Health and the state

UNIVERSITY OF CALIFORNIA
AT LOS ANGELES

UNIVERSITY of CALIFORNIA

HEALTH AND THE STATE

HEALTH
AND THE STATE

BY

WILLIAM A. BREND

M.A., Camb. ; M.D. (State Medicine), B.Sc, Lond.

OF THE INNER TEMPLE, BARRISTER-AT-LAW
LECTURER ON FORENSIC MEDICINE, CHARING CROSS HOSPITAL

SECOND IMPRESSION

LONDON
CONSTABLE AND COMPANY Ltd.

1917

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L±^^ I <\

Br;

PREFACE

A healthy population is the finest form of national
wealth, and in an industrialised country its possession
depends to a large extent upon the completeness of the
Public Health services and the success they achieve in
securing a sound environment. In this country great
efforts are made to promote healthy conditions of living :
Government Offices administer Public Health measures,
Local Authorities supervise sanitary conditions, and other
organisations, public and private, spend vast sums in
providing medical treatment for the sick. But the value
of these efforts is seriously lessened by the division of
administration among a number of uncoordinated authori-
ties, which overlap in various directions, and yet leave
large sections of the ground untouched. Social reformers,
impressed with the confusion and delay resulting from
this system — or want of system — have long urged the
formation of a Ministry of Health in order to promote
efficiency in administration, and it is not necessary at the
present time to emphasise the importance of any steps
likely to improve the health of the people. In this book I
have outlined a scheme for complete reorganisation of the
Public Health services, both central and local, the most
important function assigned to a Ministry of Health being
that of investigating the causes and distribution of disease,
while actual administration of Public Health measures

vi HEALTH AND THE STATE

is left to local authorities provided with increased powers.
To demonstrate the reasons for this scheme it has been
necessary to take a wide view of the scope of Public
Health, and to illustrate the way in which efforts to attack
disease have failed and erroneous views have been dis-
seminated owing to insufficient investigation of the
problems involved. For instance, in Chapter II. I have
examined the question of infection in relation to the
prevention of disease, with the object of showing that
fear of infection is unwarrantably exaggerated in the
public mind, and that segregation of infected persons in
fever hospitals is useless as a means of preventing or
eradicating many common infectious diseases. Again,
in Chapter III. I have shown that there is little scientific
foundation for the popular view that infant mortality is
largely a result of adverse pre-natal conditions or maternal
ignorance and neglect, and have given reasons for believing
that it is mainly caused by post-natal factors over which
the mother has little or no control. In succeeding chapters
I have endeavoured to give a picture of the actual state
of health among the people in England and Wales at the
present time, and the extent and distribution of the principal
diseases, for the purpose of showing the vast scope which
still remains for the reduction of sickness and mortality.
The main environmental causes of disease are then brought
in review, and I have tried to enforce the lesson that
curative measures yield far less return to the State than
those which sweep away the conditions causing disease.

In the last chapter I have urged that the various local
authorities at present engaged in Public Health adminis-
tration, or in providing medical services, should be com-
bined into a single Local Health Authority, responsible
for protecting the health of the whole community in the
locality, and providing such medical services as are neces-

PREFACE vii

sary. If this proposal were adopted, I would urge that
care for the health of discharged disabled soldiers, many of
whom will require medical treatment for prolonged periods,
should form one of the functions of the authority. This
suggestion is not considered in the book, because, at the
time of writing, proposals were indefinite and constantly
changing. I mention it here in order to deprecate the
tendency already observable of setting up yet another
series of institutions and organisations to provide for a
special class of the community. This remark does not
apply to the highly useful Committees which are training
soldiers in handicrafts or assisting them to find work, but
only to those movements which are concerned with the
care of their health.

Throughout the book I have endeavoured to indicate
the need for far closer investigation by the State of the
problems presented by disease, and more thorough con-
sideration of Public Health proposals before they become
law — ends which can only be achieved by the establishment
of a Ministry of Health.

Most of the chapter on the Insurance Act and parts of
other chapters have appeared in The Nineteenth Century
and After, and I am indebted to the Editor of that Review
for kind permission to reproduce them. The chapter on
Infant Mortality has been published by the Medical Re-
search Committee, and my thanks are due to the Committee
for permitting me to include it in the book. My best
thanks are due to Mr. C. E. West, F.R.C.S., for reading
the proofs and for many helpful suggestions.

W. A. B.

London, February 1917.

CONTENTS

CHAPTER I

PAGE

The Sanction of the State to safeguard the National Health . 1

The antiquity of State protection of Health — Public Health in the
Middle Ages — The national ' survival value ' of health — The influence
of disease on the distribution of races — Responsibility for the health of
native races — Health and social progress — The decline in the birth-
rate— The demand for the reduction of disease — The great knowledge
of the means of preventing and curing disease — The failure to apply that
knowledge — The reasons for the failure : vested interests, complexity
of administration, and want of knowledge in the legislature.

CHAPTER II

Nature and Disease . . . . . . .31

Evolution against disease : typhus ; smallpox ; enteric fever ;
scarlet fever ; diphtheria ; tuberculosis ; syphilis — The problems of
infection — The futility of disinfection — The assurance of the layman —
The evils of exaggerated claims.

CHAPTER III

Infant Mortality and its Problems . . . . .62

The ' natural ' rate of infant mortality — The avoidable loss of infant
life in the United Kingdom — Infant mortality in town and country —
The possible causes of infant mortality : poverty ; defective sanitation ;
infectious diseases ; artificial feeding ; industrial employment of
mothers ; lack of attendance at birth — Maternal ignorance — Adverse
pre-natal conditions — The effect of smoke and dust — The pathological
causes of infant mortality — Deaths from ' developmental conditions '
Still-births — The fall in infant mortality in recent years — Infant
mortality in Bradford — The need for further research.

HEALTH AND THE STATE

CHAPTER IV

PAGE

Disease and Defects in Children and Adults . . .114

Children below the school age — Physical and mental defects in school
children — Defectiveness in urban and rural children — Employment
of children out of school hours — Children in special schools and in-
stitutions— The folly of palliative methods — Sickness in adults — Urban
and rural sickness rates — Defects in army recruits — The principal
causes of mortality : tuberculosis ; pneumonia and other respiratory
diseases; heart-disease; cancer; diarrhoea and enteritis ; syphilis.

CHAPTER V

Public Health, Land, and Housing ..... 148

Man not biologically adapted to life in towns — Rural depopulation —
The overcrowding of cities and the means of relief — Segregation of
factories — Bad housing — The difficulties of clearing slum areas — The
cost of building — ' Summer camps ' — Sleeping out.

CHAPTER VI

Medical Treatment among the Working Classes . . . 168

The meaning of ' medical treatment ' — The growth and importance of
institutional treatment — The insufficiency of institutional treatment —
Medical treatment by general practitioners — The size of working-class
practices — ' Lightning ' diagnosis— The absence of expert assistance
— Diagnosis in general practice — The lack of laboratories for expert
diagnosis — The futility of treatment in a bad environment— The dis-
content with the panel system — Medical treatment of school children
— Mortality in child-bed and its causes — Skilled attendance in child-bed
— The pathological causes of deaths in child-bed : puerperal fever —
General practitioner or midwife ? — Attendance in confinement and
infant mortality — Maternity benefit — The question of a public mater-
nity service — Medical treatment and Public Health.

CHAPTER VII

Public Health and the National Insurance Act . . .210

The Insurance Act a Public Health measure — The German origin of
the Insurance Act — The principles of administration of the Act —
Local administration — Medical benefit — The supply of drugs — Sana-
torium benefit — Sickness benefit — The Insurance Act and insanitary
conditions — The Insurance Act and the advancement of Public Health
knowledge.

CONTENTS xi

CHAPTER VIII

PAGE

Public Health and Fraud ...... 265

Adulteration of food — Unsound food — Conditions under which food
is prepared — Patent and proprietary foods — Patent and proprietary
medicines — Unqualified practice.

CHAPTER IX

The Complexity of Public Health Administration . . 288

Central administrative authorities — Local administrative authori-
ties— The evolution of the Public Health services — Administration of
sanatorium benefit — Administrative authorities and statistics — The
discouragement of the present system.

CHAPTER X

The Need for a Ministry of Public Health . . .311

The lack of scientific criticism of Public Health measures — The
need for a Ministry of Public Health — Royal Commissions and Public
Health research — Administrative Offices and Public Health research
— The Office of the Registrar-General as the Ministry of Public Health
— The proposal to form a Ministry by uniting the present administrative
Departments — The personnel of a Ministry of Health.

CHAPTER XI

Public Health and Local Administration .... 329

The responsibility of local authorities — The decline of democratic
control in Public Health — Local needs and local control — Local ad-
ministration and the cost of sickness — A single local health authority
or ' Local Health Council ' — Should the Health Council be the present
Local Authority or a new body ? — Coordination of the Local Health
Council and the Local Authority — A suggestion for financial arrange-
ments— The question of a local medical service — The position of the
voluntary hospitals — Conclusion.

INDEX 351

CHAPTER I

THE SANCTION OF THE STATE TO SAFEGUARD THE
NATIONAL HEALTH

The antiquity of State protection of Health — Public Health in the Middle
Ages — The national ' survival value ' of health — The influence of
disease on the distribution of races — Responsibility for the health of
native races — Health and social progress — The decline in the birth-
rate— The demand for the reduction of disease — The great knowledge
of the means of preventing and curing disease — The failure to apply
that knowledge — The reasons for the failure : vested interests, com-
plexity of administration, and want of knowledge in the legislature.

The Antiquity of State Protection of Health

Sickness and disease are ancient foes of the human
race, and men have always acted in concert against
them. In early stages of society, communities groping
in ignorance and bewildered by the dangers which sur-
rounded them, turned to divine power for help. The gods
of the ancient world, of Babylon, Egypt, Greece, and
Rome, always included one whose special province was
the curing of the sick ; and at a later date the aspect of
Christ as the Healer was prominent in early Christianity.
Native races to-day entrust to the ' medicine-man,' the
most potent influence at their command, the duty of
warding ofr epidemics by incantations.

Belief in the influence of supernatural power, good or
evil, upon disease, made the province of healing the sick
far too important a duty to be left uncontrolled to the
individual ; and in early societies the function was always
assumed by the State. In Egypt the practice of medicine
was restricted to a special class of priests who had studied
the Sacred Books of Hermes which dealt with the body

B

2 HEALTH AND THE STATE

and its diseases.1 These books were believed to have been
inspired by Isis herself, and physicians who deviated from
the laws they laid down did so at their peril. Diodorus
says : "If, whilst following the rules laid down in the
" Sacred Book, they do not succeed in saving their patients,
" they are held free from all guilt ; if, on the other hand, they
" do anything contrary to those rules, they undergo capital
" punishment." 2 In Babylon exorcism was practised by
the priests ; physicians formed an independent class, but
their efforts were severely controlled by the State, as
shown by the regulations in the celebrated code of Ham-
murabi, promulgated about 2280 B.C., which prescribes
the fees patients are to pay, and ordains heavy punish-
ments for negligent treatment.3 In Greece medicine
reached a high degree of development, and its practice
was remarkably free from restraint, a condition which led
Pliny to complain that there was no law to punish the
ignorance of physicians, who were the only persons who
might kill a man with impunity.4 In ancient Rome, on
the other hand, criminal practitioners might be executed,
while negligent treatment rendered them liable to pay
damages.

But it was not only in the practice of medicine that the
State enforced control. Epidemics were believed to be
due to mysterious agencies or the work of evil spirits,
nevertheless it was rightly recognised that certain diseases
are spread by transmission from man to man, and measures
were taken by the community to prevent their progress,
by isolating sufferers. Among the Israelites, the priests
diagnosed leprosy, and for the leper it was laid down that
" all the days wherein the plague shall be in him he shall
be denied ; he is unclean : he shall dwell alone ; without
the camp shall his habitation be." Even conveyance of

1 H. Oppenheimer, LL.D., " Liability for Malapraxis in Ancient Law," Trans.
Med. Leg. Society, vol. vii. 2 Bibliotheca Historica, i. 25, 3.

3 The following examples of these provisions are quoted from Babylonian and
Assyrian Laws, Contracts and Letters, by C. H. W. Johns :

"If a surgeon has operated with the bronze lancet on a patrician for a
serious injury, and has caused his death, or has removed a cataract for a patrician
and has made him lose his eye, his hand shall be cut off."

"If a surgeon has treated a serious injury of a plebian's slave with the
bronze lancet and has caused his death, he shall render slave for slave."

4 Hist. Nat. xxix. 8.

PUBLIC HEALTH IN LATER TIMES 3

disease by clothing was recognised, for if the priest find that
the garment of the leper is infected, " he shall therefore
burn that garment, whether warp or woof, in woollen or in
linen, or any thing of skin, wherein the plague is : for it is
a fretting leprosy ; it shall be burnt in the fire." x

In the wonderful system of aqueducts and sewers in
ancient Rome we may detect appreciation of the import-
ance of water-supply and drainage in maintaining the
health of the community. Public baths existed in Greece,
and at a later date magnificent establishments, often with
gymnasia attached, were built in Rome, the therapeutic
value of which was well recognised, as shown by the follow-
ing epigram quoted by Dr. J. D. Rolleston from the Greek
Anthology : " The bath is the cause of many blessings.
It removes the humours, dissolves the thickness of the
phlegm, empties excess of bile from the bowels, eases
painful itching, sharpens the eyesight, cleanses the ear-
passages of the deaf, strengthens the memory, removes
forgetfulness, clears the mind, makes the tongue more
active and purifies and lightens the whole body." 2

Public Health in Later Times

In mediaeval Europe, the State was continually taking
measures, superstitious and futile though they were, to
protect the people from disease. Mainly these were
directed against the devastating epidemics which swept
over countries from time to time, divine help being sought
by prayers, processions, and exhibition of holy relics.
Jacobus de Voragine, Archbishop of Genoa, writing in the
thirteenth century, describes the efforts made by Gregory
the Great as early as a.d. 590 to stay the ravages of a
fierce outbreak of plague in Rome. He says : " And
" because the mortality ceased not, he ordained a procession
" in which he did bear an image of Our Lady, which as is
" said S. Luke the Evangelist made, which was a good
" painter, he had carved and painted it after the likeness
" of the glorious Virgin Mary. And anon the mortality
" ceased and the air became pure and clear, and about the

1 Lev. xiii. 2 Trans. Roy. Soc. of Med., 1913.

4 HEALTH AND THE STATE

': image was heard a voice of angels." * For hundreds of
years these processions bearing pictures of the Madonna
and effigies of saints were ordered by the ecclesiastical
authorities to traverse the streets in order to stay the
ravages of plague. In the Litany we still pray to be
delivered from plague, pestilence, and sudden death. In
later years, more scientific efforts were made, but it was
still the State which assumed responsibility. In the plague
of London the Lord Mayor issued orders for the cleaning
of the streets, the marking of houses, and the prompt
burial of the dead, and the King commanded the College of
Physicians to give advice and prescriptions for treatment.

The practice of separating lepers from their fellow-
men was continued during the Middle Ages, sufferers from
the disease being compelled to live in special houses away
from the vicinity of towns, and being prohibited from
entering churches or inns. They were required to wear
a long grey gown with hood drawn over the face, and
carry a clapper or bell in order that healthy people might
know of their approach and shun them.

The protection of the community against dangerous
lunatics was another function which was early undertaken
by the State. At first these unfortunate people were
treated with great cruelty, confined in gaols, and even
executed, and it was not until 1547 that the first Bethlehem
hospital was established for their detention in Bishopsgate.

Compulsory segregation of the sick was not, however,
the only means by which the State sought to protect
Public Health. Although hygiene has only been placed
on a scientific basis in quite modern times, many of the
essential causes of ill-health were recognised centuries ago,
and measures were taken to suppress them. It is no new
discovery that accumulations of filth, pollution of the air,
and fouling of water-courses are injurious to health, and
the archives of the city of London contain records of many
administrative measures directed against these evils.2

1 Quoted by Raymond Crawfurd, M.D., in " Plague Banners," Trans. Roy. Soc.
of Med., 1913.

2 A valuable collection of extracts from these archives is contained in Memorials
of London and London Life in the 13th, 14th, and 15th Centuries, by H. T. Riley.
These are extensively quoted by Sir John Simon in his English Sanitary Institutions.

PUBLIC HEALTH IN LATER TIMES 5

During the thirteenth and fourteenth centuries laws were
made against permitting pigs to wander in the streets,
melting tallow in Chepe, flaying horses or slaughtering
oxen, sheep, or swine in the city, and melting solder in
Eastchepe " unless the shaft of the furnace was raised."
Every man was obliged to keep clean the part of the street
in front of his own house, and the throwing of filth from
houses into the streets and lanes of the city was forbidden
under severe penalties. In 1357, Edward III. issued an
order to the Mayor and Sheriffs prohibiting the throwing
of filth into the rivers of Thames and Flete, for he " had
" beheld dung and laystalls and other filth accumulated
" in divers places in the said city upon the bank of the said
" river," and had " also perceived the fumes and abominable
" stenches arising therefrom : from the corruption of which,
" if tolerated, great peril, as well to the persons dwelling
" within the said city as to nobles and others passing along
" the river, will, it is feared, arise unless indeed some fitting
" remedy be speedily provided for the same." Under
Henry VIII., Commissioners of Sewers were appointed to
keep the water-courses in order and prevent them from
being polluted by refuse. Since these beginnings the State
has continually increased its control over the water-supply
in the interests of Public Health, either by itself under-
taking the service through municipalities, or by enforcing
laws and regulations when the supply is in the hands of
private companies.

Efforts to prevent overcrowding and disease resulting
therefrom are also of long standing. In 1580, Elizabeth
issued a proclamation forbidding the erection of new
buildings in the city or within three miles of its gates,
but in 1583 the Lords of the Council report that in spite
of this proclamation buildings had greatly increased, " to
the danger of pestilence and riot." * An Act of 1593
recites that " great mischiefs daily grow and increase by
reason of pestering the houses with divers families harbour-
ing of inmates, and converting great houses into several
tenements, and the erecting of new buildings in London
and Westminster. Under Charles I., the Commissioners

1 Simon, op. cit.

6 HEALTH AND THE STATE

of Buildings complain that, " the multitude of newly
erected tenements in Westminster, the Strand, Covent
Garden, Holborn, St. Giles, Wapping, RatclifE, Limehouse,
Southwark, and other parts . . . was a great cause of
beggars and other loose persons swarming about the city,
that the greater part of their soil was conveyed with the
sewers in and about the city, and so fell into the Thames
to the great annoyance of the inhabitants and of the river ;
that if any pestilence or mortality should happen, the city
was so compassed in and straightened with these new
buildings that it might prove very dangerous to the
inhabitants."

The jerry-builder and slum landlord were early in
existence, as may be gathered from the following extract
from a tract of the time of James I.:1

The desire of Profitte greatly increaseth Buyldinges, and so
muche the more, for that this greate Concurse of all sortes of people
draweinge nere unto the Cittie, everie man seeketh out places, highe-
wayes, lanes, and coverte corners to buylde upon,yf it be but Sheddes,
Cottages, and small Tenementes for people to lodge inn. . . . Thes
sorte of coveteous Buylders exacte great renttes, and daiely doe
increase them, in so muche that a poore handle craftesman is not able
by his paynefull laboure to paye the rentte of a smale Tenement
and feede his ffamilie. Thes Buylders neither regarde the good of
the Comon-wealthe, the preservacon of the health of the Cittie, the
maynetenance of honeste Tradesmen, neither doe they regarde of
what base condicion soever their Tenantes are, or what lewde and
wycked practizes soever they vse so as their exacted renttes be duely
payed, the wch for the moste parte they doe receave either weekely
or moontheley.

It is curious to note these efforts made by the State
hundreds of years ago to prevent overcrowding ; to recall
that they have been followed by a long succession of
Housing Acts, Building Acts, and Labourers' Dwellings
Acts right up to the Town Planning Acts of recent years ;
and then to reflect upon the deplorable housing and over-
crowding of large masses of the poorer population to-day.
Housing is the direction in which Public Health has made
least progress in spite of much legislation, and this has
been due partly to the opportunities which the building of

1 Quoted by Sir Laurence Gomme in The Making of London, 1913.

PUBLIC HEALTH IN LATER TIMES 7

houses affords for the creation of vested interests, and
partly to short-sighted legislation, which, while removing
evils in one area, has permitted their re-establishment in
another.

The prevention of adulteration of food and the selling
of bad food are other directions in which the State early
concerned itself for the benefit of the community. Dr.
Wynter Blyth has given an account of these practices and
the punishment of dishonest vendors in his well-known
book.1 Adulteration of wine and bread appears to have
begun very early. Pliny alludes to frauds practised by
bakers by adding a soft white earth to bread, and in Athens
the adulteration of wine led to the appointment of a special
inspector whose duty it was to detect and stop these
practices. In Europe, from the eleventh century onwards,
bakers, brewers, ' pepperers,' and vintners were frequently
punished for corrupt practices. The sale of bread was
regulated by Assize as early as 1203. The Assize of 1582
contains the following :

If there be any that by false meanes useth to sell meale, for
the first tyme he shall be grievously punished, the second tyme
he shall lose his meale, the III tyme he shall foreswere the towne
and so likewyse the bakers that ofTende. Also bouchers that sell
mesell porke or mozen flesche : for the first tyme they shall be
grievously amerced, for the second tyme so offendinge they shall
have the judgement of the pillory, for the third tyme they shall be
comytted to pryson until ransomed, and the fourth tyme they shall
foreswere the towne ; and thus ought other transgressors to be
punished, as cooks forestalled, regrators of the markets when the
cookes serve, roste, bake, or any otherwyse dresse, fysche or flesche
unwholesome for man's body.

Many other instances are given by Dr. Blyth of severe
punishments for adulteration of food. An Ordonnance of
Paris of 1396 forbade the colouring of butter with ' saucy
flowers,' other flowers, herbs, or drugs. In 1491 three
bakers convicted of selling bread ' too small ' were stripped
and beaten with rods through the streets of Paris. At
Biebrich in Germany, in 1482, a falsifier of wines was
condemned to drink six quarts of his own wine. He died
from the effects.

1 Foods : their Composition and Analysis.

8 HEALTH AND THE STATE

The nineteenth century witnessed a great development
of State activity on behalf of Public Health in all civilised
countries. In the British Isles, general sanitation, housing,
water-supply, food, milk, infectious diseases, insanity,
training of midwives, medical qualifications, Poor Law
infirmaries, protection of infant life and maternity, and
provision of medical treatment have all been the subject
of Acts of Parliament, many of which have been amended
and enlarged time after time. Principles of hygiene are
enforced in the home, the school, the mine, and the factory.
The early and inhuman methods of segregating infected
persons have long disappeared, and have been succeeded
by a system of compulsory notification of disease, com-
bined with provision for treatment in fever hospitals,
which is accepted voluntarily in the vast majority of
instances.

If we look at the legislation of the last half -century > it
is safe to say that Public Health measures in one form or
another have occupied a larger share of Parliamentary
time than either trade, finance, education, or even national
defence, yet alone of these activities does it not possess a
special Government Department. In the Middle Ages,
under the influence of monasticism, the body was regarded
as the enemy of the soul, and the efforts of States under the
guidance of an all-powerful Church were directed towards
securing salvation in an after-life. No punishments were
too great for infringement of ordinances which might
imperil that salvation, and men have been hanged for
eating meat on a Friday and for blasphemy. So late as
1754 the proposal to register all births and deaths in this
country was defeated in Parliament, owing to popular opposi-
tion on the ground that it would involve committing the sin
of David.1 In a more enlightened age, care for the bodily
health, as far as the State is concerned, has replaced the
mediaeval care for the soul, and the Churches also have
extended their mission to the alleviation of disease in this
world. In the words of Bishop Byle, Dean of Westminster :
"It is no longer sin which seems to be regarded as the
foe, but physical disease, suffering, and death. The war-

1 Gentleman's Magazine, 1754.

PROMINENCE OF PREVENTIVE MEASURES 9

fare which excites public sympathy is the warfare against
' bacterial rulers of darkness,' against epidemics, against
fevers, against cancer." *

The Prominence of Preventive Measures

Before examining the profound meaning of the concern
which States have always displayed for the health of
their members, we may note one feature which has been
prominent throughout, and that is the large share in the
national efforts occupied by preventive measures. The
importance early attached to water-supply, removal of
refuse, and overcrowding illustrate this point. The ruth-
less sacrifice of the individual for the protection of the
community is exemplified by the laws made against the
leper. The measures taken against epidemics, such as
the carrying of holy relics or the lighting of fires in the
streets, had for their object the averting of the terror from
those who were untouched, for the sick were often allowed
to die in solitude and neglect. Compulsory vaccination,
notification of disease, and all our recent sanitary efforts
are directed towards the prevention of sickness.

Curative measures, on the other hand, such as provision
of refuges for the sick and of medical treatment, have not
formed a conspicuous feature of State activity until quite
recent years. Everywhere the earliest institutions for
the sick were the outcome of individual benevolence or
were established by religious orders ; and the great hospital
system in this country, which had its origin in the monastic
institutions, has been developed almost entirely by private
energy and munificence. Some provision was made for
the care of the sick poor in the sixteenth century, but
except for an extended use of the fever hospitals, it was
not until the passing of the Insurance Act that any attempt
was made on a large scale to provide medical treatment
through the State for persons not belonging to the indigent
class. The State in the past has indeed been little moved
by motives of sympathy ; its ordinances have been framed
by the sound for the protection of the sound, and the

1 Sermon preached at Westminster Abbey before the members of the Seven-
teenth International Congress of Medicine, London, 1913.

10 HEALTH AND THE STATE

sick have been left to fend for themselves, or seek help
from the more kindly of their fellow-creatures. Even
when provision has been made by the State, it was quite
clearly the outcome of desire to protect others rather than
of solicitude for the sick. The cruelties which weie in-
flicted on lunatics show that they were not confined for
their own benefit, but mainly for the protection of the
public ; and the earlier Poor Laws were directed quite as
much towards the repression of mendicity and petty
crime as towards providing for the infirm poor. Harsh
though this attitude may appear, it has probably been
based upon a sound national instinct, for the sick person
was often of no further use to the community, and the
State was concerned only in protecting the community
with little reck for the sufferings of the individual who
fell by the wayside.

The National ' Survival Value ' op Health

National concera for the communal health was probably,
in the first instance, a development of the ' herd-instinct '
which leads gregarious organisms to unite for their common
protection. The survival value of this instinct is seen
in its simplest form in savage tribes, among whom it is
obvious that that tribe which can place the largest number
of able-bodied warriors in the field has the greatest chance
of overcoming its enemies in a conflict where defeat may
mean annihilation. The principle equally applies, though
on a much larger scale, to European warfare to-day, when
belligerent nations strive to arm as large a proportion as
possible of their adult male populations. The number of
men available bears a very direct relation to the average
state of health of the nation, and we know that in this
country it has been found necessary to exempt a sub-
stantial proportion of men from military service either by
reason of their defects and ailments, or from their failure
to attain a standard of growth which, measured by well-
developed individuals, must be looked upon as lamentably
low.

In the industrial competition between peoples, national

NATIONAL 'SURVIVAL VALUE' OF HEALTH 11

health also plays an important though perhaps less con-
spicuous part. We have an example in the Insurance
Act of the way in which the State looks upon health from
the utilitarian standpoint. That Act does not purport to
cure or prevent disease in the community, but only in the
working part from whom some return can be expected ;
furthermore, it definitely lays down that i incapacity for
work,' and not ill-health is the criterion for receiving
benefit, and that assistance ceases when capacity for
work is regained, though this by no means necessarily
connotes return to full health.

With the growth of knowledge and civilisation, the
primitive instinct of the savage to protect the national
health is reinforced by recognition of the influence disease
has in bringing about poverty, crime, inebriety, and other
evils. It is seen that when the bread-winner is laid low
by sickness, not only he but his entire family may become
a burden on the State ; the pathological element in much
crime is recognised ; and inebriety is more and more traced
to the degeneracy which results from a combination of
vicious influences. The Poor Laws contain an effort to
meet the destitution caused by disease, and the establish-
ment of criminal lunatic asylums is a recognition of the
fact that disease may be responsible for crime. Still later
in social progress it is recognised that in providing for the
health of the nation the State must look beyond the
existing generation. It is learnt that steps taken now
will act and react upon posterity for long periods, and that
the best way to provide sound health in the future is to
secure it in the infants and children of to-day. Though
long appreciated by students, the lateness of the State to
receive and act upon this conception is illustrated by the
fact that, in the history of Public Health efforts, measures
to protect the lives and welfare of infants were the last to
find a place.

Thus in numerous directions sound health is of the
greatest importance to a people, and may even determine
its very existence. And since the number of those who
cannot contribute to the general advancement of the
community, who, whether from disease or stunted growth,

12 HEALTH AND THE STATE

are unfit for military service or drop out of the industrial
army, or become a burden on the healthy, depends more
upon the environment than upon any other factor, the
responsibility for maintaining a healthy environment and
thereby reducing national waste to a minimum is one
which must be accepted by the whole community.

Health and Empire

So far we have been considering the survival value of
health in a people limited to one country, but the question
has aspects of still greater importance to a nation
with colonies and dependencies all over the world. The
influence of disease in fixing or modifying geographical
boundaries has been considerable ; and the present dis-
tribution of peoples on the globe has been largely deter-
mined by the prevalence of different diseases in different
areas. The white man has failed to colonise many of the
fairest and most fertile regions of the earth owing to the
deadly effect upon him of malaria, yellow fever, and other
tropical diseases ; and the negro when associated with
white communities suffers severely from tuberculosis.
But modern science has discovered the causes of many of
the diseases which have hitherto stood in the white man's
path, and has shown that they can be successfully attacked,
thus foreshadowing an entirely new era in colonisation.
Countries hitherto almost uninhabitable by Europeans
are now being rendered healthy and fit for occupation.
Already one striking result of the new knowledge has been
seen. De Lesseps and his successors failed to construct
the Panama Canal mainly because of the frightful mortality
from malaria and yellow fever among the labourers. But
the researches of Laveran, Koch, Manson, Koss, and
others on malaria, and of Reed, Carroll, Lazear, and
Agramonte on yellow fever, have shown that the parasites
of these diseases are conveyed by mosquitoes, and that by
taking precautions against the bites of these insects,
draining the pools and marshes which are their breeding
places, and preventing the development of the larvae by
covering the surface of stagnant water with petroleum,

HEALTH AND EMPIEE 13

both diseases can be practically eliminated. By adopting
such measures Colonel Gorgas, acting under the American
Government, was able to bring to a successful conclusion
one of the greatest engineering works of modern times.
Similar efforts in other countries have been equally success-
ful in reducing the incidence of these diseases, and there
is good reason to believe that science has now provided a
weapon which will enable mankind eventually to rid itself
of one of its most deadly scourges.

It is obvious that work of this sort not only ought, but
can only efficiently be carried out by the State. It is true
that the foundation work, the patient scientific research, can
be and usually has been conducted by individual effort
and initiative ; but without State assistance these efforts
are necessarily limited, and until quite recent years this
country has not been conspicuous for the help it has
rendered to scientific research, or for the rewards it has
bestowed upon those from whose labours it has derived
so great benefit. But the application of this knowledge
to a community demands funds, organisation, and control
which can only be provided by the State, whether it be
to reduce malaria or plague in India, blackwater fever in
West Africa, beri-beri in the Malay Archipelago, sleeping
sickness in Uganda, or yellow fever in South America.
To a very considerable extent indeed this has been realised
and acted upon, and colonising Powers are now setting
up laboratories at home for the study of tropical diseases,
and in their colonies are opening hospitals, establishing
State medical services, promoting sanitation, and spread-
ing knowledge of hygiene by means of leaflets, lectures,
and teaching in schools. Study of reports such as those
issued by the Advisory Committee for the Tropical Diseases
Research Fund reveals a most gratifying picture of the
energy which is being displayed in combating disease in
the remoter parts of the world. It is a remarkable fact
that it has been found possible in many colonies and
dependencies to take steps, such as the establishment of
State medical services, which vested interests have
rendered impracticable in mother-countries.

Still, there is another side to this picture. Our achieve-

14 HEALTH AND THE STATE

ments should be measured not by what we are doing, but
by what we might do having regard to our knowledge,
and we learn from the words of Sir Ronald Ross in the
Huxley Lecture for 1914, that we have still far from made
full use of that knowledge.1 After describing the extent
to which diseases are carried by insects and other organisms,
he said : " We now have a great sanitary ideal put before
us — so to manage our habitations, villages, towns, and
cities that the vermin in them shall be reduced to the
lowest possible figure. ... It demands only intelligence,
energy, and organisation on the part of administrators.
Unfortunately these qualities are not always forthcoming,
and administration often lags years behind the dictates
of science. Although fifteen years have elapsed since
many of the facts which I have described were discovered,
I think that I may say, after constant study of the subject
and with all due consideration, that mankind has hitherto
not effected more than about one-tenth of the improve-
ment of health which it might have effected already if it
had put its heart into the business. When I had com-
pleted my work in 1899, I had fondly dreamed that a few
years would see the almost complete banishment of
malaria from the principal towns and cities in the tropics
— that those benign climates and those beautiful scenes
would be almost rid at once of a scourge which had blighted
them from time immemorial. In this I have been dis-
appointed. True, much has been done in certain places,
as in Panama, Ismailia, Italy, West Africa, and parts of
India and the Malay States, and in some other spots ; but
much more might have been done had we remained fully
alive to our opportunities — and our duties. It is not the
fault of science that we do not fully utilise the gifts which
she gives to us."

Responsibility for the Health of Native Races

Apart altogether from colonial expansion or commercial

development, a great colonising Power like Britain is

under a strong moral obligation to protect the health of

subject races over which she rules, races of different colour,

1 Recent Advances in Science and their bearing on Medicine and Surgery.

HEALTH OF NATIVE KACES 15

diverse religions, and varied social customs. In regard to
India the obligation is all the greater since her native
troops have been called upon to fight in European war-
fare. In the main this obligation has been recognised and
much has been done to discharge it, but the terrible
ravages of disease in India and the Dependencies shows
that there is still vast scope for action. In India, during
the last eighteen years, more than eight and a quarter
millions of persons have died from plague, and seven
millions from cholera.1 Deaths from malaria have been
officially estimated at 1,200,000 a year in ordinary years,2
and since the case mortality is small the total number of
persons infected must be enormous. Tuberculosis is
considered by Dr. C. Muthu to cause an annual mortality
of over a million, and the rate has been steadily rising
since 1901. 3 In Uganda, sleeping sickness is estimated to
have caused 200,000 deaths between 1897 and 1906.
This country also provides an illustration of the tragic
consequences which may follow the abandonment of
native customs under the influence of European civilisation.
Before the British occupation of Uganda polygamy was
practised by the natives, and in consequence few women
were unprovided for, and there was little or no prostitution.
The introduction of Christianity led to the abandonment
of polygamy, removal of restrictions on the liberty of
women, and abolition of punishments for immoral offences,
with the result that a prostitute class came into existence,
and a devastating outbreak of syphilis occurred.4 Colonel

1 Report by Dr. R. W. Johnstone to the Local Government Board on the
Progress and Diffusion of Plague, Cholera, and Yellow Fever throughout the World,
1913. 2 Ross, op. cit.

3 " Tuberculosis in India," Practitioner, June 1915.

4 The Rev. J. Roscoe, C.M.S., Chief of the Theological College at Kampala,
who has spent twenty-five years in Uganda, says : "Among the Baganda up to about
twelve years ago a custom prevailed of keeping the women belonging to the tribe
under strict confinement and surveillance . . . hence immorality and promiscuous
intercourse did not exist. At approximately the time of the outbreak of syphilis
the chiefs of the Baganda tribe, the majority of whom had become Christians,
decided to remove these restrictions as being contrary to Christian teaching and
set the women free. This was done, and from that time the women were released,
henceforth to roam where and whither they willed, and do as they liked. The result
of the removal of these restrictions was exactly what one would have expected, i.e.
promiscuous sexual intercourse and immorality. I consider the above to have
been the main cause of the outbreak of syphilis among the tribes of the Protector-
ate."— Quoted by Col. Lambkin in A System of Syphilis, edited by D'Arcy Power,
F.R.C.S., and J. Keogh Murphy, F.R.C.S., vol. ii., 1908.

16 HEALTH AND THE STATE

Lambkin, who was appointed by the Government to in-
vestigate the conditions, estimated that more than half
the population of the Protectorate was infected, and that
in some parts of the country the incidence of the disease
was as high as 90 per cent, and was responsible for more
than half the total infant deaths. He concludes by saying
that : "In fact, as things stand at present owing to the
presence of syphilis, the entire population stands a good
chance of being exterminated in a very few years or left
a degenerate race fit for nothing." x

Sir Harry Johnstone has said of the Baganda tribe :
" In my opinion there is no race like them among the negro
" tribes of Africa. They are the Japanese of the Dark
" Continent, the most naturally civilised, charming, kindly,
"tactful, and courteous of the black people." Acting
under the best of motives, we have forced alien ideas
upon these people, and have interfered with their social
customs without taking due precautions for their safety ;
and the result has been that we have unwittingly caused
a hideous tragedy in the native villages of a country we
have rechristened a " Protectorate."

Health and Social Progress

We have considered the part which is played by health
in determining the military strength of a people, its
relation to other countries, and its colonising power, and
we must now note the not less important value of health
in internal affairs. The immense effect of sickness in
producing poverty is so well known, and has been so ably
investigated by many writers, that there is no need to
dwell further upon it here. On the other hand, the
influence of poverty in producing sickness has perhaps
been exaggerated. We shall see that it is quite possible
to be extremely poor and extremely healthy, and that
some of the healthiest classes in these Islands are among
the most poverty-stricken. The human species needs but
little to keep it in health — simple food, homely clothing.
and the rudest of shelters will suffice — though this is not

1 Op. cit.

HEALTH AND SOCIAL PROGRESS 17

to say comfort and happiness ; yet even these, health alone
will go a long way towards providing. Poverty acts as
a cause of disease mainly by compelling people to live in
an unnatural and unhealthy environment, and so long as
they remain in that environment neither Poor Law doles
nor sickness benefit will appreciably improve their health.

Much crime and vice has now also been shown to be
due to a state of degeneracy, one of the main factors in the
production of which is sickness. Dr. Goring 1 has shown
that there is no such thing as a criminal type, and we have
almost got rid of the notion that a tendency to commit
crime is inherited, save in a small proportion of persons
born with a definite pathological disorder such as feeble-
mindedness or epilepsy, a belief which was largely the
result of flagrant misunderstanding of various social in-
vestigations, as, for example, that made by R. L. Dugdale
into the history of the so-called 'Jukes' family.2 A
widespread improvement in health would lessen crime,
inebriety, and other vices, and relieve the State of part
of its burden in maintaining prisons, police forces, and
homes for inebriates.

In other directions sickness leads to loss of labour and
wages, added expense in production, diminished efficiency,
and waste of educational opportunity, for there are always
a considerable proportion of children away from school by
reason of ill-health.

We shall see in succeeding chapters that the largest
factor iD the causation of disease and mortality is a defec-
tive environment, particularly that of an overcrowded
town, and that a high proportion of sickness — not exactly
measurable, but probably not less than a third of the

1 The English Convict : a Statistical Study.

2 Professor Giddings, in his introduction to the fourth edition of The Jukes,
a Study in Crime, Pauperism, Disease and Heredity, says : " An impression quite
generally prevails that ' the Jukes ' is a thorough-going demonstration of ' heredit-
ary criminality,' ' hereditary pauperism,' ' hereditary degeneracy ' and so on. It
is nothing of the kind, and its author never made such claim for it. Far from
believing that heredity is fatal, Mr. Dugdale was profoundly convinced that environ-
ment can be relied on to modify and ultimately to eradicate even such deep-rooted
and widespread growths of vice and crime as the ' Jukes ' group exemplified."
The book shows quite clearly that those members of the family who lived under
vicious influences became criminals, paupers, and prostitutes, while those who had
opportunities of getting into a better environment became steady and industrious
members of the community, yet curiously enough it has been the illustration most
quoted by those who believe in the all-powerful influence of heredity.

C

18 HEALTH AND THE STATE

total — could be avoided by securing a healthy environ-
ment. The economy to the State which would result from
appreciably lessening sickness and disease would be very
large. At present we spend immense sums on sanatoria,
Poor Law infirmaries, public hospitals, medical services,
and sickness benefit, and to these must be added the
great volume of charitable donations which maintain
the voluntary hospitals, and private expenditure on medi-
cal treatment ; yet all this outlay, amounting to many
millions, does nothing to alter the environmental conditions
which are mainly responsible for disease, and very little to
prevent the spread of disease. A keener sense of sympathy
with suffering is probably the reason why so much greater
attention is now given to curative measures, but the earlier
policy of directing efforts mainly towards the prevention
of disease was the sounder, and in the long run is of the
greater benefit to the community.

The Decline in the Birth-Rate

There is yet another reason for urging national care for
national health, and that is the heavy and continuous fall
which has occurred in the birth-rate during the last thirty
or forty years. The effects which this fall will ultimately
have on the population are far from being generally
appreciated. Simultaneously with the decline in the birth-
rate there has been a fall in the death-rate, though not to
so great an extent ; and it has been generally assumed that
the low death-rate would continue and that, provided the
birth-rate did not fall below a certain point, there would
always be a comfortable margin between the two rates,
which would secure a reasonable annual increase of popu-
lation. But the question is not merely a simple one of
subtraction of death-rate from birth-rate. The ultimate
effect of a long-continued fall in the birth-rate is to raise
the average age of the population ; and as this rises, the
death-rate increases altogether apart from any environ-
mental conditions influencing disease. We see the effects
of this process in the relatively high death-rates in France
and Ireland, in the one case due to restriction of births,

DECLINE IN THE BIRTH-RATE 19

and in the other to long-continued emigration of the
younger people. Yet both these countries offer healthier
conditions of life than England, and their death-rates
when made truly comparable by standardisation are lower
than that of England. Thus sooner or later it seems
inevitable that we shall have a rise in the crude death-
rate in this country, and it is probable that the turning-
point has already been reached and passed, for the death-
rate after falling steadily for many years has been rising
since 1912.

The increase in the average age is not limited to the
death-rate in its effect. Eventually it begins to reduce
the proportion of women of reproductive age in the popula-
tion, which combines with deliberate restriction in still
further lowering the birth-rate. Hence with a death-rate
rising, a birth-rate tending to fall at an accelerated rate,
and the probability of extensive emigration after the War,
we are within measurable distance of a stationary if not
a declining population in this country.

The effect of the fall in the birth-rate is equivalent to
a loss of life immensely greater than has ever been pro-
duced by the most devastating epidemic, but since it is
not accompanied by the open horrors of an epidemic, the
matter is one which excites very little concern. The
causes of the decline in the birth-rate are well known, but
it is not easy to see what steps could be taken by the State
to arrest the process, and indeed it is very doubtful whether
any action by the State would be effective. There is one
school of opinion which considers that the fall in the birth-
rate has been highly beneficial to the nation, and actively
encourages its furtherance; but whatever views may be
held on this point, there can be no two opinions but that,
in view of the fall, the State should strive to make the
very best of the population which does come into existence.
No Government is in a strong position to go to mothers
and urge them to have more children so long as the infant
mortality rate remains at least twice as high as it need
be, and many thousands of young lives are sacrificed
annually to preventable causes.

20 HEALTH AND THE STATE

The Demand for Reduction of Disease

No big step in social progress is possible without the
active sympathy of large masses of the community, and
in this respect the movement for improving the national
health has the greatest support. Probably at no time have
men had so strong a sense of responsibility for others as
at present ; and the keen desire to relieve human misery
resulting from disease shows itself in the large army of
social workers who as members of Care Committees, Boards
of Guardians, Social Service Leagues, Societies for the
abolition of tuberculosis, syphilis, and other diseases,
hospital committees, infant clinics, medical aid institu-
tions, and other organisations, are devoting themselves
to helping their less fortunate fellow-creatures. Much of
this work is wasted owing to lack of coordination between
the different bodies, and sometimes to excess of zeal with-
out corresponding knowledge ; but the motive for these
efforts indicates an appreciation of national needs which
is the best augury for progress. It is certain that the
vast bulk of the people in this country do not want the
state of wretchedness at present existing among large
sections of the poor in big cities to continue. Demand
increases for vigorous attack on the evils which destroy
health ; and discontent is widely expressed with the half-
hearted measures adopted by Parliament, the unrealised
promises of Ministers, and the incompetence of official
administrators. Mr. Galsworthy has given voice to this
widely-felt sentiment in the following words : "I am
moved to speak out what I and, I am sure, many others
are feeling. We are a so-called civilised country ; we have
a so-called Christian religion ; we profess humanity. . . .
And yet we sit and suffer such barbarities and mean
cruelties to go on amongst us as must dry the heart of
God. I cite a few only of the abhorrent things done daily,
daily left undone ; done and left undone without shadow
of doubt against the conscience and general will of the
community — sweating of women workers ; insufficient
feeding of children ; employment of boys on work that
to all intents ruins their chances in after life, as mean a

DEMAND FOR REDUCTION OF DISEASE 21

thing as can well be done ; foul housing of those who have
as much right as you and I to the first decencies of life. . . .
And I say it is rotten that for mere want of Parliamentary
interest and time we cannot have manifest and stinking
sores such as these treated and banished once for all from
the nation's body. . . . Parliament is an august assembly
of which I wish to speak with all respect. But it works
without sense of proportion or sense of humour. Over
and over again it turns things already talked into their
graves ; over and over again listens to the same partisan
bickerings, to arguments which everybody knows by
heart, to rolling periods which advance nothing but those
who utter them. And all the time the fires of live misery
that could, most of them so easily, be put out, are raging,
and the reek thereof is going up." 1

Sympathy for manifest evils, and self - sacrifice for
others have no limit when the emotions are directly
stimulated. In a mining disaster, volunteers are always
ready to face almost certain death in order to rescue their
comrades. A few years ago a man was overcome by
deadly gases in a sewer. A fellow-labourer fully cognizant
of the danger at once descended to help him, but fell from
the ladder when halfway down ; another descended and
yet another. When eventually brought up, three of the
four were dead. Such acts of heroism, unexcelled by
anything done on the battlefield, serve to show the strength
of the social spirit among us. The difficulty is to arouse
this spirit against evils of which the knowledge must be
conveyed through the intellect and not by the immediate
stimulus of the emotions. Many who would spare no
effort to help a person injured in the streets before their
eyes, will read quite unmoved a statement that, " the
hospital provision in England is seriously inadequate."
Only those who know by experience what these words
mean — -the sickening delays, the anxiety of those waiting
for surgical treatment, the needless suffering, and even
loss of life — appreciate their tragic significance. The daily
record of horrors from the battlefield leads all classes to
contribute from their wealth or services to the assistance

1 Times, February^28, 1914.

22 HEALTH AND THE STATE

of wounded soldiers, but we do not hear of great houses
being placed at the disposal of men injured in a colliery
disaster, or of aristocratic ladies ministering to sick cotton
spinners of Lancashire, yet both these classes risk life
and health in doing work which is essential for national
welfare. The sympathy for them certainly exists, but the
stimulus needed to evoke it is lacking. This aspect of
the human mind has been finely expressed by Mrs. E. B.
Browning in Aurora Leigh :

A red-haired child
Sick in a fever, if you touch him once.
Though but so little as with a finger-tip,
Will set you weeping ; but a million sick . . .
You could as soon weep for the rule of three,
Or compound fractions.

Knowledge of the Means of preventing and
curing Disease

Desire to prevent or cure disease would be of little
effect without knowledge of the means by which these ends
can be achieved, and of this knowledge we now possess a
large store. Medicine has still much to learn ; the problem
of cancer remains unsolved, and the cure for many diseases
has yet to be discovered, nevertheless the advances made
during the last thirty or forty years have been unprece-
dented. Surgery, in particular, has saved many thousands
of lives and done much to repair the crippling effects
of disease ; serum therapy and kindred methods have
proved their curative value in diphtheria and their preven-
tive effects against tetanus and typhoid under the severe
test of war ; bacteriology has furnished new means of
determining the presence of grave diseases ; and X-rays,
light rays, and radium have provided potent aids to
diagnosis and treatment. Not less great, too, have been
advances in knowledge of preventive medicine. We are
still uncertain of the ways in which many diseases are
transmitted, and the whole subject of infection demands
further study, but statistics now enable us accurately to
recognise unhealthy occupations and locate disease-propa-
gating areas. The refinements of chemistry and physics

THE FAILURE TO APPLY KNOWLEDGE 23

have provided new methods of examining water, analysing
foods, testing the condition of the air, and disposing of
refuse and sewage.

The Failure to apply Knowledge

For securing sound Public Health, then, two important
conditions are fulfilled : there is first the widespread desire
among all classes to reduce sickness and disease, and there
is the knowledge furnished by science, which should enable
that end largely to be attained ; but when, bearing in mind
these facts, we survey the actual condition of large masses
of the English people to-day, the relatively small extent
to which that knowledge is utilised for the public welfare
is little short of amazing. We know that bad housing
and, particularly, overcrowding are fruitful causes of
disease, but all our large cities exhibit huge slum areas,
dirty, dismal, and unhealthy, where the infant mortality
rate reaches a height which would disgrace a savage people,
and where the efforts of local authorities, hampered by
vested interests, succeed only in clearing tiny areas often
after years of negotiation. We know that pollution of
the air is a serious evil to health, yet our laws make only
the discharge of black smoke from a factory chimney an
offence, and brown or yellow smoke may be emitted in
any volume with impunity ; our methods of collecting
dust are primitive, and we allow household refuse to be
tipped into open carts, and dust-carts to pass through the
streets at all times of day, filling the air with a cloud of
filth at every gust of wind. We know that pure milk
should be one of the staple foods of all young children,
yet the reports of the Local Government Board show that
something like 10 per cent of the samples analysed are
adulterated, while 10 per cent contain the bacilli of tuber-
culosis. We know the harmfulness of eating adulterated
food, yet adulteration was probably never more widespread
than it is to-day, many of our commonest foods being
habitually sophisticated, while the laws intended to prevent
this practice are ineffective, and the penalties imposed
upon offenders are usually quite inadequate. We deplore

24 HEALTH AND THE STATE

the ignorance of mothers and we try to encourage breast-
feeding, and at the same time we allow vendors of patent
foods for infants to placard every hoarding with lying
advertisements of their wares. We declaim against in-
temperance, while we permit ' medicated ' wines to be
sold widely to the ignorant under the pretence that they
are beneficial to health. Our general water-supply and
the drainage systems in most towns are in fact the only
directions in which we have attained the standard of
excellence demanded by modern knowledge. The pro-
vision for curative treatment is equally out of accord with
what we know to be required. In spite of the good work
done by the voluntary hospitals and many infirmaries,
the numbers of beds available in institutions for the sick
is insufficient to meet the needs of the community. The
medical inspection of school children only covers a part of
the field, and the arrangements for medical treatment of
the children are still less complete. The more scientific
methods for diagnosing disease, and the services of
specialists in various directions are beyond the reach of
large masses of the people ; and the medical treatment
provided through the Poor Law or Insurance systems is
thoroughly unsatisfactory in many districts.

If the application of our knowledge bore a reasonable
relation to its amount, we should have a vigorous and
healthy population, whereas the true state of affairs is
revealed by the returns of infant deaths, the deplorable
condition of school children in towns, and the high pro-
portion of would-be recruits who are rejected from military
service. We are apt to get an exaggerated idea of the
health of the people and of the effects of administrative
measures which have been taken in the past, partly because
nearly all our blue books and official reports on Public
Health, issued by those responsible for the establishment
or working of these measures, are distinctly partisan and
often very unscientific in their statements and claims ; *

1 A well-known writer in The New Statesman, criticising the Second Annual
Report of the Insurance Commissioners, says : " In short the Report is so success-
ful in failing to afford any picture of how the Act is working, that we are driven to
the inference that it has been no less successfully ' edited ' with the intention of
revealing no significant facts or crucial points that have not already been published
in Ministers' answers to questions or otherwise." The Annual Reports of the

THE REASONS FOR THE FAILURE 25

and partly because of the inveterate habit of politicians
and reformers when speaking on Public Health to draw-
glowing comparisons with conditions in past times. We
are continually reminded of the fall in the death-rate,
the disappearance of typhus, and the decline in tuberculosis,
for all of which credit is given without any hesitation to
administrative measures, though, as we shall see in the
next chapter, often with little foundation. But the past
is not the right standard of measurement ; comparison
should be between what we do and what we might do if
we made full use of our vast stores of knowledge. We
have no more right to take credit because things are
better than they were fifty years ago, than we should
have if we armed our soldiers with muskets, and pointed
with pride to the fact that they were a great improvement
on bows and arrows.

The Reasons for the Failure

To trace the reasons for the failure to make the best
use of medical and Public Health knowledge is the main
object of this book. The task is not easy, for the factors
operating are too diverse and yet too interwoven in their
effects to permit of a simple scheme in setting them forth ;
moreover, it will be necessary as we go along to establish
scientifically, as far as possible, various statements briefly
summarised in the preceding pages, many of which will
have appeared too sweeping at first sight.

Broadly speaking, the reasons why results in Public
Health have been so incommensurate with efforts are
three in number : viz. the opposition from vested interests ;
the complexity of Public Health administration ; and the
want of expert knowledge in those who frame the laws
and those who administer them. Vested interests offer
difficulty to Public Health progress in many directions.
Reference is not made here to the unscrupulous member
of a Local Authority or Board of Guardians who uses his
position to further his own private ends, or to the dis-

Registrar-General and the scientific monographs on Public Health subjects issued
from time to time by the Local Government Board must be exempted from the
general criticism made in the text.

26 HEALTH AND THE STATE

honest trader who adulterates the food he sells, but to the
much larger legitimate interests which the sense of justice
of the community, now or in past times, has decreed shall
not be disturbed without due compensation. There is
the landlord or house-owner, who is entitled to the highest
rent he can get, although overcrowding and bad housing
result ; there is the Borough Councillor, himself often a
tradesman, who, without any personal end, naturally
inclines towards the protection of trade interests ; there
is the factory-owner, in whom it would be sheer altruism
to do more for the health of his employees than is required
by the law ; and there is the doctor, who having built up
a practice by his own efforts, fights legitimately against
proposals to establish medical services which appear to
threaten his interests. These are well-recognised instances,
but in many less obvious ways vested interests, perhaps
quite low down in the social scale, make their appearance
and impede Public Health progress. Even the dustmen
have successfully resisted innovations in the system of
collecting dust which seemed likely to reduce their per-
quisites.1 The effects of vested interests upon Public
Health will be described in later chapters, but the methods
of overcoming these interests, with due observation of the
principles of justice, are economic questions which do not
concern this book.

The complexity of Public Health administration is a
result of the piecemeal way in which the Public Health
system has grown up in this country. The health of the
people and causes of disease have never been dealt with
as a whole, but the legislature has at different times made
provision for different groups of people and for treating
different diseases ; and as each new measure has been
adopted, the duty of carrying it out has, in the absence of
one central administrative authority, been thrust upon
some Department perhaps established originally for a
totally different purpose, or has been assigned to a new

1 The authorities of a certain town recently proposed to establish a system by
which a cart, especially built to hold a number of bins, would deposit an empty
one at each house and take away the filled receptacle without its being opened.
The dustmen, however, raised strong opposition, and it was found that they claimed
as a perquisite the right to pick over refuse and take bottles, tins, etc. A strike
was threatened, and the project was in consequence abandoned.

THE REASONS FOR THE FAILURE 27

authority created ad hoc. The consequence is, that the
central administration of Public Health is divided up
among eight or ten different Departments, uncoordinated
to an extent which is known only to those who have had
actual experience in a Government Office. Some of these
Departments do not know what the others are doing or
have done ; some are working in contrary directions ; and
sometimes they produce reports on the same matter
leading to different conclusions, or sets of statistics hope-
lessly at variance with each other, — all factors which com-
bine to produce friction, delay, and inefficiency. Locally, the
confusion is repeated owing to the division of Public Health
administration among Local Sanitary Authorities, Educa-
tion Authorities, Boards of Guardians, Insurance Com-
mittees, etc. The needless multiplication of officials puts
the country to unnecessary expense ; and the long delays,
the overlapping in some directions and the absence of
control in others, the discouragement of effort, and the
difficulty of denning responsibility, seriously prejudice
the public welfare ; while, in the chaos, vested interests,
ignorance, and apathy find their season.

Want of knowledge among legislators and adminis-
trators is in some respects the greatest hindrance to Public
Health progress, since it not only leads to costly and in-
effective legislation, but tends to popularise erroneous
views on the causation and prevention of disease, and
obscure the real factors which are working. The science
of hygiene is complex, and when its principles are grasped,
the applicability of these principles to the populace
demands further study. The practical effect of a par-
ticular step may be widely different from the result it
should have in theory ; and its actual results can often
only be foreseen by those who have intimate knowledge
and experience of the conditions and persons to whom it
is to be applied. But Parliament has no special means
of acquiring this knowledge, no body of experts from
which it can obtain information or to which it can refer
Public Health Bills for criticism. Sometimes it appoints
a Royal Commission to investigate a particular point, a
tedious and by no means always satisfactory form of

28 HEALTH AND THE STATE

procedure ; but often it appears to be believed that any one
without any special knowledge or experience of the subject
is competent to legislate upon the highly complex problems
involved in Public Health measures. A Minister may
introduce a Bill without any previous expert inquiry into
its probable effects having been made ; he may or may not
consult some of the medical officers in the Government
Departments, and if he does consult them he may dis-
regard their advice without letting it be known that he is
acting contrary to their opinion ; the Bill passes through
a House in which again it receives very little expert or
scientific criticism, and its administration as an Act is
entrusted to a Department of the Civil Service in which
medical and scientific knowledge is only permitted to
exercise a strictly limited and subordinate influence.

The result is that gross mistakes are made and huge
sums spent for wholly incommensurate return. Parlia-
ment established a vast scheme for sanatorium treatment
of tuberculosis at a time when investigation of German
experience alone would have shown that this form of treat-
ment is of very little value among working classes who
continue to live under bad conditions ; and in the same
Act it endeavoured to set up a scheme for penalising
persons responsible for sickness, which, as will be shown
in a later chapter, is wildly impracticable. It forgot the
existence of the Metropolitan Asylums Board, and it
apparently did not know that maternity may be a cause
of sickness. The mistake of taking sickness rates as the
same for men and women was an elementary one which
should never have been made, for every doctor could have
furnished information that women, especially married
women, suffer more from sickness than men ; and though
there were not sufficient statistics of sickness payments in
existence to enable a precise actuarial estimate of the
difference to be made, there were large statistics available
of medical attendance upon members of Friendly Societies
from which a very fair approximation of the difference
could have been obtained.1 These mistakes were made

1 Mr. Roberts, the Chairman of the National Insurance Joint Committee, has
recently given an entirely new and singularly interesting explanation of the way in
which these two rates came to be taken as the same. Speaking in the House of

THE EEASONS FOR THE FAILURE 29

in the Insurance Act, but other errors will be indicated in
the legislation relating to purity of food, infant mortality,
and disease, while the errors of omission which permit
grave abuses to continue unchecked year after year are
even more serious.

Another effect of the doubt which Parliament feels in
its competency to deal with medical affairs is seen in the
growing tendency to make a broad statement in an Act
and leave all details to be settled by an administrative
Department, which thus comes to possess almost legisla-
tive powers. Parliament lays down that an insured person
shall be entitled to ' adequate medical treatment,' with-
out further qualifying the words or indicating their scope,
and the Department which administers the Act proceeds
in accordance with official tradition to give them the barest
possible minimum of effect. The obscurity with which
an Act may be drafted may also have serious consequences.
Writing seven years after the passing of the Act for pro-
viding meals for school children, the Chief Medical Officer
of the Board of Education says : " The Act of 1906 . . .
was so worded as to make it at least doubtful whether they
[Local Authorities] could legally provide children with
meals on days when the schools were not open." x It is

Commons on June 20, 1916, he said : " In the case of the women there was no such
statistical base to go upon. It is true that some facts were alluded to in the
actuarial report, but they were imperfect ; though they appeared to point to a
rate of sickness similar to that of the men. Some precautions were taken, and the
actuaries proposed that there should be a margin of 31 per cent above the figures
shown, but the House of Commons during the stages of the Bill reduced the margin
to 24 per cent. It has been proved, especially in the case of married women, that
the excess is even higher than that, but before this House blames the Government
for that, I would ask hon. members to recollect what the conditions were in 1911.
In that year an agitation was raging in the country which, I think, would have
fixed hold of my proposal to differentiate between men and women as a gross
injustice. There were no facts available to justify such a differentiation which the
actuaries could point to ; if in spite of this the Government had decided to treat
the women with far less liberality and generosity than the men, and if such a
proposal had been brought down to the House of Commons, I do not think it would
have survived an afternoon's discussion. That, I think, is the defence on that
point."

This is a frank admission, which, while it exonerates the actuaries, illustrates
the loose way in which Public Health measures may be dealt with. The Govern-
ment apparently knew that their proposals were financially unsound, though they
did not know precisely to what extent ; but, influenced by a popular agitation, they
preferred to over-ride expert opinion, keep their knowledge to themselves, and let
it only be discovered later by experience, to the great embarrassment of Approved
Societies.

1 Annual Report for 1913.

30 HEALTH AND THE STATE

pitiful to think that Parliament should not have made its
intentions clear in a matter upon which depended whether
or not many children should go hungry.

Many grave mistakes will yet be made in Public Health
legislation, for medicine has far from reached finality, and
the views held by the highest authorities to-day may be
proved erroneous to-morrow. Much study is still required,
and doctrines seemingly established for all time must
continually be called in question, but we can at least
secure that at any moment the best knowledge available
shall serve as the basis of legislation. Our medical men,
bacteriologists, professors of Public Health, experts in
sanitation, and scientists do not want to order or control
the lives of their fellow-citizens ; but the representatives of
those citizens will do well if they establish a system by
which they can draw readily from the accumulated wealth
of medical and sanitary knowledge before they legislate
for the common good.

CHAPTER II

NATURE AND DISEASE

Evolution against disease : typhus ; smallpox ; enteric fever ; scarlet
fever ; diphtheria ; tuberculosis ; syphilis — The problems of infection —
The futility of disinfection — The assurance of the layman — The evils
of exaggerated claims.

Evolution against Disease

In succeeding chapters we shall discuss the value of
the efforts which have been made by the community to
reduce or eradicate disease. It is important, however, as
a preliminary step to study the great part which Nature
herself plays in bringing about these ends, since, if this is
not done, the mistake may be made of assuming that all
diminutions of disease have been due to our own efforts,
and this in its turn may lead to legislative and administra-
tive action built upon false analogies and wrong inferences.
Silently, often unobserved, and often not understood
when observed, Nature has for long ages been increasing
men's power to fight against the diseases to which their
environment exposes them ; probably through a process of
natural selection which results either in an increased degree
of immunity against the disease, or in an increased capacity
to recover from the disease when attacked. Various
aspects of this evolutionary process have been dealt with
by Metchnikoff, Karl Pearson, and others, and the whole
subject has been examined in a masterly way by Archdall
Reid. The process is most easily observable in native
races, where the influence of Nature has not been overlain,
or obscured, by the conscious action of the community.
Among such peoples, diseases newly-introduced may have
a devastating effect, though these same diseases are rela-

31

32 HEALTH AND THE STATE

tively trivial among peoples who have had a long racial
experience of them. Measles is a deadly disease among
the Polynesian Islanders, epidemics sometimes decimat-
ing whole communities : vaccination is highly dangerous
among the Esquimaux who have had no racial experience
of smallpox, and die from the effects of even its attenuated
form. A similar effect is seen in the increased mortality
from tuberculosis of the negro, or the Kalmuck of the
Russian Steppes, when brought in contact with civilisation
in white men's towns. As Archdall Reid has pointed out,
there is nothing mysterious in the disappearance of the
Red Man, the South American Indian, or the Caribbean
before the march of the white man ; they have not died
by the sword, nor from ' domestication,' but from in-
ability to resist the sudden invasion of the white man's
diseases. The same relative lack of resistance is exhibited
by white men when exposed suddenly to native diseases ;
the British civil servant, for example, suffering far more
from malaria in West Africa than the racially-acclimatised
native.

Broadly speaking, the power of a race to resist a disease
is proportional to the length of time the race has had
experience of it ; and there is no doubt that this
evolutionary process has been going on as much among
civilised as among native peoples. It has long been recog-
nised that most infectious diseases tend in course of time
to ' wear themselves out,' and the decline in virulence or
extent of tuberculosis, syphilis, and other maladies must,
in part at least, be attributed to this process. A shallow
argument has been based upon these observations, viz.
that our efforts to prevent and cure disease are unsound,
and that we ought to leave natural selection unimpeded
to work towards the evolution of a disease-free people.
But to reason thus is to show entire misconception of the
relations between heredity and environment in disease.
Our right course is to study Nature in relation to each
individual malady, and to make her yield up her secrets.
Then we shall find that often we can work in co-operation
with her, and indeed sometimes accelerate her efforts.
An example has already been given in malaria. Nature, if

EVOLUTION AGAINST DISEASE 33

left unaided, would probably in the course of time eliminate
this disease from the human race ; but science has now
furnished us with precise knowledge of its causes, and, if
we can succeed in applying that knowledge sufficiently
widely, we can probably do in a few years what would
have taken Nature as many thousands.

The influence of Nature upon disease is not restricted
to producing changes in the resisting power of human
beings. There is good reason to believe that bacteria and
other pathogenic micro-organisms themselves undergo
evolutionary processes pari passu, and this further com-
plicates the investigation of the essential causes and
tendencies of diseases. Bacteriology is a new science,
and much has still to be learnt about the changes which
bacteria undergo even in comparatively short intervals of
time ; but of the experimental and clinical observations
there is no doubt. In the laboratory bacteriologists can
now raise or lower the virulence of infective organisms at
will by passing them through various animals or subjecting
them to certain processes. The study of epidemiology has
shown that a pathogenic organism under natural conditions
may exhibit a wide range in virulence. Some epidemics
of a disease are attended by a high death-rate ; others
of the same disease, under apparently similar conditions,
cause only a low death-rate, for no reason which we can
suggest other than a change in the infecting organism
itself. A severe epidemic of smallpox may be attended
with a case-mortality of 30 per cent or more, while in
other epidemics the disease may be scarcely distinguish-
able from chicken-pox, and in an epidemic in Sydney, in
1913, among a largely unvaccinated population, there
was only one death in a thousand cases. Sometimes the
virulence of a disease exhibits no constant trend, but
varies from place to place and time to time ; with other
diseases the virulence may show a steady decline over a
large area. A good example of the latter is afforded by
the downward course of scarlet fever in England during
the last twenty years, and probably on an even larger
scale by the decline in tuberculosis in most civilised
countries during the past half-century.

I)

34 HEALTH AND THE STATE

When two processes towards the reduction of disease,
viz. the influence of Nature and the efforts of the com-
munity, are going on side by side, it must necessarily be
at times very difficult to allocate to each its real share
in the final result. Of some diseases we can speak with
considerable assurance : we have little reason to doubt
that the decline in the mortality from scarlet fever has
been due chiefly to a natural process, or that the reduc-
tion of typhoid fever has been brought about mainly by
our achievements in sanitation ; but of most other diseases
our knowledge is still too scanty for definite conclusions
to be drawn.

The last fact is one which is not generally appreciated,
with the result that when a disease is observed to decline,
and when during the period of the decline measures
have been in force intended to reduce that disease, the
assumption is invariably made that the decline of the
disease has been due to these measures ; and therefrom
the' further conclusion is drawn that similar measures
applied to other diseases will be equally beneficial. Claims
which cannot be substantiated scientifically are continu-
ally made. Ministers when introducing Public Health
measures in Parliament, and social reformers when urging
Public Health changes, point with pride to the decline in
the death-rate, and claim it as the result of sanitary
efforts ; though if this is the whole explanation, the rise
in the death-rate which has occurred since 1912, and is
likely to continue from causes wholly unconnected with
sanitation, must equally be attributed to some failure to
maintain these efforts. Similarly the disappearance of
smallpox is ascribed without doubt to vaccination ;
typhus has gone because we have cleaned and purified
our cities ; the reduction of tuberculosis is due to im-
proved housing, disinfection, etc. ; and the decline of
infant mortality is attributed to notification of births,
instruction of mothers, and similar measures. The dis-
appearance of leprosy alone is not claimed as a result
of sanitary efforts, probably because it is too well
known that the disease vanished long before there was
any effective Public Health organisation in existence,

EVOLUTION AGAINST DISEASE 35

and while general conditions were still filthy and in-
sanitary.

It is true that the standardised death-rate has fallen
substantially in the last half-century. During the period
1866 to 1870 it averaged 21*2 per thousand, while for the
years 1910 to 1914 the average was only 135 per thousand,
but we cannot be dogmatic as to the causes of this decline.
We do not know the extent of natural influences, and
it is possible that modern surgery, which saves many
thousands of lives annually, has played a larger part than
sewers. It would be unjust to the memory of Chadwick,
Farr, Simon, Shaftesbury, and other pioneers to under-
estimate the value of sanitation. But we now possess
knowledge which was not open to these men, and we are
no longer justified in generalising about disease in the way
which was the only course possible half a century ago.
We know now that different infectious diseases differ in
their degrees of infectivity, and in the conditions under
which they are conveyed to man, and that they demand
different methods for their prevention. Notification and
isolation have undoubtedly been valuable means of check-
ing smallpox, but have been of no use in reducing the
prevalence of scarlet fever or diphtheria ; and notification
of tuberculosis has probably done more harm than good,
since it has created a grossly exaggerated fear of infection
in the public mind, has increased the difficulties of
notified persons in getting work, and yet has not com-
pensated us for these drawbacks by providing statistics
of any value. Some of these statements are far from
being in accord with popular opinion, and as they will be
received with scepticism, it seems desirable to support
them by tracing the course of the commoner infectious
diseases in England and Wales during recent years, and
quoting opinions of those who have closely studied their
epidemiology.

Typhus is a disease which at one time was very prev-
alent in England and Wales, and its tendency to attack
crowded aggregates of human beings is shown by its old
names of 'gaol-fever,' 'hospital-fever,' and 'camp-fever.'
Until 1850, when Jenner at the London fever hospital

36 HEALTH AND THE STATE

confirmed the earlier work of Gerhard, Stewart, and
others, typhus was not distinguished from typhoid fever,
and it was not until 1869 that the Kegistrar - General
separated the two diseases in his reports. Accordingly,
our statistical knowledge of typhus only dates from that
year. It was believed until recent years that typhus was
transmitted through the air ; and this was held to be
supported by the observed fact that close proximity to
infected persons greatly increased the risk of contracting
the disease, judges and barristers often catching it from
infected prisoners in court, while many doctors and nurses
have died from the disease while attending patients.
But we now know that the body-louse is the principal, if
not the sole agent in the transmission of typhus, and
nearness to an infected person increases the risk simply
because it facilitates the passage of the louse from one
person to another. Defective sanitation and bad housing,
which are always held responsible, are not direct causes of
the disease, any more than are swampy districts the cause
of malaria, but only in so far as they militate against per-
sonal cleanliness and lead to overcrowding. Nor does a
poor state of health from living in insanitary surround-
ings appear markedly to predispose towards typhus, for
doctors and nurses suffer as severely as other classes.
A writer on the subject many years ago pointed out that
"close proximity to, and contact with the infected in-
dividual and his dirty belongings lead with great certainty,
even under the best sanitary circumstances and in a
healthy, well-fed people, to an attack of typhus."1
According to Sir William Osier, no other disease has
claimed so many victims among the medical profession.2

Typhus did not decline regularly in England and Wales,
but fell very markedly and abruptly during the decade
1869-79. Its course since tabulation of the disease began
is shown in the following table :—

1 Supplement to Forty-fourth Annual Report of the Local Government Board.

2 Under war conditions the mortality is often very heavy. Dr. Caldwell,
Sanitary Commissioner to the American Red Cross in Serbia during the typhus
epidemic in 1915, states that 160 members of the Serbian medical profession out
of a total of 340 died from the disease. Doctors and nurses sent by other
countries suffered as severely; five of the American physicians lost their lives,
and in one Red Cross unit eleven out of fourteen nurses contracted the disease.

EVOLUTION AGAINST DISEASE

Mortality from Typhus : England and Wales

37

Year.

Deaths.

Year.

Deaths.

1869

4281

1885

318

1870

3297

1886

245

1871

2754

1887

211

1872

1864

1888

160

1873

1638

1889

137

1874

1762

1890

151

1875

1499

1891

137

1876

1165

1892

85

1877

1104

1893

137

1878

906

1894

115

1879

533

1895

58

1880

530

1896

71

1881

552

1897

49

1882

940

1898

47

1883

877

1899-1906

39*

1884

328

1907-1914

11*

* Annual Average.

It will be noticed that the mortality from typhus fell
from 4281 in 1869, to 533 in 1879, and it is by no means
easy to find a satisfactory reason for this large and rapid
decline. Dr. Brownlee of the Medical Research Com-
mittee says : "I think the disappearance of typhus was
" as much due to natural causes as to sanitary endeavour.
" It is difficult to offer proof of either statement . . . , but
" the fact that the disease disappeared from the West
" Highlands and from the West of Ireland at the same time
" as it died out in England, suggests that some change in
" the organism was at least of as much importance as the
" application of sanitary measures." x Dr. Bruce Low
of the Local Government Board says : " It is not very
" evident what has caused this very marked diminution of
" typhus fever in England and Wales. No special measures
" have been taken against the malady, beyond isolation of
" cases in hospital and disinfection of dwellings and, in
" later years, of clothing and bedding. The decrease of
" typhus fever in this country has, however, followed close
" upon the march of sanitary progress subsequent to the

1 " Periodicity of Infectious Diseases," Public Health, March 1915.

14

5574

38 HEALTH AND THE STATE

"passing of the Public Health Acts of 1872 and 1875." 1
The last sentence, though very cautiously worded, might
be taken to suggest that these Acts had played a part in
bringing about the reduction, but it is difficult to see that
this could have been the case. A substantial fall had
occurred before the earlier of the Acts was passed, and for
the first few years the working of these Acts was very
incomplete. It is on record for example that the great
majority of the Medical Officers of Health first appointed
were simply part-time general practitioners, who could
not have had special knowledge of sanitation. Moreover,
we know that the primary agent in the transmission of
typhus, the body-louse, is to this day widely prevalent in
the poorer quarters of all large towns. With so much
uncertainty as to the causes of the decline, it may be
suggested that if about 1870 any process of protective
inoculation against typhus had been widely adopted, it
would almost certainly have been claimed as the cause of
the reduction, and we might still be insisting upon the
observation of such a measure.

These considerations show that we are dealing with a
very obscure problem. It is difficult to believe that a
change in the resisting powers of human beings can have
occurred in so short a space of time, but the rapid multi-
plication of bacteria, which compresses many generations
into a short interval, renders quite conceivable a change
in the virulence of the organism ; nor is it outside the range
of possibility that there has been a change in the constitu-
tion or habits of the louse itself. We have still much to
learn, but we probably now know sufficient to prevent an
epidemic of typhus from ever occurring again in this
country. The disease, too, is one which has ravaged
armies in the past, and we can justly take credit for the
almost complete freedom from it of our troops in the
present war, even under conditions favourable to an
outbreak ; but the claim, so often made in an eloquent
peroration, that " the disappearance of typhus is one of
the greatest triumphs of modern medicine " cannot be
substantiated by scientific investigation.

1 Supplement to Forty-fourth Annual Report of the Local Government Board.

EVOLUTION AGAINST DISEASE 39

Smallpox has been the subject of long and bitter con-
troversy regarding the causes of its decline. No reason-
able person, reading impartially the history of this terrible
disease, can doubt that vaccination played an appreciable
part in reducing its prevalence ; but it is open to argument
whether this precaution is still essential purely as a pro-
phylactic, though it is of course important during an epi-
demic among persons brought in contact with the disease.
When vaccination was first established in this country,
sanitation was still very defective, clinical knowledge was
not nearly so great as at present, doctors might easily
overlook anomalous or slight cases, and the facilities for
isolation and treatment were wholly inadequate. Under
these circumstances it was of great value. But we now
have more skilled diagnosis, and facilities for prompt
isolation of infected persons and those who have been in
contact with them. As year by year the proportion of
unvaccinated persons in the community increases without
serious epidemics, the opinion steadily grows that rigid
enforcement of these measures is sufficient to prevent an
epidemic if the disease is accidentally introduced. Dr.
Millard, the Medical Officer of Health for Leicester, has
ably stated the arguments in support of this view.1,

But while admitting the great value of vaccination in
the past, we cannot ignore the possibility that natural
influences have contributed to the reduction of smallpox.
Dr. Thomas Gibson, the Medical Officer of Health for
Wakefield, says : " The slackening off in the law with
regard to vaccination which has been a feature of recent
years, is, I am sure, viewed with considerable misgiving
by most of us. At the same time, having regard to the
modifications which diseases appear to undergo in the
course of time, I am not sure that it is wise to prophesy
as some do the certainty of a terrible retribution for the
increasing neglect of vaccination. To refer back to
typhus for a moment, although that disease was one
strikingly associated with privation and overcrowding,
I am not at all satisfied that the improvements in the
economic and housing conditions of the people have been

1 The Vaccination Question in the Light of Modern Experience, 1914.

40 HEALTH AND THE STATE

in themselves sufficiently great and potent to account
for the very marked reduction in the prevalence of the
disease. It is more likely that improved sanitation has
acted as a powerful auxiliary to a natural tendency in the
disease to die out — call it immunity or what you like, —
and it is just possible that vaccination has been working
alongside and augmenting in the process of time a similar
tendency in smallpox." x

Enteric fever was responsible in 1874 for a mortality
of 374 per million living, but the death-rate has fallen
almost uninterruptedly since that year, and in 1914 it
was only 46 per million. The decline in this disease is
perhaps our greatest and most definitely-proved achieve-
ment in sanitation. Enteric or typhoid fever is probably
almost solely conveyed by food or water, and the estab-
lishment of a pure supply of drinking-water has been by
far the greatest factor in its diminution. During recent
years we have learnt that certain persons termed ' carriers,'
who are apparently in good health, but are chronically
infected with the organisms of the disease, may act as
centres of infection, particularly if they are employed as
milkmen, cooks, etc., in the handling of food. The diffi-
culty of dealing with these persons is very great, but were
it not for this source of infection, typhoid fever would
possibly be completely stamped out in England in the
course of a few years.

