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Collaboration between the military and sanitary authorities
1915.
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teaching which gives better skill and wisdom as to the means of material self maintenance, in every judicious public or private organisation which affords kindly saccour and sympathy to the otherwise helpless members of the community, the medical specialist gratefully recognises types of contribution often not less necessary than his own towards that great system of preventive medicine which is hoped for by sanitary reformers."
MILITARY A P P O I N T M E N T S . DR. Faas. E. Fm~XIAN'r~.E, C.M.O. tI., and S.M.O. of Hertfordshire, has been promoted to the temporary rank of Lieut.-Colonel in the R.A._M.C. (T.F.), as fl'om lhe i41h Feb. DR. A. GREENWOOD, the county medical officer of health of Kent, has beer; promoted from the rank of Major to a Lieut.-Colonel%, in the Sanitary Service, R.A.M.C. DR. W. N. W. I<.RNNgD¥e assistant medical officer of health of Croydon, has received a commission in the Ist Bart. (City of London) Sanitary Corps. . DIG GEORGE S. LF,v~s, assistant school medical officer and assistant tub.erculosis officer to line Lindsey C.C., has been appointed Captain in the R.A.M.C. I)l,'. E. COLSTON ~Vu.LLaaIS, county medical el'ricer of heahh of Brcconshire, has been appohlled lemporary lAcut., R.A.M.C., and is actinpd as Sanilary Officer o f Wi/ley Carol}, Sm'rcT,
CIVIL A P P O I N T M E N T S . DR. A. J. Mar.COL~L one of the medical assistants in the Health Department of tile London County Cour)cil, has been appointed medical officer in charge of the East End division, one of the five divisions into which London is divided for the purposes of the organisation of the work of medical inspection and treatment of school children. -DR. C. E. McDADF, has been appointed temporary medical officer of health of the Metropolitan Borough of Battcrsea during the absence of I)e. G. Q. LENNANE on active service. I)R. JAMES McDoNaLD has been appointed medical officer of health of Wednesfield U.D. DR. RORV E. MeL,~RF.N has been appointed county luberculosis officer of Dorset. DR. F. A. SHARPI,:, of Chesterfield, has been appointed medical el,fleer of health of BarnsIey. DR. J. C. SMm'H has been appointed a clinical tuberculosis officer of the County of Hampshire. DR. J. C. THOMSON. assistant medical officer of health of Dmnfrlesshire, has been appoitlted an assistant school medical officer under the Din-ham C.C. OR. Ll~wls A. WmUAMS (the school medical officer) has been appoixt~d a s s s a n t medcal officer of health' of the County Bototigl of Bradford.
LIST
OF SUCCESSFUl, CANDIDATES FOR THE AND DIPI.OMA IN V E T E RINAR'~ STATE MEDICINE, UNIVERSITY OF MANCHESTER : - - T h e
D.P.H.
following gentlemen have obtained the Diploma in Public Health: T. F. Bamford, A. G. Bryce, D. !. Dakeyne, H. H. Proudfoot, D. M. Wilson. The:}o!lowing gentleman has obtained the Diplom a in -Veterinary S t a t e Medicine : R. P. Holmes,
HEALTH.
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COLLABORATION BET\¥EEN THE MILITARY AND SANITARY AUTHORITIES.* BY S. G. M O S T Y N , M . A , M.B., D . P . H , , Medical Officer of Health and School Medical Officer of Darlington.
opening a discussion on the problems that I N the recent military situation has added to those already engaging the attention of medical officers of health, it would perhaps be simplest for me to recount my own experience at Darlington. These problems have been of great variety, and occasionally of considerable urgency, but willingness to co-operate, on the part of the military authorities and the civil authorities, always proved capable of dealing with them satisfactorily. At first the relation of the civil to the military authority seemed uncertain, but no difficulty arose o n this account, as the military officers were always ready to make use of local knowledge which the borough sanitary staffpossessed. Personally I was fortunate in having taken my holiday early this year as war was not declared until the last week that I was away. At the outbreak of the war we got ready for an immediate attack off our coasts by the enemy, but were uncertain on what lines this would take place. The question of greatest urgency was the provision of hospital accommodation f o r any wounded that might be sent to us in consequence of a naval engagement off the North East Coast. The local branch of the Red Cross Society had in some way obtained possession of one of the elementary schools and had turned it into a hospital. This action subsequently led to a good deal of not very intelligent discussion and criticism ; I consider myself fortunate that I was not at home when this action was taken. After the war settled down and no raid had been made on our coasts, critics blamed the action of the Red Cros s Society as hasty, in my opinion unfairly, as we had no reason at first to be sure that raids from the sea would form nb part of the general programme i and we had not yet learned by experienc e to feel confidence in the dpinions e x p r e s s e d b y "naval experts with regard to the impossibilty of invasion, and the unlikelihood of a raid of any magnitude with the present condition of our Fleet. In one respect I d o , t h i n k there had been too great haste. No steps had been taken to find out the hospital resources already existing in the town. At the end of the first week in August I * Read before tlm Northern Branch of the Society of Officers of yIealth on Deeel!qbe!:!St 1, 1914.
