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Public Health, 

THE JOURNAL OF THE 

Incorporated Society of Medical Officers of Health. 



EDITED BY 

ARTHUR NEWSHOLME, M.D.Lond, 

MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS ; CERTIFICATE PUBLIC HEALTH, UNIV. LOND. 
MEDICAL OFFICER OF HEALTH FOR BRIGHTON. 




VOL. VIII. 
OCTOBER, 1895, TO SEPTEMBER, 1896. 



London : 
Published uy E. \V. ALLEN, Ave Maria Lane, Paternoster Row, E.G. 



LONDON: 
. H. AND L. COLUNGRIDGE, CITY PRESS, 
148 AND 149, AI.DERSGATB STREET, B.C. 



PREFACE 

TO VOL. VIII. 



WHEN a Periodical has been before the Profession and the Public for eight years, and 
during that time has been increasingly read and appreciated, it is not unreasonable 
to assume that there was some need for it originally, and that it effectually suppUes 
that need. Certainly it can be said of Public Health, the Official Organ of the IiKorporated 
Society of Medical Officers of Health, that it came into existence in response to a distinct 
demand, and that year after year it has met that demand well and adequately. 

The issue of eacK new Volume gives the President of the Society the opportunity of 
writing a few words of introduction, comment, or counsel. Availing myself of this privilege, I 
would point out that Public Health being so serviceable a Journal is largely due to its 
having a capable and independent Editor, whose good judgment can always be relied on. It 
may be taken for granted that all literary matter forwarded to him has been hitherto, and will 
be, fairly dealt with. Any improvement in the future, it seems to me, must depend upon the 
quality and representative character of the subject matter contributed. Let this be understood, 
and Itt all the Fellows of the Society personally realise the importance of bringing under the 
attention of the Editor all matters affecting Sanitation and the Public Health Service. Thus 
may our Journal be more and more informing as to what is taking place throughout this 
country and on the Continent, and an increasingly helpful record of progress, difficulties, 
suggestions, and reforms. 

FRANCIS VACHER, 

President of the Incorporated Society of Medical Officers of Health. 



INDEX 



VOL. VIII. 



Abattoir, New, at West Hartlepool ... ... ... 324 

Adulteration of Food 98, 99, 204, 205, 244, 321, 356, 

378, 382 
Adams, P. T., M.D., on the Slate as a Probable Means 
of Transmission of Diphtheria and other Diseases 
Among School Children ... ... ... ... 144 

Adams, M. A., F.R.C.S., F.I.C., M.O.H., Maidstone : 
On a Case of Typhoid Fever from Infection by 
Oysters ... ... ... ... ... ... 357 

Alford, H. J., M.D., M.O.H., Taunton, on a Twenty 
Years' Retrospect ... ... ... ... ... 66 

Alexander, F. W., M.D., M.O.H., Poplar and Bromley : 

On the Cause of Diphtheria ... 97 

Allan, F. J., M.D., F.R.S.E., M.O.H., Strand : 

On the Factory and Workshop Act, 1895 124 

,, Ice Cream... ... ... ... ... ... 256 

American Meat Inspection, Report of Committee ... 376 
Analytical Notes ... 56, 97, 143, 165, 201, 238, 242, 386 
Anti-Typhoid Serum ... ... . ... ... ... 285 

Anti-Cholera Inoculations... ... ... ... ... 92 

Anderson, Dr., M.O.H., Blackpool: 

On Food Inspection ... ... ... ... ... 150 

,, Inspection and Influence of Milk Supply ... 156 
,, Manufacture and Storage of Ice Cream 250, 256 
,, Ventilation of Sewers ... ... .. , ... 397 

Appointments 32, 64, 104, 144, 176, 208, 248, 288, 

322, 328, 360, 392, 424 
Artizans' Dwelhngs in Christiania ... ... ... 372 

Armstrong, H. E., D.Hy., M.O.H., Newcastle-on- 
Tyne : 

On Fixity of Tenure of M.O.H. ... 148,180,182 

Notes on Peculiarity of Type in Enteric Fever ... 166 
Ashley Down Sewage Works ... ... ... ... 299 

Ashby, Dr., on Fixity of Tenure of M.O.H. 149, 183, 184 
Ashton, Dr. A., M.O.H., Eccleshill : 

On Slipshod Sanitation ... ... ... ... 336 

,, The Sanitation of Public Elementary Schools 224 

Avernus, West End ... ... ... 194 

Aymard's Sterilizer .. ... ... ... 391 



B 

Bassenge, Dr., Marine Staff-Surgeon, on the Preparation 
of Sterile Drinking Water by Means of Chloride of 

Lime ... ... ... ... ... 47 

Barwise, S., M.D., M.O.H., Derbyshire : 

On Disinfection by Steam ... ... ... ... 196 

,, M.O.H. in Relation to PulMic Elementary 

Schools... ... ... ... ... ... 368 

,, Reduction of Death-Rate of Children and 

Ventilation of Schools ... ... ... 74 

,, Return Cases of Scarlet Fever 293 



PAGE 

Bartlett, Mr., on Isolation Hospital Accommoda- 
tion 165 

Barr, Dr., on the Prevention of Phthisis 305 

Bacteriological Diagnosis of Diphtheria ... I3» I5> 5^ 

,, Test of Diphtheria ... 405 

Bacteriology of the Bronchial and Mesenteric Glands ... 276 
,, of Common Catarrh... ... ... ... 276 

,, of Ice Cream... ... ... ... ... 252 

,, of Typhoid Fever ... ... ... ... 319 

,, of Vaccine Lymph ... ... ... ... 172 

,, of Vaccinia and Variola ... ... ... 273 

Bacterium Coli, Ubiquity of ... ... .. ... 390 

Bacilli, Inheritance of ... ... ... ... ... 31 

Bacilli in Market Milk 48 

Bacillus of Typhoid Fever, Detection of ... ... 285 

Bakehouses, Hygiene of ... ... ... ... ... 418 

„ Underground... ... ... 390 

BerHn Night Shelter 55 

Belgium, Registration of Cattle in ... ... ... 395 

Birth-Rates 143 

Birdwood, Dr., Med, Supt. N.E. Hospital, on the 
Relationship between Diphtheria Bacterioscopically 
Diagnosed and Clinical Diphtheria ... ... ... 403 

Blackfriars Salvation Army Shelter ... ... ... 388 

Boobbyer, P., M.B., M.O.H., Nottingham : 

On Cancer ... ... ... ... ... ... 27 

,, Return Cases of Scarlet Fever ... ... 290, 293 

Boston: Method of Dealing with Tuberculou.s Cattle ... 135 
,, Medical Inspection of Schools ... ... .. 136 

,, Prevention of Diphtheria in ... ... ... 142 

Books, Infection by ... ... ... ... ... 190 

Bond, F. T., M.D., B.A., F.R.S.E., M.O.H., 
Gloucestershire, on Fifteen Reasons for Believing in 

the Efficacy of Vaccination ... 271 

Bond, C. Hubert, M.D., &c., on the Suitability of Chalk 
Lands for the Disposal of Sewage ... ... ... 310 

Bond, W. A., M.D., M.O.H., Holborn, on the Holbom 

Meat Market 385 

Bradford : Outbreak of Scarlet Fever, due to Infected 

Milk 138 

,, Refusal to Renew License of Inn owing to 

Alteration of Premises for Sanitary Im- 
provement ... ... ... ... ... 60 

Bristol Slaughter- Houses ... ... i6c 

Brown, Dr., M.O.H., Stapleton, on an Outbreak of 
Diphtheria at Stapleton ... ... ... ... 249 

Bread and Beer, Penalty for Selling Bad 289 

Bread and Flour, Hygiene of ... ... 414 

Brook Hospital ... ... ... 40S 

Browning, B., M.D., M.O.H., Weymouth, on a Local 
Outbreak of Enteric Fever and its Lessons to Rural 

and Urban Authorities ... 112 

Buchanan, the late Sir George ... ... ... ... 46. 

Burman, Dr., on Sewage and Sewage-Grown Products 
and their EfTects on Animals ... ... ... ... 74 

Building Bye-Laws 24 



VI 



Index. 



