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Proceedings of the Northwestern Branch of the society of medical officers of health
4~
PROCEEDINGS
OF
THE
NORTH-WESTERN
with some acid, and he was astonished that success had not keen attained in separating and iden'ifying the particular acid. Why had not someone operated on a technical scale, and after careful neutralization evaporated down in a vacuum p a n some thousand gallons, so as to obtain ~. sufficient quantity of material ? Dr. Brown talked of a li~re of water having been operated u p o n - - a quanUty qmte msuffimew. W a s the acid soluble in ether ? a great many organic acids were so, and could be extracted from fluids by shaking with that solvent. The whole subject was one of great interest, and much investigation was still required to elucidate the various conditions under which lead ¢ontamina'.ion of water occurred. Mr. CHARLES CASSAL-" I agree generally with Mr. Wynter Blyth's remarks, and think that the chemical details would have been more suitable to a chemical society. All such questions, in his opinion, should be placed in the hands of the Public Analyst of the district. All waters will dissolve lead if sufficient time is given ; this is even true of hard waters, for if you take the first drops of water from a pipe which has not been drawn on for many hours, the water contains considerable quantities of lead. ! am not at all satisfied with the tests given by Dr. Brown for the detectTon of the acid. Tropaeoline is a complicated substance, and the commercial samples differ considerably. In some, acet;c acid strike a similar red colour to that given by the mineral acids ; with others the colour is different. W i t h regard to sulphate of iron, under certain circumstances it will easily decompose and produce small quantities of sulphuric acid.
Dr. CORF~tLD: I consider that the most important point is how to prevent lead poisoning. Dr. Brown has suggested to us two ways in which this may be done; in the one filtration through carbon, in the other the use of limestone and sodic carbonate. I have had a good deal of experience with regard to waters which act on lead, I allude to the
waters from the tIastings sands. These waters are acid, a n d always contain iron, which is not surprising, because iron was formerly worked there. They act on all metals ; lead, tin, zinc. I have seen pipes made of solid tin eaten quite through. It is not possible to use iron pipes, and for such waters " Barff" iron cannot be used, because flaws are so frequent that it rusts away. Lead pipes coated with tin have been g i v e n up ; also tin pipes coated with lead. T h e only metho~l I have seen satisfactory is coating .iron pipes with Angus Smith's solution. Wrought iron pipes, if they are new, can be coated with Angus S m i t h ' s solution, and they then stand the action of these soft waters very well. There is one question I should like to ask, whether the recent contamination by lead of water is due to the purity of the lead used in the pipes ? It is well known that oure lead is easier dissolved than lead which is not quite "urep. Latterly, from processes of desilverization and others, lead has been put on the market in a very pure state. Dr. BROWN briefly replied.
THE
I~EGISTRATION OF SANITARY CONDITION BY PHOTOGRAPHY.
Dr. SYKES exhibited some photographs of an insanitary area, and a portable camera called the " Kodak," and explained its working. Votes of thanks were given to Dr. Brown for his paper on lead poisoning, and to Dr. Sykes for his exhibit, and the Society adjourned. A NOVEL USE FOR PRIVIES.~Dr. Philip E. Hill, in his I4th annual report to the Crickhowell Rural Sanitary Authority, states that in one instance a privy was utilized as a place for the storage of the food and drink of the occupants of the house.
BRANCH.
PROCEEDINGS OF THE NORTHWESTERN BRANCH OF THE SOCIETY 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 MEETING of this branch was held at 44, John Dalton Street, Manchester, on Friday, May 9th. There were present: Dr. Hope (in the chair), Drs. Kenyon, Sidebotham, Hirst, Barr, Chadwick, Gornall, Barwise, Barnish, Welch, Graham, Vacher, Oldham, Martin, and Mr. Fred. Scott. The minutes of the last ordinary meeting were read and confirmed. Some discussion took place on the Contagious Diseases (Prevention) Bill. A letter was read from Dr. Thomson regretting his inability to be present. Dr. Hope, lately elected president of the branch, then read his inaugural address, his subject being-INSANITARY DWELLINGS AND AREAS, AND THE M E T H O D OF DEALING WITH T H E M IN LIVERPOOL.
Gentlemen,--Any one of the great variety of circumstances which influence the public health might fairly claim the attention of a Society of Medical Officers of Health, and this diversityof choice embarrasses the selectionof a subject for today. However, I propose to avail myself of the present opportunity to bring before you a subject which has received close attention in Liverpool, and with very practical results, viz, insanitary dwellings and areas, and the methods of dealing with them. The matter is one o f universal interest, and affects not only the population resident within the district in question, but has an important indirect influence upon the whole community. In every city and in every town, areas are to be found which are a source of constant anxiety and trouble to the medical officer and his staff; dilapidation, squalor, poverty, and filth are the superficial characteristics of these quarters, and the medical officer, whose acquaintance with them is fuller, knows also that they produce an amount of sickness and disease and a number of deaths out of all proportion to the sick-rate and death-rate of the rest of that city or town ; he knows, further, that this condition is not a transient nor an unusual one, but that for years past, as long, perhaps, as the area has been in existence--certainly since municipal records have been kept--disease and death have been the prominent features of the district, and this, notwithstanding the sanitary measures instituted from time to time, with the expectation that some of them would prove adequate to the large necessities of the case. It is hardly necessary to say that dwellings may be rendered insanitary from a variety of causes : (i) From neglect, inattention to, or ignorance of necessary and available sanitary appliances; (t) from defects caused by wear and lapse of time; (3) from illegal and improper occupation, as may
