The League of Nations interchange of health personnel in America

~9~4 .

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organs in Hampstead and 52"2 in Shoreditch (see Table E ) ; it can hardly be said then that the excess of cancer in Hampstead at all ages is due to better diagnosis, though its age distribution may be. The figures are not sufficiently numerous to j'ustify one in basing conclusions on them, but I suggest as an hypothesis that comparative excess of nutrition in Hampstead women accounts for them having more cancer. The men are usually the best fed members of working class families and consequently there would not be so much difference in nutrition between men in Hampstead and Shoreditch. But smoking is recognised to be the chief cause of cancer of the mouth and alcoholism is an important cause of cancer of the mouth, throat and stomach. ~ Table F shews that there is considerably more alcoholism in Shoreditch than in Hampstead and there is probably at least as much TABLE F. Alcoholism and Cirrhosis of Liver over 45.

1915-20.

Shoreditch.

Hampstead.

Males. Females. Males. t Females. Av. p.x 6 Av.p.x 6 Av. p. x 6lAy. p. x 6 =53,070 =84,558 =65,214 =67,776 Deaths over 45

21

13

Rate per 1,000

0"40

0"15

0"54

0"41

smoking. This perhaps accounts for the nearly equal occurrence of cancer among men in the two Boroughs. It is to be hoped that others may be induced to compare the occurrence of cancer among rich and poor with a view to answering the question, what part, if any, does the over-nutrition of civilisation --compared with savage life have in causing cancer. I have to acknowledge with thanks much kind heIp given by Dr. Stevenson, Superintendent of Statistics, in preparing the statistical basis of this note.

DR. C. E. GODDARD, O.B.E., medical officer of health for the Wembley and Harrow urban districts, has been appointed medical officer for the British Empire Exhibition. ;~ Gen. Sir A. Pearce Gould's Bradshaw Lecture, 1910, quoting a paper by Sir Arthur Newsholme, and Annual Reports on the Health of Woolwich, 1913-18.

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T H E LEAGUE OF N A T I O N S I N T E R CHANGE OF H E A L T H P E R S O N N E L IN AMERICA. BY CHARLES PORTER, M.D., B.Sc., Medical Officer of ttealth, St. Marylebone. IV. The programme prepared for the group that had Virginia allotted to it as its Southern State was a most representative one and made provision for a complete survey of the many activities of the health department throughout the State. The itinerary commenced on September 23rd, and included visits to Richmond, to Charlottesville in Albemarle County, and famous as the seat of the University of Virginia, established by Jefferson Roanoke, chief city of Roanoke county; Pulaski, a small town in Pulaski county, South West Virginia ; in the east and near the southern boundary, Newport News and Norfolk and Suffolk, which is in Nansemonde county, and famous in history because within its boundaries the earliest English settlers found their first home ; and Emporia in Greensvitle county. In each area one or more features or activities were investigated and by the end of the tour on October 21st, which on account of the acceptance of an invitation to visit the Johns Hopkins University School of Hygiene and Public Health in Baltimore, was earlier than originally proposed, we had seen sufficient to convince us that good work was being done and in many places great progress had been and was being made. Richmond, the capital city of the State and the headquarters of the State Board of Health, was the first stopping place. Here we remained ten days, spending the greater part of each day with Dr. E. G. Williams, the Commissioner of Health, and his staff, hearing from him and the heads of the various divisions something of the working of each branch, of the results obtained and hoped for. Apart from Dr. Williams, who it may be noted, was the first Commissioner to be appointed and has held office continuously since 1908, and is the maker of Virginia so far as Public Health is concerned, and one of the best loved men in the State, we came very intimately into contact ~vith Dr. Roy K. Flannagan, the Assistant Commissioner, Dr. L. L. Williams, junr., of the United States Public Health Service, and Dr. Clinton A. Kane, of the International Health Board, both authorities on Malaria and both attached to the State Board for the purpose of supervising antimalarial work. From each of these officers we received a description of the branch of work for which they are

