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The tuberculosis campaign in Ipswich
PUBLIC
HEALTH,
The milkers wear a special white suit and cap, these articles being replaced twice a week by newly-washed overalls. A special lavatory with nail brush and soap is provided for their use, and they are enjoined to keep their nails cut short. Only in exceptionally hot weather has it been necessary to provide ice, wherewith to cool the water which passes through the cooler. In any event the quantity used is but small, and ice is readily procurable and by no means can it be termed expensive, even if it be requisite to make it at the farm. The dairy is lighted by electricity, from the supply that serves also for the house. W i t h this exception, perhaps, there is nothing here furnished but what should be found in any well-regulated farm ; no costly or large buildings are required, the block containing the vertical boiler and sterilising apparatus, the butter-making, milk- cooling, and bottling room, and the cool store, covering roughly only six yards by ten. The milking shed has a suitably channeled concrete floor, and the fittings are all of iron. The public has a right to expect that milk shall be produced under satisfactory conditions, and that it should remain satisfactory until it reaches the customer; and when we take into consideration the average state of that supply as it now reaches the consumer, and the fact vouched for by Dr. Ralph Vincent that a satisfactory article can be produced for less than threepence per quart, it is the bounden duty of Government and of all health officials to press forward with all speed adequate measures to secure the object in view, i.e. the production of milk that will pass as " certified" milk by a medical Milk Commission.
THE
1911.
T H E INCREASE oF THE U N F I T . - - A t
a
meeting
of the London County Council on November i4th , the Asylums Committee reported the case of a female patient, aged 67, who was admitted to Colney Hatch Asylum on September i2th, having previously been admitted to the same asylum on 15 occasions,andto other asylumson i I occasions-25 in all. She was married when 18 years old, and had had 13 children, five of whom are dead. Her first attack of insanity was at the age of 2I, when her first child was born. Her children are said to be healthy except two, who have recently shown signs of insanity. She has two aunts in asylums, and two of her sisters have suffered from insanity, one having died in Colney Hatch, and .the other having committed suicide. The committee consider the case affords striking illustration of the need for legislation to prevent the increame of the unfit.
97
T U B E R C U L O S I S CAMPAIGN IN I P S W I C H . BY A. M. N. PRINGLE, M;B., C.M., D.P.H., Medical Officer of Health, Ipswich.
present position of the tuberculosis T H Ecampaign in Ipswich is the result of a prolonged, persevering effort to secure three essential factors to success. These are (I) the support of the local medical profession ; (2) the sanction of public opinion ; (3) the recognition by the Local Authority that the control of tuberculosis is a matter rightly falling within their jurisdiction. It is needless to discuss the means whereby these various factors have been achieved. Suffice it to say that they are now accomplished facts. The first public step in the tuberculosis campaign was taken when the Local Authority considered my Annual Report for 191o, in which I outlined a scheme for the prevention and control of tuberculosis. When this report came before the Council this portion received considerable attention and the local press devoted one or two articles to its consideration. It happened at this very time that the death of King Edward VII'. took place, and, in view of his well known interest in consumption, the Chairman of the Public Health Committee gave it as his opinion that no greater monument to the memory of that monarch could be conceived than the inauguration of a scheme for the control of tuberculosis. This view commended itself at once to all sections of the community. As a result of the expression of public opinion the Mayor, in June, I9IO, summoned a town's meeting, which was largely attended. The scheme for dealing with the problem was fully explained by the Chairman of the Public Health Committee and myself and was adopted with enthusiasm, several very large subscriptions being promised on the spot. A committee was at once appointed to collect funds, and from first to last ~'I5,OOO have been raised, whilst a site admirably suited to the erection of an institution has been presented to the Corporation. The objects of the fund are :-(I) The erection and equipment of a sanatorium. (2) The inauguration of educational propaganda. (3) The adoption of any procedures that increasing knowledge might indicate as useful in combating tuberculosis.
98
PUBL1C HEALTH.
