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Cholera Inquiry Commission 1854 - Part 1

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REPORT.

TO THE QUEEN'S MOST EXCELLENT MAJESTY.

MAY IT PLEASE YOUR MAJESTY,

WE, by your Majesty's Letters Patents of the 31st December 1853 appointed "to be the Commissioners for inquiring into the causes which have led to, or have aggravated, the late outbreak of Cholera in the towns of Newcastle-upon-Tyne, Gateshead and Tynemouth," herewith humbly submit to your Majesty:

That, immediately upon the issuing of the said Letters Patents, we proceeded to the said town of Newcastle-upon-Tyne, and there, in the Town Hall, on the 5th January, 1854, in the presence of the Mayors, Town Clerks, and others, the officers and inhabitants of all the said three towns, duly opened and read the said Letters Patents and held a public meeting under and by virtue thereof; and that, after having advertised in all the local papers during two successive weeks our intention to that effect, and having also invited any and all persons to appear and tender evidence, we proceeded, in the Town Hall of Newcastle, on the 19th, and thence de die in them till the 30th January, and again on the 7th; 10th, and 11th March, to take evidence upon oath relative to that town: examining altogether about seventy witnesses, including four Superintending Inspectors of the General Board of Health; thirteen medical officers of the Newcastle charitable institutions; all the five medical officers of the Newcastle Poor Law Union; eight other medical practitioners; and several aldermen, magistrates, and other members and officers of the Corporation of Newcastle, and of the Board of Guardians there, besides other persons:- and again proceeded, in the Town Hall of Gateshead, on the 8th, 9th, and 10th of March, to take evidence relative to that town; and further in respect of Tynemouth took the evidence of the Town Clerk there; - the greater and more material part of the minutes of all which evidence is hereto annexed; - and that having also obtained documentary information from the Registrar General of Births, Deaths, &c., and from divers other sources, and having ourselves made several personal inspections; by night as well as by day, by ourselves and in company with official and other personages, of various parts and localities of Newcastle, more than one personal inspection of parts of Gateshead, and a cursory inspection of Tynemouth, we now beg humbly to report as follows:-

AND FIRSTLY, AS REGARDS NEWCASTLE:

1. That in the fifteen years; from 1839 to 1853, both inclusive, the town of Newcastle has been visited by various epidemics, some of which have been unusually extensive and malignant.

2. That during the late outbreak of cholera there, upwards of 1500 persons (1527 or 1533) perished in about nine weeks out of a population of about 90,000, (87,784 at the census of 1851,) being a mortality of more than 1 in 60 for that short period; that of the four parishes and five townships, into which the Borough of Newcastle is divided, one township appears to have escaped altogether, while in the others the mortality varied from 1 in 189 to 1 in 45; that in still more limited districts the mortality was in many instances still higher; 8 persons out of about 150 having died in one lane, 6 out of about 100 in another, 16 out of 192 in a third; 9 out of 64 in one court, 10 out of 70 in another, and 20 out of 119 in a third; while in one case there perished as many as 8 out of 31 in a single house, and in two other cases 4 out of 5 and 5 out of 6 in a single family.

3. That the mortality among every thousand inhabitants of Newcastle during each of the last fifteen years has, according to the returns furnished to us by the Registrar General, been as follows:-

Years.183918401841184218431844184518461847184818491850185118521853
Deaths per mille.30.727.829.223.625.620.922.330.232.827.329.123.826.129.743.3

and that the mortality among every thousand inhabitants on the average of those fifteen years has been 28.6 per annum.

4. That it has been suggested to us that this death-rate is deceptive; firstly, owing to its having been increased by the deaths in Newcastle of sick strangers, brought thither for medical advice or otherwise; - an increment, however, which (With the corresponding decrement, owing to the deaths of inhabitants of Newcastle in other places, whither they may have been taken for change of air) we do not, in the absence of any proof to the contrary, deem of importance; - and secondly, owing to the deaths arising from accidents in mines and factories; but that, although in possession of no exact statistics upon this point, we have reason to believe that the increment hence arising is also comparatively but inconsiderable: to which we need only add that, as regards the first, a similar increment will appear in the death-rates of all considerable towns, and as regards the second, in the death-rates of all mining and manufacturing towns.

5. That it has further been urged upon us that the mortality of Newcastle is not by any means without a parallel; that the mortality among every thousand inhabitants of the four following places (selected for comparison with Newcastle by the Corporation of that. place) has, on the average of the same fifteen years, and on the same authority of the Registrar General, been as follows:- In Leeds, 28.5; in Hull, 29.8; in Manchester, 33.1; and in Liverpool, 37.6 per annum; but that these facts have not, in our, judgment, any material bearing on the question before us, more especially as the places compared appear to be by no means properly comparable, either in respect of natural advantages, or of many other highly important points.

