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valuable collection of those returns, their careful analysis and comparison, and their general publication; all which might be secured by that complete and effective organization to which he would then belong.

It is not my intention here to suggest those particular modifications and amendments in the periodical returns of the district medical officers, which would fit them for the purposes of a scientific registration of sickness, without diminishing their direct and immediate utility.

A few practical men, accustomed to parochial duty and to medical or sanitary inquiry, might soon devise suitable forms and schedules for these objects; and some valuable hints have been already offered on the subject.*

My design now is mainly to show that the poor being the chief and generally the earliest victims of epidemic invasions and of the neglect of sanitary precautions, their medical visitors are obviously the persons not only to notice, to collect, and to report on such facts, but practically to carry into effect all medical measures of prevention.

§ 38. To Mr. Chadwick belongs the credit of first pointing out the advantage which the public would derive from employing the medical attendants of districts in sanitary duties.†

This view was developed at greater length before Lord Ashley's Committee in 1844. Mr. Liddle and others supported it with various facts and illustrations in 1848.|| Mr. Simon, in most

Mr. Liddle contributed a very good paper on this subject to the former Journal of Public Health, vol. i. p. 92. And the able Editor of the present Journal of that name has favoured me with a sight of some excellent suggestions on the same subject, which he offered in March last to the Epidemiological Society.

+ "Were it practicable," said Mr. Chadwick in 1842, "to attach as numerous a body of paid officers to any local Boards of Health that could be established, it would scarcely be practicable to insure as certain and well-directed an examination of the residences of the labouring classes, as I conceive may be insured from the medical officers of the Unions."-General Sanitary Report, 1842, p. 343.

‡ Evidence (1844), 9361, &c.: also, Health and Sickness of Town Populations, p. 53, &c.

|| Journal of Public Health, 1848, vol. i. pp. 92, 158.

apt and eloquent terms, urged it upon the civic authorities of London in 1849.*

We have already seen the manner in which the preventive and remedial services of medical officers were demanded in the cholera epidemic of 1848-9, how admirably they were performed, and how miserably they were requited.

With regard to more permanent sanitary functions, not depending on temporary emergencies, Mr. Kingsley's plain yet striking statement was as follows:

"My own feeling is that the Medical Officer having been made a sanitary officer now, it becomes a question whether we can help looking on him as permanently such, because the Nuisances Removal Act makes him one of the public informers.

"There is no one thing which affects the condition of the medical officers of Unions now so much as the duties imposed upon them by that Act . . . In any improvements in the present medical relief, that connects itself with the pith and marrow of the whole matter affecting the position of medical officer, and the question of his salary, because it imposes new and very onerous and very invidious duties upon him."+

The appointment, under any sanitary enactment, of "Inspectors of Nuisances," or, as they ought to be called in homely Saxon, "Searchers,"could only relieve the Medical Officer of a small portion of those inquisitorial and preventive duties which he is the most competent person to perform. Besides, as the same clerical philanthropist observed with respect to mere nuisances, "they are known to the Medical Officer better than to any man;-it is he who must tell the Inspector in the long run."‡ A common searcher would often fail to

detect them.

§ 39. But there are much higher functions of a preventive

See Simon On the Sanitary Condition of the City of London. 1854, pp.

62-64.

+ Evidence (1854), 1572.

Ibid. 1578.

Mr. Leigh, also, the able Medical Registrar of Manchester, gave his opinion, that the district medical officers would make the best-the most practically useful— Health Inspectors.-Evidence, 2253.

66 MISSIONARY OF HEALTH."

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nature than those of a mere "public informer," which the district Medical Officer ought to perform.

He should become the sanitary adviser of the poor in their dwellings. Many removable causes of sickness within their own control would be pointed out during his beneficent visits. The miserable effects of alcoholic stimulation might be impressed on the minds of sufferers from intemperance, at times when no warnings or counsel save those of a medical visitor would be listened to.

