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diff --git a/old/69823-h/69823-h.htm b/old/69823-h/69823-h.htm deleted file mode 100644 index 9691d64..0000000 --- a/old/69823-h/69823-h.htm +++ /dev/null @@ -1,10345 +0,0 @@ -<!DOCTYPE html> -<html lang="en"> -<head> - <meta charset="UTF-8"> - <title> - Public Health and Insurance: American Addresses, by Sir Arthur Newsholme—A Project Gutenberg eBook - </title> - <link rel="icon" href="images/cover.jpg" type="image/x-cover"> - <style> - -body { - margin-left: 10%; - margin-right: 10%; -} - - h1,h2,h3 { - text-align: center; /* all headings centered */ - clear: both; -} - -p { - margin-top: .51em; - text-align: justify; - text-indent: 1em; - margin-bottom: .49em; -} - -hr { - width: 33%; - margin-top: 2em; - margin-bottom: 2em; - margin-left: 33.5%; - margin-right: 33.5%; - clear: both; -} - -hr.chap {width: 65%; margin-left: 17.5%; margin-right: 17.5%;} - -hr.r5 {width: 5%; margin-top: 1em; margin-bottom: 1em; margin-left: 47.5%; margin-right: 47.5%;} - -div.chapter {page-break-before: always;} -h2.nobreak {page-break-before: avoid;} - -.fs60 {font-size: 60%} -.fs70 {font-size: 70%} -.fs80 {font-size: 80%} -.fs90 {font-size: 90%} -.fs120 {font-size: 120%} - -ul.index { list-style-type: none; } -li.ifrst { - margin-top: 1em; - text-indent: -2em; - padding-left: 1em; -} -li.indx { - margin-top: .5em; - text-indent: -2em; - padding-left: 1em; -} - -table { - margin-left: auto; - margin-right: auto; -} -table.autotable { border-collapse: collapse; } - -.tdl {text-align: left;} -.tdr {text-align: right;} -.tdc {text-align: center;} -.tdlx {text-align: left; text-indent: 3em;} -.tdrp {text-align: right; padding-right: 4em; text-indent: 3em;} -.tdlp {text-align: left; text-indent: 4em;} -.tdln {text-align: left; line-height: .5em;} -.tdcnw {text-align: center; line-height: .75em; padding-left: 1em;} -.tdcwi {text-align: center; line-height: 1em; text-indent: 5em;} -.tdci {text-align: center; line-height: .75em;} -.tdcw {text-align: center; line-height: 1em; text-indent: 1em;} - -.pagenum { /* uncomment the next line for invisible page numbers */ - /* visibility: hidden; */ - position: absolute; - left: 92%; - font-size: small; - text-align: right; - font-style: normal; - font-weight: normal; - font-variant: normal; - text-indent: 0; - color: #A9A9A9; -} /* page numbers */ - -.blockquot { - margin-left: 5%; - margin-right: 10%; -} - -.figcenter { - margin: auto; - text-align: center; - page-break-inside: avoid; - max-width: 100%; -} - -.center {text-align: center;} - -.right {text-align: right;} - -.smcap {font-variant: small-caps;} - -/* Images */ - -img { - max-width: 100%; - height: auto; -} - -/* Footnotes */ -.footnotes {border: 1px dashed; margin-top: 2em;} - -.footnote {margin-left: 10%; margin-right: 10%; font-size: 0.9em;} - -.footnote .label {position: absolute; right: 84%; text-align: right;} - -.fnanchor { - vertical-align: super; - font-size: .8em; - text-decoration: - none; -} - -/* Transcriber's notes */ -.transnote {background-color: #E6E6FA; - color: black; - font-size:small; - padding:0.5em; - margin-bottom:5em; - font-family:sans-serif, serif; -} - -/* Poetry */ -/* uncomment the next line for centered poetry */ -.poetry-container2 {display: flex; justify-content: center;} -.poetry-container {text-align: center;} -.poetry {text-align: left;} -.poetry .stanza {margin: 1em auto;} -.poetry .verse {text-indent: 0em; padding-left: 0em;} - - -h2 {font-size: 130%; font-weight: normal; line-height: .75em; word-spacing: .2em;} -h3 {font-size: 100%; font-weight: normal; line-height: .75em; word-spacing: .2em;} -.no-indent {text-indent: 0em;} -.poetry .indent0 {text-indent: 0em;} -.poetry .indent2 {text-indent: 2em;} -.poetry .indent4 {text-indent: 5em;} - -.lh {line-height: .5em;} - - </style> -</head> - -<body> -<p style='text-align:center; font-size:1.2em; font-weight:bold'>The Project Gutenberg eBook of Public health and insurance, by Arthur Newsholme</p> -<div style='display:block; margin:1em 0'> -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online -at <a href="https://www.gutenberg.org">www.gutenberg.org</a>. If you -are not located in the United States, you will have to check the laws of the -country where you are located before using this eBook. -</div> - -<p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em'>Title: Public health and insurance</p> -<p style='display:block; margin-left:2em; text-indent:0; margin-top:0; margin-bottom:1em;'>American addresses</p> -<p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em'>Author: Arthur Newsholme</p> -<p style='display:block; text-indent:0; margin:1em 0'>Release Date: January 17, 2023 [eBook #69823]</p> -<p style='display:block; text-indent:0; margin:1em 0'>Language: English</p> - <p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em; text-align:left'>Produced by: Charlene Taylor, Bob Taylor and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)</p> -<div style='margin-top:2em; margin-bottom:4em'>*** START OF THE PROJECT GUTENBERG EBOOK PUBLIC HEALTH AND INSURANCE ***</div> -<div class="figcenter" style="width: 65%"> -<img src="images/cover.jpg" alt="Cover"> -</div> -<hr class="chap x-ebookmaker-drop"> - - -<p><span class="pagenum" id="Page_i">[Pg i]</span></p> - -<h1>PUBLIC HEALTH AND INSURANCE:<br><br> - -<span class="fs80">AMERICAN ADDRESSES</span></h1> -<br><br> -<p class="center">BY</p> - -<p class="center">SIR ARTHUR NEWSHOLME, K.C.B., M.D., F.R.C.P.</p> - -<p class="center fs80">LECTURER ON PUBLIC HEALTH ADMINISTRATION AT THE SCHOOL OF HYGIENE AND<br> -PUBLIC HEALTH, JOHNS HOPKINS UNIVERSITY, BALTIMORE, MARYLAND; LATE<br> -PRINCIPAL MEDICAL OFFICER OF THE LOCAL GOVERNMENT BOARD, ENGLAND;<br> -PRESIDENT OF THE SOCIETY OF MEDICAL OFFICERS OF HEALTH<br> -AND OF THE EPIDEMIOLOGICAL SOCIETY; EXAMINER IN PUBLIC HEALTH<br> -TO THE UNIVERSITY OF CAMBRIDGE, IN PREVENTIVE MEDICINE TO<br> -THE UNIVERSITY OF OXFORD, AND IN STATE MEDICINE TO THE<br> -UNIVERSITY OF LONDON, MEMBER OF THE GENERAL MEDICAL<br> -COUNCIL, OF THE COUNCIL OF THE IMPERIAL CANCER<br> -RESEARCH FUND, ETC.</p> -<br><br> -<p class="center">BALTIMORE</p> -<p class="center fs90"><span class="smcap">The Johns Hopkins Press</span><br> -1920 -</p> - -<p><span class="pagenum" id="Page_ii">[Pg ii]</span></p> -<hr class="chap x-ebookmaker-drop"> - - -<div class="chapter"> -<p class="center fs80"> -Copyright, 1920<br> -By <span class="smcap">The Johns Hopkins Press</span></p><br> -<br> -<p class="center fs60">PRESS OF<br> -THE NEW ERA PRINTING COMPANY<br> -LANCASTER PA.<br> -</p> -</div> - -<p><span class="pagenum" id="Page_iii">[Pg iii]</span></p> -<hr class="chap x-ebookmaker-drop"> - - -<div class="chapter"> -<p class="center"> -DEDICATED BY THE AUTHOR</p> -<p class="center fs70">(WITHOUT PERMISSION)</p> -<br> -<p class="center fs80">TO THE</p> - -<p class="center">RIGHT HONOURABLE JOHN BURNS</p> -<br> -<p class="center fs80">A LEADER IN PUBLIC HEALTH;<br> -<br> -WHO IN PARTICULAR MADE THE PUBLIC REALISE THE<br> -IMPORTANCE OF CONCENTRATING ON THE<br> -<br> -<span class="smcap fs120">Mother and Her Child</span><br> -</p> - -<p><span class="pagenum" id="Page_v">[Pg v]</span></p> -</div> -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> - -<h2 class="nobreak" id="PREFACE">PREFACE</h2> -</div> - - -<p>After more than three decades of work in preventive -medicine and public health, the opportunity has arisen -in connection with a year’s visit to America, to take a -panoramic view of public health in England, of the -progress which has been secured, of the factors which -have impeded progress, and of the pressing desiderata -for more efficient future action.</p> - -<p>During my stay in America I have had the privilege -of addressing public audiences in every part, from New -Orleans to Toronto, and from New York and Boston -to San Francisco and Seattle; as well as more special -audiences at Johns Hopkins University, at Saranac and -at Harvard, California, Washington, and Yale Universities; -and at the request of many friends some of -the addresses given to these audiences are now published -in volume form. These addresses briefly outline -some of the lessons of long experience, and -although the conditions under which they were delivered -rendered complete exposition impracticable, -there are, I think, advantages in not overloading the -presentation for public consideration of a many-sided -subject.</p> - -<p>It will be noted that the same problem may be mentioned<span class="pagenum" id="Page_vi">[Pg vi]</span> -in several addresses, though usually from a different -angle. The entire avoidance of repetition would -have necessitated the abandonment of the lecture -form, and would, I believe, have diminished the utility -of the volume. The table of contents and index render -cross-reference easy.</p> - -<p>Those wishing to ascertain fuller details on most of -the problems discussed in the present volume may refer, -I think with advantage, to my annual reports as -Medical Officer of the Local Government Board, England, -and to my four special reports on Maternal and -Child Mortality, which also were issued as English -Government publications.</p> - -<p>British experience is only partially applicable in the -United States, the almost complete Home Rule in each -State creating a new and interesting problem in efficient -national public health administration. Nevertheless -a review of events in Great Britain cannot fail -to be useful in America, which is faced with similar -problems. The main lines of public health administration -in Great Britain have proved their value by their -success. There has been local independence with a -minimum of central control, and the people’s representatives -in every area have been made to realize their -commercial responsibility. The mistakes made in permitting -the multiplication of small and inefficient -public health authorities, in allowing official medical<span class="pagenum" id="Page_vii">[Pg vii]</span> -work to be divided respectively between different local -and central authorities, in sanctioning the creation of -<em>ad hoc</em> authorities for special work, in associating state -medicine with monetary insurance against sickness, and -in not securing that insurance shall directly assist the -prevention of sickness, have been largely the mistakes -of politicians and of central authorities. These mistakes -involve the retracing of steps and the undoing of -the mischief resulting from ill-advised action. In -view of these conflicting events, the marvellous -achievements secured by public health authorities are -the more noteworthy.</p> - -<p>In every American city visited by me I have been -struck with the earnest desire of voluntary and official -public health and social workers to profit by English -experience, to adopt what is good, to secure the abolition -of the short tenure of office of competent officers -under the present political system, and to introduce -civil service conditions for them. There is in many -respects a close parallelism between the course of -public health on both sides of the Atlantic; in some -cities the English hygienist has much to learn in respect -of advanced and original work; and in other -American cities in which “political pull” continues, -there is evidence of the development of a wider interest -and a more general sense of communal responsibility; -a deeper trend of thought which will make for steadily<span class="pagenum" id="Page_viii">[Pg viii]</span> -increasing efficiency in public health work. As this -volume discusses public health problems especially -from a social viewpoint, it is my earnest hope that it -may be useful in this direction.</p> - -<p class="right"><span class="smcap">Arthur Newsholme</span></p> -<br> -<table class="autotable"> -<tr> -<td class="tdcwi"><span class="smcap">School of Hygiene and</span></td> -<td class="tdcwi"><span class="smcap">and</span></td> -</tr> -<tr> -<td class="tdcwi"><span class="smcap">Public Health,</span></td> -<td class="tdcwi"><span class="smcap">Athenaeum Club,</span></td> -</tr> -<tr> -<td class="tdcwi"><span class="smcap">Johns Hopkins University,</span></td> -<td class="tdcwi"><span class="smcap">London,</span></td> -</tr> -<tr> -<td class="tdcwi"><span class="smcap">Baltimore,</span></td> -<td class="tdcwi">May, 1920</td> -</tr> -</table> - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<p><span class="pagenum" id="Page_ix">[Pg ix]</span></p> - -<h2 class="nobreak" id="CONTENTS">CONTENTS</h2> -</div> -<hr class="r5"> - -<p class="center fs120">LECTURE I</p> - -<p><span style="margin-left: -1em;" class="smcap">Public Health Progress in England during</span><br> -<span style="margin-left: 1em;" class="smcap">the Last Fifty Years</span> <span style="float: right;"> -<a href="#Page_1">1-41</a></span></p> -<p class="fs90"> -<span style="margin-left: -1em;">Parallelism of Events in Old and New England.</span><br> -The Utilization of Lay Workers in Public Health Work.<br> -The Influence of Urbanization and Industrialism.<br> -<i lang="fr" xml:lang="fr">Laissez faire</i> Economic Teaching.<br> -Man and his Environment.<br> -Dirt and Disease.<br> -<span style="margin-left: 2em;">Cholera, Typhoid Fever, Typhus Fever.</span><br> -Summary of Results in Life-Saving.<br> -Specific Causation of Disease.<br> -Importance and Present Limitations of Epidemiology.<br> -The Importance of Vital Statistics.<br> -Conditions of Medical Practice Bearing on Public Health.<br> -Poor-law <em>versus</em> Public Health.<br> -Insurance <em>versus</em> Public Health.<br> -A National Medical Service.<br> -Hospitals Important Housing Auxiliaries.<br> -The Need to Avoid Complacency.</p> - -<p class="center fs120">LECTURE II</p> - -<p><span style="margin-left: -1em;" class="smcap">Historical Development of Public Health</span><br> -<span style="margin-left: 1em;" class="smcap">Policy in England</span> <span style="float: right;"> -<a href="#Page_42">42-70</a></span></p> -<p class="fs90"> -<span style="margin-left: -1em;">Town-Dwelling and Health Problems.</span><br> -The Scope of Public Health Work.<span class="pagenum" id="Page_x">[Pg x]</span><br> -Reform in the Control of Poverty.<br> -Reform in Industry.<br> -Public Health Reform.<br> -Education Authorities and Health.<br> -The <em>Ad Hoc</em> Vice.<br> -Principles of Local Government.<br> -The Training and Tenure of Office of Medical Officers of Health.<br> -The National Insurance Act and Public Health.<br> -Provision for Sickness.<br> -General Summary.</p> - -<p class="center fs120">LECTURE III</p> - -<p><span style="margin-left: -1em;" class="smcap">The Increasing Socialization of Medicine</span> -<span style="float: right;"><a href="#Page_71">71-102</a></span></p> -<p class="fs90"> -<span style="margin-left: -1em;">An Altruistic Profession.</span><br> -The Past Achievements of Medicine.<br> -The Ever-increasing Importance of Hospitals.<br> -<span style="margin-left: 2em;">Hospitals and Housing.</span><br> -The Continuing Mass of Preventible Disease.<br> -The Present Extent of Socialization of Medicine.<br> -Destitution and Sickness.<br> -Insurance and Sickness.<br> -The Needs of the Future.</p> - -<p class="center fs120">LECTURE IV</p> - -<p><span style="margin-left: -1em;" class="smcap">The Medical Aspects of Insurance against</span><br> -<span style="margin-left: 1em;" class="smcap">Sickness</span> <span style="float: right;"> -<a href="#Page_103">103-119</a></span></p> -<p class="fs90"> -<span style="margin-left: -1em;">Criteria of Value of Insurance.</span><br> -British System of Insurance.<br> -Limitations and Evils of the “Medical Benefit.”<br> -Need for further State Treatment of Disease.<span class="pagenum" id="Page_xi">[Pg xi]</span><br> -Prevention of Poverty by the Application of Medical Science.<br> -State Medicine must be Preventive throughout.<br> -Conditions of an Efficient Medical Service.</p> - -<p class="center fs120">LECTURE V</p> - -<p><span style="margin-left: -1em;" class="smcap">Some Problems of Preventive Medicine of</span><br> -<span style="margin-left: 1em;" class="smcap">the Immediate Future</span> <span style="float: right;"> -<a href="#Page_120">120-143</a></span></p> -<p class="fs90"> -<span style="margin-left: -1em;">The Incidental Gains from War.</span><br> -<span style="margin-left: 1.5em;">Its Sacrificial Work.</span><br> -<span style="margin-left: 1.5em;">The Comradeship of All Idealists.</span><br> -<span style="margin-left: 1.5em;">Women’s Work.</span><br> -<span style="margin-left: 1.5em;">The Restriction of Alcoholism.</span><br> -<span style="margin-left: 1.5em;">The Change from Empirical to Scientific Methods.</span><br> -The Still Uncontrollable Diseases.<br> -<span style="margin-left: 1.5em;">Influenza and Measles as Types.</span><br> -The Possibility of Modified Training of Nurses.<br> -The Need for a More Complete Program in Tuberculosis.<br> -The Possibilities of Control of Venereal Diseases.<br> -The More Complete Protection of Maternity and Childhood.<br> -The Abolition of Poverty Tests in Medical Assistance.<br> -Lack of Equality of Service, not Ignorance, the Chief Evil.<br> -The Continuing Value of Voluntary Workers.</p> - -<p class="center fs120">LECTURE VI</p> - -<p><span style="margin-left: -1em;" class="smcap">The Inter-relation of Various Social Efforts</span> -<span style="float: right;"><a href="#Page_144">144-156</a></span></p> -<p class="fs90"> -<span style="margin-left: -1em;">The Possibilities of Good Work under Present Economic Conditions.</span><br> -The Importance of Social Work to the Physician.<br> -The Constant Need for a Causal Outlook.<br> -<span class="pagenum" id="Page_xii">[Pg xii]</span><span style="margin-left: 1.5em;">Poverty and Disease.</span><br> -<span style="margin-left: 1.5em;">Causes of Intemperance.</span><br> -<span style="margin-left: 1.5em;">The Causation and Prevention of Venereal Diseases.</span><br> -Lop-sided Views as to Ignorance in Causation of Disease.</p> - -<p class="center fs120">LECTURE VII</p> - -<p><span style="margin-left: -1em;" class="smcap">The Obstacles to and Ideals of Health Progress</span> -<span style="float: right;"><a href="#Page_157">157-182</a></span></p> -<p class="fs90"> -<span style="margin-left: -1em;">Degree of Progress Realized.</span><br> -Obstacle of Urban Life.<br> -Obstacle of Industrialism.<br> -Obstacle of Poverty.<br> -The Influence of the Malthusian Hypothesis.<br> -Obstacle of Ignorance.<br> -Obstacle of Defects of Character.<br> -<span class="smcap">Ideals.</span><br> -Communal Action.<br> -Spread of Altruism.<br> -<span style="margin-left: 1.5em;">Supreme Importance of Mother and Child.</span></p> - - -<p class="center fs120">LECTURE VIII</p> - -<p><span style="margin-left: -1em;" class="smcap">Some Aspects of Poverty</span> -<span style="float: right;"><a href="#Page_183">183-190</a></span></p> -<p class="fs90"> -<span style="margin-left: -1em;">Disease a Chief Cause of Poverty.</span><br> -Diminution of Poverty apart from Increased Family Income.<br> -Poverty a Complex.<br> -Action Needed against Each Constituent Element of Poverty.</p> - - -<p class="center fs120">LECTURE IX</p> - -<p><span style="margin-left: -1em;" class="smcap">The Causation of Tuberculosis and the</span><br> -<span style="margin-left: 1em;" class="smcap">Measures for its Control in England</span> -<span style="float: right;"><a href="#Page_191">191-239</a></span></p> -<p class="fs90"> -<span style="margin-left: -1em;"><em>A.</em> Basic Facts as to Tuberculosis.</span><br> -<span class="pagenum" id="Page_xiii">[Pg xiii]</span><span style="margin-left: 1em;">Explanations of the Decreasing Death-rate from Tuberculosis.</span><br> -<span style="margin-left: 2.5em;">Diminished Virulence of the Tubercle Bacillus.</span><br> -<span style="margin-left: 2.5em;">Increased Human Resistance by Natural Selection.</span><br> -<span style="margin-left: 2.5em;">Immunization by Small Doses of the Contagium.</span><br> -<span style="margin-left: 1em;">Diminished Tuberculosis with Increased Aggregation of Population.</span><br> -<span style="margin-left: 2.5em;">Hospital Treatment of Consumptives.</span><br> -<span style="margin-left: 1em;">Koch’s Views as to Hospital Segregation.</span><br> -<span style="margin-left: 1em;">Improved Housing in Reduction of Tuberculosis.</span><br><br> -<em>B.</em> Measures of Control.<br> -<span style="margin-left: 2.5em;">Notification of Cases.</span><br> -<span style="margin-left: 3.5em;">Causes of Failure in Notification.</span><br> -<span style="margin-left: 2.5em;">Public Health Action following Notification.</span><br> -<span style="margin-left: 2.5em;">Examination of Contacts.</span><br> -<span style="margin-left: 2.5em;">Scope of Tuberculosis Schemes.</span><br> -<span style="margin-left: 2.5em;">Tuberculosis Dispensaries.</span><br> -<span style="margin-left: 3.5em;">Should be Part of General Dispensaries.</span><br> -<span style="margin-left: 2.5em;">The Home Visitation of Patients.</span><br> -<span style="margin-left: 2.5em;">Sanatorium Benefit.</span><br> -<span style="margin-left: 2.5em;">Residential Institutions.</span><br> -<span style="margin-left: 2.5em;">General Observations on Treatment in Sanatoria.</span><br> -<span style="margin-left: 2.5em;">Hospital Treatment.</span><br> -<span style="margin-left: 2.5em;">Industrial Colonies.</span><br> -<span style="margin-left: 2.5em;">Special Dwellings and Help in Support.</span><br> -<span style="margin-left: 2.5em;">Summary.</span></p> - -<p class="center fs120">LECTURE X</p> - -<p><span style="margin-left: -1em;" class="smcap">Child Welfare Work in England</span> -<span style="float: right;"><a href="#Page_240">240-267</a></span></p> -<p class="fs90"> -<span style="margin-left: -1em;">The Earlier Work of Medical Officers of Health.</span><br> -The Notification of Births.<br> -Chief Causes and Course of Infant Mortality.<br> -The Influence of School Medical Inspection.<br> -The Influence of Statistical Studies.<span class="pagenum" id="Page_xiv">[Pg xiv]</span><br> -The Midwives Acts.<br> -Health Visiting.<br> -Voluntary Work.<br> -Child Welfare Centers.<br> -Training and Provision of Midwives.<br> -Ante-natal Work.<br> -Dental Assistance.<br> -Creches.<br> -Observation Beds at Child Welfare Centers.<br> -Grant’s to Local Authorities.<br> -Course of Mortality in Childbearing.</p> - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<p><span class="pagenum" id="Page_1">[Pg 1]</span></p> - -<h2 class="nobreak" id="CHAPTER_I">CHAPTER I<br><br> -<span class="smcap fs80">Public Health Progress in England During the -Last Fifty Years</span><a id="FNanchor_1" href="#Footnote_1" class="fnanchor">[1]</a></h2> -</div> - -<p>After thirty-five years in active public health work -in England—during eleven of those years having been -the principal officer of its central public health department -on its medical side—I may be assumed to possess -some qualification for the task of reviewing the past -half century’s progress in public health in England.</p> - - -<h3><em>Parallelism of Events in New and Old England</em></h3> - -<p>I find it, however, beyond my power to compass -in a short address a resumé of my subject which shall -be complete, or completely in perspective, or which -shall not omit features on which, had time permitted, -one would have wished to comment; and I must ask -you to remember that only a portion—and that chiefly -non-administrative<a id="FNanchor_2" href="#Footnote_2" class="fnanchor">[2]</a>—of the history of this wonderful -half century can be embraced within the present address. -The survey should, I think, take a panoramic -view of the story as it has developed, should note the<span class="pagenum" id="Page_2">[Pg 2]</span> -changes as they have occurred, the obstacles which -impeded reforms as well as the reforms secured; and -should also, at least incidentally, state—in the light of -unfailing historical guidance, as well as of increasing -knowledge—the pressing desiderata for more efficient -and more rapid future progress. I cannot hope to -accomplish this task except to a fragmentary extent, -but I am happy to remember that sanitary history in -Old and in New England has proceeded largely on -parallel lines. The curves of annual death-rates from -all causes, from typhoid fever, from tuberculosis, and -of the mortality of infants show the closeness of the -parallelism of the public health history of England and -Massachusetts.</p> - -<p>The work of the last fifty years was built on preceding -pioneer work of men in Old and in New England; -and for a complete understanding of this work, -a momentary glance is required at the men of this -earlier generation and their work.</p> - -<p>In the old country we speak with reverence of the -names of Southwood Smith, Kay, Chadwick, Farr and -Simon; and you remember with gratitude the names -of Lemuel Shattuck, of Bowditch, of Walcott, S. W. -Abbott, and Theobald Smith; and it is gratifying to -remember that the epoch-making report of the Massachusetts -Sanitary Commission of 1850—to which were -attached the ever memorable names of Shattuck, N. P. -Banks, and Jehiel Abbott—among its many statesmanlike<span class="pagenum" id="Page_3">[Pg 3]</span> -and far-seeing proposals, recommended a sanitary -survey of the State, and referred to the recent English -sanitary surveys, with which British sanitation may be -said to have begun.</p> - - -<h3><em>The Utilisation of Lay Workers</em></h3> - -<p>Let me in passing comment on the fact that neither -Lemuel Shattuck in Boston nor Edwin Chadwick in -London was a physician; but a perusal of their writings -shows that they were men of sound judgment, of -earnest zeal for their fellow men, with a wide and -statesmanlike outlook, ready to search out, to accept -and to apply the medical knowledge on which necessarily -the prevention of disease is based. They illustrate -once for all the need for partnership between all -well-wishers of humanity in this work, and the importance -of combined effort by the sociologist and the -physician, as well as of experts in each branch of sanitation, -if all attainable success is to be attained.</p> - -<p>The tradition then established has never been lost. -In England, more perhaps than in America, the control -of public health work has been shared by intelligent -laymen on local and central authorities, and the fact -that medical officers of health have found it necessary -to convince these lay representatives of the general -public of the need for the reforms recommended, has -led to steady progress, seldom interrupted by relapses. -And this is true, although delays and disappointments<span class="pagenum" id="Page_4">[Pg 4]</span> -have beset the path of the earnest reformer, -who might well wish that his lay colleagues had been -trained in schools in which natural science formed a -more open avenue to distinction than classics; or that -the representatives on local authorities might more -fully and more quickly appreciate in Simon’s words, -what they are</p> - -<div class="blockquot fs80"> - -<p class="no-indent">sometimes a little apt to forget that, for sanitary purposes, -they are also the appointed guardians of human beings whose -lives are at stake in the business.</p> -</div> - -<p>What were the ideals with which the Fathers of -Sanitation in New and in Old England began their -work?</p> - -<p>They cannot be better expressed than in their own -words. In the 1850 Report of the Massachusetts -Sanitary Commission they are thus expressed:</p> - -<div class="blockquot fs80"> - -<p>We believe that the conditions of perfect health, either -public or personal, are seldom or never attained, though attainable; -that the average length of human life may be very -much extended, and its physical power greatly augmented; -that in every year, within this Commonwealth, thousands of -lives are lost which might have been saved; that tens of thousands -of cases of sickness occur, which might have been prevented; -that a vast amount of unnecessarily impaired health, -and physical debility, exists among those not actually confined -by sickness; that these preventible evils require an enormous -expenditure and loss of money, and impose upon the people -unnumbered and immeasurable calamities, pecuniary, social, -physical, mental, and moral, which might be avoided; that -means exist, within our reach, for their mitigation or removal; -and that measures for prevention will effect infinitely -more than remedies for the cure of disease.</p> -</div> - -<p><span class="pagenum" id="Page_5">[Pg 5]</span></p> - -<p>In a succeeding paragraph the Commissioners proceed -to quote with approval, the following remarks -made by Mr. (afterwards Sir John) Simon in the -preceding year, when he was medical officer of health -to the City of London, and before he became the principal -medical officer and adviser of the British Government -in health matters, and in that capacity laid the -foundation and built much of the edifice of our present -health organization.</p> - -<div class="blockquot fs80"> - -<p>Ignorant men may sneer at the pretensions of sanitary science; -weak and timorous men may hesitate to commit themselves -to its principles, so large is their application; selfish -men may shrink from the labour of change, which its recognition -must entail; and wicked men may turn indifferently -from considering that which concerns the health and happiness -of millions of their fellow-creatures; but in the great -objects which it proposes to itself, in the immense amelioration -which it proffers to the physical, social, and, indirectly, to -the moral conditions of an immense majority of our fellow -creatures, it transcends the importance of all other sciences; -and, in its beneficent operation, seems to embody the spirit, -and to fulfil the intentions, of practical Christianity.</p> -</div> - -<p>With such noble ideals, what measure of success -crowned their efforts and those of their successors?</p> - -<p>The earlier history I can only briefly mention, as we -are chiefly concerned today with events since 1869. -To understand these events, however, one must understand -the forces which had been accumulating and -increasing in power in earlier years, and which rendered -possible the rapid public health progress experienced<span class="pagenum" id="Page_6">[Pg 6]</span> -in the fourth quarter of the nineteenth and the -first quarter—so far as it has passed—of the twentieth -century.</p> - - -<h3><em>Laissez Faire Economic Teaching</em></h3> - -<p>Historians in future generations will refer to the -second half of the eighteenth and the first half of the -nineteenth century as the period of unmitigated industrialism, -of associated rapid increase of urban at the -expense of rural life, and of the most extreme manifestation -of <i lang="fr" xml:lang="fr">laissez faire</i> economic science. The older -semi-paternal system of interference with the economic -life of the people by King and Parliament, was -replaced, under the influence of Adam Smith, Malthus, -James Mill, and other teachers, by inaction based on -the view that in old countries poverty is the natural -and inevitable result of pressure of population on -means of subsistence, and that any interference with -freedom of competition in obtaining work or employing -workers is useless or mischievous. A similar view -found expression in President Jefferson’s dictum: that -government is best which governs least; and until the -middle of the nineteenth century these views were generally -accepted and their influence was dominant.</p> - -<p>It was assumed that given free competition, enlightened -self-interest would incite effort and improvement, -encourage self-reliance, and guarantee production and -economy.</p> - -<p><span class="pagenum" id="Page_7">[Pg 7]</span></p> - -<p>Under the conditions considered inevitable with such -teaching, although great wealth accompanied the rapid -industrial development after the Napoleonic wars, it -was associated with unrelieved misery; for homeworkers -and rural workers crowded into mean hovels -in towns, paying exorbitant rents out of a miserable -pittance of wages, and were exposed to the evils resulting -from overcrowding, and from absence of adequate -and satisfactory water supply, scavenging or drainage. -By the year 1851 about half the population of England -and Wales had become aggregated in towns; and it -may be added that in 1911, less than one fourth of the -population was left in rural districts. Urbanization -in the earlier years meant dense overcrowding and insanitation; -and that it is still an influence adverse to -health may be gathered from the information given -by the census of 1911, that over eight times as large -a proportion of the urban as of the rural population -live in one-roomed tenements, and nearly twice as large -a proportion live in two-roomed tenements, while the -proportion of one-roomed tenements in towns which -are overcrowded (in the sense of having more than -two persons to a room) in towns is seven times as -great, and of two-roomed tenements is twice as great -as in country districts.</p> - -<p>Domestic misery was associated with commensurate -industrial misery; overwork, in insanitary factories -and workshops, regardless of the health of the “hands,” -was the rule.</p> - -<p><span class="pagenum" id="Page_8">[Pg 8]</span></p> - -<p>The displacement between 1760 and 1800 of domestic -by factory manufacture represented a new -phenomenon in the world’s history, a true industrial -revolution. It was the parting of the ages; destined -not only to change the life of the people of England -from preponderantly outdoor to preponderantly indoor; -and to bring for them for many years all the -disadvantages of unregulated town life; but also, -owing to the rapid development of better roads, of -canals, and then of railroads and steamships to end -forever the practical segregation in which countries, -and even neighbouring communities, had previously -lived.</p> - -<p>It cannot be wondered at that under these circumstances -the general death-rate was excessive, and epidemic -disease spread with a rapidity and to an extent -previously unknown.</p> - -<p>The reaction against the <i lang="fr" xml:lang="fr">laissez faire</i> economic -teaching began early, and it is in accordance with the -fitness of things that the national conscience first rebelled. -The earliest evidence of reform was legislation -in 1802 on behalf of pauper children indentured -to the overseers in textile factories; and there followed -subsequent Factory and other Acts in 1819, in 1833, -in 1844 and in 1847, which prohibited the factory employment -of children under nine, limited the hours of -labour of young persons and of women, and insisted -on elementary sanitation in factories. Subsequent<span class="pagenum" id="Page_9">[Pg 9]</span> -Factory and Mining Acts, followed by Shop Hours -Acts and the Shop Seats’ Act, have completed a most -valuable code of regulations prohibiting overwork, -and securing a measure of protection against dangers -to health and limb or eyesight during industrial employment. -It is noteworthy that the first steps at improved -sanitation, and to safeguard health by preventing -overwork, were on the industrial plane. Factory -inspectors preceded medical officers of health and sanitary -inspectors appointed by local authorities.</p> - -<p>Philanthropy was the motive power in initiating factory -reform; in securing general sanitary reform, driving -power was furnished by the double motive of -economy and fear, caused by the inordinate expense -of poor-law administration, the frequently recurring -epidemics of “fever,” and the alarming occasional invasions -of Asiatic cholera. The sacrifices of life from -cholera were truly vicarious; for we owe it largely to -these that our national system of vital statistics was -initiated in 1837 and that serious efforts at sanitary -reform were begun.</p> - - -<h3><em>Man and His Environment</em></h3> - -<p>The history of these earlier steps is full of interest; -but I cannot outline it today. There can be no doubt -that as Simon<a id="FNanchor_3" href="#Footnote_3" class="fnanchor">[3]</a> put it, referring to Dr. Southwood -Smith’s report to the Poor-Law Commissioners in<span class="pagenum" id="Page_10">[Pg 10]</span> -1838 (“on Some of the Physical Causes of Sickness -and Mortality to which the Poor are particularly exposed, -and which are capable of removal by Sanitary -Regulations”)</p> - -<div class="blockquot fs80"> - -<p class="no-indent">the commencement of State interference on behalf of the -health of the labouring classes may be said to date from its -publication and to have been in a very important degree determined -by its facts and arguments.</p> -</div> - -<p>That the first principles of causation were beginning -to be appreciated is shown in the following extract -from Queen Victoria’s speech in opening Parliament -in 1849. In this speech she referred to the ravages -of cholera which it had pleased Almighty God to arrest, -and added:</p> - -<div class="blockquot fs80"> - -<p>Her Majesty is persuaded that we shall best evince our -gratitude by vigilant precautions against the more obvious -causes of sickness, and an enlightened consideration for those -who are most exposed to its attacks.</p> -</div> - -<p>Note that these words and the early attempts at public -health legislation, culminating in our great sanitary -code, the Public Health Act, 1875, incorporated the -tripod on which enlightened public health administration -must always be supported, viz.,</p> - -<p> -<span style="margin-left: 1em;">(1) attack on the causes of sickness,</span><br> -<span style="margin-left: 2em;">(2) satisfactory treatment of the sick, and</span><br> -<span style="margin-left: 2em;">(3) satisfactory care for the poor.</span><br> -</p> - -<p>I might properly add</p> - -<p> -<span style="margin-left: 1em;">(4) attack on the causes of poverty,</span><br> -</p> - -<p><span class="pagenum" id="Page_11">[Pg 11]</span></p> - -<p>for it is perhaps the chief merit of the great work of -Edwin Chadwick that, in the light of reports on local -surveys made by Kay, Southwood Smith, and others, -he was convinced and was able to convince Parliament -that a very large share of the total destitution then existing -was due to the conditions under which the people -lived, and the disease generated in these conditions.</p> - -<p>It is commonly stated that, in the past, public health -administration has concerned itself solely with mankind’s -environment, failing to recognise the predominant -importance of man himself as a transmitter of -disease, and of his personal well-being and protection -as the point to which energy should be directed. This -cannot be said to have been the intention of the legislature -or of the earlier reformers; though unhappily this -limited view received official acceptance, in large measure -owing to the increasing incompatibility between -poor-law and public health administration and the -spreading over from poor-law to public health administration -of the general influence of “deterrence” as a -motive of administration. As time went on, this principle -came to be realised as contrary to the general -interest in anything which concerns the health of the -community.</p> - - -<h3><em>Dirt and Disease</em></h3> - -<p>The crude generalization emerging from the earlier -surveys was the close relation between filth conditions -and excessive sickness; and the motive behind these<span class="pagenum" id="Page_12">[Pg 12]</span> -inquiries was the desire to remove one of the chief -causes of destitution.</p> - -<p>So late as 1874 Simon said “filth is the deadliest of -our present removable causes of disease”; and throughout -the whole series of his vividly worded and influential -reports, the same fundamentally important -teaching was urged.</p> - -<p>Chadwick’s earlier reports were similarly influenced -by the teaching of Dr. Southwood Smith and his collaborators, -to the effect that epidemic diseases as a -whole are the direct consequence of local insanitary -conditions. This generalization, as we now know, -needs a modified and more accurate statement, specialized -for each individual disease. In its original form, -however, it embodied a realisation of the immense importance -of the environment to make or to mar individual -and national life; it secured the beginning of -our national sanitary improvements, and it laid the -foundations of the house of health which as nations -we are still building.</p> - -<p>The three diseases which were especially regarded -as due to filth were cholera, typhus, and enteric fever; -and the history of public health in England is largely -concerned with these three diseases.</p> - - -<h3><em>Cholera</em></h3> - -<p>The general view then held in New as in Old England -is well stated in the following extract from the<span class="pagenum" id="Page_13">[Pg 13]</span> -Report of the Massachusetts Sanitary Commission, -1850:</p> - -<div class="blockquot fs80"> - -<p>Atmospheric contagion is generally harmless unless attracted -by local causes ... that terrible disease, Asiatic Cholera, -derives its terrific power chiefly or entirely from the accessory -or accompanying circumstances which attend it. It bounds -over habitation after habitation where cleanliness abides; -... while it alights near some congenial abode of filth or -impurity.... Wherever there is a dirty street, court, or -dwelling-house, the elements of pestilence are at work in that -neighbourhood.</p> -</div> - -<p>And the important moral is drawn that</p> - -<div class="blockquot fs80"> - -<p class="no-indent">the person who permits his neighbour’s atmosphere to be contaminated -by any filth ... is worse than a highway robber. -The latter robs us of property, the former of life.</p> -</div> - -<p>Similarly, Simon in England was teaching that “in -order to the prevention of Filth Diseases, the prevention -of filth is indispensable”; and that there was need -for local authorities “to introduce for the first time, -as into savage life, the rudiments of sanitary civilization.”</p> - -<p>The crude generalization that filth causes disease -perhaps persisted too long, and the value of Snow’s -investigation in 1855 of the outbreak of Cholera in -the area of supply of the Broad Street pump was -perhaps too slowly appreciated. The influence of -Von Pettenkofer’s theories on the relation between -subsoil conditions and Cholera was largely responsible -for this delay; but already in 1856 Simon had accepted<span class="pagenum" id="Page_14">[Pg 14]</span> -the importance of water infection, giving as his general -conclusion that</p> - -<div class="blockquot fs80"> - -<p class="no-indent">under the specific influence which determines an epidemic -period, fecalised drinking water and fecalised air equally may -breed and convey the poison (of Cholera).</p> -</div> - -<p>Still it will be noted there persisted the notion of -aerial convection of the contagia of cholera and enteric -fever, in addition to their convection by dirt, by flies, -or the more common contamination of hands or feet -or food by faecal matter; but the importance of water -supplies was beginning to be appreciated. Already in -1883 local authorities in England and Wales had outstanding -loans for waterworks amounting to twenty-nine -million and for sewerage amounting to fifteen -million pounds sterling, while between 1883 and 1912 -they expended out of rates and by means of loans one -hundred and thirty-one millions for waterworks and -eighty-nine millions sterling for sewerage.</p> - -<p>Although we realise now the greater importance of -control of excreta from persons specifically infected, -we must agree with Simon that communally</p> - -<div class="blockquot fs80"> - -<p>Nowhere out of Laputa could there be serious thought of -differentiating excremental performances into groups of diarrhœal -and healthy.... It is excrement, indiscriminately, that -must be kept from fouling us with its decay.... It is to be -hoped that ... for a population to be thus poisoned by its -own excrement, will some day be deemed ignominious and -intolerable.</p> -</div> - -<p>And it is still opportune to draw attention to the terrible<span class="pagenum" id="Page_15">[Pg 15]</span> -responsibility incurred by local authorities when -they distribute a general supply of water to the inhabitants -of their area without taking every possible precaution -against contamination. The conveniences and -advantages of public water supplies “are countervailed -by dangers to life on a scale of gigantic magnitude”; -and sanitary history, in the calamitous experience of -Lincoln, Maidstone, and Worthing and of Lowell and -other towns and districts, has given remarkable illustrations -of the need for eternal vigilance.</p> - - -<h3><em>Typhoid Fever</em></h3> - -<p>With the differentiation of typhoid fever from -typhus fever by Gerhard in Philadelphia in 1837, and -by Stewart and W. Jenner in Great Britain in 1849, it -became possible to associate the former with excremental, -the latter with respiratory filth, “the non-removal -of the volatile refuse of the human body.” -The question still remained whether typhoid fever was -producible by “emanations from decomposing organic -matter,” whether it was “often generated spontaneously -by faecal fermentation,” as contended by -Murchison, who in 1858 proposed the name “pythogenic -fever” for typhoid fever; or whether as indicated -by the remarkable observations of William Budd -of Bristol, the introduction of specific infection from a -typhoid patient was needed to start a local outbreak. -Gradually it became clear that specific contamination<span class="pagenum" id="Page_16">[Pg 16]</span> -was necessary to start an outbreak or even to cause a -single case of this disease, and between 1870 and 1880 -a number of water-borne outbreaks were traced. It -also gradually became evident that, however objectionable -or even noxious might be the gaseous emanations -from leaky drains or sewers, they did not cause typhoid -fever or diphtheria. Hence the statement, for instance, -of Oliver Wendell Holmes in 1862 (quoted for -its historical interest by Dr. Sedgwick) that “the bills -of mortality are more obviously affected by drainage -than by this or that method of practice,” which expressed -universal opinion when it was written, is now -known to be accurate only when specific matter from -drains contaminates milk or water supplies, or causes -infection by actual contact.</p> - -<p>With the general recognition of the causal relation -between impure water supplies and typhoid fever came -the rapid provision of public supplies, on which, as -already seen, large public expenditure was incurred; -and to this fact is owing, in the main, the rapid reduction -in typhoid mortality shown in the following statement:</p> - -<table class="autotable fs80"> -<tr> -<td class="tdc"></td> -<td class="tdcw">Population of England</td> -<td class="tdc"></td> -<td class="tdc"></td> -<td class="tdcw">No. of Deaths</td> -</tr> -<tr> -<td class="tdc"></td> -<td class="tdcw">and Wales</td> -<td class="tdc"></td> -<td class="tdc"></td> -<td class="tdcw">from Typhoid</td> -</tr> -<tr> -<td class="tdc">Year</td> -<td class="tdcw">in Millions</td> -<td class="tdc"></td> -<td class="tdc"></td> -<td class="tdcw">Fever</td> -</tr> -<tr> -<td class="tdl">1871</td> -<td class="tdlx">22⅘</td> -<td class="tdc"></td> -<td class="tdc"></td> -<td class="tdr">12,709</td> -</tr> -<tr> -<td class="tdl">1881</td> -<td class="tdlx">26</td> -<td class="tdc"></td> -<td class="tdc"></td> -<td class="tdr">6,688</td> -</tr> -<tr> -<td class="tdl">1891</td> -<td class="tdlx">29</td> -<td class="tdc"></td> -<td class="tdc"></td> -<td class="tdr">5,200</td> -</tr> -<tr> -<td class="tdl">1901</td> -<td class="tdlx">32⅗</td> -<td class="tdc"></td> -<td class="tdc"></td> -<td class="tdr">5,172</td> -</tr> -<tr> -<td class="tdl">1911</td> -<td class="tdlx">36⅕</td> -<td class="tdc"></td> -<td class="tdc"></td> -<td class="tdr">2,430</td> -</tr> -<tr> -<td class="tdl">1917</td> -<td class="tdlx">33⅗ (civilian)</td> -<td class="tdc"></td> -<td class="tdc"></td> -<td class="tdr">977</td> -</tr> -</table> - - -<p><span class="pagenum" id="Page_17">[Pg 17]</span></p> - -<p>The number of cases notified in England and Wales</p> - -<p class="center no-indent"> -in 1911 was 13,852<br> -in 1917 was 4,601 </p> - -<p>There was, it will be noted, a period of apparent -cessation of decline in the typhoid mortality between -1891 and 1901, followed by a striking decline between -1901 and the present time. The late decline was due -in large measure to the discovery of the relation between -contaminated shell-fish and enteric fever, and, -probably to a less extent, to the realisation of the importance -of the small minority of cases of this disease, -who continue after their recovery to spread infection. -At the present time typhoid fever promises -to become as rare in England as typhus fever or malaria; -and with increased care in the protection of -food, as well as of water supplies, and with the universal -hospital treatment of the sick and observation -of their bacterial condition on discharge, this anticipation -bids fair to be realised.</p> - - -<h3><em>Typhus Fever</em></h3> - -<p>The history of typhus is similar to that of typhoid -fever; and when Murchison in 1858 asserted its spontaneous -generation under conditions of overcrowding -and bad ventilation—</p> - -<div class="blockquot fs80"> - -<p>Its great predisposing cause is destitution; while the exciting -cause or specific poison is generated by overcrowding of -human beings with deficient ventilation—</p> -</div> - -<p><span class="pagenum" id="Page_18">[Pg 18]</span></p> - -<p class="no-indent">he was expressing the considered conclusion of his -period.</p> - -<p>Typhus Fever was not differentiated from enteric -fever in the Registrar-General’s returns prior to 1869, -but the course of events in later periods can be seen -in the following statement:</p> - -<table class="autotable"> -<tr> -<td class="tdl"></td> -<td class="tdci"><span class="fs80">Typhus Fever, No.</span></td> -</tr> -<tr> -<td class="tdl"></td> -<td class="tdci"><span class="fs80">of Deaths in England</span></td> -</tr> -<tr> -<td class="tdci"><span class="fs80">Years</span></td> -<td class="tdci"><span class="fs80">and Wales</span></td> -</tr> -<tr> -<td class="tdl">Ten years, 1871-80</td> -<td class="tdrp">13,975</td> -</tr> -<tr> -<td class="tdl">Eight years, 1903-10</td> -<td class="tdrp">210</td> -</tr> -<tr> -<td class="tdl">Seven years, 1911-17</td> -<td class="tdrp">42</td> -</tr> -</table> - - -<p>The cases in recent years were nearly all traceable -to imported infection.</p> - -<p>The main factors in the reduction of typhus fever -have been the immobilisation of infectious cases in -fever hospitals, the rigid cleansing and disinfection of -invaded households, and the surveillance of persons -who have been exposed to infection. The clearing of -insanitary courts, housing improvements, and the associated -increased cleanliness of the general population -have doubtless aided; and it is a suggestive fact that -although the virus of typhus is not yet determined, and -although it has only recently been shown that typhus -is a louse-spread disease, the point of extinction of the -disease under peace conditions has almost been reached -in countries having an efficient sanitary organization -and a cleanly people.</p> - -<p>With the demonstration that typhoid fever was commonly<span class="pagenum" id="Page_19">[Pg 19]</span> -water-borne, that the spread of typhus fever -could be controlled by sanitary surveillance and immobilisation -of infectious cases in hospital, and that -diarrhœal mortality could be reduced by increased -municipal and domestic cleanliness, much more rapid -improvement in national health occurred in the decennium -1871-1880 and in subsequent years.</p> - -<p>The course of events for typhoid and typhus fever -has already been noted. Before describing further -the action taken by central and local public health authorities -and the other influences conducing to reform, -it is convenient to summarise at this point the</p> - - -<h3><em>General Results in the Saving of Life</em></h3> - -<p>Although I do not dwell further on the influence of -increase of wages, of better and cheaper food, of sanitary -education of the people, of a steadily increasing -standard of cleanliness,—in person and in spitting -habits,—and of improving home conditions, it will not -be assumed they must be omitted in any considered -judgment as to the means by which the saving of life -shown by the following figures has been secured.</p> - -<p>The expectation of life at birth (or mean after-lifetime) -in England and Wales in 1871-80 for males -was 41.4 years, for females 41.9 years. It steadily -improved decade by decade; based on the experience -of 1910-12 the male expectation of life had been prolonged -by 10.1 years, and the female by 10.8 years. A<span class="pagenum" id="Page_20">[Pg 20]</span> -very large proportion of the lives saved were lived in -the years of greatest value to the community. Comparing -1910-12 with 1871-80, the reduction of the -death-rate meant that <em>each year</em> 116,401 male and -118,554 female lives were saved, and the future lifetime -of these persons whose lives were prolonged,—assuming -a continuance of current experience,—would -give an annual gain of nearly ten millions of additional -years of life, of which over seventy per cent. would be -lived at ages 15 to 65.</p> - -<p>Of the annual saving of 234,955 lives, 64 per cent. -was ascribable to reduced mortality from acute and -chronic infectious diseases; and of the mortality under -these headings nearly one-third was referable to respiratory -diseases, the same amount to tuberculosis, -one-seventh to scarlet fever, one-thirteenth to measles -and whooping cough, the same amount to typhus and -enteric fever, and one-sixteenth to diarrhœal diseases.</p> - -<p>The gain of life may be further illustrated by the -following figures. During the 32 years, 1881 to 1912, -over seventeen millions deaths occurred in England -and Wales. Had the experience of 1871-80 continued -throughout the subsequent years, the number of deaths -would have been increased by close on four millions.</p> - - -<h3><em>Specific Causation of Disease</em></h3> - -<p>The preceding review will have made it clear that in -the period of earlier slow sanitary reform, although<span class="pagenum" id="Page_21">[Pg 21]</span> -much invaluable work was being done, it was in some -measure a groping in the dark, a continuous search for -further light while pursuing (or at least advocating in -season and out of season) such cleansing and purification -of man’s surroundings as were evidently needed, -and such segregation of the infectious sick as could be -secured in the absence of complete information of the -cases of sickness. Happily in the case of Small Pox -there was an additional effective protection in vaccination.</p> - -<p>With Pasteur’s discoveries was inaugurated a new -era in sanitation; the general microbial origin of infectious -diseases, inferred from his discoveries, leading to -the conclusion that the chief source of disease to -others is man himself, and that his surroundings in the -main cause disease insofar only as they become a vehicle -for conveying disease by direct inhalation of -infected dirt (Sax. <cite>drit</cite> = excrement), or by swallowing -specifically infected foods.</p> - -<p>The importance of the sanitary engineer in securing -pure water supplies and satisfactory sewerage continues. -The sanitary inspector’s work in removing -nuisances and accumulations, any one of which might -be specifically contaminated,<a id="FNanchor_4" href="#Footnote_4" class="fnanchor">[4]</a> and in controlling overcrowding -and uncleanliness as well as in other respects,<span class="pagenum" id="Page_22">[Pg 22]</span> -remains indispensable. But the brunt of guidance in -the exact prevention of disease, especially of communicable -diseases, must necessarily now fall on</p> - - -<div class="poetry-container"> -<div class="poetry"> - <div class="stanza"> - <div class="verse indent4">the epidemiologist,</div> - <div class="verse indent4">the vital statistician, and</div> - <div class="verse indent4">the laboratory worker.