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areas the prevailing types may be different. (5) Inview of the persistence of the same type of organism,(a) in multiple domiciliary cases, (b) in the examinationof several colonies from a single plate, and (c) in thelarge majority of serial examinations from the samecase, our opinion is that these various causal organismsbreed true.

We beg to offer our thanks to Prof. Harold Kerr,medical officer of health, Newcastle-upon-Tyne, forthe facilities for conducting this investigation whichwere so freely placed at our disposal, and to Dr. W. M.Scott, of the Ministry of Health, for advice and assist-ance in many ways too numerous to mention. Thispaper, moreover, would be incomplete without anacknowledgment of our indebtedness to Dr. F. H. A.Clayton, in conjunction with whom the inquiry wasinitiated.

References.1. Nabarro, D.: THE LANCET, 1927, i., 460.2. Fraser, A. M., Kinloch, J. P., and Smith, J.: Jour. Hyg.,

1926, xxv., 453.3. Wiseman, W. R. : Jour. Hyg., 1926, xxv., 483.4. Charles, J. A.: THE LANCET, 1928, ii., 616.5. Breakey, S. F., and Clayton, F. H. A.: THE LANCET, 1926,

ii., 541.6. Clayton: THE LANCET, 1927, i., 391.7. Warren, S. H.: THE LANCET, 1927, i., 494.8. Kerrin, J. C. : Jour. Hyg., 1928, xxviii., 74.9. Clayton and Warren : Jour. Hyg., 1929, xxviii., 355.

10. Andrewes, F. W., and Inman, A. C.: Med. Res. Council’sSpecial Report, 1919, No. 42.

11. Clayton and Warren : Jour. Hyg., 1929, xxix., 191.

THE STATE OF THE PUBLIC HEALTH.

(Concluded from p. 574.)

WE have already dealt with the general lessons ofthe Annual Reportl of the Chief Medical Officer of theMinistry of Health for 1928 (August 31st, p. 480),and with the sections devoted to maternal and infantwelfare, and the insurance medical service. Thefollowing is a brief summary of the remaining sectionsof the report.

The Local Government A ct.The Report discusses the evolution of the poor-law

and the development of public health administrationin England since the Reform Act of 1832. It urgesmedical officers of health to be prepared to advisetheir councils on such general questions as :-

1. The desirability of discharging certain of thetransferred functions through some committee otherthan the Public Assistance Committee, to which mostof the transferred powers otherwise stand referredor may be delegated.

2. The advisability and practicability of providingcertain forms of medical assistance under the PublicHealth and other Acts rather than under the PublicAssistance Committee and the Poor-law Act.

3. Whether in districts where it is impracticableto declare that all assistance for the sick should beprovided under the Public Health Acts, it maybe desirable to appropriate one of the transferredinstitutions to hospital purposes and to administerit under one or other of these Acts.

4. The desirability in counties which have decidedto provide certain forms of relief under the EducationAct, 1921, or the Maternity and Child Welfare Act,1918, of delegating the provision of such assistance toother local authorities.The principal question is how many and which of

the poor-law medical services can be absorbed intothe public health organisation of the area, and howmany must remain ad hoc. Each individual areamust aim, not at providing every service everywhere,but at supplying as effective and complete a serviceas is practicable. The Report advises local authoritiesand their medical officers to consider the medicalfunctions of boards of guardians on the one hand andthose of county and county borough councils on the