Scarlet Fever. — The death-rate from this disease has
been steadily and rapidly falling for the last fifty years,
having been 960 per million persons in England and Wales
during the period 1866-70, and 63 per million during
1910-14. There are good reasons for believing that this
decline has been due mainly to a change in the virulence
of the organism ; but to examine this point it is preferable
to deal with a group of the population which has been more
or less under constant conditions, and to state the mort-
ality in terms of the number of cases of the disease, since
this eliminates variations due to its varying prevalence
from year to year. The cases treated in the hospitals of
the Metropolitan Asylums Board form a useful unit for this

1 Public Health, April 1915.

EVOLUTION AGAINST DISEASE

41

purpose, and the steady decline in the mortality among
these cases is shown in the following table : —

Scarlet Fever : Mortality per cent of Patients treated in
the M.A.B. Hospitals

Year.

Case Death-rate
per cent.

Year.

Case Death-rate
per cent.

1875-1879

13-5

1897

4-1

1880

12-3

1898

4-1

1881

11-1

1899

2-6

1882

10-4

1900 •

3-0

1883

12-4

1901

3-8

1884

12-3

1902

3-4

1885

9-5

1903

3-1

1886

9-0

1904

3-4

1887

9-5

1905

3-3

1888

9-9

1906

2-9

1889

8-9

1907

2-8

1890

7-9

1908

2-6

. 1891

6-7

1909

2-3

1892

7-3

1910

2-3

1893

6-1

1911

1-9

1894

5-9

1912

1-6

1895

5-4

1913

1-2

1896

4-3

1914

1-4

It will be noticed that since 1884 there has been an
almost uninterrupted fall in the case death-rate ; and in
thirty years scarlet fever has become a less deadly disease
than either measles or whooping - cough. This change
has occurred in persons drawn from the same districts,
living under practically constant conditions and treated
in essentially the same manner. There has been no great
medical discovery for the treatment of scarlet fever such
as has been made in the case of diphtheria, and indeed, in
uncomplicated cases, there is very little opportunity for
purely medicinal treatment, the essential conditions for
recovery being skilful care and nursing ; nor can the
decline be attributed to improvements in the latter, for the
high standard of nursing established quite early in the
Board's hospitals left little scope for advance. It is as
certain as anything in medicine can be, that the decline in
the mortality from scarlet fever has been due to some

42 HEALTH AND THE STATE

change in the infecting organism which has appreciably
reduced its virulence.

Diphtheria is another infectious disease which has
shown a great decline in mortality during recent years,
but the causes of the decline appear to be very different
from those which have reduced scarlet fever. Up to 1895
the case death-rate from diphtheria in the hospitals of
the Metropolitan Asylums Board ranged from 23 to 59
per cent, but about that year the modern antitoxin
treatment which had resulted from the labours of Klebs,
Loffler, Behring, and others was introduced, and in the
succeeding years a rapid fall occurred in the mortality,
which in 1914 was only 7*9 per cent of the cases treated.
Just as we may take credit for the decline in typhoid fever
as our greatest sanitary achievement, so we may regard
the decreased mortality from diphtheria as one of the
most successful results of purely clinical medicine.

The question may legitimately be asked : Why should
not the decline in mortality from diphtheria also have
been due to a lessening of the virulence of the organism
which has happened to coincide with the introduction of
a new treatment, and has accordingly led to the credit
being given to that treatment ? The answer is that in
patients who do not receive the antitoxin treatment, the
disease exhibits a virulence fully as great as that of twenty
years ago. Further, there is a very marked relation
between the mortality-rate and the period in the disease
at which the injection is given ; the earlier the day and
the shorter the time the bacteria have had to generate their
toxin, the more potent is the effect of the antitoxin. It
is certain that if all cases of diphtheria could be treated
shortly after infection, the mortality would be further
substantially reduced.

Tuberculosis. — There is no disease exact knowledge of
which is so important as tuberculosis, for it is the most
widespread and deadly affection now existing in this
country, being responsible for nearly seventy thousand
deaths in the British Isles every year, and a far larger
number of cases of sickness. Tuberculosis has exhibited
a marked decline in nearly all civilised countries during

EVOLUTION AGAINST DISEASE 43

the last half -century, and in England and Wales the
annual death-rate from all forms of the disease has fallen
from 3479 per million during the years 1851-60, to 1344
in 1914. There is no reason to doubt that this decline has
been assisted by diminution of overcrowding, clearing
away of slums, and enforcement of precautionary measures
in unhealthy trades ; although the value of the measures
adopted in recent years, viz. notification of tuberculosis
and sanatorium benefit, is more open to question.

The tendency to claim that the decrease in mortality
has been due to social measures is perhaps more strongly
exhibited in the case of tuberculosis than in any other
disease ; nevertheless this claim is by no means fully en-
dorsed by scientific research, and bacteriologists incline
more and more to the view that natural processes have
played a considerable part in bringing about the decrease.
Professor Hewlett says : " Tuberculosis is diminishing
" among the white races ; it is, however, spreading among
" many coloured races. It is to be noted that the decline
" began long before the germ origin had been demonstrated,
" and what is more, the rate of decline was almost as great
" before any administrative measures were taken against it
" as since." 1 The marked decline in the death-rate from
phthisis in Edinburgh which followed the establishment of
the dispensary system was unhesitatingly attributed to
that system, which accordingly became a model for other
localities. Unfortunately for this view the death-rate
in Aberdeen — without any dispensary — fell to a greater
extent during the same period. Professor Karl Pearson,
who has very ably analysed these and other statistics
relating to tuberculosis over a long period, sums up his con-
clusions by saying: " It seems to me that when we study the
" statistics of the fall of the phthisis death-rate, when we
" notice this fall taking place in urban and in rural districts,
" when we see that it started long before the introduction
" of sanatorium and dispensary work and that it has not
" been accelerated by modern increase of medical know-
" ledge, then we are compelled to regard that fall as part of
" the natural history of man rather than as a product of his

1 Manual of Bacteriology, 5th ed., 1914.

44 HEALTH AND THE STATE

" attempt to better environment." x Professor Karl Pearson
has argued strongly that an hereditary influence is the
main factor, those persons who have inherited a predisposi-
tion towards tuberculosis being particularly liable to the
disease. Metchnikoff, following the suggestion of Roemer,
has found increasing support among scientific men for his
view that the great majority of town-dwellers have already
suffered from an attenuated form of tuberculosis, and
have thereby acquired varying degrees of immunity against
the disease which have helped to bring about the decline.
After pointing out that " the systematic researches made
" by Dr. Naegeli and confirmed by other pathologists have
" demonstrated that nearly all human beings, dead from
" other causes than tuberculosis, present, in some part or
" other of their organism, latent and more or less extended
" lesions due to tuberculosis," Metchnikoff says : " I hold
" that in addition, to rational hygienic measures, the un-
" conscious immunisation of the population by the tuber-
" culous vaccines scattered around us must play an im-
" portant part in causing the diminution of the annual
" death-rate due to tuberculosis. . . . Just as the Kalmuk
" children easily take tuberculosis in the cities when by
" the side of their European comrades who remain free
" from it, so persons who come into the great centres of
" typhoid fever very frequently contract this malady whilst
" the original inhabitants of the country continue to enjoy
" good health. . . . These indications suffice to show the
" great importance of discovering the natural processes by
" which man acquires immunity against infectious diseases
" in general and against tuberculosis in particular." 2

Syphilis is a disease of which we have not much accu-
rate and reliable statistical knowledge, but according to
evidence given by numerous witnesses before the Royal
Commission on Venereal Diseases, there are good grounds
for believing that it has been declining both in frequency
and virulence for many years. Older physicians say that
the terribly severe types of cases met with a generation
ago are now much less frequently seen, even among patients

1 Tuberculosis, Heredity, and Environment, 1912.
2 The Warfare against Tuberculosis, Bedrock. January 1913.

THE PROBLEMS OF INFECTION 45

who have received no treatment ; and the worst forms of
the disease are encountered among native races. The
lessened frequency of syphilis is very probably due to
greater care and cleanliness and a higher moral standard ;
but the diminished severity must almost certainly be
attributed to the natural tendency exhibited by so many
diseases to die out in the course of time.

This brief summary, which has not attempted to do
more than touch upon the scientific knowledge relating
to the natural history of disease, shows that the question
as to why a disease decreases is often very obscure. Under
these circumstances the scientific investigator hesitates to
undertake the thankless task of opposing popular opinion,
when he can only support his views by scientific arguments
and statistics which the average person has neither time
nor inclination to study ; and the layman accordingly
cannot be reproached for making dogmatic statements
and jumping to conclusions which are not substantiated
by science. It might be said that the question is of purely
academic interest, and that so long as a disease disappears
it does not much matter whether it be due to a natural
process or social measures. But if these measures are
based upon erroneous beliefs they are apt to be wasteful
and sometimes actually harmful ; their apparent success
leads to similar measures being applied to other diseases ;
and they set up false views and. theories which distract
attention from the real agencies at work.

The Problems op Infection

The discovery that infectious diseases are caused by
the transmission of micro-organisms from one person to
another has been of incalculable value in the progress of
medical science. As we have seen, the fact that isolation
of persons suffering from certain diseases was an efficient
method of checking the spread of these diseases, was
observed in remote times. The demonstration of the
germ origin of disease provided a scientific explanation
of the observed facts, but it also led to the belief that
isolation would be an effective method of preventing the

46 HEALTH AND THE STATE

spread of any infectious disease. We now know that
this view is no longer tenable, and we have learnt that
the methods satisfactory for dealing with one disease are
by no means as suitable or satisfactory for another. In
the popular mind all infectious diseases are more or less
alike, and infection through the air is generally believed
to be the most frequent mode of transmission ; but science
has taught us that we cannot generalise in this way, and
has shown us that some diseases are conveyed through
food and water, some by animals, some by insects, some
possibly through the air (though this is not proved even
in the case of tuberculosis), and some only by direct contact
between man and man ; while in regard to others we
must frankly admit that we do not know their mode of
transmission.

When diseases are governed by such diverse conditions,
it is obvious that methods of prevention which will succeed
with one will not necessarily do so with another, and the
argument from analogy may lead us into serious errors.
We have for example good reason for believing that prompt
isolation is a valuable means of preventing the spread of
smallpox. Almost every year a few cases of smallpox
occur in this country, generally introduced at the sea-
ports, and when they are detected, persons suffering from
the disease are at once isolated, and those who have been
in contact with them are also isolated or kept under close
observation. The fact that it is now a good many years
since an epidemic of any size has occurred, appears to
show that these measures are sufficient.

On the other hand, isolation of patients suffering from
scarlet fever or diphtheria appears to have had no effect
upon the prevalence of these diseases. Unfortunately
our statistical knowledge for England and Wales relating
to the prevalence (apart from mortality) of scarlet fever
and diphtheria does not go back earlier than 1911, for
although these diseases were made notifiable in 1889, it
was not until 1911 that the Local Government Board
compiled and issued statistics relating to the whole
country. The following table shows the course of these
diseases in England and Wales since that year : —

THE PKOBLEMS OF INFECTION

47

Notifications of Scarlet Fever and Diphtheria in
England and Wales, 1911-1915

Year.

Scarlet Fever.

Diphtheria.

1911
1912
1913
1914
1915

104,651

107,508
130,707
165,045

127,086

47,802
44,754
50,903
59,357
53,597

In Scotland there has been the same upward tendency
in the prevalence of these diseases accompanied by the
same marked decline in the case-mortality : in 1914,
notifications of scarlet fever were 27,321, of which 21,942
were admitted to hospital ; and notifications of diphtheria
were 9667, with 7904 admissions. In Ireland, case death-
rates are not available ; the rates per 100,000 of the popu-
lation are low for both diseases, but that for scarlet fever
has risen considerably in recent years.

It may be said that these figures do not afford a justifi-
able test of the value of isolation, since some of the patients
will have been treated at home, and not at the fever
hospitals ; but this, at most, only applies to the degree of
isolation, for even when patients are attended at home
precautionary methods are adopted, the patient being
isolated in a room, a sheet saturated with carbolic acid
often being hung outside the door, and the room and
bedding being disinfected under the instructions of the
Medical Officer of Health. As regards this point, the
statistics relating to London are important, since nearly
90 per cent of cases of scarlet fever and diphtheria notified
are now received into the hospitals of the Metropolitan
Asylums Board, and these statistics have the additional
value of going back to an earlier period than those for
England and Wales. The following table shows the
number of cases of scarlet fever and diphtheria which
were notified from 1890 to 1914 : —

[Table

48 HEALTH AND THE STATE

Notifications of Scarlet Fever and Diphtheria in London

Year.

Scarlet Fever.

Diphtheria.

1890-1899

21,240*

10,506

1900-1909

18,144*

8,679

1910
1911

10,509
10,483

5,494

7,385

1912
1913
1914

11,321
17,544
25,048

7,106
7,650
9,149

* Annual average.

It will be seen that compared with the decade 1890-
1899 there has been some decline in the incidence of both
diseases, the lowest point having been reached for diph-
theria in 1910 and for scarlet fever in 1911 ; but since those
years the numbers have risen steadily, and the high
figures for 1914 show how far we are from ' stamping
out ' these diseases. The fluctuations in scarlet fever and
diphtheria suggest that their prevalence is dependent
upon some factor or factors, possibly meteorological, of
which we are still in ignorance. In any case it may be
noted that although probably a larger proportion of cases
are treated in the isolation hospitals in London than in
any other district, the incidence of diphtheria has been
higher in London for each year since 1911 than in any
other part of England ; while for scarlet fever London was
highest in 1914, and was exceeded only by the aggregate
of County Boroughs during the three preceding years. It
is clear that isolation is having very little influence on the
prevalence of these diseases.

But though the fever hospitals have thus failed in
their primary purpose of stamping out infectious disease,
it must be fully recognised that they have been of great
service in providing efficient care and treatment for a
large number of persons who would not have been satis-
factorily looked after at home ; and this is therefore the
real standard by which the value of the fever hospitals
must be judged. We must almost certainly abandon the
hope of stamping out disease through their agency, and

THE PROBLEMS OF INFECTION 49

must look upon them purely as curative institutions just
as other hospitals. But as soon as this is recognised,
the question arises whether by restricting admission to
the fever hospitals to certain types of diseases we are
making the most economical use of these institutions.
The criterion for admission is not severity of illness, but
the fact that the person is suffering from a scheduled
disease. As regards scarlet fever, we know that a large
number of beds are occupied by persons who are relatively
not seriously ill, and who need little in the way of purely
medical treatment ; on the other hand, the institutional
provision for general diseases is still very inadequate,
particularly outside London, and many persons cannot
obtain admission to a hospital although they may be far
more in need of institutional treatment than some of those
in the fever hospitals. We have reason to think now
that measles and whooping-cough are worse diseases than
scarlet fever, though we cannot be dogmatic on this point,
since there is no means of determining their case-mortality.
Among 3400 cases of measles admitted to the Metropolitan
Asylums Board in 1913, the death-rate was 11-3 per cent,
and among 1044 cases of whooping-cough it was 12-8 per
cent, being thus for each disease approximately ten times
as high as the death-rate from scarlet fever, but the
comparison is not entirely legitimate, since the scarlet
fever admissions were of all types, while those for measles
and whooping-cough were probably particularly severe
cases. If milder cases of scarlet fever were treated at
home, more space would be available for admission of
severe cases of measles and whooping-cough ; while it
might be to the advantage of the community as a whole
to devote some of the fever hospitals to tuberculosis or
general diseases. It must be remembered that since
there is a marked seasonal variation with most infectious
diseases, the prevalence usually rising rapidly during the
Autumn months, many of the beds in the fever hospitals
are unoccupied for considerable portions of the year. In
London the Metropolitan Asylums Board provides 6825
beds in its eleven hospitals for ordinary infectious diseases,
but on January 1, 1913, only 4087 of these were occupied.

E

50 HEALTH AND THE STATE

These considerations show the need of dealing with
disease as a whole, instead of making separate provision
for each malady or type of malady, or class of persons.
At present we have separate schemes for the treatment of
tuberculosis, venereal diseases, infectious diseases, diseases
among the infirm poor, and diseases in school children,
with the result that some diseases receive more attention
than their degree of seriousness really demands, while
others are comparatively neglected. We find one authority
building or enlarging a hospital or sanatorium, while
another in the same district has many empty beds. If
in each district there was a single authority which had
complete control over all the provision for treatment of
disease, this provision could be adjusted to meet the needs
of the community far better than they are provided for
at present.

We have digressed somewhat from the main subject
of this section, which is the problem of infection. In
tuberculosis this question is of particular importance,
because a very large part of the modern campaign against
tuberculosis is founded upon the belief that it is a seriously
infectious disease. Tuberculosis is notifiable, the Local
Authorities disinfect rooms and bedding which have been
occupied by a patient, and Tuberculosis Officers are now
developing a system of examining persons who have been
in contact with sufferers from the disease. In the public
mind the belief is firmly established that tuberculosis is
readily transmitted from one person to another, and that
prevention of infection is the great weapon against the
disease. It has even been urged that tuberculous persons
should be segregated from the general community or
placed under restraint ; the Vice-Chairman of the Lanca-
shire Insurance Committee, for example, writes : "So
long as consumptives are permitted freedom to live and
move without restriction, so long will there exist an active
agency spreading the disease and negativing all the efforts
otherwise made to combat it."

We have still a great deal to learn about tuberculosis
and infection, and a dogmatic attitude is unjustified ; yet
reflection will show that the infectiousness of tuberculosis

THE PROBLEMS OF INFECTION 51

must be of quite a different order from that of scarlet
fever, diphtheria, or smallpox, and is probably more com-
parable with infection by the organisms of pneumonia,
or the ordinary pyogenic or pus - producing organisms
which have never given rise to popular fear of transmis-
sion from man to man. We know that healthy persons
can expose themselves continually to the risk of infection
without acquiring the disease ; doctors and nurses in
sanatoria associate freely with patients for years and
yet rarely develop tuberculosis ; and it is not even thought
necessary in the wards of general hospitals to separate
tuberculous cases from other patients. Dr. Goring has
investigated the incidence of tuberculosis between husbands
and wives where, presumably, the greatest opportunity
for infection exists, and he finds that in the poorer
classes there is no greater chance of the mate of a tuber-
culous person being tuberculous than any other person.
Among the wealthier classes the proportion is slightly
greater, probably due, as Professor Karl Pearson has
pointed out, to selective mating, an influence only likely
to operate among educated people.1 Sir Hugh Beevor,
physician to the City of London Hospital for disease of the
chest, protesting as far back as 1892 against exaggerated
statements of the infectivity of tuberculosis, said : " The
" term ' infection ' is too loose a term to apply to both
" measles and tuberculosis. When its use does damage to
" the workman's prospects it is perpetrating an injustice
" upon him. When we see the poor results in the isolation
" of infective fevers by hospitals for fever, those who rank
" tubercle as most highly infectious must seriously doubt if
" it is a right policy to apply such a system to tubercle. . . .
" I earnestly hope that the medical profession at large will
" not encourage the public to avoid their tuberculous fellow-
" creatures. ... I would urge you as the educators of the
" public in these matters distinctly to let it be known that
" tubercle is not highly infectious. State that it is not
" a disease that requires isolation, and that only under
" certain quite exceptional conditions does it appear to be
" infectious at all. Insist that healthy people enjoy extra-

1 Op. cit.

52 HEALTH AND THE STATE

" ordinary immunity, that fresh air and open windows are
" the great armour against its attacks." l

Finally, it may be noted that the Royal College of
Physicians has thought it desirable to issue a special report
on the infectivity of tuberculosis in order to counteract the
excessive fear of infection by the disease which exists
among the public.2

We may consider another aspect of the question. The
bacillus of tuberculosis appears to be so ubiquitous that
it seems probable that all town-dwellers at all events
receive the organism again and again into their lungs
or alimentary system. If the bacilli are air-borne, we
have only to consider the condition of the streets to realise
the frequency of opportunities for infection ; and if they
are conveyed by food we may note that something like
10 per cent of the samples of milk analysed contain the
bacilli of tuberculosis, and everywhere we see pastry,
sweets, and other eatables exposed for sale in shops thronged
with passers-by, or exposed to dust from the streets. Even
the opportunities for almost direct infection are not rare.
It is a common practice for a shop assistant to moisten his
finger in order to take up a paper bag, and blow into the
bag to open it before he puts an article of food into it ;
a railway clerk will often hand out a ticket moist with
saliva, and a lady may be seen to place this ticket straight
in her mouth while opening her purse. Public telephones,
drinking-fountains, and the practice of licking stamps
and envelopes, are other conceivable channels of infection.
Finally, it may be added that many of our domesticated
animals suffer from tuberculosis. It is clear therefore
that if tuberculosis were infectious to anything like the
degree exhibited by the ordinary infectious fevers, and
the disease resulted simply from the entry of the bacilli

1 The Problem of Infection and Immunity in Tuberculosis. An address delivered
before the West Somerset Branch of the British Medical Association. 1902.

2 The resolution of the Royal College which preceded the issue of the report was
as follows : " That in view of the exaggerated fear of the infectivity of pulmonary
tuberculosis entertained by the public, the consequent unnecessary disabilities
imposed upon sufferers from the disease, and the opposition raised in many places
to the establishment of institutions for its detection and treatment, a reassuring
statement with regard to the degree of danger attaching to contact and communi-
cation with tuberculous persons oe prepared by the College and issued in its name
at an early date.'"

THE PROBLEMS OF INFECTION 53

into the system, the whole population would probably be
swept away.

Why then do some people exhibit the disease in severe
form and others not ? The answer is that it depends much
less upon infection than upon the power of resistance of
each individual to prevent that infection gaining a hold on
his system when the bacilli are swallowed or inhaled. As
we have seen, it may be that the great majority of town-
dwellers have actually been infected with the disease and
have thereby acquired partial immunity, and it would
appear that this infection occurs quite early in life. In-
vestigations made by many observers among children by
means of the Von Pirquet reaction — a very delicate test
for discovering the disease — have shown that over 90
per cent of children have already suffered from tuber-
culosis. It is possible that tuberculosis is really a disease
of childhood, like measles or whooping-cough, but that in
early years it is a comparatively slight affection, the true
nature of which is rarely recognised. But while these
questions are uncertain, there is no doubt whatever about
the environmental factors which lessen resistance. We
know that a healthy person livjmg in a healthy environment
is unlikely to develop the disease even though frequently
exposed to infection, and we know that the disease flourishes
among those who are overcrowded, breathing foul air
and insufficiently fed. Instances are sometimes brought
forward of a number of persons living in the same area or
street or even house who have developed tuberculosis, and
it is claimed that these illustrate the danger of infection.
It may be literally true that these persons have infected
each other, but the reason why they have acquired the
disease is almost certainly that the powers of resistance of
all of them have been reduced by the same bad surround-
ings. On theoretical grounds fighting the disease by dis-
infection is sound, inasmuch as if there were no tubercle
bacilli there would be no tuberculosis ; but the occasional
disinfection of a room, and the removal of a few cases to
hospital or temporarily to sanatoria, are probably as
effective as would be efforts to keep dry on a rainy day
by wiping the paving-stones. The modern belief in the

54 HEALTH AND THE STATE

dangerous infectiousness of tuberculosis is diverting atten-
tion from the main cause of the continuance of the disease,
which is a bad environment. This influence was well
known long before the tubercle bacillus was isolated,
but efforts to reduce it seem now to take the second place,
and attention is concentrated on prevention of infection.

It may be noted that many of the arguments for attack-
ing tuberculosis by destroying the bacilli can be applied
to all microbic diseases. Pneumonia, for example, re-
sembles tuberculosis in many respects. It is a bacterial
disease, it is far more prevalent in urban than in rural
areas, and susceptibility to it is increased by exposure,
under-feeding, alcoholism, and other influences tending
to lower vitality. But no fear of infection by pneumonia
exists in the public mind, notification is not required, and
the Medical Officer of Health does not disinfect rooms
which have been occupied by patients or examine
' contacts.'

Similar problems and uncertainties arise with other
infectious diseases. Dr. Hamer, the Medical Officer of
Health to the London County Council, has discussed the
etiology of typhoid fever and has shown that some at least
of the commonly accepted views of its modes of trans-
mission cannot be regarded as scientifically proved.1 He
has also described the history of a girl, known to* be a
diphtheria ' carrier,' who was kept under observation for
six years, but to whom no outbreak of the disease could
be attributed ; a case which raises doubt whether carriers
form an important factor in the spread of diphtheria.2

There is reason, moreover, to believe that the methods
of fumigation so widely employed are entirely useless to
disinfect rooms. Dr. Walcott, the State District Health
Officer for Massachusetts, has described a series of experi-
ments, extending over more than a year, which he and his
staff made to test these methods. They smeared pieces
of cotton wool and other materials with infective material
from the noses, throats, and ears of persons in the con-
tagious diseases wards and from suppurating wounds in
other wards, and put these on the floor, the table, chairs,

1 Annual Report for 1914. 2 Annual Report for 1915.

THE ASSURANCE OF THE LAYMAN 55

mantelpiece, etc., of a room at various elevations, a control
series being placed in another room. The room was then
fumigated with every known method of fumigation, for
example, sulphur candles, sulphur powder, formaldehyde,
etc., and all proprietary remedies. The room was then
sealed up and left for periods varying from 24 to 72 hours.
It was found that these methods had no consistent effect
upon the cultures used. " In one case of a proprietary
preparation where one candle was guaranteed to kill every
germ in a given room we made a little shrine of several of
these candles and put the inoculations in the centre, and the
germs lived happily through the experiment." *

As a result of these experiments fumigation has been
abandoned by the Public Health authorities in New York,
Boston, and other American cities

The Assurance op the Layman

The object of discussing somewhat fully in the preceding
pages the factors which influence infectious diseases has
been to show that obscurity and doubt exist on many
points of fundamental importance. Scientific men hesitate
to distinguish between the influence of nature and the
influence of social effort ; they are often uncertain of the
methods of transmission of diseases, and they cannot be
dogmatic as to the best ways of eradicating these diseases.
More research is required in every direction, not only
medical but sociological ; and a humble though hopeful
attitude is the only one which befits the scientific investi-
gator. But we find no echo of this doubt in the utterances
of our Ministers and legislators, who prepare and carry
through vast schemes for the lessening of disease. The
entire fall in the death-rate is boldly claimed as a result
of legislative and administrative measures, and the disap-
pearance or diminution of every disease is attributed to
similar efforts. In an ordinary person these errors would
not seriously matter, but when made by some one in high
authority they may lead to the adoption of a wrong and
costly policy. Since the main object of this book is to

1 Boston Medical and Surgical Journal, March 9, 1916.

56

HEALTH AND THE STATE

establish the case for putting our Public Health affairs
in the hands of those who have real knowledge of the sub-
ject, it is necessary to justify this statement by quoting
views which have been expressed by persons in authority.
Many instances will be given in succeeding chapters, but
here, for example, we may quote from an address on Public
Health made by the Right Hon. John Burns as Presi-
dent of the Local Government Board at the International
Congress of Medicine in 1913, to an assemblage containing
many of the most learned and distinguished medical men
from all civilised countries. The right hon. gentleman
said : —

When speaking of the marvellous reduction that has taken
place in the death-rate in this country, one is perhaps too apt to
remember only social and sanitary progress as the explanation of
this great change. My address to you to-day may, I trust, serve
to show the appreciation by the public of the fact that to a very
large extent humanity is indebted for the saving of life and of suffer-
ing that has occurred, to the vast improvements in the science of
cure as well as of prevention of disease.

The Past Saving of Life. — Some conception of the progress
already secured by the application of science, especially medical and
sanitary science, to the problem of healthy living — and I trust at
the same time to further triumphs on the part of your profession —
may be given by the comparison to which I invite your considera-
tion of the average experience of England and Wales during the
three years 1909-11 as compared with its experience during three
years based on the average experience of 1871-80. In the three
years 1909-11, 1,529,060 deaths occurred in England and Wales.
This number is 772,811 fewer than would have occurred had the
average death-rate of 1871-80 held good for these three years. The
saving of life in three years under special diseases is set out below :

Smallpox 25,463

Measles 7,824

Scarlet fever 69,974

Whooping-cough ..... 30,884

Fevers (typhus, enteric, etc.) .... 45,339

Puerperal fever ...... 3,941

Diarrhoea, dysentery, and cholera . . . 32,996

Pulmonary tuberculosis .... 114,799

Other tuberculous diseases .... 36,338

Total saving on these diseases . . . 367,558

Nearly half the total saving has occurred under the heading

THE ASSURANCE OF THE LAYMAN 57

of the diseases enumerated. If we take the whole of the thirty-two
years, 1881 to 1912, and consider the saving of life during this
period, the figures are truly colossal. The saving of life represents
a population which is nearly equal to the total population of London
or Australia or of Ireland and more than that of Switzerland.

How has the saving of life already achieved been secured ?
No complete answer can be given in a few sentences, and perhaps
my best plan is to proceed by examples, drawing inferences from
the historical facts of medicine which are open to the layman as
well as to the doctor.

The speaker then dwelt upon the work of Howard,
Elizabeth Fry, Sadler, Oastler, Shaftesbury, Dickens,
Owen, Kingsley, and particularly Chadwick and South-
wood Smith ; and he referred to the beneficial work of
factory inspectors, medical officers of health, and sanitary
inspectors in laying the foundations of national health.
He continued : —

Typhus Fever. — The history of typhus is a romance in sanita-
tion, from which the principles and practice of preventive medicine
could be adequately taught. It occurred under conditions of dirt
and overcrowding ; but, apparently, it arose only by direct infec-
tion from person to person. It was spread like smallpox, by
vagrants from parish to parish, repeatedly brought by them from
Ireland to England, and it was not brought under control until the
migrations of vagrants had been limited, the sick had been segregated
in hospitals from the healthy, ' contacts ' had been kept under
adequate supervision, and the houses harbouring the disease had
been disinfected and the vermin therein destroyed. In many
instances the courts and alleys, the favourite lurking-places of the
disease, were also swept away. Consider the following figures :
In the ten years 1871-80, in Ireland, 7495 deaths were returned
as due to typhus fever ; in the three years 1909-11 the number
had fallen to 143. In England and Wales, in the ten years 1871-80,
13,975 deaths were caused by typhus fever ; in the three years
1909-11, with a much larger population, the number was 30. . . .

Stages in Registration of Disease. — The history of registration
of disease is inseparably associated with that of public health. . . .
You will, I think, agree with me that the most important extension
of the principle of notification has been in regard to tuberculosis.
The knowledge that this disease is communicable, and the im-
portance, even apart from the fact of communicability, of having
exact knowledge of its special haunts, and of its prevalence in
different industries, and among the poor living in crowded streets
and courts, have enabled me step by step by means of Departmental

58 HEALTH AND THE STATE

Orders to apply the principle of compulsory notification to all forms
of this disease. . . .

Tuberculosis is the one disease in which the fact that measures
of treatment and of prevention are to a large extent identical is
becoming fully realised. . . . Improvements in housing, progress in
average social conditions, higher nutrition, all have doubtless borne
their share in bringing about this great reduction in tuberculosis.
More cleanly habits of the people must be given a large share in
securing the result. The habit of indiscriminate spitting, although
still prevalent, is much less so than in the past. The standard of
domestic cleanliness has improved, and this must have cleaned out
many of the former centres of infection. Even more importance
must be attached to the diminished overcrowding of bedrooms. . . .
The proportion of the total population in England and Wales living
in rural districts has decreased from one-half to less than a quarter
between 1851 and 1911. It is evident, therefore, that some import-
ant influences have been at work counteracting the effect of urban
conditions as a whole on tuberculosis. Among these, important
place must be given to the hygienic effect of the stay for months
in an infirmary or hospital of a high proportion of the total con-
sumptive population, at the most infectious and helpless periods
of their illness. At the present time the prospect of complete
control over tuberculosis is more promising than ever before. Not
only is public administration, with its magnificent past effect on
tuberculosis, becoming increasingly efficient ; but the National
Insurance Act happily has given further important means of effec-
tive attack against this disease. . . . These schemes ensure early
diagnosis, prompt treatment, and the removal of sources of in-
fection, by adequately linked-up measures of domiciliary treat-
ment, and of treatment at dispensaries, hospitals, and sanatoria.

In giving these illustrations of what medicine and the sanitary
service of the country have accomplished, my survey has neces-
sarily been incomplete. Not only is there a marvellous record for
typhus and enteric fever, and for tuberculosis, but also for the
diseases and accidents for which medical aid is required, and to a
less extent for puerperal fever. A still more striking illustration
could be found in smallpox, and even measles and whooping-cough
in recent years appear to be losing some of their power under the
influence of the child-welfare work which is gradually becoming
systematised in many sanitary areas. . . . The saving of life in this
country has not been confined to the diseases ordinarily regarded
as preventable and curable. Even cancer, if only recognised and
treated at an early stage, and when accessible to the surgeon, loses
a portion of its terrors ; and it cannot be that the concentration
on investigation of this disease in nearly every civilised country
will fail during the next few years to add it, like tuberculosis, to the

THE ASSURANCE OF THE LAYMAN 59

diseases doomed to insignificance if not actual annihilation. ... I
have not time to speak of the improvement in infant and child
mortality which has been realised in recent years thanks in large
measure to the active work undertaken by the officers of sanitary
authorities, acting in co-operation with voluntary associations.

When criticising this speech, it must be borne in mind
that the speaker was not a medical man, and that he was
not appointed to his position in consequence of any special
knowledge of medicine or hygiene. It is indeed a com-
pliment to Mr. Burns to recall that he was first made a
Cabinet Minister in recognition of his life-long devotion to
the interests of labour. Any comments of an adverse
nature, therefore, are not directed at the right hon. gentle-
man, whose lofty aims have always been manifest, but at
the system which, in order to place at the service of the
country the advice of one who has an intimate knowledge
of the conditions of the working classes, can only do so
by putting him in supreme charge of a Department for
the administration of which he has had neither training
nor experience. The Public Health work of the Local
Government Board can only be carried out efficiently
under the headship of one who has either a profound
knowledge of Public Health, or has received a scientific
training which will enable him to study and appreciate the
scientific work which has been done by others. And this
speech of Mr. Burns's shows that after nine years of office
he was still quite out of touch with scientific medicine.
From beginning to end there is no sign of any recognition
that natural causes may have played a part in " saving "
the large number of lives indicated. Nature is ruthlessly
elbowed aside, and the whole reduction of every disease
is boldly claimed as a result of sanitary progress and cura-
tive medicine. The reading of history is remarkable.
The disappearance of disease is ascribed to measures
which, if they were taken at all, were taken only on a very
limited scale, and to the abolition of evils which are still
rampant in our midst. The picture given of the steps
taken to prevent typhus is directly negatived by the state-
ment of Dr. Bruce Law, himself an officer of the Local
Government Board. The " stay for months in an infirmary

60 HEALTH AND THE STATE

or hospital of a high proportion of the total consumptive
population at the most infectious and helpless periods of
their illness " is considered to have played an important
part in bringing about the decline in tuberculosis, yet this
disease has been falling steadily for sixty years, and even
to-day, in spite of the great addition made under the
Insurance Act, the provision for institutional treatment
is notoriously inadequate. The sanatorium treatment of
tuberculosis is extolled, though investigation would have
shown the speaker that it had been almost useless among
the working classes in Germany, and experience is showing
equally in this^country that it is of little value without per-
manent change of environment. Measles and whooping-
cough are roped in with the other diseases which are
losing part of their terrors, though very little has been
done in the way of providing public treatment for these
maladies. Prevention of infection is regarded as the most
potent weapon in the attack on disease. Finally, though
the effect of urbanisation in increasing tuberculosis is
mentioned, there is no indication that the speaker realised
that this influence runs through the whole gamut of
disease. In the two succeeding chapters we shall see that
infant mortality, defects in school children, and sickness
rates and mortality from nearly all diseases, are all far lower
in rural than in urban environments. Whatever may be
the reason for this difference, urbanisation is the overwhelm-
ing factor in the causation of preventable disease, and it
links up the problem of securing a healthy people with the
problems of the land. The principles and practice of pre-
ventive medicine are not to be learnt from the ' romance '
of the history of typhus, but from a close study of the
effects of urbanisation and of the still undiscovered ultimate
causes of those effects. To omit reference to this factor,
except in regard to one or two diseases, in a speech which
surveys the whole field of Public Health, is to suggest
that its profound and widespread influence has not been
realised.

THE EVILS OF EXAGGERATED CLAIMS 61

The Evils of Exaggerated Claims

The dogmatic attitude in regard to disease has many
undesirable results. In a democratic country Public
Health efforts can never go very far in advance of public
opinion, and consequently it is exceedingly important
that that opinion should be founded upon exact know-
ledge, or upon the best knowledge obtainable at the time.
But the science of Public Health is vast and complex, and
the average man has neither the time nor the training to
study statistics and literature himself. He is obliged to
take his conclusions ready-made from others, and he
accepts, as reliable, statements made by a person in high
authority, particularly if they coincide with his precon-
ceived views. These statements go out to Borough
Councils, Education Authorities, and social reformers,
where they are quoted in argument, serve as a basis for
local administrative action, and help to establish public
opinion. Secondly, exaggeration of the ' achievements '
of Public Health administration leads to a glossing over of
the evils which still exist, paints a wholly inaccurate
picture of the real state of the national health, and creates
an undue optimism for the future. Dr. Pangloss returns
from the pages of Voltaire to tell us once more that
" everything is for the best in this best of all possible
worlds," and with Kipling we feel that —

By the rubbish in our wake, and the noble noise we make,
Be sure, be sure, we're going to do some splendid things.1

1 "Road Song of the Bandar-log."

CHAPTER III

INFANT MORTALITY AND ITS PROBLEMS

The ' natural ' rate of infant mortality — The avoidable loss of infant life
hi the United Kingdom — Infant mortality in town and country — The
possible causes of infant mortality : poverty ; defective sanitation ;
infectious diseases ; artificial feeding ; industrial employment of
mothers ; lack of attendance at birth — Maternal ignorance — Adverse
pre-natal conditions — The effect of smoke and dust — The pathological
causes of infant mortality — Deaths from ' developmental conditions '
Still-births — The fall in infant mortality in recent years — Infant
mortality in Bradford — The need for further research.

The ' Natural ' Rate of Infant Mortality

Infant mortality is measured by the number of deaths
under one year of age per thousand births, still-births
being excluded from both figures. Under the best circum-
stances a certain number of infants are bound to die in the
first year of life, for the young of all species are subjected
to special risks, and sometimes Nature herself does not
build well enough to enable the tiny spark of life to sur-
vive. We cannot determine precisely what this ' natural '
death-rate is, since we cannot study mankind under purely
natural conditions, but we can ascertain the lowest rate
among communities or classes of some size, and this is
the essential first step in an investigation of anfant
mortality, for without such a minimum there is no means
of measuring the avoidable loss of life occurring among
other groups. We will examine for this purpose, first, the
rates of infant mortality among different social classes,
and, secondly, the rates in different types of areas, which
is the more important investigation for practical purposes.
In his Report for 1911, the Registrar-General included
a table showing the rates of infant mortality in different

62

< NATURAL ' RATE OF INFANT MORTALITY 63

classes according to the father's occupation ; and in a
group of these classes consisting of doctors, solicitors,
army officers, clergymen, and others of the professional
class, but including with them woodmen and foresters,
the infant mortality rate was 42 per thousand births,
which may be contrasted with the rate of 171 among
general labourers, ironworkers, scavengers, and hawkers.
This figure would appear to show that a death-rate of
much over 40 need not occur, but the inference is not of
much practical value so long as it is drawn from these
facts, for it does not tell us why the rate is so much lower
in the professional classes ; whether, for instance, it is due
directly to their wealth enabling them to obtain more
food, better medical attendance, etc., or whether, as a
result of that wealth, they live on the whole in a better
environment. Moreover, the professional classes do not
form a community, and in any circumstances we could
never place the whole population under their conditions
as regards wealth, though it will be shown that we may
reasonably hope to do so as regards health.

The best guide for practical purposes is afforded by
the lowest rates found in actual communities which are
of sufficient size to eliminate variations due to accidental
causes.1 The following table shows the larger districts in
the British Isles which had the lowest rates of infant
mortality in 1914 : —

1 The extent to which inferences may be built up by social reformers upon the
most inadequate of statistics is well illustrated by the sweeping conclusions which
have been drawn from the experience of infant life in the small French commune
of Villiers le Due. It has been claimed as a wonderful achievement that for ten
years together — 1892 to 1903 (we are not told about more recent years) — the
infant mortality rate in the commune was zero. This absence of deaths has been
ascribed to the regulations for the protection of infant life in the district, which
have been widely quoted in this country and even fully described in a Milroy lecture
before the Royal College of Physicians. But the fact that the total number of
births during the ten years was only 5-4 is never mentioned, and rates per thousand
are worked out on a yearly average of less than 6 births. There are no doubt many
tiny English villages which can show a record as good as that of Villiers le Due,
while, as far as numbers are concerned, the experience of Crowle in Lincolnshire,
in 1914, with 75 births and no deaths, is better.

Since the above was written, the writer has ascertained that during the ten
years 1906 to 1915 there have been 43 births in the commune of Villiers le Due,
with 4 deaths. Thus during this period the infant mortality rate has been over
90 per thousand births. Taking the two periods together we get a rate of 46 per
thousand births, which is not an unusual rate for an ordinary healthy rural
district.

64

HEALTH AND THE STATE

Lowest Eates of Infant Mortality, 1914

Area.

Population.

Deaths under 1 year
per 1000 births.

England

Berkshire — Rural Districts

138,635

54

Oxfordshire „

101,197

55

Wiltshire ,,

162,987

57

Buckinghamshire „

142,538

58

Herefordshire ,,

74,116

58

Cambridgeshire „

73,188

59

Somersetshire „

232,604

61

Devonshire „

227,775

62

Dorsetshire „

105,663

62

Suffolk, West

72,957

63

Sussex, East „

128,705

64

Huntingdonshire „

31,994

65

Westmoreland „

36,570

66

Essex „

265,461

67

Northamptonshire „

118,609

67

Surrey „

230,156

67

Sussex, West „

95,649

68

Scotland

Sutherlandshire

18,829

46

Argyllshire ....

64,354

50

Ross and Cromarty .

72,726

54

Kirkcudbright ....

36,226

69

Shetland

26,503

69

Ireland

Roscommon ....

93,956

38

Cavan

91,173

40

Leitrim

63,582

42

Donegal

168,537

48

Longford

43,820

58

Sligo

79,045

58

Galway

182,224

60

Mayo

192,177

60

This table shows that large numbers of people in
widely separated parts of the country and subjected to
very different climatic conditions are living under con-
ditions which do not give rise to an infant mortality rate
of more than from 40 to 60 per thousand births, and it
could have been much extended by including smaller

INFANT MORTALITY 65

districts. It is certain that even these figures could be
lowered, and we shall see later that probably any rate over
30 should be regarded as preventable, but provisionally
we may take 50 deaths under one year per thousand
births as the standard by which excess of infant mortality
can be measured.

The Avoidable Loss of Infant Life in the
United Kingdom

We are now in a position to estimate the annual loss
of life in the United Kingdom which appears to be due to
preventable causes. The total number of births registered
in 1914 was 1,101,836, and the number of deaths under
one year of age was 114,591, giving an infant death-rate
of 104 per thousand births. If this rate had been 50 per
thousand the number of deaths would have been 55,092.
Thus we see that nearly sixty thousand lives were lost
owing to presumably preventable causes. Nor is this
loss the full measure of the evil, for as Dr. Newsholme has
shown, a high infant mortality rate is invariably associated
with a death-rate above the average at succeeding ages
at least up to twenty years. If but a quarter of this
number of deaths were caused by a sudden famine or
pestilence which brought them prominently into notice,
the most strenuous national efforts would be made to
abate the evil. It is because they are scattered, and
because we are so familiar with the evil, that we fail to
realise the magnitude of the annual tragedy.

Infant Mortality in Town and Country

Having seen where infant mortality rates are lowest,
we must now note where they are highest, and these
localities are shown in the following table, together with
the rates in some of the leading cities. It should be
observed that the rate for a whole town is as a rule
appreciably lower than those in the worst districts of the
town, which in some industrial cities are as high as 200 or
more per thousand births.

F

6G

HEALTH AND THE STATE

Highest Rates oi

t

[nfant Mortality, 1914

Town or District.

Population.

Deaths under 1 year
per 1000 births.

England and Wales

Ashton-under-Lyne . . . 45,494

184

Burnley

109,131

158

Barnsley

53,008

153

Gateshead .

118,684

151

Middlesborough

124,635

151

Nottingham

264,970

145

Stoke-on-Trent

239,515

145

Preston

118,118

143

Swansea

119,720

142

Liverpool

763,926

140

St. Helens

99,601

139

Wigan

90,842

139

Oldham

150,055

138

Dudley

51,668

137

Newcastle

271,523

137

South Shields

110,604

137

Sunderland

152,436

136

Sheffield .

472,299

132

Manchester

731,830

129

Leeds .

457,507

124

Birmingham

860,591

122

Bradford .

290,642

122

Birkenhead

135,789

122

Scotland

176,584

135

1,053,926

133

Paisley 86,593

133

Aberdeen

163,044

121

Edinburgh

324,618

110

Ireland

Dublin — Registration Area . > 434,678

145

Belfast 408,553

143

In London the infant mortality rate in 1914 was only
104, but the general rate is reduced by the low rates in
the ring of outlying districts. In the central parts the
rates range from 120 to 140 per thousand births.

The difference between urban and rural death-rates
is one of the most constant and striking features in the

INFANT MORTALITY

67

distribution of infant mortality, and affords a strong clue
to the real causes of these deaths. We may note the
effect of urbanisation on a large scale in the following table,
given by the Registrar-General for Ireland, showing the
rates in ' Civic Unions,' which are districts containing
towns with a population of 10,000 or upwards, and the
rest of Ireland.

Distribution op Infant Mortality in Ireland, 1914

Area.

Population (1911).

Deaths under 1 year
per 1000 births.

Total ' Civic Unions '
Kemainder of Ireland

Whole of Ireland

1,629,634
2,753,974

120-7
63-9

4,383,608

87-3

The influence of rural conditions is also seen on a large
scale in countries where a considerable proportion of the
population are engaged in agriculture or stock-raising.
For instance the infant mortality rate for the latest year
available was 51 in New Zealand, 65 in Norway, 71 in
Australia, 71 in Sweden, and 78 * in France.

An analysis of the rates in France in 1912 is given in
the following table : —

Area.

Population.

Deaths under 1 year
per 1000 births.

Towns of 5000 inhabitants and

Remainder of France

All France ....

15,228,000
24,422,000

111-4

57-8

39,650,000

78-0

It should be noted that 1912 was a year of exceptionally
low infant mortality in nearly all European countries.

The statistics for England and Wales as a whole do
not show such striking differences as those presented by
Ireland and France, the rates for 1914 having been 121

1 This figure is not strictly comparable with British rates, since in France
deaths occurring before registration, i.e. before the third day, are regarded as
still -births.

68 HEALTH AND THE STATE

in the aggregate of County Boroughs, 99 in other Urban
Districts, and 85 in Eural Districts, but this is due partly
to the fact that the distinction between ' urban ' and
' rural ' for registration and statistical purposes does not
always conform to the differences in the meanings of these
words as commonly understood. Since we shall have
occasion in this and the succeeding chapter to quote
frequently urban and rural statistics, it is important to
pay some attention to this point. In the figures previously
given for Ireland and for France, definite lines of division
were taken based upon population. But in England and
Wales the Kegistrar-General, when classifying deaths
according to ' Municipal Boroughs,' ' Urban Districts,'
and ' Rural Districts,' is unable to proceed on this basis,
since the distinction between these areas is often a matter
of history or convenience, and may have little relation to
the population or real character of the district. In
consequence we find included in urban districts a
large number of Municipal Boroughs with populations
of less than 5000, * and a still greater number of Urban
Districts with populations ranging from 5000 to 1000 or
even less, many of which are really rural villages. On
the other hand we find included in Rural Districts large
villages which have gradually grown up and perhaps
coalesced with adjacent villages, until they really form a
town of some size, though for registration purposes each
still forms a Rural District. This development has been
particularly marked in the northern counties of England,
where great mining areas such as those of Chester le Street
in Durham, with a population of 67,667 and an infant
mortality rate of 140, and Easington in the same county,
with a population of 64,935 and an infant mortality rate
of 159, contain large densely crowded villages with very
little of a really rural character about them. A picture
of the conditions in one of the so-called rural areas is given
on p. 91. For these reasons the statistical difference
between ' urban ' and ' rural,' when applied to the whole
of England and Wales, does not correspond entirely to real

1 E.g. Wallingford, Buckingham, Wokingham, Fowey, Helston, Penryn,
Okehampton, Lyme Regis, Chipping Norton, Bishop's Castle, Lymington, Romsey,
Southwold, Arundel, Malmesbury, Beaumaris.

INFANT MORTALITY

69

differences, and the general effect is to lower the urban
death-rate and raise the rural death-rate. In the succeed-
ing pages, therefore, most of the comparisons will be made
between the County Boroughs of the north of England
which are the great centres of industrialism, and the Rural
Districts of the south which do actually conform to their
description. The objection may be made that this com-
parison does not eliminate climatic differences, but we
shall see later that as regards infant mortality, climatic
differences appear to exert little effect, the rates and causes
of deaths being essentially the same whether we take the
south of England or the north of Scotland, and there is
no reason to doubt that this is equally true of deaths
at later ages. It is however more convenient to deal
with the statistics of the south of England than with those
of rural Scotland or Ireland since they are more complete.1
The rates of infant mortality in the areas defined are —

County Boroughs of the North . . .130

Rural Districts of the South ... 66

The preceding tables have shown the extreme difference
between purely rural and strongly urban districts. It is
important to notice however that low rates of infant
mortality may be found in towns, even of some size, in
which there is little overcrowding or industrialism, with
consequent purity of air and freedom from smoke —
" country " towns as many of them would be called —
though even in these the rates are generally higher than
in the purely rural districts. The following are examples of
such towns with their rates of infant mortality in 1914 : —

Bath .

59

Tunbridge Wells .

79

Bournemouth

72

St. Albans .

52

Canterbury .

60

Dover

76

Eastbourne

61

Folkestone .

62

Hastings

64

Worthing .

60

Oxford

72

Colchester .

82

Southend

69

Waltharnstow

77

Bedford

58

Leyton

79

Poole .

77

Hornsey

58

Rochester

80

East Ham .

76

1 In future references ' North ' includes Cheshire, Lancashire, Yorkshire, Dur-
ham, Northumberland, Cumberland, and Westmoreland ; ' South ' includes Surrey,
Kent, Sussex, Southampton, Isle of Wight, Berkshire, Wiltshire, Dorsetshire,
Devon, Cornwall, and Somerset.

70 HEALTH AND THE STATE

The proportion of seaside towns in this list is note-
worthy, and is possibly due to the fact that they are usually
built hi long strips parallel with the sea, and are thus
open to absolutely pure air along their greatest length.

The distribution of infant mortality is then very far
from uniform, the highest rates occurring in industrial
towns, the centres of great cities, and mining districts ;
while low rates are practically universal in rural districts,
and are met with in many towns of a rural character.
This distribution emphasises the need of local efforts to
reduce the evil rather than of measures of general applica-
tion which take no cognisance of local differences.

We shall see in the next chapter that the difference
between urban and rural rates of sickness and mortality
is not confined to infants, but extends to defects in
children, and to disease and death in all classes at all
ages. This is one of the most striking facts brought out
by a study of vital statistics ; but although recognised in a
general way, it is doubtful whether the full extent of the
difference has been realised, and it is certain that nothing
like sufficient attention has been devoted to ascertaining
its causes. If we are to reduce infant mortality in this
country, and improve Public Health in many other direc-
tions, recognition of the overwhelming effects of urbanisa-
tion, and investigation of its exact cause, must form the
basis of all effective action.

The Possible Causes of Infant Mortality

It might have been expected that with so important a
clue furnished by the distribution of infant deaths, some
unanimity would have existed as to the cause or causes
of these deaths. But this is not the case ; a great variety
of causes are brought forward, such as defective sanitation,
poverty, overcrowding, bad housing, insufficient nutrition
of the mother, want of breast-feeding, maternal ignorance,
and paternal vice, and there is little attempt to estimate
the relative effect of each of these factors. In general
it will be found that each investigator tends to regard
as the most potent influence that evil which is most often

POSSIBLE CAUSES OF INFANT MORTALITY 71

or most strongly brought under his notice. The gynaeco-
logist, while admitting other causes, dwells most urgently
upon pre-natal influences, such as syphilis or malnutrition,
and upon lack of attention at birth ; the educationalist
upon ignorance ; the temperance reformer upon alcohol-
ism ; and the worker among women upon the employment
of women in factories. As an illustration of the extent
to which views differ regarding the effects of different
influences, we may note the utterances of some distinguished
authorities. Dr. Newsholme, of the Local Government
Board, though he by no means excludes other factors, says
in the general summary of his report : " Infant mortality
is the most sensitive index we possess of social welfare and
of sanitary administration especially under urban condi-
tions."1 Sir George Newman, on the other hand, says :
" It is now a well-established truism to say that the most
w' injurious influences affecting the physical condition of
" young children arise from the habits, customs, and
" practices of the people themselves rather than from
" external surroundings or conditions. The environment
" of the infant is its mother. Its health and physical fitness
" are dependent primarily upon her health, her capacity
" in domesticity, and her knowledge of infant care and
" management." 2 And again : " The principal operating
" influence is the ignorance of the mother and the remedy is
" the education of the mother." 3 Dr. Mary Scharlieb, a
member of the Royal Commission on Venereal Diseases,
says : " The responsibility for the excessive amount of
" infant mortality must be distributed, as we have seen,
" among many causes, but probably the most frequent
" cause, and certainly the one most within our power both
" to avoid and cure, is syphilis." 4

There is no doubt that every one of the causes mentioned
operates to some extent ; but it is not sufficient merely
to know this, for some of them probably exert only a very
minor influence, while others are of great importance. It
is clear that we must have an idea of the relative effects
of different causes of infant mortality in order to apply

1 "Infant and Child Mortality," Supplement to Thirty-ninth Annual Re]iort
of the Local Government Board, 1910. a Annual Report for 1914.

3 Annual Report ior 1913. Italics in original. 4 Nineteenth Century, May 191 fi.

72 HEALTH AND THE STATE

sound remedies, for if we do not possess this, we may be
led to devote much attention to a factor which is only
slightly responsible, while neglecting those which produce
serious effect ; and it will be shown that this is actually
occurring. The problem of determining and measuring
the causes of infant mortality is exceedingly complex, and
in spite of the great amount of work which has been done,
still demands much further investigation, particularly
by persons not committed to definite views or holding
official positions, for these are apt in consequence to seek
only evidence in support of their views. Nevertheless, the
lowness of the infant mortality rates in rural districts
almost without exception should afford a valuable clue
as to what is the precise cause of the excessive rates in
urban environments, for it must be remembered that
many of the factors generally believed to be prejudicial to
infant life are as prevalent in country districts and villages
as in towns, and we have therefore considerable justification
for eliminating those factors which are common to the
two environments. We will examine seriatim the causes
most frequently held responsible for high infant mortality.
Poverty is often looked upon as one of the greatest
causes of infant deaths. Yet per se it does not appear to
be so. The wages paid in agricultural districts are notori-
ously the lowest paid in the community, yet the infant
mortality rate in rural Wiltshire averages only about 60,
while in Kensington the average is over 100. The earnings
of the Connaught peasant or the Highland crofter do not
approach those of the miners of Durham or Glamorgan-
shire, yet the loss of infant life among them is only one-
third of that in mining areas. The influence of poverty
is felt most directly in housing and food-supply, yet it is
impossible to say that in these respects rural districts are
better off than towns. It is well known that housing in
many rural districts is deplorable. A cottage may look
picturesque, but its thatched roof and creepers may hide
defective walls and floors, unsound drainage, low ceilings,
and ill-ventilated rooms, fully as bad as those in the
worst quarters of cities. The rooms may be overcrowded,
and there may be no adequate conveniences for cooking

POSSIBLE CAUSES OF INFANT MORTALITY 73

or maintaining cleanliness.1 And not only may the
cottages be defective, but in many villages there are
patches of overcrowding which present the worst features
of town slums. It is indeed well recognised that the
difficulty of obtaining sufficient housing accommodation
for labourers has been one of the great obstacles to agri-
cultural development in recent years. When we examine
food-supply we find no reason to suppose that the agri-
cultural worker is better off in this respect than the town
dweller. We know as a matter of fact that the poor in
rural districts are often insufficiently fed, and meat for
the family may be an exceptional luxury.

Defective Sanitation. — The word ' sanitation ' is here
used not in its widest sense as meaning all conditions
making for healthy living, but as applying to the services
for the supply of water and the removal of household waste
material, etc. As regards water-supply the services in
large towns under the control of big companies or muni-
cipalities are undoubtedly better than those in many
villages which are dependent upon wells and surface sources
for their water ; and the same difference applies to house-
hold sanitary conveniences. In various mining and in-
dustrial towns in the north of England it is true that the
ashpit system and insufficiently frequent removal of dust
and refuse contribute to infant mortality, particularly from
epidemic diarrhoea, but we cannot regard the difference
in these respects as sufficiently great or widespread to
account for the great difference between urban and rural
infant mortality. In many large towns, especially in the
south of England and the Midlands, the sanitary services
are highly efficient and in accord with the most modern

1 Mrs. Bruce Glasier has given us the following picture of such conditions : —
" I have myself lived among such women for over twelve years — for six of them
in a 5s. a week cottage in Derbyshire, and know by first-hand experience as well
as by intimate friendship what the work of such a home involves.

" There are no ' modern appliances,' no hot water at the sink, too often hardly a
decent oven, or a boiler for washing clothes ; lighting is by candle or paraffin
lamp, and mud will be mud — inches deep — and be brought into the house at all
hours of the day in wet weather as the children run to and fro. On a small wage,
in an overcrowded kitchen, to bake the bread and wash the clothes, to prepare
meals thriftily, to keep the children clean and mended and warmly provided for
— and not to let that home degenerate into an unkempt hovel or herself and her
children sink into a condition of grubby animalism, is to be a skilled and heroic
toiler, sixteen hours a day for seven days a week." — Daily News, February 21, 1916.

74 HEALTH AND THE STATE

ideas, yet some of these towns show an infant mortality
rate of over one hundred. In London, municipal sanita-
tion has attained a high level of excellence, yet wide areas
in the central parts exhibit an infant death-rate ranging
from 100 to 140 per thousand births. On the other hand,
sanitation in many rural districts is still very primitive.
In the west of Ireland many villages are deplorably insani-
tary and the habits of the people sometimes most un-
hygienic, yet these districts exhibit the lowest rates of
infant mortality to be found in the British Isles.

Infectious Diseases. — Another factor which might be
suggested, is the greater probability in towns of infection
by diseases common among children, such as measles,
whooping-cough, and diphtheria. To determine this point
with absolute certainty we require to know the number of
cases of each disease in urban and rural environments
respectively, and not merely the deaths ; but since measles
and whooping-cough are not notifiable diseases, this in-
formation is unavailable. General experience however
shows that both diseases are widespread in every type
of locality ; and wherever there is a school, opportunities
for transmission exist. Scarlet fever and diphtheria are
notifiable, and we find that the incidence of these diseases
does not differ largely in town and country ; notifications
of scarlet fever, in 1914, having been 474 per thousand of
the population in the aggregate of County Boroughs of
England, and 3 45 in the aggregate of Rural Districts ; and
notifications of diphtheria having been 1'54 and 132 re-
spectively. Arguing from analogy, we may infer that
measles and whooping-cough do not differ widely in
incidence in urban and rural districts ; though, as we
shall see later, their mortality rates are much higher in
industrial towns than in rural areas.

Breast-feeding is undoubtedly an important factor in
maintaining health in infants, but there is no reason to
suppose that it is not as widely adopted in towns as in
the country. Dr. Newsholme has estimated that over 80
per cent of wage-earning mothers suckle their children.
Dr. Manby of the Local Government Board, who specially
investigated this question in Widnes, where infant mor-

POSSIBLE CAUSES OF INFANT MORTALITY 15

tality is very high, found that breast-feeding among the
working classes was " almost universal." It may be
noted that the poorer the home the more likely is the infant
to be breast-fed, since it is the most economical course,
and also to some extent because of the widespread belief
among the uneducated that so long as a mother suckles
her child she will not again become pregnant. It is
certain that the proportion of mothers of the wealthier
classes who suckle their infants does not reach 80 per cent.1
Industrial Employment of Women. — This is a factor which
at first sight might appear to possess much importance,
since it might conceivably have an injurious effect upon the
infant while the mother is pregnant, and it is known that
after birth it tends to hinder breast-feeding. But special
researches here also have failed to establish a close and con-
stant connection between women's labour and high infant
mortality. In Wigan, for example, where only 12 per
cent of the total married women and widows are engaged
in non-domestic work, the infant mortality rate in 1913
was 180, whereas in the textile town of Rochdale with a
percentage of 28 so employed, the rate was only 106. The
question is complicated by the fact that among the poorest
classes harm caused by employment may be more than
counterbalanced by the additional food and home com-
forts which the mother is able to purchase with her earn-
ings ; but, as Dr. Newsholme has pointed out, the industrial
employment of married women cannot be looked upon

1 While it is important on many grounds to encourage breast-feeding, there is
perhaps some danger of exaggerating the harm done by artificial feeding. Statistics
certainly show that the death-rate among bottle-fed babies is much higher than
among naturally-fed infants, particularly from diarrhoea, but caution must be
observed in drawing conclusions from these, for it must be remembered that the
class of artificially-fed infants includes some who ceased to be breast-fed because
they were not thriving on that system, and their deaths may be due to some cause
acting before the artificial feeding was commenced. Experience among the
wealthier classes shows that if other conditions are satisfactory it is quite possible
to rear a healthy child on cows' milk. On the other hand, the investigations of
Dr. Lawson Dick, described on p. 118, show that rickets may be very prevalent
among children who have been breast-fed. The injurious effect of bottle-feeding
would appear to be limited to the first year of life. Dr. R. H. Norman, from a study
of 313 children between the ages of 3 and 8 years in the infant schools of St. Pancras
and Holborn, found that a larger percentage of children, who had been breast-fed
during the first year, fell below the average both in height and weight than bottle-
fed children. He points out, however, that we cannot eliminate other factors as
being responsible for the difference. ( Annual Report of London County Council on
Public Health, 1913.)

76 HEALTH AND THE STATE

as the chief cause of infant mortality. Dr. Greenwood,
formerly M.O.H. for Blackburn, found very little difference
in the infant mortality rates among mothers industrially
employed and those not so occupied, and he says: " As
a result of this investigation I came to the conclusion that
no case had been made out for the further restrictive
legislation in the prohibition of employment of women in
the cotton mills in Blackburn." x Dr. Jessie Duncan at
Birmingham found that there was scarcely any difference
in the weights of children whose mothers were industrially
employed and those whose mothers were not. We may see
that hard work is not necessarily incompatible with low
infant mortality, for women often undertake heavy labour
about farms, and even toil in the fields, in many parts of
France and the remoter districts of Scotland and Ireland.
The unprecedented demand for female labour during the
war does not seem so far to have caused any rise in the
infant mortality rate.

Skilled Attendance in Child-bed. — The value of attend-
ance by doctor or midwife will be examined in detail in
the chapter on Medical Treatment among the Working
Classes. For the present purpose it is sufficient to point
out that the facilities for such attendance are obviously
greater in towns than in country districts, in many of which
the supply of midwives is inadequate and the services of a
neighbour may be the only help available. In St. Helens,
Cardiff, Bootle, Walsall, and Stoke-on-Trent, from 80 to
100 per cent of all births are attended by midwives, yet
infant mortality in these towns is very high ; 2 on the other
hand there is no Midwives Act in Ireland, yet the infant
mortality rate in that country is very low. We shall see
later that the Midwives Act, which came into force in 1905
and has been steadily increasing the proportion of trained
midwives and improving the midwifery service generally,
has not been accompanied by any reduction in infant
mortality during the first month of life.

Ancillary services, such as infant clinics and consultation
centres, are also few and far between in rural districts.

1 Jour. Boy. San. Inst., voL.xxxii., 1911.

3 " Report on Maternal Mortality in Connection with Child-bearing," Supplement
to Forty-jourth Annual Report of the Local Government Board, 1914-15.

POSSIBLE CAUSES OF INFANT MORTALITY 77

Maternal Ignorance. — Ignorance of the mother as to
the proper way in which to feed and care for her child is at
present widely regarded as one of the chief causes of infant
mortality. Sir George Newman's views, already quoted,
meet with much support, and measures for the dispelling
of maternal ignorance form the basis of the modern cam-
paign which has led to the Notification of Births Acts,
the establishment of schools for mothers and classes in
1 mothercraft ' for girls, and the visiting and advising of
mothers on the care of infants — looked upon as a very
important part of a health visitor's duties. For the
present purpose it would be sufficient to point out that
facilities for such instruction are more numerous in towns
than in the country, and if they have an appreciable influ-
ence, we might expect mortality to be lower in urban than
rural districts. In view however of the importance now
attached to maternal ignorance as a cause of infant deaths,
it is desirable to examine the subject in greater detail.

That some ignorance exists among mothers is unques-
tionable, but many facts show that both its extent and
effects have been grossly exaggerated. If maternal ignor-
ance is the main cause of a high infant mortality rate, we
must necessarily conclude that where the rate is low
mothers are well instructed. But there is no reason to
believe that rural mothers are so much better informed in
the care of infants than their town sisters. We cannot
assume that the Con naught peasantry — many of whom
can neither read nor write — are so well instructed in the
care of infants that as a result infant mortality among
them, in spite of poverty and hard conditions, is one-half
that among the mothers of Kensington or Westminster,
and one-third of that in Bradford where so much has been
done in providing instruction for mothers. If it be ob-
jected that these areas are too widely separated and diverse
for fair comparison, then we can examine rates among
mothers drawn from the same class and brought up and
educated in essentially the same way, and we must
believe that mothers living in the peripheral parts of
London, such as Wandsworth, Stoke Newington, East
Ham, and Ilford, know far more about the care of infants

78 HEALTH AND THE STATE

than those in the central parts, such- as Bermondsey,
Finsbury, and Shoreditch. If instead of areas we examine
social classes, we find that the wives of woodmen and
foresters must be credited with as great a knowledge of
the conditions governing infant welfare as that possessed
by the professional groups ; and we must believe that the
wives of agricultural labourers and shepherds excel in this
respect all other classes of manual workers.

There is as much lack of the scientific spirit in drawing
deductions relating to infant mortality as is displayed in
regard to infectious diseases. If a school for mothers or an
infant clinic is opened in a district, and infant mortality
declines, the relation of cause and effect is at once claimed.
A well-known and earnest social reformer, describing the
instruction given to mothers at an infant clinic, writes :
" Special stress is laid on the hygiene of the home, good and
sufficient food, sufficient and suitable clothing, cleanliness,
and a proper amount of sleep. The children are examined
and weighed weekly, so that some idea can be gained as to
the beneficial results of the advice given." It is evident that
in the mind of this sincere philanthropist all improvement
must be ascribed to the advice given ; but it is impossible
to believe that those who write in this strain really know
the conditions among large masses of the poor and their
utter inability to follow the courses indicated. Dr.Wanklyn
of the London County Council has vigorously described the
difficulties against which the poor have to struggle, and
the following is an account he gives of a London tene-
ment which is typical of many such habitations : — *

The tenement comprises the two top rooms of a small house,
without any offices, conveniences, or adjuncts of any kind, except
a wall cupboard. The front room measures 14 ft. by 11 ft. by 6 ft.
6 ins., and the back room 9 ft. by 7 ft. by 6 ft. 6 ins. They are in
fair repair, but some wood-work running round the room is said to
be infested with bugs. . . . There is no place for storing food or
crockery or knives and forks and the rest, except one wall cupboard
in the front room. There is no scullery, no sink, or even water for
washing up, no draining board or any place on which to handle clean
things ; no water-closet nearer than at the foot of thirty-six stairs ;
the w.-c. is in the back-yard and is used in common by thirteen

1 " Working-class Home Conditions in London," Trans. Eoy. Soc. of Med., 1913.

POSSIBLE CAUSES OF INFANT MORTALITY 79

people in the house, no one person is responsible for its cleanliness.
There is no slop sink or a sink of any kind nearer than the w.-c.
There is a wash-house ; it is in the basement below the level of the
back- yard ; it is used on separate days by the various inmates of
the house. The yard may serve as a drying-ground, but it is a long
way off from the attic. There is no coal or wood store except the
wall cupboard in the front room. There is no cold water tap nearer
than in the back-yard or the basement. It was stated that as soon
as the tenement was occupied water was to be laid on to a tap placed
half-way between the first and second floors, with a small sink placed
underneath it. There is a small cooking range but no hot water
supply. Shortly afterwards there came to live in this tenement a
man and wife and four children, the six persons permitted by the
by-laws to occupy its cubic space.

Dr. Salter has stated recently that there are only 125
houses or tenements in Bermondsey with a bath-room,
and of these 96 are in public-houses. These conditions are
widespread, and they effectually prevent any semblance of
decent living. Cleanliness cannot be maintained ; privacy
is impossible ; children cannot sleep properly when there
are three or more in a bed ; and their growth is stunted
when their only fresh air is that of the slums, and their only
playground the streets. When we add to these conditions
the task of ekeing out a weekly wage to provide food for a
family, it becomes outrageous to ascribe dirt and neglect
to maternal ignorance under such circumstances.

Mrs. Pember Reeves, who has very ably investigated
housekeeping conditions among the poor, has given us a
number of family budgets, of which the following is a
typical one for a week : — 1
Mr. K., labourer. Wages 24s.

Rent

Burial insurance

Oil and candles

Coal .

Clothing club .

Soap, soda

Blacking and blacklead

Left for food
A note against the budget says : " Sole old pram for 3s., it was
too litle. Bourt boots for Siddy for 2s. 11 |d. Made a apeny."

Jlows wife 22s. 6d.

Six children.

s.

d.

8

6

1

0

0

8

1

6

0

6

0

5

0

li

12

H

9s. 9£

1.

1 Round about a Pound a Week, 1913.

80 HEALTH AND THE STATE

Mrs. Pember Eeeves says : " That the diet of the
poorer London children is insufficient, unscientific, and
utterly unsatisfactory is horribly true. But that the real
cause of this state of things is the ignorance and indiffer-
ence of their mothers is untrue. What person or body
of people, however educated and expert, could maintain
a working man in physical efficiency and rear healthy
children on the amount of money which is all these mothers
have to deal with ? It would be an impossible problem if
set to trained and expert people. How much more an
impossible problem when set to the saddened, weakened,
overburdened wives of London labourers ? ':

Here is another picture of life among the poor given by
a special constable i1 "On Thursday morning I was on
duty from two to six o'clock — a pouring wet morning —
and at 3 a.m. I counted no less than fourteen children
seeking the warmth of the brazier in Cheval Place. There
were three girls, aged eleven, twelve, and fourteen respec-
tively, and eleven boys, whose ages varied from nine to
fourteen. They lay huddled together on the wet flags
round the brazier in the rain — most of them thus falling
asleep — a truly pitiable sight ! One wonders what chance
these children can have of proper physical development."
These children had taken up their places in order to be the
first to buy the previous day's bread when the bakeries
opened at 6 a.m. Further letters showed that this was
not an exceptional occurrence, but that the practice had
been established for a considerable time in widely separated
districts. The children on inquiry were found to come
from respectable parents, to whom the loss of the bread
would have been a severe privation, and some of them had
walked a long way to reach the bakeries. Such are the
real conditions among the poor in this great country ; and
under these circumstances the glib statements of some
social reformers regarding maternal ignorance appear to
the writer intolerable.

1 Morning Post, January 13, 1915.

INFLUENCE OF PRE-NATAL CONDITIONS 81

The Influence of Adverse Pre-Natal Conditions

This also is regarded as a powerful cause of infant
mortality, of equal or even greater effect than maternal
ignorance. The view held is that either disease or mal-
nutrition or poor physical development in the mother affects
the infant during the period of gestation, and causes it to
be either still-born or born in a sickly condition which
leads to death soon after birth.

Of definite chronic diseases as distinguished from
general ill-health, syphilis is the only one which has a
distinct effect upon the infant and is sufficiently wide-
spread to influence the statistics, for we may neglect the
relatively small number of infant deaths due to maternal
heart-disease, diabetes, etc. Syphilis in either parent is
apt to affect the offspring, nevertheless we cannot regard
it as a large cause of infant mortality. The total recorded
infant mortality from this disease in England and Wales
in 1914 was 1*5 per thousand births, the total mortality
from all causes being 104'6. It is known that the statis-
tics on this point are unreliable, since deaths from syphilis
are sometimes certified under some other cause ; yet if we
double or even treble the recorded figure, syphilis still only
becomes responsible for a small proportion of the total loss
of life. Dr. Fildes,1 in an examination of 677 London
infants by means of the Wassermann test, found only four
syphilitic, of whom one died and two showed no symptoms.
The most frequent effect of syphilis is to cause still-birth,
but we shall see later that even in this direction there are
reasons for thinking that the effect of the disease has been
exaggerated.

The chief maternal conditions, then, which might be
expected to have an injurious effect upon the offspring
are poor development and malnutrition, and we must
examine the effect of these in the degrees commonly met
with among the working classes, and not those presented by
extreme cases. When this is done we shall find that mal-
nutrition in the mother appears to exert very little influence

1 " Report to Local Government Board upon the Prevalence of Congenital
Syphilis among the Newly-born of the East End of London," Reports on Public
Health and Medical Subjects (New Series, No. 105).

G

82 HEALTH AND THE STATE

upon the infant. It is well to be quite clear what is meant
by this statement. The writer does not suggest that a
mother who is literally half-starved or seriously mal-
formed will give birth to children as sound as those of a
well-nourished and well-developed woman ; but that on
the average the range of variation in these maternal con-
ditions from class to class and place to place is not suffi-
ciently great to produce an appreciable effect upon the
offspring. Working-class mothers in towns are certainly
on the average much less healthy and vigorous than those
in rural districts or those of the wealthier classes, but the
proportion of town mothers who exhibit extreme degrees
of defectiveness is after all but small. It would appear
that Nature provides for the offspring first, and though it is
difficult to believe that the infants of anaemic and poorly-
nourished mothers would not be affected, it seems that
unless the condition is extreme the infants do not suffer.
"Few things," says Sir George Newman, "are more re-
" markable in the life of the very poor than the apparent
" vigour and equipment of their offspring at the time of
"birth. . . . This does not indicate that the health or
" environment of the mothers during pregnancy is of no
" account. For such is not the case. The physique of
" the mother does unquestionably exert an effect on
" her offspring, but the tendency of nature is on behalf of
" her infant. It is well indeed that it is so, and it is this
" that brings perhaps 70-80 per cent of all new-born
" infants up to a mean physical standard in spite of ill
" environment or the poverty of the mother's physique." 1
To test this point we must compare the infant death-
rates of favourably and unfavourably situated classes
during the first few weeks of life before the influence of
the external environment begins to tell. If defective pre-
natal conditions are the main cause of infant mortality, we
should expect the difference in these classes to be greatest
in the early weeks of life, and to decrease as the child gets
older and farther from the original injurious influences.
On the other hand, if the post-natal environment is respon-
sible, we should expect the difference to increase the longer

1 Infant Mortality, 1906.

INFLUENCE OF PRE-NATAL CONDITIONS 83

the children are exposed to it. And this is exactly what
happens. The point is so important that it must be
examined in some detail.

The Chief Medical Officer to the London County Council
has grouped the Metropolitan Boroughs in order of ' social
condition,' the standard adopted being the percentage of
children in each Borough who were scheduled for education
in the Council schools. Group I., which is the best group,
contains Boroughs in which less than 82 per cent of the
children were so scheduled ; in Group V., which is the
worst, 97 per cent and over of the children were scheduled.
The following table shows the deaths per thousand births
in each group at various ages for the year 1913 : —

Infant Mortality in Kelation to ' Social Condition,' 1913

Age-period.

Group of Boroughs in order of ' Social Condition.'

I.

II.

III.

IV.

V.

Under 1 week
2nd week
3rd „
4th „

18-3
5-2
3-6
1-6

22-0
4-6
4-2
3-2

21-3
5-4
4-0

3-8

21-7
4-9
4-3

3-8

19-7

5-0
5-5
3-4

Under 1 month

28-7

34-0

34-5

34-7

33-6

0-3 months
4-6
7-9
10-12 „

45-1

13-3

7-6

9-0

51-7
18-2
13-6
13-2

54-5
20-0
14-6
13-6

55-1
19-3
16-0
13-6

56-9
27-0
22-0
19-2

0-12 months

75-0

96-7

102-7

104-0

125-1

Up to two weeks there is practically no difference in
the death-rate in any of the groups. After the first fort-
night the rate begins to rise in each group in comparison
with I., and exhibits the greatest rise in V. At age 4-6
months the rate in V. is twice as great as that in I., and
at 7-9 months it is nearly three times as great. It may
be of interest to give the figures for the Boroughs which
had the lowest and highest yearly rates : —

84 HEALTH AND THE STATE

Infant Mortality in Boroughs with Lowest and Highest Rates

Age-period.

Hampstead.

Lewisham.

Woolwich, j

Bermondsey.

Finsbury.

Shoreditch.

Under 1 week
2nd week
3rd „

4th „

21-1
4-5
3-0
1-5

17-0
5-1
4-0
1-4

20-0
4-2
3-8
3-8

19-8
3-6
4-9
2-5

21-2
5-5

8-2
4-3

21-6
6-5
6-8
2-3

Under 1 month

30-1

27-5

31-8

30-8

39-2

37-2

0-3 months
4-6
7-9
10-12 „

44-4

13-6

6-8

3-8

44-3
13-3

7-1
10-8

48-0

10-0

12-8

8-3

55-4
29-0
21-3
23-9

65-2
29-8
21-6
20-0

68-8
29-9
28-2
23-9

0-12 months

68-6

76-5

79-1

129-6

136-6

150-8

It will be noticed that while the rates in Hampstead
and Shoreditch are practically identical during the first
week, and Shoreditch only shows an excess of about
25 per cent in the first month, by the time the period 7-9
months is reached, the rate in Shoreditch is more than four
times as high as that in Hampstead, and at 10-12 months
it is more than six times as high.

