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 \ =: .■<
 
 THE NATIONALISATION OF HEALTH.
 
 BY THE SA2IE AUTHOR. 
 
 THE CEIMINAL. 
 
 ILLUSTRATED. 
 
 "In this work the able editor of the 'Contemporary Science 
 Series ' contributes to that excellent collection a volume well cal- 
 culated to maintain its reputation. . . . Mr. Ellis's work should 
 enlighten the British public as to the practical issues to which 
 scientific investigation of a subject of vital importance to the 
 commonwealth may conduce." — Athenceum. 
 
 " An ably written, an instructive, and a most entertaining book." 
 — Law Quarterly Review. 
 
 " A well-planned and ably executed resume of modern crimino- 
 logy." — Science. 
 
 " The subject with which it deals is by this volume introduced 
 for the first time to English readers. In many a journal, from 
 many a scientific meeting, they are likely to hear more of it in the 
 near future." — Pall Mall Gazette. 
 
 " The sociologist, the philosopher, the philanthropist, the 
 novelist — all, indeed, for whom the study of human nature has 
 any attraction — will find Mr. Ellis full of interest and suggestive- 
 ness." — Academy. 
 
 " An illustrated work of an exceedingly instructive and interest- 
 ing character. . . . The illustrations are remarkable, and the 
 book altogether commends itself as much to the medical as the 
 general scholar." — Dr. B. W. Eich.vedsox in Asclepiad. 
 
 London: WALTER SCOTT.
 
 THE NATIONALISATION 
 OF HEALTH 
 
 BV 
 
 HAVELOCK ELLIS 
 
 " The fate of man is in his own hands." 
 
 $,0x01 on 
 
 T. FISHER UN WIN 
 
 PATERNOSTER SQUARE 
 
 MDCCCXCII
 
 \\^
 
 HA 
 £4-7 n- 
 
 PEEFACE. 
 
 I HAVE here pleaded that the primary con- 
 ditions of health should be recognised as 
 of first importance to the community. 
 They have been so recognised, so far as 
 they have been understood, in every great 
 period of civilisation of which we have 
 much knowledge, as Koman and Moorish 
 ruins alone suffice to testify. That they 
 yre not so recognised to-day is the chief 
 element of rottenness in our own civilisa- 
 tion. We postpone laying the foundations 
 of our social structure in order to elaborate 
 its pinnacles. We are acquainted with all 
 possible openings for commerce through
 
 6 PREFACE. 
 
 the world ; we have explored the psycho- 
 logical ramifications of sentiment ; and we 
 do not know the course of the main sewers 
 in our city, and we pollute the sources of 
 the water we drink. We have not yet 
 learnt that a great civilisation is ill built 
 up on the bodies of men and women 
 enfeebled and distorted by over-work, filth 
 and disease. 
 
 I have further urged that the present 
 time is peculiarly favourable for taking in 
 hand seriously the organisation and sociali- 
 sation of the elementary conditions of 
 health. We have long left this primary 
 duty to the spasmodic and confused action 
 of charities, and to the interested action 
 of individuals and corporations. The be- 
 ginnings of more rational and organised 
 methods now exist : the task before us is 
 to develop them. The Third Eeport of the 
 Lords' Committee on Metropolitan Hos-
 
 PBEFAGE. 7 
 
 pitals, issued when the bulk of this Httle 
 book was ready for the press, is a valuable 
 summary of the most influential opinions 
 on certain aspects of the organisation of 
 health ; and we may reasonably hope that, 
 even though in a very small way, the 
 moderate suggestions of the Committee 
 may help to inaugurate a new movement. 
 Personally I have no elaborate plans or 
 panaceas to bring forward : it is not the 
 business of an individual but of the com- 
 munity to make plans as they are required. 
 This brief discussion of the Nationalisa- 
 tion of Health deals with but a few aspects 
 of a very large matter. I have here only 
 turned over quickly a few pages in the 
 terrible history of modern England, which 
 in this matter is that of modern Europe 
 generally. After the manner of the biolo- 
 gist, I have selected a few type specimens 
 as examples of the rest.
 
 8 PREFACE. 
 
 My interest in health questions dates 
 from many years back ; my behef in the 
 possibihty of the organisation of health 
 began ^Yith my acquaintance with the 
 conditions of health as revealed by medical 
 experiences in London, in large manu- 
 facturing towns, and in rural districts. 
 Beyond a very limited but somewhat 
 varied experience, I have no special know- 
 ledge of these matters. I do not really 
 see why I should write about them more 
 than an}^ other person. They concern 
 every one, and I have my own work to 
 do. But in the face of the apathy and the 
 ignorance that exist among us to-day, it 
 seems to be the duty of any one who has 
 an opportunity of realising the evils around 
 us to point out the paths of safety. It 
 is only the arm-chair statistician who can 
 rest comfortably when he has- shown that 
 in some other age or in some other land
 
 PREFACE. 9 
 
 the amount of disease or death due to 
 this or that cause has been even greater 
 than it is among us to-day. The diseases 
 of the soul will always be largely in- 
 calculable and beyond our reach. The 
 sins of the body, which, whatever the 
 moralists may say, must always touch 
 the mass ^of men more nearly, are largely 
 within our grasp. Is it not worth while 
 to combine to resist them, and in so doing 
 to lay more surely the foundations of our 
 social structure ? 
 
 H. E.
 
 CONTENTS. 
 
 I. 
 
 INTRODUCTION. 
 
 PAGE 
 
 The key-note of modern methods — The rise of bacteri- 
 ology and its significance — Sketch of the develop- 
 ment of health niovements — Congresses of Hygiene 17 
 
 II. 
 
 THE TREATMENT OF DISEASE. 
 
 By the medium of friendlj- societies — By private prac- 
 tice — By voluntary and charitable hospitals — The 
 art of professionalism — Tolstoi on the private prac- 
 titioner — Advantages and disadvantages of the 
 hospital system . . . . .30 
 
 III. 
 
 THE PRESENT POSITION OF THE HOSPITAL. 
 
 Only intended for panpers — Recent development- 
 Number of out-patients and in-patients — Number of
 
 12 CONTENTS. 
 
 PAGE 
 
 persons employed luy hospitals — Objections to the 
 hospitals — Remedies proposed — The dispensary — 
 Objections to the dispensary system . . 58 
 
 IV. 
 
 THE HOSPITAL OF THE FUTURE. 
 
 The ancient and the modern waj's of dealing with disease 
 — The hospital reformed into an institution of health 
 — The hospital must not be reserved for paupers — 
 The mismanagement of charitable hospitals— The 
 advantages of some degree of popular control . 66 
 
 V. 
 
 THE POOR-LAW INFIRMARIES. 
 
 The infirmaries are coming into line with the general 
 hospitals — Comparisons with regard to number of 
 patients and to expense — Reforms necessary in the 
 infirmaries . . . . ,. .76 
 
 VI. 
 
 THE REPORT OF THE HOSPITALS COMMITTEE (1892). 
 
 Scope of the inquiry — The committee's opinion of general 
 hospitals — Of special hospitals — The proposed Cen- 
 tral Hospitals Board — The committee's opinion of 
 infirmaries — The prospect of municipal hospitals . 83
 
 CONTENTS. 13 
 
 VII. 
 
 TYPHOID FEVER. 
 
 PAGF. 
 
 Its vast mortality and world-wide extension — Yet it is 
 easily preventable — The Tees Valley epidemic — The 
 experience of France — The prime necessity of pure 
 water . . . . . . 101 
 
 VIII. 
 
 BLINDNESS AND SHORT-SIGHT. 
 
 Comparative prevalence of blindness in European 
 countries — Blindness largely preventable — Its chief 
 cause — Defective ej-e-sight in Germany — In America 
 — In France — In Sweden — In England — Its causes 
 and prevention — School hygiene . ,110 
 
 IX. 
 
 MATERNITY AND ITS PERILS. 
 
 Puerperal fever — Sketch of the origin and development 
 of antiseptic midwifery — Progress made in the large 
 maternity hospitals of Vienna, Dresden, Paris, New 
 York, Berlin, London, Dublin, Copenhagen, St. 
 Petersburg— Contrast among population generally 
 — The enormous preventable mortality among j-oung 
 mothers — IManslaughter by general practitioners 
 and midwives — The registration of midwives . 123
 
 14 CONTENTS. 
 
 X. 
 
 THE dentist's PLACE IN" HEALTH NATIONALISATION. 
 
 PAGE 
 
 The neglect of the teeth — A source of disorder and 
 disease — lu childhood — Magnitude of the evil as 
 shown by investigations among school-children — 
 What might be done .... 144 
 
 XL 
 
 THE REGISTRATION OF DISEASE. 
 
 Dr. Richardson's proposed Ministry of Health — The noti- 
 fication and isolation of disease — The inclusion of 
 measles, whooping-cough, and consumption — Noti- 
 fication in America — The system carried out at 
 Zurich — The importance of including preventable 
 diseases generally, not merelj' infectious diseases . 157 
 
 XII. 
 
 THE INSPECTION OF INDUSTRIES. 
 
 The inspection of occupations is closely related to the 
 organisation of health — Yet it is still in a rudi- 
 mentary condition among us — A Home Secretary 
 on the " source and secret of commercial prosperity " 
 — The Factory Inspectors' reports — Coal-mining and 
 mineral-mining — Dr. Ogle on comparative mortality 
 — Ojiinion of the Paris International Workers' Con- 
 gress — Of the English Trades Union Congress . 170
 
 CONTENTS. 15 
 
 XIII. 
 
 WORKERS IN LEAD. 
 
 PAGE 
 
 Sketch of the history of lead-poisonmg — The various 
 occupations affected — White lead manufacture — 
 The " Dutch" process — Sj'mptoms of lead-poisoning 
 — Lead-poisoning in women — " White lead ghosts " 
 — Remedies proposed .... 185 
 
 XIV. 
 
 THE " LAISSEE FAIRE " SYSTEM. 
 
 The picture of disease and misery presented by Russia 
 — Birth-rate and death-rate — In famine time — 
 Ordinary conditions of insanitation — Russian fac- 
 tories — The cholera epidemic —The lesson of Russia 207 
 
 XV. 
 
 CONCLUSION. 
 
 The tendencies now making towards the nationalisation 
 of health : (1) Growing discontent with present lack 
 of system — (2) The beginnings of organisation — (3) 
 The inadequacy of private practice under modern 
 conditions — Every medical man must be a force on 
 the side of health-preservation — The organisation of 
 hospitals leads inevitably to the health-organisation 
 of occupations — The differences in mortality of
 
 16 CONTENTS. 
 
 PAGE 
 
 various occupations — The co-operation of workmen 
 necessary — The varying healthfiilness of towns — 
 The nationaHsation of health compared to the 
 nationalisation of education — Economic aspect — 
 The nationalisation of health leads to its inter- 
 nationalisation ..... 224
 
 THE 
 
 NATIONALISATION OF HEALTH. 
 
 I. 
 
 INTRODUCTION. 
 
 The kej'-note of modern methods — The rise of bacteriology 
 and its significance — Sketch of the development of 
 health movements — Congresses of Hygiene. 
 
 We possess to-day a closer grip of the con- 
 ditious of health than has ever been possible 
 before ; we now realise that these conditions 
 are of a complex character, and we are able, 
 to a large extent, to unravel their com- 
 plexity and to show clearly what a man 
 should do who would live a healthy life. 
 Medicine is no longer an affair of drugs — 
 useful as these are in their place — and 
 
 2 17
 
 18 NATIONALISATION OF HEALTH. 
 
 methods that ^Ye^e adopted by our bar- 
 barous ancestors when they called in the 
 aid of the medicine-man's incantations are 
 nearly out of date. An organism badly 
 born and badly bred, always placed under 
 unwholesome conditions and slowly satu- 
 rated with disease, finally breaks down and 
 is brought to the doctor to be drugged into 
 health : it is a sorry task for medical 
 science, and, what is of much more conse- 
 quence, it involves fearful expense, not 
 merely to the individual, but to all those 
 with whom he comes in contact, expense of 
 money, expense of happiness, expense of 
 life. The key- word of our modern methods 
 is not cure but j^reveiition, and while this 
 task is more complex it is also far easier. 
 It is to a gigantic system of healthy living, 
 and by a perpetual avoidance of the very 
 beginnings of evil, that our medical science 
 is now leading us.
 
 INTRODUCTION. 19 
 
 A few allied discoveries of quite recent 
 times have, more than anything else, given 
 an impetus in these new and fruitful paths 
 of medicine. The trivial discovery by 
 Leuwenhoek, a couple of centuries ago, of 
 micro-organisms, underlies the now world- 
 famous antiseptic system, initiated by an 
 Englishman, Sir Joseph Lister, which has 
 within the last fifteen years revolutionised 
 surgery, and given us a mastery never 
 before imagined over the process of disease. 
 
 The brilliant and varied researches of 
 Pasteur, centring around his great, dis- 
 covery, in 1869, that certain diseases are 
 caused and propagated by micro-organisms, 
 his subsequent discoveries that these micro- 
 organisms could be isolated, cultivated, 
 inoculated, attenuated, and the epoch- 
 marking discovery by Koch, in 1881, of the 
 bacillus of tubercle, have at the same time 
 revolutionised pathology, and opened out
 
 aO NATIONALISATION OF HEALTH. 
 
 new horizons. They have given ns an easy 
 control over many diseases ; they have 
 indicated the paths in which we must seek 
 the ehmination of disease. Every fresh 
 discovery — and discoveries are rapidly ac- 
 cumulating — of a micro-organism causing 
 disease is a promise hy no means neces- 
 sarily of a cure for that disease, hut of the 
 possihility of setting up an effectual harrier 
 against its invasion. 
 
 The picture of the world presented to us 
 b}^ the bacteriologist is undoubtedly some- 
 what awful, resembling the conception of 
 the mediaeval Christian. We are sur- 
 rounded by legions of invisible foes, always 
 ready to take advantage of a false step, of 
 the least crevice in our armour. And it is 
 satisfactory to feel assured that our right 
 course of action does not lie in swathing 
 ourselves — either literally or metaphorically 
 — in antiseptic cotton wool. ATe have
 
 INTRODUCTION. 21 
 
 another aucl better shield for allowing us 
 to move, for the most part, untouched 
 among our enemies. Fresh air and reason- 
 able garments, cleanliness in the full sense 
 of the word, pleasant work and varied 
 exercise, wholesome and abundant food, 
 the healthful play of the secretions and 
 excretions — these are the things that 
 enable some to resist while others suc- 
 cumb. The prevention of disease is some- 
 thing more than a hand-to-hand fight 
 against definite foes. It is a complex 
 organisation of health. 
 
 Together with the growth of our know- 
 ledge of the causes of disease there has 
 been thus slowly growing up also a new 
 kind of warfare against disease. It is this 
 science of hygiene which is now promising 
 to transform all the old traditional w^ays of 
 dealing with disease, and which now makes 
 possible the organisation of the conditions
 
 22 NATIONALISATION OF HEALTH. 
 
 of health. And this science of hygiene, it 
 must be repeated, rests on the exact know- 
 ledge of the causes of disease which we are 
 now obtaining. So long as we are ignorant 
 of the causes of disease we must be content 
 to deal with its manifestations as they arise 
 in each individual in accordance with the 
 traditional methods of medicine. When we 
 understand the causes of disease we can go 
 to the root of the matter ; we can deal with 
 disease collectively instead of individually ; 
 we can make medicine preventive, and we 
 can render possible the nationalisation or 
 socialisation of health. 
 
 At the beginning of the eighteenth cen- 
 tury Mead, a famous physician of that day, 
 whose reputation still lives, had proposed 
 the formation of a central board of health 
 to organise common measures for the public 
 safety. It was not, however, until more 
 than a hundred years later, in 1831, under
 
 INTBODUCTWN. 23 
 
 the influence of the terror of cholera, that 
 this first step was taken ; so that, as it has 
 been well said and often since proved, 
 " panic is the parent of sanitation." In 
 184'2 Sir Edwin Chadwick issued his report 
 on " The Sanitary Condition of the Labour- 
 ing Population of Great Britain." This 
 report produced marked effect, and may 
 truly be said to have inaugurated the new 
 era of collective action, embodying itself in 
 legislation directed to the preservation of 
 national health, an era which is thus just 
 half a century old. Chadwick's report led 
 to a Eoyal Commission, which was the first 
 step in the elevation of public health to a 
 State interest ; and a few years later (1847) 
 Liverpool, and immediately afterwards Lon- 
 don, appointed the first medical officers of 
 health in Great Britain. In 1848 another 
 epidemic of cholera appeared, and a General 
 Board of Health was established. During
 
 24 NATIONALISATION OF HEALTH. 
 
 this epidemic Dr. Snow began those in- 
 quiries which led to the discovery that the. 
 spread of the disease was due to the con- 
 tamination of drinking-water by the in- 
 testinal discharges of patients. That 
 discovery marked the first great stage 
 in the new movement. Henceforth the 
 objects to be striven for in the evolu- 
 tion of sanitation became ever more clear 
 and precise, and a succession of notable 
 discoveries in connection with various epi- 
 demics enlarged the sphere of sanitation, 
 and revealed new possibilities in the pre- 
 vention of human misery. The necessity 
 of purity of water-supply and of efficient 
 drainage was demonstrated, and a gradual 
 knowledge of the local distribution of disease 
 and of the industrial condition of the nation 
 was slowly built up. Dr. Farr's elaborate 
 reports, founded on the vital statistics of 
 the nation, were of great value in keeping
 
 INTRODUCTION. 25 
 
 alive an active interest in these matters by 
 demonstrating the progress gradually made 
 and the possibility of further advances. In 
 18GG the beneficial influence of a new 
 cholera scare led to the passing of a Sani- 
 tary x\ct, which established the duty of 
 local authorities to provide for the healthi- 
 ness of their districts, and thus a further 
 stage in the evolution of this great move- 
 ment was reached. The way was paved for 
 the recognition of the broad principle that a 
 chief business of local government is the 
 care of public health. In 1872, as the 
 natural outcome of the progress already 
 made and of a new Royal Commission, 
 the Public Health Act provided for com- 
 plete sanitary organisation, and for the 
 universal appointment of medical officers 
 of health. This mapping out of the country 
 into health-districts and the recognition that 
 the caro of public health is a great function
 
 26 NATIONALISATION OF HEALTH. 
 
 of local government was a splendid idea 
 worthily carried out. But it was not alto- 
 gether successful ; it w^as too far ahead of 
 the public opinion of the day. Local 
 authorities are still ignorant ; they are not 
 prepared to recognise that the care of public 
 health is their most important function ; 
 and they are fi'equently unwilling to pay 
 more than a nominal salary to their medical 
 officers of health. Moreover, their own 
 private interests, as well as their conserva- 
 tive tastes and traditional practices, fre- 
 quently stand in the way of efficient 
 sanitation, and the medical officer must 
 often recommend reform at his peril. So 
 it comes to pass that in 360 rural districts 
 the salary of the medical officer of health, 
 appointed b}" the Board of Guardians under 
 the Act of 1872, averages but ^21 10s., and 
 in 252 urban districts but £14: 10s. ; and 
 while there are in England and Wales some
 
 INTRODUCTION. 27 
 
 1,500 medical officers of health, little more 
 than 100 (or less than one in 15) are health 
 experts in the sense of being free from 
 practice and solely engaged in sanitary 
 work. There is yet therefore very much 
 to be accomplished. 
 
 The duty of the County Councils, assisted 
 by medical experts, to watch over the health 
 conditions of large areas, is doing much to 
 counteract the apathy of small local bodies 
 and to stimulate the energies of medical 
 officers of health and of sanitary inspectors ; 
 the establishment of the Councils has been 
 an important step in the right direction.* 
 
 * I may refer, for instance, to the energy of the Cornish 
 Council, and to its Health Eeport for 1891, which reflects 
 great credit on the Council's Sanitary Committee and their 
 Chairman. A feature of the report well worth imitation is 
 the large number of diagrams and coloured maps showing 
 the distrihution of the mortality from the chief diseases over 
 the rural divisions of the county. It is noteworthy* that 
 those divisions which the Council has found most recalcitrant 
 to sanitary reform are those which come out worst in the 
 maps. It sometimes requires considerable pressure to effect
 
 28 NATIONALISATION OF HEALTH. 
 
 The Infectious Diseases Notification Act 
 of 1889 marks another important sta^-e in 
 the gradual evohition of the process by 
 which health is becoming nationalised. 
 The exact registration of disease is an 
 essential part of all effective and compre- 
 hensive sanitation. This Act is now ex- 
 tended so as to apply to nearly five-sixths 
 of the population of England and Wales. 
 The notification and isolation of infectious 
 disease enables us to limit epidemics, to de- 
 fine the areas in which they are found, and 
 to trace the insanitary conditions by which 
 they are produced or favoured. Even this 
 Act, however, which renders optional the 
 inclusion of two such wide-spread and fatal 
 diseases as measles and whooping-cough, 
 
 any progress. Thus the Sanitary Authority at St. Ives, 
 which had repeatedly' refused to adopt the Notification Act 
 and alhed measures, has only been brought to reason during 
 the summer of 1892 by a slight local outbreak of small-pox 
 and " chicken-pox."
 
 INTIiODUCTION. 29 
 
 shows the progress which has yet to he 
 made. 
 
 Together with the Ijeginnings of this 
 moYeineut for the nationahsation of health, 
 there has heen a still later movement of in- 
 ternational character, finding expression in 
 Congresses. The honour of holding the first 
 International Congress of Hygiene belongs 
 to Belgium : it took place at Brussels in 
 1876. The French then adopted the idea, 
 and made the Congress a permanent insti- 
 tution, meeting every two years. England, 
 always behindhand where international 
 movements are concerned, sent very few 
 members to these Congresses, and it was 
 not until 1891 that an International Con- 
 gress of Hygiene and Demography was held 
 in England. On the whole these Congresses 
 have done much to consolidate, unif}^, and 
 stimulate the various movements connected 
 with public health.
 
 II. 
 
 THE TREATMENT OF DISEASE. 
 
 By the medium of friendly societies — By private practice — 
 By voluntary and charitable hospitals — The art of pro- 
 fessionaUsm — Tolstoi on the private practitioner — Ad- 
 vantages and disadvantages of the hospital system. 
 
 I HAVE briefly sketched the present position 
 of the new movement for the prevention of 
 disease. Let ns now turn to the present 
 position of the far more ancient system of 
 the treatment of disease. 
 
 There are, speaking generally, and omit- 
 ting minor varieties, three chief methods 
 practised in England to-day for distributing 
 medical assistance. 
 
 1. Private practice ; that is to say that a 
 medical man establishes himself in a dis- 
 
 30
 
 THE TREATMENT OF DISEASE. 31 
 
 trict and supplies medical assistance (usually 
 including medicine, except when his patients 
 are of a well-to-do class) hy private arrange- 
 ment, sending in a bill at stated periods. 
 
 2. By the medium of friendly societies. 
 By this method the local branch of the 
 friendly society contracts with a local 
 medical man to supply medicine and 
 medical advice to its members in considera- 
 tion of a certain annual payment by the 
 society. 
 
 3. By the medium of voluntary hospitals. 
 In this case the patient is admitted to a 
 charitable institution, either by subscriber's 
 letter or on the merits of the case, and 
 receives gratuitously the care of the medical 
 and nursing staff. 
 
 The second of these two methods, the 
 club system, may be dismissed briefly ; few 
 persons who know anything about it will 
 question that, while under existing circum-
 
 32 NATIONALISATION OF HEALTH. 
 
 stances it is a valuable makeshift, it is far 
 from being satisfactory either in theory or 
 in practice. It is a noteworthy fact that 
 the best and most independent working 
 men, while belonging to a friendly society, 
 prefer paying their own doctor to going to 
 the club-doctor ; while young medical men 
 of energj^ and ability set their faces so far 
 as thej^ can against club-practice.* For 
 the fact is that the method is equally 
 unsatisfactory to both parties, and encour- 
 ages constant suspicion and intrigue. The 
 patient, in the club-doctor's opinion, often 
 becomes ill because he wants a holiday, or 
 because (as is unfortunately sometimes the 
 case) he can get more money out of the 
 
 ■* As the medical officer of a friendly society remarks, 
 perhaps too strongly {Lancet, Oct. 3, 1891) : " None of the 
 men who hold these offices care for them. There is alwaj's 
 an innate feeling of self-degradation." To show how much 
 they are sought after, however, the same writer remarks that 
 when he was appointed to a post of this kind worth ^250 a 
 year there were seventy-two applicants, all well qualified.
 
 THE TREATMENT OF DISEASE. 33 
 
 clubs he belongs to by the help of a doctor's 
 certificate than he can earn by working. 
 Conscious that he is treated with suspicion 
 by the doctor, the club-patient naturally 
 takes up a corresponding attitude, and is 
 resolved to insist upon his rights to the 
 utmost. The club-doctor on his side knows 
 that he works very hard for the club and 
 sees very little return for his labour, and he 
 comes to view with impatience this unend- 
 ing stream of unprofitable patients. At the 
 same time he may know that nearly every 
 medical man in the town envies him, and 
 that some of them are perhaps lending 
 themselves to a growing faction that is 
 seeking to depose him. A scene of un- 
 appreciated comedy is sometimes played in 
 the club-doctor's consulting room. A stolid 
 peasant enters deliberately, grasping his 
 stick in one hand, his empty bottle in the 
 other. The doctor looks at him: " AYell, 
 
 3
 
 34 NATIONALISATION OF HEALTH. 
 
 ^Yhat's the matter now ? " The patient 
 replies slowly and laconically that he still 
 has that pain across here. The doctor 
 scrutinises the patient through his spec- 
 tacles severely ; the patient remains im- 
 penetrable and phlegmatic. Then the 
 doctor takes the bottle ; he scrutinises this 
 also with trained eyes, thinks he detects 
 signs that the patient has taken two doses 
 and thrown away the rest. Then he 
 scrutinises the patient again ; but John 
 Bull sits as before, grasping his stick and 
 not moving a single muscle ; it may be the 
 consciousness of rigid uprightness ; it may 
 be the mask of unfathomable cunning. 
 The . propriety of a physical examination 
 suggests itself to the doctor ; he percusses 
 and auscultates here and there. The re- 
 sults, from whatever reason, are negative. 
 He gives it up ; hastily fills the bottle with 
 a cheap and nauseous mixture, compounded
 
 THE TREATMENT OF DISEASE. 35 
 
 especially for the benefit of club-patients, 
 signs the certificate, and thrusts both into 
 the man's hand. Then he turns with a 
 smile of beaming benevolence to the next 
 person, who happens to be a private patient. 
 It is scarcely surprising that not every 
 w^orking man cares to be a club-patient, and 
 that few medical men regard such patients 
 with any satisfaction. The fault, it must 
 be repeated, lies for the most part neither 
 with patient nor doctor ; least of all with 
 the friendly society. The method is a bad 
 one, and while it provides w4iat is better 
 than no medical aid at all, we cannot look 
 to it for the germ of any more permanent 
 and general system. 
 
