972 POVERTY IN RELATION TO DEATH AND DISEASE IN MANCHESTER.

POVERTY IN RELATION TO DEATH ANDDISEASE IN MANCHESTER.

Dr. James Niven, medical officer of health of Man

chester, takes in his current annual report refresh

ingly comprehensive views in his survey of the healtl

and disease of the people. He seems to us to appreciate t(the full the undoubted fact that preventive medicine mustenlarge its scope if it is to continue to reduce the generadeath-rate and if, more particularly, it is to make substantialadvance in promoting the physical fitness of the people andto create an impression upon such diseases as infantilediarrhoea and measles. Dr. Niven, in fact, appreciates whatwe have endeavoured to teach in our columns for some yearsthat true preventive medicine is largely made up of sociaforces and that much which is placed to the credit side of itiaccount is largely, though of course in no sense entirely.due to the improved well-being of the people ; in a word.to the greater distribution of wealth. Considerable spaceis devoted in the report before us to what is termec"the physical progress of the community" " and th<writer as the result of his considerations as to th<

alleged deterioration of the people concludes that a;

regards children (1) there has been a steady improve-ment in the health of school children for many years,but that (2) education must be greatly retarded by the largeproportion of children suffering from mental or physicaldefects unfitting them to learn. Dr. Niven is not disposedto regard the appalling categories of defects recently reo

vealed in the condition of school children as evidence ojdegeneration so much as an indication that preventivemedicine in the proper use of the term has yet its work to do.He thinks that supervision by medical examination alone isquite insufficient and in his view it should be the duty of theschool teachers, who should themselves be properly taughtby medical men, to see to the physical welfare of the children.Dr. Niven urges, as we have ofttimes urged, that every childshould be measured and weighed once quarterly and that acareful record of such data should be kept. He insists,however, that no child should be instructed, much less

drilled, who does not receive the amount of nourishmentsufficient to insure normal growth. And here naturally comesin the problem which is being so actively debated in theTimers, the feeding of the underfed. But Dr. Niven suggeststhat even if this difficulty could be surmounted there wouldstill remain the problem of how the underfed in pre-schoolyears were to be nourished properly.The remedy proposed for this difficulty is one with which

we are quite in sympathy, although in one sense it must befor the moment a stone to those who beg for bread. In the- education of the school children we see with Dr. Niven themost practical solution-partial solution we had better say-of this problem. Could the wastage in food and drink inconnexion with the poor person’s life be prevented his povertywould be far less, and by teaching children a subject which,as Herbert Spencer has insisted, is now neglected-that ofdomestic economy in all its branches-we should be layingsure foundations for a better superstructure in the future.The children should be taught not only how to cook,to sew, to mend, and to wash, but also how to feed,to clothe, and to tend infants, while the older children-should be offered special prizes for knowledge as tohow to expend a given sum of money in the way mostcalculated to provide the highest nutritive values. Dr.Niven is in a sense an optimist. He inclines to the viewthat the diminished death-rate at the younger ages oflife indicates something more than the progress of curativemedicine. He suspects that this lowered mortality impliesthat there are less sickness and greater resisting force-i.e.,that we are not by artificial means raising up a weaker racewhich, were the outward environment to become more severe,would wither and die. We hope that Dr. Niven is right.But whatever may be the real answer to these questions- which he raises the problems themselves are of all-absorbinghuman interest and they are extremely refreshing in com-parison with the somewhat restricted views of many medical- officers of health.

Dr. Niven’s discussion on " Poverty as Productive of a

High Death-rate " is also very interesting reading. As he

says :-When one comes to reflect on the various causes productive of ill-itealth and of that more intense form of ill-health which ends in death,

the influences of poverty and more particularly of unsettled poverty

loom larger and larger. There are a great many who <Iio virtually ofstarvation year by year. There is little doubt that the vagrant classesare at present increasing. They are the terror of the country insummer and the disease carriers of the town in winter. No one whohas seen much of the inhabitants of the lower class of common

lodging-houses can help considering whether it is inevitable that greatnumbers of men should sink so low. Many of them can and dowork, perhaps earn 25s. to 30s. a week. Their lodgings cost, them 2s. aweek; their food perhaps 5s. What becomes of the rest? Others,again, more thrifty of health and effort, work a few hours in the morning and are amply supplied. These men, unshackled by family caresand expenses, keep down the price of labour and the standard of life.

