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On the prevention of tuberculosis
ON THE
PREVENTION
disseminating tuberculosis, especially amongst the young, The pathologist finds " t h a t of the total deaths under ten years of age amongst the mass of the people, about a third are due to tuberculosis,"~: and that the usual seat of the disease at that age points to food as the medium of infection. The prevalence of tuberculosis among dairy cow~ is notorious. Experiment shows that when the udder is affected the milk is viruIent. Every authority on the prophylaxis of tuberculosis places the supervision of the milk supply next to the regulation ot the expectoration of consmnptives in importance. I am inclined to think that it is at least of equivalent importance. I t certainly is much more practicable as a matter of sanitary administration. I f we remember the habits of the tubercle-bacillus, we cannot imagine a more favourable nurture-ground than the typical b y r e - - a dark or badly-lighted space, with insufficient ventilating apertures, which are unhesitatingly closed when necessary to maintain a temperature of 60 ° to 7 °0 F. by the heat of the animals; the air consequently loaded with carbonic acid, with organic impurities and moisture, full of the dust of dried dung, never penetrated by a direct ray of sunlight, in winter never vacated either in country or town for weeks, and in cities never vacated at all.i" Well may Professor Brown, of the Agricultural Department of the Privy Council, say : " Nothing worse than the insanitary conditions of the life of the average dairy cow can b e imagined." T h e natural result is that dairy stock is ravaged with tuberculosis. Yet we never hear a farmer or a dairyman speak of tuberculosis without speaking of compensation. When he puts windows in his byre, and floods it with light,- ventilates it, a n d ceases to use his cow as a heating apparatus, it will be time enough to speak of compensation. Meanwhile, the children of the town are being infected wholesale, and it behoves the authorities, not only to take every means to eliminate tuberculous cows from dairy byres, but to enforce sanitary reform in the construction, use, and condition of byres. Bye-laws as to cubic space, ventilation, lighting, cleanliness, obtain from tuberculosis a direct interest to all men. But yet more is required. T h e Glasgow Police (Amendment) Act, 189% contains powers which, if efficiently worked, would weed out tuberculous cows, not only from Glasgow byres, but from any byre from which milk is sent to the city. I n Glasgow there are some 1,6oo cows, of which 4 ° per cent. are never outside their byres. I n I892-3-4 *"'Tuberculosis viewed as an Infectious Disease; Its Prevalence and the Frequency of Recovery from it."-Professor Josepll Coates~ Sanitary Journal, November 23rd, I891. *See valuable paper by J. MacMillan, M.B., D.Sc., Edinburgh.--" An Investigation into the Condition of the Atmosphere of Cowhouses aud Stables in Edinburgh, Leith, and the County of MidIothian.'"--JournaI of Com~azalive Pathology and 2t'Tzera2~eutics, I892.
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there were 23, 9, 7, tuberculous cows detected and eliminated by the inspectors ; but the method of inspection is thoroughly inefficient. A competent veterinary inspector ought to be at once appointed who could test with tuberculin the accuracy of the suspicions suggested by his skilled general examination. I n this way only can we hope to detect a n d abolish, as milk-producers, animals which are, no doubt, at this moment contaminating the milk supply of Glasgow. A t present o u r powers are lying dormant. After putting our own house in order, an occasional inspection of the cattle at dairy farms, chosen at random in various parts of the country, would have a most wholesome effect, not limited to the detection of a few unsound animals, but leading up to more stringent bye-laws and better sanitation in country byres. County officials require a little help from the powerful commercial lever which the purchaser of country produce can apply whenever he chooses.
ON
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PREVENTION CULOSIS.
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BY JAMES NlVlgN, M.B., M.A. Cantab., M.O.H. Manchester.
IN a clear and scholarly report, Dr. Russell has recently declared his position in regard to the prc~ vention of tuberculosis. I n that report he has done me the honour to single me out for special comment as the most extreme and urgent advocate of preventive measures i n this country, so far as concerns the infective matters of the disease. Coming from one who has rendered such splend i d services to public health, this can only be looked upon as a personal compliment, and one which I am disposed in part to accept, and even to vindicate, as I conceive that I shall thereby justify Dr. Russell in his selection. Dr. Russell states that a handbill was distributed to each house in Oldham in I889, Cornet's paper having appeared in 1888. T h e handbill was, in fact, distributed in the middle of 1888, directly after the appearance of Cornet's paper, which gave occasion to the distribution of rules for the prevention of phthisis, bu t by no means occasioned the rules, which were in substance given in my report on the health of Oldham in i886. This report contained an investigation into the etiology of phthisis, from the history of a number of cases, and g~tve, amongst other items, from clinical inquiry, the average period between infection and death in the adult as lying between two and three years. About the same time, Dr. Arthur Ransome issued a set of rules directed to the same object. I n 189o, again, I made a second inquiry into the etiology of a series of deaths from tuberculosis, which proved, to my mind, that the conclusions founded by Cornet on experiment, were amply borne out by ctinicat investigation. This inquiry was
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p u b l i s h e d in t h e A n n u a l R e p o r t of O l d h a m for t h a t y e a r a n d s u b s e q u e n t l y in t h e f f r a c t i t i o z e r . I n t h e A n n u a l R e p o r t o n t h e h e a l t h of O l d h a m for 1887, before C o r n e t ' s p a p e r s were p u b l i s h e d , I p l a c e d before t h e sanitary a u t h o r i t y a n d t h e m e d i cal m e n o f O l d h a m t h e c o n c l u s i o n s at w h i c h I h a d a r r i v e d a n d w h i c h I h e r e insert. EXTRACT. In my last year's report, I made a somewhat elaborate stateme~,t of inqui,ies into this disease. I do not propose to golnto the subject, this year, in that manner. But I would point, out that, though the evidence them given--that consumption is an infectious disease--is not of a very conclusive character, yet, neither, as a rule, can we readily trace the means by which the infection of scarlet fever or typhoid fever, or in fact of most of tt~e infectious diseases, is conveyed. There are in the case of consumption difficulties which do not exist with regard to the zymotie group. Chief among these i~ the long leriod of incubation, which makes detection of the original source of the disease very difficult, and the fact that consumption is a disease widely spread in the animal klngdom~ being common amongst cattle, poultry, ~ arid rabbits, so that fresh centres of contagion are constantly springing up irrespective altogether of man. The experimental evidence, however, of the infectiousness of consumption, is overwhelming, and may be taken as practically closing discus-ion. It is a~soproved that a chief source ofdaoger, us concerns the conveyance of consumption from one person to another~ lies in the matters coughed up and spat out. These contain, in large amount, the spores of the disease, and it is prohable that, where the spittleis not carefully destroyed, it dries up and ~ets scattered about as dust of a highly infectious kind. I hxve mentioned in another part of my report~ that there is reason for believing that consumption in children is often caused by the use of consumptive milk ; but impure mill< is, prob~tbly, responsible for a considerable amount of other disease~ such as summer diarrhcea, while scarlet fever and typhoid fever have been, over and over again, traced to the use of contaminated milk. H e n c e two c a r d i n a l rules which s h o u l d b e stringently c a r r i e d o u t : - I. Z~e spillIe of ~ersom affeded wit]~, or su@ected to be a/fueLed wit/~ eonsztm~tio~z, s~oztZd be destroyed at lzome @ bei~, bztrned, a n d in t/~e worksho~ ~y bein~ drugged into an oSen @~t¢oon charged w~t~ corroszve sz~bZzmale. 2. Mid 11d/k used l% food sl~onM be z~rellboiled.
