^li jr:¥ ■■■^*«^i^.% •^^- ^ ^^ NATIONAL HEALTH. BY HENRY W. ACLAND, F.R.S. REGIUS I'ROFESSOR OF MEDICINE IN THE UNIVERSITY OF OXFORD ; HON. LL.D. CAMBRIDGE, EDINBURGH AND DURHAM ; HON. M.D. DUBLIN AND HONORARY PHYSICIAN TO H.R.H. THE PRINCE OF WALES. ©xforti anti iLontion: JAMES PARKER AND CO. 1871. i?p t1)f same i^utfjov. To be had of James Parker and Co., and all Booksellers. The Ha7'veiaii Oration for 1865. Crown 8vo., 2s. 6d. Memoir on the Cholej'aat Oxford in 1854. 4to., with Maps, I2S. Part I. History of the Epidemic. Part II. Arrangements during the Epidemic. Part III. Lessons of the Epidemic. Fever in Agricultural Disti'icts ; being a Report on Cases of Fever occurring in the Parish of Great Horwood in the County of Buckingham. 8vo., is. Forms for Registering the Condition of Cottages^ for the use of Landowners, District Visitors, and others. A volume containing 50, 2s. ; 100, 3s. 6d. Report on the General Sanitary CoJidition of Cowley Indus- trial School. 8vo., IS. Notes on Drainage.^ with especial reference to the Sewers and Swamps of the Upper Thames. 8vo., 6d. Health, Woi'k, and Play. Suggestions. Crown Svo., is. Biographical Sketch of Sir Benjamin Brodie., from the Obi- tuary Notices of the Royal Society. Crown 8vo., is. ; cloth, 2s. 6d. Letter from a Medical Student on some Moral Difficzilties in his Studies^ and on the Duty of the State to aid in lessening them. NATIONAL HEALTH BY HENRY W. ACLAND, F.R.S. REGIUS PROFESSOR OF MEDICINE IN THE UNIVERSITY OF OXFORD ; HON. LL.D. CAMBRIDGE, EDINBURGH AND DURHAM ; HON. M.D. DUBLIN AND HONORARY PHYSICIAN TO H.R.H. THE PRINCE OF WALES. ©xforti anti Hontion: JAMES PARKER AND CO. 1871. ** Supposons en effet deux populations, I'une immorale et suivant absolument, comme le feraient les animaux, les instincts de la nature, sans se laisser guider par le bon sens ni par les lumieres ; et I'autre au contraire une population eclairee, ne connaissant ni le vice, ni de faux principes. La premiere, dans son existence brute, aura une carriere courte en courant au devant des dangers ; I'autre, au contraire, tachera de la rendre la' plus longue possible. Ces deux carrieres, bien differentes, pourront presenter des exces opposes : I'une aura la vie la plus courte, et I'autre la plus longue. Cette probabilite de longueur de la vie est done inherente a I'homme, et 11 faudrait en chercher la valeur dans un calcul qui n'a jamais ete fait." — Quetelet^ An- thropomitrie ou Mesure des Differentes Facitltes de V Homme. "What, then, is the conclusion inculcated by these doctrines as regards the social progress of great communities? It is, that all political institutions, imperceptibly or visibly, spon- taneously or purposely, should tend to the improvement and organization of national intellect. " — Draper, History of the Intel- lectual Development of Europe. TO ALL WHO ARE STRIVING TO COMBINE MATERIAL PROGRESS WITH ADVANCE IN MORALITY, THESE SIMPLE THOUGHTS ARE DEDICATED. The following pages contain the substance of a Lecture delivered in the Royal College of Physicians of England, June 2, 1871, by desire of the President and Council. The Lecture is now published in ac- cordance with the kindly expressed wish of the Presi- dent. Two documents quoted at the time of delivery are reprinted in full as Appendices : they may be of service to some who might not see the originals. CONTENTS. I. THE FOUNDATIONS OF NATIONAL HEALTH, p. 7 Combination of Health and Morality. Growth of National Health. Woof and Warp of Matter and Mind. Is Education a Material Problem ? Relations of Bodily and Mental Discipline. Correlation of Death and Civilisation. Prevention of Disease follows Prevention of Destitution. Causes and Consequences of over Population in relation to National Health. Relation of Pauperism and Disease. Limits of Variation in Man. Calculations of Ouetelet and Galton as to Laws of Human Faculties, Bodily and Mental. Relative Values of Human Life. IL HOW THE FOUNDATIONS ARE SAPPED . . p. 32 Extensive Connections of the Question. Modes of Determination of National Health. Claims of Future Generations. Examples in two Extremes of the Social Scale, one of Bodily, one of Mental Injur>\ III. HOW THE FOUNDATIONS ARE STRENGTH- ENED p. 38 Stability or Instability of Human Characters. Political Movement and Physical Change. vi CONTENTS. Classes who chiefly influence National Health. Bodily and Mental Discipline. Principles of Sanitary Law. Aims of Education. Physical Qualifications for Political Rights, Instance of indirect Education, as by Music. Various Yearnings after Healthy National Constitution. Voluntary and Legal Relief. Compulsory Education and Right to Essentials of Life. Duties of the State to National Health. Progress certain, though impeded. The Two Things necessary. Jeremy Bentham's Code of Sanitary Law. High Value of Poor-Law Organisation. Memorandum in Report of Royal Sanitary Commission. The Central Authority of National Health. Extensive duties of Health Minister or Minister of Local Government. The Departments that naturally Belong to him. Functions of Medical Officers of Health. Various Acts connected with their Department. Education for care of National Health by Trinity Col- lege, Dublin. Labourers in the Work of National Health. Past Experience and Future Progress. APPENDIX A p. 73 Memorandum on Medical Officers of Public Health. APPENDIX B p. 107 Subjects of Study recommended to Candidates for Qualification in State Medicine by Trinity College, Dublin. Memorandum on State Medicine by Dr. Stokes. THE FOUNDATIONS OF NATIONAL HEALTH. 'XT O subject has received more impulse in this -^ ^ country within the last twenty-five years than the Prevention of Disease. We are ripe for comprehensive legislation. Mr. Goschen, taking a wide view of the question, has already em- bodied in a Bill provisions by which the re- lations of a large proportion of the medical profession to the public may be changed, and a new conception of the functions of medical men may be introduced into every corner of the country. Though the exigencies of political affairs have forced the withdrawal of this Bill for the mo- ment, I shall endeavour, in the observations which I am about to make, to sketch the in- tricate bearings of a subject of no small mo- ment, from the point which seems to offer the fullest conception of the groundwork of National Health. But I admit the ail-but impossibility 8 The Foundations of National Health. of the task within the limits assigned to an ordinary Lecture. If there be a National Health as distinguished from personal health, it is a problem of the last importance to know by what laws the standard of national health is raised, by what it is depressed. If national health is intimately connected with national virtue, and both with national prosperity, — if all have their founda- tions in the very conditions of human life on the earth, — then it will seem probable that na- tional vice will be found linked with physical weakness and general decline, by the same cor- relative necessity. These laws of our being are the expression of the fact, that nations, like individuals, placed in given conditions, must act within certain limits, limits admitted by all, whether they believe them to be bounded by the possible combina- tions of chance, or assigned by the intelligence of a Superior Will. National habits, good or bad, — national licence and national self-restraint, — national vice and national piety, — national vigour or national indolence, — are propagated through Hoiv Health and Morality are combined, 9 the individuals of which the nation is composed ; being attached to individual character, and handed on from generation to generation, mo- dified however by individual education, or those great catastrophes which, like subsoiling in a barren land, bring about fresh combinations, and give birth to products good or bad, better or worse, as the laws, moral and physical, which regulate the combination, may compel. It may be alleged against these fundamental conceptions that National Health is a fiction of the mind, that no such collective physical con- dition exists. The objection would be one of words. Family constitution and hereditary taint certainly exist ; and a multitude of indi- viduals forming one army, may, by the opera- tion of moral causes, go anywhere and do any- thing, or may be without power, without will, without hope. We must not stop to discuss in full by what subtle links families are bound into peoples, peoples into races ; but limiting our view to our own immediate nation, which may serve as an instance for all, consider briefly Jwiv the physical condition of our people has been at- I o The Foundations of National Health. tained f and by what meajts it may he preserved or improved? our National Health, in short, What is it? and, What are the duties of the State towards it ? The health of an individual is, the balanced condition of organs best fitted for due perform- ance of the functions of body and mind within the capacity of the individual. The National Health is, that condition of the individuals of the nation which enables the indi- viduals of the nation to discharge rightly their respective functions in the state, "to do their duty in the state of life to which they are called ;" the statesman to be in training for exercising the complex intellectual operations of his high office ; the artisan, the soldier, the abstract thinker, each for his ; and if we regard the philosophic teaching of the great author of the "Republic," parents of either sex, for the raising of the future citizens for the state ^ The sole question which here seems open to cavil is, How far we can influence national health in the wide sense just hinted at ? Can the ab- stract speculations of the "Republic" bear prac- * The Republic of Plato, Book IV. The Generation of National Health. 