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Proceedings of the Home Counties Branch of the incorporated society of medical officers of health
84
PROCEEDINGS
OF THE
James Russell, Chairman o f the Sanitary Committee of the City Council, and recently Lord Provost, has given me the key to the secret of their success.
H e says, " i n their present washing-houses, which are placed in the midst of a poor population, they have a large hall, round which there are cells containing earthenware basins let into a concrete floor, with discharge plugs, and hot and cold water. T h e people can here undress, and stand in these basins to have a wash, the hall being filled with warm a i r - - a very important feature, as they would not be got to undress and bathe in a cold room." A t present these places are only connected with the general wash-houses for clothes washing, the charge per hour paying both for the use of the clothes-washing apparatus, and for the baths afterwards. They find the women readily avail themselves of the opportunity for washing, and there seems to be no reason why the bath should not be allowed to be taken quite irrespective of the clothes washing ; and in my opinion such places ought to be provided free to the poor, and every inducement given them to come and make themselves and their children clean. I n Edinburgh, also, there is an association for improving the dwdlings of the poor, of which, also, Sir Jame Russell is chairman. In the tenements built by this association, each flat has a proper wash-house with all necessary apparatus at the disposal of the families living in the flat in rotation. T h e tenants prefer this arrangement to using the m o r e distant public wash-house, and they save the charge per hour made in them. T h e tenants are mostly very p o o r - - i n fact, were slum-dwellers. In connection with and adjoining each wash-house there is a wooden plunge-bath, which is in much request. T h e keys of these washing places pass in rotation to the next tenant, or to the tenant who is caretaker, as the case may be. Here, then, we have the germ of reform which, if steadily nurtured, may lead in the future to a very great improvement in the personal sanitation (if I may so call it) of the lower classes. I think that in the case of new houses, it should be made compulsory in all building regulations, that to every house, or to all terraces or blocks of houses, builders should provide, either by outbuilding or by proper additions to the ordinary requirements, suitable places in which cleanliness, not only of the person, but of the household necessaries, can be obtained. Of course, we shall have to meet t h e difficulties as we now find them existing in the homes o f the working-classes to-day, and the only way in which this can be done for old houses, seems to be the establishment of _puMicwash-houses on lines similar to those at present so successfully carried out in Edinburgh, and I would therefore strongly advocate the adoption of such places for all our large towns.
HOME
COUNTIES
BRANCII.
PROCEEDINGS OF THE HOME COUNTIES BRANCH OF THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. AT the meeting of this Branch, held in October, the following inaugural address was given by Dr. Seaton : " T H E PHYSICIAN'S WORK IN PUBLIC HEALTH ADMINISTRATION." BY EDWARD SEATON, IV[.]), F.R.C.P.
IT was shortlyflfter the Public Health Act of i872 came into operation that I thought of applying for one of the posts of medical officer of health then advertised by local sanitary authorities for the first time. A famous physician and former teacher (the late Dr. Bristowe) with whom I discussed my proposition, agreed that the opportunities afforded by the new Act should, even in the existing state of public opinion, afford ample scope for an honourable and useful career. " B u t , " added he, " k e e p up your connection with practical medicine~ which must always be the basis of a sound system of public health administration." I n accordance with this advice I took the membership of the London College of Physicians a few months later, and afterwards became connected with a provincial dispensary and a hospital as consulting physician, in after years serving on the Asylums Board of the Metropolis at a time when their hospitals and asylums first became available generally for the purposes of medical education. I mention these facts to you, not as being of any interest personally, but as explaining that my own bias has always been in favour of keeping the bond between public health administration and the w o r k . o f physicians as close as possible. The local medical officer of health for a large town should be placed by his salary and tenure of office, in a position equal to that of the principal town officials ; and while by the terms of his appointment, he should be debarred from private practice, he should at the same time be not only free, but in every way encouraged to accept positions of medical responsibility m connection with hospitals and dispensaries. The character of the office and its proper sphere of usefulness would thus be better suited than by any other arrangement as yet proposed or tried. I t is well for us to have an ideal before us ; but it must be admitted that up to now circumstances have not enabled us to realise it. I n the first place the public have not as yet come to fully appreciate the value of medical advice or services as applied wholly to the prevention, rather than the cure or treatment of illness. T h e subject of the appointments of medical officers of health, and their frequently unfavourable conditions of tenure, has received a large share of attention lately, not only in this Society and its branches, but in that section of the British Medical Association which is devoted
THE PHYSICIAN'S WORK IN PUBLIC HEALTH to the consideration of questions relating to the public health. But of all those who have addressed us on this subject, it seems to me that Dr. Woodforde, late President of the Society, indicated the main and essential difficulty in the way of improvement. It is that in a large proportion of instances the appointments are held by gentlemen in general medical practice. I am not about to enter into any controversial matter. I am fulty aware that among those I have the honour to address are some who may think that under existing circumstances the "specialist or whole-time" system is undesirable, and that until better initial conditions of appointment can be secured, it is not in the public interest that it should be generally recommended. I am not disposed at present to discuss this important question, but I desire to call attention to a fact that cannot be gainsaid. I t is that, notwithstanding what has been accomplished, the public do not as yet seem fully convinced of the practical utility of preventive medical work. Let me take a typical example of my meaning ~ v i z . , the case of an outbreak of scarlet fever or diphtheria associated with a particular milk supply, in which the medical officer of health happens also to be the practitioner attending on the cases. Here he has to choose between the attendance on the suffering sick, his anxious patients, and an investigation taking time, thought and care, for which his reward in most cases can only be an approving conscience. I f his object be to secure reward and thanks for his pains, there can be no doubt in which direction his interest lies. Indeed --strange, but nevertheless true--unless the outbreak assumes the proportions of an epidemic receiving wide attention, and unless it be of such a nature that it constitutes an object lesson, not even ~udos attaches to the investigation. Again, in illustration of my meaning, I may refer to institutions where the cure and prevention of illness are carried on side by side. As you may know, I have had opportunities of observation at many rate-supported hospitals. There blame is almost entirely confined to matters relating to treatment and cure of the sick, and not to those concerned in the prevention of illness. Hospital " s c a n d a l s " almost invariably relate to real or alleged neglect of the sick, not to the prevention of the spread or occurrence{of preventable illness~. T h e practice of vaccination abounds with instances of my meaning. Who is there among us ~In this respect there is a great difference between the voluntary hospitals in the management of which medical knowledge m supreme~ and the rate-supported hospitals, where it is subordinate to '"public opinion." Indeed, it seems to me the most powerful argument against maMng our hospitals '~ state" or ~"rate "-supported, is that hitherto the great advances in preventive surgery and medicine have been carried out in voluntary hospitals, and that, humanly speaking, these great triumphs would have been impossible of achievement in hospitals supported by the rates, and subject to the sort of control usually exercised n such establishments.~E. C. S.