</div> - </div> -</div> -</div> - - -<h3><em>Present Limitations of Epidemiology</em></h3> - -<p>The epidemiologist must always remain the chief of -these three, suggesting and arranging the details appropriate -to each investigation, putting together the -facts supplied by the two other workers and drawing -legitimate conclusions. In conducting his inquiries and -in searching for further light on obscure points, he will -need to remember Simon’s remarks (Eighth Report of -the Privy Council):</p> - -<div class="blockquot fs80"> - -<p>In the category of time, far out of human reach, there are -circumstances which greatly influence contagion.... These -almost cosmic arisings are spreadings of disease or facts of -cosmo-chemical disturbance which no mere contagionism can -explain.</p> -</div> - -<p>These words had special reference to cholera, and -although we still know little or nothing of the mysterious -influences which permit cholera when unimpeded -to undertake transmundane travels at irregular intervals -of time, we can claim with certainty that in any -country in which sanitary surveillance is well organised, -and the internal sanitation of the country is good,<span class="pagenum" id="Page_23">[Pg 23]</span> -the spread of cholera need not be feared. Thanks to -the great discovery of Jenner and to the complete -organization of measures for isolation of the sick, and -for vaccination and surveillance of contacts, we can -make the same claim for smallpox, whenever this mysterious -disease begins its occasional world travels.</p> - -<p>But we have to confess our continuing relative helplessness -in preventing the spread of measles, and of -acute catarrhs, among our endemic infections, and still -more of influenza when—as recently—it makes its -devastating swoop on the entire world, and secures a -larger number of victims than the World War itself.</p> - -<p>We can recommend isolation of the sick, and personal -precautions in speaking and in coughing and sneezing, -and occasionally may score an isolated success; but we -are practically helpless against this enemy. Nor are -we better acquainted with the means for preventing -the spread of poliomyelitis; and we cannot claim that -any measure against the spread of cerebro-spinal fever -has had undoubted success, except only rapid amelioration -of the conditions of overcrowding under which it -especially occurs. These instances suffice to show that -in the region of respiratory infections,—with the one -notable exception of tuberculosis, which we can control, -whenever we are ready to take the necessary complete -measures—we have much to learn. In respect -of most diseases due to respiratory infection we are -groping in darkness nearly as dense as that which<span class="pagenum" id="Page_24">[Pg 24]</span> -beset Chadwick, Farr and Simon in their earlier work, -and with little hope of any campaign comparable with -that against dirt <em>en masse</em>, which was largely effective -in reducing the specific infections of cholera, dysentery, -and enteric fever, of typhus fever and even of -tuberculosis.</p> - -<p>The great public health requirements for the future -are the conquest over acute respiratory infections, including -not only affections of the lungs, but probably -also measles and whooping cough, cerebro-spinal fever -and poliomyelitis and their allies; and the prevention -of cancer. So while thankful for the discoveries -already made, and for the beneficent work already -accomplished, we must hope that the rapid increase -of Medical Research in England and here will in due -time enable us to extend the application of preventive -medicine to diseases so far uncontrollable.</p> - - -<h3><em>The Importance of Vital Statistics</em></h3> - -<p>In England public health progress has been largely -actuated by records of mortality, which have served -to make the public realise the need for expenditure of -money on sanitary reform. Experience has shown, as -Dr. J. S. Fulton has expressed it, that</p> - -<div class="blockquot fs80"> - -<p class="no-indent">every wheel that turns in the service of public health must be -belted to the shaft of vital statistics.</p> -</div> - -<p>Accurate and complete returns of deaths and their -causes are essential in investigating the local and occupational<span class="pagenum" id="Page_25">[Pg 25]</span> -incidence of disease, and in comparing the -experience of different communities: and the various -weekly, quarterly, annual, and decennial reports issued -from the Registrar-General’s Department have rendered -invaluable service to the cause of public health. -“Ye shall know the truth, and the truth shall make -you free.”</p> - -<p>It was not the least of Chadwick’s services to the -State that he discovered William Farr, who was intrusted -with the compilation of, and comment on, our -early statistics from 1837 onwards. His reports, with -those of Simon, embody the history of sanitary progress -in England and the motives and arguments which -actuated it.</p> - -<p>The registration of births similarly enabled comparison -of birth-rates to be made; also of maternal -mortality in child-bearing and of infant mortality in -different areas, and at different parts of the first year -of life; and these studies made by medical officers of -health and more exhaustively in the Medical Department -of the Local Government Board have had great -influence in determining the intensive work for improving -the conditions of childbearing and of infant -rearing, which in recent years has been accomplished.</p> - -<p>As time went on it became clear that registration of -deaths gave a very imperfect view of the prevalence -of disease, and that so far as infectious diseases were -concerned, valuable time was lost when preventive<span class="pagenum" id="Page_26">[Pg 26]</span> -action could only be taken after the patient’s death. -Death registration told of the total wrecks which had -occurred during the storm; it gave no information as -to early mishaps, enabling others to trim their vessels -and thus weather through. It gave a list of killed in -battle, not of the wounded also.</p> - -<p>And so began gradually, in characteristic British -fashion, the notification of infectious cases, the list of -notifiable diseases being extended from time to time.</p> - -<p>From 1911 onwards the Local Government Board -prepared a weekly statement of infectious cases notified -in each sanitary area which was distributed to -every medical officer of health. Similar returns of -exotic diseases of interest to port medical officers were -distributed; and the successive annual summaries prepared -in the Medical Department of the Local Government -Board showing the incidence of the chief epidemic -diseases in every area now constitute one of the -most valuable epidemiological records extant.</p> - -<p>Collaterally with the notification of infectious diseases, -including tuberculosis, to the medical officer of -health, occurred the enforcement of notification of -various industrial diseases occurring in factories, such -as anthrax, lead and arsenic poisoning, to the Chief -Inspector of Factories, Home Office.</p> - -<p><span class="pagenum" id="Page_27">[Pg 27]</span></p> - - -<h3><em>Conditions of Medical Practice Bearing on Public Health</em></h3> - -<p>It cannot be claimed that notification of acute infectious -diseases, still less of tuberculosis, has been complete. -It is impossible to discuss the reasons for this -in the present address (see Lecture IX); but the present -conditions of medical practice are largely responsible -for the partial lack of success. Hasty conditions -of work, failure to employ laboratory means of diagnosis, -or to utilise available consultation facilities -(especially in tuberculosis), and lack of training of -medical practitioners in preventive medicine, are -among the obstacles to further control of disease.</p> - -<p>There will not be complete success until means are -discovered for training and enlisting every medical -practitioner as a medical officer of health in the circle -of his private or public practice, and of securing his -services not only in the early and prompt detection of -disease, but also in the systematic supervision during -health of the families under his care, and in advising -them as to habits or methods of life which are inimical -to health.</p> - - -<h3><em>Poor Law v. Public Health</em></h3> - -<p>An approximation to this ideal was in the minds of -the early sanitary reformers; and it was one of the -misfortunes associated with the deterrent policy of -poor-law administration in medical relief, that separation<span class="pagenum" id="Page_28">[Pg 28]</span> -between Poor Law and Public Health appeared to -offer the best prospect of sanitary progress.</p> - -<p>Had Simon’s advice been followed, when the Local -Government Board was about to take over the public -health duties of the Privy Council, the poor-law organization -might, and probably would gradually, have -been permeated by public health activities, and thus -the sanitary welfare of the poorest class of the community -would have been more completely safeguarded -on its personal as well as on its environmental side.</p> - -<p>In his Eleventh Report to the Privy Council (1868) -Simon recommended adherence to the intention of Mr. -Lowe’s Nuisance Bill of 1860, which would have identified -the health and destitution authorities. He deprecated -the institution of “a differently planned -organization for objects exclusively of health”; subject -to the conditions that public health should not be -subordinate to poor-law work and that there should -be power to combine districts for certain purposes, -and action through committees in sub-areas.</p> - -<p>Had this course been pursued, and had the central -public health policy not been preponderantly non-medical -and poor-law in sentiment and tradition, more -rapid progress in public health would have been experienced. -The central evil was intensified, as is shown -in Simon’s <cite>Public Health Institutions</cite>, by regarding the -medical officer of the Local Government Board as -merely advisory, and by the retention and extension<span class="pagenum" id="Page_29">[Pg 29]</span> -on a large scale of local inspection by lay officers of -the Central Board, for conditions which needed systematic -medical control.</p> - -<p>The problem of the proper relation between destitution -and public health and between the authorities -dealing with these, runs right through our past history -of social progress, and it is not even yet satisfactorily -adjusted.</p> - -<p>The gradually increasing dissatisfaction with Poor -Law administration led to the appointment of a Royal -Commission which after several years deliberation, in -1909 presented a Majority and a Minority Report.</p> - -<p>The dissatisfaction, which these reports justified, -may be said to have been inherent in the situation; for -the Poor Law organization was constantly attempting,—more -or less under the influence of the principle -of “deterrence,”—two incompatible tasks: to prevent -undue dependence upon parochial assistance and to -give to those needing them the medical and nursing -assistance which the principles of preventive medicine -require should be given unstintingly, and completely -freed from any deterrent element. Although in many -parochial areas admirable medical work was done, this -was the exception, not the rule; and public sentiment -rebelled against the giving or the receiving of medical -assistance to which was attached the “poor-law stigma.” -Both reports recommended the scrapping of the poor-law -machinery by abolishing the present Boards of<span class="pagenum" id="Page_30">[Pg 30]</span> -Guardians and the general mixed workhouse; and the -Minority Report went further, proposing to complete -the supersession of the poor-law by various preventive -authorities, which were already partially in operation. -Thus everything connected with the treatment of the -sick would be transferred to the Public Health Authorities, -the care of school children to Education Authorities, -of lunacy and the feeble-minded to already -existing Asylum Committees, and so on.</p> - -<p>Behind these proposals lay the principle that <em>the -treatment and the prevention of disease cannot administratively -be separated without injuring the possibilities -of success of both</em>; and this is a principle which -happily is becoming more generally accepted.</p> - -<p>Before the report of the Poor Law Commission was -issued, examples of the application of this axiom existed -in the isolation and treatment of patients with -acute infectious diseases; in the increasing provision -for the treatment of tuberculosis; in the extension of -provision for care of parturient women and for their -infants; and in the system of school medical inspection -followed to some extent by treatment.</p> - -<p>It is convenient to add here, that under each of these -headings, great extensions have been made since 1911; -and an even more spectacular public provision of treatment, -as the best method of preventing further extension -of disease, is exemplified in the gratuitous and -confidential diagnosis by laboratory assistance and<span class="pagenum" id="Page_31">[Pg 31]</span> -the treatment of venereal diseases now given in every -large town in the country, the Central Government -paying three fourths and the Local Authority one -fourth of its cost. In order further to secure the success -of this treatment,—which is provided for all -comers with no residential or financial conditions,—the -legislature has passed an enactment forbidding the -advertisement or offering for sale of any remedy for -these diseases, and forbidding their treatment except -by qualified medical practitioners.</p> - -<p>It is one of the great misfortunes of more recent -Public Health administration that the Report of the -Royal Commission on the Poor Laws has not hitherto -been made the subject of legislation. It would not -have been an insuperable task to find a common measure -of agreement between the Majority and the Minority -Reports. Indeed an adjustment has recently -been made between these two reports, as the result of -the deliberations of a House of Commons Committee, -over which Sir Donald Maclean presided; and -it may be hoped that ere long this will mean the realisation -of a much belated reform of local administration.</p> - -<p>This forms an indispensable step in the needed -further struggle against the problems of Destitution. -So much of destitution is due to sickness that the separation -of the two problems is inconsistent with success. -“One-third of all the paupers are sick, one-third children,<span class="pagenum" id="Page_32">[Pg 32]</span> -and one-quarter either widows encumbered by -young families or certified lunatics.” There are economic -causes of poverty, apart from sickness, but it is -essential to remember that every disease which is controlled -frees the community not only from a measurable -amount of sickness, but from the amount of poverty -implied by this sickness.</p> - -<p>Had the policy of transfer of the duties of Poor -Law authorities to the Councils of Counties and -County Boroughs recommended in 1909 by the Poor -Law Commission been adopted, these last named authorities -would already possess a medical service for -the poor employing some 4,000 doctors; they would be -in possession of the large infirmaries and other medical -institutions of the poor law, and given reforms and -readjustments of these which are urgently required, -and combination of the hospital arrangements of poor-law -and public health, would have a greatly improved -medical service freed from poor-law shackles and capable -of gradual extension as needs and policy indicate. -The fusion of these two services with the school medical -service would have been an easy further step; -and England would by this time have built up a National -Medical Service, for the very poor, for all purposes -of public health—including poor-law—administration, -and for children and their mothers in special -circumstances.</p> - -<p><span class="pagenum" id="Page_33">[Pg 33]</span></p> - - -<h3><em>Insurance v. Public Health</em></h3> - -<p>Political circumstances, into which it is unnecessary -to enter, led to the adoption of a course, which medically -ran directly athwart the course of needed reform. -The National (Health) Insurance Act, 1911, was -passed, giving sickness and invalidity benefits to those -employed persons below a certain income who could -contribute a weekly sum, which was considerably less -than half the estimated cost of the benefits to be received; -and an additional medical service, further -complicating the already existing medical services of -the poor law, public health, and educational authorities, -was set up.</p> - -<p>The establishment of national insurance against sickness -and disablement in the United Kingdom exemplifies -the contagiousness, under modern conditions of -life, of a new course adopted in any country; and Bismarck’s -attempt to counteract socialism by insurance -has been responsible for international, state and official -experimentation in insurance which has not generally -been well advised, and which is associated in England -with extravagant cost of administration.</p> - -<p>Insurance against sickness is a praiseworthy and -valuable provision against future contingencies; and -on its non-medical side free from drawbacks. Neither -on its medical nor on its non-medical side, however, is -it an alternative to prevention of disease; and the National -Insurance Act in England must be held in the<span class="pagenum" id="Page_34">[Pg 34]</span> -main to have delayed the public health reform which -would have been secured had equal effort been devoted -to it, and the money lavished on insurance given in the -form of central public health grants conditional on the -active coöperation of local authorities. True, the -English public have been educated to think in regard -to sickness in millions when previous provisions for -the treatment and prevention of sickness had been -thought of in thousands of pounds; and there has been -an extension of provision for the institutional treatment -of tuberculosis, which probably has been more -rapid than would otherwise have been made, in the -absence of the alternative grants named above. It -should be added that, owing to the natural insistence -of insured tuberculous patients on treatment in a sanatorium, -and to the desire of Local Insurance Committees -and their officers to satisfy insured persons, -sanatoria have often been filled with unsuitable patients, -sent there regardless of relative social and -public health needs. The Maternity Benefit (of a -sum of money on the birth of an infant to the wife -of an insured person or to an employed woman) similarly -is given unconditionally, and should be replaced -or supplemented by the provision of service needed at -this time (doctor or midwife, nurse, domestic assistance), -which would ensure the welfare of both mother -and infant.</p> - -<p>Apart from other reforms the transfer of medical -provision, of provision for tuberculous patients, and<span class="pagenum" id="Page_35">[Pg 35]</span> -for parturient women to public health authorities is -urgently needed; and the service should be given according -to need irrespective of insurance. The valuable -fund for medical research has already been placed -under the Privy Council.</p> - -<p>The absurdity of regarding insurance as anything -beyond a possibly useful handmaiden and auxiliary to -Public Health, when strict administrative arrangements -are made for this purpose, may be illustrated by -the question as to what would have been the result in -sanitary progress if Chadwick or Simon had persuaded -the government of their day to insure a favoured section -of the public against the risk of typhus or smallpox -or tuberculosis or even of non-infectious illness?</p> - -<p>Under the National Insurance Act medical domiciliary -assistance,—but only to the extent which is -within the competence of a medical practitioner of -average ability,—is provided under contract for one-third -of the total population; and evidently this implies -an immense abstraction from ordinary private -medical practice. There is no provision, hitherto, for -consultant and expert facilities when required (except -for tuberculosis), for the nursing of patients, or for -institutional treatment of any disease, except tuberculosis; -and no funds are generally available for these -purposes except such as belong to the community at -large.</p> - -<p>In view of the preceding facts and of other considerations<span class="pagenum" id="Page_36">[Pg 36]</span> -which I have not mentioned, reconstruction -of the English Insurance scheme is obviously required. -The scheme cannot persist in its present form. The -already accomplished amalgamation of the Local Government -Board and National Insurance Commission, -should make radical changes easier; an equally important -step would be the transfer of the medical functions -of the Local Insurance Committees to Public -Health Authorities. The creation of these independent -committees was one of the greatest blunders of -the National Insurance Act, which was conceived ill-advisedly, -had too short a gestation, and suffered a -premature and forced delivery; and we may hope that -ere long, it may be replaced entirely, on its medical and -hygienic side, by a rapid extension of the medical activities -of the public health service which will conduce -to the welfare of the whole nation.</p> - -<p>It is impossible to justify the continuance of state -subsidisation of benefits for a favoured portion of the -wage-earning classes, when poorer persons who do not -come within the category of employed persons or who -fall out of employment, and when clerks and others -on limited salaries who are unable to provide adequately -for sickness, are left unprovided for.</p> - - -<h3><em>A National Medical Service</em></h3> - -<p>What is most urgently needed is a national medical -service which will give for all who cannot afford them<span class="pagenum" id="Page_37">[Pg 37]</span> -hospital treatment and the services of consultants and -of scientific aids to diagnosis and treatment whenever -required; and which will provide nurses during illness -treated at home, when this is asked for by the doctor -in attendance.</p> - -<p>Outside the operation of the National Insurance -Act, these services have been provided to a steadily -increasing extent, but in a characteristically British -fashion. They have grown largely under voluntary -management, and as exemplifications of Christian philanthropy; -though official has rapidly overtaken the -voluntary provision of hospitals and nursing, the two -working side by side, each in their respective spheres, -and on the whole with cordial coöperation. The extent -to which institutional treatment with its more -satisfactory arrangements is replacing the domiciliary -treatment of disease may be gathered from the following -striking facts:</p> - -<p class="no-indent">In England and Wales</p> -<p class="lh">Of deaths from all causes, in 1881 = 1 in every 9</p> -<p class="lh">Of deaths from all causes, in 1910 = 1 in every 5</p> - -<p class="no-indent">In London</p> - -<p class="lh">Of deaths from all causes, in 1881 = 1 in every 5</p> -<p class="lh">Of deaths from all causes, in 1910 = 2 in every 5</p> -<p class="no-indent lh">occurred in public institutions.</p> - -<p>The facts as to Pulmonary Tuberculosis are even -more significant:</p> - -<p class="no-indent">In the year 1911</p> - -<p><span class="pagenum" id="Page_38">[Pg 38]</span></p> - -<p class="lh">in England and Wales 34% of male 22% of female</p> -<p class="lh">and in London 59% of male and 48% of female</p> - -<p class="no-indent">deaths from pulmonary tuberculosis occurred in public -institutions; and as each of these patients spent on an -average several months in hospital, at the most infectious -stage of their illness, a material annual reduction -in the possibility of massive infection of relatives and -others has been secured.</p> - - -<h3><em>Hospitals Important Housing Auxiliaries</em></h3> - -<p>This institutional treatment of the sick has been -one of the chief influences counteracting the pernicious -effects of industrialism and urbanization. It has -relieved housing difficulties at a time when insufficient -bedroom accommodation is most injurious; and it has -secured year by year for a steadily increasing proportion -of the total population the improvements of modern -surgery and medicine as practised in institutions, -which permit of the poor thus treated receiving more -satisfactory and more hopeful treatment than is obtainable -for a large proportion of other classes of -society.</p> - -<p>My address is already too long. Other opportunities -will be taken of explaining the rapidly increasing -part which the State and Public Health Authorities -are taking in the hygiene and care of motherhood -and childhood and of school children; in the provision -of additional nursing services for the sick, in the<span class="pagenum" id="Page_39">[Pg 39]</span> -rapid growth in numbers of public health nurses, -health visitors, school nurses, etc.; in special schemes -for the treatment of tuberculosis and of venereal diseases; -and the circumstances under which the Central -Government are to a rapidly increasing extent paying -half (or in certain instances three-fourths) of approved -local expenditure on the provision of hygienic, -nursing and medical services; and I do not therefore -dwell on these points further.</p> - -<p>Nor need I comment here on the remarkable fact -that the British Government under present circumstances -have departed from the economic position that -houses built by local authorities must be able to be let -at a rental covering all outgoings.</p> - -<p>In Lecture II I shall deal with problems of local -and central government, and with the training and -appointment of medical officers of health; but the -present review, if it omitted from consideration on the -one hand the value of specially trained whole-time -health officers, and on the other hand the health significance -of the general advance in the standard of -medical treatment, as factors of prime importance in -securing the already achieved improvement in human -life and health, would give a most imperfect picture -of the actual facts.</p> - -<p><span class="pagenum" id="Page_40">[Pg 40]</span></p> - - -<h3><em>The need to avoid Complacency</em></h3> - -<p>Such figures as I have given, showing saving and -prolongation of life during the last fifty years, are apt, -if left uncorrected, to create a complacent warmth -tending to public health inertia. It may conduce -further to this folding of the hands when I state that -Simon in his first report to the Local Government -Board expressed the opinion that the half million -deaths a year approximately which occurred in 1871 -in England and Wales were a third (125,000) more -numerous than they would be if existing knowledge -of the chief causes of disease were reasonably well -applied throughout the country; and further that had -the mortality experience during 1911-15 held good for -1871, the deaths in that year would have been reduced -by 200,000 instead of by 125,000, the ideal then aimed -at by Simon.</p> - -<p>But with increased knowledge we know that a larger -proportion of diseases are preventable than was formerly -supposed. It will be easy within the next ten -years to reduce the death-rate by one-third of its -present amount, given systematic and adequate action -on the part of Public Health Authorities and an -effective educational propaganda among the general -public. More important still, an even larger proportion -of mankind’s total illness can be avoided, and life -on a higher plane of health secured, as well as life -prolonged to its normal limit. The work carried out<span class="pagenum" id="Page_41">[Pg 41]</span> -during the last ten years, sanitary, medical and hygienic, -in improving the prospects of healthy child-bearing -and of normal infancy and childhood constitute -the most important advance toward national physiological -life on a higher plane which has hitherto been -made.</p> - -<p>Preventive medicine can never be satisfied until it -has approached Isaiah’s ideal (Isaiah, LXV, 20), -“There shall be no more thence an infant of days, nor -an old man that hath not filled his days; for the child -shall die a hundred years old.”</p> - -<p><span class="pagenum" id="Page_42">[Pg 42]</span></p> - - -<div class="footnotes"><h3>FOOTNOTES:</h3> - -<div class="footnote"> - -<p><a id="Footnote_1" href="#FNanchor_1" class="label">[1]</a> An address prepared for the celebration of the fiftieth -anniversary of the Massachusetts Board of Health, September, -1919.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_2" href="#FNanchor_2" class="label">[2]</a> The administrative side of the subject is sketched in the -next chapter.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_3" href="#FNanchor_3" class="label">[3]</a> Reprint of Reports, Vol. I, p. 448.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_4" href="#FNanchor_4" class="label">[4]</a> There is still no evidence to show that in the production -of the excessive diarrhœa which prevails in insanitary districts, -specific contamination of the filth accumulations is -necessary.</p> - -</div> -</div> - - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<h2 class="nobreak" id="CHAPTER_II">CHAPTER II<br><br> -<span class="smcap fs80">The Historical Development of Public Health -Policy in England</span><a id="FNanchor_5" href="#Footnote_5" class="fnanchor">[5]</a></h2> -</div> - -<p>The subject is too large to be treated adequately in -the course of an evening’s address; and to bring it -within manageable compass it is necessary for me to -select my material rigidly and, as far as I can, to present -this material in such a manner as will bring into -relief its salient and most instructive features.</p> - -<p>The evolution of public health in England proceeded -by experimental steps, some mistaken and then retraced, -others mistaken and not retraced, but steps -oftenest in the direction of a complete service, which -is the goal of our work.</p> - -<p>The evolution has been a gradual growth arising -out of realized needs, rather than a logical development -based on general principles; and as politicians -and legislators seldom take a wide outlook, or consider -a specific proposal in relation to what is already -being done, and to what is the desired goal, the English -experience is especially instructive.</p> - -<p><span class="pagenum" id="Page_43">[Pg 43]</span></p> - - -<h3><em>Town-living and Health Problems</em></h3> - -<p>Public health work became an urgent necessity -when men began to huddle in towns; and with the -industrial revolution of the eighteenth and early nineteenth -centuries the need for remedial action became -acute. It is hard to realize that in the days of our -grandfathers, the home was in most instances the unit -of industry; and that in the eighteenth century communications -between districts and towns were not -more advanced than those of the ancient Egyptians. -When, however, vast urban aggregations of population -multiplied, travelling facilities rapidly increased, -and the results of crowding, of contaminated water -supplies, of intensive and widespread infection, were -seen in devastating endemic and epidemic diseases. -Poverty, squalor, dirt, and their consequences, were -rampant in the towns, where underpaid work-people -were exploited by masters, whose self-centred outlook -had some share of justification in the political economy -doctrines of the time, which regarded any interference -with “freedom of contract” as useless or even -pernicious.</p> - -<p>What is public health work? It is best defined by -stating its object, which is to secure the maximum attainable -health of every member of the community, so -far as this can be secured by the authorities, local, -state, or federal, concerned in any part of government, -acting in coöperation with all voluntary agencies whose<span class="pagenum" id="Page_44">[Pg 44]</span> -work conduces to the same end. The connotation of -public health becomes wider year by year. It embraces -physiological as well as pathological life; being -as much concerned with improving the standard of -health of each person as with the prevention and cure -of disease. Hence the importance of the “concentration -on the mother and her child” (John Burns), to -secure for them by all practicable means the conditions -of complete health, which during the last twelve years -has been a vital part of our public health work, and -which is now being made to include not only all hygienic -and medical help that may be needed, but also -such domestic aid as may enable the mother to bring -her children into the world and to rear them under -advantageous conditions.</p> - - -<h3><em>Scope of Constructive Health Work</em></h3> - -<p>Public health embraces some eugenic elements, and -may comprise more when eugenists have accumulated -adequate non-fallacious evidence on which to base -valid conclusions. Already partial steps are being -taken to secure the segregation and prevent the propagation -of the feeble-minded and the insane; and in -sorting out congenital infection from true heredity -action is being taken to avoid congenital syphilis and -to prevent the large number of still-births due to this -race poison.</p> - -<p>Public health in the main is concerned primarily<span class="pagenum" id="Page_45">[Pg 45]</span> -with the environmental measures calculated to prevent -the attack of man by disease, whether pre-natal or -post-natal. These measures may be industrial, as in -the prevention of accidents, of dust, of noxious vapours; -or sanitary, as in the control of water supplies, -food, or milk, and in the removal of organic filth; or -may be the application of preventive medicine against -infectious and non-infectious diseases; or therapeutic, -consisting of the prompt and adequate treatment of -all illnesses and the curtailment of the incompetence -due to them; or educational, consisting, first in importance, -in the training of medical practitioners, of public -health officials, and nurses; and, next, in the education -of the general public and especially of the children -in our schools, in the science and practice of public -health.</p> - -<p>Advances in public health in many directions can -only be secured by continued and extended medical -research, and public health, therefore, has a direct and -immediate interest in promoting and subsidizing such -research.</p> - -<p>These being the objects of public health, how far -have we travelled toward securing the end in view? -I do not propose to myself the pleasant task of showing -to what extent the general death-rate has been -lowered, infant and child mortality greatly reduced, -the duration of life extended, how typhus and smallpox -have been almost eradicated, typhoid fever made<span class="pagenum" id="Page_46">[Pg 46]</span> -a disappearing disease, and tuberculosis has become -the cause of only half its former death rate. When -inclined to indulge in such pleasant considerations, I -recall the statement I have made elsewhere that one-half -of the mortality and disablement still occurring -at ages below seventy can be obviated by the application -of medical knowledge already within our possession.</p> - -<p>Let me attempt the more difficult task of outlining -the history of forms of administrative control of disease -since 1834.</p> - - -<h3><em>Reform in the Control of Poverty</em></h3> - -<p>Poverty and disease work in a vicious circle in which -cause and effect often change places; but it is certain -that disease is one of the most fertile causes of poverty, -using the word poverty in the sense of privation -of one or other essential of physical well being.</p> - -<p>For this reason, and because the half starved form -a constant social danger, poor-law administration long -antedated public health administration. There is not -time to follow the course of earlier poor-law administration, -with its many and grievous abuses. The -Poor-Law Amendment Act of 1834, gave the Central -Government control over the systems of local relief, -secured the combination of parishes into unions for -poor-law relief,<a id="FNanchor_6" href="#Footnote_6" class="fnanchor">[6]</a> and forbade outdoor relief to able-bodied<span class="pagenum" id="Page_47">[Pg 47]</span> -men. The creation of an organ of central control -has led to the subsequent course of aid to paupers -being determined in the main in London, action of -poor-law guardians being subject to supervision by -government inspectors, and to endorsement by the -Central Authority. At first, medical assistance under -the reformed Poor Law was made as deterrent as non-medical -relief; and although there has been much improvement, -chiefly on the institutional side, medical -treatment under the Poor Law has to some extent retained -this deterrent element, and it has, except in -the poor-law infirmaries of large cities, remained generally -disliked by the people concerned.</p> - -<p>The first Central Poor-Law Authority was a Commission -having no representative in Parliament. In -1847 it was replaced by a Board, the president of which -was a member of Parliament and of the Government. -Here once for all Parliament declared its intention to -maintain direct control of central official government, -and in this and in all other departments has done so. -If democracy is to be real,—and we have no sound, -practicable alternative to it,—evidently the representatives -of the people must be masters of the administration; -and English policy has never wavered on this -point. After many years’ experience of public life in -England, I have no hesitation in saying that this principle -is sound; that it insures progress which, although -slow, is less liable to relapse than administration under<span class="pagenum" id="Page_48">[Pg 48]</span> -autonomous expert commissions, whether centrally or -locally; and that any lack of progress that has been -experienced in central government has been as much -the result of inactivity and of lack of sympathy with -social reform on the part of the permanent officials of -government departments who have had access to their -parliamentary chief, as of the inertia of politicians or -their obstruction to reform.</p> - -<p>Dissatisfaction with Poor-Law administration has -steadily increased in the years since 1834, as the problem -of the able-bodied pauper has diminished and the -Poor Law has been concerned more and more with the -sick and infirm, the aged, and children. These at the -present time form some 98 per cent. of the total population -relieved. The fundamental principles of the -Poor Law were rightly attacked. It did not comprise -elements tending to build up disabled families, or to -prevent families from falling hopelessly and permanently -into destitution. The law was administered -almost entirely with a view to <em>relief</em>; practically not -at all as a <em>curative</em> agency. In medical language, -symptomatic and not rational causal treatment was the -rule.</p> - -<p>In medical relief, poor-law administration has been -a constant struggle between increasingly humane treatment -and the conception that the pauper’s position -must remain inferior to that of the non-pauper; an -important principle when applied to the able-bodied<span class="pagenum" id="Page_49">[Pg 49]</span> -adult who has drifted into willing dependence; mischievous -when applied to sick persons, and to dependent -women and children.</p> - -<p>The general dissatisfaction with poor-law administration -led to the appointment of a Royal Commission -on the Poor-Laws which, after several years’ deliberation, -published in 1909 a majority and a minority -report. Both these reports recommended the abolition -of boards of guardians, and the transfer of their -duties to the 144 largest public health authorities in -the country (County Councils, 44; and the Councils of -county boroughs, 82), and the abolition of the general -workhouse. The majority report would have continued -the Poor-Law Guardians as a Committee of the new -Authority; the minority report proposed to distribute -the duties of the guardians to different committees of -the Public Health Authority; thus medical treatment -to the Public Health Committee; the care of lunacy -and the feeble-minded to the Asylum Committee; care -of children to the Education Committee; vagrants, -etc., to the Police Committee; a special committee concerning -itself with all questions of monetary assistance.</p> - -<p>A compromise between these two schemes has recently -been arranged, and when the new Ministry of -Health, which will combine public health, poor-law, -insurance, and educational medical work in one department, -has found time to do urgently needed work, -the above indicated reform may be hoped for, along<span class="pagenum" id="Page_50">[Pg 50]</span> -with the even more urgently needed reform of local -public health administration, and the abolition of a -large number of the smaller and less efficient sanitary -authorities. With these reforms will come much -needed de-centralization of poor-law work. Good -work in all respects cannot be secured if the Central -Authority concerns itself, as at present, in minutiae of -local administration, and has no time to devote itself -to the larger problems, and to the task of bringing -indifferent, chiefly smaller authorities, up to the standard -of efficient local authorities. A large portion of -the expense of local poor-law administration is borne -by the central exchequer, and this money if properly -applied will give the necessary leverage for reform, -while leaving progressive Authorities, and especially -the Authorities of large towns, free to experiment and -advance.</p> - - -<h3><em>Reform in Industry</em></h3> - -<p>The industrial revolution meant the subjection of -large masses of working class families to evil conditions -of housing and work in crowded and insanitary -dwellings and factories. The public conscience first -rebelled in regard to boarded out and apprentised -pauper children; and the first Factory Act in 1802 concerned -itself with them; and with this Act emerged -the germ of machinery for securing compliance with -the law, magistrates and clergymen being appointed -as inspectors under the Act.</p> - -<p><span class="pagenum" id="Page_51">[Pg 51]</span></p> - -<p>The Act was largely futile; but it meant the beginning -of the gradual breaking down of <i lang="fr" xml:lang="fr">laissez faire</i> -doctrines; and there followed a more widely operative -Factory Act in 1833, restricting hours of labor of -children, and initiating professional inspectors controlled -and paid by the Government. In 1842 the -underground employment of women in mines was -forbidden; and at intervals since then numerous factory -and allied acts have been passed, restricting the -duration and conditions of work of women and children, -improving rules as to sanitation, insuring systematic -inspection by government inspectors, and constituting -a far reaching system of supervision and -control.</p> - -<p>The inspectors, on whom falls the burden of ensuring -compliance with the Factory Laws and regulations -made under them, are controlled by the department of -the central government known as the Home Office; -their work on the whole has been well done, and the -conditions of factory and workshop life have greatly -improved. Some portion of the sanitary supervision -of these work-places falls on the local Sanitary Authority; -but in the main the system is one of absolutely -centralized government control. This secures almost -complete absence of improper influence of interested -local persons, whether masters or workmen; but it is -arguable that this system should be replaced by a localized -system, the inspectors being officers of the 144<span class="pagenum" id="Page_52">[Pg 52]</span> -larger authorities. These local officers could be placed -in direct touch with the Home Office or the Ministry of -Health and with the central staff of inspectors having -expert knowledge in the different branches of industrial -work.</p> - - -<h3><em>Public Health Reform</em></h3> - -<p>Public health reform was a direct consequence of -the Poor-Law Amendment Act, 1834. Anxious to diminish -the enormous expense of the existing Poor -Law, and realizing that a large share of this sickness -was due to fever and other illnesses, surveys and inquiries -were set on foot by the commissioners administering -this Act, and the reports which followed revealed -a state of things urgently calling for sanitary -reform, in the interest of national economy as well as -of health. “An Act for Promoting the Public Health” -was passed in August, 1848, which created a General -Board of Health consisting of four members and a -secretary. These Commissioners, among whom was -Edwin Chadwick, former Secretary of the Poor Law -Board, initiated a system of procedure which was -largely on the lines of poor-law action, and which involved -constant pin-pricking by the Central Authority -of the grossly indifferent local authorities. The commissioners -were more zealous than discreet; and after -six years they were no longer tolerated. At that time -centralization was as much a bogie as socialism has -become in more recent years. Parliament and the localities<span class="pagenum" id="Page_53">[Pg 53]</span> -represented by its members doubtless feared -the reforming activity of Chadwick and his colleagues, -though they sheltered themselves behind their exaggerated -fears of bureaucracy and centralization.</p> - -<p>A new board replaced the old, parliamentary in character, -its president being a member of the Government. -This repeated, so far as concerns Parliamentary headship, -the story of the Poor-Law Board, and established -once more the theory of the administrative -control of the representatives of the people. Nor, although -the change meant for the time serious slackening -in sanitary reform, can objection be taken to it. -In a democratic government the elected representatives -of the people must take first place; and it is the rôle -of officials to educate them in the direction of needed -reforms. Reforms which do not carry public opinion -with them are not likely to be permanently successful; -and, whether in administration or in legislation, attempts -to sidetrack or ignore this fact are not likely -to be permanently effective.</p> - - -<h3><em>Public Health Reforms</em></h3> - -<p>When the Local Government Board was formed in -1870, a second opportunity was lost of developing -Public Health Administration on lines which we now -know to be the best adapted for a complete service of -preventive medicine. The first lost opportunity was -when sanitary authorities, completely separate from<span class="pagenum" id="Page_54">[Pg 54]</span> -poor-law authorities, were created for administering -the sanitary laws. Probably this arose from Chadwick’s -despair of getting effective sanitary reform -from poor-law guardians; but the creation of separate -authorities was scarcely consistent with the fact recognized -by him that pauperism is largely, if not predominantly -a question of sickness; or with the less -recognized fact that its treatment forms an essential -part of prevention. It was recognized that the care of -the sick was largely idle until the unnecessary causes -of disease had been cut off, but not that the adequate -treatment of sickness is an important means of preventing -it or of curtailing it. Rumsey,<a id="FNanchor_7" href="#Footnote_7" class="fnanchor">[7]</a> in 1856, stated -the unrealized possibilities of the poor-law medical -officer’s domiciliary attendance on paupers in the following -words:</p> - -<div class="blockquot fs80"> - -<p>There are much higher functions of a preventive nature -than those of a mere “public informer” which the district -medical officer ought to perform. He should become the sanitary -adviser of the poor in their dwellings ... he (should) -be in a peculiar sense, the missionary of health in his own -parish or district,—instructing the working classes in personal -and domestic hygiene,—and practically proving to the helpless -and debased, the disheartened and disaffected, that the State -cares for them, a fact of which, until of late, they have seen -but little evidence.</p> -</div> - -<p>In the result the <em>ad hoc</em> poor-law authority did not -absorb into it the newly created municipal and urban<span class="pagenum" id="Page_55">[Pg 55]</span> -and rural sanitary administration, but continued on its -separate path.</p> - -<p>Simon, in 1868, had urged the inadvisability of continuing -<em>ad hoc</em> authorities, and had urged that, at least, -sanitary should be made coterminous in area of administration -with poor-law districts. His advice was -not adopted, and there followed years in which sanitary -authorities were allowed to subdivide areas, until -the total number became 1,807 instead of 635, the -number of poor-law authorities; and in which they -concerned themselves chiefly with nuisances and water -supplies and with inadequate provision for the prevention -and treatment of infectious diseases. With the -creation of county councils and the more complete autonomy -of the councils of county boroughs, the large -centres of population developed and improved their -sanitary administration more rapidly; and it became -practicable to undertake every division of sanitary -work on an efficient scale. Although much remains -to be done, it can be claimed that in our larger towns, -containing more than half of the total population of -the country, the public health work in nearly all its -branches is of a high order. It would have been still -more efficient had the poor-law guardians been merged -in the Town Council, and had the relationship between -the school medical service and the other branches of the -public health service been closer than has been the case.</p> - -<p>What is now needed is that the defects just named<span class="pagenum" id="Page_56">[Pg 56]</span> -should be made good; that more complete autonomy -should be given to the authorities which come up to a -required standard, and that especially they should have -greater freedom in developing local possibilities of -improved administration. Central grants in aid of -local sanitary administration are steadily increasing. -Already the Government pays one-half of local expenditure -on a large program of maternity and child -welfare work, one-half of the expense of local tuberculosis -work, and three-fourths of the expense of local -work for the diagnosis and treatment of venereal diseases, -and for propaganda work concerning these. -These grants should be the means of greatly increasing -good local administration; but if,—this is improbable,—they -curtail local experimentation and extension, -and bring local public health administration into anything -approaching the subservience of local poor-law -administration, the value of these subventions will be -doubtful.</p> - - -<h3><em>Education Authorities and Health</em></h3> - -<p>The national system of compulsory elementary education -inaugurated in 1870 has had valuable indirect -influence in promoting the public health. Apart from -the beneficent effect of education, the steadily increasing -pressure on children to come to school in a cleanly -condition and the stimulus of emulation in tidiness and -cleanliness, have done much to improve the home conditions<span class="pagenum" id="Page_57">[Pg 57]</span> -of the people. After the South African war -much attention was drawn to the large number of recruits -rejected owing to physical disabilities; and an -inter-departmental committee reported <i lang="la" xml:lang="la">inter alia</i> in -favour of a system of medical inspection of pupils in -elementary schools, which had often been urged by -hygienists. Observations made in Glasgow and Edinburgh -by Leslie Mackenzie did much to draw attention -to the physical defects in Scottish school children. In -1907 the Board of Education acquired power to make -provision through the local education authorities for -the medical inspection and treatment of school children. -At first little more than inspection of pupils -was undertaken, a large number of defects of sight, -hearing, parasitic conditions, as well as malnutrition -and actual disease being discovered. Gradually some -items of treatment were undertaken at school clinics, -or at hospitals or centres subsidized by the education -authorities; though the amount of treatment is still -small compared to the defects discovered and not -otherwise treated.</p> - -<p>But there now existed in every locality three authorities -concerned in the treatment of disease:</p> - -<p>1. Poor-law guardians, treating all forms of illness -in paupers, at home and in institutions.</p> - -<p>2. Public health authorities, undertaking preventive -measures against disease, and treating fevers, tuberculosis, -and occasionally other diseases in institutions;<span class="pagenum" id="Page_58">[Pg 58]</span> -and more recently providing nurses at home for certain -conditions.</p> - -<p>3. Local education authorities, concerned in treating -certain ailments in school children.</p> - -<p>Centrally two government departments were supervising -this work, and subsidizing it to some extent -from government funds; and poor-law medical work -and public health medical work were supervised by -two divisions of the Local Government Board acting -in almost complete isolation. More recently Parliament -has permitted the Board of Education to give -grants in aid of schools for mothers, and allied institutions -for the care of children under school age; for -which institutions, substantially, the Local Government -Board in other instances was giving grants.</p> - -<p>The separation of the medical work of Education -Authorities from public health medical work was contrary -to the first principles of sound administration; -although it is possible that, owing to the inertia in some -public health circles, this separation at first favored -rapid advance in school hygiene; just as the early -development of public health apart from poor-law -administration was probably more rapid than could -have been expected from centrally ridden local authorities, -concerned chiefly in keeping down the poor rates.</p> - -<p><span class="pagenum" id="Page_59">[Pg 59]</span></p> - - -<h3><em>The Ad Hoc Vice</em></h3> - -<p>But in both instances there was an offence against -the first principles of good administration, which require -that when a special function is to be undertaken -it shall be undertaken by one governing body for the -whole community needing the service, and not for different -sections of the community by several governing -bodies. Medical treatment is needed for school children -and for the poor generally. Why separate this -into two administrations? Hospitals are required for -paupers with tuberculosis, and for non-paupers with -tuberculosis. Why have two authorities for this -work? The separate existence of Education and -Poor-Law Authorities <i lang="la" xml:lang="la">qûa</i> medical attendance on those -children needing it erred, not only in this fundamental -respect, but also because neither of these authorities -had the preventive facilities and powers possessed by -Public Health Authorities, who were also partially -engaged in the treatment of disease.</p> - -<p>The inveterate tendency in the past has been to -create a new authority when any new work was inaugurated, -this authority then fulfilling all purposes -for a special portion of the community and thus necessarily -duplicating the staffs of other departments of -local or central government. The crowning instance -of this recurring instance of legislative myopia is seen -in the case of the National Insurance Act, under which -has been provided an imperfect and unsatisfactory<span class="pagenum" id="Page_60">[Pg 60]</span> -domiciliary medical service for one-third of the entire -population of Great Britain, when by combining and -extending the medical forces of existing departments -of the state, a satisfactory service for all needing it -would have been secured. The axiom that “the object -of community service is to do away with group -competitions and bring in its place group coöperation -or team work” (Goodnow), is especially applicable -to all public health and medical work; and the spirit of -this axiom is infringed by the existence of separate, -sometimes competing, occasionally conflicting, services -under separate local and central control.