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Illness from defective sewer ventilation
234
ILLNESS
FROM
DEFECTIVE
Dr. Walford's r e c o m m e n d a t i o n , and appointed the Veterinary Inspector under the Contagious Diseases (Animals) Act to act as M e a t I n s p e c t o r under the H e a l t h Department, at an inclusive salary o f . ~ ' 3 o o . For the purposes of his Report, Dr. Walford addressed a circular letter to certain medical officers inquiring as to the practice of m e a t inspection prevailing u n d e r their jurisdictions. T h e replies are of interest, not only as showing how little is really done in this direction as c o m p a r e d with the practice abroad, but also as to the varying m e t h o d of doing what is done. Believing that m a n y of our readers will find t h e replies o f use for their own guidance, and as a point o f departure in dealing with t h e subject in the future, the tabulated statement included in Dr. Walford's R e p o r t is given here. L o n d o n is not i n c l u d e d in the list, but there is a very thorough system of inspection in force at Deptford, and, as far as we know, at Islington. F o r the rest o f t h e Metropolis, everything d e p e n d s on t h e - v a r i o u s local authorities. With the exception o f the abattoirs under the jurisdiction o f t h e City Corporation, where a very large proportion of the L o n d o n slaughtering takes place, the Metropolitan slaughter-houses, although very greatly i m p r o v e d in recent years, leave much to be desired.
SEWER ILLNESS
VENTILATION. FROM DEFECTIVE VENTILATION.
SEWER
THE grave difficulties frequently encountered when attempting to secure a d e q u a t e ventilation ot the public sewers, m o r e especially of " d e a d ends,'" are illustrated by the following extracts from a report to the Legislative Council of N e w South Wales, presented by Dr. J. Ashburton T h o m p s o n , President of the Board of H e a l t h of t h e Colony. I t appears that in October, 1894, a ventilator was erected against the side of a chapel in Sydney, at the h e a d o f a b r a n c h sewer. I n close proximity to the chapel there are three d e t a c h e d h o u s e s " S h e n l e y , " distant about 45 ft., north and west of the ventilator, " U r a l l a , " distant some IO 5 ft., west and south of the ventilator, and " G l a d s m u i r , '~ distant about 65 ft., south a n d east of the ventilator. All the m e a s u r e m e n t s are to the nearest corner of each building. Complaints were early m a d e o f smells from the shaft, which was in the first instance constructed as an inlet, and subsequently converted into an outlet. T h e records of illness at each house are given by Dr. T h o m p s o n , and are as follows : - -
STATigMENT furnished by Mr. W. C. D , "Shenley."--Length of residence at '" Shet~ley" ? Eight years last December (I895). --Present number of inmates ? Six adults and four children.--Statement as to illnesses during whole tenancy ? We had little or no illness previous to the erection of the ventilator, excepting the children (four) having measles and colds, and my eldest boy having rheumatism. Approximate date of attack.
Initials.
Remarks.
Kind of Illness.
Duration of illness, six weeks. Trained nurse, four weeks. Sore throat ; high temperature. Pronounced by Dr. Shewen as a " drain throat '~ ; ill a fortnight. Very bad throat (ulcerated) ... Since this time Miss O. has been subject to frequent attacks diarrhoea. Feverish attack, vomitin Ill four days. diarrhcea. Used same remedies as Dr. Lamrock predo. do . . . . . . . scribed in illness of other child (B. D.), Ulcerated throat .................. Ill several days. Very bad throat (ulcerated) ; Doctor attended for three weeks. Boy in high temperature, bed over a fortnight. Feverish attack, with sore Used remedies as previously prescribed by throat. Dr. Lamrock.
Miss H. O. (adult) ...... ! Oct. x7th, I894 ... Typhoid fever ..................... Mrs. D. (adult) ............ i Dec. 2ist, I894 ... Feb. 28th, I895 ... B. D. (three years)
April 6th, x895
O. D. (five years) ......... April I3th , I895 ... C. D. (ten years) ......... J u l y - - , 1895 ...... It. D. (fourteen years)... Oct. --, 1895 ......
tI. O. and C ............... ; C h r i s t m a s Day, x895, and New I Year's Day, I896 W. D ...................... ! Jan. I 6 t h , I 8 9 6 ... Diphtheria ........................
Ill in bed for three weeks. nurse for three weeks.
With trained
, "Uralla."--Length of residence at " Uralla," Llandaff street ? About eight years. STATEMENT furnished by Mr. F. B --Present number of inmates? Four females and One male ; Five adults (four females, one male) and four children, three boys and one girl. Initials.
m~
a~O~SStlO~BQ~O~I
Approximate date of attack, i
Kind of Illness.
Before erection of shaft ...... Measles and whooping cough ......... After erection o~ shaft ...... Sore throats and diphtheritic tonsilitis.
Milk from ? Date of change of source (if any). Source (c) over four years, and at present from source (a).
ILLNESS FROM D E F E C T I V E SEWER V E N T I L A T I O N .
235
STATEMENT furnished by Mr. H R. H , " G l a d s m u i r . ' - - L e n g t h of residence at " G t a d s m u i r " ? Ten months.--Preseut number of inmates? Three at present, usual number seven (four being away at Moss Vale); five adults and two children {two males and five females).
Initials. N. H ......................... H. H . . . . . . . . . . . . . . . . . . . . . . . . D. H ......................... H . H .........................
Approximate date of attack.
Kind of IHness.
Milk from?" D a ' e of change of source (if any).
