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Public Health Services.REPORTS OF MEDICAL OFFICERS OF HEALTH. ’,THE following are some of the 1926 statistics of four

county boroughs and two urban districts :-

Brighton.Dr. Duncan Forbes says the outstanding feature of

the year’s work is the establishment of an orthopaedicscheme which has been begun in a modest way. Thecorporation has arranged with the Royal NationalOrthopaedic Hospital that they should allocate fivebeds at their Stanmore institution for the receptionof Brighton cases. Payment is to be made at therate of 22 per week per bed occupied for patientsunder 16 and 22 10s. for patients over 16. Thehospital is to appoint an orthopaedic surgeon to takecharge of the scheme, to pay monthly visits to anout-patient orthopaedic clinic in Brighton, and torecommend an orthopaedic nurse, who shall be in thewhole-time employment of the Brighton Corporation.Patients are being sent to the clinic from the tubercu-losis dispensary and from the infant welfare and schoolmedical departments. It is satisfactory to know, saysDr. Forbes, that there will be fewer cripples in thefuture and that what cripples there are will have thebest treatment for the remedy of their disablement.Although 2000 additional dwellings have been

occupied since the war, there are still bad cases ofovercrowding, especially distressing when a memberof the family is suffering from open tuberculosis.Until these dangerous conditions are remedied thefurther building of new houses must continue. Thefirst area for slum clearance has now been completed.The chief difficulty is that tenants whose averagerental is 7s. to 8s. a week cannot pay the rent of thenew houses which varies from 12s. 6d. to 15s., andsome of the families are really unfit for new houses.Under present circumstances it is difficult to arrangethe necessary move round and the slum problem canonly be dealt with in piece-meal fashion. To facilitatethe move round the council have bought suitablehouses, which after the present tenants have beenmoved to the new houses will be reconditioned toreceive the tenants of the slum areas at a low rental.There were 13 notifications of ophthalmia neonatorum;three cases were very mild, but four were subsequentlyadmitted to the Brighton Sanatorium ; one childadmitted in a hopeless condition on the tenth day ofthe disease lost the sight of both eyes, and anotheradmitted on the twelfth day lost the sight of one eye.Out of the 105 milk samples examined for tubercle13, or 12-4 per cent., gave a positive result. As aresult nine cows were dealt with under the Tubercu-losis Order, but in five instances no infecting cow wasfound, probably owing to drying off, removal, or

slaughter before the farms were visited. The discoveryof tuberculous calves at the abattoir has led to theelimination of one or two tuberculous cows frommilk herds as the result of following up.

Hastings.Dr. G. R. Bruce points out that the death-rate of

just over 15 becomes 10-8 when corrected for age andsex constitution of the population. The number ofnew cases at the infant centres was about 77 per cent.of the total number of births. The work at the twoantenatal clinics has made good progress, the attend-ance at one being nearly double that of the previousyear. The Fernbank Maternity Home, a voluntaryinstitution, accommodated 100 confinement cases butcould easily take 200. Forty of those admitted weremunicipal cases, for whom the corporation guaranteesthe full fee of 2 guineas. There is no waiting-list forpatients with tubercle. Throughout the yearnegotiations have continued with the Royal EastSussex Hospital for the provision of an orthopaedicclinic, and it is hoped that this scheme will be inprogress during 1927.

Housing activities have included the completion of48 flats for the rehousing of tenants from the clearancescheme in the old town, also 50 steel houses on oneestate and the commencement of 50 on another.When these are complete the corporation will havebuilt nearly 500 houses since the war, but this willnot, says Dr. Bruce, " solve the problem either ofovercrowding or of unhygienic houses, nor, unfor-tunately, of the unsatisfactory tenant." The mainsource of the water-supply is eight deep wells in theAshdown Sand with a supplemental supply from theBrede River. The present supply is inadequate tomeet the full pressure of the summer season and thesupplementary supply has to be chlorinated. During1926 application was made to Parliament for power toobtain water from an area in the chalk betweenEastbourne and Brighton. The application was

opposed by neighbouring authorities and thrown out,mainly on the ground that water-bearing areas nearerHastings had not been exhausted. The successfulsolution of the water difficulty to meet present andfuture needs is one of the most pressing public healthproblems before the corporation. During 192688 cows were slaughtered at the knacker’s establish-ment within the borough under the TuberculosisOrder, the majority coming from the milk-producingdistricts of East Sussex and Kent, and two fromdairy farms within the borough. The hours of brightsunshine registered during 1926 were 1588-5.

