Hygeia, a City of Health
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HYGEIA A CITY OF HEALTH
BENJAMIN WARD RICHARDSON M.D., F.R.S.
TO EDWIN CHADWICK, C.B.
MY DEAR MR. CHADWICK,
_I wrote this Address with the intention of dedicating it to you, as a simple but hearty acknowledgment by a sanitary student, himself well ripened in the work, of your pre-eminent position as the living leader of the sanitary reformation of this century.
The favour the Address has received indicates notably two facts: the advance of public opinion on the subject of public health, and the remarkable value and influence of your services as the sanitary statesman by whom that opinion has been so wisely formed and directed.
In this sense of my respect for you, and of my gratitude, pray accept this trifling recognition, and believe me to be,
Ever faithfully yours_,
The immediate success of this Address caused me to lay it aside for some months, to see if the favour with which it was received would remain. I am satisfied to find that the good fortune which originally attended the effort holds on, and that in publishing it now in a separate form I am acting in obedience to a generally expressed desire.
Since the delivery of the Address before the Health Department of the Social Science Congress, over which I had the honour to preside, at Brighton, in October last, every day has brought some new suggestion bearing on the subjects discussed, and the temptation has been great to add new matter, or even to recast the essay and bring it out as a more compendious work. On reflection I prefer to let it take its place in literature, in the first instance, in its original and simple dress.
12 HINDE STREET, W.: _August_ 18, 1876.
HYGEIA, A CITY OF HEALTH
We meet in this Assembly, a voluntary Parliament of men and women, to study together and to exchange knowledge and thought on works of every-day life and usefulness. Our object, to make the present existence better and happier; to inquire, in this particular section of our Congress:--What are the conditions which lead to the pain and penalty of disease; what the means for the removal of those conditions when they are discovered? What are the most ready and convincing methods of making known to the uninformed the facts: that many of the conditions are under our control; that neither mental serenity nor mental development can exist with an unhealthy animal organisation; that poverty is the shadow of disease, and wealth the shadow of health?
These objects relate to ourselves, to our own reliefs from suffering, to our own happiness, to our own riches. We have, I trust and believe, yet another object, one that relates not to ourselves, but to those who have yet to be; those to whom we may become known, but whom we can never know, who are the ourselves, unseen to ourselves, continuing our mission.
We are privileged more than any who have as yet lived on this planet in being able to foresee, and in some measure estimate, the results of our wealth of labour as it may be possibly extended over and through the unborn. A few scholars of the past, like him who, writing to the close of his mortal day, sang himself to his immortal rest with the '_Gloria in excelsis_,' a few scholars might foresee, even as that Baeda did, that their living actual work was but the beginning of their triumphant course through the ages,--the momentum. But the masses of the nations, crude and selfish, have had no such prescience, no such intent. 'Let us eat and drink, for to-morrow we die!' That has been the pass, if not the password, with them and theirs.
We, scholars of modern thought, have the broader, and therefore more solemn and obligatory knowledge, that however many to-morrows may come, and whatever fate they may bring, we never die; that, strictly speaking, no one yet who has lived has ever died; that for good or for evil our every change from potentiality into motion is carried on beyond our own apparent transitoriness; that we are the waves of the ocean of life, communicating motion to the expanse before us, and leaving the history we have made on the shore behind.
Thus we are led to feel this greater object: that to whatever extent we, by our exertions, confer benefits on those who live, we extend the advantage to those who have to live; that one good thought leading to practical useful action from one man or woman, may go to the virtue of thousands of generations; that one breath of health wafted by our breath may, in the aggregate of life saved by it, represent in its ultimate effect all the life that now is or has been.
At the close of a Parliamentary session, an uneventful leader of a section of Parliament banters his more eventful rival, and enlivening his criticism by a sneer at our Congress, challenges the contempt of his rival, as if to draw it forth in the same critical direction. Alas! it is too true that great congresses, like great men, and even like Parliaments, do live sometimes for many years and talk much, and seem to miss much and advance little; so that in what relates to the mere present it were wrong, possibly, to challenge the sally of the statesman who, from his own helpless height, looked down on our weakness. But inasmuch as no man knoweth the end of the spoken word, as that which is spoken to-day, earnestly and simply, may not reappear for years, and may then appear with force and quality of hidden virtue, there is reason for our uniting together beyond the proof of necessity which is given in the fact of our existence. Perchance some day our natural learning, gathered in our varied walks of life, and submitted in open council, may survive even Parliamentary strife; perchance our resolutions, though no sign-manual immediately grace them, are the informal bills which ministers and oppositions shall one day discuss, Parliaments pass, royal hands sign, and the fixed administrators of the will of the nation duly administer.
These thoughts on the future, rather than on the passing influence of our congressional work, have led me to the simple design of the address which, as President of this Section, I venture to submit to you to-day. It is my object to put forward a theoretical outline of a community so circumstanced and so maintained by the exercise of its own freewill, guided by scientific knowledge, that in it the perfection of sanitary results will be approached, if not actually realised, in the co-existence of the lowest possible general mortality with the highest possible individual longevity. I shall try to show a working community in which death,--if I may apply so common and expressive a phrase on so solemn a subject,--is kept as nearly as possible in its proper or natural place in the scheme of life.
