The public indebtedness to hospitals has another aspect, too often overlooked. The aggregation during the last hundred years of a steadily increasing proportion of our population in crowded towns has meant the introduction on a gigantic scale of elements inimical to health. Smoke and obscuration of sunlight, dust and noise, the substitution of indoor for outdoor occupations, the difficulties of milk supply for children, and above all inferior housing with associated increased facilities for infection, have combined to render healthy life in towns difficult of attainment. Nor must we omit from the adverse side of the balance sheet the greater loneliness of family life in towns, the diminution in neighbourliness, and the failure of public social opinion to produce the wholesome effect on conduct which it exercises in village life. And yet, notwithstanding these factors, urban death-rates and especially tuberculosis death-rates have declined more than rural death-rates, and in parts of some countries urban is even lower than rural mortality.
Why is this? Our hospitals provide the key to the mystery. Parturition is freer from risk in town than in remote country districts; the means for the prevention of infection are better organized, and accident and disease are more promptly and more efficiently treated. The poor in towns receive as a matter of course in hospitals better treatment gratuitously than king or president could command thirty years ago. The relief to housing deficiency given by hospitals comes when most needed, in the emergencies of child-bearing and of sickness; and the net result of this and of better sanitary supervision is that although room-accommodation for families is much more restricted in towns than in country districts, the town-dwellers have a large share of their urban handicap removed by their superiority over country people in medical treatment.
The Continuing Mass of Preventible Disease
The medical record of the past on the side of preventive medicine is one of increasing control over infectious diseases. In securing this result epidemiologists, pathologists, and vital statisticians can rightly claim first place, aided by the sanitary and industrial inspector and the sanitary engineer; the epidemiologist being dependent largely on the work of the pathologist and of the statistician for guidance in his field investigations, which have led to the discovery and removal of numerous sources and channels of infection.
The record in curative medicine, especially on its surgical side, is one of increasing triumph over serious disease and injury, in which the discovery of anaesthetics and of Listerism have borne an essential part.
None of us can, however, be satisfied with the success already obtained, and I have elsewhere given reasons for concluding that at least one-half of the mortality and disablement still occurring at ages below 70 can be obviated by the application of medical knowledge already in our possession.
The Great War has shown both in Great Britain and in America the extent to which defects and disease exist in would-be recruits to our armies. In the United Kingdom only two-fifths of a large section of recruits could be placed in the first grade; and among American recruits out of two and one-quarter million men measured and examined physically at local boards 29.1 per cent. were rejected on physical grounds; though in the introduction to the Official Bulletin (No. 11, March, 1919) it is pointed out that many of the disabilities have little importance in civil life, and that these considerations possibly “reduce to 15 per cent. the proportion of males 20 to 30 years old who carry a serious handicap against normal activity in civil occupations.”
These figures, whatever doubt may attach to their exact arithmetical value, signify the existence in the community of a large amount of physical disability which must greatly reduce the sum of national efficiency and happiness. The records of our medical examinations of school children bring out the same fact, and emphasize the necessity not only for school clinics on an immensely larger scale than at present, but also for additional medical and nursing care in connection with child-bearing and during the pre-school period, which would discover defects and disease at an earlier stage, and would secure the provision not only of early preventive treatment, but also of more systematic improvement of the sanitary environment of maternity and childhood.
Present Extent of Socialization of Medicine
A mental effort is needed to realize the distance traveled in the public provision of medical assistance in the United Kingdom by the state and by voluntary organizations, including the committees of hospitals, convalescent homes, dispensaries, etc., prior to the passing of the National Insurance Act of 1911. I have already given some illustrative figures regarding hospitals. The Lancet some years ago gave a statement of the number of attendances of patients at voluntary hospitals in London during the year 1908. Assuming that each out-patient made five attendances, that all in-patients had previously been out-patients and that no patient received a hospital or dispensary letter more than once in the year, it could be inferred that a number equivalent to one in four of the total population of London had received free medical aid in these voluntary institutions during that year. And this did not include the large mass of treatment given gratuitously in poor-law infirmaries, public-health fever and tuberculosis hospitals, and lunatic asylums.