Source (~), ,...... June, I895 ......... C o l d . . . . . . . . . . . . . . . . . . . . . . . . . . October, I895 ...... Stomach attack and sore throat November, 1895 ... Feverish attack .................. Stomach attack .................. January, r896 ...... Cold and stomach attack and sore throat.
Commenting on these clinical histories, Dr. Thompson remarks : These attacks nearly all occurred consecutively (in any one household), and not simultaneously. T h e y were spread out over all the time since erection of the pipe-ventilator down to the beginning of January, I896. T h e y are, it will be perceived, illnesses of precisely those kinds which are commonly met with among people who are exposed to breathing sewer air; and while, on the one hand, it is certain that such illnesses are not due to morbifie microbes arising from the sewersj it is equally certain (and on the same experimental ground) that frequent breathing of such air acts chemically "on the body, and so as to render its attack by morbifie germs commonly floating in the upper air extremely more certain than it is in states of health such as are conduced to by pure air. T h e action of sewer air on the h u m a n body is similar to that of other chemical agents, among which it is to be classed, and hence the illnesses it produces are sometimes merely a diarrhoea or merely a slight fever, and at others an attack of specific disease such as diphtheria. For, in the former case, the probability seems to be that the illness may be merely a manifestation of natural efforts to get rid of the poison by a direct channel ; in the latter, and either during the effort mentioned, or before the body has reacted in that way to the chemical poison, a specific morbific germ is implanted (not from the same sewer air, but in the ordinary course of daily life), and is able to grow where, but for the chemical deterioration of the constitution caused by the sewer air, it would have been successfully fought and killed. T h u s , in two cases out of three, responsible people who have lived where they are now found for eight years, say, first, that illnesses which required medical attendance, and which were of the kinds commonly known to be associated with sewer air, did repeatedly occur in their households after erection of the shaft in question, and had never occurred during about six and a-half years which had elapsed before it was erected ; while the third can merely say that four or five cases of illness of those characteristic kinds had occurred during the ten months of his residence ; and, secondly, two of them say that offensive smells were first perceived after erection of the shaft, while the third can, of course, merely say that offensive smells have been perceptible at times during his term of residence. Now, I have no hesitation in saying that this evidence, as far as it has been described, is extremely forcible. Nevertheless there remain certain points tobe noticed. Ca) I n the first place, all these houses have some internal fitting in connection with the sewer, though only one has a w.c. within the house ( " G l a d s m u i r . " ) It might be that in all three houses one or other of these fittings was defective, and I have not tested them for want of the necessary staff and appliances. But the houses have all been lately connected with the sewer under supervision of the Water and Sewerage Board's staff, all the house drains are cut off by disconnecting traps from the branch sewer, and each house-system has
its own vent.-shaft ; the house-systems arc, moreover, protected by the incuIpated public ventilator, and though the flush-tank has but lately been brought into use, I may as well mention that I have been informed that in its operation it neither syphons nor forces any trap. Cb) Although the illnesses are not of the kinds (with one exception) which can be attributed to, or which throw suspicion, upon the water supply, it may be noted that all three premises are connected with the main, but that one h a s no other source of supply, while the other two have a small provision of overground iron tanks for roof-water, used chiefly in the laundry, there being no underground reservoir of water on any of the premises. (c) T h e milk supply is a much more important matter. Fortunately the sources to the three households were different. T h u s Mr. D had his own cow until August, 1895 (the illnesses in his family having been largely before that date), and in that m o n t h he employed source Ca). Mr. H during his ten months' residence has employed uniformly source {3); Mr. B - - - e m p l o y e d source (c), but four years ago resorted to source (a), to which he has since kept. Now, although speaking with special reference to the last case and the source Ca), it is true that milk at one time heaIthy may at another time be found diseased, and that this hypothesis could g)rlmdfacie be applied to Mr. B 's case, it happens that Mr. D ~ ' s furnishes a very good check ; the illnesses began to occur in that household before source Ca) had been resorted to. This, I think m is sufficient to exclude milk ; but, additionally, it may be mentioned that there has not been in this district any prevalence of illness of kinds similar to those referred to, and such as might possibly be due to milk, sufficient to cause any of the medical men concerned to suspect that the cause of the illnesses at these three houses was really not local, but of wide operation. (d) A rather more difficult point is the composition of the site on which these three houses staud closely contiguous to each other. As to this, I have been informed by a former dweller in the house which stands in Llandaff Street next to and westerly of '* U r a l l a " (but, being a detached house, at some distance from it) that his family had bad health while he lived there, and that he learned his house was built over an old water-hole which had been filled up with house refuse. It may be, therefore, that otherparts of the area on which the (now) four houses stand may have been filled up with this material. It is sufficiently well known to the Board that I consider such making up of building sites with garbage a very serious danger to health, and I should be pleased if I could trace so singularly limited an outbreak of illness as this to that cause. But I fear that there is not even presumptive ground for following up this indication. (e) Lastly, there is t h e minor point that the incriminated ventilator has from time to time been stopped (by insertion of an expansion plug above the cover used for introducing the anemometer). I believe it has been continuously so stopped since I8th January. I believe it was intermittently stopped before that date. Should any accurate statement as to times when it was stopped and times when it was left open be forthcoming, it would be
~3 6
ILLNESS
FROM
DEFECTIVE
