Proceedings of the Birmingham and Midland branch of the incorporated society of medical officers of health

PUBLIC

HEALTH,

Etje ~0ur~al of ttJ~ En¢0]~pm;at~ ~0ci~t~ ol; ~lJica~ OMm:~ of ~ealt~. S U B S C R I B E R S ' C O P I E S o/ PUBLIC HEALTH are supi~lied at los. 6d. per amzum. Single copies One Shillinf. B O U N D V O L U M E S . - - C o p i e s o f Volume 4 are now ready. Bound in cloth, gilt lettered. The yearly Volume now commences with t~e October number. .4 f e w copies of Vols. I and 2 remain on hand, price lOS. 6d. C L O T H C O V E R S for Bindingthe Volumes, price Is. 6d., may be had by order o/any Bookseller, or of the Publisher, E. W. ,411en, 4, .4~e ~/Iaria Lane, E.C. ADVERTISEMENTS.--Communlca¢iom rdaN.~" to `4dvertisements should be addressed to Messrs. PP'.t L d: L . Colllngridge, z48 and I49, `4Ider~gate Street, )E. C. Readers o/Papers before the Sociely can oMain anyreasonable number of colhies o/thefou~nal at a special price, depending upon the number required, on application to the lion. Sea. Medical O~cers o f IJeatth and other Correspondents are requested to send regularly all published re#errs and matters o/ interesf bearing upon Sanilation go the Editor, I5, College 2~oad, Br(~Mon.

PROCEEDINGS OF THE BIRMINGHAM AND MIDLAND BRANCH OF THE INCORPORA'FED SOCIETY OF MEDICAL OFFICERS OF HEALTH. A MEETING Of t h e B i r m i n g h a m a n d M i d l a n d B r a n c h was h e l d at N o t t i n g h a m o n W e d n e s d a y , July 5th. T h e m e m b e r s a s s e m b l e d at t h e Guildhall, Nott i n g h a m , a n d were c o n d u c t e d by Dr. B o o b b y e r ( M . O . H . , N o t t i n g h a m ) to t h e I n f e c t i o u s H o s p i t a l at B a g t h o r p e , where l u n c h was p r o v i d e d b y t h e C o r p o r a t i o n . A l t e r i n s p e c t i o n of t h e buildings, t h e m e m b e r s r e t u r n e d to t h e G u i l d h a l l for t h e meeting. T h e following were p r e s e n t : Dr. A. H i l l (president), Drs. R e i d , Barwise, B o o b b y e r , B o s t o c k Hill, May, Clark, Wills, Iliffe, C h a m b e r s , L i t t l e j o h n , M e r e d i t h R i c h a r d s , Bailey, a n d Manley, a n d Mr. H a r r i s o n , of Derby. Dr. ALFRED HILL briefly expressed his pleasure i n p r e s i d i n g over t h e first m e e t i n g of t h e b r a n c h in N o t t i n g h a m , a n d t h e t h a n k s of t h e m e m b e r s to t h e N o t t i n g h a m C o r p o r a t i o n for t h e i r k i n d n e s s a n d hospitality. H e also s p o k e in t e r m s of a d m i r a t i o n of t h e h o s p i t a l at B a g t h o r p e . Dr. MEREDITH RICHARDS ( N o t t i n g h a m ) t h e n r e a d a paper, DISCUSSION.

Dr. ALFRED HILL, in complimenting the author of the paper, spoke first of the difficulties attending early notifica. tion. The present generation of medical men had not happily that experience of small-pox which had been vouchsafed to their predecessors, and besides the early diagnosis of Variola was by no means easy, the modification of the No. 64. AUGUST, X893.

