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The Report of the Chief Medical Officer for 1935
HEALTH
PUBLIC
THE JOURNAL OF
THE SOCIETY OF MEDICAL OFFICERS OF HEALTH No. 4.
JANUARY, 1937
Vol. L.
Subscription 81s. 6d. per annum, post flee, in advance. Single copies 2s. 6d. post free.
"Public Health" is the Offidal Organ of the Sodety of Medical Officers of Health and a suitable medium for the advertisement of o~dal appointments vacant in the health service. Space is also available for a certain number of approved commercial advertisements. Application should be made to the Executive Secretary of the Society, at 1, Thornhaugh Street, Russell Square, London, W.C.1.
Contents Editorial PAGE
H . M . K i n g George VI . . . . . . . . . . . . T h e R e p o r t of the C h i e f Medical Officer for I935 " O p e n - C h o i c e " Domiciliary M e d i c a l Services ... A n E x t e n s i o n of H e a l t h E d u c a t i o n . . . . . . . Iodine a n d E n d e m i c Goitre .........
111 111 113 114 115
Obituary Sir J o h n Robertson, C.M.C., O.mE., M.D . . . . . . . Alfred G r e e n w o o d , M.D., B.P.H . . . . . . . . . . J a m e s T y s o n Kitchin, M.D., D.P.tl . . . . . . . . .
115 116 t 16
.
Editorial H . M . King George VI. At the December general meeting of the Society, it was unanimously agreed, on the proposition of the President, to submit to our new King the expression of loyalty which is recorded on page 135 of this issue. We have all watched with anxiety the chain of events which finally led to the abdication of another well-beloved and democratic monarch, and our welcome to King George VI and his Queen is intensified by sympathy for the circumstances of their accession. His Majesty, as Duke of York, was well known for his lively interest in the hygiene of industry, in cancer research and in the welfare and physical fitness of youth. We are doubly assured, therefore, that he will show the same disposition as his predecessors to forward all movements likely to improve the public health and happiness. In such activities he will have always the loyal support and goodwill of the members of our Society.
Special Articles T h e D o c t o r as A d m i n i s t r a t o r . M.D,,
D.P.H.~
By A r t h u r Massey,
D.P.A . . . . . . . . . .
M o d e r n M e t h o d s of D i p h t h e r i a Prevention. B'y W . A. M u r p h y , M.B., D.P.H . . . . . . . Domiciliary M i d w i f e r y with Reference to the M i d w i v e s Act, 1936. By T . Pierson, M.B., D.P.H . . . . . . . . . . . . .
Speech Defects in Y o u n g Children.
Boome,
M.B.~
M.R.C.P.,
By E. "j;
D.P.H . . . . . . .
The Report of the Chief Medical 117 Officer for 1935 121 12a 126
Papers and Discussions in Brief or Abstract Air Raid Precautions a n d the M . O . H . . . . . . . Southampton Midwives Scheme .........
lal 132
News Recent A p p o i n t m e n t s in the Public Health Service M i n i s t r y of H e a l t h Publications . . . . . . . . . Smallpox a n d Scarlet F e v e r O u t b r e a k s . . . . . . Joint T u b e r c u l o s i s Council .........
116 120 122 134
Society of Medical Officers of Health Notices of M e e t i n g s . . . . . . . . . . . . . . . Ordinary Meeting . . . . . . . . . . . . . . . Branch and Group Meetings .........
135 135 136
Book Reviews S n o w on Cholera T h e M a n a g e m e n t of'the Ne~v-Born'Babyill T h e T o x m m i a s of P r e g n a n c y ......... M a t e r n i t y a n d P o s t - O p e r a t i v e Exercises
iii ...
139 t40 140 140
Sir Arthur McNalty, in presenting his second annual statement* on the work of the Medical Department of the Ministry of Health, points out that the former detachment between prevent!ve and curative medicine has disappeared or is fast disappearing, and that the advances in public health made during the reign of George V have gradually brought all agencies for promoting national health into closer and more helpful concord. The vital and mortal statistics for the year are reviewed, and attention is drawn to the smallest number of infant deaths ever recorded, resulting in an infant mortality rate of 57 per 1,000 births. The rise in the average age of the population, which has continued, has resulted in a fall since the beginning of the century of nearly 25 per cent. in the proportion of persons under 25 years, and striking increases in the middle age and old age groups. Sir Arthur remarks that if, as appears likely, the change in age-distribution continues *On The State of the Public S t a t i o n e r y Office, 3s. 6 d .
