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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. - -Title: Public health and insurance - American addresses - -Author: Arthur Newsholme - -Release Date: January 17, 2023 [eBook #69823] - -Language: English - -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) - -*** START OF THE PROJECT GUTENBERG EBOOK PUBLIC HEALTH AND -INSURANCE *** - - - - - - Transcriber’s Notes - Italic text displayed as: _italic_ - - - - - PUBLIC HEALTH AND INSURANCE: - - AMERICAN ADDRESSES - - BY - - SIR ARTHUR NEWSHOLME, K.C.B., M.D., F.R.C.P. - -LECTURER ON PUBLIC HEALTH ADMINISTRATION AT THE SCHOOL OF HYGIENE AND - PUBLIC HEALTH, JOHNS HOPKINS UNIVERSITY, BALTIMORE, MARYLAND; LATE - PRINCIPAL MEDICAL OFFICER OF THE LOCAL GOVERNMENT BOARD, ENGLAND; - PRESIDENT OF THE SOCIETY OF MEDICAL OFFICERS OF HEALTH - AND OF THE EPIDEMIOLOGICAL SOCIETY; EXAMINER IN PUBLIC HEALTH - TO THE UNIVERSITY OF CAMBRIDGE, IN PREVENTIVE MEDICINE TO - THE UNIVERSITY OF OXFORD, AND IN STATE MEDICINE TO THE - UNIVERSITY OF LONDON, MEMBER OF THE GENERAL MEDICAL - COUNCIL, OF THE COUNCIL OF THE IMPERIAL CANCER - RESEARCH FUND, ETC. - - BALTIMORE - THE JOHNS HOPKINS PRESS - 1920 - - - - - Copyright, 1920 - By THE JOHNS HOPKINS PRESS - - PRESS OF - THE NEW ERA PRINTING COMPANY - LANCASTER PA. - - - - - DEDICATED BY THE AUTHOR - - (WITHOUT PERMISSION) - - TO THE - - RIGHT HONOURABLE JOHN BURNS - - A LEADER IN PUBLIC HEALTH; - - WHO IN PARTICULAR MADE THE PUBLIC REALISE THE - IMPORTANCE OF CONCENTRATING ON THE - - MOTHER AND HER CHILD - - - - - PREFACE - - -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. - -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. - -It will be noted that the same problem may be mentioned 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. - -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. - -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 work to be divided respectively -between different local and central authorities, in sanctioning the -creation of _ad hoc_ 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. - -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 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. - - ARTHUR NEWSHOLME - - SCHOOL OF HYGIENE AND - PUBLIC HEALTH, - JOHNS HOPKINS UNIVERSITY, - BALTIMORE, - AND - ATHENAEUM CLUB, - LONDON, - May, 1920 - - - - - CONTENTS - - - LECTURE I - - PUBLIC HEALTH PROGRESS IN ENGLAND DURING - THE LAST FIFTY YEARS 1-41 - - Parallelism of Events in Old and New England. - The Utilization of Lay Workers in Public Health Work. - The Influence of Urbanization and Industrialism. - _Laissez faire_ Economic Teaching. - Man and his Environment. - Dirt and Disease. - Cholera, Typhoid Fever, Typhus Fever. - Summary of Results in Life-Saving. - Specific Causation of Disease. - Importance and Present Limitations of Epidemiology. - The Importance of Vital Statistics. - Conditions of Medical Practice Bearing on Public Health. - Poor-law _versus_ Public Health. - Insurance _versus_ Public Health. - A National Medical Service. - Hospitals Important Housing Auxiliaries. - The Need to Avoid Complacency. - - - LECTURE II - - HISTORICAL DEVELOPMENT OF PUBLIC HEALTH - POLICY IN ENGLAND 42-70 - - Town-Dwelling and Health Problems. - The Scope of Public Health Work. - Reform in the Control of Poverty. - Reform in Industry. - Public Health Reform. - Education Authorities and Health. - The _Ad Hoc_ Vice. - Principles of Local Government. - The Training and Tenure of Office of Medical Officers of Health. - The National Insurance Act and Public Health. - Provision for Sickness. - General Summary. - - - LECTURE III - - THE INCREASING SOCIALIZATION OF MEDICINE 71-102 - - An Altruistic Profession. - The Past Achievements of Medicine. - The Ever-increasing Importance of Hospitals. - Hospitals and Housing. - The Continuing Mass of Preventible Disease. - The Present Extent of Socialization of Medicine. - Destitution and Sickness. - Insurance and Sickness. - The Needs of the Future. - - - LECTURE IV - - THE MEDICAL ASPECTS OF INSURANCE AGAINST - SICKNESS 103-119 - - Criteria of Value of Insurance. - British System of Insurance. - Limitations and Evils of the “Medical Benefit.” - Need for further State Treatment of Disease. - Prevention of Poverty by the Application of Medical Science. - State Medicine must be Preventive throughout. - Conditions of an Efficient Medical Service. - - - LECTURE V - - SOME PROBLEMS OF PREVENTIVE MEDICINE OF - THE IMMEDIATE FUTURE 120-143 - - The Incidental Gains from War. - Its Sacrificial Work. - The Comradeship of All Idealists. - Women’s Work. - The Restriction of Alcoholism. - The Change from Empirical to Scientific Methods. - The Still Uncontrollable Diseases. - Influenza and Measles as Types. - The Possibility of Modified Training of Nurses. - The Need for a More Complete Program in Tuberculosis. - The Possibilities of Control of Venereal Diseases. - The More Complete Protection of Maternity and Childhood. - The Abolition of Poverty Tests in Medical Assistance. - Lack of Equality of Service, not Ignorance, the Chief Evil. - The Continuing Value of Voluntary Workers. - - - LECTURE VI - - THE INTER-RELATION OF VARIOUS SOCIAL EFFORTS 144-156 - - The Possibilities of Good Work under Present Economic Conditions. - The Importance of Social Work to the Physician. - The Constant Need for a Causal Outlook. - Poverty and Disease. - Causes of Intemperance. - The Causation and Prevention of Venereal Diseases. - Lop-sided Views as to Ignorance in Causation of Disease. - - - LECTURE VII - - THE OBSTACLES TO AND IDEALS OF HEALTH PROGRESS 157-182 - - Degree of Progress Realized. - Obstacle of Urban Life. - Obstacle of Industrialism. - Obstacle of Poverty. - The Influence of the Malthusian Hypothesis. - Obstacle of Ignorance. - Obstacle of Defects of Character. - IDEALS. - Communal Action. - Spread of Altruism. - Supreme Importance of Mother and Child. - - - LECTURE VIII - - SOME ASPECTS OF POVERTY 183-190 - - Disease a Chief Cause of Poverty. - Diminution of Poverty apart from Increased Family Income. - Poverty a Complex. - Action Needed against Each Constituent Element of Poverty. - - - LECTURE IX - - THE CAUSATION OF TUBERCULOSIS AND THE - MEASURES FOR ITS CONTROL IN ENGLAND 191-239 - - _A._ Basic Facts as to Tuberculosis. - Explanations of the Decreasing Death-rate from Tuberculosis. - - Diminished Virulence of the Tubercle Bacillus. - Increased Human Resistance by Natural Selection. - Immunization by Small Doses of the Contagium. - Diminished Tuberculosis with Increased Aggregation of - Population. - Hospital Treatment of Consumptives. - Koch’s Views as to Hospital Segregation. - Improved Housing in Reduction of Tuberculosis. - - _B._ Measures of Control. - Notification of Cases. - Causes of Failure in Notification. - Public Health Action following Notification. - Examination of Contacts. - Scope of Tuberculosis Schemes. - Tuberculosis Dispensaries. - Should be Part of General Dispensaries. - The Home Visitation of Patients. - Sanatorium Benefit. - Residential Institutions. - General Observations on Treatment in Sanatoria. - Hospital Treatment. - Industrial Colonies. - Special Dwellings and Help in Support. - Summary. - - - LECTURE X - - CHILD WELFARE WORK IN ENGLAND 240-267 - - The Earlier Work of Medical Officers of Health. - The Notification of Births. - Chief Causes and Course of Infant Mortality. - The Influence of School Medical Inspection. - The Influence of Statistical Studies. - The Midwives Acts. - Health Visiting. - Voluntary Work. - Child Welfare Centers. - Training and Provision of Midwives. - Ante-natal Work. - Dental Assistance. - Creches. - Observation Beds at Child Welfare Centers. - Grant’s to Local Authorities. - Course of Mortality in Childbearing. - - - - - CHAPTER I - - PUBLIC HEALTH PROGRESS IN ENGLAND DURING THE LAST FIFTY YEARS[1] - - -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. - - - _Parallelism of Events in New and Old England_ - -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[2]—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 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. - -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. - -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 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. - - - _The Utilisation of Lay Workers_ - -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. - -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 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 - - 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. - -What were the ideals with which the Fathers of Sanitation in New and -in Old England began their work? - -They cannot be better expressed than in their own words. In the -1850 Report of the Massachusetts Sanitary Commission they are thus -expressed: - - 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. - -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. - - 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. - -With such noble ideals, what measure of success crowned their efforts -and those of their successors? - -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 in the fourth quarter -of the nineteenth and the first quarter—so far as it has passed—of -the twentieth century. - - - _Laissez Faire Economic Teaching_ - -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 _laissez faire_ 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. - -It was assumed that given free competition, enlightened self-interest -would incite effort and improvement, encourage self-reliance, and -guarantee production and economy. - -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. - -Domestic misery was associated with commensurate industrial misery; -overwork, in insanitary factories and workshops, regardless of the -health of the “hands,” was the rule. - -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. - -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. - -The reaction against the _laissez faire_ 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 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. - -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. - - - _Man and His Environment_ - -The history of these earlier steps is full of interest; but I -cannot outline it today. There can be no doubt that as Simon[3] -put it, referring to Dr. Southwood Smith’s report to the Poor-Law -Commissioners in 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”) - - 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. - -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: - - 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. - -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., - - (1) attack on the causes of sickness, - (2) satisfactory treatment of the sick, and - (3) satisfactory care for the poor. - -I might properly add - - (4) attack on the causes of poverty, - -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. - -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. - - - _Dirt and Disease_ - -The crude generalization emerging from the earlier surveys was the -close relation between filth conditions and excessive sickness; and -the motive behind these inquiries was the desire to remove one of -the chief causes of