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Public Health Services.INQUIRY COMMITTEES ON THE CONDUCT

OF PANEL DOCTORS : A QUESTIONOF PROCEDURE.

BEFORE a Divisional Court recently the Attorney-General appeared to show cause against a rule nisiobtained by two medical men, practising in partner-ship, Drs. A. B. and C. D., who sought to quash anorder of the Ministry of Health directing that £1000should be withheld from the remuneration payableto them by the Insurance Committee in respect oftheir panel patients. The name of each doctorappeared on the Lancashire Insurance Com-mittee’s panel, but only Dr. A. B. had a list ofinsured persons, the other partner, Dr. C. D., actingas Dr. A. B.’s deputy when attending these patients.Complaints having arisen that the doctors were

improperly charging fees to insured persons, an

investigation by the Medical Benefit Subcommitteeunder Part V. of the Medical Benefit Regulationswas instituted into the complaints against Dr. A. B.only. On a consideration of the report of this sub-committee, the Minister suggested that the InsuranceCommittee should make representations under Part VI.of the Regulations in respect of both doctors thattheir continuance on the panel was prejudicial tothe efficiency of the insured. The committeemade representations accordingly, and the Ministerappointed an inquiry committee. On considerationof the inquiry committee’s report the Ministerdecided that the doctors’ names should not beremoved from the medical list, but that £1000 shouldbe withheld from their remuneration.

In his opening speech against the rule the Attorney-General submitted that it was a fundamental principleof the National Insurance system that medicalpractitioners under it should be paid by capitationfees and should accept no other remuneration fromtheir panel patients, except in accordance withRegulations. He expressed the view that the courtwould have no desire, if it should be found to havethe power, to review the discretion of the Ministeror to inquire into the severity of the penalty imposed.The points at issue in the case were technical mattersrelating to the procedure adopted. The questionwas whether an investigation by the Medical ServiceSubcommittee under Part V. of the Regulations wasa condition precedent to the holding of an inquiryby the Minister under Part VI. of the Regulations.He submitted that the investigation under Part V.had nothing to do with the inquiry under Part VI.Sir William Finlay, K.C., who represented the medicalmen in support of the rule, pointed out to the courtthat only technical points were open to him andthat he was precluded from going into the meritsof the case or into the amount of the penalty. A

preliminary investigation had been held underPart V. of the Regulations into complaints againstDr. A. B. only. This had been followed by an inquiryunder Part VI. into the conduct of both doctors. Asthere had been no investigation by the MedicalService Subcommittee under Part V. in respect ofboth doctors, there had been no proper inquiryunder Part VI. On behalf of Dr. C. D., it was arguedthat as he had no list of insured persons, but merelyacted as Dr. A. B.’s deputy, he had not treatedinsured patients under the terms of a contract withthe Insurance Committee and that no representationsagainst him could be made to the Minister. Afterthe arguments of counsel had dealt with the technicalpoints involved at some length, the Lord Chief Justice,in giving judgment in discharging the rule nisi, saidthat the contention had not been pressed that aninvestigation by the Medical Service Subcommitteeunder Part V. must necessarily precede every inquiryunder Part VI., but it had been argued that a repre-sentation by an insurance committee with regard to

I an inquiry under Part VI. could only be made as

provided in Part V. 30 (2)-i.e., in the committee’sreport to the Minister following an investigationby the Medical Service Subcommittee. While thecommittee had a discretion to make a representationin this particular way, he considered the powers givenin Part VI. Articles 41 and 42 (regarding the makingof representations and the holding of inquiries)were general and that representations could be made,as had been done in the case of these doctors. Intheir case, after the Medical Service Subcommitteehad reported, the Minister had recommended theInsurance Committee to proceed by representa-tion under Part VI. This had had as its resultthe decision to deduct by instalments the sum

of £1000, and in his view the action of the Ministerwas not ultra vires. Mr. Justice Roche and Mr. JusticeBranson concurred, the latter stating, as regards theposition of Dr. C. D., that he was a panel practitionerand his terms of service were that he should nottake private fees from panel patients.

