Central and local authorities

September. 1921]

CENTRAL AND LOCAL AUTHORITIES

only four yea.rs' hustle. The scheme was started on January 1,1917. and the examination of three-fourths of the total population of Framingham revealed a. great quantity of hitherto undetected subereulosis. Before this da.te there were only 27 known cases of tuberculosis under care, and the survey raised this total to several hundred. Before January, 1917, the ratio of known cases to annual deaths was about three to one. After this date-and thanks to the health survey-the ratio of known. active cases to annual deaths was nine or ten to one. At first 55 per cent. of the cases were discovered in an advanced stage, Later. this percentage was reduced to 17. During lihe decade preceding the health survey the tuberculosis death-rate per hundred thousand was 121'5. For the entire demonstration period it wag 84.·2 per hundred thousand-a. reduction of about onethird . For 1920 the rate wag 64'5 per

565

hundred thousand-a reduction of about one-half. According to these figures it would seem that if the same system were adopted throughout the U.S.A.• 75,000 lives could be saved annuallv, And the cost? The programme aga.inst tuberculosis is closely interwoven with the general health programme. It is, therefore, impossible, excepting in a, most artificial way, to separate the cost of tuberculosis work from the cost of general health work. In Framingham, at the beginning of the demonstration, the community was spending approximately 40 cents. per capita per year on all kinds of health work. The community is now spending about $Z per capita per year. This amount of money will buy reasonably adequate pre-natal, infa.nt. and pre-school work. satisfactory school health work. industrial health work, special tuberculosis work along many lines. and general community sanitation."

CENTRAL AND LOCAL AUTHORITIES. POST-GRADUATE MEDICAL EDUOATION REPORT OF THE EARL OF ATHLONE'S COM1,u'1'TEE. THE Report of the Post-Graduate lIIedical Committee' is now issued as a Stationery Office publication. This Committee was appointed by Dr Addison, then Miniater of Health, last Janu~ry, and was entrusted ~ith the ~!'-ty of investigating the needs of medical practlt.lOne!8 and other graduates for further ed.uO!ltlOn lD medicine in London, and of lIubmlttlDg proposals for a practicable scheme for meeting these needs. The Earl of Athlone acted as Chairman, the other members of the Com. mittee being:., II Mr. H. J. Cardale, M.B. ; .Slr .WIlmot . erringham, Ie.C.U.G. , M.D.; Sir George Mak1Os, G.O.M.G., F.R.C.S. ; Sir George Newman, K.C.B., M.D.; Sir Robert Newman, D.L:, M.P.; Sir Edward Penton, K.!3.E. j Sir E. Cooper Perry, M.D.; Mr . J. DIll Russell. }01.B., ~'.R.C.S.; Dr. T. W. Shore, O.B.E., M.D. . , h The Report begins by SUD1marJS1~g t e pro· vision made for post-graduate medical educa-

I Report 01 the Post-Graduate Medical Committee, H.M. Sta~ionery Office. Price ld. net.

tlon In the past, and it draws attention to the fact tba~ Ilottcmpts have been made for many years in this direction, Sir Jonathan Hutch. inson was tbe pioneer in the matter in the early nineties, and more recently the Fellowship of Medicine has attempted to make the necessary facilities more accessible. But it is clear from the Report that the present organisation is far from satisfactory and that much more must be done before suitable provision can be said to exist. London 'a UniglUl Position. -Attention is drawn to the fs.ct tha.t the Continent, and in particular Vienna, has for a long time been regarded as the place where medical graduate I can most easily secure wbll.t they need in the way of general and specialised instruction. Some emphasis is laid in the Report upon the fact tha.t a.n opportunity .n ow prosents itself for providing in this country a centre at which students from overseas, whether from our own Colonies, from America, or from foreign parts. may find facilities for post -graduate medical instruction. and the :Uetropolis, with its unique supply of clinic al material and the 38,000 beds, seems singubrly well placed to provide such & centre. COttl1{J8 Hospiwls.-Another interesting Ieature oC the Report is the somewhat emphatic suggestion that cott age hospitals should be

