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Summary conclusions of the committee of general medical council on examinations in sanitary science
~46
SUMMARY
CONCLUSIONS
OF GENERAL
same number of inhabitants as when the closing order was made, and the order not having been determined by any sub'sequent order, the respondent Urban District Council, being of opinion that the houses had not been rendered fit for human habitation, and that the necessary steps were not being taken with all due diligence to render them so fit, and that the continuance of the said premises was dangerous or injurious to the health of the public or of the inhabitants of the neighbouring dwelling houses, passed a resolution under section 33 of the Act that it was expedient to order the demolition of the said houses. Notice of this resolution, dated the 27th July, 7895 , was duly served upon the appellants, in accordance with section 33 (2) of the Act, and the respondents thereby appointed the 73th of August following for the further consideration of the resolution. During July a]l the houses except No. 5 were vacated, proceedings having been taken for that purpose against the tenants by the respondents, but No. 5 was still occupied at the date o f the hearing ot this appeal. It was admitted that none of the houses were dangerous or injurious to the health o f the public or of the inhabitants o f the neighbouring dwelling houses, so long as they were kept closed. I t appeared that Nos. 4 and 6, although vacated by the tenants, had not been in the strict sense of the words " k e p t closed," and No. 6 appeared to have been used by tramps or others without the consent of the owners. It did not appear that there had been any such occupation as had in fact rendered Nos. 4 and 6 dangerous or injurious to the health of the public or of the inhabitants of the neighbouring dwelling houses. At the meeting appointed for the further consideration o f the resolution on the 73th August, the matter was adjourned in order to enable the owners to make some proposals for remedying the condition of the houses, and subsequently a further adjournment was granted ; but ultimately the proposals made by the owners were not d e e m e d sufficient, and the respondents, by five separate orders, dated "the i 2 t h November, 1895 , ordered the demolition of all the five houses. Against these orders the owners now appealed to the Court of Quarter Sessions, on the ground that the Urban District Council had no jurisdiction to make the demolition orders, because the continuance of the houses was not dangerous or injurious to the health of the public, or of the inhabitants of the neIghbouring dwelling houses. T h e Court was of opinion that in order to give the local authority jurisdiction to make an order for demolition under section 33 of the Act, in respect of a dwelling-house which had been closed by an order of the magistrates made under section 3 z of the Act, the continuance o f the building nmst be dangerous or injurious to the health of the
I~{EDICAL C O U N C I L .
public, or of the inhabitants of the neighbouring dwelling houses, not only at the date of the resoh~tion to make the order for demolition, but also at the date of the making of the order for demolition. T h e Court held that in the case of No. 5 all the conditions required by section 33 (7) of the Act were in existence at the date of the passing of the resolution for demolition, at the date of the further consideration of the resolution, and at the date of the hearing of this appeal, and that the respondent local authority was therefore right in making the order for demolition as regards that house. As regards Nos. 2, 3, 4, and 6, the Court held that as these houses had been closed before the date of the demolition orders, and it being admitted that so long as they were kept closed their continuance was not dangerous or injurious to the health of the public, or of the inhabitants of the neighbouring dwelling houses, the demolition orders must be quashed. Abridged from the report given in 60, ~usYice of the .Peace, P. ~34. H.T,
S U M M A R Y C O N C L U S I O N S O F T H E COMMITTEE OF GENERAL MEDICAL COUNC I L ON E X A M I N A T I O N S I N S A N I T A R Y SCIENCE. L WE find it necessary to call the attention of some of the Licensing Bodies to the Instruction of the Council (_/Vfinutes, Vol. XXX. p. I4) to the effect that every candidate on whom a diploma or certificate is conferred should give evidence " o f a distinctly high proficiency, scientific and practical, in each and all the branches of study which concern Public Health "; and we are of opinion that this instruction should admit of no exceptions, whether on account of the seniority of the candidates or by way of allowing excellence in one subject to compensate for failure in another. 2. We consider it a matter of primary importance that each candidate should give indication of competency as the result of an oral examination, especially in such matters as concern Practical Epidemiology and the duties of a medical officer of health. 3. Whilst we are not prepared to advocate a uniform standard for the several examinations, we are of opinion that they should all be regarded as partaking of the character of an Honours Examination. 4. We are of opinion that where the examination is conducted in two parts, no candidate should be allowed to present himself iia .Part II. until he has passed in Part I. A n d we are further of opinion that failure in any one subject in either Part ought to entail rejection in the whole of that Part.
