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Proceedings of the Incorporated society of medical officers of health
HEALTH,
PUBLIC ~t~¢ ~ottrr~at
~uci~t~ ~i~ £~e~iraI Ol~c~r~ s~ !t~ealtb.
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NOTICE. THE
INCORPORATED SOCIETY OF
MEDICAL
O F F I C E R S OF H E A L T H .
2o, Hanover Square, London, W., January, 1894. NOTICE is hereby given that an O R D I N A R Y MEETING of the S O C I E T Y will be held at No. 2o, H A N O V E R SQUARE, W., on MONDAY, the 19th day of F E B R U A R Y , 1894 , at 7.3° p.m, for the transaction of the undermentioned business : - i. Minutes. AGENDA. 2. Report of Council. 3. To Elect Candidates. The following candidates have been duly nominated for election : As Fellow--
time,EaT WILLIAMS,M.D., London' Cert. Public Health, London University, 2e~ CheyneGrove, Chelsea ? Assistant M.O.H. Port of Lon-lon; proposed by W. G. X'VooDFoRDE, M.D.j seconded by W. COLLINGRIDGE, M,D. As MembeJ--
ELWARDI-IEI,rR7 LEIViOY,M.R.C.S., L R.C.P., D.P.H., Irelat~d, Croydon Infirmary, Surrey; proposed blt F. P. WmHTWlCIG M.D., seconded by AR't'I-IUR NEWSHOLME, M.D.
4. Nomination of Candidates. 5. Correspondence. 6. To receive Dr. Armstrong's re.~olufion re "Movement of Vagrants." 7. Miscellaneous business. 8. At 8 o'clock, a Discussion wiil take place on NO. 7~. FEBRUARy, 1894.
'~ VACCINATION AND
THE
LAWS
RELATING
THERETO." The Discussion will be opened by Dr. E. Seaton, M.O It. Surrey Coun'y Council, and Dr. T. Eustace Hill, M.O.H. Durham County Council. The following gentlemen also hope to take part in the discussion: Drs. C. E. Paget (Salford), L. Parkes (Chelsea), J. W. Priestley (Leicester), J. F. J. Sykes (St. Pancras), W. N. Thursfield (S~ropshire), F. Vacher (Cheshire), and E. F. Willoughby. F. P. WIGHTWICK, "~ St., Grosvener Sq., W. I 55, Uppej.rBrook C. THRESH,
_tf07t. Sec$,
The Limes, Chelmsford. PROCEEDINGS OF T H E I N C O R P O R A T E D SOCIETY OF M E D I C A L O F F I C E R S OF HEALTH. A MEETING O[ the Incorporated Society of Medical Officers of Health was held at No. 20, Hanover Square, on Monday, January ISth , 1894. Present: The President (Dr. W. T. G. Woodforde) in the chair, Drs. L. C. Parkes, Geo. Reid, A. Whltelegge, W. H. Kempster, D. T. Skinner, L. W. Darra Mair, W. Lake, H. Start, W. Collingridge, J. F. Sykes, G, Diekenson, E. Sergeant, C. Sanders, A. NewshSlme, L. Wilde, S. Davies, R. Bangay, and E. F. Wdloughby, ann the Hart. Secs., Drs. Wightwick and Thresh. The minutes of the last meeting of the Society on December i8th, x893 , were read, approved, and signed by the Chairman. REPORT
OF T H E
COUNCIL.
The HON. SECRETARY read the report of the Council : - (a) That the Council having received a report from the Sub-Committee appointed to consider the best mode of utilising the funds derived from the Berridge Legacy, recommend that a sum of ;~25 should be placed at the disposal of the Editor during the present year for the purpose of remunerating contributors to the Jomnal. (b) Reporting other proceedings of the Council for the information of the Society. l
13o
T H E I N C O R P O R A T E D S O C I E T Y O F M E D I C A L O F F I C E R S OF H E A L T H . A s FellaZOS--
G-EORGI~ FRANCIS ~[O,N~S, M.R.C.S., L . S . A , Clarence House, Southend-on-Sea, M . O . H . Southend-on-Sea U S.D. ~CBERT GRAVES BUI~.TON,M.D.Edin., L.R.C.P.Ed!n., r, Gloucester Villas, HanweU, W., M.O.H. tIanweli U.S.D. FREDERICK ~TOCKWELL, M.D.~ Benton, M.0.H. Bunter. t:IEN~.Y R. KE~rWOOD, M.B., L R . C . P . , D.P.H., Royal College Physicians and Surgeons, Lend., I ~9. Adelaide Road, N.W., M,O.tt. Urban Sanitary District of Finchley. As -4ssociates-ADAM, Wn-SON, L.R c.P., F.R.C.S.Edln., O,.borne House, Jesmond Road, I'qeweastle-upon-Tyne. I-I. W. NEWTON, L.F.P.S.Glas., L.F.A., 2, Ellisen Place, Neweastle-upon-Tyne. SIg GEOgCZ A. PILItmGTON, M.R,C.S., J.P., Belle Vue, Lord Street, Southpott.
A~am/nalions.--A number of candidates were then nominated for election at the next meeting. I~RESENTATION TO DR. SYKES.
Dr. Sykes, who for some years has acted as Secretary of the Society, having recently resigned, was presented--as the result of the subscription opened among the Fellows of the Society for the purpose of offering him a testimonial, in recognition of the valuable services he has rendered to the Society--by the PRESIDENT, acting on behalf of the Society, with a handsome salver, and a magic lantern apparatus. Dr. WOOFORDE(the President), in making the presentation, said : I rise to perform what is a very .pleasant duty, and it is to act as your mouthpiece m expressing to our valued friend Dr. Sykes our very hearty appreciation of the valuable and able services he has rendered to the Society during the years he has acted as its secretary. We all know very well that ~hen he first took office we were comparatively a small body; we also know how large a share he had in the carrying out of those changes by which we have developed into an incorporated society with legal status and responsibilitie% while--by the affÉliation to the central body o f the provincial branches, which were scattered over the country, and the consequent very large increase in our numbers--we have taken a much more important and influential position in the estimation of the public at large. We have also, since Dr. Sykes took office, started a journal of our own, which is second to no Other sanitary organ in the kingdom--a journal which has already obtained a position of great public influence, and which, if it is continued upon the same lines as those adopted by its two succes. sive editors, will increase in power and importance as time goes on. In these things, as in the general business of the Society, Dr. Sykes has taken a leading part, and has continued his exertions to promote its success for several years; and now
that he is resigning his secretarial office, We have felt that it is impossible for us to allow him to do so without taking advantage of the opportunity it affords us of offering him some mark of our appreciation of his work, not indeed, as being ifl any way remuneration for his services, but simply in recognition of what he has done for us. I have before me a salver and some pieces of apparatus - - a s to the selection of which Dr. Sykes's owr~ wishes have been consulted--and I am sure that I express the feeling of everyone here when I say that in offering this testimonial for his acceptance, we also wish him in his retirement every happiness in his domestic relations and much success in his public work. (Applause.) Dr. SYKES, in acknowledging the testimonial, said: It is exceedingly kind of y o u , sir, to have spoken of me in such highly appreciative terms. I /eel that I hardly deserve them, although I have endeavoured to merit them. I may say that when I first heard of the intention of the society to give me a testimonial I felt highly honoured, but when I further heard that it was the intention of my friends aud colleagues to present me with a testimonial, not from the funds ot the society, but by their personal subscription, I not only felt honoured, but deeply touched. I feel that this Society is no~ merely a professional body, but a society of members working in the same cause, with a brotherly teeling and friendliness among its members--a feeling that I hope will ever increase. The small points you have mentioned el work that I have tried to do are not very large in their way, but I hope they will lead to great results in the future. I hope that those who have worked with me in thi~ Society, and those who follow, will make it prosper. So far as nay peculiar choice of testimonial is concerned, if with this lantern I can at any time be of use to the Society, if I can make its meetings more useful or interesting, I shall only be too pleased to do so.
The meeting then proceeded to consider the question of VAGRANTS
A N D T H E DISSEMINATION
OF
DISEASE.
The HeN. SECRETARYread the following letters : Dr. Gore King, of Keswick, wrote : ~ In a paper I read at the last meeting of the British Medica~ Association I suggested a ticket system as appearing to me the best way of meeting the difficulties of the case, the chief essentials being that every tramp should carry a card bearing hls name and description, without which he should not be received at any casual ward or common lodg'ng.house, and which, in case he was brought in eontaet with infectious disease at anysuch place, should be endorsed to that effect with da~e by the medical officer of healtb, so that, wherever he went he might be kept under supervision until the period of incubation was passed. I think this plan would answer nearly all the purposes o¢ enforce-1 quaran'ine, and would he much less uostlyand pre. sent fewer practical difficulties, and I believe Parliament
VAGRANTS
AND
THE
DISSEMINATION
would be more likely to sanction such a scheme as this than one which involved compulsory detention or compulsory revaccination. Dr. C. J. Russell M c L e a n , M . O . t t . for Y e a d o n , Yorks, wrote : The district for which I act as medical officer of health is only a small one, and containing under 8,000 inhabitants, but as regards vagrancy it is an important centre. There were up to theend of last year no fewer than seven lodging. houses, but with a view to discouraging vagrants in the idea that the town is a sort of headquarters for them the Sanitary Authority have reduced the nmnber oI registered lodging. houses to three. The necessity for so large an accommodation for vagrants lies in the fact that our town is situate almost midway between the important centres of Leeds and Bradford, and also about equidistant from the town of Otley, where there is a workhouse and still greater attractions for vagrants, the workhouse not being the most popular resort amongst such travellers. The result of our somewhat dentral position between these places is, that we get perhaps more than our share of visits from vagrants, many of whom simply " stay the nighg" Or thd " week end 2' In my annual report for the year I857, during which period there were cases of smalbpox amongst tramps in Leeds and Bradford (Sheffield epidemic), we had some difficulty with regard to the housing of vagrants, the lodging-house keepers refusing to put them up whenever they suspected the tramps came from either of the infected areas.