Dr. Niven then discusses with a fulness which our spacewill not allow us to follow the forces which make for

vagrancy and here again he sees the remedy in the "kindand quality of the instruction imparted to children

generally." The married man, as the author says, is sub-

jected to a severe competition from the inhabitants of

common lodging-houses, and this organisation of casuallabour might be directed to the preferential employmentof married men. But is not the real cause of the increaseof the common lodging-house vagrant of a certain sort thegrowth of selfishness, the indisposition to work more thanis necessary to supply the physical wants of the individual;in other words, the absence of ambition and of self respect!If this be so, the remedy is really in a better moral educa-tion. And perhaps this is in Dr. Niven’s mind when he says,"There is but one way to cope with this social danger. Thechildren must be educated, and well educated, in such amanner as will enable them to meet with confidence thedifficulties and temptations of life" ; and "If this object isto be achieved the education authority must see that thesechildren are adequately fed so that they may grow normallyand so that the enormous development and laying out ofbrain protoplasm necessary for educational purposes may bepromoted." We entirely agree but here we again feel our-selves confronted with the free feeding obstacle or, at anyrate, something akin to it.Some very interesting figures are also presented in the

report illustrating the intimate connexion between povertyand death in urban districts as indicated by the Manchesterfigures. The indices of poverty which are taken are thedeath-rates of those inhabitants who end their lives in theunion hospitals and in other institutions, the former in-

dicating a deeper degree of poverty than the latter :-TABLE 1.- ..,l1’era.lJe Annnal Dceath-rate (corrected for the

Cens2es Figures 1891 and 1901) for 1891-1901 amongstPersons Dying at Home, in Urtion Hospitals, and in otherInstitutions; also the Di fferent Deatk-rates for the Cityand its Three Main Divisions.

These figures tell their own story. But in order to eliminatethe fallacy which might arise from taking the death-rate atall ages Dr. Niven furnishes the following tables relative tothe death-rates at different periods of life, such deaths

including those which occur in the union and in other

hospitals from all causes and also from pulmonary tuber-culosis :-

TABLE II.-Showing Dcccthsfrom all Caiises.

973LOOKING BACK.

He has selected pulmonary tuberculosis because in his view,and we are here quite in agreement with him, it "is adisease which eminently reflects the influence of poverty,being determined by overcrowding, physical privation,anxiety, want of rest, and all the factors which are dependenton poverty." That is to say, that the reduction of the

prevalence of this already waning disease is overwhelmingly,in relation to other causes, a social problem, and the soonerthis fact is appreciated the better will it be for future

generations.As is shown by the table last given, the death-rate from

phthisis in the Manchester township is at childhood and atages 25-44 more than twice, at ages 45-64 three times, andat ages above 65 more than five times as great as that inNorthern Manchester, and in connexion with the mainthesis of this article it may be added that similar, thoughsmaller, differences at nearly every period of life are mani-fest in respect of measles, whooping-cough, diarrh&oelig;a, nervousdiseases, diseases of the circulation, pneumonia, and otherrespiratory diseases. Do we thoroughly appreciate what allthis means in relation to the scope of preventive medicineand, if so, had we better press the meaning to extremes?But Dr. Niven has carried his investigations to a furtherpoint and by adopting a line of inquiry similar to that

pursued by Mr. Rowntree in the city of York he has shownwhat a very large class there is in Manchester which iswithout the means to secure adequate nourishment for bodily efficiency. Our readers who take an interest in these

problems will remember that Mr. Rowntree was able toestablish the fact that over one-tenth of the population ofYork were in a condition of what he termed "primarypoverty"-i.e., they were unable to procure the necessitiesof existence. As Dr. Niven states, it is necessary fully toappreciate the meaning of primary poverty. The stuntedchild is nature’s method of expressing insufficiency of foodand a stunted body is but too frequently accompanied by acontracted mind. " If." says the report before us,

" a man

has not enough to eat he cannot do his work. To save hislife, therefore, he must shirk work. The badly fed man isinefficient of necessity. If he cannot shirk work sufficiently,so that his food provides for the internal work of his organsand animal heat and the work he does, he takes disease anddies. It is a process very costly to the community, thoughworse evils might attend the wrong remedy."Now proceeding upon the same general lines adopted by

Mr. Rowntree at York, and making due allowance for thecurrent price of food in Manchester, Dr. Niven found that itis possible to obtain a bare subsistence diet for a man for aslittle as 3 3/4d. per diem but that allowing for the necessity forvariety probably 5d., or even 7d. in most families, is thesmallest amount for which an adequate diet could be obtained.Dr. Niven then had inquiries made with respect to the circum-stances of a number of families such as are usually visited bythe health visitors of the Ladies Public Health Society andit was found that out of 76 families so visited seven couldnot afford a diet equivalent to 3 3/4 d. per man, while 46 couldnot afford 7d. per man. From an analysis of all his figuresit was concluded by Dr. Niven that 29 families must havebeen suffering from actual insufficiency of food. We shouldvery much like to see this inquiry extended and elaboratedand it would be well if medical officers of health of othertowns would initiate inquiries upon similar lines. Therecan surely be no question that inquiries of thisnature are the very essence of public health, unless,that is to say, it is contended that the " disease calledinsufficiency of food is not capable of alleviation.Inquiries of this sort will at least bring out one point andthat is the need for education in the matter of pro-curing the greatest food values for a given expenditure ofmoney. With knowledge of this nature many persons whoare at present practically starving could be furnished with asufficiency of food and with a due appreciation of theextravagance of alcohol much money might be divertedfrom physiologically useless into physiologically productivechannels. We are fully aware of the social and politicalstrife which is not unlikely to arise out of questions of thisnature and public health in its own interests should avoidpolitics as it avoids the plague. But preventive medicinemay fairly ask, and our sanitary authorities who are nowthe education authorities have a right to insist, that thechildren shall at least be taught how to procure their nutri-ment as economically as possible. Herein is a partialalleviation of poverty which preventive medicine must useevery endeavour to promote.

