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DIFFICULTIES UNDER THE INFECTIOUS DISEASES (NOTIFICATION) ACT.
DIFFICULTIES UNDER THE INFECTIOUS DISEASES in their further dissemination. There is, indeed, evidence for believing that flies or other insects may be the media of infection. It is, however, by systematic inquiries, such as
by the medical officer of health of Norwich, expect ultimately to find an answer to such
we
1297
respect of these details will probably
those carried out
that
(NOTIFICATION) ACT.
may and it is
be combined with carelessness in other directions-as, for instance, in the disposal of the ejecta and the washing of the napkins, so that in one and the same household all the conditions may conceivably be present for the transmission of infective material from the sick child to the otherwise healthy infant. The fact that the Shiga or Flexner-Harris bacillus appears to be a more or less normal constituent of the bacterial flora of the alimentary tract in infants may explain some of the cases of apparent autogenous origin. In these cases it may be assumed that the natural powers of resistance have been reduced to the danger point by various debilitating conditions. Such a view, however, does not in the least lessen the advisability of taking every precaution to prevent the further dissemination of the virus, and further it emphasises the necessity for maintaining the powers of resistance of the infant at the highest pitch
gratifying to see that many of our officers of health are taking up the question of infant feeding with In America the Rockefeller Institute for Medical zeal. Research has recently undertaken to support an investigation with a view to the elucidation of the bacteriology of summer diarrhoeas in children and to defray the expense of testing upon infants suffering from one or another of the varieties of the disease the value of an anti-dysenteric serum obtained from horses which have been previously inoculated with the bacillus dysenterim. The report of the investigations which have so far been concluded and which has been edited by Dr. SiMON FLEXNER and Dr. EMMETT HoLT has been published recently and was reviewed in our columns. Its perusal possible by the best methods of feeding. leaves little doubt that most, if not all, serious dysenteric diarrhoeas in infants are associated with, if not directly due to, the presence of either the Shiga or Flexner-Harris variety of the bacillus dysenteric ; indeed, in the extended "Ne quid nimis." researches which have been conducted to test the value of the anti-dysenteric serum it has been assumed that this DIFFICULTIES UNDER THE INFECTIOUS causal association does exist. Although the results so far DISEASES (NOTIFICATION) ACT. obtained from the use of the anti-dysenteric serum do not EVER since the introduction of compulsory notification permit of any very definite expression of opinion as to its of infectious disease cases have been numerous in which therapeutic value or general trustworthiness, nevertheless practitioners have resented several of the methods followed they are sufficiently encouraging to justify a continuation of by local authorities. These conflicts have taken a variety the researches on the lines hitherto pursued by those of forms but they usually originate in, and centre investigators who have been working in cooperation with the round, questions connected with the diagnosis of the Rockefeller Institute. Since at present there are no means at notified disease. Diagnosis, it must be admitted, has its social and legal as well as its clinical perplexities. hand of clinically distinguishing the different varieties or, Some diseases are seldom mentioned by name in the perhaps more correctly, strains of bacilli to which the circle and many others are by the average ininfection in any individual case may be due it has been veiled under discreet euphemisms. In ordinary found advisable to employ a polyvalent serum obtained from cases it is not the duty of strangers to probe the facts, animals immunised against the two more definite types so far but when the disease happens to be a notifiable one a number of interests, some of them conflicting, are at once recognised-naniely, the Shiga and the Flexner-Harris affected. A person falls ill and is declared to have a bacilli. For although the Shiga serum is not without some feverish cold or tonsillitis or nettlerash-a tentative effect in infections with the Flexner-Harris type of organism diagnosis and often given very guardedly. Not much and vice versi the effect is noticeably better when serum is is thought of the matter until the family is alarmed employed which is possessed of a polyvalency. by the appearance of what is evidently a similar case With a view to the prevention of the disease this report either in the same household or in that of friends or from the Rockefeller Institute well deserves attention, since neighbours. Then the diagnosis is revised in the light of recent events and the disease is acknowledged to be scarlet it establishes beyond a doubt that these dysenteric diarrhoeas fever, or diphtheria, or measles, or small-pox. The facts now are contagious, although the degree of their contagion and become public property and people may say that the medical the method of the distribution of the micro-organisms con- adviser is to blame, for if he had understood questions
.
