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Proceedings of the Birmingham and Midland Branch of the Society of Medical Officers of Health
PROCEEDINGS OF THE
B I R M I N G H A M AND MIDLAND BRANCH.
The President took the view that communicationsmade to a health officer were confidential, and that the School Board had no right to pry in.o affairs that did not belmg to them. He detailed the system in force at Newcastle. If there were an undue number of cases reported connected with a particular school, a communicationwas seat to the school authorities by letter. Dr. Willoughby: In Ontario and some of the American States the physician is compelled to notify to the local authority every case of infectious disease, and the local authority informs the head of all schools ; while on the other hand all teachers of schools are compelled to report to the local authority the absence of every child who has not attended school for three days. That is the kind of thing that is wanted. Dr. Newsholme: It is very important that the school teachers should be afforded every information. In Brighton a written communication is sent to the school, giving information of infectious disease in a household from which the children attend any particular school. It is most important that the medical officerof health should give this informatiou to the school authorities. He had tried requesting the parents to keep the children at home, but had found this method of preventing school attendance not effectual. Dr. Sykes : I think the course should be taken for the sanitary authorities, to whom the letter is addressed, to answer, sayingthat the informationasked for is not necessary, because at present the information is given to the schoolmasters. Dr. Newsholme moved that " I t is advisable for the master of a school to be informed of the existence of infectious disease among the scholars." The resolution was seconded and carried. ISOLATION AND DISINFECTION, T h e resolution, standing in Dr. Bates' name, was at his request referred to the Council.
HOUSING OF THE WORKING CLASSES. A letter from Mr. Theodore Dodd, published in PUBLIC HEALTh, V01. ii., No. 259, was ordered to be received. A letter from Dr. W. R. Smith, published in PUBLIC HEALTH, VO1. ii, NO. 259, was allowed, after a few words from Mr. Shirley Murphy, to stand over. T h e Society adjourned.
P R O C E E D I N G S OF T H E B I R M I N G H A M AND MIDLAND BRANCH OF THE SOCIETY OF MEDICAL O F F I C E R S OF HEALTH. THE annual meeting of the Birmingham and Midland Branch of the Society of Medical Officers of Health was held January 2nd, I89o , at the Council House ; Mr. Hollinshead presiding. There were also present Drs. A. Hill, Bostock Hill, H. Underhill (Tipton), Dr. Page (Redditch), Welch (Handsworth), and Mr. May (Aston Manor). T h e Chairman said he regretted to announce the death of Mr. G. Ashmead, of Brierley Hill, a member of the branch. H e had seven days prior to his death accepted an invitation to be present that day. H e moved that a vote of condolence be sent to Mr. Ashmead's friends. Dr. Underhill seconded the
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motion, which was carried. The Hon. Secretary's report stated that the branch now consisted of twenty-five members, and during the year the meetings had been better attended than formerly, and greater interest had been taken in the discussions. The financial statement showed a balance in favour of thesociety of . ~ i 3 XTS. 6½d. On the motion of Dr. Bostock Hill, seconded by Dr. Underhill, the report and balance-sheet were adopted. T h e Chairman proposed the election of Mr. Henry May as president for the ensuing year, and said that if anyone was entitled to the honour it was Mr. May. H e had acted as secretary for several years, and had always taken the deepest interest] in the ,society's welfare. Dr. Underhill seconded the motion, which was carried. Mr. May took the chair, and after thanking the members for electing him, proposed a vote of thanks to the retiring president. When that society was turned into a branch some two years ago he had some misgivings as to its success, but those misgivings had all been swept away by the success of the past two years, due to their indefatigable secretary, and to Dr. Bostock Hill and Mr. Hollinshead. (Hear, hear.) Dr. Alfred Hill seconded the resolution, and bore testimony to the zealous manner in which Mr. Hollinshead had filled the duties pertaining to the office of president. I t seemed a pity their rotation took place so rapidly. (Hear, hear.) Mr. Holtinshead, in reply, said he hoped during the year more papers would be read by the members. (Hear, hear.) Dr. Underhill was re-elected vice-president. Votes of thanks were passed to Dr. Page and Dr. Bostock Hill for their services as secretary and treasurer respectively, and those gentlemen were re-elected to the offices named. The president then gave his address as follows : THE ISOLATION OF INFECTIOUS DISEASE IN HOSPITALS. By HENRY MAY, L.R.C.P. The isolation of infectious disease is a subject on which medical officers of health and the general public are very much interested at the present time, and I propose to speak of it both in its general application and in its relation to the duties of the medical officer of health. (I have been engaged in this work for several years as the medical officer to an infectious hospital, to which one large rural and two urban sanitary authorities contribute and send their cases, besides the urban one to which it belongs, and to which I am medical officer of health.) I believe as early as i 8 7 i the main principles by which the provision of infectious hospitals should be governed were set forth in a memorandum of" the Privy Council. I n I882, the ye~rin which the Local Government Board published Dr. Tlaorne's elaborate report on " t h e use and influence of hospitals for infectious diseases," the practice of
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THE
ISOLATION OF INFECTIOUS
isolation had been adopted in a considerable number of towns in this country, though there were not many hospitals to which he could refer as suitable and efficient ones. The information that report contained has served as a valuable summary of the practical experience acquired upon this subject, and the principles it illustrates and enforces have been embodied in a large number of firstclass hospitals which have since been erected. During the same period public opinion has also made a rapid advance in appreciating their utility, and the press has taken an active part in effecting it. A sanitary authority is now regarded as having neglected an obvious nublic duty which has not made any provision, either directly or in combination with others, for isolating cases of dangerous infectious disease, and the growth of popular sentiment in favour of sending such cases to hospitals is no less remarkable. But though the establishment of a well-appointed hospital at the public cost is now rightly regarded as the most important of the sanitary measures required to be taken by local authorities to ward off epidemics and arrest th e spread of infection, it is not the only means they must adopt, and it would be a great mist~tke to over-estimate the protection which such a hospital affords or to neglect subsidiary measures. There is no royal road to the prevention of infectious disease. To obtain even a moderate and limited amount of success in this direction, we find it necessary to employ a whole series of arrangements, such as : The compulsory notification of infectious cases, Hospital isolation, Occasionally compulsory removal, The disinfection of bedding and clothing, The cleansing and stripping the dwelling, The withdrawal of children from school, The temporary closing of sch6ols, Compulsory vaccination, The abatement of nuisances, and all these imply considerable sacrifices; the invasion of the Englishman's castle: an interference with the ordinary habits and routine of life : an opposition to parental instincts : a considerable expenditure of m o n e y : sacrifices to which submission is yielded, only because it is enforced by serious penalties of increased disease and deaths which are incurred by their neglect. I cannot compare a conjunction of them to a chain where one link is useless alone. Each is useful alone, though each lends help to the others, and increases its usefulness. They are like a series of out-posts, established for sanitary defence, the chief one of which--hospital isolation-is strengthened by other out-posts in connection with it. I have spoken of the moderate and limited amount of success which attends the employment
DISEASE IN HOSPITALS.
