Chapter XXXI: Appendix (21)

When the great importance of the general land drainage to the health of those who labour upon it and to their most productive employment is fully considered, it will, I conceive, be found entitled to all collateral aid, to which an additional title would be conferred by equal contribution of the owners and occupiers to the expenses of public drainage. If officers of proper qualifications and responsibilities were appointed, the works for sewerage branching from the towns, and the road drainage, could not fail to aid, as indeed I conceive it should be directed to aid, the private land drainage. The same surface levels and sewerage, if made on the scale proposed by the Poor Law and Tithe Commissioners (namely, of three chains to an inch) would serve for all civil purposes, whether of towns or general land drainage, or road drainage, for determining the descent of streams, for the application of the water of which it is desirable to rid the upland wastes, and would frequently be most beneficially applied for the use of the towns, and for the use of the poorer districts.

The appointment of persons having the scientific qualifications and position of civil engineers might serve to supply a want which is generally found to be the chief impediment to the drainage of land subdivided amongst numerous small holders, namely, the means of reference or appeal to some authority deriving confidence from skill and impartiality to determine on the need of works, and the mode of executing them, or to arbitrate; and on the compensation due from damage arising from them. Given such an authority, and in those small, but, from their great number, most important cases, where the expense of an application to Parliament is out of the question, it might, be safe to say, by a general provision, that the inhabitants of a town may procure springs of water, and make, deepen, and scour drains through the circumjacent district; that regulations may be made for arching over or covering the sewers to proper distances from the towns; for the purchase of ground, and for the erection of works for rendering the refuse of the towns available for agricultural purposes: power might also be given to lay pipes in the highways, to put plugs for the supplies of water against fires, and for watering the roads.

On referring to the experience of the efforts made in Ireland for the drainage and reclaiming of bog lands, by which large tracts would be obtained, it appears that the working of legislative measures for those purposes have extensively failed, because the landowners had not sufficient security that the work would be properly planned and executed.[46]

I would here beg leave to guard myself from an apparent inconsistency. In 1838, I was examined before a committee of the House of Commons on their resolution, “That it is expedient that the parishes, townships, and extra-parochial places should be united in districts for the repair of the highways throughout England and Wales.” On that occasion I adverted to the evil of the unnecessary multiplication of new establishments as well as new officers, to their inevitable inefficiency and to the expense and obstruction to improvement which they created; and I submitted these, amongst other grounds, for proposing that the new duties should devolve on the boards of guardians of the new unions, as such duties had been in various instances combined under local Acts. The committee recommended the proposal for adoption. On the premises then placed before me, as to the expediency of establishing a new administrative body with new clerks and officers for the collection and management of the fund for repairs of the highways _alone_, and in small districts for which even the areas of unions were thought large, I should still adhere to the same conclusion.[47]

The present inquiry, however, has shown the general primary importance of the works of sewerage and drainage throughout the country. The execution of those works would properly devolve upon the commissioners of sewers already in existence in the towns, or in the marsh districts, or upon commissions of sewers which it will be found necessary to issue to places where there has been no need of surface drainage, but which stand in need of under-drainage. These being the primary works for making the ground clear and keeping it clear for all other works, would necessarily require the highest science and skill, and the strongest establishment; and it would be only carrying farther the principle of consolidation, as the only means of obtaining the most efficient service, the most conveniently and at the lowest cost, now to recommend that the care of the roads should, of all structural works, be made to devolve upon that body which has the best means of executing them, namely, the commissions of sewers, revised as to jurisdiction, and amended and strengthened as to power and responsibility. What Colonel J. F. Burgoyne, the experienced chairman of the Board of Works in Ireland, stated in his evidence before the committee of the House Commons in 1836, (question 35,) on the consolidation of the turnpike trusts, may be applied to the consolidation of other local works:—“One office and account will then do for the whole; a superior superintendent could then be employed, and more perfect machinery; the means will be more generally available, and can be concentrated where required, by which the works will be carried on with more advantage, and a system of regular and rigid maintenance can be established so much more economical and beneficial than that of occasional and periodical repairs.”

