26,t PUBLIC HEALTH. AUGUST,

55. The Hygienic Aspect o] the Coal-mlning Industry, Milroy Lec- tures, 1914, F. Shultlebothana, lecture iii. THE WORK OF A TUBERCULOSIS 56. Monographie hygidniqua de la ]abricatiol~ d~ pldtraerle~ 1,'rance, DEPARTMENT.* H6bert, Maute, and Helm, 191~, Duruy et Cir., P ". 57. Report on the Prevalence of Fhthisis among ~uarry Workers and BY GEORGE JESSEL, M.A., M.B., B.Ch. taxon), Miners, S. Bar\vlse, i913. l)elfl~y (:aunty. 58, Royal Commission on MetalliJerous Mines aml Ouarries, Minute~ D.P.H. (Vict.), Tuberculosis Officer to Lancashire of Evidence, Vol. iii., Appendix P., 19I.i. Wyman & Sons, Ltd. County Council and County Borough of Wigan; now (Cd. 7478.) 59. Annual Report o[ the ChieJ Inspector o[ Factories ]or I9H. also Acting Medical Officer of Health of Wigan, PP. 203-$. Wyman & Sons, Ltd, (Cal. 6239.) 59a. Ibid. pp. 23o.i" 60. ]~hresberichte der Gewerbe-Aussichtsbe~lmten und Bergbehorden ]ur da's Jahr. 1oH, OD. q84-4~0. Berlin. 6I. On the Mortal[ty of'Fl~-l~'o'vhers, C. D. Purdah, 1873. HE following paper deals with the work 62. Jute, H. J. Wilson, Dangerous Trades, edited by T. Oliver, 19o2, T p. 66o. John Murray. "" now being carried out at the three tuber- 63. An Address on Pneumonia, Sit" James Barr. British Medical Journal, Jan. Ioth, 19i 4. culosis dispensaries, situated respectively in 64. Report to the Royal ColleGe o] Physicians o)) the l*lJettivity o] Pulmonary Tuberculosis. British Medical Jot r m , Ap- I iith the County Borough of Wigan and the Boroughs IqI4. 65. The EXperimental Production o] Pneumonia, R. B. Armstroug. of Charley and Leigh, and serving not only Supplement to British Me(ica Journal, July 18th. 19i 4. 66. The Lumleian Lectures, Dr. P~ Kidd. Lancet, Vol. i., 1912. these boroughs, but the surrounding town- 66a. Ibld. p. 159o. 66b. Ibld. p. x668. ships, comprising altogether a population of 68. Les Pneumonies A scories, Monnier. Gaz. Med. de Nantes, Nov. x2th, ~898' nearly 3oo,o0o persons. The staff, in addition 69. Les Pneumoaies c~ stories, Gatttret. Th~se de Paris, i899. to myself, consists of two assistants, five 7 o. Final Report o] Departmental Committee on Certain Miscellaneous Dangerous Trades, p. 13 , x899' Eyl-e & Spo|tiswoode. (C.-- nurses, and two clerks. 95090 7 ~. TheCause, Ef]ect, Incidence aml Prevention o] Pneumonoconiosi~ I have been fortunate in being allowed con- °l Lmartz Miners, J. S. Purdv The Practitioner February 1012 7 z. Melbourne.M ers" Phthisis r t Ben&go.• ~',~v~, Stlmnlons,- 19o7. ' Sttlhvell " • '& Co, siderable freedom in the organisation and 73. Report o] the Royal Commissioner on Pulmonary Diseases amongst management of these dispensaries, and I think Miners, p. 6% i91o. Perth, Western Australia. 74, Die Staubinhalations.I(~ankheiten, Dr. Ludwig Hh't. Die Krnnk- that some account of the methods and pro- heiten der Arbelter, Erster Thcil. 13reslau, 187*. 7S. Diseases o[ the Lungs, Powell arm l!artley, Fourth Edition, 19il. cedure adopted may perhaps prove of interest. H. K. Lewis, London. 76. Report oJ Departmental Committee upon Merionethshire ,Slate Although the functions of a tuberculosis dis- ~.I[nes, 1895' (C.-- 7692.) Eyre & Slmttiswoode, 77. lV**m~tes o] Evidence. Ro)al Commission on Metalll]erous Mines pensary as laid down in the interim report of a~d Ouarvi~s Vol. lit., *9xa,, p. 115. Wyman & Sons, lad. ¢C<1 7478.f " the Inter-departmental Committee in 1912 77a. Ibid. pp. 145_~M" 77 b. Ibid. 188. are fairly definite, there appears to be no little 77 c. Ibld. p. ~36. 77 d. I~bid. pp. 18iq89, and Appendix P. diversity of opinion as to the best means of 78. necnercnes experimentales sur Its conditions physiologiques du travail des ouw, iers sableurs, ~9 n. Brlault. Th6se du Paris. carrying these recommendations into effect. 79. Report o] Medical Officer o[ 1lealth ]or the City o] Aberdeen ~9o9, p. ~o7. This is not unnatural when the varying circum- 80. Report on the p ..... l ...... l Lung Di ...... g the Wortters a~ .t,rr*nsndl ~)uarries, J. Wheallev ~912. Shrewsbury. stances of the districts concerned, whether 8I. ~}epovt o] a Commission o t Miners ~ P] I isis a d P D o ary 'uberculosis in So~ h Alrica. ,gta, pp. 7-1o. Cape Towll. urban or rural, are considered. Apart from 8z. Report oI Medical Officer oJ Health o] loYmm~esburg ~st July. this, however, there are sharp differences both 1912, to 3oth June, ~9t3 . Charles Porter, M~I)., p. 2o. Johannes- burg. in theory or practice in areas apparently 83. Transactions oj the Pathological Sociely o~ London, Vol. xx., ~869. similar in character. 