BOUGHT WITH THE INCOME PROM THE SAGE ENDOWMENT FUND THE GIFT OF 1S91 h.z.^<:^(:i'\\ xis^\I\\'i^. 5931 DATE DUE Irtol*^^ wH^m\ f is Mm^ *t dF^ -if^ WSKf ..-># 3?f^^' GAYLORD PRINTED IN U.S.A. Cornell University Library RA 427.F86 A traveller's study of health and empire 3 1924 012 496 174 Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/cletails/cu31924012496174 HEALTH AND EMPIRE PREACHING INOCULATION Outside a Small, Plague-stricken Town in the Punjab. ■-(The preacher is a missionary, and the picture illustrates two vital principles^hat the essence of health-promotion is education of the public, and that the chief agents must be those most in touch with its daily life.) A TRAVELLER'S STUDY OF HEALTH AND EMPIRE BY FRANCIS FREMANTLE COUNTY MEDICAL OFFICER OF HEALTH A uthor of "A Doctor in Khaki " " Scdus popiili suprema lex " LONDON JOHN OUSELEY LTD. FLEET LANE, FARRINGDON STREET, E.G. DEDICATED BY PERMISSION TO THE STATESMAN-PIONEER OF A HEALTHY EMPIRE The Right Hon. JOSEPH CHAMBERLAIN, M.P. BY ONE OF HIS MANY YOUIJG DISCIPLES AND FOLLOWERS LIST OF ILLUSTRATIONS Preaching inoculation outside a small plague stricken town in the Punjab . Zenana work at Tarn-Taran : (a) Saved from leprosy ; {b) Saved from famine {a) The medical man of India and his dispensary in the street ; (b) In the Lunatic Asylum of Lahore Frontispiece To face page 15 12, 13 14, 15 16 4. (a) Inoculation against plague ; {b) Boys in the school-yard await their turn . 5. Disinfection out in the forest 6. Disposal of Sewage : (a) Bullock-cart for removal of slops ; (b) New septic tank for Simla 7. Water-supply : (a) A roadside well by Dehli {b) A Persian wheel in Lahore 8. The verandah at Kasauli .... 9. (a) The Colonel injects enough poison to kill 6000 ponies ; {b) Milking a cobra at Parel 0. Women washing in the slums of Bombay . 1. Slums of Winnipeg in the making Sewage disposal on the rice-fields of Japan An episode in the Russo-Japanese War: (a) Russian forage smouldering and Chinese junks waiting for loot ; {b) The first Japanese scouts into Niu-chwang .... Discharging wounded from the Hospital-ship Kobe Maru at Sasebo A modern Buddhist cathedral in Japan : (a) The Higashi Hongwanji, Kyoto, built in 1895; (3) The interior, the congregation and the image displayed San Francisco : (a) Outwardly, in Market Street ; (b) Inwardly, where plague broke out in the old Globe Hotel, Chinatown . . . . 16 18 40 48 49 75 82 95 146 190 201 205 286 307 CONTENTS Preface ...... The Argument ..... CHAPTBR I. The Cry of the Plague-Stricken Punjab Footnote on Sanitation . II. British Rule and the Gamble in Life III. The Mad Dog .... IV. The Flea ..... V. Beri-Beri ..... VI. "Seek and ye shall find" VII. Malaya and the Science of Towning . VIII. Housing and the Future of Hong-Kong IX. Schools and Public Health in Japan . X. The Evacuation of Niu-chwang XI. The Naval Hospital at Sasebo . XII. Japanese Red Cross XIII. The Aftermath of the Russo-Japanese War XIV. Religion in the Far East XV. Health-faking in San Francisco XVI. Federal Hygiene in the States XVII. Mr. Chamberlain's Speeches XVIII. Conclusion — Health and the British Empire PAGE ix I 13 49 SO 63 88 100 109 136 149 176 194 205 221 254 274 293 315 331 347 PREFACE Circumstances and a kindly master in the shape of a County Council enabled the author of this book in 1903 to leave his work in charge of a deputy and to set off on eighteen months' travel. His direct object was to study the wider problems of health and empire, in other climates, in other races and under other systems of government, and so to fit himself, should occasion arise, for parliamentary service. His ultimate aim was and will ever be to persuade the public of the significance of those problems and to secure a due attention to their solution in the future administration of the British Empire. A year was allotted to wider travel, six months to study in countries nearer home. The chief extreme from conditions at home would be found in the Asiatic tropics, where orderly government and primi- tive conditions of life would give the basis of numbers, variation and administrative experience required. It seemed best then to concentrate on India, and there, as an integral part of the sanitary administra- tion, to study one district first for a whole winter's season, for one season's visitation of the plague. The governments of India and of the Punjab were X PREFACE most helpful in advancing this plan. " In six months," said a high official in Simla, " you will know more of Indian problems than any but a dozen members or so of the House of Commons." The exaggeration was a pledge of interest ; but no one certainly, when once a Member of Parliament and man of rank, can obtain in a mere visit an equally intimate experience of Indian life and rule. More- over the pay of a plague medical officer is ample and is a useful subscription to the traveller's purse. A winter was the restdt in the Lahore and Amritsar districts, and then a dash from Lahore to Peshawar and the Afghan frontier, through Lahore again south- eastwards to Calcutta. There was no time to lose, for war had broken out in the Far East. Visits were paid in passing to various cities and lands, Burmah, the Malay States, Singapore, French Cochin-China. Hong-Kong, Canton, Shanghai, Japan, and so to the seat of war. Physicians and surgeons in every hospital, workers in every laboratory, medical officers of health in every port and town unlocked the secrets of each place in turn ; the hospitality and friendship surpassed those of freemasonry and can never be repaid. A short experience of war, of Northern China and again of Japan completed the Asiatic chapter. Passing by the Hawaii Islands, America was entered at San Francisco ; and a few weeks spent in passing up the west coast to Vancouver, PREFACE xi over the Rockies, across the prairies to Winnipeg ; down to Chicago and St. Louis for the world's fair ; across to catch the spirit of health administration in three or four cities in the eastern states. A last winter was sufficient for the purpose in view in Paris, Geneva, Berlin and Hamburg and certain towns on and off the way. This book, written for general rather than pro- fessional consumption, is designed to carry a reader, perhaps only tepidly interested in his country's welfare, through the more intense and profitable experiences of the traveller, without the travel's drawbacks. It does not profess fully and scientific- ally to prove the statement that its title would suggest. But it expects to be read with common intelligence and an open mind, and trusts that the reader will then agree as if from personal experience in the fundamental importance to a modern empire of attention to the public health. Thanks are due to Mr. Chamberlain for permission to dedicate the book to him, for a kindly expression of sympathy with its aim and for the dates of his speeches in point ; but infinitely more for those speeches themselves and the inspiration thus given to medical officers of health in their work and ideals on behalf of the state. Grateful acknowledgment is due to The Times, The Lancet, The National Review and The Civil and xii PREFACE Military Gazette of Lahore for permission to republish ; to Professor W. J. Simpson, the first hving expert in imperial health, for advice and assistance ; and to various friends of all races and degrees for their help towards the fascinating experiences that have re- sulted in this book An Imperial Conference and the crowning of a new King have marked this year in the history of the British Empire. The future of our empire will rest, it is said, on treaties, tariffs, and defence. These pages seek to show that defence of health is as im- portant as defence of territory. For disease is a deadlier foe than man ; health and morale give greater strength than armaments. And mutual effort throughout the sister-dominions of the crown will be far more effective than independent action in building up the imperial strength and in diminish- ing the piteous tale of sickness and misery, of weak- ness, inefficiency and death. The attention of all has been called to the heritage of empire. In a few weeks attention will be diverted to hoUdays and health. It is hoped that this book may aptly combine the two ideas cind bring home to those who are well and strong the importance of the physical asset to the security of our empire. FRANCIS FREMANTLE. 2,2nd June 191 1. HEALTH AND EMPIRE THE ARGUMENT Turn over the fat, blue, repellent volume of figures issued by the Registrar-General every year and on page 112 of the last Report, that for 1909, you will find the Birth-rates and Death-rates of thirty-four different countries for the last twenty-nine years. Here are the actual facts, that record the strength and weakness, the rise and fall in human strength of the modern world. Here we have the preliminary mandate for the Public Health Service, by which it shall direct nations how to be fruitful and replenish the earth, to conserve their human asset, to diminish their tale of sickness, which is strength and labour lost, to promote and strengthen life and to postpone death. Here we see the British death-rate reduced from 20 deaths every year out of 1000 living in 1891 to 15 in igo8 ; the Australian death-rate reduced from 15 to 10 ; the German from near 25 to 18 ; the French from 23 to 19 ; while the Japanese rate is still 21 and the Russian 30. What individual sickness and suffering do these figures represent ! What national weakness and loss of productive power ! How much might have been prevented ! How much 2 HEALTH AND EMPIRE may in the future be prevented ! What promise for those nations that recognise, those individuals who desire to utiUse, the value of health to empire ! But of what value is all this talk of empire, if we can promise no manhood and womanhood for its development ? Here then on this same page 112, of world-wide moment, let us notice, not only the general reduction of the death-rate, which has its inevitable limits, but an equally general reduction in the birth- rate, which knows no bounds. A quarter of a century back 1000 Britishers brought into the world over 32 young Britishers every year to carry on and develop the work of the 19 who died. Now, to replace the 15 that die, only 26 enter the lists. The Australian rate is reduced to 25 ; the French to 20 ; while the German is still 32, the Russian 48 and the / Japanese, alone of all nations, has risen from 25 to 34 — ay, and may continue to rise. A vivid scene may attract attention ; and the scheme of the book opens in its first chapter with the impression of six winter months spent in a life and death struggle with plague in the Punjab, a ■ gigantic struggle — ^far more deadly than any war — in which over 7,000,000 have lost their lives in the last fourteen years, and to which we see at present no ending. We are at once face to face with the health responsibihties and vulnerability of the Enipire. An experience of this sort, in individual and daily touch with Indian village life as a responsible officer of the imperial administration, gives an opportunity, unusual to a traveller whether medical- or lay, of estimating the value of British rule. Chapter II. THE ARGUMENT 3 shows in certain respects the success of this rule and at the same time the inevitable dissatisfaction of an Oriental in being thus deprived of his gamble in life, a fact which is seldom realised by Europeans at home in considering the dilemmas of eastern government. The third chapter introduces the scourge of hydro- phobia and the miraculous saving of life affected in India by science and government ; the fourth shows the light now shed by the same means in Bombay and Hong-Kong on the cause of plague, an essential preliminary to its extinction ; the fifth deals with another imperial danger in the disease named kakke or beri-beri in Singapore and KuAla Lumpur, the fascinating capital af the Malay States. Here, as also in the sixth chapter, the direct value to the state of properly equipped scientific research, the essential preliminary to efficient measures against disease, is further illustrated by the French hospital at Saigon, the laboratory of the international muni- cipality at Shanghai and the Japanese Institute at Tokyo, in which the plan of campaign was being prepared not only against the plague, snake-poison, kakkt and hydrophobia, but also against smallpox, erysipelas, tuberculosis and diphtheria ; against cholera, typhoid, dysentery and anthrax ; against glanders and tetanus in the horse ; against rinderpest in cattle ; against the destructive action of red ants on sugar-cane and other diseases of plants, grains and trees. With this is contrasted an abortive scheme of vaccination instituted by the late Corean authorities. The seventh chapter, in discussing the development of the Malay States, deals with a detail of sanitary 4 HEALTH AND EMPIRE progress, now much to the front at home, the healthy and economic planning of towns in advance, as illustrated by Kuila Lumper, their capital ; the eighth shows the difficulty of housing and the oppor- tunity of town-planning in the further development of the colony of Hong-Kong. The ninth chapter gives glimpses farther east of education and public health in Japan, a country to which we may well look for new applications of European methods, where the start is made with open minds, a clean slate and a hearty and progressive public spirit. Here we are at the theatre of war ; and war, the historic foundation-stone of nations, the struggle for existence, the avenue for commercial development and social progress, preaches us a most striking sermon on the value, the national necessity, of medical work and above all of the prevention of disease. Chapter X. gives an epitome of the war in the graphic incident of the battle at Ta'hsi Chiao and the evacuation of Niuchwang, reprinted by kind per- mission from The Times. The proprietors of The National Review have allowed the reproduction in Chapter XI. of an article describing the chief Japanese naval hospital, in charge of an English-trained Surgeon-General, as a type of the several that were visited by the courtesy of the Foreign Office at Tokyo and the British Ambassador. Chapter XII. shows the re- markable organisation of the Japanese Red Cross. Chapter XIII. suggests the aftermath of the Russo- Japanese war ; and Chapter XIV., as its corollary. THE ARGUMENT 6 is based on a paper read before the Christian Con- ference on religion in the far east. These chapters are not wholly irrelevant to the theme ; for war, diplomacy and spiritual strength are essentially related to the public health ; and he would indeed have a warped mind who witnessed such scenes as those described without including them in his estimate of imperial strength. Chapter XV. takes us to America, where the commercial value of a reputation for health was attested by the action of the late Mayor Eugen Schmitz, who declared that plague was not plague, and was defeated in his perversion of the truth only by Federal action on firm administrative and sound scientific lines. Corruptio veri pessima ; in lesser degree the same truth holds good in English ad- ministration of public health. A chapter on Federal Hygiene in the States supplies an example for the co-operation of all constituent communities and the practical utilisation of the health information at their command in the future development of our own empire. Space has prevented any adequate account of further experiences; and it seemed best to omit them; for the new Encyclopaedia itself would not contain the books that should be written on the themes that presented themselves — of slums in Winnipeg, of meat and twenty-three languages in Chicago, of tall houses and boulevards, the excep- tional care of the public health in Massachusetts, and other American conceptions on the grand scale ; of school-feeding and Continental schools ; of Geneva 6 HEALTH AND EMPIRE and the milk-supply; in France, of the struggle against tuberculosis, the cleanly streets and sewerage of Paris, the municipal slaughter-houses, the river- side ambulance stations, the state protection of destitute infants, the Assistance Publique and the Public Health Law of 1902; in Germany, of school- hygiene, milk-supply, the museums of public health, national insurance against accidents and sickness, and the housing philanthropy of the Krupp family at Essen. If the microscope is essential for the scientific progress of public health, there is still more need of telescopic study in administrative methods and practical experiments. Hitherto content with local experience, pioneers and teachers of Public Health must in future adopt a more cosmopolitan method. This subject is a study of empires, not villages ; of all climates, not one; of all races, all conditions, all times. What then is the profession of Public Health ? It is the cure of bodies in the mass ; it is the charge of the primary forces of the nation, which correspond directly to their environment and are capable of gradual atrophy through neglect or of almost infinite development by the light of modem knowledge ; of forces on which in almost direct proportion depend the effective commercial, mental, spiritual power of the country ; of forces which should be the first care of government and often have been its last ; which can be and actually are in large measure affected by legislation and which, if rightly used, should become the chief comer-stone of the Empire. Life is a battle and the battle is to the strong. THE ARGUMENT 7 Health, hitherto regarded with benevolence as an ornament, must henceforth be counted a weapon essential to every part of the national life. Health to a nation is as vital as good material to an engine ; as exact alloy to a coin. It can be trained and developed to increase the output ten and a hundred fold both in variety and in degree. But left to itself it is neglected, forgotten ; it loses power and the public wonder at the failure of the national machine, which appears to their diverted attention so full of wonder and promise. An offensive policy is the best defence. A healthy body will best cope with disease. But prevention of disease, as of war, has none of the tragic pomp and glory that attract attention to its cure. Prevention of sickness in the individual implies constant self- restraint and a careful habit of life. Prevention of sickness in the community implies wise statesman- ship, detailed perseverance and mutual co-operation between statesmen, officials and the people. The care of personal health is civilised selfishness in its logical extreme. The care of the public health is the very incarnation of reasoning unselfishness. The instincts of animal man lead him to struggle for food, physical pleasure and existence ; lead him to cultivate personal health for those ends. The instincts of civilised man teach him that mutual support may replace competition ; prompt him to congregate and move freely amongst his fellows, and to co-operate for the public health. The health of the individual has been ever an axiom of human life ; the health of the community has been an occasional 8 HEALTH AND EMPIRE instniment, rediscovered in times of need by great statesmen and soldiers, and soon again returned to the dusty shelf. The baths and aqueducts of Rome, that brought three hundred gallons of water a day for every inhabitant ; the detailed rules of the Levitic code for cleanliness and for the avoidance of infection, fill with surprise the Londoner, content with his thirty gallons and grumbling in wilful ignorance against the new-fangled by-laws of his Borough Council. But now the tide again is turning ; the health of the community holds in increasing degree the atten- tion of the legislature, the executive and the public. DisraeU was probably the first prime minister in re- corded history to pronounce with all the authority of his of&ce the supreme importance of the popular health. The interests of the working classes were, he declared, paramount, and the working man's health was his greatest asset. It was he that gave public health its magna charta and created the present sanitary authorities in the Act of 1875 ; it was Lord Salisbury that created county councils in 1888 ; Mr. Gladstone, parish councils in 1894 ; and during the last twenty-five years big acts and little acts, by-laws and regulations have been formulated in bewildering confusion. A codifying, unif5dng and extending measure is urgently needed. The community pays for these measures by an increase in the rates ; but their effect has been a very large reduction in the amount of sickness and in the number of deaths, with the consequent average addition of five years to every infant's expectation of THE ARGUMENT 9 life. During the last twenty years the death-rate for England and Wales has fallen from 20 to 13-4 per 1000 per annum. In every 1000 of the population, therefore, 6 or 7 lives or, in a population of 35,000,000, over 120,000 lives are saved every year. It will be remembered too, that a low rate of sickness and death means increased health and spirits to all, greater happiness and a larger capacity for work. The friendly societies tell us that thirteen times as much work-time is lost by sickness as by death. But this improvement in the national well-being is not by any means entirely due to the law or to the sanitary officials and authorities that administer and execute it. A large share of credit must be given to the people themselves, who in their societies and papers, their schools, their family life, are learning more and more to inculcate, at least on each other, the lessons of sound health. Medical officers, in this respect, are preachers, content to see their ideals gaining ground, without receiving much share of public recognition. The vast importance of this lay co-operation must never be forgotten. It is a better stepping-stone to the attainment of the ideal than any number, however efficient, of acts, regulations or officials. Yet, despite the facts, the public health has not attained proper recognition. Soldiers, politicians, preachers, councillors, seldom refer to the subject except as a question of mere humanity. Humanity it undoubtedly is. But humanity plays only a minor part in the rivalry, on which prosperity of com- munities must in this Hfe depend. For this end the 10 HEALTH AND EMPIRE nation aims at the maximum of effective output with the minimum of effort. The output varies im- mediately with the health and strength of the nation ; efficiency and economy of effort vary with its in- telligence and education. Health is possible without education, but education is impossible without health. And so, for mere national efficiency, the public health is of all things most important. Times without number has the influence of health on military operations asserted itself in an extreme degree. The Assyrians before Samaria, the iU-fated Walcheren expedition, our South African army at Bloemfontein, the standing camp of the United States army in its war with Spain, are illustrations only confirmed by the attention paid to the pre- servation of health in the Manchurian army of the ever-zealous Japanese. Time and time again haVe nations suffered the most serious loss through epidemic or endemic scourges of disease. The 7,000.000 of lives lost through the epidemic of plague, now again on the increase in India ; the losses from malaria, yellow fever, blackwater, sleeping sickness or other tropical diseases, which till the end of the last century made tropical possessions the most expensive jewels in an imperial crown ; the decimation by disease of the labourers on the Panama Canal, that defeated De Lesseps and ruined his magnificent project ; are they not sufficient evidence of the value of health to empire ? But now the curtain is lifting. We have the keys to the cause of the plague, the cause of malaria, the THE ARGUMENT 11 cause of yellow fever, the cause of sleeping sickness ; and in some cases we already know how to fit the key in the lock, to turn it and open the gate. In others, as in smallpox, we can open the gate without a key. And so we can let in the floods of health ; and so Dr. Gorgas, by his medical dictatorship, has enabled the United States to triumph where De Lesseps failed, and has taught the world that attention to the public health is the avenue to achievements and to wealth beyond the dreams of avarice. If such are the striking lessons of the tropics, such also are the lessons here at home. We, too, have our preventable deaths and ailments, due largely to the artificial growth of town life ; we, too, at home suffer incalculable loss and misery from unnecessary sick- ness ; the effect being only hidden by the very con- gestion that is its cause and by the comparative immunity from the wars and pestilence of old days. But our empire calls aloud for men ; and as in the tropics, so also at home by earnest, instead of half- hearted, attention to the public health, we could halve our losses, double our output, quadruple our personal security and happiness and increase a hundredfold our strength in the undeveloped fields of work which have been committed — ^for a season — to our charge. The battle is to the strong. So ends this book with Mr. Chamberlain's pro- nouncements, with an outhne of policy for advance- ment of the imperial health, and above all with an earnest appeal for thought and attention to the health of the community, as the essential basis of empire on sure and progressive lines. CHAPTER I THE' CRY OF THE PLAGUE-STRICKEN PUNJAB " Dr. F. is requested to proceed without delay to Amritsar and report himself to the Civil Surgeon for inoculation work in the Tarn-Taran tehsil." This order reached me by special messenger in the wilds of the Lahore district. I was sitting alone in a solitary vacant official bungalow in comfort and grey flannels before a blazing fire, after a drive in pelting rain to an infected village, which refused all my offers of help, charmed I never so wisely. This year, 1903-1904, we offered help ; the winter before our predecessors gave it without much asking. We offered help ; pointed out the hundreds of villages infected, the thousands dying daily, the myriads that had died since plague attacked the Punjab in 1896. We offered inoculation and told tales of the Bombay jail, where under the same conditions most of the inoculated escaped and most of the un- inoculated died ; tales of the little villages like Wirana close by, where only five frightened females, fleeing at the approach of the inoculator, escaped inoculation and only those five females died. Statisr tics are useless ; the Indian peasant is imaginative and likes tales, which must be graphic and need not be scientifically correct — as is nevertheless the tale 13 14 HEALTH AND EMPIRE of Wirana. We talked by means of our keen young Mohammedan munshi, who, being of high family and descended from Ali, the Prophet's favourite nephew, carried weight with the strict Mussulman ; or we talked through our energetic young Sikh compounder, who, wearing his hair uncut and twisted up in a knot inside his turban, wearing the comb, the drawers, the steel bangle and steel miniature knife, the five signs, with the uncut hair, of a true Sikh, was able to appeal to the prejudices of the Sikh ; or, in default of either, we talked through our Goanese bearer or valet, who, Mahratta with a touch of Portuguese in him, Roman Catholic, and attired like an Italian organ-grinder, carried weight with all natives as a member of the aristocracy. A smattering of Urdu enabled one to keep watch over their interpreting ; and the intervals were useful for reflection, which is an essential part of the native's method for the exchange of ideas. We talked rather than harangued ; we drew on the local schoolmaster or village officials or greybeards to ask questions and state objections, and so by degrees we fancied ourselves able sometimes to sow a little good seed. If inoculation seemed a bad card to play, we tried a stronger card and suggested evacuation of the village ; and if popular feeling, or, as in the present case, the elements were against evacuation, we fell back on systematic disinfection. If the villagers had had experience of chemical dis- infection and did not like it, we suggested disin- fection by heat. And if they refused all these measures, we proposed that they should wait till one out of every four of their friends, their relatives. TUTS g*^ fSogo E S < ,» S 5 _, o iC. C- = ^c^2 c i o S = N 2 > Z > o > H > z > > £ 3 =3 l-rH *d 3 THE PLAGUE-STRICKEN PUNJAB 15 themselves had died, and then should apply to the Civil Surgeon of the district to come and save the rest. Meanwhile we had no desire to interfere with their hberty of dying or to undertake extra work ; and so we wished them good-day. A nine-mile drive through the rain in a rickety country cart, splashing through the mud, soaked through to the skin, escorted half the way by a couple of strapping fellows, who ride bareback behind us waiting for the honour of an English salaam, brings us eventually to the railway — munshi, compounder, bearer, cook, bedding, inoculation and disinfection outfit, personal baggage, a couple of carts and drivers and myself ; and picking up my pony and syce and my bicycle on the way at Lahore, we take orders from the civU-surgeon at Amritsar and ride and drive out the fifteen miles to Tarn-Taran. Tam-Taran, a little town of under 4000, is one of the centres of the Sikh religion ; and twice a year a crowd of nearly 100,000 congregates there to bathe in the tank of the Golden Temple. It is the centre of a large Sikh district and the head- quarters of a C.M.S. and a Zenana Mission (Plate 2), whose guiding star is a jovial, athletic, devoted English padre, still young after twenty-three (now thirty) years' work in the country. Knowing the people intimately, through constant visits to the 370 villages of his beat, acquainted with every man of the meanest position who has grown up during his time, and on good terms with all but a few shnking knaves, who have felt his firm hand, President of the Municipality and trusted py Sikh and Christian 16 HEALTH AND EMPIRE alike, he has asked for an EngUsh inoculating officer to work with him during this season of the epidemic. English he must be, for the natives do not trust a native, however well qualified. Every class of native official is, according to western ideas', corrupt ; he takes advantage of his position to exact his dues, which we should call blackmail ; policemen for a rupee will let anyone through a cordon, if it is safe for him to do so ; an interview with an Enghsh official of some standing may cost five rupees before the scarlet and gold coated chaprasi will announce your presence and business ; and even the native assistant- surgeon, whom I succeeded in one district, a man of good repute in the department, was driven about fbr nothing and was fed by his disinfecting coolies. So we go into partnership, the padre and I ; and the result in a couple of months is 2500 inoculations, with a maximum for one day of 350. Not very good ; but not very bad considering that plague was only sporadic in the district during those two months, and that the people had to be persuaded into it in nearly every instance. In India, as in England, it is only a good rousing epidemic that will persuade anyone, from statesman to peasant, to take action, and often, alas, not even that. Here is the kind of day we spend. We are out in camp. The tents with other baggage have reached their new destination on the backs of our six camels and been pitched outside the town two or three hours, before the padre and I jog in on our ponies, followed by my inoculation-cart and professional suite. The (a) The Hakim or Doctor and his Dispensary in the Street. (b) In the Lunatic Asylum at Lahore, [A victim oE Indian hemp — ruler, he will tell you, of the asylum — is linked with a madman always on the grin, who becomes aggressive if you da not grin back. Behind them a Jogi, a wandering- religious fanatic, who owns nine rubies, each equal to the treasury of eight kings. To the rights the head-keeper. To the left, a veteran who killed his man thirty-four years ago, and whom, though almost sane, they dare not discharge. THE PLAGUE-STRICKEN PUNJAB 17 headmen and elders of the village are there to receive us, and one or two hold out a rupee on their open palm for us to touch, — and not to take away, as one of my predecessors naively did last year to the old man's considerable Surprise. This village contains 2500 inhabitants ; it was attacked last year, they say ; 300 people died and only 5 of the 150 inoculated. This year the people, they are sure, will come in thousands to receive the wonderful medicine which the kind-hearted government has so graciously sent through these its most charming, honoured and mighty officers. They will announce it through all the village by beat of drum ; and do all they can to induce their townsmen to be inoculated. Exeunt all but the Christians, representing a much persecuted little community of about fifty, whom the padre arranged to visit at ten o'clock next day. The descent close by of half-a-dozen kordn — good shooting and good eating — closes the conference. Exeunt padre and myself, guns on our shoulders, followed by a motley and excited crowd. The sun sets and we return after an hour to join the memsahib for dinner ; but we avoid the subject of the birds. The next morning, after an early breakfast, we walk up to the village and find inoculation-apparatus and staff all ready on the raised earth platform under the big peepul-tree, with roots dripping from its branches into the ground — the common gossip-house of the place. As spectators we have a few pot- bellied brown urchins, clad in a pocket-handkerchief each with a blue turquoise necklace and a steel ring or two through the nose or ear. Chairs and light 18 HEALTH AND EMPIRE wooden biedsteads are brought, the headmen appear and after a little brisk repartee between them and the padre one of them brings his children and his brother's children and his friend's children to be inoculated. The padre goes off to preach. Munshi squats in a corner, takes down particulars of each person, and gives him the certificate to be signed after inoculation (Plate 4). The compounder on the moderately white tablecloth has a magazine of little bottles in front of him, siic full doses in each, of Haffkine's prophylactic ; a growing cemetery of the empty bottles ; an aluminium bowl of oil in which he has sterihsed half-a-dozen injection- needles over a spirit lamp ; another bowl of carbolic to hold the forceps with which from time to time he opens a fresh bottle and puts it to my nose for me to smell, before refilling one of the two S3ainges which are kept in constant use. My two chaprasis or messengers are hard at work scrubbing the left arms just behind and below the shoulder, one with soap and water, the other with lysol, by means of lint held in clip-forceps. The hnt, it may be noted, requires very frequent changing. Finally the clean patch of left arm. covered by a patch of lint soaked in lysol, comes to the end of the long row in which its owner has been squattingly awaiting his turn and at last he passes me his certifi- cate. I run my eye down the particulars. Unless his health is marked good, I look at his tongue and feel his pulse ; as it is most important for the credit of the operation not to inoculate any with plague already upon them, nor to produce an aggravation {ci) Inoculation against Plague. The Munshi, a Mussulman, in the background, fills in the forms; The chaprasi, a Hindu, on the right, scrubs the shoulders ; The compounder, a Sikli, in the cenlre, fills the syringe; The doctor, an Englishman, drives the syringe home The padre, from another world, takes the photograph. (6) Boys in the School-yard await their turn. THE PLAGUE-STRICKEN PUNJAB 19 of any other existing fever. According to age I decide the dose, one cubic centimetre at one year, three at seven years, five at fifteen and upwards, and adjust the stop-screw of the syringe accordingly. " Dekho — Look out ! " And if the compounder has sharpened the needle over night, it slips in and all is over without trouble. If not, the victim makes a grimace, and the onlookers, up to this point silent in their breathless interest, break into a laugh and a brisk exchange of wit follows. The compounder writes the dose given on the Certificate ; I add my signature by rubber stamp ; and another inoculation has been added to the roll. We do twenty in as many minutes ; then there is a hitch ; then another twenty and there is nobody left to do. Half-an-hour more and the return of the inoculated to their homes without serious damage has produced a few of their relatives ; and then the stream begins and the work goes on at full pace for an hour or two, accelerated by the return of the padre after his preaching. A score of women and infants are inoculated in a separate compound with other women and infants looking on from every neighbouring roof, cows and buffalo mooing, donkeys braying, children squalling and struggling — a fine pandemonium. And last of all come the sweepers ; no one will be done after the sweepers ; it is the end. Half the inoculated have been Christians, who have risen to a man ; the total number is 120, and the headmen present their books of testimonials and are quite upset when we refuse to testify to their good works in assisting the cause of inoculation. The thousands they promised 20 HEALTH AND EMPIRE would, they say, have come if any human inducement could have had that effect ; they had undergone untold trouble to induce the people ; but the people were foolish. Had not all their own families been inoculated ? They are warned that any outbreak that may occur in the village will be due to their failure to induce the greater part of the village to be inoculated. The government will hold them responsible. They must do better next time or it will go ill with them. And so — good-day. Let us turn to another scene, where the syringe invaded even the harem. In the south-east corner of the Lahore district there is a town named Gharyala. Passing through the town of Gharyala, where I in- terviewed the officials six miles before my entry, we came, my native staff of seven and myself, to Patti, a largish town of 8000 inhabitants, where in the previous year they lost 312 people from the plague, only 26 being inoculated, of whom one got the plague and none died. This is an out-of-the-way corner of the district, seldom visited by European officials. Nevertheless, my Sikh compounder, Achhar Singh, a bright youth of nineteen, having galloped ahead on his rough little pony, met me with the chief officials outside the town and the welcome news that it con- tained the finest rest-house we had yet met on our tour. This had been erected in his own garden by Mirza Mubarek Beg for sahibs on tour, and had been furnished with walnut furniture, apparently from Tottenham Court Road, and a piano made in Bombay. It was six months since the rest-house had been occupied, but there it was ready for use, a THE PLAGUE-STRICKEN PUNJAB 21 bungalow of considerable size, with every room opening directly on to the verandah, well screened from the heat of the sun, in the midst of Oriental vegetation — the word garden gives no idea — ^under the care of a native gardener and caretaker. After exchanging the usual salaams and receiving the usual assurances from Mubarek Beg that hundreds and probably thousands