It is clear that a sum such as that stated, whilst it might be adequate for the purposes of sanatorium construction and equipment, could offer nothing towards maintenance. It is also evident that the greater proportion of phthisical patients are quite unable to afford the expense ot sanatorium treatment. It was brought home to the Town Council by the enthusiasm with which the project was received and the readi-~ ness with which all classes of the community contributed to the fund in sums varying from a penny to £5,ooo that the maintenance of the institution by the municipality would meet with popular approval. Accordingly, at a meeting of the Town Council in the end of I9~O, it was unanimously resolved by the municipality to accept the gift of the sanatorium and to maintain it subsequently. Thus the question of municipal control of tuberculosis in Ipswich is now an accomplished fact, at least in so far as the sanatorium is concerned. We are now in a position to consider the tentative complete scheme proposed to be established in the borough. The various points of the scheme will be taken seriatim and those already in existence will be duly indicated. , (I) Compzdsory Notific~tiou of Pulmo~ary Tuberculosis.--This step was unanimously approved by the Ipswich Clinical Society, no single member being in favour of voluntary notification. So far as this borough is concerned, notification takes place under three conditions, viz.:-(a) All Poor Law cases are notifiable under the Poor Law Regulations, 19o8. (b) All hospital cases are notifiable under the Hospital Regulations, 1911. (c) All other cases are notifiable under the Ipswich Corporation Act, 1911. This last group comes into actual operation on December Ist, 1911. The clauses in the Ipswich Act dealing with compulsory notification are framed on the lines of the Sheffield Act. Thus complete compulsory notification is now in existence in the borough. I confess that it has always been an insoluble conundrum to me why the Local Government Board refuse compulsory notification to a municipality. So fat as I have been able to discover the Board do not grant notification unless satisfied that the Local Authority have made some provision for dealing with the cases notified. In my view this is putting the cart before the horse. The establishment of notification must
D~cEM~mq
obviously give the Local Authority some conception of the number and type of cases occurring in their area and will clearly enable them to arrive at a more or less definite conception of the kind and amount of institutional treatment required. The present position is that the Local Authority must provide accommodation in the dark and await results. (2) Educ~tio~al Pr@agaud~.--It is perfectly evident that notification of pulmonary tuberculosis is absolutely useless unless it is followed up. My Corporation have therefore appointed a special nurse for the purpose of paying personal visits to the patients notified and the giving of personal advice. I am no believer in printed instructions alone. They have a certain value if supplemented by personal advice, but the municipality that trusts to their influence alone is inviting failure. I believe that in certain cities "a special inspector has been appointed for this purpose. Possibly this step may suit the cities concerned, but I do not consider such a step generally applicable. I consider that a suitably qualified nurse will more readily acquire the confidence of the people than an inspector and will be much less likely to exhibit the blighting effects of officialism. Generally speaking the duties of the nurse are directed towards the securing of a rational conception of the meaning of a hygienic existence, whilst at the same time full information. is given as to the steps to be taken to secure the prevention of infection. It may be well to indicate her principal duties in more detail :-(a) She reports upon sanitary environment, so that any necessary steps may be taken. (b) Information as to the history of cases is collected. (c) Victims of the developed disease are advised as to their mode of life and the steps necessary to prevent the spread of infection. (d) The watching of contacts is undertaken. (e) Patients discharged from the sanatorium are kept under observation. (f) The shelters provided by the Authority are periodically examined. (g) Every agency that can be brought to bear upon the cases is being gradually brought into touch with the nurse, so that all available help is obtained by the patient and family. (h) Every step taken by the nurse is under the direct control of the Medical Officer of Health.
1911.
PUBLIC HEA LTH.