831. l!~[d., V(~I. xvi. ~865' p~ 59_60 84. .~cmnee 1ram an Easy Chair, a second serles, i912 , Sir Ray The tuberculosis dispensary enters into 85. La~kester, pp. 19 .... Adlard & Son, I.ond .... " , emm, A new translation, VV. F. Smith, ~893, VoI. i., chap relationship with-- xx]x.:, p.. 343. Alexander p. Watt. 86. ~e *Tygte~{e des Bergmannes Halle ~0o3 Goldman i. Public Health Department. 87 . • ne so-catted Anthracosis and, Phthisis , . in ~Coal-miners, . R. S. Trotter. British Medical Jourual, 23rd May, ~9o3. ii. General practitioners. .y ji, a. Wainwright and H J. Nic~os Ane'cal Journal ot iii. The general public. t~a,e ~vje,d~c91 Sciences, ~9o5 Vol. cxxx. ppj 403-4~4. 89. ~)tt)ters Phthisis, Sir T. Oliver, British Medical Join'hal, ~2(a iv. Other organisations. Sept., i9o3. 90. Weavers" Co gh Annual Report of the Chief Inspector of Fac- I.--RELATIONSHIP WITH PUBLIC HEALTH ~r~eeSsfe~rolg'3, P- 15o. ,Vy ..... & S ..... Ltd. (Cd. 749'.) 91' I the lungs Item Mechanical Causes, G. Calvert Hol- DEPARTMENTS, land, ~843, p. ~3. John Churchill, I,ondon. 9ra. Ibid. pp. 36_7. 9H). Ibid. p. 6o. This should be as intimate and cordial as 9 ~. Diseases o] Occupation, Sir T. Oliver, p. 294. ~9o7. Metbuen & Co. possible. The problem of tuberculosis is clffsely 9,3. Report. o] Departmental Commitlee on Compensation for ln ttls- trial Diseases, !]linntes el Evidence, pp, 197-2o2, ~9o7, (Cd. 3406 ) associated with questions of housing and sani- Wyman & Sons, Ltd. 94- Pneunlonoconiosis, Sir. T. Olivor. System of Medicine, Al!hutt tation, which are the concern of the medical and Rolleston, Vol, v., 19o9, p, 469. Macmillan & Co., Ltd. 94 a. Ibid. p. 462. officer of health. The latter has, moreover, 95. Staubi~lhalalion u)ld Staubmetaslase, Julius Arnold, 1885. 96. Erkrankunge.~ des Respiratio s pparates, E. Aufrecht Nothnagel's certain statutory obligations under the Tuber- Speclelle ~pathoh,gie u ~d Therap e B .... ' culosis Order, 1912. On this account there 97. ~,a :l~a~m,~a des Ardoisiers. la Schistose, Rehn% ~9oo. Imprlmcqb,. blatot-Bralne. should be a definite system for the prompt and 98' Pj°~ieo;;linvgs O]vi Royal Society o[ Medici .... Electro-Therapeutical Proc edi ' " " 1914' PP 93"98 ready exchange of information between him 99. e ..rigs at Royal Society o[ Medicine, PathologicM Sc~etion V~alttv~. :, part ...... 9'4, TuberculoM P ...... losls, S. G. and the tuberculosis officer. The former ~oa. The Relation o] Industrial a~d ga~ itary (ondilions to Pauperism, receives notifications as to persons suffering Mr. A%D. Maitland and Miss Rose Squh'e p. Io 9 and" pp. i25-6 '9o9 • Wyman & Sons, Lfd. (Cd. 4653 .) from tuberculosis of all forms, and also returns ~OL Annales de l'Institut Pasteur, Paris, ~914, xxvHi. xo2. Staubinbalationskraukheilen der Lungen, p. x7I, Zenker. * Read before a meeting of the North-Western Branch o[ the Society of Io3. Deutseh. Archly. fkh- kiln. Medic. 13d. 2, ~867. Ibhl. pp. ~t6-~72. Medical Ofilcers of ftealth on January iftb , 2915. 1915. PUBL fC HEA L TH. 265 of deaths. At Wigan such information is This is what obtains at Wigan, where it is transmitted daily from the Health Department proving successful. It appears, however, that as regards cases in the borough, while returns in many cases the administrative difficulties are sent weekly from the county medical due to local rivalries are proving a serious officer of health's department. In the latter obstacle to such joint appointments. case there is a certain amount of unavoidable II.--RELATIONSHIP WITH GENERAL PRAC- delay, as notifications are first received by the TITIONERS. district medical officer, and then transmitted to the county medical officer. To obviate this, The first essential is to enlist the support of arrangements have been made whereby local the local medical profession. This is not a medical officers transmit to the dispensary difficult matter when once it is realised that duplicates of their returns to the county the dispensary exists as a special centre, and medical officer. Stamped addressed envelopes is in no way in competition with private prac- are provided, and as a quid :~ro quo a copy of titioners; the