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MINISTRY OF HEALTH.ANNUAL REPORT OF THE CHIEF MEDICAL

OFFICER, 1927.

Sir George Newman reviews the state of the publichealth in England under 14 headings. His intro-ductory chapter deals with population, births anddeaths, notifiable infectious diseases, sickness andinvalidity. Sections follow on General Epidemiology,Tuberculosis, Venereal Disease, Cancer, Maternityand Child Welfare, the Insurance Medical Service,Relation of Food to Health and Disease, MedicalIntelligence and Environmental Hygiene, AcuteRheumatism, Light Therapy, International Healthand Health Education. He then summarises therecord of ] 927 with appropriate comments and suppliesas appendices statistical tables and a list of the

personnel of his department.The principal facts concerning the physical life

and health of the people in England and Wales duringthe year under review were the birth-rate of16-6, the lowest on record ; the death-rate of 12-3 per1000, of which deaths 36-4 per cent. occurred under50 years of age, and an infant mortality-rate of 70 per1000 births, being the same as in 1926. The chiefcauses of death in order of mortality were diseases ofthe heart and circulation (201 per 1000 deaths),bronchitis, pneumonia and other respiratory diseases(157); cancer (111) ; diseases of the nervous system(90) and all forms of tuberculosis (79). These fiveconditions are together responsible for 64 per cent. ofthe death-rate, and it is against them even more thanagainst the epidemics feared by our grandparents thatbattle has to be waged. It is impossible to compressall Sir George Newman’s views and hopes for theimprovement of the public health into small space,but it seems desirable to ascertain what he has tosay as to the prevention and treatment of thesedevastating diseases.

. PREVENTION OF DISEASES OF HEART ANDCIRCULATION.

Acute rheumatism and syphilis are the diseases whosesequelae are responsible for many of the deathsdirectly due to lesions of the circulatory system. It ispertinent to inquire what steps are being taken underthe auspices of the Ministry to combat rheumaticinfections and venereal diseases.

Acute Rheumatism.Sir George Newman holds that a general compulsory

notification of acute rheumatism would probably beimpracticable at the present time in view of thedifficulties of exact definitions, but that a validcase can be made out for the experimental trialof a system of compulsory notification for a definiteperiod of years in selected districts where housing andother records are readily available, where an efficientmachinery exists for investigating the cases notified,and where institutional accommodation can beobtained. These conditions are fulfilled in Paddingtonand Kensington, where acute rheumatism in childrenunder 16 years of age is now notifiable.The Paddington scheme of compulsory notification

came into force on March 1st, 1927, but the Rheuma-tism Supervisory Centre at the Paddington GreenChildren’s Hospital, under Dr. Reginald Miller, hadbeen opened on Oct. 9th of the previous year, and Dr.Miller and Dr. M. Sanderson have published a reportshowing the working of the centre during the first year.The number of cases dealt with was 175, of which six

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were judged to be definitely non-rheumatic ; and of theremainder (169) only seven seem to have been notifiedunder the compulsory notification system in forcein Paddington, the rest being referred through thehospital, school medical service, or coming from adjoiningareas. Of the 169 cases 13, or only 8 per cent., showed activerheumatic infection ; 51, or 30 per cent., showed potentialand mild rheumatism ; whilst 105, or 68 per cent. showedquiescent rheumatic infection at their first attendance.This classification will show the extreme difficulty ofattempting differentiation. The observation, super-

vision. and treatment of children in the earliest stagesof rheumatic infection with a view to studying thefirst appearance of serious disease, and the preventionof heart disease are regarded as the most importantfunctions of this centre.The Kensington scheme commenced on Oct. lst,

1927, the rheumatic centre being situated at the newPrincess Louise Hospital, under the direction of Dr.R. C. Lightwood.

Investigation is being made into environmental factorssuch as locality, housing (with special reference to dampness),family incidence, social position and the conditions of schoollife, and into certain clinical factors. especially the effect oftonsillectomy and institutional treatment, and into thesignificance of certain physical signs in connexion with acuterheumatism.

In the West of England a scheme for the prevention,treatment, and research into setiological factors ofrheumatism is in process of evolution. The areacovered by its activities will be the counties ofGloucester, Somerset, and Wiltshire, and the cities ofBristol and Bath.Work is to be directed towards accumulating more

accurate information as to the distribution of heart diseaseof rheumatic origin, studying aetiological factors of the disease,providing expert examination and diagnosis for cases ofheart disease in children, and obtaining information as to theneed for institutional or other specialised types of treatment.The central coordinating agency is a cardiac clinicat the General Hospital at Bristol, in charge of DrCarey Coombs.The accommodation in England for children suffering

from this disease is strictly limited. The MetropolitanAsylums Board provides 230 beds, the InvalidChildren’s Aid Association 46 beds (and 85 for conva-lescent heart cases), the Birmingham Local EducationAuthority 90 beds.l Thus something is being doneto stem the tide of this vast burden of disease, but, asSir George Newman says, it is not enough. The needis urgent and the continuance of this widespread anddisabling condition is impairing the strength of thenation. There is a pressing need for coordinated.action for the thorough and continuous investigationof this malady in all its forms, and then for a well-devised and systematic attack upon it.

