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On the work of the portsmouth tuberculin dispensary
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and such an o p p o r t u n i t y should not be denied to the assistant medical officer of health. W h e n a district or t o w n has a capable assistant, opportunities should be givdn to make it worth his while to r e m a i n in t h a t district. T h e efficiency of a service is not increased by constant changes, and, moreover, an assistant acquires local knowledge which is valuable in the discharge of his duties. Briefly the scheme I would suggest is as follows : - I. In towns or small areas employing one assistant the salary should be £25o as at present. 2. T o w n s or areas with two assistants. T h e s e should receive ~-3oo and ~25o. 3. T o w n s or areas with three assistants. Salaries should be £35 o, £3oo and £25 o. 4. T o w n s or areas with four assistants. Salaries should be £400, £35 ° , £3oo and £250. 5. T o w n s or areas with five or more assistants. Salaries should l~e £ 4 5 ° for the Ist, £400 for the 2nd, £35 ° for the 3rd, £300 for the 4th, and £25 ° for all the others. £ 4 5 ° might be recognised as the m a x i m u m salary for an assistant medical officer of health. In all large towns and c o u n t y areas the senior assistant would thus arrive at his position through having filled the lower posts, and would be in a b e t t e r position to supervise the work below him. H e would be responsible to the chief medical officer for certain routine work carried on by the junior staff. T h e large c o u n t y areas and the large towns would thus secure a superior class of assistants who, being paid a Eying wage, would be content to r e m a i n and perform useful work. I f such a scheme as this were adopted universally there would not be the present complaint, and a senior assistant would become recognised as a m a n who had had experience in the various branches of the public health service, and as such would be c o m p e t e n t to take charge of a district. T h e present system is unscientific, unjust, and has been allowed to remain far too long a period. It is time for all of us who have the interest of the public health service at heart to spare no energy to alter it. APPOINTMENTS UNDER THE~NATIONAL INSURANCE
ACT.--Ttm number of applications which were received within the prescribed dates from men for employment upon the outdoor staff of the English Health Insurance Commission was very large-approximately 45$ooo--although the total number Of appointments to be made scarcely exceeds 200.
JULY,
ON T H E W O R K oF THE P O R T S M O U T H TUBERCULIN DISPENSARY.": BY J. FAIRLEY, M.D., D.P.H, Assistant Medical Officer of Health. Portsmouth, Late Assistant Medical Officer " Queen Alexandra Sanatorium," Davos Platz, Switzerland. the time allowed we c a n n o t a t t e m p t an I N exhaustive description of our work at the Dispensary, and I have therefore taken up a few of the points which seem to be of interest to judge by the questions of the visitors we have. T h e first fact I wish to emphasise is t h a t in our efforts to reduce c o n s u m p t i o n we do not pin our faith to tuberculin alone. T h i s is in some danger at times of being lost sight of. W e are only too glad to avail ourselves of every help we can get in the way of bettering t h e h o m e conditions, teaching the elements of hygiene, utilising sanatorium t r e a t m e n t when we consider it to be indicated, etc., etc. ; but with all this we believe tuberculin to be one of the most potent, if not the most potent, agent in t r e a t i n g tuberculosis, and the one most applicable in a large proportion of cases. T h e a t t e n t i o n r e c e n t l y directed to tuberculin has resulted in the publication of several useful text books detailing the m e t h o d s of applying the drug. I will not therefore enter into particulars of the m e t h o d s we adopt further t h a n to state that we use what is t e r m e d the intensive m e t h o d originated by Koch and i n t r o d u c e d into this c o u n t r y largely t h r o u g h the efforts of Dr. C a m a c Wilkinson, of L o n d o n . I f a n y o n e is interested in the details I will endeavour later on to answer any questions that m a y be put. One of the a r g u m e n t s in favour of the e s t a b l i s h m e n t of Dispensaries for t r e a t m e n t is t h a t such organisations are of themselves, and without the aid of a hospital or sanatorium, able to deal successfully with a large proportion of phthisical patients. T h a t a Dispensary should act as a clearing house for the distribution of patients to appropriate institutions such as sanatoria, convalescent homes, P o o r L a w infirmaries or other places seems natural, and is part of our preconceived idea of what a Dispensary ought to d o ; but to undertake at a dispensary the t r e a t m e n t of phthisical patients, a large n u m b e r of w h o m are not at any time transferred to such institutions, constitutes a new d e p a r t u r e which is affecting our whole outlook on the t r e a t m e n t of this disease. Can *Read at a Meeting of the Southern Branoh of tile Society of Medical Offl,:els of Health, on June 7th, i9~2,
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a D i s p e n s a r y efficiently carry out these extra duties ? I have endeavoured to answer this question by the following analysis of the patients who presented themselves during the 71 m o n t h s from the opening of the Dispensary till the end of J a n u a r y of this year. My reason for confining myself to this period will be a p p a r e n t later on. In all, 452 persons applied at the Dispensary. Of these, 37o were tubercular ; of the remainder, were found to be free from the disease, and the o t h e r ¼ either had not a t t e n d e d long enough for diagnosis to be arrived at, or were still under observation. Of the tubercular patients, 7 ° per cent. were taken on for t r e a t m e n t , 15 per cent. were too ill for Dispensary treatment, and 15 per cent. were referred elsev~here on a c c o u n t of surgical or other complications. T h e 257 patients who were taken on for t r e a t m e n t can be sub-divided into 63 who for various reasons stopped t r e a t m e n t in less t h a n 3 months, and 194 whose course extended to more t h a n 3 m o n t h s . T h r e e - f o u r t h s of the 63 patients whose course was short, stopped t r e a t m e n t for reasons not directly connected with our treatment, viz., some had other complications, some left the town and some refused to go on. Of the other fourth, viz. 16 patients, 4 were so m u c h b e t t e r that we felt justified in giving an interval in their t r e a t m e n t , while 12 were stopped because t h e y were worse, or at least showed no i m p r o v e m e n t . T h i s is w o r t h y of note then, t h a t only 12 of the 257 patients who began t r e a t m e n t were forced to stop in less than 3 m o n t h s because t h e y were unsuitable, i.e., less t h a n 5 per cent. This is more remarkable when we consider how ill some of these patients were on admission. W e had grave doubts as to their suitability for t r e a t m e n t , not only with regard to this 5 per cent., but also with regard to some others who have been able to continue. One hesitates in such cases to refuse t h e m the chance offered by tuberculin, i n speaking of this class let me quote from the recently published work on " T u b e r c u l i n T r e a t m e n t " by Riviere and Morland. T h e y say (p. 78), " It is impossible to exclude from tuberculin t r e a t m e n t a certain class because it will recover without ; or a n o t h e r because no i m p r o v e m e n t is possible. In practice such classes c a n n o t be defined and those whose experience of tuberculin is the greatest do rmt draw up lists of c o n t r a indications but decide from case to case on grounds of expediency. It is natural t h a t as experience increases and difficulties are