1 1 tical fruit ? Can we influence all the factors which are contained in the elements of national health ? Let us see what they are. Take any given Englishman. What is his descent,— Roman, Norman, Saxon, Dane, French ? What influences have operated on him since his progenitors were among the num- ber of workers in flint or in bone, or bronze } Did they become farmers, warriors, chiefs t Intellectually accustomed to command or to obey ? physically to endure or to shrink } mo- rally thrifty, contented, peaceful or turbulent, drunkards and dissolute ? Were they in later times exposed to the diseases of hot climates ? Were any syphilitic ? did they intermarry in close relationships, or seek far a-field the part- ners of their lives } What would be the qua- lities which, like the now famous Black Bar of the Rock Pigeon, might reappear on their scutcheons 1 pride, pugnacity, syphilis, gout, phthisis ? Terrible questions these which the third and fourth generations ask of the sins of their forefathers and of their own. There is much to be said for the Squire who never passed the picture of his great-grandfather, but he 12 The Foundations of National Health. shook his stick at him with an oath and said, ''Your drink brought gout down upon us all^" Philosophically, indeed, this most anxious en- quiry might, we now know, be pursued, and is being, with rare practical discernment, pursued into the very origin of our race. But I for- bear, in a question of great practical import, to do more than remark, that Darwin's discussion has a direct bearing on the conception of national health. It tends to confirm the con- viction that acquired habits, whether of body or mind, may be very permanent in a race. That acquired increments for good may be per- manent for good we cannot doubt, with the qualification that they must be maintained by each individual of each generation. The po- tential good being inherited may, by moral or physical struggle, be retained, and the potential evil be to some extent eradicated. But in every case we must believe that the inherited good '' The Chinese have very strict notions as to hereditary taint ; chiefly, however, on moral grounds. The children of actors^ among others, for three generations are excluded from the greatest privileges of citizenship, and capital punishments may follow unlawful attempts to exercise them. Not long since, thirty Examiners, including an ex-Chancellor, were put to death for admitting an actor to a competitive examination ! The Woof and Warp of Mind and Matter. 1 3 attained, perhaps by generations of valour or virtue, maybe, in a moment, shattered Hke some lovely work of fictile art that was produced only after years of education and months of applied skill. These general reflections bear mainly on bodily characters, but not wholly so. A woof of mind runs through the web of all animal organisation, and the view we take of the ele- ments of national health is coloured by our conception of the respective relations of body and spirit. When we look abroad on the ani- mal world, we perceive such union of mental and bodily functions, that we are at a loss to say whether the matter, of which the organism is composed, and by which alone the bundle of mental qualities which it possesses can operate in the world, is primarily set in motion by mind, or is itself the /nw2^;;^2 mobile, the basis and very essence of mind. The difficulty of solving this question, so fundamental to all speculation on the organised world, has increased with time, and so the principles on which the education of man shall be conducted have become a subject of yet keener debate. He who believes that we 14 The Foundations of National Health. are but what we see, and handle, and measure, and weigh ; he who looks not beyond the pre- sent chemical concurrence of some half-hundred elements, combined within themselves ; and he who says in his heart, " There is no God ;" all these can look on education and on health as problems only of physical science, to be settled by material measures. But without pur- suing a subject far too long for our present opportunity, let it be said this hard material view which has once and again cropped up in history, since culture and literature began, can- not be accepted as other than an hypothesis for settling the insoluble problem of the nature of man and his co-tenants of our planet. Look out and see every spot of earth, of water, of air, occupied by beings fitted, if you will, for their place by natural selection ; adorned, if you please, by the sexual impulse to display ; and what do you find t Material organism fitted to perform certain material functions ; bundles of mental powers fitted to put that adapted machinery in operation. Machinery and mind are alike in- herited ; their qualities improvable, and trans- mitted ; the temper, so to say, of progenitors Is Education a Material Problem ? 15 lost, and reappearing. Shall any one presume to say that as yet the Genesis or Pan-genesis of this complicated organisation of earth is so known to him, that he can declare that matter alone rules mind, and that mind, whence it is, and what it is, is so understood by him, that he can say it does not and cannot exist alone, does not and cannot act upon what we call matter, can have no independent being. Does the denizen of air, of water, of earth, who is ferocious, attack ferociously, solely because his weapons make him desire to attack ? Does he who flees and is timid, flee because his limbs impel him to dive, or to burrow, or to run away .-* Do you not think he flees for that he is timid, or fights for that he is ferocious } Have his bundle of mental qualities no real ex- istence ? Hopeless questions ! If we cannot, with Malebranche, assert that in an understood and understandable manner, "God is in all things, and all things in God," we, at all events, cannot, as scientific men, allow that it is proved that blind chance has made us ; and may on this safely appeal to the un- prejudiced witness of Darwin, who shews, by 1 6 The Fotmdations of National Health. hundreds of instances, the coercive powers of purpose. Moreover, by whatever road man has reached his present state, freedom of action, moral responsibility, are his ; and now, at all events, he possesses the will and the reason by which he is mainly distinguished from the varied animal world about him. Throughout the animal world we find skill and power, as in the ant, in the dog, in the tiger ; but skill and power little, if ever, improved, because the reason to mould the conditions of existence, and compel nature to be their servant, is absent, or applicable only to single instances. With man, on the contrary, with educated, moral, and pro- gressive man, the skill and the power are be- coming evidently correlative with the powers which are locked up in nature, and are attain- able by him ; and they are, on the whole, trans- mitted unlost from generation to generation. Slight and imperfect as is this sketch of the relations of man, in his bodily and his spiritual nature, to the world in which he is placed, the thoughts to which it invites must be present to us, if we are to take a true survey of the ground of national health. Relations of Bodily and Mental Discipline. 1 7 The conclusion to which they point is this — that the soul of man is not the abject slave of mechanical organisation ; that in some way which science cannot at present ascertain it acts on, as well as is acted upon by the physical structure through which alone it here exists ; and that the groundwork of sound national health lies as much in mental as in physical training and guidance. Thus, a task of the highest importance is imposed on the profes- sion of Medicine. They and they only can be at present expected to be able to measure fairly the strain which the nervous system of the human animal at various ages can bear ; they and they only can say what bodily training may be most conducive to mental development, and mental activity. But the problem involves questions far beyond the reach of average men worn by the strife of daily life. Philosophers and Poets have spent some of their greatest efforts on this subject — Milton and Locke in their essays on Education, Rousseau in his Emile, Herbert Spencer in his treatises, and a host of minor thinkers in theirs, have en- deavoured to grapple with the question of the C 1 8 The Foundations of Natio7tal Health. relation between mental and bodily discipline, and, viewing the question from the psycho- logical side, have insisted on guiding the de- velopment of the body in order to furnish a fit organism for the mind. A caution must be entered, as public opinion heaves to and fro, lest the physician lay too much stress on mate- rial agency, and claim too much value for me- chanical appliances in aiding the public health. The union of moral with intellectual and phy- sical health (if indeed they can be separated), can alone save a people entered on the struggle of so-called civilisation. True, indeed, is it that without good sewers and healthy dwellings the poor can neither labour well nor reasonably enjoy their being ; but as true that without a pure state of the moral sentiments no material improvements will insure to a people present happiness or permanent stability. Material comfort and material luxury are apt to engen- der, even in a noble race, meanness of soul, and woe and destruction wait on its fall. Physicians, therefore, in discussing the grounds of National Health, must compass the whole bearings of this question, if they wish to be fol- Correlatio7i of Deaths and Progress. 