of these sanitary measures, but whether it'is to be so regarded, depends upon how much we expect from them, and the best way to avoid the sense of failure, which is so often followed by disgust and re-action, is to acknowledge the inevitable limitations of our efforts, and accept as a satisfactory result what is practicable and within reach. There are some infectious diseases which are apparently beyond the control of any reasonable means we can bring to bear upon them ; but there are some so far amenable to control that the number of cases which occur can be very much diminished, and an epidemic delayed for a long period, and there are others which seem within a measurable distance of being kept away altogether. It is very desirable we should recognise the part which isolation plays in this work, and the circumstances and conditions by which the usefulness of infectious hospitals are governed. Take, for example, the most virulent of modern infectious diseases--small-pox--which lends itself so well to control by proper measures that we might fairly hope to stamp it out altogether, We possess an exceptional means of rendering the person insusceptible to it by efficient vaccination, but vaccination is so much neglected, and so often evaded, that it is an absolutely necessary duty to make provision of a hospital for isolating cases of smallpox in connection with every sanitary district. By means of the operation of the compulsory vaccination laws, and the prompt isolation of first cases, small-pox has been practically banished from this population of half a.million, and I see that during the quarter ending Michaelmas, I889, although there were 3,282 deaths from other zymotic diseases in the dense population of the metropolis, there was not one from small-pox~ Isolation has also contributed largely towards stamping out typhus and relapsing fever in places where they were formerly endemic. Though scarlet fever was not regarded as a manageable disease at all until recent years, a large amount of our sanitary efforts are now directed "to preventing its spread, with most encouraging results. Though much has been done towards limiting t h e extension of this disease by isolation at home and careful disinfection, its infection is so diffusible and intense, and the period of infectiousness so prolonged, that the isolation which hospitals afford can alone be regarded as effectual. T h e members of this branch of the Society of Medical Officers of Health watch with extreme interest the gigantic experiment which the Corporation of Birmingham is making, as to the possibility of staying the spread of this dangerous disease, and cutting short an epidemic by an extensive provision of hospital accommodation, and endeavours to isolate all known cases ; and we congratulate the sanitary authority of Birmingham and its officers on the success which has attended their efforts. We hear of the ~large amount of money which
THE
I S O L A T I O N O F I N F E C T I O U S D I S E A S E IN H O S P I T A L S .
has been spent, but as the effectual withdrawal of infected children has prevented any occasion for closing the public elementary schools--with the resulting inconvenience and loss--the cost has been saved on this item alone. Typhoid fever, diphtheria, and membranous croup are infectious diseases in which isolation cannot take so prominent a place in their prevention as in those I have mentioned, since other causes produce them besides infection from person to person, and this is .of moderate intensity. (It has been recommended in a paper which was read to us this year, that sanitary authorities should make provision for isolating them, and especially diphtheria.) I am of opinion that cases of these diseases, when not treated at home, may be safely and wisely treated in cottage or ordinary hospitals, and that it is not the obvious duty of sanitary authorities to make special provision for their isolation and treatment at the public ~:ost, although there can be no objection to utilising available accommodation for the purpose. Measles, hybrid measles, and whooping cough are very highly infectious diseases, but they do not lend themselves readily to control by isolation, by reason of their early infectiveness and their liability to affect large numbers simultaneously. No reasonable accommodation could overtake an epidemic, neither would parents consent to part with children during slight though not the less infectious attacks. There, may, however, be occasions when timely isolation of these proves highly beneficial. The "closure of public elementary schools is a useful means of limiting their diffusion, especially in country districts, where school is the only occasion .children are brought into contact. It would be a very difficult thing to formulate any rule as to the amount of hospital accommodation which a district requires, and yet it is very ad*¢isable that provision should be made in advance. O n the other hand we have seen in the recent ,scarlet fever hospital extensions in Birmingham how quickIy deficient accommodation can be remedied when an authority is in earnest. It is also desirable that different infectious diseases isolated in one hospital should be as widely separated as possible with distinct pavilions and nurses for each disease, since every disease admitted adds greatly to the complications of management. For these reasons I consider it good policy to have one large hospital for a combination of districts rather than a number of smaller ones for each district. Considering how much an isolation hospital partakes of the nature of a sanatorium, wherein t~atients require to be detained during a long *:onvalescence, it seems undesirable to establish or even to permanently enlarge one in the midst of the unwholesome atmosphere and surroundings o f a large town, especially since by the assistance of the telephone distances of four or five miles are of no practical inconvenience.