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that has ever been thanked for vaccinating susceptible persons, even in households immediately threatened with smallpox ? In mentioning the above examples t have chosen those in which the close connection of prevention and cure is apparent to the medical profession, though not always to the general public. If, in such cases, the preference is usually given to the ]utter--to the cause of actually suffering humanity as some would put i t - - i s it to be wondered at that tile compara° tiveIy far away preventive work in which we are daily engaged so often fails to win appreciation ? The indication of nuisances injurious to health, which may be remedied by money expenditure, and the estimation of the probabilities of their proving so injurious ; the institution of a system of notification of preventable illness, which may furnish the basis of a sound public health organisation 5 the skilful analysis of sickness or vital statistics, so as to ascertain some fact connected with the habits or customs of a population tending to the development or increase of some disease; the cultivation of the art of diagnosis ; the study of micro-pathology--these, to mention no other, are examples of the physician's work in public health administration, the fundamental importance of which we, in the medical profession, recognise. When will its importance be fully recognised by the public ? Thus far it might seem that I am presenting an aspect of the physician's work which, if not deterrent, is certainly not encouraging to those who have to earn a living and make a career in their profession. But there are hopeful signs that, with the progress of education, by the gradual extension of the sphere of local government, together with a large increase in the number of persons actively interested or engaged therein, the work for which we claim a high position will come more and more to be appreciated. In order to promote this end~ it is desirable from time to time to recapitulate some of the principal achievements of preventive medicine. This has already been done, with co-ordinative skill and literary ability, by Dr. Thorne Thorne, in his book on " T h e Progress of Preventive Medicine during the Victorian Era." I t is no detraction from his interesting and valuable record to say that it is incomplete, for in such a comprehensive subject there is ample field for work for physicians in the service of local authorities, as well as those attached to Her Majesty's Local Government Board. I would, moreover, specially remark that the labours of those who are officially unattached, but who work at p u n i c health problems as earnestly as the time they can spare from their practice permits, is valuable mainly on account of its independence of official bias. My own brief recapitulation shall relate entirely to matters within my own experience, and if I give you more of my own
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opinions than those of other people, I will ask you to excuse m e on account of the position in which you have placed me this evening. I. The Arousing of t~e Poor.--It would form an interesting chapter in the history o f sanitary progress during the latter half of the Victorian era to trace the influence of the medical profession in promoting the greatest humanitarian movement of the n i n e t e e n t h c e n t u r y - - a m o v e m e n t which has made enormous strides in a comparatively very short time. This I cannot attempt to do now, but it is particularly interesting to note the action taken by the College of Physicians in initiating or promoting this great work. EXTRAORDINARY mEETING OF THE COLLEGE,
February i9th, 1874.
.dunaZs XXXI., p. 93.
The committee appointed at the last college meeting to prepare a Memorial to the First Lord of the Treasury, laid before the college the draft of a memorial, which was amended, and on the motion of Dr. Anstie, seconded by Dr. ]Sasham, was adopted as follows : - a*THE ~/~Ei*CIORIAL '~ Of the Corporation of the Royal College of Physicians of London C¢ T o
" First Lord of the Treasury ¢~ SHEWETH
'*That your memoriallsts in the daily exercise of their profession as physicians are brought much into contact with the poorer classes of the population, and are deeply interested in anything that concerns the welfare of these classes, n o : only (,n account of the poor themselves, but; also because the evils engendered among them affect the whole of society. " T h a t it is well known to your memorialists that overcro~ding--especially in unwholesome and ill-constructed habitations---originates disease, leads to drunkenness and immorality, and is likely to produce discontent among the poorer portion of the population. "That it is within the knowledge of your memorialists that the wholesale demolition of the houses inhabited by the poor, which have been carried on of late years under various Railway and Improvement Acts, while it has been serviceable in removing many very bad streets and dwellings, has incidentally caused much distress to the persons displaced, and has almost uniformly driven them to crowd into neighbouring quarters which were already as full as or fuller than was eonsistent with healthiness. al;'aTnha~2proateede~aterpriseeicSoP°mWe~la~Sot° P~l°v(ades theequflreeh for those who have been expelled from their former habitations, in addition to that whieh is called for by the constant increase of the population, by reason of the impossibility of securing suitable sites for building. Even so rich and powerful a body as the trustees of the Peabody Fund has been repeatedly foiled in particular attempts to obtain land to build on. ""fhat your memoriallsts believe that the mere enabling powers which are at present entrusted to various authorities have proved, and must prove, insufficient to effect the desired object. "That in the opinion of your memorialists a remedy for these evils is urgently needed. They therefore venture to express the hope that you will favour them by holding out some prospect that this question of the Dwellings of the London Poor, upon which the health and morality of the pc)pie so much depend, will be taken up by Government in the present session of Parliament. °~And your memoriatists will ever prays" etc. The president, censors, and regisf;rar were appointed a deputation to present the memorial.