19 lowed by a sagacious and toiling people. A large-minded promoter of sanitary measures says, in a letter to the people of India, " There is so constant a relation between the health of a people and their social civilisation, that, alas ! one of the best indications of the social state of populations is afforded by the num- ber who die year by year^" The education of the younger portion of the people in this country is proceeding so rapidly, and the knowledge and conception of material laws, thanks to a periodical literature, which is, on the whole, noble and enlightened, is becoming so much en- larged, that no Health measures which are defi- cient either by reason of inattention to material wants, or of inattention to moral and intellectual aspirations, or based on the old views of medi- cine as a purely curative as distinguished from a preventive art, will find public acceptance. To prove this it is sufficient to note the growth of resolute conviction among the people with respect to the abuse of alcohol, and with regard to the necessity of great Engineering works « Miss Nightingale, remarkable letter to the Bengal Social Science Association. See Report on Improvements in India, 1870, p. 290. 20 The Foundations of National Health, for sanitary purposes, such as those carried out in Lancashire under the Poor-Law Board during the Cotton Famine. Shortly after the existing Poor Law had come into operation in England, a noble con- troversy arose in Scotland between Chalmers and William Alison, as to whether the care of the sick poor and of the destitute should be left to the voluntary exertions of the charitable, or be placed under the strict eye of the law. The two men were equals in Christian goodness and philanthropy; their experience and their knowledge of the poor was the same. But the science and logic of Alison prevailed. He shewed, once for all, that whatever might have been the evils engendered in England by the Poor Law, the evils of destitution left to charity were greater both to the nation and to the in- dividuals. The ideas of legal claims to relief on the part of the destitute, and to cure on the part of the sick, are so familiar to this generation, that the early contest against the establishment of these ideas can now be scarcely credited. We are fast reaching a further social conception, that ■ Prevention of Destitution and Disease. 2 1 preventio7i of sickness is a yet more rational course, and therefore a yet more sacred duty than its awe. But the nation requires further familiarity with the proposition before it will accept it ; and that familiarity cannot come, until the community at large, as well as the medical profession, have fully realised the obvious proposition, that prevention of all dis- ease that is not surgical, and of much disease that is surgical, is as strictly a department of Medicine as treatment. They appreciate this in Vaccination and Small-Pox. They do not appreciate the efforts of the younger labour- ers, who are striving to discover new protec- tion against other scourges of man. But no medical knowledge, no sanitary pro- visions, and no sanitary legislation, can make head against Jaws of nature, physical or moral. If population increases beyond the means of healthy subsistence, disaster must follow. It seems to me that at present sufficient atten- tion is not paid by sanitary writers to the fundamental truths advanced by Malthus, but often overlooked or misunderstood. While we have been honestly endeavouring for the 22 The Foundations of National Health. last twenty-five years to abate the general torpor and selfishness of the previous century, and to stop the growth of further sanitary evils, the average mind of England has not sufficiently heeded the coming, nay, the pre- sent, difficulties of over-population. We are too apt to look on the East of London, or the growth of the manufacturing towns, as excep- tional instances. They are the necessary con- sequences of unthriftiness in marriage, of hmited area, of difficulty in emigration, and of working and trading for the world. The reality of our difficulty about population is told in a very few words — England and Wales are increasing by about 200,000 annually. This number will of course increase by a small increment. Since A.D. 18 10 the population, which was 10,000,000, has become 22,000,000, and at the same rate will become by A.D. 1920 over 45,000,000. The acres in England and Wales, are about 37,325,000, including waste ground. There are now, therefore, nearly two acres per man ; there will be in fifty years not one ; in Glasgow there are already 94 inha- bitants to an acre, and in Liverpool 103. No Over Population, Causes and Consequences. 23 single arrangement can meet the necessities, therefore, of every district. The urban and rural districts have each respectively their sani- tary difficulties. The land question presses in one shape in the towns, in another in the country. Here, as in America, or in every manufacturing country, causes suddenly operate to convert rural into urban lands ; and to im- port, into wholly unprepared country districts, all the troubles of an urban population. Of this a striking instance is seen in the coal dis- tricts of Durham and Northumberland, many more in Lancashire and Yorkshire. The danger of all these circumstances in re- lation to national health is admirably stated by Professor Fawcett : — " It w411, therefore, be well distinctly to appre- ciate what is implied in bringing into operation causes which will produce greater mortality ; some definite idea may be formed on the sub- ject, by considering the results involved in the present high death-rate prevailing amongst the children of the poor. Assume that there are 1,000 of these children, that 500 of them die before the age of five, whereas if they were 24 The Foundations of National Health. as well cared for as the children of more wealthy parents, only 200 of them would die before this age. The death, therefore, of 300 is to be traced to defects in our social and economic condition. These children are lite- rally slaughtered, and in a manner, moreover, which indicates prolonged suffering. But this is only a part, and perhaps the smaller part, of the mischief which is done ; the causes which produce this excessive mortality do not alone affect the children who die ; all those who survive are also brought under the same blight- ing influence. Consequently, to all the struggle for existence becomes more severe, the more weakly succumb ; even the stronger who sur- vive, in passing through the trying ordeal, often contract the germs of future disease, their con- stitutions being in too many, cases undermined. Physical deterioration ensues, and a whole people riiay thus become gradually stunted and enfeebled ^." It is not possible to reflect on this subject •• Professor Fawcett : * * Pauperism, its Causes and Reme- dies," p. 108. London, 1871. A book which cannot be too widely read. Pauperism and Disease. 25 without recognising the truth of the proposi- tion that, making every allowance for the action of counteracting causes, excessive development of a population on a limited area like Great Britain, must in the end be disastrous to the nation, unless, first, the population can be kept healthy, and, secondly, the commodities of life are obtainable to a commensurate extent. The arithmetical bearings of this point have been worked out by Mr. Samuel Ruggles, in a Report to the President of the United States ^. The conclusion, then, seems almost forced upon us, that whenever our population increases beyond the power of our area to maintain it, two effects will follow, more especially in times of commotion — increased pauperism, increased disease among the adults. If philanthropic or legislative efTorts succeed, there will be added, the rearing of wretched children, incapable in body and mind ; multiplication of lunatic asy- « See an abstract of his Paper in the "Times," May 17, 1 87 1. John Lambert, Esq., C.B., has referred me to an in- teresting work on the condition of the poor, by another Mr. Ruggles, viz., "The History of the Poor and the Laws re- specting them,'* by Thomas Ruggles, Esq., 1797. The work contains many thoughts of permanent value. 