At that time I recommended ,a That some sort of registration or certification of vagrants having no fixed abodes should be adopted, showing ~here they last came from, etc., and without which they would be refused admission to any public lodging-h0use, especially during any serious epidemic" {this probably under police supervision). Again, in my repoxt for the year I888, I made somewhat similar remarks, owing to the outbreak of typhoid fever ia an adjoining township. Again, in my third report for the year ISgt, with regard to an outbreak of measles during the annual " f a i r " visit of the "'travelling shows and caravans," I advised that " T h e r e should be health certificates {granted and signed only by the Medical Officer of Health) given to the owner ofj or affixed to each caravan, when the owner leaves a town, so that at the next place visited a clean bill of health or otherwise can be produced for the guidance of the authorities there. As such attractions are chiefly patronised by children, the danger in many cases, as in this one, when measles was the prevalent disease~ becomes greater. Of course, such aplan as this could only be sanctioned by the Local Government Board but I consider there has been neglect of duty that an Act for this purpose has not been framed and placed amongst the many other Parliamentary Acts pertaining to the Public tlealth." T h e following paper was then read : ~ VAGRANTS AND THE DISSEMINATION OF DISEASE. By HENRY E. ARMSTRONG, D. tIy., Medical Officer of Health for Newcastle-upon-Tyne, etc. T h e introduction of small.pox into the Newcastle W o r k h o u s e in December, r892 , by a m a n on tramp, and t h e subsequent re-introduction of the disease into the same place and also c o m m o n lodging-houses in the city by other tramps, gave rise to a great deal of trouble and some expense. T h e e x p e r i e n c e - - b y no means n e w - - a n d the knowledge that other vagrants had in other, places been the means of spreading the disease, gave rise
OF
DISEASE.
J31
to the desire to ascertain more about the matter. H e n c e the application in May of last year to the m e d i c a l officers of health of the large urban districts for the particulars which are e m b o d i e d in my report on " S m a l l . p o x and Vagrancy," ~ h i c h h a s appeared in the journal of this Society. The replies furnished in response to m y queries yielded information the consideration of which cannot but create a strong feeling of the need of a p r o m p t and energetic remedy for a gross defect in the present system of the administration of preventive m e d i c i n e - - v i z . , that which allows the broadcast spread of disease by vagrants. F r o m the returns of the Local G o v e r n m e n t Board, it appears that the first town affected with small-pox in the present e p i d e m i c was D e w s b m y (in May, r 8 9 i ). T h e source of infection there was not reported to me. I n the same m o n t h the disease began in London, Liverpool, Birmingham, and Bristol. H o w it was i n t r o d u c e d into the first two of these towns is not known to m e ; but it c a m e to the two latter in the persons of vagrant,& T h e next two urban districts invaded were West H a m and Croydon, infection in b o t h cases having b e e n first c o n v e y e d there by a vagrant. Passing over Southampton, into which port the disease had been bronght by ship,eand also Middlesborough, Wakefield, a n d Bath, from which I received no returns, I find small-pox was next introduced (also by vagrants) into W e s t Bromwich and H u l l ; afterwards into Manchester (from which I have n o i n f o r m a t i o n ) ; then, again by a vagrant, into Cardiff. This was in D e c e m b e r , 189I. Thus, in the first h a l f - y e a r of the epidemic, fifteen towns were attacked. O f the eight of those towns from which I received replies to m y q u e r i e s , seven had received their first infection by tramps. I n I892 the disease slowly and steadily advanced, m o n t h by month, ft'om town to town. By May, I893, i n 7 or in8 of the r i 7 large urban districts reporting their infectious cases to t h e Local G o v e r n m e n t Board were invaded by smallp o x , . a n d the n u m b e r of cases they yielded was upwards of 5,6oo. A t the height of the e p i d e m i c - - £ e . , about May l a s t - - t h e n u m b e r averaged a b o v e 360 per week. O f 63 .towns invaded, the medical officers of health of which have been so good as to favour m e with particulars, 37 or 59 per cent. had the infection primarily from vagrants. T h e disease was brought secondarily by vagrants into 36 towns, including s o m e into which first cases h a d also b e e n brought by the same class of persons. Such secondary infections occurred as often as nine times in Carlisle, Southampton, and Sunderland, x2 times in Warrington, 15 times in Keighley, ~8 times in Blackburni and no less than z5 times in Nottingham ! I n x 9 instances only out of the 63 towns reporting was small-pox infection stated to have been brought otherwise than by vagrants, a n d in I-I 2
I32
T H E I N C O R P O R A T E D S O C I E T Y O F M E D I C A L O F F I C E R S OF H E A L T H .
seven of these it was subsequently re-introduced by vagrants no less than 25 times. The epidemic is still going on. Tramps bring their infectious diseases either to workhouses or common lodging-houses. According to the returns on which my report is based, in t h e above mentioned instances infected vagrants were housed 3~ times in the former and 80 times in the latter. Each of those lodging-houses gave infection to an average of one case in the same house, but to how many other persons it is impossible to say. I n Blackburn, where the workhouse was infected with small-pox five times, and lodginghouses four times, there had been 56 cases of the disease by the end of May last. I n Halifax, where small-pox had been brought to lodging-houses six times, infecting in these ~9 other persons, the number of cases in the town in little more than a year from the date of the first one, was 360. I n Warrington, where the disease was brought to both workhouse and lodging-houses by tramps, the number of cases in the borough in the first year was 598 . The majority (44 in 73) of the medical officers of health have recorded their opinion that it is desirable that during the prevalence of s m a l l pox or other epidemic disease all vagrants, before leaving a workhouse or common lodging-house, should be compelled to report their next place of destination to the master or keeper of such house. The compulsory detention during possible incubation of disease, together with disinfection during epidemic times--and, in case of small.pox, the re-vaccination--of vagrants in workhouses and lodging-houses is advocated by 56 of the 73 medical officers of health responding to my inquiry on that point. Several medical officers of health make suggestions as to other practical measures to be taken with the object of preventing the spread of infectious disease by the class of persons under consideration. These are so valuable that I make no apology for repeating the following summary of them from my xeport : QuEsTIoN No. i I . - - W h a t other steps, if any, would you suggest should be taken with the view of preventing the spread of small-pox or other infectious diseases by vagrants ? The replies may be summarised as follows : - I. Where an epidemicis prevalent it should be possible to prevent vagrants visiting the district, and to arrest them on infringement of this condition. 2. Only a county medical officer of heaIth can deal with diffusion of disease through a county. 3. Vagrants should be systematicallyexamined on entering the union. 4. Strict inspection should be maintained, with history of routes travelled. 5, Make compulsorythe medical inspection of all vagrants with the view of discovering mild cases which might otherwise escape notice.
6. Attend closely to the common lodging-houses,e~pecially by night. 7. Each common lodging-house should provide a free bath, and each vagrant should have fresh water. 8. Common lodging-housesmight be closed for a time. 9. The establishment of model lodgi~gThouses in towns shouM be general. 1o. Sanitary authorities and Poor Law and union authorities should be compelledto provide means of isolation. It. Adopt the separate cell system at all unions. 12. Vagrancy should, as far as possible, be prevented, say, by retaining all tramps who enter workhouses for a fortnight, and compellingthem to work whilst there. 13 Vagrants should be detained under observation. 14. The medical officer of health should keep a spare room for suspected vagrants. 15. Suspiciouscases should be isolated immediately. x6, Vagrants should not be allowed to infest the crowded precincts of police stations for orders for admission to the workhouse. If the police continue to give these orders a separate place should be provided for the pur. pose. I7. Every vagrant should be re-vaccinated ; better still, everyone else. I$. Re-vaccination of all vagrants lodged in a casual ward should be compulsory. If they had the choice between being re-vaccinated or doing their task they wouldj in the majority of cases, prefer the former. I9. Vagrants should be allowed to travel about on ticket or pass only. 20. There should be communication with prisons~ workhouses~ commonlodging-houses~masters of canal boats, etc.j directing attention to prevalence of epidemic and local powers relating thereto. 2I. More attention should be paid to the migratory habits ot other persons than vagrants. Vagrants, as a class, occupy a specially dangerous position with regard to their means of spreading infectious disease. They come and go where they please unquestioned, and are accountable to no one in this respect. I know of two tramps who, whilst infected with small-pox, visited a casual ward where they were bathed in water used by ten other persons. Vagrants are of two k i n d s k t h e professional and the occasional. The former is lazy, idle, and good for nothing. The latter is seeking for work, and is therefore entitled to some consideration. T h e community derive no benefit from the professional vagrant. They cannot prevent his arrival or departure o r trace his movements. On the other hand, they have to maintain him. Therefore they have the right to subject him to special regulations, in order to protect themselves from any evil he may do them. Their powers to this end are at present inadequate to the necessities of the circumstances under consideration. Among possible difficulties in the way of carrying out of remedial measures is the objection that may be raised to compulsory re.vaccination. This point is, as regards the general question, of comparatively little importance. The great thing isj not to prevent the tramp catching disease, but to prevent him from giving it to others. Re-vaccination applies only to small-pox, but there are typhus and other infectious diseases, the infection of which he may carry from place to place.
VAGRANCY AND The London County Council are now taking action to give effect to the proposal to convene a conference of the urban sanitary authorities of England and Wales for the purpose of considering the steps necessary to prevent the spread of infection by vagrants. An expression of the views of the Incorporated Society of Medical Officers of Health will be useful to that conference. I therefore beg leave to move the following resolution ; - fn~clious Disease and Vagrancy.--Preveztive Measures. ' T h a t the Incorporated Society of Medical Officers of Health consider it desirable"(x) That vagrants should be restrained in their powers of carrying infection about the country, especially in epidemic times. "(2) That they should be made to report their movements. " (3)That they should, when considered requisite, be subject to disinfection and detention for such time as the sanitary authority of the district in which they are may think necessary for the protection of the public health. " (4) That in epidemic times all persons frequenting casual wards or common lodging houses should be medically examined on admission. " (5) That sanitary authorities and the police should have power to detain for medical examination any vagrant found in any public place. ''* The following paper was then read : VAGRANCY AND S M A L L - P o x . By EDWARD SERGEANT, L . R . C . P . , etc., M . O . H . Lanc. C.C. It gives me great pleasure to add my testimony in support of Dr. Armstrong's views with respect to vagrancy and small-pox. The information on the subject which he has been able to obtain from various parts of the country will prove of great value. The remarks I have to make apply more especially to Lancashire and are the outcome of my official experience in that county. The suggestions I shall submit for your consideration seem to me practicable and desirable for restraining a danger which has assumed serious proportions. The health of the country is menaced by persons who tramp from place to place having no certain dwelling or not abiding in it. They escape the usual laws observed by good citizens and pay little attention to vaccination or the laws of health ; as a result, when small-pox is prevalent they fall a prey to the disease, and owing to ignorance or carelessness much distribution of the infection * T h e above resolution is given in the amended form adopted by the mover on tke ~uggesiions ol Drs. Sergeant, Newsholme, and Sykes.