HEALTH AND CIVILISATION.
Before I proceed to this task, it is right I should ask of the past what hope there is of any such advancement of human progress. For, as my Lord of Verulam quaintly teaches, 'the past ever deserves that men should stand upon it for awhile to see which way they should go, but when they have made up their minds they should hesitate no longer, but proceed with cheerfulness,' For a moment, then, we will stand on the past.
From this vantage-ground we gather the fact, that onward with the simple progress of true civilisation the value of life has increased. Ere yet the words 'Sanitary Science' had been written; ere yet the heralds of that science (some of whom, in the persons of our illustrious colleagues, Edwin Chadwick and William Fair, are with us in this place at this moment), ere yet these heralds had summoned the world to answer for its profligacy of life, the health and strength of mankind was undergoing improvement. One or two striking facts must be sufficient in the brief space at my disposal to demonstrate this truth. In England, from 1790 to 1810, Heberden calculated that the general mortality diminished one-fourth. In France, during the same period, the same favourable returns were made. The deaths in France, Berard calculated, were 1 in 30 in the year 1780, and during the eight years, from 1817 to 1828, 1 in 40, or a fourth less. In 1780, out of 100 new-born infants, in France, 50 died in the two first years; in the later period, extending from the time of the census that was taken in 1817 to 1827, only 38 of the same age died, an augmentation of infant life equal to 25 per cent. In 1780 as many as 55 per cent. died before reaching the age of ten years; in the later period 43, or about a fifth less. In 1780 only 21 persons per cent. attained the age of 50 years; in the later period 32, or eleven more, reached that term. In 1780 but 15 persons per cent, arrived at 60 years; in the later period 24 arrived at that age.
Side by side with these facts of the statist we detect other facts which show that in the progress of civilisation the actual organic strength and build of the man and woman increases. As in the highest developments of the fine arts the sculptor and painter place before us the finest imaginative types of strength, grace, and beauty, so the silent artist, civilisation, approaches nearer and nearer to perfection, and by evolution of form and mind developes what is practically a new order of physical and mental build. Peron,--who first used, if he did not invent, the little instrument, the dynamometer, or muscular-strength measurer,--subjected persons of different stages of civilisation to the test of his gauge, and discovered that the strength of the limbs of the natives of Van Diemen's Land and New Holland was as 50 degrees of power, while that of the Frenchmen was 69, and of the Englishmen 71. The same order of facts are maintained in respect to the size of body. The stalwart Englishman of to-day can neither get into the armour nor be placed in the sarcophagus of those sons of men who were accounted the heroes of the infantile life of the human world.
We discover, moreover, from our view of the past, that the developments of tenacity of life and of vital power have been comparatively rapid in their course when they have once commenced. There is nothing discoverable to us that would lead to the conception of a human civilisation extending back over two hundred generations; and when in these generations we survey the actual effect of civilisation, so fragmentary and overshadowed by persistent barbarism, in influencing disease and mortality, we are reduced to the observation of at most twelve generations, including our own, engaged, indirectly or directly, in the work of sanitary progress. During this comparatively brief period, the labour of which, until within a century, has had no systematic direction, the changes for good that have been effected are amongst the most startling of historical facts. Pestilences which decimated populations, and which, like the great plague of London, destroyed 7,165 people in a single week, have lost their virulency; gaol fever has disappeared, and our gaols, once each a plague-spot, have become, by a strange perversion of civilisation, the health spots of, at least, one kingdom. The term, Black Death, is heard no more; and ague, from which the London physician once made a fortune, is now a rare tax even on the skill of the hardworked Union Medical Officer.
From the study of the past we are warranted, then, in assuming that civilisation, unaided by special scientific knowledge, reduces disease and lessens mortality, and that the hope of doing still more by systematic scientific art is fully justified.
I might hereupon proceed to my project straightway. I perceive, however, that it may be urged, that as mere civilising influences can of themselves effect so much, they might safely be left to themselves to complete, through the necessity of their demands, the whole sanitary code. If this were so, a formula for a city of health were practically useless. The city would come without the special call for it.
I think it probable the city would come in the manner described, but how long it would be coming is hard to say, for whatever great results have followed civilisation, the most that has occurred has been an unexpected, unexplained, and therefore uncertain arrest of the spread of the grand physical scourges of mankind. The phenomena have been suppressed, but the root of not one of them has been touched. Still in our midst are thousands of enfeebled human organisms which only are comparable with the savage. Still are left amongst us the bases of all the diseases that, up to the present hour, have afflicted humanity.
