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HOUSING AND HYGIENE.
144 Commission will or will not recommend that under the medical benefits given to the insured there shall be provided a pathological service of experts. If this occurs, all that pathological work which lies outside the confines of public health would naturally be undertaken by individual pathologists for the most part in the laboratories provided in the voluntary hospitals. These pathologists would be the experts whom the practitioners of the district will consult for their panel patients in accordance with a statutory scale, and for their private patients in response to proper fees. The extension of medical benefits which is expected will demand a proportionate increase in the number of medical men working at pathology whose services, while partly at the disposal of the panels, should also be available for other than the insured population, and these will not be expected, or expect, to accept the advantages gratuitously. In other words, the expert pathologist, like the medical practitioner in other branches, will give of his best in response both to those who pay through the State and to those who pay individually. The natural centres for the work of these men will be the laboratories attached to the voluntary hospitals which are, on the one hand, acting as centres for the insured patients of their districts, and which, on the other hand, provide a medical staff for cooperation with the practitioners of the neighbourhood. Proper arrangements between the great commercial firms and the medical profession can be looked for safely, but the competition of county laboratories becomes a serious matter for the private pathologist when a
county council, what does not
at
come
its laboratory, proposes to do within the proper purview of a
county authority. HOUSING AND HYGIENE. HAVE we turned the corner as regards the housing The Minister of Health, in whom the problem members of the public health services have great confidence, appears optimistic ; last month he stated in the House of Commons that more houses were built during 1925 than the annual average during the building boom at the beginning of the century, and that more schemes for slum clearances were submitted and confirmed in the six years 1919 to 1925 than in the 24 years before the war. All that is good hearing, but Dr. F. E. FREMANTLE was right when he emphasised that what was wanted now was goodwill and national endeavour. Of late years the job of building has out of the hands of the private builder largely into those of the local sanitary authority and of the Government. Whether this transfer is temporary and accidental, or marks a permanent tendency in the conduct of affairs, even the clerk to the London County Council has not made up his mind.1 In any case the housing question needs to be lifted out of the ruts of trades-union politics and party dissensions, and medical men should take every opportunity of using their special knowledge for the general enlightenment. For medical men there has been sufficient evidence in the past as to the effects on health of bad housing to make comment appear superfluous, but because the doctors and the statisticians know the connexion between the prevalence of diseases in various localities and the housing accommodation in those localities -its character, the number of rooms per house, and the rest-it does not follow that the public is equally well informed. No pains should be spared to advance cogent arguments as to the relation between bad
passed
Sir James Bird : Housing and What it Does for London. Hodder and Stoughton. 6d. 1
and bad health. The families which occupy the worst houses are generally the worst off in all other respects, and this may disguise the most fundamental of their drawbacks, which is their home. What are the essentials of a healthy homeDuring the debate on Dec. 18th last in the House of Commons Sir LESLIE SCOTT referred to the 2246 back-to-back houses of Liverpool as being unfit for anyone to live in for a week. We are hardly in a position, however, to damn all houses of the back-to-back type without particular consideration. In his report for 1924 the medical officer of health for Leeds states that, although more than two-thirds of the houses in that great city are built back to back, about half of them are of a type which does not differ appreciably in healthiness from through houses. Only two-thirds of the deaths from all causes in Leeds during 1924 occurred in these back-to-back houses-in other words, they had their proper proportion of deaths. But no health officer has any doubt that on the whole disease is more prevalent and more fatal in bad than in good Exact evidence on the question is, however, singularly lacking, although we may well hope that it will be made good in the five-year survey which the Minister of Health has asked for to accompany the 1925 reports. Some indications may, however, be quoted. Dr. STANLEY BANKS, in his recent report for the Burgh of Motherwell and Wishaw, states that there are 13,965 inhabited houses in his burgh and that 72-3 