Dr. Forbes, the Medical Officer of Health for Brighton,
has shown that in his district the death-rate under one
week is 20 '4 in the poorest class, and 20*5 in the well-to-
do class, whereas the rates for the whole year are 144 and
67 respectively. He remarks that if his statistics are
correct, " then the better feeding, the better housing, the
freeing of the mother from manual work and anxiety
before the birth of the child have no effect upon the health
of the child at birth."1

Dr. Stevenson, of the Registrar-General's Office, in-
cluded in his report for 1911 a special investigation into
the relations between infant mortality and the father's
occupation. He did not separate the rates in the first
week, but the following are his results at different
months : —

1 Jour. Roy. San. Inst., December 1915.

INFLUENCE OF PRE-NATAL CONDITIONS 85

Infant Mortality in Social Classes at Different Months
of 1st Year, 1911

Social Class.

Under 1
Month.

Middle and upper class
Agricultural labourers
Shopkeepers, dealers.

etc

Skilled workmen
Intermediate workmen
Textile workers .
Unskilled workmen .
Miners ....

30-2
36-8

36-5
36-8
38-6
444
42-5
46-5

2-3 4-6

Months. Months.

7-9

Months.

10-12
Months.

Total
under
1 Year.

14-9
17-9

20-6
21-2

22-7
27-9
28-6
28-3

13-0
18-2

20-3
22-1
23-8
32-3
31-4
33-7

9-9
13-0

16-3

17-8
19-7
23-6
26-2

27-5

8-4
11-0

12-7
14-8
16-7
19-9
23-8
24-1

76-4
96-9

106-4
112-7
121-5
148-1
152-5
160-1

These statistics show that the excess of mortality in
the class consisting mainly of unskilled labourers over
that of the middle and upper classes was 41 per cent in
the first month, 92 per cent at 2-3 months, 165 at 7-9
months, and 183 at 10-12 months. We shall see later
that even in the first month the excess among miners,
textile workers, and unskilled labourers must be attributed
to conditions in the external environment and not to pre-
natal influences. Commenting on the table, Dr. Stevenson
says : " These astonishing figures not only show what can
be done, but clearly point to the plan of campaign, viz.
an attack upon the causes of mortality in the later months
of the first year of life."

We have now compared death-rates at periods during
the first year in different types of urban areas and in
different social classes, and we will complete the investiga-
tion by comparing the rates in urban and rural districts,
this being the most important comparison of all in view of
the great difference in the yearly rates between these two
classes of areas. Unfortunately no recent statistics are
available showing the rates in the first week, nor can we set
out the figures for the extremes of conditions represented by
the County Boroughs of the North and the Rural Districts
of the South. The Registrar-General however gives the
rates for the County Boroughs and Rural Districts for

86

HEALTH AND THE STATE

England and Wales as a whole, and the following are his
figures for the year 1914 : —
Infant Mortality in County Boroughs and Rural Districts

. Under 1
Area- ! Month.

i

2-3

Months.

4-6

Months.

7-9

Months.

10-12

Months.

Under
] Year.

County Boroughs i 414
Rural Districts . j 36-7

22-8
14-8

22-2
13-4

18-2
11-2

16-2
9-3

120-8
854

Here again we notice that the difference between
urban and rural rates is small during the first month, but
increases steadily as age progresses. Dr. Stevenson says
of these figures : " The chances of survival seem to differ
but little at birth in town and in the country, but the
noxious influences of the former soon come into play,
and make themselves felt to an increasing extent as the
first year of life progresses, and to a still greater extent in
the second and third years when the urban excess generally
approaches 100 per cent, thereafter gradually declining."

Rates of mortality do not afford an absolutely complete
index of healthiness, for in addition we ought to compare
physical development and the incidence of non-lethal
defects in different classes. Information on these points
during the first month of life is scanty, but we may note
Dr. Kerr-Love's interesting and important observation
that the children of the poorest mothers in Glasgow weigh
on an average 7'1 lb. at birth, the average weight of a
healthy child being 7 lb.1

When we see therefore that the infant death-rate in
the first week of life is almost constant under all circum-
stances, and that the range of variation in the first month
is small, but that thereafter differences between favourably
and unfavourably situated classes become progressively
greater as the child gets older, we are led irresistibly to
the conclusion that these differences are almost entirely
due to the action of the post-natal environment and not
to the influence of pre-natal conditions. Unexpected
though the conclusion may have appeared at first, it is

1 Evidence given before the Royal Commission on Venereal Diseases.

SMOKE- AND DUST-POLLUTED ATMOSPHERE 87

impossible to interpret the figures otherwise than by the
view that on the average the children of all classes under
all circumstances are born equally healthy. This is not to
deny that in each class and in each type of environment
a certain number of children die from the pre-natal effects
of some deficiency or defect in the maternal organisation,
but we shall see later that this number is remarkably
constant and appears to have no relation to the external
environment. The town mother, though on the average
less well-nourished than her country sister, seems yet to
have a margin to spare, and Nature takes care that her
infant does not suffer. If the view that the infants of all
classes are born equally healthy is correct, it follows that
as far as physical development is concerned there is little in
the cry that we are breeding mainly from the ' worst stocks.'

The Effect of a Smoke- and Dust-polluted
Atmosphere

We have now examined, with one exception, the main
factors which might be held to account for a high rate of
infant mortality, and we find that differences neither in
poverty, bad housing, insufficient feeding, defective sanita-
tion, disease, industrial occupation of women, nor mal-
nutrition of mothers can be regarded as adequate to
explain the excessive and widespread difference between
urban and rural rates of infant mortality. The factor
which remains to be examined is that of smoke and dust
in the atmosphere. Dirtiness of the air appears to be the
one constant accompaniment of a high infant mortality :
purity of the atmosphere is the one great advantage which
the agricultural labourer of Wiltshire, the Connaught
peasant, and the poverty-stricken crofter of the High-
lands enjoy over the resident in the town. In the opinion
of the writer, a smoky and dusty atmosphere as a cause
of infant mortality far transcends all other influences.

We have noticed that the highest rates of infant
mortality always occur in manufacturing towns, and over
these there hangs throughout the year a pall of smoke
which has been estimated to cut off 20 per cent of bright

88 HEALTH AND THE STATE

sunshine, and as much as 40 per cent of the total light.
The soot emitted from the chimneys is not carried off by the
wind, but falls rapidly in the immediate neighbourhood.
This is established by investigations such as that of A. G.
Kuston,1 who has shown that the amount of solid material
deposited in the industrial area of Leeds is 1900 lb. per acre
per annum, while three miles north-east of the centre of
the town it is only 90 lb., and five miles from the centre
it is reduced to 62 lb. per acre. In Greater London the
annual fall is about 440 tons per square mile ; in Glasgow
it is 1330 tons, and in Coatbridge, the centre of the
Scottish iron industry, it reaches the amazing total of
1939 tons. In such towns, if the sanitary services for the
removal of refuse are not of the highest efficiency, the
atmosphere is further polluted by the dust blown up
from the dirty streets, back-yards, and ash-pits, and con-
tributes particularly to epidemics of enteritis among
infants. On the other hand, the purity of the atmosphere
explains the relatively low rates of infant mortality ex-
hibited by scattered, open, residential, or seaside towns
which have few factories. In correlation with these facts
we shall note the excessive mortality from respiratory
diseases among infants living in industrial towns.

The factories however are not alone to blame. In
large crowded areas the smoke poured out from the
thousands of domestic chimneys is equally pernicious,
and it is a remarkable fact that in all large cities the
infant mortality rate tends to increase steadily as we go
from the periphery towards the central districts which
never receive a wind that has not passed over a smoke-
laden area. This distribution is well illustrated by
London, but in order to study it we must have before us
a map of ' greater ' London, since we are not concerned
with the arbitrary boundary of the London County Council
area, but with the whole great patch of streets and houses.
There is an outlying ring all round London in which the
average infant mortality rate was 74 in 1914, and was as
low as 48 in Wanstead (66 in 1913, and 47 in 1912), 58 in
Hornsey, and 61 in Ilford. Inside this is an inner ring

1 Jour. Roy. San. Inst., 1912.

SMOKE- AND DUST-POLLUTED ATMOSPHERE 89

where the average rate in 1914 was 97 ; and in the centre
there is an area consisting of Finsbury, Shoreditch, Bethnal
Green, City of London, Southwark, Bermondsey, Stepney,
and Poplar, in which the average was 124, and the highest
figure 142 in Shoreditch.1

These differences may be due in part to the outlying
and more salubrious districts containing a larger pro-
portion of the wealthier classes, but it is clear that this
cannot be a preponderating influence from the fact that
the rates in such places as Ilford, East Ham, Waltham-
stow, Leyton, and Wanstead are as low or lower than
that in Hampstead, and lower than those in Kensington,
Paddington, and Westminster. We can test this point
better by reference to the urban area consisting of Paris
and its extensions beyond the walls, since Paris is a city
much more uniform in character than London and devoid
of large slum areas. In 1911 the infant mortality rates
in the central arrondissements ranged from 128 to 189 ;
in the outer districts they were from 70 to 110, while out
at Passy the rate was only 54. When considering the
distribution of infant mortality in a town, it must be
borne in mind that the children of the wealthier classes
are by no means so continuously subjected to the adverse
influence as those of the poorer classes. Not only are
there occasional and week-end visits to the country, but

1 The principal districts forming the outer ring are Ilford, East Ham, Barking,
Woolwich, Lewisham, Wandsworth, Barnes, Chiswick, Ealing, Willesden, Finchley,
Hampstead, Hornsey, Stoke Newington, Tottenham, Walthamstow, Leyton, and
Wanstead.

The inner ring consists of West Ham, Greenwich, Deptford, Camberwell,
Lambeth, Battersea, Fulham, Chelsea, Hammersmith, Kensington, Paddington,
Marylebone, St. Pancras, Islington, and Hackney.

There are no marked exceptions in the distribution described, but the rate in
Barking, 97, is exceptionally high for the outer ring. A most interesting object-
lesson is afforded by a comparative study of the two adjacent districts of Barking
and East Ham. Barking contains a number of large works, and its infant mortality
rate has averaged 105 for the three years 1912-14. East Ham is a clean Borough
with wide streets and open spaces, and at the time of the writer's visit the only
smoky chimney was that of the municipal electric generating station from which
great volumes of black smoke were pouring forth. It is but fair to add, however,
that the general condition of the streets, every one of which appeared to be lined
with trees, showed evidence of excellent municipal administration. The average
infant mortality rate in the Borough for 1912-14 was 70.

In the inner ring the rate of 64 in Chelsea was exceptionally low, but in 1913
the rate in this Borough was 90, and for the four years 1908-12, it averaged 99.
In the central area the rate in the City of London, 103, was lower than those in the
adjacent districts, but the number of births upon which it was based was only 185.

90 HEALTH AND THE STATE

a large proportion of the children are taken away from
town during the hottest month of the year, thus escaping
a particularly trying period, and increasing their power
of resisting adverse conditions on their return. It would
be interesting to know how much infant mortality in the
West End of London would rise, relatively high though
it is, if infants and their mothers saw as little of the country
throughout the year as most of the mothers in Bermondsey
and Shoreditch.

In Liverpool, Manchester, and most other large cities
the same tendency for infant mortality to increase rapidly
as the central and most crowded parts are approached is
observable.

The Committee for the Investigation of Atmospheric
Pollution is at present conducting an exceedingly im-
portant investigation into the purity of the atmosphere
in various districts, reports on which appear from time to
time in the Lancet. These results so far show remarkable
variations in the amount of solid material deposited in
districts not widely separated. Thus in Birmingham
Central, the mean monthly deposit amounts to 23 '23
metric tons per square kilometre, whereas in the south-
west district it is only 6 '04 ; in Manchester the deposit is
26 '79 tons at Ancoats Hospital, and only 5 '69 at Bowden ;
in London the measurement is 19 '47 tons in the Embank-
ment Gardens, 9 '40 at Wandsworth Common, and 8'44 at
Ravenscourt Park. As further information accumulates
the work of the Committee may prove to be one of the most
important Public Health investigations undertaken in
recent years.

Besides the large industrial towns, mining districts
almost always show high rates of infant mortality, particu-
larly the colliery districts. If a map showing the incidence
of infant mortality in England and Wales x be compared
with a map of the coal-fields, a very marked degree of
resemblance will be observed. In these districts there is
not only smoke, but dust to pollute the atmosphere.
Dr. Fletcher reporting on Chester -le- Street Rural (!)

1 Such a map will be found in the " Second Report on Infant and Child Mor-
tality," Supplement to the Forty-second Annual Report of the Local Government
Board.

SMOKE- AND DUST-POLLUTED ATMOSPHERE 91

District has at once drawn a good picture of trie conditions
and paid a tribute to the miners' wives. He says : —

As a class, however, and bearing in mind their inferior house-
accommodation and depressing surroundings of pit-mounds and
black coal-dusty paths, roads and open spaces about their houses,
and the general absence of gardens, the miners and their wives deserve
credit for their indoor cleanliness and tidiness, a condition the main-
tenance of which involves much labour in dry and windy weather,
when everything becomes smothered with coal-dust.

Dwellers in large towns, even in the better parts, are
largely unconscious of the dirtiness of the air which they
breathe every minute. The atmosphere may be com-
pared with a great lake of pure water, and the air in towns
resembles muddy pools in this lake, with the difference
that we can see the mud in the pools, but we cannot
see the dirt in the air. We can see it, however, when
it has collected in the little masses which are termed
:' blacks " so freely scattered over our window-sills.
Homely illustrations may help appreciation more than
statistics of deposits. The housewife well knows how
much more frequently she has to change her white curtains
in London than in her country cottage ; the city man,
though he travels first class, and sits in an apparently
spotless office, can note the difference in his cuffs and
linen between one day in town and a much longer time
in the country ; the schoolboy who climbs a tree in a
London park comes down begrimed, but he may climb
trees in the Surrey woods and scarcely show any such
effect. We are continually washing, cleaning, painting,
and papering the insides of our houses, but we cannot
touch a balcony rail outside without making our hands
filthy. This is the air which at every breath we take into
our lungs, and which is so vital to us that if we are
deprived of it for a couple of minutes we die. Can we
wonder that it has a poisonous effect upon the untried
lungs of the newly-born infant ?

The rain of solid particles falls upon us continuously
throughout the year, but is far greater in the winter
months when more fires are burning ; and it is possible
that a considerable part of the rise in the general death-

92 HEALTH AND THE STATE

rate which occurs in winter — the increase being particu-
larly marked in diseases of the respiratory system — is not
due to the cold to which we attribute it, but to the greater
pollution of the atmosphere owing to the larger number
of fires. Even more marked is the effect of the black fogs
of large towns, a single week of which causes a rapid rise in
the death-rate. In this case the moisture has precipitated
the dirt in the air and largely concentrated it in the lower
layers of the atmosphere.

Our knowledge of the physiology of respiration and
of the pathology of pulmonary diseases is still insufficient
to enable us to say how a polluted atmosphere exerts its
deleterious effect. Until quite recent years it was believed
that the harmful factors in ill- ventilated rooms were excess
of carbonic acid or diminution of oxygen. Leonard Hill
has however shoY\'n that this view is no longer tenable,
and has established that in close, ill-ventilated rooms the
deleterious factors are excessive heat and moisture in the
air.1 But this explanation will not account for the per-
nicious effect of smoke in the external air, and further
research is required to determine whether the harm is
actually due to solid particles or to mineral acids, sulphur-
ous fumes, or other noxious gases which accompany
smoke. The effects of breathing air containing dust of
particular kinds have long been recognised and are signi-
ficantly described by the terms ' coal miner's lung,'
' knife-grinder's rot,' and ' stone-mason's phthisis.' Post-
mortem examinations however show that the lung tissues
of all persons who live in smoky towns are impregnated
with sooty particles ; and it is scarcely a stretch of language
to say that in such an environment every one suffers from
a modified form of ' coal-miner's lung,' a condition which
lessens the power to resist bacterial invasion whether the
bacilli are directly inhaled or enter the body through
another channel.

We can actually see the injurious effects of a smoky
atmosphere in two directions in which we can definitely
eliminate other factors. The stone-work of buildings

1 " Report on Ventilation and the Effect of Open Air and Wind on the Re-
spiratory Metabolism," Reports to the Local Government Board on Public Health
and Medical Sxibjects (New Series, No. 100).

PATHOLOGICAL CAUSES OF INFANT DEATHS 93

becomes extensively corroded in course of time, particu-
larly that of older buildings erected before architects had
learnt which stones possess the greatest power of resisting
atmospheric corrosion. The effect of a smoky atmosphere
on vegetation is very obvious. Few plants grow as vigor-
ously in towns as in pure country air, and many will not
survive at all ; it is said, for instance, that lichens will
not live within several miles of London, and so far the
efforts to establish lichens upon the Mappin terraces in the
Zoological Gardens have failed. There is no question here
of ' maternal ignorance ' or ' pre-natal influences,' and the
effect is clearly due to some widespread factor in the air,
which if so injurious to vegetable life may reasonably be
supposed to be harmful to animal life.

In correlation with these facts we may note the im-
portance attached to the open-air treatment of disease,
long recognised in the case of phthisis, and now being
extended to the treatment of children suffering from
infectious diseases, and, as at Cambridge, of wounded
soldiers. But if the views of the writer are correct we
must distinguish sharply between ' pure ' air and ' open '
air. We do not provide conditions of health merely by
inducing slum-dwellers to keep their windows open, or by
lending, under sanatorium benefit, shelters for consump-
tives to be erected in the back-gardens of smoky towns.

The Pathological Causes of Infant Deaths

We have so far examined the environmental causes of
infant mortality, but we can also examine the question
from the totally different standpoint of the pathological
causes, and we shall find that, using a quite different chain
of reasoning and quite different sets of statistics, we can
confirm many of the conclusions reached in the preceding
pages.

If we enumerate all the diseases and conditions from
which infants die we obtain a fairly long list ; but most of
these are only of occasional occurrence, and, as a matter
of fact, by far the larger part of the mortality is brought

94

HEALTH AND THE STATE

about by quite a small number of diseases which fall into
the three following sharply-distinguished groups : —

(1) Respiratory diseases mainly pneumonia and bron-
chitis, but including deaths from measles and whooping-
cough, since nearly all fatal cases of these maladies are due
to the supervention of pneumonia or bronchitis.

(2) Epidemic diarrhoea and enteritis.

(3) Developmental diseases and malformations, that
is, conditions arising from some defect in the child present
at birth, a group which will be considered in detail sub-
sequently.

The following table shows the death-rates from these
causes in England and Wales, and in the extremes of urban
and rural conditions, for the year 1914 : —

Pathological Causes of Infant Deaths, 1914

Cause of Death.

Deaths under 1 year per 1000 births.

England
and Wales.

County
Boroughs
of North.

Rural

Districts
of South.

Total respiratory diseases

Pneumonia

Bronchitis ....

Whooping-cough

Measles ....

Pulmonary phthisis .

Other respiratory diseases
Diarrhoea and enteritis
Developmental conditions
Other diseases

25-65

10-40
7-75
4-38
2-14
•35
•63
17-37
35-97
25-63

35-03

14-03
10-76
5-31
3-77
•43
•73
23-54
39-42
31-78

13-86
6-01
4-69
2-14
•27
•29
•46
6-11
28-84
16-72

All causes ....

104-62

129-77

65-53

It will be noticed that the excess of infant mortality in
the County Boroughs over that in the Rural Districts is
mainly due to the great increase in deaths from two causes,
viz. respiratory diseases and enteritis. The excess from
respiratory diseases is 153 per cent, and from diarrhoea
285 per cent; whereas the excess from developmental
conditions is only 37 per cent and from other diseases 90
per cent. The class ' other diseases ' consists mainly of

PATHOLOGICAL CAUSES OF INFANT DEATHS 95

non-pulmonary tuberculosis, rickets, convulsions, and so-
called overlying, and it is probable that a certain number
of these deaths might equally well have been certified as
due to respiratory causes. There are reasons for believing,
for instance, that a large proportion of the deaths attributed
to overlying are really due to respiratory diseases (v. p. 298)
and ' convulsions ' is a purely symptomatic term, the
deaths usually resulting from rickets. In view of the
possibility discussed on p. 74 that the higher death-
rates from measles and whooping-cough in the County
Boroughs of the North are due to greater incidence of these
diseases owing to increased opportunity for infection, it
may be noted that in the County Boroughs of the South,
where probably the opportunities for infection are just as
great but the atmosphere is distinctly purer, the death-
rate in 1914 from measles was 107 and from whooping-
cough 3'39 per 1000 births.

It is impossible not to correlate the very marked
excess of infant mortality from respiratory diseases in
large towns with impurities in the atmosphere. It would
not be appropriate here to discuss in detail the pathology
of the process, but it is most probable that the irritation set
up in the lungs renders them peculiarly liable to attacks
of micro-organisms.

Epidemic diarrhoea is a disease the exact etiology of
which is still obscure. Nevertheless it is definitely estab-
lished that the disease is most prevalent and fatal in hot
dusty weather, the incidence always rising rapidly in the
third quarter of the year in all types of districts, though
the increase is far greater in the County Boroughs than in
the Rural Districts.1 Dr. Newsholme has repeatedly em-
phasised the injurious effect of dust blown up from dirty
streets, ash-pits, and privies in towns where scavenging
is inefficient. It seems probable that the infection is
conveyed into the system through food, and it is possible

1 Dr. Ralph Vincent says : " The higher the temperature of the late summer,
the greater the prevalence of the disease, especially if this high temperature be
associated with but Uttle rain. In other words, meteorological conditions involving
a high temperature with much dust are those which promote the conditions which
accompany the greatest incidence of the disease." — Etiology of Zymotic Enteritis,
1910.

96

HEALTH AND THE STATE

that the value of breast-feeding arises not so much from
an inherent superiority of human milk as from the fact
that it affords a pure supply.

The criticism may be made that the writer has ignored
climatic differences in comparing the warm and dry south
with the relatively cold and wet north, and it may be urged
that this is at least partially responsible for the excess of
respiratory diseases. To meet this criticism therefore
the following table has been compiled for the County
Districts of the northern half of Scotland, where, if cold
and wet are important factors in producing respiratory
diseases in infants, the greatest effect should be observed.
The area dealt with consists of the counties of Orkney,
Shetland, Caithness, Sutherland, Eoss and Cromarty,
Nairn, Aberdeen, Elgin, Banff, Inverness, Kincardine,
Argyll, Perth, and Forfar for the year 1914, the total
number of births being 11,107.

Pathological Causes of Infant Deaths in Northern
Scotland, 1914

Cause of Death.

Deaths under 1 year
per 1000 births.

Total respiratory diseases .
Pneumonia

15-50
6-32

Bronchitis ....

4-86

Whooping-cough
Measles ....

2-97
•54

Pulmonary phthisis .
Other respiratory diseases
Diarrhoea and enteritis

•18
•63
6-12

Developmental conditions .
Other diseases

26-38
j 19-08

All causes ....

67-08

We have here a record of the pathological causes of
infant mortality under perhaps the most extreme differ-
ence of rural conditions as compared with the south of
England to be found in the British Isles, yet it will be
noticed that the differences in the death-rates are astonish-
ingly small. Deaths from pneumonia, bronchitis, and
diarrhoea are almost identical, and the difference in whoop-

DEVELOPMENTAL CONDITIONS 97

ing-cough and measles would probably have disappeared
if the statistics had been calculated over a term of years.

Deaths from Developmental Conditions

We must now direct attention to the third great cause
of infant mortality, viz. developmental conditions, from
which we can learn lessons of entirely different character
but of equally great importance. The tables given show
that the range of variation in the mortality from develop-
mental conditions does not approach in any degree that
exhibited by other causes of death, leading to the remark-
able and apparently paradoxical result that in rural dis-
tricts, although the mothers are the healthiest, develop-
mental conditions form by far the largest single cause of
infant mortality, accounting for more than 40 per cent
of the total deaths in the first year. In Berkshire and
Oxfordshire, the two counties in winch the rural infant
mortality was lowest in 1914, no less than 111 out of a
total of 243 infant deaths were due to developmental
conditions.

The actual range of variation in deaths due exclusively
to conditions existing at birth is, however, even smaller
than that shown by the deaths in the table, since the latter
include a small proportion which are really due to the in-
fluence of the post-natal environment. In order to bring
out this fact and demonstrate the remarkable constancy
under all circumstances in the death-rate from conditions
present at birth, we must analyse this group more fully.

The term ' developmental conditions ' is applied to a
group of diseases or structural deficiencies, well recognised
by medical men, which consists of the following sub-
divisions : —

Premature birth.
Congenital malformations.
Atrophy, debility, and marasmus.
The first two are clearly due to conditions operating
before birth ; the third is less definite. It is applied to
conditions of wasting observed in young infants, not
caused by any definitely recognisable disease. In the first

H

98

HEALTH AND THE STATE

month deaths from atrophy, etc. appear almost always to
be due to some deficiency existing at birth, but in the later
months it is impossible to distinguish with certainty
between the influence of the environment and congenital
influences. In order therefore to eliminate as far as pos-
sible this element of uncertainty we must measure deaths
from developmental conditions not by the mortality in the
whole year, but by that in the first month. The following
table shows the distribution of deaths from all three causes
according to months of the first year : —

Infant Mortality
per

from Developmental Conditions
1000 Births, 1914

Cause of Death.

Under 1
Month.

2-3

Months.

4-6 7-9

Months. Months.

10-12
Months.

Total
under
1 Year.

Premature birth
Congenital mal-
formations
Atrophy,debility,
and marasmus

17-88
2-47
6-55

1-57

•73

3-01

•24

•40

1-79

•03
•18

•70

•01

•11

•37

19-73

3-89

12-42

The two influences, pre-natal conditions and post-natal
environment, really interdigitate to some extent, but the
above figures show that by drawing the line at the end of
the first month we obtain a fairly sharp line of division ;
for in those deaths, even from premature birth and con-
genital malformations, which occur after the first month
we cannot positively exclude the effect of the environment ;
while, on the other hand, we know from the earlier investi-
gations that the influence of the post-natal environment
in causing mortality is small during the first month.

We have now to examine the death-rates from develop-
mental conditions in the first month under various circum-
stances. The comparison between urban and rural dis-
tricts is the most important, but unfortunately statistics
are not available to enable the rates in the County Boroughs
of the North and the Rural Districts of the South to be
compared. The Registrar-General, however, gives the fol-
lowing figures for London, the County Boroughs, other
Urban Districts, and Rural Districts for England and

DEVELOPMENTAL CONDITIONS

99

Wales as a whole. We can introduce into the same table
another element of variation by including the figures for
1911 as well as those of 1914. The year 1911 was one
with a summer heat of almost tropical intensity, and infant
mortality in England and Wales rose to 130 ; 1914 was a
comparatively cool year and the rate was only 105.1

Deaths from Developmental Conditions under one Month
per 1000 Births

Area.

Premature Congenital
Birth. j Malformations.

Atrophy,

Debility, and

Marasmus.

1911.

1914. 1911. 1 1914.

1911.

1914.

London ....
County Boroughs .
Other Urban Districts .
Rural Districts
All Urban Districts

16-43
19-66
18-21
17-09
18-51

16-14
19-30
17-76
16-77
18-16

2-58
2-21
2-43
2-12
2-36

2-14
2-45
2-64
2-44
2-47

5-24
7-98
8-07
8-49

7-58

4-41

6-78
6-84
7-06
6-42

We note in this table the small range of variation in
the death-rates from developmental conditions, whether
we compare different types of areas or years of very differ-
ent meteorological conditions. London has a small advan-
tage throughout, but this is probably due partly to differ-
ences in diagnosis.2 In any case the range of variation
is of a wholly different order from that presented by the
total infant mortality in urban and rural areas, or that
exhibited by the death-rates from pneumonia and diarrhoea.
In the first month the mortality from these two diseases
is small everywhere, but is nevertheless 60 per cent higher
in London and in the County Boroughs than in the Rural
Districts.

We have yet another system of classification which

1 The writer has preferred to take 1914, since it is the most recent year for
which statistics are available, but the contrast between the two years would have
been increased by taking 1912, when the infant mortality rate was 95, the lowest
on record. As a matter of fact the figures for 1912 are practically identical with
those for 1911 or 1914.

2 It may be noticed that in London deaths certified as due to syphilis, pneu-
monia, and atelectasis (a condition of collapse of the lungs occurring shortly after
birth), though causing in the aggregate only a small mortality in the first month,
are all higher than in any other part of the country.

100

HEALTH AND THE STATE

admits of further comparisons, viz. social classes. The
death-rates from developmental conditions in the first
month according to social classes were tabulated as part
of the special investigation undertaken by the Kegistrar-
General in 1911, and the following are his figures : —

Deaths from Developmental Conditions under one Month
per 1000 Births in Social Classes, 1911

Social Class.

Premature
Birth.

Congenital
Malformations.

Atrophy,

Debility, and

Marasmus.

Middle and upper class
Shopkeepers, dealers, etc
Skilled workmen
Intermediate workmen
Unskilled workmen .
Textile workers
Miners
Agricultural labourers

13-8
16-6
17-1
17-7
19-0
19-1
20-3
16-9

2-3
2-0
2-4
2-4
2-4
3-0
2-3
2-2

5-6
6-3
6-6

7-0
8-2
8-7
9-9
8-1

Again we notice the small range of variation from class
to class and the remarkable way in which the figures agree
with those given in the preceding table. Unskilled work-
men, textile workers, and miners, who are under the worst
conditions, show some increase above the upper and
middle classes as regards death from prematurity and from
atrophy, but it would be almost impossible to determine
whether this is due to causes acting on the mother before
birth, or to adverse factors in the post-natal environment
killing off: some prematurely-born infants in the first month,
who would have survived, either permanently or until after
the first month, if they had received the care and attention
they are likely to receive in the upper and middle classes.
Statistics showing the mortality during the first week,
and still more in the first day, in different social classes
would materially assist to determine this point. The
smaller number of premature births in the upper and
middle classes may also in part be due to some premature
births being regarded as still-births, for about one- quarter
of the total deaths in the first month occur during the first
day, and in those cases where an infant dies very shortly

DEVELOPMENTAL CONDITIONS 101

after birth, perhaps only having made a few movements
or convulsive gasps for breath, it is a very fine line which
divides live-birth from dead-birth. It is a fact of some
psychological interest that many mothers are less distressed
at having a miscarriage than at giving birth to an infant
which dies immediately ; and the slight straining of the law
to spare the mother's feelings is perhaps more apt to occur
among a class where births are mainly attended by doctors
than in a class where they are principally attended by
midwives.

The most significant feature of the table is the agree-
ment of the rates among agricultural labourers with those
in other classes of manual workers, although, as we have
seen, they have so great an advantage over other classes
in all other causes of infant mortality.

We have now compared deaths from developmental
conditions during the first month in urban and rural areas ;
in years of different meteorological conditions; and in dif-
ferent social classes, and we find a remarkably constant
death-rate running throughout, which presents the strongest
possible contrast to other causes of infant deaths. Mor-
tality from this cause appears to bear almost no relation to
the external environment of the mother : a very hot year
does not send it up ; rural conditions do not bring it down ;
and, even if we assume that the statistical difference
between the middle and upper classes and miners represents
a real difference, the effect of the best social circumstances
over the worst is far smaller than that apparent in other
causes of infant mortality. To the writer these facts
seem to lead irresistibly to the conclusion that the great
bulk of these deaths are due to some obscure internal
derangement of normal processes in the mother or infant,
which are either independent of the external environment,
or are due to some factor or factors in the external environ-
ment equally common among all classes and in all environ-
ments. It would appear that the structural or physiologi-
cal defects leading to these deaths really fall into the same
category as those minor defects, such as moles, nsevi,
contracted foreskins, etc., which are exhibited by a certain
proportion of children, but do not characterise any par-

102 . HEALTH AND THE STATE

ticular class or environment, and do not appear to have
any recognisable relation to external conditions. We can
write ofE a small proportion of deaths from premature birth
in large cities as due to syphilis, but we know that this is
an inappreciable cause of prematurity in rural districts.
A few others are due to acute illness or accidents to the
mother ; but of by far the greatest number of deaths from
developmental conditions we do not know the cause, and
we do not know how to prevent this mortality. It would
conceivably be possible to reduce the death-rate to some
extent by carefully watching every mother from the begin-
ning to the end of pregnancy, providing her with a highly
skilled gynaecologist during confinement, and protecting
premature infants by means of incubators and other scien-
tific refinements. But these extreme measures are not
practicable, and, as we shall see later, all our efforts in this
direction have not so far had any appreciable effect in
reducing infant mortality. Nor is it certain that the rear-
ing of a certain number of congenitally puny and sickly
infants would be of any benefit to the race, for these deaths
appear to represent Nature's failures. Just as in every
packet of seeds there are some that do not germinate,
and in the young of every flock some which do not
survive, so it would appear that mankind must inevitably
lose a certain proportion of his offspring, and with his
present knowledge he cannot hope to prevent this loss.
The deaths from developmental conditions in the first month
appear to range from 25 to 30 per thousand births, and
this probably represents the real natural death-rate which
was postulated at the beginning of the chapter. We see
here natural selection in operation, uncontrolled and unin-
fluenced by man's efforts, steadily eliminating the unfit ;
and we realise how utterly shallow is the argument some-
times brought forward that by preventing infant deaths
we are in the long run injuring the national physique by
interfering with natural processes. We cannot save those
whom Nature has condemned ; we can only prevent
deaths from our own errors.

We have still to examine another class of facts bear-
ing upon this conclusion, particularly the reasons for the

STILL-BIRTHS 103

decline in infant mortality during recent years, and the
period in the first year at which this decline has occurred.
It will be convenient, however, to digress for a moment and
examine the subject of still -births since this is so inti-
mately connected with maternal conditions.

Still-Births

Still-births are not registered in this country, and we
have consequently no reliable statistics regarding them.
Still-births occurring after the twenty-eighth week of
pregnancy must now be notified under the Notification of
Births Acts, but the law is so incompletely observed —
the proportion of notifications ranging from 77"8 per thou-
sand births in Blackpool and 56" 1 in Rochdale to 18'3 in
Liverpool and 16*3 in Southampton — that no reliable
deductions can be drawn from the returns.

Knowledge of the causes of still-births is still very
indefinite. Probably a large number are due to inevitable
and uncontrollable natural conditions, and some are caused
by accident, acute illness, excessive fatigue, etc. ; but for
the present purpose it is only necessary to consider one
cause, viz. syphilis, since it is practically the only one over
which the community might exercise some measure of
control. Syphilis is generally believed to be responsible
for a very high proportion of still-births. Dr. Newsholme
in his report for 1913-14 says : "It appears likely that in
' the practice of midwives the dead births amount to about
' 3 per cent of all the births attended by them. Dr. Routh,
' on the basis of a wide series of observations by many
' authorities over a large field, estimates that abortions at
' an earlier period of pregnancy are four times the number
' of dead-births. This would imply a total ante-natal
' mortality of 150 per thousand births, which is much
' higher than the total mortality in the first year after
' birth. From evidence published by the Royal Com-
' mission on Venereal Diseases, it appears likely that one-
' half of this ante-natal mortality is ascribable to syphilis."
It is of course well established that syphilis is an im-
portant cause of still-births, and there is no doubt that it

104 HEALTH AND THE STATE

is responsible for a considerably higher pre-natal than
post-natal mortality. Nevertheless, in the opinion of the
writer the estimate of the Royal Commission is seriously
exaggerated. Careful search through the report and
volumes of evidence issued by the Commission fails to
yield any scientific data in support of the estimate ; and it
appears to have been based upon personal impressions
of witnesses derived mainly from hospital experience in
large towns, where, as we know, syphilis is most prevalent.1
More scientific investigations appear to indicate that the
proportion of still-births due to syphilis is considerably
smaller. Dr. Whitridge Williams, for example, has found
in a study of 705 fetal deaths after the seventh month of
pregnancy and including the first fortnight after delivery,
among 10,000 consecutive admissions of women to the
Johns Hopkins Hospital in Baltimore, that in the white
women the percentage of these due to syphilis was only
fourteen. Among negro women the percentage was
thirty-five.2 It is significant to note that notwithstand-
ing the most painstaking investigation no satisfactory
explanation could be found for 18 per cent of the total
fetal deaths from all causes.

Much greater investigation of the causes, number, and

1 The exact statement made in the report is as follows : — " Of registered still-
births probably at least half are due to syphilis (Q. 6519, 11,650, 13,040)."

The author assumes that ' registered ' in this statement means ' notified.'

The following were the questions and answers to which reference is given in
support of the statement : —

6519. Could you give us any idea as to what proportion of these 3 per cent
would be due to syphilis ? — (Sir Thomas Barlow) This is only an impression, but
my impression is that the vast majority of them are.

11,650. So that a very large percentage of still-births, nearly half we might
say, is due to syphilis ? — (Dr. Florence Willey) Yes.

[Dr. Willey had submitted statistics showing that among 77 still-births
occurring in five years in the outdoor practice of the Royal Free Hospital,
24, or 31 "2 per cent, were considered to be due to syphilis. In the majority of
these cases the diagnosis had been based on clinical evidence only.]

13,040. Would you agree that it is 50 per cent as has been suggested here by a
witness ? — (Miss Frances Ivens, M.S.) Yes, I should think quite that.

[In a previous question Miss Ivens stated that she had no statistics.]

It will be noticed that three impressions by persons, each of whom is attached
to a hospital in a large town, is the foundation for the sweeping statement in the
report. The next stage in the creation of a belief is the issue of circulars and
leaflets by philanthropic societies in which the word ' probably ' and references
to evidence are dropped ; and finally it becomes an established canon that more
than one-half of all still-births whether notified or not, are due to syphilis.

2 " The Limitations and Possibilities of Pre-Natal Care," Jour. Amer. Med. Ass.,
January 9, 1915.

DECLINE IN INFANT MORTALITY

105

distribution of still-births is required before we can speak
with any degree of certainty as to the future. We may
be able to reduce fetal deaths from syphilis, but to the
author the outlook for reducing still-births from other
causes is not very promising.

The Decline in Infant Mortality in Recent Years

To return to infant mortality. The conclusions we
have come to are : (1) that the preventable deaths of in-
fants are those due to conditions in the post-natal environ-
ment, mainly smoke and dust in the atmosphere, giving
rise to respiratory diseases and enteritis ; and (2) that
the mortality from developmental conditions, which is
almost restricted to the first month, is practically beyond
control. If these conclusions are correct, then efforts
specially directed towards conditions prevailing before
birth and in the first few weeks of life are futile and wasted.
The greater part of our efforts to reduce infant mortality,
such as the Midwives Act, the Notification of Births Acts,
pre-natal clinics, schools for mothers, and infant consulta-
tion centres, are of this character, and it will be — as it
often has been — claimed that the fall in infant mortality
has proved the value of these measures. This point there-
fore demands very careful investigation.

The following table shows the movements in infant
mortality since 1880 in England and Wales : —

Infant Mortality in England and Wales, 1881-1915

Deaths under

Deaths under

Year.

1 Year per

Year.

1 Year per

1000 Births.

1000 Births.

1881-1885

139

1907

118

1886-1890

145

1908

120

1891-1895

151

1909

109

1896-1900

156

1910

105

1901

151

1911

130

1902

133

1912

95

1903

132

1913

108

1904

145

1914

105

1905

128

1915

110

1906

132

106 HEALTH AND THE STATE

It will be seen that there has been by no means a
constant downward trend. The rate for the period 1891
to 1901 was for some unknown reason high as compared
with the rate in 1881-85. Thereafter the fall has
occurred mainly in two periods. There was an abrupt
decline in 1902, and then, with some rise in 1904, the rate
remained constant until 1906. Two years of intermediate
mortality are followed by another abrupt fall in 1909, and
again with an exceptional rise in 1911, and an exceptional
fall in 1912, the rate has remained nearly constant to the
present year.

It is impossible to correlate those movements with
legislative and administrative measures. The Midwives
Act was passed in 1902, but did not come into force
until 1905 ; and it did not produce any abrupt change as
it took in all midwives then in bona fide practice, and it is
estimated that even in 1913 more than 50 per cent of
practising midwives were untrained women who came in
at the beginning.1 The Notification of Births Act, which
is the foundation of modern methods, was passed m
August 1907, but it was then an adoptive Act, and several
years elapsed before it was at all widely adopted by Local
Authorities. Even by the end of 1913 the Act was not
in force in 13 County Boroughs, 159 Municipal Boroughs,
and 1230 Urban and Rural Districts with a total population
of nearly 15 millions. The Act cannot be held to account
for the abrupt fall in 1909, for if its very partial adoption
during the first two years produced so great an effect, why
has not this effect continually increased in subsequent
years with the steadily increasing extension of the Act ?
The growth of schools for mothers, infant clinics, ante-
natal clinics, and visiting by health visitors has occurred
almost entirely since 1910, and has increased with each
year, but the effect on the infant mortality rate seems to
have been nil.

It is perhaps fairer to test the value of these methods,
not by reference to the infant mortality rate for the whole
country, but by the rate in a district where they have been

1 " Report on Maternal Mortality in connection with Child-Bearing," Supple-
ment to Forty-fourth Annual Report of Local Government Board.

DECLINE IN INFANT MORTALITY

107

most zealously applied. Bradford affords a good instance
for this purpose. The city was one of the first to adopt
the Notification of Births Act, and it has earned a high
reputation for the energy it has shown in providing for
the care of infant and maternal life. It possesses an ante-
natal clinic and maternity hospital, an infant clinic with
hospital attached, a system of supplying nursing and
expectant mothers with food in order to encourage breast-
feeding, a municipal milk depot, and a staff of health
visitors, who are in touch with all the departments of the
child welfare scheme. We have here a picture of municipal
concern for the Public Health which affords one instance
in reply to those who assert that Local Authorities are
"' neglectful ' ; and if these efforts are largely wasted and
futile, it is not for want of local enterprise and energy, but
for lack of an independent, central, investigating authority,
whose business it should be to determine the real factors
influencing Public Health, afford sound guidance to Local
Authorities, and prevent the dissemination of erroneous
views.

For what has been the infant mortality record of
Bradford ? We will examine the rates for the same years
as in the previous table.

Infant Mortality in Bradford, 1881-1915

1 Deaths under

Deaths under

Year.

1 Year per

Year.

1 Year per

1000 Births.

1000 Births.

1881-1885

160

1907

124

1886-1890

170

1908

143

1891-1895

176

1909

116

1896-1900

165

1910

127

1901

168

1911

140

1902

139

1912

99

1903

148

1913

128

1904

167

1914

122

1905

144

1915

123

1906

152

i

Comparison with the previous table shows that infant
mortality in Bradford has varied almost exactly as it has
in England and Wales as a whole. There was a high rate

108

HEALTH AND THE STATE

from 1891 to 1901 ; an abrupt fall in 1902, which continued
to 1906, except for a rise in 1904 ; and a further abrupt
fall in 1909, which has continued to 1915, broken by the
rise in 1911 and the fall in 1912. It is obvious that these
variations have not been due to local efforts but to changes
in conditions which have prevailed more or less all over
England and Wales. When we recall that there are
reasons for thinking that a natural death-rate need not
exceed 30 per thousand, and that wide areas in all parts
of the country exhibit a rate which does not exceed 60
per thousand, it is clear that even if we ascribe the whole
decline to the efforts made, these efforts are merely touch-
ing the fringe of the problem.

We will complete this investigation by showing at what
periods in the first year infant mortality has declined.
Unfortunately the Kegistrar-General did not tabulate
deaths in the first month previous to 1905, though we can
get earlier statistics for the first three months together.
The following table shows the information available for
England and Wales : —

Infant Mortality in Periods op First Year, 1898-1914

Year.

Under 1

2-3

Total under

4-6

7-12

Month.

Months.

3 Months.

Months.

Months.

1898

1

75-1

35-2

50-1

1899

76-9

35-7

50-0

1900

74-2

32-7

47-3

1901

74-8

32-0

44-5

1902

68-4

25-8

38-7

1903

67-6

26-2

37-8

1904

70-9

30-1

44-3

1905

41-7

24-8

66-6

24-8

36-8

1906

41-9

25-7

67-6

27-0

37-9

1907

40-7

23-3

64-0

21-3

32-3

1908

40-3

24-2

64-4

23-6

32-4

1909

39-7

20-4

60-1

19-2

29-4

1910

38-5

20-0

58-5

18-8

28-2

1911

40-6,

24-8

65-4

26-1

38-5

1912

38-4

17-6

56-0

14-8

23-9

1913

39-4

20-3

59-7

19-8

28-9

1914

38-5

19-4

57-9

18-8

28-0

DECLINE IN INFANT MORTALITY 109

It will be seen that during the first month the death-rate
has been almost constant for ten years. In the second and
third months it has fallen about 20 per cent comparing
1905 with 1914. In the fourth, fifth, and sixth months
it has fallen 24 per cent in the same period, and nearly
50 per cent if we go back to 1898. In the period including
the seventh to the twelfth month the rate has fallen 24
per cent comparing 1905 and 1914, and again nearly 50
per cent as compared with 1898. It is not necessary to
set out similar tables for Urban and Rural Districts, since
they present exactly the same characters, the average rate
in the first month in the County Boroughs of England and
Wales during the four years 1911-14 having been 42'0 ;
while in the Rural Districts, in the same period, it was 38 0,
again showing how limited is the special effect of an urban
environment during the first month. Infant mortality
has declined appreciably during the last ten years ; there
has been some fall during the second and third months
of the first year, but by far the larger part of the decline
has occurred during the last nine months of the first year.
There is no reason to correlate this decline with efforts
specially concerned with conditions during the first few
weeks, the death-rate from which has scarcely varied.
On the other hand, as we shall see in the next chapter,
the fall has been part of a larger general decline in the
death-rate, which has been particularly marked during
the earlier years of life. We shall see that the death-rate
during the second year has fallen 40 per cent since 1895,
and that during the third, fourth, and fifth years the fall
has been even greater, though no special efforts have been
made to protect life at these ages. There seems every
reason to believe that the circumstances — natural or
social — which have led to the decline in one case have
also brought it about in the other.

The fact appears to be that under the term ' infant
mortality ' we are classing together two radically different
types of deaths, which are brought about by different
causes and governed by different influences. The first
type consists of deaths due to developmental factors which
vary but little from place to place, year to year, and class

110 HEALTH AND THE STATE

to class ; and are caused by fundamental influences which
we do not fully understand and apparently cannot pre-
vent. The second type consists of deaths, mainly due
to respiratory diseases and enteritis, caused by influences
in the post-natal environment, most prevalent in crowded
mining and industrial districts, and probably entirely
preventable.

These two types of deaths overlap somewhat in time,
but the end of the first month gives us a fairly sharp line
of division. Some 75 per cent of all deaths before that
line are due to developmental conditions, though the pro-
portion among miners, textile workers, and unskilled
labourers is rather less ; on the other side of the line the
proportion of deaths due to developmental conditions is
small. Broadly speaking, mortality in the first month is
a special thing which has hitherto baffled us and may con-
tinue to do so indefinitely ; mortality after that age is
part and parcel of the general mortality, due to the same
causes and demanding for its reduction the same measures.
For various statistical purposes we must no doubt continue
to tabulate deaths according to years of age ; but in future
analyses relating to deaths of infants we should do well
to drop altogether the misleading term ' infant mortality,'
and call mortality in the first month by some such term
as ' developmental ' or ' birth ' mortality, and mortality
from the end of the first month to the end of, say, the
third year as ' mortality of early childhood.' We are at
present forcing an arbitrary and artificial classification
upon a series of phenomena which fall naturally into quite
different classes, and by adopting some such scheme as
that suggested we should classify these deaths approxi-
mately according to the lines which Nature herself has
laid down. Further, we should have a better means of
estimating the effect of any particular step, and we should
have brought home to us the fact that measures specially
directed towards saving life among infants are of very
little value, while those which will benefit all children,
and indeed all classes of the community, are also those
which will reduce mortality in the first year of life.

One final point remains to be considered, and that is

DECLINE IN INFANT MORTALITY 111

the reason why mortality during the later part of the
first year has declined. To ascertain this a prolonged and
laborious investigation would be necessary, applying not
only to the first year, but to the second and third years.
Probably a number of factors, such as better social con-
ditions and prosperity, improved general sanitation, im-
proved methods of medical and surgical treatment, in-
creased institutional treatment, and natural decline in the
virulence of certain diseases, have combined to reduce the
mortality. The widespread substitution of electric and
incandescent gas lighting for the gas flame in street,
workshop, and house may have had an appreciable effect
in improving the condition of the atmosphere, and possibly
explains why black fogs have been less frequent in London
in recent years.1 It would be impossible to allocate to
each influence its exact share in the final result, but we
may notice the important effect of meteorological con-
ditions upon the death-rate in infants. We have seen
that variations in climate between different parts of the
British Isles in the same year have very little influence,
nevertheless widespread changes over the whole country
from year to year have considerable effect. A chart of
the infant mortality in England, Scotland, and Ireland
shows that for many years the tracings have risen and
fallen with a high degree of parallelism, indicating that
some influence common to the three countries has year
by year affected the rates, and this can only be meteoro-
logical variations.2 We may note this influence on an
even larger scale, for the very hot year 1911 was one of
high infant mortality in most European countries, while,
on the other hand, 1912 saw the lowest rates on record
established in Austria, Belgium, Denmark, Finland, France,
Germany, Holland, Hungary, Italy, Switzerland, and the
United Kingdom. No greater contrast exists than in the

1 Many housewives who used the old ' bat's-wing ' burner will recall that no
sooner was a ceiling whitewashed than a grey patch again began to appear above
the gas jet, and in a few months the condition of the ceiling was worse than it
becomes now after as many years of electric lighting. It is probable that from
this change alone the modern nursery of the wealthier classes is much more
hygienic than was the nursery of twenty years ago.

2 The Report of the Registrar-General for Ireland for 1914 contains such a
chart beginning with the year 1861.

112 HEALTH AND THE STATE

rates provided by these two consecutive years, and in
every country for which later figures are available the
rates have risen in succeeding years. We may note that
during recent years we have had a remarkable series of
mild winters and cool wet summers, broken only by 1911,
and it is possible that these conditions have had an im-
portant influence in reducing the infant mortality rate.

The Need for Further Eesearch

Whether the views put forward in the preceding para-
graphs are correct or not, it is clear that there is still a
vast field for research into infant mortality ; and it is
equally clear that we have adopted a number of expedients
without any adequate investigation of the effects they
might be anticipated to produce, or examination of their
value after they have been in force. We have here the
first instance of the way in which futile efforts are made
and money wasted to the detriment of Public Health,
owing to the lack of a central, independent, investigating
authority, specifically charged with the duty of studying
all questions relating to Public Health, a function which
could only be discharged by a Ministry of Health possessing
power to prescribe returns and reports. Statistical in-
vestigations such as those in the previous pages are exceed-
ingly laborious ; there is little pecuniary reward attached
to the work ; and it is rarely possible for a private
individual to devote to them the time they demand.
An immense amount of material for research is already
in existence, but is scattered through the reports,
statistics, and returns of all countries. If the views
expressed are correct, then we should expect to find
infant mortality in France, Germany, America, and our
Colonies exhibiting essentially the same characteristics,
the same difference between town and country, and the
same constancy in developmental defects, etc. ; and
where differences occurred, new light would be thrown
upon the subject by ascertaining the causes of these
differences. But to examine the vast series of blue-books,
reports, and scientific papers is the work, not of one

NEED FOR FURTHER RESEARCH 113

man, but of a staff. In this country what is most
required is a detailed study of a rural district. We have
had numerous investigations into infant mortality in large
towns, but no one appears yet to have thought it worth
while to make an exact study of rural mortality. If we
knew the precise causes and circumstances attending, say,
even one hundred consecutive deaths under one month
in a rural district, we should have some indication whether
congenital and unpreventable influences do actually play
the large part suggested.

The constitution and functions of a Ministry of Health
will be discussed in detail in a subsequent chapter, but we
may here anticipate this to the extent of urging that the
great function of such a Ministry should be to undertake
research into all questions of Public Health, scientific and
sociological, but particularly the latter since this field is
not, and cannot be, covered by the present Research
Committee. Further, this research must be in the hands
of those who are unfettered in their judgment and un-
connected with administration. At present each Depart-
ment responsible for the administration of a Public Health
measure conducts its own investigations, and in its annual
report acts as its own judge, with the result that we too
often get views which are biassed and prejudiced. The
Registrar-General is the only authority who is entirely
independent of administration, and he and his staff are
doing by far the most important Public Health research
undertaken in this country. Of all the Government
Departments, they alone have indicated the right course
to adopt in attacking infant mortality. We have many
' experts ' but few ' scientific men.' We may leave adminis-
tration in the hands of experts, but if we are to avoid
great mistakes, useless expenditure, and propagation of
erroneous views, we must trust science only in the investi-
gation of Public Health problems.

CHAPTEK IV

DISEASE AND DEFECTS IN CHILDREN AND ADULTS

Children below the school age — Physical and mental defects in school
children — Defectiveness in urban and rural children — Employment
of children out of school hours — Children in special schools and in-
stitutions— The folly of palliative methods — Sickness in adults- — Urban
and rural sickness rates — Defects in army recruits — The principal
causes of mortality : tuberculosis ; pneumonia and other respiratory
diseases ; heart-disease ; cancer ; diarrhoea and enteritis ; syphilis.

We can best study disease and mortality in children
and adults by considering separately : — children below the
school age, children at the school age, army recruits, and
the extent and distribution of the diseases causing the
greatest mortality and sickness.

Children below the School Age

Following the principle adopted in the previous chapter,
we will endeavour to ascertain what unnecessary loss of
life is occurring among young children, and where is found
the highest mortality, by comparing the death-rates in
different types of area in different parts of the country.

Mortality in Early Childhood, 1914

Area.

Age 2 years.

Age 3-5 years.

England and Wales .

County Boroughs of North

„ ,, Midlands
„ „ South

Rural Districts of North

„ ,, Midlands .
„ „ South

32-8
35-6
55-7
38-3
21-7
294
16-6
11-7

8-8
9-5
13-5
10-2
6-6
7-8
5-0
3-8

114

CHILDREN BELOW THE SCHOOL AGE 115

The preceding table shows the death-rate for the second
year of life, and for the age three to five years inclusive
(mean annual mortality), in terms of a thousand living at
each age.

It will be seen that the distribution of these deaths fol-
lows exactly that found for infant mortality, and again we
notice the overwhelming effect of urbanisation. In the
County Boroughs of the North the death-rate in the second
year is nearly five times as high as that in the Rural Dis-
tricts of the South ; and for the age 3-5 years it is more
than three times as high. Out of every 10,000 children
born in the County Boroughs of the North, 2113 are dead
by the end of the fifth year ; whereas out of the same
number born in the Rural Districts of the South only 870
die in the first five years. The County Boroughs of the
South are much more favourable to child life, but it must
be remembered that these include many open country
towns and sea-coast towns. In noting the relatively high
rates in the Rural Districts of the North we must again
recall the fact that the word ' rural ' in its ordinary mean-
ing is an incorrect description of many of these districts.

In Connaught the death-rate in the second year per
thousand living at that age was 122 ; in Belfast Comity
Borough it was 54*7. The Registrar-General for Scotland
does not tabulate separately deaths in the second year,
an instance of the defectiveness of the Scottish vital
statistics, to which further reference will be made.

The total deaths in the second year of life in England
and "Wales in 1914 were 24,967. Had the death-rate been
that prevailing in the Rural Districts of the South, more
than 16,000 of these deaths would not have occurred.
At the age of 3-5 years the total deaths were 21,039, and
of these at least 9085 were presumably avoidable. These
losses must be added to the 50 per cent at least of infant
deaths which are due to conditions in the environment, and
must be regarded as preventable.

We must now examine the chief pathological causes
of this mortality. Those responsible for a mortality ex-
ceeding '7 per thousand are as follows : —

[Table

116 HEALTH AND THE STATE

Causes op Death in Second Year per 1000 Living, 1914

Disease.

Total respiratory diseases

Pneumonia

Bronchitis .

Measles

Whooping-cough

Pul. phthisis

Other respiratory diseases
Diarrhoea and enteritis
Rickets and convulsions
Diphtheria ....
Violence ....
Other diseases

England
and Wales.

19-24

7-87
2-42
4-86
315
•48
•46

County
Boroughs
of North.

Rural

Districts of

South.

33-25

5-86

4-21

1-78
•80
•70

6-04

13-44

3-81

9-47

4-99

•83

•71

2-66

1-31

•39

111

•21

•18

8-22
*

1-21
•94

12-09

•97
*

•18

•75
3-96

All causes

32-77

55-71

11-72

* In these subdivisions of the country, the Registrar-General's tables do not
separate rickets and convulsions from ' other diseases.'

Again we notice that respiratory diseases in some form
or other constitute the largest cause of death, accounting
for more than half the total mortality. Diarrhoea and
enteritis come next. In both cases the mortality is re-
duced to a remarkable extent in the rural districts. It
is clear therefore that mortality in the second year
resembles closely that in the first year after the first
month, both in distribution and causation, and is governed
by the same influences.

In the period from the third to the fifth year the propor-
tion of deaths due to other causes increases, but the urban
excess of deaths from respiratory diseases and enteritis
is even more marked, as shown in the following table : —

Causes of Death at Age 3-5 years, 1914

„. County Boroughs
Dlsease- of North.

Rural Districts
of South.

Respiratory diseases
Diarrhoea and enteritis .
Other causes ....

7-09

•86

5-55

1-18

•12

2-50

All causes ....

13-50

3-80

DEFECTS IN CHILDREN BELOW SCHOOL AGE 117

Thus while respiratory diseases are six times and
diarrhoea seven times as high in the County Boroughs as
in the Rural Districts, the mortality from all other causes
is only slightly more than doubled. It may be noted
that neither this nor the preceding table give a complete
separation of all deaths in which respiratory conditions
played a part, for ' other causes ' includes deaths from
scarlet fever, diphtheria, rickets, and other conditions
the most frequent complications of which, as shown
by the Registrar-General's secondary classification, are
bronchitis and pneumonia.

We may note further that, as with deaths in the last
three-quarters of the first year, there has been in recent
years a substantial decline in the mortality in each year
from the second to the fifth. In the second year for
example the death-rate in 1881-85 was 531 per thousand,
while in 1914 it was only 32*8 per thousand. This decline
has occurred without any special efforts having been made
to protect the health of children under the school age, for
such children only share to a very limited extent the advan-
tages of the recently established infant clinics, etc., and they
do not come under the school medical service. If we had
established a medical service of any kind for these children,
or taken other special measures, it is highly probable that
the fall in their death-rate would have been claimed as a
result of these measures. We do not know the reasons
for the fall nor the diseases in which it has mainly occurred,
and to determine these would be an exceedingly laborious
task, though one that might fitly and with advantage be
undertaken by a Ministry of Health. Probably various
causes, enumerated in the preceding chapter, have com-
bined to produce the final result.

Sickness and Defects in Children below the
School Age

Mortality statistics do not tell the full tale of ill-health
among children, for there are some diseases which, while
not causing a heavy mortality, are nevertheless responsible
for much sickness and permanent injury to health and
growth. The most important of these affections is rickets,

118

HEALTH AND THE STATE

a disease which is a frequent cause of convulsions in young
children, and brings about a softening of the bones, often
leading to permanent curvature of the spine, malformation
of the chest, ' knock-knee,' ' bandy leg,' and other deform-
ities. A large proportion of the defects for which recruits
are refused admission to the army can be traced to rickets
during infancy. We do not know the exact cause of
rickets, but deprivation of fresh air, exercise, and sun-
light, appear to be the largest factors in producing the
disease. Defective feeding is perhaps only a subsidiary
influence. The disease is very widespread in large cities.
Sir William Osier estimates that from 50 to 80 per cent
of all the children treated at the hospital clinics in London
exhibit signs of rickets. Dr. Lawson Dick, when examining
the teeth of 1000 Jewish children atteodingthe L.C.C. schools
in the East End of London, found that 80 per cent of them
showed distinct evidence of rickets, and he considers that
this disease is an important cause of defectiveness of the
teeth.1 It is of interest to note that over 80 per cent of these
children had been breast-fed for twelve to eighteen months.
Of other defects in young children we have little
statistical knowledge, since no public authority examines
these children and records their condition. The West-
minster Health Society has however made some valuable
observations, and if the children examined represent a fair
sample of the poorer population, as there is every reason to
believe they do, the observations reveal a terrible state of
affairs. The following table is taken from the report of
the Society for 1913:—

Defects in Young Children

Age of child

0 to 1

1 to 2

2 to 3

3 to 4

4 to 5

Numbers examined .

294

119 120

79

52

Decayed teeth .
Enlarged tonsils
Adenoids ....
Rickets ....

1 Defects per cent.

30

19-0

1-7

6-7

84

244

16-7
21-7

20-0
8-3

45-6

27-8

39-2

5-0

55-8

30-8

48-0

1-9

1 " The Teeth in Rickets," Proc. Roy. Soc of Med., 1916.

CHILDEEN OF SCHOOL AGE 119

A lamentable fact shown in this table is the steady
increase in the number of physical defects at each year
of age, so that by the time the fifth year is reached more
than half the children have at least one physical defect
and many have several. From the point of view of health,
childhood is probably the most important period in life.
If during early years a child is well fed, well cared for, and
surrounded by a good environment, vigorous growth will
be ensured, and a foundation of health laid which will
enable it much better to resist adverse conditions in later
years. Children living in large cities are however sub-
jected to harmful influences from the time they are born,
with the result that when they come under the school
medical officer at the age of five, a large proportion of
them are already badly nourished, stunted in growth, and
suffering from various defects. The State in its wisdom
then begins a half-hearted attempt to correct the evil
wrought, and cure defects which need never have arisen
if the children had had a better environment in earlier
years.

Children of School Age

The death-rate among school children is low. The
adverse conditions of early years have by this time nearly
completed their work in killing; and their effect on the
survivors before and during the years of school life is to
be measured by malnutrition, poorness of physique, and
defectiveness.

We have now a great mass of information relating to
the health of school children as a result of the system
of medical inspection which was established under the
Education Act of 1907, and this must be examined first.
But let us note that ' school children ' and ' children of the
school age ' are not the same ; the former are to an appre-
ciable extent a picked class, from which the children who
are too ill or too defective to attend school have been
separated, and placed in asylums, hospitals, sanatoria, and
other special institutions, or simply kept at home. More-
over, the statistics relating to school children deal almost
entirely with physical defects, and we have no measure

120 HEALTH AND THE STATE

whatever of the sickness and disease which keeps children
temporarily away from school. We cannot attempt to
measure the sickness caused by measles and whooping-
cough, though we know that the cases of scarlet fever and
diphtheria, which are notifiable diseases, amount to many
thousands annually.

The total number of children who were medically
inspected in England and Wales in 1913-14 was 1,900,000
(of whom 1,395,133 were entrants or leavers), and the
total number of those who were found to be suffering
from defects or diseases needing medical treatment was
650,000.

The Board of Education has not yet found it possible
to compile a table showing the prevalence of defects among
the total school population in England and Wales, which
amounts to some 5,381,500; but the figures in the preced-
ing paragraph will enable some estimate of this number
to be made. The point we have to consider is whether we
can justly infer that the proportion of defects in children
who were not examined is as high as in those who were
examined. A child is not medically examined every year,
and it might be supposed that health is better in the years
succeeding examination as a result of that examination.
The present regulations require the medical inspection of
all children in the year they enter school, all children who
are between the ages of 8 and 9 years, and all between
12 and 13 years, together with those over 13 who have not
already been examined after the age of 12. One of the
great advantages which was promised from the system of
school medical inspection was " the early detection of
unsuspected defects and the checking of incipient maladies
at their onset," but it will be noticed that two periods of
two years each pass without any medical examination of
the child unless for some reason a special exception is
made ; and if the one examination was at the beginning
of the year and the next at the end of the year nearly four
years might elapse between the two examinations. During
these periods new defects will arise and pass unnoticed
unless particularly severe, when the child may have
a special examination. Again, detection of a defect by

NATURE OF DEFECTS IN SCHOOL CHILDREN 121

no means necessarily involves its cure or even an attempt
at its cure ; for we shall see that only about half the
children referred for medical treatment are actually
treated, and of these only some four-sevenths are described
as ' remedied,' and about two-sevenths as ' improved.'
For these reasons it may be assumed that the health of
school children during the intervening years is not appre-
ciably better than that during the year of examination ;
and this view is confirmed by the statistical returns, which
show that the proportion of defects found at each succeed-
ing examination is just as high as that at the preceding
examination, though no doubt different children figure to a
considerable extent in the returns.

Balancing one consideration against another therefore,
it may be assumed on the basis of the defects found in
the 1,900,000 school children who were examined in 1913-
1914, that the total number of defective children in the
elementary schools of England and Wales is at least a
million and a half, and this is exclusive of physically and
mentally defective children in special schools.1

The Nature of Defects in School Children

The chief defects found in school children are mal-
nutrition and poor physical development, dental caries,
uncleanliness (i.e. presence of vermin or nits), defective
vision, diseases of the nose, throat, or ears, affections of
the heart and circulation, and diseases of the lungs. It
may be useful to examine these in detail.

Malnutrition is probably the main cause of stunted
growth in height and weight, and of deficient chest measure-
ment— conditions which increase liability to definite dis-
eases. It is not possible to measure malnutrition exactly
by figures, since no definite criteria can be laid down, and
the judgments and standards of medical officers are bound
to vary within wide limits ; but when all allowance is made

1 In his report for 1915-16, Sir George Newman says : " Not less than a quarter
of a million children of school age are seriously crippled, invalided or disabled ;
not less than a million children of school age are so physically or mentally defective
or diseased as to be unable to derive reasonable benefit from the education which
the State provides."

122 HEALTH AND THE STATE

for this source of uncertainty, it is clear that defective
nutrition is widespread among school children, particu-
larly in large cities ; and there is no doubt that in many
poor districts it actually increases during school life. In
London, in 1913, 10'8 per cent of the entrant boys and
9" 8 per cent of the entrant girls showed poor and bad nutri-
tion ; while among leavers, 14' 7 per cent of the boys and
14" 3 of the girls showed the same condition. Sir George
Newman, the Chief Medical Officer of the Board of Educa-
tion, says in his report for 1913 : "Making allowance for
" differences of standard among the numerous school
" medical inspectors, it is impossible to doubt the general
" result of their findings, that taking London as a whole,
" there is evidence that the school child undergoes some
" amount of physical deterioration as regards nutritional
" condition during school life." It appears therefore that
so far all our efforts in the direction of providing medical
treatment and meals for necessitous children have not
been sufficient even to maintain the relatively low standard
exhibited at the beginning of school life. In some of the
industrial towns of the North, and in the worst quarters of
large cities, the percentages very much exceed those given
above. In Bethnal Green, in 1913, the nutrition of 51*9
per cent of the boys and 40*7 of the girls was described
as ' poor ' or ' bad.' In country districts the proportion
is much smaller than in large towns.

We do not know the precise reason why so many city
children exhibit malnutrition or defective growth. It is
not entirely a question of insufficient or improper feeding
— possibly not even mainly — for the condition may be
displayed by a child who has always been well fed. Im-
portant contributory factors are rickets in earlier years,
overcrowding, pollution of the air, want of exercise and
proper playing-fields, insufficient sleep, too long hours shut
up in class-rooms, and employment out of school hours.1

1 An extreme instance of the effect of these conditions was brought before the
Royal Society of Medicine (May 26, 1916) by Dr. Cautley, who exhibited a boy
aged 6 years and 8 months. This boy was only 26£ inches in height and weighed
only 16 lb. 14 oz. ; he was pot-bellied, markedly rachitic, mentally dull, and ex-
hibited numerous defects. There was no evidence of disease to account for the con-
dition. Commenting on the case, Dr. Mitchell Smith said : "I agree with the
opinion of the chairman. This child has not had a fair chance since its conception.

NATURE OF DEFECTS IN SCHOOL CHILDREN 123

Defective Teeth. — This is the commonest defect found
in school children. The statistical returns from different
school areas show a wide range of variation in the percent-
age of school children who display this condition, but un-
doubtedly the variation depends to a considerable extent
upon the thoroughness and skill with which the teeth are
examined. When a group of children are examined by a
dentist, with the aid of a reflecting mirror and probe, some-
times not a single child will be found with an absolutely
perfect and complete set of teeth. Obvious and serious
decay affecting several teeth is exhibited by from 50 to 90
per cent of school children. The condition becomes worse
as the child grows older, and at the leaving age many of
the permanent teeth are already badly decayed. The
condition of the teeth in many young domestic servants
and in recruits is often exceedingly defective. The worst
effects of decayed teeth are the secondary diseases which
they set up, such as abscess of the jaw, enlargement of the
glands, which may become tuberculous, digestive disorders,
anaemia, and ' rheumatism.' These evils are more manifest
in adults than in school children.

We are steadily increasing the number of dental clinics,
etc., for curing defectiveness of the teeth, but there is
little reason to doubt that the condition could be largely
prevented by suitable feeding. Dr. Sim Wallace,1 Dr.
Wheatley, and others have shown that decay of the teeth
is mainly due to feeding children on soft, pappy, starch-
containing foods, and their excessive eating of sweets. The
appearance of the teeth is Nature's indication that the child
should be given food which requires chewing, particularly
fibrous fruit, at the end of a meal, and where this has been

The mother is not a robust woman, and the last four babies were born within a
period of three years and four months. In addition to suckling the previous child
up to the date of this child's birth, the mother shared her supply between the two
children for some time. From 18 months to 3 years old the child was fed on Nos.
1 and 2 Allenbury, and was also given 20 minims of brandy daily to assist its
growth. So far as I could ascertain he had no fresh milk till he was over the age
of 3 years, and since then ho has had one pint or less per diem. The child has been
equally unfortunate as regards a proper supply of fresh air and sunlight. He has
never been in the covintry, and has spent practically all his life indoors at his home,
which is in a poor low-lying district in the Potteries. The home is clean, but ill-lit
and overcrowded, and he is only in the fresh air when his mother can find time to
take him out in the perambulator."
1 Prevention of Dental Caries, 1912.

124 HEALTH AND THE STATE

done astonishing results have followed. It is an interest-
ing fact that the worst condition of the teeth is found
among children in good - class schools. In the poorest
schools the children have better teeth and retain their
temporary teeth for a longer period, probably because
they eat fewer sweets and because, as Sir George Newman
has pointed out, neglected children " are left to pursue
their natural aptitude for chewing uncooked fruit and
vegetables." Here we have probably an instance of real
maternal ignorance, but it is doubtful whether many of
those appointed to dispel this ignorance are much better
informed than the mothers themselves. It will probably
be many years before parents cease to regard decay of a
child's teeth as inevitable ; and abandon the belief that the
condition is due to inherited defectiveness of their own
teeth.

Uncleanliness in school children, though substantially
reduced in recent years, is still widely prevalent. Pediculi
appear to be present in rather more than 2 per cent of
school children, but nits in the hair are found in over 20
per cent of the children in many schools, particularly
among girls, owing to their longer hair. These conditions
reduce the general health of the child, the constant irrita-
tion is apt to produce nervous disorders, and the scratch-
ing of the skin may lead to serious septic conditions.
Further, it is possible that infectious disease among
children may be spread by vermin.

Other conditions of ill-health met with in school
children are diseases of the nose and throat ; discharging
ears, " the most serious and difficult problem of all the
diseases dealt with as ' minor ailments ' " ; defective
vision ; and disorders of the heart and lungs.

Defectiveness among School Children in
Urban and Rural Areas

As with mortality, the great cause of defectiveness in
school children is an urban environment. Industrial
towns are the worst, but residential towns show an appreci-
able excess over rural areas, particularly in the graver

DEFECTIVENESS AMONG SCHOOL CHILDREN 125

conditions of diseases of the ears, the heart, and the lungs.
The following table from Sir George Newman's report for
1914 shows the distribution of defects in the three types
of areas, and also gives us a picture of the deplorable
condition of school children in industrial areas at the end
of school life, in spite of the medical service, feeding, and
other efforts at improvement.

Physical condition, etc.

Percentage

of defective leavers in

i

14 Industrial

15 Residential

11 Rural

Areas.*

Towns, f

Areas. J

Uncleanliness of head .

21-2

13-7

8-3

Uncleanliness of body .

7-8

4-1

3-8

13-2

117

8-9

Diseases of nose and throat

18-1

17-3 15-7

External eye disease .

1-9

2-0 1-9

Defective vision ....

30-5

29-1 19-2

Diseases of ears ....

2-2

24 14

Defective hearing ....

2-8

4-2 1-9

79-7

67-6

66-5

Diseases of heart and circulation

8-0

5-9

2-6

Diseases of lungs ....

3-8

1-6

1-0

* The industrial areas were : Birkenhead, Bradford, Bury, Hull, Leicester,
Manchester, Northampton, Pontypridd, Sheffield, South Shields, Tynemouth.
Wallasey, Wallsend, Wolverhampton. Total number of leavers inspected, 56,163.

•f The residential towns were : Beckenham, Blackpool, Bromley, Chester,
Colchester, Gloucester, Hastings, Margate, Richmond, Salisbury, Shrewsbury,
Southport, Taunton, Torquay, Weymouth. Total number of leavers inspected,
10,126.

J The rural areas were : Cornwall, Devon, Essex, Norfolk, Oxon, Somerset,
Westmorland, Isle of Wight, Wiltshire, Yorks East Riding, Yorks North Riding.
Total number of leavers inspected, 45,015.

Kural areas have an advantage throughout, but the
greatest difference occurs in diseases of the lungs, which
are nearly four times as high in industrial areas, again
pointing almost certainly to the influence of smoke. The
residential towns show a much smaller increase in diseases
of the lungs over rural areas, but we may notice from the
list that nearly all these towns were of an open character
or were seaside places, and, with the exception of Black-
pool, all had low rates of infant mortality. The pro-
portion of children suffering from malnutrition in rural

126 HEALTH AND THE STATE

districts seems higher than might have been expected,
but probably each medical officer takes more or less as
his standard the average for the district, and if urban
and rural malnutrition were both measured by the same
standard it appears likely that the difference would be
considerably greater. Diseases of the nose and throat,
which are mainly enlarged tonsils and adenoids, also
cannot be measured by any definite standard.

The causes of defects in school children will not be
further examined here, since they are essentially the same
as those producing ill-health in all classes of the com-
munity. There is, however, one special cause, affecting
mainly boys, which may be conveniently dealt with at
this point, and that is the employment of school children
out of school hours.

Employment of Children out of School Hours

Year after year Sir George Newman calls attention in
his annual reports to the harm done among school children
by this practice, and strengthens his protests by quoting
numerous extracts from reports of school medical officers
and teachers. We learn from these that large numbers
of boys are employed in delivering milk or newspapers in
the early morning hours before school opens, or in running
errands or working often late into the evening after school
hours. During the war the employment of children has
largely increased ; we will not, however, examine the evil
under abnormal conditions, but will note some of the
instances of such employment, and its effect on health
during the year 1914.

The school medical officer for Jarrow reports : —

Some of these boys go out with papers as early as 5.30 a.m.,
and many are crying papers imtil 10 p.m. or later. The teachers
tell me that they often fall asleep during morning school and are
quite incapable of sustained work. Many of these paper boys work
on Saturdays and Sundays, the total number of hours per week
reaching 30 or over in quite a number of cases.

From Manchester : —

6081 children were employed out of school hours for wages . . .
156 children of 7 and 8 years of age (including 94 girls) are working

EMPLOYMENT OF CHILDREN 127

out of school hours. Of these 96 (including 52 girls) are going
errands, that is, delivering milk, papers, and goods for small shops.
Domestic work and ' minding ' babies account for 36 girls and 2
boys. Two boys of 8 years of age are engaged in delivering coal
from retail coal-yards. . . . The boys not only showed a decided
inferiority in mental capacity and attainment, but are also lower,
distinctly so, in moral tone. . . . One boy aged 13 works nearly 3
hours before morning school, 3| hours each evening, 12| hours on
Saturday, and 5 hours on Sunday.

From Plymouth : —

In many cases the boys are suffering physically and mentally
from overstrain. Some of them come to school at 9.45 utterly unfit
for school work. . . . Children are described as follows : ' Frequently
drops asleep in school ' ; ' pale and fagged ' ; ' nervous and very
restless.'

From Tynemouth : —

Incidentally I discovered that there were still certain boys
employed as late as 10 o'clock on a Friday night and 11 o'clock on
a Saturday night, though this became in March of this year a punish-
able offence on the part of the employer.

From York : —

There is undoubtedly need for some carefully-planned regula-
tion of the employment of children ; otherwise children are ex-
ploited to their excessive fatigue, insufficiency of sleep, arrest of
growth, and general physical detriment.

It will be noticed that these reports, and many similar
which could be quoted, all refer to running errands, selling
goods, etc., in large towns. There is very little evidence
in any reports that agricultural employment— at least if
supervised — is harmful to boys. The school medical
officer for Rutland makes the following report, in which
however he does not specifically state the occupations of
the boys, though it may be inferred that they were mainly
agricultural : —

Ninety-seven children, 87 boys and 10 girls, worked out of
school hours, and a careful examination of their condition as com-
pared with other children inspected was made and displayed in a
table of percentages. . . . These figures go to show that in the aggre-
gate no harm is done to the children working out of school hours.
Nutrition is certainly better among the workers, cleanliness is not
appreciably affected, and the condition of the teeth, nose, and
throat is distinctly better among the workers.

128 HEALTH AND THE STATE

Most significant too is the report of the school medical
officer of Dorset, where the County Education Committee
has consented to the employment of children of school age
on agricultural work only. He says : "As regards the
physical condition of the children who had been exempted
for agricultural employment, I was informed by the head
teachers that in a number of instances marked improve-
ment had been noticed in the health of the children after
being so employed." x

The School Medical Officer for Lancashire also finds
agricultural work beneficial. He says : —

Lighter forms of agricultural work such as weeding root crops,
potato picking, and milking are not unsuitable for half-time
children. Many of our school children are engaged in potato
picking annually, and there is no evidence that their health is
prejudiced thereby. The children who have been taking the milk-
ing classes instituted by the Lancashire Education Committee have
improved in health.2

The question as to the relative effects on health of
different kinds of employment in different types of areas
demands further investigation, but these reports appear
to show that the evil is mainly one relating to errand work
in towns. The writer — who may perhaps unduly prefer
the claims of health to those of education — would go so
far as to urge, if possible, that all older school children
should be turned out of the large towns to work in the
fields, under suitable restrictions, during the summer
months.