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The general adoption of isolation tends to increase the duties and responsibilities of medical officers of health. It has been well said that the medical officer of health is an adviser and not an administrator, but it is his duty in relation to the prevention of disease not only to " v i s i t " and to "advise," but also to "assist," and in this department his work very nearly approaches an administrative character. The carrying out of the details of isolation is not always a matter of plain sailing, and many problems have to be solved in its practical application. The bmden of a satisfactory solution of them lies generally upon the shoulders of the medical officer of health. It wilt not only be his duty to advise his authority as to their policy in regard to isolation, but its smooth working, and the success with which it is carried out in his district will depend very much upon his judgment and tact in assisting to carry it out. He acts as the medium between the medical practitioners and the sanitary authority, and he must endeavour to obtain their confidence and co-operation, both in supplying him with information and in recommending removal to their patients in order to secure to the hospital its full. measure of utility. (In Birmingham this desirable result is facilitated by the Corporation paying an extra fee to the medical attendant when the result is removal, in addition to the ordinary fee paid for notification.)* Sometimes the Inspector has authority to send cases to the hospital, and takes the necessary steps upon the receipt of a medical certificate, but generally they are sent under the authority of the medical officer of health, and as far as possible he relies upon the medical attendant as to its being a suitable case, and accepts his diagnosis. Sometimes he must use his official position and influence to obtain a patient's removal, and occasionally he has to resort to compulsory powers of removal. H e has often an opportunity of protecting the medica attendant from the results of a premature or mistaken diagnosis, and should be willing to afford him such assistance as his experience may warrant in the diagnosis of cases concerning which there is doubt as to the propriety of isolating them. H e will offer his services, or wait until they are sought, according to his temperament or tact, although it goes without saying that in any conference or consultation he must be strictly guided by the rules of professional etiquette. 1 well remember a late leading member of our profession, when speaking publicly as to the relations between medical practitioners and medical officers of health, saying they must always remember that their office was the child of t h e medical profession, and they should therefore give its members their first consideration. To this I replied that that if our office was the child of the medical profes,,r
* This arrangement will cease upon the adoption of the Infectious Diseases Notification Act.
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sion, it had only the stronger claims in consequence upon the members for assistance and support. A sanitary authority in this neighbourhood resolved recently that their medical officer of health should personally verify the diagnosis of the medical attendant, and the correctness of his certificate, before authorizing the removal of cases to the hospital, Such interference would have been most obnoxious, and calculated to cause much friction between the authority and the medical men. The medical officer rightly appealed to the Local Government Board, by whom the resolution of the sanitary authority was not approved. I do not wish to raise any discussion this afternoon on the subject of the compulsory notification of infectious diseases, as I hope it will become the subject of a special paper at some future meeting, but I ought to say, in relation to medical certificates under that Act, that I consider they devolve a larger amount of professional responsibility upon the medical man who gives them than the voluntary notifications of former days. It is also very desirable that they should be accompanied with voluntary information from the medical man as to the suitability, or otherwise, of the case for removal. Failing this, medical officers of health will feel they are entitled to ask (through the inspector), as to the disposition of the patient or friends to avail themselves of isolation. Notwithstanding a medical certificate has been received concerning a case where the diagnosis is ~#rimdfade doubtful, a medical Officer of health will probably feel it does not altogether relieve him of responsibility in allowing the case to go to hospital, where it might occasion serious complications to the patient or to other cases inside. To limit this risk every infectious hospital should have probationary wards and nurses, to receive the frequent mistaken and doubtful cases which are sent there. The position which a medical officer of health holds in relation to the medical supervisiou and professional treatment of cases in a hospital in connection with his district must vary widely according to special circumstances. In first class hospitals, there is ample field for division of labour, and the appointment of a resident medical superintendent relieves thc medical officer of health of any responsibility. Often in smaller hospitals in large sanitary areas a local practitioner is responsible for attendance on cases in the hospital, the medical officer of health having a general supervision. In the majority of hospitals, I believe, the medical officer of health is medical officer to the hospital, as a separate appointment, which includes attendance on the inmates. Though it is no part of the duties (.f his office, I see no reason why he should not accept the position of medical officer to an infectious hospital, if he is otherwise qualified for its duties, and many obvious reasons why he should. Whenever his
appointment to analogous offices, such as public analyst, poor-law medical officer, or medical officer to an infectious hospital, will enable a sanitary authority to maintain a medical officer of health who does not engage in private practice, this is evidently an advantage. The policy which a sanitary authority adopts ira regard to the terms on which cases are admitted to its hospital is a matter of considerable importance. Under the I32nd section of the Public Health Act, " A n y expenses incurred by a local authority in maintaining in a hospital a patient who is not a pauper shall be deemed to be a debt due from such patient, and may be recovered." Though it is permissive to require payment, the generally accepted opinion is that since isolation is adopted for the benefit of the community, no charge should be made upon the patient, and also that by so doing it hinders the adoption of isolation and delays the admission of the case. I should be exceedingly sorry if your President should not prove orthodox, and should be discovered to have any unsound views on this matter. There are certainly some cases of disease where the need for their isolation is urgent, and when it is necessary it should be gratuitous, but I am not prepared to say that an authority which has established an infectious hospital, neglects its duty because it requires, as a rule, a graduated payment to be made towards the maintenance and treatment of the cases admitted, and it is possible in the long run its hospital may become as popular a s one where maintenance and medical treatmen~ are given gratuitously to all classes. There is a strong feeling that gratuitous medical and other services have a tendency to demoralize people, and as these hospitals confer a great benef~ upon the patient and ]ais household, as well as upot~ the community, a moderate and graduated charge is quite legitimate. This is the policy the Manor of Aston Local Board have hitherto a d o p t e d ~ t h e guardians of the poor paying for destitute cases--and my experience is that though there are many difficulties cf detail, in arrangements for obtaining a payment--difftculties which are not diminished by the custom to the contrary which prevails in Birmingham and all, the adjoining districts--they are not insuperable. The admission of cases depends more upon t h e attitude which the medical attendant takes than upon the fact of a payment being required. This attitude varies from that of the medical man wh<> declines to attend upon any case of scarlet fever, to that of him who objects to the removal of hi~ cases on the ground that it is starving the doctors. An efficient disinfecting apparatus is an indispensable appendage to a well-appointed hospital, and the medical officer of health must feel quite satisfied that the clothing, as well as the person of the patient after detention in the hospital, are free from infection.
