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Pauperism in relation to phthisis
404
PUBLIC
directly under municipal control, the others being voluntary. One important thing to be aimed at in London is that all the dispensaries when started should be on the same lines and should confine themselves to their own boundaries, should be free of the letter system, and should co-operate with each other in the exchange of patients. When London gets her network of dispensaries, as Berlin, New York, Chicago, and many other great cities have recently got them, the day when tuberculosis ceases to be anything but a name will have been brought appreciably nearer, and it is an evidence of the fact that this happy state of affairs is drawing nearei" that you have asked me here this afternoon to explain the dispensary system to you. I can only say that it has been a great pleasure anti privilege to me to have had the opportunity of doing so. T H E APPOINTMENT OF H E A L T H V l s I T O R S . - - T h e
President of the Local Government Board has introduced a Bill to enable local authorities to appoint health visitors. The Bill contains two clauses, which are as follows :-I. (t) The local authority for the purposes of the Notification of Births Act, 19o7, of any area outside London in which that Act is for the time being in force, may appoint suitable women, to be known as health visitors, for the purpose of giving to persons advice as to the proper nurture, care, and management of children under five years of age, includi,ng the promotion of cleanliness. (2) The qualifications tb be possessed by persons appointed to be health visitors under this section shall be such as the local authority may, after consultation with their medical officer of health, require. 2. This Act may be cited as the Health Visitors Act, 191o, and shall be construed as one with the Notification of Births Act, 19o7. SALE OF P U T R I D RABBITs.--At the Hereford City Police Court on July I4th a hawker was summoned for selling five rabbits which were unfit for human food. The town clerk, who appeared to prosecute, said the rabbits were sold to a woman in Friar Street for is. 8d. When she came to inspect them they were full of maggots. Mrs. Clara Bevan, who bought the rabbits, said the stench made her daughter vomit, and she was ill for two days afterwards. Dr. Miller said he examined seventeen rabbits, all of which were unfit for human food, and likely to cause ptomaine poisoning. The defendant, who did not appear, was fined ~2o and costs, or in default three calendar months' hard labour.
HEALTH.
AUGUST,
P A U P E R I S M IN R E L A T I O N TO PHTHISIS.* By JOHN C. McVAIL, M.D., LL.D., Medical Officer of Health of the County Councils of Stirling and Dunbarton. LST W t I Iyears
engaged in an investigation three ago of Poor Law medical relief in England, at the request of the Royal Commission on the Poor Laws, the importance of the phthisis problem in respect of the working man was brought before me more Urgently and impressively than ever before. The question whether phthisis is a cause of pauperism or pauperism a cause of phthisis naturally made itself prominent from the beginning of the inquiry. The answer, broadly speaking, is that phthisis causes pauperism in one generation and pauperism causes phthisis in the next. The causes of tuberculosis in the working man include hereditary tendency, unhealthy occupations and workshops, irregular work, insufficient income, exposure, misconduct, especially alcoholic abuse, affecting health and surroundings ; bad housing conditions in respect of structure, for which the owner is responsible; want of ventilation and cleanliness, for which the occupier is responsible; dirty skin and dirty clothing ; dietary defective as to quality, quantity, and cooking; and general ignorance and neglect of domestic economy. Having been impoverished in one or more of these ways, the working man comes under the charge of the Poor Law. I visited a large number of houses in which phthisical paupers were being treated at home. In many of them the conditions were such as to give phthisis all the opportunity possible for the operation of its infective power. Precautions as to sputum might be attempted or neglected, and if attempted might be more perfunctory than thorough. Often, I am bound to say, a window was open--a most valuable measure--but dirty skins, clothing, furniture and floors were common. The Poor Law Authority provided the weekly dole through the relieving officer, who might either call with or send it ; but even where the relieving officer called and saw conditions requiring remedy, he was not at that time in any proper correlation to the Health Authority, and the same remark applies to the district medical officer. The Poor Law officials had knowledge which it was not their duty to utilize, whilst the Public Health officials, on whom the duty lay, were without the knowledge. That, I am glad to say, is largely altered * Read at the Tuberculosis Congress, Edinburgh, July 5tla, ~9xo.