Health,
1935.
II.M.
III
PUBLIC HEALTH
JANUARY
the altered needs will lead to some regrouping considerable variations in mortality from tuberculosis in different parts of England and Wales, of health services. The report reviews recent work in the applica- and concludes with a note of the very large increase tion of the experimental method to the study of in the use of X-ray examinations in diagnosis, and epidemiological problems, and gives a useful, of the necessity for carrying out contact examinathough necessarily brief, presentation of the work tions upon definite and systematic lines. of Greenwood, Topley and their associates. There has been a continued decline in the In recording the striking fall in the death rate incidence of syphilis and gonorrhcea, and there from measles, the acceleration in decline since the is increasing resort to the use of serum tests for child welfare services came into being is noted, syphilis, cultural tests for the gonococcus, and and details are given of the use of convalescent gonococcal complement-fixation tests--all evidence serum, adult serum and placental extract in of steady improvement in the methods employed at prevention. There was a slight reduction in the treatment centres. incidence and fatality rate of diphtheria, and in this The Ministry of Health keeps in close touch connection it is reported that facilities for artificial with cancer work. There is still, unfortunately, immunisation now exist in about two-thirds of the no sign of any decline in cancer mortality, the county boroughs, and in the great majority of the number of deaths certified from the disease being metropolitan boroughs, as well as in many smaller 64,507 in 1935, or 1,244 in excess of the previous sanitary districts. Mention is made in the para- year. Sir Arthur McNalty says that when, however, graphs on scarlet fever of the fact that a high the increasing longevity of the population (cancer incidence of the disease among, adults has been being a disease of the later ages) and the more noted in certain districts, and of the work of the accurate diagnosis of the disease are taken into Ministry's pathological laboratory which suggests account, it is probably fallacious to assume that the that the accidental reinfection with a second strain increased frequency of the disease connotes " a of streptococcus of the convalescent while in correspondingly greater .prevalence. of whatever hospital is commonly the reason which gives rise to factors are concerned m causatlon." Recent a return case after he goes home. researches into causation seem to indicate connectIn recording the present position in maternal ing links between the virus theory and that of welfare with a slight reduction in the maternal carcinogenic substances, and the conclusion of the death rate from 4-6 to 4.11, the report remarks that report is that research has reached a promising the problems of maternal care may have tended stage. It would, however, the report continues, of late years to have obscured the steady work in be extremely unsafe to assume that if and when it connection with the welfare of the infant and young provldes an explanation of the way in which child, which is both progressive and successful. malignant change is brought about in the cells, In the section on the Insurance Medical Service, it will necessarily furnish a clue to a means of which provides medical benefit for nearly prevention or bring about a radical change in sixteen million people in England and Wales met'hods of treatment. through some 16,600 medical practitioners, attenRheumatism again receives notice in a special tion is again drawn to the great increase in the chapter, and there are sections concerning the number of prescriptions issued, an increase which relation of food to health and disease, which record is not accounted for by any known fact relating the progress made in several studies being pursued to the incidence of disease in the country. Not in conjunction with local authorities, studies dealing only is there no contention that the expenditure with dietaries of working class families, the state of some two and a quarter million pounds on the of nutrition of individuals as determined by provision of medicines is necessary or desirable, measurement and test, and the effect of dietary but on the contrary it has been repeatedly stated supplements on the growth and health of children. by representative practitioners that a very large Other sections of the report deal with miscelproportion of the present physicking of. the popula- laneous points such as the working hours of tion is wholly unnecessary, and that if all doctors nurses, the great increase in the deaths of young felt themselves free to order only such medicinal men from accidents, the progress of research treatment as in their unfettered professional in diabetes and in pernicious anaemia, and the best judgment they considered necessary, the total cost means of eradicating bed bugs. of prescribing would at once fall spectacularly-Sir Arthur McNalty concludes his report with as far, some assert, as to half its present dimensions. the reflection that " despite increasing population The pages dealing with tuberculosis draw atten- increasing urbanisation and the aftermath of a tion to the main functions of the care and after- world-wide war, the standard of national health care organisations which should be associated with has been raised to heights undreamed of when the tuberculosis work of local authorities. This Chadwick and Simon started their beneficent section discusses the difficulties in explaining the work. So rapid has been the progress in the past 112