interesting to compare it with Mr. D - - ' s record of iUnesses. I conclude, then, that the ill-health experienced in these three houses which stand grouped, though detached, withi.n quite a short distance of a pipe-ventilator connected with a public sewer, was due to the influence of offensive gases which escaped by that vent. T h e c a s e as p r e s e n t e d a b o v e a p p e a r s t o b e fairly convincing, but the report by Dr. Kendall, Medical Officer to the Board of Water Supply and Sewerage, Sydney, puts a somewhat different complexion on it, b u t d o e s not, in o u r o p i n i o n , e n t i r e l y r e b u t t h e e v i d e n c e b r o u g h t f o r w a r d b y Dr. T h o m p s o n . Dr. K e n d a l l ' s r e p o r t is a s follows : - 26th June, I896. [Copy of report by Board's Medical Officer re ventilating shaft adjoining " Shenley," Waverley Street, Waverley, the residence of Mr. W. C. D .] As requested by the Secretary, I met Dr. Ashburton Thompson on Tuesday, z3rd June, x896. The ventilator, which was at first an induct-shaft, was erected on the 27th of October, 1894, and Iundeestand t,~a~ at the time Mr. D ex~'essed his strong anti~oathy to the structure, and his intention o~ having it removed. A medical certificate was forwarded to the Board. This certificate, dated u8th February, I89~ , states : - "Different diseases which have been undoubtedly due to bad drainage and consequent foul smells, have during the last few months been treated at the residence of Mr. W. C. D ." Mention is also made of a "so-called escape pipe," and attention was drawn to the dangerous proximity of certain cesspits attached to the Congregational Church adjoining Mr. D 's land. In the year 1894, soon after the erection, Mr. D complained of the nuisance created by this shaft, and it was closed down, and remained so till January, I895 , when it was changed from a downcast shaft to an exhaust shaft. It remained open for a short time and was then closed down again. As soon as the foregoing certificate was received the shaft was examined and found to be tightly sealed. On 5th March, I895 , a second medical certificate was received stating that a case of enteric fever had at some time, not specified, been treated at Mr. D 's house. The shaft was again examined and found to be tightly sealed. On 6th March, 1895 , in company with the Assistant Engineer for Sewerage, Mr. Griffiths, I made a morning inspection of the locality. Mr. D himself showed us the balcony from which, he said, the smell could be noticed. The room containi .rig the watercloset opens on to this balcony. I could not perceive any smell proceeding trcm the ventilator. I, however, respected the two cesspits, which were referred to both in the first and second medical certificates, and found them very foul. The ventilating-shaft was sealed again after inspection, and remained tightly sealed for six weeks. On xgth March, t895 , Mr. W. C. D wrote a letter drawing attention to the different cases of sickness occurring in his house, and stated : ~ " The ventilating-shaft off your Pe-sewer at the rear of my premises is discharging a very odour." The shaft on this date was still tightly sealed. On 2oth March, i895 , Mr. E , o f " Uralla," Llandaff Street, Waverley, wrote complaining of the abominable stench proceeding from the ventilating-shaft, and stated that on Tuesday, 19th March, the stench was so terrible that he had to close all the doors and windows and use carbolic acid to keep down the terrible smell. At this time the shaft was tightly sealed, and had been so for some weeks. The engineer (Mr. Small) visited the place, and satisfied himself that all wss right. On x6th January, I896, it is said that Mr. D contracted diphtheria, and a certificate dated ISth January,
SEWER
VENTILATION.
I896, signed by three medical men, was forwarded to the Board by Mr. D ~ , who stated that a copy of it had been sent to the Board of H e a l t h . . This certificate states : - - " We have eKamined, the ventilatlng-shaft at the rear of the premises. We are o~ opinion that, in the face of the fact that a case of entel~ fever and several cases of acute sore throat, and now a case of diphtberia, have occurred in this houses the ventilatingshaft in question should be immediately removed. We are supported in our opinion by the fact that a most unpleasant edour is distinctly noticeable in the balcony of this house, and that th~ odour can be undoubtedly traced to the shaft in question." One of the gentlemen signing the certificate has informed me that he himself personally had never smelt any smell from the ventilator, and a second gentleman, has I believe, stated the same. The date when the odour was detected, as it could not have been the I8th of January, as the ventilator was tightly sealed before that date% and the inspector was sent on the I8th to assure Mrs. D that it was closed, would be somewhat interesting. On 2oth April, z896, Dr. Ashburton Thompson wrote a report. H e s t a t e s : - - " I ascertained from one of the gentlemen signing the certificate of 18th January, x896, that he had perceived a smell on the back verandah of "Shenley," and having satisfied himself that it did not arise from the premises themselves, he went to Llandaff Street, in a southeasterly direction, and found that there was no smell there, consequently he was satisfied that the smell did notf proceed from the ventilator. Later in his report he states : - - " It has already been stated that at ' S h e n l e y ' a smell was, on at least one occasion, perceived by a competent observer. It was identified by him as that peculiar smell which he knows is characteristic of air emanating from a foul sewer." If, however, this observer had, as is before stated in the first quoted portion of the report, satisfied himself that the smell did not proceed from the incriminated ventilator, I fail to see the importance of the observation as bearing upon the danger accruing through the ventilating-shaft, and as the other observers, Messrs. D and B , complained of an abominable stench existing while the ventilator was tightly sealed, and had been for so long a time that there were three inches of water above the plug, through condensation from the sides of the unused shaft, their evidence must refer to a stench arising from some other source. The report also makes mention of the composition of the soil of the building sites, which is very important, and if it were true that a house had been built upon a site formed by house garbage and street refuse it would certainly be a menace to health. I have read the whole papers very carefully, and fail to see the connection between the cases of sickness and the ventilating-shaft. THEO. MAILLER KENDALL. D r . T h o m p s o n , in his final n o t e to t h e r e p o r t , r e m a r k s t h a t Dr. K e n d a l l ' s r e p o r t d o e s n o t d i s p u t e " t h e o b s e r v e d f a c t s o f illness. I h a v e n o d o u b t that the illnesses were due to a cause locally o p e r a t i n g , a n d t h a t its o p e r a t i o n w a s c o n f i n e d t o t h e t i m e d u r i n g w h i c h t h e p i p e - v e n t i l a t o r was p r e s e n t a n d i n t e r m i t t e n t l y o p e n ; in fact, t h a t t h a t local c a u s e o f i l l n e s s was d i f f u s i o n o f very o f f e n s i v e s e w e r air i n t h a t p a r t i c u l a r locality." I t w o u l d have been interesting to know whether the shaft was u l t i m a t e l y r e m o v e d , a n d if s o w h e t h e r a n y * Mr. D told me verbally that an employee of the Water and Sewage Board closed the vent on this date in consequence of the fresh complaint made at his instance.~ J. A. T. T Copyist's error.