Cameron, J. Spottiswoode, M.D,, B.Sc, M.O.H., 
Leeds, on the Destruction of Town Refuse by 

Heat 49 

Cattle Registration in Belgium 395 

Cape Town, Annual Report of M.O.H. 241 

Carbides, Recent Research on ... ... 327 

Cameron, R. W. D. M., M.D., D.Sc, M.O.H. 
Kirkcudbright and Wigtown, on High Farming and 

Disease, a Rural Outbreak of Diphtheria 406 

Certification of Cause of Death 389 

Census of London, 1896 ... ... ... 195 

,, French ... ... ... ... ... ... 326 

Chapin, Dr. C. V., Providence, U.S.A. : 

On the Etiology and Prevention of Scarlet Fever... 58 
,, the Supposed Etiology of Diphtheria ... ... 57 

Cheshire County Council, Re-appointment of M.O.H. 74 
Christiania, Artizans' Dwellings in ... ... ... 372 

Cholera Inoculation ... ... ... ... ... 92 

Chalk Lands and Sewage Disposal ... ... .. 310 

Clyde, Pollution of. 412 

Cleanliness of the Lower Working Classes ... 83 

Closing Order ... ... ... 26 

Climate and Health 129 

Closet Accommodation and Infantile Diarrhrea ... 287 

Cj:lon Industry and Health of the Operatives ... ... 218 

Collins, Dr , on Tenure of Office of M.O.H 184 

Cook, J. N., M.R.C.S., D.P.H., M.O.H., Madras: 

On the Bacieri'ilogy of Ice Cream ... ... ... 252 

„ Fibrinous Rhinitis or Diphtheria ... ... 217 

Coppered Peas ... 321, 378 

Columbia, Enteric Fever at ... ... ... ... 317 

Copeman, S. M., M.A., M.D., M.R.C.P., L H., on 

the Bacteriology of Vaccinia and Variola 273 

Cotterell, A. P. I., A.M.I.C.E., on the Principles of 

Sewage Disposal... ... 294 

Connecticut, Outbreak of Enteric Fever due to Sewage- 
Contaminated Oysters ... ... ... ... 350 

Correspondence : 

Aerial Convection of Small-pox (Dr. R. Dud- 
field) 104 

Disinfection by Steam (Dr. S. Barwise) ... ... 287 

Disinfection by Steam (Washington Lyon)... ... 287 

Enteric Fever and the Pail System (Dr. J. 

Robertson) ... ... ... ... 63 

Fixity of Tenure (Dr. II. May) 207 

Measles (Dr L. Newton) ... ... ... ... 207 

Quarantine Regulations at Mauritius (J. T. 

Clarke) 63 

Resignation of Dr. Armstrong, M.O.H., River 

Tyne P.S.A 63 

The Slate as a Means of Transmission of Diph- 
theria and other Diseases among School Children 

(Dr. P. T. Adams) 144 

Crime, Prevention of ... ... ... ... 286 

Croydon Isolation Hospital 28 

Crocker, J. H., .M.D., D.S.Sc, M.O.H., F.ccles, on 
Water Closets for Cottage Property ... I<S 



131 



D 

Darwinism and the Medical Profession ... 
Davies, D. S., >T.D.. .M.O.H., Bristol: 

On the Bacteriological Diagnosi- of Diphtheria 13, 52 
,, ,, Supposed Etiology of Diphtheria ... ... 24 

,, Tenure of Office of M.O.H iSi 



Davies, S., M.A., M.D., M.O.H., Plumstead : 

On an Epidemic of Enteric Fever at Plum- 

steail ... ... ... ... ... ... 119 

,, Fibrinous Rhinitis or Diphtheria 217 

Death-Rate among Children ... ... ... ... 74 

Death, Certification of Cause of ... ... ... ... 389 

Destructor, New ... ... ... ... ... ... 193 

Diarrhiua and Earth Temperature ... ... ... 138 

,, in Glasgow ... ... ... ... ...:;i5 

,, Infantile, and Closet Accommodation ... 2S7 

Diphtheria, Antitoxin Treatment of ... ... ... 345 

,, at Aston Manor ... ... ... •■• IS9 

,, in Birmingham ... ... ... ... 342 

,, at Boston, Prevention of ... ... ... 142 

,, Bacteriological Diagnosis of... ... 13,15,52 

,, Bacteriol gical Diagnosis and Clinical 

Diphtheria... ... 403 

,, Bacterioscopic Test of ... ... ... 405 

,, ami Climatic Conditions ... ... ... 349 

Etiology of 24, 57, 96, 320, 348, 404 

,, Duration of Infectivity of ... ... ... 321 

,, Endemic Character ... ... ... ... 348 

,, and Foul Dust Bins ... ... ... ... 348 

,, or Fibrinous Rhinitis ... ... 211 

,, (Fowl) and Public Healtli 95 

,, at Flint 103 

,, in Gla.sgow ... ... ... ... ... 340 

,, in London ... ... ... ... 338 

,, Mediate Infection in... ... ... ... 423 

,, Means of Minimising Incidence of... ... 345 

,, Notes on the Origin of ... ... ... 344 

,, Postscarlatinal ... ... 402 

Post Morbillary ... 247 

,, Rural Outbreak ... ... ... ... 406 

,, Relation to Insanitary Conditions ... ... 4 

,, in Scotland ... ... ... ... ... 30 

,, at Stapleton ... ... ... 249 

,, and School Attendance ... ... 338, 349 

., and Surface Sewer Ventilators ... ... 348 

,, Spontaneous Origin ... ... ... ... 348 

and Wet Weather 348 

Dibdin, Mr., Chemist to L.C.C., on Microscopical 
Examination of Water ... ... ... ... ... 279 

Disease and High Farming ... ... ... ... 406 

Disinfecting Apparatus, New ... ... ... ... 23 

Disinfection by Steam ... ... ... 196 

„ after I'hthi.sis 326 

Disease and Insanitary Conditions ... ... ... 115 

,, and the Weather 45 

Diseased Meat ... ... .. ... ... ... 206 

Dowson, W., M.D., Asst. M.O.H., Bristol : 

On the Bacterioscopical Test of Diphtheria ... 405 

,, the Bacteriological Diagnosis of Diphtheria ... 15 
,, Fibrinous Rhinites of Diphtheria ... ... 217 

Driier, Dr., Asst. at Hygienic Inst, of Konigsberg, on 

the Self Purification of Rive-s ... ... 48 

Drain or .^ewer ... -"5,99 '75. 352. 35 ). 4i9. 42i 

Drains or Fungi ... ... ... ... ... ... 326 

Dry Ash and Contents of Pail Closets, Treatment of ... 193 

Dublin Isol.ation Hospitals ... ... 286 

Dust, Infectivity of 199 

Duration of Life of the Jew 308 

DudliHd, R., M.D., M.O.H., P.addington : 

On the Aerial Convection of Small-pox 104 

,, Fixity of Tenure of M.O.H 149, 185 

,, Ice Cream... ... 256 

,, Low English Birth Rates 143 

,, the Metropolitan Water Supply 4I 

Dudheld, T. O., M.D., M.O.ll.. Kensington : 

On Antitoxm Treatment of Diphtheria 345 

,, the Exjiosure of Infected Persons 139 

,, the Metropolitan Water Supply 40 

,, the Removal of Offensive Matter 102 

., the .Significance of the Zymotic Death-rate ... 11 
,, Tenure of Office of M.O.H 88.184 



Index. 



Vll 



E PAGE 

Earth Temperature and Summer Diarrhcea ... ... 138 

Enteric Fever, Anti-Typhoid Serum ... 285 

Enteric Fever, Bacteriology of 318 

,, Bacillus, Detection of ... ... ... 285 

,, Dust Borne ... ... ... ... 27 

,, Due to Contaminated Water Supply ... 46 

,, and Discharge of Steam into Sewers ... 143 

,, and Diarrhcea ... ... ... ... 423 

,, Etiology of ... ... ... ... 170 

,, in Glasgow, Diminution of ... ... 315 

,, Hospital, Isolation of ... ... ... 358 

,, and Intrauterine Infection ... ... 175 

,, and Laryngeal Complications ... ... 285 

,, in Llangyfelach Rural vSanitary District 282 

„ atLoddon... ... ... ... ... 103 

,, Midden Generated ... ... ... 26 

,, in Murich ... ... ... ... ... 176 

,, and Oysters 9.349.357 

,, at Plumstead ... ... ... ... 119 

,, Peculiarity of Type .. ... ... 166 

,, at Rennes ... ... ... 146 

,, at Sheffield 142 

,, at Sydney 135 

,, Among Swine ... ... ... ... 384 

,, and Thames Water after Flood... ... 102 

,, at Weymouth ... ... ... ... 112 

,, at West Bromwich •■•'57 

,, in Washington and Columbia ... ... 317 

Epidemics, Prevention of 35 

Epping, Failure to Close Polluted Well 61 

Erysipelas and Puerperal Fever 186 

Evans, W. A., M.D., M.O.H., Bradford : 

On Enteric Fever and Discharge of Steam into 

Sewers ... ... ... ... ... ... 143 

,, the Initial Rashes of Small-Po.x 21 

„ an Outbreak of Scarlet Fever Due to Infected 

Milk 138 

Exposure of Infected Persons 139 

,, of Unwholesome Meat 378 



F 

Farming and .Disease 406 

Factory and Workshops' Act, 1895 ... 124 

Factory and Workshop Sanitation ... 228 

Fibrinous Rhinitis or Diphtheria ... ... 211 

Field, O., M.D., D.P.H., M.O.H., Clapham, on 

Notification of Sickness... ... ... 108 

Finchley Sewage Farm ... ... ... 411 

Fixity of Tenure of M.O.H. 88, 148, 161, 162, 176, 

17S, 185, 186, 188, 189, 190, 226 
Fixity of Tenure of M.O.H., Case for Opinion of 