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responsible and by them we were conducted round the State for the purpose of investigating the situation generally. Others with whom we worked and from whom we heard were Dr. Ptecker, the Director of the State Bureau of Vital Statistics, a very learned and very enthusiastic statistician and health worker; Mr. Straus, who is in charge of the State Laboratory; Dr. G. C. Payne, the recently appointed State Epidemio!ogist ; Dr. Robertson, of the United States Public Health Service, who is supervising sanitary works in rural areas in the State ; Dr. Bryden, Director of the Child Welfare Bureau, who gave u s a whole day and brought with her to address us, Dr. Ballon, the Director of Mouth ttygiene (who is doing most excellent work amongst the school children); and a number of school and maternity and public health nurses collected from all over the State. Also we met the officer in charge of the graphoscope and portable electric light power plant, and had from him a showing of the State Board of Health moving pictures for Public Health Education. In a note such as this it is impossible to set out at length the information that we were given and that we obtained as a result of direct observation. All that is proposed is to say something with regard to organisation generally, and to indicate as briefy as possible, the kind of impression received. So far as organisation is concerned, our chief sources of information were the Commissioner and a gentleman of the name of Col. Keily, who in the course of a quite short address, gave us a beautifully clear description of the relations between the Federal and the State Governments, and an outline of the powers and duties of the various authorities and officers in the State. Col. Keily impressed all of us as a man of remarkable ability and of great influence in the State. Deeply interested in public health work he is exerting his influence in order tO get things done. A Col. Keity would be a very useful addition to the Public Health Service in England. From him and from Dr. Williams we learned that the problem of the State Board of Health in Virginia is in the main a rural health problem. The State has an area of 40,262 square miles, is divided into 100 counties, and has a total population of about two millions. Of this number only about one-third reside in communities of over 2,000, the combined urban population being about 670,000. The rural population numbers about one million, six hundred thousand, and in some places the density is in the neighbourhood of 45 to the square mile. T h e chief citizen of the State is the Governor. He holds office for a period of four years, and anmngst other

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MARCI-I,

things, he has the power and duty of appointing the State Board of Health and the Commissioner of Health. The State Board consists of 14 members, one from each congressional district, two from the City of Richmond, one a dentist, and five of the 14 must be doctors of medicine. This is the constitution as required by taw in Virginia; the law in regard to this matter, and the constitution of the Board, vary in different States. The Board meets once a year. The Governor holding office for four years, the Commissioner of Health holds office also for this same period. He may, however, be appointed for further periods, and Dr. Williams has held office continuously since 1908. The powers of the Board and the Commissioner are very considerable. During periods when the legislature is not in session the Board may issue rules and regulations that have all the force of law. They appoint the Board of Health--consisting Of three physicians with the Chairman of the Board of Supervisors as ex-officio Chairman---of the counties and through the Commissioner endeavour to induce and assist these bodies to set up health units and carry out health work. Getting health work done, however, has been very uphill work, and up to the present, something under half of the counties have an organisation. The character of the organisation varies very muCh, from the complete health unit which includes a medical health officer with or without a special health qualification, one or more sanitary inspectors and one or more public health nurses, to the unit consisting only of a sanitary officer or inspector or a public health nurse. What is provided depends entirely upon the amount of " appropriation " the local board is prepared to make, and in order to induce the boards to make any at all the State Board of Health offers to share the cost and uses all the powers of persuasion at its disposal. If the county is not prepared to do more than appoint a sanitary officer to help the inhabitants to protect the wells and dispose of human fitth in a decent and safe manner, it must put up 1,500 dollars, and to this the State will add 1.,000 dollars, 700 derived from State funds, and 300 from Federal Government grants. Out of this the officer receives his salary, 1,500-1,800 dollars, and is provided with a Ford car to take him about his district which may extend to 300, 400, 500 or more square miles, with a population of anything up to 20,000. Of units of this type there are eleven in the State. If the State Board succeeds in inducing the county authorities to instal a public health or school nurse they contribute 500 dollars o u t o f the monies received under the Sheppard,Towner Act to the amount

~924.