It is due to state that in petitions from ratepayers much dissatisfaction is expressed with the proceedings of the commissions of sewers, and their objectionable working is assigned to their irresponsibility, and a favourite remedy proposed is to make them elective; but if the administration of expenditure by elective vestries be examined, it is found to be no better; and of entirely open vestries, even worse; and the practical responsibility for injustice done to individuals, or to any one who cannot get up a party, still less. It may, however, be submitted for consideration, whether the commissions for sewers might not be so far modified as to admit some infusion of the representative principle in their composition, by including, as ex-officio members of the commission, the chairman and vice-chairmen for the time being of the Boards of Guardians of the poor law unions included within the jurisdiction of the commission. These officers are elected by the elected representatives of the ratepayers—the guardians. It will be seen that much of the evil which the preventive measures within the province of the commission of sewers must provide against, is presented, in the first instance, to the Board of Guardians, in the shape of claims to relief on the ground of destitution occasioned by sickness. The chairman or the vice-chairman, before whom the cases are thus brought, would form an efficient medium of communication. The measures of drainage and structural improvement are permanent improvements of the greatest importance to the labouring men, in common with other classes; but it is matter of fact that such improvements are the least supported by those who have the least permanent interest—the smaller occupiers; or by those who have the least means and have the greatest dread of immediate expenses—the smaller owners. The chairmen and the vice-chairmen of the unions in the rural districts are, however, the chief landed proprietors, who are elected by the guardians for the interest they take in the improvement of local administration. The most important improvements in the residences of the labouring classes that have been brought to view by this inquiry have arisen from the spontaneous benevolence of the larger proprietors; and so much improvement must depend upon their voluntary exertion, that, for the sake of the labouring classes, it recommends itself as an important arrangement, that those who, as chairmen of the Boards, have the distribution of relief to the destitution attendant on sickness, should be placed in a position to represent the need of the means of prevention, and urge forward their execution.

When the extent of the removable causes of sickness and mortality are more clearly and extensively understood, as they will be, the Board of Guardians will of necessity occupy much of the position of the Leet, as a body fitted to act on complaints made, and to reclaim the execution of the law against omissions and infractions which occasion illness or injury to the most helpless classes.

_Boards of Health, or Public Officers for the Prevention of Disease._

In reports and communications, the institution of district Boards of Health is frequently recommended, but in general terms, and they nowhere specify what shall be their powers, how they shall seek out information or receive it, and how act upon it. The recommendation is also sanctioned by the committee which sat to inquire into the health of large towns; and the committee state that “the principal duty and object of these boards of health would be precautionary and preventive, to turn the public attention to the causes of illness, and to suggest means by which the sources of contagion might be removed.” “Such boards would probably have a clerk, paid for his services, whose duty it would be to make minutes of the proceedings, and give such returns in a short tabular form as might be useful for reference, and important, as affording easy information on a subject of such vital interest to the people.”

I would submit that it is shown by the evidence collected in the present inquiry, that the great preventives—drainage, street and house cleansing by means of supplies of water and improved sewerage, and especially the introduction of cheaper and more efficient modes of removing all noxious refuse from the towns—are operations for which aid must be sought from the science of the civil engineer, not from the physician, who has done his work when he has pointed out the disease that results from the neglect of proper administrative measures, and has alleviated the sufferings of the victims. After the cholera had passed, several of the local boards of health that were appointed on its appearance continued their meetings and made representations; but the alarm had passed, and although the evils represented were often much greater than the cholera, the representations produced no effect, and the boards broke up. In Paris a Board of Health has been in operation during several years, but if their operations, as displayed in their reports, be considered, it will be evident that, although they have examined many important questions and have made representations, recommending for practical application some of the principles developed in the course of the present inquiry; still as they had no executive power, their representations have produced no effect, and the labouring population of Paris is shown to be, with all the advantages of climate, in a sanitary condition even worse than the labouring population of London. In the Appendix I have submitted a translation of a report descriptive of the labours of the Conseil de Salubrité, in Paris. From this report it will be seen that they have few or no initiative functions, and that they are chiefly called into action by references made to them by the public authorities to examine and give their opinion on medical questions that may arise in the course of public administration as to what manufacturing or other operations are or are not injurious to the public health.

The action of a board of health upon such evils as those in question must depend upon the arrangements for bringing under its notice the evils to be remedied. A body of gentlemen sitting in a room will soon find themselves with few means of action if there be no agency to bring the subject matters before them; and an inquiring agency to seek out the evils from house to house, wherever those evils may be found, to follow on the footsteps of the private practitioner would be apparently attended with much practical difficulty.

The statements of the condition of considerable proportions of the labouring population of the towns into which the present inquiries have been carried have been received with surprise by persons of the wealthier classes living in the immediate vicinity, to whom the facts were as strange as if they related to foreigners or the natives of an unknown country. When Dr. Arnott with myself and others were examining the abodes of the poorest classes in Glasgow and Edinburgh, we were regarded with astonishment; and it was frequently declared by the inmates, that they had never for many years witnessed the approach or the presence of persons of that condition near them. We have found that the inhabitants of the front houses in many of the main streets of those towns and of the metropolis, have never entered the adjoining courts, or seen the interior of any of the tenements, situate at the backs of their own houses, in which their own workpeople or dependents reside.