destitution. - -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. - -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. - -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. - - - _Cholera_ - -The general view then held in New as in Old England is well stated in -the following extract from the Report of the Massachusetts Sanitary -Commission, 1850: - - 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. - -And the important moral is drawn that - - 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. - -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.” - -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 the importance of water infection, giving as his -general conclusion that - - under the specific influence which determines an epidemic period, - fecalised drinking water and fecalised air equally may breed and - convey the poison (of Cholera). - -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. - -Although we realise now the greater importance of control of excreta -from persons specifically infected, we must agree with Simon that -communally - - 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. - -And it is still opportune to draw attention to the terrible -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. - - - _Typhoid Fever_ - -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 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. - -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: - - Population of No. of Deaths - England and Wales from Typhoid - Year in Millions Fever - - 1871 22⅘ 12,709 - 1881 26 6,688 - 1891 29 5,200 - 1901 32⅗ 5,172 - 1911 36⅕ 2,430 - 1917 33⅗ (civilian) 977 - -The number of cases notified in England and Wales - - in 1911 was 13,852 - in 1917 was 4,601 - -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. - - - _Typhus Fever_ - -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— - - Its great predisposing cause is destitution; while the exciting - cause or specific poison is generated by overcrowding of human - beings with deficient ventilation— - -he was expressing the considered conclusion of his period. - -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: - - Typhus Fever, No. - of Deaths in England - Years and Wales - - Ten years, 1871-80 13,975 - Eight years, 1903-10 210 - Seven years, 1911-17 42 - -The cases in recent years were nearly all traceable to imported -infection. - -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. - -With the demonstration that typhoid fever was commonly 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. - -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 - - - _General Results in the Saving of Life_ - -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. - -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 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 _each year_ 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. - -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. - -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. - - - _Specific Causation of Disease_ - -The preceding review will have made it clear that in the period -of earlier slow sanitary reform, although 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. - -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. _drit_ -= excrement), or by swallowing specifically infected foods. - -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,[4] and in controlling -overcrowding and uncleanliness as well as in other respects, remains -indispensable. But the brunt of guidance in the exact prevention of -disease, especially of communicable diseases, must necessarily now -fall on - - the epidemiologist, - the vital statistician, and - the laboratory worker. - - - _Present Limitations of Epidemiology_ - -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): - - 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. - -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, 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. - -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. - -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 beset Chadwick, Farr and Simon in -their earlier work, and with little hope of any campaign comparable -with that against dirt _en masse_, which was largely effective in -reducing the specific infections of cholera, dysentery, and enteric -fever, of typhus fever and even of tuberculosis. - -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. - - - _The Importance of Vital Statistics_ - -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 - - every wheel that turns in the service of public health must be - belted to the shaft of vital statistics. - -Accurate and complete returns of deaths and their causes are -essential in investigating the local and occupational 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.” - -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. - -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. - -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 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. - -And so began gradually, in characteristic British fashion, the -notification of infectious cases, the list of notifiable diseases -being extended from time to time. - -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. - -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. - - - _Conditions of Medical Practice Bearing on Public Health_ - -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. - -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. - - - _Poor Law v. Public Health_ - -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 between Poor Law and Public Health appeared to offer the -best prospect of sanitary progress. - -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. - -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. - -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 -_Public Health Institutions_, by regarding the medical officer of -the Local Government Board as merely advisory, and by the retention -and extension on a large scale of local inspection by lay officers -of the Central Board, for conditions which needed systematic medical -control. - -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. - -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. - -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 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. - -Behind these proposals lay the principle that _the treatment and the -prevention of disease cannot administratively be separated without -injuring the possibilities of success of both_; and this is a -principle which happily is becoming more generally accepted. - -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. - -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 -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. - -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. - -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, -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. - -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. - - - _Insurance v. Public Health_ - -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. - -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. - -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 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. - -Apart from other reforms the transfer of medical provision, of -provision for tuberculous patients, and 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. - -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? - -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. - -In view of the preceding facts and of other considerations 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. - -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. - - - _A National Medical Service_ - -What is most urgently needed is a national medical service which -will give for all who cannot afford them 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. - -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: - - In England and Wales - - Of deaths from all causes, in 1881 = 1 in every 9 - Of deaths from all causes, in 1910 = 1 in every 5 - - In London - - Of deaths from all causes, in 1881 = 1 in every 5 - Of deaths from all causes, in 1910 = 2 in every 5 - occurred in public institutions. - -The facts as to Pulmonary Tuberculosis are even more significant: - - In the year 1911 - - in England and Wales 34% of male 22% of female - and in London 59% of male and 48% of female - -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. - - - _Hospitals Important Housing Auxiliaries_ - -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. - -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 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. - -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. - -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. - - - _The need to avoid Complacency_ - -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. - -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 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. - -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.” - - -FOOTNOTES: - -[1] An address prepared for the celebration of the fiftieth -anniversary of the Massachusetts Board of Health, September, 1919. - -[2] The administrative side of the subject is sketched in the next -chapter. - -[3] Reprint of Reports, Vol. I, p. 448. - -[4] 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. - - - - - CHAPTER II - - THE HISTORICAL DEVELOPMENT OF PUBLIC HEALTH POLICY IN ENGLAND[5] - - -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. - -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. - -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. - - - _Town-living and Health Problems_ - -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. - -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 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. - - - _Scope of Constructive Health Work_ - -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. - -Public health in the main is concerned primarily 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. - -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. - -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 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. - -Let me attempt the more difficult task of outlining the history of -forms of administrative control of disease since 1834. - - - _Reform in the Control of Poverty_ - -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. - -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,[6] and forbade outdoor relief to -able-bodied 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. - -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 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. - -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 -_relief_; practically not at all as a _curative_ agency. In medical -language, symptomatic and not rational causal treatment was the rule. - -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 -adult who has drifted into willing dependence; mischievous when -applied to sick persons, and to dependent women and children. - -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. - -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 