HOME
COUNTIES
BRANCH.
O n e of the ways in which medical influence has b e e n most usefully exercised has been in keeping to the front principles which should guide statesm e n in their method of d e a t i n g w i t h this intricate q u e s t i o n - - p r i n c i p l e s which have been so ably expressed by Sir J o h n Simon in his " English Sanitary Institutions.' Not less influentla has been the inhibitory influence of the profession. I refer to the cautious utterances of e m i n e n t physicians, such as Dr. Bristowe, in correcting exaggerated statements. It is ten years ago now that I conferred with my old teacher on the subject of diphtheria and its relation to insanitary conditions. I was about to read a paper at our Metropolitan Society, and I then took the opportunity of proclaiming the facts respecting this disease, which were a n d are very m u c h in contradiction to what our respected friends, the sanitary engineers a n d inspectors, were teaching at that time. z. Industrial ffygiene.--This subject especially comes within the scope of physicians, whether practising as such, or whether wholly engaged in official work, as was Dr. Ballard. T h e Milroy lectures of Dr. Arlidge, a n d the admirable series of lectures in the Transactions of the Sanitary Institute, should mark a new era in public health administration. T h e way has been paved for fresh legislation a n d administrative reform, which, it is hoped, will soon lead to practical results comparable with the enormous improvements which have taken place in the dwellings of the poor. 3. A m o n g the notable achievements, I place the
Systematic Notification of I~zfectious Diseases.
I
do this not so m u c h because of the i m m e d i a t e benefits to be derived from it (although I think these are already by no means small in the ease of some diseases, such as small-pox a n d scarlet fever), but on account of the opportunities it affords for systematic local sanitary administration, a n d the scientific observation of epidemic diseases. Local sanitary authorities have the entire credit of initiating the s y s t e m - - a by n o m e a n s easy achievement, as some of us well know. 4. I n the field of scientific research we owe much to the labours of the Medical D e p a r t m e n t of the Local G o v e r n m e n t Board, especially as Dr. T h o m e has shown in that department which deals with .JZ~idemlology. I n connection with small-pox, he dwells o n the importance of Mr. Power's opinions as to the spread of the disease through the general atmosphere, which he says now meets with the almost u n a n i m o u s support of c o m p e t e n t scientific judges. I n the same interesting volume, published in i888, he discusses in detail the same observer's discovery of what is known as the H e n d o n disease, which some of us thought likely to constitute, a n d which may still prove to be, a material part of the etiology of scarlet fever. T h e great respect entertained for the scientific accuracy a n d conscientiousness of Mr. Power~ a n d those
THE
PHYSICIAN'S WORK IN PUBLIC HEALTH
associated with him at the Local Government Board, commanded the earnest and careful atten, tion of unprejudiced observers to the latter discovery. It will, I think, be generally held that the absence of similar independent observations during the last ten years makes it necessary to review with very great caution the position to be assigned to these very important observations. In his address, Dr. Thorne spoke of " a n exaggerated trust in," or " a n over-estimation of the power of vaccination." May we express the hope that there may not arise an exaggerated fear of small-pox hospitals, which would seriously impede the further control of this eminently preventable disease. The work of Snow, of Stewart, of Parkes, ot Jenner, of Buchanan, and Bowditch, which had begun to produce these results before the time which I cover in this address, have furnished a basis for practical work in the prevention of cholera, typhoid, typhus, and phthisis, in which there has been no important change. There has, however, been some valuable addition to our knowledge in the contributions ot" Dr. Charles Kelly and Dr. Arthur Ransome, which will probably help to explain the law relating to phthisis distribution and soil moisture. The subject of phthisis and tuberculosis is at the present time attracting attention in another direction. The Tuberculosis Commission has by its report established certain facts which slzozdd influence public health administration in an important degree, viz., by altering our present system of the slaughter of animals, and their preparation for food, which so urgently needs improvement. I purposely refrain from entering, in this' address, into the subjects of laboratory research which have sprung from the work of the great Pasteur, and which constitute a large share of the preventive medical work Of our time, preferring, to dwell on important matters not generally receiving attention. I would, however, refer especially to the momentous discovery of the tubercle bacillus by Koch, and to the wonderful efficiency of tuberculin in detecting tuberculosis. Lectures, articles, and letters occasionally appear on this subject in the columns of leading journals. The Times of September 3oth contains an excellent letter on " F r e s h Aspects of the Tuberculosis Question," setting forth the arguments which logically prove our present system of slaughterhouses in England to be as bad as possible. But the writer probably hardly realises that which would be only too well known to his neighbours, our experienced colleagues, Drs. Woodforde and Ashby~ viz., the enormous difficulty of altering the long established customs of the meat trade. - This is a case for constant reiteration of indisputable facts, and explaining from the physician's point of view their full significance. Lastly, in the field of scientific research, which by way of contrast to laboratory research has been
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termed "field observation," or epidemiology, I have to say a few words on diphtheria, and those simply in illustration of what I have been saying this evening upon the importance of the physician's work in prevention as well as cure. The discovery of antitoxin may or may not make a very material difference in the mortality statistics of diphtheria. Be that as it may, the diagnosis and the prevention of the disease should rank as of even greater importance than its treatment or cure. It is much more important, in bur estimation, that medical officers should be appointed under conditions which enable them to watch and arrest the development of epidemic disease at schools, or wherever they may arise (also, that aids to diagnosis and opportunities of isolation should be afforded), than that medical talents should be directed almost exclusively to the treatment of the disease when it has arisen. This may not be tile popular view, but it is that which we must constantly endeavour to keep to the front. Certainly, though it may not be showy work, the study of the natural history of the disease as carried on for several years by the medical officers of the Local Government Board and Dr. Longstaff and Dr. Adams, of Maidstone, and others, has already and will continue to produce the most valuable results. Here let me refer to the highly important lectures of Dr. Newsholme, on acute rheumatism, and to the hypothesis which he has advanced, and which will require careful attention of epiderniologists and all who are interested in preventive medicine. Having so far spoken of the achievements in preventive medical work, let me now briefly speak of some of the openings for further progress. The duty of a medical officer of health includes inquiry into the causes, origin, and distribution of diseases within a district, and ascertaining to what extent the same have depended on conditions capable of removal or mitigation. Hitherto such inquiries have been chiefly confined to diseases of the zymotic class, and to those directly connected with what are called sanitary conditions. There is undoubtedly awide field of labour still before us, even in this direction. But even if we take such a subject as the housing of the working classes, it is becoming evident that the subject has come now to be mainly a question of local government and economies, and that the sphere of the medical officer will in the future be rather that of an executive officer, whose reports will form a necessary basis of action in securing improvements. Far-reaching as such improvements may be expected to be in the future, they cannot be said to touch even remotely the causes of illness into which it is our duty to inquire. Insanity alone accounts for a large proportion of disabling illness ~ o f t e n permanent~the control or prevention of which should be a subject of discussion in the reports of medical officers of health. It is impossible to read the Lumleian Lectures by Dr.