THE MIDWIVES' REGISTRATION
BILL
237
further illness of a nature similar to that reported thinking that if the very onerous and unpleasant above occurred subsequent to its removal. The duties foreshadowed in the above clauses are to be suggestion that the site may have been made up imposed upon medical officers of health, there with filth,seems to be invalidated by the fact that should be some provision securing them an adefor some years preceding the erection of the quate remuneration. I f this be not done, there ventilator, there was no illness of a character will be a repetition of the practice prevailing under indicating poisoning with sewer air, and the same the Customs and Inland Revenue Acts, whereby might be said, but perhaps not so surely, of any medical officers are required to perform a large possible defects in the house drains. It might bc amount of responsible work without fee or reward. noted here that in one house only was there an We are pleased to note that the Bill has heen internal w.c.,and that in high-class houses, and referred to the Council of the Society, who, we trust, that all the houses were intercepted from the sewer will take this point, among others, into serious and were provided with upcast ventilation. .Pace, consideration. Dr. Kendall, we cannot help thinking that Dr. Thompson was right in his conclusions. PUERPERAL FEVER.
(Communicated.) THE
MIDWIVES'
REGISTRATION BILL, 1897. T H E Bill introduced into the House of C o m m o n s during February last contains the following clauses affectingmedical officersof health. LOCAL SUPERVISION OF MIDWIVES,
9. Every local sanitary authority throughout England and Wales shall, on the passing of this Act, appoint its medical officer of health or other registered medical practitioner or practitioners, as the local supervising authority over midwives in the sanitary district. It shall be the duty of the local supervising authority-(I.) To exercise general supervision over all midwives practising within the sanitary district in accordance with the rules to be laid down under the provisions of this Act. (z.) To investigate charges of malpractice, negligence, or misconduct on the part of any midwife practising within his district, and if he consider that a prim~fade case is established to report the same to the Midwives Board. (3.) To report at once to the Midwives Board the name of any midwife practising in his district convicted of a misdemeanour or felony. (4.) To keep a current copy of the midwives register, accessible at all reasonable times for public inspection. (5.) To satisfy himself, in the case of any midwife practising, or desiring to practise, within his district, as to the validity of her claim to be placed on the register. NOTICE OF DEATH OF A MIDWIFE.
xo. The local supervising authority shall at once report to the Midwives Board the death of any midwife, or any change in the name or address of any widwife in his district, so that the necessary alteration may be made in the register. We are of opinion that a system of registration and supervision of midwives would be beneficial, and might tend to the reduction of the mortality ~rom puerperal fever. We cannot, however, help
T H E undiminished mortality from puerperal fever in England and Wales was the topic selected by Dr. Cullingworth for his Inaugural Address to the Obstetrical Society of London on March 3rd last. The same subject was dealt with more minutely by Dr. W. Williams in his communication "Puerperal Mortality," read before the Epidcmiological Society on March 2oth, i896. The experience of maternity hospitals has conclusively proved that puerperal fever can be absolutely stamped out, and the continued loss of life from this disease, which takes place throughout the country, I will not say in private medical practice, is a disgrace to the present generation. I have avoided including private medical practice because m y own enquiries, and those made by others,have convinced m e that in by far the greater number of cases, no medical practitioner is called in until puerperal fever has supervened. This factgoes far to minimise the apparent disgrace to sanitation. It is frequently urged that insanitary conditions are the preponderating causes for the prevalence of this diseas=. I acknowledge, unhesitatingly,that dirt of every kind, sort,and description,including foul air, whether from overcrowding or sewage emanations, material filthon the person, wails,and contents of the room, &c., ought to be banished from the lying-inroom, but I cannot ignore the fact that m y experience has taught m e that w o m e n will make marvellous recoveries under the most unsatisfactory hygienic conditions. This must be a matter of c o m m o n experience, otherwise, having regard to the conditions prevailingin many of the back streets of our great towns, the disease ought to be Jar more prevalent. What then may be deemed to bc the added cause leading to the persistence of the disease ? I believe it will be found in undue interference with the puerperal w o m a n by persons who are eitherignorant of the firstprinciplesof antiseptics or very imperfectly trained therein. I have had charge of patients in some of the filthiestrooms in Dublin, and I think I may say with a clear conscience that I never had a high temperature. I believe that resultwas duc to m y practiceof abstain-
ILLNESS
FROM
DEFECTIVE
Dr. Walford's r e c o m m e n d a t i o n , and appointed the Veterinary Inspector under the Contagious Diseases (Animals) Act to act as M e a t I n s p e c t o r under the H e a l t h Department, at an inclusive salary o f . ~ ' 3 o o . For the purposes of his Report, Dr. Walford addressed a circular letter to certain medical officers inquiring as to the practice of m e a t inspection prevailing u n d e r their jurisdictions. T h e replies are of interest, not only as showing how little is really done in this direction as c o m p a r e d with the practice abroad, but also as to the varying m e t h o d of doing what is done. Believing that m a n y of our readers will find t h e replies o f use for their own guidance, and as a point o f departure in dealing with t h e subject in the future, the tabulated statement included in Dr. Walford's R e p o r t is given here. L o n d o n is not i n c l u d e d in the list, but there is a very thorough system of inspection in force at Deptford, and, as far as we know, at Islington. F o r the rest o f t h e Metropolis, everything d e p e n d s on t h e - v a r i o u s local authorities. With the exception o f the abattoirs under the jurisdiction o f t h e City Corporation, where a very large proportion of the L o n d o n slaughtering takes place, the Metropolitan slaughter-houses, although very greatly i m p r o v e d in recent years, leave much to be desired.