In this connexion Sir George Newman calls attentionto the reports published by the Ministry on (1) Inci-dence of Rheumatic Disease, and (2) AcuteRheumatismin Children, respectively reviewed in THE LANCET ofMarch 1st, 1924 (p. 451), and July 30th, 1927 (p. 245).

Venereal Disease.At the close of 1927 the number of V.D. treatment

centres was 186—viz., 177 in England and 9 in Wales.The number of sessions averaged 780 weekly, of which549 were in voluntary hospitals, 158 in special premises,and 73 elsewhere. The number of centres at whichattendance can be made at any time of the day orevening was five. It is hoped that three more centreswill be reorganised during the present year to providethese all-day facilities. Besides the treatment providedat the regular centres special arrangements exist at11 maternity and child welfare centres by whichwomen and children discovered to be suffering fromgonorrhoea or syphilis can be treated there. Thenumber of hostels for the care of girls suffering fromvenereal diseases was 14 and the number of casesmaintained in them in 1927 was 895 as compared with903 in 1926. There are eight institutions for the

reception of pregnant women suffering from venerealdiseases, and there is similar provision in ten of thehostels mentioned above. Included among thesehostels there is one special institution for the care ofchildren suffering from gonorrhoeal vulvo-vaginitis,or from congenital syphilis, and the number of casestreated there in 1927 was 51. The number of medicalofficers, either whole or part-time, employed at the186 centres was 389. The number of laboratoriesapproved for pathological tests in connexion withdiagnosis was 76, and the total number of tests

1 This accommodation is being extended by the provision of350 additional beds at Carshalton (see THE LANCET,Oct. 20th, p. 829),and by some 20 beds at Cardiff (see p. 896).ED.L..

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carried out for treatment centres and practitionerswas 308,408. The returns from venereal diseasetreatment centres for 1927 show a 3-7 per cent.increase in the new cases of syphilis, a 9.1 per cent.increase in those of gonorrhoea. The number of thosewho attended for advice on the suspicion that theywere suffering from venereal disease again increased,indicating the continued popularity of the centres, whilethe attendances, an inverse index of defaulting beforecompletion of treatment, were, in 1927, 46-4 per cent.more than in 1920, though the total new cases were17,049 (16-2 per cent.) less than in 1920 and the totalnew cases diagnosed as venereal disease were 22,831(26-7 per cent.) less.The Avoidance of Relapse.-An analysis of results of treat-

ment of male cases of syphilis at the St. Thomas’s HospitalTreatment Centre shows clearly that even in primary casesin which serum reactions have not yet become positive lessthan two courses of ten injections each of " 914 " (orequivalent in other arsenobenzene compounds) and ofbismuth or mercury totalling approximately 6 g. " 914 "

and 3 g. bismuth results in too high a percentage of relapses,while three such courses are barely sufficient for early casesin which the blood reactions have become positive. Theanalysis shows clearly, also, the great advantage of com-mencing treatment whilst the serum reactions are stillnegative.

The Question of Compulsory Treatment.Notification was originally introduced in connexion

with acute infectious diseases and was primarilydesigned to give information which would allow thehealth authorities to take action to protect the public.These diseases were of relatively short duration andthe period of infectiousness could be predicted withfair accuracy. When one considers statutory notifica-tion in connexion with the more chronic communicablediseases, such as tuberculosis and venereal disease, itis clear that quite different considerations arise.The conveyance of infection in venereal disease usually

implies special circumstances, sexual intercourse, &c., andthese diseases are not comparable in this respect with theordinary notifiable infectious diseases. Then again there isa social relationship and stigma in the case of venerealdisease which causes reluctance on the part of medicalpractitioners to certify venereal disease. The existence of asystem of notification is also only too likely to lead patientsto conceal their condition as long as possible and haverecourse to " quacks " (who will promise secrecy) instead ofobtaining sound medical advice promptly or attendingclinics or hospitals. Moreover, notification may inflict someinjustice, and perhaps even irreparable social harm, uponinnocent individuals or families. Again, syphilis and gonor-rhoea are diseases which may be greatly prolonged in theindividual, and pass through various stages or degrees ofhistory, severity, and infectivity, and hence it might beimpracticable to define the stage of disease which should be Inotifiable. On the whole, therefore, it has hitherto beendeemed inexpedient to introduce a compulsory system ofnotification of venereal disease.

