THE CAUSES OF THE IMPROVEMENT IN THE HEALTH OF LONDON
TOWARD THE END OF THE EIGHTEENTH AND BEGINNING OF THE NINETEENTH CENTURIES.

    Although, as I have shown, there is ample proof of the great improvement in the sanitary condition of London during the latter part of the eighteenth and the early part of the nineteenth centuries in the great and exceptional decrease of the general death-rate, and especially in the infant death-rate, as pointed out by the late Dr. Farr, it will be well to give a brief sketch of the various changes, not only in London itself, but in the habits and especially in the food of the people, which combined to bring it about.

    In the early part of the eighteenth century London was in a condition of overcrowding and general filth which we can now hardly realize. The houses were low and overhung the streets, and almost all had cesspools close behind or underneath them. The streets were narrow, the main thoroughfares only being paved with cobblestones, which collected filth, and allowed it to soak into the ground beneath till the soil and subsoil became saturated. Slops and refuse of all kinds were thrown into the streets at night, and only the larger streets were ever cleaned. The by-streets and the roads outside London were so bad that vehicles could only go two or three miles an hour; while even between London and Kensington coaches sometimes stuck in the mud or had to turn back and give up the journey. The writers of the time describe the streets as dangerous and often impassable, while only in the main thoroughfare were there any footways, which were separated from the narrow roadway by rows of posts. Gay, in his "Trivia," speaks of the slops thrown from the overhanging windows, and the frequent dangers of the night, adding:

            "Though expedition bids, yet never stray
            Where no rang'd posts defend the rugged way."

And throughout this poem, dirt, mire, mud, slime, are continually referred to as being the chief characteristics of the streets. They mostly had a gutter on each side, and with few exceptions rain alone [[p. 317]] prevented them being blocked with refuse. The effects of a heavy shower in the city are forcibly described by Swift in his usual plain language:

            "Now from all parts the swelling kennels flow,
            And bear their trophies with them as they go;
            Filths of all hues and odors seem to tell
            What street they sailed from by their sight and smell.

                                        *                *                *

            "Sweepings from the butchers' stalls, drugs, guts, and blood,
            Drown'd puppies, stinking sprats, all drench'd in mud,
            Dead cats, and turnip tops, come tumbling down the flood."

Macaulay tells us that down to 1726 St. James' Square, though surrounded by houses of the nobility, was a common receptacle for refuse of all kinds, and that it required an Act of Parliament to stop its being so used. Hogs were kept in St. George's, Hanover Square, and in 1760 many were seized as a common nuisance.

    The numerous small streams which flowed through London from the northern heights--Langbourne, Wallbrook, Fleet, Tybourne, and Westbourne--which were in earlier times a source of health and water supply, gradually became noisome open sewers, and one after another were arched over. There were many wells in London, indicated by such names as Holywell, Clerkenwell, and Aldgate Pump, and there were also conduits in Cheapside and Cornhill; but it is certain that, from the filthy streets and house cesspools, all the water derived from them must have been contaminated, and thus helped to produce the terrible mortality from plague and fevers of the seventeenth century. It has been often suggested that the Great Fire of London in 1666 was the cause of the final disappearance of the plague, but how, except that the new houses were for once clean and wholesome, has not, I think, been satisfactorily explained. I believe, however, that it can be found in the action of the fire upon the soil, which for more than a thousand years had been continuously saturated with filth, and must, as we now know, have afforded a nidus for every kind of disease germs. The long-continued fire not only destroyed the closely-packed houses, but in doing so must have actually burnt the whole soil to a considerable depth, and thus have destroyed not only the living germs, but all the organic matter in it. The new city, for the first time in many centuries, had beneath it a dry and wholesome soil, which to this day has not had time to get so foully polluted as before the fire.

    When we come to consider how the people lived, the conditions were equally bad. The houses were often sunk below the level of [[p. 318]] the ground, and had very low rooms, as indicated by Gay's lines on the Strand:

            "Where the low penthouse bows the walker's head,
            And the rough pavement wounds the yielding tread."