 It is obvious at once how much more 
 advantageous the system of private practice 
 is for both parties. The patient can go to 
 any doctor he likes ; he can change his 
 doctor as often as he pleases ; and as the
 
 36 NATIONALISATION OF HEALTH. 
 
 payment is in the ratio of services rendered, 
 lie feels that he is able to assume an air of 
 independence, or, if circumstances permit, 
 of patronage. He knows that his " medical 
 attendant " (that is the private practitioner's 
 time-honoured title) may be relied upon to 
 come at his earliest summons, and to treat 
 his sjmptoms with all the attention and 
 sympathy they merit. And when, as hap- 
 pened formerly, perhaps, more frequently 
 than now, the doctor has known the family 
 for many years, and is familiar with all their 
 peculiarities and all their little ailments, he 
 becomes, so far at all events as those ail- 
 ments are concerned, the most skilful and 
 experienced adviser that the patient could 
 obtain : at the same time his position is 
 that of a trusted counsellor and friend. On 
 his side the private practitioner may have 
 little to complain of. It is true that at the 
 outset of his career he often finds that
 
 THE TREATMENT OF DISEASE. 37 
 
 patients are alarmingly few ; and that as 
 time goes on he complains that he is being 
 worked to death ; but he does not forget 
 that the pay is in proportion to the work, 
 and that the work is full of human interest. 
 This is one's first impression on taking a 
 general survey of the method of private 
 medical practice ; and until comparatively 
 recent times it was regarded as a final view 
 of the matter. But let us look into it a 
 little more closely. It is true that for 
 ordinary ailments the private practitioner 
 cannot generally be improved upon, and 
 such ailments form the majority of cases in 
 which his aid is required. But the minority 
 is precisely the most grave and urgent pro- 
 portion, and here, too often, the private 
 practitioner is lamentably at fault. That 
 he is so is usually his misfortune. Medicine 
 nowadays is a complex business ; and long 
 and arduous as is the course of the medical
 
 38 NATIONALISATION OF HEALTH. 
 
 student he cannot be a master of every- 
 thing, even with the best will and a very 
 fair capacit3\ The general public are, in- 
 deed, already so thoroughly impressed with 
 this truth that they constantly leave their 
 own " medical attendants " to consult a 
 specialist at some large centre — often quite 
 unnecessarily. The old school of practi- 
 tioners who know nothing of the clinical 
 thermometer, and who regard the stetho- 
 scope as an unnecessary luxury, are rapidly 
 dying out, though they still survive here 
 and there. But under no conditions, even 
 with the very best scientific training, is it 
 possible to give the private practitioner a 
 full equipment of skill and of instruments. 
 Every year it is becoming less possible. 
 The sura of skill is increasing, and the 
 means of applying it ; but the individual 
 private practitioner's chance of using them 
 must remain strictly limited. Too many of
 
 THE TREATMENT OF DISEASE. 39 
 
 US are acquainted with instances, so con- 
 stantly occurring, of ignorance, of deficient 
 judgment or skill on the part of private 
 practitioners — broken limbs so badly set 
 that they are useless save at the price of a 
 serious operation ; a dislocated shoulder, 
 even, treated merely with a bandage and 
 a liniment ; tumours not diagnosed until 
 another medical man is called in to find 
 that there is now no help possible ; diph- 
 theria repeatedly diagnosed as mumps by 
 the sixpenny East-End doctor ; an impru- 
 dently administered opiate, and the imme- 
 diate result, death. I do not wish to insist 
 on this aspect of the question, and unfortu- 
 nately it is not necessary to do so. In 
 surgery the private practitioner is generally 
 feeble and timid. It is not compulsory in 
 England to perform a single operation in 
 order to become a private practitioner ; and 
 the private practitioner persuades his well-
 
 40 NATIONALISATION OF HEALTH. 
 
 to-do patient to call in a hospital surgeon ; 
 while if the patient is poor he either refuses 
 to undertake the case at all, or puts him to 
 great inconvenience and expense by ulti- 
 mately sending him, perhaps a long dis- 
 tance, to some large hospital, sometimes 
 merely to receive a snip or two with scissors 
 or knife that is done in less than a minute. 
 It is doubtless chiefly owing to this timidity 
 that, in the manipulation of joints, the 
 "bone-setter" in the north of England 
 fi'equently obtains such brilhant successes 
 when the private practitioner has failed. 
 It would not be fair, however, to suppose 
 that it is always, or even generally, from 
 incompetence that the private practitioner 
 refuses to perform a trifling operation. 
 Here again it is the system rather than the 
 man that is at fault. He knows that under 
 the most favourable circumstances there is 
 a certain risk, even in a trifling operation :
 
 THE TREATMENT OF DISEASE. 41 
 
 it is not worth his while to run the risk, 
 aloue, of possible and unnieiited discredit. 
 In diagnosis the private practitioner is 
 usually perfectly reliable when the ailment 
 is simple and famihar ; it would perhaps be 
 too much to expect him to be very skilful 
 outside the beaten track, and his errors are, 
 very frequently, signal, though not neces- 
 sarily grave in their consequences. It is 
 the exception to find a private practitioner 
 examining his patient carefully and me- 
 thodically ; he perhaps prides himself (often 
 with justice) on his aptitude for diagnosing 
 instinctively and immediately ; for various 
 reasons he generally finds, sooner or later, 
 that in private practice careful examination 
 is a mistake ; sometimes his patient suffers 
 in consequence, sometimes his own reputa- 
 tion. In the matter of treatment the 
 private practitioner has certain routine 
 practices which answer w^ell on the whole,
 
 42 NATIONALISATION OF HEALTH. 
 
 but he is not sufficiently in touch with 
 fellow-practitioners to be able to make 
 much progress, or to follow intelligently 
 recent therapeutic advances. He rarely 
 fails to take in some medical journal, but 
 that is not quite the same thing as present 
 and quickening experience. In regard to 
 instruments, either for diagnosis or treat- 
 ment, his case is hopeless ; the experience, 
 trouble, and expense which instruments 
 involve render them a luxury which he 
 avoids so far as possible ; and yet they are 
 more and more coming to the front. Take, 
 even, the ophthalmoscope, now regarded as 
 indispensable ; what percentage of private 
 practitioners, one would like to know, are 
 competent to use it intelligently ? 
 
 The sole object of a doctor's activity is 
 supposed to be the cure of his patient ; and 
 there should therefore be nothing to impede 
 him in the attainment of this object. But
 
 THE TREATMENT OF DISEASE. 43 
 
 how is the private practitioner situated? 
 A new patient enters his consulting-room 
 for advice and medicine. The doctor must 
 ask himself: Can he pay? and hy a few 
 judicious questions he is generally soon ahle 
 to come to a decision on the matter. If it 
 is unfavourable he perhaps makes up a 
 mixture, and holds out the bottle with a 
 polite but firm request for immediate pay- 
 ment of the trifling sum at which active 
 competition has obliged him to rate his 
 services. Not inh-equently the patient 
 departs without the medicine. But suppose 
 that he is dealing with one of his hest 
 patients — he must still keep an eye on 
 something which is beside the main aim : 
 he must consider what his patient wants, 
 humour him, make himself agreeable, main- 
 tain his own credit and an air of general 
 control over the circumstances of the case. 
 These accomplishments impart to the
 
 44 NATIONALISATION OF HEALTH. 
 
 private practitioner that professional man- 
 ner which is an art by itself, altogether 
 distinct from the qualities that make him a 
 skilful physician. Here again it is not fair 
 to blame the private practitioner. It con- 
 stantly happens that a doctor — sometimes 
 even a man who stands near the head of his 
 profession — is deserted by a patient for 
 some one else of inferior ability who can 
 speak with assurance and is a master in the 
 arts of professionalism.* 
 
 ■■• If any one does not quite realise this professionalism let 
 him turn to the novels in which Tolstoi, with that calm 
 realism which makes his books equally interesting to those 
 who care for hfe or art, describes incidentally the private 
 practitioner. Ivan Ilyitch, for instance, is a judge who, 
 noticing in himself certain obscure symptoms of illness, 
 gradually increasing, resolves to consult a famous doctor. 
 
 " He went. Everything was as he expected ; everything 
 was done according to the usual way — the having to wait, 
 and the pompous doctorial air of importance, so familiar to 
 him, the same as he himself assumed in court, and the 
 tapping and the auscultation and the leading questions re- 
 quiring answers predetermined, and apparently not heard, 
 and the look of superlative wisdom which seemed to say :
 
 THE TliEATMENT OF DISEASE. 45 
 
 During the last half-century a change 
 has taken place which has done much to 
 dislocate the private practitioner. Fifty 
 years ago it was the universal custom for 
 students to be apprenticed for at least eigh- 
 teen months to a private practitioner. They 
 
 ' You, now, just trust yourself to us, and we will do every- 
 thing ; we understand without fail how to manage ; every- 
 thing is done in the same way for every man.' Everything 
 was just exactly as in court. The airs that he put on in 
 court for the benefit of those brought before him, the same 
 were assumed by the famous doctor for his benefit.'' 
 
 Or, again, near the fatal termination of Ivan Ilyitch's 
 illness : — 
 
 " There ! the bell in the corridor. It is the doctor, fi-esh, 
 hearty, portly, jovial, with that expression as if he said : 
 * You may feel apprehension of something or other, but we 
 will immediately straighten things out for you.' The 
 doctor knows that this expression is not appropriate here, 
 but he has already put it on, and he cannot rid himself of it 
 — like a man who has put on his dress-coat in the morning 
 and gone to make calls. The doctor rubs his hands with an 
 air of hearty assurance. ' I am cold. A healthy fi'ost. Let 
 me get warm a little,' says he, with just the expression that 
 signifies that all he needs is to wait until he gets warmed a 
 little, and when he is warmed then he will straighten things 
 out."
 
 46 NATIONALISATION OF HEALTH. 
 
 probably gained very little insight into the 
 science of medicine, but they were thus 
 undoubtedly enabled to acquire a con- 
 siderable acquaintance with the art of 
 private practice. Then they came up to 
 London, " walked the hospitals " for a time, 
 were examined at the College of Surgeons 
 and at Apothecaries' Hall, and the thing 
 was done. The examination at the College, 
 we are told, occupied twenty minutes only, 
 and was entirely viva voce. This simple 
 little proceeding is curiously unlike the 
 prolonged and complex ordeal, lasting 
 at the least five years, with an examina- 
 tion at every turn, through which the 
 would-be private practitioner has to pass 
 nowadays, but it succeeded in producing 
 the typical private practitioner. This the 
 present system will never be able to do. 
 The student now is trained from first to last 
 at a hospital. This fosters careful and
 
 THE TREATMENT OF DISEASE. 47 
 
 exact methods of study, a simple and 
 straightforward way of dealing w4th patients, 
 a full and various acquaintance with cases 
 and treatment. But it does nothing to 
 furnish the student with that tincture of 
 professionalism of which the private practi- 
 tioner makes such large use ; nor — a more 
 important matter — does it give the student 
 much opportunity of studying those trivial 
 complaints to which the private practitioner 
 must chiefly confine his attention. Thus it 
 happens that when the young medical man 
 is pitchforked into a private practice he has 
 very often nearly the whole art to learn, 
 and sometimes no special aptitude for such 
 learning. Moreover, it is by no means 
 always the most skilful man who is best 
 able to pick up the arts of professionalism, 
 or who is most desirous of doing so, and it 
 is not without an effort that he recognises 
 the necessity of this demoralising art, and
 
 48 NATIONALISATION OF HEALTH. 
 
 the inevitable concomitant adoption of the 
 methods of the small shopkeeper in doling 
 out his pills, potions, and advice. 
 
 The question of payment leads us to 
 another of the disadvantages of the method 
 of private practice, and to one of the most 
 serious. It has long been a matter of good- 
 humoured comment that the doctor is only 
 paid so long as his patient is ill, and that it 
 is his interest to keep him so. His business 
 is to cure if he can ; if not, to alleviate 
 — rarely to prevent. That this plan is 
 flagrantly abused by the private practitioner, 
 those who are best acquainted with him will 
 be most ready to deny ; and it is by no 
 means uncommon for the private practi- 
 tioner to inform the patient that he (or 
 more often she) needs neither medicine nor 
 medical advice. But the fact that the 
 system is not often abused is scarcely a 
 sufficient justification for its existence.
 
 THE TREATMENT OF DISEASE. 49 
 
 One other point may be alluded to. The 
 inevitable development of specialism in 
 private practice and its evils have been 
 frequently pointed out. The growing com- 
 plexity of medical science renders specialism 
 more and more necessary, at all events 
 within certain limits, while it renders the 
 specialist more and more incapable of 
 treating the body as a whole. Thus the 
 patient who is fairly dealt with should be, 
 and not infrequently is, made to visit — at 
 the expense, naturally, of much time, 
 trouble, and money — a succession of 
 specialists, in order to obtain an authori- 
 tative opinion upon his condition. 
 
 This brief review may suffice to indicate 
 that while the private practitioner himself 
 is usually a high-minded man, acting to the 
 best of his ability under the circumstances, 
 the system is, from the point of view of 
 modern science, thoroughly bad. It will be 
 
 4
 
 50 NATIONALISATION OF HEALTH. 
 
 necessary to return to this matter. It is 
 enough to say here that a system which, 
 hke that of private practice, is based on 
 the casual tinkering of disease, and which 
 regards as an impertinence the far more 
 vital question of prevention, stands a very 
 poor chance of being accepted as the system 
 of the future. 
 
 The third chief method at work amongst 
 us for the distribution of medical assistance 
 is that of the voluntary hospital. The 
 advantages of our large modern hospitals 
 are sufficiently obvious, and are well recog- 
 nised. They are the centres of medical 
 science and skill, organised on an extensive 
 scale, combined with the best nursing any- 
 where obtainable. A hospital appointment 
 is the ambition of every young medical 
 man who aspires to rise in his profession. 
 Without this he can scarcely hope to attain 
 experience and proficiency ; and every dis-
 
 THE TREATMENT OF DISEASE. 51 
 
 tingiiished physician or surgeon is more or 
 less intimately connected with some large 
 hospital. While hospitals are sometimes 
 compelled to close certain of their beds, 
 economical considerations have a very 
 trifling effect in limiting either the treat- 
 ment or the dietary. Formerly a hospital 
 ward was by no means the dainty home 
 of sweetness and light, of fresh air and 
 cleanliness, of flowers and pictures and 
 books that we find it to-day, not merely on 
 show occasions, but at every hour of the 
 day or night. Nursing had not then 
 become an art which no woman need think 
 it beneath her to exercise. Moreover, the 
 place itself was a focus of infection ; the 
 patient, long before he w^as cured, stood a 
 good chance of being carried off by some 
 other disease. All that has been changed. 
 A hospital can never be the healthiest of 
 spots to live in, but the dangers of every
 
 52 NATIONALISATION OF HEALTH. 
 
 hospital which can stand modern tests have 
 been reduced to an insignificant minimum. 
 To-day any chance ragamuffin who is ad- 
 mitted gratuitously into one of the large 
 London hospitals has at his disposal a 
 complex organisation, prepared to meet 
 every emergency in the most immediate 
 and effective manner, which no middle-class 
 man in his wildest dreams could hope to 
 bring to his suburban villa, and which can 
 be but partially installed, with much diffi- 
 culty and expense, at the palace of a 
 millionaire or a member of the royal 
 family. 
 
 This is one aspect of the hospital system ; 
 unfortunately it is not the only aspect. 
 Here also, as in considering the system of 
 private practice, we have to face grave disad- 
 vantages. The source of one of the gravest, 
 under present conditions, lies, in the eyes of 
 many people, in the very perfection of the
 
 THE TREATMENT OF DISEASE. 53 
 
 service it is able to render. While it is fre- 
 quently necessary to shut out from want of 
 accommodation many who are quite unable 
 to pay, among those who are admitted there 
 is always a considerable proportion who are 
 able to pay something. This is a source of 
 constant friction and irritation with the 
 private practitioner. He is quite willing, 
 even anxious, to see poor patients go to the 
 hospital, but he feels that it is his place to 
 provide medical assistance to the patient 
 who is able to pay something. The intel- 
 ligent patient knows where it is best for 
 him to go. As a rule, however, he does not 
 go, and for a reason which affects nearly all 
 who attend the hospital. It is a charitable 
 institution : this fact to a great extent 
 negatives its advantages in the eyes of the 
 Englishman. He is very ready to give 
 charity ; by no means so ready to receive 
 it ; and as soon as possible he leaves the
 
 54 NATIONALISATION OF HEALTH. 
 
 liospital for the services of his "medical 
 attendant," which, however inferior they 
 may be, at least enable him to preserve his 
 sense of independence. And he is perfectly 
 right ; charity, as we are now taught, is one 
 of the chief demoralising forces in our 
 midst. 
 
 Another serious disadvantage of the 
 hospital system lies in its voluntary and 
 irresponsible character. We see here a 
 great national and absolutely indispensable 
 institution, the headquarters of medical 
 science, giving employment in London alone 
 to many thousand people, in the hands of 
 private persons. Let it be granted — and 
 probably it may be granted — that these 
 persons do not abuse their position, and 
 still the system produces an inevitable crop 
 of evils. I doubt whether many people 
 realise the suspicion with which a certain 
 section of the more ignorant classes regards
 
 THE TREATMENT OF DISEASE, 55 
 
 hospitals. Indeed, even among the more 
 intelhgent classes, the critics of medicine 
 are in England, as a distinguished French 
 surgeon has recently said they are in 
 France, frequently conspicuous for their 
 " enormous incompetence." Charges of 
 gross neglect, charges of treating patients 
 as subjects for experiment, are freely and 
 fiercely expressed, and occasionally they 
 gain a prominent position in newspapers 
 and novels. On investigation these charges 
 usually turn out to be ridiculously devoid 
 of foundation ; and any one who is familiar 
 with the working of our large hospitals 
 knows that such accusations are so absurd 
 that it is difficult to consider them seriously. 
 But in the case of an institution supported 
 by voluntary subscriptions, such accusations 
 must exert a distinctly detrimental effect. 
 Attempts have been made to establish a 
 kind of informal taxation among working
 
 56 NATIONALISATION OF HEALTH. 
 
 men for the support of hospitals. All such 
 attempts are doomed to disappomtment. 
 Taxation without representation is opposed 
 to all our modern notions. That those 
 who benefit by hospitals should share in 
 supporting them is reasonable, but they 
 certainly will not consent to this unless 
 they have a share also in the control. 
 
 Serious charges of extravagance have 
 been made against hospitals. They spend 
 enormous sums, we are told, in the effort to 
 attract money, and to work the voluntary 
 system. These charges, at all events, 
 require investigation. And the extra- 
 ordinary variation in the expense per 
 patient in the London hospitals is a matter 
 which gives food for much reflection. Thus 
 the cost per bed at one hospital is very 
 much more than double that at another in 
 the same neighbourhood, and the cost per 
 out-patient varies from sixpence to twenty
 
 THE TREATMENT OF DISEASE. 57 
 
 shillings. AVhen all allowance has been 
 made, it is quite clear that there is room 
 here for control. 
 
 Notwithstanding, however, the grave dis- 
 advantages now attaching to the hospital 
 system, I think we shall have to recognise 
 that it is the hospital which furnishes us 
 the germ of a better sj^stem ; it is the 
 hospital which has carried medical science 
 to its present position ; it is the hospital 
 which has made the most successful at- 
 tempts to render this science available. 
 This, after all, is the main thing. Let us 
 consider the present position of the hospital.
 
 III. 
 
 THE PRESENT POSITION OF THE HOSPITAL. 
 
 Only intended for paupers — Eecent development — Number 
 of out-patients and in-patients — Number of persons 
 employed by hospitals — Objections to the hospitals — 
 Eemedies proposed— The dispensary — Objections to the 
 dispensary system. 
 
 The present position of the hospital is such 
 that, in the words of the chief EngHsh 
 medical organ, to be treated in one is " only 
 one shade less demoralising than downright 
 pauperism." It is impossible to say that 
 this is not a correct statement of the case. 
 It is worth while, however, to recollect the 
 large and rapidly increasing position which 
 this demoralising institution is taking to- 
 day. In Birmingham alone the out-patients 
 
 58
 
 PHESEXT POSITION OF THE HOSPITAL. 59 
 
 of the hospitals have advauced in twenty 
 years (IVoni 18G7 to 1887) from 07,000 to 
 166,000. In London the twelve large 
 hospitals, founded in the last century or 
 in the earlier part of the present century, 
 now contain nearly 5,000 heds. In addition 
 there are a large number of smaller and 
 special hospitals ; the total accommodation 
 in the eighty-six hospitals of London is over 
 8,000 beds ; wdiile for infectious cases the 
 Metropolitan Asylums Board has 3,500 
 beds. The total number of in-patients 
 treated in London hospitals during a year 
 is over 80,000. 
 
 In the out-patient department the number 
 of patients is of course vastly greater. In 
 six of the large London hospitals alone it 
 appears (according to the Eeport of the 
 Lords' Committe) that the number of out- 
 patients yearly is 244,000 ; the yearly 
 number of out-patients at the eleven Lon-
 
 60 NATIONALISATION OF HEALTH. 
 
 don hospitals possessing medical schools 
 approaches half a million, while the number 
 of attendances would be nearly treble this 
 figure. 
 
 It has been calculated — though I do not 
 bind myself to accept the calculation — that, 
 taking the country generally, the number of 
 persons during one year treated at 759 hos- 
 pitals and dispensaries and the metropolitan 
 fever hospitals, including also those who 
 receive free medical relief through the 
 Poor-Law and otherwise, exceeds 4,000,000. 
 Dr. Rentoul, who makes this calculation,* 
 adds : "I think if one said that one person 
 in three was provided with free medical 
 relief in this country a very near approach 
 to accuracy would be made. I do not say 
 that the medical profession is not paid 
 something for treating some of the above, 
 but I have no hesitation in stating that if 
 
 ■■'• Lancet, November 9, 1889.
 
 PRESENT POSITION OF THE HOSPITAL. 61 
 
 all the money received were evenl}" divided 
 over the above number it would not exceed 
 Id. per patient per annum." And the 
 President of the General Practitioners' 
 Alliance stated before the Lords' Hospital 
 Committee that, in his opinion, if general 
 hospitals were open in the evening, " it 
 w^ould crush out general practice alto- 
 gether." 
 
 This vast system in London alone employs 
 nearly 1,500 doctors in hospitals and nearly 
 2,000 nurses, to say nothing of stewards, 
 chaplains, secretaries, clerks, collectors, 
 dispensers, housekeepers, male and female 
 servants, &c. If to these are added those 
 engaged on the staffs of the Metropolitan 
 Asylums Board and in the Poor Law 
 infirmaries, it would be found that nearly 
 8,000 persons are employed throughout the 
 year in tending the sick " paupers " of 
 London alone.
 
 62 NATIONALISATION OF HEALTH. 
 
 It is clear, then, that the general hospital 
 is a growing and nourishing institution.* 
 There is ample evidence to show that, even 
 under present conditions, persons of all 
 classes gladly avail themselves of the great 
 advantages which hospitals offer. 
 
 The two main objections brought against 
 the hospital are firstly from the moral point 
 of view, that the hospital is a demoralising 
 influence since it offers charity, and secondly 
 that embodied in the wail of the general 
 practitioner who feels that he is being- 
 stamped out of existence. 
 
 The chief remedy so far proposed by both 
 parties lies in the extension of cheap dis- 
 pensaries. The Birmingham Committee on 
 Hospital Keform in 1891, desiring to arrest 
 the rapid growth of hospitals, proposed the 
 
 ■''• In speaking of the hospital I always mean the general 
 hospital. From the point of view of the community there 
 is, with exception in a few cases, very little to be said in 
 favour of tlie special hospital.
 
 PRESENT POSITION OF THE HOSPITAL. 63 
 
 formation of an inquiry agency to investigate 
 the circumstances of patients, and the chief 
 remedy they had to offer was the exten- 
 sion of dispensaries. The system of dispen- 
 saries has, however, been in existence for a 
 considerable time, and grows very slowly, 
 usually with the aid of voluntary contribu- 
 tions. It has been well called " a kind of 
 hybrid charity," and it lacks vitality, as 
 such a system inevitably must. Nor does 
 it satisfy any one. To the private prac- 
 titioner it is a more formidable and un- 
 scrupulous opponent than the hospital. 
 ^' The necessity for medical reform may be 
 obvious to most of us," writes a private 
 practitioner, "but it is as necessary in the 
 dispensary as in the hospital. It will be a 
 grave pity if, in curing hospital abuses, w^e 
 increase those of the dispensary. Expe- 
 rience should w^arn us that dispensary 
 managements are apt to attempt too much.
 
 64 NA Tl OXALISA TION OF HEAL TH. 
 
 Becoming greedy for a financial success, 
 thej' commence touting for patients, repu- 
 diate the wage-limit system, and help to 
 turn the noblest of professions into the 
 most miserable of trades. Under such 
 circumstances the dispensary is, even to 
 the public, a curse rather than a blessing. 
 To the self-respecting general practitioner 
 who holds to the old traditions of medical 
 etiquette it is an unscrupulous opponent. 
 Bound bv no traditions, with the conscience 
 of a committee, it employs agents, scatters 
 advertisements broadcast, and invites all 
 men to purchase physical salvation for Id. 
 per week." * Thus the dispensary is not 
 satisfactory even to the private practitioner 
 on whose behalf it is advocated. It is still 
 less satisfactory to the public. The dispen- 
 sary does not attract the highest class of 
 medical men. and it offers few facilities for 
 
 * " Hospital Reform," Lancet, April 4, 1891.
 
 PBESENT POSITION OF THE HOSPITAL. Go 
 
 the proper examination and treatment of 
 patients. Its poverty and lack of centrali- 
 sation place it immeasurably below the 
 hospital as an instrament for coping with 
 disease, and it is to the hospital that the 
 dispensary send its more serious cases. 
 Except as an extension of the out-patient 
 department of a larger central institution, 
 it is difficult to see how the dispensary can 
 occupy a really satisfactory position.
 
 IV. 
 
 THE HOSPITAL OF THE FUTUEE. 
 
 The ancient and the modern ways of deahng with disease — 
 The hospital reformed into an institution of health — 
 The hospital must not be reserved for paupers — The 
 mismanagement of charitable hospitals — The advantages 
 of some degree of popular control. 
 
 There are thus two entirely different 
 agencies working against disease on lines 
 that are unconnected, if not even inhar- 
 monious. On the one hand there is the 
 ancient and traditional system, which still 
 attracts most attention, of waiting until 
 diseases are w^ell developed and then fight- 
 ing against them as best we may ; on the 
 other hand we have the new system of 
 going so far as possible to the causes of 
 
 66
 
 THE HOSPITAL OF THE FUTURE. 67 
 
 disease cind guarding against the first in- 
 vasion of evil. The task that now lies 
 before the community is to unite these 
 two systems and to give to the second 
 the first place, which justly belongs to it, 
 and which it may at length reasonably 
 claim to take. 
 
 The hospital, it seems clear, must be the 
 centre of medical activity, but it must be 
 a reformed hospital thoroughly in touch 
 with the growing sanitary organisation of 
 the country. The hospital as a charitable re- 
 fuge for such broken-down human creatures 
 as misery may toss into it must become a 
 thing of the past. The hospital which we 
 now need must be a national institution of 
 health. It can no longer be a charitable 
 institution or a self-centred island, apart 
 from the control and co-operation of the 
 community as a whole and of the sanitary 
 organisation of the country.
 
 68 NATIONALISATION OF HEALTH. 
 
 The existing large hospitals would doubt- 
 less in many cases willingly associate them- 
 selves with such an organisation, the con- 
 trol in such cases being apportioned to the 
 relative amount of support furnished by the 
 community and by the charity ; and the 
 awkward and costly devices now needed to 
 attract money to the hungry exchequers of 
 the voluntary hospitals would become un- 
 necessary. There is no extravagance or 
 mismanagement in the hospitals or dis- 
 pensaries in India, it is said, because they 
 are under Government administration.* In 
 most parts of the country there are insti- 
 tutions which could, by local arrangement, 
 be brought up to the standards of size, 
 
 * A word should be said here for the Hospitals' Associa- 
 tion, which has done so much to enlighten and reform the 
 details of hospital administration and to create an intelligent 
 interest in the matter ; thus helping to tide over the present 
 period of transition, and to prepare the way for a sounder 
 system.
 