would come on the morrow for inoculation, and that his exertions would be, as they had ever been, of incomparable effect in carrying out the wishes of the government to that end, we re- tired to the solitude of the bungalow. The next day was a hard one. We were up at seven, and after breakfast walked up into the city to inoculate the whole of Umra and Shaja Beg's household, nineteen in all, including the ladies in purdah. These were of the family of Mubarek Beg, for the families lived together in clan, and Mirza and all his family were anxious to stand well with the government. Mirza Shaja Beg, the son of Mubarek Beg, acted as interpreter, having learned English at the Amritsar school. It appeared that Umra was anxious to get the vacant Zuildan or mayorship, which he declared was promised him in succession to his father, who died prematurely when Umra was still a lad. Umra, after my , visit to Patti, followed me for five days round the country with a fine dali or present of fruit and vegetables, and secured in return a direct note to the deputy commissioner, who told me later, however, that Umra was not the chosen man. Inoculation, like charity, begins at home, and every available arm should be produced in order to ac- 22 HEALTH AND EMPIRE centuate the merits of the Mirza's family. We found our way by what seemed a small back entrance, although in reality the chief entrance, into the rough red-brick building — red brick being of itself a mark of distinction. A small room, twelve feet square, with lattice windowfe looking out on to the slums on one side, the balcony on the other, was given up to the purpose. A deal table was with difficulty found and stood in the middle of the room, with a couple of European chairs, quite incongruous to the general surroundings. My Indian staff, of course, could not be allowed in the same room as the women of the household. They therefore prepared the bottles and basins, my clerk showed Shaja Beg how to fill in the prescribed forms, and I was left alone with the gentlemen of the household to inoculate first them- selves and then their ladies. The ladies were brought in one by one and dumped down at my side, gazing at me through their peepholes. They were covered, head and all, by dirty cotton shrouds, like the furniture in a London house out of the season. A slit had been made in the sheet behind the left shoulder, and a square inch of brown flesh was presented for the purposes of ablution and inocula- tion. The opening having been extended a few inches and the lysol vigorously applied, as was most neces- sary, until the pinky-brown flesh appeared in its native and beautiful tint, the inoculation was per- formed in dead silence. There was something un- canny in those black eyes watching intently every detail of the operation from within a complete fortress of white sheeting, without any other sign of THE PLAGUE-STRICKEN PUNJAB 23 life or feeling but the real flabby fleshiness of the left arm. Umra Beg, husband, father, or master as the case might be, was asked to address a few words in explanation of the performance to moderate their presumed anxieties, but in his opinion such fore- thought was unnecessary, and certainly, in the event, so far as all external manifestations of feehng were concerned, one might have been inoculating a bolster. The son and heir, however, evidently a spoiled young rascal six or seven years of age, displayed no such self-restraint — a wild horse or infant in arms could not have resisted more violently or shouted more lustily, and the pandemonium that ensued, when the father, the mother, the uncle, and a couple of servants endeavoured to give the inoculator a chance, was indescribable. Poor women, they were turned off again into the prison-like desolation of the harem, back to the life of the few yards of God's earth, the dozen or so of God's creatures, that they are ever destined to see on this side of the grave. " Salaam, Sahib ! " said Umra Beg. " Salaam, Sahib ! " said Shaja Beg. They had done their duty, and they hoped that their efforts and my influence would stand them in good stead when Mubarek retired from his ofiicial position and one or other of them be- sought the deputy commissioner to appoint him to the vacant place. This was an end of inoculation at Patti, for, although the drum was beaten round the town incessantly, ihough the family Beg assured us that they were doing their utmost to persuade the people to follow their example, though the cloth was spread over the inoculation table in a most tempting 24 HEALTH AND EMPIRE position on the verandah of the bungalow, not another soul availed himself of the government's munificence. The fact is that inoculation had not and, it seems, still has not as yet had fair play in the Punjab. Compulsory measures being considered out of the question, the inhabitants have been left merely the option of adopting this new method of treatment or refusing it. With their limited horizon of view, they do not think of taking care for the morrow. They wait till the plague comes, and comes in considerable force. Then, like children, they are seized with panic ; they apply to the government for aid, and the government sends them the inoculator. But if in England nearly half the children in the schools are now unvaccinated, it is easily understood that in India the vast majority object to inoculation against the plague. Medicines they could understand, charms and incantations they are used to, but a prick with a needle gives definite pain, experience shows that for two or three days afterwards, and sometimes for more, the arm is almost useless, and there is a general feehng of undoubted illness. How can fatalists such as they be expected to reaUse the eventual benefit of such an unpalatable method ? It is only by such obvious instances as that of the little village of Wirana already mentioned, it is only where in the midst of death the inoculated are in life, that the lesson is learned, if at all. And if there is this difficulty for those of some understanding, the difficulty with those who have none seems insuper- able. THE PLAGUE-STRICKEN PUNJAB 25 In the early years of the plague epidemic, one of the ablest of deputy commissioners made a tour through his district, speaking of plague and its pre- vention. On his second tour, in almost every village, he found a fine temple erected to the Goddess of Plague, the best temple by far in the place, and this even in Mohammedan villages, where they believe in only one God, but thought they might as well be on the safe side. His method was to discuss fully and freely the whole matter with them, to provoke criticism and heckling in order to answer it. " Does your Gospel," they would ask, " say all this about the plague ? — Because the Koran does not ! " His answer would be ready : " You are perhaps a cobbler : does the Koran tell you how to make a pair of boots ? " Or again, the Hindu asks, " Do you suppose angels trouble themselves with little worms ? If they have decided to send the pestilence, it is Kismet, and nothing that you can do will prevent it." His answer again was ready : " Providence sends you the harvest, but you must first sow the seed. Providence sends bread through the seed of com ; Providence sends its pestilence through little worms." Then there is the more revolutionary objector : " Government does not really want to save us ; it wants to poison us." The answer comes : " If you have a good bullock which is ill, do you try to poison it ? How wiU the government get its revenue if thousands of taxpayers die ? " Some there were, who were persuaded and believed. After one of the discourses, half-a-dozen men came the next morning, bearing in triumph an earthworm 26 HEALTH AND EMPIRE eight inches long : " Sahib, we have got the worm ! " Education, was the conclusion of this of&cer, must be the eventual and final preventive, but meanwhile there should be more mild coercion than at present, inter-communication between infected and unin- fected villages should be stopped, and with this as a lever privileges allowed to those who disinfect their houses. In inoculating such a series of cases, one cultivates a habit of routine, and occasionally a detail may by mistake be omitted. In one case, having carelessly failed to screw down the buffer of the syringe which limits the dose, I injected ten times the customary dose into a young fellow, who, though strong and only eighteen years of age, looked of delicate con- stitution. Although there is little reason for believ- ing that an overdose is poisonous, I was naturally anxious for a whole month until the welcome news came that at least no one at Patti was any the worse for my visit. At Kasel by mistake we gave double doses to about twenty persons, the dosage of the bottles we were then using being discovered to our dismay to be double the strength of the prophylactic we had always used. This was on a Saturday, and I was due at Mian Mir for the Sunday. The com^ pounder who was directly responsible for the over- sight, and the young clerk, were made to stay there overnight, and take the people's temperatures in the morning, and again in the evening, but not one was above 100*5, ^^'^ ^ly assistants were accordingly able to rejoin me on the Monday morning at Tam- Taran. THE PLAGUE-STRICKEN PUNJAB 27 Kasel was interesting in several ways. I visited it with the civil surgeon under whom I was working, a Lieutenant-Colonel in the Indian Medical Service, whom I assisted to extract his ten thousandth cataract from a man attracted by his fame from beyond the Himalayas. We drove out the fourteen miles to make inquiries . Last year 500 people were inoculated . None of those inoculated got the plague, although several others in the village died of it. This winter the village had again been infected, so we made out, through the visit of 5 Mohammedan and 2 other inhabitants to the Id-Ghar at Amritsar, on the Feast of Id (28th December) . All of them developed plague within five days, and by 19th January, the day of our visit, there had been 74 cases, and already 34 deaths. Only one man, however, despite the successful experience of inoculation in the previous year, vohmteered for inoculation. They were told to let the civil surgeon know if more wished for it or for disinfection. By the ist of February 126 cases had been reported, with 61 deaths. On the 12th of March I met the Zaildar at a neigh- bouring village, and he told me there had been over 300. I decided therefore to try again, and on the 19th of March paid a second visit to Kasel. To show how difficult it is to secure any information of the disease, we found in the registers that as early as December, when, according to oral information at our first visit, there had been no deaths from plague, 22 people were said to have died of fever, as compared with previous years, when only two or three deaths would occur and those not from 28 HEALTH AND EMPIRE fever. This was obviously an early invasion of the plague. With some difficulty we inoculated 43 persons. At the village of Jauhal-Raju-Singh we inoculated 132 between four and six o'clock one evening. Four days later, hearing that one of the inoculated was ill, I bicycled over there, after a long day's work, the roads appearing more impossible than ever, and found plague rampant. Evidently, as usual, my first inoculations had been made in a population already terrified by prevalent disease. They were anxious for my help on any lines, but the mischief for the most part was already done. Escorted by the local officials and fifteen or twenty of the population, I paid a visit first to one house, then to another, and so on to most of the wretched hovels infected through- out the village. One would enter through a narrow opening in one of the mud walls, flanking a three-foot lane, into a squalid yard some twenty feet across, six inches deep in mud, occupied by several goats, two or three head of cattle, and two or three char- payes, or plain native bedsteads, on which a few of the worst cases had been brought out to die. They lay in the last stages of fever, huddled up and d5dng under the dirty padded bedclothes. The bedclothes were removed, and one went through a certain routine of medical examination, more by way of form and excuse for passing the time than for any other purpose. One passed on into the house, a mud erection on the ground floor, with mud floor, mud walls, a couple of doors open only for our benefit, and a couple of tiny wooden-shuttered windows THE PLAGUE-STRICKEN PUNJAB 29 that evidently were seldom unbarred. In this dark, dismal space, perhaps twenty feet long and ten wide, were four dying patients on charpayes and two on the floor, with half-a-dozen friends or relatives crouch- ing by their side, wiping away the saliva from their hps, and giving a little ghee, or sour whey. The burden of responsibiUty was oppressive. What in- deed was the value of our European rule and of all our science, under such impossible conditions. To say a few words of comfort ; to warn the attendants against allowing the patients to move, under any circumstances, for fear of heart failure ; to promise a bottle of medicine next morning, knowing full well it would be practically useless in any but the strongest cases, this was all. The next day we returned and inoculated 244 cases, taking as much care as possible that those who were inoculated had not the disease already upon them ; but there can be no doubt some of them were already infected, and, when they are already infected, the inoculation cannot overtake the virus of the plague. In such cases, death after inoculation may well appear to the native to be due to the inoculation, and there are many who say it is most unwise to have anything to do with a village on which the plague has taken strong hold, for such procedure brings discredit upon the operation and deters other villages from applying for it in time. But human sympathy is strong, and the conviction that at Jauhal-Raju-Singh so many persons might yet be saved by inoculation induced me to waive the higher and probably more statesmanhke attitude of refusal. The case is very like that of charity 72 HEALTH AND EMPIRE available in everj' bacteriological laboratory, instead of in elaborate institutes only. The inoculation of the rabbits is performed under chloroform. A neat midget trephine removes a small bony disc from the skull ; the needle of the syringe is inserted direct into the brain ; the scalp wound is left to heal up, as it does perfectly well within a few days ; and the rabbit is immediately returned asleep to its cage, the whole operation taking perhaps three minutes. Dr. Kitasato, in Japan, on the other hand, in his research laboratory in Tokyo, does not even trephine, but injects the poison directly, under chloroform, by a needle of the pre- cisely requisite length, along the side of the eye and optic nerve, through the optic foramen into the brain. This method seems astonishingly simple and ingeni- ous, but I must confess that the first rabbit I saw thus treated died on the spot, all attempts at artificial respiration proving useless. The difficulty of conducting such treatment in this institute may well be imagined, for the virulence of the cords decreases daily, and on any one day ar- rangements may have to be made — as, for instance, on the day of my visit — for thirty-six doses of all degrees of virulence — ^so many of third-day cord, so many of fourth, so many of seventh, and so on. Two rabbits were inoculated for the purpose of preparing virus every day, however few patients there might be in the institute. The cord, which is used within the first three days to supply fixed virus, is depended on to supply virus on each successive day, of diminishing virulence, until it has all been THE MAD DOG 73 used by the end of the fourteenth day. Should both the rabbits inoculated on any day die, or their cords after death become contaminated at any stage be- tween the inoculation and the attainment of the standard of virulence for which the cords are to be used, the gap in the treatment of all patients is definite and irreparable. Extreme care has therefore to be taken in the dr3dng-room, in which the cords are kept at a uniform temperature, at a uniform degree of moisture of the atmosphere and devoid of all light, the walls and ceiling being papered in black ; for moisture, light and heat are all disturbing elements. For each dose half-an-inch of the cord is cut off with sterile scissors and mashed up with a teaspoonful of salt (normal saline) solution, being used one day as third-day cord, the next as fourth-day cord and so on. Course of the Treatment. — When a patient arrives at the institute he is seen by the director, and is ordered treatment according to the intensity and pre- sumed danger of his case. In ordinary cases it will be as follows : — ist day, an injection of fourteenth- day cord ; 2nd day, thirteenth-day cord in the morn- ing and twelfth-day cord in the evening ; 3rd day, eleventh and tenth day cords ; 4th day, ninth and eighth ; and, on successive days, seventh, sixth, fifth, f&urth, and third day cord respectively ; then, on the nth day, back to seventh and sixth day cords, and, on successive days, fifth, fourth and third ; on the 15th day again, sixth and fifth day cords ; then fourth and third ; on the i8th day, sixth and fifth ; 72 HEALTH AND EMPIRE available in every bacteriological laboratory, instead of in elaborate institutes only. The inoculation of the rabbits is performed under chloroform. A neat midget trephine removes a small bony disc from the skull ; the needle of the syringe is inserted direct into the brain ; the scalp wound is left to heal up, as it does perfectly well within a few days ; and the rabbit is immediately returned asleep to its cage, the whole operation taking perhaps three minutes. Dr. Kitasato, in Japan, on the other hand, in his research laboratory in Tokyo, does not even trephine, but injects the poison directly, under chloroform, by a needle of the pre- cisely requisite length, along the side of the eye and optic nerve, through the optic foramen into the brain. This method seems astonishingly simple and ingeni- ous, but I must confess that the first rabbit I saw thus treated died on the spot, all attempts at artificial respiration proving useless. The difficulty of conducting such treatment in this institute may well be imagined, for the virulence of the cords decreases daily, and on any one day ar- rangements may have to be made — as, for instance, on the day of my visit — for thirty-six doses of all degrees of virulence — so many of third-day cord, so many of fourth, so many of seventh, and so on. Two rabbits were inoculated for the purpose of preparing virus every day, however few patients there might be in the institute. The cord, which is used within the first three days to supply fixed virus, is depended on to supply virus on each successive day, of diminishing virulence, until it has all been THE MAD DOG 73 used by the end of the fourteenth day. Should both the rabbits inoculated on any day die, or their cords after death become contaminated at any stage be- tween the inoculation and the attainment of the standard of virulence for which the cords are to be used, the gap in the treatment of all patients is definite and irreparable. Extreme care has therefore to be taken in the drying-room, in which the cords are kept at a uniform temperature, at a uniform degree of moisture of the atmosphere and devoid of all light, the walls and ceiling being papered in black ; for moisture, light and heat are all disturbing elements. For each dose half-an-inch of the cord is cut off with sterile scissors and mashed up with a teaspoonful of salt (normal saline) solution, being used one day as third-day cord, the next as fourth-day cord and so on. Course of the Treatment. — When a patient arrives at the institute he is seen by the director, and is ordered treatment according to the intensity and pre- sumed danger of his case. In ordinary cases it will be as follows : — ist day, an injection of fourteenth- day cord ; 2nd day, thirteenth-day cord in the morn- ing and twelfth-day cord in the evening ; 3rd day, eleventh and tenth day cords ; 4th day, ninth and eighth ; and, on successive days, seventh, sixth, fifth, f&urth, and third day cord respectively ; then, on the nth day, back to seventh and sixth day cords, and, on successive days, fifth, fourth and third ; on the 15th day again, sixth and fifth day cords ; then fourth and third ; on the i8th day, sixth and fifth ; 34 HEALTH AND EMPIRE that trade between towns, dealing as it did with markets direct, spread the plague, which was mainly diffused in his opinion by women who go to mourn at funerals, and who by custom lie on the bed with the patient up to, and even after, death, and on the following night always lie on the bare earth. It was for this reason, he considered, that plague was commoner in women than in men. But he admitted, rather unwillingly, that this difference between the sexes might be due to the transmission of the disease through fleas, since the women are dirtier, and stay more at home ; they are more ignorant and careless about infection ; and, moreover, it was recognised that rats, formerly plentiful, were absent during the plague in these villages, having all died or migrated and, according to the flea theory, left their fleas to find their food on less palatable man. He gave an interesting instance of the value of inoculation in Kesel Gurh in the previous year, when ninety per cent, of the population were inoculated. Twenty of these had plague, and none died, while of the remaining ten per cent, nine had the plague, and six died. Plague having devastated the Punjab to an in- creasing extent from 1894 onwards, the Punjab Government decided in 1902 to undertake an exten- sive scheme of inoculation, devised both in principle and detail by one of their medical officers, afterwards Major Wilkinson, Chief Plague Medical Officer of the Punjab. It was hoped to inoculate a very large proportion of the population in the autumn, in advance of the annual invasion of the plague, which THE PLAGUE-STRICKEN PUNJAB 35 commences a little before the New Year. Their ordinary medical officers were obviously too well engaged in their other duties to be able to spare time for siich an extensive measure. They engaged there- fore upwards of fifty young doctors of high pro- fessional quality from the London medical schools, at a remuneration sufficient to ensure a selection of that ability which they considered essential to the success of their scheme. This learned expedition has passed unnoticed, but it is one of many instances, unique and unprecedented in the world's history, of experiments made in the development of our empire. These pioneers arrived in September 1902, and for some weeks were expected to do little but accustom themselves to Indian ways of life and administration. For every one of them a particular sphere of work was mapped out, a staff of ample proportions was engaged, and tents and equipment were prepared on a liberal scale. It was a new experiment, and the machine was with some difficulty set to work. Some men were unsuited to the climate ; some, despite professional abihty, entirely unsuited to the work ; and long before the experiment was in full swing a melancholy disaster occurred which shattered the whole scheme. In a small village named Mulkowal the inoculating officer, whom no one could impugn either on the score of professional ability or sense of responsibility and tact, awaited for six hours, with all his apparatus prepared, the return of the villagers from the fields, to which they had fled on his approach. Eighteen persons were inoculated at Mulkowal and one at 86 HEALTH AND EMPIRE Ferozpore, all from the same bottle. Every one of these cases died of lockjaw or tetanus. This bottle was only one out of a large brew which had left the laboratory at Parel, outside Bombay, four weeks previously. The others caused no tetanus ; therefore the infection was one not of the brew but of the bottle. The question was whether the bottle was infected on the spot or at the time of bottling at Parel four weeks before. The answer depended on expert bacterial examination of the partictdar bottle concerned. A commission of three was appointed to inquire into the whole matter ; they concluded that the con- tamination occurred at Parel. The question was referred, however, to the Lister Institute in London and they, after further experiments, first concurred and then threw doubt on this finding. Mr. Haffkine finally appealed to the home government in an exhaustive review of the case ; and a letter to The Times from ten leading authorities in Great Britain and the United States showed that Mr. Haffkine had proved his point. Contamination occurred at Mul- kowal. The Indian government, however, had to justify itself to the people and it seized on the methods in use at Parel. It appeared that, a few months before the occurrence of the Mulkowal incident, Mr. Haffkine had for good reason introduced a change in his method of preparing the prophylactic. The modification was based on an analogy with his cholera experiments and on the experience of the Pasteur Institute in Paris, but it opened the way to ten times as many chances of pollution. The government discovered THE PLAGUE-STRICKEN PUNJAB 37 that this change had been made, and concluded that it might have been responsible for the whole ttouble. They ordered a return to the former methods, and, when a sufficient supply of prophylactic, produced on the old lines and tested by more stringent tests than ever, was ready, they were in a position to announce to the natives of the Punjab that recourse could be had, with perfect safety and great advantage to themselves, to the operation for inoculation. The government entirely exonerated the inoculating officer from any responsibility for the infection ; they dispensed with the services of Mr. Haffkine. It was a lamentable fiasco. Of all the vast supply of prophylactic prepared in advance up to that date at Parel, so long as the question of infection at Parel was still undecided, not one bottle could be used, and in the event it was iall destroyed. No further inoculation could be performed until a safe supply of prophylactic could be guaranteed, and by that time it had become spread throughout the length and breadth of the Punjab that nineteen persons had been poisoned by the government's measures. To continue inoculation under such circumstances, at least with any show of pressure, was clearly im- possible ; the government could only fall back on their former attitude of offering assistance where it was asked for. There are some who think it would have been well if the government, so soon as the safety of the Parel prophylactic was ascertained, had continued their scheme of inoculation as if nothing had happened, using as much official pressure as possible, relaxing it only when the popular feeling 38 HEALTH AND EMPIRE against it rose to a dangerous extent. But such is not the principle of the Punjab government, nor indeed of the Indian administration in any depart- ment. It is considered the best course to let the people, by slow degrees and by constant affliction, learn their lesson and come to a fatherly govern- ment willingly for help, than that they should be coerced into submission to measures which at first appearance often seem to them worse than the disease. It must be at the same time noted that compulsory measures lead to concealment of cases, and so to uncontrolled spread of the disease. The flaw in this argument is that the people do not learn the lesson but continue to die in increasing numbers. The year after the Mulkowal incident I was touring round the villages of the Lahore and Amritsar dis- tricts, and found, in so far as it is possible to arrive at the convictions of the Indian people on any subject, that the fact of the Mulkowal incident rankled in their breasts, and was a very real and probably the chief obstacle to inoculation ; and I am bound to admit that I was not wholly without anxiety myself — perfectly unreasonable anxiety, no doubt — when the padre and I subjected ourselves to inocula- tion for an example, and at least professedly as a security in our work, in the Gate of the Golden Temple of Tam-Taran. This year the government had decided to apply no pressure, and so, instead of the fifty indculation officers, there were now only six such special officers retained, to whose number I was privileged to be added as a seventh. It was our duty to go round the THE PLAGUE-STRICKEN PUNJAB 39 villages, preaching, through the medium of our munshis, the history of recent outbreaks of the plague, the almost certainty of its recurrence in increasing virulence, and the measures which the government suggested to guard against it. You may prevent disease in the individual, but it is obviously far more effective to prevent it in bulk ; and however great the claims of inoculation to guarantee the safety of the individual may be, there seemed no doubt that infinitely the most effective method of combating the plague was by prompt evacuation of an infected village. The inhabitants, however, could not be left to find their lodging in other villages, for so they would only spread the plague more widely. As with our city improvement schemes at home, accommodation must be found for a displaced population ; and this accommodation would in general be found by the erection, at some little distance from the village, of mat sheds, or other temporary houses, into which the whole population were bound to move, and within which they were to be confined for a certain period until plague was at an end in their midst. In some parts, for instance, of the United Provinces this method had been most effective, but in the Punjab the first difficulty arose in the reluctance of the natives to leave their homes at any cost, and in the supposed insecurity of their possessions and valuables in the new encampment. The second difficulty lay in deciding who should pay for the cost of removal. The answer of the Punjab government was distinct, that the expense must be borne by the locaHty ; and although in other parts 40 HEALTH AND EMPIRE localities had agreed to bear this expense, and had succeeded almost invariably thereby in stamping out the plague, in our own districts not a single village was prepared to fall in with this suggfestion. Inoculation then was practically useless to the community — for what are 2500 inoculated persons amongst so many ? Evacuation was refused. There remained only one suggestion, the makeshift of dis- infection. Of this I had but one experience. A wire came to me on 20th December, out in a distant village — " Plague broken out Changa Manga. Go there immediately." I arrived in advance of my staff and equipment, and spent the night with the native forester. A hospital assistant arrived next morning, and set his men hard at work removing, with the help of the inhabitants, the furniture from their infected huts, brushing down the walls with chemicals and washing out the floor (Plate 5). But the people dry the floor afterwards by putting fresh dry earth, which may itself be infected, upon it, and sleep on it themselves with clothes not dis- infected. Such a thing as a fuU-length bath is un- known, and, if we had one, it would be impossible to use it. The first improvement to make was at least to suggest a wash and the disinfection of clothes ; the second to disinfect, not by chemicals but by heat. Whether conveyed solely by fleas or not, there was no doubt that the infection came largely from direct contact with the earth. Of these ten disinfecting coohes only one had had the plague ; but they had all been made to wear leather boots and leggings. The one exception was found to have objected to his Disinfection Out "in the Forest. Coolies at work inside, while tenants, their wives, cattle and other possessions bask in the sun outside. A sweeper's wife in the far corner is dying. THE PLAGUE-STRICKEN PUNJAB 41 boots and leggings, and to have been in the habit of removing them. It was only this year that they had taken to thus protecting their feet ; formerly their predecessors had suffered most severely from plague. But chemical disinfection by fluids is use- less enough in England ; it is quite useless in India as performed in mud huts by the Indian native. It is also very expensive ; and a far better method is desiccation, or disinfection by heat. My compounder brought a stove for this purpose — a cheap affair of thin iron, in which we burned wood and banana-tops, and anything else handy ; and we started with this to disinfect the infected row of sixteen back-to-back huts. All contents had been turned out into the sun — in itself a good disinfectant. The walls were still painted green with the chemical up to a height of six feet. The colour at least gave confidence and a check on the work done. The floors were scraped, and an inch of earth carted away to the forest. The contents of the hut were now packed inside — a close fit when room had to be made for the stove in the centre of the floor. The little chimney in the roof was stopped up, cracks and doors were closed, and an hour and a half passed before the iron bolts of the door, by their uncomfortable heat, showed that a sufficient temperature was reached inside for disinfection to be considered to have begun. Meanwhile the second and the third huts were packed up again with their ventilated sun-dried contents, ready for the use of the stove when the first hut was finished. It was a long business, and to disinfect seven huts in a day was good work. 42 HEALTH AND EMPIRE Even so, the process was not perfect. We had no clean spare garments with which the poor people might cover themselves while waiting after a bath for their clothes to be heated in the next house. In the second place, when it came to a sweieper's house, the Mohammedan women who were their neigh- bours would not admit any of the sweepers' things for disinfection into their own houses, and they obviously could not use their houses both for bathing and disinfection at the same time. In the third place, they aU object to washing, especially in carbohc, because it smells. And, fourthly, the paint on their gaudy furniture is liable to suffer. Nevertheless, the process is accompanied with perhaps less dis- comfort than any other system adopted by the Government, and it had the additional and very considerable recommendation that it left the huts hot and dry. At the end of a winter's work one feels fairly well in despair as to the whole business ; seven years later the despair is confirmed. The death-rate from plague in 1904 in the Lahore and Amritsar districts in which I worked was 25 per 1000. Over 1,000,000 Indians died of plague in 1904, over 1,000,000 in 1905 ; in 1906, 332,000 and it was thought the end was in sight. But 640.000 died in the first four months of 1907 ; in 1908, 321,000 died ; in 1909 only 175,000, but in 1910 again very nearly 500,000, and this year more than ever. The United Provinces had barely been reached by the epidemic in 1904 ; now with a popu- lation equal to that of the United Kingdom they have THE PLAGUE-STRICKEN PUNJAB 43 been losing 20,000 every week; and the Punjab 34,000 in one week, 39,000, 47,000, 54,000, 60,000, and so on, — over 430,000 in the first four months of this year in a population of 25,000,000. Imagine Great Britain and Ireland losing the same proportion — over 1,000,000 from plague in half a year. And India as a whole has in fifteen years lost over 7,000^000 from plague. Why wonder at her un- rest ! What then can the government do ? The only complete scheme has been killed by the Mulkowal incident ; extermination of rats is impossible ; disin- fection on a large scale is impracticable ; evacuation of villages cannot be done voluntarily on any universal scale ; the government wiU not apply compulsion, and such evacuation is quite useless without a rigid cordon of police or military that will prevent communication between one infected village and others not yet in- fected. A cordon, it has been proved over and over again, cannot be maintained ; the native who wishes to pass it has only to present some official with a cautious rupee. Extermination of rats in an Asiatic country has often failed ; but here is with- out a shadow of doubt the key to the problem. The methods formerly adopted had been to give a capita- tion grant for every rat brought to the appointed place, and before long it was found, for instance in Bombay, that an extensive trade had grown up in the breeding of rats, whereby, at a few annas apiece from the government, many families were able to sustain a comfortable existence. The same thing was once done with regard to poisonous snakes ; a 44 HEALTH AND EMPIRE breeding-farm of extensive proportions was dis- covered in full operation in order to take benefit of the government grant. But since sentence on the rat-flea has been pronounced for the murder of 7,000,000 persons and over, the best method for his extermination will not be far off. Sulphur is coming again into favour and we are reminded that both in Rome and in Mesopotamia non-poisonous snakes were kept, it is beUeved, for this purpose. Cats, however, are useless as they may themselves take the plague. In any cases total extermination is improbable. It is often debated whether even half-measures are worth being continued. Professor W. J. Simpson, in his exhaustive monograph on the plague and in 1907 in his Croonian Lectures, has shown how in history epidemics of plague have come and gone in different countries with long intervals between them, often of one hundred and thirty to one hundred and fifty years. In the eighteenth century, for instance, India seems to have been almost free of the plague, but early in the seventeenth century it suffered severely. The present epidemic is assuming, as for as we can trust previous records, unprecedented proportions ; probably after a few years it will die out again. An occasional cynic may argue that, since we have saved so many thousands of lives annually from famine and from wars, it may be just as well to let the plague take their place. To such a pessimistic and inhuman conclusion it is impossible for one moment to subpiit. It may be that for economic reasons some parts of the Indian Empire would be happier if their population were THE PLAGUE-STRICltEN PUNJAB 45 less dense ; but it does not follov(^ that we should allow death to stalk uninterrupted, unopposed, and apparently without Umit, throughout the country. Economics apart, we may yet be absolutely con- vinced, whether as doctors or as statesmen, that it is our mission, our duty, to protect the populations included under British rule to the best of our abihty against every scourge as it may arisie ; and there- fore it is urgent that such measures as we have be pushed forward with the utmost vigour. We cannot aim in this world at perfection ; we must often be content with half-measures, and it is through half- measures that we often find the clue to complete control of the situation. But those half -measures must be adopted vigorously and in earnest ; and it would seem a very considerable mistake that such effective measures as evacuation of a complete population should have to depend entirely upon local funds. If anything is to be supported by the general exchequer, whether of the provinces or the government of India, surely it is measures for the