6. That the town of Newcastle is situated on a steep slope, ascending from the Tyne to the height of some two or three hundred feet, at a point where this general slope is further cleft into lateral slopes and valleys by several tortuous burns, deans or brooks, which there run into the Tyne; that the whole site of the town is a succession of acclivities and declivities, steep enough in many instances to be traversable only by long flights of steps; a great majority of the streets and thoroughfares lying at very considerable elevations, and even the lowest being from five to eight feet above springtide highwater; and that (by universal consent) it affords remarkable facilities for sewerage, drainage, and other sanitary arrangements; that the main body of the town does certainly lie in a kind of amphitheatre, surrounded on the west, north and east, by ground higher than itself, and having on its south the Tyne, just where that river makes a considerable bend; but that the dimensions of this amphitheatre are too large, and the width of the river too great, to allow of our regarding these circumstances as any serious impediment to the general ventilation of the town; and that excepting these, and excepting that almost all the upper part of the town lies on clay or loam approaching thereto, we know of nothing in any degree unfavourable about its physical position, but, on the contrary, are of opinion that it might and ought to be a very healthy town.

7. That the death-rate of Newcastle above-mentioned, whether high or low as compared with that of other places, is unquestionably very high for Newcastle, and might as unquestionably be very greatly reduced; that, bearing in mind the great sanitary capabilities of Newcastle, we are of opinion that, on the average of the last fifteen years, the actual annual mortality has been nearly double the natural or necessary mortality of the place; and that (supposing no life were wasted for want of sanitary precautions and arrangements) 16 per 1,000 per annum would be an over high, 15 per 1,000 a moderate, and 14 per 1,000 by no means an unwarrantable estimate of that natural or necessary mortality; whence follows that, on the average of those fifteen years, (supposing the population during that period to have averaged 80,000), certainly 1,000, probably 1,100, and possibly even 1,200 lives have annually been sacrificed in Newcastle, owing to the artificial aggravation of natural diseases.

8. That for each of the 1,000, 1,100 or 1,200 fatal cases thus annually produced in Newcastle, there will also have been produced several not fatal, but more or less severe, cases of the same artificially aggravated diseases; and that, when we reflect upon the amount of misery and distress entailed upon all classes, and of destitution, pauperism and even crime but too frequently entailed upon the poorer classes by such calamities - (to say nothing at the present moment of the expense of tending the sick, burying the dead, &c., especially to the payers of the poor's rate, who not only have to pay for their own, but also for their pauper neighbours' shares in these disasters) - we cannot but feel shocked at the spectacle before us: a spectacle, which is rendered only the more deplorable by the consideration, that the Corporation of Newcastle is not only ancient, wealthy and influential, but has for at least seven years possessed under its own local Acts (in addition to those conferred on it by public Statutes) unusually extensive sanitary powers, the exercise of which could not have failed signally to mitigate and reduce this excess of disease and mortality.

9. That the late outbreak of cholera in Newcastle was unquestionably more severe than any previous outbreak of that disease in that town. but not apparently more so than previous outbreaks of it in other places: and that this greater severity appears to have consisted rather in the greater extent of its attacks, than in the greater malignancy of them, or in the higher proportions of deaths to cases.

10. That this greater severity cannot in any material degree have been owing to a circumstance, which (when present) habitually increases the virulence of epidemics generally, and which is known to have aggravated some of the previous epidemics in Newcastle, viz:- distress and insufficiency of food among the poorer classes; the whole population appearing to have participated in the recent prosperity of the place.

11. That it has been suggested to us that this greater severity has been due to a greater intensity of some supposed ultimate virus or specific poison; but that we have no evidence of the operation, if even of the existence, of any such virus or poison, except in the presence of sanitary defects and grievances; and that it seems probable that this increased severity of cholera has been mainly due to an increased intensity of predisposing local causes.

12. That many of the causes, which beyond all question have materially aggravated the virulence of many previous epidemics there, and, as we doubt not, of the late outbreak of cholera also, are obvious on a very slight inspection of the town, especially of the poorer districts; that few persons, probably, in any degree acquainted with sanitary matters, could pass through certain of those districts without at once seeing indications of sanitary defects and grievances sufficient to account for almost any extent of preventible disease and mortality; and that it would be difficult, we think, for any such persons to make a detailed inspection of those districts, or even to read the accounts of such detailed inspections, without coming to strong conclusions on the matter; and that the evidence which we have taken has mainly served, firstly to confirm in detail the accuracy of the impressions produced upon us by our personal examinations of the town, and secondly to convince us that no other tenable explanation of the habitual virulence of epidemics and continual excess of mortality there was forthcoming.