1937
PUBLIC HEALTH
them at the request of a Relieving Officer, with the fees payable for confinements and other special services, and with the actual cost of emergency drugs dispensed by them to patients. In the year under review, 8,193 persons were attended, of whom 611 were " long period," or chronic, patients receiving treatment for three consecutive quarters or for the whole year; the remaining 7,852 were " short period" cases, where treatment was required for periods of varying duration, but never throughout three consecutive quarters. From the data in his possession, Dr. Charles "Open-Choice" Domiciliary Medical submits :I Services (a) That the remuneration per unit service, The duty of local authorities to provide medical which amounted to 11.38d. per unit, is twice the attention for those members of the community previous rate of 5.656d. ineligible for National Health Insurance medical (b) That the services rendered to both long benefit and unable to pay the fees of private practitioners has led to the formation in certain and short period cases appear to be reasonable areas of panels of doctors, from whom a choice of in number. The typical " short period " case medical attendant may be made by such persons in which treatment is complete within three when sick. It is clear that this " open-choice " months (and frequently in a much shorter period) method of providing domiciliary medical assistance had 4-5 visits or attendances. The typical chronic substantially reduces association with the case received 26.4 services during the nine months machinery of Poor Law, and it is desirable that or year during which it was under medical attenfull examination shall be made of the experience tion; this can be regarded as equivalent to a of their working which is now being gained. fortnightly visit or attendance. (c) That there was an attendance-to-visit ratio Accordingly attention is drawn to the valuable of 1.7 to 1, and this tendency to replace domiciliary report which Dr. J. A. Charles, Medical Officer of Health for Newcastle-on-Tyne, has presented visiting by the easier process of surgery consultadealing with such a scheme as operated in seven tions cannot be regarded favourably as a whole. In this connection, however, we note that there of the ten relief districts of the city during the appear to be wide variations in the practice in year ended February 29th, 1936. The report covers the period during which p a y m e n t by different parts of the country, inasmuch as the capitation rate has replaced the method of payment corresponding ratios in similar schemes in Warfrom a fixed pool which had obtained during.the rington and in Bootle have been 3 to 1 and 8 to 1 first ten months of the operation of open-choice respectively. The expenditure in respect of medical practimethods. Under the scheme, a patient requiring treatment tioners' services averaged 8s. l~d. per patient presents to the panel practitioner of his choice the treated; in respect of prescriptions dispensed relieving officer's order, together with a medical (from Central Dispensaries)5.7d. per prescriprecord card which is valid for a period of three tion and 3s. 7½d. per patient treated; and in months from the date of issue. At the end of that respect of administration charges 9.5d. per patient period the record is forwarded to the Health treated, making in all a cost of 12s. 6d. per patient Department, and if the treatment of the patient treated. Dr. Charles remarks that, even when has been completed, the practitioner is credited allowances have been made for the extended with a fee of 5s. If, in the opinion of the doctor, duration of the second review period and the larger treatment is still necessary, a note to that effect number of patients treated, there is an actual is made on the record card, and the Public increase in the number of prescriptions dispensed Assistance Officer is instructed by the Health of at least 40 per cent. No satisfactory explanaDepartment to issue a renewal of treatment card, tion of this increase can be offered, but it is valid for a further period of three months. The obviously a matter which will.require close superamounts payable to members of the Panel are vision. He further states that although the based primarily on the number of three-monthly clerical section has been considered by some too record cards which they send to the Health costly, yet it is a key point of the scheme, for Department, each card being valued at 5s. through it is maintained a close liaison between Practitioners are also credited with one shilling the panel practitioner on the one hand and the in respect of every medical certificate issued by municipal hospitals, the statutory health services, that at times impatience is manifested that further improvements in national health do not become generally apparent with the same dramatic suddenness of earlier days. It is iaot appreciated how many years of toil and endeavour were spent in preparing for the triumph. It is often not realised how much labour is involved in consolidating and maintaining the victories won over death and d i s e a s e . . . Some understanding of the toil and pains inseparable from progress in public health and medical work may be gathered from the pages of this report."
