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THE LANCET.

LONDON: SATURDAY, DECEMBER 17, 1921. z

Municipal Health Services.As may be seen from a brief report in another

column, medical practitioners in Willesden have nowmet the executive committees of local associations of

ratepayers in a discussion of the health policy of theUrban District Council as set forth in the medicalofficer’s forty-fifth annual health report. Thememorandum,’ drawn up by a special committee ofthe B.M.A., Willesden division, criticising the Council’shealth policy, was before this meeting on Dec. 7th andformed the basis of discussion. No formal resolutionwas passed, but the tenor of opinion was in harmonywith Resolution 7 passed on Nov. 15th-viz.,

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Thedivision calls the attention of the Willesden rate-

payers to the health policy of their council, whichthreatens to destroy the freedom not only of themedical profession but of every individual in the

community, and urges the ratepayers strenuously tooppose at the next municipal election those who areresponsible for a policy which the medical professionof Willesden considers to be a serious and increasingmenace to the public health." Then the ratepayersinvited the doctors to cooperate in selecting muni-cipal candidates to oppose the existing health policy.Two medical men present at the meeting were willingto become such candidates. It was pointed out byone of the medical speakers that doctors unable toserve on the Council would be ready with theiradvice if coopted on the Health Committee. Alocal advisory medical council was suggested byanother speaker as the right agency for puttinghealth matters in the urban district upon right lines.Finally, the ratepayers expressed their appreciationof the opportunity afforded to them of conferring onlocal health problems with members of the medicalprofession, and they expressed a wish that such

opportunities should be encouraged. ."-

In Willesden it is the municipal hospital aroundwhich has centred the hottest part of the controversy.To this hospital the private practitioner has no

access, and it would therefore be fair to let theWillesden health service stand or fall by the successof this nearly unique experiment, provided thatthose who run it have had the materials to hand for

making it the success at which they were striving.A speaker at last week’s meeting spoke of this hospitalas a disgrace. But, as may be seen from the medicalsuperintendent’s annual statement, which appears onp. 85 of the health report, he had there to complain,in the same terms as a year ago, of a shortage of beds,of an inadequate nursing staff, and of insufficientmedical help. In the year 1920, with 199 availablebeds, 2608 patients were dealt with by a staff of51 nurses and two medical officers ; the sickness-rateamong the nurses was high, and at no time was therea clean bill of health among them ; the residentmedical officers were on duty seven days a week,with no break from year end to year end save forannual leave. In this hospital during the year 1920the following fever cases were admitted : Scarlet 445,diphtheria 605, other infections 63, including typhoid 8,infantile diarrhoea 16, and erysipelas 8. Pressure

1 THE LANCET, Nov. 26th, p. 1124.

upon the maternity beds was continuous ; 470 caseswere dealt with, as compared with 239 in the previousyear; complications included placenta praevia 6,contracted pelvis 5, eclampsia 2, pelvic inflamma-tion 5, sapraemia and septicaemia 10. Gynaecologicalcases numbered 81, including incomplete abortion 19,and acute mastitis 8. 524 anaesthetics were adminis-tered to operation cases, amongst them tonsillotomy340, phimosis 44, abscess and appendicectomy each19, for hernias of various forms 16. This amount ofwork is claimed to be equal to that ordinarily doneat a hospital double the size, and in the view of themedical superintendent it implies an enormous strainon the limited resources. It was alleged at lastweek’s meeting that most of the non-infectious casesmight have been treated at home. There are 72 bedsat the Willesden Hospital, and 330 occupied beds atthe infirmary in Acton-lane. London hospitals, itwas said at the meeting, were available for Willesdenpatients. The matter of hospital accommodation inWillesden is certainly one for the ratepayers to lookinto.The health policy of the Willesden Council raises

a profound question of principle which demandsbroad and statesmanlike handling. Preventive andcurative medicine are at bottom one and indivisible.There may appear to be one glory of the sun and oneglory of the moon, and the larger luminary sometimeshas its radiance completely obscured by the darkside of the smaller, but the source of light is the same.It is becoming a truism to insist that the generalpractitioner is now and always will be the chief

agent of preventive medicine. The preventist becomesall too readily a mere cataloguer of morbid conditionsin relation to certain lines of civic conduct. The

public vaccinator is the embodiment of business inthe prevention of small-pox, but what service wouldhe be to the community should the influence of thepractitioner in the home so wane that parents lostfaith in vaccination and refused to submit theirchildren to it. Inspection of children of school

age becomes a weariness to the flesh of medical menand women engaged in it, unless combined with somekind of treatment which allows them to see thefruition of their labours. In this respect, no doubtinevitably, the medical staff of the London CountyCouncil is sadly handicapped. The remedy, whichis only the concentrated wisdom of the DawsonReport, is to abolish as far as possible the cleavagebetween preventive and curative work. It is impos-sible to prevent evils which you do not foresee. A

practical knowledge of ill-health is the only way to.acquire a real insight into the conditions of health,and the search for the earliest manifestations ofdisease is the chief stand-by of preventive medicine.Like goodness or purity, health is not an attainableideal, and the immunity which appears to last isthat produced by repeated small contacts withmorbid influences. Innocence has little chance in an

epidemic. As a nation we are proud of our adminis-trative flexibility, and there is much to be said foreach area solving its own public health problems.Willesden and Bradford have both had visions of amunicipal health service without the help of the generalpractitioner ; and indeed the branches of practicetouched by municipal clinics were almost untouchedby clinical medicine. Curative work on an indivi-dualistic basis had left out to a remarkable extentany effective supervision of maternity, of the nursling,and of the pre-school child. The gauntlet has nowbeen thrown down. The Willesden division of theB.M.A. has inquired of the parent body how it isthat members of the Association can be found to-

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accept positions in such a health service. Thecurrent issue of Public Ilealt7t points out to theAssociation that if it ombarks on a campaign againstthis service it shows its intention to ally itself withany and every reactionary force in order to opposethe natural development of public medical services.We believe that the solution in Willesden, as in

Bradford, must needs come-neither confounding thepersons nor dividing the substance-along the linesof a local medical advisory council.