REVIEW. ~. W e entirely e n d o r s e t h e o p i n i o n t h a t Practical Bacteriology s h o u l d form a d i s t i n c t part of e v e r y e x a m i n a t i o n for a d i p l o m a or certificate in P u b l i c Health. 6. W e also c o n s i d e r t h a t practical e x a m i n a t i o n in the o u t - d o o r work of t h e m e d i c a l officer o f health, i n c l u d i n g a test of ability properly to interpret plans, s h o u l d form part of every e x a m i n ation qualifying for a d i p l o m a or certificate i n Public H e a l t h . 7. W h i l s t we a t t a c h great i m p o r t a n c e to t h e possession by every successful c a n d i d a t e of distinctive c o m p e t e n c y in relation to t h e cIinical aspects of the infectious diseases, a n d to t h e Wholes o m e n e s s of carcases as food-supplies, we are n o t at p r e s e n t p r e p a r e d to say t h a t p r a c t i c a l e x a m i n ation in t h e s e m a t t e r s s h o u l d in every case necessarily form part of t h e e x a m i n a t i o n .
THE
ETIOLOGY
OF POST-SCARLATINAL
AND POST-MORBILLARY
DIPHTHERIA.
AT t h e m e e t i n g of t h e E p i d e m i o l o g i c a l Society, o n F e b r u a r y 2 i s t , Dr. G o o d a l l r e a d a careful p a p e r on this subject. S u c h cases, h e stated, o c c u r r e d mostly a m o n g p a t i e n t s who have b e e n some t i m e in h o s p i t a l ; the age i n c i d e n c e is t h e s a m e as t h a t of d i p h t h e r i a , b u t t h e fatality is m u c h g r e a t e r . T h e r e is n o p r o p o r t i o n b e t w e e n t h e n u m b e r o f these cases arid t h e n u m b e r o f d i p h t h e r i a cases a d m i t t e d as such. This appears to eliminate, except in rare i n s t a n c e s , t h e a g e n c y of t h e n u r s i n g staff in s p r e a d i n g t h e disease. N o r is t h e origin of these cases in t h e c o n c e n t r a t i o n of severe cases c a u s e d b y t h e early r e m o v a l of c o n v a l e s c e n t s supp o r t e d by s t a t i s t i c s . By a process of exclusion, Dr. G o o d a l l t h u s arrives at t h e c o n c l u s i o n t h a t d i p h t h e r i a was i n t r o d u c e d into t h e hospitals b y the scarlet fever a n d measles p a t i e n t s t h e m s e l v e s in u n r e c o g n i s e d forms, T h e majority of cases of original scarlatina were s h o w n by t h e bacteriological test to b e n o n - d i p h t h e r i t i c , b u t t h e t r u e d i p h t h e r i a bacilli were p r e s e n t in a c e r t a i n n u m b e r of cases of scarlatina a n d measles. T h e cases o f s c a r l a t i n a in w h i c h d i p h t h e r i a bacitii were f o u n d were mostly of a m i l d type, the m i x e d c h a r a c t e r of which c o u l d not h a v e b e e n r e c o g n i s e d by s i m p l e clinical observation. F r o m ~892 to 1894 , 83 cases o f measles were a d m i t t e d into t h e E a s t e r n H o s p i t a l . I n 17, or 20'4 per cent., of t h e s e t h e d i p h t h e r i a bacillus was f o u n d , a n d atso in 9 of i o o cases of me~/sles o c c u r r i n g a m o n g s t t h e scarlatinal patients. T h e c o m b i n a t i o n of measles with d i p h t h e r i a was ext r e m e l y fatal, 23 o u t of t h e s e 26 cases h a v i n g d i e d . P e r h a p s ~;he m o s t i n t e r e s t i n g part o f D r . G o o d a l l ' s p a p e r was t h a t in w h i c h h e showed', by r e f e r e n c e to statistics, t h a t t h e p r e v a l e n c e of post-scarlatinal d i p h t h e r i a i n hospitals closely followed t h a t o f t h e
~47
p r i m a r y fever, a n d t h a t its i n c i d e n c e a m o n g scarlatinal c h i l d r e n was n o t materially greater t h a n a m o n g t h e c h i l d r e n o f like ages in L o n d o n generally.