The existing calendar of diseases, studied in connection with the classical history of the diseases written for us by the longest unbroken line of authorities in the world of letters, shows, in unmistakable language, that the imposition of every known malady of man is coeval with every phase of his recorded life on the planet. No malady, once originated, has ever actually died out; many remain as potent as ever. That wasting fatal scourge, pulmonary consumption, is the same in character as when Coelius Aurelianus gave it description. The cancer of to-day is the cancer known to Paulus Eginæta. The Black Death, though its name is gone, lingers in malignant typhus. The great plague of Athens is the modern great plague of England, scarlet fever. The dancing mania of the Middle Ages and the convulsionary epidemic of Montmartre, subdued in their violence, are still to be seen in some American communities, and even at this hour in the New Forest of England. Small-pox, when the blessed protection of vaccination is withdrawn, is the same virulent destroyer as it was when the Arabian Rhazes defined it. Ague lurks yet in our own island, and, albeit the physician is not enriched by it, is in no symptom changed from the ague that Celsus knew so well. Cholera, in its modern representation is more terrible a malady than its ancient type, in so far as we have knowledge of it from ancient learning. And that fearful scourge, the great plague of Constantinople, the plague of hallucination and convulsion which raged in the Fifth Century of our era, has in our time, under the new names of tetanoid fever and cerebro-spinal meningitis, been met with here and in France, and in Massachusetts has, in the year 1873, laid 747 victims in the dust.
I must cease these illustrations, though I could extend them fairly over the whole chapter of disease, past and present. Suffice it if I have proved the general propositions, that disease is now as it was in the beginning, except that in some examples of it it is less virulent; that the science for extinguishing any one disease has yet to be learned; that, as the bases of disease exist, untouched by civilisation, so the danger of disease is ever imminent, unless we specially provide against it; that the development of disease may occur with original virulence and fatality, and may at any moment be made active under accidental or systematic ignorance.
A CITY OF HEALTH.
I now come to the design I have in hand. Mr. Chadwick has many times told us that he could build a city that would give any stated mortality, from fifty, or any number more, to five, or perhaps some number less, in the thousand annually. I believe Mr. Chadwick to be correct to the letter in this statement, and for that reason I have projected a city that shall show the lowest mortality. I need not say that no such city exists, and you must pardon me for drawing upon your imaginations as I describe it. Depicting nothing whatever but what is at this present moment easily possible, I shall strive to bring into ready and agreeable view a community not abundantly favoured by natural resources, which, under the direction of the scientific knowledge acquired in the past two generations, has attained a vitality not perfectly natural, but approaching to that standard. In an artistic sense it would have been better to have chosen a small town or large village than a city for my description; but as the great mortality of States is resident in cities, it is practically better to take the larger and less favoured community. If cities could be transformed, the rest would follow.
Our city, which may be named _Hygeia_, has the advantage of being a new foundation, but it is so built that existing cities might be largely modelled upon it.
The population of the city may be placed at 100,000, living in 20,000 houses, built on 4,000 acres of land,--an average of 25 persons to an acre. This may be considered a large population for the space occupied, but, since the effect of density on vitality tells only determinately when it reaches a certain extreme degree, as in Liverpool and Glasgow, the estimate may be ventured.
The safety of the population of the city is provided for against density by the character of the houses, which ensures an equal distribution of the population. Tall houses overshadowing the streets, and creating necessity for one entrance to several tenements, are nowhere permitted. In streets devoted to business, where the tradespeople require a place of mart or shop, the houses are four stories high, and in some of the western streets where the houses are separate, three and four storied buildings are erected; but on the whole it is found bad to exceed this range, and as each story is limited to 15 feet, no house is higher than 60 feet.
The substratum of the city is of two kinds. At its northern and highest part, there is clay; at its southern and south-eastern, gravel. Whatever disadvantages might spring in other places from a retention of water on a clay soil, is here met by the plan that is universally followed, of building every house on arches of solid brickwork. So, where in other towns there are areas, and kitchens, and servants' offices, there are here subways through which the air flows freely, and down the inclines of which all currents of water are carried away.
The acreage of our model city allows room for three wide main streets or boulevards, which run from east to west, and which are the main thoroughfares. Beneath each of these is a railway along which the heavy traffic of the city is carried on. The streets from north to south which cross the main thoroughfares at right angles, and the minor streets which run parallel, are all wide, and, owing to the lowness of the houses, are thoroughly ventilated, and in the day are filled with sunlight. They are planted on each side of the pathways with trees, and in many places with shrubs and evergreens. All the interspaces between the backs of houses are gardens. The churches, hospitals, theatres, banks, lecture-rooms, and other public buildings, as well as some private buildings such as warehouses and stables, stand alone, forming parts of streets, and occupying the position of several houses. They are surrounded with garden space, and add not only to the beauty but to the healthiness of the city. The large houses of the wealthy are situated in a similar manner.
The streets of the city are paved throughout with the same material. As yet wood pavement set in asphalte has been found the best. It is noiseless, cleanly, and durable. Tramways are nowhere permitted, the system of underground railways being found amply sufficient for all purposes. The side pavements, which are everywhere ten feet wide, are of white or light grey stone. They have a slight incline towards the streets, and the streets have an incline from their centres towards the margins of the pavements.
From the circumstance that the houses of our model city are based on subways, there is no difficulty whatever in cleansing the streets, no more difficulty than is experienced in Paris. That disgrace to our modern civilisation, the mud cart, is not known, and even the necessity for Mr. E.H. Bayley's roadway moveable tanks for mud sweepings,--so much wanted in London and other towns similarly built,--does not exist. The accumulation of mud and dirt in the streets is washed away every day through side openings into the subways, and is conveyed, with the sewage, to a destination apart from the city. Thus the streets everywhere are dry and clean, free alike of holes and open drains. Gutter children are an impossibility in a place where there are no gutters for their innocent delectation. Instead of the gutter, the poorest child has the garden; for the foul sight and smell of unwholesome garbage, he has flowers and green sward.