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necessary to pay her salary of round about 100 dollars per month, and provide the inevitable Ford. The counties in which there are public health nurses number 84. T h e assistance rendered to the county in which there is the complete health officer unit is, of course, greater, amounting in all to from 8,000 to 10,000 dollars per annum. Of this sum half must be appropriated locally, the remainder coming from the State Board and the International Health Board, which operates With funds derived from the Rockefeller Trust. In general, it may be noted the two bodies named do not Contemplate contributing indefinitely to the support of the unit, making it clear to the local board that in the course of four or five years, the total expenditure must be met out of a local appropriation. A full time organisation of this type for every county is the aim of Dr. Williams. At the moment, however, they are by no means numerous in the State, and in counties in which they have been set up the health officer usually acts not only for the county: but for the principal town therein. During the period of our stay in Virginia we had opportunities of meeting the officers making up units of the types described, of observing their work, and of seeing some of the results of their activities. In the bulk of instances the personnel has been found by the State Board for the local boards. This is absolutely essential, mainly because the number of men and women willing to take up the work is limited, the reason for this being, of course, that there are easier and pleasanter ways of earning a living and the salaries offered are much lower than Can be obtained outside public appointments. Since the men and women in the work are in it becanse of its call, and are picked people, they are of a fine type. It was a pleasure to meet and talk with them, and one felt with them very much as one feels in meeting and talking with colleagues and Co-workers at home. The atmosphere was much the same, and it was the same shop. In Enrico county, the county in which Richmond ties ; in Albemarte county, of which, as already mentioned, Charlottesville is the chief city ; and in Nansemonde county, Suffolk being the most important town, we had experience of a health officer unit. In the firstnamed we had our first opportunity of seeing a school dentist at work. In Virginia the school dentists, of whom there are ten, are in charge of a state director of mouth hygiene and go to various schools throughout the State, examining the children and afterwards treating such cases as the parents agree to have treated. Children requiring treatment carry home a report as to the exact number of teeth calling for attention, and a slip showing the payments to be

~43

made. The fee charged is about one-third the ordinary cost, the State and the County contributing the remainder. In this connection it may be noted that the State Department in Virginia does not believe in free treatment for anything, none of the clinics, for venereal diseases and so on, being quite free. Further with regard to school dentists it should be mentioned that here as in other connections, the colour line is not forgotten, the dentists visiting the schools for white children being white, and those dealing with coloured children in their respective schools being coloured also. The school we visited in Enrico was a coloured school, and in addition to seeing the dentist at work and examining his portable outfit, and inspecting certain improvements in progress in connection with privy arrangements, we had the added pleasure of listening to some delightful singing by the school children. SUNDAYPROPAGANDA. A remarkable experience provided for us by the health officer of Enrico county, Dr. Bagby, came o n our first Sunday in Virginia, when in a body we attended a service in a coloured church. Space does not permit of the giving of anything like a full description of the happenings here; it may be mentioned, however, that the service commenced at or about 7 in the evening, and did not close till 10.30, to the great regret of the congregation who were prepared to remain listening and singing till long past midnight; that Dr. Bagby gave an admirable address on sanitation; that Col. Keiiy told funny stories ; and that the English and the Italian representatives gave short talks in their native tongues. Also we all sang hymns and prayed with the utmost enthusiasm and at great length. In .Albemarle county the organisation is rather more extensive than in the majority of the counties visited, there being in addition to the Health Officer (Dr. Keisler, a graduate of Johns Hopkins School of Public IIealth) two sanitary officers and three nurses. For the reason that the coloured population of the city and county is considerable, and there are a number of cotoured schools and coloured midwives one of the nurses is coloured. In Nansemonde county, the health officer, Dr. Riggin, acts also for the City of Suffolk. One of the outstanding problems is malaria and though the unit has been in existence--as in the case of Albemarie--only a year or two, a great deal has been done by means of drainage, etc. The roads in this county are dreadful. THE SANITARYOFFICER UNIT. Examples of the sanitary officer unit we met in Roanoke and Pulaski. The former, the chief city of Roanoke county, less than 40 years ago, was a

144

PUBLIC HEALTH.

