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THE RECENT WORK OF THE GOVERNMENT LABORATORY.
734 the other the richness of the serum in specific antibodies-in order to observe whether they gradually diminish. Dr. Weinberg’s paper is an important addition to our knowledge of hydatid disease, and the method of diagnosis he has established seems likely to be one of great value. He points out that it is more trustworthy than the Wassermann reaction for syphilis, because in the hydatid fluid there is available an absolutely pure antigen. He states that this can be preserved on ice or in the dry state, He has also studied the so that it can be always available. of method diagnosis employed by Fleig and precipitin Lisbonne, but has found it less trustworthy, since it was only obtained in one-third of the cases. He is to be congratulated upon the thorough manner in which he has investigated the question, and his method, if confirmed by other investigators, should eventually become almost a routine procedure in the diagnosis of hydatid disease.
eosinophilia,
and may be commended to the attention of the skilled The light thrown by observers in our fever hospitals. this statistics on and kindred questions is of great importance, but will not by itself suffice to determine the nature of the malady. -
THE RECENT WORK OF THE GOVERNMENT LABORATORY.
THE official report of the principal chemist (Sir Thomas E. Thorpe) of the Government laboratory for the year ended March 31st, 1909, has been issued. Sir Thomas Thorpe may be congratulated upon the completion this year of 15 years’ service, during which the work and equipment of the laboratory have been extended considerably. The report, which will be the last one from his pen, shows that the number of samples examined has increased by about 100,000 and the staff by 27. The increase in the number of samples has been due principally to a greater activity HÆMORRHAGIC DIPHTHERIA. in the Excise department, 117,379 samples having been Now that the great majority of all cases of infectious examined last year as against 46,375 in 1894. The disease are isolated in special hospitals we have to depend number of samples of food and drugs referred to the Governfor advances in our knowledge of them upon the medical ment laboratory during the past official year was 120. Of officers of the Metropolitan Asylums Board and other similar these samples the Government analysts agreed with the institutions. We are glad to find that these officers have not public analysts’ certificate in regard to 100. 82 of the referred -only inclination but also facilities for scientific work. An ex. samples were of milk, and 12 were of butter. Amongst .ample may be seen in the interesting paper on Hasmorrhagic miscellaneous samples appears a case of fish poisoning. The Diphtheria contributed by Dr. J. D. Rolleston to the Metro- river Lemon, which is within the jurisdiction of the Teign politan Asylums Board Report for 1908, in which statistics Board of Conservators, proved to be contaminated with are given based on 78 cases of this condition among 1550 copper, the source of which was mine drainage. Dead trout From the figures given it appears that taken from a spot near the source of pollution contained cases of diphtheria. the hæmorrhagic form of the disease occurs from year to year copper. The metal was found in the matter washed from the with curious regularity, the percentage of such cases being gills, in the viscera, and in other parts of the body of the usually between 5 and 6. The incidence is not influenced by fishes. Samples of the river water on standing deposited a In some analytical work the season of the year or by the age or sex of the sufferer, and sediment containing copper. it does not appear that previous ill-health is a cause of the undertaken at the instance of the recent Royal Commalignancy of the disease. Along with the haemorrhages mission on Whisky Sir Thomas Thorpe reports that there were invariably present other signs of grave infection, the whisky sold at fairs and markets, public-house and such as extensive membrane, "faucial and palatal oedema, refreshment bars was free from any deleterious ingredisproportionate adenopathy, pitting of the skin over the dients such as methylated spirit, vitriol or other mineral glandular swelling, and absence of, or delay in, reaction to acids, or salt, which have been alleged to be used for antitoxin." The mortality of these haemorrhagic cases adulterating whisky of this kind. Most of the samples, he reached 83’ 3 per cent. Grave as is this figure, it yet has a adds, consisted mainly of patent-still spirits, but the prices at hopeful aspect, for in days gone by practically all these which they were sold corresponded generally to the character patients died. The saving of nearly 17 per cent. of the of the mixture, and as a rule were not excessive. In regard lives is probably due to treatment with antitoxin, the to materials used in the making of beer, 559 samples were relationship of which to this affection is of consider- examined, of which 30 proved to contain over1/100th grain able interest. It would seem from Dr. Rolleston’s observa- of arsenious acid per pound in the case of solids or per tions that early administration of large doses of this remedy gallon in the case of liquids. Of 114 samples of malt exahas the power of preventing, or at least modifying, the mined only one exceeded the limit, while none exceeded the onset of hæmorrhagic symptoms. Thus no cases of this nature limit when 278 samples of glucose were examined. 