Counsel ... ... ... ... ... ... ... 258 

Fixity of Tenure of M.O.H. , Letter from Dr. Seaton... 163 
Flour and Bread, Hygiene of ... ... ... ... 414 

Fowl Diphtheria and Public Health 95 

Food Analysis ... ... ... ... ... ... 238 

Food Adulteration 98, 99, 204, 205, 244, 321, 356, 

378, 382 
Food Inspection ... ... ... ... .., ... 150 

Fosbrooke, Dr., D.P.H., on the Relation of the 

M.O.H. to Public Elementary Schools 369 

Frost, Fog, and Lung Diseases ... ... .. ...317 

French Census ... ... ... ... ... ... 326 



Garrett, J. PL, M.D., D.P.H., M.O.H., Cheltenham : 

On the Hospital Isolation of Enteric Fever ... 358 

Germany, Compulsory Vaccination in 240 

Gipsies ... ... ... 141 

Gibbon, Dr. S., late M.O.H., Holborn, on the Metro- 
politan Water Supply ... ... ... 40 

Glamorganshire Water Supply ... 6 

Gloucester, Small-pox in ... ... ... 271 

Glasgow Public Health Administration 314 

Glasgow, Diphtheria in ... 340 

Goodall, Dr. E. W., Med. Supt. Eastern Hospital : 

On Post-Scarlatinal Diphtheria 402 

,, the Etiology of Post-Scarlatinal and Post- 

Morbillary Diphtheria ... ... ... 247 

Great Britain, Leprosy in ... ... ... ... ... 129 

Gregory, Dr., Cape Colony, on the Supposed Etiology 

of Diphtheria ... .. ... ... 57 

Groves, J. B. A., M.B., M.O.H., Isle of Wight Rural : 
On the Co-operation of Health Officers, and on 

Water Supply from the Chalk 109 

,, Fibrinous Rhinitis or Diphtheria 217 

,, Ice Cream... ... ... ... ... ... 256 

,, the Limits of Chemical Analysis of Water ... 143 

,, Tenure of Office of M.O.H 181,185 

Graham, W., M.D., M.Ch., M.O.H., Middleton : 

On the Duties of the M.O.H. with regard to the 

Smoke Nuisance ... ... ... ... 329 

,, the Inspection and Influence of Milk SuppHes 156 
Gwinn, Dr., M.O.H., Hampstead, on the Metropolitan 
Water Supply 41 



H 

Harris, Dri, M.O.H., Islington, on the Metropolitan 

Water Supply 41 

Haft'kine, Dr., on Anti-Cholera Inoculation ... 92 

Hamilton, J. L., M.R.C.S., on Fowl Diphtheria and 



Public Health 



95 



Haworth, Dr., on the Duties of the M.O.H. with 

regard to Puerperal Fever and Erysipilas 188 

Hamburg Port Sanitary Regulations , 323 

Health Officers, Co-operation of ... ... ... .. 109 

Heaven, J. C, L.R.C.P., D.Ph., Asst. M.O.H., 
Bristol, and M.O.H., Keynsham : 

On Fibrinous Rhinitis ur Diphtheria ... ... 211 

,, Slaughter House Difficulties in Rural Districts 380 
Herron, J., M.D., M.O.H., St. Saviour's, Southwark, 
on a Coppered Pea Case ... ... ... ... 378 

Hill, A., M.D., M.O.H., Birmingham : 

On Diphtheria in Birmingham ... 342 

,, the Epidemic of Small-pox in Birmingham ... 5 
,, the Relation of the M.O.H. to Public Elemen- 
tary Schools ... ... ... 368 

,, Return Cases of Scarlet Fever ... ... ... 292 

,, Small-pox Experience in Birmingham ... ... 413 

,, a School Outbreak of Diphtheria at Aston 

Manor ... ... ... .. 160 

Hill, E., M.D., M.O.H., Durham : 

On Dust Borne Enteric Fever 27 

,, Isolation Hospital Accommodation ... ... 165 

,, the .Supposed Etiology of Diphtheria ... .. 57 

,, Tenure of Office of M.O.H 183, 185 

Hill, Professor Bostock : 

On Fixity of Tenure of M.O.H., 148, 149, 180, 182, 184 

,, Return Cases of Scarlet Fever 293 

,, Typhoid Fever at West Bromwich ... ... 157 

Higgins, Dr., on Sewage and Sewage Grown Products 74 
Hospital Accommodation in London ... ... ... 60 

, , , , for Cases of Measles . . ... 286 

,, Isolation of Enteric Fever 358 



VllI 



Index. 



Hoist, A., Professor of Hygiene, on an Investigation 

of the Artizans Dwellings in Christiania 
Hoffman, Dr. : 

On the Density of Population and Mortality 

„ Duration of Life of the Jews 

Holbom, Diseased Meat at ... 

,, Meat Market 

Housing of the Working Classes Act — Demolition 
House Refuse Removal by Contractors ... 

Homerton, Food Poisoning at 

HoUinshead, Dr., on the Relation of the M.O.H. to 

Public Elementar)- Schools 
Hygiene of Bakehouses ... 

,, of Flour and Bread ... 



I 



Ice Cream Manufacture and Storage 

,, Bacteriology of 

Illegitimacy 

Improvement Schemes, Problem of re-Housing Persons 

Displaced 

Infantile Diarrhoea and Closet Accommodation 
Insanitary Conditions and Disease 

Infected Persons, Exposure of 

Infection by Books 

Infectious Diseases and Libraries . 

,, Disease, Failure to Notify 

,, ,, Plea of Ignorance ... 

,. Diseases, Hospital Bedding 

,, ,, ,, in Dublin ... 

,, ,, ,. in Glasgow 

„ ,, ,, Nuisance from 

,, ,, , Negligence 

Inoculations 

„ Preventive 

Inoculation of Cattle with Tuljerculosis 

Ireland, Excessive Mortality from Phthisis in ... 
Iiolation Hospital Accommodation 

,, Hospitals' Act, 1893 

,, Hospital, Croydon 

,, Hospitals on Chalk Strata 

„ ,, for Rural Districts ... 



372 

92 
30S 
206 

385 
245 
314 
357 

368 
418 
414 



250 
252 
326 

102 
2S7 
IIS 
139 
190 
202 
324 
423 
•57 
286 

315 
172 

244 
171 
261 

305 
10 
164 
128 
28 
128 
300 



Jacks<3n, M., M.D., on a School Outbreak of Diph- 
theria at Aston Manor 

Jcnner Centenary Memorial 

Jews, Duration of Life among 

Jones. H, C, Esq., Hon. Solicitor, Candidate for 

Clerk to L.C.C 

Jones, H., D.P.H., M.O.H. , Crewe : 

On the Duties of the M.O.H. with regard t" 
Puerperal Fever and Erysipelas 
„ Food Inspection .. 
,, the Inspection and Influence of Milk Supplies 

,, the Prevention of Phthisis 

,, Slop Closets 
Jordan, J. W., M.O.H., Heaton Norris, on Return 

Cases of Scarlet Fever ... 

Jiirgensen, Herr Dr. aus Kopenhagen, on the Hygiene 
of Bakehouses 



160 
360 
308 

106 



188 

»5* 

156 

3"5 
362 

349 
418 



Kaye, J.R., M.D., M.O.II., Huddersfield : 
On Stillborn Children 
,, Sewage and Sewage-grown Products and their 
Effects on Animals 
Kanthack, Dr. A. A., on the Ubiquity of the Bacterium 

Coli 

Kenwood, H., M.B., D.P.H., M.O.H., Stoke 
Newington : 

On Fixity of Tenure of M.O.II 

„ the Finchley Sewage Farm 
,, the Origin of Diphtheria 
Kelly, Dr., M.O.H., West Sussex, on Tenure of Office 

of M.O.H 

Kempster, Dr., M.O.H. Battersea : 
On Ice Cream ... 

„ Tenure of Office of M.O.H 

Kjennerid, Dr. Ingjald, Norway, on the Hygiene of 

Flour and Bread .. 