</p> - - -<h3><em>Principles of Local Government</em></h3> - -<p>The preceding considerations bear on the perennial -problem of efficient government, local and central. -There are three functions to be performed in government, -legislation, determination of administrative policy -and extent of work, and the actual executive work. -In England, legislation is in the hands of Parliament -and is usually national in scope. Large cities, however, -not infrequently obtain special legislative power -to meet local needs; and by this means have succeeded -in advancing local efficiency above the average standard. -Local authorities, furthermore, have the power -to make regulations and by-laws for special purposes, -subject to the approval of the Central Authority.</p> - -<p>In settling the details of local administration, the<span class="pagenum" id="Page_61">[Pg 61]</span> -elected representatives of the public are supreme. -They meet in Council, and action is taken on a majority -vote. The councils of counties and cities, and even -of smaller municipal boroughs divide themselves into -committees, each consisting of about a dozen members, -elected by vote of the whole Council. The chairman -or mayor of the Council has no special power, -except that he may give a casting vote.</p> - -<p>The chief defect in local sanitary administration in -England is the continued existence of a large number -of small and relatively inefficient local authorities. -The larger authorities, as a rule, do their work well, -and politics enter but little into elections. Official -posts are not vacated with changing councils. These -councils are approximating to the ideal of a complete -local Parliament dealing with all governmental concerns, -and to the further ideal that each unit of government -should be large enough to minimize the influence -of local interested motives, and to undertake each department -of municipal work on a considerable scale. -The local Parliament has committees concerned with -police, finance, public health, education; and when the -urgently needed poor-law reforms are made, and -when the Education Committee hands over its medical -work to the Public Health Committee, the ideal will -become a fact.</p> - -<p>Power is already given to coopt on to some of these -committees a few persons who are not members of<span class="pagenum" id="Page_62">[Pg 62]</span> -the Council, from among men or women having special -knowledge of the Committee’s work; and the exercise -of this power has been found to be useful.</p> - -<p>But in each committee it is the direct representatives -of the public who decide points of policy and settle the -main outlines of administration. There is growing up -a tendency to appoint local advisory committees, consisting -of special groups representing professional or -trade interests. Thus a medical committee may be -consulted on medical proposals, and so on. This is -still in the experimental stage. It will probably prove -permanently useful, as voicing the occupational aspect -of any proposed work of the municipality; but it will -need to be kept to its strictly consultative limitations, -and the responsibility of the Council as representing -the combined wisdom or unwisdom of the entire community -must be maintained.</p> - -<p>All substitutes for government of the people by the -representatives of the whole population are open to -objection. They do not contain within them the elements -of permanence. If there is a corrupt council, -the remedy is not its supersession by an independent -executive. Such an executive is the abrogation of -popular government. “Good and efficient government -is possible under almost any form of organization. -More depends upon men than devices.... But -... if we believe that the functions of deliberation -or determination of municipal policy and of administration<span class="pagenum" id="Page_63">[Pg 63]</span> -or the execution or carrying out of that policy -should be kept distinct, we cannot avoid the conclusion -that a city council is a necessary part of the municipal -organization.”<a id="FNanchor_8" href="#Footnote_8" class="fnanchor">[8]</a></p> - -<p>Each committee of the local Council is advised by -the County Clerk or Town Clerk on legal and administrative -matters; and the medical officer of health and -other expert officers, like the legal adviser, in nearly -every instance, hold office during good behaviour. -Under the above arrangements the elected members -and the officials are kept in touch with each other. -The latter’s recommendations and actual work must -be approved by the former; and this works well under -the system of determination of policy by committees, -subject to confirmation and control by the entire Council. -The motive power is public opinion. Good work -cannot for any prolonged period go beyond what the -public demand, and the work of officials is one of constant -education of their masters and of the public.</p> - - -<h3><em>The Training and Tenure of Office of Health Officers</em></h3> - -<p>Every sanitary district is required to appoint a medical -officer of health and since 1888 every medical -officer of health for a district with a population exceeding -50,000 must have a special diploma in public -health. The enforcement of this requirement has<span class="pagenum" id="Page_64">[Pg 64]</span> -done much to raise the standard of work of these -officers. It is significant, furthermore, that while in -1873 the percentage of the total population of England -and Wales having whole-time medical officers of -health was only 20.6, it had increased to 61.4 per cent. -in 1911. In the metropolis, in the whole of Scotland, -in every English county (forty-four) and in many -other districts these officers possess security of tenure, -in the sense that they cannot be removed from office -without the consent of the Central Government, which -usually pays half their salaries. Even without this -safeguard, removal from office by the local authority -is rare; but there has been long delay in securing the -further reform that in all areas the medical officer of -health should be able to perform his difficult and sometimes -obnoxious duties without fear of removal from -office, or of reduction in his emolument, except as the -result of deliberate action on appeal to a central authority.</p> - -<p>When pensions can be earned by medical officers -of health and by all medical men on the public health -staff, their position will become more attractive for -men of good standing; and this reform has become -more important in view of the steadily increasing complexity -of the medical work now undertaken in a large -public health department. It will include <i lang="la" xml:lang="la">inter alia</i> -the following officers and activities: superintendent -medical officers of health; district medical officers of<span class="pagenum" id="Page_65">[Pg 65]</span> -health; tuberculosis officers; medical officers of maternity -and child welfare centres, of venereal disease -centres; fever hospitals, and tuberculosis sanatoriums -and hospitals.</p> - -<p>The development of a graduated public health medical -service in which each physician employed will be -able to develop his own special abilities, will be easier -when to the above list is added the work of district -(late Poor-Law) medical officers; medical practitioners -attending insured persons and such other persons -as are treated at the expense of the State; treatment -centres for special conditions of the ear, eye, throat; -gynecological and other special departments; hospital -treatment for general diseases.</p> - -<p>That there will be development in these directions -when the tangle caused by the National Insurance Act -of 1911 has been unravelled, there can be no doubt.</p> - -<p>I have in Lecture IV expressed my opinion as to -the additional tangle introduced into the central and -local government of the United Kingdom by the National -Insurance Act of 1911.</p> - -<p>The failure of the British Government to act on the -recommendations of the Poor-Law Commission of -1909 was a serious misfortune to public health. Sickness -is the cause of a predominant part of our total -destitution, and to allow the continued separation of -administrative action respecting these two problems is -inconsistent with a full measure of success. Political<span class="pagenum" id="Page_66">[Pg 66]</span> -circumstances, however, led to the adoption of a course -which, medically, ran directly athwart the course of -needed reform.</p> - - -<h3><em>The National Insurance Act and Public Health</em></h3> - -<p>The National Insurance Act was passed, placing -one-third of the total population (all employed manual -workers and other employed workers with an income -below £160, since increased to £250) under an obligation -to pay 4d weekly (women 3d), 3d being contributed -for each person by the employer and 2d by the -State. In return each worker receives a money payment -weekly during disability from illness, attendance -by a doctor, sanatorium treatment for tuberculosis, and -a maternity benefit on the birth of a child to his wife -(30 shillings), or, if the wife also is industrially employed, -an additional 30 shillings. The medical benefit -is limited to such domiciliary attendance as a medical -practitioner of average ability can furnish. It continues -the old popular conception of private medical -practice, and allows the public to remain obsessed with -the notion that satisfactory medical care consists in a -“visit and a bottle.” No provision is made for pathological -aids to diagnosis, beyond what is already provided -by public health authorities. No nurses are -available for serious cases; the insured person is not -entitled to surgical operations, when needed, except of -the simplest character. With few exceptions, no appliances<span class="pagenum" id="Page_67">[Pg 67]</span> -are provided; the treatment of special diseases -of the eye, ear, nose and teeth is commonly excluded. -No hospital provision whatever, except for tuberculosis, -is made.</p> - -<p>The contract system of medical practice has been -accompanied by a serious amount of lax certification -of sickness. The sanatorium benefit is unnecessary, -as soon as the duty of public authorities to provide -treatment for tuberculosis is declared obligatory. It -is already very largely provided. The maternity benefit -is entirely unconditional; there is no guarantee -that it is devoted to the welfare of the mother and -infant. It needs to be supplemented or replaced by -the arrangements for providing nurses, doctors, midwives, -and domestic assistance which are in process of -development by public health authorities. In short, -there is no justification for providing medical services, -preponderantly at the expense of the state (contributions -by employers are a form of taxation), which are -limited to a favored portion of the total population, -and which do not benefit all in need of these services.</p> - - -<h3><em>Provision for Sickness</em></h3> - -<p>The principle of monetary insurance against sickness -and disability is thoroughly sound. It forms a -praiseworthy and valuable provision against future -contingencies. Insurance, however, is not synonymous -with prevention as is too often suggested. In<span class="pagenum" id="Page_68">[Pg 68]</span> -England insurance has been an actual impediment to -public health work, though it might have gradually -become a useful auxiliary to it if otherwise organized, -and especially if the creation of independent insurance -committees representing interests to a preponderant -extent had been avoided. But any medical service -needed for purposes of insurance should not form part -of the insurance system. Medical aid is needed for a -large section of the population who are unable to afford -deductions from their wages, or who have no -wages. It is needed for wives and children as much -as for the industrially employed head of the household; -and it is needed for many others who are excluded -from the scope of the National Insurance Act. -Only when the medical is separated from the insurance -service, and when the medical practitioner, as far as -practicable, is made independent of the patient who -desires too facile a sick-certificate, will good medical -work and sound sickness insurance be secured.</p> - - -<h3><em>General Summary</em></h3> - -<p>The preceding review of the history of public health -in England is necessarily fragmentary. It does not -include, for instance, a discussion of the relationship -of the medical profession to public health authorities. -On this I content myself with repeating my oft stated -opinion that until every medical practitioner is trained -to investigate each case of illness from a preventive<span class="pagenum" id="Page_69">[Pg 69]</span> -as well as from what is often rather a pharmaceutical -than a really curative standpoint, until a communal -system of consultant and hospital services independent -of any insurance system is made available for all -needing it, and until every medical practitioner is related -by financial and official ties to this communal -system, full control over disease,—to the extent of our -present available medical knowledge,—will not be -secured.</p> - -<p>The communal system will include not only the provision -of domiciliary nurses for all needing them, but -also a greatly increased staff of public health nurses -engaged in educational supervision in connection with -the work of the communal services and of each individual -practitioner. Such a system will repay the -community manifold in improved health and in a -higher standard of happiness and well being.</p> - -<p>If objection is taken to such wide sweeping proposals, -let me remind you that free communal services of -sanitation and education are already provided; and -that the care of personal health is of equal importance -with these. All will agree that a large proportion of -the population cannot afford to pay individually for -medical attendance and nursing under present conditions, -still less for the consultant and hospital services -which advances in medical service have rendered indispensable. -There is always present in our midst a -large mass of illness which might have been avoided<span class="pagenum" id="Page_70">[Pg 70]</span> -or curtailed, had there been an organized system of -state medicine.</p> - -<p>Lest there should be alarm as to the possible consequences -of the coöperative provision on such a scale -of this primary need of humanity, let me also remind -you that coöperative medical aid differs from financial -aid in an essential particular. It does not create a demand -for further aid, but is always engaged in diminishing -this demand. Dependency on financial -assistance is liable to continue indefinitely; much wants -more. This result of medical aid is almost inconceivable. -The Reverend Doctor Chalmers, of Glasgow, -said early in the last century: “Ostensible provision -for the relief of poverty creates more poverty. An -ostensible provision for the relief of disease does not -create more disease.”</p> - -<p>Doctor Chalmers was opposed to the giving of any -domiciliary assistance from rates or taxes, and he -organized his parish so that every needy person was -adequately helped out of charitable funds. But he -advocated extended hospital and other medical assistance -for the poor; and until this is done, apart altogether -from any system of insurance, and as a complete -measure on the lines of our educational system, -we cannot say that all that is practicable has been done -to secure the physical well being of our fellow citizens.</p> - -<p><span class="pagenum" id="Page_71">[Pg 71]</span></p> - - -<div class="footnotes"><h3>FOOTNOTES:</h3> - -<div class="footnote"> - -<p><a id="Footnote_5" href="#FNanchor_5" class="label">[5]</a> An Address at the Forty-seventh Annual Meeting of the -American Public Health Association, New Orleans, October -27, 1919.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_6" href="#FNanchor_6" class="label">[6]</a> The importance of this is seen in the fact that there are in -England and Wales 14,614 parishes, and only 646 unions for -the relief of the poor.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_7" href="#FNanchor_7" class="label">[7]</a> Rumsey: Essays in State Medicine, 1856, pp. 190, 277, 282.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_8" href="#FNanchor_8" class="label">[8]</a> Goodnow: Municipal Problems, p. 226.</p> - -</div> -</div> - - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<h2 class="nobreak" id="CHAPTER_III">CHAPTER III<br><br> -<span class="smcap fs80">The Increasing Socialization of Medicine</span><a id="FNanchor_9" href="#Footnote_9" class="fnanchor">[9]</a></h2> -</div> - -<p>Medicine has always been the most altruistic of -learned professions; and can proudly claim that its -practitioners have ever been ready to give gratuitous -assistance to all in need of it. Even more than when -Burton wrote his Anatomy of Melancholy—for then -medicine was an art with but limited foundation in science—physicians -can be defined as “God’s intermediate -ministers”; and can rightly assume the proud -position which Burton gives them:</p> - -<div class="blockquot fs80"> - -<p>Next, therefore, to God, in all our extremities (<em>for of the -Most High cometh healing</em>, Eccles. XXXVIII, 2) we must -seek to, and rely upon, the Physician, who is the <i lang="la" xml:lang="la">Manus Dei</i> -(the Hand of God), said Hierophilus, and to whom He hath -given knowledge, that he might be glorified in his wondrous -works.</p> -</div> - -<p>Each medical practitioner in his own circle, and to -the extent of his medical competence, is a medical officer -of health, having more influence in directing and -controlling the habits, occupation, the housing, the -social customs, the dietary and general mode of life of -the families to which he has access, than any other<span class="pagenum" id="Page_72">[Pg 72]</span> -person. It must be added that in most instances he -has even more influence than the minister of religion -in regulating the ethical conduct of his patients, especially -as regards alcoholism and sexual vices. In the -United States the federal government has relieved the -medical profession from their duty of restricting individual -alcoholic consumption, and an experiment has -been begun which if continued—and I trust nothing -will prevent this—must forthwith reduce the income of -practising physicians throughout the American continent, -and at the same time do more to diminish crime, -accidents and sickness and to increase national efficiency -than any other single step that could be taken, -with one exception. This would consist in the universal -raising of the standard of sexual conduct of -men to that which they expect from their future wives, -thus securing a rapid reduction and early disappearance -of gonorrhoea and syphilis, diseases which rank -with pneumonia, tuberculosis and cancer as chief -among the captains of death and disablement in our -midst.</p> - -<p>The growing possibilities of improvement in personal -and social welfare depend very largely on the -extent to which, as I have put it elsewhere, “each -practitioner becomes a medical officer of health in the -range of his own practice.” Even on their present -record, if—at least on one side—the Kingdom of God -consists in “the union of all who love in the service<span class="pagenum" id="Page_73">[Pg 73]</span> -of all who suffer,” medical men can proudly and yet -humbly take their place as essential agents in the daily -fulfilment of the daily prayer, “Thy Kingdom come.”</p> - -<p>It is perhaps desirable to attempt at this stage a definition -of the sense in which I employ the term socialization -of medicine. In it I would include the rendering -available for every member of the community, -irrespective of any necessary relation to the ordinary -conditions of individual payment, of all the potentialities -of preventive and curative medicine. Within the scope -of medicine are included the basic sciences of physiology -and pathology; and the instruction and training of -every child and young person in elementary hygiene, -including dietetics, necessarily come also within the -range of our subject.</p> - -<p>There are still agnostics, usually of exclusively classical -and mathematical education, even among men -holding official sanitary administrative positions, who -doubt the value of the application of medical knowledge -to the extent indicated; and it becomes desirable, -therefore, briefly to refer to some results already -obtained by the application of preventive and curative -medicine.</p> - - -<h3><em>The Past Achievements of Medicine</em></h3> - -<p>The increasing span of life is scarcely realized as it -should be. Addison’s description of the bridge of -human life, in his Vision of Mirza, is familiar. Its<span class="pagenum" id="Page_74">[Pg 74]</span> -seventy to a hundred arches support a bridge which is -interrupted by broken arches and hidden pitfalls, set -very thick at the entrance of the bridge, thinner towards -its middle, but multiplied and laid close together -towards its further end. Preventive medicine is gradually -repairing the broken arches of earlier life; with -the prospect of rapid reduction of tuberculosis, of -syphilis and gonorrhoea, the removal of pitfalls and -the repair of both earlier and middle arches are ensured, -if the knowledge we already possess is applied; -and although pneumonia and cancer still erode and -render unsafe the arches of middle and later adult life, -we have already advanced far towards the ideal of -euthanasia in old age.</p> - -<p>I may be excused from quoting English figures, as -our vital statistics are more accurate and complete -than those hitherto available for the United States. -Parenthetically, may I say that it is a continual source -of astonishment to me that in some American states -death statistics, and in many more states birth statistics -should still be so dubious in their quality as to cause -hesitation in utilizing them. And this in a country -which in other respects combines the highest business -qualities with an underlying idealism which emerges in -important crises!</p> - -<p>Between 1871-80 and 1910-12 in England the average -expectation of life at birth for males increased -from 41.4 to 51.5, for females from 44.6 to 55.4,—an<span class="pagenum" id="Page_75">[Pg 75]</span> -increase within three or four decades of 10 or 11 -years in average duration of life. The annual saving -of life shown by these figures means that the persons -whose lives <em>each year</em> are thus saved in England from -premature death, have the prospect of living in the -aggregate nearly ten million additional years of life, -of which the greater part will be lived during the -working period of life.</p> - -<p>But perhaps more striking than collective statistics -are the illustrations of unnecessary premature mortality -with which history and literature in the Georgian -and Victorian period supply us. Many such instances -will occur to you. William Pitt died at the age of -47, Charles James Fox at 57. The history of the -Brontë family, given the clue that tuberculosis was at -work, can be seen on the tablet which I have often -read in Haworth Church. Each sister and the brother -died in steady succession at intervals of two and three -years; the only exception being Charlotte, who had -lived much away from home, and who died at the age -of 39 of unrestrained vomiting, a condition which -probably would not have been allowed to kill the expectant -mother today. Robert Burns died at the age -of 37, Keats at the age of 26. Lord Byron on his -thirty-third birthday, only three years before his death, -wrote as a man already “in the sere and yellow leaf”</p> - -<span class="pagenum" id="Page_76">[Pg 76]</span> - - -<div class="poetry-container2 fs80"> -<div class="poetry"> - <div class="stanza"> - <div class="verse indent4">Along life’s road, so dim and dirty,</div> - <div class="verse indent4">I’ve travelled till I’m three and thirty;</div> - <div class="verse indent4">And what has this life left for me:</div> - <div class="verse indent4">Nothing but my thirty-three.</div> - </div> -</div> -</div> - - -<p>Did time permit, the claims of preventive medicine -might be illustrated in the facts as to the almost complete -annihilation of typhus fever in this country and -in Great Britain, under the influence of hospital segregation -of each case, of supervision of contacts, and of -increased national cleanliness; in the rapid reduction -of enteric fever brought about by pure water and milk -supplies, the avoidance of sewage-contaminated shell-fish, -the control of carriers among food handlers, and -the hospital immobilization of cases; and in the almost -complete abolition of smallpox, secured by prompt -recognition, notification and isolation of each case, the -searching out and vaccination of all contacts, and their -continued surveillance. The list of medical triumphs, -especially in tropical diseases, might easily be extended. -I do not fail to remember that respiratory infections -have hitherto proved refractory to preventive measures; -and that common catarrh, pneumonia, and still -more influenza—as also cerebro-spinal fever and poliomyelitis—constitute -territories on which the flag of -public health has not yet been firmly placed. Tuberculosis -must not be thought of in the same category. -It is a controllable disease, so soon as physicians, public -health authorities and the patients themselves will -combine on an adequate scale to adopt measures -already within reach. These measures will be less<span class="pagenum" id="Page_77">[Pg 77]</span> -costly than the present position of partial inertia; -health is always less costly than disease, and, as Dr. -Herman Biggs has often reminded us, can be purchased -within natural limits, to the extent which we -really desire. This is preëminently true for tuberculosis.</p> - -<p>Medical triumphs have not been restricted to preventive -medicine. Time would fail me to speak of -the introduction of general anaesthetics by Morton -and Simpson, which has rendered possible the reaping -of the full harvest of the work of Pasteur and Lister. -Conversely modern surgery has itself abolished more -pain than anaesthetics themselves.</p> - -<p>The chief triumphs of modern curative medicine -and surgery have been rendered practicable by the -more accurate study of disease and the more skilled -attention for the masses of the population obtainable -in hospitals. The steady advance in the provision of -skilled nursing has kept pace with medical advance.</p> - - -<h3><em>Increasing Importance of Hospitals</em></h3> - -<p>From a return prepared by the Local Government -Board in 1915 it appears that the number of hospital -beds in England and Wales (not including lunatic asylums, -tuberculosis institutions, or convalescent or nursing -homes) was 4.9 per 1,000 of the population. In -the United States, according to the Modern Hospital -Year Book for 1919, the number of hospital beds<span class="pagenum" id="Page_78">[Pg 78]</span> -amounts to 6 per 1,000 of the population, or 3.4 per -1,000, excluding beds for mental and nervous cases. -It is not certain that the two sets of figures are comparable; -but in both instances the distribution of hospital -provision is very unequal, and large tracts of -each country are left unprovided with available hospital -accommodation.</p> - -<p>Hospital services have grown in a manner which is -characteristic of the Anglo-Saxon: first largely under -voluntary management, and as examples of Christian -charity; afterwards continued in the same way, but -followed by official provision of hospitals on an even -larger scale, the two systems working side by side. -The extent to which the more satisfactory institutional -treatment is replacing the domiciliary treatment of -disease may be gathered from the striking facts that -in England and Wales one in every nine of the deaths -from all causes in 1881 occurred in public institutions, -and in 1910, one in every five; while in London the -proportion increased from one in five in 1881 to two -in five in 1910.</p> - -<p>The facts as to pulmonary tuberculosis are even -more significant. In the year 1911 in England and -Wales 34 per cent. of male and 22 per cent. of female -and in London 59 per cent. of male and 48 per cent. -of female deaths from pulmonary tuberculosis occurred -in public institutions. As each of the patients, -who thus had the solace of good nursing and treatment<span class="pagenum" id="Page_79">[Pg 79]</span> -when they were needed most, spent on an average -several months in hospitals, at the most infectious -stage of their illness, an important annual reduction -in the possibility of massive infection of relatives and -others has also been secured.</p> - - -<h3><em>Hospitals as a Partial Solution of Housing Difficulties</em></h3> - -<p>We may fairly claim that general and special hospitals -have been important agents, not only in reducing -the fatality of disease, and in restoring to efficiency -more rapidly than in the past a large proportion of -the total population; but also in reducing the incidence -of tuberculosis, of syphilis, and of other diseases.</p> - -<p>The public indebtedness to hospitals has another -aspect, too often overlooked. The aggregation during -the last hundred years of a steadily increasing proportion -of our population in crowded towns has meant -the introduction on a gigantic scale of elements inimical -to health. Smoke and obscuration of sunlight, -dust and noise, the substitution of indoor for outdoor -occupations, the difficulties of milk supply for children, -and above all inferior housing with associated increased -facilities for infection, have combined to render -healthy life in towns difficult of attainment. Nor -must we omit from the adverse side of the balance -sheet the greater loneliness of family life in towns, the -diminution in neighbourliness, and the failure of public -social opinion to produce the wholesome effect on conduct<span class="pagenum" id="Page_80">[Pg 80]</span> -which it exercises in village life. And yet, notwithstanding -these factors, urban death-rates and -especially tuberculosis death-rates have declined more -than rural death-rates, and in parts of some countries -urban is even lower than rural mortality.</p> - -<p>Why is this? Our hospitals provide the key to the -mystery. Parturition is freer from risk in town than -in remote country districts; the means for the prevention -of infection are better organized, and accident and -disease are more promptly and more efficiently treated. -The poor in towns receive as a matter of course in -hospitals better treatment gratuitously than king or -president could command thirty years ago. The relief -to housing deficiency given by hospitals comes when -most needed, in the emergencies of child-bearing and -of sickness; and the net result of this and of better -sanitary supervision is that although room-accommodation -for families is much more restricted in towns -than in country districts, the town-dwellers have a -large share of their urban handicap removed by their -superiority over country people in medical treatment.</p> - - -<h3><em>The Continuing Mass of Preventible Disease</em></h3> - -<p>The medical record of the past on the side of preventive -medicine is one of increasing control over infectious -diseases. In securing this result epidemiologists, -pathologists, and vital statisticians can rightly -claim first place, aided by the sanitary and industrial<span class="pagenum" id="Page_81">[Pg 81]</span> -inspector and the sanitary engineer; the epidemiologist -being dependent largely on the work of the pathologist -and of the statistician for guidance in his field investigations, -which have led to the discovery and removal -of numerous sources and channels of infection.</p> - -<p>The record in curative medicine, especially on its -surgical side, is one of increasing triumph over serious -disease and injury, in which the discovery of anaesthetics -and of Listerism have borne an essential part.</p> - -<p>None of us can, however, be satisfied with the success -already obtained, and I have elsewhere given -reasons for concluding that at least one-half of the -mortality and disablement still occurring at ages below -70 can be obviated by the application of medical -knowledge already in our possession.</p> - -<p>The Great War has shown both in Great Britain -and in America the extent to which defects and disease -exist in would-be recruits to our armies. In the -United Kingdom only two-fifths of a large section of -recruits could be placed in the first grade; and among -American recruits out of two and one-quarter million -men measured and examined physically at local boards -29.1 per cent. were rejected on physical grounds; -though in the introduction to the Official Bulletin (No. -11, March, 1919) it is pointed out that many of the -disabilities have little importance in civil life, and that -these considerations possibly “reduce to 15 per cent. -the proportion of males 20 to 30 years old who carry<span class="pagenum" id="Page_82">[Pg 82]</span> -a serious handicap against normal activity in civil -occupations.”</p> - -<p>These figures, whatever doubt may attach to their -exact arithmetical value, signify the existence in the -community of a large amount of physical disability -which must greatly reduce the sum of national efficiency -and happiness. The records of our medical -examinations of school children bring out the same -fact, and emphasize the necessity not only for school -clinics on an immensely larger scale than at present, -but also for additional medical and nursing care in -connection with child-bearing and during the pre-school -period, which would discover defects and disease -at an earlier stage, and would secure the provision -not only of early preventive treatment, but also of -more systematic improvement of the sanitary environment -of maternity and childhood.</p> - - -<h3><em>Present Extent of Socialization of Medicine</em></h3> - -<p>A mental effort is needed to realize the distance -traveled in the public provision of medical assistance -in the United Kingdom by the state and by voluntary -organizations, including the committees of hospitals, -convalescent homes, dispensaries, etc., prior to the -passing of the National Insurance Act of 1911. I -have already given some illustrative figures regarding -hospitals. The <cite>Lancet</cite> some years ago gave a statement -of the number of attendances of patients at voluntary<span class="pagenum" id="Page_83">[Pg 83]</span> -hospitals in London during the year 1908. -Assuming that each out-patient made five attendances, -that all in-patients had previously been out-patients -and that no patient received a hospital or dispensary -letter more than once in the year, it could be inferred -that a number equivalent to one in four of the total -population of London had received free medical aid -in these voluntary institutions during that year. And -this did not include the large mass of treatment given -gratuitously in poor-law infirmaries, public-health fever -and tuberculosis hospitals, and lunatic asylums.</p> - -<p>The majority of the medical profession in Great -Britain is engaged in either whole-time or part-time -service for the state or for local authorities. Of the -24,000 medical practitioners in England and Wales, -some 5,000 are engaged as poor-law doctors, some -4,000 or 5,000 in the public-health service, possibly -500 in the lunacy service, some 1,300 in the school -medical service, and smaller numbers in various other -forms of medical service for the state. This is exclusive -of the general practitioners who undertake -contract work under the National Insurance Act, and -who cannot fall far short of three-fourths of the total -membership of the profession. It should be noted -that many doctors hold several appointments.</p> - -<p>The state has, quite apart from National Insurance, -given a rapidly increasing amount of medical assistance -to the public.</p> - -<p><span class="pagenum" id="Page_84">[Pg 84]</span></p> - -<p>1. Under the Poor Law, every destitute person is -entitled to gratuitous medical attendance, at home or -in an institution, and after a fashion has received this -during the last century.</p> - -<p>2. The institutional treatment of lunacy has grown -to an extent which permits the treatment in an asylum -of every certified lunatic.</p> - -<p>3. The treatment at the expense of the state of -feeble-minded persons is rapidly increasing.</p> - -<p>4. Public health authorities provide institutional, -and to a limited extent domiciliary, treatment of infectious -diseases, this treatment being given, as in the -preceding cases, in nearly every instance gratuitously.</p> - -<p>5. To some extent prior to, and to an increased -extent since, the passing of the National Insurance -Act, sanatoriums and hospitals for the treatment of -tuberculosis are provided by the public health authorities, -the central government contributing to the local -authority undertaking this duty one-half of all approved -expenditure on these institutions, on tuberculosis -clinics, and of the expenses incurred in the domiciliary -nursing and supervision of tuberculosis patients.</p> - -<p>6. Similarly the central government pays one-half -of the approved expenditure incurred by local authorities -or in certain cases by voluntary agencies in assistance -given in aid of maternity and child welfare, e.g., -in the provision of midwives, of consultant doctors, -of lying-in homes and hospitals, of beds for præpartum<span class="pagenum" id="Page_85">[Pg 85]</span> -treatment, of convalescent homes for mothers or -their children, of infant consultations and clinics, etc.</p> - -<p>7. In regard to venereal diseases the central government -has gone still further. It has made it obligatory -on the larger local authorities to provide facilities for -pathological diagnosis, and for the treatment of patients -suffering from these diseases irrespective of any -residential or financial limitations. Arseno-benzol -preparations are given gratuitously to medical practitioners, -as also laboratory assistance in diagnosis. To -ensure the success of the local arrangements the central -government pays three-fourths of their total cost; -and have passed an act which prohibits the treatment -of venereal diseases by any unqualified person, as also -the advertisement or sale of any remedies for these -diseases.</p> - -<p>8. Many public health authorities provide gratuitous -assistance to medical practitioners in the bacteriological -diagnosis of tuberculosis, enteric fever, diphtheria, -etc. Recently Wasserman tests and searches -for gonococci and spirochaetes have been added. In -1914 plans for further development, including the provision -of complete clinical laboratories for the gratuitous -use of practitioners had been planned, and the -necessary grant had been obtained from Parliament; -but the war led to the plans remaining in abeyance. -At the same time government grants in aid of nursing, -and of the provision of consultants and referees for<span class="pagenum" id="Page_86">[Pg 86]</span> -insured patients were passed, but were similarly held -in abeyance.</p> - -<p>9. The local education authorities provide for the -medical inspection of each scholar in elementary day -schools several times during the nine years of his compulsory -attendance at school. Parents are advised as -to treatment needed, in suitable cases are referred to -hospitals (payment being made by the education authorities), -and for an increasing number of conditions -actual treatment is provided at school clinics (teeth, -eyes, ringworm, etc.).</p> - -<p>The above enumeration, which does not include the -recently necessitated activities of the Pensions Department -for sailors and soldiers, and those under the National -Insurance Act, is not otherwise complete; but -it serves to indicate that the state is already committed -very deeply to provide for the medical needs of the -community. That the work done on behalf of the -community, <em>plus</em> the work accomplished by private -medical practitioners, is not equal to national needs is -obvious to any one considering the vast amount of -avoidable disease in our midst. Why is this and what -is the remedy? A partial answer is given by English -experience. The medical provision made in a large -proportion of cases is belated and inadequate; and in -perhaps a still larger proportion of cases medical advice -is not obtained, or being obtained, is not followed. -This applies even more to hygienic than to clinical -medical advice.</p> - -<p><span class="pagenum" id="Page_87">[Pg 87]</span></p> - - -<h3><em>Destitution and Sickness</em></h3> - -<p>It was one of the greatest misfortunes in the history -of medicine in England that poor law medicine and -public health medicine were not administratively combined -when the Local Government Board was formed -in 1870, and that the preventive ideals of public health -were not allowed to operate in the treatment and supervision -of the destitute. Although there has been -a fairly steady improvement in the conditions of medical -treatment under the poor law, its association with -the deterrent general policy of that department of -state, as well as its actual defects, culminated in the -appointment of a royal commission of inquiry, which -in 1909 presented reports recommending the abolition -of the local boards of guardians and transference of -their duties to the larger public health authorities.</p> - -<p>Behind these proposals of the royal commission lay -the absolutely sound principle—which many years previously -had been recognized by the pioneers of public -health—that the treatment and the prevention of disease -cannot administratively be separated without injuring -the possibilities of success of both. The public -health activities preceding the report of the royal commission -illustrate this axiom, such as the isolation and -treatment of infectious cases, the treatment of tuberculosis, -the provision for the care of parturient women -and of their infants, and the medical inspection and -treatment of school children.</p> - -<p><span class="pagenum" id="Page_88">[Pg 88]</span></p> - -<p>It was an even greater misfortune to the satisfactory -progress of public medicine that the report of the royal -commission on the poor laws was not followed by legislation -on the lines of its recommendations. So much -of destitution is associated with sickness, and sickness -is the cause of such a preponderant share of the total -destitution in our midst, that the continued administrative -separation of the two problems of poverty and -sickness is inconsistent with a full measure of success.</p> - -<p>Had the transfer of the duties of the poor law authorities -to the councils of counties and county boroughs -been adopted, and ancillary legislation enacted, -the public health organization would have at once -possessed a medical service for the poor of some 4,000 -doctors, in addition to the doctors already engaged in -the public health service; it would have had large infirmaries -and the other medical institutions of both -services; would have been able to make liaison working -arrangements with the committees of voluntary -hospitals; and there would have been secured a greatly -improved medical service, freed from poor-law -shackles, which could gradually be extended as needs -and policy indicated.</p> - - -<h3><em>Insurance versus Public Health</em></h3> - -<p>Political circumstances led to the adoption of a -course which medically ran directly athwart the course -of needed reform. The National Insurance Act of<span class="pagenum" id="Page_89">[Pg 89]</span> -1911 was passed, giving sickness and invalidity benefits -to all employed manual workers and to others below -an income limit of £160 (recently increased to £250), -who could contribute a weekly sum which was considerably -less than half of the estimated cost of the -benefits to be received; and a new medical service was -created, further complicating administratively the already -existing medical services of the poor law, public -health, and educational authorities, and converting the -majority of general practitioners into part-time civil -servants.</p> - -<p>The case is an illustration of the moral contagiousness -under modern conditions of life, of a new course -adopted in any country. Bismarck’s attempt to counteract -socialism by insurance has been responsible for -state and official experimentation in insurance in -many countries, which at least in England was not -actuarially, financially, or medically sound, and which -has involved expenditure in administration entirely incommensurate -with the benefits received.</p> - -<p>Insurance against sickness and disability is a praiseworthy -and valuable provision against future contingencies. -I am not concerned here to point out inequalities -to the insured in the English Insurance Act -inherent in the apportionment of a flat rate for all -ages, districts and occupations, and for both sexes, -irrespective of known or suspected incidence of sickness, -nor the difficulties created by continuing the nonlocalized<span class="pagenum" id="Page_90">[Pg 90]</span> -work of friendly societies and other private -organizations, and at the same time creating local insurance -committees, who furthermore were not organically -related to local health authorities, and had no -opportunity, therefore, to develop the conceivable potentialities -of insurance experience as an aid to public -health work. The act in its present form is now generally -condemned; and it is significant that the need -for its radical reorganization appears to be universally -accepted.<a id="FNanchor_10" href="#Footnote_10" class="fnanchor">[10]</a></p> - -<p><span class="pagenum" id="Page_91">[Pg 91]</span></p> - -<p>Two medical benefits (medical and sanatorium) and -a maternity benefit were conferred under the act; but, -as they have been administered, it cannot be affirmed -that any marked public benefit has accrued; and it is -certain that if the same amount of money had been -placed in the hands of public health authorities to provide -adequate medical aid to those needing it, of the -kind most lacking and which they could least afford -to obtain, great benefit to the public health would have -been secured.</p> - -<p>What was given? (1) There was the medical benefit, -each insured person being entitled to the services<span class="pagenum" id="Page_92">[Pg 92]</span> -of a medical practitioner of his own choice (a “panel” -doctor). The services given were limited by regulation -to mean such medical attendance as is “within -the ordinary professional competence and skill” of a -medical practitioner; and so the treatment given has -often been more limited than what is given by the -more advanced poor law authorities. The latter can -supply hospital treatment and expert assistance when -required; under the insurance system no such provision -is made. The insured patient is not entitled -to surgical operations when needed, except of the simplest -character; treatment of eye, ear, nose and teeth -conditions is commonly excluded; no appliances are -given except a few bandages and simple splints; and -there are no facilities for modern scientific laboratory -investigation, except those provided gratuitously by -public health authorities. Furthermore, by the rules -of most friendly societies sickness (monetary) benefit -during treatment of illness due to the patient’s misconduct -is excluded.</p> - -<p>The title of the act—National (Health) Insurance -Act—has hitherto proved a misnomer. The panel or -contract system of medical treatment of insured persons -has done much to continue the obsession of the -public with the conception of medical care as consisting -of a “visit and a bottle”; and so long as the -doctor’s medical work is on the present basis, and he -is under the constant temptation, not only to accept<span class="pagenum" id="Page_93">[Pg 93]</span> -more patients on his panel than he can satisfactorily -treat and to give each patient on application the mental -satisfaction of a “bottle,” but also to be more than -lenient in the giving of sickness certificates, it will -remain questionable whether on the balance state insurance -against sickness does more good than harm. -If medical consultants and referees, treatment centres, -and hospitals are in the future provided for insured -patients, this will mitigate the evils of the panel system; -but the present contributions of patients will not -purchase this additional provision. All the new money -needed, and most of the money needed under present -conditions, must continue to be provided by the state -and employers of the insured (a form of taxation); -and provisions thus made, like the present contributions -of the state for insured persons, are in direct -contravention of the general principle that government -grants being derived from the whole community, -should enure to the benefit of the whole community -in need of them, and not only to the benefit of a section -of it.</p> - -<p>About one-third of the total population of Great -Britain is included within the terms of the National -Insurance Act. If the wives and children of insured -men were also included, as has been proposed, over -two-thirds of the total population would be embraced -in the scheme; but as persons manually employed, but -working for themselves—e.g., cotters and hawkers, are<span class="pagenum" id="Page_94">[Pg 94]</span> -encluded, and as persons not manually employed cannot -be insured unless their income is below £160 (recently -raised to £250), large classes of the population -who can ill-afford to pay for their own medical attendance -are excluded from the operation of the act, -and taxed to pay the benefits of insured persons.</p> - -<p>(2) The sanatorium benefit was intended to secure -for the insured person special treatment for tuberculosis, -while capital sums were provided for the erection -of sanatoria and hospitals for consumptives for -insured and non-insured alike. Fortunately during the -passage of the bill, the provision of these institutions -for insured persons was delegated to public health -authorities; and as it was already within the power -of these authorities to provide such institutions and -tuberculosis clinics for the entire population, and as -the infection of tuberculosis is no respecter of parliamentary -distinctions between insured and non-insured, -there was little difficulty in persuading the government -to promise half the total approved local expenditure -on the treatment of tuberculosis in institutions, whether -this was given to insured or non-insured persons. Indeed -when local authorities were willing to undertake -their share in a complete scheme for the treatment of -tuberculosis an insured consumptive person might be -regarded even as paying fractionally for his treatment -while a non-insured person received such treatment -gratuitously.</p> - -<p><span class="pagenum" id="Page_95">[Pg 95]</span></p> - -<p>(3) The maternity benefit, conferring thirty shillings -on the wife of an insured person, and an additional -thirty shillings if she also is an employed person -within the meaning of the act, on the birth of her infant, -was perhaps the most popular benefit under the -act. The money was given unconditionally, and thus -an opportunity was lost of insuring that the benefit -should improve maternal and infantile prospects.</p> - -<p>Collaterally public health authorities, central and -local, were beginning to organize medical and nursing -assistance during pregnancy, in confinement and afterwards -for the mother, and similar assistance on a large -scale for infants and children under five years of age. -And there will, I think, be no hesitation in agreeing -that the <em>supply of service</em> at this critical period of the -mother’s and infant’s life, so as to insure the most -satisfactory recovery of parent and the best start in -infantile life, is infinitely more important than a money -grant.</p> - -<p>I cannot pretend to have more than touched on the -fringe of the complicated subject of insurance in relation -to public health. The inauguration of the act -meant an enormous increase in the direct relationship -of the medical profession to the state. A great stride -in the socialization of medicine was taken. But it was -done ill-advisedly; it continued a false and low ideal -of isolated general medical practice; it has even been -described as a fraud on the insured, in view of the<span class="pagenum" id="Page_96">[Pg 96]</span> -incompleteness of the medical service provided; and -it diverted into an unsatisfactory channel the energy -and money which were urgently needed for the immense -good obtainable by reform of poor law and -public health administration, and extension of their -medical services. Had the lines indicated by history -and experience and by the report of a strong royal -commission on the poor law—there was a majority -and a minority report, but both agreed in the chief -essential points—been followed, England would now -possess a nearly completely unified state medical service, -instead of standing at the point whence false steps -need to be retraced, with a view to a coördinated and -simplified medical and public health policy. With the -principle of contributory insurance to secure monetary -support during illness there can be no quarrel; but in -the interest of national efficiency complete medical provision, -preventive and curative, must be made by the -state, irrespective of insurance, for all in need of it; -and the medical practitioners employed in the necessary -certification of such insurance work as is continued -must, if the insurance is to be satisfactory, be -employed under conditions which will render them -independent of the favor of the insured, and will enable -them to utilize their knowledge of each patient’s -case for the needed preventive measures, whether -these be concerned with the sanitation of home or factory -or workplace, or with personal habits.</p> - -<p><span class="pagenum" id="Page_97">[Pg 97]</span></p> - - -<h3><em>The Need of the Future</em></h3> - -<p>It is, I think, clear that the state will year by year -take an increasing hand in medical matters. It is useless, -even if it were desired, to attempt to oppose the -inevitable and the eminently desirable trend towards -vastly increased utilization by the state of medical science -in the interests of humanity. It is for physicians -to guide the course of events, and to insure that no -plant is sown which will afterwards need to be uprooted; -that no development is permitted which will -hinder the fulfillment of our ideal. Personal hygiene -forms a rapidly increasing part of public health work; -hence it is indispensable that all forms of public medical -service shall be linked up with the public health -service and controlled locally and centrally in accordance -with this. This may imply—and in England it -does imply—the urgent need for reform and reconstruction -of local as well of central public health administration; -but to attempt to separate medical from -public health provision is to repeat the blunders which, -despite skilled advice to the contrary, have been made -on two great historic occasions.</p> - -<p>A complete service, adequate to the needs of the -community, cannot be secured by a session’s legislation. -It must grow as the result of steady advance. -The motto in growth might well be, “First things -first.” What are the medical services which are provided -too sparsely at the present time and for which<span class="pagenum" id="Page_98">[Pg 98]</span> -the masses of the population cannot afford individually -to pay, except possibly to a fractional extent? There -can be no doubt as to the answer. What is most -urgently needed is the provision of skilled hospital -attendance for every patient who can be more satisfactorily -treated in hospital than at home. Next to this -comes the provision of gratuitous medical services—(e.g., -maternity and infant consultations, eye, throat, -ear, skin and venereal diseases, tuberculosis, X-ray departments) -preferably linked around a hospital, where -patients can be sent by private practitioners for an -expert opinion, or in certain cases may present themselves -independently. And as important as either of -the preceding desiderata, is the provision of a complete -nursing service, on which each private practitioner -can call for assistance as required, payment, if -any is exacted, being on the easiest possible conditions, -and not made compulsory.