Transcriber’s Notes
Text between _underscores_ and =equal signs= represents text printed
in italics and bold face, respectively. Small capitals have been
changed to ALL CAPITALS.
More transcriber’s notes may be found at the end of this text.
REPORTS
RELATING TO
THE SANITARY CONDITION
OF THE
CITY OF LONDON.
BY
JOHN SIMON, F.R.S.
SURGEON TO ST. THOMAS’S HOSPITAL, AND
OFFICER OF HEALTH TO THE CITY.
LONDON:
JOHN W. PARKER AND SON, WEST STRAND.
MDCCCLIV.
LONDON:
SAVILL AND EDWARDS, PRINTERS, CHANDOS STREET,
COVENT GARDEN.
TO
LOUIS MICHAEL SIMON,
OF THE STOCK EXCHANGE, LONDON, AND OF
THE PARAGON, BLACKHEATH,
I DEDICATE THIS REPRINT OF MY REPORTS:
LOOKING
LESS TO WHAT LITTLE INTRINSIC MERIT THEY MAY HAVE,
THAN TO THE YEARS OF ANXIOUS LABOUR THEY REPRESENT:
DEEMING IT FIT TO ASSOCIATE
MY FATHER’S NAME
WITH A RECORD OF ENDEAVOURS TO DO MY DUTY:
BECAUSE IN THIS HE HAS BEEN MY BEST EXAMPLE;
AND
BECAUSE I COUNT IT THE HAPPIEST INFLUENCE IN MY LOT,
THAT, BOUND TO HIM BY EVERY TIE OF GRATEFUL AFFECTION,
I HAVE LIKEWISE BEEN ABLE, FROM MY EARLIEST CHILDHOOD
TILL NOW--THE EVENING OF HIS LIFE,
TO REGARD HIM WITH UNQUALIFIED AND INCREASING RESPECT.
CONTENTS.
Page
DEDICATION iii
PREFACE vii
FIRST ANNUAL REPORT 1
FURTHER REMARKS ON WATER-SUPPLY 72
SECOND ANNUAL REPORT 77
THIRD ANNUAL REPORT 177
FOURTH ANNUAL REPORT 211
FIFTH ANNUAL REPORT 213
APPENDIX OF TABLES ILLUSTRATING THE SANITARY CONDITION OF
THE CITY OF LONDON. 264
REPORT ON CITY BURIAL-GROUNDS 280
REPORT ON EXTRAMURAL INTERMENTS 285
PREFACE.
The following Reports, officially addressed to the Commissioners of
Sewers of the City of London, were originally printed only for the use
of the Corporation; and although, to my very great pleasure, they have
been extensively circulated through the medium of the daily press, there
has continued so frequent an application for separate copies that the
surplus-stock at Guildhall has long been exhausted. Under these
circumstances--believing the Reports may have some future interest, as
belonging to an important educational period in the matters to which
they refer, I have requested the Commission to allow their collective
reprint and publication; and this indulgence having been kindly accorded
me, I have gathered into the present volume all my Annual Reports,
together with a special Report suggesting arrangements for extramural
burial.
From the nature of the work, I have not considered myself at liberty to
make those extensive alterations of text which usually belong to a
second edition. I have restricted myself to a few verbal corrections,
and to rectifying or omitting some unimportant paragraph, here or there,
in case its matter has been more fully or more correctly stated in parts
of a subsequent Report. Frequently, where I have wished to explain or
qualify passages in the text, I have added foot-notes; but these are
distinguished as interpolations by the mark--J. S., 1854.
My Reports lay no claim to the merit of scientific discovery. Rather,
they deal with things already notorious to Science; and, in writing
them, my hopes have tended chiefly towards winning for such doctrines
more general and more practical reception. It has seemed to me no
unworthy object, that, confining myself often to almost indisputable
topics--to truths bordering on truism, I should labour to make trite
knowledge bear fruit in common application.
Nor in any degree do they profess to be cyclopædic in the subject of
Preventive Medicine; for it is but a small part of this science that
hitherto is recognised by the law; and that--so far as the metropolis is
concerned, scarcely beyond the confines of the City. It would have been
an idle sort of industry, to say much of places or of matters foreign to
the jurisdiction of those whom I officially addressed.
In re-publishing documents which proclaim extreme sanitary evils, as
affecting the City, I think it right to draw attention to the dates of
the several Reports, and to state that for the last five years many of
these evils have been undergoing progressive diminution, of late at a
rapid and increasing rate; while, at their worst, they represented only
what I fear must be considered the present average condition of our
urban population.