(3) Institutiolml Treatment.--The institutional treatment at the present time available in the borough is as follows : - (a) Sixteen beds at the Union Infirmary, eight for men and eight for women. These are contained in two recently constructed annexes to the male and female wards of the institution. Clearly these are practically utilised for advanced+ cases only. Thus provision is made for the isolation of at least 16 cases in the advanced and most infectious stage of their illness. It may be urged that this provision is not intended for isolafion purposes. Possibly so, but the fact remains that the beds are occupied by the class of patient requiring isolation. (b) At the Borough Isolation Hospital a ward containing 12 beds is utilised for the treatment of male cases of pulmonary tuberculosis. At the present time all types of cases are dealt with, early and late. In addition, one of the smallpox wards at the Isolation Hospital has been altered to suit the requirements of phthisical patients, and thus accommodation is provided for 16 female patients. Here again at present all kinds of cases are dealt with. Later on it is proposed to utilise these wards for cases not suitable for the sanatorium and also for the isolation of advanced and infectious cases outside the care of the Poor Law. (c) At the present time the Sanatorium, for which the sum of £15,ooo was raised, is in course of construction. The Institution will contain 6 5 beds, of which 4 ° will be reserved for Ipswich patients. These will be maintained free by the municipality. The remaining 2 5 beds will be for paying patients, not necessarily inhabitants of Ipswich, the amount to be charged being 3os. per patient per week. It is hoped that the Institution will be open for patients in May, 1912. The type of building adopted for our Sanatorium is really a mixture of various sanatoria visited by a small sub-committee. The subcommittee, of which I was a member, visited Frimley, Benenden, Holt, Kelling, Nayland, Salterley Grange and Mundesley. We were accompanied on these visits by our architect, and we consider that the Institution to be erected in Ipswich will possess as few disadvantages as a n y institution with which we are acquainted. The accompanying sketches will sufficiently explain the kind of wards selected and also the type of administrative block.
99
In so far as the management of patients is concerned the method of procedure followed will be that in force at Frimley. Dr. Paterson's methods are now too well known to require any description from me. The cost of the Ipswich Sanatorium works out at about £23o per bed. This sum is in excess of that originally estimated for various reasons, the principal of which is the fact that the Institution is intended to be a King's memorial. The sub-committee were of opinion that a more ambitious style of construction was required on account of this fact. Thus Ipswich will be able to deal with a proportion of early consumptives at the Sanatorium, and with advanced and infectious cases either at the Isolation Hospital or at the Poor Law Infirmary, according to circumstances. Such, briefly, is the institutional provision at present in use and shortly to be extended. (4) It is needless to state that all necessary disinfection of premises and articles is carried out at death or removal. It may be stated that the Ipswich Corporation Bill, 1911 , gives power of disinfection either at death or removal. (5) The examination of sputum is made free of charge to all Ipswich practitioners, and is carried out by myself in the municipal laboratory. (6) In this scheme no mention has been made of a dispensary. In so far as the coordinating work of a dispensary is concerned, such an institution is unnecessary in Ipswich, as all needful co-ordination is carried out from the office of the medical officer of health in whose hands compulsory notification has placed the controlling lever~ and who is directly responsible for the whole scheme. Coordination in my opinion can, at. least in the case of this borough, be far more effectually carried out by the medical officer of health than by the officials of a separate establishment. The question of treatment is, however, on a different basis. At present it is intended to adopt the admirable method in existence in Birmingham, which is one that will readily adapt itself to the methods of treatment in existence in the Ipswich Isolation Hospital. (7) Thequestion of tuberculin administration is one of profound importance. At the present time I am treating the great majority of the cases at the Isolation Hospital with tuberculin after the method in use at the Yardley Road Sanatorium, Birmingham. The results fully bear out the contention that tuberculi~ administered u~der conditions o] ~dequc~te and ibr@er
100
DECEYIBER,
P U B L I C H E A L TIt.
•
1911.
PUBLIC H EAL T H .
Ikl
El - ~ I
101
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i L~.,~
8
.~.
, .... _ r~"
I~
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/ /ed /
O~ /
/
,
-
/ /i t
"
T, e.-
LLZ ~'-.'-. ,
I
I
100
P UBLYC H E A L T H . ,
control is a therapeutic agent of great value in suitable cases. (8) At the present time four shelters of approved design are in use in t h e borough. T h e y are let out at a small weekly rental to patients who have passed t h r o u g h the ward of the Isolation Hospital. T h e shelters are a most useful adjunct to the o t h e r m e t h o d s in use.