The duty of visiting loathsome abodes, amidst close atmospheres compounded of smoke and offensive odours, and everything to revolt the senses, is a duty which can only be expected to be regularly performed under much stronger motives than can commonly be imposed on honorary officers, and cannot be depended upon even from paid officers where they are not subjected to strong checks. The examination of loathsome prisons has gained one individual a national and European celebrity. Yet we have seen that there are whole streets of houses, composing some of the wynds of Glasgow and Edinburgh, and great numbers of the courts in London, and the older towns in England, in which the condition of every inhabited room, and the physical condition of the inmates, is even more horrible than the worst of the dungeons that Howard ever visited. In Ireland provisions for the appointment of Boards of Health have been made, but they appear to have failed entirely. One of the medical practitioners examined before the Committee of the House of Commons was asked, in respect to the operation of these provisions:—

“3297. But in ordinary times, when the fever is not of very great
intensity, and is confined to the dwellings of the humbler classes,
there is no such provision put into force?—No, but then there is
another provision which may be put into force; this Act provides, that
‘whenever in any city, town, or district, any fever or contagious
distemper shall prevail, or be known to exist, it shall and may be
lawful for any one or more magistrates, upon the requisition of five
respectable householders, to convene a meeting of the magistrates and
householders of such city, town, or district, and of the medical
practitioners within the same, in order to examine into the
circumstances attending such fever or contagious distemper.’ There is
another Act of 59 Geo. III., c. 41, which enables the parishes to
appoint officers of health; that is, a permanent power. Those officers
have very considerable authority; they can assess a rate.

“3298. Are they appointed?—They are appointed, I think, in all the
parishes in Dublin except two; but they are inoperative: they are
unpaid, and it is a very disgusting duty. They can be made to serve,
but there is no control as to the amount of service they perform; so
that the provision is quite inoperative, unless an alarm exists.

“3299. Do you not think the appointment of some such officers,
properly appointed, properly paid, and having reasonable power, for
the purpose of suggesting and enforcing such measures as shall be
beneficial, would be highly valuable?—I am sure it would, and it would
save an amazing quantity of expenditure to the country.”

It has only been under the strong pressure of professional duties by the physicians and paid medical and relieving officers responsible for visiting the abodes of the persons reduced to destitution by disease that the condition of those abodes in the metropolis have of late been known; and I believe that it is only under continued pressure and strong responsibilities and interests in prevention that investigation will be carried into such places, and the extensive physical causes of disease be effectually eradicated.

Whilst experience gives little promise even of inquiries from such a body as Boards of Health without responsibilities, still less of any important results from the mere representations of such bodies separated from executive authority, I would submit for consideration what appears to me a more advantageous application of medical science, viz., by uniting it with boards having executive authority.

Now, the claim to relief on the ground of destitution created by sickness, which carries the medical officer of the union to the interior of the abode of the sufferer, appears to be the means of carrying investigation precisely to the place where the evil is the most rife, and where the public intervention is most called for. In the metropolis the number of cases of fever alone on which the medical officers were required to visit the applicants for relief, at their own residences, amounted during one year to nearly 14,000. The number of medical officers attached to the new unions throughout the country, and engaged in visiting the claimants to relief on account of sickness, is at this time about 2300.

Were it practicable to attach as numerous a body of paid officers to any local Boards of Health that could be established, it would scarcely be practicable to insure as certain and well directed an examination of the residences of the labouring classes as I conceive may be ensured from the medical officers of the unions. In support of these anticipations of the efficiency of the agency. of the medical officers when directed to the formation of sanitary measures, I beg leave to refer to the experience of a partial trial of them under a clause of the recent Metropolitan Police Act, by which it is provided, that if the guardians of the poor of an union or parish, or the churchwardens and overseers of the poor of any parish within the Metropolitan Police district, together with the medical officer of any such parish or union, shall be of opinion, and shall certify under the hands of two or more of such guardians, churchwardens, and overseers, and of such medical officer, that any house, or part of any house, is in such a filthy unwholesome condition that the health of the inmates is thereby endangered, then the magistrates may, after due notice to the occupiers, cause the house to be cleansed at his expense.

The defects of the provision are, that it only authorizes cleansing and not providing for the means of cleansing and personal cleanliness, by directing supplies of water to be laid on; that it does not extend to the alterations of the external condition of the dwelling; that the immediate expense falls upon the occupier, who is usually in so abject a state of destitution as to serve as a barrier to any proceeding apparently tending to any penal infliction. With all these disadvantages, its working may be submitted to show the general eligibility of the medical officers of unions as officers for the execution of sanitary measures. The following account is given by the clerk to the Board of Guardians of Bethnal Green of the working of the provision in that part of the metropolis:—

_Mr. William Brutton._—We have taken prompt measures to execute the
clause of the Metropolitan Police Act, and the Commissioners’
recommendations upon it, in our parish, and the effect produced has
already been beneficial. For example, the medical officer recently
reported, through me, to the Board of Guardians, that fever had arisen
in certain small tenements in a court called Nicholl’s Court, and that
it was likely to spread amongst the poorer classes in the district. He
reported that others of the houses than those in which fever existed
(and the inmates) were in a filthy condition, and that, unless
measures were taken for cleansing them properly, fever must
necessarily ensue. The Board, on receiving this communication, desired
me to proceed instantly, and take such measures as appeared to me to
be necessary for the abatement and prevention of the evil. I
immediately obtained a summons from the magistrates for the attendance
of the owner of the houses. He came directly, and stated that he was
not aware that the premises were in the condition in which our medical
officer had found them; and he promised that measures should be taken
for proper cleansing. Those measures were taken: the furniture of the
houses was taken out and washed; the houses were lime-washed. Some of
those who were ill died, but the progress of the fever was certainly
arrested.