4347 occurred among patients who were treated with antitoxin on samples of beer were taken from the premises of 1591 the first day of the disease, but the percentage steadily rose publicans and retailers of beer, and 8’ 1 per cent. of these as the delay in the administration of the serum increased. were found to be diluted with water, five were adulterated cases in 23 which less than while Further, 33,000 by the addition of"saccharin,and three by the addition among units of antitoxin were given none recovered, among 55 who of a" heading " solution. In considering these quite few received this and larger quantities 12 finally survived. All facts, which are scattered amongst a great number of those who recovered went through an attack of paralysis. others in the report, it is obvious how very important to the This seems to suggest that there may be one and the same community this Government department of control has poison at work in the production of haemorrhage and of the become. neural lesion. We hope that Dr. Rolleston will pursue his researches into the pathology of the condition, which needs A TELEGRAM from the Governor of Hong-Kong to the careful elucidation. Is there a mixed infection in these Secretary of State for the Colonies, received on August 28th, cases ? Is there any particular strain of diphtheria bacillus declared Hong-Kong to be free from plague. which causes this complication ? Are there any special morbid lesions of the various viscerawhich accompany it ? THE Earl of Crewe, Secretary of State for the Colonies, Seeing the close connexion that sometimes exists between has and as in snake the case of venom, haemorrhage, appointed a scientific committee for the study of haemolysis it might be interesting to examine the serum for hasmolytic entomology in relation to the propagation of diseases in man substances. These and other problems still await solution and animals and to the cultivation of plants in the Colonies ___
735 and Protectorates of British Tropical Africa.
This comAfrican Entomomittee, which will have the title of the logical Research Committee, and will be under the chairmanship of the Earl of Cromer, has a distinguished scientific constitution. The committee will publish its results in journal form. _______________
DOMICILIARY MEDICAL TREATMENT UNDER THE POOR-LAW. BY MAJOR GREENWOOD, M.D. BRUX., LL.B. LOND., D.P.H., BARRISTER-AT-LAW ; HONORARY SECRETARY, OFFICERS’ ASSOCIATION OF ENGLAND
POOR-LAW MEDICAL AND WALES.
I.-MAJORITY REPORT. To the critic of the Medical Relief proposals of the Majority Commissioners one thing is apparent, which must be greeted with approval by all practical Poor-law reformers. The necessity of a Destitution Authority is frankly admitted, and that in my opinion raises the value of their proposals far above those of the Minority. Regarded closely, the general scheme of the Majority does not tend to do away with all the foundations on which for more than two centuries the English Poor-law has been slowly and laboriously constructed; and although there seems to be some grounds for censuring the fantastical manner in which exception has been taken to many old Poor-law terms-an error which the Minority have not failed to make the most of-those wishing to see practical reform in our present Poor-law system without parting with all the land-marks of the past, will be inclined to smile at this weakness, and to welcome as far as they can the efforts to reform much which calls out loudly for reform. The proposals of the Majority, as to the creation of new Destitution Authorities throughout the country, are not so revolutionary as at first sight might appear, and do not necessarily invite the opposition of the medical profession. To such authorities the present powers of the guardians might be readily transferred, and the system of cooption recommended might also tend to prevent the new boards of guardians from some of the abuses which disgrace the old. The principles laid down might be modified in various ways, according as direct or indirect election of the Destitution Authority were thought best adapted for the needs of the present time. With regard to this and other recommendations, I have the greatest sympathy, and so far I think many of my brethren in the Poor-law Medical Service would be in agreement. It is only when we come to the proposal to base Poor-law medical relief on a system of pseudoprovident dispensaries that our sympathy becomes alienated, and that some of us are tempted to look with preference on the scheme of the Minority; and on account of the apparently better treatment proffered to us as a public service, to shut our eyes to the not unlikely ruinous changes that would be brought upon our common profession by the abolition of the Destitution Authority and the general break up of the Poor-law, as foreshadowed in their sweeping and revolutionary recommendations. In fact, we part company with the signatories of this portion of the Majority Report together with Miss Octavia Hill and Dr. Arthur Downes, and we do so because these Commissioners seem to us to be doing what they profess to be opposed to, and to be practically bringing about what they give excellent reasons for not
doing.