13. That these aggravative causes not only are now obvious, but have long been notorious in the town; that in the year 1846 remarkable sanitary powers for the suppression of many of them were obtained by the Corporation under a Local, Act; that in the year 1847 two Sanitary Associations were formed there, the one consisting of the chief medical practitioners, town councillors and other principal inhabitants of that place and of Gateshead, and the other of the working men there, who from that time to this have taken a remarkable interest in such matters; and that these Associations, in their interviews and communications with the Corporation, in their reports and at their public meetings, have from time to time drawn particular attention to the existence and pernicious influence of those causes, as well as to the powers possessed by the Corporation for the suppression of them; that in the three years, 1847-9, a variety of memorials and representations on the subject were made to the Town Council and other local authorities in a variety of ways: and that in December 1849, an official inquiry into the mortality of Newcastle was instituted under the Public Health Act by Superintending Inspector of Health Mr. Rawlinson, in the course of which a great number of these aggravative causes, and the non-exercise by the Corporation of their then powers for the suppression of them, were specially and publicly adverted to.

14. That the annual reports of the Medical Charitable Institutions of the place (the trustworthiness of which has been affirmed by numerous medical witnesses), in commenting on the virulence and fatality of successive epidemics, have habitually indicated and pointed out those aggravative causes. For instance, in reference to the great scarlatina epidemic of 1845-7, we find it stated, that its ravages "were far from being greatest in the lower parts of the town," and that "the disease was fearfully fatal in confined courts, where the drainage was superficial, filth accumulated, and the houses were devoid of proper means of ventilation."

In like manner, in reference to the great Irish fever epidemic of 1846-8, we find it stated that the poverty, filth, and bad ventilation in the chosen seats of the disease were such "as to warrant the fear of an epidemic disease being generated among them, without an actual importation of it;" that "nothing could be more ingeniously adapted for the engendering or disseminating of infection than the tramper's boarding-house, or the tenemented dwellings of the lower Irish;" that "here fever had its constant home;" and that "from hence, when aggravated by privation, epidemic influence or other depressing cause, it spread abroad."

Again, in allusion to the epidemics of 1852-3, we find it reported that "the fatal issue of some of the cases seemed to be caused or hastened by the dark, dirty, damp dwellings, in which the patients were confined, many of them not being fit for the habitation of human beings;" that "a very large number of cases of illness occurred among persons residing in the most crowded and filthy rooms, possessing no means whatsoever of ventilation, so that the air was of the most vitiated and stifling description;" and that the "maladies affecting patients of this kind were usually of the most fatal character."

15. That the medical committee of the Newcastle and Gateshead Sanitary Association, in their report to Mr. Rawlinson, December 1849, after stating that the "excessive mortality during the last few years had arisen solely from zymotic or epidemic, which are in fact the most preventible diseases," proceeded as follows: "To describe the seats of typhus and other forms of continued fever, would be to enumerate all the narrow undrained alleys in the older parts of the town, together with many equally unhealthy, because still more neglected, districts in the suburbs. In many parts of Newcastle fever maybe said to be never absent; and a continued residence in those unwholesome dwellings is certain to involve the prostration, and eventually the death, of some members of the family by fever."

Again, after alluding to "the comparative exemption of Newcastle from the then recent visitation of cholera," "as a remarkable instance of the efficacy of even the slight and partial measures then recently adopted for the sanitary improvement of the town, and as a strong ground of encouragement for the further prosecution of that improvement," the medical committee proceeded to observe, that "the comparatively few cases of malignant cholera which had occurred in Newcastle supplied, they thought, amply sufficient evidence both of the invariable dependence of attacks of this epidemic on certain predisposing physical causes, and also of the necessity for continued vigilance on the part of the authorities, lest this fearful disease, in the event of a further visitation, by no means an uncommon accident in its erratic course, should exercise a more destructive influence upon the inhabitants of Newcastle."