Carlisle.Dr. Joseph Beard reports that 24 samples of fresh

cow’s milk and four of pasteurised were examined fortubercle bacilli. One sample from an outside dairygave a positive result. The county veterinaryinspector examined 46 cows on the farm and foundthree with disease of the udder. The city inspectorhad samples examined from a suspected animal ateach of two farms. As a result both were slaughteredunder the Order, and advanced disease was foundpost mortem. Up to the end of the year the cor-poration had received the sanction of the Ministry forthe erection of 1344 houses-160 parlour and 1184non-parlour. Of these, 984 have been erected.The sanitary inspector’s report gives some par-ticulars of the move round of the tenants. Thirty-sixnew houses were built for the accommodation of38 tenants dishoused under an improvement scheme.Only six of the 38 elected to take the new houses,and 32 had to be rehoused by the method of exchange.In connexion with the demolition scheme 24 houseswere erected on one of the estates, but only five of the36 tenants of the demolished houses would take thenew ones and the remaining 31 were accommodatedby exchanges arranged through the sanitary inspectors.In the last case several of the tenants had alreadymoved once from another condemned area, and theinspectors found great difficulty in getting privateowners to accept them for the second move.

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Bury.Dr. G. Granville Buckley says the worst feature in

the 1926 figures is the maternal death-rate fromchildbirth. Of the eight deaths, five were due toeclampsia. Some of these deaths might undoubtedlybe prevented, he says, if expectant mothers wouldeither consult their own doctor or attend at theantenatal clinic. The antenatal clinic was attendedby 52 new cases, the total births in the boroughbeing 816. The conversion of privies into w.c.s is

proceeding very quickly; 1588 were dealt withduring 1926. The chief occupations of Bury are themanufacture of textile goods, machinery, paper, andfelt hats. The sewage is of a complex nature, andcontains trade waste from tanneries, fell-mongers,wool-scouring, hatters, and breweries, and threeseparate systems follow the sedimentation tanks atthe sewage works-namely, 3 acres of double contactbeds, 2 acres of percolating beds, and a recentlyinstalled unit on the activated sludge system workedon the surface aeration principle. At present thesludge is disposed of by lagooning, but a completesludge pressing plant is being installed. Emissions ofblack smoke which exceed the limit of two minutes perhalf-hour allowed for mill chimneys are notified Iat once to the firm, in order that the cause may be z,removed promptly. This action is much appreciated ’,by the mill-owners. Bury has had a public abattoir ’’,since 1903. It is modern in every respect, with ’,,railway siding and cattle dock, so that animals arriving !,by rail need not be driven through the streets.

Shrewsbury.Dr. A. D. Symons claims that Shrewsbury has as

complete provision for maternity needs as any townof its size. The births numbered 588, and the newcases at the antenatal clinic show a steady increase-viz., 59 in 1924, 94 in 1925, and 123 in 1926. Thematernity home is conducted by the Nursing Associa-tion, and patients are examined at the antenatalclinic before admission. Dr. Symons mentions asevidence of a " brighter Shrewsbury " movementthe attention given to aesthetic considerations inarchitectural development and to the repainting andpreservation of the old black-and-white houses, andgoes on to say that the movement would receive afurther impetus if the town council would adoptmore efficient methods for the cleansing of the streetsand the removal of refuse. The prosperity of thetown will be increased if cleanliness combined withantiquity renders it more attractive to visitors. Themain streets now have a waterproof surface, he says,and should be swilled in the early morning. Sweepingof the pavements opposite shops should not bepermitted after 9 A.M. Modern dust-carts with a lowbody and an efficient cover should be substituted forthe high carts, which create clouds of dust when adust receptacle is emptied into them. Refuse tipsneed not be a nuisance, and an energetic supervisorshould be appointed to see that they are properlycovered over with soil, &c. Shrewsbury is not a verysmoky place, but there are about a dozen workschimneys which intermittently belch forth largequantities of smoke, including three under the controlof the corporation. As the town lies low, smoke isnot readily blown away, but tends to hang. Thedomestic smoke is being reduced by the large use ofgas. There are 2865 gas fires and 5623 gas cookersin the 7000 houses. More houses were built lastyear than in any year since the outbreak of the war-namely, 90 municipal, 76 by private enterprise withState assistance, and 32 others. A further 101municipal houses will be completed during 1927.

