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THE LANCET.

LONDON : SATURDAY, MAY 11, 1929.

HEALTH OF THE MERCHANT SEAMAN.

HEALTH OF THE MERCHANT SEAMAN.A National Conference on the Health and Welfare

of the British Merchant Navy at home and overseaswas held at the Royal United Service Institution,Whitehall, on Friday last, May 3rd. The Conferencewas organised by the British Social Hygiene Counciland the British Council for the Welfare of theMercantile Marine, and should be useful in bringingbefore those who are immediately concerned the fact,often insisted upon in these columns, that the care ofthe mercantile marine in these directions has not beenof the standard which is recognised as necessaryamong other sections of the population. It must besaid, and with great pleasure, that the apathy, whichwas a marked feature in the situation until recently,has now disappeared, and that owners are wishful tofollow in every direction where they can the opinionsof medical and sanitary advisers. Further, theirdifficulties in doing so are now widely recognised, thenecessary environment of seamen, whether on wateror land, being one where the rules of health are

exceedingly hard of application.The principal discussion at the Conference turned

upon the morals of the seamen, and it must havebecome apparent to the audience that the provisionof suitable accommodation and chances of recreationat ports proved no sufficiently attractive alternativeswith large sections of the men to diversions where therisks of venereal infection would be run. The senseof the meeting was that, while reading rooms, oppor-tunities for indoor and outdoor sports, and the

provision of instructional films were all to the good,they are not effective yet, if ever they will be, asmeasures for the prevention of venereal disease, sothat practical attention must constantly be directedto the checking of dissemination and rapid treatment.As recently as April 5th of this year, at a meeting ofthe Medical Society for the Study of Venereal Diseases,reported fully in our columns on April 13th, a discus-sion on these questions was opened by Dr. H. iM.HANSCHELL, medical superintendent and medicalofficer V.D. department of the Seamen’s Hospital,London, and Dr. A. 0. Ross, V.D. officer of the Cityand Port of Liverpool. These observers pointed outfrom their large experience the risks run by seamenafter promiscuous coitus, and at the same meetingColonel L. W. HARRIS ON said that the only remedylay in the equipment of ships for the modern treat-ment of venereal disease, with its implication thatships’ doctors should be trained to use this equipment.At the Conference Dr. Ross stressed the point thatchancroid was essentially an imported disease, andproduced figures showing that quite one-third of allthe venereal disease treated at the Liverpool clinicsis imported from abroad. He pleaded for theexamination of every seaman before every voyage,this examination being directed not only to theheart and hernial orifices but to the genitalia wheresimple examination would reveal acute disease if

present. He testified to the impossibility of gettingmen on coastal trade to leave their employment inorder to have treatment. Treatment of syphilis, he

said, can usually be arranged for them, but in thecase of gonorrhoea casual irregular treatment meantthat cure remains for ever on the unattainablehorizon.The message which the Conference has delivered

is that there must be facilities provided on ship-board for the treatment of venereal disease; pre-liminary examination, even if insisted upon, will notremove its incidence thoroughly. Nor is there anyreason to suppose that owners would be otherwisethan extremely eager to offer the full facilitiesdemanded, but it must be pointed out that reformsalong this line (which are already being introduced),while meeting the case in many prominent directions,could still leave out of count a large body of seamenwhose avocations take them for extended periodsaway from land upon ships which carry no doctor.These men are deprived at the present of expertadvice in- the direction either of diagnosis or treat-ment. It is good that these things should be nowcommanding real attention, for publicity should pavethe way to reform. And it would be better that thereshould be no more delay in the institution of workingmethods.

THE PROPOSED DIPLOMA IN PUBLICDENTISTRY.

PUBLIC dental service has increased largely duringthe last decade. There is every reason to think thatthe future will see a still further increase of this branchof dentistry, and that a growing number of dentistswill, at some period in their career, find employmentin a whole-time or part-time capacity under publicauthorities. The dental treatment of school-children,while partly remedial, is concerned to an importantextent with prophylaxis and prevention. Its valueto the community, like that of the school medicalservice, is priceless, and it is essential for its officersto be highly trained and fully competent to carry outtheir responsible duties. There is at present keencompetition for vacancies as school dentist and theappointing authorities have a wide range of candi-dates from whom to choose. Preference is naturallygiven to those who have had hospital experience,preferably as house surgeon in a dental hospital;but it must be remembered that dental hospitals arefew and that only a minority of newly qualifiedpractitioners can hope to obtain such experience.A large proportion of those appointed to the schooldental service have had only a limited experience,and their knowledge of the particular problemsinvolved in the dental treatment of children is neces-