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T H E T E N U R E OF O F F I C E BY M E D I C A L O F F I C E R S OF H E A L T H .
Blandford--especially that delivered on April 4th, which appeared in the 7~ritis'; 7kfedicafJo~rnaland Zamel of April 2oth--without being impressed with the need for calling public attention to the subject of insanity, especially its prophylaxis. The question whether insanity is increasing may be difficult to decide, but Dr. Blandford gives many reasons for thinking that it is. But even if it be not so, surely there is sufficient reason for anxiously considering whether its prevalence may not be reduced. The insanity that may be said to be produced by alcoholic indulgence, and which, in a remote way, may be influenced by the character of dwellings, is not at all equal (Dr. Blandford says) to heredity as a producer of mental disorder. " I f , " says he, " w e wish to save our race from gradual mental decay, and not only to preserve life from such ills as zymotic diseases, but to raise up a strong and vigorous breed of healthy men and women, it is absolutely necessary that more attention should be paid than has been hitherto to the selection of individuals who are about to marry and reproduce." I would wish to quote more from these valuable and suggestive lectures. I would also desire to speak of the necessity for bringing about a closer connection between the treatment of insanity and our existing system of public health administration. But as the limit of this short address will not allow of this, permit me to express the hope that the crude remarks I now make will be presented to you later on in maturer form and more definite shape.
M E M O R A N D U M ON T H E T E N U R E O F F I C E BY M E D I C A L O F F I C E R S HEALTH.
OF OF
PRI~PARED BY
DR. T. ORI~E DUDFIELD.
THE first Public Act enjoining upon sanitary authorities the duty of appointing medical officers of health was the Metropolis Local Management Act, 1855 (i8 and 19 Vict., e. 12o, section 132 ). I n London the medical officer was, prior to the passing of the Local Government Act, 1888, appointed during, and removable at, the pleasure of the sanitary authority. The custom of appointment for a limited period only did not obtain, so that, practically, the appointment was made during good behaviour. The officers so appointed have in many cases been pensioned under the provisions of the Superannuation Allowances Act, 1866 (29 Vict., cap. 31) ; an Act " t o provide for superannuation allowances to officers of vestries and other boards within the area of the Metropolis Management Act." Several retired medical officers of health are at the present time in the receipt of pensions granted under the provisions of this Act.
The Public Health Act, 1872 (35 and 36 Vict., cap. 79, section Io) made provision for the appointment of medical officers of health in the country generally by the several urban and ruraI sanitary authorities. Unfortunately, it was enacted that " the appointmentsfirst made after the passing of this Act shall be for a period not exceeding five years." It would appear to have been intended by the Legislature that subsequent appointments should be permanent, for the section further enacts that " t h e Local Government Board shall have the same powers as they have in the case of a district medical officer of a union with regard to the qualification, appointment, duties, salary, and le~re of o~ice of a medical officer of health . . . any portion of whose salary is paid out of moneys voted by Parliament." The Public Health Act, T875 (38 and 39 Vict., cap. 55), which repealed the Public Health Act of 1872 , re-enacts the provisions with regard to the a0pointment of medical officers, and to the powers of the Local Government Board with respect to their tenure of office. The " powers" of the Local Government Board with respect to tenure of office were conferred by the 4th and 5th Will. IV., cap. 76, see. 46. Prior to the year I855 , the Poor Law Medical Officer did not enjoy security of tenure of office. In x854, however, the Select Committee of the House of Commons, appointed to consider the mode in which medical relief was administered to the poor, adopted, by a very l a n e majority, the following resolution : - - " Your Committee recommend that every medical officer to be appointed after the 25th of March, ~855 , should continue in office until he may die, resign, or become legally disqualified to hold such office, or be removed therefrom by the Poor Law Board." This resolution, adopted after a very careful investigation, was subsequently reported by the Committee to the House of Commons. With the view of giving it effect, the Poor Law Board, in February, I855 , issued a General Order relating to medical officers. In lieu of that Order, however, and in consequence of it not being found to give full effect to the recommendation of the Committee, the Board put forth a further Order, dated the 25th of May, I857, on the subject of the tenure of office by medical officers. This last-named Order came into force on the 24th of June, 1857. It prescribes as follows : - "Art. I . - - E v e r y medical officer of a workhouse, duly qualified at the time of his appointment, according to the regulations of the Poor Law Board then in force, shall hold his office until he shall die, or resign, or be proved to be insane, by evidence which the Poor Law Board shall deem sufficient, or become legally disqualified to hold such office, or be removed by the Poor Law Board." "Art. 2.--Every district medical officer duly qualified as aforesaid at the time of his appoint-
PROCEEDINGS
OF THE
James Russell, Chairman o f the Sanitary Committee of the City Council, and recently Lord Provost, has given me the key to the secret of their success.