prevention, cur- tailment and stamping out of so terrible an epidemic. A practical pohcy is urgently needed, and this practical pohcy might with advantage, to my mind, go a little further in the direction of compulsion than the Punjab government have lately been inchned to go. In the winter with which this chapter deals, the only duty of the local officials in the matter of plague was to notify the first five cases that occurred to the deputy commissioner and the civil surgeon of their district, and this duty, intended as at least a warning of the incidence of the disease, was neg- THE PLAGUE-STRICKEN PUNJAB 47 been made. India has now established a Central Research Laboratory in each province, and will doubtless get much good work out of the distinguished officers there engaged. But there is need for a definite and permanent organisation to investigate the subject of epidemics in all parts of the empire, both in their scientific and administrative aspects. To some extent the late Lieut. -Col. Leslie, who in 1904 was appointed Sanitary Commissioner to the Government of India, was doing this for India in addition to his innumerable other duties and anxi- eties ; many other members of the service, in their several vacations and callings, are engaged in the same pursuit ; our home government has appointed another commission on more scientific lines to shut the stable-door after the horse has bolted ; and there have been many commissions, of many European countries besides our own, which have investigated the plague without as yet having found the final clue to its prevention and extermination. But for a study of this sort, and for practical measures which shall be of use to us throughout the empire, we again feel the need, which will be referred to frequently in this book, of an imperial conception of preventive medicine, and of an imperial organisation to study the causes of epidemic disease and to inaugurate measures to cope with it. The empire needs a general staff for disease as much as for war. So long as we go on nibbling at the cherry, it will always elude us ; so long as we appoint occasional com- missions and occasional officials, with a multitude of other duties on their hands, to deal with the question 48 HEALTH AND EMPIRE of one epidemic in one country at one particular time with that epidemic at its height, the question will never be settled. A large well-endowed imperial organisation, with the powers and responsibilities of the War Office or the Admiralty, would undertake the question with a proper sense of proportion ; and, if the government were determined with their assist- ance to find some way out of the present difficulties, I am convinced that such a body would find it, for the direct benefit of India, and the indirect benefit of science and the whole world. The commission appointed four years ago, now caUed an advisory board, is stiU at work, and has done good work too. But it was a bacteriological commission, which has spent all its time in proving to the hilt the truth of the rat-fiea theory of the transmission of bubonic plague, as put forward by M. Simond of the Pasteur Institute in 1898 and proved at least to my satisfaction by Capt. Liston in 1903. This did not require such complete verification ; and no time appears to have been yet spent in the far more important questions as to other possible means of infection. The mistake made is in the nature and purposes of the commission. What is required is to discover practical measures for the arrest of plague. The present medical staff has its hands full. A special sanitary staff is essential and a considerable ex- penditure will have to be incurred. The creation of such a staff, its duties and its methods, require the most careful consideration. A small but strong and independent commission DISPOSAL OF SEWAGE. {a) Bullock-Cart for Removal of Slops. (6) New Septic Tank for Simla. Southward from May-Day Hill. ^ being provided for every man's bottle each morning and at intervals along the line of march, with the strictest orders against drinking from any other source. Thcxjapanese colonel admitted that the flasks became emptied on a long day's work, often without any opportunity of being refilled, and that then the men probably had resort to ordinary pools ; but he thought this occurred only seldom. In any case there seemed to be very little typhoid fever, only a little enteric and dysentery, and no typhus, as had been reported, or other epidemic, at the front. Lieutenant-Colonel Macpherson's official medical and sanitary report in 1908 on the Russo-Japanese War — a well-illustrated and most unofficially interesting book — bears out this report. Tired and thirsty soldiers might occasionally escape the vigilance of officers and water-sentries and drink from an unpro- tected well ; but as a rule cleanliness was so ingrained, the regular lectures on health, even in the field, were so appreciated, the disgrace of illness from any pre- ventable cause was so clearly recognised, that disease was far less rife than might have been expected from the hardships and exposure endured. It is interest- ing to find that Colonel Macpherson gives the sickness- rate per 1000 per annum of the Japanese forces in 224 HEALTH AND EMPIRE Manchuria as 590 as compared with a rate of 727 for our forces in South Africa, although the Japanese death-rate from disease was 41 as compared with our South African rate of 24. At the close of the tour round the hospital we ended up in one of the committee rooms, where the European ladies, under the Red Cross Society, were busy rolling long gauze bandages, first by hand and secondly on machines — nice and tight but too long for our ideas — about ten yards. Every day ladies were at work — the Europeans one day, the Japanese five days a week, a most convenient way of keeping them busy and useful. The cynic might remark that it would save both time and trouble for the ladies to subscribe for the bandages ready-rolled ; but this would over- look the main object of a Red Cross Society, which is that of utilising, if not at cost price, then with as little extravagance as possible, the available labour of the voluntary helpers, especially ladies who wish with their own labour to help their countrymen in the field. Thus the authorities had come to terms with the Red Cross Society, and the ladies working under it sent off a few weeks before my visit 20,000 bandages, the result of months of work. Their bandages, as has been already related, had all gone down in the Hitachi Maru ; and so the ladies with courage had set themselves to work again, starting at seven o'clock every morning. They were dressed in uniform — white overalls and caps — they had to scrub and sterihse their hands carefully beforehand ; and the bandages were steril- ised both before and after being rolled. These were JAPANESE RED CROSS 225 all untrained ladies, under the supervision of one or two trained nurses, but there were some ladies with a little hospital training who were allowed to make " first field-dressings " in a special room for the purpose. I was given one of these first field-dressings — to tell the truth, a poor affair, except that it cost four- pence instead of our eightpence-halfpenny. Let it be remembered that these first field-dressings were sewn inside the coat of every soldier going into action. They might therefore have to bind up the dirtiest and most extensive wounds for many hours, perhaps for more than a day, until the injured men could reach proper surgical aid. In the first place they had oiled paper with which to cover over the gauze dressing on a wound. At Wynberg, in South Africa, we early discovered the mistake of an impervious dressing, bottling in often large accumulations of pus. This oiled paper was in the centre of the packet in- stead of outside it, where in our own field-dressing we used to have a waterproof covering to preserve its asepticity. The Japanese dressing again con- tained only one safety-pin against our two. It con- tained no strapping, which is by far the most efficient means that can be given an uneducated man of fastening on a dressing to his wound ; the gauze in the Japanese article was a piece, instead of a strip which might be wound round and round a limb, this helping to keep it in position ; and, finally, the bandage was of the obsolete triangular form, instead of a roller bandage. At a subsequent visit to the Russian prisoners' hospital at Matsuyama, Surgeon-General 226 HEALTH AND EMPIRE Kikuzi, a Fellow of our Royal College of Surgeons, took these remarks very kindly and appeared on the whole to agree with them, so that it is possible that the form of the first field-dressing in Japan may latterly have been materially changed for the better. What then is this Red Cross Society, of which they talked so much during the war in Japan, and which appeared to include in its organisation, in one capacity or another, almost the whole population who were unable personally to go into the field ? The society had its origin in thfe " Haku-ai-sha," or Society of Benevolence, founded during the Satsuma Rebellion in 1877 f°r the purpose of giving relief to the sick and wounded soldiers without distinction of parties. This rebeUion was the last smouldering embers of Japanese tory dissatisfaction with western reforms. In the year 1854 the first treaty with the United States was concluded, and in the year 1863 a British squadron bombarded Kagoshima as a punishment for the murder of Mr. Richardson, who had made the mistake of intruding near Yokohama upon the Daimyo of Satsuma's retinue. Thenceforward the province of Satsuma, in the south-westernmost comer of Japan, became the centre of pohtical activity, the feudal chiefs in the island of K3mshiu maintaining their positions with much pomp and circumstance. This and the fighting qualities of the Satsuma men led to the Revolution of 1868, and the overthrow of the Shoguns or Prince-Regents of Japan, whose authority the Southern Japanese resented. But the same qualities induced still further dissent from the Europeanising policy which followed the resumption JAPANESE RED CROSS 227 by the Emperor of his proper power ; and so Saigo Takamori went out in rebelUon, only to be suppressed after eight or nine months' active warfare, when the town of Kagoshima for the second time fell a prey to the flames, and Saigo, fighting bravely on a hill behind the town, saw that all was lost, and committed harakiyi. In the eyes of the law, the Kagoshima fighters were rebels ; many battles, great and small, had been fought between the insurgents and the imperial arms ; and the numerous sick and wounded on both sides were almost untended. It is a striking tribute to the humane virtues, which are often wrongly denied by western writers to the Japanese, that the association, first-organised by four of the Japanese nobility for the care of wounded, should have resolved on the funda- mental principle of treating patients regardless of party — the outstanding principle of all Red Cross work. It may be pointed out here that Red Cross work and the work of an army medical corps are different, both in principle and in practice. Their divergent aim is only now, with the advance of science and the experience of recent wars, coming to be recognised. The main principle on which an army medical corps must work is that of assisting in the first instance to maintain and increase, from a medical pcant of view, the fighting efficiency of the army ; the guiding principle of a Red Cross Society is the humane desire to diminish suffering at all costs. Now in practice it is clear that both the army medical corps and the Red Cross Society work with both ends in 228 HEALTH AND EMPIRE view. The Red Cross people would naturally refrain, unless they were singularly devoid of tact — in which case, as occurred occasionally in South Africa, they would be made to refrain — from any action that would undermine the discipline of the army, or betray mili- tary secrets. On the other hand, the army medical corps, whose work is primarily that of preserving or restoring to health, with a view to miUtary efficiency, the sick and wounded, would always, so far as possible, give effect to their humane sjanpathies, and endeavour to relieve suffering in every way. But, essentially, the difference between the two branches of work remains and has become more definite with each successive campaign. Occasions may and do occur when some sacrifice of life is necessary ; when the wounded perhaps must be left for some time to take their chance ; when the healthy, on the other hand, may perhaps have to be restrained in their action for fear of certain dangers to health. The advice of army medical authorities and the work of an army medical corps may therefore either lead to a greater freedom of the military power, by relieving it of sick and wounded, or it may involve a restriction of that power as a safeguard against sickness. Above all, their aim must be, as has been said, to maintain a maximum physical efficiency in the fighting force, and in organisation and methods of working to con- form with perfect accuracy to the usual methods of army organisation and army discipUne. It must be admitted that this was not the original intention of supplying medical aid to our fighting services. That original intention was the same as the JAPANESE RED CROSS 229 desire which inspired Count Tsunetami Sano and his colleagues to found the Society of Benevolence, which has become the Red Cross Society of Japan — the natural desire, that is, so far as is possible, to relieve suffering. It was with this purpose that surgeons were formerly appointed in the British army to live and die with their regiments, and it is with this purpose that the work of our Royal Army Medical Corps often meets with the fiercest and most un- deserved criticism, not only, I fear, in society and the Press, who may be excused for being less well- informed, but even in the army at large. It was, on the other hand, by the growth of sanitary science — which the country owes very largely to Dr. Parkes, a military surgeon in the Crimean War — that the strategic advantage of saving life, of preventing disease, and of returning the wounded as soon as possible to duty, was discovered ; and these dis- coveries have shown without a doubt the necessity to an army of prime attention being paid to this aspect of medical work. It was in keeping, not so much with this sanitary principle of strategy as with the accompan3dng principle of conformity with military procedure, combined with the advancement of surgery, that led in our army to the organisation of the Royal Army Medical Corps, with all its system of separate medical units, corresponding to the military units or stations, both in peace and war, and the extinction as such of the friendly but professionally decadent regimental surgeon. The change is cer- tainly for the advantage of the patient in all serious cases ; he is now no longer at the mercy of a man who 230 HEALTH AND EMPIRE may never have seen such a case since his hospital days ; and, if time allow, he has at his command the advice of specialists in all branches of modern medicine. In dealing with large numbers of sick and wounded in the field, often on the march, under great difficulties of transport and sick accommodation, efiiciency is only possible through a properly organ- ised service, and it is at the front that the essentially military character of an army medical service should prevail. But at the base, on the other hand, in war, and still more in peace, the two principles of military efficiency and individual relief are closely intermingled. It is well that voluntary agencies, which have only at heart the individual relief, should be allowed here to have full play ; for at the base-hospitals voluntary agencies can be kept properly in check under super- vision of the army medical corps, and to give such free play is to the advantage not only of the patients but also of the workers, the friends and relations of their countrymen, anxioUs to share in the nation's work. It operates also for the general welfare of the nation in dividing responsibility with the public and in giving a vent to feelings which would otherwise result in much widespread discontent. But voluntary agencies, when thus permitted to share in the medical work of an army, should remem- ber — unfortunately they too often forget — ^that vmi- formity is the essence of efficiency, and that their own civilian efforts may be detrimental to the effect- ive value of the army, may be a distinct hindrance to their country's cause, if not properly surrounded by JAPANESE RED CROSS 281 safeguards which will ke6p the train on the rails. Hence it is that military doctors exact and must exact respect for their authority and rank ; hence it was in South Africa that some of us young civilians found that our soldier patients would unbend to us as they would not unbend to the officers over us, and, in consequence, that they treated us with greater confidence and familiarity, and were correspondingly lax in the observance of our rules. The voluntary worker scoffs at the peremptory command, " 'Shun ! " shouted by the sergeant when the major enters the ward ; he derides the major's determination to have each patient's boots in the exact spot prescribed by the regulations ; he treats with some ridicule the diet-sheets and forms by which his work is circum- scribed. But, when the occupants of his ward return to duty, it is the major-doctor that they will obey, and not the civilian ; it is the major-doctor who will be able to fit them to their kit, and estimate their fitness to return to the ranks ; it is the major-doctor who will err, if at all, on the side of strictness, in order to brace his patients up for further military use ; while it is the voluntary worker who will, without tliinking, do his best to get every patient a holiday before he returns to duty. Thus we see then the natural difficulties of em- ploying voluntary aid in connection with the medical work of an army, and we see the difference in prin- ciple between the work of the official army medical department and the voluntary Red Cross Sisters. We see the need, in enlisting the help of voluntary workers, of bringing their work into line with the 232 HEALTH AND EMPIRE usages, general administration and ultimate aims of the army. These principles are admirably preserved in the constitution of the Red Cross Society of Japan. When the Satsuma Rebellion was at an end the Society of Benevolence made itself into a permanent organisation and took steps to prepare for relief measures in time of war. Nine years later, in 1886, Japan acceded to the Geneva Convention, and the Haku-ai-sha became the Red Cross Society of Japan, with its Christian cross and all. This society is semi- officially under the protection of the Emperor and Empress, the honorary presidency of a prince of the imperial house, and the management of a council, including in its forty-four members several nobles and gentlemen of distinction. The society is supervised by the department of the imperial household, as well as in other particulars by the army and navy. During the Chino- Japanese War the society sent out over 1500 helpers, and during the Boxer outbreak nearly 500, to give relief to sick and wounded on both sides. The experience of the former war resulted in the con- struction of two hospital ships to transport patients from the front to Japan. In this way, in the first campaign 181,428 patients were relieved, nearly 1500 Chinese prisoners of war being brought over as patients to Japan, and treated by the society ; while in the Boxer trouble 11,348 wounded were reheved, including 123 French and two Austrian patients, who were brought to Japan from the allied forces. The society does not confine its work to the calami- ties of war, but has also displayed the greatest JAPANESE RED CHOSS 233 activity in the disasters that afflict Japan more than most countries in times of peace. In 1888, as a result of the eruption of Mount Bandai, 140 miles north of Tokyo, nearly 500 persons were killed and 40 wounded, and the Red Cross Society gave most useful assistance. In 1891 a stupendous earthquake, which laid waste two provinces in the centre of Japan, accounted for over 7000 deaths and more than 11,000 injured ; the Red Cross Society at once rose to the occasion with a couple of temporary hospitals, nine ambulance carts and a small army of workers. Inundations again are of almost annual occurrence, and a tidal wave in 1896, which destroyed 20,000 houses and caused 21,000 deaths, as well as injuring 4000 people, was the occasion for the greatest relief work done by the society in peace-time. Railway accidents and fires supply other similar opportunities. The decision- whether relief shall be given or not in case of any public calamity, and as to the way in which such relief shall be given, rests with the chiefs of local sections, assisted by the local councils. Either the local section of the society or the local authority may take the initiative. Food, lodging and coolie labour for the use of the relief staff are provided by the local authorities ; expenses, however, even where the relief staff of neighbouring sections is invoked, must be borne by the local section of the society. Whatever use be made of its resources in case of pubUc calamity, it is laid down that no interference shall be made with the preparations for the fundamental object of service in time of war. The society numbered in 1904 nearly 1,000,000 mem- 234 HEALTH AND EMPIRE bers, and is arranged in local sectians, organised under the general supervision of the central council in Tokyo. The Emperor and Empress, besides giving an endowment producing £1000 a year, have so far identified themselves with the work of the society that it appears to be a matter of etiquette for all his Majesty's representatives in official positions similarly to give it their assistance. The royal patronage has been exploited to its utmost extent. This patron- age was explained to the prefectural governors in Tokyo on the organisation of the society in 1887, and the Marquis Ito, then Master of the Imperial Household, enjoined them all to become chiefs of the sections established in their respective prefectures. The silver medal of membership is allowed to be worn on public occasions by the side of State Orders, and is considered a great houour ; a still higher decoration, a Medal of Merit, is awarded to those who have rendered special service in recruiting new members or otherwise ; and the attractive force of these de- Qorations, contrary to what one might expect in Japan, is said to have been marvellous. The society is further popularised by annual local assembUes which have become the great social events of the year, including exhibitions of work in field-hosjatals, with wrestling, fireworks and other entertainments. The desire of the rural Japanese to see royalty is shown by the fact that, when it was decided that the honorary president could only attend the general meetings of sections whose membership attained the proportion of i to 100 of the population, the number JAPANESE RED CROSS 285 of such sections rose in three years from 4 to 28, and at the time of my visit only 2 out of the 48 local sections were below the mark. The work of the society had been made known, even in distant villages, by the magic lantern, by various publica- tions, and, for the previous fifteen years, by a monthly magazine entitled The Japan Red Cross. It will be seen therefore that the Red Cross Society of Japan, although represented by local sections, is well organised at the centre. Indeed it has the advantage of having grown centrifugally, from the centre outwards, instead of starting, as a large number of local societies, with conflicting rules, and often conflicting interests, which it might be extremely difficult at a later period to reconcile and co-ordinate. These two different systems in the formation of Red Cross Societies were much discussed at the last International Conference on the subject of Red Cross work in St. Petersburg. The only effective argument against centralisation is the lack of local interest that may result from it. In Japan this interest, as we have seen, is ensured by various social functions and by the organisation of local sections, which, moreover, arouse the greater local interest by their active services in case of public calamity during peace. In Russia, where the opposite system is in force and the whole organisation is entirely decentralised, tv^'o or more local societies may even exist in the same locality, independent of each other, and the local societies are allowed to spend their income as they will. The result of this, as seen in Manchuria, was undoubtedly a very great display of munificence 286 HEALTH AND EMPIRE in the provision of a large number of hospitals and hospital-trains by Red Cross agency, but also, as may be surmised, by absolute chaos. Up to 15th July 1904 the Russian Red Cross Society had sent 138 hospitals to the front, with 15,000 beds, 400 doctors, 1750 attendants and 800 Sisters of Mercy. Many of the best Russian families had sent one member or more to aid in this beneficent work of charity, and various officials on leave had similarly assisted in the work ; but criticism, which is one of the most useful results of war, showed that there had been a great deal of peculation in the management of Red Cross funds. The Moscow branch had become a byword in this connection ; and the Moscow merchants, and many private individuals, Zemstvos and other associations — it was said — preferred to equip their own hospital- trains rather than entrust money for the purpose to the Red Cross Sisters. Prince Tusupoff had his own hospital-train running between Kharbin and Mukden ; and the Empress herself had equipped the most sumptuous train of which I have ever heard, with accommodation for some 200 l5dng-down patients, and an equal number of others, with swing cots on springs, with baths, kitchen and operating theatre, and complete arrangements for a staff of 4 medical officers, so many nurses and 36 attend- ants on each train. Indeed, Dr. Kanal, a most genial and courteous medical officer, ranking as a lieutenant-colonel and attached to the administra- tion at Niu-chwang, spoke with some contempt of the superfluities of the Red Cross, just as one heard JAPANESE RED CROSS 237 similar complaints against some of the private hospitals in South Africa. A Russian banker from Kharbin had himself just seen their No. 20 hospital- train, and described the luxuries with which it was lavishly equipped. " How splendid," the tender- hearted supporters of the Russian Red Cross, or of the South African Imperial Yeomanry Hospital, might exclaim, " to think that the poor fellows will have every luxury that money can buy ! " But this is just one of the glaring fallacies from which Red Cross work must, in order to be efficient, be preserved by the army medical department. Apa;rt from the leakage of luxuries, of which many instances could be quoted, the provision of €xtra luxuries in private hospitals makes for discontent amongst all patients who find themselves in the military hospitals, and makes therefore against the army medical department, weakening considerably the hands and the hearts of its officials. There can be no doubt that the only proper system is that of the Japanese Red Cross, which co-ordinates all private effort into one machine working directly under the array medical authorities, an undertaking being given that the equipment and supplies of the Red Cross units shall be of the same kind only as those supplied by government. Thus, all parts of the machine are interchangeable. When stores give out in a Red Cross hospital they can be supplied by government ; when instruments or comforts are deficient in an army medical hospital they can be replaced by any that a Red Cross hospital may have to spare. Here still is abundant scope for charity. If the 288 HEALTH AND EMPHIE government hospitals are not sufficiently comfort- able, then they must be improved to equal the com- fort which the Red Cross subscribers are allowed to provide ; while, on the other hand, if the Red Cross subscribers wish for further outlet to their charity, they must find it in providing more hospital ac- commodation on the same scale. Uniformity, as I have already said, is the soul of military efficiency. A further lack of uniformity in the Russian system, to which we had some parallel in South Africa in the case of Militia, Yeomanry and Volunteer Medical Officers ordered out to the war, consisted in the miserable pay^ — 144 roubles, or £14 a month — allowed to Reserve Medical Officers drawn from civil life, who had been excused military service in peace- time in return for an unpaid liability to be called out in time of war. Many of them had therefore been obliged to throw up their practices, and for ;£i68 a year to support themselves on active service, and their wives and families at home. Not only had private charity in Russia during the late war to cope with the difficulties of bad organisa- tion and military apathy, but, when they took matters into their own hands, the public had fre- quently to face the often insurmountable obstruction of peculant officials. An association of nobles in the south of Russia — so I was confidently informed — equipped a special ambulance for the war ; all the preparations were complete, and the train was ready to start, but the requisite official permission was repeatedly and for no given reason delayed. One of the members of the association went personaEy to JAPANESE RED CROSS 239 St. Petersburg on the subject, and finally discovered the cause of the trouble in a certain highly-placed military official. A substantial douceur having been provided, all difficulties vanished, and the ambulance was allowed to proceed. I was told again of a former chief of police who had been dismissed and imprisoned for peculation some years ago but was sent out by the Red Cross Society with the sum of £60,000 to be expended in the Far East. The whole sum disappeared — ^none of it on the objects for which it was intended — and im- pudent bribery had gained such a foothold in official circles that the ex-chief of police was recalled and given another appointment at headquarters. The evidence one picks up in war-time and at the seat of war must without doubt be taken with a double pinch of salt ; but the evidence on this point was too general, too succinct, to have been far wrong. In the forty-nine prefectures of Japan, including Hokkaido and Formosa, local Red Cross sections are instituted, partly by the officials of the local govern- ments and partly by the functionaries of the society. They are assisted by a council of influential citizens ; their headquarters are often in the local government offices ; and local committees, with the mayors as their chiefs ex officiis, are formed in all cities and country districts. Besides a few honorary members of the imperial family, membership of the society is either special, following on special service or the donation of ;£20 and upwards, or ordinary, entaiUng a donation of £2, los. or an annual subscription of 3 yen (or florins) for a period of ten years. In 240 HEALTH AND EMPHIE addition to these subscriptions, donations and legacies are also made .by private benefactors, and grants by the imperial household. Of the income of the society a part goes to the local sections in the pro- portion, firstly, in Formosa and Hokkaido, of 54 per cent. ; secondly, in prefectures where there are headquarters of army divisions or naval stations, of. 40 per cent. ; and, thirdly, in other prefectures, of 35 per cent. The remainder goes to the central board. The funds of the society amounted to over 8,000,000 yen, or £800,000; the annual subscriptions in the year in question were 2,354,558 yen, or nearly 3^235,000. In the summer of 1904 the staff of the society included 314 physicians, 129 dispensers, 239J nurses, 717 male attendants, 150 stretcher- bearers, 87 clerks and 5 administrators. As a retaining-fee administrators, physicians and dis- pensers received 6s. a month; assistant dispensers and the chief male attendants, 3s. ; other male attendants and stretcher-bearers, is. ; and nurses, nothing. This lack of pay to the nurses is justified by the fact that they have received a gratuitous, training, which enables them to find good employ- ment. On being called up for active service, or for manoeuvres and other instruction, or for assistance in the case of public calamity, some " departure money '■ and travelling expenses are paid to them, and a salary so much better than that paid to members of the army medical service as is justified by the fact that they are summoned from civil life to undertake their duties. JAPANESE RED CROSS 241 A special feature of the preparation of this reserve is the training of its members. The society con- tracts with certain chosen medical students in the imperial universities of Tokyo and Kyoto to pay the expense of their education, on condition that, on graduation, they become reserve-physicians of the society. They are then attached to the central hospital of the society in Tokyo, where the famous Dr. Baron Hashimoto decides on their efficiency. One or two of these young doctors are always study- ing in Europe at the expense of the society, but for the present it would be impossible to train their whole staff, and certain physicians trained in private medical schools are engaged on the reserve of the society, and instructed in the special duties of military work by appropriate courses of lectures. The training of nurses is of greater interest, because it strikes new ground, and has a wider social effect, in opening to the women of Japan a calling which had not previously been held in good repute. In so essentially aristocratic a country, it required some courage and much tact to overcome the stigma that naturally attached to the work of the sick-nui:se. The step was taken by certain ladies of high degree, who boldly faced the situation and designedly inaugurated the new system, with the result that the stigma had by 1904, at least in the main centres, entirely died out. Candidates for the nursing staff of the Red Cross Society, between the ages of seven- teen and thirty, are admitted, after an examination in elementary subjects, to a three years' training at headquarters or under the local sections, either in Q 242 HEALTH AND EMPIRE hospitals of the society or by a specially instituted training board or in private hospitals. Uniforms and outfit are lent to them, and a monthly allowance made of from ten to fifteen shillings for pocket-money. Emphasis is evidently laid on the scientific side of their training, for the first year and a half is devoted to theoretical instruction and only the last half of their training to practice. After successfully passing their final examination, they enter the reserve of the society under vow. The best are selected to undergo a further six months' training under Baron Hashimoto at Tokyo, and, if they successfully pass a further examination, they are nominated chief nurses as vacancies may occur. During the period of their vow the nurses are eagerly sought after in hospitals and for private work. They may marry if they Uke, but they remain at the call of the society ; and now the society has created at headquarters a " Board of External Service " for the nurses, practic- ally a nursing institution, which receives all fees and pays the nurses an annual wage. The training of male attendants is an easier matter. Perhaps it should be taken as a compliment to the greater abiUty of the male mind that a training of ten months is considered sufficient for the male attendant ; his age is from twenty to thirty-four, and his allowance double that of the nurses — viz. sixteen to thirty shiUings a month. Of this training the first five months are spent in theory, and the remaining five in practice in hospitals of the imperial army. The men are thus brought up in the atmosphere of military organisation as the very breath of thdr JAPANESE RED CROSS 248 nostrils. The best are selected for a further two months of study, with increased allowance. Un- fortunately, they can find after graduation but little private employment, and so they are given frequent exercise at their duties in manoeuvres, and, whenever possible, in cases of public calamity. Stretcher-bearers form a fourth class for whom training must be provided. They must be under thirty-seven years of age, and, during three months' training in the art of transporting the sick and wounded, they are taught such useful sundries as the improvisation of ropes and stretchers, their ingenuity in this line being probably unequalled in any other army in the world. During this training they receive a monthly allowance of thirty shilhngs, with uniform and outfit, and the best are given a month of further training, which quahfies them for appoint- ment as chief stretcher-bearers. They too can find but little private employment as such and there is some difficulty in recruiting them. The vow of all nurses is for fifteen years ; that of male attendants, ten years ; of stretcher-bearers, seven years ; of physicians, dispensers, administra- tors, clerks, chief attendants and chief stretcher- bearers, five years. For nurses, dispensers, physi- cians and administrators, the retiring age is fifty-five ; for all others, forty-five. To understand the careful way in which the work of the Red Cross Society is sandwiched in with that of the army medical department, and the whole embodied in the general military system, instead of being a mere appendage, it is necessary briefly to 244 HEALTH AND EMPIRE describe the scheme on which the medical service both in the army and in the society is organised. After the Chinese War of 1894-1895 missions were sent over to Europe to study the work of sister- societies. In accordance with this mission, in con- sultation with the military authorities, the first regulation for relief service in time of war was rati- fied by the minister of war in October, 1898, and put into practice in the Boxer troubles in 1900, which suggested certain modifications embodied in its newer form in November, 1903. In a campaign the sphere of military activity is divided into three zones — the base ; the lines of communication, or Hape ; and the front. At the front the sanitary corps and the field-hospitals are administered under the direction of the chief of the medical staff of the army, or of the divisions composing it. Along the lines of communication the transport of sick and wounded and the maintenance of hospitals are carried out under the chief of the medical staff of each line of communication. The base is divided into so many territorial divisions, each with its medical service under a chief who administers the affairs of the base- hospitals. Attached to imperial headquarters, which may be situated at the base or on the Unes of com- munication, is the director-general of field sanitary service, to whom the chiefs of the medical service on each line of communication are directly re- sponsible. Such being the organisation of the army medical service, that of the Red Cross Society follows it closely. The reserve-hospital and rest-stations at JAPANESE RED CROSS 245 the base are under the direct control of the president and the chiefs of local sections, who are in touch with the commanders of the corresponding territorial