I N S A N I T A R Y D W E L L I N G S AND AREAS IN L I V E R P O O L . bc the case in over-crowded sublet houses, or uncontrolled common lodging-houses, or illegal cellars. The class we have now to consider does not include any of these, but consists of houses which are insanitary on account of original faulty construction, both in regard to the individual houses themselves, and to the way in which they are aggregated and stand in relation to one another-a class, moreover, which appears to have been but little affected by the works undertaken with a view to improve them. These works have, in the cases in question, embraced (i) an efficient system of scavenging, prompt removal of refuse, and strict attention to street and external cleanliness as far as possible ; and by unceasing vigilance on the part of a large inspectorial staff, cleanliness has also been aimed at within the dwelling ; (2) prevention of overcrowding--this has been rigorously enforced ; (3) prompt removal to hospital of the infectious sick ; (4) structural alterations, e.g., opening up of courts and alleys by the demolition of a house here and there, which obstructed the light and ventilation of the rest, and, where practicable, and with a similar object, substitutingiron railings for partitions between courts; (5) laying down impervious pavements, and improving the water supply and the closet accommodation. These are measures which have been adopted for years in the poorer districts of Liverpool, and they have unquestionably had very material effect in lessening the death-rate of those districts and in improving the. condition of their inhabitants. They have not, however, answered all expectations (though they may have reduced the death-rate from 60 to 40 per thousand), and in the resistent districts now referred to, no measure short of entire demolition and reconstruction is satisfactory. The property in regard to which this line of action is adopted is localised in the older parts of the city, and was for the most part erected prior to I842, when no Local Act, not bye-law, nor any other means existed to control the erection of buildings; the builder, absolutely unfettered by restrictions, in erecting the largest number of dwellings on the smallest possible space, displayed an ingenuity which a bee might envy, and, singularly enough, many of those houses were so solidly built that, although the property as a whole is decayed and ruinous, yet a number of them after 5o years' wear are as sound in the brickwork as ever. In structure, each house consists of three rooms placed one over the other, the top room usually having no fire-place; the staircase leads directly from one room to another without any landing or doorway, and consequently the same atmosphere pervades the whole house ; commonly there is, or was, an underground cellar to each house, but in a large number of cases these have been filled up at the cost of the Corporation, as they became receptacles for filth and garbage. The houses are arranged in courts, £e., in rows, placed back to back, having neither windows, open
43
spaces, nor means of ventilation at either rear or side, and consequently no through ventilation ; the entrance to the court is about four feet wide, and this entrance is frequently converted into a tunnel by the houses facing the street; the width of the court averages ten feet, it is blocked at the far end by a wall or building of varying height ; the houses, in fact, are cul-de-sacs within cul-de-sacs. The closets are troughs situated usually at the far end of the court, seldom at the entrarlce, and movable ash-boxes are usually placed near the closets ; there are no closets within the houses. The blocks of property of this description most recently dealt with by the Corporation are situated, one at the north end, and the other at the east end of the City; they include 55o houses, and together have a population of 2,539 persons. The plans of the property are before you, and are fairly illustrative of the general disposition of a large quantity of similar property already demolished, and of a good deal which stiU has to be dealt with. It has been shown that ventilation of these dwellings is an impossibility ; the stagnant atmosphere within them is foul and noisome, owing to respiratory impurities, personal filth of the inmates, and the frequent retention of excreta in open vessels in the rooms, owing to deficient closet accommodation. No chemical test is needed to support the evidence of the senses as to the impurity of the air, but the presence of ~'2 vols. of carbonic acid per x,ooo, Le., double the quantity that should exist, has been demonstrated by me in several of these dwelling-rooms. Bacteria and moulds exist in considerable excess of what are found in an ordinary dwelling-room, and can of course be easily cultivated. These are points not only of interest but importance, and supplement the evidence upon which such property is condemned as unfit for human habitation, the main features of such evidence being the following: (I) It is shown that the districts have for years produced an unduly large share of zymotic diseases, and that typhus fever, now comparatively rare, has lingered longest, and was formerly most rife there ; the disappear ance of this disease is due to sanitary measures already referred to, which are maintained at great cost, and which of course cannot be relaxed. (z) The death-rate, and notably the death-rate from diseases of the respiratory system is highwvery high. (3) The sick rate is in proportion, implying inability to work, and consequent toss of money and means to provide food, clothing, and other necessaries of life. With regard to the actual death-rate in the two districts last presented, the figures are as follows : - No. of Populatlon. Hott~es, (S.) Mann Street I 1,639 District . . . . . [ .
Death-rateper r,ooo from all Causes. xSSS, x88~, Average.
440 ... 43"3 ... 36.0 . . . . .
39"6
(E.) Duckinfield ~ 900 2zo ... 43"3 ... 45"5 .-. 44"4 St. District ... j ""
4~
P R O C E E D I N G S OF T H E N O R T H - W E S T E R N B R A N C H . Deaths from Pulmonary Diseases per Loop llv|ag. ~,88. x889. 20"7 ...... I4"6
Mann Street District ......
Duckinfield Street District ... 16"6 ......
22"2
With these may be contrasted (Q the Victoria Square Buildings, to be presently referred to, erected by the Corporation for tenants of the class displaced from these dwellings ; and (2) the deathrate for the whole city. Death.rate per 1,pop from all causes.
z888.
Population.
~88~
",
Victoria Square
...
1,2oo
...
Me'no 2i'3
The whole City
...
--
...
20"3 ... 2I'5 Mean.