Klein, Dr. : 

On the Bacteriology of Vaccine Lymph 

Investigations of the Etiology of Enteric Fever ... 
On Protective Inoculations ... 
Knackers, Licensing and Regulations of... 
Kossel, Dr., on Tuberculosis in Early Childhood 
Korosi, M.J., Director of Municipal Bureau of 
Statistics in Budapest : 
A Study of the Laws of Increase of Population 



58 
74 



390 



149 

411 
344 

180 

256 
184 

414 

172 
70 

171 
280 
370 



Law, J., Esq., Cornell University of New York : 

Special Investigation of Bovine Tuberculosis on 

behalf of the State of New York 131 

Laberge, Dr. L., Montreal, on Scarlet Fever in 

Montreal ... ... 144 

Lancashire and Isolation Hospital Act, 1893 ... ... 128 

Lanark. Diphtheria at ... ... ... .. ... 348 

Lake, W. W., D.P.H., M.O.II., Guildford, on the 

Means of Mmimising the Incidence of Diphtheria ... 345 
Law Reports : 

Attorney-General v. Stone and Others (Gipsies) ... 14I 
Attorney-General v. The Guildford, Godalming, 
and Woking Joint Hospital Board (Nuisance 
from Infectious Diseases Hospital) ... ... 17* 

Beckenham Rural District Council v. Wood and 

Another (Drain or Sewer)... ... 421 

Borrow f. Rowland (Removal of Refuse) 355 

Badley v. Cucktield Union Rural District Council 
(Building Bye-laws) ... ... ... ... 24 

British Insul.ited Wire Company v. Prescott Urban 

District Council (Contract) 99i 1°° 

Cook V. White (Sale of Food and Drugs Act) ... 244 

CoUman v. Roberts (Shop Hours Act) =43 

Fortune v. Hanson (Sale of Food and Drugs Act)... 204 
Florence v. Paddington Vestry (Drain or Sewer) ... 175 
Hewitt V. Taylor (Sale of Food and Drugs Act) ... 205 

Hides V. Littlejohn (Slaughter-house) 203 

Ker.^hawf. Taylor (Sewer or Drain) ... 25, 99 

Keegan v. Mayor and Corporation of Birmingham 

(Infectious Diseases Hospital) 244 

Kyffin »•. East London Water Company (Constant 

Supply) 243 

Moore v. Pcarce's Dining and Refreshment Rooms, 

Limited (Adulteration of Food, Margarine Act) 98 
The Queen v. Slade, Ex-partt Saunders (Closing 

Order) 26 

Keg. V. Vestry of Bethnal Green (Sewer or Drain) 419 



Itidex. 



IX 



1 ,a\v Reports — continued : 

K^SL- "■ ^ estry of Betlinal Green (Sewer or Drain, 
Mandamus I o Compel Repair) ... ... ... 353 

Reg. *. vSmith and Kerr (Sale of Milk) 356 

Reg. V. Tynemouth Rural District Council (New 
Building) ... ... ... ... .. 383 

Smith and Others v. King's Norton Rural District 
Council (Sewer Ventilator — Death from Bloid 
Poisoning) ... ... ... ... ... .. 420 

Spiers and Pond v. Bennett (Sale of Food and 

Drugs Act) 382 

Sale of Preserved Peas Coloured with Sulph. of 

Copper 321 

Toler V. Bishop (Adulterated Food, Margarine Act) 99 
Thompson and Novis Manufacturing Co. v. Hawes 
(Nuisance, Recovery of Expenses from Owner by 
Occupier) ... ... ... ... ... ... 174 

Vestry of Fulham v. Solomon (Notice to Alter 
Water-Closet) ... ... ... ... ... 205 

Vale and Another v. Southall Norwood Urban 
District Council (Housing of the Working Classes 

Act) 245 

Vestry of St. Leonard's, Shoreditch, v. Phelan 
(Sewer or Drain) ... ... ... ... ... 352 

Legge, Dr. T. M. : 

Book on Public Health in European Capitals ... 39 
On Notification of Sickness ... ... ... ... io8 

Leprosy in Great Britain ... ... ... 129 

Littlejohn, H., M.D., M.O.H., Sheffield: 

On Enteric Fever in Sheffield ... ... ... 142 

,, Slipshod Sanitation ... .. ... ... 336 

,, Tenure of Ofiice of M.O.H 183, 185 

Livingstone, Dr., Chairman of Health Committee, 
County of Durham, on Isolation Hospital Accom- 
modation ... ... ... ... ... ... 164 

Llangyfelach Rural Sanitary District, Enteric Fever at 282 
Local Government, Scotland, Act ... ... ... 29 

Local Government Board : 

Annual Report ... ... ... ... ... 237 

Medical Department and Measles ... ... ... 37c 

Report of Medical Department ... ... ... 103 

Scientific Investigations on the Etiology of Enteric 
Fever ... ... ... ... ... ... 170 

Scientific Investigations on the Chemical Pathology 
of Tetanus ... ... ... ... ... ... 275 

London Census, 1896 '.. 195 

,, Diphtheria in ... ... ... ... ... 338 

,, Insufficient Hospital Accommodation ... ... 60 

,, Water Supply ... 40,44, 102, 191,243, 276 

Loddon, Enteric Fever at... ... ... ... ... 103 

Lowestoft Sanitation ... ... ... 103 

Logan, Mr., on Isolation Hospital Accommodation ... 165 

Lovett, Dr. on Tenure of Office of M.O.H 184 

Lung Disea.ses, and Frost and Fog ... ... ... 317 

Lunacy : Is it on the Increase ... ... ... ... 277 

Lumleian Lectures on CEtiology ... ... ... ... 13 

Lying-in Patient. Responsibility to, from a Sanitary 
Point of View 140 



M 

Malaria Experimental 31 

Malarial Germs, Aerial Transportation of 103 

Malet, H., M.D., B.A., M.O.H., Wolverhampton : 

On Poverty in Relation to Sanitation ... ... 91 

,, Returti Cases uf Scarlet Fever ... ... ... 293 

,, Scarlet Fever in Wolverhampton, and Results 

of Hospital Isolation... ... ... ... 137 



Marsden, R. S., M.B., D.Sc, F.R.S., M.O.H., 
Birkenhead : 
On Closure of Schools in Relation to Spread of 

Measles... ... ... ... ... ... 43 

,, Difficulties in connection of Personal Cleanli- 
ness of the Lower Working Classes and the 

Submerged Tenth 83 

,, Food Inspection ... ... ... ... ... 152 

,, Ventilation of Sewers and Surface Grid.*; 396, 397 
Margarine Act ... ... ... ... ... 98, 99 

May, H., L.K.C.P., M.O.H., Aston Manor : ' 

On the M.O.H. in Relation to Public Elementary 

Schools... ... ... ... ... ... 369 

,, the Office of M.O.H. from a Local Practitioner's 

Point of View... ... ... ... ... 277 

,, a School Outbreak of Diphtheria at Aston 

Manor ... ... ... ... 159 

Manley, H.. M.B.. D.P.H., M.O.H., West Bromwich : 
On the M.O.H. in Relation to Public Elementary 

Schools... ... ... ... ... 367, 369 

,, a School Outbreak of Diphtheria at Aston 

Manor 160 

,, Typhoid Fever at West Bromwich 157 

Macfadyen, A., M.B., B.Sc, on the Principles of 

Preventive Inocculation and their Practical Application 261 
Mair, L. W. D., M.D., M.O.H., Croydon Rural, on 

the Duration of Infectivity of Diphtheria 321 

Mason, D., M.O.H., Hull, on Slipshod Sanitation ... 336 
Macdonald, C. R., M.D., D. P. H., M.O.H., Ayr, on 

the Effluent from Sulphate of Ammonia Works ... 389 
MacMarlin, R. W. D., M.D , D.Sc, M.O.H., 

Galloway, on Well Analyses 386 

Measles and Closure of Schools ... ... ... ... 43 

,, Hospital Accommodation for ... ... ... 286 

,, Notification of ... ... ... ... ... 199 

,, from the Standpoint of the Medical Dept. of 

the L.G.B 370 

Medical Preparations 287, 424 

,, Practitioners to be Public Vaccinators ... 399 

,, Profession and Darwinism ... ... ... 131 

„ Inspection of Schools in Boston ... ... 136 

,, Council on Examinations in Sanitary Science... 246 
Medical Officer of Health : 

Appointments, 32, 64, 104, 144, 176, 208, 248, 

288, 328, 360, 392, 424 
Duties with regard to Smoke Nuisance ... ... 329 

„ „ ,, Less Notified Diseases ... 186 
From a Local Practitioner's Point of View ... 277 

Half Salaries Repaid by County Councils ... ... 237 

In Relation to Public Elementary Schools 367 

Reports, Date of Issue of ... ... ... 127 

„ 24, 27, 28, 57, 58, 96, 97, 100, 143, 144, 

200, 201, 241, 324, 325, 326, 359, 384, 423 
Tenure of Office 88, 14S, 161, 162, 176, 17S, 185, 

186, 188, 189, 190, 226 

,t ,, Opinion of Counsel 258 

>, ,, Letter from Dr. Seaton ... ... 163 

Tamworth, Reappointment of 227 

And the Tyne P6rt Sanitary Authority 46 

Metropolitan Water Supply 40, 44 

,, Asylums Board and Scarlet Fever ... 161 

M >, ,, Status of Patients ... 284 

Menthol Snuff 98 

Meat Market, Holborn ., ... 385 

,, Diseased ... ... ... ... 206 

,, Inspection, Necessity for Co-operation ... ... 376 

„ Tuberculous ... ... ... ... ... 230, 384 

„ Unwholesome ... ... ... ... ... 378 

Microscopical Counting of Plates 20 

,, Examination of Water ... ... ... 279 

Milk as a Vehicle of Disease 164 

,, Condensed ... ... ... ... ... ... 227 

,, Filtration of ... .. ... ... ... ... 192 

„ Supplies, Veterinary Control ... ... ... 218 

,, ,, Inspection and Influence of ... ... 152 



Index. 