disease by vaccination rendering many cases uncertain. The custom in Birmingham was to send the resident medical officer of the infectious hospital to decide cases of doubtful diagnosis, tie certainly did not consider it his duty to visit every case notified, nor would he "have leisure to do so. With regard to efficient disinfection, in his opinion it could only be efficient when done by the sanitary authority. Dr. ILIFF~ (Derby) agreed that the supervision of diagnosis by the medical officer of health was quite impossible, and further, that it would seriously imperil the good feeling which should exist between the medical officer of health and the other practitioners. His own custom was to only visit such cases as a consultant, and charge the usual guinea. Otherwise he thought the medical attendant must take the responsibility of his own diagnosis. In Derby disinfection was almost always performed by the sanitary authority. With respect to probation wards, he failed to see much use in them, unless they were separate rooms con. taining one patient only, and with separate preparation of food, etc., etc. Dr. MANLEY (West Bromwich) spoke of the risks of keep ing small-pox in the same institution as other diseases. This question had recently been given considerable prominence, and he regretted that Dr. Priestley had left before giving them the story of the Leicester experiences. He wished to know how far the wards should be apart to ensure anything like safety Everybody, of course, kne W the classical reports of Power and Barry, and the inference that small-pox spread by aerial infection. The question was of great interest to him, because at the present moment both diseases were under treatment in his own hospital only 7° yards apart. It had been suggested that entirely separate hospitals should be provided, but he felt that if that were suggested there would be a danger of frightening sanitary authorities by the double expense and losing the isolation of diseases other than small-pox. Dr. BOOB]~YER(Nottingham) said that the Local Government Board insisted upon complete separation. At Nottingham it was lOCi yards. They had, however, old experience at Nottingham in Dr. Seatou's time, where small= ox had spread across an intervening space of 4o feet. here had, however, been cases comparatively recently where the Local Government Board had sanctioned a space of only ioo feet. Dr. MAY (Aston Manor) heartily congratulated Nottingham and its officers on their attention to detail. He admired the fact that Dr. Boobbyer had personally visited every notified ease of small-pox, but he felt thatD without going as far as that, an amount of intelligent preliminary supervision could be exercised. He preferred to correct errors before patients were taken to hospital, and did not believe in the practicability of quarantine wards. If quarantine was successfully carried out the expense of private rooms and separate nurses to each room would be enormous. At Aston, on a site of four acres, the Local Government Board had absolutely declined to permit more than one disease to be treated, making it an absolute condition of granting a loan. Dr, BARWlSE(Derbyshire) invited the president to state the experience of Birmingham with regard to mixed hos. pitals. He did not believe that local authorities would decline to maintain two entirely separate institutions ; in facts he had persuaded Blackburn to do so. He approved of observation wards, where cases could be detained forty-eight hours for absolute diagnosis. Dr. BOSTOCKHILL (Sutton Coldfield) said that forty-eight M

322

PROCEEDINGS OF THE BIRMINGHAM

hours were not enough for certain diagnosis. Recent ex. periences of his own had demonstrated the great difficulty of distinguishing modified small-pox from chicken-pox. He did not consider it the duty of the medical officer of health to visit other men's cases unless specially requested. It was neither right iia law nor in etiquette. He felt that if a mistake m diagnosis had been made the medical mart notifying was responsible~and that the medical officer of health was fully protected by law. Dr. H. LITTLEJOHN (Sheffield) said they had tried the two diseases on the same site at a distance of fifty yards, but that he felt there was considerable danger. The sanitary authority did their own disinfecting, and took no medical certificate from anyone. With regard to visiting, every medical man had to be treated according to his ideas, many of the cheaper practitioners expected no etiquette in the matter, and he was not careful to observe it except with those of higher professional ethics. Dr. ALFREDHILL briefly explained the arrangements at the Birmingham Hospital, and expressed his disbelief in aerial infection. Dr. MEREDITHRICHARDSbriefly replied. Dr. Boobbyer read a short paper on " Cholera Precautions," but time did not permit of any discussion.