20 "9
No doubt a more accurate return would have been given had the census specially undertaken for this inquiry shown also the age and sex distribution. Had this been done, it would have told strongly against the condemned area, for some propertyagents exclude families with young children, and will not have such as tenants, from the desire, as far as I can ascertain, to keep a cleaner bill ot health. The amount of care bestowed by the owners upon this class of property is evidenced by the fact that, during the last two years, it was necessary to send no less than 907 notices from the sanitary department to owners of the now presented property, in respect to insanitary conditions existing on this very property; and during the same period no less than 250 notices were sent from the same office to limewash the courts in which these houses are situated. The state of repair of the property may be gauged from these facts. The evidence of the medical officers of the Corporation was in this instance supported by that of Dr. Littlejohn and Dr. Corfield, and the grand jury having, by part of their number, viewed the premises, were of opinion that the dwellings were unfit for human habitation and ought to be demolished, and they found accordingly. A few words are necessary in regard to the legal processes adopted in dealing with these dwellings. In 1846, Liverpool obtained a Sanitary Act, which was the precursor of the Public Health Act of x848, and which contained provisions regulating the construction of houses, courts, and streets, and their efficient drainage. This ensured from that period a more satisfactory system in the construction of the houses of the labouring classes, but the evils resulting from the old dwellings already existing were so great that the Corporation obtained a special Act in I864, termed the Liverpool Sanitary Amendment Act, to deal with that class of property. By this Act it i.~ provided that, " If the medical officer of health shall find that any court or alley, or any premises is or are unfit for human habitation, or in a condition, state, or situation injurious, dangerous, or prejudicial to health, he shall
report the same, and that the powers of this Act ought to be put in force in respect to such court, alley, or premises, and whether the ascertained defects can be remedied by structural alterations and improvements or otherwise, or whether such court, alley, or premises, or any and what p~rt thereof, ought to be demolished." Conditions which could not be summarily dealt with under the Pablic Health Act nor reached as a nuisance, come within the scope of this clause; the medical officer specifies the work required to be done in his report, which is delivered to the town clerk, with a duplicate for the clerk of the peace. Where owners of property meet the views of the city council, a settlement is effected, otherwise the proceedings are by pre. sentment after a second report by the medical officer, and a reference of the duplicate to the clerk of the peace. This duplicate is laid by the clerk of the peace before the Grand Jury, at the next Court of Quarter Sessions for the city, who take it into consideration, and hear evidence in reference to it. The owners of the property, who must be duly notified, have the right to place their views before the jury themselves, or be represemed by counsel. The jury having, if they think fit, viewed the prendses specified in the report, make a presentment thereon according to what they consider the requirements of the case. This presentment is laid by the town clerk before the city council, who instruct the engineer to prepare plans and specifications of the works (if any) required to be executed. The owner receives notice of thdse plans, and if he is not willing that the wo;k should be done, he may appeal to the Court of Quarter Sessions, or may require the Corporation to purchase the premises, then, if the amount of purchase money cannot be agreed upon, the amount of compensation to be paid to the owner shall be settled by arbitration, the arbitrator to be appointed by the Local Government Board. By the decision of the arbitrator any value based on the r~zlal of premises occupied as dwellings, cannot be entertained, as the fact of their being presented is evidence that they are not fit for human habitation, and consequently cannot be let for that purpose, or have any value as such. The owner may elect to retain the site, and receive compensation only for the building (£e., material) ; but he cannot erect any buildings upon the site without the consent of the Corporation. Since this act was passed in I864, two important provisions have been introduced ; one enables the Corporation to purchase the property if the owner is willing to sell it, on report of the medical officer, without going through all the forms of a presentment. Another is the appointment of an arbitrator, to decide the value of the premises, instead of proceeding under more cumbrous and expensive legal formalities. It will be noted also that houses can be dealt with which in themselves are perfectly sanitary, but which from their position injuriously
I N S A N I T A R Y D W E L L I N G S AND AKI~AS IN L I V E R P O O L . affect others by obstructing ventilation; in this respect the powers of this Act extend further than those of the Public Health Act. A somewhat similar provision, however, has been introduced into the .~.rtizans and Labourers' Dwellings Acts Amendment Act. As soon as an area is cleared, the object of the Corporation is that no time should be lost in pro. viding on the vacant site, dwellings of a character suitable to the requirements of the people who have been displaced. These dwellings have either consisted of four-roomed cottages, or of blocks of tenements several stories high. This latter class of building, which is so common and so popular in London and other large cities, must also be regarded as a necessity in Liverpool if the present and future labouring population are to be provided for within reasonable distance of their work, since necessity imposes a serious restriction upon the area of habitation ; however cheap the means of locomotion may be to or from dwellings at a distance from the place of work, yet the time lost, and a fare amounting even to one shilling a-week, are matters of the utmost consequence to the poorer class of labourers. This is the circumstance which unfortunately limits the number of four-roomed cottages, which in themselves present so many advantages over the other classes of dwellings. But in either case, builders have evinced very little readiness to undertake to build for this class of the community. In a few instances buildings of the requisite class have been erected by private enterprise, but the bulk of the requirements has been met by the Corporation, in the absence of private enterprise. One of the most important blocks erected by the Corporation is that known as Victoria Square, to which reference has already been made, and the plans and elevation of which are before you. The buildings, which provide accommodation for about a thousand persons, occupy part of a site formerly known as Nash Grove, in which some x,3oo persons were living under the worst sanitary conditions. The site is bounded on every side by streets, and the dwellings enclose a quadrangular space, suitably laid out, of over 5,ooo square yards. Tramways pass along two of the streets. The buildings are five floors in height, and are divided by party walls into thirteen separate sections ; two of the blocks have shops on the ground floor, and the remainder are entirely devoted to dwellings. Each dwelling has a separate entrance from the quadrangle and common staircase, and is a tenement in itself. There are altogether 271 tenements and a superintendent's house, made up as follows : - 86 three-roomed tenements. 164 two-roomed tenements. 2 t one-roomed tenements. The water-closets are two on each floor for the joint use of the four tenements; they are tho-
45
roughly disconnected from the tenements, and are of approved sanitary construction. The dust and ashes are disposed of through a ventilated shoot, formed in the angle of the lobby leading to the w.c., which appears to answer well ; orderly.bins are provided for other refuse. Each tenant has the sole use for a fixed day of a spacious laundry, appropriately lighted and fitted up, placed centrally on each floor, for the use of the four tenements on that fl:or; on each side of the laundry is a scullery with double sink--one sink for each tenant. The interior of the tenements is attractive and cheerful; the walls are plastered and finished in distemper; the necessary cupboards, drawers, bunkers, etc., are provided. The windows are divided into small squares, the lower portion having tinted gla,~s. They are fitted with stained and varnished venetian blinds. Sewerage and drainage have received the closest attention, and need not be further referred to. The estimated cost of the dwellings, including the market value of the site, is .£7o,ooo. The rents charged vary from 6s. per.week for the threeroomed tenements, to 2s. per week for the oneroomed tenements. Other buildings, practically similar in construction, are in course of erection close to these. Since the work of demolishing insanitary areas can only proceed pari 2~asszt with the provision of suitable houses for the people dispossessed, it must necessarily be slow. During the last ten years some 2,ooo insanitary houses have been demolished, and the Corporation have some 6dO in hand at the preset, t time. The mortality, as I have shown, in the new dwellings, is about one-half what it was in the old ; and whatever other influences may have contributed to this result, there can be no doubt that the removal from wretched and miserable hovels to light and airy dwellings, in which every facility for personal and domestic cleanliness is at hand, has been the main factor in effecting the change. In conclusion, I may quote the views expressed by the Grand Jury when making their last presentment, and added by them as a rider thereto : - "The Grand Jury say further, that whilst they entirely approve of the Corporation method of dealing with districts of insanitary property, and not with individual houses only, they are of the opinion that where houses at present insanitary might by reconstruction be made habitable but their removal is necessary as part of a scheme for promoting the public health, this should have due weight when the question of compensation to the owners has to be considered. "The Grand Jury are further of the opinion that n pulling down these houses the Corporation assume the responsibility of seeing that those which may be built to replace them are not inferior to the present houses in any sanitary particular. With
46
T H E I N F L U E N Z A I N MID-ESSEX.