In the selection of tenants preference is given tothose with large families. The practice of taking inlodgers was one of the restrictions imposed on thetenants, but a recent survey showed that lodgerswere being taken in 24 per cent. of the houses onone estate. In future application will have to bemade to the housing committee for leave to takelodgers and will receive reasonable consideration.

A campaign for cleaner milk was started during theyear. The accepted limit for dirt in milk, says Dr.Symons, is two parts per 100,000. Proceedings weretaken against a milk-seller whose milk showed40 parts. The retailer pleaded a warranty; a

summons was then issued against the wholesaler,but the magistrates dismissed the case. Anothercase was that of a cow-keeper who supplied milk16 per cent. deficient in fat. An appeal to the cowconfirmed the fact that the cows were giving milkthus poor in fat. The conclusion arrived at was thatthe cows were old, in poor condition, and badly fed, butthat as there was no adulteration no legal action couldbe taken. Shrewsbury has a public abattoir but alsotwo small private slaughter-houses.

IVeston-s uper-Mare.Dr. John Wallace mentions that two water-supply

schemes are under consideration. The present supplyfrom Banwell spring is a limestone water which ispumped to two reservoirs and to a water tower onWorlebury Hill (450 feet), which is capable of supplyingthe highest buildings in the district. The onlystreams in the district are " rhynes," by means ofwhich land drainage is effected. The rhynes areconsiderably polluted by manured lands and pig andcattle sheds, and it is difficult to prevent this. Flood-ing causes complaints, and is relieved by the wideningof culverts and the clearing of the rhynes. Gas is souniversally in use for heating and cooking that thehouse refuse contains little ash. Also it is oftendifficult to see any smoke from which to judge thedirection of the wind. Weston has a public abattoirand no private slaughter-houses. The hours of brightsunshine in 1926 were 1269-7, nearly 200 less than theprevious ten years’ average of 1454-2.

SCHOOL MEDICAL SERVICE.

* With 1413 routine inspections outside the code groups,this is 6276. n.s., not stated.

Blackburn.Dr. Oscar M. Holden describes the system of

coordination by which, while each medical officerhas his own duties, yet all share in the school work.Thus the medical officer of health is the schoolmedical officer and assists with routine medicalinspections as the need arises, and the assistantschool medical officer who does the largest share ofthe school work is also assistant medical officerof health. The woman assistant medical officerdevotes part of her time to school work, and thetuberculosis officer, who is also resident medicalofficer of the corporation hospital, is from time to timecalled upon to do routine school inspections. Thereis also close coordination in the work-for example,the record-cards of children who have attended thewelfare centres are forwarded on to the school sideupon the children reaching the age of 5. The childrenunder 5 attending school remain under the care of thewelfare department, and the health visitors continueto go to the homes when necessary. In school a" march-past " is made of these infants before theschool medical inspector, and in this way obviousdefects can be detected and treated. Then, again,the school dentist devotes 12 sessions to the maternityand child welfare department.

Dr. Holden deprecates the wholesale removal ofmoderately enlarged but healthy tonsils. Thosewhom he recommends for operative measures are

the cases with enlarged, unhealthy tonsils and

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-adenoids, especially those who are mouth-breathersand whose past history consists of a succession ofcatarrhs and sore-throats. In his note on rheumatismhe shows that in connexion with this disease it is

imperative that a careful scrutiny be maintained onthe condition of the throat and mouth in school-children. His very rational outlook has its result inthe small proportion of parents who refuse to havethe operations performed that have been recommended;out of 265 cases where treatment was advised221 actually received operation under the authorities’scheme, and several others were dealt with throughother channels. Special attention is given to aftercare of these cases at the clinic for remedial i

