occur frequently amongst the paupers. For general supervision as well as
for the elucidation of particular questions, the Board have proved the
practicability of obtaining for the public service the highest medical
skill and science. They have availed themselves of more various
acquirements than would be found in any standing _conseil de salubrité_.
On questions respecting fever they have availed themselves of the
services of the physician of the London Fever Hospital; on questions of
vaccination they have consulted the Vaccine Board of London, and the
authorities on the same question in Scotland. On questions as to
ventilation they have availed themselves of the services of Dr. Arnott;
and on the general questions affecting the sanitary condition of the
population they have consulted that gentleman and Dr. Kay, and Dr.
Southwood Smith, and others who could be found to have given special
attention to the subject. When serious epidemics have broken out in
particular unions the central Board has dispatched physicians to their
aid, or suggested to the guardians that they should have recourse to the
services of physicians in the neighbourhoods. The services of Dr.
Arnott, Dr. Kay, and Dr. Southwood Smith were thus directed in aid of
the medical officers of the eastern districts of the metropolis; and
their reports first developed to the public and the legislature the
evils which form the subject of the extended inquiry, and that might
otherwise have continued without chance of notice, or mitigation or
removal, to have depressed the condition of the labouring classes of the
population. But the results of such occasional visits appear to prove
the necessity and economy of an increase of the permanent local medical
service, and to establish a case for the appointment of a superior
medical man for a wider district than an ordinary medical officer, for
the special aid and supervision of the established medical relief.
It will frequently be found that there is the like need of immediate
local inspection of the medical treatment of the destitute that there is
of a grade of inspecting surgeons for the military hospitals. It cannot
be otherwise than that amidst a numerous body of men there must be much
error and neglect in the treatment of the destitute, in the absence of
immediate securities against, neglect. The most able of the guardians
would confess that if they are not entirely incompetent to supervise
medical service, they are at the best but imperfectly qualified for such
a task, and the medical officers would act with more satisfaction to
themselves from the supervision of officers from whom they might derive
aid and confidence.
But besides the medical treatment of the inmates of the workhouses and
prisons, there are other cases within most districts which need the
preventive service of a superior medical officer for the protection of
the public health.
First, in the cases where the poorer classes are assembled in such
numbers as to make the assemblages _quasi_ public, and afford facilities
for medical inspection, as in schools.
Secondly, also in places of work and in workmen’s lodging-houses. The
occasional visits of a district officer, for the prevention of disease
would lead to the maintenance of due ventilation, and to the protection
of the workpeople on such points as are already specified as injurious
to the health, and that arise simply from ignorance, and are not
essential to the processes. An examination of such places, if only
quarterly, would lead to the most beneficial results.
So far as I have observed the working of the Factory Act, it appears to
me that the duties now performed by the sub-inspectors of factories
might be more advantageously performed by superior medical officers, of
the rank of army surgeons, who are independent of private practice.
I am confirmed in this view by the following evidence of _Mr. Baker_,
surgeon of Leeds, the only factory inspector who has such
qualifications:—
“Have you, as a surgeon, whilst visiting the factories as an
inspector, had occasion to exercise your professional
knowledge?—Frequently; during my service I have turned out great
numbers of children with scald-heads, which they were apt to propagate
amongst the rest of the children; some with phthisis, whose subsequent
death was more than probable; some with scrofulous ulcers; a great
many with extreme cases of ophthalmia; probably I may have removed a
thousand of these cases altogether. I rarely go to a mill where I do
not see a case of scald-head.
“Have you ever had occasion to interpose in respect to
ventilation?—Frequently in extreme cases of variable temperature, also
in cases of offensive privies, which I find attended by dysenteric
affections; and also where there has been offensive water from
neglected sewers. I have also endeavoured to enforce personal
cleanliness on the children through the instrumentality of overlookers
and parents. One practice amongst the children in all kinds of mills
is to wear handkerchiefs on the head, by which the neglect of personal
cleanliness was concealed. Under these handkerchiefs were most of the
cases of scald-head, in a state of filthiness not easily describable.
I have assured the operatives that by the Act I had the power to
direct measures for the protection of their health as well as labour;
and I have established in many places the rule that the children shall
come with the faces clean, and the hair combed, and without
handkerchiefs whilst at work.”
By such inspection of workpeople in the places of work do you conceive
it would be practicable to influence largely the sanitary condition of
the labouring population without inspection of the private
houses?—Yes; for the ill health which was occasioned by the state of
their houses or other places, would of course be visible on such
inspection. If they were removed from their places of employment on
the presentation of such appearances, the inattention which had
occasioned it would be removed too.