H e says, " i n their present washing-houses, which are placed in the midst of a poor population, they have a large hall, round which there are cells containing earthenware basins let into a concrete floor, with discharge plugs, and hot and cold water. T h e people can here undress, and stand in these basins to have a wash, the hall being filled with warm a i r - - a very important feature, as they would not be got to undress and bathe in a cold room." A t present these places are only connected with the general wash-houses for clothes washing, the charge per hour paying both for the use of the clothes-washing apparatus, and for the baths afterwards. They find the women readily avail themselves of the opportunity for washing, and there seems to be no reason why the bath should not be allowed to be taken quite irrespective of the clothes washing ; and in my opinion such places ought to be provided free to the poor, and every inducement given them to come and make themselves and their children clean. I n Edinburgh, also, there is an association for improving the dwdlings of the poor, of which, also, Sir Jame Russell is chairman. In the tenements built by this association, each flat has a proper wash-house with all necessary apparatus at the disposal of the families living in the flat in rotation. T h e tenants prefer this arrangement to using the m o r e distant public wash-house, and they save the charge per hour made in them. T h e tenants are mostly very p o o r - - i n fact, were slum-dwellers. In connection with and adjoining each wash-house there is a wooden plunge-bath, which is in much request. T h e keys of these washing places pass in rotation to the next tenant, or to the tenant who is caretaker, as the case may be. Here, then, we have the germ of reform which, if steadily nurtured, may lead in the future to a very great improvement in the personal sanitation (if I may so call it) of the lower classes. I think that in the case of new houses, it should be made compulsory in all building regulations, that to every house, or to all terraces or blocks of houses, builders should provide, either by outbuilding or by proper additions to the ordinary requirements, suitable places in which cleanliness, not only of the person, but of the household necessaries, can be obtained. Of course, we shall have to meet t h e difficulties as we now find them existing in the homes o f the working-classes to-day, and the only way in which this can be done for old houses, seems to be the establishment of _puMicwash-houses on lines similar to those at present so successfully carried out in Edinburgh, and I would therefore strongly advocate the adoption of such places for all our large towns.
HOME
COUNTIES
BRANCII.
PROCEEDINGS OF THE HOME COUNTIES BRANCH OF THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. AT the meeting of this Branch, held in October, the following inaugural address was given by Dr. Seaton : " T H E PHYSICIAN'S WORK IN PUBLIC HEALTH ADMINISTRATION." BY EDWARD SEATON, IV[.]), F.R.C.P.
IT was shortlyflfter the Public Health Act of i872 came into operation that I thought of applying for one of the posts of medical officer of health then advertised by local sanitary authorities for the first time. A famous physician and former teacher (the late Dr. Bristowe) with whom I discussed my proposition, agreed that the opportunities afforded by the new Act should, even in the existing state of public opinion, afford ample scope for an honourable and useful career. " B u t , " added he, " k e e p up your connection with practical medicine~ which must always be the basis of a sound system of public health administration." I n accordance with this advice I took the membership of the London College of Physicians a few months later, and afterwards became connected with a provincial dispensary and a hospital as consulting physician, in after years serving on the Asylums Board of the Metropolis at a time when their hospitals and asylums first became available generally for the purposes of medical education. I mention these facts to you, not as being of any interest personally, but as explaining that my own bias has always been in favour of keeping the bond between public health administration and the w o r k . o f physicians as close as possible. The local medical officer of health for a large town should be placed by his salary and tenure of office, in a position equal to that of the principal town officials ; and while by the terms of his appointment, he should be debarred from private practice, he should at the same time be not only free, but in every way encouraged to accept positions of medical responsibility m connection with hospitals and dispensaries. The character of the office and its proper sphere of usefulness would thus be better suited than by any other arrangement as yet proposed or tried. I t is well for us to have an ideal before us ; but it must be admitted that up to now circumstances have not enabled us to realise it. I n the first place the public have not as yet come to fully appreciate the value of medical advice or services as applied wholly to the prevention, rather than the cure or treatment of illness. T h e subject of the appointments of medical officers of health, and their frequently unfavourable conditions of tenure, has received a large share of attention lately, not only in this Society and its branches, but in that section of the British Medical Association which is devoted
THE PHYSICIAN'S WORK IN PUBLIC HEALTH to the consideration of questions relating to the public health. But of all those who have addressed us on this subject, it seems to me that Dr. Woodforde, late President of the Society, indicated the main and essential difficulty in the way of improvement. It is that in a large proportion of instances the appointments are held by gentlemen in general medical practice. I am not about to enter into any controversial matter. I am fulty aware that among those I have the honour to address are some who may think that under existing circumstances the "specialist or whole-time" system is undesirable, and that until better initial conditions of appointment can be secured, it is not in the public interest that it should be generally recommended. I am not disposed at present to discuss this important question, but I desire to call attention to a fact that cannot be gainsaid. I t is that, notwithstanding what has been accomplished, the public do not as yet seem fully convinced of the practical utility of preventive medical work. Let me take a typical example of my meaning ~ v i z . , the case of an outbreak of scarlet fever or diphtheria associated with a particular milk supply, in which the medical officer of health happens also to be the practitioner attending on the cases. Here he has to choose between the attendance on the suffering sick, his anxious patients, and an investigation taking time, thought and care, for which his reward in most cases can only be an approving conscience. I f his object be to secure reward and thanks for his pains, there can be no doubt in which direction his interest lies. Indeed --strange, but nevertheless true--unless the outbreak assumes the proportions of an epidemic receiving wide attention, and unless it be of such a nature that it constitutes an object lesson, not even ~udos attaches to the investigation. Again, in illustration of my meaning, I may refer to institutions where the cure and prevention of illness are carried on side by side. As you may know, I have had opportunities of observation at many rate-supported hospitals. There blame is almost entirely confined to matters relating to treatment and cure of the sick, and not to those concerned in the prevention of illness. Hospital " s c a n d a l s " almost invariably relate to real or alleged neglect of the sick, not to the prevention of the spread or occurrence{of preventable illness~. T h e practice of vaccination abounds with instances of my meaning. Who is there among us ~In this respect there is a great difference between the voluntary hospitals in the management of which medical knowledge m supreme~ and the rate-supported hospitals, where it is subordinate to '"public opinion." Indeed, it seems to me the most powerful argument against maMng our hospitals '~ state" or ~"rate "-supported, is that hitherto the great advances in preventive surgery and medicine have been carried out in voluntary hospitals, and that, humanly speaking, these great triumphs would have been impossible of achievement in hospitals supported by the rates, and subject to the sort of control usually exercised n such establishments.~E. C. S.
