Cholera Inquiry Commission 1854 - Part 3


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76. That besides these variable and temporary nuisances there existed but too many almost permanent nuisances on a great scale; that several of the ancient burns, deans or brooks, now converted into sewers, but still only partially covered in, appear to have been complained of as such for years together, and at all events to have deserved so to be; that the general want of house drainage and of proper privy accommodation causes so large an amount of excrement to be mingled with the street sweepings, ashes and other house refuse that, as reported by Mr. Baynes in 1848, the Corporation middensteads, or places to which the contents of the scavengers' carts are conveyed, become themselves intolerable nuisances; that frequent complaints appear from time to time to have been made, not merely as regards the condition, but also as regards the situation of some of these; and that even at the time of our inquiry, one or more of them continued both in improper places and in a bad state.

77. That, considering that of the 9453 houses in the borough only 1421 had faecal drainage, and that of the faecal produce of these 1421 houses a considerable proportion seems, - especially in dry summer weather, such as prevailed before and during the late outbreak, - to have been retained in the adjacent sewers; thence, but too frequently, to return its noxious gases, either through the untrapped gratings into the general atmosphere of the streets, or else through the ill-fitting water-closets into the houses themselves: considering that the faecal produce of the remaining 8032 houses (and part of the produce of the other 1421 also) was either stored in open privies, in immediate proximity to the houses, or in kits, within living and sleeping rooms or at stair-corners close beside them, or else was thrown upon the surface, there, in a great measure, to remain until removed by rain or by evaporation: considering the absence or imperfection of the paving in many of the districts most exposed to the evil last mentioned, and the consequent perpetual soakage and stampage of excrement into the soil, and subsequent re-exhalation of noxious vapours into the air, as well as the constant infiltration into the soil from the almost universally conjoined privy and ashpit: considering. the extensive diffusion of faecal matters on surfaces too well paved to admit of such soakage or stampage to any great extent, and the very general absence of scavenage in the private courts and entries most exposed to such diffusion: considering the, especially just before the late outbreak, generally unemptied and uncleansed condition of the privies and ashpits which did exist, as well as the very general accumulation of offensive matters in places not destined for their reception and elsewhere; and finally, considering the hot, heavy, stagnant condition of the air, which appears to have prevailed about the time of the late outbreak: it will, we think, be obvious, not only that almost the whole faecal produce of the town during several months was about that time retained in a more or less, but frequently very much, exposed form in the close vicinity of the houses and rooms in which the inhabitants at large were living and sleeping, but also that the whole town may, almost without exaggeration, be said to have been breathing continually an atmosphere of their own excrements; to which must be added that the but too general want even of surface drainage, by allowing superfluous moisture to remain upon the clayey soil, not merely to promote decomposition, but also by its own evaporation to serve as a vehicle for the diffusion of the noxious gases thence arising, will obviously have tended to the aggravation of a state of things, which in itself was already sufficiently appalling.

78. That the joint committee of the Town Council and of the Board of Guardians in October 1853, after alluding to the accumulations above mentioned, reported that "the slaughter-houses are found to occasion or aggravate many of these accumulations of offensive matter"; that in 1846, under their then Local Improvement Act, the Town Council obtained power "to make bye-laws for making regulations for the registration and inspection of slaughter-houses and knackers' yards, and for keeping the same in a cleanly and proper state, and for removing the filth therefrom at least once in every week," and "to ascertain and fix what pecuniary penalties should be incurred by persons breaking such laws;" that in 1847 Dr. Robinson, honorary secretary to the Newcastle and Gateshead sanitary association, publicly drew attention to them "as sources of putrefaction and disease," as also to the fact that the powers in respect of them had been allowed to remain "wholly inoperative;" that in 1848 Mr. Baynes reported that "some of these places were very offensive;" that in 1849, on the occasion of Mr. Rawlinson's official inquiry, the medical committee of the Newcastle and Gateshead Sanitary Association publicly suggested "the registration and sanitary regulation of slaughter houses," as one of the "remedies, which they would desire to see applied to the removal of existing morbific causes;" but that no such regulations appear ever to have been made: and that other nuisances arising from tripe-boileries, bone-dealeries, tanneries, fish-cureries, &c., also existed, for the abatement of which, either at common law or under their own local Acts, the Town Council might, but never have, proceeded.