I will instance two principles which they clearly lay down, to my mind, quite inconsistent with the provident dispensary scheme they propose to carry out : (1) The necessity for having a better system of inspecting outdoor medical relief ; and (2) that on no account is gratuitous medical relief to be made general. 1. In Part V., Chap. 2, Par. 127, we read :The primary responsibility of the Public Assistance Authorities for adequate inspection and supervision of the medical relief arrangements should, we think, be clearly recognised and carefully maintained. From this paragraph we see that not only is a better system of inspection in the new Poor-law scheme to be maintained by the Destitution Authority, but also by the Central Board through the appointment of more medical inspectors. If an impartial survey is taken of the present routine of Poor-law medical relief, and an endeavour made to compare it with
what might be expected under the new, it seems to me that the present system offers many advantages over the oneproposed. It may be true that there is little or no inspection of Poor-law medical relief at the present time; but it is not true that it is due to any fault in the present system, which presents facilities for an efficient inspection superior to any that could be hoped for from a provident dispensary system. Every district medical officer at the present time keeps a large and compendious medical register, in which it is his duty to inscribe every consultation he has with, and every visit he makes to, a Poor-law patient. In addition, he is required to record his prescriptions and general treatment, with the result of the same in a special column. If this is properly done, as it should be, it is difficult to see how a better means for testing Poor-law medical relief could be furnished, If the authorities do not trouble to inspect these records it is not the fault of the medical officer. A better medical inspection might be required to see that this work is properly done, but it cannot be denied that there now exists an excellent machinery for doing it. It can scarcely be argued that the proposed dispensary system offers no obstacles to the adoption of the same method. Under any system such as that proposed the main principle is that no distinction is to be made in the treatment of the patients at these dispensaries. All must be treated alike, and what is done in the case of one patient must be done for another. If only State patients are to have records of their treatment enteredfor inspection it is clear that a different scale of payment must be adopted for State patients. If all are to be treated alike a new scale of fees will have to be paid, having little relation with the present payments of provident dispensary members. If the idea in the minds of the Commissioners is the creation of a series of selfsupporting provident dispensaries, where the majority of the patients are not State patients, it would have been thought by most people that the State minority would rank ,variyassqt with the other patients, and that records of their In that case, away cases would be kept in a similar manner. would go all the elaborate reports that are now required in the case of Poor-law patients, and proper inspection would If only State patients are to have become impossible. registers allotted them like the present, the fees for their attendance will have to be increased, and competition will arise among the dispensary doctors to get as many of them as possible, to the more or less neglect of the other patients ;9 and if all the doctors attached to the dispensary are to have an equal claim to State patients a multiplication of registers will be necessary that will not make an adequate-inspection easier. From whichever point of view we regard it, it seemsclear that a special service for State patients is clearly indicated. Whenever a provident dispensary has been successful, if its practical working is inspected, it will be found that it approximates more or less to the common type of out-patient practice at general hospitals. At these institutions no attempt has hitherto been made to record the cases in the way directed by the Poor-law Orders for obvious reasons. The record required by the Poor-law Orders is essentially for Poor-law reasons ; in the case of the general hospitals it is for medical reasons ; that is, a record is required only for cases with a special medical interest-a comparatively small and limited number. In Poor-law cases the medical interest, if not unimportant, is subsidiary to the necessity of an accurate registration of all, as imposition on the State is quite as likely to occur in commonplace medical cases as others, and therefore a machinery of its own for doing this work isspecially required. The more the matter is examined in detail the more the necessity appears of treating State patients apart from others. A much closer inspection of the treatment of State patients is necessitated for another reason. A member of this class has always been assumed on account of his destitution to be unable to protect his own interests. For that reason he has had hitherto a special State-appointed doctor to attend to him, who can be, and is, held responsible for neglect. It would be impossible to make all doctors share in this kind of responsibility, for the reason that an ordinary patient can protect himself by changing his doctor. So that the permission given to the State patient to change his doctor puts him on the same level in this respect as other patients, and far from being a gain is a distinct loss by lessening the responsibility which otherwise the State doctor would
eosinophilia,
and may be commended to the attention of the skilled The light thrown by observers in our fever hospitals. this statistics on and kindred questions is of great importance, but will not by itself suffice to determine the nature of the malady. -
THE RECENT WORK OF THE GOVERNMENT LABORATORY.
