- Email: [email protected]
Incorporated society of medical officers of health
14o
PROCEEDINGS OF T H E M E T R O P O L I T A N BRANCH.
2. Respiratory disease. 3. DiarrhoeaI and digestive disorders. L Prematurity and Zow Vitadily at Birt/a.-The Registrar-General has found that the number of deaths resulting from these causes is relatively very much greater in textile manufacturing towns than in rural districts. This may possibly be in part the result of progressive physical degeneration of the mothers under the conditions o f town life, which in comparison with country life entail greater liability to insanitary surroundings, and to the inception of phthisis, syphilis, anaemia, etc. There can, however, be little doubt that a most important factor is the employment of women at millwork during the latter months of pregnancy, and this cause suggests its own remedy. _Respiratory Disease.JAs already stated, respiratory disease has, in Stockport at any rate, been the assigned cause of death in a larger number of cases than any other class of malady. I wish to direct attention to this fact. Dr. Hugh R. Jones points out that infants, being less able to adapt themselves to sudden changes in environment, are specially susceptible to the influence of cold. This susceptibility is in no way lessened by their often scanty or utterly unsuitable clothing, quite insufficient to protect them from changes of temperature, or even to maintain sufficient warmth. Further, there can be little doubt that the employment of mothers in factories is attended by an increased mortality from this cause, especially in cold weather, for it is well known that women hastening to their work in the morning frequently lift their infants from warm beds, and carry them, often scantily covered, to the person who is supposed to care them during the mother's absence. At night a second exposure is probably incurred. Overcrowding, and the moral impossibility of securing proper ventiIafion in the homes of many of the poor, is doubtless another pre-disposing cause of respiratory disease. _Diarrhoea/Diseases.--Amongst the predisposing causes of diarrhoea, early weaning and injudicious hand-feeding are pre-eminent. Insanitary conditions of residence are also powerful for evil, and this fact is strikingly borne out by the diarrhoea spot-map for Stockport in I893. Dr. Baltard's views as to the virulent chemical poison which is the proximate cause of the disease, the habitat of the organism which produces it, and the relation of the disease to the temperature of the 4" earth thermometer are well known to all. Viewed in the light of his researches, and having regard to the prolonged heat of the spring and summer of ~893, it is not surprising to find that diarrhmal diseases were specially destructive, no fewer than x54 infant deaths having been registered, as compared with an average of sixty-six during each of the four preceding years. But, as has been pointed out by Dr. Jones, even these figures do not fully represent all the deaths attributable to diarrhoea. Many
cases result in chronic wasting, and atrophy, and the children are returned as subsequently dying from debility, atrophy, or inanition. In America it has been noticed that deaths from these causes are more numerous after an epidemic of diarrhoea, and that they are more numerous during the later months of the year, following the seasonal prevalence of diarrhcea. ~ (2"o be continued.) INCORPORATED SOCIETY OF MEDICAL OFFICERS OF H E A L T H . METROPOLITAN BRANCH.
A MEETING of the Metropolitan Branch was held on Friday, the 3oth November, 1894 , at No. 197, High Holborn. Present : Dr. Yarrow (president) in the chair, and Drs. Roberts, Kempster, Allan, Hartt, Harner, Lovett, James, Orme Dudfietd, Millson, Young, Parkes, Bond, Smith, Herron, Field, Jackson, Gwynn, and Murphy. The minutes of the last meeting were read, approved, and signed by the chairman. DIPHTHERIA IN LONDON.
The following circular, which had been sent to the Metropolitan Medical Officers of Health by the Medical Officer of Health of the London County Council, was read : LONDONCOUNTY COUNCIL. Public Health Department, Spring Gardens, S.W., 22nd October, 1894. DIPHTHERIA IN LONDON.
DEAR SIR,--I have been instructed to report on the prevalence of diphtheria in London, and as a preliminary step have prepared a memorandum on the statistics bearing on the subject which are now availabl% and which I beg to enclose. These statistics necessarily raise the question whether this prevalence may not in some part be due to school influence. It is not suggested that they afford proof of such influence. Nevertheless, it has been thought desirable that effort should be made to ascertain whether arm to what extent the aggregation of children in schools is contributing to diphtheria prevalence. I am directed therefore by a Committee of the Council to express the hope that the medical officers of health of the several London sanitary districts will seek to obtain more definite knowledge than is yet available on this subject. I may add that the Medical Officer of the London School Board has promised his co.operation in this matter. Obviously any such investigation to be fruitful would have to be extended over London generally~ and would have to be continued during a considerable period ; and inasmuch as a plurality of workers would be engaged in connection with itp there is the more need that some uniform system of recording the results of inquiry should be adopted. It is with this last object that I beg to forward you a form indicating the points which appear especially deserving of record, and to say that I shall be happy when sufficient observations have been made to co-ordinate the reports of those who are good enough to co-operate in the work. I am, dear Sir, yours faithfully, SHIRLEY F. MURPHY, Medical Officer of Health. * '~ The Perils and Protection of Infant Life." Statist. Society, March 1894.
Journ.