26 The Foundations of National Health. lums, reformatories, and workhouse schools, and crushing taxation of the industrious, capable, and healthy. Conversely, if the preventive checks of Mal- thus, and especially education, (in which I place first, moral culture, however attained,) can be brought into operation, two results might be expected ; first, that the population may be kept in some check ; and secondly, that the internal administration of the country may be greatly improved by the political sense of the masses. Through these two causes there may be hope for the nation. It is doubtless true, first, that in the history of the world we have seen nations almost brought to a stand by epidemics, as, for instance, in various parts of Europe during the fourteenth century by the astonishing ra- vages of Black Death ; secondly, some check is induced by wars ; and thirdly, an excessive mor- tality of children produces the same results. The operation of these natural checks is emi- nently uncertain, and to count upon them as substitutes for self-control, prudence in marriage, and good political administration, is deliberately to substitute the instinctive life of brutes or Limits of Variation in Man. 27 savages for the progressive experience, the rea- son and morality of the human race, and to accept the destiny which such life brings with it. When savages and brutes meet in conflict with civilised man, that destiny has usually been extinction. Moreover, whatever opinion there may be at present as to the origin, first of species, and secondarily of race, constitution, and individual temperament, there can be none as to the effect of food, climate, habits of life, and culture, either upon the individual or the progeny. It is suffi- cient here to remark on the feebleness of the descendants of Europeans in India, notwith- standing the vigour of the first generation, and on the rapidity with which the Anglo-Saxon race has changed in North America. Doubtless the limits of variation of man, or of any race of men, have not yet been determined ; but we are rapidly approaching precise knowledge on the subject. Life insurance offices will ere long furnish a fund of information ; and the labours of our great statisticians, when they include sickness returns from the public health autho- rities, will give all attainable scientific informa- 28 The Fotmdations of National Health. tion of the causes and nature of health fluc- tuations in this country, in comparison with the same in other countries. To say truth, the accumulating knowledge of the facts of Humanity is becoming more marvellous than the fancies of Utopia. The newspapers tell us weekly — thanks to the sagacity of Major Graham and of Dr. William Farr — the compara- tive death-rates of great towns not only in Eng- land but on the continent of Europe, in India, and at New York. We are able to judge what the energy and determination of one man can do in controUingthehealth-destiny of vast popu- lations, by studying the admirable results of the work of Dr. Hewlett ^ in Bombay, and the sani- tary progress in Calcutta. India bids fair to set us an example of accomplished sanitary ad- ministration, which will be fruitful alike of knowledge and of practical benefits to the people ^. Nor is this all. Quetelet ^ and Galton^ have opened a mine of precise know- ' Dr. Hewlett's Quarterly Reports on Bombay. s See various Reports on Health of India, for the last five years, •• Anthropometric de 1' Homme, 1870, and Essai de Physique Sociale, edit. 2, 1869. ' Hereditary Genius, 1869. Quetelet and Galtoiis Calculations. 29 ledge regarding the finer causes of "limits of variation" which have been just touched upon. Quetelet, indeed, has proved what, a priori, might have been safely inferred, that the limits of the factors of human nature, whether mental or bodily, may be fairly expressed in terms of mathematical formula and curves ; so that, indeed, the average proportion out of a given number of persons possessing any mental quality may be as directly predicated as their heights or their weights. It is true that this is only the expression of a fact which it does not explain. But Francis Galton has with great skill, in his work on Hereditary Genius, shewn some of the consequences of this fact or law. They are startling. Just " as a cook combines or creates a dinner, the fish director can create," he says, *' a particular sort of fish ^ according to a predetermined pattern ;" then, he adds, " the reflections raised by what has been stated of fish are equally applicable to the life of man." " The entire human race, or any one of its varieties, may indefinitely in- crease its number by a system of early mar- '' Galton, " Hereditaiy Genius," 1869, p. 373. 30 The Foundations of National Health. riages, or it may wholly annihilate itself by the observance of celibacy. It may also in- troduce new human forms by means of the intermarriage of varieties, and of a change in the conditions of life." Galton's speculations — I ought rather to say, his logical and precise discussion — should be carefully weighed by every thinker on public health, because, in one sense, it is directly opposed to the conclu- sions of Malthus. He has worked out the ef- fects of early and late marriages in respect of progeny, and has shewn that, given certain con- ditions to two races, M or N, — one, M, marry- ing early, and N marrying late, — at the end of one century the mature men of M will be four times as numerous as those of N ; at the end of two centuries, ten times ; and at the end of three centuries, twenty-seven times as nume- rous. Now if M were reckless and imprudent, and N careful and prudent, all else being equal (which, however, would not be the case), the prudent race would be driven out of the field. A terrible disaster ! " It may seem monstrous that the weak should be crowded out by the strong, but it is still more monstrous that the Relative Value of Human Lives. 31 races best fitted to play their part on the stage of life should be crowded out by the incom- petent, the ailing, and the desponding." In forming a fair estimate of the whole of this question, many other causes would have to be considered, and their effects calculated. But reason tells us that there must be some rela- tive value in lives, though the human eye may fail to count it right. There is a moral in the tale of the fowlers in the Northern Seas. As the three egg-hunters are, one by one, drawn up along the face of the cliff by the same rope, highest is fastened the lad, the father next, and last the grandsire. If the strain is over great, the lowest, least worth, is to cut the rope and fall into the abyss ; next, if need be, the father ; so that the chafing strands may perchance save that life which may be longest and is youngest. So is it in nature. We have our being under just and necessary laws, moulded by hidden causes we cannot see nor understand. II. HOW THE FOUNDATIONS ARE SAPPED. Such being the general conception of the foundations of national health, it would at first seem to be an easy task to describe the causes which may sap them. It would be easy, if dealing with a social tabula rasa. In an old country, however, growing with unprecedented rapidity on a limited area, the questions in- volved touch every point of political economy. Theories concerning population, religion, liberty, existing privileges, and natural rights, are to be met, accepted, or denied at every point. Ignorance and prejudice have to be dealt with among honest persons, self-interest with the unpatriotic. The haste to be rich among the unwise, the intolerance among the cultivated of opinions counted narrow, and inadequate ap- preciation of the extent to which our world lies under law, (binding even the seeming free agency of man,) all check the progress of po- pular knowledge as to the foundation of Na- Claims of Future Generations. 33 tional Health. Take the single illustration of Mills on streams. How long, after the effect of damp subsoil in injuring the health of the people has been proved, is it just to a popu- lation that one man should keep up mill-dams to such a height as to swell his profits by some small per centage, and destroy his neighbour's health, when other arrangements might, with little loss to him, at once abate the evil. It is an instance of a thousand. The mill owner, it is true, would have claim to compensation for his prior rights, earlier occupancy, and interests hitherto permitted, nay, protected, by law. But the human race and every civilised community is essentially progressive, and no society ought to shrink from dealing with rights which have produced consequences essentially different from anything that could have been contemplated when they were allowed to grow up. One main duty of the present age of the world, and in this country urgent, is to strive to prepare for coming generations. The foundations of the National Health may be sapped in so many ways, that the cata- logue is as long as it is dismal. Bad air, D 34 How the Foundations are Sapped. bad food, bad clothing, deficient fuel, too long hours at work, intemperance, all excesses, exces- sive exercise, excessive study, fanaticism, glut- tony, idleness, late hours, intermarriage among unfit persons, depressing passions — as gambling, whether in hells or on the Stock Market — over- crowding and bad lodgings, bad dwellings, or dwellings on unfit sites, all engender disease, and deteriorate the race. They produce struma, rickets, gout, hypochondriasis, and many other diseases, with consequent loss of power, imper- fect work, moroseness, and misery to others be- sides those affected, in an ever-expanding circle. Again, bad water produces not only actual fatal disease in individuals, but short of that, as was stated at length and with much acute- ness long since by Hippocrates % engenders con- tinuous feeble health, when acting either with or without the other causes above-named. These various mischief-bringing elements in the " pan- genetic" structure of society may act either on a single person, or on the masses. Some act on the poor, some on the rich, some equally on both. Time forbids me to analyse or extend ' In his treatise on "Air, Water, and Places." Vicious Destruction of Body. 35 the ' list, and shew the precise way in which each member of the ghastly catalogue acts on the human constitution. I will only add one instance formerly quoted by me elsewhere. A girl, having been seduced, entered a workhouse. A female child was born. She was brought up in the union, and was there at school till nearly of age. She went out, straightway became first a prostitute, then syphilitic ; returned to the workhouse, and brought forth a syphilitic in- fant, to be reared, like her mother, with diffi- culty. There she lives in misery, and may perhaps repeat the dismal tragedy of her grand- parent and of her parent at the cost of the nation. But are we sure that the needless waste of the higher kind of life is not in other ways as reckless and as pitiful } I do not speak of death by war or by avoidable accidents, of mad races against time by sea, or of wholly unneces- sary speed by rail, though these imply mischiev- ous wear and tear to individuals and to classes of men ; but I allude to useless wear and tear of health imposed on public men, and the waste thereby of power valuable to the nation. 