SEWER ILLNESS
VENTILATION. FROM DEFECTIVE VENTILATION.
SEWER
THE grave difficulties frequently encountered when attempting to secure a d e q u a t e ventilation ot the public sewers, m o r e especially of " d e a d ends,'" are illustrated by the following extracts from a report to the Legislative Council of N e w South Wales, presented by Dr. J. Ashburton T h o m p s o n , President of the Board of H e a l t h of t h e Colony. I t appears that in October, 1894, a ventilator was erected against the side of a chapel in Sydney, at the h e a d o f a b r a n c h sewer. I n close proximity to the chapel there are three d e t a c h e d h o u s e s " S h e n l e y , " distant about 45 ft., north and west of the ventilator, " U r a l l a , " distant some IO 5 ft., west and south of the ventilator, and " G l a d s m u i r , '~ distant about 65 ft., south a n d east of the ventilator. All the m e a s u r e m e n t s are to the nearest corner of each building. Complaints were early m a d e o f smells from the shaft, which was in the first instance constructed as an inlet, and subsequently converted into an outlet. T h e records of illness at each house are given by Dr. T h o m p s o n , and are as follows : - -
STATigMENT furnished by Mr. W. C. D , "Shenley."--Length of residence at '" Shet~ley" ? Eight years last December (I895). --Present number of inmates ? Six adults and four children.--Statement as to illnesses during whole tenancy ? We had little or no illness previous to the erection of the ventilator, excepting the children (four) having measles and colds, and my eldest boy having rheumatism. Approximate date of attack.
Initials.
Remarks.
Kind of Illness.
Duration of illness, six weeks. Trained nurse, four weeks. Sore throat ; high temperature. Pronounced by Dr. Shewen as a " drain throat '~ ; ill a fortnight. Very bad throat (ulcerated) ... Since this time Miss O. has been subject to frequent attacks diarrhoea. Feverish attack, vomitin Ill four days. diarrhcea. Used same remedies as Dr. Lamrock predo. do . . . . . . . scribed in illness of other child (B. D.), Ulcerated throat .................. Ill several days. Very bad throat (ulcerated) ; Doctor attended for three weeks. Boy in high temperature, bed over a fortnight. Feverish attack, with sore Used remedies as previously prescribed by throat. Dr. Lamrock.
Miss H. O. (adult) ...... ! Oct. x7th, I894 ... Typhoid fever ..................... Mrs. D. (adult) ............ i Dec. 2ist, I894 ... Feb. 28th, I895 ... B. D. (three years)
April 6th, x895
O. D. (five years) ......... April I3th , I895 ... C. D. (ten years) ......... J u l y - - , 1895 ...... It. D. (fourteen years)... Oct. --, 1895 ......
tI. O. and C ............... ; C h r i s t m a s Day, x895, and New I Year's Day, I896 W. D ...................... ! Jan. I 6 t h , I 8 9 6 ... Diphtheria ........................
Ill in bed for three weeks. nurse for three weeks.
With trained
, "Uralla."--Length of residence at " Uralla," Llandaff street ? About eight years. STATEMENT furnished by Mr. F. B --Present number of inmates? Four females and One male ; Five adults (four females, one male) and four children, three boys and one girl. Initials.
m~
a~O~SStlO~BQ~O~I
Approximate date of attack, i
Kind of Illness.
Before erection of shaft ...... Measles and whooping cough ......... After erection o~ shaft ...... Sore throats and diphtheritic tonsilitis.
Milk from ? Date of change of source (if any). Source (c) over four years, and at present from source (a).
ILLNESS FROM D E F E C T I V E SEWER V E N T I L A T I O N .
235
STATEMENT furnished by Mr. H R. H , " G l a d s m u i r . ' - - L e n g t h of residence at " G t a d s m u i r " ? Ten months.--Preseut number of inmates? Three at present, usual number seven (four being away at Moss Vale); five adults and two children {two males and five females).
Initials. N. H ......................... H. H . . . . . . . . . . . . . . . . . . . . . . . . D. H ......................... H . H .........................
Approximate date of attack.
Kind of IHness.
Milk from?" D a ' e of change of source (if any).