DIPHTHERIA MR. SHIRLEY M U K P H Y then addressed the meeting. He drew attention to the very great mortality among children in London from diphtheria, and its largely increased prevalence in late years, and maintained that a systematic inquiry into the cause of such prevalence was one of the first duties of medical officers of health. What was wanted was information as to t h e first case in a family, and the idea was to get that information with regard to every case of diphtheria on a uniform plan, so that details from all sanitary districts might be comparable, and particularly in reference to schools, which he thought were frequent sources of infection, t i e thought it would be desirable for the investigations of the medical officers of health to be directed especially to the spread of diphtheria from the point of view of the home, whilst Dr. W. R. Smith should if possible afford information to them as to the amount of diphtheria in the individual schools. This was important, because many schools drew their pupils from more than one sanitary district. DR. W. R. SMITH stated that this matter had caused h i m very great anxiety. The increase of diphtheria in London was one of the most important public health questions of the present day, and they were naturally very anxious to help forward any inquiry in the matter that would be productive of good ; but he ventured to think there was something they ought to do before they went into the inquiry suggested by Mr. Murphy. This inquiry acted on the assumption that every case notified was a c ~ e of diphtheria, whereas they knew that a large number of cases returned as diphtheria were not diphtheria cases at all. In the Metropolitan Asylums Board Hospitals, they found by bacteriological examination that a high percentage of cases had been admitted which were not really diphtheria. T h e same thing was shown in the statistics recently published as to Paris and New York. He therefore thought it necessary that they should try to bring about some system by which accuracy as to what was really diphtheria could be obtained. He had done his best to induce the Metropolitan Asylums Board to take stepsin this direction, and he was pleased to say they had instituted a system by which, so far as their hospitals were concerned~ every case would be bacteriologically examined ; but he thought they did not go quite far enough, they would probably find that the examination shouId take place before the case was removed ; if any such system as that could be adopted, they would, he thought, be taking the first steps in suceessfatly dealing with the matter. Dr. MURPHY stated that the London County Council would, next Tuesday, have before them a recommendation from the Public Health Committee, " T h a t arrangements be made wi~h some competent bacteriologist who has at his disposal a suitable laboratory, by means of which the loeat medical officers of health should be given an opportunity of obtaining bacteriological examination of cases of suspected diphtheria°" and he suggested that perhaps, after what Professor Smith had said, the Metropolitan Branch would like to move that a petition be presented to the Council in favour of that recommendation. The CHAIRMA~¢: I should like to ask you how the medical officer of health is to obtain the examination of patients who are not removed? I am inclined to believe that some cs~es notified as diphtheria, and which are not removed, are sot diphtheria. What power can the medical officer of health have over such cases ? Dr. MURPHY : N o doubt there are cases returned as diphtheria which are not diphtheria, but that would not apply especially to children attending school--that is a general condition, and I do not think it would make any difference in the comparison between two classes, i.e., those who go to school and those who do not. [Dr. Murphy then submitted a diagram showing the prevalence of diphtheria amungst four classes of people--viz., under three years, three to thirteen years, over thirteen years, and at all ages. The diagram showed the highest prevalence in the school period of life.] Resuming, Dr. Murphy said : I think we may take it that if we prove that schools are playing a material part in the dissemination of diphtheria, that the medical or
IN
LONDON.
I4I
sanitary aspect of the question must he faced by the ratepayers, and it might he necessary, for instances to have smaller classes. That, of course, would be a very great expense to the ratepayers. Dr. SMITH: My point is this, that assuming the cases notified are not diphtherias it is fallacious to have returns made of them. Dr. MURPHY : There are not likely to be mistakes in August more than in any other month. [He then showed a diagram indicating a remarkable fall in the notifications of diphtheria following the commencement of the summer holiday in 1893.] Dr. MILLSON would be sorry to see any obstacle put in the way of the notification of sore throat. The slight cases were often the means of spreading true diphtheria, and they would get dissemination from every slight cases if they put obstacles in the way of medical m e n notifying them. As to the suggested return, he knew that to himself and others like him it would be almost impossible on the ground of time alone, nor did he see how they could undertake the bacteriological examination. Dr. MURPHY : An examination of those which are clinically diphtheria is not required. Dr. SMITH: I think you should have a bacteriological examination in all cases. With reference to the proposition which is to go before the County Council on Tuesday, I think there should ~ e one body dealing with this question. T h e whole question of dealing with diphtheria and other infectious diseases should be done under a bacteriological establishment which would be best in connection with the hospital authority, i.e., the Metropolitan Asylums Board. I think in the interests of the Metropolls it would be a great pity to have two bodies dealing with the question. Most of you have no doubt seen in the papers that an arrangement has been made with the Laboratory of the Colleges of Physicians and Sm'geons ior six months, for the examination of cases, not only when admitted into the hospitals~ but before they are discharged. In addition to this, there is, of course, the very important question of the treatment of diphtheria. The anti-toxin serum treatment may be said to have gone beyond the. experimental stage, and it has been urged upon the Metropolitan Asylums Board that every fatality should be given for treatment with this method, and a recommendation is being made to them to arrange for the necessary supply of anti-toxin. Dr. PARKES was sure they would all be glad to learn that the Metropolitan Asylums Board had embarked on such an enlightened policy. There wele, of course, difficulties in the way--one was that the medical officer of health would not be able tO do anything himself, it would have to be done by the medical practitioner ; unless the practitioner was desirous of having his patient bacteriologically examined, he did not see how the medical officer could compel him. It was the poorest practitioners who had the largest number of diphtheria patients, and these would be the least likely to wish for a bacteriological