 THE HOSPITAL OF THE FUTURE. 69 
 
 completeness, and efficiency required. In 
 many cases the local Poor Law Infirmaries 
 — some of which are already among the 
 best hospitals in the kingdom — would con- 
 stitute the natural nucleus. Special hos- 
 pitals — the stumbling-block in the way of 
 all hospital reformers — would be left either 
 to die out or to amalgamate with the 
 national hospitals. In the end every 
 medical man in the country would be 
 attached to a hospital, and every person 
 would be living within the district of a 
 great institution of health. There is no 
 reason wdiy such a state of things should 
 be introduced precipitately ; it must neces- 
 sarily, indeed, be introduced slowly, and 
 most people will be of opinion that while 
 certain general methods and standards of 
 efficiency must be determined, the estab- 
 lishment of such national hospitals should 
 be left to local communities. Private
 
 70 NATIONALISATION OF HEALTH. 
 
 practice need not be prohibited ; with the 
 removal of the disadvantages at present 
 attaching to hospitals, few people would 
 hesitate to avail themselves of their ad- 
 vantages ; the large number of medical men 
 attached to the hospital would enable every 
 one to be attended to expeditiousl}- ; the 
 multiplication of hospitals would disperse 
 the students, who are at present an anno}'- 
 ance to sensitive persons, and the element 
 of popular control will remove all minor 
 abuses. It is only within the walls of a 
 hospital that specialism, the inevitable 
 nature of which is now generally recog- 
 nised, can be carried out without harm or 
 inconvenience. A patient can be passed in 
 a few minutes from the physician to the 
 surgeon, the ophthalmist, or the gynaeco- 
 logist ; while at any time a helj^ful con- 
 sultation can be held. At the same time 
 persons who could afford it would be free
 
 THE HOSPITAL OF THE FUTURE. 71 
 
 to obtain the services of a medical man 
 privately, and, under certain conditions, of 
 the hospital organisation at his back. 
 
 But this is not possible until the present 
 anomalous position of the hospital comes to 
 an end. The hospital has now reached a 
 position in which it is able to offer the very 
 best advice, the best nursing, the most 
 complete means of combating disease, the 
 most favourable conditions for obtaining 
 restoration to health. Not even the most 
 able private practitioner can offer such 
 advantages to his wealthiest patient. The 
 hospital is thus a gigantic eneni}' to the 
 private practitioner, and the chief weapon 
 that he possesses against it — a weapon 
 which, under the circumstances, he is 
 justified in using — lies in its cJiariti/. 
 What was once its glory he stigmatises 
 as its shame, and he would establish a 
 severe inquisition to weed out from the
 
 72 NATIONALISATION OF HEALTH. 
 
 hospitals all those persons who could afford 
 to pay a few pence for his own advice and 
 medicine. As a medical man recently de- 
 clared before the House of Lords' Com- 
 mittee on Hospitals, he " regarded it as 
 unfortmiate that j)6ople should accept 
 hospital relief without feeling that they 
 were paupers." There can be no doubt 
 that this expresses the natural feeling of 
 every medical man who finds himself in 
 competition with a hospital. His interests 
 demand that the four million ^^ersons who 
 receive free medical relief in this country 
 should all be branded as " paupers." The 
 hospital is incomparably the most satisfactory 
 method of giving relief to every member of 
 the community, but at present every general 
 practitioner is bound to wish that no person 
 should seek the best form of medical relief 
 open to him unless in such a condition of 
 hopeless dejection that he regards himself 
 as a pauper.
 
 THE HOSPITAL OF THE FUTURE. 73 
 
 At the same time, the introduction of the 
 element of popular control will remove what 
 are at present the only great blots on our 
 hospital system. If we put aside the chari- 
 table character of the assistance offered by 
 the voluntary hospitals, the great objection 
 brought forward against them is their irre- 
 gularity, their occasional extravagance and 
 mismanagement, and the vast sums which 
 they sometimes expend in seeking to attract 
 subscriptions. It is certainly not reasonable 
 that 25 to 50 per cent, should be spent, as 
 it is said to be by some hospitals, in raising 
 their annual income ; nor that, of two 
 general hospitals in the same district, and 
 treating the same class of cases, the cost 
 per bed in one should be more than double 
 that of the other. This must necessarily 
 cease as soon as the organisation of hos- 
 pitals begins, and as soon as there is no need 
 for such institutions to compete frantically
 
 74 NATIONALISATION OF HEALTH. 
 
 in appeals for public support. The element 
 of popular control will also do much good 
 by the elfect it will have in removing the 
 suspicion which occasionally haunts more 
 ignorant persons regarding them. It is rare 
 that the stories frequently circulated, and 
 sometimes believed by credulous people, as 
 to the cruelties and inhumanities practised 
 in hospitals or in turning sufferers away from 
 them will bear examination ; but it would 
 be a great advantage if they could be at 
 once investigated and if the management 
 of the hospital w^as sufficiently in touch 
 witJi popular feeling to make charges of 
 this kind difficult to make when ill-founded 
 and easy to deal with when well-founded. 
 There are some minor, but by no means un- 
 important, respects in which the ^^atients of 
 hospitals, and especially the out-patients, do 
 suffer some hardship, which would become 
 at once impossible if hospitals were placed
 
 THE HOSPITAL OF THE FUTURE. 75 
 
 under popular control. At most hirge hos- 
 pitals out-patients are systematicall}' kept 
 for many weary hours in the middle of the 
 day awaiting their turns. Not only is this 
 very trying to many sick persons, but it is 
 extremely inconvenient to the class who 
 seek help at hospitals ; and there are also 
 in the crowded waiting-rooms additional 
 risks of infection. This state of things is 
 to no one's advantage ; a very little judi- 
 cious organisation would render it unne- 
 cessary, and when an element of popular 
 control is brought into hospital manage- 
 ment it will very speedily come to an end.
 
 V. 
 
 THE POOE LAW INFIEMAEIES. 
 
 The infirmaries are coming into line with the general 
 hospitals — Comparisons with regard to number of 
 patients and to expense — Reforms necessary in the 
 infirmaries. 
 
 The twenty-four Poor Law Infirmaries of 
 London cannot strictly be classed with the 
 general hospitals. But the Poor Law 
 Infirmaries of Great Britain, notwithstand- 
 ing the somew^hat depressing name under 
 which they suffer, are now^ (with notable ex- 
 ceptions) splendid and w^ell-organised insti- 
 tutions. When they are a little further 
 developed and better equipped — when the 
 nursing system has received the attention 
 
 76
 
 TEE POOR LAW INFIBMAIilES. 77 
 
 it needs in many cases, when the medical 
 staff has been considerably increased, and 
 when the infirmaries are thrown open to 
 students, and receive that healthy stimu- 
 lation which always comes to large teaching- 
 centres — these institutions will in every 
 respect deserve to be called the Hospitals 
 of the State. It is now becoming clear 
 that progress in health reform involves 
 to a very considerable extent that the in- 
 firmaries and the general hospitals should 
 fall into line. The infirmaries of London 
 contain nearly 14,000 beds (of which 12,000 
 are in continuous employment), and their 
 annual cost is nearly ^500,000 — a very much 
 smaller cost per bed, it may be noted in 
 passing, than in any of the voluntary hos- 
 pitals supported by charity ; while the cost 
 per bed in the general hospitals ranges 
 from j£80 to .£150, and beyond this figure 
 in some of the special hospitals, in the
 
 78 NATIONALISATION OF HEALTH. 
 
 infirmaries it usually ranges only from £30 
 to £50 ; it may be reasonably held that 
 something more might be spent on the 
 infirmaries with advantage, but it is diffi- 
 cult to avoid seeing that considerable 
 wastefulness and mismanagement must be 
 responsible for the large sums spent by the 
 irresponsible directors of some of the 
 general hospitals. Some of the London 
 infirmaries equal in size our largest hospitals. 
 Thus St. George's Infirmary contains 780 
 beds, and St. Saviour's 786 beds, while the 
 London, the largest of the general hospitals, 
 only contains 780 beds, and St. Bartholo- 
 mew's 650. It has been estimated that in 
 1890, 30,000 persons were admitted into 
 the metropolitan infirmaries, and that 
 129,340 orders were given to Poor Law dis- 
 pensary officers for attendance on patients 
 outside. There can be no doubt that 
 practically, as TJie Lancet lately remarked.
 
 THE POOB LA W INFIRMARIES. 79 
 
 infirmaries '' are becoming more and more 
 part of our hospital system," and rightly 
 so. But while in some respects the 
 hospitals must be approximated to the 
 infirmaries, in other respects the hospitals 
 still lead the way Why, it is beginning to 
 be asked, should the patient in the London 
 Hospital, afflicted with a grave disease, have 
 the benefit, if necessary, of a consultation 
 of the whole of the stafi' of specialists, 
 while the i)atient in the neighbouring 
 Whitechapel Infirmary, with perhaps an 
 equally grave disease, can only have the 
 advice of a single medical man ? At the 
 Paddington Infirmary there are only three 
 resident medical men, and no consulting 
 physicians or surgeons. At the neigh- 
 bouring St. Mary's Hospital, almost of the 
 same size, the medical stafi" consists of nine 
 residents and nine visitors. It was sug- 
 gested to the Lords' Hospital Committee
 
 80 NA TIONALISA TION OF HE A L TH. 
 
 by Dr. Bridges, the Poor Law Inspector of 
 the Meti'opohtan District, that the medical 
 staff of the general hospitals should give 
 part of their time to the infirmaries ; such 
 an arrangement, however, is not practicable, 
 save as a temporary make-shift. The 
 medical staff of the general hospitals already 
 have their hands full. What is needed is 
 a great increase in the medical staff of the 
 infirmaries. 
 
 A similar criticism applies to the nursing 
 at infirmaries. It has been stated that even 
 of the matrons of the London infirmaries, 
 not twelve out of twenty have been hospital- 
 trained. At some of the infirmaries, also, 
 there is a system of pauper-help which 
 ought to be abolished at once. Now that 
 attention has been called to these abuses 
 and irregularities by the Lords' Hospital 
 Committee, it may be hoped that they will 
 speedily be remedied.
 
 THE POOE LAW INFIBMARIES. 81 
 
 Hospital reform in the future will largely 
 develop around the infirmaries. It is not 
 certain that the voluntary hospitals will be 
 willing to fall into line with the new move- 
 ment ; they have done excellent service in 
 the past ; it is possible that in the future 
 they may be unable to adapt themselves to 
 new conditions, and so fall into the back- 
 ground. But the State Hospitals — as we 
 ought to call them — are established on a 
 sure though simple basis, and have largely 
 overcome the official and popular prejudice 
 which maimed and limited their proportions 
 at the outset. Already the great principle 
 has been recognised that it is not necessary 
 to become a pauper to be admitted to the 
 infirmary. When those abuses to which I 
 have referred have been remedied, the 
 infirmaries will add to their existing ad- 
 vantages the chief advantages now 
 monopolised by the general hospitals, and
 
 82 NATIONALISATION OF HEALTH. 
 
 with them, or even without them, wall form 
 some approximation to the hospitals of the 
 future.
 
 VI. 
 
 THE REPORT OF THE HOSPIT.VLS COMMITTEE 
 
 (1892). 
 
 Scope of the iuquiry- — The Committee's opiuiou of general 
 hospitals — Of special hospitals — The proposed Central 
 Hospitals' Board — The Committee's opinion of in- 
 firmaries — The prospect of municipal hospitals. 
 
 During 1890 and 1891 a Select Committee 
 of the House of Lords took evidence con- 
 cerning the hospitals, infirmaries, and allied 
 institutions in London. Besides various 
 authorities on charitable matters, such as 
 the secretaries of the Charity Organisation 
 Society and the Chief Charity Commissioner, 
 they called before them representative 
 members of all grades and classes of medical 
 
 83
 
 84 NA TIONALISA TION OF HEAL TH. 
 
 iiien — general practitioners, specialists, 
 members of the consulting staff of various 
 general and special hospitals, superin- 
 tendents of Poor Law infirmaries, &c. The 
 evidence taken occupies two large volumes, 
 and the final Eeport of the Committee, 
 issued in June, 1892, is a very fair state- 
 ment of the widely different and often 
 opposed opinions held on these subjects. 
 The recommendations of the Committee, 
 though their moderation may almost be 
 described as of an extreme type, are entirely 
 on the right lines, and it is to be hoped 
 that it will not be long before they are 
 embodied in practice. 
 
 In dealing with the medical adminis- 
 tration of the large general hospitals — that 
 is to say, with the care bestowed on the 
 patients by doctors and nurses — the Com- 
 mittee, after full examination, entirely 
 justified the hospitals. It was not found
 
 REPORT OF THE HOSPITALS' COMMITTEE. 85 
 
 that there were any abuses calHng for 
 reform. The alleged careless and hurried 
 manner of dealmg with out-patients does 
 not exist.* At Guy's, for instance, on an 
 exceptionally busy day some 480 cases are 
 treated, but this only means twenty new 
 cases in each department. At the London, 
 which receives by far the largest number of 
 out-patients, it was shown that new cases 
 on the medical side are seen at the rate of 
 thirteen per hour; while Sir Andrew Clark, 
 speaking of his own experience at this 
 hospital, said that each new case would 
 have ten minutes or more. Similar evi- 
 dence was given concerning other large 
 
 =■'■ If the Committee could have compared the treatment 
 of patients in the out-patient departments of the large 
 general liospitals with the treatment of patients in their 
 homes by the average private practitioner, it would have 
 been shown that the care and thoroughness in examination 
 and treatment bestowed on patients at the hospital is very 
 much greater than that bestowed on them in their homes.
 
 86 NATIONALISATION OF HEALTH. 
 
 hospitals. In regard to the quaHty of the 
 food snppHed to in-patients, a great number 
 of questions were asked ; but, on the whole, 
 little evidence was elicited of an unfavour- 
 able character. One witness, indeed, con- 
 sidered that the hospitals were administered, 
 m matters concerning the comfort of the 
 patients, in an unnecessarily luxurious 
 style. The defects which were mentioned 
 were not of a very serious or deeply-rooted 
 character ; and strong evidence in con- 
 firmation of the general good administration 
 of the hospitals in all that concerns the 
 comfort of their patients was given by the 
 Chairman of the Saturday Fund, who testi- 
 fied that the great majority of complaints 
 which had been brought to his notice by 
 ex-patients had proved, on investigation, to 
 be unfounded. With the present high 
 standard of medical and nursing efficiency, 
 the most careful scrutiny can scarcely lead
 
 REPORT OF THE HOSPITALS' COMMITTEE. 87 
 
 to auy other result. All that can be said 
 is, that in the absence of any element of 
 popular control there is an excuse for such 
 complaints. 
 
 As regards the business administration of 
 the hospitals, however, the Report of the 
 Committee is by no means so favourable. 
 In the case of the three great endowed 
 hospitals, for instance (St. Bartholomew's, 
 St. Thomas's, and Guy's), the Committee 
 consider that the administration does not 
 compare favourably with that which exists 
 at the other general hospitals, too much 
 power and responsibility being placed in the 
 hands of one individual — the treasurer. It 
 is to this cause that the committee sets down 
 the recent outbreak of diphtheria among 
 the nurses at St. Bartholomew's ; the 
 drainage system was altogether defective, 
 and had not been properly surveyed ; this 
 neglect, in the opinion of the Committee,
 
 88 NATIONALISATION OF HEALTH. 
 
 could not have occurred had there been in 
 existence at the hospital a proper system of 
 sub-committees meeting at frequent inter- 
 vals. The system which largely exists at 
 present of allowing subscribers to give 
 "letters" entitling to treatment, comes 
 in for considerable criticism. It is admitted 
 that this system supplies some hospitals 
 with " a substantial part of their funds," 
 but it is shown at the same time that the 
 " letters " were frequently not given to the 
 most deserving persons ; many witnesses 
 w^ere in favour of the entire abolition of 
 "letters," on the ground that "contribu- 
 tions given by way of charity ought not to 
 entitle the giver to any services in return." 
 This, it need scarcely be said, opens up im- 
 portant ground which the Committee were 
 too cautious to enter upon ; the subscriber 
 who thinks that he is entitled to a return 
 for his payment is certainly gaining ground
 
 REPORT OF THE HOSPITALS' COMMITTEE. «9 
 
 among all classes of subscribers ; the rich 
 subscriber considers himself entitled to be 
 made a governor and to have the privilege 
 of giving "letters" ; the poor subscriber con- 
 siders himself entitled to treatment. Why 
 should the poor subscriber be severely repri- 
 manded, as he invariably is, for expecting 
 even the smallest return for his subscription, 
 when the rich subscriber is rewarded with 
 the privileges of governorship ? 
 
 It is the special hospitals, and more 
 especially a certain class of them, that are 
 most severely treated at the hands of the 
 Committee. They are careful to point out 
 that with the present luisystematic and 
 irregular method of showing the accounts 
 it is not possible to attach any exact value 
 to figures showing the relative cost of beds 
 in the various hospitals ; but they cannot 
 refrain from showing the very high figure at 
 which it is placed at some of these small
 
 90 NATIONALISATION OF HEALTH. 
 
 hospitals (in one case reaching =£285, while 
 at an infirmary it is under .£36) ; "it seems 
 evident that they are very much more expen- 
 sive institutions than the larger hospitals." 
 The establishment of small special hospitals 
 by medical men for their own advancement 
 is a course of action, as the Committee 
 reasonably conclude, which "leads to the 
 establishment of hospitals where they are 
 not wanted, to waste of money incident to 
 the creation of badly managed and small 
 institutions, and to the deception of the 
 public by inducing them to subscribe to 
 undertakings alleged to be of public benefit, 
 but which are in reality mere schemes for 
 private emolument, and also are useless for 
 teaching purposes." This class of small 
 special hospitals " the Committee do not 
 consider are of any real benefit either to the 
 sick or to science." Virchow's words are 
 quoted, " that no speciality can flourish
 
 BEPOIiT OF THE HOSPITALS' COMMITTEE. 91 
 
 which separates itself entirely from the 
 common source of- science ; that no speci- 
 ality can develop fruitfully and beneficially 
 if it does not ever and anon draw from the 
 common fountain, if it does not take the 
 other specialities into account, and if all 
 the specialities do not mutually assist one 
 another." The Committee go on to say 
 that there would be some difficulty in trans- 
 ferring the special hospitals to the special 
 departments of the general hospitals, as 
 urged by many witnesses. '' The only way 
 by which the desired object could be attained 
 would seem to be the affiliation (if that were 
 possible) of special to general hospitals." 
 A grave difficulty here comes in owing to 
 the extreme disinclination of the hospitals 
 and similar institutions to combine or to 
 work harmoniousl3^ Competition runs wild, 
 and the hand of each is against all the 
 others. This is very well described by the
 
 92 NA TIONALISA TION OF HEAL TH. 
 
 Committee. " Many witnesses drew atten- 
 tion to the want of co-operation among the 
 hospitals themselves, and between them and 
 the dispensaries, the Poor Law infirmaries, 
 and the private practitioners, and various 
 remedies were suggested. So far from there 
 being at the present time any general system 
 of combination, or any definite division of 
 work among the various institutions, they 
 are, on the contrary, for the most part com- 
 peting with one another at every point for 
 public support and to a great extent for 
 patients. This condition of things is shown 
 to be wasteful as regards the subscriptions 
 of the public, and prejudicial, not only to 
 the public who subscribe their money, and 
 to the sick for whom these institutions 
 exist, but also to the interests of medical 
 science and education, since a wide field 
 for observation and practice is closed to the 
 clinical teacher and his pupils, while the
 
 REPORT OF THE HOSPITALS' COMMITTEE. 93 
 
 hospitals, for the sake of then- schools, lest 
 the requisite material should fail, are driven 
 to take in and treat a cro^yd of patients 
 unsuitable for hospital treatment, and the 
 general practitioner complains that he is 
 being ruined." And elsewhere " the Com- 
 mittee regret to remark that there does not 
 seem to be any genuine wish for co-operation 
 between the various kinds of medical institu- 
 tions. They are of opinion that much more 
 might be done than at present by the hearty 
 co-operation between the special hospitals 
 and general hospitals, between dispensaries 
 of all kinds and general hospitals, and 
 between general practitioners and general 
 hospitals." The question the public now 
 have to consider is : How can this con- 
 dition of anarchy be most speedily and 
 effectually brought to an end ? 
 
 This brings us to the Committee's most 
 important recommendation — the establish-
 
 94 NATIONALISATION OF HEALTH. 
 
 ment of a Central Hospitals' Board. " The 
 great weight of the evidence from within 
 the hospitals, as well as from outside, was 
 favom-able to the idea of a central board." 
 There was, however, considerable divergence 
 of opinion as to the constitution of the 
 Board. While a few witnesses were in 
 favour of some form of Government control, 
 or at least inspection, a larger number were 
 decidedly against Government control, and 
 in favour of maintaining what they consider 
 the "healthy rivalry" at present existing. 
 The Committee do not pronounce in favour 
 of any of the proposals brought before them. 
 They consider that the Board should repre- 
 sent the various interests affected, and that 
 its duties should be such as the following : — 
 (1) It should receive annual reports, state- 
 ments of accounts, and balance sheets, from 
 all hospitals and dispensaries, together with 
 a return of the total number of in-patients,
 
 BEPOBT OF THE HOSPITALS' COMMITTEE. 05 
 
 out-patients, and casualty patients ; (2) It 
 should require that all accounts be audited 
 by competent chartered accountants ; (3) It 
 should arrange that all medical charities 
 should be visited and reported on periodi- 
 cally ; (4) It should report from time to 
 time, as occasion required, all proposals 
 for new hospitals. The most obvious defect 
 in the constitution of the Hospitals' Board, 
 as proposed by the Committee, is the omis- 
 sion of the infirmaries and other Poor Law- 
 institutions, which, as Sir E. Hay Currie 
 rightly claims, should have an important 
 share in any scheme of the kind. The 
 private practitioner, also, is entirely ignored. 
 This is not desirable, whether he is left 
 alone to fight against an organised hospital 
 system, or (as we may hope will ultimately 
 be the case) his co-oj^eration is gained in 
 the organised fight against disease, and all 
 other petty rivalries lost together with the
 
 96 NATIONALISATION OF HEALTH. 
 
 old-world title of " private practitioner." 
 To be thoroughly effective, also, the Hos- 
 pitals' Board must be in close touch witli 
 the County Council, if, indeed, it does not 
 become eventually a department of the 
 Council. Any consummation of this cha- 
 racter lies ahead, however ; at present the 
 large hospitals (although some of the 
 wealthiest, like St. Thomas's and Guy's, 
 are not sufficiently wealthy to utilise all 
 their beds) are sufficiently rich to prefer a 
 state of "healthy rivalry," as it is euphe- 
 mistically termed, to any organised sub- 
 ordination to the interests of the community 
 generally. The Committee's scheme seems, 
 however, to offer a minimum of difficulties, 
 and is so moderate that no reasonable objec- 
 tion can be made by any one to its speedy 
 realisation, while at the same time it would 
 serve to pave the way for more extensive 
 action in the future.
 
 REPORT OF THE HOSPITALS' COMMITTEE. 97 
 
 It is worthy of note that the Committee 
 fully recognise the significance of the 
 development of the Poor Law infirmaries. 
 " It should always be borne in mind," they 
 remark at the conclusion of their investiga- 
 tions, " that the establishment of Poor Law 
 infirmaries and rate-supported asylums, 
 under the Metropolitan Po(*r Law Act, 
 1867, has in great measure altered the 
 relations between the poor and the hospitals, 
 and everything associated with medical 
 charity." This is a very significant ad- 
 mission. It is also interesting to find the 
 Committee elsewhere recognising that " the 
 poorest class which is treated in these Poor 
 Law institutions is, in fact, better provided 
 for in this respect than the poor class just 
 above the pauper class, for whom, except in 
 a few charitable institutions, such as the 
 Cancer Hospital, and the Hospital for 
 Incurables at Putney, no hospital accom- 
 
 7
 
 98 NATIONALISATION OF HEALTH. 
 
 modatioii is provided when tliey are suffer- 
 ing from chronic or incurable complaints. 
 The poor, it seems, do not generally regard 
 the infirmary as they regard the workhouse ; 
 they look upon it rather as a state-supported 
 hospital ; they come to the infirmary, are 
 cared for, cured, and go out again, without 
 feeling that they are tainted with pauper- 
 ism." While recognising that the evidence 
 on the whole shows the "high standard 
 of efficiency attained by the best of the new 
 infirmaries, both in their structure and in 
 their general arrangement and manage- 
 ment," it is pointed out that the medical 
 staff should be increased, that the nurses 
 are often insufficiently trained, and that 
 infirmary practice, as well in the interests 
 of medical education as of the patients, 
 should be thrown open to students. There 
 can be little question as to the desirability 
 of these reforms, which have already been 
 referred to in the foregoing pages.
 
 REPORT OF THE HOSPITALS' COMMITTEE. 99 
 
 On the whole, we cannot fail to recognise 
 that the Committee's Report points out, 
 although w4th great moderation, the safest 
 and most reasonable steps which medical 
 organisation must begin to take in the near 
 future. When the Hospitals' Board is once 
 established on a sound and popular basis, 
 its functions cannot fail eventually to 
 develop much beyond the scope laid out 
 for it by the Committee. At the least the 
 Committee have deserved well by the 
 valuable evidence they have collected, and 
 by showing that the general tendency, both 
 of popular and of scientific opinion, is in the 
 direction of the greater organisation of 
 medicine. As the Committee point out, 
 working men are beginning to contribute to 
 the hospitals, and at the same time are 
 beginning to believe that their contribu- 
 tions "entitle them to use the hospitals as 
 a right." Recently, also, another distinct
 
 100 NA TIONALISA TION OF HEAL TH. 
 
 step has been taken in the organisation of 
 medical senice ; under the Public Health 
 (London) Act, 1891, everi/ inhahitant suffer- 
 ing from any dangerous infectious disease 
 is entitled to free treatment at one of the 
 hospitals of the Metropolitan Asylums 
 Board. It is not surprising that the Com- 
 mittee should find that the stigma attaching 
 to free medical relief is disappearing, and 
 that they should recognise, as they do at 
 the conclusion of their Keport — though they 
 seem to hold out this prospect rather as a 
 threat than a hope — that " a time may 
 come when it will be necessary to have 
 recourse either to Government aid or 
 municipal subvention."
 
 VII. 
 
 TYPHOID FEVEE. 
 
 Its vast mortality and world-wide exteusiou— Yet it is easily- 
 preventable — The Tees Valley epidemic — The experience 
 of France — The prime necessity of pure water. 
 
 The meaniDg of the nationalisation of health 
 is very well illustrated by the problem of 
 the prevention of typhoid (or enteric) fever. 
 Typhoid fever is not only a disease \Yhich 
 offers loop-holes for death to enter at very 
 many points ; it is a prolonged, insidious 
 and peculiarly distressing fever ; many die ; 
 those who recover, having once gone 
 through it in a well-marked form, do not 
 easily forget the experience, and may pass 
 the rest of their lives with permanently 
 depressed vitality. 
 
 101
 
 10>2 NATIONALISATION OF HEALTH. 
 
 It is a disease of \YOiid-wide extension ; 
 in England alone it has claimed two million 
 victims in the course of a centmy ; and that 
 means that at least ten millions have in 
 this country, during the same period, gone 
 through the disease in a well-marked form, 
 to serve as foci of misery and suffering, 
 while a vastly greater number have had 
 milder attacks.* It is a disease of the 
 countr}^ as well as of the town ; of the 
 New World as much as of the Old ; it is 
 common among the poor, and by no means 
 spares the palaces of the rich ; it flourishes 
 at Melbourne as vigorously as at Florence. 
 It attacks the young by preference ; in 
 France it kills 23,000 persons in the course 
 of a year, mostly between the ages of 
 
 ■■'■ In Englanil and Wales in 1869 the death-rate from 
 typhoid fever was 390 per miUion Uviug. Since then it has 
 gradually fallen, but in 1890 it was still 179 per million, and 
 since 1887 it has shown a slight tendency to increase. 
 British Medical Journal, Sept. 10, 1892.
 
