“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.