REPORTS OF MEDICAL OFFICERS OFHEALTH.

THE following table gives some of the principalhealth statistics for 1923 of one county borough, sixboroughs, and one urban district, the health reportsof which are commented on below :—

* Gillingham’s population for the calculation of death-rates is47,620.

t Indicates that the information is not given in the report.

Eastbourne.Dr. W. G. Willoughby reports that housing is still

the most adverse factor in this county borough andthat the outlook is only very gradually improving.However much one may theoretically believe in privateownership, he says, there is no alternative to Statehousing if private owners refuse to let houses tofamilies with young children. Such an attitude onthe part of private owners is common in Eastbourne.For the municipal houses, on the other hand, prefer-ence is given to large families. Dr. Willoughby con-siders that about 700 new houses would meet presentrequirements. The houses completed during 1923numbered 102, of which 30 were municipal houses.All the municipal houses have baths, and the rentsare 18s. 4d. per week for parlour houses and 14s. Sd.for non-parlour houses. Reference is made to thehopeless state of the law as regards milk which doesnot come up to the standard of 3 per cent. for fat and8-5 per cent. for non-fatty solids. The only twoprosecutions undertaken failed. Some of the specialdifficulties of the tuberculosis scheme are the wantof satisfactory housing accommodation, of hospitalprovision for surgical tuberculosis, and of suitableemployment for tuberculous persons who can do a

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little work. The municipal maternity and infants’home did useful work ; 17-6 per cent. of all the birthsin the borough took place there and 32 ailing infantswere admitted in addition to those born in the home.Considerable trouble has been experienced with regardto unqualified women acting as midwives, and theproviso in the Act as to " habitually " and " for gainmakes legal action difficult.

In his school report Dr. Willoughby says it is tooearly to speak as to the effect of the introduction ofthe system of charging for treatment, but he is gladthe board have allowed them some latitude in theapplication of the new regulations. Permission toestablish a massage and electrical clinic was refused,but fortunately the work has been carried on at avoluntary clinic. The reduction of uncleanliness and verminous conditions in the schools is marked inrecent years. There are many refusals to acceptdental treatment. The open-air school, formed out ofarmy huts and opened in June, 1920, has fullyjustified its existence, and its accommodation has beenincreased to 75 places. Medical inspection of the658 children in the two municipal secondary schoolsshowed that 272 required treatment or observation.For the majority of these the parents were asked toprovide medical attention, but 33 were treated freeat the school clinics. Dr. E. H. Coghill reports thatamong the girls the outstanding defects were enlargedtonsils and enlarged cervical glands, probably arisingfrom tonsils and teeth. The general physique wasgood and cases of spinal curvature few. As regardsthe boys, Dr. T. Turner reports a gratifying reductionin flat-feet, which he attributes to the disappearanceof the effects of poor feeding during the war. Enlargedtonsils and adenoids are now negligible, owing totreatment, breathing exercises, &c., during the earlierschool period. Dental caries is, however, much toocommon.