 TYPHOID FEVEE. 103 
 
 fifteen and twenty-five. It causes less con- 
 sternation than the occasional invasions of 
 cholera — a disease which is propagated in 
 precisely the same w^ay — but it is ever and 
 everywhere with us, and is, as Brouardel 
 truly says, far more terrible and dangerous 
 to man than cholera. 
 
 Yet no disease is simpler in its origin, 
 and more easy to prevent, than typhoid 
 fever. It is caused by nothing more, or 
 nothing less, than the use of drinking water 
 which has been contaminated by the ex- 
 crement of persons who are themselves 
 suffering from the disease. It cannot be 
 too well known that 99 per cent, of the 
 cases of typhoid are probably due to this 
 disgusting practice, a practice which, in any 
 fairly well-regulated community, ought to be 
 rendered impossible for reasons quite other 
 than the prevention of disease. It is not 
 so, however, and from time to time great
 
 104 NATIONALISATION OF HEALTH. 
 
 epidemics occur to emphasise the filthy 
 nature of the source of many of our water 
 suppHes, but by no means invariably to 
 induce us to adopt more cleanly habits. It 
 is only necessary to refer to one example 
 which has been recently investigated — the 
 Tees Valley epidemic. The Tees receives 
 the drainage of a town of six thousand 
 inhabitants, of fifteen to twenty villages, 
 as well as grave-yards and farmsteads. Now, 
 it is true, although scarcely credible, that 
 this filth-polluted w^ater is given to drink 
 to half a million persons who live in Dar- 
 lington, Middlesbrough and Stockton. The 
 inhabitants of these towns are, therefore, 
 liable to drink any excremental poison that 
 may be poured into the river above them. 
 In such river water as this the typhoid 
 bacillus is certain to be present, and when 
 there is an exceptionally heavy rainfall a 
 special flush of filth is sw^ept into the in-
 
 TYPHOID FEVER. 105 
 
 takes of the water companies which supply 
 these three large towns. At the end of 
 August, 1890, occurred one of the heaviest 
 rainfalls ever known in the Tees Vallev, 
 and within a few days an epidemic of 
 typhoid broke out at Darlington, Middles- 
 brough, and Stockton. In such localities 
 as received no other water supply than from 
 the Tees, the rate of attack varied from 
 11 to 13 households per 1,000. If the 
 typhoid bacilli mingled uniformly with 
 water, in the same way as a chemical 
 substance in solution, it need scarcely be 
 said that the invasion of the disease would 
 have been still more marked.* 
 
 ='= They manage these things better even in " Darkest 
 Africa." Tlie dwellers on the banks of the Congo are more 
 cleanly than those on the banks of the Tees. Mr. Parke, 
 the surgeon who accompanied Staulej', writes : — " The 
 natives, e^-en here, have very pronounced ideas on the sub- 
 ject of sanitation. They always make their beds at some 
 height from the ground, and have special pits for collection 
 of ash and refuse ; some of them, however, situated un-
 
 106 NATIONALISATION OF HEALTH. 
 
 Wherever the water suj^ply has been 
 rendered purer, there typhoid fever has 
 receded. At Bristol and at Croydon, at 
 Edinburgh and at Glasgow, improved sani- 
 tary conditions been led to a reduction of 
 the mortality to one-half, one-third, even 
 one-fifth. In France, again, as Dr. Brou- 
 ardel has lately shown, the same results 
 have everywhere been produced. When the 
 inhabitants of Yienne drank surface water, 
 i.e., water that is constantly polluted, the 
 typhoid mortality was 200 per 100,000 ; 
 when a good water supply was obtained it 
 fell to 10 per 100,000. At Angouleme the 
 reduction in the number of typhoid cases 
 on the introduction of a supply of pure 
 water was represented by the proportion of 
 
 desirably close to the hute. In some villages, indeed, tbey 
 have rather well-made latrines — even closets — to sit on ; 
 and vipou the whole they are much cleaner and tidier than 
 the inhabitants of our remote villages at home." Exjjeriences 
 in Equatorial Africa, p. 77.
 
 TYPHOID FEVER. 107 
 
 0-063 to 18. At Amiens, among the 
 military population, the typhoid mortality 
 fell from 111 to 7 per 1,000 when pure 
 water was secured by artesian wells. 
 When the inhabitants of Kennes drank the 
 water of contaminated wells typhoid fever 
 was constantly present. When pure water 
 was introduced the deaths from typhoid fell 
 from 43 to 2 per 1,000. Investigations 
 carried out at Besan^on, Tours, Carcassonne, 
 Bordeaux, and Paris, give corroborating 
 results. It is well known that in Paris, 
 whenever the water of the Seine is turned 
 on for drinking purposes — as is sometimes 
 necessary in summer in some districts of 
 the city — there is in those districts an out- 
 break of typhoid fever. The Thames, 
 though in a less degree, is also a source of 
 typhoid fever.* 
 
 * The Loudou Water Companies demonstrated once for 
 all what can be done with water containing choleraic dis-
 
 108 NATIONALISATION OF HEALTH. 
 
 One of the very first essentials for the 
 healthy life of any community is an abun- 
 dant supply of pure water. The assertion 
 sounds like a truism, but it is, unfortu- 
 nately, a truism which still needs a great 
 deal of repetition. It is difficult to say 
 what requirement of life comes before pure 
 water ; the most practically and humanly 
 
 charges. When their intakes were iu tlie ueighbourhood of 
 Londou Bridge the comi^auies succeeded in the two cholera 
 epidemics of 1849 and 1854 in destroying 25,000 lives. It 
 was a valuable but costly experiment. The intakes are 
 higher up now, but still higher up sewage is discharged into 
 the river, and the Elvers Pollution Prevention Act is more 
 or less a dead letter. (See evidence of experts before the 
 Pioyal Commission on Metropolitan "Water Supplj', Brit. 
 Med. Journal, Sept. 17 and 24, 1892). Water highly polluted 
 with excrement may be drunk with safety so long as it does 
 not contain the germs of disease. But these may at any 
 moment enter. The recent cholera epidemic at Hamburg is 
 said to have been initiated through Paissian emigrants 
 camping on the river bank above the intake. For a popular 
 summary of the present state of knowledge regarding the 
 prevalence and cause of tj'phoid, the reader may be referred 
 to the Hon. lioUo Paissell's lately pubhshed "Epidemics, 
 Plagues, and Fevers : their Causes and Prevention," 1892, 
 pp. 293-337.
 
 TYPHOID FEVEIi. 109 
 
 civilised of the great nations of old under- 
 stood this, although their knowledge was 
 empirical ; the Romans and the Moors 
 understood it. A race that has not yet 
 understood this elementary truth has no 
 true claim to he called civilised. One 
 wonders what our descendants will think 
 of nations which stuffed Regent Street 
 and the Palais Royal with costly and idle 
 luxuries, and drank contentedly the diluted 
 and poisonous excrement of their diseased 
 fellow creatures.
 
 VIII. 
 
 BLINDNESS AND SHOET-SIGHT. 
 
 Comparative prevalence of bliudness in European countries 
 — Blindness largely preventable — Its chief cause — De- 
 fective eye-sight in Germany — In America — In France 
 — In Sweden — In England — Its causes and prevention — 
 School hygiene. 
 
 Blindness is one of the most terrible of 
 misfortunes to the young and healthy. In 
 England it is slowly declining, but this 
 country by no means shows very favourably 
 in comparison with many other European 
 countries. According to Dr. Armitage,* 
 blindness is rarest in Holland, after which 
 come in order of increasing frequency Den- 
 mark, Sweden, Belgium, Erance, Scotland, 
 
 * " Education and Employment of the Blind," London, 
 1886. 
 
 110
 
 BLINDNESS AND SHORT-SIGHT. Ill 
 
 England and Wales, Germany, Italy, Spain, 
 Ireland, Hungary, Norway and Finland. 
 
 It cannot be too widely known that a very 
 large proportion of the existing cases of 
 blindness might have been easily prevented 
 by the adoption of the very simplest anti- 
 septic precautions at birth. Magnus, 
 Bremer, and Steffan estimate the number 
 of preventable cases as about 40 per cent. 
 Cohn's important investigations have shown 
 that out of 1,000 cases of blindness 329 
 might certainly have been prevented, 433 
 were possibly preventable, only 238 — less 
 than a fourth — were unavoidable. There 
 are 23,000 blind persons in England and 
 Wales. If, therefore, this estimate is fairly 
 correct (it cannot be far wrong), about 
 15,000 of them have been unnecessarily 
 deprived of sight. It is needless to point 
 out all that this fact involves. 
 
 The precaution to be observed for the
 
 H2 NATIONALISATION OF HEALTH. 
 
 prevention of blindness through inflamma- 
 tion of the eyes at birth is of the simplest 
 and most routine character. In the year 
 1884 it was ascertained by a committee 
 of the Ophthalmological Society of Great 
 Britain that in the institutions for the blind 
 in London, York, Belfast, and Hull, 30 to 
 40 per cent, of the inmates owed their blind- 
 ness to purulent ophthalmia in infancy, and 
 that at least 7,000 persons in the United 
 Kingdom had lost their sight from this cause. 
 Professor Magnus of Breslau finds that no 
 less than 71 "99 per cent, of all who become 
 blind during the first year of life are ren- 
 dered blind by purulent ophthalmia, and 
 even of those who become blind before 
 the twentieth year of life it constitutes as 
 much as 23*50 per cent. Looking at the 
 subject in another way, he shows that of 
 every 10,000 children under five years of 
 age 4*28 are blinded by purulent ophthalmia.
 
 BLINDNESS AND SHORT-SIGHT. 113 
 
 Owing to the ignorance of the serious nature 
 of the disease, or of the possibiHty of arrest- 
 ing its progress by judicious treatment, in 
 this country the proportion of the ])Hnd from 
 this cause in the Normal College of Music 
 is no less than 32*14 per cent. ; whilst in 
 the blind asylums in Switzerland the pro- 
 portion is 26 per cent.; in the blind asylums 
 of Austria, Hungary, and Italy about 20 per 
 cent. ; whilst in Spain and Belgium it falls 
 to about 11 or 12 per cent.* Even the 
 washing of the child's eyes at birth with 
 plain water without an antiseptic (though 
 it is desirable to use an antiseptic solu- 
 tion) has been found efficient to prevent 
 this disease. Yet at present in works on 
 midwifery, or in books intended for the in- 
 struction of midwives or nurses, it is veiy 
 rare to hnd any allusion to this important 
 disease or its prevention. To ensure ade- 
 
 * Lancet, July 20, 1889. 
 8
 
 114 NATIONALISATION OF HEALTH. 
 
 qnate attention to this simple but important 
 precaution, it is important that all those 
 who are entrusted with the care of child- 
 birth should be properly instructed, and 
 also that they should be kept alive to their 
 responsibilities, and to the most effective 
 means of fulfilling them, by contact with 
 the life and enthusiasm of a large teaching 
 centre. 
 
 The question of the rapid increase of de- 
 fective eye- sight in connection with our 
 modern civilisation, and especially w^ith our 
 modern methods of education, is now recog- 
 nised by those who have an acquaintance 
 with the matter to be one of considerable 
 gravity. 
 
 In this country the question has scarcely 
 at present attracted attention, and no large 
 and systematic investigations have been 
 made into the increase and prevalence of 
 short-sight, although observers, like Mr.
 
 BLINDNESS AND SHORT-SIGHT. 115 
 
 Bmdenell Carter and Dr. Francis Warner, 
 have sought to call attention to the matter. 
 The question is, however, an international 
 one. 
 
 In Germany, where modern methods of 
 education are carried on with greater energy, 
 eye-sight has suffered more than in any other 
 country. Professor Pfiiiger stated some 
 time ago that of 45,000 children examined 
 in Germany, more than one-half were suffer- 
 ing fi'om defective eye-sight, while in some 
 schools the proportion of the short-sighted 
 was 70 or 80 per cent., and at the Heidel- 
 berg " Gymnasien " it rose to 100 per cent. 
 The medical inspection of 24 Prussian 
 "Gymnasien" and " Eealschulen " has 
 shown that out of over 9,000 scholars 37 
 per cent, were suffering from short-sight, 
 and the investigations revealed a gradual 
 progress in defectiveness from the lower 
 classes to the higher classes ; thus while in
 
 116 NATIONALISATION OF HEALTH. 
 
 the sixth aud lowest class the average was 
 22 per cent., in the fifth it was 27 per cent., 
 in the fourth 36 per cent., in the third 46 
 per cent., in the second 55 per cent., and 
 in the first class it w^as 58 per cent. 
 At the Paris International Congress of 
 Hygiene in 1889 Dr. Motais of Angers 
 gave the result of investigation of 6,700 
 children. He found that short-sight was 
 much less frequently found in France than 
 in Germany, but that it was growing to 
 an alarming extent. In Sweden, among 
 11,000 boys, Professor Axel Key shows that 
 short-sightedness ranges from 6 per cent, at 
 the age of 11, to 37*3 per cent, at the age of 
 19, a sudden rise occurring about the age 
 of 15. Among about 3,000 Swedish girls ex- 
 amined, it was found that short-sightedness 
 ranged from 21*4 per cent, at the age of 10, 
 to 50 per cent, and over at the age of 20.* 
 
 ■■'• See a valuable paper read by Professor Axel Key at the
 
 BLINDNESS AND SHOBT-SIGHT. 117 
 
 In America the same result lias been found. 
 The short-sighted in the Philadelphia schools 
 are at 8 years of age but 5 per cent. ; among 
 scholars of 17 years the proportion has risen 
 to 20 per cent. Out of 2,400 children ex- 
 amined no fewer than 1,000 were suffering 
 more or less from eye troubles.* Tests made 
 on the strength of sight among the school 
 children at Worcester, Mass., U.S.A., showed 
 that out of 793 boys .308 (or 38 per cent.), 
 and out of G02 girls 313 (or 52 per cent.), 
 were short-sighted, f 
 
 In England, in 1884, Mr. Frost found in 
 a large London Board School that rather 
 more than one fourth of the children had 
 
 Berlin International Medical Congress in 1890 on "Die 
 Pubertfitsentwickelung unci das Verbiiltniss derselben zu den 
 Krankheitserscheinungen der Scliuljugend." Sonderabdruek, 
 Hirscbwald, Berlin. 
 
 '■'■'■ See a valuable paper on "Defective Vision in School 
 Children," discussing this danger and its prevention, in the 
 American Educational Eevieto, for April, 1892. 
 
 f American Journal of Psychology, Aug. 1892.
 
 118 NATIONALISATION OF HEALTH. 
 
 subnormal vision. Dr. Warner, in his Milroy 
 Lectures on " An Inquiry as to the Physical 
 and Mental Condition of School Children " 
 (carried out on 50,000 children), has shown 
 the frequency of eye-defect, and the great 
 need of school children for ophthalmic at- 
 tention. And wherever careful investigation 
 has been made similar results are usually 
 brought out.* 
 
 There is a strange degree of ignorance 
 and indifference among parents, even among 
 people who claim to be fairly well educated, 
 as to what defective sight is, and what it 
 
 ■■'■ It is to be regretted that the observations so far made in 
 England are of au imperfect and fragmentary character, and 
 not altogether harmonious. In the Report of the Anthropo- 
 metric Committee of the British Association for 1884 (p. 281) 
 is presented a series of observations on the eye-sight of boys 
 at Marlborough College, made by the Rev. T. A. Preston. It 
 by no means shovv^s (except in the tendency to astigmatism 
 to increase with age) any marked defect of sight. This 
 seems to indicate that (as the researches of others tend to 
 show) defective eyesight is distinctly connected with defec- 
 tive conditions generallj' and underfeeding.
 
 BLINDNESS AND SHOIiT-SIGHT. 119 
 
 involves. To have one's vision circum- 
 scribed within a circle of a few yards or 
 feet or even inches is to be shut out from a 
 large part of the world and all that is to Ije 
 learnt from the observation of it ; it means 
 blindness to the most beautiful and ex- 
 pressive thing in the world — the human 
 face. The short-sighted person is a source 
 of perpetual discomfort to himself and to 
 others, and however great his intelligence, 
 his mind must always work in a partial and 
 biassed manner and under difficulties. One 
 can understand the repugnance which 
 Goethe, with his large and sane way of 
 looking at things, felt for the people who 
 peer at the world through spectacles. 
 
 The causes of defective eye-sight, as well 
 as the methods of combating them, seem at 
 present to be rather complex. Motais con- 
 siders heredity a highly important factor in 
 the evolution of myopia or short-sightedness.
 
 120 NATIONALISATION OF HEALTH. 
 
 In a recent contribution, however, to the 
 subject, brought forward at the Paris 
 Academy of Medicine, he maintains that 
 myopia is a product of civiUsation, and he 
 finds unexpected confirmation of this view 
 in the condition of the eyes of wild beasts, 
 such as tigers, hons, &c. Having examined 
 their eyes by means of the ophthahiioscope 
 he discovered that animals captured after 
 the age of six or eight months are, and 
 remain, normal ; but that those captured 
 earlier, and still more those born in capti- 
 vity, are short-sighted, the myopia being evi- 
 dently induced by artificial conditions of life. 
 Javal, in another recent communication 
 to the Paris Academy of Medicine, believes 
 that by the exercise of proper precautions 
 children, even wdren predisposed by heredity, 
 can be prevented from becoming myopic. 
 It is probable that some slight modifications 
 of our educational methods will be involved.
 
 BLINDNESS AND SHOUT-SIGHT. 121 
 
 There is general agreement that the arrange- 
 ment of our sehooh'ooms is often in a high 
 degree faulty. Our o^Yn Education Depart- 
 ment ordains " that the windows should be 
 so placed that a full light should fall upon 
 the faces both of the teachers and the 
 children." This rule has often been severely 
 condemned ; it is directly opposed to the 
 most elementary principles of common-sense 
 hygiene in such matters. Children instinc- 
 tively turn away or lower their heads when 
 their eyes are exposed to the full glare of 
 the light. We shall probably find that it 
 is necessary to avoid prolonged strain of the 
 eyes in children, and to educate them in 
 seeing objects at a distance, carefully avoid- 
 ing small print. 
 
 But the first and essential point is the 
 methodical examination of the eyes as a 
 matter of routine, and at stated intervals. 
 ^Yhen this is systematically done — and it
 
 122 NATIONALISATION OF HEALTH. 
 
 is a very simple tiling to do — we sliall be 
 in a better position to understand tlie 
 causes wliich are producing tliis unfortu- 
 nate development of short-sight, and we 
 shall be better able to remedy them. It 
 is impossible, and scarcely desirable, that 
 the parents should be responsible for this 
 examination being duly made. When, 
 however, every district has a recognised 
 hygienic and medical centre, the effective 
 performance of this simple but important 
 investigation, involving also advice or treat- 
 ment when necessary, will become a fairly 
 easy matter.* 
 
 ■■'■ See " Die Schulknrzsiclitigkeit und ibre Bekiimpfung," 
 von Dr. H. Scbmidt-Pdmpler, Leipzig, 1890. The sug- 
 gestions here given are the result of investigations made at 
 the request of the Prussian Minister of Education. Dr. 
 Ferdinand's School Teacliefs OjihtJiahnic Guide (Aberdeen : 
 W^j'lhe and Sou, 1892) may be recommended. Its " sole 
 object is to cheek the increase of defective vision among 
 school children,"' and it contains many simple and valuable 
 suggestions. See also Brudenell Carter's Eye-Sight : Good 
 and Bad.
 
 IX. 
 
 MATEENITY AND ITS PERILS. 
 
 Puerperal fever — Sketch of the origin and development 
 of antiseptic midwifery — Progi'ess made in the large 
 maternity hospitals of Vienna, Dresden, Paris, New 
 York, Berlin, London, Dublin, Copenhagen, St. Peters- 
 burg — Contrast among population generally — The enor- 
 mous preventable mortality among young mothers — 
 Manslaughter by general practitioners and midwives — 
 The registration of midwives. 
 
 The lives of young mothers are among the 
 most vahiable to the community. It is in 
 saving such lives that the new era of pre- 
 vention has achieved one of its very greatest 
 triumphs. The triumph, moreover, is one 
 which we have so far been guilty of leaving 
 terribly incomplete, and it is worth while, 
 therefore, to deal with it in some detail. 
 
 123
 
 124 NATIONALISATION OF HEALTH. 
 
 No scheme for the organisation of medicine 
 worth any consideration can fail to take 
 this matter into accomit. 
 
 The mortahty among women in child- 
 birth is mostly due to the various inflam- 
 matory causes vaguely called puerperal 
 fever. White, a Manchester surgeon, is 
 supposed to have been the first to assert 
 the infectious nature of puerperal fever, so 
 long ago as 1773, and Gordon, an Aberdeen 
 doctor, subsequently brought forward con- 
 firmatory facts. Oliver Wendell Holmes, 
 in 1843, WTote an eloquent essay on its 
 contagiousness and on the folly of those 
 w^ho disregarded the evidence. That folly 
 was well illustrated a few years later, when 
 no few^er than forty-five cases of puerperal 
 fever occurred in the practice of one medical 
 man, while no patients of the other doctors 
 in the place w^ere attacked. An important 
 step in advance was made in 1847, when
 
 MATERNITY AND ITS PEBILS. 125 
 
 SeminelweisB, amid much ridicule, declared 
 that puerperal fever is due to the ab- 
 sorption of decomposiug animal matter, 
 and that the poison is usually conveyed to 
 the woman by the doctor. By means chiefly 
 of simple disinfection of the hands he suc- 
 ceeded in reducing the mortality in the 
 lying-in wards of the General Hospital in 
 Vienna from about 12 per cent, to 1 or 2 
 per cent, within a year. That was an ex- 
 perience the importance of which was, as 
 Haller declared, beyond calculation. 
 
 It is now generally agreed that puerperal 
 fever is infectious, always depending on the 
 introduction of microscopic organisms from 
 without. Wherever progress has been made 
 in the battle against this terrible disease 
 it has been by an enlightened attention to 
 cleanliness. 
 
 Both in the ordinary and in the surgical 
 sense of the word complete antisepsis is
 
 126 NATIONALISATION OF HEALTH. 
 
 scarcely practicable. Adequate antisepsis 
 has, however, been found to result from the 
 adoption of a variety of precautions which 
 have been the gradual outcome of ex- 
 perience. 
 
 It appears that to Copenhagen belongs 
 the title of "the cradle of antiseptic mid- 
 wifery." * Previous to 1865 the mortality 
 from puerperal fever at the Maternity Hos- 
 pital of that city had been as high as 1 in 
 24 women delivered, but in that year Pro- 
 fessor Stadtfeldt resolved to apply Lister's 
 antiseptic principles to midwifery, and his 
 success was immediate. Since then the pro- 
 gress in antiseptic obstetrics has become 
 more general. 
 
 At Vienna, in the largest lying-in hos- 
 pital in the world, the mortality has fallen 
 
 '■' This is the opinion of Dr. W. 0. Priestley, who has 
 investigated the matter. See paper " On the Improved 
 Hygienic Condition of Maternity Hospitals," read at the 
 London Congress of Hygiene.
 
 MATERNITY AND ITS PERILS. 127 
 
 in twenty years — through the introduction, 
 first, of hygienic reforms, and then of anti- 
 sepsis — from 28 per thousand to G per thou- 
 sand. At the Dresden hospital puerperal 
 fever has been so nearly banished that only 
 one fatal case arises among nearly 1,500 
 cases. At the Maternite at Paris the total 
 death-rate has fallen from 93 per thousand, 
 first, owing to sanitary improvements, 
 to 23 per thousand, and then, after the 
 introduction of antiseptics, to 11 per thou- 
 sand. For the year 1890-91 Professor Tar- 
 nier, the eminent French obstetrician, 
 reports that out of 1,340 women delivered 
 in his wards only 14 died, a mortality of 
 1*04 per cent., as against 2*50 per cent. 
 of eight years ago, and 9 per cent, of thirty 
 years ago. Of these 14 deaths not one 
 could be put dowai to puerperal fever. It 
 must be remembered that these wards are 
 occupied by patients drawn from the lowest
 
 128 NATIONALISATION OF HEALTH. 
 
 social strata of Paris, and that as Parisian 
 women are usually attended by midwives 
 a large proportion of the cases sent into 
 hospital are difficult ones. In America the 
 results are still more startling. The mor- 
 tality from puerperal fever at the New York 
 Maternity Hospital has been reduced from 
 60 per thousand in 1883 to 2 per thousand, 
 and at the Boston Hospital from 55'5 per 
 thousand in 1882 to zero. 
 
 England was late in adopting antiseptic 
 midwifery. The Lying-in Hospital in York 
 Road, London, was, until 1877, scarcely 
 ever free from puerperal fever, and the mor- 
 tality was sometimes so fearful that the 
 hospital was several times closed for long 
 periods. In 1877 antiseptic principles were 
 adopted, and the mortality, which from 
 1833 to 1860 had averaged 30 per thousand, 
 and from 1860 to 1877, 17 per thousand, 
 fell to 6 per thousand, and puerperal fever
 
 MATEBNITY AND ITS PEBILS. 129 
 
 was almost entirely banished. By the use 
 of simple and rational methods so excellent 
 a state of things has been brought about 
 that in this large London lying-in hospital 
 there has been but one death from puerperal 
 fever in three years. Antiseptic precautions 
 were introduced in 1882 at the Eotunda 
 Hospital in Dublin by Dr. Macan, and the 
 results were, as usual, in the highest degree 
 satisfactory. At the International Medical 
 Congress of 1884 Dr. Ingerslev, of Copen- 
 hagen, gave an interesting summary of his 
 researches into puerperal mortality in Den- 
 mark, carefully checking his conclusions, 
 which showed a distinct decrease in puer- 
 peral mortality, undoubtedly due to the 
 adoption of antiseptic precautions. More 
 recent statistics show that in Denmark, 
 where antiseptics are in universal use among 
 midwives, the mortality has steadily de- 
 clined, and is now only about 3 per 
 
 9
 
 130 NATIONALISATION OF HEALTH. 
 
 1,000 for the country generally. At the 
 Berlm International Medical Congress of 
 1890, Sla^^'jansky, of St. Petersburg, read 
 a paper on antiseptic midwifery in Eussia. 
 In that country it has been everywhere 
 introduced with the result that puerperal 
 disease and mortality is decreasing from 
 year to year, and already shows quite satis- 
 factory figures ; in 1889, in fifty-two institu- 
 tions, there were 21,280 births; 60, i.e., 2'8 
 per thousand, died of puerperal fever. In 
 the large Maternity Hospital at St. Peters- 
 burg, one of the best regulated in the world, 
 only one death from puerperal fever occurred 
 in three years, and that w^as in the case of a 
 woman who w^as brought ill to the hospital. 
 In St. Petersburg generally, outside the 
 hospital, the general and puerperal mor- 
 tality is very large.* 
 
 '•= See the important discussion at the Berlin Interna- 
 tional Congress (section of Geburtshitlfe und Gynakologie), 
 when papers were read by Slawjansky of St. Petersburg, 
 .Stadtfeldt of Copenhagen, and Fritsch of Breslau.
 
 MATERNITY AND ITS PERILS. 131 
 
 Such is the condition of things to-day 
 wherever attempts have been made to 
 adopt reasonable precautions for the pre- 
 vention of this terrible disease. But how 
 does the matter stand in relation to the 
 population generally ? 
 