This national prevalence of sanitary neglect is a very grievous fact;
and though I pretend to no official concern in anything beyond the City
boundaries, I cannot forego the present opportunity of saying a few
words to bespeak for it the reader’s attention. I would beg any educated
person to consider what are the conditions in which alone animal life
can thrive; to learn, by personal inspection, how far these conditions
are realised for the masses of our population; and to form for himself a
conscientious judgment as to the need for great, if even almost
revolutionary, reforms. Let any such person devote an hour to visiting
some very poor neighbourhood in the metropolis, or in almost any of our
large towns. Let him breathe its air, taste its water, eat its bread.
Let him think of human life struggling there for years. Let him fancy
what it would be to himself to live there, in that beastly degradation
of stink, fed with such bread, drinking such water. Let him enter some
house there at hazard, and--heeding where he treads, follow the guidance
of his outraged nose, to the yard (if there be one) or the cellar. Let
him talk to the inmates: let him hear what is thought of the bone-boiler
next door, or the slaughter-house behind; what of the sewer-grating
before the door; what of the Irish basket-makers upstairs--twelve in a
room, who came in after the hopping, and got fever; what of the
artisan’s dead body, stretched on his widow’s one bed, beside her living
children.
Let him, if he have a heart for the duties of manhood and patriotism,
gravely reflect whether such sickening evils, as an hour’s inquiry will
have shown him, ought to be the habit of our labouring population:
whether the Legislature, which his voice helps to constitute, is doing
all that might be done to palliate these wrongs; whether it be not a
jarring discord in the civilisation we boast--a worse than pagan
savageness in the Christianity we profess, that such things continue, in
the midst of us, scandalously neglected; and that the interests of human
life, except against wilful violence, are almost uncared for by the law.
And let not the inquirer too easily admit what will be urged by less
earnest persons as their pretext for inaction--that such evils are
inalienable from poverty. Let him, in visiting those homes of our
labouring population, inquire into the actual rent paid for
them--dog-holes as they are; and studying the financial experience of
Model Dormitories and Model Lodgings, let him reckon what that rent can
purchase. He will soon have misgivings as to dirt being cheap in the
market, and cleanliness unattainably expensive.
Yet what if it be so? Shift the title of the grievance--is the fact less
insufferable? If there be citizens so destitute, that they can afford to
live only where they must straightway die--renting the twentieth
straw-heap in some lightless fever-bin, or squatting amid rotten
soakage, or breathing from the cesspool and the sewer; so destitute that
they can buy no water--that milk and bread must be impoverished to meet
their means of purchase--that the drugs sold them for sickness must be
rubbish or poison; surely no civilised community dare avert itself from
the care of this abject orphanage. And--_ruat cœlum_, let the principle
be followed whithersoever it may lead, that Christian society leaves
none of its children helpless. If such and such conditions of food or
dwelling are absolutely inconsistent with healthy life, what more final
test of pauperism can there be, or what clearer right to public succour,
than that the subject’s pecuniary means fall short of providing him
other conditions than those? It may be that competition has screwed
down the rate of wages below what will purchase indispensable food and
wholesome lodgment. Of this, as fact, I am no judge; but to its meaning,
if fact, I can speak. All labour below that mark is masked pauperism.
Whatever the employer saves is gained at the public expense. When, under
such circumstances, the labourer or his wife or child spends an
occasional month or two in the hospital, that some fever-infection may
work itself out, or that the impending loss of an eye or a limb may be
averted by animal[1] food; or when he gets various aid from his Board of
Guardians, in all sorts of preventable illness, and eventually for the
expenses of interment, it is the public that, too late for the man’s
health or independence, pays the arrears of wage which should have
hindered this suffering and sorrow.
[1] Twenty years’ daily experience of hospital surgery enables me to
say, from personal knowledge, that our wards and out-patient rooms are
never free from painful illustrations of the effects of insufficient
nutrition--cases, in fact, of chronic starvation-disease among the
poor; such disease as Magendie imitated, in his celebrated
experiments, by feeding animals on an exclusively non-azotised diet.
Probably on no point of political economy is there more general
concurrence of opinion, than against any legislative interference with
the price of labour. But I would venture to submit, for the
consideration of abler judges than myself, that before wages can safely
be left to find their own level in the struggles of an unrestricted
competition, the law should be rendered absolute and available in
safeguards for the ignorant poor--first, against those deteriorations of
staple food which enable the retailer to disguise starvation to his
customers by apparent cheapenings of bulk; secondly, against those
conditions of lodgment which are inconsistent with decency and health.
But if I have addressed myself to this objection, partly because--to the
very limited extent in which it starts from a true premiss, it deserves
reply; and partly because I wish emphatically to declare my conviction,
that such evils as I denounce are not the more to be tolerated for their
rising in unwilling Pauperism, rather than in willing Filth; yet I doubt
whether poverty be so important an element in the case as some people
imagine. And although I have referred especially to a poor
neighbourhood--because here it is that knowledge and personal refinement
will have least power to compensate for the insufficiencies of public
law; yet I have no hesitation in saying that sanitary mismanagement
spreads very appreciable evils high in the middle ranks of society; and
from some of the consequences, so far as I am aware, no station can call
itself exempt.