THE official report of the principal chemist (Sir Thomas E. Thorpe) of the Government laboratory for the year ended March 31st, 1909, has been issued. Sir Thomas Thorpe may be congratulated upon the completion this year of 15 years’ service, during which the work and equipment of the laboratory have been extended considerably. The report, which will be the last one from his pen, shows that the number of samples examined has increased by about 100,000 and the staff by 27. The increase in the number of samples has been due principally to a greater activity HÆMORRHAGIC DIPHTHERIA. in the Excise department, 117,379 samples having been Now that the great majority of all cases of infectious examined last year as against 46,375 in 1894. The disease are isolated in special hospitals we have to depend number of samples of food and drugs referred to the Governfor advances in our knowledge of them upon the medical ment laboratory during the past official year was 120. Of officers of the Metropolitan Asylums Board and other similar these samples the Government analysts agreed with the institutions. We are glad to find that these officers have not public analysts’ certificate in regard to 100. 82 of the referred -only inclination but also facilities for scientific work. An ex. samples were of milk, and 12 were of butter. Amongst .ample may be seen in the interesting paper on Hasmorrhagic miscellaneous samples appears a case of fish poisoning. The Diphtheria contributed by Dr. J. D. Rolleston to the Metro- river Lemon, which is within the jurisdiction of the Teign politan Asylums Board Report for 1908, in which statistics Board of Conservators, proved to be contaminated with are given based on 78 cases of this condition among 1550 copper, the source of which was mine drainage. Dead trout From the figures given it appears that taken from a spot near the source of pollution contained cases of diphtheria. the hæmorrhagic form of the disease occurs from year to year copper. The metal was found in the matter washed from the with curious regularity, the percentage of such cases being gills, in the viscera, and in other parts of the body of the usually between 5 and 6. The incidence is not influenced by fishes. Samples of the river water on standing deposited a In some analytical work the season of the year or by the age or sex of the sufferer, and sediment containing copper. it does not appear that previous ill-health is a cause of the undertaken at the instance of the recent Royal Commalignancy of the disease. Along with the haemorrhages mission on Whisky Sir Thomas Thorpe reports that there were invariably present other signs of grave infection, the whisky sold at fairs and markets, public-house and such as extensive membrane, "faucial and palatal oedema, refreshment bars was free from any deleterious ingredisproportionate adenopathy, pitting of the skin over the dients such as methylated spirit, vitriol or other mineral glandular swelling, and absence of, or delay in, reaction to acids, or salt, which have been alleged to be used for antitoxin." The mortality of these haemorrhagic cases adulterating whisky of this kind. Most of the samples, he reached 83’ 3 per cent. Grave as is this figure, it yet has a adds, consisted mainly of patent-still spirits, but the prices at hopeful aspect, for in days gone by practically all these which they were sold corresponded generally to the character patients died. The saving of nearly 17 per cent. of the of the mixture, and as a rule were not excessive. In regard lives is probably due to treatment with antitoxin, the to materials used in the making of beer, 559 samples were relationship of which to this affection is of consider- examined, of which 30 proved to contain over1/100th grain able interest. It would seem from Dr. Rolleston’s observa- of arsenious acid per pound in the case of solids or per tions that early administration of large doses of this remedy gallon in the case of liquids. Of 114 samples of malt exahas the power of preventing, or at least modifying, the mined only one exceeded the limit, while none exceeded the onset of hæmorrhagic symptoms. Thus no cases of this nature limit when 278 samples of glucose were examined. 