The Board followed up these proceedings by circulating the
Commissioners’ instruction and form of notification in every part of
the parish. But the proceeding had a very good effect in the immediate
neighbourhood. The proceeding was observed by the neighbours, and
there is every reason to believe that they have set to work to cleanse
and prevent a similar visitation. We have also learned that the
landlords of some of these smaller tenements have been rather more
particular than before: they have said we must see to the cleansing of
these places lest we should be had up for it before the magistrates.

The guardians, considering the form of notifications useful, have
directed that they should be issued periodically before the times when
disease usually appears. In the course of a fortnight or three weeks
hence, when the equinoctial gales prevail, and when we have usually
much sickness and claims to relief, we shall probably have another
issue of the notifications.

We have also given instructions to the relieving officer, as well as
the medical officer, to report on the existence of any filth or things
likely to be productive of disease that he may observe in the course
of his visits to the houses where he is called by the claims to
relief. The services of the relieving officer are highly important, as
he has an opportunity of observing the state of filth and the obvious
predisposition, and perhaps of causes of disease, preventing it before
the visits of the medical officer, who is of course only called upon
to attend when disease has arisen. The relieving officers visit more
frequently than the medical officer, and give the tickets or orders
requiring his attendance.

You are Commissioner of the Sewers in the Tower Hamlets, are you
not?—Yes, I am.

And you are of course aware of their procedure?—Yes.

Do you think that body would be available for the execution of
sanitary measures?—Certainly not as compared with the Board of
Guardians: the Commissioners of Sewers meet only monthly, and have no
medical officers and no relieving officers. The Board of Guardians
meets weekly, and their officers are constantly at work, night and
morning. We have not even waited for the landlords, where prompt
measures appeared to be necessary for the removal of any active cause
of disease. Where cesspools have overflowed, and where there has been
a stoppage of water, we have directed the surveyor of the roads to
ascertain the cause of the stoppage, and to remedy the mischief
forthwith.

But what legal right have the guardians had to do that: they have no
legal right to direct the road surveyor in the performance of his
duties?—Strictly speaking, we have not, but we have forcibly suggested
it as a matter of expediency.

Between the notification of the evil and the execution of the remedy,
in the example you have cited by the Board of Guardians, what length
of time elapsed?—From the Friday to the Monday following.

What time, so far as you have had experience, need ordinarily elapse
if execution follow immediately on the report?—Execution would follow
immediately on the order of the Board of Guardians. I think, however,
that the union officers should, in case of emergency, have a summary
acting power immediately for the preservation of life. The Guardians
thought their examination of the spot unnecessary after the report of
the medical officer.

The following is the examination of the clerk to the Strand union as to the practical working of the same measure in another district:—

_Mr. James Corder_, clerk to the Strand union, examined;—

What has been done in the Strand union in respect to the provisions of
the Metropolitan Police Act, 2 and 3 Vict., c. 71, sec. 41, with
respect to the powers conferred by that statute for the cleansing of
houses which are in an unwholesome condition?

The attention of the medical officers was immediately drawn to the
section of the Act, and the instructions of the Poor Law Commissioners
relating thereto; and the result has been that proceedings have been
had in several cases, in all of which the necessary cleansing has been
performed by the owners, without the guardians being driven to the
necessity of causing the requisite lime-whiting and cleansing to be
done. The medical officer had frequently complained of the condition
of the places into which the cleansing had been carried. Those places
had for years been in the filthiest and most unwholesome condition: in
some courts and alleys the pavements were covered with an accumulation
of the most offensive matter, including the carcases of dead animals,
such as dogs and cats, which the scavengers said formed no part of
their contract to remove: their contract was only to cleanse the
carriage ways. Some of these courts and alleys abound in the principal
thoroughfares in the metropolis. The public, in passing through a
thoroughfare like the Strand, would scarcely imagine that an evil of
so much magnitude was close at hand.

The powers conferred by the clause in question appears to be
restricted to the cleansing of the houses and the passages within the
cartilage. What proceedings did the guardians take with relation to
these external passages?

They directed the condition of the places to be represented to the
Commissioners for paving and cleansing the district, who caused the
filth complained of to be removed. The cleansing of the footways,
however, forms no part of the duty of the Commissioners of Pavement,
nor of their surveyor, nor of the scavenger appointed by them; and
what was done was done extra-officially.

It cannot, therefore, be relied upon for the future?