The fact is, as I have said, that, except against wilful violence, life
is practically very little cared for by the law. Fragments of
legislation there are, indeed, in all directions: enough to establish
precedents--enough to testify some half-conscious possession of a
principle; but, for usefulness, little beyond this. The statutes tell
that now and then, there has reached to high places the wail of physical
suffering. They tell that our law-makers, to the tether of a very scanty
knowledge, have, not unwillingly, moved to the redress of some clamorous
wrong. But--tested by any scientific standard of what should be the
completeness of sanitary legislation; or tested by any personal
endeavour to procure the legal correction of gross and glaring evils;
their insufficiencies, I do not hesitate to say, constitute a national
scandal, and, perhaps in respect of their consequences, something not
far removed from a national sin.
In respect of _houses_--here and there, under local Acts of Parliament,
exist sanitary powers, generally of a most defective kind; pretending
often to enforce amendments of drainage and water-supply; sometimes to
provide for the cleansing of filthy and unwholesome tenements; in a few
cases to prevent over-crowding; very rarely to ensure stringent measures
against houses certified to be unfit for human habitation.
Occasionally--but a few lines would exhaust the list, an application of
the Public Health Act, or some really efficient local Act, has put it
within reach of the authorities to do all that is needful under certain
of these heads. But I know of no such town that would bear strict
examination as to its possession of legal powers to fulfil, what I
presume must be the principle contemplated by the law--that no house
should be let for hire unless presenting the conditions indispensable
for health, or be hired for more occupants than it can decently and
wholesomely accommodate.[2] However this may be expressed, and in
whatever laws embodied, local or general, I will venture to say that no
Government should suffer a town, either to be without the means of
enforcing this principle, or, having such means, to shirk their
exercise. Our Constitution may properly concede that local
representative authorities shall have their option whether, for sanitary
purposes, to fall under a general law, or to have Local Improvement Acts
of their own; but, in the present state of knowledge, it certainly seems
incontestable that one or other of these alternatives should be
compulsory, and that all Local Improvement Acts should be required, in
their sanitary clauses, to come up to the standard of the Public Health
Act of the time, whatever it may be.
[2] In addition to the ordinary powers--given, for instance, in the
Public Health or City Sewers Act, for abating accumulated nuisances
and for enforcing wholesome constructional arrangements; a principal
requirement of all bodies having jurisdiction for the public health
is, that there should be vested in them some authority, _enabling them
to regulate_, in the spirit of the Common Lodging House Act, _all
houses which are liable to be thronged by a dangerous excess of low
population_. Almost invariably such houses are of the class
technically known as ‘tenement-houses,’ i. e., houses divided into
several tenements or holdings; whereof each--though very often
consisting but of a single small room, receives its inmates without
any available restriction as to their sex or number, and without
regard to the accommodation requisite for cleanliness, decency, and
health. The inhabitants of such houses, especially where of the lower
order of Irish, constantly lapse into the most brutal filthiness of
habits, and live in almost incredible conditions of dirt,
over-crowding, and disease. See sections of the following Reports,
beginning severally at pages 44, 146, and 195. Powers for dealing with
these evils might be given to Local Boards of Health, most usefully, I
think, in some such form as the following: 1) that--in respect of any
house occupied by more than one family, if it be situate in any court,
alley, or other place having no carriage-way, and be not assessed to
the poor-rate at a higher rental than £...... _per annum_; or if in it
any occupied holding consist of only one room, provided the rent of
such room do not exceed the sum of ......shillings per week, or if in
it there reside, or within three months previous have resided, any
person receiving parochial relief, medically or otherwise; on the
certificate of a duly authorized medical officer, that any such house,
or part thereof, is habitually in a filthy condition, or that from
over-crowding or defective ventilation the health of its inmates is
endangered, or that there has prevailed in it undue sickness or
mortality of an epidemic or infectious kind; the Local Board may call
upon its owner to register it in a book kept for this purpose; and in
respect of all houses thus registered, the Local Board may make rules
for periodical washing, cleansing, and limewhiting, and for the
regular removal of all dust or refuse-matter, may fix the number of
tenements into which it shall be lawful to divide any such house, or
the total number of inmates who may at one time be received therein,
may require its better ventilation by the construction of additional
windows or louvres, and may from time to time make such other
regulations and orders as they shall judge necessary for the
maintenance of health and decency; and may recover from the owner or
lessee of any such house penalties for neglect of any legal
requisitions, rules, and orders, as aforesaid: 2) that--on the
certificate of a duly authorised medical officer, that the condition
of any house or room is such as to render probable the rise or the
spread of infectious and dangerous disease among its inmates, the
Local Board may cause the owner or lessee of such house to be summoned
before a magistrate; who, after due hearing, or in default of the
owner’s or lessee’s appearance, may order the house, or any part of
it, to be evacuated of all tenants within such time as he shall judge
fit, and not again to be tenanted till after licence from the Local
Board given on the certificate of their medical officer that its
causes of unhealthiness are abated; and the magistrate may enforce
penalties for non-compliance with his order, as aforesaid: 3)
that--after an Order in Council bringing into action the extraordinary
clauses of the Nuisances Removal Act, the Local Board, on receiving
the certificate of their medical officer that any house, or part of
house, is in such condition as to be imminently dangerous to the lives
of its inmates in respect of the prevailing epidemic, or any similar
disease, may issue a peremptory order for its evacuation, and may
recover, from the owner or lessee to whom such order is addressed,
penalties for every day during which, or part of which, after such
order, the house, or any part thereof, continues to be tenanted; nor,
under like penalties, shall it be lawful, except after written licence
from the Local Board, given as aforesaid, to allow such house to be
re-occupied.