T h i s by n o m e a n s e x h a u s t s t h e m a t t e r s requiring to b e c o n s i d e r e d in t h e p r e v e n t i o n of c o n s u m p t i o n , b u t I shall c o n t e n t m y s e l f with r e p e a t i n g t h e o t h e r p r a c t i c a l r e c o m m e n d a t i o n s m a d e in m y r e p o r t for 1886, w h i c h are o n t h e s a m e lines as t h o s e issued, i n d e p e n d e n t l y , by Dr. R a n s o m e , of Bowdon. T h e s e are : - i, Consumptive patients should be~ as far as possible, isolated, just like fever cases. 2. Kissing, and other intimate intercourse with them should be prohibited. 3. The rooms which they inhabit should be well aired~ and what they spit should be destroyed by fire. 4 - A non-consumptive should not sleep with a consumptive person. 5. VVhen a medical man has diagnosed consumption, the fact should be at once made known to the relations. 6. All workers in rooms filled with irritating dust, or * Chicken tuberculosis is not, now, generally regarded as giving rise to tuberculosis in man. Rabbits do notj probably, suffer much from tuberculosis in the wild state.
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fine particles of fibres, should wear respirators, and carry a stock so as to change the respirator when it gets clogged. 7. The utmost attention should be directed to the draining of damp sub-soils, and to the separation of house foundations trom damp. 8. It is of the utmost importance that the rooms be well ventilated, without draught, and that there be no overcrowding. 9. Every measure taken to improve house sanitation, such as the freer admission of light, draining and paving of back courts, &c., is directed also against consumption. Io. There is reason to' believe that consumption may be got from eating the flesh of animals who have sl.lffered from the disease, and therefore a heavy penalty sho~lld be inflicted in any case in which such flesh has been sold for food. T h e p o r t i o n s singled o u t for italics are, it will b e seen, practically i d e n t i c a l with t h e c o n c l u s i o n s arrived at by t h e A c a d d m i e d e m ~ d e c i n e in 189o (Russell, p. 34). N o t only so, b u t t h e g e n e r a l hygienic m e a s u r e s on w h i c h Dr. Russell rightly insists so strongly, are in t h a t r e p o r t clearly e n u n c i a t e d , to t h e e x t e n t to which they especially affected O l d h a m . T h e y are, o f course, p l a c e d in a s u b o r d i n a t e position to direct p r e v e n t i v e m e a s u r e s ; b u t t h a t is b e c a u s e t h e i r i m p o r t a n c e was already clearly recognised a n d u n d i s p u t e d . O n t h a t subj e c t it is well, here, to say a word or two. T o o v e r l o o k t h e i m p o r t a n t part w h i c h general a d v a n c e s in s a n i t a t i o n play in p h t h i s i s would b e trivial a n d foolish. T h e y may, however, be left to l o o k after themselves, as t h e y are n e c e s s a r y in t h e a m e l i o r a t i o n of m a n y o t h e r forms o f disease. H o w m u c h m o r e foolish m u s t it t h e n a p p e a r to a t t e n d to t h a t w h i c h r e q u i r e s n o special a t t e n t i o n , a n d to n e g l e c t t h o s e p r e c a u t i o n s w h i c h are special a n d i n c i d e n t only to t h e particular disease w h i c h it is o u r o b j e c t to p r e v e n t . A n y o n e r e a d i n g Dr. R u s s e l l ' s p a m p h l e t would i m a g i n e t h a t those, like myself, who h a v e u r g e d t h e necessity o f direct p r e v e n t i v e measures, h a v e forgotten t h e virtue of fresh air, o f o p e n spaces, a n d o f dry a n d well-lighted houses, as well as t h e evil o f overcrowding. So far from t h a t b e i n g t h e case, year after year, a n d i n c o n v e r s a t i o n w e e k after week, I h a v e from ray first e x p e r i e n c e of p u b l i c h e a l t h k e p t repeating, with w e a r i s o m e iteration, t h e evil effects of d a m p . T h e value of s u n l i g h t in t h e d e s t r u c t i o n of disease, a n d t h e necessity of ventilation, were n o t m e r e l y t a l k e d of in O l d h a m , b u t given effect to so far as t h e i n f l u e n c e of t h e h e a l t h office e x t e n d e d . T h e s e are, in fact, t h e p r i n c i p i a o f p r a c t i c a l c o n d u c t , which h a v e b e c o m e , by t h e labours Of a g e n e r a t i o n of workers, m e r e a u t o m a t i c i m p u l s e s to m e d i c a l officers of health, like b r e a t h i n g a n d sleeping. W e m a y t h e r e f o r e dismiss the p r o p o s i t i o n s in Dr. R u s s e l l ' s paper, w h i c h deal with p r e c a u t i o n s f o u n d e d o n s u c h c o n s i d e r a t i o n s as t r u e , n o d o u b t , but truisms--emphatic enunciations of undoubted verities--such as we S c o t c h m e n were said b y C h a r l e s L a m b to b e specially p r o n e to.
