A ministry of health, and other addresses

Preface

Three of these addresses, published originally in the * Gentleman's Magazine,' having been often called for, are supplied in this volume, together with six others dealing with allied subjects.

The first address, on A Ministry of Health, was delivered before the Sanitary Institute of Great Britain, at the Stafford Congress of the Institute, in October last, and was intended to invite attention to one of the most pressing reforms of the day. The favour with which the address was received by almost all sections of the public press leads me to hope that the time is near when the legislative bodies will find the subject it discusses worthy of earnest consideration.

I have been much gratified by the kind notice vlii PREFACE.

that has been taken of the third address, entitled A Homily Clerico-Medical. This address, which was delivered in St Paul's Cathedral as one of the Trophy Room lectures of the Homiletical Society, and which was first published in the Clergymaiis Magazine, is an attempt to show the points of contact of two of the leading learned professions. The subject it broaches is also one for the future ; and if I have opened it ever so slightly for serious discussion the labour will be well rewarded.

The eighth address, on the Registration of Disease^ was delivered as far back as 1862, before the Social Science Association. It relates to a subject on which I had then been labouring for several years, at much cost and with little success. The time now seems opportune for getting the plan suggested in the essay carried out on a complete scale under central and Governmental direction. When this is done, and not until then, we shall begin to be sanitary reformers in deed as well as word, for we shall begin to study disease in its entirety, in its habitat, and in its season.

In the address on TJie World of Physic, which formed an inaugural to one of the Sessions of the

PREFACE. ix

St Andrews Graduates' Association, and in each of the other addresses, I have tried either to point a new suggestion that may be of practical service, or to bring into notice, in plain and simple language, some matter of information that has not as yet become knowledge in common.

12 HiNDE Street, W. : January i, 1879.

Contents

PAGE

I. A MINISTRY OF HEALTH I

II. WILLIAM HARVEY 3 1

I. A Ministry Of Health

T^ 7" HEN EVER the question of legislative procedure is brought forward in England, we have to consider in relation to it two distinct orders of mind, the centralizing and the self-governing. These orders of mind have no necessary reference to what is called party feeling. They are neither Whig, nor Tory, nor Radical. The designations of party are the mere designations of sets of men who are struggling to rule. The orders of mind, centralizing and self-governing, are the natural components of the national character, and exist in all the parties. To the foreigner this peculiarity of the English character is perplexing beyond measure. He can make nothing of it. One of the shrewdest of Frenchmen, who, during the rule of the Empire, lived in England, and who was a politician of the purest kind, — a politician by talent as well as by learning, — told me this was the difficulty of difficulties to under stand. He would adduce examples. " There is such and such a member of Parliament for a Radical borough ; a Radical of the deepest dye ; a Radical amongst Radicals, who lived in the days when that almost forgotten book, the * Radicals of Marylebone,' was written, and who might have written the book. That man is as great a centralizer as * Napoleon le petit ' himself. There is another member of Parliament for a Tory borough, who talks of nothing but the glory of the British constitution, and the horrors of the Radical programme. Yet he is in dead enmity to everything that partakes of absolute authority, local or general ; is opposed to every movement in the vestry of his parish that savours of improvement ; and would not let another Act of Parliament pass if he could possibly prevent it."

This was the tone in which my logical French friend spoke of us islanders ; and no doubt he spoke with perfect correctness of us, as we presented ourselves to him. We were peculiar and contradictory to him, if words could be trusted, in respect to our principles of political action. Principles of policy are not, in fact, the principles by which we are moved and by which we move.

The simple truth is, that the impulses which lead us to action are in our natures, and move us independently of our professions, which, being accidentally acquired, are always secondary influences. It is necessary, therefore, in thinking of legislation, not to think so much of party as of the primary motives of those who make up the nation, and of what the nation is likely to permit and is likely to put to the test of practice.

Computing by this test, there are, I think, very few thoughtful people who would try any legislation for England that had in it much of a centralizing disposition. If the mind of the nation could be fairly tested as to its desires, I should say that three out of four would prefer the self-governing to the central method in any measure that might be proposed, even though the measure had reference to the dearest of all interests, the first of all interests, — the health of the nation, in its individual and collective state. We have not, it is true, had much experience on this point ; for the genius of the nation, by which term I mean the special or particular tendency of the nation, has run counter to experiments that would lead to experience. But, whenever we have, in a small way, gained an experience from a political experiment in which central authority has been the source of pov/er, the result has, perhaps without an exception, been, at best, but partly successful. At this moment, in relation to sanitary work, there are in operation two measures eminently promising in regard to the good they are likely to effect for the health of the people : yet no two measures could be more intensely opposed — opposed not by Whigs, Tories, or Radicals specially, but by men who at the election booth vote entirely differently, and who represent the most conflicting party interests.