SMALL-POX.
I33
takes place among frequenters of their haunts before the sanitary authorities are able to discover the source of the mischief. I know that Englishmen have an objection to any interference with the liberty of the subject, but this feeling ought to give way in tha case of vagrants who avoid all means of honest livelihood, preferring to attach themselves to a society like a parasitic growth. Fortunately such pests have not entire freedom ofaction,for~under an Act passed in i824 relating to the punishment of idle and disorderly persons, etc., a vagrant " n o t having any visible means of subsistence and not giving a good account of himself" is liable to be deemed a vagabond and punished with imprisonment, "while an incorrigible rogue (not being a female) may also be punished by whipping at such time during his imprisonment." Why should the law not go further and say that vagrants shall not by their actions endanger the public health ? The proposals for accomplishing this end have in many towns been more or less carried out with good effect, but general action is wanted and greater efficiency would be secured by a legal enactment. In the administrative county of Lancaster the distribution of small-pox by vagrants during the past two years has been abundantly demonstrated, and the want of power to cope with the evil has been much felt. The disease, after spreading extensively in Yorkshire during the early part of ~892, was introduced by vagrants into the Borough of Warrington, and from thence was distributed to Ashtonunder-Lyne, Withington, Garstang (R), Warrington (R), and many other districts. From the reports issued by the Lancashire County Boroughs further evidence is given of the important part played by vagrants in the spread of small pox, and in the majority of these boroughs outbreaks of the disease have been repeatedly ascribed to tramp origin. As mentioned by Dr. Armstrong, of the towns attacked with small-pox throughout England and Wales 58 per cent. had the disease first introduced by vagrants, and in 72 per cent. of the towns the disease was sooner or later conveyed there by persons of this class, and on the average of five times to each town. In a recent report on the prevalence of small-pox in Salford during the years x892-3, Dr. Paget states that the first case of the epidemic was a vagrant from Stalybridge, and the infection was afterwards carried into the borough in a similar manner on seventeen occasions ; while Warrington--I892-3--suffered thirteen times from the tramp conveyance of smallpox. In the administrative county of Lancaster during I89e , 6~2 cases of small-pox broke out in 28 districts, including 6 boroughs, i6 urbau and 6 rural districts, and in one-third of them the disease was primarily introduced by vagrants, or by frequenters of common lodging-houses. To the end
134
T H E I N C O R P O R A T E D SOCIETY OF MEDICAL OFFICERS OF H E A L T H .
of the past year I,OOo cases have been reported from 76 districts, 15 being borough's~ 48 urban and ~3 rural. Of the total districts attacked during the two years, 3 ° per cent. attribute to vagrants the responsibility of conveying the infection. Frequently the disease first appeared in the common lodging-houses, and on becoming known the other lodgers, as a rule, disappeared without waiting to hear the wish of the sanitary authority as to precautionary measures, and in this way infection was conveyed from district to district. Many workhouses and tramp wards have been attacked with small.pox ; and vagrants, while suffering from advanced symptoms of the disease, have been discovered in the public thoroughfares. The only power possessed by sanitary authorities over vagrants is by section 83, Public Health Act, ~875, which provides that the keeper of a common 10dging&ouse, " i n which beggars and vagrants are received to lodge/' shall from time to time report to the local authority every person who resorted to such house during the preceding night. It would be better if sanitary authorities, on the outbreak of dangerous infectious disease, such as small-pox, could, b y resolution, require the observance of the following additional provisions, viz.-(a) That keepers of ail common lodging-houses keep registers of persons resorting to such houses, and daily forward specified schedules to the local atithority, such schedules to contain correct information in respect of the proposed movements of the lodgers enumerated. (b) That the officers of the local authority, or police when requested by the local authority, exercise supervxston over vagrants, and be emp,owered to detain any vagrant for medical inspectmn as to the state of his health, and when f o u n d to be unvaccinated or imperfectly vaccinated the public vaccinator be authorised to vaccinate him. If the medical officer of health should consider it necessary he may detain t h e vagrant in an isolation hospital when available, or, with the consent of the guardians, in a workhouse or: tramp ward, and all reasonable expenses shall be paid by the local authority. (c) That the officers of the local authority provide for the disinfection of the clothing or persons of Vagrants if required; by reason of their having associated with infected persons, or on suspicion of their havir~g so associated. (d) T h a t the medical officer of health on the outbreak of small-pox or other dangerous infectious disease in a common lodging-house, make an inspection of the lodging:house without delay, and have power to place the other lodgers under quarantine f o r a period specified by resolution of the local authority, a n d take any further precautions for preventing the spread of disease he may consider desirable.
It is suggested that any person without the permission of the local authority leaving such lodginghouse or in any way contravening the above requirements, would render himself guilty of an offence punishable by fine or imprisonment. Suitable payments might be made by the sanitary authority to the keepers of common lodginghouses for their daily lists of lodgers, and the vagrant would be responsible for the correctness of the statement concerning his destination. I n case of quarantine the sanitary authority ought to pay the reasonable expenses incurred. These provisions would be best carried out in the administrative counties under the supervision of the county councils than left to the small isolated authorities, perhaps not provided with a sufficient staff, or with any of the appliances required in the case of epidemic disease. I n addition to the above recommendations, I think it would be well if vagrants throughout the country were registered, as much valuable information would in this way be obtained for police and sanitary purposes. Each vagrant should be required to possess a certificate of registration, with particulars of place of birth, age, name, etc., and he should also be supplied after medical inspection with a health certificate. T h e vagrant would be required to produce these certificates on the demand of any police officer or sanitary official. I f vagrants were kept under strict regulation, as suggested, I feel satisfied that they would soon cease to be carriers of infection. DISCUSSION. Dr. ~VVHITELEGG]Ethought they were all agreed as to the necessity of something being done with regard to vagrants, but he had not made up his mind what was best to be done. As to the system of registration, he could not see how any guarantee as to correct information was to be obtained. He thought it was undesirable that the supervision of casual wards should be performed by the county councils, that work ought to be in the hands of the local authorities. He could fully hear outj from the reportslssued in his district, what had been said as tO small'p0x being br0u~ht in by tramps. He thought if they were going to the L~cal Government Board with any recommendations they might say something as to the isolation of infectious diseases in workhouses. In some cases tramps Suffering from infectious disease were taken to the workhouse as a meansof isolation--that was making the best use of the tramp system for spreading disease. Another particular point to which he wished to draw attention was as to tramps and common lodging-houses. If a sanitary authority foundc a case of small-pox had broken out in a common lodginghouse, and they wished to isolate the patient, they could, of course~ remove it, and they could, by voluntary arrangementj proceed further to quarantine the lodglng-house. They would have to pay the expensesof the people there, and recompense the owner of the lodglng.house, but in doing so they not only incurred some risk, but were certain to be surcharged by the auditor, Dr. NEWSlIOLI~IEsaid the main point to be emphasized in any application for additional power ,,wasthe power tor the compulsory detention of vagrants ; that seemed to him more important than revaccination. He thought the compulsory detention should come first, though they might i a practice retrain from enforcingit when vagrants submitted to revaccination. IIe thought that the mioimumperiod of quarantine should be eighteen day.-'. In the present state of public
VAGRANCY
AND
SMALLPOX.~DISCUSSION.
opinion it would not be politic to put revacciaation before detention. They ought rather to go for emnpulsory ~detention. Ite had happily had very little experience of smalbpox in his own district, but in one instance he had ~ffered a number of vagrants, who had been lodged for a fortnight in the stone c~sual ward as a small-pox patient, one shilling each to submit to revaccioation, and the whole of lhem had consented. ~)r. PARKES thought that what they wanted to determine was what was practicable in the matter, and what the House o f Commons would assent to ; and it appeared to him that "~heyhad better adopt those measures which did not interfere 'with the liberty of the subject, as other measures would not ,pass tbrough the House of Commons. That almost disposed ,of compulsory detention. (" No, no ! ") It appeared to him ~they might approach the Local Government Board and ask them to introduce an Amendment Bill to the Public Health Act, with a view to framing regulations similar to those they have for cholera, which they might put into effect when they thought fit. He thought they might adopt the ticket regis'tration system. There was no great harm in that. Every tramp would be required to produce his ticket with his name •and the place he last left, and the ticket would be signed by the keeper ol the 10dying-house, or the relieving officer if he came from a casual ward, and also by a medical vaau who examined him ; and a note should be added if ,there was any small.pox or other infectious disease in the town he had lef. He thought the regulations should pro'vide for medical examination of all casual wards and .commom lodging houses ; similar regulations v~ould apply 'to those ad~pted in cholera times. T h e district medical .officer would be empowered to visit at night, and examine all people applying for beds, and any tramp who would not foermit himself to b e medically examined would be subject ,to a penalty or to imprisonment. It would, of course, be a considerable expense~ but that they must not mind. Coml~ulsory detention would not only interfere with the liberty o f the subject, but would cause great diffieul!y. It would 'be necessary to provide accommodation for the delained. ~f a town had only one common lodglng.house, and they ~sed it, what would be done with the other tramps ? If, on ,the other hand, they used the workhouse for the infected tramps, the disease would be likely to spread to the inmates .and the staff. As to disinfection, there could be none if a vaan was in the incubation period, and if he was actually Suffering from the disease there was already power to disinfect. Dr. SYKES d flared in logo with Dr. Parkes on one point s "which was,. that the prop r course to pursue was what was expedient. It was the duty of the medical officer of health to point out what was right, throwing on the local authority the responsibility of refusing to act. He entirely disagreed "with Dr. Parkas as to the powers of detention. It was just because they had not got those powers that all the trouble arose. If a person had small-pox in a casual ward or a common lodging-house next morning they would have the mortification of seeing other menj who had almost certainly been in close contact with the patiefit, simply walk out 0I the ~aouse, and tlley could not stop them. They wanted to be able to give presumably infected persons in charge there and ~hen. Referring to compulsory registration, he could not see how they were going to prove identity. These tramps would " s w o p " their cards, and there w a s ' n 0 means of proof. Revaecination might be a n advantage, and it was possible to a certain extent. He presumed that in all .districts there was now a nightly examination of all casuals. T h e very first thing he did When small-pox broke out was to petition the guardiars to have a nightly medical examination~ and that was Still done. The result was, in three instances, within three minutes of a man coming in he was • Lspotted." What was required was to be able to give an order, and~ if necessary, to instruct the policemen to take ,any man ~ho had been in contact with a small-pox patient .in charge if he dared to go out. Ninety-nine medical men ~ut of IOO would say that anyone who had been in contact with a small-pox patient for 24 hours would be infected.