1 On the State of the Public Health. H.M. StationeryOffice. Pp. 295. 3s.

other hand, and to devise an organisation most likelyto prove effective for the joint performance of thesefunctions in the varying circumstances. It offersa most valuable guide in a complete review of themedical functions of both bodies, and mentions theprincipal matters which will require the promptattention of medical officers of health. Perhaps themost essential thing to secure is effective coordination,not only between the various branches of the serviceand the various institutions carrying out relatedduties, but also between local authorities and voluntaryagencies and between institutional medical treatmentand environmental hygiene and sanitation. Theservices which must now be woven into a unifiedorganisation on behalf of the whole community includewater-supply, drainage, refuse collection, housing,smoke abatement; the control of the food- and milk-supply ; health in the office and factory ; maternity,infant and child welfare ; school medical service ;isolation hospitals and treatment of fevers ; baths andwash-houses; cleansing of persons, and the directtreatment of such diseases as tuberculosis and venerealand mental disorders. " For the first time in thehistory of the public health service the medicalofficer of health has a direct and ample opportunityfor closely and effectually coordinating in his areaall the varied medical services of the State."

Epidemics during 1928.The outstanding events of the year in general

epidemiology were the continued prevalence ofsmall-pox (to which we referred in an earlier issue 2),an unusually large incidence of scarlet fever, and awidespread epidemic of influenza in the winter of1928-29. The diphtheria figures are also greater thanduring the preceding quinquennium, and the mortalitywas 5-2 per cent. Seventeen borough councils inLondon, but only 19 local authorities in otherparts, are now providing immunisation againstdiphtheria. The personal influence of the health visitor,supported by a simple pamphlet, usually provides asteady flow of applicants at the clinic. Toxoid-antitoxin mixture is generally used, but a preparationof toxoid alone is equally safe and is said to be equallyeffective. The experience of the year has strengthenedbelief in the value of the method, but has shown thatbetter results are obtained if an interval of two or threeweeks is allowed between each injection.

Scarlet fever continues to be mild, with a casemortality of 0-56 per cent. More use is being made ofantitoxin, which reduces the tendency to complications,but the progress of active immunisation with toxinis limited by the number of doses required.

Measles ranks second only to whooping-coughas the most fatal infectious disease of childhood.During 1928 it accounted for 4302 deaths. Theserum of convalescent patients has been found a veryuseful prophylactic, although not of much use intreatment.The deaths from whooping-cough show a decline

from 3681 in 1927 to 2976 in 1928.A study of the outbreaks of enteric and the para-

typhoid fevers show that gross sanitary defects arebecoming less and less responsible, while special dangerlurks in the modern methods of wholesale distributionof foodstuffs, which make it difficult to track down theoriginator and distributing agents. During July andAugust nearly 400 persons in London were attackedby paratyphoid B ; it was found impossible to tracethe infection beyond a wholesale cream dealer whoreceived cream from three different sources, two ofthem outside the country.

There was a decrease in prevalence of infectiousdiseases of the nervous system, especially of acutepoliomyelitis and, to a lesser extent of encephalitislethargica. The encephalitis unit at WinchmoreHill is to be extended, and progress has been madewith the arrangements for dealing at the RamptonState Institution with cases certified under theMental Deficiency Acts.

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There was no plague in 1928, although plague-infected rats were found on board several ships whichreached this country, and the anticipated drift ofcholera westward did not materialise. There werethree cases of typhus, two of them in Stepney beingconfirmed by the Weil-Felix reaction. The 683cases of dysentery notified during the year representsa considerable increase ; 58 per cent. of the casesoccurred in mental hospitals.

Influenza.Since the third pandemic wave in March, 1919,

there have been several trailers : in January, 1920 ;in April and May, 1923 ; and early in 1924. In