I make these observations as a preliminary to the subject proper of my present discourse. Amongst sanitarians there is now actively enkindled an enthusiasm which has never before been witnessed in any other country, and never before in this country. The health topic is the social topic of the hour, the leading subject of discourse through all society. In one of the most unsophisticated fishing villages of this kingdom, in a village on the outskirts of the kingdom, in a village where the people rarely see it necessary to go abroad to find mates for marriages and where they seem all to be one family, in a village in which of all others I should, by passing through it, have least expected to find the light of sanitary science, — in that remote and simple place there occurred recently a death, said to have been from typhoid fever. I, being in the village at the time as a tourist, heard, by accident, of this death from the postmistress, in whose house I found a friendly retreat during a heavy shower. In an almost automatic method I asked, as the fact reached me, what was the mode in which the houses of the place were drained. Judge my astonishment at hearing, in reply, from my informant, that the case in question could not be connected with drainage; that it was not a case of typhoid fever from special contagion conveyed by water ; that it was a case of fever after confinement, which had assumed a typhoid character ; that the water supply of the place had no communication whatever with the sewage ; that although such communication was now known to be commonly present when there was an epidemic of typhoid, the place I was now in, bad as it looked, was safe from an outbreak of typhoid fever from that cause ; but that she could not say so much for it if typhus should occur, since typhus was disposed to travel by the air and, if it did break out, would probably find a great many victims, the ventilation of the houses being very bad. Judge further my surprise at her conclusion, that the villagers, although they were not rich nor much educated, nor much in the way of the world, were quite aware of what was necessary to preserve the health of the community ; that they had no kind of superstitions, as their fathers and mothers had, about diseases being necessary evils and that nonsense ; and that if they could not build a model town, they could at all events go on improving what they had got.

Such homely facts as these show how the current of popular opinion goes at present on the subject of health, and affords, at one and the same time, a reason and an excuse for the zeal and enthusiasm of those who are in the first rank of the sanitary advance. To them the temper of the nation seems to be towards some design that shall transform projected measures for perfecting the health of the community into practical working measures, and that shall make men and women and children the sanitary salt of the earth, not by your leave and with your leave, but by subpoena and at your peril.

Against this conception I am anxious, before I proceed further, to raise my voice. Few men have been longer in the trained service of sanitary science than myself. Few men have followed more closely the development of that science. There is scarcely one large lecture-theatre in the kingdom in which I have not taught some sanitary lesson. There are few earnest sanitarians of the day with whom I have not held communication or exchange of knowledge and opinion. And, if from all these experiences I am able to form a judgment of any kind that is definite, it is, firstly, that nothing has so much forwarded the great progress we have witnessed during the past quarter of a century as the perfect freedom of action that has been permitted ; and secondly, that nothing more disastrous at this stage of our course, or possibly at any stage, could occur, than the interposition of a central authority that should attempt to enforce even the wisest of rules on the community by serving it with a subpoena to attend even to its health. Nor have we far to seek for the reasons of this. The reasons are simple because the problem of health is simple ; because so very little requires to be done to reach what is perfect ; and, because all that has to be done is so easy to be done, that to inflict on the most willing people any heavy yoke of authority would be the exercise of an unwarrantable and complicated instrument of force. When at this very time we, as practical sanitarians, look at the conditions of our houses and our towns, and at the social state of the masses of the people ; and, when from that picture we turn to the tables of mortality, our wonder is, not that we suffer so much, but that we are half so healthy as we are. With that wonder we take in at a glance an appreciation of the fact, that the extension of the most obvious and childish rules of self-preservation would accomplish almost everything that could be accomplished, and that what is demanded now, when the weight of superstition is removed, and every man feels that disease is a burthen he carries on his own shoulders, is education, with time to give it room to

8 J MINISTRY OF HEALTH.

turn in, and freedom to give to it readiness and facility of action.