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All that, whether as practical recommendation or theoretic reasoning, may be set aside, and we must get at the real points of difference. Dr. Russell recapitulates the facts of infection, and joins issue on their application. In my criticism of his criticisms I have to distinguish questions of method, and quest;ons of profound difference. I take exception to the manner in which he brings out some lesser recommendations, included for the sake of completeness, and puts up the destruction of sputum as the one great direct proceeding in preventive work. Doubtless the great bulk of infection between man and man passes by means of dried sputum. Buti could any one, who has read the memorandum on phthisis of the North-Western Branch of the Association of Medical Officers of Health (drafted by Mr. Paget, of Salford) fail to remark the clearness with which this is thrown into the foreground, as the most important part of the business. No one could possibly mistake the purport of that memorandum, which was to lay special emphasis on this feature of the disease, and on the ease with which the danger might be combated. This, as I have said, appears to me more a matter of method. But there are, in reality, profound points of difference. In the first place, Dr. Russell, though friendly to the distribution of information on the infectious nature of phthisis, regards the memorandum of the North-Western Branch as alarmist in character, and calculated to place the consumptive in an unnecessarily isolated and miserable position. " I ' h e r e is," he says, "already evidence of mischief being done by the indiscriminate attachment of the idea of infection to phthsis. We have heard of a consulting physician being referred to by a clerk in one of our large warehouses, at the instance of his employers, for an opinion as to the safety of his being permitted to continue in his employment." I should like to ask what milder and more insignificant consequence could you expect, not of the infectiousness of tubercle, but of the mere suspicion that it is infectious. Moreover, where is the mischief? Surely nothing better could be done than to consult a physician on such a point. No medical man would, I presume, require that the clerk should be removed from his emplo,yment. No well-informed and conscientious physician would tell the clerk that he could continue his employment without taking certain precautions to ensure the safety of his fellow clerks. Is there, in fact, any doubt that a phthisical clerk is a distinct source of danger to the other employ6s, in the absence of precautions ? Dr. Russell tells us that the alarmist character of the memorandum of the North-Western Branch is given to it in great measure by the absence of any clause stating that, if due precautions are taken,
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the phthisical patient need be a source of danger to no one. I n considering the memorandum, the advisability of inserting such a clause was well discussed, and I, for one, was opposed to it. The object of such memoranda is to endeavour to alarm the public, and it is by no means an easy thing to do. Anyone, who has had the experience of a working and intimate acquaintance with the subject knows that nothing is more difficult than to arouse the apprehensions of the people in regard to infectious disease, and especially is this the Case in regard to such a disease as phthisis, in which you can see the end, but have to hunt for the beginning. Is it not a fact, well known to Dr. Russell, that a large section of the community are indifferent to the dangers arising from ordinary infectious disease, both to their own families and to their neighbours, and take not the slightest means to avert them ? These are not obscure dangers that they cannot see, but risks of such a disease as smallpox, the infectiousness and loathsomeness of which they e/m easily recognise. I n truth, there is no danger of alarming the people, but there is much need, if it could only be done. T h e one thing on which you can always safely rely, in peer and peasant, in the manufacturer and in the artisan, is the " conservative instinct of an ancient people." We are told that "the West E n d fear of infection is indiseriminating, even tb absurdity. Enteric fever, scarlet fever, whooping cough, and small-pox, all entail the same s6cial ostracism." Personally, I have not much experience of West E n d circles, but I should be disposed to imagine that this indiscriminate and absurd aversion to infection may have something to do with the ridiculously low mortality of the West End. T h e truth i s - - d e a r l y beloved truism--that the health of the more prosperous section of the community is not the result merely of fresh air, light, good construction, and ample room to turn round, but is due largely to the quality which makes for prosperity, namely, a faculty of attention to many details, which the h a r d e r worked section of the community have neither the ability nor the energy to bestow. But, it is not with the West End circles that sanitary authorities are most concerned. Their terrors may be safely left to the assuaging care of a skilful physician, to whom they will conduct the victim. Moreover, the extent to which exalted circles suffer from phthisis is small compared with that which afflicts the great bulk of the community, who are, it must be repeated, only too difficult to convince of the extent of the danger. I have, I hope, made it abundantly claar that I recognise equally with Dr. Russell the preponderating value to be attached, in the prevention of tuberculosis, to the destruction of the sputum. But there are other sources of infection which are by no means insignificant. It may be said, generally, that all tuberculous discharges which are
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liable to become dried and dispersed as dust, are sources of danger. Hence, I could not agree to pass indifferently by the numerous cases of discharging tuberculous glands and diseased bones which we have in our midst. Doubtless, the amount of infective matter in proportion to the total discharge is much less than in the case of phthisical lungs, but it is by no means a negligible quantity. Further, the discharges from tuberculous bowels in infants are a serious source of danger, exactly as they are in the case of typhoid fever patients suffering from diarrhcea. Then, again, there are a number of minor matters, such as the employment of eating utensils which have just been used by a tuberculous patient, and the necessity of not kissing a tuberculous person, which appear to be trifling, and by comparison, no doubt, are trifling. But they are not negligible, if it is remembered how frequently tuberculous people suffer f¥om ulcerating tuberculous sores of the mucous membrane of the mouth. T h e great object of inserting a number of details is to cause the public to reflect on the various ways in which the disease is liable to infect, and thus to add to the importance o f the central requirement, namely, the removal of tuberculous discharges. Dr. Russell says, " n o w that we have come to the practical issue to this inquiry, it is well at once to raise the question, ts tuberculosis ' an infectious d i s e a s e ? ' T h e answer is ' Y e s ' and ' N O . ' It must be apparent from what precedes, that, while in the academic sense tuberculosis is infectious, in the popular sense it is not. Even in the language o f the schools, where words are weighed and meanings are qualified to a nicety, hydrocephalus, although it is tuberculous, cannot in any sense be said to be infectious. Neither can many forms of tuberculosis o f glands, bones, and. joints. U n t i l a ' d i s c h a r g e ' is established, they cannot be infectious," and so forth. Further on, he says, "Tuberculosis, therefore, even in an academic sense, is a disease which, though in all cases caused by infection, is not in all cases infectious." Now, no one ever maintained that all cases of tuberculosis are infective, or that the disease is infective at all, until discharge ensues. Syphilis is not in all cases contagious. But that does not hinder syphilis from being a contagious disease. I do not understand all these fine distinctions. I n nil cases the infective element of tuberculosis is present, where the disease exists, and, although we must have regard to administrative possibilities, and to the necessity, of graduating our precautions according to the nature of the case, the disease is infectious in the usual sense of the term. Take, for instance, a case of tubercular meningitis in a child. There is a considerable likelihood that the infection, which produces this meningitis,