16. That "the continued vigilance on the part of the authorities," which, according to the report of that medical committee, had been proved to be necessary in order to guard against a further and more destructive outbreak - such as actually occurred last autumn - does not appear to have been exercised by those authorities; that, except in certain points partially affecting its outdoor condition, no material or permanent improvement in the sanitary condition of the town, especially of the poorer districts, appears to have taken place for many years; that the descriptions of the sanitary state of the town in previous years, hereto annexed, were in the main applicable to it in the autumn of 1853; that the same causes, which at those previous periods were reported as exercising an unfavourable influence in respect of the then prevalent epidemics, were also to a very great degree present last autumn, and exercised a similar unfavourable influence in respect of the late outbreak of cholera; and that the sanitary state, especially of the poorer districts of Newcastle, at the time of the late outbreak, was such as to warrant the apprehension that an epidemic, if it did make its appearance, would prevail there very severely.

17. That some of the medical practitioners, who gave evidence before us, while concurring in the received views as to the laws which regulate the attacks and ravages of epidemics generally, made various statements and suggestions tending to intimate that the cholera, at its late outbreak in Newcastle, did not obey the same laws as ordinary epidemics, but proved itself more or less independent of the local causes predisposing to other epidemics; and, in particular, endeavoured to instance to us the occurrence of cholera in localities free from any material sanitary defects or predisposing local causes.

18. That we at once accepted the task of the investigation thus proposed to us, and from time to time pursued the inquiry into the true sanitary state of the localities thus suggested to us as free from material sanitary defects; but that these investigations, far from conducing to the conclusions in support of which they were originally proposed, serve, in our opinion, rather to bear out the contrary, and to illustrate the close connection habitually prevailing between the virulence of cholera and the neglect of ordinary sanitary precautions.

19. That the circumstance, which chiefly gave rise to these peculiar views and suggestions, appears to have been this, viz.:- That the cholera, during its late outbreak, did not, as on former occasions, confine itself almost exclusively to the ordinary and habitual seats of disease, inhabited by the poorer classes, but also extended its ravages to adjacent and in some respects better conditioned localities, inhabited by the middling and even upper classes; but that this circumstance is, in our opinion, properly and easily explicable on recognized sanitary principles, and affords an illustration of, rather than an exception to, the ordinary laws of public health.

20. That one such explanation of a similar feature in the great scarlatina epidemic of 1845-7 was suggested in the Newcastle Dispensary Report for 1847, which, after observing that "in these confined courts the drainage was only superficial, and that large masses of filth were allowed to accumulate round the doors, while the houses themselves were almost entirely devoid of proper means of ventilation, and this in localities surrounded on all sides by the habitations of the wealthier classes," proceeded to inquire: "Can it then be a matter of surprise that disease should occasionally visit them (the habitations of the wealthier classes) with as much severity as the late epidemic has, in too many instances, done ?" - and that a similar explanation of this same feature of that epidemic was also given at the time by an independent medical practitioner.

21. That on the 12th September 1853, in the height of the recent outbreak, Mr. Grainger, Superintending Inspector of Health in the medical department, reported to the General Board of Health that "there was no doubt that the general malaria, rising out of the neglected and miserable parts of Newcastle, overhangs the whole town and penetrates into every domicile, and acts in this epidemic period as an intensifying, predisposing, and all-influential cause."

22. That, bearing in mind the unusually heavy and stagnant state of the atmosphere, which appears to have prevailed in the town during the worst dominance of the late epidemic, we are of opinion that the above is to a certain extent a true solution or explanation of the circumstance alluded to; and that we entertain no doubt whatsoever as to the virulence of the late outbreak having been substantially dependent upon the same sanitary defects, to which the virulence of other epidemics is known and admitted to have been attributable, and which are hereinafter adverted to.

23. That the outbreak of cholera in Newcastle, A.D. 1848-9, was light and mild, and that this circumstance appears to have been ascribed, not only by the inhabitants generally, but also by the medical practitioners especially, to the temporary mitigation of the sanitary defects of the town, which had just previously been brought about under pressure of the great Irish fever epidemic, A.D. 1847-8, particularly in respect of a general cleansing which had then been effected by the Corporation, of an improved water supply, and of a newly established system for the removal and exportation of town refuse.

24. That in further corroboration of the above opinions we would observe, that, during the late outbreak of cholera in Newcastle, there were registered among the 519 persons then residing within the walls of the barracks there, over and above nine cases of dysentery, no less than 451 (more or less slight) cases of diarrhoea, of which, however, not a single one passed on into the more advanced or developed stage of cholera; while in the village of Spital Tongues (within the borough of Newcastle), very similarly situated and within 200 or 300 yards of the barracks - but whose sanitary condition appears to have been very bad - there occurred no less than twenty-seven or twenty-eight fatal, beside other not fatal, cases of cholera in a population of about 500 persons; that this comparative exemption of the barracks, although in part, no doubt, owing to the generally robust health of the inmates, will also in part have been owing to its originally better sanitary condition and to the energetic adoption of sanitary and medical precautions there immediately on the breaking out of the disease in the town; and that the adoption of similar precautions in Spital Tongues and throughout the rest of Newcastle could hardly have failed to exercise a similar influence in mitigating the virulence of the epidemic there also.

