames. "Kent Water Company.-The waters of the Ravensbourne supply Green- wich, where the mortality from cholera was 75 in 10,000 inhabitants; and parts of Lewisham, where the cholera was at the rate of 30 in 10,000 inhabit- ants. "Two or more companies supply some districts. The district of St. James, Westminster, is supplied by the Kew and the New River waters : the mortality from cholera was 16 in 10,000 inhabitants. Kensington is supplied by the West Middlesex, the Chelsea, and the Grand Junction Companies : the mortality from cholera was 33 in 10,000. St. Pancras is supplied by the New River, Hampstead, and the West Middlesex Companies : the mortality from cholera was 22 in 10,000. Shoreditch and Hackney are supplied by the New River and the East London Companies : the mortality in the two districts from cholera was 76 and 25 in 10,000.
"Arranging the groups of districts in the order of mortality, it appears that the mortality from cholera was lowest in districts which have their water chiefly from the Thames so high in its course as Hammersmith and Kew. Upon the other hand, the mortality was greatest in the districts which derive their water from the Thames so low down as Battersea and the Hungerford Bridge. The districts of the New River occupy an interme- diate station.
"In the six districts which are supplied with water taken from the Thames at Kew and Hammersmith, 15 in 10,000 inhabitants died from cholera; and the mortality ranged from 8 to 33. " In the twenty districts which are supplied with water from the Amwell, the Lea, and the Ravensbourne, 48 in 10,000 inhabitants died of cholera ; and the mortality ranged from 19 to 96. " In the twelve districts which are supplied with water taken from the Thames between Battersea and the Waterloo Bridge, 123 in 10,000 inhabit- ants died of cholera ; and the mortality ranged from 28 to 205."
This question might be pushed further, but the subject would be unpleasant from its foulness. Water, however, not only influences the system when used for domestic purposes, but, whether fluid or stagnant, affects the air through evaporation.
'The Thames presents a large evaporating surface which must be taken into account, and it gives off vapours day and night in quantities which the phaenomena of a 'London fog' reveal. The still air then condenses the mat- ter which at other times enters the atmosphere invisibly, and escapes obser- vation. The mean lowest night temperature of the Thames, from May 27th to September 15th 1849, was 64' ; the mean lowest night temperature of the air was 52" ; so that the wide simmering waters were breathing incessantly into the vast sleeping city tainted vapours, which the temperature of the air at night would not sustain.
" It is a fact well worthy of attention, that after the temperature of the Thames has risen above 60', diarrhoea, summer cholera, and dysentery be- come prevalent, and disappear as the temperature subsides. The cholera reached London in the new epidemic form about October 1848 ; it prevailed through the winter, and destroyed 94 lives in the second week of January, when the temperature of the Thames was 37' ; it declined rapidly through April and May ; the night temperature of the Thames then rose to 62° in the week ending June 2d; with some fluctuations it went up to 68' in July, and remained above 60' until the middle of September, (week ending September 15th.) The deaths from cholera registered during each of the sixteen weeks were 9, 22, 42, 49, 124, 152, 339, 678, 783, 926, 823, 1230, 1272, 1663, 2026, 1682. The mean night temperature of the Thames fell to 56', the deaths from cholera to 839, in the week September 16-22 ; the temperature gradually fell to 38' on the last week of November, when there was only one death from cholera registered.
" The mortality from cholera increases generally in descending the river on the South side : in Wandsworth it was at the rate of 100 in 10,000 in- habitants, in Lambeth 120 ; St. Saviour, 153; St. Olave, 181; Bermondsey, 161 ; Rotherhithe, 205,-where the water was perhaps most impure ; Green- wich 76, where it had lost some of its impurities.
"On the North side, commencing at the highest part of the river, the mortality from cholera was, in Kensington 33, Chelsea 46, Belgravia 28, Westminster 68, St. Martin-in-the-Fields 37, Strand 35, West London (on the old Fleet Ditch) 96, London City 38, East London 45, Whitechapel 64, St. George in the East 42, Stepney 47, Poplar 71. The mortality from cho- lera in the three sub-districts of Stepney adjoining the Thames was twice as great as in the two districts away from the river. The result is here dis- turbed by elevation. No good analysis has been made of the Thames water at different points of its course ; but the matter in suspension is perhaps greatest between London Bridge and Limehouse Reach against Rotherhithe.