 In England and Wales 4,500 women die 
 every year in childbirth. According to the 
 most reliable statistics about 70 per cent. 
 of this mortality is due to puerperal fever, 
 so that, in the words of an eminent London 
 physician, " almost the whole of this mor- 
 tality might be avoided." That is to say, 
 that every year in England and Wales over 
 3,000 women, the mothers of young children, 
 are unnecessarily slain in the performance 
 of a simple physiological function. 
 
 If we take a somewhat wider outlook we 
 find 'tkat in the thirty years from 1847 to 
 1876 no fes- than 105,568 mothers died 
 in childbirth. And if we look abroad, to
 
 132 NATIONALISATION OF HEALTH. 
 
 the United States, for instance, we find 
 that in New York City alone, during the 
 years between 1868 and 1875, 3,342 women 
 died from diseases associated with child- 
 bearing. On investigation 42 per cent, of 
 these deaths are found to be due to 
 hcemorrhage, consumption, or other non- 
 puerperal diseases liable to complicate child- 
 birth. The remaining 58 per cent, were 
 due to puerperal fever. The actual number 
 of births for the nine years in question 
 was roughly estimated at 284,000, an 
 estimate erring on the side of liberality. 
 The total number of deaths to the entire 
 number of confinements was thus, as Dr. 
 Lusk points out, at least in the proportion 
 of 1 to 85 ; or, fi'om puerperal fever alone, 
 in the proportion of 1 to 146. The Puer- 
 peral Fever Commission, appointed by the 
 Berlin Society of Obstetrics and Gj^asco- 
 logy, collected statistics from which it
 
 MATERNITY AND ITS PERILS. 133 
 
 appears that this disease destroys nearly 
 as many Hves as small-pox or cholera.* 
 But ^Yhile these diseases exert their most 
 fatal influence on the feeble, the young, 
 and the aged, puerperal fever finds its 
 victims among the mothers of children, 
 adult and healthy \Yomen, who have simply 
 become vulnerable through the exercise of 
 the chief physiological function of their 
 lives. 
 
 How unnecessary this slaughter is we 
 realise when we investigate the experience 
 of a medical man who, even amid the many 
 difficulties of private practice, has been 
 animated by a high sense of his responsi- 
 bilities, and has always succeeded in main- 
 taining an intelligent system of sanitary 
 precautions. Dr. Dysart McCaw has re- 
 
 * Bohr calculated that in Prussia aloue iu the years 
 1810-75 over 300,000 women died of puerpeial fever, being 
 as many as from cholera and small-pox together during the 
 same period.
 
 134 NA TIONAL ISA TION OF HE A L TH 
 
 cently stated that cluriDg an experieuce of 
 some twent3'-two years he has attended 
 2,500 labours without a single maternal 
 death. He attributes this very happy 
 record mainly, if not solely, to the obser- 
 vance of strict cleanliness in himself, the 
 nurse, the patient, and the surroundings. 
 The counsel to be addressed to the modern 
 obstetrician is, with a difference of meaning, 
 the same as that w^hich midwifery writers 
 of old urged on their disciples : " Thine is a 
 high and holy calling ; see tbat thou exer- 
 cise it with purity." 
 
 But, as a matter of fact, what do we find ? 
 ^Ye have seen w^hat is possible at great 
 centres of medical activity, and what is 
 possible also even in the case of a single- 
 handed private practitioner, who is intelli- 
 gently alive to his responsibilities. Our 
 private practitioners are often over-w^orked, 
 and consequently apathetic ; they are sub-
 
 MA TEENITY AND ITS PEIilLS. 135 
 
 ject to no inspection, and in touch with no 
 great quickening centres of medical activity ; 
 they are not legally compelled, as in Ger- 
 many, Russia, and elsewhere, to use any 
 antiseptic precautions, and, as a matter of 
 fact, they rarely do use any such precau- 
 tions.* Under these circumstances, the 
 
 ■'• As an example of the precautious to be adopted by mid- 
 wives it is worth while to quote the foUowiug Rules issued in 
 January-, 1892, by the Committee of the Lying-in Hospital, 
 •York Road, Lambeth, and to be obtained from the Secretary 
 for one penny. They were drawn up in consequence of an 
 appeal for some authoritative code, by Dr. Culhngworth, of 
 St. Thomas's Hospital, and were carefully considered by other 
 distinguished London obstetricians. It may be added that 
 the rules fairly correspond with those used abroad ; corrosive 
 sublimate was first introduced into obstetric jn-actice by 
 Prof. Tarnier, of Paris ; he is, however, very guarded in its 
 use, preferring for internal use (af5 recommended in these 
 Rules) permanganate of potassium. 
 
 Bulea for the use of Antiseptics in the Practice of Outdoor 
 Maternities issued by the Committee of the General 
 Lying-in Hospital. 
 
 1. Every midwife should possess a bag, which she should 
 take with her whenever she is summoned to a woman in 
 labour.
 
 136 NATIONALISATION OF HEALTH. 
 
 results which we actually fiud are not sur- 
 
 2. The bag should contain, besides other necessaries, the 
 following : — i'l) A box containing twelve antiseptic powders, 
 each powder consisting of 10 grains of corrosive sublimate 
 (perchloride of mercury) and 1 grain of cochineal. The box 
 should be labelled, '• The corrosive sublimate powders — 
 l^oisjn." (b) An ouuce bottle (with wide mouth) contaia- 
 ing crystals of permanganate of potassium, (c) A bottle 
 containing 2 fluid ounces of glycerine, in which 1 grain of 
 corrosive sublimate has been dissolved. The bottle should 
 be labelled, " The corrosive sublimate glycerine — poison." 
 
 (d) A douche tm, capable of holding two quarts, and fitted 
 with a long india-rubber tube, stop-cock, and vaginal nozzle, 
 
 (e) A nail brush and a piece of soap. (/) A bath thermo- 
 meter. 
 
 3. Before making a vaginal examination, the midwife 
 should prepare an antiseptic solution in the following way : — 
 One of the corrosive sublimate powders should be placed in a 
 clean basin, and one pint of hot water should be poured upon 
 it, and stirred with the finger until completely dissolved. 
 This solution will be of the strength of one part in 1,000. 
 
 4. The midwife's nails should be kept short. 
 
 o. Before making the examination or touching the genital 
 organs the midwife should wash her hands and wrists with 
 soap and hot water, cleaning her nails with a nailbrush ; she 
 should next rinse them free from soap ; then she should hold 
 her hands for a full minute in the antiseptic solution already 
 prepared. The hands should not be wiped before making 
 the examination, but the fingers should be anointed with the 
 " corrosive sublimate glycerine." Note — No substitute for
 
 MATERNITY AND ITS PERILS. 137 
 
 prising. The hospitals have led the way, 
 
 the " coiTosive sublimate glycerine," such as lard or vaseline, 
 should 1)6 iTsed for anoiutiug the fingers. 
 
 6. Having made the examination, she should again wash 
 her hands in soap and water. 
 
 7. All sponges should be plunged in the antiseptic solution 
 and kept in it for a full minute before being used. 
 
 8. After labour the external parts should be washed with 
 the antiseptic solution. 
 
 9. Catheters, before being used, should be plunged in the 
 antiseptic solution for a full minute, and then anointed with 
 the " corrosive sublimate glycerine." 
 
 10. If the discharge become offensive, and a vaginal douche 
 be required, the douche should be prepared by dissolving one 
 teaspoouful of the crystals of permanganate of potassium in 
 two quarts of hot water, of a temperature of 110' F. The 
 solution should be of the colour of claret. 
 
 11. To prevent ophthalmia, or sore eyes, in the child, the 
 midwife should wipe its eyelids with a clean napkin as soon 
 as its head is born. This should be done, if possible, before 
 the eyes have been opened. When washing the child the 
 midwife should separate tlie lids, and squeeze over the eyes 
 a clean white rag or piece of cotton wool that has been soaked 
 in the antiseptic solution. 
 
 12. If the midwife has been brought into contact with a 
 case of puerperal fever, or other illness supposed to be in- 
 fectious, she should immediately report the fact to the 
 Managing Committee of the Charity. She should not pro- 
 ceed to any case of labour, or visit any of her patients, until 
 she has the Committee's permission to do so.
 
 138 NATIONALISATION OF HEALTH. 
 
 but the private practitioners have not fol- 
 lowed, and the puerperal mortality to-day, 
 and certain tragic occurrences which take 
 place from time to time, are lamentably in 
 evidence. Over and over again has puer- 
 peral fever singled out the patients of some 
 private practitioner who has brought death 
 to mother after mother in succession. Every 
 medical man knows of such cases. Dr. 
 Lusk has investigated this matter in New 
 York. Studying the records of that city for 
 nine years, " I find," he says, "that the oc- 
 currence of two deaths from puerperal dis- 
 ease, following one another so closely as to 
 lead to the suspicion of inoculation occurred 
 to thirty physicians ; a sequence of three 
 cases occurred in the practice of three phy- 
 sicians ; one physician lost three cases, and 
 afterwards two, in succession; one physician 
 had once two deaths, once three deaths, and 
 twice four, deaths, following one another;
 
 MATERNITY AND ITS PElilLS. 139 
 
 finally, a pbj^sician reported once a loss of 
 two cases near together, then of six patients 
 in six months, and then of six patients in six 
 weeks." After enumerating these awful facts, 
 he adds : " Not one of the sequences men- 
 tioned occurred in the practice of a ph}^- 
 sician connected with a lying-in hospital." 
 He found that the total loss occurring from all 
 puerperal causes in the private practice of ten 
 physicians intimately associated with such 
 institutions numbered during nine years but 
 twenty-one cases ; while a single physician, 
 unconnected with any hospital, lost during 
 the same period twenty-seven cases, of 
 which twenty-one were cases of puerperal 
 fever. Dr. Lusks point out, at the same 
 time, that, in his opinion, the infection is 
 even more often carried by nurses than by 
 doctors.* 
 
 * Liisk, " Science and Art of Midwifery," p. 634. Dr. 
 Oliver, in a paper on " Puerperal Septicaemia," read at the
 
 140 NA TIONALISA TION OF HEAL TH. 
 
 In the present year a series of deaths 
 from puerperal fever led to the appearance 
 of an uncertificated midwife at the Old Bailey 
 on a charge of manslaughter. This woman 
 attended, on the 8th of December, 1891, a 
 case in which death resulted from puerperal 
 fever ; on the 12th of December she attended 
 another woman, who also died from puer- 
 peral fever ; she was warned by a doctor that 
 she ought not to attend anymore cases for a 
 couple of months, and that she should disin- 
 fect herself; but on the 12th of January she 
 was found in attendance on another woman, 
 who also died from puerperal fever. The 
 prisoner said she was " ignorant of having 
 any complaint about her" ; one or two wit- 
 nesses talked vaguely about " drainage and 
 
 British Gynaecological Society Congress in 1891, gave the 
 history of numerous cases in private practice which had come 
 under his notice, in which disease and death had been carried 
 from patient to patient by both doctors and nurses owmg to 
 the neglect of elementary antiseptic precautions.
 
 MATERNITY AND ITS PERILS. 141 
 
 unhygienic surroundings." The jury found 
 a verdict of " Not guilty," and expressed 
 the opinion that the midwife " left the court 
 without a stain on her character," and the 
 judge " quite agreed." It would be difficult 
 to find a better illustration of the present 
 state of things, and comment is scarcely 
 necessary. The verdict itself, it may be 
 said, was much more reasonable with refer- 
 ence to an uncertificated midwife than it 
 would have been with reference to a qualified 
 medical man. The judge and jury seem to 
 have felt that this woman's " negligence " 
 was too natural and habitual to be fairly 
 called " criminal," and that therefore she 
 must be allowed, "without a stain on her 
 character," to pursue her sanguinary career. 
 The real crime, it cannot be too emphati- 
 cally asserted, lies at the door of the com- 
 munity which permits a totally ignorant 
 woman to exercise a responsibility fraught
 
 142 NATIONALISATION OF HEALTH. 
 
 with such terrible issues. There are in this 
 country 900,000 births per annum, and of 
 this number midwives attend about 500,000, 
 more than half. The average mortality 
 in childbirth is about 1 in 200, but it is 
 found that in the cases undertaken by such 
 trained midwives as are employed in lying- 
 in hospitals the mortality is only 1 in 600. 
 So that from this point of view also we see 
 an annual slaughter of 3,000 mothers, which 
 might be prevented by ensuring the training 
 of midwives. In all other countries mid- 
 wives are more or less under State control ; 
 in this country any woman, however foolish 
 and ignorant, may practise as a midwife, 
 and let the results be as awful as they will, 
 she emerges as we see " without a stain 
 upon her character." We have a deep- 
 rooted love of liberty in England, even when 
 liberty means wholesale manslaughter. 
 Several attempts have indeed been made to
 
 MATERNITY AND ITS PEBILS. 143 
 
 introduce the most necessary reform in- 
 volving the due training and registration of 
 midwives, but hitherto they have proved 
 abortive, largely in consequence of lack of 
 active support from the medical profession. 
 The reform, as Lord Cranbrook lately 
 pointed out, is not one that can be settled 
 by laymen alone, and the apathy, or even 
 actual opposition of medical men is, I am 
 bound to confess, far from creditable to the 
 profession. 
 
 It is clear that the exercise of the mid- 
 wife's art can only be safely entrusted to 
 well- trained men and w^omen, who are in 
 contact with some large central institution, 
 and who are, to some extent, subject to 
 supervision. 
 
 It is also very clear that, if this very 
 necessary end is to be attained, we need a 
 far more educated public opinion than we 
 possess at present.
 
 X. 
 
 THE dentist's PLACE IN HEALTH 
 NATIONALISATION. 
 
 The neglect of the teeth — A source of disorder and disease 
 —In childhood — Magnitude of the evil as shown by 
 investigations among school children — What might be 
 done. 
 
 The care of the teeth has at present only 
 to a very limited extent, and in very few 
 countries, been regarded as a matter of 
 public health, to be dealt with systemati- 
 cally. Here and there the routine examina- 
 tion of children's teeth at school has been 
 introduced, but for the most part the matter 
 has been left entirely to individual apathy 
 and ignorance. The result is that among 
 all classes — for the well-to-do are in this 
 
 144
 
 THE DENTIST'S PLACE. 145 
 
 matter usually as uncivilised as the poorest 
 — the teeth are often left to take care of 
 themselves until some prolonged attack of 
 toothache makes life intolerable, or until, 
 perhaps, there are very few teeth left to 
 care for. Not many of us learn until we 
 are approaching middle age the comfort, 
 economy, and hygienic importance of the 
 trifling amount of attention necessary for 
 the care and preservation of the teeth. 
 This means a vast amount of avoidable 
 misery and discomfort. It means also that 
 the mouth must frequently be converted 
 into a cavern of impurity not pleasant to 
 contemplate. And it is now beginning to 
 be recognised that neglected caries of the 
 teeth is responsible for a considerable 
 amount of more serious disease. " Neu- 
 ralgia," in a great number of cases, it is 
 scarcely necessary to remark, has its point 
 of origin in a neglected tooth. The same 
 
 10
 
 14G NATIONALISATION OF HEALTH. 
 
 cause often leads to diseases of the upper 
 jaws, such as empyema of the antrum. 
 Cases have been recorded m which decayed 
 teeth have produced epilepsy, which ceased 
 with the removal of the teeth. It has lately 
 been said by an experienced dental prac- 
 titioner connected with a hospital for the 
 special treatment of nervous diseases, " I 
 am, after mature consideration, of opinion 
 that three-fourths, or certainly a large pro- 
 portion, of those nervous troubles which 
 defy the physician in various parts of the 
 body have their origin in the teeth. So 
 interminably tangled and complicated is 
 the nervous system, so nicely does it adjust 
 the relations of all our organs, that there is 
 little need for surprise when we find that 
 cause and effect are widely separated in an 
 anatomical sense." However this may be, 
 and the estimate is no doubt excessive, 
 there can be no doubt whatever as to the
 
 THE DENTIST'S PLACE. 147 
 
 great desirability of the routine examin- 
 ation of the teeth, and as to oiir habitual 
 indifference concerning the matter. More 
 especially is this indifference marked in 
 childhood and youth, precisely the period 
 when the matter should especially claim 
 attention. As Mr. Fox, dental surgeon to 
 the Victoria Hospital for Children, has 
 recently said in an address to the Medical 
 Officers of Schools' Association : — " The 
 care of the teeth in childhood is a sub- 
 ject of real and great importance, and 
 should claim the attentive consideration of 
 medical men, and especially of those whose 
 energies are exerted on behalf of the young. 
 Much may be done during the early years 
 of life — especially in that important epoch, 
 the second dentition — by combating dele- 
 terious inffuences to further the develop- 
 ment of sound structures, and to give some 
 promise of useful masticating agents.
 
 148 NATIONALISATION OF HEALTH. 
 
 Doubtless many of the dental troubles of 
 adult life are due to a careless disregard of 
 the teeth when first erupted, and during the 
 earlier years of life, at a time when frequent 
 inspection and judicious attention may 
 encourage the hope of some immunity from 
 dental disease. . . . Caries is the most fre- 
 quent disease of the dental structures, 
 occurring as a rule in early adolescence, 
 soon after the teeth have been subjected to 
 the exposure and wear and tear of their 
 function, when the perfection of their 
 structural development is put to the test 
 and is but too often found wanting, and in 
 consequence of inherent defect incapable of 
 resisting the action of pernicious influences, 
 such as pressure of contiguous teeth, the 
 solvent properties of abnormal saliva, and 
 acid mucous secretion of the gums and oral 
 tissues. These conditions are the imme- 
 diate causes of decay, the deposition of
 
 THE DENTIST'S PLACE. 149 
 
 tartar of a peculiarly destructive character 
 forming a nidus for the growth of bacteria and 
 leptothrix, and rapidly affecting the enamel 
 by disintegrating its structure ; the presence 
 of supernumerary teeth, and other abnormal 
 conditions also calls for prompt treatment. 
 . . . Not only is an irregular position 
 of the teeth disfiguring, but, by the in- 
 creased and continuous pressure upon con- 
 tiguous teeth which this condition usually 
 entails, it constitutes a most frequent cause 
 of decay of their structures, as well as being 
 an occasional cause of certain systemic 
 derangements arising from reflex nervous 
 irritation." * 
 
 The magnitude of the evil that may be so 
 easily remedied may be shown by briefly 
 stating the results of some recent investiga- 
 
 * Mr. Smith Turner's presidential address at the meeting 
 of the British Dental Association, 1891 (printed in the Journal 
 of the Association), is an excellent epitome of the causes of 
 tooth degeneration.
 
 150 NA TIONALISA TION OF HEAL TH. 
 
 tions carried on in this country. The 
 Report of the School Committee appointed 
 by the British Dental Association in 1891, 
 derived from the examination of over 4,000 
 children mostly in industrial schools, refor- 
 matories, and training-ships, showed some 
 startling figures with reference to the preva- 
 lence of dental caries. From the nature of 
 the investigations these children belong to 
 the lower class, but a comparatively very 
 small number of cases examined in a 
 middle-class school gave even worse re- 
 sults. In infants — defined to be those who 
 have not cut a permanent tooth — the 
 figures showed that a considerable number 
 of teeth are decayed as early as the second 
 or third year, that the number of decayed 
 teeth increases as age advances, and that 
 the proportion of those free from caries is 
 about 2G j3er cent. only. Perfect sets 
 of permanent teeth, observations of which
 
 THE DENTIST'S PLACE. 151 
 
 were takeii between ten and twelve years of 
 age, gave 109 per 1,000. Under the head- 
 ing of retarded eruptions of permanent and 
 undue retention of deciduous teeth there 
 was over 11 per cent., and the Report adds 
 that this class of cases serves clearly to 
 explain how a large number of irregularities 
 of the permanent teeth occur which are 
 obviously of a preventable nature, and 
 irregularities being a recognised predispos- 
 ing cause of decay, the importance of this 
 table is considerable. Honeycombed teeth 
 existed in about 5 per cent., and hereditary 
 syphilitic teeth, the peg-shaped teeth of 
 Hutchinson, in 0*5 per cent.* 
 
 At the London International Congress of 
 Hygiene, Dr. Cunningham brought forward 
 statistics he had collected, showing that 56 
 per cent, of the upper molars were decayed 
 before the eighth year. The lower molars 
 
 =:= Lancet, August 29, 1891.
 
 152 NATIONALISATION OF HEALTH. 
 
 came first and decayed at once, 20 per cent, 
 being decayed during the first year and 70 
 per cent, by the third year. The cause, he 
 considered, was not due to fermentable 
 matter in the mouth, otherwise the central 
 incisors and other teeth would be equally 
 attacked. The cause was intrinsic ; the 
 molars came with defects in shape and were 
 injured by the decay of the first teeth. The 
 mouth was practically an incubator for the 
 development of bacteria, and we wanted 
 better teaching of the protection of the 
 teeth. In some schools they gave good 
 marks to children who kept their teeth clean, 
 and one dentist, for the modest salary of 
 £'20 per annum, was found to have saved 
 80 per cent, of the pupils' teeth when the 
 figures were compared with the average 
 prevalence of decay. In 1892, Mr. E. 
 Denison Pedley and Mr. Sidney Spokes 
 asked and received permission to examine
 
 THE DENTIST'S PLACE. 153 
 
 the mouths of the 1,000 children at the 
 Central London District Schools at Hanwell, 
 and at the request of the Board of Manage- 
 ment furnished a report. The number of 
 teeth examined amounted to some 20,000, 
 and the statistics occupied four months in 
 compilation. Of the temporary teeth 1,119 
 required stopping and 745 extracting; of 
 the permanent teeth 1,222 required filling 
 and 271 extracting ; there were, therefore, 
 as many as 3,357 unsound teeth present in 
 the 903 mouths examined, while over and 
 above this 83 mouths required the teeth to 
 be regulated by mechanical means. There 
 were only 137 mouths in which the denti- 
 tion was sound. * Still more recently there 
 
 * In a Report presented by these gentlemen to the British 
 Pental Association (British Medical Jonnml, March 26, 
 1892), they made the following excellent observations and 
 suggestions : — " There is an increasing recognition of the 
 importance of a systematic care of the teeth, apart from any 
 aesthetic consideration. In the case of children, who during 
 the growth of the body have not merely to maintain nutri-
 
 154 NATIONALISATION OF HEALTH. 
 
 has been an investigation of the teeth of 
 nearly 2,000 children in the schools at Sutton, 
 
 tiou, it is surely a matter of urgency that all the organs of 
 digestion should be kept in a state of functional integrity, 
 and if, as seems to be the case, diseases of the digestive tract 
 are increasing, it is evident that any departure from the 
 normal dentition places the child and the future adult at a 
 disadvantage. Instead of waiting until a child suffers pain, 
 and thus directs attention to a decayed tooth, it is far better 
 for both patient and operator that the earliest appearance of 
 caries should be noted, and the progress prevented by a 
 regulated sj'stem of inspection and prompt treatment. 
 Under such circumstances dental disease and the necessity 
 for painful operations become reduced to a minimum, and at 
 the same time the function of mastication is retained in 
 accordance with what is now recognised as the most bene- 
 ficial pi'actice. Referring once again to the figures, we 
 woidd point out that 760 children have between them 3,357 
 unsound teeth, 1,222 of which are permanent teeth requiring 
 filling. This points the way so clearly that we have no 
 hesitation in recording our opinion that a duly qualified 
 dental surgeon should be appointed to your school, and, after 
 careful consideration, we append the following suggestions 
 with reference to such an appointment: — That in order to 
 cope with the disease of the teeth at present existing in the 
 school, it is advisable that the dental surgeon should attend 
 once a week (morning and afternoon) for at least two years. 
 That an inspection of the children's mouths be so arranged 
 that each would be examined twice during the year, new
 
 THE DENTIST'S PLACE. 155 
 
 and the resulting report sent in to the Board 
 of the South London Metroi3ohtan School 
 District has revealed a state of things no 
 less serious than that at Han well. 
 
 A periodical examination of the teeth, 
 with the correction of any defects, should 
 be a matter of routine in childhood and 
 youth ; the examination could best be carried 
 out in connection with the school, and the 
 correction of defects would naturally be 
 made at the hospital or health institution of 
 the district. Even the most independently 
 
 cases being seen at the first visit after their arrival. Tliat a 
 record be kept of all operations perfoniied at each visit, and a 
 report presented to the board. That the board should paj- a 
 salary of at least i'lOO per anmim for the first two years, and 
 provide the following : Dental chair (say) i'7 10s. ; dental 
 engine (say) £7 10s. ; stopping materials (say) £5 (annu- 
 ally.)" lu accordance with these recommendations a dental 
 surgeon was shortly afterwards appointed (July, 18U2), 
 with the sanction of the Local Government Board, to 
 the Central London School District. He is to attend 
 weekly, and furnish a monthly statement for the House 
 Committee, and a general report at the end of twelve
 
 156 NATIONALISATION OF HEALTH, 
 
 minded person conld scarcely object to so 
 simple and wholesome an examination being 
 carried out systematically. After the 
 school- age, however, it seems scarcely 
 necessary to make a periodical examination 
 compulsory. When the good habit had 
 once been formed and its desirability shown, 
 the continuation of it might very well be 
 left to the individual's own good sense. 
 
 months. The work will be so arranged as to secure an ex- 
 amination of each child every six months, those in the pro- 
 bationary ward being inspected on the first visiting day after 
 admission. The equipment includes a Morrison chair, 
 dental engine, and other necessary instruments. This is 
 certainly an important step in the right direction.
 
 XI. 
 
 THE EEGISTEATION OF DISEASE. 
 
 Dr. Ilichardson's proposed Ministry of Health — The no- 
 tihcation and isolation of infectious disease — Tlie in- 
 clusion of measles, whooping-cough and consumption 
 — Notification in America — The system carried out 
 at Zurich — The importance of including preventable 
 diseases generally, not merely infectious diseases. 
 
 When Dr. B. W. Eichardson some years 
 ago suggested the establishment of a 
 Ministry of Health, by a true instinct he 
 proposed to found it on the present Eegis- 
 trar- General's office. " That office," he 
 observed, " amended in name and in 
 function, supplies all that is required as 
 a nucleus. The work of estimating life 
 and death which now goes on there is the 
 true foundation of all our efforts. This
 
 158 NATIONALISATION OF HEALTH. 
 
 work ought to remain as the foundation." 
 The duties of the Ministry of Health were 
 to embrace — (1) registration ; (2) reporting 
 meteorological conditions ; (3) collecting 
 coroners' returns ; (4) transfer of the medical 
 duties of the Local Government Board ; (5) 
 the superintendence of food analysis and 
 the detection of adulteration; (6) factory 
 supervision ; (7) veterinary supervision ; (8) 
 prison and police supervision ; (9) super- 
 vision of public works. 
 
 This scheme is, no doubt, still too ex- 
 tensive to be within the range of practical 
 politics, and the desirability of some of 
 its details may, to-day at all events, be 
 matter of question. But in regard to its 
 fundamental element — the importance of 
 the methodical registration of disease, and 
 of the chief conditions which influence 
 disease — there can be no sort of doubt. 
 This is, indeed, a matter which is every
 
 THE BEGISTRATION OF DISEASE. 159 
 
 day becoming better recognised ; and since 
 Dr. Richardson laid down the chief lines 
 of his proposed Ministry of Health on 
 the basis of registration, the Notification of 
 Diseases Act has been passed. In former 
 years this Act would have been regarded 
 as an unwarrantable infringement of the 
 right of the subject to have, and to inflict 
 on his neighbours, as many infectious 
 diseases as he may think proper ; to-day, 
 this Act has not only been passed with ease, 
 1)ut amid murmurs called forth by its in- 
 complete and merely permissive character. 
 The omissions have, especially, called forth 
 severe criticism. 
 