We may add that in the gaol at Newcastle, usually a healthy establishment, there occurred as many as 9 deaths from cholera out of a number of inmates never at any one time much exceeding 144, and, including all who at different periods of the epidemic passed through the prison, amounting to 236; chiefly owing, as it should seem, to the temporarily impure condition of the atmosphere there, arising from the temporarily overcrowded state of that institution.

25. That there is no evidence whatever to show that the late outbreak in Newcastle was in any degree owing to the arrival there of any infected ships, sailors or other persons from any already infected localities, or to any such importation from abroad as quarantine regulations or sanitary cordons could have prevented.

26. That considerable districts of Newcastle to this day present all the worst insanitary features of old walled towns, greatly aggravated by other evils of a comparatively modern origin; that except in respect of the destruction of a few small pestilent courts and entries effected by the driving of the York, Newcastle and Berwick and other railways through the town, by the making or preparing for some among the many new streets, which the Town Council by their local Acts have taken power to make, and by the pulling down of about thirty buildings in Sandgate, the older and lower parts of the town may, many of them, be said to have remained unaltered in their form of house-construction for centuries; the joint committee of the Town Council and of the Board of Guardians, in their report, Oct. 1853, observing that "Sandgate has existed, as it now exists, for hundreds of years."

27. That there are considerable districts, especially in the lower and older parts of Newcastle, in which almost all the houses are built back to back, so as to be incapable of through ventilation, and with their fronts within so few feet of one another, as to render it almost impossible for sunshine, wind or rain to reach directly even their exterior walls; many of these miserable lanes or entries being moreover closed up or covered over at one or even at both ends.

28. That in the district known by the name of Sandgate there are a number of narrow lanes and entries. extending from the thoroughfare of that name and from St. Ann's Street northward to the New Road and southward to the Quay, whose aggregate length exceeds a mile, while their average breadth at the bottom but rarely exceeds four feet; the upper stories of the houses, many of which are lofty, often projecting over the lower ones, so as to leave at the top nothing but a mere chink or rift for light and air to make their way through.

29. That, on entering some of the houses in such localities during our day inspections of the town, we were arrested at the door by a darkness which was little less than total, and were obliged to wait a moment or two before we could see sufficiently well to grope our way up the stairs: and that more than one of the parochial medical officers have spoken to the fact of their sometimes labouring under the necessity of taking a candle, in order to see their patients in some of the rooms in these places, even at noonday in the height of summer.

30. That the sanitary defects of such a character of house-construction (which can hardly have been otherwise than considerable, even when a substantial burgher with his single family occupied an entire house), are frightfully aggravated now-a-days; when, owing to the removal of the wealthier classes into the loftier and airier districts of the extending town, these lower and older parts have fallen almost exclusively into the occupation of the lower and lowest classes; and when, over and above that the houses, many of them centuries old, have become miserably decayed and dilapidated, not only is almost every single room throughout each house occupied by a separate family, but also many single and small rooms serve as the only habitation for two or more entire families, or for a whole family and for several additional inmates, visitors or lodgers.

31. That there are other and considerable districts of Newcastle, in which, owing to the abruptness with which the site of the town slopes down to the river or its tributaries, whole rows of houses are built into or against the bank, so as to have the earth of the declivity above piled up against their back or side walls for a greater or less height, and so as to incur, in respect of so much of them at least, all the worst disadvantages of underground dwellings.

32. That the soil of the upper and by far the greater part of the site of Newcastle consists of a thinnish stratum of strong loam or clay, irregularly veined with sand or gravel, lying on a thick stratum of very impervious strong clay; that, owing to the very general want of drainage in many districts, this soil is necessarily and habitually damp; and that this dampness of the soil, aggravated in many instances by the infiltrations from the excessive filth with which the surface of the ground is strewn, is absorbed into the brick and timber work of the houses, especially of those built into and against the bank-side, until the walls of many of them are permanently and habitually damp, and but too frequently with worse than mere water.