No; and it is to be observed that the Metropolitan Paving Act
evidently contemplates that the cleansing of the footways shall be
done by the inmates of the houses. In the poorer districts, however,
this is entirely omitted to be done; in addition to which these courts
and alleys are frequently made, on account of their obscurity, a
depository for most offensive matter. In the better neighbourhoods,
the service of cleansing is performed by the servants; but the poor
people, who rise before daylight, go to their work, and return at a
late hour, have no time to cleanse their courts, and their earnings
are too scanty to allow payment to others for the performance of the
duty. In the better neighbourhoods, the cleansing does not always take
place. The medical officers report, that there is a better average
health in the streets that are well cleansed than in others where the
people are otherwise in the same condition of life.

What are the main defects you have experienced in respect to the
provision of the Metropolitan Police Act, empowering the guardians to
take measures for cleansing houses?

First, the delay which must take place before the provisions of the
Act can be put in operation. The medical officer has first to make his
report to the Board of Guardians; several days elapse before the Board
meets: then guardians have to inspect the premises in conjunction with
the medical officer previously to certifying as to the state thereof:
then application is made to the magistrate, who issues his summons,
returnable in seven days; at the expiration of which, if the cleansing
be not performed, the guardians are empowered to cause it to be done;
but they must first obtain a magistrate’s warrant for the purpose. All
this engenders delay; in addition to which our guardians have, in the
first instance, caused the landlord to be written to with a view to
prevent further proceedings, which in some instances have been
successful; but when it is not successful, it creates a further delay,
during which disease may rapidly increase and spread. The second
defect of the provision is, that the owners are not liable for the
expenses incurred; and the occupiers are mostly of the poorest class,
who have no effects on which a distraint could be made. With all these
difficulties, however, this provision has been very beneficial in its
operation; and it is very much to be desired that larger facilities
should be afforded for carrying its intention more fully into effect.
It may be added, that the medical officer should have remuneration for
the trouble he entails upon himself, by a report, in attending before
magistrates, until the object is effected.

_Mr. John Smith_, the clerk to the Whitechapel union:—

Have you taken any proceedings under the 41st clause of the
Metropolitan Police Act?

We have issued notifications to every house in the union of the
necessity of cleansing the houses by whitewashing them inside and out,
and that the owners and occupiers were amenable for any neglect. The
relieving officers report to me, that these notifications have already
been productive of very good effects, and that whitewashing has been
actively practised. The relieving officers were instructed, wherever
they found a case of neglect, to threaten the landlord that he would
be proceeded against unless the tenement was duly cleansed. But as yet
we have taken no legal proceedings, because we have advised with the
magistrates, who do not consider that the owners can be proceeded
against in the first instance, and the occupiers of the tenements,
which are liable to be proceeded against, are most of them paupers and
persons in extreme poverty.

With respect to the remedies, I find that the personal inconvenience
to which the clause subjects the guardians of visiting the spot is a
provision which will greatly obstruct its operations, and will at all
events greatly delay proceedings from time to time. The guardians who,
in our union, are men of business, consider that their time is fully
occupied at the Board, and they object to any attendance out of the
Board, and would give it reluctantly. If the cases are taken before
the magistrate, it appears desirable that the medical officer should
not be compelled to attend unless it were absolutely requisite, and
that the relieving officer should be allowed to prove the facts as to
the state of the dwellings recited in the medical officer’s
certificate, which could rarely be disputed. If the point were
disputed by the owner, then the medical officer or other witnesses
might be forthcoming.

What is the number of houses in the union?—About 8000.

How many cases on the average do your medical officers visit in the
year?—About 4000.

Those visits of course are sometimes to different rooms of the same
tenement?—No doubt of that, and very frequently to the inmates of the
same room.

Are the visits of the relieving officers to the dwellings of the
labouring classes more extensive than the visits of the medical
officers?—I should say more extensive.

Between the two, are any class of the poorer and otherwise neglected
residences that would probably escape visitation?—I should say that
they must visit every spot within the district.

Within such districts as that of Whitechapel, do you think the three
present medical officers and the relieving officers would suffice to
carry out sanitary measures actively and efficiently?—I think that for
efficiency additional strength would be required; perhaps one officer,
whose especial duty it should be to attend to the duties connected
with sanitary measures, supposing them carried out by the agency of
the existing establishments.

From the consideration of such practical evidence, it will be seen that the ordinary duties of the relieving officer in the first instance, and of the medical officer afterwards, ensure domiciliary inspection of large districts to an extent and with a degree of certainty that could scarcely be ensured or expected of any agents or members of a board of health unconnected with positive administrative duties. The inspection of these officers of the boards of guardians more than supplies the external inspection of inquests or of the leets; and it is submitted that in their position these boards may most beneficially exercise the functions of the leet in reclaiming the execution of the law, as against acts of omission and of commission, by which the poorest of the labouring classes are injured and the ratepayers burdened.