79. That in 1846, under their then Local Improvement Act, the Town Council obtained power "to make byelaws for regulating the manner of keeping swine," &c., and "to ascertain and fix what pecuniary penalties should be incurred by persons breaking such law;" that in October 1848, during the then outbreak of cholera, such byelaws were made and have since been put in force to a certain, although inadequate, extent; and that the nuisance hence arising has been considerably abated of late years, especially in some districts; that nevertheless very many such were kept improperly, and in contravention of such byelaws, before and during the time of the late outbreak, to the detriment of the public health; that in October 1853 the joint committee of the Town Council and of the Board of Guardians reported that "the practice of keeping pigs in improper places had been found to be productive of much annoyance to the inhabitants," but that they had "found the existing byelaws sufficient to repress the practice;" notwithstanding which it appears that the practice had not been repressed down to the time of our inquiry in March.

80. That since the passing of the Nuisances Removal Act, 1848, and the Nuisances Removal Amendment Act, 1849, the Board of Guardians in Newcastle (who were originally charged with the execution of those Acts there) have possessed powers for the removal of a variety of nuisances, and appear, especially the chairman and vice-chairman and perhaps other members of the board, to have exerted themselves faithfully to fulfil the duties thereby devolving upon them, so far at least as their staff and system would permit; but that the inadequacy of their staff and other circumstances, and their (perhaps consequent) system of passively waiting for complaints of nuisances instead of actively proceeding against them, have prevented all the benefit accruing from their efforts that could have been desired; that in the discharge of these duties they have been in but little, if any, degree assisted by the Corporation, and, on the other hand, have been frequently obliged to issue formal notices against the Corporation, and on at least two occasions have been to the utmost resisted by that body, and have been obliged to summon it before the magistrates, and obtain a decision against it, before it would remove or abate nuisances of its own creation; that by the Local Improvement Act, 4th August 1853, it was enacted that "it should be lawful for the Council to use and exercise all and every the powers given by the Nuisances Removal Act, &c., to the guardians of the poor;" but that the Town Council does not appear to have taken advantage of this enactment till some days after the late outbreak reached its climax, and then not in a very active or efficient manner.

81. That the powers of the Nuisances Removal Act are limited to the removal of nuisances when created, and do not extend to the prevention or anticipation of nuisances by comprehensive measures, and consequently were wholly inadequate to meet the case of Newcastle, in which, for want of such comprehensive measures, the recurrence and re-recurrence of the same nuisance in the same place was matter of almost inevitable necessity; that, in contradistinction to these limited powers of the Nuisances Removal Act, the Town Council, under their Local Improvement Acts, have possessed, ever since 1846, extensive powers for the anticipation and radical prevention of the great bulk of nuisances, by being enabled to provide comprehensive systems of sewerage and drainage, to compel the paving, &c., of private courts and entries, and the provision of suitable domestic conveniences, to introduce proper systems of scavenage, to make regulations for the systematic emptying and cleansing of privies, ashpits, public necessaries, slaughter-houses, &c.; that in 1849, on the occasion of Mr. Rawlinson's official inquiry, the inadequacy of the powers of the Nuisances Removal Act in the case of Newcastle was publicly adverted to; but that (as already stated in detail) the Town Council appear to have made hardly any use whatsoever of their superior powers, except perhaps in times of epidemics: to which we need only add that, of course, no amount of energy displayed under pressure of an epidemic can compensate for the systematic neglect of valuable powers during long intervening periods.