It will be seen, from what has been already told, that in this our model city there are no underground cellars, kitchens, or other caves, which, worse than those ancient British caves that Nottingham still can show the antiquarian as the once fastnesses of her savage children, are even now the loathsome residences of many millions of our domestic and industrial classes. There is not permitted to be one room underground. The living part of every house begins on the level of the street. The houses are built of a brick which has the following sanitary advantages:--It is glazed, and quite impermeable to water, so that during wet seasons the walls of the houses are not saturated with tons of water, as is the case with so many of our present residences. The bricks are perforated transversely, and at the end of each there is a wedge opening, into which no mortar is inserted, and by which all the openings are allowed to communicate with each other. The walls are in this manner honeycombed, so that there is in them a constant body of common air let in by side openings in the outer wall, which air can be changed at pleasure, and, if required, can be heated from the firegrates of the house. The bricks intended for the inside walls of the house, those which form the walls of the rooms, are glazed in different colours, according to the taste of the owner, and are laid so neatly, that the after adornment of the walls is considered unnecessary, and, indeed, objectionable. By this means those most unhealthy parts of household accommodation, layers of mouldy paste and size, layers of poisonous paper, or layers of absorbing colour stuff or distemper, are entirely done away with. The walls of the rooms can be made clean at any time by the simple use of water, and the ceilings, which are turned in light arches of thinner brick, or tile, coloured to match the wall, are open to the same cleansing process. The colour selected for the inner brickwork is grey, as a rule, that being most agreeable to the sense of sight; but various tastes prevail, and art so much ministers to taste, that, in the houses of the wealthy, delightful patterns of work of Pompeian elegance are soon introduced.
As with the bricks, so with the mortar and the wood employed in building, they are rendered, as far as possible, free of moisture. Sea sand containing salt, and wood that has been saturated with sea water, two common commodities in badly built houses, find no place in our modern city.
The most radical changes in the houses of our city are in the chimneys, the roofs, the kitchens, and their adjoining offices. The chimneys, arranged after the manner proposed by Mr. Spencer Wells, are all connected with central shafts, into which the smoke is drawn, and, after being passed through a gas furnace to destroy the free carbon, is discharged colourless into the open air. The city, therefore, at the expense of a small smoke rate, is free of raised chimneys and of the intolerable nuisance of smoke. The roofs of the houses are but slightly arched, and are indeed all but flat. They are covered either with asphalte, which experience, out of our supposed city, has proved to last long and to be easily repaired, or with flat tile. The roofs, barricaded round with iron palisades, tastefully painted, make excellent outdoor grounds for every house. In some instances flowers are cultivated on them.
The housewife must not be shocked when she hears that the kitchens of our model city, and all the kitchen offices, are immediately beneath these garden roofs; are, in fact, in the upper floor of the house instead of the lower. In every point of view, sanitary and economical, this arrangement succeeds admirably. The kitchen is lighted to perfection, so that all uncleanliness is at once detected. The smell which arises from cooking is never disseminated through the rooms of the house. In conveying the cooked food from the kitchen, in houses where there is no lift, the heavy weighted dishes have to be conveyed down, the emptied and lighter dishes upstairs. The hot water from the kitchen boiler is distributed easily by conducting pipes into the lower rooms, so that in every room and bedroom hot and cold water can at all times be obtained for washing or cleaning purposes; and as on every floor there is a sink for receiving waste water, the carrying of heavy pails from floor to floor is not required. The scullery, which is by the side of the kitchen, is provided with a copper and all the appliances for laundry work; and when the laundry work is done at home the open place on the roof above makes an excellent drying ground.
In the wall of the scullery is the upper opening to the dust-bin shaft. This shaft, open to the air from the roof, extends to the bin under the basement of the house. A sliding door in the wall opens into the shaft to receive the dust, and this plan is carried out on every floor. The coal-bin is off the scullery, and is ventilated into the air through a separate shaft, which also passes through the roof.
On the landing in the second or middle stories of the three-storied houses there is a bathroom, supplied with hot and cold water from the kitchen above. The floor of the kitchen and of all the upper stories is slightly raised in the centre, and is of smooth, grey tile; the floor of the bath-room is the same. In the living-rooms, where the floors are of wood, a true oak margin of floor extends two feet around each room. Over this no carpet is ever laid. It is kept bright and clean by the old-fashioned bees'-wax and turpentine, and the air is made fresh and is ozonised by the process.
Considering that a third part of the life of man is, or should be, spent in sleep, great care is taken with the bed-rooms, so that they shall be thoroughly lighted, roomy, and ventilated. Twelve hundred cubic feet of space is allowed for each sleeper, and from the sleeping apartments all unnecessary articles of furniture and of dress are rigorously excluded. Old clothes, old shoes, and other offensive articles of the same order, are never permitted to have residence there. In most instances the rooms on the first floor are made the bed-rooms, and the lower the living-rooms. In the larger houses bed-rooms are carried out in the upper floor for the use of the domestics.