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that has ever been thanked for vaccinating susceptible persons, even in households immediately threatened with smallpox ? In mentioning the above examples t have chosen those in which the close connection of prevention and cure is apparent to the medical profession, though not always to the general public. If, in such cases, the preference is usually given to the ]utter--to the cause of actually suffering humanity as some would put i t - - i s it to be wondered at that tile compara° tiveIy far away preventive work in which we are daily engaged so often fails to win appreciation ? The indication of nuisances injurious to health, which may be remedied by money expenditure, and the estimation of the probabilities of their proving so injurious ; the institution of a system of notification of preventable illness, which may furnish the basis of a sound public health organisation 5 the skilful analysis of sickness or vital statistics, so as to ascertain some fact connected with the habits or customs of a population tending to the development or increase of some disease; the cultivation of the art of diagnosis ; the study of micro-pathology--these, to mention no other, are examples of the physician's work in public health administration, the fundamental importance of which we, in the medical profession, recognise. When will its importance be fully recognised by the public ? Thus far it might seem that I am presenting an aspect of the physician's work which, if not deterrent, is certainly not encouraging to those who have to earn a living and make a career in their profession. But there are hopeful signs that, with the progress of education, by the gradual extension of the sphere of local government, together with a large increase in the number of persons actively interested or engaged therein, the work for which we claim a high position will come more and more to be appreciated. In order to promote this end~ it is desirable from time to time to recapitulate some of the principal achievements of preventive medicine. This has already been done, with co-ordinative skill and literary ability, by Dr. Thorne Thorne, in his book on " T h e Progress of Preventive Medicine during the Victorian Era." I t is no detraction from his interesting and valuable record to say that it is incomplete, for in such a comprehensive subject there is ample field for work for physicians in the service of local authorities, as well as those attached to Her Majesty's Local Government Board. I would, moreover, specially remark that the labours of those who are officially unattached, but who work at p u n i c health problems as earnestly as the time they can spare from their practice permits, is valuable mainly on account of its independence of official bias. My own brief recapitulation shall relate entirely to matters within my own experience, and if I give you more of my own
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opinions than those of other people, I will ask you to excuse m e on account of the position in which you have placed me this evening. I. The Arousing of t~e Poor.--It would form an interesting chapter in the history o f sanitary progress during the latter half of the Victorian era to trace the influence of the medical profession in promoting the greatest humanitarian movement of the n i n e t e e n t h c e n t u r y - - a m o v e m e n t which has made enormous strides in a comparatively very short time. This I cannot attempt to do now, but it is particularly interesting to note the action taken by the College of Physicians in initiating or promoting this great work. EXTRAORDINARY mEETING OF THE COLLEGE,
February i9th, 1874.
.dunaZs XXXI., p. 93.
The committee appointed at the last college meeting to prepare a Memorial to the First Lord of the Treasury, laid before the college the draft of a memorial, which was amended, and on the motion of Dr. Anstie, seconded by Dr. ]Sasham, was adopted as follows : - a*THE ~/~Ei*CIORIAL '~ Of the Corporation of the Royal College of Physicians of London C¢ T o
" First Lord of the Treasury ¢~ SHEWETH
'*That your memoriallsts in the daily exercise of their profession as physicians are brought much into contact with the poorer classes of the population, and are deeply interested in anything that concerns the welfare of these classes, n o : only (,n account of the poor themselves, but; also because the evils engendered among them affect the whole of society. " T h a t it is well known to your memorialists that overcro~ding--especially in unwholesome and ill-constructed habitations---originates disease, leads to drunkenness and immorality, and is likely to produce discontent among the poorer portion of the population. "That it is within the knowledge of your memorialists that the wholesale demolition of the houses inhabited by the poor, which have been carried on of late years under various Railway and Improvement Acts, while it has been serviceable in removing many very bad streets and dwellings, has incidentally caused much distress to the persons displaced, and has almost uniformly driven them to crowd into neighbouring quarters which were already as full as or fuller than was eonsistent with healthiness. al;'aTnha~2proateede~aterpriseeicSoP°mWe~la~Sot° P~l°v(ades theequflreeh for those who have been expelled from their former habitations, in addition to that whieh is called for by the constant increase of the population, by reason of the impossibility of securing suitable sites for building. Even so rich and powerful a body as the trustees of the Peabody Fund has been repeatedly foiled in particular attempts to obtain land to build on. ""fhat your memoriallsts believe that the mere enabling powers which are at present entrusted to various authorities have proved, and must prove, insufficient to effect the desired object. "That in the opinion of your memorialists a remedy for these evils is urgently needed. They therefore venture to express the hope that you will favour them by holding out some prospect that this question of the Dwellings of the London Poor, upon which the health and morality of the pc)pie so much depend, will be taken up by Government in the present session of Parliament. °~And your memoriatists will ever prays" etc. The president, censors, and regisf;rar were appointed a deputation to present the memorial.