</p> - -<p>The hospital under such circumstances would become -a centre from which community work of the -highest value would radiate; and patients, private -practitioners, and the staffs of hospitals would alike -live in a new world in which the interest and efficiency -of medical work would be greatly increased. The -present irregular localization of hospitals makes the -realization of such a scheme difficult; but local partially -successful schemes are already in operation; -difficulties can be overcome with good-will; and eventually<span class="pagenum" id="Page_99">[Pg 99]</span> -we may hope to have for each unit of subdivided -public health administration and as an organic -part of this, a hospital, with out-patient or dispensary -clinics, and radiating from these the various forms of -medical attendance, domiciliary nursing, public health -nursing, and sanitary supervision which are needed.</p> - -<p>In securing such a result there will be needed medical -practitioners who are imbued with the ideals of -preventive medicine in its widest sense. Let me, in -this connection quote the following extract from a -recent official report of my own:</p> - -<div class="blockquot fs80"> - -<p>There is needed a reconstruction of the training of each -medical student, which will make preventive medicine in its -widest sense an integral part of his training, and will insure -that before he begins practice he has definite instruction in -the application of the whole of his knowledge to preventive -purposes. The past conception by the public of the relation -of medical men to the community—apart from the special case -of medical officers of health—has been mistaken. The doctor -has been regarded as a help when serious or acute incapacitating -illness occurs, and he has but seldom had the opportunity -of giving advice in the earlier and more controllable -stages of illness. His training has been conducted on the -assumption that his chief rôle should be on present lines, -with the result that most medical practitioners enter into practice -with a too scanty knowledge of hygiene and preventive -medicine, and have to learn slowly in belated experience the -influence of environment on the health of their patients. The -teaching of medicine should be much more largely physiological -and hygienic than at present, and such subjects as food -values, the hygiene of infancy and childbirth, the physiology -of breast feeding, and the influence of environment on the -health of their future patients should be the subject of careful<span class="pagenum" id="Page_100">[Pg 100]</span> -training—especially in regard to housing, feeding, clothing, -and conditions of work. Were this done, the ideal condition, -in which each medical practitioner becomes a medical officer -of health in the range of his own practice, would approach -realization.—[Annual Report to the Local Government Board, -1917-18.]</p> -</div> - -<p>Many medical practitioners already fulfill this ideal. -It would oftener be realized were it not for the excessive -work which many are obliged to undertake. -In the early history of public health in England poor -law medical officers, attending the impoverished in -their dwellings and familiar with their home conditions, -became part-time medical officers of health. -But the attempt to combine prevention and treatment -proved unsuccessful, because these officers visited only -a small proportion of the dwellings of the poor, because -they were not trained in preventive work, and -because the good seed of preventive work was choked -by the increasing demands of lucrative private practice. -In connection with the future general medical -service, curative as well as preventive, it is not beyond -the range of human ingenuity to provide schemes for -district medical officers (health and clinical) adequately -trained in public health work, and linked up closely -with the hospital and dispensary unit for their area.</p> - -<p>This will cost money. But sound health is our -greatest personal and national asset, and disease is -always more expensive than health. “Who winds up -days with toil, and nights with sleep” has “the forehand<span class="pagenum" id="Page_101">[Pg 101]</span> -and vantage of the king,” if the latter suffers in -body or mind. The real wealth of a nation does not -consist in its money, in the volume of its trade, or in -the extent of its dominion. These are only valuable -insofar as they help to maintain a population—and not -only a portion of it—of the right quality; men, women -and children possessing bodily vigor, alert mind, firm -character, courage and self-control. This ideal can -never be realized unless and until the medical men of -the future train themselves for and devote themselves -to their essential share in its fulfillment, and while -keeping this ideal in view see to it that every step -taken is one which will be consistent with the complete -scheme of the future.</p> - -<p>We are all concerned in the efficiency of every member -of the community, from an economic as well as -from a humanitarian standpoint. Can we be satisfied -while a large proportion of the population do not -obtain medical and ancillary assistance to the extent of -their needs? Does such a state of things conduce to -the settlement of social unrest? Is it consistent with -Christian principles?</p> - -<p>If communal provision has been recognized as a -duty for police protection, for sanitation, for elementary -education, should it not likewise be admitted for -the more subtle and maleficent enemies of health -which have been recognized, but which in no community -have hitherto been completely combatted?</p> - -<p><span class="pagenum" id="Page_102">[Pg 102]</span></p> - -<p>We scarcely realize how far we have gone in the -socialization of medicine. It is impossible to go back, -or to stand still. The services of the medical profession -are needed, not only to provide the necessary -service, but in helping to determine its conditions. -One essential item will be the substitution for fees -during sickness of an annual payment to private practitioners -by each family for supervising its members -in health, for inquiry into their industrial and domestic -life, so far as it contains elements inimical to health, -and for giving preventive more than curative advice. -The second and most urgent element consists in the -organization of hospital and consultative expert services -for all, which, while greatly increasing each patient’s -prospect of prompt recovery, will enable the -general practitioner to escape from the soul-destroying -inefficiency of unaided medical practice.</p> - -<p>Of course, any service provided, whether partial or -complete, will need to be kept free from “political -pull.” This spells inefficiency; and inefficiency means -disease and death. “Political pull,” although not in -the official list of Causes of Death, is among the potent -causes of excessive mortality; and for this, every one -of us must bear his individual share of responsibility, -insofar as we have abstained from active support of -sound and clean government, when we were unable -to take an actual share in government.</p> - -<p><span class="pagenum" id="Page_103">[Pg 103]</span></p> - - -<div class="footnotes"><h3>FOOTNOTES:</h3> - -<div class="footnote"> - -<p><a id="Footnote_9" href="#FNanchor_9" class="label">[9]</a> The Wesley M. Carpenter lecture delivered October 2, -1919, before the New York Academy of Medicine.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_10" href="#FNanchor_10" class="label">[10]</a> Thus Mr. Bishop Harman, an ophthalmic surgeon, and a -member of the Council of the British Medical Association, -says:</p> - -<p>“In my out-patient clinic 60% of the patients are insured -persons who attend for treatment that is essential to their -industrial efficiency.... A scheme of medical benefit which -does not provide for specialist service and for institutional -treatment is no scheme, it is poorer in status than the Poor -Law provision which does all these things.” (<cite>British Medical -Journal</cite>, Mar. 15, 19).</p> - -<p>Dr. R. Sanderson, of Brighton, writing on behalf of medical -practitioners, says:</p> - -<p>“We are the victims of a half-fledged, inadequate piece of -legislation which is founded apparently on the supposition that -disease can be dealt with effectually by giving bottles of medicine -or liniment to the sick, or that if this fails and the sick -get worse, they can be sent to one of the overcrowded voluntary -hospitals with which the legislature has nothing whatever -to do. Anything more unsatisfactory to the sick, or demoralizing -to us as a profession, it is hard to imagine.”</p> - -<p>He then proceeds to advocate an urgent need of the profession, -viz: the establishment of an adequate number of auxiliary -hospitals throughout the country, staffed by teams -of general practitioners, to which all practitioners can have -access, and to which they can send cases requiring clinical -observation of any kind, rest or treatment that cannot be -carried out in the sick person’s home. (<cite>British Medical Journal</cite>, -July 19, 19.)</p> - -<p>Dr. Howarth, Medical Officer of Health of the City of -London, and Dr. B. A. Richmond, Secretary of the London -Panel Committee, affirm “the limitation of medical benefit -to insured persons alone cannot continue. Another service -has been added to the many competing classes of state treatment”; -and they bring out the fact that personal contributions -of insured persons are swallowed up in supplying the sickness -and disablement benefit, and contribute nothing to the cost of -the sanatorium benefit, maternity benefit, or medical benefit.</p> - -<p>Dr. H. S. Beadles, Secretary of the Stratford & West Ham -Panel Committee, says: “The British Medical Association -should fearlessly acknowledge that the attendance under the -National Insurance Act, which is itself a part-time State -service, is an absolute failure and amounts to little more than -first aid, carried on at an enormous cost.”</p> - -</div> -</div> - - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<h2 class="nobreak" id="CHAPTER_IV">CHAPTER IV<br><br> -<span class="smcap fs80">Insurance and Health</span><a id="FNanchor_11" href="#Footnote_11" class="fnanchor">[11]</a></h2> -</div> - -<p>So far as a majority of the population are concerned, -it is necessary to realize that they are never far removed -from the line dividing destitution from adequacy, -using the word destitution to mean insufficiency -or lack of some provision essential for health and continued -welfare.</p> - -<p>It may be urged that this is owing in large measure -to the improvidence or thriftlessness of the wage-earners -who are chiefly concerned; but such a statement -fails to appreciate the higher standard of conduct -and the greater self-denial which is demanded from -weekly wage-earners than from ourselves, if out of -their wages provision is to be made for a “rainy day,” -without affecting unfavourably the present health of -the worker or his family.</p> - -<p>The general appreciation of the above considerations -has led to the provision of non-contributory old-age -pensions in the United Kingdom; and similar sentiments -have led in many countries to compensation -for accidents at the expense of employers; and to the<span class="pagenum" id="Page_104">[Pg 104]</span> -various national systems of insurance against sickness. -With the principle of sickness insurance there can be -no quarrel. It is the substitution of coöperative for -individual provision, thereby distributing some of the -loss and eliminating some of the risk of suffering from -illness.</p> - -<p>The value of any system of sickness insurance, however, -must necessarily be judged by several criteria.</p> - - -<h3><em>Criteria of Value of Insurance</em></h3> - -<p>Is the adopted system one which is equitable in its -incidence and economical in its administration; and -does it supply maintenance during sickness adequate -for the needs of the patient and his family, while at -the same time offering no temptation to the patient to -continue on the sick funds, when his condition no -longer necessitates this?</p> - -<p>In the case of the English National Insurance Act, -these questions unfortunately cannot be answered completely -in the affirmative.</p> - -<p>The finance of the Act arranges for the uniform -contributions (differing for each sex) from some thirteen -million persons, living under most diverse conditions, -to furnish equal benefits (differing for each sex) -to all insured persons, irrespective of age, locality, or -occupations; while at the same time some 23,000 independent -insurance societies continue to administer the -distribution of money benefits, each with its own segregated<span class="pagenum" id="Page_105">[Pg 105]</span> -experience, some prosperous, others owing to -excessive sickness almost bankrupt. There is the remote -possibility for each society to pay additional -benefits if justified on the quinquennial valuation.</p> - -<p>Substantially men and women have been placed on -a similar financial basis. The sickness of pregnancy -apparently was overlooked; and for this and other -reasons the insurance funds for women are financially -inadequate for the benefits promised.</p> - -<p>On the point of equity, it must be admitted that any -system of so-called insurance which, like that of the -English Act, excludes a large proportion of the population -who, while paying in taxes in aid of the insured, -require but do not receive their benefits, is contrary -to the principle that any expenditure of Government -funds should enure to the whole community in need -of the provision in question.</p> - -<p>The provision of 10 shillings a week for incapacity -lasting 26 weeks (7s. 6d for women), followed by 5s. -a week disablement benefit, although inadequate provision -for family maintenance during sickness undoubtedly -is helpful. It is mischievous when in consequence -of this provision, the patient is tempted to -remain at home under unsatisfactory domiciliary -treatment, instead of receiving the shorter and more -successful institutional treatment, which should have -been given.</p> - -<p>As to economy of administration, I can speak only -with reserve; but it requires little imagination to appreciate<span class="pagenum" id="Page_106">[Pg 106]</span> -that the numerous migrations of wage-earners -imply great difficulties in book-keeping as well -as in securing insurance medical attendance, and that -a very high percentage of the total insurance funds is -swallowed up in elaborate and meticulous account -keeping.</p> - -<p>The point as to malingering can best be considered -in connection with a discussion of the</p> - - -<h3><em>Medical Benefit</em></h3> - -<p>This consists of such medical treatment, at home or -at the office of the panel doctor,<a id="FNanchor_12" href="#Footnote_12" class="fnanchor">[12]</a> as “can consistently -with the best interests of the patient be properly undertaken -by a practitioner of ordinary professional -competence and skill.”</p> - -<p>The Act itself promised “adequate medical attendance -and treatment,” but under regulations this has -been limited, so that in practice it means chiefly the -treatment only of minor ailments. Thus (<em>a</em>) there -is no provision for hospital treatment of patients -needing this, except the Sanatorium provision for tuberculosis; -(<em>b</em>) with the same exception, there is no -provision for expert services. A patient requiring -operative treatment for fractures, for an amputation, or -an operation for appendicitis, or needing treatment for -some affection of the eyes, or nose, or throat, or ears,<span class="pagenum" id="Page_107">[Pg 107]</span> -or the intravenous treatment of syphilis is excluded -from medical benefit. So likewise are dental requirements. -(<em>c</em>) There is no provision for pathological -diagnosis, except such as is common to the entire -population, and no X-ray diagnosis, except possibly -for tuberculosis. (<em>d</em>) There is no provision for nursing -assistance.</p> - -<p>In view of the unequal distribution and insufficient -provision of hospitals for the general population, of -their inaccessibility to large masses of patients, and of -the insufficiency of the present provision for the scientific -aid to treatment which modern medicine demands -for insured and non-insured alike, it is evident that the -provision for medical treatment under the Act is unsatisfactory -and inadequate, and that it conduces to -prolonged illness, which treatment provided on more -satisfactory lines would avoid.</p> - -<p>To state adequately the defects of the medical provisions -of the Insurance Act a long address would be -required. They are, however, generally well known, -and their existence and seriousness is admitted by all. -(See also page <a href="#Page_90">90</a>.)</p> - -<p>It is necessary, however, to say more on the</p> - - -<h3><em>General Practitioner Treatment</em></h3> - -<p>provided under the Act. Every insured person is allowed -to choose his own doctor within a given distance. -In practice very few patients change their doctor at a<span class="pagenum" id="Page_108">[Pg 108]</span> -fixed time each year as they are allowed to do; and a -considerable proportion of insured persons do not -trouble to choose a doctor at all. The free choice of -doctors is rather a sentimental than a real demand. -The panel doctor is paid an annual capitation fee, and -hitherto no limit has been placed on the number who -may place themselves on his roll. The domiciliary -treatment given by some doctors is entirely satisfactory -within the limits stated above. Commonly, however, -it is as unsatisfactory as the “club practice” -which preceded it, and against which the British Medical -Association inveighed. It involves a continuance -of the mischievous ideal of medical practice of the -past, a conception still held by a large portion of the -public to its own detriment, that a hasty inquiry, a -perfunctory examination, and a bottle of medicine, -represent the best that scientific medicine can offer a -patient. Had there been organized a chain of medical -services for all needing it, including consultations and -expert assistance when needed, every patient having -the right to call for these when dissatisfied with his -panel doctor, including also hospital provision and -nursing as required, what a different story could now -be told!</p> - -<p>It is probable that some at least of these additional -services will be added gradually; but it must be noted -that the present payments of the insured will not -suffice to pay for them; and that if they are to be provided,—as<span class="pagenum" id="Page_109">[Pg 109]</span> -they will probably need to be,—out of -public funds, the general public are in equity entitled -to these services even though they are not insured.</p> - -<p>If these complete services were provided, the medical -treatment now provided largely at the expense of -the community could be made a means for advancing -the public health. This it can not at present claim to -be. For nothing is more certain than that the prompt -and adequate treatment of disease curtails its duration, -diminishes its severity, and prevents its spread -to others.</p> - -<p>But even such a service would not fulfil its complete -possibilities for good unless it were joined to a system -of hygienic supervision of each insured person and of -each insured person’s family, this system being organically -linked up with the wider public health work of -the larger Public Health Authorities.</p> - -<p>The chief justification of a national system of insurance -against sickness is that it shall be an active auxiliary -in the prevention of disease. At present it is -doubtful whether any national system of sickness insurance -has been so. It has only been so, to the extent -to which the medical treatment of the masses of the -population has been improved by it; and no such improvement -can be claimed for British insurance. The -wider possibilities of prevention of illness and elevation -of the general standard of health, by making each -medical practitioner a family adviser on health more<span class="pagenum" id="Page_110">[Pg 110]</span> -than a practitioner in medicine, have not been realised -or even brought within sight.</p> - - -<h3><em>Evils of the Present Medical Benefit</em></h3> - -<p>The inadequacy and unscientific character of the -medical treatment given to insured persons are associated -with a large amount of lax certification of illness, -which is injurious to the character of doctor and -patient, besides being unfair to the insurance funds. -Those interested in this point should read paragraphs -118, 119, 120, 121, 123, 125 of the Report of the Departmental -Committee on Sickness Benefit Claims -(Official Report Cd 7687).</p> - -<div class="blockquot fs80"> - -<p>There is almost universal testimony of the belief (of representatives -of friendly societies) that medical certificates are -granted recklessly (par. 119).</p> - -<p>Doctors ... feel a difficulty in refusing certificates owing -to the possible effect upon their practice.... If a doctor falls -out with his patient he loses the entire family (par. 120).</p> - -<p>These statements ... are representative of an enormous -volume of dissatisfaction with the action of the medical profession.</p> -</div> - -<p>The Committee state:</p> - -<div class="blockquot fs80"> - -<p>We are of opinion that in many cases doctors have given -certificates for sickness benefit in circumstances in which these -certificates were not justified.</p> -</div> - -<p>From the standpoint of the conscientious practitioner -the present position is profoundly unsatisfactory. -He has no official access to arrangements for<span class="pagenum" id="Page_111">[Pg 111]</span> -consultative and expert advice, he has no hospital beds, -no skilled nurses. For the patient the position is -anomalous and leaves him with but a fragment of -what he could reasonably expect under the terms of -the Act.</p> - -<p>Of the other medical benefit, i.e., the Sanatorium -benefit and of the Maternity benefit, I can say only a -few words here. The former gives the insured patient -little more than in the more enlightened sanitary districts -is being provided, independently of insurance, -by Public Health Authorities. It would have been -practicable to make it obligatory on all Public Health -Authorities to provide adequate treatment for all consumptive -patients. They are already authorized to do -this under Public Health Acts, and the duty could -have been, and can still be made, obligatory by regulation. -And in that case the connection of the Sanatorium -Benefit with the National (Health) Insurance -Act would happily cease, and one great obstacle to a -really national organization against tuberculosis would -disappear.</p> - -<p>The Maternity Benefit provides a money payment -for each insured woman and for the wife of each insured -man on the birth of a child. The money payment -is made through the Insurance Societies unconditionally, -instead of being made a means of securing -that the birth takes place under circumstances favourable -to mother and infant. During recent years public<span class="pagenum" id="Page_112">[Pg 112]</span> -health authorities (aided by grants from the Government -of one half of the total approved local expenditure) -have been making medical and nursing -provision for the care of women in pregnancy, in parturition, -and during the nursing period, on a rapidly -increasing scale, the grants including not only skilled -assistance but also domestic aid (home helps) in suitable -cases. There can be no question that increased -provision in these directions will have a more generally -beneficial influence than money payments, and should -at least supplement the latter.</p> - -<p>To sum up, if the national English system of insurance -is to continue, it ought in my view to be shorn -of its medical functions and to be limited to money -payments during sickness, in return for the weekly -contribution made by employees and employers. If it -be thought inadvisable to limit the State’s contribution, -as in Germany, to what is spent in administration, -then in equity the present system of insurance cannot -continue to be limited to those now participating in it.</p> - -<p>I hold strongly that the State should embark on a -much larger scale than at present on</p> - - -<h3><em>The State Treatment of Disease</em></h3> - -<p>The great and fundamental mistake made in the -initiation of the English Insurance Act was that in -effect it ignored the entire history of the relation of -preventive and curative medicine to the State. This -history cannot be detailed now: but, briefly, for long<span class="pagenum" id="Page_113">[Pg 113]</span> -years the destitute had been entitled to domiciliary -and institutional treatment at the public expense. -This medical aid was given by Poor Law Authorities, -and their method of doing this work had rendered the -benefaction commonly unacceptable. Then Public -Health Authorities on a steadily increasing scale found -it necessary to treat disease in order the more effectively -to prevent it. And so fevers and smallpox, and -chronic infective diseases like tuberculosis and syphilis -came under treatment, practically for all comers, at -the public expense. As already mentioned the fundamental -importance of maternity and childhood has also -been realised, and the State is now taking an increasing -share in ensuring health at these periods of life. -And while Public Health Authorities were increasing -their activities, Education Authorities began to subject -school children to medical inspection, and to -treat them for the detected defects, the treatment -of which they could not otherwise secure. And so, -not to make this sketch too complex, three great central -government departments or sub-departments and -three sets of local authorities were engaged in medically -treating the people at the public expense. This -sketch does not include the smaller (nevertheless -enormous) amount of treatment of disease by voluntary -hospitals. It is safe to state that at any one time -one-half of the total treatment of disease is being carried -out at the public expense. If the domiciliary<span class="pagenum" id="Page_114">[Pg 114]</span> -treatment of insured persons is worthy to come into -the same category as the skilled services mentioned -above, the proportion of disease already treated at the -public expense greatly exceeds 50 per cent. (Note.—Less -than four-ninths of the cost of medical treatment -of insured persons comes from the contributions of -the insured.)</p> - -<p>The complexity of local authorities concerned in the -treatment of disease was wilfully increased under the -National (Health) Insurance Act; and, contrary to -the advice of public health workers and of the Royal -Commission on the Poor Laws a golden opportunity -for securing the merging of poor law into public health -work and for initiating a unified system of State Medicine -for all who need it was lost.</p> - -<p>Poverty to a preponderant extent is due to sickness. -Two statements have recently been made by the Medical -Society of the State of New York, viz., that “evidence -is against the fact that any considerable amount -of impoverishment is caused by illness,” and that they -can find no “available evidence that ... in the main, -medical attendance in this State is grossly deficient in -quantity or grossly defective in quality.” (<cite>Monthly -Labor Review</cite>, January, 1920, p. 256.)</p> - -<p>One can admire the optimism, while denying the accuracy -of the first statement: of the second statement, -as it refers to the State of New York, I can say -nothing, except that a statement identical with the one<span class="pagenum" id="Page_115">[Pg 115]</span> -denied above would be literally true for England. In -1907 I wrote, “the coexistent but uncoördinated systems -of treatment of disease have failed lamentably -to provide what the health of the community requires—means -for ensuring effectively the early recognition -and proper treatment of all disease” (<cite>British Medical -Journal</cite>, Sept. 14, ’07). That remains broadly true, -and no remedy will suffice which does not ensure for -every member of the community in essential particulars -as good treatment as the most favored now -possess.</p> - -<p>The socialization of medicine has gone too far, its -beneficent effects are becoming too well appreciated, -to render it possible, even were it not undesirable and -mischievous, to hinder its further extension. We have -travelled more than half the road towards the goal of -general provision of skilled medical assistance by coöperative -means, i.e., out of the communal purse. If -this is desirable for elementary general education, it -is even more important when the aim is the restoration -and the maintenance of the highest attainable level of -health for each member of the community, who is -willing to share in the offered benefits. If we include -the third of the total population who now receive in -Great Britain the unsatisfactory medical benefit under -the National (Health) Insurance Act, and remember -the rapidly increasing scope of voluntary and official institutional -treatment of disease, hesitation in accepting<span class="pagenum" id="Page_116">[Pg 116]</span> -the inevitable should be replaced by a determination -to guide future developments and to render them efficient -and economical. What is good for the public is -good also for the members of the medical profession.</p> - -<p>If asked to advise on the steps which it is advisable -to take in regard to Sickness Insurance in a community -which has not adopted a scheme, I should emphasise -the prior necessity for the State to secure a completely -satisfactory system of public medical care before engaging -in the more difficult task of providing monetary -payments in sickness. It is well to bear in mind that -medical attendance is a form of communal assistance -the demand for which does not tend to increase with -the supply; whereas monetary benefits have always -shown this trend, as demonstrated by the experience -of both Friendly Societies and charitable agencies. -As satisfactory administration of monetary benefits -during sickness depends on securing medical certification -which is above suspicion, it is fundamentally important -that under any method of public medical -attendance the certification (for incapacity to work) -should be completely independent of any coexistent -system of sickness insurance.</p> - -<p>A completely efficient public medical service, if preventive -as well as curative, will diminish greatly the -monetary calls on sickness insurance and lower its -expense. Let me briefly enumerate the conditions -which such a medical service must fulfil:</p> - -<p><span class="pagenum" id="Page_117">[Pg 117]</span></p> - -<p>1. It must possess facilities for consultations with -physicians and surgeons having special knowledge, -equalling in efficiency those possessed by the well-to-do.</p> - -<p>2. All modern pathological and physical aids to -diagnosis and treatment must be available.</p> - -<p>3. Hospital treatment must be secured for all whose -illness cannot be satisfactorily treated at home.</p> - -<p>4. In the ordinary treatment of patients by medical -practitioners there must be provision for team work, -as for instance at local dispensaries, so that a patient -may, where this is desirable be conveniently examined -by several doctors. (Group medicine.)</p> - -<p>5. Skilled nursing must be obtainable for patients -needing to be treated at home, though the extent to -which this is required will be greatly reduced by increased -use of hospital beds.</p> - -<p>6. In every district the patient might have the choice -between several doctors; but unnecessary change of -doctors should be discouraged. Subject to general -regulations, however, he should be entitled to demand -a consultation when not satisfied as to his treatment.</p> - -<p>7. The doctor chosen by the head of the family -should be held responsible for supervising the health -of the whole family; and should be required at least -once in three months to arrange to see each member -of it, to ascertain any existing disease, or any habits, -manner of life or work tending to cause disease, and -to make a concise statement to the medical officer of<span class="pagenum" id="Page_118">[Pg 118]</span> -health or health commissioner embodying his recommendations -as to any public health action which may -be needed.</p> - -<p>8. The scheme at first might be limited to one section -of the population, but there is no reason why ultimately -it should not embrace all willing to join it.</p> - -<p>9. The remuneration of doctors engaging in this -public work should be adequate at once to attract junior -members of the profession. The remuneration -should not be on a capitation basis, but by salary, -modified according to the success achieved. The -scheme would enable doctors to have ample leisure -and holidays and to take part in post-graduate courses. -Every inducement should be given to physicians to -undertake along with their family work special work -in connection with one of the following activities:</p> - - -<ul style="list-style: none;"> -<li>Pathological laboratories,</li> -<li>Hospitals,</li> -<li>Health centres for infants and mothers,</li> -<li>Prenatal and post-natal clinics,</li> -<li>Consultant obstetric work,</li> -<li>Pre-school clinics,</li> -<li>School medical inspection and clinics,</li> -<li>Industrial inspections and clinics, etc.</li> -</ul> - -<p>10. Medical schemes on the above general lines can -only be completely satisfactory to the extent to which -every physician taking part in them becomes imbued -with an appreciation of the <em>almost unlimited preventive<span class="pagenum" id="Page_119">[Pg 119]</span> -possibilities opened up by the opportunity to -treat disease</em>, and by the realization likewise that an -essential part of his family work should consist in -detecting the <em>beginnings of disease</em> and in detecting -and securing the removal of domestic, dietetic, housing, -industrial or other factors liable to cause disease.</p> - -<p>If these ideals can be even partially realised, we -shall have approached the time when every practising -physician will become a hygienist, and when any sickness -insurance still demanded or required will be on a -scale much lower than is necessary at the present time. -In short, compulsory sickness insurance under present -conditions is a measure of relief. It has almost as -little prevention involved in it, as has insurance against -the risk of fire. Relief must be given, by insurance or -otherwise. How much preferable, however, it would -be to precede it by a far-reaching scheme of effective -preventive and curative work, or at the least to place -it in a strictly subsidiary position to such a scheme in -actual operation!</p> - -<p><span class="pagenum" id="Page_120">[Pg 120]</span></p> - - -<div class="footnotes"><h3>FOOTNOTES:</h3> - -<div class="footnote"> - -<p><a id="Footnote_11" href="#FNanchor_11" class="label">[11]</a> An address given to the Quiz Medical Society, New York, -Feb. 14, 1920.</p> - -</div> - -<div class="footnote"> - -<p><a id="Footnote_12" href="#FNanchor_12" class="label">[12]</a> <em>I. e.</em>, any doctor in a given area who is willing to treat -patients under the conditions of the Insurance Act.</p> - -</div> -</div> - - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<h2 class="nobreak" id="CHAPTER_V">CHAPTER V<br><br> -<span class="smcap fs80">Some Problems of Preventive Medicine of the -Immediate Future</span><a id="FNanchor_13" href="#Footnote_13" class="fnanchor">[13]</a></h2> -</div> - -<p>The Great War has changed our outlook on social, -including medical, problems; and has made all of us -consider anxiously in the midst of the terrible wreckage -from war, what useful lessons may be garnered -for our future guidance. In speaking of losses, I am -not referring to financial burdens, though these are -fabulously high—the bare statement that the British -national debt has increased from 645 to near 8,000 -millions sterling, brings this home—and we shall, -most of us, go relatively poor for the rest of our lives -and our children likewise. Nothing but the most -effective and scientific use of our energies on the part -of workers of every class can save us from protracted -poverty.</p> - -<p>I am thinking rather, however, of the losses of life -and limb, of hearing and eyesight, and of reason, which -have been experienced—one or other—in nearly every -other family in the British Empire, and which show -once more the wantonness of war: how cheaply life<span class="pagenum" id="Page_121">[Pg 121]</span> -is held by it, how careless it is of the individual; and -how disregardful it is of human promise and performance.</p> - -<p>The destruction of over 700,000 lives of sharers in -our common Empire, killed in battle or dead from -wounds, represents an imperial loss, a terrible destruction -of the real capital of the Empire—its manhood—and -of the flower of that manhood; and generations -will come and go before the Empire recovers -completely.</p> - - -<h3><em>Gains from War</em></h3> - -<p>But we can set out some great gains from war.</p> - -<p>1. Not the least of these is the fact that the fears -entertained by the more pessimistic that we had become -enervated and decadent have been falsified on -many a stricken field; and not less in the strenuous -work of those who have worked remote from the battlefield. -Our men and many women also have shown -themselves willing to give their lives for great impersonal -ends. Their lives have been sacrificed—for our -children, for liberty, for peace, for security against -military barbarism, and for high ideals of life. The -emergence of such a high proportion of our total population -from selfishness and self-centred life to a sacrificial -position, raises hope that rightly directed appeal -to the collective self of the community during peace -time for aid against the horrors of peace—especially<span class="pagenum" id="Page_122">[Pg 122]</span> -those caused by disease—will also succeed in enlisting -the assistance of the majority of the population and -thus removing the vast mass of removable disease and -disablement which now prevails.</p> - -<p>2. The war has knitted together in active comradeship -the Old Country and its younger and more energetic -children in the Dominion of Canada and in other -parts of the British Empire, in bonds of mutual indebtedness -and gratitude and in admiration of great deeds, -in a manner and to an extent which must forever preclude -misunderstanding or separation.</p> - -<p>In these two respects especially—and in others which -I shall dwell on more fully—we can, as Wordsworth -put it, when commenting on the wars of the French -Revolutionary period:</p> - - -<div class="poetry-container2 fs80"> -<div class="poetry"> - <div class="stanza"> - <div class="verse indent4">Though doomed to go in company with Pain,</div> - <div class="verse indent4">And Fear and Bloodshed, miserable train!</div> - <div class="verse indent4">Turn our necessity to glorious gain.</div> - </div> -</div> -</div> -<h3><em>The Work of Women</em></h3> - -<p>3. The war has revealed to us the great extent to -which women in emergencies can replace men. I need -not repeat the story of how women in a few months -mastered mechanical intricacies in munition works, for -which previously a long training was thought necessary; -nor how educated women after a few months’ -intensive training were able, under war conditions, to -undertake the work of fully trained nurses. We cannot<span class="pagenum" id="Page_123">[Pg 123]</span> -ignore these facts; and in regard to nursing, they -should lead us to consider whether, under modern conditions -of life, it is necessary that the great body of -nurses, like the great majority of medical practitioners, -need to be experts in major operations, and whether -they should not be trained chiefly from the standpoint -of the ordinary illnesses of the household. Particularly, -it is important to recognize that the training of -the health visitor or public health nurse must diverge -at an early period of training from that of the clinical -nurse.</p> - -<p>In another direction women are about to influence -vitally the problems of public health in the near future. -The municipal and parliamentary vote has been given -to women in England, and is not likely long to be -withheld here. How will they use it? When they -use it will “politics” be a name for a contemptible -thing as it has become in some towns and states, or -will women insist on clean administration and efficient -work to secure the health and welfare of the community?</p> - - -<h3><em>Prohibition of Alcoholic Drinks</em></h3> - -<p>4. The prohibition law against alcoholic drinks in -the U. S. A. is largely the work of American women. -Whatever view be taken of this law—and I regard it -as one of the most significant social events of the age—let -there be no doubt as to the essential facts of the -problem.</p> - -<p><span class="pagenum" id="Page_124">[Pg 124]</span></p> - -<p>Alcoholism is a potent enemy of the race. It is a -great creator of avoidable poverty. It makes the bed -ready for tuberculosis. It is a frequent excitant of -exposure to the infection of venereal diseases; it swells -the ranks of fatherless children, and of neglected infants; -it helps to fill our prisons and our hospitals. -Let it be admitted, if you like, that light wines and -beers are pleasant, and in strict moderation with meals -are beverages to which little or no harm can be traced; -but heavier drinks and all non-medicinal spirit drinking -are to be condemned; and the country which distinguishes -itself by abolishing these drinks will, other -things being equal, in my opinion, inevitably attain -quickly an industrial and economic superiority over all -countries which continue to follow the older ways.</p> - -<p>5. A great gain during the war is constituted by the -fact that science has come into its own. The war has -been described as a war of engineers. Its chief successes -have been won largely by applied science; and -it is gratifying to record that the Anglo-Saxon intellectuals, -when their services have been engaged, have -proved themselves more than equal to the German -scientist, whether in physics or chemistry or medicine.</p> - -<p>The facts as to the wonderful extent to which disease -has been prevented during this war need not be -detailed. Intestinal diseases have been kept strictly -under control. In no previous war has smallpox or -typhoid fever claimed so small a toll on the belligerents.</p> - -<p><span class="pagenum" id="Page_125">[Pg 125]</span></p> - -<p>Malaria, it is true, has claimed many victims, owing -to our soldiers having to operate in countries in which -the needed precautions could not be completely carried -out. Typhus has scarcely claimed a victim among the -British forces, and although trench fever was common, -medical discovery, by showing its relationship to the -bite of the louse, has placed within reach an immediately -practicable means for avoiding this serious -cause of military disablement.</p> - -<p>Three sets of diseases have not been successfully -combatted during the war—the group of respiratory -affections, tuberculosis, and venereal diseases, and on -each of these it is desirable to make a few remarks.</p> - - -<h3><em>Respiratory Diseases</em></h3> - -<p>6. In the group of respiratory diseases I think we -should include a number of diseases not commonly -regarded as such, but in which, so far as can be judged, -infection is received by inhalation; and I would, therefore, -group together such miscellaneous diseases as -poliomyelitis, cerebro-spinal fever, measles, bronchitis, -pneumonia, and influenza. All agree in one particular, -that attempted preventive measures against their -spread are dubious in effect. These diseases naturally -divide themselves into two groups: the first comprising -measles and influenza, both of which spread—when, -as in influenza, the almost unknown conditions -determining spread are present—to an extent only<span class="pagenum" id="Page_126">[Pg 126]</span> -limited by the failure of susceptible persons; and the -second comprising the other diseases already enumerated, -of the conditions determining attack from -which we are profoundly ignorant. We do know, -however, concerning cerebro-spinal fever and measles, -that they spread more easily and become more severe -under conditions of massive overcrowding; and their -unusual severity in war is thus partially explained. -Beyond this obvious indication for prevention we can -do but little.</p> - -<p>It may, however, be mentioned, that in England -during the last few years, we have determined that -our lack of ability to prevent outbreaks of measles -shall not prevent us from attempts to <em>diminish their -fatality</em>, and the notification of this disease has therefore -been enforced, as a necessary preliminary to -prompt and fairly complete action, and local authorities -have been urged to provide nurses to assist in the -domiciliary nursing of cases of measles. Grants of -half the expenditure expended in nursing this and -some other children’s diseases are paid by the Central -Government. If the spread of infection cannot be -stayed, it is our duty to diminish the loss of life -by providing nursing assistance whenever required. -This provision of nursing assistance in a number of -children’s and maternal illnesses, half the expenditure -being paid from Central and half from local funds, -will, I trust, soon be followed by a general provision -of nursing assistance from public funds.</p> - -<p><span class="pagenum" id="Page_127">[Pg 127]</span></p> - -<p>The recent epidemic of influenza has taught us several -important lessons—First, we have been painfully -reminded that we are completely ignorant of the causes -of the pandemic waves of this terrible disease, which, -at irregular intervals of years, traverse the world. We -may surmise that the crowding and the mental and -physical depression of war caused increased rapidity -of spread and a greater fatality in the present outbreak; -but influenza has spread and been only less -fatal than in the present outbreak when there was no -war, and we must admit our ignorance of the cause -of this.</p> - -<p>Numerous investigators in many lands have been -striving to illumine our ignorance; but until success -crowns their efforts, it is well to admit that on the -large scale all attempts to prevent the spread of influenza -have failed.</p> - -<p>But, in this disease, as in measles, this failure in -prevention is no reason for refraining from every possible -effort to restrain death. In every country and in -nearly every invaded district, many sick were unable -to obtain adequate nursing and other domestic care. -Here and there organized mobile team work partially -overcame the difficulty; but the one lesson which -emerges from this great pandemic is the necessity for -having in every area a large nursing reserve. Here is -one of many spheres of utility, which should, I think, -be occupied by Red Cross workers, who have done -such admirable work during the Great War.</p> - -<p><span class="pagenum" id="Page_128">[Pg 128]</span></p> - -<p>Many of these Red Cross workers were not fully -trained before the war, but intelligent workers under -stress of circumstances showed themselves competent -in many instances to undertake highly skilled work; -while a much larger number under the supervision of -more fully trained nurses and doctors were able to -carry out satisfactorily the routine but still extremely -important work, of ordinary nursing. During the influenza -outbreak many such “Nursing Aids” did -admirable work, and the epidemic has demonstrated -once for all the absolute necessity of having available -a large number of such nursing aids. Cannot these -be employed on a large scale when no epidemic is -raging? Is it necessary for every case of sickness -that a fully-trained nurse should be engaged? Would -not the physician be equally satisfied in a large proportion -of his cases, if he had available a less elaborately -trained assistant, who understood personal hygiene -thoroughly, who could give an enema, could take -temperatures, and would follow instructions implicitly -and intelligently?</p> - -<p>Incidentally I consider that some such modified and -simplified training in actual nursing would form an -adequate background for the special training required -to obtain a competent school nurse, tuberculosis nurse, -or public health nurse (health visitor); and that under -present conditions a three years’ training as a nurse is -not the best foundation on which to build the special -training required for these public health nurses.</p> - -<p><span class="pagenum" id="Page_129">[Pg 129]</span></p> - - -<h3><em>Tuberculosis</em></h3> - -<p>7. A serious penalty of war conditions has been the -increase of tuberculosis. It is not surprising that the -crowding in barracks, the overwork and overstrain, -the dirtier habits, and risks from expectoration in -massed communities, should have increased tuberculosis -among soldiers; both by activating latent tuberculosis -and by introducing new infection. Nor is it -surprising that under analogous conditions tuberculosis -has increased among women, especially at the -ages in which the enormous increase in their industrial -employment has taken place.</p> - -<p>The national anti-tuberculosis arrangements which -were made in connection with the National Insurance -Act had scarcely been fully organized when the war -began. At an early stage it had become plain that in -essentials non-insured must be provided for as well -as insured, and Government grants of half the approved -expenditure on the treatment of tuberculosis -in the general population endorsed this principle. -There was no reason, therefore, for the continued -separate existence of the “Sanatorium Benefit”; and -had it not been for political considerations the treatment -of tuberculosis would probably already have been -handed over to public health authorities, while leaving -intact the general provisions of the National Insurance -Act as to monetary payments and benefits. The same -transference should apply also to the treatment of any<span class="pagenum" id="Page_130">[Pg 130]</span> -disease undertaken at the public expense. The treatment -of disease, especially in its more difficult specialist -and institutional branches, should become a matter -of communal provision, to which every person would -be entitled as he is to the common provision under our -system of elementary education, or to the common use -of free libraries and of drinking water.</p> - -<p>There is needed a widely extended propaganda -against tuberculosis. The public as well as the medical -profession need to be educated, the latter in the -carrying out of complete and prompt notification of -cases of the disease, and in the use of all facilities provided -for aiding diagnosis; the former in the risks of -industrial and other dust infections, of indiscriminate -expectoration, of alcoholism, of imperfect nutrition, -of bad housing, and so on. We all need to learn the -folly of imperfect measures against tuberculosis. Complete -success can only be attained if we assume responsibility -for the whole course of the life of the -consumptive. Not only must educational sanatoria -be provided—and, still more important—hospital treatment -for all the emergencies of the disease and in -advanced disease; but in the quiescent intervals assistance -must be forthcoming to cover the margin between -a living wage and the earning capacity of the ex-patient, -and economic assistance must be provided for -protecting the patient, and still more his family, from -defective nutrition and from infection. To stop short<span class="pagenum" id="Page_131">[Pg 131]</span> -of this is to be extravagantly parsimonious; to do this -is to economize in sickness and to secure increased -efficiency in future generations. What better work -can be thought of for Red Cross volunteers than in -supplementing the work already carried out by anti-tuberculosis -organizations and in extending and systematizing -these agencies. Is not such peace work -equal in importance with the war work which Red -Cross workers have already accomplished?</p> - - -<h3><em>Venereal Diseases</em></h3> - -<p>8. Venus and Mars are always closely associated, -and it is a lamentable fact that one heritage of the war -will be a great increase of venereal diseases in our -midst. In England we had become thoroughly aroused -to the magnitude of this evil even in peace time. The -report of the Royal Commission on Venereal Diseases -and the propaganda since actively carried out, have -led to the taking of measures which I can only briefly -enumerate. The duty has been imposed on every -county and county borough council of providing aids -to pathological diagnosis, and of providing clinics for -the treatment of these diseases for all comers, irrespective -of residential or monetary conditions. These -clinics have been generally started throughout the -country, and their use has been widely advertised and -encouraged by propaganda in the form of lectures and -addresses in factories and to various social groups,<span class="pagenum" id="Page_132">[Pg 132]</span> -and by public advertisement. In addition an enactment -has been secured absolutely prohibiting the treatment -of venereal diseases except by qualified medical -practitioners, and prohibiting the advertising or offering -for sale of any remedy for venereal diseases. In -addition, arsenobenzol preparations are supplied to -medical practitioners who have experience in their use -for their own patients.</p> - -<p>These measures do not cover the entire ground. -The enforcement of police regulations against vice, the -detention of infectious persons who cannot be trusted -to refrain from spreading disease, the raising of the -general standard of sexual morality—until public opinion -demands that it shall be as high for men as for -women—are among the reforms which are called for.</p> - -<p>In encouraging social reform in these directions Red -Cross workers have a most fruitful field of work, and -they can render invaluable assistance in removing a -canker which at present eats into the vitals of the -community, and is responsible for untold suffering in -women and children, for premature old age and paralysis -in men, and for a large share of the total inmates -of our lunatic asylums.</p> - - -<h3><em>The Mother and the Child</em></h3> - -<p>9. I have left myself but scant time to speak of -what is at once a chief lesson of the war and the -most pressing problem in the preventive medicine of<span class="pagenum" id="Page_133">[Pg 133]</span> -the immediate future. I refer to the need for more -complete protection of motherhood and childhood -against the dangers besetting them.</p> - -<p>It would be a mistake to assume that only since war -began have efforts both by sanitary authorities and by -voluntary agencies been made on a large scale to diminish -infantile and maternal mortality. But during -the war, and since it terminated, these efforts have -been redoubled and are becoming universal; and there -is opening out a prospect of safe maternity for mothers -and of protected infancy for all newcomers on the -stage of life. If only we are prepared to do what is -almost immediately practicable for this end, death or -injury associated with child-bearing will become rare, -the loss of infant and child life will be halved, and -what is still more important, mothers and infants will -cease to be damaged by neglect or ignorance at critical -periods of their life, and will not become burdens to -themselves and to the community.</p> - -<p>This is no visionary dream. Past experience shows -that it is within reach. What other interpretations -can be placed on the facts revealed in official reports?