The following Reports, officially addressed to the Commissioners of Sewers of the City of London, were originally printed only for the use of the Corporation; and although, to my very great pleasure, they have been extensively circulated through the medium of the daily press, there has continued so frequent an application for separate copies that the surplus-stock at Guildhall has long been exhausted. Under these circumstances—believing the Reports may have some future interest, as belonging to an important educational period in the matters to which they refer, I have requested the Commission to allow their collective reprint and publication; and this indulgence having been kindly accorded me, I have gathered into the present volume all my Annual Reports, together with a special Report suggesting arrangements for extramural burial.

From the nature of the work, I have not considered myself at liberty to make those extensive alterations of text which usually belong to a second edition. I have restricted myself to a few verbal corrections, and to rectifying or omitting some unimportant paragraph, here or there, in case its matter has been more fully or more correctly stated in parts of a subsequent Report. Frequently, where I have wished to explain or qualify passages in the text, I have added foot-notes; but these are distinguished as interpolations by the mark—J. S., 1854.

My Reports lay no claim to the merit of scientific discovery. Rather, they deal with things already notorious to Science; and, in writing them, my hopes have tended chiefly towards winning for such doctrines more general and more practical reception. It has seemed to me no unworthy object, that, confining myself often to almost indisputable topics—to truths bordering on truism, I should labour to make trite knowledge bear fruit in common application.

Nor in any degree do they profess to be cyclopÆdic in the subject of Preventive Medicine; for it is but a small part of this science that hitherto is recognised by the law; and that—so far as the metropolis is concerned, scarcely beyond the confines of the City. It would have been an idle sort of industry, to say much of places or of matters foreign to the jurisdiction of those whom I officially addressed.

In re-publishing documents which proclaim extreme sanitary evils, as affecting the City, I think it right to draw attention to the dates of the several Reports, and to state that for the last five years many of these evils have been undergoing progressive diminution, of late at a rapid and increasing rate; while, at their worst, they represented only what I fear must be considered the present average condition of our urban population.

This national prevalence of sanitary neglect is a very grievous fact; and though I pretend to no official concern in anything beyond the City boundaries, I cannot forego the present opportunity of saying a few words to bespeak for it the reader’s attention. I would beg any educated person to consider what are the conditions in which alone animal life can thrive; to learn, by personal inspection, how far these conditions are realised for the masses of our population; and to form for himself a conscientious judgment as to the need for great, if even almost revolutionary, reforms. Let any such person devote an hour to visiting some very poor neighbourhood in the metropolis, or in almost any of our large towns. Let him breathe its air, taste its water, eat its bread. Let him think of human life struggling there for years. Let him fancy what it would be to himself to live there, in that beastly degradation of stink, fed with such bread, drinking such water. Let him enter some house there at hazard, and—heeding where he treads, follow the guidance of his outraged nose, to the yard (if there be one) or the cellar. Let him talk to the inmates: let him hear what is thought of the bone-boiler next door, or the slaughter-house behind; what of the sewer-grating before the door; what of the Irish basket-makers upstairs—twelve in a room, who came in after the hopping, and got fever; what of the artisan’s dead body, stretched on his widow’s one bed, beside her living children.

Let him, if he have a heart for the duties of manhood and patriotism, gravely reflect whether such sickening evils, as an hour’s inquiry will have shown him, ought to be the habit of our labouring population: whether the Legislature, which his voice helps to constitute, is doing all that might be done to palliate these wrongs; whether it be not a jarring discord in the civilisation we boast—a worse than pagan savageness in the Christianity we profess, that such things continue, in the midst of us, scandalously neglected; and that the interests of human life, except against wilful violence, are almost uncared for by the law.

And let not the inquirer too easily admit what will be urged by less earnest persons as their pretext for inaction—that such evils are inalienable from poverty. Let him, in visiting those homes of our labouring population, inquire into the actual rent paid for them—dog-holes as they are; and studying the financial experience of Model Dormitories and Model Lodgings, let him reckon what that rent can purchase. He will soon have misgivings as to dirt being cheap in the market, and cleanliness unattainably expensive.