all their faults, many of the existing houses appear to be so well built that the warmth of the inmates is to a great extent secured. The Grand Jury consider that warmth is scarcely less essential to the health of the poor than ventilation, and they suggest that the Corporation, either by building themselves, or by means of stringent building regulations rigidly enforced, should see that the new houses are so substantially built that as regards warmth they are not inferior to the old. " T h e Grand Jury also strongly recommend the disuse of asbpits, which are invariably a receptacle for waste vegetable matter, and the substitution of dust-bins in the streets to be cleared daily or as occasion may require. They highly commend the action of the Corporation in dealing as they are doing with the insanitary districts of the city. ~t JOSEPH CHADWICK,Foreman." On the motion of Dr. Kenyon, seconded by Dr. Vacher, Dr. Hope was cordially thanked for his interesting and instructive address. (2~nd of Froceedlngs of ~ociety of Medical O~cers of Health .)
THE FOOD OF THE LABOURING CLASSES IN THE DISTRICT OF ADRIANOPLE(TU~KEV):--H.M. Consul, Mr. H. A. Cumberhatch, makes the following observations in a recent report : - - " The diet of labourers in towns and villages is very frugal and inferior to that of the same class of men in the rest of Europe. The town labourer feeds himself during the day on a loaf of bread with a little fruit added thereto in summer, and a slice of cheese or a few olives, or only an onion, in winter; at the end of the day's work his meal consists of a dish of vegetables, seldom accompanied by wine ; the Mussulman labourer never drinks wine, but has several cups of black coffee in the course of the day. The villager and farm hand get a soup mixture made of flour, water, and oil of sesamum, with a flavour of onion, and bread, as a morning meal; at midday they eat a small loaf of bread with a few olives, or onions, or with a pinch of salt or red pepper ; the morning meal is repeated in the evening, meat being tasted perhaps six or eight times a year, on grand feast days, and dried fish occasionally. The bread is made of maize or millet, especially the latter, which is found much more satisfying. In some places potatoes have been introduced, but have not been appreciated. Bread soaked in whey from the churn is a common dish in summer, and garlic, washed down by weak vinegar, is much consumed by reapers during harvest time. NonMussulman producers of wine put a barrelful aside for home consumption, and do not replenish the supply when terminated, but buy a small quantity on great" festivals. They prefer taking an occasional glass of ' r a k i ' (brandy) at the village tavern."
ttbti,
¢ult .
T H E I N F L U E N Z A I N MID-ESSEX. Paper Read before the East Auglian Bramh aft l ~ Brit. Med. Assoc. at Haverhill, May 2rid, I~9o.
By J. C. THRISH, M.B., D.Sc., M.O.H. for Che]msford and Maldon R. S. Districts. DURING the past three months the epidemic of influenza must have attracted more of the attention of the general medical practitioner than almost all other diseases combined, and, therefore, whilst most of the facts in connection with it are fresh in our memories, a comparison of the phenomena observed by different men may help to elucidate some of the mysteries by which influenza epidemics are always surrounded. The notes which I have to read to you have reference to the epidemic in that portion of the county of Essex contained in the rural sanitary districts of Chelmsford and Maldom The district, as you are aware, is almost a purely agricultural one, and very flat except in the middle and north-west portions, and practically the whole of it is upon the London clay. The area is about 300 square miles, and the population is in round numbers 42,000. If we include the urban districts, which are almost in the centre of their respective rural districts, the population is 57,000. My information is chiefly derived from reports kindly furnished by the various district medical officers in reply to series of questions sent by me. Prior to the outbreak of the influenza proper, there was an excessive amount of sickness amongst children in several parishes. Whooping cough was very prevalent in many villages, and measles in one. In mid-November there was a distinct and peculiar epidemic amongst children, which appears to have commenced in the village of Pleshey, and spread somewhat rapidly into the surrounding hamlets, where it became merged into the true influenza. In several other parts of the district so many children were ill in mid.December that I am inclined to think that here also some form of epidemic was also prevalent. At Pleshey, Dr. Cockey, who attended most of the cases, says fully two.thirds of the children were attacked in rapid succession towards the end of November. The symptoms were feverishness, headache, cough, and bronchitis, sometimes associated with nausea, but, so far as I can gather, there was little or no catarrh and no limb pains. In the other villages the symptoms were much the same, but not so severe, and catarrh was fairly common. Whatever may have been the relation of this sickness to the outbreak of influenza which occurred later, two things are especially noteworthy. First, that in most of these localities the onset of the true influenza was not nearly of so sudden and. explosive a character as in the villages where no such illness was prevalent ; and, second, that when the epidemic ultimately
PROCEEDINGS
OF
THE
NORTH-WESTERN
with some acid, and he was astonished that success had not keen attained in separating and iden'ifying the particular acid. Why had not someone operated on a technical scale, and after careful neutralization evaporated down in a vacuum p a n some thousand gallons, so as to obtain ~. sufficient quantity of material ? Dr. Brown talked of a li~re of water having been operated u p o n - - a quanUty qmte msuffimew. W a s the acid soluble in ether ? a great many organic acids were so, and could be extracted from fluids by shaking with that solvent. The whole subject was one of great interest, and much investigation was still required to elucidate the various conditions under which lead ¢ontamina'.ion of water occurred. Mr. CHARLES CASSAL-" I agree generally with Mr. Wynter Blyth's remarks, and think that the chemical details would have been more suitable to a chemical society. All such questions, in his opinion, should be placed in the hands of the Public Analyst of the district. All waters will dissolve lead if sufficient time is given ; this is even true of hard waters, for if you take the first drops of water from a pipe which has not been drawn on for many hours, the water contains considerable quantities of lead. ! am not at all satisfied with the tests given by Dr. Brown for the detectTon of the acid. Tropaeoline is a complicated substance, and the commercial samples differ considerably. In some, acet;c acid strike a similar red colour to that given by the mineral acids ; with others the colour is different. W i t h regard to sulphate of iron, under certain circumstances it will easily decompose and produce small quantities of sulphuric acid.