January, 1925, the whole country was affected. iThere was only a slight recrudescence in 1926, but in I1927 there was an epidemic of the second order ofimportance. The year 1928 passed without anyinfluenza, but the news from America caused dis-quieting anticipations which were fulfilled by a seriousepidemic from January to March, 1929. The death-rate per 1000 rose from 0-16 for the great towns in thefirst week of December to 5-78 in the last week ofFebruary. There seem to have been two mainwaves, the first proceeding southward from Glasgowwhile the other extended northwards from greaterLondon. None of the signs recognised by epidemi-ologists as precursors of an influenza epidemicwas noticed in this country in the autumn of1928, and it seems probable that the infection wasintroduced directly from America and fostered by theexceptionally cold weather in January and February.The public schools suffered considerably in thisepidemic, but the disease was mild. Otitis media,however, was a rather common complication. Thereport discusses the symptoms of influenza and thevariations shown in the different epidemics. That of1928 was characterised by a four days’ fever withsome pulmonary catarrh and two kinds of onset:sudden, with acute hyperpyrexia, followed generallyby rapid convalescence, or insidious, with earlysubnormal temperature, headache, and malaise,followed by a protracted convalescence. The respira-tory system was frequently involved and acutesinusitis was common. The symptomatology, how-ever, varied in different parts of the country. TheReport draws attention to the possibility that a rashmay be associated with influenza, and outlines the Iprinciples of treatment and prevention. i

Tuberculosis.

During 1928 a total of 77,881 new cases oftuberculosis were notified, and it is generally agreedthat notification is steadily becoming more effective.Nevertheless, 4252 of these new cases were only notifiedafter death, so that there is still room for improve-ment. The number of deaths from all forms oftuberculosis was 36,623, a decrease on the previous ’,year. Since 1911 the gross death-rate from pulmonarytuberculosis in men has fallen from 1233 to 879per million, while the reduction in non-pulmonarytuberculosis is from 436 to 188. These encouragingfigures show that the measures taken to combat Ithe disease are well worth continuing. TheReport discusses the present accommodation fortuberculous patients, the possible modifications underthe new Act, and the notification returns. The newAct should greatly assist local authorities in theimportant task of formulating wise schemes for after-care and technical education. Investigations havebeen and are still being made into immunisationof the newly-born by Prof. Calmette’s method. Theresults of the special inquiry into tuberculosis amongprinters have now been published ; the report doesnot explain the high incidence of this disease amongprinters, but brings out certain differences betweenthe occupational groups which will pave the way forfurther inquiry.

Cancer and Radium Treatment.Cancer continues to exact its heavy toll, the death-

rate in 1928 per million population being 1425,an increase of 50 on the previous year. Sir George

Newman discusses the problems which are broughtout by the statistics relating to cancer incidence andreviews the special inquiries which have been madeby the Departmental Committee. Especial attentionis given to the possibilities of treatment by radiumand the effects and modes of application of radio-therapy. The conclusion reached is that radium alone,properly applied, will bring about the disappearance

’ of a primary cancer, in a fair proportion of cases, fromthe skin, the cervix uteri, and the mouth and tongue.There is not as yet sufficient experience available toclaim an equal success against cancer in other partsof the body, and secondary cancer in glands requiressupplementary X ray treatment in every case. TheReport reviews the organisation of radium therapy inthe various European countries and lays down certainguiding principles for its development in England.These are :

1. If this rare element is to be used as economically aspossible it should be kept constantly in action, so that asmany patients as possible receive treatment.

2. The radium must be maintained in different quantitiesin containers of various sizes and shapes for use in differentregions.

3. The supply of patients at suitable centres must beadequate to keep the radium in continuous use ; sendingradium to patients causes loss of radio-active time and islikely to lead to inefficient treatment.

4. The services of regional surgical and radiologicalspecialists must be available.

5. Attendants must be fully trained in the use of radium,both from the point of view of skilled service and from thatof their own safety.

6. Radium can be used safely and wisely only bythoroughly competent experts.

7. The radiotherapist and the surgeon must cooperatefrom the very beginning of treatment.The conclusion is the same as that of the Radio-

logical Subcommission of the League of Nations 2that radium therapy can only be adequately developedby means of specialised centres serving largepopulations, and that research and treatment mustproceed hand in hand.