latter are usually not slow in the tuberculosis nurse's report is promptly sent realising the advantages to themselves and to the district medical officer, who is thus their patients which result from close co- enabled to make use of same for his own operation. The dispensary not only affords purposes. assistance in diagnosis. It serves also as a One of the special tuberculosis nurses visits clearing-house for cases which are suitable for each case as soon as the notification is received institutional treatment, is a centre for special at the dispensary. It is her duty not merely forms of treatment, and is actively concerned to collect information, but to give advice arid in the supervision of patients while at home. assistance in improving the home conditions. The relationship of the tuberculosis officer to She furthermore assists insured persons to panel doctors is clearly defined in the Local fill up the requisite form of application for Government Board Order of July, 1912. The sanatorium benefit, and, as these forms bear status of the former is that of consultant, and the stamp of the dispensary, the clerks to the he is, moreover, charged with the general insurance committees do not require the supervision of the domiciliary cases. It is customary medical certificate. clear that if smooth and harmonious work- In her reports to the senior tuberculosis ing is to be obtained the machinery must officer particular attention is paid to sanitary be simple and effective. A telephone at the defects, especially lack of ventilation, windows dispensary makes for ease in communication, that cannot be opened, etc. After due veri- and is indispensable. The tuberculosis officers fication the reports are forwarded to the district are available at short notice to accompany a medical officer of health, who alone has the practitioner to one of his cases, and doctors power to take effective action in order that these are encouraged to send or refer their difficult sanitary defects may be remedied. Informa- cases to the dispensaries. It is important that tion is also sent to the Public Health Depart- every examination should be considered as a ment when patients are sent to various consultation. The patient's doctor always institutions, in order that the house may be receives due notice as to the time and place, disinfected. and if unable to be present he receives promptly The practice of appointing junior officers to a statement as to diagnosis" and appropriate the charge of borough dispensarie s at compara- treatment. tively low salaries is to be deprecated. It is As a i'esult of the above procedure the work contrary to the recommendations of the Astor of the dispensaries is becoming more and more Report and tile model scheme of the British appreciated both by doctors and patients, and MedicalAssociatiom Medical Officers ofhe~/lth, is:accomplished .with a.minimum of friction. who have the necessary.qualifications, are It would appear that in some parts of the usually far too busy personally to act as con- country the above state of affairs does not sultants; junior officers at lower salaries are obtain. There are those who hold the view seldom acceptable to the local profession, to that domiGiliary treatment can be more whom they should prove a help and stimulus. efficiently administered either through or by In tb2 case of small boroughs a joint appoint- the dispensary staff alone. In other cases the ment with a neighbouring borough or adjacent local practitioners have been allowed to shirk county is a convenient arrangement, and finds their undoubted legal responsibilities under the favour with the Local Government Board. Insurance Act. In my view the dispensary 266 PUBLIC HEALTH. AUGUST, should not seek to supplant, but rather to of cases the results have been encouraging, co-ordinate and supplement, existing agencies. and at any rate the moral effect has proved III.