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are entitled to obtain these drugs at the Council's expense for the treatment of Poor Law patients, and
that they represent a considerable proportion of the annual cost. In view of the fact that a Poor Law
infirmary may become an approved centre for the treatment of cases of venereal disease, and that in
London seven such infirmaries have been approved for this purpose by the Ministry of Health and
receive grants, it is not quite clear why they should not undertake the supply of their own Salvarsan
substitutes instead of applying for them to the hospitals under the scheme. It is recommended
therefore that where a Poor Law infirmary has been approved by the Ministry of Health as a centre
for the treatment of venereal disease, they should also make their own arrangements for the supply of
such Salvarsan substitutes as are required for the treatment of their own patients.
Approved practitioners.- In a circular dated 29th August, 1916, the Local Government Board
expressed the opinion that Salvarsan or its approved substitutes should be supplied free, for the purpose
of intravenous administration to patients, to all registered medical practitioners who could produce
satisfactory evidence of training or experience in the administration of these drugs. To comply with
this requirement, the Board suggested that applicants for inclusion on the free list should possess one or
other of the following qualifications:—
(i.) Holds a certificate of having satisfactorily fulfilled the duties of clinical assistant
in a hospital department recognised by the Local Government Board in connection with a
local authority's scheme for the diagnosis and treatment of venereal diseases in their communicable
stages.
(ii.) Holds a certificate of satisfactory attendance at a course of instruction in the diagnosis
and treatment of venereal diseases (including intravenous medication), in such a hospital
department, or in a recognised medical school or post graduate college.
(iii.) Is or has been within the last five years a member of the permanent staff of a hospital
managed by a Committee, and containing not less than 50 beds.
(iv.) Produces satisfactory evidence, other than that indicated in the foregoing paragraphs,
that he has had adequate experience in the administration of these drugs by intra-venous
injection.
Evidence of having held an appointment or attended a course of instruction in a military hospital,
for the treatment of these diseases, recognised by the Army Council, will be regarded as complying with
the Local Government Board's requirements.
The number of medical practitioners in the County of London placed on the list, after complying
with the above requirements, during the year 1917 was 108, by the end of 1918 this number had increased
to 178, and by December, 1919, to 240. The cost of the drugs supplied has been £510 in 1917, £1,356
in 1918, £2,200 in 1919.
When a private medical practitioner in the London area desires to obtain a Salvarsan substitute
free of charge for the treatment of a patient, he must (a) be on the approved list, (b) fill up form V2 and
(c) write or send for the same to one of the hospitals at which a venereal disease clinic has been instituted
under the London scheme. In view of the fact that all patients who are unable to afford to pay for
treatment can obtain it free of charge at the venereal disease clinics, it has been suggested that
a rule should be made that Salvarsan substitutes should not be supplied, free of charge, to a medical
practitioner for the benefit of a patient who is well able to afford payment both for treatment and all
drugs required. There is undoubtedly the further fact that in all cases it may not be known to the
patient that the Salvarsan substitute has been obtained free of cost to the practitioner. It is therefore
recommended that in all cases where medical practitioners apply for Salvarsan substitutes, free of charge,
for the benefit of private patients they should be required to sign a form in the presence, and with the
knowledge, of the patient, declaring that the patient is unable to pay the cost of the drug
supplied.
Laboratory facilities.—Generally speaking, the laboratory facilities provided for the London
clinics are sufficient and they are freely employed. In some cases the pathologist attends to take his
own specimens, but in most they are taken by the clinician. Most of the work consists in microscopical
examination and Wassermann tests, and very little cultural or complement fixation work in gonorrhoea
is carried out. With regard to microscopical examinations, it would appear that much more of this
work should be carried out in the clinic itself than is done at present. Admittedly time is consumed
and this may be precious during the rush of an evening clinic, but the advantages of an immediate
examination are so great, particularly in securing an early diagnosis of syphilis, that it is often time
very well spent. It appears also that much more cultural work might be carried out, with advantage.
This is often stated to be impracticable because the pathologist cannot attend to take specimens
just when they are required, but it is certain that, with a little training, the taking of cultural specimens
could safely be entrusted to clinicians. It is notable that in no clinic are examinations made of the
cerebro-spinal fluid as a routine measure. At present this cannot be expected to be carried out in view
of the period which the patient must rest in bed after lumbar puncture.
IV.
Still Births.
The following table gives the total number of still births notified in London during the years
1916 to 1919 exclusive. The fall in the numbers during 1918 and 1919 particularly is associated with
the fall in the birth-rate consequent upon war conditions. The rise in the percentage of cases occurring
in the practice of midwives is associated with the largely increased number of births attended by
midwives.
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