566

'fUBEIWLE

used to a. greater extent than at present for mcreasing; the experience and efficiency of general pra.ctitioners. The Report states that it is desirable that all practitioners within the area ser ved by a cottage hospit&l should have the facilities, if they wish, to bring their own cases Into the wards and to attend them there. In this way better treatment would be secured for the pa.tient, while the general practitioner would ha.ve an opportunity of consulting with his professional colleagues. The Need for a Central Hospital. - -The chief recommendation made in the Report is for the establishment of a Central Po st-Graduate Ho spital and School which should be devoted to post -graduate work . It is not recommended tbat a. new bospita.l should be built. The hOflpital should be one equipped in an up-todate fashion with at lea.st 300 beds, with a fully developed out-patient department. Associated with this central hospital and school would be the great special hospitals of the M:tr~polis. It is suggested that one of the exiating undergraduate schools mi ght be converted into such a centre. A Central Office. -The Committee also recommend the institution of a Contral Office which ~ould .link up pos~.gra.duate study i~ tbe Umh·d Kmgdom, and In due course with tbat of the Continent of Europe and America. Th is Central Office should he in t he charge of a .whole.time Principal Officer and its Commtttee of Management should be responsible for the organisation of the system as a. whole. Atta.ched to, and as part of, the Central Office there should be provided social facilities in the shape of reading rooms, So restaurant, and a library of periodicals. A hostel for the convenience of doctors attending the courses from a. distance would also be desirable, An Institute of State Medicine.-It is further suggested tha.t public health post-graduate work should be concentrated in an Institute of State Medicine, directly connected with the University of London and under its administration, occupying a position analogcus to that held by the Institute of H istorical Research. The Institute, in addition to providing instruction in public health, would furnish courses in forensic medicine, in toxi cology, and in industrial medicine. It would accommodate students from overseas and foreign countries and create an imperial link between them. The Cost of the SclWlme.-The scheme pro. posed above would involve an annual charge of £28,000. Support from local rates will not be expected. Inasmuch as the School and Institute are proposed as constituent parts of the pnive~sity of Lon?on, they will he eligible for ~ncl,!sl0!1ln the list. of grant-aided university l~stItutlons for which money is already provided by the Treasury through the University Gra.nts Committee.

[September, 1921 CITY OF CARLISLE.

REPonTS ON THE SANITARY CONDrrION OF THE CITY AND ON THll: WORK OF THE MEDICAL

I NSPECTION FOR 1920. The arrangements for the treatment and supervision of persons suffering from tuhercuIosis were carried out on similar lines as in the previous year. There is one tuberculosis dispensary in the City, worked by Dr. Spence. the Assistant Medical Officer of Health. This is open on two afternoons and one evening in the week for adults, and on \Vednesday afternoon for school children. The ~orporat ion possess no residen· tial institution of their own, but have 20 beds reserved in Blencathra Sa.natorium for the treatment of early and intermediate Cases of tuberculosis. No provision has yet been made for advanced cases, Various sites in the city have been inspected by the Health Committee with a view to providing a tuberculosis hospital but their selection of Coleda.le Hall was so much 0J>posed that It fell through. This building has smce been purchased by the Education Com. mittee who are going to use it as an open -air school. The He alth Committee have since considered otherproposa.ls but no other suitable property has bcen found, and the time Within which schem es for the treatment of advanced cases of tuberculosis were to be submitted to the Ministry of Health in order to qualify for a All gra.nt of £180 a bed bas now passed institutions in other areas where these Il.d;anced cases could .he sent are already fun. Tu~erculm has been used in treatment from the dlsp,ensary f~r a. number ?fcarefully selected eas~s'l?ostly c};lJldr~n, who lDspite of the usual hygienic ~nd dietetic treatment have fa.iled to ma~e any lmprovemen~. The use of tuberculin B.E. and P.~. E. has given encoura.ging results. No Commlttee for the care and after-ears of tuberculous patients has been formed and no shelters have been provided for use at'home T~e num~er of notifications of tuberculo'sis re~eIved dur!ng t~e year was 148. The ratio of pru:nary uotificatlons to deaths was 265 notifl, cations to 100 deaths. Fifty.six patients received trea.tment in a sanatorium during the year. Of these five left befor~ the treat~ent was completed, the average duration of residence of the remainder being 139:3 days. ~ess troubls was experienced during the year In persuadmg patients to remain for a sufficiently long period . 1I1ll.ny think that three months is sufficient to effect a cure Sixty.nine discharged soldiers attend~d the tuberculosis dispensary, 37 new and 32 old cases. THE SCHOOL lIIEDICAL OF~'ICEB'S ANNUAL REPORT.