135
Dr. BANGAY : IS it to be supposed from the last speaker that the infection has taken place in the man's person or his clothes ? ]Dr. S'el.:~s : Both. Both his clothes and he personally, and the remedy would be to keep him in charge until his clothes were disinfected and he revaecinated. Dr. BANGAY : .That being the case, of course, as far as infection from the person is concernsd, there would be no danger until he had developed the disease, and as far as his clothes are concerned, how about medical men's clothes ? They go from house to house and do not change their clothes. The PRESIDENT I do not think medical men are in the habit of remaining twenty-four hours" with a small-pox patient. Dr. REID thought that if they wanted anything done t would be necessary to go to the Local Government Board n very strong force, and it might be considered whether it would not be desirable to co-operate with some other society. The Local Government Board had the opportunity of obtaining the very best advice from their own medical staff; but did not apparently avail themselves of it, which was instanced by the fact that the inspection of lodging-houses was in the hands of the police, which o[ten meant that a sergeant visited to ascertain whether any criminals were in the house, and that was all. They would have to get a great deal of reformation as to the inspection of lodginghouses, and it was a question whether they should not recommend that the police should have no authority over lodging-houses except for the detection of crime. Dr. SANDZRS was satisfied that no system of tickets would really be workable. With regard to the expediency of approaching Parliament on the question of detention~ he thought they had an analogous case in the detention at home of children belongio~ to a family in which an infectious case occurred. It certainly was a much more serious matter to detain children from school, When school would be a benefit to them, than it would be to detain a tramp who apparently had no means of subsistence. A question whicti struck him was as to the definition of a tramp--did it mean only the occupiers of common lodging-houses and casual wards, o r did it include carmen and sailors arriving in port ; in fact~ anyone who had no actual domicile of his own ? Dr. PARKES : I should like to point out, with reference to what Dr. Sykes said as to infected persons, if he is prepared to say the person is infected he has Bowers under the Public Health (London) Act already. Dr. S'¢K~s : You have to proceed by summons. It is true you can summon a man~ but you cannot stop him. Even if a summons is made returnable the same day, the man may be six miles away when you have it. The PRESIDENT : We have heard a great deal of smallpox io large urban districts. Now, I have twelve rural districts under my charge, and I have had small-pox introduced on several occasions by vagrants and by persons of the lower class of hawkers. These persons come into a district and stay for one, two, or three weeks, keeping themselves very much to themselvesm so much so, that in ohe ease a man was nearly dying before anyone knew he was ill. The question of expense is, I think, one that should not trouble us at all, because the expense of the medical inspection of these vagrants would be far less than that involved in consequence of the spreading of {he disease. With regard to detention, my own feeling is tbat if th:re is any practical way Of carrying it out it should be attempted. Tl~e ticket system would probably not be efficient. As Dr. Sykes has -pointed out, the identity would be very difficult. Dr. Woodforde went on to suggest that if the motion of Dr. Armstrong was carried, it should be referred to a special committee for further consideration. Dr. PARKeS: Would it not be better to refer it to the committee first, sir, then they could go thoroughly into the matter, and brin~ up a scheme for the approval of the~ Society. :
1.36
PROCEEDINGS
OF THE
BIRMINGHAM
The PRESIDENT: As I understand Dr. Armstrong's motion, it would simply form a basis tor the consideration cf the matter by the committee. Dr. SKINNER referred to the desirability of tracing the movements of the tramps backwards as well at forwards, and he referred to the institution originated by the police, called the "Mendicity Organisation," by which they requested people not to give wgrants money, and they supplied anybody who cared to have them with tickets, which they could give to these people, and which ticket would, on production at the baker's, procure them bread. It seemed to him this might he utili ed as a means of tracing tramps The effect the system had had on the vagrant society in Dor~,et was most wonderful; the men really in want did.not m~nd receiving these tickets, but the professional vagrant did, and consequently he cleared out of the district. Dr. AI~MSTR051%in replying, supported Dr. Sergeant's proposal that lodging.house keepers should keep for the daily information of the sanitary authority registers of the lodgers visiting their houses~ and would be glad if it were possible to have registration of detai!s as to the movements, etc., etc., of vagrants. He accepted the suggestions of Drs. Sergeant, Newsl=clme, and Sykes amending his resolution. If it were carried he would propose that cop~es should be fmwarded to the Local Government Board and 1he London County Council. He thought Dr. Parkes had failed irt his attempt to *'dispose of the subject of the detention of vagrants " by raising the old cry against '~ the liberty of the subject." ]Dr. Parkes seemed to forget the possibility of a vagrant incubating diso.ase whilst on tramp, and fo overlook the chance of a wholesale stampede of lodgers from any house in which a case of small-pox~ etc., appeared. The "ticket slstem" advocated by Dr. Reid was desirable. It would be well that such tickets should state whether there was infectious disease in the house or place from which the tramp came. tn reply to the question of Dr. Sanders, tramlcs might be defined as persons without occupation, moving trom place to place arm stayisg at lodging.houses or casual wards. Such a definition would not apply to such persons as Lascars ~ho come to a port in the capacity of sailor*. He'_accepted with pleasure the s,~ggestlon o| the President to refer his resolution to a e~mmittee. A conversation took place at the close of Dr. Armstrong's reply as to the exact terms of the resolution, and ultimately, cn the motion cf Dr. THRESH, seeondtd by Dr. AR~ISTRONG, it was re.,olved that it l'e referred to a committee consisting of the President, and Drs. Armstrong, Sergeant, and Whitelegge for report at the next meeting. A vote of thanks to Drs. Armstrong and Sergeant brought the meeting to a close.
PROCEEDINGS OF THE BIRMINGHAM AND MIDLAND BRANCH OF THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. A •EETING of the B i r m i n g h a m and Midland Branch of the Incorporated Society of Medical Officers of H e a l t h was held on Thursday, January i zlh, at the Council House, Birmingham. T h e r e were p r e s e n t : Dr. B o o b b y e r (president), Drs. A. Hill. ]3ostock Hill, Tew, Hollinshead, Bailey, H . May, Thursfield, Priestiey, G. Reid, H . Manley (hon. sec.), and Morton, with Mr. C. K. Millard (Birm i n g h a m City Hospital). Dr. Meredith Richards, of the City Hospital, Birmingham, was elected a m e m b e r of the branch.
A
AND MIDLAND
SCHOOL
OUTBREAK
BRANCH.
OF INFLAMMATORY SORE THROAT. By GEo. REID, M.D, M.O. [-t. to the Staffordshire County Count 1. A short history of a school outbreak of s o r e throat, which c a m e to m y notice in the autumn of last year, may prove of interest, especially on account of its apparent connection with the opening of an old and filthy drain a d j o i n i n g the scholia question. Mr. Langley Webb, the medical officer of health of the Cheadle R u r a l District, where t h e outbreak occurred, very kindly called my attention to it, and it is with his approval that I a m recording the facts, it being doubtful whether he himself could attend this meeting. T h e first symptoms complained of were headache, feverishness, and pain on swallowing ; on the second day the throat began to swell and b e c o m e tender, and the patient felt too ill to get about ; o~ the third day all the symptoms were aggravated, and, in addition to the throat symptoms, the lymphatics of the neck b e c a m e swollen and tender ; in s o m e cases very m u c h so, in others less so, but in all to some extent ; in fact, so great was the swelling and tenderness in m a n y of the cases, that the master c f the school thought the patients were suffering from mumps until he was disabused of this i d e a b y Mr. Webb, who was consulted only when the master's own family were attacked, about ten days after the first cases occurred. T h e throat appearances were those of ordinary follicular tonsillitis, and in none of the cases examined, either by Mr. W e b b or myself, was there any trace of diphtheritic m e m b r a n e to be found ; neither was any rash apparent on the skin. A b o u t the fourth day the.acute symptoms began to subside, but the tonsillar swelling and the e n l a r g e m e n t of the lymphatics remained for some days after the patients were able to take ordinary food. T h e r e were no fatal cases, and none of the patients suffered from paralysis in any form, I t was not until ten days after the first cases occurred that Mr. W e b b b e c a m e aware of their existence, and he called my attention to them t h e following day, October i 8 t h last, when I had occasion to see him with reference to another matter. I at o n c e visited the school, and elicited from the schoolmaster the following particulars, which were verified by his assistants : A b o u t a fortnight previously the attendance in the infants' d e p a r t m e n t of the school began noticeably to fall off; in fact, on the first day of this period twelve infants were absent, and each day afterwards a few others absented themselves. M y visit took place on a Wednesday, and up to the Friday of the week b e f o r e - - t h a t is to say, ten days after the first noticeable falling off in the attendance - - t h e absentees were almost entirely infants. O n the Monday, however (Saturday being a holiday),, besides a very marked increase in the n u m b e r
PUBLIC ~t~¢ ~ottrr~at
~uci~t~ ~i~ £~e~iraI Ol~c~r~ s~ !t~ealtb.