“What length of time do you find such inspection would require each
time, say in a mill of about 1000 persons, and how frequent should
such inspection be?—On the average about two hours; to a practised eye
the symptoms of indisposition are discernable almost in walking
through a room. Under some circumstances an inspection of once in
three months would suffice.
“Are there masters in your district who are aware of the interest they
have in the health of their workpeople?—Yes; there are many who pay
particular attention. I might mention two where a surgeon is specially
employed to take care of their workpeople. When persons are ill, they
are listless and sleepy, and negligent; there is also more waste made
in the processes of manufacture.”
The superior economy of preventive services by such inspection as that
above displayed will scarcely need elucidation.
From a consideration of such opportunities of inspection it will be
perceived that the enforcement of sanitary regulations on such
inspection by superior and independent officers, qualified by previous
examination, as in the army, would be a wise economy. By such
arrangements efficient medical superintendence would be provided for the
independent labourer employed in crowded manufactures, as well as for
the soldier and the sailor, not to speak of the pauper or the criminal.
One such officer would be able so to inspect and keep under sanitary
regulations the places of work, the schools and all the public
establishments of such a town as Leeds, which would bring under view
perhaps the greater proportion of the lower classes of the population.
There would still remain, however, those of the labouring classes who do
not work or lodge in large numbers, or work in a quasi-public manner, to
bring them within the means of convenient inspection. There would also
remain without protection the cases of persons of the middle classes.
To meet these cases, I would suggest that the information brought to the
superintendent registrar as to the cause of death, imperfect and hearsay
as it yet is, may serve as the most accurate index to the direction of
the labours of a district officer appointed to investigate the means of
protecting the health of all classes. Having suggested the registration
of the causes of death (under medical superintendence), a head of
information not contained in the original draught of the Deaths’
Registration Bill, I would guard against an over-estimate of the
importance of that provision; but I feel confident it would be found,
when properly enforced, one of the most important, means of guiding
preventive services in an efficient direction. For example, wherever, on
the examination of these registries, deaths from fever or other
epidemics were found to recur regularly, and in numbers closely
clustered together, there will be found, on examination, to be some
common and generally removable cause in active operation within the
locality. Amongst whatsoever class of persons engaged in the same
occupation deaths from one disease occur in disproportionately high
numbers or at low ages, the cause of that disease will generally be
found to be removable, and not essential to the occupation itself. The
cases of the tailors, miners, and dressmakers, and the removable
circumstances which are found to govern the prevalence of consumption
amongst them, I adduce, as examples of the importance of the practical
suggestions to be gained from correct and trustworthy registries of the
causes of death occurring in particular occupations as well as in
particular places. When a death from fever or consumption occurs in a
single family, in the state of isolation in which much of the population
live in crowded neighbourhoods, they have rarely any means of knowing
that it is not a death arising from some cause peculiar to the
individual. Even medical practitioners who are not in very extensive
practice may have only a few cases, and may be equally unable to see in
them, in connexion with others, the operation of an extensive cause or a
serious epidemic. The registration of the causes of death, however,
presents to view the extent, to which deaths, from the same disease, are
common at the same age, at the same time, or at the same place, or in
the same occupation.
One of the most important services, therefore, of a superior medical
officer of a district would be to ensure the entries of the causes of
death with the care proportioned to the important uses to be derived
from them. The public should be taught to regard correct registration as
being frequently of as much importance for the protection of the
survivors as a post-mortem examination is often found to be.
The mortuary registries and the registration of the causes of death are
not only valuable as necessary initiatives to the investigation of
particular cases, but as checks for the performance of the duty. The
system of registration in use at Geneva, combining the certificate and
explanation of the private practitioners and the district physician,
corresponds with a recommendation originally made for the organization
of the mortuary registries in England, and the experience of that
country might, perhaps, be advantageously consulted.
It would be found that the appointment of a superior medical officer
independent of private practice, to superintend these various duties,
would also be a measure of sound pecuniary economy.
The experience of the navy and the army and the prisons may be referred
to for exemplifications of the economy in money, as well as in health
and life, of such an arrangement. A portion only of the saving from an
expensive and oppressive collection of the local rates would abundantly
suffice to ensure for the public protection against common evils the
science of a district physician, as well as the science of a district
engineer. Indeed, the money now spent in comparatively fragmentations
and unsystematized local medical service for the public, would, if
combined as it might be without disturbance on the occurrence of
vacancies, afford advantages at each step of the combination. We have in
the same towns public medical officers as inspectors of prisons, medical
officers for the inspection of lunatic asylums, medical officers of the
new unions, medical inspectors of recruits, medical service for the
granting certificates for children under the provisions of the Factory
Act, medical service for the post-mortem examinations of bodies, the
subject of coroners’ inquests, which it appears from the mortuary
registries of violent deaths in England amount to between 11,000 and
12,000 annually, for which a fee of a guinea each is given. These and
other services are divided in such portions as only to afford
remuneration in such sums as 40_l._, 50_l._, 60_l._, or 80_l._ each; and
many smaller and few larger amounts.
