310

THE LANCET.

LONDON: SATURDAY, JANUARY 29,1910.

Report of the Medical Officer of

the Local Government Board

for 1908-09: InterestingFigures.

THE most noteworthy feature of this report is that it takes

a broader and more comprehensive view of preventivemedicine than has hitherto been the case. An investigationinto the prevalence of hernia is not a subject which, so far aswe are aware, has up to the present attracted much attention

from medical officers of health, but this fact is in itself

obviously no justification for abstaining from considerationof a condition which, especially in certain age groups and

among certain classes, is responsible for a large amountof disability and inefficiency ; and preventive medicine

liberally interpreted has as much concern with the

production of efficiency as it has with the prevention andlimitation of a few communicable diseases ; and this is

surely the whole spirit of the most recent development of pre-ventive medicine-the medical inspection of school children.Dr. ARTHUR NEWSHOLME, the’principal medical officer to theLocal Government Board, in his introduction to the reportmakes some very interesting observations upon the generaldeath-rates of different sections of the community, and he

prefaces his comments by pointing out the inconveniencewhich arises from the fact that the annual reports of the

Registrar-General do not furnish the vital statistics for

separate sanitary areas, those for registration counties

and districts being alone given, and it is but rarely thatthe registration and sanitary areas coincide with one

another. We have pointed out recently, in reviewingthe report of the new Registrar-General for 1908, that

Mr. BERNARD MALLET thinks it may in future be possibleexcept as regards the smaller districts, to redistribute

the returns according to administrative areas, as the

area of collection does not necessarily govern that of

presentation. Dr. NEWSHOLME takes for consideration the provisional

statistics which are contained in the Registrar-General’sannual summary and which relate to 29 metropolitanboroughs, 76 large towns, - and 142 smaller towns.

Although these statistics relate to only 247 out of 1789,im so far as districts are concerned, they have referencein the matter of population to more than 21,000,000 of thetotal 35,000,000 which England and Wales were estimated

1 THE LANCET, Jan. 1st, 1910, 1910, p. 3.

to comprise in 1908. Over 16,000,000 of the total 21,000,000spend their lives under the conditions which obtain in the76 great towns, inclusive of the metropolis, which have eacha population of over 50,000, while the remainder live in

142 smaller towns with populations ranging from 20,000 to50,000. The general death-rate during 1908 of the countryas a whole was 14 . 7 per 1000, while the death-rate (correctedfor age and sex distribution) per 1000 of population in eachinstance of the 76 great towns, with London, was 15 8 ; ofthe 142 smaller towns 14-7; and among the 14,000,000people living in the smaller urban and in the rural districtsit was 13.8.2 Having given these figures Dr. NEWSHOLMEdraws attention to the disparities in the death-rates amongstthe 21,000,000 comprised in the metropolis and in the 217

provincial towns already referred to. Of these, 2 per cent.

(about 398,000) had a death-rate-per 1000 in each case-under 10 ; 16.8 per cent. of 10 0 to 12-5 ; 33. 5 per cent. of12-5 to 15-0 ; 29-4 per cent. of 15- 0 to 17 ; 18-3 per cent. of17 - 5 to 20 - 0and 0-3 per cent. of over 20. It is then pointedout that had the towns referred to had a death-rate of 13. g

per 1000, which was the average death-rate of the 14,000,000people living under the conditions existing in the remainderof England and Wales, the total number of deaths in the

country for 1908 would have been 33,831 fewer than wasactually the case. Dr. NEWSHOLME regards this savingof life as attainable, and he draws attention to the fact

that the death-rate in towns of very various sizes and

having together a population of over 4,000,000 was under12’ 5 per 1000. It is an admirable notion to put a

concrete view of this sort before the public, and the ideal

suggested raises most interesting issues as to practica-bility and cost. We shall doubtless see the subject dis-cussed in fuller detail in subsequent annual reports, and

a differential analysis will be made of all the causes of

death in the several groups alluded to. It is important to remember that the figures are already corrected for age andsex distribution, and thus that one important statistical

fallacy has been removed. The difficulty in the fascinatingstudy of death-rates is to ascertain to what extent the

differences are due to purely social conditions and to whatextent they are attributable to conditions which may be

fairly regarded as within the scope of public health. Prob-

ably it will be found practicable to study the precise con-ditions existing in certain typical towns of each class byway of securing some sort of standard data ; while as

regards distinction between purely social and purely publichealth influences is it not impossible to draw any hard andfast lines, for are not these factors inextricably bound

up with one another? 2 But is it not true also that amongthe most potent social forces of the present day is that

which is exercised through the agency of sanitary reform ? ?Dr. NEWSHOLME makes a somewhat similar comparison

with reference to infantile mortality-rates, and, dealing withthe same populations as before, he shows that 6. 2 per cent.had an infantile mortality per 1000 births of 90; 9 per cent.of 90 to 100 ; 12 - 7 per cent. of 100 to 110 ; 8’8 8 per -cent. of110 to 120 ; 11-6 per cent. of 120 to 130 ; 15-5 5 per cent. of130 to 140 ; 20-3 per cent. of 140 to 150 ; and 15-9 per cent. of

over 150 ; and he draws attention to the fact that if the same2 Compare provisional figures for 1909 on p. 326.