OF TUBERCULOSIS. has arisen from a previous focus in the bowels or iff the lung, as I have myself witnessed, I n the bowel, especially, the lesion may have produced no obvious effect until its contents were discharged into the vascular system. Yet, this case may well have been for some time an infective one. Moreover, the closed tuberculous cavity may, at any time, set up tuberculous change in such a position as to lead to infective discharge without any appearance of lesion. The distinction which Dr. Russell draws does not, in fact, exist in nature. Nevertheless, in urging the notification only of cases in which a tuberculous discharge was ascertained, I took, for practical purposes, the dividing line which he now draws. T h e greatest difference of opinion, however, arises in assessing the relative influence of general hygienic measures, and of special precautions in dealing with the prevention of tuberculosis. Now, I should like to make. it perfectly clear that I by no means undervalue the effect of genera~ hygienic meaures. I would not even dispute that general hygienic measures in one place may have effected more tha n specific preventive effor~ in another, though I am not aware o f any place where the latter has become an established system, ex-. cept to a very partial extent. But that is no reason why both should not be employed, and~ in my opinion, it would be infinitely easier to get specific preventive measures carried out than to do the amount of hygienic general work required to greatly reduce the disease. The number of tuberculous, people with discharging sores in any community is limited, but distress, drunkenness~ darkness, dirt, and overcrowding are recurring factors which are not so easy to control. T h e obstruction of vested interests, also, we have always with us. Moreover, just as general hygienic measures will reduce other diseases besides tuberculosis, so the notification of tuberculosis will lead to a large amount of detail work which will prevent other conditions of bad health. I n no infectious disease is the influence of co-operating causes, among which the hygienic conditions of the home and of the workshop may be specially mentioned, so potent an aid to infection as in tuberculosis. These it should be our object to discover and to remove befdre the mischief, which they help to produce, is done. Now, you cannot do this work without knowing where the cases are, and you cannot know where the cases are without notification. I will not stop here to argue this point, which is sufficiently obvious. Permit me here to recapitulate the conclusions arrived at by the Medical Society of Oldham after two evenings of arduous discussion. Extract from the La~cet, I893, Vol. II., p. 1257. OLDHAM MI~;DICALSOCIETY.~On October 24th, a discussioa on the subject of Notification of Phthsis was opened by Mr. Fawsitt, president of the society, at a very gull meeting. Several members took part in the discussion, and
PUBLIC HEALTH at the close of the meeting the subiect was adjourned to another meeting which was heId on November 7th. A number of speakers having expressed their views on the question, it was understood that the objectsof notificationwould be :-I. The sanitaty authority would disinfect the room occupied by the tuberculouspatient, as might be required. 2. Inasmuch asthe transmissionof tuberculosis is, in a l~.rge proportion of cases, determined by the presence of insanitary conditions, such as damp, overcrowding, deficiencyof 'light, and so forth, an opportunity would be afforded to the authority of removing such conditions and so saving other members of the household. 3- Further evidence would be collected bearing on the modes and conditions of transmission of the disease. 4. The personal hygiene of the patient would in no way come under the care Of the sanitary authority ; it was hoped, however, that the medical attendant would confer with the medical officer of health, when convenient, as to the precise means by which tuberculous discharges might be most usefully destroyed. At the same time, the sanitary .department would in no way interfere with tile treatment of the patient, and all instructions in dealing with discharges from the patient wonld come from the medical attendant. 5. Onlysuch caseswould be reported in which phthisical expectoration was taking place from the lungs, cases with tuberculous diarrhoea, and cases with copious discharge from tuberculous bones and tuberculous ulcers. Theseand other matters having been fullydiscussed, the tollowing resolution was carried unanimously: G~ That the Society, having had its attention drawn to the infection of tuberculous diseases and to the great mortality and injury to the population arising therefrom, is of opinion that these diseases should be the subject of voluntary notification to the sanitary authority." It wais understood that a copyof the resolution wouid be sent to the Sanita*y Committee of Oldham, as well as to the medicaljournals. The reluctance of the Oldham Medical Society to go in for compulsory notification, arose mainly from a wish to see how the thing would work out before committing themselves further. ; I may say, that I should acquiesce in the experiment of paid voluntary notification for a time, so that before it becomes compulsory, one may arrive at a modus ~ivendi. But I still hold that, in the end, notification, if it is to be of much use, must be compulsory. As regards the provision of isolation for consumptive people in the later stages of the disease, that also will, no doubt, be commenced as a voluntary proceeding. Indeed, I should never wish to do other than advance with great caution in the provision of isolation. It is, however, an urgent need, and I have therefore very great pleasure in finding that Mr. W. J. Crossley, of this city, has, on grounds of humanity, just opened a home for ten advanced phthisicar patients, the success of which I shall watch with much interest. I t will, I hope, prove the forerunner of more efforts in the same direction. I f Dr. Russell and I do not altogether agree in our views of what the facts of tuberculosis require in man, it is with the more pleasure that I heartily wish him success in his attempt to intercept the infection from tuberculous cows, though I think that he might as well have extended his efforts to other infective mammals, especially as his judgment and moderation would have been valuable in the elaboration of practical methods of procedure.
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P U B L I C H E A L T H ( S C O T L A N D ) BILL. THE Bill recently introduced in the House o~ Lords by Lord Balfour, Secretary for Scotland, proposes to amend the Public Health Act of 1867o T h e sources from which the provisions of this Bill are derived are the following : The principal Public Health Act of 1867 ; the Public Health (Scotland) Amendments Acts of 187I , 1875 , I882, 1890 , 1891 ; Public Health (England) Act of 1875 ; and the Public Health (London) Act of 189I. It will be seen that there are already in existe n c e five Amendment Acts, and the Bill now before the Lords only proposes to amend the Act of 1867, and to repeal the A m e n d m e n t A'cts i 8 7 i , i875 , i882, and 189o. The Act of i 8 6 7 - - w i t h about twenty new clauses substituted for a similar number of clauses to be repealed by the new A c t - is the measure for the reform of the principal Public Health Act for Scotland, on which Lord Balfour is to stake his name as a sanitary reformer. When the Bill was being read for the first time in the Lords, Lord Balfour raised the hopes of the medical officers and sanitary inspectors of Scotland by stating that another Bill was to follow, to codify and consolidate the variousPublie Health Acts at present in force. Although it was anticipated t h a t much confusion would ensue if the amending Bill became law in advance of the consolidating Bill, still it was satisfactory to think that at last there was a reasonable chance of homogeneity and coherency taking the place of heterogeneity a n d chaos. This hope has been doomed to disappointment, as it has leaked out that this great promise is, after all, only to be a miserable Bill to consolidate the unrepealed clauses of the Act of 1867 with the clauses of the Bill which it is expected will shortly become an Act. It is somewhat difficult to compare the sanitary laws in force in Scotland with those in England. I n such towns as Edinburgh, Glasgow, Dundee, etc., there are private municipal Acts, giving extensive powers to deal with conditions relative to the public health, and burghs are dealt with by the Burgh Police Act of 1892, which contains extensive provisions relative to water, drainage, scavenging, and cleansing. This Act only deals with populous places, which have been formed into burghs, and does not deal with rural areas at all. Rural areas are governed by the Local Government Act of I889, which, amongst other things, provided that every county and district of a county must have a medical officer with a public health qualification, and to hold his office ad vitam ant culpam. Sanitary inspectors have the same fixity of tenure. By the Burgh Police Act of I89Z, every medical officer to a burgh, appointed after May, 1894 , must be a holder of a public health qualification. I n these respects, Scotland is ahead of England ; hut~