It may therefore be submitted as an eligible preliminary general arrangement, that it shall be required of the medical officer as an extra duty, for the due performance of which he should be fairly remunerated, that on visiting any person at that person’s dwelling, on an order for medical relief, he shall, after having given such needful immediate relief as the case may require, examine or cause to be examined any such physical and removable causes as may have produced disease or acted as a predisposing cause to it; that he shall make out a particular statement of them, wherein he will specify any things that may be and are urgently required to be immediately removed. This statement should be given to the relieving officer, who should thereupon take measures for the removal of the nuisance at the expense of the owner of the tenement, unless he, upon notice which shall be given to him, forthwith proceed to direct their removal. Except in the way of appeal by the owner against the proceedings of either officer, or where a higher expense than 5_l._, or a year’s rent of the tenement, were involved by the alterations directed by the medical officer, it appears to be recommended that no application to the Board of Guardians or the magistrates should be required in the first instance, as it frequently happens that the delay of a day in the adoption of measures may occasion the loss of life and the wide spread of contagious disease; and an application to the Board of Guardians or to the petty sessions would usually incur delay of a week or a fortnight. To repeat the words of Blackstone,—“The security of the lives and property may sometimes require so speedy a remedy, as not to allow time to call on the person on whose property the mischief has arisen to remedy it.” When any tenement is in a condition to endanger life from disease, as it comes within the principle of the law, so it should be included within its provisions, and should be placed in the same condition as a tenement condemned as being ruinous and endangering life from falling.

The instances above given of the working of the provisions of the Metropolitan Police Act for the cleansing of filthy tenements are, however, instances of zealous proceedings taken by competent officers in unions, where the attention of the guardians was specially called to the subject, and where there were no opposing interests. But several other instances might be presented, where the execution of the law is as much needed, but where it is already as dead as any of the older laws for the public protection, and the reason assigned is, that the local officers will not, for the sake of principle and without manifest compulsion, enter into conflicts by which their personal interests may be prejudiced. Medical officers, as private practitioners, are often dependent for their important private practice, and even for their office, on persons whom its strict performance might subject to expense or place in the position of defendants. Under such circumstances it is not unfrequent to hear the expression of a wash from these officers, that some person unconnected with the district may be sent to examine the afflicted place, and initiate the proper proceedings. The working of the provisions of the Factory Act for the limitation of the hours of labour of children has been much impeded by the difficulty of obtaining correct certificates of age and bodily strength from private medical practitioners. On this topic a large mass of evidence might be adduced, showing the unreasonableness of expecting private practitioners to compromise their own interests by conflicts for the public protection with persons on whom they are dependant.

Cases of difficulty requiring superior medical experience and skill occur frequently amongst the paupers. For general supervision as well as for the elucidation of particular questions, the Board have proved the practicability of obtaining for the public service the highest medical skill and science. They have availed themselves of more various acquirements than would be found in any standing _conseil de salubrité_. On questions respecting fever they have availed themselves of the services of the physician of the London Fever Hospital; on questions of vaccination they have consulted the Vaccine Board of London, and the authorities on the same question in Scotland. On questions as to ventilation they have availed themselves of the services of Dr. Arnott; and on the general questions affecting the sanitary condition of the population they have consulted that gentleman and Dr. Kay, and Dr. Southwood Smith, and others who could be found to have given special attention to the subject. When serious epidemics have broken out in particular unions the central Board has dispatched physicians to their aid, or suggested to the guardians that they should have recourse to the services of physicians in the neighbourhoods. The services of Dr. Arnott, Dr. Kay, and Dr. Southwood Smith were thus directed in aid of the medical officers of the eastern districts of the metropolis; and their reports first developed to the public and the legislature the evils which form the subject of the extended inquiry, and that might otherwise have continued without chance of notice, or mitigation or removal, to have depressed the condition of the labouring classes of the population. But the results of such occasional visits appear to prove the necessity and economy of an increase of the permanent local medical service, and to establish a case for the appointment of a superior medical man for a wider district than an ordinary medical officer, for the special aid and supervision of the established medical relief.

It will frequently be found that there is the like need of immediate local inspection of the medical treatment of the destitute that there is of a grade of inspecting surgeons for the military hospitals. It cannot be otherwise than that amidst a numerous body of men there must be much error and neglect in the treatment of the destitute, in the absence of immediate securities against, neglect. The most able of the guardians would confess that if they are not entirely incompetent to supervise medical service, they are at the best but imperfectly qualified for such a task, and the medical officers would act with more satisfaction to themselves from the supervision of officers from whom they might derive aid and confidence.

But besides the medical treatment of the inmates of the workhouses and prisons, there are other cases within most districts which need the preventive service of a superior medical officer for the protection of the public health.

First, in the cases where the poorer classes are assembled in such numbers as to make the assemblages _quasi_ public, and afford facilities for medical inspection, as in schools.

Secondly, also in places of work and in workmen’s lodging-houses. The occasional visits of a district officer, for the prevention of disease would lead to the maintenance of due ventilation, and to the protection of the workpeople on such points as are already specified as injurious to the health, and that arise simply from ignorance, and are not essential to the processes. An examination of such places, if only quarterly, would lead to the most beneficial results.

So far as I have observed the working of the Factory Act, it appears to me that the duties now performed by the sub-inspectors of factories might be more advantageously performed by superior medical officers, of the rank of army surgeons, who are independent of private practice.

