311 of the salary suggested by the Department of Local Government and Public Health for a medical appoint- ment in the gift of the local authority. This is, however, what has just happened at Limerick. The Department had fixed the salary of a junior house surgeon at .El 20 a year in lieu of 200 a year decided on by a committee of the Limerick city board of health. The board of health denounced the proposed amount as " scandalous " in view of the cost of professional education, pointing out that tradesmen working in the same institution received wages of 4 6?. 8d. a week. PUBLIC HEALTH SERVICES ANNUAL REPORTS OF MEDICAL OFFICERS OF HEALTH. THE following are 1930 statistics of six counties and of the Islancl of Guernsey. Registered stillbirths per 100 live births : Warwickshire 4-2, Norfolk 4-5, East Suffolk 3-4, Breconshire 5’6, Guernsey 4-0. Warwickshire. Dr. A. H. Wood says the nine transferred institu- tions are of the mixed type and in no case provided with a separate hospital. Relief to the mental hospital at Hatton has been afforded by the transfer of 30 mild lunacy cases to Alcester institution. Occasion has not arisen for consultation with the voluntary hospitals. Two applications for help from rural districts towards water-supply schemes and one towards sewerage have been received. The county nursing association, employing 62 nurses, covers five-sixths of the county, and the remaining large rural area on the east is looked after by the Newnham Association with six nurses. The former body undertook 786 midwifery and 290 maternity cases, and the latter 175 and 58. These nurses do not attend infectious cases, except tuber- culosis. The practising midwives numbered 219 and summoned medical help in one out of every three of their cases. Dr. Wood enumerates the measures taken in recent years to improve the midwifery service in the county, and deplores the fact that deaths in childbirth are much as they were twenty years ago. He has suggested to his committee paying the fees of the practitioners for antenatal examinations at a cost of about J61400 per annum and paying the fees of the midwives for acting as maternity nurses, in cases where a doctor has been engaged, at a cost of about ;S1500 per annum. Of the 5940 births in 1930, 3472 were attended by midwives alone and 1127 by midwives acting as maternity nurses, leaving 1341 (or 23 per cent.) who were attended by doctors either alone or with nurses unqualified in midwifery or with handywomen. Surely, says Dr. Wood, the time has come for every lying-in woman to have the advantage of a nurse skilled in midwifery. The condition of the Tame, thanks to better sewage treatment by the towns of the Black Country, improves slowly, and the account of the Avon is more hopeful still. Six rural district councils have promised grants, amounting to 3356, for the reconditioning of 61 houses under the Housing (R.W.) Act, but only four out of 14 rural districts refer to a shortage for the agricultural population. Of the 195 beds at the sanatorium, 64 are reserved for advanced cases. Dr. Wood thinks this is a. mistake, and that eventually the public assistance institutions will be able to free the sanatorium for its proper work. The orthopaedic scheme comprises 12 clinics and beds at five hospitals, but two years ago, in order to lessen expenditure, the hospital beds were limited. As a result, many cases wait- months for operative treatment, although beds may be available. On Dec. 31st there was a waiting-list of 23 children at one hospital and 22 at another. There are five V.D. clinics, but they fail to reach the whole of the rural population, and many patients must still be receiving unskilled treatment. Gloucestershire. Dr. J. M. Martin shows that in altering the county boundaries 15 parishes (population 4918) have been transferred to Warwickshire and Worcestershire, and ten parishes (population 3859) from Wiltshire and Worcestershire have been added to Gloucester. A pro- visional scheme for grouping of districts for appoint- ments of medical officers of health and for isolation hospitals has been approved. The health visitors have 193 nurse-children under supervision under the Children Act. The 14 institutions transferred, of the mixed type and built about 1840, have 2500 beds including 750 infirmary beds. Except for Thornbury, with a hospital (46 beds), built 20 years ago, the infirmary beds are not satisfactory. There are four large areas now without a hospital. Three of these might be served by extensions of existing hospitals, but the i fourth in the north-east should have a new general hospital, serving all classes of the community. There are 212 practising doctors, of whom 175 treat insured patients and 75 are poor-law medical officers. Dr. Martin suggests that the