small village and now is a most thriving and progressive city, a great railroad centre, and likely to become one of the most important places in the' South of Virginia. Pulaski is a pleasant little town, and.the capital of Pulaski county. It contains an important chemical and iron works, and also a plant that turns out vast quantities of men's socks. Particularly in this and the chemical works very great attention appeared to be given to the welfare of the workers : in the former the lighting and 9entilation of the workrooms are particularly well provided for. Pulaski county is mainly agricultural and is interesting because of the fact that many of the cattle for the English market are raised here on the " blue grass." Alfalfa, is largely grown, the fact that once planted, this grass, which is, I believe a form of clover, continues to grow year after year for some years, yielding regularly three or four crops per annum I discovered here. In the course of our visit to this county we were conducted over certain coat mine~ - - t h e Parrott mines--and the village occupied by the Morgans and Evanses, Joneses and Williams' who get the coal. The houses, mainly of wood, occupy a narrow strip of land between a steep bluff and a wide stream. The conditions so far as housing is concerned, appeared to be deplorable, but as a result of the substitution of pit-privies for closets of the open back type that formerly lined the bank of the stream, typhoid fever has practically disappeared. SOME RESULTS OF HEALTH WORK.

It is in connection with efforts to get improvements of this kind carried out, to induce the occupiers of the better type of dwelling where there is no sewerage system to introduce a septic tank privy, and to get wells and water supplies generally protected, that the Sanitary Officer has .proved most useful. Throughout the State there has been and still is plenty of room for officers of this kind. Probably just as I was, many of my colleagures may be inclined to criticise a health scheme that puts a layman in charge of health activities and leaves him without proper medical direction. In this regard, however, there are several points to be borne in mind: first, that though in the State of Virginia many of the problems which we consider modern, and have "only recently tackled--Venereal Disease, Tuberculosis, Maternity and Child Welfare, are being worked at; at the same time she is dealing also with problems in sanitation in her country areas that we have largely solved, and have very definite powers of dealing with; secondly, as already explained, that qualified medical people are scarce, and shy of public health work, and certainly not prepared, as an officer m u s t be to show how the

MARCH,

pit-privy must be constructed, and the ingress and egress of filth bearing flies prevented and how the double chamber of the septic-tank must be formed, and the overflow pipe laid from the outer chamber to its termination at least 100 feet from the premises. Above all it must not be forgotten that it was only in 1908 that Dr. Williams began his work and that in order to get anything done, he had to fight poverty, penury, prejudice, ignorance and apathy amongst a people prepared to accept typhoid fever, hookworm disease and malaria as natural conditions, and to regard the surface of the ground anywhere around the home as the only proper place for the deposit of excreta. Stories innumerable we heard of the struggles to awaken not only a sanitary conscience, but a sense of decency. These I need not repeat. Only at the end we came to understand why Dr. Williams had broken down, and to marvel at the wonderful results obtained in regard to typhoid fever particularly, the case rate ~of which has fallen from 697 in 1909, to 109 in 1920, and the death record from 709 in 1918 to 260 in 1928. TttE GROWTH OF THE SCHEME. Almost as extraordinary as the progress made in the direction of improving sanitation has been that in connection with the building up of the public health scheme. In 190S the active force of the Board consisted of the Commissioner, an Assistant Commissioner, a Bacteriologist and one clerk. To-day, including the staffs at the three State Sanatoria, one for coloured patients, several hundreds are engaged in the work of the State Board. One of the first departments to be organised was the laboratory. THE STATE LABORATORY. In 1908 the examinations made numbered 3,480 ; in 1922 t h e total was 21,000. The work done is exclusively diagnostic for, amongst other diseases, malaria, syphilis and gonorrhoea and hook-worm disease. Chemical examinations are also made, and specimens are examined free upon request of any physician in the State and in order to facilitate matters it is proposed to set up branch laboratories in various towns throughout the State, a beginning having been made at Norfolk down in the south-eastern portion of the State. At the headquarters laboratory the work for the City of Richmond is also carried out, and for the convenience of practitioners outfits may be obtained and specimens left at selected drug stores. The bacteriologist in charge of the laboratory, as appears to be commonly the case in State laboratories, is not medically qualified. MATERNITY AND CHILD WELFAREWORK

has made a very good start in Virginia. The SheppardTowner Act which, as already explained, ensures a

PUBLIC H E A L T H .