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. - - - _Reform in Industry_ - -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. - -The Act was largely futile; but it meant the beginning of the gradual -breaking down of _laissez faire_ 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. - -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 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. - - - _Public Health Reform_ - -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 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. - -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. - - - _Public Health Reforms_ - -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 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,[7] in 1856, stated -the unrealized possibilities of the poor-law medical officer’s -domiciliary attendance on paupers in the following words: - - 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. - -In the result the _ad hoc_ poor-law authority did not absorb into -it the newly created municipal and urban and rural sanitary -administration, but continued on its separate path. - -Simon, in 1868, had urged the inadvisability of continuing _ad hoc_ -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. - -What is now needed is that the defects just named 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. - - - _Education Authorities and Health_ - -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 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 _inter alia_ 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. - -But there now existed in every locality three authorities concerned -in the treatment of disease: - -1. Poor-law guardians, treating all forms of illness in paupers, at -home and in institutions. - -2. Public health authorities, undertaking preventive measures against -disease, and treating fevers, tuberculosis, and occasionally other -diseases in institutions; and more recently providing nurses at home -for certain conditions. - -3. Local education authorities, concerned in treating certain -ailments in school children. - -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. - -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. - - - _The Ad Hoc Vice_ - -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 _qûa_ 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. - -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 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. - - - _Principles of Local Government_ - -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. - -In settling the details of local administration, the 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. - -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. - -Power is already given to coopt on to some of these committees a few -persons who are not members of 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. - -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. - -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 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.”[8] - -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. - - - _The Training and Tenure of Office of Health Officers_ - -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 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. - -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 _inter alia_ the following officers and activities: -superintendent medical officers of health; district medical officers -of health; tuberculosis officers; medical officers of maternity and -child welfare centres, of venereal disease centres; fever hospitals, -and tuberculosis sanatoriums and hospitals. - -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. - -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. - -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. - -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 circumstances, however, led to the -adoption of a course which, medically, ran directly athwart the -course of needed reform. - - - _The National Insurance Act and Public Health_ - -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 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. - -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. - - - _Provision for Sickness_ - -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 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. - - - _General Summary_ - -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 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. - -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. - -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 or curtailed, had there been -an organized system of state medicine. - -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.” - -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. - - -FOOTNOTES: - -[5] An Address at the Forty-seventh Annual Meeting of the American -Public Health Association, New Orleans, October 27, 1919. - -[6] 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. - -[7] Rumsey: Essays in State Medicine, 1856, pp. 190, 277, 282. - -[8] Goodnow: Municipal Problems, p. 226. - - - - - CHAPTER III - - THE INCREASING SOCIALIZATION OF MEDICINE[9] - - -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: - - Next, therefore, to God, in all our extremities (_for of the Most - High cometh healing_, Eccles. XXXVIII, 2) we must seek to, and rely - upon, the Physician, who is the _Manus Dei_ (the Hand of God), said - Hierophilus, and to whom He hath given knowledge, that he might be - glorified in his wondrous works. - -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 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. - -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 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.” - -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. - -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. - - - _The Past Achievements of Medicine_ - -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 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. - -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! - -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 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 _each year_ 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. - -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” - - Along life’s road, so dim and dirty, - I’ve travelled till I’m three and thirty; - - And what has this life left for me: - Nothing but my thirty-three. - -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 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. - -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. - -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. - - - _Increasing Importance of Hospitals_ - -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 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. - -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. - -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 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. - - - _Hospitals as a Partial Solution of Housing Difficulties_ - -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. - -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 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. - -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. - - - _The Continuing Mass of Preventible Disease_ - -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 -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. - -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. - -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. - -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 a serious handicap against normal activity in -civil occupations.” - -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. - - - _Present Extent of Socialization of Medicine_ - -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 _Lancet_ some -years ago gave a statement of the number of attendances of patients -at voluntary 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. - -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. - -The state has, quite apart from National Insurance, given a rapidly -increasing amount of medical assistance to the public. - -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. - -2. The institutional treatment of lunacy has grown to an extent which -permits the treatment in an asylum of every certified lunatic. - -3. The treatment at the expense of the state of feeble-minded persons -is rapidly increasing. - -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. - -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. - -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 treatment, -of convalescent homes for mothers or their children, of infant -consultations and clinics, etc. - -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. - -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 insured patients -were passed, but were similarly held in abeyance. - -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.). - -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, _plus_ 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. - - - _Destitution and Sickness_ - -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. - -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. - -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. - -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. - - - _Insurance versus Public Health_ - -Political circumstances led to the adoption of a course which -medically ran directly athwart the course of needed reform. The -National Insurance Act of 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. - -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. - -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 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.