(9) S p u t u m flasks are provided free of charge to all patients who present themselves and whose circumstances are such t h a t t h e y cannot afford to buy the flasks. All patients at the Isolation Hospital are provided with a flask on departure. (Io) T h e Tuberculosis E x h i b i t i o n p r o m o t e d by the National Association for the p r e v e n t i o n ' of consumption was held in Ipswich in March of this year. T h e E x h i b i t i o n was open for six days and was visited by 17,ooo people, a sufficient indication of the interest aroused in the borough by the tuberculosis campaign. T h e expenses of the E x h i b i t i o n were defrayed out of the King E d w a r d Memorial Fund, in consideration of the educational value of the Exhibition. ( t i ) T h e investigation of c o n t a c t s by the tuberculosis nurse has already been indicated. Clearly, however, the part o'f the nurse will be confined to enquiries as to previous health, history of cough, evident signs of delicacy of constitution, or actual illness, and in short any other s y m p t o m s that might point to a tuberculous lesion. E v i d e n t l y the only means w h e r e b y the precise condition of c o n t a c t s c a n be properly assessed is by examination by a medical man. In so far as children of school age are concerned, the tuberculosis nurse will find out the school at which the children are in a t t e n d a n c e and will hand the names to the school nurse, who will at the next visit of the medical inspector present these children for his examination. As every school in Ipswich is visited by the medical inspector once in every three weeks, no delay will follow this plan. As regards P o o r L a w c o n t a c t s and hospital contacts, which appear in Ipswich to provide a considerable n u m b e r apart from the school ctiildren, the medical e x a m i n a t i o n m a y be carried out by the Poor L a w medical officer and the hospital staff, or by the medical officer of health by agreement. In the case of private patients the examination m a y b e carried out by the private practitioner in a t t e n d a n c e on the family. T h e r e are several obvious objections to this
DECE~aB~,
m o d e of procedure, but the same s t a t e m e n t m a y be made as to any plan yet formulated b y the wit of man. Only experience will indicate the lines along which ultimate d e v e l o p m e n t will take place. (12) In addition to all these procedures the Public H e a l t h C o m m i t t e e will continue to pay due a t t e n t i o n to the housing conditions of the people, a factor of the very first i m p o r t a n c e in the campaign. Such, briefly, is an outline of the f u n d a m e n t a l points of the Ipswich m e t h o d s of procedure. T h e y are to be regarded as the skeleton of the scheme, and all details proved by experience to be necessary will be filled in as time goes on. T h e r e is no question of finality in the present position. PROSECUTION
UNDER
THE
NOTIFICATION
OF
BIRTHS ACT.--Dr. Beattie, Of iio, Fernhead Road, Paddington, was summoned before Mr. Paul Taylor; by the Paddington Borough Council, on Oct. 9th, for failing to give notice in writing to Dr. Dudfield, the medical officer of health for the borough, of the birth of the child of Robert Clarke, of 176 , Ashmore Road, which he had attended. The father of the child was also summoned for a similar offence. Dr. Beattie urged in mitigation that he left a card of notification with the mother, with the request that she would ask her husband to fill it in and forward it to the medical officer, and he was under the impression that that was done. Mr. Dennis, the solicitor for the council, replied that even so that did not excuse the doctor from giving notice himself unless he had reasonable grounds for believing that notice had been given. Dr. Beattie pointed out that since the Act was adopted by the council he had attended 60o of these cases, and this was the first one in which the parents had failed to send in the notice. Dr. Beattie was fined5s, and the father lOS. POPULATION.--Comfort and competence await the man settling upon the land. H e will be more valuable in so far as his rural life will develop the country in its best way. Wealth is to be won from the soil. Settlers know that the strength and sinew of a fair-sized family will be a distinct asset, and wiU eschew the demoralising tendency, common in town life, of limiting the family. For many generations ample room may be found for an expanding rural population in comfortable circmnstances; probably carrying on the old traditions of home life in its best form, and tend to bring about that condition throughout the State, and relieve it from the devastating influence the want of this is producing.--Dr. James W.
Hope, Principal M~dical O~er, Western Austr~lia~ Ann,.~aI R•ort, I9IO.