82. That another very considerable source of detriment to the sanitary condition of the town during the late outbreak arose from the excessive contamination of the atmosphere there, not merely by ordinary smoke, but also by acrid and offensive fumes from alkali and other chemical-product works, factories, &c., of which it is alleged that no town for its size possesses more than Newcastle; that by the Local Improvement Act of 1846 It was enacted "that, from and after the first day of July 1847, all furnaces employed or to be employed, in the working of engines by steam, or in any mill, factory, dyehouse, brewery, bakehouse, gas-works or other buildings used for the purposes of trade or manufacture within the said borough (although a steam engine be not employed therein), should be constructed so as to prevent or consume, so far as is practicable, their own smoke," with cumulative penalties against all persons who after that day should "use any furnace for any of the purposes aforesaid within the said borough which should not be so constructed as aforesaid, or should negligently use any furnace so constructed as aforesaid, or should carry on any trade or business which should occasion any noxious or offensive effluvia, or otherwise annoy the neighbourhood or inhabitants, without using the best practicable means for preventing or counteracting such annoyance," and "that it should be lawful for the Council to cause any chimney or furnace, which should be rebuilt or erected or continued contrary to the provisions of that Act, to be taken down or altered" at the expense of the owner; that, in 1847 and 1848, during the pressure of the Irish fever epidemic, some efforts appear to have been made to enforce the first of these enactments, and in two or three cases at least with success; but that difficulties in enforcing it were experienced, as might have been expected, especially where some of the magistrates and of those charged with the, execution of the law were themselves among the greatest offenders against the law, and that it was not effectually enforced; that from 1848 downwards, as complained of and admitted at the time of Mr. Rawlinson's official inquiry in 1849, the powers, instead of being carried out, have been left entirely in abeyance; and that the smoke and noxious effluvia, instead of decreasing, have progressively increased; that, in respect of these powers also, it has been suggested to us that they were not strong enough; but that, on the other hand, it has not been even alleged that, since the first enforcements in 1847 and 1848, any other efforts have ever been made to apply them even to those cases for which they were unquestionably available.

83. That at the outbreak of cholera in 1848-9 the state of the churchyards in Newcastle was such that one of them was regarded by one medical man as "the monster nuisance" of the time; that in December 1849, at the time of Mr. Rawlinson's official inquiry, the vicar of Newcastle stated that they were generally too full; and that before and during the late outbreak they were in very bad condition, and accordingly were shut up as soon as possible after its commencement.

84. That the water supplied to Newcastle by the Whittle Dean Water Company for about two months before, and also during the rise and progress of, the late epidemic appears to have been almost universally complained of, and is variously described to have been "bad," "very bad," "extremely" or "shockingly bad," "much discoloured," "turbid," "perfect puddle," "highly objectionable," or "unfit for drinking," &c.; that many people felt obliged to give up using it themselves, and that several medical men felt themselves called upon to dissuade their families or patients from using it; and that the first step taken by the committee of the Town Council and of the Board of Guardians during the late epidemic was to endeavour to obtain a purer supply; that many witnesses have deposed to its having had a disagreeable taste, and that several have sworn most positively to its having had an offensive smell, as though containing putrid organic matter; while others on the other hand have declared that they never noticed anything beyond discolouration, as from peat, or turbidity, as from clay or sand, - a conflict of evidence, which, notwithstanding the impartial and undiscriminating operations of the Water Company, inclines us to imagine that, from some local and no doubt wholly unsuspected circumstance, the water drawn for use was not alike in all parts of the town; especially as more than one witness has pointed to the western parts as those in which the complaints were loudest and the water worst: to which we would add that the water from some of the wells and springs, usually reputed excellent, is also stated to have become temporarily offensive during the late outbreak.