Ramsgate.Dr. W. J. Bannister also says that housing is still

the most pressing problem, and that the only hopefor an adequate provision of small houses lies in aState or municipal scheme. No municipal houseswere erected in 1923. Two of the 121 cows housedin the borough were found to be suffering fromgeneralised tuberculosis and were destroyed at theknacker’s yard. Most of the meat sold is importedforeign meat. Efficient supervision of the meatkilled in the borough is not possible owing to thesituation of the various private slaughter-houses andthe fact that killing goes on at all hours. On theother hand, the butchers have an insurance schemeagainst condemnation, which encourages the notifica-tion of suspicious meat to the health department.The council’s station for the sterilisation of shell-fishdealt with 34,614 gallons of cockles during the year.The premises on which ice-cream was made andstored were reported to be satisfactorily kept. Theschool report shows that seven of the nine elementaryschools are non-provided and do not comply withmodern sanitary requirements. Six prosecutions ofparents were undertaken for uncleanliness of their i,children. Many of the children, found to be in a pre- tuberculous condition, have to be excluded from schoolfor long periods, in the absence of an open-air school.During the year 152 children were found to haveenlargement of tonsils or adenoids. In most casesthe condition yielded to attention to carious teeth,&c. ; only 14 cases received operative treatment. Theschool dentist, Mr. P. H. Hickman, reports that manyparents refuse treatment for their children. Noorganiser of physical training for the area has beenappointed, although Dr. Bannister reports strongly infavour of such an arrangement.

Margate.Dr. Rowan McCombe refers-the reference is

cumulative-to the handicap to the standard of Ihealth and cleanliness resulting from the deplorableshortage of houses. In 1923, 22 municipal houses Iwere built, but 300 are needed immediately. In the

older parts of the town not only cottages but alsobetter-class houses have no bathrooms, and theprovision of public baths is greatly needed. Of thefour midwives practising in the town, two are

municipal and occupy their spare time in antenatalvisiting. In his school report Dr. McCombe reportsthat uncleanliness has been more prevalent among theschool-children during 1923. He would like to havesome more prompt and direct method of dealing withapathetic parents, such as power to cut the hairshort or making it an offence to send children to schoolwith verminous heads or bodies. Dr. McCombewould also like to see an open-air school establishedto accommodate 20 to 30 children.

Hendon.

" Happy Hendon " had, Dr. T. S. McIntosh tellsus, no public health history in 1923. A scheme is incourse of preparation for the coordination andextension of the child welfare and school medicalservices, and more supervision is needed of childrenbetween the ages of 2 and 5. Hendon is apparentlyunique among urban districts in having no housingproblem. The number of houses erected during 1923was 625, of which 20 were municipal. One closingand demolition order was carried out, and at the endof the year there were no houses unfit for habitation.

Gillingham.Dr. W. A. Muir reports that the isolation hospital

is unsuitable for its purpose and its site too small.Suitable sites for a modern hospital have been offered,and it is suggested as an alternative that the boroughmight join with the neighbouring boroughs ofChatham and Rochester. Like the medical officersof many large urban districts, Dr. Muir thinks thesupervision of midwives should be transferred fromthe county council and form part of the Gillinghammaternity and child welfare scheme. Two firms inGillingham now sell wrapped bread and the hospitalcommittee are among their customers. The chiefsanitary inspector attended the demonstration ofmethods of slaughtering arranged by the NationalFederation of Meat Traders’ Associations. Dr. Muirrefers to the view of the Federation that the humanekiller interferes with the keeping properties of themeat, more especially of pig’s flesh, with regard towhich investigation is still taking place. There isstill a marked shortage of houses, but no municipalhouses were built during the year. About £15,000was advanced during the year ended March 31st,.1924, to enable tenants to acquire the ownership oftheir houses under the Small Dwellings AcquisitionAct, 1899.

Watford.Dr. W. J. Cox prefaces his report on housing by

extracts from a speech delivered by the King at ahousing reception held at Buckingham Palace onApril llth, 1919. Since then nearly 1000 municipalhouses have been erected, but 1000 more are needed.There are about 300 houses unfit for habitation,many of them in an extreme state of disrepair andsome indescribably filthy and infested with rats andother vermin. The Infants’ Home at Little Nascott,which was originally started as a war creche, is nowserving a useful purpose as a home for the receptionof delicate and ailing babies, 44 of 77 admissionsduring the year being of that type. A dental clinichas been begun for nursing and expectant mothers,and children under school age. The Watford specialschool for mentally defective children (accommoda-tion 40) continues to do good work.