36 How the Foundations are Sapped. For instance, the House of Commons contains within it the picked executive of a free people, who have deliberately selected them from the whole nation for the decision of the greatest problems of the national life. Yet custom will allow that Ministers thus carefully selected for their special aptitude to do the finest work, are often occupied more than half the night on for- mal and unimportant discussions. Thus the real work of their office is done under unnecessary pressure such as none but the most robust can bear, and their health fails perhaps at the mo- ment of their highest administrative perfection. Again, — The buildings which public men occupy are often far less calculated for main- taining health than they might be ; and trifling as may seem the remark, it is to be doubted if they can always obtain with readiness food suited to the necessity of exhausted nerve- power. There can be no doubt that actual illnesses are often brought on from these two avoidable causes. We cannot, however, now consider all the ways in which the habits or pressure of civilised life needlessly tend to waste the force, and Frivolous A ttack on Mental Power. 37 crush the physical elasticity of the people. In- stances of various kinds will occur to every mind. Let these, from the extremes of the social scale, suffice for illustration. Rather let us here seek, if means of prevention may be found such as will per\^ade the whole framework of the national life. III. HOW THE FOUNDATIONS ARE STRENGTHENED. If the foundations of National Health be of the kind we have stated, and the causes which may sap them so general, so diverse, and so en- grained in the nature of things, then the prin- ciples which have to guide mankind in main- taining the physical stability of nations cannot be less fundamental and extensive. Now we must not conceal from ourselves the fact that, if we except some eastern and some barbarian races, the whole history of mankind tells of two conditions — progress and decay. National hibernation is, in a low state of national life, perhaps possible ; but the awakening is generally by the rude shock of a destroyer, who lives on the ashes of a race he came professing to revive. In four short years a whole tribe of North American Indians has died out under the ad- vance of civilisation. There is nothing in history more solemn than this flowing and ebbing of nations. It were blindness not to Physical Change and Political Movement. 39 see that civilised people, in the surging to and fro of modern material life, are bursting the barriers of all former experience. So entirely are the telegraph and facile transport modifying opinions, equalising the knowledge of distant states, and welding it into one world-wide pub- lic opinion, that the problems presented to the modern Statesman are almost as new as when Roman law was being consolidated. History would seem to teach that as long as love of conquest follows possession of power, and as long as the human frame consists of an intricate combination of tender organic tissue, so long physical changes may be expected from violent political movement ; and waves of dis- ease, whether cholera, syphilis, small-pox, black death, fever, or the diseases that follow famine, may sweep over the denser masses of man- kind. One can neither contemplate without admiration the order of great modern cities, nor look without anxiety on their danger. How instructive — materially, morally, intellec- tually — is now the great drama of Western Europe, in which almost every virtue and every crime has been flashed before our eyes, as 40 How the Foundations are Strengthened. though to shew how unstable still is the fabric of society. There are four classes of persons who have the physical conditions of the nation more or less in their power : first, the lawgivers ; second, the physicians ; third, the ministers of religion and teachers ; fourth, the people. The lawgivers in a free country are almost limited to legalising public opinion, but may promote a wide or a narrow conception of the State, according to the type of their own con- victions. The physicians are the guardians of public health, bound as much to prevent as to cure disease. The ministers of religion and teachers are the instructors of the people, either knowing or not knowing what conduces to National Health. The masses of the people modify their own conditions by good or bad habits, physical, moral, and intellectual. It is certainly not too much to say that, be- fore the present century, public opinion — as de- pending upon people, ministers of religion and teachers, physicians, and lawgivers — was, as far Education of Body. 41 as regards the public health, entirely below the necessities of mankind. This is at once proved, by the alterations which we now know may be made to take place in the death-rate of armies and of towns by proper sanitary regulations, or the neglect of them. The question suggests itself, How the public opinion on this matter is to be raised to the best attainable standard ? The modern answer is. By Education. But Education itself must have a definite aim, and be based on an intelligent conception of the end to be attained, and the means of at- taining it, whether they be physical, moral, in- tellectual. One cannot contemplate without astonishment the spectacle of the three hundred millions of Chinese — a third of the human race — who have cohered, almost unaltered for some thousands of years, with the stability of the crystal, without the growth of a living organi- sation. Compulsory education of a low kind seems to have effected this ^. Education by a * There is no stranger chapter in statecraft than the history and practice of the competitive examinations in China. Sir Bartle Frere was so kind as to direct me to a photographic account of this in "Social Life of the Chinese," by Justus PnoHttle, vol ii. (New York, 1865). 42 How the Foundations are Strengthened. stereotyped method, necessarily produces simi- lar results in successive generations. In this Western world we have seen feudal rule gra- dually giving way to self-regulation by the people ; obedience to self-government ; empiri- cism to positive science ; and hypothesis to knowledge of facts. Some would say, super- stition is being replaced by reason, emotion and instinct by intellect, moral self-discipline by scientific knowledge. Be this as it may, the conviction is gaining every day more strength, that however true it may be that, as has been advanced above, the mind has influence over the body, it is as true that National Health cannot be fully secured without strict attention to the material conditions in which the people are placed. This consideration has of late years occupied the attention of our statesmen. Re- gulations afi"ecting trades, workshops, mines, shipping, dwelling-houses, have within twenty- five years reached such dimensions as to have a literature of their own. We have not, there- fore, so much to discuss the necessity of this attention, as the principles on which, in im- mensely widening circumstances, it should bf Principles of Sanitary Law. 43 directed into practical results. Those princi- ples mainly rest on the following considera- tions : — That no individual should for his own profit poison his neighbour. That the State must, in certain things essen- tial for health, assist the masses in what they cannot assist themselves. That the cost of permanent sanitary im- provements should be borne in some reasonable proportion by posterity. That compulsion of the ignorant in sani- tary matters, when their ignorance injures so- ciety, is justifiable. That compulsion will, we hope, be unneces- sary when scientific education is adequately extended. That good conduct, based either on know- ledge or on obedience, is as essential to health, as is any physical arrangement which is not an actual necessary of life. That in the present state of the world, mischief-bringing ignorance in sanitary ques- tions is especially inexcusable in the law-making classes. I 44 How the Foundations are Strengthened. That local government by the people, well informed by a central authority, is essential to the physical education of the nation. For the practical working out of these prin- ciples, legislators have to devise education worthy the name. Education depends on very complex questions, affecting the whole nature of man and the very structure of society. It is now thoroughly understood that the emotions, the will, and the mere action of the reason, affect not only individual organs, but the whole frame and the general health. Not only may individuals, if ill-educated, become virtually of unsound mind, but so may whole masses of people. There is a "glory in the determined will" which produces vigorous bodily as well as vigorous mental action. You see it in the contour of the man. A perfectly trained na- tion, morally, intellectually, and physically, will act in its sphere as an individual so trained. It will respect and be respected. We have seen in the dancing Mania of the fourteenth century the extent to which, in a superstitious age, masses may be moved to Physical Constittction and Political Rights. 