Yet what if it be so? Shift the title of the grievance—is the fact less insufferable? If there be citizens so destitute, that they can afford to live only where they must straightway die—renting the twentieth straw-heap in some lightless fever-bin, or squatting amid rotten soakage, or breathing from the cesspool and the sewer; so destitute that they can buy no water—that milk and bread must be impoverished to meet their means of purchase—that the drugs sold them for sickness must be rubbish or poison; surely no civilised community dare avert itself from the care of this abject orphanage. And—ruat coelum, let the principle be followed whithersoever it may lead, that Christian society leaves none of its children helpless. If such and such conditions of food or dwelling are absolutely inconsistent with healthy life, what more final test of pauperism can there be, or what clearer right to public succour, than that the subject’s pecuniary means fall short of providing him other conditions than those? It may be that competition has screwed down the rate of wages below what will purchase indispensable food and wholesome lodgment. Of this, as fact, I am no judge; but to its meaning, if fact, I can speak. All labour below that mark is masked pauperism. Whatever the employer saves is gained at the public expense. When, under such circumstances, the labourer or his wife or child spends an occasional month or two in the hospital, that some fever-infection may work itself out, or that the impending loss of an eye or a limb may be averted by animal[1] food; or when he gets various aid from his Board of Guardians, in all sorts of preventable illness, and eventually for the expenses of interment, it is the public that, too late for the man’s health or independence, pays the arrears of wage which should have hindered this suffering and sorrow.

Probably on no point of political economy is there more general concurrence of opinion, than against any legislative interference with the price of labour. But I would venture to submit, for the consideration of abler judges than myself, that before wages can safely be left to find their own level in the struggles of an unrestricted competition, the law should be rendered absolute and available in safeguards for the ignorant poor—first, against those deteriorations of staple food which enable the retailer to disguise starvation to his customers by apparent cheapenings of bulk; secondly, against those conditions of lodgment which are inconsistent with decency and health.

But if I have addressed myself to this objection, partly because—to the very limited extent in which it starts from a true premiss, it deserves reply; and partly because I wish emphatically to declare my conviction, that such evils as I denounce are not the more to be tolerated for their rising in unwilling Pauperism, rather than in willing Filth; yet I doubt whether poverty be so important an element in the case as some people imagine. And although I have referred especially to a poor neighbourhood—because here it is that knowledge and personal refinement will have least power to compensate for the insufficiencies of public law; yet I have no hesitation in saying that sanitary mismanagement spreads very appreciable evils high in the middle ranks of society; and from some of the consequences, so far as I am aware, no station can call itself exempt.

The fact is, as I have said, that, except against wilful violence, life is practically very little cared for by the law. Fragments of legislation there are, indeed, in all directions: enough to establish precedents—enough to testify some half-conscious possession of a principle; but, for usefulness, little beyond this. The statutes tell that now and then, there has reached to high places the wail of physical suffering. They tell that our law-makers, to the tether of a very scanty knowledge, have, not unwillingly, moved to the redress of some clamorous wrong. But—tested by any scientific standard of what should be the completeness of sanitary legislation; or tested by any personal endeavour to procure the legal correction of gross and glaring evils; their insufficiencies, I do not hesitate to say, constitute a national scandal, and, perhaps in respect of their consequences, something not far removed from a national sin.

In respect of houses—here and there, under local Acts of Parliament, exist sanitary powers, generally of a most defective kind; pretending often to enforce amendments of drainage and water-supply; sometimes to provide for the cleansing of filthy and unwholesome tenements; in a few cases to prevent over-crowding; very rarely to ensure stringent measures against houses certified to be unfit for human habitation. Occasionally—but a few lines would exhaust the list, an application of the Public Health Act, or some really efficient local Act, has put it within reach of the authorities to do all that is needful under certain of these heads. But I know of no such town that would bear strict examination as to its possession of legal powers to fulfil, what I presume must be the principle contemplated by the law—that no house should be let for hire unless presenting the conditions indispensable for health, or be hired for more occupants than it can decently and wholesomely accommodate.[2] However this may be expressed, and in whatever laws embodied, local or general, I will venture to say that no Government should suffer a town, either to be without the means of enforcing this principle, or, having such means, to shirk their exercise. Our Constitution may properly concede that local representative authorities shall have their option whether, for sanitary purposes, to fall under a general law, or to have Local Improvement Acts of their own; but, in the present state of knowledge, it certainly seems incontestable that one or other of these alternatives should be compulsory, and that all Local Improvement Acts should be required, in their sanitary clauses, to come up to the standard of the Public Health Act of the time, whatever it may be.