REVIEW. The Theory and Practice of Hygiene. By J. LANE NOT'FEE, M.A., M.D., and R. H. FIRT~t, F.R.C.S. London. (J. and A. Churchill, 7, Great Marlborough Street, I896.)
A zV'ezv ~ex~-Zlook on Ifygiene.
The tong-familiar names of Parkas and De Chaumont have disappeared from the title-page of our standard textbook of hygiene, which has now been issued in a re-arranged and somewhat enlarged form by Notter and Firth. 'lhe arrangement of the new volume is excellent, and, full as it is of matter, the matter has been so put as to be easily grasped and assimilated. The mind of a n average man is very llke his digestion, requiring a certain amount of bulk in its food to do the best work. There is in these days a tendency to reduce text-books to such a limit as to make them hardly readable by anyone who is not weI1 up in his subject. The book before us, however, is readable throughoutD and strikes a happy mean between the elementary and the abstruse; for whilst on the one hand it is by no means an elementary text-book for the nse of schools, there are very few places in which the class of readers for whom it is intended will find any difficulty in following the authors. It is, of course, primarily a text-book, written by educationalists, for the public health examinations, hut it wid be a useful volume in the reference library of a medical officer of health, or of an army medical officer. In this respect, perhaps the most useful addition is the bibliography at the end of each chapter. It is a common experience for a medical officer of health, when he meets with a dif~culty in his work, to look up the point in whatever books he possesses, and to find that whilst the writers go all round the question, they do not give him the information which he specially requires. It is then a matter of great convenience to have a handy bibliography of all the special works on the particular branch of sanitary or other science to guide him in hts selection of volumes from a medical library. In our opinion, the best chapters in the book are those on Water~ A~r, Ventilation and Heating. Food (except the part dealing with diseases of cattle and meat inspection), Parasites, Climate, Meteorology,Vital Statistics, Offensive Trades, and Sanitary Law. In the chapter on Sewage, the authors commence by stating that " t h e teim ' sewage ' is here used in its widest sense, and is meant to include the solid and liquid excreta of men and animals ; the refuse from houses (dustp ashes, etc.), and the waste waters from sinks and lavatories ; the liquid and solid refuse from stables, cowsheds, and slaughter-houses; the waste waters used for trade purposes, and the sweepings of streets and alleys." On the same page, however, they give analyses of j" sewage" which certainly do not include dust, ashes, street sweepings, or solid refuse generally, except excreta. The disposal of street sweepings and dustbin refuse appears to be omitted altogether, and we have found no reference to any form of destructor or incinerator, though this is a subject on which medical officers of health are required to give opinions, and queshons on it are sometimes asked in public health examinations. In the chapter on Disinfection, the authors have done excellent work in bringing out the scientific basis or chemical and physical side of the various questions deak with, but they have not clearly shown the t~ifferent actions of superheated steam, and steam under pro.sure. This is a most important point in the choice of a disimector, as Esmareh's investigations have demonstrated the fact that the valuable aid ot latent heat is to a great extent lost, and. consequently the most resistant spores are not always killedj when superheated steam is used~as it is very commonly in this country, but not so much on the Continent, where the
SUMMARY
CONCLUSIONS
OF GENERAL
same number of inhabitants as when the closing order was made, and the order not having been determined by any sub'sequent order, the respondent Urban District Council, being of opinion that the houses had not been rendered fit for human habitation, and that the necessary steps were not being taken with all due diligence to render them so fit, and that the continuance of the said premises was dangerous or injurious to the health of the public or of the inhabitants of the neighbouring dwelling houses, passed a resolution under section 33 of the Act that it was expedient to order the demolition of the said houses. Notice of this resolution, dated the 27th July, 7895 , was duly served upon the appellants, in accordance with section 33 (2) of the Act, and the respondents