--The general public may be classified as- good. Patients who are able to visit the dis- (a) Patients; (c) Suspects ; pensary are encouraged to attend o.nce a fort- (b) Contacts; (d) Others. night, in order that their weight may be As regards patients the activity of the dis- recorded on a card which they keep. Each pensaries are available for the whole popula- patient also receives a brief dogmatic leaflet tion, whether insured or not, as the control of containing the essential rules of treatment. these institutions is rightly in the hands of Sputum papers and paper bags are also county councils and county boroughs. provided. Tuberculin has been used very The first necessity is early diagnosis. It has sparingly, but would be used more frequently been found that, as the dispensaries have if it could be definitely proved that its advan- become better known, and as the confidence of tages were at all commensurate with the risks. the general practitioners and the public is The dispensary should certainly act as a centre secured, cases present themselves for examina- for special treatment, but must not be allowed tion at an earlier stage than was formerly the to degenerate to the level of an out-patient case. In I9t 4 285 cases were referred to me department or provident dispensary. for diagnosis by general practitioners. Examinatiot~ of Co~tacts.--These are invited The diagnosis of phthisis in the early stage to be present at visits of the tuberculosis is often very difficult. officers to patients' homes, and are examined At Wigan reliance is placed on-- as far as possible. In the Borough of Wigan i. Physical examination. the assistant school medical officer is also the ii. Slight rise in evening temperature. assistant tuberculosis officer, and is responsible iii. Gradual loss of weight. for the examination of child contacts. It is iv. Sputum examination. recognised that in this way early cases may be Tuberculin and X-Rays have not been used. detected before the advice of the patient's Treatmeut.--It was laid down in the Astor doctor has been sought. Report that the dispensary should exist as a clearing-house and centre for treatment. IV.--AssOClATION WITH OUTSIDE Suitable cases are, in fact, drafted off to insti- ORGANISATIONS. tutions, e.g., sanatoriums, hospitals, etc., as The tuberculosis officer, being the adviser to vacancies occur. As regards cases at home, the insurance committees, a good deal of work the view is taken at Wigan that in general the is involved in preparing for and attendance at immediate responsibility for domiciliary treat- meetings. ment should devolve upon the panel doctor or The work of the after-care committees is of other practitioners--at any rate, as far as the great importance. These have been success- provision of drugs is concerned. The Local fully established both for Wigan and the Government Board Domiciliary Order of July, county areas. At Wigan alone over ten gallons I912, is carried into effect as regards insured of milk are being distributed to poor consump- patients, and blank forms of report with stamped tives daily, while nine single bedsteads with addressed envMopes are sent out to panel bedding are on loan for the isolation of cases doctors as required, usually at intervals of who are too poor to obtain these for them- eight weeks. These are timed to refer to a selves. period midway between two examinations. As It is unnecessary to do more than aliude the treatment of phthisis is essentially a matter to the importance of a proper system of of hygiene rather than of therapeutics, the full and accurate records of each person dispensary is very active in the matter of examined. This is important both for clinical supervision of the patients. The domiciliary and statistical purposes. reports of"panel doctors and the tuberculosis Patients are, as far as possible, seen by officers' examinations have already been men- appointment. Intimation is sent by letter to tioned; in addition, the dispensary n~arses both patient and doctor, and if the latter is not visit the homes frequently, usually about once present at the examination a letter is promptly in three weeks, and sometimes oftener. They sent to him containing clinical information, teach the patients how to record their own together with the treatment recommended. temperatures, thermometers and cards being To some this may seem to involve unnecessary provided from the dispensary. In the majority labour, but it has been found that the results 1915. PUBLIC HEALTH. 9,67

