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Services by Medical Officers ofHealth to Military Authorities.

THE LANCET.

LONDON : SATURDAY, OCTOBER 31, 1914.

As a result of the issue of the War Office andLocal Government Board directions, to which wereferred last week, medical officers of health haveconsidered the position which they are asked bythe Government to occupy in relation to troopsstationed in their areas. The duties enumeratedare at first sight rather formidable. They coversuch matters as the distribution of troops in

billets, the sanitation of camps, the sufficiency andpurity of water-supplies, and provision for casesof infectious disease among the military popula-tion. Medical officers of health who have in the

past paid little attention to military hygienemay well at the beginning feel doubtful both of thevalue of the assistance which they can give, andof the reception which any proposals which

they make may receive from commanding officersor from their colleagues on the Army MedicalStaff. With regard to the latter situation cases

have already been brought to our notice in whichthe medical officer of health has not found his

appearance on the scene or his offers of assistancewell received. All such difficulties, however, shouldnow be effectively removed by the new official

directions. The question whether the medical

officer of health has any right of entry under PublicHealthActs on military premises does not now arise.He is officially regarded as a local expert officer onthe spot whose assistance is to be invited by the mili-tary, and he is given authorityto report serious condi-tions affecting the health of the troops in his district,both to the War Office and to the Local GovernmentBoard.As to the work required, medical officers of

health are unlikely to go far wrong if they apply tothe new environment the general principles of

their civil action. Military conditions do not

affect the underlying facts of infection and ill-

health resulting from overcrowding, accumulationsof refuse, excretal nuisances, presence of flies and

vermin, or absence of general cleanliness. The

remedy may be somewhat different in application,and standards may in some cases have to be morelenient and in others more strict. Sufficient guideon the orthodox views in these matters is, how-ever, to hand in the admirable little manual of

military hygiene issued by the War Office, and local Icircumstances will often enable new departures to ’,be made with excellent results, as may already beseen in the arrangements for water-supply, latrines,

and scavenging which have been extemporisedin some of the provincial towns which are

now occupied by billeted troops. One of themost important of the duties which theLocal Government Board has placed on themedical officer of health is that of ascertaining andbringing to the notice of the local authority, forimmediate action, any public services which thatauthority can render to the troops. Many suchservices at once suggest themselves: opening publicbaths, giving facilities for washing clothes, lendingmunicipal clinics or dispensaries for the examina-tion of recruits, providing evening recreation rooms,disinfecting clothing and blankets, and similar

matters. The occasion should be taken also to remedyany defects in the ordinary sanitary services of thedistrict and to cooperate with the military authori-ties in preventing the use of unsuitable or

dangerous quarters for billeting. Isolation hospitalaccommodation should be seen to, and if necessaryenlarged, and bakehouses, slaughter-houses, or

other places used for the preparation of food for thetroops should receive special attention.In many of the important centres where troops

are aggregated the new directions will be almostsuperfluous. Much of the work specified was

begun at once after the outbreak of the war, with-out waiting for official warrant, and we believe thatthe local sanitary authorities have seldom beenappealed to in vain for any practical assistance whichthey can give in the national emergency. It shouldbe recognised also that in many instances, as inLondon, Territorial troops have had the advantageof including in their organisation medical officersof health and others who, as sanitary officersfor divisions or smaller units, have themselves

since their mobilisation taken such vigorousmeasures for the health of the soldiers under their

charge as to leave very little to be supplementedby work under the new scheme. The latter, if weproperly understand its intention, does not in

any way remove the responsibility of the militarymedical service in matters affecting the health of thetroops, and much military hygiene is work whichcannot be done on outside advice, however good.The education of the individual soldier in the

proper care of his person and environment in

particular is daily work for the execution of whichthe army must look to its own medical service.The new troops have had to draw for theirmedical officers on men untrained in militarywork, and it is of first importance that they,like their colleagues in the regular service, shoulddevote:themselves not only to the care of sick andwounded, but also to the study of all matters

affecting the daily life of the soldier, and be readywith confidence to give advice to all ranks whichmake for health and efficiency, and be fearless inforwarding to higher authority reports of deficiencieswhich in their opinion ought to be remedied.With information thus coming to army head-

quarters from both the military and civil sides,with local cooperation and goodwill in every locality

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where troops are quartered, and with increasingappreciation by combatant oflicers of the import-ance of health considerations, the outlook will besatisfactory if the individuals play their allottedpart. And this we make no doubt they will do.The Sanitary Committee now appointed by the WarOffice should have its task appreciably lightenedby the existence of the new scheme, the workingof which can be periodically watched and supple-mented under the advice of the Committee as

experience is gained. The personnel of this Com-mittee is announced on page 1069.