Milk, Stcniizecl 
,, Tuberculous ... 
,, and Tubercle Bacilli 
,, Use of Preservatives in 
,, Variable Standards ... 



PAGE 

30, 61 

... 230 

... 48 

... 421 

61 



Mitchell, T., M.D., M.O.H., Gorseinon, Notes on an 
Outbreak of Typhoid Fever, due to Contaminated 

Water Supply ... ••• 46 

Millard, Dr. : 

On Return Cases of Scarlet Fever 293 

,, a School Outbreak of Scarlet Fever at Aston 

Manor ... ... ... ... • ••• 160 

Mortality and Density of Population 92 

Montreal, Scarlet Fever at 144 

Model Lodging House, Salford 390 

Muroby, B. H., M.D., D.P.H., late M.O.H., 
Portsmouth : 

Resume of 10 years' Sanitary Work 392 

Retirement of 422 

Municipnl Night Shelter in Paris 23 

Munich, Enteric Fever at 176 

Munro, Dr. Campbell, on Tenure of Office of M.O.H. 182 
M'Vail, J. C, M.D., D.P.H.: 

On Sanitary Prospects under the Parish Councils 

(Local Government Scotland Act, 1894) ... 29 

,, the Supposed Etiology of Diphtheria 57 

,, Vaccination or Sanitation ... ... ... 266 



N 

Nasmyth, T. (,., xM.D., D.Sc, M.O.H. , County 
of Fyfe, on the Relation of Diphtheria to Insanitay 

Conditions ... ... ... ... ... ... 4 

New York, Prevention of Tuberculosis in ... ... 374 

,, Tenement Dwellings in ... ... ... 12 

,, Investigation of Bovine Tuberculosis ... 131 
Newsholme, A., M.D., M.O.H., Brighton, on a 

National System of Notification of Sickness... ... 106 

New Zealand, the Healthiest Country in the World ... 307 

New South Wales Public Heath Administration ... 422 

,, ,, Destruction of Tuberculous Cattle ... 130 

New Buildings ... ... ... . 383 

Niven, J., M.A., M.B., M.O.H., Manchester : 

On the Cotton Industry and Health of Operatives 224 
„ Hospital Isolation in Relation to Scarlet Fever 

Epidemics I43 

,, Inspection and Influence of Milk Supplies ... 156 

,, the Prevention of Phthisis ... ... ... 305 

,, the Prevention of Tuberculosis ... ... ... 231 

,, the Feasibility of Examining all Carcases for 

Tuberculosis ... ... ... ... ... 82 

Notification, Cost of ... ... ... ... ... 420 

,, of Disease, Belfa.<;t ... 26 

,, of Measles ... ... ... ... ... 199 

,, of Infectious Diseases .. ... ... 186 

„ of Infectious Disease, Failure to Notify ... 324 

„ Progress of 237 

„ in Switzerland ... ... ... ... 390 

,, of Sickness, a National System ... ... 106 

Nuisance from Infectious Diseases Hospital 172 

,, Notice to Alter W.C 20$ 

„ Recovery of Expenses from Owner by Occupier 1 74 



O 

Obituary— Dr. Welch 176 

Obermiiller, Dr., on the Presence of Tubercle Bacilli 

in Market Milk 48 

Offensive Matter, Removal of ... ... ... ... 102 

Oldham, Disea.scd Meat at . ... ... ... 206 

Oliver. M.J., M.B., D.P.H., M.O.H., RoVburgh, on 

the Rclationshiii of Water Mains to .Sewers ... 409 

Oysters and Typhoid Fever 9, J50, 357 





185 


320, 


348 


24, 


404 




152 




149 




390 



I'altin, Dr. Co0|.(.'r, .M.O.H., Norwich : 

Deed Poll 

On the Etiology of Diphtheria 
Paget, C. E., M.D., M.O.H., Salford : 
On the Etiology of Diphtheria 
,, Food Inspection ... 
,, Fixity of Tenure of M.O.H. ... 
,, Salford Model Lodging House ... 
Parkes, L., M.D., M.O.H., Chelsea, on the Metro- 
politan Water Supply .. ... ... 41 

Paris Municipal Night Shelter 23 

„ Density of Population ... ... ... 224 

Parliamentary Papers, Monthly List of, 64, 287, 328, 360, 

392, 424 

Pail Closets, Treatment of Contents 193 

Peas Coppered ... ... 378 

„ Preserved, Coloured with Sulphate of Copper ... 321 
Phthisis, Excessive Mortality from, in Ireland ... ... 10 

,, Disinfection after ... ... ... ... 326 

„ Prevention of 93.303.375 

Phthisique Pourquoi et Comment on Devient ... ... 375 

Pilkington, Dr., M.O H., Preston, on the Duties of the 
M.O.H. with regard to Less Frequently Notified 
Diseases ... ... ... ... ... ... ... 186 

Plumstead, Epidemic of Enteric Fever at ... ... 119 

Pollution of the Clyde 412 

Poverty and Sanitation ... .. ... ... ... 9' 

Population and Mortality ... ... ... ... ■• 92 

Population, Laws of Increas.7 of ... ... ... ... ICX) 

Portsmouth, Sanitary Work in ... ... ... ••• 39^ 

Porter, C, M.D., M.O.H., Stockport : 

On the Introduction and Working of Slop-closets 365 
,, the Inspection and Influence of Milk Supplies 156 
,, the Licensing and Regulation of Knackers ... 280 

,, the Prevention of Phthisis 305 

Priestley, J., B.A , M.D., on Summer Diarrhoea in Rela- 
ticm to Earth Temperature ... ... ... ... 138 

Prior, Dr., M.O.H., Bedford, on the Etiology of 
Diphtheria ... ... ... ... ... ... 96 

Puerperal Fever and Erysipelas ... ... ... ... 186 

Public Medicine Scholarships ... ... 3^5 

Public Health Administra ion in New South Wales ... 422 
,, ,, Administration Physician's Work ... 84 

„ ,, and Fowl Diphtheria ... 95 

,, ,, Laboratory, Report on the Bacteriology 

of Diphtheria ... ... 15 

„ „ Scotland Bill 235 

Post-Scariatinal Diphtheria 247. 402 



Quarantine .. 
Query 



236 



Ramsden, Dr., on the Remedial Evils Attendant on the 

Lives of Two People 69 

Read, Dr., M.O.H., Worcester: 

On Return Cases of Scarlet Fever 293 

,, Typhoid Fever at West Bromwich 158 

Recent Research : 

Carbides 32? 

Inoculation of Cattle with Tuberculosis ... ... 305 

Microscopical Counting of Plates ... 20 

Preparation of Sterile Drinking Water by means 

of Chloride of Lime 47 

Presence of Tubercle Bacilli in .Market Milk ... 48 

Self Purifiration of Rivers 4S 



Index. 