Dr. CORF~tLD: I consider that the most important point is how to prevent lead poisoning. Dr. Brown has suggested to us two ways in which this may be done; in the one filtration through carbon, in the other the use of limestone and sodic carbonate. I have had a good deal of experience with regard to waters which act on lead, I allude to the
waters from the tIastings sands. These waters are acid, a n d always contain iron, which is not surprising, because iron was formerly worked there. They act on all metals ; lead, tin, zinc. I have seen pipes made of solid tin eaten quite through. It is not possible to use iron pipes, and for such waters " Barff" iron cannot be used, because flaws are so frequent that it rusts away. Lead pipes coated with tin have been g i v e n up ; also tin pipes coated with lead. T h e only metho~l I have seen satisfactory is coating .iron pipes with Angus Smith's solution. Wrought iron pipes, if they are new, can be coated with Angus S m i t h ' s solution, and they then stand the action of these soft waters very well. There is one question I should like to ask, whether the recent contamination by lead of water is due to the purity of the lead used in the pipes ? It is well known that oure lead is easier dissolved than lead which is not quite "urep. Latterly, from processes of desilverization and others, lead has been put on the market in a very pure state. Dr. BROWN briefly replied.
THE
I~EGISTRATION OF SANITARY CONDITION BY PHOTOGRAPHY.
Dr. SYKES exhibited some photographs of an insanitary area, and a portable camera called the " Kodak," and explained its working. Votes of thanks were given to Dr. Brown for his paper on lead poisoning, and to Dr. Sykes for his exhibit, and the Society adjourned. A NOVEL USE FOR PRIVIES.~Dr. Philip E. Hill, in his I4th annual report to the Crickhowell Rural Sanitary Authority, states that in one instance a privy was utilized as a place for the storage of the food and drink of the occupants of the house.
BRANCH.
PROCEEDINGS OF THE NORTHWESTERN BRANCH OF THE SOCIETY 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 MEETING of this branch was held at 44, John Dalton Street, Manchester, on Friday, May 9th. There were present: Dr. Hope (in the chair), Drs. Kenyon, Sidebotham, Hirst, Barr, Chadwick, Gornall, Barwise, Barnish, Welch, Graham, Vacher, Oldham, Martin, and Mr. Fred. Scott. The minutes of the last ordinary meeting were read and confirmed. Some discussion took place on the Contagious Diseases (Prevention) Bill. A letter was read from Dr. Thomson regretting his inability to be present. Dr. Hope, lately elected president of the branch, then read his inaugural address, his subject being-INSANITARY DWELLINGS AND AREAS, AND THE M E T H O D OF DEALING WITH T H E M IN LIVERPOOL.
Gentlemen,--Any one of the great variety of circumstances which influence the public health might fairly claim the attention of a Society of Medical Officers of Health, and this diversityof choice embarrasses the selectionof a subject for today. However, I propose to avail myself of the present opportunity to bring before you a subject which has received close attention in Liverpool, and with very practical results, viz, insanitary dwellings and areas, and the methods of dealing with them. The matter is one o f universal interest, and affects not only the population resident within the district in question, but has an important indirect influence upon the whole community. In every city and in every town, areas are to be found which are a source of constant anxiety and trouble to the medical officer and his staff; dilapidation, squalor, poverty, and filth are the superficial characteristics of these quarters, and the medical officer, whose acquaintance with them is fuller, knows also that they produce an amount of sickness and disease and a number of deaths out of all proportion to the sick-rate and death-rate of the rest of that city or town ; he knows, further, that this condition is not a transient nor an unusual one, but that for years past, as long, perhaps, as the area has been in existence--certainly since municipal records have been kept--disease and death have been the prominent features of the district, and this, notwithstanding the sanitary measures instituted from time to time, with the expectation that some of them would prove adequate to the large necessities of the case. It is hardly necessary to say that dwellings may be rendered insanitary from a variety of causes : (i) From neglect, inattention to, or ignorance of necessary and available sanitary appliances; (t) from defects caused by wear and lapse of time; (3) from illegal and improper occupation, as may
I N S A N I T A R Y D W E L L I N G S AND AREAS IN L I V E R P O O L . bc the case in over-crowded sublet houses, or uncontrolled common lodging-houses, or illegal cellars. The class we have now to consider does not include any of these, but consists of houses which are insanitary on account of original faulty construction, both in regard to the individual houses themselves, and to the way in which they are aggregated and stand in relation to one another-a class, moreover, which appears to have been but little affected by the works undertaken with a view to improve them. These works have, in the cases in question, embraced (i) an efficient system of scavenging, prompt removal of refuse, and strict attention to street and external cleanliness as far as possible ; and by unceasing vigilance on the part of a large inspectorial staff, cleanliness has also been aimed at within the dwelling ; (2) prevention of overcrowding--this has been rigorously enforced ; (3) prompt