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made inquiries and found that including ninety beds arranged for by the Red Cross Society, Darlington had nearly three hundred beds which could have been used for wounded soldiers. Had all these been filled with acute cases the necessary medical attention would have severely taxed the medical men and nurses available to look after them. It would have been of no use to increase the nmnber of beds when the necessary staffto attend to them could not be obtained. Since that time we have had in Darlington about one hundred sick and wounded nursed in the workhouse hospital, a building well suited for this purpose ; thirty or more have been nursed in the Friends' Meeting House by the Red Cross Society, and from thirty to forty infectious cases from troops in the district have been treated in the Darlington fever ho.apital. I am glad to say ttiat very few of these infectious cases came from troops billeted in Darlington. At first we were a little nervous about the protection of otir water supply, not indeed because we thought that the enemy would instruct any of their agents to pollute o'ur reservoirs, but I feared that some misguided C,erman might think that any harm done to our community was a help to his country. Soon after the .outbreak of the war about five thousand men were encamped for training in two parks in the town. At first the Waterworks reservoirs which are near the town were guarded by civilians, but when the troops i came here, a guard was provided by the military authorities. I have no reason to think that this guard was really necessary. Though the arrangements for billeting might have been better in some respects, there was not very much to complain of. The sanitary notions of t h e men were at first rudimentary, but they were soon taught better ways, and finally the campswere very well kopt. Water pipes were laid down confiected with the town's supply, but great difficulties were found in disposing of waste water. The subsoil in both camps was usually impervious and unless a field drain i could be found,' the collecting pits did not discharge themselves and had to be pumped out daily irlto carts. This work was done by the staff of the borough surveyor. Pigkeepers in t he neigh bourhood readily came to remove the Swill from the camps. Their methods were crude and the receptacles they provided were unsatisfactory, but the supervision of the civil and the military sanitary staff produced great :improvement. A s soon as the camps were established I-got
Avv.IL,
into touch with the officers in command, who expressed themselves very ready and willing to have visits from the sanitary inspectors to look over the camps and make suggestions of a n y improvements that could be carried out. The military authorities were helped greatly by the inspectors in this way, as the inspectors knew the resources of the town and were able to tell them where to get materials and appliances that were needed. The latrine accommodation in the camp furthest from the town consisted of shallow open trenches. These trenches were regularly cleared every day. In the camp nearer the town and on some smaller premises where troops were billeted galvanized iron receptacles were provided and a mixture of sand and disinfectant powder was provided by the borough, surveyor to cover the d e p o s i t s . These pans also were emptied every day. After the camp was removed, care was taken to fill in these trenches and to dig over the soil near by which was likely to be fouled by urine. Since the soldiers were shifted from their summer quarters new troops have been brought into the town. These are all billeted in halls or in public schools. These troops, who are now in winter quarters, are not packed so tight as was the case when the same schools and halls were used as temporary summer quarters in August r It is possible that in a short time all the elemgntary schools in the town may be used as billets for troops, and that school work will have to be postponed at any rate until the early summer. Just at present some of the schools are being used double time so that the teachers and children, whose schools are occupied by the troops, are accommodated at other schools. It will not be possible to provide accommodation for all the school chitdren in halls or Sunday schools when the elementary schools are all used for troops, but an effort will b e made to continue theeducation of the older scholars. I am glad to say that durhig the gummer the camps Were remarkably free from infectious disease. The only insanitary condition of importance was the existence of pediculosis" vestimentorum in both camps. This is a trouble to which all encampments are l!able, and the Darlington camps were no ei~ception. It had got a firm hold before it was noticed, a n d the military medical officers at o n c e t o o k steps to deal with it. T h e troops infectecl.were treated b o t h a t the workhouse_and at the fever hosPital. In t h e latter, fortunately, there was a n empty ward available. By means of disinfecting
1915.
P U B L I C H E A L TH.
baths and by steam disinfection Of the clothing at/d bedding One camp .was'entirety freed froin this trouble, an-d the other was .almost: flee whenTthe damps were broken u p . Since the troopshave been billeted f~or the second time in the schools; there h a v e - b e e n five or-six cases of scarlet fever at one school. W a n t Of s p a t e r o o m made it very difficult to carry out disinfection of the building affected, but I have reason to think that the energetic action of the medical Officer in charge has been 'able to control the outbreak. A few cases of sore throat occurredin connexion with one of the battalions, but e'xamination of suabs by the Northern Command Laboratory o{ the military hospital at York, shewed that they were free from diphtheria bacilli. Four of the men affected were isolated at the fever hospital until the results Of the examination were known. N o Cases of typhoid fever have occurred among the t r o o p s in Darlington, btlt twenty-four cases from.Bishop Auckland have been removed to Darlington for treatment in the feve-r:hospital. This outbreak is at present b e i n g considered by a Local Government Board Inspector Who came down to investigate it, and it seems likely that the cause of it was food pollution by an infected person among the troops. Half of these cases w e r e considered ready for discharge last .week, but examples of their faeces and firine examined at the Northern Command Laborafo@, shewed that three of them still carried bacilli. These three have been retained and further specimens from them have been sent up for" examina:tion. I s h o u l d like to have the opinion of the meeting as to what steps should be taken if negative-results are not obtained in a short, time from these men. Returns of cases of infectious disease and Of all houses where such c a s e s are know to exist are made to the A~D.M-.S. , Newcastle. T h e s e houses are marked with large l e t t e r s " S," "D," an'~#"' E " f o r s c a r l e t fever, diphtheria, and enteric fever, respectively , and soldiers are informed that all houses, t h u s m a r k e d are out 5f bounds. S i n c e August the sanitary ,auth°rity has been given the names of all local Con'tractors' supplying the troops, and special attention is paid to their Shops and v~areh0uses, both withl regard {o cleanliness and with regard to t h e quality'of the goods Supplied.. The condition of t h e rooms where men are billeted varies, but o n tlhe ~a;hole it is ve.ry: good. A t first in home places there Was a