Under circumstances like those just adverted to, may be found traces of
enactment against _offensive and injurious trades_. Unregulated
slaughtering throughout all London, except the City, tallow-melting in
St. Paul’s church-yard, bone-boiling beside Lambeth Palace, may serve to
illustrate the completeness and efficiency of these laws--even in our
metropolitan area. Here we greatly lack some competent authority, on the
part of the Government, to investigate all circumstances connected with
such establishments, generally; to suggest laws for their prospective
restriction, as to places wherein they may lawfully settle; and to frame
regulations--enforceable by any Local Board of Health, for ensuring that
all available measures be employed to mitigate their nuisance.
Considering the circumstances under which many of these establishments
have existed, no one can entertain a thought, that--even for the public
health, they should be liable to the tyranny of an unconditional
displacement. But if there existed--as undoubtedly there should exist,
some skilled tribunal, competent to speak on the subject; then, I will
venture to say, it might be quite in accordance with our English sense
of liberty, that--after a certain condemnatory verdict by this tribunal,
it should be open to the Local Board of Health to procure their
expulsion, on payment of whatever compensation an ordinary jury might
award.
Again, with _factories_; thanks to Lord Shaftesbury’s indefatigable
benevolence, the law has appointed an inspection of certain
establishments, a restriction of their hours of labour, and some care
against the dangers of unboxed machinery. And with mining also the law
has interfered, chiefly as to the ventilation of mines; but hitherto so
ineffectively that, while I write, the coal-miners are remonstrating
with the Legislature on the thousand lives _per annum_ still sacrificed
through the insufficient protection accorded them. If there be meaning
in this legislation--if it imply any principle, the meaning and the
principle require to be developed into a general law, that every
establishment employing labour be liable to inspection and regulation in
regard of whatever acts and conditions are detrimental or hazardous to
life. If factory-children are cared for, lest they be over-worked; and
miners, lest they be stifled; so, for those who labour with copper,
mercury, arsenic, and lead, let us care, lest they be poisoned! for
grinders, lest their lungs be fretted into consumption! for
match-makers, lest their jaws be rotted from them by phosphorus! And
here let it again be noticed, as in the class of cases last spoken of,
how greatly wanted is some skilled tribunal, to form part of any lawful
machinery which might ensure that, in these and similar instances, no
precautions necessary to life are withheld through ignorance or
parsimony.
Against _adulterations of food_, here and there, obsolete powers exist,
for our ancestors had an eye to these things; but, practically, they are
of no avail. If we, who are educated, habitually submit to have copper
in our preserves, red-lead in our cayenne, alum in our bread, pigments
in our tea, and ineffable nastinesses in our fish-sauce, what can we
expect of the poor? Can they use[3] galactometers? Can they test their
pickles with ammonia? Can they discover the tricks by which bread is
made dropsical[4], or otherwise deteriorated in value, even faster than
they can cheapen it in price? Without entering on details of what might
be the best organisation against such things, I may certainly assume it
as greatly a _desideratum_, that local authorities should uniformly have
power to deal with these frauds (as, of course, with every sale of
decayed and corrupted food) and that they should be enabled to employ
skilled officers, for detecting at least every adulteration of bread and
every poisonous admixture in condiments and the like.
[3] The proverbial dilutions of milk are not its only deteriorations.
Cows are so ill kept in London, and in consequence so often sickly,
that milk suffers--sometimes by mere impoverishment, sometimes by much
graver derangements. If there were instituted a proper Inspection of
Provisions, one function of its officers should be to visit
cow-houses, and to prevent the distribution of milk thus damaged or
infected. I suspect that a sanitary reform of these establishments
would make a sensible difference to the nursery-population of the
metropolis.
[4] A chief artifice in the cheapening of bread is to increase its
weight by various means which render it retentive of water. The other
usual frauds consist in the employment of inferior flours--either not
cereal, or damaged and partially deglutinised.