Source (~), ,...... June, I895 ......... C o l d . . . . . . . . . . . . . . . . . . . . . . . . . . October, I895 ...... Stomach attack and sore throat November, 1895 ... Feverish attack .................. Stomach attack .................. January, r896 ...... Cold and stomach attack and sore throat.
Commenting on these clinical histories, Dr. Thompson remarks : These attacks nearly all occurred consecutively (in any one household), and not simultaneously. T h e y were spread out over all the time since erection of the pipe-ventilator down to the beginning of January, I896. T h e y are, it will be perceived, illnesses of precisely those kinds which are commonly met with among people who are exposed to breathing sewer air; and while, on the one hand, it is certain that such illnesses are not due to morbifie microbes arising from the sewersj it is equally certain (and on the same experimental ground) that frequent breathing of such air acts chemically "on the body, and so as to render its attack by morbifie germs commonly floating in the upper air extremely more certain than it is in states of health such as are conduced to by pure air. T h e action of sewer air on the h u m a n body is similar to that of other chemical agents, among which it is to be classed, and hence the illnesses it produces are sometimes merely a diarrhoea or merely a slight fever, and at others an attack of specific disease such as diphtheria. For, in the former case, the probability seems to be that the illness may be merely a manifestation of natural efforts to get rid of the poison by a direct channel ; in the latter, and either during the effort mentioned, or before the body has reacted in that way to the chemical poison, a specific morbific germ is implanted (not from the same sewer air, but in the ordinary course of daily life), and is able to grow where, but for the chemical deterioration of the constitution caused by the sewer air, it would have been successfully fought and killed. T h u s , in two cases out of three, responsible people who have lived where they are now found for eight years, say, first, that illnesses which required medical attendance, and which were of the kinds commonly known to be associated with sewer air, did repeatedly occur in their households after erection of the shaft in question, and had never occurred during about six and a-half years which had elapsed before it was erected ; while the third can merely say that four or five cases of illness of those characteristic kinds had occurred during the ten months of his residence ; and, secondly, two of them say that offensive smells were first perceived after erection of the shaft, while the third can, of course, merely say that offensive smells have been perceptible at times during his term of residence. Now, I have no hesitation in saying that this evidence, as far as it has been described, is extremely forcible. Nevertheless there remain certain points tobe noticed. Ca) I n the first place, all these houses have some internal fitting in connection with the sewer, though only one has a w.c. within the house ( " G l a d s m u i r . " ) It might be that in all three houses one or other of these fittings was defective, and I have not tested them for want of the necessary staff and appliances. But the houses have all been lately connected with the sewer under supervision of the Water and Sewerage Board's staff, all the house drains are cut off by disconnecting traps from the branch sewer, and each house-system has
its own vent.-shaft ; the house-systems arc, moreover, protected by the incuIpated public ventilator, and though the flush-tank has but lately been brought into use, I may as well mention that I have been informed that in its operation it neither syphons nor forces any trap. Cb) Although the illnesses are not of the kinds (with one exception) which can be attributed to, or which throw suspicion, upon the water supply, it may be noted that all three premises are connected with the main, but that one h a s no other source of supply, while the other two have a small provision of overground iron tanks for roof-water, used chiefly in the laundry, there being no underground reservoir of water on any of the premises. (c) T h e milk supply is a much more important matter. Fortunately the sources to the three households were different. T h u s Mr. D had his own cow until August, 1895 (the illnesses in his family having been largely before that date), and in that m o n t h he employed source Ca). Mr. H during his ten months' residence has employed uniformly source {3); Mr. B - - - e m p l o y e d source (c), but four years ago resorted to source (a), to which he has since kept. Now, although speaking with special reference to the last case and the source Ca), it is true that milk at one time heaIthy may at another time be found diseased, and that this hypothesis could g)rlmdfacie be applied to Mr. B 's case, it happens that Mr. D ~ ' s furnishes a very good check ; the illnesses began to occur in that household before source Ca) had been resorted to. This, I think m is sufficient to exclude milk ; but, additionally, it may be mentioned that there has not been in this district any prevalence of illness of kinds similar to those referred to, and such as might possibly be due to milk, sufficient to cause any of the medical men concerned to suspect that the cause of the illnesses at these three houses was really not local, but of wide operation. (d) A rather more difficult point is the composition of the site on which these three houses staud closely contiguous to each other. As to this, I have been informed by a former dweller in the house which stands in Llandaff Street next to and westerly of '* U r a l l a " (but, being a detached house, at some distance from it) that his family had bad health while he lived there, and that he learned his house was built over an old water-hole which had been filled up with house refuse. It may be, therefore, that otherparts of the area on which the (now) four houses stand may have been filled up with this material. It is sufficiently well known to the Board that I consider such making up of building sites with garbage a very serious danger to health, and I should be pleased if I could trace so singularly limited an outbreak of illness as this to that cause. But I fear that there is not even presumptive ground for following up this indication. (e) Lastly, there is t h e minor point that the incriminated ventilator has from time to time been stopped (by insertion of an expansion plug above the cover used for introducing the anemometer). I believe it has been continuously so stopped since I8th January. I believe it was intermittently stopped before that date. Should any accurate statement as to times when it was stopped and times when it was left open be forthcoming, it would be
~3 6
ILLNESS
FROM
DEFECTIVE