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disseminating tuberculosis, especially amongst the young, The pathologist finds " t h a t of the total deaths under ten years of age amongst the mass of the people, about a third are due to tuberculosis,"~: and that the usual seat of the disease at that age points to food as the medium of infection. The prevalence of tuberculosis among dairy cow~ is notorious. Experiment shows that when the udder is affected the milk is viruIent. Every authority on the prophylaxis of tuberculosis places the supervision of the milk supply next to the regulation ot the expectoration of consmnptives in importance. I am inclined to think that it is at least of equivalent importance. I t certainly is much more practicable as a matter of sanitary administration. I f we remember the habits of the tubercle-bacillus, we cannot imagine a more favourable nurture-ground than the typical b y r e - - a dark or badly-lighted space, with insufficient ventilating apertures, which are unhesitatingly closed when necessary to maintain a temperature of 60 ° to 7 °0 F. by the heat of the animals; the air consequently loaded with carbonic acid, with organic impurities and moisture, full of the dust of dried dung, never penetrated by a direct ray of sunlight, in winter never vacated either in country or town for weeks, and in cities never vacated at all.i" Well may Professor Brown, of the Agricultural Department of the Privy Council, say : " Nothing worse than the insanitary conditions of the life of the average dairy cow can b e imagined." T h e natural result is that dairy stock is ravaged with tuberculosis. Yet we never hear a farmer or a dairyman speak of tuberculosis without speaking of compensation. When he puts windows in his byre, and floods it with light,- ventilates it, a n d ceases to use his cow as a heating apparatus, it will be time enough to speak of compensation. Meanwhile, the children of the town are being infected wholesale, and it behoves the authorities, not only to take every means to eliminate tuberculous cows from dairy byres, but to enforce sanitary reform in the construction, use, and condition of byres. Bye-laws as to cubic space, ventilation, lighting, cleanliness, obtain from tuberculosis a direct interest to all men. But yet more is required. T h e Glasgow Police (Amendment) Act, 189% contains powers which, if efficiently worked, would weed out tuberculous cows, not only from Glasgow byres, but from any byre from which milk is sent to the city. I n Glasgow there are some 1,6oo cows, of which 4 ° per cent. are never outside their byres. I n I892-3-4 *"'Tuberculosis viewed as an Infectious Disease; Its Prevalence and the Frequency of Recovery from it."-Professor Josepll Coates~ Sanitary Journal, November 23rd, I891. *See valuable paper by J. MacMillan, M.B., D.Sc., Edinburgh.--" An Investigation into the Condition of the Atmosphere of Cowhouses aud Stables in Edinburgh, Leith, and the County of MidIothian.'"--JournaI of Com~azalive Pathology and 2t'Tzera2~eutics, I892.
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there were 23, 9, 7, tuberculous cows detected and eliminated by the inspectors ; but the method of inspection is thoroughly inefficient. A competent veterinary inspector ought to be at once appointed who could test with tuberculin the accuracy of the suspicions suggested by his skilled general examination. I n this way only can we hope to detect a n d abolish, as milk-producers, animals which are, no doubt, at this moment contaminating the milk supply of Glasgow. A t present o u r powers are lying dormant. After putting our own house in order, an occasional inspection of the cattle at dairy farms, chosen at random in various parts of the country, would have a most wholesome effect, not limited to the detection of a few unsound animals, but leading up to more stringent bye-laws and better sanitation in country byres. County officials require a little help from the powerful commercial lever which the purchaser of country produce can apply whenever he chooses.
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BY JAMES NlVlgN, M.B., M.A. Cantab., M.O.H. Manchester.
IN a clear and scholarly report, Dr. Russell has recently declared his position in regard to the prc~ vention of tuberculosis. I n that report he has done me the honour to single me out for special comment as the most extreme and urgent advocate of preventive measures i n this country, so far as concerns the infective matters of the disease. Coming from one who has rendered such splend i d services to public health, this can only be looked upon as a personal compliment, and one which I am disposed in part to accept, and even to vindicate, as I conceive that I shall thereby justify Dr. Russell in his selection. Dr. Russell states that a handbill was distributed to each house in Oldham in I889, Cornet's paper having appeared in 1888. T h e handbill was, in fact, distributed in the middle of 1888, directly after the appearance of Cornet's paper, which gave occasion to the distribution of rules for the prevention of phthisis, bu t by no means occasioned the rules, which were in substance given in my report on the health of Oldham in i886. This report contained an investigation into the etiology of phthisis, from the history of a number of cases, and g~tve, amongst other items, from clinical inquiry, the average period between infection and death in the adult as lying between two and three years. About the same time, Dr. Arthur Ransome issued a set of rules directed to the same object. I n 189o, again, I made a second inquiry into the etiology of a series of deaths from tuberculosis, which proved, to my mind, that the conclusions founded by Cornet on experiment, were amply borne out by ctinicat investigation. This inquiry was
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p u b l i s h e d in t h e A n n u a l R e p o r t of O l d h a m for t h a t y e a r a n d s u b s e q u e n t l y in t h e f f r a c t i t i o z e r . I n t h e A n n u a l R e p o r t o n t h e h e a l t h of O l d h a m for 1887, before C o r n e t ' s p a p e r s were p u b l i s h e d , I p l a c e d before t h e sanitary a u t h o r i t y a n d t h e m e d i cal m e n o f O l d h a m t h e c o n c l u s i o n s at w h i c h I h a d a r r i v e d a n d w h i c h I h e r e insert. EXTRACT. In my last year's report, I made a somewhat elaborate stateme~,t of inqui,ies into this disease. I do not propose to golnto the subject, this year, in that manner. But I would point, out that, though the evidence them given--that consumption is an infectious disease--is not of a very conclusive character, yet, neither, as a rule, can we readily trace the means by which the infection of scarlet fever or typhoid fever, or in fact of most of tt~e infectious diseases, is conveyed. There are in the case of consumption difficulties which do not exist with regard to the zymotie group. Chief among these i~ the long leriod of incubation, which makes detection of the original source of the disease very difficult, and the fact that consumption is a disease widely spread in the animal klngdom~ being common amongst cattle, poultry, ~ arid rabbits, so that fresh centres of contagion are constantly springing up irrespective altogether of man. The experimental evidence, however, of the infectiousness of consumption, is overwhelming, and may be taken as practically closing discus-ion. It is a~soproved that a chief source ofdaoger, us concerns the conveyance of consumption from one person to another~ lies in the matters coughed up and spat out. These contain, in large amount, the spores of the disease, and it is prohable that, where the spittleis not carefully destroyed, it dries up and ~ets scattered about as dust of a highly infectious kind. I hxve mentioned in another part of my report~ that there is reason for believing that consumption in children is often caused by the use of consumptive milk ; but impure mill< is, prob~tbly, responsible for a considerable amount of other disease~ such as summer diarrhcea, while scarlet fever and typhoid fever have been, over and over again, traced to the use of contaminated milk. H e n c e two c a r d i n a l rules which s h o u l d b e stringently c a r r i e d o u t : - I. Z~e spillIe of ~ersom affeded wit]~, or su@ected to be a/fueLed wit/~ eonsztm~tio~z, s~oztZd be destroyed at lzome @ bei~, bztrned, a n d in t/~e worksho~ ~y bein~ drugged into an oSen @~t¢oon charged w~t~ corroszve sz~bZzmale. 2. Mid 11d/k used l% food sl~onM be z~rellboiled.