</p> - -<p>I am unable to quote Canadian figures; but I am -justified in assuming that differences similar to these -I am about to quote from my own reports exist also -here. The average number of deaths of mothers from -complications arising during pregnancy, and at or -after confinement, are one maternal death for every<span class="pagenum" id="Page_134">[Pg 134]</span> -250 infants born alive. In some parts of England -instead of four mothers, six or even eight or nine -mothers die for every thousand infants born. There -are marked differences in maternal mortality in neighbouring -towns and districts; and the only conclusion -which fits in with the facts is that, in many parts of -the country, the arrangements for medical attendance -on mothers at and before their confinement are inadequate -or deficient in quality or both.</p> - -<p>The Maternity Benefit under the National Insurance -Act, though a valuable evidence of the interest of the -State in maternity, has not provided a sufficient remedy. -It was an unconditional benefit limited to insured -women or the wives of insured men, and there -was no guarantee that the money allotted would be -utilized in supplying the medical, midwifery, or nursing -assistance needed by the patient, or in relieving -her from domestic duties which she is unfit to perform. -It was furthermore, inadequate for these purposes. -We should not think of handing over to each -individual householder an annual sum of money, advising -him to expend it on a supply of books or in the -education of his children. It is more economical and -more effective to provide free libraries and public elementary -schools without payment of fees. Is not -similar action important in connection with child-bearing, -on which the continuity of family life and -civilization depends? That this is so is recognized in<span class="pagenum" id="Page_135">[Pg 135]</span> -the steps towards the desired end taken in recent years -by the Local Government Board jointly with local authorities. -Let me enumerate some of these. The -Central Authority have undertaken to pay one-half of -approved expenditure incurred locally on the following -agencies:</p> - -<p>(<em>a</em>) The salaries and expenses of inspectors of midwives;</p> - -<p>(<em>b</em>) The salaries and expenses of health visitors and -nurses engaged in maternity and child welfare work;</p> - -<p>(<em>c</em>) The provision of a midwife for necessitous -women in confinement and for areas which are insufficiently -supplied with this service;</p> - -<p>(<em>d</em>) The provision, for necessitous women, of a -doctor for illness connected with pregnancy and for -aid during the period of confinement for mother and -child;</p> - -<p>(<em>e</em>) The expenses of a Centre, i.e., an institution -providing any or all of the following activities: Medical -supervision and service for expectant and nursing -mothers, and for children under five years of age, and -medical treatment at the Centre for cases needing it;</p> - -<p>(<em>f</em>) Arrangements for instruction in the general hygiene -of maternity and childhood;</p> - -<p>(<em>g</em>) Hospital treatment provided or contracted for -by local authorities for complicated cases of confinement -or complications arising after parturition, or for -cases in which a woman to be confined suffers from<span class="pagenum" id="Page_136">[Pg 136]</span> -illness or deformity, or for cases of women who, in -the opinion of the Medical Officer of Health cannot -with safety be confined in their homes or such other -provision for securing proper conditions for the confinement -of necessitous women as may be approved -by the Medical Officer of Health;</p> - -<p>(<em>h</em>) Hospital treatment provided or contracted for -by local authorities for children under five years of -age found to need in-patient treatment;</p> - -<p>(<em>i</em>) The cost of food provided for expectant mothers -and nursing mothers and for children under five years -of age, where such provision is certified by the Medical -Officer of the Centre or by the Medical Officer of -Health to be necessary and where the case is necessitous;</p> - -<p>(<em>j</em>) Expenses of creches and day nurseries and of -other arrangements for attending to the health of children -under five years of age, whose mothers go out -to work;</p> - -<p>(<em>k</em>) The provision of accommodation in convalescent -homes for nursing mothers and for children under -five years of age;</p> - -<p>(<em>l</em>) The provision of homes and other arrangements -for attending to the health of children of widowed, -deserted and unmarried mothers, under five years of -age;</p> - -<p>(<em>m</em>) Experimental work for the health of expectant -and nursing mothers and of infants and children under<span class="pagenum" id="Page_137">[Pg 137]</span> -five years of age, carried out by local authorities or -voluntary agencies with the approval of the Board;</p> - -<p>(<em>n</em>) Contributions by the local authority to voluntary -institutions and agencies approved under the -scheme.</p> - -<p>Grants will be paid to voluntary agencies aided by -the Board on condition:</p> - -<p>1. That the work of the agency is approved by the -Board and coördinated as far as practicable with the -public health work of the local authority and the school -medical service of the local education authority.</p> - -<p>2. That the premises and work of the institution are -subject to inspection by any of the Board officer’s or -inspectors.</p> - -<p>3. That records of the work done by the agency are -kept to the satisfaction of the Board.</p> - -<p>Possibly much of the past failure to protect maternity -and to reduce the still-births and mortality among -infants under a month old has been due to the erroneous -assumption that damage to health and life at -these times is in the main inevitable. That this is not -so for maternal mortality is proved by the great difference -in experience of sickness and death for mothers -in different social strata and according to the availability -of skilled midwives and doctors. There are -similar differences locally and socially in the proportion -of still-births. Wassermann tests, followed by -appropriate medical action, in all instances in which<span class="pagenum" id="Page_138">[Pg 138]</span> -there have been previous miscarriages or in which for -other reasons syphilis comes under suspicion, and subsequent -action based on the diagnosis thus secured, -would at once greatly reduce maternal and infantile -mortality. So also would systematic examination of -urine during pregnancy and the ascertainment that in -other respects the physical conditions of normal parturition -are present. These are adequate reasons for -the establishment of ante-natal consultations, which -happily are rapidly increasing in England under the -stimulus of the Government grants already mentioned.</p> - -<p>The further fact that about one-third of the total -deaths in the first year after live-birth occur in the -first four weeks of life, adds force to my plea for the -establishment of these ante-natal consultations in connection -with all lying-in institutions and at child welfare -centres, where infants and children up to school -age will be submitted to periodical medical examination -and supervision.</p> - -<p>It has been erroneously asserted that the greater -part of this early infant mortality is unavoidable; but -careful examination of national and local statistics -shows that in some places it is twice as high as in others, -and examination of the causes of death in the districts -with more favourable mortality shows that their experience -can be improved. All experienced obstetricians -and pædiatricians will agree that, given adequate -care of the mother during pregnancy, skilled care by<span class="pagenum" id="Page_139">[Pg 139]</span> -a competent obstetrician during labor, and satisfactory -medical and nursing care in the following month, there -can be secured large reductions in the early infant -mortality of the first month after birth, as well as in -the number of still-births and in the present toll on -maternal life.</p> - -<p>In early infancy, as in advanced old age, the hold on -life is slight, normal and abnormal are soon interchanged, -and there is needed not only more knowledge -on the part of mothers and nurses, and even of physicians, -of the hygienic side of medicine as applied to -the physiological life of the mother and her infant, -but also personal care and assistance to enable the -mother to apply the useful information and advice -given by the public health nurse. I lay special stress -on this association of counsel and assistance. It is -important also that nursing and medical assistance -should be so given as not to create a feeling of dependence. -In view of the wide provision of medical -assistance from public funds which already obtains, -I submit that poverty tests in the giving of such assistance -should be abolished, or that, at least, the -availability of such assistance should be greatly extended. -Given the fulfilment of this condition, it will -be practicable to enlist the remunerated coöperation -of the medical profession in a general provision of -medical and nursing facilities, which will secure the -early detection of disease of every kind and its prompt<span class="pagenum" id="Page_140">[Pg 140]</span> -and adequate treatment. Not only so, but the same -service can be utilized for the preservation of health -by securing the change of habits and customs and conditions -of housing or work which are likely to prove -detrimental.</p> - -<p>I have laid stress on the ideal after which we must, -in my opinion, strive. Meanwhile, it is essential that -we should not regard the mere removal of ignorance -as the <i lang="la" xml:lang="la">summum bonum</i>. This is plain when we come -into close contact with the facts of life as lived by the -greater part of the wage-earning classes.</p> - -<p>Has the wife of the wage-earner domestic help such -as her well-to-do sister possesses? Is there a nurse -to help her even when the children are sick, much less -while they remain fairly healthy? How often has -every kettle-full of water to be heated separately on a -stove? Under such circumstances is it reasonable to -expect the cleanliness which is an indispensable condition -of health? Is there a clean supply of milk for -every working-man’s family and are there arrangements -for sanitary and cool storage of food in his -dwelling?</p> - -<p>And so we might go on multiplying questions, knowing -that, if the answers are well-informed and candid, -they will confess that the mothers of the wage-earning -classes, especially in our large cities—in England, if -not also here—have not a fair chance to keep themselves -well, or to rear a healthy and robust family.</p> - -<p><span class="pagenum" id="Page_141">[Pg 141]</span></p> - -<p>I do not wish to stress this view of the case; but I -have said enough to justify the action of the British -Government in deciding during the war—and announcing -the fact in more than one official circular -issued to all Local Authorities by the Local Government -Board—that, next to the active pursuance of -war, measures for promoting maternal and child welfare -ranked next in importance, and that no efforts -must be spared to continue and extend such measures. -And the history of the last four years shows that this -has been done. The central grants for special maternal -and child welfare work undertaken by local authorities -and voluntary agencies have increased twelve-fold, -the number of health visitors has been more than -doubled, and the number of maternity and child welfare -centres has increased five-fold; and coincident -with these facts, infant mortality, which was falling -before the war, has continued to decline steadily during -the war,—the corrected figures for the years 1912-17 -respectively were 104, 117, 113, 111, 98, and 94—although -the number of mothers employed away from -home has greatly increased during the same period.</p> - - -<h3><em>The Work of Voluntary Agencies</em></h3> - -<p>I have several times in this address mentioned the -valuable work of voluntary health agencies. No official -can fail to recognize that pioneer work is commonly -started by them; and it has often happened that<span class="pagenum" id="Page_142">[Pg 142]</span> -only when the evidence of its value has become obtrusive -has it been taken over by local authorities. -This is the true function of voluntary agencies, and -will remain so, until local authorities (which after all -are manned by voluntary workers) become saturated -with the ideals of voluntary workers and of the new -women-voters. Local authorities always have one -great advantage over voluntary societies, that their -action can be supported by legal powers.</p> - -<p>The proper attitude of voluntary workers is to initiate -and demonstrate the value of reforms, to persuade -local authorities to adopt them, themselves to -become members of these local authorities to ensure -this end, and thus eventually render the voluntary -organization for the object in question superfluous. -There need be no fear; openings for further desirable -voluntary work will always appear, as official work -increases. In the main, however, the care of the health -of the people is a governmental function, whether it -has to do with the prevention of sickness or the satisfactory -medical treatment and nursing of the sick.</p> - -<p>There is no early prospect of voluntary workers becoming -unnecessary; for average human nature, as -represented on governmental bodies, is shortsighted -and needs much education, morally and intellectually, -before it will undertake the whole sphere of work -called for in the interest of the welfare of the mother -and her child. Hence my plea that the magnificent<span class="pagenum" id="Page_143">[Pg 143]</span> -potentialities of the Red Cross organization should not -be allowed to fall into abeyance; that they should replace -their relief work by preventive work; that, to -use a well-known simile, they should erect a parapet -at the top of a dangerous cliff as well as provide ambulances -at its foot. In so doing they will, I am confident, -not encroach on present successful work of -existing bodies concerned with promoting child welfare, -or with the prevention of tuberculosis or of -venereal diseases, or with existing agencies for providing -nurses for the poor. But they can supplement -the efforts of these organizations; they can bring -monetary as well as personal assistance; and they can, -above all, bring a mass of public opinion to bear on -local and central governing bodies which will lead to -the only real economy, which consists in expenditure -on an adequate scale, bringing to the aid of the families -of the people the preventive, the medical, and the -nursing facilities of which they remain in need.</p> - -<p><span class="pagenum" id="Page_144">[Pg 144]</span></p> - - -<div class="footnotes"><h3>FOOTNOTES:</h3> - -<div class="footnote"> - -<p><a id="Footnote_13" href="#FNanchor_13" class="label">[13]</a> An address to the Academy of Medicine, Toronto, June -20, 1919.</p> - -</div> -</div> - - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<h2 class="nobreak" id="CHAPTER_VI">CHAPTER VI<br><br> -<span class="smcap fs80">The Inter-relation of Various Social Efforts</span><a id="FNanchor_14" href="#Footnote_14" class="fnanchor">[14]</a></h2> -</div> - -<p>On examining the local city directory, one cannot -but be impressed by the multiplicity of voluntary organizations -having for their object the immediate relief -of destitution or the social or economic “uplift” -of sections of the population. The multiplicity of -these agencies becomes more striking when one remembers -that probably every one of the hundreds of -churches and chapels in the city has its periodical sacramental -and other collections for the poor, and may -have also a system of parochial district visiting, with -such auxiliary assistance as is provided through -mothers’ meetings, etc. Nor does this exhaust the -possibilities of social help available for the poorer -members of society in cities in which there is a satisfactory -distribution of rich and poor, that is, in which -the segregation of different social strata in separate -areas has happily not befallen. There is the further -help provided by individual charity, the amount of -which in the aggregate probably exceeds beneficence -through churches and social agencies.</p> - -<p><span class="pagenum" id="Page_145">[Pg 145]</span></p> - -<p>If these different agencies could pool their resources, -while retaining the enthusiasm and driving power of -separate organization, what an economy of effort and -what increase of efficiency would result, especially if -these agencies were also satisfactorily related to the -official organizations of local and central governing -bodies having the same object!</p> - -<p>But I am not concerned this evening to discuss the -machinery of social help or the attempts already made -in different centres for securing their satisfactory coöperation. -Nor am I disposed to discuss the economic -problems underlying the need for social assistance of -the poor. Ideally we must agree with St. Augustine’s -statement: “Thou givest bread to the hungry; but -better were it, that none hungered, and that thou -had’st none to give him.” My present object, however, -is to set out some elementary—and when stated fairly -obvious—considerations bearing on social evils and -their remedies under present conditions of society, -the recollection of which if followed by practical action, -would secure greatly increased efficiency in social -work.</p> - -<p>For the following reasons I do not hesitate to bring -this subject before a gathering of graduate medical -students:</p> - -<p>First.—Every physician as soon as he engages in -medical practice almost immediately comes into touch -with organized and unorganized social workers, and<span class="pagenum" id="Page_146">[Pg 146]</span> -his success—personal as well as communal—can almost -be measured in terms of his outlook towards their -work;</p> - -<p>Second.—The physician, with his scientific training -in the tracing of effects back to their causes, is in a -specially favourable position to promote rational as -contradistinguished from empirical social help; and</p> - -<p>Third.—The physician is now learning to appreciate -that he can only treat his patients satisfactorily in the -light of knowledge of their social, including housing -conditions, of their industrial relationships, and of -their personal history and habits of life.</p> - -<p>This is the age of anxiety to give social help.</p> - -<p>I hold strongly the view that ere many of you are -advanced in years the fundamentally important social -help which is constituted by adequate medical attendance -will be provided, for all who wish to have it thus, -at the expense of the state, i.e., coöperatively by means -of common charges on every member of the community -according to his means, exactly as elementary -education is now provided. This will involve radical -reconstruction of the relationship between hospital and -private medical practice, and will, I trust, include also -the introduction of preventive medicine into the practice -of every physician. But this is in the future. -How can medical practice under present conditions, -and how can non-medical social agencies, be made subservient -to the fullest extent to the welfare of the community?</p> - -<p><span class="pagenum" id="Page_147">[Pg 147]</span></p> - -<p>A few elementary illustrations will show the many -unexploited or only partially exploited or misused -opportunities for efficient social help.</p> - -<p>The greatest science is to know the causes of things; -and there is no branch of work in which this is more -important than in medicine. But causation is complex. -A given result commonly follows from a chain, -or it may be a bundle of events: and as we shall -shortly see the end links of the chain are oftimes -joined, thus forming a circle.</p> - -<p>If a man shoots a companion with whom he has -quarrelled, it may be urged that a more rigid system -of license for the use of firearms would have prevented -the calamity; that the companion was also quarrelsome; -that the homicide had been the spoiled child of -his mother and had not had a satisfactory up-bringing; -and that he inherited from his father a violent temper; -but none of these circumstances,—all of which may -have contributed to the murder,—is likely to succeed -in preventing the murderer from being hanged after -due trial.</p> - -<p>It would be difficult to find a more striking instance -of the linking of elements in causation than in the -origin of a case of malaria. For the transmission of -this disease two human beings, one already infected -with the specific contagium, and a mosquito are required, -and the chain of causation can be broken at -the infecting person, by strict screening from mosquitos,<span class="pagenum" id="Page_148">[Pg 148]</span> -and by the use of quinine; at the mosquito by -preventing its emergence from the larval stage, and -later by preventing its access to the patient; or at the -prospective patient, possibly by prophylactic medication, -more certainly by strict screening from mosquitos. -Hence one might claim lack of segregation -of infected persons, lack of screening of the healthy, -failure to drain marshes, to apply oil to the surface -of stagnant pools, or to adopt allied measures destroying -the larvae of mosquitos as each of them the cause -of malarial disease.</p> - -<p>There is a constant excess of sickness among the -poor as compared with the well-to-do. Measures for -the relief of poverty, therefore, may be regarded as -within the scope of the physician’s prescription. This -may be accomplished for the moment by monetary or -material help; but unless the causes of poverty are -sought out and counteracted, the assistance given is -merely palliative. For nothing is more certain than -that poverty tends to become a self-perpetuating condition.</p> - -<p>Thus poverty leads to premature employment of -children, with detriment to their normal growth, followed -by diminished efficiency in adult life. This implies -low wages throughout life, and so poverty is -passed on to a second generation.</p> - -<p>Evidently timely assistance to induce the parent to -delay employing the boy, until he has been prepared<span class="pagenum" id="Page_149">[Pg 149]</span> -for work, and to ensure his being put to work which -will not be a “blind-alley” occupation, might have obviated -the evil chain of events.</p> - -<p>Poverty again when carried to the point of destitution -may tempt to larceny; this may be followed by -loss of employment, and so the temporary unrelieved -poverty is liable to become permanent.</p> - -<p>Intemperance has been almost wiped out as a cause -of disease in the United States; and we have in the -fact that the whole country has “gone dry” a remarkable -example of a “short-cut” towards social salvation -from alcoholism which will be most instructive. Apart -from such universal prohibition of alcoholic beverages, -the physician has to think of an alcoholic patient -under his care as the possible victim of one or more or -all of several coöperating influences conducing to intemperance. -The alcoholic habit may have been gradually -acquired as the result of protracted social indulgence -in moderation acting on a person of unstable -mental constitution; it may, especially in wage-earners, -have been hastened by the evil custom of treating. It -not infrequently follows overwork, with the associated -feeling of need for stimulants; it accompanies bad -housing, with unsatisfactory sleeping accommodation; -and it is aided by poor and badly cooked food, due to -shiftlessness, overwork, or lack of domestic training -of the man’s wife. If there is to be successful control -of alcoholism, action in all the directions briefly indicated<span class="pagenum" id="Page_150">[Pg 150]</span> -above, and in other directions which will suggest -themselves, is necessary; and although the physician -cannot himself do all this, his efforts should run parallel -with social efforts in these directions.</p> - -<p>Even when the “short-cut” of compulsory abstinence -has been taken, the efforts indicated above are -still needed; for alcoholism is not the only resultant of -bad social habits, of overwork, of unsatisfactory feeding, -of deficient sleep, and so on.</p> - -<p>Perhaps even more far reaching in their evil effects -than intemperance are the Venereal Diseases. As you -know, special efforts during and since the war have -been made to limit the spread of these diseases. I do -not propose to trouble you with statistics to prove the -mischief caused by these diseases. Has not Osler said -that the whole of clinical medicine can be taught -around syphilis, and that it is the third in importance -of the killing diseases? And as a further illustration, -let me add that no less than one-tenth of the total -accommodation in our lunatic asylums might be dispensed -with if syphilis were eliminated.</p> - -<p>Among the measures being taken to combat these -diseases are educational propaganda, and the provision -of clinics, free for all, at which patients may be treated -promptly and adequately. It is evident, however, that -if the medical and educational efforts now being made -are to succeed they must include recognition of all the -factors causing sexual vice, and appropriate action in<span class="pagenum" id="Page_151">[Pg 151]</span> -respect of each of these—they must indeed go further -than this; for self-restraint is a wider problem than -in relation to exposure to these diseases. It embraces -the whole subject of formation of the habit of self-control. -One of the most striking facts in the great -war has been the extent to which young girls of previously -decent behaviour have fallen victims to what -has sometimes appeared to be passion combined with -a perverted form of patriotism; and one of the measures -most called for is better mothering and maternal -training of both girls and boys. The problem is one -of special difficulty as regards the economically independent -girl; and to shield her the combined efforts of -home influence, of girls’ clubs, and of various social -and religious organizations are all required.</p> - -<p>Judicious and restrained teaching of the physiology -and hygiene of sex would do much to counteract the -evil influence of bad teaching by companions; and in -emphasizing this duty on parents the physician may do -untold good. So also, especially when the daughters -of his patients are about to marry “men of the world,” -he should urge the need for asking a satisfactory certificate -from the intended bridegroom of freedom -from infection.</p> - -<p>The influence of unaccustomed alcoholic indulgence -in leading to the first “slip,” often with the production -of life-long disease, is well known.</p> - -<p>Nor must we leave out of account the tolerance of<span class="pagenum" id="Page_152">[Pg 152]</span> -vice in conversation between young men, as a frequent -excuse of and even excitant to vice. The happiest -young man is he who can go to the marriage ceremony -with the same sexual purity as is even now expected -from the bride. Is it too much to expect that our -social conscience will grow up to this standard? I -think not; and when this point has been reached, -venereal diseases will have almost entirely disappeared, -and the sum total of human happiness and -efficiency will be enormously enhanced.</p> - -<p>Meanwhile partial remedies must be pushed for all -they are worth—and this is much. Fear of consequences -may deter some from vice; fear of consequences -to future wife and child form a much more -potent argument. Treatment of venereal diseases, especially -of syphilis, is a most valuable means of preventing -their spread. This treatment may be urged -even at the stage after exposure to infection before -any symptoms of illness appear; and the more -promptly this is done the more successful is it. There -has been much heated debate as to whether persons -known to intend to expose themselves to possible infection -should be provided with disinfectant or other -arrangements for obviating infection. This cannot be -done without some loss of moral position; it almost -makes the provider a co-partner with the sensualist. -It may be urged, however, but with dubious cogency,<span class="pagenum" id="Page_153">[Pg 153]</span> -that if the man is told beforehand that immediately -afterwards he can have access to disinfectant provisions, -the same objection holds good. I do not -regard the provision of “outfits” as wise. Evidence -tends to the conclusion that they are commonly not -used efficiently; and there is a distinct loss in the -moral position by their use. The whole subject is one -of great difficulty. The prevention of venereal diseases -is clearly, however, not merely a medical problem; -and the physician who realises this and throws -the weight of his influence, in warning and in counsel, -on the side of moral restraint, is adding greatly to the -value of his social service to the community.</p> - -<p>Other instances will occur to you, illustrating the -importance of a broad outlook in the causation of disease -or other forms of social misery. I will adduce -one more. It is well known that infant mortality is -much heavier among the poor than among the well-to-do. -The rule does not hold universally in rural -areas, but in towns it applies almost without exception. -And it is assumed by a large school of social -workers that enlightenment of the ignorance of the -poor mother will effectively correct this evil. Such a -lop-sided view ignores many of the elements of the -problem of infant mortality. Think for a moment of -the contrast between the working-class mother of five -children living in a small city tenement, and the -mother of an equal number of children in easy circumstances,<span class="pagenum" id="Page_154">[Pg 154]</span> -living in a residential suburb, and having -domestic servants, a nurse, and a physician always -available. The two mothers probably differ but little -in their knowledge of the hygiene of infancy; but the -one has helpers to ensure scrupulous cleanliness, to -prevent over-fatigue of the nursing mother, to detect -the first sign of infantile illness and provide the -needed action; while the other mother has to struggle -alone in respect of her infant, without either domestic -or nursing assistance, the struggle being complicated -by the fact that the care of four older children and of -her husband is on her shoulders. Even when there -is no actual direct poverty in the working-class home, -the differences thus indicated—supplemented by the -inability of the mother to obtain medical advice for -apparently minor ailments—outweigh enormously the -factor of ignorance as a cause of excessive infant -mortality. By all means let instruction be given by -public health nurses or other agencies, and this is most -valuable; but it does not fully meet the needs of the -case. There is required also actual domestic, as well -as nursing, assistance in the home of the overworked -working-class mother, especially after the birth of her -infant and when illness attacks any of her children; -and unless the physician realises these elements in the -problem, his efforts in securing the welfare of his patient -and in reducing infant mortality can have but -partial success.</p> - -<p><span class="pagenum" id="Page_155">[Pg 155]</span></p> - -<p>The main lessons arising from the foregoing illustrations -of medical and social problems are two: Each -evil should be attacked in its causal relationships; and -causation is multiple.</p> - -<p>Hence—apart from total prohibition—in attacking -alcoholism, the physician may bless the efforts of tee-total -advocates, of those engaged in reducing the number -of saloons, of those securing better dietetics and -cooking, less industrial fatigue, or more satisfactory -domestic sleeping accommodation, and of parents and -teachers engaged in promoting self-control in the -young as a habit of life; and he will call them all in -aid of his curative and preventive life work.</p> - -<p>So, also in the control of venereal diseases, early -and prompt diagnosis and treatment must go hand in -hand with police measures for the suppression of prostitution, -with educational work respecting these diseases, -and with the inculcation of a higher standard -of morality, considered as part of the general cultivation -of moral self-restraint.</p> - -<p>And in the prevention of infant mortality and of the -even more serious handicapping of the up-growing -child produced by the factors of infant mortality, we -need to bring to bear all our medical and hygienic -knowledge, and to realise that until every mother in -the land is furnished with the elementary requirements, -domestic, sanitary, social, and medical, for rearing -a healthy family, we have no right to mental comfort<span class="pagenum" id="Page_156">[Pg 156]</span> -while enjoying these elementary needs of family -life ourselves.</p> - -<p>Coöperation and solidarity of effort are needed on -the part of the multitude of workers engaged in social -work for the community—official and non-official; and -in bringing this about the physician of the early future -will, I am confident, take a leading part.</p> - -<p><span class="pagenum" id="Page_157">[Pg 157]</span></p> - - -<div class="footnotes"><h3>FOOTNOTES:</h3> - -<div class="footnote"> - -<p><a id="Footnote_14" href="#FNanchor_14" class="label">[14]</a> An address to the Alpha-Kappa-Kappa Club, Johns Hopkins -University, Wednesday, December 10, 1919.</p> - -</div> -</div> - - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<h2 class="nobreak" id="CHAPTER_VII">CHAPTER VII<br><br> -<span class="smcap fs80">The Obstacles to and Ideals of Health Progress</span> -<a id="FNanchor_15" href="#Footnote_15" class="fnanchor">[15]</a></h2> -</div> - -<p>There are two ways in which Health Problems can -be approached: what may be called the microscopic -method, which examines in minute detail each individual -problem; and the conspective method, in which -an attempt is made to obtain an unbiased and comparative -view of the chief problems concerned, in -order that their relative importance may be assessed, -and the possibilities of improvement may be gauged. -In proposing to myself the latter and more difficult -task, I appreciate the impossibility of discussing all -the items which emerge.</p> - -<p>I would not have us forget what has already been -achieved. Taking the national figures for England -and Wales as an illustration, it is noteworthy that the -death-rate from all causes fell from 22.4 per 1,000 of -population in 1846-50 to 13.8 in 1911-15, a reduction -of nearly 40 per cent. Comparing the decennium -1871-80 with the quinquennium 1911-15, the incidence -of reduction of death-rate at different ages was -as follows:</p> - -<p><span class="pagenum" id="Page_158">[Pg 158]</span></p> - -<p class="center"><em>Percentage reduction in death-rate</em></p> - -<table class="autotable fs80"> -<tr> -<td class="tdc">Age</td> -<td class="tdl"></td> -<td class="tdc">Age</td> -<td class="tdl"></td> -</tr> -<tr> -<td class="tdr">0-5</td> -<td class="tdrp">42</td> -<td class="tdlp">35-45</td> -<td class="tdr">42</td> -</tr> -<tr> -<td class="tdr">5-10</td> -<td class="tdrp">48</td> -<td class="tdlp">45-55</td> -<td class="tdr">25</td> -</tr> -<tr> -<td class="tdl">10-15</td> -<td class="tdrp">43</td> -<td class="tdlp">55-65</td> -<td class="tdr">15</td> -</tr> -<tr> -<td class="tdl">15-20</td> -<td class="tdrp">46</td> -<td class="tdlp">65-75</td> -<td class="tdr">10</td> -</tr> -<tr> -<td class="tdl">20-25</td> -<td class="tdrp">51</td> -<td class="tdlp">75-85</td> -<td class="tdr">7</td> -</tr> -<tr> -<td class="tdl">25-35</td> -<td class="tdrp">50</td> -<td class="tdlp">85 and upwards </td> -<td class="tdr">15</td> -</tr> -</table> - - -<p>The survey is saddened by the terrible losses of War, -and the even more devastating ravages of influenza; -and we realize our inadequacy to prevent catarrhal -infections, until further research into preventive possibilities -proves successful, and until the standard of -universal conduct for catarrhal affections becomes -much higher than at present. We realize furthermore -that probably at least half the deaths from all causes -which occur could be postponed until old age. But the -standard of health of the general population has greatly -improved; typhus has practically disappeared under -peace conditions; yellow fever approaches its demise; -malaria and typhoid are controllable; tuberculosis and -venereal diseases are only waiting for systematic, complete, -and continuous measures to secure their rapid -decline or actual disappearance; the mortality from -childbearing and of young children has greatly declined; -and this is an incomplete statement of what -has already been done.</p> - -<p><span class="pagenum" id="Page_159">[Pg 159]</span></p> - - -<h3><em>Obstacles</em></h3> - -<p>This improvement is all the more remarkable in -view of the additional obstacles imposed to health improvement -by modern conditions of urban and industrial -life.</p> - - -<h3><em>Urbanization</em></h3> - -<p>The population during the last century has steadily -flocked to the towns from country districts. Streets -have taken the place of green fields; rows of unsatisfactory -dwellings have replaced country cottages; we -have dust and belching smoke and noise instead of -sunshine and country air and quiet; bustle and turmoil -instead of life in close touch with mother-earth: and -this change has been associated with an almost unlimited -inter-communication of human beings, and a corresponding -increase in opportunities for the convection -of germs of disease.</p> - -<p>Until the time of the industrial revolution in England -modes of locomotion were little if any more advanced -than among the ancient Egyptians; and disease, -when it travelled at all, travelled by slow and deliberate -stages. Now the infections of the entire world -may be sampled in any one district in the course of a -few weeks. Man has, in fact, reverted from the land-tied -condition involved in agriculture to the migratory -habits of an earlier period of man’s life on the earth. -As Wells has put it: “in every locality ... countless -people are delocalised,” and it is not the least evil of<span class="pagenum" id="Page_160">[Pg 160]</span> -urbanization that, in consequence of this, the administration -of local affairs falls too often “into the hands -of that dwindling moiety which sits tight in one place -from the cradle to the grave,” or of persons who have -a financial axe to grind.</p> - -<p>The difficulties of water supply, of scavenging, and -of drainage, until they were overcome, have made -towns the inevitable destroyers of mankind. The conditions -of housing are worse in towns than in country -districts, higher rents and less ground space implying -that each family on an average lives in fewer and -more crowded rooms than in rural districts.</p> - -<p>Furthermore, in towns there is greater difficulty in -securing satisfactory arrangements for the storage of -food, especially milk, and in obtaining fresh milk and -vegetables; and there is the serious disadvantage, especially -for children, that their playgrounds are in streets -instead of the fields, and that the possibilities of deriving -infection from dried expectoration and from fæcal -or other organic contamination in yards and backstreets -as well as directly from other children or adults -are multiplied manifold.</p> - -<p>Even more important, town life for the father of a -family generally means an indoor and often a dusty -indoor occupation; the mother not infrequently is also -industrially employed; and these adverse circumstances, -so far as they are allowed to continue, now -affect three-fourths of the population of England and<span class="pagenum" id="Page_161">[Pg 161]</span> -Wales and probably one-half of that of the United -States.</p> - -<p>And yet the death-rate from all causes, and especially -from communicable diseases is steadily declining, -to an even greater extent in urban than in rural communities.</p> - -<p>It is but fair to add that the differences between -urban and rural populations tend to decrease; at least -this is so in England; probably the same is true to a -less extent in America. The nominally rural population -is becoming more and more urban in character, -and composed not solely of rustics,—who live in and -by the soil and are altogether more natural in their -habits,—but largely of town-dwellers who only sleep -in country dormitories. But this makes it all the more -remarkable that notwithstanding the multitudinous -circumstances which have tended to increase disease, -the death-rate has been lowered to an amount already -indicated, and life has been prolonged to an extent -which has secured an increase in its average expectation -of 10 or 11 years within the last thirty years.</p> - - -<h3><em>Industrialism</em></h3> - -<p>Considerations of time render it impracticable to -discuss in this address the mischievous influence of -modern industrialism on national health. This influence -runs collaterally with that of urbanization; and -in it in the past can be seen the evil results of overwork,<span class="pagenum" id="Page_162">[Pg 162]</span> -of dust inhalation, of chemical poisoning, of -industrial infections including tuberculosis, and of the -general depressing effect of protracted monotonous -work. The evils of industrialism like those of urbanization -are happily being in a large measure counteracted.</p> - - -<h3><em>Poverty</em></h3> - -<p>The problems of industrialism in relation to health -cannot be adequately discussed apart from a consideration -of the remuneration for work, which necessarily -depends on the power of the worker to strike a -satisfactory bargain with his employer, and the extent -to which he can ensure regular employment. If these -conditions cannot be fulfilled, or if the breadwinner is -dead or disabled, poverty results, using this word here -in the sense of inability to provide for the personal and -family essentials of health. And here we are at once -faced with the problem of relation of population to -means of subsistence. Malthus in 1798 advanced the -pessimistic hypothesis that poverty is the inevitable -result of increase of population, which entitles him -to be characterised as the Schopenhauer of Political -Economy, as Schopenhauer was the Malthus of Philosophy. -Without attempting detailed discussion of -Malthus’s hypothesis, it is clear that the wealth of the -population depends upon</p> - -<p class="no-indent">1. The amount of food produced,<br> -2. The amount of materials produced,<span class="pagenum" id="Page_163">[Pg 163]</span><br> -3. The efficiency in preparation of these materials, and<br> -4. Convenience of transport.<br> -</p> - -<p>In all these particulars means of subsistence, considered -internationally, have during the last century -grown more rapidly than population; and now, whether -we like it or not, a new element has entered into the -problem in this and several other countries,—voluntary -control of births,—necessitating the estimation of -future growth of population on a radically different -basis from that of the past, and banishing the fear of -poverty as the result of too large a population.</p> - -<p>It may even become necessary to adopt some method -of national remission of taxation or subsidisation of -wages in accordance with size of the family, not only -in France, but hereafter in England, if in England, as -already in France, the voluntary control of births is -practised to an extent resulting in a stationary or even -a decreasing population. In America the possible need -for such action will not arise for several generations, -during which, however, unless the present trend of -events is changed, Roman Catholics appear likely -largely to replace Protestants, and the Slavonic and -Irish to preponderate over the Anglo-Saxon elements -of the population. It is possible, of course, that in -another generation the Roman Catholic Church may -not be able to continue its ban on birth-control, and -that the more “backward” (?) races will adopt similar -devices, including even the Japanese and the -Chinese.</p> - -<p><span class="pagenum" id="Page_164">[Pg 164]</span></p> - - -<h3><em>The Malthusian Hypothesis</em></h3> - -<p>(<em>a</em>) The Malthusian hypothesis has been held to -justify <i lang="fr" xml:lang="fr">the laissez faire, laissez aller</i> policy which held -the industrial world in its malignant grip during the -latter part of the eighteenth and the earlier part of the -nineteenth century, and from which we are not yet -completely freed. Workers were exploited and reduced -to a position of modified slavery; and this was -assumed by clergy and political economists alike to be -part of the ordered course of life. This doctrine was -made to support the belief that God had ordained the -poor man’s lot, with its attendant misery and hopelessness.</p> - -<p>On page 438 of the sixth edition of his book Malthus -says:</p> - -<div class="blockquot fs80"> - -<p class="no-indent">that the principal and most permanent cause of poverty has -little or no direct relation to forms of government, or the -unequal division of property; and that, as the rich do not in -reality possess the power of finding employment and maintenance -for the poor, the poor cannot in the nature of things, -possess the right to demand them, are important truths flowing -from the principle of population.</p> -</div> - -<p>In the first edition of his book a more extreme, -plainer statement of the position, as assumed by -Malthus, was given, but was omitted from later editions -(the extract is translated by Beale from a French -edition):</p> - -<div class="blockquot fs80"> - -<p>A man born into the world already occupied, if his family -can no longer keep him, or if society cannot utilise his work,<span class="pagenum" id="Page_165">[Pg 165]</span> -has not the least right whatever to claim any share of food, -and he is already one too many upon the earth. At the great -banquet of Nature there is no cover laid for him. Nature -commands him to go and she is not long in putting this order -herself into execution.</p> -</div> - -<p>Malthus supplied the clue which helped to start Darwin -on his epoch-making investigations; and to the -present day there are men who do not appreciate that -the mutual aid which is fundamental in human society -is an enemy to the continued operation of natural selection, -and that we cannot revert to natural selection -without destroying the characteristic work of civilization. -To think otherwise is the secret behind German -aggression; to act otherwise is to revert to barbarism. -Man has definitely replaced natural by rational selection, -and will, I have no doubt, to a steadily increasing -extent replace competition by coöperation.</p> - -<p>(<em>b</em>) The Malthusian hypothesis and the policy based -on it ignored the human element in industry. Happily -revolt against the strict application of the <i lang="fr" xml:lang="fr">laissez -faire</i> policy set in soon after urbanization and industrialism -(under the then conditions) began their maleficient -work, first in regard to children, then for -women, and latterly more general in character.</p> - -<p>Nothing is more conspicuous in recent years than -the growth of sensibility on the subject of economic -evils, especially as to the conditions of industry. Economic -efficiency, as a sole object, appeared to preclude -regard to morality of method, and the result has been<span class="pagenum" id="Page_166">[Pg 166]</span> -poverty for the masses of mankind. If this is to cease, -satisfactory minimum standards of comfort and welfare -for the entire population must be accepted, which -will form a first charge on industry. This can only be -hoped for when there is complete practical acceptance -of the fact that “we are members one of another,” and -servitude is completely replaced by the ideal of mutual -service.</p> - -<p>(<em>c</em>) The Malthusian hypothesis ignores the great -though paradoxical truth, that although under circumstances -permitting malnutrition and defective training, -large families spell poverty, especially when population -is not distributed where it is needed, the real -wealth of the world after all depends on man himself. -Nature gives him little that he can use in the form in -which he finds it. It is by him and by him alone that -“wealth” is created by converting useless into useful -matter.</p> - -<p>It appears to me clear that over-population need not -excite apprehension; that population in itself is the -only means by which national wealth can materialise; -and that our chief aim in securing national efficiency -must be to train each unit of the population adequately -for work, and to prevent the terrible loss of efficiency -due to avoidable sickness.</p> - -<p>And this brings me to the direct statement of the -truism that health progress can only be secured by -preventing preventible illness.</p> - -<p><span class="pagenum" id="Page_167">[Pg 167]</span></p> - -<p>Poverty and disease are allied in the closest relationship; -and while it is true that the removal of poverty -would effect a great improvement in national health, -it is even truer that the prevention of illness forms the -most important means for the avoidance of poverty.</p> - -<p>In various reports it has recently been shown that -in a number of districts an inverse correlation exists -between infant mortality and the amount of the family -income; the implication appearing to be that increase -of the lower income is the best and perhaps the only -method for obviating excessive loss of infantile life.</p> - -<p>In such an argument poverty evidently is considered -as an element, instead of as a highly complex -phenomenon needing to be further analyzed into its -constituent parts. In the instance quoted, the fact -that the correlation between poverty and high infant -mortality is not essential can be shown by examples -of low infant mortality in communities in which poverty -is the rule; by examples of high infant mortality -in which wages are high; and by other examples of -communities in which high infant mortality has been -lowered without any change in economic conditions.</p> - -<p>The social conscience cannot be satisfied until every -family has an income sufficing for all its essential -needs; but there are possibilities of successful attack -on infant mortality which can be pursued when economic -change is not within reach, and when such economic -change would not obviate the need for further<span class="pagenum" id="Page_168">[Pg 168]</span> -measures. Among such measures may be mentioned -the abolition of alcoholism, the provision of a pure -and adequate milk-supply, increased attention to domestic -and municipal sanitation, health teaching by -public health nurses, and prompt and adequate medical -and nursing assistance when required.</p> - - -<h3><em>Ignorance</em></h3> - -<p>It may have surprised you that I have not placed -ignorance in the forefront, before industrialism, urbanization, -and poverty, as the chief enemy of personal -and public health. I have no hesitation in -making the statement that although there is need for -large additions to present educational work in hygiene, -the utilisation of existing knowledge by those holding -responsible positions is even more important. Is it -not true that it is easier to promote educational -“drives” for any single branch of health education, -than to obtain money for the actual execution of health -work?</p> - -<p>Let us look more critically at educational work in -hygiene. Whose ignorance is it proposed to enlighten? -Ignorance is common to all classes, and it is fundamentally -important that systematic instruction in physiology -and hygiene should be given in all our schools; -and that especially every teacher should have adequate -training in these subjects, and in the recognition of the -common mental and physical defects of children. If<span class="pagenum" id="Page_169">[Pg 169]</span> -a course of instruction were given for all, approaching -that which is given for public health nurses at Yale -University, how much more hopeful would be the -prospect of public health progress, both in New and -Old England. But this does not cover the entire -needs of the case. Consider, for instance, the relation -of maternal ignorance to excessive child mortality.</p> - -<p>Maternal ignorance is sometimes regarded as a chief -factor in the causation of excessive child mortality. -It is a comfortable doctrine for the well-to-do person -to adopt; and it goes far to relieve his conscience in -the contemplation of excessive suffering and mortality -among the poor.</p> - -<p>This doctrine has found favour in occasional official -reports and in miscellaneous addresses. It embodies -an aspect of truth, but it is mischievous when it implies, -as it sometimes does, that what is chiefly required -is the distribution of leaflets of advice, or the -giving of theoretical instruction as to matters of personal -hygiene.</p> - -<p>There is little reason to believe that the average -ignorance in matters of health of the working-class -mother is much greater than that of mothers in other -classes of society. Furthermore, it would appear that -working-class mothers give their infants the supremely -important initial start of breast feeding in a larger -proportion of cases than do the mothers in other stations -of life.</p> - -<p><span class="pagenum" id="Page_170">[Pg 170]</span></p> - -<p>The mothers in both classes may be ignorant; in -both there is deficient training in habits of observation, -especially in regard to the beginnings of illness; but -the mother in comfortable circumstances is able to -ensure for her infant certain advantages which the -infant of the poorer mother often cannot obtain. -What are these?</p> - -<p>1. The well-to-do mother is commonly able to devote -herself to her infant and have assistance in this -duty; the working class mother is single-handed, and -has also to perform, unaided, all the duties of her -household, including the washing and cooking for her -husband and herself and possibly for several children.</p> - -<p>2. The well-to-do mother is commonly able to ensure -that the milk for her infant is purchased under -the best circumstances, is stored in a satisfactory pantry, -and is prepared under cleanly conditions. The -working-class mother often is supplied with stale, impoverished -milk, may have no pantry, and, except -when suckling her infant, is handicapped at every -stage in the cleanly preparation of her infant’s food.</p> - -<p>3. If the well-to-do mother is ill, adequate medical -and nursing assistance is at once available, and the -child’s welfare can be safeguarded; if the working-class -mother is ill, the child usually must suffer with -its mother.</p> - -<p>4. If the child of the well-to-do mother falls ill, -everything that good nursing and medical attendance<span class="pagenum" id="Page_171">[Pg 171]</span> -can furnish is commonly at once available; for the -child of the working-class mother the state of matters -is remote from the ideal. Facilities for obtaining -medical attendance and nursing vary greatly in different -districts; but in none are they satisfactory for -the poor, and especially for the classes who have -limited incomes, but do not as a rule receive skilled -hospital treatment, or avail themselves of help from -nursing associations. Prompt medical assistance at -home commonly cannot be afforded for children of -wage-earners, and particularly not for the children of -unskilled workers.</p> - -<p>5. Infants and nursing mothers are very rapidly influenced -by their environment. This environment is -complex. The mother is the main element in the environment -of the infant. If she is overworked and -suffers from chronic fatigue her infant must suffer; -directly, because the mother’s milk under these circumstances -is liable to be scanty or impoverished or -otherwise unwholesome; or indirectly, owing to her -being unable to give sufficient attention to her infant. -The infant of the well-to-do mother is less likely to -suffer in either of these ways.</p> - -<p>6. Not only are the milk supply, and the storage and -preparation of artificial food, important parts of the -environment of the infant, but so also are the housing -conditions of the family, and the sanitary conditions -of the back-yard and of the street in which the house<span class="pagenum" id="Page_172">[Pg 172]</span> -is situate. The superiority of the circumstances of -the one mother and infant over those of the other in -these respects is obvious.