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overcome, the range of application of a remedy should also incretse and cases be excluded which do not respond so easily and require some m a n a g e m e n t . " It is self evident t h a t those who are too ill to a t t e n d the Dispensary c a n n o t be taken on for t r e a t m e n t , but on the other h a n d it must not be lost sight of that after a period of rest, the condition of a n u m b e r of these will improve sufficiently to enable t h e m to attend. If a prolonged rest in bed be found necessary, which cannot be satisfactorily provided at home, then it is that we fal! back upon the s a n a t o r i u m or other institution to provide t h a t rest; and here one would differentiate between those in whom the disease had advanced so far that any c h a n c e of their ever returning to work is obviously out of the question and who will go to a home ; as distinguished from a sanatorium p r o p e r which will take those in w h o m there is a reasonable prospect of working capacity being restored. A short rest in bed can usually be carried out quite efficiently at home, but under certain conditions, e.g., when the patient is in lodgings, or for other reasons, it is b e t t e r to have him away for the time. T o take these cases will be the main function of a hospital for acute cases which should always be provided in connection with a Dispensary. T h e smallpox hospital with i r such beds is being used temporarily for this purpose at P o r t s m o u t h . In the statistics I am about to quote, it must not be lost sight of t h a t a n u m b e r of the patients are so ill on applying that t h e y need a preliminary rest in bed. Of the 257 patients whose course of treatm e n t has extended to more than 3 months, 166 are still under t r e a t m e n t . W e will confine our attention to the 91 cases who have finished their course for the present. T o include those who, for one reason or another, stopped before 3 m o n t h s t r e a t m e n t was carried out is hardly applying a fair test to the method. T h i s was my reason for not including cascs who applied after the end of January. T h e actual period of t r e a t m e n t in these cases averages almost exactly six m o n t h s . On admission they were classified a~ follows :-2 were contacts, 5 cases of cervical adenitis, 5 other non-pululonary lesions, and the remaining 79 were p u l m o n a r y tuberculosis. These last are further divided into i6 of advanced disease, 28 intermediate, and 35 early cases. In 38 of these patients, i.e., in 46 per cent. the diagnosis was verified by finding tubercle bacilli in the sputum.
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First the advanced cases, corresponding to the T u r b a n G e r h a r t Stiidium iii. A dispensary hardly seems the place to treat advanced phthisis; but some of these patients are able and will be able for years to carry on useful work. T h e y c a n n o t all go to sanatoria or poor law institutions, and even if t h e y do go there for a season in the more acute phases of their disease, no one will propose t h a t such a large n u m b e r of persons be p e r m a n e n t l y kept there, while their d e p e n d e n t s are supported by the public authorities. W h a t is to be done with such applicants ? No dne pretends to be able to cure t h e m in the sense of restitution of lost tissue, but one can expect in m a n y cases to be able to ameliorate their s y m p t o m s , make t h e m more fit to do their day's work and live more comfortable lives ; and while hopeful t r e a t m e n t is being carried out, such patients will m u c h more readily adopt precautions against infecting others. Although however the object in taking t h e m on is not to cure t h e m so much as to bring about a physiological tolerence to their disease for the relief of s y m p t o m s , some remarkable results are obtained individual cases, and for all practical purposes the patient is cured and remains well for m a n y years. This is testified to by all who have had a long experience of tuberculin. Of our 16 advanced cases the disease was arrested in 4; 5 were improved; and of these 7 are at work now (June). W h i l e 7 were worse t h a n on admission, o r at least not improved. In the i a t e r m e d i a t e cases which correspond to the T u r b a n G e r h a r t S t a d i u m ii, one hopes to do more t h a n simply relieve symptoms. H e r e the aim is to bring about a condition of compensation which will p e r m i t of the patient living a m o d e r a t e l y active life, and of our 28 intermediate patients, i o were discharged in this c o n d i t i o n : 15 were i m p r o v e d ; and 3 were in the same condition or worse than on admission. It is in the early cases of course that the administration of tuberculin like any other form of t r e a t m e n t will give the best results. I n d e e d its efficacy in these cases is so great that some physicians claim that in this d r u g w e have a certain specific for early phthisis. T h e i r experience has surely been very fortunate. It is hardly reasonable to expect t h a t a m e t h o d of t r e a t m e n t which demands some power of resistance on the part of the patient can be successful in every individual case. Some early cases pass so rapidly to the advanced stage that every form of t r e a t m e n t - s e e m s hopeless to
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stop their p r o g r e s s ; but this acute t y p e with an a p p a r e n t absence of any resisting power is fortunately not common, and as a rule the early cases do particularly well on tuberculin. T w e n t y - n i n e of our 35 cases were discharged as arrested, and in m a n y of these healing was so complete t h a t no abnormal physical signs could be detected in the chest. F o u r were improved while in two the t r e a t m e n t had a p p a r e n t l y no effect. O f the 79 p u l m o n a r y cases, 54 per cent. were discharged with disease arrested ; 31 per cent. improved and 15 per cent. were not improved. Although the first course of treatment has been completed, t h e s e patients have not been lost sight of. T h e y all come back to report themselves at intervals of 1-6 m o n t h s varying according to their condition ; t h e y are on a period of probation, and if at any time it be considered advisable a second course of t r e a t m e n t will be undertaken. T h e word "discharged" then is not applicable to all these cases, as in some it means only an interval in their t r e a t m e n t , but it seems b e t t e r to classify t h e m t o g e t h e r i n t h i s way because one c a n n o t foretell how m a n y will be rea d m i t t e d for a second or even a third course of t r e a t m e n t . All authorities recognise t h a t the best results are to be obtained in a fair p r o p o r t i o n of cases only by this m e t h o d of dividing up the whole t r e a t m e n t into shorter courses alternating with intervals. As the resources of tuberculin t r e a t m e n t have not yet been exhausted in these patients, we can look forward to our final results showing b e t t e r percentages t h a n those I have given you. As regards the working capacity, 38 of the 91 cases were not fit for full work when t r e a t m e n t was begun ; 5 of these were on partial work and 5 were stopped work on admission, and if we neglect these and two other cases which were off work for long periods (3 years and I year respectively) the average time off work was io½ weeks. Of these 38 cases, 14 were still unfit at the end of the t r e a t m e n t , 3 were partially fit, and 21 were quite fit. T h i s 21 includes the 5 who were on partial work at the start, the other 16 had been off work for an average period of 9½ weeks. Speaking of Dr. Fraser's report on the advisability of setting up a tuberculin dispensary, the L a n c e t , of J a n u a r y 2tat, I 9 I I , has this p a r a g r a p h : - - " I f the B o r o u g h Authorities decide to carry out these r e c o m m e n d a t i o n s , the results obtained should be of great interest and value, but only if the strictest precautions
1912.