removal to hospital of the infectious sick ; (4) structural alterations, e.g., opening up of courts and alleys by the demolition of a house here and there, which obstructed the light and ventilation of the rest, and, where practicable, and with a similar object, substitutingiron railings for partitions between courts; (5) laying down impervious pavements, and improving the water supply and the closet accommodation. These are measures which have been adopted for years in the poorer districts of Liverpool, and they have unquestionably had very material effect in lessening the death-rate of those districts and in improving the. condition of their inhabitants. They have not, however, answered all expectations (though they may have reduced the death-rate from 60 to 40 per thousand), and in the resistent districts now referred to, no measure short of entire demolition and reconstruction is satisfactory. The property in regard to which this line of action is adopted is localised in the older parts of the city, and was for the most part erected prior to I842, when no Local Act, not bye-law, nor any other means existed to control the erection of buildings; the builder, absolutely unfettered by restrictions, in erecting the largest number of dwellings on the smallest possible space, displayed an ingenuity which a bee might envy, and, singularly enough, many of those houses were so solidly built that, although the property as a whole is decayed and ruinous, yet a number of them after 5o years' wear are as sound in the brickwork as ever. In structure, each house consists of three rooms placed one over the other, the top room usually having no fire-place; the staircase leads directly from one room to another without any landing or doorway, and consequently the same atmosphere pervades the whole house ; commonly there is, or was, an underground cellar to each house, but in a large number of cases these have been filled up at the cost of the Corporation, as they became receptacles for filth and garbage. The houses are arranged in courts, £e., in rows, placed back to back, having neither windows, open
43
spaces, nor means of ventilation at either rear or side, and consequently no through ventilation ; the entrance to the court is about four feet wide, and this entrance is frequently converted into a tunnel by the houses facing the street; the width of the court averages ten feet, it is blocked at the far end by a wall or building of varying height ; the houses, in fact, are cul-de-sacs within cul-de-sacs. The closets are troughs situated usually at the far end of the court, seldom at the entrarlce, and movable ash-boxes are usually placed near the closets ; there are no closets within the houses. The blocks of property of this description most recently dealt with by the Corporation are situated, one at the north end, and the other at the east end of the City; they include 55o houses, and together have a population of 2,539 persons. The plans of the property are before you, and are fairly illustrative of the general disposition of a large quantity of similar property already demolished, and of a good deal which stiU has to be dealt with. It has been shown that ventilation of these dwellings is an impossibility ; the stagnant atmosphere within them is foul and noisome, owing to respiratory impurities, personal filth of the inmates, and the frequent retention of excreta in open vessels in the rooms, owing to deficient closet accommodation. No chemical test is needed to support the evidence of the senses as to the impurity of the air, but the presence of ~'2 vols. of carbonic acid per x,ooo, Le., double the quantity that should exist, has been demonstrated by me in several of these dwelling-rooms. Bacteria and moulds exist in considerable excess of what are found in an ordinary dwelling-room, and can of course be easily cultivated. These are points not only of interest but importance, and supplement the evidence upon which such property is condemned as unfit for human habitation, the main features of such evidence being the following: (I) It is shown that the districts have for years produced an unduly large share of zymotic diseases, and that typhus fever, now comparatively rare, has lingered longest, and was formerly most rife there ; the disappear ance of this disease is due to sanitary measures already referred to, which are maintained at great cost, and which of course cannot be relaxed. (z) The death-rate, and notably the death-rate from diseases of the respiratory system is highwvery high. (3) The sick rate is in proportion, implying inability to work, and consequent toss of money and means to provide food, clothing, and other necessaries of life. With regard to the actual death-rate in the two districts last presented, the figures are as follows : - No. of Populatlon. Hott~es, (S.) Mann Street I 1,639 District . . . . . [ .
Death-rateper r,ooo from all Causes. xSSS, x88~, Average.
440 ... 43"3 ... 36.0 . . . . .
39"6
(E.) Duckinfield ~ 900 2zo ... 43"3 ... 45"5 .-. 44"4 St. District ... j ""
4~
P R O C E E D I N G S OF T H E N O R T H - W E S T E R N B R A N C H . Deaths from Pulmonary Diseases per Loop llv|ag. ~,88. x889. 20"7 ...... I4"6
Mann Street District ......
Duckinfield Street District ... 16"6 ......
22"2
With these may be contrasted (Q the Victoria Square Buildings, to be presently referred to, erected by the Corporation for tenants of the class displaced from these dwellings ; and (2) the deathrate for the whole city. Death.rate per 1,pop from all causes.
z888.
Population.
~88~
",
Victoria Square
...
1,2oo
...
Me'no 2i'3
The whole City
...
--
...
20"3 ... 2I'5 Mean.