Under circumstances like those just adverted to, may be found traces of enactment against offensive and injurious trades. Unregulated slaughtering throughout all London, except the City, tallow-melting in St. Paul’s church-yard, bone-boiling beside Lambeth Palace, may serve to illustrate the completeness and efficiency of these laws—even in our metropolitan area. Here we greatly lack some competent authority, on the part of the Government, to investigate all circumstances connected with such establishments, generally; to suggest laws for their prospective restriction, as to places wherein they may lawfully settle; and to frame regulations—enforceable by any Local Board of Health, for ensuring that all available measures be employed to mitigate their nuisance. Considering the circumstances under which many of these establishments have existed, no one can entertain a thought, that—even for the public health, they should be liable to the tyranny of an unconditional displacement. But if there existed—as undoubtedly there should exist, some skilled tribunal, competent to speak on the subject; then, I will venture to say, it might be quite in accordance with our English sense of liberty, that—after a certain condemnatory verdict by this tribunal, it should be open to the Local Board of Health to procure their expulsion, on payment of whatever compensation an ordinary jury might award.

Again, with factories; thanks to Lord Shaftesbury’s indefatigable benevolence, the law has appointed an inspection of certain establishments, a restriction of their hours of labour, and some care against the dangers of unboxed machinery. And with mining also the law has interfered, chiefly as to the ventilation of mines; but hitherto so ineffectively that, while I write, the coal-miners are remonstrating with the Legislature on the thousand lives per annum still sacrificed through the insufficient protection accorded them. If there be meaning in this legislation—if it imply any principle, the meaning and the principle require to be developed into a general law, that every establishment employing labour be liable to inspection and regulation in regard of whatever acts and conditions are detrimental or hazardous to life. If factory-children are cared for, lest they be over-worked; and miners, lest they be stifled; so, for those who labour with copper, mercury, arsenic, and lead, let us care, lest they be poisoned! for grinders, lest their lungs be fretted into consumption! for match-makers, lest their jaws be rotted from them by phosphorus! And here let it again be noticed, as in the class of cases last spoken of, how greatly wanted is some skilled tribunal, to form part of any lawful machinery which might ensure that, in these and similar instances, no precautions necessary to life are withheld through ignorance or parsimony.

Against adulterations of food, here and there, obsolete powers exist, for our ancestors had an eye to these things; but, practically, they are of no avail. If we, who are educated, habitually submit to have copper in our preserves, red-lead in our cayenne, alum in our bread, pigments in our tea, and ineffable nastinesses in our fish-sauce, what can we expect of the poor? Can they use[3] galactometers? Can they test their pickles with ammonia? Can they discover the tricks by which bread is made dropsical[4], or otherwise deteriorated in value, even faster than they can cheapen it in price? Without entering on details of what might be the best organisation against such things, I may certainly assume it as greatly a desideratum, that local authorities should uniformly have power to deal with these frauds (as, of course, with every sale of decayed and corrupted food) and that they should be enabled to employ skilled officers, for detecting at least every adulteration of bread and every poisonous admixture in condiments and the like.

In some respects this sort of protection is even more necessary, as well as more deficient, in regard to the falsification of drugs. The College of Physicians and the Apothecaries’ Company are supposed to exercise supervision in the matter; so that at least its necessity is recognised by the law. The security thus afforded is, in practice, null. It is notorious in my profession that there are not many simple drugs, and still fewer compound preparations, on the standard strength of which we can reckon. It is notorious that some important medicines are so often falsified in the market, and others so often mis-made in the laboratory, that we are robbed of all certainty in their employment. Iodide of potassium—an invaluable specific, may be shammed to half its weight with the carbonate of potash. Scammony, one of our best purgatives, is rare without chalk or starch, weakening it, perhaps, to half the intention of the giver. Cod-liver oil may have come from seals or from olives. The two or three drops of prussic acid that we would give for a dose may be nearly twice as strong at one chemist’s as at another’s. The quantity of laudanum equivalent to a grain of opium being, theoretically, 19 minims; we may practically find this grain, it is said, in 4.5 minims, or in 34.5. And my colleague, Dr. R. D. Thomson, who has much experience in these matters, tells me that of calamine—not indeed an important agent, but still an article of our pharmacopoeia—purporting daily to be sold at every druggist’s shop, there has not for years, he believes, existed a specimen in the market.[5]

Again, with the promiscuous sale of poisons, what incredible laxity of government! One poison, indeed, has its one law. Arsenic may not be sold otherwise than coloured, nor except with full registration of the sale, and in the presence of a witness known to both buyer and vender. Admirable, so far as it goes! but why should arsenic alone receive this dab of legislation? Is the principle right, that means of murder and suicide should be rendered difficult of access for criminal purposes? Does any one question it? Then, why not legislate equally against all poisons?—against oxalic acid and opium, ergot and savin, prussic acid, corrosive sublimate, strychnine?