funds available should be divided among the practitioners willing to do the former poor-law domiciliary work on a capitation basis. Thus the insured father and his family, if in receipt of assistance, would probably have the same doctor. I About one in 30 confinements took place in hospital. Some patients had to be moved long distances, and there is need for more maternity beds in some parts of the county. An antenatal centre was opened at Cinderford in 1929, and a second at Lydney in April, 1930. The mothers made good attendances and the midwives are enthusiastic. It is intended to open a new centre every three months. Midwives attended 56 per cent. of the total births and sent i for medical help in the same proportion of their cases. The medical services scheme continues its growth. Four additional out-stations were opened in 1930. The orthopaedic scheme, formerly run from Cheltenham Hospital with one surgeon, is now based on hospitals at Cheltenham, Gloucester, and Bristol, and has the services of three orthopaedic surgeons. Venereal disease can now be treated at the out-stations, after
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of the salary suggested by the Department of LocalGovernment and Public Health for a medical appoint-ment in the gift of the local authority. This is,however, what has just happened at Limerick.The Department had fixed the salary of a juniorhouse surgeon at .El 20 a year in lieu of 200 a yeardecided on by a committee of the Limerick cityboard of health. The board of health denounced theproposed amount as
" scandalous " in view of thecost of professional education, pointing out thattradesmen working in the same institution receivedwages of 4 6?. 8d. a week.
PUBLIC HEALTH SERVICES
ANNUAL REPORTS OF MEDICAL OFFICERS
OF HEALTH.
THE following are 1930 statistics of six countiesand of the Islancl of Guernsey.
__
Registered stillbirths per 100 live births : Warwickshire 4-2,Norfolk 4-5, East Suffolk 3-4, Breconshire 5’6, Guernsey 4-0.
Warwickshire.
Dr. A. H. Wood says the nine transferred institu-tions are of the mixed type and in no case providedwith a separate hospital. Relief to the mentalhospital at Hatton has been afforded by the transferof 30 mild lunacy cases to Alcester institution.Occasion has not arisen for consultation with thevoluntary hospitals. Two applications for help fromrural districts towards water-supply schemes and onetowards sewerage have been received.The county nursing association, employing 62
nurses, covers five-sixths of the county, and theremaining large rural area on the east is lookedafter by the Newnham Association with six nurses.The former body undertook 786 midwifery and 290maternity cases, and the latter 175 and 58. Thesenurses do not attend infectious cases, except tuber-culosis. The practising midwives numbered 219and summoned medical help in one out of everythree of their cases. Dr. Wood enumerates themeasures taken in recent years to improve themidwifery service in the county, and deplores thefact that deaths in childbirth are much as they weretwenty years ago. He has suggested to his committeepaying the fees of the practitioners for antenatalexaminations at a cost of about J61400 per annum
and paying the fees of the midwives for acting asmaternity nurses, in cases where a doctor has beenengaged, at a cost of about ;S1500 per annum. Of the5940 births in 1930, 3472 were attended by midwivesalone and 1127 by midwives acting as maternitynurses, leaving 1341 (or 23 per cent.) who wereattended by doctors either alone or with nurses
unqualified in midwifery or with handywomen.Surely, says Dr. Wood, the time has come for everylying-in woman to have the advantage of a nurseskilled in midwifery.The condition of the Tame, thanks to better
sewage treatment by the towns of the BlackCountry, improves slowly, and the account of theAvon is more hopeful still. Six rural districtcouncils have promised grants, amounting to 3356,for the reconditioning of 61 houses under the Housing(R.W.) Act, but only four out of 14 rural districtsrefer to a shortage for the agricultural population.
Of the 195 beds at the sanatorium, 64 are reservedfor advanced cases. Dr. Wood thinks this is a.
mistake, and that eventually the public assistanceinstitutions will be able to free the sanatorium forits proper work. The orthopaedic scheme comprises12 clinics and beds at five hospitals, but two yearsago, in order to lessen expenditure, the hospitalbeds were limited. As a result, many cases wait-months for operative treatment, although beds maybe available. On Dec. 31st there was a waiting-listof 23 children at one hospital and 22 at another.There are five V.D. clinics, but they fail to reach thewhole of the rural population, and many patientsmust still be receiving unskilled treatment.