"The seven districts of London in which the mortality is highest from ordinary causes, are the West London District (between Smithfield and the Thames), St. Saviour, Whitechapel, St. George-in-the-East, Chelsea, St. Olave, and Rotherhithe. They all adjoin the Thames."
It cannot be said that these evils are beyond remedy owing to general opinion ;, for on the secession of Lord John Russell to office in 1846, he bid.for popularity by taking up Sanitary Reform. In six years the Water question has produced nothing but some abor- tive bills ; while the drainage of the Metropolis and the purifica- tion of the Thames has been handed over to commissions, which have done nothing effectively but tax and spend. The effect of elevation-that is, of a removal from foul air and bad water-as a preservative from cholera, is perhaps more remark- able. In the first of the following instances, however, mere eleva- tion was not the sole cause of safety. The river-side population of Lambeth is mostly of a low and poor kind, and when not in abject poverty the people are generally dissipated and exposed. In the enormous parish of Lambeth it so happens that we rise in social as we rise in geographical elevation. At Kennington there is a good deal of middle-class respectability mixed with shabbiness and some poverty.' ; at Brixton respectability still further predominates, and is of a higher kind; at Norwood it is probable the social con- comitants are as favourable to life as they well can be. " The great, striking, practical fact which the Inquiry into the Mortality of Cholera in England has elicited, is the influence of slight degrees of ele- vation. In the vast population of London it is rendered evident. In the part of the parish of Lambeth near the level of the Thames, the cholera, in 10,000 inhabitants, destroyed 163; at Kennington, 8 feet high, 90; at Brixton, 56 feet high, 55; and finally, in Norwood, the highest sub-district of the parish, where the inhabitants are at least 128 feet above the river, only 5 in 10,000. And this was not accidental : elevation within these moderate limits operated with the regularity of a general law ; and the in- fluence of elevation has been felt all over the kingdom-everywhere the low cities have suffered.
" Besides the trial which the population has gone through in the epidemic of the world, there is another test of health-the longevity of the inhabit. ants of various places, and the rate of mortality experienced from ordinary causes and home epidemics. The hundred diseases which afflict, derange,
and destroy the frame of man, acknowledge various causes ; camps and cities suffer certainly on low ground from one train of diseases ; in high localities starvation, density, impurities, generate other maladies, which are not less certainly fatal The mortality of a dense, dirty city, on a bill, seated on cesspools, and ill supplied with water, may be higher than the mortality of an open town on the margin of low marshes; but the other conditions being equal, the mortality in the long run will be greatest in the low situation. The causes which make cholera, plague, remittent fever, yellow fever, peri- odically fatal, are always in operation, and furnish their daily quota to the hospital, the sick chamber, and the grave. Accordingly, we find on reverting to the Tables of Mortality, for the seven years 1838-14, that, as a general rule, the mortality declines as we ascend the rivers. The majority of the healthy districts are at a certain elevation above the sea."
Those who wish to pursue the subjects we have alluded to must consult Mr. Farr's Report ; which will well repay the patient reader for the time expended upon it. Before concluding, we will quote one passage from the survey of the decline of empires in connexion with depreciation of race from sanitary circumstances.