It is not infrequently suggested that the localauthority should have powers of compulsory treatmentof venereal disease, particularly in the case of personswho have begun treatment without finishing it. Ifofficial notification be an incentive to concealment anda deterrent to effective treatment, a fortiori is thistrue of compulsory treatment.

Defaulters.- It is alleged that " defaulters " shouldat least be compelled to continue their treatment forvenereal disease. In England it is estimated thatabout one-third of the persons who submit themselvesfor treatment fail to continue it to the final stage ofcure. The question is not as simple as it appears.After all, what is a defaulter ? In any given com-munity the persons suffering from venereal disease fallinto three groups : (1) those who submit to completetreatment, (2) those who submit to partial treatment,(3) those who are not treated at all. It seems clearthat all the persons who submit to partial treatment,and still more those who are not treated at all, arein fact the defaulters, that is to say, they do not submitthemselves to complete treatment. But it must beremembered that the complete treatment of syphilisby salvarsan is a prolonged and serious undertaking ;the patient may well be kept under supervision for twoor even three years. At what stage in this long

process of treatment can it fairly be said that a patientdefaults in the sense that lie has become a danger tothe community ?

There is a further question which will occur to us, Howfar does such defaulting take place in the treatment of otherdiseases ? How many patients suffering from other maladiesalways complete the treatment prescribed for them ? Howmany persons with unsound teeth default in dental treat-ment ? How many unfinished medicines repose in domesticcupboards ? How many defaulters are there for operationfor adenoids, or for rheumatism, for tuberculosis, or forcancer ? It is necessary to view this question of defaultcircumspectly and consider its bearings in regard to socialconditions as well as medical and surgical treatment generally.The cause of default in prolonged treatment must first beestablished-the disease may have been remedied, or thepatient may be dead, or have left the district, or prohibitivecircumstances may have arisen to prevent the continuationof treatment. Again, compulsory treatment by the Stateimplies guarantees of cure, which cannot be given ; and suchcompulsory treatment must entail no risks of life or injury.

These are the general grounds which have hithertoimposed serious limitations on any proposal for thecompulsory treatment of disease. In the particulardisease of syphilis there is a further issue, for the onlyjustification for any form of compulsion would be anassurance that compulsory treatment of the individualensured the protection of the public from the risk ofinfection by him. On this we must remember, first,that long before the syphilitic defaulter can be declaredcompletely cured he has, in nearly all cases, becomenon-infective ; secondly, that syphilis infection is notusually conveyed through ordinarv social life, but onlyby direct and particular sexual intercourse ; and,lastly, any compulsory treatment, to be effective uponthe community, must be applied to all cases ofvenereal disease and not to those only who havecommenced but failed to complete treatment. Itseems at present impracticable to fulfil these conditions.

(To be continued.)

IRELAND.

(FROM OUR OWN CORRESPONDENT.)

The Ceimorshiln of Publications.THE second reading of the Censorship of Publica-

tions Bill was under discussion in the Dail last week,on the motion of Mr. FitzGerald-Kenney, Minister forJustice. The principal provisions of the Bill were givenin these columns some weeks ago.1 From the Minister’sstatement it appears that the Bill is not intended tocover so wide a ground as its actual wording suggests.The words in the Bill in reference to a book or

edition that " it is indecent or obscene or tends toinculcate principles contrary to public morality or isotherwise of such character that the sale or distributionthereof is or tends to be injurious or detrimental toor subversive of public morality," are taken by theordinary reader to signify grounds of complaint onother grounds than of indecency or immorality merelyin regard to sexual matters. The Minister stated thatthe Bill would only deal with indecency or immoralityin respect of sexual matters, and promised to add suchwords to the Bill as would make this limitation clear.Had the Bill been clearly drafted in the first instancein this essential clause, much of the opposition rousedby the wider interpretation would have been avoided.The clause was universally read as bringing expressionsof opinion on philosophical, sociological, and even ’religious matters within the purview of the BillThe definition of the term " indecent " as including" calculated to excite sexual passion or to suggest or

incite to sexual immorality or in any other way tocorrupt or deprave " has given rise to much criticism.The last words render the definition so wide that theCensorship Board could bring under it anything thatthey disliked or of which they disapproved. Moreover,it is pointed out that sexual passion is not immoral,unless wrongly directed, and that to declare indecentanything which may excite sexual passion is unjusti-fied. (One critic, indeed, had suggested that the

1 THE LANCET, August 18th, p. 354.