33. That the report of the medical committee of the Newcastle and Gateshead Sanitary Association, made the 18th December, 1849, after alluding to one of the most notorious of such localities, in which, during three months of the epidemic of 1847, there had occurred 5 deaths and 50 cases of fever among 55 inhabitants, proceeds to observe:- "Nor was there any difficulty in discovering the physical causes which thus doomed the unfortunate inhabitants of these pest-houses to certain suffering, and the possible contingency of premature death; for being built in close contact with the earth forming the side of a steep bank, the walls of these houses were necessarily and constantly imbued with moisture, while a large collection of every species of filth from piggeries and heaps, &c., on the summit of the bank above, supplied a constant source of putrefying liquid to mingle with the natural drainage water, and ooze with it into the porous walls of the subjacent dwellings. It is but proper to mention that, since the period of that visit, the Town Council have enacted a bye-law forbidding pigs to be kept within the town; but the other evils remain unremedied, and are unfortunately but too common in all the low lying parts of the town:" - to which we can only add, that many of the localities thus alluded to continued, until the time of our visits even, to exist in a state not materially altered from that in which they are thus described to have existed in 1847 and 1849; and that at the time of the late outbreak there were, we fear, but too many places to which such a description was in a great degree applicable.

34. That the far too frequent practice of building privies and ash-pits, where such conveniences exist at all against the walls of houses, so as occasionally. to allow of the liquid filth oozing directly through the walls into living and sleeping rooms, and so as habitually to bring these "poison pits" directly alongside or below them or otherwise close to their doors and windows, is another instance of the artificial and gratuitous aggravation of sanitary evils; and that, owing to the custom of allowing heaps of filth to accumulate in the corners of courts and entries against the walls of houses, every shower of rain, by saturating these heaps, tends to render and keep damp the walls of the adjoining houses, even where the means of ordinary surface drainage are not wanting.

35. That there are districts in Newcastle which, in the totality of sanitary evil, or in respect of the many sanitary defects simultaneously exhibited, are, according to three Superintending Inspectors of Health, whom we have examined, more misconditioned probably- than any other districts of anything like the same area in any other town in Great Britain; that a negative confirmation of this testimony may probably be gathered from the refusal of the present superintendent of police in Newcastle (formerly a member of the metropolitan police in the Westminster district,) to answer our questions in respect even of the very first point, in which we proposed to institute a comparison between the worst districts of Westminster and of Newcastle; and that, whatever be the comparative condition of these latter districts, their actual condition is in the highest degree lamentable and prejudicial to health.

36. That the joint committee of the Town Council and of the Board of Guardians in their report, October 1853, affirmed that "the greater part of Sandgate is not fit to be inhabited;" and that there are considerable districts in the town which not only appear to be in the main unfit for human habitation, but also to be so radically misconstructed and decayed as to be, by consent of several witnesses, almost incapable of being rendered fit for habitation so long as the present structures shall exist.

37. That the district, most frequently referred to as an instance hereof, is that of Sandgate, which, however, appears to be by no means the worst in all respects among the districts of Newcastle; that a district. known by the name of Pandon is probably worse than Sandgate; and that there are other districts also whose sanitary condition appears to be but little, if any, better.

38. That the insanitary condition of the older parts of Newcastle has, in many instances, been the slow and cumulative result of gradual, and therefore imperceptible, changes; whereas in the newer parts a similar miscondition has arisen from the deliberate intentions of the builders: many rows and streets having been erected or re-built, even quite recently, and let as tenemented (which is only another name for overcrowded) houses, which were utterly unsewered and undrained, incapable of proper ventilation, wholly unsupplied with necessary domestic conveniences or else supplied with them in the most objectionable situations, and which had neither paving, flagging nor channelling about them to prevent in any degree the constant sinking and trampling of all sorts of filth and refuse into the ground, and the subsequent re-exhalation of noxious vapours into the air; while in several cases cellars and under-ground rooms, things almost unknown in the older parts of the town, have been introduced and converted into dwellings.

39. That the joint committee of the Town Council and of the Board of Guardians, in their report, October 1853, observed, that "some modern streets and lanes had been formed by speculators in those townships, which were added to the Borough under the Municipal Reform Act, which were scarcely less calculated to generate disease than the closely. packed habitations of Sandgate;" that Superintending Inspector of Health Mr. Lee, in his report to the General Board of Health, September 1853, in speaking of a part of the township of Westgate, observed that "typhus-fever, cholera or other epidemic disease ought never to have existed in the neighbourhood, and never would have done, but for the criminal cupidity of builders, and the absence or non-enforcement of proper regulations;" and again, that, "after witnessing the awful destruction of human life in this locality within the last month, it was impossible to repress the strong feeling of indignation, which arose from a conviction that it was all entirely preventible;" on all which points his report has since been confirmed by the testimony of Mr. Slang, parochial medical officer of the district including Westgate.