I924.

grant from the Federal Treasury immediately" on its adoption, has been in operation for only a short time, but in that time a special division has been set up, and in a considerable number of counties nurses are at work, and clinics are held at intervals at which, amongst other things, infant consultations are conducted. Of pure infant consultations we saw nothing during our visit, the clinics seen being more or less of the nature of general out-patients' clinics, though held in a school and intended primarily for children. In one place near Charlottesville many of the persons attending for medical advice were adults and appeared to be quite prosperous if one might judge from the automobiles (not Fords) parked outside the building. At this clinic a number of children were vaccinated by the health officer and some came forward to receive a dose of toxin-antitoxin mixture. At this school I was interested to find young men of 19 and 20 in attendance, and submitting themselves for weighing and measuring. One of these pupils, on account of the necessity for working, had been prevented from finishing the High School Course earlier and as he proposed to study for the Church at the University of Virginia, was now getting ready to graduate from the High School prior to seeking admission to the University. Apropos of work, it may be noted that quite a considerable proportion of University students, women as well as men, work during the time they are at college or during vacation. One young fellow I met had managed a Cabaret the whole of the preceeding summer ; another runs an eating-house, or " lunch" as such places are called, for students; and another for a small charge sees that the luggage of his fellow students is attended to on arrival and departure. Many of the women students take posts as waitresses in restaurants during the summer. MIDWIFERY. Work among midwives in the State is being very actively taken up by the State Board of Health. From all that we were t01d the midwife problem is a very pressing and a very difficult one. In the State nearly one-third of the births are reported by midwives which means that nearly one-third of the mothers in the State are attended in childbirth by a midwife only, since in the State, as in the States generally, the onus of making known the occurrence of a birth is on the person in attendance, and not the parents. Practically none of the women have had any training; a large proportion are coloured, are unable to read or write, and are steeped in superstitions in which they indulge for the benefit of the women upon whom they attend. By law all midwives are required to register with the State Regis-

I45

trar of Vital Statistics, and as a result, some thousands of women and possibly men also (I heard of at least one non-medical man-midwife) have been reached. A supervisor of midwives recently appointed is busily engaged with the assistance of the nurses in the counties in trying to give instruction to the women individually and by means of leaflets, and all are being induced to obtain a properly fitted bag through the department, which supplies it at a reduced rate. In the work amongst midwives, Dr. Plecker, the Director of the Bureau of Vital Statistics, takes a deep interest and is assisting tremendously by keeping in touch with all those who make reports of births. Speaking generally, I imagine midwifery work, so far as midwives are concerned, to be in a worse condition than with us before the passing of the Midwives Act. That they wilt ever, in Virginia at any rate, and possibly also the other States in the South, make such provision as we have, appears to be doubtful. In the cities the question is, of course, much less difficult than in the rural areas where as Dr. Williams himself admitted, the midwives " constitute a serious menace as a result of their ignorance." In cities hospitals have been, or will be provided, and possibly in time also, in the rural areas the provision of hospital accommodation conveniently situated will lead to a solution of the problem. This, I take to be the opinion of the medical profession in general. SCHOOL HYGIENE AND SCHOOL MEDICAL W O R K

are receiving c]ose attention. Virginia is one of several States that make school attendance compulsory although, as a matter of fact, and mainly on account of the large numbers of coloured children in the State, the law is not very actively enforced. Probably indeed, quite as large a number of children as can be accommodated do attend school. In connection with these institutions I should like to say that all the members of the group were most favourably impressed by the type of modern school now springing up all over the State. Whoever is responsible for the design appears to have studied the question most fully, and has ensured that practically every detail, even the most minute, shall receive attention. As rapidly as possible all the old-fashioned school houses are being got rid of, and are being replaced by larger buildings conveniently placed for the service of as large an area as possible, generally a radius of about ten miles, and in order to get the children from outlying districts to and from school fleets of trolleys (motor charabancs) are provided. In Suffolk county we inspected two such schools and fleets, and were quite convinced of the wisdom of those who decided that it was cheaper and better

i46

PUBLIC, HEALTH.