thereby appointed the 73th of August following for the further consideration of the resolution. During July a]l the houses except No. 5 were vacated, proceedings having been taken for that purpose against the tenants by the respondents, but No. 5 was still occupied at the date o f the hearing ot this appeal. It was admitted that none of the houses were dangerous or injurious to the health o f the public or of the inhabitants o f the neighbouring dwelling houses, so long as they were kept closed. I t appeared that Nos. 4 and 6, although vacated by the tenants, had not been in the strict sense of the words " k e p t closed," and No. 6 appeared to have been used by tramps or others without the consent of the owners. It did not appear that there had been any such occupation as had in fact rendered Nos. 4 and 6 dangerous or injurious to the health of the public or of the inhabitants of the neighbouring dwelling houses. At the meeting appointed for the further consideration o f the resolution on the 73th August, the matter was adjourned in order to enable the owners to make some proposals for remedying the condition of the houses, and subsequently a further adjournment was granted ; but ultimately the proposals made by the owners were not d e e m e d sufficient, and the respondents, by five separate orders, dated "the i 2 t h November, 1895 , ordered the demolition of all the five houses. Against these orders the owners now appealed to the Court of Quarter Sessions, on the ground that the Urban District Council had no jurisdiction to make the demolition orders, because the continuance of the houses was not dangerous or injurious to the health of the public, or of the inhabitants of the neIghbouring dwelling houses. T h e Court was of opinion that in order to give the local authority jurisdiction to make an order for demolition under section 33 of the Act, in respect of a dwelling-house which had been closed by an order of the magistrates made under section 3 z of the Act, the continuance o f the building nmst be dangerous or injurious to the health of the
I~{EDICAL C O U N C I L .
public, or of the inhabitants of the neighbouring dwelling houses, not only at the date of the resoh~tion to make the order for demolition, but also at the date of the making of the order for demolition. T h e Court held that in the case of No. 5 all the conditions required by section 33 (7) of the Act were in existence at the date of the passing of the resolution for demolition, at the date of the further consideration of the resolution, and at the date of the hearing of this appeal, and that the respondent local authority was therefore right in making the order for demolition as regards that house. As regards Nos. 2, 3, 4, and 6, the Court held that as these houses had been closed before the date of the demolition orders, and it being admitted that so long as they were kept closed their continuance was not dangerous or injurious to the health of the public, or of the inhabitants of the neighbouring dwelling houses, the demolition orders must be quashed. Abridged from the report given in 60, ~usYice of the .Peace, P. ~34. H.T,
S U M M A R Y C O N C L U S I O N S O F T H E COMMITTEE OF GENERAL MEDICAL COUNC I L ON E X A M I N A T I O N S I N S A N I T A R Y SCIENCE. L WE find it necessary to call the attention of some of the Licensing Bodies to the Instruction of the Council (_/Vfinutes, Vol. XXX. p. I4) to the effect that every candidate on whom a diploma or certificate is conferred should give evidence " o f a distinctly high proficiency, scientific and practical, in each and all the branches of study which concern Public Health "; and we are of opinion that this instruction should admit of no exceptions, whether on account of the seniority of the candidates or by way of allowing excellence in one subject to compensate for failure in another. 2. We consider it a matter of primary importance that each candidate should give indication of competency as the result of an oral examination, especially in such matters as concern Practical Epidemiology and the duties of a medical officer of health. 3. Whilst we are not prepared to advocate a uniform standard for the several examinations, we are of opinion that they should all be regarded as partaking of the character of an Honours Examination. 4. We are of opinion that where the examination is conducted in two parts, no candidate should be allowed to present himself iia .Part II. until he has passed in Part I. A n d we are further of opinion that failure in any one subject in either Part ought to entail rejection in the whole of that Part.