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difficulty in getting scrubbing brushes and cleaning materials owing to t h e a r m y routine in such matters, but there has been an improvement lately: It m u s t be remembered that many of these men are fresh recruits and have not yet learnt thoroughly the lessons of cleanliness, whfch it is to be hoped their army training wiU teach-them. At first men were inclined to l e a v e l o a v e s of bread and o t h e r eatables on the floor beside their kit, but this is being St0pped by the medical officers. ' It is possible that practices of this: kind at Auckland w e r e responsible for the typhoid outbreak to which I have referi'ed. Soon after the troops arrived in Darlington arrangements were made forthe.use by,them of the public baths.i~ Darlington fortunately. has a big shower bath recently put ~ in for the use of the school children. I n t h i s fifty children' can wash at the same time. This bath has been greatly appreciated by the troops. The billeting of the troops in the elementary schools seemed likely to put an end to all ordinary school medical inspection ; I was very anxious. t h a t the work of the school clinic, which has only lately been o p e n e d in DarIington, should not be interfered with. I n order that this work might go on, the medical inspection of the school children has been accelerated and modified; so as to get as large a number~of school children requiring-treatment on to our lists as possible. If-the" schools are closed after Christmas an attempt will b e m a d e . t o ' deal with cases of ringworm, defective t e e t h , defective eyesight:, and minor ailmen,ts; and it is to be hoped that a large number of cases known to exist will be-disposed of i n t h i s way. The Board of Education will, of course, n o t b e surprised if the routine medical inspection :of school children gets behindhand. Even after receiving the L o c a l Government Bdard circular in which medical officers I of h~atth were definitely instructed t o co-operate with themilitary authorities it was not clear to: me exactly where my'duties and responsibilities e n d e d . I have taken up the~p0sition that a medi'cal 0ffic& of health ig expected to know of the a'rrangements that are being made in his district , and t 9 criticize'and take steps to al}er any method s t.hathe may consider dangerous or uns~ttisfactory, but I do not consider that it is his duty to s~pervise the minor sanitatiqn of camps; as they are all trader the charge of the milita W medical' officers; I have, however, tho.ught it wise to l e t the saTnitary inspectors. pay frequent visits t o a l l places where troops B
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are living, and I m a y r e m a r k incidentally that they have taken the same p r e c a u t i o n s where Belgian refugees are living, in both cases with excellent results; the responsible officers are only too glad to have this help. I should also like in conclusion to state that the whole of the staff of m y health d e p a r t m e n t including the fever hospital have shewn themselves ready to help in every way at any time both on week days and Sundays. T h o u g h the a m o u n t of additional work required in this w a y has been very large, it has not been necessary, except at the fever hospital where the n u m b e r of patients has been greatly increased, to obtain any additional help. E v e r y o n e has clone his or her best to help with this work, which, t h o u g h quiet and out of sight of the public, is not one of the least i m p o r t a n t parts of the arrangem e n t s for c a r r y i n g on the war. DISCUSSION. DR. CAMERON said he understood that it was in rural districts that the chief difficulties had arisen. In the county of Durham it had been necessary to put some pressure on the military authorities to secure proper attention to sanitary matters. H e thought the system of filling up a latrine trench each day and making a new one would eventually lead to contamination of the whole of the surrounding ground. The practice of depositing all slops in a corner of a field was most unsatisfactory. In one instance within his knowledge, but not in this county, the place used for this purpose adjoined a reservoir~ and it had been necessary to bring up to the camp a sewer, with which a large gully was connected, down which all slops were thrown. In another case the difficulty had been met by the provision of barrels for slop-water and pails in the latrines, which were emptied daily by a local contractor. DR. TAYLOR said his experience of the military camps had not been a happy one. He had had in one camp about 5,000 troops in his district during the summer. In this camp he had found the latrine trenches placed at the highest part of a.piece of sloping ground. The trenches were six or seven feet deep. A little soil was thrown on each day, and when full the whole was covered in arid left. They were satisfactory. The method of disposal of urine and waste water was very unsatisfactory, and resulted in a very considerable nuisance. In billets he had suggested that w.c.'s be provided at one or two places where the arrangements were nmst primitive, but these were objected to on the ground that they would become choked; but he thought that soldiers were not more likely to cause chokage of w.c.'s than were civilians. W.c.'s were the proper conveniences for militaiy
*3xPRI L,
camps and billets. Objections to other necessary sanitary measures were made by the military because there was no nuisance#erceivable. In one case, at a country house, there was seine leakage from the cooking utensils, so a hole was dug in the kitchen floor, and the water allowed to collect in this, and periodically baled out with buckets. With regard to lice in clothing he had found ironing with a very hot iron efficacious. DR. RENNE¥ said he had had little trouble in Sunderland. In most of the biilets in his town the men were eating and sleeping in the same room, which was most undesirable. Owing to this the places could not be brushed out with water, and, as there were no tables, the men fed from the floor. Bread and similar articles of food were extremely likely to be contaminated. DR. KERR said his experience was very similar to Dr. Mostyn's. In camps within the city boundaries he had taken steps to prevent latrine trenches being used, and had arranged for buckets instead. An arrangement was made for the troops to use the public baths in rotation. A large amount of disinfection of blankets and clothing had been done. Such disinfection seemed to be very important. The mixing of batches of blankets was no doubt the cause of the spread of lice. He had made a point of examining every billet before occupation. Some trouble had arisen with regard to overcrowding. He understood that 4 ° square feet per man was the minimum allowance by the W a r Office for billets, but he had not insisted on more than 25 square feet, as the higher number was practically impossible in Newcastle. H e allowed privy pails where he could not get w.c.'s, more especially as he understood that most of the troops in the city would be put under canvas in the summer. In some of the billets he had had trouble from chokage of w.c.'s. The standard for closet accommodation was 5 per cent., and the same for ablution basins. Ninety-six to ninety-eight of the men in most of the units in Newcastle had been inoculated against enteric fever. Diarrhoea had given rise to much trouble, chiefly in over. crowded or dir@billets. Food was often stored uncovered in a big room, which was swept out without sprinkling, and the eatables could not but become polluted, especially seeing the filth which the men trod into the room. He thought this was the cause in the outbreaks he had experienced. His authority had come to an agreement with the military authorities to take over all cases of infectious disease amongst troops in the Northern Division at a cost which covered working expenses. Special temporary pavilions for this purpose were being erected on a site adjoining the City Hospital, and would be completed shortly.