113
PUBLIC
THE JOURNAL OF
THE SOCIETY OF MEDICAL OFFICERS OF HEALTH No. 4.
JANUARY, 1937
Vol. L.
Subscription 81s. 6d. per annum, post flee, in advance. Single copies 2s. 6d. post free.
"Public Health" is the Offidal Organ of the Sodety of Medical Officers of Health and a suitable medium for the advertisement of o~dal appointments vacant in the health service. Space is also available for a certain number of approved commercial advertisements. Application should be made to the Executive Secretary of the Society, at 1, Thornhaugh Street, Russell Square, London, W.C.1.
Contents Editorial PAGE
H . M . K i n g George VI . . . . . . . . . . . . T h e R e p o r t of the C h i e f Medical Officer for I935 " O p e n - C h o i c e " Domiciliary M e d i c a l Services ... A n E x t e n s i o n of H e a l t h E d u c a t i o n . . . . . . . Iodine a n d E n d e m i c Goitre .........
111 111 113 114 115
Obituary Sir J o h n Robertson, C.M.C., O.mE., M.D . . . . . . . Alfred G r e e n w o o d , M.D., B.P.H . . . . . . . . . . J a m e s T y s o n Kitchin, M.D., D.P.tl . . . . . . . . .
115 116 t 16
.
Editorial H . M . King George VI. At the December general meeting of the Society, it was unanimously agreed, on the proposition of the President, to submit to our new King the expression of loyalty which is recorded on page 135 of this issue. We have all watched with anxiety the chain of events which finally led to the abdication of another well-beloved and democratic monarch, and our welcome to King George VI and his Queen is intensified by sympathy for the circumstances of their accession. His Majesty, as Duke of York, was well known for his lively interest in the hygiene of industry, in cancer research and in the welfare and physical fitness of youth. We are doubly assured, therefore, that he will show the same disposition as his predecessors to forward all movements likely to improve the public health and happiness. In such activities he will have always the loyal support and goodwill of the members of our Society.
Special Articles T h e D o c t o r as A d m i n i s t r a t o r . M.D,,
D.P.H.~
By A r t h u r Massey,
D.P.A . . . . . . . . . .
M o d e r n M e t h o d s of D i p h t h e r i a Prevention. B'y W . A. M u r p h y , M.B., D.P.H . . . . . . . Domiciliary M i d w i f e r y with Reference to the M i d w i v e s Act, 1936. By T . Pierson, M.B., D.P.H . . . . . . . . . . . . .
Speech Defects in Y o u n g Children.
Boome,
M.B.~
M.R.C.P.,
By E. "j;
D.P.H . . . . . . .
The Report of the Chief Medical 117 Officer for 1935 121 12a 126
Papers and Discussions in Brief or Abstract Air Raid Precautions a n d the M . O . H . . . . . . . Southampton Midwives Scheme .........
lal 132
News Recent A p p o i n t m e n t s in the Public Health Service M i n i s t r y of H e a l t h Publications . . . . . . . . . Smallpox a n d Scarlet F e v e r O u t b r e a k s . . . . . . Joint T u b e r c u l o s i s Council .........
116 120 122 134
Society of Medical Officers of Health Notices of M e e t i n g s . . . . . . . . . . . . . . . Ordinary Meeting . . . . . . . . . . . . . . . Branch and Group Meetings .........
135 135 136
Book Reviews S n o w on Cholera T h e M a n a g e m e n t of'the Ne~v-Born'Babyill T h e T o x m m i a s of P r e g n a n c y ......... M a t e r n i t y a n d P o s t - O p e r a t i v e Exercises
iii ...
139 t40 140 140
Sir Arthur McNalty, in presenting his second annual statement* on the work of the Medical Department of the Ministry of Health, points out that the former detachment between prevent!ve and curative medicine has disappeared or is fast disappearing, and that the advances in public health made during the reign of George V have gradually brought all agencies for promoting national health into closer and more helpful concord. The vital and mortal statistics for the year are reviewed, and attention is drawn to the smallest number of infant deaths ever recorded, resulting in an infant mortality rate of 57 per 1,000 births. The rise in the average age of the population, which has continued, has resulted in a fall since the beginning of the century of nearly 25 per cent. in the proportion of persons under 25 years, and striking increases in the middle age and old age groups. Sir Arthur remarks that if, as appears likely, the change in age-distribution continues *On The State of the Public S t a t i o n e r y Office, 3s. 6 d .