40. That under their Local Improvements Acts, 1837 and 1846. the Town Council of Newcastle obtained complete powers of supervision, and extensive though not perhaps complete powers of control over the formation of new streets and the erection or re-erection of houses there, with a view to the enforcement of "all the regulations relative to the proper construction of houses and buildings within the Borough," including the provision of proper domestic conveniences and other important points; that in 1849, on the occasion of Mr. Rawlinson's official inquiry, the Town Surveyor admitted that the latter Act had "been a dead letter altogether;" and that the same disregard of these important powers appears to have continued after that inquiry as before.

41. That the house accommodation of the poorer inhabitants of Newcastle is, as a whole, exceedingly defective, not only in respect of the habitually bad form of house-construction, frequent dilapidation and dampness, and general destitution of necessary conveniences, but also in respect of other deliberately effected grievances, such as the making fixtures of windows, and thereby precluding ventilation, in order to avoid the expense of moveable sashes; and that there is no evidence to show that it has in any material degree been improving, internally at least, of late years.

42. That the Corporation of Newcastle are themselves the owners of a considerable amount of house-property in the occupation of the poorer classes, especially in Sandgate, where they have been buying ever since 1837, professedly with the design of pulling a great part of it down; that within five or six years the condition of the Corporation property there was (if possible) worse than that of any other, and at all events so bad as to induce Mr. Newton, parochial medical officer of the district including Sandgate, to write several letters in one of the local newspapers, giving an account of some detailed inspections of parts of it, and stating that "a great part of their tenemented property (in his district) was really unfit for human habitation and should be condemned as such;" that since then their property there has been improved so as to be somewhat better in condition than some of the adjoining private properties, but still remains in a very bad state, and in many parts unfit for human habitation; and that in other parts of the town some of the Corporation property still continues in a condition, not only in itself extremely bad, but also worse than that of the private properties immediately adjoining.

43. That the extent of this miserable house-property throughout the Borough may be judged of from the statement, that the tenemented (and until within a few months unrated) property alone produces a rental of about £50,000 out of a total Borough rental of about £300,000 per annum; that, beside the interest arising in connection with the Corporation property, the ownership of house property by individual corporators and citizens is acknowledged to constitute an important element in the Town Council, and to have exercised an influence fatal to the enactment of certain clauses in the last local Act of 1853, which would have been of the highest sanitary advantage; and that under these circumstances it seems difficult to avoid a conclusion as to what has caused, or conduced to, the obvious neglect by the Town Council of the various powers by their own local Acts (as well as by public Statutes) conferred upon them for the improvement of the house property, and the suppression of many sanitary evils, throughout the town.

44. That the poorer inhabitants of Newcastle are not only very ill lodged, but exceedingly overcrowded in their lodgings - in some degree, no doubt, owing to the comparatively high rents demanded for their miserable habitations; that "the overcrowded, ill-ventilated, and ill-arranged dwellings occupied by the mass of the labouring population in tenements and lodging-houses" was the third of "the chief preventible causes of the excessive mortality lately experienced in Newcastle," to which the medical committee of the Newcastle and Gateshead Sanitary Association alluded in their report to Mr. Rawlinson in 1849 and that this overcrowding among the poor is not unfrequently greatest at times when cholera or other epidemics are likely to be most prevalent, viz., in or about harvest time, when an additional influx of harvesters takes place, and when the autumnal season is producing its usual unfavourable effects.

45. That there are stated to be about 9,453 houses in the whole Borough, and 20,000 families or thereabouts, or on the average rather more than two families to each house throughout the Borough; that of those 9,543 houses, 6,900 or thereabouts are stated to be occupied as "self-contained houses" by as many single families, leaving about 2,553 houses to be occupied in tenements by the remaining 13,100 families, which gives an average of rather more than five families to each "tenemented house" throughout the Borough; and that from calculations, of approximate accuracy, made by the first Commissioner, (from documentary information furnished to him by the clerk to the Board of Guardians in Newcastle,) it appears, that of the whole number of families in the Borough of Newcastle only 34.7 per cent. occupy "self-contained houses," and only 2.5 per cent. occupy tenements consisting of three or more rooms each; while 23.5 per cent. occupy tenements consisting of two rooms each, and 39.2 per cent occupy tenements consisting of but a single room each.

46. That, owing to some of the self-contained houses alluded to containing (to our own knowledge and experience) but a single room apiece, and owing to many of the tenants of the single-room tenements habitually taking other lodgers, and even whole families, to share with them the occupancy of their single rooms, 39.2 will by no means adequately express the per centage of the families or population of Newcastle residing in such tenements; and that we shall not probably be overstating the case, if we compute that about half the families in Newcastle are confined exclusively to the occupancy or joint occupancy of exceedingly overcrowded single-room tenements.