per cent. of the population live in houses of one or two rooms. The notifications of tuberculosis, he finds, are higher in the very small houses ; the 19 per cent. of the population who live in one-roomed houses contributed 35 per cent. of the notifications of tuberculosis for the period 1921 to 1924. Dr. BANKS also deals with the incidence of other infectious diseases on the persons living in houses of each class during the years 1923 and 1924, and says that the attack rate of scarlet fever and diphtheria "hardly varies at all with size of house," but for pneumonia " the attack rate is considerably higher in the oneroomed and to a lesser extent in the two-roomed house." Speaking generally, it is notorious that we have had exceptionally low death-rates during all this period of bad housing. It is possible that a better educated people has to some extent been able to rise triumphant over its housing troubles. There have been signs, however, during the last year or two of a set-back to the progressiveimprovement of the tuberculosis death-rate. To turn to morbidity, Sir JOHN ROBEftTSON believes the amount of rickets in such " flatted " towns as Glasgow, Munich, and Chicago to be ten times as great as in the towns where cottages predominate.2 Dr. AUSTIN PRrFSTMAN’s recent inquiry into adenoids and otorrhoea among Folkestone school-children leads him to regard overcrowding and insanitary conditions as almost the sole factors in their production.3 Until the 1925 reports come in from the public health service most people will be content to rest the case for better housing on the tribulations of houseless families in every part of the country and on those conditions which make the decencies of life utterly impossible. There is more than enough evidence before the public already to show that this problem is urgent and must be faced. The peculiar knowledge of doctors, however, and the fact that the public health is more the concern of the doctors than anyone else, make it necessary that they should leave no stone unturned in promoting national endeavour
housing
I houses.
2 The Health of the House : What the Modern Dwelling Needs 1925. to be. Faber and Gwyer (the Scientific Press). 3 The Medical Officer, Jan. 2nd, 1926, p. 8.
145 and Colonel CHRISTOPHERS calculates that, by his rousing the national conscience. In a letter ligures, which apply to the cold, non-malarious season, offers a the published in our columns, correspondent hypercndcmicity is to be associated with an infection
and in
kind of evidence—evidence of failure-which must be brought home to the nation, and pleads for the cooperative effort which ought to be a main contribution of the profession to the political and social life of to-day.
MALARIA AND INDUSTRY. A HAPPY discrimination is shown by the public .demand which has necessitated the re-issue, in the Indian Journal of Medical Research for October, 1925, of two Government publications’under the title " Two Malarial Surveys Connected with Industrial Projects in Certain very Highly Malarious Localities Both these industrial concerns are, in India." in fact, situated in areas where malaria is hyperendemic. The first comprises about 10,000 acres of a wide, almost level, plain of high grass jungle interspersed with swamp, near the foothills bounding the valley of the Brahmaputra to the north. Habitations have been placed where they would interfere least with
agricultural operations-namely, on trimmings of land lying along swamp and stream which breed those recognised malaria carriers Anopheles listoni and A. minimits. In the layout of the estate it was clearly not recognised that malaria might determine the commercial value of the undertaking and that the first procedure should have been a malaria survey to determine, within the area selected for cultivation, the most suitable housing site-which in this instance would have been the central plot of
intense that it practically amounts to a continuous attack, with over 10,000 parasites per c.mm., extending over a period of two years. This stage is designated as acute infestation." Over the age of 2, while the proportion of children infected is as high as ever, the average number of parasites falls to 1200 per c.mm. so
"
between two and five years, and to 1000 between six and ten. This stage is designated " immune infestaSimilar figures apply to immigrant nontion." immune children, at least during the first two years of residence. Correlating these counts with enlarged spleens, it was found that a spleen projecting 4 to 6 cm. from the costal margin (correction being made to a sitting height of 60 cm.) was that associated with acute infestation. It is concluded that the net result of passing childhood under hyperendemic conditions is the acquirement of a form of immunity. The parasitic forms found were almost uniformly rings of 2 to 3 p. in diameter, identified tentatively as Plasmodium tenue Stephens, 1914. The readiness with which Colonel CHRISTOPHERS will be followed on this point will depend on the extent to which it is believed that the differences on which this form is separated from P. jalciparum are reliable, when there is used, as is customary with malariologists, a mode of preparation which is rejected for other protozoa as giving no reliable information regarding structure. Gametocyte formation was associated with heavy infection of the cutaneous blood and with the period of acute infestation. The proportion of gametocytes to rings was 1 to 390. Of adults, 51 per cent. were found infected and the average number of parasites was 109 per c.mm. It is concluded that this peculiar relationship of low value of infection and high percentage of infected must represent immunity in the adult. In them, as in children, crescents were associated with the