REVIEW. ~. W e entirely e n d o r s e t h e o p i n i o n t h a t Practical Bacteriology s h o u l d form a d i s t i n c t part of e v e r y e x a m i n a t i o n for a d i p l o m a or certificate in P u b l i c Health. 6. W e also c o n s i d e r t h a t practical e x a m i n a t i o n in the o u t - d o o r work of t h e m e d i c a l officer o f health, i n c l u d i n g a test of ability properly to interpret plans, s h o u l d form part of every e x a m i n ation qualifying for a d i p l o m a or certificate i n Public H e a l t h . 7. W h i l s t we a t t a c h great i m p o r t a n c e to t h e possession by every successful c a n d i d a t e of distinctive c o m p e t e n c y in relation to t h e cIinical aspects of the infectious diseases, a n d to t h e Wholes o m e n e s s of carcases as food-supplies, we are n o t at p r e s e n t p r e p a r e d to say t h a t p r a c t i c a l e x a m i n ation in t h e s e m a t t e r s s h o u l d in every case necessarily form part of t h e e x a m i n a t i o n .
THE
ETIOLOGY
OF POST-SCARLATINAL
AND POST-MORBILLARY
DIPHTHERIA.
AT t h e m e e t i n g of t h e E p i d e m i o l o g i c a l Society, o n F e b r u a r y 2 i s t , Dr. G o o d a l l r e a d a careful p a p e r on this subject. S u c h cases, h e stated, o c c u r r e d mostly a m o n g p a t i e n t s who have b e e n some t i m e in h o s p i t a l ; the age i n c i d e n c e is t h e s a m e as t h a t of d i p h t h e r i a , b u t t h e fatality is m u c h g r e a t e r . T h e r e is n o p r o p o r t i o n b e t w e e n t h e n u m b e r o f these cases arid t h e n u m b e r o f d i p h t h e r i a cases a d m i t t e d as such. This appears to eliminate, except in rare i n s t a n c e s , t h e a g e n c y of t h e n u r s i n g staff in s p r e a d i n g t h e disease. N o r is t h e origin of these cases in t h e c o n c e n t r a t i o n of severe cases c a u s e d b y t h e early r e m o v a l of c o n v a l e s c e n t s supp o r t e d by s t a t i s t i c s . By a process of exclusion, Dr. G o o d a l l t h u s arrives at t h e c o n c l u s i o n t h a t d i p h t h e r i a was i n t r o d u c e d into t h e hospitals b y the scarlet fever a n d measles p a t i e n t s t h e m s e l v e s in u n r e c o g n i s e d forms, T h e majority of cases of original scarlatina were s h o w n by t h e bacteriological test to b e n o n - d i p h t h e r i t i c , b u t t h e t r u e d i p h t h e r i a bacilli were p r e s e n t in a c e r t a i n n u m b e r of cases of scarlatina a n d measles. T h e cases o f s c a r l a t i n a in w h i c h d i p h t h e r i a bacitii were f o u n d were mostly of a m i l d type, the m i x e d c h a r a c t e r of which c o u l d not h a v e b e e n r e c o g n i s e d by s i m p l e clinical observation. F r o m ~892 to 1894 , 83 cases o f measles were a d m i t t e d into t h e E a s t e r n H o s p i t a l . I n 17, or 20'4 per cent., of t h e s e t h e d i p h t h e r i a bacillus was f o u n d , a n d atso in 9 of i o o cases of me~/sles o c c u r r i n g a m o n g s t t h e scarlatinal patients. T h e c o m b i n a t i o n of measles with d i p h t h e r i a was ext r e m e l y fatal, 23 o u t of t h e s e 26 cases h a v i n g d i e d . P e r h a p s ~;he m o s t i n t e r e s t i n g part o f D r . G o o d a l l ' s p a p e r was t h a t in w h i c h h e showed', by r e f e r e n c e to statistics, t h a t t h e p r e v a l e n c e of post-scarlatinal d i p h t h e r i a i n hospitals closely followed t h a t o f t h e
~47
p r i m a r y fever, a n d t h a t its i n c i d e n c e a m o n g scarlatinal c h i l d r e n was n o t materially greater t h a n a m o n g t h e c h i l d r e n o f like ages in L o n d o n generally.