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are taken in regard to the diagnosis of the cases treated by the tuberculin method." This is an eminently fair statement, and, in justice to tuberculin, we must do our best to meet it, and at the same time to meet those critics who have asserted that tuberculin statistics are based on the treatment of cases who are not actually suffering from tuberculosis. It is important, then, for us to substantiate our diagngsis, in as many cases as possible, by finding tubercle bacilli in the sputum; and where these organisms cannot be demonstrated under the microscope, it will be well to state what facts we base our diagnosis upon, and our statistics must include only those patients who show definite signs and symptoms of the disease. Any other cases treated because they are contacts, or the so-called pre-tuberculous, or those with indefinite signs and symptoms must be eliminated. A short statement of our routine method of coming to a diagnosis may be of interest. When the history of the patient is noted and the examination made, the sputum, if there be any, is examined. W h e n tubercle bacilli are found, the diagnosis is, of course, settled. If no tubercle bacilli are found, and unless the diagnosis is considered certain from the physical signs present and a history of h~emoptyses, recurrent pleurises, etc., the test doses of tuberculin are given. In testing, we prefer the subcutaneous test to Calmette's or Von Pirquet's; and a focal reaction at the site of the lesion is considered of far greater importance than a constitutional reaction, or a local reaction at the site of injection, as it has not been proved that a person with a healed lesion will not react constitutionally and locally. In preference to the ordinary old tuberculin we use the albumose--free old tuberculin for testing. By it, one is much less apt to get a constitutional reaction than when one uses the ordinary old tuberculin, which contains various extractives and albumoses. This enables one to push the dose with the object of bringing out the focal reaction in a lesion. The focal reaction, such as persistent moist crepitations occurring in a patch of lung we previously looked on with suspicion, we take to be a certain sign of involvement of the lung. The cases with merely indefinite symptoms and suspicious signs where we have not been able to get moist sounds, even on testing, are not classified as cases of tuberculosis, but are qualified under the classification o f " Probable" or " V e r y Probable" cases.
As regards contacts, unless they have some suspicious signs or symptoms, we do not apply the tuberculin test, but are content to keep them under observation; and for this reason, that we do not consider ourselves justified in giving what might be termed prophylactic doses to persons in contact with the infection, when our time can be so fully occupied treating those who already harbour the infection. Unless, under exceptional circumstances, therefore, we are satisfied with a negative clinical examination of contacts. Bearing in mind the principles I have just enunciated, upon which our diagnosis is based, let us consider the patients who are at present attending. I have chosen the present patients for this purpose in preference to the old ones as my connection with the dispensary did not begin until January of this year, and I am therefore more intimately acquainted with the conditions of these cases, the great majority of whom have been taken on during my term of office. They number 299. Of these, 3 are contacts ; they are being treated as such, and in subsequent reports of the Dispensary they will be dealt with in a class by themselves. I m a y remark that they do not get such a prolonged course of tuberculin as our other patients : the rise in dose is more rapid and in some cases only old tuberculin is used. If they can be sent off to the country, or the infecting cause be removed, the course is stopped. 22 are nonpulmonary tuberculosis, including bone, joint or gland cases, etc., and 3o are being tested. This leaves a total of 244 pulmonary patients under treatment at present. Of these 244, tubercle bacilli have been found in the sputum in 96 cases, or in nearly 4o per cent. Lack of time to examine so thoroughly as one would like has kept this percentage lower than it ought to be. I a m sure that a more thorough search would raise it ; in some the sputum has been examined only once. If our figure is to be compared witl{ the percentage of T B 4- cases in sanatorium statistics we must take this fact also into consideration-that in an institutionwhere one has the patient more under control a better specimen of sputum will be obtained for examination than the average dispensary specimen. Again, a dispensary must get earlier cases than a sanatorium (1) because it does not interfere with a person's work, and therefore early first stage cases will attend w h e n not prepared to give up work and enter a sanatorium, and (2)
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because we examine contacts. Another factor which keeps our figure low is the large proportion of children we are treating, and these, it is well known, are much more apt to swallow the sputum t h a n to e x p e c t o r a t e it. Of the 148 cases who are classed as pulmonary, and in whom no tubercle bacilli have been found, 44 are children of 12 years and under, and in no patient of this age have the organisms been found at the dispensary. F o r convenience in discussion, I have divided the 148 cases in w h o m no tubercle bacilli have been found into three c l a s s e s - - t h o s e in w h o m the diagnosis is " quite certain," who n u m b e r 94 ; those in w h o m it is " v e r y probable," who n u m b e r 45 i and those in w h o m it is " p r o b a b l e , " who n u m b e r 9. T h e " quite c e r t a i n " are those who might be described as typical text-book cases of tuberculosis of the lung. T h e y have a history of cough with or without sputum, repeated pluerisies or h~emoptyses, with perhaps night sweats or laryngeal s y m p t o m s , and the physical signs found on examination are such that the physician would grant at once t h a t there was no doubt about the diagnosis in these 94. It remains for us to justify our t r e a t m e n t of the 45 w h o m I called " very probable " cases. T h e following is typical of this class: the patient is usually a child in contact with an infectious parent, delicate and very liable to take colds and coughs, which take a long time to clear u p ; o t h e r s y m p t o m s are perhaps present, such as loss of energy, night sweats, etc. In almost every case the l y m p h a t i c glands are found enlarged in the neck axillae and groins ; sometimes one is suspicious of the abdomen, where there are local areas of tenderness and increased resistance. At one of the apices, or elsewhere, the percussion note is impaired and the respiratory m u r m u r is broncho-vesicular in character. No moist sounds can be heard, however, and there is no sputum, or, if present, no tubercle bacilli can be found in it. On testing with tuberculin, constitutional and local reactions take place, but no definite focal reaction in the chest or elsewhere can be found. T h e r e are some who will argue t h a t the only place to prove absolutely that such a child has tuberculosis is the ~ost-mortem table, and it is in deference to these extremists t h a t I have picked out all such cases and classified them as " v e r y probably " tubercular. My own opinion is that t h e y are undoubtedly tubercular, but as we are applying rigid scrutiny let us call them " v e r y p r o b a b l e " cases. You m a y ask, w h y