’
.
Annotations.
domestic
dividual
greatly
cerned
up the clinical conclusions which may be drawn in reference to the question of infection Dr. HoLT says :"From present experience are
not
yet proved.
In
summing
high degree of contagion does not seem probable ; the spreading takes place most likely through the discharges ; this calls attention to the necessity for disinfection and the
a
closest attention to prevent contamination of food or water by persons handling the child’s napkins." This recommendation is of special interest when taken in conjunction with Dr. PATTIN’S observations-namely, that in the great
majority of fatal cases
discoverable,
either
u handled and and
as
gross act of negligence is usually regards the manner in which the milk some
kept, or as regards insanitary feeding bottles.
the
use
of unboiled water
Acts of carelessness in
the nature of the first case the relatives and friends would have been warned in time and the further extension of the disease might have been prevented. Of course, cases occur where medical men are too positive in their first impressions, but as a rule it is the friends of the patient who jump to pleasing conclusions before a certain medical opinion can be given. The position of a medical man who has too hastily pronounced a case to be infectious and has set in motion the machinery by which the patient is removed to the isolation hospital is, again, a very uncomfortable one. Several possibilities then present themselves, one of which is that the patient may shatter the diagnosis by the involuntary"control experiment " of contracting the illness which he was supposed to have had at the time of admission. In the hope of lessening these mishaps some medical officers of health have systematically themselves examined
1298 notified
the purpose suggests at first sight a danger owing to the volatile nature of mercurial salts. On the other hand it is conceivable that a good proportion of the chloride of mercury injected would be rendered inert by combining with the cellular substances of the wood and forming an innocuous, insoluble, and fixed compound of mercury. Yet in, the case of arsenical wall-papers we know that the arsenic exists in an insoluble form, in spite of which symptoms of arsenical poisoning are often experienced by individuals sleeping in a room papered with a paper coloured with arsenical pigment. It has been stated by some that the arsenic is converted into a gaseous form by the intervention of a mould and others have been content to conclude that the poisoning arises from the occurrence of a fine arsenical dust in the air of the room. We should hardly expect to find that any transformation of mercury into a permanent gas would be accomplished by moulds, but it is possible that the dust in a room timbered with mercurialised timber would be found to contain mercury, Considering the volatile nature of mercurial compounds we think that on the whole their use for preserving timber destined for building domestic dwellings at any rate is undesirable, especially in view of the fact that other agents much less dangerous than mercuric salts are probably just as effective in arresting or preventing the In the great majority of notified cases of infectious disease it attacks of "dry rot." Moreover, when timber is properly appears to the Board to be both unnecessary and undesirable that a seasoned there is no necessity for impregnating it with medical officer of health should make such examinations. Special cases may, however, arise from time to time, as where the disease is poisonous substances at all as long as it is fixed in buildings suspected to be one which would threaten serious danger to the which are efficiently ventilated. Dampness is the precursor community or where the attendant circumstances might call for exceptional action, in which it is desirable that the medical officer of of "dry rot."
cases prior to removal to hospital-an injudicious for the willing cooperation of the medical profession policy, and the general public with the sanitary authorities is essential in any successful scheme of disease prevention, and medical officers of health might foresee that their visits to private houses would not be regarded with favour in any quarter. Misunderstandings of various kinds became so frequent after the passing of the Act that nearly ten years ago-viz., in January and February, 1895-a series of articles on the subject appeared in THE LANCET, which In a have since been reprinted in pamphlet form. chapter entitled, The Nature of the Visit by the Medical Officer of Health," a concluding paragraph expressly states that the medical officer of health has no right to inspect patients, that such inspection is as a rule very undesirable, and that it should not be contemplated, even when it is necessary, except after communication with, and if possible in cooperation with, the medical practitioner in attendance on the case. But that the practice still obtains among some medical officers of health is shown by a correspondence which we have just received from the President of the Medical Defence Union, Limited. In one of these letters, which are dated in October, 1904, and addressed by the Local Government Board to a borough council and a rural council respectively, the Board says :......