HEALTH,
The milkers wear a special white suit and cap, these articles being replaced twice a week by newly-washed overalls. A special lavatory with nail brush and soap is provided for their use, and they are enjoined to keep their nails cut short. Only in exceptionally hot weather has it been necessary to provide ice, wherewith to cool the water which passes through the cooler. In any event the quantity used is but small, and ice is readily procurable and by no means can it be termed expensive, even if it be requisite to make it at the farm. The dairy is lighted by electricity, from the supply that serves also for the house. W i t h this exception, perhaps, there is nothing here furnished but what should be found in any well-regulated farm ; no costly or large buildings are required, the block containing the vertical boiler and sterilising apparatus, the butter-making, milk- cooling, and bottling room, and the cool store, covering roughly only six yards by ten. The milking shed has a suitably channeled concrete floor, and the fittings are all of iron. The public has a right to expect that milk shall be produced under satisfactory conditions, and that it should remain satisfactory until it reaches the customer; and when we take into consideration the average state of that supply as it now reaches the consumer, and the fact vouched for by Dr. Ralph Vincent that a satisfactory article can be produced for less than threepence per quart, it is the bounden duty of Government and of all health officials to press forward with all speed adequate measures to secure the object in view, i.e. the production of milk that will pass as " certified" milk by a medical Milk Commission.
THE
1911.
T H E INCREASE oF THE U N F I T . - - A t
a
meeting
of the London County Council on November i4th , the Asylums Committee reported the case of a female patient, aged 67, who was admitted to Colney Hatch Asylum on September i2th, having previously been admitted to the same asylum on 15 occasions,andto other asylumson i I occasions-25 in all. She was married when 18 years old, and had had 13 children, five of whom are dead. Her first attack of insanity was at the age of 2I, when her first child was born. Her children are said to be healthy except two, who have recently shown signs of insanity. She has two aunts in asylums, and two of her sisters have suffered from insanity, one having died in Colney Hatch, and .the other having committed suicide. The committee consider the case affords striking illustration of the need for legislation to prevent the increame of the unfit.
97
T U B E R C U L O S I S CAMPAIGN IN I P S W I C H . BY A. M. N. PRINGLE, M;B., C.M., D.P.H., Medical Officer of Health, Ipswich.
present position of the tuberculosis T H Ecampaign in Ipswich is the result of a prolonged, persevering effort to secure three essential factors to success. These are (I) the support of the local medical profession ; (2) the sanction of public opinion ; (3) the recognition by the Local Authority that the control of tuberculosis is a matter rightly falling within their jurisdiction. It is needless to discuss the means whereby these various factors have been achieved. Suffice it to say that they are now accomplished facts. The first public step in the tuberculosis campaign was taken when the Local Authority considered my Annual Report for 191o, in which I outlined a scheme for the prevention and control of tuberculosis. When this report came before the Council this portion received considerable attention and the local press devoted one or two articles to its consideration. It happened at this very time that the death of King Edward VII'. took place, and, in view of his well known interest in consumption, the Chairman of the Public Health Committee gave it as his opinion that no greater monument to the memory of that monarch could be conceived than the inauguration of a scheme for the control of tuberculosis. This view commended itself at once to all sections of the community. As a result of the expression of public opinion the Mayor, in June, I9IO, summoned a town's meeting, which was largely attended. The scheme for dealing with the problem was fully explained by the Chairman of the Public Health Committee and myself and was adopted with enthusiasm, several very large subscriptions being promised on the spot. A committee was at once appointed to collect funds, and from first to last ~'I5,OOO have been raised, whilst a site admirably suited to the erection of an institution has been presented to the Corporation. The objects of the fund are :-(I) The erection and equipment of a sanatorium. (2) The inauguration of educational propaganda. (3) The adoption of any procedures that increasing knowledge might indicate as useful in combating tuberculosis.
98
PUBL1C HEALTH.
