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In the first place in which we were called upon directly to interfere at Dumfries the parochial Board allowed a period of 20 days to elapse with a steadily progressive and alarming increase of the disease [cholera], without adopting a single efficient measure of precaution. On the first outbreak of the epidemic, indeed, a system of medical relief, apparently well adapted for meeting it, was agreed to; but this was broken up on the following day, by order of the parochial Board, on the alleged ground of expense Though the attention of the local authorities had been specially called to our regulations, they had, up to this period, taken no steps with reference to operations of cleansing, to providing a house of refuge, or to organising a proper system of medical relief.
"I arrived in Dumfries," reported Dr. Sutherland, "on the 6th December; up to that time, I believe, that no fewer than 147 persons had already been buried, after having been struck down by the epidemic, and that without an effort to save them although the power had been placed in the hands of the parochial Board for the express purpose of being exercised. Precious time was wasted in mere petty squabbles; the town has been clothed in mourning in consequence. Not a moment was lost by me. I collected a staff as quickly as possible, arranged the districts, and put everything in motion, but this process required further time, equally precious with that which had been irretrievably lost; and it appears from our returns, that it was not till the 13th of December that any material effect was produced. and by that day 250 people had been consigned to the grave".
The local powers for the execution of the law were found to be extremely defective; the authorities for executing them, commonly not less so; with divided responsibility frequently conflicting, and wanting in the unity requisite to carry out prompt remedial measures, even when tolerable information existed with reference to them.
The separation of local administrative bodies in respect to the execution and control of works; the separation of the works for the water supply from the works for sewerage; the separation of the works for sewerage from those for house drainage, and of the whole from those for surface cleansing; the separation of the surface cleansing from the cleansing of sewers and drains, and even, as is sometimes the case, the separation of the cleansing of the main streets from that of courts and alleys; the separation of these and other services, for the consolidation and combination of which the Legislature has provided in the Public Health Act, have seriously impeded the execution of the Diseases Prevention Act.
The Legislature contemplates the Poor-Law Union in England and Wales with its medical officers, its Union house with its new fever wards, and its provision for medical relief, as the chief local administrative body by which preventive measures could be best carried out; and in general, it is the most eligible for the purpose But, in towns, there are also Commissioners of Pavements under Local Acts, who are charged with the duty of surface-cleansing as well as paving, who act independently, and who were frequently found to be unwilling to receive directions from the Boards of Guardians or the medical officers appointed by them. The Municipal Town Councils, have in some instances, the control over the road-ways, and they have also under their direction a body of police, whose services are of great importance, in the execution of orders, especially where it is requisite immediately to carry out combined regulations. Even where there is a fair and liberal desire to co-operate, on the part of these separate authorities, there has been a serious loss of time in the service of notices, and in framing expositions of the grounds of requests from one to the other. Added to these impediments. the separation affords the means of shifting responsibility from the one to the other.
Adopting a large remedial interpretation of the terms of the Act, "for taking measures of precaution with promptitude according to the exigency of the case", we had contemplated the issuing of regulations for carrying these provisions into effect, as we believe the Legislature would have done, had there been laid before it the special circumstances of the case, by forming Special Boards of Health, composed of members of the Town Councils, of the Boards of Guardians, and of the Paving Boards, who might give united directions to their officers. The law officers, however, were of opinion, that the general terms of the statute could not be so construed as to authorise a combination of the local authorities, with a view to bring their united powers to bear in the manner we proposed. The regulations were therefore carried out, chiefly by the separate powers of the Boards of Guardians, with the voluntary co-operation of the municipal or other authorities; but, at the best, with the inconveniences of delay from the separate action. Had it been possible to combine the various authorities, as at first contemplated, a far greater unity and efficiency would have been ensured both in England and Scotland.
In the metropolis, the multiplicity of the Paving Boards, some parochial and others not, charged with the duty of surface cleansing, and the removal of refuse, has also been productive of considerable inconvenience, since it has prevented answers being given or directions issued, until these Acts could be sought out and the powers and duties provided under them ascertained.