Nor can our past legislators be more boastful of their labours for the medical profession—either for its scientific interests, or for the public protection against ignorance and quackery.[6] Nearly two dozen corporate bodies within the United Kingdom are said to grant licences for medical practice; and I hardly know whether it lessens or aggravates this confusion, that such licences are in many cases partial; that one licentiate may practise north of the Tweed, but nowise to the south; that one may practise in London, another only seven miles beyond it. Not that the licence seems much to matter! for innumerable poachers in all directions trespass on what the law purports to sell as a secured preserve for qualified practitioners: their encroachments are made with almost certain impunity; and—as for the titles of the Profession, any impostor may style himself doctor or surgeon at his will. Even where licences are held, conveying identical titles, they imply neither equal privileges (as I have said) nor even uniform education. The law has troubled itself little as to the terms on which they shall be granted; and the qualifications exacted from candidates—the conditions preliminary to their becoming eligible for licence, vary in so remarkable a degree among the many corporate bodies which are fountains of this honour, that the credentials conferred have really little meaning, apart from a context which the public is unable to supply. It is charged against particular institutions, that their degrees and licences are attained with a very inglorious facility; and when it is recollected that the issuing of such testimonials is a source—sometimes a chief source—of income to the corporations which grant them, it will be felt that at least there must exist great danger of this reproach being sometimes deserved. If a national title to practise medicine is to be granted by several Boards, and if yet the tenure of that title is to determine public confidence in favour of its holder, it would seem indispensable that some guarantee should be given for these several licences representing equal qualifications—some guarantee that the holder in each case possesses professional knowledge, and has enjoyed professional opportunities, at least above some uniform standard recognised as a minimum qualification by all the diplomatising bodies. Indispensable, however, as this may seem, years of endeavour have failed to attain it. What is called medical reform has been agitated longer than I can remember; and more than one minister has been willing to legislate for its promotion. Unfortunately the very magnitude of the evils has delayed their cure. With the constitution I have described—a system of conflicting jurisdictions, of licences without titles, and titles without licences, how could we escape internal dissension? how escape the antagonism, perhaps the jealousies, of rival corporations and of different professional classes? Home-Secretaries have had little leisure to fathom these things to the bottom. Unexamined and unadjudicated by any competent authority, such influences have bewildered public judgment, made statesmen regard us with despair, postponed legislative correction, and maintained us in a state of anarchy and confusion, best to be appreciated when we compare with our own the organisation and government of the legal profession.

And be it noted, how this reacts upon the State. So completely is our government dissevered from Science in general, and, most of all, from the sciences relating to Life, that, on such subjects, there exists not for state-purposes anything like a tribunal of appeal. The Legislature recognises no Medical Authority. Occasionally this fact stands out in painful conspicuousness, and brings most injurious results. In contested cases requiring scientific testimony—before Parliamentary Committees, for instance, and in a variety of legal proceedings,—instead of the Court having satisfactory power of referring particular questions to skilled impartial adjudicators, the uniform practice is, that scientific men are retained on opposite sides, to support partisan interests. The advantages, such as they are, which belong to this system, might, I believe, easily be obtained under altered arrangements: the disadvantages are glaring. It might be invidious to refer to illustrations of their reality: but it is of course impossible to doubt of the working of this system, that, in so far as it makes each witness feel himself engaged to maintain the views of his employer, it tends towards a moral prostitution and subornation of science. In the interests of truth, it would surely seem desirable that scientific evidence should be tendered, so far as may be, in a judicial spirit towards the suit; either that the technical point should be referred to a technical jury, or that the technical witness should be summoned at the Court’s discretion, should be examined in-chief by the Court, and should be subject only to such cross-examination as may procure the most complete statement of his knowledge on the matter in hand.

Having said so much on the defects and the wrongs of our existing sanitary condition, perhaps I may venture to speak of the almost obvious remedy. ‘Almost obvious’ I say; for surely no one will doubt that this great subject should be dealt with by comprehensive and scientific legislation; and I hardly see how otherwise, than that it should be submitted in its entirety to some single department of the executive, as a sole charge; that there should be some tangible head, responsible—not only for the enforcement of existing laws, such as they are or may become, but likewise for their progress from time to time to the level of contemporary science, for their completion where fragmentary, for their harmonisation where discordant.