PROCEEDINGS
OF
THE
NORTH-WESTERN
W i t h o u t these p r e c a u t i o n s of detail a n d m a n y others, t h e whole e x p e n s i v e m a c h i n e r y of isolation which has b e e n put in m o t i o n m a y prove o f n o avail. E v e n with t h e m t h e original infection is liable to attack o t h e r m e m b e r s of t h e h o u s e h o l d , a n d the disease may lurk in u n s u s p e c t e d places, a n d occasion b y its r e - a p p e a r a n c e d i s a p p o i n t m e n t at t h e a p p a r e n t l y unsatisfactory results o f isolation. T h e m o t t o o f the medical officer of health is t h a t " P r e v e n t i o n is better t h a n cure." W e m a y n o t always be able to stop the spread o f p r e v e n t a b l e disease, b u t d o we not often fail to cure ? T h e r e is n o m a g i c in isolation, b u t a n a d e q u a t e hospital for the p u r p o s e occupies a foremost place in our array of m e a n s for carrying out the policy of prevention, a n d it also marvellously assists in effecting cures. I n f e c t i o u s hospitals are n o longer in t h e experim e n t a l stage, b u t there is s o m e t h i n g yet to learn from e x p e r i e n c e as to t h e m o d e in which t h e s e institutions should b e e r e c t e d , a n d t h e principles on which t h e y should b e c o n d u c t e d ; a n d it is very desirable that the farther d e v e l o p m e n t s of their usefulness, w h i c h t h e future has in store, s h o u l d b e assisted a n d h a s t e n e d by the lessons o f t h e p a s t a n d the p r e s e n t . DiscussioN. Mr. tlotlinshead, in moving a vote of thanks to Mr. May tor his interesting paper, said he agreed with all he had said, and even went further. He should like to see diphtheria and measles isolated, believing that it would largely tend to lessen zymotic diseases if first cases were removed. All these diseases could not be treated in one establishment, and it was a question whether there should not be separate hospitals for scarlet-lever, small-pox, and measles. The suggestion that medical officers of health should verify diagnoses of infectious diseases would not work. As to the question of payment, he believed that those people who could pay should do so, but to the rank and file of the working classes infections hospitals should be free. If they made a charge, patients would be kept at home, and the result would be that infectious diseases would be seriousIy spread. The Board under whom he worked authorised him to make a charge, hut the poor people said they could not afford to pay anything, and ultimately the Board withdrew their application for fees. Dr. Bostock Hill, in seconding the mot.;on, disagreed entirely with the suggestion that diagnoses of infectious diseases should be verified by medical officers before cases were admitted to hospitals, contending that the onus of the diagnoses was properly placed upon the medical practitioner, and that the medical officer had nothing to do with it. Mr. May would have the medical officer consulted before the admission of a "7~rimd facie doubtful case ; " but what was a 7~rimd.facie doubtful case? Ife agreed that infectious hospitals should be absolutely free. If notification was made compulsory and isolation was desirable the only logical conclusion was that isolation should be free. The hospital was not provided for the benefit of the infected individual, but for the better conservation of the public health, and the hospital was in that sense a public institution and should be supported as such. Disinfection should also be free. Diphtheria should be isolated. He believed there were few diseases that were more infectious, and that before long it would be a prime necessity to isolate it just as they did scarlatina and small-pox. Dr. Alfred Hill spoke strongly in favour of enforcing the notification of infectious diseases, maintaining that even if
BRANCH.
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there were no hospitals it would be advantageous, and might lead to the provision of hospitals, because local authorities could not keep on receiving notifications without doing what was necessary to isolate infectious cases. His experience as medical officer for the city of Birmingham convinced hira that if infectious hospitals were to be useful they must be absolutely free, although special accommodation might be provided for those who liked to pay for it. If all the people who were admitted had to pay, instead of there being 40o or 50o patients, the number would not exceed 40 or 5° . He had told the local authority in Birmingham that they did not want to make money out of the people who contracted infectious diseases, but to isolate them for their own benefit and the benefit of the community, and they now did so without making any charges except, of course, upon the rates. Dr. Underhitl also made afew remarks, and the President briefly replied. He defended his contention that primal.ratio doubtful cases should be verified, by stating that the first reported ease of small-pox might be something else, and that for the reputation of a district, as well as in the interests of a patient and the community, the authorities should make absolutely sure before isolating an],"cases. After the meeting the ex-President (Mr. Itollinshead) invited the members to a dinner at the Conservative C!ub, Temple Row. The members present at the annual meeting were joined by Dr. Fenton (Coventry) and Dr. Clarke (Lichfield). The cloth being removed, the President said he wished to give them one toast, without which no assembly of Englishmen was complete, viz., the health of Her Majesty and the rest of the Royal Family. This was enthusiastically honoured. The ex-President observed he was glad to meet the members of the Branch that evening under those circumstances. IIe believed it was x5 years since the first President of the Society, Dr. A. tlill, inaugurated similar festive proceedings. He thought it was a happy idea and a good thing for such a society to meet once a year. The British Medical Association and other societies had their annual dinner, and he thought they ought to. I-Ie did not mean that he thought it should fall to the gratuitous hospitality of the President to provide it, but it should be arranged on the lines oftheother societies. Dr. Alfred tlill thought, although there was no formal toast list, at least they would not object to one more ; with the permission of their host he begged to give them " Success tb the Birmingham and Midland t~ranch of the Society of Medical Officers of Health." (Hear, hear). Animated and friendly converse brought this pleasant evening to a close. PROCEEDINGS OF THE NORTH-WESTERN BRANCH OF THE SOCIETY OF MEDICAL OFFICERS OF HEALTH. A ~IEETINO o f this B r a n c h was h e l d a t 44, J o h n D a l t o n Street, M a n c h e s t e r , on Friday, J a n u a r y Ioth. Dr. W e l c h (Blackpool), P r e s i d e n t o f the B r a n c h , was in the chair. T h e m i n u t e s of the last m e e t i n g were read a n d confirmed. T h e foEowing g e n t l e m a n , having b e e n duly n o m i n a t e d , was e l e c t e d a . m e m b e r of t h e B r a n c h : C. E. Paget, L . R . C . P . L o n d o n , M e d i c a l Officer of H e a l t h , Salford. T h e following g e n t l e m e n , having b e e n duly n o m i n a t e d , were elected, subject to the approval o f t h e Society : S. Barwise, M . R . C . S , M e d i c a l Officer o f H e a l t h , B l a c k b u r n ; a n d H . E. Edlin, M . R . C . S . , M e d i c a l Officer o f H e a l t h , L e v e n s h u l m e . T h e f o l l o w i n g p a p e r was r e a d by t h e H o n . Secretary : - -
B I R M I N G H A M AND MIDLAND BRANCH.