The following reply from the General Board of Health to an inquiry from the Rev. W. Dodsworth, the incumbent of Christ Church, Regent's-park, as to "what he should do in order to effect the cleansing and draining of his parish," in other words, what was the local law under which the parishioners were living, is illustrative of a very common obstacle to prompt. efficient, and economical local administration.
"The General Board take the opportunity to state, that they have received applications similar to your own from householders, inquiring what steps they may take to obtain the removal of refuse, or to enforce proper cleansing, and what is the actual law and the state of its administration for sanitary purposes within their respective parishes, and what they, as householders, may do for its enforcement or aid. The General Board have been prevented giving early replies, as well as eventually satisfactory ones, by the excessive variety of the provisions of the numerous local Acts by which the objects have been sought to be attained.
"The work of surface cleansing is, in many cases, performed by bodies of various descriptions, under the authority of local Acts. The jurisdiction of the authorities constituted under these Acts are as various as their powers. It is one of the Topics of the local inquiries, directed by the Legislature to be instituted under the Public Health Act, to ascertain upon the spot what the local Acts are, what are the bodies constituted under them, and how the powers so conferred are executed. Unless the General Board itself is informed upon these points, it is unable either to apply its own orders with the particularity which is requisite. or to give such information as that which is now sought.
"The number, condition, and action of the bodies constituted by the local Acts is one object of investigation by the Metropolitan Sanitary Commissioners, and they have been hitherto unable to complete that inquiry.
"There appear to be upwards of 120 local Acts for the more dense portions of the Metropolis, for the management of upwards of 80 distinct local jurisdictions, many of which coincide neither with parish, nor Union, nor police district. nor any other recognised division. When a householder, who gives his address in a particular street. applies to know how he may proceed - if the local Act be sought out and the provision in relation to the matter in question be also sought out - he cannot always be safely answered, inasmuch as streets are frequently divided, sometimes longitudinally. and paved and cleansed at different times, under different jurisdictions. At present no public maps are known to exist by which the area of the jurisdiction could in any such cases be ascertained correctly.
"In the parish of St. Pancras, where you reside, there are no less than 16 separate Paving Boards, acting under 29 Acts of Parliament, which would require to be consulted before an opinion could be safely pronounced as to what it might be practicable to do for the effectual cleansing of the parish as a whole.
"The General Board of Health can only state in answer to such applications, that the information sought can be obtained by no other means than local inquiry; and they hope that this will be done on behalf of householders, by the Parochial Board acting under the general directions of the Board of Health now issued."
The following extract from a letter by Mr. Payne, the coroner of the City of London, displays the general consequences of these defects; and the inconveniences and evils here represented will, we hope, be diminished by the consolidations provided for by the Public Health Act - "The first child was attacked 10 days ago, and died last Sunday; the second was attacked on Tuesday morning last, and died in the afternoon; and the third since then; and two more were very ill from the same cause.
"The father of two of the children had not complained to anybody except his landlord, because he said he did not know the state of the law. The medical officer reported to the clerk of the Board of Guardians on Saturday last; and Mr. Simon, the Officer of Health, said that no report had been made to the Guardians till Thursday morning last, which he thought a great neglect in the clerk to the Board.
"I found that the police constable, whose attention was drawn to the nuisance on Tuesday, reported it to his sergeant, the sergeant to the inspector, the inspector to the Commissioner of Police, and the latter to the Commissioners of Sewers.
"All this roundabout mode of doing business I deprecated as injudicious, and suggested chat it would be desirable if the inmates of the courts and alleys were informed that they might complain direly to the Inspector of Nuisances for the district, whose duty it would be in such case to see to it immediately.
"There is every reason to believe that some of these lives would have been saved if the matter had been properly made known in the first instance."
Theoretically, it is supposed, that all the inhabitants are best acquainted with the state of their local law, and take an interest and part in its administration. Practically, their knowledge of it, in busy towns, is generally found to be such as that displayed in the above extracts; and resistance to local consolidation and simplification arises from the active canvassings of office-bearers, and persons pecuniarily interested in the administration, rather than from any spontaneous desire on the part of the great body of the population. The advantages, for the sake of efficiency and despatch, of uniform local procedure and administrative arrangements, have been pointed out before, but they are strongly re-enforced by the disastrous delays recently experienced.