The system of permitting ' half-timers ' to work is
allowed by law, subject to restrictions relating to hours
and conditions of work. If these regulations were strictly
observed the practice would still be sufficiently undesirable,
but there is evidence in many districts of open and whole-
sale disregard of the law. The Board of Education report
shows that in Liverpool the by-laws had not been com-
plied with in 161 instances among 1059 boys, and 3 out
of 17 girls were employed illegally ; and the school medical
officer at Bromley says, " infringements of these by-laws

1 Report of Chief Medical Officer to Board of Education for 1915.
2 Ibid.

CHILDREN IN SPECIAL SCHOOLS 129

are at present terribly frequent." The worst case was at
Margate, where among 166 boys employed, 114 were
illegally employed.

Seventy years ago Lord Macaulay, speaking in defence
of a Bill for limiting the labour of young persons in factories
to ten hours a day, said : " Rely on it that intense labour,
beginning too early in life, continuing too long every day,
stunting the growth of the body, stunting the growth of
the mind, leaving no time for healthful exercise, leaving
no time for intellectual culture, must impair all those
high qualities which have made our country great. Your
overworked boys will become a feeble and ignoble race of
men, the parents of a more feeble and more ignoble
progeny. . . . Never will I believe that what makes a
population stronger and healthier and wiser and better,
can ultimately make it poorer." *

Conditions have improved since these words were
spoken, nevertheless, though two generations have elapsed,
the reports of the Board of Education every year reveal
to us that early labour is spoiling the growth and impair-
ing the prospects of large numbers of children in all our
great cities.

Children in Special Schools and Institutions

The state of the ordinary school child as shown by the
records is bad enough, yet it does not represent the full
tale of ill-health among children. As we have noted, the
worst cases of defectiveness have been sifted out of the
child population, and are to be found in the special schools
for mentally and physically defective children, in the
institutions for the treatment of tuberculosis, ophthalmia,
ringworm, etc., the Poor Law infirmaries, and the institu-
tions of the Metropolitan Asylums Board. Sir George
Newman estimated the dull or backward, physically
defective, epileptic, mentally deficient, deaf and dumb,
and blind children at 131,250 in 1914. In addition there
were on January 1, 1915, in lunatic asylums and Poor Law
institutions, 18,483 children below the age of sixteen

1 House of Commons, May 22, 1846.

130 HEALTH AND THE STATE

who were suffering from sickness, accident, or bodily
or mental infirmity. In the hospitals and schools of
the Metropolitan Asylums Board for sick and debilitated
children, and those suffering from ringworm or ophthalmia,
5856 were under treatment during 1914, in addition to
38,862 persons — the great majority being children under
fifteen — who were treated in the fever hospitals for in-
fectious disease. In none of these statistics are repre-
sented sick or defective children who are kept at home.

The Folly of Palliative Measures

The appalling mass of disease and defectiveness among
children represents much pain and misery, and great
economic loss to the community, for many of these children
are impaired throughout life. And yet the great bulk of
it could be avoided. The overwhelming cause is clearly
an urban environment, particularly that of large indus-
trial towns, but we do relatively little to counteract this
influence. Our efforts to clear slums and establish open
spaces are not nearly great enough ; we continue to build
our schools in close proximity to gasworks, factories, and
noisy main-roads ; and we provide them with stone-
paved courts which are wholly insufficient and inappro-
priate as playgrounds. Instead of attacking the causes
of disease, we have established an elaborate and much-
vaunted system of medical inspection, which examines a
child once in three years in order to detect ' incipient '
maladies ; and an inadequate scheme for medical treat-
ment which only succeeds in reaching about half the
children reported as requiring medical attention, and then
only classes as ' remedied ' less than 60 per cent of those
treated.

The folly of this system is manifest. Preventive
measures benefit all classes of the community at once ;
curative measures benefit only the one class, and that prob-
ably only to a limited extent so long as environmental con-
ditions are unsatisfactory. At present we deal with persons
in isolated groups, and we act as though we believed
that disease is a different thing in infants, children,

SICKNESS IN ADULTS 131

paupers, insured persons, etc., instead of realising that to
a large extent the main diseases are the same, and that to
a much larger extent the main causes of preventable dis-
ease are the same throughout the country in all classes of
the community. Palliative measures mean infant clinics,
medical inspections, treatment centres, panel services,
sickness benefit, hospitals, infirmaries, and sanatoria.
Preventive measures are open spaces, larger playgrounds,
clearing of slums, segregation of factories, wider streets,
increased means of transit, and scattering of the people in
crowded areas over outlying districts. It is for the com-
munity to choose which it will have.

Sickness in Adults

We possess now a good deal of information relating to
the amount and distribution of sickness apart from
mortality, from the returns which are issued by Approved
Societies under the Insurance Act. We must however
note here also that the insured population is selected, and
does not give us a true picture of the average health of the
community. The Act applies only to the working part
of the populace, and the returns do not therefore show
sickness among cripples, insane persons, and others pre-
vented by permanent incapacity from coming under its
provisions ; moreover, it excludes casual labourers, who
form one of the unhealthiest sections of the working classes.
Further, some three-quarters of insured persons are men,
who as a class have a lower average sickness-rate than
women. Even for insured persons, the returns do not
include that sickness which does not entitle to benefit on
the ground that the patient was suffering from a disease
the result of his misconduct, or was in arrears with his
contributions, or otherwise ineligible. Yet even these
incomplete returns have shown that there is an appalling
amount of sickness, particularly among women. It is now
known that nearly all the women's societies except those
consisting of lives above the average, such as domestic
servants, are insolvent, in some of them the actuarial
estimate having been exceeded by as much as 100 per cent.

132

HEALTH AND THE STATE

Among men's societies many which contain a large pro-
portion of coal-miners, quarrymen, steel-smelters, boiler-
makers, and others engaged in unhealthy trades have
considerably exceeded the standard.

Rural and Urban Sickness

The distribution of sickness teaches the same lesson
as that afforded by mortality and defectiveness in infants
and children. Unfortunately we cannot express sickness
in relation to the same areas as those employed by the
Registrar - General for mortality, an instance of unco-
ordination in Public Health statistics which, as we shall
see later, is very characteristic. We must have recourse
therefore to the returns issued by individual Approved
Societies, and as an example the following average amounts
paid per member in different counties by the Manchester
Unity Society during the nine months ending July 5, 1914,
may be quoted : —

s. d.
Durham . . . 12 2

Northumberland

10 10

Derbyshire .
Lancashire

10 7
10 4

Sussex

7 10

Kent .

7 7

Surrey
Hampshire .

6 11
6 11

It should be noticed that these figures do not represent
the difference between exclusively urban and rural areas,
but only those between counties mainly urban and mainly
rural. The full difference between rural and urban areas
would be even greater than that shown in the table.
Moreover, the figures should be corrected for sex and age,
the effect of which would probably be still further to
increase the difference, since the average age is appreciably
higher in rural districts than in towns, and probably there
was a larger proportion of men in the Durham and North-
umberland societies than in the rural counties. Many other
reports could be quoted to show that sickness in urban
environments is very considerably higher than in rural areas,
but it is not necessary to do this, for indeed the difference

RURAL AND URBAN SICKNESS 133

exhibited by the people living in these two types of environ-
ment is patent to any observant person who mixes with
the working classes. The contrast between the healthy
frame of the average country woman and the pallid faces,
blotchy skins, and poor physical development of many of
the women in the poorer parts of large cities can scarcely
escape notice.

It may be observed that since the incidence of sick-
ness is so unequal, the flat rate of contribution under the
Insurance Act invalidates the fundamental principle of
insurance, which demands equality of payment for reason-
able equality of risk.1 This principle is recognised in the
system of fire insurance, premiums being raised when a
building is situated in a specially dangerous area or subject
to exceptional risk, and lowered where the owner agrees
to observe special precautions. But under the Insurance
Act rural contributors are paying for the benefits of
urban contributors. It is true that in theory rural workers
need not lose, since they can form their own societies.
But in practice the Act has not worked in this direction,
the tendency having been towards the formation of large
societies which draw their members from all parts of the
country, and grow continually by the absorption of smaller
societies. None the less it is the gain on the rural
members which compensates or helps to compensate for
loss on members in unhealthy towns. It is, indeed, this
factor which has kept some societies solvent, for if rural
workers had everywhere kept themselves separate, a larger
number of urban societies wTould have been in financial
difficulties. Broadly speaking, it may be said that the
agricultural South of England is paying for the industrial
North ; and the ultimate effect is to impose a tax upon the
agricultural labourer, the most poorly-paid manual worker
in the community, for which he gets no fair return ; and
upon rural industries, which of all in this country we ought

1 Mr. Bathurst several times called attention to this effect of the Insurance Act
during the debates in the House of Commons. Speaking on the Amendment Bill
he said : " As long as the flat rate of payment remains, the agricultural labourers
and their employers have a well-founded grievance " ; and he supported his views
by quoting the experience of " the largest rural workers' Friendly Society in the
kingdom," which, on the actuarial estimate, should have received £8200 in the
quarter, but did, in fact, receive only £4869. — Parliamentary Debates, vol. 55, No. 79.

134 HEALTH AND THE STATE

most to encourage. How little this seemingly obvious
development was foreseen may be judged from the follow-
ing extract from one of Mr. Lloyd George's speeches : —

The rural workman will be a different being with a powerful
organisation at his back. He will no longer tolerate some of the
wretched conditions under which he now lives — too often dark and
dank cottages held on precarious tenures ; too often in many
counties miserable wages for long hours — tricked out of his commons
by the ancestors of persons who send him to gaol because he traps
a hare which may scamper across the commons that belonged to
his fathers ; land which was formerly his own let out to him re-
luctantly by the pennyweight as if every grain of it glinted with
radium. The first message of real hope that he received was the
old age pension. That made him a free man — after seventy. The
organisations which he will form under this Act will help to free him
for the rest of his life. The labourers of ancient Rome were only
allowed to organise themselves for burial purposes. They used
those organisations to discuss other matters, including the greatest
matter of all. And my own opinion is that these societies formed
in rural areas for provident purposes will help eventually to win
for the agricultural labourer a treasure more valuable than any you
can put in an Act of Parliament — his independence.1

These flights of imagination would be harmless in an
ordinary person, but when in place of hard facts they
influence the actions of one who has power to initiate vast
and costly social changes, they demonstrate the necessity
of placing consideration of Public Health measures in the
bands of those who have some knowledge of the subject.

Defects among Army Recruits

The return of the reasons for which army recruits are
rejected gives us some indication of the prevalence of
physical defects in the adult male population. Figures
are not available for the period of the War, though it is
known that the number of rejections has been large,
despite a substantial lowering of the standard. The
following table from the Board of Education Report gives
the chief defects for which recruits were rejected in 1912: —

1 Times, February 13, 1912.

DEATHS FROM PRINCIPAL DISEASES 135

Recruits rejected from October 1, 1911, to September 30, 1912
Total number inspected, 47,008.

Cause of Rejection.

Impaired constitution and debility-
Defective vision
Diseases of eyes and eyelids .
Diseases of nose and mouth .
Diseases of ears .
Deafness ....
Loss or decay of many teeth .
Flat-feet ....
Malformation of chest and spine
Under height
Under chest measurement
Under weight
Other defects

Total

Rate per 1000
rejected.

2-89
21-08

1-57

1-64

4-32

7-25
22-44

7-30

4-25

5-23
29-23

3-62
112-94

223-77

It will be noticed that nearly one-quarter of all who
offered themselves were rejected. The fine appearance of
bodies of troops marching through the streets creates in
the public mind an impression of the vigour of British
manhood. But it is forgotten that these men are selected,
and a morning spent with the Medical Officer of a
recruiting station will give a very different picture of
physical conditions among large masses of the male
population in these Islands.

The Number and Distribution of Deaths from
the Principal Diseases

This chapter may be concluded by a general examina-
tion of the diseases which are responsible for the greatest
numbers of deaths. The International List of the Causes
of Deaths contains 189 headings many of which have sub-
headings, nevertheless the great bulk of deaths are caused
by quite a small number of diseases or groups of diseases.
The following table shows the more important causes or
groups of causes which were responsible for mortality in
England and Wales in 1914 : —

136

HEALTH AND THE STATE

Causes of Deaths in England and Wales, 1914

Respiratory diseases —

Bronchitis .

. 40,189

Pneumonia .

. 40,070

Pulmonary phthisis

. 38,637

Measles and whooping-cough

. 17,184

Other respiratory diseases .

. 6,109

Total respiratory diseases

142,189

Diseases of heart

55,107

Diseases of blood-vessels (including

apoplexy)

39,822

Cancer .

39,517

Premature birth, etc. .

35,160

Diarrhoea and enteritis

23,510

Nephritis and Bright's disease

.

15,912

Non-pulmonary tuberculosis .

11,661

Violence .

21,440

Old age .

30,163

Other causes .

•

102,261

All causes

516,742

We see from this table that, in the aggregate, respira-
tory diseases account for more than one-quarter of the total
mortality from all causes; a very significant fact, which
shows that in his present environment man's lungs are by
far his most vulnerable organs and the most likely to
become the seat of disease.

The distribution of the mortality from all causes accord-
ing to types of area is shown by the following table in which
the death-rates have been standardised, that is, corrected
for differences in age and sex constitution so as to render
them comparable : —

Death-Rates from all Causes, 1914

England and Wales

13-6

London .....

14-6

County Boroughs of North

17-6

„ ,, Midlands

14-9

„ ,, South

12-0

Rural Districts of North

12-6

„ „ Midlands

10-2

„ „ South

9-5

We notice that the standardised death-rate in the
County Boroughs of the North is 85 per cent higher than
that in the Rural Districts of the South.

TUBERCULOSIS

137

An examination of the distribution of the causes most
frequently responsible for death will indicate the directions
in which the greatest scope now lies for preventing disease
and improving the Public Health.

Tuberculosis

Tuberculosis is the most deadly disease from which
we suffer, being responsible for more than 10 per cent of
the total deaths from all causes in the British Isles, and
probably for much more than 10 per cent of the total
sickness. The following table shows the death-rates from
tuberculosis in different types of area : —

Death-Kates per Million from Tuberculosis, 1914

Area.

Males.

Females.

County Boroughs of North
„ ,, Midlands
„ „ South

Rural Districts of North

„ ,; Midlands .
„ „ South

2266
2105
1804
1704
999
925
1067

1331

1452

1249

1195

944

875

910

We may notice that the death-rates among males are
considerably higher throughout than among females, a fact
of much interest, the precise causes of which require further
investigation. As regards geographical distribution there
is no doubt that the differences in the table appreciably
under-represent real differences, owing to the tendency of
tuberculous persons to migrate from urban to rural or sea-
side localities as soon as the disease is detected ; and since
illness is usually long enough to lead to the death being
registered in the new district, the result is to lower the
urban and raise the rural rate. It has long been recog-
nised that the death-rate in the County Boroughs of the
South is swollen by the consumptives who migrate to and
die in the seaside resorts along the south coast, while
deaths in smaller places raise the rural rate.1 It is known

1 Dr. Newsholrne has discussed this point in his Report for 1912-13.

138

HEALTH AND THE STATE

too that a certain number of young persons who migrate
from the country to towns acquire the disease in their new
environment, and return to their old homes to die. This
would be more likely to happen in the Eural Districts of
the South than those of the North, for if a miner develops
tuberculosis he will probably die in his native village, but
a London servant or shop-girl with a home in the country
will probably return there. There can be little doubt that
if the statistics for the Rural Districts of the South repre-
sented only native cases, the death-rate would be consider-
ably lower even than that shown in the table.

The death-rate from phthisis among coal -miners is
lower than that among persons engaged in other forms
of mining and unhealthy occupations, which is perhaps
another reason why the death-rate from tuberculosis in the
Rural Districts of the North approximates more to the
general rural rate than do the death-rates from other
diseases in these districts. The question of occupation in
relation to tuberculosis, with which is probably associated
the difference in male and female death-rates, still offers a
considerable field for research, though admittedly much
has been done in this direction. Tuberculosis, however, is
in both sexes essentially a disease of the large industrial
towns, and it may be of interest to compare the rates in
some of these with those in counties mainly agricultural.

Death-Kates

PEE

Million fkom Tuberculosis, 1914

County Borough or Town.

Administrative County.

Dublin .... 3565

Hertfordshire

930

Belfast

3034

Herefordshire

927

Warrington

2265

Surrey ....

905

Manchester

2240

Wiltshire

884

Salford .

2193

Buckinghamshire

884

Gateshead

2140

Dorsetshire .

871

Dundee

2130

Gloucestershire .

864

Liverpool .

2087

Westmorland

679

Glasgow .

1990

Newcastle

1978

Tynemouth

1911

Swansea .

3

1879

PNEUMONIA, BRONCHITIS, ETC.

139

The following table from the Report for 1913 of the
Chief Medical Officer to the London County Council, show-
ing the rates for the years 1908-12 in certain Metropolitan
Boroughs, is also very striking : —

Death-Rates from Phthisis in certain Metropolitan
Boroughs

Borough.

Corrected
Death-Rate.

Comparative

mortality

Figure.

London

Finsbury .
Shoreditck
Southwark
Bermondsey
Holborn .
Stepney .

Paddington
Stoke Newington
Kensington
Wandsworth .
Lewisham
Hampstead

1-29

2-04
1-90
1-85
1-82
1-81
1-74

0-96
0-93
0-90
0-87
0-70
0-61

1000

1577
1470
1428
1405
1400
1346

739
717
699
672
541
474

As with infant mortality, the highest death-rates are
in the central area, and the lowest in the peripheral
districts.

Pneumonia, Bronchitis, Measles, and Whooping-

Cough

The distribution of these conditions in 1914 is shown
in the table on the following page.

Again we notice in all three diseases the marked differ-
ence between urban and rural death-rates, and particularly
between the rates in the County Boroughs of the North
and the Rural Districts of the South. We notice further,
in pneumonia the considerably higher death-rate among
males than among females, probably owing to a larger pro-
portion of the former being engaged in dust-producing

140

HEALTH AND THE STATE

Deaths per million.

Area.

Males.

Females.

Pneumonia

1502

1009

County Boroughs of North

1962

1331

„ ,, Midlands

1454

1010

„ ,, South

1051

727

Rural Districts of North

1041

760

,, ,, Midlands

762

562

„ „ South

710

473

Bronchitis

London ... ...

1193

1152

County Boroughs of North

1487

1430

,, „ Midlands

1315

1228

,, „ South

947

999

Rural Districts of North

895

887

,, „ Midlands

910

850

,, „ South

772

806

Measles and Whooping -Cough

530

490

County Boroughs of North

828

787

,, „ Midlands

589

589

„ ,, South

268

236

Rural Districts of North

401

438

,, „ Midlands

228

234

„ „ South

94

122

occupations, such as quarrying, and cutlery and pottery
making.

Diseases of the Heart and Blood-Vessels, Nephritis,
and Bright's Disease

This group of diseases stands in marked contrast to those
from respiratory affections, in that the death-rate varies
very little in different types of area and between the two
sexes, though for heart-disease the rate among women is
slightly higher than among men. It is clear therefore
that the general environment exerts only a minor influence,
if any, upon the incidence of these diseases, and the power

CANCER 141

of the State to prevent them is limited. Heart-disease and
allied conditions are due to a number of causes, including
congenital defects, acute illnesses (particularly rheumatic
fever), and pathological changes which are frequently
associated with heavy and prolonged muscular exertion,
syphilis, and alcoholism. State effort might bring about
a reduction of deaths from the last two causes, of which
syphilis will be examined later. Alcoholism is responsible
not only for deaths from heart-disease, but for affections
of the liver and other organs, and the habit undoubtedly
increases the liability to pneumonia. Prevention of
alcoholism is however more a social than a Public Health
problem, for action by the State is limited to restriction
of the drink traffic, abolition or control of public-
houses, and educational measures. Any great or lasting
improvement must come from increased self - control
among the people themselves. It is for these reasons
that not much is said about alcoholism in this book, but
it must not be inferred that the writer does not fully
appreciate the great amount of disease for which it is
responsible.

Cancer

Preventive medicine has unfortunately almost no con-
cern with cancer. We do not know the causes of this
disease nor the conditions which lead to it, except that it
sometimes follows chronic irritation. Cancer belongs to
the domain of the surgeon, who undoubtedly saves large
numbers of lives ; and all that public authorities can do is
to emphasise the importance of early diagnosis and treat-
ment. Geographically the standardised mortality increases
with urbanisation, the deaths per million in 1914 having
been 864 in the Rural Districts of England and Wales,
976 in the smaller urban districts, 1040 in the County
Boroughs, and 1111 in London. These differences how-
ever may have been due to better diagnosis and perform-
ance of more autopsies in the large towns. Mortality from
cancer has apparently been increasing for many years, but
again, part at least of this is due to better diagnosis, while

142

HEALTH AND THE STATE

the crude rate has risen somewhat owing to the increasing
proportion of persons in the community at ages at which
the disease is most prevalent.

DlARRHCEA AND ENTERITIS

We have already considered these conditions in infants,
among whom three-fifths of the total deaths occur, but it
may be useful to tabulate the differences between urban
and rural environments for the total deaths.

Deaths per million.

Males.

Females.

London

County Boroughs of North .

,, „ Midlands

„ „ South
Rural Districts of North

„ „ Midlands .

,, „ South

949
1113
899
435
819
338 /
247

672
855
652
342
611
289
213

In London, in 1913, the death-rate of infants under
two years of age per thousand births from diarrhoea
was 59 in Shoreditch, 42 in Bermondsey, 14 in Stoke
Newington, 14 in Lewisham, and 13 '5 in Hampstead.

Syphilis

Syphilis, according to the tables of the Registrar-
General, was responsible in England and Wales in 1914
for only 2146 deaths, of which 1361 were of children under
one year of age. These figures do not however represent
the total mortality, partly because the real nature of the
death is sometimes withheld from the certificate, and partly
owing to the death being certified under some condition,
such as paralysis or degeneration of the arteries, to which
the disease has led. The ravages of syphilis are to be
measured much more by the sickness and pathological
conditions it produces than by its mortality, for the disease
is not one which kills quickly, and there is probably no

SYPHILIS 143

disease — not even cancer — in which the sickness and
secondary complications bear so large a proportion to the
mortality as syphilis. It may attack and injure or destroy
any organ of the body, and the nose, eyes, ears, throat, or
skin. It is an important cause of heart-disease, Bright's
disease, arterial degeneration, aneurism, paralysis, and
insanity ; and it appears to be responsible for perhaps
15 to 20 per cent of still-births. As we have seen, it is not
a large cause of infant mortality. The Royal Commission
on Venereal Diseases estimated that in large cities the
number of persons who have been infected with syphilis,
acquired or congenital, is not less than 10 per cent of the
population, though they point out that they were unable
to obtain any positive figures. This is an unexpectedly
high estimate, and to the writer the evidence upon which
it was based does not appear convincing ; but in any case
the extent of the disease — though probably exaggerated
in the public mind — is sufficient to justify action by the
State which seems likely to lead to its reduction.

Syphilis is essentially a disease of large towns. The
Commissioners say : " County Boroughs return the highest
mortality under each heading in the four divisions of the
country dealt with, and are followed at some distance by the
smaller towns, while the rural mortality is low in every
instance." The experience of practitioners in regard to
sickness from syphilis is the same. Witnesses before the
Commission stated that in the rural parts of Ireland the
disease is practically non-existent, and many practitioners
had not seen the disease for years except in an occasional
tramp. The worst foci of the disease appear to be the
large seaports. In Sweden, where the disease must be
notified, the distribution is the same, the incidence of new
cases in 1914 having been 217 of the population in Stock-
holm, 0 26 per cent in the smaller towns, and 0"02 per cent
in the country districts.

Following the recommendation of the Royal Com-
mission, steps are now being taken to provide free treat-
ment for those suffering from the disease, and in view of
the facts that modern discoveries have much improved the
methods of treating syphilis, and that the facilities of

144 HEALTH AND THE STATE

higher treatment have hitherto been seriously inadequate
among the working classes, this provision should be of con-
siderable value. The criticism may be made however,
that since 75 per cent of the cost of treatment is to be met
by Government grants, rural districts free from the disease
are being made to pay a part of the cost of syphilis in
towns ; whereas if each locality was obliged to pay the
cost of its own sickness — not only from syphilis, but from
other conditions — local authorities would have a strong
inducement to adopt measures for the prevention of
disease.

The prevention of syphilis is a difficult problem, and
one which cannot be examined from the Public Health
aspect only, since it involves social and moral questions,
discussion of which is outside the scope of this book.
The giving of lectures and advice to young persons is a
desirable measure, as is also the providing of healthy forms
of recreation, which witnesses before the Commission stated
had had an appreciable effect in reducing the disease among
soldiers. Certain prophylactic measures have been en-
forced in the Navy for a number of years, in the opinion of
competent authorities with great benefit ; and since 1911
the Board of Trade has encouraged their adoption in the
merchant service. The Royal Commission did not how-
ever refer to these methods in their report, and since they
were required to examine the question from every point of
view, it must be assumed that, in their opinion, objections
to spreading knowledge of these methods outweighed any
advantage to health which might result from them.

The recorded mortality from syphilis fell from 89 per
million in 1875 to 51 per million in 1911, though the greater
part of this fall was previous to 1901, the figures since that
date having fluctuated only between narrow limits. These
figures are of course quite useless as an absolute measure,
though there is no obvious reason why they should be
rejected as an indication of a real decline in the incidence
of the disease ; the Commission however did not accept
the view that they represented a real fall. On this point
Dr. Stevenson pointed out that if the actual incidence of
the disease had remained constant there are several

SYPHILIS 145

important factors which would have tended to increase the
recorded death-rate, such as : improvement in diagnosis ;
the large increase in the proportion of deaths from all
causes which occur in institutions and are more likely to
be accurately certified ; and the increase in the proportion
of the urban population, which, since syphilis is essentially
a disease of large towns, should have markedly increased
the death-rate. A further indication of reduction of the
disease in the civil population is afforded by the decrease
in the proportion of recruits for the army rejected for
syphilis, the rate having been 16 5 per thousand in 1873,
6 3 in 1890, and 1*4 in 1911-12. The Commissioners ex-
plain the decrease — at least since 1890 — in the following
words : " It is probable that the signs of the disease are
' better known than formerly, and that men recognising
' these signs may not offer themselves as recruits. Further,
' recruiting sergeants seeing that candidates are diseased
1 may tell them to get cured before presenting themselves
' for medical examination. Again, soft chancre was not
' definitely distinguished in the statistics from syphilis till
' about 1892, and since 1901 there has been a rise in the
' percentage of rejections from ' other diseases of the genital
' organs,' which may be due to transference from the cate-
' gory of syphilis, thus diminishing the percentage ascribed
' to the latter disease." It is difficult however to regard
this statement as a convincing explanation of the decline,
for the signs of the disease recognisable to the affected
man have not changed ; it is impossible to believe that
recruiting sergeants can pick out four or five men from
the half-dozen or so in every thousand who are suffering
from syphilis ; and the report nowhere states the per-
centage which have been transferred from ' syphilis ' to
' soft chancre.'

Several medical witnesses of wide and long experience
expressed the opinion that syphilis has shown a decline
both in extent and virulence during the last thirty years,
and to the writer the evidence given before the Commission
seems to point strongly to this being a sound conclusion.
It is difficult to read the report without gaining the im-
pression that, bad as syphilis is, the Commissioners have

L

146 HEALTH AND THE STATE

made the worst of the case. They appear to have strained
the evidence in two directions : increasing on the one hand
the number of still-births due to syphilis, and the total
prevalence of the disease ; and minimising on the other
the indications that it has declined. The writer does not
presume to question the value of the consideration given by
the Commission to difficult social and moral questions ; but
if his criticisms are justified, they illustrate the disadvan-
tages of entrusting the investigation of purely scientific
questions to Royal Commissions, a point to which further
reference will be made.

The review in this and the preceding chapter of the
state of Public Health in England at the present day shows
that the condition of large masses of the population is
thoroughly unsatisfactory if measured by the healthiest
communities. Mortality among infants and young children
is at least twice as high as it need be ; defectiveness is wide-
spread among school children ; rejections of army recruits
are high ; preventable diseases claim many thousands of
lives ; and the death-rates in the rural districts of the Mid-
lands and South show that the present rate for the whole
country would be reduced by at least a quarter if the
healthiest conditions were universal. We have fallen
into the habit of regarding Public Health efforts in this
country with some complacency, and it is true that the
standardised death-rate has declined 25 per cent since 1881 ;
but when we deduct from this decline that part of it which
is due to natural diminution of disease, and that which is
due to progress in surgery, it is evident that the results of
our vast volume of preventive efforts are still relatively
small. It may be that these deaths are preventable only
in theory, and that in practice economic conditions forbid
the wide adoption of the measures necessary to prevent
them ; but if this is so, let us at least realise the price we
are paying for commercialism — a price which will steadily
increase unless radical changes are made in urban environ-
ments. In Ireland the crude death-rate in 1914 was 16 '5
compared with 14*0 in England and Wales, but the stand-
ardised death-rate is lower than that in England and

SYPHILIS 147

Wales.1 This result is due to the higher average age of the
population owing to the emigration for many years past
of young people. In France, with only three-eighths of its
population living in towns of 5000 inhabitants and over,
restriction of births for many years has led to a death-rate
which averages about 18. In this country, also, restriction
of births is steadily raising the average age ; but when event-
ually our age-constitution resembles that of France or Ire-
land, we may expect a higher death-rate than those at
present shown by these countries, siuce so much larger a
proportion of our population — already nearly four-fifths —
is urban.

Another lesson to be learnt from the distribution of
disease is the importance of localisation of effort. Control
of the Public Health services is largely central, and we
continually pass Acts of Parliament which apply equally
to the whole country. But the rural districts do not need
these measures — or at least need them to a relatively small
extent — and we could safely leave them alone for the
present, neither forcing changes upon them nor requiring
them to pay for national measures. For instance, to
establish a national medical service maintained by Imperial
taxation would be one of the greatest injustices we could
inflict upon the rural districts. The great centres of
disease are London and the large industrial and mining
towns, and it is upon these that attention and effort should
be concentrated. Probably the best means to achieve
this would be to decentralise much of our Public Health
machinery, and increase the powers and responsibilities of
Local Authorities, proposals which will be examined in
greater detail in a subsequent chapter.

We can attack disease by preventive and by curative
measures. Preventive measures are indissolubly bound up
with questions of land and housing, and we will examine
the relation of these factors to Public Health in the next
chapter.

1 I.e. standardised in terms of the population of England and Wales.

CHAPTER V

PUBLIC HEALTH, LAND, AND HOUSING

Man not biologically adapted to life in towns — Rural depopulation — The
overcrowding of cities and the means of relief — Segregation of factories
— Bad housing — The difficulties of clearing slum areas — The cost of
building — ' Summer camps ' — Sleeping out.

MAN NOT BIOLOGICALLY ADAPTED TO LlFE IN TOWNS

The deadly effect of urbanisation — particularly its hurt-
fulness to the organs of respiration in both young and old
— possesses a profound biological significance. Zoologists
have shown that species only become gradually adapted
to their environments as the result of processes which may
extend over vast periods of time ; and man is not yet bio-
logically adapted to the environment of densely-crowded
towns. For hundreds of thousands of years his Paleo-
lithic and Neolithic ancestors lived under natural con-
ditions in plain and forest, with caves, tents of skins, or
huts of clay and twigs for habitations. The era of life in
cities is only a day in the history of mankind. Even when
we reach the period of the so-called ' ancient ' civilisations,
we can trace little resemblance between their greatest
cities, Babylon, Alexandria, and Rome, and the huge
aggregations of smoke-covered houses which form the
modern centres of industry. How recent is the growth
of these, is shown by the fact that as late as the year 1700 the
whole population of England was less than that of London
to-day.

This abrupt change in man's environment profoundly
affected all his habits of life. Previously he had lived a
primitive existence in harmony with his structure, breath-

148

MAN NOT ADAPTED TO LIFE IN TOWNS 149

ing pure air and obtaining his food directly from the soil
or by the chase. Within a few centuries he developed his
commerce, began to use coal, discovered steam-power and
the application of electricity, dug his mines, and built his
railways. Thenceforth communities were divided into
two groups. One group continued to live a healthy life
in the fields ; the other, and in this country the larger
group, abandoned the fresh air for the polluted atmo-
sphere of towns, and devoted itself in dense masses to
continuous toil in factory or mine.

But man is not constructed to thrive in this new
environment, and its effect upon him is precisely the same
as that which we can observe in wild animals in captivity.
The death-rate among animals surrounded by unnatural
conditions is very high, and often their young can only
be reared by taking the utmost precautions. London
reads with regret the fate of litter after litter of the cubs
of ' Barbara,' the polar bear in Regent's Park, which live
at the most for a few weeks and then die from pneumonia.
The higher apes suffer severely from tuberculosis, and nearly
all the mammalian cubs develop rickets. Man in towns is
subjected to the same conditions and suffers only a degree
less severely. There is good reason for believing that
many of the diseases which he acquires in cities are modern
developments. We can only judge of diseases which leave
traces in the bones, but rickets was probably unknown
among the Neolithic folk, and the teeth of these people
were well formed and extraordinarily free from caries.1

It might be urged that since man is ultimately governed
by natural laws, the change which he has wrought in his
environment is part and parcel of his natural evolution.
But this assumes that evolution of society and evolution
of physical structure are the same ; and raises the diffi-
cult question of the relations between intelligence and

1 Professor Keith, describing a number of Neolithic skeletons found in Kent,
says : " There is not a single carious tooth to be found in the Coldrum collection.
The teeth are regular in their arrangement, the palates were well formed, but in
actual size the teeth possess the same dimensions as those of modern English
people. All these changes which are appearing in the teeth and jaws of modern
British people, arise, we suppose, from the soft nature of our modern diet. We
believe that were modern men to resume a Neolithic diet their teeth and palates
would again be moulded in the ancient manner." — Antiquity of Man, 1915.

150 HEALTH AND THE STATE

instinct in man's development. Mankind did not
make the change deliberately and willingly with know-
ledge of its ultimate extent and effects, but each in-
dividual was caught up and carried along willy-nilly in
a great flood of ' progress,' which, once started, rushed
on uncontrollable. Yet in many little ways we can see
that an urban environment is opposed to all man's
fundamental instincts, and he is continually rebelling
against the surroundings in which he finds himself im-
prisoned. There is no other species which exhibits the
same keen desire to escape at every opportunity from its
customary habitat as town-dwelling man. The rich take
their holidays in the country, the poor man goes to Epping
Forest or Hampstead Heath. Yet other animals pass all
their existence in one environment. The forest-loving
animal does not seek the plains, the bat shuns the day-
light, and the mole thrives in his underground burrow
where the squirrel would die. Man alone, forced into one
habitat by his work, tries to create another for his leisure.
The very term ' bricks and mortar ' is used in a sense of
reproach, yet there is no logical reason why we should not
admire a collection of houses as much as a collection of
trees, or why a patch of paving-stones should not appeal
to us as strongly as a well-kept lawn. The deep-seated
craving for a sight of something green struggles to find
expression in the making of gardens around houses, the
forming of parks in cities, and the planting of trees in the
streets. Even the humblest classes try to introduce some
suggestion of the country into their homes. An observant
person coming into London by one of the main railways,
which is perhaps the best way of realising quickly the grim
ugliness and horror of the poorer parts, will continually
notice stunted plants on the window-sills or nasturtiums
and Virginia creeper struggling against the sooty atmo-
sphere. The Biblical chroniclers understood human nature
when they placed Paradise in a garden and made the first
man a tiller of the soil.

RURAL DEPOPULATION 151

Rueal Depopulation

Yet in spite of natural tendencies, the British people,
under the influence of commercial development, have been
steadily forsaking the fields and flocking into the towns,
until the depletion of the country-side has become one of
the great tragedies in our history. In 1861 England and
Wales had a rural population of 9,105,000 and an urban
population of approximately 10,961,000 ; in 1914 these
numbers had become respectively 7,893,000 and 29,068,000.
In little more than half a century the rural population,
from being nearly equal to the urban population, has
become considerably less than one-quarter of the total.
In Scotland the rural population, after remaining nearly
stationary from 1901 to 1911, has decreased by 55,000 since
the latter year, while the population of the burghs has
increased by 41,000. In Ireland the population has de-
clined from 5,775,588 in 1862 to 4,381,000 in 1914, mainly
as a result of emigration from the rural districts. Thus
we have been losing year by year our healthiest and most
virile stocks, and have been augmenting the numbers who
are exposed to the deleterious influence of town life.

The causes of this decline mainly concern the econo-
mist. Probably the largest factor has been the attraction
of higher wages offered by industrialism in towns, while
insufficient housing accommodation in agricultural districts
has played an important part; and lack of opportunity
drives the energetic and adventurous to the plains of
Australia or the wheat-fields of Canada. We are now
fully alive to the dangers and disadvantages of depending
for our food-supply upon foreign countries, and it is uni-
versally recognised that the future safety and prosperity
of Britain depends in large measure upon increased de-
velopment of agriculture, though whether this is to be
done by some scheme of land nationalisation, the ' single
tax,' agricultural bounties, duties on imported foods, or
development of small holdings, is not within the province
of this book to discuss. The only object here is to rein-
force the economic arguments by showing that the land
question is intimately bound up with that of national

152 HEALTH AND THE STATE

health. It will be of little avail to instruct mothers, or
build school clinics, or establish schemes of insurance
unless we recognise this fact both in town and country ;
and when we have recognised it and have acted upon
our knowledge, there will be little need for palliative
measures. In considering proposals for land development
we must be guided, not only by the return of wealth, but
by the volume of employment, those measures being most
beneficial which give occupation to the greatest number.
Schemes which would not yield a material return for some
years must necessarily be undertaken by State effort, and
of these perhaps afforestation is one of the best. Sir
John Stirling-Maxwell has recently uttered a weighty plea
for an extensive scheme of this sort, and has pointed out
that in Great Britain alone there are some sixteen million
acres of sheep ground and deer forest of which probably
six millions could be planted.1 A large scheme of affores-
tation would provide work under ideal conditions for
persons suffering from early phthisis, and for many of
those discharged from sanatoria, who now have no choice
but to drift back to their old surroundings, where too
often the disease reasserts itself with fatal effect. To
measure the value of these schemes solely by economic
return is seriously to under-estimate their national im-
portance. Development of agriculture, reclaiming of vast
areas of marsh and moor in Ireland, and afforestation of
millions of acres in the Highlands, in addition to benefiting
health, would offer a varied life to the many thousands of
the sturdiest stock who now leave our shores every year
for the Colonies or the United States.2

1 The Times, June 19, 20, and 26, 1916.

2 In his book, Land and Labour in Belgium, Mr. Seebohm Rowntree quotes the
following remark made by the Chief Inspector of Forests in Belgium : " Ah, you
English, you always want to know will it pay. In Belgium we look at the matter
differently. We realise that the afforestation of waste lands affords an enormous
amount of healthy work for the Belgian people, work required just when otherwise
the men would be unemployed. We realise the importance of providing a large
amount of home-grown timber in view of the depletion of the world's timber
supply ; and we think, too, of the beneficial effects of forests, not only upon climate,
but on the soil of the waste lands, to the great advantage of the country."

OVERCROWDING OF CITIES 153

The Overcrowding of Cities and the Means
of Relief

But while much can be done to increase the rural
population, we are bound to recognise that we must always
remain chiefly an industrial and town-dwelling people ; for
the greatest sources of our wealth are industries which
depend upon our coal-fields and iron-ores, and upon the
peculiar fitness of the Lancashire climate for cotton-
spinning. We should certainly be a healthier, and prob-
ably a happier, people if we became a simple agricultural
community, but we need not speculate upon the possibility
of this happening.

The problem then is to discover the means by which
we can best render our towns fit for human habitation,
and the first step is to determine the factor or factors which
make our great cities so unhealthy. We have fallen into
the habit of talking vaguely about insanitary surroundings,
bad housing, insufficient feeding, dirt, and ignorance, forget-
ful of the fact that all these evils may be rampant in a
country village whose inhabitants nevertheless display
remarkable vigour. But we need further investigation
and much more precise knowledge. On this point the
views of the writer have already been expressed, viz. that
pollution of the atmosphere by smoke and dust is now
by far the largest factor in the causation of preventable
disease. More might be done directly to prevent these
evils by better scavenging and greater use of smoke-con-
suming stoves, but our present methods are quite in-
adequate. There are some restrictions on emission of
black smoke, but these are often not enforced ; and, with
this exception, manufacturers can permit the discharge
of volumes of brown and yellow smoke and gases, or
fill the air with clouds of dust to the common detriment
of the community. Even if the smoke of factories were
reduced, it would still be necessary to introduce smoke-
consuming stoves into all the homes of the poor in
crowded districts, and it is doubtful whether under the
best circumstances these measures could ever be enforced
sufficiently widely to secure healthy conditions in large
towns.

154 HEALTH AND THE STATE

But though we may leave undecided the exact cause
of the unhealthiness of towns, we have now quite suffi-
cient knowledge to recognise the type of towns which pro-
vide relatively healthy conditions of life. These are towns
which, though they may contain populations ranging from
twenty to forty thousand inhabitants, are essentially of
a rural character. They have not been cramped in their
growth, contain no large agglomerations of small streets
or smoke-flooded areas, and have wide open spaces and
lines of houses straggling into the surrounding country.
It is these characteristics which account for the healthiness
of many of the towns and watering-places in the South of
England and the suburbs all round London. Many such
towns exhibit a relatively low death-rate and an infant
mortality rate below 80 per thousand, which, though
well above the achievable minimum, represents a vast
improvement upon the high rates of the industrial cities
of the North.

The really serious problem is presented by the manu-
facturing towns, the great seaports, and the central parts
of large cities. The congestion of these is not easily realised
by those who are familiar only with the wealthier and
better-built parts. Within the London County Council
area of 116 square miles are crowded together more than
four and a half millions of persons, one-eighth of the whole
population of England and Wales, and Dr. Wanklyn, of
the London County Council, has estimated that more than
2,365,000 persons are housed in 646,700 tenements of from
one to four rooms.1 There are 168 persons to the acre in
Bethnal Green, 166~ in Shoreditch, 166 in Southwark, 156
in Stepney, and 144 in Finsbury. On the other hand, all
round this closely-packed mass of streets there is a wide
expanse of beautiful country, which is but thinly scattered
over with villages and towns. The contrast in density of
population afforded by this area is striking. Taking the
counties immediately adjacent to London and including
the County Boroughs and Urban Districts, the density of
population per acre is 1*4 in Essex, 8*1 in Middlesex, 19
in Surrey, and l'l in Kent. Both sets of figures are

1 " Working-Class Home Conditions in London," Proc. Roy. Soc. of Med., 1913.

OVERCROWDING OF CITIES 155

based upon the estimated populations in the middle of
1914. Very similar features are exhibited by Liverpool,
Glasgow, Belfast, and other great cities and their vicinities.

A good deal can be done to relieve this congestion by
increasing the parks and open spaces in cities and forming
larger playgrounds for children. The clearing of slums is
also all to the good, though the cost renders extensive
schemes prohibitive, and it is very doubtful whether the
policy of re-covering the cleared areas with blocks of
' model dwellings ' and tenements is really sound. The
brightly-painted doors and window-frames of these erec-
tions give an air of cheerfulness to the exterior which is
an improvement on the wretched houses demolished, but
the rooms are small, the interiors often lacking in com-
fort, and the tenants have little in the way of a garden,
often a stone court being all that is provided for the whole
block. Moreover, though there may be some decrease
of chimneys, the great advantage of an open space, from
which there is no contribution to the general smoke-cloud,
is lost. We could make better use too of the open spaces
we actually possess. In many parts of London, and not
only the wealthy parts, there are squares the use of which
is restricted to a few of the surrounding inhabitants who
rarely enter them, while children of the poorer classes
have nowhere but the neighbouring streets to play in.
Then there are cemeteries and burial-grounds, through
some of which paved paths have now been constructed
and seats placed round ornamental (!) erections of old
tombstones. Respect for the dead requires that these
should be treated with reverence, but there need be no
violation of feeling if the memorials were removed and
re-erected elsewhere. It would indeed be a great gain if
all interments within the precincts of cities were forbidden,
and all cemeteries and burial-grounds within the boundaries
acquired as public open spaces, thus relieving, in one
direction at least, the pressure of the dead hand upon the
living.

Much more important however is it to develop the
policy of taking people right out of the crowded districts
and scattering the towns, so to speak, over a much wider

156 HEALTH AND THE STATE

area of country. There is no longer any need for people
to live together in dense masses. Our towns were built
for bygone conditions, when the science of road-making
was unknown and travelling was slow. But the rapid
growth of railway, motor, and electric transport has now
made our finest cities anachronisms ; and our models for
the future need no longer be vast cities like Glasgow, with
its great docks and its infant mortality rate of 133 ;
Liverpool, with its stately Municipal Buildings and its 1600
deaths a year from tuberculosis ; or Dublin, with its Vice-
Kegal Castle, its Trinity College, and its 20,000 families
in single -room tenements ; but such places as Letchworth
and East Ham, where, though the mansions of the rich
are not numerous, the masses of the poor live under
healthy conditions. As Walt Whitman says : —

The place where a great city stands is not the place of stretch'd wharves,

docks, manufactures, deposits of produce merely,
Nor the place of ceaseless salutes of new-comers or the anchor-lifters

of the departing,
Nor the place of the tallest and costliest buildings or shops selling goods

from the rest of the earth,
Nor the place of the best libraries and schools, nor the place where

money is plentiest,
Nor the place of the most numerous population.

Where the city of the healthiest fathers stands,
Where the city of the best-bodied mothers stands,
There the great city stands.

The scattering of a city over a wider area demands
broader roads, increased means of transit, and termination
of the vicious system of holding up land in suburbs for
higher rent. In many industrial towns of moderate size
these measures would enable the workers to live outside,
and come in daily to their work without undue travelling
or expense, but in the largest cities we cannot remove the
people unless we remove their work as well. It is pitiful
to witness the crowds of tired workers struggling for even
standing room in 'bus, tram, or train in many parts of
London at the end of the day ; and in wet weather the
conditions are simply deplorable. To spend perhaps two
hours every day travelling in an overcrowded vehicle is a
heavy price to pay for a few hours of purer air at night.

SEGREGATION OF FACTORIES 157

But the way out of this impasse has already been shown.
At Letchworth in Hertfordshire there has been carried
out within the last twelve years perhaps the most success-
ful and instructive social experiment of recent times. A
large area of land was purchased by a limited liability
company to be developed as a building estate. The enter-
prise however is not a commercial venture in the ordinary
sense of the word, since 5 per cent is the maximum rate of
interest which can be paid on its capital, any remaining
profits being devoted to improvement of the estate.
Houses have been built for all classes and factories estab-
lished, the latter being one of the distinguishing features
of the movement. We are familiar with attractively-
built districts, whether called ' garden-suburbs ' or not,
which are springing up all round London, but these provide
residences mainly for the wealthier classes, and factories
in them are discouraged. Letchworth is distinguished
by its policy of actually inviting manufacturers to move
into its area, thus affording numbers of the working classes
opportunities to earn their living within easy reach of
their dwellings under the most healthy conditions. The
population of Letchworth, which is rapidly growing, is
now about 12,000, but it is not to be allowed to exceed
30,000, while large areas have been marked off which are
never to be built upon.

Segregation of Factories

Yet another lesson can be learnt from Letchworth.
The factories there are limited to special districts which
are separated from the workers' cottages. This is a principle
which could be widely extended. Until the passing of the
Town Planning Acts practically no attempt was made to
separate factories from residences, except in the districts
occupied by the wealthier classes, with the result that
each factory has tended to become the centre of a little
community which is aroused in the early morning by the
shriek of its syren, and lives under the smoke of its
chimneys throughout the year. The Town Planning Acts
enable Local Authorities to define certain areas for the

158 HEALTH AND THE STATE

erection of factories, but it will be many years before we
can substantially alter conditions in our large towns,
sweep away our hideous slums, and dot the country round
London and other great cities with Letchworths. Never-
theless a beginning has been made, and the interests of
national health demand that further efforts should be
pushed on with all vigour. Meanwhile, in the towns we
could endeavour to undo or avoid some of the mistakes
of the past. We need not continue to build schools in
close proximity to gas-works or in main thoroughfares,
where double windows are necessary to keep out the noise
and incidentally such fresh air as there may be ; we need
not establish our hospitals and manure-strewn railway
sidings within a few yards of each other ; and we need not
permit the odours from a pickle factory or a brewery to
disseminate themselves through the principal shopping
thoroughfares of the metropolis.

Bad Housing

Bad housing is believed to be a fruitful cause of ill-
health, and many Acts have been passed in recent years
intended to improve the homes of the working classes.
The deplorable housing condition of many of the poorer
classes both in town and country has been ably described
by Geddes, Savage, Booth, Rowntree, and others, as well
as in the annual reports of the Local Government Board
and the reports of many Medical Officers of Health. Two
evils are usually combined, viz. crowding together of too
many houses, and bad or dilapidated structure of the
houses. For the moment we will examine only the latter,
leaving for separate consideration the evil of overcrowding
of houses ; and we are concerned simply with the effects of
bad housing on health independently of discomfort, de-
moralisation, and other evils which it causes.

It will simplify the investigation if we note that defects
in housing may be divided broadly into two main groups,
viz. (1) defects in the sanitary systems, i.e. the arrange-
ments for the supply of water and for the removal of waste
material, excreta, etc. ; and (2) structural defects, such as

BAD HOUSING 159

damp walls, leaky roofs, broken floors, low ceilings, and
general dilapidation.

Defects belonging to the first group are far more im-
portant as a cause of ill-health than those of the second.
A pure water-supply is one of the first conditions of health,
and we know that if the drinking water is inefficiently
filtered, or becomes polluted owing to faults in the service
allowing access of sewage to it, grave epidemics may
result. Now, speaking generally, the water supplied to
all classes of the community in this country is pure. It
is true that the supply is often deficient in quantity in poor
neighbourhoods, and that the provision of water-taps and
baths is frequently inadequate, with the result that cleanli-
ness is sometimes next to impossible, but on the ground
of impurity there is little scope for complaint. We can
speak with assurance on this point, for we know that
certain diseases, particularly typhoid fever, are mainly
conveyed by water, and the low rate of incidence to which
these diseases have now been reduced is proof of the
general excellence of our water-service. This real and
great achievement in Public Health has only been rendered
possible by municipal control over the water-services, the
municipality either providing the supply itself, or exer-
cising supervision over private companies by means of
statutory powers and sanitary inspection. The advantage
of a pure water-supply is shared by all districts, and in
condemning bad housing we must remember that in one
exceedingly important respect the humblest home is now
in a better position than was many a great and even
royal mansion half a century ago.

The sanitary arrangements for the removal of waste
water and excreta are also, generally speaking, good. Local
Authorities now exercise a very considerable degree of
control over these services, and they require many pre-
cautions in the nature of trapping, flushing, and soundness
of structure of drains, sinks, and water-closets to be
observed. In the North of England the sanitary systems
are not on the whole as satisfactory as those in the South,
insanitary ash-pits still being in considerable use. Rapid
progress is however being made in the conversion of ash-

160

HEALTH AND THE STATE

pits, and it may be anticipated that before long, efficient
systems will have been generally established in their
place.

We may include also, as a sanitary requirement,
properly constructed and covered dustbins for household
refuse. If these are allowed to become foul they are un-
doubtedly a cause of ill-health, but the prevention of
nuisance arising from them is not so much a question of
housing as of frequent removal of contents by municipal
authorities.

The fact is that the great bulk of defects which sani-
tary authorities discover and require to be remedied are
structural defects in walls, floors, and roofs. When a
house is so dilapidated that it is considered unfit for
human habitation the Local Authority, after somewhat
complex procedure, can issue a closing or a demolition
order, but the number of houses closed or demolished is
small in comparison with the number of those in which
defects are remedied. The following list from the report
of the Medical Officer of Health of a large industrial town
in Yorkshire illustrates the type of defects which are most
frequently detected by house-to-house inspection : —

Foul walls around house sinks

Sinks defective or foul

Houses requiring general repairs .

House roofs defective

Eaves spouts or down spouts defective

Defective plaster on walls and ceilings

Defective ash-pit doors

Dirty houses or parts thereof

Damp houses

General repairs to water-closets .

Windows not made to open

Houses without sinks

Choked drains

Filthy water-closet apartments .

Other defects

53
34
31
30
26
23
23
20
14
12
12
10
6
5
11

310

Tables of this sort look imposing, but those who study
without bias this particular town, or any similar town,
with its squalid and sunless courts, its noisy and narrow

BAD HOUSING 161

streets filled with children, its dense population, and its
infant mortality running up in some districts to nearly
200 per thousand births, will soon realise that the whole
of these efforts amounts to little more than superficial
tinkering. It is of course easier to deal with this aspect
of the housing problem than with clearance of areas necessi-
tating heavy expenditure and interference with vested
interests, which the average Local Authority hesitates to
undertake. Thus an appearance of activity is created
which suggests that far more is being done to improve
conditions than is actually the case. " Progress has been
made with the Town Planning Acts mainly in the direction
of remedying defects," is a statement which appears in
the report of the Medical Officer of Health of a large city
in a northern county, and is typical of many reports on
housing.

But defective housing by itself is probably only a minor
cause of ill-health. It is only when the houses are aggre-
gated in large masses that the worst effects arise, and then
the evil is due not nearly so much to the defectiveness of
the houses as to the overcrowding both of occupants per
room and of houses per acre. If we could take out a
patch of, say, fifty acres from the most crowded and worst-
built district of London, Liverpool, or Dublin and set it
down precisely as it is among the pines of Surrey, or on
the wind-swept moors of Yorkshire, the probability is
that the improvement in the health of the inhabitants
would be enormous. There are in fact patches of bad
housing in many country towns and villages presenting
the worst features of slums whose occupants, nevertheless,
exhibit a high degree of healthiness. The agricultural
labourer forms the healthiest class of manual workers, yet
his bad housing is notorious ; and the wretchedly-housed
peasants of Connaught, the Highlands, and many parts of
rural England exhibit the lowest rates of infant mortality
to be found in the kingdom. Sir John Gorst says : "I
" have seen magnificent children living in hovels condemned
" as unfit for human habitation in the West of Ireland,
" models of health and vigour. The explanation was that
" they lived almost entirely in the open air. The children

M

162 HEALTH AND THE STATE

" of gipsies and vagrants who live in tents on commons,
" though filthy and untaught, are far healthier in their free,
" open-air surroundings than the corresponding class in the
" slums of the city." 1 Medical Officers of Health have called
attention to the same fact. Dr. Lyster, the M.O.H. for
Hampshire, for instance, says : " This [bad housing] is
" one of the less important factors in the production of a
" high infant mortality, or in the causation of consumption.
". . . The modern requirements as regards housing cannot
" be regarded as belonging to the essentials for a healthy
" existence, such as food for instance ; and we shall only be
" endangering our cause by making ill-founded claims of
" this kind." 2

On many grounds improvement of the wretched homes
of the poor is an urgent social duty, but do not let us
conclude that the mere remedying of structural defects
is going to have an appreciable influence in lessening the
unhealthiness of cities.

The Difficulties of Clearing Slum Areas

Clearing of slum districts being then of far greater
importance than patching of walls, it may be worth while
to examine more closely some of the difficulties which
hinder widespread adoption of this policy. These are
mainly the necessity of recouping part of the expenditure,
and the rehousing of the displaced population (or an
equivalent number of other persons) partly on the cleared
area and partly elsewhere.

The cost of clearance schemes in towns is so great that
Local Authorities cannot afford simply to lay out an area
as an open space, but find themselves obliged to recover
some of their expenditure by re-erecting, on part of the
land at least, tenements and shops from which they derive
rents and rates. This is a purely economic question with
which we are not here concerned, beyond pointing out
that in so far as the cost is due to purchase of land it is
part and parcel of the larger question which we have seen
is so intimately associated with Public Health. We may

1 The Children of the Nation, 1906.
2 " Housing Problems in County Areas," Jour. Roy. San. Inst., 1912.

THE COST OF BUILDING 163

note however that the difficulty affords an example of
the way in which a Local Authority may be pulled in differ-
ent directions by different motives, as a result of giving it
diverse functions to perform. One and the same body is
continually urged to keep down the rates, and at the same
time is expected to find large sums of money for the ad-
vancement of Public Health. It is for reasons of this
kind that the writer has urged in a later chapter that
Public Health administration should be separated from
other forms of municipal activity.

The necessity of rehousing some of the displaced popula-
tion arises from the fact that many of these persons are
bound to remain near the scene of their daily work. But
if the principle, in operation at Letchworth, of moving
factories and industries out of towns were more widely
adopted, this hindrance to clearing congested areas would
become progressively less.

The Cost of Building

We have still to consider the obstacle to rehousing
which arises from cost of building apart from that of land.
The cost of building is proportionately much greater in
rural than in urban areas, for in the latter the tenement
system enables a number of families to be housed under
one roof on a small piece of land. In the country it is
usually necessary to build separate cottages, and the low
rents obtainable do not make it profitable for landlords
to erect even the cheapest cottages if they are to conform
to modern requirements.

But the view may be put forward that we have culti-
vated an unnecessarily elaborate idea of the dwellings
which human beings require for a healthy and comfortable
life. We are so saturated with the belief that health
depends upon housing that we have created a whole
series of building laws and by-laws relating both to
material and construction from foundation to roof ; and
we do not regard a person as properly housed unless he
lives in a structure of bricks and mortar, with white-
washed plaster ceilings, papered walls, and the latest

164 HEALTH AND THE STATE

sanitary appliances. Yet, in rural districts at all events,
a far simpler and less costly structure would be equally
healthy and equally comfortable, and even the sanitary
arrangements may be of a primitive character provided the
water - supply is free from risk of contamination. The
backwoodsman in America builds his hut of logs or planks,
and the Scottish crofter and the Irish peasant live in the
humblest of habitations. During recent years a move-
ment has grown among the wealthier classes of spending
the summer months in buildings of a very simple character.
' Bungalow ' towns have sprung up along the south coast,
and some of the structures in these are merely old con-
verted railway carriages. Many of the bungalows up the
river which are occupied for months together are really
only elaborate and ornamented sheds.

The importance of taking masses of the people out of
the purlieus of cities is so great that it seems mere foolish-
ness to impede the process by clinging to a notion that
human beings must live within bricks and mortar. During
the last two years many lessons have been learnt in
the rapid construction of ' huts ' for soldiers, and these
can be rendered quite comfortable and cheerful. Some
of the temporary hospitals are simple erections of wood
or corrugated iron, built on short piles of bricks so as to
avoid cost of foundations, and these have proved quite
satisfactory for wounded men. We cannot create a Letch-
worth in a day, but Local Authorities could rapidly
establish ' bungalow ' towns, with schools, playing-fields,
etc. attached, in the country districts all round large
cities.1 It might be argued that such quarters would not

1 Mrs. Francis Acland has given the following description of ' Elisabeth-
dorp,' a village constructed in Holland for the benefit of interned Belgian soldiers
and their families : " When I visited the place in December 1915, it consisted of
ten houses only ; this summer, on my second visit, I found a thriving village with
over eight hundred inhabitants. There are some hundred houses, extensive
carpenters' shops for the men, work-rooms for the women, schools and a creche
for the children ; a prosperous vegetable garden ; a village bakery and restaurant ;
a well-equipped hospital. Every building is movable, and immediately after the
War will be transported into Belgium. The houses are four-roomed, each family
having two rooms ; they are bunt on a strong wooden framework, covered with
weather-boarding, and roofed with asbestos tiling, the whole designed so as to take
to pieces for transport. Gaily painted, and with flower-boxes at the windows,
they present, thanks to the care and pride of their Belgian tenants, a most attractive
appearance. Each house, complete with furniture, costs from £100 to £105." —
Daily News, August 16, 1916.

' SUMMER CAMPS 5 165

be suitable for winter, but they can as a matter of fact be
made quite comfortable. Those who would oppose them
on this ground should reflect again upon me wretched con-
ditions of life in crowded areas which they are intended
to replace. A bungalow may not make an ideal home,
but at least it is preferable to a tenement in a slum. Again
let us recall that only yesterday man was a primitive
savage wandering freely over the land, and even to-day —
if health were the only consideration — something but
little better than a fox-hole would suffice for his home.
We cannot provide marble staircases, pictures, and
tapestries for the masses, and perhaps after all these only
minister to an artificial sense of comfort, but we can secure
to them good health, and that with a very considerable
degree of comfort.1

' Summer Camps '

A modification of the above proposals which might be
tested at even less cost, is the opening by municipal
authorities of ' summer camps ' in the vicinity of towns.
These could be largely constructed of canvas, sites and
tents being let for small weekly rents. We know that
parties of boys often camp out for weeks together in the
summer months with great benefit to their health, and the
camps would enable many a working man and lad living
as lodgers to get away to fresher air after their day's labour.

1 In connection with these proposals the following paragraph from the report
of the chief medical officer to the Board of Education for 1915 may be quoted :
" One successful and interesting experiment during the year, in the provision, at
a minimum cost, of classrooms of an open-air type in connection with a school for
mentally defective children, is worthy of notice. In the autumn of 1915 arrange-
ments were made for the accommodation of boys from the Usher Street and Grange
Road Schools at Bradford for mentally defective children, in the grounds attached
to the Margaret McMillan School at Thackley. At first the boys' school was
conducted as a Camp School under canvas, but on the approach of winter it was
decided to erect wooden huts, and these have been constructed by the boys them-
selves. A number of separate classrooms have been provided with windows on
three sides, all of which can be opened if desired. The construction has been
reduced to the simplest ; no artisan labour has been employed. One of the class-
rooms was in constant use during the erection of these huts as a woodwork room in
which about fifteen of the boys were kept busy making parts of the new rooms.
Other boys laid out the garden allotted to the school. The whole enterprise is
most creditable and affords a valuable lesson in self-help on the part both of
the Authority and the scholars themselves which should not be allowed to pass
unheeded."

106 HEALTH AND THE STATE

They would also afford an opportunity for poor working-
class families to obtain a cheap holiday during the hot
weather when epidemic diarrhoea is at its worst among
children in towns. The annual exodus of hop-pickers
from the East End of London shows how eagerly any
opportunity is grasped by the workers of getting into the
country at little cost. If too we are led to adopt some
system of national physical training for boys and youths,
it might well take the form of requiring them to spend
three months of each year, say from the age of fourteen to
seventeen, in camp. Our education authorities have in the
opinion of the writer devoted too much attention to mental
development of children and far too little to physical train-
ing. If our schools were provided with adequate play-
grounds, the writer would urge that afternoon school should
be abolished for children under twelve and the time spent
in games in the open air. Possibly the soundest educational
movement of recent times, using the words in their broadest
sense, is the boy-scout movement, and this we owe not to
an educationalist but to a soldier.

Sleeping Out

Incidentally too, we might abolish our absurd laws
against sleeping out. Sleeping in the open air is natural
and beneficial to mankind. During the War we have heard
many accounts of the improved health of the erstwhile
city worker, who, often for the first time, has lived under
something approaching natural conditions. In New York,
during spells of hot weather, thousands of persons are
permitted to sleep in the parks and on the neighbouring
sea beaches. But in this country if a man has " no visible
means of subsistence," and has therefore a double motive
for sleeping out, we can put him in prison for so doing.
Yet being destitute he is probably in a state of health
which makes sleeping in the open air the best thing for him.
It is obviously undesirable to permit people to sleep pro-
miscuously in the streets, but there is no adequate reason
why the parks in London and other large cities should not
be open all night, and homeless persons not only not pro-

SLEEPING OUT 167

hibited but actually encouraged to sleep in them. During
the summer months at all events they would be better
off than in the casual wards. Those who consider that
observance of conventional morality is more important
than health, will object to this proposal on the ground
that it would afford opportunity for unseemly behaviour.
But assuming that this is a real risk, the closing of the
parks does not prevent it, but merely drives it elsewhere,
satisfying, nevertheless, that type of mind which believes
that if an evil is hidden it no longer exists.

We have now examined the main environmental factors
in the causation of disease, and we have seen that the land
question lies at the bottom of nearly all the forces which
make for ill-health, whether they be rural depopulation,
holding up of suburban land, continuance of slums, or in-
sufficient housing, for the question also enters into this,
through the cost of building materials. Curative and
palliative measures alone will never secure a healthy
population. We may multiply Medical Officers of Health,
sanitary inspectors, and health visitors, and we may
establish insurance systems and medical services of all
sorts, but unless we deal with the great environmental
causes which in large cities are continually producing
disease in our midst, we shall still lose our thousands of
infants every year, we shall still have our defective school
population, and we shall still be ravaged by tuberculosis
and other preventable diseases. The majority of the
people in these islands — by nature a freely-roaming species
— are landless in the country for which they fight and
whose wealth they create. Whether the ultimate solution
of this great problem is to be found in national purchase
or in progressive taxation or otherwise, the words are as
true to-day as when they were first spoken that " the only
way to get the people back to the land is to get the land
back to the people."

CHAPTER VI

MEDICAL TREATMENT AMONG THE WORKING CLASSES

The meaning of ' medical treatment ' — The growth and importance of
institutional treatment — The insufficiency of institutional treatment —
Medical treatment by general practitioners — The size of working-class
practices — ' Lightning ' diagnosis — The absence of expert assistance
— Diagnosis in general practice — The lack of laboratories for expert
diagnosis — The futility of treatment in a bad environment — The dis-
content with the panel system — Medical treatment of school children
— Mortality in child-bed and its causes — Skilled attendance in child-bed
— The pathological causes of deaths in child-bed : puerperal fever —
General practitioner or midwife ? — Attendance in confinement and in-
fant mortality — Maternity benefit — The question of a public maternity
service — Medical treatment and Public Health.

The Meaning of ' Medical Treatment '

We will turn now from consideration of the causes of
disease and examine the facilities available among the
working classes for medical treatment. It is necessary
however, as a preliminary step, to determine the mean-
ing which should be attached to the words ' medical treat-
ment,' and the services which should be included, in the
light of modern knowledge relating to the cure of disease.
The history of medicine shows that methods for heal-
ing the sick have passed broadly through three stages.
The first was the era of superstition, during which diseases
were believed to be the work of evil spirits ; and charms,
rites, and incantations were employed to drive them out of
those afflicted. The grosser elements of superstition in
this form of treatment have disappeared, but ' Christian
Science ' and ' Faith Healing ' still indicate belief in
mystic powers to cure disease. The second stage was
marked by the change from belief in magic to belief in
medicaments. Evil spirits were succeeded by ' humours,'
and the efforts of doctors were directed towards controlling

168

THE MEANING OF 'MEDICAL TREATMENT' 169

these or expelling them from the body. The whole animal,
vegetable, and mineral world was ransacked to discover
new drugs, and we need not go back very many years to
find such extraordinary things as unicorn's horn, newts'
tongues, and frog's blood being prescribed. There was
little scientific knowledge of the mode of action of drugs,
and the prescriptions were usually of a blunderbuss char-
acter, containing many ingredients in the hope that if
one failed another might succeed. This stage has indeed
not yet passed. The laity have a widespread belief in
the all-sufficiency of drugs, ' tonics,' etc., which leads to
an enormous amount of self -medication and to the prodi-
gious sale of patent and proprietary remedies, the vendors
of which laud their wares as ' purifiers ' of the blood,
while ' uric acid ' replaces the ' humours ' of earlier
centuries. The importance still attached to drugs was
exemplified in the Insurance Act, under which two out of
every nine shillings provided for medical benefit was
allocated to the purchase of medicines. Circumstances
compel doctors to give a more or less tacit assent to the
belief in the efficacy of drugs, though Sir Samuel Wilks is
credited with having said that half a dozen drugs would
do all that is possible in medicine by the administration
of medicaments. Without rigidly hmiting them to this
minimum, it is probable that most doctors would be satis-
fied with a mere handful of drugs out of the many thou-
sands which are contained in the Pharmacopoeia and
Extra-Pharmacopoeia.

The third and modern stage of medical treatment is
based upon scientific study of disease and of the human
body. Exact diagnosis of the malady is the first step, and
efforts are then made to cure it which bear, as far as pos-
sible, distinct relation to its cause. For these purposes
medicine no longer blindly administers nauseous com-
pounds, but calls to its aid physiology, anatomy, chemistry,
physics, and other sciences, and at the same time studies
the constitution of the patient and his surroundings, in-
cluding in its treatment suitable dieting, care, nursing,
and hygienic conditions. Let us consider what the full
medical treatment of a serious case of illness may involve.

170 HEALTH AND THE STATE

For the purpose of diagnosis it may be necessary to
employ X-rays, or make a bacteriological examination
of the sputum, or a microscopic investigation of a new
growth, all methods demanding the highest technical skill
•and elaborate apparatus. If the patient is admitted to a
hospital he is placed under the charge of the physician
or surgeon who at first seems most appropriate, but
during the course of the illness it may be found necessary to
transfer him to a ward for special diseases. If an operation
is contemplated, consultations may be held between the
physician and surgeon, and either may obtain a special
opinion from the oculist or aurist upon some exceptional
condition of the eyes or ears. The advice of the gynaecolo-
gist may be sought for a woman. Before the operation
is undertaken the dentist may be asked to correct faulty
condition of the teeth. During the operation the surgeon
has the assistance of an anaesthetist, his house-surgeon, and
a staff of sisters and nurses, and he may ask any of his
colleagues to be present and advise him if necessary.
During convalescence the patient may receive various
forms of special treatment, such as massage or electrical
treatment. Finally the instrument-maker may be required
under the supervision of the surgeon to fit him with arti-
ficial supports, etc. This procedure, involving as it does
co-operation between specialists of the most diverse
character, is the only one which can be regarded as
providing medical treatment in consonance with modern
knowledge.

The growth of medicine during the last half-century
has also profoundly affected the medical profession. The
volume of knowledge is now so vast that it is far beyond
the capacity of even the ablest man to master the whole.
Hence specialism has arisen in all directions. Physicians
and surgeons were early separated, but the process has
now been carried much further. Physicians specialise in
diseases of the heart, the lungs, the nervous system, or the
digestive system, in children's diseases, mental diseases,
diseases of the skin, and tropical diseases. Even a single
affection may form a domain by itself, such as tuberculosis,
venereal diseases, or gout. Surgeons devote themselves

THE MEANING OF 'MEDICAL TREATMENT' 171

to the surgery of the throat, nose, and ear, the eye, the
brain, the abdomen, the excretory system, the generative
system, or the muscles and limbs. Gynaecologists concern
themselves with conditions peculiar to women. In quite
recent years diagnosis and treatment by X-rays, light
rays, electricity, and radium have called into being a new
class of specialists who devote themselves to these methods.
Besides the clinicians, there are pathologists and bacterio-
logists who, although they may never see the patient, may
be directly responsible for the methods adopted to treat
him, as a result of their reports on the excretions, the blood,
morbid growths, or micro-organisms.

It is quite clear that for all but the wealthy classes,
medical treatment of this character can only be provided
through hospitals and institutions. The poor cannot afford
to pay the fees of specialists, their homes are not suited for
proper care and nursing during serious illness, and facilities
for elaborate methods of diagnosis are inadequate. In
the middle classes the problem has been partially solved by
the establishment of nursing homes, but even with this
advantage it is doubtful whether, on the whole, the medical
treatment received by these classes is as thorough as that
provided for the poor at a large hospital. Medical treat-
ment for serious illness to-day necessarily involves treat-
ment at an institution in which all modern methods are
available, if any real meaning is to be attached to the
words.

This conception of medical treatment appears to find
no place for the general practitioner, but so far from this
being the case, his functions are in some respects the
most important of those performed by medical men. His
primary duty is, or should be, that of diagnosis. Unless
the patient goes straight to a hospital, the general practi-
tioner is the first to see the sick person, and upon his
correct reading of the complaint may depend the whole
future course and treatment of the case. If it is a trivial
affection he can treat it himself, if it is a serious disease he
should be able to indicate the appropriate institution or
form of special treatment most likely to ensure recovery.
Error in diagnosis may be disastrous. If a general prac-

172 HEALTH AND THE STATE

titioner regards a case of cancer of the stomach as ' dys-
pepsia,' strangulated hernia as ' colic,' enteric tever as
diarrhoea, diphtheria as sore throat, or early phthisis as
a simple cough — mistakes which have all been made with
regrettable frequency, — the opportunity of effecting a cure
may have been irretrievably lost by the time the error is
discovered. The general practitioner should himself there-
fore be a specialist — a specialist in diagnosis, — and to aid
him in this work he should have every facility in the way
of laboratories for bacteriological and pathological ex-
aminations. It is sheer impossibility for a general practi-
tioner to apply all modern methods of treatment or even to
keep himself up to date with new discoveries in treatment ;
but if he performs the first step of diagnosis efficiently he
becomes the channel through which patients suffering
from serious illness find their way to hospital, where they
can receive the best treatment.

Division of function and co-operation in a scheme in
which every one plays a skilled and useful part is in fact
the essential characteristic of modern medicine ; and a
system of medical attendance which consists simply in
providing the services of a general practitioner is no more
an adequate service than would be a postal service con-
sisting of sorters without postmasters, clerks, telegraphists,
and telephonists.

We have now sketched out the division of function
among medical men to which growth of knowledge has
inevitably led ; and we have next to consider how far an
organised scheme is in actual operation among the work-
ing classes, beginning with the provision for institutional
treatment.

The Growth and Importance of Institutional
Treatment

The most striking fact about institutional treatment
is its remarkable growth during the last forty years or so.
We cannot measure this directly by the number of patients
treated, since no complete record is even now compiled,
but we can gain a very fair idea from the number of deaths

INSTITUTIONAL TREATMENT

173

which occur in institutions and are stated in the Annual
Reports of the Registrar-General. The following table
shows the deaths in institutions in England and Wales for
the years 1870 and 1914 :—

Deaths in Public Institutions

Institution.

Percentage of Total Deaths.

1870.

1914.

Workhouses and Workhouse Infirmaries
Lunatic Asylums

5-6
2-0

•7

11-51

841
2-33

Total

8-3

22-25

We see from this table that in forty-four years the
percentage of deaths in institutions has increased by nearly
threefold, and that now more than one-fifth of all the
deaths in England and Wales occur in public institutions.
A better idea of the extent to which institutions are used
can however be gained by comparing their distribution in
different types of area. The following table shows the
distribution according to place of occurrence of the 516,742
deaths which occurred in England and Wales in 1914 : —

Deaths according to Place op Occurrence

Area.

London

County Boroughs
Other Urban Districts
Eural Districts .

Deaths in Public
Institutions.

30,459
44,210
27,838
13471

Deaths in Other
Places.

35,578
140,962
137,955

86,269

It will be noticed that in London not far short of half
the total deaths occur in public institutions, and of these
rather more than half are in Poor Law institutions. In the
County Boroughs the proportion is rather less than 25 per
cent of the total. In the smaller Urban Districts and in
the Rural Districts the percentage is very much less, but
in gauging the usefulness of institutions it must be remem-

174 HEALTH AND THE STATE

bered that the need for them is appreciably smaller in
rural areas than in towns, since the amount of prevent-
able disease is much less, and the proportion of deaths
from senile conditions for which medical treatment can
do but little, is greater. Moreover, a considerable propor-
tion of the cases which would benefit by hospital treatment
come into the towns to receive it.

We can supplement these figures by certain additional
facts. In the hospitals of the Metropolitan Asylums Board
for infectious diseases, the proportion of patients actually
admitted to those legally admissible has grown from 33 '6
per cent in 1890 to 87"5 per cent in 1914, and the percentage
of admissions is as high in good-class as in poor-class
neighbourhoods, which shows that little prejudice exists
against accepting free State assistance during illness from
these diseases. Institutions are now provided by public
authorities for the treatment of ringworm, ophthalmia,
epilepsy, and mental diseases ; while under the Insurance
Act sanatoria for those suffering from tuberculosis are
now being established in many parts of the country. These
statements refer only to in-patients, but several millions
of out-patients must be added to the number of those who
receive treatment through hospitals. Education author-
ities are making arrangements with hospitals for the
treatment as out-patients of large numbers of school
children, and quite recently the Government has indicated
its intention of providing treatment through hospitals for
those suffering from venereal disease.

When we reflect upon the vast numbers of persons who
either as in-patients or out-patients pass through the doors
of our institutions, upon the fact that practically all
serious operations among the working classes must be
performed in hospitals, and that large numbers of persons
suffering from chronic ailments are maintained permanently
in infirmaries, it becomes quite evident that the hospitals
and kindred institutions form the real backbone of medical
treatment in this country. The general practitioners may
see a larger number of patients during the year, but it is
certain that the hospitals do the great bulk of all the more
serious work among the working classes.

INSTITUTIONAL TKEATMENT 175

A process of evolution has in fact been driving the
general practitioner into the place naturally indicated for
him in an organised scheme, that of diagnostician, and has
steadily reduced the volume of treatment left to him to
perform. Thirty years ago an average case of scarlet
fever or diphtheria probably meant several weeks' attend-
ance by the doctor and the earning of substantial fees ;
to-day as soon as he diagnoses the case it is removed to
the fever hospital. In many other ways the growth of
institutional treatment has been eating into his practice,
while the tuberculosis officer, the school doctor, and the
registered midwife have deprived him of part of his work
in other directions. The decline of general practice was
in the very nature of things inevitable, and although the
Insurance Act, by the importance it has assigned to medical
treatment by general practitioners, has tried to reverse
the evolutionary process, it is not likely to have any per-
manent effect upon the strong tendency towards specialism
and institutional treatment.

But there is much need for these facts to be realised
by legislators. To speak of ' adequate ' medical treat-
ment in an Act of Parliament, and to mean thereby treat-
ment by a general practitioner, is, without in any way
reflecting upon the practitioner, simply to play with
words. And in the debates on the Insurance Act no one
seems to have realised that adequate medical attendance
for all serious affections means hospital attendance both
in theory and in fact. It was not even until two
years after the Act had been passed that the Govern-
ment, for the first time, made a census of hospital beds in
this country, after the necessity had been shown by the
Fabian Society. Yet had it not been for the voluntary
hospitals, medical benefit under the Insurance Act would
have been a farce.