TTene7eal Disease.At the end of 1928 there were 188 treatment centres

for venereal disease in England and Wales, employing386 medical officers and with an average of 787sessions weekly. There was a decrease of 2-7 per cent.in the new cases of syphilis, an increase of 9-9 percent. in gonorrhoea, and an increase of 10’2 per cent.in patients who attended the centre but were found tobe free of venereal disease. The London CountyCouncil initiated during the year a scheme forcontinued observation of girls discharged from hostels.Through the Central Council for the Social Welfare ofGirls and Women in London, a certain number ofrescue homes have agreed to take in girls who havebeen under treatment for venereal disease but havebecome fit to mix with others. This will providecontinued treatment and observation for these girlswhile at the same time enabling the existing hostelsto find room for a greater number of acute cases.Experience continues to show that the most importantfactors in the success of a treatment centre are thepersonality of the staff and the convenience of thepremises. There is a definite improvement in thepromptitude with which patients seek treatment,and this is attributed to the steady educational workcarried out by local authorities and the British SocialHygiene Council. Expenditure on propaganda iseconomically justified, for the cost of treatment ofa patient whose serum reactions have become positiveis at least -&bgr;2 more than that of a primary case

in which the reactions are still negative. Review-ing veneral disease schemes in other countries the ’Report points out that the British scheme has theadvantage of central supervision and universal freetreatment.

Food.

I An ever-increasing interest is being taken in dieteticquestions, and the value of milk for growing childrenis becoming generally recognised. More than one

2 THE LANCET, August 17th, p. 348.

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dairy organisation has inaugurated a scheme for payingfarmers a bonus on the bacteriological cleanliness oftheir milk. The suggestion that

" if the public willdrink more milk they will get a better, cleaner, andcheaper supply " is characterised as putting the cartbefore the horse. Not until a better, cleaner, andcheaper supply is provided can increased consumptionbe expected. There seems no doubt that the coolingof milk at depots and its despatch in bulk in suitabletanks is a great improvement, both economicallyand hygienically. Its only disadvantage is the

difficulty which it imposes when any district wishesto trace an infected sample to its origin. The solutionseems to lie in the development of a more activecontrol by the authorities of the producing areas.The number of producers and distributors who obtainlicences for Certified and Grade A milk is steadilyincreasing. Of the 12,000 milch cows in licensedherds in 1928, some 4800 were in Certified herds and7200 in Grade A tuberculin-tested herds. The intra-dermal tuberculin test has been found the easiest andmost reliable under ordinary farm conditions. A

large number of samples were taken for bacteriologicalexamination, and most of them were satisfactory.As the Report remarks, the indirect effect of gradingis of paramount importance, for it has stimulated thewhole industry to produce better milk.Imported meat proved satisfactory during the year,

except for some consignments of tuberculous meatfrom the Irish Free State, and a rather large incidenceof caseous lymphadenitis in mutton imported fromSouth America and Australia. The new Food andDrugs (Adulteration) Act came into force on

Jan. lst, 1929, and will simplify the work of thoseconcerned in its administration. Of 129,034 samplesof food analysed during the year, 7524 were foundadulterated or below standard, and 757 contravenedthe Preservative Regulations. Nearly half thesewere sausages or other meat products. The ArtificialCream Act, which came into operation on June lst,1929, attempts to regulate the " reconstituted cream,"which is prepared by emulsifying butter, driedskim milk and water, and which, if carefully blended,cannot be distinguished from natural cream by theanalyst. There were no striking outbreaks of foodpoisoning during the year, but the Report discussesa number of cases where it was not possible to provethe source of the infection.

Hygiene and International Health.The Intelligence Section has continued its collection,

tabulation, and indexing of medical information fromhome and foreign sources, and a number of importantreports and memoranda were issued during the year.The working arrangement between the Ministry, theMedical Research Council, and the London School ofHygiene and Tropical Medicine has proved satis-factory. During 1928 a great deal of importantstatistical work was carried out, including investiga-tions into anthropometric data, pre- and neonatalmortality, cancer, certified incapacity, and experi-mental and clinical epidemiology. The Ministry’spathological laboratory has been paying specialattention to the immunological classification ofstreptococci3 and a revision of the serological types ofthe Flexner group.