sarily meagre.These considerations have spurred the British

Dental Association to examine the case for the estab-lishment of a diploma in public dentistry. The curri-culum for qualification is already overloaded, but thestudent who does not propose to practise dentistryin private would surely welcome an opportunity ofacquiring special training for public health work andwould not grudge extra time devoted to this end. Awell-planned post-graduate course leading up to anextra diploma gives not merely an academic hall-mark but a guarantee of such training as will enabletechnical skill to be used with the greatest advantagein connexion with the general health service of thecommunity. The degrees in dentistry instituted bymost universities do not meet the need, since thediplomate in dentistry who has not taken a universitycourse from the beginning cannot proceed to a degree.The higher dental diplomas instituted by the examin-ing bodies in Edinburgh and Glasgow are general in

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character and could scarcely be modified to providea special course of the kind suitable for those engagedin public dentistry. A provisional syllabus for a

diploma in public dentistry has therefore beenframed by the British Dental Association and circu-lated to the various examining and licensing bodiesfor their consideration. It would seem a reasonablehope that, since the diplomas in ophthalmology andtropical diseases have admittedly been of service, ahigher dental diploma would raise the standard ofdental public health work and in the long run providefor a more efficient school dental service. So far,however, the response of the bodies to whom the pro-posal has been submitted, has not been propitious.The Dental Executive Committee of the GeneralMedical Council consider that no sufficient case hasbeen established for the institution of a diploma inpublic dentistry. A gleam of encouragement, however,comes from the University of St. Andrews, whileother provincial universities are evidently giving thescheme sympathetic consideration. The provisionalsyllabus framed by the British Dental Associationis, on the whole, well balanced. It provides for a

period of study of not less than a year and includescourses in bacteriology, parasitology, the principlesof public health and sanitation, epidemiology and vitalstatistics, oral hygiene, electrotherapy, and ortho-dontics. The practical syllabus provides for workunder the supervision of a medical officer of healthand a senior dental officer for not less than six months,and must include experience of the services organisedfor maternity and child welfare, venereal disease, andtuberculosis. Attendance at practical courses inorthodontics to be held at a recognised dental schoolis also necessary. The suggestion is that the examina-tion, like that for the D.P.H., might conveniently bedivided into two parts.The scheme does not seem to us over-ambitious nor

need the test be unduly severe. The objection thatthe dentist who does not possess a medical groundingmight not be able to assimilate so miscellaneous acurriculum can be disregarded, since it is not intendedto do more than to ensure that an officer concernedwith one branch of public health should have a

sufficient working knowledge of its other aspects.In two respects, however, the proposed curriculummight be strengthened. First, the practical instruc-tion at a dental hospital should include not onlyorthodontics but also the general remedial treatmentof dental disease in children, as contrasted withadults. Many special difficulties are encounteredwhich the newly qualified rarely appreciate unless

they have been warned. Secondly, since successfultreatment of children requires not only a liking forthem but also some knowledge of their psychology,the elements of child psychology might well form

part of the course of study for a diploma in publicdentistry. In private practice there is time to makefriends with small patients, and most dentists soonacquire the art. But in school practice the difficultchild may cause delay and disorganisation, and heresome knowledge of modern ideas as to the probablecauses of negativism and obstinacy may help thedentist to cope with an awkward situation. In ourview the scheme outlined by the British DentalAssociation deserves consideration. It is designed toincrease the efficiency of the school dental serviceand to make it easier to select suitable applicants forcoveted posts. A properly planned diploma in publicdentistry would not only enhance the prestige ofthe dental profession but would also strengthen thepublic health service of the country by promotingcorrelation between important branches of this service.