[10] - -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. - -What was given? (1) There was the medical benefit, each insured -person being entitled to the services 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. - -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 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. - -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 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. - -(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. - -(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. - -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 _supply of service_ 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. - -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 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. - - - _The Need of the Future_ - -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. - -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 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. - -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 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. - -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: - - 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 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.] - -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. - -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 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. - -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? - -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? - -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. - -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. - - -FOOTNOTES: - -[9] The Wesley M. Carpenter lecture delivered October 2, 1919, before -the New York Academy of Medicine. - -[10] Thus Mr. Bishop Harman, an ophthalmic surgeon, and a member of -the Council of the British Medical Association, says: - -“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.” (_British Medical Journal_, Mar. 15, 19). - -Dr. R. Sanderson, of Brighton, writing on behalf of medical -practitioners, says: - -“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.” - -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. (_British -Medical Journal_, July 19, 19.) - -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. - -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.” - - - - - CHAPTER IV - - INSURANCE AND HEALTH[11] - - -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. - -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. - -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 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. - -The value of any system of sickness insurance, however, must -necessarily be judged by several criteria. - - - _Criteria of Value of Insurance_ - -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? - -In the case of the English National Insurance Act, these questions -unfortunately cannot be answered completely in the affirmative. - -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 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. - -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. - -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. - -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. - -As to economy of administration, I can speak only with reserve; but -it requires little imagination to appreciate 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. - -The point as to malingering can best be considered in connection with -a discussion of the - - - _Medical Benefit_ - -This consists of such medical treatment, at home or at the office of -the panel doctor,[12] as “can consistently with the best interests -of the patient be properly undertaken by a practitioner of ordinary -professional competence and skill.” - -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 (_a_) there -is no provision for hospital treatment of patients needing this, -except the Sanatorium provision for tuberculosis; (_b_) 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, or the intravenous -treatment of syphilis is excluded from medical benefit. So likewise -are dental requirements. (_c_) 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. (_d_) There is no -provision for nursing assistance. - -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. - -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 90.) - -It is necessary, however, to say more on the - - - _General Practitioner Treatment_ - -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 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! - -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 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. - -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. - -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. - -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 than a practitioner in -medicine, have not been realised or even brought within sight. - - - _Evils of the Present Medical Benefit_ - -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). - - There is almost universal testimony of the belief (of - representatives of friendly societies) that medical certificates are - granted recklessly (par. 119). - - 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). - - These statements ... are representative of an enormous volume of - dissatisfaction with the action of the medical profession. - -The Committee state: - - We are of opinion that in many cases doctors have given certificates - for sickness benefit in circumstances in which these certificates - were not justified. - -From the standpoint of the conscientious practitioner the present -position is profoundly unsatisfactory. He has no official access to -arrangements for 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. - -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. - -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 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. - -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. - -I hold strongly that the State should embark on a much larger scale -than at present on - - - _The State Treatment of Disease_ - -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 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 -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.) - -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. - -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.” (_Monthly Labor Review_, January, 1920, p. 256.) - -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 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” (_British Medical -Journal_, 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. - -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 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. - -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. - -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: - -1. It must possess facilities for consultations with physicians and -surgeons having special knowledge, equalling in efficiency those -possessed by the well-to-do. - -2. All modern pathological and physical aids to diagnosis and -treatment must be available. - -3. Hospital treatment must be secured for all whose illness cannot be -satisfactorily treated at home. - -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.) - -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. - -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. - -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 health or health -commissioner embodying his recommendations as to any public health -action which may be needed. - -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. - -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: - - Pathological laboratories, - Hospitals, - Health centres for infants and mothers, - Prenatal and post-natal clinics, - Consultant obstetric work, - Pre-school clinics, - School medical inspection and clinics, - Industrial inspections and clinics, etc. - -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 _almost unlimited -preventive possibilities opened up by the opportunity to treat -disease_, and by the realization likewise that an essential part -of his family work should consist in detecting the _beginnings of -disease_ and in detecting and securing the removal of domestic, -dietetic, housing, industrial or other factors liable to cause -disease. - -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! - - -FOOTNOTES: - -[11] An address given to the Quiz Medical Society, New York, Feb. 14, -1920. - -[12] _I. e._, any doctor in a given area who is willing to treat -patients under the conditions of the Insurance Act. - - - - - CHAPTER V - - SOME PROBLEMS OF PREVENTIVE MEDICINE OF THE IMMEDIATE FUTURE[13] - - -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. - -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 is held -by it, how careless it is of the individual; and how disregardful it -is of human promise and performance. - -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. - - - _Gains from War_ - -But we can set out some great gains from war. - -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 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. - -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. - -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: - - Though doomed to go in company with Pain, - And Fear and Bloodshed, miserable train! - Turn our necessity to glorious gain. - - - _The Work of Women_ - -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 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. - -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? - - - _Prohibition of Alcoholic Drinks_ - -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. - -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. - -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. - -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. - -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. - -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. - - - _Respiratory Diseases_ - -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 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. - -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 _diminish -their fatality_, 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. - -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. - -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. - -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. - -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? - -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. - - - _Tuberculosis_ - -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. - -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 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. - -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 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? - - - _Venereal Diseases_ - -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, 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. - -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. - -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. - - - _The Mother and the Child_ - -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 the immediate future. I refer to the need -for more complete protection of motherhood and childhood against the -dangers besetting them. - -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. - -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? - -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 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. - -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 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: - -(_a_) The salaries and expenses of inspectors of midwives; - -(_b_) The salaries and expenses of health visitors and nurses engaged -in maternity and child welfare work; - -(_c_) The provision of a midwife for necessitous women in confinement -and for areas which are insufficiently supplied with this service; - -(_d_) 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; - -(_e_) 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; - -(_f_) Arrangements for instruction in the general hygiene of -maternity and childhood; - -(_g_) 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 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; - -(_h_) Hospital treatment provided or contracted for by local -authorities for children under five years of age found to need -in-patient treatment; - -(_i_) 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; - -(_j_) 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; - -(_k_) The provision of accommodation in convalescent homes for -nursing mothers and for children under five years of age; - -(_l_) 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; - -(_m_) Experimental work for the health of expectant and nursing -mothers and of infants and children under five years of age, carried -out by local authorities or voluntary agencies with the approval of -the Board; - -(_n_) Contributions by the local authority to voluntary institutions -and agencies approved under the scheme. - -Grants will be paid to voluntary agencies aided by the Board on -condition: - -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. - -2. That the premises and work of the institution are subject to -inspection by any of the Board officer’s or inspectors. - -3. That records of the work done by the agency are kept to the -satisfaction of the Board. - -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 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. - -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. - -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 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. - -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 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. - -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 _summum bonum_. 