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not send t h e m off to the country, under ideal conditions, where they will ahnost certainly do well ? W e do; but it is not possible in every case, and in a numb'er where it has already been tried the s y m p t o m s reasserted themselves on the patients' return to the old conditions. W e have some under observation who are having no particular t r e a t m e n t except improved hygienic c o n d i t i o n s - - t h e s e we see from m o n t h to m o n t h . As a rule this type of patient improves greatly with tuberculin. T i m e is needed before the best line of t r e a t m e n t is decided o n - - w h e t h e r we can leave some alone with impunity or w h e t h e r we must adopt active t r e a t m e n t for t h e m all; but in the m e a n t i m e we are justified by their i m p r o v e m e n t in treating some at least with tuberculin. Of the 9 classed as " p r o b a b l e " I will say very little. T h e y are being treated more as contacts t h a n a n y t h i n g else, but they present some signs or symptoms, t h o u g h not enough to w a r r a n t their inclusion a m o n g the " v e r y p r o b a b l e " cases. But for the fact that these persons are apt to be very sensitive to tuberculin, their course, like t h a t of the contacts, would be of s h o r t e r duration t h a n the average. T h e i r willingness t o continue a t t e n d i n g for what might be called "disagreeable t r e a t m e n t " proves t h a t they themselves think they are benefiting, and as a rule the benefit in this class of case is marked. In p r e p a r i n g statistics their results also will be kept separate. T o come to a definite diagnosis in early tuberculosis of the lungs is very difficult-in the present state of our knowledge it will be granted, I think, that in some individual cases it is impossible; if we are to do a n y t h i n g to help these patients we must act on probabilities, and, therefore, in a d i s p e n s a r y l i k e ours such cases must always be found. If our critics expect an absolutely certain p r o o f of the presence of the disease in too per cent. of our patients t h e y will be d i s a p p o i n t e d ; to wait till all our cases have " open " lesions would be to defeat one of the objects of our existence as a dispensary. But it is a simple and a satisfactory solution of the difficulty to treat them separately in our statistics, and this is what we are endeavouring to do. T h e r e are other points of primary i m p o r t a n c e in connection with the dispensary work which might have been taken up this afternoon--e.g., the Care Committee, which so m a t e r i a l l y increases the scope of our w o r k : or again one might have discussed how" far such a scheme as ours is applicable to other districts. B u t I
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have said enough possibly to open discussion on the subject and to show that in P o r t s m o u t h an honest effort is being made to deal with the problem, and t h a t we have, at least, some grounds for believing that we a re working on the right lines. SCIENTIFIC RESEARCH LOCAL GOVERNMENT
FOR THE BOARD.
of the Local Government Board T H EhasPresident authorised the following special researches to be paid for out of the annual grant voted by Parliament in aid of scientific investigations concerning the causes and processes of disease. I. Further investigations (a) as to the distribution of tubercle bacilli in children having died between the ages of two and ten years, and the special characteristics of such bacilli; and (b) in collaboration with the General Register Office, on the incidence of different forms of tuberculosis in different parts of the country, according to age, sex, occupation and other conditions. 2. A continuation of a research into the causes of premature arterial degeneration in man by Dr. F. W. Andrewes, of St. B trtholomew's Hospital. 3. A joint investigation into the virus of poliomyelitis by Drs. F. W. Andrewes and H. 1V[. Gordon, of St. B:trthol~mew's Hospital. 4. A continuation of an investigation into the micro-organisms known as non-lactose fermenters occurring in the alimentary canal of infants by Dr. C. J. Lewis, of Birmingham University, Dr. D. M. Alexander, of Liverpool University, and Dr. Graham-Smith, of C~mbridge University. 5. A continuation of the investigation by Professor Nattatl of Cambridge University on fleas and on the range of flight of the domestic and allied flies.
t{IDDERIVIINSTER M~DICAL
OFFICgRSHIP--At
the
meeting of the Kidderminster Town Council, on May 7th, the Health Committee reported : - - " That having received a letter from the Local Government Board declining to sanction the appointment of Dr. W. H. Moore as medical officer of health for the borough, and Dr. Moore having stated teat he is prepared to carry out the duties for the sum of ~5o per annum, they recommend that the offer made by him be accepted on the understanding that he gives an undertaking to accept that sum until such time as the Local Covernment Board sanctions the appointment." The recommendation was adopted. Dr. Moore recently resigned his membership of the town council in order to become a candidate for the medical officership.
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THE ADMINISTRATION OF THE SANATORIUM BENEFIT UNDER THE NATIONAL INSURANCE ACT, I9II.* BY EDWARD SERGEANT, M.R.C.S., L.R.C.P., D.P.H., County Medical Officer of Health, Lancashire. some diffidence t h a t I introduce for I T yisowith u r consideration my i n t e r p r e t a t i o n of the clauses contained in the I n s u r a n c e Act for providing the t r e a t m e n t of insured persons suffering from tuberculosis or any allied disease in sanatoria and other institutions.
Administration of Sanatorium [email protected] is made under Section 16 (a) for t r e a t m e n t by the local authoritiesf of insured persons resident outside as well as those resident within their area. T h e i n s u r a n c e C o m m i t t e e s are authorised to make an a r r a n g e m e n t for treatm e n t with persons or local authorities (other t h a n Poor L a w authorities) which must prove satisfactory to the I n s u r a n c e Commissioners, and meet with the approval of the L o c a l G o v e r n m e n t Board. B u t an insured person shall not be entitled to sanatorium t r e a t m e n t unless the Insurance C o m m i t t e e r e c o m m e n d s the case for such b e n e f i t - - S e c t i o n i6 (3).
Extension of Sanatorhtm benefit to de~endants.-It is i m p o r t a n t to note t h a t Section 17 0) provides that the Insurance C o m m i t t e e may, " i f it thinks fit," extend the sanatorium benefit to the d e p e n d a n t s of the insured persons resident in the county or any part of the c o u n t y or c o u n t y borough, or to any class of such dependants.
11t case fimds for SauatorimJ~ be~tefit ins~fident. - - I t is stipulated that if in any year the funds available for defraying the e s t i m a t e d expenditure on sanatorium benefit are insufficient for insured persons and dependants, the Insurance C o m m i t t e e m a y apply to the T r e a s u r y and c o u n t y or borough council (Section 17 (2)) for sanction to the additional expenditure, and if t h e y are satisfied, the excess will be defrayed by the T r e a s u r y paying one-half and the c o u n t y or borough paying the other half of the a m o u n t sanctioned; while by Section 22 provision is made for p a y m e n t s by borough or district councils towards the excess expenditure on medical or sanatorium benefit so far as such excess is properly attributable to the borough or district.
Local authorities and the provision of Sanatoria. - - B y the Finance Act, 1911, a sum of £'I,5oo,ooo was made available for the distribution of * Read at a meeting of the N o r t h - W e s t e r n Bcanch of the Society of Medical Officers of Health on March i5th, ~912. "[ There is no defirtition of lo¢,al authorities its thi~ Act.'