45 emotional madness. Is it certain that, uncon- sciously to themselves, there may not sweep over nations equally contagious intellectual errors depending upon faulty morality ? It is mainly a question for the psychologist and statesman, but it is also a question for the thinker on pub- lic health — what manner of life in the several classes of men and women, what labour, what recreation, what personal habit of body, con- duces most to that tone of the nervous system, which puts the nerve-power of each man at the best for the discharge of his duty as a citizen. The worn-out man, the speculator, the vicious man, and, still more, masses of such men, become, from physical causes, intellec- tually and morally unfit to form a sound public opinion. Now a people is educationally affected by indirect nearly as much as by direct means. Take a single and minor instance, — the in- direct educational effect of music on the chil- dren of a rural district. Music, like other things, is of two kinds — bad and good. It may be a source of foulness, disorder, degradation, impiety — even the Christmas carol — may lead 46 How the Foundations are Strengthened, to the public-house, to folly, and to drunken- ness ; or it may, in Wordsworth's words, though rude in its kind, be '* A tnie revival of the light Which nature and these rustic powers In simple childhood, spread through ours." We know how, through ballads and songs such as the " Wacht am Rhein," vigour is thrown into the hearts of a nation. So, also, pure and good music is a sure and powerful instrument for refinement when superadded to other intel- lectual attainment. In one aspect it is purely sensuous, and may, as with some refined Ty- rolean singer, be pursued as a dexterous art or accomplishment. But even as art it miay not be undervalued. It excites feelings of the warmest sympathy and admiration to hear the attained results of Leslie's Choir, or such socie- ties as now exist in many of our towns, where persons of every class and occupation shew an advanced mastery and appreciation of the choice works of Handel, Mozart, Beethoven, Mendelssohn, and acquire a pure culture unal- loyed by eating or drinking, or other frivolous ways ; culture, moreover, not of a light kind, Sound Health variously sought. 47 but one which ensures the development of cer- tain mental qualities of accuracy, attention, pre- cision, and refinement, which may be equalled but not surpassed by the exercise of other of our faculties. The right care of the body is, therefore, such a management of the instrument by whose agency mental actions are alone possible here, as that the body shall obey the inner spirit in its higher impulses. To this all philosophy tends, whether expressed by the conceptions of the ''Republic" of Plato, the "Utopia" of More, the "Atlantis" of Bacon. For this the Apostle of the Gentiles taught the duty of "keeping the body in subjection ;" this was the aim of the mistaken self-tortures of the asto- nishing Ascetics of Alexandria ; of the yearn- ings of Comte, the manly teaching of the great English Physiological Text-Book ; of the labour of all labourers for public health, of Chadwick, of Southwood Smith, Shaftesbury, Farr, Rum- sey, both the Trevelyans, Matthew. These all seek, in bettering the conditions of the body, to give free play to the divine element that is in the mind of men. We must not let ourselves 48 How the Foundations are Strengthened. be diverted from our great practical aim by the fascination of philosophic enquiry into the causes of things. What is the past history of man as compared with the well-doing of the present, for the sake, not of ourselves alone, but of those that are yet to come ? What avail to us the virtues of feudal days, if we neglect to cultivate their virtues in our own ? Were the Crusades, indeed, a worthier end for man than the redeeming from destruction the bodies and the souls of the struggling millions of Ireland or London ? Was there ever a nobler task for the energy of noble or prince than the harmonising relief by law with will- ing relief from the charitable heart " ? than dis- *^ Almost all the practical thinkers in this country seem to look at the relation of relief, whether legal or voluntary, to labour, as a most urgent question. Notwithstanding the wise labours of Lord Derby, Sir Charles Trevelyan, Mr. G. M. Hicks, with a host of coadjutors, we must despair of any per- manent work in this direction, until the Ministry of Health and Relief has been established, as the pivot for combined operation. Sir Charles Trevelyan truly writes : — "I am convinced more strongly than ever that there is no single specific for London pauperism, and that if our metro- politan population is ever to be restored to an industrious, pro- vident, independent character, it must be by a whole cycle of Requisites of Life. 49 cussions on the terrible question now before the nation, whether it is best for the moral and physical health of the people that the law of Elizabeth should continue, though it annually cost nearly seven millions annually to maintain it : or whether it is best with Chalmers, to throw on the voluntary alms of the rich the care of the poor? Do we concede the moral obligation of maintenance assumed by Eliza- beth, and refuse to carry it into effect by law ? or shall we divide the healthy from the sick, and grant to the sick what we withhold from the sound ? If so, do we reasonably protect the sound from becoming sick, when we leave them unaided in matters in which they cannot aid themselves ? Or again ; Germany, and now England, have practically decided that their millions ought to be compulsorily educated, i.e. that their minds shall be disciplined. Have they yet concluded that, on the same broad principle, the body shall be cared for in all essentials for health, so as to measures directed against all the influences which have reduced it to its present state." This remark equally applies to National Health. E 50 How the Foundations are Strengthened. give to the school a reasonable chance of doing its work ? Take the case of the three essen- tials of life, — Food, Air, Water ; (Clothing, Habitations, Fuel, and Work, being minor ne- cessities, depending chiefly on the exigencies of climate, may be omitted). — Is there yet a country which systematically punishes a man for wilfully or negligently poisoning another's food, air, and water, as well as for stealing his brushwood, turnips, or wild-fowl ? But all old countries are being forced again to consider what are the elementary conditions of life, and are revising from various points the methods of adjusting them to the necessities of compli- cated civilisation ; drawing lessons from all past experience, from the village communities of India to the land tenures of Scandinavia ^, and apply- ing them to the new and yet undeveloped con- ditions in which we find ourselves placed. So, when we come to consider what is to be reasonably required of the Legislature under the circumstances which have been now stated, it would seem as though we had to describe ^ See " Village Communities in the East and the West," by Henry Sumner Maine, 1871. Progress impeded, hut certain. 5 1 what should be the whole internal economy of the State. There is scarce a department of the State which is not connected with the public health. Wherever there is army or marine, school or factory, workshop or prison ; wherever a town, a village or a hospital, — there the State has to decide in what particulars the employer or the worker under him, the landlord or the tenant, the owner or the occupier, the vendor or the purchaser, the manufacturer or the con- sumer, shall lose his free agency, and be forced to subject his will to that of the majority in the State. Legislation has been steadily progres- sive, though the progress in this country has been made under needless difficulty, and at un- justifiable expense. Local acts for every con- ceivable' purpose, voluntary associations for in- numerable ends, have, after much agitation and labour, obtained remedies for evils, some of which ought not to have existed at all ; some which, existing lawfully, ought, on due com- pensation, to be abated. The authorities who should abate them are numerous, and often conflicting. 