It is clear that a sum such as that stated, whilst it might be adequate for the purposes of sanatorium construction and equipment, could offer nothing towards maintenance. It is also evident that the greater proportion of phthisical patients are quite unable to afford the expense ot sanatorium treatment. It was brought home to the Town Council by the enthusiasm with which the project was received and the readi-~ ness with which all classes of the community contributed to the fund in sums varying from a penny to £5,ooo that the maintenance of the institution by the municipality would meet with popular approval. Accordingly, at a meeting of the Town Council in the end of I9~O, it was unanimously resolved by the municipality to accept the gift of the sanatorium and to maintain it subsequently. Thus the question of municipal control of tuberculosis in Ipswich is now an accomplished fact, at least in so far as the sanatorium is concerned. We are now in a position to consider the tentative complete scheme proposed to be established in the borough. The various points of the scheme will be taken seriatim and those already in existence will be duly indicated. , (I) Compzdsory Notific~tiou of Pulmo~ary Tuberculosis.--This step was unanimously approved by the Ipswich Clinical Society, no single member being in favour of voluntary notification. So far as this borough is concerned, notification takes place under three conditions, viz.:-(a) All Poor Law cases are notifiable under the Poor Law Regulations, 19o8. (b) All hospital cases are notifiable under the Hospital Regulations, 1911. (c) All other cases are notifiable under the Ipswich Corporation Act, 1911. This last group comes into actual operation on December Ist, 1911. The clauses in the Ipswich Act dealing with compulsory notification are framed on the lines of the Sheffield Act. Thus complete compulsory notification is now in existence in the borough. I confess that it has always been an insoluble conundrum to me why the Local Government Board refuse compulsory notification to a municipality. So fat as I have been able to discover the Board do not grant notification unless satisfied that the Local Authority have made some provision for dealing with the cases notified. In my view this is putting the cart before the horse. The establishment of notification must
D~cEM~mq
obviously give the Local Authority some conception of the number and type of cases occurring in their area and will clearly enable them to arrive at a more or less definite conception of the kind and amount of institutional treatment required. The present position is that the Local Authority must provide accommodation in the dark and await results. (2) Educ~tio~al Pr@agaud~.--It is perfectly evident that notification of pulmonary tuberculosis is absolutely useless unless it is followed up. My Corporation have therefore appointed a special nurse for the purpose of paying personal visits to the patients notified and the giving of personal advice. I am no believer in printed instructions alone. They have a certain value if supplemented by personal advice, but the municipality that trusts to their influence alone is inviting failure. I believe that in certain cities "a special inspector has been appointed for this purpose. Possibly this step may suit the cities concerned, but I do not consider such a step generally applicable. I consider that a suitably qualified nurse will more readily acquire the confidence of the people than an inspector and will be much less likely to exhibit the blighting effects of officialism. Generally speaking the duties of the nurse are directed towards the securing of a rational conception of the meaning of a hygienic existence, whilst at the same time full information. is given as to the steps to be taken to secure the prevention of infection. It may be well to indicate her principal duties in more detail :-(a) She reports upon sanitary environment, so that any necessary steps may be taken. (b) Information as to the history of cases is collected. (c) Victims of the developed disease are advised as to their mode of life and the steps necessary to prevent the spread of infection. (d) The watching of contacts is undertaken. (e) Patients discharged from the sanatorium are kept under observation. (f) The shelters provided by the Authority are periodically examined. (g) Every agency that can be brought to bear upon the cases is being gradually brought into touch with the nurse, so that all available help is obtained by the patient and family. (h) Every step taken by the nurse is under the direct control of the Medical Officer of Health.
1911.
PUBLIC HEA LTH.