XI 



Reports of Medical Officers of Health 24, 27, 28, 57, 
58, 96, 97, 100, 143, 144, 200, 201, 241, 324, 325, 

326, 359, 384, 423 
Registrar (ieneral's Annual Report ... ... ... 196 

Keuews : 

Catalogue of Sanitary Appliances (T. Crapi)er and 

Sons) 32 

Clinical Sketches (Smith, Elder and Co.) 144 

Disinfection and Disinfectants (S. Rideal, D.Sc.) 31 
Diagrametes for Teaching Hygiene (W. Knight) 62 
Diet in Sickness and in Health (Mrs. E. Hart) ... 62 
Diseases of Children's Teeth (R. D. Pedley, 

M.R.C.S.) ... 103 

Foods, their Composition and Analysis (A Wynter 

Blythe) 327 

Geographical Distribution of Tropical Disease 

(R. W. Felkin, M.D.) 424 

Hygiene de I'Enfance (Dr. E.Thomas) ... ... 327 

Hygienic Pocket Book (Dr. Erwin von Esmarch)... 392 
Law and Chemistry of Food and Drugs (H. M. 
Robinson and C. H. Chubb) ... ... ... 423 

Les Maladies V6nericuns dans les Armees Anglaise 
Francaise and Russe (Par Dr. O. Commenge) ... 31 

Medic? 1 Annual 327, 

Microbes and Disease Demons (E. Berdoe, 

M.R.C.S.) 32 

Metropolitan Sanitation (W. H. Daw, F.S.I.) ... 208 
Nalioi al Immunity against Cholera (C. G. Gvimpel) 62 

Premature Burial (F. Hartzmann, M.D.) 288 

Rural Water Supply (A. Greenwell, C.E.) ... 62 

>pas and Mineral Waters of Europe (H. Weber, 

M.D., and F. P. Weber, M.D.) 391 

Seventh Special Report of Commission on Labour 

(C. D. Wiight) .. 62 

Summary cT Vital .Statistics of the New England 

Stats 63 

Treamcnt of Phthisis (A. Ramsden, M.D.) ... 327 
'I'rulh about Vaccination (E. Hart, D.C.L.) ... 32 
Text Book of the Science and Art of Bread Making 

(W. Jago, F.I.C) 32 

Text Book on Hygiene (J. L. Noittr, M.D.) ... 247 
Vaccination Question (A. H. Hutlon, M.A.) ... 62 

Vital Statistics of Ma.ssachusetts for 1893 62 

Rio de Janeiro, Epidemic of Yellow Fever at ... ... 238 

Rivers, Pollution of ... ... ... ... .... 412 

,, Self Purification of ... ... ... ... 48 

Rowton House, Nfw ... ... ... ... ... 283 

Rogers, Dr., M.O.H., Limehouse, on the Metropolitan 
Water Supply ... ... ... ... ... ... 40 

Robertson, J., M.D., B.Sc, M.O.H., St. Helens : 

On the Etiology of Diphtheria ... ... ... 404 

,, Food In.spection ... ... ... ... ... 152 

„ Inspection and Influence of Milk Supplies ... 152 
,, .Slop Closets ... ... ... ... ... 36G 

,, Ventilation of .Sewers ... ... ... ... 397 

Russell, J. B., M.D., M.O.H., Glasgow : 

On Diphtheria in Glasgow ... ... ... ... 340 

„ Public Health Administration in Glasgow ... 314 
,, the Prevention of Tuberculosis ... ... ... 228 

Rural Districts Slaughter House, Difficulties in ... 380 



Salford Model Lodging-house 
Sanitary Appliances 

,, Science Examination 
,, Work in Glasgow... 
,, ,, Portsmouth 
Sanitation of Factories and Workshops 
„ Is it Worth the Cost? ... 
,, and Poverty 
,, V. Vaccination 



... 390 

• 391 

156, 246 

... 314 

••• 392 

... 228 

•" 323 
... 91 
... 266 



banders, Dr., M.O. H., West Hani, on the Friolngy of 
Diphtheria ... ... ... ... ... ... 96 

Sergeant, Dr., M.O. H. Lancashire : 

On the Cotton Industry and Healtii of Operatives 224 

,, Food In.i-pection ... ... ... 152 

,, Inspection and Influence of Milk Supplies ... 155 

,, Slop Closets ... ... ... 366 

Sale of Food and Drugs Acts Cases 98, 99, 204, 205, 

244, 321, 356, 378, 382 
Salmon, D. E., D.V.M., Chairman of Committee, 
Report of Committee on Animal Diseases and 
Animal Foods ... ... ... ... ... ... 376 

Salmon, Tinned, Death from Eating 206 

Salvation Army Sr.elter, Blackfriars 388 

Scholarships in Connection with Public Medicine ... 385 
Scurfield, H., M.D., D.P.H., on the Use of Tuberculin 239 

Scotland, Diphtheria in 30 

Public Health Bill 235 

Schools, Closure for Measles 43 

,, and Diphtheria ... ... ... ... ... 328 

,, M.O.H. in Relaiion to 367 

,, Medical Inspection in Boston 136 

,, Outbreak of Diphtheria at Aston Manor ... 159 
,, Sanitation of ... ... ... ... ... 224 

,, Ventilation of ... 74 

Scarlet Fever, Discharge of Patient from Hospital 

while still Suffering from. Damages 244 

Scarlet Fever, Etiology and Prevention of ... ... 58 

,, Hospital Isolation 143 

,, and Infected Milk 138 

,, and the Metropolitan Asylums Board ... 161 

,, Return Cases 90, 290, 349 

,, at Tbingoe ... 200 

,, in Wolverhampton, Results of Isolation 

Hospital '37 

Sewage and Sewage-Grown Products, Effects on 

Animals 69 

Sewage Disposal ... ... 294 

,, ,, on chalk Lands ... 310 

,, Farms, Influtnce on Public Health 284 

,, Farm, Finchley ... ••. 4'' 

,, Purification 299 

,, Precipitation ... 238 

Treatment, Novel Method 337 

Sewer or Drain 25, 99, 175, 352, 353. 4I9. 42i 

.Sewers, Ventilation of ... ... ■• ... ... 39^ 

Sewer Ventilator, Death from Blood Poisoning .. 420 

.Sewers and Water Mains ... ... ... ... ... 409 

Serum, Anti-Typhoid ... ... ... ... ... 285 

Seamen, Cul)ic Sjiace in Merchant V^essels ... ... 359 

Seaton, E., M.D., F.R.C.P. : 

On Fixity of Tenure of M.O.H. ... 163, 181, 183 

,, Isolation Hospitals on Chalk Strata ... ... 128 

,, ,, ,, for Rural Districts 302 

,, the Physician's Work in Public Health 

Administration ... ... ... ... 84 

Sheffield, Enteric Fever at 142 

Shadwell, St. Clair B., M.D., D.P.H., on Disease 

Coincident with Insanitary Conditions 115 

Shop Hours Act ... ... .. ... ... •■• 243 

Shelters, Philanthropic 325, 3^^ 

Slop Clo.sets 362,365 

Slaughter-houses of Bristol 160 

„ Bye Products i6<i 

Slaughter-house Difficulties in Rural Districts 380 

,, Continuous User . . 20? 

Slipshod Sanitation 33'' 

Smith, P. C, M.D., M.O.H., Wandsworth, on the 

Metropolitan Water Supply 4' 

Smith, Professor, M.O.H., Woolwich, on the Metro- 
politan Water Supply 4' 

Smoke Nuisance, Duties of M.O.H 32; 

Small pox. Aerial Convection of If'4 

,, Bacteriology of 273 

„ in Birmingham ... St 4'3 



Xll 



Inaex. 



105, 145. 



.. 108, 148, 180, 

.. 34, 65, 147, 
34, 66, 147, 178, 
... 34, 66, 178, 



... 74 

... 157 

... 157 

292, 368 

... 367 

367 

74. >57. «79, 189, 290, 367 



157, 158, 160, 



Small-iiox at Gloucester 

Initial Rashes of 
,, Segregation of Cases ... 
Society of Arts Gold Medal 
Society of Medical Officers of Health 
.Agenda ... ■. i, 

Annual Meeting 

,, Provincial Meeting ... 

Auditors' Report 

Case for Opinion of Counsel 
Discussions 
Editor's Report 
Election of Fellows ... 
,, of Members ... 
,, of Associates 
„ of Ofificers ... 
Hon. Solicitor, Change of Address... 
Mode uf Election of Members 
Nomination Forms ... 

Notices I, 33, 65, 105, 145, 177, 

• Proceedings 34,65,106,146,177, 

Presidential Address 

Resolution a.s to Manufacture of Ice Cream 

Report of Council 2,65,146, 

Treasurers Report 

Birmingham and Midland Branch — 
Annual Meeting 
Appointment nl President 
Bye-laws 
Discussions 
Election of Council . . . 

,, of Officers 
Proceedings 

Home Counties Branch — 
Discussions 
Proceedings 

Metropolitan Branch — 
Discussions 

F-lection of Additional 
Council of the Society 
PHection of Council ... 
,, of Officers ... 
,, of President ... 
Proceedings ... 
Repoit of Council 

Northern Branch — 
Ant.ual .Meeting 
Flection of Fellows ... 

,, of Members ... 

,, of Officers ... 
Proceedings 
Report of Hon. .Secretary 

North Western Branch — 

Adjourned Annual Meeting ... 

Discussions 152, 155, 188, 223, 305, 335, 

Flection of Fellows ... 

,, of Mcml)ers ... 

,, of Officers ... ... 

,, of President 
Presidential Address ... 
Proceedings 42,82, 149, 152, 179, 186,218, 

32*^. 
Scotti.sh Branch- 
Election of Council ... 