examination. Dr. T. Og~E DUD'FIELD advised further consideration of the matter before a decision was come to by the branch. He did not think the time was ripe for undertaking so large a matter as the investigation asked for by Mr. Shirley Murphy. Dr. HARTT said that the enormous increase m the mortality from diphtheria during the last and present years warranted M r . Shirley Murphy in making investigations as to the cause ; and whilst agreeing that something should be done in that way, did not think that the medical officers of health in the Metropolis could find sufficient time, with other work, to devote to so important a subjecb which was colossal. Unless the investigation was thorough it was useless ; and as it would be of benefit to London as a whole, he was of opinion that it should be undertaken by the London County Counei! (who were not behindhand in spending money for other purposes), and who might with advantage employ twenty or more gentlemen accustomed to p a n i c health work to investigate with despatch the cause of this horrible scourge. If that were done, he would willingly give every assistance in his power. With regard to the
~42
P R O C E E D I N G S OF T H E
suggestion made by Professor Smith, that the cases of sore throat should be examined by medical officers of health bacteriologicallybefore being sent to hospital, with a view to determine those that were true diphtheria, he considered that the suggestion was quite impracticable, as it would create friction between the medical officer of health and the general practitioner; and, further, he believed the people would resist any such examination. It was resolved, on the motion of Drs. Parkes and Hartt, that the matter be referred to a committee for consideration and report. Resolved, that the committee consist of the .following seven members : - - T h e President (Dr. Yarrow), Professor Smith, and Drs. S. Murphy. T. Orme Dudfield, Louis Parkes, Millson and I-Iartt. Cound[ a n d - B ~ e - Z a w s . - - T h e meeting then proceeded to consider the report of the committee re council and bye-laws. The Secretary read the report of the Committee (a) recommending the appointment of a council. Resolved, on the motion of Dr. Dudfield, seconded by Professor Smith, that the recommendation be adopted. (~) Submitting certain bye-laws and recommending their adoption. Resolved, on the motion of Dr. Dudfield, seconded by Dr. Kempster, that the same be approved and adopted, Resolved, that the following (with the officers) be elected the Council of the Branch:--Drs. Allan, Lovett, Millson, Roberts, Parkes, and T. O. Dudfield. Resolved, that the best thanks of the Branch be accorded to Dr. Dudfield for his trouble in connection with the preparation of the bye-laws. A MEETING of the lVIetropolitan Branch was held at No. i97 , High Holborn, W.C., on the i9th December, i894. PIesent: Dr. Kempster (vicepresident) in the chair, Drs. Roberts, Kempster, Allan, Hartt, Hamer, Lovett, James, T. O. Dudfield, Millson, Young, Parkes, Bond, Smith, Herron, Jackson, Gwynn, Murphy, Yarrow, and Field. The minutes of the last meeting were read, approved, and signed by the chairman. REPORT OF COMMITTEE ~'e DIPHTHERIA IN LONDON. The HOE. SECRETARYstated that the committee appointed by the branch to consider the desirability of an inquiry being made into the prevalence of diphtheria in London had met, and he read a report as follows: " T h a t it is desirable that an inquiry into the wevalence of infectious throat illness be made on the lines suggested in the letter of the London County Council, the form suggested to be divided into two--the information in the first part to be obtained by the medical officer of health, and that in the second part, relating to the absentees from school, etc., from the head teacher of the school."
METROPOLITAN BRANCH. A letter was read by the HOE. SECRETARYfrom Professor Smith, regretting his inability to attend, and adding : " I may say that it is the intention of the School Board to make a full inquiry into the whole question of the increased incidence of diphtheria in London, more particularly from the point of view of school influence. I mention this because the branch may think it prudent to postpone any decision on the subject of returns until the lines of the School Board inquiry are formulated." Dr. PARKEDstated that when the committee met, Dr. Murphy stated that he would be very glad, on behalf of the County Council, to supply the necessary forms to mediea. officers of health. Nearly the whole of the torm could be filled up by the inspector. As soon as a case was notified, the inspector would go to the house with his form, fill it un, and send on the other part to the school teacher. The committee proposed that it should be an inquiry into infectious throat illness, that would do away with any difficulty as to whether the case was diphtheria or not. Dr. MURPHY,replying to Dr. Millson, said he did not think the whole of the work could be clone by the sanitary inspector. Dr. ttAR'rT: The first difficulty in the circular is " I f recently suffered from throat illness, state the nature of such illness." There is no difficultyin the other questions. Dr. DE,NAYS: Are we to report this to the County Council and the School Board as well ? Dr. MtrRPtty: If the SchooI Board made an inquiry into what is happening in their schools, it would be most valuable, but we should not then get the whole story, because what we want to do is to see whether the first person to he attacked is a scholar. Dr. PARKES: It is possible,if the School Board are going to make this inquiry, they will decline to give us the information we wmat. We can get the informationMr. Murphy wants in the first part, but if we cannot get the second it may perhaps be better to wait until we see what they are going to do. In the course of further conversation,it was pointed out that they did not hear of cases of throat illness. Dr. M~J~:PK¥: But you are moved by the notificationyou receive to go to the house and see if any previous case of throat illness has occurred. Because you only examinehalf the cases of scarlet fever in Lon&m, it does not follow that you have not sufficientinformation to draw conclusions. The questions on the circular were then gone through seriatim, and some alterations were agreed to. Dr. PARKES moved that the report of the Committee, with the foregoing amendment to the circular, be adopted. The motion having been seconded by Dr. Hartt, was put to the meeting, and carried zero. con. It was moved by Dr. Parkes, seconded by Dr. Bernays, and resolved, that a letter be sent to Proiessor W. R. Smith, informing him that the branch, having considered his letter, has resolved that it is desirable to obtain information on the prevalence of notified diphtheIia in London in relation to school attendance, and forwarding for his information a list of the inquiries proposed to be made by the medical officers of heakh; also asking him to lay before the School Board for London the request of this b r a n c h - - t h a t the Beard will instruct the head teachers to furnish to
ANNOTATIONS. the medical officers of health, who ask for the information, the answers to the questions under the head, " Remarks," in Mr. Murphy's sheet, The meeting then adjourned.