PRECAUTIONS AGAINST CHOLERA. Dr. BOOBBYER stated that when preparing a report upon this subject some little time before for his committee and the Local Government Board, he had been struck at the outset with the difficulty of stating exactly by what practical measures such an urban authority as that of Nottingham should endeavom', in the face of an epidemic, to carry into effect those preventive principles that all are so ready to lay down as necessary of observance. As to the actual factors essential to the production of an epidemic of cholera he did not concern himself greatly ; probably neither Pettenkofer nor Koch were altogether right, Impure food, water, air, subsoil, and general surroundings certainly determined the incidence and fostered the spread of cholera, and as water was very liable to pollution, and, when polluted, a very certain medium for bringing the virus into intimate relation with the internal human economy, it had c o m e - - a n d probably with much j u s t i c e - - t o be regarded as a primcipat agent in the propagation of the disease. Many people, indeed, at the present time would go the length of saying that satisfactory attention need only be paid to public water supplies in order to insure practical immunity even in the most active epidemic times. T h e speaker referred to Mr, Ernest H a r t ' s advocacy of the water-carriage theory in America, and cited the comparative immunity of Altona during the Hamburg epidemic of 1892 as one of the most striking examples on record, of the advantage of purifying a public water supply (by filtration) during the epidemic prevalence of cholera. H e also referred to the experience of the London water companies in 1849, 1854, 1856, and i866 as evidence of the same import. The case of the isolated family at H a m p s t e a d infected through drinking water from the distant Golden Square

AND MIDLAND BRANCH.

pump, in I854, was perhaps the most remarkable of all. Still, as with typhoid, so with cholera, we must not forget the existence of air-borne dust, of fomites, even of flies, and the whole class of agents to which such belong. As practical sanitarians it behoved us, he said, to guard against all possible sources of danger, and to advocate, at any rate, the use of the best possible means of prevention. The pathogenic r61e of the comma bacillus was pretty generally admitted, but protective inoculation was not likely, in the near future at any rate, to become the first line of defence. T h e general adoption of such a measure indeed was probably undesirable, except perhaps among persons living in districts abroad where the disease was endemic owing to hopeless insanitation. Quarantine, though still prac. tised in this country and abroad, and especially advocated in America, had long been losing ground among scientific men. Though undoubtedly of much value, when properly enforced, in preventing the introduction of persons liable to communicate the disease among those previously uninfected, it was, he said, unfortunately liable to frequent evasion ; also by giving rise to a feeling of false security among the ignorant, it might prevent the removal of those insanitary conditions which were known to foster the spread of the disease. As Pettenkofer had said, it was far more satisfactory to remove the explosive material than tO endeavour to enclose it, o r ' c a t c h the sparks falling into it. Dr. Boobbyer next proceeded to enumerate the actual precautions he had considered it desirable to recommend in face of an epidemic. 1. Water Su~ply.--This in Nottingham being almost exclusively derived from deep borings in the Bunter Sandstone, filtration was unnecessary, but the people in the outlying suburbs, where shallow well, or even river water, were sometimes used, would be urged to boil invariably before applying it to any domestic purpose. Filtration was not recommended because domestic filters, unless wisely chosen in the first instance, and subsequently well looked alter, were worse than useless. T o show that even deep borings in solid rock were not always entirely sale, he mentioned an instance in Nottingham where a fault in the Bunter Sandstone had been found to allow of a connection between the water in the borehole and the drainage o f a neighbouring cemetery. H e laid stress upon the necessity of exercising a strict supervision over all workmen and plant employed in the manipulation of water intended for, or in c o u r s e of distribution. T h e Worthing and Caterham epidemics of typhoid were cited to show that the danger from work-people was not only imaginary. 2. D r a i n a g e . I D e f e c t i v e drainage must be looked to, and disconnection from the house and public sewers, whenever possible, insisted on.