5 2 How the Foundations are Strengthened. Much time was lost in the period from Howard to Shaftesbury, and from Pringle to Sidney Herbert. The laws, the arts, and the sciences on which the preservation of health depend, are growing up under the eyes of the present generation. If we are living on the verge of an epoch of great social difficulty, we are also living at a moment when there was never so great knowledge, never so bright a light, and never more patient desire in every class to set aside injustice, and discover the means by which opportunity may be given to the capable and industrious, help to the weak, and knowledge to the ignorant. Whoever has had experience of the public work of the coun- try, must know that the offices of our Govern- ment, concerned in these questions, have the hearty services of men whose labours and cha- racters should be no less our admiration than our example. To omit to say this much would be unworthy and ungrateful : to name the per- sons would not become me. What, then, re- mains to be done ? Two things, and two only,— First, To continue to interest, intelligently, Trusting to the Nation, 5 3 the mass of the people in sanitary progress, and to interest them more systematically. England must rule herself in this as in all other matters. The time is gone when people can be dragooned into cleanliness and virtue. We hear that the middle class of Eng- land is inefficient, the guardians of the poor bad, and the working-classes ignorant. If so, still they are the people ; they and their chil- dren pay the penalty of disease and of vice. Shew them, truly and without exaggeration, the source of avoidable disease and of destruc- tive vice, — they will abate it. Bring the know- ledge to their doors, — they have heart and will ; give the power by enactment, and the work is done. Second, To establish such a Health Depart- ment in the Metropolis, as shall with certainty appreciate the growing wants of the people, as shall bring in Bills to meet their wants, and shall disseminate information and advice with- out stint to every part of the country. Jeremy Bentham saw clearly the necessity of a Health Minister. The " talents specially required of him and his various subordinates" 54 How the Foundations are Strengthened. were to be, — " Medical Art and Science in all its branches ; Chemical Art and Science, all its branches ; Mechanical Art and Science, vari- ous branches ; Natural History, most of its branches ; Geography, in so far as regards cli- mate and temperature, of countries which mem- bers of the community may have occasion to visit, either for war or trade ^" To him were to belong^ all duties with re- spect to the medical functionaries serving under the Indigence Relief Minister ; to the regu- lation of hospitals, lazarettos, and public la- boratories ; the medical inspection of prisons, madhouses, edifices belonging to the service of the Indigence Minister, and the Education Mi- nister ; of all " shops and storehouses, in which drugs designed to be employed for medical pur- poses are kept for sale, or otherwise for dis- tribution ; more particularly with reference to the precautionary arrangements directed to be observed by the Preventive Minister relating to the sale of poisons ;" so also as to the contents of all shops for chirurgical purposes, and ''all * Jeremy Bentham, Works, by Bowring, vol. ix. p. 273. ^ Ibid., p. 443. Jeremy Beiithanis Sanitary Code. 55 medicines and drugs designed to be employed for medical purposes," and to be conveyed to the army service, navy service, or the Indigence Relief Hospital service. He was also to see to the water supply of towns, and to have ''consideration of their extent and the density of their population," including the ''quantity, quality, and proportionality of distribution." He was to have under review all such "situations as are liable to harbour or give rise to exhalations detrimental to health," such as " lands which, to whatsoever proprietors be- longing, are habitually or occasionally covered with stagnant water ;" mines, considered in re- spect of such dangerous gases as they are liable to contain; common sewers and drains; theatres, and other similarly crowded places of enter- tainment, and places of interment ; manufactur- ing establishments, as far as regards health. He will superintend the bills of mortality. He will report on mortality and diseases in the hospitals and establishments under the manage- ment of the army, navy, preventive service, in- digence relief, and education ministers. Also he will elicit and record " from the several 56 How the Foundations are Strengthened. different places registers of the weather, in so far as habitually framed and preserved in the record establishments above-mentioned ; also from any other public sources from whence they may conveniently be procured, and from pri- vate sources, so far as procurable from those sources, with the free consent of the individuals interested." He is also to have " instructional " museums for shewing the registrars' reports above referred to, and other objects. More- over, the Health Minister is to be respon- sible for all examinations of aspirants " to those offices, the functions of which are exercises of the art of medicine in any of its several branches, and to whatsoever subject applied." To him " it will especially belong to be upon the watch against all injury to the health of the community, by the operation of particu- lar interests in the breasts of medical prac- titioners at the expense of public interest ; and, as occasion calls, to make report accord- ingly." To the result of the exercise of these func- tions, he is to give the utmost publicity that can be given consistently with a due regard Power of the Poor-Laiv for Good. 57 to public economy and the feelings of persons subject to the exercise of his functions. Since Bentham's time, the arrangements for the relief of the poor have become far more complete. A fashion now prevails among irre- sponsible persons of attacking this department of the State. The officials are hard, the laws are inefficient ; or, on the other side, the officials are lax, and the laws breed pauperism. In- stances are produced on either side. The fact is, the circumstance that every person in Eng- r>. land is safe_Jrom_starYSjtiQn. is a safety-valve in the working of a machine under high pres- sure, and the ubiquity of the staff of the poor- law, acquainted with ever}' lodging of the poor- est, gives in the present day an organisation which is unequalled. Time would fail, nor is it needful, to state in detail, the value of this machinery, if we are in earnest to secure pre- vention, as well as cure, of disease. Invest the Guardians of rural districts with adequate power, give them the requisite knowledge, appoint per- sons to the office with special qualifications, and trust them, on behalf of the people, to do all that can be done for maintainincr the na- 5 8 How the Foundations are Strengthened, tional health in their district. Keep the medical officers informed of all established knowledge bearing on health functions ; give them in the eyes of their fellow-men an honourable office ; and a scientific and trained staff is at once to your hand in every corner of the nation. The arrangements for the great centres of popula- tion must be different. Special officers, still in connection with the relief staff, must be re- tained, and relieved of all curative functions. Their number, and the conditions of their ap- pointment, will vary with the wants of their district. They will be centres of all existing knowledge of preventive measures, and a means thereby of maintaining an interest in sound progressive scientific knowledge. They will, in this department, be as the parochial clergy of the middle ages, who were the local centres of the knowledge and culture of their day. In a Memorandum ^ contained in the second volume of the Report of the Royal Sanitary Com- mission, which I cannot name without record- ing the debt which is due to the energy, skill, and patience of Sir Charles Adderley, its Chair- « See Appendix A. The Central AtitJiority for National Health. 59 man, is contained a sketch of the possible functions of such medical officers. They may seem to some excessive, and what once were called unpractical ; but it is not hard to foresee the value of them, and what pleasure the dis- charge of them would bring to the neighbour- hood, as well as to a medical man of culture in rural districts. He also would know that his public work was appreciated, and, that being part of a great national system, it would never be wasted. It is non-appreciation and sense of wasted effort, as well as want of guidance, which has made many a youth entering life discard the culture and aspirations of his stu- dent days, and let down his tastes, and some- times his habits, to the level of the most un- cultivated of his neighbours. In considering the bearings of this subject, the medical pro- fession has to remember, that however indebted the world has been in past time to it for a large portion of its physical science, the day of ex- clusive possession by any class of the Ark of natural knowledge is gone by. The medical practitioner will often find, and every year more and more, a worthy rnatch in biology 6o How the Foundations are Strengthened. among the laymen and ministers of his district. These will be his coadjutors or his critics, just as his own attainments and habits may- decide. The modern student of medicine has little to dread from the competition. I would refer to the report of the Sani- tary Commission, for details as to the medical officers of health, and their official coadjutors, as well as for discussions concerning the Area over which they should act. The good work- ing of the local authorities does not depend entirely upon their constitution. Bentham evidently relied on the central authority for regulating and instructing the local execu- tive. The Bill introduced by Mr. Goschen, ar- rived at the same result. By Part VI. and a few clauses in Part VIII. of that Bill, the central authority was to consist of a Minister, who should preside over the public health, relief of the poor, and all local government connected therewith. The subjects now distributed through various offices, would be united under the direc- tion of this Minister. It Is a misfortune that in consequence of being linked with the complex and difficult cognate question of incidence of A rrangements of L ocal Government Office. 