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DR. HISLOP thought the main point was the disposal of refuse and excreta. Most of the troops in his district were billeted in public buildings or private houses. In the majority of cases w.c.'s were provided, but pails were allowed to supplement the permanent accommodation. T h e troops had access to the public baths, the men using a large spray before taking a bath. H e had done a considerable amount of work in the supervision of contractors who supplied food to the troops. DR. McLAcHLAN said that until recently few men had been quartered in his district. About a month ago, however, about 6,ooo men entered the town without the slightest warning. E v e r y school was commandeered at a moment's notice. T h e billets were grossly overcrowded, but in the exceptional circumstances nothing could be done. The men slept and ate in the same room. There had been a considerable outbreak of scarlet fever amongst the troops. This originated in a man t h o u g h t to have diphtheria. Bacteriological examination, however, proved negative, and the man returned to duty. L a t e r he was found to be desquamating. T h e closet accommodation, in addition to the w.c.'s, generally consisted of wooden erections with pails, which were emptied daily. Special pails were provided for urine. There were no public baths in this district, but in one billet the commanding officer had put up a bath for his men. LIEUT. CLEGG said a pamphlet was being distributed by the Anti-Vaccination Society, advising the men not to submit to inoculation against enteric fever. He was having trouble with the men, who were being influenced by the pamphlet. Could the B r a n c h take any action in the matter ? DR. MOSTYN, replying to the discussion, said that he did not understand at first that the medical officer of health had power to deal with billets, but Dr. Hill, the county medical officer of Durham, has informed him that this was the case even before the publication of the Local Governlnent Board circular. The trenches in the camps were well looked after ; where pans were provided a narrow plank was provided in front as a seat ; this was kept well scrubbed, and the whole arrangement was in plain view, and had no hidden corners. No charge had been made for disinfection of blankets on account of lice, but the actual expense of doing this work amounted to about ¢~< a day. Thorough disinfection of rooms in the schools was difficult, owing to the constructioI1 of the buildings, and spray disinfection had to be used-. T a b l e s were now being provided for the men s meals. T h e spread of lice m the camps was due to the men using blankets in common, and also in one case to the guard tent becoming early infected. T h e regulation of floor space was 4 ° square feet per man, but in one c a s e this had been diminished to as little as 18 square feet. The rule for the use of schools : as bglets was stated to be three men to ten children. L a r g e placards against typhoid inoculation had been posted on the hoardings, but 9 ° per cent. of the troops had been inoculated before this. It was probable that the p l a c a r d s would do harm.
HEALTH. A
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COMPARATIVE STUDY OF TOWN AND COUNTRY \VITH REGARD TO DEFECTS IN SCHOOL CHILDREN.
the outse.t, school medical officers have F ROM found difficulty i n . t u r n i n g to good account, often with inadequate clerical assistance, the vast mass o f facts now accumulating from medical inspections. The Medical Officer to the Board of E d u c a t i o n notices every year in his annual report certain useful studies, of greater or less statistical value, contained in the current local reports. This year (Report for 1912) he has suggested in his Appendix J an elaborate record of every defect in every child with a view to a comparison of summaries for different areas. Tim advantage of such summaries would, however, be very largely discounted by various inherent and uncertain differences between the several areas as regards climate, race and methods of record and observation. A carefully chosen selection of records for the elucidation of a specific problem may have a more precise value. In his sixth annual report on the. school-health of Hertfordshire, that for t9r3, Mr. F r e m a n t l e gives the first quinquennial results of medical inspection in certain districts, selected and arranged so as to give a comparison, as nearly accurate as possible, between the physical defects of children in town and country. F o r this purpose he eliminates racial and climatic differences as far as possible by selecting for the comparison the four chief towns in the county and the rural districts surrounding them. A n y personal differences of observation and record by the different medical inspectors are neutralised by the fact that in three out of four of the rural districts inspection is carried out by the same officers as in the corresponding towns, and in the fourth the difference is considered immaterial. T h e field of study consists of 18,2oi children (out of some 70,000 inspected during these five years), i2,ooo or so urban to 6,0oo rural. A large table gives the number and percentage of 25 different defects s e p a r a t e l y for boys, girls and both, respectively in the urban and rural groups at each of three ages, 5, 7 a n d ' i 2 . T h e exact definition of each group, each age, each defect, and the method of recording in e a c h case is also s t a t e d ; while tl~e chief figures are repea,ted and discussed in separate sections for each defect. W e may allude to a few of the findings. Heights arid Weights.--Village boys have the advantage both in height and weight ; but in the girls there {s no difference, except t h a t village girls in their twelfth year average 5 lbs. more than town girls. Comparative figures are given from other British inquiries. Mr. Greenwood's figures s,howed that the H e r t f o r d s h i r e children compare favourably with those of neighbouring counties, B2
PUBLIC
teaching which gives better skill and wisdom as to the means of material self maintenance, in every judicious public or private organisation which affords kindly saccour and sympathy to the otherwise helpless members of the community, the medical specialist gratefully recognises types of contribution often not less necessary than his own towards that great system of preventive medicine which is hoped for by sanitary reformers."