311

rate of infantile mortality as obtained in the rest of this

country prevailed amongst the 21,000,000 to which the above

figures relate there would have been 9959 fewer deaths than

actually occurred. That the high infantile mortality whichat present exists in many parts of the country can be verysubstantially reduced is a question which admits of no doubtwhatever; and the work of Dr. E. W. HOPE, who foundin Liverpool that the personnel of the parents was a verydominant factor in promoting or reducing infantile mor-

tality, holds out promises in this direction. The Notifica-

tion of Births Act-a measure which the medical professioncan, for obvious reasons, be only half pleased with-andthe systematic employment of tactful and well-trained

health visitors, will assist in the performance of these

promises. And as to both these points, the report beforens contains some instructive details. Of the total popula-tion of 21,000,000 dealt with above, districts comprisinga population of nearly 13,000,000 have already adopted thestatute in question, and in those districts which have doneso there are at work some 115 health visitors. In the

near future this number will no doubt undergo great ex-

pansion, more especially as, through the teaching of hygienein schools and the work of medical inspection, the enormous

importance of preventive medicine becomes more fullyrealised by the public.We refer now only to one more point dealt with by

Dr. NEWSHOLME in his interesting report, and that is

the manner in which enteric fever has behaved in

Nottingham and Leicester respectively, for most importantgeneral lessons can be drawn from this comparison.Both towns some years ago possessed two features in

common: a conserving system of excrement disposal anda high death-rate from enteric fever. Nottingham hasmade but slow progress in the adoption of the water-carriage system; in Leicester the progress has been rapid. As

regards enteric fever, the death-rate in Nottingham is still

high, while that in Leicester has undergone a very markeddiminution. Dr. PHILIP BOOBBYER, the medical officer of !ihealth of Nottingham, has for many years past drawnattention to the association between enteric fever and

houses furnished with midden-privies or pail-closets as

eompared with those supplied with water-closets, buthis appeals have met with only a very partial response ; and as to the history of these two towns Dr. NEWSHOLME ’’,,writes: "A gigantic experiment has been performed on these two communities under circumstances which enable

fairly trustworthy comparison to be made ; and at the

present time it remains, then, that in Nottingham a largenumber of deaths from diarrhoea and from enteric fever are

occurring year by year which would cease to occur were this

wity in every part of it to adopt, like Leicester, a more

cleanly system of disposal of excremental matter." We are

glad to hear that during 1908 the Local Government Boardcommunicated with various urban sanitary authorities urgingthem to use the powers which they possess for the conversion.f conservancy systems into water-carriage systems ; and innext year’s report we are promised some valuable data as totke rapidity of conversion which has taken place in differenttowns. Many other matters of interest in the report will beiiscasaed further in our columns.

The Difficulties of Dispensing.AT the conclusion of an inquest held on Jan. 4th at

Fulham the jury asked the coroner to lay the facts of thecase before the notice of the Home Secretary, 11 in order that

legislation providing for a distinctive form of bottle mightbe brought about." Regulations as to the methods of storingand dispensing poisons have been in existence more than 40

years. They were framed by the Pharmaceutical Society, withthe consent of the Privy Council, and under an Act of Parlia-ment it is an offence to fail to comply with those regulations.The regulations are in all cases applicable to the shops of

dispensing chemists, but not to all medical practitionersof medicine who may happen to dispense drugs. For

Section XVI. of the Pharmacy Act, 1868, as all our readers

know, exempts from the first 15 sections of the Act any

"legally qualified apothecary," while shortly after this Actwas passed, the question having been raised whether medical

practitioners other than Licentiates of the Society of

Apothecaries were comprehended by these words, in orderto make the matter perfectly clear, an amending Bill wasintroduced into Parliament and passed in 1869. The intro-

duction of this Bill was mainly due to THE LANCET, and its

provisions specifically exempted all medical practitionersregistered at the time of the passing of the Act, and those

registered subsequently, who in order to obtain diplomasshall have passed an examination in pharmacy. It is

clear, therefore, that those practitioners are exemptedfrom the provisions of this Act who are Licentiates

of the Society of Apothecaries, who became registeredbefore August llth, 1869, or who have become registeredsince that date but have passed an examination in

pharmacy. There are comparatively few practitioners who

dispense their own medicines who have not passed such anexamination.

There are therefore few practitioners amenable to the

restrictions of the Pharmacy Act; but this fact in no

way lessens the obligation of medical men who dis-

pense to carry out the same methods of safety to the

public as if that Act was obligatory upon them. All

poisons should be properly stored and bottled, and

no poisonous preparations for external use should be

issued to patients in any but proper poison bottles. But

if the law imposes little "legal" responsibility on practi-tioners in the important matter of dispensing poisons, it

imposes none in the more difficult and responsible duty of

writing prescriptions. And while the medical man has direct

responsibilities with regard to dispensing, he has also indirectones of equal importance. He has to prescribe manypoisons, and it is his duty to do so with all care and

attention. Though there are traditional methods and formsfor writing prescriptions, the former have become of

late years too much neglected and the latter too much

abbreviated. We received some time ago a paper upon

the subject from Mr. DONALD McEWAN, read by him

before the Pharmaceutical Society of Great Britain, con-

taining many points bearing on this very situation upon

which comment may be useful to our readers. The

relationship between the prescriber of a formula and its

dispenser should never produce any difficulty, but it is