In some respects this sort of protection is even more necessary, as well
as more deficient, in regard to _the falsification of drugs_. The
College of Physicians and the Apothecaries’ Company are supposed to
exercise supervision in the matter; so that at least its necessity is
recognised by the law. The security thus afforded is, in practice, null.
It is notorious in my profession that there are not many simple drugs,
and still fewer compound preparations, on the standard strength of which
we can reckon. It is notorious that some important medicines are so
often falsified in the market, and others so often mis-made in the
laboratory, that we are robbed of all certainty in their employment.
Iodide of potassium--an invaluable specific, may be shammed to half its
weight with the carbonate of potash. Scammony, one of our best
purgatives, is rare without chalk or starch, weakening it, perhaps, to
half the intention of the giver. Cod-liver oil may have come from seals
or from olives. The two or three drops of prussic acid that we would
give for a dose may be nearly twice as strong at one chemist’s as at
another’s. The quantity of laudanum equivalent to a grain of opium
being, theoretically, 19 minims; we may practically find this grain, it
is said, in 4.5 minims, or in 34.5. And my colleague, Dr. R. D. Thomson,
who has much experience in these matters, tells me that of
calamine--not indeed an important agent, but still an article of our
pharmacopœia--purporting daily to be sold at every druggist’s shop,
there has not for years, he believes, existed a specimen in the
market.[5]
[5] Dr. Thomson tells me that he has known white precipitate of
mercury sold in hundred-weights as calomel, and in one case (he
believes by accident or ignorance) as trisnitrate of bismuth. In my
text I have endeavoured to adduce such illustrations as I suppose to
be most notorious; but I may refer the reader to various interesting
papers published, through the last two or three years, in the LANCET
(_Analytical Sanitary Commission_) from one of which I quote the
astounding instance, given above, of variations in the strength of
laudanum. Mr. Thomas Taylor, of Vere Street, informs me that, whereas
an ounce of laudanum should contain about four grains of morphia, he
finds the actual quantity varying in different specimens from two
grains to six; and that in two specimens of solid opium, outwardly
alike and supposed to be of equal quality, he has found the per
centage of morphia to vary from 3½ to 10. It requires little
instruction in medicine to appreciate these facts.
Again, with the _promiscuous sale of poisons_, what incredible laxity of
government! One poison, indeed, has its one law. Arsenic may not be sold
otherwise than coloured, nor except with full registration of the sale,
and in the presence of a witness known to both buyer and vender.
Admirable, so far as it goes! but why should arsenic alone receive this
dab of legislation? Is the principle right, that means of murder and
suicide should be rendered difficult of access for criminal purposes?
Does any one question it? Then, why not legislate equally against all
poisons?--against oxalic acid and opium, ergot and savin, prussic acid,
corrosive sublimate, strychnine?
Nor can our past legislators be more boastful of their labours for the
_medical profession_--either for its scientific interests, or for the
public protection against ignorance and quackery.[6] Nearly two dozen
corporate bodies within the United Kingdom are said to grant licences
for medical practice; and I hardly know whether it lessens or aggravates
this confusion, that such licences are in many cases partial; that one
licentiate may practise north of the Tweed, but nowise to the south;
that one may practise in London, another only seven miles beyond it. Not
that the licence seems much to matter! for innumerable poachers in all
directions trespass on what the law purports to sell as a secured
preserve for qualified practitioners: their encroachments are made with
almost certain impunity; and--as for the titles of the Profession, any
impostor may style himself _doctor_ or _surgeon_ at his will. Even where
licences are held, conveying identical titles, they imply neither equal
privileges (as I have said) nor even uniform education. The law has
troubled itself little as to the terms on which they shall be granted;
and the qualifications exacted from candidates--the conditions
preliminary to their becoming eligible for licence, vary in so
remarkable a degree among the many corporate bodies which are fountains
of this honour, that the credentials conferred have really little
meaning, apart from a context which the public is unable to supply. It
is charged against particular institutions, that their degrees and
licences are attained with a very inglorious facility; and when it is
recollected that the issuing of such testimonials is a source--sometimes
a chief source--of income to the corporations which grant them, it will
be felt that at least there must exist great danger of this reproach
being sometimes deserved. If a national title to practise medicine is to
be granted by several Boards, and if yet the tenure of that title is to
determine public confidence in favour of its holder, it would seem
indispensable that some guarantee should be given for these several
licences representing equal qualifications--some guarantee that the
holder in each case possesses professional knowledge, and has enjoyed
professional opportunities, at least above some uniform standard
recognised as a _minimum_ qualification by all the diplomatising bodies.