To facilitate communication between the kitchen and the entrance-hall, so that articles of food, fuel, and the like may be carried up, a shaft runs in the partition between two houses, and carries a basket lift in all houses that are above two stories high. Every heavy thing to and from the kitchen is thus carried up and down from floor to floor and from the top to the basement, and much unnecessary labour is thereby saved. In the two-storied houses the lift is unnecessary. A flight of outer steps leads to the upper or kitchen floor.
The warming and ventilation of the houses is carried out by a common and simple plan. The cheerfulness of the fireside is not sacrificed; there is still the open grate in every room, but at the back of the firestove there is an air-box or case which, distinct from the chimney, communicates by an opening with the outer air, and by another opening with the room. When the fire in the room heats the iron receptacle, fresh air is brought in from without, and is diffused into the room at the upper part on a plan similar to that devised by Captain Galton.
As each house is complete within itself in all its arrangements, those disfigurements called back premises are not required. There is a wide space consequently between the back fronts of all houses, which space is, in every instance, turned into a garden square, kept in neat order, ornamented with flowers and trees, and furnished with playgrounds for children, young and old.
The houses being built on arched subways, great convenience exists for conveying sewage from, and for conducting water and gas into, the different domiciles. All pipes are conveyed along the subways, and enter each house from beneath. Thus the mains of the water pipe and the mains of the gas are within instant control on the first floor of the building, and a leakage from either can be immediately prevented. The officers who supply the commodities of gas and water have admission to the subways, and find it most easy and economical to keep all that is under their charge in perfect repair. The sewers of the houses run along the floors of the subways, and are built in brick. They empty into three cross main sewers. They are trapped for each house, and as the water supply is continuous, they are kept well flushed. In addition to the house flushings there are special openings into the sewers by which, at any time, under the direction of the sanitary officer, an independent flushing can be carried out. The sewers are ventilated into tall shafts from the mains by means of a pneumatic engine.
The water-closets in the houses are situated on the middle and basement floors. The continuous water-supply flushes them without danger of charging the drinking water with gases emanating from the closet; a danger so imminent in the present method of cisterns, which supply drinking as well as flushing water.
As we walk the streets of our model city, we notice an absence of places for the public sale of spirituous liquors. Whether this be a voluntary purgation in goodly imitation of the National Temperance League, the effect of Sir Wilfrid Lawson's Permissive Bill and most permissive wit and wisdom, or the work of the Good Templars, we need not stay to inquire. We look at the fact only. To this city, as to the town of St. Johnsbury, in Vermont, which Mr. Hepworth Dixon has so graphically described, we may apply the description Mr. Dixon has written: 'No bar, no dram shop, no saloon defiles the place. Nor is there a single gaming hell or house of ill-repute.' Through all the workshops into which we pass, in whatever labour the men or women may be occupied,--and the place is noted for its manufacturing industry,--at whatever degree of heat or cold, strong drink is unknown. Practically, we are in a total abstainers' town, and a man seen intoxicated would be so avoided by the whole community, he would have no peace to remain.
And, as smoking and drinking go largely together, as the two practices were, indeed, original exchanges of social degradations between the civilised man and the savage, the savage getting very much the worst of the bargain, so the practices largely disappear together. Pipe and glass, cigar and sherry-cobbler, like the Siamese twins, who could only live connected, have both died out in our model city. Tobacco, by far the most innocent partner of the firm, lived, as it perhaps deserved to do, a little the longest; but it passed away, and the tobacconist's counter, like the dram counter, has disappeared.
The streets of our city, though sufficiently filled with busy people, are comparatively silent. The subways relieve the heavy traffic, and the factories are all at short distances from the town, except those in which the work that is carried on is silent and free from nuisance. This brings me to speak of some of the public buildings which have relation to our present studies.
It has been found in our towns, generally, that men and women who are engaged in industrial callings, such as tailoring, shoe-making, dressmaking, lace-work and the like, work at their own homes amongst their children. That this is a common cause of disease is well understood. I have myself seen the half-made riding-habit that was ultimately to clothe some wealthy damsel rejoicing in her morning ride act as the coverlet of a poor tailor's child stricken with malignant scarlet fever. These things must be, in the ordinary course of events under our present bad sanitary system. In the model city we have in our mind's eye, these dangers are met by the simple provision of workmen's offices or workrooms. In convenient parts of the town there are blocks of buildings, designed mainly after the manner of the houses, in which each workman can have a work-room on payment of a moderate sum per week. Here he may work as many hours as he pleases, but he may not transform the room into a home. Each block is under the charge of a superintendent, and also under the observation of the sanitary authorities. The family is thus separated from the work, and the working man is secured the same advantages as the lawyer, the merchant, the banker now possesses: or to make the parallel more correct, he has the same advantage as the man or woman who works in a factory, and goes home to eat and to sleep.