the estate. As a result 91 per cent. of the children had, at the time of the inquiry, palpable spleens. Owing to heavy invaliding the staff of Europeans, mechanics, and servants is constantly changing, heavier infections. recruitment is a difficulty, and the cost of training These considerations have this practical value, that the new staff considerable. Regarding a remedy, the present labour is " salted," and not in such urgent and writing with personal knowledge of the sub- need of as are " non-immune " persons. protection soil drainage system which has so successfully Observations of the 15 species of anopheles discovered combated malaria in the Federated Malay States, to A. listoni and A. culifaciens as primarily point Colonel CHRISTOPHERS held this procedure to be here implicated in infection, with A. wilmori as an unknown financially impracticable. It will, however, be element of danger. In the matter of preventing recollected that Sir MALCOLM WATSON himself visited, breeding there is a short length in one ravine held in 1924, a large group of tea estates in Upper Assam, suitable for treatment along the lines of subsoil where A. maculatus and A. minimus are abundant, so extensively and happily employed in the drainage instituted a system of subsoil drainage designed to Federated Malay States. For the rest it is concluded strike at their breeding-places, and expressed little that the most fundamental work open to the Company doubt that malaria would soon be under control. is the choice in the first instance of situations for The other industrial venture concerns mines in the quarters, and bungalows that are either naturally Singhbhum District of Bihar and Orissa. The mining lines, free from liability to anophelism or can be made so camps lie in alluvial-bottomed valleys within the hills. with the least If outside labour be imported Inspection was made during three weeks of the cold from relativelydifficulty. non-malarious parts serious incapacity The average spleen-rate in children was 69. season. is to be and the choice of suitable situations The basis of the inquiry, perhaps the first instance on for their expected, lines would become almost the only practicable which this has been attempted from the hygienic antimalarial measure which would not be excessively aspect, is a quantitative determination of the degree of costly. The fundamental error of both these large infection by malaria parasites in the cutaneous blood ; industrial concerns is, then, that they have been and the conclusions to which it leads are striking. By instituted in hyperendemic areas without adequate -spreading a determined quantity of blood in a thick effort being made to determine how best malarial film upon a determined area of slide, examining this infection of the staff could be avoided. Their present with a square-apertured ocular giving a field of deterheavy financial handicap is the direct result of their mined size, and counting the parasites in 200 square failure to obtain sound sanitary advice before launching fields, the number of malaria parasites in a cubic into heavy expenditure. millimetre of blood was estimated. It varied, where they were detected, from 4 to 134,232 ; 85 per cent. THE CONTRIBUTORY PENSIONS ACT.-The Ministry of parasites came from those who had lived on the of Health announces that the number of claims received in estate for two years and under. In those who had Great Britain under the Widows’, Orphans’, and Old Age been born on the estate the similar percentage was 92. Contributory Pensions Act was 163,000. The number of Infection in the second year of residence approximated pensions so far awarded is 103,000 ; about 25,000 have been to 100 per cent., and the average parasite value was rejected or withdrawn, and there are still over 34,000 under over 12,000 per c.mm. Now the number of parasites investigation. In any case where pensions are awarded the payment will be dated back to Tan. 5th, and it is associated with febrile attacks of 103° F. or estimated always that the number already approved covers more -over seemed here to be somewhat under 5000 per c.mm. then 306,000 widows and children. The main grounds for 1 I. Report on Malaria at the Assam Sugar Estates and Factories, Ltd., Nalbari, Assam, 1921. II. Inquiry on Malaria, Blackwater Fever, and Ankylostomiasis in Singhbhum, 1923. By Lieut.-Colonel S. R. Christophers, C.I.E., O.B.E., I.M.S., Director, Central Research Institute, Kasauli.