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and such an o p p o r t u n i t y should not be denied to the assistant medical officer of health. W h e n a district or t o w n has a capable assistant, opportunities should be givdn to make it worth his while to r e m a i n in t h a t district. T h e efficiency of a service is not increased by constant changes, and, moreover, an assistant acquires local knowledge which is valuable in the discharge of his duties. Briefly the scheme I would suggest is as follows : - I. In towns or small areas employing one assistant the salary should be £25o as at present. 2. T o w n s or areas with two assistants. T h e s e should receive ~-3oo and ~25o. 3. T o w n s or areas with three assistants. Salaries should be £35 o, £3oo and £25 o. 4. T o w n s or areas with four assistants. Salaries should be £400, £35 ° , £3oo and £250. 5. T o w n s or areas with five or more assistants. Salaries should l~e £ 4 5 ° for the Ist, £400 for the 2nd, £35 ° for the 3rd, £300 for the 4th, and £25 ° for all the others. £ 4 5 ° might be recognised as the m a x i m u m salary for an assistant medical officer of health. In all large towns and c o u n t y areas the senior assistant would thus arrive at his position through having filled the lower posts, and would be in a b e t t e r position to supervise the work below him. H e would be responsible to the chief medical officer for certain routine work carried on by the junior staff. T h e large c o u n t y areas and the large towns would thus secure a superior class of assistants who, being paid a Eying wage, would be content to r e m a i n and perform useful work. I f such a scheme as this were adopted universally there would not be the present complaint, and a senior assistant would become recognised as a m a n who had had experience in the various branches of the public health service, and as such would be c o m p e t e n t to take charge of a district. T h e present system is unscientific, unjust, and has been allowed to remain far too long a period. It is time for all of us who have the interest of the public health service at heart to spare no energy to alter it. APPOINTMENTS UNDER THE~NATIONAL INSURANCE
ACT.--Ttm number of applications which were received within the prescribed dates from men for employment upon the outdoor staff of the English Health Insurance Commission was very large-approximately 45$ooo--although the total number Of appointments to be made scarcely exceeds 200.
JULY,
ON T H E W O R K oF THE P O R T S M O U T H TUBERCULIN DISPENSARY.": BY J. FAIRLEY, M.D., D.P.H, Assistant Medical Officer of Health. Portsmouth, Late Assistant Medical Officer " Queen Alexandra Sanatorium," Davos Platz, Switzerland. the time allowed we c a n n o t a t t e m p t an I N exhaustive description of our work at the Dispensary, and I have therefore taken up a few of the points which seem to be of interest to judge by the questions of the visitors we have. T h e first fact I wish to emphasise is t h a t in our efforts to reduce c o n s u m p t i o n we do not pin our faith to tuberculin alone. T h i s is in some danger at times of being lost sight of. W e are only too glad to avail ourselves of every help we can get in the way of bettering t h e h o m e conditions, teaching the elements of hygiene, utilising sanatorium t r e a t m e n t when we consider it to be indicated, etc., etc. ; but with all this we believe tuberculin to be one of the most potent, if not the most potent, agent in t r e a t i n g tuberculosis, and the one most applicable in a large proportion of cases. T h e a t t e n t i o n r e c e n t l y directed to tuberculin has resulted in the publication of several useful text books detailing the m e t h o d s of applying the drug. I will not therefore enter into particulars of the m e t h o d s we adopt further t h a n to state that we use what is t e r m e d the intensive m e t h o d originated by Koch and i n t r o d u c e d into this c o u n t r y largely t h r o u g h the efforts of Dr. C a m a c Wilkinson, of L o n d o n . I f a n y o n e is interested in the details I will endeavour later on to answer any questions that m a y be put. One of the a r g u m e n t s in favour of the e s t a b l i s h m e n t of Dispensaries for t r e a t m e n t is t h a t such organisations are of themselves, and without the aid of a hospital or sanatorium, able to deal successfully with a large proportion of phthisical patients. T h a t a Dispensary should act as a clearing house for the distribution of patients to appropriate institutions such as sanatoria, convalescent homes, P o o r L a w infirmaries or other places seems natural, and is part of our preconceived idea of what a Dispensary ought to d o ; but to undertake at a dispensary the t r e a t m e n t of phthisical patients, a large n u m b e r of w h o m are not at any time transferred to such institutions, constitutes a new d e p a r t u r e which is affecting our whole outlook on the t r e a t m e n t of this disease. Can *Read at a Meeting of the Southern Branoh of tile Society of Medical Offl,:els of Health, on June 7th, i9~2,
1919,.
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a D i s p e n s a r y efficiently carry out these extra duties ? I have endeavoured to answer this question by the following analysis of the patients who presented themselves during the 71 m o n t h s from the opening of the Dispensary till the end of J a n u a r y of this year. My reason for confining myself to this period will be a p p a r e n t later on. In all, 452 persons applied at the Dispensary. Of these, 37o were tubercular ; of the remainder, were found to be free from the disease, and the o t h e r ¼ either had not a t t e n d e d long enough for diagnosis to be arrived at, or were still under observation. Of the tubercular patients, 7 ° per cent. were taken on for t r e a t m e n t , 15 per cent. were too ill for Dispensary treatment, and 15 per cent. were referred elsev~here on a c c o u n t of surgical or other complications. T h e 257 patients who were taken on for t r e a t m e n t can be sub-divided into 63 who for various reasons stopped t r e a t m e n t in less t h a n 3 months, and 194 whose course extended to more t h a n 3 m o n t h s . T h r e e - f o u r t h s of the 63 patients whose course was short, stopped t r e a t m e n t for reasons not directly connected with our treatment, viz., some had other complications, some left the town and some refused to go on. Of the other fourth, viz. 16 patients, 4 were so m u c h b e t t e r that we felt justified in giving an interval in their t r e a t m e n t , while 12 were stopped because t h e y were worse, or at least showed no i m p r o v e m e n t . T h i s is w o r t h y of note then, t h a t only 12 of the 257 patients who began t r e a t m e n t were forced to stop in less than 3 m o n t h s because t h e y were unsuitable, i.e., less t h a n 5 per cent. This is more remarkable when we consider how ill some of these patients were on admission. W e had grave doubts as to their suitability for t r e a t m e n t , not only with regard to this 5 per cent., but also with regard to some others who have been able to continue. One hesitates in such cases to refuse t h e m the chance offered by tuberculin, i n speaking of this class let me quote from the recently published work on " T u b e r c u l i n T r e a t m e n t " by Riviere and Morland. T h e y say (p. 78), " It is impossible to exclude from tuberculin t r e a t m e n t a certain class because it will recover without ; or a n o t h e r because no i m p r o v e m e n t is possible. In practice such classes c a n n o t be defined and those whose experience of tuberculin is the greatest do rmt draw up lists of c o n t r a indications but decide from case to case on grounds of expediency. It is natural t h a t as experience increases and difficulties are