Gloucestershire.
Dr. J. M. Martin shows that in altering the countyboundaries 15 parishes (population 4918) have beentransferred to Warwickshire and Worcestershire, andten parishes (population 3859) from Wiltshire andWorcestershire have been added to Gloucester. A pro-visional scheme for grouping of districts for appoint-ments of medical officers of health and for isolationhospitals has been approved. The health visitors have193 nurse-children under supervision under the ChildrenAct. The 14 institutions transferred, of the mixed
type and built about 1840, have 2500 beds including750 infirmary beds. Except for Thornbury, with ahospital (46 beds), built 20 years ago, the infirmarybeds are not satisfactory. There are four large areasnow without a hospital. Three of these might beserved by extensions of existing hospitals, but thei fourth in the north-east should have a new generalhospital, serving all classes of the community. Thereare 212 practising doctors, of whom 175 treat insuredpatients and 75 are poor-law medical officers.Dr. Martin suggests that the funds available should
be divided among the practitioners willing to dothe former poor-law domiciliary work on a capitation basis. Thus the insured father and his family, if inreceipt of assistance, would probably have the samedoctor.I About one in 30 confinements took place in hospital.Some patients had to be moved long distances, andthere is need for more maternity beds in some partsof the county. An antenatal centre was openedat Cinderford in 1929, and a second at Lydney inApril, 1930. The mothers made good attendancesand the midwives are enthusiastic. It is intendedto open a new centre every three months. Midwivesattended 56 per cent. of the total births and senti for medical help in the same proportion of their cases.
The medical services scheme continues its growth.Four additional out-stations were opened in 1930.The orthopaedic scheme, formerly run from CheltenhamHospital with one surgeon, is now based on hospitalsat Cheltenham, Gloucester, and Bristol, and has theservices of three orthopaedic surgeons. Venerealdisease can now be treated at the out-stations, after
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’being excluded for seven years. In the autumn of1931 dental treatment of pregnant and nursingmothers and young children will be undertaken.Existing isolation hospitals will be used for the present,but the county council will insist on the pooling ofresources and interchangeability of patients, so thataccommodation may be found for the rarer infectious,diseases, and that the occurrence of two cases of small-pox in different districts will not entail the opening’of two small-pox hospitals.
Norfolk.
Dr. T. Ruddock-West records considerable progressduring the last five years. Housing conditions haveimproved ; more parishes have been provided withdistrict nurses ; practically the whole county hasbeen covered for health visiting purposes, and dentaltreatment has been extended to necessitous expectant.and nursing mothers. On the passing of the LocalGovernment Act the county council decided that thepublic health committee with added members shouldalso function as the public assistance committee.’The new committee is styled the public health andassistance committee, and has subcommittees todeal with the various departments, with the exception.of school medical inspection and treatment. The 14-transferred public assistance institutions are all of themixed type. Arrangements are on foot to adapt.and use the Heckingham institution for mentaldefectives and to transfer the cases of senile dementia- to the Swainsthorpe institution in order to relievethe mental hospital.The hospital accommodation in the county for
medical and surgical cases appears to be adequateexcept for cases of surgical and advanced pulmonarytuberculosis. Since Stanninghall Colony (45 beds)was transferred to the council, it has been proposedto provide accommodation there for tuberculousand non-tuberculous crippling defects. Isolationaccommodation both for infectious diseases andsmall-pox is inadequate, and the county council hasapproved the principle of a central hospital for thoseareas with no adequate provision, but owing tofinancial stringency no further action is to be takenat present. Plumstead Hall has 70 beds for mentaldefectives, and a scheme has been approved for itsextension to form a 300-bed colony with servicebuildings for 500 patients.