Whatever may be yet required for placing the union medical officers on a
completely satisfactory footing, the combination of the services of
several parish doctors in the service of fewer union medical officers
will be found to be advances in a beneficial direction. The
multiplication or the maintenance of such fragmentitious professional
services is injurious to the public and the profession. It is injurious
to the profession by multiplying poor, ill-paid, and ill-conditioned
professional men.[48] Although each may be highly paid in comparison
with the service rendered, the portions of service do not suffice for
the maintenance of an officer without the aid of private practice; they
only suffice, therefore, to sustain needy competitors for practice in
narrow fields. Out of such competition the public derive no improvements
in medical science, for science comes out of wide opportunities of
knowledge and study, which are inconsistent with the study to make
interests and the hunt for business in poor neighbourhoods.
A medical man who is restricted to the observation of only one
establishment may be said to be excluded from an efficient knowledge
even of that one. Medical men so restricted are generally found to
possess an accurate knowledge of the morbid appearances, or of the
effects amongst the people of the one establishment, but they are
frequently found to be destitute of any knowledge of the pervading cause
in which they are themselves enveloped, and have by familiarity lost the
perception of it. Thus it was formerly in the navy that medical officers
on board ship, amidst the causes of disease, the filth, and bad
ventilation, and bad diet, were referring all the epidemic disease
experienced exclusively to contagion from some one of the crew who was
discovered to have been in a prison. We have seen that local reports
present similar examples of similar conclusions from the observation of
single establishments in towns, in which reports effects are attributed
as essential to labour, of which effects that same labour is entirely
divested in establishments in the county, or under other circumstances
which the practitioners have had no means of observing and estimating.
The various contradictory opinions on diet, and the older views on the
innocuousness of miasma, are commonly referable to the circumstances
under which the medical observers were placed; and examples abound in
every district of the errors incidental to narrow ranges of observation
in cases perplexed by idiosyncracies, and by numerous and varying
antecedents. It should be understood by the public that the value of
hospital and dispensary practice consists in the range of observation
they give; and that the extent of observation or opportunities of
medical knowledge are influenced or governed by administrative
arrangements. In several of the medical schools of the metropolis,
however, the opportunities of knowledge are dependent on the cases which
may chance to arise there. Fortunate administrative arrangements have,
in Paris, greatly advanced medical knowledge, by bringing large classes
of cases under single observation. The most important discoveries made
with respect to consumption, those made by M. Louis, were based on the
results of the post-mortem examinations of nearly 1300 cases by that one
practitioner. Nearly all the important conclusions deduced from this
extensive range of observations were at variance with his own previous
opinions and the opinions that had prevailed for centuries. The later
and better knowledge of the real nature of fever cases has been obtained
by a similar range of observation gained from the cases in fever
hospitals. Applications have been several times made to the
Commissioners by medical men engaged in particular researches to aid
them in the removal of the impediments to extended inquiry, by
collecting the information to be derived—from the sick-wards of the
workhouses and the out-door medical relief lists.
The highest medical authorities would agree that, whatsoever
administrative arrangements sustain narrow districts, and narrow
practice, sustain at a great public expense, barriers against the
extension of knowledge by which the public would benefit, and that any
arrangements by which such districts or confined practice is newly
created, will aggravate existing evils. An examination of the state of
medical practice divided amongst poor practitioners in the thinly
populated districts shows that, but for the examinations, imperfect
though they be, as arrangements which sustain skill and respectability,
a large part of the population would be in the hands of ignorant
bone-setters.
On a full examination of the duties which are suggested for a district
physician, or officer of public health, that which will appear to be
most serious is not the extent of new duties suggested, but the extent
of the neglect of duties existing. The wants, however, which it is a
duty to represent and repeat, as the most immediate and pressing, for
the relief of the labouring population, are those of drainage,
cleansing, and the exercise of the business of an engineer, connected
with commissions of sewers, to which the services of a board of health
would be auxiliary. The business of a district physician connects him
more immediately with the boards of guardians, which, as having the
distribution of medical relief, and the services of medical officers, I
would submit, maybe made, with additional aid, to do more than can be
done by any local boards of health of the description given, separated
from any executive authority or self-acting means of bringing
information before them.