Light and air were shut out by the overhanging of each successive floor, and by enormous signboards projecting over the street; while any effective ventilation was out of the question, and, indeed, was never thought of. Water had usually to be brought from the public wells or conduits, and was used sparingly; and most business people lived for whole days and weeks without ever leaving the polluted air of their shops and houses. A friend of Mr. William White told him that he served his apprenticeship to a grocer in Cheapside from 1786 to 1793; that the shop was opened at seven in the morning and closed at ten at night; that he slept under the counter; that his ablutions were limited to his face and hands, and that he never went out except to meeting on Sunday. Bishop Wilson of Calcutta was in a silk merchant's shop about the same time, and worked similar hours. He records that the apprentices rarely left the house for weeks together, and that it was three years before he had his first holiday. William Cobbett, in 1783, was in a lawyer's office in Gray's Inn, where, he relates, "I worked like a galley slave from five in the morning till eight or nine at night, and sometimes all night long. I never quitted this gloomy recess except on Sundays, when I usually took a walk to St. James' Park."¹

    When we remember the filthy condition of the streets, and that, owing to the cesspools either under or close behind the houses, the scarcity of water, and the absence of ventilation, the shops and living rooms were always full of foul air, bad smells, and poisonous gases, how can we wonder at the prevalence of zymotic disease and the dreadful amount of infant and general mortality? And in many houses there was an additional peril in the vicinity of churchyards. In Nicoll's "Illustrations of Literary History" (vol. iv. p. 499), Mr. Samuel Gale is quoted as writing, in 1736, as follows:

    "In the churchyard of St. Paul, Covent Garden, the burials are so frequent that the place is not capacious enough to contain decently the crowds of dead, some of whom are not laid above a foot under the loose earth. The cemetery is surrounded every way with close buildings; and an acquaintance of mine, whose apartments look into the churchyard, hath averred to me that the family have often rose in the night time and been forced to burn frankincense and [[p. 319]] other perfumes to dissipate and break the contagious vapor. This is an instance of the danger of infection proceeding from the corrupt effluvia of dead bodies."

    Many illnesses then originated in churches, and even those whose houses were exceptionally wholesome were often exposed to a dangerous atmosphere when they went to church on Sundays.

    The general food of the poor and the middle classes added greatly to their unhealthiness, and itself caused disease. Owing to the absence of good roads, it was impossible to supply the large population of London with fresh food throughout the year, and, consequently, salt meat and salt fish formed the staple diet during the winter. For the same reason fresh vegetables were unattainable; so that meat, cheese, and bread, with beer as the common drink at all meals, was the regular food, with chiefly salted meat and fish in winter. As a result, scurvy was very common. Dr. Cheyne, in 1724, says: "There is no chronical distemper more universal, more obstinate, and more fatal in Britain than the scurvy." And it continued to be common down to 1783, when, Dr. Buchan says, "The disease most common in this country is the scurvy." But very soon afterward it decreased, owing to the growing use of potatoes and tea, and an increased supply of fresh vegetables, fruit, milk, etc., which the improved roads allowed to be brought in quantities from the surrounding country.

    Now, it is quite certain that the excessively unhealthy conditions of life, as here briefly described, continued with very partial amelioration throughout the middle portion of the century; and we have to consider what were the causes which then came into operation, leading to the great improvement in health that undoubtedly occurred in the latter portions of it and in the early part of our century.

    Beginning with improvements in the streets and houses, we have, in 1762, an Act passed for the removal of the overhanging sign-boards, projecting waterspouts, and other such obstructions. In 1766 the first granite pavements were laid down, which were found so beneficial, and in the end economical, that during the next half century almost all London was thus paved. In 1768 the first Commissioners of Paving, Lighting, and Watching were appointed, and by 1780 Dr. Black states that many streets had been widened, sewers made; that there was a better water supply and less crowding.² From this date onward, we are told in the "Encyclopædia Britannica" (art. "London"), a rapid rate of progress commenced, and that since 1785 almost the whole of the houses within the city had been rebuilt, [[p. 320]] with wider streets and much more light and air. In 1795 the western side of Temple Bar and Snowhill were widened and improved, and soon afterward Butchers' Row, at the back of St. Clement's Church, was removed. Of course, these are only indications of changes that were going on over the whole city; and, coincident with these improvements, there was a rapid extension of the inhabited area, which, from a sanitary point of view, was of far greater importance. That agglomeration of streets, interspersed with spacious squares and gardens, which extends to the north of Oxford Street, was almost wholly built in the period we are discussing. Bloomsbury and Russell Squares and the adjacent streets occupy the site of Bedford House and grounds, which were sold for building on in 1800. All round London similar extensions were carried out. People went to live in these new suburbs, giving up their city houses to business or offices only. Regent's Park was formed, and Regent Street and Portland Place were built before 1820, and the whole intervening area was soon covered with streets and houses, which for some considerable period enjoyed the pure air of the country. At this time the water supply became greatly improved, and the use of iron mains in place of the old wooden ones, and of lead pipes, by which water was carried into all the new houses, was of inestimable value from a sanitary point of view.