gymnastics in the form of breathing exercises and ’,training in correct respiration, without which, Dr.Holden says, the operation of removal of adenoidsis a waste of time and energy. The number ofexceptional children noted is in general rather low,but accommodation seems to have been found formost of them, except that there is much need formore places in the residential open-air school. Withthe cripple children, however, the reverse is true.The scheme for the detection of crippling defects iscertainly fairly comprehensive, including the work ofan orthopaedic surgeon, Dr. Briggs, and he is in closetouch with the valuable clinic for remedial gymnastics ;but there is no special physically defective school,which is obviously needed, and its provision couldmake it possible to reduce the unfortunately largenumber of children who have had to lose theirtreatment at the clinic owing-to the inability of theparents to bring them. ,

Coventry.Dr. E. H. Snell draws attention to the varying

percentage of children who are said to requireoperative treatment for enlarged tonsils, and it is

suggested that this depends so much on individualopinion that figures compiled by different doctorsare of no comparative value. For instance, in 1914.and 1919, when an assistant school medical officer(Dr. Newton) was working alone, the percentage of

cases referred for operation was 2-5 and 3 per cent.respectively ; while later, when other doctors werealso working, it was higher ; 7 per cent. in 1925 and16 per cent. in 1926. The ratio is reflected inverselyin the proportion of those referred who were actuallytreated; for in 1925 this was 25 per cent., while in1926 it was under 20 per cent.-i.e., out of fivechildren who were recommended for treatment inonly one was it actually secured. But the increasein the number of cases referred may be due notmerely to personal equation but to increasingrealisation of the value of removing a septic focusor pathway for infection. We note that last yearDr. Newton himself was specially investigating thesubject of rheumatism, in which the value of efficienttonsillectomy is becoming widely recognised,particularly in reducing the liability to cardiac com-plications.

There seems to be a large number of delicate childrenin Coventry, and it is a sign of the sound sense ofthe city that the residential camp at Corley is beingrebuilt, with accommodation for 90 instead of 30children. Another indication of the wisdom ofthis authority is given by the fact that the schoolfor mentally deficient children, which is doing excellentwork, was established as far back as 1910.The report of the school dentists alludes to the harm

done to the teeth by soft food and fermentingcarbohydrates which adhere to the teeth and gums.As to the causation of dental caries, there are severaldifferent schools of thought, one regarding as theessential cause the lack of vitamin D in the diet,and another blaming especially oral sepsis, andadvocating mouth-washes, toothbrush drill, and thelike, A third is that cited here, in favour of whichthere was striking evidence in the Birmingham reportfor 1925, where there is a comparison of the conditionsof the teeth of the children in Birmingham with thosein New Zealand. Those in the Dominion were

immensely worse, although the standards of diet

and of general hygiene are much better, thedetermining factor being apparently the larger amountof sweets and biscuits eaten there, causing thecarbohydrate fermentation alluded to by the Coventrydentists, Messrs. Raeside and Shelvin, who would,however, of course, agree that the right idea of

prophylaxis against dental caries is to use everymethod and to interpret the terms correct diet andoral hygiene in the broadest possible sense.

Scarborough.Dr. S. F. Linton describes the coordination of

school and general public health work appropriatefor a small area such as Scarborough. Child welfarework is carried out on the premises of the schoolclinic by the assistant school medical officer, Dr.Annie Roxburgh. Debilitated children under schoolage continue under the care of the centre and thehealth visitors until they come to school, when theyare transferred to the school medical service. Asrecords are kept of all cases continuity of work ismaintained. It is much to be regretted that inthe interest of "

economy " the nursery school has

been closed.There seems to have been a great improvement

in the cleanliness of the school-children of the borough,but ringworm causes much trouble and loss of schoolattendance. Dr. Linton, for example, cites the case of achild who has been kept out of school for two years.He wonders whether it would not be justifiable toallow such children to remain at school providedthat they wear linen caps. Other authorities havefound that infection is limited if under such a capthe scalp is covered with a thick greasy ointment,but a far better method is the use of X rays, whichreduce the period of exclusion to two or three weeks.There are no special schools in Scarborough. Thereis less need for an open-air school in Scarborough,Dr. Linton thinks, than in a dense industrial centre.A special class is provided for the dull and backward,including many feeble-minded children, and theopening of the Orthopaedic Hospital at Kirbymoorsidehas marked an advance in the treatment of cripples,for it affords institutional and specialist treatment.Apart from this, Dr. Crockatt, the orthopaedic surgeon,holds a monthly clinic at the local hospital, where a

masseuse attends and gives instruction to parents.