divisions. To imperial headquarters is attached the general administrator of the whole society, whose function it is to direct and control the service of all the relief corps of the society sent out to the lines of communication. These corps work only at the base or on the lines of communication ; and their work appears to be good ; but there appears to be one slight flaw in the arrangements. The general ad- ministrator of the society takes his orders only in medical affairs from the director-general of the field sanitary service, in others from the inspector-general of the lines of communication. He works similarly through his administrators, one for each line of com- munication, who in their turn take orders only in medical affairs from the chiefs of the medical staff of their lines of communication, but otherwise from the inspectors, who are purely military officers. The relief despatched by the society to the Unes of com- munication takes the form of reUef corps, under a manager, who again takes his orders in purely medical affairs from the chief medical officer of the locality or unit, but other orders from the military or naval authorities, subject always to the instructions of the administrator along his line of communication. As a rule the manager of such a relief corps is not a physician. The society's service, therefore, is work- ing under two separate authorities, medical and military, as is the army medical service itself ; in professional duties only are its agents under the 246 HEALTH AND EMPIRE control of the medical officers of the military service. Such a system must entail much extra trouble and delay; a military service should, subject to its general subordination to mihtary command, be able to manage all its own affairs by itself^ The relief corps of the society consists of separate detachments, which are found far more useful to the army than separate hospitals. The relief detach- ments have as their standard an organisation reckoned to treat loo patients, with 2 physicians, a dispenser, a clerk, and 22 nurses or attendants. Of 112 such detachments for the army and 4 for the navy in 1904, 94 were formed with nurses, and they alone were used at the base ; 18 were formed with male attend- ants, and they were more frequently employed along the lines of communication. Three relief corps are organised as transport columns, calculated for the transport of 30 specially serious patients, with a manager, a physician, a clerk, 5 attendants and 123 stretcher-bearers. Two relief corps are organised in the equipment of two hospital-ships — one for 200 and the other for 100 patients — in which corps, in time of war, it is interesting to read that a mechanic, an interpreter, a barber and a washerman are also in- cluded. Another relief corps is organised as a supply d6p6t for medical and sanitary material, for clothing and bedding, and for stationery, to work on the lines of communication. In time of peace only one such d6p6t is kept ready, but in war others may be formed at once. Finally, the Red Cross Society organises in Japan rest-stations at ports of disembarkation, and at railway stations through which patients travel, JAPANESE RED CROSS 247 the regulations and the staffing for such rest-stations being left entirely to the local sections of the pre- fectures in which they are situated. It will thus be seen that the organisation of the Red Cross Society is complete and independent. The material needed by the relief corps serving at the base is supphed directly by the headquarters of the society ; that required by rehef corps on the lines of communication by the supply d6p6t in the field. Rapid mobiUsation is ensured by two detailed reports of the preparation made for the purpose for the coming year, presented by the president of the society to the ministers of war and navy before the end of September in each yean On receiving these reports the ministers assign to such relief corps as are likely to be needed fixed services in the naval and miUtary systems in case of war. The whole plan of mobihsation, with the necessary orders — already as far as possible printed — ^is stored away at headquarters and with the local sections, so that only the date, names and time and place of formation have to be filled in before issue. The distances of the abodes of different members of the corps are kept in a list, so that it may be known exactly in how many hours orders can reach them. Baroness Sannomiya's kind invitation took me on ist July 1904 to the Red Cross Society's d6p6t and store, in a different part of Tokyo from the hospital. The ladies of the Red Cross had formed a volunteer aid society, which, with all other voluntary bodies concerned with the bodily and monetary reUef of soldiers and sailors and their f amiUes, was co-ordinated 248 HEALTH AND EMPIRE under the Red Cross Society ; and of this a small donation had made me a life-member, with medal, ribbon, button and certificate in Japanese characters, signed by the Emperor, complete. The Baroness Sannomiya, an English lady, and wife of the Master of the Imperial Household, was the heart and soul of the ladies' organisation. She herself on the occasion of my visit showed me all the details of the work, introducing me to several of the workers. An elderly, white-bearded doctor, retired from the Japanese Army Medical Service, was giving his weekly lecture on bandaging and first-aid on a dummy to a large roomful of little native women in sandals, Japanese costume, and elaborate coiffures, associates of the Red Cross Society ; " such an ex- cellent thing," as the baroness said, " for their homes, if not of very great importance to the army." The nobility appear on these occasions — for evidently their presence is a considerable attraction to the people — as, for instance, two delicate little ladies of royal blood, besides the Princess Nashimoto, whose husband was on his way to the front and who talked of photography in eager French. A fourth lady, who sat with them in an alcove of the room, and with whom I made a vain endeavour to shake hands as with the rest, must have been a lady-in-waiting; and bustling about in the crowd were Baroness Nobeshima, mother of Princess Nashimoto and wife of the only daimyo who takes any prominent part in public affairs, and Marchioness Oyama, who has lived for some time in America, and spoke charm- ingly in fluent English of her many Anglo-Saxon JAPANESE RED CROSS 249 friends. In a corner were two or three large cards, on which were mounted abou> fifty models, beauti- fully made, of every kind of improvised stretcher and carrying apparatus for sick and wounded. To my intense delight, the Red Cross Society, at the instance of the baroness, subsequently made and sent me as a present a replica of these beautiful models, which are now exhibited in the museum of our Royal Army Medical College at Millbank. Two kindly Japanese gentlemen showed me round the vast stores, in which, without being able to under- stand their comments, I noticed several useful im- provements on our South African equipment — light and handy trunks instead of our clumsy and heavy hide-covered panniers ; scales on the Danish lever principle ; measures and cups of hard paper ; paper for use as mops in surgical dressings ; powders al- ready made up in Uttle paper packets ; stomach and rectal rubber tubes ; and a really useful and intelligent selection of surgical instruments. They had good cases of carpenters' tools, presumably for the purpose of making splints and stretchers. Their warm quilted clothing looked at least extremely comfortable — ^if it wears well and does not become infested with animal Ufe, it would be of use for our own or our Indian army in cold climates. In only two points — their lacquered aluminium water-bottles and their supply of " gooched " wood for splints^ — should I say that we in South Africa had the advantage. I have treated at some length of the constitution and work of the Japanese Red Cross Society, for some effort is now being made in an interval of peace 850 HEALTH AND EMPIRE to organise our own scattered and conflicting instru- ments for voluntary relief in time of war into an effective machine, on a recognised basis, with recog- nised duties and responsibilities, professedly after the foreign model. It is unnecessary to dilate upon the waste of money and material that resulted from the lack of such organisation in South Africa ; it is unnecessary to labour the jealousies and rivalries to which it gave rise and the diminution of authority, of efficiency and of subsequent credit which it im- posed on the Royal Army Medical Corps. What is necessary is to drum three ideas into our countrymen's heads : firstly, that whatever may be our belief as to the moral or even commercial value and as to the feasibility of abolishing war, no such beliefs in the positive are shared by continental nations, from which it follows that war may come on us even this year, as on France in 1870, as a thief in the night, and against that calamity we should prepare ourselves, insure ourselves, forthwith ; secondly, that preparation for war makes a most attractive and practical framework for the citizen's duties in times of peace ; thirdly, that the movement should be national, not sectional, the burden spread over the whole populace and not confined to those who realise their duties most keenly. To this end in 1898 a " Central British Red Cross Council " was formed of representatives from " The National Society for Aid to the Sick and Wounded in War," the St. John's and St. Andrew's Ambulance Associations and the Army Nursing Service Reserve, with three representatives of the War Office and one JAPANESE RED CROSS 251 of the Admiralty. To this end, after the South African War, in which the National Aid Society spent ;£i62,ooo, these bodies were fused in 1905 into a single British Red Cross Society, with King Edward as patron; Queen Alexandra, president ; Lord Rothschild, chairman of council, and Sir Frederick Treves, chair- man of the executive. To the same end, in co-opera- tion with the British Red Cross Society, the War Office in 1909 initiated a scheme for the organisation of voluntary aid detachments under the county associations responsible for the territorial force throughout Great Britain. Of these voluntary aid detachments there were 415 at the end of January last, with a personnel of nearly 4000 men and over 8000 women, or 12,500 in all. The peace value of this organisation is likely to be considerable, owing to the requirement by the War Office that candidates for the women's detach- ments should be either trained nurses or cooks, or should be in possession of certificates for first-aid and in home-nursing. For this purpose lectures are being given and classes held in the basis of a syllabus alike to that of the London County Council. Combined with the boys' and girls' scout movement this should serve to raise very materially the knowledge of the rules of health and to stimulate public opinion as to their value. It is on this general knowledge and apprecia- tion of the rules of health that the health of the nation must ultimately depend. But the Red Cross Society has as its primary object the furnishing of aid both to the navy and army, both to the territorial and to the expeditionary force, in 252 HEALTH AND EMPIRE time of war and for this^object to promote the organisation of Red Cross work throughout the Empire as well as at home. In case of war it would propose, following the precedent set in South Africa, to equip hospital ships and trains, provide auxiUary hospitals and convalescent homes, make supplementary arrange- ments for transport of sick and wounded, establish f ood-d6p6ts along Unes of communication and supply certain articles of clothing and comforts over and above the official requirements. The Red Cross Society might also perform a most useful function in supplying additional personnel for the medical services of the army. Machinery should be established through someone of influence at each medical school, for the selection, when required, of suitable young surgeons, on whom, however, any retaining fee is absolutely thrown away. A still greater difficulty in the South African War was that of supplying the need of male nurses ; and for this purpose arrangements should be made, in connection with the work of the voluntary aid detachments, for civilian hospitals to undertake the training of male nurses, of whom there is always need for a few in the casualty ward and strong-room. Owing to the better organisation of our army medical department, especially since Mr. Brodrick's reforms, the work required of a British Red Cross Society is less essential to the welfare of the navy and army than that required of the Red Cross Society of Japan. But it must be remembered that the standard of comfort desired, if not demanded, for the sick and wounded in the field differs widely in the two cases ; JAPANESE RED CROSS 258 the standard of comfort to which the soldiers and sailors of the two island powers are accustomed in times of peace is very different. Moreover it is essential to give scope for the activities of those who, full of patriotic feeUng and of sympathy for the com- batants, are themselves debarred from fighting. The actual value of the bandages rolled in the Red Cross d6p6t at Tokyo may have been small ; the moral effect of those classes was very large. The extra- ordinary influence which the Emperor and Empress of Japan and the leading Japanese nobility have brought to bear with effect on the formation and triumphant working of their Red Cross Society gives warrant for an earnest hope that their Majesties, King George and Queen Mary, may similarly succeed in consoHdating a work of such great beneficence to the individual soldier, of such great importance to the nation, under a Royal Red Cross Society extend- ing to every comer of the British Empire. CHAPTER XIII TH-E AFTERMATH OF THE RUSSO-JAPANESE WAR The International Rank of Japan.— For those who read with understanding, or have been privileged to see something of latter-day Japan, it is difficult to write without an undue use of the superlative. There can be no doubt as to the completeness of her victory in the recent war, both on land and sea ; none as to the thoroughness of her official preparation for the struggle, or the sympathy with official action that saturated every class of her people ; none as to the simplicity and natural power of her domestic life ; no doubt, in short, as to her first-rate equip- ment for competition with other great nations of the world, or her paramount naval and military supre- macy, at least amongst all powers east of Suez. We Englishmen and our American cousins are above all qualified to appreciate the significance of her unique and rapid rise to this position. Our own defeat of Spain and Holland in the sixteenth centmy and subsequent mastery of the waterways of the world ; our own conquest or colonisation of North America, of India, of Australia ; our permeation of Africa ; our European victories a century ago ; the spread of our flag and of our trade in ports of aH the seven seas and the lands behind them, enable us to imagine »S4 THE AFTERMATH 255 the significance of the recent rise to power in Asia of a nation with a history, strategic position, resources, spirit and temper in many ways hke our own. In relation to the oceanic world, the United States hold the keys of America; Great Britain, for the present, of Europe, Africa and Australia. Japan seems destined to hold the keys of the Asiatic continent. This stipulates, without a doubt, a certain faith in the commercial abihties of the Japanese people, with an expansive power to stimulate the growth of a large merchant-fleet and necessitate the constant efficiency and the increase of her navy and army. If so we read the facts, we must grant to Japan the first position on the waters between at least the Straits of Malacca and the American coast, north of the Panama Canal, and the Indo-Australian ocean-road. The Aims of Japan. — If we rightly understand the motives and ambitions of our eastern ally, it would seem certain that her object has been no mere military triumph, but a stable condition of affairs in which she may have full opportunity to develop her commercial activities. She has thrown off the corset to give her body full play. In establishing, therefore, her new position in the hegemony of the world, she would above aU seek to establish international peace on the sea and secure equal rights and opportunities for her trade with other nations that may in trade be her rivals. In the recent war she has striven not merely to defeat Russia, but to estabhsh her in- dependent power and prestige in the sight of all nations. It is not least for that reason that she 256 HEALTH AND EMPIRE prided herself on her financial achievements, that she conformed strictly to the properties of western diplomatic usage, that she refused all offers of help from outside, even from myself and others in the care of her sick and wounded, and showed a noteworthy advance in her humanity since her war with China ; and that she steadfastly preserved the integrity of the ring round herself and her late antagonist. It was not least on these grounds, we believe, amongst others, that she was content to forego many of her demands that appeared legitimate and reasonable in the final negotiations at Portsmouth, since the ulti- mate terms assured in some degree the future peace of the maritime world, as well as freedom for Japanese expansion on the Asiatic continent. It is these facts that suggest a practical policy for adoption in the interests of universal peace by five chief nations of the world. The suggestion was made while Russia was still at war with Japan, while Great Britain, in addition to her traditional distrust of Russian policy in near and middle east, was fired by the admiration of her valiant ally and was smarting under the provocation of Rojhdestvensky's exploit in the North Sea. The suggestion, recorded in ink and rejected by two monthly reviews as premature, in 1905, is already in 1911 to some extent an established fact and out of date. Its prospect is therefore encouraging. The Five-Pomer League. — This proposal is inspired by the success that has alteady attended King Edward VII. 's most remarkable diplomatic achieve- THE AFTERMATH 257 ment, the cordial agreement between Great Britain and France. For half-a-century these two nations had been at loggerheads. In one diplomatic movement these difficulties were frankly recognised, considered and swept aside ; each nation acknow- ledged the legitimate aims of the other, and by a scheme of give-and-take they now appear before the world as the staunchest of friends. As with France, so with Russia. The Crimea, India, Persia are no longer a source of contention and distrust. The mid-east has to count now on our co-operation, not our rivalry ; and in her struggles for peaceful development at home Russia draws nearer to Great Britain every day. There is then a certain basis of fact — the alliance between Russia and France, the agreement between France and ourselves, the no less remarkable alli- ance between ourselves and Japan, and the friendly sympathy of our kinsmen in the United States. There is already a definite knot connecting every pair of nations here named, which thus constitute a girdle of power, beginning with Japan, passing across North America and the Atlantic to ourselves and France, ending in European and Asiatic Russia. Since agreement has now been confirmed between the two ends of this chain, whose extremes met in the recent campaign, the circle is diplomatically com- plete and the world girdled by a zone of powers, content with the present disposition of the earth's surface and therefore intent on peace. This war we look on as the necessary preparation for such an arrangement. Before the war Russia did not reahse 258 HEALTH AND EMPIRE the strength and the future of Japan ; it is not certain that Japan or the other great powers of the world yet fully realise the strength, still less the probable and legitimate future, of Russia. It was impossible, without some such understanding, for Russia and Japan to come to terms. That being now effected, it will now also be possible for the five nations in question to agree upon a general policy. The Effect oj Improved Communications. — The full significance of last century's achievements, through steam and electricity, penny postage, national education and the Press, has not yet been fully realised. Is it not a logical result of these inven- tions that no national or international act be- tween civilised powers can now be done in secret ? Did not these very agencies avert the most serious issue in the case of the Dogger Bank incident, when their absence might have precipitated a second battle of Navarino ? Differences and mishaps such as this may then surely and invariably henceforth be settled between peaceable nations by agreement ; and the peaceable attitude may be no less surely prepared by a deliberate and comprehensive survey between all nations of their respective strength and interests and by a series of ententes, at first between nations already friendly and then between those reputedly hostile. The loss is in each case small, the loss of any advantage that might have been obtained by bluff or other war-endangering device. The advantage would seem in proportion great, the businesslike advantage of national security in the THE AFTERMATH 259 pursuit of acknowledged aims, coupled with the active help of the co-operating nations in their pursuit. The loss appears ever less as the influence of last century's scientific progress becomes more clearly realised. This is the true method of pre- venting war, apart from the inculcation of the idea that peace is desirable. It is operating now and has already prevented war ; and it can always claim a precedent in that duelUng has ceased in England for nearly a century. Arbitration is quite another thing. Arbitration between two powers who have come to blows without a previous understanding and without the desire for peace is of little value ; and we may be grateful to the German Chancellor for reminding us that might is still right in the eyes of many and that arbitration in those eyes is valueless. Grant, however, the understanding and the desire for peace, as in the case of the United States and ourselves ; and arbitration \yill become a useful and natural method of settling disputed points. Arbitration is diplomacy in public ; but it cannot enforce its conclusions on nations who may deny their justice and have power to resist them. The advantages of mutual understanding are adver- tised by each successive international agreement, great or small. In a game of bridge, beginners play every hand through to a finish ; experts throw their hands on the table, three, four or more tricks before the end. Politics is but a game of cards for heavy stakes. It is generally a game of bridge, not of whist, with at least one dummy hand exposed throughout. We have so many tricks, let 260 HEALTH AND EMPIRE us say ; for we have one or two leading cards in our hand. You take the rest. Let us count the score. The United States. — If then the understandings and agreements between France, Russia, Japan and ourselves be likely to prevent international war, so much the more probable and effective will be the inclusion of the United States in this group. The proposals for fiscal reciprocity between the States and Canada, their common interests and growing communications with Australia, New Zealand and the United Kingdom, are drawing the States closer to each dominion of the British Empire; while their relations with Japan on the one side and France on the other are free and friendly. If only for selfish reasons, they must, like ourselves, desire the world's peace. They would not, therefore, enter into any such powerful combination, if such action were viewed with hostility, for instance, by the triple alliance. For that reason the agreement proposed must de- velop slowly and naturally ; understanding with other powers must develop concurrently ; but public attention must for practical reasons be focussed on the agreement of the five powers as the first aim. The Triple Alliance. — It is an age of large con- cerns; and this proposal aims at concentrating the most active powers of the world into two definite groups, the five-power chain to match the triple alliance. But the friendship between ourselves and Italy should act like the understanding between ourselves and France during the Russo-Japanese THE AFTERMATH 261 War, when feeling ruled high under much pro- vocation between this country and Russia. Italy might be the means of gradually accustoming the chain and the triple alliance to understand each other's power and aims. Surely a comprehensive understanding is more likely to be effected by first grouping the powers on two sides than by a series of partial understandings between each pair of the eight powers concerned. This possibility is made more likely by the increasing co-operation between Germany and ourselves in the near and far east, by the increasing facilities for the expression of inter- national opinion, by the more widespread apprecia- tion of the burden of armaments, and of the hindrance it imposes on commerce and therefore on national prosperity. In a general understanding between the chain and the triple alliance lies the best, if not the only, hope for the limitation of armaments and the cessation of war. But the understanding must come first. The Danger of Further Understandings. — But the danger of this policy must be freely stated for it to be avoided. In seeking friendship with the triple alliance we shall be endangering our friendship with France unless it is clear that the one is dependent on the other. No major diplomatic agreement there- fore is desirable between individual nations on either side, except by the consent of their partners. Such no doubt is the policy of our diplomatic service at the present day. It needs to be impressed also on pubhc opmion. 262 HEALTH AND EMPIRE So in the same way closer direct relations between our dominions and other, even friendly, powers must tend to loosen the bonds of Empire, and should only be entertained concurrently with the progressive consolidation of the Empire. German Expansion. — And meanwhile we must go armed to the teeth. Nothing strikes the British traveller more, if he is concerned in world politics, than the astonishing growth of German influence in all spheres of modern life and in all parts of the globe. Saturated at home with his original articles and text-books, newspapers and blue-books, in every case comparing British conditions more especially with German and showing an extraordinary development to the advantage and credit of Germany during the last thirty years, the Briton sets out on a holiday to Switzerland or the Riviera, and finds the German competing with him again in the wealth and leisure hitherto considered the monopoly of the Englishman and the American. He travels to South America or the States, and the German is there also ; to each port in the circuit of Africa, and the German is established in every one ; to the most distant lands in the Pacific, and German commerce is growing. In Singapore — the naval and commercial cross- roads from Europe and India to Australasia and the far east — ^the business men seem to be mostly German or Dutch, and the finest building of the sort is the German club-house. Both there and in Hong- Kong the proportion of German shipping had, at the time of my visit, been steadily increasing, and THE AFTERMATH 263 the German leasehold of Kiao Chau was being methodically developed as a centre of German com- merce and power in celestial waters. This is no occasion for jealousy ; the British character is not selfish, and indirectly British com- merce takes its share of any commercial development, except that behind closed ports. But would a German Sir Walter Raleigh rest content in the present day ? There is every need of anxiety, for we have everything, Germany little, to lose by a war ; we oc- cupy with a scanty population many of the countries best suited for development ; Germany, longing for similar outposts, is bursting with commercial and imperial energy. She will soon have usurped the jingo song : " We've got the men, we've got the ships, We've got the money too," and when the favourable opportunity occurs and the military party in Prussia see their way, it will then go hard with our empire in the Pacific, unless in every vulnerable quarter — and Australasia is the most vulnerable, — unless in constant proportion to rival powers, we go armed to the teeth. The Function of Navies. — A self-contained country with peaceful intentions requires little of a navy for the protection of its coasts and its com- merce. But extension of power and of commerce requires naval strength ; and a scattered empire requires naval strength. A navy is above all re- quired for the protection of commerce, and must bear a definite proportion to the amount and vulnerability 264 HEALTH AND EMPIRE of trade it has to protect ; that is the justification for expanding the British navy. But the navy gives power in every sea, and no country with growing energies can submit to be permanently subject in every sea to the dominance of its rival, on whose motives and justice it cannot feel sure. That is the reason for the miracle of the German navy. Neither country can object to the naval policy of the other ; but interests are bound to clash, and even the most peaceable intentions for settlement are in fact subject to the final arbitrament of war, either latent or realised. The sooner we rivet up the five-power chain the sooner will it be possible to come to a general understanding with the triple aUiance, to reduce the probability of great wars and to set free money now spent on the arts of war for the more productive arts of peace. China. — We shall be none too soon ; for the nations of the west are in face of a greater danger than war between themselves, a greater danger than war itself. China, the most peaceful of nations when undisturbed, the least ambitious because the most assured of its pre-eminence, has against its will been enhghtened and aroused by the forceful intrusion of the European powers. Actuated for the most part by the internal impulse of expansion, to some extent by a partial benevolence towards the Chinese, they have insisted on a policy of peaceful penetration, grounded on force. Portugal and England, Russia and France, Germany and the United States have all assisted in this policy in China, a policy, indeed, THE AFTERMATH 265 applied not specifically to China, but generally to the whole non-Europeanised world. Regardless of other civilisations, ignorant of other codes of morality and justice, of other standards of happiness and prosperity, Europe has insisted on disturbing the social equilibrium of every race unable to withstand interference, in order to do away with injustice, to do away with the gamble in life, to force their treasures and their labour into the world's market and to force on them the consequent discontent which leads to luxury, revolution and the misery inseparable from international competition. Japan was the first to take up the challenge. Fifty years ago the Japanese were the toythings of Europe ; to-day they are a power of the first class. Ten years ago the Boxer outbreak showed the strength and weakness of China to the world and to herself ; even five years ago her professed intention to abolish the opium habit was regarded as a trick ; to-day it is on the way to accomplishment. She is building railways; she is building up a constitution ; she is learning European inventions and sciences ; she too is entering the " comity " of nations. When China too begins to preserve life and to swell with the desire for expan- sion, in which direction will she expand ? Through inhospitable Thibet into India ? Through Turkestan into Russia ? Or across the seas to the vacant lands of AustraUa ? " Eventually," said Li Hung-Chang once to one of my feUow-traveUers, " you will all have to go; unless — you stay behind as coohes." And Sir Robert Hart has told us that a Viceroy exclaimed : " Fools, you Europeans, trying to wake 266 HEALTH AND EMPIRE us up to military power. We don't want it ; but it will come now, and you will be sorry for it." The Real Yellow Peril. — But there is no need to presume she will have to use the force that will inevitably be hers, with her one-fifth of the world's population, and her national characteristics of wisdom, ruthlessness and endurance. She too is already adopting a reciprocal policy of peaceful penetration. In Singapore all the shops appeared to be Chinese ; in Perdk the big villas belonged to the prosperous Chinese; the Malay States were de- pending for revenue and for development on tin, and the tin mines on voluntary importations of Chinese ; Kudla Lumpiir, their capital, in a population of 32,000 at the last census in 1901 numbered no less than 23,000 Chinese. The boat which took me from Saigon to Hong-Kong under an Enghsh captain was one of the old blue-funnels of the Holt Line, which had sold its Borneo steamers to the Nord-Deutscher Lloyd and this boat and another to a Chinaman, once an office-clerk in Hong-Kong. In every country round the Pacific the Chinese are known to be the most honest and the best workers, either as labourers, clerks or merchants. Force China into the world's markets and she will beat every one of her rivals to whatever extent she may please. She is so being forced; her appetite is being whetted; our European imports are rammed down her throat and Chinese exports must in return be exploited abroad. As yet the competition is little felt, felt mostly by those firms whose secrets China has, as yet indifferently. THE AFTERMATH 267 learned, and whose services are now superseded in China's home markets. And when Chinese manu- facturers enter foreign markets, they must at first be handicapped by distance and by experience. But that will pass and then the yellow peril will be realised. Personal industry, intelligence, numerical strength and an incredibly low wage combine to make China a commercial power in the future with which there would seem to be no possibility of competing. A rising physician, a young Scot, once told me his ideal laboratory would be worked by Chinese, supervised by Germans and directed by himself. The Birth-rate. — The numerical strength of the Asiatic powers is no small factor in the situation. For the last thirty or forty years the birth-rate of all white nations, with the exception of Russia, has been steadily declining ; that of Japan has steadily risen ; those of China and India can only be surmised. The white nations have learnt how to save, but also how to prevent life ; Asia has learnt neither. We are teaching the Asiatics how to prevent or minimise war, famine and pestilence, to check infanticide, to strengthen and prolong life. Under such conditions the natural increase of the coloured races will be overwhelming. Are we to wish that they too will lose the natural desire for children and learn how to check the birth-rate ? If not — since Japan at least is forewarned and forearmed, and China will not fail to profit by the experience and weakness of the white nations — we have to face in the future an expanding 268 HEALTH AND EMPHIE force, which will intensify beyond measure the force of the yellow peril. Protection by Exclusion of Chinese. — How is this real Chinese peril to be met ? It is already met in one respect by the most obvious method of pro- tection, the importation of Chinese labour being forbidden, or taxed out of serious existence, in most or all the white men's ports south and east of the Pacific. If China were to set up factories of her own in the white man's land, even free trade would hide her head, or would have no more head to hide. Great as are the benefits of free competition to the consumer, their price is too high if it is to lower the standard of living in white communities to that in China. And yet this would be the logical outcome of theoretical free trade carried into universal practice. Chinese labour working under European direction on equal terms would in time be able to undersell the produce of European labour ; and it is for that reason that white labour, rather than white capital, is unanimous in excluding Chinese workmen from the shores of the Pacific, on which the white men are themselves developing industries. Effect on White Labour oj Chinese Competition. — But protection of white labour cannot stop there. Asiatic labour lives more cheaply, will be content with lower wages, at home than in a white man's land ; and as merchaints in Asia, whether white or Asiatic, find it worth their while, so will they be able to develop industries based on Asiatic labour ; they THE AFTERMATH 269 would be handicapped after a time only by the cost of freight, subject to the supply of raw material, of which there is in China an ample supply of nearly every kind awaiting exploitation. What is to pre- vent Chinese rails, now making their Mhut on the Chinese railways, from undercutting European rails also abroad ? China is aboHshing the opium habit, reforming her government, her army, her currency ; and as a precedent Japanese products are already competing with European in European markets. At first western capital may face the competition and be content with smaller earnings ; but capital is fluid and soon finds its way to the source of high dividends — even to the Far East, if needs be, to support our successful rivals. Free competition must in time focus itself on labour and the present rivalry in armaments be replaced by rivalry in reduc- tion of the standard of living. The New Bonds of Empire. — The rapid rise of Japanese military power may then have its counter- part in commerce, in both respects to be followed by the slow but terribly sure and momentous pr()gress of China. If this be eventually true of Asiatic labour, it must be true between all nations competing at the present day. As surely as duelling has died out or is dying out and the influences noted early in this chapter are making for peace, so surely is inter- national rivalry becoming focussed on industry. Nay, more ; the lines of Empire are being rearranged according to the channels of communication, in sub- stitution for those of physical defence, and the navy 270 HEALTH AND EMPIRE and army are required only for the protection of those channels, those bonds, which are becoming the real meshwork of Empire. Consanguinity is losing its force : firstly through migration, intermarriage and free communications ; secondly through the materialisation of ideal, resulting from modern com- petition. The emigrant to Australia is at first, no doubt, in close touch and sympathy with home ; but he has a hard struggle to live, and if that struggle brings him, through certain facilities, into constant relations with a German house of business, it is with Germany, not with England, that his interests will lie ; correspondence, visits, education and even intermarriage will in a few generations have shifted the main sympathies of his family from England to Germany. The same must be true of a whole trade or state in proportion to the volume of its com- munications ; and its communications will be mainly those of commerce. Free Competition and Social Reform. — As sug- gested