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overcome, the range of application of a remedy should also incretse and cases be excluded which do not respond so easily and require some m a n a g e m e n t . " It is self evident t h a t those who are too ill to a t t e n d the Dispensary c a n n o t be taken on for t r e a t m e n t , but on the other h a n d it must not be lost sight of that after a period of rest, the condition of a n u m b e r of these will improve sufficiently to enable t h e m to attend. If a prolonged rest in bed be found necessary, which cannot be satisfactorily provided at home, then it is that we fal! back upon the s a n a t o r i u m or other institution to provide t h a t rest; and here one would differentiate between those in whom the disease had advanced so far that any c h a n c e of their ever returning to work is obviously out of the question and who will go to a home ; as distinguished from a sanatorium p r o p e r which will take those in w h o m there is a reasonable prospect of working capacity being restored. A short rest in bed can usually be carried out quite efficiently at home, but under certain conditions, e.g., when the patient is in lodgings, or for other reasons, it is b e t t e r to have him away for the time. T o take these cases will be the main function of a hospital for acute cases which should always be provided in connection with a Dispensary. T h e smallpox hospital with i r such beds is being used temporarily for this purpose at P o r t s m o u t h . In the statistics I am about to quote, it must not be lost sight of t h a t a n u m b e r of the patients are so ill on applying that t h e y need a preliminary rest in bed. Of the 257 patients whose course of treatm e n t has extended to more than 3 months, 166 are still under t r e a t m e n t . W e will confine our attention to the 91 cases who have finished their course for the present. T o include those who, for one reason or another, stopped before 3 m o n t h s t r e a t m e n t was carried out is hardly applying a fair test to the method. T h i s was my reason for not including cascs who applied after the end of January. T h e actual period of t r e a t m e n t in these cases averages almost exactly six m o n t h s . On admission they were classified a~ follows :-2 were contacts, 5 cases of cervical adenitis, 5 other non-pululonary lesions, and the remaining 79 were p u l m o n a r y tuberculosis. These last are further divided into i6 of advanced disease, 28 intermediate, and 35 early cases. In 38 of these patients, i.e., in 46 per cent. the diagnosis was verified by finding tubercle bacilli in the sputum.
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First the advanced cases, corresponding to the T u r b a n G e r h a r t Stiidium iii. A dispensary hardly seems the place to treat advanced phthisis; but some of these patients are able and will be able for years to carry on useful work. T h e y c a n n o t all go to sanatoria or poor law institutions, and even if t h e y do go there for a season in the more acute phases of their disease, no one will propose t h a t such a large n u m b e r of persons be p e r m a n e n t l y kept there, while their d e p e n d e n t s are supported by the public authorities. W h a t is to be done with such applicants ? No dne pretends to be able to cure t h e m in the sense of restitution of lost tissue, but one can expect in m a n y cases to be able to ameliorate their s y m p t o m s , make t h e m more fit to do their day's work and live more comfortable lives ; and while hopeful t r e a t m e n t is being carried out, such patients will m u c h more readily adopt precautions against infecting others. Although however the object in taking t h e m on is not to cure t h e m so much as to bring about a physiological tolerence to their disease for the relief of s y m p t o m s , some remarkable results are obtained individual cases, and for all practical purposes the patient is cured and remains well for m a n y years. This is testified to by all who have had a long experience of tuberculin. Of our 16 advanced cases the disease was arrested in 4; 5 were improved; and of these 7 are at work now (June). W h i l e 7 were worse t h a n on admission, o r at least not improved. In the i a t e r m e d i a t e cases which correspond to the T u r b a n G e r h a r t S t a d i u m ii, one hopes to do more t h a n simply relieve symptoms. H e r e the aim is to bring about a condition of compensation which will p e r m i t of the patient living a m o d e r a t e l y active life, and of our 28 intermediate patients, i o were discharged in this c o n d i t i o n : 15 were i m p r o v e d ; and 3 were in the same condition or worse than on admission. It is in the early cases of course that the administration of tuberculin like any other form of t r e a t m e n t will give the best results. I n d e e d its efficacy in these cases is so great that some physicians claim that in this d r u g w e have a certain specific for early phthisis. T h e i r experience has surely been very fortunate. It is hardly reasonable to expect t h a t a m e t h o d of t r e a t m e n t which demands some power of resistance on the part of the patient can be successful in every individual case. Some early cases pass so rapidly to the advanced stage that every form of t r e a t m e n t - s e e m s hopeless to
JuLy,
stop their p r o g r e s s ; but this acute t y p e with an a p p a r e n t absence of any resisting power is fortunately not common, and as a rule the early cases do particularly well on tuberculin. T w e n t y - n i n e of our 35 cases were discharged as arrested, and in m a n y of these healing was so complete t h a t no abnormal physical signs could be detected in the chest. F o u r were improved while in two the t r e a t m e n t had a p p a r e n t l y no effect. O f the 79 p u l m o n a r y cases, 54 per cent. were discharged with disease arrested ; 31 per cent. improved and 15 per cent. were not improved. Although the first course of treatment has been completed, t h e s e patients have not been lost sight of. T h e y all come back to report themselves at intervals of 1-6 m o n t h s varying according to their condition ; t h e y are on a period of probation, and if at any time it be considered advisable a second course of t r e a t m e n t will be undertaken. T h e word "discharged" then is not applicable to all these cases, as in some it means only an interval in their t r e a t m e n t , but it seems b e t t e r to classify t h e m t o g e t h e r i n t h i s way because one c a n n o t foretell how m a n y will be rea d m i t t e d for a second or even a third course of t r e a t m e n t . All authorities recognise t h a t the best results are to be obtained in a fair p r o p o r t i o n of cases only by this m e t h o d of dividing up the whole t r e a t m e n t into shorter courses alternating with intervals. As the resources of tuberculin t r e a t m e n t have not yet been exhausted in these patients, we can look forward to our final results showing b e t t e r percentages t h a n those I have given you. As regards the working capacity, 38 of the 91 cases were not fit for full work when t r e a t m e n t was begun ; 5 of these were on partial work and 5 were stopped work on admission, and if we neglect these and two other cases which were off work for long periods (3 years and I year respectively) the average time off work was io½ weeks. Of these 38 cases, 14 were still unfit at the end of the t r e a t m e n t , 3 were partially fit, and 21 were quite fit. T h i s 21 includes the 5 who were on partial work at the start, the other 16 had been off work for an average period of 9½ weeks. Speaking of Dr. Fraser's report on the advisability of setting up a tuberculin dispensary, the L a n c e t , of J a n u a r y 2tat, I 9 I I , has this p a r a g r a p h : - - " I f the B o r o u g h Authorities decide to carry out these r e c o m m e n d a t i o n s , the results obtained should be of great interest and value, but only if the strictest precautions
1912.