’ MENTAL HOSPITAL REPORTS.

THE Cumberland and Westmorland Mental Hospitalhad 815 patients resident at the end of the year.There has been a marked diminution in the maleadmission since the war, and those sent in are nearlyall incurable. The superintendent feels that this mustreflect an unwillingness to certify in early stages,and regrets the necessity of having to refuse admissionto those who are willing to enter the hospital withoutcertification. The recovery-rate was 32’7 per cent.and the death-rate 6’7 per cent. The general healthwas good, except for influenza. Parole on the estateis allowed to 20 men but to none outside, and thereare no open wards.

The Glamorgan County Mental Hospital at Bridgendreports an increase of 73 in its population, chieflymales. This is ascribed mainly to the lowered death-rate-8’6 per cent.-and the smaller number of .

relieved patients discharged. The number of menpatients-1076-is a record and means overcrowding.The recovery-rate was 22’8 per cent. The number of Ideaths from tuberculosis has fallen from 31 to 14. ’

Eighty post-mortem examinations were held. Thegeneral health was good and free from zymotic disease,apart from 84 cases of influenza. A dentist has beenappointed to attend weekly. Parole is allowed beyondthe estate to 9 men and to 85 more within the grounds, ,

but to no women, and there are no open doors except Bin the convalescent villa. There is a small laboratory,and the visiting commissioners urge the appoint- Iment of a technical assistant, so that full use may be Imade of it. General paralytics have not been treated

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by malaria as yet. Fourteen attendants and twonurses obtained their certificate in May.The City of Leicester lllental Hospital at TVest

Humberstone had 923 patients on its books onDec. 31st, an increase of 33 during the year. Somany reports speak of the urgent need for increasedaccommodation that it is interesting to find Dr. J. F.Dixon pleading, not for more beds in mental hospitals,but for decertification of a large proportion of theirpopulation, which might well be housed in specialinstitutions for harmless and helpless dements.The ratio of Leicester " insane " to the city populationis now 1 in 304 ; five years ago it was 1 in 355. Therecovery-rate for the year was 44’2 per cent. and thedeath-rate 5’5 per cent. The cause of death was

verified by autopsy in 82 per cent. of the cases. Thegeneral health in 1926 was good, except for someinfluenza. There were no cases of zymotic disease.Forty-eight per cent. of men patients and 37 per cent.of the women were on full or limited parole, and leaveof absence was granted 1491 times to men and 1013times to women. Seventy-seven per cent. of thepatients were kept fully employed. Small partiesof female patients went to the cinemas regularly andothers for motor drives into the country. The farmand garden again yielded a substantial profit. A newlaboratory assistant has been appointed and the

pathological work has therefore been extended.Malarial inoculation therapy was tried for generalparalytics ; 3 out of 13 were discharged " recovered."Since 1924, when this treatment was first used,19 per cent. of the cases treated have been dischargedwell, 15 per cent. improved mentally and physically,while 31 per cent. remain unimproved. An investiga-tion into the incidence of syphilis in the chronicpopulation of the hospital has been commenced.So far 15 per cent. of the men examined (201) haveshown a positive vVassermann reaction. In the

summer tinea marginata cruris was again troublesomeon the male side. The visiting dentist supplies areport stating that he has treated 287 patients andinspected and passed 44 more. He remarks on thekeenness of the nursing staff in carrying out the inten-sive course of dental hygiene which is of such import-ance in cleaning up a septic mouth. A completelist is given of all nurses and attendants who have eobtained their M.P.A. certificate. The cricket teamhad a successful season.

INFECTIOUS DISEASE IN ENGLAND ANDWALES DURING THE WEEK ENDED

AUGUST 6TH, 1927.