All the urban districts except Wells have a pipedwater-supply. In Wells itself 55 houses have a
piped supply but the remainder draw their supplyfrom some 350 shallow wells, mostly liable to seriouscontamination. Outside the towns most of thewater is obtained from shallow wells liable to pollution.Many of the houses occupied by agricultural
labourers and people in similar circumstances are
poor in fabric and accommodation and cannot beconsidered in any way as reasonably fit. The agri-cultural labourer with 30s. a week cannot pay morethan 4s. in rental. A table is included in thereport showing the housing activities of the districtcouncils, from which it appears that certain councilshave been able to let houses at a rental of from 2s. 6d.to 3s. per week, inclusive of rates. Dr. Ruddock-West points out that if a large family occupies acondemned house, a special grant for rehousing-them is available under Section 26 of the HousingAct, 1930. Some districts have used the Housing(B.W.) Act with satisfaction, while others haveneglected it.
East Suffolk.
Dr. B. Wood-White shows that the districtnursing associations have increased in number from36 in 1921 to 70 in 1930. Of 320 parishes, 49 lackthe services of a district nurse. From the point ofview of public health administration, the provisionof a general nursing service in urban and rural areasis of primary importance, and Dr. Wood-White thinks Iit is the right policy for the council to employ thedistrict nurses as health visitors, in order that districtnursing associations may ultimately cover the whole- of the county. Some of the district nurses, however,
have not had a general hospital training, and theirexperience and knowledge are not equal to those of awhole-time health visitor. Dr. Wood-White was
unfortunately ill for five months during 1930, and hiscomments on the transferred medical services andinstitutions are not therefore available. He hasmuch to say, however, as to the transferred ChildrenAct, 1908. During the last quarter of the year thehealth visitors and district nurses supervised 357nurse-children. The supervision age should, he thinks, .
be extended from 7 to 15 years. He regards lumpsum payments as on the same footing as insurancepolicies. The arrangements for getting informationfrom the foster-mother he finds inadequate. He citesa bad case of neglect, which came before a lenientbench. If, however, he had removed all the childrento a place of safety, no bench of magistrates couldhave ordered the children to be taken back until thehouse was fit for their reception. Everyone willagree with Dr. Wood-White that the foster-mothersand their homes should be registered before anychild is received.
In the towns of Eye, Framlingham, NeedhamMarket, and Wickham Market there is no constantand pure water-supply, and in most of the ruraldistricts a constant and pure supply of water is ararity. Although the rural population drinks waterthat is polluted to some extent from time to time,Dr. Wood-White has not come across an outbreakof water-borne disease during his eight years’experience.
There is no tuberculosis dispensary in East Suffolk ;patients are visited systematically at their own
homes by the tuberculosis officers. There is, however,an examination centre at Lowestoft (population 44,000)which is apparently not much used, and Dr. Wood-White gives his reasons for thinking it would beimpracticable to set up an examination centre inany other place.
Breconshire.Dr. Herbert Davies says four poor-law institutions
were transferred to the council and that one of themhas since been closed, the inmates being moved toone of the others. The beds available are 43 for men,42 for women, and 19 for children. The mentalhospital at Talgarth, with accommodation for 481, isused jointly with the counties of Montgomery andRadnor. Health visiting and school nursing iscarried out by four whole-time visitors, and the 19nurse-midwives of the local nursing associations,which are subsidised according to the work done.There are 79 practising midwives, 71 trained andeight" bona fide." The midwives attended 827 of the932 live births and 43 stillbirths. They sent formedical help in 204 of their cases. There are 12maternity and child welfare centres, conducted by thelocal nursing associations. The centres receive grantsand are attended by the assistant medical officer ofhealth, Dr. Winifred E. Probert. No action has asyet been taken with regard to antenatal centres. -
Dumfriesshire.Dr. John Ritchie, referring to the high maternal
mortality (which compares with a rate of 7-0 for allScotland), expresses his conviction that this ratecould be reduced if adequate prenatal supervisionwere possible. It is comparatively easy to provideantenatal clinics in towns, but these have no place inrural administration with a widely scattered popula-tion, and the only promising scheme must be basedon the local practitioners and district nurses.Water-supply is the most difficult problem before
the county and governs the question of house provi-sion. A number of water schemes have been putforward recently and all given up on account of thecost. Dr. Ritchie suggests that the provision ofgravitation water on a large scale must be a matterfor earnest consideration. There are several placeswhere reservoirs could be constructed to serve thewhole county, but the vast cost of distribution isthe obstacle, which the Town and Country PlanningBill may help to remove.