85. That owing to the water supplied by the Water Company haring been compounded of about one third of Tyne water and two-thirds of Whittle Dean water, and to the fact that no analysis was made of it, we are unable to state exactly what the constitution of the compound was; and that, on this head, we can only refer to some more or less trustworthy analyses of the separate waters, and to the analysis of a somewhat similar compound supplied in 1850; that during the prevalence of the epidemic it was unquestionably supposed and stated that the use of it had produced, or aided to produce, diarrhoea, &c.; that, before the cholera broke out, diarrhoea and dysentery did prevail to a considerable extent after it began to be supplied; that several medical men have stated to us their opinion that it did produce diarrhoea in other people, although they could not directly trace and prove it, while one or two have distinctly declared that, they believe it produced diarrhoea in themselves, and that they could trace that effect to the use of it; but that others have as distinctly declared, that they did not believe it had had any such operation; that, in the absence of chemical and microscopical analyses made at the time, we cannot arbitrate between these conflicting assertions; that, if we accept without reserve the statements as to the water having contained foetid organic matter, we cannot doubt that it would have been the tendency of such water to produce diarrhoea, and very grievously to aggravate whatever epidemic diarrhoea or cholera then prevailed; that - setting aside these statements as contradicted, and confining our attention to those qualities of the water, as to which the witnesses are generally agreed - we cannot but come to the conclusion that the water was such as ought never to have been distributed; and that, on the most favourable view we can adopt, it must be regarded with grave suspicion in relation to its influence on the late outbreak.

86. That the water usually supplied by the Company appears to be hard, varying, perhaps, from eighteen or twenty degrees of hardness in seasons of extreme drought to five or six degrees, perhaps, in seasons of extreme rain, and, at the time of our first visit to Newcastle in January, was hard enough to attract our attention almost every time we used it; but that the waters of the neighbourhood appear generally to be hard, and that it has barely been suggested that any softer could have been obtained; that no filter has existed hitherto for the filtration of the Whittle Dean water, and that this appears to have given rise to an occasional (but, we believe, unfrequent) muddiness of it, such as occurred once within our own experience in March; but that, save in these points, the water appears to have been usually and habitually good, and to have been administered on the principle of constant supply, and in both these points and otherwise to have been an immense improvement on the previous supply, which was wholly derived from the Tyne, and administered on the intermittent principle.

87. That, so far as we can judge, no complaint, or cause of complaint, would have arisen against the Water Company but for certain operations, whereby they so reduced their store of water as to be incapable of maintaining their supply, except by recruiting that store from the waters of the Tyne; and that in our opinion the deterioration of the quality of the water supplied by them was mainly or entirely the result of their improper reduction of the quantity of it; that the Company, having in their prospectus dwelt upon the then general complaints against the Tyne water as unfit for the supply of the town, and having been supported and established (adversely to the old company, whom they superseded) on the faith of their procuring a much better supply, ought to have been very chary of all such operations as might by any chance risk the necessity of returning to so universally condemned a source; that the works by which they drew the water from the Tyne were those of the old company, unaltered and by long disuse probably not improved: that the filter in particular, constructed in 1836, should seem to have been in some way out of order or of repair, and at all events far from adequate properly to perform the duties thus suddenly rethrust upon it; that, notwithstanding the deficiency of house-drainage in Newcastle, and the long retention about the houses of a large proportion of its faecal produce, a certain proportion of sewage and of other pollutions does ultimately find its way into the river, and some of it into the immediate vicinity of the spot whence the water was drawn by the Company - circumstances which at first might seem to afford one way of accounting for the occasionally putrid smell deposed to by several witnesses; but that the sewer discharge in question takes place at a point below that at which the Company pumped from the river, and that all the officers and servants of the Company, whom we examined, concurred in declaring most positively, that no pumping had occurred except at periods of the ebb, when they conceived it to be impossible that the portion of the stream, from which they pumped, could in any degree be contaminated with the sewage or other impurities thence discharged; and that hence we hesitate to affirm that the explanation thus suggested is the true one - to which should be added that, although the annual mortality of Newcastle has not been proportionate to the use or disuse of Tyne water per se, it is matter of history that, in the two cases in which cholera has raged violently in Newcastle, viz., in 1831 and 1853, the water supply has (owing to a sudden failure of other sources) been more or less derived from the Tyne, and that in the third case, in which the supply of better water continued abundant, viz., in 1848-9, the outbreak of, cholera was light and mild; and further, as a coincidence, if nothing more, that on the fifth day after the company ceased to draw from the Tyne, and within a still shorter period after the time when all admixture of Tyne water in the pipes and reservoirs of the Company will by perpetual dilution have passed away, the late outbreak of cholera did certainly commence a rapid and never-checked decline.