I am confirmed in this view by the following evidence of _Mr. Baker_, surgeon of Leeds, the only factory inspector who has such qualifications:—

“Have you, as a surgeon, whilst visiting the factories as an
inspector, had occasion to exercise your professional
knowledge?—Frequently; during my service I have turned out great
numbers of children with scald-heads, which they were apt to propagate
amongst the rest of the children; some with phthisis, whose subsequent
death was more than probable; some with scrofulous ulcers; a great
many with extreme cases of ophthalmia; probably I may have removed a
thousand of these cases altogether. I rarely go to a mill where I do
not see a case of scald-head.

“Have you ever had occasion to interpose in respect to
ventilation?—Frequently in extreme cases of variable temperature, also
in cases of offensive privies, which I find attended by dysenteric
affections; and also where there has been offensive water from
neglected sewers. I have also endeavoured to enforce personal
cleanliness on the children through the instrumentality of overlookers
and parents. One practice amongst the children in all kinds of mills
is to wear handkerchiefs on the head, by which the neglect of personal
cleanliness was concealed. Under these handkerchiefs were most of the
cases of scald-head, in a state of filthiness not easily describable.
I have assured the operatives that by the Act I had the power to
direct measures for the protection of their health as well as labour;
and I have established in many places the rule that the children shall
come with the faces clean, and the hair combed, and without
handkerchiefs whilst at work.”

By such inspection of workpeople in the places of work do you conceive
it would be practicable to influence largely the sanitary condition of
the labouring population without inspection of the private
houses?—Yes; for the ill health which was occasioned by the state of
their houses or other places, would of course be visible on such
inspection. If they were removed from their places of employment on
the presentation of such appearances, the inattention which had
occasioned it would be removed too.

“What length of time do you find such inspection would require each
time, say in a mill of about 1000 persons, and how frequent should
such inspection be?—On the average about two hours; to a practised eye
the symptoms of indisposition are discernable almost in walking
through a room. Under some circumstances an inspection of once in
three months would suffice.

“Are there masters in your district who are aware of the interest they
have in the health of their workpeople?—Yes; there are many who pay
particular attention. I might mention two where a surgeon is specially
employed to take care of their workpeople. When persons are ill, they
are listless and sleepy, and negligent; there is also more waste made
in the processes of manufacture.”

The superior economy of preventive services by such inspection as that above displayed will scarcely need elucidation.

From a consideration of such opportunities of inspection it will be perceived that the enforcement of sanitary regulations on such inspection by superior and independent officers, qualified by previous examination, as in the army, would be a wise economy. By such arrangements efficient medical superintendence would be provided for the independent labourer employed in crowded manufactures, as well as for the soldier and the sailor, not to speak of the pauper or the criminal. One such officer would be able so to inspect and keep under sanitary regulations the places of work, the schools and all the public establishments of such a town as Leeds, which would bring under view perhaps the greater proportion of the lower classes of the population. There would still remain, however, those of the labouring classes who do not work or lodge in large numbers, or work in a quasi-public manner, to bring them within the means of convenient inspection. There would also remain without protection the cases of persons of the middle classes.

To meet these cases, I would suggest that the information brought to the superintendent registrar as to the cause of death, imperfect and hearsay as it yet is, may serve as the most accurate index to the direction of the labours of a district officer appointed to investigate the means of protecting the health of all classes. Having suggested the registration of the causes of death (under medical superintendence), a head of information not contained in the original draught of the Deaths’ Registration Bill, I would guard against an over-estimate of the importance of that provision; but I feel confident it would be found, when properly enforced, one of the most important, means of guiding preventive services in an efficient direction. For example, wherever, on the examination of these registries, deaths from fever or other epidemics were found to recur regularly, and in numbers closely clustered together, there will be found, on examination, to be some common and generally removable cause in active operation within the locality. Amongst whatsoever class of persons engaged in the same occupation deaths from one disease occur in disproportionately high numbers or at low ages, the cause of that disease will generally be found to be removable, and not essential to the occupation itself. The cases of the tailors, miners, and dressmakers, and the removable circumstances which are found to govern the prevalence of consumption amongst them, I adduce, as examples of the importance of the practical suggestions to be gained from correct and trustworthy registries of the causes of death occurring in particular occupations as well as in particular places. When a death from fever or consumption occurs in a single family, in the state of isolation in which much of the population live in crowded neighbourhoods, they have rarely any means of knowing that it is not a death arising from some cause peculiar to the individual. Even medical practitioners who are not in very extensive practice may have only a few cases, and may be equally unable to see in them, in connexion with others, the operation of an extensive cause or a serious epidemic. The registration of the causes of death, however, presents to view the extent, to which deaths, from the same disease, are common at the same age, at the same time, or at the same place, or in the same occupation.

One of the most important services, therefore, of a superior medical officer of a district would be to ensure the entries of the causes of death with the care proportioned to the important uses to be derived from them. The public should be taught to regard correct registration as being frequently of as much importance for the protection of the survivors as a post-mortem examination is often found to be.