The law gives to this Board no power to originate prosecutions for neglect or violation of its orders and regulations, and therefore we have no direct control over Guardians, whatever course they may adopt with reference to the orders of the Board, in consequence of which those orders have been, to a considerable extent deprived of the authority which it was the intention of the Legislature to give to them, and which they must possess to accomplish that object fully.
The Guardians indeed incur a serious responsibility if any fatal consequence should be proved, by the verdict of a coroner's inquest, to result from their unlawful omission of the orders of the General Board of Health; but however important and necessary the investigation may sometimes be, to be able to fix responsibility only by the indirect and uncertain result of a coroner's inquest, appears to be a fundamental defect.
Examplifications of the impunity with which some Boards of Guardians consider they may disregard orders made under the authority of the Legislature, with the view of carrying out its provisions, have been afforded by the course adopted by the Guardians of the Whitechapel Union, by some of the Boards of Guardians connected with the Tooting children, and, more recently by the select vestry of the borough of Liverpool.
At a time when deaths had already occurred from cholera, under extremely painful circumstances, and when there was reason to apprehend a serious outbreak of the disease, the Guardians of the Whitechapel Union entered on their Minutes the following resolution : -"That it is the opinion of the Guardians that, at present, the order of the Board of Health, of the 18th of November last, need not be acted on in this Union.
It appears that this deliberate act of disregard to the orders of the Board of Health was resolved upon on the same evening when the medical officers of the Union presented to the Guardians a written statement to the effect that malignant cholera had broken out in some parts of the district.
Here is an instance of a Board, composed for the most part of persons engaged in the daily routine of trade, not having in general, it must be presumed, the means of judging from any large observation or experience of the matter on which they decide, deliberately acting on a medical question against the opinion of their own medical officers, and in direct opposition to regulations framed on the largest experience, not only of this country, but of the whole of Europe - regulations so framed for the purpose of carrying out the express provisions of the Legislature.
It further appears, that on the 21st of November the Clerk of this Union having in conformity with the order of the Board of Health, laid before the Guardians returns from the four medical officers, and from some of the registrars of births and deaths, of those places in the Union where epidemic, endemic, and contagious diseases have of late been prevalent, the Guardians came to the following resolution:-
"That the Clerk forward such particulars to the various Local Boards in the Union, but that the medical officers be not called upon to visit the places in question."
It must be borne in mind that this resolution was adopted by the Guardians at a time when cholera was not only actually prevailing in the district, but was spreading there under circumstances of so painful a nature, as to attract the attention of one of the coroners of Middlesex, Mr. Baker, who, on the 24th of November, addressed a letter of expostulation to them on the neglect of the measures which the circumstances of the time obviously required.
On the 14th of December the coroner again addressed a letter to the Clerk of the Union, in which he says: "My attention as coroner has this day been called to several cases of sudden death in the parish of St. Mary, Whitechapel. of a most awful and appalling character, and I cannot but feel that a very heavy responsibility rests not only upon my shoulders, but upon those also of the Board of Guardians of the Whitechapel Union, in reference to these and all such cases, it appearing that there have been no less than 16 under the care of the medical officer lately.
"I have this day been engaged in an inquiry into some of the deaths, more particularly alluded to in that letter, in Hairbrain-court, Rosemary-lane, and have myself viewed this evening the dead bodies of no fewer than three persons. but have been witness also to the most agonising and appalling situation of others in a dying state in the same locality (within a few yards of the former), who were found by me to be in a state of distress and misery, which could not but be most afflicting to my mind, being surrounded by the most foetid and unwholesome vapours from privies and bad drainage, and filthiness, and much overcrowded; and allow me to say, in such a state as I could scarcely have deemed it possible to have existed, after the publication of the documents to which I have above alluded."...
... Yet more recently the Guardians of the parish of Liverpool appear to have pursued the following course. The affairs connected with the relief of the poor in the parish of Liverpool. are under the control of a Select Vestry, who here exercise the duties ordinarily performed by Guardians. The Select Vestry has nominated out of its own members, a "Medical Relief Committee," to which the direction of what concerns the medical relief is committed; and in order to facilitate the carrying into operation the Act for the Removal of Nuisances and Prevention of Contagious Diseases, a "Joint Committee" has been constituted, consisting of a certain number of members selected from the Health Committee of the Town Council, from the Medical Relief Committee of the Select Vestry, and from the West Derby Board of Guardians; the object of this Joint Committee being to consider the measures necessary to promote the health of the town, and to communicate the results to the other bodies.