88. That the Whittle Dean Water Company obtained its first Act in 1845, on the basis of a drainage area of nearly 3,600 acres, and a reservoir capacity of 215,000,000 gallons, which at the then rate of consumption (700,000 gallons per diem) afforded storage for 307 days' supply; that its original works were completed in 1848, by which time the daily consumption had risen to 1,000,000 gallons, and their reservoir or storage capacity fallen to 215 days' supply; that in 1850, the daily consumption having increased to 1,500,000 gallons, and their storage capacity fallen to 143 days' supply, their water signally failed them, so that they were obliged to eke out their store by pumping from the Tyne; that thereupon the Company voluntarily and without delay proceeded to make arrangements with the landowners for making a cut to the river Pont, whereby to increase their drainage area from 3,600 to 4,600 acres, and to obtain an additional supply from the Pont, whenever that stream rose beyond the level required for the purposes of the millowners on its banks, as also for increasing their reservoir capacity from 215,000,000, to 330,000,000 gallons; that these additional works were completed in September 1851, and their storage capacity thereby raised, the daily consumption having by this time risen to about 1,700,000 gallons, to about 196 days' supply; that in the early part of 1853 the daily consumption had increased to nearly 2,500,000 gallons, and their storage capacity fallen to about 132 days' supply; that at this time they had had experience in 1849 of 100 days of drought (or of weather in which so little was flowing into their reservoirs that they might be regarded as wholly dependent on their storage), in 1850 of 212 such days, and in 1851 of 118 days - 1852 being a decidedly exceptional year -; but that, notwithstanding this experience, and notwithstanding that their storage had so signally failed them in 1850, when they had a capacity for 143 days' supply, they nevertheless in 1853, when they already had a capacity for but 132 days' supply, voluntarily proceeded to extend their range of supply some way down the river; that the first instance of such extension took place on the 26th May 1853, to a factory, which consumed nearly 1,000,000 gallons a week; and that on the 5th July 1853, within 40 days or less than six weeks from this first instance of extension, they had so far reduced the amount of their storage as to be compelled to begin to pump water from the Tyne in aid thereof.

89. That the amount of rain-fall in 1853 was 20.5 inches, as compared with 17.68 inches in 1850, 21.33 in 1851, and 34.7 inches in 1852; that, even if these figures could, as we think they cannot, justify the Company in regarding 1853 as a year of unusual drought, the accidents of droughty seasons are precisely among those, against which a Water Company is bound to provide; that it is further true that a considerable diminution of their storage was occasioned by an accidental subsidence of the soil beneath an old reservoir, owing to the excavations of the earth below by colliery workings; but that, as similar accidents had happened there more than once before, and might be regarded as by no means improbable under the circumstances, this ought to have been provided and allowed for; and that the range of supply ought not to have been extended, as though such accidents were wholly unlikely or impossible; that the Water Company have further stated that they were misled by their expectations as to the amount of water derivable from one source, which expectations, however, they do not seem to have had any experience to justify; and further, that the increase of consumption during the past year was greater than the increase of the range of their supply would have led them to expect; but that after allowing all due weight to these statements and considerations, we are of opinion that the extension of the supply beyond the amount of 2,000,000 gallons per diem was an extension of questionable propriety, and the extension of it beyond 2,500,000 gallons per diem was unquestionably most injudicious and improper, at all events until some further sources of supply should have been obtained: to which should be added that we in no degree impute to the Water Company any wilful or intentional recklessness in respect hereof, but merely an insufficient consideration of the manifold risks and contingencies before them.

90. That the water supply to the inhabitants of Newcastle, though by no means adequate either in extent or form, is still considerable, and under the, auspices of the existing Company has increased nearly fourfold in little more than eight years; that in some of the poorer districts it is more deficient than elsewhere, but that no blame appears to attach to the Water Company in respect hereof; who, both as regards reasonableness of rates and willingness to defray the expense of pipe-fitting, &c., in respect of tenemented property, appear to have afforded the inhabitants very considerable facilities; and that the blame hereof attaches partly to the owners of the house property in question, and partly to the Corporation, who, while averse to the application of the Public Health Act, which would have empowered them to compel landlords to do their duty to their tenants, in respect of providing them with a proper water supply, have nevertheless neglected to obtain, under any of their own local Acts, similar powers of control over negligent and mercenary landlords.