20 "9
No doubt a more accurate return would have been given had the census specially undertaken for this inquiry shown also the age and sex distribution. Had this been done, it would have told strongly against the condemned area, for some propertyagents exclude families with young children, and will not have such as tenants, from the desire, as far as I can ascertain, to keep a cleaner bill ot health. The amount of care bestowed by the owners upon this class of property is evidenced by the fact that, during the last two years, it was necessary to send no less than 907 notices from the sanitary department to owners of the now presented property, in respect to insanitary conditions existing on this very property; and during the same period no less than 250 notices were sent from the same office to limewash the courts in which these houses are situated. The state of repair of the property may be gauged from these facts. The evidence of the medical officers of the Corporation was in this instance supported by that of Dr. Littlejohn and Dr. Corfield, and the grand jury having, by part of their number, viewed the premises, were of opinion that the dwellings were unfit for human habitation and ought to be demolished, and they found accordingly. A few words are necessary in regard to the legal processes adopted in dealing with these dwellings. In 1846, Liverpool obtained a Sanitary Act, which was the precursor of the Public Health Act of x848, and which contained provisions regulating the construction of houses, courts, and streets, and their efficient drainage. This ensured from that period a more satisfactory system in the construction of the houses of the labouring classes, but the evils resulting from the old dwellings already existing were so great that the Corporation obtained a special Act in I864, termed the Liverpool Sanitary Amendment Act, to deal with that class of property. By this Act it i.~ provided that, " If the medical officer of health shall find that any court or alley, or any premises is or are unfit for human habitation, or in a condition, state, or situation injurious, dangerous, or prejudicial to health, he shall
report the same, and that the powers of this Act ought to be put in force in respect to such court, alley, or premises, and whether the ascertained defects can be remedied by structural alterations and improvements or otherwise, or whether such court, alley, or premises, or any and what p~rt thereof, ought to be demolished." Conditions which could not be summarily dealt with under the Pablic Health Act nor reached as a nuisance, come within the scope of this clause; the medical officer specifies the work required to be done in his report, which is delivered to the town clerk, with a duplicate for the clerk of the peace. Where owners of property meet the views of the city council, a settlement is effected, otherwise the proceedings are by pre. sentment after a second report by the medical officer, and a reference of the duplicate to the clerk of the peace. This duplicate is laid by the clerk of the peace before the Grand Jury, at the next Court of Quarter Sessions for the city, who take it into consideration, and hear evidence in reference to it. The owners of the property, who must be duly notified, have the right to place their views before the jury themselves, or be represemed by counsel. The jury having, if they think fit, viewed the prendses specified in the report, make a presentment thereon according to what they consider the requirements of the case. This presentment is laid by the town clerk before the city council, who instruct the engineer to prepare plans and specifications of the works (if any) required to be executed. The owner receives notice of thdse plans, and if he is not willing that the wo;k should be done, he may appeal to the Court of Quarter Sessions, or may require the Corporation to purchase the premises, then, if the amount of purchase money cannot be agreed upon, the amount of compensation to be paid to the owner shall be settled by arbitration, the arbitrator to be appointed by the Local Government Board. By the decision of the arbitrator any value based on the r~zlal of premises occupied as dwellings, cannot be entertained, as the fact of their being presented is evidence that they are not fit for human habitation, and consequently cannot be let for that purpose, or have any value as such. The owner may elect to retain the site, and receive compensation only for the building (£e., material) ; but he cannot erect any buildings upon the site without the consent of the Corporation. Since this act was passed in I864, two important provisions have been introduced ; one enables the Corporation to purchase the property if the owner is willing to sell it, on report of the medical officer, without going through all the forms of a presentment. Another is the appointment of an arbitrator, to decide the value of the premises, instead of proceeding under more cumbrous and expensive legal formalities. It will be noted also that houses can be dealt with which in themselves are perfectly sanitary, but which from their position injuriously
I N S A N I T A R Y D W E L L I N G S AND AKI~AS IN L I V E R P O O L . affect others by obstructing ventilation; in this respect the powers of this Act extend further than those of the Public Health Act. A somewhat similar provision, however, has been introduced into the .~.rtizans and Labourers' Dwellings Acts Amendment Act. As soon as an area is cleared, the object of the Corporation is that no time should be lost in pro. viding on the vacant site, dwellings of a character suitable to the requirements of the people who have been displaced. These dwellings have either consisted of four-roomed cottages, or of blocks of tenements several stories high. This latter class of building, which is so common and so popular in London and other large cities, must also be regarded as a necessity in Liverpool if the present and future labouring population are to be provided for within reasonable distance of their work, since necessity imposes a serious restriction upon the area of habitation ; however cheap the means of locomotion may be to or from dwellings at a distance from the place of work, yet the time lost, and a fare amounting even to one shilling a-week, are matters of the utmost consequence to the poorer class of labourers. This is the circumstance which unfortunately limits the number of four-roomed cottages, which in themselves present so many advantages over the other classes of dwellings. But in either case, builders have evinced very little readiness to undertake to build for this class of the community. In a few instances buildings of the requisite class have been erected by private enterprise, but the bulk of the requirements has been met by the Corporation, in the absence of private enterprise. One of the most important blocks erected by the Corporation is that known as Victoria Square, to which reference has already been made, and the plans and elevation of which are before you. The buildings, which provide accommodation for about a thousand persons, occupy part of a site formerly known as Nash Grove, in which some x,3oo persons were living under the worst sanitary conditions. The site is bounded on every side by streets, and the dwellings enclose a quadrangular space, suitably laid out, of over 5,ooo square yards. Tramways pass along two of the streets. The buildings are five floors in height, and are divided by party walls into thirteen separate sections ; two of the blocks have shops on the ground floor, and the remainder are entirely devoted to dwellings. Each dwelling has a separate entrance from the quadrangle and common staircase, and is a tenement in itself. There are altogether 271 tenements and a superintendent's house, made up as follows : - 86 three-roomed tenements. 164 two-roomed tenements. 2 t one-roomed tenements. The water-closets are two on each floor for the joint use of the four tenements; they are tho-
45
roughly disconnected from the tenements, and are of approved sanitary construction. The dust and ashes are disposed of through a ventilated shoot, formed in the angle of the lobby leading to the w.c., which appears to answer well ; orderly.bins are provided for other refuse. Each tenant has the sole use for a fixed day of a spacious laundry, appropriately lighted and fitted up, placed centrally on each floor, for the use of the four tenements on that fl:or; on each side of the laundry is a scullery with double sink--one sink for each tenant. The interior of the tenements is attractive and cheerful; the walls are plastered and finished in distemper; the necessary cupboards, drawers, bunkers, etc., are provided. The windows are divided into small squares, the lower portion having tinted gla,~s. They are fitted with stained and varnished venetian blinds. Sewerage and drainage have received the closest attention, and need not be further referred to. The estimated cost of the dwellings, including the market value of the site, is .£7o,ooo. The rents charged vary from 6s. per.week for the threeroomed tenements, to 2s. per week for the oneroomed tenements. Other buildings, practically similar in construction, are in course of erection close to these. Since the work of demolishing insanitary areas can only proceed pari 2~asszt with the provision of suitable houses for the people dispossessed, it must necessarily be slow. During the last ten years some 2,ooo insanitary houses have been demolished, and the Corporation have some 6dO in hand at the preset, t time. The mortality, as I have shown, in the new dwellings, is about one-half what it was in the old ; and whatever other influences may have contributed to this result, there can be no doubt that the removal from wretched and miserable hovels to light and airy dwellings, in which every facility for personal and domestic cleanliness is at hand, has been the main factor in effecting the change. In conclusion, I may quote the views expressed by the Grand Jury when making their last presentment, and added by them as a rider thereto : - "The Grand Jury say further, that whilst they entirely approve of the Corporation method of dealing with districts of insanitary property, and not with individual houses only, they are of the opinion that where houses at present insanitary might by reconstruction be made habitable but their removal is necessary as part of a scheme for promoting the public health, this should have due weight when the question of compensation to the owners has to be considered. "The Grand Jury are further of the opinion that n pulling down these houses the Corporation assume the responsibility of seeing that those which may be built to replace them are not inferior to the present houses in any sanitary particular. With
46
T H E I N F L U E N Z A I N MID-ESSEX.