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are taken in regard to the diagnosis of the cases treated by the tuberculin method." This is an eminently fair statement, and, in justice to tuberculin, we must do our best to meet it, and at the same time to meet those critics who have asserted that tuberculin statistics are based on the treatment of cases who are not actually suffering from tuberculosis. It is important, then, for us to substantiate our diagngsis, in as many cases as possible, by finding tubercle bacilli in the sputum; and where these organisms cannot be demonstrated under the microscope, it will be well to state what facts we base our diagnosis upon, and our statistics must include only those patients who show definite signs and symptoms of the disease. Any other cases treated because they are contacts, or the so-called pre-tuberculous, or those with indefinite signs and symptoms must be eliminated. A short statement of our routine method of coming to a diagnosis may be of interest. When the history of the patient is noted and the examination made, the sputum, if there be any, is examined. W h e n tubercle bacilli are found, the diagnosis is, of course, settled. If no tubercle bacilli are found, and unless the diagnosis is considered certain from the physical signs present and a history of h~emoptyses, recurrent pleurises, etc., the test doses of tuberculin are given. In testing, we prefer the subcutaneous test to Calmette's or Von Pirquet's; and a focal reaction at the site of the lesion is considered of far greater importance than a constitutional reaction, or a local reaction at the site of injection, as it has not been proved that a person with a healed lesion will not react constitutionally and locally. In preference to the ordinary old tuberculin we use the albumose--free old tuberculin for testing. By it, one is much less apt to get a constitutional reaction than when one uses the ordinary old tuberculin, which contains various extractives and albumoses. This enables one to push the dose with the object of bringing out the focal reaction in a lesion. The focal reaction, such as persistent moist crepitations occurring in a patch of lung we previously looked on with suspicion, we take to be a certain sign of involvement of the lung. The cases with merely indefinite symptoms and suspicious signs where we have not been able to get moist sounds, even on testing, are not classified as cases of tuberculosis, but are qualified under the classification o f " Probable" or " V e r y Probable" cases.
As regards contacts, unless they have some suspicious signs or symptoms, we do not apply the tuberculin test, but are content to keep them under observation; and for this reason, that we do not consider ourselves justified in giving what might be termed prophylactic doses to persons in contact with the infection, when our time can be so fully occupied treating those who already harbour the infection. Unless, under exceptional circumstances, therefore, we are satisfied with a negative clinical examination of contacts. Bearing in mind the principles I have just enunciated, upon which our diagnosis is based, let us consider the patients who are at present attending. I have chosen the present patients for this purpose in preference to the old ones as my connection with the dispensary did not begin until January of this year, and I am therefore more intimately acquainted with the conditions of these cases, the great majority of whom have been taken on during my term of office. They number 299. Of these, 3 are contacts ; they are being treated as such, and in subsequent reports of the Dispensary they will be dealt with in a class by themselves. I m a y remark that they do not get such a prolonged course of tuberculin as our other patients : the rise in dose is more rapid and in some cases only old tuberculin is used. If they can be sent off to the country, or the infecting cause be removed, the course is stopped. 22 are nonpulmonary tuberculosis, including bone, joint or gland cases, etc., and 3o are being tested. This leaves a total of 244 pulmonary patients under treatment at present. Of these 244, tubercle bacilli have been found in the sputum in 96 cases, or in nearly 4o per cent. Lack of time to examine so thoroughly as one would like has kept this percentage lower than it ought to be. I a m sure that a more thorough search would raise it ; in some the sputum has been examined only once. If our figure is to be compared witl{ the percentage of T B 4- cases in sanatorium statistics we must take this fact also into consideration-that in an institutionwhere one has the patient more under control a better specimen of sputum will be obtained for examination than the average dispensary specimen. Again, a dispensary must get earlier cases than a sanatorium (1) because it does not interfere with a person's work, and therefore early first stage cases will attend w h e n not prepared to give up work and enter a sanatorium, and (2)
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because we examine contacts. Another factor which keeps our figure low is the large proportion of children we are treating, and these, it is well known, are much more apt to swallow the sputum t h a n to e x p e c t o r a t e it. Of the 148 cases who are classed as pulmonary, and in whom no tubercle bacilli have been found, 44 are children of 12 years and under, and in no patient of this age have the organisms been found at the dispensary. F o r convenience in discussion, I have divided the 148 cases in w h o m no tubercle bacilli have been found into three c l a s s e s - - t h o s e in w h o m the diagnosis is " quite certain," who n u m b e r 94 ; those in w h o m it is " v e r y probable," who n u m b e r 45 i and those in w h o m it is " p r o b a b l e , " who n u m b e r 9. T h e " quite c e r t a i n " are those who might be described as typical text-book cases of tuberculosis of the lung. T h e y have a history of cough with or without sputum, repeated pluerisies or h~emoptyses, with perhaps night sweats or laryngeal s y m p t o m s , and the physical signs found on examination are such that the physician would grant at once t h a t there was no doubt about the diagnosis in these 94. It remains for us to justify our t r e a t m e n t of the 45 w h o m I called " very probable " cases. T h e following is typical of this class: the patient is usually a child in contact with an infectious parent, delicate and very liable to take colds and coughs, which take a long time to clear u p ; o t h e r s y m p t o m s are perhaps present, such as loss of energy, night sweats, etc. In almost every case the l y m p h a t i c glands are found enlarged in the neck axillae and groins ; sometimes one is suspicious of the abdomen, where there are local areas of tenderness and increased resistance. At one of the apices, or elsewhere, the percussion note is impaired and the respiratory m u r m u r is broncho-vesicular in character. No moist sounds can be heard, however, and there is no sputum, or, if present, no tubercle bacilli can be found in it. On testing with tuberculin, constitutional and local reactions take place, but no definite focal reaction in the chest or elsewhere can be found. T h e r e are some who will argue t h a t the only place to prove absolutely that such a child has tuberculosis is the ~ost-mortem table, and it is in deference to these extremists t h a t I have picked out all such cases and classified them as " v e r y probably " tubercular. My own opinion is that t h e y are undoubtedly tubercular, but as we are applying rigid scrutiny let us call them " v e r y p r o b a b l e " cases. You m a y ask, w h y
H E A L TH.