Adenoids.CHRONIC hypertrophy of the nasopharyngeal tonsil,

the condition commonly known as " adenoids," is tobe found all over the surface of the globe, but it ismore frequent in damp temperate climates, and is

perhaps commoner in England than in any other partof the world. Here it is amongst the commonestdiseases of childhood ; it produces disabilities of far-reaching importance and, although the hypertrophyusually disappears about puberty, much of the damageit has done remains throughout life, and constitutesa mass of disability of serious import to the State.The mechanical obstruction to nasal breathing pro-duces deformities of the face and chest which per-manently impair the normal respiration ; infectionspreads from the pharynx to neighbouring parts,causes cervical adenitis, and is responsible for a largeamount of the catarrhal and suppurative disease ofthe ears "hich disables a multitude of our population ;infection also reaches the gastro-intestinal tract, andthe relationsh;p of adenoids to such diseases as ricketsand appendicitis has been the subject of inquiry invarious quarters. Adenoid children are often dulland apathetic, though the reason of this peculiar"

aprosexia " has not been satisfactorily explained.In addition to all this, various neuroses are relatedto the presence of adenoids ; they form a long list,and include laryngeal spasm, asthma., stammering,habit spasms, enuresis, and even epilepsy.The enumeration of the ill-effects of adenoids

makes such a formidable array that we must guardagainst the error of supposing that all the affectionsin the long list are always due to this cause ; par-ticularly is this the case among the so-called " reflex "effects, for no one supposes that epilepsy or enuresis,for instance, are only caused by adenoids, or thatthere is no other factor in their production ; not allchildren with even large adenoids are dull and back-ward, nor do deformities of the jaws and palatenecessarily result. On the other hand, it should beremembered that adenoids in a roomy nasopharynxmay cause no nasal obstruction, and yet may produceinflammation of the ears. The effects of adenoids,as well as the final results of treatment. come moreconstantly under the observation of the generalpractitioner than of the specialist. A paper byDr. H. MERRALL appeared in THE LANCET of Nov. 12thwhich dealt with some of the results he had observed.Naturally all his conclusions will not find universalacceptance, and some have indeed stimulateddiscussion. Among these we note his statements thatenlargement of the palatine tonsils is always secondaryto enlargement of the pharyngeal tonsil, and thatflat-foot is an almost invariable accompaniment ofadenoids; while the success of the adenoid operation incuring such affections as epilepsy, chorea, and nocturnalenuresis, and the inter-relationship of adenoids andrickets, remain as fields of observation and research.We have been informed by Dr. J. W. KYNASTON thata Council has now been formed representing the belief

among certain qualified medical practitioners that" operations for nasal obstruction are being altogetheroverdone." This Council for the Promotion of Oro-Nasal Hygiene has a secretary who may be com-municated with at 26, Welbeck-street, London, W.Now the presence of adenoids is one of the prin-cipal causes of nasal obstruction. With such a

category of possible ills due to the presence of adenoidsas that just set out, those who criticise the clinicalactions of their colleagues in making a practice ofoperating will require a good deal of positive evidencebefore proving good their case. The positive evidence,to be really useful, would mean the records of a verylarge number of cases where the presence of adenoidshas been undoubted at a previous period, and wherenon-removal has led to no ill consequences.We publish in another column a paper by Mr.

DAVID RANKEN, nose, throat, and ear specialist tothe R.A.F. Medical Service, in which are set out

problems presented by the international medicalrequirements for air navigation with special referenceto nose, throat, and ear. It is the common opinionof those who sit upon medical boards for the examina-tion of candidates for aviation that a pilot should beorganically sound, especially in regard to the nose,throat, and ear, but the notes of actual examina-tion of candidates given by Mr. RANKEN show thatthe commonly accepted regulation can be set aside inparticular cases, and that there is an admirable absenceof pedantry in the verdicts upon those who presentthe results of old nose or throat and ear trouble. Ofadenoids it is said that the candidate in whom theyhave been discovered is not rejected for that alone,nor is operation insisted upon where mouth-breathingconstitutes apparently no disability. The assessmentof the symptoms determines the results of theexamination. Medical boards which examine candi.dates for aviation have, therefore, before them thematerial upon which some collective and considered

judgment could be given as to the place which

operation plays in the treatment of adenoids. Fromthese boards particular information might be obtainedin time upon the following points : the number ofcandidates who, having adenoids, can still rank as

practically sound ; the number whose remaining dis-abilities are due to neglected adenoids; the numberwith adenoids who are rejected for deafness ; and thenumber able to pass the hearing tests, who have beenoperated upon already. If figures like these could becollected in some mass, the results would be veryuseful to the medical profession.

The Dental Board.ON Dec. 7th was opened the first session of the

Dental Board of the United Kingdom, a title whichin view of current political developments may have tobe revised. The Board, which consists of appointedmembers has as its first duty to construct and assemblethe machinery for carrying out the Dentists Act of1921. The members will hold office for such term notexceeding three years from the commencement of theAct (July 28th, 1921) as the Privy Council maydetermine, and after the expiration of whateverperiod may thus be fixed a Board consisting of sevenappointed and six elected members will carry on thework so initiated. In opening the session the chair-man of the Board, The Right Hon. F. DYKE ACLAND,M.P., referred to the committee over which he hadpresided in 1918, a body appointed to report upon theextent and gravity of the evils attending dentalpractice. He is to be congratulated upon the