REVIEW. The Theory and Practice of Hygiene. By J. LANE NOT'FEE, M.A., M.D., and R. H. FIRT~t, F.R.C.S. London. (J. and A. Churchill, 7, Great Marlborough Street, I896.)
A zV'ezv ~ex~-Zlook on Ifygiene.
The tong-familiar names of Parkas and De Chaumont have disappeared from the title-page of our standard textbook of hygiene, which has now been issued in a re-arranged and somewhat enlarged form by Notter and Firth. 'lhe arrangement of the new volume is excellent, and, full as it is of matter, the matter has been so put as to be easily grasped and assimilated. The mind of a n average man is very llke his digestion, requiring a certain amount of bulk in its food to do the best work. There is in these days a tendency to reduce text-books to such a limit as to make them hardly readable by anyone who is not weI1 up in his subject. The book before us, however, is readable throughoutD and strikes a happy mean between the elementary and the abstruse; for whilst on the one hand it is by no means an elementary text-book for the nse of schools, there are very few places in which the class of readers for whom it is intended will find any difficulty in following the authors. It is, of course, primarily a text-book, written by educationalists, for the public health examinations, hut it wid be a useful volume in the reference library of a medical officer of health, or of an army medical officer. In this respect, perhaps the most useful addition is the bibliography at the end of each chapter. It is a common experience for a medical officer of health, when he meets with a dif~culty in his work, to look up the point in whatever books he possesses, and to find that whilst the writers go all round the question, they do not give him the information which he specially requires. It is then a matter of great convenience to have a handy bibliography of all the special works on the particular branch of sanitary or other science to guide him in hts selection of volumes from a medical library. In our opinion, the best chapters in the book are those on Water~ A~r, Ventilation and Heating. Food (except the part dealing with diseases of cattle and meat inspection), Parasites, Climate, Meteorology,Vital Statistics, Offensive Trades, and Sanitary Law. In the chapter on Sewage, the authors commence by stating that " t h e teim ' sewage ' is here used in its widest sense, and is meant to include the solid and liquid excreta of men and animals ; the refuse from houses (dustp ashes, etc.), and the waste waters from sinks and lavatories ; the liquid and solid refuse from stables, cowsheds, and slaughter-houses; the waste waters used for trade purposes, and the sweepings of streets and alleys." On the same page, however, they give analyses of j" sewage" which certainly do not include dust, ashes, street sweepings, or solid refuse generally, except excreta. The disposal of street sweepings and dustbin refuse appears to be omitted altogether, and we have found no reference to any form of destructor or incinerator, though this is a subject on which medical officers of health are required to give opinions, and queshons on it are sometimes asked in public health examinations. In the chapter on Disinfection, the authors have done excellent work in bringing out the scientific basis or chemical and physical side of the various questions deak with, but they have not clearly shown the t~ifferent actions of superheated steam, and steam under pro.sure. This is a most important point in the choice of a disimector, as Esmareh's investigations have demonstrated the fact that the valuable aid ot latent heat is to a great extent lost, and. consequently the most resistant spores are not always killedj when superheated steam is used~as it is very commonly in this country, but not so much on the Continent, where the