The Insufficiency of Institutional Treatment

But great though the growth of institutional treatment
has been, it has not kept pace with the continually-increasing
demands of the community, and nearly all large hospitals

176 HEALTH AND THE STATE

have long lists of applicants waiting for admission, most of
the cases being in need of surgical treatment. To quote
some examples : in 1914 the Western Infirmary in Glasgow,
with about 600 beds, had a waiting list of between 700 and
800,1 and the Royal Victoria Infirmary had a similar list
of 1300.2 The Insurance Act has demonstrated the need
of further hospital accommodation, the immediate effect
of medical benefit being a much greater demand on the
in-patient space of nearly all the hospitals. This was
the result of an Act which applied to only one-third of the
population, and that the healthiest third, since it consists
of people capable of work and mainly of men. Had the
Act applied to women and children and the class of casual
labourers, it is reasonable to suppose that the increase in
the demand for beds would have been very considerably
greater. This means that many thousands of women and
children are not getting the hospital treatment which a
simple sorting out by panel doctors would show them to
require. It is estimated that about 50 per cent of the
in-patients in the hospitals of the United Kingdom are
insured persons. That is, one-half of the accommodation
is devoted to one-third of the populace who happen to be
under better conditions for having their maladies detected.
The Fabian Society has the credit of having made the
first complete survey of hospital accommodation in this
country. In their report, published in 1914, they esti-
mated the need for hospital beds at between 2 and 4
per thousand of the population, exclusive of provision for
tuberculosis and other notifiable diseases. In Germany
provision is made for 5 per thousand in towns and 3 per
thousand in the country ; in France the minimum is 2 per
thousand. In England, according to the report, in not
one county does the number of hospital beds reach the
standard of 2 per thousand of the population, while in
many it falls below 1 per thousand. A rough estimate
made by the Local Government Board at a later date
showed about 1 3 hospital beds per thousand of the popula-
tion in England and Wales, or-L7 including institutions
for convalescence. As in the Fabian Society's estimate,

1 Hospital, December 1914. 2 Hospital, June 1914.

TREATMENT BY GENERAL PRACTITIONERS 177

hospitals for infectious diseases and Poor Law infirmaries
are excluded. If we examine special institutions, for
example sanatoria for tuberculosis, we find the same
story of deficiency.

From these figures it would appear that at least another
17,000 beds are required in England and Wales to bring
the proportion up even to the minimum of 2 per thousand
of the population. It is important to notice however
that the deficiency is by no means equally distributed.
The table given on p. 173 shows that the County Boroughs
as a whole are far less well supplied than London, and
experience shows that even London cannot be regarded as
overprovicled. It is true that the London hospitals draw
some of their inmates from outside the county area, but
this is also true of other large towns. The underprovision
in rural districts is not so serious having regard to the
smaller demand. It is in the large industrial and mining
towns, the very places where sickness is greatest and
hospital treatment most needed, that the really grave
deficiency exists.

Medical Treatment by General Practitioners

Medical treatment, otherwise than through hospitals,
is given among the working classes by private practice,
panel practice, clubs, medical institutes, dispensaries, and
outdoor medical relief. In addition a great deal of medical
treatment of a land is given by herbalists, bone-setters,
chemists, and other unqualified practitioners. In their
essentials these systems do not differ very much from each
other. They all provide practically the same treatment
for the same class of patients under the same disadvan-
tages and difficulties. Club practice has been as roundly
condemned by doctors as by any other persons ; private
practice in districts where the fees range from 6d. to 2s. for
advice and a bottle of medicine is probably not so good as
club practice ; and panel practice, as far as patients are
concerned, differs little from club practice except that the
scope of treatment given is rather more limited. The
investigation in the following pages relates mainly to

N

178 HEALTH AND THE STATE

practice in the poorer quarters of towns, where conditions
are often demoralising for the doctor, and treatment futile
for the patient. In better-class districts the conditions
are not so bad, and in rural districts the efforts of the
doctor are aided by the healthiness of the surroundings.

The main reasons why general practice, whether
private or contract, is unsatisfactory among the working
classes are: (1) many doctors attempt to do a great deal
more work than they can possibly manage satisfactorily,
with the result that their patients are not properly ex-
amined and treated ; (2) the facilities for obtaining con-
sultant assistance, or expert diagnosis, or special forms of
treatment are very limited ; and (3) the environmental
conditions of many patients are so bad that medical treat-
ment is often useless, and the doctor, unable to do more,
falls into the habit of continually giving medicine as a
' placebo.' In view of the proposals which are now put
forward for modifying the panel service or establishing
some form of a national medical service it is desirable
to examine each of these factors somewhat more fully.

The Size of Working-Class Practices

It is impossible to lay down a hard-and-fast limit to the
number of persons one doctor can attend satisfactorily,
for this depends upon the amount of sickness in the district,
the capacity of the doctor, and the distribution of his
practice ; but it is well known that many practices are far
too large. A considerable number of panel doctors, work-
ing without partners or assistants, have 2000 insured
persons on their lists ; some have 3000, and even 4000 is
reached. Most of these are undertaking private practice
as well, and if we assume that on the average each insured
person connotes one and a half dependents, it follows that
a doctor with a panel list of 2000 has actually a total
clientele of some 5000 persons. Many instances have been
given of the way in which doctors with these large practices
rush through their work in order that they may see all
their enormous number of patients. Dr. Alfred Salter,
speaking in 1914 at a public meeting in support of a

SIZE OF WORKING-CLASS PRACTICES 179

national medical service, stated that he saw "on an
average 76 cases in the morning and 92 in the evening.
It worked out at 3 J minutes for each patient, lj of which
was taken up in writing. Patients had to wait on an aver-
age 2| hours for their turn, unless present at the very-
start." *

In an investigation at Cambridge by the Insurance
Commissioners into the conduct of a panel practitioner,
whose dispenser had written prescriptions and given
medical certificates, it was shown that the practitioner's
consultations and visits to panel patients in 1914 amounted
to 12,457, and that with private patients the total was
brought up to 20,660.2

It is frequently said that this is a result of shortage
of doctors in working-class neighbourhoods ; and statistics
have been issued to show that while there is one doctor to
every five or six hundred of the population in good- class
neighbourhoods, there is only one to every two to four
thousand in working-class districts, though as a matter of
fact the proportion is rarely less than one to three thou-
sand even in the worst-provided districts. But none of
these tables are convincing, since they all ignore the
hospitals, which appreciably relieve the doctors in the
poorest neighbourhoods, while there is no means of com-
puting accurately the number of assistants the doctors
may have.

As a matter of fact, large practices are far more due
to unequal distribution of patients than to shortage of
doctors. In many towns one-fifth of the doctors attend
more than half the insured persons.3 The tendency for the
bulk of medical practice in working-class districts to pass
into the hands of a relatively small proportion of the
doctors, noticeable before the passing of the Insurance Act
and equally observable in Germany, is the direct result of
' free choice ' of doctor. It might have been supposed
that the long delays in crowded waiting-rooms and hurried

1 Medical World, April 1914. 2 Hospital, September 18, 1915.

8 In Bradford in 1913, seven medical men earned from panel practice between
£1000 and £1500; two between £800 and £1000; fifteen between £500 and £800;
thirty-two between £300 and £500 ; thirteen between £250 and £300 ; and twenty-
nine less than £50. One practitioner, without a partner, had 4000 insured persons
on his list. — Lancet, March 14, 1914.

180 HEALTH AND THE STATE

attendance would have led patients to distribute themselves
more equally, but this has not occurred. The writer has
spent an evening in the surgery of a panel doctor where
over seventy patients were seen in the course of three hours.
Some of these had been waiting their turn for hours, and
towards the close of the evening they were shown into the
consulting-room three at a time. A short distance up the
street a very capable doctor saw less than a dozen patients
during the same evening. The fact is that there is as
much fashion in doctors and desire to go to the " best man "
in Mile End as in Mayfair, and when once a doctor has
earned a reputation, people prefer to put up with any
amount of inconvenience in order to see him, rather than
go to his less busy but less well-known neighbour. Psycho-
logy was forgotten when ' free choice ' was given under
the Insurance Act. It is important to realise the strength
of these tendencies, since some of the impossible schemes
for a national medical service seek to retain free choice
and at the same time distribute patients among the doctors
approximately equally. If free choice is to be observed,
we cannot fix any limit to a doctor's practice ; and if, on
the other hand, excessive numbers are to be prevented
free choice must be abandoned.

The ' Lightning ' Diagnosis

The immediate effect of attempting to treat such large
numbers is to encourage hasty and inefficient work. There
is not time to make an adequate examination of the
patient, and since the great bulk of those who come to the
surgery are suffering from relatively trivial ailments, the
doctor jumps to his conclusion after a few questions and
a superficial investigation, with the result that serious
errors are made from time to time, as Coroners' inquests
and reports of Insurance Committees and Approved
Societies have shown. The best picture of panel practice
under these conditions has been furnished by a panel
practitioner himself in the two following letters to one of
the medical journals : — x

1 Medical World, April 2 and 16, 1914.

THE 'LIGHTNING' DIAGNOSIS 181

Sir, — Much, is said about the 'lightning diagnosis' that busy-
panel doctors must make. I hope Mr. Parker will not be greatly
upset when I inform him that I often see from 60 to 70 patients of an
evening between 6.30 and 9, i.e. an average of one every two minutes.
And yet it is very simple. Each patient on entering the surgery is
presented with a numbered ticket by my nurse. This, I may say, is
much appreciated and prevents confusion and waste of time. I
have already seen, during the past week, nine-tenths of my to-night's
visitors. To my question, " How are you getting on ? " the answer
as a rule is, "Very well, but I think another bottle would help me
more." The prescription is ready as they utter the last word. A
number want documents signed, leaving me plenty of time to
thoroughly examine the seven new patients. " But they are all
trivial cases," I think I hear some one say. Is not almost every
deviation from the path of health trivial ? Let us look at a few of
our to-night's ' trivial ' cases. No. 1, chill ; No. 2, eczema ; No.
3, dyspepsia ; No. 4, alveolar abscess ; No. 5, chill ; No. 6, sprain
ankle ; No. 7, ulcer leg ; No. 8, injury to foot ; No. 9, chill ; No.
10, chronic nasal catarrh ; No. 11, neuralgia ; No. 12, chill ; No. 13,
dyspepsia ; and so on. Who will say that one of these is trivial ?
Yours, etc., An Old Hand.

In a second letter the ' Old Hand ' lets us more fully
into the secret of his methods. He says, in reply to
criticisms : —

Thanks to an excellent training at the ' London ' in the ' spot-
ting class ' (20 years ago), plus a study of the methods of Dr. Bell
(Sherlock Holmes), it does not take long to sum up a patient. When
to these are added the mastication and assimilation of such books
as Malingering, Emergencies of General Practice, the latest books
on skin, eyes, ear, etc., I am equipped for my night's work. My
to-night's new patients number seven. The first is ' indigestion.'
I hand the patient a printed slip, ' What to eat and what to avoid,'
and ask him to keep it for reference. After a few enquiries as to
the kind of indigestion I hand him my prescription. No. 2, urticaria.
I knew at once, in this district, that fried fish is most likely the cause.
I tell her that two days ago she had fried fish for supper ; she
admits the soft impeachment, and with a little good advice she
departs, happy in mind that it is not S.F.1 No. 3, neuralgia. It
ranges between temple and jaw. The offending molar is at once
detected, and a visit to the dentist advised. Nos. 4 and 5, chills ;
quick pulse — " \ min. thermometer." " Go to bed at once ; take the
medicine, and I shall call to-morrow to see you." No. 6, a man
hobbles into the surgery — injury to foot. I inquire kindly, " Why

1 Scarlet fever.

182 HEALTH AND THE STATE

didn't you send f or me ? " "I thought I could save you the trouble
of calling." (Bless them ! Almost without exception they wish to
* save trouble ' ; they are very good.) I advise the man to go home
and I will follow at the close of surgery. No, 7, lumbago.

It would be unfair to class all panel practitioners with
the ' Old Hand/ nevertheless he describes a type of con-
ditions which is far too common. Six out of his twenty-
cases mentioned are diagnosed as ' chill/ to be seen to-
morrow, but meanwhile medicine prescribed ; the patient's
own statement that she requires more medicine is accepted
without question and the prescription given at once ; the
newcomer's own diagnosis of indigestion received without
examination and medicine ordered ; printed slips kept in
order to save the time of verbal advice ; while the one
useful service which would have been worth all the pre-
scriptions, viz. extraction of the ' offending molar,' is
not performed. We can understand how with these
methods the ' Old Hand ' gets through his large number
of cases, but it is not easy to see when he manages to
' masticate and assimilate ' the ' latest books on skin,
eyes, ear, etc' and how these assist him.

These large practices are generally mixed private and
panel, the treatment given to private patients being
essentially the same ; but instead of a prescription the
private patient receives a bottle of medicine, usually drawn
from a ' stock-mixture ' made up in large quantities for
all and sundry, the fee for advice and medicine averaging
about a shilling. Such practices can only be carried on by
means of a machine-like system, and the doctor has rarely
time to read current medical literature or keep proper
medical records of his cases. Minor surgery is performed
in a manner which would horrify a surgeon. There is no
time to sterilise properly instruments, hands, or skin. The
writer on one occasion saw a doctor at the close of three
hours' surgery open a deep abscess in the breast by an
incision an inch and a half long. The knife was just
dipped into a weak solution of carbolic acid, no attempt
was made to sterilise the skin in any way, and there was
no suggestion that the patient should have even a local
anesthetic. The girl paid her shilling, but refused to let

THE ABSENCE OF EXPEKT ASSISTANCE 183

the doctor call the next day, as she could not afford a
further fee.

The big panel and dispensary practices are exceedingly
lucrative, but they are demoralising to both patients and
doctors. It is but fair to recognise however that in
many smaller practices and in large practices where suffi-
cient medical assistants have been engaged, considerably
better treatment is given.

The Absence of Expert Assistance

The poor cannot afford the fees of consultants, and no
provision is made under the Insurance Act for this form
of assistance, so freely sought in better -class practice.
The doctor therefore, unless he sends his patient to a
hospital, must rely upon his own knowledge for diagnosis
and treatment in every form of difficulty. He must be
surgeon, physician, and gynaecologist in one ; he must
undertake the treatment of grave cases which emphatically
ought to be in hospital ; advise on the feeding, care, and
treatment of infants ; attend women in pregnancy and
childbirth ; do his best for patients waiting for surgical
operation ; give anaesthetics for a brother practitioner,
and attend many cases of infectious disease in children.
For the purposes of diagnosis he should be able to employ,
and have time to employ, scientific instruments of pre-
cision, such as the ophthalmoscope and the laryngoscope,
the use of which he learnt in his student days. He should
be capable of making skilled investigations of the blood
and the excreta. Finally, he may be called upon in an
accident or emergency to perform almost any service in
the whole range of medicine or surgery. Besides his purely
clinical duties the modern doctor must observe a long
series of legal obligations, rules, and regulations relating
to notification of disease, keeping records, giving of certi-
ficates, etc. We are accustomed to regard specialism as
demanding the higher degree of mental attainments, but
as a matter of fact the specialist, limited to one subject,
does not embrace anything approaching the wide and

184 HEALTH AND THE STATE

varied volume of knowledge expected of the general
practitioner.

Besides being unable to obtain expert medical assist-
ance, the doctor is further handicapped by absence of the
accessory but exceedingly important aids to medical
treatment which are at the command of the wealthier
classes, such as skilled nursing and invalid food ; and he
may have to attend his patient in a sick-room which is
small, noisy, dirty, and depressing.

Diagnosis in General Practice

Considering the circumstances of general practice in
poor urban areas, it is not surprising that serious mistakes
are made by doctors. We have already noticed the im-
portance of accuracy in diagnosis, and it is probably in
this respect that most errors are made, partly owing to
insufficient facilities for skilled methods, and partly owing,
it must be admitted, to failure of the doctors to utilise
these facilities when they are available. In regard to
phthisis in children, for example, Dr. Hugh Thursfield, of
St. Bartholomew's Hospital, writes : "In the course of a
year I have to examine a large number of children who
have been certified as the subjects of pulmonary tuber-
culosis, and I do not exaggerate if I say that in at least
two-thirds there is no evidence whatever of the existence
of the disease." 1

The statistics of erroneous diagnosis made by doctors
when notifying cases of infectious disease in London are
shown in the tables of admissions to the hospitals of the
Metropolitan Asylums Board. In 1913 the number of
patients sent from their homes to the fever hospitals on
doctors' certificates was 27,746, and of these 2501 were
found not to be suffering from the diseases certified. The
following table shows the cases in detail : —

1 Medical World, June 16, 1916.

DIAGNOSIS IN GENERAL PRACTICE 185

Admissions to Fevee Hospitals of the M.A.B.

Disease certified.

Total Admissions
direct from Home.

Number not

suffering from

Disease certified.

Scarlet fever

Diphtheria

Enteric fever

Measles

Whooping-cough

Cerebro-spinal fever

Puerperal fever

Typhus

Poliomyelitis

Smallpox .

Uncertified

15,973

6,484

399

3,603

1,099

20

68

5

11

2

82

963

1009

161

203

55

15

10

1

0

2

82

27,746

2501

It may be noticed that nearly 16 per cent of the cases
sent in as diphtheria, and more than 40 per cent of those
sent in as enteric were suffering from other maladies.
Among the cases wrongly diagnosed as one or other of the
notifiable diseases were 927 instances of tonsillitis, 288 of
erythema, 152 of German measles, 77 of pneumonia, 70 of
laryngitis, 59 of bronchitis, and 230 in which no obvious
disease could be found on admission. A considerable
number of these persons must have been acutely ill, for
111 of them died while in the fever hospitals.

These statistics are for the whole of London, but when
we examine the experience of individual hospitals we find
considerable variation in the proportion of errors. In
admissions for scarlet fever, the percentage of errors was
10'G at the Eastern Hospital and 1*6 at the Brook Hospital.
For the same two hospitals the percentages of errors in
admissions for diphtheria were 29 '9 and 81 respectively.
It is difficult to account for these wide local variations,
except on the view that the hospitals with the high per-
centages of errors draw a larger proportion of their patients
from the poorer districts, where the doctors devote less
time and attention to their patients.

These figures are startling, but it must be remembered

186 HEALTH AND THE STATE

that some cases are very difficult to diagnose, and that
in doubtful case's doctors are encouraged to notify rather
than to wait until clear indications develop. On the other
hand, these are not cases overlooked in the hurry of surgery
work, but patients who presumably have been very care-
fully examined ; the practitioner is under no obligation to
notify until he is satisfied of the presence of the disease ;
and in doubtful cases the opinion of the Medical Officer
of Health can usually be obtained. After making every
allowance for difficult cases it is certain that the percentage
of errors is much too high. The Medical Superintendent
of one of the largest fever hospitals has stated that in
at least two-thirds of the cases wrongly diagnosed, the
mistake ought never to have been made. The experience
of the M.A.B. hospitals for diseases other than infectious
fevers shows that when patients are under conditions for
efficient examination very few errors need occur. Among
the patients in these hospitals 73 cases arose which were
diagnosed as infectious fevers and were sent to the fever
hospitals, where only one was found to have been wrongly
diagnosed. These figures illustrate in striking manner the
ineffectiveness of general practice under present conditions.
Speaking of working-class practice, Dr. Newsholme
says : " This practice will not be likely to be satisfactory
unless patients under its conditions have the same modern
facilities for diagnosis as are commonly available for
hospital patients." 1 In regard to the special examination
of sputum in suspected phthisis he says : " After making
full allowance for the varying extent to which practitioners
examine sputa for themselves, or have them examined
in private laboratories, there can, I think, be no doubt
that this aid to the diagnosis of tuberculosis is greatly
neglected in a large portion of the country."

The Lack of Laboratories for Special Diagnosis

Most of the larger Local Authorities, including the
Metropolitan Borough Councils, now undertake bacterio-
logical examinations in cases of suspected diphtheria and

1 Annual Report to Local Government Board for 1913-14.

THE LACK OF LABORATOKIES 187

enteric fever for practitioners free of charge, and where
such facilities are available, the doctor alone is to blame
for not making use of them. But these opportunities are
not provided everywhere, and facilities for investigations
less frequently required, such as examinations of blood,
excretions, and new growths, and diagnosis by X-rays,
are almost non-existent except on payment of fees. The
importance of providing public laboratories for these
purposes was frequently mentioned in debates and dis-
cussions on the Insurance Act, and it was actually made
a condition of the extra-Parliamentary grant for medical
benefit that doctors should employ these modern methods
of diagnosis; but the Insurance Commissioners have not
yet taken any steps to provide the laboratories necessary
for the doctors to fulfil their obligations. For the first
two years after the passing of the Act no thought seems
to have been given to the matter at all ; for 1914-15 a
sum of £50,000 was voted by Parliament for the purpose,
but still no action was taken and the money was not spent ;
in 1915-16 a sum of £25,000 for pathological laboratories
was included in the estimates but was vetoed by Parlia-
ment. The provision of facilities for expert diagnosis
would not have been a difficult matter. The cost is not
high ; there are no vested interests to be overcome, and
the laboratories of Local Authorities, hospitals, univer-
sities, clinical research associations, etc., afford opportunities
for making arrangements. It is impossible to find any
other reason for the failure to provide these facilities than
sheer official lethargy or ignorance of their need. As a
nation we are frequently reproached for not sufficiently
employing scientific methods, but in this case the fault is
not with the people, nor the doctors who have shown the
need, nor Parliament, at least up to 1915-16, but with the
highly - paid administrators who draw their salaries and
neglect their public duties. In a later chapter proposals
will be made to decentralise much of our Public Health
administration, increasing the powers of Local Authorities
and diminishing these of the central departments. Since
it is urged against this proposal that Local Authorities are
apt to neglect Public Health duties and require ' gingering '

188 HEALTH AND THE STATE

by the central authorities, it is well to bear in mind that
the latter are often quite as much in need of this process
themselves.

The Futility of Treatment in a Bad
Environment

Perhaps the most disheartening feature of medical
practice among the working classes is the hopelessness of
attempting to produce any permanent and substantial
improvement in health under existing conditions of the
environment. We can realise this by studying rather
more closely the nature of the ailments from which the
patients who throng the doctors' surgeries suffer. A
large proportion of these, as indeed of all the working
classes in large towns, are not suffering from definitely
definable diseases, but are in a state of chronic ill-health,
which is variously described as ' debility,' ' run down,'
' out-of -sorts,' etc., the result of a life of toil in insanitary
surroundings. Another large group suffer from ailments
to which more definite names can be given, such as anaemia,
dyspepsia, nervous breakdown, varicose veins and ulcer-
ated legs, milder forms of bronchitis, chronic rheumatism,
and effects of decayed teeth ; uterine displacements in
women ; and rickets and malnutrition in children ; all
conditions not in their early stages serious, nor even neces-
sarily incapacitating for work, but sufficient to make fife
wretched, and to serve as thef oundationf or graver maladies.

The fact we have to realise is that these people are
urgently in need of fresh air, rest, and good feeding, and
that medical treatment can do little for them beyond giving
temporary relief to symptoms, so long as their surroundings
remain unchanged. The practitioner may treat the shop-
assistant suffering from varicose veins or ulcers with
ointments for months, but only a prolonged period of rest
will be of any real benefit. He may prescribe quarts of
bismuth aod soda mixture for the chronic dyspeptic, but
so long as his patient lives on unsound or unsuitable food,
or has only a hurried interval for his meals before resuming
work, the symptoms will continue. He may prescribe

THE APOTHEOSIS OF DRUGS 189

without result cod-liver oil and Parrish's food for the slum
child, whose daily breakfast (and often dinner and tea as
well) consists of tea and bread and jam, and he will find
grey powder and citric acid useless for the sickly infant
needing plenty of good fresh milk. He may vainly dose
with phenacetin the woman who is suffering from continual
headaches while sewing all day in a hot stuffy room, per-
haps with an error of refraction which he could probably
neither measure nor prescribe for.1 Only a change of
environment will produce any lasting improvement in
the great majority of these patients. The anaemic girl
must be taken away from her daily life in the scullery ; the
woman with the displaced uterus from her charing ; the
chronic bronchitic from the fog and dust of cities; and
the neurasthenic from the noise and turmoil of the street
or factory. But the general practitioner possesses no
magician's wand to effect these transformations, and he
cannot send his patients empty away. Hence he falls
back upon medicine as the only procedure which has a
semblance of giving help, and all his patients receive their
iron and strychnine ' tonic,' pill, or ointment as a wholly
inadequate substitute for the real measures their condition
demands. As a very able panel practitioner once re-
marked to the writer at the end of a heavy evening's
surgery : " Well, I have prescribed many gallons of
medicine to-night, and if I could have given each one of
these people a good square meal it would have done them
a great deal more good."

The Apotheosis of Drugs

Unfortunately belief in the curative value of drugging
is now firmly established in the minds of all classes of
the community. This is the result partly of mediaeval
tradition and partly of the unscrupulous devices of the
patent-medicine vendor ; but doctors themselves are also

1 The referees appointed by the Insurance Commissioners to adjudicate on the
scope of medical benefit, have decided that testing the eyes for errors of refraction,
and prescribing as a result of the test, is not a service which " consistently with the
best interests of the patient, can properly be undertaken by a general practitioner
of ordinary professional competence and skill."

190 HEALTH AND THE STATE

in a measure responsible. Sir Clifford Allbutt has said :
Physicians resent all that savours of quackery, at any
rate in medicine ; yet is there any custom more apt to
engender and to foster quackery than to encourage snobs
to wander round our halls for potions to be hugged to their
bosoms as charms ? In not a few cases, it is true, these
herbs and salts have some virtue ; but in how many are
they not stock receipts, either wholly futile or at best
impotent as auxiliaries against unwholesome habits and
conditions of life which the physician, unable to
ameliorate, gets weary of denouncing ? Too soon he
learns to say to himself, ' Poor creatures, errant or
sinful, God help them, I cannot ; yet if pill or potion
be a comfort to them, or a hope, by all means let them
have it.' And the quackery does not end here ;
unhappily it permeates into the higher social ranks, to the
degradation of scientific therapeutics." 1
It is not probable that doctors will relegate drugs to
their proper and useful sphere, any more than the sister
profession, the Church, will officially abandon beliefs now
recognised by educated persons as erroneous; for prescribing
is the only element of mystery left in medical treatment.
But the result is a wholly exaggerated idea of their value in
the public mind. The worst feature of this belief is that it
is shared by legislators, and under the Insurance Act some-
thing like one and a half millions are provided annually
for medicines, while the far more urgent need for specialist
services and nursing are entirely neglected, surgical and
medical appliances are restricted to the barest minimum,
and the extra food for consumptives is rigidly limited.
All over the country a large staff of salaried officials are
employed in checking prescriptions given by panel doctors,
which probably number not less than thirty millions a
year, while a sick person has no right to even an occa-
sional visit from a nurse to perform a special service. The
amount spent by the community on the purchase of drugs,
whether from doctor, chemist, or through the Insurance
Act, must be enormous, and the sale of patent medicines

1 Hospitals, Medical Science, and Public Health. An address delivered at the
opening of the Medical Department of Victoria University, Manchester, 1908.

DISCONTENT WITH THE PANEL SYSTEM 191

has actually increased since the Act came into force, pre-
sumably as a result of the general advertisement given by
the Government to medicines. How much better would
this money be spent in removing some of the conditions
which lead to the demand for drugs !

The Discontent with the Panel System

Dissatisfaction with the panel system is widespread.
The doctors complain that they are harassed by unneces-
sary regulations and circulars from administrative author-
ities ; that sick visitors and agents of Approved Societies
interfere with their treatment of patients ; that their
certificates are sometimes overruled ; that an excessive
amount of clerical work is required from them ; and that
they are not paid fully and promptly. The non-panel
doctors complain that insured persons are not freely per-
mitted to be attended by them. The officials of Approved
Societies state that they cannot rely upon the doctors'
certificates, and that they do not exercise sufficient care
when examining patients. Insured persons complain
that they do not get proper and sufficient treatment ;
that a distinction is made between them and private
patients ; that sometimes they cannot get a doctor at all ;
and that sometimes they are made to pay for services to
which they are entitled without charge.

There is a large measure of truth in all these com-
plaints, but the fault lies far more with the circumstances
and the system than with the doctors who are often
working under conditions of exceptional difficulty. The
panel system was unsound from the beginning. It was
based upon a form of contract practice which had never
been ideal, and it worsened rather than improved the
previous system. It does not meet the crying need of the
working classes for greater hospital treatment. It expects
the doctor to perform satisfactory work in the worst en-
vironments without giving him assistance from consultants,
facilities for skilled diagnosis, or nursing ; it does nothing
to increase his interest in the scientific side of his profes-
sion ; and it perpetuates competition between doctors

192 HEALTH AND THE STATE

instead of establishing co-operation. A national medical
service at least could not be less satisfactory ; but the best
solution is probably to be found in giving Local Authorities
power to establish municipal medical services with wide
latitude as to the form of the service, according to the
needs and circumstances of each district.

Medical Treatment of School Children

We have seen that roughly about one -third of the
school children in England and Wales undergo a medical
examination in the course of the year, and from the number
found defective it was estimated that the total number of
school children who require medical treatment is more
than a million and a half. But detection of a defect by
no means assures its treatment. The school doctor who
examines the child is precluded from undertaking treat-
ment, and, except in districts where the Education
Authorities have made special arrangements, recourse
must be had to private practitioners or the Poor Law.
Under these conditions it is inevitable that a large number
of children should fail to receive treatment. There is no
return for the whole country of the number of children who
receive treatment, but the following table relating to some
59 school areas, representing a total average attendance
of about 754,000 school children, shows how large is the
field still to be covered : —

Medical Treatment of School Children 1

Number of defects needing treatment . . 131,157

Number of defects treated .... 74.124

Number of defects not treated . . . 32,375

Number for which no report is available . . 24,658
Results of treatment —

Remedied 42,884

Improved ...... 24,915

Unchanged ...... 6,325

It appears therefore that less than 60 per cent of the
defects found were treated actually, and only about 33

1 From the Report of the Chief Medical Officer to the Board of Education for
1914.

TREATMENT OF SCHOOL CHILDREN 193

per cent were remedied, while a smaller percentage appear
under the somewhat elastic title of ' improved.' Since
only one-third of the school population comes under
medical inspection in the year, and since only one-third
of the children found defective on inspection have their
defects remedied, it follows that out of the total mass of
defectiveness the school medical service is still only correct-
ing one-ninth in the course of the year. And be it remem-
bered that at the best the school medical service only
deals with chronically defective children. Except for
infectious diseases there is no State provision for the
many thousands of children who in serious illness are
kept at home. It is obvious that the present system
can have only a very limited effect upon the great mass
of sickness and defectiveness among school children.

To provide merely for the medical inspection of every
school child once a year would entail trebling the present
staff ; and it may be noted that, since they are not followed
by treatment, more than 40 per cent of the inspections
are wasted, except for the statistical information they
yield.

The failure to provide medical treatment is due partly
to parents not appreciating the importance of having their
children treated, and partly to their inability to pay
doctors' fees in the absence of other facilities. Poor Law
medical relief can sometimes be sought, but parents are
often reluctant to take this course, and the treatment
available may be insufficient. The school medical officer
for Shropshire writes : —

" In cases where the parents are unable to afford
treatment and cannot get charitable help, one is compelled
to suggest application to the Guardians. It cannot be
considered that this is satisfactory from any point of view.
Parents who have never had poor law relief do not care
to apply for treatment of defects in their children which
to them often appear trivial. The result in many cases is
that the parents deny that any defect exists and refuse to
do anything. Nor have the Boards of Guardians any
special facilities for the provision of treatment for the
defects of the eye, ear, and throat, which form the large

o

194 HEALTH AND THE STATE

majority of the defects amongst school children requiring
treatment." x

A welcome development during recent years has been
that of school clinics, which now number upwards of 350,
and are to be found in nearly all the large towns. The
system is steadily growing, but the number of clinics is
still far from sufficient to meet the demand, and many of
the clinics limit the scope of the treatment they give, some
treating minor ailments only, others errors of refraction
alone, and others confining themselves to dentistry.
Besides establishing school clinics, some Local Authorities
have now made arrangements with hospitals for the treat-
ment of school children, and in some districts special
institutions have been provided for the treatment of
tuberculosis, ringworm, and ophthalmia.

Defectiveness in school children, as most disease else-
where, is mainly a matter of environment ; and the most
economical course in the long run is to prevent defective
conditions arising by enlarging playgrounds, increasing
open-air classes, and similar measures. Nevertheless it
would be well worth while to establish a thorough and
efficient system of school medical inspection and treatment,
for in children medical treatment yields a greater return
than in adults. Children can often be permanently bene-
fited by early attention to the throat, ears, eyes, or teeth,
whereas in adults often little can be done. Probably the
best plan for the community would be to place treatment
as well as inspection in the hands of the school doctor, who
should be definitely attached to a group of schools, should
be a specialist in diseases of children, and should be pro-
vided with a properly-equipped centre at which minor
operations could be performed. It is no use however
disguising the fact that this course would arouse great
hostility among a section of general practitioners.2

In rural districts we might with advantage adopt the

1 Quoted in Report of Chief Medical Officer to the Board of Education for 1913.

2 The following resolution was passed by the British Medical Association in
1914 : " Treatment by an education authority should be confined to necessitous
children — that is, to those children whose parents cannot afford to pay privately
for the treatment recommended as a result of inspection. Parents should always
in the first place be recommended to seek treatment for their children from their
family doctor.

MORTALITY IN CHILD-BED AND ITS CAUSES 195

system of travelling school hospitals which has been very-
successful in Australia. The unit could consist of a small
medical staff, including an oculist and a dentist, and should
be properly equipped with the necessary appliances. It
would travel about the country from village to village
attending the children in need of treatment, and would thus
bring a very large number under treatment in the course
of the year at comparatively small cost.

An important adjunct to the school medical service is
the school nurse. She helps to treat minor ailments and
uncleanliness, and is of great service in ' following up '
cases recommended for treatment.1 The Medical Officer
to the Board of Education considers that one nurse cannot
deal with a school population of more than from 2000 to
3000, an opinion with which those familiar with the con-
dition of school children will thoroughly agree. But in
England and Wales as a whole there is still only one nurse
to about every 6000 children, counting two part-time
nurses as one whole-time. Thus to bring the nursing
staff up to even the minimum standard we should have to
double the number of nurses at present employed, though
this again would be a thoroughly sound and economical
step. The money we are now spending on a large staff of
insurance prescription checkers would have yielded far
greater return if it had been employed in increasing the
school nursing service, for the school nurse exerts a direct
and immediate influence upon the health of the school
child.

Mortality in Child-bed and its Causes

The number of deaths of mothers in England and Wales
from pregnancy and child-birth averages about 3500 per
annum in roughly 880,000 births, that is one death in
about every 250 births. This rate has not varied widely
for a considerable number of years, as may be seen from
the following table : —

1 In Sheffield, in 1915, the school nurses made 83,793 examinations of children
for the treatment of uncleanliness alone, and many more for other purposes.

196 HEALTH AND THE STATE

Year.

Deaths per 1000 Births.*

1899-1908 .

. 4-22

1909

. 3-70

1910

. 3-56

1911

. 3-67

1912

. 3-78

1913

. 3-71

1914

. 3-95

* Exclusive of deaths from puerperal nephritis and albuminuria. Up to 1911
these deaths were not classified as puerperal, and to make the figures comparable
they have accordingly been deducted in the rates for 1911 and subsequent years.
Their inclusion would raise the figures by about *25 all through.

It is of course very desirable to prevent this loss of life
as far as possible ; and the belief that much of it is due to
bad surroundings and lack of skilled assistance at birth
has led to a strong movement for increasing medical and
midwifery services, lying-in homes, maternity benefits,
and similar measures. Nevertheless, knowledge of the
causation of these deaths is still very imperfect ; and in this
direction also, as in infant mortality, we seem to have
jumped to conclusions without adequate investigation.
Until a year ago few persons would have hesitated to say
that lack of medical attendance, insanitary surroundings,
poverty, and working of pregnant women in factories were
potent causes of maternal mortality. But the whole sub- .
ject has recently been investigated by Dr. Newsholme and
his staff, as far as material permits, and their singularly
interesting report shows that none of these factors can be
regarded as of overwhelming importance.1

Let us note first the distribution of maternal mortality.
We have seen in previous pages the very marked effect of
rural conditions in lowering sickness and disease from
practically all causes ; but when we turn to deaths in child-
bed, we are at once struck by the fact that the distinction
between rural and urban environments no longer holds
good. In the whole of the North of England the death-rate
is somewhat higher than in other parts of the country,
but there is very little difference between the rates in the
aggregate of County Boroughs and of Rural Districts.

1 " Maternal Mortality in connection with Childbearing and its Relation to
Infant Mortality," Supplement to Forty-fourth Annual Report of the Local Govern-
ment Board, 1914-15.

MORTALITY IN CHILD-BED AND ITS CAUSES 197

In the Midlands and the South of England the rural rates
are slightly higher than the urban rates. The highest
rates are found in the Rural Districts of Wales. With this
exception, the cause of which is not clear, the range of
variation between aggregates of Urban and Rural Districts
is everywhere small and does not faintly approach that
exhibited by infant mortality. We have for diseases taken
for extreme comparison the County Boroughs of the North
and the Rural Districts of the South, and for maternal
mortality in child-bed the rates for these areas are respect-
ively 4- 35 and 3*76 per thousand births for the period
1911-14.

When we examine towns we can find no constant
difference between those which exhibit a high and those
with a low death-rate. Taking a series of towns in the
same county, Lancashire for instance, we find the follow-
ing variations : Rochdale, 7*21 ; Burnley, 6*57 ; Blackburn,
6'55 ; Liverpool, 361 ; St. Helens, 339 ; and Bootle, 3'08
deaths per thousand births. These statistics are for a
period of four years, 1911-14. It is quite possible that if
they were compiled for a different four years, the towns
would show a different order, or if they were taken over
a longer period the differences would disappear. More
significant perhaps are the variations in the rates in the
Metropolitan Boroughs. The lowest rates were 281 in
Stepney, 2"62 in Shoreditch, 2" 61 in Bethnal Green, 2 33
in Southwark, and 2*06 in Bermondsey. In West Ham
the rate was 220. The highest rates were 4*73 in West-
minster, 4*47 in Hampstead, 4*46 in Stoke Newington, and
3*97 in Chelsea, all districts in which presumably a high
proportion of mothers are attended by medical practitioners.
It is a singularly interesting fact that the most poverty-
stricken districts of London, where the infant mortality is
the highest, show the lowest rates of maternal mortality ;
whereas the wealthier districts which have the lowest infant
mortality have also the highest maternal death-rate. It
would appear that neither social position nor standard of
comfort have any greater effect in reducing the maternal
death-rate than they have in reducing the infant mortality
rate during the early weeks of life.

198 HEALTH AND THE STATE

Nor can a consistent relationship be traced between
excessive mortality from child-birth and a high degree of
employment in factories. Textile towns as a whole show
some excess, but there are remarkable exceptions. In
Nottingham, with 26 per cent of the total married and
widowed women engaged in non-domestic occupations,
the mortality rate was 3 "79 per thousand births ; whereas
in Halifax, with only 16 per cent of the women so em-
ployed, the rate was 623. The experience of rural Wales
shows that a high rate of maternal mortality can exist
where only a few women are engaged in factory work.
Unexpected too is the conclusion that maternal mortality
from child-bearing appears to be largely independent of
general sanitary conditions, some towns with a low
standard of general sanitation, such as Bolton and St.
Helens, showing as low a rate of maternal mortality as
towns with a much higher standard, such as Croydon.

Inability to pay for medical assistance or sufficient
food or other necessaries has often been regarded as a
cause of maternal deaths, and the primary object of
maternity benefit was to meet these deficiencies. But the
experience of the poorest quarters of London and various
industrial towns does not support this view. Moreover,
if poverty had been an appreciable factor we should have
expected that maternity benefit, which, where both husband
and wife are insured, now provides a sum of £3, would
have lowered the death-rate. Maternity benefit is not a
provision the effect of which will only become visible after
a considerable period, but one which, if it was going to
produce any effect at all, would produce it at once. Yet
reference to the table on p. 196 will show that the rate
has actually risen somewhat during the two years the
Act has been in operation. In Scotland during the same
period the rate has risen from 5*5 to 6*0 per thousand
births.

Finally it may be noted that neither a high nor a low
birth-rate appears to have any marked influence upon
the rate of maternal mortality ; and the same may be
said of illegitimacy.

CAUSES OF DEATHS IN CHILD-BED 199

Skilled Attendance in Child-bed

This, the most important question for the purposes of
the present chapter, was also investigated by the Local
Government Board; and here again the author of the
report is unable to come to definite conclusions. In some
areas where attendance appears satisfactory the death-
rate is high, while in others with inadequate attendance
the rate is low. In Newport (Mon.) 74*7 of the total
births were attended by midwives, and in 18'4 per cent
the midwives obtained additional assistance from doctors,
yet the death-rate was 5'28 ; whereas in Newcastle,
though only 28 '8 per cent of the births were attended by
midwives, with assistance from doctors in 9*3 per cent,
the death-rate was 3" 89 per thousand births. Dr. News-
holme remarks of the statistics on this point that " they
do not themselves justify any general conclusion as to
relationship between mortality in child - bearing and
attendance in confinement by midwives or doctors. Much
more minute local investigation is required in each County
and County Borough concerned."

The Pathological Causes of Deaths in Child-bed

It is clear from the foregoing summary that the problem
of maternal mortality, so far from being one which is to
be solved by the simple provision of more doctors and
midwives and maternity benefits, is really highly obscure.
If we had accurate information regarding the pathological
causes of these deaths, firm conclusions could perhaps be
drawn just as was possible with infant mortality, but un-
fortunately the statistics on this point are scanty and
unreliable. General knowledge however shows that the
causes of maternal deaths, as those of infants, may be
divided into two broad classes, viz. (1) abnormalities in
the mother and defects arising during gestation, most of
the deaths from which are unavoidable, except perhaps
with the most highly skilled attendance, and then only to
a limited extent, and (2) accidents or septic infection
during or after labour, which must be regarded as almost

200 HEALTH AND THE STATE

entirely preventable. In the latter group puerperal fever
is by far the most important and most frequent of the
avoidable causes of maternal deaths, and we know that it
is almost always due to failure on the part of the doctor
or midwife to observe strict antiseptic precautions.

Puerperal Fever. — If we had statistics which showed
whether mothers who are attended in child-birth by
doctors or midwives suffer less from puerperal fever than
those who receive no skilled attendance, or whether the
incidence is less among those who are attended by doctors
than those attended by midwives, we should have a very
fair means of gauging the effect of medical treatment in
reducing the death-rate, and of comparing the value of
doctor and midwife. Unfortunately the statistics on this
point are on the face of them not reliable. Puerperal
fever is a notifiable disease, and in towns where there is
active municipal midwifery supervision the death-rate
ranges between 20 and 40 per cent of the cases notified.
Broadly speaking, therefore, notifications should be about
three times the number of deaths ; yet so negligently is the
law observed that in ten County Boroughs and in fifteen
Counties the registered deaths from puerperal fever actually
exceeded notifications in 1911-14, and in eleven other areas
the numbers were equal. There is reason to think that
medical practitioners are more lax in notifying puerperal
fever than midwives. To a limited extent also the
statistics are made unreliable by the differences of mean-
ing attached to the words ' puerperal fever ' by different
medical men. The term is really an obsolete one, dating
from the time when the condition was believed to be a
definite disease, but, unless understood to mean all puer-
peral septic infections, it ought now to be abandoned.

General Practitioner or Midwife ?

But while we cannot be dogmatic, we cannot ignore
certain indications which appear to point to doctors being
more responsible for puerperal fever than midwives. Sir
Halliday Croom, after referring to the great reduction in
mortality from puerperal fever in lying-in hospitals, says :

GENERAL PRACTITIONER OR MIDWIFE ? 201

But while these wonderful results have taken place in hospitals,
mark you, the same has not been the case in out-door practice.
There the disease still persists, and the death-rate from blood-
poisoning in private practice still remains very high. Why is it
so ? Because while in maternity hospitals the nurses and doctors
are under discipline, and the antiseptic regulations are carried out
under pain of dismissal, such does not apply to private practice
where nurses and doctors do as they please. They are taught in
the maternity hospital the strict and careful use of antiseptics, but
unfortunately both the attendants become less scrupulously careful.
... I should like to ask you to look for a moment not only at the
mortality, but at the morbidity — by that I mean the ill-health
induced by perfunctory and inaccurate midwifery, . . . the amount
of ill-health which is induced by unskilful midwifery is endless. . . .
Among the poorer classes women remain permanently disabled and
handicapped for the rest of their lives.1

It should be pointed out that in so far as Sir Halliday
Croom's remarks relate to mid wives they do not apply to
England and Wales, where the Midwives Act has been in
force since 1905, nor do they now apply to Scotland.

Dr. George Geddes has made an exhaustive investiga-
tion of puerperal sepsis in Lancashire, and he finds that
at least midwives are not more responsible for causing
puerperal fever than are doctors, while some of his statistics
show that they are far less so. In the residential town of
Blackpool, for instance, the puerperal rate among women
attended by midwives was 2'4, and among those attended
by doctors it was 4*8 ; in the mining town of St. Helens
the midwives' rate was 1'7, while the doctors' rate was
13'2. Dr. Geddes attributes the excess among doctors
in mining districts largely to the fact that they are so
frequently dressing small septic injuries from which they
go straight to their maternity cases.2

In studying the relative advantage of doctor or mid-
wife it is important to bear in mind that child-birth is not
sickness but a natural process; and there is good reason
to believe that the great majority of mothers, in the
absence of medical attendance, would go through their

1 Address delivered at a conference of Delegates of Approved Societies, Edin-
burgh, 1915, on the invitation of the National Health Insurance Commission
(Scotland).

2 Etiology and Distribution of Puerperal Sepsis, 1913.

202 HEALTH AND THE STATE

confinements safely without further assistance than that
of some one sufficiently skilled to perform certain necessary
but simple services as soon as the child is born. In by
far the larger number of cases the ideal treatment is to do
little beyond encouraging the mother and relieving symp-
toms of discomfort. This course may somewhat prolong
labour, but in the long run it is the best for both mother
and infant, the absence of intimate examination or use of
instruments enormously diminishing the risk of puerperal
fever. Midwives are severely restricted in the methods
of this nature which they may employ. But it will be
objected that, while this is quite true, the presence of a doctor
is important in order that he may do what is necessary in
the exceptional complicated case. In theory this is so,
and if doctors always adopted the expectant attitude, and
only interfered when occasion really demanded, no criticism
could be made. Unfortunately it is well known that in
working-class practice, and even to some extent in better-
class practice, this is far from being the case. The fees
paid for attendance in confinement are disproportionate
to the time which the case demands if properly dealt with ;
and the doctor may have a long list of patients to see, or
may be anxious to get back for his consultation hours.
He is consequently under strong temptation to cut short
the case by applying the forceps at the earliest possible
moment ; the instruments are often not properly sterilised
— indeed in the homes of the poor it may be impossible
to do this — and the risk of puerperal fever to the mother
and of injury to the infant is greatly increased. It is
notorious that this course is adopted in a considerable
number of uncomplicated cases which if left to themselves
would terminate naturally. The custom among doctors
in the poorer quarters of certain towns of leaving the
earlier conduct of a case to an unregistered midwife and
rushing in towards the end to finish it off — almost amount-
ing to ' covering ' — has grown to such an extent that
the General Medical Council has recently found it neces-
sary to issue a special warning on the subject. This may
happen in a case where a doctor has been engaged to
attend. When a midwife has charge of the case she is

GENERAL PRACTITIONER OR MIDWIFE ? 203

required to summon a practitioner in certain eventualities,
the doctor's fee being paid by the Board of Guardians,
or in some districts by the Local Authority ; and if the case
is one which ' requires the use of instruments,' the doctor
receives an additional fee. Some of these cases demand
the highest skill of a gynaecologist, but the general practi-
tioner cannot have, and does not profess to have, this
degree of skill. Undoubtedly he saves life in some
instances, but we must look at the matter as a whole, and
unfortunately there is no doubt that in working-class
practice a considerable amount of harm is done by hasty,
unnecessary, or unskilled interference. The harm is not
represented only by deaths. A much larger number of
women suffer permanent ill-health or discomfort from
injuries received or sickness caused.1

We have noticed the exceptionally low rates of
maternal mortality in the poorest districts of London,
and at first sight it might appear that this is inconsistent
with the foregoing remarks. But it must be remembered
that a large proportion of the mothers in these districts
are attended by students from the medical schools,
who are taught to allow full time for natural delivery,
and that if instrumental interference becomes necessary
it will only be done by, or under the immediate super-
vision of, the skilled resident accoucheur of the hospital
specially summoned for the purpose. Dr. Newsholme
considers that this is the most probable explanation of
the low rates of maternal mortality in these districts.

We do not know why mortality from child-birth has
risen during recent years ; and it is possible that the in-
crease is only an accidental fluctuation. We know that

1 Dr. Drummond Maxwell, of the London Hospital, writes : " There are ad-
mitted into the London Hospital a considerable number of cases in which the
lower genital tract, cervix, vagina, and perineum are lacerated and bruised to an
almost inconceivable extent. One would almost infer from inspection of these
cases that the accoucheur had set out to inflict deliberately the maximum injury
consistent with survival and been thoroughly successful in his aim. ... I am bound
to say that I do not find the notable improvement that might be expected to follow
the better teaching in recent years of clinical obstetrics, and I expect one will have
to wait a few years longer before that teaching bears fruit. Certainly the number
of mutilated cases one sees is most disheartening, and constitutes a grave indict-
ment against much of the midwifery of the present time." — The Practitioner,
February 1916.

204 HEALTH AND THE STATE

since the passing of the Insurance Act some busy doctors
have given up attending confinements, and that a much
larger number of women are now in a position to pay for
attendance by a doctor, but we have no means of deter-
mining whether a larger or smaller proportion of births
are now attended by doctors than before the Act. It is
however disquieting to find that, comparing 1914 with
1912, the increase in maternal mortality has been chiefly
in puerperal fever, and that it has occurred in London
and the County Boroughs ; the rate in the smaller Urban
Districts having remained constant, while that in the
Rural Districts has actually fallen to a small extent.

Attendance in Confinement and Infant Moetality

We have already examined this question in an earlier
chapter, and found no reason to believe that attendance
in confinement by doctors has any appreciable effect in
reducing infant mortality. One additional point is all
which needs mention here. Deaths certified as due to
' injury at birth ' have been steadily increasing for a
number of years. In 1900, with 927,062 births in England
and Wales, the deaths of infants from this cause were
448 ; in 1914, with 879,096 births, the number was 1051.
The rates for 1913 and 1914 show larger increases than
any previous years. It is possible that these figures are
an indication of the steadily-increasing use of forceps.

Mateknity Benefit

Since maternity benefit has failed to reduce mortality
among mothers, must it then be regarded as a useless waste
of money ? We will answer this question by quoting
from an investigation made by Miss Margaret Bondfield
the two following instances of the deplorable conditions
under which women may be confined : — *

Mrs. D. Husband a hawker of sawdust. Woman was confined
in a cellar, where rats ran about the floor. The door, about \
foot from the steps, let all the wind and rain into the place — a

1 " The National Care of Maternity," New Statesman, May 16, 1914.

PUBLIC MATEENITY SERVICE 205

most horrible place. A maternity nurse appealed to a Ladies'
Charity, but no help came till two days after the confinement. No
maternity benefit.

Mrs. F. Husband a casual labourer — deposit contributor —
now out of work. Had only 2s. to draw. Two rooms only. Four
girls sleep in one small bed in back room ; boys sleep in parents'
room. No maternity benefit.

Maternity benefit is, in fact, an exceedingly valuable
provision for helping mothers through a period of stress.
Complaints have been made that the money is wrongly
expended by mothers, and it has been urged that the
money should be taken out of their hands and expended
more judiciously for them by others, which means in
accordance with orthodox views. But we cannot separate
one need from another at such a time, and the mother
alone knows what is most urgently required. Whether the
money is spent in paying rent, or providing clothes for the
other children, or food for the family, or taking household
articles out of pawn, it is none the less serving a very
useful purpose. Many mothers have employed part of
the money in obtaining extra assistance in the household,
and those who know the poor, appreciate what a boon it
is for a mother who is laid up to be able to get some one in
to look after the home, keep the children clean, and send
them to school. If we measure the advantage of maternity
benefit by the statistics of maternal or infant mortality,
we shall meet with nothing but disappointment ; but if we
regard the provision as a means of increasing the mother's
comfort when most needed, we shall realise what a great
blessing it has been to many thousands of poor mothers.

The Question of a Public Maternity Service

Proposals have been made for establishing a National
or Municipal Maternity Service, gynaecologists being ap-
pointed to attend mothers in confinements, and lying-in
homes provided at the cost of the State. This would be a
useful step in towns where the number of births is sufficient
to render it economically sound. In rural districts efforts
must be mainly directed towards increasing and improving

206 HEALTH AND THE STATE

the service of midwives. Be it noted however that a
maternity service — i.e. apart from maternity benefit — is
by no means our most pressing want. If it be assumed
that a death-rate of, say, 2 per thousand is unavoidable,
we should only save 1750 lives in the course of the year,
and this only when we had covered the whole country
with the service, necessarily at very great cost. Much as
this is desirable, we are bound to recognise that the same
amount of money spent in other directions, for instance
on a school medical service, would yield a far greater
return from the Public Health point of view. In any case
it is clear that before any further large scheme of public
assistance is contemplated, a thorough and detailed in-
vestigation of the whole subject is required.

Medical Treatment and Public Health

We may conclude this chapter by examining the general
influence of medical treatment in reducing the death-rate
and prolonging the average duration of life, particularly
in view of the proposals now made for establishing a
national medical service. The first step is to recognise
the real services which a doctor renders in the social scheme.
To the individual these services are immense and varied.
The doctor relieves anxiety of parents and relatives, he
does much to increase the comfort of his patient, allevi-
ates symptoms, assuages pain, cheers and encourages.
If it be held that these advantages alone justify medical
treatment being placed within the reach of every one, then
the case for a national medical service is strong. On the
other hand, if we look at the question exclusively from
the point of view of Public Health, we must not make the
mistake — as there is distinct tendency to do nowadays —
of supposing that medical treatment has a large effect in
preventing sickness or in reducing the death-rate, that is,
medical treatment in the limited sense of treatment by a
doctor, and not as including surgery, nursing, etc. We
have already noticed the uselessness of much medical
treatment of minor ailments under existing conditions.
When we examine more serious illness which keeps the

MEDICAL TREATMENT AND PUBLIC HEALTH 207

patient in bed, we find again that the great service of the
physician is to relieve and comfort. It is the rest in bed,
care, and nursing which effect the cure of bronchitis,
pneumonia, and many other acute illnesses ; medicine is
almost useless in tuberculosis ; medical treatment of
cancer is summed up in the word ' morphia.' If doctors
are necessary to maintain health or prevent disease we
should not find the healthiest conditions in some districts
where the doctors are fewest, and the worst in others
where they are relatively numerous. Connaught has the
lowest death-rate — 13*6 — of the four provinces of Ireland,
yet 47*7 per cent of all deaths were not certified in 1914,
i.e. the persons were not attended even in their last illness
by doctors. Leinster has the highest death-rate, 17*7,
yet only 14*7 per cent of the deaths were uncertified.
Mr. Walter Long has stated recently that during 1915
Public Health in England has been highly satisfactory,
yet a large proportion of the doctors have been withdrawn
from the civil population for special military service.
This is not to under-estimate the value of medical treat-
ment, but to recognise the real nature of its services. The
doctor is not a Public Health officer and never will be ;
his duties are those of alleviator and counsellor.

On the other hand, a very different view may be taken
of modern surgery, which is undoubtedly the means of
saving many thousands of lives every year. There is
scarcely an organ of the body which is not now accessible
to the surgeon, and there is scarcely a disease which, in
some manifestation or other, is not benefited by surgical
treatment. Cancer in accessible parts can be completely
removed, and in women suffering from cancer of the breast
or uterus a high proportion of cures is effected, while in
other cases life is prolonged. Surgical treatment is appro-
priate in many cases of tuberculosis, from removal of
glands in children to treatment of serious affections of
joints. Abdominal surgery in appendicitis, acute obstruc-
tions, ulceration, etc., saves many fives which a generation
ago would certainly have been lost, while various conditions
of the lung-cavities, the kidneys, the throat, and other
organs are cured or relieved by surgical treatment. Among

208 HEALTH AND THE STATE

women removal of non-malignant tumours of the uterus
is exceedingly common, and removal of diseased ovaries
is effected every day in our large hospitals, though when
the operation was first introduced the coroners threatened
Lawson Tait with holding inquests on his non-successful
cases. Even where surgery has not for its immediate
object the saving of life, it may undoubtedly do this by
increasing the health of the patient. The large number
of operations for adenoids in children cannot have been
without a substantial effect in improving health in later
years. To the surgical treatment of disease must be
added that of injuries. Grave conditions, such as fracture
of the skull and injuries to important organs, can frequently
be treated successfully, while antiseptic measures have
substantially reduced blood - poisoning in all forms of
injury and wounds. The grave septic infections, such as
1 phagedena ' and ' hospital gangrene,' are now practically
unknown, and many students go through their whole
training without ever seeing a case. Nor are the advan-
tages of surgery limited to saving life, for injuries, diseases,
and deformities of limbs and joints can now often be treated
in such a way as to restore the normal functions.

There can be no doubt that the development of surgery
has had a very appreciable effect in reducing the death-rate
and increasing the average age. We have already noticed
the great increase in the volume of institutional treatment
in this country ; and pari passu there has been a steady
decline in the death-rate. As Dr. Newsholme has pointed
out, this represents an immense change in the conditions
under which disease is treated in this country. If we could
pursue the matter further, we should almost certainly find
that the surgical wards have had a far larger share in pro-
ducing this result than the medical wards. Surgery has
perhaps been the greatest factor in the decline of the death-
rate, which has fallen about 4 per thousand since the
period 1881-85. If surgery is only saving in each year two
lives more in every thousand people than it did thirty years
ago, half the total fall is accounted for. When we add to
these the effect of natural decline of disease, we see how
grossly exaggerated are the bombastic claims of those who

MEDICAL TREATMENT AND PUBLIC HEALTH 209

would attribute all improvement in Public Health to
sanitary services. It may be noted that surgeons them-
selves have been singularly modest in calling attention to
the importance of their work in Public Health.

If we are to establish any form of a public medical
service we must emphatically begin by providing surgical
and institutional treatment. Such a service would not
be so difficult to create as was the panel service, for it
would not involve interfering with vested interests. More-
over, the question of free choice of doctor would not arise,
for the personal relation between doctor and patient,
rightly insisted upon under the Insurance Act having
regard to the real nature of the services the practitioner
renders, need not exist in the case of the surgeon to whom
in hospital the patient freely trusts his life, though he
may never have seen him before. A mere extension of
the panel system, or of any other system on similar lines,
would be one of the most profitless steps we could take.

CHAPTER VII

PUBLIC HEALTH AND THE NATIONAL INSURANCE ACT

The Insurance Act a Public Health measure — The German origin of the
Insurance Act — The principles of administration of the Act — Local
administration — Medical benefit — The supply of drugs — Sanatorium
benefit — Sickness benefit — The Insurance Act and insanitary con-
ditions— The Insurance Act and the advancement of Public Health
knowledge.

The Insurance Act a Public Health Measure

The National Insurance Act is the most ambitious piece
of Public Health legislation ever carried through in this
country. No previous measure has directly affected so
large a number of persons, involved so great a cost, made
such demands upon administration, or been introduced
with such lavish promises of benefit to follow ; and no
previous measure has ever failed so signally in its primary
object. In preceding chapters the operation of maternity,
and to some extent medical benefit, have been considered,
and we have now to examine the other leading provisions
of the Act mainly for the lessons which can be derived from
them, and for the light they throw upon the weak points
in our present system of dealing with Public Health affairs.
Probably the greatest obstacle to the development of a
sound and comprehensive scheme for protecting the health
of the community has been the failure of legislators to
appreciate the complexities and difficulties of the questions
with which they were dealing. Public Health is a science
which demands years of study for its understanding ;
many of its problems are obscure, and often the seemingly
apparent remedies for its defects may be more harmful
than beneficial. Health legislation in Parliament has

210

THE INSURANCE ACT 211

always suffered from the almost complete absence of
scientific medical criticism, and the Insurance Act was
no exception to this rule. In its genesis, in its modifica-
tions in the House of Commons, and very largely in
its subsequent administration, it has been the work of
amateurs, and it contains in consequence the most glaring
blunders.

The main object of the Insurance Act was to improve
the health of the working part of the community, and by
its results in this direction the Act must be judged. If
it has not improved the Public Health, or has not improved
it relatively to its cost, then the Act has failed in its most
important object. It is necessary to insist upon this point,
for though there is much discussion of the financial position
of approved societies, the scope of medical benefit, and
other questions, the fundamental purpose of the Act seems
in danger of being lost sight of.

It is probable that the National Insurance Act was
indirectly the outcome of the Report of the Royal Com-
mission on the Poor Laws, that painstaking and ex-
haustive inquiry to the recommendations of which so
little effect has been given. Both the Majority and
Minority Reports called attention to the association of
poverty with sickness, but neither recommended national
insurance as a remedy, nor took the view that poverty was
the main cause of ill-health. The authors of the Insurance
Act seem' to have believed however that the relation be-
tween poverty and sickness is much closer than is really the
case. They do not appear to have realised that poverty —
short of absolute destitution and consequent starvation —
exercises hostile influence mainly by compelling a person
to five in an unhealthy environment, and that it is quite
possible to be extremely poor and extremely healthy.
They ignored, or did not know, that the most poorly-paid
section of the working classes, the agricultural labourers,
are also the healthiest, and they seem to have come to the
conclusion that the payment of a small sum weekly during
sickness, while doing practically nothing to improve the
environment, would have a great effect in improving the
national health. This belief gave the Insurance Act its

212 HEALTH AND THE STATE

essential character, which is that of a palliative rather than
a preventive measure, and in this respect made it a re-
versal of nearly all earlier Public Health legislation. There
is scarcely a remedial provision of the Act which comes
into force before sickness or disablement is actually present,
and the few clauses which were intended to deal with the
environmental causes of sickness have, in practice, proved
inapplicable.

The German Origin of the Insurance Act

The proposal to establish national insurance in this
country was not preceded by a public inquiry of any sort.
There was no Royal Commission or Departmental Com-
mittee to investigate the value of national insurance, nor
was any public report or opinion obtained from the General
Medical Council, the Royal College of Surgeons, the Royal
College of Physicians, the Society of Medical Officers of
Health, or other bodies concerned with Public Health
questions. Since the partial inquiry by the Inter-Depart-
mental Committee on Physical Degeneration in 1904, there
had been no general investigation into the state of Public
Health in this country, nor into the best means of prevent-
ing sickness. It is significant of the want of consideration
on the most fundamental points that after passing a gigantic
Act for the prevention and cure of sickness, the Govern-
ment found it necessary to appoint a Committee to inquire
into the causes of excessive sickness chiefly among women ;
a little later it appointed a Royal Commission to inquire
into the extent and means of preventing venereal disease in
the community ; and still later it instituted an investiga-
tion into the adequacy of the hospital service in this country.
Succeeding years will probably witness public inquiries
into many other points concerning national health, all of
which should have been investigated before any compre-
hensive scheme of dealing with sickness was adopted. It
is only necessary to look at the list of Royal Commissions
and Departmental Committees in recent years in order
to see that on many matters of far less sweeping im-
portance, public inquiries have preceded legislative or

INSURANCE ACT : GERMAN ORIGIN 213

administrative action. There is little doubt that if a
Royal Commission had been appointed to inquire into
the state of Public Health and the steps necessary to
improve it, a very different measure would have
been introduced, possibly without including national in-
surance at all.

As far as public knowledge goes, Mr. Lloyd George
must be regarded as the originator of the main principles
of the Insurance Act ; and it is necessary to consider the
significance of this fact in relation to our present methods
of dealing with Public Health matters. We have no
Ministry of Public Health, and no machinery by which
Bills relating to Public Health can be submitted to expert
opinion before their introduction into Parliament. Con-
sequently measures involving highly scientific questions
are introduced by persons who are quite without previous
training or experience in Public Health work. We may
indeed be grateful to Mr. Lloyd George for the eminent
services he has rendered to the country in other directions,
and the adverse criticism of his efforts in Public Health,
which must again and again be made in this chapter,
reflect much more upon the system, for which Parliament
is primarily responsible, than upon him personally. When
Mr. Lloyd George introduced the Insurance Bill he had
not held any of the offices which would have brought him
in touch with Public Health affairs. He had been President
of the Board of Trade, and was still Chancellor of the
Exchequer; but he had not been President of the Local
Government Board, which is our nearest approach to a
Ministry of Health, nor Secretary to the Board of Educa-
tion, an appointment which might at least have familiarised
him with conditions of health among children. Nor, so far
as is publicly known, had he made any special study of
Public Health questions or had other experience which
would have entitled him to be regarded as an expert.
Yet he has constantly expressed opinions upon the most
erudite questions with a dogmatism which must astound
many a Medical Officer of Health.

But it is perhaps not quite accurate to say that no
special investigation preceded the Insurance Act, for Mr.

214 HEALTH AND THE STATE

Lloyd George appears to have been strongly impressed by
the national insurance scheme in Germany, and it is under-
stood that during 1910 he spent some weeks in that country
studying the system. At that time we were obsessed by
belief in German science, forethought, and organisation,
and it would be unfair to condemn imitation of German
methods merely because our views of the German national
character have since undergone a radical change. But the
German system could have been condemned at that time
and on its merits. Mr. Lloyd George's investigation must
have been very superficial, for closer study of conditions in
Germany would have shown that in that country national
insurance, from the Public Health point of view, had been
a failure just as great as it has since proved in our own.
Germany has had a comprehensive system of national
insurance since 1884, the benefits of which have extended
to large groups of dependents, non-working women, and
children ; nevertheless, the general death-rate, though it
has fallen during recent years, has always been about 20
per cent higher than that of England and Wales, and this in
spite of the fact that the average age of the population
is appreciably less than that of the population of Great
Britain. After many years of sanatorium treatment the
death-rate from tuberculosis in Germany was 50 per cent
higher than in this country where no special efforts had
been made. Yet when introducing the Bill, Mr. Lloyd
George said : "In Germany they have done great things
in this respect. They have established a chain of sanatoria
all over the country, and the results are amazing. The
number of cures that are effected is very large." x We
adopted national insurance on the faith of statements such
as these, and are now realising our mistake. Yet the
merest glance at the German vital statistics would have
shown that Germany is the very last country from which
we can learn lessons in Public Health or Preventive
Medicine. Not only is the general death-rate high, and
the death-rate from tuberculosis excessive, but the infant
mortality rate has always been very high, and between
1901 and 1910 the deaths of infants under one year of age

1 Parliamentary Debates, May 4, 1911.

INSURANCE ACT : GERMAN ORIGIN 215

averaged 187 per thousand births. Bad as is the British
record, it does not approach these appalling figures.1
Other countries which have adopted some form of com-
pulsory insurance against sickness are Austria, Hungary,
and Russia, and in none of them does the state of Public
Health provide any testimony of the value of this principle.
France is almost certainly the country of Europe in which
the highest standard of general sanitation and healthy
living prevails, and it would have afforded a much better
model, but our Public Health authorities appear to have
devoted little attention to its conditions. English travellers
in France are accustomed to be somewhat scornful because
they may find sanitary arrangements in hotels not quite
so good as those in England ; but any disadvantages in this
respect, or in the water-supply, are far outweighed by the
higher standard of housing, the comparative absence of

1 It deserves to be noted that the soundest criticisms of the proposal to intro-
duce the German insurance scheme into this country were made by Mr. E. Lesser,
representing the Apprenticeship and Skilled Employment Association at the
National Conference on the Prevention of Destitution, May 30- June 2, 1911. He
said, to quote the Report of the proceedings : " Lest they should take too optimistic
a view of what the future of England was going to be when we had got the National
Insurance scheme at work, he would like to call their attention to some figures from
Germany, where, as they knew, a sickness insurance scheme had been in existence
for twenty-five years, and invalidity for about twenty years. While admitting
to the full the beneficial results which had been obtained in Germany from the
operations of those two schemes, it was none the less somewhat significant that he
was able to give them the following figures. Taking the death-rate in the German
Empire per 1000 he found it was in 1908 as high as 18, whereas in England and
Wales it was only 14-7; in Scotland it was 16-1 ; in Ireland 176. If they took
the infantile mortality statistics this country compared most favourably. In the
German Empire the death-rate of children under one year of age was 17-8 per
cent; in England and Wales it was only 12-1 ; and in Scotland it was only 1 1 ; and
in Ireland it was only 9-7. Then they came to other statistics as regarded mort-
ality from certain diseases — diphtheria, measles, scarlet fever, tuberculosis of the
lungs — and in respect of all those diseases our figures were far better than those of
Germany. In tuberculosis of the lungs the death-rate per 100,000 inhabitants in
Germany was 159-2, whereas in England it was only 111-7. In diphtheria the
figures for Germany were 22-9, whereas the English figure was only 16-7. What
did these figures show ? He thought they were entitled to say that they showed
that thanks to our very efficient public health service, we had been enabled to keep
ahead of Germany as regarded the health of the people without their elaborate
insurance scheme. The point he wanted to make was that the money which we
had been spending on improving the health of the people, on improving housing
accommodation, and sanitation, and such like things, had been really preventive
work because it had indirectly helped the people to live under more healthy con-
ditions, and therefore become less likely to fall victims to sickness. To come to
the Government insurance scheme, they were really beginning at the wrong end in
launching a scheme of this kind. In his opinion they would be investing the
money to better purposes if they set to build up a healthier race of children than
they were now getting instead of spending large sums in seeking to cure the
unhealthy and the unsound."

216 HEALTH AND THE STATE

slums, and the splendid open spaces which characterise so
many of the cities of France.

In support of his proposals Mr. Lloyd George issued
from the Treasury a " Memorandum of Opinions of various
Authorities in Germany " from " leading companies and
firms in the more important German industries." These
opinions, the writers of only two of which are named,
consist of paragraphs written in perfectly general terms
all extolling the benefits of the Insurance Laws. We are
informed that they " have undoubtedly had a good influ-
ence on the position of the working-man " ; that, " on the
whole England would do well to adopt similar institutions
to those which have for years been a blessing to the German
working classes " ; that " the Insurance Laws, together
with the increase of wages, have exercised an enormously
beneficent influence on the health, the standard of life,
and the efficiency of the working classes " ; and that the
Insurance Legislation has relieved the Poor Law to a
degree that cannot be mistaken." The paragraphs obvi-
ously express only the employers' point of view, but there
is one naive opinion which gives a glimpse of other views.
The President of ' one of the largest Associations of Em-
ployers in the iron and steel industry ' writes : " That the
" workpeople themselves are contented is not maintained.
" Even were the benefits under the Insurance Laws greater
" than they are, and granted at the employers' expense,
" there would be no permanent satisfaction of the work-
" people's wishes ; but the reason for this lies in human
" nature and not in the laws." The conception that human
nature should adapt itself to law, rather than that law
should be made to conform to human nature is perhaps
characteristic of Germany, and may be suited to the amen-
able people of that country ; but it has always proved a
bad foundation for social legislation in England, and the
Insurance Act has again exemplified the fact.

This collection of opinions is not a scientific report.
It presents only one side of the case ; it gives no
statistics showing the sickness rates in Germany before
and after the adoption of national insurance ; it contains
no opinions from Public Health authorities and no argu-

INSURANCE ACT : GERMAN ORIGIN 217

merit or statement which carries the smallest scientific
weight. Regarded as a presentation of the advantages of
national insurance in Germany it is entirely unconvincing
and inadequate ; yet it was the sole evidence of this kind
which was placed by the Government before the country
previous to the passing of an Act which was to apply com-
pulsion to one-third of the population, and cost many
millions annually.1

An important difference in the objects of the two
schemes should be noticed here. In Germany the insur-
ance system is also a form of Poor Relief, and provides for
necessities which are more or less covered in this country
by the Poor Laws and the Old Age Pension Act. For
example the Societies are required to provide death-
benefit, old-age pensions, and, under certain conditions,
pensions for the widow and children of a deceased insured
person, while the hospitals undertake the treatment of
many persons, who, in this country, would be admitted to
the Poor Law infirmaries.2 This aspect of German insur-
ance is repeatedly referred to in the collection of opinions
cited above. In the British insurance scheme all sug-
gestion of Poor Law Relief was rigidly excluded, as shown
by the prohibition of the use of Poor Law institutions for
the treatment of tuberculosis and other diseases. Hence
the success or failure of the two systems cannot be
measured by the same test. One is designed chiefly for
the prevention and cure of sickness, the other is in addi-
tion admittedly a form of Poor Relief.

But while the general principle of the British Insurance
Act was taken from Germany, substantial modifications
were introduced in the details, and unfortunately some of
the best features were omitted, while some of the least
satisfactory provisions were adopted. Perhaps the best
feature of the German system is the excellence and com-
pleteness of the arrangements for higher medical treatment,
medical benefit providing treatment at hospitals, sanatoria,

1 The Memorandum on Sickness and Invalidity Insurance in Germany issued
in 1911 merely sets out the differences in the British and German schemes. It
contains no examination of the advantages believed to have resulted from com-
pulsory insurance in Germany.

2 For further details see Medical Benefit in Germany and Denmark, I. C. Gibbon,
1912.

218 HEALTH AND THE STATE

convalescent homes, and forest resorts, treatment by
specialists for affections of the eye, ear, etc., nursing,
baths, electric treatment, milk, wine, etc., and medical and
surgical requisites. Instead of taking this system as a
model, we in this country have limited medical treatment
to the barest possible minimum. On the other hand we
took over from Germany the panel system of providing
treatment through medical practitioners, although it had
for years led to strife in that country between insurance
societies and the doctors with strikes or threatenings
of strikes by the latter, and had been shown to lead to
malingering and other evils which have now become
apparent here.

Thus the Insurance Bill was introduced without any
previous inquiry as to its need or probable effects in this
country, without adequate investigation of the results of
national insurance in other countries, and without the pro-
posals having been before the country. The central prin-
ciple was taken from a people who for many years had been
well drilled and were accustomed to organisation, and was
applied to a nation which, to say the least, is impatient
of official control; and the best features of the foreign
scheme were not copied. The Bill originated with a
Minister who had no expert knowledge of Public Health ;
its value in preventing sickness was assumed without
proof on the basis of vague generalities ; and promises of
benefit to follow were made which scientific investigation
would have shown to be unrealisable. We may anticipate
here the proposals which will be put forward in detail in a
later chapter, and urge that this experience provides the
strongest argument for the establishment of a ministry
of Health, from which alone Government measures con-
nected with Public Health shall originate, after they have
been subjected to close examination and investigation by
those who have specially studied the problems involved.

In its passage through Parliament the Insurance Bill
underwent many changes, some of which were of a dis-
tinctly retrograde character, but it will be more convenient
to indicate these when examining the provisions in detail.
Again the absence of expert criticism was felt, and many

INSURANCE ACT : ADMINISTRATION 219

matters of the greatest importance were neglected, while
other proposals were discussed in detail which could at the
time have been shown to be unsound and have subse-
quently in practice proved unworkable.

The Principles of Administration of the Act

The Insurance Act, as it left Parliament, contained
many unsatisfactory features ; nevertheless its very vague-
ness and incompleteness afforded opportunity for public
benefit, for in no previous Act had such great powers been
given to the authorities charged with administration, and
so many decisions of importance been left to their discretion.
They were empowered to issue Regulations, which have
all the force of law after they have been laid before both
Houses of Parliament, and an address has not been pre-
sented to His Majesty, within twenty-one days, praying
for their annulment ; thus making the Commissioners to
a considerable extent a legislative body.1 In case this
should not be sufficient, they were, for the purpose of over-
coming initial difficulties, given powers of suspension and
alteration of the law unprecedented in any Act of Parlia-
ment. Clause 78 of the Act provides that —

If any difficulty arises with respect to the constitution of
Insurance Committees or the advisory committee or otherwise in
bringing into operation this part of this Act, the Insurance Com-
missioners, with the consent of the Treasury, may by order make
any appointment and do anything which appears to them necessary
or expedient for the establishment of such committees or for bringing
this part of this Act into operation, and any such order may modify
the provisions of this Act so far as may appear necessary or ex-
pedient for carrying the order into effect. Provided that the
Insurance Commissioners shall not exercise the powers conferred
by this section after the first day of January nineteen hundred and
fourteen.

1 In 1915 the Scottish Insurance Commissioners proposed to institute a uniform
and comprehensive audit and issued Regulations for the purpose. When they were
on the point of laying these before Parliament the Insurance Committee of the Burgh
of Glasgow applied for an interdict on the ground that the proposed Regulations
were ultra vires and an invasion of the statutory functions and right of independent
action of the Committee. The Court held that they had no jurisdiction to entertain
any questions as to the validity of the Regulations and dismissed the application.

220 HEALTH AND THE STATE

With these enormous powers even a badly-drafted Act
could have been made to yield good results if ably adminis-
tered ; but few will maintain that the Commissioners have,
as a matter of fact, taken advantage of the extensive
powers and opportunities given to them. The administra-
tion has been allowed to assume a degree of complexity
which baffles comprehension ; the medical service is
notoriously inadequate and inefficient, while the Public
Health aspects of the Act have been almost lost sight of.
Doctors, chemists, insured persons, and society officials
are all alike dissatisfied. On the other hand, in fairness
to the Commissioners it must be pointed out that a prin-
ciple was observed in their selection which must have
hampered collective action from the beginning; and this
point demands further examination.

During the passage of the Insurance Bill through
Parliament various bodies with more or less divergent
vested interests became alarmed lest their rights and privi-
leges should be interfered with, and much heated dis-
cussion arose. The doctors were afraid of too much official
control and too little remuneration ; the Friendly Societies
were anxious to protect the position of their members ;
the commercial insurance companies demanded admission
into the scheme ; and representatives of women's organisa-
tions concerned themselves with women's interests. Some
attempt was made in the Act to unite these various in-
terests, but Parliament left its work in this direction un-
finished, and assigned it to the Commissioners to complete.
For this purpose a principle was adopted in the selection of
the Commissioners which, if not new, had certainly never
been followed to the same extent previously, viz. the
representation of specific interests in the administrative
authority itself. The Medical Secretary of the British
Medical Association, a body which had vigorously defended
the interests of medical practitioners, was appointed
Deputy Chairman of the English Commission ; another
Commissioner represented the Insurance Companies ;
another the Friendly Societies ; another who had been
prominently associated with the interests of labour may
be taken to represent the insured persons ; and another

INSURANCE ACT : ADMINISTRATION 221

represented women's interests. The remaining members
were the Chairman, who had had a long and distinguished
association with educational matters, and had been Per-
manent Secretary to the Board of Education ; another
who had also been connected with the Board of Education ;
the Chief Registrar of Friendly Societies who is ex officio
a member of the Commission ; and a representative of the
Treasury. No objection could be taken to the composi-
tion of this body from the point of view of reconciling or
representing the divergent interests concerned, but it is
important to note that the course adopted involved sacri-
ficing any idea of making the Commission authoritative in
Public Health questions. Not one of the members, how-
ever eminent in other directions, would claim to have had
any special experience in Public Health administration,
or special knowledge of its more scientific problems ; yet
they were called upon to administer an Act which touched
Public Health questions in every direction, and one which,
so far from providing a fully- worked- out scheme, left to
the discretion of the Commissioners many matters of the
greatest importance.