Liverpool has the further advantage of having an Officer of Health who so long since as August 9 1848 in anticipation of the probable re-appearance of cholera in England, reported to the Health Committee of the Town Council, that in the event of the return of cholera, besides greater activity in the general measures of cleansing, scavenging, supply of water, &c., it would be necessary to make an addition to the parochial medical staff, and to that of the dispensaries, in order that immediate assistance might be given in the early stage of the disease, and to provide hospitals in different quarters of the town for the accommodation of the destitute, whom it might be inexpedient to treat at their own dwellings. A copy of this Report was sent to the Select Vestry.
The Joint Committee was appointed in the month of October, 1848. One of its earliest steps was to ascertain what measures were proposed by the Select Vestry, to afford medical attendance and medicines in the event of the re-appearance of cholera in Liverpool. In reply to inquiries made on this subject, the Chairman reported at a meeting held on December 12, 1848, that the Select Vestry had made preparations for appointing additional medical officers over and above the permanent staff of 13 employed by the Select Vestry; for providing dispensaries in every district of the parish, with hospitals attached to the same; and for opening of houses of refuge. The impression produced by this statement on the mind of the Officer of Health was, that all the measures requisite to meet an outbreak of cholera were in such a state of forwardness that they could be completed in a few days whenever the necessity arose; and he says that this being his conviction, he took no farther steps at that time.
On the 9th February, 1849, the Select Vestry did open a cholera hospital, and appointed two medical officers to take charge of it; but they chose it in a situation so remote and inconvenient, that the Medical Officer of Health thought it necessary on the 29th of March, to make to the Health Committee the following statement: "The Medical Officer of Health begs to represent, that in the event of cholera becoming epidemic in Liverpool, the present cholera hospital in Queen Anne Street, will be found to be placed at an inconvenient distance from the localities where the disease is likely chiefly to prevail.
"On the Sunday last, a woman who was removed from Henry Edward Street, in the state of collapse was found to be dead on her arrival at the hospital."
A copy of this Report was forwarded to the Medical Relief Committee.
On the 5th April, cholera still advancing, and no change having been made in the situation of the hospital, nor any steps, as far as could be ascertained, having been taken to provide a house of refuge, the Joint Committee again requested the Select Vestry to inform them what provision had been made for treating cholera cases among the poor.
On the 30th of April, cholera still advancing, and nothing having as yet been one, the Medical Officer of Health again addressed a letter to the Chairman of the Medical Relief Committee, stating his belief that lives had been lost in consequence of the non-removal of the hospital, and that the opening of a house of refuge was urgently required. To this representation the Officer of Health received a reply from the Chairman, stating, that his letter was read to the Committee and entered on their Minutes, but that it did not appear to change their plans materially. "For myself," he adds , "I may say that I would gladly have been guided by your advice."
By this time the disease of cholera being very alarming, and finding that none of the measures recommended by him were adopted, the Medical Officer of Health next, that is, on the 30th of May, addressed the Joint Committee, calling their attention to the fact of the rapid increase of cholera, and stating that the great majority of the cases still continued to occur in a district remote from the hospital; that immediate steps should be taken to provide hospital accommodation in the locality where the disease prevails; that instances having occurred, in which several persons had been attacked in succession in the same house, a house of refuge ought to be opened without delay, in order that where deemed advisable, the healthy inmates of houses in which cholera appears may be removed for a few days, until the infected dwellings have been thoroughly cleansed and purified; and that as attacks of cholera generally take place in the night, stations should be appointed in the affected districts, where a medical practitioner being in attendance during the night might be ready to give immediate aid when called upon by the poorer inhabitants.