in the future competition of Asiatic races, so now in rivalry between the white, the burden of free competition must eventually fall on labour and its rising standard of living. But the health and strength and output of a nation depend not least on its standard of living, its food, its water-supply, its sanitation, its faciUties for recreation, its skilled treatment in sickness. Health is the index of well^ being ; every movement for social progress involves or depends upon a rising standard of living for the masses. All these essentials of success must be cut THE AFTERMATH 271 down under free competition. Free competition, absolute free trade, is in the end incompatible with social reform. The Neglected Measures of Defence. — As against Asiatic rivalry, so in all international rivalry, protection cannot stop with mere bodily exclusion of the extremists in cheap production. We must deny to ourselves, as consumers, the benefits of sweated labour, according to our criterion of sweating, while retaining the benefits of free competition in other respects. We must officially encourage manu- factured imports from markets which work under the same labour conditions as our own and dis- courage in proportion all imports produced by labour under worse conditions. To some extent and for the present this may be done by improvement of communications ; under shelter of naval defence and of the postal service the British Government has already made a timid step in this form of protection, following the road-making example of imperial Rome and the direct example of shipping subsidies by Germany and Japan, amongst others. Indeed it would be logical on sea as on land for the state to establish means of transit without cost. But all these measures are minor, palhative, temporary. What strikes one in the Far East, in the development of German influence, is their strategic use of every means within their power. A German Consul and a German trader with twenty years' experience in Chinese waters summed up for me the advantages of their trade in, firstly, their use of the metric 272 HEALTH AND EMPIRE system ; secondly, their adaptability to customers' needs ; thirdly, their consular and commercial services ; fourthly, their education ; fifthly, our free advertisement of their goods as " Made in Germany " ; but lastly and above all their Bis- marckian policy, as they called it, of the scientific use of a protective tariff. " Why not protect," they said, " to the extent of enabling your producers to produce what would otherwise be produced by their rivals ? " The Full Imperial Policy in the Interests of Progress and Peace. — It is this deliberate strengthen- ing of every nerve and sinew, this use and develop- ment of every sense and every nerve-cell, alike in commerce and armament, that make the mailed fist a formidable power throughout the world. It is useless for us to tinker with one detail after another ; to depend on natural development and on the sup- remacy or monopoly which Great Britain has long enjoyed in trade overseas. Reciprocity of one dominion with the United States ; separate com- mercial treaties with several countries ; the threads of the shuttle being thrown to and fro between our several dominions and foreign nations ; all tend in themselves to undermine the community of the British Empire. Now is the time to consolidate the empire, as the United States were consolidated a hundred and fifty years ago ; for the ocean is less of a barrier now than were distances of land then. The consolidation must be defensive and constitutional. But these are only the outworks ; the essential bond is THE AFTERMATH 273 that of trade ; and, while protection of trade is essential to maintain the national health and strength as against nations of lower standard, so equally must we aim at free trade within the Empire, where a common standard for white labour is recognised and coloured labour is under control. To this end — ^but only as part of the whole scheme and with all the essential safeguards, limitations and adapta- bilities — a scientific scheme of import duties is inevitably required, framed on the Bismarckian model and giving, in the shape of imperial preference, the power of the purse. It is a real empire in being, not merely a nation with distant connections, that should thus hope to engage in the understanding with four other powers. It is this five-power chain that may hope to secure by further understanding with the triple alliance the future military and commercial peace of the world. It is this peace that alone can assure to the world the utmost enjoyment of its fruits without any impairment in the standard of living on which, according to western belief, the health, strength and happiness of nations must rest. CHAPTER XIV RELIGION IN THE FAR EAST {Read before the Christian Conference, London, 1905, and adapted) It was seven years ago, in June, 1904, when the Russo- Japanese War was in its fifth month, that I found myself with a fortnight in which to study conditions affecting the pubUc health at that toll-gate of British and international commerce in the far east, Hong- Kong. It was only eighty mUes, seven hours in a delightfully clean and spacious paddle-steamer, owned and officered by Britishers, up the broad but difficult Pearl River to Canton, the great commercial terminus of South China, whence and whither most of the foreign trade is conveyed in junks to or from Hong-Kong. Here, more easily than in the other main treaty ports of China, one is immediately in the midst of real Chinese life. All European lousiness in South China centres in Hong-Kong ; and the European community at Canton is therefore limited to the Shameen — a few hundred yards of river- frontage — with its gate guarded by a Chinese sentry. For the night I was hospitably entertained by a couple of young officials respectiyely of the British Consulate and Chinese Customs, in the old Yamen locked up in the heart of the native city. Locked up — for at six-thirty the gates of Canton are closed for the night ; and we were probably the only Europeans in the midst of two million Chinese. 274 RELIGION IN THE FAR EAST 275 The experience of a night and a few hours of day- Hght in this Chinese London gave a first introduction to the Ufe and problems of the Celestial Empire of superlative importance as a foundation on which to build out of subsequent glimpses and passing friend- ships some conception of the Chinese character, of the problems they have to face in their foreign intercourse, and of the future towards which they are tending. My hosts were eagerly learning the Chinese lan- guage. Their instructor, a Chinese gentleman of about forty, came to them one evening in great glee, having received his commission in the imperial army. What tests, they asked, had be been called on to satisfy. He had been examined and found pro- ficient, was his answer, in the Chinese classics, and the use of the bow and arrow. " The use of the bow ! " we exclaim, " and the Chinese classics ! How absurd ! " But let us think again. Is it more absurd than to examine candidates for Sandhurst in Latin and Greek and to teach them the use of the sword ? Sword and bow, classics of East and West, are all alike obsolete. But the test still served till recently in either hemisphere as a criterion of how a candidate had fared in the competition with others of his class, as a criterion of zeal and ability and of the education befitting, it was supposed, a gentleman. The moral to be drawn is the similarity of degree to which civihsation has reached in China and in Europe, with the definite development of the gentleman in either hemisphere, and all the complexity and subtle delicacy of feeling involved in the self-respect which is at least as marked there as here. 276 HEALTH AND EMPIRE To one who had hitherto recognised but little the reality of Chinese literature and culture, the trip in a palankeen through the streets of Canton was of itself a revelation. In this city of 2,000,000 every street was under ten feet across and even so en- croached on by stalls and bundles and goods on show, and by the striking vertical signboards inscribed with bold Chinese characters in black and gold. The open shop-fronts showed vistas of splendid black- wood furniture, silk-looms, native jewellery and massive coffins — a common feature — sandwiched in between shopfuls of Manchester cottons, German clocks and American tobaccos ; but few European and only one English advertisement did I see — the substance, in other words, but not the acknowledg- ment of foreign influence. The busy crowds streamed along on foot, mostly in single file ; and, above all other impressions, it was their faces that made the most indehble impression, active and thoughtful, alive with power and individuality, although lacking in softness or sympathy. So they bustled along, taking little notice of us; as we might bustle up Threadneedle Street, taking httle notice of an organ- grinder and his monkey. An organ-grinder and his monkey — for whereas in India one feels a certain recognised superiority over the masses, here it was curious to feel that the passers-by felt as much superior to the European as the European to them, and that they looked on him not with respect, not with pity, but with evident disdain. The pride of the Chinese is not confined to the upper classes. The masses of the nation have also an intense self-respect. RELIGION IN THE FAR EAST 277 For this there is good reason. Culture is widely diffused ; indeed the Chinese consider it sadly lacking in Canton and the other treaty ports. On my way from Shanghai to Japan I travelled with an American medical missionary on his way home with wife and children on furlough, after twenty years inland on the Yangtsze at Nankin. For real informa- tion about a country, commend me to doctors and missionaries. The former have an essential power of observation and sense of proportion ; both have a conspicuous love of what appears to them the truth ; both lead a life, unique amongst the foreign community, in close contact with all classes of the population. A missionary — ^to borrow a metaphor from worldly life — ^lays his " hand " down on the table ; he conceals nothing, and such bias as he has is perfectly honest and easily appreciated. This doctor gave a most surprising account of the extent to which China was becoming infiltrated with western literature. He had himself found it worth his while to translate Herbert Spencer's " First Principles," and, as a set-off to it, Patrick Edward Dove's " Theory of Human Progression," into Chinese : in a Chinese monthly magazine of or concerning English literature and history his translation was appearing in sections of Green's " Short History " ; and European litera- ture, as evidenced, for instance, by the sale of this magazine, is read to an astounding extent by the upper and middle classes, right into the interior of China, constituting a veritable renaissance. Even the remotest up-country villages have their literary societies, whose members meet to read essays and 278 HEALTH AND EMPIRE poems of their own composition or to discuss, per- haps, or recite their classics. But personal impressions are perhaps the strongest evidence ; and in a trip from Japan by Corea to Tien-tsin my new conception of the Chinese char- acter was confirmed by a few days' friendship with an elderly officer of state, retiring from the Chinese Consulate at Fusan to his home near Pekin. This gentleman, coming on board in the well-known blue silk dress, plaited pig-tail and stiff black cap, like a biretta, adorned with the red button indicating his rank, took his place quite naturally at table with the first-class passengers and behaved himself with such reserve and natural dignity as could not fail to attract attention. He had been for four years in the Embassy at Washington, and at our first con- versation expressed regret that he had been too idle to study English. Nevertheless he spoke our language fluently, with an excellent use of idiom, and we were able to converse freely. It was surprising to find that, in talking to a person whom the common idea in Europe would class generically as a barbarian, one was talking to a man of the utmost refinement, with the feelings and courteous manners of a gentleman, the mental attitude of a high government official, the detached view and sense of responsibility of a far-sighted and trustworthy statesman. He talked frankly and with horror of the Boxer outbreak ; he admitted the blot it left on Chinese national honour in the eyes of the world ; but he pointed out its origin in the essential ignorance amongst all classes in China of anything outside the Chinese Empire. RELIGION IN THE FAR EAST 279 The governing classes, too, shared this ignorance ; and it was on this ignorance that clever and un- scrupulous imperial favourites, with some knowledge of the outside world, were able to play with so much effect. There were, he considered, hardly half-a- dozen officials of any standing in Pekin who comprehended the reality of European power and education, beyond the obvious triumph of inventing fascinating toys and engines, such as battleships and sewing machines, a feat which ranked their in- ventors with the magicians. But these half-a-dozen, including such men as Yuen-shi-kai, then Governor of Chili, knew which way the wind blew, and a similar rising was impossible in the future. This, however, is a parenthesis. The retiring Chinese Consul was a symbol to my mind of the extremely high qualities of his countrymen, material of the greatest potentialities for the work of the pohtical craftsmen, the moulder of states. When his country arouses itself from its self-contentment^ actively, instead of passively, to face European ex- pansion, it is with equal, if not superior, intelligence and culture that the nations of the west will have to deal. At first we find it difficult to believe that this is not an exaggerated view of the higher characteristics in a people that can be "guilty of such atrocities as are a matter of common knowledge. To the traveller this is a very great difficulty ; for he touches only at the ports, he sees only the fringe, he hears only the tales of intercourse with such unrepresenta- tive sections of the Chinese people as deal with the 280 HEALTH AND EMPIRE foreign intruder. It was my own experience to see the prosperous state of the Chinese community imported into the Straits Settlements, primarily in order to work the tin mines ; to witness the depar- ture of the first shipload of carefully selected coolies from Hong-Kong for South Africa ; to visit the slums of Hong-Kong, the gambling dens of San Francisco, and the workhouse, founded by Li Hung- Chang on European hues, at Tien-tsin ; and to witness the unlicensed looting of Russia-town outside Niu-chwang in Manchuria, after its evacuation by Russians and before its occupation by the Japanese, a scene that wiU always live in my mind as a typical picture of unbridled savagery and anarchy. But when we think what perfect economical, political and literary self-contentment means to a people of 400,000,000, when we realise to how small a degree that self-contentment has been touched by European influence, and when, to help the current of our thoughts, we read the personal impressions of those who know the interior hfe of China, — Chinese, like Mr. Chiu, who have Hved in Europe ; acute thinking Europeans, like the best missionaries, who have Uved amongst the Chinese, — then we shall begin to realise that this estimate of the high qualities of Mr. Chili's race is in no way exaggerated. There is merely an immense gulf of misunderstanding or lack of understanding fixed between the two types of mankind. For better or for worse, the inexorable laws of human development have decided that national seclusion shall now cease. Our aim must, therefore, be to remove this lack of RELIGION IN THE FAR EAST 281 understanding and to secure gradual inter-penetration on peaceable lines. For this purpose English readers cannot do better than read Dr. Arthur Smith's entertaining and valuable books entitled " Chinese Characteristics " and " Village Life in China " ; those of Mr. and Mrs. Archibald Little ; the volume of essays entitled " These from the Land of Sinim," by Sir Robert Hart, whose sympathetic and states- manlike views of these questions after fifty years' official life in the Imperial Customs is unequalled ; and lastly, a little shilling pamphlet published a few years ago by Brimley Johnson and entitled " Letters from John Chinaman." What then is the attitude of the Chinese towards Christian Missions ? To answer this question, we must first briefly estimate the religious and moral standpoint of the Chinese. This is not very difficult, up to the point we require. The moral standards appear to be high and worthy of the Confucian code. Polygamy being allowed, one chief form of vice is to a large extent obviated. Indulgence in opium does not, according to the small but very good evidence given me, cause greater personal or domestic ravaged in China than does alcohol with us. Great as that is, it is now steadily on the decline. Mutual help and family duty and affection are marked characteristics of a domestic life from which we may learn much ; co-operation in trade-guilds is more universal ; and government, if carried out with severity and some personal rapaciousness on the part of the officials, appears to be in accordance with principles under- stood and recognised by the people, constant, firm 282 HEALTH AND EMPIRE and just. Official posts from the lowest to the highest are open to the common child in any village school by a complete system of examinations. The Chinaman at home appears peaceable and hard- working ; his outlook and his ambitions are confined to very modest limits ; his honesty is proverbial. It is doubtful if we in England follow the teaching of the Gospels in our common life nearly so thor- oughly as the Chinese villager follows the rule of Confucius, as he has received it. Religion, however, appears conspicuous by its absence. However closely one may inquire into the shadows of rfeligious systems or the more obvious ghtter of ancestral worship, and seek to distinguish the reasonable from the meaningless or preposterous, one cannot but conclude that the Chinaman has no conception of a personal God : has in fact no religion. In Canton the traveller is taken to these wretched temples, miserably kept up and evidently but little frequented. The buildings were not striking ; and the hall of 500 Genii, including amongst others Marco Polo with his cardinal's hat, were empty of any signs of devotion or use, except for the joss-sticks, kept fizzling in front of some of the effigies by the attendant. One temple, better maintained than the others, was a Buddhist shrine with two huge Buddhas as a centre-piece and a dozen bronze saints in niches on either side. But of public use and religion there was no sign. Ancestral worship, it seems clear, is essentially derived from the same fear of the elements which accounts for demon-worship in Central Africa or the RELIGION IN THE FAR EAST 283 polytheism of the Indian hill-tribes. In China these powers of nature are in no way correlated to the creation of the universe, but to the action of departed spirits. And it is in fear of these departed spirits that the people offer food, money and clothes to help the dead in the other world, and prevent their taking vengeance on their neglectful living de- scendants. Amongst the uneducated classes this amounts to a fear and a superstition ; amongst the educated it implies a considerable ritual, hallowed by domestic memories and accumulated custom, the centre of their domestic and so of their national life. Argument is powerless to overcoftie it. Habit is stronger than reason. Here then is the nucleus of Chinese feeling towards the missionary. For the missionary, by Chinese belief, is primd facie a foreign devil, possessed by a destitute spirit, in search of vengeance for neglect by his descendants. Hence, if plague or famine break out in a place where a foreigner resides, it is the foreign devil that has caused it and must be driven away or, better still, exterminated so as no longer to afford refuge for the spirit. This natural pubUc feeling may obviously be inflamed by in- judicious propagandism or protection of evil char- acters, by lack of education or sympathy on the part of the foreigner ; but it may on the other hand be mitigated by kindness and self-devotion, as medical missionaries have especially found. One, already quoted in this paper, habitually travelled alone up to a hundred miles from Nankin without fear. He spoke so soberly as to give confidence in his assertion 284 HEALTH AND EMPIRE that the missionaries are seldom the cause of riot in China, but are often the victims of a general riot against white men, promoted by the drastic and often totally unprincipled action of traders, or militarists like the Germans in Kiaochao, or the Roman Catholic priests, bidden by papal order to assume Mandarin rank as a Chinaman might come to England (if he makes haste) and claim a seat in the House of Lords ! Indeed, in the late Boxer troubles, started primarily in a movement against an Italian trading company in Shantung, the local missionaries were spared by being able, after much trouble, to prove that they belonged to the mission. Is ancestor-worship, then, merely a system of re- verence for the dead ? Surely not. The Jesuits, indeed, in 1610, under Ricci, shortly after their arrival in China in 1582, tolerated it ; the Dominicans in 1651 forbade it. Emperor Kang Hyi, appealed to by the Jesuits in 1699, replied : " The customs of China are political " ; but Pope Clement XL in 1704 issued a papal bull, which still holds good, forbidduig it. Four hundred Protestant missionaries in con- ference in Shanghai in 1900 discussed the plea of Dr. Martin, President of the Chinese College at Pekin, for toleration of the custom, wishing to " leave reformation of the system to the influence of divine truth " ; but the proposal was rejected, the conference deciding that idolatry was an essential constituent of the custom. Here we must leave it, convinced in our behef that religion, in our sense of the word, has no part in Chinese life or thought. This chapter has dealt at length with the Chinese RELIGION IN THE FAR EAST 285 character, for this is the extreme point from which all conclusions as to the relationship of Confucianism, Buddhism and Christianity in the far east should start. The essential Japanese mind and life, as born into the life of the world by the overthrow of the Shoguns in 1868, are deducible, though very different, from the Chinese in the present day. Indeed, if we eliminate the influences of the last forty years, all that Japan is or has is derived from China. Buddhism came over from China, and asserts itself in symbols of art and letters even on the archways — torii — of the Buddhist temples. The characters of writing are Chinese ; the abacus, or calculator in use in every shop and school, came from China ; food and customs, as of ancestor-worship, forms of government and methods of war, art in painting, embroidery and architecture came across from the mainland, following indeed the Japanese themselves. But the Chinese, it is said, are the Germans of the far east ; the Japanese are the French. The rich, heavy, detailed embroidery, the ponderous brass- work, the solid black -wood furniture, so highly appreciated by the European community at Shanghai, are but the forerunners of the delicate, gauzy silks, with large flowing designs, the natural lifelike bronzes, the light lacquer work of Japan. Japan adopts the material and the conventions of China ; but instils into them a wealth of versatile feeling, giving them a new life, in keeping with her mar- vellous life-giving spirit. China is essentially the thoughtful originator. Japan is seldom the originator; she is the adapter. As in her inter- 286 HEALTH AND EMPHIE course with China, so in her history of the last forty years, Japan has invented Httle ; but she has been quick to seize on all that is best in every domain of European civilisation, to adapt it to her own ends, and gradually to develop it to suit her own purposes. The medical schools, for instance, at Tokyo and the half-dozen naval and military hospitals throughout the country, showed an almost slavish imitation of the German methods in which Drs. Baelz, Scriba, von Scheube and post-graduate study in Germany have instructed the Japanese doctors of to-day. These methods were but adapted to the scanty financial circumstances and the climate and the commonly available materials of Japan. But it will not be long before this adaptation in the light of active experience wUl produce new developments of intrinsic value. Japan is not an originator ; but she is a remarkably good adapter. Now in Japan there is considerable sign of the presence of active religious feeling. Not in the artistic wonders of the tombs of the Shoguns at Tokyo, nor in those of the temples at Nikko and Kyoto ; for of itself the art does not prove the existence of the religious sense. But it was the new temple at Kyoto, the Higashi Hongwanji, which was most impressive as a sign of active religion (Plate 15) . The temple itself was erected only during the last twenty years by small popular subscriptions amount- ing to £100,000 in all, in the place of its historic predecessor, burnt down. Entering into the great nave, one morning, and sitting down on the padded matting in a corner, one was first impressed by the A MODERN BUDDHIST CATHEDRAL IN JAPAN. (a) The Higashi Hongwanji, Kyoto, built in 1895. (fc) The Interior : the Congregation and the Image displayed. RELIGION IN THE FAR EAST 287 sense of restful beauty, of grandeur and of repose, both in the broad outlines of construction and in the details of lacquer work and ornament ; but the effect was still more impressive of seeing a devout con- gregation of a hundred or so Japanese following a service, strangely like that of the Roman Church. From behind a barrier, separating nave from chancel, came sounds of some sacred reading in clear and definite tone ; after this was finished a priest in fine robes advanced as it were to the altar ; in absolute silence a bell was tinkled, and reverently the shrine was opened, displaying the image of Buddha. All bowed prostrate to the ground, and remained so, it appeared, in silent prayer, for one or two miniites. The bell again tinkled ; the doors of the shrine were closed, and the people rose to leave the temple. It is difficult to say how much the Japanese feel the profounder problems of the universe and the need of a personal God. From the few learned and good Japanese with whom I had an opportunity of free conversation, it would seem that these matters are of no interest to the enlightened classes. And it wiU be realised that throughout the Japanese Empire elementary education is in an advanced state ; and in the towns, the halfpenny papers have a wide vogue, even amongst rickshaw men and labourers, so that what affects the upper, affects also the lower classes. Religion would seem as yet in general to have rather a practical than a senti- mental or theoretical interest for them. But is this surprising ? Is it not natural that, in encountering 288 HEALTH AND EMPIRE the civilisation of the west, they have first to establish their material strength with a view to the sixrvival of the fittest among nations ; that they should be first struck with the wonders of science and manu- facture, and should direct all their energies to the establishment first of their military and then of their commercial position in the eastern seas ? For the present, therefore, it can be well understood that they are content to look for all that contributes outwardly to make a nation great ; while, for their credit in the eyes of the civilised world, they are developing a more humane regard for weakness — in their care of women and children, their treatment of the sick and wounded, of prisoners and criminals and animals — have adopted certain conventionalities, such as the top-hat, black coat and starched collar for official circumstances, to facilitate their treat- ment by other nations on terms of equality ; have constructed an enlightened judicial code ; and are laboriously studjdng every form of knowledge and experience in Europe and North America. It is a quaint but somewhat mortifying fact that not long ago a commission of Japanese students, sent over to study European methods and manners, reported the total severance of Christianity from modern progress and modern European life. It was on this report that it was decided not to pro- claim Christianity the established faith of Japan. For this result Christians may be thankful ; but it reads them a very obvious lesson. It is possible for Europeans, nurtured in the Christian faith, to learn the meaning of religion, quite apart from the RELIGION IN THE FAR EAST 289 form — the words — in which the religion is expressed. These words, these forms, were drawn up many centuries ago. In common use the words and phrases have often acquired a different meaning to accord with modern scientific developments ; but their religious use remains the same. In the spirit in which our immutable religion was revealed to the early Jewish and Christian churches, we still believe in the resurrection of the body, we still read with profit the first chapter of Genesis. But the Japanese examine such documents with the critical standards of modem scientific nomenclature ; and do not, perhaps, realise that the exact order of creation, the exact chemical significance of the risen body, are of minor importance, and were never part of the revealed religion to which alone we subscribe. Here, then, is the essential difficulty the mission- aries have to face — in China, as in Japan, though at different stages of development. The missionaries deserve the utmost honour and support. With few exceptions, they are whole-hearted and zealous, even to martyrdom ; and they stand to the credit of the white races as the sole evidence that commerce, Empire and selfish aggrandisement are not the essence of their strength or the end of their aim. It is for that reason that missionaries, however little they may desire it, should be protected to the utmost of our national power by our official representatives ; for an insult to a missionary is an insult to his race, not to his faith ; and if we do not officially protect him, we lend colour to the suggestion that our public 290 HEALTH AND EMPIRE aims are purely commercial, militant and selfish. The missionaries, however, do not as a rule make out the best case for the Christian faith. Too often they and their supporters at home cling to the letter, when the spirit alone giveth life. Acknowledging as they do the power of the Spirit, they cannot allow tjie absolute unimportance of the phrases in which it is cloaked. And so their gospel is concealed by what to us is a true, but to the Asiatic an entirely false, mantle of dogmatic creed. Let us go further. Is it essential to Christianity that it should be based on Old Testament history ? This is the way in which it has been brought to us ; but is it essential for the Asiatics, to whom the Jews are of no importance and for whom they have no interest ? May it be asked, humbly and reverently, Had Our Lord been bom in China or in Japan, would He have begun His mission by preaching Jewish tradition and history ? Would He not have taken as His foundation all that is so noble and inspiring in the doctrines of Confucius and grafted on that His glorious revelation of the eternal purposes of God? I venture to suggest that from that and from no other direction of investigation on the part of Chinese and Japanese scholars and patriots can any con- siderable spread of the Christian Church be possibly expected in China or Japan. There can be do doubt that the six English and American bishops of the " Church of Japan " will be succeeded by Japanese ; that the result of the recent war, as one of these bishops confessed, will undoubtedly tend towards RELIGION IN THE FAR EAST 291 the independence of this Japanese Church, so soon as it can be assured of financial stabiUty, and that any such Church, unless securely built into the rock of Japanese tradition and virtue, will have to choose, on the one hand, between the formal doctrines of western Christianity, as we have learned it, involving complete alienation from the life of the Japanese people, and, on the other hand, such startling developments as may lead to schism within and separation from othet branches of the Catholic Church without. The possibilities of Christianity are well shown in Tokyo by the wonderful labours of the late Russian Bishop Nicolei, who by his own magnetic influence attracted 120,000 converts, so it was said, to the Greek Church. It is for us to see that those at home and those sent out as missionaries to the Far East should be of the highest intellectual culture possible, men of broad sjonpathy, high statesman- like ability, and, it is needless to add, of glowing faith and fervent zeal. Scholars from home are wanted to interpret to the eastern the essential basis of the Christian faith, in terms which they will under- stand, in accordance with the life and history which is part of themselves. The basis of their work must be some such presentment of modern faith, if a filial tribute may be permitted, as that by the Dean of Ripon in his little book entitled " Natural Chris- tianity." This is all that the west can do. The seed must then be allowed to grow ; for it is to Japanese and Chinese teachers and preachers, to some Japanese or Chinese prophet that shall arise, that the eventual development of a religious system 292 HEALTH AND EMPHIE must be left ; it is they that must evangelise the mighty nations of Japan a;nd China ; and it is He, who hath begun a good work in our western lands, that will in His own time and in His own way con- tinue it in the countries we so Uttle understand in the Far East. CHAPTER XV HEALTH-FAKING AT SAN FRANCISCO The serious effect of epidemic disease upon commerce to which attention has constantly been drawn in the preceding chapters is nowhere more strikingly shown than in the extraordinary action of the municipal officials at San Francisco in the first few years of this century. The story on the one hand points to the need of medical advice, and of due attention to that advice, in the administration of public health ; on the other to the financial value of health measures and to the consequent miscarriage of justice that may deliberately be effected by local officials, even of a large city, when not properly supervised or controlled by the central authority. Plague broke out in San Francisco in the year 1900, and it is not difficult to trace the steps by which the dreaded epidemic thus reached the United States. Extensive traffic between Japan on the one hand and Formosa, Hong-Kong and other Chinese ports on the other, is sufficient to account for the small footing which plague obtained in Japan during the course of the epidemic. In 1894, i case was recorded as imported to Japan ; in 1896, 1897 and 1898 the disease was imported three times in each year ; and in 1899 six times. In December 1899 elaborate 293 294 HEALTH AND EMPIRE and most effective regulations were issued for the management of plague at Kob6, the great central port of Japan, Osaka, the chief manufacturing centre, close by, and other districts that might be subse- quently invaded by plague. Up to the 22nd Decem- ber 23 cases and 19 deaths had been recorded at Kobe ; but Professors Kitasato and Ogata were of the opinion that plague was the cause of death in most of 270 cases which had occurred in September and October 1899 from acute pneumonia — a disease not at all common, it is said, in Japan — ^in 230 deaths attributed to acute meningitis ; and in 266 deaths attributed to beri-beri. Kob6, be it noticed, has a population of about 230,000. At a meeting of the Central Sanitary Association at Tokyo it was concluded that the disease was prob- ably brought to Japan from Hong-Kong or Formosa. By the reward of a penny for every rat brought to the authorities in Osaka and Kob6, 3,050,000 rats were killed in the eighteen months up to April 1901. In Osaka about one-tenth, and in Kob6 as many as one-fifth, of these were found by bacteriological experts to be suffering from the disease. In this and other ways the disease has been kept in check, the maximum number of reported cases in Japan in any one year being 646, and the total number for thirteen years, to the end of 1909, under 2500. The epidemic was now spreading to the Sandwich or Hawaiian Islands, the half-way house of most of the trade routes between Eastern Asia and the United States. On i8th June, 1899, the steamer, Nippon Maru, from Hong-Kong and Japan for America, HEALTH-FAKING AT SAN FRANCISCO 295 landed a body which was found to have died from plague. A few other cases were also found on ships calling at Honolulu, but it was not till November that the local authorities began to realise that the infection had in reahty gained a footing in the islands. The earliest cases were recognised by a Chinese doctor early in November, corroborated after post-mortem examination by Dr. Hoffman, bacteriologist of the Hawaiian board of health, and confirmed by bacterio- logical investigation and by experiments on animals. On i2th December, 1899, the board of health officially declared plague to have broken out at Honolulu. The amount of trade passing between the Sandwich Islands, now part of the United States, and San Francisco, is very considerable, and on 6th March, 1900, the dead body of a Chinaman was removed from the Globe Hotel, in the Chinese quarter, death being found, by bacteriological and inoculation experiments, to have resulted from plague. The deceased China- man had resided in San Francisco for fifteen years. Two days later six suspected cases came under observation in " Chinatown," and immediately the local board of health instituted a general inspection of the Chinese quarter, with scavenging of all pre- mises. The Chinese consul and other influential Chinese residents in San Francisco undertook to see proper precautions carried out ; but by 19th March fresh cases began to be heard of in different parts of the Chinese quarter, and in one of the fatal instances post-mortem examination, followed by bacteriological investigation, proved the death to have been due to plague. It was evident to the authorities that the \ 296 HEALTH .AND EMPHIE Chinese population were concealing cases in order to escape inspection of their houses and removal of their sick to the hospital. On 19th May the local board of health officially declared the existence of plague at San Francisco. Further house-to-house inspections were ordered, but this measure was frustrated in a large degree by the Asiatics keeping their houses barred and declining to admit the inspectors. Railway and transport companies were ordered to refuse tickets to Chinese and Japanese unless they possessed certificates granted by the health authorities. Inoculation by Haffkine's prophylactic was freely offered, but little use was made of it by the public. It is said that a Chinese secret society, known as the " High Binders," threatened to assassinate all Chinamen in San Fran- cisco who submitted to the process^ The Japanese, on the other hand, largely submitted