to provide a large central school and means of conveyance, than to construct a number of smaller schools. Another reason that, no doubt, led to a decision in favour of large schools, is the diffic.ulty encountered in obtaining teacher s for county schools. The tendency to desert tile country for the city is as marked amongst teachers as others in this and other States, and this, by the way, is another of the many problems that face the United States. The question of school medical inspection is one I did not discuss very much with m y friends in Virginia, and of which I do not propose to say very much here as I never properly understood the method adopted in connection with it. Under a law known as the West law, every child in school is required to undergo a physical examination once every year. The physical examinations are, in the main, carried out by the school teachers, with some assistance f r o m n u r s e s acting as school and public health nurses, the latter of whom, b y the way, not uncommonly carry out vaccinations in the schools, the Public Vaccinator b e i n g apparently unknown. The examination is entirely an external examination, a n d directed to determine roughly the condition of the teeth, hearing and vision. The parents of any children the teachers think require medical attention are advised to take t h e m to a doctor. The school or public health nurse is given the name and address of each child thus referred and foUows up to find out what is being done. We m e t n o school doctors in Virginia, and saw no school clinics as understood in England. Women training for teaching in normal schools and institutions receive instruction' in hygiene, physical exercises, and the methods to be employed in carrying out the physical examinations. Teachers already holding posts are instructed by correspondence. PUBLIC HEALTH NURSING. T h e public health nurses are all fully trained women, and have had in addition in most instances, some instruction in hygiene and public health work. The nurses themsel'Ces have organized a system of registration and endeavour to ensure that none but such as have been registered shall be appointed public health nurses. By some o f the nurses it is claimed that of all the officers forming health units, not excepting the health officers, they alone are properly qualified by training to hold a position. Up to the present I have had no opportunity of visiting any institution in which special courses are provided for public health nurses, though it is well known that, in New York State for example, district nurses are transformed into public health nurses by means of correspondence courses. Despite the

MARCH,

claims referred to, the relations between the nurses and the other officers appeared to be, in general, friendly. The pay of the public health nurse is somewhat lower than t h a t of the sanitary officer, who receives to begin with, about 125 dollars per month, and a Ford car. Of actual nursing, public health nurses in Virginia do nothing, the home visits they make being for other purposes, e.g., follow up work.. Their part in the clinics of the type already mentioned, appears to be supervising of the general conduct of the clinic and of the voluntary workers who keep records, collect any fees, and so on. The nurses do not appear to attend the dental clinics. Of clinics for expectant mothers (ante-natal clinics) there are none in the rural areas. Occasional visits are paid by the nurses to women about to become mothers and, as already noted, correspondence courses have b e e n prepared for them. TUBERCULOSIS has a division to itself at headquarters in charge of a lady, Miss Randolph, a descendant of Jefferson and an able organiser. According to Miss Randolph nothing much was done until 1916, after an investigation which revealed that the death-rate from tuberculosis in 1915 was 1'17 for whites, and for coloured, 2"70 per 1,000. The Bureau of Tuberculosis was established in 1919; before this, however, three sanatoria, one for coIoured of 100 beds, and two for whites, containing between them about 450 beds, had been opened. Tuberculosis like other communicable diseases, is reportable without fee by practitioners, and a t the moment there are approximately 80,000 consumptives in the State. In the cities organisations more or less on the lines followed by us are in existence, but in the rural and thinly populated areas the problem is naturally more difficult. Some attempt is made to find cases by holding clinics from time to time in various areas, and apparently a considerable number of individuals have been examined. In all cases in which sputum is submitted for examination, an attempt is' made tO obtain from the medical practitioner the name and address of the patient, and permission to send literature. The information, and the permission, are invariably given, and a considerable number of leaflets are distributed ~annually, both to persons found to be positive and to those giving a negative result. Another piece of preventive work done is in connection with children found to be ill-nourished on inspection in the schools. For the benefit of these an expert in nutrition and dietetics has been appointed to arrange demonstrations and lectures for the mothers. In this connection it may be noted, that

PUBLI~ HEALTH.