ANNOTATIONS. SEC. 83 PUBLIC HEALTH ACT, 1875. Section 83 of the Public Health Act, 1875, which requires the keepers of lodging houses to furnish the Medical Officer of Health, when so desired, with lists of their previous day's lodgers, was early put in force during 1892 , but the practical utility of this return has not proved as great as was anticipated, and my experience of the past two years goes to show that nothing can take the place of actual and continual supervision, for the early detection and prompt isolation of cases among the nmates requiring removal. I may say here that my only assistant in this work, during the past two years, has been an experienced and trustworthy inspector. I mention this because I know that many authorities are of opinion that all tramps and occasional lodgers should be daily examined by a medical man in these places of sojourn. In the casual wards of our local workhouses this has been done for some time past, but the daily medical examination of the lodging-house and shelter population is a very different and a very much more difficult matter.--(Jerom tae Annual Report, _~. O.H. WolEngham, I893.) THE CLOSURE OF INSANITARY DWELLINGS AT BIRMINGHAM. THE Corporation of Birmingham have been successful in obtaining closing orders in respect of twelve houses, which Dr. Alfred Hill, the M.O.H. for the city had officially reported as unfit for human habitation under Part II. of the Housing of the Working Classes Act. The interest in the cases lies in the fact that the condition causing the unfitness tbr human habitation was chiefly dampness. Dr. Hill gave evidence that-So porous were the walls that after a few hours' rain the moisture came through. He could scratch away the substance of the bricks with his fingers. The buck wall was match-boarded and papered, and damp could be observed wherever the boarding joined the side walls and on the ceilings. He displaced one of the boards and found that the wall behind it was damp. Upstairs the wall was very damp, and there was evidently a defect in the roof at the eaves. Dampness was permeating the walls and staining the oolour. In his opinion the house was so dangerous to live in as to be unfit for habitation. Cold and damp were on every4aand reeognised as highly prejudicial to health, partieu!arly in a house of this kind, where there was no through ventilation to effect any kind of drying. They lowered the general vitality of people who might be exposed to their influence, and, although the robust might withstand them to a certain extent, delicate people would instantly fall ill. Catarrhs, colds, bronchitis, neuralgia, diphtheria, and consumption were especiallyqiable to be produced.
143
T H E SIGNIFICANCE OF FOUR-FOOT EARTH TEMPERATURES. Judging by some remarks in his monthly MeteorologicalMagazine for December, 1894, Mr. Symons, F.R.S. does not fullyagreewith the importance attached to these temperatures by Dr. Ballard and others. H e points out that he has shown in the Met. _lYing.,XXVI., i 8 9 I , p. i3o , that the dates of maximum and of minimum temperatures of the soil are retarded in regular sequence about five days for each increase of one foot in d e p t h ; "therefore to say that any disease occurs a fortnight after the soil temperature at four feet reaches any given point, is very much the same as saying that it does so thirty-four days after the air temperature has reached alaother given point." T H E EARLY DIAGNOSIS OF DIPHTHERIA. The County Council of Worcestershire, on the recommendation of Dr. Fosbroke, have arranged on payment of a fee of half-a-crown for each case to undertake a bacteriological examination of material from sore throats, with a view to early and accurate diagnosis. T h e examination will be made on behalf of the County Council by the British Institute of Preventive Medicine. T h e importance of such an aid to early diagnosis is now becoming generally recognised. Dr. Roux showed that in Paris 20 pet cent. of the cases in the diphtheria ward of the Children's Hospital were not suffering with diphtheria at all. CUBICSPAcE AT THE SALVATIONARMY SIIELTERS.
Dr. Waldo, in his last annual report, gives some striking particulars of the overcrowding in the Salvation Army Shelter in the Blackfriars Road. The shelter, which harbours on an average 35% and occasionally as many as 5o0 persons, has on the former estimate a floor space of eight square feet and a cubic space of I 3 0 cubic feet per head. On the higher estimate of 500 occupants the dormitory gives only six superficial and ninety cubic feet of space to each inmate. I n common lodging-houses in London, which are under police supervision, the existing regulations insist on thirtyone superficial and 341 cubic feet of space to each adult over twelve years. I n workhouses 300 cubic feet are allowed for each adult in a dormitory ; in military barracks about 6oo cubic feet; in prison cells, under the separate confinement system, about 800 cubic feet, with artificial ventilation ; and in the best general hospitals about 1,2oo cubic feet of space for each bed, and ioo superficial square feet of floor space. From a comparison of these faCtS and figures it will seen that Dr. Waldo does not exaggerate when he says that overcrowding to a dangerous extent exists in the Blackfriars Shelter, especially when we consider the exhalations given off from the dirty bodies and clothes of the vagrants by whom it is frequented.