It is not surprising that under these circumstances the
Commissioners have never regarded themselves as form-
ing a Public Health authority. This is clear from their
administrative actions and public utterances. They have
devoted their energies mainly to creating the machinery
for enforcing insurance ; they have been satisfied with mere
names, as for instance " domiciliary benefit " in place of
an efficient system of treating tuberculosis ; and they have
neglected almost entirely (as we shall see when examining
them in detail) those provisions of the Act which demanded
scientific knowledge or were of a preventive character.
We may note in the difference between the reports issued
by the Insurance Commissioners and those published by
the Local Government Board and Board of Education,
the view which the Commissioners take of their functions.
The Local Government Board and the Board of Education
each issues a special report by its Chief Medical Officer
which is not limited to administrative details, but discusses
the work of the Department in relation to Public Health.

222 HEALTH AND THE STATE

The influence of that work in reducing sickness or mortality
is pointed out ; information is given as to what has been
done, and what it is intended to do ;| local opinions are
quoted, and suggestions are made for improving the services
with which the Department is concerned. Besides the
annual medical report, special reports on scientific and
Public Health questions are issued from time to time,
particularly by the Local Government Board. The In-
surance Commission has also a Chief Medical Officer, but
he issues no medical report, and the annual report pub-
lished by the Commissioners contains only a record of
official transactions and administrative steps. As far as
official sources of information are concerned, the public
has been left entirely in the dark regarding the influence
the National Insurance Act has had on the health of the
people. No statistics relating to the health of insured
persons have been issued by the Commissioners ; no steps
have been taken to provide Insurance Committees with
suggestions or schedules of lectures on Public Health ; and
no leaflets have been issued on the care of health. In
America the larger Life Insurance Companies have found
it profitable to distribute pamphlets to their members on
such subjects as the health of the worker, consumption,
open-air living, housing, health of children, recreation,
etc. But though the Commissioners have issued many
hundreds of circulars, orders, and memoranda, not one
of these has, up to the present, borne directly upon the
fundamental objects of the Act, viz. the prevention and
cure of sickness.

Local Administration

In local administration also the Insurance Act has
fared badly from the Public Health point of view. The
Bill, as originally introduced, contained the sound proposal
for the establishment in each county and county borough
of a " Local Health Committee." This body was charged
with the administration of medical benefit for deposit
contributors, and of sanatorium benefit for all persons
entitled, but its most important function was outlined in

INSUEANCE ACT : LOCAL ADMINISTRATION 223

the clause : " It shall consider generally the needs of the
county or county borough with regard *to all questions of
public health, and may make such reports and recom-
mendations with regard thereto as it may think fit." In
his speech on May 4, 1911, Mr. Lloyd George attached
great importance to this duty of the Local Health Com-
mittee, and in a Memorandum issued later he said : " The
new authority will have an invaluable amount of statistics
at its disposal which will enable it to locate any ' black
spots ' in any trade or district very quickly." Unfor-
tunately, when the administration of medical benefit was
taken away from the Approved Societies, and assigned to
this new local authority, the whole character of the latter
was changed. The name " Local Health Committee "
disappeared and was replaced by " Insurance Committee " ;
and the duty to " consider generally the needs of the county
or county borough with regard to all questions of public
health " was no longer required. Insurance Committees
still have power to make reports on the health of insured
persons and are also required to provide lectures on health ;
but in actual working, the time of these bodies has been so
fully occupied by administrative details, that their Public
Health functions have been almost entirely unexercised.
Where Local Health Committees might have been making
exceedingly valuable investigations into infant mortality,
adulteration of food, bad housing, atmospheric pollution,
prevention of tuberculosis, etc., Insurance Committees
have spent their time in preparing and maintaining
registers and panel lists ; in discussing such questions as
to whether doctors may write " Rep. Mist." instead of a
prescription; in negotiating with chemists over the cost
of drugs and pricing prescriptions ; in keeping voluminous
accounts ; and in deciding the maximum number of eggs
or pints of milk which may be given under " domiciliary
treatment " to a person in an advanced stage of phthisis.
The change has also seriously increased the complexity
and cost of administration. The administration of medical
benefit was removed from Approved Societies to Insurance
Committees in order to meet the wishes of the British
Medical Association ; but judging from the widespread

224 HEALTH AND THE STATE

dissatisfaction with the present arrangement it is doubtful
whether the doctors have really gained anything by the
change. On the other hand the abolition of the Local
Health Committees was undoubtedly a disastrous step so
far as the interests of Public Health are concerned.

Medical Benefit

The value of the panel system from the Public Health
point of view in providing medical attendance and treat-
ment has already been considered, and it was shown that,
on the whole, the standard of treatment among the insured
class is no better than that which prevailed before the pass-
ing of the Act. It is now necessary to consider this benefit
in relation to the light it throws upon the methods of deal-
ing with Public Health questions in Parliament and by the
Administrative Departments.

Medical benefit is defined in Section 8 of the Act as
" Medical treatment and attendance, including the pro-
vision of proper and sufficient medicines and such medical
and surgical appliances as may be prescribed by regula-
tions to be made by the Insurance Commissioners," and
in Section 15 the Insurance Commissioners are required
to secure that insured persons shall receive adequate
medical attendance and treatment from the medical prac-
titioners with whom arrangements are made. The Bill
was some mne months in its passage through Parliament,
but it is not possible to find in the whole course of the dis-
cussions any clear indication of the scope of treatment,
or of the meaning which Parliament intended to attach
to these words. It has already been pointed out that
specialist services and institutional treatment are by far
the most crying needs among the working classes, and no
system can be regarded as " adequate," in any ordinary
sense of the term, which does not provide these. Never-
theless, it does not appear that Parliament recognised their
importance ; and the Act finally left the House with medical
benefit so incompletely defined that the Commissioners
have been able to give it a meaning which, it is safe to say,
the majority of legislators would not have sanctioned had

INSURANCE ACT : MEDICAL BENEFIT 225

they been able to anticipate the Commissioners' inter-
pretation. The mere fact that any doubt could arise as
to the interpretation of so important a provision, con-
stitutes a strong argument for assigning the drafting of
future Public Health measures to a Ministry of Health.

Definition of the scope of medical treatment being
accordingly left to the Commissioners, that body proceeded
to lay down that an insured person is entitled only to
" such treatment as is of a kind which can consistently
with the best interests of the patient be properly under-
taken by a practitioner of ordinary competence and skill,"
and it may be recalled that these words have now the
force of an Act of Parliament. We will consider this
definition from its Public Health and legal aspects sepa-
rately.

From the Public Health point of view the decision was
disastrous. The Regulations did not even prescribe the
highest standard of general practice, and at a stroke of
the pen all opportunity of providing consultant services,
institutional treatment, surgical procedure, and nursing
was lost. It is true that when the extra Parliamentary
grant for the doctors was provided, a half-hearted attempt
was made to couple this with provision of facilities for
laboratory examinations, but no such facilities were in
fact provided. The system has given panel practitioners
an opportunity of charging insured persons for services
which they held were outside the scope of their contracts,
and it has led to disputes as to what services might be
regarded as within the scope of a practitioner of ordinary
competence and skill. To settle these disputes the Com-
missioners have adopted the remarkable course of appoint-
ing an outside body of Referees to whom the differences
are submitted ; thus declining responsibility for the inter-
pretation of a definition which they themselves had framed.

From the legal point of view it is open to doubt whether
the action of the Commissioners can be justified. Although
the word " adequate " is not defined in the Insurance Act,
there are several arguments which tend to show that it
does not bear the exceedingly narrow meaning given to it
by the Commissioners. We may for example refer to

Q

226 HEALTH AND THE STATE

another Act of Parliament in which the same word is used,
and note the meaning which has been given to it by the
Courts. Section 12 of the Children Act of 1908 provides
that " a parent or other person legally liable to maintain
a child or young person shall be deemed to have neglected
him in a manner likely to cause injury to his health if he
fails to provide adequate food, clothing, medical aid, or
lodging for the child or young person." Under this clause
parents have been convicted for failing to have defective
eyesight in their children treated, and have been required
to provide spectacles for them. A parent has also been
prosecuted and convicted for refusing to have an operation
for adenoids performed on his daughter.1 If these actions
by the Courts are legally correct, the words " adequate
medical aid " in the Children Act clearly include at least
special treatment of the eye and throat, and it is difficult
to see why the words " adequate medical attendance and
treatment " in the Insurance Act should bear any lesser
meaning.

The Insurance Act itself contains a schedule of addi-
tional benefits which Approved Societies may give when
their funds permit. These benefits include medical treat-
ment and attendance for dependents of insured persons ;
payment of the cost of dental treatment ; increase of sick-
ness or maternity benefit ; assistance during convalescence ;
payment of superannuation allowances ; repayment of the
whole or part of contributions, etc., etc. They do not
include any power to provide the services of consultants,
surgeons, or gynaecologists, or any form of institutional
treatment except for convalescents. If these services are
not included in medical benefit, then they cannot be pro-
vided under the Insurance Act at all. It is surely reason-
able to suppose that the Act provides a complete medical
service for insured persons, before benefits are extended
to persons outside the Act, or contributions are reduced ;
if not it becomes simply ludicrous.

There is a curious admission in the " Conditions of
Service for Practitioners " laid down by the Commissioners,
which indicates that the Commissioners themselves were

1 Report of Chief Medical Officer to Board of Education, 1912.

INSURANCE ACT : MEDICAL BENEFIT 227

not satisfied that the panel system was adequate. Clause 2
of these conditions runs as follows : —

Where the condition of the patient is such as to require services
beyond the competence of an ordinary practitioner, the practitioner
shall advise the patient as to the steps which should be taken in
order to obtain such treatment as his condition may require.

It is clear therefore that the Commissioners antici-
pated that conditions would occur among insured persons
for which the panel service would not provide adequate
treatment, and in securing that these persons should receive
only " advice " instead of the treatment their condition
demanded, the Commissioners were not carrying out the
intentions of the Act.

These arguments are reinforced by Mr. Lloyd George's
own interpretation of the powers of the Act. In his speech
to the Advisory Committee on January 2, 1913, more than
a year after the passing of the Act, he said, speaking of a
salaried service : —

I will show you what this means. We thought that we should
have had an opportunity of setting up a service of this kind at
Bradford. Bradford was very anxious for it. There was a real
demand from the working classes for it. The doctors were very
very obdurate, and we worked up our plan. Now the doctors came
in in time ; and so there is no salaried service at Bradford. But I
will just show you how it would have worked out within the money
available. You have 100,000 insured persons in Bradford. You
have 7s. or 7s. 6d. as the case may be. That depends upon the
debateable 6d. for drugs. If you make it 7s. that is £35,000. If
you make it 7s. 6d. that is £37,500. We proposed to engage 50
doctors at £500 a year. . Then we thought it would be necessary to
have a certain number of consultants and specialist surgeons, so
that it was proposed the service should include three specialist
surgeons, one of them being an oculist, and that at the head of the
service there should be a consulting physician, a superintendent at a
salary of £1200 a year. The specialist surgeons were to receive
£1000 a year. With the remaining £8000 we proposed to get other
assistance for the doctors. We proposed that there should be 50
nurses. You will find that still there would be something to spare,
especially on the 7s. 6d. basis, for the provision of aids to exact
diagnosis which pathology and bacteriology have placed at the
disposal of modern medical science.

For the moment we are not concerned with the reasons

228 HEALTH AND THE STATE

why this service was not established. The important
point to notice is that the authorities had already decided
to establish it, and had been able to come to this decision
without going to Parliament for further powers. It was
clearly at that time their conception of what constituted
an ' adequate ' service. If this service could not legally
be provided, then Mr. Lloyd George's speech was mere
' bluff.' On the other hand, if it is the correct interpreta-
tion of the Act, then for four years the Commissioners have
not been fulfilling their legal obligations.

On the other side of this question there are two points
which in fairness to the Commissioners must be noticed.
In the first place, the statement has been freely made (for
instance in the Fabian Society's Keport) that since Mr.
Lloyd George had been obliged to give the doctors all the
money available under the Act, as well as an additional
1| millions by a special Parliamentary grant, there was
nothing left to pay for consultants and special services.
If this statement is correct, it reveals a curious state of
affairs. It means that Parliament passes an Act intend-
ing that certain things shall be done; and the persons
appointed to carry out this Act find that there are not
sufficient funds for the purpose. Instead of reporting to
Parliament that they have been asked to undertake an
impossible task, and leaving the legislature to decide
whether the things proposed should not be done, or what
part of them should not be done, or whether additional
funds should be provided to carry out the whole pro-
gramme, the administrators themselves, or the minister
responsible for the Department, decide which part of the
duties assigned to them shall be done, and which part
shall be disregarded. This is of course the complete sub-
stitution of bureaucracy for Parliamentary Government.

The second point which might be urged in defence of
the course taken by the Commissioners is, that the Act
requires them in the first place to arrange for a list of
practitioners in each district who will undertake treatment
of insured persons, every qualified practitioner having the
right to be included in such lists. But there is an im-
portant proviso to these clauses which runs : —

INSURANCE ACT : MEDICAL BENEFIT 229

Provided that, if the Insurance Commissioners are satisfied after
inquiry that the practitioners included in any list are not such
as to secure an adequate medical service in any area, they may
dispense with the necessity of the adoption of such system as afore-
said as respects that area, and authorise the Committee to make such
other arrangements as the Commissioners may approve ; or the
Commissioners may themselves make such arrangements as they
think fit, or may suspend the right to medical benefit in respect of
any insured persons in the area for such period as they think fit,
and pay to each such person a sum equal to the estimated cost of
his medical benefit during that period.

But while the Commissioners were thus bound to
initiate the panel system, there does not seem to be any
reason in the Act why they should not have strengthened
it by appointing to each panel a staff of consultants and
specialists ; for the word ' practitioner ' includes specialists
as well as general practitioners. It has been argued against
this view that the Act only entitles an insured person to
the services of one medical man ; but this limitation clearly
only applies to his right to choose one medical practitioner
from the panel list. There is no prohibition against his
receiving additional attendance from a consultant, though
he has not the right to select this consultant. As a matter
of fact, the Commissioners do appear to contemplate an in-
sured person receiving services from two doctors simultane-
ously, for in a few districts where the system of ' payment
by attendance ' has been adopted by the panel doctors,
instead of payment by capitation fee, the list of services
officially recognised by the Commissioners as those for
which payment can be made includes : " Surgical opera-
tion requiring local or general anesthetic," and " Adminis-
tration of general anaesthetic." It can hardly be supposed
that the Commissioners intended one and the same person
to perform an operation and give a general anaesthetic.
Moreover, the first series of Regulations issued by the
Commissioners in October 1912 contained in the list of
services entitling to payment, " Consultation : (a) for the
ordinary attendant ; (b) for the consultant (if himself a
practitioner on the panel)." It is significant that this
entry disappeared in later issues of the Regulations.

But though the Commissioners are empowered to make

230 HEALTH AND THE STATE

other arrangements where the service is inadequate, they
have never made any public inquiry into its efficiency.
Previous to the middle of 1914, when the outbreak of war
rendered such a course impracticable, the Commissioners
could at any time have acquainted themselves with the
conditions in poor-class districts, the overcrowded waiting-
rooms, the ' lock-up ' surgeries, the hasty and inefficient
attendance, and other evils which have been so fully in-
vestigated and made known by independent bodies. With
their extensive powers they could have strengthened the
service in the worst districts, and could even have gone
the length of establishing a whole-time medical service if
necessary. It is more and more frequently urged that the
present panel system should be supplanted by a national
medical service. The arguments for and against this pro-
posal will be considered in a later chapter, but here it may
be noted that as far as insured persons are concerned, no
further legislation is required for this purpose, and that
the Commissioners can not only establish such a service,
but are actually bound to improve the present system
if they find it inadequate ; while from the estimates given
by Mr. Lloyd George in regard to Bradford, it may be
inferred that the present funds are ample to provide for
this service.

In a letter to the Times of January 3, 1912, Sir Clifford
Allbutt said : " In his Insurance Bill the Chancellor was
content with an antiquated notion of medicine and of
medical service ; he took for granted, without inquiry, a
notion built of some vague knowledge of village clubs,
and of the old-fashioned vade mecum way of doctoring.
This is, ' For such and such a disease such and such a drug ;
take the mixture, drink it regularly, and get well if Nature
will let you.' And if our people have ceased to check the
doctor's bill by the pill-boxes, bottles, and pots on the
shelf, even Cabinet Ministers have not escaped from this
ancient habit of thought."

This conception of medical treatment has apparently
governed the administration of the Act, and no effort
seems to have been made to rise above the standard of
treatment among the old Friendly Societies, or even to

INSURANCE ACT : SUPPLY OF DRUGS 231

investigate the needs of the community. Nor is the
insufficiency of the service the only evil. The panel
system has increased the element of commercialism in
medical practice ; it has done nothing to strengthen the
interest of the doctor in the scientific side of his pro-
fession ; it has led to considerable ill-feeling between non-
panel and panel practitioners ; and it has brought about
the evil foreseen from the first, that of establishing
a distinction between the ' rich man's ' and the ' poor
man's ' doctor.

The Supply of Drugs

The history of the drug supply under the Insurance
Act affords some interesting lessons in official muddle and
extravagance. Out of every nine shillings paid for medical
benefit, approximately two shillings represent the cost
of drugs and medicines. For 14 million insured persons,
therefore, the total annual cost is £1,400,000, and this
is exclusive of certain supplementary sums and cost of
administration. Previous to the Insurance Act it was the
custom in working-class practice for doctors to dispense
their own medicines, but Mr. Lloyd George assigned this
work to chemists, for the reason which he gave in the House
of Commons, that ' there ought to be no inducement for
underpaid doctors to take it out in drugs.' This step
substantially increased the expense. The special in-
vestigation made later by Sir William Plender for the
Government, showed that the average cost of drugs to
doctors practising in towns, including dispensers' fees, etc.,
was 5d. per head of the population. In a series of Friendly
Society Institutes, with an aggregate membership of
75,500, the average cost of drugs, including bandages,
dispensers' salaries, etc., was lOd. per member. It is
clear, therefore, that the mere change of system involved
an additional cost of at least £700,000 annually. It is
probable that the Government did not even know the cost
of drugs, when supplied by doctors, until Sir William
Plender made his inquiry nearly a year after the Insur-
ance Act had been passed.

232 HEALTH AND THE STATE

We must now note how far this costly change of system
has achieved its object, viz. that of improving the quality
of drugs supplied. The Government offered the chemists
a capitation fee of Is. 6d. per insured person for the supply
of drugs. The chemists, through the Pharmaceutical
Society, expressed the view that this amount was in-
sufficient. Eventually the question was settled by the
establishment of the ' floating sixpence,' an arrangement
which was described by Mr. Lloyd George as follows :
' The doctor is the only person we can trust to check
' drugs. We are going to leave that 6d. there between the
' doctor and the chemist. It will provide £320,000. That
' £320,000 will be available if the drug bill exceeds the
' Is. 6d. provided ; and where it does not exceed that
' Is. 6d. it will be available for the doctor. That is not the
' case with regard to the Is. 6d. I want to make it clear
' that, at any rate up to Is. 6d., there ought to be no induce-
' ment to the doctor to cut down the drugs. We want the
' best drugs available in the market for the treatment of
•' the industrial population of this country, in the interests
' of the State as well as for humanitarian reasons, and we
' realise that it mil be necessary to have at least Is. 6d.
' available for the provision of drugs." 1 Thus, after taking
away the dispensing from the doctors because they could
not be trusted to supply good drugs, Mr. Lloyd George
finds, eighteen months later, that they are the only persons
whom he can trust to check drugs ; and while reiterating
his demand for the best drugs in the interests of the State,
he gives the doctors a direct financial interest in prescribing
the minimum amounts and cheapest qualities.

But soon pressure was brought to bear from other
directions to reduce the cost of drugs. The Commissioners
gave tacit assent to a tariff which was drawn up by the
Pharmaceutical Society, and at the end of 1913, and still
more at the end of 1914, the fund, even with the aid of the
' floating sixpence,' was insufficient in many localities to
pay the chemists in full, and their bills were accordingly
discounted 10, 20, and even 30 per cent. This gave rise
to great dissatisfaction among the chemists, and to meet

1 Supplement to British Medical Journal, October 26, 1912.

INSURANCE ACT : SUPPLY OF DRUGS 233

their complaints efforts were made by the Insurance
Commissioners and Committees to reduce the supply and
cost of drugs. All thought of providing only the ' best '
drugs went to the winds. Expensive drugs were eliminated
from the lists, ' stock ' mixtures were introduced, tap-
water was substituted for distilled water, and finally a
system of investigating practitioners' prescriptions was
established in order to put a stop to what was termed
' excessive prescribing.' Many doctors who in May 1911
were to be under no restrictions in supplying medicines
were now required to attend before tribunals to justify
their orders for medicines in particular cases, and were
liable to surcharge.1

Under these circumstances it is not surprising that
there have been numerous complaints as to the quality of
drugs supplied and of faulty dispensing by panel chemists.
For instance, in Salford, out of nineteen samples of
mixtures dispensed under the Insurance Act which were
analysed by the borough chemist, eight were found to be
unsatisfactory. In Birmingham, nineteen prescriptions
by panel doctors ordering a mixture and a paint were
analysed, and sixteen samples of medicine from twelve
chemists were found not to have been properly dispensed.
In an inquiry by the Insurance Commissioners in Man-
chester, it was shown that among 17,000 prescriptions dis-
pensed by one firm, 3000 were prima facie irregular. A
doctor who gave evidence said that he had examined 3194
prescriptions signed by him, and about 2000 contained
improper alterations. It would appear therefore that
insured persons are at least no better off than they would
have been if dispensing had been left in the hands of the

1 The following extracts from Memo. No. 648/1. C, issued by the Scottish Com-
missioners in July 1915, illustrate the official pressure which was brought to bear
upon the doctors : —

" For the guidance of practitioners it is suggested that every prescription should
in the meantime conform to the following conditions :

"(1) The quantity prescribed at one time should be strictly limited.

" (2) The drugs employed should be, ceteris paribus, the least expensive of
their class.

" (3) Flavouring agents should be reduced to a minimum, and the more ex-
pensive, where a less costly equivalent is not available, should be restricted to
cases in which therapeutic benefit would not be obtained without their use.

" (4) Drugs should be put up in the least expensive form consistent with the
requirements of the case."

234 HEALTH AND THE STATE

doctors. Indeed it is not clear that the charge that
doctors were wont to ' take it out in drugs ' is, as a
general statement, substantially true. In country districts
where no chemist is available, panel practitioners are
allowed to do dispensing, but, so far as the writer is aware,
complaints against these doctors have not included any of
supplying bad medicines.

Early in 1915 the Commissioners seem to have come to
the conclusion that the original drug tariff drawn up by
the Pharmaceutical Society, which without adequate in-
vestigation they had allowed to form the basis of contracts
between Insurance Committees and chemists all over the
country, might be revised ; and accordingly a Depart-
mental Committee was appointed for the purpose, and
issued a report in September. This report showed that
the tariff was full of anomalies and defects, and that
although occasionally imposing hardships on chemists,
it yielded high profits on a large number of drugs and pre-
scriptions. A new tariff based upon commercial principles
was drawn up by the Committee, and came into force in
1916. Thus four years after the Insurance Act was
passed, the supply of drugs was for the first time placed
upon a business footing. But even now the muddle is
not at an end. The ' floating sixpence ' is still retained,
and since its division between the chemists and the doctors
was based upon the old tariff, this tariff must be main-
tained for the purpose ; thus in every district the cost of
drugs must be determined twice over and on two separate
scales.

The system of supplying drugs under the Insurance
Act has involved an immense expenditure of labour and
time. A glance at a few agenda of Insurance Committees
will show that chemists' accounts and questions of drug
supply form one of the matters most frequently under
consideration. The checking and pricing of the millions
of prescriptions has entailed the appointment of numerous
salaried accountants with staffs of checkers and sorters.
The Insurance Commissioners have issued sheaves of reports
and circulars, including a ' Keady Reckoner ' for arriving
at the prices of ingredients of prescriptions to the second

INSURANCE ACT : SANATORIUM BENEFIT 235

place of decimals.1 Numerous Committees of Inquiry
nave been constituted by chemists, doctors, and officials,
and voluminous reports have been issued. On the other
hand, an additional shilling to the doctor's capitation fee
for dispensing would have paid the doctors very well
in view of Sir William Plender's report, would have
saved the country half the cost of the present system,
secured at least as good a supply of drugs, and averted
endless dissatisfaction and confusion. The tragedy of this
waste becomes all the more apparent when we realise how
utterly disproportionate is the benefit to the health of
insured persons derived from the whole system.

The duty of drawing up a schedule of medical and
surgical appliances for insured persons was also left to
the Commissioners. The list consists of ordinary dressings
and ice-bags, splints and catheters. Other appliances are
however urgently needed, particularly trusses, which
many of the Friendly Societies formerly supplied free of
charge. The cost of these would probably be covered
many times over by their enabling persons sooner to
resume their work.

Sanatorium Benefit

This benefit is denned in the Act as : " Treatment in
sanatoria or other institutions or otherwise when suffering
from tuberculosis or such other diseases as the Local
Government Board with the approval of the Treasury
may appoint." To meet the cost, Parliament provided a
capital sum of one and a half millions for grants in aid to
sanatoria and similar institutions, and an annual contri-
bution of Is. 3d. per insured person, equivalent to an
annual sum of one million. Sanatorium benefit may be
extended to dependents of insured persons, and if in any

1 The British Medical Journal of January 29, 1916,criticising this Ready Reckoner,
says : " It occupies twenty-four foolscap pages of figures with two pages of de-
scription as to their use, and a page is also devoted to an account of the twenty-
three varieties of dispensing fees, which will probably be a source of endless questions
and disputes. The Ready Reckoner will undoubtedly save much trouble to the
pricing staffs, with a consequent saving of expense, but one cannot help feeling
that in the years to come it will be regarded, with the cumbrous system for which
it stands, as a curious relic of antiquity."

236 HEALTH AND THE STATE

district the annual amount available to meet the cost is
insufficient, the deficit may be made good by the county
or county borough paying one half, and the Treasury pay-
ing the other half.

This benefit also has in practice proved very different
from what appears to have been intended by Parliament.
Throughout the debates the importance of providing
sanatoria for the tuberculous was insisted upon, and it
was clearly for this purpose that the money was intended
mainly to be spent. But when Mr. Lloyd George made
the financial arrangements with the doctors, the scheme
was widely altered. " Domiciliary treatment," a term
which does not occur in the Act and was not heard in
the debates, was invented, and 6d. was taken from the
Is. 3d. to pay the doctors for this treatment. Now domi-
ciliary treatment is simply ordinary medical treatment by
a general practitioner, with the addition of a small weekly
allowance of milk, eggs, or cod-liver oil, and sometimes
the loan of a shelter to be erected in the back garden. At
the present time the majority of the tuberculous insured
persons are receiving their sanatorium benefit in this form.
The funds for the maintenance of sanatoria have been
raided to the extent of 40 per cent ; the ' chain of sana-
toria throughout the country ' is still far from complete,
and many persons whose condition demands institutional
treatment are unable to obtain admission into sanatoria
or other institutions. Legal justification for this course
is found in the words ' or otherwise ' in the Act ; but in
reality it was simply a means of transferring a sum of
money from one fund to another, and it illustrates again
the extent to which an Administrative Department or a
Minister can alter an Act of Parliament. Had the legis-
lature been aware that instead of the great benefits pro-
mised being realised, two-fifths of the sum provided for
the maintenance of sanatoria would be allocated to an
entirely different and inferior form of treatment, it seems
very doubtful whether it would have agreed to the scheme.

Dispensary treatment, a form of treatment which brings
the patient under the cognisance of an expert tuberculosis
officer, has undoubtedly proved more useful, mainly for

INSURANCE ACT : SANATORIUM BENEFIT 237

purposes of diagnosis. Sanatorium treatment requires
detailed consideration.

Sanatorium treatment of tuberculosis arose from the
observed value of breathing pure air in the treatment of
phthisis, and was first developed on an extensive scale in
Germany and the United States. The treatment consists
essentially in spending as much time in the open air as
possible, together with adequate and appropriate diet,
suitable exercise, rest, and medical care. During early
years there was a tendency to exaggerate the value of the
treatment, almost certain cure being promised provided
the disease was not too far advanced. Later experience
modified these sanguine expectations, but nevertheless
established that in sanatorium treatment we had a valu-
able means of combating tuberculosis in appropriate cases.
It was found that after a residence of from six to eighteen
months in a sanatorium, the disease might be permanently
arrested in some persons who were not suffering from it in
an advanced form, while others were substantially bene-
fited and their lives prolonged, even if they eventually
succumbed to the malady. But it was one thing to improve
patients while under treatment, and another to maintain
that improvement after they left the sanatorium. It
soon became clear that discharged patients, if they are
to benefit permanently by their treatment, must continue
to live under conditions approximating to those within
the sanatorium, i.e. lead an out-door life in pure country
air, with abundance of nourishing food and perfectly
hygienic surroundings. Patients who go back to sedentary
occupations in close, ill- ventilated rooms or factories in a
crowded and smoky city, are almost certain to suffer a
recurrence of the disease.

The earlier optimistic beliefs in the efficacy of sana-
torium treatment were drawn mainly from the experience
of paying institutions opened for the wealthier classes.
These are, however, just the people among whom the best
results might be expected, since they are in a position to
make the necessary modifications in their form of living
and some spend months of each year in health resorts. To
suppose that anything like such good results would follow

238 HEALTH AND THE STATE

the provision of sanatorium treatment for an industrial
working-class population was to ignore wholly the neces-
sities demanded after the actual period of treatment. Yet
this was done under the Insurance Act. Insured persons
suffering from tuberculosis have received treatment in
sanatoria for some months, though frequently for too
short a period to derive the full advantage, have gained
markedly in health, and have on their discharge figured
in the statistics as ' cured ' or ' improved.' They have
then gone back to their old environment, and after a
longer or shorter period the disease has reasserted itself.
The opinion is now widely held among Tuberculosis Officers
and Medical Officers of Health that sanatorium treatment
is of comparatively little value among the working classes.
In support of this statement the following opinions of
persons specially qualified to judge may be quoted : —

Dr. Squire, the adviser on sanatorium benefit to the London
Insurance Committee, has said in a report : "In chronic cases —
where the disease though not active is still smouldering — cure or
complete arrest is improbable, and the most that can be anticipated
from institutional treatment is such improvement in general health
as to allow of a temporary return to work, the duration of which
will be largely conditioned by the nature of the employment and
the hygienic environment to which the individual returns on
leaving the institution. Thus, patients returning to a poverty-
stricken home are likely — or indeed almost certain — to break down
soon after their return, and the benefit derived from the treatment
is of little practical value. Economically the benefit derived is not
worth the expenditure on the treatment. A few weeks' stay in an
institution from which they return to conditions under which they
quickly revert to their previous state of ill-health is of little practical
utility either to themselves or to the community."

At a meeting of the Northern Branch of the Society of Medical
Officers of Health, December 1915, Dr. Dickinson, the Tuberculosis
Officer for Newcastle, said : " One is bound to confess that sana-
torium treatment of the phthisical poor has never come up to expecta-
tions, and practically never results in the cure of open tuberculosis.
... In my experience the results are uniformly bad amongst children
who have tubercle bacilli in their sputum." Dr. Hemborough, the
County M.O.H. for Northumberland, considered that sanatorium
patients would derive little permanent benefit from the treatment
so long as they had to return to the bad home-conditions under
which so many of them lived. Dr. Taylor, M.O.H. for Chester-le-

INSURANCE ACT : SANATORIUM BENEFIT 239

Street, said that it was useless to treat a man in a sanatorium, where
he lived under ideal conditions, and then discharge him to an ill-
ventilated, insanitary home, where the family convenience was a
bar to everything he had been taught. Dr. Renney, M.O.H. for
Sunderland, considered that ill - ventilated and closely crowded
dwellings were the great unit in the spread of infection. The poorer
sanatorium patients almost invariably declined after returning home.
Dr. A. Smith, M.O.H. for Whickham, said he had latterly come
to regard the infectiousness of phthisis as over-emphasised. . . .
Notwithstanding all that had been done under the Insurance Act
and by the tuberculosis dispensary, the death-rate from phthisis in
his district was markedly higher than previously. Dr. Allen, the
President of the Society, was disappointed with the results of
sanatorium treatment. Poverty and insanitary home-conditions
were all against sanatorium patients after their discharge. Not one
speaker at this meeting spoke in favour of sanatorium treatment
among the working classes.

Dr. Guy, the Tuberculosis Officer for Edinburgh, said in a recent
report : " The housing question is one of the vital points in dealing
with the problem of tuberculosis. Hitherto we have heard a great
deal about sanatoria, etc., and too little about these houses. The
disease should be attacked there ; and my opinion inclines to the
belief that if all the money which is at present being poured out
on sanatoria had been spent on an improvement of housing condi-
tions, the results would certainly not have been less satisfactory."

Dr. Williamson, the M.O.H. for Edinburgh, has said : " Sana-
toria and dispensaries are not of themselves likely to be attended
by markedly beneficial results in the absence of other definite
preventive measures."

Dr. J. E. Esslement, Medical Superintendent of the Home
Sanatorium, Bournemouth, after pointing out the advantages of
sanatorium treatment, at a congress on tuberculosis in 1914,
said that sanatorium treatment, however, had great limitations.
As a means of stamping out tuberculosis the great expectations
with regard to its efficacy had not been realised. It was expensive.
Treatment could seldom be carried out for longer than three or six
months. Cures were seldom complete, and little was accomplished
in preventing the spread of infection in the community. In Ger-
many in 1910 there were 800,000 infectious cases of tuberculosis ;
41,262 received sanatorium treatment, but of these only 3300 were
rendered non-infectious.

Statistics relating to the condition of patients on dis-
charge from sanatoria are of little use as a means of measur-
ing the value of the treatment, since the terms employed,
' disease arrested,' ' condition improved,' ' fit for work,'

240 HEALTH AND THE STATE

etc., are unavoidably indefinite, and give no indication
of the state of patients one year and two years after dis-
charge. When we examine the reports of individual
sanatoria which do give this information, the results are
often melancholy. For instance, from a report by the
Clerk of the Insurance Committee of the County of Ayr,
we learn that of 237 persons who were sent in 1914 and
1915 to sanatoria, 69, or nearly one-third, were dead by the
middle of 1916. Yet these appear to have been cases
selected as favourable for the treatment, since others were
sent to hospitals or infirmaries, or were refused benefit
on account of the disease being too far advanced. Of 49
persons treated in 1915 in the Paisley sanatorium, 12
were discharged improved, 10 not improved, 3 left, 15
died, and 9 were still under treatment.

When we examine the mortality returns for the whole
country, which should reflect the influence not only of
sanatorium treatment but also of tuberculosis dispens-
aries and domiciliary treatment, we find little encourage-
ment for the belief that sanatorium benefit has had any
appreciable effect in reducing tuberculosis. The death-
rates from phthisis in England and Wales were : 1017 per
million in 1912; 989 in 1913; and 1022 in 1914. While
for 1915,1 admittedly under exceptional circumstances,
the rate, 1140, was higher than in any year since 1907.

While admitting that a certain number of persons have
derived benefit from residence in sanatoria, and a larger
number have received care and attention which they could
not have obtained at home, there is no doubt that sana-
torium benefit as a means of preventing and curing tuber-
culosis has been a great and costly failure. It was not
suitable for application to the working classes ; it does
nothing to destroy the environmental causes of the dis-
ease ; it has led to the outpouring of large sums of money
which could have been much better employed in clearing
overcrowded areas ; and, saddest of all, it has created

1 At the time of writing, the Report of the Registrar-General for 1915 is not
published. The death-rate from phthisis, which relates only to the civil popula-
tion, is however given in the Report of the Chief Medical Officer to the Board of
Education. The increase though highest at military ages is not confined to those
ages.

INSURANCE ACT : SANATORIUM BENEFIT 241

hopes in the minds of many thousands of poor persons torn
by disease, which have not been and could not have been
realised.

For the purposes of this book it is necessary to examine
how this great mistake came to be made, and here aga'in
we are bound to recognise the effect of Mr. Lloyd George's
personal influence and optimism. On July 7, 1911, he said
in the House of Commons : —

If this experiment is a success, and it becomes perfectly evident
that it is effectively stamping out consumption, it will be a great
mistake for the State not to face any liability within reason in order
to effectively stamp out this scourge altogether. ... I am a believer
in sanatoriums as my hon. friends are ; but it is an experiment.
There are doctors in this country of great experience who are not
quite so confident as to this being the best method of stamping out
consumption. I think it is worth while making the experiment,
and it is worth while making it well. . . . Some one suggested that
the danger was that this provision will be for the better class. As a
matter of fact, it is for the wretched people who have no homes
where they can be cured that these sanatoriums will be most use-
ful. ... I invite the House to try the experiment on this very con-
siderable scale — £1,500,000 towards building and £1,000,000 towards
maintaining them.

On July 12, 1911, Mr. Lloyd George said :—

A good many remedies which after years of struggle have
managed to secure the approval of the profession have come to
stay, and the case of sanatoria is a case of that kind. It is not
something which has been suggested within the last few years. It
is something which was suggested a good many years ago — I
forget how many ; but I am not sure it is not forty or fifty years ago
when an English doctor tried the experiment. It has been a long
experiment, and it has gone through the same stages as every other
successful experiment. It has taken very many years to convert
the faculty, and it is only because the experiments extending over a
good many years have been a success that doctors have been at
last convinced that there is a good deal to be said for it. I do not
therefore put it in the same category as a sort of fashionable craze.
It is something tried and tested by the most severe test of all, the
test of experience extending over something like two generations.

It may be noted that the only experiment at that time
made on a national scale was in Germany, the results
of which had been anything but encouraging.

242 HEALTH AND THE STATE

The right hon. gentleman quoted in the debate the ex-
perience of the Hearts of Oak sanatorium and the Post Office
sanatorium. But in these two together the total number
of cases tabulated was only 226 ; the results were described
under the vague headings ' disease arrested,' ' improved,'
' unimproved ' ; and the information related to condition
on discharge. Nevertheless, on these utterly inadequate
data, Mr. Lloyd George committed himself to the general
statement : " This shows that experiments in this country
have been a very considerable success."

Mr. Lloyd George was not left uninformed that much
expert opinion was against his views. In the course of
the debate, Mr. Walter Long, an ex-President of the Local
Government Board, said : —

I can find no reliable evidence to show that treatment in
sanatoria has been really effective. . . . The results so far as real
cures are concerned have so far been very moderate. . . . Messrs.
Elderton and Perry, of the Department of Applied Mathematics,
University College, as a result of their study of the " Mortality of
the Tuberculous and Sanatorium Treatment," arrived at the follow-
ing conclusions : (1) the mortality of tuberculous patients treated
in sanatoria, even when the disease is taken in an incipient stage,
is four times as heavy as in the general population, and (2) that
the mortality of the apparently cured (sanatorium) is twice as heavy.

Dr. Hillier quoted Professor Koch that, " neither in
Germany nor in any other country had the really necessary
measures for preventing the disease been taken," and added:

. . . any proposal which merely regards sanatoria as places for
the treatment of early phthisis, or places where advanced cases may
be treated and then allowed to go back to the family, really fails
to achieve the first requirement of any great preventive measure.

Mr. Arthur Lynch said : —

I wish to speak more in regard to the importance of research. . . .
You may spend millions of money upon sanatoria, and ten years
afterwards when you take a retrospect of what has been accom-
plished the answer may be almost nothing. . . . There is a powerful
school of medicine, comprising, broadly, those who are in the fore-
front of bacteriological work, who doubt whether much advantage
scientifically is derived from sanatoria if limited to the expectant
treatment. . . . Before sitting down I should like to propose the
impossible, that is, I think all this is a case for special examination
by a special committee.

INSURANCE ACT : SANATORIUM BENEFIT 243

Dr. Esmonde said : —

I would ask the Chancellor of the Exchequer not to spend his
million and a half on large buildings which may be utterly and
completely useless within a few years, but to spend a good deal of
it in research. . . . Experience of the plan of sanatoria is that a
person goes to one of these institutions believing that he is going
to get well because he has got the disease in the first stage ; he
comes back to his home and after a very short time dies. We have
really nothing definite to go upon, and any man in general practice
in this country during the last twenty-five years must be deeply
despondent at the results which have been achieved.

Other opinions might be quoted, but these are sufficient
to show that adverse criticism now of sanatorium benefit
is not an instance of ' being wise after the event.' Medical
and expert opinion in 1911 held that sanatorium treat-
ment was a useful measure in certain selected cases, among
people who could continue to live under hygienic sur-
roundings, but it never endorsed the sweeping statements
and proposals of the Chancellor of the Exchequer ; and
those members of the House of Commons best qualified
to judge pleaded for further investigation.

It was however apparently German experience which
most influenced Mr. Lloyd George, and he quoted in detail
certain German statistics as justification for his views.
But reading his speeches carefully, it is difficult not to
come to the conclusion that he had misunderstood these
statistics, and he appears equally to have misled those he
was addressing. The statistics with which he made most
play were those which showed the proportion of persons
discharged from sanatoria as able to return to work. But
he did not state that German authorities use those words
to mean not only persons fully capable of working, but
also those capable of working in the sense of the sickness
insurance law, i.e. possessing one-third of the normal capa-
bility ; and it seems clear that they were interpreted by
the House of Commons as meaning persons cured of the
disease. The statistics showing the proportions discharged
as ' cured,' ' improved,' etc., give a much less favourable
picture, but Mr. Lloyd George did not refer to these.
German writers themselves have exposed the hollowness

244 HEALTH AND THE STATE

of the statistics relating to capacity for work. The Fiirsor-

gestellen (Assistance Centres) for phthisical patients have

found that a large percentage of patients discharged from

sanatoria with the certificate ' fully capable of work '

relapse very often within the year. Dr. S. Fuchs-Wolfring

(Paris) in a paper which is an amplification of one read

in Rome at the Seventh International Congress for

Tuberculosis, after showing how small are the results

achieved in Germany and how great their cost, says :

' It is only the reports of private sanatoria which are dis-

' tinguished by an optimism which is in direct opposition

' to facts. These optimistic reports are rendered possible

' only by the employment of the elastic classifications

' ' regained capability of work ' and ' working capability in

' the sense of the law,' which are very deceptive and veil the

' real facts as given in the official statistical reports. The

' official reports acknowledge that the ' regained capability

' to work ' so far only exists on paper. This method of

' classification is a cruelty to patients and is misleading

' from a national economic point of view." x

It is true that there has been a considerable decline in
tuberculosis in Germany, but there have also been sub-
stantial declines in other countries where no special efforts
had been made. When the Insurance Act was introduced,
the death-rate in Germany from consumption, after many
years of sanatorium benefit, was almost 50 per cent higher
than it was in England and Wales.

Mr. Lloyd George spoke of sanatorium benefit as an
' experiment,' but it would probably be impossible to
alter the scheme now that we have established sanatoria,
appointed tuberculosis officers all over the country, and
made arrangements with the doctors. We must keep our
sanatoria as homes for care and treatment ; but we must dis-
miss the extravagant ideas of cure which were promised. As
far as the prevention of tuberculosis and the ' stamping out '
of this scourge is concerned, we are exactly where we were
in 1911, with the exception that a number of false views
have been propagated, and a great deal of money spent for
very little return. This however is part of the price we

1 Medical World, May 14, 1914.

INSURANCE ACT : SICKNESS BENEFIT 245

must continue to pay so long as we are content to be
guided in the profound and difficult problems of Public
Health by those who have no special knowledge of the
subject.

The complex system of administration set up for
sanatorium benefit will be more conveniently examined in
Chapter X. in connection with Public Health administra-
tion generally.

Maternity Benefit

This benefit has already been examined. It has not
had any demonstrable effect in reducing maternal or
infantile mortality, but has undoubtedly enabled many
mothers to make better preparation for their confinement.

Sickness Benefit

Sickness benefit is a payment of 10s. a week to men
and 7s. 6d. to women while ' rendered incapable of work
by some specific disease or by bodily or mental disable-
ment.' We have to consider: (1) the conditions which
entitle to benefit, and (2), the influence of the benefit in
the ' prevention and cure of sickness.'

The difficulties which occur in connection with sickness
benefit have given rise to much dissatisfaction. Insured
persons complain that they do not always receive the
payments to which they are entitled ; officials of Approved
Societies state that malingering is encouraged and that
the doctors' certificates are not reliable ; the doctors com-
plain that they are called upon to give unnecessary certifi-
cates, that their certificates are questioned and sometimes
rejected by lay officials. Approved Societies agitate for
more control over the doctors ; while the doctors chafe
under the restrictions to which they are already subjected.

The root cause of these difficulties is the fact that the
right to sickness benefit is based upon an unsound principle.
Benefit during sickness is only payable, according to the
Act, when a person is ' rendered incapable of work.' In
practice it is impossible in a very large number of cases to
observe this condition. A person may still be capable of

246 HEALTH AND THE STATE

work — it depends a good deal upon the nature of the
work — even if suffering from relatively severe illness. He
may be able to work during the early stages of acute
illnesses, or while suffering from chronic affections such as
tuberculosis, heart-disease, aneurism, etc. Apart from
severe affections, it is certain that if the Act were inter-
preted literally, many thousands of payments in respect
of anaemia, dyspepsia, and other conditions could not be
justified. What therefore actually happens is that unless
the doctor is dealing with a case of obviously incapacitat-
ing illness, he pays little attention to the strict requirements
of the Act. Established in his mind he has a kind of
standard inherited from the old Friendly Society days,
and if he thinks that a patient's condition is such that he
ought not to work even if he could, or that a period of rest
at home will appreciably facilitate his recovery, he gives
a certificate for sickness benefit.1 Thus the doctor and the
Approved Society official tend to look at the case from very
different points of view. The doctor regards chiefly the
interests of his patient and the importance of getting him
well ; the Approved Society official has his eye upon the
funds of the Society, and tends to object to any payments
for conditions which do not clearly satisfy him that the
patient is incapable of work. With serious illness diffi-
culty does not often arise, but, as we have seen, a con-
siderable proportion of the working classes in large towns
are in a chronic state of ill health in consequence of over-
work or bad environment, without suffering from any
clearly definable disease. A person comes to the doctor
in such a condition that if he or she belonged to the
wealthier classes, abstention from work would certainly be
advised. But it is not possible for the doctor to do more
than certify that the patient is suffering from ' debility,'
or fix upon some prominent symptom such as ' anaemia,'

1 Many utterances of panel practitioners might be quoted in support of this
view. Dr. Round, the Chairman of the Deptford Panel Doctors' Committee, says,
for example : " An old married woman has been under my care and on the funds
for some months. She surfers from rheumatic arthritis, and earns her living in
the winter as a wood-chopper, and during the summer she washes jam jars. Since
when has a woman with rheumatic arthritis been fit to wash jam jars or chop wood,
I wonder ? Members like this one deplete the funds no doubt, but the Act was
instituted for the benefit of such people, and I, for one, am not going to ' bully them '
to go back to work." — Medical World, December 18, 1913.

INSURANCE ACT : SICKNESS BENEFIT 247

1 nervous exhaustion,' or ' dyspepsia,' and put that in the
certificate. Then comes the Approved Society official,
who complains that these are not serious conditions, that
they do not incapacitate for work, and that the doctor is
not making a careful diagnosis or giving his certificates
with justification.

This confusion results from a change having been made
from one system to another without suitable adjustments
having been introduced. The words ' incapable of work '
really come from the regulations of the old Friendly
Societies, and though not interpreted literally even then,
difficulty rarely arose, since the doctors knew what the
Friendly Societies meant and required. Moreover, the
relations between the Friendly Societies and the doctors
who were appointed and paid by the Societies, were so
close that difficulties when they arose were easily adjusted,
and the doctors themselves were interested in the smooth
and economic working of the Societies. The transference
of the administration of medical benefit to Insurance
Committees altered the whole relation of the doctors to
the Societies ; but no thought seems to have been given to
the question whether a form of words which had proved
suitable for one system would be equally satisfactory when
applied to a totally different system.

The fact that there is not a constant relation between
sickness and capacity for work probably explains the
apparently excessive amount of malingering among insured
persons. Some Insurance Committees have appointed
medical referees to examine persons in receipt of sickness
benefit, and these referees have invariably found that a
considerable proportion of the persons examined were not
legally entitled to the benefit. In one large Society, in
six months, 12,375 members in possession of certificates of
incapacity were requested to attend for examination by the
Society's permanent medical referees, as a result of which
1375 declared off the funds voluntarily ; 1795 failed to
attend for examination ; and 3186 of the 9208 examined
were declared ' capable of work ' by the referees. It
would be an error to suppose that all those found capable
of work were deliberate malingerers. Probably the doctors

248 HEALTH AND THE STATE

had considered that the conditions exhibited by the great
majority of these persons were such that they ought not
to be at work ; while the referee, taking the strictly legal
view of the position, found himself unable to uphold the
doctors' certificates. These considerations also explain
why claims for sickness benefit tend to vary with the rate
of wages and the general demand for labour. During 1915,
when unemployment was reduced to a minimum, sickness
claims fell off to a remarkable extent. It might be said
that this was due to reduction of sickness in consequence
of better food-supply, but probably the main reason is that
when wages are good and work is abundant, ailing persons
often pull themselves together and go to work, although
they are in a condition in which many doctors would give
them a certificate of incapacity ; just as the business man
will sometimes disregard the advice of his doctor to lie up,
and will insist on going to his office, perhaps to his serious
detriment. When trade declines there is less inducement
for persons to remain off the sick list, and in poorly paid
occupations — for instance, some forms of women's labour —
the amount received from benefit may actually exceed the
amount which could be earned in wages. This is the more
likely to occur among the large body of persons who are
insured for sickness in private societies and organisations
besides under the National Insurance Act. Thus, though
the condition of the person may be the same at both
periods, at one time there is an inducement for him to go
to work, and at the other the inducement may be in the
opposite direction.

Probably no satisfactory scheme of sickness benefit
will be established until the distinction between restora-
tion to health and restoration to working capacity has
been clearly recognised, and when recognised, its observance
insisted upon. If sickness benefit is to be regarded strictly
as a provision for preventing destitution until the recipient
is just able to struggle back to work, then a clear intima-
tion of this rendering should be given to the doctors. If,
on the other hand, restoration to full health is the first
concern, then the benefit should be supplemented without
delay by public provision for higher medical treatment,

INSURANCE ACT : INSANITARY CONDITIONS 249

institutional treatment, nursing, convalescent homes, and
all other needs of an invalid which the Insurance Act does
not provide and sickness benefit is insufficient to buy ;
and the patient should be entitled to his benefit as long as
he can derive advantage from any of these forms of treat-
ment which would be interfered with by his return to
work. In the long run, provision of these services would
be the soundest national economy. At the present time
sickness benefit, like maternity benefit, is undoubtedly a
boon among the working classes during periods of illness,
since it may enable the rent to be paid, may provide or
help to provide food for the family, and may even save a
family on the margin from having to go to the workhouse.
But it has little effect in curing or preventing sickness, for
it will not enable a patient to obtain what he needs, it will
not send him to the country or seaside, and indeed it will
usually not even maintain his normal income in health ;
while a family which is just managing to keep itself afloat
with the aid of the 10s. a week is not likely to be living
under conditions which prevent sickness.

Disablement Benefit

Disablement benefit, a payment of 5s. a week while
incapable of work after the expiration of sickness benefit,
is admittedly a form of relief, and, as such, is a useful
measure which does not demand criticism ; though it may
be questioned whether it would not have been better to
have made this provision by establishing invalidity pensions
rather than by collecting the funds through the compli-
cated machinery of the Insurance Act.

The Insurance Act and Insanitary Conditions

It is now necessary to examine the provisions of the
Insurance Act which were specifically directed towards
preventing disease by improving environment and attack-
ing causes of sickness. The most ambitious of these is
contained in Section 63 of the Act, which gives power to
the Insurance Commissioners, or any Approved Society
or Insurance Committee, to allege that the sickness among

250 HEALTH AND THE STATE

insured persons for the administration of whose sickness or
disablement benefit they are responsible is excessive, and
that such excess " is due to the conditions or nature of
" employment of such persons, or to bad housing or in-
" sanitary conditions in any locality, or to an insufficient or
" contaminated water-supply, or to the neglect on the part
" of any person or authority to observe or enforce the pro-
" visions of any Act relating to the health of workers in
" factories, workshops, mines, quarries, or other industries,
" or relating to Public Health, or the housing of the working
" classes or any regulations made under any such Act or to
" observe or enforce any Public Health precautions." The
Commissioners, Society, or Committee may then send to
the person or authority alleged to be in default a claim for
the payment of the extra expenditure alleged to have been
incurred through any of the preceding causes, and if they
fail to arrive at any agreement with the person or authority,
they may apply to the Secretary of State or the Local
Government Board for an inquiry to be held.

If, upon such inquiry being held, it is proved that the
amount of such sickness has

"(i.) during a period of not less than three years

before the date of the inquiry ; or
" (ii.) if there has been an outbreak of any epidemic,
endemic or infectious disease, during any less
period " ;

been in excess of the average expectation of sickness by
more than 10 per cent, and that such excess was in whole
or in part due to any of the causes enumerated, then the
extra expenditure incurred must be made good by the
employer or local authority or owner, lessee or occupier
of premises, or water company, found to have been
responsible.

For the purpose of this Section the average expectation
of sickness is to be calculated in accordance with the
tables prepared by the Insurance Commissioners for the
purposes of valuations, but neglecting excessive sickness
due to disease or injury in respect of which damages or
compensation are payable under the Employers' Liability

INSURANCE ACT : INSANITARY CONDITIONS 251

Act, or the Workmen's Compensation Act, or at Common
Law.

At first sight these provisions may appear very drastic
and far-reaching, but closer examination will show that
they are simply bristling with difficulties. At the moment
of writing, five years after the passing of the Insurance
Act, no steps have been taken to put them into force, and
it is exceedingly doubtful whether they ever could be put
into force. The great difficulty arises from the fact that
the sickness rates necessary to prove the allegation, must
be compiled in regard to a definite body of persons who
are subject to the influence or neglect complained of, such
as the employees of a particular factory, the occupants of
an area of bad housing, or the persons supplied with
drinking - water by a particular company or authority ;
whereas all our statistical information relating to sickness
is in terms of membership of Approved Societies, a large
number of which may be represented among the body of
persons in respect of which action is taken. There is no
relation between the sickness rates we possess or are
accumulating, and those required for the purposes of this
Section. Some examples may demonstrate the difficulties
arising.

Let us take what is probably the simplest case, that of
a factory where, say, 500 insured persons are employed ;
let us suppose that the allegation is made by an Approved
Society which considers that the provisions of some Public
Health Act are not being enforced in the factory; and
further, for the sake of simplicity, let us suppose that all
the 500 employees belong to one Approved Society. In
order that the allegation may be proved, the Society will
have to keep for three years a special record of the exact
numbers of its members in the factory, and their sickness
and age and sex constitution. But this number will vary
not only from year to year, but from month to month and
week to week with normal and abnormal periods of trade
activity or depression. Persons will drop out of insurance
on marriage, or for other reasons, or will fall into arrears ;
others will change their Society or go into other employ-
ment, or be lost sight of. Experience has shown that

252 HEALTH AND THE STATE

insured persons are not prompt in keeping their Societies
informed of changes of address, and whenever a general
notice is sent out by a Society or an Insurance Committee
a considerable proportion of the notices are returned
through the ' dead letter ' office. When the number has
been arrived at, and the aggregate sickness determined
after deducting sickness due to disease or injury in respect
of which damages, etc., are payable, it will still be neces-
sary to know the exact ages and sex constitution of the
employees in order to apply corrections for the natural
excess of sickness among elderly persons and women, for
the purpose of rendering the sickness rate comparable with
the average expectation of sickness. It is obvious that a
Society would find it exceedingly difficult to maintain the
close touch necessary to obtain a result within 10 per cent
of accuracy with a continually fluctuating group of its
members ; and when we add the fact that ordinarily the
500 employees will be distributed among a number of
Societies the difficulty of even the first step becomes almost
insuperable.

But let us suppose that such a rate has been deter-
mined, and that it is in excess of the average expectation
of sickness by more than 10 per cent. It is now necessary
to show that the excess was due, in whole or in part, to
neglect of the employer to enforce statutory provisions
relating to health in the factory. It would, however, be
almost impossible to separate the effect of any particular
adverse factor in the factory from other hostile influences
acting independently from the factory. In an industrial
town a large proportion of the employees may be badly
housed, overcrowded, inadequately treated when ill, and
living under defective conditions of sanitation. Inebriety
may be more than the average ; and it may be impossible to
disprove the assertion that the excess of sickness was due
to climatic conditions, an exceptionally hot summer or
severe winter. If in all other respects the operatives were
living under healthy conditions, the excess of sickness
among them might conceivably be attributed to conditions
in the factory ; or if these conditions were outrageously
bad, they might be held to outweigh other influences.

INSURANCE ACT : INSANITARY CONDITIONS 253

But in these days of factory inspection it is hardly con-
ceivable that such a state of affairs could continue for
three years. Breaches of the Factory Acts are usually
relatively small, and it is impossible to imagine that the
instances of neglect in the degree usually met with, such
as some insufficiency of cubic space, or inadequacy of
working arrangements or sanitary conveniences, could ever
produce the immense effect necessary to outweigh all the
adverse influences usually associated with industrialism.

Nor do these arguments by any means exhaust the
possible defences and replies open to an employer. It
might happen, for example, that a few cases in excess of
the average of a disease accompanied by long illness, such
as cancer, for which the employer could not be held re-
sponsible, might appreciably raise the average sickness
among the relatively small number of employees. If, to
take another illustration, it is hoped to avoid this difficulty
by applying the process to a much larger number of
persons, say some thousands of men employed in a mine,
then the difficulties previously described of keeping in
touch with this mine population for three years, deter-
mining their sickness rates, etc., are proportionately in-
creased.

Taking all these facts into consideration, it is safe to
say that no Society with its members scattered all over the
country is going to undertake the labour of collecting for
three years the evidence, and compiling the rates neces-
sary for a highly problematical result, at the best only
repaying them a proportion of the expenditure on sickness
and disablement benefit, which would probably cost less
to pay without question. The Section also provides that
where the excess of sickness is found to be due to an insuffi-
cient or contaminated water-supply, the local authority,
company, or person by whom the water is supplied must
pay the extra cost, unless it can be shown that the insuffi-
ciency or contamination arose from circumstances over
which they had no control. Let us imagine an allegation
against a water company supplying part of a large town.
In this instance the Society taking action must ascertain
the exact area of streets and houses supplied by the com-

254 HEALTH AND THE STATE

pany or authority, and the numbers, sickness, and details
as to sex and age of all its members who live in that area
— a practically impossible task. Having found that their
sickness rate is 10 per cent in excess of the average, they
must then prove that this sickness was due to the bad
water-supply, and they must be prepared to refute the
defence that the badness was due to circumstances over
which the company had no control. Both these involve
highly complex scientific questions which would entail
costly expenditure upon expert witnesses and counsel.

The Section however does not limit the right to make
allegations to an Approved Society, but empowers the
Insurance Commissioners or an Insurance Committee to
take action, the latter being only able to act on behalf of
deposit contributors, while the Insurance Commissioners
can act on behalf of any insured persons. Let us see what
this would involve if the Insurance Commissioners con-
templated taking action against an authority or employer
in regard to all the insured persons engaged in a particular
employment, or deriving their water-supply from a common
source, or living in an area of bad housing. Since there
are no general rates of sickness whatever in terms of
geographical or administrative areas, the Insurance Com-
missioners in order to establish the sickness rates on which
to proceed with their allegation would have to obtain from
every Approved Society which has members engaged in the
particular occupation, or supplied by the water-supply, or
living in the area of bad housing (which apparently the
Commissioners can define as they please), a return showing
for three years the number of these members, and the
sickness among them, and their ages and sexes ; and it
must obtain from the Insurance Committee or Committees
similar details in respect of deposit contributors. If the
number of persons selected for the process is small, then the
averages will not be reliable ; if the number is large, then
the Societies involved may amount to many hundreds.
The labour in compiling the sickness rates would be gigan-
tic, and by the time it was finished probably the whole
thing would be hopelessly out of date.

There is yet another difficulty. When the allegation

INSURANCE ACT : INSANITARY CONDITIONS 255

is made against a factory owner, a water company, or a
local authority, at least the person held to be responsible
is clearly defined. But when action is taken in regard to
an area of bad housing, the property impugned may be in
the hands of a number of owners, lessees, and occupiers,
and the responsibility may be partially shared by the
Local Authority. This opens up a prospect of endless
dispute and litigation, for even if it were proved that the
bad housing of the district were responsible generally for
the excess of sickness, it would be almost impossible to
apportion responsibility among individual owners, occu-
piers, and local authorities.

Apart from the hopeless complexity of the machinery
of this Section there is another condition which practically
nullifies its value for Public Health purposes. Excess of
sickness is to be determined by comparison with the
' average expectation of sickness,' which is to be calcu-
lated in accordance with tables prepared by the Insurance
Commissioners for the purpose of valuations. Presum-
ably an average expectation for each sex, and for each
year of age, will be determined for each of the four king-
doms. But the object of the Section is to detect excess-
ive sickness due to local causes, and for this purpose
the comparison should be between the group subjected to
this special cause of sickness and other persons living
under approximately the same conditions except as regards
the special cause. What is really required is an average
local sickness rate for every district. The comparison
with the rate for the whole country takes no note of broad
differences due to climatic conditions or general character
of the environment or occupation. In the agricultural
South of England the standard of comparison would be too
high ; in the industrial districts of the North it would be
inequitably low. In a rural town or district of Sussex
it might well happen that a local cause was appreciably
increasing the sickness rate among a group subjected to it,
above the sickness rate of the district, yet when the com-
parison is made between the sickness of the group and the
average expectation of the whole country, no excess may
be apparent, simply because the general conditions of the

256 HEALTH AND THE STATE

district are so healthy. On the other hand, in a crowded
mining or industrial town, the general sickness rate may
be constantly 10 per cent or more above the average
expectation of the whole country, owing to the aggregate
evils of industrialism, and it would be impossible to prove
that an individual manufacturer was responsible for the
excess in his particular mill. As the writer interprets the
Act, comparison cannot be made with local sickness rates
for the purposes of this Section ; but even if it could be,
the extreme difficulty of determining those rates remains.

The above paragraphs have analysed the leading
principles of Section 63. In detail the whole Section is
very vaguely drafted, and contains numerous words and
phrases, such as ' any public precautions,' ' any extra
expenditure,' ' period,' ' conditions or nature of work,' ' in
default,' ' insufficient,' ' contaminated,' ' payable,' etc. etc.,
which are not further defined, and would give rise to inter-
minable legal argument. These points are investigated in
National Insurance, by Messrs. Carr, Garnett, and Taylor.

Section 63 of the National Insurance Act was presum-
ably drafted in a Government Department, but it seems
impossible to believe that it was ever submitted for criticism
to any one with a knowledge of statistical requirements or
Public Health administration. It was debated at length
in Parliament, but there also no one pointed out its inherent
absurdity. This fantastic scheme seems to regard sickness
as something which can be measured in a pint-pot, and it
is based upon a mechanical conception of society which
assumes that human beings can be sorted, grouped, and
ticketed in a way that a shepherd would find difficult with
his flock. Unlike some Sections of the Act it has not led
to a great waste of money ; it has been, and will be, merely
a dead-letter, but none the less it illustrates the futility
of legislating on Public Health without consulting expert
opinion.

The Insurance Act and the Advancement of
Public Health Knowledge

One of the numerous advantages promised from the
Insurance Act was increase of knowledge relating to the

INSURANCE ACT : PUBLIC HEALTH 257

causes of disease. As far as purely scientific investigations
are concerned, there is good reason to hope that this
promise will be fulfilled. A Research Committee has been
set up, and provided with funds amounting to approxi-
mately £60,000 per annum. Investigators working under
the Committee have already published papers of value,
and during the War the Committee has been conducting
research in military hygiene. Although one of the least
costly, the establishment of this Committee may eventu-
ally prove to be one of the most valuable provisions of the
Act, though it may be pointed out that the Committee is
no part of the general insurance scheme, and could have
been appointed independently at any time of the long
period during which the need tor research has been becom-
ing steadily more urgent and more apparent.

But the Research Committee cannot build without
bricks, and it is not constituted to collect for itself the
immense mass of information relating to the causes and
distribution of sickness which is urgently required for
Public Health purposes. It is moreover quite clear that
the promoters of the Insurance Act intended that its
machinery should be used for the collection of data and
advancement of knowledge altogether independently of
the scientific investigations undertaken by the Research
Committee. Speaking in 1913, Mr. Lloyd George said : —

" To heal disease is good work ; to hinder it is best.
That will be the work of the Act. An official will go round
like an angel of light and ask, ' What is the matter ? ' ' What
can we do for you ? ' Their wants will be recorded. We
shall know what is happening, and, believe me, knowledge
is hope. That is what we are going to get from the Act.
And we will get it. It was worth you and myself taking
off our coats and facing opposition, misrepresentation,
calumny, and I thank you. We shall know something
about the causes of disease, bad housing, overcrowding,
bad industrial conditions, underfeeding, drink — we shall
know it all, all the evils that are sapping the vitality of
the race, depressing the energies of the people and destroy-
ing their lives. We shall know year by year more and
more, and as sufficient knowledge accumulates in the

s

258 HEALTH AND THE STATE

minds of all classes in this country of what is happening,
they will put an end to it whatever it costs." 1

We do not know what official Mr. Lloyd George had in
his mind as this celestial visitor, and it is not easy to
recognise an ' angel of light ' in either an insurance in-
spector or Approved Society agent, but it is certain that
no investigations of the kind indicated have been or are
being made. There are however two possible directions
in which the machinery of the Act might have been
employed in collecting information, viz. reports from
Insurance Committees, and records kept by the doctors ;
but not much can be expected from the first, and in regard
to the second the Insurance Commissioners have estab-
lished a system which completely defeats its object.

Section 60 of the Act places on an Insurance Committee
the following obligation : —

It shall make such reports as to the health of insured persons
within the county or county borough as the Insurance Commis-
sioners after consultation with the Local Government Board may
prescribe, and shall furnish to them such statistical and other
returns as they may require, and may make to them such other
reports on the health of such persons, and the conditions affecting
the same, and may make such suggestions with regard thereto as it
may think fit.

The Insurance Commissioners are then required to
send copies of these reports and suggestions to the
' councils of the counties, boroughs, and urban and rural
districts which appear to be affected.' The reports and
returns must ' enable an analysis and classification to be
made of the persons who are deposit contributors.'

Incidentally we may note the extreme degree of
centralisation and complexity of administration which this
system involves : Insurance Committees not communicat-
ing directly to the local authorities in their own district,
but reporting to the Insurance Commissioners, who then
send the reports back to the local authorities. Up to the
present the Insurance Commissioners have not prescribed
any reports, and Insurance Committees have done little

1 The Times, January 18, 1913.

INSURANCE ACT : PUBLIC HEALTH 259

on their own initiative, probably because their time is
so fully occupied with administrative details. It should
be observed however that Insurance Committees are to
make statistical returns, which alone possess scientific
value, and these returns must at least separate deposit
contributors. But at once the Committee encounters the
obstacle already described, viz. that while it exercises
authority over a defined geographical area, the records of
sickness among insured persons in that area are scattered
through innumerable offices of Approved Societies all over
the country. An Insurance Committee does not even
know within a considerable margin of error the number
of persons for whom it administers medical benefit. Thus
any reports it may make will either refer to small groups
about whom it can readily obtain information, such as the
inmates of a sanatorium ; or will be of a perfectly general
character, in which case they will be covering, for insured
persons, ground already covered much more fully for the
whole community of the district by the Medical Officer of
Health.

The greatest opportunity for the collecting of scientific
information lay in the medical records kept by the doctors.
One of the conditions attached to the extra Parliamentary
grant for medical benefit was that the doctors should keep
these records, solely for the advancement of medical know-
ledge. They are quite distinct from the sickness certifi-
cates, and are not required for any other purposes, financial
or administrative. The Commissioners seem however to
have failed entirely to understand the scientific object of
these records, and instead of seizing an excellent oppor-
tunity for adding to knowledge, they have devised a
system which, while giving the doctors considerable labour,
has not and will not yield results of the smallest scientific
value. They have required the doctors to keep a record
of every case which comes before them, and since the
great bulk of insurance patients are suffering from rela-
tively trivial affections, which often can only be defined
by reference to some prominent symptom, the result is a
mass of ill-defined entries without any information as to
the cause, treatment, or course of the case, which is

260 HEALTH AND THE STATE

utterly useless for scientific purposes.1 In an actual
record of 100 consecutive cases in an urban district,
'bronchitis' occurs 17 times, 'tonsillitis' 11 times,
' influenza ' 7, ' muscular rheumatism ' 5, ' nervous de-
bility ' 5, and ' general debility ' 4 times, while other
entries are ' anaemia,' ' constipation,' ' dyspepsia,' ' cephal-
algia,' ' inflamed glands,' ' ulcer of leg,' ' contused eye,'
' sprained ankle,' and ' septic hand.'

It does not require scientific training to realise that no
use could be made of a list of entries of this kind. It
might however be said that we could at least pick out from
the lists entries of graver diseases, such as cancer or tuber-
culosis, and use these as a basis for scientific investigation.
But herein, apart from the fact that no detailed informa-
tion is given, another difficulty presents itself, viz. that
the Commissioners have not prescribed any uniform
system of terminology to be used by the doctors. In the
Registrar-General's classification of the causes of death
an International List of diseases is employed, and medical
men are given instructions to avoid in death- certificates
various terms which are not clearly defined ; but nothing
of the sort has been prescribed in the insurance records.
With sickness, even more than mortality, it may be
possible to describe a given condition under one of several
headings, hence in attempting to collate the panel doctor's
records, serious error would arise owing to absence of
uniformity in terminology. The system is not only
wasteful and irritating, but is discouraging to those doctors
who are really interested in the scientific side of their
profession.2

Finally it may be noted that if, as appears to be the

1 These records are now kept on cards, but at first the Commissioners issued
an unwieldy and unworkable ' day-book,' which, after being distributed all over
the country, was withdrawn in a few weeks.

2 This effect is well expressed in the following extract from a letter written
by a panel practitioner : " I hope I am sufficiently public -spirited willingly to do
any reasonable work calculated to be of any real public or economic value, but the
keeping of this enormous mass of utterly useless information, which one knows
will never be used and never could be used because of its irrelevance, fills one with
a sense of profound depression and wasted energy. The time and effort wasted
over recording the occupation, age, sex, number, and society of every man and
woman who has a headache or a stomach-ache or a cut finger or a sleepy feeling in
the morning might be so much better spent either in attending to the patients'
ailments or in keeping real records of genuine value."

INSURANCE ACT : PUBLIC HEALTH 261

case, some 50 per cent of insured persons consult the
doctor in the course of the year, the total number of record
cards sent to the Commissioners at the end of the year will
amount to six or seven millions. When it is remembered
that the Registrar-General and his staff are only called
upon to deal with less than half- a- million death-certificates
in the course of the year, the immense labour involved
and the large staff necessary to collate the panel records
become apparent. Even if it be desired to deal only with
a single disease, every card must be examined to obtain a
record applicable to the whole country. Probably long
before the investigation was completed, the utter useless-
ness of the whole proceeding would have been realised
and the cards consigned to the waste-paper basket : yet
the Commissioners have inflicted substantial fines on
doctors for not sending in these worthless records. It is
impossible to believe that the Insurance Commissioners
obtained advice from any one possessing knowledge of
statistics or scientific medicine before they devised this
extraordinarily inept scheme.

We may note the opportunities the Commissioners have
lost. There are several conditions in regard to which
information is urgently needed, and the Commissioners
could have selected some of these conditions, and required
the doctors to furnish full details of them, their cause,
treatment, etc. (except names of patients), to the ex-
clusion of all else. Syphilis, for example, is a disease of
which our statistical knowledge is exceedingly scanty and
unreliable. The importance of collecting information
regarding the prevalence of this disease was emphasised
by the Committee on Physical Deterioration in 1904, and
subsequently in various reports of the Local Government
Board and at the International Congress of Medicine in
1913. We have really no accurate information of the
prevalence of this disease, and if the Commissioners had
required panel doctors to record every case of syphilis, with
details of its origin (congenital, acquired, marital infec-
tion, etc.), the treatment adopted, and the course of the
case, much useful information regarding active syphilis
among insured persons would have been available for the

262 HEALTH AND THE STATE

purposes of the recent Royal Commission on Venereal
Diseases. Another subject on which knowledge is re-
quired is the extent of abortion, natural or criminal ; we
are told that pre-natal loss of life is very heavy, and that
artificial methods of causing abortion are widespread and
increasing, but statements of the number of cases are
based upon little more than guess-work. Chronic lead-
poisoning might have been added to these two subjects.
-The Departmental Committee on the Use of Lead in
Painting of Buildings point out that there are no reliable
statistics relating to lead-poisoning, except among persons
who come under the Factory Acts ; and in their report,
issued after the Insurance Act had been in operation for
more than two years, they recommend that the machinery
of the Act should be used for collecting this information.
If a few conditions such as these had been selected for
recording, it would probably have been possible to obtain
the co-operation of the hospitals and thus increase the
value of the records. The conditions could be changed
from time to time, or different conditions examined in
different localities ; and if the Commissioners did not
possess among themselves sufficient knowledge of Public
Health science to determine what conditions should be pre-
scribed, they could presumably have obtained advice from
the Local Government Board or the Registrar-General.

If the Insurance Commissioners had focussed attention
upon these three subjects, the total amount of labour
demanded from the doctors in keeping records would have
been far less than that required at present ; the doctors
would have undertaken it willingly since they would have
appreciated its scientific and Public Health importance ;
and the knowledge gained would have been much greater
than anything likely to result from the present cumber-
some, inaccurate, and futile scheme.

Many other questions which have arisen under the
Insurance Act are not dealt with here since they do not
touch its larger Public Health aspects. Such are the
solvency or otherwise of the scheme ; the appalling com-
plexity of administration ; the difficulties regarding married

INSURANCE ACT : PUBLIC HEALTH 263

women ; the question of arrears, the regulations concern-
ing which extend to sixty-five sections ; the confusion of
the registers ; and the position of deposit contributors —
questions which have already entailed numerous com-
mittees and other forms of inquiry. In taking a broad
view, the advantages of the Act must not be minimised.
The weekly payments of sickness benefit have undoubtedly
helped many poor persons through a period of distress ;
maternity benefit has been a substantial boon to mothers ;
and disablement benefit has constituted a small pension
for incapacitated persons. But these benefits are all in
the nature of Poor Relief under another name, and they
do little to alter the conditions which bring about sickness.
As far as improvement of the Public Health is concerned,
the influence of the Act has probably been almost nil.
The medical service is no better than that which preceded
it, the main change being that a certain number of persons
who formerly went to infirmaries and hospital out-patient
departments now go to panel doctors ; sanatorium treat-
ment has proved of little value among the working classes ;
the provisions intended to deal with the evils of bad
housing and insanitary conditions are unworkable ; and
the schemes for collecting Public Health information are
futile, though the Research Committee will probably add
to our knowledge of scientific medicine. Nearly all classes
grumble at the Act, and though the panel practitioners
have benefited financially, the medical profession has been
split into two camps between which much bitterness exists.
The Act is unsound as a scheme of Insurance, since the
flat rate of contribution assumes an equality of risk which
does not exist ; the lower incidence of sickness in rural
districts making it in effect a tax on rural industries and
occupations, for the benefit of town- dwellers.

The root cause of the failures in the directions indicated
is from first to last the absence of expert knowledge among
the framers and administrators of the measure, and their
omission to obtain expert criticism of their proposals or
their disregard of this criticism when given. The Act was
based upon the shallowest knowledge of the results of a
similar measure in another country, where more thorough

264 HEALTH AND THE STATE

investigation would have shown that the effects upon
Public Health had been very small ; it was not subjected
to adequate examination during its passage through Par-
liament; and finally its administration in England was
entrusted to a body of persons who did not include in their
number any with special Public Health knowledge or
experience. The War has made the importance of
securing sound health among the people overwhelming.
To achieve this result immense efforts are required in
numerous directions. Continuation of the present system
will inevitably lead to further great mistakes and pouring
out of money in directions from which we shall get little
or no return. If real improvement is sought, the essential
first step is to place at the disposal of legislators and
administrators, when dealing with Public Health, that
assistance of science which is now so eagerly demanded in
the spheres of commerce, industry, and education.

CHAPTER VIII

PUBLIC HEALTH AND FRAUD

Adulteration of food — Unsound food — Conditions under which food is pre-
pared — Patent and proprietary foods — Patent and proprietary
medicines — Unqualified practice.

Adulteration of Food

Adulteration of food is a serious evil in this country,
but there is no means of measuring fully its injurious
effects. Unsound food may cause acute illness and even
death ; adulteration, however, is rarely so excessive as to
produce these results, but manifests its harmfulness chiefly
in dyspepsia, gastro-intestinal irritation, headache, etc.,
and, particularly among infants and children, in mal-
nutrition owing to the food not possessing the nutritive
value with which it is credited.

It is not easy to give a picture of the extent to which
adulteration is practised, since the detected instances only
represent a fraction of those which occur ; and because
Local Authorities, Medical Officers of Health, and In-
spectors of Foods find themselves obliged to allow many
forms of the evil to flourish unchecked, though perfectly
well aware of what is going on, owing to the faulty
machinery at their command for preventing these practices.
Sometimes it is the laxity or obscurity of the law which is
responsible, and at other times it is the impossibility of
securing the conviction of an offender before a particular
magistrate. The annual reports of the Local Government
Board contain much interesting information relating to
adulteration and contamination of food, and from these
most of the following statements concerning our principal
food-stuffs are taken.