Health,
1935.
II.M.
III
PUBLIC HEALTH
JANUARY
the altered needs will lead to some regrouping considerable variations in mortality from tuberculosis in different parts of England and Wales, of health services. The report reviews recent work in the applica- and concludes with a note of the very large increase tion of the experimental method to the study of in the use of X-ray examinations in diagnosis, and epidemiological problems, and gives a useful, of the necessity for carrying out contact examinathough necessarily brief, presentation of the work tions upon definite and systematic lines. of Greenwood, Topley and their associates. There has been a continued decline in the In recording the striking fall in the death rate incidence of syphilis and gonorrhcea, and there from measles, the acceleration in decline since the is increasing resort to the use of serum tests for child welfare services came into being is noted, syphilis, cultural tests for the gonococcus, and and details are given of the use of convalescent gonococcal complement-fixation tests--all evidence serum, adult serum and placental extract in of steady improvement in the methods employed at prevention. There was a slight reduction in the treatment centres. incidence and fatality rate of diphtheria, and in this The Ministry of Health keeps in close touch connection it is reported that facilities for artificial with cancer work. There is still, unfortunately, immunisation now exist in about two-thirds of the no sign of any decline in cancer mortality, the county boroughs, and in the great majority of the number of deaths certified from the disease being metropolitan boroughs, as well as in many smaller 64,507 in 1935, or 1,244 in excess of the previous sanitary districts. Mention is made in the para- year. Sir Arthur McNalty says that when, however, graphs on scarlet fever of the fact that a high the increasing longevity of the population (cancer incidence of the disease among, adults has been being a disease of the later ages) and the more noted in certain districts, and of the work of the accurate diagnosis of the disease are taken into Ministry's pathological laboratory which suggests account, it is probably fallacious to assume that the that the accidental reinfection with a second strain increased frequency of the disease connotes " a of streptococcus of the convalescent while in correspondingly greater .prevalence. of whatever hospital is commonly the reason which gives rise to factors are concerned m causatlon." Recent a return case after he goes home. researches into causation seem to indicate connectIn recording the present position in maternal ing links between the virus theory and that of welfare with a slight reduction in the maternal carcinogenic substances, and the conclusion of the death rate from 4-6 to 4.11, the report remarks that report is that research has reached a promising the problems of maternal care may have tended stage. It would, however, the report continues, of late years to have obscured the steady work in be extremely unsafe to assume that if and when it connection with the welfare of the infant and young provldes an explanation of the way in which child, which is both progressive and successful. malignant change is brought about in the cells, In the section on the Insurance Medical Service, it will necessarily furnish a clue to a means of which provides medical benefit for nearly prevention or bring about a radical change in sixteen million people in England and Wales met'hods of treatment. through some 16,600 medical practitioners, attenRheumatism again receives notice in a special tion is again drawn to the great increase in the chapter, and there are sections concerning the number of prescriptions issued, an increase which relation of food to health and disease, which record is not accounted for by any known fact relating the progress made in several studies being pursued to the incidence of disease in the country. Not in conjunction with local authorities, studies dealing only is there no contention that the expenditure with dietaries of working class families, the state of some two and a quarter million pounds on the of nutrition of individuals as determined by provision of medicines is necessary or desirable, measurement and test, and the effect of dietary but on the contrary it has been repeatedly stated supplements on the growth and health of children. by representative practitioners that a very large Other sections of the report deal with miscelproportion of the present physicking of. the popula- laneous points such as the working hours of tion is wholly unnecessary, and that if all doctors nurses, the great increase in the deaths of young felt themselves free to order only such medicinal men from accidents, the progress of research treatment as in their unfettered professional in diabetes and in pernicious anaemia, and the best judgment they considered necessary, the total cost means of eradicating bed bugs. of prescribing would at once fall spectacularly-Sir Arthur McNalty concludes his report with as far, some assert, as to half its present dimensions. the reflection that " despite increasing population The pages dealing with tuberculosis draw atten- increasing urbanisation and the aftermath of a tion to the main functions of the care and after- world-wide war, the standard of national health care organisations which should be associated with has been raised to heights undreamed of when the tuberculosis work of local authorities. This Chadwick and Simon started their beneficent section discusses the difficulties in explaining the work. So rapid has been the progress in the past 112