The President took the view that communicationsmade to a health officer were confidential, and that the School Board had no right to pry in.o affairs that did not belmg to them. He detailed the system in force at Newcastle. If there were an undue number of cases reported connected with a particular school, a communicationwas seat to the school authorities by letter. Dr. Willoughby: In Ontario and some of the American States the physician is compelled to notify to the local authority every case of infectious disease, and the local authority informs the head of all schools ; while on the other hand all teachers of schools are compelled to report to the local authority the absence of every child who has not attended school for three days. That is the kind of thing that is wanted. Dr. Newsholme: It is very important that the school teachers should be afforded every information. In Brighton a written communication is sent to the school, giving information of infectious disease in a household from which the children attend any particular school. It is most important that the medical officerof health should give this informatiou to the school authorities. He had tried requesting the parents to keep the children at home, but had found this method of preventing school attendance not effectual. Dr. Sykes : I think the course should be taken for the sanitary authorities, to whom the letter is addressed, to answer, sayingthat the informationasked for is not necessary, because at present the information is given to the schoolmasters. Dr. Newsholme moved that " I t is advisable for the master of a school to be informed of the existence of infectious disease among the scholars." The resolution was seconded and carried. ISOLATION AND DISINFECTION, T h e resolution, standing in Dr. Bates' name, was at his request referred to the Council.
HOUSING OF THE WORKING CLASSES. A letter from Mr. Theodore Dodd, published in PUBLIC HEALTh, V01. ii., No. 259, was ordered to be received. A letter from Dr. W. R. Smith, published in PUBLIC HEALTH, VO1. ii, NO. 259, was allowed, after a few words from Mr. Shirley Murphy, to stand over. T h e Society adjourned.
P R O C E E D I N G S OF T H E B I R M I N G H A M AND MIDLAND BRANCH OF THE SOCIETY OF MEDICAL O F F I C E R S OF HEALTH. THE annual meeting of the Birmingham and Midland Branch of the Society of Medical Officers of Health was held January 2nd, I89o , at the Council House ; Mr. Hollinshead presiding. There were also present Drs. A. Hill, Bostock Hill, H. Underhill (Tipton), Dr. Page (Redditch), Welch (Handsworth), and Mr. May (Aston Manor). T h e Chairman said he regretted to announce the death of Mr. G. Ashmead, of Brierley Hill, a member of the branch. H e had seven days prior to his death accepted an invitation to be present that day. H e moved that a vote of condolence be sent to Mr. Ashmead's friends. Dr. Underhill seconded the
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motion, which was carried. The Hon. Secretary's report stated that the branch now consisted of twenty-five members, and during the year the meetings had been better attended than formerly, and greater interest had been taken in the discussions. The financial statement showed a balance in favour of thesociety of . ~ i 3 XTS. 6½d. On the motion of Dr. Bostock Hill, seconded by Dr. Underhill, the report and balance-sheet were adopted. T h e Chairman proposed the election of Mr. Henry May as president for the ensuing year, and said that if anyone was entitled to the honour it was Mr. May. H e had acted as secretary for several years, and had always taken the deepest interest] in the ,society's welfare. Dr. Underhill seconded the motion, which was carried. Mr. May took the chair, and after thanking the members for electing him, proposed a vote of thanks to the retiring president. When that society was turned into a branch some two years ago he had some misgivings as to its success, but those misgivings had all been swept away by the success of the past two years, due to their indefatigable secretary, and to Dr. Bostock Hill and Mr. Hollinshead. (Hear, hear.) Dr. Alfred Hill seconded the resolution, and bore testimony to the zealous manner in which Mr. Hollinshead had filled the duties pertaining to the office of president. I t seemed a pity their rotation took place so rapidly. (Hear, hear.) Mr. Holtinshead, in reply, said he hoped during the year more papers would be read by the members. (Hear, hear.) Dr. Underhill was re-elected vice-president. Votes of thanks were passed to Dr. Page and Dr. Bostock Hill for their services as secretary and treasurer respectively, and those gentlemen were re-elected to the offices named. The president then gave his address as follows : THE ISOLATION OF INFECTIOUS DISEASE IN HOSPITALS. By HENRY MAY, L.R.C.P. The isolation of infectious disease is a subject on which medical officers of health and the general public are very much interested at the present time, and I propose to speak of it both in its general application and in its relation to the duties of the medical officer of health. (I have been engaged in this work for several years as the medical officer to an infectious hospital, to which one large rural and two urban sanitary authorities contribute and send their cases, besides the urban one to which it belongs, and to which I am medical officer of health.) I believe as early as i 8 7 i the main principles by which the provision of infectious hospitals should be governed were set forth in a memorandum of" the Privy Council. I n I882, the ye~rin which the Local Government Board published Dr. Tlaorne's elaborate report on " t h e use and influence of hospitals for infectious diseases," the practice of
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isolation had been adopted in a considerable number of towns in this country, though there were not many hospitals to which he could refer as suitable and efficient ones. The information that report contained has served as a valuable summary of the practical experience acquired upon this subject, and the principles it illustrates and enforces have been embodied in a large number of firstclass hospitals which have since been erected. During the same period public opinion has also made a rapid advance in appreciating their utility, and the press has taken an active part in effecting it. A sanitary authority is now regarded as having neglected an obvious nublic duty which has not made any provision, either directly or in combination with others, for isolating cases of dangerous infectious disease, and the growth of popular sentiment in favour of sending such cases to hospitals is no less remarkable. But though the establishment of a well-appointed hospital at the public cost is now rightly regarded as the most important of the sanitary measures required to be taken by local authorities to ward off epidemics and arrest th e spread of infection, it is not the only means they must adopt, and it would be a great mist~tke to over-estimate the protection which such a hospital affords or to neglect subsidiary measures. There is no royal road to the prevention of infectious disease. To obtain even a moderate and limited amount of success in this direction, we find it necessary to employ a whole series of arrangements, such as : The compulsory notification of infectious cases, Hospital isolation, Occasionally compulsory removal, The disinfection of bedding and clothing, The cleansing and stripping the dwelling, The withdrawal of children from school, The temporary closing of sch6ols, Compulsory vaccination, The abatement of nuisances, and all these imply considerable sacrifices; the invasion of the Englishman's castle: an interference with the ordinary habits and routine of life : an opposition to parental instincts : a considerable expenditure of m o n e y : sacrifices to which submission is yielded, only because it is enforced by serious penalties of increased disease and deaths which are incurred by their neglect. I cannot compare a conjunction of them to a chain where one link is useless alone. Each is useful alone, though each lends help to the others, and increases its usefulness. They are like a series of out-posts, established for sanitary defence, the chief one of which--hospital isolation-is strengthened by other out-posts in connection with it. I have spoken of the moderate and limited amount of success which attends the employment
DISEASE IN HOSPITALS.