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. - -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? - -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. - -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. - - - _The Work of Voluntary Agencies_ - -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 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. - -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. - -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 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. - - -FOOTNOTES: - -[13] An address to the Academy of Medicine, Toronto, June 20, 1919. - - - - - CHAPTER VI - - THE INTER-RELATION OF VARIOUS SOCIAL EFFORTS[14] - - -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. - -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! - -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. - -For the following reasons I do not hesitate to bring this subject -before a gathering of graduate medical students: - -First.—Every physician as soon as he engages in medical practice -almost immediately comes into touch with organized and unorganized -social workers, and his success—personal as well as communal—can -almost be measured in terms of his outlook towards their work; - -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 - -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. - -This is the age of anxiety to give social help. - -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? - -A few elementary illustrations will show the many unexploited or only -partially exploited or misused opportunities for efficient social -help. - -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. - -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. - -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, 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. - -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. - -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. - -Evidently timely assistance to induce the parent to delay employing -the boy, until he has been prepared 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. - -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. - -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 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. - -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. - -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. - -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 -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. - -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. - -The influence of unaccustomed alcoholic indulgence in leading to the -first “slip,” often with the production of life-long disease, is well -known. - -Nor must we leave out of account the tolerance of 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. - -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, -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. - -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, 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. - -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. - -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. - -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. - -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 while enjoying these elementary needs of -family life ourselves. - -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. - - -FOOTNOTES: - -[14] An address to the Alpha-Kappa-Kappa Club, Johns Hopkins -University, Wednesday, December 10, 1919. - - - - - CHAPTER VII - - THE OBSTACLES TO AND IDEALS OF HEALTH PROGRESS[15] - - -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. - -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: - - _Percentage reduction in death-rate_ - - Age - - 0-5 42 - 5-10 48 - 10-15 43 - 15-20 46 - 20-25 51 - 25-35 50 - 35-45 42 - 45-55 25 - 55-65 15 - 65-75 10 - 75-85 7 - 85 and upwards 15 - -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. - - - _Obstacles_ - -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. - - - _Urbanization_ - -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. - -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 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. - -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. - -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. - -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 Wales and probably -one-half of that of the United States. - -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. - -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. - - - _Industrialism_ - -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, 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. - - - _Poverty_ - -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 - - 1. The amount of food produced, - 2. The amount of materials produced, - 3. The efficiency in preparation of these materials, and - 4. Convenience of transport. - -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. - -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. - - - _The Malthusian Hypothesis_ - -(_a_) The Malthusian hypothesis has been held to justify _the laissez -faire, laissez aller_ 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. - -On page 438 of the sixth edition of his book Malthus says: - - 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. - -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): - - A man born into the world already occupied, if his family can no - longer keep him, or if society cannot utilise his work, 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. - -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. - -(_b_) The Malthusian hypothesis and the policy based on it ignored -the human element in industry. Happily revolt against the strict -application of the _laissez faire_ 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. - -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 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. - -(_c_) 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. - -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. - -And this brings me to the direct statement of the truism that health -progress can only be secured by preventing preventible illness. - -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. - -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. - -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. - -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 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. - - - _Ignorance_ - -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? - -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 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. - -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. - -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. - -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. - -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? - -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. - -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. - -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. - -4. If the child of the well-to-do mother falls ill, everything -that good nursing and medical attendance 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. - -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. - -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 is situate. The superiority of the circumstances of the -one mother and infant over those of the other in these respects is -obvious. - -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. - -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. - -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 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. - -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 _membrana nictitans_ from our eyes, and to consider the -physical and moral as well as the intellectual obstacles to health. - -In the cultivation of communal health - - - _Defects of Character_ - -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 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 _the one “drive” which, above all others, is necessary_: 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 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 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. - -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 an indispensable condition of the further -triumphs of preventive medicine now waiting to be secured. - - - _Ideals_ - -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. - -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 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. - -The first lesson, then, which has already been partially learnt, is -that _no member of a community can live to himself_. 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 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. - -Secondly, the Great War, though the most terrible calamity to -humanity of the ages, has brought out a most comforting and elevating -thought. _Our brothers and our sons_,—and our daughters also in a -multitude of munition and other works,—have proved that, under the -overwhelming moral compulsion of national need, they _are willing -and ready to lay down their lives for great impersonal things_, 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? - -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. - -This can only be done by ensuring, chiefly through its mother, _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_. - -The ideal that every child should have equality of opportunity is -really part of a general upward movement in our national ethical life. - - The thoughts of men are widened with the process of the suns. - -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 happily is now certain to replace the -materialistic doctrine of the German type which drives the weaker to -the wall. - -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. - -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 -in communal practice of every measure for uplifting mankind. - -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. - - A child more than all other gifts - That earth can offer to declining man - Brings hope with it and forward looking thoughts. - (Wordsworth.) - -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. - - -FOOTNOTES: - -[15] A lecture given to the Alumni Association of the University of -Yale, January 22, 1920. - - - - - CHAPTER VIII - - SOME ASPECTS OF POVERTY[16] - - -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. - -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. - -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 164.) 