 Measles is an infectious disease, which 
 produces terrible mortality, while little or 
 nothing is done to prevent its spread. It 
 causes some 15,000 deaths in the course 
 of a year in this country, more than double 
 as many as scarlet fever. It has, more-
 
 160 NATIONALISATION OF HEALTH. 
 
 over, increased within the last fifteen years, 
 the mean death-rate from this disease 
 throughout England and Wales having 
 risen from 277 per million of the population 
 for the decennium 1871-80, to 422 in that 
 of 1881-1890. " Of the 3,291 deaths from 
 measles in London in 1890," as Dr. Steven- 
 son remarks, " mostly of children under five 
 years of age, a number nearly quadruple 
 that fi"om scarlet fever, and the highest 
 recorded during the last fifty years, it may 
 he safely affirmed that the greater number 
 were preventable." Yet it is rarely con- 
 sidered necessary to add measles to the list 
 of notifiable diseases, and so to bring it 
 under control ; though by means of the 
 notification system it has been found 
 possible to avoid closing schools during 
 epidemics, wdth all the evils which such 
 a step involves, and to stamp out a threat- 
 ening epidemic by close personal medical
 
 THE REGISTRATION OF DISEASE. 161 
 
 supervision, the exclusion of children from 
 infected houses, and instructions to teachers 
 to watch for the first febrile or catarrhal 
 symptoms, sending home and reporting any 
 that seem in the least degree suspicious.* 
 
 It is probable that whooping-cough — a 
 disease almost as fatal as measles — would, 
 if similarly dealt with, be brought with 
 equal ease under control, but as yet the 
 attempt is rarely, if ever, made. Nor have 
 we yet seriously considered the question of 
 how to deal with consumption, which is 
 
 ■■'■ See the experiences of Dr. A. Campbell-Munro narrated 
 to the Epidemiological Society, Lancet, June 20, 1891, aud 
 to the Society of Medical Officers of Health, June 18, 1892. 
 He showed that in Jarrow there had been between 1883 and 
 1891 inclusive five biennial outbreaks, and the notification 
 having been respectively none, voluntary late, voluntary 
 earlj', compulsory late, and compulsory early, the mortality 
 had steadily declined fi-om 4*0 to 07 per 1,000, or nearly 
 one-sixth. On one occasion 28 out of the first 29 cases 
 occurring simultaneously in one district were those of 
 children in the infant department of a single school. Under 
 these circumstances prompt closure led to the extinction of 
 the epidemic in a fortnight or three weeks. 
 
 11
 
 162 NATIONALISATION OF HEALTH. 
 
 only among the least terrible, because un- 
 fortunately among the most familiar of the 
 infectious diseases we have to meet. 
 
 In those countries in which the notifica- 
 tion of infectious diseases has been carried 
 out more thoroughly than in England, the 
 results are, as might be expected, more 
 striking. Thus, at the London meeting of 
 the International Congress of Hygiene, Dr. 
 Hewitt, of Minnesota, remarked that in his 
 own State a notification Act had been passed 
 at the request of the people, and had been 
 in force for eight years. Before this Act was 
 passed, out of a population of 600,000 there 
 were 1,200 deaths from diphtheria per 
 annum ; now the population had more than 
 doubled, while the annual deaths from diph- 
 theria had fallen to 761. In England, as is 
 well known, diphtheria is on the increase. 
 In Montreal, again, stringent regulations 
 are in force, with the result that " epidemic
 
 THE REGISTRATION OF DISEASE. 163 
 
 diseases are becoming rapidly stamped out." 
 Tiie Congress, after hearing the objections 
 to the notification system (coming chiefly 
 from a very small section of medical men 
 %Yho could not see Avhy the duty of notifica- 
 tion should be thrust upon the doctor), 
 almost unanimously passed a resolution 
 that " Notification of infectious diseases in 
 all countries should be compulsory." 
 
 One of the best systems at present exist- 
 ing for the notification of disease is that 
 ^Yhich has been established at Zurich as the 
 result of experiments which have been carried 
 on for many j^ears.* A board of health for 
 the town is estabhshed in the ofiice of the 
 police, whose duty is to attend to the 
 sanitation of the town, its water-supply, 
 and all questions affecting the health of the 
 inhabitants. To this ofiice all communica- 
 tions concerning health and sanitation must 
 
 ^ See Lancet, January 18, 1890.
 
 164 NATIONALISATION OF HEALTH. 
 
 be sent ; and prompt action when necessary 
 is immediately taken by the health in- 
 spector. Every case of sickness to which 
 a medical man is summoned must be 
 reported by him direct to the health bureau 
 on his first visit ; if of infectious type, 
 whether mild or virulent, no choice is per- 
 mitted : his report is compulsory. All 
 medical men are officially supplied with 
 a book of printed forms, of which the 
 following is a copy : — 
 
 Announcement of Infectious Diseases. 
 
 (This certificate is to be delivered to the Board of Health 
 of the place of abode of the i^atient.) 
 
 Disease . 
 
 Christian and surname Male or Female 
 
 Age . 
 
 Calling (if children, calling of the parents) . 
 
 Place of abode street house No. Flat. 
 
 Alleged duration of illness to date days. 
 
 Private treatment since (Date of the first 
 
 visit). 
 Hospital treatment in since (Date of hospital 
 
 admission).
 
 THE REGISTRATION OF DISEASE. 105 
 
 the 18—. 
 
 Doctor m attendance. 
 
 N.B— That printed above and on the back which does not 
 apply is to be struck through. 
 
 On the back of the form is printed : — 
 
 1. — Presumed source of infection, iinknown, or what ? . 
 
 2. — Is the patient domiciled here '? Yes or No. Has 
 
 he travelled hither ? Yes or No. . Whence ? . 
 
 3. — Regulations : Isolation of the patient. Yes or No. 
 Prohibition of the visit of public meetings, schools, for all 
 members of the famil}'. Yes or No. Disinfection of the 
 dwelling ; of the excretal substances. Yes or No. House- 
 arrest. Yes or No. 
 
 4. — Remarks : Sporadic or epidemic appearance . 
 
 These letters are always sent free of 
 postage. Notice is not necessary in non- 
 infectious and chronic illness. Where 
 summoned, the medical man only is required 
 to report ; dual notice to the officials, as in 
 the English Act, is not required. Should 
 a case of infectious disease occur in which 
 the doctor fails to report, he is liable to a 
 penalty of from 10 francs to 100 francs,
 
 166 NATIONALISATION OF HEALTH. 
 
 unless satisfactory evidence is given that 
 the omission was unintentional; on a second 
 omission the penalty may be increased to 
 200 francs. In every return of puerperal 
 fever the doctor must give the name and 
 address of the nurse in attendance, so that 
 she may be brought under the more imme- 
 diate regulations provided in such cases. 
 By this means slow or rapid dissemination 
 is immediately traceable ; if need be, more 
 stringent steps can be taken to stamp it 
 out. From these reports the central Board 
 of Health issues weekly a most important 
 table, giving the number of new cases 
 occurring in the previous week. A copy 
 of this table is sent to the doctors and 
 members of the ten councils. This return 
 is of a complete character ; the numbers 
 attacked in each parish enable the faculty 
 to see the state of each, the immediate 
 contagious disease more or less prevalent,
 
 THE BEGISTIiATION OF DISEASE. 167 
 
 and the exact locality in which any given 
 epidemic has distinctly declared its presence. 
 Should any one form of contagious disease 
 assume a virulent type, the table can be 
 issued daily. 
 
 A system for the registration of so-called 
 "infectious" diseases only, however ex- 
 cellent in its results, is not sufficient. The 
 field of infectious disease, as generally under- 
 stood, is but a small portion of the great 
 field of preventable disease. The nationalisa- 
 tion of hospitals would eventually involve 
 the registration at each institution of every 
 illness and every injury, and the house or 
 workshop in which it occurred. Thus 
 every hospital would be able to show 
 an exact and complete chart of all disease 
 within its district. Such register would 
 not be open to general inspection, ])ut 
 it would be an indispensable guide to 
 the sanitary administration, and as reports
 
 168 NATIONALISATION OF HEALTH. 
 
 would be issued periodically, in the same 
 way as the Vital Statistics (of which these 
 more detailed reports would simply be 
 au extension), it would also be an exact 
 guide in the diagnosis of an innumerable 
 number of social evils. We should possess 
 in it a delicate instrument for ascertaining 
 the relative healthfulness of occupations, as 
 well as of houses, workshops, and streets ; 
 we could trace every source which poisoned 
 the health of the community, and obtain an 
 easy grip on the beginnings of disease. 
 
 There can be no doubt that a thorough 
 system of disease-registration would be a 
 source of increased trouble to various 
 persons, and even of expense. It has, 
 however, been calculated that preventable 
 disease, even in the narrow sense of the 
 word, kills yearly about 125,000 people in 
 this country, and that, considering the large 
 number of cases for every death, 78;^ millions
 
 THE REGISTRATION OF DISEASE. 1C9 
 
 of days of labour are lost annually, which 
 may be said to mean .£7,750,000 per annum, 
 not including the minor ill-health caused 
 by insanitary conditions. However this 
 may be, it is very certain that the expense 
 and trouble of even the most thorough 
 system of registration would form but a 
 small percentage of the saving it w^ould 
 ultimately effect.
 
 XII. 
 
 THE INSPECTION OF INDUSTRIES. 
 
 The inspection of occupations 13 closely related to the organi- 
 sation of health — Yet it is still in a rudimentary condi- 
 tion among us — A Home Secretary on the " source and 
 secret of commercial prosperity'' — The Factory Inspec- 
 tors' Reports — Coal-mining and mineral-mining — Dr. 
 Ogle on comparative mortality — Opinions of the Paris 
 International Workers' Congress — Of the English Trades 
 Union Congress. 
 
 Undee any rationally organised system for 
 the nationalisation of health, the oversight 
 of the conditions under which the workers 
 of all kinds live will receive far more 
 attention than, unfortunately, it receives at 
 present. The Department of the Inspection 
 of Industries must be closely related with 
 the Health Department, if, indeed, it should 
 
 170
 
 THE INSPECTION OF INDUSTIUES: 171 
 
 not be amalgamated with it. It is in tlie 
 interests of the community as a whole that 
 the hospital population should be brought 
 down to the low^est possible minimum; there 
 is no more effective method of securing this 
 result than by ensuring that the workers of 
 the country should carry on their labour 
 under conditions of maximum health and 
 comfort. The inspecting force is thus the 
 auxiliary of the hospitals ; it is our first line 
 of defence against disease ; and economic 
 motives alone, apart from humanitarian 
 considerations, suggest that its efficiency 
 should be raised to the highest possible 
 point. The key to this, as to every other 
 part of the health question, is that preven- 
 tion, from every point of view, is better 
 than cure. 
 
 The inspection of the conditions of health 
 in occupation is still in a very rudimentary 
 condition among us, although even in its
 
 172 NATIONALISATION OF HEALTH. 
 
 present elementary form the advantages it 
 has bestowed are universally recognised to 
 be immense. It has over and over again 
 been pointed out that the powers of the 
 inspectors are too limited,* that their 
 number is so absurdly inadequate that they 
 must sometimes take years to get through 
 a single cycle of their duties, that a vast 
 number of occupations are absolutely free 
 from inspection, and that there are no 
 women inspectors, even for such occupations 
 as dress-making, in which women are exclu- 
 sively employed. 
 
 While, however, these statements are 
 constantly repeated, in official documents 
 as well as in every newspaper, by those who 
 
 '■'■'■ Thus, to take an example whicli comes to my baud at 
 the moment, Mr. Martm, a Chief Inspector of Mines, writes 
 in his Report for 1891 : " I have had much trouble and 
 correspondence with several parties about old mine holes 
 [in Cornwall] ; in one case twenty-six communications passed 
 before I succeeded in getting the work done."
 
 THE INSPECTION OE INDUSTRIES \T6 
 
 are acquainted with the facts, our round- 
 about pohtical methods still enable a Home 
 Secretary to put them aside with a promise 
 for " careful consideration," and the remark 
 that "it would be impracticable and, indeed, 
 mischievous if it w^ere attempted for the 
 Government to undertake the supervision 
 and control of private establishments by 
 Government officials. It would be substi- 
 tuting Government management of indus- 
 trial concerns for that private management 
 which had been the source and secret of 
 commercial prosperity." * Lawyers and 
 members of Parliament are perfectl}^ willing 
 to sacrifice human lives wholesale to gratify 
 their fanciful notions as to " the source and 
 secret of commercial prosperity." Nor are 
 those who take an emotional view of life 
 much more sensitive. The Society for the 
 
 * Mr. Matthews (late Home Secretary), as reported in 
 the Daily Chronicle, May 11, 1892.
 
 174 NATIONALISATION OF HEALTH. 
 
 Preyention of Cruelty to Animals is better 
 sujoported than the Society for the Preven- 
 tion of Cruelty to Children. Criminals, it 
 is well known, frequently combine cruelty to 
 their fellows with extravagant kindness to 
 lower animals. The criminal sentimentalism 
 of our time is aroused to fury by a few expe- 
 riments on rabbits or monkeys, even though 
 carried on under legal control and for a 
 legitimate object ; it bears with tolerable 
 equanimity the reckless and wholesale sac- 
 rifice of human life. 
 
 To realise how great that sacrifice of human 
 life is — to say nothing of the human misery 
 which cannot be measured or recorded — it 
 is sufiicient to glance at Government publi- 
 cations. Thus, if we open almost at random 
 Factory Inspectors' Reports, although these 
 are by no means always so full or so care- 
 fully tabulated as they should be, we find, for 
 instance, that the Leeds inspector, summa-
 
 THE INSPECTION OF INDUSTIilES. 175 
 
 rising his experience, registered 460 fatal 
 accidents, of which 370 might have been 
 avoided, only 90 being unavoidable. In the 
 following year the total had risen to 496, 
 and the proportion of preventable accidents, 
 rising with still greater rapidity, reached 
 450, leaving only 46 to be accounted for 
 by causes beyond control. In Germany, it 
 appears from official reports that the 
 number of workmen killed by accidents 
 every year is about 5,000, and varies little 
 from year to year ; about 35,000 are 
 seriously wounded per year. As M. Yacher 
 has pointed out, this number of killed and 
 wounded is far larger than that at Grave- 
 lotte, one of the most murderous battles of 
 the century. In England, of 527,000 
 persons employed in coal-mining, 100,000 
 are disabled for a longer or shorter period 
 every year, and 1,000 killed; or, to take a 
 single region, there are in the Monmouth
 
 176 NATIONALISATION OF HEALTH. 
 
 and South Wales district, it appears, 28Q 
 non-fatal accidents per thousand miners- 
 employed. Apart from accidents, coal- 
 mining, as judged by the mortality rates, 
 seems to be a rather healthy occupation. 
 Other kinds of mineral-mining are directly 
 injurious to health. In some of our 
 mining towns the stunted and diseased 
 aspect of the passers in the streets some- 
 times suggests a procession of hospital 
 out-patients. If we turn to the tin and 
 copper mines of Cornwall, we find the pro- 
 portion of accidents lower because we have 
 not to reckon with the risks of fire-damp 
 and machinery working at high velocities 
 in long roadways and shafts. But, on the 
 other hand, the mortality from disease is 
 far greater among the Cornish metalliferous 
 miners than among coal-miners, and is 
 double that for Cornish males generally. 
 It has increased rather than decreased of
 
 THE INSPECTION OF INDUSTRIES. 177 
 
 recent years, possibly because mining in 
 Cornwall is a decaying industry, not now 
 employing more than 12,000 men (as 
 against 30,000 in 1873), many of them too 
 young. For nearly fifty years, however, 
 two-thirds of the mortality of Cornish 
 miners has been due to phthisis and other 
 diseases of the respiratory organs, and the 
 mortality from these causes, and in a less 
 degree from other causes, has shown a 
 marked excess over that of coal-miners as 
 well as over that of Cornish males gene- 
 rally. Dr. Ogle * has shown that what he 
 terms the comparative mortality of these 
 diseases in the aggregate, which among 
 fishermen is 198, rises steadily in the 
 various dust-producing occupations to 760 
 among cutlers, 783 among file-makers, 1,118 
 among those engaged in earthenware manu- 
 
 f' Registrar- General's Supplement to the Forty-fifiU 
 Annual Report. 
 
 12
 
 178 NA TIONALISA TION OF HEAL TH. 
 
 facture, and to 1,148 among Cornisli miners. 
 The comparative mortality from diseases of 
 the respiratory organs, apart fi'om phthisis, 
 is from 90 among fishermen to 458 among 
 Cornish miners, rising still higher to 645 
 among earthenware manufacturers. The 
 mortality from the two headings combined 
 is nearly four times as high among Cornish 
 miners as among coal-miners. It is neces- 
 sary to bear in mind this double stress on 
 the workers from these two sets of unsafe 
 conditions and unhealthy conditions. The 
 curious compensation between them — the 
 relatively healthy being unsafe and the 
 relatively safe unhealthy — might be illus- 
 trated in numerous occupational fields. 
 
 Although facts of this order are to a large 
 extent ignored by politicians, too busily 
 occupied with the academic discussion of 
 *' Coercion," " Home Eule," and other more 
 or less admirable panaceas, they have by
 
 THE INSPECTION OF INDUSTRIES. 179 
 
 no means escaped the attention of working- 
 class Parliaments. It is sufficient to refer to 
 the wise decisions formulated by two recent 
 congresses of workers, one national, the 
 other international. 
 
 In 1889 an International Workers' Con- 
 gress, the largest and most representative 
 that has ever been brought together, was 
 held in Paris. It was organised by the 
 Possibilists, who form a considerable sec- 
 tion of the Municipal Council of Paris. 
 There were 613 delegates present, repre- 
 senting fourteen countries — France, Eng- 
 land, Belgium, Austria, Hungary, the 
 United States, Denmark, Portugal, Italy, 
 Holland, &c. This influential Congress 
 gave much attention to questions of health. 
 They unanimously passed a resolution 
 fixing the day's work at ten hours as 
 a maximum, to be enforced by an inter- 
 national law ; an amendment proposing
 
 180 NATIONALISATION OF HEALTH. 
 
 an eight hours' day was lost by a small 
 majority. They proposed to prohibit the 
 work of children under fourteen, and restrict 
 that of young persons between the ages of 
 fourteen and eighteen. They insisted on 
 the importance of due inspection, and of 
 working-men inspectors. It was also re- 
 commended that home-work should be 
 abolished, or else that homes in which it 
 was carried on should be registered and 
 brought under inspection. The Congress 
 declared that the same price should be paid 
 to both men and women for the same work. 
 Such were a few resolutions of this Con- 
 gress, bearing directly or indirectly on the 
 nationalisation and internationalisation of 
 health. At the English Trade Union Con- 
 gress, held in the following year, sanitary 
 questions also occupied much of the dele- 
 gates' time and attention. Thus there was 
 a discussion of the composition of coroners'
 
 THE INSPECTION OF INDUSTIilES. 181 
 
 juries in cases of death from accident. It 
 was pointed out that a jury of tradesmen 
 were not competent to decide concerning 
 the cause of an accident in a coal mine, and 
 a resokition was passed demanding that 
 steps should be taken to enable men of the 
 same trade as the deceased to sit on the jury. 
 The question of inspection was discussed on 
 several occasions. It was pointed out that, 
 while Corporations sometimes passed excel- 
 lent by-laws for the protection of workers 
 fi'om disease, there were no efficient bodies of 
 inspectors to see them carried out, and that 
 the workmen engaged did not dare to relate 
 what they knew. The insufficient number 
 of factory inspectors was a subject of very 
 general complaint. Many delegates bore 
 witness to the constant infringement of the 
 Factory Act, and to the frequency with 
 which women were made to work overtime.* 
 
 - Thus Mrs. Skelley, of the Liverpool Tailoresses' Union,
 
 182 NATIONALISATION OF HEALTH. 
 
 Kesolutions were passed demanding the 
 abolition of fines in factories, the increase 
 of factory inspectors, and the nomination 
 of women inspectors, as well as of men who 
 had a practical knowledge of the '^ tricks of 
 the trade." It was also argued that there is 
 
 declared that members of lier trade were unanimoiis in de- 
 mauding the appointment of more inspectors, and these in 
 some cases should be women. The workwomen would be 
 able to speak more easily to a woman inspector, especially if 
 their complaints related to sanitary matters. She had found 
 very often that when the inspector was about to visit a tailor's 
 workshop the women were sent to other parts of the house, 
 and were thus never seen by the inspector. In many shops, 
 though the women were supposed to be allowed an hour for 
 dinner, either at twelve or one o'clock, they were often kept 
 by stress of work till four and five o'clock. This irregularity 
 in the meal hour, coupled with excessive work in unwhole- 
 some, overcrowded worksliops, contributed gi'eatly to ruin 
 the health of tailoresses. Not only are the wages insufficient, 
 but numerous fines are inflicted which greatly reduce the 
 earnings, esj)ecially of female workers. In some workshops 
 women are charged Id. per week for a peg to hang their hats 
 and cloaks upon. Other employers charge Id. for the lava- 
 tories, some 3d. a week for washing the floor of the work- 
 shop, yet the women have to do the scrubbing themselves • 
 the money they pay is supposed to be spent in buying soap 
 and brushes.
 
 THE INSPECTION OF INDUSTEIES. 183 
 
 as much need to control workshops as puhlic- 
 houses and theatres, and a resokition was 
 carried demanding that notice of intention 
 to open a workshop shouhl be served on the 
 local authority, and that a duly qualified 
 inspector sliould visit it to see whether it 
 is properly lighted and decent accommoda- 
 tion provided, and that in all cases not less 
 than COO cubic feet of space should be pro- 
 vided for each person employed. Many 
 other resolutions were passed dealing with 
 questions of health, sometimes possibly of 
 an impracticable character, but on the 
 whole showing wisdom and common sense, 
 and coinciding closely with the opinions of 
 medical health experts.* 
 
 ■■'■ It may be as well to point out that employers and 
 employed are too often, on both sides, equally ignorant and 
 reckless where the conditions of health are concerned. Dr. 
 Stanwell, a factory surgeon at liochdale (writing in the 
 Lancet, March 14, 1891), says : " In the mouth of July, 1881, 
 I was obliged to write to H.M. inspector in a case where an 
 employer defied my refusal, and insisted on working a boy
 
 184 NATIONALISATION OF HEALTH. 
 
 It appears from the evidence given before 
 the Labour Commission that in certain 
 occupations, " coffin money," as it is called, 
 is deducted from the men's wages. Every 
 man pays a half-penny a week towards his 
 own coffin. This is a merciful provision, 
 and might be introduced into many employ- 
 ments, though the amount per week should 
 be much larger. I wish now to call special 
 attention to one such group of coffin in- 
 dustries. 
 
 witli heart disease and serious eye disease, for which I am 
 happy to say he was fined. On another occasion a bad case 
 of heart disease and chorea, or St. Vitus's dance, was refused, 
 and very soon ended fatally. On one occasion I have been 
 threatened with legal proceedings by the father of a girl wlio 
 had an epileptic fit in the mill office, while I was there for 
 purposes of certifying ; on another, in the case of a boy, totally 
 unfit for factory employment, who had been three times pre- 
 sented to me for certificate, in the hope he might pass by a 
 *' fluke " ; in another case the parents offered to indemnify 
 the employer against consequences if accident or death from 
 machinery should ensue to a girl suffering from deaf-mutism 
 and debility." In Lancashire and Yorkshire alone nearly 
 140,000 half-time children are employed.
 
 XIII. 
 
 WORKERS IN LEAD. 
 
 Sketch of the history of lead-poisoning — The various 
 occupations affected — White lead manufacture — The 
 "Dutch" process — Symptoms of lead-poisoning — Lead- 
 poisoning in women — " White lead ghosts" — Remedies 
 proposed. 
 
 I SHALL never forget an impression I re- 
 ceived as a child when on a voyage out to 
 Australia. The ship's carpenter lay sick 
 in his berth for long w^eeks, and whenever 
 I chanced to pass by the deck-house I 
 heard the groans of the man tossing in his 
 bunk. When we got into harbour the 
 sallow, shrunken creature was lowered into 
 a boat and taken to the hospital to die. 
 For years after that ship's carpenter re- 
 
 185
 
 18G NATIONALISATION OF HEALTH. 
 
 mainecl fixed on my young mind as the 
 supreme embodiment of human misery. It 
 was the first case of lead-poisoning I had 
 seen; I have seen many since. 
 
 Lead-poisoning is not a new disease or a 
 modern discovery, although sometimes (as 
 at Poitou, in the sixteenth century, through 
 poisoned wine) it has been endemic for nearly 
 a century without being recognised. Galen 
 knew that if water passed tiirough leaden 
 pipes it might cause a kind of dysentery in 
 those who drank it. Nicander, who lived a 
 century before the Christian era, had an 
 accurate knowledge of the symptoms of 
 lead-poisoning ; and Yitruvius, the Eoman 
 architect of the time of Augustus, would 
 not allow the use of lead for the purpose of 
 conducting water. It may be said, indeed, 
 on the whole, that the ancients were far 
 more careful in the use of lead than we 
 have been during the present century, in
 
 WOBKEIiS IN LEAD. 187 
 
 which lead has been iutroducecl for a vast 
 number of piu'poses with terrible results. 
 
 In the form of ore lead produces plumbism 
 (or lead-poisoning) among miners by means 
 of dust, and among smelters by means of 
 vapour, as well as among the makers of 
 oxide of lead during the process of cal- 
 cination. In many occupations there is 
 much dust and leading of the hands and 
 clothes ; thus file-cutters bed the files in 
 lead when nicking them; leather-cutters cut 
 upon leaden slabs, and sometimes in electric 
 light works the plates are, it seems, bedded 
 in red lead, a practice which leads to much 
 lead-poisoning wherever it is adopted. 
 Those who roll sheet lead, the makers of 
 leaden pipes and utensils, of shot and of 
 lead-foil, weavers employed at Jacquard 
 looms furnished with leaden weights, 
 plumbers, and workers in letter-type foun- 
 dries, are all liable to suffer from plumbism.
 
 188 NATIONALISATION OF HEALTH. 
 
 In the form of alloy lead proves dangerous 
 to pewterers, the makers of soft metallic 
 capsules and of inferior German silver or 
 pinchbeck. Potters (or rather dippers) 
 have always suffered greatly from plumbism, 
 as is shown by passages in old authors ; the 
 pots are dipped into a solution containing 
 lead, in order to give the glaze to the ware. 
 The makers of enamels or glazing materials 
 also suffer, and among japanners plumbism 
 is very common ; the japanned articles are 
 brushed by women with colours that often 
 contain lead, and in the brushing much 
 dust is produced. Plumbism is also found 
 among makers of floor-cloth and linoleum, 
 lapidaries and cameo-makers, brush-makers, 
 who employ it to colour the hair or bristles, 
 picture-frame makers, who sometimes form 
 the raised pattern with a sort of cement or 
 putty of which lead forms an ingredient ; 
 also among those who are engaged in the
 
 WOEKEIiS IN LEAD. 189 
 
 operatious of whitening Brussels lace, of 
 colouring and weighting sewing threads and 
 woven tissues, in the colouring of vulcanised 
 india-rubber, used for feeding-bottles, and in 
 gumming bands on to cardboard boxes. 
 Lead, even in its more insoluble forms, will 
 produce symptoms of poisoning, if taken 
 into the system during a prolonged period ; 
 it is, however, the acetate, the oxide, and 
 the carbonate which produce most disastrous 
 results. It is in the form of the carbonate 
 (or white lead) in the process of manufac- 
 ture and among house-painters, as well as 
 among colour-makers and mixers, that lead 
 produces some of its most terrible and most 
 common results. 
 