Looking Back.FROM

THE LANCET, SATURDAY, SEPT. 30,1826.VISIT OF BARON DUPUYTREN AT GUY S HOSPITAL-OPERA-

TION OF LITHOTOMY BY AIR. KEY.

On Tuesday last, that illustrious French surgeon, BaronDupuytren, visited Guy’s Hospital, and went round the wardswith Sir Astley Cooper. The circumstance of his beingabout to visit the Hospital being generally known on thepreceding day, a large concourse of pupils assembled tomeet him, by whom he was received with marked attentionand politeness. He immediately proceeded round the wardswith Sir A. Cooper; amongst the cases which were pointedout as particularly worthy of notice, were the case of

strangulated hernia related in this week’s reports, a case ofempyema, and compound fracture of the cranium.A long discussion ensued between Dupuytren and Sir

Astley Cooper in Accident Ward, on the subject of fractureof the neck of the thigh bone. We understood the formerto assert the possibility of ossific union taking place ; he saidthat he had a preparation illustrative of this fact, which hewould take care to forward for Sir Astley’s inspection. Thetreatment usually adopted by him in fractures of the neck ofthe thigh bone, he said was, to place the limb on a doubleinclined plane, and he usually found that the parts hadunited at the termination of eighty days, that is, aboutdouble the length of time usually assigned for the union offractures in other parts of the thigh bone. When Dupuytrenwas about to enter the Accident Ward, Sir Astley Cooperturned round, and addressing Mr. Key and Mr. Callaway inhis usual jocose manner said, " Now if you have got a goodfracture of the thigh, and one properly done up, let the Baronsee it, but for God’s sake do not shew him one of the ram’shorn cases which every now and then happens."Dupuytren objected generally to the beds used in this

Hospital; he recommended first a straw mat, then a flockmattrass, and lastly on this a flock bed. After seeingseveral other cases, he proceeded to the operating theatre,in order to witness the operation of lithotomy by Mr. Key.The patient, a boy about five years of age, was placed on

the table; the straight staff was passed without difficulty,and Mr. Key effected his incision into the bladder with hisaccustomed dexterity. The forceps were now introduced,and speedily afterwards Mr. Key withdrew them, and passinghis finger through the wound into the bladder, turned round,and looking aghast, exclaimed, "The stone is not in thebladder, it is in an abscess at the neck of the bladder." Itwas somewhat unfortunate that Mr. Key should have madethis remark, for on raising the forceps, he found that thecalculus had been withdrawn, and was then actually betweenthe blades of the instrument, but it was so small that it hadpreviously escaped observation. The satisfaction depicted inthe operator’s countenance on making this discovery, mayreadily be conceived. Sir Astley Cooper afterwards remarkedto a pupil, (apparently with great feeling,) it is fortunate forthe honour of Guy’s Hospital, that the operation terminatedin this satisfactory manner."The best thing you could have done," said Sir Astley to

Mr. Key, " if you had not found a stone, would have been tohang yourself up by the neck." (What says Ben Travers tothis ?)Dupuytren expressed his approbation of Mr. Key’s opera-

tion in the highest possible terms of praise; he said that hehad frequently seen the operation performed with muchdexterity, but never ’’ more promptly, more decisively, or

more happily (bonkeur) than on the present occasion."Baron Dupuytren, after the operation, visited the museum,

the Lecture room, and other parts of the new buildings.When he took his leave of Sir Astley Cooper, he saluted theworthy baronet on each cheek; the manner in which SirAstley submitted to this ceremony, afforded no small shareof amusement to the pupils standing round, which washeightened by his observing, "Well, I am even with theBaron, for I saluted his daughter yesterday, when he was outof the way."A scene worthy of the pencil of Hogarth occurred in the

presentation of the Pharmacopoeia Guyensis (plurimum aucta.et emendata) to Dupuytren, by the venerable Stocker-thestandard-pestle of Guy’s Hospital.