PROCEEDINGS OF T H E M E T R O P O L I T A N BRANCH.
2. Respiratory disease. 3. DiarrhoeaI and digestive disorders. L Prematurity and Zow Vitadily at Birt/a.-The Registrar-General has found that the number of deaths resulting from these causes is relatively very much greater in textile manufacturing towns than in rural districts. This may possibly be in part the result of progressive physical degeneration of the mothers under the conditions o f town life, which in comparison with country life entail greater liability to insanitary surroundings, and to the inception of phthisis, syphilis, anaemia, etc. There can, however, be little doubt that a most important factor is the employment of women at millwork during the latter months of pregnancy, and this cause suggests its own remedy. _Respiratory Disease.JAs already stated, respiratory disease has, in Stockport at any rate, been the assigned cause of death in a larger number of cases than any other class of malady. I wish to direct attention to this fact. Dr. Hugh R. Jones points out that infants, being less able to adapt themselves to sudden changes in environment, are specially susceptible to the influence of cold. This susceptibility is in no way lessened by their often scanty or utterly unsuitable clothing, quite insufficient to protect them from changes of temperature, or even to maintain sufficient warmth. Further, there can be little doubt that the employment of mothers in factories is attended by an increased mortality from this cause, especially in cold weather, for it is well known that women hastening to their work in the morning frequently lift their infants from warm beds, and carry them, often scantily covered, to the person who is supposed to care them during the mother's absence. At night a second exposure is probably incurred. Overcrowding, and the moral impossibility of securing proper ventiIafion in the homes of many of the poor, is doubtless another pre-disposing cause of respiratory disease. _Diarrhoea/Diseases.--Amongst the predisposing causes of diarrhoea, early weaning and injudicious hand-feeding are pre-eminent. Insanitary conditions of residence are also powerful for evil, and this fact is strikingly borne out by the diarrhoea spot-map for Stockport in I893. Dr. Baltard's views as to the virulent chemical poison which is the proximate cause of the disease, the habitat of the organism which produces it, and the relation of the disease to the temperature of the 4" earth thermometer are well known to all. Viewed in the light of his researches, and having regard to the prolonged heat of the spring and summer of ~893, it is not surprising to find that diarrhmal diseases were specially destructive, no fewer than x54 infant deaths having been registered, as compared with an average of sixty-six during each of the four preceding years. But, as has been pointed out by Dr. Jones, even these figures do not fully represent all the deaths attributable to diarrhoea. Many
cases result in chronic wasting, and atrophy, and the children are returned as subsequently dying from debility, atrophy, or inanition. In America it has been noticed that deaths from these causes are more numerous after an epidemic of diarrhoea, and that they are more numerous during the later months of the year, following the seasonal prevalence of diarrhcea. ~ (2"o be continued.) INCORPORATED SOCIETY OF MEDICAL OFFICERS OF H E A L T H . METROPOLITAN BRANCH.
A MEETING of the Metropolitan Branch was held on Friday, the 3oth November, 1894 , at No. 197, High Holborn. Present : Dr. Yarrow (president) in the chair, and Drs. Roberts, Kempster, Allan, Hartt, Harner, Lovett, James, Orme Dudfietd, Millson, Young, Parkes, Bond, Smith, Herron, Field, Jackson, Gwynn, and Murphy. The minutes of the last meeting were read, approved, and signed by the chairman. DIPHTHERIA IN LONDON.
The following circular, which had been sent to the Metropolitan Medical Officers of Health by the Medical Officer of Health of the London County Council, was read : LONDONCOUNTY COUNCIL. Public Health Department, Spring Gardens, S.W., 22nd October, 1894. DIPHTHERIA IN LONDON.
DEAR SIR,--I have been instructed to report on the prevalence of diphtheria in London, and as a preliminary step have prepared a memorandum on the statistics bearing on the subject which are now availabl% and which I beg to enclose. These statistics necessarily raise the question whether this prevalence may not in some part be due to school influence. It is not suggested that they afford proof of such influence. Nevertheless, it has been thought desirable that effort should be made to ascertain whether arm to what extent the aggregation of children in schools is contributing to diphtheria prevalence. I am directed therefore by a Committee of the Council to express the hope that the medical officers of health of the several London sanitary districts will seek to obtain more definite knowledge than is yet available on this subject. I may add that the Medical Officer of the London School Board has promised his co.operation in this matter. Obviously any such investigation to be fruitful would have to be extended over London generally~ and would have to be continued during a considerable period ; and inasmuch as a plurality of workers would be engaged in connection with itp there is the more need that some uniform system of recording the results of inquiry should be adopted. It is with this last object that I beg to forward you a form indicating the points which appear especially deserving of record, and to say that I shall be happy when sufficient observations have been made to co-ordinate the reports of those who are good enough to co-operate in the work. I am, dear Sir, yours faithfully, SHIRLEY F. MURPHY, Medical Officer of Health. * '~ The Perils and Protection of Infant Life." Statist. Society, March 1894.
Journ.