4347 occurred among patients who were treated with antitoxin on samples of beer were taken from the premises of 1591 the first day of the disease, but the percentage steadily rose publicans and retailers of beer, and 8’ 1 per cent. of these as the delay in the administration of the serum increased. were found to be diluted with water, five were adulterated cases in 23 which less than while Further, 33,000 by the addition of"saccharin,and three by the addition among units of antitoxin were given none recovered, among 55 who of a" heading " solution. In considering these quite few received this and larger quantities 12 finally survived. All facts, which are scattered amongst a great number of those who recovered went through an attack of paralysis. others in the report, it is obvious how very important to the This seems to suggest that there may be one and the same community this Government department of control has poison at work in the production of haemorrhage and of the become. neural lesion. We hope that Dr. Rolleston will pursue his researches into the pathology of the condition, which needs A TELEGRAM from the Governor of Hong-Kong to the careful elucidation. Is there a mixed infection in these Secretary of State for the Colonies, received on August 28th, cases ? Is there any particular strain of diphtheria bacillus declared Hong-Kong to be free from plague. which causes this complication ? Are there any special morbid lesions of the various viscerawhich accompany it ? THE Earl of Crewe, Secretary of State for the Colonies, Seeing the close connexion that sometimes exists between has and as in snake the case of venom, haemorrhage, appointed a scientific committee for the study of haemolysis it might be interesting to examine the serum for hasmolytic entomology in relation to the propagation of diseases in man substances. These and other problems still await solution and animals and to the cultivation of plants in the Colonies ___
735 and Protectorates of British Tropical Africa.
This comAfrican Entomomittee, which will have the title of the logical Research Committee, and will be under the chairmanship of the Earl of Cromer, has a distinguished scientific constitution. The committee will publish its results in journal form. _______________
DOMICILIARY MEDICAL TREATMENT UNDER THE POOR-LAW. BY MAJOR GREENWOOD, M.D. BRUX., LL.B. LOND., D.P.H., BARRISTER-AT-LAW ; HONORARY SECRETARY, OFFICERS’ ASSOCIATION OF ENGLAND
POOR-LAW MEDICAL AND WALES.
I.-MAJORITY REPORT. To the critic of the Medical Relief proposals of the Majority Commissioners one thing is apparent, which must be greeted with approval by all practical Poor-law reformers. The necessity of a Destitution Authority is frankly admitted, and that in my opinion raises the value of their proposals far above those of the Minority. Regarded closely, the general scheme of the Majority does not tend to do away with all the foundations on which for more than two centuries the English Poor-law has been slowly and laboriously constructed; and although there seems to be some grounds for censuring the fantastical manner in which exception has been taken to many old Poor-law terms-an error which the Minority have not failed to make the most of-those wishing to see practical reform in our present Poor-law system without parting with all the land-marks of the past, will be inclined to smile at this weakness, and to welcome as far as they can the efforts to reform much which calls out loudly for reform. The proposals of the Majority, as to the creation of new Destitution Authorities throughout the country, are not so revolutionary as at first sight might appear, and do not necessarily invite the opposition of the medical profession. To such authorities the present powers of the guardians might be readily transferred, and the system of cooption recommended might also tend to prevent the new boards of guardians from some of the abuses which disgrace the old. The principles laid down might be modified in various ways, according as direct or indirect election of the Destitution Authority were thought best adapted for the needs of the present time. With regard to this and other recommendations, I have the greatest sympathy, and so far I think many of my brethren in the Poor-law Medical Service would be in agreement. It is only when we come to the proposal to base Poor-law medical relief on a system of pseudoprovident dispensaries that our sympathy becomes alienated, and that some of us are tempted to look with preference on the scheme of the Minority; and on account of the apparently better treatment proffered to us as a public service, to shut our eyes to the not unlikely ruinous changes that would be brought upon our common profession by the abolition of the Destitution Authority and the general break up of the Poor-law, as foreshadowed in their sweeping and revolutionary recommendations. In fact, we part company with the signatories of this portion of the Majority Report together with Miss Octavia Hill and Dr. Arthur Downes, and we do so because these Commissioners seem to us to be doing what they profess to be opposed to, and to be practically bringing about what they give excellent reasons for not
doing.