of these sanitary measures, but whether it'is to be so regarded, depends upon how much we expect from them, and the best way to avoid the sense of failure, which is so often followed by disgust and re-action, is to acknowledge the inevitable limitations of our efforts, and accept as a satisfactory result what is practicable and within reach. There are some infectious diseases which are apparently beyond the control of any reasonable means we can bring to bear upon them ; but there are some so far amenable to control that the number of cases which occur can be very much diminished, and an epidemic delayed for a long period, and there are others which seem within a measurable distance of being kept away altogether. It is very desirable we should recognise the part which isolation plays in this work, and the circumstances and conditions by which the usefulness of infectious hospitals are governed. Take, for example, the most virulent of modern infectious diseases--small-pox--which lends itself so well to control by proper measures that we might fairly hope to stamp it out altogether, We possess an exceptional means of rendering the person insusceptible to it by efficient vaccination, but vaccination is so much neglected, and so often evaded, that it is an absolutely necessary duty to make provision of a hospital for isolating cases of smallpox in connection with every sanitary district. By means of the operation of the compulsory vaccination laws, and the prompt isolation of first cases, small-pox has been practically banished from this population of half a.million, and I see that during the quarter ending Michaelmas, I889, although there were 3,282 deaths from other zymotic diseases in the dense population of the metropolis, there was not one from small-pox~ Isolation has also contributed largely towards stamping out typhus and relapsing fever in places where they were formerly endemic. Though scarlet fever was not regarded as a manageable disease at all until recent years, a large amount of our sanitary efforts are now directed "to preventing its spread, with most encouraging results. Though much has been done towards limiting t h e extension of this disease by isolation at home and careful disinfection, its infection is so diffusible and intense, and the period of infectiousness so prolonged, that the isolation which hospitals afford can alone be regarded as effectual. T h e members of this branch of the Society of Medical Officers of Health watch with extreme interest the gigantic experiment which the Corporation of Birmingham is making, as to the possibility of staying the spread of this dangerous disease, and cutting short an epidemic by an extensive provision of hospital accommodation, and endeavours to isolate all known cases ; and we congratulate the sanitary authority of Birmingham and its officers on the success which has attended their efforts. We hear of the ~large amount of money which
THE
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has been spent, but as the effectual withdrawal of infected children has prevented any occasion for closing the public elementary schools--with the resulting inconvenience and loss--the cost has been saved on this item alone. Typhoid fever, diphtheria, and membranous croup are infectious diseases in which isolation cannot take so prominent a place in their prevention as in those I have mentioned, since other causes produce them besides infection from person to person, and this is .of moderate intensity. (It has been recommended in a paper which was read to us this year, that sanitary authorities should make provision for isolating them, and especially diphtheria.) I am of opinion that cases of these diseases, when not treated at home, may be safely and wisely treated in cottage or ordinary hospitals, and that it is not the obvious duty of sanitary authorities to make special provision for their isolation and treatment at the public ~:ost, although there can be no objection to utilising available accommodation for the purpose. Measles, hybrid measles, and whooping cough are very highly infectious diseases, but they do not lend themselves readily to control by isolation, by reason of their early infectiveness and their liability to affect large numbers simultaneously. No reasonable accommodation could overtake an epidemic, neither would parents consent to part with children during slight though not the less infectious attacks. There, may, however, be occasions when timely isolation of these proves highly beneficial. The "closure of public elementary schools is a useful means of limiting their diffusion, especially in country districts, where school is the only occasion .children are brought into contact. It would be a very difficult thing to formulate any rule as to the amount of hospital accommodation which a district requires, and yet it is very ad*¢isable that provision should be made in advance. O n the other hand we have seen in the recent ,scarlet fever hospital extensions in Birmingham how quickIy deficient accommodation can be remedied when an authority is in earnest. It is also desirable that different infectious diseases isolated in one hospital should be as widely separated as possible with distinct pavilions and nurses for each disease, since every disease admitted adds greatly to the complications of management. For these reasons I consider it good policy to have one large hospital for a combination of districts rather than a number of smaller ones for each district. Considering how much an isolation hospital partakes of the nature of a sanatorium, wherein t~atients require to be detained during a long *:onvalescence, it seems undesirable to establish or even to permanently enlarge one in the midst of the unwholesome atmosphere and surroundings o f a large town, especially since by the assistance of the telephone distances of four or five miles are of no practical inconvenience.