91. That the gas supplied to the inhabitants of Newcastle, although described by two witnesses as of average quality, has been much complained of by many others as "far from good," "bad," "very bad" "very impure," &c.; that the impurities evolved into the atmosphere during the combustion of such a gas, especially in the case of persons exposed thereto in shops or rooms not adequately ventilated, may otherwise have been detrimental to the general health; but that no evidence has come before us to show that it aggravated the late epidemic in any degree.

92. That. other causes, original or aggravative, of a general nature, such as the consumption of unwholesome food, bad fruit, excessive drinking, &c., will also have been in operation in Newcastle as elsewhere under such circumstances, but that we do not think it necessary, in the present case, to dwell at any length on matters such as these.

93. That the late outbreak was also no doubt further aggravated by circumstances, in a correct appreciation of which the powers and proceedings of the General Board of Health, the conduct of two of the Superintending Inspectors of that Board, the operations of the Board of Guardians in Newcastle, the dissensions between certain members of the medical profession there, and divers other considerations are involved; that one of the complaining witnesses frankly admitted that he felt called upon to complain of the circumstances, without professing to know exactly who might be to blame in respect thereof; but that some have distinctly complained of the General Board of Health, - affirming that Newcastle would have done better without any interference on the part of that Board, and that the arrangements adopted in 1831-32, and 1848-49, when the General Board did not interfere, were superior to and more effective than those adopted in 1853, when they did -; while others have accused at least one of the, Superintending Inspectors of that Board of incompetency or inefficiency, and others again have made similar imputations against the Board of Guardians; and that accordingly we have thought it requisite to go into an investigation of these matters.

94. That one complaint against the General Board of Health is, that they were tardy in acting on an intimation that was given them of the approaching outbreak; but that the facts of the case on this head appear to be as follows:- that on the 2d September 1853, a single medical practitioner of Newcastle wrote to the General Board, stating that "the town was threatened by an outbreak of the disease in a malignant form," in support of which statement he alluded to one "fatal case" of cholera and another case of "choleraic symptoms, indicating a fatal termination;" that some days previously, viz., on the 30th August, the General Board had directed inquiries to be made into several cases of cholera in different places, and in respect of those in the metropolis had ascertained that the disease was not epidemic there; that the receipt of the letter above-mentioned on the 3d September, did not, therefore, necessarily convey to their minds the conviction that the disease was epidemic in Newcastle, and that they did not immediately despatch any officer to that place, although the minutes and correspondence, hereto annexed, will suffice to show the immediate activity of their proceedings; that on the 9th September a second intimation of the existence of cholera in Newcastle having been received, they at once despatched Superintending Inspector of Health, Mr. Grainger, to that place, who arrived there at 6 a.m. on Saturday the 10th; and that having on the same 10th September received a short telegraphic despatch, and on Monday the 12th a letter, from him to the effect that cholera was epidemic in Newcastle, they, on Tuesday the 13th September, addressed a formal communication to the Privy Council, submitting that the time had arrived for issuing an order in Council for putting in force the extraordinary powers of the Nuisances Removal and Contagious Diseases Prevention Act, 1848; and on the 16th received a copy of the order in Council issued the previous day.