    Then, just at the same time, began the great improvement in the roads, consequent on the establishment of mail coaches in 1784. This at once extended the limits of residence for business men, while it facilitated the supply of fresh food to the city. In 1801, London, within the Bills of Mortality, was increased in area by almost fifty per cent., with comparatively very little increase of population, owing to the suburban parishes of St. Luke's, Chelsea, Kensington, Marylebone, Paddington, and St. Pancras being then included; and even in 1821 this whole area had only a million inhabitants, and was therefore still thinly peopled, and enjoying semi-rural conditions of life.³ The slight increase of population from 1801 to 1821 (about one hundred and fifty thousand), notwithstanding this extension of area, proves that these suburban parishes were almost wholly peopled from the denser parts of the city, and to a very small extent by fresh immigrants from the country. It is also clear that many city inhabitants must have removed to outlying parishes beyond the Bills of Mortality, in order to explain the very small increase of population in twenty years. This dispersion of the former city population over a [[p. 321]] much larger suburban area was, in all probability, the most powerful of the various sanitary causes which led to the great diminution of mortality, both general and from the zymotic diseases.⁴

    Another very important agency, at about the same time, was the great change in the popular diet that then occurred--the change from bread, beer, and salted meat or fish to potatoes, tea or coffee, and fresh meat. Dr. Poore tells us that potatoes were first used in hospital diet in 1767.⁵ They steadily grew in favor, and in the early part of this century had become so common that they almost completely abolished scurvy, the prevalence of which had no doubt rendered other diseases more fatal. At the same time tea became a common beverage. The consumption of tea in England in 1775 was 5,648,000 pounds, and in 1801, 23,730,000 pounds--a more than four-fold increase; a rate which has never been approached in any subsequent twenty-five years. With tea came the more general use of milk and sugar; and it was this, perhaps, that helped to cause the exceptionally rapid decrease of infant mortality. Again, in the same period, the disuse of the city churchyards for interments became general; cemeteries were formed in various parts of the suburbs, till such interments in any part of London were forbidden in 1845, thus removing one more, and not an unimportant, source of disease from the more crowded areas.

    Now, the various classes of improvements here briefly indicated--those in the city itself, in wider, cleaner, and less obstructed streets, the construction of sewers, and better water supply; the more wholesome food, especially in the use of potatoes and other vegetables, and tea, with its accompanying milk and sugar, becoming common [[p. 322]] articles of diet; and, most important of all, the spreading out of the population over a much wider area, enabling large numbers of persons to live under far more healthy conditions--all, as we have seen, occurring simultaneously, and effecting this most fundamental change within the half century from 1775 to 1825, are in their combination amply sufficient to account for that remarkable decrease of mortality, not, as the Royal Commissioners suggest, pre-eminently in small-pox, but in all the more important diseases, which especially characterized this period. This is strikingly shown by Dr. Farr's table printed in the Third Report (p. 198), of which the portion that especially concerns us is here given. It shows us for two periods, 1771-80 and 1801-10, the deaths per one hundred thousand living from the more important diseases.