j u Lv,
not send t h e m off to the country, under ideal conditions, where they will ahnost certainly do well ? W e do; but it is not possible in every case, and in a numb'er where it has already been tried the s y m p t o m s reasserted themselves on the patients' return to the old conditions. W e have some under observation who are having no particular t r e a t m e n t except improved hygienic c o n d i t i o n s - - t h e s e we see from m o n t h to m o n t h . As a rule this type of patient improves greatly with tuberculin. T i m e is needed before the best line of t r e a t m e n t is decided o n - - w h e t h e r we can leave some alone with impunity or w h e t h e r we must adopt active t r e a t m e n t for t h e m all; but in the m e a n t i m e we are justified by their i m p r o v e m e n t in treating some at least with tuberculin. Of the 9 classed as " p r o b a b l e " I will say very little. T h e y are being treated more as contacts t h a n a n y t h i n g else, but they present some signs or symptoms, t h o u g h not enough to w a r r a n t their inclusion a m o n g the " v e r y p r o b a b l e " cases. But for the fact that these persons are apt to be very sensitive to tuberculin, their course, like t h a t of the contacts, would be of s h o r t e r duration t h a n the average. T h e i r willingness t o continue a t t e n d i n g for what might be called "disagreeable t r e a t m e n t " proves t h a t they themselves think they are benefiting, and as a rule the benefit in this class of case is marked. In p r e p a r i n g statistics their results also will be kept separate. T o come to a definite diagnosis in early tuberculosis of the lungs is very difficult-in the present state of our knowledge it will be granted, I think, that in some individual cases it is impossible; if we are to do a n y t h i n g to help these patients we must act on probabilities, and, therefore, in a d i s p e n s a r y l i k e ours such cases must always be found. If our critics expect an absolutely certain p r o o f of the presence of the disease in too per cent. of our patients t h e y will be d i s a p p o i n t e d ; to wait till all our cases have " open " lesions would be to defeat one of the objects of our existence as a dispensary. But it is a simple and a satisfactory solution of the difficulty to treat them separately in our statistics, and this is what we are endeavouring to do. T h e r e are other points of primary i m p o r t a n c e in connection with the dispensary work which might have been taken up this afternoon--e.g., the Care Committee, which so m a t e r i a l l y increases the scope of our w o r k : or again one might have discussed how" far such a scheme as ours is applicable to other districts. B u t I
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have said enough possibly to open discussion on the subject and to show that in P o r t s m o u t h an honest effort is being made to deal with the problem, and t h a t we have, at least, some grounds for believing that we a re working on the right lines. SCIENTIFIC RESEARCH LOCAL GOVERNMENT
FOR THE BOARD.
of the Local Government Board T H EhasPresident authorised the following special researches to be paid for out of the annual grant voted by Parliament in aid of scientific investigations concerning the causes and processes of disease. I. Further investigations (a) as to the distribution of tubercle bacilli in children having died between the ages of two and ten years, and the special characteristics of such bacilli; and (b) in collaboration with the General Register Office, on the incidence of different forms of tuberculosis in different parts of the country, according to age, sex, occupation and other conditions. 2. A continuation of a research into the causes of premature arterial degeneration in man by Dr. F. W. Andrewes, of St. B trtholomew's Hospital. 3. A joint investigation into the virus of poliomyelitis by Drs. F. W. Andrewes and H. 1V[. Gordon, of St. B:trthol~mew's Hospital. 4. A continuation of an investigation into the micro-organisms known as non-lactose fermenters occurring in the alimentary canal of infants by Dr. C. J. Lewis, of Birmingham University, Dr. D. M. Alexander, of Liverpool University, and Dr. Graham-Smith, of C~mbridge University. 5. A continuation of the investigation by Professor Nattatl of Cambridge University on fleas and on the range of flight of the domestic and allied flies.
t{IDDERIVIINSTER M~DICAL
OFFICgRSHIP--At
the
meeting of the Kidderminster Town Council, on May 7th, the Health Committee reported : - - " That having received a letter from the Local Government Board declining to sanction the appointment of Dr. W. H. Moore as medical officer of health for the borough, and Dr. Moore having stated teat he is prepared to carry out the duties for the sum of ~5o per annum, they recommend that the offer made by him be accepted on the understanding that he gives an undertaking to accept that sum until such time as the Local Covernment Board sanctions the appointment." The recommendation was adopted. Dr. Moore recently resigned his membership of the town council in order to become a candidate for the medical officership.
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THE ADMINISTRATION OF THE SANATORIUM BENEFIT UNDER THE NATIONAL INSURANCE ACT, I9II.* BY EDWARD SERGEANT, M.R.C.S., L.R.C.P., D.P.H., County Medical Officer of Health, Lancashire. some diffidence t h a t I introduce for I T yisowith u r consideration my i n t e r p r e t a t i o n of the clauses contained in the I n s u r a n c e Act for providing the t r e a t m e n t of insured persons suffering from tuberculosis or any allied disease in sanatoria and other institutions.
Administration of Sanatorium [email protected] is made under Section 16 (a) for t r e a t m e n t by the local authoritiesf of insured persons resident outside as well as those resident within their area. T h e i n s u r a n c e C o m m i t t e e s are authorised to make an a r r a n g e m e n t for treatm e n t with persons or local authorities (other t h a n Poor L a w authorities) which must prove satisfactory to the I n s u r a n c e Commissioners, and meet with the approval of the L o c a l G o v e r n m e n t Board. B u t an insured person shall not be entitled to sanatorium t r e a t m e n t unless the Insurance C o m m i t t e e r e c o m m e n d s the case for such b e n e f i t - - S e c t i o n i6 (3).
Extension of Sanatorhtm benefit to de~endants.-It is i m p o r t a n t to note t h a t Section 17 0) provides that the Insurance C o m m i t t e e may, " i f it thinks fit," extend the sanatorium benefit to the d e p e n d a n t s of the insured persons resident in the county or any part of the c o u n t y or c o u n t y borough, or to any class of such dependants.
11t case fimds for SauatorimJ~ be~tefit ins~fident. - - I t is stipulated that if in any year the funds available for defraying the e s t i m a t e d expenditure on sanatorium benefit are insufficient for insured persons and dependants, the Insurance C o m m i t t e e m a y apply to the T r e a s u r y and c o u n t y or borough council (Section 17 (2)) for sanction to the additional expenditure, and if t h e y are satisfied, the excess will be defrayed by the T r e a s u r y paying one-half and the c o u n t y or borough paying the other half of the a m o u n t sanctioned; while by Section 22 provision is made for p a y m e n t s by borough or district councils towards the excess expenditure on medical or sanatorium benefit so far as such excess is properly attributable to the borough or district.
Local authorities and the provision of Sanatoria. - - B y the Finance Act, 1911, a sum of £'I,5oo,ooo was made available for the distribution of * Read at a meeting of the N o r t h - W e s t e r n Bcanch of the Society of Medical Officers of Health on March i5th, ~912. "[ There is no defirtition of lo¢,al authorities its thi~ Act.'