</p> - -<p>There is no reason to assume that the one mother is -more ignorant than the other. But the ignorance of -the working-class mother is dangerous, because it is -associated with relative social helplessness. To remedy -this what is needed is that the environment of the -infant of the poor shall be levelled up towards that of -the infant of the well-to-do, and that medical advice -and nursing assistance shall be made available for the -poor as promptly as it is for persons of higher social -status.</p> - -<p>The assistance given will include advice, but it will -be the advice which a medical practitioner gives to his -patient; which a health visitor or public health nurse -gives as to personal hygiene; and which a sanitary inspector -gives to a householder. It should include also -the advice given by a trained midwife or midwifery -nurse, who is in a favourable position to secure the -adoption of her advice by the mother. Such advice is -becoming available to a steadily increasing extent, but -in some industrial towns a majority of midwives and -midwifery nurses are still untrained women, who are -not competent to give the best advice.</p> - -<p>I would not have it assumed that I do not attach -high values to the teaching which the physician gives -to his patient and the public health nurse to the healthy<span class="pagenum" id="Page_173">[Pg 173]</span> -mother and infant; but unless this is combined with -assistance to provide the necessary means to health, -whether this be hospital treatment, home nursing, pure -milk, improved domestic conditions, or help to the -over-tired mother, the advice falls far short of its -potentialities for good.</p> - -<p>There is need for further instruction of the public -in all branches of hygiene; and we need, if we are -to be efficient in social work, to follow the advice of -Oliver Wendell Holmes, to remove the intellectual -<i lang="la" xml:lang="la">membrana nictitans</i> from our eyes, and to consider the -physical and moral as well as the intellectual obstacles -to health.</p> - -<p>In the cultivation of communal health</p> - - -<h3><em>Defects of Character</em></h3> - -<p class="no-indent">are even more pernicious than lack of knowledge. No -member of any of our local authorities can fail to -have been warned that typhoid fever is still being -spread in many communities by impure water, and as -the result of inadequate hospital isolation of cases. -The means of prevention of tuberculosis are well -known; but how few local authorities will face the -problem of supplying adequate funds for clinics, for -examination of contacts, for hospitals for bed-ridden -cases, and for convalescent homes; and how few are -willing to give help to ensure that the consumptive<span class="pagenum" id="Page_174">[Pg 174]</span> -patient has a separate bedroom? In how few instances -are the regulations against indiscriminate expectoration -enforced, and how seldom are physicians -called to account for not obeying the law as to prompt -notification of cases of tuberculosis? Will all the -“drives” against tuberculosis effectually remedy this -condition of things? Would not public opinion amply -support <em>the one “drive” which, above all others, is -necessary</em>: a systematized effort on the part of all social -workers to exact a definite promise from every -candidate for local or state office that he will give -earnest support to all well-considered anti-tuberculosis -measures, for the diminution of venereal diseases, for -improving the welfare of mothers and their children, -for promoting school hygiene, and for improving the -housing of the poor. Democratic Government, alas! -hitherto, has meant government by active minorities. -The great danger of democracy is that the minority -may and often does consist largely of persons having -a mercenary interest in the machinery of local government. -Why should not it become an active and -preponderant minority of health gospellers? This -will involve the taking of infinite trouble to overcome -the multiform activities associated with “political -pull”; it will involve the watching of the record of -each elected person, merciless exposure of those who -do not whole-heartedly support reforms, and systematic -effort to prevent the reëlection of all whose record<span class="pagenum" id="Page_175">[Pg 175]</span> -proves unsatisfactory. Are we equal to this task? Is -our national and local patriotism equal to this heroic -test, involving most prosaic work, the surveillance and -the “besting” of the politician? If not, our indirect -attack on the enemy by means of special educational -drives can have relatively little effect. Where the -enemy is, there our fight should be; and the chief enemies -of health are local authorities possessing powers -to secure health for the community, who corruptly or -parsimoniously refrain from their duty. Nor can we -avoid responsibility, or the need for strenuous effort -after efficiency by not taking part in official or voluntary -administrative work. We may have sufficiently -good reasons for this abstinence; and onlookers have -their rôle in life. If all were authors, where would -be the readers? There are many indifferent writers -who would be appreciative readers, and the same remark -applies in local administration. Appreciation is -necessary as well as a subject to be appreciated; and -the onlooker at social work may be most helpful. If -he is to be helpful he must be kindly and charitable, as -well as watchful. Rancorous and ill-informed criticism -must be avoided, and the onlooker must be ready -to do justice to good work, or attempted good work. -Nothing has made it so difficult to secure good men to -undertake the burden of local government as the undiscriminating -and uncharitable criticism aimed at -those engaged in it. Criticism of representatives has<span class="pagenum" id="Page_176">[Pg 176]</span> -often been deserved; but critics are too often those -who will not aid to the slightest extent in the work -which, often without sufficient knowledge of the facts, -they vilify. When we read of administrative scandals, -it is desirable to have a sense of proportion, and -to remember, as the reader of old records or even of -Pepys’ diary will scarcely need to be reminded, that -corruption was rampant in the past, and especially to -remember that the best way to remove that most subtle -and mischievous form of corruption which consists in -giving and accepting appointments as political rewards, -is by ourselves taking a part in local government, -or by steadily upholding those who are doing so -with integrity.</p> - -<p>The onlooker, then, has his duty to perform as well -as the administrator. He cannot do his duty unless -he intelligently studies local administration, even -though he takes no part in it. A chief need is this interested -study of the phases of local administration -by the general inhabitants of each district. Happily -there are indications of the increasing local patriotism -which such study implies. The exact knowledge thus -acquired is the best means of neutralising much of -the ill-natured, because ill-informed, criticism with -which the founts of local administration are too often -fouled. A high moral ideal on the part of onlookers -as well as of administrators is needed if we are to -secure that high standard of social efficiency which is<span class="pagenum" id="Page_177">[Pg 177]</span> -an indispensable condition of the further triumphs of -preventive medicine now waiting to be secured.</p> - - -<h3><em>Ideals</em></h3> - -<p>In my discussion of the difficulties of health progress, -I have evidently encroached here and there on the second -division of my lay sermon. Let me now attempt -to state more systematically some ideals of health and -means for their realisation.</p> - -<p>Intelligent human society, permeated more than we -realise by the essentials of Christianity, has already -gone far in securing remedies, notwithstanding the too -frequent other-worldliness or lack of vision of those -who should have been foremost in rebuilding Jerusalem -in this green and pleasant land. Industrialism -no sooner huddled together labourers and their families -in the courts and alleys of insanitary towns and -overworked them for scanty wages, than the voices of -such philanthropists as Percival, Oastler, Shaftesbury, -Owen, and of many others were heard in favour of -interference with that freedom (!) of contract between -workers and employers, which the professors -of the dismal science regarded as a fundamental principle -in political economy. And so gradually, too -slowly, regulated industry, improved sanitation, better -housing, the isolation and hospitalisation of infectious -cases, the readier access than in rural districts of all<span class="pagenum" id="Page_178">[Pg 178]</span> -sick to skilled treatment, higher wages, better food -began to counteract the evils of industrialism and -urbanization. Communal action was taken in the -regulation of industry, in the promotion of sanitation, -in providing elementary education; and the result is -seen in the remarkable fact that, notwithstanding its -enormous handicap, urban life has become almost as -safe as rural life, so far as life itself is concerned, -though not in standard of health.</p> - -<p>The first lesson, then, which has already been partially -learnt, is that <em>no member of a community can -live to himself</em>. We now believe in the solidarity of -society; that the sores of one section of it means peril -for all. And we are gradually learning to appreciate -that this is true not only in respect of the acute infectious -diseases, and of chronic infectious diseases, such -as tuberculosis and syphilis, but of every disease and -of every other factor in life which causes individual -inefficiency, and which consequently inflicts additional -burdens on the competent section of the community. -I do not wish to underestimate the basic self-centredness, -if not actual selfishness, which, to a varying extent, -is part of the nature of all of us; but in industrial, -as in other social problems, whatever may be the intermediate -turmoil and misunderstandings and disturbance -which appear to loom so threateningly, it is plain -that the mere cash nexus of relationship is becoming -more and more entangled in a moral nexus; and that a<span class="pagenum" id="Page_179">[Pg 179]</span> -prophet’s vision is scarcely needed to forecast a future -of consolidation and conformity of efforts of employers -and employed such as has never yet been generally -realised. In such a consolidation the idea of servitude -will disappear, and mutual service will take its place. -This will happen by the growth of an idealistic standpoint; -even more, perhaps through motives of community -self-defence.</p> - -<p>Secondly, the Great War, though the most terrible -calamity to humanity of the ages, has brought out a -most comforting and elevating thought. <em>Our brothers -and our sons</em>,—and our daughters also in a multitude -of munition and other works,—have proved that, under -the overwhelming moral compulsion of national need, -they <em>are willing and ready to lay down their lives for -great impersonal things</em>, and in their hundreds of thousands -they have done so. Coincidently with this, a -great impetus has been given to work for the health -and welfare of the civilian population, and especially -of mothers and their children. The removable horrors -and losses of peace, in the aggregate, are greater than -those of war. Cannot an equal spirit of sacrifice be -induced against these? Is it not possible to evoke a -like devotion to secure the triumph of good over evil, -of clean administration over political pull, of fair dealing -over industrial exploitation, of adequate output -over “slacking,” of determination to spend and be -spent to secure the welfare of all, in peace as in war?</p> - -<p><span class="pagenum" id="Page_180">[Pg 180]</span></p> - -<p>Thirdly, prior to the war, for years, many among us -had been realising to an increasing extent the supreme -importance of the Mother and the Child, in safeguarding -family life, and in securing the beginnings of personal -and national health. In past years medical officers -of health have been busily occupied in struggling -to overcome epidemic diseases, and in attacking the -circumstances favouring their prevalence. But for -twenty years, at least, the outlook has widened; the -physiological as well as the pathological aspects of -hygiene have received attention; and it has been realised, -more and more, that in the conservation and -upbuilding of the health of the infant and the pre-school -child rests the chief hope of the future; and -somewhat more recently, public health policy has directed -itself to the protection of motherhood, on which -depends essentially the welfare of the child.</p> - -<p>This can only be done by ensuring, chiefly through -its mother, <em>for every newcomer on the stage of life, in -all essential points, a footing of equality of opportunity, -physical, mental, and moral, with all others</em>.</p> - -<p>The ideal that every child should have equality of -opportunity is really part of a general upward movement -in our national ethical life.</p> - -<div class="blockquot fs80"> - -<p>The thoughts of men are widened with the process of the suns.</p> -</div> - -<p>We begin to appreciate the full significance of the -older words, “it is not the will of your Father that one -of these little ones should perish”; and this ideal<span class="pagenum" id="Page_181">[Pg 181]</span> -happily is now certain to replace the materialistic doctrine -of the German type which drives the weaker to -the wall.</p> - -<p>Progress has been slow; but when we recall how -true it was in St. Paul’s day that “the whole creation -groaneth and travaileth in pain together until now”; -and how gradually through the ages the mass of human -suffering has been abated, we can, while regretting -the slow rate of progress, gain encouragement for -more rapid future advance. The abolition of slavery, -the higher position of women, the steadily increasing -force leading towards one standard of sexual morality -for both sexes, the improved conditions of housing and -sanitation notwithstanding the impediments of urban -life, and the increasingly humanitarian conditions of -modern industrialism, all give us reason to lift up our -hearts.</p> - -<p>There have been three stages in the attitude of mankind -to altruistic work. The first of these is illustrated -by the attitude of the father who said to his -son: “Learn, my son, to bear tranquilly the calamities -of others.” Is not the second stage, illustrated by the -sleeping disciples in the Garden of Gethsemane, ignorant -or regardless of the impending tragedy; while -the third stage is manifest in the thousands of earnest -social workers,—and the supremely important conscientious -members of our governing bodies come in this -group,—who are endeavouring to secure the realisation<span class="pagenum" id="Page_182">[Pg 182]</span> -in communal practice of every measure for uplifting -mankind.</p> - -<p>It is well for mankind that the Mother and the -Child have become the foundation on which, more and -more, we expect health progress to be built.</p> - -<div class="poetry-container fs80"> -<div class="poetry"> - <div class="stanza"> - <div class="verse indent4">A child more than all other gifts</div> - <div class="verse indent4">That earth can offer to declining man</div> - <div class="verse indent4">Brings hope with it and forward looking thoughts.</div> - </div> -</div> -</div> -<p class="right fs80">(Wordsworth.)</p> - -<p class="no-indent">The history of the Mother and Child summarises the -history of the uplifting of mankind: and although -there are not lacking sinister elements in the present -position, it is a great gain that both in regard to the -Mother and Child and to the saving of life and improvement -of national health generally, we are beginning -to realise that this is not merely a question of -self-interest, personal or national; but that we are concerned -also with duty, and honour, and chivalry.</p> - -<p><span class="pagenum" id="Page_183">[Pg 183]</span></p> - - -<div class="footnotes"><h3>FOOTNOTES:</h3> - -<div class="footnote"> - -<p><a id="Footnote_15" href="#FNanchor_15" class="label">[15]</a> A lecture given to the Alumni Association of the University -of Yale, January 22, 1920.</p> - -</div> -</div> - - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<h2 class="nobreak" id="CHAPTER_VIII">CHAPTER VIII<br><br> -<span class="smcap fs80">Some Aspects of Poverty</span> -<a id="FNanchor_16" href="#Footnote_16" class="fnanchor">[16]</a></h2> -</div> - -<p>I use the word Poverty, for the purpose of this discussion, -as meaning Destitution, in the sense of lack -of means to provide some specific requirement, indispensable -for the health of the family, or the individual.</p> - -<p>Such poverty is evidently undesirable and mischievous, -from the point of view of both rich and -poor; and I think we shall agree that, given the adoption -of the requisite measures, its continuance in most -instances is unnecessary. Hence the real subject for -discussion is, how poverty may be diminished and -prevented.</p> - -<p>I do not propose to touch on the important subjects -of unemployment, of under-employment, or of the relation -between the size of family and poverty, though -the last named of these opens up an interesting subject -of discussion. (On this see page <a href="#Page_164">164</a>.) I shall confine -my remarks to the very obvious relation between poverty -and sickness, and to the neglect to act on our -present knowledge, which if acted on would in a short -time lead to a great reduction of poverty in our midst.</p> - -<p><span class="pagenum" id="Page_184">[Pg 184]</span></p> - -<p>There is much truth in each of the statements that -poverty is responsible for much disease, that disease is -responsible for the greater part of the total poverty in -our midst, and that poverty begets poverty.</p> - -<p>Poverty and disease are allied by the closest bonds, -and nothing can be simpler or more certain than the -statement that the removal of poverty would effect an -enormous reduction of disease. The removal of poverty -must, therefore, be in itself an object always fascinating -to those whose study is the public health. -The diseases which would be reduced by this means, -include not merely those which physicians treat, but -many moral diseases which persist because they are -only to be avoided by the poor through the exercise of -discipline and self-restraint far beyond what is practised -by the average person in classes not subject to -poverty. The happiness of a community being in itself -a desirable object, a national asset, it is also not -irrelevant to consider that the removal of poverty -involves enlarged opportunities for enjoyment which, -rightly directed, would be only of less value than the -removal of disease. It is not surprising, therefore, -that the first impulse of a student of the public well-being, -in which the public health is the most important -factor, is to attack disease by demanding the reduction -of poverty, with its more or less inevitable accompaniments -of over-fatigue, privation, overcrowding, and -dirt. And it must be freely admitted that when the<span class="pagenum" id="Page_185">[Pg 185]</span> -most active public health administration, including -adequate medical aid for the sick, has attained its utmost -efficiency, and has in every respect done all that -it can to reduce disease, there will still remain a cruel -residuum which can be attacked in no other way than -by the removal of poverty, or by the removal from -poverty of the elements of personal privation which -affect the public health.</p> - -<p>The importance attached to poverty as a cause of -illness and mortality is illustrated in reports on local -investigations, displaying an inverse relationship in -different communities between family income and the -rate of infant mortality, the reader being left to infer, -that increase of the lower incomes is the one method -for obviating excessive loss of infantile life. In suggesting -this crude generalization it is evident that poverty -is being regarded as an element, instead of as a -highly complex phenomenon, which needs to be further -analysed into its constituent parts. The crude generalised -statement as to the relation between excessive -mortality and poverty, furthermore, fails to bring out -three essential points, viz., that infant mortality may -be very low in communities in which poverty is the -rule; that it may be high in the absence of poverty; -and that where infant mortality is high, it can be -greatly reduced without change of economic conditions.</p> - -<p>There should be an adequate family income for -every family; and the social conscience cannot be satisfied<span class="pagenum" id="Page_186">[Pg 186]</span> -until this is realised. But, in seeking for practical -reform we must appreciate that a large share of -the disease and of the inefficiency of the individual and -family associated with poverty can be remedied otherwise -than by an increase of the family income. This -is shown by national and international experience. -The death-toll on infant life is very much lower in -Norway and in Ireland—both relatively poor countries—than -in England. Poverty in these instances -evidently has less weight than the favorable factors -of rural life and natural feeding. A like discrepancy -in experience of infant mortality is seen between the -experience of towns, and of wards in the same town, -with approximate equality as regards poverty. Similarly -in England the infants of miners with relatively -high wages suffer a higher mortality (160 per 1,000 -births in 1911) than the infants of textile operatives -(148) with relatively low wages; while the latter suffer -more than the infants of agricultural labourers (97). -These instances at once suggest that some conditions -in town life play an important part in causing excessive -infant mortality; that in towns insanitary conditions -and habits of life are even more injurious than the -absence from home of the industrially employed -mother; and that the causation of infant mortality is -complex, and its prevention necessitates a multifarious -attack on social and industrial evils, the character of -this attack necessarily varying in different localities,<span class="pagenum" id="Page_187">[Pg 187]</span> -in accordance with the incidence of these evils. That -the influence of urban life in causing excessive mortality -can be counteracted is shown by the varying -mortality in different urban communities, and in different -parts of the same town.</p> - -<p>We may in a given instance be totally unable to increase -the family income; but the family’s present expenditure -may be more satisfactorily distributed; and -some, at least, of the constituent elements of poverty -producing excessive child mortality can be obviated. -We know, indeed, that this can be done. The fact -that in the United States no part of the family income -can be spent on alcoholic drinks, implies the removal -from multitudes of families of the demoralising influences -associated with alcoholism, which are unfavourable -to the health of adults and children alike.</p> - -<p>Similarly, increased attention to domestic and municipal -sanitation and to the provision of a pure and -adequate milk supply, the health teaching given by -public health nurses, and the prompt medical and hygienic -guidance at Child Welfare Centres are having -an important influence in the same direction. Work -on these medical and sanitary lines, for both adults -and children, comes legitimately within the sphere of -the work of Public Health Authorities, provided out -of rates and taxes.</p> - -<p>It may be urged that such provision, after all, means -supplementation of the family income at the public expense.<span class="pagenum" id="Page_188">[Pg 188]</span> -It is more properly to be regarded as a measure -of insurance against contingencies by which every -member of the community is benefited; for we are -each and all concerned in the efficiency of every other -member of the community. We are members one of -another. The objection stated above has no greater -validity than an argument similarly advanced against -the provision of police protection or of sanitary measures -out of public funds.</p> - -<p>Elementary, and to some extent secondary and university, -education are regarded as not only the legitimate -subjects of communal provision, but also as incapable -of being provided satisfactorily by each individual -family; and this view applies with even greater -force to the provision of hospitals and expert medical -assistance, of nursing assistance, and of such additional -occasional domestic service as is required to -maintain the functional integrity of the family.</p> - -<p>I have given the above as a special instance of the -contention that poverty is a complex, including a number -of elements, and that it is our duty to ascertain in -each area by careful local inquiry what are these constituent -elements, and if practicable their relative -weight; and then to apply the most urgently needed -remedies, not contenting ourselves with the relatively -useless generalisation that the evils we see are ascribable -to poverty.</p> - -<p>I lay special stress on the provision of skilled medical<span class="pagenum" id="Page_189">[Pg 189]</span> -advice and treatment, and of nursing assistance -at the public expense, which at present are sorely deficient -for the vast majority of the population, and perhaps -for none more so than for the less well-to-do -people who receive salaries and not weekly wages. -This assistance possesses the special advantage previously -pointed out, that it does not tend to create a demand -for further assistance, when such assistance is -not required.</p> - -<p>The greatest bulk of poverty is due directly to sickness. -A vast mass of sickness still occurs, which is -not owing to lack of family or communal means, but -is due to ignorance or neglect on the part of the individual, -of the responsible owners of houses, of the -employers of work-people, and still more of the members -of local authorities or state legislatures. Typhoid -fever still commonly prevails as the result of neglected -sanitation; hookworm disease still causes incapacity -of hundreds of thousands for the same reason; malaria, -still one of the greatest scourges of humanity, -might be reduced to a fraction of its present amount -if each community and each person would carry out -available simple preventive measures; tuberculosis is -still spread throughout every civilized community -chiefly because indiscriminate expectoration is unregulated, -and satisfactory and acceptable hospital treatment -is not provided for all those who need it. And -so we continue to allow avoidable poverty to be perpetuated, -and to impose not only on the sick poor themselves,<span class="pagenum" id="Page_190">[Pg 190]</span> -but also on the efficient and solvent part of the -community a heavy burden, the removal of which -would, to an almost incredible extent, increase the -general happiness of mankind.</p> - -<p>The relief of poverty is at the best an inefficient and -expensive remedy. It is seldom adequate, and it has -few preventive elements. The prevention of poverty -by prevention of the illness causing it, and by early -and satisfactory treatment of such illness as fails to -be prevented is the only efficient, as well as in the long -run the only economical plan of campaign. Money insurance -against sickness has its place as a means of -alleviating the results of poverty. But it is not an aid -to its prevention; under any existing system of insurance -the money payment is insufficient and definitely -limited in duration. Although such relief is useful, -it is totally unsatisfactory when not linked up with a -complete system of hygienic measures, and when not -associated with adequate medical treatment and nursing. -For the linking of treatment provided largely -out of public funds with insurance there is no justification, -and it is contrary to the public interest; and -it is unfortunate that monetary insurance has been -provided in England for a section of the population -under these unsatisfactory conditions, thus diverting -expenditure from the public health services in which -it was urgently needed, and in which its use would at -once have been fruitful in increased health and happiness.</p> - -<p><span class="pagenum" id="Page_191">[Pg 191]</span></p> - - -<div class="footnotes"><h3>FOOTNOTES:</h3> - -<div class="footnote"> - -<p><a id="Footnote_16" href="#FNanchor_16" class="label">[16]</a> An address to the Political Economy Club, Johns Hopkins -University, Jan. 19, 1920.</p> - -</div> -</div> - - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<h2 class="nobreak" id="CHAPTER_IX">CHAPTER IX<br><br> -<span class="smcap fs80">The Causation of Tuberculosis and the Measures -for its Control in England</span><a id="FNanchor_17" href="#Footnote_17" class="fnanchor">[17]</a></h2> -</div> - -<p>My task is to attempt to give a bird’s-eye view of -“The Methods of Controlling Tuberculosis in England,” -and to revaluate, as far as is practicable, in the -light of many years’ study of the disease, the relative -value of the measures which historically have been -followed by the greatly reduced mortality from tuberculosis. -The subject teems with difficulties, and as -you are aware there is no unanimity of opinion when -tuberculosis is thus considered. This is the more surprising -in view of our present accurate knowledge of -the pathology of disease caused by bovine and human -tubercle bacilli, and in view of the fairly general unanimity -of opinion as to the methods of control which -are needed to secure still more rapid reduction of the -devastations of tuberculosis. This general opinion -may, I think, be summarised in the statement which I -have made elsewhere, that the removal or diminution -of infection from each single case of tuberculosis -reduces correspondingly the prospect of further cases,<span class="pagenum" id="Page_192">[Pg 192]</span> -but that tuberculosis will not be completely controlled -until every tuberculous patient receives such care -throughout the whole course of his life, as will ensure -his welfare and will obviate the likelihood of his infecting -others.</p> - -<p>It is noteworthy that the English death-rate from -pulmonary tuberculosis—which is responsible for 71 -per cent. of the total mortality from tuberculosis, and -which is practically always due to infection from a -human source,—declined in males between 1871-75 -and 1876-80 by 7.2 per cent.; in the next quinquennium -by 9.8 per cent.; between 1881-85 and 1886-90 -by 8.3 per cent.; in the next quinquennium by 9.5 per -cent.; between 1896-1900 and 1901-05 by 7 per cent.; -and between 1901-06 and 1906-10 by 9.7 per cent. -Evidently a large share of the reduction of the death-rate -from phthisis occurred before it was generally regarded -as an infectious disease, and before sanatoria -were in existence for its treatment. It should be -added that since the possibilities of infection have been -realised and the need for treatment of the disease has -been appreciated, there has in no part of the world, -so far as I am aware, been an adequate application of -known methods of prevention and treatment.</p> - -<p>We must look elsewhere, therefore, than to intentional -measures directed against tuberculosis for an -explanation of its decline during the period before -Koch discovered the tubercle bacilli and before the<span class="pagenum" id="Page_193">[Pg 193]</span> -significance of this discovery was appreciated; and -attempt to appreciate the relative value of the factors -of decline operating before and since our outlook on -the disease was fundamentally changed.</p> - -<p>Certain facts stand out beyond controversy, and -on these administrative control must necessarily be -based.</p> - - -<h3><em>Basic Facts as to Tuberculosis</em></h3> - -<p>1. Tuberculosis is a chronic infectious disease with -a low degree of infectivity. Circumstances favouring -infection have a high degree of importance; but tuberculosis -does not develop in the absence of the tubercle -bacillus. No infection, no disease.</p> - -<p>2. Tuberculosis may remain latent in the system for -many years, and there is strong reason for thinking -that the infection of a large proportion of early adult -tuberculosis was acquired in childhood.</p> - -<p>3. The two types of tubercle bacilli, bovine and human, -are stable both in character and in degree of -virulence, and are not interchangeable so far as can -be shown by protracted experimentation. The human -type of bacillus is the chief source of infection of -mankind, though bovine infection is not negligible.</p> - -<p>Out of 98 children between the age of 2 and 10 years -who had died in various hospitals from all causes unselected, -18 or 18.4 per cent. were found to have been -infected by tubercle bacilli of the bovine type, and 81<span class="pagenum" id="Page_194">[Pg 194]</span> -or 81.6 per cent. by tubercle bacilli of the human type. -(Report on Investigations made in the Laboratory of -the Local Government Board, Annual Report of the -Medical Officer of the Local Government Board, -1913-14, p. lix.)</p> - -<p>4. Animal experimentation shows that in animals of -the same species the extent of tuberculosis produced -depends to a large and probably to a dominant extent -on the number of tubercle bacilli introduced into the -system. Although doubtless there are variations in -susceptibility in families, and in each individual at different -periods, there is little doubt that in the main -the same rule holds good for mankind.</p> - -<p>5. Experience shows that dusty occupations, indoor -occupations, alcoholism, over-fatigue, an attack of -acute illness, especially of influenza, measles, or enteric -fever, increase the danger of minimal doses of tubercle -bacilli, and serve to bring latent foci of disease into -activity.</p> - - -<h3><em>Explanations of the Decreasing Death-rate from Tuberculosis</em></h3> - -<p>In the light of the above facts, how is the steady -and continuous decline in the death-rate from tuberculosis -during the last fifty years to be explained?</p> - -<p>(<em>a</em>) No support is given by animal experiment to -the assumption that the types of human bacillus infecting -mankind have declined in virulence; and changes<span class="pagenum" id="Page_195">[Pg 195]</span> -in the severity of consumption historically or currently -in different races of mankind are equally explicable on -the ground of differences in social misery, in sanitary -conditions and associated heavier dosage of infection -and neglect of treatment.</p> - -<p>(<em>b</em>) The facts do not appear to me to be reconcilable -with the assumption that natural selection has -increased human resistance to infection by tuberculosis; -though, were this so, it would not justify refraining -from every possible effort to control infection and -to treat every tuberculous patient by the best known -methods. Tuberculosis is an ancient disease, there -being evidence of it in Egyptian mummies 1000 years -B.C.; and any selective agency has, therefore, had -ages for its operation. If the steady decline—approximating -2 per cent. per annum in the death-rate from -pulmonary tuberculosis in England during the last -thirty or forty years—has resulted from the acquirement -of racial immunity, it is remarkable that a somewhat -similar decline has occurred almost simultaneously -during the last forty years in Great Britain, -Germany, and America; while in France, Norway, -and Ireland there has been little if any decline, or it -has occurred only in very recent years.</p> - -<p>To assume that susceptibility to the tubercle bacillus -in the course of its natural history has diminished in -England, and that Ireland has not shared in this privilege -would be to add one more to Irish grievances!<span class="pagenum" id="Page_196">[Pg 196]</span> -This assumption does not fit in with international facts; -which point rather to the conclusion that, during the -period in question, unsatisfactory sanitary and social -circumstances, including opportunities for massive and -protracted infection, have continued to a greater extent -and for a longer time in Ireland and France than in -Great Britain, America and Germany.</p> - -<p>(<em>c</em>) If the assumption of increasing racial immunity -does not consist well with all the facts, more perhaps -can be said in favour of the unproved hypothesis that -a high proportion of the population are from time to -time temporarily immunized by small doses of tubercle -bacilli; and their resistance to larger doses of infection -thereby increased. Experimentally calves inoculated -with small doses of tubercle bacilli remain during the -next year or two unaffected by much larger doses of -tubercle bacilli, unlike calves not submitted to this -treatment. Tubercle bacilli are somewhat widely distributed, -though they occur chiefly in the immediate -environment of careless consumptive patients; and it -is conceivable that minimal doses of bacilli may arouse -the resistance of the cells and fluids of the body and -prepare them to resist successfully larger doses of -infection. This is consistent with the fact that while -one in about ten deaths from all causes is caused by -tuberculosis, a majority of the total population are -shown by pathological evidence to have been at one -time or another infected by tuberculosis, and yet have<span class="pagenum" id="Page_197">[Pg 197]</span> -either never been ill, or have recovered, usually without -the existence of tuberculosis being detected or -even suspected. Obviously this is satisfactory evidence -that mankind is relatively resistant to the infection -of tuberculosis.</p> - -<p>The fact just mentioned naturally leads to the question: -what determines the result when tubercle bacilli -invade the human subject? Assuming fairly uniform -virulence of tubercle bacilli, the result for an infected -person depends on two factors: the dosage of infection, -and the resistance of the cells and fluids of the -invaded person; and evidently increase in the dosage -of infection and lowering of personal resistance may -have identical effect in determining serious disease. -Of the importance of the already mentioned factors -which lower personal resistance to disease,—often also -at the same time increasing infection,—there can be -no doubt.</p> - -<p>It is impossible in most instances to set out separately -circumstances increasing infection from circumstances -lowering resistance. During the last three or -four decades there has been improvement in respect -of the factors lowering resistance to attack, but there -has been simultaneously a great decline in opportunities -for infection on a massive scale, as a result of -habits of greater cleanliness, especially in regard to -spitting, of diminished overcrowding of population, -and of increased treatment and the incidental segregation -of advanced cases of disease in hospital beds.</p> - -<p><span class="pagenum" id="Page_198">[Pg 198]</span></p> - - -<h3><em>Hospital Treatment of Consumptives</em></h3> - -<p>I have seen no reason for revoking the conclusion -expressed in 1908 in a lecture to the Washington International -Congress on Tuberculosis that historically the -hospital treatment and coincident segregation of patients -suffering from pulmonary tuberculosis has been -an important and probably a dominant factor in producing -the national decline in the death-rate from tuberculosis -in the countries in which a decline has been -experienced. This explanation fits in with our knowledge -of the disease, and with the analogous history of -leprosy; and it is supported by the fact that by complete -segregation of infected from non-infected cattle -tuberculosis can be eliminated at will from a herd of -cattle. It is remarkable, as I have elsewhere set out -in much detail, that improved general health, increased -well-being, and sanitary education have operated in -Great Britain, Germany, Belgium, Denmark, and Massachusetts -side by side with great decrease in the death-rate -from pulmonary tuberculosis; while up to very -recent years the same influences in France, Norway, -and Ireland have produced little or no decrease in the -national death-rate from tuberculosis. And similarly -no constant relation can be shown between the degree -of sanitary and social well-being in different countries -and cities, and the amount of mortality imposed by -tuberculosis. How is it that in some countries a high -degree of domestic overcrowding is associated with a<span class="pagenum" id="Page_199">[Pg 199]</span> -low and declining phthisis death-rate and conversely -that a persistently high phthisis death-rate may occur -with a less but still diminishing degree of overcrowding? -The explanation is contained, I maintain, in the -following statement:</p> - -<p><em>A given amount of domestic overcrowding with a -large amount of institutional segregation of consumptives -is associated with less tuberculosis than when -overcrowding is less but accompanied by only a small -amount of institutional segregation of consumptives.</em> -The data as to institutional segregation are difficult -to obtain; but there is sufficient evidence to show that -in countries which have experienced a large reduction -in the death-rate from tuberculosis a large proportion -of hospital treatment for many years has been provided -for consumptives, while in countries which have -not experienced this decline such provision has been -absent or imperfect. In London about 56 per cent., -in county boroughs 35 per cent., in other urban districts -21 per cent., and even in rural districts of England -near 16 per cent. of all deaths from pulmonary -tuberculosis occur in hospitals (poor-law institutions, -general and special hospitals, and asylums). Prior to -the patient’s death he has had on an average at least -three months, and probably in the aggregate more -nearly five or six months, residential treatment, and -this at the stages of disease in which there is the greatest -discharge of infective material, in which owing to<span class="pagenum" id="Page_200">[Pg 200]</span> -feebleness the patient is least able to control its hygienic -disposal, and in which—had the patient been -treated at home—the relatives would be especially -liable to receive massive infection, and would be enfeebled -by overwork and anxiety, or by the malnutrition -associated with poverty.</p> - -<p>Some writers have failed to visualize the fact that -the segregation of a minority of the total cases of pulmonary -tuberculosis for a portion of their illness can -have had a marked influence on the prevalence of this -disease. They appear to be judging tuberculosis by -the same measure as they would apply to smallpox, -which in an unprotected community spreads rapidly if -a few cases are overlooked. The case of tuberculosis, -like that of leprosy, is governed by the considerations -that both these diseases as a rule require intimate and -protracted contact for their spread, and that in both -diseases there may be prolonged latency before active -disease develops. A hypothetical illustration may serve -to elucidate the order of magnitude of the influence -exercised by institutional segregation. Let us assume—as -is probably the case in England—that one-fifth of -the cases of pulmonary tuberculosis are treated during -one-third of a year institutionally under conditions in -which they will not be liable to spread infection. Let -us assume further that each of these cases has an infectious -lifetime of three years. Thus one-fifth of the -cases are deprived of their power to spread infection<span class="pagenum" id="Page_201">[Pg 201]</span> -during one-ninth of their period of “open” disease. -It being assumed that personal infection causes pulmonary -tuberculosis and that segregation is efficient, -segregation to the extent indicated above should secure -a reduction in the death-rate from pulmonary -tuberculosis of 100/(5 × 9) approximately 2 per cent.</p> - -<p>In actual fact the decline in the English death-rate -from pulmonary tuberculosis since 1871 has been at a -rate slightly under 2 per cent. per annum.</p> - - -<h3><em>Koch’s Endorsement of Segregation View</em></h3> - -<p>An extract from an article written by Robert Koch -shortly before his death may be permitted (Epidemiologie -der Tuberkulose Zeitschr. für Hyg. und Infektious -Krankheiten. 4. XVII, 1910).</p> - -<div class="blockquot fs80"> - -<p>I am entirely in agreement with Newsholme that the allocation -of consumptives to institutions for the sick, as freely -as possible and for as long as possible, is the most active -means of avoiding infection and the consequent spread of -phthisis.</p> - -<p>In my experience, too, phthisis has shown the most marked -decline in those places where comprehensive measures have -been taken for bringing consumptives into hospitals, and the -converse has been the case where the converse conditions -prevail. It is indeed obvious that in no other way can the -danger of infection, which a phthisical patient constitutes, be -so effectively removed as by isolation in hospital. Strong -support of this method is afforded by leprosy, where good -results in attacking the disease have been obtained by following -the same principle.</p> - -<p>In addition to this factor there is a second, which also -plays a very important part, viz., housing.</p> -</div> - -<p><span class="pagenum" id="Page_202">[Pg 202]</span></p> - -<p>A hypothesis explanatory of a given phenomenon -should be consistent with all the associated facts. We -have seen that the hypothesis that segregation of consumptives -is an important factor in the reduction of -the death-rate from pulmonary tuberculosis agrees (1) -with our knowledge of the tubercle bacillus, and (2) -with veterinary and agricultural experience; also (3) -that,—although exact data are unobtainable,—the degree -of segregation when ascertainable is consistent -with the degree of decline in the death-rate; (4) it is -important to note also that this hypothesis is consistent -with the otherwise anomalous facts that although the -proportion of the population subjected to urban conditions -of life has steadily increased, and the number of -persons per inhabited room remains much greater in -towns than in country districts, the death-rate from -pulmonary tuberculosis in England has declined as -much in them as in country districts; and that notwithstanding -the greater overcrowding in towns, the urban -is rapidly falling to the level of the rural death-rate -from this disease. The town dweller’s better and -more frequent treatment in hospitals is an important -factor in overcoming the handicap of urban conditions -of life, including overcrowding and preponderance of -indoor and dusty occupations.</p> - -<p>It is desirable to supplement the above statement by -some remarks on</p> - -<p><span class="pagenum" id="Page_203">[Pg 203]</span></p> - - -<h3><em>Improved Housing as a Means of Reducing Tuberculosis</em></h3> - -<p>Not infrequently the thoughtless remark is made -that given improved housing sanatoria and hospitals -for consumptives would be unnecessary. The frequent -occurrence of tuberculosis in well-to-do families -shows the absurdity of this statement. It is true that -tuberculosis is more prevalent among the poor living -in small tenements that among the well-to-do; but -there is no consistent proportion between the degree -of overcrowding in different districts or towns and -the death-rate from tuberculosis. Improved housing -and institutional treatment for tuberculosis cannot -properly be regarded as alternatives. They are necessary -complements to each other, and there must be -increased expenditure in both directions, if tuberculosis -is to be more rapidly reduced in amount. There -are in fact two housing problems—for the healthy, -and for the sick. The most rapid method of improving -housing for the healthy is to remove the sick, and -especially the tuberculous sick to a hospital. This is -being done year by year to an increasing extent. In -England and Wales in 1870, 8.3 per cent., and in 1912 -21.6 per cent. of all deaths from all causes occurred in -public institutions. It is difficult to exaggerate the -practical relief implied in these figures in respect of -satisfactory housing, especially in its functional aspect. -Apart altogether from the tuberculosis problem much<span class="pagenum" id="Page_204">[Pg 204]</span> -of the decline in the general death-rate must be attributed -to the skilled treatment which a large proportion -of the total population have received in our hospitals -of various types.</p> - -<p>I may, I think, claim to have answered in part the -question asked at an earlier stage of this address, as -to the causes of the steady decline in the death-rate -from tuberculosis in recent decades. I do not claim -that any one factor has brought about this result. I -do not claim that it has been caused entirely by diminution -of opportunities of infection; but I deprecate -the view that improved nutrition and other conditions -diminishing susceptibility have played a predominant -part. The facts of international hygienic history rebut -this view. Although segregation of patients in -institutions has played a great part in bringing about -the result, diminution of domestic infection as the -result of more cleanly habits has doubtless had an important -influence; as has also the reduction of industrial -dust.</p> - -<p>It is significant that general hygiene and improved -care of the sick—quite apart from any intention to -segregate—were associated with a large reduction in -the death-rate from tuberculosis before the importance -of reducing infection was fully appreciated; and that -since the necessity for direct measures against tuberculosis -was realised, since such measures have been -begun, however imperfectly, in many countries, and<span class="pagenum" id="Page_205">[Pg 205]</span> -since anti-tuberculosis educational propaganda has -been somewhat active, there has been no increase -in the rapidity of decline of the death-toll of tuberculosis. -Of course, it cannot be seriously—though -it is foolishly—argued from this fact that such direct -measures are futile. Every year there has been increasing -migration of masses of people into towns, -with a corresponding increase of undesirable domestic -overcrowding and of indoor occupations. If, therefore, -such anti-tuberculosis measures as have been -adopted,—whether direct measures or general sanitary -measures,—had been associated with an absence of -decline or with actual increase in the death-rate from -tuberculosis it might still be that these measures have -achieved much. Many conflicting agencies are at -work, and it might well be that the apparent lack of -success of the measures taken is due to the increased -operation of countervailing influences. The importance -of direct action for the control of tuberculosis -must be judged not solely by necessarily imperfect -statistical measurement on the basis of a few years’ -observation, but <em>by ascertaining that the proposed -measures are in accord with our knowledge of the natural -history of the disease</em>. As we have seen, both -comparative and human pathology assure us that tuberculosis -is a communicable and therefore a preventible -disease, and point the way to the means for securing -this end.</p> - -<p><span class="pagenum" id="Page_206">[Pg 206]</span></p> - -<p>Before describing the direct measures which have -been adopted for the control of tuberculosis, it should -be added that in no country have these been in operation -sufficiently long, and in no country have they been -so adequately applied, as to render it practicable to -apply statistical measurement of their value; meanwhile -these measures must be judged in the light of -our knowledge of the pathology of tuberculosis.</p> - - -<h3><em>Notification of Tuberculosis</em></h3> - -<p>If every tuberculous patient were intelligent, and -willing and able to follow the advice given by his doctor, -if he consulted his doctor for the first symptoms -of illness, if his disease were recognized by the doctor -at its earliest recognizable stage, and if the doctor in -every instance gave the right advice and made the necessary -examinations of all “contacts,” no occasion -would arise for the intervention or assistance of Public -Health Authorities, except in providing bacteriological -facilities and institutional accommodation. In -actual fact these conditions are not secured for the -majority of patients; and the private practitioner, -however willing, is seldom in a position to remedy the -domestic and industrial insanitary conditions which -favour infection and lower resistance to infection.</p> - -<p>Hence notification of cases of tuberculosis was advocated -for many years by pioneer medical officers -of health who secured voluntary notification by doctors<span class="pagenum" id="Page_207">[Pg 207]</span> -of a considerable proportion of the total cases in -their districts, and in a few instances secured compulsory -notification by local enactment, before any general -regulations on the subject were made. It is noteworthy -that in this early period a town like Brighton, -which had voluntary notification with sanatorium provision -for patients willing thus to be treated, secured -the notification of a larger proportion of total cases -than another town in which notification was compulsory, -but no sanatorium accommodation had been provided. -The point is mentioned as emphasizing the -general principle that compulsory measures in public -health, if they are to be successful, require to be associated -with full provision for the action which should -follow the compulsory enactment; which provision, as -in this case, may be a direct inducement to compliance -with the enactment. In view of the change of central -policy involved and of the unpreparedness of most -local authorities to give the assistance needed for notified -cases, the general enforcement of notification of -tuberculosis was brought about in stages; in 1909 -poor-law cases of consumption were made notifiable -throughout England and Wales, hospital cases in 1911, -consumption in the general community in 1912, and all -forms of tuberculosis in 1913.</p> - -<p>It was not anticipated that complete notification of -cases would be obtained for some years, but a review of -English national experience of notification of tuberculosis<span class="pagenum" id="Page_208">[Pg 208]</span> -up to the present time necessitates the confession -that there has been failure to secure the coöperation -of an unexpectedly large proportion of the medical -profession in this public-health duty. Many cases -have never been notified and in a large number of -other cases notification has been belated; Dr. Barwise, -County Medical Officer of Health of Derbyshire, obtained -information as to 417 deaths certified during -1917 to be due to tuberculosis, and found that of this -number 39 per cent. had never been notified, and that -over 70 per cent. had either not been notified or died -within twelve weeks of notification. This may be an -exceptionally bad experience; but the duty of notification -in many areas is only imperfectly performed, and -no adequate steps are being taken to diminish this -default.</p> - -<p>As notification is the first step towards coördinated -measures for the patient and in the interest of the -public health, the causes of delay in notification and -of failure to notify deserve further examination.</p> - - -<h3><em>Causes of Failure in Notification</em></h3> - -<p>1. The patient himself commonly is responsible for -much delay in the recognition of his disease. A large -proportion of consumptive patients refrain from applying -for treatment until disease is fully established, -and until they are incapacitated for work. Not infrequently -this means that the patient does not consult a<span class="pagenum" id="Page_209">[Pg 209]</span> -doctor until a few months or even weeks before his -death. Until the conditions of general medical practice -are altered, and every person has the right to state-paid -medical consultations, belated recourse to medical -advice will continue.