Rheumatism and Undulant Fever.The value of the notification of rheumatism remains

doubtful. The number of rheumatism supervisorycentres is increasing, and the number of beds for thetreatment of rheumatic affections under the Metro-politan Asylums Board has increased to 520, in additionto the special unit for 60 acute cases at Carshalton.Recent investigation has shown that cases of

undulant fever occur in European countries where thedisease had not been suspected, and the Ministrytherefore investigated the possibility of its occurrencein this country. Although it does not appear thatthere is any endemic undulant fever in England,it is unwise to assume that there never will be, and

3 THE LANCET, 1928, ii., 697.

medical practitioners and bacteriologists are asked tobear the possibility in mind.

Miscellaneous.

Among other inquiries carried out by the Ministryin 1928 was one into the existing provision for sickpublic-school boys and the principles which shouldunderlie sanatorium accommodation. Anotherinquiry was made into the supervision which isexercised by local authorities over working conditionsin offices. Liverpool seemed to be the only town whereoffices not associated with workshops undergo anyroutine inspection. Cubic space, ventilation, lighting,and sanitary accommodation are points of greathygienic importance for office workers, but it must beadmitted that detailed systematic inspection of alloffices would be extremely onerous, and in the opinionof the Ministry it is doubtful whether the results wouldjustify the time and expense involved. An officecommittee has considered the hygiene of swimmingbaths and has laid down certain principles for itsmaintenance. The Reports on rural water-suppliesand artificial light treatment have already beennoticed in our columns. 4 The unhappy conditionof the coalfields in 1928 led to an inquiry into theconditions of the inhabitants of certain miningareas. The results on the whole were reassuring,apart from an increase in rickets in certain areas ofSouth Wales and a lack of vitality among women,especially expectant and nursing mothers.

THE INTERNATIONAL CONGRESS OF

OPHTHALMOLOGY.

MEETING IN HOLLAND.

THE Thirteenth International Congress of Ophthal-mology-the first meeting of this nature to take placesince the war-was held from Sept. 5th to 13th inHolland. Under the presidency of Prof. J. VAN DERHoEvE the Congress was officially opened by theQueen Mother’ in Amsterdam, while the concludingsessions were held in the seaside resort of Scheveningen.The meeting was a very large one-larger than anypreviously held-and the members included the greatmajority of the leading ophthalmic surgeons fromevery country in the world ; the social arrangementswere efficiently and delightfully organised and boretestimony to the boundless hospitality of the Dutch,not the least pleasing aspect being the personalinterest shown by the Royal House ; and the scientificproceedings throughout were of sustained interest andhigh standard.

Glauco7na.The first question for discussion was the aetiology

and Non-operative Treatment of Glaucoma, uponwhich a symposium was held. It, was opened byDuke-Elder (London) who introduced the subjectfrom the physiological point of view. He suggestedthat in glaucoma the raised tension, although themost obvious symptom, was not the basically essentialfactor, but was one of the more striking manifestationsof a general derangement of the intimate metabolismof the eye. He discussed the economy of the eyein so far as it affected glaucoma under three headings :the equilibrium between the capillary blood plasmaand the intraocular fluids ; that between the intra-ocular fluids and the vitreous body ; and that betweenthe blood in the choriocapillaris and the retina.He concluded that in the majority of cases glaucomawas ultimately due to an upset of these equilibriadetermined by changes in the capillaries and changesof a physico-chemical nature in the vitreous body,while the onset of pressure was largely conditioned bya failure in the facilities for drainage at the canal ofSchlemm. Hagen (Oslo) followed with a paperwherein he stressed the importance of diurnal

4 THE LANCET, 1928, ii., 1070 ; 1929, i., 884.