1937
PUBLIC HEALTH
them at the request of a Relieving Officer, with the fees payable for confinements and other special services, and with the actual cost of emergency drugs dispensed by them to patients. In the year under review, 8,193 persons were attended, of whom 611 were " long period," or chronic, patients receiving treatment for three consecutive quarters or for the whole year; the remaining 7,852 were " short period" cases, where treatment was required for periods of varying duration, but never throughout three consecutive quarters. From the data in his possession, Dr. Charles "Open-Choice" Domiciliary Medical submits :I Services (a) That the remuneration per unit service, The duty of local authorities to provide medical which amounted to 11.38d. per unit, is twice the attention for those members of the community previous rate of 5.656d. ineligible for National Health Insurance medical (b) That the services rendered to both long benefit and unable to pay the fees of private practitioners has led to the formation in certain and short period cases appear to be reasonable areas of panels of doctors, from whom a choice of in number. The typical " short period " case medical attendant may be made by such persons in which treatment is complete within three when sick. It is clear that this " open-choice " months (and frequently in a much shorter period) method of providing domiciliary medical assistance had 4-5 visits or attendances. The typical chronic substantially reduces association with the case received 26.4 services during the nine months machinery of Poor Law, and it is desirable that or year during which it was under medical attenfull examination shall be made of the experience tion; this can be regarded as equivalent to a of their working which is now being gained. fortnightly visit or attendance. (c) That there was an attendance-to-visit ratio Accordingly attention is drawn to the valuable of 1.7 to 1, and this tendency to replace domiciliary report which Dr. J. A. Charles, Medical Officer of Health for Newcastle-on-Tyne, has presented visiting by the easier process of surgery consultadealing with such a scheme as operated in seven tions cannot be regarded favourably as a whole. In this connection, however, we note that there of the ten relief districts of the city during the appear to be wide variations in the practice in year ended February 29th, 1936. The report covers the period during which p a y m e n t by different parts of the country, inasmuch as the capitation rate has replaced the method of payment corresponding ratios in similar schemes in Warfrom a fixed pool which had obtained during.the rington and in Bootle have been 3 to 1 and 8 to 1 first ten months of the operation of open-choice respectively. The expenditure in respect of medical practimethods. Under the scheme, a patient requiring treatment tioners' services averaged 8s. l~d. per patient presents to the panel practitioner of his choice the treated; in respect of prescriptions dispensed relieving officer's order, together with a medical (from Central Dispensaries)5.7d. per prescriprecord card which is valid for a period of three tion and 3s. 7½d. per patient treated; and in months from the date of issue. At the end of that respect of administration charges 9.5d. per patient period the record is forwarded to the Health treated, making in all a cost of 12s. 6d. per patient Department, and if the treatment of the patient treated. Dr. Charles remarks that, even when has been completed, the practitioner is credited allowances have been made for the extended with a fee of 5s. If, in the opinion of the doctor, duration of the second review period and the larger treatment is still necessary, a note to that effect number of patients treated, there is an actual is made on the record card, and the Public increase in the number of prescriptions dispensed Assistance Officer is instructed by the Health of at least 40 per cent. No satisfactory explanaDepartment to issue a renewal of treatment card, tion of this increase can be offered, but it is valid for a further period of three months. The obviously a matter which will.require close superamounts payable to members of the Panel are vision. He further states that although the based primarily on the number of three-monthly clerical section has been considered by some too record cards which they send to the Health costly, yet it is a key point of the scheme, for Department, each card being valued at 5s. through it is maintained a close liaison between Practitioners are also credited with one shilling the panel practitioner on the one hand and the in respect of every medical certificate issued by municipal hospitals, the statutory health services, that at times impatience is manifested that further improvements in national health do not become generally apparent with the same dramatic suddenness of earlier days. It is iaot appreciated how many years of toil and endeavour were spent in preparing for the triumph. It is often not realised how much labour is involved in consolidating and maintaining the victories won over death and d i s e a s e . . . Some understanding of the toil and pains inseparable from progress in public health and medical work may be gathered from the pages of this report."
113