These observations as to the development, past, present, and future, of the science of health may sound at first singular as a preface to an address which has for its promise the consideration of the duties that belong to an officer of the State who is to be called a Minister of Health. There is, however, nothing in what I have said that is opposed to the appointment of such an important officer of the State, while out of what I have referred to there is overwhelming argument to be found for his creation, at as early a date as is possible. My object in the preface has been to indicate at once that any officer placed in the central position to which attention is drawn, must be an authority, not a disciplinarian ; a judge and director, not a commanding officer ; a collator and teacher of all learning relating to health, not a dogmatic professor ; an interpreter of the laws which bear upon health, not an officer of justice enforcing them on the community. He should, in a word, be to the people what the judge is to the jury and to the officers of justice who bring up cases for judgment or carry out the verdict.

As with the judge, the Minister of Health would soon find there are sufficient numbers of laws for all purposes if they were only enforced under proper

A MJmSTRY OF HEALTH. 9

direction. For himself, instead of asking to be invested with special powers of a legal kind, it would rather be his duty to investigate the mode of action and value of the many laws which are at present in force ; to determine which are useful and practical, which useless and cumbersome ; and to advise the Government on the subject of a complete and revised code for sanitary administration, local and imperial.

A minister so constituted as to his duties and powers would come into office without prejudice. If he did not quite meet the views of the small minority who would crave for centralising powers as a part of his official functions, and who, in their zeal for the sanitary cause, would create a fatal impcrmm m imperiOy he would, as a central authority, meet their ideal of the necessity for his existence, and, in the end, would probably suit them better than if he were armed with powers which he might, in the exercise of his supreme mercy, inflict on themselves. To the members of the great majority, which I have called the self-governing, he would be acceptable without fear. They would listen to his direction calmly, because the power to act would rest with themselves ; and they would be more likely, from that very circumstance, to submit to his directions, and to act in accordance with his recommendations.

If it be asked what evidence there is that a public lo A 31INISTRY OF HEALTH.

officer, placed as I have indicated, would be of any effective service to the community, I answer that the most notable evidence of the kind that has ever been recorded is to be found in the career and work of the officer who, in the year 1838, was appointed under the name or title of the 'Registrar-General of Births, Deaths, and Marriages.' When, in another century, the history of English sanitation comes to be written, the historian will find in the returns of the Registrar- General the kernel of sanitary science in England during the past forty years. Each week the daily papers publish from those returns an abstract at which now all England glances, and on which all thoughtful England speculates, in relation to questions of health. By that record towns are put on their mettle to compete for the best health, in a manner which no mandate from a central government office, charged with power to enforce, could ever produce. By that record every sanitary improvement is tested and shown at its true value, so that the masses of the people are directly influenced by it. The Registrar-General is a judge, not a ruler. He merely puts the case, the jury rules ; and if, in many instances, its ruling may be poor and faulty, it is in the right direction, and, what is above all price of computation, it day by day improves.

These returns, moreover, do more than aftect the

A MINISTRY OF HEALTH. II

masses ; they affect a smaller and yet most influential class, the thinking part of the nation, the cerebral part, if I may so express myself. From these returns mortalities have been extracted, and causes of mortalities specially traced. From them the dark regions of disease in the land have been discovered, mapped out and demonstrated at a glance, as counties and towns are demonstrated. From them influences of seasons on diseases are made manifest. From them the relation of occupations to the duration of life of the occupied has been deduced. From them the relation of birth to death has been wrought out with a precision which Arbuthnot and Halley, with all their prescience, could hardly have dreamed of. I do not mean to claim for these returns that they are perfect. I do not mean to say that they explain all anomalies and all coincidences. I do not claim that the annual reports founded on them by their officers, — remarkable state documents as those are which bear the honoured name of William Farr, — are all that could be wished. But, taking the work of the Registrar-General's department for forty years, I do mean to say that it has no parallel ; that it has served a purpose of good far beyond all expectations of it ; that it is the finest piece of contemporary vital history that has ever been written ; and, that we, the representatives of health and science in this day.

could not have been the scholars of health we are, if those papers had not been our treasure trove.

The facts of one department are, it seems to me, the natural proofs of what in England, and it is no business of mine to speak for any other country, can be effected by official direction of intelligence. I am led thereby, as from a minor to a major consideration, to the study of the new office of a Ministry of Health.