T h i s by n o m e a n s e x h a u s t s t h e m a t t e r s requiring to b e c o n s i d e r e d in t h e p r e v e n t i o n of c o n s u m p t i o n , b u t I shall c o n t e n t m y s e l f with r e p e a t i n g t h e o t h e r p r a c t i c a l r e c o m m e n d a t i o n s m a d e in m y r e p o r t for 1886, w h i c h are o n t h e s a m e lines as t h o s e issued, i n d e p e n d e n t l y , by Dr. R a n s o m e , of Bowdon. T h e s e are : - i, Consumptive patients should be~ as far as possible, isolated, just like fever cases. 2. Kissing, and other intimate intercourse with them should be prohibited. 3. The rooms which they inhabit should be well aired~ and what they spit should be destroyed by fire. 4 - A non-consumptive should not sleep with a consumptive person. 5. VVhen a medical man has diagnosed consumption, the fact should be at once made known to the relations. 6. All workers in rooms filled with irritating dust, or * Chicken tuberculosis is not, now, generally regarded as giving rise to tuberculosis in man. Rabbits do notj probably, suffer much from tuberculosis in the wild state.
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fine particles of fibres, should wear respirators, and carry a stock so as to change the respirator when it gets clogged. 7. The utmost attention should be directed to the draining of damp sub-soils, and to the separation of house foundations trom damp. 8. It is of the utmost importance that the rooms be well ventilated, without draught, and that there be no overcrowding. 9. Every measure taken to improve house sanitation, such as the freer admission of light, draining and paving of back courts, &c., is directed also against consumption. Io. There is reason to' believe that consumption may be got from eating the flesh of animals who have sl.lffered from the disease, and therefore a heavy penalty sho~lld be inflicted in any case in which such flesh has been sold for food. T h e p o r t i o n s singled o u t for italics are, it will b e seen, practically i d e n t i c a l with t h e c o n c l u s i o n s arrived at by t h e A c a d d m i e d e m ~ d e c i n e in 189o (Russell, p. 34). N o t only so, b u t t h e g e n e r a l hygienic m e a s u r e s on w h i c h Dr. Russell rightly insists so strongly, are in t h a t r e p o r t clearly e n u n c i a t e d , to t h e e x t e n t to which they especially affected O l d h a m . T h e y are, o f course, p l a c e d in a s u b o r d i n a t e position to direct p r e v e n t i v e m e a s u r e s ; b u t t h a t is b e c a u s e t h e i r i m p o r t a n c e was already clearly recognised a n d u n d i s p u t e d . O n t h a t subj e c t it is well, here, to say a word or two. T o o v e r l o o k t h e i m p o r t a n t part w h i c h general a d v a n c e s in s a n i t a t i o n play in p h t h i s i s would b e trivial a n d foolish. T h e y may, however, be left to l o o k after themselves, as t h e y are n e c e s s a r y in t h e a m e l i o r a t i o n of m a n y o t h e r forms o f disease. H o w m u c h m o r e foolish m u s t it t h e n a p p e a r to a t t e n d to t h a t w h i c h r e q u i r e s n o special a t t e n t i o n , a n d to n e g l e c t t h o s e p r e c a u t i o n s w h i c h are special a n d i n c i d e n t only to t h e particular disease w h i c h it is o u r o b j e c t to p r e v e n t . A n y o n e r e a d i n g Dr. R u s s e l l ' s p a m p h l e t would i m a g i n e t h a t those, like myself, who h a v e u r g e d t h e necessity o f direct p r e v e n t i v e measures, h a v e forgotten t h e virtue of fresh air, o f o p e n spaces, a n d o f dry a n d well-lighted houses, as well as t h e evil o f overcrowding. So far from t h a t b e i n g t h e case, year after year, a n d i n c o n v e r s a t i o n w e e k after week, I h a v e from ray first e x p e r i e n c e of p u b l i c h e a l t h k e p t repeating, with w e a r i s o m e iteration, t h e evil effects of d a m p . T h e value of s u n l i g h t in t h e d e s t r u c t i o n of disease, a n d t h e necessity of ventilation, were n o t m e r e l y t a l k e d of in O l d h a m , b u t given effect to so far as t h e i n f l u e n c e of t h e h e a l t h office e x t e n d e d . T h e s e are, in fact, t h e p r i n c i p i a o f p r a c t i c a l c o n d u c t , which h a v e b e c o m e , by t h e labours Of a g e n e r a t i o n of workers, m e r e a u t o m a t i c i m p u l s e s to m e d i c a l officers of health, like b r e a t h i n g a n d sleeping. W e m a y t h e r e f o r e dismiss the p r o p o s i t i o n s in Dr. R u s s e l l ' s paper, w h i c h deal with p r e c a u t i o n s f o u n d e d o n s u c h c o n s i d e r a t i o n s as t r u e , n o d o u b t , but truisms--emphatic enunciations of undoubted verities--such as we S c o t c h m e n were said b y C h a r l e s L a m b to b e specially p r o n e to.