the rejection of claims are : (1) the claimant has no child under 14 ; (2) the widow has re-married ; and (3) the normal occupation of the husband at the time of his death would not have been insurable under the Act if it had then been in force.
county council, what does not
at
come
its laboratory, proposes to do within the proper purview of a
county authority. HOUSING AND HYGIENE. HAVE we turned the corner as regards the housing The Minister of Health, in whom the problem members of the public health services have great confidence, appears optimistic ; last month he stated in the House of Commons that more houses were built during 1925 than the annual average during the building boom at the beginning of the century, and that more schemes for slum clearances were submitted and confirmed in the six years 1919 to 1925 than in the 24 years before the war. All that is good hearing, but Dr. F. E. FREMANTLE was right when he emphasised that what was wanted now was goodwill and national endeavour. Of late years the job of building has out of the hands of the private builder largely into those of the local sanitary authority and of the Government. Whether this transfer is temporary and accidental, or marks a permanent tendency in the conduct of affairs, even the clerk to the London County Council has not made up his mind.1 In any case the housing question needs to be lifted out of the ruts of trades-union politics and party dissensions, and medical men should take every opportunity of using their special knowledge for the general enlightenment. For medical men there has been sufficient evidence in the past as to the effects on health of bad housing to make comment appear superfluous, but because the doctors and the statisticians know the connexion between the prevalence of diseases in various localities and the housing accommodation in those localities -its character, the number of rooms per house, and the rest-it does not follow that the public is equally well informed. No pains should be spared to advance cogent arguments as to the relation between bad
passed
Sir James Bird : Housing and What it Does for London. Hodder and Stoughton. 6d. 1
and bad health. The families which occupy the worst houses are generally the worst off in all other respects, and this may disguise the most fundamental of their drawbacks, which is their home. What are the essentials of a healthy homeDuring the debate on Dec. 18th last in the House of Commons Sir LESLIE SCOTT referred to the 2246 back-to-back houses of Liverpool as being unfit for anyone to live in for a week. We are hardly in a position, however, to damn all houses of the back-to-back type without particular consideration. In his report for 1924 the medical officer of health for Leeds states that, although more than two-thirds of the houses in that great city are built back to back, about half of them are of a type which does not differ appreciably in healthiness from through houses. Only two-thirds of the deaths from all causes in Leeds during 1924 occurred in these back-to-back houses-in other words, they had their proper proportion of deaths. But no health officer has any doubt that on the whole disease is more prevalent and more fatal in bad than in good Exact evidence on the question is, however, singularly lacking, although we may well hope that it will be made good in the five-year survey which the Minister of Health has asked for to accompany the 1925 reports. Some indications may, however, be quoted. Dr. STANLEY BANKS, in his recent report for the Burgh of Motherwell and Wishaw, states that there are 13,965 inhabited houses in his burgh and that 72-3 per cent. of the population live in houses of one or two rooms. The notifications of tuberculosis, he finds, are higher in the very small houses ; the 19 per cent. of the population who live in one-roomed houses contributed 35 per cent. of the notifications of tuberculosis for the period 1921 to 1924. Dr. BANKS also deals with the incidence of other infectious diseases on the persons living in houses of each class during the years 1923 and 1924, and says that the attack rate of scarlet fever and diphtheria "hardly varies at all with size of house," but for pneumonia " the attack rate is considerably higher in the oneroomed and to a lesser extent in the two-roomed house." Speaking generally, it is notorious that we have had exceptionally low death-rates during all this period of bad housing. It is possible that a better educated people has to some extent been able to rise triumphant over its housing troubles. There have been signs, however, during the last year or two of a set-back to the progressiveimprovement of the tuberculosis death-rate. To turn to morbidity, Sir JOHN ROBEftTSON believes the amount of rickets in such " flatted " towns as Glasgow, Munich, and Chicago to be ten times as great as in the towns where cottages predominate.2 Dr. AUSTIN PRrFSTMAN’s recent inquiry into adenoids and otorrhoea among Folkestone school-children leads him to regard overcrowding and insanitary conditions as almost the sole factors in their production.3 Until the 1925 reports come in from the public health service most people will be content to rest the case for better housing on the tribulations of houseless families in every part of the country and on those conditions which make the decencies of life utterly impossible. There is more than enough evidence before the public already to show that this problem is urgent and must be faced. The peculiar knowledge of doctors, however, and the fact that the public health is more the concern of the doctors than anyone else, make it necessary that they should leave no stone unturned in promoting national endeavour
housing
I houses.