DIPHTHERIA MR. SHIRLEY M U K P H Y then addressed the meeting. He drew attention to the very great mortality among children in London from diphtheria, and its largely increased prevalence in late years, and maintained that a systematic inquiry into the cause of such prevalence was one of the first duties of medical officers of health. What was wanted was information as to t h e first case in a family, and the idea was to get that information with regard to every case of diphtheria on a uniform plan, so that details from all sanitary districts might be comparable, and particularly in reference to schools, which he thought were frequent sources of infection, t i e thought it would be desirable for the investigations of the medical officers of health to be directed especially to the spread of diphtheria from the point of view of the home, whilst Dr. W. R. Smith should if possible afford information to them as to the amount of diphtheria in the individual schools. This was important, because many schools drew their pupils from more than one sanitary district. DR. W. R. SMITH stated that this matter had caused h i m very great anxiety. The increase of diphtheria in London was one of the most important public health questions of the present day, and they were naturally very anxious to help forward any inquiry in the matter that would be productive of good ; but he ventured to think there was something they ought to do before they went into the inquiry suggested by Mr. Murphy. This inquiry acted on the assumption that every case notified was a c ~ e of diphtheria, whereas they knew that a large number of cases returned as diphtheria were not diphtheria cases at all. In the Metropolitan Asylums Board Hospitals, they found by bacteriological examination that a high percentage of cases had been admitted which were not really diphtheria. T h e same thing was shown in the statistics recently published as to Paris and New York. He therefore thought it necessary that they should try to bring about some system by which accuracy as to what was really diphtheria could be obtained. He had done his best to induce the Metropolitan Asylums Board to take stepsin this direction, and he was pleased to say they had instituted a system by which, so far as their hospitals were concerned~ every case would be bacteriologically examined ; but he thought they did not go quite far enough, they would probably find that the examination shouId take place before the case was removed ; if any such system as that could be adopted, they would, he thought, be taking the first steps in suceessfatly dealing with the matter. Dr. MURPHY stated that the London County Council would, next Tuesday, have before them a recommendation from the Public Health Committee, " T h a t arrangements be made wi~h some competent bacteriologist who has at his disposal a suitable laboratory, by means of which the loeat medical officers of health should be given an opportunity of obtaining bacteriological examination of cases of suspected diphtheria°" and he suggested that perhaps, after what Professor Smith had said, the Metropolitan Branch would like to move that a petition be presented to the Council in favour of that recommendation. The CHAIRMA~¢: I should like to ask you how the medical officer of health is to obtain the examination of patients who are not removed? I am inclined to believe that some cs~es notified as diphtheria, and which are not removed, are sot diphtheria. What power can the medical officer of health have over such cases ? Dr. MURPHY : N o doubt there are cases returned as diphtheria which are not diphtheria, but that would not apply especially to children attending school--that is a general condition, and I do not think it would make any difference in the comparison between two classes, i.e., those who go to school and those who do not. [Dr. Murphy then submitted a diagram showing the prevalence of diphtheria amungst four classes of people--viz., under three years, three to thirteen years, over thirteen years, and at all ages. The diagram showed the highest prevalence in the school period of life.] Resuming, Dr. Murphy said : I think we may take it that if we prove that schools are playing a material part in the dissemination of diphtheria, that the medical or
IN
LONDON.
I4I
sanitary aspect of the question must he faced by the ratepayers, and it might he necessary, for instances to have smaller classes. That, of course, would be a very great expense to the ratepayers. Dr. SMITH: My point is this, that assuming the cases notified are not diphtherias it is fallacious to have returns made of them. Dr. MURPHY : There are not likely to be mistakes in August more than in any other month. [He then showed a diagram indicating a remarkable fall in the notifications of diphtheria following the commencement of the summer holiday in 1893.] Dr. MILLSON would be sorry to see any obstacle put in the way of the notification of sore throat. The slight cases were often the means of spreading true diphtheria, and they would get dissemination from every slight cases if they put obstacles in the way of medical m e n notifying them. As to the suggested return, he knew that to himself and others like him it would be almost impossible on the ground of time alone, nor did he see how they could undertake the bacteriological examination. Dr. MURPHY : An examination of those which are clinically diphtheria is not required. Dr. SMITH: I think you should have a bacteriological examination in all cases. With reference to the proposition which is to go before the County Council on Tuesday, I think there should ~ e one body dealing with this question. T h e whole question of dealing with diphtheria and other infectious diseases should be done under a bacteriological establishment which would be best in connection with the hospital authority, i.e., the Metropolitan Asylums Board. I think in the interests of the Metropolls it would be a great pity to have two bodies dealing with the question. Most of you have no doubt seen in the papers that an arrangement has been made with the Laboratory of the Colleges of Physicians and Sm'geons ior six months, for the examination of cases, not only when admitted into the hospitals~ but before they are discharged. In addition to this, there is, of course, the very important question of the treatment of diphtheria. The anti-toxin serum treatment may be said to have gone beyond the. experimental stage, and it has been urged upon the Metropolitan Asylums Board that every fatality should be given for treatment with this method, and a recommendation is being made to them to arrange for the necessary supply of anti-toxin. Dr. PARKES was sure they would all be glad to learn that the Metropolitan Asylums Board had embarked on such an enlightened policy. There wele, of course, difficulties in the way--one was that the medical officer of health would not be able tO do anything himself, it would have to be done by the medical practitioner ; unless the practitioner was desirous of having his patient bacteriologically examined, he did not see how the medical officer could compel him. It was the poorest practitioners who had the largest number of diphtheria patients, and these would be the least likely to wish for a bacteriological