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The general adoption of isolation tends to increase the duties and responsibilities of medical officers of health. It has been well said that the medical officer of health is an adviser and not an administrator, but it is his duty in relation to the prevention of disease not only to " v i s i t " and to "advise," but also to "assist," and in this department his work very nearly approaches an administrative character. The carrying out of the details of isolation is not always a matter of plain sailing, and many problems have to be solved in its practical application. The bmden of a satisfactory solution of them lies generally upon the shoulders of the medical officer of health. It wilt not only be his duty to advise his authority as to their policy in regard to isolation, but its smooth working, and the success with which it is carried out in his district will depend very much upon his judgment and tact in assisting to carry it out. He acts as the medium between the medical practitioners and the sanitary authority, and he must endeavour to obtain their confidence and co-operation, both in supplying him with information and in recommending removal to their patients in order to secure to the hospital its full. measure of utility. (In Birmingham this desirable result is facilitated by the Corporation paying an extra fee to the medical attendant when the result is removal, in addition to the ordinary fee paid for notification.)* Sometimes the Inspector has authority to send cases to the hospital, and takes the necessary steps upon the receipt of a medical certificate, but generally they are sent under the authority of the medical officer of health, and as far as possible he relies upon the medical attendant as to its being a suitable case, and accepts his diagnosis. Sometimes he must use his official position and influence to obtain a patient's removal, and occasionally he has to resort to compulsory powers of removal. H e has often an opportunity of protecting the medica attendant from the results of a premature or mistaken diagnosis, and should be willing to afford him such assistance as his experience may warrant in the diagnosis of cases concerning which there is doubt as to the propriety of isolating them. H e will offer his services, or wait until they are sought, according to his temperament or tact, although it goes without saying that in any conference or consultation he must be strictly guided by the rules of professional etiquette. 1 well remember a late leading member of our profession, when speaking publicly as to the relations between medical practitioners and medical officers of health, saying they must always remember that their office was the child of t h e medical profession, and they should therefore give its members their first consideration. To this I replied that that if our office was the child of the medical profes,,r
* This arrangement will cease upon the adoption of the Infectious Diseases Notification Act.
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sion, it had only the stronger claims in consequence upon the members for assistance and support. A sanitary authority in this neighbourhood resolved recently that their medical officer of health should personally verify the diagnosis of the medical attendant, and the correctness of his certificate, before authorizing the removal of cases to the hospital, Such interference would have been most obnoxious, and calculated to cause much friction between the authority and the medical men. The medical officer rightly appealed to the Local Government Board, by whom the resolution of the sanitary authority was not approved. I do not wish to raise any discussion this afternoon on the subject of the compulsory notification of infectious diseases, as I hope it will become the subject of a special paper at some future meeting, but I ought to say, in relation to medical certificates under that Act, that I consider they devolve a larger amount of professional responsibility upon the medical man who gives them than the voluntary notifications of former days. It is also very desirable that they should be accompanied with voluntary information from the medical man as to the suitability, or otherwise, of the case for removal. Failing this, medical officers of health will feel they are entitled to ask (through the inspector), as to the disposition of the patient or friends to avail themselves of isolation. Notwithstanding a medical certificate has been received concerning a case where the diagnosis is ~#rimdfade doubtful, a medical Officer of health will probably feel it does not altogether relieve him of responsibility in allowing the case to go to hospital, where it might occasion serious complications to the patient or to other cases inside. To limit this risk every infectious hospital should have probationary wards and nurses, to receive the frequent mistaken and doubtful cases which are sent there. The position which a medical officer of health holds in relation to the medical supervisiou and professional treatment of cases in a hospital in connection with his district must vary widely according to special circumstances. In first class hospitals, there is ample field for division of labour, and the appointment of a resident medical superintendent relieves thc medical officer of health of any responsibility. Often in smaller hospitals in large sanitary areas a local practitioner is responsible for attendance on cases in the hospital, the medical officer of health having a general supervision. In the majority of hospitals, I believe, the medical officer of health is medical officer to the hospital, as a separate appointment, which includes attendance on the inmates. Though it is no part of the duties (.f his office, I see no reason why he should not accept the position of medical officer to an infectious hospital, if he is otherwise qualified for its duties, and many obvious reasons why he should. Whenever his
appointment to analogous offices, such as public analyst, poor-law medical officer, or medical officer to an infectious hospital, will enable a sanitary authority to maintain a medical officer of health who does not engage in private practice, this is evidently an advantage. The policy which a sanitary authority adopts ira regard to the terms on which cases are admitted to its hospital is a matter of considerable importance. Under the I32nd section of the Public Health Act, " A n y expenses incurred by a local authority in maintaining in a hospital a patient who is not a pauper shall be deemed to be a debt due from such patient, and may be recovered." Though it is permissive to require payment, the generally accepted opinion is that since isolation is adopted for the benefit of the community, no charge should be made upon the patient, and also that by so doing it hinders the adoption of isolation and delays the admission of the case. I should be exceedingly sorry if your President should not prove orthodox, and should be discovered to have any unsound views on this matter. There are certainly some cases of disease where the need for their isolation is urgent, and when it is necessary it should be gratuitous, but I am not prepared to say that an authority which has established an infectious hospital, neglects its duty because it requires, as a rule, a graduated payment to be made towards the maintenance and treatment of the cases admitted, and it is possible in the long run its hospital may become as popular a s one where maintenance and medical treatmen~ are given gratuitously to all classes. There is a strong feeling that gratuitous medical and other services have a tendency to demoralize people, and as these hospitals confer a great benef~ upon the patient and ]ais household, as well as upot~ the community, a moderate and graduated charge is quite legitimate. This is the policy the Manor of Aston Local Board have hitherto a d o p t e d ~ t h e guardians of the poor paying for destitute cases--and my experience is that though there are many difficulties cf detail, in arrangements for obtaining a payment--difftculties which are not diminished by the custom to the contrary which prevails in Birmingham and all, the adjoining districts--they are not insuperable. The admission of cases depends more upon t h e attitude which the medical attendant takes than upon the fact of a payment being required. This attitude varies from that of the medical man wh<> declines to attend upon any case of scarlet fever, to that of him who objects to the removal of hi~ cases on the ground that it is starving the doctors. An efficient disinfecting apparatus is an indispensable appendage to a well-appointed hospital, and the medical officer of health must feel quite satisfied that the clothing, as well as the person of the patient after detention in the hospital, are free from infection.