265

266 HEALTH AND THE STATE

Milk. — The importance of a pure milk-supply needs
no emphasis. Milk forms, or should form, one of the
staple foods of all young children, while for infants it is
the best substitute — if a substitute is necessary — for
mother's milk. The ill-effects of cows' milk, sometimes
seen in infants, are probably most often due to the fact
that the milk has been adulterated, contaminated with
dirt, or infected with micro-organisms. For infants whose
mothers are unable to feed them naturally, a supply of
pure cows' milk is of the greatest importance.

During the year 1913, in England and Wales, 52,304
samples of milk were analysed under the Sale of Food and
Drugs Acts, and of these, 5533, or more than 10 per cent,
were found to have been adulterated or were not up to
the minimum standard fixed by the Regulations. The
adulteration of milk by the addition of water is now giving
way to a more ingenious process less liable to detection,
which is termed ' toning.' This consists in adding to
pure milk the separated milk remaining after the fat has
been extracted for the manufacture of butter or cream,
which would otherwise be a waste product or perhaps be
used in country districts for feeding pigs. The increase
of toning in London during recent years is reflected in the
statistics relating to milk adulteration. Up to 1907 the
rate of adulteration was always higher, and often a great
deal higher, in London than in the provinces ; but since
that date the position has been reversed, and the adultera-
tion returns in the metropolis have declined by 35 per
cent in recent years. The Local Government Board how-
ever points out that control of the milk sent to London
has passed more and more into the hands of middlemen
and large companies, who are well aware of the quality of
milk demanded by the Regulations, and are in a position
to tone it down or standardise it by the addition of separ-
ated milk before it is distributed to the retailers. Thus
there is little scope for milkmen to dilute the milk further.
Adulteration is the same, but it is effected by few persons
instead of many, and thus the number of convictions
declines. The Board says : " We understand that as a fact
" toning or standardising milk is regularly practised in

ADULTERATION OF FOOD 267

" certain quarters, and that this is done with skill and
" precision, so that official limits are seldom passed. It is
" most difficult under the present law to bring home any
" offence to the scientific ' toner.' Whatever may be the
" explanation of the difference in recent years between
" London and the provinces, it is open to doubt whether
" the decrease reported in the rate of London milk adultera-
" tion is accompanied by any corresponding increase in the
" quality of the milk- supply."

In the provinces the percentage of milk adulteration
in samples taken has risen from 9'5 during the period of
years 1899-1903, to 113 during the period 1909-13.

Facts such as these illustrate the extreme difficulty of
circumventing the wiles of dishonest milk-vendors. In
spite of all our Acts of Parliament, regulations, and inspec-
tions, adulteration of milk is increasing in the provinces,
and its apparent decline in London is accompanied by a
supply of inferior quality. There seems nothing to prevent
the practice of toning spreading all over England, so that
ultimately, in towns at least, it may be impossible to get
anything but the poorest quality of milk.

Apart from the addition of separated milk or water,
milk may be adulterated by adding to it boric acid, form-
aldehyde, glycerine, sodium nitrite, and colouring matter.

It is very interesting to trace the subsequent history of
the 5533 samples of milk mentioned above as having been
reported against during the year. In only 2418 instances
were criminal proceedings taken by Local Authorities, and
convictions were secured in 1767 cases, with penalties
amounting in the aggregate to £4136. There were 256
fines of £5 each and upwards, fifty-three being of £10 each,
fifteen between £10 and £20, nine of £20 each, four of £25,
four of £30, seven of £50, and two of £100. It will be seen
therefore that even if an offence is detected, the chances are
still nearly three to one against a conviction being secured.
Moreover the bulk of the fines are so small that dishonest
vendors find it profitable to continue their practices and
pay any penalties they may incur. Reporting on a
milk company formed to take over the ' business of a
previous company ' which had been convicted more than

268 HEALTH AND THE STATE

twenty times, the Middlesex Health Committee states
that the new company had to be prosecuted during the
year and was fined £70. The report continues : " It is
expected that this company will shortly be succeeded in
its turn by another, which will then be able if necessary
to come before the Courts with a clean record." In
another instance a company which had been fined £50
immediately dissolved in order to avoid payment of the
penalty.

Besides deliberate adulteration, milk is liable to be
contaminated with dirt or infected with micro-organisms
at various stages in its passage from the cow to the con-
sumer. The milker may be dirty in his person or his
habits, the pails and cans may be imperfectly cleaned, and
the milk may be polluted in transit or while stored in in-
sanitary premises or exposed for sale in shops. Something
like 10 per cent of the samples of milk examined are found
to contain the bacilli of tuberculosis, and it is recognised
that this is a contributory cause of abdominal tuberculosis
in children.

The final result is that the milk supplied to a large
proportion of children in the poorer quarters of towns is
a weak, dirty, and dangerous fluid. The law is inadequate
to prevent adulteration ; Local Authorities have in-
sufficient control over cowsheds, dairies, and dairymen ;
and the fines for adulteration inflicted by magistrates are
disproportionately small. It is doubtful whether any
remedy will be found for these evils, until some system of
control over the milk-supply is established, analogous to
that which governs the supply of water by Municipalities.
Local Authorities could then own their cows and be held
responsible for the cleanliness and transit of the milk from
start to finish.

Cream has an even worse record than milk. Under
the Public Health (Milk and Cream) Eegulations, cream
which is sold as ' cream ' and not as ' preserved cream '
must not contain any preservative ; but of 1026 samples
described only as ' cream ' which were analysed in 1913, no
less than 410 were found to contain a preservative which
consisted of boric acid in all but four samples, in which

ADULTERATION OF FOOD 269

it was a fluoride. Again it is interesting to note the sub-
sequent history. The Regulations provide that before the
Local Authority institutes legal proceedings, it shall afford
the person implicated an opportunity of explaining the
circumstances. This procedure was followed in 263 cases,
and in 239 the Authority accepted the explanation, but
administered a caution in most instances. In regard to
143 cases, in which ' cream ' had been found to contain
boric acid, no action was taken, chiefly because the
samples had been purchased without the prescribed
formalities. Legal proceedings were instituted in twenty-
four instances. In five cases the magistrates dismissed
the summonses, in twelve they were withdrawn, and in
only seven cases were convictions obtained with fines
ranging from Is. to £5.

Butter. — The samples of butter examined during the
year numbered 21,932, and of these, 1131, or 5'2 per cent,
were condemned. In the majority of cases margarine had
been substituted for butter ; in other instances there was
an excess of water, or a preservative consisting of boric
acid, sodium fluoride, or sugar had been added. Besides
the samples condemned, there were 6866 other samples
which, though passed as genuine by the analysts, contained
boric acid. In all, over 33 per cent of butter samples con-
tained preservatives. Sometimes when proceedings are
taken before a magistrate for adding boric acid to food,
evidence is brought to show that the small amount present
would not be harmful Medical opinion by no means
accepts this as established ; but even if it were so, it must
not be forgotten that boric acid is added to so many
varieties of food that the total amount consumed may be
considerable.

Margarine appears to be less subject to adulteration
than butter. An ingenious method of substitution is to
fill the centre of a roll of butter with margarine, the sample
cut off from the end by the inspector being then found to
be genuine. Incidentally it may be noted that up to
1913 the Board of Agriculture had approved of 1831 names
for margarine and 44 for mixtures of butter with milk.

Other articles of food which are frequently adulterated

270 HEALTH AND THE STATE

are flour, coffee, cocoa, sugar, confectionery, jam, rice,
sago, potted meat and fish, and sausages. Of a total of
108,157 samples analysed in 1913, the number found to
have been adulterated was 8860, or 8*2 per cent. The cunning
of dishonest traders is illustrated by their practice, now well
known to Medical Officers of Health, of selling only genuine
articles to a stranger lest he may be a food inspector.
This is continued until the purchaser is regarded as an
ordinary regular customer, when an adulterated article
will be supplied again and again. The reports of the
Local Government Board every year describe numerous
instances of fraudulent practices, but they never mention
the names of persons convicted. This has an appearance
of unnecessary concern for the protection of dishonest
traders, and the establishment of a ' black list ' might be
a deterrent step. Medical Officers of Health have already
adopted this course in certain localities.

The Sale of Food and Drugs Act, under which proceed-
ings for adulteration are usually taken, prohibits the sale
of any article of food to the prejudice of the purchaser
which is not of the ' nature, substance, and quality de-
manded.' These words have formed a fruitful source of
legal argument, and their vagueness has enabled many an
offender to escape the consequences of his dishonesty.
Except for milk, cream, and butter no standards in regard
to the nature or quality of foods are laid down by any
Acts of Parliament or regulations ; and no Authority has
power to prescribe standards or to state what a food should
or should not contain. When criminal proceedings are
taken, expert witnesses may be called by each side, scientific
evidence is given, and the Bench of Justices or Stipendiary
Magistrate, without any power to summon an assessor and
usually without expert knowledge themselves, must come
to a decision on matters involving an intimate knowledge
of chemistry, physiology, and hygiene. The result is that
practice varies from place to place, one Bench convicting
where another would dismiss the charge, and decisions are
given, some of which are not in the interests of Public
Health, though we must assume them to be sound law.
It has been held, for instance, that a mixture of cocoa

UNSOUND FOOD 271

containing 18 per cent of the husk or shell of the cocoa nib
is of the ' nature, substance, and quality ' demanded
when ' cocoa ' is asked for, and may be sold under that
name.

The uncertainty of magisterial decisions reacts upon
the food inspectors, who cease to take samples when they
know it will be almost impossible to obtain a conviction
for an offence. Mr. R. A. Robinson, the inspector under
the Food and Drugs Acts for Middlesex, writes : " There
are at the present time practically only two articles of
food (milk and butter) which are to any serious extent
adulterated in such a way as to make it reasonably possible
to institute proceedings successfully. ... I do not feel,
save in very exceptional cases, that I can usefully advise
proceedings to be instituted in respect of any of the follow-
ing among a host of other articles — cream, vinegar, jams,
golden syrup, treacle, aerated waters, rice, preserved
vegetables, tinned fruits, chocolate, lime juice, sausages,
potted meats, wines, and various drugs." *

Unsound Food

Apart from adulteration, food may be unfit for human
consumption from the presence of disease in the animal,
or from decomposition, the danger attending the latter
being far greater with animal than vegetable food.
Diseased or unsound meat may be seized by a Medical
Officer of Health or Sanitary Inspector when exposed for
sale or deposited in any place for the purpose of sale, and
the meat is then submitted to a magistrate, who has power
to order its destruction. In many districts where the
inspectors are vigilant, their powers seem to be sufficient
to prevent the sale of unsound meat, but in this matter
also, different standards of meat inspection exist in con-
tiguous districts and give rise to many anomalies. The
Local Government Board has repeatedly called attention
to the need of a uniform system throughout the country.
One effect of the differences in standard is that diseased
animals or unsound meat are transferred from districts

1 Transactions of Medico-Legal Society, vol. vii.

272 HEALTH AND THE STATE

where inspection is severe to districts where it is lax, and
sold therein. The following example of this practice is
quoted from a medical officer's annual report in the Local
Government Board Report for 1913-14 : —

I received information that a beast which was very emaciated
had been slaughtered on unlicensed premises early in the morning
and was being conveyed into the town. As my information was
very imperfect, I had some difficulty in tracing the matter. After
instituting inquiries I visited some stables but found them locked.
The occupier, who saw me enter the yard, had disappeared when I
came out to require admission to the stables. I accordingly set a
trap for him, and as a result I found him gliding in a lane near.
Upon seeing me he ran away. I caught him, and on gaining ad-
mission to the stables I found the hide, but not the carcase. The
occupier, in reply to my question, said it had gone to the knacker's
yard. To satisfy myself that the carcase had not gone for human
food, I proceeded to the only two yards within some miles of the
town and found that this information was untrue. A few days
later I received information from which there was very little doubt
that the carcase had gone for human food to a district a few miles
away, and it is very probable that the carcase was affected with
some organic disease.

The difficulties of dealing with this illicit meat traffic are very
great, and necessitate long watching of the class of persons who
deal in ' slink ' meat.

The reports of the Local Government Board contain
numerous examples of the trade in unsound meat on a
large scale. A co-operative society was found to be in
possession of nearly 1| tons of offensively- smelling and
tainted meat on premises where the manufacture of
sausages was proceeding. The evidence revealed a par-
ticularly disgusting condition of things, and the magistrates
inflicted a fine of £20, with £10 : 10s. costs. A meat- vendor
who sold unsound meat habitually was warned by the
Sanitary Authority. The warning did not however act
as a deterrent ; he was again detected in the act of selling
such meat to different customers, and on proceedings being
taken was fined £15 and £2 : 2s. costs. The Local Govern-
ment Board speaks of this as a ' substantial ' penalty,
but the consumers of the meat might take a different view ;
they might think that a term of imprisonment would not
have been amiss, and they might ask why the offender

UNSOUND FOOD 273

was permitted to escape in the earlier instances simply
with k' a warning."

When we recall that during the War one of the largest
firms of caterers in the country has been fined the maxi-
mum amount for supplying unsound meat to the troops,
the magistrate expressing the opinion that the negligence
involved not only the employees, but also the managers
of the firm; and that another large company was fined
the maximum amount for supplying adulterated butter
to troops, we see that patriotism weighs as little with
dishonest traders as concern for Public Health.

Meat is not the only article over which it is necessary
to exercise vigilance. A manufacturer for instance was
found deliberately using unsound jam, fat, and other
articles in the preparation of confectionery. He is
described as a ' wholesale and retail baker in a large way
of business,' and was fined £15 and £2 : 2s. costs.

When unsound food is submitted to a magistrate, the
question for determination is whether it is fit for human
consumption or not. Usually magistrates recognise the
danger of unsound food and take a severe view of offences.
Sometimes, however, their decisions are contrary to expert
opinion and opposed to the public interest, an interesting
example of which has been described in a circular issued
by the Medical Officer of Health for Bermondsey. In
June 1915 the Wharves and Food Inspector found eighty-
two casks of imported butter rancid and unfit for human
consumption. This opinion was confirmed by the Medical
Officer of Health and the Public Analyst, who had found
3*16 per cent of free fatty acids present, the normal amount
in fresh butter being well under '5 per cent. A prosecu-
tion was instituted, and for the defence it was urged that,
while the butter was not fit to be sold over the counter, it
could be used for making cakes and confectionery, in which
its rancid taste and smell would be disguised by other
flavourings. After examining the butter the magistrate
decided that it was fit for human consumption, and the
casks were released.

It appears, therefore, that while a vendor may be
summoned for having 1 per cent of water in his butter

T

274 HEALTH AND THE STATE

above the prescribed standard, he may have more than
3 per cent of free fatty acids without committing an
offence. The Medical Officer of Health for Bermondsey
has declared that the War Office, Boards of Guardians,
and other public authorities would refuse to accept such
butter ; and only the general public fails to secure protection
against food- stuffs made of impure or unsound materials
whose rottenness is concealed by other flavourings.

A case described in the report of the Local Government
Board for Scotland for 1914 illustrates another way in
which legal decisions may be opposed to the public interests.
The carcase of a cow killed in the public slaughter-house
of a burgh in the north of Scotland was found to be tuber-
culous throughout. The veterinary surgeon condemned
it, the owner of the carcase admitted that it was the
' worst case of the kind ' he had ever seen, and orders
were given that it should be buried. Nevertheless the
owner removed the meat from the slaughter-house and
distributed it in various directions throughout the com-
munity. After legal proceedings involving the butcher,
the veterinary surgeon, the Town Clerk, the Chief Con-
stable, the Local Authority, and the Procurator-Fiscal,
the matter was eventually referred to the Crown Office,
who gave their opinion that there was a reasonable chance
of securing a conviction against the butcher for obstruct-
ing the Local Authority or Sanitary Inspector from carry-
ing out their duties. Accordingly a prosecution was
instituted by the Procurator-Fiscal in the Sheriff Court,
where it was decided that removal of portions of a carcase
while it was only liable to be seized and had not been
actually carried away, did not amount to obstruction in
terms of Section 163 of the Public Health Act.

A pleasing practice described in the same report is
that of ' blowing ' meat, which was formerly done by the
mouth, but is now effected by a machine. Air is blown
into the tissues which gives a false appearance of plump-
ness to the meat. Besides being a direct fraud, the
practice alters the appearance of the meat so as to increase
the difficulty of detecting disease, and increases the danger
of contamination by dirt, dust, and micro-organisms.

FOOD PREPARATION 275

Conditions under which Food is prepared

The work of the Local Government Board in con-
nection with inspection of food to be used by troops has
brought to light another weakness in the scheme for pro-
tecting the food of the community. Under ordinary
circumstances the power of Sanitary Authorities to inspect
and control the conditions under which food is prepared
is very limited. The War Office however when making
contracts for the supply of food, requires that the food
shall be prepared under hygienic conditions ; and this
stipulation has given the food inspectors opportunities
of observing conditions which were previously denied to
them. Wlule, speaking generally, the quality of the
materials used in the preparation of food for the troops
has been found to be good, the inspectors have had on
many occasions to take exception to the conditions under
which it was being prepared. To quote the Local Govern-
ment Board Report : " While the conditions found in some
6 of the principal food-preparing places concerned were
' quite satisfactory, many instances have been met with in
1 which manufacturers have not seen or appreciated the
' necessity of observing ordinary rules of cleanliness in all
6 operations connected with food preparation. It has
' been quite common to find foods being prepared in rooms
' littered with dirty rubbish, benches frequently have been
' dirty and loaded with grease, and floors and walls cracked
'- and uneven, thus harbouring dirt. The state of personal
c cleanliness of the workers, also, frequently has left much
' to be desired. Aprons and overalls, if worn at all, were
' often filthy, and in some instances old and dirty sacking
' was considered good enough for the work-people to wear
' over their own clothes. ... As has already been indi-
' cated, action in such cases has been possible only through
' officials being in position to enforce War Office require-
' ments, and it is to be feared that the improved standards
' of cleanliness which have been secured will not be main-
' tained by many of the firms when they are no longer
' engaged on War Department work."

If these were the conditions found in the premises of

276 HEALTH AND THE STATE

firms which had agreed to observe hygienic surroundings,
and knew they were liable to inspection, it may be inferred
that the conditions are worse in places for preparing food
which are not under stipulation or control. The probability
is that if we could see the dirt and adulterants in much of
our food, there is very little that we should care to eat. Let
any one who buys a glass of milk in a tea-shop imagine
what it would look like if it had been water, and had gone
through the processes and journeyings through which the
milk has passed. Part of this is due, as the Local Govern-
ment Board points out, to sheer ignorance of what constitute
cleanly conditions. The shopkeeper takes care to protect
dainty fabrics from dust and dirt by keeping them behind
glass windows, but it is common to see butter, ham, and
other articles of food intended to be eaten as they are,
quite uncovered in shops which are anything but clean,
or even exposed for sale outside in crowded and dirty
streets, where particles from horse droppings and other filth
in the roads may be blown upon them by every gust of
wind. The costers' barrows, with their plates of shell-fish,
or slushy mess sometimes termed * fresh -picked straw-
berries,' are even worse. Inside some of the best shops
and large stores we find pastries and sweets laid out on a
counter by the side of which a throng of customers con-
tinually passes. These conditions are not necessary, but
so far as the writer knows there is only one large shop in
London which keeps and displays its food-stuffs under
really hygienic conditions. We hear a great deal now-
adays about the necessity of educating mothers, but it is
certain that some of this effort might with advantage be
directed towards educating not only vendors of food-stuffs
but also the general public, who are apparently quite
satisfied to have their food prepared and sold under the
conditions described.

Patent and Proprietary Foods

These widely -sold foods are objectionable mainly in
consequence of the extravagant claims which are made for
their value, and their unsuitability for the purposes for

PATENT AND PROPRIETARY FOODS 277

which they are advertised. Artificial foods for infants are
probably the most pernicious. As shown by the analyses
made by Mr. Julian Baker and Dr. Coutts for the Local
Government Board,1 a large proportion of these foods
contain high percentages of starch ; in many the starch
exists in practically an unchanged condition ; and the
majority contain a very low percentage of fats. Such
foods are unsuitable for young infants, and may cause
serious illness ; nevertheless they are boomed by advertise-
ments which are often little short of fraudulent. Pictures
of Gargantuan babies fed on the food are pasted on the
hoardings, and mothers are assured that only by taking
the food will their children thrive. Condensed milks, con-
taining a large proportion of cane-sugar and very little fat,
are belauded to credulous women as entirely satisfactory
substitutes for mothers' milk. Thus, while Public Health
and Education Authorities are doing all they can to
encourage breast-feeding, vendors of infants' foods and
milks are allowed largely to nullify these efforts by spread-
ing broadcast their unwarranted claims. In France, the
Roussel law prohibits the administration of any solid food
to infants under the age of twelve months without the
express direction of a medical man. In Australia a
regulation is general which demands that starch-containing
foods shall bear a label with the words, ' Not suitable for
infants under the age of six months ' ; but in this country
no such safeguards exist.2

A further objection to these foods is their cost, which
is generally out of all proportion to their value, a packet
containing perhaps two pennyworth of flour being sold
for a shilling or more. The poor are thus paying for the
excessive advertising, with money which might be much
better spent in buying natural food.

Of proprietary foods for adults, probably those which
are pushed with the most misleading statements are
various meat extracts, often advertised with pictures of
lusty oxen or Highland cattle. These substances consist

1 Food Report*, No. 20.

2 See " Proprietary Foods in Infant Feeding," by Hector Charles Cameron,
M.D., Brit. Med. Journ., Aug. 21, 1915.

278 HEALTH AND THE STATE

of the salts, flavouring material, etc., of meat, but do not
contain any meat fibre, albumin, or fat, though in some
preparations small quantities of these are added to give
the extract a certain food value. When made into solution
with warm water they serve on appropriate occasions as
useful stimulants, and perhaps do some good by lessening
the sale of alcohol, but their food value is very small, and
they produce neither heat nor energy. Nevertheless the
public are led to believe that they are valuable and sus-
taining foods ; and during recent months they have been
widely advertised as enabling munition workers to endure
heavy toil, and as the best present for soldiers in the
trenches.

No one would propose to prevent the trade in pro-
prietary foods, but there seems little reason why advertise-
ments of such foods should not be submitted before
publication to a central Public Health authority, which
should have power to delete any claims not in accordance
with fact.

Patent and Proprietary Medicines

The whole question of the sale of patent and proprietary
medicines has recently been investigated exhaustively by
a Select Committee which issued its report in 1914, a
report which is probably unequalled among Government
publications as an exposure of commercial fraud, legisla-
tive muddle, and shameless exploitation of credulity and
ignorance.

The trade in proprietary remedies is very large and
increasing, the receipts for medicine stamp duty having
risen from £327,857 in 1912, and £328,319 in 1913, to
£360,377 in 1914, a much larger increase than in any
previous year, which suggests that the Insurance Act,
owing to the importance attached in that measure to
drugs, has actually stimulated the trade, despite the fact
that insured persons now get medicines free from the
doctors. The number of medicine duty stamps issued
during the year ending March 31, 1914, was 44,427,166,
estimated to represent sales exceeding the value of

PATENT AND PROPRIETARY MEDICINES 279

£3,200,000, and this is exclusive of large classes of medi-
cines which, for various reasons, are not required to pay
duty. Figures for individual businesses indicate the
magnitude of the trade. The daily sale of a well-known
pill amounts to more than a million ; the proprietors of a
certain syrup pay upwards of £40,000 a year in wages
only ; and several owners of much- advertised remedies
have left fortunes exceeding £1,000,000. Enormous sums
are spent on advertising. The proprietors of a ' medicated '
wine spend £50,000 a year for this purpose, and a well-
known swindler, now deceased, is believed to have spent
£20,000 a year in advertising an alcohol cure. The London
Chamber of Commerce estimates that £2,000,000 is spent
annually in this country on advertisements of proprietary
medicines.

The sale of secret remedies undoubtedly constitutes a
grave and widespread public evil. Some of them contain
powerful and dangerous drugs, which should only be taken
on a doctor's prescription, and the so-called ' soothing
powders ' may be particularly harmful to children. A
much larger number, however, contain some common drug,
very frequently a purgative, with colouring and flavour-
ing agents; or consist of dilute solutions of substances
possessing no medicinal value — at least in the amounts
given — such as glycerine, citric acid, sulphurous acid, and
sodium bicarbonate, flavoured with capsicum, pepper-
mint, cinnamon, etc. These are sold with grossly fraudu-
lent claims of their power of curing disease, at prices which
are often several hundred times the cost of manufacture.
Cures for consumption, diabetes, paralysis, locomotor
ataxy, Bright's disease, lupus, fits, epilepsy, rupture, deaf-
ness, diseases of the eye are advertised with stories of the
discovery of a rare root in Central Africa, or of a philan-
thropic clergyman who was profoundly impressed by the
death of his young wife, etc. A " well-known London
surgeon " promises a cure for cancer by natural means
without operation, and supports his claim by testimony
" from medical men in all parts of the world." Advertise-
ments are accompanied by garbled extracts from the
writings of deceased physicians of eminence, and by

280 HEALTH AND THE STATE

testimonials from persons in all ranks of society, many of
which are quite genuine, but have clearly emanated from
those unable to distinguish between post hoc and propter
hoc. Sometimes puffs are inserted in the ordinary columns
of the journals as items of interesting news. The result
is that many thousands of ignorant persons buy these
remedies when ill ; and if suffering from a serious disease,
may postpone seeking skilled medical advice until grave
harm has been done or a fatal termination is in-
evitable. Persons with early tuberculosis have recourse
to ' lung tonics,' and many a woman suffering from cancer
of the breast has allowed the opportunity for a permanent
cure to pass, while she has been applying inert ointments,
or causing ulceration by using a caustic paste to destroy
the ' roots ' of the growth. The habit of taking drugs
becomes established, and many persons continually pur-
chase ' blood purifiers,' ' uric acid solvents,' ' kidney
pills,' ' headache cures,' and other nostrums. The waste
of money in the purchase of these drugs by the working
classes is very large. An inquiry made in 1909-1911 by
the Board of Trade into the weekly personal expenditure
of a number of wage-earning women and girls, showed
that more than five times as much was paid to chemists
as to doctors. The condition and complaints of these
girls are indicated by the titles of the drugs purchased.
' Blaud's pills,' ' soda - mint tablets,' ' throat pastilles,'
and ' camphorated oil ' occur again and again, and tell
a weary tale of struggle against ill-health.

A particularly pernicious form is the sale of prepara-
tions purporting to produce abortion. These are largely
advertised, for some curious reason or other, in some of
the Sunday journals, with statements which but thinly
disguise their object. They are warranted to remove the
" most stubborn cases of obstruction and irregularity,"
and are a " safe, certain, and speedy remedy," but are
" on no account to be taken by ladies wishing to become
mothers." Sometimes the revenue stamp which must be
affixed to the box is cunningly represented as a guarantee :
" My female specifics are Government stamped, without
which they are a forgery." Such preparations are sold

PATENT AND PKOPKIETARY MEDICINES 281

in various ' strengths,' the ' extra strong ' running up
to 20s. a box, but the difference in the qualities does not
extend farther than the label and the price. Most of
these substances are inert and harmless, but some of them
contain powerful drugs or strong purgatives which, if
taken in large quantities, may cause serious illness. During
recent years the practice of taking pills made of diachylon
plaster or other compounds of lead has become frequent,
and has led to numerous grave and even fatal cases of
chronic lead-poisoning. The practice originated in the
Midlands, and is now spreading to other parts of the
country. The knowledge is conveyed from mother to
mother, and some midwives of an inferior type appear
also to be responsible. Many of the women who take these
preparations are unaware of their dangerous properties,
or even of the fact that they contain lead.

Mischief is also done by the sale of ' medicated ' wines,
many of which contain from 15 to 20 per cent or more of
alcohol, and can be readily purchased from chemists and
grocers. The report of the Select Committee says :
" There can be no doubt that many persons acquire the
" ' drink habit ' by taking these wines and preparations,
" either knowing that they are alcoholic, since they can be
" purchased and consumed without giving rise to a charge
" of ' drinking,' or in ignorance that they are highly in-
" toxicating liquors." Some of these preparations are not
even called wine, such names as ' liquid peptonoids,' or
' nutritive elixir,' concealing all suggestion of the fact
that they contain alcohol.1 A trifling amount of meat
extract is added to some wines, which are then claimed to
be nutritive. One well-known preparation is advertised
as giving " a strength that is lasting because in each wine-
glassful there is a standard amount of nutriment," and
another is described as " the world's greatest tonic, restora-
tive blood-maker, and nerve food." The pictures of
languid invalids reclining on couches while doctor or
nurse hands them a glass of one of these alcoholic concoc-
tions are among the most objectionable of advertisements.

1 Quite recent regulations now require the amount of alcohol in patent prepara-
tions, etc., to be stated on the label.

282 HEALTH AND THE STATE

Some medicated wines contain cocaine, and there is
reason to believe that the habit of taking this drug, which
had recently assumed serious proportions in Paris, is now
increasing in this country.

Great difficulty exists in exposing to the public the
fraudulence of this trade, owing to the reluctance of the
newspapers to publish anything which reflects on the value
or efficiency of secret remedies. It is estimated that
a sum of more than £2,000,000 a year is spent upon adver-
tisements in the Press, and most newspapers draw a
considerable proportion of their income from this source,
while a number of small provincial newspapers probably
could not exist without their advertisements of secret
remedies. The Select Committee point out that when the
British Medical Association issued its volume entitled
Secret Remedies, containing analyses, costs, etc., of a large
number of proprietary medicines, not only was the volume
not noticed editorially by most papers, but even advertise-
ments were declined by many journals, some of them of
the highest class. They also say : "A trial in Edinburgh,
" in the course of which the judge described the business of
" the proprietors of ' Bile Beans ' as based on unblushing
" falsehood for the purpose of defrauding the public, was,
" we were informed, with few exceptions not reported in
" the Press, and the remedy still has a considerable sale."
Even the medical Press is not entirely free from blame ;
and one medical journal, which claims to have a con-
siderable circulation though it would not be recognised
as one of the leading organs, mixes with its letterpress
scarcely distinguishable puffs of patent medicines and
illustrations of appliances to prevent conception.

The law relating to the sale of patent and proprietary
medicines and its administration are described by the
Select Committee as ' chaotic' The Statutes begin from
1804, and are numerous, overlapping, and sometimes in-
consistent ; the administration touches the Privy Council,
the Home Office, the Local Government Board, the Patent
Office, and the Board of Customs and Excise. Many
curious anomalies exist. ' Cough mixture,' ' liver tonic,'
and ' headache powder ' are dutiable, but ' chest mix-

UNQUALIFIED PRACTICE 283

ture,' ' liver mixture ' and ' head powder ' are not.
Smelling-salts pay duty, but asthma cigarettes do not.
Identically the same substance is sold under a great
variety of names, but if asked for under one name the
chemist may not sell it under another. Almost the whole
of this mass of law and administration exists, not for the
purpose of protecting the public, but for the object of
adding a relatively small sum to the revenue. There is
no Department of State nor public officer charged with
the duty of controlling the sale and advertisement of
secret remedies in the interests of Public Health ; the
Home Office and the Local Government Board are virtu-
ally powerless in this respect ; and the powers of the
Privy Council are practically restricted to scheduling
powerful poisons.

The Select Committee on Patent Medicines considered
that legislation was urgently needed, and made a number
of recommendations, which included control of the sale of
patent and secret medicines by a Ministry of Health when
that should be created, and meanwhile by the Local
Government Board. The outbreak of war is perhaps
sufficient reason why no action has been taken, but as the
question pertains to no special Department, it will prob-
ably provide another instance of those matters which are
put aside year after year, simply because it is no one's
business to be concerned with them.

Unqualified Practice

In this country any person, however ignorant, may
undertake the treatment of disease. The law of medical
registration does not do, and does not purport to do,
more than provide a means whereby the public can dis-
tinguish between persons professing medicine who are
registered and recognised by law in virtue of their having
undergone a specified medical training and passed certain
examinations, and others who have had no such training
or examination. Medical treatment is far older than
medical law, and it is not probable that the community
will ever restrict the practice of medicine exclusively to a

284 HEALTH AND THE STATE

professional class. Nor, indeed, would the medical pro-
fession ask for this ; medicine has still much to discover ;
and doctors are not infallible, and they would not be
justified in demanding that the sick should be prohibited
from seeking assistance from any but those who have
gone through the prescribed training. But while practice
by unregistered persons must be permitted, there is no
reason why it should be associated with grave abuses.
The community is justified in taking steps to protect the
ignorant and credulous from false claims and fraudulent
practices of unregistered persons ; while the doctors are
entitled to ask that the distinction which the law has
sought to make should be real, that their titles should not
be usurped by unregistered persons, and that only registered
doctors should be recognised by the State for official
purposes.

The Medical Act of 1858, which governs the use of
medical titles, prohibits a person from wilfully and falsely
using the title of Physician, Surgeon, etc., or any title or
description implying that he is registered under this Act or
that he is recognised by law as a Physician, Surgeon, etc.
At first sight this section would appear to afford ample
protection to registered medical men, but the words in
italics have given rise to much dispute, and successive
legal decisions have so reduced their application that now
the spirit of the section, if not the letter, may be violated
with impunity. Any person may call himself ' doctor,'
since this has been held not to imply that he is registered ;
and may publish circulars and advertisements relating to
medical matters, from which the public is clearly intended
to infer that he is a doctor of medicine. ' Dr.' Macaura,
* Dr.' Bodie, and ' Dr.' Crippen afford instances of the
use of this title. And with regard to the use of letters
after the name, while ' M.D.' alone is held to be an in-
fringement of the Act, any one may add ' M.D., U.S.A.,'
though if this is meant to imply ' United States of
America,' there is of course no university of that name.
The result is that a large number of ignorant persons,
even if they are aware that the person they consult is
unregistered, believe that he is qualified in some special

UNQUALIFIED PRACTICE 285

way to give medical or surgical advice. The medical
profession, too, have a legitimate grievance in that their
privileges are infringed. By law, only a registered medical
man can give a certificate of death, but until quite recent
years registrars were empowered to accept from other
persons ' information ' concerning a death which amounted
to a death certificate in all but name. Under the regu-
lations made by the Insurance Commissioners, insured
persons may be medically treated by unregistered persons,
though there is nothing in the Act to justify this course,
and the Royal Colleges have protested strongly against
it.1 The Commissioners have, however, considered them-
selves bound by a verbal promise which was given in the
House of Commons, but was not embodied in the Act.

Some unregistered persons pose as qualified medical
men, and treat all classes of diseases, or claim to be
specialists in the treatment of cancer, consumption,
venereal diseases, affections of the eye or deafness. Others,
such as herbalists, bone-setters, and faith-healers, boldly
distinguish themselves from medical men, and claim that
their methods of treatment are superior, since they are
not bound by the traditions of orthodoxy. Much prescrib-
ing and treatment of minor illness is also done by chemists.
That great harm is done by these persons has been shown
again and again. The report of the Inquiry into Un-
qualified Practice, made by the Privy Council in response
to an appeal from the General Medical Council, gives
numerous examples of grave and even fatal results due to
ignorant treatment, and other instances have appeared
in the public Press. Sometimes errors of diagnosis are
made, but frequently there is no question that the patient
is suffering from cancer, diabetes, consumption, or other
deadly disease ; nevertheless he is persuaded to undergo
a course of treatment which involves the purchase of
quantities of costly drugs or instruments. Though all the

1 The following resolution was passed by the Royal College of Physicians in
1914 : " Hitherto none but duly qualified medical practitioners have been employed,
as such, in any public capacity; and the College deplores that under an Act pro-
fessing to promote the health of the nation, recognition should be given and pro-
vision made for the payment of public money to a class of persons who have not
obtained a legal qualification to practise medicine, and concerning whose medical
knowledge there exists no sort of guarantee."

286 HEALTH AND THE STATE

time steadily getting worse, the patient is assured that he
is rapidly improving, and tricks are played to convince
him of the fact. In one instance portions of pig's entrails
were shown to a woman to convince her that the cancer
had come away from her breast. Sometimes the quack
will continue to suck his victim like a vampire until death
releases him from his clutches, but more often, having
gone as far as he dare, he will let the sufferer pass under
the care of a qualified practitioner in order that there may
be no difficulty about the death certificate.

A pernicious class consists of those who undertake the
treatment of venereal diseases. According to the above-
mentioned report, the treatment of venereal diseases in
many large towns is to a considerable extent in the hands
of unqualified persons. Chemists and herbalists frequently
undertake the work, and the number of so-called specialists
in venereal diseases appears to be increasing. The oppor-
tunity for these practitioners is very great, owing to the
fear of many sufferers of their condition becoming known,
and their reluctance to consult their family doctor. These
persons advertise a rapid and painless cure for all sexual
ailments, ' loss of virility,' etc., with testimonials and
hours of attendance. Sometimes they give instructions
for the sufferer to make his own diagnosis, and describe
perfectly natural phenomena as evidence of disease. They
will even undertake to examine secretions. In one case
the police, under an assumed name, sent to a man who
advertised that he was principal of the ' British Health
Institute,' a bottle of fluid consisting of tea, soap, and
colouring matter, and received a reply that he was suffer-
ing from internal catarrh, but was assured that : "I have
every confidence that by following my treatment you should
soon derive very considerable benefit." One medicament
found on the premises of the ' Institute ' consisted of salt
coloured pink with aniline dye. The influence of these
practices upon Public Health is very injurious. The
Royal Commission on Venereal Diseases say : " We have
" no hesitation in stating that the effects of unqualified
" practice in regard to venereal diseases are disastrous, and
" that, in our opinion, the continued existence of unqualified

UNQUALIFIED PRACTICE 287

" practice constitutes one of the principal hindrances to the
" eradication of those diseases." As we have seen, action
has now been taken to provide skilled treatment.

Abortion-mongers are obliged largely to carry on their
trade in secret, though they may advertise ' female reme-
dies/ and they frequently associate the sale of Malthusian
appliances with their business. In addition to the immense
trade in pills, etc., there is no doubt that a great deal of
instrumental interference is performed, particularly in the
Midlands and northern counties. The cases which come
to light owing to the death of the woman and the holding
of a coroner's inquest, represent only a small fraction of
the operations actually performed. Many abortionists
now exercise a considerable degree of skill in their manipu-
lations ; they are aware of the dangers, have some knowledge
of anatomy, and employ antiseptics, thus substantially
reducing the risk of a fatal termination, though their
efforts may be followed by serious illness, and perhaps
permanent ill-health. Much interesting information relat-
ing to abortionists will be found in an article, " Criminal
Abortion and Abortifacients," by Dr. W. F. J. Whitley,
in Public Health of February 1915.

Another type of bogus doctor relies more upon appeal-
ing to a whole class than to individual patients, and makes
his profit by the sale of some appliance— an ' electric '
belt, a ' vibrator,' or an ear-drum. These things may be
advertised in the Press, but often in addition the proprietor
travels round the country, widely advertises his visit to a
town, and holds huge meetings, at which a pretence is
made of examining patients then and there, and numbers
of the appliances are sold. One of these quacks, after
holding meetings which filled the Albert Hall, not satisfied
with his gains in this country, started his practices in Paris,
where, under a sterner law, he was promptly arrested and
sentenced to imprisonment. These appliances are bought
by the more ignorant members of the community, and in
many an agricultural labourer's cottage a vibrator or a
useless ear instrument will be found, perhaps purchased
for several guineas out of wages of 14s. a week.

CHAPTER IX

THE COMPLEXITY OF PUBLIC HEALTH ADMINISTRATION

Central administrative authorities — Local administrative authorities —
The evolution of the Public Health services — Administration of sana-
torium benefit — Administrative authorities and statistics — The dis-
couragement of the present system.

The Public Health services in this country are administered
centrally by nearly a dozen independent and uncoordinated
Departments, Boards, and Councils ; and locally by nearly
as many local authorities. Before examining the growth
and effects of this system it may be useful to give a list of
the authorities concerned.

Central Administrative Authorities

The Local Government Board. — This office contains two
separate and distinct medical departments, one for Poor
Law and the other for general Public Health purposes.
The Chief Medical Inspector for Poor Law purposes
exercises control over the medical activities of Boards of
Guardians, and is concerned with the central administra-
tion of the vaccination laws. The Chief Medical Officer
to the Board advises on the issue of orders and instruction
to Local Sanitary Authorities on Public Health matters,
such as drainage, sanatoria, and maternity centres ; is
responsible for special medical inspection in relation to
infectious diseases and epidemics, defective housing,
adulteration of food, etc. ; and conducts or arranges for
scientific investigation in matters of hygiene.

Tlve General Register Office addresses its annual report
to the President of the Local Government Board, but other-

288

CENTRAL ADMINISTRATIVE AUTHORITIES 289

wise seems to have no connection with that Department.
It compiles the national vital statistics, and issues the
annual report on Births, Deaths, and Marriages, which
every year contains a valuable dissertation on the dis-
tribution and principal causes of deaths.

The Home Office supervises sanitary conditions in
factories ; controls dangerous trades ; has duties in con-
nection with the Mental Deficiency Act ; and is concerned
with the prison medical service and inebriety. This Office
also appoints Medical Referees and Certifying Factory
Surgeons under the Workmen's Compensation Act.

The Board of Education administers the Acts for the
medical inspection and treatment of school children, and
controls grants in aid of schools for mothers for instruction
in infant care and welfare.

The Treasury — though without a medical adviser —
exercises important Public Health duties under the
National Insurance Act. It determines whether extra
expenditure upon medical benefit is reasonable or not ;
gives its sanction before certain exceptional expendi-
ture upon sanatorium benefit is incurred ; and has a con-
trolling voice in determining what diseases other than
tuberculosis shall be medically treated under sanatorium
benefit.

The National Insurance Commission administers the
Insurance Act. There is a separate Commission for each
of the four divisions of the United Kingdom, which are
more or less brought into coordination by a fifth body,
the Joint Committee.

The Privy Council has duties in connection with the
General Medical Council, the Central Midwives Board, and
the Pharmaceutical Society. As an example of the Privy
Council's activities in Public Health, reference may be
made to the report it issued in 1910 on the " Practice of
Medicine and Surgery by Unqualified Persons in the United
Kingdom," though the information upon which the report
was based was collected vicariously through the Local
Government Board.

The Board of Trade appoints medical inspectors to
examine seamen in ports ; has duties in connection with

u

290 HEALTH AND THE STATE

sickness among emigrants ; and looks after the health of
crews in certain particulars. It is of great interest to note
that the Board has issued a book, the Ship Captain's
Medical Guide, which all merchant ships must carry, and
which contains instructions on the prophylactic measures
against venereal disease referred to in an earlier chapter ;
and that since 1911 it has been supplying merchant ships
with the medicaments necessary for this purpose.1 Thus
the Board of Trade is conveying to seamen, and indirectly
to the general public, knowledge of preventive methods
which are ignored completely in the report of the Royal
Commission on Venereal Diseases, and in the reports on
Public Health of the Local Government Board.

The Board of Agriculture prescribes, or may prescribe,
the standards for milk, cream, butter and cheese ; issues
the ' Sale of Milk Regulations ' ; and has power to inspect
and register premises for milk-blending and margarine-
making.

The Colonial Office investigates or assists investigations
of tropical diseases, and publishes reports thereon. The
Board of Customs and Excise has duties in connection with
the sale of patent and proprietary foods and remedies.

The preceding authorities are Government Depart-
ments, and are not concerned exclusively with Public
Health. In addition the following central authorities
discharge important duties in connection with Public
Health :—

The Board of Control, through the Commissioners in
Lunacy, exercises general control over the supervision and
protection of mentally defective persons, and the manage-
ment of lunatic asylums, and appoints guardians and
visitors of certified lunatics.

The Ministry of Pensions exercises various functions
in connection with the care and training of disabled
soldiers.

The General Medical Council keeps the register of
medical practitioners, superintends the standard of
examinations for medical qualifications, and exercises

1 See the evidence of Dr. Burland and Mr. Shepherd before the Royal
Commission on Venereal Diseases. Appendix to Final Report, vol. ii.

LOCAL ADMINISTRATIVE AUTHORITIES 291

disciplinary control over the medical profession in pro-
fessional matters. This body also publishes the British
Pharmacopoeia, the volume which prescribes the standard
strengths of drugs and the usual doses for administration,
a new edition of which has just appeared after a lapse of
fifteen years.

The Central Midwives Board maintains the register of
midwives, lays down regulations for their conduct of cases,
and conducts examinations in midwifery for midwives.

The Pharmaceutical Society examines and registers
chemists under the Pharmacy Acts, and advises the Privy
Council on the control of the sale of poisons.

The preceding are all statutory authorities for England,
and most of them have their counterparts in Scotland and
Ireland. But the list by no means exhausts the bodies
which do in fact influence Public Health affairs. Large
and active Societies, such as those for the prevention of
tuberculosis, venereal diseases, infant mortality, inebriety,
etc. etc., investigate Public Health questions, issue reports
which help to form public opinion, and are sometimes the
means of securing the appointment of Royal Commissions,
and of initiating legislation. To these must be added the
large charitable organisations, such as King Edward's
Hospital Fund and other hospital funds, the Charity
Organisation Society, maternity charities, nursing associa-
tions, social service leagues, etc., which annually disburse
sums amounting to several millions in the interests of
Public Health.

Local Administrative Authorities

In local administration we find a similar multiplicity
of authorities, the principal bodies engaged in Public
Health work being the following : —

The Local Sanitary Authority. — In County Boroughs
this is the Borough Council. In Urban and Rural Districts
it is the Urban or Rural District Council, though certain
duties are discharged for the County as a whole (exclusive
of the County Boroughs) by the County Council. The
chief Public Health duties of a Local Sanitary Authority

292 HEALTH AND THE STATE

are connected with infectious diseases, tuberculosis, housing,
scavenging, drainage, adulteration of food, meat inspec-
tion, milk supply, health visiting, etc. These are carried
out under the advice of the Medical Officer of Health
who is assisted by a staff of inspectors and health visitors.

The Board of Guardians maintains infirmaries for sick
paupers ; provides outdoor medical relief through a staff
of Poor Law Medical Officers ; and undertakes public
vaccination.

The Insurance Committee administers medical benefit
under the Insurance Act, but must consult or act in con-
junction with a number of other bodies, such as the Medical
Benefit Sub-Committee, the Local Medical Committee, the
Panel Committee, and the Pharmaceutical Committee.
Sanatorium benefit is administered by a combination of
the Insurance Committee and Local Authority, which has
led to endless confusion and delay. Sickness and maternity
benefit are administered by Approved Societies, except for
deposit contributors, who come under the Insurance
Committee.

The Local Education Authority, which is the Local
Authority acting through the Education Committee, pro-
vides for the medical inspection and to some extent for
the treatment of school children, and has duties in con-
nection with schools for mothers.

The Coroner inquires into deaths from unnatural
causes. His inquests upon deaths from accidents in
factories, etc., poisoning by trade processes, neglect, and
other preventable causes are important from the Public
Health point of view, and the accuracy of his investigations
has an appreciable effect on the national vital statistics,
since more than 10 per cent of all deaths come under the
purview of coroners.

The Magistrates and Justices are in effect in some of
their duties Public Health officers, for they may be called
upon to determine complex questions in relation to adulter-
ation of food or condemnation of meat or standards of
milk, and whether food is prejudicial to health or is of the
nature and quality demanded.

Besides the statutory authorities enumerated, Hospitals,

EVOLUTION OF PUBLIC HEALTH SERVICES 293

Provident Dispensaries, Care Committees, District Nurses,
Guilds of Health, and other private agencies are all en-
gaged locally in important Public Health work.

In London, administration is further complicated by
the division of power between the London County Council
and the twenty-eight Metropolitan Boroughs and the Cor-
poration of the City. Other authorities peculiar to London
or its vicinity are the Metropolitan Asylums Board ; the
Metropolitan Water Board, which is responsible for the
maintenance and purity of the water-supply, though the
Thames Conservancy Commission exercises powers to
prevent pollution of the river ; and the Port of London
Sanitary Authority, a department of the Corporation of
the City which supervises the sanitary condition of
shipping and the Port of London generally.

The Evolution of the Public Health Services

This multiplicity of authorities is a result of the piece-
meal way in which Public Health affairs have been dealt
with in this country. Except for the general sanitary
services, we have never provided for the needs of the
country as a whole, but only for isolated groups, paupers
school children, insured persons, etc. ; and — except for a
brief interval in the middle of the nineteenth century — we
have never had one central authority definitely charged
with the protection of Public Health without other duties.
As each new Act has been passed, its administration has
been either thrust upon an existing Department, perhaps
created originally for quite other purposes, or has been
assigned to a new authority created ad hoc. We may
learn several lessons by noticing some instances of these
processes.

The original object of the Poor Laws was mainly
the repression of crime and vagrancy. The Statutes of
Elizabeth and enactments up to the eighteenth century
refer again and again to " rogues, vagabonds, and sturdy
beggars" ; and such persons might be whipped, branded,
set in the stocks, or even hanged. The harsher laws were
only gradually replaced by more humane legislation, and

294 HEALTH AND THE STATE

the Poor Law authorities slowly assumed their important
function of providing for the sick and infirm poor. Poor
Law Unions and Boards of Guardians were created by
the Act of 1834, and later years saw the growth of the
infirmary system and other forms of medical relief. How
completely the Poor Laws have changed their character
since the days when they existed mainly for the suppression
of vagrancy, may be realised from an analysis of the 762,196
persons in receipt of relief on January 1, 1915. Of these
415,449, or 54*5 per cent, were definitely suffering from
sickness, accident or mental or bodily infirmity, and
223,062 others were children. The remainder included per-
sons over seventy years of age, persons relieved on account
of sickness or infirmity of wife or child, persons weak or
feeble from premature senility or other circumstances,
widows, wives living apart from their husbands, etc. The
class who were, broadly speaking, in health and free from
mental infirmity, but were more or less inefficient,
numbered less than 20,000.

The Poor Law system, with its great infirmaries scattered
all over the country, is in fact our largest public pro-
vision of medical treatment and care for the poorer
classes, particularly for those suffering from chronic ill-
ness or permanent incapacity. It is therefore much to
be regretted that a prejudice exists among the working
classes against accepting this form of assistance, a prejudice
which is undoubtedly inherited from the time when the
Poor Laws were so closely associated with the repression
of crime and vagrancy. This hostile sentiment is not
manifested towards the voluntary hospitals, although they
limit their assistance mainly to the poorer classes ; and the
view that this attitude should be encouraged as a sign of
healthy independence is only put forward by those ignor-
ant of the facts, and still possessed by the ' sturdy beggar '
theory. When the Insurance Act was under consideration,
an opportunity existed of sweeping away this stigma by
incorporating the Poor Law medical system into a general
public medical service, but unfortunately the opposite step
was foolishly taken, and Poor Law authorities were rigidly
excluded from those with whom Insurance Committees

EVOLUTION OF PUBLIC HEALTH SERVICES 295

might make arrangements for sanatorium benefit. Then,
after emphasising the stigma of pauperism, the Insurance
Act provides no alternative but the Poor Law infirmaries
for many thousands of tuberculous insured persons.

But while the Poor Law medical service is restricted
to indigent persons, the local administration of the vaccina-
tion laws by the Poor Law authorities for all classes of the
community affords an illustration of a duty which has no
relation whatever to pauperism. When, in 1840, vaccina-
tion was first provided at the public cost, the old Poor Law
Board (with no medical officer in its service) was made the
central authority, and local administration was entrusted
to Boards of Guardians and overseers, for at that time there
was no Local Sanitary Authority in existence. But since
that date there have been many changes. Vaccination was
made compulsory in 1853 ; the Poor Law Board has been
swept away, and Local Sanitary Authorities created ; but
though in earlier years the service was bad and there were
flagrant instances of disastrous maltreatment, the Boards
of Guardians have ever since continued to provide or
supervise vaccination among all classes of the community.

The Metropolitan Asylums Board is an offshoot from
the Poor Law, which now occupies a distinctly anomalous
position. It was created in 1867 to provide for the recep-
tion and relief of the sick, insane, infirm, and other classes
of the poor in London. By an Act of 1883, the civil
disabilities which had till then attached to admission to
the Board's hospitals were removed ; and by later Acts the
Board was authorised to admit non-pauper cases of fever.
Now the fever hospitals are used for the reception of
patients of all social classes, and no trace of the stigma of
pauperism attaches to admission thereto, although the
Board is still legally a Poor Law authority. We may
note here the extraordinary position to which this gave
rise under the Insurance Act. We have seen that this
,Act requires arrangements for sanatorium benefit to be
made with bodies other than Poor Law authorities. When,
after the passing of the Act, arrangements for London
were considered, it was at once realised that the Metro-
politan Asylums Board, with its well-equipped hospitals

296 HEALTH AND THE STATE

and sanatoria and buildings capable of being converted
into sanatoria, was eminently the appropriate body with
which to make arrangements. Indeed without its help
there was no hope of making reasonable provision in
London for a long time. Then arose the question : was
the Board a ' Poor Law Authority ' ? No guidance was
to be found in the Act or in the Parliamentary debates,
and in fact it seems clear that Parliament had forgotten
either the existence of the Board or its anomalous char-
acter. The managers of the Board themselves say in
their report for 1912 : " There is no doubt that the
special position in London of the Metropolitan Asylums
Board as in fact a Public Health and infectious hospital
authority, was lost sight of." After prolonged discussion
and taking of legal opinion, it was finally decided that the
London Insurance Committee was prohibited from making
arrangements with the Board. It was however held that
the Insurance Committee might make arrangements with
the London County Council, while the Council in its turn
could make arrangements with the Metropolitan Asylums
Board, and this was done, thus arriving at the end desired
by a circuitous route. Then a year later, in the amending
Act of 1913 the London Insurance Committee was authorised
to enter directly into arrangements with the Board ; from
which it may be inferred that Parliament, if it had realised
the position, would not have excluded the Board in the
original Act. We may admire the ingenuity with which
the administrative authorities circumvented the expressed
intention of the Act, but we could not have a better lesson
in the need for expert knowledge in Parliament when
Public Health measures are under consideration, than the
fact that this body, in a debate on the provision of sana-
toria for the tuberculous, forgot either the existence or the
anomalous character of the largest local authority in the
country specifically charged with the duty of providing
hospitals for infectious diseases, and actually maintaining
sanatoria for tuberculosis at the time.

The Coroner affords another example of an interesting
change of function. Though not usually recognised as a
Public Health official, he does in fact conduct many

EVOLUTION OF PUBLIC HEALTH SERVICES 297

inquiries into deaths which closely touch Public Health
matters. These duties are indeed more important than
those connected with the detection of crime, which are
for all practical purposes discharged by the police and
magistrates ; the police collecting the information upon
which the Coroner acts, while, if the inquest verdict and
magistrates' decision are not the same, the criminal courts
are almost invariably guided by the latter. The Coroner,
however, who dates from the twelfth century, was origin-
ally a revenue officer of the Crown, and was charged with
the duty of confiscating the goods of criminals, taking
possession of wrecks and seizing treasure-trove, a duty
which still remains. He inquired into deaths for the
purpose of ascertaining whether the deceased was an out-
law or felon or suicide, in which case his property escheated
to the Crown.1 Escheat however has been abolished,
and the tax-collecting functions of the Coroner have long
disappeared, but the ancient machinery with its obligation
upon the Coroner to hold land in his district lest he might
abscond with the proceeds of his inquiries, its jury of
' good and lawful ' men, and its ' view,' the object of
which was to make sure that there actually was a body
present, still remain to serve a radically different purpose.
It is obvious that if we were now for the first time
providing for the investigation of deaths from unnatural
causes we should never dream of setting up the present
machinery. The Coroner is not necessarily a medical
man, and he need not and often does not call medical
evidence ; his procedure is not suitable for a scientific
inquiry ; and the final responsibility rests with a jury
usually composed of artisans. ' Riders ' are merely ex-
pressions of opinion which involve no legal consequences,
and if abuses are detected, the Coroner has no machinery
for bringing pressure to bear upon those responsible.
Under these circumstances it is not surprising that verdicts
are often palpably absurd, and serious errors are made in
medical and scientific matters, perhaps the greatest of

1 Pepys gives a very interesting pieture of an inquest in the seventeenth century,
and of the devices which were adopted by relatives to defeat this harsh law, in his
account of the inquest.

298 HEALTH AND THE STATE

which is the cruel injustice inflicted annually upon some
hundreds of mothers who are informed, after a superficial
investigation, that they have caused the death of their
infants by ' overlaying ' them in bed. If these deaths
were the subject of efficient inquiry, there is strong reason
to believe that the great bulk of them would be found to
have been due to natural causes.1

It is of interest to recall that at one time we had
a central Public Health Authority which distinctly
approached a Ministry of Health, and would probably
have developed into such a Ministry had it been given fair
opportunity. This was the General Board of Health
created in 1848 in consequence of the frequency of epi-
demics and the insanitary state of the country generally,
which had been revealed in the reports of the Poor Law
Commissioners. The new Board numbered among its
members eminent men, such as Chadwick, Shaftesbury,
and Southwood Smith, and did much useful work, particu-
larly in the direction of removing refuse and improving
drainage. But it worked under great difficulties : its
existence was precarious, as it had only been appointed
for a limited period ; its executive powers were restricted ;
and it was not even authorised to appoint a medical officer
until two years after its formation. The labours of the
Board to improve sanitation aroused bitter hostility
among vested interests, and the Board was also virulently
attacked by those who, without knowledge of sanitary
science, assumed the role of authorities and upheld the
orthodoxy of the period.2 In 1858 the Board was swept

1 Justification for this statement will be found in An Inquiry into the Statistics
of Deaths from Violence, by the author, 1915. Briefly, the reasons for the view
expressed are : that there is no constant relation between overcrowding and deaths
from overlying ; that the rural death-rate is far smaller than the urban death-rate,
the decrease being much greater in proportion than the decrease in overcrowding ;
that there is a marked seasonal variation in these deaths, the number declin-
ing in summer and rising in winter ; that this variation agrees precisely with that
of deaths from broncho-pneumonia, infantile convulsions, and atrophy, conditions
presenting post-mortem appearances very similar or actually undistinguishable
from those of overlying ; and that when the post-mortems are performed by expert
pathologists, overlying is very rarely found to be the cause of death.

2 Herbert Spencer, for example, said : " These impatiently agitated schemes
for improving our sanitary condition by Act of Parliament are needless, inasmuch
as there are already efficient influences at work gradually accomplishing every
desideratum " ; and of the Board of Health he wrote : " It had more than a year's
notice that the cholera was on its way here. . . . Well, what was the first step which

EVOLUTION OF PUBLIC HEALTH SERVICES 299

away and its medical duties were divided between the
Privy Council and the Home Office. Sir John Simon has
described the abolition of the Board as a ' catastrophe.'
He says : " An earnest, powerful endeavour had mis-
" carried. ... In our sanitary case, too, the immediate
" failure was only part of what had to be regretted. For
" the invectives which had been meant to destroy the Board
" had been too angry in their aim not to do much collateral
" damage ; and they continued to operate for several years
" on a considerable scale, in maintaining suspicion and
" prejudice against sanitary proposals and those who made
"them."1

The Local Government Board was created in 1871 as
a result of the report of the Royal Sanitary Commission
of 1868, which demonstrated the confusion into which the
administration of Public Health affairs had fallen. To
the new authority were transferred the duties and staffs
of the Poor Law Board and the General Register Office,
and most of the medical duties of the Privy Council,
though some of the latter remain to be discharged by that
body, resembling the ' vestigial structures ' of biologists.
The union of authorities under the Local Government
Board was however more in name than in fact, for the
Registrar- General and the Poor Law and Public Health
branches have always remained independent ; and ever
since the Local Government Board was created, we have
been re-establishing the old confusion by assigning medical
duties to other offices, or creating new authorities for

might have been looked for from it ? Shall we not say the suppression of intra-
mural interments ? Burying the dead in the midst of the living was manifestly
hurtful ; the evils attendant on the practice were universally recognised ; and to
put it down required little more than a simple exercise of authority. If the Board
of Health believed itself possessed of authority sufficient for this, why did it not
use that authority when the advent of the epidemic was rumoured ? If it thought
its authority not great enough (which can hardly be, remembering what it ulti-
mately did) then why did it not obtain more ? Instead of taking either of these
steps, however, it occupied itself in considering future modes of water-supply and
devising systems of drainage. ... As was said by a speaker at one of the medical
meetings held during the height of the cholera, ' the Commissioners of Public
Health had adopted the very means likely to produce that complaint. Instead of
taking their measures years ago, they had stirred up all sorts of abominations now.
They had removed dunghills and cesspools and added fuel tenfold to the fire that
existed.' " — Social Statics.

Later knowledge has of course shown that the Board was entirely right in the
measures it adopted, but it was clearly in advance of its time.
1 English Sanitary Institutions, 1890.

300 HEALTH AND THE STATE

special purposes. It may be of interest to examine some
examples of the complexity of administration to which the
constant multiplying of authorities has now led.

The Administration of Sanatorium Benefit

The central administration of this benefit is divided
among three Government Offices : the Insurance Com-
missioners, who exercise control over the arrangements
made by Insurance Committees ; the Local Government
Board, which is charged with the duty of inspecting and
approving sanatoria and dispensaries, and of approving
the appointments of tuberculosis officers ; and the
Treasury, which assents, if it thinks fit, to expenditure in
excess of that provided by the Act, and must also approve
proposals to treat diseases other than tuberculosis under
sanatorium benefit. This division of authority greatly
complicates administration, but the public do not become
familiar with the conferences, committees, reports, etc.,
rendered necessary, since they affect mainly the internal
working of the offices. Occasionally however it is possible
to detect in the official reports issued by the Departments
discreetly-worded evidence of acute difference of opinion
which must have been productive of difficulty. The
report of the Local Government Board for 1913-14, for
instance, points out that while it is the duty of an
Insurance Committee to decide whether an insured person
should be recommended for sanatorium benefit, the
Insurance Act does not require the Committee to deter-
mine the form of treatment he is to receive ; and it shows
further that many difficulties would have been avoided if
it had been left to the tuberculosis officer to decide whether
the applicant should receive sanatorium, hospital, or
dispensary treatment, since he is the expert medical officer,
and could determine the appropriate form of treatment
on medical grounds. The Insurance Commissioners, on
the other hand, hold that Insurance Committees must
determine the form of treatment, and could not properly
delegate this discretion to the tuberculosis officer, their
reason apparently being fear lest the tuberculosis officer

ADMINISTRATION OF SANATORIUM BENEFIT 301

should recommend too many persons for sanatorium treat-
ment. The view of the Commissioners prevailed, but it
is quite clear that the interests of the community were
sacrificed thereby.

Locally, similar complexity exists. The Insurance
Committee recommends insured persons for benefit and
pays a contribution in respect of their treatment in sana-
toria ; but the Local Authority provides the sanatoria and
dispensaries, and appoints the tuberculosis officers ; while
in London the position is further complicated by the
powers and duties of the London County Council and the
Metropolitan Asylums Board. Local arrangements have
to be approved both by the Insurance Commissioners and
the Local Government Board, and in many instances years
of negotiation have preceded the final approval and
adoption of a local scheme, while the money provided by
Parliament for the relief of sufferers remains unspent.
The amount allocated to England for grants in aid of
sanatoria under the Finance Act of 1911 was £1,116,156,
but up to June 1914 only £232,054 out of that sum had
been promised to Local Authorities, and only £62,026 had
actually been paid.1 If the hardships tell upon those
responsible for the confusion and delay, it would be deserved
Nemesis, but unfortunately it is borne by many poor and
inarticulate persons in desperate need of assistance. The
number of beds is slowly increasing, but even with the aid
of the voluntary hospitals and Poor Law infirmaries, and
shortening of periods of residence in sanatoria, the accom-
modation is insufficient, and many sick persons are waiting
for admission to the promised homes.

We may note another direction in connection with
sanatorium treatment in which Parliament showed itself
hopelessly lacking in appreciation of administrative diffi-
culties. The Act provides that diseases other than
tuberculosis can, on the recommendation of the Local
Government Board, with the approval of the Treasury, be
specially treated under sanatorium benefit " in sanatoria
or other institutions or otherwise." To the inexperienced
it may seem a simple matter to add other diseases when

1 Forty-third Annual Report of the Local Government Board.

302 HEALTH AND THE STATE

once a scheme for tuberculosis is in satisfactory work-
ing order, but those who have knowledge of administra-
tion will appreciate the immense difficulties in the way.
New contracts and new arrangements would be required
with Insurance Committees, Local Authorities, Approved
Societies, doctors and chemists. Special statistics would
be demanded in order that new estimates of cost might be
obtained. Volumes of circulars, orders and instructions
would be issued, and every step would necessitate con-
sideration by committees and conferences, the reconciling
of different authorities, and the satisfying of vested
interests. No doubt the Departments concerned would
cheerfully undertake the task, but the public should
realise that it is proceedings of this kind which demand
the services of so many thousand clerks and officials, and
so enormously increase the cost of administration. Accord-
ing to the statement of Mr. Roberts, the present Chairman
of the Joint Committee, it costs £600 merely to call the
Advisory Committee together for one meeting. It is
significant to note that the Local Government Board in
the new arrangements for the treatment of venereal
disease has not availed itself of the machinery theoretically
available, by adding syphilis to the diseases treated under
sanatorium benefit (which can be extended to non-insured
persons), but has gone direct to the Local Authorities.

Administration in Connection with Maternal
and Infant Welfare

Let us consider as another illustration of complexity
in administration, the authorities concerned with the
welfare of the mother and infant. The pregnant woman,
if an industrial worker, is subject to laws restricting
employment which are administered by the Home Office.
At her confinement, if insured, she receives maternity
benefit through her Approved Society ; if she is a pauper
she may receive attendance through the Board of Guardians,
while the midwife who attends her is subject to regulations
made by the Central Midwives Board. The birth of the
infant must be notified to the Medical Officer of Health,

MATEKNAL AND INFANT WELFAKE 303

but it must be registered at the office of the local Registrar,
and the Board of Guardians again steps in to see that the
child is vaccinated. If the child is put out to nurse, the
person who undertakes its care is subject to supervision by
the Local Authority. If the mother wishes for advice or
help in the care of her baby she may go to a ' school for
mothers ' which is under the Education Authorities, or to
an ' infant welfare centre ' under the control of the Local
Authority and assisted by grants from the Local Govern-
ment Board, and either of these institutions may send a
health visitor to advise her as soon as the infant is born.1

It is of some interest to compile a list of inspectors and
officials from whom a working-class mother with a family
of children may now receive visits. The list includes the
Medical Officer of Health, the Sanitary Inspector, the
Housing Inspector, the Health Visitor, the School Attendance
Officer, the School Nurse, the District Nurse, a Member of
the School Care Committee, the Sick Visitor or agent of
her Approved Society, the Insurance Inspector, and in
cases of poverty the Relieving Officer, and perhaps a repre-
sentative from the Charity Organisation Society. It is
well known that this continual series of inspections among
the working classes has given rise to a widespread feeling
of irritation, and a sense of infringement of privacy. The
most recent movement is one for notification of pregnancy,
and already certain Local Authorities {e.g. at Nottingham
and Huddersfield) have instituted a system of such notifica-
tions, though it is not clear under what powers they have
acted. If the visits of these inspectors and officials were
productive of proportionate benefit a great deal could be
said in their defence, but it is doubtful whether the whole
system is having any appreciable effect in improving the

1 In the matter of infant welfare the Board of Education and the Local Govern-
ment Board are doing essentially the same work, and in the sections of their Annual
Reports dealing with infant welfare they cover much the same ground. It is well
known that this needless overlapping caused a disagreement between the two offices
which led to a long delay before something approaching a working scheme was
devised. The chief difference between the two sets of institutions is that while
those assisted by the Local Government Board may provide treatment, the Board
of Education centres are ' primarily educational,' the provision of medical and
surgical advice and treatment being only ' incidental.' But, as Mrs. Acland has
said : " When Mrs. Smith's baby begins to put on weight, who shall say whether we
rejoice primarily because that means an improvement in Mrs. Smith's education
or in the baby's health ? "

304 HEALTH AND THE STATE

health of the working classes or reducing the death-rate.
With the exception perhaps of the sanitary inspector, they
do little or nothing to improve the environment ; they do
not provide healthy conditions of life or efficient medical
attendance, or lying-in homes for mothers. As Mr. G. K.
Chesterton has said, "they only move persons from
Schedule A to Schedule B," while they lead the poor to
feel that their liberty is infringed in a way the rich would
not tolerate.

Many other instances could be given of the wearisome
delays and confusion which this system of administration
involves. There is, for example, the dust-siding at East
Dulwich station, immediately adjacent to the Southwark
Infirmary, instalments of the story of which have been
appearing in the public Press since 1913. The Guardians
alleged that dust was blown into the children's wards and
set up enteritis, and the dispute has involved inspections
and reports by four medical experts, — the Medical Officer
of Health, the Medical Superintendent of the Infirmary, the
Medical Inspector of the Local Government Board, and
the Medical Officer of a Children's Hospital, while negotia-
tions between the Guardians, the Borough Council, the
Local Government Board, and the London County Council
had extended over two years without a settlement having
been reached at the time the last report was published.

Some of the disputes between overlapping authorities
terminate in an agreement after more or less protracted
negotiations ; others end by the aggrieved authority be-
coming weary of the proceedings and letting the matter
drop ; but the most absurd termination, from the public
point of view, is in litigation between the authorities. We
have had examples of Insurance Committees taking legal
action against Insurance Commissioners ; of the London
County Council proceeding against Borough Councils ; and
of Boards of Guardians threatening the Metropolitan
Asylums Board. All these bodies are servants of the
public, they are supposed to be acting in the interests of
the public, and the public pays for their litigation which-
ever side wins. In the present chaos, litigation is no
doubt sometimes unavoidable, but the situation is as

AUTHORITIES AND STATISTICS 305

absurd as if a householder were compelled to pay for
litigation between his cook and his housemaid as to who
should clean his knives or boots.

Administrative Authorities and Statistics

The lack of coordination among Government Depart-
ments is almost incredible to those who have not had
actual experience of their internal working. There are
instances of one Department laboriously setting to work
to collect information on a subject, full details of which
are in possession of another Department, and have perhaps
actually been published ; of two Departments inde-
pendently making precisely the same investigation ; of
one Department not knowing what another has done or
is doing ; and of one Department not being able to take
an obviously desirable step because it would infringe the
prerogative of another. These matters do not usually
become public, but we have a striking illustration of the
want of coordination in the annual returns and statistics
published by the different offices.

Statistics relating to Public Health are of great im-
portance. They afford the only scientific means of deter-
mining the extent and distribution of disease either in
classes of persons or geographical areas ; they furnish a
test of the effects of legislation and administrative orders ;
and they are, or should be, the basis of new Public Health
legislation. Without statistical knowledge of the preval-
ence and causation of industrial diseases and accidents
in factories, mines, and railways ; of sickness in special
areas; and of invalidity — efforts to improve conditions
are based upon little more than guesswork.

The value of different sets of statistics is very greatly
increased when they are in a form which renders them
comparable one with another ; and for this purpose,
speaking generally, it is necessary that they should apply
to the same geographical units or units of population and
the same period of time, divide the classes of persons into
the same age-periods, employ the same basis of classifica-
tion of diseases and causes of death, and use scientific terms

x

306 HEALTH AND THE STATE

with a constant meaning throughout. But when we turn
to the Public Health statistics issued by the Govern-
ment Departments we find the most extraordinary want of
coordination among them, which often effectually prevents
them from being used together, and seriously reduces their
value both individually and collectively. There are at
least ten different reports which bear upon Public Health
issued annually by the Home Office, the Registrar- General,
the Local Government Board, the Board of Education, and
the Board of Trade, but scarcely any two of them (even
when issued by the same office) agree in their geographical
units, or periods of the return, or age-periods, or system
of classification and nomenclature. There are separate
Registrar- Generals for Scotland and Ireland, and each
adopts a form of classification differing in important
respects from the English system. Some statistics are for
the United Kingdom only, returns for the separate countries
not being distinguished ; some are for England, Scotland
and Wales as a whole ; some for England and Wales, and
some for England excluding Wales. Uniformity is not
even observed in the boundaries of the countries, Mon-
mouthshire, for example, being placed in Wales by the
Registrar- General and in England by the Home Office.
The Local Government Board and the Board of Education
begin their year in April, most of the other offices begin in
January, but the report on the Working of the Boiler
Explosions Act begins in July. Some reports tabulate
deaths registered during the year, others the deaths which
actually occurred during the year.1 Systems of nomen-
clature vary, and even such words as ' violence,' ' neglect,'
' suffocation,' and ' abortion ' have different interpreta-
tions placed upon them by different Departments.

The writer has elsewhere brought forward numerous
instances of the confusion and difficulties which result

1 A good instance of the confusion which results from this particular want of
uniformity is afforded by the returns relating to deaths in coal mines for the year
1911. According to the Home Office report there were in that year 1050 deaths
in English and Welsh coalfields ; according to the Registrar-General the number
was 1364. The difference is almost entirely accounted for by 342 deaths which
occurred in the Pretoria mine disaster on December 21, 1910, but were not registered
till January, thus appearing in the Home Office statistics for 1910 and in the
Registrar-General's volume for 1911.

AUTHORITIES AND STATISTICS 307

from this want of uniformity, and the way in which they
impede investigation.1 Deaths from infectious diseases
are tabulated in one volume, the Registrar- General's
report, but cases of sickness from these diseases are con-
tained in another, issued by the Local Government Board ;
and if we attempt to use these volumes together, we find
that the Registrar- General classifies his deaths according
to aggregates of Administrative Counties, County Boroughs,
Rural Districts, etc., in England and Wales, while the
Local Government Board classifies the cases in similar
aggregates for England and for Wales separately. Hence
the two returns are not comparable except as regards
England and Wales as a whole, and London, though these
two offices are supposed to be ' united,' and are under the
same Minister of the Crown. Remarkable discrepancies
are revealed by comparison of reports dealing with the
same deaths, the Registrar-General, for example, recording
36 deaths from ' alcoholism ' in Liverpool in 1912, while
the Home Office tabulates 113 inquest verdicts of ' death
from excessive drinking.' Three Departments, the Local
Government Board, the Registrar-General, and the Home
Office, tabulate deaths from starvation, cold, exposure, etc.,
but their totals and geographical distribution of the deaths
differ widely from each other, and a very simple analysis
of the Local Government Board report will show that it is
seriously incomplete.

Since we have no central statistical office, each Depart-
ment decides for itself what matters shall be the subject of
statistical analysis, and how far that analysis shall be
carried, with the result that remarkable disproportion
exists between the amount of attention and space given
to different matters, some being analysed minutely, and
others of equally great or greater importance being
neglected. We can learn from the Board of Trade the
precise number of signal-box lads who suffered from sprain,
of railway porters who received cuts or lacerations, and of
engine-drivers who were burnt or scalded. On the other
hand, the Poor Larw branch of the Local Government
Board issues no medical report ; and, except for a few

1 Op. cit.

308 HEALTH AND THE STATE

details connected with maternity, we have no statistical
information whatever relating to the great number of
patients in Poor Law infirmaries ; though the Board
requires medical officers of these institutions to keep
proper records. As far back as 1904 the Inter-Depart-
mental Committee on Physical Deterioration made the
following recommendation : —

It appears to the Committee in the highest degree desirable
that a Register of Sickness not confined to infectious diseases should
be established and maintained. For this purpose the official
returns of Poor Law Medical Officers could, with very little trouble
and expense, be modified so as to secure a record of all diseases
treated by them. And, further, it ought not to be difficult to
procure the co-operation of hospitals and other charitable institu-
tions throughout the country, so as to utilise for the same purpose
the records of sickness kept by such institutions.

The Local Government Board however took no action
in regard to Poor Law medical officers, and it was nobody's
business to secure co-operation of the hospitals. Had
the recommendation been acted upon, it seems probable
that useful information would have been available for the
actuaries when estimating for the Insurance Act. The
statistics would not have given a sickness rate in a working
population, but they would at least have shown that sick-
ness is greater among women than among men, that
married women suffer more illness than single women, and
that pregnancy may be a cause of sickness.

The Annual Reports of the Registrar-General for
England and Wales are models of clearness and scientific
accuracy, and are probably the best of the kind issued by
any Government in the world. A central statistical
Department for Public Health purposes is urgently needed,
and we could not do better than make the Registrar-
General's Office the nucleus of this Department, not only
for England and Wales, but for the United Kingdom.
The report of the Registrar-General for Ireland is also
good, but in some respects the statistics need standard-
ising and coordinating in order to render them comparable
with those of England and Wales. Of the report of the
Registrar- General for Scotland, Professor Karl Pearson

DISCOURAGEMENT OF PRESENT SYSTEM 309

said some years ago : " The Scottish statistics are very
" bad. Scotland has done with her relatively small means
" such splendid scientific work, that I hope she will pardon
" me when I say that the data provided by her Registrar-
" General rank almost at the bottom of European
" statistics." 1 This criticism is still deserved to-day, for the
statistical tables seem almost designed to give the minimum
of information with the maximum of inconvenience.

