304

All cases of malaria are made notifiable (unlessthey are known to have previously been notified inthe same district within six months), but the specialaction required of the medical officer of health islimited to those cases in which he considers thatsteps should be taken to prevent the spread of infec-tion. The greater number of notified cases willbe in soldiers and others who have contractedinfection abroad and who then relapse in this

country: when this fact has been ascertained nothingfurther will as a rule be required of the medicalofficer of health. If, however, there is evidence ofthe disease being contracted locally, he is requiredto take all practicable steps to see that malarialcases in his area are supplied with mosquitonetting, receive necessary quinine treatment, andproper advice as to precautions. On the occurrenceof a focus of indigenous malaria (defined as

two or more cases contracted within the district)the local authority may be required by theLocal Government Board to appoint and pay anapproved medical practitioner for house-to-house

visits, collection of blood films, and supervision ofhousehold precautions. Section 130 of the PublicHealth Act of 1875, under which this Order is

made, was introduced into that Act with the specialobject of taking emergency measures againstimported cholera, and it is interesting to see thatafter this lapse of time it has proved possible toutilise this section to provide a code of actionwhich is based on scientific knowledge of the

prevention of the diseases now in question. The

application of the regulations evidently calls forclose expert guidance from the centre if they areto be most effectively used. Medical officers ofhealth will need the advice of those who have

specialised in the study of diseases such as malariaand dysentery or have special knowledge of the

bacteriology of carriers. It is presumably withthis object that the Order requires each individualcase of trench fever, typhus, relapsing fever, ormalaria of indigenous origin to be reported at onceby the medical officer of health to the Local Govern-ment Board, as well as any outbreak of dysentery.The effect of the Order in practice has yet to beascertained, but it is evident that its success willlargely depend on the opportunities afforded to theepidemiologists of the Local Government Boardor of the future Ministry of Health to observeand direct its working. But the spade-work, thediagnosis, will have to be done by the generalpractitioner, and for shilling fees, unless the publicconscience is aroused at the degrading discrepancybetween the size of the payment and the import-ance and responsibility of the judgment which setsthis official machinery in motion.

A Tuberculosis Service.THE meeting held at the Royal Society of

Medicine on Saturday last to consider a scheme forthe formation of a complete and self-containedtuberculosis service was not a large one, but itwas widely representative of the various branches oftuberculosis practice. The meeting was summonedby the Tuberculosis Society, which had previously

circulated a draft scheme amongst its members,and this draft, after some modification in detail, waspassed substantially in the form submitted by theunanimous vote of those present. Accordingly, adeputation was arranged to wait upon the PrimeMinister and the Minister in charge of the Ministryof Health Bill. The scheme, which we print infull on p. 310, asks for a special department ofthe Ministry of Health to deal with the preventionand treatment of tuberculosis. It asks that the

personnel of this department should include medicalcommissioners, filled from the ranks of the tuber-culosis service, who, along with other commissionersappointed by the Crown on account of their specialknowledge and experience, should advise a com-mittee representing medicine, the public healthservices, local authorities, the Ministry of Pensions,trade unions, Friendly Societies, and other organi-sations interested in social welfare. No doubt willarise in regard to the need for cooperation amongall these agencies. The work of controlling tuber-culosis has been hampered in one district by lackof funds, in another by deficient resident accom-modation, in a third by want of any organi.sation for after-care, in a fourth by apathyon the part of the public health authority,and in a fifth by failure to cooperate with thegeneral practitioner. All these defects must beremedied if success is to be achieved.But while admitting the necessity for cooperation

in all branches of tuberculosis work, the amateuradministrator might argue, with some show of

reason, that no far-reaching scheme of preventionand treatment should be organised from top to

bottom, from patient to Government department,for the sake of one pathogenic organism. Surely,he would say, the Pfeiffer bacillus or the pneumo-coccus or the new filter-passer has a similar claimto a special anti-service. But in practice, tuberculosisis a special case. It is a life-long infecting agent ofrelatively low infective power, raising problems ofprevention and treatment which exist side by sideand must be dealt with concurrently. Tuber-culosis seems, in fact, to provide at present themost promising field for that combination of clinicaland administrative service for the development ofwhich all eyes are turned towards the Ministry ofHealth. The mechanism of such a tuberculosisservice may in the future be found applicable toother than the white plague. If so, pneumonia andinfluenza, standing as they do in such close relationto the problems of tuberculosis, might then be asso-ciated with it. But that is no reason for hesitatingto make a beginning with the coordination ofmeasures against tuberculosis.Granted that a special tuberculosis service has

its justification at the present time, it is no lesscertain that its relation to the general publichealth service must be an intimate one, closer

perhaps than Saturday’s meeting had in mind.There may be, it is true, a certain number ofmedical officers of health who are inclined to treatthe tuberculosis officer as a clinical tyro; there maybe also inexperienced tuberculosis officers with beesin their bonnets, whose acquaintance with the waysof local authorities and with the mechanism neces-

305

sary to deal with social conditions leaves somethingto be desired. It is obviously expedient to makethe tuberculosis officer responsible for the adminis-tration of his own special work; but when all is said and done it would be impossible forhim alone to provide those large measures

of reconstruction-clean streets, open spaces,

proper housing-which are destined to play sucha large part in raising the standard of publichealth on which the prevention of all disease largelydepends. The tuberculosis problem will not besolved by working in a water-tight compartment.The spirit of the times is against it. Any such pro-posal would be reactionary, not reconstructive. Wesee little hope of lasting benefit from any schemewhich does not make the local authority (whethercounty or county borough) the coordinating centreof all hygienic and social measures in its own area.There is a movement on foot to enlarge the PublicHealth Service along the lines of the proposedchanges in the constitution of the Society ofMedical Officers of Health. This is more urgentat the moment than scales of salaries and

commissionerships.