examination. Dr. T. Og~E DUD'FIELD advised further consideration of the matter before a decision was come to by the branch. He did not think the time was ripe for undertaking so large a matter as the investigation asked for by Mr. Shirley Murphy. Dr. HARTT said that the enormous increase m the mortality from diphtheria during the last and present years warranted M r . Shirley Murphy in making investigations as to the cause ; and whilst agreeing that something should be done in that way, did not think that the medical officers of health in the Metropolis could find sufficient time, with other work, to devote to so important a subjecb which was colossal. Unless the investigation was thorough it was useless ; and as it would be of benefit to London as a whole, he was of opinion that it should be undertaken by the London County Counei! (who were not behindhand in spending money for other purposes), and who might with advantage employ twenty or more gentlemen accustomed to p a n i c health work to investigate with despatch the cause of this horrible scourge. If that were done, he would willingly give every assistance in his power. With regard to the
~42
P R O C E E D I N G S OF T H E
suggestion made by Professor Smith, that the cases of sore throat should be examined by medical officers of health bacteriologicallybefore being sent to hospital, with a view to determine those that were true diphtheria, he considered that the suggestion was quite impracticable, as it would create friction between the medical officer of health and the general practitioner; and, further, he believed the people would resist any such examination. It was resolved, on the motion of Drs. Parkes and Hartt, that the matter be referred to a committee for consideration and report. Resolved, that the committee consist of the .following seven members : - - T h e President (Dr. Yarrow), Professor Smith, and Drs. S. Murphy. T. Orme Dudfield, Louis Parkes, Millson and I-Iartt. Cound[ a n d - B ~ e - Z a w s . - - T h e meeting then proceeded to consider the report of the committee re council and bye-laws. The Secretary read the report of the Committee (a) recommending the appointment of a council. Resolved, on the motion of Dr. Dudfield, seconded by Professor Smith, that the recommendation be adopted. (~) Submitting certain bye-laws and recommending their adoption. Resolved, on the motion of Dr. Dudfield, seconded by Dr. Kempster, that the same be approved and adopted, Resolved, that the following (with the officers) be elected the Council of the Branch:--Drs. Allan, Lovett, Millson, Roberts, Parkes, and T. O. Dudfield. Resolved, that the best thanks of the Branch be accorded to Dr. Dudfield for his trouble in connection with the preparation of the bye-laws. A MEETING of the lVIetropolitan Branch was held at No. i97 , High Holborn, W.C., on the i9th December, i894. PIesent: Dr. Kempster (vicepresident) in the chair, Drs. Roberts, Kempster, Allan, Hartt, Hamer, Lovett, James, T. O. Dudfield, Millson, Young, Parkes, Bond, Smith, Herron, Jackson, Gwynn, Murphy, Yarrow, and Field. The minutes of the last meeting were read, approved, and signed by the chairman. REPORT OF COMMITTEE ~'e DIPHTHERIA IN LONDON. The HOE. SECRETARYstated that the committee appointed by the branch to consider the desirability of an inquiry being made into the prevalence of diphtheria in London had met, and he read a report as follows: " T h a t it is desirable that an inquiry into the wevalence of infectious throat illness be made on the lines suggested in the letter of the London County Council, the form suggested to be divided into two--the information in the first part to be obtained by the medical officer of health, and that in the second part, relating to the absentees from school, etc., from the head teacher of the school."
METROPOLITAN BRANCH. A letter was read by the HOE. SECRETARYfrom Professor Smith, regretting his inability to attend, and adding : " I may say that it is the intention of the School Board to make a full inquiry into the whole question of the increased incidence of diphtheria in London, more particularly from the point of view of school influence. I mention this because the branch may think it prudent to postpone any decision on the subject of returns until the lines of the School Board inquiry are formulated." Dr. PARKEDstated that when the committee met, Dr. Murphy stated that he would be very glad, on behalf of the County Council, to supply the necessary forms to mediea. officers of health. Nearly the whole of the torm could be filled up by the inspector. As soon as a case was notified, the inspector would go to the house with his form, fill it un, and send on the other part to the school teacher. The committee proposed that it should be an inquiry into infectious throat illness, that would do away with any difficulty as to whether the case was diphtheria or not. Dr. MURPHY,replying to Dr. Millson, said he did not think the whole of the work could be clone by the sanitary inspector. Dr. ttAR'rT: The first difficulty in the circular is " I f recently suffered from throat illness, state the nature of such illness." There is no difficultyin the other questions. Dr. DE,NAYS: Are we to report this to the County Council and the School Board as well ? Dr. MtrRPtty: If the SchooI Board made an inquiry into what is happening in their schools, it would be most valuable, but we should not then get the whole story, because what we want to do is to see whether the first person to he attacked is a scholar. Dr. PARKES: It is possible,if the School Board are going to make this inquiry, they will decline to give us the information we wmat. We can get the informationMr. Murphy wants in the first part, but if we cannot get the second it may perhaps be better to wait until we see what they are going to do. In the course of further conversation,it was pointed out that they did not hear of cases of throat illness. Dr. M~J~:PK¥: But you are moved by the notificationyou receive to go to the house and see if any previous case of throat illness has occurred. Because you only examinehalf the cases of scarlet fever in Lon&m, it does not follow that you have not sufficientinformation to draw conclusions. The questions on the circular were then gone through seriatim, and some alterations were agreed to. Dr. PARKES moved that the report of the Committee, with the foregoing amendment to the circular, be adopted. The motion having been seconded by Dr. Hartt, was put to the meeting, and carried zero. con. It was moved by Dr. Parkes, seconded by Dr. Bernays, and resolved, that a letter be sent to Proiessor W. R. Smith, informing him that the branch, having considered his letter, has resolved that it is desirable to obtain information on the prevalence of notified diphtheIia in London in relation to school attendance, and forwarding for his information a list of the inquiries proposed to be made by the medical officers of heakh; also asking him to lay before the School Board for London the request of this b r a n c h - - t h a t the Beard will instruct the head teachers to furnish to
ANNOTATIONS. the medical officers of health, who ask for the information, the answers to the questions under the head, " Remarks," in Mr. Murphy's sheet, The meeting then adjourned.