</p> - -<p>With this there is badly needed further education of -the public as to seeking advice for protracted colds and -coughs, or for other symptoms suggestive of tuberculosis; -and a wider hygienic propaganda as to housing, -overcrowding, dusty indoor occupations, expectoration, -etc., is also called for.</p> - -<p>2. Under present conditions of medical practice, -early diagnosis of tuberculosis often fails to be secured, -even when the patient places himself under -medical care. It is to the private practitioner that -most patients resort, and the early recognition and -treatment of disease depends primarily (<em>a</em>) on his skill, -(<em>b</em>) on his not being so overworked as to be unable to -devote adequate time to the examination of each patient -coming under his care, and (<em>c</em>) on his willingness -to refer doubtful cases for consultation with the official -tuberculosis officer of each area. These officials -have only existed during the last few years; their -work was partially in abeyance during the four and a -half years of war; and apart from this, they have not -always succeeded in persuading the private practitioner -that their coöperation is to be welcomed and -that they are not agents for depriving him of his private<span class="pagenum" id="Page_210">[Pg 210]</span> -patients. This assumed antagonism between private -and public medical practice is one of the most -serious difficulties in securing more rapid progress in -anti-tuberculosis work.</p> - -<p>3. For nearly every sanitary area gratuitous facilities -are now provided for the examination of sputum -for tubercle bacilli, and yet in many areas there is -grave neglect to utilize this provision, and patients -with chronic phthisis may be treated during long -months or even years for “winter cough,” “bronchitis,” -etc., without adequate physical examination of -sputum. The diagnosis of pulmonary tuberculosis -ought, it is true, to be made before tubercle bacilli are -found in the sputum, and failure to recognize the disease -prior to this implies that the disease has already -become serious; but in fact a very large proportion of -consumptive patients for many months have tubercle -bacilli in their sputum, before the diagnosis of tuberculosis -is made.</p> - -<p>4. When, as in some areas, the medical officer of -health or the tuberculosis officer takes little, if any, -useful action after notifications have been received, the -practitioner has an excuse for not notifying subsequent -cases. He can argue with some cogency that -notification has no value <em>per se</em>; its utility depends on -the action which follows on notification. Unless useful -action follows on notification, default in notification -has little practical importance.</p> - -<p><span class="pagenum" id="Page_211">[Pg 211]</span></p> - - -<h3><em>Public Health Action Following Notification</em></h3> - -<p>Under the English Tuberculosis Regulations the -medical officer of health or an officer of the local authority -acting under his instructions is required to -make such inquiries and take such steps as may be -necessary or desirable for investigating the source of -infection, for preventing the spread of infection, and -for removing conditions favourable to infection. The -action required includes <i lang="la" xml:lang="la">inter alia</i></p> - -<p>1. Attention to the personal hygiene of the patient, -including instruction in the necessary precautions as -to coughing and expectoration.</p> - -<p>2. Any assistance needed to ensure for the patient</p> - -<p>(<em>a</em>) Skilled medical attendance and nursing as required -while he is treated at home;</p> - -<p>(<em>b</em>) Institutional treatment when required;</p> - -<p>(<em>c</em>) Supplementation of the convalescent patient’s -funds, when needed, to obviate the necessity for him -at once to embark in full-time work; to provide additional -bedroom accommodation when needed; and to -ensure that the patient and his family are not undernourished -or overworked.</p> - -<p>3. Remedial action for any insanitary conditions of -the home, such as uncleanliness, dampness, overcrowding; -or of the patient’s workplace, especially for dusty -occupations.</p> - -<p>4. Examination of home contacts with the patient.</p> - -<p><span class="pagenum" id="Page_212">[Pg 212]</span></p> - -<p>The last named item may conveniently be considered -further at this point.</p> - - -<h3><em>Examination of Contacts</em></h3> - -<p>This branch of tuberculosis work is most important. -Often the first notified case is not the first clinical case -of tuberculosis in a given family; and from the standpoint -of prevention the detection of such cases of -longer standing is important. Examination of contacts -also frequently discovers patients in an earlier -and more curable stage of disease than the notified -patient.</p> - -<p>It is important that all home contacts of each notified -case of tuberculosis should be examined; and one -of the most important functions of the tuberculosis -officer is to arrange for this. The examination may -be carried out by arrangement at the tuberculosis dispensary; -but otherwise, at the home of the invaded -family. When there is a medical practitioner in attendance -his coöperation and presence should as a rule -be invited.</p> - -<p>Such systematic examination of the household not -only is more efficient in discovering sources of continuing -infection than the desultory examination of a -few contacts,—which often still represents the extent -of this important work,—but it has in addition a -greater educational effect on the public; and general -recourse to such systematic observations would rapidly<span class="pagenum" id="Page_213">[Pg 213]</span> -improve the prospect of satisfactory control of -tuberculosis.</p> - -<p>Even when examination of contacts is practised -after notification of a case of pulmonary tuberculosis, -it is too often neglected after notification of non-pulmonary -cases. This represents a great public-health -loss; the majority of cases of non-pulmonary -tuberculosis are caused by infection of human source, -and this source often is an unrecognized case of pulmonary -tuberculosis in the patient’s family.</p> - - -<h3><em>Scope of Tuberculosis Schemes</em></h3> - -<p>Prior to the general enforcement of notification of -tuberculosis in England excellent local work had been -done in a relatively small number of areas in direct -efforts to control the spread of tuberculosis, in addition -to the previous general measures, such as improved -sanitation, better housing, more satisfactory -nutrition, and especially the hospital treatment of a -large proportion of advanced and acute cases of tuberculosis. -The Report of the last Royal Commission on -Tuberculosis appeared in 1911; and although precautions -against human infection by tuberculous cows’ -milk are still very incomplete, the pasteurisation or -boiling of milk is more generally practised than in -the past.</p> - -<p>Local Authorities prior to 1911 had power to build -sanatoria or otherwise provide institutional accommodations<span class="pagenum" id="Page_214">[Pg 214]</span> -for the treatment of tuberculous patients; -relatively little had been done in most areas. In 1911 -the Finance Act provided a sum of £1,116,000 for the -erection of sanatoria in England and Wales, and this, -with money provided by local rates, has led to rapid -increase in accommodation for the residential institutional -treatment of tuberculosis. In England in 1911 -local authorities, other than poor-law authorities, had -about 1300 beds for the institutional treatment of tuberculosis, -while there were 4,200 beds in private sanatoria -and voluntary institutions. In 1917 the total -available beds numbered 12,441, of which about one-half -had been provided by local authorities.</p> - -<p>In 1911 the National Insurance Act was passed and -came into operation in July, 1912. This provided a -special “Sanatorium Benefit.”</p> - -<p>The Departmental Committee appointed to make -recommendations as to detailed direct measures against -tuberculosis, reported in April, 1912, that any scheme -which is to form the basis of an attempt to deal with -the problem of tuberculosis should be available for the -whole community, and that its organization should be -undertaken by the large local authorities (the councils -of counties and county boroughs). These recommendations -were at once adopted by the Government, -which undertook to provide out of the national exchequer -one-half of the net cost of approved local -schemes for the general treatment of tuberculosis.<span class="pagenum" id="Page_215">[Pg 215]</span> -Local authorities were invited at once to prepare -schemes for institutional treatment, residential and -non-residential, domiciliary treatment remaining in the -hands of private practitioners, of poor-law doctors, -and of doctors engaged in the contract work under the -National Insurance Act (“panel doctors”). The -last named are in medical charge of the large mass of -the wage-earners of the community, comprising roughly -one-third of the total population, in so far as their -treatment at home is within the power of a practitioner -of average competence. The schemes proposed -for each area comprised,</p> - -<p>1. The appointment of a tuberculosis officer, usually -a whole-time official, who was required to have had -special experience in the diagnosis and treatment of -tuberculosis, and who as a rule was an officer in the -public-health department under the administrative supervision -of the medical officer of health, but independent -in his clinical work;</p> - -<p>2. The establishment of tuberculosis dispensaries, at -which patients were treated, consultations as to doubtful -cases held, and contacts examined;</p> - -<p>3. The provision of beds in residential institutions -for curable and for acute and advanced cases;</p> - -<p>4. The organization of arrangements for “following -up” and “after-care.”</p> - -<p>During 1912 and 1913 advance was made in these -directions. In 1911 there were 25-30 tuberculosis<span class="pagenum" id="Page_216">[Pg 216]</span> -dispensaries: in 1917 their number had increased to -371. In 1914 the onset of the Great War prevented -further development of tuberculosis work and seriously -crippled and reduced the efficiency of work -already initiated; and this increased as the military -demand for medical officers and institutions became -greater. It may be stated generally that in only a -relatively small number of areas have fairly complete -arrangements for the institutional treatment of tuberculosis -come into operation; and that even in these -areas the arrangements have been at work for only a -limited period. It is evident, therefore, as already -pointed out, that no argument as to the utility of these -arrangements can be based on the facts that the death-rate -from tuberculosis has not declined with increased -rapidity in recent years, and that women during the -war, especially at the working years of life have experienced -an increased death-rate from this disease.</p> - - -<h3><em>Tuberculosis Dispensaries</em></h3> - -<p>The tuberculosis officer is the essential element in -the dispensary; and in rural districts he may be said -to carry the dispensary under his hat. The dispensary -if properly organized should serve as the centre -of official anti-tuberculosis measures. The medical -officer of health receives the notifications of recognised -cases whether they are attending the dispensary -or not; and it simplifies administration if the home supervision<span class="pagenum" id="Page_217">[Pg 217]</span> -of all tuberculous patients notified to the -medical officer of health, and not only of dispensary -patients, is placed under the supervision of the tuberculosis -officer. At the dispensary itself the tuberculosis -officer examines patients, makes records of their -condition, and of all facts bearing on their welfare, -and recommends the special form of continued treatment -adapted to their condition. This may be domiciliary, -or given at the dispensary, or in a sanatorium, -or in a hospital. A dispensary which does not supervise -and treat a large proportion of the total notified -cases, including especially patients before and after -they have received treatment in a residential institution, -is not fulfilling its possibilities of utility.</p> - -<p>At the dispensary is organized also the examination -by the tuberculosis officer of “contacts,” and of school -children suspected to be tuberculous; though it is -often necessary to arrange for this officer to make -similar examinations at patients’ homes. At the dispensary -consultations with private practitioners are -conveniently held; though in this instance also the -tuberculosis officer should arrange when this is desired -for the consultations to be held at the patient’s home.</p> - -<p>The dispensary alone cannot ensure the welfare of -the tuberculous patient. It is necessary that the tuberculosis -officer should have consultations concerning -difficult cases with the medical staff of general and -special hospitals. To segregate the treatment of tuberculosis<span class="pagenum" id="Page_218">[Pg 218]</span> -from that of other diseases means reduced -efficiency of the tuberculosis officers and lowered quality -of treatment.</p> - - -<h3><em>Tuberculosis Dispensaries should become Parts of General Dispensaries</em></h3> - -<p>Public Health and School Authorities have already -established many centres at which hygienic instructions -and medical treatment are given for mothers and -their young children when ailing, or with a view to the -prevention of future illness; for tuberculosis; for -venereal diseases; and for various ailments of school -children.</p> - -<p>In England in addition there is poor-law provision -(sometimes at dispensaries) for patients dependent on -official charity. Evidently the multiplicity of authorities, -local and central, concerned in this medical work, -is not conducive to efficiency; and it will, we hope, -soon disappear. Similarly it will be in the interest of -efficiency, as well as of economy, to provide for the -treatment of the above-named groups of cases in a -common Medical Institute for each defined area, at -which also it will be advantageous to arrange for much -of the treatment of insured persons. By this means it -will become practicable to arrange for consultations -between experts in different departments of medicine, -to the advantage of all concerned.</p> - -<p>It will be contrary to the communal interest if the<span class="pagenum" id="Page_219">[Pg 219]</span> -resources of voluntary hospitals in large towns are not -also utilised in official medical work. Many of these -hospitals have specialised departments (e.g., X-ray, -eye, ear, throat, skin, and other special clinics), the -use of which ought to be obtainable, even though for -many years it may not be practicable to arrange for all -hospitals to be financed in part at least out of rates -and taxes.</p> - -<p>The tuberculosis officer in order to be able to treat -his dispensary patients with adequate knowledge, and -in order to advise as to the form of treatment—in a -residential institution or not,—most fitted to the patient’s -case, must know the sanitary and social circumstances -of the patient’s industrial and domiciliary life. -He must, therefore, have reports on these circumstances -respecting each patient. This raises the general -question of the relation of the tuberculosis officer -to the medical officer of health. The medical officer -of health is officially responsible for controlling the -tuberculous patient and his environment from a public -health standpoint. As the tuberculosis officer also -needs the information acquired in the inquiries which -it is the duty of the medical officer of health to make -personally or by an authorized agent, coördination of -the work of the two officers is evidently required; -and this need cause no difficulty when the tuberculosis -officer is an officer in the Public Health Department of -which the medical officer of health is the chief administrator.</p> - -<p><span class="pagenum" id="Page_220">[Pg 220]</span></p> - - -<h3><em>The Home Visitation of Patients</em></h3> - -<p>This is important, (<em>a</em>) to inquire into the social circumstances -of each patient; (<em>b</em>) to instruct him in -detail as to the carrying out of instructions for treatment -and in the hygiene of his life; (<em>c</em>) to make a -sanitary survey of the dwelling house, and especially -of the patient’s bedroom, and to advise as to any -needed reforms; and (<em>d</em>) in certain cases to give actual -assistance in nursing the patient.</p> - -<p>The report on these inquiries should be seen by both -the medical officer of health and the tuberculosis officer, -and on them in conjunction with the tuberculosis -officer’s knowledge of the medical condition of the -patient, the subsequent course of supervision and -treatment will depend.</p> - -<p>Home visitation can be carried out by nurses attached -to the dispensary or by inspectors of the public -health department. The latter will usually be more -competent in detecting and remedying sanitary defects -in the home; the former in encouraging the patient to -carry out the needed requirements in personal hygiene -and nursing. Many visitors are equally competent in -both directions; and as the number of women specially -trained in tuberculosis work increases this will more -generally be the rule.</p> - -<p>The dispensary should be the active working centre -from which home visitation is undertaken; and this is -especially important in “following up” work. Following<span class="pagenum" id="Page_221">[Pg 221]</span> -up is needed for persons who have been examined -once, concerning whom there is doubt as to their -freedom from disease and who fail to present themselves -for later examination. It is needed also for -patients who have been under treatment and neglect -to continue it; and for patients who after having been -treated have been discharged and fail to report themselves -at intervals as directed. It is important to have -efficient arrangements for ascertaining these leakages -and for making the necessary inquiries. The method -of securing this will vary according to local circumstances; -but the following example given by Dr. Chapman -of an official method may be placed on record:</p> - -<div class="blockquot fs80"> - -<p>When a patient is instructed to attend again at the dispensary -his name is noted in a diary under the date upon which -he is asked to attend. In some instances a definite time is -fixed for the appointment so as to save the patient’s time. -The names of all patients who attended the dispensary upon -the day appointed are ticked off as they are seen, and at the -end of the day the names of patients who have failed to -attend remain on the list. Letters are then sent reminding -these patients of their engagement and making another appointment. -If they still fail to attend they are visited by the -dispensary nurse or the health visitor. Failure to attend may -be due to relapse, and, when this is likely, an early visit of -inquiry by the nurse is advantageous.</p> - -<p>Examination of a register kept for facilitating work of this -kind showed that the majority of the patients followed up -attended subsequently, and that in the cases of the remainder -non-attendance as a rule was satisfactorily explained.</p> -</div> - -<p>In areas having, as yet, no adequate system of following<span class="pagenum" id="Page_222">[Pg 222]</span> -up, an appreciable percentage of patients usually -cease to attend during the course of treatment at -a dispensary, and many are lost sight of after discharge -from a sanatorium. The value of the work of -a dispensary and of after-care work is materially impaired -in the absence of a system of “following up.” -As schemes develop, more stress will doubtless be -generally laid upon this branch of the dispensary -function.</p> - - -<h3><em>“Sanatorium Benefit.”</em></h3> - -<p>Under the National Insurance Act the annual sum -of 1s 3d (30 cents) was set apart for each insured -person; as the result of subsequent bargaining with -medical practitioners 6d of this was devoted to the -domiciliary treatment of tuberculosis patients (payable -on the number of panel patients on each doctor’s list, -not on the number of his tuberculous patients), the -remainder being payable to local authorities who undertook -the provision of institutions for the treatment -of tuberculous insured patients.</p> - -<p>Thus the “Sanatorium Benefit” comprises</p> - -<p class="no-indent"><em>A</em>. Domiciliary treatment.<br> -<em>B</em>. Institutional treatment.<br> -<span style="margin-left: 2em;">(<em>a</em>) Non-residential—Dispensaries.</span><br> -<span style="margin-left: 2em;">(<em>b</em>) Residential—Sanatoria,</span><br> -<span style="margin-left: 9em;">Hospitals,</span><br> -<span style="margin-left: 9em;">Convalescent Homes and</span><br> -<span style="margin-left: 9em;">“Farm Colonies.”</span><br> -</p> - -<p><span class="pagenum" id="Page_223">[Pg 223]</span></p> - -<p>Soon after the passing of the National Insurance -Act in 1911 representations were made that tuberculosis -affected non-insured as well as insured; that -treatment of insured could have only partial success -so long as non-insured members of the same household -were neglected; and that this was work for public -health authorities which they were already partially -undertaking. It was evident that the inextricably interlaced -measures for the prevention and the treatment -of tuberculosis must accrue to the whole population; -and the mistake of the National Insurance Act -was remedied to the extent that Public Health Authorities -were informed that the National Treasury -was prepared to pay one-half of the approved expenditure -incurred by these authorities in establishing -schemes for the treatment of tuberculosis available for -the entire population. Such schemes were proceeded -with, as already indicated; but there remained the fact -that insured persons who had paid their weekly quota -and were therefore entitled to “Sanatorium Benefit” -usually interpreted this as a right to three months’ -treatment in a Sanatorium. The choice of persons to -receive treatment in a Sanatorium lay with Local -Insurance Committees appointed under the National -Insurance Act, who generally acted on the advice of -the tuberculosis officer; but influences other than medical -led to the unsatisfactory use of institutional treatment. -A large number of patients were sent to and<span class="pagenum" id="Page_224">[Pg 224]</span> -retained in sanatoria for prolonged periods, who -might have been adequately treated at home, or who -should have been in hospitals. Satisfactory results -for sanatorium treatment were not secured under -these conditions; and there will probably be no material -improvement until the Sanatorium Benefit is withdrawn -as a special benefit under the National Insurance -Act, and the treatment of tuberculosis becomes -an obligatory duty of Public Health Authorities, with -a minimum standard of provision to which all must -attain.</p> - - -<h3><em>Residential Institutions</em></h3> - -<p>The extent to which these have been provided in -England since 1911 has already been stated. The -number of beds available in 1917 was 12,441, in addition -to some 9,000 beds in poor-law institutions, which -in 1911 were occupied by consumptives. From the -point of view of the provision required in residential -institutions for the treatment of tuberculosis the following -classification is useful. It is confined to pulmonary -cases:</p> - -<div class="poetry-container"> -<div class="poetry"> - <div class="stanza"> - <div class="verse indent0">Group <em>A</em>—Cases in which permanent improvement or</div> - <div class="verse indent4">recovery can usually be anticipated.</div> - <div class="verse indent2"></div> - <div class="verse indent0">Group <em>B</em>—Cases in which only temporary, though</div> - <div class="verse indent4">possibly prolonged, improvement may be</div> - <div class="verse indent4">anticipated.</div> - <div class="verse indent2"></div> - <div class="verse indent2">This group will include</div> - <div class="verse indent2"></div> - <div class="verse indent0">1. Patients who may be expected to recover considerable -<span class="pagenum" id="Page_225">[Pg 225]</span></div> - <div class="verse indent2">ability to work, as a result of protracted</div> - <div class="verse indent2">treatment.</div> - <div class="verse indent2"></div> - <div class="verse indent0">2. Patients admitted for a short term for educational</div> - <div class="verse indent2">treatment.</div> - <div class="verse indent2"></div> - <div class="verse indent0">3. Patients with advanced disease, many of whom improve</div> - <div class="verse indent2">greatly under institutional treatment.</div> - <div class="verse indent2"></div> - <div class="verse indent0">Group <em>C</em>—Advanced cases requiring continuous medical</div> - <div class="verse indent4">care and nursing.</div> - <div class="verse indent2"></div> - <div class="verse indent0">Group <em>D</em>—Cases requiring Special Observation.</div> - <div class="verse indent2"></div> - <div class="verse indent0">1. Patients admitted for the purpose of diagnosis.</div> - <div class="verse indent2"></div> - <div class="verse indent0">2. Patients needing to be watched, before the best form</div> - <div class="verse indent2">of continued treatment can be determined.</div> - <div class="verse indent2"></div> - <div class="verse indent0">Emergency cases, e.g., patients with haemoptysis, and</div> - <div class="verse indent2">patients requiring surgical treatment may come</div> - <div class="verse indent2">within any of the above groups.</div> - <div class="verse indent2"></div> - </div> -</div> -</div> - -<p>Of the 12,441 beds probably 5,000 are in the hands -of voluntary organizations, and are intended for patients -in group <em>A</em>, though for the reasons set out on -pages 208 and 223 they contain a large proportion of -patients in the other groups. It appears not unlikely, -however, that the total accommodation, official and -voluntary, for patients in group A has reached one bed -per 5,000 population, the accommodation recommended -by the Departmental Committee on Tuberculosis as -immediately advisable. This accommodation is unevenly -distributed and much of it is being utilised for<span class="pagenum" id="Page_226">[Pg 226]</span> -patients coming within groups <em>B</em>, <em>C</em>, and <em>D</em>. All the -evidence available shows a great need for additional -beds for patients coming within the last-named groups. -The Departmental Committee recommended that the -total needs of the community might be assumed to -amount to one bed to 2,500 population for all stages -of pulmonary tuberculosis, in addition to poor-law accommodation. -This means a provision of some 14,000 -beds in addition to the 9,000 poor-law beds, or a total -provision of about one bed to 1,500 population.</p> - -<p>If we include cases of non-pulmonary tuberculosis -it may be safely assumed that each community should -aim at having available for the treatment of tuberculosis -at least one bed per 1,000 inhabitants. Fewer -beds may suffice for sparsely populated communities, -and more will be needed in some towns.</p> - -<p>In England various existing institutions have been -utilised in the treatment of tuberculosis.</p> - -<p>1. Emphasis has already been laid on the large number -of beds in <em>workhouse infirmaries under the Poor-Law -Authorities</em>. Of the historical, as well as of the -present value of this accommodation for advanced -cases of tuberculosis in the poorest section of the population—which -is most seriously exposed domestically -to massive infection,—there can be no doubt.</p> - -<p>But there has been prejudice against the use of -this accommodation for insured persons, and such use -is legally precluded; and since the passing of the National<span class="pagenum" id="Page_227">[Pg 227]</span> -Insurance Act additional provision has been -made by Public Health Authorities, and ere long the -whole of the present poor-law accommodation should -come under public health authorities.</p> - -<p>2. Detached pavilions of <em>hospitals for infectious diseases</em> -have also been employed for the treatment of -tuberculosis, and experience has demonstrated that in -well-conducted institutions consumptives are not exposed -to risk of acquiring acute infectious diseases.</p> - -<p>The use of these institutions favours economy of -administration. It possesses the advantage that patients -are, as a rule, more accessible to their relatives -than in a sanatorium; and this renders patients suffering -from progressive disease more willing to remain -in the institution than they would otherwise be. Patients -can advantageously be placed in such an institution -for observation, before deciding whether prolonged -treatment in a distant curative sanatorium is -indicated.</p> - -<p>Occasionally empty <em>smallpox hospitals</em> have also -been employed for the institutional treatment of tuberculosis; -but if this plan were to be generally adopted, -tuberculosis work would be seriously crippled if smallpox -became epidemic. The treatment of consumptives -in a smallpox hospital should only be permitted for -patients who could be at once transferred and who can -be at once vaccinated.</p> - -<p><em>General hospitals</em> are well fitted to deal with the following -classes of cases of tuberculosis:</p> - -<p><span class="pagenum" id="Page_228">[Pg 228]</span></p> - -<p class="no-indent">(<em>a</em>) Patients admitted for observation, with a view to<br> -<span style="margin-left: 2em;">diagnosis;</span></p> - -<p class="no-indent">(<em>b</em>) Patients admitted to ascertain the form of treatment<br> -<span style="margin-left: 2em;">best adapted for the patient’s needs;</span></p> - -<p class="no-indent">(<em>c</em>) Emergency cases, e.g., haemoptysis;</p> - -<p class="no-indent">(<em>d</em>) Patients requiring surgical aid for intercurrent<br> -<span style="margin-left: 2em;">diseases;</span></p> - -<p class="no-indent">(<em>e</em>) Patients with advanced disease admitted for special<br> -<span style="margin-left: 2em;">purposes;</span></p> - -<p class="no-indent">(<em>f</em>) Patients with non-pulmonary tuberculosis, requiring<br> -<span style="margin-left: 2em;">special surgical treatment.</span></p> - -<p>In approving arrangements for the treatment of -pulmonary tuberculosis in a general hospital, it should -be made a condition that they shall not be received into -general wards of the hospital in which there are persons -suffering from other diseases, unless for a sudden -emergency, or for a short period for operative treatment, -or unless there is no expectoration, or if this, on -repeated examinations has been found to be free from -tubercle bacilli.</p> - - -<h3><em>Sanatoria and Combined Institutions</em></h3> - -<p>To ensure efficiency in a sanatorium a resident physician -is, as a rule, necessary; and this is desirable also -for a tuberculosis hospital. Smaller authorities may -be unable to combine together or to provide alone an -institution with about 100 beds, which is generally regarded -as the unit best adapted to secure a well-placed<span class="pagenum" id="Page_229">[Pg 229]</span> -and efficiently organized institution, with due regard -to economy of administration. To provide such a -unit, and even apart from this, the desirability of treating -patients in all stages of disease in the same institution -should be considered. Experience in England -has shown that this combination presents no medical -administrative difficulties, provided that the type of -sleeping accommodation for patients consists chiefly -of rooms for one or two patients or of small wards. -With such an arrangement, if a section of the institution -consisting of one or two bedded rooms or small -wards is devoted to patients needing special nursing, -irrespective of the stage of disease, efficiency is secured, -the special needs of each class of patients can -be met, and—this is especially important—the patient -with advanced disease cannot infer the hopeless character -of his illness from his place in the institution. -Such a combined institution affords the medical and -administrative advantage that the tuberculosis officer -can, as a rule, watch his patients throughout the whole -course of their treatment, both in the residential institution -and at the dispensary.</p> - -<p>In choosing a sanatorium an area of at least twenty -acres should be available; and at least one-fifth of an -acre should be allowed per patient. For a hospital a -smaller area is permissible. There should be a floor-space -of at least 64 square feet for each patient; and -the centres of the heads of adjacent beds should not<span class="pagenum" id="Page_230">[Pg 230]</span> -be distant less than 8 feet measured against the wall. -Experience appears to show that in a large sanatorium -one nurse will generally be adequate for every twelve -patients. In a hospital for advanced patients, or in a -combined institution a larger staff may be required.</p> - - -<h3><em>Observation Beds</em></h3> - -<p>There is but little systematised experience as yet of -the employment of observation beds; a difficulty arising -from the fact that the tuberculosis officer under -most local tuberculosis schemes has not been sufficiently -in touch with the medical officers of the residential -institutions to which he sends patients. There -are practical difficulties in the provision of observation -beds on the dispensary premises, including the -difficulty of due regard to economy of administration -in the nursing and treatment of three or four in-patients -at a dispensary. Whatever arrangements are -made for such beds, it is desirable that the tuberculosis -officer should have access to the patients treated in -them.</p> - - -<h3><em>General Observations on Treatment in Sanatoria</em></h3> - -<p>In 1911 the extent and limitations of the utility of -sanatorium treatment of tuberculosis were already -fairly well recognized by physicians; and it is unfortunate -that in connection with the passage of the National -Insurance Act this treatment acquired a somewhat<span class="pagenum" id="Page_231">[Pg 231]</span> -political aspect, and became the subject of much -popular misapprehension and exaggeration. Disappointment -necessarily followed on the sending of -patients to sanatoria for treatment with a view to cure -at a stage of disease when anything beyond ephemeral -improvement was impossible. The patients who, under -present conditions, are admitted to sanatoria come -roughly into two groups:</p> - -<p>First. Patients with limited disease and little or no -systemic disturbance. Comparatively few patients who -now enter sanatoria come within this group.</p> - -<p>Second. Patients with more extensive or acute disease. -In a large proportion of cases within the first -group the immediate result of sanatorium treatment -extending over three to six months is the complete -restoration of general health and working capacity -with arrest of disease. In a large further proportion -of cases in the same group there is recovery of working -capacity and apparent restoration of general health -without complete arrest of disease.</p> - -<p>For patients coming within the second group a similar -period of treatment in a sanatorium results:</p> - -<p>(<em>a</em>) In restoration of general health and working -capacity with arrest of disease in only a small proportion -of cases;</p> - -<p>(<em>b</em>) In recovery of working capacity and apparent -restoration of general health without arrest of disease -in a fair proportion of cases; and</p> - -<p><span class="pagenum" id="Page_232">[Pg 232]</span></p> - -<p>(<em>c</em>) In the remainder, disease progresses steadily -with or without temporary improvement in general -health.</p> - -<p>The subsequent history of sanatorium patients varies -greatly. Some of them maintain their health indefinitely -on return to their ordinary life. Others who -have been discharged with arrested disease ultimately -relapse, even if they live under excellent environmental -conditions; and such relapses are excessive among -those who return to unsatisfactory conditions of life -and work.</p> - -<p>Among patients discharged from a sanatorium without -arrest of the disease a small proportion ultimately -recover completely, but the majority relapse at a date -which is earlier or later in accordance more or less -with the conditions under which they live and work -and the severity of their disease.</p> - -<p>The experience of the last few years has been that -only a small proportion of the patients admitted to -sanatoria are cases in which arrest of the disease can -be anticipated; and this will continue until the disease -is more generally detected at an earlier stage than at -present, and the sanatorium treatment is prescribed -and continued solely in accord with the medical needs -of the patient.</p> - -<p>The conditions of local administration of the Sanatorium -Benefit under the National Insurance Act have -led to a very high proportion of consumptives being<span class="pagenum" id="Page_233">[Pg 233]</span> -treated in sanatoria with a view to cure, who might -advantageously have received educational treatment -for a few weeks and then have been treated at home -or at a tuberculosis dispensary. Furthermore, a large -number of patients with advanced disease have been -sent to sanatoria for whom treatment in a hospital was -more appropriate.</p> - - -<h3><em>Educational Work of Sanatoria</em></h3> - -<p>Apart from the question of cure, which with belated -treatment can only be expected in a minority of cases, -the sanatorium serves an important purpose, not only -in restoring patients to a considerable degree of health -and working capacity for a longer or shorter time, but -also in educating the patients how to live and conduct -themselves. A stay in a sanatorium for a short period—a -month or six weeks—under doctors and nurses -who realise the value of this work—would there were -more of these!—secures the training of the patient on -lines beneficial to his future health and enables him to -obviate all danger for others.</p> - -<p>In such a short stay in a sanatorium what may be -called tuberculosis discipline can be and is acquired -when the sanatorium is satisfactorily administered; -and the patient thus disciplined is in a much more -favorable position for securing his own welfare and -that of others than the undisciplined patient, just as -the soldier who has had routine drill under a competent<span class="pagenum" id="Page_234">[Pg 234]</span> -instructor is more efficient than the untrained -recruit.</p> - -<p>The preceding remarks as to the treatment of tuberculosis -in sanatoria illustrate certain well-known features -in the natural history of this disease. In the majority -of instances of disease recognised under present conditions -we are dealing with a slowly progressing disease. -This sometimes become spontaneously arrested; -occasionally it may be arrested or its course delayed -under medical treatment at home associated with manageable -changes in domestic and industrial life. In -still further instances it may be arrested by treatment -in a sanatorium; while for other cases sanatorium -treatment, however prolonged, is followed by only -temporary improvement, and the chief benefit thus -received is that of training as to mode of life, which -might have been secured by a much less protracted -stay in the institution, followed by measures supplementing -sanatorium treatment. We have further to -recognise the fact that, under present conditions of -social life and medical practice, many tuberculous patients -will slowly, by intermittent stages, but none the -less surely, die from tuberculosis in the course of one, -three or five years. Regard must be paid to this fact -if our total measures for the control of tuberculosis -are to be successful.</p> - -<p><span class="pagenum" id="Page_235">[Pg 235]</span></p> - - -<h3><em>Hospital Treatment</em></h3> - -<p>This fact emphasizes the importance of adequate -hospital treatment for all patients acutely ill or bed-ridden, -who cannot be hygienically treated at home; -and the importance becomes evident of exercising -<em>complete supervision over and provision for the whole -of the sick life of the consumptive, whether he is trending -towards complete recovery or to death</em>.</p> - -<p>Such complete supervision and provision necessitates -further development in three directions in which -beginnings have already been made:</p> - - -<h3><em>Industrial Colonies</em></h3> - -<p>These are the provision of “Farm or Industrial -Colonies,” the adaptation of domestic dwellings to -meet the special needs of consumptives, and the more -complete organization of “Care” and “After-care” -arrangements.</p> - -<p>In a large proportion of cases, the patient on leaving -the sanatorium is unable at once to embark on full -work without risk of early relapse, or to refrain from -this without endangering his nutrition and that of his -family. His work, furthermore, may be unsuitable -for a consumptive.</p> - -<p>This has led to many tentative efforts to train the -consumptive in a suitable occupation while under sanatorium -treatment, or in an industrial colony which -should preferably be attached to or in close communication<span class="pagenum" id="Page_236">[Pg 236]</span> -with a sanatorium, in order that the patient -may continue under skilled medical supervision. The -graduated labour which forms part of the routine -method of treatment in many sanatoria can be made a -preparatory stage in this industrial training. The -training may be made to merge into the pursuit of an -actual livelihood; and then the sanatorium becomes -an industrial colony. Market gardening, pig-keeping, -forestry, and other occupations may be thus pursued -for protracted periods, if the patients are suitably selected. -The ex-patients continue to live under protected -conditions, earning part at least of their livelihood. -Attempts in this direction are not likely to -have wide success unless the patient is re-instated in -his family; and the most promising efforts are those -which install the ex-consumptive with his family in a -cottage near a sanatorium, where he can remain under -partial medical supervision, while engaged in his daily -work. It remains to be seen to what extent such -arrangements are practicable on a considerable scale, -and the experiments now being made will be watched -with interest.</p> - - -<h3><em>Special Dwellings and Help in Support</em></h3> - -<p>An alternative to the “colony” proposal, which will -probably be found practicable in a much larger number -of cases is to arrange for the ex-patient to be housed -at his home under special conditions and for his work<span class="pagenum" id="Page_237">[Pg 237]</span> -to be graduated according to his physical condition, -assistance being given by way of payment of rent, or -otherwise to ensure that the patient and his family -live under satisfactory conditions. Proposals have -been made by Dr. Chapman in a report to the English -Local Government Board that in connection with new -housing schemes a certain proportion of the houses -erected should have rooms providing free perflation -of air reserved for consumptive patients. If with this -is combined the assistance indicated above, the risk of -the ex-patient relapsing will be materially reduced, and -the risk of other members of the family becoming -consumptive may be obviated.</p> - -<p>Whatever methods are employed, the principle already -enunciated must be maintained that the patient -in his own interest and in that of his family must be -the subject of uninterrupted care and supervision.</p> - -<p>In securing this end <em>Care Committees</em> play a valuable -part. Owing to the war their development has -been retarded; but a local scheme for such supervision -and assistance as the members or agents of a -Care Committee can give forms an essential part of a -complete tuberculosis scheme.</p> - -<p>These Committees are formed of non-official persons, -inasmuch as a large share of their work is at -present beyond the scope of official possibilities, outside -the poor-law organization; they can help,</p> - -<div class="poetry-container"> -<div class="poetry"> - <div class="stanza"> - <div class="verse indent0">(<em>a</em>) in obtaining appropriate work for the ex-patients;</div> - <div class="verse indent0">(<em>b</em>) in supplementing his wages;<span class="pagenum" id="Page_238">[Pg 238]</span></div> - <div class="verse indent0">(<em>c</em>) in providing separate sleeping accommodation for</div> - <div class="verse indent2">the patient, additional food or clothing, or in</div> - <div class="verse indent2">loaning out an additional bed or bedding;</div> - <div class="verse indent0">(<em>d</em>) in aiding the family during the absence of the</div> - <div class="verse indent2">patient in a sanatorium, and thus reducing the</div> - <div class="verse indent2">temptation to terminate institutional treatment</div> - <div class="verse indent2">prematurely, and</div> - <div class="verse indent0">(<em>e</em>) in encouraging each patient to take the necessary</div> - <div class="verse indent2">precautions and to adopt the special treatment</div> - <div class="verse indent2">recommended for him.</div> - </div> -</div> -</div> -<p>Some of these activities overlap into the activities -of the tuberculosis officer and of the visiting nurse of -the local authority; but there need be no practical difficulty -in adjusting this. It is important that Care -Committees should act in coöperation with local authorities, -insurance committees, and charitable agencies, -and should have representatives of these bodies -on them. The medical officer of health and tuberculosis -should also be ex-officio members of their committee.</p> - -<p><em>Summary</em>.—The preceding review of the problem of -tuberculosis may be summarised in a few final statements.</p> - -<p>1. Our knowledge of tuberculosis, if fully applied -by combined attack on the disease by all known -methods, is adequate to secure a great reduction in -its prevalence, if not its absolute abolition.</p> - -<p><span class="pagenum" id="Page_239">[Pg 239]</span></p> - -<p>This is true, although certain problems respecting -tuberculosis still need elucidation, e.g., as to improved -methods of treating the diseases, and of increasing -individual immunity during exposure to protracted -infection.</p> - -<p>2. Domestic protection is at once practicable against -infected cows’ milk; and control of this source of infection -at its source is also practicable.</p> - -<p>3. Of the circumstances favouring the development -of pulmonary tuberculosis industrial dust and domestic -overcrowding are the most potent. More detailed -and systematic supervision of factories and workshops -is needed, followed by general adoption of remedies, -which would increase industrial efficiency as well as -reduce tuberculosis.</p> - -<p>4. Tuberculosis is especially a “bedroom infection.” -But improvement in housing is a dual problem, and it -is a blunder to assume that improved housing, so long -as the healthy and tuberculous sick continue to be -housed together, will produce a rapid decline in the -prevalence of tuberculosis. Hospital provision for the -sick is as necessary as improved general housing.</p> - -<p><span class="pagenum" id="Page_240">[Pg 240]</span></p> - - -<div class="footnotes"><h3>FOOTNOTES:</h3> - -<div class="footnote"> - -<p><a id="Footnote_17" href="#FNanchor_17" class="label">[17]</a> The substance of two lectures at the Summer School on -Tuberculosis, Trudeau Sanatorium, Saranac, N. Y., July, 1919.</p> - -</div> -</div> - - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<h2 class="nobreak" id="CHAPTER_X">CHAPTER X<br><br> -<span class="smcap fs80">Child Welfare Work in England</span> -<a id="FNanchor_18" href="#Footnote_18" class="fnanchor">[18]</a></h2> -</div> - -<p>The subject of child welfare, in its chief developments, -cannot be separated from that of Public Health, -of which it forms a constituent part, though I do not -ignore the fact that child welfare is largely dependent -also on the extent to which child labor is exploited, -and to which expectant and nursing mothers,—as also -other mothers whose extra-domestic employment or -whose employment for gain is within the home itself,—involves -neglect of young children.</p> - -<p>Improvement in child welfare has occurred as the -sanitary and social progress of the country has advanced. -Whereas in the decade 1871-80, when money -began to be spent more freely on elementary sanitary -reform, the expectation of life or mean after-lifetime -at birth of males was 41.4 years and of females was -44.6 years; in the years 1910-12 these had increased -to 51.5 and 55.4 years respectively. The greater part -of the saving of life which this addition of ten years -to the average duration of life was the result of reduced -mortality in children under five years of age.</p> - -<p><span class="pagenum" id="Page_241">[Pg 241]</span></p> - -<p>The first direct steps towards the reduction of infant -mortality were directed against epidemic or summer -diarrhœa. Medical officers of health have always -been required in their annual reports to summarize the -vital statistics in their districts; and since 1905 a more -detailed statement of infant mortality during each part -of infancy has been required. Annually, therefore, -as well as when they received the weekly returns of -deaths from the local registrars, there was forced -upon their attention the fact that deaths of infants -under one year of age formed a high proportion of -total deaths at all ages (12.9 per cent. in 1917), and -that of these infantile deaths a large proportion were -caused by diarrhœa, the number varying with the temperature -and the deficiency of rainfall in the summer -months. In 1912, a year of relatively small mortality -from diarrhœa, this disease caused 8.1 per cent. of all -deaths under one year of age.</p> - -<p>For many years past it has been customary for medical -officers of health to issue warnings as to summer -diarrhœa, to arrange for the distribution of leaflets of -advice concerning the disease, and to urge the necessity -of more thorough cleanliness both municipal and -domestic during the summer months. Even before -the early notification of births became obligatory, in -many areas the addresses of infants were obtained -from the registrars of births and special visits were -made to the mothers of infants during the months of<span class="pagenum" id="Page_242">[Pg 242]</span> -June and July and especially to the mothers of those -infants who were known to be artificially fed.</p> - -<p>The reports of medical officers of health of many -of the large towns from 1890 onwards show that much -valuable work was being accomplished, and the way -was being prepared for more general measures against -infant mortality.</p> - -<p>The importance of municipal sanitation in aiding -the elimination of diarrhœal mortality is illustrated in -the experience of many towns, and strikingly by the -comparative experience of Leicester and Nottingham. -The chief difference between the sanitary condition of -the two towns was that in Nottingham in 1909 pail -closets still served more than half the houses, while -Leicester had abandoned this system entirely, substituting -water-closets. Between 1889-93 and 1909 the -diarrhœal mortality in Leicester had declined 52 per -cent.; in Nottingham it had only declined 4 per cent.</p> - -<p>Diarrhœa is not the only disease of infancy which -can be greatly diminished by improved public health -administration. Tuberculosis and whooping cough -and measles figure largely in the infantile death returns. -Over 21 per cent. of the total deaths in infancy -are due to these three diseases and to diarrhœa. The -amount of syphilis appearing in the death-returns is -small; but its actual amount is much greater than the -figures show. If pneumonia and bronchitis, which -account for 19 per cent. of the deaths in infancy, be<span class="pagenum" id="Page_243">[Pg 243]</span> -regarded—as they should—as infective diseases, then -it may be said that the problem of saving child life and -securing the correlative improvement in the standard -of health of children who survive to higher ages, <em>consists -very largely in the prevention of infections</em>, including -diarrhœal diseases and acute respiratory diseases.</p> - -<p>It follows from this that even if the limited and -erroneous view be taken that Sanitary Authorities are -concerned only with the prevention of infectious diseases, -the reduction of infant mortality is a duty devolving -on these authorities, and cannot be effectively -carried out without their coöperation. Voluntary -effort must therefore always, in large measure, be -directed towards stimulating local authorities to perform -their duties.</p> - -<p>The influence of diarrhœal summer mortality on the -progress of child welfare work is further shown by -the fact that among the earliest efforts were those to -provide pure cows’ milk to infants. In England official -Milk Depots for this purpose were never numerous; -and little voluntary effort went in this direction. -There now remain very few such Milk Depots; but -many local authorities provide milk, more particularly -dried milk, to infants for whom it is specially prescribed -at Infant Consultations. Early investigations -at Brighton and elsewhere showed that the mortality -of infants fed on condensed milk,—chiefly of the<span class="pagenum" id="Page_244">[Pg 244]</span> -sweetened variety,—was greater than that of infants -fed on fresh cows’ milk, and directed attention to the -supreme importance of domestic cleanliness in the -prevention of summer diarrhœa. The Milk Depots -and the concurrent agitation for purer cows’ milk -served a useful purpose; though it cannot yet be said -that the cows’ milk ordinarily supplied in England is -satisfactorily clean.</p> - -<p>It became evident ere long that the broadcast distribution -of instructions as to how cows’ milk might -safely be stored and prepared for infants had but a -limited utility, and that the directions given were liable -to be misinterpreted by mothers as an encouragement -to abandon breast-feeding; and there is reason to believe -that these directions did sometimes have this -effect. Hence the importance of the work initiated by -the late Dr. Sykes at the St. Pancras School for -Mothers, which brought into relief the importance of -encouraging breast-feeding by every possible means. -In towns in which the aided supply of milk was continued, -advice as to its use was also initiated; and thus -gradually Infant Consultations, in which the main element -was the giving of individual advice and treatment -as required, superseded Milk Depots, and were established -in very large numbers where Milk Depots had -never been started. These had educational as well -as medical and hygienic activities; and there need be -no dispute as to the relative value of these two aspects<span class="pagenum" id="Page_245">[Pg 245]</span> -of the work of Infant Consultations (also known as -Schools for Mothers, Child Welfare Centres, Baby -Weighings, Mothers’ Welcomes, etc.); for whether -advice and instruction are given to the individual -mother or to mothers collectively,—or as is advisable -in both ways,—it should be exactly the advice which a -physician skilled in the hygiene of infancy as well as -in the treatment of infantile complaints would give to -his individual patient. In this sense it remains true, -as Professor Budin, the distinguished founder of Infant -Consultations said: “An infant consultation is -worth precisely as much as the presiding physician.” -This is true whether it is possible to arrange for a physician -to be present at each meeting of a Child Welfare -Centre; or whether, as has happened during the Great -War in England, nurses or health visitors trained -under such a physician have given hygienic advice in -his absence.