HOME
COUNTIES
BRANCH.
O n e of the ways in which medical influence has b e e n most usefully exercised has been in keeping to the front principles which should guide statesm e n in their method of d e a t i n g w i t h this intricate q u e s t i o n - - p r i n c i p l e s which have been so ably expressed by Sir J o h n Simon in his " English Sanitary Institutions.' Not less influentla has been the inhibitory influence of the profession. I refer to the cautious utterances of e m i n e n t physicians, such as Dr. Bristowe, in correcting exaggerated statements. It is ten years ago now that I conferred with my old teacher on the subject of diphtheria and its relation to insanitary conditions. I was about to read a paper at our Metropolitan Society, and I then took the opportunity of proclaiming the facts respecting this disease, which were a n d are very m u c h in contradiction to what our respected friends, the sanitary engineers a n d inspectors, were teaching at that time. z. Industrial ffygiene.--This subject especially comes within the scope of physicians, whether practising as such, or whether wholly engaged in official work, as was Dr. Ballard. T h e Milroy lectures of Dr. Arlidge, a n d the admirable series of lectures in the Transactions of the Sanitary Institute, should mark a new era in public health administration. T h e way has been paved for fresh legislation a n d administrative reform, which, it is hoped, will soon lead to practical results comparable with the enormous improvements which have taken place in the dwellings of the poor. 3. A m o n g the notable achievements, I place the
Systematic Notification of I~zfectious Diseases.
I
do this not so m u c h because of the i m m e d i a t e benefits to be derived from it (although I think these are already by no means small in the ease of some diseases, such as small-pox a n d scarlet fever), but on account of the opportunities it affords for systematic local sanitary administration, a n d the scientific observation of epidemic diseases. Local sanitary authorities have the entire credit of initiating the s y s t e m - - a by n o m e a n s easy achievement, as some of us well know. 4. I n the field of scientific research we owe much to the labours of the Medical D e p a r t m e n t of the Local G o v e r n m e n t Board, especially as Dr. T h o m e has shown in that department which deals with .JZ~idemlology. I n connection with small-pox, he dwells o n the importance of Mr. Power's opinions as to the spread of the disease through the general atmosphere, which he says now meets with the almost u n a n i m o u s support of c o m p e t e n t scientific judges. I n the same interesting volume, published in i888, he discusses in detail the same observer's discovery of what is known as the H e n d o n disease, which some of us thought likely to constitute, a n d which may still prove to be, a material part of the etiology of scarlet fever. T h e great respect entertained for the scientific accuracy a n d conscientiousness of Mr. Power~ a n d those
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associated with him at the Local Government Board, commanded the earnest and careful atten, tion of unprejudiced observers to the latter discovery. It will, I think, be generally held that the absence of similar independent observations during the last ten years makes it necessary to review with very great caution the position to be assigned to these very important observations. In his address, Dr. Thorne spoke of " a n exaggerated trust in," or " a n over-estimation of the power of vaccination." May we express the hope that there may not arise an exaggerated fear of small-pox hospitals, which would seriously impede the further control of this eminently preventable disease. The work of Snow, of Stewart, of Parkes, ot Jenner, of Buchanan, and Bowditch, which had begun to produce these results before the time which I cover in this address, have furnished a basis for practical work in the prevention of cholera, typhoid, typhus, and phthisis, in which there has been no important change. There has, however, been some valuable addition to our knowledge in the contributions ot" Dr. Charles Kelly and Dr. Arthur Ransome, which will probably help to explain the law relating to phthisis distribution and soil moisture. The subject of phthisis and tuberculosis is at the present time attracting attention in another direction. The Tuberculosis Commission has by its report established certain facts which slzozdd influence public health administration in an important degree, viz., by altering our present system of the slaughter of animals, and their preparation for food, which so urgently needs improvement. I purposely refrain from entering, in this' address, into the subjects of laboratory research which have sprung from the work of the great Pasteur, and which constitute a large share of the preventive medical work Of our time, preferring, to dwell on important matters not generally receiving attention. I would, however, refer especially to the momentous discovery of the tubercle bacillus by Koch, and to the wonderful efficiency of tuberculin in detecting tuberculosis. Lectures, articles, and letters occasionally appear on this subject in the columns of leading journals. The Times of September 3oth contains an excellent letter on " F r e s h Aspects of the Tuberculosis Question," setting forth the arguments which logically prove our present system of slaughterhouses in England to be as bad as possible. But the writer probably hardly realises that which would be only too well known to his neighbours, our experienced colleagues, Drs. Woodforde and Ashby~ viz., the enormous difficulty of altering the long established customs of the meat trade. - This is a case for constant reiteration of indisputable facts, and explaining from the physician's point of view their full significance. Lastly, in the field of scientific research, which by way of contrast to laboratory research has been
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termed "field observation," or epidemiology, I have to say a few words on diphtheria, and those simply in illustration of what I have been saying this evening upon the importance of the physician's work in prevention as well as cure. The discovery of antitoxin may or may not make a very material difference in the mortality statistics of diphtheria. Be that as it may, the diagnosis and the prevention of the disease should rank as of even greater importance than its treatment or cure. It is much more important, in bur estimation, that medical officers should be appointed under conditions which enable them to watch and arrest the development of epidemic disease at schools, or wherever they may arise (also, that aids to diagnosis and opportunities of isolation should be afforded), than that medical talents should be directed almost exclusively to the treatment of the disease when it has arisen. This may not be tile popular view, but it is that which we must constantly endeavour to keep to the front. Certainly, though it may not be showy work, the study of the natural history of the disease as carried on for several years by the medical officers of the Local Government Board and Dr. Longstaff and Dr. Adams, of Maidstone, and others, has already and will continue to produce the most valuable results. Here let me refer to the highly important lectures of Dr. Newsholme, on acute rheumatism, and to the hypothesis which he has advanced, and which will require careful attention of epiderniologists and all who are interested in preventive medicine. Having so far spoken of the achievements in preventive medical work, let me now briefly speak of some of the openings for further progress. The duty of a medical officer of health includes inquiry into the causes, origin, and distribution of diseases within a district, and ascertaining to what extent the same have depended on conditions capable of removal or mitigation. Hitherto such inquiries have been chiefly confined to diseases of the zymotic class, and to those directly connected with what are called sanitary conditions. There is undoubtedly awide field of labour still before us, even in this direction. But even if we take such a subject as the housing of the working classes, it is becoming evident that the subject has come now to be mainly a question of local government and economies, and that the sphere of the medical officer will in the future be rather that of an executive officer, whose reports will form a necessary basis of action in securing improvements. Far-reaching as such improvements may be expected to be in the future, they cannot be said to touch even remotely the causes of illness into which it is our duty to inquire. Insanity alone accounts for a large proportion of disabling illness ~ o f t e n permanent~the control or prevention of which should be a subject of discussion in the reports of medical officers of health. It is impossible to read the Lumleian Lectures by Dr.