themselves to inoculation. Reports were circulated of Chinamen being made very ill and dying from the effects of in- oculation, and this helped to keep the Chinese from coming forward to submit to the operation ; but in- oculation was insisted upon when Chinese residents wished to travel from San Francisco. The state of aiKairs now reached headquarters at Washington, and a number of medical ofl&cers of the marine hospital service were despatched to San Francisco, to take part in railway and road inspection, and to assist in carrying out the preventive measures. Further inter-state quarantine regulations were added to those already existing in May, 1890. The matter was clearly one of national importance to the HEALTH-FAKING AT SAN FRANCISCO 297 whole of the United States. From 6th March to the end of the year 1900, 22 cases, all fatal, were officially reported ; 10 were verified by post-mortem and bacteriological examination. None of these ten cases came under the observation of the health authorities during life. All were Chinese and had lived in the Chinese quarter. In his annual report to Congress for 1901 the secretary of the treasury re- ported as follows : — " The existence of bubonic plague in San Francisco, which was first reported on March 8th, 1900, and of which mention was made in the last annual report, was confirmed by a commission appointed by the department, consisting of three bacteriologists of the highest reputation, who had had no previous connection with government service. This Commission reached San Francisco in February, 1901, and after an exhaustive investigation rendered a report so conclusive in its nature as to result in measures being taken to cleanse Chinatown, where the plague existed," It was inconvenient, however, to the reputation and commercial welfare of San Francisco that plague should exist, or be even suspected to exist, within the city. Neglecting the advice of their board of health, the local authorities declared that it did not exist. Notwithstanding the fact that the disease had been proved, by post-mortem examinations, by bacterio- logical investigation, and by experiments on animals, to have existed in the bodies of the dead Chinese, the governor, as reported publicly in The San Francisco Chronicle of 14th June, 1900, convened a meeting of the leading commercial men of the city, at which a strongly worded protest was drawn up and sent to the secretary of state, denying the exist- 298 HEALTH AND EMPIRE ence of plague, either then or previously. Some medical men of no great repute, but connected with the local authorities, signed this protest, giving only vague reasons for their dissent from the declaration of the board of health. No case, they said, had been diagnosed as plague during life ; only ii deaths had occurred, as they put it, in a Chinese population of 35,000 ; there were no cases amongst whites ; in- vestigation of the supposed plague cases had been incomplete ; the recorded mortality from all causes had not risen ; there was no proof that the so-called plague had been transmitted from one person to another ; there had been no multiple cases in families — in other words, they sheltered themselves under the fact that the Chinese had done their utmost to defeat the law, and the authorities to obstruct the investiga- tion of the disease by their own board of health. Finally, the allegation that plague existed in San Francisco was characterised by the governor as an aspersion upon the character of that " great and healthful city," and it degraded San Francisco in the eyes of the whole world. It is asserted that at a later stage the governor of San Francisco, in a message to the legislature alleged that " certain physicians, having cultures of plague bacilli in their possession, have, innocently or otherwise, inoculated the dead body of a Chinaman with them, and that the finding of the germs in such dead body has resulted in spreading a false alarm calculated to strengthen the hands of Dr. Kinyoun, the federal quarantine officer, and to induce the City of San Francisco to appropriate more money for its board of health." The action now taken by the mayor of San Fran- HEALTH-FAKING AT SAN FRANCISCO 299 Cisco is hardly credible. On 25th March, 1902, with- out previous warning of his intention, an order was issued from his office, peremptorily removing those members of the board of health who were appointed by his predecessor, and substituting in their place certain persons of his own selection. Each member of the board received a letter of dismissal, giving reasons for this action, but these letters were received only after the newly appointed board had effected an artificial organisation. The reason for this action was said to be based upon the thorough investiga- tion which the mayor said he had conducted into the case. The original board, however, with pluck and in- dependence worthy of the race, refused to be deposed, and on the following day made application for an in- junction restraining the mayor, his attorney, and all other persons' from interfering with the members of the board or their employees in discharging their official duties, and proMbiting his Honour from in- truding into the rooms or offices of the board. The injunction was granted by the presiding judge of the superior court, and the mayor brought a motion for its dismissal, which was decided on 19th May. It was ruled that the old board maintained possession of their offices until definitely ousted in the course of legal proceedings by a writ of quo warranto. Such proceedings were accordingly instituted by a clerk in the mayor's office on 27th May, 1902, but it had not yet come up for final hearing before the board of health which refused to be deposed issued on 30th June its annual report for the year 1901, a bulky 300 HEALTH AND EMPIRE volume of five hundred pages, with a long prefatory letter, teeming with capitals and italics, wMch must be quite unique in documents of this description. " To the Honourable Eugene E. Schmitz [it began], Mayor of the City and County of San Francisco. Sir : The Department of Public Health of the City and County of San Francisco has the honour to present for your consideration its Annual Report for the fiscal year terminating on this date." The report was a sweeping condemnation to his face of the mayor's extraordinary action, no attempt being made to conceal the motives which were sup- posed to have promoted his action. The authors regretted the absence of proper maps and charts, owing to his Honour, despite funds having been pro- vided by the finance committee of the board of super- visors, having declined to approve of the expenditure. A daily newspaper published in the city was quoted as reporting the mayor to have accused the board of health of incompetence for not issuing reports for the two preceding fiscal years. It was shown that the budgets of those fiscal years did not provide for the printing of such reports. With remarkable candour, the report declared that " careful examination of the information contained in this Report will indicate to one who is willing to be instructed the char- acter and amount of work being accomplished under the direction of this Board, and will further serve to demonstrate that the Department of Public Health is conducted for purposes other than the protection of political pets and the extravagant and unneces- sary expenditure of municipal funds. During the past year much official business has been transacted. ... All dealings have been conducted without serious differences ; and at present writing HEALTH-FAKING AT SAN FRANCISCO 301 this Department appears to exist in harmony with all branches of the MunicipaHty except the Mayor's office." The history already narrated, as to the relations between the mayor and the board of health, were now set forth in detail, with much plainness of speech. As to the thorough investigation said to have been conducted by his Honour, " it would appear as if said ' investigation ' were either vision- ary or entirely ex -parte. It will be remembered that shortly after the induction of Your Honour into office the members of this Board called to present their official respects, and at that time, in response to a request to visit and inspect the operations of this Department, Your Honour stated that such was your intention. . . . There is no evidence, however, that Your Honour has ever visited the Health Office since assuming the duties of Mayor, except in one individual instance, when, supported by Your Honour's attorney and accompanied by the gentlemen comprising the so-called new Board of Health, and a staff of newspaper re- presentatives, you invaded the rooms of the Department for the purpose of taking possession thereof, and installing in office the said so-called new Board of Health. There is no evidence to show that Your Honour ever asked any member of the Board of Health, or any responsible officer connected therewith, any question whatever regarding the existence of bubonic plague in San Fran- cisco, nor does it appear that Your Honour has ever sought to examine the records in the Health Office for such facts as might be presented on the subject, except on one occasion, when you asked for a transcript of the report in a case of plague, which was dis- covered by Federal officers, and by them reported to this Depart- ment. Notwithstanding the failure or neglect on the part of Your Honour to have submitted, for use in your investigation, the records on file in this office, you assigned as a reason for the dismissal of this Board the following : — ' It is evident from recent instances and developments, — one as late as February 21st, 1902, — that you are absolutely and unchangeably committed to the policy of main- 302 HEALTH AND EMPIRE taining, harbouring, and proclaiming this baseless bubonic plague agitation, that you are proceeding even at this late date upon the theory that every case investigated is a suspicious case, and that every such case must be assumed to be and published as a true case of biibonic plague until the contrary is so clearly established by overwhelming evidence that the true disease can no longer be concealed under the mask of the bubonic plague. This policy is one of irreparable injury to the people whose protectors you are supposed to be, it is against the welfare and prospeTity of the city, and is in my opinion ample and abundant justification for your removal. . . . For three months past I have carefully examined and investigated all accessible reports and records, and have personally enquired into numerous specific cases reported and declared by you, and under your authority, to have been cases of bubonic plague, and I am unalterably convinced that, notwith- standing your investigation and publications, bubonic plague has not existed and does not exist in San Francisco.' " It is a mistake that officials should give a reason to their inferiors for their action, and the late mayor of San Francisco will meet with little sympathy in the pillory to which he is thus subjected. Having ex- pressed the resentment of the board at " the diaphan- ous courtesy of an expressed regret " with which the letter of dismissal ended, the report went on to enu- merate the steps they had taken to enlighten the public as to the actual conditions. The facts of the existence of the plague are set forth with brutal frankness: — " If Your Honour will consult the last two Annual Reports issued by this Department, a brief statement will be found in each." " Notwithstanding Your Honour's assertion that you have carefully examined and investigated all accessible reports and records relating to plague, you are again reminded that the reports HEALTH-FAKING AT SAN FRANCISCO 303 and records on file in the Health Office, as well as those in posses- sion of the Marine Hospital Service, have not as yet been consulted by you." " In summing up the result of Your Honour's investigation, you have neglected to mention the Report of the Federal Commission on this subject, which was issued as an Official Bulletin by the United States Treasury Department, and has been accepted as an authoritative opinion by all who possess sufficient intelligence to appreciate the standing of the members of the Commission and the character of the investigation conducted by them. Your Honour has also omitted to note the reports of medical men from Honolulu on file in the Health Office, or the report of the Health Officer of British Columbia, who spent several weeks in San Fran- cisco conducting an investigation." ' " Your Honour has also failed to make reference to the report of Dr. H. L. Ryikogel, of this city, formerly Bacteriologist of the State Board of Health, whose report was suppressed by the Board under which he served, and who was deposed from his position by order of the Governor, and was further refused payment for the services he performed, all of which occurred because he had found plague, and had sufficient courage to declare it in spite of the Executive displeasure." The Board of Health next proceeds to pillory the " Report of the Special Health Commissioners appointed by the Governor to confer with the Federal authorities at Washington respecting the alleged existence of bubonic plague in California ; also Report of State Board of Health. The purpose of this Report is palpably one of deception. Its contents add nothing whatever to scientific information, and its conclusions contribute still less to veracity. ... It scarcely seems reasonable that a Commission made up of editors, an attorney, and a manufacturer, no matter how distinguished, should possess the scientific qualifications which render their judgment in matters appertaining to any disease, and particularly plague, superior to that of a Commission consisting of the leading bacteriologists of the United States, such as was the confidential Commission appointed by the Honourable Secretary 304 HEALTH AND EMPIRE of the Treasury, with the approval of President William McKinley. . . . Little need be said about the professional evidence secured by the Special Health Commission and the State Board of Health. It may be true that the influence of the Commission has been potent in producing the testimony of medical men subversive of truth and in contempt of medical ethics. It may be also true that there are physicians in public office who are sufficiently pliable to forget at will the duties of their calling, and bow their heads in response to the dictum of a political power. It may likewise be true that, when gifts of lucrative appointment or military title are held forth as inducements to depart from paths of professional rectitude, the bait is too alluring to meet with resistance on the part of some who yearn for the trappings of gilded pomp, or crave for a little brief authority." In the last page of their preface, this defiant — if it were not for the justice of their cause one would say insolent — Board of Health come to business. " The Board of Health now announce to you that since March 6th, 1900, fifty-seven cases of bubonic plague have been observed by this Department, twenty- three of which have occurred during the fiscal year ending this date. The discussion of plague in this report is now closed. " The prospects of satisfactory work under direction of this Board, for the coming fiscal year, appear favourable. The Board of Supervisors has made liberal allowance in the Budget for this Department in all its branches. The members of this Board r^ret exceedingly that Your Honour saw fit to exercise the veto power upon so many of the very important items provided for this Department in the annual Appropriation, but we view with satis- faction and pleasure the recent action of the Board of Supervisors in permitting the Budget to remain unmutilated. We feel con- fident that, had Your Honour possessed a more intimate acquaint- ance with the actual work of the Department of Public Health, and had not listened so willingly to its detractors, your veto might not have been applied so freely." HEALTH-FAKING AT SAN FRANCISCO 305 The Board are able to devote one short paragraph to the congratulation of his Honour on his action which resulted in the provision of a special tax for the erection and maintenance of a new City and County Hospital. They conclude by declaring with biting sarcasm : " It is difficult to determine whether membership on the Board of Health of this City and County is to be looked upon as a crime or as a joke. If it be the latter, the sooner the Charter is amended, so as to permit of the appointment of editors and professional politicians to such membership, the sooner will the city be safe- guarded from the dangers which threaten it through the mis- directed efforts of medical men, who persistently decline to have their opinions manufactured to order. If it be a crime, informa- tion should be filed with the Grand Jury, which will tend to bring about the indictment of the criminals and their subsequent obliteration from the official community. " Respectfully submitted : " (Signed) John M. Williamson, M.D-, " President, Board of Health." Many persons used to official work in this country will read with growing impatience the disdain and disrespect for authority shown, and, indeed, insisted on, in these paragraphs. But it must be remembered that the writers of those paragraphs were fighting with the mayor to whom they made that report,- not only for their own existence as a board, but far more, for the welfare and safety of San Francisco, and for the deliverance not only of their fellow-citizens, but of California and the whole of the United States, from that terrible danger which in India has cost us 7,090,000 lives, and may, for all we know, work fear- ful ravages if ever it be allowed to gain a foothold 306 HEALTH AM) EMPIRE in a white population. No honeyed words or official courtesy would sufficiently express their sense of the grave injury which might result through the action of the local authorities ; the blind eye, they were determined, should no longer be turned towards the unmistakable facts of the case. It was war to the knife, but, if they should perish in the attempt, they would anyhow have done their best to save their city, their state and their country from a terrible danger. Fortunately they did not have to fight their battle alone. A special commission, as I have already said, was sent from Washington, and, in accordance with an agreement between the federal department, the authorities of the state of California and the city of San Francisco, the work of inspection, isolation and disinfection in Chinatown, San Francisco, was carried on by a corps of physicians and employes of the state and city, under the advice and direction of a surgeon and a corps of assistants of the marine hospital service. The work was completed on 21st June, 1901, at which time, 1180 houses, containing 14,117 rooms had been disinfected, the burden of expense falling upon the local and state authorities, the federal treasury paying only the salaries and incidental expenses of its own officers. This work being completed, a skeleton- organisation was maintained for the purpose of making examinations of the sick and dead in China- town and assisting, when requested, in the dis- infection of premises where cases were found. From the beginning of the outbreak to the end of 1901 over 50 cases were found. On the occasion of my visit to San Francisco in SAN FRANCISCO. (a) Outwardly: In Market Street. (b; Inwardly : Where Plague broke out, in the Old Globe Hotel, Chinatown, and the Federal Service was now giving it a thorough clear-out. HEALTH-FAKING AT SAN FRANCISCO 307 September, 1904, the laboratory of the marine hospital service, the federal institution with headquarters at Washington, was in full swing and Dr. Blue and two others engaged in the work of stamping out plague took me round Chinatown to see the measures they were conducting for the purpose. Their tact evidently had taken effect. We were admitted in and out of barred opium dens, in which, previous to their arrival, it would have been easy to hide cases of plague. " Dens " is an appropriate name for these squalid hovels. Doors and windows were made fast and windows covered ; there was little or no ventilation for lamp, fire, or opium smoke ; and only the smallest shaft of light, if any, came down a chimney-like opening at the back of the diminutive premises. We were only admitted after being inspected, as at the door of a convent, through a little window looking into the dark passage by which we approached the door, so that the inhabitants might convince them- selves that we were not police. The police, however, very seldom raided the opium dens and the fantan or gambling-houses, as the Chinese born in the country (and others are not now admitted) have votes, on which the judges and officials depend for political support. We went down to the basement of the old Globe Hotel, where the plague first broke out in 1900, a fifth-rate eating-shop on the edge of the Chinese quarter (Plate 16). The plaster was down from the walls and ceilings, and the basement was being cemented, the uncemented part standing an inch deep in water. It was easy to imagine 308 HEALTH AND EMPIRE the conditions which fostered the outbreak of plague. Dr. Blue and his staff in 1904 believed in soil in- fection as the chief agent, independent of rats, and the measures on which they therefore depended were the cementing of basement floors and the occasional pulling down of insanitary buildings. It was a pity that — ^no doubt for good of&cial reason— through- ventUation was not aimed at, even in new or renewed houses. Building seemed to be taking place on any and no principle ; but my friends had undoubtedly made one most useful step in advance in gradually insisting on concreted basements in aU houses of those miserable slums. From February — that is, for over six months — the city had, so far as they were able to teU, been entirely free from plague. It is well to know that the danger of plague secur- ing a footht)ld in San Francisco was recognised by other states as one of more thaii merely local im- portance. The concealment of plague by the officials at San Francisco excited lively indignation in other state boards of health, and this feeling found expression in their motions and minutes. As an example may be taken the report of a committee to which the matter was referred by the state board of health of Iowa. They were " forced to believe that facts pertaining to the true and exact conditions then existing were purposely and unwisely withheld from health boards and sanitary authorities, directly interested, by the officials of the state of Cahfornia and by the marine hospital service for commercial reasons and against the best interests of the people of all the states." HEALTH-FAKING AT SAN FRANCISCO 309 They protested " against this policy of suppressing facts, and putting the commercial interests of any state or community above that of public health." Whatever the exact result of the proceedings between Mayor Schmitz and the board of health he had sought summarily to dismiss may have been, the fact remains that the report of the department of public health in 1904, a couple of months previous to my visit to San Francisco, was signed by a new pre- sident, James W. Ward, and contained no mention of the plague. It stated that, from 30th June 1903, for six months, the chairman of the board of health was a layman who submitted no report to the board as to the service during the first half of the fiscal year. Since then, the commissioners constituting the new board of health had sought to fulfil a policy of general upbuilding of the department. Through the un- stinted efforts of Dr. W. C. Hassler, the chief of the sanitary bureau, insanitary conditions through the city, especially in the Chinese district, were being actively corrected. An ordinance had been pro- posed to compel property-owners to make their basements and cellars rat-proof. The basements and cellars of four large blocks, containing 125 buildings, had thus been condemned, deprived of their wood floors, partitions and ceilings, and con- creted. The crusade against the general insanitary condition of Chinatown had been most energetically followed. From a place of filthy accumulations and 310 HEALTH AND EMPIRE infectious odours it had become one of comparative and habitable cleanUness. It was proposed to buy a portable steriliser, to assist in the disinfection of certain contents of premises that would otherwise require destruction, and to insist on the disinfection and stamping as disinfected of all fabric merchandise exported from Chinese quarters. The co-operation between the United States public health and marine hospital service, the state board of health and the commission for public health of the city and county of San Francisco had resulted in the organisation of a " Public Health Commission of California," with past-assistant surgeon Dr. R. Blue as its president, in order by monthly meetings to promote interchange of ideas and to enable the members to look at public health from a wider standpoint than would otherwise be possible to them. The story of the graft-conspiracy in California and its eventual defeat reads like a criminal romance of the most fantastic kind. It was well told in The Times of 23rd January, 1907, and ist and 2nd January, 1908, and there is no room to repeat it here. But readers of this chapter will want to know the back- ground and the sequel of the incident here related. It was due to a grant by the legislative of a well- meant but ignorant charter in 1898 that the hitherto good administration of San Francisco was put under the absolute control of the popularly-elected mayor. In 1901 an extremely able and unscrupulous French Jew, named Abraham Ruef, secured by a small majority through the support of the powerful labour- unions the election to the mayoralty of Eugen Schmitz, HEALTH-FAKING AT SAN FRANCISCO 311 with himself as his recognised adviser. Schmitz at the time, having failed in various business enterprises, was president of the musicians' union and leader of a theatre orchestra at a salary of £8 per week. By labour-union votes he was re-elected to the mayoralty in 1903 and 1905. The earthquake and fire occurred soon after the election of 1905, and formed an oppor- tunity for extending on a vast scale the system of blackmail and corruption which Schmitz and Ruef had been gradually constructing. By the end of 1905 the most powerful system of " graft " ever evolved was in full operation, and the proceeds must have run into six or seven figures sterhng. The salvation of San Francisco was wrought by four men : Mr. Rudolph Spreckels, millionaire ; Mr. Francis J. Heney, federal district attorney ; Mr. Fremont Older, editor of The San Francisco Bulletin ; and Mr. William J. Burns, a secret-service detective in federal employ. The story of corruption that they revealed was incredible, and the difficulty of gaining a fair trial and of securing evidence was immense. Finally, however, on 8th July, 1907, Judge Dunne sentenced the ex-mayor to prison, and added : " You will suffer the humiliation of knowing that your career of hypocrisy, duplicity, and dishonour has been ex- posed, and that you stand before those who believed in and honoured you morally naked, shamed and disgraced." To a group of newspaper men around him Schmitz announced that he would again be candidate for the office of mayor in the following autumn. 312 HEALTH AND EMPIRE Ruef also was subsequently condemned, but was liberated on enormous bail ; Schmitz, on release in 1908, gloried in having spent a term in gaol, giving a banquet to the embezzlers and other criminals who were in prison with him. But the power of recovery in such a community is astonishing. The loss of property from the fire is reckoned at over £70,000,000 ; but the total assessed value of all buildings in the city exceeds to-day by £4,000,000 sterling that of the buildings assessed before the fire in 1905. Thirty-five million pounds have been spent in building since the fire, and in spite of the " graft " scandals, in spite of the fire, in spite of the recent financial depression in the United States, the loss has been made good. It is evident that the stand made by the best medi- cal men in San Francisco against the deUberate burking of evidence and shameful neglect of their duty on the part of the local administrative authorities had as its result the stamping out of plague from the western door of the United States. In this reflection, apart from other considerations, the members of the health board will feel weU rewarded. The sub- sequent condemnation and imprisonment of the mayor and his accomplices in these astonishing " graft-scandals " will have been far less gratifying to them than the purification of municipal affairs under a sterling representative of their own profession in Dr. Edward Robeson Taylor. In a progressive com- munity of motley complexion, devoid of tradition and independent of the outer world, the qualities required of an administrator are pre-eminently those HEALTH-FAKING AT SAN FRANCISCO 318 required of the medical man, as attributed to the ideal physician in daily life by Robert Louis Stevenson. Stevenson's memory in San Francisco is aptly pre- served by a little Spanish galleon, standing on a granite pedestal in Portsmouth Square, with sails bellying out before the wind, filled with the breezy vigour of his man-compelling books. How his spirit must have revelled in the triumph of the health-board over the product of corrupt democracy ! Prig-like, we may be incUned to give thanks that our municipal life is incapable of such corruption. But it is a fact to which every medical officer even in this country will testify that, time and again, youth- ful enthusiasm and mature and wise counsel for the public good are alike suppressed in municipal service by a slovenly or slothful, timorous or pig-headed re- fusal to budge from precedent, to listen to new ideas, to risk on an experiment the life of a dog or the health oi one individual, where the health and happiness of thousands are yearly sacrificed by preventable causes. Evil is just as prevalent under the smooth-faced, press-flattered democracy of to-day as under many a mediaeval tyranny ; just as hateful in the enlightened and wealthy corporations of the old world as in the wild-oat-sowing, hustling municipalities of the new. The public standards differ ; the contrasts over there are more marked ; nothing can escape advertise- ment. But the responsibilities on this side of the seas are as great ; humanity is as frail ; and humanity in public servants, not least when engendered by the soul-inspiring training and ideals of the healing art, is hardly less generous or strong than in the upholders of 314 HEALTH AND EMPIRE the public health throughout the " graft-scandals " of California. The true instincts of the medical man are for the elaboration of truth and the service of the world. It is well that the public should occasionally be reminded of the extent to which this spirit of innate patriotism imbues the whole profession, in all countries and in all societies, even in face of the blind eye of the egregious Mayor Schmitz, of the city of San Francisco. CHAPTER XVI FEDERAL HYGIENE IN THE STATES We talk a great deal nowadays of the glorious possibilities of the British Empire. It has grown up haphazard, despite the efforts of the British public to forget it, of politicians to be rid of it. We now see — we selfish people of the motherland — that the empire is one of our greatest assets. But in the struggle of the nations for survival of the fittest haphazard arrangements are of no use ; our sense of the artistic, poetic and natural must be violated, the empire, if it is to continue, must be organised. We talk therefore of imperial defence and of com- mercial bonds within the empire. I venture to add the suggestion in this book of imperial defence against epidemic disease. It is significant that our own offspring should teach us many lessons of the greatest importance in our task of empire management ; and, as we look for many internal political experiments to New Zealand, so we look for the result of many experiments in co-operation between different governments under one head to the United States of America — America more than Germany, because of the essential and congenital analogies, both in individual character and in public administration, between our American cousins and ourselves. 3^5 816 HEALTH AND EMPIRE Such organisation of the pubhc health under the federal government is found in germ in the " United States Public Health and Marine Hospital Service." This organisation is unique ; independent of the navy or army, it works under a central bureau at Washington, and superintends, or at least super- vises, the health of every port in the United States. The marine hospital service has its headquarter buildings and publishes its official documents in Washington, where it occupies in a small way the position of the sanitary department of our Local Government Board or of the ministry of the interior in a continental capital. The marine hospital, as this building is called, is a glaring misnomer ; in Washington there is no marine and in this particular building there is no hospital. But it represents the department which has to do with quarantine and the sanitary protection of the marine or sea- faring mercantile community throughout the whole of the United States. It represents a federal board of health, and was established by an Act of the United States Congress as a result of the panic created by the spread of yeUow fever in the Southern States in 1878. Health-legislation — ^how well we know it in England — ^usually has to wait until so many innocent victims have died for the people. This change was in keeping with the general principles of American government, by which centralisation is extremely difficult and is only attempted when obviously necessary in matters such as those of diplomacy, public defence and the tariff. Defence, however, against infectious disease from without FEDERAL HYGIENE IN THE STATES 317 is equally a matter for national rather than for local action ; and so it was thought sufficient to establish a national public health bureau for this purpose alone by means of the marine hospital service. The term "quarantine service" would in reality better explain its functions. While re- pudiating all intention of interfering with the state legislatures, this service, on behalf of the federal government, has sent its commissioners to the different seaport towns to supervise the arrival of foreign persons and merchandise and deal with them under the orders of the central government. Thirty-nine quarantine maritime stations had in 1904 been thus established. This system was primarily directed against the foreigner, but it was before long extended to the " enforcement of rules and regulations made by the secretary of the treasury to prevent the introduction of contagious or infectious diseases into the United States from foreign countries, and into one state or territOTy from another." If the municipal or state authorities do not apply such regulations efficiently, the national government has a right to appoint its own officials to enforce due observance of the rules. The next step taken towards co-opera- tion between the states was the issue by state, municipal and port sanitary authorities of weekly reports of the sanitary condition of ports and places within the states. The United States as a nation claim thus at least the right to know what is taking place within each state. But there are no funds available by which experts may be sent to hold local 318 HEALTH AND EMPIRE courts of inquiry and report, as is done by our Local Government Board. A still further step is that the supervising surgeon- general of the marine hospital service, under the direction of the secretary of the treasury, has now a right to do more than inquire as to the disease in each state ; he has the right, by an Act of 27th March, 1890, to promulgate such rules and regulations as may be necessary to prevent the spread of that disease from one state or territory to another, the Act im- posing a fine of five hundred dollars, or two years' imprisonment, for the violation of such rules. But it is one thing to prevent disease being im- ported to any country or state ; it is another to take precautions which may prevent such disease taking root. It is just this power which is lacking at Washington. According to the intelUgence and activity of local authorities, so is the chance of any particular state of escaping infection. Where, as too often happens, the authorities are not particularly intelligent, or, as at San Francisco, are too afraid of vested interests and the displeasure of local leaders to carry through even the most necessary measures of sanitation, there the sword of Damocles will always hang, and an outbreak may at any time occur. As at San Francisco, it may then be of considerable use to send a special commission to assist the local authorities in the administration of measures to exterminate the disease or, to a large extent, to supplant them ; but in many cases the horse is stolen before the stable-door is locked. By degrees the United States, like ourselves and other powers, FEDERAL HYGIENE IN THE STATES 319 will doubtless recognise the value of such centralisa- tion of sanitary administration ; and, although opposed to the spirit of the American nation and constitution, as is the army, as is the navy, it will no doubt be effected within the next fifty years. The marine hospital service finds considerable assistance in a law administered by the department of agriculture, and dated 3rd March, 1891, under the title, " An Act to provide for the inspection of live cattle, hogs, and the carcases and products thereof, which are subject to inter-state commerce, and for other purposes." Similarly, more recent regulations forbid the sale of vaccine lymph, antitoxin serums and other similar articles, unless produced by licensed manufacturers working under the supervision of inspectors appointed by the federal government. In the making of lymph and the canning of meat, the principle of national control is admitted ; but national control of the imported disease is far easier and less open to opposition, and it is this work which is the principal and most striking function of the marine hospital service. When the existence of plague in San Francisco came to the ears of the government, it was this service which sent a federal commission in 1901 to inquire into the state of affairs. For three years Dr. Blue and his assistant had, by arrangement with the local authorities, been busily engaged on the sanitation of the slums, and as a result plague appeared to have died out. In the week ended 13th August, 1904, over 2000 rooms had been inspected, and over 2500 persons ; 4 dead had been examined ; 41 rats 820 HEALTH AND EMPIRE had been examined bacteriologically ; over 200 places had been limed and disinfected ; the Danysz virus for extermination of rats, conveying to them a bacillus which is death to them but harmless to man, had been spread throughout ten blocks of buildings ; and various details of sanitary work had been effected. These facts are quoted from the weekly reports of the public health and marine hospital service. This weekly bulletin is the model statement of the facts on which the work of such a federal