Hyde.Dr. Nicolas Gebbie, like his colleagues, refers to

the shortage of houses and overcrowding. Hisreferences to the smoke problem leave the impressionthat practically no action is being taken with regardto mill and factory chimneys. He states that thesmoke problem " is in large measure a problem of thehousehold chimney." A glance at the statisticaltable above tempts one to suggest that industrial

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smoke may be one reason why the death-rate from Irespiratory diseases in Hyde is nearly three times Ithat of the other towns and that industrial smokemay be worth while tackling, whilst the public isbeing slowly educated in the matter of the domesticuse of coal. In his report on the maternity and childwelfare work Dr. Gebbie refers to the high neonatalmortality, and says the antenatal branch of the workdoes not increase like the rest of the work and that,so far, only a few of the midwives have availedthemselves of the invitation to bring or send casesto the antenatal clinic. The school dentist, Mr.E. A. P. Parker, reports that of the children selectedfor treatment about 78 per cent. avail themselves ofthe opportunity.

Stafford.Dr. J. T. Macnab says housing difficulties continue

to be acute but that fresh activity is being shown,and it is hoped that the current year will bring somerelief. Dr. Macnab advocates the protection ofchildren during their school career against diphtheriaby the administration of the two or three necessaryinjections of toxin-antitoxin. This offer is now madeto parents in Stafford. Referring to the high neonatalmortality and the crowding at the infant welfarecentres, Dr. Macnab mentions that sanction has beenasked to the appointment of a second health visitorin order to enable antenatal work to be done andthe holding of more sessions at the centre. A

duplicate water main from Milford was brought intouse early in the year, so that the supply of the townis now protected against accidental stoppage. Cesspitsand privies will be abolished as the result of thecompletion of the new sewers at Rising Brook andDoxey. Waste-water closets cause much trouble bybecoming blocked, the liability to stoppage beingabout eight times that of the pedestal w.c. withflushing cistern. ____

SCHOOL MEDICAL SERVICE.

Glasgow.IN Scotland the school year now ends on July 31st

and the medical officer’s statement is incorporatedin the Director of Education’s annual report. It isdifficult from this rather brief statement to get anadequate idea of the enormous amount of good work,much of it pioneer, which we know is going on inGlasgow. The total number of children for whom theeducation authority is responsible is 194,267, of whom790 are under 5 years of age and 1134 over 14.Thirteen hostels are in operation for children whoseparents have to leave them during the day. In sevencases nursery sections are attached for children from2 to 5 years of age. These children are looked afterby women appointed for the purpose, while in thelarger nursery schools teachers are in charge. Duringthe year 32,639 children came under routine medicalinspection, and of these 45-2 per cent. were found withdefects. There are six principal and 12 subsidiaryclinics, with, in addition, two special clinics for tonsiland adenoid operations and ringworm and favus cases.The treatment of chronic otorrhoea by zinc ionisationhas been extended, and during the year 152 of thesecases were dealt with. The statistics regarding treat-ment show a considerable increase in cases generally,which is in part attributed by Dr. E. T. Roberts to the industrial depression. There was an increase of17 per cent. in ear cases, 6 per cent. in eye cases,10 per cent. in skin disease, and 24 per cent. in otherdiseases. The large increase of 44 per cent. in thenumber of cases of chronic suppuration of the middleear was possibly due to the severe epidemic of measleswhich occurred in the first half of 1922.From a survey of heights and weights for the five

pre-war and four post-war years it appears that war-time conditions have resulted in a slightly improvedphysique among the children. There is a post-warincrease in 13 of the 16 averages given. At the sametime the lowered state of health found among thechildren for 1922 is continued into 1923. During one

month of the winter of 1922 four mild cases of sorethroat made their appearance in the Langside Deafand Dumb Institution. Bacteriological examinationrevealed these as cases of diphtheria. Swabs of130 children and 43 members of the staff were taken,and 35 positive or potential carriers discovered.These were kept under strict supervision until

bacteriologically negative, and a Schick test was carriedout with the consent of the parents on 115 pupils andon 35 consenting members of the staff. The resultswere positive in 36 cases. All susceptible pupils wereimmunised against the disease, and as a result of suchprompt and thorough methods no further cases

occurred in the institution.