PROCEEDINGS
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W i t h o u t these p r e c a u t i o n s of detail a n d m a n y others, t h e whole e x p e n s i v e m a c h i n e r y of isolation which has b e e n put in m o t i o n m a y prove o f n o avail. E v e n with t h e m t h e original infection is liable to attack o t h e r m e m b e r s of t h e h o u s e h o l d , a n d the disease may lurk in u n s u s p e c t e d places, a n d occasion b y its r e - a p p e a r a n c e d i s a p p o i n t m e n t at t h e a p p a r e n t l y unsatisfactory results o f isolation. T h e m o t t o o f the medical officer of health is t h a t " P r e v e n t i o n is better t h a n cure." W e m a y n o t always be able to stop the spread o f p r e v e n t a b l e disease, b u t d o we not often fail to cure ? T h e r e is n o m a g i c in isolation, b u t a n a d e q u a t e hospital for the p u r p o s e occupies a foremost place in our array of m e a n s for carrying out the policy of prevention, a n d it also marvellously assists in effecting cures. I n f e c t i o u s hospitals are n o longer in t h e experim e n t a l stage, b u t there is s o m e t h i n g yet to learn from e x p e r i e n c e as to t h e m o d e in which t h e s e institutions should b e e r e c t e d , a n d t h e principles on which t h e y should b e c o n d u c t e d ; a n d it is very desirable that the farther d e v e l o p m e n t s of their usefulness, w h i c h t h e future has in store, s h o u l d b e assisted a n d h a s t e n e d by the lessons o f t h e p a s t a n d the p r e s e n t . DiscussioN. Mr. tlotlinshead, in moving a vote of thanks to Mr. May tor his interesting paper, said he agreed with all he had said, and even went further. He should like to see diphtheria and measles isolated, believing that it would largely tend to lessen zymotic diseases if first cases were removed. All these diseases could not be treated in one establishment, and it was a question whether there should not be separate hospitals for scarlet-lever, small-pox, and measles. The suggestion that medical officers of health should verify diagnoses of infectious diseases would not work. As to the question of payment, he believed that those people who could pay should do so, but to the rank and file of the working classes infections hospitals should be free. If they made a charge, patients would be kept at home, and the result would be that infectious diseases would be seriousIy spread. The Board under whom he worked authorised him to make a charge, hut the poor people said they could not afford to pay anything, and ultimately the Board withdrew their application for fees. Dr. Bostock Hill, in seconding the mot.;on, disagreed entirely with the suggestion that diagnoses of infectious diseases should be verified by medical officers before cases were admitted to hospitals, contending that the onus of the diagnoses was properly placed upon the medical practitioner, and that the medical officer had nothing to do with it. Mr. May would have the medical officer consulted before the admission of a "7~rimd facie doubtful case ; " but what was a 7~rimd.facie doubtful case? Ife agreed that infectious hospitals should be absolutely free. If notification was made compulsory and isolation was desirable the only logical conclusion was that isolation should be free. The hospital was not provided for the benefit of the infected individual, but for the better conservation of the public health, and the hospital was in that sense a public institution and should be supported as such. Disinfection should also be free. Diphtheria should be isolated. He believed there were few diseases that were more infectious, and that before long it would be a prime necessity to isolate it just as they did scarlatina and small-pox. Dr. Alfred Hill spoke strongly in favour of enforcing the notification of infectious diseases, maintaining that even if
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there were no hospitals it would be advantageous, and might lead to the provision of hospitals, because local authorities could not keep on receiving notifications without doing what was necessary to isolate infectious cases. His experience as medical officer for the city of Birmingham convinced hira that if infectious hospitals were to be useful they must be absolutely free, although special accommodation might be provided for those who liked to pay for it. If all the people who were admitted had to pay, instead of there being 40o or 50o patients, the number would not exceed 40 or 5° . He had told the local authority in Birmingham that they did not want to make money out of the people who contracted infectious diseases, but to isolate them for their own benefit and the benefit of the community, and they now did so without making any charges except, of course, upon the rates. Dr. Underhitl also made afew remarks, and the President briefly replied. He defended his contention that primal.ratio doubtful cases should be verified, by stating that the first reported ease of small-pox might be something else, and that for the reputation of a district, as well as in the interests of a patient and the community, the authorities should make absolutely sure before isolating an],"cases. After the meeting the ex-President (Mr. Itollinshead) invited the members to a dinner at the Conservative C!ub, Temple Row. The members present at the annual meeting were joined by Dr. Fenton (Coventry) and Dr. Clarke (Lichfield). The cloth being removed, the President said he wished to give them one toast, without which no assembly of Englishmen was complete, viz., the health of Her Majesty and the rest of the Royal Family. This was enthusiastically honoured. The ex-President observed he was glad to meet the members of the Branch that evening under those circumstances. IIe believed it was x5 years since the first President of the Society, Dr. A. tlill, inaugurated similar festive proceedings. He thought it was a happy idea and a good thing for such a society to meet once a year. The British Medical Association and other societies had their annual dinner, and he thought they ought to. I-Ie did not mean that he thought it should fall to the gratuitous hospitality of the President to provide it, but it should be arranged on the lines oftheother societies. Dr. Alfred tlill thought, although there was no formal toast list, at least they would not object to one more ; with the permission of their host he begged to give them " Success tb the Birmingham and Midland t~ranch of the Society of Medical Officers of Health." (Hear, hear). Animated and friendly converse brought this pleasant evening to a close. PROCEEDINGS OF THE NORTH-WESTERN BRANCH OF THE SOCIETY OF MEDICAL OFFICERS OF HEALTH. A ~IEETINO o f this B r a n c h was h e l d a t 44, J o h n D a l t o n Street, M a n c h e s t e r , on Friday, J a n u a r y Ioth. Dr. W e l c h (Blackpool), P r e s i d e n t o f the B r a n c h , was in the chair. T h e m i n u t e s of the last m e e t i n g were read a n d confirmed. T h e foEowing g e n t l e m a n , having b e e n duly n o m i n a t e d , was e l e c t e d a . m e m b e r of t h e B r a n c h : C. E. Paget, L . R . C . P . L o n d o n , M e d i c a l Officer of H e a l t h , Salford. T h e following g e n t l e m e n , having b e e n duly n o m i n a t e d , were elected, subject to the approval o f t h e Society : S. Barwise, M . R . C . S , M e d i c a l Officer o f H e a l t h , B l a c k b u r n ; a n d H . E. Edlin, M . R . C . S . , M e d i c a l Officer o f H e a l t h , L e v e n s h u l m e . T h e f o l l o w i n g p a p e r was r e a d by t h e H o n . Secretary : - -