In most towns throughout the kingdom the laundry system is dangerous in the extreme. For anything the healthy householder knows, the clothes he and his children wear have been mixed before, during, and after the process of washing, with the clothes that have come from the bed or the body of some sufferer from a contagious malady. Some of the most fatal outbreaks of disease I have met with have been communicated in this manner. In our model community this danger is entirely avoided by the establishment of public laundries, under municipal direction. No person is obliged to send any article of clothing to be washed at the public laundry; but if he does not send there he must have the washing done at home. Private laundries that do not come under the inspection of the sanitary officer are absolutely forbidden. It is incumbent on all who send clothes to the public laundry from an infected house to state the fact. The clothes thus received are passed for special cleansing into the disinfecting rooms. They are specially washed, dried and prepared for future wear. The laundries are placed in convenient positions, a little outside the town; they have extensive drying grounds, and, practically, they are worked so economically, that homewashing days, those invaders of domestic comfort and health, are abolished.
Passing along the main streets of the city we see in twenty places, equally distant, a separate building surrounded by its own grounds,--a model hospital for the sick. To make these institutions the best of their kind, no expense is spared. Several elements contribute to their success. They are small, and are readily removable. The old idea of warehousing diseases on the largest possible scale, and of making it the boast of an institution that it contains so many hundred beds, is abandoned here. The old idea of building an institution so that it shall stand for centuries, like a Norman castle, but, unlike the castle, still retain its original character as a shelter for the afflicted, is abandoned here. The still more absurd idea of building hospitals for the treatment of special organs of the body, as if the different organs could walk out of the body and present themselves for treatment, is also abandoned.
It will repay us a minute of time to look at one of these model hospitals. One is the _fac simile_ of the other, and is devoted to the service of every five thousand of the population. Like every building in the place, it is erected on a subway. There is a wide central entrance, to which there is no ascent, and into which a carriage, cab, or ambulance can drive direct. On each side the gateway are the houses of the resident medical officer and of the matron. Passing down the centre, which is lofty and covered in with glass, we arrive at two sidewings running right and left from the centre, and forming cross-corridors. These are the wards: twelve on one hand for male, twelve on the other for female patients. The cross-corridors are twelve feet wide and twenty feet high, and are roofed with glass; The corridor on each side is a framework of walls of glazed brick, arched over head, and divided into six segments. In each segment is a separate, light, elegant removable ward, constructed of glass and iron, twelve feet high, fourteen feet long, and ten feet wide. The cubic capacity of each ward is 1,680 feet. Every patient who is ill enough to require constant attendance has one of these wards entirely to himself, so that the injurious influences on the sick, which are created by mixing up, in one large room, the living and the dying; those who could sleep, were they at rest, with those who cannot sleep, because they are racked with pain; those who are too nervous or sensitive to move, or cough, or speak, lest they should disturb others; and those who do whatever pleases them:--these bad influences are absent.
The wards are fitted up neatly and elegantly. At one end they open into the corridor, at the other towards a verandah which leads to a garden. In bright weather those sick persons, who are even confined to bed, can, under the direction of the doctor, be wheeled in their beds out into the gardens without leaving the level floor. The wards are warmed by a current of air made to circulate through them by the action of a steam-engine, with which every hospital is supplied, and which performs such a number of useful purposes, that the wonder is, how hospital management could go on without the engine.
If at any time a ward becomes infectious, it is removed from its position and is replaced by a new ward. It is then taken to pieces, disinfected, and laid by ready to replace another that may require temporary ejection.
The hospital is supplied on each side with ordinary baths, hot-air baths, vapour baths, and saline baths.
A day sitting-room is attached to each wing, and every reasonable method is taken for engaging the minds of the sick in agreeable and harmless pastimes.
Two trained nurses attend to each corridor, and connected with the hospital is a school for nurses, under the direction of the medical superintendent and the matron. From this school, nurses are provided for the town; they are not merely efficient for any duty in the vocation in which they are always engaged, either within the hospital or out of it, but from the care with which they attend to their own personal cleanliness, and the plan they pursue of changing every garment on leaving an infectious case, they fail to be the bearers of any communicable disease. To one hospital four medical officers are appointed, each of whom, therefore, has six resident patients under his care. The officers are called simply medical officers, the distinction, now altogether obsolete, between physicians and surgeons being discarded.
The hospital is brought, by an electrical wire, into communication with all the fire-stations, factories, mills, theatres, and other important public places. It has an ambulance always ready to be sent out to bring any injured persons to the institution. The ambulance drives straight into the hospital, where a bed of the same height on silent wheels, so that it can be moved without vibration into a ward, receives the patient.
The kitchens, laundries, and laboratories are in a separate block at the back of the institution, but are connected with it by the central corridor. The kitchen and laundries are at the top of this building, the laboratories below. The disinfecting-room is close to the engine-room, and superheated steam, which the engine supplies, is used for disinfection.
The out-patient department, which is apart from the body of the hospital, resembles that of the Queen's Hospital, Birmingham,--the first out-patient department, as far as I am aware, that ever deserved to be seen by a generous public. The patients waiting for advice are seated in a large hall, warmed at all seasons to a proper heat, lighted from the top through a glass roof, and perfectly ventilated. The infectious cases are separated carefully from the rest. The consulting rooms of the medical staff are comfortably fitted, the dispensary is thoroughly officered, and the order that prevails is so effective that a sick person, who is punctual to time, has never to wait.
The medical officers attached to the hospital in our model city are allowed to hold but one appointment at the same time, and that for a limited period. Thus every medical man in the city obtains the equal advantage of hospital practice, and the value of the best medical and surgical skill is fairly equalised through the whole community.