S U B S C R I B E R S " C O P I E S of PUBLIC ttEALTH are su:pZied at IOS. 6d. per annu:m Single copies One S/zil/inf . B O U N D V O L U M E S . - - C o f l i e s of Volume ~ are now
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Contribution. Medical O~cers of t:eMtk and other Correspondents are recuested to send reg~daHy all ~Oublis~ed repor/s and matLers of interest bearing upon Sanitation to the Editor, I5, College Road, 13riglzton.
NOTICE. THE
INCORPORATED SOCIETY OF
MEDICAL
O F F I C E R S OF H E A L T H .
2o, Hanover Square, London, W., January, 1894. NOTICE is hereby given that an O R D I N A R Y MEETING of the S O C I E T Y will be held at No. 2o, H A N O V E R SQUARE, W., on MONDAY, the 19th day of F E B R U A R Y , 1894 , at 7.3° p.m, for the transaction of the undermentioned business : - i. Minutes. AGENDA. 2. Report of Council. 3. To Elect Candidates. The following candidates have been duly nominated for election : As Fellow--
time,EaT WILLIAMS,M.D., London' Cert. Public Health, London University, 2e~ CheyneGrove, Chelsea ? Assistant M.O.H. Port of Lon-lon; proposed by W. G. X'VooDFoRDE, M.D.j seconded by W. COLLINGRIDGE, M,D. As MembeJ--
ELWARDI-IEI,rR7 LEIViOY,M.R.C.S., L R.C.P., D.P.H., Irelat~d, Croydon Infirmary, Surrey; proposed blt F. P. WmHTWlCIG M.D., seconded by AR't'I-IUR NEWSHOLME, M.D.
4. Nomination of Candidates. 5. Correspondence. 6. To receive Dr. Armstrong's re.~olufion re "Movement of Vagrants." 7. Miscellaneous business. 8. At 8 o'clock, a Discussion wiil take place on NO. 7~. FEBRUARy, 1894.
'~ VACCINATION AND
THE
LAWS
RELATING
THERETO." The Discussion will be opened by Dr. E. Seaton, M.O It. Surrey Coun'y Council, and Dr. T. Eustace Hill, M.O.H. Durham County Council. The following gentlemen also hope to take part in the discussion: Drs. C. E. Paget (Salford), L. Parkes (Chelsea), J. W. Priestley (Leicester), J. F. J. Sykes (St. Pancras), W. N. Thursfield (S~ropshire), F. Vacher (Cheshire), and E. F. Willoughby. F. P. WIGHTWICK, "~ St., Grosvener Sq., W. I 55, Uppej.rBrook C. THRESH,
_tf07t. Sec$,
The Limes, Chelmsford. PROCEEDINGS OF T H E I N C O R P O R A T E D SOCIETY OF M E D I C A L O F F I C E R S OF HEALTH. A MEETING O[ the Incorporated Society of Medical Officers of Health was held at No. 20, Hanover Square, on Monday, January ISth , 1894. Present: The President (Dr. W. T. G. Woodforde) in the chair, Drs. L. C. Parkes, Geo. Reid, A. Whltelegge, W. H. Kempster, D. T. Skinner, L. W. Darra Mair, W. Lake, H. Start, W. Collingridge, J. F. Sykes, G, Diekenson, E. Sergeant, C. Sanders, A. NewshSlme, L. Wilde, S. Davies, R. Bangay, and E. F. Wdloughby, ann the Hart. Secs., Drs. Wightwick and Thresh. The minutes of the last meeting of the Society on December i8th, x893 , were read, approved, and signed by the Chairman. REPORT
OF T H E
COUNCIL.
The HON. SECRETARY read the report of the Council : - (a) That the Council having received a report from the Sub-Committee appointed to consider the best mode of utilising the funds derived from the Berridge Legacy, recommend that a sum of ;~25 should be placed at the disposal of the Editor during the present year for the purpose of remunerating contributors to the Jomnal. (b) Reporting other proceedings of the Council for the information of the Society. l
13o
T H E I N C O R P O R A T E D S O C I E T Y O F M E D I C A L O F F I C E R S OF H E A L T H . A s FellaZOS--
G-EORGI~ FRANCIS ~[O,N~S, M.R.C.S., L . S . A , Clarence House, Southend-on-Sea, M . O . H . Southend-on-Sea U S.D. ~CBERT GRAVES BUI~.TON,M.D.Edin., L.R.C.P.Ed!n., r, Gloucester Villas, HanweU, W., M.O.H. tIanweli U.S.D. FREDERICK ~TOCKWELL, M.D.~ Benton, M.0.H. Bunter. t:IEN~.Y R. KE~rWOOD, M.B., L R . C . P . , D.P.H., Royal College Physicians and Surgeons, Lend., I ~9. Adelaide Road, N.W., M,O.tt. Urban Sanitary District of Finchley. As -4ssociates-ADAM, Wn-SON, L.R c.P., F.R.C.S.Edln., O,.borne House, Jesmond Road, I'qeweastle-upon-Tyne. I-I. W. NEWTON, L.F.P.S.Glas., L.F.A., 2, Ellisen Place, Neweastle-upon-Tyne. SIg GEOgCZ A. PILItmGTON, M.R,C.S., J.P., Belle Vue, Lord Street, Southpott.
A~am/nalions.--A number of candidates were then nominated for election at the next meeting. I~RESENTATION TO DR. SYKES.
Dr. Sykes, who for some years has acted as Secretary of the Society, having recently resigned, was presented--as the result of the subscription opened among the Fellows of the Society for the purpose of offering him a testimonial, in recognition of the valuable services he has rendered to the Society--by the PRESIDENT, acting on behalf of the Society, with a handsome salver, and a magic lantern apparatus. Dr. WOOFORDE(the President), in making the presentation, said : I rise to perform what is a very .pleasant duty, and it is to act as your mouthpiece m expressing to our valued friend Dr. Sykes our very hearty appreciation of the valuable and able services he has rendered to the Society during the years he has acted as its secretary. We all know very well that ~hen he first took office we were comparatively a small body; we also know how large a share he had in the carrying out of those changes by which we have developed into an incorporated society with legal status and responsibilitie% while--by the affÉliation to the central body o f the provincial branches, which were scattered over the country, and the consequent very large increase in our numbers--we have taken a much more important and influential position in the estimation of the public at large. We have also, since Dr. Sykes took office, started a journal of our own, which is second to no Other sanitary organ in the kingdom--a journal which has already obtained a position of great public influence, and which, if it is continued upon the same lines as those adopted by its two succes. sive editors, will increase in power and importance as time goes on. In these things, as in the general business of the Society, Dr. Sykes has taken a leading part, and has continued his exertions to promote its success for several years; and now
that he is resigning his secretarial office, We have felt that it is impossible for us to allow him to do so without taking advantage of the opportunity it affords us of offering him some mark of our appreciation of his work, not indeed, as being ifl any way remuneration for his services, but simply in recognition of what he has done for us. I have before me a salver and some pieces of apparatus - - a s to the selection of which Dr. Sykes's owr~ wishes have been consulted--and I am sure that I express the feeling of everyone here when I say that in offering this testimonial for his acceptance, we also wish him in his retirement every happiness in his domestic relations and much success in his public work. (Applause.) Dr. SYKES, in acknowledging the testimonial, said: It is exceedingly kind of y o u , sir, to have spoken of me in such highly appreciative terms. I /eel that I hardly deserve them, although I have endeavoured to merit them. I may say that when I first heard of the intention of the society to give me a testimonial I felt highly honoured, but when I further heard that it was the intention of my friends aud colleagues to present me with a testimonial, not from the funds ot the society, but by their personal subscription, I not only felt honoured, but deeply touched. I feel that this Society is no~ merely a professional body, but a society of members working in the same cause, with a brotherly teeling and friendliness among its members--a feeling that I hope will ever increase. The small points you have mentioned el work that I have tried to do are not very large in their way, but I hope they will lead to great results in the future. I hope that those who have worked with me in thi~ Society, and those who follow, will make it prosper. So far as nay peculiar choice of testimonial is concerned, if with this lantern I can at any time be of use to the Society, if I can make its meetings more useful or interesting, I shall only be too pleased to do so.
The meeting then proceeded to consider the question of VAGRANTS
A N D T H E DISSEMINATION
OF
DISEASE.
The HeN. SECRETARYread the following letters : Dr. Gore King, of Keswick, wrote : ~ In a paper I read at the last meeting of the British Medica~ Association I suggested a ticket system as appearing to me the best way of meeting the difficulties of the case, the chief essentials being that every tramp should carry a card bearing hls name and description, without which he should not be received at any casual ward or common lodg'ng.house, and which, in case he was brought in eontaet with infectious disease at anysuch place, should be endorsed to that effect with da~e by the medical officer of healtb, so that, wherever he went he might be kept under supervision until the period of incubation was passed. I think this plan would answer nearly all the purposes o¢ enforce-1 quaran'ine, and would he much less uostlyand pre. sent fewer practical difficulties, and I believe Parliament
VAGRANTS
AND
THE
DISSEMINATION
would be more likely to sanction such a scheme as this than one which involved compulsory detention or compulsory revaccination. Dr. C. J. Russell M c L e a n , M . O . t t . for Y e a d o n , Yorks, wrote : The district for which I act as medical officer of health is only a small one, and containing under 8,000 inhabitants, but as regards vagrancy it is an important centre. There were up to theend of last year no fewer than seven lodging. houses, but with a view to discouraging vagrants in the idea that the town is a sort of headquarters for them the Sanitary Authority have reduced the nmnber oI registered lodging. houses to three. The necessity for so large an accommodation for vagrants lies in the fact that our town is situate almost midway between the important centres of Leeds and Bradford, and also about equidistant from the town of Otley, where there is a workhouse and still greater attractions for vagrants, the workhouse not being the most popular resort amongst such travellers. The result of our somewhat dentral position between these places is, that we get perhaps more than our share of visits from vagrants, many of whom simply " stay the nighg" Or thd " week end 2' In my annual report for the year I857, during which period there were cases of smalbpox amongst tramps in Leeds and Bradford (Sheffield epidemic), we had some difficulty with regard to the housing of vagrants, the lodging-house keepers refusing to put them up whenever they suspected the tramps came from either of the infected areas.