Annotations.THE RETURN OF INFLUENZA.

11 No quid nimis."

To speak of the return of influenza is to implythat this multiform, obstinate, and in manydirections mysterious epidemic, whose manifesta-tions among us at two epochs in 1918 were so

serious, had definitely gone, and this, we are certain,should not be assumed. We have not enough know-ledge. Major Astor, Parliamentary Secretary to theLocal Government Board, stated in the House onTuesday last, in reply to a question, that influenzamay be combated by continuous research and intel-ligence work: until such endeavours have bornefruit, it must be impossible to say for certain eitherhow long the infection of influenza may lingerin a community, or what are the circumstanceswhich conduce to its quick removal or to its longpersistence. Many of these circumstances are

assuredly common to the natural history of all

epidemic visitations, but it is proven, if only by thediffering views of expert pathologists, that in thecase of influenza we do not yet know the wholestory. What, for example, induces changes in age-incidence ? -? And how far is immunity conferred byprevious attack or other pathological conditions ?The extent to which the disease is now prevalentamong us can be gauged from sporadic reports, aswell as from such definite figures as those furnishedin our summary of vital statistics (see p. 311), andundoubtedly many communities are faced with areturn of the troubles which they were experienc-ing last autumn. While medical men are workingalong useful lines for prevention and with thera-peutic methods which sore experience has per-fected, it is the duty of the public to avoid as far aspossible the spread of the mischief. The localhealth authorities may take steps for lessening thepublic opportunities of infection, but they will beuseless till the public is ready to institute for them-selves a system of domestic inspection by which prompt medical attention is obtained. Where the

public is intelligent the medical service, public andprivate, becomes doubly efficacious, while remark-able results have been and will be obtained fromintelligent nursing. How many serious cases havebeen saved, and how many less serious cases havebeen lost, by the respective presence or absence ofthe competent nurse would be a bold piece ofguessing, but, without attempting any exact reply,we are convinced, on the numerous reports whichwe have received, that when influenza has got adefinite hold upon a patient it is the nurse, andanxious domestic care, which turn the scale mostfrequently in the patient’s favour. Major Astorstated the intention of the Local Government Boardand other bodies to assist in the provision ofmedical nursing and domestic aid to those attacked,and any activity displayed along this line will befully rewarded. Research work has been proceed-ing for a long time in the hands of many observers,and the medical officers of the Local GovernmentBoard are at the present moment in active coopera-tion with other experts outside the Department bymeans of a committee which meets at short andregular intervals. All this is most valuable for

the direction of preventive measures, both now andin future epidemics; but, in the place where we standto-day, the two urgent things are the assistanceof the medical man by the intelligent cooperationof the public, and the assistance of the patient bythe provision of adequate nursing. A memorandumwill be issued by the Local Government Board thisweek recommending the steps which should betaken by the local authorities and also by thepublic. This memorandum, we understand, will beof a practical nature..

COÖRDINATION OF MEDICAL SERVICE: SIR

GEORGE NEWMAN’S APPOINTMENT.

Sir George Newman, Chief Medical Officer of theBoard of Education, has been appointed PrincipalMedical Officer to the Local Government Board,retaining his position at the Board of Education,where he is also Medical Assessor to the Uni-versities Branch of the Board. The post of

Principal Medical Officer to the Local Govern-ment Board is a new one, and Sir George Newmanwill have the position of a Secretary of theBoard with administrative duties and responsi-bilities in respect of the work of his depart-ment. It should be clearly understood thatthis is not the post of " Medical Officer " whichwas recently held by Sir Arthur Newsholme.Nothing in the new appointment, we are glad tosay, prevents the existing medical staff of theLocal Government Board, who have been bearingthe burden within the department of the publicsanitary service, from being advanced to a post ofthe same standing, if not with the same title, asthat recently vacated by Sir Arthur Newsholme.The appointment of Sir George Newman as prin-cipal medical officer of the Board is a directstep towards that coordination of public medicalservice, which has been stated to be the primaryobject of the Ministry of Health. Sir GeorgeNewman has had practical experience, both urbanand rural, in the work of the medical officer ofhealth, while he is a recognised authority in schoolhygiene. Moreover, in all questions of medical andeducational administration he has shown himselfon the side of the general practitioner, recognisingthat a medical department can only be run satis-factorily from the top if the real executive, the