1.924

the nntrition expert is becoming quite definitely to be regarded as suitable for inclusion in the health department and appointments have been, and are being made in a number of States for work amongst school children, in Sanatoria, etc. If it has not been already noted, it may be mentioned here, that work in relation to housing is practically unknown in the State. There are no Housing Committees in the Counties; no Housing Acts, and no organised house-to-house inspections. The Sanitary Officers at the moment are too busily engaged in having privies and water supplies " sanitated " to do anything else. Probably when work in this direction has been well advanced, the sanitary officer will become more like our sanitary inspector, and will perform duties in relation to housing, etc., similar to those now allotted to him. In the Sanatoria one thing that interested me very greatly was the method adopted in connection with the feeding arrangements in the patients' dining rooms, the " cafeteria " system, which involves, as explained in an earlier note, self service, being in vogue; the individual taking a tray to the serving counter, and obtaining portions of various articles. Having been served, he or she, child or adult, carries the loaded tray to a table and consumes the meal. Myself I could not have imagined any place in which such a system should have been less appropriate than. a sanatorium. Nevertheless, it works quite satisfactorily, and after having been in operation for some time, is approved not only by the staff, but by the patients as well. Curiously enough, as we were to learn later, the system is not found to lead:to any reduction in labour, its main advantages being that the patient's food is hotter and fresher, and there is a very great reduction in the amount of food wasted by being left on plates. VENEREAL DISEASE

i n ;virginia is combated on lines very similar to those adopted in Great Britain. Like the Tuberculosis Division, that dealing with ;venereal Diseases, the Social Hygiene Division so called, is in charge of a lay-woman, Mrs. Fox, well known as an organiser and teacher. The venereal diseases are reportable in ;Virginia. Wlde publicity is given to facts regarding the dangers of these conditions by means of posters, leaflets, lectures and films, though activities have been greatly curtailed by a reduction in the amount of grant. We had the opportunity of visiting a clinic a t t h e hospital in Richmond, and were greatly interested.to learn that treatment is not given free, and that every patient attending any department is examined for the Wassermann reaction, and if found positive, is referred to the venereal disease

z47

clinic for appropriate treatment. ANTI-MALARIA WORK.

In connection with the work done in relation to Malaria most useful and informative addresses were given to us by Dr. L. L. Williams and Dr. Kane, who, as already explained, represent the United States Public Health Service and the International Health Board at the State Health Department. Stimulated by these two men, who are experts in this subject, Boards of Health in malarious districts are being worked up in the most splendid way. In several counties health officers have been appointed and excellent results have been obtained by draining, ditching, oiling, etc., and by recommending screening and quinine where these seemed to be the only suitable preventives. BUREAU OF EPIDEMIOLOGY. During our stay a very interesting morning was spent with the recently appointed State Epidemiologist, Dr. Payne, who discussed with us certain plans already put into effect and many others which he was then engaged in working out. I was interested to learn something of another new disease--new to me at any rate--variously described as Dabney's or Devil's Grip or Epidemic Transient Diaphragmatic Spasm. Of this condition some 3,000 cases occurred at the beginning of July, 1933, and gave rise to very widespread alarm. Having regard to the fact that the attack comes on without warning, and is characterised by intense epigastric pain, shooting through to the back, and there is so much difficulty in breathing that the patient appears like to die, this is not to be wondered at. The attack generally lasts only a short time, and there are only occasionally any sequelae. The cause is unknown, though Rosenau has, I believe, suggested that it may be due to a streptococcus, and may be related to influenza or encephalitis. Talking of diphtheria, Dr. Payne expressed himself as a firm believerin the efficacy of the toxin-antitoxin mixture. Most of the people I have talked to, indeed, do believe in it. If it ever is definitely accepted in England it occurs to me that as a beginning at any rate, the administration might be put into the hands of the public vaccinators, who could offer to carry it out on any individual willing to accept it. In Virginia the cost of the mixture for a course of three injections is 15 cents. Amongst the functions of the Bureau of Epidemiotogy are the dealing with vital statistics and the handling of biologic products. VITAL STATISTICS, In this matter the epidemiotogist keeps in close touch with the Bureau of Vital Statistics, a department that is doing splendid service under Dr. Plecker, who, having been for many years a health