</p> - - -<h3><em>The Notification of Births</em></h3> - -<p>For many years before the Notification of Births -Act was passed, it had been customary, especially in -towns, to arrange for inquiry by a sanitary inspector -or female visitor into death occurring under one year -of age, and in many instances for the giving of systematic -advice to mothers concerning their infants. -More than twenty years ago the Manchester and Salform -Sanitary Association had initiated a system of<span class="pagenum" id="Page_246">[Pg 246]</span> -home visitation by volunteer ladies and by women -workers paid by the Association who went from house -to house, gave elementary sanitary advice, and reported -serious defects to the Sanitary Authority. The -City Council at an early stage showed its appreciation -of the importance of this work by giving grants -towards the expenditure incurred.</p> - -<p>In order to enable early visits to be made, the town -council of Salford had begun as early as 1899 a system -of voluntary notification of births by midwives.</p> - -<p>Prior to the stage at which early notifications of -births was obtained, the medical officer of health was -dependent for his information on the registration of -births, for which an interval of six weeks after birth -was permitted before it became compulsory. During -this interval a large proportion of the total mortality -of infancy had occurred,—approximately one-fifth of -the total deaths in the first year after birth occur in -the first week and one-third in the first month after -birth,—and the possibility of successfully influencing -the mother to continue breast-feeding had gone. The -action of the town of Huddersfield in 1906 in obtaining -Parliamentary power to secure the compulsory -notification of births within thirty-six hours of birth -represented a rapid growth of opinion based on experience -in that and other towns to the effect that in the -absence of early information of birth the necessary -sanitary precautions and counsel as to personal hygiene<span class="pagenum" id="Page_247">[Pg 247]</span> -could not be given with the greatest prospect of -success. This local pioneer work doubtless facilitated -the passing of the Notification of Births Act in 1907.</p> - -<p>Much important work followed the notification of -births. Home visits to the mother were regarded and -continue to be regarded as the most important part of -this work; but there also grew up rapidly the present -system of Infant Consultations and similar organizations.</p> - -<p>The Notification of Births (Extension) Act, 1915, -not only made the enforcement of this act universal, -but it also empowered each local authority administering -the Act to exercise any powers which a sanitary -authority possesses under the Public Health Acts “for -the purpose of the care of expectant mothers, nursing -mothers, and young children.” In drawing the attention -of Local Authorities to the terms of the Act the -Local Government Board, as well as earlier in the war, -deprecated false economy during the war. They said:</p> - -<div class="blockquot fs80"> - -<p>At a time like the present the urgent need for taking all -possible steps to secure the health of mothers and children and -to diminish ante-natal and post-natal infant mortality is obvious, -and the Board are confident that they can rely upon -local authorities making the fullest use of the powers conferred -on them.</p> -</div> - -<p>The Board in the same circular laid stress on “the -importance of linking up this work with the other<span class="pagenum" id="Page_248">[Pg 248]</span> -medical and sanitary services provided by local authorities -under the Public Health and other Acts.”</p> - -<p>The passing of this Act has been followed by an -increasingly rapid development of Maternity and Child -Welfare work, and the Maternity and Child Welfare -Act passed in August, 1918, made it obligatory on -each Council exercising powers under the Act to appoint -a Maternity and Child Welfare Committee, -which must include at least two women, and may include -persons specially qualified by training or experience -in subjects relating to health and maternity who -are not members of the Council.</p> - -<p>In the circular letter sent out to local authorities explaining -the new Act, the Local Government Board -reëmphasizes its previously stated views that child -welfare work was second only in importance to direct -war work, and was really a “measure of war emergence,” -and added:</p> - -<div class="blockquot fs80"> - -<p class="no-indent">although we have enjoined as local authorities the necessity -of the strictest of economy in public expenditure, we have -urged increased activity in work which has for its object the -preservation of infant life and health. We are glad to note -that the great majority of local authorities have realized the -value of continuing and extending their efforts for child welfare -at the present time.</p> -</div> - - -<h3><em>The Causes of Child Mortality</em></h3> - -<p>For detailed consideration of the causes of infant -mortality and of mortality during the next four years<span class="pagenum" id="Page_249">[Pg 249]</span> -of life in England and Wales, the reader may be referred -to official reports by the writer.</p> - -<p>No consistent and continuous decline had taken -place in infant mortality prior to 1900, although there -had been marked reduction of the mortality in each -of the next four years of life. This difference corresponds -in the main with the facts that greater success -had been achieved in the general measures of sanitation -and in the reduction of prevalence of and mortality -from such infectious diseases as scarlet fever, -diphtheria, and enteric fever, than in respect of the -special causes of mortality in infancy. These special -causes may be placed under three headings: First, infections,—acute -respiratory diseases, measles, whooping -cough, syphilis, tuberculosis, and diarrhœa; second, -errors of nutrition, due largely to poverty, to mismanagement, -and to imperfect provision of facilities -for healthy family life; and third, developmental conditions -present at the birth of the infants. Under -none of these headings had marked success been -achieved prior to 1900, though the steady work devoted -to the subject of diarrhœa had already begun to -show fruit.</p> - -<p>The statistics of infant mortality may be stated as -follows:</p> - -<p><span class="pagenum" id="Page_250">[Pg 250]</span></p> - -<p class="center"><em>England and Wales</em></p> - -<table class="autotable fs80"> -<tr> -<td class="tdl"></td> -<td class="tdcnw" colspan="3">Deaths of Infants under</td> -</tr> -<tr> -<td class="tdcnw">Period</td> -<td class="tdcnw" colspan="3">1 Year per 1,000 Births</td> -</tr> -<tr> -<td class="tdl">1896-1900</td> -<td class="tdr">156</td> -<td class="tdr"></td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1901-1905</td> -<td class="tdr">138</td> -<td class="tdr"></td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1906-1910</td> -<td class="tdr">117</td> -<td class="tdr"></td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1911</td> -<td class="tdr">130</td> -<td class="tdr"></td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1912</td> -<td class="tdr">95</td> -<td class="tdr"></td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1913</td> -<td class="tdr">108</td> -<td class="tdr"></td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1914</td> -<td class="tdr">105</td> -<td class="tdr"></td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1915</td> -<td class="tdr">110</td> -<td class="tdr"></td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1916</td> -<td class="tdr">91</td> -<td class="tdr"></td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1917</td> -<td class="tdr">96</td> -<td class="tdr"></td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1918</td> -<td class="tdr">97</td> -<td class="tdr"></td> -<td class="tdr"></td></tr> -</table> - - -<p>The above are the crude rates, the infantile death-rate -being stated by the usual method per 1,000 births -<em>during the same year</em>. Owing to the great decline of -births during the war, this method overstates the infant -mortality in recent years. In a table given in the -Registrar-General’s annual report for 1917, this unusual -source of error is corrected. When this is done, -and the infantile deaths are stated “per 1,000 of population -aged 0-1,” the rates for the years 1912-17 -inclusive in successive years became respectively</p> - -<p class="center">104, 117, 113, 111, 98, and 94.</p> - -<p>In other words, there has been a steady and uninterrupted -decline in the death-rate of infants during the -war.</p> - -<p>This decline has followed similar declines in preceding -years, and it is to be noted that much of this decline<span class="pagenum" id="Page_251">[Pg 251]</span> -occurred during the period when the hygienic work -effecting child-welfare was confined to general public -health measures. Thus it anticipated the more direct -and active measures adopted by voluntary societies -and by local authorities for the prevention of infant -mortality. Comparing the five year periods 1896-1900 -and 1901-05, a decrease in the death-rate of 12 -per cent. is seen; comparing 1901-05 with 1906-10, a -decline of 15 per cent. occurred; comparing 1906-10 -with the average experience of the three years 1911-13 -mortality declined 5 per cent.; comparing these -three years with the average experience of the five -years 1914-18, during which war conditions prevailed -more or less, a reduction 9 per cent. was experienced. -The actual reduction during war time is greater than -is indicated by these percentages, when allowance is -made for the statistical error indicated above. The -exceptional experience of the year 1911 illustrates one -of the chief sources of error in forming conclusions -on the experience of a single year. In this year the -summer was excessively hot, and summer diarrhœa -prevailed to an exceptional extent; and the illustration -is important, as serving to remind us of the limitations -of the value of statistical tests and of the fact that -increase of good work tending to improve child life -may be associated temporarily with increase of total -infant mortality.</p> - -<p><span class="pagenum" id="Page_252">[Pg 252]</span></p> - - -<h3><em>The Influence of School Medical Inspection</em></h3> - -<p>In the development of child welfare work in England -important place must be given to the system of -medical inspection of school children initiated in 1907. -The numerous physical defects found in school children -have led to the beginning of measures for remedial -action, confined in some areas to measures for -securing greater cleanliness and the treatment of minor -skin diseases; but extending in other areas to such -measures as the remedial treatment of adenoids, the -cure of ringworm, the correction of errors of refraction, -and the provision of dental treatment. Perhaps -the chief value of the system of medical inspection of -school children has been the fact that it has demonstrated -the extent to which children when they first -come to school are already suffering from physical disease -which might have been prevented or minimized -by attention in the pre-school period. The information -thus accumulated has had much influence in encouraging -the institution of Infant Consultations, with -a view to the early discovery of disease or of tendency -to disease.</p> - - -<h3><em>The Influence of Statistical Studies</em></h3> - -<p>The intensive study of our national and of local vital -statistics has also had a most important bearing on the -further development of maternity and child welfare<span class="pagenum" id="Page_253">[Pg 253]</span> -work. In successive official reports it has been shown -that infant mortality varies greatly in different parts -of the country, irrespective of climatic conditions; -that it varies greatly in different parts of the same -town, in accordance with variations in respect of industrial -and housing conditions, of local sanitation, of -poverty and alcoholism; that the variations extend to -different portions of infant life, the death-rate in infants -under a week, or under a month in age, for instance, -being two or three times as high in some areas -as in others; and that the distribution of special diseases -in infancy similarly varies greatly. Intensive -studies of infant mortality on these and other lines -have pointed plainly the directions in which preventive -work is especially called for; and have incidentally -demonstrated the fundamental value of accurate statistics -of births and of deaths in the child welfare -campaign. Surveys of local conditions both statistical -and based on actual local observations form an indispensable -preliminary to and concomitant of good child -welfare work; and it is to combined work on these -lines that the improvement of recent years is largely -attributable. To <em>act helpfully</em> we must <em>know thoroughly</em> -the summation of conditions which form the -evil to be attacked.</p> - -<p>One important result of investigations such as those -already mentioned has been to bring more clearly into -relief the fact, which previously had been partially<span class="pagenum" id="Page_254">[Pg 254]</span> -neglected, that <em>child welfare work can only succeed -in so far as the welfare of the mother is also maintained</em>.</p> - -<p>This may imply extensions of work involving serious -economic considerations; but apart from such possibilities -and apart from questions of housing, and of -provision of additional domestic facilities for assisting -the overworked mother, there is ample evidence that -medical and hygienic measures by themselves can do -much to relieve the excessive strain on the mother -which childbearing under present conditions often involves.</p> - - -<h3><em>The Course of Mortality from Childbearing</em></h3> - -<p>The general course of mortality from childbearing -(including deaths ascribable to pregnancy) in England -and Wales is shown by the following table:</p> - -<p class="center fs80"><em>Average Annual Death-rates per 100,000 births from</em></p> - -<table class="autotable fs80"> -<tr> -<td class="tdc"></td> -<td class="tdc">Puerperal</td> -<td class="tdc"> Other Diseases</td> -</tr> -<tr> -<td class="tdcnw"></td> -<td class="tdcnw">Septic</td> -<td class="tdcnw">of Pregnancy</td> -</tr> -<tr> -<td class="tdc"></td> -<td class="tdc">Diseases</td> -<td class="tdc"> and Childbirth</td> -</tr> -<tr> -<td class="tdln">5 years, 1902-06</td> -<td class="tdc">185</td> -<td class="tdc">228</td> -</tr> -<tr> -<td class="tdln">5 years, 1907-11</td> -<td class="tdc">152</td> -<td class="tdc">215</td> -</tr> -<tr> -<td class="tdln">3 years, 1912-14</td> -<td class="tdc">148</td> -<td class="tdc">233</td> -</tr> -<tr> -<td class="tdln">2 years, 1915-16</td> -<td class="tdc">151</td> -<td class="tdc">239</td> -</tr> -</table> - - -<p>It will be noted that although there has been a -marked decline of deaths from puerperal sepsis, the -death-rate from other complications of childbearing -has not declined. The decline in puerperal sepsis is<span class="pagenum" id="Page_255">[Pg 255]</span> -general throughout the country, and evidences the -greater care in midwifery both on the part of doctors -and of midwives. The administration of the Midwives -Act, 1902, has doubtless done much to secure -this. The death-rate from conditions other than puerperal -fever continues to differ greatly throughout the -country. It is highest in Welsh counties, Westmoreland, -Lancashire and Cheshire coming next in order -of unfavourable portion; in many industrial, including -textile, towns it is also excessive. The general conclusion -reached by the writer in an elaborate official -report on the subject is that “the quality and availability -of skilled assistance before, during, and after -childbirth are probably the most important factors in -determining the remarkable and serious differences in -respect of mortality from childbearing shown in the -report.”—“The differences are caused in the main by -differences in availability of skilled assistance when -needed in pregnancy, and at and after childbirth.”</p> - - -<h3><em>The Midwives Act, 1902</em></h3> - -<p>This Act forbade any woman after April 1, 1906, -who was not certified under the Act, from using the -title of midwife or any similar description of herself. -It forbade after April 1, 1910, any such woman from -“habitually and for gain attending women in childbirth, -except under the direction of a qualified medical -practitioner”; and it forbade any certified midwife to<span class="pagenum" id="Page_256">[Pg 256]</span> -use an uncertified person as her substitute. The Act -defined the limits of function of the midwife by stating -that the Act did not confer upon her any title to give -certificates of death or of still-birth, or to take charge -of any abnormality or disease in connection with parturition.</p> - -<p>The Act set up the Central Midwives Board, giving -it special disciplinary powers over midwives. It also -imposed on county councils and the councils of county -boroughs the duty of supervising the work of midwives. -For further details the Act itself and the -Rules of the Central Midwives Board made under the -Act should be consulted.</p> - -<p>The Midwives Act, 1918, gave further powers to the -Central Midwives Board and to local supervising authorities, -and made it the duty of the latter to pay the -fee of a doctor called in by a midwife in any of the -emergencies for which Rules are made by the Central -Midwives Board, the fee paid to be in accordance with -a scale prescribed by the Ministry of Health.</p> - -<p>As at least three-fourths of the total births in England -and Wales are attended by midwives with or -without the assistance of doctors, their work has great -importance in relation to the reduction of maternal -disablement and mortality and to the prevention of -early infant mortality, and it is of happy augury that -they are being enlisted more and more in official work -for safeguarding the health of the mother and her unborn<span class="pagenum" id="Page_257">[Pg 257]</span> -or recently delivered infant. An important recent -addition has been made to the rules of the Central -Midwives Board, which makes it obligatory on the -midwife to notify to the medical officer of health any -instance, while the patient is under her charge, in which -for any reason breast-feeding has been discontinued.</p> - -<p><em>Administrative Work.</em>—Largely through the machinery -provided by the Midwives Act and the Notification -of Births Act a system of supervision of maternity -and child welfare has been organized in every -county and county borough, and this has been responsible -for a large share of the improvement experienced -in recent years. The character and extent of development -of the work varies greatly in different centres; -and as a rule the work is more fully developed in -county boroughs than in counties. In county districts -it has sometimes been found necessary to unite -the offices of assistant inspector of midwives, infant -visitor and tuberculosis visitor in one adequately -trained health visitor, thus saving time in travelling by -enabling the visitor to have a smaller district allotted -to her than if she undertook only one branch of work. -In some counties the school nurse’s work is also undertaken -by the health visitor. In some country areas -arrangements have been made for infant visiting to -be carried out by district nurses who are also midwives.</p> - -<p><em>Voluntary Workers.</em>—Much of the success so far -achieved in improving the health conditions of infancy<span class="pagenum" id="Page_258">[Pg 258]</span> -and childhood has been secured by coöperation -between voluntary and official health visitors. Excellent -work has been done by local and other societies, -particularly during the last ten years, in educating -public opinion and in direct assistance to mothers and -their infants. It is essential that such voluntary work -should have a nucleus of highly trained and well-paid -workers; but given this condition, a large amount of -good work can be accomplished by voluntary aid.</p> - -<p>The main work has been that of the <em>health visitor</em>. -The details of this work, the conditions of qualification -of workers, the number of visits which it is desirable -to make, the character of the advice intended to be -given at these visits are set out in an official memorandum -of the Medical Officer of the Local Government -Board and it is unnecessary to repeat this information -in these pages.</p> - -<p>A similar remark applies to the next most important -development of work, the institution of <em>Maternity and -Child Welfare Centres</em>. The conditions of work of -these institutions are set out in the same document.</p> - - -<h3><em>Training and Provision of Midwives</em></h3> - -<p>The provision of additional trained midwives is a -pressing problem. The increased cost of living, longer -training required, and the rapid development of less -laborious and more lucrative occupations, have made it -difficult to secure women to train as midwives, or to<span class="pagenum" id="Page_259">[Pg 259]</span> -continue to practise in this capacity after qualification. -In many industrial areas the older <em>bonâ fide</em> midwife -is preferred, although it is the almost universal experience -that the trained midwife more quickly detects -conditions endangering the life of the mother or infant, -and sends for medical help. In order to encourage -further the supply of practising midwives, the -government gives grants for increased remuneration -to midwives newly appointed by local authorities, sufficient -to recoup them in the course of a few years’ -service for the cost of their training.</p> - -<p>At a recent date, of some 30,543 trained midwives -on the Roll, only 6,754 were returned as being in actual -practice as such.</p> - -<p>In order to make midwives available for all women -needing them, the Board repays to local authorities -and voluntary associations half the cost of the provision -of a midwife for necessitous women. During -the Great War a woman might receive assistance in -her confinement from several central sources; for in -addition to the above</p> - -<div class="poetry-container"> -<div class="poetry"> - <div class="stanza"> - <div class="verse indent0">(1) If she was the wife of an insured person, or if she</div> - <div class="verse indent2">herself is insured, she received under the conditions</div> - <div class="verse indent2">of the National (Health) Insurance Act</div> - <div class="verse indent2">30s. in cash, or if she is insured and the wife of</div> - <div class="verse indent2">an insured person 60s. in cash.</div> - <div class="verse indent0">(2) If she was the wife of a soldier or sailor and not</div> - <div class="verse indent2">entitled to maternity benefit she received from</div> - <div class="verse indent2">10s. per week up to £2 from the Local Pensions<span class="pagenum" id="Page_260">[Pg 260]</span></div> - <div class="verse indent2">Committee.</div> - <div class="verse indent0">(3) If she was a munition worker she might be aided</div> - <div class="verse indent2">under a scheme provided under the Ministry</div> - <div class="verse indent2">of Munitions.</div> - <div class="verse indent0">(4) She also might obtain priority for the supply of</div> - <div class="verse indent2">milk, or obtain free milk or milk at cost price</div> - <div class="verse indent2">under the Local Committee Board Food Control</div> - <div class="verse indent2">Order, No. 1, 1918, empowering local authorities</div> - <div class="verse indent2">to supply milk and food and an extra</div> - <div class="verse indent2">ration under the Food Controller’s Order. In</div> - <div class="verse indent2">addition, after confinement she had available</div> - <div class="verse indent2">the ration apportioned to the infant and its</div> - <div class="verse indent2">allowance of milk under the priority scheme.</div> - </div> -</div> -</div> - -<p>There was evidently need for simplification and unification -of effort in the above cases.</p> - -<p>In many instances maternity nursing is required. -The midwife may have too many patients to be able -to give this during the ten days in which she is in -charge of the patient; and even when she carries out -her duty in this respect in accordance with the Rules -of the Central Midwives Board additional help is required -in the feeding and care of the mother and infant, -and in the care of the household. Often also -nursing is required for both mother and infant for a -considerable period beyond the ten days. For these -persons the government gives grants for maternity -nursing and for “home helps.”</p> - -<p><span class="pagenum" id="Page_261">[Pg 261]</span></p> - -<p>Even when all the above requirements are or can be -fulfilled, there remain a large number of cases of pregnant -women, and especially of unmarried women, who -cannot be satisfactorily confined at home, either because -of their social or sanitary circumstances, or because -abnormal or complicated childbirth is expected. -For such cases hospital provision is needed. This is -one of the most urgent requirements of the present -time.</p> - -<p>Under present conditions, institutional lying-in provision -is chiefly voluntary in character; and the government -has advised local authorities to contract for -its use, rather than wait for the erection of special -hospitals. In other instances houses are being taken -and adapted as maternity homes.</p> - - -<h3><em>Ante-natal Work</em></h3> - -<p>The progress made in the organisation of ante-natal -work is slow for reasons which are fairly obvious. -There has been difficulty under war conditions in securing -assistance from doctors and midwives. There -is the well-known difficulty as to notification of pregnancy, -which the government has not encouraged, except -when the definite consent of the mother has been -previously obtained. The facilities for help provided -at the Centre have in some areas attracted patients; -and health visitors and midwives have done much in -other areas to persuade mothers of the advisability of<span class="pagenum" id="Page_262">[Pg 262]</span> -safeguarding themselves against possible complications, -as well as of securing adequate preparation for -the lying-in period.</p> - -<p>This subject is closely associated with that of abortions, -still-births, and deaths in the first two weeks after -birth. One of the most promising methods for securing -the sound development of ante-natal work consists -in the investigation of still-births and early infant -mortality. When these inquiries are made mothers -can be induced to obtain medical advice not only at the -time, but also in the event of a subsequent pregnancy. -The investigation at the patient’s home of all such -cases and assistance in prevention of recurrence of -unnecessary ante-natal, natal, and early post-natal -deaths have as great an importance as the building up -of a successful ante-natal clinic. The anti-syphilis -work now being carried on will help greatly in this -direction.</p> - - -<h3><em>Dental Assistance</em></h3> - -<p>There has been a large extension of dental assistance -at Centres for expectant and for nursing mothers, -and for children, especially in the metropolis and its -vicinity. The government has lately extended its -grant to cover dentures for mothers who are nursing -or pregnant, if the medical officer of the Centre is -satisfied that the woman’s health will be materially -improved by the denture, and that she is unable to provide -it for herself.</p> - -<p><span class="pagenum" id="Page_263">[Pg 263]</span></p> - - -<h3><em>Creches</em></h3> - -<p>Creches and day nurseries may be expected to exercise -influence in educating mothers in the care of their -children. For this purpose it is very desirable to have -the creche attached to or near an infant welfare centre.</p> - -<p>These creches, unless managed with the most rigid -medical and general cleanliness, are very apt to spread -infectious diseases; not merely such diseases as whooping -cough, measles, and chickenpox, but also catarrhal -and diarrhœal diseases. In the prevention of all of -these the enforcement of the strictest cleanliness is -essential, especially during the summer months for -the last named diseases. For the prevention of catarrhal -infections, it is essential that the creche should -be conducted, so far as practicable, on strict open-air -lines. Open-air creches give admirable occasional relief -to mothers, even when these do not go out to work. -The “toddler’s playground” is a blessing to all concerned, -but the indoor creche may be, and often is, -mischievous. The risks are greatly reduced by insisting -on open-air conditions and by not allowing large -groups of children to come together. Smaller groups -mean greatly decreased possibility of cross-infection.</p> - - -<h3><em>Observation Beds at Child Welfare Centres</em></h3> - -<p>At infant welfare centres infants are not infrequently -seen who fail to make progress while living at -home, and who yet are not ill enough to be sent to a<span class="pagenum" id="Page_264">[Pg 264]</span> -hospital. This especially applies to cases of defective -nutrition. For these cases beds in connection with -centres have been found to be necessary for observation -purposes and to initiate further treatment. In -some instances, especially for failure of breast-feeding, -it is advisable to admit the mother with the infant.</p> - -<p>On July 30, 1914, the Local Government Board sent -a circular letter and a covering memorandum by their -Medical Officer which may be claimed to have been the -starting point of maternity and child welfare work on -a larger scale, more generally distributed throughout -the country, and more completely covering the whole -sphere of medical and hygienic work for this purpose -than had previously been envisaged. Although the -country at that time might be said to be already under -the shadow of war, these documents had been previously -prepared, and their appearance four days before -the declaration of war was a coincidence. The -chief burden of the additional work to which local -authorities were urged was that there should be <em>continuity -in dealing with the whole period from before -birth until the time when the child is entered upon a -school register</em>; and the memorandum contemplated -that “medical advice and, where necessary, treatment -should be continuously and systematically available -for expectant mothers and for children till they are -entered on a school register, and that arrangements -should be made for home visitation throughout this<span class="pagenum" id="Page_265">[Pg 265]</span> -period.” It was added that “the work of home visitation -is one to which the Board attach very great importance -and in promoting schemes laid down in the -accompanying memorandum the first step should be -the appointment of an adequate staff of health -visitors.”</p> - -<p>The main provisions of this memorandum are -printed on page <a href="#Page_135">135</a>.</p> - -<p>The increase of work since that date may be gathered -from the following table, which shows the increase -each year in the number of health visitors, of -child welfare centres, and of grants given on the 50 -per cent. basis by the Local Government Board and -the Board of Education.</p> - - -<p class="center fs80"><em>Amounts of Grants (pounds sterling) in Each Financial Year -to Local Authorities and Voluntary Agencies, on the Basis -of 50 Per Cent. of Total Approved Local Expenditure</em></p> - -<table class="autotable fs80"> -<tr> -<td class="tdl">Financial Year</td> -<td class="tdc" colspan="2">Local Government Board</td> -<td class="tdcw" colspan="2">Board of Education</td> -</tr> -<tr> -<td class="tdl">1914-15</td> -<td class="tdr">11,488</td> -<td class="tdr"></td> -<td class="tdr">10,830</td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1915-16</td> -<td class="tdr">41,466</td> -<td class="tdr"></td> -<td class="tdr">15,334</td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1916-17</td> -<td class="tdr">67,961</td> -<td class="tdr"></td> -<td class="tdr">19,023</td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1917-18</td> -<td class="tdr">122,285</td> -<td class="tdr"></td> -<td class="tdr">24,110</td> -<td class="tdr"></td> -</tr> -<tr> -<td class="tdl">1918-19 (estimated)</td> -<td class="tdr">209,000</td> -<td class="tdr"></td> -<td class="tdr">44,000</td> -<td class="tdr"></td> -</tr> -</table> - - -<p>These grants do not cover the entire scope of child -welfare work carried out throughout the country, and -their amount must not be taken as a complete indication -of the extent of this work.</p> - -<p>The increase during the war period has been very<span class="pagenum" id="Page_266">[Pg 266]</span> -great; and this can be attributed to the desire to do -everything practicable for mothers and children, especially -those belonging to soldiers and sailors who were -risking their lives for the country; and to the increased -realisation of the importance of preserving and improving -our chief national asset which consists in a -healthy population. During this period there was a -great increase in the industrial employment of women, -including married women, in factories including munition -and other works. This increase it is believed -amounted to a million and a half workers.</p> - -<p>Notwithstanding the many adverse influences, to -which must be added great overcrowding in many industrial -areas, especially those in which new industries -were hurriedly started, and the increasing cost of food -and especially of milk with a scarcity of supply, it has -been seen that infant mortality remained low and on -the whole declined during the whole period of the war.</p> - -<p>To what circumstances can this be ascribed?</p> - -<p>It is unnecessary to assume that this result was entirely -due to the active measures favorable to maternity -and child welfare which were taken as an unexampled -scale, though these measures can claim an -important share in the result.</p> - -<p>A number of contributory factors were at work:</p> - -<p>1. In none of the years in question did the summer -weather favor an excess of diarrhœal mortality. With -this factor, however, eliminated the infant mortality -each year was lower than in previous years.</p> - -<p><span class="pagenum" id="Page_267">[Pg 267]</span></p> - -<p>2. Although so many husbands were away from -home, in a large proportion of cases the wife, in virtue -of her separation allowance, was financially in a more -favorable position than when she was dependent on -her husband’s wages or such portion of it as he allowed -her for the support of the household.</p> - -<p>3. In addition, every soldier became an insured person, -and his wife was therefore entitled to the Maternity -Benefit of 30 shillings on the birth of a child, and -an additional 30 shillings if she was herself an employed -person.</p> - -<p>4. There can be no reasonable doubt that the restrictions -on the consumption of alcoholic drinks and -the limitation of hours for opening public houses were -a factor in improving domestic welfare.</p> - -<p>But attaching full value to these and other similar -factors which undoubtedly were at work, chief place -must, I think, be given to the awakening of the public -conscience on the subject, and to the concentration on -the mother and her child which had been urged in -season and which now became a fact. An indication -of the public mind is given by the advice issued by the -Local Government Board in August, 1918, which is -quoted on page <a href="#Page_248">248</a>.</p> - -<p><span class="pagenum" id="Page_268">[Pg 268]</span></p> - - -<div class="footnotes"><h3>FOOTNOTES:</h3> - -<div class="footnote"> - -<p><a id="Footnote_18" href="#FNanchor_18" class="label">[18]</a> Extracted from addresses given at Conferences held by the -Children’s Bureau of the Department of Labor, Washington.</p> - -</div> -</div> - - -<hr class="chap x-ebookmaker-drop"> - -<div class="chapter"> -<h2 class="nobreak" id="INDEX">INDEX</h2> -</div> - - -<ul class="index"> -<li class="ifrst">Abbott, J., <a href="#Page_2">2</a></li> - -<li class="indx">Abbott, S. W., <a href="#Page_2">2</a></li> - -<li class="indx">Alcoholic drinks, <a href="#Page_123">123</a>, <a href="#Page_149">149</a>, <a href="#Page_187">187</a></li> - -<li class="indx">Anaesthetics, <a href="#Page_77">77</a></li> - -<li class="indx">Ante-natal work, <a href="#Page_261">261</a></li> - - -<li class="ifrst">Bacteriological diagnosis, <a href="#Page_85">85</a></li> - -<li class="indx">Banks, N. P., <a href="#Page_2">2</a></li> - -<li class="indx">Biggs, H., <a href="#Page_77">77</a></li> - -<li class="indx">Bowditch, <a href="#Page_2">2</a></li> - -<li class="indx">Budd, Wm., <a href="#Page_15">15</a></li> - -<li class="indx">Burns, John, <a href="#Page_44">44</a></li> - -<li class="indx">Burton, R., <a href="#Page_71">71</a></li> - - -<li class="ifrst">Care Committees, <a href="#Page_237">237</a></li> - -<li class="indx">Causation, <a href="#Page_147">147</a></li> - -<li class="indx">Causation, specific, <a href="#Page_20">20</a></li> - -<li class="indx">Cerebro-spinal fever, <a href="#Page_23">23</a>, <a href="#Page_76">76</a>, <a href="#Page_126">126</a></li> - -<li class="indx">Chadwick, <a href="#Page_2">2</a>, <a href="#Page_3">3</a>, <a href="#Page_11">11</a>, <a href="#Page_12">12</a>, <a href="#Page_25">25</a>, <a href="#Page_52">52</a>, <a href="#Page_54">54</a></li> - -<li class="indx">Chalmers, <a href="#Page_70">70</a></li> - -<li class="indx">Chapman, <a href="#Page_221">221</a>, <a href="#Page_237">237</a></li> - -<li class="indx">Character and health, <a href="#Page_173">173</a></li> - -<li class="indx">Childbearing, care of, <a href="#Page_137">137</a>, <a href="#Page_254">254</a></li> - -<li class="indx">Child mortality, causes of, <a href="#Page_248">248</a></li> - -<li class="indx">Child welfare work, <a href="#Page_240">240</a></li> - -<li class="indx">Cholera, <a href="#Page_12">12</a></li> - -<li class="indx">Colonies for consumptives, <a href="#Page_235">235</a></li> - -<li class="indx">Consumption, see Tuberculosis.</li> - -<li class="indx">Contacts in tuberculosis, <a href="#Page_212">212</a></li> - -<li class="indx">Creches, <a href="#Page_263">263</a></li> - - -<li class="ifrst">Decadence, <a href="#Page_121">121</a></li> - -<li class="indx">Democracy and public health, <a href="#Page_47">47</a></li> - -<li class="indx">Dental assistance, <a href="#Page_262">262</a></li> - -<li class="indx">Destitution (see also Poor Law), <a href="#Page_31">31</a>, <a href="#Page_65">65</a>, <a href="#Page_87">87</a></li> - -<li class="indx">Deterrence, principle of, <a href="#Page_29">29</a></li> - -<li class="indx">Diarrhœal diseases, <a href="#Page_20">20</a>, <a href="#Page_241">241</a></li> - -<li class="indx">Dirt and disease, <a href="#Page_11">11</a></li> - -<li class="indx">Dispensaries for tuberculosis, <a href="#Page_216">216</a></li> - -<li class="indx"><span style="margin-left: 1em;">” general, </span><a href="#Page_218">218</a></li> - -<li class="indx">Domiciliary treatment, <a href="#Page_35">35</a></li> - - -<li class="ifrst">Education authorities and public health, <a href="#Page_56">56</a>, <a href="#Page_58">58</a>, <a href="#Page_86">86</a></li> - -<li class="indx">Educational propaganda, <a href="#Page_130">130</a>, <a href="#Page_168">168</a></li> - -<li class="indx"><span style="margin-left: 1em;">” work of sanatoria, </span><a href="#Page_233">233</a></li> - -<li class="indx">Enteric fever, see Typhoid.</li> - -<li class="indx">Epidemiology, present limitations of, <a href="#Page_22">22</a>, <a href="#Page_81">81</a></li> - -<li class="indx">Eugenics and public health, <a href="#Page_44">44</a></li> - -<li class="indx">Expectation of life, <a href="#Page_20">20</a>, <a href="#Page_74">74</a>, <a href="#Page_192">192</a></li> - - -<li class="ifrst">Factory hygiene and legislation, <a href="#Page_8">8</a>, <a href="#Page_26">26</a></li> - -<li class="indx">Farr, Wm., <a href="#Page_2">2</a>, <a href="#Page_25">25</a></li> - -<li class="indx">Fulton, J. S., <a href="#Page_24">24</a></li> - - -<li class="ifrst">Gerhard, <a href="#Page_15">15</a></li> - -<li class="indx">Goodnow, <a href="#Page_60">60</a>, <a href="#Page_63">63</a></li> - -<li class="indx">Grants in aid, <a href="#Page_56">56</a>, <a href="#Page_135">135</a>, <a href="#Page_265">265</a></li> - - -<li class="ifrst">Historical development of public health, <a href="#Page_42">42</a></li> - -<li class="indx">Holmes, O. Wendell, <a href="#Page_16">16</a></li> - -<li class="indx">Hospitals, see Institutional treatment.</li> - -<li class="indx"><span style="margin-left: 1em;">” as housing auxiliaries, </span><a href="#Page_38">38</a>, <a href="#Page_77">77</a>, <a href="#Page_79">79</a>, <a href="#Page_98">98</a></li> - -<li class="indx"><span style="margin-left: 1em;">” and private practice, </span><a href="#Page_146">146</a></li> - -<li class="indx">Housing, <a href="#Page_38">38</a>, <a href="#Page_79">79</a></li> - -<li class="indx"><span style="margin-left: 1em;">” and tuberculosis, </span><a href="#Page_203">203</a></li> - -<li class="indx">Huddersfield, <a href="#Page_246">246</a></li> - - -<li class="ifrst">Ideals of public work, <a href="#Page_4">4</a></li> - -<li class="indx">Ignorance and sickness, <a href="#Page_168">168</a></li> - -<li class="indx"><span class="pagenum" id="Page_269">[Pg 269]</span>Immunity to tuberculosis, <a href="#Page_196">196</a></li> - -<li class="indx">Industrial colonies, <a href="#Page_235">235</a></li> - -<li class="indx">Industry and public health, <a href="#Page_50">50</a>, <a href="#Page_161">161</a></li> - -<li class="indx">Infant consultations, <a href="#Page_243">243</a></li> - -<li class="indx">Infant mortality, <a href="#Page_144">144</a>, <a href="#Page_250">250</a></li> - -<li class="indx">Infant mortality and poverty, <a href="#Page_153">153</a>, <a href="#Page_185">185</a></li> - -<li class="indx">Infants, care of, <a href="#Page_30">30</a></li> - -<li class="indx">Influenza, <a href="#Page_23">23</a>, <a href="#Page_76">76</a>, <a href="#Page_127">127</a></li> - -<li class="indx">Inspectors of factories, <a href="#Page_51">51</a></li> - -<li class="indx">Institutional treatment, <a href="#Page_37">37</a>, <a href="#Page_79">79</a>, <a href="#Page_98">98</a></li> - -<li class="indx">Insurance and public health, <a href="#Page_33">33</a>, <a href="#Page_59">59</a>, <a href="#Page_66">66</a>, <a href="#Page_88">88</a>, <a href="#Page_92">92</a>, <a href="#Page_95">95</a>, <a href="#Page_103">103</a></li> - -<li class="indx">Intemperance, <a href="#Page_149">149</a></li> - - -<li class="ifrst">Jefferson, President, <a href="#Page_6">6</a></li> - -<li class="indx">Jenner, Wm., <a href="#Page_15">15</a></li> - - -<li class="ifrst">Kay, <a href="#Page_2">2</a>, <a href="#Page_11">11</a></li> - -<li class="indx">Koch, Robert, <a href="#Page_192">192</a></li> - -<li class="indx"><span style="margin-left: 1em;">” and segregation in tuberculosis, </span><a href="#Page_201">201</a></li> - - -<li class="ifrst">Laissez faire policy, <a href="#Page_6">6</a></li> - -<li class="indx">Lay workers, utilisation of, <a href="#Page_3">3</a></li> - -<li class="indx">Loans for public health work, <a href="#Page_14">14</a></li> - -<li class="indx">Local Government Board, <a href="#Page_53">53</a>, <a href="#Page_58">58</a>, <a href="#Page_77">77</a></li> - -<li class="indx">Lowe, Robert, <a href="#Page_28">28</a></li> - - -<li class="ifrst">Mackenzie, L., <a href="#Page_57">57</a></li> - -<li class="indx">Maclean, D., <a href="#Page_31">31</a></li> - -<li class="indx">Malaria, <a href="#Page_147">147</a></li> - -<li class="indx">Malthus, <a href="#Page_6">6</a>, <a href="#Page_162">162</a></li> - -<li class="indx">Malthusian hypothesis, <a href="#Page_164">164</a></li> - -<li class="indx">Massachusetts, <a href="#Page_2">2</a>, <a href="#Page_4">4</a></li> - -<li class="indx">Maternity benefit, <a href="#Page_34">34</a>, <a href="#Page_95">95</a>, <a href="#Page_111">111</a>, <a href="#Page_134">134</a></li> - -<li class="indx">Measles, <a href="#Page_20">20</a>, <a href="#Page_126">126</a></li> - -<li class="indx">Measurement of results in life saving, <a href="#Page_19">19</a></li> - -<li class="indx">Medical benefit, <a href="#Page_34">34</a>, <a href="#Page_106">106</a>, <a href="#Page_110">110</a></li> - -<li class="indx">Medical practice and public health, <a href="#Page_27">27</a>, <a href="#Page_83">83</a></li> - -<li class="indx">Medical officers of health, <a href="#Page_63">63</a></li> - -<li class="indx">Midwives Act, <a href="#Page_255">255</a></li> - -<li class="indx">Midwifery nursing, <a href="#Page_260">260</a></li> - -<li class="indx">Milk depots, <a href="#Page_243">243</a></li> - -<li class="indx">Mill, James, <a href="#Page_6">6</a></li> - -<li class="indx">Ministry of Health, <a href="#Page_49">49</a></li> - -<li class="indx">Mother and child, <a href="#Page_132">132</a>, <a href="#Page_180">180</a></li> - -<li class="indx">Murchison, Chas., <a href="#Page_15">15</a>, <a href="#Page_17">17</a></li> - - -<li class="ifrst">National Health Insurance Act, <a href="#Page_33">33</a>, <a href="#Page_59">59</a>, <a href="#Page_88">88</a>, <a href="#Page_104">104</a></li> - -<li class="indx">National medical service, <a href="#Page_32">32</a>, <a href="#Page_36">36</a></li> - -<li class="indx">New England, <a href="#Page_1">1</a></li> - -<li class="indx">Notification of tuberculosis, <a href="#Page_206">206</a></li> - -<li class="indx"><span style="margin-left: 1em;">” of births, </span><a href="#Page_245">245</a></li> - -<li class="indx">Nursing, training of, <a href="#Page_122">122</a></li> - -<li class="indx"><span style="margin-left: 1em;">” public health work of, </span><a href="#Page_126">126</a></li> - - -<li class="ifrst">Oastler, <a href="#Page_177">177</a></li> - -<li class="indx">Overcrowding, <a href="#Page_7">7</a>, <a href="#Page_199">199</a></li> - -<li class="indx">Over-population, <a href="#Page_166">166</a></li> - -<li class="indx">Owen, <a href="#Page_177">177</a></li> - - -<li class="ifrst">Panel doctors, <a href="#Page_215">215</a></li> - -<li class="indx">Pasteur, <a href="#Page_21">21</a></li> - -<li class="indx">Percival, <a href="#Page_177">177</a></li> - -<li class="indx">Pettenkofer, Von, <a href="#Page_13">13</a></li> - -<li class="indx">Philanthropy and public health, <a href="#Page_9">9</a>, <a href="#Page_37">37</a></li> - -<li class="indx">Physical defects, <a href="#Page_81">81</a></li> - -<li class="indx">Pneumonia, <a href="#Page_76">76</a></li> - -<li class="indx">Poliomyelitis, <a href="#Page_23">23</a>, <a href="#Page_76">76</a></li> - -<li class="indx">Political pull, <a href="#Page_102">102</a>, <a href="#Page_175">175</a></li> - -<li class="indx">Poor law and public health, <a href="#Page_27">27</a>, <a href="#Page_29">29</a>, <a href="#Page_31">31</a>, <a href="#Page_46">46</a>, <a href="#Page_49">49</a></li> - -<li class="indx">Population problem, <a href="#Page_163">163</a></li> - -<li class="indx">Poverty, causes of, <a href="#Page_31">31</a>, <a href="#Page_182">182</a></li> - -<li class="indx"><span style="margin-left: 1em;">” control of, </span><a href="#Page_46">46</a>, <a href="#Page_114">114</a></li> - -<li class="indx"><span style="margin-left: 1em;">” tests, </span><a href="#Page_139">139</a></li> - -<li class="indx"><span style="margin-left: 1em;">” and sickness, </span><a href="#Page_148">148</a>, <a href="#Page_162">162</a>, <a href="#Page_167">167</a>, <a href="#Page_184">184</a>, <a href="#Page_189">189</a></li> - -<li class="indx">Preventive medicine, <a href="#Page_99">99</a></li> - -<li class="indx">Progress of public health, <a href="#Page_1">1</a></li> - -<li class="indx">Public health nurses, <a href="#Page_128">128</a>, <a href="#Page_154">154</a></li> - - -<li class="ifrst">Racial immunity, <a href="#Page_196">196</a></li> - -<li class="indx">Red Cross workers, <a href="#Page_127">127</a>, <a href="#Page_132">132</a>, <a href="#Page_143">143</a></li> - -<li class="indx">Registrar-General’s returns, <a href="#Page_18">18</a>, <a href="#Page_25">25</a></li> - -<li class="indx"><span class="pagenum" id="Page_270">[Pg 270]</span>Relief <em>v.</em> prevention, <a href="#Page_109">109</a>, <a href="#Page_190">190</a></li> - -<li class="indx">Relief <em>v.</em> prevention, <a href="#Page_48">48</a></li> - -<li class="indx">Research, <a href="#Page_24">24</a>, <a href="#Page_35">35</a></li> - -<li class="indx">Resistance <em>v.</em> infection, <a href="#Page_195">195</a></li> - -<li class="indx">Respiratory diseases, <a href="#Page_23">23</a>, <a href="#Page_125">125</a></li> - -<li class="indx">Rumsey, <a href="#Page_54">54</a></li> - -<li class="indx">Rural conditions, <a href="#Page_161">161</a></li> - - -<li class="ifrst">Sanatorium benefit, <a href="#Page_34">34</a>, <a href="#Page_94">94</a>, <a href="#Page_111">111</a>, <a href="#Page_129">129</a>, <a href="#Page_214">214</a>, <a href="#Page_222">222</a></li> - -<li class="indx">Sanatorium treatment, <a href="#Page_228">228</a></li> - -<li class="indx">Sanitation and infant mortality, <a href="#Page_242">242</a></li> - -<li class="indx">Scarlet fever, <a href="#Page_20">20</a></li> - -<li class="indx">Schools for mothers, <a href="#Page_244">244</a></li> - -<li class="indx">School medical inspection, <a href="#Page_30">30</a>, <a href="#Page_57">57</a>, <a href="#Page_252">252</a></li> - -<li class="indx">Scope of public health work, <a href="#Page_44">44</a></li> - -<li class="indx">Sedgwick, <a href="#Page_16">16</a></li> - -<li class="indx">Segregation of feeble-minded, <a href="#Page_44">44</a></li> - -<li class="indx"><span style="margin-left: 1em;">” in tuberculosis, </span><a href="#Page_200">200</a></li> - -<li class="indx">Sex teaching, <a href="#Page_151">151</a></li> - -<li class="indx">Shaftesbury, <a href="#Page_177">177</a></li> - -<li class="indx">Shattuck, L., <a href="#Page_2">2</a>, <a href="#Page_3">3</a></li> - -<li class="indx">Shop hygiene, <a href="#Page_9">9</a></li> - -<li class="indx">Sickness and pauperism, <a href="#Page_67">67</a>, <a href="#Page_68">68</a></li> - -<li class="indx">Sickness insurance, <a href="#Page_10">10</a>, <a href="#Page_32">32</a>, <a href="#Page_65">65</a>, <a href="#Page_67">67</a>, <a href="#Page_87">87</a>, <a href="#Page_116">116</a></li> - -<li class="indx">Sickness registration, <a href="#Page_26">26</a></li> - -<li class="indx">Simon, Jno., <a href="#Page_2">2</a>, <a href="#Page_4">4</a>, <a href="#Page_5">5</a>, <a href="#Page_9">9</a>, <a href="#Page_12">12</a>, <a href="#Page_13">13</a>, <a href="#Page_22">22</a>, <a href="#Page_25">25</a>, <a href="#Page_28">28</a>, <a href="#Page_55">55</a></li> - -<li class="indx">Smallpox, <a href="#Page_21">21</a></li> - -<li class="indx">Smith, Adam, <a href="#Page_6">6</a></li> - -<li class="indx">Smith, Southwood, <a href="#Page_2">2</a>, <a href="#Page_9">9</a>, <a href="#Page_11">11</a>, <a href="#Page_12">12</a></li> - -<li class="indx">Smith, Theobald, <a href="#Page_2">2</a></li> - -<li class="indx">Snow, Jno., <a href="#Page_13">13</a></li> - -<li class="indx">Socialization of medicine, <a href="#Page_82">82</a>, <a href="#Page_102">102</a>, <a href="#Page_115">115</a></li> - -<li class="indx">State treatment of disease, <a href="#Page_112">112</a>, <a href="#Page_137">137</a></li> - -<li class="indx">Statistical studies, influence of, <a href="#Page_252">252</a></li> - -<li class="indx">Still-births, <a href="#Page_137">137</a></li> - -<li class="indx">Syphilis, <a href="#Page_137">137</a></li> - -<li class="indx">Sykes, J. F. J., <a href="#Page_244">244</a></li> - - -<li class="ifrst">Town living, influence on health, <a href="#Page_43">43</a></li> - -<li class="indx">Tuberculosis, <a href="#Page_20">20</a>, <a href="#Page_23">23</a>, <a href="#Page_34">34</a>, <a href="#Page_76">76</a>, <a href="#Page_78">78</a>, <a href="#Page_129">129</a>, <a href="#Page_192">192</a></li> - -<li class="indx">Tuberculosis and hospital treatment, <a href="#Page_198">198</a></li> - -<li class="indx"><span style="margin-left: 1em;">” and overcrowding, </span><a href="#Page_199">199</a></li> - -<li class="indx"><span style="margin-left: 1em;">” and housing, </span><a href="#Page_203">203</a></li> - -<li class="indx"><span style="margin-left: 1em;">” notification of, </span><a href="#Page_206">206</a></li> - -<li class="indx">Typhoid fever, <a href="#Page_15">15</a></li> - -<li class="indx">Typhus fever, <a href="#Page_17">17</a>, <a href="#Page_20">20</a></li> - - -<li class="ifrst">Unqualified practice, <a href="#Page_31">31</a></li> - -<li class="indx">Urbanization, <a href="#Page_7">7</a>, <a href="#Page_159">159</a></li> - - -<li class="ifrst">Venereal diseases, <a href="#Page_30">30</a>, <a href="#Page_85">85</a>, <a href="#Page_131">131</a>, <a href="#Page_150">150</a></li> - -<li class="indx">Victoria, Queen, <a href="#Page_10">10</a></li> - -<li class="indx">Vital statistics, importance of, <a href="#Page_24">24</a></li> - -<li class="indx">Voluntary agencies, <a href="#Page_141">141</a></li> - - -<li class="ifrst">Walcott, <a href="#Page_2">2</a></li> - -<li class="indx">War, <a href="#Page_81">81</a>, <a href="#Page_120">120</a>, <a href="#Page_158">158</a>, <a href="#Page_179">179</a></li> - -<li class="indx">Water supplies and health, <a href="#Page_16">16</a></li> - -<li class="indx">Wells, <a href="#Page_159">159</a></li> - -<li class="indx">Whooping cough, <a href="#Page_20">20</a></li> - -<li class="indx">Women, work of, <a href="#Page_122">122</a></li> - -<li class="indx"><span style="margin-left: 1em;">” position of, </span><a href="#Page_184">184</a></li> -</ul> -<hr class="chap x-ebookmaker-drop"> - - -<div class="transnote"> - -<h2>Transcriber’s Notes</h2> - -<ul> -<li>pg 14 Changed groups of diarrhoeal to: diarrhœal</li> -<li>pg 19 Changed and that diarrhoeal to: diarrhœal</li> -<li>pg 20 Changed one-sixteenth to diarrhoeal to: diarrhœal</li> -<li>pg 34 Changed doctor or mid-wife to: midwife</li> -<li>pg 34 Changed in a sanatorum to: sanatorium</li> -<li>pg 42 Changed of the excessive diarrhoea to: diarrhœa</li> -<li>pg 49 Changed and the feebleminded to: feeble-minded</li> -<li>pg 89 Changed England was not actuarily to: actuarially</li> -<li>pg 101 Changed if the latters to: latter</li> -<li>pg 105 Changed for the benfits to: benefits</li> -<li>pg 114 Added period after: due to sickness</li> -<li>pg 115 Changed assistance by cooperative to: coöperative</li> -<li>pg 118 Changed period to comma after: Pre-school clinics</li> -<li>pg 145 Changed their satisfactory cooperation to: coöperation</li> -<li>pg 159 Changed rows of unsatistory to: unsatisfactory</li> -<li>pg 164 Changed power of finding enployment to: employment</li> -<li>pg 171 Changed she is over-worked to: overworked</li> -<li>pg 176 Changed facts, they villify to: vilify</li> -<li>pg 178 Changed more and more entagled to: entangled</li> -<li>pg 184 Changed accompaniments of overfatigue to: over-fatigue</li> -<li>pg 221 Changed Examination of a register kept for faciliating to: facilitating</li> -<li>pg 228 Changed efficiency in a santorium to: sanatorium</li> -<li>pg 241 Changed caused 8.1 percent to: per cent</li> -<li>pg 246 Changed total deaths in ths to: the</li> -<li>pg 259 Added period after: Insurance Act 30s</li> -<li>pg 262 Changed that of abortions, stillbirths to: still-births</li> -<li>pg 262 Changed investigation of stillbirths to: still-births</li> -<li>pg 267 Changed it as he ollowed to: allowed</li> -<li>pg 268 Changed Antenatal work, 261 to Ante-natal</li> -<li>pg 268 Added period after: Enteric fever, see Typhoid</li> -<li>pg 268 Added period after: Hospitals, see Institutional treatment</li> -<li>pg 270 Sickness and pauperism had no page references added 67, 68</li> -<li>Table of contents used lectures, but refers to chapters</li> -<li>Many hyphenated and non-hyphenated word combinations left as written.</li> -</ul> -</div> - -<div style='display:block; margin-top:4em'>*** END OF THE PROJECT GUTENBERG EBOOK PUBLIC HEALTH AND INSURANCE ***</div> -<div style='text-align:left'> - -<div style='display:block; margin:1em 0'> -Updated editions will replace the previous one—the old editions will -be renamed. -</div> - -<div style='display:block; margin:1em 0'> -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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