I have submitted the chief grounds on which it appears to me that
whatever additional force may be needed for the protection of the public
health it would everywhere be obtained more economically with unity, and
efficiency, and promptitude, by a single securely-qualified and
well-appointed responsible local officer than by any new establishment
applied in the creation of new local boards. Including, as sanitary
measures, those for drainage and cleansing, and supplies of water as
well as medical appliances, I would cite the remarks on provisions for
the protection of the public health, made by Dr. Wilson at the
conclusion of a report on the sanitary condition of the labouring
population of Kelso. After having noted some particular improvements
which had taken place, as it were, by chance, and independently of any
particular aids of science directed to their furtherance, he remarks
that “it is impossible to avoid the conclusion that much more might
still be accomplished, could we be induced, to profit by a gradually
extending knowledge, so as to found upon it a more wisely directed
practice. When man shall be brought to acknowledge (as truth must
finally constrain him to acknowledge) that it is by his own hand,
through his neglect of a few obvious rules, that the seeds of disease
are most lavishly sown within his frame, and diffused over communities;
when he shall have required of medical science to occupy itself rather
with the prevention of maladies than with their cure; when governments
shall be induced to consider the preservation of a nation’s health an
object as important as the promotion of its commerce or the maintenance
of its conquests, we may hope then to see the approach of those times
when, after a life spent almost without sickness, we shall close the
term of an unharassed existence by a peaceful euthanasia.”
VIII.—COMMON LODGING-HOUSES.
A town may be highly advanced in its own internal administration, its
general drainage, and its arrangements for house and street-cleansing
may be perfect, and they may be in complete action, and yet if the
police of the common lodging-houses be neglected, it will be liable to
the continued importation, if not the generation, of epidemic disease by
the vagrant population who frequent them. I have reserved the evidence
respecting them in order to submit it for separate considerations,
because they may apparently be better considered independently of the
administrative arrangements which affect the resident population of the
labouring classes.
From almost every town from whence sanitary reports have been received
that have been the results of careful examinations, the common
lodging-houses are pointed out as _foci_ of contagious disease within
the district. These houses are stages for the various orders of tramps
and mendicants who traverse the country from one end to the other, and
spread physical pestilence, as well as moral depravation. The evidence
everywhere received distinguishes them prominently as the subjects of
immediate and decidedly strong legislative interference for the public
protection.
The following extract from the Report of _Mr. E. W. Baines_, the medical
officer of the Barnet union, is submitted as an example of the
information received respecting them from the rural unions:
“The lodging-houses for trampers are a prolific source of disease, and
productive of enormous expense to the parish in which they may be
situate; from one I have within this week sent into the union
workhouse six cases, namely, two of fever, three of itch and
destitution, and one of inflammatory dropsy. These unhappy beings are
boarded and bedded in an atmosphere of gin, brimstone, onions, and
disease, until their last penny be spent, and their clothes pledged to
the keeper of the house, when they are kicked out and left to the
mercy of the relieving officer.”
The committee of physicians and surgeons, who have made a sanitary
report on the condition of the labouring population in Birmingham, give
the following account of the lodging-houses in that town:—
“Lodging-houses for the lowest class of persons abound in Birmingham.
They principally exist near the centre of the town, many of them in
courts; but great numbers of front houses, in some of the old streets,
are entirely occupied as lodging-houses. They are generally in a very
filthy condition; and, being the resort of the most abandoned
characters, they are sources of extreme misery and vice. These houses
may be divided into three kinds,—mendicants’ lodging-house,
lodging-houses where Irish resort, and houses in which prostitutes
live, or which they frequent.
“We find it stated in Mr. Burgess’s return, that in 47 of these the
sexes indiscriminately sleep together. In the day time the doors of
these houses are generally thronged with dirty, half-dressed women and
children; and if visited in an evening, the inmates are found to be
eating, drinking, and smoking. Such houses are, for the most part,
occupied by beggars and trampers, but many of them are the resort of
thieves. Some idea may be formed of the description of persons who
frequent some of these abodes, by stating that in two of them, one of
which was situate in John-street and the other in Thomas-street, a
chain, fastened at one end by a staple and at the other secured by a
padlock, was placed on the outside of the door, at the foot of the
staircase which led to the sleeping apartments. Upon asking the
mistress of the house for what purpose that was required, she stated
that she employed it to lock in the lodgers until she released them in
the morning, as they would otherwise decamp, and take away whatever
furniture or moveables they could carry with them. Some of these
houses are occupied exclusively by foreigners. In a court in
Park-street we visited one which was inhabited by Italians, men and
women, with their stock of musical instruments, monkeys, and other
small animals. We are informed that there is another Italian
lodging-house in Lichfield-street, as well as one which is frequented
only by the Flemish or German broom-girls.”
In whatever part of the kingdom these receptacles are examined they
exhibit common characteristics. _Dr. Jenks_, in his report on the
sanitary condition of the labouring classes in Brighton, gives the
following account of the lodging-houses:—