2 The Health of the House : What the Modern Dwelling Needs 1925. to be. Faber and Gwyer (the Scientific Press). 3 The Medical Officer, Jan. 2nd, 1926, p. 8.
145 and Colonel CHRISTOPHERS calculates that, by his rousing the national conscience. In a letter ligures, which apply to the cold, non-malarious season, offers a the published in our columns, correspondent hypercndcmicity is to be associated with an infection
and in
kind of evidence—evidence of failure-which must be brought home to the nation, and pleads for the cooperative effort which ought to be a main contribution of the profession to the political and social life of to-day.
MALARIA AND INDUSTRY. A HAPPY discrimination is shown by the public .demand which has necessitated the re-issue, in the Indian Journal of Medical Research for October, 1925, of two Government publications’under the title " Two Malarial Surveys Connected with Industrial Projects in Certain very Highly Malarious Localities Both these industrial concerns are, in India." in fact, situated in areas where malaria is hyperendemic. The first comprises about 10,000 acres of a wide, almost level, plain of high grass jungle interspersed with swamp, near the foothills bounding the valley of the Brahmaputra to the north. Habitations have been placed where they would interfere least with
agricultural operations-namely, on trimmings of land lying along swamp and stream which breed those recognised malaria carriers Anopheles listoni and A. minimits. In the layout of the estate it was clearly not recognised that malaria might determine the commercial value of the undertaking and that the first procedure should have been a malaria survey to determine, within the area selected for cultivation, the most suitable housing site-which in this instance would have been the central plot of
intense that it practically amounts to a continuous attack, with over 10,000 parasites per c.mm., extending over a period of two years. This stage is designated as acute infestation." Over the age of 2, while the proportion of children infected is as high as ever, the average number of parasites falls to 1200 per c.mm. so
"
between two and five years, and to 1000 between six and ten. This stage is designated " immune infestaSimilar figures apply to immigrant nontion." immune children, at least during the first two years of residence. Correlating these counts with enlarged spleens, it was found that a spleen projecting 4 to 6 cm. from the costal margin (correction being made to a sitting height of 60 cm.) was that associated with acute infestation. It is concluded that the net result of passing childhood under hyperendemic conditions is the acquirement of a form of immunity. The parasitic forms found were almost uniformly rings of 2 to 3 p. in diameter, identified tentatively as Plasmodium tenue Stephens, 1914. The readiness with which Colonel CHRISTOPHERS will be followed on this point will depend on the extent to which it is believed that the differences on which this form is separated from P. jalciparum are reliable, when there is used, as is customary with malariologists, a mode of preparation which is rejected for other protozoa as giving no reliable information regarding structure. Gametocyte formation was associated with heavy infection of the cutaneous blood and with the period of acute infestation. The proportion of gametocytes to rings was 1 to 390. Of adults, 51 per cent. were found infected and the average number of parasites was 109 per c.mm. It is concluded that this peculiar relationship of low value of infection and high percentage of infected must represent immunity in the adult. In them, as in children, crescents were associated with the