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Among infectious diseases the event of the yearwas a water-borne epidemic of enteric fever atEcclefecham. The cases of enteric in the countyduring the last four years numbered 2, 3, 3, and 5.In 1930 they rose in number to 70. In the earlypart of the year there were three cases, and in thefirst three weeks of September, 23, 31, and 6 caseswere removed to hospital. Investigation showedthat water was the only common factor, and laterthat the pipes leading from the springs to one of thetanks had faulty joints close to a land drain. One ofthe four farm servants was found to be a carrier. Thecarrier has worked in this area for more than threeyears, but the chain of circumstances favourable to awater-borne epidemic had evidently not occurredbefore, and on this occasion the water was probablyonly infective for a few days between August 10thand 14th. There were few secondary cases, which isin great contrast with the year 1895, when thenotification reached a similar figure at a period whentyphoid was endemic.Two poor-houses, with 27 beds for the sick,
were transferred to the council under the LocalGovernment Act. Dr. Ritchie puts forward an
attractive scheme for improving the hospital serviceof the county. There are at present four smallisolation hospitals. He suggests that of these,Lochmaben should be slightly enlarged and carryout all the isolation work. There would then beavailable 74 beds in three modern well-constructedbuildings, which could be easily converted into cottagehospitals and used as annexes of the four voluntarygeneral hospitals, thus providing for convalescenceand abolishing waiting-lists.
Guernsey.Dr. H. D. Bishop says that the births during the
first thirty years of the century numbered 26,919,and the maternal deaths in childbirth 55, giving arate of 2-04 per 1000 births. The deaths fromtuberculosis in 1930 were 36, of which 35 were due tophthisis and one to tuberculous meningitis. Thesingle death from non-pulmonary tuberculosis isinteresting on account of the claimed absence of thebovine bacillus. Dr. Bishop complains thatpulmonary tuberculosis is only sent to the sanatoriumat an advanced stage ; he would like the otherhospitals in the Islands to make greater provisionfor the isolation of advanced cases. His suggestionthat the poor-law board should be renamed thecommittee for public assistance, and cease to restrictits hospital provision to paupers, may be helpful.The " homes for workers " committee has completedits housing scheme, and now lends money at a lowrate of interest to persons who wish to build smallhouses for themselves. The chief housing need now,says Dr. Bishop, is for cheap flats for the smallnumber of families who are really undesirable tenants.A sum of money is voted every year for the treat-ment of mental defectives, and occasionally cases
after a very long delay are sent to English institutions.Dr. Bishop recommends that the Channel Islandsshould establish a joint institution, with facilitiesfor grading and education. He also advocates theformation of a cancer care committee to undertakepublicity work and render assistance to sufferers.
INFECTIOUS DISEASEIN ENGLAND AND WALES DURING THE WEEK ENDED
JAN. 23RD, 1932.Notifications.-The following cases of infectious
disease were notified during the week :-Small-pox,55 (last week 68) ; scarlet fever, 1502 ; diphtheria,946 ; enteric fever, 22 ; pneumonia, 1786 ; puerperalfever, 46 ; puerperal pyrexia, 108 ; cerebro-spinalfever, 57 ; acute poliomyelitis, 4 ; acute polio-encephalitis, 1 ; encephalitis lethargica, 16 ; continuedfever, 1 ; dysentery, 17 ; ophthalmia neonatorum,103. No case of cholera, plague, or typhus feverwas notified during the week.