1910.
PUBLIC HEALTH.
now, as the Poor Law medical officer is required to intimate all cases to the medical officer of health. Suchwere often the conditions whilst the patient lived, and there was every opportunity for sowing the seeds of infection. When he died his widow and children were in no better plight. The Poor Law would give to the widow an allowance of perhaps 2s. a week in respect of each of three children, and would tell her to go (~ut and work to eke out this income. The children would be ]eft alone in a city slum. The house would be dirty and unventilated, and the slops unemptied. The kitchen table would be littered with scraps of food--cold tea, bread and jam and the like, left from breakfast. The woman, on her return at night, would be too tired or too ignorant to prepare a dinner. In these ways phthisis would have found for itself no stony ground nor thorns, but good ground excellently suited for its propagation. Thus the disease is encouraged to spread from one generation to another. The system is utterly unprofitable. The widow, with her children, should be sent away from the city slum into the country. She should be allowed enough money to feed the children properly, and the Local Authority should make a point of seeing that the money is expended properly, and that the elements of cleanliness and wholesome dietary are attended to. Also the children should come under periodical medical inspection, so that their general health would be supervised and disease if possible nipped in the bud. As regards the working man himself, the prevention of phthisis is infinitely more profitable and more practicable than the cure of phthisis. A few days ago the Chancellor of the Exchequer made in Parliament a pronouncement of the greatest possible interest and significance as bearing on the possibilities of phthisis prevention. Next year he proposes to introduce a great scheme of invalidity insurance for the working classes. It is to be contributed to by the State, by the employer, and by the worker himself or herself. It is to embrace about thirteen millions of male and female workers, or well on to one-third of the total population of the United Kingdom. If this great scheme takes due cognizance not merely of relief during invalidity but of t h e prevention of invalidity, a tremendous step will have been taken towards the e r a d i c a t i o n o f consumption. The scheme wilt of course involve medical attendance during illness. It
405
ought also to involve an annual or biennial visit by the medical attendant, quite independ e n t l y of Allness. H i s duty should be to ascertain in this way the general conditions of health of those who are committed to his care, and he should advise them both as to restorative and as to preventive measures. The condition of the house as regards cleanliness and ventilation should be noted, and the value of fresh air should be insisted on for the prevention and not merely for the treatment of consumption. Where required, a warning should be given as to any bad features in the domestic regime so far as bearing on health; All this should be in supplement to the inspection of factories and workshops which is already being increasingly practised. As concerns isolation and cure of existing cases of the disease, I am of opinion that more attention should be given than at present to the boarding out of suitable patients. In country cottages, boarding out of Poor Law children and of certain classes of the mentally defective is already practised, with most admirable results. It could well be extended to many cases of phthisis. Many an old woman whose family has grown up and left her, and who is living in a little cottage in the country, could receive a boarder of this sort, say a working-class girl, who could sit out of doors in the garden, or on the roadside, or in a field during the day, or might have a little shelter provided for her if necessary, and could take such exercise as her condition permitted. In speaking of the work done by the Poor Law, I should have mentioned that in large urban unions in England hundreds of cases of advanced phthisis are now removed to the union infirmaries, and in this way the spread of infection cannot but be diminished. Each case removed is a benefit to those who are left at home, as the risks of sputum infection are at once stopped, but the family should not be left without supervision. The Poor Law medical officer should call periodically to see whether they remain well, and their home conditions should be under systematic inspection; at the same time the allowance made by the Guardians should be adequate to provide them with proper food. On these lines a very decided advance can be made in the prevention and control of tuberculosis amongst the working classes. DR. ill. BANKS RAFFLE, medical officer to the South Shields Education Committee, was called to the Bar at Gray's Inn on July 8th.