The state of the apartments of the poor, their clothing and bedding, the choice and preparation of their food, the physical management of their children, their nursing in sickness,— would all come occasionally under his cognizance. He would often be the first to detect unwholesome occupations or trades in the neighbourhood, by their effects on those under his charge. In the execution of his ordinary duties, he might often be led to suspect the adulteration or impurity or decay of some article of food, or the deleterious quality of some pretended medicine or falsified drug taken by the poor;-and if the precise cause of mischief were beyond his means of detection, he would direct the attention of the superior Officer of Health, or the local administrative body, to the matter.

Injuries sustained in factories and other employments, for which the law provides a remedy, and which might never transpire but for his observation, would be reported by him to the authorities. His opinion would often decide a knotty question of sanitary improvement between the working man and his landlord. His information, not less than his mediation, would be of the highest value, both to the poor and to the local Boards of Health. He should always be the Vaccinator of the district, whoever else might assist in carrying that measure into effect.

"The very responsible duties of active sanitary inspection, in conjunction with those of vigilant supervision of the health of the different districts, are thus devolved upon those who, by their local knowledge, and their professional avocations, can most efficiently discharge them; thus making a first, but most important step towards the formation of a health police."-Times, Nov. 1854.

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QUALIFICATIONS OF OFFICERS.

Advice as to the removal and interment of the dead, and protection of the survivors, in zymotic disease, would also be his province in ordinary times.

I do not mean that he should perform those duties, which belong, as will hereafter be shown, to a Medical Superintendent or consulting Officer of Health, in a district of districts. But he would be, in a peculiar sense, the Missionary of Health in his own parish or district-instructing the working classes in personal and domestic hygiéne-and practically proving to the helpless and the debased, the disheartened and disaffected, that the State cares for them, a fact of which, until of late, they have seen but little evidence.

I have no hesitation in affirming that a well-organized domiciliary visitation, to be performed by a medico-sanitary staff, whose duty and interest it would be to raise the standard of health in their respective districts, would be a much more effectual step than any yet adopted, towards diminishing the rate of sickness and mortality, and averting the consequences (as injurious to society at large, as to the individual) of neglected ailments, by attention to their causes and premonitory stages.

XII. As to the Qualifications, Number, Salaries, and Appointment of District Medico-Sanitary Officers.

§ 40. It is not enough that the existing body of Union surgeons have proved their ready capability for a wider and higher sphere of duty, under the pressure and during the perils of recent pestilences.

The special qualifications needed for such an office as I have described in the preceding section, ought to be insured and tested in all future appointments. As vacancies occur in this corps, they should, as a general rule, be filled up by those only, whose theoretical knowledge of various branches of preventive medicine has been ascertained by such legally constituted examining bodies, as have been recommended in the Second

Essay; and who have also been practically trained for employment in the public service under officers already appointed.

An ordeal of this kind is as necessary for the Civil Medical Service* as it is for the Military or Naval; and it deserves consideration whether special, if not competitive,† examinations should not follow upon the general examination and licence which forms the portal of the profession.

The AGE of those elected to district appointments is another important element in their qualification.

In Ireland, the Dispensary Commissioners have wisely raised the minimum of age to twenty-three years. If, as I have before suggested, the age required for the licence, simply to practise, were twenty-three, an additional period of two years of study and experience would very properly be demanded of candidates for the full District Surgeoncy.

To render that further period of probation of the greatest public utility, it would be advisable to permit those young men who had acquired the State licence, to act officially, as unpaid deputies, or supernumeraries, in districts, until- they had attained the age of twenty-five, and were elected to a vacancy in the higher charge.||

§ 41. The number of officers needs to be augmented by a further diminution in the extent of the Visitation Districts, which require revision throughout the kingdom.

Their original faultiness, namely, non-adaptation to the medical and sanitary wants of the people,―has been remedied, in some measure, by the failure of inconsiderate and mischievous arrangements; but, together with the establishment of public dispensaries, and liberation from poor-law control, many terri

* Papers on the Re-organization of the Civil Service, Mr. Chadwick, p. 171.

+ Competitive examinations are again noticed in the Sixth Essay.

General Rules for Dispensary Districts-Ireland, Art. 16, II.-See First Annual Report, p. 46.

|| Mr. Kingsley urged the importance of experience and a knowledge of the locality for several years, in taking charge of the general health of a district.-Evidence (1854), 1599. Hippocrates was of the same opinion.