At that time I recommended ,a That some sort of registration or certification of vagrants having no fixed abodes should be adopted, showing ~here they last came from, etc., and without which they would be refused admission to any public lodging-h0use, especially during any serious epidemic" {this probably under police supervision). Again, in my repoxt for the year I888, I made somewhat similar remarks, owing to the outbreak of typhoid fever ia an adjoining township. Again, in my third report for the year ISgt, with regard to an outbreak of measles during the annual " f a i r " visit of the "'travelling shows and caravans," I advised that " T h e r e should be health certificates {granted and signed only by the Medical Officer of Health) given to the owner ofj or affixed to each caravan, when the owner leaves a town, so that at the next place visited a clean bill of health or otherwise can be produced for the guidance of the authorities there. As such attractions are chiefly patronised by children, the danger in many cases, as in this one, when measles was the prevalent disease~ becomes greater. Of course, such aplan as this could only be sanctioned by the Local Government Board but I consider there has been neglect of duty that an Act for this purpose has not been framed and placed amongst the many other Parliamentary Acts pertaining to the Public tlealth." T h e following paper was then read : ~ VAGRANTS AND THE DISSEMINATION OF DISEASE. By HENRY E. ARMSTRONG, D. tIy., Medical Officer of Health for Newcastle-upon-Tyne, etc. T h e introduction of small.pox into the Newcastle W o r k h o u s e in December, r892 , by a m a n on tramp, and t h e subsequent re-introduction of the disease into the same place and also c o m m o n lodging-houses in the city by other tramps, gave rise to a great deal of trouble and some expense. T h e e x p e r i e n c e - - b y no means n e w - - a n d the knowledge that other vagrants had in other, places been the means of spreading the disease, gave rise
OF
DISEASE.
J31
to the desire to ascertain more about the matter. H e n c e the application in May of last year to the m e d i c a l officers of health of the large urban districts for the particulars which are e m b o d i e d in my report on " S m a l l . p o x and Vagrancy," ~ h i c h h a s appeared in the journal of this Society. The replies furnished in response to m y queries yielded information the consideration of which cannot but create a strong feeling of the need of a p r o m p t and energetic remedy for a gross defect in the present system of the administration of preventive m e d i c i n e - - v i z . , that which allows the broadcast spread of disease by vagrants. F r o m the returns of the Local G o v e r n m e n t Board, it appears that the first town affected with small-pox in the present e p i d e m i c was D e w s b m y (in May, r 8 9 i ). T h e source of infection there was not reported to me. I n the same m o n t h the disease began in London, Liverpool, Birmingham, and Bristol. H o w it was i n t r o d u c e d into the first two of these towns is not known to m e ; but it c a m e to the two latter in the persons of vagrant,& T h e next two urban districts invaded were West H a m and Croydon, infection in b o t h cases having b e e n first c o n v e y e d there by a vagrant. Passing over Southampton, into which port the disease had been bronght by ship,eand also Middlesborough, Wakefield, a n d Bath, from which I received no returns, I find small-pox was next introduced (also by vagrants) into W e s t Bromwich and H u l l ; afterwards into Manchester (from which I have n o i n f o r m a t i o n ) ; then, again by a vagrant, into Cardiff. This was in D e c e m b e r , 189I. Thus, in the first h a l f - y e a r of the epidemic, fifteen towns were attacked. O f the eight of those towns from which I received replies to m y q u e r i e s , seven had received their first infection by tramps. I n I892 the disease slowly and steadily advanced, m o n t h by month, ft'om town to town. By May, I893, i n 7 or in8 of the r i 7 large urban districts reporting their infectious cases to t h e Local G o v e r n m e n t Board were invaded by smallp o x , . a n d the n u m b e r of cases they yielded was upwards of 5,6oo. A t the height of the e p i d e m i c - - £ e . , about May l a s t - - t h e n u m b e r averaged a b o v e 360 per week. O f 63 .towns invaded, the medical officers of health of which have been so good as to favour m e with particulars, 37 or 59 per cent. had the infection primarily from vagrants. T h e disease was brought secondarily by vagrants into 36 towns, including s o m e into which first cases h a d also b e e n brought by the same class of persons. Such secondary infections occurred as often as nine times in Carlisle, Southampton, and Sunderland, x2 times in Warrington, 15 times in Keighley, ~8 times in Blackburni and no less than z5 times in Nottingham ! I n x 9 instances only out of the 63 towns reporting was small-pox infection stated to have been brought otherwise than by vagrants, a n d in I-I 2
I32
T H E I N C O R P O R A T E D S O C I E T Y O F M E D I C A L O F F I C E R S OF H E A L T H .
seven of these it was subsequently re-introduced by vagrants no less than 25 times. The epidemic is still going on. Tramps bring their infectious diseases either to workhouses or common lodging-houses. According to the returns on which my report is based, in t h e above mentioned instances infected vagrants were housed 3~ times in the former and 80 times in the latter. Each of those lodging-houses gave infection to an average of one case in the same house, but to how many other persons it is impossible to say. I n Blackburn, where the workhouse was infected with small-pox five times, and lodginghouses four times, there had been 56 cases of the disease by the end of May last. I n Halifax, where small-pox had been brought to lodging-houses six times, infecting in these ~9 other persons, the number of cases in the town in little more than a year from the date of the first one, was 360. I n Warrington, where the disease was brought to both workhouse and lodging-houses by tramps, the number of cases in the borough in the first year was 598 . The majority (44 in 73) of the medical officers of health have recorded their opinion that it is desirable that during the prevalence of s m a l l pox or other epidemic disease all vagrants, before leaving a workhouse or common lodging-house, should be compelled to report their next place of destination to the master or keeper of such house. The compulsory detention during possible incubation of disease, together with disinfection during epidemic times--and, in case of small.pox, the re-vaccination--of vagrants in workhouses and lodging-houses is advocated by 56 of the 73 medical officers of health responding to my inquiry on that point. Several medical officers of health make suggestions as to other practical measures to be taken with the object of preventing the spread of infectious disease by the class of persons under consideration. These are so valuable that I make no apology for repeating the following summary of them from my xeport : QuEsTIoN No. i I . - - W h a t other steps, if any, would you suggest should be taken with the view of preventing the spread of small-pox or other infectious diseases by vagrants ? The replies may be summarised as follows : - I. Where an epidemicis prevalent it should be possible to prevent vagrants visiting the district, and to arrest them on infringement of this condition. 2. Only a county medical officer of heaIth can deal with diffusion of disease through a county. 3. Vagrants should be systematicallyexamined on entering the union. 4. Strict inspection should be maintained, with history of routes travelled. 5, Make compulsorythe medical inspection of all vagrants with the view of discovering mild cases which might otherwise escape notice.
6. Attend closely to the common lodging-houses,e~pecially by night. 7. Each common lodging-house should provide a free bath, and each vagrant should have fresh water. 8. Common lodging-housesmight be closed for a time. 9. The establishment of model lodgi~gThouses in towns shouM be general. 1o. Sanitary authorities and Poor Law and union authorities should be compelledto provide means of isolation. It. Adopt the separate cell system at all unions. 12. Vagrancy should, as far as possible, be prevented, say, by retaining all tramps who enter workhouses for a fortnight, and compellingthem to work whilst there. 13 Vagrants should be detained under observation. 14. The medical officer of health should keep a spare room for suspected vagrants. 15. Suspiciouscases should be isolated immediately. x6, Vagrants should not be allowed to infest the crowded precincts of police stations for orders for admission to the workhouse. If the police continue to give these orders a separate place should be provided for the pur. pose. I7. Every vagrant should be re-vaccinated ; better still, everyone else. I$. Re-vaccination of all vagrants lodged in a casual ward should be compulsory. If they had the choice between being re-vaccinated or doing their task they wouldj in the majority of cases, prefer the former. I9. Vagrants should be allowed to travel about on ticket or pass only. 20. There should be communication with prisons~ workhouses~ commonlodging-houses~masters of canal boats, etc.j directing attention to prevalence of epidemic and local powers relating thereto. 2I. More attention should be paid to the migratory habits ot other persons than vagrants. Vagrants, as a class, occupy a specially dangerous position with regard to their means of spreading infectious disease. They come and go where they please unquestioned, and are accountable to no one in this respect. I know of two tramps who, whilst infected with small-pox, visited a casual ward where they were bathed in water used by ten other persons. Vagrants are of two k i n d s k t h e professional and the occasional. The former is lazy, idle, and good for nothing. The latter is seeking for work, and is therefore entitled to some consideration. T h e community derive no benefit from the professional vagrant. They cannot prevent his arrival or departure o r trace his movements. On the other hand, they have to maintain him. Therefore they have the right to subject him to special regulations, in order to protect themselves from any evil he may do them. Their powers to this end are at present inadequate to the necessities of the circumstances under consideration. Among possible difficulties in the way of carrying out of remedial measures is the objection that may be raised to compulsory re.vaccination. This point is, as regards the general question, of comparatively little importance. The great thing isj not to prevent the tramp catching disease, but to prevent him from giving it to others. Re-vaccination applies only to small-pox, but there are typhus and other infectious diseases, the infection of which he may carry from place to place.