I will instance two principles which they clearly lay down, to my mind, quite inconsistent with the provident dispensary scheme they propose to carry out : (1) The necessity for having a better system of inspecting outdoor medical relief ; and (2) that on no account is gratuitous medical relief to be made general. 1. In Part V., Chap. 2, Par. 127, we read :The primary responsibility of the Public Assistance Authorities for adequate inspection and supervision of the medical relief arrangements should, we think, be clearly recognised and carefully maintained. From this paragraph we see that not only is a better system of inspection in the new Poor-law scheme to be maintained by the Destitution Authority, but also by the Central Board through the appointment of more medical inspectors. If an impartial survey is taken of the present routine of Poor-law medical relief, and an endeavour made to compare it with
what might be expected under the new, it seems to me that the present system offers many advantages over the oneproposed. It may be true that there is little or no inspection of Poor-law medical relief at the present time; but it is not true that it is due to any fault in the present system, which presents facilities for an efficient inspection superior to any that could be hoped for from a provident dispensary system. Every district medical officer at the present time keeps a large and compendious medical register, in which it is his duty to inscribe every consultation he has with, and every visit he makes to, a Poor-law patient. In addition, he is required to record his prescriptions and general treatment, with the result of the same in a special column. If this is properly done, as it should be, it is difficult to see how a better means for testing Poor-law medical relief could be furnished, If the authorities do not trouble to inspect these records it is not the fault of the medical officer. A better medical inspection might be required to see that this work is properly done, but it cannot be denied that there now exists an excellent machinery for doing it. It can scarcely be argued that the proposed dispensary system offers no obstacles to the adoption of the same method. Under any system such as that proposed the main principle is that no distinction is to be made in the treatment of the patients at these dispensaries. All must be treated alike, and what is done in the case of one patient must be done for another. If only State patients are to have records of their treatment enteredfor inspection it is clear that a different scale of payment must be adopted for State patients. If all are to be treated alike a new scale of fees will have to be paid, having little relation with the present payments of provident dispensary members. If the idea in the minds of the Commissioners is the creation of a series of selfsupporting provident dispensaries, where the majority of the patients are not State patients, it would have been thought by most people that the State minority would rank ,variyassqt with the other patients, and that records of their In that case, away cases would be kept in a similar manner. would go all the elaborate reports that are now required in the case of Poor-law patients, and proper inspection would If only State patients are to have become impossible. registers allotted them like the present, the fees for their attendance will have to be increased, and competition will arise among the dispensary doctors to get as many of them as possible, to the more or less neglect of the other patients ;9 and if all the doctors attached to the dispensary are to have an equal claim to State patients a multiplication of registers will be necessary that will not make an adequate-inspection easier. From whichever point of view we regard it, it seemsclear that a special service for State patients is clearly indicated. Whenever a provident dispensary has been successful, if its practical working is inspected, it will be found that it approximates more or less to the common type of out-patient practice at general hospitals. At these institutions no attempt has hitherto been made to record the cases in the way directed by the Poor-law Orders for obvious reasons. The record required by the Poor-law Orders is essentially for Poor-law reasons ; in the case of the general hospitals it is for medical reasons ; that is, a record is required only for cases with a special medical interest-a comparatively small and limited number. In Poor-law cases the medical interest, if not unimportant, is subsidiary to the necessity of an accurate registration of all, as imposition on the State is quite as likely to occur in commonplace medical cases as others, and therefore a machinery of its own for doing this work isspecially required. The more the matter is examined in detail the more the necessity appears of treating State patients apart from others. A much closer inspection of the treatment of State patients is necessitated for another reason. A member of this class has always been assumed on account of his destitution to be unable to protect his own interests. For that reason he has had hitherto a special State-appointed doctor to attend to him, who can be, and is, held responsible for neglect. It would be impossible to make all doctors share in this kind of responsibility, for the reason that an ordinary patient can protect himself by changing his doctor. So that the permission given to the State patient to change his doctor puts him on the same level in this respect as other patients, and far from being a gain is a distinct loss by lessening the responsibility which otherwise the State doctor would