Indispensable, however, as this may seem, years of endeavour have failed
to attain it. What is called _medical reform_ has been agitated longer
than I can remember; and more than one minister has been willing to
legislate for its promotion. Unfortunately the very magnitude of the
evils has delayed their cure. With the constitution I have described--a
system of conflicting jurisdictions, of licences without titles, and
titles without licences, how could we escape internal dissension? how
escape the antagonism, perhaps the jealousies, of rival corporations and
of different professional classes? Home-Secretaries have had little
leisure to fathom these things to the bottom. Unexamined and
unadjudicated by any competent authority, such influences have
bewildered public judgment, made statesmen regard us with despair,
postponed legislative correction, and maintained us in a state of
anarchy and confusion, best to be appreciated when we compare with our
own the organisation and government of the legal profession.
[6] Legislative passiveness towards scientific medicine is not the
only evil we have to complain of. Surely, in selling Letters Patent
for the protection of quack-medicines--in seeming to sanction and
authenticate whatever lies their proprietor may post upon the wall,
the State demeans itself into complicity with fraud, and soils its
fingers with something fouler than the Vespasian tax. It illustrates
the curious _forgetfulness_ shewn towards medicine by the Legislature,
that this immoral practice of giving patents for pretended cures of
disease should have been allowed to continue--as of course it must
have continued, solely by oversight, till past the middle of the
nineteenth century.
And be it noted, how this reacts upon the State. So completely is our
government dissevered from Science in general, and, most of all, from
the sciences relating to Life, that, on such subjects, there exists not
for state-purposes anything like a tribunal of appeal. The Legislature
recognises no _Medical Authority_. Occasionally this fact stands out in
painful conspicuousness, and brings most injurious results. In contested
cases requiring scientific testimony--before Parliamentary Committees,
for instance, and in a variety of legal proceedings,--instead of the
Court having satisfactory power of referring particular questions to
skilled impartial adjudicators, the uniform practice is, that scientific
men are retained on opposite sides, to support partisan interests. The
advantages, such as they are, which belong to this system, might, I
believe, easily be obtained under altered arrangements: the
disadvantages are glaring. It might be invidious to refer to
illustrations of their reality: but it is of course impossible to doubt
of the working of this system, that, in so far as it makes each witness
feel himself engaged to maintain the views of his employer, it tends
towards a moral prostitution and subornation of science. In the
interests of truth, it would surely seem desirable that scientific
evidence should be tendered, so far as may be, in a judicial spirit
towards the suit; either that the technical point should be referred to
a technical jury, or that the technical witness should be summoned at
the Court’s discretion, should be examined in-chief by the Court, and
should be subject only to such cross-examination as may procure the most
complete statement of his knowledge on the matter in hand.
Having said so much on the defects and the wrongs of our existing
sanitary condition, perhaps I may venture to speak of the almost obvious
remedy. ‘Almost obvious’ I say; for surely no one will doubt that this
great subject should be dealt with by comprehensive and scientific
legislation; and I hardly see how otherwise, than that it should be
submitted in its entirety to some single department of the executive, as
a sole charge; that there should be some tangible head, responsible--not
only for the _enforcement_ of existing laws, such as they are or may
become, but likewise for their _progress_ from time to time to the level
of contemporary science, for their _completion_ where fragmentary, for
their _harmonisation_ where discordant.
If--as is rumoured, the approaching re-constitution of the General Board
of Health is (after the pattern of the Poor-law Board) to give it a
Parliamentary President, that member of the Government ought to be open
to challenge in respect of every matter relating to health. What, for
this purpose, might be the best subordinate arrangements of such a
Board, it would take a volume to discuss. But at least as regards its
constituted head, sitting in Parliament, his department should be, in
the widest sense, to _care for the physical necessities of human
life_. Whether skilled coadjutors be appointed for him or not;
engineers--lawyers--chemists--pathologists; whether he be, as it were,
the foreman of this special jury, or, according to the more usual
precedent of our public affairs, collect advice on his own
responsibility, and speak without quotation of other authority than
himself, his voice, unless the thing is to be a sham, must represent all
these knowledges.
The people, through its representatives, must be able to arraign him
wherever human life is insufficiently cared for.
He must be able to justify or to exterminate adulterations of food; to
shew that alum ought to be in our loaves, or to banish it for ever; to
shew that copper is wholesome for dessert, or to give us our olives and
greengages without it; to shew that red-lead is an estimable condiment,
or to divert it from our pepper-pots and curries.
Similarly with drugs and poisons--the alternatives of life and death--a
minister of Public Health would, I presume, be responsible for whatever
evils arise in their unlicensed and unregulated sale. He would hardly
dare to acquiesce in our present defencelessness against fraud and
ignorance; in doses being sold--critical doses, for the strength of
which we, who prescribe them, cannot answer within a margin of _cent.
per cent._; or in pennyworths of poison being handed across the counter
as nonchalantly as cakes of soap.[7] Surely, before he had been six
months in office, he would have procured some enactment to remedy this
long neglect of the legislature, by providing that the druggist’s trade
be exercised only after some test of fitness, and in subjection to
certain regulations.