department should be based, and is highly suggestive for our own use. It consists of two parts, the first affecting the United States ; the second, foreign and insular, concerning all other parts of the world. The reports are addressed, directly or indirectly, to the surgeon- general at the head of the service, and give a clue to the many-sided, thoughtful and statesman-like work in which the members of the service are engaged. Let us run through the contents of the bulletin in any particular week, that for instance in the week ending 13th August, 1904. Through the director of the hygienic laboratory at Washington, evidently an appanage of the marine hospital service, the chief of the division of zoology sends a preliminary report upon an investigation into the so-called " Spotted Fever " (tick-fever, or pyroplasmosis) of the Rocky Mountains, the result being negative to the usual theories of the disease. Allusion has already been made to a second report — ^that on the work at San Francisco. A third report announces the discovery of the anopheles mosquito in Key West, due credit being given by name to the medical FEDERAL HYGIENE IN THE STATES 321 undergraduate who made the discovery. Work is reported on account of smallpox in Northern Maine, on the Canadian border ; other work on account of yellow fever in Texas, and especially on the lower Rio Grande, and the proceedings of the inspection service along the Mexican border. Notice is given of yearly and monthly reports of the chief facts, statistical or otherwise, concerning the public health of the various states and cities, with a discussion of the mortality figures for June in New York state and city ; and reports are^iven as to the alien immigrants arriving at the various ports during the preceding week and month. An eye is thus kept upon serious illness of an epidemic character affecting any part of the United States, special commissioners being sent down to investigate any unusual outbreak, as Dr. Blue was sent down to San Francisco, or as Dr. Bulstrode might be sent down to inspect oyster-beds at Whitstable. These reports are followed by tabular reports from all national quarantine and inspection stations, enumerating the vessels that have sailed or arrived, with certain details concerning their freight, and any action that may have been taken for their disinfection. The first part of the weekly bulletin ends, in this particular instance, with tables of all the smallpox cases reported for the previous (+,wo months from every part of the United States, over 2500 in number, with 60 deaths ; a similar report of yellow fever, 6 cases in six months ; of plague in Cahfornia for the previous four and a half years — 22, 30, 41, 17 322 HEALTH AND EMPIRE and 9 cases respectively, only 6 of which recovered ; and the weekly mortality table from the chief causes of death of some sixty cities of the United States. So far, we may say, there is nothing very original in this bulletin. The weekly mortality table does not in any way correspond in importance and care of production with the weekly report of our registrar- general ; there is no systematic record of deaths notified for the several parts of any area, correspond- ing to that now issued by the local government board for England and Wales ; and in this country the detailed reports of the medical officer of our local government board, although rare in their appearance, give the public ample opportunity of knowing for themselves what our central department is doing, so soon as it can be pubUshed with sufficient pre- caution to prevent misunderstanding. It is the second part of the United States bulletin that may attract our attention for a few pages. It consists of a detailed and full series of reports con- cerning the public health at every port of importance throughout the world. We open upon the official report of plague in the Cape Colony, issued from the colonial secretary's office at Cape Town on nth July. This bulletin is issued five weeks later. The next report is from the department of public health at Brisbane, dated six weeks previously and for- warded by the consul-general at Melbourne, giving details as to the rats and mice examined at the bacteriological institute and destroyed during June, and as to the results of treatment in the plague hospital. A similar report on plague in rats and man FEDERAL HYGIENE IN THE STATES 323 is sent from Sydney, and another from Western Australia, also forwarded by the consul-general at Melbourne. The consul at Bahia, with less complete opportunities, reports the cause of death for all bodies buried during July in the Bahia cemeteries and the occurrence of fifteen cases of smallpox in the last half of the month. An acting assistant surgeon reports the vessels and cargoes leaving Rio and the measures taken to prevent the spread of plague in Brazil, including the use, at least in hospital, of " anti-pest " serum and vaccine. A note follows as to the installation of a complete disinfecting plant in the port at Para, with a general report upon the mortality and sanitary condition of Rio a couple of months previously. Reports are published from British Honduras and Canada, giving in the latter instance the number of immigrants rejected after inspection. The next report deals with China, on the authority of past-assistant surgeon White, giving an account of plague, smallpox and cholera in the various districts of Southern China, the maintenance of quarantine at nearly all oriental ports against arrivals from Hong-Kong and details as to the ravages of an epidemic disease, believed to be rinder- pest, in the jungles of Lower Burmah. The reports from Limon, a fruit-port in Costa Rica, and from Panama are of importance in connection with the canal, while that from several parts of Cuba shows the conditions for which the States undertook tem- porary responsibility, including a condemnation of sanitary conditions associated with outbreaks of scarlet and enteric fever at Matanzas, and an outline 324 HEALTH AND EMPIRE of the problem with which the city is confronted in seeking to remedy this evil. It is surprising to read that the water-rent is so high — at fourteen dollars, or sixty shiUings, per month — that it is impracticable to forbid the poorer classes the use of contaminated water from the city wells. From Germany not only the weekly death-rate of Berlin and other chief cities, and its principal constituents, are given, but also the German report of plague, cholera and small- pox in Egypt, Japan, British South Africa, Brazil and Turkey. From India two pages of figures are given as to the mortality in Bombay city from various causes in previous months and years. A brief statement is also made of health at Calcutta. Re- ports from South and Central America and the West Indies are of course of the greatest importance to the United States ; and so we have detailed ac- counts of the work being carried on against yellow fever and of mortuary records in different parts of Mexico, Nicaragua, Panama and Peru ; while the dangers threatened to the Philippine Islands from cholera, from plague and from smallpox in Hong- Kong and Saigon, are fully described. ■ A quotation from this paragraph shows the nature of the information embodied in the bulletin, and its evident advantage to sea-borne commerce: " The contagious diseases report of Manila is particularly, encouraging at this time, because the quarantinable diseases in the near-by foreign countries have been decidedly on the increase. At Hong-Kong alone ninety-nine cases of plague were reported for the two weeks ended June 25th ; at Amoy plague is reported to be increasing very rapidly ; at Saigon the cholera situation remains FEDERAL HYGIENE IN THE STATES 325 unchanged. The French bills of health report cholera as being present in the interior, but information obtained from ship captains is to the effect that the disease is also present in the port of Saigon. The masters of vessels plying between this port and Saigon have shown a great willingness to aid in preventing the introduction of cholera from that port. So far as it has been possible to ascertain they have faithfully carried out the sugges- tions that none of their crews be permitted to go ashore, to take aboard no fresh vegetables, and not to take any water at Saigon if it can possibly be avoided. In view of the fact that there are no available data upon the wholesomeness of the Saigon water, every ship that arrives here from that port carrying Saigon water is required to discharge the same before entering the harbour, and the tanks are disinfected with permanganate of potassium." Thus it may be seen that merchants shipping goods to the Philippines on 20th August were able at least to know the condition of affairs in Manila and the ports connected with Manila two months previously ; those shipping goods to Hong-Kong or Amoy would know the danger they ran of being quarantined afterwards at any other port at which they might call, on account of plague ; and those shipping goods to Saigon would know that there was a considerable possibility of their ships' crews being attacked and decimated by cholera and their cargoes destroyed. The commercial value of this infomia- tion is undoubtedly of the first importance. Further evidence is given of this car6 of the federal government for their citizens trafficking abroad by a circular quoted in the bulletin, signed by an assistant surgeon in the marine hospital service, approved by the United States consul and the consul of Panama, and headed, " Callao, Peru. To Steamship Com- 326 HEALTH AND EMPIRE panies, Agents, Masters, Physicians of Merchant Vessels, and Others concerned." This circular draws attention in detail to the " requirements of the United States quarantine regulations, which are to be observed at this port by vessels bound for ports in the United States and the republic of Panama." A brief account follows at random of yearly and monthly statistical reports of mortality from various cities and countries all over the world — England and Wales, Lourenco Marques, Batavia, Nagasaki, Georgetown (Demerara), Barcelona and Gibraltar. Last of all, reports received from United States consuls thirough the department of state and from other sources as to cholera, yellow fever, plague and smallpox, the four most dreaded human scourges of the tropics, are given as fully as is possible under the circumstances. The information given in this bulletin is partial in the extreme, and it is at least one if not two months out of date by the time it is published ; but that it forms the nucleus of information which might be of the greatest value to the shipping world is beyond question. For British purpose it may well be sug- gested that an essential undertaking of our Board of Trade or of any department that may be constituted for imperial government should be to institute a system of health-intelligence, to collect information with the help of the colonial, foreign, India and war offices, of the local government board and of the admiralty, to estimate its value and to publish the results in the most convenient form and with the FEDERAL HYGIENE IN THE STATES 327 least possible delay for the use of the mercantile community. The precedent has only been established this year in the weekly publication by our local government board of the returns of notifiable disease in the United Kingdom. This requires extension to ports and countries overseas. At present, but only when attention has been drawn to certain conditions demanding notice, such as the prevalence of plague in India, South Africa, or Hong-Kong, official state- ments appear to be cabled home weekly and issued to the Press. This system of casual information should be replaced by a weekly system of notification of all infectious diseases of importance to commerce, from every port and chief city, not only in our own empire but throughout the world, where there may be a British consul, a ship, a resident, or an official representative of any sort. These reports, received by wire during the slack hours of the week-end, should be published in bulletin form, resembling that issued by the public health and marine hospital service of the United States, on every Monday evening. By Tuesday, in that case, every British shipowner would know the epidemic dangers to which his business is subjected, as judged by a report only three days' old. Is it worth while ? Official experience teaches early that the worth of any proposal in this world must be measured by finance. If the government were to produce regularly, with the high authority that it could command, a bulletin of such value as this to the commercial world, the commercial world would probably be glad to repay it. 328 HEALTH AND EMPIRE It is difficult, without the advice of an inter-depart- mental committee, to estimate what the cost of such a bulletin would be. But the personnel required for the purpose is already to hand; the advantage would be like that of starting a newspaper with your correspondents already paid by other concerns and your plant established and kept going on a lirge scale by your other businesses. The cost of pro- duction would amount to little more than the cost of the telegrams at government rates and of an expert, with clerical help to deal with them. The bulletin, indeed, by the inclusion of advertisements, might become a most paying concern ; but that is one of the economies which it would seem futile to impress upon government, for reasons which they have doubtless often and fully considered. It has seemed advisable to suggest a commercial ground for supporting the proposal of a weekly im- perial bulletin of health, because neither our govern- ment nor the general public, nor even the commercial men themselves, have yet recognised, as is recognised in Germany and America to a considerable degree, the immediate pecuniary value of science to the con- cerns in which they are interested. If any proposal affect trade — affect trade, that is, directly — they are at once all ears to hear of it. If it affect trade only in- directly through scientific research, they want to be shown definitely and clearly how such scientific measures are likely to benefit trade. If research be merely proposed in the general hope that it may lead to the advancement of knov^ledge in the sciences on which trade transactions are based, then they consign FEDERAL HYGIENE IN THE STATES 329 it at once to the tender care or eternal oblivion of private charity. But, to those who have eyes to see, it will be obvi- ous that here in the British Empire, here in London in the departments of government which supervise the all-pervading trade of our race, we have to our hand an agency which can present us with the most com- plete and regular statistical basis of the science on which rests the prevention of disease. As we of the health-service believe that to prevent disease is a task more honourable although less honoured than to cure it ; as we know that the prevention of disease depends to a large extent, especially in warm climates, on the prevention of infectious disease spreading in epidemics throughout the world ; so must we consider it of the first importance that we should know authoritatively and at regular periods the strength, distribution and movements of these plagues, in relation to the varied conditions of climate^ habit and race in different parts of the world. Until that knowledge is at hand we are at a manifest disadvantage in considering their hfe history and in devising means to exterminate them and prevent their recurrence. This task may eventually be undertaken by the international bureau of hygiene at Paris. But there are difficulties in the way of international action in such a matter ; and the result, if more comprehensive, would be less detailed. Nationalism is a stronger force than internationalism ; and reports from British re- presentatives only would be standardised and of greater value. For the present therefore, at least, it is best to propose a report on a British official basis. 330 HEALTH AND EMPIRE It may be hoped that the result of such a proposal will not stop at reports by correspondence. A system thus initiated would lead naturally to the employ- ment of many highly-trained experts, whose large practical experience in various parts of the world and in various services is at present wasted in retirement, for further service in investigating, reporting and advising on such health-problems of different parts of the Empire as require consideration by other than the experts and permanent staff of the locality. It would co-ordinate the work hitherto undertaken by missions from the Liverpool and London schools of tropical medicine, by royal commissions, by experts casually employed by the colonial and foreign offices. It would lead to the creation of an Imperial General Staff to conceive and advise as to the execution of plans, on imperial lines and by general co-operation, for the arrest and prevention of pestilence and the promotion of health in every part. As the basis of this organisation and as the neces- sary equipment for the campaign which it is the proud duty of health officers to wage against disease in every shore and sea, I ask for the weekly publication of the latest and fullest possible returns of epidemic disease from every place in which the British govern- ment is represented throughout the whole world. CHAPTER XVII MR. chamberlain's SPEECHES ON THE POLICY OF HEALTH AND EMPIRE The credit is due to Mr. Chamberlain of having been the first minister of the crown to reaUse and formu- late the value of health to our imperial power ; and to adopt the duty of attention to the public health as an axiom of our imperial rule. His attention was first drawn to the subject in connection with the health of the administrative staff of our imperial colonies. Appointed colonial secretary in 1895, he had already succeeded in securing the establishment of the London School of Tropical Medicine, as the first step in a practical policy for discovering and removing the cause of tropical diseases, when on the loth May, 1899, he presided at a festival dinner of the Seamen's Hospital Society and appealed for funds for the school and for the enlargement of the branch hospital in the docks to fifty beds. The House of Commons had voted ;f3500 for this object and promised £1000 a year for its maintenance. Lord Lansdowne, as secretary of state for war, said that of all the enemies the British soldier had to encounter, tropical diseases were the most formidable. ' We are met here to-night,' said Mr. Chamberlain, 331 332 HEALTH AND EMPIRE ' to promote Imperial Policy. The British Empire contains, I suppose roughly, something hke 300 millions of coloured people, hving mostly in tropical climates, and it is the government and control of the tropics which form the principal part of that " white man's burden," the immensity of which has caused some of our statesmen to regard the future with anxiety akin to fear. The other day Mr. Rhodes in a speech referred to a conversation that he had had with Mr. Gladstone, in which that great minister had said that he was afraid lest the number of men qualified for colonial administration should be insufficient for the work which an extended empire involved. For myself I agree with the reply which was made by Mr. Rhodes. I believe so long as the British character remains unchanged, the opportuni- ties of distinction, the prospect of adventure, and the love of responsibility which is deep-seated in our character will always prove a sufficient temptation to secure that the supply shall be equal to the de- mand. But, my lords and gentlemen, that does not relieve us from the obligation to see that every pre- caution is taken and every effort made to prevent this splendid material, those potent instruments of our greatness, those props of our empire, from being wasted and thrown away owing to the neglect of precautions, which, if they were properly fulfilled, might save their lives or extend their usefulness. ' It is impossible for anyone, who occupies the position which I have the honour to fill, not to be painfully impressed with the tragedy which is always being enacted, that of the mortality which cuts off MR. CHAMBERLAIN'S SPEECHES 833 young men of great promise in the very outset of their career, which strikes down in their prime ex- perienced administrators and able and conscientious officials, which, even though it is not vital to indi- viduals, at all events weakens the service by constant illness, disorganises the administration and prevents anything like continuity of policy owing to the fre- quent breaks which are necessary in order that im- paired health and strength may be restored.' The policy proposed then should consist of (i) training medical practitioners for the tropics to investigate the cause and cure of disease; (2) in- structing all who go to the tropics in the rules of health ; (3) providing the best medical and nursing attendance on the sick. Mr. Chamberlain referred to the Colonial Nursing Association, to the work done in Italy and by Dr. Ross in India as to malaria, to the investigation about to be undertaken in Italy and in Central and West Africa by the Royal Society on malarial and blackwater fevers, to the Colonial Office circular to the schools of medicine, asking them to give their students some special training in tropical diseases. But these measures would be incomplete without a school devoted to tropical medicine, and for that he made an eloquent appeal for funds. ' I think I am not too sanguine when I say that we have a right to expect a bountiful and beneficial harvest. Why should we despair ? Is it too much to ask of science that it should confer this great benefit upon mankind ? When I look at what has been done in the past by the efforts of science, the plagues of the Middle Ages which devastated vast 334 HEALTH AND EMPIRE districts and which have now ceased out of the land, at the fact that within our own time cholera and typhus have lost most of their terrors; when I remember what we have been told by Sir A. Hoskins and how in the West Indies the frequency and virul- ence of the epidemics of yellow fever have been greatly diminished ; when I know that colonies like Hong-Kong, cities like Calcutta, which during the present century earned the evil reputation of being a white man's grave, have now become comparatively safe, I say there is no reason to despair that science may yet do something to lessen the unhealthiness of other settlements, more especially of those in Africa, thus removing the greatest hindrance to the develop- ment of that vast continent. ' My lords and gentlemen, the man who shall successfully grapple with this foe of humanity and find the cure of malaria, for the fevers desolating our colonies and dependencies in many tropical countries and shall make the tropics liveable for white men, — who shall reduce the risk of disease to something Uke an average — will do more for the world, more for the British Empire, than the man who adds a new province to the wide dominions of the Queen. And those who co-operate in securing this result, whether by personal service or by some pecuniary sacrifice will be entitled to share the honour and to add their names to the greatest record of the benefactors of mankind.' On the 25th of July of the same year Mr. Chamber- lain and Mr. Asquith spoke at the Annual Meeting of the Colonial Nursing Association at Stafford House. MR. CHAMBERLAIN'S SPEECHES 335 Founded in 1896 by Mrs. Piggott of Mauritius, this body has now sent 258 nurses abroad and finds the ^§6 35 to 50 best. It was only appealing for a modest endowment of £5000. Mr. Chamberlain testified to the advantages derived by tropical colonies from the services of the Colonial Nurses. A letter from Col. Willcocks on the Niger River declared that the recovery of some of his young officers from blackwater fever was due to the attention and care of these nurses. ' It is a mission to all those who are interested in the development of the great empire of which we form a part. Lives such as these, so precious to the empire, the lives of those who are the successors of those who gained the empire for us, such lives ought not to be wasted. We owe it to them and to ourselves to do all in our power to pre- serve them, and to see, so far at all events as that may be possible, that when they are struck down, as unfortunately they often are in the course of their duty, by illness, at aU events they shall not want the tending of skilful and kindly hands, and that sym- pathy, that womanly attention, which will be found to be the best anodyne for their pain and perhaps the most effective cure for their disease.' On the 15th March, 1901, a deputation went to the Colonial Office representing the London, Liverpool and Manchester Chambers of Commerce and the Liverpool School of Tropical Medicine, to present a statement which proposed : " (i) That the governments of the various colonies on the west coast of Africa be invited to pre- 336 HEALTH AND EMPIRE pare schemes, with estimates, for the complete organisation of sanitation in the coast ports in the vicinity of quarters permanently occu- pied by any considerable number of Europeans, especially with regard to " (a) removal and disposal of refuse ; " (b) complete surface drainage of the soil and removal of bush and undergrowth ; " (c) removal of native huts where their pre- sence is a menace to the health of Europeans ; " (d) institution of sanitary regulations for observance by the public within the areas indicated above. " (2) That at the same time a sanitary com- missioner, or sanitary commissioners, be appointed by the colonial office to visit repeatedly all the said colonies, and to re- port to the secretary of state the condition of sanitation in each colony, and the steps being taken to improve it by the local authorities. " (3) That where new settlements are ' being planned, quarters for Europeans shall be arranged as far as possible on the Indian cantonment model, and that special regula- tions shall be made to prevent the over- crowding of such cantonments by the general pubUc." In reply Mr. Chamberlain, in disagreement with some of his predecessors in office, expressed his belief in the future of West Africa, and addressed MR. CHAMBERLAIN'S SPEECHES 337 himself to the proposition that health was a financial asset, which justified expenditure on its preserva- tion. After noting the influence on morality of the unhealthy and lonely conditions of Ufe in many tropical posts, he referred to the importance he had found attached to this subject by every colonial governor that had returned home from the coast since he had been at the Colonial Office. He differed from the deputation by showing that more was being done in this direction than was realised, and, in pointing out the limits of expenditure justifiable on sanitary inspection, said : Sanitary inspection was carried on in this country (England) under circumstances to which the Gold Coast presented no parallel. Arrangements here could be made without difficulty which could not be made in a new and tropical colony. Even here they sometimes complained of being a little overburdened by inspectors, and said that a counsel of perfection was sometimes put before them which was not really possible of attainment. If they were to have a house-to-house inspection in those colonies on the West Coast, of natives as well as of Europeans, and inspectors in turn were to be themselves inspected by a superior officer with all the scientific require- ments which were necessary, and if, again, those inspectors were to be supervised by travelling inspectors sent over from this country, he confessed that he trembled at the budget which would be pro- duced, and there might be a reaction in consequence of attempting too much. No doubt the matters to which his attention was called deserved and required 338 HEALTH AND EMPIRE urgent attention. But schemes for which they asked were already in preparation, and in some cases had been prepared. The water-supply was undoubtedly of first-rate importance, but also, unfortunately, it involved a very heavy expenditure. The question of sewage disposal was another question, the difficulty and magnitude of which everybody who was con- nected with the government of a big town must be fully aware of. But, still, all these points had been and were receiving the careful consideration of the Government, and he trusted that they might be able to do something in connection with them. A great deal had been said, with reason, as to the danger caused by the too close proximity of the European residences to the residences of the native population. In Accra that matter had been to a great extent dealt with, and the dwellings of the Europeans had been moved away from those of the native population. In Sekondi, which was going to be a considerable place, owing to the establishment of the railway, which if continued to Kumasi would be of great importance. Major Maitland had already acquired a very considerable portion of land, with the object of building upon that land, separately and away from any native population, the buildings required for any Europeans. In other places the same sort of precautions were already being taken. He had great hopes as a result of the great railway work which was now going on, of which about 400 miles had been made in the West Coast colonies during the five years he had been in office. The general effect on commerce and trade of this had MR. CHAMBERLAIN'S SPEECHES 339 a very definite bearing upon the question they were now discussing, because if they could have railways running into the interior and a more elevated country it would not be impossible to establish in all the colonies sanitary places, to which at all events a considerable amount of the administrative work of the colonies might be moved and with it a considerable portion of the European population. Of course the coast ports must always have a European population dealing with the Customs and the large export and import trade. Even with that population, if the railways were sufficient, and if, as he hoped, they were very greatly and very quickly extended, even that population might be carried out of the town at short intervals, perhaps every day, certainly every week, and they might enjoy at intervals the fresh air and better conditions which he hoped would have a very considerable effect upon their health. He suggested therefore the appointment of a small sanitary commission to consist of three members of the chambers of commerce, with a sanitary ex- pert and a representative of the Colonial Office. He should refer to them also the question of how the funds were to be provided. He would ask them to estimate the cost in each colony and to report to him how the money required to carry it through could be provided with the least inconvenience to those con- cerned. He was glad to see in the memorandum of the Manchester Chamber a statement to the effect that they were not unwilling that a sanitation rate should be levied, either in the form of an additional import duty or some form of local taxation, the 340 HEALTH AND EMPIRE money raised to be devoted solely to the improve- ment of the health of the colonies. That would be a matter for this Commission to consider. But the Manchester Chamber went on to say that they would like to draw attention to the enormous increase there had been in expenditure in recent years and re- commended that it should be raised by economy in other directions rather than by increase of taxation. If it could be found by economy rather than by increased taxation, they all agreed that that would be a far preferable method. To this same Com- mission he would refer this branch of the Inquiry and if they could recommend economy which could be carried out without injury to the administration or to the security of those colonies he would be only too glad to consider it favourably. On 30th June, 1904, a banquet was given to Mr. Chamberlain by the Royal Institute of Pubhc Health, " in recognition of his services to preventive and tropical medicine whilst filling the office of Colonial Secretary, 1895-1903." The large and dis- tinguished assembly present in his honour included Mr. Lyttleton, Lord Onslow and Mr. Balfour. In proposing his health, the President of the Institute referred to the municipal undertakings of Birming- ham, for which Mr. Chamberlain was in large part due, and showed his exceptional activity in promoting health in the tropics. Mr. Chamberlain in his reply disclaimed excep- tional credit for his action. ' I claim no more than may be usually claimed by every other statesman, by everyone who is interested either in social reform MR. CHAMBERLAIN'S SPEECHES 841 or in colonial development— -that is the interest which we all take in the work of medical research and preventive medicine, and the expectation we enter- tain of the great results which may be expected from them.' He spoke of diphtheria antitoxin and the advances made in curative medicine. ' But, while we look with confidence to the further results of curative medicine, I think we shall all be agreed that pre- ventive medicine is better still. Now, at any rate, the importance of securing healthy conditions of life is recognised by everybody who cares for the welfare of his fellow-creatures. I recollect very well the speech which was made, I think in the early seventies, by Mr. Disraeh, and which was at that time the subject of some ridicule from myself and others, in which he spoke of the importance of sanitary reform as the foundation of every other re- form. None of us are likely to ridicule such a state- ment now. Now we feel that sanitary reform is not unworthy of the attention of the highest statesman- ship. Now we recognise that without it social re- form is an empty phrase. The housing of the poor, the attempt to prevent the physical deterioration of the race, and all other matters to which we legislators devote such part of our time and attention as we can spare from party conflict, all these things depend, are founded upon, sanitary reform. Pre- ventable disease, at this moment, is, as we all know, a great agent for filling our workhouses, for raising our taxes, for weakening the fibre of the people, for preventing us from competing successfully in that 842 HEALTH AND EMPIRE eternal struggle for existence which must go on as long as the world shall last. In peace it is of the utmost importance ; in war the same cause destroys more of our soldiers than the bullets or the swords of the enemy, and meanwhile the administration of the army is lessened in efficiency by preventable disease to which the agents of the Empire are constantly subject. And, Mr. President, I may be excused in regard to my experience if I say that it is this branch of preventive medicine which at the present time enlists my warmest sympathies. ' For, after all, I repeat what I have said on other occasions. The work of this century, or at all events, of the beginning of the century upon which we have entered, is the consolidation of our Empire. And this is one branch of the greatest of all subjects ; how are we to fulfil the task which Providence has laid upon our shoulders, a greater task than has ever been imposed upon any other nation, a task which we are now fulfilling not without success, but the greatness, the increasing greatness of which may well fill even the boldest of us with some anxiety.' The work of our countrjnnen in the colonies was then described, both in peace and war and in the prevention of war and slavery. ' These men are the greatest assets of the Empire. Let us prize them and value them, let us do everything to keep them in the vigour of life ; and it is for that reason that I attach so much importance to these investigations, to those studies, to this research, which is going, I verily believe, — sanguine optimist as I always am — ^in the course of time to make these tropical climates, which MR. CHAMBERLAIN'S SPEECHES 343 have been each in their turn the white man's grave, to make them places where white men can hve in comfort. It is because of this that I wish to conclude by saying that, after all, one of these almost un- known students working in laboratories in London, Liverpool and elsewhere may be doing more good for the Empire than any statesman has been able to do, however high his position. It is with that feeUng that I have had so much pleasure in attending this meeting, and it is with that feeling that I thank you one and all most heartily for that sympathy which you have shown, I will not say with perform- ance, but at all events with intention, to that ideal which I hope every patriotic Englishman sets before himself.' ' Mr. Balfour, in replying to the toast of " Preventive Medicine and the State," epitomised the duties of the state in this regard, as involving, firstly, the internal problem of maintaining, despite increas- ing urbanisation, ' the inevitable physical basis of every great national and imperial aspiration ' ; and, secondly, the external problem of turning the ex- traordinary natural resources of the tropics to the best account. It was in this respect, as well as in the other more public spheres of his official work, that Mr. Chamberlain would be reckoned on aU sides as the greatest colonial minister the country had seen. ' Turn our great tropical colonies into places where the white man could live in reasonable health and comfort, and they would add, directly and in- directly, incalculable gains to the commercial future and industrial prosperity of this country.' 