The same close co.ordination between the School Medica.l and Tuberculosis Services has continued. The Tuberculosis Officer being also the Assistl\nt School Medical Officer has held special clinics at tbe dispensary for the purpose of examination of school children. SixtY-seven new cases attended, 39 of whom were SUffering

September, 1921]

SOCIETIBS

from tuberculosis. The localisation of disease in the 39 was as follows: 'l'uberculosis of the lungs, Stage I .. .. .. Stage 2 .. " .. Stage II .•••.. " Glands . Skin " Abdomen . . Bones and Joints

the 28 I I 2

..

3 2 2

"

39 One hundred and thirty old cases attended the dispensary during the year, making a total of 197 children in attendance. 'I'wenty-seven children received special treatment by means of injections of tuberculin B.E. The treatment commenced with '0005 to '002 cubic millimetre of tuberculin B.E., the dose being increased by approximately 50 per cent. each fortnight. The results. are stated to be satisfactory. Three children were treated in a sanatorium.

TUBERCULOSIS IN ABERDEENSHIRE. The fifth annual report on the Incidence a d Treatment of Tuberculosis in the county Aberdeenshire for the year to December 31 ast has just been issued. The summary of the statistics given in the ~elPlort in comparison with last year is as o ows:_

1l

NlUnber of notifications(1) All forms of tuberculosis (2) Phthisis pulmonalia

1919

1020

342 242

367 266

567

Number of deaths from(1) All forms of tuberculosis 130 137 (2) Phthisis pulmonalis . • 96 loa Number of new cases treated in(1) Sanatoriums .. 109 104 (2) Hospitals 45 52 Average duration of institutional treatment-days 169 162 Bacteriological work(1) Number of sampl es of sputum examined •• . . 218 501 (2) Number of miscellaneous ma.terials examined .. 43 (3) Number of vaccines prepared 83 Number of county shelters 61 61 Number of house and shelter dis. infections by sanitary in. specters .. •• .• 93 97 The dea.th-rate, although fluctuating somewhat, has , on the whole, been on the decline for tbe past thirty years. The increase in numbers notified is due to the greater keenness of practitioners in notify. ing early cases which a few years ago would not have been regarded as suffering from tuberculosis at all, but probably from bronchitis or other allied complaints. 72 per cent. of the dwelling houses visited were found to be .. satisfactory" ; 18 per cent. were classed as II fair," the defects being uncleanliness, overcrowding, or the failure to use existing means of ventilation; 12 per cent. were designated" bad," as, in these, marked overcrowding or structural defects existed. .. Bcx-beds," uufortunately, were still not uncommon.

SOCIETIES. THE 25TH GEmtAN TUBERCULOSIS CONGRESS. {) The 25th Congress, convened by the German entral Committee for the prevention of tU1}erculosis_the first Conference after the w.ar-;-beld at Elster from May 19 to 21, was dlstmguished by a numerous attendance and by a considerable number of excellent and interesting papers. On the first day .. Development and spread of Tuberculosis" was discussed from all points of view by Wassermann, Neufeld, Bablnowitsch Uhlenhuth, Bauer and many others, In the opening paper Kirchner (Berlin) spoke on the influence of the war on tuber. oulosis. The mortality from phthisis has considerably increased during the war and has now reached the height of 18llu, or 200 per 100,000 as compared with 137 in 1913. In the former Austrta-Hungary the rise of the phthisis death-rate was still greater (Vienna 1914, 28u'8 ; 1917, 405'2 : Budapest, 1914, 340;

1917,470 per 100,000.) Likewise the neutral countries bordering upon Germany show an increased tu berculosis mortali ty , especial!y Denmark, to a less degree Holland and Switzerland, whereas in Sweden and Norway no increase bas been observed. The rate with which the tuberculosis mortality increased was by no means uniform, either with regard to the years or to the different parts of Germany, for it exceeded the 1914 ra.te by 10: 1915 by 12; 1916 by 16 per cent. Since 1919 & slight diminution bas set in. The augmentation amounted in Prussia to 68 per cent., in Bavaria to not more than 38 per cent. As a rule, during the war more people died from phthisis in the industrial districts and in the towns than in the country where the increase was later and less, and where after the armistice an early and rapid decline could be ascertaiulld. Thus the average of the phthisis death·rate in the town for the years 1914-18 was !:l09, in the country, however, only 144. Very striking is