PELVIC DISPROPORTION.AT the Congress of Obstetricians and Gynaecologists

held in Dublin, reported on p. 999, interest in the-first subject for discussion was well sustained through-out the day. Pelvic disproportion is indeed a subjectof perennial interest and importance. It is doubtful,however, whether the practitioner will be able to

disentangle from the views expressed any clear-

messages, apart from the vehement pronouncementsagainst the use of forceps until the child’s head isvisible at the vulva. High-forceps and mid-forcepsoperations have been formally banished fromobstetric practice and must not again figure in theobstetric literature and teaching of this country.Axis-traction forceps, with whose application and

management the students of a generation onlyrecently past were largely concerned, are to beregarded as obsolete instruments. Such an unequivocaland unqualified declaration of tactics, coming frommany experienced obstetricians, and disclaimed bynone, must certainly carry great weight. Probably moregood than harm will result from this ban, and casesof " failed-forceps "-the nightmare of every obstet-rician-will be less common. Still, we must bear inmind the fact, not sufficiently emphasised in thediscussion, that malpresentations are a very commonsource of pelvic disproportion when both the pelvis.and the child’s head may be normal in size ; andthat of all the malpresentations of the head occipito-posteriors are the commonest. Indeed, in probably35 per cent. of all cases the head of the child at thebeginning of labour presents in this way. Spon-taneous rectification usually occurs, but if it does notinterference is desirable. Instrumental rotation is.not now recommended by any responsible school, butmost authorities agree that after manual rotationit is usually necessary to apply forceps to maintainsthe corrected position. This may be an unimportantexception to a sound general rule, but there are others-of the same order, and they illustrate the danger inobstetrics of decrees that are too absolute. Undue

dogmatism was exhibited also by certain speakers inregard to induction. Some agreed with the dictumof WHiTRiDGE WILLIAMS that this procedure shouldnever be performed ; others were equally confidentthat it should be the method of choice in minor

degrees of disproportion. But can the presence ofminor disproportions be diagnosed with any certainty,and if so, by what criteria ’? It was argued that muckdepends on the moulding of the child’s head, but toolittle was said about the chief factors concerned inthis process-namely, the degree of ossification of theskull-bones, the force of the uterine contractions, andthe strength of the accessory muscles employedduring labour. In regard to the first of these factors,.postmaturity is of the utmost importance, and isindeed a common cause of disproportion. It is the

practice of one school to have an X ray picture takenof every patient who does not come into labour atthe estimated date. If the child’s skull is seen to bewell ossified and if the centres of ossification of thelower end of the femur and head of the tibia are-

present, induction is immediately practised. It is.

likely that in this way a number of difficult labours.are avoided. In the medicinal induction of labour-

preferably by pituitary extract, since the efficacy andsafety of quinine is in doubt-we have a safe methodand one following which uterine contractions are-

likely to be augmented.Another factor which may simulate disproportion

or greatly complicate a difficult delivery is uterineinertia, of which little was said at the Congress.

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Craniotomy and Cfesarean section have been per-formed for supposed disproportion on occasions whenin reality uterine inertia was the cause of the troubleencountered, and many patients who have suffereda series of difficult labours have been found in laterconfinements to have inertia and have been relieved

by the judicious use of pituitary extract. It emergedfrom the discussion that the procedure of choice incases of pelvic disproportion is a " trial labour." Itwas generally agreed that in a well-equipped institu-tion where the patient can be watched by experts,very little harm could result from a trial labour, andthat many cases would be observed to terminate

naturally, or at most after a low forceps delivery.But it was not stated with sufficient emphasis that atrial labour should never be allowed in a doubtfulcase in general practice. If the idea gets abroad thatthis is a proper method whereby to arrive at a decisionas to the obstetrical possibilities of any given mother,the result will be a far larger number of emergencyCaesarean sections and craniotomies than at present.Moreover, the point of view of the prospective mothercannot be ignored, and it is unlikely that she wouldwelcome expectant treatment which may involvedistress of far longer duration than would inductionor Caesarean section. The avoidance of maternalinjuries and disablement was not perhaps givenenough prominence in last week’s debates. Yet it is asubject of grave national importance as well as beingthe point where an obstetric case may be preventedfrom developing into a gynaecological one. In this con-nexion stress might have been laid on the associationof the funnel-shaped pelvis (not at all an uncommondeformity) and perineal laceration. Owing to thenarrowing of the transverse measurement of theoutlet in this type of pelvis the head is compelled toshift backwards as far as possible towards the rectumand to be born with inevitable serious laceration.In most patients presenting complete perineal lacera-tions there is considerable narrowing of the transversediameter of the outlet.