47. That in 1847 the sub-committee of the Newcastle and Gateshead Sanitary Association in their inspections of certain entries in Sandgate found "from nine to seventeen persons in one room;" that in 1849, at the time of Mr. Rawlinson's official inquiry, evidence was given by one of the inspectors of nuisances of "as many as fifteen, sixteen and nineteen persons" having been found in single rooms; that in February 1851, the inspector of nuisances reported that he had "visited sixteen lodging rooms" in Eddy's entry, Sandgate, and had "found from eight to ten women and children in each room," while the parochial medical officer reported that in one out of fourteen rooms, which he had visited, there were sixteen people, while in each of two others there were three whole families, numbering nine and twelve persons respectively; that in September 1853, Superintending Inspector of Health Mr. Granger obtained information of cholera having broken out in rooms, in which as many as twenty or twenty-five occupiers were congregated; there being, in the latter instance, but fifty cubic feet of space or air (furniture, &c., not considered) for each individual - the smallest allowance usually permitted in registered lodging-houses being, as we believe, from 300 to 350 cubic feet, and the allowance usually recommended for each inmate by the inspectors of prisons, the directors of hospitals, &c., being, as we are informed, about 1,000 cubic feet or upwards; that on the 20th November 1853, just after the cessation of the late outbreak, the inspector of lodging-houses and the parochial medical officer of the district found 220 inmates in twenty-three rooms in Eddy's entry; and that out of the fourteen among those rooms, whose dimensions as well as the numbers of their inmates were taken, there were two, in each of which were fifteen persons, having on the average 97 cubic feet of space apiece (furniture, &c., not considered); one in which were fourteen persons, having 104 cubic feet apiece; three, in each of which were twelve persons, having 120 or 121 cubic feet apiece; two, in each of which were nine persons, having 128 cubic feet apiece; two, in each of which were twelve persons, having 150 cubic feet apiece, and one in which were eight persons, having 156 cubic feet apiece: and that our own experience during our nocturnal inspections of the town goes fully to confirm the impressions from the foregoing statements derivable.

48. That in consequence of the frequent ill construction, ill ventilation and overcrowding of the habitations of the poorer classes (as well as of the want of sewerage, drainage, proper domestic conveniences and other matters hereafter to be adverted to) the condition of many of the tenements, which form the residences of about three-fourths - and especially the condition of many of the single-room tenements, which form the residences of about half - of the entire population of Newcastle, has habitually been "filthy and unwholesome," even where not technically describable as "unfit for human habitation;" that the stench experienced on entering some of them is in the highest degree offensive, so as occasionally to cause nausea and vomiting, even among persons who from their avocations might be expected to be more or less inured thereto; and that the effects of all this upon the health of the inmates and of the vicinity generally can only be equalled by the corresponding effect upon their morals and sense of decency.

49. That the Local Improvement Act for Newcastle, 1846, enacted that it should be "lawful for the Town Council from time to time to make bye-laws for laying down rules for cleansing filthy and unwholesome dwellings," "and to ascertain and fix what pecuniary penalties should be incurred by persons breaking such laws;" that towards the close of the next year, 1847, Dr. Robinson, honorary secretary to the Newcastle and Gateshead Sanitary Association, by a paper published in the Journal of Public Health, drew attention not only to the existence of these powers, and of the evils for the suppression of which they might have been exercised, but also to the fact that they had been allowed to remain "wholly inoperative;" that the Newcastle Medical Institutions and Sanitary Associations in their reports and at their public meetings, &c., heretofore alluded to, would seem to have frequently, all but in terms, suggested the propriety of enforcing this power; and that the exercise of it would at all events have been eminently desirable, and would no doubt signally have mitigated the ravages of the late epidemic; but that no such exercise or enforcement of it appears ever to have taken place, and that no such rules or byelaws have ever been made.

50. That from the evidence of Superintending Inspector of Health Mr. Lee, as confirmed by the testimony of the parochial medical officer, Mr. Sang, it appears that at the time of the late outbreak "hundreds of the newly built tenements," in one district of the township of Westgate alone, "ought to have been immediately closed by the local authorities as unfit for human habitation;" that within eleven weeks after the putting in force of a provision to that effect in the Local Improvement Act of 1853, 102 tenements in Newcastle were shut up as "unfit for human habitation," while many more required and require so to be; the chief limit to such a proceeding, apparently, being that suggested by the fear of leading to a still greater overcrowding of the tenements not shut up.

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