,, of Officers 
Proceedings 

Southern I'.ranch- 
Accounis 

Election of Members ... 
Presidential Address ... 
Proceedings ... ... ... 109, 179, 

Visit to Winchester (Cathedral 



PAGE 

... 271 

... 21 

... 306 

. 329 

177, ro9 

•■• 34 

146, 361 

... 4 

... 258 

217, 256 

•. 3 

178, 249 
211, 249 
211, 249 

... 249 

I 

... iqi 

... 289 

209, 289 

210, 249 

... 35 

... 1 4(1 

210, 249 



84, 115, 179, 227, 



Representative to 



40, 119, 178. 



... 302 

257, 300 

... 40 
the 

... 119 
•■ 392 
•• 392 
... 392 
185, 392 
... 119 



117 
119 

337 
iiS 



117, 179, 188, 257, 337 
iiS 



... 42 

366, 397 

'49. 396 

152, 329 

... 396 

• 3^6 

... 42 
303, 

362, 396 

190 

... 190 
170, too 

... 100 
... 109 
... 109 
189, 392 
. ■ 392 



Society of Medical Officers of \\(:i\\.\\— continued : 
West of England and South Wales Branch — 

Annual Meeting 66 

Discussions 68 

Election of Council and Ofificers ... 66 

Presidential Address ... ... •• 66 

Proceedings 66,179,190.294 

Treasurer's Report 66 

Yorkshire Branch — 

Discussions ... •. 74. 226, 

Election of President... ... 

Presidential Address ... 

Proceedings ... 69, 179, 224, 335 

Sterilized Milk 3°. 61 

Stillborn Children ... 

Steam Disinfection ... 

Stapleton, Outbreak of Diphtlieria at 

Steeves, G. W., B.A., M.D , on Responsibility to 

Lying-in Patient fiom a Sanitary Point of View 
Stainthorpe, Dr., on Fixity of Tenure of M.O.H. 

Sulphate of Ammonia Works, Effluent ... 

Sydney, Enteric Fever at 

Sykes, J. F. J., M.D., M.O.H. , St. Pancras : 

Appointment as Lecturer of Public Health at Guy's 

Hospital School 

On the Etiology of Diphtheria 

,, the Notification of .Sickness 
,, the Problem of Re-housing Pers(jns Displaced 
by Improvement Schemes 



336 

335 

69 



58 
196 
249 

140 

'49 
389 

135 



9 

96 

108 

102 



G. Board on the 



P'ssex 



Tamworth R. 1). C, Re-appointment of M.O.H. ... 227 
Talbot, Dr., M.O.H., Bow and Bromley, on the 

Metropolitan Water .Supply 

Tatham, Dr., Decennial .Supplement 

Tetanus, Chemical Pathology of ... 
Tenement D\Aellings in New \oxV 
Tenure of Office of M.O.H. 68, 14S, i6t, 162, 163, 

176, 178, 185, 186, l88, 1S9, 190, 226, 25S 
Thome Thome, Dr., C.B.: 

On the Chemical Pathology of Tetanus 

„ Milk as a Vehicle of Disease 
Scientific Investigations of the I 
Etiology of Enteric Fever 
Thresh, J. C, D.Sc. M.B., M.O.H 
On Mortlity among Children 
,, the Provision of Isolation Hospitals in Rural 
Districts 
Thompson, Dr. J. A., on Public Health Administr.alion 

in New South Wales ... 
Thomson, Dr.T , M.(XH. to Local Government Board, 
Re^iort on Measles 

Tinned Salmon, Death from Eating 

Town Refuse, Destruction by Heat 

Tonbridge, Exposing Unwholesome Meat 
Tubercle Bacilli, Precnce in Market Milk . . 

Tuberculin, Discussion on... ... ... 

,, Inoculation of Cattle... 

Tuberculous Meal ... 

,, ,, and Milk 

,, Cattle, Destruction of 

,, ,, Method of Dealing with at Boston 135 

Tuberculosis and the Use of Tuberculin... ... ... 239 

,, Inoculation with Tuberculin ... ... 305 

,, (.Vnim.il), Relation to Human 

,, (Bovine), Inrestigation at New York 

„ E.xaminalion of all Cnrcases for ... 



41 
400 

275 
12 



275 
164 

170 

27 

300 

422 

370 

206 

49 

48 
»S7 
305 
384 
230 
130 



Index. 



Xlll 



I'ACE 

Tuberculosis in Early Childhood .. 370 

,, Prevention of ... 8, 22, 231, 374, 375 
,, ,, Registration of Cattle ... 395 

,, .Second Commission on 257,361 

Typhoid Fever. Sec Enteric Fever 

Tyne Port Sanitary Authority and their M.O.H. ... 46 



V 



Vaccinia v. Variola 273 

Vaccination Centenary of Introduction ... ... 191, 192 

,, in Germany ... ... ... 240 

,, Fifteen Reasons for Believing in Efficacy of 271 

,. Report of Royal Commission ... ... 397 

,, V, Sanitation... ... ... ... ... 266 

Vacher, F., F.R.C.S., M.O.H., Cheshire : 

Reappointment of ... ... ... 74 

On the Cotton Industry and Health of Operatives 223 
Fibrinous Rhinites or Diphtheria ... ... 217 

Ice Cream ... ... ... ... ... 256 

Inspection and Influence of Milk Supply ... 156 
Midden Generated Enteric Fever ... ... 26 

Prevention of Epidemics... ... ... ... 35 

Prevention of Phthisis ... ... ... ... 305 

Tenure of Office of M.O.H 180 

Ventilation of Sewers ... ... ... ... 397 

Ventilation of Sewers ... ... ... ... ... 396 



I'AGE 

Water Closets for Cottage i'roperty 18 

Well Analyses ... ... ... ... 386 

,, Failure to Close Polluted ... ... 61 

West Bromwich, Typhoid Fever at ... ... ... 157 

,, Riding .Sanitary Work ... ... ... ... 336 

Weather and Disease ... ... ... ... ... 45 

Weymouth, Enteric Fever at ... ... ... ... 112 

Welch, Dr., M.O.H,, Handsworth, Death of 176 

Whitaker, H., M.D., Supt. M.O.H., Belfast : 

On the Excessive Mortality from Phthisis in 
Ireland... 
„ Notification of Di.sease ... 
Wilson, J. T.,M.D., D.P.H., M.O.H., Lanark, on the 

Prevention of Tuberculosis 
Wills, Dr., M.O.H., Newark, on the Prevention of 

Phthisis ... ... ... ... 

Williams, W., M.A., M.D., D.P.H. , M.O.H., 
Glamorganshire, on the Water Supply of Glamorgan- 
shire ... .. 

Wilde, L., xM.D., M.O.H., Croydon : 

Appointment as Consulting M.O.H. to East Sussex 

C.C - 

On Fibrinous Rhinitis or Diphtheria 

,, the Prevention of Phthisis 

,, the Supposed Etiology of Diphtheria ... 

Willoughby, Dr., on Notification of Sickness ... 

Womersley, Councillor, Leeds, on Slipshod Sanitation 336 

Working Men's Dwellings Bill ... ... ... ... 280 

Woodforde, Dr. W. T. G. : 

On Fibrinous Rhinitis or Diphiheiid ... ... 218 

Memorandum of Public Health Act, 1872 90 

On Notification of Sickness ... ... ... ... 108 

„ Tenure of Office of M.O.H 184 



10 
26 

374 
303 



39 
217 

93 

24 

108 



W 



Water, Chemical, Analys s of 


143 


,, Microscopical Examination of 


279 


,, Mains and Sewers ... 


409 


,, Preparation of Sterile Drinking 


47 


,, Regulations... 


42 


,, Supply from the Chalk 


109 


,, ,, Glamorganshire 


6 


,, „ London 


276 


,, ,, East London 44, 


243 


,, „ Report of Col. W. Ducat... 


191 


,, ,, Metropolis 


40 


„ ,, and Typhoid Fever 


46 


Watercress Beds 


325 



Yarrow, Dr. : 

On Fibrinous Rhinitis or Diphtheria 
,, Notification of Sickness ... 
Yellow Fever Epidemic at Rio de Janeiro 
Young, M., M.B., CM., M.O.H., Brighouse and 
Halifax, on the Effects of Sewage and Sewage-Grown 
Products upon Animals, and through them upon Man 



218 
108 
238 



69 



Zymotic Death- Rate, Significance of 



LIST OF ILLUSTRATIONS. 



PAGE 

Chalk Sewage Filter ... ... ... 312 

Chart showing Death-Rate from Croup and Diphtheria 

in Glasgow ... ... ... ... ... ... 341 

Chart showing Deaths from Diphtheria in Birmingham 342 
Diagrams Showing I^evels of Underground Water in 

Glamorganshire ... ... ... ... ... 6, 7, 8 



Diagram showing Age Distribution per 

from Diarrhcea in Glasgow 
Defective School Drainage 
Thresh's Disinfector 
Ventilation of Public Schools 
Ventilation of Schoolroom 



100 Deaths 



316 

226 

197 

79 

304 



London : W. H. and L. Coilingridge, City Press, 148 and 149, AlderSijats S*eet, E.C. 