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. - -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. - -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 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. - -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. - -There should be an adequate family income for every family; and the -social conscience cannot be satisfied 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, 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. - -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. - -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. - -It may be urged that such provision, after all, means supplementation -of the family income at the public expense. 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. - -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. - -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. - -I lay special stress on the provision of skilled medical 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. - -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, 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. - -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. - - -FOOTNOTES: - -[16] An address to the Political Economy Club, Johns Hopkins -University, Jan. 19, 1920. - - - - - CHAPTER IX - - THE CAUSATION OF TUBERCULOSIS AND THE MEASURES FOR ITS CONTROL IN - ENGLAND[17] - - -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, -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. - -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. - -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 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. - -Certain facts stand out beyond controversy, and on these -administrative control must necessarily be based. - - - _Basic Facts as to Tuberculosis_ - -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. - -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. - -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. - -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 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.) - -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. - -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. - - - _Explanations of the Decreasing Death-rate from Tuberculosis_ - -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? - -(_a_) No support is given by animal experiment to the assumption -that the types of human bacillus infecting mankind have declined in -virulence; and changes 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. - -(_b_) 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. - -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! 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. - -(_c_) 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 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. - -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. - -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. - - - _Hospital Treatment of Consumptives_ - -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 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: - -_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._ 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 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. - -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 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. - -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. - - - _Koch’s Endorsement of Segregation View_ - -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). - - 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. - - 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. - - In addition to this factor there is a second, which also plays a - very important part, viz., housing. - -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. - -It is desirable to supplement the above statement by some remarks on - - - _Improved Housing as a Means of Reducing Tuberculosis_ - -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 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. - -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. - -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 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 _by ascertaining that the proposed measures are in -accord with our knowledge of the natural history of the disease_. 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. - -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. - - - _Notification of Tuberculosis_ - -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. - -Hence notification of cases of tuberculosis was advocated for many -years by pioneer medical officers of health who secured voluntary -notification by doctors 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. - -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 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. - -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. - - - _Causes of Failure in Notification_ - -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 -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. - -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. - -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 (_a_) on his skill, (_b_) 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 (_c_) 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 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. - -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. - -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 _per se_; its utility depends on the -action which follows on notification. Unless useful action follows -on notification, default in notification has little practical -importance. - - - _Public Health Action Following Notification_ - -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 -_inter alia_ - -1. Attention to the personal hygiene of the patient, including -instruction in the necessary precautions as to coughing and -expectoration. - -2. Any assistance needed to ensure for the patient - -(_a_) Skilled medical attendance and nursing as required while he is -treated at home; - -(_b_) Institutional treatment when required; - -(_c_) 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. - -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. - -4. Examination of home contacts with the patient. - -The last named item may conveniently be considered further at this -point. - - - _Examination of Contacts_ - -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. - -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. - -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 improve the prospect of -satisfactory control of tuberculosis. - -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. - - - _Scope of Tuberculosis Schemes_ - -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. - -Local Authorities prior to 1911 had power to build sanatoria or -otherwise provide institutional accommodations 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. - -In 1911 the National Insurance Act was passed and came into operation -in July, 1912. This provided a special “Sanatorium Benefit.” - -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. 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, - -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; - -2. The establishment of tuberculosis dispensaries, at which patients -were treated, consultations as to doubtful cases held, and contacts -examined; - -3. The provision of beds in residential institutions for curable and -for acute and advanced cases; - -4. The organization of arrangements for “following up” and -“after-care.” - -During 1912 and 1913 advance was made in these directions. In 1911 -there were 25-30 tuberculosis 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. - - - _Tuberculosis Dispensaries_ - -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 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. - -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. - -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 from that of other diseases means reduced efficiency of -the tuberculosis officers and lowered quality of treatment. - - - _Tuberculosis Dispensaries should become Parts of General - Dispensaries_ - -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. - -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. - -It will be contrary to the communal interest if the 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. - -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. - - - _The Home Visitation of Patients_ - -This is important, (_a_) to inquire into the social circumstances -of each patient; (_b_) to instruct him in detail as to the carrying -out of instructions for treatment and in the hygiene of his life; -(_c_) 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 (_d_) in certain cases to give actual assistance in nursing the -patient. - -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. - -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. - -The dispensary should be the active working centre from which -home visitation is undertaken; and this is especially important -in “following up” work. Following 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: - - 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. - - 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. - -In areas having, as yet, no adequate system of following 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. - - - _“Sanatorium Benefit.”_ - -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. - -Thus the “Sanatorium Benefit” comprises - - _A_. Domiciliary treatment. - _B_. Institutional treatment. - (_a_) Non-residential—Dispensaries. - (_b_) Residential—Sanatoria, - Hospitals, - Convalescent Homes and - “Farm Colonies.” - -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 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. - - - _Residential Institutions_ - -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: - - Group _A_—Cases in which permanent improvement or recovery can - usually be anticipated. - - Group _B_—Cases in which only temporary, though possibly prolonged, - improvement may be anticipated. - - This group will include - - 1. Patients who may be expected to recover considerable ability to - work, as a result of protracted treatment. - - 2. Patients admitted for a short term for educational treatment. - - 3. Patients with advanced disease, many of whom improve greatly - under institutional treatment. - - Group _C_—Advanced cases requiring continuous medical care and - nursing. - - Group _D_—Cases requiring Special Observation. - - 1. Patients admitted for the purpose of diagnosis. - - 2. Patients needing to be watched, before the best form of continued - treatment can be determined. - - Emergency cases, e.g., patients with haemoptysis, and patients - requiring surgical treatment may come within any of the above groups. - -Of the 12,441 beds probably 5,000 are in the hands of voluntary -organizations, and are intended for patients in group _A_, 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 patients coming -within groups _B_, _C_, and _D_. 