[7] Without referring to what may be considered rare--the sale of
poison for the purposes of intended homicide, I may remind the reader
of the very dreadful facts collected by the Commissioners on Trades
and Manufactures, as to the immense sales of opium in our principal
manufacturing towns, for the purpose of quieting--and with the effect
of killing, children, while their poor mothers are absent from home in
their several occupations.
Within his province, likewise, it would fall to be cognisant of all that
relates to the constitution of the Medical Profession. The difficulties
which have baffled successive Home-Secretaries might soon find their
solution in the less divided attention which he could bring to their
study. Amid conflicting opinions and an apparent scramble for power, he
would soon distinguish where might be the strife of jealousy and
covetousness, where a truthful zeal for the honour and efficiency of
medicine. I think he could not be long in curing our more scandalous
anomalies. Probably--unless human bowels require other doctoring in
London than in Manchester, he would manage that a doctor there should
be a doctor also here; that no licence for the partial practice of
medicine should be recognised--no licence admitting a man to do in
Edinburgh what it would be a misdemeanour for him to do in Greenwich.
And obviously, in order to this--since a professional diploma is the
only criterion by which the public can measure the competence of those
who seek their patronage, he would see that, as far as may be, the
various licensing bodies exact from their candidates equal and
sufficient qualifications; that the diploma entitling a man to call
himself Surgeon or Physician, Accoucheur or Apothecary, mean the same
thing--imply the same education, whether it be got in Scotland, Ireland,
or England; and that any falsification of such diploma, or any
unauthorised assumption of the title which implies its possession, be
promptly punishable at law.[8]
[8] This check at least seems indispensable, for the reason above
given, that a professional diploma is the only criterion by which the
public can measure professional competence; and for the validity of
such a criterion, it therefore, I think, becomes the duty of a
government, on behalf of the public, to provide. For anything beyond
this (except in one particular case) the matter might take its natural
course. No law can supersede a necessity for common sense in the
subject; and medicine, I think, requires no _protection_. Let my
neighbour, by all means, if he desire it, send for a green-grocer to
reduce his dislocation or assuage his gout! and let him take the
consequences of his folly, in a spoilt limb or in a hair’s breadth
escape with his life. Only--let the green-grocer be punishable, if he
seek this office under false pretences, calling himself by any title
which implies a professional qualification. And, for what harm he may
do--let him of course (as would, if necessary, the presidents of our
colleges) be prepared to abide before judge and jury his trial for
malpractice. But, in strict adhesion to the principle I have
professed, that protection is wanted, not for the profession, but for
the public, I would suggest one exception to what otherwise might be
universal free-trade in medicine. I refer to the case of druggists;
who, whenever the Legislature may awake to the necessity of regulating
their trade, ought, I think, to be expressly prohibited from the
treatment of disease. To an immense majority of our population--to all
the under-educated classes, the druggist’s shop appears an emporium
for medical skill, as well as for medical appliances. They probably
have some vague overestimate of our art of healing, and think perhaps
that the several bottles on the shelf correspond to the several
ailments they can specifically cure. They ask for something “good for
a dropsy,” or “good for a wasting,” or “good for a palpitation;” not
knowing how much skill may be requisite to interpret the symptom; not
knowing that, to our highest skill, there is no medicine thus
indiscriminately, or even generally, “good.” At present almost
universally, druggists, with no medical qualification, are tampering
more or less with serious medical responsibilities; and the mischief
thus occasioned--especially among the poorer classes, is a matter of
notoriety, on which persons engaged in hospital practice would be
competent and tolerably impartial witnesses. It is because this evil
arises in the _almost inevitable ignorance_ of those who chiefly
suffer from it, that, in accordance with the principle above
suggested, I think it deserves consideration from the Legislature.
Into the hands of this new minister--advised, perhaps, for such purposes
by some permanent commission[9] of skilled person, would devolve the
guardianship of public health against combined commercial interests, or
incompetent administration. He would provide securities for excluding
sulphur from our gas, and animalcules from our water. He would come into
relation with all Local Improvement Boards, in respect of the sanitary
purposes of their existence. To him we should look, to settle at least
for all practical purposes the polemics of drainage and water-supply; to
form opinions which might guide Parliament, whether street sewers really
require to be avenues for men, whether hard water really be good enough
for all ordinary purposes, whether cisternage really be indispensable to
an urban water-supply.