 White lead manufacture is a large in- 
 dustry. Over 60,000 tons are manufactured 
 annually in Great Britain, and it is also 
 imported in considerable quantities from 
 Germany. It is used largely by shipping
 
 190 NATIONALISATION OF HEALTH. 
 
 companies for boats, deck, and cabin work, 
 or wherever a white coating is required. 
 Eailway companies use it for stations, 
 signals, waggons, carriages, palings, &c. 
 The London and North- Western Company, 
 for instance, invite tenders annually for 
 from five to six hundred tons, while the 
 Admiralty require seven hundred tons. 
 Besides its use as a white coating, it forms 
 the body in nearly every coloured paint. 
 
 In our own country nearly all this white 
 lead is produced by one method, the so- 
 called "Dutch" or "dry" process, which 
 was introduced about the year 1780. As 
 many as eight hundred patents for new 
 processes have, it seems, been taken out 
 during the last fifty years, but the old 
 Dutch method still appears to maintain its 
 place. It is a simple process, but slow, 
 costly, and extremely dangerous to the 
 health of those employed. The chief
 
 WOIiKEBS IN LEAD. 191 
 
 centres of the manufacture are at Newcastle, 
 Glasgow, and London, and it may be briefly 
 described thus * : — Thin sheets of lead are 
 placed upon the top of small earthenware 
 pots, which contain strong acetic acid ; the 
 pots are arranged side by side in ordinary tan, 
 and covered with planks ; another layer of 
 pots similarly arranged in tan is placed over 
 these, and over these again another, and 
 thus a " stack " is formed of alternations of 
 planks and layers of pots. This is known 
 as the " blue beds," and is of itself not 
 dangerous. The acetic acid slowly volati- 
 lises by the heat induced through fermenta- 
 tion of the tan, and the lead is converted 
 into a subacetate, and subsequently into a 
 carbonate. When the conversion has 
 become complete, girls enter the stack — 
 now known as " white beds " — and remove 
 
 'f' I chiefly follow here the account of the process given by 
 Prof. Oliver.
 
 192 NATIONALISATION OF HEALTH. 
 
 the layers of carbonate of lead, carrying it 
 in little trays on their heads, first to the 
 rolling mills, where the white is separated 
 h-orn the metallic lead, and subsequently it 
 is taken to the stoves — a chamber not unlike 
 a dairy, shelved all round for the trays to 
 rest upon, and always at a high temperature, 
 seldom less than 190° F. It usually takes 
 about fourteen weeks for the lead in a stack 
 to be completely converted into lead car- 
 bonate or white lead. If the girls are 
 allowed to enter the stack too soon — that is, 
 before the lead acetate is fully converted 
 into lead carbonate — they suffer very readily 
 and severely from colic. The readiness 
 with which girls suffer in the white beds is 
 regarded by observant overseers as an indica- 
 tion of the incompleteness of the lead ace- 
 tate. The " white beds " and the " stoves " 
 are probably the most dangerous parts of 
 the lead making, and nothing injures a girl
 
 WOBKEES IN LEAD. 193 
 
 more than a few weeks of work in this part 
 of the process. After being thoroughly 
 dried the lead is ground and w^orked, then 
 reduced to a fine powder. In this form it is 
 packed in casks ; this operation is also 
 attended by a certain amount of danger. 
 
 It is among the workers in these white 
 lead factories that acute cases of lead- 
 poisoning most fi'equently occur ; it has 
 been carefully studied by Dr. Thomas 
 Ohver at Newcastle, the headquarters of 
 the manufacture. One of the earliest 
 symptoms is a rapidly increasing anaemia ; 
 this is followed by colic, headache, vomit- 
 ing, and defective or double vision. In a 
 few days the patient may become convulsed, 
 comatose, and die. The illness may be so 
 rapid that no alteration can be found in the 
 organs, beyond a watery condition of the 
 brain. Lead-poisoning is much more fi'e- 
 quently chronic, and in the chronic form its 
 
 18
 
 194 NATIONALISATION OF HEALTH. 
 
 disastrous results, although more various 
 and prolonged, are scarcely less serious. 
 Dr. Oliver * considers that, while it is 
 difficult to say how plumhism in men and 
 animals is brought about, it affects primarily 
 the organs of elimination, such as the liver 
 and the kidneys, and that whatever conse- 
 quences follow are due to the presence in 
 the blood of secondary poisons, arising out 
 of the imperfection of liver and kidney 
 functions. One of the peculiarities of this 
 terrible and insidious poison lies in the fact, 
 which makes it specially dangerous to 
 workers using lead, that its introduction 
 into the human system in very minute 
 quantities over a lengthened period is 
 followed by more serious and persistent 
 symptoms than when it is taken in larger 
 quantities for a shorter period. The symp- 
 
 "■' Goulstonian Lectures on Lead-poisoning, delivered at 
 the Royal College of Physicians of London, 1891.
 
 won Kims IN LEAD. 195 
 
 toms may be so variable, insidious, and 
 remote, that medical men sometimes fail to 
 trace the patient's disease to its source, and 
 it has even been said that the medical 
 author of a book on lead-poisoning himself 
 suffered from the malady without kno^Ying 
 the cause of his illness. In estimating the 
 mischief wrought by lead on the workers we 
 must, as Dr. Oliver points out, consider not 
 only its direct mortality, but also the num- 
 ber of deaths due to diseases of organs that 
 are known to suffer in lead-poisoning, such 
 as the kidneys and nervous system. The 
 high death-rate among plumbers, painters, 
 and glaziers is largely due to the direct 
 inlluence of lead-poisoning, but associated 
 with this there is an extremely high mor- 
 tality from diseases of the kidneys and ner- 
 vous system, indirectly due to the same 
 cause. Among file-makers also, who, as has 
 already been mentioned, suffer much from
 
 190 NATIONALISATION OF HEALTH. 
 
 lead-poisoning, there is a high death-rate 
 from diseases of the kidneys, nervous sys- 
 tem, and circulatory organs. 
 
 It is very easy to bring forward examples 
 of the subtle and remote action of this wide- 
 spread poison. An inquest was recently 
 held on a woman who had been engaged in 
 a white lead factory on the Tyne ; and a 
 verdict of poisoning from lead was recorded; 
 it was shown that she had left off the work 
 for tw^o years and a half. Cases of paralysis, 
 at first put down to other causes, have been 
 found to be due to the use of hair-dyes con- 
 taining lead. Even sleeping in a house in 
 which rooms remote from the sleeping 
 chamber have been recently painted has 
 caused undoubted symptoms of plumbism. 
 In France women have suffered from the 
 same cause simply through washing the 
 clothes of their husbands wdio were workers 
 in lead factories.
 
 WOBKEBS IN LEAD. 197 
 
 The same influence extends to animals. 
 The fumes that arise from the smelting of 
 lead cause lead-poisoning in the cattle 
 grazing in the neighbourhood. In some of 
 the dales of Durham the animals thus 
 affected are said to be " bellond," an old 
 term connected with the French heUon. 
 This poisoning has sometimes been of a 
 wholesale character, the animals dying with 
 symptoms of pain in the abdomen, and con- 
 stipation. Dogs which have slept on the 
 coats of their masters who were lead smel- 
 ters have also become '' bellond." Birds 
 that have eaten the berries of mountain 
 ashes near forges in Germany have fallen 
 either dead or paralysed at the foot of the 
 trees. The stags who roam about the 
 country near these same forges show dis- 
 eased or stunted antlers, and their repro- 
 ductive organs, like those of men, are also 
 affected by the poison.
 
 198 NATIONALISATION OF HEALTH. 
 
 This influence of lead on the reproductive 
 organs is of some importance. Lead strikes 
 early at the sexual functions, producing 
 sterility, liability to abortion, and many 
 other disorders peculiar to women. Now, 
 women, as Dr. Oliver has shown, are pecu- 
 liarly sensitive to the action of lead ; they 
 suffer at an earlier age ; they are more 
 likely to suffer severely ; and they are more 
 liable to serious nervous complications, as 
 epilepsy ; also in epidemics of lead-poison- 
 ing, due to the contamination of drinking 
 water by passing through lead pipes, women 
 are affected in larger proportions than men. 
 And many of the industries in which lead is 
 employed are very largely in the hands of 
 women. That portion of humanity which 
 is most vulnerable to the attack of this 
 strange and terrible enemy is set in the 
 front of the battle. Women are largely 
 engaged in the most dangerous departments
 
 WOBKEliS IN LEAD. 199 
 
 of white lead factories — the " white beds " 
 and the " stoves " — and the result of even 
 a few weeks' work on a girl here are often 
 most disastrous. The enamelling industry, 
 again, is largely in the hands of women; and 
 a surgeon at Bilston recently stated at the 
 inquest on a girl-enameller of seventeen who 
 died from lead-poisoning, that he " did not 
 know a woman who worked at the trade wdio 
 did not suffer more or less from lead-poison- 
 ing. He had attended a large number of 
 such cases." * As to the precise effect 
 which lead produces on the nervous systems 
 of women, perhaps no more graphic picture 
 could be presented than that given by Mr. 
 Bevan Lewis, the superintendent of the 
 West Kiding Lunatic Asylum. He is 
 referring to the frequency of the insanity of 
 adolescence among the poorer classes : 
 
 ^' British Medical Jo7irnal, April 9, 1892.
 
 200 NATIONALISATION OF HEALTH. 
 
 *' One of the most glaring instances is pre- 
 sented by certain white lead manufactories, 
 where young women are occasionally em- 
 ployed at an early age. They are con- 
 tinuously exposed during their employ- 
 ment to the direct contact of the metal 
 with the skin, and to the acid fumes 
 arising from the stacJcs. Their work is 
 laborious, irksome, devoid of interest, and 
 most prejudicial to health. The metal 
 is rapidly absorbed, and produces profound 
 changes in the constitution of the blood ; 
 extreme anaemia results, nutrition is gener- 
 ally impaired, and the menstrual discharge, 
 if not present, is checked and suppressed 
 indefinitely ; or, if it has appeared, it be- 
 comes irregular, and soon absent. Lead 
 colic is frequent ; yet the i)oor sufferers per- 
 sist in their insanitary occupation. Their 
 pallid faces, immature growth, and arrest of 
 the usual indications of budding woman-
 
 WORKEES IN LEAD. 201 
 
 hood, t^Jiin for them in then- neighbourhood 
 the sobriquet of the ' white lead ghosts.' 
 Employment here at an early age before 
 puberty is established, always results in its 
 arrested development, and in indications of 
 serious malnutrition of the nervous centres. 
 Hysteric attacks are frequent ; the natural 
 w^omanly instincts are not aroused, or are 
 replaced by morbid sentiments, unnatural 
 desires, and vicious habits. In place of the 
 expansion of the higher emotional nature 
 which befits her for the duties of womanhood, 
 and which renders her an object of respect 
 and regard upon the part of the other sex, 
 she remains a girl with childish sympathies 
 up to mature years ; or sexual instincts 
 awakened into partial life, uncontrolled by 
 higher emotional developments, render her 
 an object of aversion to others. Nervous 
 derangements are peculiarly frequent ; cho- 
 rea, epiliptiform seizures, cataleptic states
 
 •202 NATIONALISATION OF HEALTH. 
 
 or actual insanity may develop." * Such is 
 the price we pay for white paint. 
 
 I have but faintly outlined a few aspects 
 of the lead industries as they exist in Eng- 
 land to-day to poison the lives of so many 
 men and women, but even this slight 
 sketch seems enough to show that it is the 
 duty of the community — to whom, after all, 
 these " white lead ghosts " belong — to exer- 
 cise in regard to these industries a severe 
 organisation and oversight. Wherever 
 "individual initiative and independence" 
 is but a fine euphemism for the ruin of 
 human lives as cheaply as possible, and as 
 young as possible, there should be a certain 
 amount of check to individual liberty and 
 initiative. 
 
 It is probable that many of the most 
 dangerous processes could either be im- 
 
 <■■ Bevan Lewis, " Text-book of Meutal Diseases," 1889 ; 
 p. 350.
 
 WORKERS IN LEAD. 203 
 
 proved by the substitution of some other 
 substance, or aboHshed. Considering the 
 great danger of these industries, this is a 
 question in which the community is clearly 
 entitled to a voice. Where lead must still 
 be regarded as essential, the control of ex- 
 perts might ensure the adoption of slight 
 modifications in the process or the aj)pa- 
 ratus, leading to a great gain of health and 
 life ; this has already been done in part with 
 very beneficial result ; thus the introduction 
 a few years ago of a hood in front of the 
 smelting furnace, thus sending the fumes up 
 the chimney, has had a good effect on the 
 health of the smelters, although they are 
 still affected to some extent. There should 
 certainly be a very rigid medical control of 
 the workers in lead industries, more especi- 
 ally in the case of women, who are especi- 
 ally sensitive to the poison. There should 
 be a period of probation ; some persons are
 
 204 NA TIONALISA TION OF HE A L TH. 
 
 far more susceptible than others ; the sus- 
 ceptible should be eliminated at the outset. 
 It is vain to tell a man who has learnt his 
 trade that he cannot continue his work with 
 impunity ; it is too late for him to go and 
 learn a new trade ; he prefers, usually with- 
 out hesitation, to accept all the dangers of 
 his own trade. The age at which a youth 
 or girl may be permitted to enter the lead 
 industries should certainly be high, for it is 
 about puberty thfit its effects are often 
 most disastrous, and at this early age there 
 is great recklessness in regard to the neces- 
 sary precautions. At present, unfortunately, 
 there is a tendency to the employment of 
 very young girls at the white lead factories, 
 and as enamellers, &c. ; and in the Stafford 
 pottery industries the majority of the 
 dippers employed by some prominent manu- 
 facturers are mere lads. The strict use of 
 precautions will still be necessary. At
 
 WOIiKERS IN LEAD. 205 
 
 present it is very difficult to ensure the 
 observance of these. The workers are 
 young, ignorant, reckless, often drawn from 
 the lowest class and brought up with no 
 traditions of personal cleanliness. Dr. 
 Malet, the Medical Officer of Health for 
 Wolverhampton, writes, for instance, with 
 reference to the japanners : '' The handker- 
 chief over the mouth is a perfect farce, the 
 women seldom or never wearing it." Even 
 when the prescribed precautions — such as 
 washing the hands before meals and the use 
 of sulphuric acid lemonade — are observed, 
 it is not unconnnon to find plumbism still 
 occurring in an individual who is suscep- 
 tible. Intemperance and the use of alcohol 
 fi'equently determine the appearance of an 
 attack of plumbism ; on the other hand, 
 wholesome food is to some extent protec- 
 tive ; it is said that a free breakfast has 
 materially diminished the cases of poisoning
 
 206 NATIONALISATION OF HEALTH. 
 
 in some of the white lead works. All these 
 preventive measures require investigation, 
 and strict enforcement where necessary. 
 
 I have dealt briefly with one group of 
 dangerous industries. It is but a specimen 
 of the groups which might be brought for- 
 ward. In our love of independent indi- 
 vidual initiative, and in our anxiety to 
 ensure to the employer the right to poison, 
 and to the worker the right to be poisoned, 
 we cheerfully build hospitals for the victims 
 of these lead industries to die in, or to be 
 patched up in a sufficiently sound way to 
 stand further poisoning ; and we establish 
 asylums for those who are hopelessly 
 ruined. But would it not be more reason- 
 able, more humane, and also more econo- 
 mical, to begin at the beginning by orga- 
 nising and overseeing these dangerous 
 industries ?
 
 XIV. 
 
 THE LAISSER-FAIRE SYSTEM. 
 
 The picture of disease and misery presented by Russia — 
 Birth-rate and death-rate — In famine time — Ordinary 
 conditions of insanitation — Russian factories — The 
 cholera epidemic — The lesson of Russia. 
 
 Theee are many persons even to-day who 
 are somewhat sceptical as to the desirabiHty 
 of organising the conditions of liealth. It 
 is an advantage to be able to present a 
 picture of the state of things under what is 
 practically a laisser-faire system with regard 
 to the preservation of public health. We 
 have such a picture in Russia. Russia 
 possesses elaborate statistics as to the 
 state of public health, and is beginning to 
 adopt various energetic measures for its 
 
 207
 
 208 NATIONALISATION OF HEALTH. 
 
 preservation. At present, however, these 
 measures are in an early stage, and the 
 Bussian statistics reveal to us an awful 
 picture of misery, disease, and death on 
 a gigantic scale. 
 
 There is but one doctor in Eussia to 
 every 12,000 inhabitants, and, as is usually 
 the case, owing to the concentration of the 
 profession in towns, the proportion for the 
 country districts is still lower. The people, 
 we are told, place great confidence in their 
 own quacks and witch-doctors. The latter 
 employ spells and herbs, with occasional 
 orthodox remedies, such as mercury in 
 syphilis. The witches also supply the 
 population with poisons to put in each 
 other's gruel. In these circumstances the 
 figures yielded by statistics as to the pre- 
 valence of disease must be very much below 
 the actual facts. Still they are sufficiently 
 remarkable. In one year (1886), nearly
 
 THE LAISSEIi-FAIIiE SYSTEM. 209 
 
 88,000 persons are set down as lia\"ing 
 been treated for small-pox, and nearly 
 17,000 as having died ; 97.000 persons 
 were treated for scarlet fever, and 18,000 
 died ; nearly 84,000 for diphtheria, of whom 
 30,000 died ; 132,000 for measles, of whom 
 12,000 died. And so on with other related 
 diseases. The prevalence of typhus is espe- 
 cially noteworthy, because it is the disease 
 of filth, overcrowding, and starvation ; it is 
 now rarely met with in this country, hut in 
 Eussia 252,000 are set down as treated for 
 this disease in one year, and 15,000 died ; in 
 previous years the mortality has been much 
 higher ; in 1881 the number of cases quad- 
 rupled, and during some months the mor- 
 tality rose as high as 50 per cent. Scarlet 
 fever has become more prevalent and more 
 fatal ; in the government of Elizavetpol 
 there was a mortality of 66*7 per cent. It 
 need scarcely be added that there are no 
 
 14
 
 •2 10 NA TIONALISA TION OF HEAL TH. 
 
 methods of checking the dissemination of 
 these diseases. The clothes of infected 
 persons are not subjected to any process 
 of disinfection, even in the majority of 
 hospitals. We find, indeed, one attempt 
 to check the spread of disease : it is pro- 
 hibited in one diocese to administer the 
 sacrament \Yith the same spoon to the sick 
 and healthy ! Typhoid fever in 1886 was 
 present in every government in Eussia, 
 except Tiflis and Erivan, and it has been 
 on the increase, though the mortality has 
 decreased. The chief causes of its pre- 
 valence are considered to be the pollution 
 of the soil, and the throwing of sewage into 
 the rivers. Filth is often heaped up on the 
 banks of the rivers, or remains for months in 
 the courtyards of the houses. Insufficient 
 and improper food is responsible for a large 
 amount of disease. There were 105,000 
 cases of dysentery, with a mortality in
 
 THE LAISSEB-FAIEE SYSTEM. 211 
 
 Erivan of 44 per cent., and the disease, 
 which attacks children chiefly, in summer 
 and autumn, is largely traced to the con- 
 sumption of unripe fruit and vegetables, 
 and the drinking of impure water. There 
 is an extraordinary prevalence of blindness. 
 According to the statistics in the census of 
 1886 in fifty governments of Eussia there 
 w^ere 21 blind persons to 10,000 inhabitants, 
 or almost five times more than in Holland, 
 four times more than in Austria and the 
 United States, and three times more than 
 in Saxony, Denmark, and Switzerland. 
 There is a vast infant mortality among 
 the working population, due largely to the 
 scanty use of milk, and to every imaginable 
 sin against the laws of dietetics ; infants at 
 the breast, also, are often attacked hj a dis- 
 order of digestion to which the people have 
 given the descriptive name of grijz (gnaw- 
 ing). Out of 1,000 deaths, the proportion
 
 212 NATIONALISATION OF HEALTH. 
 
 of infants under one year is 113 in Norway, 
 190 in England, 216 in France, and no less 
 than 313 in Eussia. In some of the pro- 
 vinces of Eussia 60 and even 67 per cent, 
 of the children die during the first five years 
 of life. Serebrenikoff has given interesting 
 details concerning Irbit, a town in the 
 government of Perm, distinguished for its 
 absolute neglect of sanitary considera- 
 tions ; the mortality of children in the first 
 year of life here reaches 44*9 per cent. ; and 
 children under five years of age constitute 
 half of the total mortality, though this is so 
 large that it considerably exceeds the births. 
 And this mortality is ever present in the 
 town ; it is not the chance of a single year. 
 Of 1,568,315 boys born in Eussia in the 
 year 1858, only 750,622 were alive in 1879, 
 and when out of this number 272,974 were ex- 
 amined for the purpose of military conscrip- 
 tion, 58,824 men — i.e., 21*5 per cent. — were
 
 THE LAISSER-FAIIiE SYSTEM. 213 
 
 found to be suffering from various incurable 
 or chronic diseases, and had consequently 
 to be returned as unfit for military service. 
 So that of all boys born in 1858, 47*8 per 
 cent, reached their twenty-first year, but 
 only 37*6 per cent, preserved good health. 
 The birth-rate is higher in Russia than in 
 any other part of Europe, but the death- 
 rate is also higher than elsewhere, and 
 sometimes even exceeds the birth-rate, 
 while the significant fact must be noted 
 that it is often even larger in the country 
 than in the town. Dr. N. Leinenberg, of 
 Odessa, from whom some of the facts I have 
 quoted are taken, presents an awful picture 
 of the mortality of Russia.* The excessive 
 mortality in Russia forms, also, the subject 
 of an interesting monograph by N. Ekk. 
 According to this authority, in Russia there 
 
 ■■' Die Sterblicbkeit ia Russland, Internationale Elinische 
 Rundschau, Sept., 1889.
 
 214 NATIONALISATION OF HEALTH. 
 
 die every year per thousand 9 individuals 
 more than among the same number of Ger- 
 mans, 12 more as compared with France, 15 
 with England, 18 with Sweden and Denmark, 
 and 19 more compared with Norway. An 
 excess mortality of 15 means a loss of 
 1,650,000 lives to the State in one year. 
 And this is mainly due to neglect of the 
 most elementary sanitary precautions. 
 
 During a period of famine, such as 
 occurred in 1891-92, it is needless to say 
 that the picture of filth, disease, and death 
 presented by Kussia becomes even far more 
 terrible. During the famine in question an 
 epidemic of malignant scurvy made its 
 appearance simultaneously in many of the 
 famine-stricken regions. It attacked most 
 severely adult women, especially those 
 already suffering from syphilis or other 
 chronic disease, while upwards of 50 per 
 cent, of the patients seeking medical aid
 
 TEE LAISSER-FAIBE SYSTEM. 215 
 
 presented milder scorbutic symptoms. At 
 the same time all the other infectious 
 diseases, so prevalent in Russia, became 
 aggravated in extent and in intensity. The 
 hospitals overflowed with infectious cases, 
 especially typhus ; accommodation and 
 medical aid were alike inadequate ; and 
 the doctors, overworked and themselves 
 often suffering from poverty, died of the 
 same diseases as their patients.* 
 
 Even in the two chief cities of the 
 Empire, and in the houses of the well-to-do 
 classes the simplest hygienic principles are 
 systematically disregarded. Everywhere in 
 Russian towns filth and rubbish are piled 
 up to cause by their organic decomposition 
 the pollution of air, soil, and water. Scores 
 of regulations are made at St. Petersburg 
 concerning dwellings, shops, markets, 
 
 * " Famine anil Disease in Eussia," British Medical 
 Journal, May 7, 1892.
 
 216 NATIONALISATION OF HEALTH. 
 
 streets, &c., but no one carries them out 
 unless compelled to do so. " The shop- 
 keeper is kept in awe by unexpected and 
 rapidly executed raids on his establishment. 
 Protocols, processes, and fines follow. The 
 most obvious result of the system is that no 
 one cleans his back staircase, his court- 
 yard, or shop, or gives up selling all kinds 
 of adulterated foods, of which margarine is 
 the least offensive, till compelled so to do 
 by a visit of the police or a citation before 
 a court. The po^Dulation generally presents 
 a massive inertia, and never itself shows 
 any sanitary enterprise. From every 
 government we find reports of the pollu- 
 tion of the water-supply due to the dirty 
 and ignorant habits of the people or the 
 economy of manufacturers in getting rid of 
 their waste products. Even in St. Peters- 
 burg there exist to this day no drains, the 
 sewage being removed in open carts. A
 
 THE LAISSER-FAIRE SYSTEM. 217 
 
 town filter has just been completed, thirty 
 3' ears after the installation of water pipes. 
 The Town Conncil — a representative body, 
 be it observed, here as elsewhere — were 
 found till lately in opposition. Even one 
 of the chief analysts pooh-poohed the filter 
 because it only removed fish, molluscs, 
 weeds, &c. At the metal gauze which forms 
 the first filter there might be established a 
 flourishing biological station to study the 
 flora and fauna of the icy bottom of the 
 Neva. An inspection of various educa- 
 tional establishments and manufactories 
 (especially those called 'kustaruij, of the 
 character of village or domestic industries) 
 has revealed the total inadequacy or 
 absence of hygienic requirements. The 
 same story comes from the prisons, in spite 
 of their decenniad of reformed existence. 
 The recent report of the Commission of 
 Inquiry into the working of the Kursk-
 
 218 NATIONALISATION OF HEALTH. 
 
 Kharkov-Azov Eailway, on which line the 
 Borki accident occurred a year ago, has 
 revealed horrors of insanitation almost 
 beyond belief. In the case of convict 
 parties on the march to their destination 
 in Siberia or to the Amm*, the details 
 published by Kenyon and Frost in the 
 Centurij magazine are only corroborated 
 by other observers. But, it must be re- 
 membered, quite similar sufferings are 
 undergone by the i)ereselentsy, or bands of 
 peasants migrating from European Eussia 
 to their new homes. They often carry 
 typhus with them, and communicate it to 
 the villai?es which harbour them on the 
 road. And these ill-planned wanderings 
 constantly end only in the return of the 
 ruined and hunofer-stricken bands to their 
 
 "O' 
 
 original abodes. To combat all these evils, 
 the central and local authorities have 
 hitherto done joractically nothing." * 
 
 * " The Health of Bussia," Lawce^, January 11 and 18, 1890.
 