95. That another complaint against the General Board, or rather, perhaps, against its Superintending Inspectors, is that they addressed themselves too exclusively to the Board of Guardians and to the district medical officers, the servants of that Board; that reiterated complaints have been founded on the fact that the medical profession of Newcastle as a body were never called together, either by the officers of the General Board of Health or by the Boar a of Guardians, until after the epidemic had reached its climax; and that, so far as we can judge, the want of concert between the officers of the General Board of Health and the Board of Guardians, on the one side, and of the medical practitioners and other influential inhabitants of the town at large, on the other, did lead to circumstances adverse to the most effectual repression of the outbreak, and did in so far tend to aggravate it; that, on the other hand, the powers of the General Board of Health have reference to, and invest their officers with authority over, hoards of Guardians only; that all applications by them to the medical practitioners or other inhabitants of a town are consequently matters of discretion; and that some of the complaining witnesses have admitted or intimated that such a step fell rather within the province of the active body, the Board of Guardians, than of their counsellors and supervisors, the Inspectors of the Board of Health; that there existed in Newcastle notoriously a schism between considerable sections of the medical profession there, which to this day renders it doubtful, in our eyes, whether the cordial co-operation of the profession at large could very readily have been obtained either by the officers of the General Board of Health or by the Board of Guardians; that the first step taken by Mr. Grainger was to call upon, and to put himself in communication with, as many members of the profession as possible; but that in the course of this proceeding observations were made to him and circumstances relative to this schism were brought to his knowledge, which were calculated most seriously to perplex and embarrass him in the execution of any such step as the calling together the whole medical profession; that Mr. Grainger accordingly did not think fit to take the initiative in respect of any such step, although he expressed his willingness to be present at any meeting of the profession which might arise out of any other circumstances; that, considering the immense pressure of the crisis, and the unimportance which such a discretionary point would naturally assume in his eyes, as compared with the discharge of other specific and imperative duties, and further considering the known and admitted character of Mr. Grainger, we see no reason to impute any blame to him in respect of this omission, more especially when we consider what actually befel Superintending Inspector Dr. Gavin, when at a later period he judged it proper to do what Mr. Grainger previously had not thought necessary.

96. That it, has further been complained that the officers of the General Board of Health, or the Board of Guardians, or both, were blameable in respect to the delay which occurred in the organization of the system requisite for the repression of the outbreak; in respect of the employment, in carrying out that system, of medical students, not natives or inhabitants of the place; in respect of an alleged non-publicity of the arrangements made for such carrying out thereof; in respect of the tardy provision of tents or houses of refuge for the inhabitants of the worst affected districts, and of the non-provision of hospitals for those already attacked by the disease; in respect of the non-issuing until too late of a prescription or formula for the treatment of the disease in its various stages, _&c. &c.: that, in respect of one of these points at least, viz., the delay and tardiness, &c., it seems clear, that neither the General Board nor their Superintending Inspectors were legally authorized to require or compel the Board of Guardians to adopt any steps whatever for the repression of the epidemic until after the issuing of the requisite Order in Council; - the fact of the issuing whereof was only communicated to the General Board in London on the same day (the 16th September) on which the epidemic reached its climax in Newcastle; - and that the blame (if any) of any delay in carrying out the recommendations of the Superintending Inspector attaches, up to that or the following day, to the Board of Guardians Only; that in respect, of a second point, viz., the non provision of cholera hospitals, we are of opinion that the complaints are by no means well-founded, the benefits of such establishments being, in the judgment of those who were responsible for such non-provision, not only not clearly demonstrated, but rather perhaps gainsayed by experience hitherto; that in respect of two or three others, viz., the non-issuing of a fixed formula, the employment of medical students, not connected with the locality, as house-to-house visitors, and the alleged non-publicity of the arrangements, we are very much in doubt whether there be any ground of complaint whatsoever: and that after giving our best consideration to all, and while reporting that some of the circumstances alluded to did operate in a manner adverse to the most effectual repression of the disease, we see no cause for censuring the officers of the General Board of Health or the Board of Guardians, or either, in respect of any of them.

97. That the reports and statements of the proceedings of the officers of the General Board of Health, hereto annexed, will, we think, suffice to show that they performed their duties diligently and conscientiously; that many of the most. eminent medical witnesses before us unequivocally testified their approval of their efforts and services; that, so far at least as regards Dr. Gavin, (whose stay in Newcastle was protracted for weeks, whereas Mr. Grainger's health permitted him to remain but ten days in the place,) the testimonials hereto annexed' from the Board of Guardians, and from forty-seven medical practitioners in Newcastle, will no doubt be regarded as conclusive; whilst, as regards Mr. Grainger, in addition to what may be inferred from the latter of the above testimonials, it appears, not only that his exertions there were such as severely to affect his health, but also that during the time of those exertions he was more than once publicly complimented by one member of the medical profession, who has since been among the most active complainants in the matter; and that, although in looking back on such a crisis it is easy to imagine that the Board of Guardians might have acted somewhat differently with advantage, we see no reason for withholding a similar testimonial to their intentions and endeavours.