On the following day (June the 1st) the Joint Committee, in consequence of this communication, passed resolutions, recommending the Select Vestry to adopt forthwith the several measures here recommended. But instead of adopting these measures the Select Vestry merely called upon the regular medical officers of the parish, to give their attention to their patients by night as well as by day; and appointed two additional medical officers for one week, to make a house-to-house visitation in two streets.
The Joint Committee not satisfied with these proceedings of the Medical Relief Committee, on the 7th of June again called the attention of the Select Vestry to their recommendations and requested to be informed what arrangements bad been made for carrying them out. During these discussions and delays, cholera had increased from 16 in the week ending the 19th of May, to 27 on the following week; 67 on the next week; 145 on the week following, and 187 on the week ending the 16th of June.
Though we were not at that time cognizant of the proceedings of the Select Vestry above described, yet, observing the progressive increase of cholera in this populous city, not perceiving any preparations for carrying the regulations under the Act into effect, and being constantly told in the Reports forwarded to us, that with cholera daily extending, there was no appearance of premonitory diarrhoea, an event which, if true, would have been an exception to the experience of every other place, both in this country and in Europe; we directed one of our Medical Inspectors (Mr. Grainger) to obtain authentic information on all the circumstances connected with this dangerous outbreak.
From Mr. Grainger's report. it appears, that no lists such as are required by the regulations of the General Board of Health had been made out; that no adequate medical relief had been provided; that no systematic plan for detecting and treating premonitory diarrhoea had been adopted; that no stations or depots had been opened, for affording assistance to the poorer classes in the night, and that no houses of refuge, and no sufficient hospital accommodation had been afforded.
Up to this time the Select Vestry, as well as all the authorities of Liverpool. were ignorant of the existence in any part of the town of any unusual prevalence of bowel complaint, and positively denied the fact, though, for a fortnight previously, at least, these disorders had increased to such an extent in the affected districts, that the inhabitants were in a state of alarm, and one of the witnesses examined said, that for the eight or ten days previously he had had many applications for medicine for bowel complaints, amounting to as many as 20 in a day; while another stated, that in consequence of the great increase of these attacks he had been detained for some nights preceding till half-past 11 or 12 o'clock at night, though his usual custom was to leave his shop for his residence at half-past nine.
From this and other evidence winch we received, we issued on the 18th of June a Special Order requiring the Select Vestry to adopt the several measures which our Inspector represented to be necessary, and in the necessity of which the Officer of Health for Liverpool coincided; the first of which regulations was, that the Board of Guardians forthwith appoint 12 extra medical officers, who should make house-to-house visitations once each day at the least, &c. On the reception of this Order, the Select Vestry thought proper to decide that no extra medical officers should be appointed, as required by our Order, and separated without making any preparation for r carrying into effect the other regulations contained in the Order.
The body which thus deliberately violated the law, had neglected the discharge of their duties for at least a period of two months, in spite of repeated warnings by the Officer of Health of their own borough, and the earnest remonstrances of a Committee consisting partly of their own members, and that at a time when between 30 and 40 fresh attacks of cholera were occurring in their city daily; a neglect of duty which is described as inflicting much suffering and sacrifice of life.
We submit that the protection of the poor and helpless from preventable sickness, suffering, and premature disablement, and death, is a duty of the highest importance, and that negligence or omission in relation to it is a grave offence. The examples we have now received show that if measures for the prevention of these evils are placed on the footing of mere recommendations no attention will be paid to them. Such evils can be abated only by the exercise of powers adequate to enforce the measures which are required for their suppression. When it is intended that the operations of a law shall be efficient, the power of prosecuting for disobedience, as well as of laying down executive regulations are placed not in separate but the same hands; and the experience of the working of this Act shows that its provisions cannot be carried out. and consequently that the intentions of the Legislature cannot be realised, unless a power be given to the General Board of Health, similar to that given to other Boards, such as the Lunacy Commission, to originate prosecutions for the neglect or violation of its regulations.
The powers conferred for the prevention of epidemic diseases must, to accomplish their object. necessarily be summary; but if the orders made by one department can be enforced only by application to another department, delay must be incurred where promptitude is essential. On these grounds, and under the conviction that the object of the Legislature cannot be otherwise attained, we submit that this Board should be entrusted with the power of prosecuting for the neglect of its regulations.
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