MILITARY A P P O I N T M E N T S . DR. Faas. E. Fm~XIAN'r~.E, C.M.O. tI., and S.M.O. of Hertfordshire, has been promoted to the temporary rank of Lieut.-Colonel in the R.A._M.C. (T.F.), as fl'om lhe i41h Feb. DR. A. GREENWOOD, the county medical officer of health of Kent, has beer; promoted from the rank of Major to a Lieut.-Colonel%, in the Sanitary Service, R.A.M.C. DR. W. N. W. I<.RNNgD¥e assistant medical officer of health of Croydon, has received a commission in the Ist Bart. (City of London) Sanitary Corps. . DIG GEORGE S. LF,v~s, assistant school medical officer and assistant tub.erculosis officer to line Lindsey C.C., has been appointed Captain in the R.A.M.C. I)l,'. E. COLSTON ~Vu.LLaaIS, county medical el'ricer of heahh of Brcconshire, has been appohlled lemporary lAcut., R.A.M.C., and is actinpd as Sanilary Officer o f Wi/ley Carol}, Sm'rcT,
CIVIL A P P O I N T M E N T S . DR. A. J. Mar.COL~L one of the medical assistants in the Health Department of tile London County Cour)cil, has been appointed medical officer in charge of the East End division, one of the five divisions into which London is divided for the purposes of the organisation of the work of medical inspection and treatment of school children. -DR. C. E. McDADF, has been appointed temporary medical officer of health of the Metropolitan Borough of Battcrsea during the absence of I)e. G. Q. LENNANE on active service. I)R. JAMES McDoNaLD has been appointed medical officer of health of Wednesfield U.D. DR. RORV E. MeL,~RF.N has been appointed county luberculosis officer of Dorset. DR. F. A. SHARPI,:, of Chesterfield, has been appointed medical el,fleer of health of BarnsIey. DR. J. C. SMm'H has been appointed a clinical tuberculosis officer of the County of Hampshire. DR. J. C. THOMSON. assistant medical officer of health of Dmnfrlesshire, has been appoitlted an assistant school medical officer under the Din-ham C.C. OR. Ll~wls A. WmUAMS (the school medical officer) has been appoixt~d a s s s a n t medcal officer of health' of the County Bototigl of Bradford.
LIST
OF SUCCESSFUl, CANDIDATES FOR THE AND DIPI.OMA IN V E T E RINAR'~ STATE MEDICINE, UNIVERSITY OF MANCHESTER : - - T h e
D.P.H.
following gentlemen have obtained the Diploma in Public Health: T. F. Bamford, A. G. Bryce, D. !. Dakeyne, H. H. Proudfoot, D. M. Wilson. The:}o!lowing gentleman has obtained the Diplom a in -Veterinary S t a t e Medicine : R. P. Holmes,
HEALTH.
159
COLLABORATION BET\¥EEN THE MILITARY AND SANITARY AUTHORITIES.* BY S. G. M O S T Y N , M . A , M.B., D . P . H , , Medical Officer of Health and School Medical Officer of Darlington.
opening a discussion on the problems that I N the recent military situation has added to those already engaging the attention of medical officers of health, it would perhaps be simplest for me to recount my own experience at Darlington. These problems have been of great variety, and occasionally of considerable urgency, but willingness to co-operate, on the part of the military authorities and the civil authorities, always proved capable of dealing with them satisfactorily. At first the relation of the civil to the military authority seemed uncertain, but no difficulty arose o n this account, as the military officers were always ready to make use of local knowledge which the borough sanitary staffpossessed. Personally I was fortunate in having taken my holiday early this year as war was not declared until the last week that I was away. At the outbreak of the war we got ready for an immediate attack off our coasts by the enemy, but were uncertain on what lines this would take place. The question of greatest urgency was the provision of hospital accommodation f o r any wounded that might be sent to us in consequence of a naval engagement off the North East Coast. The local branch of the Red Cross Society had in some way obtained possession of one of the elementary schools and had turned it into a hospital. This action subsequently led to a good deal of not very intelligent discussion and criticism ; I consider myself fortunate that I was not at home when this action was taken. After the war settled down and no raid had been made on our coasts, critics blamed the action of the Red Cros s Society as hasty, in my opinion unfairly, as we had no reason at first to be sure that raids from the sea would form nb part of the general programme i and we had not yet learned by experienc e to feel confidence in the dpinions e x p r e s s e d b y "naval experts with regard to the impossibilty of invasion, and the unlikelihood of a raid of any magnitude with the present condition of our Fleet. In one respect I d o , t h i n k there had been too great haste. No steps had been taken to find out the hospital resources already existing in the town. At the end of the first week in August I * Read before tlm Northern Branch of the Society of Officers of yIealth on Deeel!qbe!:!St 1, 1914.