Radcliffe.Dr. John Gibson deplores the uncleanly state of the

Radcliffe schools, and points out what his predecessor,the late Dr. D. P. M. Farquharson, reiterated time aftertime : " If a child is brought up in a dirty, over-crowded home and attends a school where no oneseems to care if the floor and windows are dirty anddust is seldom disturbed, then that child will in laterlife be quite content with a low standard of cleanliness."He suggests that the children might assist in thecleansing of their classrooms. The remedy proposedis distinctly a debatable one, but something ought tobe done to remedy conditions where, as was pointedout in 1921,

" dust lies thick on every place where itcan find a lodgment." The outside sanitary arrange-ments here are evidently good, but the administrationis bad ; at some of the schools where the troughsystem of closets is in use they are flushed but oncea week. Flushing twice a day should be the rule laiddown for every school. During the year there were2924 attendances at the dental clinic, the number ofscalings and cleaning being 309. The school dentist,explaining this apparently large proportion, says thateven though the use of the tooth-brush is unknown inmany homes, he very much doubts its efficacy in theprevention of dental caries. Out of a school roll ofbetween 3000 and 4000 considerably more than halfwere medically examined. By an arrangement withthe school attendance officers all children absent fromschool on account of sickness are at once notified tothe medical officer and are visited by the school nurse.This is considered one of the most important dutiesof the nurse. There are two nurses employed, atsalaries of £181 and £166 10s. (including bonus).

INFECTIOUS DISEASES IX ENGLAND AND WALESDURING THE WEEK ENDED MAY 31sT, 1M4.

Notifications.—The following cases of infectious diseasewere notified during the week—namely, small-pox, 75 (asagainst 101 the previous week) : scarlet fever, 1450 ; diph-theria, 788 ; enteric fever, 88 ; pneumonia, 900; puerperal fever,45 ; cerebro-spinal fever, 14 ; acute poliomyelitis, 6 ; acutepolio-encephalitis, 1 ; encephalitis lethargica, 251 (as against261 the previous week) ; trench fever, 1 ; dysentery, 9 ; oph-thalmia neonatorum, 150. There were no cases of cholera,plague, or typhus fever notified during the week. Of the 14cases of cerebro-spinal fever 6 were notified from the Countyof London (Bermondsey 1, Hackney 2, St. Pancras 1. Shore-ditch 1, Woolwich 1), 2 from Durham (Sunderland), and1 each from Cumberland (Carlisle), Lancaster (Liverpool),Northampton (Vellingborough), Somerset (Weston-super-Mare), Surrey (Wimbledon), and Yorks, W. Riding (Bradford).Of the cases of encephalitis lethargica 23 were notified fromthe county of Durham (Sunderland 9, West Hartlepool 1,Felling U.D. 1, Hebburn 2, Rvton 1, Spennymoor 2,Auckland R.D. 1, Chester-le-Street R.D. 1, Easington R.D. 1,Sedgefield R.D. 2, Sunderland R.D. 2), 24 from Lancaster(Liverpool 8, Manchester 4), 23 from Warwick (Birming-ham 16), and 27 from Yorks, W. Riding (Sheffield 10).

Deaths.-In the aggregate of great towns the deaths frominfluenza fell further from 67 to 52. There were in London9 deaths from diphtheria, 12 only from measles.

FOREIGN DECORATIONS.—The King has given toMr. Douglas Erith Derry, M.B., Ch.B. Edin., licence andauthority to wear the Decoration of the Order of the Nile(Insignia of the Third Class), which has been conferred uponhim by the King of Egypt in recognition of valuable servicesrendered.