"The population of England increased slowly in the seventeenth and in the first half of the eighteenth century. The towns and seaports were not then places of great magnitude, and their population was sustained by immi- grants from the country-the high nursing-grounds of the kingdom. 'The supply of London alone,' says Davenant, from King's observations, takes u above half the neat increase of the kingdom.' The burials greatly exceeded the christenings in London, and it is probable that of the whole population of England only an insignificant portion was born in the low parts of towns and ports. The great increase of the town population in the present century is chiefly due to immigration ; which has not only sustained the old pro- portion of the population, but has introduced a great excess of healthy life from the high inlands. The result is, that a large proportion of the popu- lation of England is now iu the low seaports, manufacturing towns, and cities. The population in 117 districts, comprising the chief towns, was 6,612,958 in 1841, and 7,795,882 in 1851 ; the population in 506 districts, comprising chiefly small towns and country parishes, was 9,301,190 in 1841, and 10,126,886 in 1851. A large proportion of the next generation of Eng- lishmen will consequently be born in town districts ; some of which are high and healthy, while others, low, insalubrious, subject to inundations and to- the incursions of cholera, present many of the circumstances in which a de- gradation of race is inevitable. So, while the drainage of the marshes, the cultivation of the soil, the sanitary measures in the old towns, and the dif- fusion of education, have tended to promote the amelioration of the English race, the descent of the population to the low places, which have in the last ten years increased twice as fast (two per cent per annum) as the healthy parts-the sudden growth of large mining and manufacturing places left un- drained, ill-cleansed-the liberation of multiplying vagabonds and criminals who were in the old times transported, cruelly destroyed by gaol fever, or hanged, have had a tendency proportion to increase the pportion of deteriorated or- ganizations. Idiots and lunatics, who are no longer plunged in cells for a short life, and other persons labouring under hereditary diseases, are also in- creasing, probably from a similar cause. In addition to the inhabitants of the old towns, which have always been fatal, several millions of people are now in the seaports, in South Wales, in Staffordshire, in the mining dis- tricts of the North, in the towns of the West Riding of Yorkshire, and in the. dense districts of Lancashire ; where the health of parents is depressed, and the circumstances are often so prejudicial to their offspring that of the coming generation five instead of two of every ten born are destroyed in the first five- years of life, and the survivors, with a few happy exceptions, are left with shattered, feeble, febrile, and disorganized frames. The countenance of the children is painful in these districts ; and in all the places where cholera has raged, presents the most striking contrast to the healthy, hardy aspect of the children in salubrious fields. Their degeneration is as inevitable as the de- generation of horses, oxen, sheep, in circumstances equally unfavourable. "All analogy, however, proves that no extensive or permanent degenera- tion of a race can be accomplished in less than two or three generations. The great change is as slow and insidious as it is certain. It is rarely per- ceived by its victims ; who remain rooted and benumbed on the spot unless they and the community are aroused by sudden and terrible catastrophes. That angel which, it would seem, it has pleased the Almighty Creator and Preserver of Mankind to charge with this dread mission is the pestilence. Wherever the human race, yielding to ignorance, indolence, or accident, is in such a situation as to be liable to lose its strength, courage, liberty, wis- dom, lofty emotions-the plague, the fever, or the cholera comes; not com- mitting havoc perpetually, but turning men to destruction, and then sud- denly ceasing, that they may consider. As the lost father speaks to the family and the slight epidemic to the city, so the pestilence speaks to nations in order that greater calamities than the untimely death of the population may be averted. For to a nation of good and noble men death is a lees evil
than degradation of race. •
"Great Britain enjoys undoubtedly many advantages over the Babylons of the ancient world, and the decayed maritime city states. Extensive habit- able highlands and fertile fields must always be the birthplace of a majority of its children. Its population and power can never be circumscribed within a single city or within the low ports of an alluvial coast ; and it is surrounded, by the refreshing sea. The vast populations which have recently settled in bad localities may almost invariably, find in the neighbourhood sites at ele- vations which in these latitudes cholera does not climb. With wealth, in- dustry, and science at command, it is still possible to drain, and supply with tire water and a purer air, districts as low as Southwark, Westminster, Liverpool, and Hull ; thus disarming them of much of their fatal power. " But malaria begets apathy. The unhappy inhabitants of unhealthy places disregarded statistical calculations-the counsels of their medical men -the analogies of nature, and the results of experience. The wan looks of their children and the multitudinous voices of their dead did not move them. The community was also in the wrong; for the laws left them without warn- ing, punishment, or effectual assistance. Then cholera came; and in two heayy visitations carried off more victims than the United Kingdom has lost in many wars. It may if nothing is done, after a season return, for it still reigns in India. But let these human sacrifices suffice. The great sanitary reforms which will shield the country from pestilence, while they save the lives of thousands, will prevent the degradation of successive generations, and promote the amelioration and perfection of the human race.'