PUBLIC
directly under municipal control, the others being voluntary. One important thing to be aimed at in London is that all the dispensaries when started should be on the same lines and should confine themselves to their own boundaries, should be free of the letter system, and should co-operate with each other in the exchange of patients. When London gets her network of dispensaries, as Berlin, New York, Chicago, and many other great cities have recently got them, the day when tuberculosis ceases to be anything but a name will have been brought appreciably nearer, and it is an evidence of the fact that this happy state of affairs is drawing nearei" that you have asked me here this afternoon to explain the dispensary system to you. I can only say that it has been a great pleasure anti privilege to me to have had the opportunity of doing so. T H E APPOINTMENT OF H E A L T H V l s I T O R S . - - T h e
President of the Local Government Board has introduced a Bill to enable local authorities to appoint health visitors. The Bill contains two clauses, which are as follows :-I. (t) The local authority for the purposes of the Notification of Births Act, 19o7, of any area outside London in which that Act is for the time being in force, may appoint suitable women, to be known as health visitors, for the purpose of giving to persons advice as to the proper nurture, care, and management of children under five years of age, includi,ng the promotion of cleanliness. (2) The qualifications tb be possessed by persons appointed to be health visitors under this section shall be such as the local authority may, after consultation with their medical officer of health, require. 2. This Act may be cited as the Health Visitors Act, 191o, and shall be construed as one with the Notification of Births Act, 19o7. SALE OF P U T R I D RABBITs.--At the Hereford City Police Court on July I4th a hawker was summoned for selling five rabbits which were unfit for human food. The town clerk, who appeared to prosecute, said the rabbits were sold to a woman in Friar Street for is. 8d. When she came to inspect them they were full of maggots. Mrs. Clara Bevan, who bought the rabbits, said the stench made her daughter vomit, and she was ill for two days afterwards. Dr. Miller said he examined seventeen rabbits, all of which were unfit for human food, and likely to cause ptomaine poisoning. The defendant, who did not appear, was fined ~2o and costs, or in default three calendar months' hard labour.
HEALTH.
AUGUST,
P A U P E R I S M IN R E L A T I O N TO PHTHISIS.* By JOHN C. McVAIL, M.D., LL.D., Medical Officer of Health of the County Councils of Stirling and Dunbarton. LST W t I Iyears
engaged in an investigation three ago of Poor Law medical relief in England, at the request of the Royal Commission on the Poor Laws, the importance of the phthisis problem in respect of the working man was brought before me more Urgently and impressively than ever before. The question whether phthisis is a cause of pauperism or pauperism a cause of phthisis naturally made itself prominent from the beginning of the inquiry. The answer, broadly speaking, is that phthisis causes pauperism in one generation and pauperism causes phthisis in the next. The causes of tuberculosis in the working man include hereditary tendency, unhealthy occupations and workshops, irregular work, insufficient income, exposure, misconduct, especially alcoholic abuse, affecting health and surroundings ; bad housing conditions in respect of structure, for which the owner is responsible; want of ventilation and cleanliness, for which the occupier is responsible; dirty skin and dirty clothing ; dietary defective as to quality, quantity, and cooking; and general ignorance and neglect of domestic economy. Having been impoverished in one or more of these ways, the working man comes under the charge of the Poor Law. I visited a large number of houses in which phthisical paupers were being treated at home. In many of them the conditions were such as to give phthisis all the opportunity possible for the operation of its infective power. Precautions as to sputum might be attempted or neglected, and if attempted might be more perfunctory than thorough. Often, I am bound to say, a window was open--a most valuable measure--but dirty skins, clothing, furniture and floors were common. The Poor Law Authority provided the weekly dole through the relieving officer, who might either call with or send it ; but even where the relieving officer called and saw conditions requiring remedy, he was not at that time in any proper correlation to the Health Authority, and the same remark applies to the district medical officer. The Poor Law officials had knowledge which it was not their duty to utilize, whilst the Public Health officials, on whom the duty lay, were without the knowledge. That, I am glad to say, is largely altered * Read at the Tuberculosis Congress, Edinburgh, July 5tla, ~9xo.