Notifications.—The following cases of infectious disease were notified during the week :-Small-pox,172 (last week 185) ; scarlet fever, 1234 ; diphtheria,671 ; enteric fever, 73 ; pneumonia, 489 ; puerperalfever, 38 ; puerperal pyrexia, 73 ; cerebro-spinalfever, 9 ; acute poliomyelitis, 14 ; acute polio- encephalitis, 1 ; encephalitis lethargica, 21 ; dysen-tery, 7 ; ophthalmia neonatorum, 104. There wasno case of cholera, plague, or typhus fever notifiedduring the week.

Deaths.—In the aggregate of great towns, includingLondon, there was no death from small-pox, 3 (1)from enteric fever, 31 (1) from measles, 2 (0) fromscarlet fever, 13 (3) from whooping-cough, 24 (5)from diphtheria, 45 (7) from diarrhoea and enteritisunder two years, and 16 (6) from influenza. Thefigures in parentheses are those for London itself.

The number of stillbirths registered during theweek was 241 in the great towns, including 42 inLondon.

REMUNERATION OF CORONERS.—The coroners ofCheshire districts have sent in an application to the countyauthorities for increased remuneration owing to additionalwork caused by the provisions of the Coroners AmendmentAct, 1926, and the requirements of the Home Office.

Special Articles.COMPULSORY TREATMENT OF

VENEREAL DISEASE.

THE NEW SOUTH WALES PLAN.

THE report of the Director-General of PublicHealth in New South Wales for the year 1925 con-tains paragraphs on the working of the system ofcompulsory notification of venereal disease underthe Venereal Disease Act of 1918 (No. 46 of the NewSouth Wales Acts of 1918). Notification is by number,not by name ; if, however, a patient fails to continueunder treatment till cured the medical attendant isrequired to report the name and address to theCommissioner, who is a medical practitioner nominatedfor the purposes of the Act by the Governor of NewSouth Wales. The patient is then informed of thepenalties to which he is liable unless he resumes.treatment. In practically all cases where a patientcan be reached resumption of treatment follows ;in only a few instances, observes the report, has itbeen found necessary to resort to prosecution. Thegrave difficulty of this process of following up defaulters-a difficulty mentioned also in the recent report ofthe Scottish Board of Health-is due to the largepercentage of persons who give the doctor a falsename or wrong address. In 1925 it was necessary tonotify 955 persons in New South Wales for failureto continue treatment; of these no fewer than538 (about 55 per cent.) could not be traced owing toa wrong name or false address; 241 resumed treatment ;and 176 cases were under investigation at the end ofthe year.

In England we still seem to be far from compulsorvnotification of venereal disease, and, except in localexamples such as the Bradford Corporation Act of1925, there is an evident reluctance to make it acriminal offence to fail to notify or to omit to undergotreatment. It is’ nevertheless interesting to studythe features of a far-reaching enactment like theVenereal Diseases Act of New South Wales. Powerwas given to the Governor to bring the Act into forcein different areas and at different times ; it is now inforce everywhere in New South Wales. In forbiddingthe advertisement of remedies, and in insisting thattreatment of venereal disease shall be by medicalpractitioners only, the Act corresponds with our ownVenereal Disease Act of 1917. But in many ways itgoes much further. Under Section 4 a personsuffering from this form of disease must, within threedays of becoming aware of his’ condition, consulta medical practitioner, to whom he must furnish hiscorrect name, occupation, and address, and to whomhe must submit himself for treatment. Disobedienceof this section is punishable with a fine of £100 orimprisonment for three months. The section includes.a special provision for professional secrecy in the.following terms : " Any medical practitioner who,otherwise than in accordance with the provisionsof this Act, communicates to any person or in anyother way makes known any name or address so

furnished to him shall be liable to a penalty notexceeding £100 and shall be deemed to be guilty ofprofessionally infamous conduct." Under Section 9the medical practitioner must notify the Commissioneron a prescribed form within a prescribed period ;failure to do so involves a fine not exceeding £20 onthe first occasion and not less than £20 or more

than £100 on any subsequent occasion. Marriageby a venereal disease patient while knowingly inan infectious stage is an indictable offence punishablewith the substantial penalty of £500 fine or five years’hard labour or both. In this connexion strict ideasof professional secrecy are disturbed in a mannerwhich anticipates a passage in Lord Riddell’s recent,address. If the doctor has reason to believe that a