The number of cases in the Infectious Hospitals of the-London County Council on Jan. 26th-27th was as follows ;-
Small-pox, 124 under treatment, 6 under observation(last week 133 and 2 respectively) ; scarlet fever, 1189 ;diphtheria, 1451 ; enteric fever, 8 ; measles. 756 ; whooping-cough, 330 ; puerperal fever, 16 (plus 11 babies) ;encephalitis lethargica, 223 ; poliomyelitis, 3 ; " otherdiseases," 277. At St. Margaret’s Hospital there were
25 babies (plus 14 mothers) with ophthalmia neonatorum.Deaths.—In 117 great towns, including London.
there was no death from small-pox or enteric fever,40 (12) from measles, 5 (2) from scarlet fever, 41 (10)’ )’from whooping-cough, 34 (13) from diphtheria49 (17) from diarrhoea and enteritis under two years,.and 392 (115) from influenza. The figures inparentheses are those for London itself.The deaths from influenza show a slight drop from the
figure of the two previous weeks, but the total for the yearso far amounts to 1155, against 486 for the correspondingperiod of 1931. Of the great towns Birmingham stands.highest this week with 24 deaths from influenza, followedby Manchester with 21, Bradford with 11, and Willesdenwith 10. Eleven deaths from measles were reported fromManchester, 4 from Stoke-on-Trent. Liverpool andBirmingham each reported 5 deaths from whooping-cough,Manchester and Newcastle each 3. Small-pox is mentionedas a cause of death in December last in a case assigned toAlfreton U.D., Derby.The number of stillbirths notified during the weekwas 287 (corresponding to a rate of 43 per 1000 births),including 47 in London.
DEATH CLASSIFIED TO SMALL-POX.THE fatal case assigned to Alfreton U.D., Derby--
shire, was. Dr. Sydney O. Bingham tells us, of theordinary mild type. It was that of a female infant.,aged 6 months, who had just previously had anattack of chicken-pox. The cause of death wasstated in the certificate as (1) (a) heart failure, (b) septic-aemia, (c) cellulitis of leg ; (2) small-pox. Therewas no post-mortem examination.
A CORRECTION.—In summarising the annual healthreport of Belfast in our issue of Jan. 9th (p. 105) weare sorry to have attributed to Dr. P. S. Walker someobservations and opinions of Dr. Andrew Trimble.It was Dr. Trimble who pointed out that albumoseor albumin is generally present in a positive sputum,.and the particulars of pregnancy and tuberculosiswere also contained in his report as chief tuberculosisofficer.
THE SERVICESROYAL NAVAL MEDICAL SERVICE.
F. W. A. Fosbery to be Surg. Lt.ROYAL NAVAL VOLUNTEER RESERVE.
Proby. Surg. Lt. E. F. St.J. Lyburn to be Surg. Lt.
ROYAL ARMY MEDICAL CORPS.
Majs. W. B. Stevenson and C. J. H. Little retireon retd. pay.
Lts. H. W. Daukes, A. T. H. Marsden, and L. R. H.Keatinge to be Capts.
ROYAL AIR FORCE.
Flight Lt. J. W. Harper relinquishes his commission,on completion of service and is permitted to retain his ranka.
AUXILIARY AIR FORCE.
No. 600 (City of London) (Bomber) Squadron.—H. W.Walter is granted a commission as a Flying Officer.
DEATHS IN THE SERVICES.Deputy Inspector General Samuel William Vasey, R.N.
retd., a St. George’s man who qualified in 1877, died at’Teignmouth on Jan. 17th, aged 76. He entered the Navyas a surgeon in 1878 and a year later saw active service inthe Zulu War, landing with the Naval Brigade of theBoadicea (Zulu Medal and Clasp) ; later he was presentat the destruction of Batolonga on the West Coast of Africa ;:and during the Egyptian War of 1882 was surgeon of theSeagull (Egyptian Medal and Khedive’s Bronze Star):In 1890 he became staff surgeon, and four years later fleetsurgeon. In 1900 he served in the Cent1trion, the flagshipof Vice-Admiral Sir Edward Seymour during the Chinaoperations, and after being appointed to the Defiance, thetorpedo school ship at Devonport, retired in 1909.
