Reports Relating to the Sanitary Condition of the City of London

by John Simon

[7] Without referring to what may be considered rare—the sale of poison for the purposes of intended homicide, I may remind the reader of the very dreadful facts collected by the Commissioners on Trades and Manufactures, as to the immense sales of opium in our principal manufacturing towns, for the purpose of quieting—and with the effect of killing, children, while their poor mothers are absent from home in their several occupations.

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

[8] This check at least seems indispensable, for the reason above given, that a professional diploma is the only criterion by which the public can measure professional competence; and for the validity of such a criterion, it therefore, I think, becomes the duty of a government, on behalf of the public, to provide. For anything beyond this (except in one particular case) the matter might take its natural course. No law can supersede a necessity for common sense in the subject; and medicine, I think, requires no protection. Let my neighbour, by all means, if he desire it, send for a green-grocer to reduce his dislocation or assuage his gout! and let him take the consequences of his folly, in a spoilt limb or in a hair’s breadth escape with his life. Only—let the green-grocer be punishable, if he seek this office under false pretences, calling himself by any title which implies a professional qualification. And, for what harm he may do—let him of course (as would, if necessary, the presidents of our colleges) be prepared to abide before judge and jury his trial for malpractice. But, in strict adhesion to the principle I have professed, that protection is wanted, not for the profession, but for the public, I would suggest one exception to what otherwise might be universal free-trade in medicine. I refer to the case of druggists; who, whenever the Legislature may awake to the necessity of regulating their trade, ought, I think, to be expressly prohibited from the treatment of disease. To an immense majority of our population—to all the under-educated classes, the druggist’s shop appears an emporium for medical skill, as well as for medical appliances. They probably have some vague overestimate of our art of healing, and think perhaps that the several bottles on the shelf correspond to the several ailments they can specifically cure. They ask for something “good for a dropsy,” or “good for a wasting,” or “good for a palpitation;” not knowing how much skill may be requisite to interpret the symptom; not knowing that, to our highest skill, there is no medicine thus indiscriminately, or even generally, “good.” At present almost universally, druggists, with no medical qualification, are tampering more or less with serious medical responsibilities; and the mischief thus occasioned—especially among the poorer classes, is a matter of notoriety, on which persons engaged in hospital practice would be competent and tolerably impartial witnesses. It is because this evil arises in the almost inevitable ignorance of those who chiefly suffer from it, that, in accordance with the principle above suggested, I think it deserves consideration from the Legislature.

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

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

Organisations against epidemic diseases—questions of quarantine—laws for vaccination, and the like, would obviously lie within his province; and thither, perhaps, also his colleagues might be glad to transfer many of those medical questions which now belong to other departments of the executive—the sanitary regulation of emigrant ships, the ventilation of mines, the medical inspection of factories and prisons, the insecurities of railway traffic, et hoc genus omne.

There is another subject respecting which I should reluctantly forego the present opportunity of saying something. To the philosopher, perhaps, any partial sanitary legislation—even for a metropolis, may seem of low importance, as compared with our commanding need that the general legislation of the country be imbued with deeper sympathies for life. Yet London is almost a nation in itself; and the good which might be effected by its sanitary regeneration would, even as example, be of universal influence. Now, at this moment, there seems a chance—such a chance as may not soon recur—for gaining a first step towards this consummation. The re-construction of the Metropolitan Commission of Sewers, on the principle of local representation, affords extraordinary facilities for providing London, at length, with an efficient sanitary government. For, while any administration for this purpose would require to be entrusted with very extensive and very stringent powers, it seems probable that such authority might by the public be willingly conceded to a body constituted, in great part, of persons representing local interests. The jurisdiction required would be substantially such as is already vested in the City Commissioners of Sewers, for the sanitary control of the city; the concession of which—because to a representative body—was never any matter of municipal dispute. In so vast a government as that of the metropolis, Local Boards of Health for its various sections would seem indispensable; it is presumed that these boards[10] would be represented in the general Commission; which, in conjunction with them, and including certain skilled assessors, might constitute a complete sanitary organisation, consultative and executive.

[10] It would seem premature to discuss what might be the best constitution of such Local Boards for the metropolis; but it will appear to the reader, on a moment’s reflection, that there would be no difficulty in finding materials for their organisation. If, according to suggestions lately ventilated, municipal institutions should be given to the parts of London hitherto without them; these new corporations would probably have sanitary functions allotted them, and might readily become Local Boards of Health under such a constitution as I have sketched. If, on the other hand, our present non-municipal system were to be continued, probably our several Boards of Guardians might seem specially proper to act as Local Boards of Health; first, as being elected representative bodies, already invested with certain authority of the kind—as, for instance, under the Nuisances Removal Act; secondly, because various of their officers would be almost indispensable parts of any sanitary machinery. Indeed, my experience of such matters suggests it to me as not unimportant, that, under any arrangement which may be made, the jurisdiction of Local Boards of Health should, at least in area, be conterminous with Poor Law Unions; so that those who administer sanitary affairs—affairs which are always chiefly relative to the poor—may, as far as possible, in their several districts, come into relation with single sets of Poor Law officers.

I have one word more to say about the Reports. They have been received by the public with such remarkable indulgence and favour, that I feel some anxiety lest I may seem to have plumed myself with other feathers than my own. Let me, therefore, at least in part, confess my debts.

Before my first enlistment in the service of public health, others had fought this great cause with rare courage and devotion; establishing its main principles in a manner to require no corroboration, and to admit little immediate increase. The true patriarchs of the cause in this country are the present working members of the General Board of Health. The constitution of my city appointment is quite independent of this Board; but I should be acting an unworthy part if I refrained from acknowledging, that, in innumerable instances, I have gathered most valuable knowledge from the Board’s official publications, and that, in personal intercourse with its members and officers, I have had abundant reason to be grateful for information invariably given with that frank kindness which belongs to brotherhood in science, and to sympathy for common objects.