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. - -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. - -In England various existing institutions have been utilised in the -treatment of tuberculosis. - -1. Emphasis has already been laid on the large number of beds in -_workhouse infirmaries under the Poor-Law Authorities_. 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. - -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 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. - -2. Detached pavilions of _hospitals for infectious diseases_ 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. - -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. - -Occasionally empty _smallpox hospitals_ 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. - -_General hospitals_ are well fitted to deal with the following -classes of cases of tuberculosis: - - (_a_) Patients admitted for observation, with a view to diagnosis; - - (_b_) Patients admitted to ascertain the form of treatment best - adapted for the patient’s needs; - - (_c_) Emergency cases, e.g., haemoptysis; - - (_d_) Patients requiring surgical aid for intercurrent diseases; - - (_e_) Patients with advanced disease admitted for special purposes; - - (_f_) Patients with non-pulmonary tuberculosis, requiring special - surgical treatment. - -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. - - - _Sanatoria and Combined Institutions_ - -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 -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. - -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 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. - - - _Observation Beds_ - -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. - - - _General Observations on Treatment in Sanatoria_ - -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 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: - -First. Patients with limited disease and little or no systemic -disturbance. Comparatively few patients who now enter sanatoria come -within this group. - -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. - -For patients coming within the second group a similar period of -treatment in a sanatorium results: - -(_a_) In restoration of general health and working capacity with -arrest of disease in only a small proportion of cases; - -(_b_) In recovery of working capacity and apparent restoration of -general health without arrest of disease in a fair proportion of -cases; and - -(_c_) In the remainder, disease progresses steadily with or without -temporary improvement in general health. - -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. - -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. - -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. - -The conditions of local administration of the Sanatorium Benefit -under the National Insurance Act have led to a very high proportion -of consumptives being 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. - - - _Educational Work of Sanatoria_ - -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. - -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 instructor is more efficient -than the untrained recruit. - -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. - - - _Hospital Treatment_ - -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 _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_. - -Such complete supervision and provision necessitates further -development in three directions in which beginnings have already been -made: - - - _Industrial Colonies_ - -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. - -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. - -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 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. - - - _Special Dwellings and Help in Support_ - -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 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. - -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. - -In securing this end _Care Committees_ 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. - -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, - - (_a_) in obtaining appropriate work for the ex-patients; - - (_b_) in supplementing his wages; - - (_c_) in providing separate sleeping accommodation for the patient, - additional food or clothing, or in loaning out an additional bed or - bedding; - - (_d_) in aiding the family during the absence of the patient - in a sanatorium, and thus reducing the temptation to terminate - institutional treatment prematurely, and - - (_e_) in encouraging each patient to take the necessary precautions - and to adopt the special treatment recommended for him. - -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. - -_Summary_.—The preceding review of the problem of tuberculosis may be -summarised in a few final statements. - -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. - -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. - -2. Domestic protection is at once practicable against infected cows’ -milk; and control of this source of infection at its source is also -practicable. - -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. - -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. - - -FOOTNOTES: - -[17] The substance of two lectures at the Summer School on -Tuberculosis, Trudeau Sanatorium, Saranac, N. Y., July, 1919. - - - - - CHAPTER X - - CHILD WELFARE WORK IN ENGLAND[18] - - -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. - -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. - -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. - -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 June and July -and especially to the mothers of those infants who were known to be -artificially fed. - -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. - -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. - -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 -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, _consists very largely in the prevention of infections_, -including diarrhœal diseases and acute respiratory diseases. - -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. - -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 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. - -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 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. - - - _The Notification of Births_ - -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 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. - -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. - -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 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. - -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. - -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: - - 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. - -The Board in the same circular laid stress on “the importance of -linking up this work with the other medical and sanitary services -provided by local authorities under the Public Health and other Acts.” - -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. - -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: - - 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. - - - _The Causes of Child Mortality_ - -For detailed consideration of the causes of infant mortality and of -mortality during the next four years of life in England and Wales, -the reader may be referred to official reports by the writer. - -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. - -The statistics of infant mortality may be stated as follows: - - _England and Wales_ - - Deaths of Infants under - Period 1 Year per 1,000 Births - - 1896-1900 156 - 1901-1905 138 - 1906-1910 117 - 1911 130 - 1912 95 - 1913 108 - 1914 105 - 1915 110 - 1916 91 - 1917 96 - 1918 97 - -The above are the crude rates, the infantile death-rate being stated -by the usual method per 1,000 births _during the same year_. 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 - - 104, 117, 113, 111, 98, and 94. - -In other words, there has been a steady and uninterrupted decline in -the death-rate of infants during the war. - -This decline has followed similar declines in preceding years, and -it is to be noted that much of this decline 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. - - - _The Influence of School Medical Inspection_ - -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. - - - _The Influence of Statistical Studies_ - -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 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 _act helpfully_ we must _know thoroughly_ the -summation of conditions which form the evil to be attacked. - -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 neglected, that _child welfare work -can only succeed in so far as the welfare of the mother is also -maintained_. - -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. - - - _The Course of Mortality from Childbearing_ - -The general course of mortality from childbearing (including deaths -ascribable to pregnancy) in England and Wales is shown by the -following table: - - _Average Annual Death-rates per 100,000 births from_ - - Puerperal Other Diseases - Septic of Pregnancy - Diseases and Childbirth - - 5 years, 1902-06 185 228 - 5 years, 1907-11 152 215 - 3 years, 1912-14 148 233 - 2 years, 1915-16 151 239 - -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 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.” - - - _The Midwives Act, 1902_ - -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 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. - -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. - -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. - -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 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. - -_Administrative Work._—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. - -_Voluntary Workers._—Much of the success so far achieved in improving -the health conditions of infancy 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. - -The main work has been that of the _health visitor_. 