interesting to compare it with Mr. D - - ' s record of iUnesses. I conclude, then, that the ill-health experienced in these three houses which stand grouped, though detached, withi.n quite a short distance of a pipe-ventilator connected with a public sewer, was due to the influence of offensive gases which escaped by that vent. T h e c a s e as p r e s e n t e d a b o v e a p p e a r s t o b e fairly convincing, but the report by Dr. Kendall, Medical Officer to the Board of Water Supply and Sewerage, Sydney, puts a somewhat different complexion on it, b u t d o e s not, in o u r o p i n i o n , e n t i r e l y r e b u t t h e e v i d e n c e b r o u g h t f o r w a r d b y Dr. T h o m p s o n . Dr. K e n d a l l ' s r e p o r t is a s follows : - 26th June, I896. [Copy of report by Board's Medical Officer re ventilating shaft adjoining " Shenley," Waverley Street, Waverley, the residence of Mr. W. C. D .] As requested by the Secretary, I met Dr. Ashburton Thompson on Tuesday, z3rd June, x896. The ventilator, which was at first an induct-shaft, was erected on the 27th of October, 1894, and Iundeestand t,~a~ at the time Mr. D ex~'essed his strong anti~oathy to the structure, and his intention o~ having it removed. A medical certificate was forwarded to the Board. This certificate, dated u8th February, I89~ , states : - "Different diseases which have been undoubtedly due to bad drainage and consequent foul smells, have during the last few months been treated at the residence of Mr. W. C. D ." Mention is also made of a "so-called escape pipe," and attention was drawn to the dangerous proximity of certain cesspits attached to the Congregational Church adjoining Mr. D 's land. In the year 1894, soon after the erection, Mr. D complained of the nuisance created by this shaft, and it was closed down, and remained so till January, I895 , when it was changed from a downcast shaft to an exhaust shaft. It remained open for a short time and was then closed down again. As soon as the foregoing certificate was received the shaft was examined and found to be tightly sealed. On 5th March, I895 , a second medical certificate was received stating that a case of enteric fever had at some time, not specified, been treated at Mr. D 's house. The shaft was again examined and found to be tightly sealed. On 6th March, 1895 , in company with the Assistant Engineer for Sewerage, Mr. Griffiths, I made a morning inspection of the locality. Mr. D himself showed us the balcony from which, he said, the smell could be noticed. The room containi .rig the watercloset opens on to this balcony. I could not perceive any smell proceeding trcm the ventilator. I, however, respected the two cesspits, which were referred to both in the first and second medical certificates, and found them very foul. The ventilating-shaft was sealed again after inspection, and remained tightly sealed for six weeks. On xgth March, t895 , Mr. W. C. D wrote a letter drawing attention to the different cases of sickness occurring in his house, and stated : ~ " The ventilating-shaft off your Pe-sewer at the rear of my premises is discharging a very odour." The shaft on this date was still tightly sealed. On 2oth March, i895 , Mr. E , o f " Uralla," Llandaff Street, Waverley, wrote complaining of the abominable stench proceeding from the ventilating-shaft, and stated that on Tuesday, 19th March, the stench was so terrible that he had to close all the doors and windows and use carbolic acid to keep down the terrible smell. At this time the shaft was tightly sealed, and had been so for some weeks. The engineer (Mr. Small) visited the place, and satisfied himself that all wss right. On x6th January, I896, it is said that Mr. D contracted diphtheria, and a certificate dated ISth January,
SEWER
VENTILATION.
I896, signed by three medical men, was forwarded to the Board by Mr. D ~ , who stated that a copy of it had been sent to the Board of H e a l t h . . This certificate states : - - " We have eKamined, the ventilatlng-shaft at the rear of the premises. We are o~ opinion that, in the face of the fact that a case of entel~ fever and several cases of acute sore throat, and now a case of diphtberia, have occurred in this houses the ventilatingshaft in question should be immediately removed. We are supported in our opinion by the fact that a most unpleasant edour is distinctly noticeable in the balcony of this house, and that th~ odour can be undoubtedly traced to the shaft in question." One of the gentlemen signing the certificate has informed me that he himself personally had never smelt any smell from the ventilator, and a second gentleman, has I believe, stated the same. The date when the odour was detected, as it could not have been the I8th of January, as the ventilator was tightly sealed before that date% and the inspector was sent on the I8th to assure Mrs. D that it was closed, would be somewhat interesting. On 2oth April, z896, Dr. Ashburton Thompson wrote a report. H e s t a t e s : - - " I ascertained from one of the gentlemen signing the certificate of 18th January, x896, that he had perceived a smell on the back verandah of "Shenley," and having satisfied himself that it did not arise from the premises themselves, he went to Llandaff Street, in a southeasterly direction, and found that there was no smell there, consequently he was satisfied that the smell did notf proceed from the ventilator. Later in his report he states : - - " It has already been stated that at ' S h e n l e y ' a smell was, on at least one occasion, perceived by a competent observer. It was identified by him as that peculiar smell which he knows is characteristic of air emanating from a foul sewer." If, however, this observer had, as is before stated in the first quoted portion of the report, satisfied himself that the smell did not proceed from the incriminated ventilator, I fail to see the importance of the observation as bearing upon the danger accruing through the ventilating-shaft, and as the other observers, Messrs. D and B , complained of an abominable stench existing while the ventilator was tightly sealed, and had been for so long a time that there were three inches of water above the plug, through condensation from the sides of the unused shaft, their evidence must refer to a stench arising from some other source. The report also makes mention of the composition of the soil of the building sites, which is very important, and if it were true that a house had been built upon a site formed by house garbage and street refuse it would certainly be a menace to health. I have read the whole papers very carefully, and fail to see the connection between the cases of sickness and the ventilating-shaft. THEO. MAILLER KENDALL. D r . T h o m p s o n , in his final n o t e to t h e r e p o r t , r e m a r k s t h a t Dr. K e n d a l l ' s r e p o r t d o e s n o t d i s p u t e " t h e o b s e r v e d f a c t s o f illness. I h a v e n o d o u b t that the illnesses were due to a cause locally o p e r a t i n g , a n d t h a t its o p e r a t i o n w a s c o n f i n e d t o t h e t i m e d u r i n g w h i c h t h e p i p e - v e n t i l a t o r was p r e s e n t a n d i n t e r m i t t e n t l y o p e n ; in fact, t h a t t h a t local c a u s e o f i l l n e s s was d i f f u s i o n o f very o f f e n s i v e s e w e r air i n t h a t p a r t i c u l a r locality." I t w o u l d have been interesting to know whether the shaft was u l t i m a t e l y r e m o v e d , a n d if s o w h e t h e r a n y * Mr. D told me verbally that an employee of the Water and Sewage Board closed the vent on this date in consequence of the fresh complaint made at his instance.~ J. A. T. T Copyist's error.