6 1 local taxation, the clauses which would have made the strong central health office were withdrawn with the fiscal portions. They were not necessarily connected. The executive, in- deed, once remodelled, would have fresh powers to adjust further detail. It would be wholly premature, if it were becoming, here to inquire into the detailed construction of the office of the Health Minister. Suffice it that, when that portion of the Bill has passed, the prevention of disease, and the promotion of national health will take equal rank with the first preservative functions of the State, and everything else con- nected with the office and its executive will fall into place. The office will start with a staff connected with every spot in the country. The kind of complementary aid, and the extent of aid which the office may require, will be quickly dis- covered, and all that is valuable in the func- tions described in Bentham's crabbed system will be performed. In connection with these functions it may not be out of place to quote from the memorandum of the Sanitary Com- mission the following details. 62 How the Foundations are Strengthened. Under the Minister there would be sub- departments for — " a. Law of local government. "^. Engineering. *'r. Registration and statistics. *'^. Relief of poor. *'^. Medical care of public health and poor. "/. Legislation bearing on the profession of medi- cine. " III. A body of inspectors attached to the Health Office. These are to be of two kinds, as at present, with a third body of consulting experts. " I St. General inspectors attached to, and generally residing in the 'registration divisions,' 'poor-law districts,' or (as they will also be) 'public health areas.' " 2nd. Special inspectors, viz. legal, engineering, scientific, and medical. "3rd. Special experts, whose names should be at- tached to the Office, and who should advise pro- fessionally on special points for special fees, such persons to be appointed for five years and re-eligible. " 4th. Then will be required local clerks of unions, and of town councils, local surveyors under local boards and unions, local public health (medical) officers of local boards, unions, parishes, subordinate executive officers. " No office now existing need be destroyed. Some Functions of Officers of Health. 6$ will be amplified. A few more clerks will be re- quired at the Central Office, and an arrangement made for obtaining special advice when needed, in aid of the permanent staff of the office, and of the inspectors. " The advantages are many. Not only will the plan be efficient and complete, but it will be economical. The work of the Local Government, Law, and Engi- neering departments, of the Registrar-General, of the Poor-Law Board, of the medical adviser of the Privy Council, will be harmonized, and will never be chargeable either with unnecessary repetitions or with omission, as at present. So also, neither money nor skill will be wasted. " All reports bearing on public health will be con- nected one with the other, mutually illustrating each other. They will cover the whole ground of the science of prevention of disease, which has become both so important and serious for the well-being of old and densely-peopled countries. The connection of the office of the Minister of Health with the medical profession, 4,000 members of which would be in direct relation to him, would in itself be bene- ficial to the whole country. It would disseminate established scientific knowledge uniformly through the country districts, affecting not the medical man only, but the clergy and the schools, doing in that way alone as much at least as direct legislation for the same purpose could do. It would bring to light 64 How the Foundations are Strengthened. in every corner all that could be advanced as bearing on the physical condition of the masses of the peo- ple, while all crude theories or impracticable plans would instantly fade before the experience of the Central Office. "The publications of the statistical department would exhibit what could be shewn of the progress of sickness. They might give also useful deductions from local meteorological and scientific observations, in connection with those of Kew, the Government Meteorological Office, the Meteorological Society of Scotland, and such private enterprises as those of Mr. George Symonds on rainfall. They would furnish data for sanitary maps, which can only be of any worth when carefully constructed on rigorous local knowledge, and they would in time get rid of the fallacious application of conclusions deduced from averages, and erroneously applied to particular places or instances. In this way, the real causes of variation in death-rate would be more surely ascertained than at present. " Great encouragement should be given to the local public health officers to send in any observa- tions which would promote the progress of accurate knowledge. ** The British Public Health Reports thus con- structed, printed in an uniform 8vo. form, stitched in five parts, (legal, statistical, engineering, medical (in- cluding medico-legal), and general papers of inspec- Subject-matter of Sanitary Administration. 65 tors,) would be a series of great value. The Central Office should immediately on the first issue of the collected series make arrangement for regular inter- change with all foreign countries of similar reports, according to the established usages of academies. These documents should be accessible for reference in the public health library of the minister, to all persons connected with the department. " Public Health laboratories should be maintained or aided by grants from time to time. In them not only points bearing on the general pathology of man and animals, would be from time to time investigated under the best guidance, but persons would be trained to be thoroughly qualified in all medico-legal ques- tions. Hereby some of the scandal of ex-parte scien- tific witnesses might be checked or removed. Such laboratories should be aided or maintained as well in the metropolis as in some of the great towns where scientific institutions and medical schools exist, e.g. Oxford, Cambridge, Birmingham, Leeds, Newcastle, Bristol. These centres are conveniently situated for various sections of the kingdom. From the state- aided laboratories the inspectors would obtain an- alyses of waters or, in disputed cases, of any sub- stances requiring examination." The following passage also demands special consideration : — "In giving a judgment on the question of State F 66 How the Foundations are Strengthened, organisation relative to public health, much of the general tenor of modern legislation with respect to our internal economy should be present to the mind. It must therefore be remembered that those who will be responsible for local sanitary administration will have collectively, if not individually, to ad- minister Acts bearing on the following subjects : *'§ lo. I. Plans bearing on sanitary engineering or on local government, i.e., drainage, sewer- age, water supply, baths and wash houses, nuisances, offensive trades, smoke, public places of recreation, streets and roads, build- ings, cellars, and lodgings, burial-grounds, mortuaries, appointments of officers, artisans' dwellings, labourers' dwellings. *' 2. Care of personal health and safety, i.e. health in factories and workshops, mines, bakehouses, dangerous occupations. " 3. Regulation of quality of food, i.e., adulte- rations, markets, diseased cattle, slaughter- houses. "4. Medical, i.e., prevention of disease, epide- mics, endemics, syphilitic disease, small-pox (vaccination), quarantine, lunacy, hospitals, whether, first, rate supported, such as work- house hospitals, or hospitals under local boards, or secondly, voluntary, whether gene- ral or special, endowed or subscriptional, Diplomas in State Medicine. 6/ county or small village hospitals, or hospitals for the insane, and prisons, sale and adul- teration of drugs, poisons, supervision of re- ports of officers of health. "5. To which must be added medico-legal arbi- trations." An important step has been recently taken by Dr. Stokes, the Regius Professor of Medicine in Dublin, and his colleagues. They have in- stituted an examination with the view of grant- ing a diploma in the subjects bearing on Na- tional Health, or, as it is sometimes called, State Medicine. This examination, of which full particulars are given at the end of the present Essay, will comprise certain parts of Law, Engineering, Pathology, Vital and Sani- tary Statistics, Chemistry, Meteorology, and Medical Jurisprudence. That such opportunity of systematically learning what is essential to the maintenance of the National Health should be now given by Trinity College, Dublin ^ does great honour to that enlightened body. It is to be hoped that ere long, a learned compendium of the required knowledge will issue from the Irish '^ See Appendix B. 6S How the Foundations are Strengthened. press. Any one who has studied this subject knows, that in consequence of the labours of Parkes ^ Simon ^ Farr ^, Seaton "^^ Glen ^ Rum- sey °, Rawlinson p, Stewart