So far as I have observed the working of the Factory Act, it appears to me that the duties now performed by the sub-inspectors of factories might be more advantageously performed by superior medical officers, of the rank of army surgeons, who are independent of private practice.
I am confirmed in this view by the following evidence of Mr. Baker, surgeon of Leeds, the only factory inspector who has such qualifications:—
“Have you, as a surgeon, whilst visiting the factories as an inspector, had occasion to exercise your professional knowledge?—Frequently; during my service I have turned out great numbers of children with scald-heads, which they were apt to propagate amongst the rest of the children; some with phthisis, whose subsequent death was more than probable; some with scrofulous ulcers; a great many with extreme cases of ophthalmia; probably I may have removed a thousand of these cases altogether. I rarely go to a mill where I do not see a case of scald-head.
“Have you ever had occasion to interpose in respect to ventilation?—Frequently in extreme cases of variable temperature, also in cases of offensive privies, which I find attended by dysenteric affections; and also where there has been offensive water from neglected sewers. I have also endeavoured to enforce personal cleanliness on the children through the instrumentality of overlookers and parents. One practice amongst the children in all kinds of mills is to wear handkerchiefs on the head, by which the neglect of personal cleanliness was concealed. Under these handkerchiefs were most of the cases of scald-head, in a state of filthiness not easily describable. I have assured the operatives that by the Act I had the power to direct measures for the protection of their health as well as labour; and I have established in many places the rule that the children shall come with the faces clean, and the hair combed, and without handkerchiefs whilst at work.”
By such inspection of workpeople in the places of work do you conceive it would be practicable to influence largely the sanitary condition of the labouring population without inspection of the private houses?—Yes; for the ill health which was occasioned by the state of their houses or other places, would of course be visible on such inspection. If they were removed from their places of employment on the presentation of such appearances, the inattention which had occasioned it would be removed too.
“What length of time do you find such inspection would require each time, say in a mill of about 1000 persons, and how frequent should such inspection be?—On the average about two hours; to a practised eye the symptoms of indisposition are discernable almost in walking through a room. Under some circumstances an inspection of once in three months would suffice.
“Are there masters in your district who are aware of the interest they have in the health of their workpeople?—Yes; there are many who pay particular attention. I might mention two where a surgeon is specially employed to take care of their workpeople. When persons are ill, they are listless and sleepy, and negligent; there is also more waste made in the processes of manufacture.”
The superior economy of preventive services by such inspection as that above displayed will scarcely need elucidation.
From a consideration of such opportunities of inspection it will be perceived that the enforcement of sanitary regulations on such inspection by superior and independent officers, qualified by previous examination, as in the army, would be a wise economy. By such arrangements efficient medical superintendence would be provided for the independent labourer employed in crowded manufactures, as well as for the soldier and the sailor, not to speak of the pauper or the criminal. One such officer would be able so to inspect and keep under sanitary regulations the places of work, the schools and all the public establishments of such a town as Leeds, which would bring under view perhaps the greater proportion of the lower classes of the population. There would still remain, however, those of the labouring classes who do not work or lodge in large numbers, or work in a quasi-public manner, to bring them within the means of convenient inspection. There would also remain without protection the cases of persons of the middle classes.