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PUBLIC': H E A L T H

officer, appreciates what is wanted, and has developed a wonderful schemeof getting it, and also of recording it. T h e information, upon which the epidemiologist acts is derived largely from the Bureau, but comes also from the State Bacteriologist who reports regularly as to the number of specimens received and their origin. Information as to the number of notifications received is obtained from County health officers, sanitary officers, etc. Reports of disease are unfortunately very irregular, varying somewhat with the type of organisation. In large cities it is, of course, the duty of the health officer to deal with the reports, and investigations are made at once by the inspectors who, in Richmond at least, are medical men. In counties with a full time health officer the situation is also very satisfactory. In 86 out of the 100 counties, however, there is no health .officer and reports are only asked for once a month, though generally six weeks elapse before they are received. The obvious solution is to require that cases shall be reported direct to the State Board, but there appear to be so many difficulties in the way that this course cannot be adopted. No notification fee is paid in this State though in others, particularly in the north, we were informed there is provision f o r this. Biologic products, e.g., antitoxin, are supplied by the Board, and a great deal: can be learned as to the number of cases in any particular locality by watching t h e sales of these t o the practitioners No provision is made by the State Board for manufacturing and testing biologic products. This note, already too long, might very easily be extended by references to very many Other i~teresting things heard and seen, not only at headquarters in Richmond, but in the course of the tour of t h e State. The temptation to tell of the many kindnesses and the great hospitality we received everywhere; of the numberless items of general information we picked up--with regard to t h e cultivation of peanuts, for example, the price o f land, taxation, prohibition, fried chicken, ice ~cream, and speech-making, must, however, be resisted. MILK HYGIENE IN RICHMOND. One thing only I must add, and that is that amongst other advantages we enjoyed was that of meeting Dr~ Levy, the Director of Public Welfare in Richmond, and President this year of the American Public Health Association. One of the pioneers i n the a t t e m p t to obtain clean milk, we had from him a most interesting address on the scheme in operation in Richmond, and with him an interesting tour round the, dairy farms from which the city obtains its supply. I t is almost inevitable, like every medical officer o f health who has been in the United States;

MARC:H,

that I shall feel at some time compelled to speak of the methods employed in this connection. I n the meantime, therefore, all that I propose to say is that the inhabitants of Richmond, thanks to Dr. Levy, appear to have as clean and safe a milk supply as anyone could possibly expec t . In my view, the main reason for this is that Dr. Levy possesses practically unlimited power. No one, even in the county area, may produce milk without the permit of Dr. Levy ; no one has been or is given a permit till everything is to his satisfaction: regular and frequent inspections are made of all dairies, all of them outside the city limits, and the permit may be withdrawn temporarily or permanently, if u n satisfactory conditions are found, and not righted. Further, Richmond is particularly fortunately situated in that it is possible to obtain all milk from farms not far distant, and to find farmers willing to become purely producers of milk, and not general farmers producing milk as a side-line. Also, Richmond having a population of just over 170,000 is of a manageable size, genuine problems in connection with milk supply being in the really small towns or the really large ones--the former providing too little trade to make it worth the farmers while to go in for milk producing only, and the latter too large to allow of the supply being drawn from an area that can be controlled and patrolled by the city health department and staff. The system of grading in Richmond is comparatively simple, and pasteurisation is not compulsory except in the case of milks (Grade " B.") not derived from tested cows. Milk from cows proved by test to be tubercle free, and from farms that comply with a high standard may be sold unpasteurised. This is Grade " A " milk, and constitutes only about 2 per cent. o f the total. All milk delivered to houses and sold in restaurants; drug stores and such like, must be bottled. The price of Grade " B " milk at the time of our visit was 14 cents per quart, roughly 10d. per quart to us, as the American quart is less than the English. Grade " A " milk is about 2 cents dearer. These prices are, of course, much more than the poor can afford, and I noted in my walks abroad that the general shops in the poorer quarters carried a suspiciously large stock of tinned milks. Dr: Levy, who went into every detail with us, explained that his aim, so far as milk supply was concerned, had been to obtain one dairy farm for every 1,000 of the population, and with his present population the number now on the list--200--was more than adequate. T h e day spent in the Richmond Health Department was full of interest, and the opportunity of meeting and talking to Dr. Levy was one very greatly appreciated.