Is there any requirement for such a Ministry ? will be the first question that comes forward. We have rapidly progressed as we have proceeded so far without such a Ministry, and we found, during the short time that we had a President and an acting Board of Health, no great satisfaction in that experiment. Why should we move at all into that which is new and problematical .''

The answer to this is, that we must move, because we cannot remain as we are. We have piled up such a number of sanitary valuables, we do not know how or where to lay our hands on them when we want them. We have a library without a librarian or a catalogue, I had almost said without a shelter. Until we get a house with an orderly department and an official direction, we can have no system in our work ; while day by day, with an increasing public intelligence, the work becomes harder and a systematized plan of it the more absolutely necessary.

At this time there are half-a-dozen IMinisters of Health, and half-a-dozen boards with a number of intelhgent men, some of the highest intelligence, acting practically as clerks, doing sanitary work which clerks could well do, and chafing under the infliction of labours which have no satisfactory end. The President of the Local Government Board is one of these ministers ; the Secretary of State for the Home Department is another ; the Registrar-General is a third ; the Chief Commissioner of Works is a fourth ; the Lord President of the Privy Council is a fifth ; and the President of the Board of Trade is a sixth. There is not one of these important State functionaries who has not something to consider bearing on the health of those whose interests he superintends ; while some of them have more sanitary details to consider than any other. I name these officials specially, leaving out of sight, but not out of mind, the heads of the Army and Navy Departments, the Postmaster-General, and the semi-governmental President of the Metropolitan Board of Works.

But with all this multiplication of officers connected with particular parts of the sanitary service, we have no one reliable Minister of Health. Not one to whom application can be made for immediate and

J distinct information ; not one from whom information is issued that is complete in its bearings; not one who is ready at any moment to furnish the Government of the day with the data by which it could come to a decision in the event of any great crisis affecting the health of the people ; not one to wdiom the people would pay an instant and a willing deference.

It is a Minister and Ministry able to carry out these duties that is now required, and to the creation of which our attention should be devoted.

Basis.

The basis of a Ministry of Health is already laid. I do not think there can be two opinions on the subject, that the basis lies with the office of the Registrar- General. That office, amended in name and in function, supplies all that is required as a nucleus. The work of estimating life and death which noAv goes on there is the true foundation of all our efforts. This work ought to remain as the foundation. It may admit of being improved and widened, and some think that it ought to be. I have nothing to say on that matter, except that, if all else were half as good and perfect, we should be in the way of rapid and safe progress.

It is by modification of, and additions to, this department, as it now exists, that the new official and governmcrital institution for which I plead should be established. The modifications and additions are not, after all, many; and they are, I believe, all practicable. They would introduce nothing actually new, but would bring together what is already extant. The department would be no longer for mere registration, but would include all that relates to health. Correctly re-named, it would be a Ministry of Health, or a State Department for Health. The shortest and at the same time the most distinctive title would be the Ministry of Health ; and in accordance with this the head of the department, instead of being called the Registrar-General, would be called the Minister of Health. There is a great deal in securing this title. It would give dignity to the office, and would fix the office in the minds of the people as an office which they understood and which they respected ; an office closely associated with all that is of most vital interest to them and to theirs.

Construction and Duties.

The construction and duties of the Ministry of Health would lead to several divisions of labour.

I. Registration. — In addition to the duty of collecting the registrations of births, deaths, and marriages, the Ministry of Health would collect the registrations of disease throughout the kingdom. A complete system of registration would be establ6 A MINISTRY OF HEALTH.

lished, and the returns supplied by it would include not only the diseases affecting human kind, but the diseases affecting animals and plants in every locality. By this means the leaders of public opinion and knowledge would every hour have at their command the facts of the state of health of the entire country. By a very 'simple arrangement and extension of the information that has been already collected by the geological survey, the local natural history of each district could be appended to the returns, so that the relations of disease to local conditions could shortly be known with precision, and philosophically discussed.

II. Aleteorology. — To the same Ministry the reports of meteorological conditions would be duly sent from all the observatories. In this manner the relations of meteorological states, embracing of course those pertaining to season and climate, would be connected with the prevailing health, and the connection between the two would be effectively and systematically traced out.