ANNOTATIONS. SEC. 83 PUBLIC HEALTH ACT, 1875. Section 83 of the Public Health Act, 1875, which requires the keepers of lodging houses to furnish the Medical Officer of Health, when so desired, with lists of their previous day's lodgers, was early put in force during 1892 , but the practical utility of this return has not proved as great as was anticipated, and my experience of the past two years goes to show that nothing can take the place of actual and continual supervision, for the early detection and prompt isolation of cases among the nmates requiring removal. I may say here that my only assistant in this work, during the past two years, has been an experienced and trustworthy inspector. I mention this because I know that many authorities are of opinion that all tramps and occasional lodgers should be daily examined by a medical man in these places of sojourn. In the casual wards of our local workhouses this has been done for some time past, but the daily medical examination of the lodging-house and shelter population is a very different and a very much more difficult matter.--(Jerom tae Annual Report, _~. O.H. WolEngham, I893.) THE CLOSURE OF INSANITARY DWELLINGS AT BIRMINGHAM. THE Corporation of Birmingham have been successful in obtaining closing orders in respect of twelve houses, which Dr. Alfred Hill, the M.O.H. for the city had officially reported as unfit for human habitation under Part II. of the Housing of the Working Classes Act. The interest in the cases lies in the fact that the condition causing the unfitness tbr human habitation was chiefly dampness. Dr. Hill gave evidence that-So porous were the walls that after a few hours' rain the moisture came through. He could scratch away the substance of the bricks with his fingers. The buck wall was match-boarded and papered, and damp could be observed wherever the boarding joined the side walls and on the ceilings. He displaced one of the boards and found that the wall behind it was damp. Upstairs the wall was very damp, and there was evidently a defect in the roof at the eaves. Dampness was permeating the walls and staining the oolour. In his opinion the house was so dangerous to live in as to be unfit for habitation. Cold and damp were on every4aand reeognised as highly prejudicial to health, partieu!arly in a house of this kind, where there was no through ventilation to effect any kind of drying. They lowered the general vitality of people who might be exposed to their influence, and, although the robust might withstand them to a certain extent, delicate people would instantly fall ill. Catarrhs, colds, bronchitis, neuralgia, diphtheria, and consumption were especiallyqiable to be produced.
143
T H E SIGNIFICANCE OF FOUR-FOOT EARTH TEMPERATURES. Judging by some remarks in his monthly MeteorologicalMagazine for December, 1894, Mr. Symons, F.R.S. does not fullyagreewith the importance attached to these temperatures by Dr. Ballard and others. H e points out that he has shown in the Met. _lYing.,XXVI., i 8 9 I , p. i3o , that the dates of maximum and of minimum temperatures of the soil are retarded in regular sequence about five days for each increase of one foot in d e p t h ; "therefore to say that any disease occurs a fortnight after the soil temperature at four feet reaches any given point, is very much the same as saying that it does so thirty-four days after the air temperature has reached alaother given point." T H E EARLY DIAGNOSIS OF DIPHTHERIA. The County Council of Worcestershire, on the recommendation of Dr. Fosbroke, have arranged on payment of a fee of half-a-crown for each case to undertake a bacteriological examination of material from sore throats, with a view to early and accurate diagnosis. T h e examination will be made on behalf of the County Council by the British Institute of Preventive Medicine. T h e importance of such an aid to early diagnosis is now becoming generally recognised. Dr. Roux showed that in Paris 20 pet cent. of the cases in the diphtheria ward of the Children's Hospital were not suffering with diphtheria at all. CUBICSPAcE AT THE SALVATIONARMY SIIELTERS.
Dr. Waldo, in his last annual report, gives some striking particulars of the overcrowding in the Salvation Army Shelter in the Blackfriars Road. The shelter, which harbours on an average 35% and occasionally as many as 5o0 persons, has on the former estimate a floor space of eight square feet and a cubic space of I 3 0 cubic feet per head. On the higher estimate of 500 occupants the dormitory gives only six superficial and ninety cubic feet of space to each inmate. I n common lodging-houses in London, which are under police supervision, the existing regulations insist on thirtyone superficial and 341 cubic feet of space to each adult over twelve years. I n workhouses 300 cubic feet are allowed for each adult in a dormitory ; in military barracks about 6oo cubic feet; in prison cells, under the separate confinement system, about 800 cubic feet, with artificial ventilation ; and in the best general hospitals about 1,2oo cubic feet of space for each bed, and ioo superficial square feet of floor space. From a comparison of these faCtS and figures it will seen that Dr. Waldo does not exaggerate when he says that overcrowding to a dangerous extent exists in the Blackfriars Shelter, especially when we consider the exhalations given off from the dirty bodies and clothes of the vagrants by whom it is frequented.