The mortuary registries and the registration of the causes of death are not only valuable as necessary initiatives to the investigation of particular cases, but as checks for the performance of the duty. The system of registration in use at Geneva, combining the certificate and explanation of the private practitioners and the district physician, corresponds with a recommendation originally made for the organization of the mortuary registries in England, and the experience of that country might, perhaps, be advantageously consulted.

It would be found that the appointment of a superior medical officer independent of private practice, to superintend these various duties, would also be a measure of sound pecuniary economy.

The experience of the navy and the army and the prisons may be referred to for exemplifications of the economy in money, as well as in health and life, of such an arrangement. A portion only of the saving from an expensive and oppressive collection of the local rates would abundantly suffice to ensure for the public protection against common evils the science of a district physician, as well as the science of a district engineer. Indeed, the money now spent in comparatively fragmentations and unsystematized local medical service for the public, would, if combined as it might be without disturbance on the occurrence of vacancies, afford advantages at each step of the combination. We have in the same towns public medical officers as inspectors of prisons, medical officers for the inspection of lunatic asylums, medical officers of the new unions, medical inspectors of recruits, medical service for the granting certificates for children under the provisions of the Factory Act, medical service for the post-mortem examinations of bodies, the subject of coroners’ inquests, which it appears from the mortuary registries of violent deaths in England amount to between 11,000 and 12,000 annually, for which a fee of a guinea each is given. These and other services are divided in such portions as only to afford remuneration in such sums as 40_l._, 50_l._, 60_l._, or 80_l._ each; and many smaller and few larger amounts.

Whatever may be yet required for placing the union medical officers on a completely satisfactory footing, the combination of the services of several parish doctors in the service of fewer union medical officers will be found to be advances in a beneficial direction. The multiplication or the maintenance of such fragmentitious professional services is injurious to the public and the profession. It is injurious to the profession by multiplying poor, ill-paid, and ill-conditioned professional men.[48] Although each may be highly paid in comparison with the service rendered, the portions of service do not suffice for the maintenance of an officer without the aid of private practice; they only suffice, therefore, to sustain needy competitors for practice in narrow fields. Out of such competition the public derive no improvements in medical science, for science comes out of wide opportunities of knowledge and study, which are inconsistent with the study to make interests and the hunt for business in poor neighbourhoods.

A medical man who is restricted to the observation of only one establishment may be said to be excluded from an efficient knowledge even of that one. Medical men so restricted are generally found to possess an accurate knowledge of the morbid appearances, or of the effects amongst the people of the one establishment, but they are frequently found to be destitute of any knowledge of the pervading cause in which they are themselves enveloped, and have by familiarity lost the perception of it. Thus it was formerly in the navy that medical officers on board ship, amidst the causes of disease, the filth, and bad ventilation, and bad diet, were referring all the epidemic disease experienced exclusively to contagion from some one of the crew who was discovered to have been in a prison. We have seen that local reports present similar examples of similar conclusions from the observation of single establishments in towns, in which reports effects are attributed as essential to labour, of which effects that same labour is entirely divested in establishments in the county, or under other circumstances which the practitioners have had no means of observing and estimating. The various contradictory opinions on diet, and the older views on the innocuousness of miasma, are commonly referable to the circumstances under which the medical observers were placed; and examples abound in every district of the errors incidental to narrow ranges of observation in cases perplexed by idiosyncracies, and by numerous and varying antecedents. It should be understood by the public that the value of hospital and dispensary practice consists in the range of observation they give; and that the extent of observation or opportunities of medical knowledge are influenced or governed by administrative arrangements. In several of the medical schools of the metropolis, however, the opportunities of knowledge are dependent on the cases which may chance to arise there. Fortunate administrative arrangements have, in Paris, greatly advanced medical knowledge, by bringing large classes of cases under single observation. The most important discoveries made with respect to consumption, those made by M. Louis, were based on the results of the post-mortem examinations of nearly 1300 cases by that one practitioner. Nearly all the important conclusions deduced from this extensive range of observations were at variance with his own previous opinions and the opinions that had prevailed for centuries. The later and better knowledge of the real nature of fever cases has been obtained by a similar range of observation gained from the cases in fever hospitals. Applications have been several times made to the Commissioners by medical men engaged in particular researches to aid them in the removal of the impediments to extended inquiry, by collecting the information to be derived—from the sick-wards of the workhouses and the out-door medical relief lists.

The highest medical authorities would agree that, whatsoever administrative arrangements sustain narrow districts, and narrow practice, sustain at a great public expense, barriers against the extension of knowledge by which the public would benefit, and that any arrangements by which such districts or confined practice is newly created, will aggravate existing evils. An examination of the state of medical practice divided amongst poor practitioners in the thinly populated districts shows that, but for the examinations, imperfect though they be, as arrangements which sustain skill and respectability, a large part of the population would be in the hands of ignorant bone-setters.