The Discouragement of the Present System

The wasteful, cumbersome, and dilatory procedure of
Public Health administration in this country is demoralis-
ing to the official and discouraging to the social reformer.
The official who comes newly into a scheme which has
gradually grown up through long ages, finds himself bound
by Acts of Parliament, legal decisions, regulations made
by his predecessors, customs and rights. By himself he
can do little to bring order into the chaos, and his efforts
at reform will be met by snubs from those who have
become bond-servants of tradition. Soon he also learns
that ease and advancement are to be attained by adherence
to established routine. Social reformers find it difficult
to fix responsibility : their representations and proposals
go from Committee to Council, from Council to Board, and
back to them without effect ; they see their efforts defeated
again and again, and the abuses they would check, flourish-
ing year after year. The futility of agitation is realised,
zeal in the public service is destroyed, and ultimately
effort is abandoned. All the time knowledge is being
wasted, and many of the gifts medicine could bring to the
nation are lost. Sir Clifford Allbutt has well described the
effects of this confusion in the following words : —

" Medicine, as a function of the State, is still working
as it were with her left hand. Her scattered official
members have no unity ; working everywhere piecemeal
she has no coordination, no integrated self -conscious-
ness. With no fixed apparatus for concerted action, energy

1 Tuberculosis Heredity and Environment, 1912.

310 HEALTH AND THE STATE

is wasted in overlap, in jostling, in divided purposes,
and in anomalies. Although her influence is penetrating
into almost every function of society, and directly and
indirectly she is spending a great revenue, yet she passes
through the councils of the nation veiled and irresponsible.
The new ideas which are stirring society are largely medical,
yet society does not know where, in the back staircases
or garrets of the Local Government Board, of the Home
Office, of the Colonial Office, of the Education Office, of
the Board of Trade, of the Post Office, of the Registrar-
General's Department, of the Lunacy Commission, and
so forth, each bee buzzing in its own little cage, medicine
is to be found ; nor how this new solvent and all-pervading
influence is to be brought to the book of revenue, or to the
bar of public opinion and responsibility." x

1 Hospitals, Medical Science and Public Health, 1908.

CHAPTER X

THE NEED FOR A MINISTRY OF PUBLIC HEALTH

The lack of scientific criticism of Public Health measures — The need for
a Ministry of Public Health — Royal Commissions and Public Health
research — Administrative Offices and Public Health research — The
Office of the Registrar- General as the Ministry of Public Health — The
proposal to form a Ministry by uniting the present administrative
Departments — The personnel of a Ministry of Health.

The Lack of Scientific Criticism of Public Health

Measures

We have now surveyed the causes responsible for the
failure to make the best use of medical and scientific know-
ledge in the interests of the State, and consequently for a
low standard of Public Health, and we find that they fall
broadly into three groups, viz. (1) vested interests — mainly
those attaching to land ; (2) complexity of administration ;
and (3) mistakes and ignorance of legislators and adminis-
trators. The first we have already examined ; ways and
means of overcoming the second and third have now to be
considered.

Throughout almost the whole range of Public Health
activity we find instances of waste and inefficiency which
have resulted from sheer lack of knowledge among those
responsible either for enactment or administration of
Public Health measures. Preventive medicine is a pro-
found science, but no expert knowledge seems to be thought
necessary in those who endeavour to apply its teachings
to society. When proposals for any new step are made,
the views of the amateur appear to be regarded as of equal
weight with those of the lifelong student of Public Health ;
vague generalities masquerade as scientific deductions ;

311

312 HEALTH AND THE STATE

and conclusions put forward by scientific men with reserva-
tion, and intended only to hold good under certain condi-
tions, become established truths of universal application.
We have examined many instances of this process.
Medicine taught that sanatorium treatment is sometimes
beneficial in selected cases of tuberculosis ; but politicians
were responsible for magnifying this into a sweeping general-
isation, disregarding the truth that tuberculosis is the out-
come of environment, ignoring the lessons of Germany, and
thrusting upon the country a costly scheme of treatment
now shown to be of little avail to cure or prevent tubercu-
losis among the working classes. Science did not establish
a system of medical treatment of children which begins at
an age when already great harm has been done, and
endeavours to detect ' incipient ' maladies by an examina-
tion every two or three years ; and science does not
countenance the view that small weekly payments during
sickness will compensate for a vicious environment ; nor
that men and women suffer equally from sickness ; nor that
maternal ignorance is the great cause of infant mortality ;
nor that half the total still-births are due to syphilis ;
nor that tuberculosis is a seriously infectious disease.
Scientific investigators eagerly demand more knowledge
of the distribution and causation of disease ; but they
were not responsible for the folly of the medical record
cards, and the recording of everything from a cut finger
to cancer as a basis for scientific monographs. It was
hasty assumption which gave us a panel service without
the need for hospital accommodation ever having been
investigated ; attached so overwhelming a value to treat-
ment by drugs ; and produced a provision intended to
improve conditions, based upon sickness rates which cannot
be obtained. It is ignorance which claims all decline in the
death-rate as due to sanitary effort ; and ignorance which
every year leads to more than a thousand mothers being
wrongfully told that they have overlain and killed their
babies. Unsound views initiated in high places spread to
the masses, among whom it may be years before they can
be eradicated ; while in the accumulation of errors and un-
workable measures the fundamental causes of sickness

MINISTRY OF PUBLIC HEALTH 313

become obscured, and costly palliatives one after another
are adopted. Wherever effort to improve Public Health
has failed, it has not been the fault of medical science,
but of legislators and administrators who have misunder-
stood that science, or have failed to appreciate the diffi-
culties and conditions under which they proposed to apply
its teachings.

Under the present system a Public Health Bill may
pass through the legislature without receiving any expert
criticism during its whole course. It may be drafted
in an administrative Department by non-medical civil
servants, or, if a medical officer to the Department is
consulted, his views may be overruled by lay authority
without the public becoming aware of the fact. It may
be introduced by a Minister who has no special knowledge
of the subject, and who has not obtained expert opinion
or consulted learned Societies dealing with its problems.
The Bill passes through a House of Commons in which
there is only a handful of medical men, most of whom have
abandoned medicine for other professions ; and finally
when it becomes an Act, its administration is placed in
the hands of a Department in which medicine is kept in
a strictly subordinate position. We may contrast the
representation of the medical profession in Parliament
with that of the legal profession, which contributes one
quarter of the members of the House of Commons, as well
as numerous members of the Government ; and we may
also compare it with the conditions in France, where in
the legislative body at a recent date, 59 Deputies, 37
Senators, and 2 Ministers of State were all members of
the medical profession.

The Need for a Ministry of Public Health

The first great step, then, in reorganisation of Public
Health affairs is the creation of a central investigating
authority, a Ministry of Public Health, which shall examine
generally all conditions militating against health, and shall
advise upon all proposals intended to cure or prevent
disease. The Ministry would examine all Government

314 HEALTH AND THE STATE

Bills relating to Public Health, study the conditions under
which they are to operate, and estimate as far as possible
their probable effects. It should have the right to in-
stitute inquiries on its own initiative into conditions
affecting health in any class or locality ; it should receive
all scientific and medical reports from other Government
Offices, Local Authorities, Medical Officers of Health, Poor
Law Medical Officers, School Doctors, Factory Inspectors,
etc. ; and it should have power to prescribe the forms in
which statistics are to be compiled, and returns made by
every Public Health authority or officer, central or local,
throughout the country, in order that it may become a
central Public Health Statistical Office. The Department
would be a great repository of knowledge, and could act
in a consultative or advisory capacity to all authorities
engaged in Public Health administration.

It is important to notice that the type of research
which would be undertaken by the Ministry is not so much
that which depends upon pure science, as that which relates
to the sociological side of medicine, that is the applicability
of scientific discoveries to Society. Purely scientific re-
search into what has been termed the ' test-tube ' side of
medicine is now fairly well provided for by the Kesearch
Committee, the grants disbursed by the Local Government
Board, and assistance provided by the Cancer Research
Fund, Universities, and learned Societies. These bodies
however are not constituted adequately to undertake
sociological medical research, since they have no power to
prescribe returns and statistics, and to coordinate different
authorities, and they do not possess the staffs necessary to
conduct the great and laborious investigations required.
Sociological research however equally demands pro-
found knowledge of hygiene and independence of judg-
ment in the investigator. To secure these, the Ministry
must be staffed by persons of the highest scientific
eminence, and it must be practically free from direct
responsibility for administration.

Before discussing further proposals for reorganising
the Public Health services, it may be useful to examine
two directions in which partial compensation exists for the

ROYAL COMMISSIONS AND PUBLIC HEALTH 315

absence of an investigating authority, viz. Royal Com-
missions on Public Health questions, and investigations
by Government Departments. By noting the disadvan-
tages which attach to those methods we shall learn further
lessons in the need for an independent research authority.

Royal Commissions and Public Health Research

The practice of submitting some Public Health questions
to Royal Commissions, Departmental Committees, or
similar bodies, is itself an indication of the deficiency in
expert knowledge in Parliament ; but it does not meet the
want, for not all questions may be so submitted, and
Bills of great importance may be introduced without any
previous investigation having been made. Royal Com-
missions vary widely both as regards the functions which
are assigned to them, and as regards the thoroughness of
their investigations and the value of their reports. Some
— mainly those appointed primarily to conduct a piece of
scientific research, and staffed by scientific men — have
done work of the highest importance. Such were the
Royal Commission on Human and Bovine Tuberculosis,
and the Departmental Committee on Lighting in Factories
and Workshops. The report of the latter, though not of
general interest, embodies research of the most highly
scientific, painstaking, and detailed character, and if all
our Public Health proposals had been submitted to so
excellent and thorough an investigation we should have
been saved many a grievous mistake. On the other hand,
some Royal Commissions are appointed not so much to
conduct investigations as to give effect to certain widely-
held, preconceived views ; and their members then usually
consist of those who hold those views most strongly, those
who might be expected to oppose them, and representatives
of persons or interests likely to be affected by the proposals,
with the result that the main function of the Commissioners
is to arrive at a compromise between conflicting opinions
as to what can or ought to be done. Such a Commission
may be both useful and necessary, but it is not constituted

316 HEALTH AND THE STATE

to conduct a scientific inquiry, and it cannot be regarded
as replacing that inquiry. An instance of this kind was
the Eoyal Commission on Venereal Diseases, which consisted
of eminent doctors some of whom held strong views on
the subject before their appointment, representatives of
religious organisations, Government officials, and persons
specially interested in women's welfare. The proposals
of the Commission were therefore highly useful as repre-
senting the views of a very diverse body of persons as to
the measures which can be applied to the community.
But their report cannot be regarded as a scientific docu-
ment. It makes scarcely any increase in our scientific
knowledge of these diseases, it contains conclusions founded
on the scantiest of evidence, and statements which
appear to the writer contrary to the evidence given by
witnesses.

Another objection to Royal Commissions is the slow-
ness with which most of them work. The Royal Com-
mission on Sewage Disposal was appointed in 1898, but
did not present its final report until 1915. The Depart-
mental Committee on the Use of Lead in the Painting of
Buildings, appointed in 1911, took three years over its
investigations and preparing its report, but only met on
forty-nine days during that period. These delays are
mainly due to the fact that Royal Commissions are
generally staffed by men busily engaged in other occupa-
tions who can devote only a limited amount of time to the
purposes of the inquiry.

When a Commission has issued its report it is dis-
banded, and no authority exists which can continue its
labours, keep its statistics up to date, and maintain interest
in its proposals. Thus if action is not promptly taken on
the report, often the whole matter is dropped, and the
labour of the Commission is largely wasted. The history
of Public Health effort is beset with instances where this
has happened. It is notorious, for example, that the present
system of registering deaths is highly unsatisfactory and
even dangerous ; and amendment of the law was urged by
the Select Committee on Registration and Certification of
Death as long ago as 1893, and at intervals subsequently

ADMINISTRATION AND PUBLIC HEALTH 317

by various public bodies including the London County
Council and the Medico-Legal Society, but no action has
ever been taken. State action in regard to venereal disease
affords another instance. In 1904 the Inter-Departmental
Committee on Physical Deterioration strongly advised an
investigation into the prevalence of venereal disease, but
it was ten years before the Local Government Board,
stimulated by the International Medical Congress, made
any inquiry, or took steps leading to the appointment of
the recent Royal Commission. The central investigating
body here suggested would in effect be a standing Royal
Commission on all Public Health questions, and would
not allow proposals to be dropped until they had been
considered by Parliament.

Administrative Offices and Public Health

Research

The administrative Departments have also at times
conducted investigations of great value — those, for
example, of Dr. Newsholme and his staff on infant mor-
tality have become classic. But the great disadvantage
of a Department undertaking research into the matters
it administers, is the difficulty of getting unbiassed in-
vestigation ; since the Department is nearly always com-
mitted to some definite line of policy, and is responsible
for carrying that policy into effect. The Insurance
Commissioners, for example, are obviously not the persons
to approach for an impartial investigation into the value
of the Insurance Act in improving Public Health ; the
Board of Education cannot avoid exaggerating the im-
portance of instruction in hygiene, or attributing larger
effects to the school medical service than it has produced
or is likely to produce ; and the Local Government Board
is not the authority to give us, for example, an unbiassed
monograph on the necessity of continuing vaccination.
It is impossible to read the Blue-books and reports issued
by these authorities without realising that each exaggerates
its own sphere of usefulness in the Public Health scheme.
Even in reports in which clearly every effort has been

318 HEALTH AND THE STATE

made to be scientific we find official bias tends to appear.1
Freedom from administration is essential for independence
of judgment.

Another result of having several Government Depart-
ments each investigating conditions in an isolated section
of the community, is to give us an incomplete picture of
the state of Public Health as a whole. Much attention for
example has been focussed upon infant mortality, but few
observers have directed notice towards the great and pre-
ventable loss of life which is occurring in the second year of
life. Some diseases and conditions are kept continually
before the public eye, while others equally or even more con-
trollable are relatively neglected ; every one is familiar
with the evil of tuberculosis, but few have realised the ex-
tent to which we are ravaged by pneumonia and bronch-
itis from infancy upwards. And equally we receive an
incomplete and distorted picture of the causes of disease
and of the steps necessary to prevent them. Certain
causes of ill-health are continually emphasised while other
matters of the greatest importance are never investigated
at all. The Board of Education would have us believe
that education is the great path to sound national health ;
the Local Government Board bids us place our faith in
sewers ; and the Insurance Commissioners will cure us with
drugs and doctors ; but none of these authorities, or any
other Government Department, has ever made a compre-
hensive investigation into the difference between urban

1 For example, the recent report of the Local Government Board on Maternal
Mortality in connection with Child-bearing, attributes the high rate of maternal
mortality in certain Welsh counties in part to deficiency in the quality of supply
of midwifery assistance, and continues : " If the excessive mortality from child-
bearing in Welsh and northern counties is ascribable to a material extent to de-
ficiency of skilled assistance in child-birth, it might be anticipated that the low
mortality in the last-mentioned counties [Isle of Wight, Buckinghamshire, West
Sussex, Oxfordshire, Isle of Ely, Stoke of Peterborough, and Rutland] would be
associated with an adequate medical and nursing service. The evidence on this
point is, however, imperfect." But why is this evidence imperfect ? These counties
are more accessible and easier of investigation than those of Wales. Why are
figures, which prima facie appear to negative the preceding deduction, dismissed
in a single sentence, and the report published before the exact conditions in the
counties to which they relate have been investigated ? In another part of the
report we find the unscientific statement : " No completely consistent relation-
ship between excessive mortality from child-bearing and a high degree of employ-
ment in factories is visible in these tables, though it can scarcely be doubted that a
close association exists between the two factors." It must not, however, be in-
ferred from these extracts that the report is not a brilliant piece of research into
an intricate subject.

MINISTRY OF PUBLIC HEALTH 319

and rural mortality and its causes, or has shown that at
the bottom of nearly all our Public Health difficulties lies
the land question. Quite properly they would consider
that this subject is outside their respective spheres, and
being so, it is outside the sphere of any office — except, to a
limited extent, that of the Registrar-General — and thus
this question, the most important of all which relate to
Public Health, is never adequately studied.

The Office of the Registrar-General as the
Ministry of Public Health

There is one Government Department which is admir-
ably adapted to be transformed into a Ministry of Public
Health of the type suggested, and that is the office of the
Registrar- General. This office is already almost entirely
in the nature of a research Department ; it has no admin-
istrative functions except those necessary for its own
special purposes ; and it produces every year the most
valuable and highly scientific report on Public Health
which we possess. The Annual Reports of the Registrar-
General are conspicuously free from bias ; they serve as
the basis of all accurate knowledge relating to mortality ;
they are continually used and quoted by the medical
officers of other Government Departments who indeed
would be almost powerless without them ; and their cold
hard facts give us a true picture of what is occurring,
without which we should be still more led astray by the
eulogistic utterances of other Departments which are their
own judges of their work. The Registrar- General com-
piles the statistics of births and marriages ; but the great
bulk of his report is devoted to an analysis of the causes
and distribution of deaths. What is here proposed is that
the Registrar-General should do for sickness and disease
among all classes, infants, children, mothers, insured and
non-insured persons, paupers, factory operatives, etc.,
what he is doing for mortality ; and that for this purpose
the whole of the medical statistical work of the Local
Government Board, the Board of Education, the Home
Office, and the Insurance Commission should be handed

320 HEALTH AND THE STATE

over to him with the staffs specially concerned with that
work.

The Proposal to form a Ministry by Uniting
the present administrative departments

It will be objected that the scheme outlined above still
leaves a number of isolated medical Departments working
independently, for it is to prevent this that the proposal
to form a Ministry of Public Health by uniting the present
offices finds so much favour. But attractive though this
proposal may seem at first, careful consideration will show
that there are strong reasons against it. In the first place,
the medical administrative duties of some of these offices
are so closely connected with their general spheres of work
that to separate them would be highly inconvenient. It
is obvious, for example, that the Board of Education must
administer the school medical service, for it would be
extremely confusing for another Department to frame
regulations concerning grants, visits of school doctors,
duties of teachers in connection with medical inspection,
and other matters which demand familiarity with the
distribution of the schools, the size of classes, times of
holidays, etc. Similarly the Home Office, which is
responsible for the general administration of the Factory
Acts, must control the routine work of the medical
inspectors who assist in carrying out those Acts. On
the other hand, the purely scientific and research work
of both the Board of Education and the Home Office
could quite fitly be transferred to the Ministry of Public
Health.

The fact is, that it is not so much uniting as coordinat-
ing which these bodies need, and it is mainly in the scientific
and statistical work that coordination is required. More-
over, any union would probably be more in name than in
fact. We could take out the medical staffs of the Local
Government Board, the Board of Education, Home Office,
Insurance Commission, etc., set them down in a building
in Whitehall, and call them a Ministry of Health ; but the
result would almost certainly be jealousy and confusion,

MINISTRY OF PUBLIC HEALTH 321

ending in the establishment of a number of separate
branches, which, though under one roof, would remain as
much uncoordinated and distinct as they are at present —
repeating what happened when the Registrar-General, the
Poor Law Board, and the Local Government Board were
"united."

Finally the great disadvantage would remain that a
Ministry of Health created by uniting the present medical
Departments, would still be its own critic and judge. At
present an administrative Department includes or omits
just what it pleases in its annual report, prepares the
answers to Parliamentary questions impugning its ad-
ministration, and, when publicly attacked, takes refuge
in the unwritten law — excellent for the Department, but
prejudicial to the public — that a Government office shall
never reply to or defend itself against attacks, except
through the Minister responsible for the office to Parlia-
ment. In return the actions of the Minister must be
supported. Thus a kind of confederacy grows up which
necessarily brings the Department under political influences.
The officials come to regard their first duty as owed to their
political chief instead of to the public, and the Department
must always be made to cut a good figure in Parliament.
Eulogistic statements and statistics are drafted in the
office for the Minister to present to Parliament, and if an
Act does not appear to be working satisfactorily, the
Department provides the Minister with ingenious answers
to questions, statements of the extent of its operations, and
statistics of the number of persons it claims to have
benefited. The investigations and returns of a Ministry
of Health would give us more reliable information, and
would indicate what measures had been beneficial and
what further efforts are required.

But while on the whole the principal Departments
must be left to administer their special services, there is
undoubtedly room for coordination and re-arrangement
among them. Administration would be much simplified
by decentralising many services, and in the next chapter
proposals will be made for increasing the powers of local
authorities, particularly in the direction of allowing them

322 HEALTH AND THE STATE

to establish local medical services in accordance with the
needs of the locality. If this principle were adopted, many
of the duties at present discharged by central authorities
would be transferred to local bodies. It will be proposed
that medical and sanatorium benefit should be taken out
of the Insurance Act, and merged into local medical services
no longer applying exclusively to insured persons. The
Insurance Commission would then remain simply a
financial office responsible for the central administration
of sickness and maternity benefit as forms of assistance,
and would have no relation to Public Health. Similarly,
the medical side of the Poor Law might be absorbed by
the local medical service, and the medical functions of the
Poor Law branch of the Local Government Board would
then disappear. The overlapping of the Board of Educa-
tion and the Local Government Board in the matter of
maternal and infant welfare might come to an end, and as
there is no reason why these duties should be performed
by the Board of Education, they should be transferred to
the Local Government Board. The duty of compiling
the annual statistics relating to coroners' inquests should
be transferred to the Ministry of Health from the Home
Office ; for the latter has left them practically unrevised,
and in an almost useless state for nearly fifty years. The
grant made to the Local Government Board for research
should be transferred to the Ministry, and the Research
Committee should form part of the new office. The
Ministry of Health should take the place at present
occupied by the Privy Council in relation to the Central
Midwives Board and the General Medical Council, leaving
these authorities otherwise unchanged, though it might
take over from the General Medical Council the duty of
issuing the British Pharmacopoeia which is a purely
scientific matter. The duty of the Pharmaceutical Society
to advise on the scheduling of poisons might also be trans-
ferred to the Ministry.

The medical duties of the War Office and the Admiralty
must remain entirely distinct ; and the functions of the
Colonial Office in the investigation of tropical diseases are
also so sharply delimited that there would be no need to

MINISTRY OF PUBLIC HEALTH 323

interfere with them, though the Ministry of Health might
be authorised to assist in the establishment of schools and
laboratories for this purpose.

There are certain other matters which, though they
involve administrative action, are almost entirely of a
scientific character, and are therefore appropriate to be
transferred to the Ministry. Such are the determination
of what infectious and industrial diseases shall be notified
under the Infectious Diseases Act and the Factory Acts ;
the prescribing of standards of purity of milk, butter, and
other foods, and the issue of regulations for the purpose of
detecting and preventing adulteration. If the recom-
mendation of the Committee on Patent Medicines be
adopted, the control of advertisements of these prepara-
tions should also be assigned to the Ministry.

The preceding paragraphs do not purport to contain
more than the barest outline of a scheme for reorganising
the Public Health Departments. The suggestions are
intended to make clear the general principle proposed, viz.
the establishment of a Ministry of Health, limited in its
executive powers, but investigating and recording in every
direction ; and coordinated with it, administrative Depart-
ments directly responsible for administering Public Health
measures which demand executive action. But while the
principle of division is clear the details will require pro-
longed consideration and very careful adjustment. Prob-
ably the best plan would be to appoint the Ministry first
on the lines suggested, and authorise it to inquire into the
whole system of Public Health administration and recom-
mend what further changes are desirable. Any other
course would lead to serious delay in a matter which is of
the greatest urgency. Suppose for example it is decided
to form a Ministry on the lines usually proposed of uniting
the present Departments. The Bill necessary would be
gigantic in its scope ; and would involve many difficult
questions, and affect many interests. It could not be
satisfactorily considered if introduced before the termina-
tion of the War, and it would probably be delayed until a
new Parliament had been elected, and even then deferred
until various after-war problems had been dealt with. If

324 HEALTH AND THE STATE

the question were referred to a Royal Commission further
delay would occur.

On the other hand it would be a comparatively simple
matter to create the Ministry side by side with the present
Departments. We should at once meet the greatest
necessity in our present system, that of an investigating
authority ; and we could add other duties to the Ministry
one by one, thus effecting the change with the minimum
of inconvenience.

The Personnel of a Ministry of Health

In order that it may properly discharge the functions
suggested, the permanent staff of the Ministry of Health
must consist almost exclusively of medical and scientific
men. It must include those who have devoted themselves
to the purely scientific aspects of medicine and hygiene ;
those who are authorities in special branches, bacteriology,
pharmacology, food analysis, hospital construction and
equipment, sanitary engineering, water-supply, industrial
diseases, statistics, etc. ; and those who have had personal
experience among the poor as Medical Officers of Health,
Poor Law Medical Officers, school doctors, and practi-
tioners, and who know the practical difficulties which
have to be overcome in applying the results of scientific
medicine to human beings under the worst possible
environment.

This proposal involves a break with the traditional
belief that lay civil servants can fitly undertake the ad-
ministration of medical and Public Health affairs. The
view that medical men cannot be trusted to exercise more
than very limited authority, and that they are present in
a Government office mainly in an advisory capacity
though they need not be consulted nor their advice taken,
strongly characterised the earlier administration of the
Public Health services ; and, though modified, exists to
this day in the Civil Service to a degree only known to
those who have had personal experience in a Government
Office. Writing of the old Poor Law Board, which exercised

PERSONNEL OF A MINISTRY OF HEALTH 325

numerous medical functions from 1847 to 1871, Sir John
Simon said : —

Perfunctoriness had characterised its work in matters of medical
responsibility. The root of the fault, giving rise to much which
had gone wrong in the medical relations of the Office, was, that the
Board had relied very unduly on the sufficiency of non-medical
officers in those relations. The original theory seems to have been
that on any extraordinary occasion extraordinary assistance could
be obtained ; but that for the ordinary medical business of the
Board, the common sense of secretaries, assistant secretaries and
secretarial inspectors did not require to be helped by doctors.

And writing in 1890 of the earlier years of the Local
Government Board he said : —

They did not entrust to the Medical Department any systematic
share in the supervision. The essentially supervisional arrange-
ments were to be non-medical ; and except as to the superintendence
of vaccination (which was let continue much as it had previously
been) the Medical Department was only to have unsystematic
functions. In cases where the President or a Secretary or Assistant-
Secretary might think reference to the Department necessary the
individual reference would be made ; and where, on motion from
the Medical Department or otherwise, he might think medical
inspection necessary, he would specially order the inspection ; but
these unsystematised inspections could not extend to more than
comparatively few localities in a year, for the medical staff was not
allowed the enlargement which had been hoped for a provision for
larger usefulness. In general, the business of the Public Health
seems to have been understood as not requiring any other system
of supervision than the non-medical officers could supply.

At the present day the Chief Medical Officers of some
Departments have considerable liberty of action though they
are always subordinate to lay authority. But this is not
universal. Under other circumstances the Chief Medical
Officer of a Government Office, though highly salaried and
brilliantly qualified, may be kept in a strictly subordinate
position devoid of influence or dignity. He may not write
an official letter, he has no voice in the appointment of his
junior staff, he may or may not be consulted by his ad-
ministering authority, and, if consulted, his opinion on a
purely technical point may be disregarded. Some of the
most elementary mistakes in recent Public Health adminis-
tration have resulted from such conditions.

326 HEALTH AND THE STATE

The distrust of the medical administrator in the Civil
Service appears to arise from fear that he may make a
mistake in some legal point, or may fail to carry out his
duties in a strictly official manner. Hence practically only
lawyers and those who have had a Civil Service training
may be permitted to handle the administrative machine.
Even the Chairman of the purely scientific Medical
Research Committee is a member of the legal profession.
It is not realised that a mistake in medicine by a legal
administrator may be infinitely more disastrous to the
community than a mistake in law by a medical adminis-
trator. The present theory of official control leads to an
aggrandisement of the means at the expense of the end.
The fact that the ultimate aim of the whole machinery,
authorities, committees, experts, Acts, and regulations,
is the improvement of Public Health tends to be lost sight
of ; and the working of the machine in strict accordance
with the letter of the law, whether beneficial or not, is
regarded as the great object to be achieved.

But the training of neither the lawyer nor the civil
servant fits them to deal with the problems of Public
Health. Few of them have had personal experience of
the lives and conditions of the poor when struggling against
sickness ; the things they deal with are not real to them,
and in consequence they lack the sense of responsibility
which knowledge of the way their actions may affect the
lives of many thousands of humble folk would bring to
them. This knowledge is only possessed by one who has
been through the mill himself, who has heard the " knocker-
up " at 4 a.m., while he sits waiting for the baby to be
born in a northern slum tenement from which the father
and children have been turned out on to the stairs,
or into the overcrowded room of a kindly neighbour ;
or has spent hours prescribing for a crowd of ailing panel
patients, knowing all the time how little real good he can
do them ; or has served as medical officer to a committee
or authority which can determine his tenure of office, and
includes among its members some most interested in
maintaining the very abuses he seeks to abolish. If civil
servants had had these experiences it is certain that they

PERSONNEL OF A MINISTRY OF HEALTH 327

would give far more consideration to the circulars and
administrative orders which emanate from Government
offices. We should not have red tape continually hinder-
ing the already tardy assistance given to the working
classes ; decisions arrived at on the most perfunctory
investigation ; the last items on a Committee's agenda
hurried through ; medical opinion continually overruled ;
and vitally important questions indefinitely postponed
simply because they are difficult to deal with. It was once
proposed that every Judge of a Criminal Court should
spend a week of the year in prison; and on the same
principle it is to be regretted that we cannot compel every
lay Public Health official to spend a month as a panel
doctor in a slum district.

Moreover, the average civil servant has not had the
scientific training, which would enable him to distinguish
between sound deductions and unverified generalities ; and
he has no means of acquainting himself with advances in
medicine and hygiene. It is the absence of this training
in the majority of civil servants which makes them so
timorous of doing anything that involves innovation or
liberty of action. For every step justification must be found
in an Act of Parliament or regulation, and the attitude
towards medical men is expressed in the words of a Secre-
tary of a Government Office who said to the writer : " The
medical men we want here are humdrum persons who
won't be continually proposing new things. We don't
want clever doctors in the Civil Service." Tradition and
precedent are their guides, reinforced by the appreciable
proportion of lawyers in the service ; yet precedent, so
dear to the lawyer, is the very last principle which should
govern administration of the ever-changing and ever-
widening sphere of Public Health.

The objection may be made to these proposals that
they tend to place too much power in the hands of doctors.
The fact must be recognised that, whether justified or not,
there is among the laity considerable distrust of the
medical profession ; and the plea would certainly be made
that, even if the staff are medical men, the supreme head
of the Department must be a layman, — a principle which

328 HEALTH AND THE STATE

has been almost invariably observed in the War Office and
Admiralty.1 These, however, are executive offices, possess-
ing powers of compulsion over the acts and lives of citizens,
and in a democratic country their ultimate control must
remain in lay hands. But the Ministry of Health here
proposed is of an entirely different character. It is to be
an office for research and investigation, and is to have no
authority, except such as comes from the weight of its
opinion ; and no power of issuing orders, except such as
are required for purposes of research and the advancement
of knowledge. It is therefore much more comparable
with, let us say, the Geological Survey, and at the head of
this no one would propose to place other than a geologist.
But just as the authorities which use the results of the
Geological Survey, its maps, its knowledge of mines, its
information regarding water-supply, etc., are under lay
control, so the administrative Departments which em-
ployed the knowledge collected by the Ministry of Health
would remain as at present under lay authority. Whatever
scheme for a Ministry of Public Health be adopted, it
must be recognised that if it is to be administrative, it
must ultimately be subject to lay authority. Nothing
else is in accord with democratic principles. But in the
opinion of the writer it is well worth sacrificing all authori-
tative power in order to obtain the inestimable advantage
of a scientific, independent, and unbiassed body which
would be continually investigating the state of Public
Health and the value of measures designed to improve
it, thereby reducing to a minimum the costly errors and
futile efforts which have sometimes attended Public Health
activity in the past.

1 Mr. Bernard Shaw has said : " I do not know a single thoughtful and well-
informed person who does not feel that the tragedy of illness at present is that it
delivers you helplessly into the hands of a profession which you deeply mistrust."
— Preface to The Doctor's Dilemma. And Miss Margaret McMillan, voicing un-
educated opinion, has said : " Yet I think it is impossible to deny that while the
individual doctor has many friends, the profession is regarded by the public with
some doubt and even distrust. No one who has been engaged for years in trying
to bring the doctor into the schools of the land can help knowing that there is a
strong and deep feeling of misgiving at the thought of extending the power and
influence of the medical profession."

CHAPTER XI

PUBLIC HEALTH AND LOCAL ADMINISTRATION

The responsibility of local authorities — The decline of democratic control
in Public Health — Local needs and local control — Local administration
and the cost of sickness — A single local health authority or ' Local
Health Council ' — Should the Health Council be the present Local
Authority or a new body ? — Coordination of the Local Health Council
and the Local Authority — A suggestion for financial arrangements —
The question of a local medical service — The position of the voluntary
hospitals — Conclusion.

The Responsibility of Local Authorities

Local administration in Public Health is, or should be,
governed by very different principles from those observed
in central administration. Local authorities — including
in the term not only Local Sanitary Authorities, but
Insurance Committees, Boards of Guardians, etc. — are
the actual executive bodies, since they have to carry into
effect all orders and decisions, whether made by them-
selves or by higher administrative authority, or embodied
in Acts of Parliament. Democratic principles demand
therefore that local authorities should have a large share
in the making of these decisions, and in determining the
means by which they are to be given effect. Though a
central investigating body composed of scientific men
must necessarily have severely limited powers, executive
power must exist somewhere, and in the scheme to be
outlined in this chapter it is proposed that local authorities
— or rather one local authority formed by combining the
various local Public Health authorities — shall be given the
largest share in the control of Public Health affairs for
local purposes.

329

330 HEALTH AND THE STATE

The Decline of Democratic Control in
Public Health

This is a democratic country, nevertheless the system
of Public Health administration which has grown up is
rapidly removing the control of the people over many
matters which intimately affect their lives and welfare.
We have seen that the Insurance Act was passed without
any mandate from the country ; this however was done
by Parliament, and the constitution provides a means of
reversing it — in theory at all events — if popular disapproba-
tion is sufficiently great. But there is no means of con-
trolling the actions of administrative bodies. Parliament
more and more leaves matters unfinished or undefined in
Acts of Parliament, and assigns to Government offices the
duty of giving them shape and form ; with the result that
some of these offices are now almost legislative authorities,
issuing orders and regulations of sweeping importance,
which have not only not received democratic assent, but
clearly never would have received that assent. It might be
argued that these orders and regulations relate to matters
requiring special knowledge which are therefore unsuitable
for democratic control, and if Departmental administra-
tion had always been sound, and conducted solely with a
view to public welfare, we might accept this proposition ;
but we have only to look again at the state of Public
Health in this country, and to recall the numerous
mistakes, muddles, and partiality of C4overnment offices,
in order to realise that local democratic control would at
least not have been a greater failure than control by civil
servants who are in no sense representative.

It may be noted that even when an Act of Parliament
purports to give a degree of local autonomy, liberty of
action may be nullified by the central Departments. Con-
sider, for example, Section 15 of the Insurance Act which
begins : " Every Insurance Committee shall for the purpose
of administering medical benefit make arrangements with
duly qualified medical practitioners in accordance with
regulations made by the Insurance Commissioners." An
ordinary person reading these words would suppose that

DECLINE OF DEMOCRATIC CONTROL 331

Insurance Committees had some freedom of action in
regard to medical benefit, and his belief would be
strengthened by other elaborate provisions of the Act for
securing that Insurance Committees should be representa-
tive of insured persons, County Councils, etc. But as a
matter of fact all arrangements made by Insurance Com-
mittees must be " approved " by the Insurance Com-
missioners, and by the simple process of intimating
beforehand the only arrangements they will approve, the
Insurance Commissioners obtain at one stroke entire
control throughout the country. Insurance Committees
have no voice in determining the rate of remuneration of
doctors, or the scope of medical benefit, and no power to
make better arrangements. A glance at the agenda of
an Insurance Committee will show how trivial are the
matters in which they are allowed any freedom, and as a
matter of fact, almost all their duties could have been dis-
charged by a clerk directly appointed by the Insurance
Commissioners. The result is that men of public spirit
and energy do not care to accept positions of so little
dignity and importance, and local administration suffers.
This has been well expressed by a recent writer in the
Hearts of Oak Journal who, commenting on resignations
of members of the City Council of Exeter from the In-
surance Committee, said : " We need not examine griev-
" ances in detail. Every one who has been associated with
" the management of the Act is cognisant of the struggle
" that has been waged between local administration and
" bureaucracy. It is a case of centralisation v. decentral-
" isation, and the central powers having the purse have
'w been able to make their will prevail. Insurance Com-
" mittees are now very little more than conduits, without
" initiative or authority, and I believe the public men
" who have just retired from the Exeter Committee feel
" that they can put their time to better use."

It is important to bear in mind the extent to which
local bodies are controlled by higher authority, since this
is one reason why local administration sometimes appears
defective, and is blamed unjustly. Those who advocate
centralisation of Public Health control generally do so on

332 HEALTH AND THE STATE

the ground that local authorities are inclined to be ' apa-
thetic,' and that the central Departments must be in a
position to bring pressure to bear upon them. But we
cannot rely upon this pressure being exercised even where
it would be justified ; and for many difficulties and apparent
neglect, the central Department is often more to blame
than the local authority. The Local Government Board
or the Insurance Commissioners, however much they may
inspect and obtain reports, can never be as fully informed
of the local conditions and difficulties as those who are
living on the spot, and if a central authority issues orders
which are inappropriate, or refuses assent to schemes
which are sound, the local authority is too often blamed
for the consequent failure.

Local Needs and Local Control

Another reason for giving wide discretionary powers
to local authorities in Public Health administration is the
fact that they know better than any central authority
what are the causes of sickness in the locality, and how
they may best be prevented ; and decentralisation permits
of wide elasticity in the measures taken according to local
needs and exigencies. The conditions and requirements
of Public Health in different localities — an industrial town,
an agricultural district, a seaport or a mining area, are
so diverse that it is simply impossible to deal with them
by uniform methods ; yet this is what centralisation in-
volves. We have applied a rigid and uniform panel
system over the whole country, yet so enormously does
the demand for medical attendance vary, that while one
doctor finds his remuneration averages Is. 6d. per attend-
ance, another receives several pounds for each visit or
consultation. We have made the Notification of Births
Act compulsory over the whole country, yet we have seen
that the distribution of infant mortality is exceedingly
unequal, and that in a large number of rural districts it
is probably as low as it is possible to make it by human
endeavour. Identical conditions of bad housing or over-
crowding are far more injurious, and demand more radical

LOCAL ADMINISTRATION 333

treatment in large urban areas than in country villages ;
and the incidence of tuberculosis, venereal diseases, in-
ebriety, etc., vary within such wide limits, and depend so
much upon local conditions, that they can only be dealt
with effectively by persons intimately acquainted with the
circumstances of the locality. The application of uniform
methods is extravagant and inefficient, and the belief that
what is good for one district is necessarily good or desirable
for another, leads to an erroneous method of measuring a
local authority's activity, which is a further cause of un-
reasonable complaint against local administration. Critics
of a Borough Council's work do not estimate its value
from the local death-rate or incidence of sickness, which
often they know nothing about, but from the number of
officials it has appointed, and the number of schemes it
has devised for doing things, many of which may be un-
necessary. If a Borough Council has not appointed a
staff of health visitors, it is certain nowadays to be held
up to public obloquy, no matter how low the local rate of
infant mortality may be. Under the scheme here pro-
posed, the local authority responsible for the case of Public
Health should have full control over all matters pertaining
thereto, except those which must obviously be uniform
over the whole country, such as the methods of preventing
food adulteration or the notification of industrial diseases ;
should have power to provide whatever medical services,
institutions, etc., are necessary in the locality ; and should
be able to act on its own initiative without having to incur
the delays necessitated by continually submitting its pro-
posals to Government Departments.

Local Administration and Cost of Sickness

If local authorities are made responsible for the care
of health and for the provision of medical services and
institutions for treatment, it almost necessarily follows
that each locality must bear the cost, or the major part of
the cost, of these measures. This principle has the great
advantage that by making each locality pay the cost of
its own sickness, a strong stimulus is provided towards

334 HEALTH AND THE STATE

remedying insanitary conditions. Ratepayers and local
authorities would find that in the long run it was much
cheaper to clear slums and otherwise establish healthy
conditions, than to pay for the continued upkeep of
hospitals, infirmaries, sanatoria, and medical services.
Moreover, this system is very much fairer in view of the
unequal incidence of sickness. We have seen how the
Insurance Act is operating as a tax on rural areas for the
benefit of industrial towns ; and a large part of Government
expenditure and Parliamentary grants-in-aid, provided
out of general taxation for Public Health purposes, such
as those for the school medical service, Poor Law infir-
maries, housing schemes, and infant clinics, in the last
analysis, penalise healthy for the benefit of unhealthy
districts and industries. Perhaps the most striking
example is the recent provision for the treatment of
venereal diseases. Although the report of the Royal
Commission showed that syphilis is much more prevalent
in large towns than in rural districts, only 25 per cent of
the cost is to be raised locally, and 75 per cent is to be
provided by Government grant, thus making many
districts where syphilis is almost unknown contribute a
substantial part of the expenditure, and proportionately
reducing the incentive to the Local Authorities, where
the incidence of the disease is high, to take steps to
prevent it. Nor are grants-in-aid alone involved, for
healthy localities are also paying an unfair share of the
cost of central administration and official salaries.

While the general principle of local payment of cost
might be observed, it would not necessarily be sound to
insist on its rigid observance in every case. Very poor
districts might legitimately receive special assistance, and
where the action of one authority benefits contiguous areas,
as in a scheme for water-supply or drainage, the cost would
need to be apportioned. Moreover, the sickness in a
particular district may not be entirely its own fault ; the
sickness in Stepney, for instance, is undoubtedly partly
due to the fact that it is surrounded by other unhealthy
districts, but for the purposes indicated, London would
probably have to be regarded as one unit. These how-

SINGLE LOCAL HEALTH AUTHORITY 335

ever are matters of adjustment which do not affect the
general principle.

To summarise then, the chief reasons for increasing
local authority in Public Health are : (1) to preserve
democratic control ; (2) to enable local authorities to
provide exactly what they need ; and (3) to give them a
direct incentive in reducing local sickness to the minimum.
The charge that local authorities are apathetic is not estab-
lished as a general truth. We have already noticed the
zeal displayed by Bradford and other Borough Councils, and
an increase in the dignity and power of these authorities
would attract men of capacity to their service, and stimu-
late public interest in the problems with which they deal.

A Single Local Health Authority or ' Local
Health Council'

We have seen that in central administration of
Public Health it is desirable to keep certain Departments
separate, since their medical duties are so closely related
to their general spheres of activity ; but in local administra-
tion the reasons for division of authority no longer hold
good. A local authority is concerned with a definite
geographical unit, and a community of persons all subject
to more or less the same conditions, and it is wasteful and
inefficient to have a number of uncoordinated bodies,
Local Sanitary Authorities, Insurance Committees, Boards
of Guardians, and Education Authorities, each concerned
with a special section of the community as though it were
in a water-tight compartment. These should be replaced
by a single body or ' Local Health Council,' as it
might be termed. The new authority should be con-
cerned with the health of all persons within its district ;
it should be empowered to investigate all the causes
responsible for preventable disease within its juris-
diction, and it should provide the medical attendance,
hospitals, sanatoria, lying-in homes, convalescent homes,
and other institutions which the particular conditions
within its area necessitate. If this plan were adopted,
certain local administrative bodies would disappear, and

336 HEALTH AND THE STATE

others would remain simply to discharge non-medical
functions. It has already been suggested that medical
and sanatorium benefit should be taken out of the Insurance
Act ; and Insurance Committees could then be abolished,
the obligation to provide necessary medical attendance
not only for insured persons, but for their dependents
being discharged by the Local Health Council, while all
sanatoria and dispensaries for tuberculosis would pass into
their possession. The Boards of Guardians would hand
over to the new authority their duty of providing for the
sick poor, no longer to be distinguished from other classes
of the community unable to afford adequate medical
attendance, and their work in connection with public
vaccination ; and would transfer their infirmaries and
similar institutions, and their staffs of indoor and outdoor
medical officers. Thus the Guardians would remain
simply as an authority for the relief of destitution. The
school medical service would be administered by the Local
Health Council, but only as a part of a larger scheme for
providing for all children whether at school or not. The
Medical Officer of Health would be the chief permanent
medical officer of the Local Health Council, and the
tuberculosis officers and staff of sanitary inspectors, health
visitors, etc., would pass under its control ; the local
registrar of births, deaths, and marriages should be affiliated
to the Council ; and the Coroner should be required to
send to the Council reports on all deaths from industrial
diseases, neglect, starvation, lack of medical attendance,
etc.

Should the Local Health Council be the Peesent
Local Authoeity oe a New Body ?

The question remains to be considered whether the
Local Health Council should be the present Local
Authority with its powers enlarged, or whether it should
be an entirely new body to which are transferred the Public
Health duties of the present Local Authority together with
those of other authorities. The first system has the merit
of simplicity, since it would place all local administration

LOCAL HEALTH COUNCIL 337

in the hands of one body. Nevertheless it appears to the
writer more advantageous to adopt the second, thus giving
us a Local Health Council in every County and County
Borough dealing exclusively with Public Health affairs,
and a Local Authority concerning itself with all other
spheres of municipal activity. A plan for coordinating
these two bodies, and for adjusting certain matters wherein
they might overlap, will be considered later.

The first reason for advocating an independent Health
Council is the fact that the present Local Authority may
be influenced by different and opposite motives, some of
which may not operate in the interests of Public Health.
It is the rating authority, and usually a proportion of its
members have been elected for the express purpose of
lowering the rates ; while at the same time it is expected
to undertake schemes for the protection and improvement
of the Public Health, some of which may be of a costly
character. Secondly, a Local Authority is usually, and
quite properly, interested in the commercial prosperity of
its town or district ; and since local administration has
tended to pass largely into the hands of the trading and
business class, the Local Authority may be unduly con-
cerned in protecting commercial interests to the prejudice
of Public Health. A scheme for rebuilding or widening
a main street or establishing an open space is considered
not only from the point of view of Public Health, but also
as regards the effect it will have on the general trade of the
locality and on the interests of the shopkeepers displaced,
some of whom may actually be members of the Local
Authority. In a fashionable resort or seaside watering-
place a fever hospital must not be built here or a sanatorium
there, lest it may keep visitors from the town ; in an in-
dustrial district, the interests of the factory, in which large
numbers of the local people earn their living, and which
has perhaps ' made ' the town, must not be unduly inter-
fered with. Nor is concern lacking for even humble
interests. In many districts costers are permitted to
crowd narrow thoroughfares with their stalls, and litter
the road with vegetable refuse, simply because they have
an ancient prescriptive right to be there. It is not

z

338 HEALTH AND THE STATE

suggested that Local Authorities are wrong in taking this
attitude, having regard to their character and general
functions, but it is one which clearly must often conflict
with strict concern for the Public Health.

As regards the method of appointing a Local Health
Council, while the principle of democratic control must
be observed, it would perhaps be better for the Council
to be nominated by bodies themselves elected rather than
be directly elected by popular vote. It may be suggested
that the Local Authority should nominate one-half of the
members of the Local Health Council, which would in
effect amount to its transferring its Sanitary Committee
to the new Authority. One-quarter might be nominated
by the Boards of Guardians, and the remainder by the
managers of local hospitals and the Ministry of Health.
One member might be nominated by the Member of Parlia-
ment for the locality, a system which would give the Health
Council a direct connecting link with Parliament, and
afford ready expression of its opinions in the legislature.
The advantage of nomination over election lies in the fact
that it would enable persons to become members of the
Council who would not care to face popular election,
such as professional men, writers, and University lecturers.
A service which had a sphere of scientific investigation and
a direct concern with all Public Health questions would
undoubtedly prove attractive to a type which at present
rather tends to hold aloof from municipal administration.

In London the question is more complicated. Perhaps
the best plan would be to enlarge the powers of the Metro-
politan Asylums Board, making it the general authority in
London to provide medical services, and leave to the London
County Council most of its present Public Health duties.
The London Insurance Committee would disappear. A
Local Health Council could be created in each of the
Metropolitan Boroughs, but the division of function
between it and the enlarged Metropolitan Asylums Board
would require to be defined. The Boards of Guardians
would remain only as authorities for the relief of destitution.

FINANCIAL ARRANGEMENTS 339

Coordination of the Local Health Council
and the Local Authority

In most directions, particularly those of providing local
medical services, the duties of the Local Health Council
would be sharply denned, but inconvenient overlapping
might arise in certain matters which are not exclusively
concerned with Public Health, such as Town Planning and
housing schemes, and water-supply. These matters in-
volve heavy expenditure, interference with vested interests
and rights, compensation and other legal questions with
which, apart from their Public Health aspects, the Local
Health Council would not be best suited to deal. Matters
of this nature, which concern closely both Authorities,
might be referred for settlement to a standing Joint Com-
mittee, one-half appointed by the Local Authority, and
one-half by the Local Health Council.

A Suggestion for Financial Arrangements

It would obviously be highly inconvenient to have two
authorities raising local funds, and the Local Authority
must clearly remain as the only local rating authority.
Moreover, it must have reasonable power to control or
approve of expenditure by the Local Health Council, for
if the latter were given carte blanche to spend what it
liked, its zeal might easily outrun economic discretion.
The following scheme for securing co-operation may be
suggested : The Local Health Council should annually
estimate its expenditure for the forthcoming year, and
present this estimate to the Local Authority with a full
statement as to the reasons for the expenditure, the Local
Authority being entitled to ask for any further information
it considered necessary. If the Local Authority approved
the expenditure, it would provide the sum required. If it
disagreed on any points, these matters should be referred
in the first instance to the Standing Joint Committee. If
the Committee were unable to arrive at a settlement
acceptable to both authorities, then the disputed questions
should be referred for final decision to the Local Govern -

z2

340 HEALTH AND THE STATE

ment Board acting in conjunction with the Ministry of
Health.

The Question of a Local Medical Service

The provision of a complete and adequate medical
service for the treatment and care of sick persons is one of
the most difficult questions which the country must face
in the near future. The service established under the
Insurance Act has not fulfilled its original intentions, has
been very costly, and has given rise to widespread dis-
satisfaction. It is well known that reorganisation of the
panel service is contemplated, and the proposal to establish
a national medical service, though not generally approved
by the doctors, is steadily gaining adherents. In favour
of a national service it is argued, that while paying the
doctors good salaries it would be less costly than the
present system ; that it would enable a better distribution
of doctors to be made ; that the doctors would no longer
be competing against each other for patients or be in-
fluenced by financial considerations ; and that consultants,
specialists, and institutional treatment could be added to
the service. The extreme proposals extend to nationalisa-
tion of the voluntary hospitals. Against a national medical
service it is urged, mainly by the doctors, that it would
preclude freedom of choice of doctor by patient, would
make the doctor a servant of the State thereby limiting
his freedom of action, and would lessen his personal interest
in the welfare of his patient.

It is doubtful however whether those who advocate
a national medical service have fully realised the immense
difficulties which stand in their way. Let us for the
moment fix attention upon that part of the service which
is concerned with medical practitioners, leaving institu-
tional and special treatment for later consideration. In
the first place the service must be open to all but the upper
and middle classes ; for as soon as we begin to define the
persons who should be entitled to the service, we find it
impossible to draw any other line than that which would
be voluntarily adopted ; and this would entail a much
greater degree of interference with private practice than

LOCAL MEDICAL SERVICE 341

was effected by the Insurance Act. A service of whole-
time salaried officers clearly could not be restricted to
insured persons, for that would lead to one doctor attend-
ing the father, and another the wife and children, a system
which would never be satisfactory. If the doctors were
only part-time, and were allowed to undertake private
practice as well, other obvious objections would arise in
many districts. The first enlargement then would be to
include dependents of insured persons ; but this would
involve all kinds of difficulties in defining a ' dependent,'
and it would leave out of the service a large number of
poor persons who are neither insured nor dependents of
insured persons. The next proposal accordingly is to take
in all persons whose income is below a certain limit. But
apart from the fact that it would be very difficult to obtain
agreement as to what the limit should be, and that the
scheme takes no notice of varying claims on income, it is
almost impossible to determine incomes among the work-
ing classes ; and in the end we should have to adopt the
limit taken for revenue purposes, which the doctors would
almost certainly consider too high. During the con-
troversy over the Insurance Act the British Medical
Association urged the fixing of an income limit of £2 per
week. To observe this it would be necessary to obtain
returns from millions of the working classes ; to determine
the annual incomes of wage-earners employed during part
of the year and unemployed for another part, sometimes
at one rate and sometimes at another, and perhaps in
different localities ; to decide questions of allowances for
tools, insurance, children, etc. ; and to determine the
position of the wife's income from charing, or the son's
from selling newspapers. The scheme is so impossible
that it is difficult to realise how it could ever have been
seriously put forward. It would be practicable to adopt
the income tax limit, but even this would entail an immense
amount of indexing, registering, compiling of doctors' lists,
etc. The number of income tax payers and their de-
pendents in England and Wales has been estimated at
some six millions.1 Under the scheme, therefore, the State

1 This was before the recent lowering of the limit of income subject to taxation.

342 HEALTH AND THE STATE

would have to provide a medical service for some 30,000,000
persons, and find salaries for the great majority of general
practitioners in the country. However strongly this
course may be urged, we may be certain that under circum-
stances now existing, and likely to exist for a considerable
time, it will not be adopted. Moreover, for large numbers
of people in healthy districts a medical service is by no
means the most pressing need, and even in towns a
service of general practitioners is not nearly so urgently
required as an increase of hospital accommodation.
Finally, we must recognise that rightly or wrongly the great
bulk of general practitioners are strongly opposed to a
national medical service, and no one wishes the scenes and
incidents of 1911 and 1912 to be repeated ; yet without the
co-operation of the practitioners, a national service is
almost impossible of achievement.

But even if it were feasible, the great objection to a
national medical service remains, viz. that it takes little
cognisance of differences in local needs and conditions. It
applies the same principle to Bournemouth and Birmingham,
to Cumberland and Camberwell. Under these circum-
stances therefore it is suggested that we should abandon
the idea of a rigid, centralised medical service, and
endeavour to establish instead an elastic, local medical
service under the Local Health Council, which should
have wide powers to vary the service according to the
needs of its district.

The reasons for leaving the form of a medical service
to local decision are even more numerous than those which
apply to other branches of Public Health, for in addition
to variations in the causes and incidence of sickness, it is
necessary to take into consideration social circumstances
and geographical conditions. Difficulties which arise in
Kensington would not occur in Whitechapel. In one
district the establishment of a complete medical service
working through clinics would meet with no opposition ; J

1 It is of interest to note that such a system has been in operation for many
years at Swindon among the 43,000 employees of the Great Western Railway and
their families. There is a staff of doctors with graduated salaries, and the town
is divided into a series of districts, each under the care of one doctor with a central
dispensary for the whole system. The medical service is good and the arrange-

LOCAL MEDICAL SERVICE 343

in another it would only be necessary to supplement private
practice by appointing a certain number of salaried medical
officers in charge of public dispensaries ; in scattered areas
arrangements could be made with private practitioners to
attend outlying villages or hamlets ; and in yet others the
doctor might be guaranteed a minimum income, or pro-
vided with a motor or a house on the lines followed by the
Highlands and Islands Board, a development which itself
shows how local circumstances have compelled a modifica-
tion of a general scheme. Different systems of payment
would be available, and would enable the remuneration of
a doctor to be adjusted broadly to the time and services
he gives. A capitation fee which yielded Is. 6d. per
attendance would be recognised as too low, and one from
which the return is measured in pounds per attendance
as too high. The arrangements made with the doctors
might only apply to certain areas, and the doctors could be
limited as to the number of patients they attended. It
may be noted that since the fundamental cause of dis-
satisfaction among the doctors is interference with lucrative
private practice, the poorer the district and the greater its
needs the less likely is difficulty to arise.

The Local Health Council should also be empowered
to investigate the need for special or hospital treatment in
its district, and to provide whatever forms of institutional
treatment are required. Probably in most districts this
would be found to be the most pressing want, and if
adequately met, it would often not be necessary to provide
general practitioners or interfere with private practice at
all. The Local Health Council would take cognisance
of voluntary hospitals in the district ; and its endeavour
would be not to establish its own complete service, but to
supplement existing services and make good deficiencies,
providing in one district a hospital, in another a sana-
torium, in another a convalescent home, while infant
clinics, children's clinics, lying-in homes, bacteriological
laboratories, and institutions for the permanently disabled

ments appear to have been satisfactory to both patients and doctors. Such a
scheme is only feasible where the area is compact, the persons entitled to the benefit
of the service are clearly and easily defined, and the bulk of the populacion consists
of these persons.

344 HEALTH AND THE STATE

who require medical care should all be within its province
to establish if necessary.

Towards the provision of these services the Local
Health Council would have already entered into possession
of municipal hospitals and sanatoria, Poor Law infirmaries,
school clinics, and kindred institutions. Where further
accommodation was needed, the Health Council should be
able to build its own hospitals, or make arrangements with
voluntary hospitals, or combine with adjacent localities
in the joint use of hospitals. Coordination alone would
appreciably increase accommodation, for at times Poor
Law infirmaries have many vacant beds while voluntary
hospitals in the same town have long waiting lists. There
are signs of a new era in hospital construction which should
substantially reduce the cost of building. Open-air treat-
ment is dow being extended to infectious diseases ; and at
Cambridge an open-air hospital with 1450 beds has been
erected for wounded soldiers and has achieved highly
satisfactory results. Dr. Shipley considers the cost of
construction of the Cambridge hospital to be only £17
per bed.1

The Position of the Voluntary Hospitals

These proposals open up an exceedingly wide and
important question, viz. the relation of the voluntary
hospitals to the scheme proposed, or to any other scheme
for reorganisation of the public medical services. National-
isation or State support of the voluntary hospitals has been
strongly urged by that school which believes in the advan-
tage of nationalisation or municipalisation as a general
principle. But the reasons adduced for applying the
principle to the voluntary hospitals are not convincing.
It is stated for one thing that the hospitals are often in-
adequately supplied with funds, and that they cannot
therefore increase their accommodation to meet the
demands made. This is undoubtedly true, but it furnishes
only an argument for supplementing the voluntary pro-

1 Furthe- details of this interesting experiment will be found in Dr. Shipley's
pamphlet, " The Open-Air Treatment of the Wounded."

POSITION OF VOLUNTARY HOSPITALS 345

vision, and not for State acquisition of the whole system.
Another reason, which possesses more force, is that the
care for national sickness should be a national charge, and
should not be left to the uncertain charity of philanthropic
persons. To those general arguments are sometimes added
assertions that the hospitals are extravagant and in some
cases inadequately staffed.

But while due consideration must be given to these
views, the arguments against them appear to the writer
overwhelming. In the first place most of the larger
hospitals, though not technically so, are actually
" national " for all practical purposes, particularly those
which have accepted a degree of supervision by the great
hospital funds, to which contributions are made by all
classes of the community. Most hospitals publish accounts
of their expenditure ; are governed by a representative
body of managers ; and are liable to public criticism for
errors or inefficiency, which is far more likely to be effective
than if they were institutions of the State. Moreover,
there is little scope for improved management under State
control, for the organisation and internal administration
of the British hospitals has deservedly earned a high
reputation. When we consider the number, size, and
variety of the voluntary hospitals, the extent of the funds
they handle, the number of persons who receive treatment
from them, the responsibility of their work, and the tact
and discretion demanded in maintaining harmonious
relations between patients, doctors, nurses, and sub-
scribers, it is astonishing how rare are complaints of in-
efficient treatment, mismanagement, or malversation of
funds. In a nation not conspicuous for excellence of
public administration very strong reasons should be shown
before terminating this system and placing the hospitals
in the hands of the Civil Service. The medical staffs of
the voluntary hospitals are almost always selected on the
grounds of merit, and in the making of appointments there
is far less nepotism or exercise of improper influences than
occurs in the Civil Service Departments.

Another reason is of a practical rather than an ethical
character. The community should realise that in the

346 HEALTH AND THE STATE

hospital service at all events they have made an exceedingly
good bargain with the doctors. It is probably not often
appreciated that as far as private practice is concerned the
whole body of consulting physicians, and still more of
surgeons draw their clientele from a small fraction of the
community. Harley Street and Wimpole Street derive
more income from an acre in the west than from a square
mile in the east of London ; and it is only the voluntary
hospitals which bring their services to the aid of many
thousands of poor persons. It is not denied that there
are indirect advantages in being on a hospital staff, particu-
larly to the younger men who have yet to make their
reputations, but we find many eminent physicians and
surgeons to whom such considerations have long ceased to
appeal, continuing to visit the hospital year after year on
their appointed days, and discharging their duties without
remuneration. In their case, while admitting that the
work is of interest and the position dignified, undoubtedly
a sense of duty to the hospital and philanthropy to the
poorer sections of the community keeps them at their
post. If the voluntary hospitals were converted into
State institutions under official control, it is very probable
that this public-spiritedness would be lessened, and the
doctors would be justified in asking for remuneration for
their labours.

Yet one more point must be mentioned. If the State
were to take over the hospitals, many charitably-disposed
persons would consider that the hospitals no longer
required private support, and would seek other oppor-
tunities for their benefactions. Thus the State would
find itself committed to heavy expenditure upon the staff-
ing, civil and medical, of the hospitals, and would find
simultaneously the ordinary income of the hospital rapidly
decline. Under present circumstances therefore it may
be assumed that nationalisation or municipalisation of the
voluntary hospitals is a remote contingency.

Nevertheless the voluntary hospitals must form an
important part of a local medical service ; and this could
be effected by empowering the Local Health Council to
make any agreements with the hospitals which seemed

POSITION OF VOLUNTARY HOSPITALS 347

suitable and were acceptable to both parties. In some
districts the Health Council might itself supplement
the voluntary provision by building or enlarging its own
hospitals ; in other districts it might agree with the
voluntary hospitals for the latter to undertake the treat-
ment of a certain number of persons, or of certain types of
diseases or special affections : and in yet others it might
assist the hospitals to enlarge their buildings. But the
last two suggestions involve payment to the funds of the
hospitals, and this is the crux of the difficulty, for the
moment public money is paid, the cry is raised that public
control should be exercised. Now this is undoubtedly a
sound general principle, but it may be carried too far if it
exacts control on purely theoretical grounds where no
reasonable need for that control exists. Whatever may
be the technical position, the public already possesses a
substantially greater degree of control over the hospitals
than it does over Government Departments, for the
former are amenable to public opinion while the latter are
almost regardless of this. Moreover, the principle is even
now not rigidly observed. In various parts of the country
Local Education Authorities have made arrangements
with voluntary hospitals to treat school children for ring-
worm, defective eyesight, enlarged tonsils, etc., and for
these services substantial contributions have been paid to
the hospital fimds, but the Education Authorities have not
stipulated for any voice in the internal administration of
the hospitals. Another instance is afforded by the recent
provision for the treatment of venereal diseases by the
voluntary hospitals, where, though public money is to be
spent, neither the Local Government Board nor Local
Authorities have claimed any right to interfere with the
management of the hospitals.

These arrangements afford instances of the way in
which voluntary hospitals could be fitted into a scheme
for a local medical service. In some instances, however,
Local Health Councils may wish to make substantial
grants for enlarging or rebuilding hospitals, and in these
cases it is suggested that the Health Council should
have the right to satisfy itself that the grant is actually

348 HEALTH AND THE STATE

expended upon the purpose for which it is made. If a new
wing is to be built, the Health Council shall have the
right to see that the money is spent exclusively upon that
new wing, and no part of it upon repairs or reconstruction
of older buildings ; and if the Health Council agrees to
pay for the annual maintenance of a hundred beds in the
hospital, it shall be entitled to see the accounts and ascer-
tain that the money is spent solely upon those beds ; but
this right should give it no voice in the making of appoint-
ments, or in medical or administrative questions except
such as may be agreed upon. These powers would form a
sufficient safeguard of public interests, and at the same
time would probably be regarded as reasonable by the
hospital managers. If the proposal that the voluntary
hospitals should nominate certain members of the Local
Health Council be adopted, agreements between the two
bodies would be facilitated.

Conclusion

The main object of this book has been to demonstrate
the need for complete reorganisation of the Public Health
services. There is in this country an immense amount of
entirely avoidable sickness, and we fail very gravely to
make the best use of modern medical and scientific know-
ledge to prevent it. We spend vast sums on mere pallia-
tives, and we fail to handle vigorously the great environ-
mental causes of disease which entail further cost by
helping to fill our gaols, asylums, and workhouses. As a
first and immediate step it is urged that we should create a
Ministry of Health which should itself examine the whole
position, and report upon what further changes are desir-
able in the way of coordinating central administration,
giving local authorities effective power to deal with the
causes of disease, and making provision for the care
and treatment of those who cannot obtain these advan-
tages under the present confused and imperfect system.
We must necessarily proceed by steps, but each step
should bring nearer the achievement of a complete

CONCLUSION 349

and coordinated scheme for the protection of the public
welfare.

Humanity cannot escape suffering, for that is insepar-
able from life ; but organised society can abolish much of
the misery which results from disease. No nation has
yet realised the immense possibilities which exist in this
direction, and in the past the efforts to improve Public
Health have been haphazard and costly. But the era
which will follow the war will see new methods adopted,
new ideals pursued, and added value attached to human
life. Already great changes have been effected in social
customs, which long years of peace might have failed
to achieve. Russia has swept away much of her drink
traffic ; we have prolonged our hours of daylight to the
advantage of all classes, and have made individual interests
and rights of property subservient to the national welfare
in a degree unprecedented. Stern lessons too have brought
home to every one the ultimate dependence of all upon
the produce of the land. The grave problems which the
early years of peace must bring more and more demand
and receive attention. We hear of vast schemes for the
reorganisation of Imperial Government, conferences on
trade, proposals for international co-operation, plans for
increasing the return from the land, reform in education,
and greater application of science to industry. But no
insistent voice has yet made itself heard on behalf of the
nation's health. Yet this may be the most useful task
of all, for though material needs must be met, prosperity
brings little happiness to those worn by disease or
physically imperfect. Some of the steps proposed on
economic grounds will themselves do much to promote
national health. The benefits of settlement on the land,
of afforestation, and of agricultural development will not
be represented fully by increase of acres under cultivation
or enlarged returns of wheat ; but we have no means of
expressing in figures the further gain in human growth
and vigour which these movements will bring. The secret
of health is to live the life for which we are constituted ;
but for centuries man has ignored this truth, and the loss
of his health is the penalty demanded from him for having

350 HEALTH AND THE STATE

in his great cities permitted social development to outstrip
natural evolution. To-day his knowledge is sufficient to
enable him to work with Nature instead of against her ;
to undo many of the evils he has unwittingly created ;
and to save the lives of his offspring now sacrificed to the
blind driving forces of industry. To apply this knowledge
widespread, is one of the first tasks of Peace.

INDEX

Abortifacients, sale of, 280
Abortion, criminal induction of, 287
Acland, Mrs. Francis, quoted, 164, 303
Adulteration of food, 7, 265
Afforestation, value of, in Public Health,

152
Agriculture, Board of, Public Health

duties of, 290
Alcoholism and disease, 141, 281
in Liverpool, deaths from, 307
Allbutt, Sir Clifford, on medical benefit,

230
on Public Health administration, 309
on small value of drugs, 190
Atmosphere, effects of smoke and dust

in, 87
Atmospheric Pollution, Committee for

Investigation of, 90
Atrophy, debility, and marasmus,

deaths from, 97 et aeq.

Baths, insufficiency of, in Bermondsev,
79
therapeutic value of, recognised in
Greece, 3
Bathurst, Captain, M.P., on Insurance

Act, 133
Beevor, Sir Hugh, M.D., on infectivity

of tuberculosis, 51
Birth, premature, deaths from, 98
Birth-rate, decline of, 18
Board, Local Government, Public
Health duties of, 288
of Agriculture, Public Health duties

of, 290
of Guardians, establishment of, 294

Public Health duties of, 292
of Trade, Public Health duties of,
289
Bradford, earnings of panel doctors in,
179
infant mortality in, 107
medical service in, intended, 227
Breast-feeding, 74
Bronchitis, death-rates from, 140
Browning, Mrs. E. B., quoted, 22

Brownlee, Dr., on typhus, 37

Building, cost of, 163

Burns, Rt. Hon. John, on Public Health.

56
Butter, adulteration of, 269, 273

Cancer, mortality from, 141

Capacity to work and sickness benefit,

245
Central Mid wives Board, 291
Chester -le-Street Rural District, condi-
tions in, 91
Child-bed, mortality in, 195 et seq.
Children Act, 1908, and medical treat-
ment, 226
below school age, mortality in, 114
in special schools, 129
Committee, Medical Research, under
Insurance Act, 257
on Atmospheric Pollution, 90
on Lead in Painting of Buildings,

316
on Lighting in Factories, 315
on Physical Deterioration, 308, 317
on Registration of Death, 316
Congenital malformations, deaths from,

97 et seq.
Coroner in relation to Public Health,

292, 296
Cream, adulteration of, 268
Croom, Sir Halliday, M.D., on unskilled
midwifery, 201

Death-rate, decline of, in England and
Wales, 35
influence of surgery upon, 207

Developmental conditions, infant mor-
tality from, 97

Diagnosis in panel practice, 180, 184
of infectious diseases, errors in, 184

Diarrhoea and enteritis, influence of
dust in causing, 95

Dick, Dr. Lawson, on rickets in London
children, 118

Diphtheria, decline in mortality from,

351

352

HEALTH AND THE STATE

Diphtheria, prevalence of, 47, 48

Diseases, principal, deaths from, in
England and Wales, 136

Disinfection of rooms, 54

Dispensing, cost of, 231

Domiciliary treatment, 236

Drugs, exaggerated belief in value of,
169, 189
supply of, under Insurance Act, 231

Drummond, Dr. Maxwell, quoted, 203

Dust and epidemic diarrhoea, 95
effect of inhaling, on lungs, 92
collection of, and vested interests, 26
siding at East Dulwich, 304

Education, Board of, Public Health
duties of, 289

Employment of children out of school
hours, 126

Enteric fever, decline of, 40

Esmonde, Dr., on sanatorium treat-
ment, 243

Fabian Society, report of, on hospital

accommodation, 176
Factories, segregation of, 157
Fever hospitals, utilisation of, 48
Fildes, Dr., on syphilis in London

infants, 81
Fletcher, Dr., on conditions in Chester-

le-Street Rural District, 91
' Floating sixpence,' the, 232
Food, adulteration of, 7, 265

conditions under which prepared, 275
unsound, sale of, 271
Foods, patent and proprietary, 276
Forbes, Dr., on infant mortality in

Brighton, 84
France, medical men in legislature,

313
state of Public Health in, 215
Fumigation of rooms, small value of, 54

Galsworthy, Mr., quoted, 20

Geddes, Dr. George, and puerperal

fever, 201
General Board of Health, 1848, 298
Medical Council, duties of, 290
Register Office, duties of, 288
George, Rt. Hon. D. Lloyd, on in-
sanitary conditions, 257
on sanatorium treatment, 241
German origin of National Insurance

Act, 212
Germany, medical benefit in, 217
sanatorium statistics in, 243
state of Public Health in, 214
Gibson, Dr. Thomas, on smallpox and

typhus, 39
Glasgow Insurance Committee and
validity of Regulations, 219

Glasier, Mrs. Bruce, on rural housing,

73
Greenwood, Dr., quoted, 76
Guardians, Board of, Public Health

duties of, 292

' Half-timers,' illegal employment of,
128

Hammurabi's Code of Laws, 2

Hewlett, Prof., on tuberculosis, 43

Hillier, Dr., on sanatorium treatment,
242

Home Office, Public Health duties of,
289

Hospital accommodation, 176

Hospitals, deaths in, 173
fever, admissions to, 48
position of, in public medical service,
344

Houses, early efforts to prevent over-
crowding of, 5

Housing, defective, 6, 158

India, disease in, 15
Infant mortality and industrial employ-
ment of women, 75

and maternal ignorance, 77

and occupation of father, 63

and pre-natal conditions, 81

and social conditions, 83

causes of, 70 et seq.

decline of, 105

highest rates of, 66

in Bradford, 107

in Brighton, 84

in France, 67

in Germany, 214

in Ireland, 67

in London Boroughs, 83, 84

in Paris, 89

in Scotland, 96

in United Kingdom, 65

in Villiers le Due, 63

lowest rates of, 64

pathological causes of, 93
Infant welfare, authorities concerned

with, 302
Inspectors and visitors, list of, 303
Institutional treatment, growth of, 172
Insurance Act v. National Insurance
Act-
Committee, reports by, 258
duties of, 292
Ireland, infant mortality in, 67

uncertified deaths in, 207

vital statistics of, 308

Keith, Prof., on teeth in Neolithic

skeletons, 149
Kerr-Love, Dr., on weights of infants

at birth, 86

INDEX

353

Laboratories for special diagnosis, 186
Leeds, soot-fall in, 88
Leprosy, precautions against, among
Israelites, 2
precautions against, in Middle Ages,
4
Lesser, Mr. E., on Public Health in

Germany, 215
Letchworth, town planning in, 157
' Lightning ' diagnosis, 180
Local Government Board, creation of,
299
Public Health duties of, 288
Health Committees in Insurance

Bill, 222
medical service proposed, 340
sanitary authority, duties of, 291
London, infant mortality in, 88

overcrowding in, 154
Long, Rt. Hon. Walter, on sanatorium

treatment, 242
Low, Dr. Bruce, on typhus, 37
Lungs, effect of inhaling dust upon, 92
Lynch, Mr. Arthur, on sanatorium

treatment, 242
Lyster, Dr., on relative unimportance
of housing, 162

Macaulay, Lord, on employment of
school children, 129

McMillan, Miss Margaret, on public
distrust of doctors, 328

Malaria, Sir Ronald Ross on, 14

Malingering, apparent frequency of,
under Insurance Act, 247

Malnutrition in school children, 121

Maternal ignorance as cause of infant
mortality, 77 et seq.
mortality in child -bed, 195 et seq.

Maternity benefit, value of, 204
service considered, 205

Maxwell, Dr. Drummond, on unskilled
midwifery, 203

Maxwell, Sir John Stirling, on afforesta-
tion, 152

Measles, death-rates from, 49, 140

Meat, unsound, sale of, 271, 274

Medical Act, 1858, 284
benefit, 224

in Germany, 217
records under Insurance Act, 259
service at Swindon, 342
local or national, 340
treatment, and Public Health, 206
meaning of, 168

' Medicated ' wines, sale of, 281

Medicines, patent and proprietary, sale
of, 278

Metchnikoff on tuberculosis, 44

Metropolitan Asylums Board and pro-
vision of sanatoria, 296

Metropolitan Asylums Board, beds in
hospitals of, 49
duties of, 295

erroneous diagnosis in cases sent to
hospitals of, 185
Midwives and maternal mortality, 200,
318
attendance by, and infant mortality,
76
Milk, adulteration of, 266
Mortality in early childhood, 114

National Insurance Act, administration
of, 219

and advancement of knowledge, 256

and insanitary conditions, 249

German origin of, 212

maternity benefit, 204

medical benefit, 224
records, 259

Research Committee, 257

sickness benefit, 245
National medical service considered, 340
Newman, Sir George, on defective
children, 129

on defects in school children, 119

on infant mortality, 71

on vigour at birth, 82
Newsholme, Dr., on infant mortality,
71

on syphilis as cause of still-births, 103
Notification of Births Act, 106

Overcrowding, early efforts to prevent,
5
evil effects of, 153, 161
' Overlying,' cause of death in, 298

Panama Canal, construction of, delayed

by disease, 12
Panel practices, size of, 178
Paris, infant mortality in, 89
Pathological causes of infant mortality,

93
Pearson, Prof. Karl, on Scottish vital

statistics, 309
on tuberculosis, 43
Phthisis, death-rates from, in England
and Wales, 240
death-rates from, in Metropolitan

Boroughs, 139
Physical Deterioration, Committee on,

308, 317
Plague, mediaeval efforts to stay, 3
Pneumonia, death-rates from, 140
Poor Law medical service, evolution of,

293
Population, densities of, in London and

vicinity, 154
Poverty and infant mortality, 72
Pregnancy, notification of, 303

354

HEALTH AND THE STATE

Premature birth, deaths from, 97 et seq.

Pre-natal conditions and infant mor-
tality, 81

Privy Council, Public Health duties of,
289

Public Health reports, uncoordination
of, 306

Puerperal fever, 200

Records/medical, under Insurance Act,

259'
Recruits, defects in, 134
Reeves, Mrs. Pember, on family budgets

among poor, 79
Register of sickness recommended, 308
Registrar-General and Ministry of

Health, 319
Research Committee under Insurance

Act, 257
Rickets in young children, 118
Robinson, Mr. R. A., on adulteration of

food, 271
Rolleston, Dr. J. D., baths in ancient

Greece, 3
Roscoe, Rev. J., on syphilis in Uganda,

15
Ross, Sir Ronald, on malaria, 14
Royal College of Physicians, resolution

on unqualified practice, 285
report on infectivity of tuberculosis,

52
Royal Commission on Sewage Disposal,

316
on Tuberculosis, 315
on Venereal Diseases, 103, 143, 286,

316
Royal Commissions and Public Health,

315
' Rural ' and ' Urban ' Districts, dis-
tinction between, 68
Rural depopulation, 151

Sale of Food and Drugs Act, 270
Sanatorium benefit, 235 et seq.

administration of, 300
Scarlet fever, mortality from, 40

prevalence of, 47
Scharlieb, Dr. Mary, on syphilis and

infant mortality, 71
School children, defects in, 120 et seq.
employment of, 126
medical treatment of, 192
nurse, 195
Scottish vital statistics, Prof. Karl

Pearson on, 309
Sewage Disposal, Royal Commission on,

316
Ship Captain's Medical Guide, 290
Sickness benefit, 245

rates in men and women, 28
urban and rural, 132

Simon, Sir John, on Departmental
administration, 325

on General Board of Health, 299
Sleeping out, 166
Smallpox, decline of, 39

variations in death-rate from, 33
Smoke, pollution of atmosphere by,

88, 90
Spencer, Herbert, on General Board of

Health, 298
Statistics uncoordination of, 305
Stevenson, Dr., on chances of survival
in infants, 86

on infant mortality and father's
occupation, 84

on probable decline of syphilis, 144
Still-births, 103

' Summer camps ' proposed, 165
Surgery, influence of, on death-rate, 207
' Survival- value ' of national health, 10
Swindon, medical service at, 342
Syphilis as cause of still-births, 103

decline of, 44, 144

in London infants, 81

in Uganda, 15

mortality from, 142

Teeth, condition of, in school children,
123
defective, as cause of rickets, 118
Trade, Board of, Public Health duties

of, 289
Treasury, the, Public Health duties of,

289
Tuberculosis and infection, 50
decline of, 42 et seq.
mortality from, 137
Typhus, decline of, 35 et seq.

Uganda, syphilis in, 15
Uncleanliness in school children, 124
Unqualified practice, 283
Unsound food, sale of, 271

Vaccination, provision of, 295

Venereal disease, treatment of, by un-
qualified persons, 286
Diseases, Royal Commission on, 103,
143, 286, 316

Vincent, Dr. Ralph, on zymotic en-
teritis, 95

Voluntary hospitals, position of, in
public medical service, 344

Wanklyn, Dr., on housing conditions
in London, 78
on overcrowding in London, 154
Westminster Health Society, 118
Whooping-cough, death-rates from, 49,

140
Women and sickness rates, 28

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