the estate. As a result 91 per cent. of the children had, at the time of the inquiry, palpable spleens. Owing to heavy invaliding the staff of Europeans, mechanics, and servants is constantly changing, heavier infections. recruitment is a difficulty, and the cost of training These considerations have this practical value, that the new staff considerable. Regarding a remedy, the present labour is " salted," and not in such urgent and writing with personal knowledge of the sub- need of as are " non-immune " persons. protection soil drainage system which has so successfully Observations of the 15 species of anopheles discovered combated malaria in the Federated Malay States, to A. listoni and A. culifaciens as primarily point Colonel CHRISTOPHERS held this procedure to be here implicated in infection, with A. wilmori as an unknown financially impracticable. It will, however, be element of danger. In the matter of preventing recollected that Sir MALCOLM WATSON himself visited, breeding there is a short length in one ravine held in 1924, a large group of tea estates in Upper Assam, suitable for treatment along the lines of subsoil where A. maculatus and A. minimus are abundant, so extensively and happily employed in the drainage instituted a system of subsoil drainage designed to Federated Malay States. For the rest it is concluded strike at their breeding-places, and expressed little that the most fundamental work open to the Company doubt that malaria would soon be under control. is the choice in the first instance of situations for The other industrial venture concerns mines in the quarters, and bungalows that are either naturally Singhbhum District of Bihar and Orissa. The mining lines, free from liability to anophelism or can be made so camps lie in alluvial-bottomed valleys within the hills. with the least If outside labour be imported Inspection was made during three weeks of the cold from relativelydifficulty. non-malarious parts serious incapacity The average spleen-rate in children was 69. season. is to be and the choice of suitable situations The basis of the inquiry, perhaps the first instance on for their expected, lines would become almost the only practicable which this has been attempted from the hygienic antimalarial measure which would not be excessively aspect, is a quantitative determination of the degree of costly. The fundamental error of both these large infection by malaria parasites in the cutaneous blood ; industrial concerns is, then, that they have been and the conclusions to which it leads are striking. By instituted in hyperendemic areas without adequate -spreading a determined quantity of blood in a thick effort being made to determine how best malarial film upon a determined area of slide, examining this infection of the staff could be avoided. Their present with a square-apertured ocular giving a field of deterheavy financial handicap is the direct result of their mined size, and counting the parasites in 200 square failure to obtain sound sanitary advice before launching fields, the number of malaria parasites in a cubic into heavy expenditure. millimetre of blood was estimated. It varied, where they were detected, from 4 to 134,232 ; 85 per cent. THE CONTRIBUTORY PENSIONS ACT.-The Ministry of parasites came from those who had lived on the of Health announces that the number of claims received in estate for two years and under. In those who had Great Britain under the Widows’, Orphans’, and Old Age been born on the estate the similar percentage was 92. Contributory Pensions Act was 163,000. The number of Infection in the second year of residence approximated pensions so far awarded is 103,000 ; about 25,000 have been to 100 per cent., and the average parasite value was rejected or withdrawn, and there are still over 34,000 under over 12,000 per c.mm. Now the number of parasites investigation. In any case where pensions are awarded the payment will be dated back to Tan. 5th, and it is associated with febrile attacks of 103° F. or estimated always that the number already approved covers more -over seemed here to be somewhat under 5000 per c.mm. then 306,000 widows and children. The main grounds for 1 I. Report on Malaria at the Assam Sugar Estates and Factories, Ltd., Nalbari, Assam, 1921. II. Inquiry on Malaria, Blackwater Fever, and Ankylostomiasis in Singhbhum, 1923. By Lieut.-Colonel S. R. Christophers, C.I.E., O.B.E., I.M.S., Director, Central Research Institute, Kasauli.
the rejection of claims are : (1) the claimant has no child under 14 ; (2) the widow has re-married ; and (3) the normal occupation of the husband at the time of his death would not have been insurable under the Act if it had then been in force.