In addition to the hospital building is a separate block, furnished with wards, constructed in the same way as the general wards, for the reception of children suffering from any of the infectious diseases. These wards are so planned that the people, generally, send sick members of their own family into them for treatment, and pay for the privilege.
Supplementary to the hospital are certain other institutions of a kindred character. To check the terrible course of infantile mortality of other large cities,--the 76 in the 1,000 of mortality under five years of age, homes for little children are abundant. In these the destitute young are carefully tended by intelligent nurses; so that mothers, while following their daily callings, are enabled to leave their children under efficient care.
In a city from which that grand source of wild mirth, hopeless sorrow and confirmed madness, alcohol, has been expelled, it could hardly be expected that much insanity would be found. The few who are insane are placed in houses licensed as asylums, but not different in appearance to other houses in the city. Here the insane live, in small communities, under proper medical supervision, with their own gardens and pastimes.
The houses of the helpless and aged are, like the asylums, the same as the houses of the rest of the town. No large building of pretentious style uprears itself for the poor; no men badged and badgered as paupers walk the place. Those poor who are really, from physical causes, unable to work, are maintained in a manner showing that they possess yet the dignity of human kind; and that, being worth preservation, they are therefore worthy of respectful tenderness. The rest, those who can work, are employed in useful labours, which pay for their board. If they cannot find work, and are deserving, they may lodge in the house and earn their subsistence; or they may live from the house and receive pay for work done. If they will not work, they, as vagrants, find a home in prison, where they are compelled to share the common lot of mankind.
Our model city is of course well furnished with baths, swimming baths, Turkish baths, playgrounds, gymnasia, libraries, board schools, fine-art schools, lecture halls, and places of instructive amusement. In every board-school drill forms part of the programme. I need not dwell on these subjects, but must pass to the sanitary officers and offices.
There is in the city one principal sanitary officer, a duly qualified medical man elected by the Municipal Council, whose sole duty it is to watch over the sanitary welfare of the place. Under him, as sanitary officers, are all the medical men who form the poor law medical staff. To him these make their reports on vaccination and every matter of health pertaining to their respective districts; to him every registrar of births and deaths forwards copies of his registration returns; and to his office are sent, by the medical men generally, registered returns of the cases of sickness prevailing in the district. His inspectors likewise make careful returns of all the known prevailing diseases of the lower animals and of plants. To his office are forwarded, for examination and analysis, specimens of foods and drinks suspected to be adulterated, impure, or otherwise unfitted for use. For the conduction of these researches the sanitary superintendent is allowed a competent chemical staff. Thus, under this central supervision, every death, every disease of the living world in the district, and every assumable cause of disease, comes to light and is subjected, if need be, to inquiry.
At a distance from the town are the sanitary works, the sewage pumping works, the water and gas works, the slaughter-houses and the public laboratories. The sewage, which is brought from the town partly by its own flow and partly by pumping apparatus, is conveyed away to well-drained sewage farms belonging to, but at a distance from, the city where it is utilised.
The water supply, derived from a river which flows to the south-west of the city, is unpolluted by sewage or other refuse, is carefully filtered, is tested twice daily, and if found unsatisfactory is supplied through a reserve tank, after it has been made to undergo further purification. It is carried through the city everywhere by iron pipes. Leaden pipes are forbidden. In the sanitary establishment are disinfecting rooms, a mortuary, and ambulances for the conveyance of persons suffering from contagious disease. These are at all times open to the use of the public, subject to the few and simple rules of the management.
The gas, like the water, is submitted to regular analysis by the staff of the sanitary officer, and any fault which may be detected, and which indicates a departure from the standard of purity framed by the Municipal Council, is immediately remedied, both gas and water being exclusively under the control of the local authority.
The inspectors of the sanitary officer have under them a body of scavengers. These, each day, in the early morning, pass through the various districts allotted to them, and remove all refuse in closed vans. Every portion of manure from stables, streets, and yards is in this way removed daily, and transported to the city farms for utilisation.
Two additional conveniences are supplied by the scientific work of the sanitary establishment. From steam-works steam is condensed, and a large supply of distilled water is obtained and preserved in a separate tank. This distilled water is conveyed by a small main into the city, and is supplied at a moderate cost for those domestic purposes for which hard water is objectionable.
The second sanitary convenience is a large ozone generator. By this apparatus ozone is produced in any required quantity, and is made to play many useful purposes. It is passed through the drinking water in the reserve reservoir whenever the water shows excess of organic impurity, and it is conveyed into the city for diffusion into private houses, for purposes of disinfection.
The slaughter-houses of the city are all public, and are separated by a distance of a quarter of a mile from the city. They are easily removable edifices, and are under the supervision of the sanitary staff. The Jewish system of inspecting every carcase that is killed is rigorously carried out, with this improvement, that the inspector is a man of scientific knowledge.
All animals used for food,--cattle, fowls, swine, rabbits,--are subjected to examination in the slaughter-house, or in the market, if they be brought into the city from other depôts. The slaughter-houses are so constructed that the animals killed are relieved from the pain of death. They pass through a narcotic chamber, and are brought to the slaughterer oblivious of their fate. The slaughter-houses drain into the sewers of the city, and their complete purification daily, from all offal and refuse, is rigidly enforced.