III. Coroners' Returns. — To the Ministry of Health would be entrusted the collection and arrangement of another set of returns, which, important as they are, are now practically lost. I mean the returns of the Coroners' courts. These documents are invaluable as signs of the moral and physical states of the people ;

A MINISTRY OF HEAITII, 17

for no complete estimate of the health of the nation and the causes of its prosperity or decadence can be supplied if the catalogues of deaths by violence, accident, and design, be left out of the record. Those who would correctly appreciate what is conveyed in this suggestion, should study the annual reports which the late Coroner for Central Middlesex, Dr. JLankester, so ably and laboriously compiled from his official experience.

IV. Medical Local Duties. — To the Ministry of Health would be referred all the work that is now carried out by the medical department under the control of the local Government Board. The duties of attending to vaccination throughout the kingdom, of reporting the outbreaks of epidemics, and of instituting inquiries into injurious trades by which life and health are imperilled, would be under the direction of the Health department. By this same character of direction the Health minister, through the heads or chiefs of his office, would come into communication with the medical officers of health, of which body of gentlemen he would rank as the official head, and the labours of which he would direct into systematic order for the common good, without at all interfering with the local authorities for whom specially the labours are conducted. Above all, the Minister of Health would collate the leading facts connected with the work of the various sanitary officers of the kingdom, and condense them, annually, into a form that would serve as a permanent history of the results of sanitary progress. To this end each local authority would send to him, at stated time, and always once annually, the report of its medical officer on the health of the whole district under its charge ; a report systematically arranged for ready reference, and for after-arrangement by the central department.

At this moment some hundreds, if not thousands, of the most valuable reports of different medical officers of Health are scattered about in a manner that renders them, as a whole, practically useless ; so that questions which they, if they had been systematically studied, could answer at once in the most certain manner, have to be answered and answered again and again, each time at the cost of new labour and more money. If it were for no other purpose than to bring into official and perfect organisation the labours of the Medical Officers of Health, the Ministry of Health is urgently wanted. It is due to these admirable officers themselves, not less than to the country, to have their works officially and authoritatively supervised and published.

V. Adulteration Rcpoi'ts. — The working of the Act that deals with the subject of adulteration, and that carries out public analyses, would of necessity be brought under the direction of the Ministry of Health. The same observations that apply to the medical officers of health hold good in respect to the public analysts. The reports of these gentlemen, — reports, in many instances, of the utmost value, — are scattered far and wide, and practically are useless, except for the local purpose they were originally intended to serve. Collected and systematically condensed, these reports would indicate, at regular intervals of time, the natural progress in the production of all articles of food and drink.

Moreover, the section of the Health office to which I now refer would be most useful to the nation in other important ways. It would take under its direction analyses of all kinds that are conducted for the common good. It would supervise the analyses of waters, and would be an authority to which the parliamentary committees might at any time refer for arbitration and advice in cases of difficult evidence. It might even, with advantage, be a centre of reference in cases of poisoning, when the evidence of the analysts or experts was doubtful or conflicting. In relation to these matters the Government of the day has sometimes had to appoint a temporary authority of its own, to which it could refer for skilled research and guidance. Under the plan I venture to suggest, every Government would at all times have at hand the authority which it can now only appoint for a special occasion, and on which the public has no natural dependence, because it may have no practical or particular knowledge of the attainments of the person or persons who have, for the moment, been appointed.

VI. Factory Supervisioft. — There is at present much confusion in the interworking of the Public Health Acts and the supervision of the factory hands under the Factory Acts. The factory medical inspectors, who know the duties of sanitary work in the great manufactories better than any other class of men, and whose functions are of longest date, are crippled in their efforts by the circumstance that their supervision is too limited. It is of such vital importance to the nation that the health of the great industrial population should be completely attended to, that, as it seems to me, all the sanitary supervision of the factory should be transferred, under proper regulations, to the factory surgeons. If this were done, the officers appointed under the new regulation would specially report to the Ministry of Health on the sanitation of the factories in the whole of the kingdom. I know of nothing that requires more serious consideration than this public question. It is at the present moment a critical question of the first order. The mortality incident to industrial pursuits is a drain on the national vital wealth which stands before emigration in importance, and is a source of silent disaffection which no one can comprehend who has not inquired into it with intelligence, and at some cost of labour. There are now nine hundred factory surgeons who know more about the vital state of the industries of England than all the legislators put together who have made up the legislative bodies of the present reign. But the work of these factory surgeons, as yet essentially local, or little more, is lost to the nation because there is no centre where the reports of it can be properly or effectively utilised.