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. - -A similar remark applies to the next most important development of -work, the institution of _Maternity and Child Welfare Centres_. The -conditions of work of these institutions are set out in the same -document. - - - _Training and Provision of Midwives_ - -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 -continue to practise in this capacity after qualification. In many -industrial areas the older _bonâ fide_ 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. - -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. - -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 - - (1) If she was the wife of an insured person, or if she herself is - insured, she received under the conditions of the National (Health) - Insurance Act 30s. in cash, or if she is insured and the wife of an - insured person 60s. in cash. - - (2) If she was the wife of a soldier or sailor and not entitled to - maternity benefit she received from 10s. per week up to £2 from the - Local Pensions Committee. - - (3) If she was a munition worker she might be aided under a scheme - provided under the Ministry of Munitions. - - (4) She also might obtain priority for the supply of milk, or obtain - free milk or milk at cost price under the Local Committee Board - Food Control Order, No. 1, 1918, empowering local authorities to - supply milk and food and an extra ration under the Food Controller’s - Order. In addition, after confinement she had available the ration - apportioned to the infant and its allowance of milk under the - priority scheme. - -There was evidently need for simplification and unification of effort -in the above cases. - -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.” - -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. - -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. - - - _Ante-natal Work_ - -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 safeguarding themselves -against possible complications, as well as of securing adequate -preparation for the lying-in period. - -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. - - - _Dental Assistance_ - -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. - - - _Creches_ - -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. - -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. - - - _Observation Beds at Child Welfare Centres_ - -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 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. - -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 -_continuity in dealing with the whole period from before birth until -the time when the child is entered upon a school register_; 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 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.” - -The main provisions of this memorandum are printed on page 135. - -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. - - -_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_ - - Financial Year Local Government Board Board of Education - 1914-15 11,488 10,830 - 1915-16 41,466 15,334 - 1916-17 67,961 19,023 - 1917-18 122,285 24,110 - 1918-19 (estimated) 209,000 44,000 - -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. - -The increase during the war period has been very 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. - -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. - -To what circumstances can this be ascribed? - -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. - -A number of contributory factors were at work: - -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. - -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. - -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. - -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. - -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 248. - - -FOOTNOTES: - -[18] Extracted from addresses given at Conferences held by the -Children’s Bureau of the Department of Labor, Washington. - - - - - INDEX - - - Abbott, J., 2 - - Abbott, S. W., 2 - - Alcoholic drinks, 123, 149, 187 - - Anaesthetics, 77 - - Ante-natal work, 261 - - - Bacteriological diagnosis, 85 - - Banks, N. P., 2 - - Biggs, H., 77 - - Bowditch, 2 - - Budd, Wm., 15 - - Burns, John, 44 - - Burton, R., 71 - - - Care Committees, 237 - - Causation, 147 - - Causation, specific, 20 - - Cerebro-spinal fever, 23, 76, 126 - - Chadwick, 2, 3, 11, 12, 25, 52, 54 - - Chalmers, 70 - - Chapman, 221, 237 - - Character and health, 173 - - Childbearing, care of, 137, 254 - - Child mortality, causes of, 248 - - Child welfare work, 240 - - Cholera, 12 - - Colonies for consumptives, 235 - - Consumption, see Tuberculosis. - - Contacts in tuberculosis, 212 - - Creches, 263 - - - Decadence, 121 - - Democracy and public health, 47 - - Dental assistance, 262 - - Destitution (see also Poor Law), 31, 65, 87 - - Deterrence, principle of, 29 - - Diarrhœal diseases, 20, 241 - - Dirt and disease, 11 - - Dispensaries for tuberculosis, 216 - - ” general, 218 - - Domiciliary treatment, 35 - - - Education authorities and public health, 56, 58, 86 - - Educational propaganda, 130, 168 - - ” work of sanatoria, 233 - - Enteric fever, see Typhoid. - - Epidemiology, present limitations of, 22, 81 - - Eugenics and public health, 44 - - Expectation of life, 20, 74, 192 - - - Factory hygiene and legislation, 8, 26 - - Farr, Wm., 2, 25 - - Fulton, J. S., 24 - - - Gerhard, 15 - - Goodnow, 60, 63 - - Grants in aid, 56, 135, 265 - - - Historical development of public health, 42 - - Holmes, O. Wendell, 16 - - Hospitals, see Institutional treatment. - - ” as housing auxiliaries, 38, 77, 79, 98 - - ” and private practice, 146 - - Housing, 38, 79 - - ” and tuberculosis, 203 - - Huddersfield, 246 - - - Ideals of public work, 4 - - Ignorance and sickness, 168 - - Immunity to tuberculosis, 196 - - Industrial colonies, 235 - - Industry and public health, 50, 161 - - Infant consultations, 243 - - Infant mortality, 144, 250 - - Infant mortality and poverty, 153, 185 - - Infants, care of, 30 - - Influenza, 23, 76, 127 - - Inspectors of factories, 51 - - Institutional treatment, 37, 79, 98 - - Insurance and public health, 33, 59, 66, 88, 92, 95, 103 - - Intemperance, 149 - - - Jefferson, President, 6 - - Jenner, Wm., 15 - - - Kay, 2, 11 - - Koch, Robert, 192 - - ” and segregation in tuberculosis, 201 - - - Laissez faire policy, 6 - - Lay workers, utilisation of, 3 - - Loans for public health work, 14 - - Local Government Board, 53, 58, 77 - - Lowe, Robert, 28 - - - Mackenzie, L., 57 - - Maclean, D., 31 - - Malaria, 147 - - Malthus, 6, 162 - - Malthusian hypothesis, 164 - - Massachusetts, 2, 4 - - Maternity benefit, 34, 95, 111, 134 - - Measles, 20, 126 - - Measurement of results in life saving, 19 - - Medical benefit, 34, 106, 110 - - Medical practice and public health, 27, 83 - - Medical officers of health, 63 - - Midwives Act, 255 - - Midwifery nursing, 260 - - Milk depots, 243 - - Mill, James, 6 - - Ministry of Health, 49 - - Mother and child, 132, 180 - - Murchison, Chas., 15, 17 - - - National Health Insurance Act, 33, 59, 88, 104 - - National medical service, 32, 36 - - New England, 1 - - Notification of tuberculosis, 206 - - ” of births, 245 - - Nursing, training of, 122 - - ” public health work of, 126 - - - Oastler, 177 - - Overcrowding, 7, 199 - - Over-population, 166 - - Owen, 177 - - - Panel doctors, 215 - - Pasteur, 21 - - Percival, 177 - - Pettenkofer, Von, 13 - - Philanthropy and public health, 9, 37 - - Physical defects, 81 - - Pneumonia, 76 - - Poliomyelitis, 23, 76 - - Political pull, 102, 175 - - Poor law and public health, 27, 29, 31, 46, 49 - - Population problem, 163 - - Poverty, causes of, 31, 182 - - ” control of, 46, 114 - - ” tests, 139 - - ” and sickness, 148, 162, 167, 184, 189 - - Preventive medicine, 99 - - Progress of public health, 1 - - Public health nurses, 128, 154 - - - Racial immunity, 196 - - Red Cross workers, 127, 132, 143 - - Registrar-General’s returns, 18, 25 - - Relief _v._ prevention, 109, 190 - - Relief _v._ prevention, 48 - - Research, 24, 35 - - Resistance _v._ infection, 195 - - Respiratory diseases, 23, 125 - - Rumsey, 54 - - Rural conditions, 161 - - - Sanatorium benefit, 34, 94, 111, 129, 214, 222 - - Sanatorium treatment, 228 - - Sanitation and infant mortality, 242 - - Scarlet fever, 20 - - Schools for mothers, 244 - - School medical inspection, 30, 57, 252 - - Scope of public health work, 44 - - Sedgwick, 16 - - Segregation of feeble-minded, 44 - - ” in tuberculosis, 200 - - Sex teaching, 151 - - Shaftesbury, 177 - - Shattuck, L., 2, 3 - - Shop hygiene, 9 - - Sickness and pauperism, 67, 68 - - Sickness insurance, 10, 32, 65, 67, 87, 116 - - Sickness registration, 26 - - Simon, Jno., 2, 4, 5, 9, 12, 13, 22, 25, 28, 55 - - Smallpox, 21 - - Smith, Adam, 6 - - Smith, Southwood, 2, 9, 11, 12 - - Smith, Theobald, 2 - - Snow, Jno., 13 - - Socialization of medicine, 82, 102, 115 - - State treatment of disease, 112, 137 - - Statistical studies, influence of, 252 - - Still-births, 137 - - Syphilis, 137 - - Sykes, J. F. J., 244 - - - Town living, influence on health, 43 - - Tuberculosis, 20, 23, 34, 76, 78, 129, 192 - - Tuberculosis and hospital treatment, 198 - - ” and overcrowding, 199 - - ” and housing, 203 - - ” notification of, 206 - - Typhoid fever, 15 - - Typhus fever, 17, 20 - - - Unqualified practice, 31 - - Urbanization, 7, 159 - - - Venereal diseases, 30, 85, 131, 150 - - Victoria, Queen, 10 - - Vital statistics, importance of, 24 - - Voluntary agencies, 141 - - - Walcott, 2 - - War, 81, 120, 158, 179 - - Water supplies and health, 16 - - Wells, 159 - - Whooping cough, 20 - - Women, work of, 122 - - ” position of, 184 - - - - - Transcriber’s Notes - - pg 14 Changed groups of diarrhoeal to: diarrhœal - pg 19 Changed and that diarrhoeal to: diarrhœal - pg 20 Changed one-sixteenth to diarrhoeal to: diarrhœal - pg 34 Changed doctor or mid-wife to: midwife - pg 34 Changed in a sanatorum to: sanatorium - pg 42 Changed of the excessive diarrhoea to: diarrhœa - pg 49 Changed and the feebleminded to: feeble-minded - pg 89 Changed England was not actuarily to: actuarially - pg 101 Changed if the latters to: latter - pg 105 Changed for the benfits to: benefits - pg 114 Added period after: due to sickness - pg 115 Changed assistance by cooperative to: coöperative - pg 118 Changed period to comma after: Pre-school clinics - pg 145 Changed their satisfactory cooperation to: coöperation - pg 159 Changed rows of unsatistory to: unsatisfactory - pg 164 Changed power of finding enployment to: employment - pg 171 Changed she is over-worked to: overworked - pg 176 Changed facts, they villify to: vilify - pg 178 Changed more and more entagled to: entangled - pg 184 Changed accompaniments of overfatigue to: over-fatigue - pg 221 Changed Examination of a register kept for faciliating - to: facilitating - pg 228 Changed efficiency in a santorium to: sanatorium - pg 241 Changed caused 8.1 percent to: per cent - pg 246 Changed total deaths in ths to: the - pg 259 Added period after: Insurance Act 30s - pg 262 Changed that of abortions, stillbirths to: still-births - pg 262 Changed investigation of stillbirths to: still-births - pg 267 Changed it as he ollowed to: allowed - pg 268 Changed Antenatal work, 261 to Ante-natal - pg 268 Added period after: Enteric fever, see Typhoid - pg 268 Added period after: Hospitals, see Institutional treatment - pg 270 Sickness and pauperism had no page references added 67, 68 - Table of contents used lectures, but refers to chapters - Many hyphenated and non-hyphenated word combinations left as written. - -*** END OF THE PROJECT GUTENBERG EBOOK PUBLIC HEALTH AND -INSURANCE *** - -Updated editions will replace the previous one--the old editions will -be renamed. - -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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