made notifiable, as has been suggested, is a matter for serious consideration.

REGION III.

Notes on Cases of Bronchitis referred for Examination.

In this region, and probably in other regions, three leading sources of incapacity are heart disease, rheumatism and bronchitis. The present statement deals exclusively with bronchitis.

An

Bronchitis seems not to have received its due share of special investigation, though it would seem to be more widespread, more general, and to appear at least as frequently on death certificates as either of the other two diseases. analysis of the occupational and age incidence of the referred cases diagnosed as bronchitis may prove of some interest, and possibly may help to stimulate a desire for a more thorough investigation into its causation, particular and general, its prevention and its treatment. The year 1925 is taken for this analysis in view of the abnormal state arising from the mining stoppage during 1926.

Approximately 6,000 cases of all types were referred during the year, and of these 495 were submitted with the diagnosis of bronchitis as the incapacitating condition. This means that in 8 per cent. (or 1 in 12) of all cases, bronchitis was considered to be the essential cause of the incapacity. One fairly large Society which investigated its records, and which has a widespread membership from all classes of employment, states that out of a total of 4,000 claims for 1925, bronchitis was found to be the stated cause of incapacity in 15 per cent. of the cases. This indicates that a considerable proportion of bronchitis cases as such are being referred. It is interesting to note that the medical referee agreed with the practitioner's view in 72 per cent. of the bronchitis cases actually seen by him, as compared with 68 per cent. of all cases actually examined. That there should have been this greater percentage of agreement suggests all the greater need for thorough investigation of this widespread cause of ill-health and incapacity.

At the same time experience resulting from the actual examination of a very large number of these cases suggests that the view commonly held by practitioners in regard to chronic bronchitis in relation to the Health Insurance Act requires some revision. No medical man would doubt that there is a lowering in working value (capacity for work) in all these cases, but it may be questioned whether there is any permanent reduction to a "nil" capacity from this condition alone, except possibly in a very small percentage of cases.

Further, except during superadded acute or subacute attack. these cases are generally capable of some form of work, and therefore, except for comparatively short periods at a time, should not be certified as incapable of work. In actual experience it is found that the majority of these referred cases have been continuously on sick benefit for three, six, nine or twelve

months or more before reference. This prolonged certification of incapacity in chronic bronchitis is probably due in part to the fact that the practitioner considers this question, in relation to the particular employment of his patient, on a misunderstanding or misreading of the Health Insurance Act. For the practical working of the Health Insurance Act as it now stands, the question of " capacity for work" in all chronic cases should be considered from the general point of view of any" work, and not from the point of view of the particular work of the insured person concerned as would be legitimate in an acute or passing illness.

66

Analysis of 495 cases.-A table shewing the occupations of the cases referred as bronchitis will be found at the end of this chapter. There are many striking features in the analysis of the 495 cases for which it is difficult to find any very clear explanation.

Half of the cases occur in miners and general labourers, and fully two-thirds of these are found to involve miners alone. This represents a very serious drain on health and wealth, and would justify an enquiry as to the cause of this excessive incidence.

Excluding miners, whose working conditions tend to bronchial troubles, and general labourers, who are generally a "residual" class of irregular habits, of more casual employment, with a low standard of wage and exposed to all weather conditions, all of which doubtless are factors in the production of ill-health and some of which may tend particularly to chest troubles, there are left only 41 cases amongst the workers in heavy trades. This number compares favourably with the 61 domestic workers.

The comparatively small number of the shop-assistant class also compares very favourably with the number of domestic workers, and suggests that the shorter hours of work and less confinement in shops may render shop-assistants less liable to this disease.

Of the outdoor workers referred it is interesting to note that out of a total of 39, agricultural labourers numbered 17. Among factory workers 14 out of 39 cases were woollen workers.

In regard to the incidence of the disease at various ages, it is observed that between the ages of 16 and 45 there were 250 cases, while between the ages of 45 and 70 there were 245 cases, an almost equal number. There is, as might have been expected, a gradual small rise in the decennial periods from 73 in the age period 16-25 to 110 in the age period 55-65, with a marked fall to 28 in the age period over 65. This latter fall is no doubt accounted for by the incidence of deaths, and by the probability that after the age of 65 Societies more readily accept the statement of incapacity from any and every cause.

The fact that the cases actually seen and examined shew generally a chronic condition of chest, with some recent superadded acute or subacute attack of bronchitis, suggests that there is a comparatively early incidence of the disease among miners,

as by the age of 45 more than half (102 out of 199 cases) of the cases appear. Metal workers, woollen workers, domestic servants and agricultural workers shew a very similar incidence.

Admittedly it is impossible to draw definite conclusions from an analysis, such as this, of a small number of cases selected from many more cases of the same disease in Societies' books. Moreover, the figures take no account of the numbers engaged in the various employments. At the same time the figures appear to be sufficiently striking to suggest that there is a real need for more information as to the general and particular conditions that give rise to chronic bronchitis, e.g. among workers in mines, factories and houses, and also as to the treatment of the chronic bronchitic. Treatment seems in general to consist of giving an occasional expectorant or sedative cough mixture for a short period while the patient is seeking advice, followed by a more or less prolonged interval when nothing at all, or perhaps cod liver oil or emulsion, is given. Meantime during all this period the patient is racked with a morning or evening cough, or his sleep is disturbed by a cough, though he no longer complains but accepts what he considers the inevitable, because of course it is "chronic bronchitis " from which he suffers and he finds others suffering without complaint and without treatment.

This rapid survey of the facts in a limited area shews that there is room and need for a systematic medical enquiry into the whole question of bronchitis as a cause of incapacity. The best means of organising such an enquiry is a matter for careful consideration.

Analysis of 495 cases referred to the District Medical Officer with the Diagnosis of Bronchitis as the Incapacitating Condition.

CHAPTER XVIII.

POOR LAW.

ADMINISTRATION OF POOR RELIEF.

1. Number of Poor.-Details of the number of poor in Scotland on three given days in each year, over a period of years, are given in Appendix XV.

(a) Poor at 15th May, 1926.-The number of poor of all classes, including dependants, in receipt of relief on 15th May, 1926, was 285,946, or 58 per thousand of the estimated population, made up as follows:

Sane poor excluding destitute able-bodied and miners and their families* :

Paupers. Dependants.

Other than sane poor (i.e. lunatics and

mental defectives) :

In asylums and institutions for imbeciles 14,071

In licensed wards of poorhouses,

Greenock parochial asylum, and
poorhouses which are "certified in-
stitutions for mental defectives".

...

1,347 2,677

Of the sane poor excluding destitute able-bodied and miners and their families (113,753), 10.9 per cent. were in receipt of indoor relief and 89.1 per cent. were receiving outdoor relief. Of the poor other than sane 77-8 per cent. were in asylums, &c.,

The term "miners and their families" refers to coal miners whose families were relieved during the coal stoppage. Such cases started to become chargeable a few days prior to 15th May, 1926, and up to that date the relief afforded amounted to only £1,481.