have fully justified the trouble taken, both as SOME REMARKS ON SECOND-HAND regards the appreciation of the patients and CLOTHING AND THE SPREAD OF the increased stimulus given to the doctors. INFECTIOUS DISEASE.* The importance of a dispensary as an educa- BY G. W. N. JOSEPH, M.D., D.P.H, tional centre cannot be over-estimated. In Medical Oftid-~r of Health, Warrington. addition to the education of patients, by the staff and through leaflets, a great many lantern VERY year more evidence seems to be lectures have been given throughout my area E forthcoming limiting the part played by to large and appreciative audiences, usually direct aerial conveyance of infectious disease, under the auspices of the town or district and proving that infection from perso n to council, with a prominent man as chairman. person or by intermediary " fomites " is almost They have done much to stimulate not only invariably the rule. The opportunity for the the interest of the public in tuberculosis but spread of infectious disease, together with also the councils themselves in matters affecting certain contagious ones and parasites, cannot the public health. be doubted in such businesses as those of dealers in second-hand clothes and bedding. There are more or less four branches of this CORRESPONDENCE. trade :-- (i.) Pawnshops. The Editor does not accept re@o#sibility for the opinions o)c corr~stondents. (2.) Second-hand clothes shops (" putty" To the Edifor, PUBLIC HEALTH. shops). (3.) Rag and bone dealers. THRIFT IN FOOD SUPPLIES. (4.) Buyers of second-hand clothing at SIR,--It is to be hoped that tile suggested private houses. (Although the latter are Committee will co-opt such men as Dr. Harry closely connected with the dealers under Campbell and Dr. Sire Wallace, and that the the second heading). question will be dealt with on philosophical lines, The points I am going to bring forward deal care being taken to subordinate any statement of calorific and nutritive values of food substances largely with the conditions of the pawning of to anatomical and physiological principles. clothing as it is into these that most of my The present increased price of meat is partly investigations have been made. But what is due to the fact that more people among the poorer true for this branch of the business holds good classes consume meat than formerly, through with even greater force for the other classes. separation allowances putting them into a better financial position than they were ever in before. I havenothing whatever to say against the Though national thrift is incumbent on all, it is brokers themselves--they have always shown well to recollect that these people should not be themselves willing ,to co-operate with the lectured to eat no more meat than they did before Health Department whenever possible, but the the war. It is good for the nation as a whole risk of the spread of infection is certainly that they should eat more meat than the scanty allowances they were hitherto accustomed to ; on present in this class of trade and it is to their the other hand, it will be equally good for the own advantage, as well as to that of the public nation (and incidentally for individuals) if the at large, that these things should be remedied, more opulent eat less meat than they have been if possible. accustomed to. A very large amount of pawning of clothing I would just like to mention one other point. A hygienic disposal of vegetable :and animal goes on regularly anaongst the poorer classes in waste from households will enable potatoes to our large industrial towns. Once a family has be grown' at no expense or labour beyond that started the system it is nearly always necessary of digging trenches in garden beds for the burying to continue it. of o~dinary scullery refuse, including p6tato sMfis. As a ru'ie it is the best'clothes of the house- My own experience has been that disposing of fresh scullery refuse in this way several potato hold that are pawned on the Monday morning plants have sprouted' from the eyes in the potato to be redeemed for the week-end or before any peelings which were buried--surely a thrifty and special holiday, if funds permit. economical, as well as hygienic, way of obtaining Parents ellen take advantage of the fact that a valuable article of food. a child is ill to pawn some of the garments Yours, etc., J. T. C. NASH, quite, regardless as to whether the child is County Medical Officer of Health suffering or not from an infectious disease. Norwich, for Norfolk. * R~ad before the North Western Branch of the Society of Medical July 3rd, 1915. Officers of Health on November~oth, i914.