The buildings, sheds, and styes for domestic food-producing animals are removed a short distance from the city, and are also under the supervision of the sanitary officer; the food and water supplied for these animals comes equally, with human food, under proper inspection.
One other subject only remains to be noticed in connection with the arrangements of our model city, and that is the mode of the disposal of the dead. The question of cremation and of burial in the earth has been considered, and there are some who advocate cremation. For various reasons the process of burial is still retained. Firstly, because the cremation process is open to serious medico-legal objections; secondly, because, by the complete resolution of the body into its elementary and inodorous gases in the cremation furnace, that intervening chemical link between the organic and inorganic worlds, the ammonia, is destroyed, and the economy of nature is thereby dangerously disturbed; thirdly, because the natural tendencies of the people lead them still to the earth, as the most fitting resting-place into which, when lifeless, they should be drawn.
Thus the cemetery holds its place in our city, but in a form much modified from the ordinary cemetery. The burial ground is artificially made of a fine carboniferous earth. Vegetation of rapid growth is cultivated over it. The dead are placed in the earth from the bier, either in basket work or simply in the shroud; and the monumental slab, instead of being set over or at the head or foot of a raised grave, is placed in a spacious covered hall or temple, and records simply the fact that the person commemorated was recommitted to earth in those grounds. In a few months, indeed, no monument would indicate the remains of any dead. In that rapidly-resolving soil the transformation of dust into dust is too perfect to leave a trace of residuum. The natural circle of transmutation is harmlessly completed, and the economy of nature conserved.
Omitting, necessarily, many minor but yet important details, I close the description of the imaginary health city. I have yet to indicate what are the results that might be fairly predicted in respect to the disease and mortality presented under the conditions specified.
Two kinds of observation guide me in this essay: one derived from statistical and sanitary work; the other from experience, extended now over thirty years, of disease, its phenomena, its origins, its causes, its terminations.
I infer, then, that in our model city certain forms of disease would find no possible home, or, at the worst, a home so transient as not to affect the mortality in any serious degree. The infantile diseases, infantile and remittent fevers, convulsions, diarrhoea, croup, marasmus, dysentery, would, I calculate, be almost unknown. Typhus and typhoid fevers and cholera could not, I believe, exist in the city except temporarily, and by pure accident; small-pox would be kept under entire control; puerperal fever and hospital fever would, probably, cease altogether; rheumatic fever, induced by residence in damp houses, and the heart disease subsequent upon it, would be removed. Death from privation and from purpura and scurvy would certainly cease. Delirium tremens, liver disease, alcoholic phthisis, alcoholic degeneration of kidney and all the varied forms of paralysis, insanity, and other affections due to alcohol, would be completely effaced. The parasitic diseases arising from the introduction into the body, through food, of the larvae of the entozoa, would cease. That large class of deaths from pulmonary consumption, induced in less favoured cities by exposure to impure air and badly ventilated rooms, would, I believe, be reduced so as to bring down the mortality of this signally fatal malady one third at least.
Some diseases, pre-eminently those which arise from uncontrollable causes, from sudden fluctuations of temperature, electrical storms, and similar great variations of nature, would remain as active as ever; and pneumonia, bronchitis, congestion of the lungs, and summer cholera, would still hold their sway. Cancer, also, and allied constitutional diseases of strong hereditary character, would yet, as far as I can see, prevail. I fear, moreover, it must be admitted that two or three of the epidemic diseases, notably scarlet fever, measles, and whooping cough, would assert themselves, and, though limited in their diffusion by the sanitary provisions for arresting their progress, would claim a considerable number of victims.
With these last facts clearly in view, I must be careful not to claim for my model city more than it deserves; but calculating the mortality which would be saved, and comparing the result with the mortality which now prevails in the most favoured of our large English towns, I conclude that an average mortality of eight per thousand would be the maximum in the first generation living under this salutary _régime_. That in a succeeding generation Mr. Chadwick's estimate of a possible mortality of five per thousand would be realised, I have no reasonable doubt, since the almost unrecognised, though potent, influence of heredity in disease would immediately lessen in intensity, and the healthier parents would bring forth the healthier offspring.
As my voice ceases to dwell on this theme of a yet unknown city of health, do not, I pray you, wake as from a mere dream. The details of the city exist. They have been worked out by those pioneers of sanitary science, so many of whom surround me to-day, and specially by him whose hopeful thought has suggested my design. I am, therefore, but as a draughtsman, who, knowing somewhat your desires and aspirations, have drawn a plan, which you in your wisdom can modify, improve, perfect. In this I know we are of one mind, that though the ideal we all of us hold be never reached during our lives, we shall continue to work successfully for its realisation. Utopia itself is but another word for time; and some day the masses, who now heed us not, or smile incredulously at our proceedings, will awake to our conceptions. Then our knowledge, like light rapidly conveyed from one torch to another, will bury us in its brightness.
_By swift degrees the love of Nature works
And warms the bosom: till at last, sublimed
To rapture and enthusiastic heat,
We feel the present DEITY, and taste
The joy of GOD to see a happy world!_
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