1910.
PUBLIC HEALTH.
now, as the Poor Law medical officer is required to intimate all cases to the medical officer of health. Suchwere often the conditions whilst the patient lived, and there was every opportunity for sowing the seeds of infection. When he died his widow and children were in no better plight. The Poor Law would give to the widow an allowance of perhaps 2s. a week in respect of each of three children, and would tell her to go (~ut and work to eke out this income. The children would be ]eft alone in a city slum. The house would be dirty and unventilated, and the slops unemptied. The kitchen table would be littered with scraps of food--cold tea, bread and jam and the like, left from breakfast. The woman, on her return at night, would be too tired or too ignorant to prepare a dinner. In these ways phthisis would have found for itself no stony ground nor thorns, but good ground excellently suited for its propagation. Thus the disease is encouraged to spread from one generation to another. The system is utterly unprofitable. The widow, with her children, should be sent away from the city slum into the country. She should be allowed enough money to feed the children properly, and the Local Authority should make a point of seeing that the money is expended properly, and that the elements of cleanliness and wholesome dietary are attended to. Also the children should come under periodical medical inspection, so that their general health would be supervised and disease if possible nipped in the bud. As regards the working man himself, the prevention of phthisis is infinitely more profitable and more practicable than the cure of phthisis. A few days ago the Chancellor of the Exchequer made in Parliament a pronouncement of the greatest possible interest and significance as bearing on the possibilities of phthisis prevention. Next year he proposes to introduce a great scheme of invalidity insurance for the working classes. It is to be contributed to by the State, by the employer, and by the worker himself or herself. It is to embrace about thirteen millions of male and female workers, or well on to one-third of the total population of the United Kingdom. If this great scheme takes due cognizance not merely of relief during invalidity but of t h e prevention of invalidity, a tremendous step will have been taken towards the e r a d i c a t i o n o f consumption. The scheme wilt of course involve medical attendance during illness. It
405
ought also to involve an annual or biennial visit by the medical attendant, quite independ e n t l y of Allness. H i s duty should be to ascertain in this way the general conditions of health of those who are committed to his care, and he should advise them both as to restorative and as to preventive measures. The condition of the house as regards cleanliness and ventilation should be noted, and the value of fresh air should be insisted on for the prevention and not merely for the treatment of consumption. Where required, a warning should be given as to any bad features in the domestic regime so far as bearing on health; All this should be in supplement to the inspection of factories and workshops which is already being increasingly practised. As concerns isolation and cure of existing cases of the disease, I am of opinion that more attention should be given than at present to the boarding out of suitable patients. In country cottages, boarding out of Poor Law children and of certain classes of the mentally defective is already practised, with most admirable results. It could well be extended to many cases of phthisis. Many an old woman whose family has grown up and left her, and who is living in a little cottage in the country, could receive a boarder of this sort, say a working-class girl, who could sit out of doors in the garden, or on the roadside, or in a field during the day, or might have a little shelter provided for her if necessary, and could take such exercise as her condition permitted. In speaking of the work done by the Poor Law, I should have mentioned that in large urban unions in England hundreds of cases of advanced phthisis are now removed to the union infirmaries, and in this way the spread of infection cannot but be diminished. Each case removed is a benefit to those who are left at home, as the risks of sputum infection are at once stopped, but the family should not be left without supervision. The Poor Law medical officer should call periodically to see whether they remain well, and their home conditions should be under systematic inspection; at the same time the allowance made by the Guardians should be adequate to provide them with proper food. On these lines a very decided advance can be made in the prevention and control of tuberculosis amongst the working classes. DR. ill. BANKS RAFFLE, medical officer to the South Shields Education Committee, was called to the Bar at Gray's Inn on July 8th.