(3) Institutiolml Treatment.--The institutional treatment at the present time available in the borough is as follows : - (a) Sixteen beds at the Union Infirmary, eight for men and eight for women. These are contained in two recently constructed annexes to the male and female wards of the institution. Clearly these are practically utilised for advanced+ cases only. Thus provision is made for the isolation of at least 16 cases in the advanced and most infectious stage of their illness. It may be urged that this provision is not intended for isolafion purposes. Possibly so, but the fact remains that the beds are occupied by the class of patient requiring isolation. (b) At the Borough Isolation Hospital a ward containing 12 beds is utilised for the treatment of male cases of pulmonary tuberculosis. At the present time all types of cases are dealt with, early and late. In addition, one of the smallpox wards at the Isolation Hospital has been altered to suit the requirements of phthisical patients, and thus accommodation is provided for 16 female patients. Here again at present all kinds of cases are dealt with. Later on it is proposed to utilise these wards for cases not suitable for the sanatorium and also for the isolation of advanced and infectious cases outside the care of the Poor Law. (c) At the present time the Sanatorium, for which the sum of £15,ooo was raised, is in course of construction. The Institution will contain 6 5 beds, of which 4 ° will be reserved for Ipswich patients. These will be maintained free by the municipality. The remaining 2 5 beds will be for paying patients, not necessarily inhabitants of Ipswich, the amount to be charged being 3os. per patient per week. It is hoped that the Institution will be open for patients in May, 1912. The type of building adopted for our Sanatorium is really a mixture of various sanatoria visited by a small sub-committee. The subcommittee, of which I was a member, visited Frimley, Benenden, Holt, Kelling, Nayland, Salterley Grange and Mundesley. We were accompanied on these visits by our architect, and we consider that the Institution to be erected in Ipswich will possess as few disadvantages as a n y institution with which we are acquainted. The accompanying sketches will sufficiently explain the kind of wards selected and also the type of administrative block.
99
In so far as the management of patients is concerned the method of procedure followed will be that in force at Frimley. Dr. Paterson's methods are now too well known to require any description from me. The cost of the Ipswich Sanatorium works out at about £23o per bed. This sum is in excess of that originally estimated for various reasons, the principal of which is the fact that the Institution is intended to be a King's memorial. The sub-committee were of opinion that a more ambitious style of construction was required on account of this fact. Thus Ipswich will be able to deal with a proportion of early consumptives at the Sanatorium, and with advanced and infectious cases either at the Isolation Hospital or at the Poor Law Infirmary, according to circumstances. Such, briefly, is the institutional provision at present in use and shortly to be extended. (4) It is needless to state that all necessary disinfection of premises and articles is carried out at death or removal. It may be stated that the Ipswich Corporation Bill, 1911 , gives power of disinfection either at death or removal. (5) The examination of sputum is made free of charge to all Ipswich practitioners, and is carried out by myself in the municipal laboratory. (6) In this scheme no mention has been made of a dispensary. In so far as the coordinating work of a dispensary is concerned, such an institution is unnecessary in Ipswich, as all needful co-ordination is carried out from the office of the medical officer of health in whose hands compulsory notification has placed the controlling lever~ and who is directly responsible for the whole scheme. Coordination in my opinion can, at. least in the case of this borough, be far more effectually carried out by the medical officer of health than by the officials of a separate establishment. The question of treatment is, however, on a different basis. At present it is intended to adopt the admirable method in existence in Birmingham, which is one that will readily adapt itself to the methods of treatment in existence in the Ipswich Isolation Hospital. (7) Thequestion of tuberculin administration is one of profound importance. At the present time I am treating the great majority of the cases at the Isolation Hospital with tuberculin after the method in use at the Yardley Road Sanatorium, Birmingham. The results fully bear out the contention that tuberculi~ administered u~der conditions o] ~dequc~te and ibr@er
100
DECEYIBER,
P U B L I C H E A L TIt.
•
1911.
PUBLIC H EAL T H .
Ikl
El - ~ I
101
~'~.
i L~.,~
8
.~.
, .... _ r~"
I~
/,'ALl//~/~/,7 /
/ /ed /
O~ /
/
,
-
/ /i t
"
T, e.-
LLZ ~'-.'-. ,
I
I
100
P UBLYC H E A L T H . ,
control is a therapeutic agent of great value in suitable cases. (8) At the present time four shelters of approved design are in use in t h e borough. T h e y are let out at a small weekly rental to patients who have passed t h r o u g h the ward of the Isolation Hospital. T h e shelters are a most useful adjunct to the o t h e r m e t h o d s in use.