PRECAUTIONS AGAINST Unless the rainfall should reach an aggregate "5 inch during a week, all drains, public and private, and all courts, alleys, and streets should be flushed at least once in that period. All cholera stools should, as far as possible, be excluded from the drains, special iron pails being provided iJor their reception. It should not be forgotten that comma bacilli were stated to have been detected in impure harbour water at Marseilles twelve weeks after their passage horn the body. Closets.--Privies and wooden pails, the speaker said, were anachronisms. Where existent, they should be scavenged, the first once a month, the second once a week at the least. Iron pails, or some form of w.c. or w. latrine, were the only admissible forms. T h e public were to be urged to disinfect the pail contents as far as possible with crude carbolic each night ; they were to be warned also of the danger of neglecting the flushing apparatus of w.c.'s and latrines, especially when interior. A special iron pail should be provided (as in the case of typhoid fever) for every house in which a case of cholera was notified, to receive the dejections of all the inmates, whether affected with the disease or not. The pail should be furnished with a spring lid, and be accompanied by a drum of crude carbolic acid for disinfecting the contents. It should be removed for scavenging once in the twenty-four hours, and its contents burnt in the destructor. Before being returned it should be thoroughly cleansed with an iron wire scrubber, and one in ten solution of carbolic acid. In towns such as Nottingham, where the pail system was still in use, a huge bulk of night soil (more than I,ooo tons a week in Nottingham) had to be disposed of, and a great part of u, in inland towns at any rate, must still be used as manure in neighbouring districts. Dr. Boobbyer would not advise his authority to attempt the destruction or disinfection of this material in any quantity. Special precautions, as described above, he thought, must be confined to specifically infected dejections. He had strongly impressed upon his committee the absolute necessity tor the immediate exportation of all such material from the town ; there must be no tips or other deposits within one mile of any populous places. By a standing order maintained throughout the period of epidemic prevalence, all other accumulations within the borough must be reduced to a minimum. Horse manure and dry house refuse, for instance, should be scavenged at least twice a week ; offensive trade refuse must be removed (by thetrader) daily. All that could not be immediately disposed of as manure must go to the destructor. The Keeping of Pigs, Poultry, etc., in populous places should, as far as possible, be curtailed ; much could be, and, lately, had been done in many large towns, by quiet and persistent discouragement, in this direction. Imfwrtation of Possible Tomites.--An excellent

CHOLERA.

323

system of notification was now in force in many of our ports for bringing the fact of such importation to the knowledge of the inland local authority. Nottingham had only to do with a small quantity of lace, hosiery, and the like material under this heading. Rags and other refuse material imported so largely by many towns were matters probably of more serious consideration. Milk Su~ply.--Most towns and welt-managed rural districts had now regulations in force respecting their dairies and cow-sheds, and a certain amount of reciprocity could in most cases be counted upon between neighbouring districts. Notwithstanding this, however, it was far safer to insist upon the invariable necessity of boiling all milk before using it as food. Butter, cream, and cheese were doubtless also possible sources of danger, but very difficult to deal With sarisfactorily. Public ftandbills.--Dr. Boobbyer thought that nothing but good could result from the issue of these, warning the public of the principal sources of danger, and particularly enjoining the necessity of protecting their mouths and all going into them against contact with infected material. BrigadeSurgeon Striven had given an account of cases seen by him in India where cholera was apparently contracted by the act of kissing. Typhoid fever was undoubtedly often acquired by attendants, through simple carelessness, or uncleanliness. The printed rules should comprise simple instruction for the nursing of the sick and the management of a house with an infected inmate. Notification should, of course, be as prompt as possible by telephone, telegraph, or messenger. This had been obtained for small.pox ; it could doubtless be secured for cholera. In the case of cholera promptitude was especially desirable if removal to hospital were contemplated, because, unless the patient were taken in the first stage, removalwould often be out ofthequestion. It had long been the custom in Nottingham for the medical officer of health to verify the diagnosis of all reported cases of small-pox, and such a course he would endeavour to follow with cholera. With a due regard on his part to the feelings of the medical attendants, there was he thought very little liability to a misunderstanding between him and them. The provisions under section 83, Public Health Act, I875 , would be enforced (in Nottingham) for cholera as they had been for small-pox. The casuals at the two large workhouses in the Boro' would also be daily inspected by a medical man. Patients would be removed to hospital in the Corporation Ambulances, which would be mopped out with a solution of perchloride of mercury after each time of using. In the hospital the same precautions in dealing with the patient, his dejecta, and his surroundings would be adopted as were advocated for home M

2

324

PROCEEDINGS OF THE

NORTH-WESTERN BRANCH.