--
health in order to be better able to advise his council should make a personal examination of the patient. A notified case of chicken-pox in an adult or adolescent or occurring under circumstances favouring the THE DWELLINGS OF THE POOR. spread of infection is an instance in point, many outbreaks of smallin cases at first mistaken for pox having originated chicken-pox. WE have received the report for the year ending Indeed, it is for the purpose of facilitating the detection of such unhas in cases of that districts June 30th last of the Mansion House Council on the small-pox many recognised chicken-pox been made compulsorily notifiable during the recent prevalence of of the Poor and congratulate the council upona small-pox. In this connexion I am to remind the Boro Council of the Dwellings Board’s circular letter of Dec. 27th, 1901. It must, however, be record of good work, discreetly conducted. The main busiremembered that a personal examination can only be made with the consent of the patient or of those having charge of the patient ; and it is ness of the council is to promote the formation of local desirable that the medical practitioner in charge of the case should committees throughout the metropolitan area, committees always be conzm2anieated with and that his coöperation should be secured where it is possible to do so without involving undue delay. composed of persons interested in the sanitary well-being oi The Board would point out the importance of exercising tact and the locality and willing to give their services to promote discretion where a reconsideration of the diagnosis upon which the of has is notification the case been based involved. sanitary reform. Caution in the choice of such persons is
The Local Government Board here legal and professional views.
exactly
the very sensible and proper should not be harassed by many different visitors, and it is laid down as imperatively necessary that no distribution of charity should be made in the name of the committees, which are constituted for an entirely different purpose. Their business is to receive complaints of insanitary domestic conditions and to see that these are rectified either by tenants or owners or by appeals to local authorities to enforce the law. It is manifest that the existence of such committees will be likely to have a powerfully stimulating effect upon local administration, even to the extent of assisting to bring about the election of the most suitable candidates for public office, and that it will also render good service in the education of public opinion. For the better attainment of this latter object the committees are provided with leaflets and other means of instruction, and they are directed to keep in touch with School Board visitors and other workers in the respective districts as well as to obtain the aid of local ministers of all denominations in making sanitary work a regular part of the duties of their district visitors. The general report contains summaries of the separate reports of the local committees for Bethnal Green, Hampstead, Kennington, Mile End, North and East St. Pancras, Shoreditch, Whitechapel, St. George’s-in-the-East, and Limehouse, and we regret to observe that both in Bethnal Green and in Mile End the aid given by the clergy of specified churches is described as affording a contrast to general clerical indifference. Such indifference seems to us to be not only a
specially recommended ground that the poor
state the proper
IS TIMBER PRESERVED WITH CORROSIVE SUBLIMATE INJURIOUS TO HEALTH P THIS question has been addressed to us by a correspondent who states that within recent years, owing to the rapidity with which modern buildings are being constructed and the consequent use of immature and imperfectly seasoned wood, a great demand for perchloride of mercury for destroying the fungus merulius lacrymans, popularly known that formerly as "dry rot," has arisen. It appears " a process known as "Kyanising" (after the name of the patentee Kyan) was employed which consisted in immersing the timber in a bath of corrosive sublimate. As far as preserving goes the method has been improved byr placing the wood in a chamber in which the air and moisture! are partially .removed from the wood cells and then ani alcoholic solution of corrosive sublimate is injected under pressure. Similar processes have been employed in which, however, far less powerful substances than corrosive: sublimate have been used. Such are calcium chloride: and sulphate of iron, chloride of zinc, tar, and creasote, acetate of iron impregnation being effected in a strong. cylindrical vessel connected with an exhaust pump. In this; vessel a vacuum is first produced and then a high pressureI is applied so as to force the liquid as far as possible into theI pores of the wood. The use of perchloride of mercury for .