The Graduated Labour Treatmentof Pulmonary Tuberculosis.

WE have received a copy of an interesting reporton the after-histories of patients discharged fromthe Brompton Hospital Sanatorium at Frimley inSurrey during the years 1905-1910. The report hasbeen issued by four of the physicians to the

Brompton Hospital who are or have been visitingphysicians to the sanatorium-Dr. S. H. HABERSHON,Dr. F. J. WETHERED, Dr. P. HORTON-SMITH HARTLEY,and Dr. J. J. PERKINS, and the medical superintendentof the sanatorium, Dr. W. 0. MEEK. The sanatoriumwas formally opened on June 25th, 1904, but

it was not until the following year thatthe institution was in full working order. The

statistics accordingly refer to the period March 8th,1905, to Dec. 31st, 1910. The sanatorium was

originally intended for 100 patients, but in 1908 thebeds were increased in number, and at the presenttime there is accommodation for 148 patientsIn arriving at a conclusion as to the result of thetreatment carried out at Frimley it is important tobear certain points in mind. The great majorityof the patients have passed through the wards

of the Brompton Hospital in London, whenceif found suitable after a period of observation

they have been drafted on to the sanatorium.The patients were not taken at random, but

were carefully selected, only those patients beingchosen who were free from fever or other seriousconstitutional symptoms, who possessed consider-able vitality, and had already shown indications ofa favourable response to treatment. So far as

possible also patients with signs of limited diseasewere selected, although it was soon found that

patients with extensive disease, but of a quiescenttype, often did remarkably well. In other words,more importance lies in whether auto-inoculationis, or is not, easily induced than in the pathologicalstage of the disease. Only those individualsshould be placed on graduated labour who

can take a fair amount of exercise without

exciting undue febrile response. Another pointon which the physicians at Brompton lay stress

is the likelihood of the patient obtaining workupon his discharge from the institution, and

it early became apparent that if the patient had nowork to return to after leaving the sanatorium he

would almost certainly relapse quickly throughinability to obtain adequate nourishment. In the

introduction to the report attention is rightlydrawn to the conditions under which patients aresent to Frimley, for, as the physicians remark, itwould be a mistake to suppose that the results

obtained there in regard to the arrest of

the disease and prolongation of life give anyaccurate index of the economic results which

might be expected if all cases of tuberculosis of thelungs were sent haphazard to sanatoriums. We are

glad to see stress laid on this point; emphasismust be given to the fact that graduated labourtreatment is only suitable for a certain class of

case, and would be the reverse of beneficial if all

patients suffering from pulmonary tuberculosis weresubmitted to the regime. In the early days of

sanatorium treatment the idea arose that it wassuitable for every variety and stage of the disease,hence much disappointment arose, and the methodsadopted at Frimley would suffer a like disrepute ifa careful selection was not made.The report deals with the details of the treatment

which are now known to the profession at large.Elaborate statistical tables, admirably drawn out,are given to demonstrate the results achieved.The total number of patients discharged duringthe six years covered by the report was 1892. The

patients were communicated with at periodicalintervals after they were discharged, and the resultsare based on the after-histories of 1674 of these

cases, the remaining 218 being accounted for by 64who only remained for a few days in the sanatorium,91 in whom a diagnosis of pulmonary tuberculosiscould not definitely be made, 19 who had sufferedfrom pleurisy with effusion but without definiteevidence of pulmonary involvement, 24 admittedfor a second period of treatment, and 10 who diedin the sanatorium. The object of the report is

stated to be to show the proportion of the 1674patients who during each year following their

discharge have been (a) well and able to

work; (b) alive; (c) known to be dead; and (d)lost sight of. Further, in order to render thestatistics more reliable in each year the patientsin whose sputum acid-fast bacilli were foundare tabulated separately from those in whose

sputum such bacilli were not present. This is

a course highly to be commended, for a consider-able number of physicians who have had a largeexperience in that disease are convinced thatthe only pathognomonic test for pulmonarytuberculosis is the demonstration of tuberclebacilli in the sputum. We strongly support thoseauthorities who maintain that the results of anysupposed treatment for the disease based upon casesin which the bacilli have not been so found aretoo fallacious to be of any value. The cases

are classified from the clinical aspect, accordingto the number of lobes in which physical signsof disease were found on or shortly after theiradmission to the sanatorium. The statisticaltables are divided into three series. The first deals