[9] There are many instances in my mind, some already adverted to,
where the existence of a standing jury for scientific--especially for
sanitary, purposes might be of great utility. It is an organisation
which prevails extensively in France, under the name of _Conseils de
Salubrité_; forming, in most of the large towns there, a constant
board of reference for the municipality, in respect of sanitary
regulations. _Mutatis mutandis_, it might become invaluable as an
English institution, in respect of many matters touched upon in this
sketch; and perhaps with some division of duties, into such as would
best belong to a General Board of the kind, and such as might properly
be vested in Local Boards. To determine the indispensable conditions
of healthy lodgment; to examine the influence of trades and
occupations, and to devise the regulations they may require, for the
neighbourhood’s sake, or for their operatives’; to supervise the sale
of food and drugs; to be cognisant of medical matters; would seem,
either locally or generally, to require the co-operations of several
skilled persons. But, though I have spoken of such, as indispensable
jurors for these subjects, I do not forget that other interests than
those of life may need to be consulted. For the fair representation of
these, the lay faculty of _educated common-sense_ will fulfil an
inestimable usefulness, if it may be there to mediate between science,
which is sometimes crotchety, and trade, which is sometimes selfish.
Organisations against epidemic diseases--questions of quarantine--laws
for vaccination, and the like, would obviously lie within his province;
and thither, perhaps, also his colleagues might be glad to transfer many
of those medical questions which now belong to other departments of the
executive--the sanitary regulation of emigrant ships, the ventilation of
mines, the medical inspection of factories and prisons, the insecurities
of railway traffic, _et hoc genus omne_.
There is another subject respecting which I should reluctantly forego
the present opportunity of saying something. To the philosopher,
perhaps, any partial sanitary legislation--even for a metropolis, may
seem of low importance, as compared with our commanding need that the
general legislation of the country be imbued with deeper sympathies for
life. Yet London is almost a nation in itself; and the good which might
be effected by its sanitary regeneration would, even as example, be of
universal influence. Now, at this moment, there seems a chance--such a
chance as may not soon recur--for gaining a first step towards this
consummation. The re-construction of the Metropolitan Commission of
Sewers, on the principle of local representation, affords extraordinary
facilities for providing London, at length, with an efficient sanitary
government. For, while any administration for this purpose would
require to be entrusted with very extensive and very stringent powers,
it seems probable that such authority might by the public be willingly
conceded to a body constituted, in great part, of persons representing
local interests. The jurisdiction required would be substantially such
as is already vested in the City Commissioners of Sewers, for the
sanitary control of the city; the concession of which--because to a
representative body--was never any matter of municipal dispute. In so
vast a government as that of the metropolis, Local Boards of Health for
its various sections would seem indispensable; it is presumed that these
boards[10] would be represented in the general Commission; which, in
conjunction with them, and including certain skilled assessors, might
constitute a complete sanitary organisation, consultative and executive.
[10] It would seem premature to discuss what might be the best
constitution of such Local Boards for the metropolis; but it will
appear to the reader, on a moment’s reflection, that there would be no
difficulty in finding materials for their organisation. If, according
to suggestions lately ventilated, municipal institutions should be
given to the parts of London hitherto without them; these new
corporations would probably have sanitary functions allotted them, and
might readily become Local Boards of Health under such a constitution
as I have sketched. If, on the other hand, our present non-municipal
system were to be continued, probably our several Boards of Guardians
might seem specially proper to act as Local Boards of Health; first,
as being elected representative bodies, already invested with certain
authority of the kind--as, for instance, under the Nuisances Removal
Act; secondly, because various of their officers would be almost
indispensable parts of any sanitary machinery. Indeed, my experience
of such matters suggests it to me as not unimportant, that, under any
arrangement which may be made, the jurisdiction of Local Boards of
Health should, at least in area, be conterminous with Poor Law Unions;
so that those who administer sanitary affairs--affairs which are
always chiefly relative to the poor--may, as far as possible, in their
several districts, come into relation with single sets of Poor Law
officers.
I have one word more to say about the Reports. They have been received
by the public with such remarkable indulgence and favour, that I feel
some anxiety lest I may seem to have plumed myself with other feathers
than my own. Let me, therefore, at least in part, confess my debts.
Before my first enlistment in the service of public health, others had
fought this great cause with rare courage and devotion; establishing its
main principles in a manner to require no corroboration, and to admit
little immediate increase. The true patriarchs of the cause in this
country are the present working members of the General Board of Health.
The constitution of my city appointment is quite independent of this
Board; but I should be acting an unworthy part if I refrained from
acknowledging, that, in innumerable instances, I have gathered most
valuable knowledge from the Board’s official publications, and that, in
personal intercourse with its members and officers, I have had abundant
reason to be grateful for information invariably given with that frank
kindness which belongs to brotherhood in science, and to sympathy for
common objects.
I must likewise acknowledge constant obligations to the courtesy of the
Registrar-General, and express with how much pleasure and instruction I
have studied the works of his inestimable office. Especially I would
offer my tribute of respect to Dr. Farr’s learning and industry, as well
as to that capacity for generalisation which the world has long
recognised in his eloquent and thoughtful writings.
And, though this be not the place to boast of private friendships, I may
venture to say that there are few topics relating to sanitary medicine
that I have not enjoyed the advantage of discussing with men who have
given genius, inquiry, and reflection to their development.