(9) S p u t u m flasks are provided free of charge to all patients who present themselves and whose circumstances are such t h a t t h e y cannot afford to buy the flasks. All patients at the Isolation Hospital are provided with a flask on departure. (Io) T h e Tuberculosis E x h i b i t i o n p r o m o t e d by the National Association for the p r e v e n t i o n ' of consumption was held in Ipswich in March of this year. T h e E x h i b i t i o n was open for six days and was visited by 17,ooo people, a sufficient indication of the interest aroused in the borough by the tuberculosis campaign. T h e expenses of the E x h i b i t i o n were defrayed out of the King E d w a r d Memorial Fund, in consideration of the educational value of the Exhibition. ( t i ) T h e investigation of c o n t a c t s by the tuberculosis nurse has already been indicated. Clearly, however, the part o'f the nurse will be confined to enquiries as to previous health, history of cough, evident signs of delicacy of constitution, or actual illness, and in short any other s y m p t o m s that might point to a tuberculous lesion. E v i d e n t l y the only means w h e r e b y the precise condition of c o n t a c t s c a n be properly assessed is by examination by a medical man. In so far as children of school age are concerned, the tuberculosis nurse will find out the school at which the children are in a t t e n d a n c e and will hand the names to the school nurse, who will at the next visit of the medical inspector present these children for his examination. As every school in Ipswich is visited by the medical inspector once in every three weeks, no delay will follow this plan. As regards P o o r L a w c o n t a c t s and hospital contacts, which appear in Ipswich to provide a considerable n u m b e r apart from the school ctiildren, the medical e x a m i n a t i o n m a y be carried out by the Poor L a w medical officer and the hospital staff, or by the medical officer of health by agreement. In the case of private patients the examination m a y b e carried out by the private practitioner in a t t e n d a n c e on the family. T h e r e are several obvious objections to this
DECE~aB~,
m o d e of procedure, but the same s t a t e m e n t m a y be made as to any plan yet formulated b y the wit of man. Only experience will indicate the lines along which ultimate d e v e l o p m e n t will take place. (12) In addition to all these procedures the Public H e a l t h C o m m i t t e e will continue to pay due a t t e n t i o n to the housing conditions of the people, a factor of the very first i m p o r t a n c e in the campaign. Such, briefly, is an outline of the f u n d a m e n t a l points of the Ipswich m e t h o d s of procedure. T h e y are to be regarded as the skeleton of the scheme, and all details proved by experience to be necessary will be filled in as time goes on. T h e r e is no question of finality in the present position. PROSECUTION
UNDER
THE
NOTIFICATION
OF
BIRTHS ACT.--Dr. Beattie, Of iio, Fernhead Road, Paddington, was summoned before Mr. Paul Taylor; by the Paddington Borough Council, on Oct. 9th, for failing to give notice in writing to Dr. Dudfield, the medical officer of health for the borough, of the birth of the child of Robert Clarke, of 176 , Ashmore Road, which he had attended. The father of the child was also summoned for a similar offence. Dr. Beattie urged in mitigation that he left a card of notification with the mother, with the request that she would ask her husband to fill it in and forward it to the medical officer, and he was under the impression that that was done. Mr. Dennis, the solicitor for the council, replied that even so that did not excuse the doctor from giving notice himself unless he had reasonable grounds for believing that notice had been given. Dr. Beattie pointed out that since the Act was adopted by the council he had attended 60o of these cases, and this was the first one in which the parents had failed to send in the notice. Dr. Beattie was fined5s, and the father lOS. POPULATION.--Comfort and competence await the man settling upon the land. H e will be more valuable in so far as his rural life will develop the country in its best way. Wealth is to be won from the soil. Settlers know that the strength and sinew of a fair-sized family will be a distinct asset, and wiU eschew the demoralising tendency, common in town life, of limiting the family. For many generations ample room may be found for an expanding rural population in comfortable circmnstances; probably carrying on the old traditions of home life in its best form, and tend to bring about that condition throughout the State, and relieve it from the devastating influence the want of this is producing.--Dr. James W.
Hope, Principal M~dical O~er, Western Austr~lia~ Ann,.~aI R•ort, I9IO.