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All that, whether as practical recommendation or theoretic reasoning, may be set aside, and we must get at the real points of difference. Dr. Russell recapitulates the facts of infection, and joins issue on their application. In my criticism of his criticisms I have to distinguish questions of method, and quest;ons of profound difference. I take exception to the manner in which he brings out some lesser recommendations, included for the sake of completeness, and puts up the destruction of sputum as the one great direct proceeding in preventive work. Doubtless the great bulk of infection between man and man passes by means of dried sputum. Buti could any one, who has read the memorandum on phthisis of the North-Western Branch of the Association of Medical Officers of Health (drafted by Mr. Paget, of Salford) fail to remark the clearness with which this is thrown into the foreground, as the most important part of the business. No one could possibly mistake the purport of that memorandum, which was to lay special emphasis on this feature of the disease, and on the ease with which the danger might be combated. This, as I have said, appears to me more a matter of method. But there are, in reality, profound points of difference. In the first place, Dr. Russell, though friendly to the distribution of information on the infectious nature of phthisis, regards the memorandum of the North-Western Branch as alarmist in character, and calculated to place the consumptive in an unnecessarily isolated and miserable position. " I ' h e r e is," he says, "already evidence of mischief being done by the indiscriminate attachment of the idea of infection to phthsis. We have heard of a consulting physician being referred to by a clerk in one of our large warehouses, at the instance of his employers, for an opinion as to the safety of his being permitted to continue in his employment." I should like to ask what milder and more insignificant consequence could you expect, not of the infectiousness of tubercle, but of the mere suspicion that it is infectious. Moreover, where is the mischief? Surely nothing better could be done than to consult a physician on such a point. No medical man would, I presume, require that the clerk should be removed from his emplo,yment. No well-informed and conscientious physician would tell the clerk that he could continue his employment without taking certain precautions to ensure the safety of his fellow clerks. Is there, in fact, any doubt that a phthisical clerk is a distinct source of danger to the other employ6s, in the absence of precautions ? Dr. Russell tells us that the alarmist character of the memorandum of the North-Western Branch is given to it in great measure by the absence of any clause stating that, if due precautions are taken,
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the phthisical patient need be a source of danger to no one. I n considering the memorandum, the advisability of inserting such a clause was well discussed, and I, for one, was opposed to it. The object of such memoranda is to endeavour to alarm the public, and it is by no means an easy thing to do. Anyone, who has had the experience of a working and intimate acquaintance with the subject knows that nothing is more difficult than to arouse the apprehensions of the people in regard to infectious disease, and especially is this the Case in regard to such a disease as phthisis, in which you can see the end, but have to hunt for the beginning. Is it not a fact, well known to Dr. Russell, that a large section of the community are indifferent to the dangers arising from ordinary infectious disease, both to their own families and to their neighbours, and take not the slightest means to avert them ? These are not obscure dangers that they cannot see, but risks of such a disease as smallpox, the infectiousness and loathsomeness of which they e/m easily recognise. I n truth, there is no danger of alarming the people, but there is much need, if it could only be done. T h e one thing on which you can always safely rely, in peer and peasant, in the manufacturer and in the artisan, is the " conservative instinct of an ancient people." We are told that "the West E n d fear of infection is indiseriminating, even tb absurdity. Enteric fever, scarlet fever, whooping cough, and small-pox, all entail the same s6cial ostracism." Personally, I have not much experience of West E n d circles, but I should be disposed to imagine that this indiscriminate and absurd aversion to infection may have something to do with the ridiculously low mortality of the West End. T h e truth i s - - d e a r l y beloved truism--that the health of the more prosperous section of the community is not the result merely of fresh air, light, good construction, and ample room to turn round, but is due largely to the quality which makes for prosperity, namely, a faculty of attention to many details, which the h a r d e r worked section of the community have neither the ability nor the energy to bestow. But, it is not with the West End circles that sanitary authorities are most concerned. Their terrors may be safely left to the assuaging care of a skilful physician, to whom they will conduct the victim. Moreover, the extent to which exalted circles suffer from phthisis is small compared with that which afflicts the great bulk of the community, who are, it must be repeated, only too difficult to convince of the extent of the danger. I have, I hope, made it abundantly claar that I recognise equally with Dr. Russell the preponderating value to be attached, in the prevention of tuberculosis, to the destruction of the sputum. But there are other sources of infection which are by no means insignificant. It may be said, generally, that all tuberculous discharges which are
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liable to become dried and dispersed as dust, are sources of danger. Hence, I could not agree to pass indifferently by the numerous cases of discharging tuberculous glands and diseased bones which we have in our midst. Doubtless, the amount of infective matter in proportion to the total discharge is much less than in the case of phthisical lungs, but it is by no means a negligible quantity. Further, the discharges from tuberculous bowels in infants are a serious source of danger, exactly as they are in the case of typhoid fever patients suffering from diarrhcea. Then, again, there are a number of minor matters, such as the employment of eating utensils which have just been used by a tuberculous patient, and the necessity of not kissing a tuberculous person, which appear to be trifling, and by comparison, no doubt, are trifling. But they are not negligible, if it is remembered how frequently tuberculous people suffer f¥om ulcerating tuberculous sores of the mucous membrane of the mouth. T h e great object of inserting a number of details is to cause the public to reflect on the various ways in which the disease is liable to infect, and thus to add to the importance o f the central requirement, namely, the removal of tuberculous discharges. Dr. Russell says, " n o w that we have come to the practical issue to this inquiry, it is well at once to raise the question, ts tuberculosis ' an infectious d i s e a s e ? ' T h e answer is ' Y e s ' and ' N O . ' It must be apparent from what precedes, that, while in the academic sense tuberculosis is infectious, in the popular sense it is not. Even in the language o f the schools, where words are weighed and meanings are qualified to a nicety, hydrocephalus, although it is tuberculous, cannot in any sense be said to be infectious. Neither can many forms of tuberculosis o f glands, bones, and. joints. U n t i l a ' d i s c h a r g e ' is established, they cannot be infectious," and so forth. Further on, he says, "Tuberculosis, therefore, even in an academic sense, is a disease which, though in all cases caused by infection, is not in all cases infectious." Now, no one ever maintained that all cases of tuberculosis are infective, or that the disease is infective at all, until discharge ensues. Syphilis is not in all cases contagious. But that does not hinder syphilis from being a contagious disease. I do not understand all these fine distinctions. I n nil cases the infective element of tuberculosis is present, where the disease exists, and, although we must have regard to administrative possibilities, and to the necessity, of graduating our precautions according to the nature of the case, the disease is infectious in the usual sense of the term. Take, for instance, a case of tubercular meningitis in a child. There is a considerable likelihood that the infection, which produces this meningitis,