To meet these cases, I would suggest that the information brought to the superintendent registrar as to the cause of death, imperfect and hearsay as it yet is, may serve as the most accurate index to the direction of the labours of a district officer appointed to investigate the means of protecting the health of all classes. Having suggested the registration of the causes of death (under medical superintendence), a head of information not contained in the original draught of the Deaths’ Registration Bill, I would guard against an over-estimate of the importance of that provision; but I feel confident it would be found, when properly enforced, one of the most important, means of guiding preventive services in an efficient direction. For example, wherever, on the examination of these registries, deaths from fever or other epidemics were found to recur regularly, and in numbers closely clustered together, there will be found, on examination, to be some common and generally removable cause in active operation within the locality. Amongst whatsoever class of persons engaged in the same occupation deaths from one disease occur in disproportionately high numbers or at low ages, the cause of that disease will generally be found to be removable, and not essential to the occupation itself. The cases of the tailors, miners, and dressmakers, and the removable circumstances which are found to govern the prevalence of consumption amongst them, I adduce, as examples of the importance of the practical suggestions to be gained from correct and trustworthy registries of the causes of death occurring in particular occupations as well as in particular places. When a death from fever or consumption occurs in a single family, in the state of isolation in which much of the population live in crowded neighbourhoods, they have rarely any means of knowing that it is not a death arising from some cause peculiar to the individual. Even medical practitioners who are not in very extensive practice may have only a few cases, and may be equally unable to see in them, in connexion with others, the operation of an extensive cause or a serious epidemic. The registration of the causes of death, however, presents to view the extent, to which deaths, from the same disease, are common at the same age, at the same time, or at the same place, or in the same occupation.
One of the most important services, therefore, of a superior medical officer of a district would be to ensure the entries of the causes of death with the care proportioned to the important uses to be derived from them. The public should be taught to regard correct registration as being frequently of as much importance for the protection of the survivors as a post-mortem examination is often found to be.
The mortuary registries and the registration of the causes of death are not only valuable as necessary initiatives to the investigation of particular cases, but as checks for the performance of the duty. The system of registration in use at Geneva, combining the certificate and explanation of the private practitioners and the district physician, corresponds with a recommendation originally made for the organization of the mortuary registries in England, and the experience of that country might, perhaps, be advantageously consulted.
It would be found that the appointment of a superior medical officer independent of private practice, to superintend these various duties, would also be a measure of sound pecuniary economy.
The experience of the navy and the army and the prisons may be referred to for exemplifications of the economy in money, as well as in health and life, of such an arrangement. A portion only of the saving from an expensive and oppressive collection of the local rates would abundantly suffice to ensure for the public protection against common evils the science of a district physician, as well as the science of a district engineer. Indeed, the money now spent in comparatively fragmentations and unsystematized local medical service for the public, would, if combined as it might be without disturbance on the occurrence of vacancies, afford advantages at each step of the combination. We have in the same towns public medical officers as inspectors of prisons, medical officers for the inspection of lunatic asylums, medical officers of the new unions, medical inspectors of recruits, medical service for the granting certificates for children under the provisions of the Factory Act, medical service for the post-mortem examinations of bodies, the subject of coroners’ inquests, which it appears from the mortuary registries of violent deaths in England amount to between 11,000 and 12,000 annually, for which a fee of a guinea each is given. These and other services are divided in such portions as only to afford remuneration in such sums as 40l., 50l., 60l., or 80l. each; and many smaller and few larger amounts.
Whatever may be yet required for placing the union medical officers on a completely satisfactory footing, the combination of the services of several parish doctors in the service of fewer union medical officers will be found to be advances in a beneficial direction. The multiplication or the maintenance of such fragmentitious professional services is injurious to the public and the profession. It is injurious to the profession by multiplying poor, ill-paid, and ill-conditioned professional men.[48] Although each may be highly paid in comparison with the service rendered, the portions of service do not suffice for the maintenance of an officer without the aid of private practice; they only suffice, therefore, to sustain needy competitors for practice in narrow fields. Out of such competition the public derive no improvements in medical science, for science comes out of wide opportunities of knowledge and study, which are inconsistent with the study to make interests and the hunt for business in poor neighbourhoods.