If—as is rumoured, the approaching re-constitution of the General Board of Health is (after the pattern of the Poor-law Board) to give it a Parliamentary President, that member of the Government ought to be open to challenge in respect of every matter relating to health. What, for this purpose, might be the best subordinate arrangements of such a Board, it would take a volume to discuss. But at least as regards its constituted head, sitting in Parliament, his department should be, in the widest sense, to care for the physical necessities of human life. Whether skilled coadjutors be appointed for him or not; engineers—lawyers—chemists—pathologists; whether he be, as it were, the foreman of this special jury, or, according to the more usual precedent of our public affairs, collect advice on his own responsibility, and speak without quotation of other authority than himself, his voice, unless the thing is to be a sham, must represent all these knowledges.

The people, through its representatives, must be able to arraign him wherever human life is insufficiently cared for.

He must be able to justify or to exterminate adulterations of food; to shew that alum ought to be in our loaves, or to banish it for ever; to shew that copper is wholesome for dessert, or to give us our olives and greengages without it; to shew that red-lead is an estimable condiment, or to divert it from our pepper-pots and curries.

Similarly with drugs and poisons—the alternatives of life and death—a minister of Public Health would, I presume, be responsible for whatever evils arise in their unlicensed and unregulated sale. He would hardly dare to acquiesce in our present defencelessness against fraud and ignorance; in doses being sold—critical doses, for the strength of which we, who prescribe them, cannot answer within a margin of cent. per cent.; or in pennyworths of poison being handed across the counter as nonchalantly as cakes of soap.[7] Surely, before he had been six months in office, he would have procured some enactment to remedy this long neglect of the legislature, by providing that the druggist’s trade be exercised only after some test of fitness, and in subjection to certain regulations.

Within his province, likewise, it would fall to be cognisant of all that relates to the constitution of the Medical Profession. The difficulties which have baffled successive Home-Secretaries might soon find their solution in the less divided attention which he could bring to their study. Amid conflicting opinions and an apparent scramble for power, he would soon distinguish where might be the strife of jealousy and covetousness, where a truthful zeal for the honour and efficiency of medicine. I think he could not be long in curing our more scandalous anomalies. Probably—unless human bowels require other doctoring in London than in Manchester, he would manage that a doctor there should be a doctor also here; that no licence for the partial practice of medicine should be recognised—no licence admitting a man to do in Edinburgh what it would be a misdemeanour for him to do in Greenwich. And obviously, in order to this—since a professional diploma is the only criterion by which the public can measure the competence of those who seek their patronage, he would see that, as far as may be, the various licensing bodies exact from their candidates equal and sufficient qualifications; that the diploma entitling a man to call himself Surgeon or Physician, Accoucheur or Apothecary, mean the same thing—imply the same education, whether it be got in Scotland, Ireland, or England; and that any falsification of such diploma, or any unauthorised assumption of the title which implies its possession, be promptly punishable at law.[8]

Into the hands of this new minister—advised, perhaps, for such purposes by some permanent commission[9] of skilled person, would devolve the guardianship of public health against combined commercial interests, or incompetent administration. He would provide securities for excluding sulphur from our gas, and animalcules from our water. He would come into relation with all Local Improvement Boards, in respect of the sanitary purposes of their existence. To him we should look, to settle at least for all practical purposes the polemics of drainage and water-supply; to form opinions which might guide Parliament, whether street sewers really require to be avenues for men, whether hard water really be good enough for all ordinary purposes, whether cisternage really be indispensable to an urban water-supply.

[9] There are many instances in my mind, some already adverted to, where the existence of a standing jury for scientific—especially for sanitary, purposes might be of great utility. It is an organisation which prevails extensively in France, under the name of Conseils de SalubritÉ; forming, in most of the large towns there, a constant board of reference for the municipality, in respect of sanitary regulations. Mutatis mutandis, it might become invaluable as an English institution, in respect of many matters touched upon in this sketch; and perhaps with some division of duties, into such as would best belong to a General Board of the kind, and such as might properly be vested in Local Boards. To determine the indispensable conditions of healthy lodgment; to examine the influence of trades and occupations, and to devise the regulations they may require, for the neighbourhood’s sake, or for their operatives’; to supervise the sale of food and drugs; to be cognisant of medical matters; would seem, either locally or generally, to require the co-operations of several skilled persons. But, though I have spoken of such, as indispensable jurors for these subjects, I do not forget that other interests than those of life may need to be consulted. For the fair representation of these, the lay faculty of educated common-sense will fulfil an inestimable usefulness, if it may be there to mediate between science, which is sometimes crotchety, and trade, which is sometimes selfish.