OF TUBERCULOSIS. has arisen from a previous focus in the bowels or iff the lung, as I have myself witnessed, I n the bowel, especially, the lesion may have produced no obvious effect until its contents were discharged into the vascular system. Yet, this case may well have been for some time an infective one. Moreover, the closed tuberculous cavity may, at any time, set up tuberculous change in such a position as to lead to infective discharge without any appearance of lesion. The distinction which Dr. Russell draws does not, in fact, exist in nature. Nevertheless, in urging the notification only of cases in which a tuberculous discharge was ascertained, I took, for practical purposes, the dividing line which he now draws. T h e greatest difference of opinion, however, arises in assessing the relative influence of general hygienic measures, and of special precautions in dealing with the prevention of tuberculosis. Now, I should like to make. it perfectly clear that I by no means undervalue the effect of genera~ hygienic meaures. I would not even dispute that general hygienic measures in one place may have effected more tha n specific preventive effor~ in another, though I am not aware o f any place where the latter has become an established system, ex-. cept to a very partial extent. But that is no reason why both should not be employed, and~ in my opinion, it would be infinitely easier to get specific preventive measures carried out than to do the amount of hygienic general work required to greatly reduce the disease. The number of tuberculous, people with discharging sores in any community is limited, but distress, drunkenness~ darkness, dirt, and overcrowding are recurring factors which are not so easy to control. T h e obstruction of vested interests, also, we have always with us. Moreover, just as general hygienic measures will reduce other diseases besides tuberculosis, so the notification of tuberculosis will lead to a large amount of detail work which will prevent other conditions of bad health. I n no infectious disease is the influence of co-operating causes, among which the hygienic conditions of the home and of the workshop may be specially mentioned, so potent an aid to infection as in tuberculosis. These it should be our object to discover and to remove befdre the mischief, which they help to produce, is done. Now, you cannot do this work without knowing where the cases are, and you cannot know where the cases are without notification. I will not stop here to argue this point, which is sufficiently obvious. Permit me here to recapitulate the conclusions arrived at by the Medical Society of Oldham after two evenings of arduous discussion. Extract from the La~cet, I893, Vol. II., p. 1257. OLDHAM MI~;DICALSOCIETY.~On October 24th, a discussioa on the subject of Notification of Phthsis was opened by Mr. Fawsitt, president of the society, at a very gull meeting. Several members took part in the discussion, and
PUBLIC HEALTH at the close of the meeting the subiect was adjourned to another meeting which was heId on November 7th. A number of speakers having expressed their views on the question, it was understood that the objectsof notificationwould be :-I. The sanitaty authority would disinfect the room occupied by the tuberculouspatient, as might be required. 2. Inasmuch asthe transmissionof tuberculosis is, in a l~.rge proportion of cases, determined by the presence of insanitary conditions, such as damp, overcrowding, deficiencyof 'light, and so forth, an opportunity would be afforded to the authority of removing such conditions and so saving other members of the household. 3- Further evidence would be collected bearing on the modes and conditions of transmission of the disease. 4. The personal hygiene of the patient would in no way come under the care Of the sanitary authority ; it was hoped, however, that the medical attendant would confer with the medical officer of health, when convenient, as to the precise means by which tuberculous discharges might be most usefully destroyed. At the same time, the sanitary .department would in no way interfere with tile treatment of the patient, and all instructions in dealing with discharges from the patient wonld come from the medical attendant. 5. Onlysuch caseswould be reported in which phthisical expectoration was taking place from the lungs, cases with tuberculous diarrhoea, and cases with copious discharge from tuberculous bones and tuberculous ulcers. Theseand other matters having been fullydiscussed, the tollowing resolution was carried unanimously: G~ That the Society, having had its attention drawn to the infection of tuberculous diseases and to the great mortality and injury to the population arising therefrom, is of opinion that these diseases should be the subject of voluntary notification to the sanitary authority." It wais understood that a copyof the resolution wouid be sent to the Sanita*y Committee of Oldham, as well as to the medicaljournals. The reluctance of the Oldham Medical Society to go in for compulsory notification, arose mainly from a wish to see how the thing would work out before committing themselves further. ; I may say, that I should acquiesce in the experiment of paid voluntary notification for a time, so that before it becomes compulsory, one may arrive at a modus ~ivendi. But I still hold that, in the end, notification, if it is to be of much use, must be compulsory. As regards the provision of isolation for consumptive people in the later stages of the disease, that also will, no doubt, be commenced as a voluntary proceeding. Indeed, I should never wish to do other than advance with great caution in the provision of isolation. It is, however, an urgent need, and I have therefore very great pleasure in finding that Mr. W. J. Crossley, of this city, has, on grounds of humanity, just opened a home for ten advanced phthisicar patients, the success of which I shall watch with much interest. I t will, I hope, prove the forerunner of more efforts in the same direction. I f Dr. Russell and I do not altogether agree in our views of what the facts of tuberculosis require in man, it is with the more pleasure that I heartily wish him success in his attempt to intercept the infection from tuberculous cows, though I think that he might as well have extended his efforts to other infective mammals, especially as his judgment and moderation would have been valuable in the elaboration of practical methods of procedure.
( S C O T L A N D ) BILL.
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P U B L I C H E A L T H ( S C O T L A N D ) BILL. THE Bill recently introduced in the House o~ Lords by Lord Balfour, Secretary for Scotland, proposes to amend the Public Health Act of 1867o T h e sources from which the provisions of this Bill are derived are the following : The principal Public Health Act of 1867 ; the Public Health (Scotland) Amendments Acts of 187I , 1875 , I882, 1890 , 1891 ; Public Health (England) Act of 1875 ; and the Public Health (London) Act of 189I. It will be seen that there are already in existe n c e five Amendment Acts, and the Bill now before the Lords only proposes to amend the Act of 1867, and to repeal the A m e n d m e n t A'cts i 8 7 i , i875 , i882, and 189o. The Act of i 8 6 7 - - w i t h about twenty new clauses substituted for a similar number of clauses to be repealed by the new A c t - is the measure for the reform of the principal Public Health Act for Scotland, on which Lord Balfour is to stake his name as a sanitary reformer. When the Bill was being read for the first time in the Lords, Lord Balfour raised the hopes of the medical officers and sanitary inspectors of Scotland by stating that another Bill was to follow, to codify and consolidate the variousPublie Health Acts at present in force. Although it was anticipated t h a t much confusion would ensue if the amending Bill became law in advance of the consolidating Bill, still it was satisfactory to think that at last there was a reasonable chance of homogeneity and coherency taking the place of heterogeneity a n d chaos. This hope has been doomed to disappointment, as it has leaked out that this great promise is, after all, only to be a miserable Bill to consolidate the unrepealed clauses of the Act of 1867 with the clauses of the Bill which it is expected will shortly become an Act. It is somewhat difficult to compare the sanitary laws in force in Scotland with those in England. I n such towns as Edinburgh, Glasgow, Dundee, etc., there are private municipal Acts, giving extensive powers to deal with conditions relative to the public health, and burghs are dealt with by the Burgh Police Act of 1892, which contains extensive provisions relative to water, drainage, scavenging, and cleansing. This Act only deals with populous places, which have been formed into burghs, and does not deal with rural areas at all. Rural areas are governed by the Local Government Act of I889, which, amongst other things, provided that every county and district of a county must have a medical officer with a public health qualification, and to hold his office ad vitam ant culpam. Sanitary inspectors have the same fixity of tenure. By the Burgh Police Act of I89Z, every medical officer to a burgh, appointed after May, 1894 , must be a holder of a public health qualification. I n these respects, Scotland is ahead of England ; hut~