VAGRANCY AND The London County Council are now taking action to give effect to the proposal to convene a conference of the urban sanitary authorities of England and Wales for the purpose of considering the steps necessary to prevent the spread of infection by vagrants. An expression of the views of the Incorporated Society of Medical Officers of Health will be useful to that conference. I therefore beg leave to move the following resolution ; - fn~clious Disease and Vagrancy.--Preveztive Measures. ' T h a t the Incorporated Society of Medical Officers of Health consider it desirable"(x) That vagrants should be restrained in their powers of carrying infection about the country, especially in epidemic times. "(2) That they should be made to report their movements. " (3)That they should, when considered requisite, be subject to disinfection and detention for such time as the sanitary authority of the district in which they are may think necessary for the protection of the public health. " (4) That in epidemic times all persons frequenting casual wards or common lodging houses should be medically examined on admission. " (5) That sanitary authorities and the police should have power to detain for medical examination any vagrant found in any public place. ''* The following paper was then read : VAGRANCY AND S M A L L - P o x . By EDWARD SERGEANT, L . R . C . P . , etc., M . O . H . Lanc. C.C. It gives me great pleasure to add my testimony in support of Dr. Armstrong's views with respect to vagrancy and small-pox. The information on the subject which he has been able to obtain from various parts of the country will prove of great value. The remarks I have to make apply more especially to Lancashire and are the outcome of my official experience in that county. The suggestions I shall submit for your consideration seem to me practicable and desirable for restraining a danger which has assumed serious proportions. The health of the country is menaced by persons who tramp from place to place having no certain dwelling or not abiding in it. They escape the usual laws observed by good citizens and pay little attention to vaccination or the laws of health ; as a result, when small-pox is prevalent they fall a prey to the disease, and owing to ignorance or carelessness much distribution of the infection * T h e above resolution is given in the amended form adopted by the mover on tke ~uggesiions ol Drs. Sergeant, Newsholme, and Sykes.
SMALL-POX.
I33
takes place among frequenters of their haunts before the sanitary authorities are able to discover the source of the mischief. I know that Englishmen have an objection to any interference with the liberty of the subject, but this feeling ought to give way in tha case of vagrants who avoid all means of honest livelihood, preferring to attach themselves to a society like a parasitic growth. Fortunately such pests have not entire freedom ofaction,for~under an Act passed in i824 relating to the punishment of idle and disorderly persons, etc., a vagrant " n o t having any visible means of subsistence and not giving a good account of himself" is liable to be deemed a vagabond and punished with imprisonment, "while an incorrigible rogue (not being a female) may also be punished by whipping at such time during his imprisonment." Why should the law not go further and say that vagrants shall not by their actions endanger the public health ? The proposals for accomplishing this end have in many towns been more or less carried out with good effect, but general action is wanted and greater efficiency would be secured by a legal enactment. In the administrative county of Lancaster the distribution of small-pox by vagrants during the past two years has been abundantly demonstrated, and the want of power to cope with the evil has been much felt. The disease, after spreading extensively in Yorkshire during the early part of ~892, was introduced by vagrants into the Borough of Warrington, and from thence was distributed to Ashtonunder-Lyne, Withington, Garstang (R), Warrington (R), and many other districts. From the reports issued by the Lancashire County Boroughs further evidence is given of the important part played by vagrants in the spread of small pox, and in the majority of these boroughs outbreaks of the disease have been repeatedly ascribed to tramp origin. As mentioned by Dr. Armstrong, of the towns attacked with small-pox throughout England and Wales 58 per cent. had the disease first introduced by vagrants, and in 72 per cent. of the towns the disease was sooner or later conveyed there by persons of this class, and on the average of five times to each town. In a recent report on the prevalence of small-pox in Salford during the years x892-3, Dr. Paget states that the first case of the epidemic was a vagrant from Stalybridge, and the infection was afterwards carried into the borough in a similar manner on seventeen occasions ; while Warrington--I892-3--suffered thirteen times from the tramp conveyance of smallpox. In the administrative county of Lancaster during I89e , 6~2 cases of small-pox broke out in 28 districts, including 6 boroughs, i6 urbau and 6 rural districts, and in one-third of them the disease was primarily introduced by vagrants, or by frequenters of common lodging-houses. To the end
134
T H E I N C O R P O R A T E D SOCIETY OF MEDICAL OFFICERS OF H E A L T H .
of the past year I,OOo cases have been reported from 76 districts, 15 being borough's~ 48 urban and ~3 rural. Of the total districts attacked during the two years, 3 ° per cent. attribute to vagrants the responsibility of conveying the infection. Frequently the disease first appeared in the common lodging-houses, and on becoming known the other lodgers, as a rule, disappeared without waiting to hear the wish of the sanitary authority as to precautionary measures, and in this way infection was conveyed from district to district. Many workhouses and tramp wards have been attacked with small.pox ; and vagrants, while suffering from advanced symptoms of the disease, have been discovered in the public thoroughfares. The only power possessed by sanitary authorities over vagrants is by section 83, Public Health Act, ~875, which provides that the keeper of a common 10dging&ouse, " i n which beggars and vagrants are received to lodge/' shall from time to time report to the local authority every person who resorted to such house during the preceding night. It would be better if sanitary authorities, on the outbreak of dangerous infectious disease, such as small-pox, could, b y resolution, require the observance of the following additional provisions, viz.-(a) That keepers of ail common lodging-houses keep registers of persons resorting to such houses, and daily forward specified schedules to the local atithority, such schedules to contain correct information in respect of the proposed movements of the lodgers enumerated. (b) That the officers of the local authority, or police when requested by the local authority, exercise supervxston over vagrants, and be emp,owered to detain any vagrant for medical inspectmn as to the state of his health, and when f o u n d to be unvaccinated or imperfectly vaccinated the public vaccinator be authorised to vaccinate him. If the medical officer of health should consider it necessary he may detain t h e vagrant in an isolation hospital when available, or, with the consent of the guardians, in a workhouse or: tramp ward, and all reasonable expenses shall be paid by the local authority. (c) That the officers of the local authority provide for the disinfection of the clothing or persons of Vagrants if required; by reason of their having associated with infected persons, or on suspicion of their havir~g so associated. (d) T h a t the medical officer of health on the outbreak of small-pox or other dangerous infectious disease in a common lodging-house, make an inspection of the lodging:house without delay, and have power to place the other lodgers under quarantine f o r a period specified by resolution of the local authority, a n d take any further precautions for preventing the spread of disease he may consider desirable.
It is suggested that any person without the permission of the local authority leaving such lodginghouse or in any way contravening the above requirements, would render himself guilty of an offence punishable by fine or imprisonment. Suitable payments might be made by the sanitary authority to the keepers of common lodginghouses for their daily lists of lodgers, and the vagrant would be responsible for the correctness of the statement concerning his destination. I n case of quarantine the sanitary authority ought to pay the reasonable expenses incurred. These provisions would be best carried out in the administrative counties under the supervision of the county councils than left to the small isolated authorities, perhaps not provided with a sufficient staff, or with any of the appliances required in the case of epidemic disease. I n addition to the above recommendations, I think it would be well if vagrants throughout the country were registered, as much valuable information would in this way be obtained for police and sanitary purposes. Each vagrant should be required to possess a certificate of registration, with particulars of place of birth, age, name, etc., and he should also be supplied after medical inspection with a health certificate. T h e vagrant would be required to produce these certificates on the demand of any police officer or sanitary official. I f vagrants were kept under strict regulation, as suggested, I feel satisfied that they would soon cease to be carriers of infection. DISCUSSION. Dr. ~VVHITELEGG]Ethought they were all agreed as to the necessity of something being done with regard to vagrants, but he had not made up his mind what was best to be done. As to the system of registration, he could not see how any guarantee as to correct information was to be obtained. He thought it was undesirable that the supervision of casual wards should be performed by the county councils, that work ought to be in the hands of the local authorities. He could fully hear outj from the reportslssued in his district, what had been said as tO small'p0x being br0u~ht in by tramps. He thought if they were going to the L~cal Government Board with any recommendations they might say something as to the isolation of infectious diseases in workhouses. In some cases tramps Suffering from infectious disease were taken to the workhouse as a meansof isolation--that was making the best use of the tramp system for spreading disease. Another particular point to which he wished to draw attention was as to tramps and common lodging-houses. If a sanitary authority foundc a case of small-pox had broken out in a common lodginghouse, and they wished to isolate the patient, they could, of course~ remove it, and they could, by voluntary arrangementj proceed further to quarantine the lodglng-house. They would have to pay the expensesof the people there, and recompense the owner of the lodglng.house, but in doing so they not only incurred some risk, but were certain to be surcharged by the auditor, Dr. NEWSlIOLI~IEsaid the main point to be emphasized in any application for additional power ,,wasthe power tor the compulsory detention of vagrants ; that seemed to him more important than revaccination. He thought the compulsory detention should come first, though they might i a practice retrain from enforcingit when vagrants submitted to revaccination. IIe thought that the mioimumperiod of quarantine should be eighteen day.-'. In the present state of public
VAGRANCY
AND
SMALLPOX.~DISCUSSION.
opinion it would not be politic to put revacciaation before detention. They ought rather to go for emnpulsory ~detention. Ite had happily had very little experience of smalbpox in his own district, but in one instance he had ~ffered a number of vagrants, who had been lodged for a fortnight in the stone c~sual ward as a small-pox patient, one shilling each to submit to revaccioation, and the whole of lhem had consented. ~)r. PARKES thought that what they wanted to determine was what was practicable in the matter, and what the House o f Commons would assent to ; and it appeared to him that "~heyhad better adopt those measures which did not interfere 'with the liberty of the subject, as other measures would not ,pass tbrough the House of Commons. That almost disposed ,of compulsory detention. (" No, no ! ") It appeared to him ~they might approach the Local Government Board and ask them to introduce an Amendment Bill to the Public Health Act, with a view to framing regulations similar to those they have for cholera, which they might put into effect when they thought fit. He thought they might adopt the ticket regis'tration system. There was no great harm in that. Every tramp would be required to produce his ticket with his name •and the place he last left, and the ticket would be signed by the keeper ol the 10dying-house, or the relieving officer if he came from a casual ward, and also by a medical vaau who examined him ; and a note should be added if ,there was any small.pox or other infectious disease in the town he had lef. He thought the regulations should pro'vide for medical examination of all casual wards and .commom lodging houses ; similar regulations v~ould apply 'to those ad~pted in cholera times. T h e district medical .officer would be empowered to visit at night, and examine all people applying for beds, and any tramp who would not foermit himself to b e medically examined would be subject ,to a penalty or to imprisonment. It would, of course, be a considerable expense~ but that they must not mind. Coml~ulsory detention would not only interfere with the liberty o f the subject, but would cause great diffieul!y. It would 'be necessary to provide accommodation for the delained. ~f a town had only one common lodglng.house, and they ~sed it, what would be done with the other tramps ? If, on ,the other hand, they used the workhouse for the infected tramps, the disease would be likely to spread to the inmates .and the staff. As to disinfection, there could be none if a vaan was in the incubation period, and if he was actually Suffering from the disease there was already power to disinfect. Dr. SYKES d flared in logo with Dr. Parkes on one point s "which was,. that the prop r course to pursue was what was expedient. It was the duty of the medical officer of health to point out what was right, throwing on the local authority the responsibility of refusing to act. He entirely disagreed "with Dr. Parkas as to the powers of detention. It was just because they had not got those powers that all the trouble arose. If a person had small-pox in a casual ward or a common lodging-house next morning they would have the mortification of seeing other menj who had almost certainly been in close contact with the patiefit, simply walk out 0I the ~aouse, and tlley could not stop them. They wanted to be able to give presumably infected persons in charge there and ~hen. Referring to compulsory registration, he could not see how they were going to prove identity. These tramps would " s w o p " their cards, and there w a s ' n 0 means of proof. Revaecination might be a n advantage, and it was possible to a certain extent. He presumed that in all .districts there was now a nightly examination of all casuals. T h e very first thing he did When small-pox broke out was to petition the guardiars to have a nightly medical examination~ and that was Still done. The result was, in three instances, within three minutes of a man coming in he was • Lspotted." What was required was to be able to give an order, and~ if necessary, to instruct the policemen to take ,any man ~ho had been in contact with a small-pox patient .in charge if he dared to go out. Ninety-nine medical men ~ut of IOO would say that anyone who had been in contact with a small-pox patient for 24 hours would be infected.