98. That in our judgment the true explanation of the untoward circumstances which have given rise to all the complaints under consideration, must be sought for partly in the (owing to the extraordinarily bad sanitary condition of the town) exceeding suddenness and vehemence of the outbreak, and partly in the difficulties and embarrassments arising out of the disunion among the medical practitioners; that on the 1st September the first death from cholera occurred there; that on the 3d September a first, and on the 9th September a second, intimation of the approaching outbreak reached the General Board of Health; that at six a.m. on the 10th September Superintending Inspector of Health, Mr. Grainger, arrived in Newcastle, and about noon the same day informed the General Board by telegraph that cholera was epidemic there; that on the 16th September, the General Board of Health in London obtained a copy of the order in Council of the previous day, putting in force the extraordinary powers of the Nuisances Removal and Contagious Diseases Removal Act; but that on that very day, the 16th, the outbreak had already reached its climax in Newcastle, and within four days afterwards was largely on the decline; that in the meantime Mr. Grainger, finding himself without authority, and having been made aware of the disunion among the medical practitioners, and of the embarrassments not unlikely to be thrown in the way of any discretionary proceedings on his part, confined himself strictly to the line of his imperative duties; that, on the other hand, the medical practitioners, informed of the presence of an officer of the General Board of Health, but uninformed as to his want of power, looked to him to take the initiative in some energetic repression of the disease, by the exercise of an authority with which he was not invested; and that in this way, without any blame being imputable to him in respect thereof, the presence of Superintending Inspector of Health, Mr. Grainger, may have served to discourage efforts which might otherwise have been made, as in previous outbreaks they had been mad;., by the medical practitioners and other influential inhabitants of the place, for resisting the advances of the epidemic.

99. That from about the 21st of September, in addition to various kinds of charitable assistance previously in operation (under the auspices of the Board of Guardians- and otherwise) for affording relief to persons affected by the epidemic, au extensive system of house-to-house visitation (especially for the discovery and treatment of premonitory diarrhoea) began to be worked under the direction of Superintending Inspector of Health Dr. Gavin; and that it is impossible to doubt that this must have contributed to the mitigation of the disease; but that, inasmuch as the epidemic had already, on the 16th September, attained its maximum, and had in the five following days so far declined, as to have reduced its daily quota of deaths from 114 to 67, we cannot speak with confidence as to the degree of good, which may have resulted from measures adopted during the natural subsidence of the disease.

100. That the only other point to which we think it necessary to draw attention in respect of Newcastle, is the exceeding waste of money (to say nothing further of life, health, &c.) which has resulted, under this recent outbreak, from the neglect of sanitary powers and precautions there; that during the prevalence of it an expense of nearly £4000 appears to have been incurred by the Board of Guardians for immediate services; that between 6,000 l. and £7,000 appear to have been expended under the supervision of the vicar of Newcastle; that an excess of at least £3,000 above the usual expenditure for sick and funeral monies appears to have been incurred by the benefit societies of the place; that 5001. was expended by the Town Council; that an annual expense of about £2,600 has been incurred by the Board of Guardians for the maintenance of widows, orphans, and others on account of the cholera become chargeable to the poor rates, which at only eight years' purchase would be worth some £21,000; making altogether. an expense of £35,000 or thereabouts, over and above the apparently very serious, but not so obviously computable, loss to the town arising from stoppage of trade, &c.; that the judicious expenditure of a similar sum a few months before the outbreak might have done much to avert or mitigate that calamity, not only for the year 1853 but for many years to come; whereas, under actual circumstances, there has been nothing but a dead loss of so much money, without the slightest defence or guarantee having been obtained against the recurrence of a similar calamity, even in the autumn of this very year 1854, supposing the cholera should again make its appearance in the neighbourhood during the summer.

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