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T H E T E N U R E OF O F F I C E BY M E D I C A L O F F I C E R S OF H E A L T H .
Blandford--especially that delivered on April 4th, which appeared in the 7~ritis'; 7kfedicafJo~rnaland Zamel of April 2oth--without being impressed with the need for calling public attention to the subject of insanity, especially its prophylaxis. The question whether insanity is increasing may be difficult to decide, but Dr. Blandford gives many reasons for thinking that it is. But even if it be not so, surely there is sufficient reason for anxiously considering whether its prevalence may not be reduced. The insanity that may be said to be produced by alcoholic indulgence, and which, in a remote way, may be influenced by the character of dwellings, is not at all equal (Dr. Blandford says) to heredity as a producer of mental disorder. " I f , " says he, " w e wish to save our race from gradual mental decay, and not only to preserve life from such ills as zymotic diseases, but to raise up a strong and vigorous breed of healthy men and women, it is absolutely necessary that more attention should be paid than has been hitherto to the selection of individuals who are about to marry and reproduce." I would wish to quote more from these valuable and suggestive lectures. I would also desire to speak of the necessity for bringing about a closer connection between the treatment of insanity and our existing system of public health administration. But as the limit of this short address will not allow of this, permit me to express the hope that the crude remarks I now make will be presented to you later on in maturer form and more definite shape.
M E M O R A N D U M ON T H E T E N U R E O F F I C E BY M E D I C A L O F F I C E R S HEALTH.
OF OF
PRI~PARED BY
DR. T. ORI~E DUDFIELD.
THE first Public Act enjoining upon sanitary authorities the duty of appointing medical officers of health was the Metropolis Local Management Act, 1855 (i8 and 19 Vict., e. 12o, section 132 ). I n London the medical officer was, prior to the passing of the Local Government Act, 1888, appointed during, and removable at, the pleasure of the sanitary authority. The custom of appointment for a limited period only did not obtain, so that, practically, the appointment was made during good behaviour. The officers so appointed have in many cases been pensioned under the provisions of the Superannuation Allowances Act, 1866 (29 Vict., cap. 31) ; an Act " t o provide for superannuation allowances to officers of vestries and other boards within the area of the Metropolis Management Act." Several retired medical officers of health are at the present time in the receipt of pensions granted under the provisions of this Act.
The Public Health Act, 1872 (35 and 36 Vict., cap. 79, section Io) made provision for the appointment of medical officers of health in the country generally by the several urban and ruraI sanitary authorities. Unfortunately, it was enacted that " the appointmentsfirst made after the passing of this Act shall be for a period not exceeding five years." It would appear to have been intended by the Legislature that subsequent appointments should be permanent, for the section further enacts that " t h e Local Government Board shall have the same powers as they have in the case of a district medical officer of a union with regard to the qualification, appointment, duties, salary, and le~re of o~ice of a medical officer of health . . . any portion of whose salary is paid out of moneys voted by Parliament." The Public Health Act, T875 (38 and 39 Vict., cap. 55), which repealed the Public Health Act of 1872 , re-enacts the provisions with regard to the a0pointment of medical officers, and to the powers of the Local Government Board with respect to their tenure of office. The " powers" of the Local Government Board with respect to tenure of office were conferred by the 4th and 5th Will. IV., cap. 76, see. 46. Prior to the year I855 , the Poor Law Medical Officer did not enjoy security of tenure of office. In x854, however, the Select Committee of the House of Commons, appointed to consider the mode in which medical relief was administered to the poor, adopted, by a very l a n e majority, the following resolution : - - " Your Committee recommend that every medical officer to be appointed after the 25th of March, ~855 , should continue in office until he may die, resign, or become legally disqualified to hold such office, or be removed therefrom by the Poor Law Board." This resolution, adopted after a very careful investigation, was subsequently reported by the Committee to the House of Commons. With the view of giving it effect, the Poor Law Board, in February, I855 , issued a General Order relating to medical officers. In lieu of that Order, however, and in consequence of it not being found to give full effect to the recommendation of the Committee, the Board put forth a further Order, dated the 25th of May, I857, on the subject of the tenure of office by medical officers. This last-named Order came into force on the 24th of June, 1857. It prescribes as follows : - "Art. I . - - E v e r y medical officer of a workhouse, duly qualified at the time of his appointment, according to the regulations of the Poor Law Board then in force, shall hold his office until he shall die, or resign, or be proved to be insane, by evidence which the Poor Law Board shall deem sufficient, or become legally disqualified to hold such office, or be removed by the Poor Law Board." "Art. 2.--Every district medical officer duly qualified as aforesaid at the time of his appoint-