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made inquiries and found that including ninety beds arranged for by the Red Cross Society, Darlington had nearly three hundred beds which could have been used for wounded soldiers. Had all these been filled with acute cases the necessary medical attention would have severely taxed the medical men and nurses available to look after them. It would have been of no use to increase the nmnber of beds when the necessary staffto attend to them could not be obtained. Since that time we have had in Darlington about one hundred sick and wounded nursed in the workhouse hospital, a building well suited for this purpose ; thirty or more have been nursed in the Friends' Meeting House by the Red Cross Society, and from thirty to forty infectious cases from troops in the district have been treated in the Darlington fever ho.apital. I am glad to say ttiat very few of these infectious cases came from troops billeted in Darlington. At first we were a little nervous about the protection of otir water supply, not indeed because we thought that the enemy would instruct any of their agents to pollute o'ur reservoirs, but I feared that some misguided C,erman might think that any harm done to our community was a help to his country. Soon after the .outbreak of the war about five thousand men were encamped for training in two parks in the town. At first the Waterworks reservoirs which are near the town were guarded by civilians, but when the troops i came here, a guard was provided by the military authorities. I have no reason to think that this guard was really necessary. Though the arrangements for billeting might have been better in some respects, there was not very much to complain of. The sanitary notions of t h e men were at first rudimentary, but they were soon taught better ways, and finally the campswere very well kopt. Water pipes were laid down confiected with the town's supply, but great difficulties were found in disposing of waste water. The subsoil in both camps was usually impervious and unless a field drain i could be found,' the collecting pits did not discharge themselves and had to be pumped out daily irlto carts. This work was done by the staff of the borough surveyor. Pigkeepers in t he neigh bourhood readily came to remove the Swill from the camps. Their methods were crude and the receptacles they provided were unsatisfactory, but the supervision of the civil and the military sanitary staff produced great :improvement. A s soon as the camps were established I-got
Avv.IL,
into touch with the officers in command, who expressed themselves very ready and willing to have visits from the sanitary inspectors to look over the camps and make suggestions of a n y improvements that could be carried out. The military authorities were helped greatly by the inspectors in this way, as the inspectors knew the resources of the town and were able to tell them where to get materials and appliances that were needed. The latrine accommodation in the camp furthest from the town consisted of shallow open trenches. These trenches were regularly cleared every day. In the camp nearer the town and on some smaller premises where troops were billeted galvanized iron receptacles were provided and a mixture of sand and disinfectant powder was provided by the borough, surveyor to cover the d e p o s i t s . These pans also were emptied every day. After the camp was removed, care was taken to fill in these trenches and to dig over the soil near by which was likely to be fouled by urine. Since the soldiers were shifted from their summer quarters new troops have been brought into the town. These are all billeted in halls or in public schools. These troops, who are now in winter quarters, are not packed so tight as was the case when the same schools and halls were used as temporary summer quarters in August r It is possible that in a short time all the elemgntary schools in the town may be used as billets for troops, and that school work will have to be postponed at any rate until the early summer. Just at present some of the schools are being used double time so that the teachers and children, whose schools are occupied by the troops, are accommodated at other schools. It will not be possible to provide accommodation for all the school chitdren in halls or Sunday schools when the elementary schools are all used for troops, but an effort will b e made to continue theeducation of the older scholars. I am glad to say that durhig the gummer the camps Were remarkably free from infectious disease. The only insanitary condition of importance was the existence of pediculosis" vestimentorum in both camps. This is a trouble to which all encampments are l!able, and the Darlington camps were no ei~ception. It had got a firm hold before it was noticed, a n d the military medical officers at o n c e t o o k steps to deal with it. T h e troops infectecl.were treated b o t h a t the workhouse_and at the fever hosPital. In t h e latter, fortunately, there was a n empty ward available. By means of disinfecting
1915.
P U B L I C H E A L TH.
baths and by steam disinfection Of the clothing at/d bedding One camp .was'entirety freed froin this trouble, an-d the other was .almost: flee whenTthe damps were broken u p . Since the troopshave been billeted f~or the second time in the schools; there h a v e - b e e n five or-six cases of scarlet fever at one school. W a n t Of s p a t e r o o m made it very difficult to carry out disinfection of the building affected, but I have reason to think that the energetic action of the medical Officer in charge has been 'able to control the outbreak. A few cases of sore throat occurredin connexion with one of the battalions, but e'xamination of suabs by the Northern Command Laboratory o{ the military hospital at York, shewed that they were free from diphtheria bacilli. Four of the men affected were isolated at the fever hospital until the results Of the examination were known. N o Cases of typhoid fever have occurred among the t r o o p s in Darlington, btlt twenty-four cases from.Bishop Auckland have been removed to Darlington for treatment in the feve-r:hospital. This outbreak is at present b e i n g considered by a Local Government Board Inspector Who came down to investigate it, and it seems likely that the cause of it was food pollution by an infected person among the troops. Half of these cases w e r e considered ready for discharge last .week, but examples of their faeces and firine examined at the Northern Command Laborafo@, shewed that three of them still carried bacilli. These three have been retained and further specimens from them have been sent up for" examina:tion. I s h o u l d like to have the opinion of the meeting as to what steps should be taken if negative-results are not obtained in a short, time from these men. Returns of cases of infectious disease and Of all houses where such c a s e s are know to exist are made to the A~D.M-.S. , Newcastle. T h e s e houses are marked with large l e t t e r s " S," "D," an'~#"' E " f o r s c a r l e t fever, diphtheria, and enteric fever, respectively , and soldiers are informed that all houses, t h u s m a r k e d are out 5f bounds. S i n c e August the sanitary ,auth°rity has been given the names of all local Con'tractors' supplying the troops, and special attention is paid to their Shops and v~areh0uses, both withl regard {o cleanliness and with regard to t h e quality'of the goods Supplied.. The condition of t h e rooms where men are billeted varies, but o n tlhe ~a;hole it is ve.ry: good. A t first in home places there Was a
161