THE MIDWIVES' REGISTRATION
BILL
237
further illness of a nature similar to that reported thinking that if the very onerous and unpleasant above occurred subsequent to its removal. The duties foreshadowed in the above clauses are to be suggestion that the site may have been made up imposed upon medical officers of health, there with filth,seems to be invalidated by the fact that should be some provision securing them an adefor some years preceding the erection of the quate remuneration. I f this be not done, there ventilator, there was no illness of a character will be a repetition of the practice prevailing under indicating poisoning with sewer air, and the same the Customs and Inland Revenue Acts, whereby might be said, but perhaps not so surely, of any medical officers are required to perform a large possible defects in the house drains. It might bc amount of responsible work without fee or reward. noted here that in one house only was there an We are pleased to note that the Bill has heen internal w.c.,and that in high-class houses, and referred to the Council of the Society, who, we trust, that all the houses were intercepted from the sewer will take this point, among others, into serious and were provided with upcast ventilation. .Pace, consideration. Dr. Kendall, we cannot help thinking that Dr. Thompson was right in his conclusions. PUERPERAL FEVER.
(Communicated.) THE
MIDWIVES'
REGISTRATION BILL, 1897. T H E Bill introduced into the House of C o m m o n s during February last contains the following clauses affectingmedical officersof health. LOCAL SUPERVISION OF MIDWIVES,
9. Every local sanitary authority throughout England and Wales shall, on the passing of this Act, appoint its medical officer of health or other registered medical practitioner or practitioners, as the local supervising authority over midwives in the sanitary district. It shall be the duty of the local supervising authority-(I.) To exercise general supervision over all midwives practising within the sanitary district in accordance with the rules to be laid down under the provisions of this Act. (z.) To investigate charges of malpractice, negligence, or misconduct on the part of any midwife practising within his district, and if he consider that a prim~fade case is established to report the same to the Midwives Board. (3.) To report at once to the Midwives Board the name of any midwife practising in his district convicted of a misdemeanour or felony. (4.) To keep a current copy of the midwives register, accessible at all reasonable times for public inspection. (5.) To satisfy himself, in the case of any midwife practising, or desiring to practise, within his district, as to the validity of her claim to be placed on the register. NOTICE OF DEATH OF A MIDWIFE.
xo. The local supervising authority shall at once report to the Midwives Board the death of any midwife, or any change in the name or address of any widwife in his district, so that the necessary alteration may be made in the register. We are of opinion that a system of registration and supervision of midwives would be beneficial, and might tend to the reduction of the mortality ~rom puerperal fever. We cannot, however, help
T H E undiminished mortality from puerperal fever in England and Wales was the topic selected by Dr. Cullingworth for his Inaugural Address to the Obstetrical Society of London on March 3rd last. The same subject was dealt with more minutely by Dr. W. Williams in his communication "Puerperal Mortality," read before the Epidcmiological Society on March 2oth, i896. The experience of maternity hospitals has conclusively proved that puerperal fever can be absolutely stamped out, and the continued loss of life from this disease, which takes place throughout the country, I will not say in private medical practice, is a disgrace to the present generation. I have avoided including private medical practice because m y own enquiries, and those made by others,have convinced m e that in by far the greater number of cases, no medical practitioner is called in until puerperal fever has supervened. This factgoes far to minimise the apparent disgrace to sanitation. It is frequently urged that insanitary conditions are the preponderating causes for the prevalence of this diseas=. I acknowledge, unhesitatingly,that dirt of every kind, sort,and description,including foul air, whether from overcrowding or sewage emanations, material filthon the person, wails,and contents of the room, &c., ought to be banished from the lying-inroom, but I cannot ignore the fact that m y experience has taught m e that w o m e n will make marvellous recoveries under the most unsatisfactory hygienic conditions. This must be a matter of c o m m o n experience, otherwise, having regard to the conditions prevailingin many of the back streets of our great towns, the disease ought to be Jar more prevalent. What then may be deemed to bc the added cause leading to the persistence of the disease ? I believe it will be found in undue interference with the puerperal w o m a n by persons who are eitherignorant of the firstprinciplesof antiseptics or very imperfectly trained therein. I have had charge of patients in some of the filthiestrooms in Dublin, and I think I may say with a clear conscience that I never had a high temperature. I believe that resultwas duc to m y practiceof abstain-