A medical man who is restricted to the observation of only one establishment may be said to be excluded from an efficient knowledge even of that one. Medical men so restricted are generally found to possess an accurate knowledge of the morbid appearances, or of the effects amongst the people of the one establishment, but they are frequently found to be destitute of any knowledge of the pervading cause in which they are themselves enveloped, and have by familiarity lost the perception of it. Thus it was formerly in the navy that medical officers on board ship, amidst the causes of disease, the filth, and bad ventilation, and bad diet, were referring all the epidemic disease experienced exclusively to contagion from some one of the crew who was discovered to have been in a prison. We have seen that local reports present similar examples of similar conclusions from the observation of single establishments in towns, in which reports effects are attributed as essential to labour, of which effects that same labour is entirely divested in establishments in the county, or under other circumstances which the practitioners have had no means of observing and estimating. The various contradictory opinions on diet, and the older views on the innocuousness of miasma, are commonly referable to the circumstances under which the medical observers were placed; and examples abound in every district of the errors incidental to narrow ranges of observation in cases perplexed by idiosyncracies, and by numerous and varying antecedents. It should be understood by the public that the value of hospital and dispensary practice consists in the range of observation they give; and that the extent of observation or opportunities of medical knowledge are influenced or governed by administrative arrangements. In several of the medical schools of the metropolis, however, the opportunities of knowledge are dependent on the cases which may chance to arise there. Fortunate administrative arrangements have, in Paris, greatly advanced medical knowledge, by bringing large classes of cases under single observation. The most important discoveries made with respect to consumption, those made by M. Louis, were based on the results of the post-mortem examinations of nearly 1300 cases by that one practitioner. Nearly all the important conclusions deduced from this extensive range of observations were at variance with his own previous opinions and the opinions that had prevailed for centuries. The later and better knowledge of the real nature of fever cases has been obtained by a similar range of observation gained from the cases in fever hospitals. Applications have been several times made to the Commissioners by medical men engaged in particular researches to aid them in the removal of the impediments to extended inquiry, by collecting the information to be derived—from the sick-wards of the workhouses and the out-door medical relief lists.
The highest medical authorities would agree that, whatsoever administrative arrangements sustain narrow districts, and narrow practice, sustain at a great public expense, barriers against the extension of knowledge by which the public would benefit, and that any arrangements by which such districts or confined practice is newly created, will aggravate existing evils. An examination of the state of medical practice divided amongst poor practitioners in the thinly populated districts shows that, but for the examinations, imperfect though they be, as arrangements which sustain skill and respectability, a large part of the population would be in the hands of ignorant bone-setters.
On a full examination of the duties which are suggested for a district physician, or officer of public health, that which will appear to be most serious is not the extent of new duties suggested, but the extent of the neglect of duties existing. The wants, however, which it is a duty to represent and repeat, as the most immediate and pressing, for the relief of the labouring population, are those of drainage, cleansing, and the exercise of the business of an engineer, connected with commissions of sewers, to which the services of a board of health would be auxiliary. The business of a district physician connects him more immediately with the boards of guardians, which, as having the distribution of medical relief, and the services of medical officers, I would submit, maybe made, with additional aid, to do more than can be done by any local boards of health of the description given, separated from any executive authority or self-acting means of bringing information before them.
I have submitted the chief grounds on which it appears to me that whatever additional force may be needed for the protection of the public health it would everywhere be obtained more economically with unity, and efficiency, and promptitude, by a single securely-qualified and well-appointed responsible local officer than by any new establishment applied in the creation of new local boards. Including, as sanitary measures, those for drainage and cleansing, and supplies of water as well as medical appliances, I would cite the remarks on provisions for the protection of the public health, made by Dr. Wilson at the conclusion of a report on the sanitary condition of the labouring population of Kelso. After having noted some particular improvements which had taken place, as it were, by chance, and independently of any particular aids of science directed to their furtherance, he remarks that “it is impossible to avoid the conclusion that much more might still be accomplished, could we be induced, to profit by a gradually extending knowledge, so as to found upon it a more wisely directed practice. When man shall be brought to acknowledge (as truth must finally constrain him to acknowledge) that it is by his own hand, through his neglect of a few obvious rules, that the seeds of disease are most lavishly sown within his frame, and diffused over communities; when he shall have required of medical science to occupy itself rather with the prevention of maladies than with their cure; when governments shall be induced to consider the preservation of a nation’s health an object as important as the promotion of its commerce or the maintenance of its conquests, we may hope then to see the approach of those times when, after a life spent almost without sickness, we shall close the term of an unharassed existence by a peaceful euthanasia.”