difficulty in getting scrubbing brushes and cleaning materials owing to t h e a r m y routine in such matters, but there has been an improvement lately: It m u s t be remembered that many of these men are fresh recruits and have not yet learnt thoroughly the lessons of cleanliness, whfch it is to be hoped their army training wiU teach-them. At first men were inclined to l e a v e l o a v e s of bread and o t h e r eatables on the floor beside their kit, but this is being St0pped by the medical officers. ' It is possible that practices of this: kind at Auckland w e r e responsible for the typhoid outbreak to which I have referi'ed. Soon after the troops arrived in Darlington arrangements were made forthe.use by,them of the public baths.i~ Darlington fortunately. has a big shower bath recently put ~ in for the use of the school children. I n t h i s fifty children' can wash at the same time. This bath has been greatly appreciated by the troops. The billeting of the troops in the elementary schools seemed likely to put an end to all ordinary school medical inspection ; I was very anxious. t h a t the work of the school clinic, which has only lately been o p e n e d in DarIington, should not be interfered with. I n order that this work might go on, the medical inspection of the school children has been accelerated and modified; so as to get as large a number~of school children requiring-treatment on to our lists as possible. If-the" schools are closed after Christmas an attempt will b e m a d e . t o ' deal with cases of ringworm, defective t e e t h , defective eyesight:, and minor ailmen,ts; and it is to be hoped that a large number of cases known to exist will be-disposed of i n t h i s way. The Board of Education will, of course, n o t b e surprised if the routine medical inspection :of school children gets behindhand. Even after receiving the L o c a l Government Bdard circular in which medical officers I of h~atth were definitely instructed t o co-operate with themilitary authorities it was not clear to: me exactly where my'duties and responsibilities e n d e d . I have taken up the~p0sition that a medi'cal 0ffic& of health ig expected to know of the a'rrangements that are being made in his district , and t 9 criticize'and take steps to al}er any method s t.hathe may consider dangerous or uns~ttisfactory, but I do not consider that it is his duty to s~pervise the minor sanitatiqn of camps; as they are all trader the charge of the milita W medical' officers; I have, however, tho.ught it wise to l e t the saTnitary inspectors. pay frequent visits t o a l l places where troops B
162
PUBLIC HEALTH.
are living, and I m a y r e m a r k incidentally that they have taken the same p r e c a u t i o n s where Belgian refugees are living, in both cases with excellent results; the responsible officers are only too glad to have this help. I should also like in conclusion to state that the whole of the staff of m y health d e p a r t m e n t including the fever hospital have shewn themselves ready to help in every way at any time both on week days and Sundays. T h o u g h the a m o u n t of additional work required in this w a y has been very large, it has not been necessary, except at the fever hospital where the n u m b e r of patients has been greatly increased, to obtain any additional help. E v e r y o n e has clone his or her best to help with this work, which, t h o u g h quiet and out of sight of the public, is not one of the least i m p o r t a n t parts of the arrangem e n t s for c a r r y i n g on the war. DISCUSSION. DR. CAMERON said he understood that it was in rural districts that the chief difficulties had arisen. In the county of Durham it had been necessary to put some pressure on the military authorities to secure proper attention to sanitary matters. H e thought the system of filling up a latrine trench each day and making a new one would eventually lead to contamination of the whole of the surrounding ground. The practice of depositing all slops in a corner of a field was most unsatisfactory. In one instance within his knowledge, but not in this county, the place used for this purpose adjoined a reservoir~ and it had been necessary to bring up to the camp a sewer, with which a large gully was connected, down which all slops were thrown. In another case the difficulty had been met by the provision of barrels for slop-water and pails in the latrines, which were emptied daily by a local contractor. DR. TAYLOR said his experience of the military camps had not been a happy one. He had had in one camp about 5,000 troops in his district during the summer. In this camp he had found the latrine trenches placed at the highest part of a.piece of sloping ground. The trenches were six or seven feet deep. A little soil was thrown on each day, and when full the whole was covered in arid left. They were satisfactory. The method of disposal of urine and waste water was very unsatisfactory, and resulted in a very considerable nuisance. In billets he had suggested that w.c.'s be provided at one or two places where the arrangements were nmst primitive, but these were objected to on the ground that they would become choked; but he thought that soldiers were not more likely to cause chokage of w.c.'s than were civilians. W.c.'s were the proper conveniences for militaiy
*3xPRI L,
camps and billets. Objections to other necessary sanitary measures were made by the military because there was no nuisance#erceivable. In one case, at a country house, there was seine leakage from the cooking utensils, so a hole was dug in the kitchen floor, and the water allowed to collect in this, and periodically baled out with buckets. With regard to lice in clothing he had found ironing with a very hot iron efficacious. DR. RENNE¥ said he had had little trouble in Sunderland. In most of the biilets in his town the men were eating and sleeping in the same room, which was most undesirable. Owing to this the places could not be brushed out with water, and, as there were no tables, the men fed from the floor. Bread and similar articles of food were extremely likely to be contaminated. DR. KERR said his experience was very similar to Dr. Mostyn's. In camps within the city boundaries he had taken steps to prevent latrine trenches being used, and had arranged for buckets instead. An arrangement was made for the troops to use the public baths in rotation. A large amount of disinfection of blankets and clothing had been done. Such disinfection seemed to be very important. The mixing of batches of blankets was no doubt the cause of the spread of lice. He had made a point of examining every billet before occupation. Some trouble had arisen with regard to overcrowding. He understood that 4 ° square feet per man was the minimum allowance by the W a r Office for billets, but he had not insisted on more than 25 square feet, as the higher number was practically impossible in Newcastle. H e allowed privy pails where he could not get w.c.'s, more especially as he understood that most of the troops in the city would be put under canvas in the summer. In some of the billets he had had trouble from chokage of w.c.'s. The standard for closet accommodation was 5 per cent., and the same for ablution basins. Ninety-six to ninety-eight of the men in most of the units in Newcastle had been inoculated against enteric fever. Diarrhoea had given rise to much trouble, chiefly in over. crowded or dir@billets. Food was often stored uncovered in a big room, which was swept out without sprinkling, and the eatables could not but become polluted, especially seeing the filth which the men trod into the room. He thought this was the cause in the outbreaks he had experienced. His authority had come to an agreement with the military authorities to take over all cases of infectious disease amongst troops in the Northern Division at a cost which covered working expenses. Special temporary pavilions for this purpose were being erected on a site adjoining the City Hospital, and would be completed shortly.