,
on
by the medical officer of health of Norwich, expect ultimately to find an answer to such
we
1297
respect of these details will probably
those carried out
that
(NOTIFICATION) ACT.
may and it is
be combined with carelessness in other directions-as, for instance, in the disposal of the ejecta and the washing of the napkins, so that in one and the same household all the conditions may conceivably be present for the transmission of infective material from the sick child to the otherwise healthy infant. The fact that the Shiga or Flexner-Harris bacillus appears to be a more or less normal constituent of the bacterial flora of the alimentary tract in infants may explain some of the cases of apparent autogenous origin. In these cases it may be assumed that the natural powers of resistance have been reduced to the danger point by various debilitating conditions. Such a view, however, does not in the least lessen the advisability of taking every precaution to prevent the further dissemination of the virus, and further it emphasises the necessity for maintaining the powers of resistance of the infant at the highest pitch
gratifying to see that many of our officers of health are taking up the question of infant feeding with In America the Rockefeller Institute for Medical zeal. Research has recently undertaken to support an investigation with a view to the elucidation of the bacteriology of summer diarrhoeas in children and to defray the expense of testing upon infants suffering from one or another of the varieties of the disease the value of an anti-dysenteric serum obtained from horses which have been previously inoculated with the bacillus dysenterim. The report of the investigations which have so far been concluded and which has been edited by Dr. SiMON FLEXNER and Dr. EMMETT HoLT has been published recently and was reviewed in our columns. Its perusal possible by the best methods of feeding. leaves little doubt that most, if not all, serious dysenteric diarrhoeas in infants are associated with, if not directly due to, the presence of either the Shiga or Flexner-Harris variety of the bacillus dysenteric ; indeed, in the extended "Ne quid nimis." researches which have been conducted to test the value of the anti-dysenteric serum it has been assumed that this DIFFICULTIES UNDER THE INFECTIOUS causal association does exist. Although the results so far DISEASES (NOTIFICATION) ACT. obtained from the use of the anti-dysenteric serum do not EVER since the introduction of compulsory notification permit of any very definite expression of opinion as to its of infectious disease cases have been numerous in which therapeutic value or general trustworthiness, nevertheless practitioners have resented several of the methods followed they are sufficiently encouraging to justify a continuation of by local authorities. These conflicts have taken a variety the researches on the lines hitherto pursued by those of forms but they usually originate in, and centre investigators who have been working in cooperation with the round, questions connected with the diagnosis of the Rockefeller Institute. Since at present there are no means at notified disease. Diagnosis, it must be admitted, has its social and legal as well as its clinical perplexities. hand of clinically distinguishing the different varieties or, Some diseases are seldom mentioned by name in the perhaps more correctly, strains of bacilli to which the circle and many others are by the average ininfection in any individual case may be due it has been veiled under discreet euphemisms. In ordinary found advisable to employ a polyvalent serum obtained from cases it is not the duty of strangers to probe the facts, animals immunised against the two more definite types so far but when the disease happens to be a notifiable one a number of interests, some of them conflicting, are at once recognised-naniely, the Shiga and the Flexner-Harris affected. A person falls ill and is declared to have a bacilli. For although the Shiga serum is not without some feverish cold or tonsillitis or nettlerash-a tentative effect in infections with the Flexner-Harris type of organism diagnosis and often given very guardedly. Not much and vice versi the effect is noticeably better when serum is is thought of the matter until the family is alarmed employed which is possessed of a polyvalency. by the appearance of what is evidently a similar case With a view to the prevention of the disease this report either in the same household or in that of friends or from the Rockefeller Institute well deserves attention, since neighbours. Then the diagnosis is revised in the light of recent events and the disease is acknowledged to be scarlet it establishes beyond a doubt that these dysenteric diarrhoeas fever, or diphtheria, or measles, or small-pox. The facts now are contagious, although the degree of their contagion and become public property and people may say that the medical the method of the distribution of the micro-organisms con- adviser is to blame, for if he had understood questions
.