all their faults, many of the existing houses appear to be so well built that the warmth of the inmates is to a great extent secured. The Grand Jury consider that warmth is scarcely less essential to the health of the poor than ventilation, and they suggest that the Corporation, either by building themselves, or by means of stringent building regulations rigidly enforced, should see that the new houses are so substantially built that as regards warmth they are not inferior to the old. " T h e Grand Jury also strongly recommend the disuse of asbpits, which are invariably a receptacle for waste vegetable matter, and the substitution of dust-bins in the streets to be cleared daily or as occasion may require. They highly commend the action of the Corporation in dealing as they are doing with the insanitary districts of the city. ~t JOSEPH CHADWICK,Foreman." On the motion of Dr. Kenyon, seconded by Dr. Vacher, Dr. Hope was cordially thanked for his interesting and instructive address. (2~nd of Froceedlngs of ~ociety of Medical O~cers of Health .)
THE FOOD OF THE LABOURING CLASSES IN THE DISTRICT OF ADRIANOPLE(TU~KEV):--H.M. Consul, Mr. H. A. Cumberhatch, makes the following observations in a recent report : - - " The diet of labourers in towns and villages is very frugal and inferior to that of the same class of men in the rest of Europe. The town labourer feeds himself during the day on a loaf of bread with a little fruit added thereto in summer, and a slice of cheese or a few olives, or only an onion, in winter; at the end of the day's work his meal consists of a dish of vegetables, seldom accompanied by wine ; the Mussulman labourer never drinks wine, but has several cups of black coffee in the course of the day. The villager and farm hand get a soup mixture made of flour, water, and oil of sesamum, with a flavour of onion, and bread, as a morning meal; at midday they eat a small loaf of bread with a few olives, or onions, or with a pinch of salt or red pepper ; the morning meal is repeated in the evening, meat being tasted perhaps six or eight times a year, on grand feast days, and dried fish occasionally. The bread is made of maize or millet, especially the latter, which is found much more satisfying. In some places potatoes have been introduced, but have not been appreciated. Bread soaked in whey from the churn is a common dish in summer, and garlic, washed down by weak vinegar, is much consumed by reapers during harvest time. NonMussulman producers of wine put a barrelful aside for home consumption, and do not replenish the supply when terminated, but buy a small quantity on great" festivals. They prefer taking an occasional glass of ' r a k i ' (brandy) at the village tavern."
ttbti,
¢ult .
T H E I N F L U E N Z A I N MID-ESSEX. Paper Read before the East Auglian Bramh aft l ~ Brit. Med. Assoc. at Haverhill, May 2rid, I~9o.
By J. C. THRISH, M.B., D.Sc., M.O.H. for Che]msford and Maldon R. S. Districts. DURING the past three months the epidemic of influenza must have attracted more of the attention of the general medical practitioner than almost all other diseases combined, and, therefore, whilst most of the facts in connection with it are fresh in our memories, a comparison of the phenomena observed by different men may help to elucidate some of the mysteries by which influenza epidemics are always surrounded. The notes which I have to read to you have reference to the epidemic in that portion of the county of Essex contained in the rural sanitary districts of Chelmsford and Maldom The district, as you are aware, is almost a purely agricultural one, and very flat except in the middle and north-west portions, and practically the whole of it is upon the London clay. The area is about 300 square miles, and the population is in round numbers 42,000. If we include the urban districts, which are almost in the centre of their respective rural districts, the population is 57,000. My information is chiefly derived from reports kindly furnished by the various district medical officers in reply to series of questions sent by me. Prior to the outbreak of the influenza proper, there was an excessive amount of sickness amongst children in several parishes. Whooping cough was very prevalent in many villages, and measles in one. In mid-November there was a distinct and peculiar epidemic amongst children, which appears to have commenced in the village of Pleshey, and spread somewhat rapidly into the surrounding hamlets, where it became merged into the true influenza. In several other parts of the district so many children were ill in mid.December that I am inclined to think that here also some form of epidemic was also prevalent. At Pleshey, Dr. Cockey, who attended most of the cases, says fully two.thirds of the children were attacked in rapid succession towards the end of November. The symptoms were feverishness, headache, cough, and bronchitis, sometimes associated with nausea, but, so far as I can gather, there was little or no catarrh and no limb pains. In the other villages the symptoms were much the same, but not so severe, and catarrh was fairly common. Whatever may have been the relation of this sickness to the outbreak of influenza which occurred later, two things are especially noteworthy. First, that in most of these localities the onset of the true influenza was not nearly of so sudden and. explosive a character as in the villages where no such illness was prevalent ; and, second, that when the epidemic ultimately