344 HEALTH AND EMPIRE On the I2th January, 1905, Mr. Chamberlain at- tended a lecture by Major Ronald Ross in Liverpool on " The Progress of Tropical Medicine." In an informal speech Mr. Chamberlain let fall a definition of our colonial policy. ' I remember on one occasion a foreign monarch said to me, "Of all the things in connection with your British history, the one I admire most is your colonial policy." I said to him, " Sir, I think you do us too much honour. We have never had a colonial pohcy, but somehow or other, we have been allowed to blunder into the best parts of the world." ' And again he gave his tribute, as of personal obligation, to the imperial workers in the tropics, emphasising the debt due to those who by research or by practice help to prevent tropical disease and so bear their share in the foundation of the Empire. The last public speech on this subject was made by Mr. Chamberlain in again presiding over a dinner in aid of the London School of Tropical Medicine, on the nth May, 1905. He came back to them, he said, to rejoice in the past success and to provide for their future. His interest in that question was unex- hausted, indeed unabated. This duty had increased in recent years with the continual extension of our territory, with the increase of our scientific know- ledge and our opportunity and also with the awaken- ing of our imperial conscience. We owed this duty to the vast population for which we had gradually made ourselves responsible. He praised the gener- osity of Liverpool in providing ^^40,000 for their school of tropical medicine ; recalled the services MR. CHAMBERLAIN'S SPEECHES 345 of the 503 students, officials, traders and missionaries who had even then passed through the London school ; deplored their difficulties in raising, even with much assistance from the government and the empire, £30,000 in a city so dependent as London on tropical development, and he appealed for £100,000. There could not be a more desirable application of superfluous wealth than to enable that institution to unite the work of the investigator and the work of the physician, which was after all the ideal union between scientific inquiry and its practical applica- tion. He asked them to sympathise with those workers of our empire who had already done so much to secure its renown, and who had contributed, and were contributing, to the happiness and welfare of the vast populations which we had gathered together under the protecting influence of a single flag. It will be noticed that Mr. Chamberlain's advocacy of health as of imperial importance concerned itself mainly with the health of the white men, especially the administrators, in the tropics. That is only a small part of the problem considered throughout this book, which seeks to show the value of health in the rank and file, not merely in the officers' mess. His appreciation of this more general proposition as the basis of social reform is indeed shown by Mr. Chamberlain in practice as Mayor of Birmingham and in principle in the speech to the Royal Institute of Health, already quoted (p. 341). But in office the keen business eye, selecting the more pressing and more obvious needs of colonial administration, fixed on the most vulnerable point and attacked it with 346 HEALTH AND EMPIRE a will, being assured of public sympathy for those who sacrifice their lives or health in carrying out a recognised imperial duty. Secure the health of the white man, and from the same source, if not from the same measures, the health of the masses will follow. Secure the health of the tropical dependencies ; the white men need less reminder of the need of health- measures in their respective homelands. Thus did Mr. Chamberlain lay the foundation-stone of a policy of health and empire, and start a tra- dition on which his successors have built and will doubtless build in future. It is the object of this book to promote this policy, and in doing so it has seemed well to recall the pioneer part played in this movement by Mr. Chamberlain. CHAPTER XVIII HEALTH AND THE BRITISH EMPIRE THE PRACTICAL CONCLUSION " It seems to me best to approach the prevention of disease, not so much from Jts humanitarian as from the economic point of view. Disease always causes a large expenditure of money . . . and mosquito-borne disease is especially a source of such expense. . . . The prevention of disease should be looked on economically as insurance against the useless expenditure caused by such maladies." — Professor Ronald Ross, in Report of the Advisory Committee for the Tropical Diseases Research Fund for 1910, Appendix I., p. 21. It is hardly too much to claim that Professor Ross by his proof, obtained by incredible labours in India under the most trying and discouraging conditions, that malarial infection was invariably conveyed by the mosquito, is thereby, with Pasteur and Lord Lister, the greatest preserver of human Hfe and deliverer from sickness yet given or likely to be given to the world, and that he has thereby done more than any soldier, trader, explorer or politician to strengthen the British Empire. It is therefore of importance to note his emphasis on the financial rather than the humanitarian aspect of national and imperial health. It is not so much that philanthropy is of minor importance as that finance is the medium 347 848 HEALTH AND EMPIRE in which the whole business of the world is transacted. What does it cost, what does it save in cash as representing so much thought and will-power, labour and raw material ? That is the problem directly or indirectly in every proposal, worldly or other-worldly, that presents itself to the efficient man. The outcry of certain pseudo-philanthropists against money- making is due either to shallow thought or slipshod expression. The objection should be to faulty money-spending. It has been the aim of this book, as of the travels on which it was based, to prove that health was a matter of business efficiency in imperial welfare. It is also, as in the case of Indian plague, a matter of humanity ; and on that score may attract occasional and ephemeral attention. But governments and the public take a purely fatalistic and careless view of it. A despatch to the Indian government, a circular to overworked district commissioners, a report as to the need of economy — and the matter drops. The local administrators know it is only a matter of philanthropy ; agriculture, poUce, education on western lines are solid business, and it is on these they will be judged. Granted, however, that we are learning to recognise the solid money-making worth of every healthy citizen, that we are learning in civil Ufe the hard lessons learnt by the army that medical work on preventive and strengthening lines is essential to the working, fighting strength, let us consider in conclusion the practical steps available to secure the utmost physical efficiency and therefore wel- HEALTH AND THE BRITISH EMPIRE 349 fare for the 400,000,000 inhabitants of the British Empire. THE NEED OF COMMON ACTION Of all departments of national life, none more urgently requires the widest possible field of study and action than that of health. Health depends on the relation of the human frame to its environment, animate and inanimate. It is essential to discover the limits of this relationship before we can under- stand the cause of its disturbance. It is absurd to confine our study of health and disease to a single race, living in fixed conditions in an equable climate. Experiment on the human body is subject to natural restrictions ; experience under the widest possible range of circumstance throws a wider light on its capabilities. Study of health and disease, therefore, should extend to the whole animal and vegetable creation ; should extend to all races of mankind in every climate and condition of life. Hanson's study of elephantiasis, Ross's study of malaria, have turned attention at home to the part played by flies, fleas, ticks and other insects in the spread of the commoner infectious diseases. The result is already seen in the extraordinary diminution of infantile diarrhoea and mortality in the last few years. It is the unfortunate heritage, not the fault, of the medical schools that they show an utter lack of appreciation of these possibilities and of the need of this wider view. Tropical disease, botanical and veterinary pathology, 350 HEALTH AND EMPIRE are to them things apart ; their study and teaching of medical science is Umited to the narrow groove of curative medicine as applied to man, the Englishman, in England; and few of their pupils can realise the full scope of health and disease until their subsequent duties in life bring them in touch with different condi- tions to those seen at a general hospital in these isles. It is of importance therefore to co-ordinate the experience of health and disease in each category of life, in every part of the world. It is on these lines that M. Jacques Cazotte conducts the International Bureau of Hygiene in Paris. But international systems and inquiries have limitations of another order ; they lose in driving-power and in co-ordina- tion more than they gain in breadth, at least as compared with the possibilities of similar under- takings throughout the British Empire. Some na- tions hide awkward facts ; others deliberately lie ; we alone adopt the policy of declaring the whole truth, and if our news be false the ambassador con- cerned makes immediate inquiries. But the diversity of race and climate, which our empire affords, and of every condition compatible with life, offers a com- plete field of study, complete enough at least for the present, in this regard. The aim too of international effort, as of pure science, is too remote from daily life to attract the co-operation of the inexpert. Nationalism is a growing, not a dying, force ; it is a most effective handle to the machinery of life. As charity must begin at home, so should research and defence of life begin with the most concise unit capable of HEALTH AND THE BRITISH EMPIRE 351 supplying the necessary factors ; and that is, for British sanitarians, the British Empire. The assistance of the inexpert but intelligent layman is indispensable. The expert is indeed the keystone of the arch ; but the arch consists and is founded on the common hfe. Both in administra- tion and also in the observation and reporting of facts, which constitute the most important ground- work of sanitary discovery, health-officers must work through their colleagues in general medical practice ; and doctors all must work through the individuals they serve. As health in the school depends in the end on the teacher, health in the army on the company officer, so health and its investiga- tion in the community must depend on those re- sponsible in various degrees for the daily life and work of the community. The basis required for effective development of the imperial health is a co-ordination of the forces that influence the health and disease of all classes and races under the rule of King George. INTELLIGENCE The first requirement in morbid, as in military, warfare is a proper system of intelligence. Intelli- gence there is in abundance ; blue-books without end ; reports from every microscopic unit of British government — ^when required by some inquisitive parUamentary elector — " papers " and figures from every port, city and village that sings " God Save the King." It is the bane of modern government, 352 HEALTH AND EMPIRE another misery inflicted by the inventions of the nineteenth century, that superficially accurate figures must be in stock to give to every reader of Tit-Bits a concise statement of every action that passes or should pass under the ken of any representative of the British taxpayer. In the plains of the Punjab one of the best of Indian civilians complained bitterly of the useless office work to which he was condemned, at the expense of the time available for the more primitive and infinitely more satisfactory system, both for rulers and ruled, of touring round his pro- vince and dispensing justice under the village banyan- tree. In every part of official life, a statistical committee should decide what figures were worth collating, what forms should be required to make these figures comparable and of value. The co- ordination of statistics bearing on health and disease throughout the Empire is urgently required. The first report on the Census of the British Empire was issued as a three-and-fivepenny blue-book in 1906, and dealt with the figures of 1901. A glance through its sixty-four fascinating pages of letterpress, without reference to its three hundred pages of tables, shows the need, there expressed, for such a regulation of the decennial census. But the regulation must cope with real democratic imperial authority behind it. A decennial census is the basis of vital statistics ; and they again are the groundwork of research and progress in the advancement of the public health. The next requisite is an official annual report on the health of the empire. Casual paragraphs in the newspaper, occasional papers in the technical Press, HEALTH AND THE BRITISH EMPIRE 353 reports of conferences and notices of epidemics in distant lands are of no permanent value. The public cannot collate them. Even the journals of tropical medicine and hygiene can only devote a small amount of labour and space to the task. As Somerset House has undertaken to produce a decen- nial report on the imperial census ; as the medical officer to the board of education produces an annual report, reviewing the annual reports on school health throughout England and Wales ; as the medical officer to the Local Government Board includes in his annual report some review of the prevalence of epidemic diseases throughout the world ; so should some imperial organisation issue an annual review, in due proportion, of imperial health. But annual reports fail to give information of current events while they are still passing. In our sixteenth chapter we have already stated the useful- ness of the weekly bulletin issued by the Marine Hospital Service of the United States and have shown the value of a similar weekly issue for our own empire. Port medical officers know the value of such returns in assisting them in their invaluable work of defending their countries against attack from imported disease. The health officer of Shanghai sent me recently copies of weekly returns received by him from the several ports in touch with his own — Japan, Hong-Kong, the Philippines, Penang, Calcutta, Colombo and Bombay^two or three weeks late. A weekly system of notification and distribution 354 HEALTH AND EMPIRE from a single imperial centre by wire would save many an outbreak and much money. Any organisation for the collection of such informa- tion would thereby be enabled with the utmost advantage to issue official news to the Press from time to time of disease occurring in the several dominions and possessions ; of research being con- ducted and remedial works undertaken, with their cost and result ; of conferences held, hke the imperial malaria conference held at Simla in 1908 ; news which should be invaluable in arousing and main- taining public opinion and of uniq;ue importance to the whole tropical world, whereas it is at present bottled up in the official pigeon-holes or rubbish baskets of each separate country. A single instance may be given of the need for such mutual information and concerted study. The Times, in its commercial supplement of 21st January, 1907, published an interesting article on " Mining practice ; comparative efficiency of labour on the Rand and in Kalgurli." The prevalence of miners' phthisis in the South African mines is in pitiful contrast with the complete absence of locally-con- tracted cases of phthisis in the Australian. Better ventilation and a less dangerous dust at Kalgurli do not account for the whole difference, the balance of which is attributed to the habits of life on the Rand and the complete change of clothing of every miner on leaving work each day at KalgurH. Here is a clear case for the exchange of information, dependent at present on a chance article in the Press. Such an organisation as is suggested would be HEALTH AND THE BRITISH EMPIRE 355 well fitted to issue pamphlets, to employ lecturers and advisers, to make use of various educational methods, which may conduce to a proper understand- ing and iftiprovement of the conditions that make for or against the maintenance of health and strength. It is melancholy to consider that the recent imperial education conference in London did not so much as touch on the questions of physical education and promotion of health. And yet we are officially told that our Board of Education " look upon the work of physical training as a national service from the point of view of education and discipline as well as from that of physique " ; and that the reader of their reports will find " a new understanding of the amplitude, purpose and opportunity of education, a new application of it, fresh fields to be conquered by it." There is, in fact, no co-ordination of in- telligence on matters of imperial health, no organisa- tion prepared and required to take a conspectus of the whole problem and to urge forward to the conquest of these fresh fields. Such an organisation is urgently required. AUTHORITIES CONCERNING IMPERIAL HEALTH Certain official organisations already in existence pledge the government to an acceptance of the principles here enunciated: A. An Advisory Committee for the Tropical Diseases Research Fund was constituted by Mr. Chamberlain as Colonial Secretary in 1904 and issues an annual report on an expenditure of some ;f5ooo. In 1910 the imperial government contributed £1000, the 356 HEALTH AND EMPIRE government of India ;^5oo, the dominion govern- ment of Australia £200, and the other governments of other tropical colonies over £1500 between them. Grants were made of about ^^2000 each to the schools of tropical medicine in London and Liverpool, with lesser sums to the universities of London and Cam- bridge. The last report for 1910 includes much interesting information not only on research but also on the effect of preventive measures in various parts of the world, including a report from Bang- kok by permission of the government of Siam. It is however partial in the extreme and arranged merely as a non-edited series of independent reports. B. An Advisory Medical and Sanitary Committee for Tropical Africa advises the Colonial Secretary on medical and sanitary questions connected with tropical Africa. C. As a sequel to the international conference of Africa protectorates — French, German, Belgian, Portuguese, British — held in London in 1907, a Sleeping Sickness Bureau was established, also under the Colonial Office, in 1908. Five out of the seven members, including Sir J. West-Ridgeway as chair- man, are amongst the eleven members of the Tropical Diseases Research Fund Committee. But the Bureau is housed by the Royal Society ; is supported by the Royal Society, by the Uganda protectorate, and, as to one-fourth the cost of upkeep, by the Sudan Government ; and is independently directed by Dr. Bagshawe of the Uganda medical staff. It publishes scientific work for those engaged in research or medical administration, and less technical inf orma- HEALTH AND THE BRITISH EMPIRE 357 tion for the use of lay residents in the African tropics. It is also engaged in mapping out the distribution of the disease and of blood-sucking insects. D. As a result of thirteen or fourteen years' continuance of plague in India and the reports of a second Royal Commission, the India Office established an Advisory Board on Plague in India, with its head- quarters at the Lister Institute. This Advisory committee has done admirable work in proving beyond all question the part played by the rat-flea in transmission of bubonic plague. It has not yet thrown much light on the spread of pneumonic plague, and it does, not appear to have concerned itself with the practical or administrative problem ; nor indeed was it intended to do so, judging by its constitution and the methods of its work. E. Both naval and army medical services have now medical advisory hoards, including civilians, whose duties give them information and responsi- bilities with regard to sanitation in most parts of the world. In the composition of these boards, however, there is far too high a proportion of eminent physicians and surgeons who have had but Uttle experience of preventive medicine in relation to the public health. F. The Colonial Office is officially advised by Sir Patrick Manson, a pioneer in tropical research and clinical work, although his experience of pubhc health work must necessarily be indirect ; the India Office by Surgeon-General Branfoot, a distinguished re- presentative of the finest all-round medical service in the world ; and the Foreign Office appHes to the Local Government Board for advice and often for the loan 358 HEALTH AND EMPIRE of a medical officer who will never have lived in the tropics, in connection with the sanitary matters, often requiring foreign travel in tropical regions, with which it has to deal. G. The London and Liverpool schools of tropical medicine receive grants for research and the London school is extensively subsidised by the Colonial Office for the specific training of its probationary medical officers. There have been many proposals for corresponding imperial action in connection with other departments of government affecting the welfare of the several diminions over the seas, as for instance in the case of colonial agriculture, the complete scheme brought up at the recent imperial conference for a permanent imperial council. The reasons for which the latter scheme was for the present rejected would not how- ever apply to the limited and utiHtarian purposes of a health-scheme. As miUtary and naval warfare require the creation of a general staff and a supreme Committee of Imperial Defence, so does the struggle for health require the creation of an imperial advisory council for the promotion of health. THE AUTHORITY PROPOSED For this purpose then it is suggested that each of the dominion governments should appoint one of their experienced medical officers of health as medical secretary to their high-commissioner or agent-general in London ; and that these, with medical officers representing the several departments in Whitehall, HEALTH AND THE BRITISH EMPIRE 359 and with an equal number of lay administrators, permanently responsible for the consideration of health matters in their respective governments or departments, should constitute a permanent advisory council, with London as its headquarters. The members of this council must be chosen, not for their skUl and eminence as physicians or surgeons, but for their experience and ability in connection with pre- ventive medicine and physical improvement. This body would take over the work of the scattered advisory committees — not merely departmental in scope — already existing ; it would divide its work in departments, probably by diseases, on the analogy of the sleeping sickness bureau and the advisory committee on plague ; it would appoint special committees for the consideration of special topics, and would despatch missions under its own complete con- trol, for local investigations of exceptional conditions. During the last few years committees would thus, with untold advantage, have been formed for the consideration of Indian plague during the first eight years of the outbreak, when nothing was done ; of sleeping sickness before two-thirds of the population of 300,000 in the infected district in Uganda had been killed by it ; of beri-beri, tuberculosis and alcohol ; of eugenics and the declining birth-rate; of mid- wifery and nursing ; of sanitary inspection and health- visiting ; of physical training and health in schools ; of public education in matters of health; of the changes required in medical education in view of the different, the preventive task now demanded of doctors by the state. 360 HEALTH AND EMPIRE Such a body would employ, for purposes of in- spection and report, an ever-increasing staff, experi- enced both in temperate and tropical sanitation from the administrative standpoint. This inspectorate is already to hand, waiting idle in this country with nothing to do. Of&cers of the Indian, Naval, Army and Colonial medical services have had a unique experience of the kind required ; their records would show their respective worth ; most retire in early middle age, many even earlier ; few find congenial work at home that will make use of their special abilities and experiences. There are others, retired from service under municipalities or district boards, and doubtless many still engaged in all parts who would gladly take engagement in such a service. Laymen of experience would be no more difficult to find. As the Local Government Board by its admir- able inspectorate — medical, engineering and archi- tectural — ^has acquired the respect of every district in England and Wales, so would such an imperial inspectorate earn for the advisory council proposed the confidence and support of every government throughout the empire. EDUCATIONAL MEASURES Much space was devoted in the earlier chapters of this book to the fundamentally important question of research. Excellent as is the work being done in laboratories in all parts of the empire under the encouragement of the home or Indian or dominion governments, there is sore need for their co-ordina- HEALTH AND THE BRITISH EMPIRE 361 tion. In a campaign it is of little value for scouts to be forging ahead, as chance may lead them, inde- pendent of any direction and out of touch with the forces they are to protect. All over the world much time, money and labour are lost for lack of specific direction of research ; still more are lost because the workers, even under direction, work all day in their laboratories and see nothing of work outside. It is one thing for a scout to be guided by what he finds, for the investigator to be open-minded and equally critical of all results, however obvious ; it is quite another thing to work without any guiding idea. The most useful investigations are based, Darwin said, on imagination, constahtly revised. Both the imagination and the revision can only useftiUy be supplied by a body of world-wide outlook in a matter so dependent as public health on the limits of immunity, susceptibility and endurance in the human frame. A central authoritative body, authorised by its effect- ive scientific credit rather than by law, would use these laboratories as a general will throw out his scouts ; efforts would be concentrated, although not confined, to one problem, even one aspect af each problem, at a time. Every laboratory would be as one mesh in the dredger's net, working slowly up- stream, confident that nothing can escape its reach. Every fact ascertained, yes or no, would be filed in its place in the records of the imperial bureau ; every worker would be enlisted in the general scheme and inspired by common and effective direction. Much too is lost through the common tendency to speciaUsm in research. As in chnical work so in 362 HEALTH AND EMPIRE public health, research and practice should go hand in hand. The workers at present far too often live glued to their microscopes and cut off from the outside world. But the worker, above all, the director, in a laboratory should be in frequent and responsible touch with the actualities of the conditions he is investigating ; he should either devote part of his time to research, part to administrative duties ; or he should take spells of service, first at one, then the other. This comment is more necessary at home than abroad ; more in civilian work than in the government services, where research has constantly to be justified ahd where duties are frequently changed. It is suggested, then, that in these ways research may be made far more effective and may so command a far greater measure both of private and of official support. Of the need of such support there is no question. In comparison with the bacteria and other parasites already known, the microbic worlds as yet unex- plored are as the universe to a single spot of earth ; in exploring the ultra-microscopic or ultra-violet or any other fields outside the range of our present instruments, we are in far worse case than Captain Scott in seeking the Antarctic Pole. The fields are beyond imagination ; we require endless work, well- directed work, well-endowed work to attract the permanent services of men of culture and thought and to secure them the requisite freedom from monetary care. The niggardly grants yet made by parlia- ment for research are but mere drops in the ocean ; and since parliament, we are told, represents the electorate, it is the electorate and their leaders that HEALTH AND THE BRITISH EMPIRE 363 must bear the burden before the eternal judgment- seat of those millions of preventable deaths in the Punjab, inasmuch as they have starved the research on which the remedy could alone be found. There is no further need to endorse the proposal recently put forward by Lord Northcote for an Edward VII. Tropical Research Fund and warmly supported by such representatives of imperial needs as Lord Crewe and Lord Elgin, Lord Kitchener and Lord Rothschild^ Mr. Ramsay Macdonald and Mr. Joseph Chamberlain^ The value of all this research work, especially in relation to tropical conditions, has lain in the Ught it has thrown on the whole science of preventive medi- cine. But the education of the medical officer of health remains the same, and it requires considerable altera- tion. When the diploma in public health was first instituted, sanitary engineers, as such, did not exist ; and public health was mainly a question of water- pipes and sewerage. The curriculum and examina- tion were ordered accordingly. After a time bacterio- logy was added to the course. But now sanitary engineering may largely be left to the engineers ; while public health is seen to depend far more on personal influence and habit than on material circum- stance. More applied physiology ; more attention to the physical improvement of the individual is required ; for the work of school-health has shifted the basis of public health work. The course too should require residence and practical experience for a month in a small urban and the surrounding rural districts. Moreover, the science of preventive 364 HEALTH AND EMPIRE medicine depends as we have seen on a far wider range of experience than that of the British Isles ; and tropical conditions of climate, government and race supply a far wider and sounder basis of study than those to which the teaching of public health is at present confined. Courses and examinations should be to some extent altered in these directions ; provision should be made for centrahsing the teaching for the diploma in the London schools under a staff directed by a professor able to make a wide and academic, as well as a prac- tical study of the whole subject. But unfortunately the body entrusted with the regulation of these matters is ill-equipped for the purpose. Mention has already been made of changes re- quired in the general medical education to meeT the modern demand of the state for preventive rather than curative medicine, for attention to the com- munity rather than to the individual. Medical education runs in a vicious circle. Physicians and surgeons control medical education and naturally educate their pupils to follow in their steps. If one of those pupils takes up public health, there is no room for him on the hospital staff, and he is thus eliminated from the bodies that control the curriculum. A hospital numbers fifty or sixty physicians on its staff, but not a single representative of tropical or veterinary medicine or of the public health. For the purposes of its medical school a local medical of&cer of health is engaged to fill a subordinate and un- remunerative position, and so satisfy the require- ments of the examining boards. But medical HEALTH AND THE BRITISH EMPIRE 365 students complain bitterly of their ignorance on the innumerable questions of public health they know they will have to face in practice ; and the consultants who rule the roost, in the schools, in the Royal Colleges of Physicians and Surgeons, and in the medical faculties of the universities, both for education and examination, seem bhnd to the important part that public health questions are likely to play in general practice ; blind to the prospect that faces a large proportion of medical students of practising, if only for a time, in tropical climates without any knowledge of tropical disease ; blind to the declining demand for their own function and the increasing demand for the prevention of illness ; blind to the inadequacy of their own presentment of medical and surgical science. The blame attaches not to them but to the vicious circle established by custom and law. The circle must be broken ; the constitution of the General Medical Council must be revolutionised and the whole curriculum and syllabus of examination be completely revised in the light of new conditions and new requirements. But of even greater importance is the education of the public in the importance of public health. Disease is a calamity which essentially requires pro- fessional attention and advice. But the maintenance of health depends on the individual and can for the most part be ensured by a careful and inteUigent way of Ufe. He must certainly be defended against the main attacks of disease by a proper system of sanitation, devised and supervised by engineering, veterinary and medical experts ; but here again the 366 HEALTH AND EMPIRE layman and the semi-lay woman, the nurse, are of first importance. The first attention therefore should be paid to the instruction of teachers in every school, college and university throughout the empire in the aims and methods of public as well as of personal health. The enUghtenment of the next generation depends on the enlightenment of their teachers. Physical welfare, for the citizen as for the soldier, is the basis of his working strength ; and the basis of every moral and spiritual development. Given a proper system of sanitation and proper conditions of work, every man's health, every woman's health, and with their health to a large extent their happiness, is in their own hands. Medical officers of health and those who think with them should be given a large share in the training of teachers. As for the average citizen, so infinitely more for the man and woman of position and influence a proper training in public health is required. It is our boast that India, for instance, is ruled on the whole exceeding well by a handful of young English- men. It is our melancholy experience that the Indian government has been powerless to check the ravages of plague and to prevent the loss of 7,000,000 lives ; that so many millions die every year of malaria ; so many millions more from other preventable causes. How can Indian civilians be expected to devise or in any large degree to approve the empiric methods that should be adopted in an endeavour to find a remedy ? At school and university lads are crammed with knowledge of classics and mathe- matics, history, languages, economics and law ; HEALTH AND THE BRITISH EMPIRE 367 and with this equipment they are sent out to rule over provinces whose fortunes depend on agriculture and are mainly threatened by disease. As for India and the other British dominions, so also at home. As professional men or officers in the services, church or state ; as thinkers and writers ; as fathers and land- lords ; above all, as magistrates and judges, councillors and members of parliament, they are called on in their turn to play their part in national prosperity. The prosperity of the nation depends on its health ; its health depends on care and attention in every phase of life; and this care, whether private or public, depends very largely on public opinion. It is the men from the public schools and universities to-day that will form the public opinion of to-morrow. In that sense we are at present taking no thought for the morrow ; we are turning out a body of men utterly ignorant and therefore indifferent to the prevention of preventable disease and to their future responsibihties in the maintenance of the public health. The remedy for this must be gradually formed. Im- mediate steps should be taken to establish lectureships and professorships for the laity in every university, to provide simple and attractive lectures and demon- strations in every school, to include in the compulsory syllabus of every final examination some knowledge of the principles and methods of individual, national and imperial health. Much may be taught by museums and exhibitions, which, dealing with famihar subjects, can easily be made attractive. The crowded audiences at the tuberculosis exhibitions of recent years have been a 368 HEALTH AND EMPIRE revelation of popular feeling. The museum for in- struction in workmen's welfare at Berlin inspired a scheme for a similar permanent museum in London, now laid before the King Edward VIL Memorial Committee for London by the National League for Physical Education and Improvement. If this be true of the men it is truer still of the women. The habits of the household depend mainly on the mother ; the influence of the woman on cleanli- ness, rest, food and the other conditions essential to health is supreme. Sick-nursing, midwifery and health-visiting are essentially womanly occupations ; it is on these that the main hope for improvement of the national health must in no small measure depend ; and every girl, in whatever station, should be taught not merely the dry principles of " domestic hygiene," but the practical application of these principles to her own and to the national life. The health of the people is the supreme law. If this doctrine, properly interpreted, is thoroughly ingrained into the popular imagination, there is little doubt that the people will themselves demand that far more attention shall be paid to matters of health in the education of every child and/ in the administration of every department of hfe. The inevitable corollary is the co-operation of all the governments of the empire to this end ; and it is to be hoped that at the next meeting of the Imperial Conference time may be found for the discussion of a resolution presented to the conference of 1907 by the Royal Sanitary Institute to the effect elaborated in this final chapter. We of the British isles move HEALTH AND THE BRITISH EMPIRE 369 forward in the style of the kangaroo. In motors, in aeroplanes, in national insurance, to take three recent instances, we wait to use the experience of others ; we then give a mighty leap and land ahead of those who have inspired our move ; and there we stick tiU the world has again gone past us. In wise and liberal expenditure on education and research, and again in imperial organisation, we are far behind both the German Empire and the United States. Now at the opening of a new reign, here more especially in the question of the pubUc health, is the occasion for the next leap of the British kangaroo. So may his Gracious Majesty King George be able to promote the health and welfare of his empire and in future days to say that ill-health, if preventable, has been prevented. " And the young king said : ' I have found it, The road to the rest ye seek : The strong shall wait for the weary, The hale shall halt for the weak ; With the even tramp of an army, Where no man breaks from the line. Ye shall march to peace and plenty In the bond of brotherhood — sign ! ' " RuDYARD Kipling. — " An Imperial Rescript." 2A THE RIVERSIDE PRESS LIMITED, EDINBURCSH, 46 HEALTH AND EMPIRE lected far and wide. The Mulkowal incident, a mere fly in the ointment, paralysed the Indian govern- ment, and the Plague Commission which reported in 1903 gave them little security or certainty as a basis for adopting any strong poUcy. As an instance might be noted the conclusions of the Plague Com- mission, that whereas, in an extensive system of examination of travellers at railway stations through- out the Indian Empire, very few cases of plague had been detected, all trammels on railway intercom- munication should be suspended. But in point of fact this measure had indirectly limited com- munication, by deterring plagtie patients from travelling, and so to a very considerable extent pre- venting the dissemination of the disease. The rules were relaxed, and already, within a few months before I had left India, there was evidence to show that plague had broken out in certain villages to which it was previously unknown ; whereas in a few adjoining districts, where railway inspection still continued, plague was as yet unknown. Education of the people is certainly the bedrock of all progress ; whether in schools or in the Press or by leaflets, posters, lantern slides and lectures. Little if anything was being done in this way in 1904 with a view to the arrest of the plague — ^just a memorandum issued to village authorities every now and then. But to educate, the government must have a method and a policy. Whatever be the best method to adopt, there can be no doubt that in India we have an enormous field of research, of which insufficient use has hitherto