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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,

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,

B.W. RICHARDSON.

PREFATORY NOTE.

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.

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, 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 , 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 Eginaeta. 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.

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.

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.

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.

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