’
.
Annotations.
domestic
dividual
greatly
cerned
up the clinical conclusions which may be drawn in reference to the question of infection Dr. HoLT says :"From present experience are
not
yet proved.
In
summing
high degree of contagion does not seem probable ; the spreading takes place most likely through the discharges ; this calls attention to the necessity for disinfection and the
a
closest attention to prevent contamination of food or water by persons handling the child’s napkins." This recommendation is of special interest when taken in conjunction with Dr. PATTIN’S observations-namely, that in the great
majority of fatal cases
discoverable,
either
u handled and and
as
gross act of negligence is usually regards the manner in which the milk some
kept, or as regards insanitary feeding bottles.
the
use
of unboiled water
Acts of carelessness in
the nature of the first case the relatives and friends would have been warned in time and the further extension of the disease might have been prevented. Of course, cases occur where medical men are too positive in their first impressions, but as a rule it is the friends of the patient who jump to pleasing conclusions before a certain medical opinion can be given. The position of a medical man who has too hastily pronounced a case to be infectious and has set in motion the machinery by which the patient is removed to the isolation hospital is, again, a very uncomfortable one. Several possibilities then present themselves, one of which is that the patient may shatter the diagnosis by the involuntary"control experiment " of contracting the illness which he was supposed to have had at the time of admission. In the hope of lessening these mishaps some medical officers of health have systematically themselves examined
1298 notified
the purpose suggests at first sight a danger owing to the volatile nature of mercurial salts. On the other hand it is conceivable that a good proportion of the chloride of mercury injected would be rendered inert by combining with the cellular substances of the wood and forming an innocuous, insoluble, and fixed compound of mercury. Yet in, the case of arsenical wall-papers we know that the arsenic exists in an insoluble form, in spite of which symptoms of arsenical poisoning are often experienced by individuals sleeping in a room papered with a paper coloured with arsenical pigment. It has been stated by some that the arsenic is converted into a gaseous form by the intervention of a mould and others have been content to conclude that the poisoning arises from the occurrence of a fine arsenical dust in the air of the room. We should hardly expect to find that any transformation of mercury into a permanent gas would be accomplished by moulds, but it is possible that the dust in a room timbered with mercurialised timber would be found to contain mercury, Considering the volatile nature of mercurial compounds we think that on the whole their use for preserving timber destined for building domestic dwellings at any rate is undesirable, especially in view of the fact that other agents much less dangerous than mercuric salts are probably just as effective in arresting or preventing the In the great majority of notified cases of infectious disease it attacks of "dry rot." Moreover, when timber is properly appears to the Board to be both unnecessary and undesirable that a seasoned there is no necessity for impregnating it with medical officer of health should make such examinations. Special cases may, however, arise from time to time, as where the disease is poisonous substances at all as long as it is fixed in buildings suspected to be one which would threaten serious danger to the which are efficiently ventilated. Dampness is the precursor community or where the attendant circumstances might call for exceptional action, in which it is desirable that the medical officer of of "dry rot."
cases prior to removal to hospital-an injudicious for the willing cooperation of the medical profession policy, and the general public with the sanitary authorities is essential in any successful scheme of disease prevention, and medical officers of health might foresee that their visits to private houses would not be regarded with favour in any quarter. Misunderstandings of various kinds became so frequent after the passing of the Act that nearly ten years ago-viz., in January and February, 1895-a series of articles on the subject appeared in THE LANCET, which In a have since been reprinted in pamphlet form. chapter entitled, The Nature of the Visit by the Medical Officer of Health," a concluding paragraph expressly states that the medical officer of health has no right to inspect patients, that such inspection is as a rule very undesirable, and that it should not be contemplated, even when it is necessary, except after communication with, and if possible in cooperation with, the medical practitioner in attendance on the case. But that the practice still obtains among some medical officers of health is shown by a correspondence which we have just received from the President of the Medical Defence Union, Limited. In one of these letters, which are dated in October, 1904, and addressed by the Local Government Board to a borough council and a rural council respectively, the Board says :......