 THE LAISSEB-FAIEE SYSTEM. 219 
 
 At the International Congress of Hygiene, 
 held at Paris in 1889, Madame Thatcheff 
 read a very interesting and carefull}^ pre- 
 pared paper on the Condition of the AVork- 
 ing Classes in Eiissia, which produced a 
 deep impression on the Congress. Irre- 
 spective of Siberia and Poland, she said 
 there were about 932,000 operatives em- 
 ployed in the mills and factories of Eussia. 
 The way a considerable proportion of these 
 workers were recruited had a great influence 
 on public health. Many of them were agri- 
 culturists, who, being unable to earn enough 
 to live, came to the industrial centres and 
 worked in factories from September to 
 February. They had no homes in those 
 industrial centres, but slept very often in 
 the factory itself, in the midst of the 
 machinery, or in a sort of dormitory pro- 
 vided for them just above the works, and 
 separated h'om the works only by a rude
 
 220 NATIONALISATION OF HEALTH. 
 
 wooden floor, through which all the bad 
 odours passed. Here the workers lay down 
 on wooden shelves. They slept in their 
 clothes, and at best had a little sacking. 
 The shelves were placed one above the 
 other, so that sometimes there were only 
 a hundred cubic feet of space per person. 
 All the inspectors appointed by Govern- 
 ment to inquire into these questions had 
 complained of the dirt, overcrowding, and 
 the promiscuity, for men and women often 
 slept in the same dormitory. The hours of 
 work varied from twelve to fourteen, and 
 the food was altogether insufficient. The 
 clothing w^as also of the poorest description. 
 It was rare that a man could afford to wear 
 leather boots, but contented himself with 
 wrapping his feet in paper and rags and 
 thrusting them in woollen shoes. Shirts 
 were considered a vain luxury, and but for 
 the sheep's skins, worn with the wool inside,
 
 THE LAISSEE-FAIBE SYSTEM. 221 
 
 the people would die of cold. This sort of 
 life soon destroj^ed all sense of self-respect, 
 and fearful immorality \Yas the result. The 
 migrations of villagers into towns for a 
 short time each year had brought hack 
 syphilis to the villages, and there were 
 some villages in Kussia where every single 
 inhabitant was syphilitic. In some de- 
 partments 10 per cent, of the recruits 
 were syphilitic. There was but one re- 
 deeming feature : the Eussian, however 
 poor, alwaj^s insisted on having a bath. 
 He would as soon go without his food as go 
 without his weekly bath. There were no 
 statistics to show what was the mortality 
 of the Eussian working-class population, 
 but the general mortality was sufficiently 
 significant.* 
 
 Such is the usual state in which the 
 
 ■-■= I quote from the Lancefs excellent report of this 
 Congress.
 
 222 NATIONALISATION OF HEALTH. 
 
 elementary conditions of health are found 
 among the Russian people. Under unusual 
 conditions everything is, of course, much 
 worse. This may be judged by the reports 
 which have reached us from time to time 
 concerning the recent cholera epidemic. 
 We have heard of disease raging unchecked, 
 of scarcity of doctors, while of the few who 
 were at the post of duty many were driven 
 away, some even killed — thrown into the 
 streets, or soaked in kerosene and burnt,* 
 while vast crowds assembled outside the 
 hospitals, set fire to them, and cried, " Let 
 the cholera rage as it will ! " 
 
 It is true that in this country we are far 
 removed from Russia when viewed fi'om the 
 sanitary point of view ; but it must be re- 
 membered that in many or most respects 
 the condition of things found in Russia to- 
 day corresponds with that which existed in 
 
 ■■'■ This appears to have happened in Astrakhan.
 
 THE LAISSEE-FAIRE SYSTEM. 223 
 
 Western Europe, not only in mediaeval, but 
 in much later times. ^Ye have emerged 
 from such conditions, and the fact that so 
 much progress is possible is a stimulus to 
 still greater progress. Not the least value 
 of the example of Eussia lies in the proof it 
 offers that in these matters — as indeed in 
 most others of social concern — the good 
 intentions of a despotic government, and 
 the enlightenment of a small minority of 
 the population, are utterly helpless in face 
 of the ignorance and apathy of the mass of 
 the population. Here as elsewhere we are 
 concerned with the true significance of 
 democracy. It is the extension of en- 
 lightenment that we need more than its 
 intension. The nationalisation of education 
 precedes and leads by the hand the nation- 
 alisation of health.
 
 XV. 
 
 CONCLUSION. 
 
 The tendencies now making towards the nationaUsation of 
 heahh (ll Growing discontent with present lack of 
 system ; (2) The beginning of organisation ; (3) The 
 inadequacy of private practice under modern conditions 
 — Every medical man must be a force on the side of 
 health-preservation — The organisation of hospitals leads 
 inevitably to the health-organisation of occupations — 
 The difference in mortality of various occupations — 
 The co-operation of workmen necessary — The varying 
 healthfulness of towns — The nationalisation of health 
 compared to the nationalisation of education — Economic 
 aspect — The nationalisation of health leads to its inter- 
 nationalisation. 
 
 We have now seen something of the various 
 tendencies that are making towards the na- 
 tionalisation of health. 
 
 There is, first, the growing discontent 
 with the present irregular and expensive 
 
 224
 
 CONCLUSION. 225 
 
 methods by which what is really a great 
 public department is conducted by means of 
 institutions which, with all their undoubted 
 advantages from the medical and scientific 
 standpoint, combine, so far as administration 
 is concerned, the defects of being voluntary, 
 charitable, isolated, and irresponsible ; the 
 absence of organisation and co-operation 
 alone constituting a defect which no per- 
 fection of administration in individual hos- 
 pitals could compensate. This growing 
 discontent no doubt accounts for the fact 
 that the income of the hospitals is on the 
 whole a diminishing quantity, and it has 
 now found authoritative voice in the Eeport 
 of the Lords' Committee on Metropolitan 
 Hospitals. 
 
 Then in at least three directions we are 
 able to see how advantageous, as well as 
 economical, is an organised system of public 
 health and public medicine under State or 
 
 15
 
 226 NATIONALISATION OF HEALTH. 
 
 municipal control. The great municipal 
 infirmaries which are everywhere arising 
 now only need development to rival the 
 best of the endow^ed voluntary hospitals. 
 The admirably organised system for battling 
 with infectious disease, which is in the 
 hands of the Metropolitan Asylums Board, 
 shows, like the London Fire Brigade 
 system, how fine and precise an instrument 
 for dealing with emergencies can be con- 
 structed with sound centralised methods.* 
 Above all, we see around us the formation 
 of a great network of public health, with a 
 vast corps of medical ofiicers of health, 
 
 ■■'■ Thus during the week in September, 1892, when the 
 London epidemic of scarlet fever was at its height, and there 
 were about 3,400 cases of the disease under treatment in the 
 Metropolitan Asylums Hospitals, the deaths were only 27, 
 actually below the average number for the corresponding 
 week of the preceding ten j-ears. Sanitation does little to 
 prevent the spread of scarlet fever, but in many parts of the 
 cotmtry even the earliest attempts at notification and isolation 
 have diminished the mortality from the disease by about 25 
 per cent.
 
 CONCL US ION. 227 
 
 banded together in the effort to secure 
 reasonable conditions of pubhc health in 
 certain of its more elementary aspects ; 
 and everywhere we witness the activity of 
 the County Councils stimulating the energy 
 of the medical officers of health. 
 
 In the third place, we are brought face to 
 face with the ob^dous inadequacy and disso- 
 lution of the system of private practice. 
 We scatter medical men across country and 
 town, giving them perhaps a dispensary with 
 a miscellaneous assortment of drugs and a 
 few instruments (sometimes so old that the 
 possessor cannot use them, or so new that 
 he does not know how to use them), and 
 we expect from him, and even feel that we 
 are entitled to expect from him, all the skill 
 and resource of a fully equipped hospital. 
 He is expected, as a private practitioner 
 has ingeniously expressed it, ''to be ready 
 with his services to rich and poor
 
 228 NATIONALISATION OF HEALTH. 
 
 alike ; to be prepared at a moment's 
 notice to undertake cases of every de- 
 scription — from abscess to anaemia ; from 
 baldness to bronchitis ; from colic to cir- 
 rhosis ; from delirium tremens to dropsy ; 
 from epilepsy to epithelioma ; from febricula 
 to fistula ; from gangrene to gout ; from 
 hcTBmorrhoids to hernia ; from inflammation 
 to insanity ; from knock-knees to klepto- 
 uiania ; from leucorrhoea to lock-jaw ; from 
 measles to mal-de-mer ; from nephritis to 
 n?evus ; from pimples to paralysis ; from 
 rickets to rheumatism ; from sick headache 
 to syphilis ; from toothache to tuberculosis 
 — for each and every bodily ailment he is 
 expected to give advice and prescribe 
 remedies." 
 
 This is far from an exaggeration ; and it 
 can scarcely excite surprise that the usual 
 reward of the necessarily perfunctory work 
 of such a Jack-of-all-trades is, as the same
 
 CONCLUSION. 229 
 
 writer goes on to say, " the hardly- veiled 
 sneer of the consultant and the 23atronising 
 condescension of the patient." To make 
 the private practitioner's position still more 
 absurd, it now frequently happens that he 
 is at the same time medical officer of health ; 
 so that during part of his time his interests 
 are bound up with the prevention of disease, 
 and during the rest of his time with its 
 causation ; as a medical officer of health he 
 is taking the bread out of his own mouth as 
 a private practitioner. That he is able to 
 get through these anomalous duties in a 
 conscientious manner says much for his 
 moral character, but very little for the 
 system, or want of system, that he is 
 forced to carr}^ out. 
 
 Along, then, at least these three lines — 
 the growing discontent with the present 
 lack of method in tlie organisation of public 
 medicine, the tendency of a sounder S3'stem
 
 230 NATIONALISATION OF HEALTH. 
 
 to realise itself already, and the perception 
 of the increasingly untenable position of 
 the private practitioner — it is possible to 
 discern the hope of better things. Under 
 any rationally organised system every 
 medical man would be a force on the side 
 of health ; it would be his primary duty 
 not to seek to pull out with spasmodic 
 effort the mangled wretches who float down 
 to the sea in the great torrent of disease 
 and misery, but to help to maintain firmly 
 the dykes which protect us against the 
 sources of disease and misery. 
 
 There will doubtless remain a limited 
 scope for the activities of the private prac- 
 titioner ; there is at the least the great field 
 of "minor ailments; " but he will have at 
 his back the hospital, largely reformed into 
 a Health Institute, with which his duties 
 will keep him constantly in touch, and with 
 which his interests will be bound up. The
 
 CONCLUSION. 231 
 
 exact methods by wliicli this reform will be 
 effected constitute a problem which the 
 future must settle, but its gradual realisa- 
 tion has in the course of events become 
 not merely desirable but inevitable. 
 
 But, as we have also seen, the organisa- 
 tion of the hospital is but a part of the 
 nationalisation of health. A no less im- 
 portant part is the inspection and reason- 
 able regulation of all forms of industry 
 which, carried on as they so often are 
 at present under unhealthy conditions, do 
 so much to choke our hosj)itals with diseased 
 or disordered persons. So long as hospital 
 relief is largely left to voluntary charity, the 
 community has collectively an excuse for 
 believing that it is not directly interested 
 in the prevention of disease. The greed of 
 certain members of the communit}^ it is 
 true, produces unhealthy conditions of work, 
 but the charity, it may be said, of (in large
 
 232 NA TIONALISA TION OF HEALTH. 
 
 measure) these same greedy members goes 
 to relieve the victims of the unhealthy con- 
 ditions. When the community has a direct 
 interest in the cure of disease, it ^'ill 
 perceive, with no great intellectual effort, 
 that it has a direct interest in the preven- 
 tion of disease. Medical officers of health 
 and inspectors of industry must be recog- 
 nised as, if not members of the same public 
 department, very closely allied in their 
 functions. 
 
 The work of statisticians alread}^ presents 
 results which are full of light for us in the 
 task of nationalising health. How is it, 
 for instance, that there are such immense 
 differences in the mortality of those en- 
 gaged in different occupations ? * It is 
 
 * See Supplement to the Fortj-Eigbtli Eeport of the 
 Registrar-General, 1885 ; Dr. Ogle's and M. Jacques Ber- 
 tillon's papers read to the Congress of Hygiene, 1891 ; and 
 the recently published Diseases of Occujmtions (1892) by Dr. 
 Arlidge, who has devoted many years to the study of this 
 important subject.
 
 CONCLUSION. 233 
 
 clearly unreasonable that such enormous 
 discrepancies should exist. If, after full 
 investigation, it is found that certain occu- 
 pations are inevitably attended by unusual 
 risks, then such occupations should be 
 supervised with especial care; the extra- 
 ordinary dangers they present should be 
 met by extraordinary precautions. It 
 would probably be found in most cases 
 that those unusual risks are, in a large 
 proportion of cases, not inevitable.* 
 
 =J= It need scarcely be said that these questions cannot be 
 decided without the co-operation of the workmen themselves ; 
 and that under wholesome conditions of work at least a 
 certain freedom of organisation must be left to the workers. 
 
 I quote {iroui Freedom) the following excellent suggestions 
 by a workman regarding his own and allied occupations : 
 
 " In the trade I am employed in —the building hne — there 
 is a great deal of hard and dirty work, which is quite uu- 
 nessary, e.g., carryiug the hod, mixing mortar by hand, 
 wheeling navvies' barrows, and other such work I could 
 mention, which it has been proved could be done by 
 machinery ; only slaves in these cases are cheaper than 
 machines, so machinery is not used. 
 
 " Again, in the painting line, it is very unhealthy and dis-
 
 •234 NATIONALISATION OF HEALTH. 
 
 The vast difference between the healthful- 
 ness of towns is another matter in regard 
 
 agreeable to have to work ten or twelve hours in the midst 
 of white lead and other poisons, not knowing from one day 
 to another but that you may have the painter's colic ; but if 
 the hours were less and the men had time to be clean and 
 to take an interest in their work, painting would become a 
 pleasure instead of drudgery. 
 
 " In the paper-hanging line it is a pleasure to hang good 
 sanitary paper, and it is perfectly safe ; but how many paper- 
 hangers have lost their lives by the poisonous colom- coming 
 off the common paper, which makes paper-hanging unhealthy 
 and disagreeable, and is used simply in consequence of the 
 competition amongst paper manufacturers to undersell one 
 another. 
 
 " In the plumbing line there is not much that is in itself 
 disagreeable or unhealthy work. The hardship is to be 
 working for eight or nine hours a day amongst lead, and 
 constantly handling it. That not only becomes monotonous, 
 but often results in lead-poisoning. 
 
 " Besides these particular evils I have mentioned as 
 brought about in these special branches of my trade by 
 the present system of organising labour, there are others 
 which apply to all branches of building, e.g., the fixing of 
 unsafe scaffolding, using rotten boards and ladders, and 
 being obliged to climb about without proper precautions ; all 
 of which go to make the men's lives uncomfortable, and all 
 of which we could put an end to if we could have a free use 
 of capital and organise our own work. If a mere race for
 
 CONCLUSION. 235 
 
 to which at present there is a widespread 
 indifference. That a person who lives in 
 Preston should have on every hand far 
 more chances of disease and death than 
 one who lives in Brighton is, unfortunately, 
 far too simple of explanation ; and within 
 no easily measurable period will the health 
 standard of the one town be levelled up to 
 
 profit were not the object of the present organisers of 
 industry the unhealthy, dangerous, and disagreeable work 
 could be almost entirely banished h'om our trade, and with 
 the aid of improved machinery what remains could be very 
 easily planned and carried out by co-operation amongst our- 
 selves. . . . 
 
 " Now in the painting line there are different kinds of 
 work ; some are dangerous, while others are quite safe. Yet 
 even as things are, the men, if left to themselves, soon find 
 out who is willing or who prefers to do the top work, and if 
 none of them like it, they arrange to take it in turns ; whilst, 
 if the master interferes, it very often falls to the lot of one 
 to do all the top work, and perhaps he is giddy or nervous or 
 in some way the most unfit man for the job. Very often 
 accidents occur in this way ; but I have never yet seen a 
 case where a man who is nervous has been compelled by his 
 fellow-workers to do anything dangerous. Indeed the men 
 are mostly willing to help or take the place of a nervous 
 man who has got a dangerous job."
 
 236 NATIONALISATION OF HEALTH. 
 
 that of the other. But why should towns 
 which exist under almost the same condi- 
 tions display such wide differences from 
 this point of view ? Birmingham and Man- 
 chester are both great inland manufacturing 
 cities, not very far apart from each other, 
 yet there is a difference between them in 
 the death-rate, amounting at times to nearly 
 40 per cent. The key to this difference lies 
 in the fact that Birmingham is, from the 
 sanitary point of view, a well-governed city, 
 while Manchester is notoriously an ill- 
 governed city. The root of such ill-govern- 
 ment can only lie in the ignorance and 
 apathy of the inhabitants in respect to their 
 own vital interests.* 
 
 The case for the nationalisation of health 
 may be compared to that for the nationalisa- 
 
 • ■ With reference to the growing evils of town life, through 
 defective air, light auJ space, and for the methods of com- 
 hating these evils, see Dr. Sykes's Public Health Problems 
 (Contemporary Science Series), 1892.
 
 CONCLUSION. 237 
 
 tion of education which has for some years 
 been accomplished in this and other civihsed 
 countries. It is difficult to bring forward 
 any argument in favour of the nationalisa- 
 tion of education which does not apply even 
 more strongly to the national recognition of 
 health. The advantages of public over 
 private education, undoubted as they are, 
 are comparatively trivial compared with the 
 advantages of an organised medical service 
 over the present irregular private systenj. 
 Under no national system can training of 
 the mind be placed before the life of the 
 body. Moreover, in England (unlike our 
 large colonies) class distinctions are still so 
 marked that a very small proportion of the 
 well-to-do classes care to avail themselves 
 of public education, while the same class 
 are prepared to take what is at present an 
 unfair advantage of the present charity 
 hospital, and would certainly avail them-
 
 238 NATIONALISATION OF HEALTH. 
 
 selves of the advantages of the national 
 hospital. Yet we know that as soon as a 
 sound scheme for the nationalisation of 
 education was presented, and its advan- 
 tages perceived, it was generally accepted. 
 We can scarcely doubt that the far stronger 
 case for the complete nationalisation of 
 health, when once clearly presented and 
 fully understood, will meet with similar 
 acceptance. It is certainly the duty of all 
 those who realise the magnitude of the 
 issues involved to take every opportunity to 
 spread information on the matter, and to 
 create an intelligent public opinion. 
 
 It is true that the nationalisation of health 
 is a somewhat more complicated task than 
 the nationalisation of education. We can- 
 not expect to lind it fully established within 
 a few years. In accordance with our usual 
 British methods, it will be a matter for com- 
 promise and for gradual, even voluntary, expe-
 
 CONCLUSION. 239 
 
 riment. And iu the first place it will in- 
 volve expenditure, although for the founda- 
 tion of national hospitals the present poor- 
 law infirmaries and charitable hospitals 
 furnish a basis for operation which did not 
 exist in the case of education. Yet even if 
 national health were heavilj^ to " burden the 
 already over-burdened ratepayer" — to use 
 the stereotj'ped phrase — it would not be 
 difiicult to set forth the soundness of such 
 expenditure. It is really a question, even 
 in the financial sense, of economy.* There 
 are very few households that, under a 
 rationally organised system of health, even 
 with the heaviest hospital-rate, would not 
 find themselves better off at the end of the 
 year than they are now. When the trouble 
 
 * Every trifling outbreak of infectious disease involves not 
 only a large indirect loss through decrease in trade, etc., but 
 also a considerable direct loss. Thus a slight outbreak of 
 small-pox at Wakefield recently led to a supplemental call 
 ou the overseers equal to a rate of twopence iu the pound.
 
 240 NATIONALISATION OF HEALTH. 
 
 and misfortune involved are also considered, 
 the balance of advantage in favour of an 
 organised system is almost incalculable. 
 And^a nation tliat can afford to spend 
 indefinite millions on a sliow navy or a 
 petty war among remote barbarians * can 
 certainly afford to inaugurate a better state 
 of things in a matter which touches every 
 member of the community so closely 
 home. 
 
 The nationalisation of health, as here 
 advocated, is not used in opposition to any 
 conception of its internationalisation. It is 
 simply used as a convenient term to indicate 
 a rational and organised system of securing 
 the conditions of health as against the 
 private, individual, sporadic lack of system 
 which, as we are now fortunately beginning 
 
 ■■• As a clistinguislied eanitarian, the late Dr. Alfred 
 Carpenter, poiutetl out a few years since, while nearly 
 l'3;j,000,000 are expended on self-defence, less than 1 per 
 cent, is devoted to medical purposes.
 
 CONCLUSION. 241 
 
 to recognise, is no longer suited to the needs 
 of our time. The nationalisation of health 
 leads up to the internationalisation of health, 
 and must to some extent go hand in hand 
 with it. This was well pointed out at the 
 International Workers' Congress of 1889 by 
 Dr. Caesar de Paepe,who, as himself both the 
 son of a simple workman and physician to 
 one of the largest hospitals in Brussels, 
 speaks with recognised authority on the 
 question of sanitation among the masses. 
 On this occasion he proposed that the Legis- 
 latures of all countries should combine to 
 prohibit the use in factories of poisonous 
 substances, such as lead and phosphorus, 
 when these could be replaced by non- 
 injurious materials. Where the use of 
 poisonous materials was inevitable, then the 
 industry should be subject to very strict pro- 
 tective regulations. As all these reforms 
 and remedies were to be of an international 
 
 16
 
 242 NATIONALISATION OF HEALTH. 
 
 character, and the labour parties of each 
 country were to press them upon their 
 respective Governments, and make these 
 Governments come together and agree to a 
 general assimilation of labour laws. Dr. de 
 Paepe urged that international inspectors 
 should be appointed. If an abuse was 
 abolished in another country, it was sure 
 to reappear on the other side of the 
 frontier. Thus, in one country the use of 
 salicylic acid for the preservation of beer 
 is abolished, but it is largely used in 
 another ; and while toys made in one 
 country are dear, but free from poisonous 
 paints, toys made in another are cheap but 
 not so harmless. As for the difficulty of 
 applying internationally laws of this descrip- 
 tion, there already existed international 
 laws relating to fishing rights ; and surely, 
 if it was possible to control fishing smacks 
 sailing over the broad seas, it was more
 
 CONCLUSION. 243 
 
 easy to watch over workshops and fac- 
 tories.* 
 
 These proposals bring forward an aspect 
 of the question on which we may well finally 
 pause. The maintenance of the conditions 
 of health is not a merely national question. 
 It is impossible to enter on the path of 
 health reform without a strong national 
 sentiment and some degree of realised 
 national progress : but before we have 
 continued long on the path we may at any 
 moment be confronted by the westerly move- 
 ments of some monstrous epidemic coming 
 out of its Asiatic lair and breathing forth 
 death and misery ; and when, again, we turn 
 to the question of the diseases of occupation 
 and the due regulation of employments we 
 are brought face to face with the industrial 
 and commercial web which now covers the 
 
 - I quote from the report of Dr. de Paepe's speech in 
 Lancet, July 27, 1889.
 
 244 NATIONALISATION OF HEALTH. 
 
 greater part of the world with threads so 
 sensitive that we cannot touch them at one 
 spot without producing actions and reactions 
 throughout their whole extent. Within our 
 own corner of the world we can doubtless do 
 much to establish the conditions of health ; 
 their more complete establishment awaits 
 the international self-realisation of demo- 
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 " An admirable series." — Spectator. 
 
 " Each volume is written by one of the most foremost English authorities on the 
 subject with which it deals. . . . It is almost impossible to o\er-esiimate the 
 value of a series of carefully prepared volumes, such as are the majority of those 
 comprising this library." — Guardian. 
 
 '7 9 Sirilv (PhcEnician, Greek, and Roman), By E. A. 
 »5 * J Freeman, D.C.L. [January.
 
 lO 
 
 -^i. The Byzantine Empire. ByC. w.c.Oman, 
 
 '^ J r M.A. ^December. 
 
 30. The Tuscan Republics and Genoa. 
 
 B7 Bella Duffy. {December. 
 
 29. The Normans. By Sarah Orne jewett. 
 
 28. Portugal. By H. Morse Stephens. 
 
 27. Mexico. By Susan Hale. 
 
 26. Swiczerland. By Lina Hug and R. Stead. 
 
 25. Scotland, By John macintosh, LL.D. 
 
 24. The Jews under the Roman Empire. 
 
 By W. Douglas Morrison, M.A. 
 23. Russia. By W. R. Morfill, M.A. 
 
 2 2. The Barbary Corsairs. By Stanley Lane- 
 
 J Poole. 
 
 2 1. Early Britain. By Prof. a. J Church, Author of 
 / " Carthage, &c. 
 
 20. The Hansa Towns. By Helen Zimmern. 
 
 1 9. Media. By z. a. Ragozin. 
 
 18. Phoenicia. ByCanon Rawlinson. 
 
 I 7. Persia. By S. G. W. benjamin, second Edition. 
 
 16. Medieval France. ^J.^XiIL,.''"""''- 
 1 1; Holland. ?>" '\= '";=. ""'"f"'" '^"°'""-" '^°°""- 
 
 J • Second Ldition.
 
 II 
 
 Id.. 1 UrKGy. By Stanley Lane-Poole. Second Edition. 
 
 J1 A<;<;vrin ^^ Zi^na'ide A. Ragozin, Author of 
 
 O' J • u Chaldca," &c. 
 
 12. The Goths. By Henry Bradley. Third Edition. 
 
 -,- _ r^lr-jlrlp'l ^y ^' ^' ^ACoziN, Author of "Assyria," 
 
 ' &c. Second Edition. 
 
 TO Trflnnrl ^X ^^^^ Hon. Emily Lawless, Author of 
 lU. llClclllU. ..'ii^rrish." Third Edition. 
 
 Q. The Saracens : ^^."^ '^'J-fT ^'T\'" '^'" 
 
 >• Pall of Bagdad. By Arthur 
 
 Oilman, IVT.A., Author of" Rome," &c. 
 
 Q Unnrrirv ^T Prof. A.iminius Vamb^ry, Author of 
 O, nUU^aiy. ..-pravels in Central Asia." Fourth 
 Edition. 
 
 7. Ancient Eg-ypt. By Canon Ravvlinson Author of_ 
 / • oy F ' The rive Great Monarchies 
 
 of the World." Fifth Edition. 
 
 6 The Moors in Soain By Stanley Lane-Poole, 
 Mosque." Fourth Edition. 
 
 c. Alexander's Empire. ^>'^^°^-J;!!v^^"7;' 
 
 J 1 Author ot "Social Lite 
 
 in Greece." Fourth Edition. 
 
 r^nrt-linfre By Prof. Alfred J. Church, Author of 
 4- ^«-ll Lllcl^C. ..Stories from the Classics," &c. Fifth 
 Edition. 
 
 rf r^prmnnv By Rev. S. Baring-Gould, Author of" 
 J. VJLllllclliy. cc Curious Myths ofthe Middle Ages," &c. 
 
 Fourth Edition. 
 
 ^ nr]-ip TpWS ^^ Ancient, Mediaeval, and Modern 
 • J * Times. By Prof. J. K. Hosmer. 
 
 Second Edition. 
 
 1 Romp Bv Arthur Gilman, M.A., Author of ** A 
 I. XVUIllC. History of the American People," &c. Third 
 Edition,
 
 (^iogra|?pg. 
 
 The Life and Times of Niccolo 
 Machiavelli. By Prof. Pasouale Villari, Author of 
 " The Life of Savonarola," (!v:c. Translated by Linda 
 Villari. New and Revised Edition, in two vols., with 
 New Preface and Two New Chapters. Containing 
 four Copper-plate and 29 other Illustrations. Demy 
 8vo., cloth, 32s. 
 
 Extract from Preface to New Edition. — This is the first complete 
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 shortened to suit tlie c .nvenience of its publisher. Whereas the two fi st volumes 
 were issued intact with all the documents appertaining to them, the rest of the work 
 was deprived of two entire ch-ipters, and every document suppressed. One of the 
 eliminated chapters treated of Art, and it was precisely in the Fme Arts that the 
 Renaissance found is fullest and most distinctive expression. 
 
 BehramiiM. Malabari : a Biographical sketch. By 
 
 J Dayaram Cjidumal, LL.rJ., 
 
 C.S., Acting District Judge, Shikarpur. With Introduction 
 by Florence Nightingale. Crown 8vo., cloth, 6s. 
 
 Life of John Boyle O'Reilly, i?-^ JA^^Es Jeffrey 
 
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 13 
 
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 D Williams. 
 
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 24 
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 2. A London Plane-Tree, and other Poems. By amy levy. 
 7. Wordsworth's Grave, f?r'^ ^'^^^ P°^"^ ^y William 
 
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 A Tnhicrpnla In DplnKi With some Tmnslninn-; frorn thp Grefk, 
 
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