135
Dr. BANGAY : IS it to be supposed from the last speaker that the infection has taken place in the man's person or his clothes ? ]Dr. S'el.:~s : Both. Both his clothes and he personally, and the remedy would be to keep him in charge until his clothes were disinfected and he revaecinated. Dr. BANGAY : .That being the case, of course, as far as infection from the person is concernsd, there would be no danger until he had developed the disease, and as far as his clothes are concerned, how about medical men's clothes ? They go from house to house and do not change their clothes. The PRESIDENT I do not think medical men are in the habit of remaining twenty-four hours" with a small-pox patient. Dr. REID thought that if they wanted anything done t would be necessary to go to the Local Government Board n very strong force, and it might be considered whether it would not be desirable to co-operate with some other society. The Local Government Board had the opportunity of obtaining the very best advice from their own medical staff; but did not apparently avail themselves of it, which was instanced by the fact that the inspection of lodging-houses was in the hands of the police, which o[ten meant that a sergeant visited to ascertain whether any criminals were in the house, and that was all. They would have to get a great deal of reformation as to the inspection of lodginghouses, and it was a question whether they should not recommend that the police should have no authority over lodging-houses except for the detection of crime. Dr. SANDZRS was satisfied that no system of tickets would really be workable. With regard to the expediency of approaching Parliament on the question of detention~ he thought they had an analogous case in the detention at home of children belongio~ to a family in which an infectious case occurred. It certainly was a much more serious matter to detain children from school, When school would be a benefit to them, than it would be to detain a tramp who apparently had no means of subsistence. A question whicti struck him was as to the definition of a tramp--did it mean only the occupiers of common lodging-houses and casual wards, o r did it include carmen and sailors arriving in port ; in fact~ anyone who had no actual domicile of his own ? Dr. PARKES : I should like to point out, with reference to what Dr. Sykes said as to infected persons, if he is prepared to say the person is infected he has Bowers under the Public Health (London) Act already. Dr. S'¢K~s : You have to proceed by summons. It is true you can summon a man~ but you cannot stop him. Even if a summons is made returnable the same day, the man may be six miles away when you have it. The PRESIDENT : We have heard a great deal of smallpox io large urban districts. Now, I have twelve rural districts under my charge, and I have had small-pox introduced on several occasions by vagrants and by persons of the lower class of hawkers. These persons come into a district and stay for one, two, or three weeks, keeping themselves very much to themselvesm so much so, that in ohe ease a man was nearly dying before anyone knew he was ill. The question of expense is, I think, one that should not trouble us at all, because the expense of the medical inspection of these vagrants would be far less than that involved in consequence of the spreading of {he disease. With regard to detention, my own feeling is tbat if th:re is any practical way Of carrying it out it should be attempted. Tl~e ticket system would probably not be efficient. As Dr. Sykes has -pointed out, the identity would be very difficult. Dr. Woodforde went on to suggest that if the motion of Dr. Armstrong was carried, it should be referred to a special committee for further consideration. Dr. PARKeS: Would it not be better to refer it to the committee first, sir, then they could go thoroughly into the matter, and brin~ up a scheme for the approval of the~ Society. :
1.36
PROCEEDINGS
OF THE
BIRMINGHAM
The PRESIDENT: As I understand Dr. Armstrong's motion, it would simply form a basis tor the consideration cf the matter by the committee. Dr. SKINNER referred to the desirability of tracing the movements of the tramps backwards as well at forwards, and he referred to the institution originated by the police, called the "Mendicity Organisation," by which they requested people not to give wgrants money, and they supplied anybody who cared to have them with tickets, which they could give to these people, and which ticket would, on production at the baker's, procure them bread. It seemed to him this might he utili ed as a means of tracing tramps The effect the system had had on the vagrant society in Dor~,et was most wonderful; the men really in want did.not m~nd receiving these tickets, but the professional vagrant did, and consequently he cleared out of the district. Dr. AI~MSTR051%in replying, supported Dr. Sergeant's proposal that lodging.house keepers should keep for the daily information of the sanitary authority registers of the lodgers visiting their houses~ and would be glad if it were possible to have registration of detai!s as to the movements, etc., etc., of vagrants. He accepted the suggestions of Drs. Sergeant, Newsl=clme, and Sykes amending his resolution. If it were carried he would propose that cop~es should be fmwarded to the Local Government Board and 1he London County Council. He thought Dr. Parkes had failed irt his attempt to *'dispose of the subject of the detention of vagrants " by raising the old cry against '~ the liberty of the subject." ]Dr. Parkes seemed to forget the possibility of a vagrant incubating diso.ase whilst on tramp, and fo overlook the chance of a wholesale stampede of lodgers from any house in which a case of small-pox~ etc., appeared. The "ticket slstem" advocated by Dr. Reid was desirable. It would be well that such tickets should state whether there was infectious disease in the house or place from which the tramp came. tn reply to the question of Dr. Sanders, tramlcs might be defined as persons without occupation, moving trom place to place arm stayisg at lodging.houses or casual wards. Such a definition would not apply to such persons as Lascars ~ho come to a port in the capacity of sailor*. He'_accepted with pleasure the s,~ggestlon o| the President to refer his resolution to a e~mmittee. A conversation took place at the close of Dr. Armstrong's reply as to the exact terms of the resolution, and ultimately, cn the motion cf Dr. THRESH, seeondtd by Dr. AR~ISTRONG, it was re.,olved that it l'e referred to a committee consisting of the President, and Drs. Armstrong, Sergeant, and Whitelegge for report at the next meeting. A vote of thanks to Drs. Armstrong and Sergeant brought the meeting to a close.
PROCEEDINGS OF THE BIRMINGHAM AND MIDLAND BRANCH OF THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. A •EETING of the B i r m i n g h a m and Midland Branch of the Incorporated Society of Medical Officers of H e a l t h was held on Thursday, January i zlh, at the Council House, Birmingham. T h e r e were p r e s e n t : Dr. B o o b b y e r (president), Drs. A. Hill. ]3ostock Hill, Tew, Hollinshead, Bailey, H . May, Thursfield, Priestiey, G. Reid, H . Manley (hon. sec.), and Morton, with Mr. C. K. Millard (Birm i n g h a m City Hospital). Dr. Meredith Richards, of the City Hospital, Birmingham, was elected a m e m b e r of the branch.
A
AND MIDLAND
SCHOOL
OUTBREAK
BRANCH.
OF INFLAMMATORY SORE THROAT. By GEo. REID, M.D, M.O. [-t. to the Staffordshire County Count 1. A short history of a school outbreak of s o r e throat, which c a m e to m y notice in the autumn of last year, may prove of interest, especially on account of its apparent connection with the opening of an old and filthy drain a d j o i n i n g the scholia question. Mr. Langley Webb, the medical officer of health of the Cheadle R u r a l District, where t h e outbreak occurred, very kindly called my attention to it, and it is with his approval that I a m recording the facts, it being doubtful whether he himself could attend this meeting. T h e first symptoms complained of were headache, feverishness, and pain on swallowing ; on the second day the throat began to swell and b e c o m e tender, and the patient felt too ill to get about ; o~ the third day all the symptoms were aggravated, and, in addition to the throat symptoms, the lymphatics of the neck b e c a m e swollen and tender ; in s o m e cases very m u c h so, in others less so, but in all to some extent ; in fact, so great was the swelling and tenderness in m a n y of the cases, that the master c f the school thought the patients were suffering from mumps until he was disabused of this i d e a b y Mr. Webb, who was consulted only when the master's own family were attacked, about ten days after the first cases occurred. T h e throat appearances were those of ordinary follicular tonsillitis, and in none of the cases examined, either by Mr. W e b b or myself, was there any trace of diphtheritic m e m b r a n e to be found ; neither was any rash apparent on the skin. A b o u t the fourth day the.acute symptoms began to subside, but the tonsillar swelling and the e n l a r g e m e n t of the lymphatics remained for some days after the patients were able to take ordinary food. T h e r e were no fatal cases, and none of the patients suffered from paralysis in any form, I t was not until ten days after the first cases occurred that Mr. W e b b b e c a m e aware of their existence, and he called my attention to them t h e following day, October i 8 t h last, when I had occasion to see him with reference to another matter. I at o n c e visited the school, and elicited from the schoolmaster the following particulars, which were verified by his assistants : A b o u t a fortnight previously the attendance in the infants' d e p a r t m e n t of the school began noticeably to fall off; in fact, on the first day of this period twelve infants were absent, and each day afterwards a few others absented themselves. M y visit took place on a Wednesday, and up to the Friday of the week b e f o r e - - t h a t is to say, ten days after the first noticeable falling off in the attendance - - t h e absentees were almost entirely infants. O n the Monday, however (Saturday being a holiday),, besides a very marked increase in the n u m b e r