--
health in order to be better able to advise his council should make a personal examination of the patient. A notified case of chicken-pox in an adult or adolescent or occurring under circumstances favouring the THE DWELLINGS OF THE POOR. spread of infection is an instance in point, many outbreaks of smallin cases at first mistaken for pox having originated chicken-pox. WE have received the report for the year ending Indeed, it is for the purpose of facilitating the detection of such unhas in cases of that districts June 30th last of the Mansion House Council on the small-pox many recognised chicken-pox been made compulsorily notifiable during the recent prevalence of of the Poor and congratulate the council upona small-pox. In this connexion I am to remind the Boro Council of the Dwellings Board’s circular letter of Dec. 27th, 1901. It must, however, be record of good work, discreetly conducted. The main busiremembered that a personal examination can only be made with the consent of the patient or of those having charge of the patient ; and it is ness of the council is to promote the formation of local desirable that the medical practitioner in charge of the case should committees throughout the metropolitan area, committees always be conzm2anieated with and that his coöperation should be secured where it is possible to do so without involving undue delay. composed of persons interested in the sanitary well-being oi The Board would point out the importance of exercising tact and the locality and willing to give their services to promote discretion where a reconsideration of the diagnosis upon which the of has is notification the case been based involved. sanitary reform. Caution in the choice of such persons is
The Local Government Board here legal and professional views.
exactly
the very sensible and proper should not be harassed by many different visitors, and it is laid down as imperatively necessary that no distribution of charity should be made in the name of the committees, which are constituted for an entirely different purpose. Their business is to receive complaints of insanitary domestic conditions and to see that these are rectified either by tenants or owners or by appeals to local authorities to enforce the law. It is manifest that the existence of such committees will be likely to have a powerfully stimulating effect upon local administration, even to the extent of assisting to bring about the election of the most suitable candidates for public office, and that it will also render good service in the education of public opinion. For the better attainment of this latter object the committees are provided with leaflets and other means of instruction, and they are directed to keep in touch with School Board visitors and other workers in the respective districts as well as to obtain the aid of local ministers of all denominations in making sanitary work a regular part of the duties of their district visitors. The general report contains summaries of the separate reports of the local committees for Bethnal Green, Hampstead, Kennington, Mile End, North and East St. Pancras, Shoreditch, Whitechapel, St. George’s-in-the-East, and Limehouse, and we regret to observe that both in Bethnal Green and in Mile End the aid given by the clergy of specified churches is described as affording a contrast to general clerical indifference. Such indifference seems to us to be not only a
specially recommended ground that the poor
state the proper
IS TIMBER PRESERVED WITH CORROSIVE SUBLIMATE INJURIOUS TO HEALTH P THIS question has been addressed to us by a correspondent who states that within recent years, owing to the rapidity with which modern buildings are being constructed and the consequent use of immature and imperfectly seasoned wood, a great demand for perchloride of mercury for destroying the fungus merulius lacrymans, popularly known that formerly as "dry rot," has arisen. It appears " a process known as "Kyanising" (after the name of the patentee Kyan) was employed which consisted in immersing the timber in a bath of corrosive sublimate. As far as preserving goes the method has been improved byr placing the wood in a chamber in which the air and moisture! are partially .removed from the wood cells and then ani alcoholic solution of corrosive sublimate is injected under pressure. Similar processes have been employed in which, however, far less powerful substances than corrosive: sublimate have been used. Such are calcium chloride: and sulphate of iron, chloride of zinc, tar, and creasote, acetate of iron impregnation being effected in a strong. cylindrical vessel connected with an exhaust pump. In this; vessel a vacuum is first produced and then a high pressureI is applied so as to force the liquid as far as possible into theI pores of the wood. The use of perchloride of mercury for .
,
on