nursing. After disinfection the stools would be absorbed by sawdust and burnt in the hospital incinerator. The disinfection of houses, premises, and household material would invariably, as with other dangerous zymotics, be undertaken by the Health Department. The bodies of cholera victims would, if possible, be buried in 9 feet graves outside the town within 12 hours of death. Public opinion was not yet sufficiently advanced for cremation. In conclusion, Dr. Boobbyer stated that his remarks were intended to open a discussion upon a subject of importance, and one necessarily of much interest to all of them at the present time, although he was fain to regard the existing cholera scare, so far at any rate as most inland towns were concerned, as little more than a blessing disguised, an excellent sanitary stalking horse. The members dined together at the George Hotel. During dinner Dr. Boobbyer's health was drunk with great enthusiasm, and he was warmly congratulated on his recent marriage. PROCEEDINGS OFTHE NORTH-WESTERN B R A N C H OF T H E INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. THE ordinary monthly meeting of this branch was held at the rooms of the Chemical Club, Manchester, on Friday, July i4th, at 4 p.m. Present: Drs. Paget (president), Anderson, Barr, Gornall, Graham, Kenyon, Littlejohn, Niven, Patterson, Pilkington, Porter, Robertson, Sellers, Sergeant, Tattersall, and Wheatley. The minutes of the last monthly meeting were read and confirmed. It was resolved upon the motion of Dr. NIVEN, seconded by Dr. KENYON, " T h a t this branch expresses its general approval of the Public Health Acts Amendment Bill." It was proposed by Dr. ANDERSON, seconded by Dr. WHEATLEY, and resolved, " T h a t a Subcommittee, consisting of Drs. Paget, Anderson, Niven, and Wheatley be appointed to further consider this Bill." Read a letter from Lord Thring, acknowledging a communication from the branch, expressing approval of.the Infectious Hospitals Bill. Read a letter from J. Carter Bell, Esq., thanking the branch for electing him an associate. H. R. Etches, L.R.C.P., Lond., M.R.C.S. and D.P.H,, Lond., Deputy Medical Officer of Health for Macclesfield, who was nominated at the last meeting of the branch, was duly elected a member. The following nomination was r e a d : R. S. Marsden, M.B., C.M., D.Sc., F.R.S.E., Medical Officer of Health for Birkenhead ; proposed by Dr. VACHER, and seconded by Dr. PAGET.

A paper on '~ Small-pox" was then read by Dr. NIVEN. SMALL-Pox PROBLEMS. By J-AMES NIVEN, M.O.H. for Oldham. I do not intend to trouble you t~-night with detailed masses of statistics or interesting episodes in the history of small-pox cases. " In venturing again on the subject of small-pox, which has been so well treated by so many writers, and to which Dr. Gornall, son of the medical officer of health for Warrington, has recently made so valuable a contribution, my object is rather to come at once to the consideration of important practical matters. I n regard to vaccination I have to chronicle the usual course of events, although I wishto direct attention to an attempt to throw some light on a question regarding the history of small-pox. Smallpox was imported from Batley into Oldham in the early part of January, i892 , having been there contracted by a young man who went from Oldham to see a football match ~ and pursued a straggling and indefinite course up to November, when it assumed formidable proportions, which it has since maintained. With two exceptions all the cases have been treated in Westhulme Hospital, lying on the outskirts of Oldham and Chadderton, though nearest to Chadderton, from which it is only I oo yards away. Not only have the Oldham cases been treated here, but all those from the neighbouring districts of Chadderton, Royton, and Crompton. It is alleged that the presence of the hospital has caused a very formidable incidence of the disease in Chadderton. My purpose, then, is to give you in as brief a form as possible the results of an examination of the course of small-pox in Oldham from the beginning of ~892 up to the end of March, i893 , and to see what practical influences can be drawn therefrom. I wish also to ask the question, Is compulsory vaccination necessary, and could we get on without it ? This question is necessarily, I think, raised by the course of small-pox in Oldham, a course similar to that which it pursued in the previous much slighter outbreak of i888. Then the question of small-pox hospitals is an important one, and on that also our experience throws some light. Let me first dispose of the vaccination statistics : Up to June x 7th, I893, therewere treated altogether in Westhutme Hospital 6o 5 cases. Reckoning amongst the unvaccinated those with no marks of vaccination as well as those vaccinated not more than twelve days before the appearance of the small-pox eruption, we get : Vacc.

Unvacc.

Died.

Recovered, Vacc.

Unvacc.

447 759 542 79 44 The case death percentage is thus amongst the vaccinated 4"3, amongst the unvaccinated 27"7. I also show in the annexed form on the above supposition the number of cases of vaccinated and