The subject of pelvic disproportion includes almostthe whole of obstetrics, since nearly all difficulties arerelated to the primary one of delivering a livinghealthy child through a narrow passage without

injury to the walls. It would have been impossibleto touch on all its aspects in the time allotted, andthe practitioner should be grateful for one piece ofconcrete teaching offered-the denunciation of high-and mid-forceps when used for traction alone. Heis also likely to agree with the condemnation of thepresent method of conducting and staffing the ante-natal clinics throughout the country. The generalopinion was that supervision of pregnancy andantenatal examinations should be undertaken bythe medical man or woman who is going to attendthe labour. One of the first duties of the proposedCollege of Obstetricians and Gynaecologists might bethe framing of an alternative scheme which wouldprovide for this continuity of control.

THE OSLER Cr.UB.—On April 30th this club cele-brated its first anniversary. Sir Farquhar Buzzard read apaper on the History of Neurology, in which he traced fromtheir sources the different channels which have led up to

the modern science, and prophesied a greater importancefor neurology, in its widest sense, in the solution of social,and especially educational, problems. Mr. Falconer Madanspoke on Osler and Burton, and Dr. J. D. Rolleston gave ashort sketch of the life and work of Theodor Billroth.Portraits and works of Burton and of Billroth and theclub’s collection of Osleriana were exhibited.

Annotations.

THE PARATYPHOID OUTBREAK OF LAST

SUMMER.

"Ne quid nimis."

ABOUT the end of July last year five cases ofparatyphoid fever were removed to St. James’sHospital, Balham, from a residential children’s nurseryin Streatham, and from there to one of the M.A.B.fever hospitals, when the infection had been identifiedby serological tests as paratyphoid B. A day or twolater 15 cases of a similar illness were reported amongwell-to-do families in Kensington, and the Londoncounty health authority learned of an outbreak inEpsom somewhat earlier in which four children fromtwo households had sickened within a few hours ofone another after having consumed strawberries andcream. Many other cases occurred shortly after inthe Western area of London and in the neighbouring-parts of Surrey around Sutton, and inquiry revealedthat most of the patients had partaken of - creampurchased from retailers who obtained their supplies.from one common source-namely, a large wholesaledairy. The circumstances of this outbreak were setout in our columns at the time, when it was pointedout that the outbreak showed no respect for age orclass, was not closely localised to any one area, wascharacterised by abundant rose spots and a slightlyenlarged spleen, and was not alarming in its severityalthough one death at least was reported. Dr.J. A. H. Brincker, senior medical officer to theLondon County Council, was deputed to collate allthe available evidence so far as it concerned the-County of London, and his report 1 two the Public HealthCommittee is now presented by Dr. Kay Menzies..From the first some article of diet such as cream was-under grave suspicion of being responsible for theinfection, and Dr. Menzies points out how the whole-hearted cooperation of all the medical officers con-cerned has solved the immense difficulty of trackingdown the probable source of infection. The evidencefor incriminating the cream of a particular wholesaledairy was cumulative. In London most of the provedcases (201 in number) of paratyphoid B developedtheir illness during the third and fourth weeks ofJuly, and the same was true of the 219 proved casesin the home counties. It was clear therefore thatthe outbreak originated about the end of the firstweek in July, when, the weather being warm andfruit abundant, cream traced to this dairy had beenfreely supplied to the areas affected and hadbeen consumed by the majority of the patients. In.Kensington 41 out of 55 cases had certainly this-cream, a proportion creating a high degree of pre-sumption, for in investigations of this kind it is rarefor more than half to be definitely ascribed to thesuspected source of infection. A striking piece ofcorroboration was afforded by a Suffolk visitor who-partook of strawberries and cream with a Londonfriend on July 7th ; both of them sickened of para-

typhoid after a fortnight’s interval. The evidence,.however, remains presumptive only, for no para-typhoid organisms could be discovered in the creamwhen samples were taken three weeks after theinfection had occurred ; which does no more thansuggest that the infection was of a transitory character-such as would be produced by an intermittent carrier.The cream itself was derived from three principalsources, and definite evidence of contamination withthe colon bacillus was obtained from two of thesesources. The discovery of this gross contaminationindicated that the cream must have been exposed to-pollution at some stage of its production or in transitsNo evidence of infection, after repasteurisation, byany employee of the firm could be discovered, and the

1 An Outbreak of Paratyphoid Fever. Report by the MedicalOfficer of Health, London County Council. No. 2643. LondonP. S. King & Son, Ltd., 1929. 1s.