    Here we see that, in the thirty years from 1775 to 1805, a change occurred which reduced the mortality from all the chief diseases to half, or less than half, their previous amount. Small-pox no doubt shows the largest decrease; but as it is a decrease which was mainly effected before vaccination was heard of, that operation cannot have been its cause.⁶ Now, the remarkable feature of this diminution of mortality is, that in no similar period between 1629, when the Bills of Mortality began, down to the present year, has there been anything like it. And the same may said of the causes that led to it. Never before or since has there been such an important change in the food of the people, or such a rapid spreading out of the crowded population over a much larger and previously unoccupied area; and these two changes are, I submit, when taken in conjunction with the sanitary improvements in the city itself, and the much greater facilities of communication between the town and country around, amply sufficient to account for the sudden and unexampled improvement in the general health, as indicated by the great reduction of the death-rate from all the chief groups of diseases, including small-pox.

    [[p. 323]] Now, in the whole of the Final Report, I can find no recognition whatever of the remarkable and exceptional improvement in the general health of London that has been shown to have occurred in the period embracing the end of the last and the beginning of the present centuries; nor of the equally exceptional changes of various kinds, all tending to improved health in the people. And, in view of the facts here adduced, the statement of the Royal Commissioners that "no evidence is forthcoming to show that during the first quarter of the nineteenth century these improvements differentiated that quarter from the preceding quarter or half of the preceding century in any way at all comparable to the extent of the differentiation in respect to small-pox," has, I submit, been shown to be wholly erroneous.

    And with respect to the absence of proof of similar changes having occurred in other European countries, which they also urge against the sanitation theory, we hardly need any such proof in detail. The very fact of the immediate adoption of vaccination in all the more civilized countries shows how rapid was the spread of ideas and of customs at that very period. And when we consider, further, that in the last century all the great European cities were at about the same level of filth and unhealthiness with London, and that a century later there is not much difference between them, the probability is in favor of their having all advanced approximately pari passu. And with regard to the all-important change in diet and other habits, the same rule applies. The use of potatoes and of tea or coffee, the better water supply, drainage, ventilation, and good roads were all adopted,--in France and Germany, at all events,--approximately about the same period as with us. Hence it is not surprising that a similar diminution in general mortality as well as in mortality from zymotic diseases, including small-pox, should have occurred almost simultaneously. The fact that when we have fairly good statistics, as in Sweden, the great improvement in small-pox mortality is shown to have occurred before the introduction of vaccination or before it could have affected more than a small fraction of the population, sufficiently proves that this was the case.

    I have now supplied the last piece of confirmatory evidence which the Commissioners declared was not forthcoming; not because I think it at all necessary for the complete condemnation of vaccination, but because it affords another illustration of the curious inability of this Commission to recognize any causes as influencing the diminution of small-pox except that operation. In this, as in all the other cases I [[p. 324]] have discussed, their Report is founded upon the opinions and beliefs of the medical and official upholders of vaccination; while "the great masses of national experience," embodied in statistics of mortality from various groups of diseases, as well as the well-known facts of the sanitary history of London during the critical half-century 1775-1825, are either neglected, misunderstood, or altogether overlooked.

Notes Appearing in the Original Work

    1. White's "Story of a great Delusion," p. 81. [[on p. 318]]

    2. See "Fourth Report of the Royal Commission on Vaccination," Q. 10,917. [[on p. 319]]

    3. These figures are given in the Eighth Annual Report of the Registrar-General, and the parishes included are from the "Encyclopædia Britannica." [[on p. 320]]

    4. I have already repeatedly referred to the vital importance of space, air, and light for a healthy living. A few more illustrations may be here given. In his work, already quoted, Dr. Poore gives a table of the mortality by measles and whooping-cough of children under five, for the years 1871-80, in the different districts of London, according to density of population. It gives the following results:

    The general death-rate follows the same law. In Lewisham, Wandsworth, and Hampstead, with densities under 35 per acre, the death-rates are under 15 per thousand; while in Shoreditch, Whitechapel, St. George-in-the-East, and St. Savior, Southwark, with densities from 185 to 208 per acre, the death-rates are from 20 to 24 per thousand, according to the latest returns of the Registrar-General. [[on p. 321]]

    5. "London from a Sanitary and Medical Point of View." 1889. [[on p. 321]]

    6. The decrease is probably exaggerated, owing to the confusion of measles with small-pox. Measles shows an increased mortality in the above period from forty-eight to ninety-four, and as it increased through the whole of the Bills of Mortality it was probably being slowly differentiated from small-pox. [[on p. 322]]