1915.
PUBLIC
DR. HISLOP thought the main point was the disposal of refuse and excreta. Most of the troops in his district were billeted in public buildings or private houses. In the majority of cases w.c.'s were provided, but pails were allowed to supplement the permanent accommodation. T h e troops had access to the public baths, the men using a large spray before taking a bath. H e had done a considerable amount of work in the supervision of contractors who supplied food to the troops. DR. McLAcHLAN said that until recently few men had been quartered in his district. About a month ago, however, about 6,ooo men entered the town without the slightest warning. E v e r y school was commandeered at a moment's notice. T h e billets were grossly overcrowded, but in the exceptional circumstances nothing could be done. The men slept and ate in the same room. There had been a considerable outbreak of scarlet fever amongst the troops. This originated in a man t h o u g h t to have diphtheria. Bacteriological examination, however, proved negative, and the man returned to duty. L a t e r he was found to be desquamating. T h e closet accommodation, in addition to the w.c.'s, generally consisted of wooden erections with pails, which were emptied daily. Special pails were provided for urine. There were no public baths in this district, but in one billet the commanding officer had put up a bath for his men. LIEUT. CLEGG said a pamphlet was being distributed by the Anti-Vaccination Society, advising the men not to submit to inoculation against enteric fever. He was having trouble with the men, who were being influenced by the pamphlet. Could the B r a n c h take any action in the matter ? DR. MOSTYN, replying to the discussion, said that he did not understand at first that the medical officer of health had power to deal with billets, but Dr. Hill, the county medical officer of Durham, has informed him that this was the case even before the publication of the Local Governlnent Board circular. The trenches in the camps were well looked after ; where pans were provided a narrow plank was provided in front as a seat ; this was kept well scrubbed, and the whole arrangement was in plain view, and had no hidden corners. No charge had been made for disinfection of blankets on account of lice, but the actual expense of doing this work amounted to about ¢~< a day. Thorough disinfection of rooms in the schools was difficult, owing to the constructioI1 of the buildings, and spray disinfection had to be used-. T a b l e s were now being provided for the men s meals. T h e spread of lice m the camps was due to the men using blankets in common, and also in one case to the guard tent becoming early infected. T h e regulation of floor space was 4 ° square feet per man, but in one c a s e this had been diminished to as little as 18 square feet. The rule for the use of schools : as bglets was stated to be three men to ten children. L a r g e placards against typhoid inoculation had been posted on the hoardings, but 9 ° per cent. of the troops had been inoculated before this. It was probable that the p l a c a r d s would do harm.
HEALTH. A
163
COMPARATIVE STUDY OF TOWN AND COUNTRY \VITH REGARD TO DEFECTS IN SCHOOL CHILDREN.
the outse.t, school medical officers have F ROM found difficulty i n . t u r n i n g to good account, often with inadequate clerical assistance, the vast mass o f facts now accumulating from medical inspections. The Medical Officer to the Board of E d u c a t i o n notices every year in his annual report certain useful studies, of greater or less statistical value, contained in the current local reports. This year (Report for 1912) he has suggested in his Appendix J an elaborate record of every defect in every child with a view to a comparison of summaries for different areas. Tim advantage of such summaries would, however, be very largely discounted by various inherent and uncertain differences between the several areas as regards climate, race and methods of record and observation. A carefully chosen selection of records for the elucidation of a specific problem may have a more precise value. In his sixth annual report on the. school-health of Hertfordshire, that for t9r3, Mr. F r e m a n t l e gives the first quinquennial results of medical inspection in certain districts, selected and arranged so as to give a comparison, as nearly accurate as possible, between the physical defects of children in town and country. F o r this purpose he eliminates racial and climatic differences as far as possible by selecting for the comparison the four chief towns in the county and the rural districts surrounding them. A n y personal differences of observation and record by the different medical inspectors are neutralised by the fact that in three out of four of the rural districts inspection is carried out by the same officers as in the corresponding towns, and in the fourth the difference is considered immaterial. T h e field of study consists of 18,2oi children (out of some 70,000 inspected during these five years), i2,ooo or so urban to 6,0oo rural. A large table gives the number and percentage of 25 different defects s e p a r a t e l y for boys, girls and both, respectively in the urban and rural groups at each of three ages, 5, 7 a n d ' i 2 . T h e exact definition of each group, each age, each defect, and the method of recording in e a c h case is also s t a t e d ; while tl~e chief figures are repea,ted and discussed in separate sections for each defect. W e may allude to a few of the findings. Heights arid Weights.--Village boys have the advantage both in height and weight ; but in the girls there {s no difference, except t h a t village girls in their twelfth year average 5 lbs. more than town girls. Comparative figures are given from other British inquiries. Mr. Greenwood's figures s,howed that the H e r t f o r d s h i r e children compare favourably with those of neighbouring counties, B2