Public Health, 

€\}t Journal of tf]e Cncorporateti Societg of Pletiical ©fftcers of ?^ealtl). 



SUBSCRIBERS' COPIES of Public Health are 
supplied at \os. 6d. peramttini. Single copies One Shilling, 

BOUND VOLUMES.— Co/zVj of Volume VI. are now 
ready, bound in cloth, gilt lettered, trice \os. 6d. A 
few copies of Vols. /., //., IV., attd V. are also on hand. 

CLOTH COWKRS for Binding the Volumes, price li.6d., 
may be had by order of any Bookseller. 

Orders should be addressed to E. W. Allen, 4, Ave Maria 
Lane, E.G. 

ADVKRTISKMKNTS. — Communications relating to 
Advertisements should be addressed to Messrs. W. H. &^ L. 
Collingridge, 14S and i^g, Aldersgate Street, E. C. 

Every Reader of a Paper before the Society, or Contributor 
of a Signed Article, is entitled to twenty five copies of the 
issue oj Public Health containing the contribution in 
question ; but application for this or any smaller number 
must be made to the Editor not later than the TWENTY- 
FOURTH day of the month previous to insertion of the 
Contribution. 

Medical Officers of Health and other Correspondents are 
requested to send regularly all published reports and 
matters of interest bearing upon Sanitation to the Editor, 
J' ^' 'icester Place, Brighton 

\ NOTICES. 
1 

If! 

r -D SUBSCRIPTION FOR MEMBERS OF 
2. INCORPORATED SOCIETY M.O.H. 
ttention of Fellows and Members of the Incorporated 
vv^^.. 's called to the fact that dating from October, 1894, 
the subscription to the Society will be one guinea instead of 
half-a-guinea as hitherto. It must be noted that this will 
include the subscription as members of a branch of the 
Society, the guinea subscription being inclusive for all 
purposes. 

It will be seen from this that there will be no very 
material increase in the subscription for those who are 
members of the parent Society and of one of its branches. 
There will, however, be considerable saving of trouble in 
collecting subscriptions, etc., as one subscription only will 
be payable. The subscriptions (and those for Associates, 
which remain half-a-guinea) should be sent to the Trea- 
surer, Dr. Kempster, Chesterfield, North Side, Clapham 
Common, London, S.W. 



The Honorary Secretary wishes to draw atten- 
tion to the fact that there are still vacancies for 
Papers during the forthcoming Session of the 
Society, and that application in connection with 
these should be made forthwith to him. 

The address of Mr. Henry C. Jones, Hon. 
Solicitor to the Incorporated Society of Medical 
Ofificers of Health, has been changed from 27, 
Bloomsbury Square to 197, High Holborn, W.C. 

N o. 90. October, 1895. 



The Incorporated Society of Medical 
Officers of Health. 

20, Hanover Square, London, W., 

23rd September, 1895. 



Notice is hereby given that the Annual 
General Meeting of the Incorporated Society 
of Medical Officers of Health will be held on 
Thursday, the 17th day of October, 1895, at 
197, High Holborn, W.C., at 5.30 o'clock in the 
afternoon, for the transaction of the following 
business : — 

AGENDA. 

1. The President Elect (Dr. F. Vacher) will 
be introduced to the Meeting by the retiring 
President (Dr. S. R. Lovett). 

2. The Minutes of the Adjourned Ordinary 
Meeting of the Society, held on the 8th of April 
last, will be read and confirmed. 

3. The following candidates, having been duly 
nominated, will be balloted for : — 

Nominated at Meeting of 8th April. 

As Fellows. 

Rayner, Edwin, M.D., &c., Tiviot Da'e, Stockport, 

M.O.H. Stockport (retired) ; proposed by J. C. Thresh ; 

seconded by Reginald Dudfield. 
Simpson, Reginald Palgrave, M.D., 11, Gloucester 

Row, Weymouth, M.O.H. Weymouth Port S.A. ; 

proposed by B. H. Mumby ; seconded by Reginald 

Dudfield. 
Stephens.Lockart Edward Walker, M.R.C.S.,L.S. A., 

White House, Emsworth, Hants, M.O.H. Wartlington 

U.S.D. ; proposed by George Turner; seconded by 

J. C. Thresh. 

As Ordinary Members. 
Rogers, G., M.R.C.S., L.R.C.P.,24, High Street, Sheer- 
ness-on-Sea, Ass. -M.O.H. Port of London ; proposed 
by W. Collingridge ; seconded by the President. 

As Associates. 

Hunt, Gilbert J., Weymouth, Borough Surveyor, Wey- 
mouth ; proposed by G. H. Mumby ; seconded by 
Reginald Dudfield. 

Laurie, McPherson (Dr.), Greenhill, Weymouth; 
proposed by B. H. Mumby ; seconded by Reginald 
Dudfield. 

Matthews, William, C.E., Municipal Offices, South- 
ampton, Water Engineer to Borough of Southampton ; 
proposed by B. H. Mumby ; seconded by Reginald 
Dudfield. 



Nominated at the Provincial Meeting, July 27TH. 
As Fellows. 

Elias, James, D.P.H., Neath, M.O.H. Neath U.S.D. ; 
proposed by the President ; seconded"' by Reginald 
Dudfield. 

Legate, Robert Lloyd, L.R.C.P, Bridge House, Christ- 
church, Hants, M.O.H. Christchurch U.S.D. ; pro- 
posed by B. H. Mua>' v ; seconded by Chas. Kelly. 



THE INXORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. 



Peskett, Alfred F., M.R.C.S., Leyton, M.O.H. Leyton 

U.S.D. ; proposed by St. Clair Stiadwell ; seconded by 

John C. Thresh. 
Skegg, John Joseph, L.R.C.P. Edin., M.R.C.S. Eng., 

29, Craven Street. Strand, M.O 11. St. Martin's-in-the- 

Fields Metropolitan S.D. ; proposed by the President ; 

seconded by Reginald Dudfield. 
Waters, Avery Clough, M.B., Southend-on-Sea, M.O.H. 

Southend-on-Sea U.S D. ; proposed by John C.Thresh ; 

seconded by J. S. Tew. 

As Ordinary Members. 

Eraser, A. Mearns, M.B., D.P.H. Camb., 277, Cold- 
harbour Lane, Brixton, S.W. ; Assistant to Dr. Thresh, 
M.O.H, Chelmsford; proposed by John C. Thresh; 
seconded by Reginald Dudfield. 

O'Connor, Michael, M.B., Perth, "Western Australia; 
proposed by John C. Thresh ; seconded by the 
President. 

4. To receive the names of candidates for 
election as Fellows, Ordinary Members, and 
Associates. 

5. To receive the following Reports for the 
Session 1894-95 : — 

(a) The Report of the Council ; 

\b) The Report of the Hon. Editor ; 

{c) The Report of the Hon. Treasurer, 

together with Statement of Accounts 

and Balance-sheet ; 
{d) The Report of the Auditors. 

6. To receive any further Report of the Council 
(if any). 

7. The President to read his Inaugural 
Address. " On the Prevention of Epidemics." 

8. To transact any other business. 

{Signed) John C. Thresh, 

The Limes, Chelmsford. 1 jr 
Reginald Dudfield, \ „ "^^' 

19, Blomfield Road, ' '^^^^• 

Maida Vale, W. 



THE INCORPORATED SOCIETY OF 
MEDICAL OFFICERS OF HEALTH. 

Report of the Council for the Session 
1894-5. 

Your Council beg to report that the number of 
Members at present on the Register of the Society 
is 650, comprising 515 Fellows, 60 Ordinary Mem- 
bers, and 75 .Associates. During the Session 50 new 
Members were elected, viz., 25 F'ellows, 10 Ordinary 
Members, and 15 Associates. The Society lost 
during the Session 10 Fellows and i Associate by 
death, and 22 Fellows, 16 Ordinary Members, and 
2 Associates by resignation. Among the deceased 
Fellows were two Vice-Presidents — Sir George 
Buchanan, F.R.S., late Principal Medical Officer 
to the Local Government Board, and Dr. J. S. 
Bristowe, F.R.S., both of whom have filled the 
office of President of the Society. In Sir John 
Simon, K.C.B., F.R.S., who resigned during the 
year on the grounds of the increasing infirmity 



of age, the Society lost one of its oldest and most 
distinguished Members. 

2. One new Branch, the "Southern," has been 
formed during the Session, with Dr. Kelly as 
President, and Dr. Mumby as Hon. Secretary. 
Negotiations have been opened for the formation 
of Branches to represent the Members in Scotland 
and Ireland respectively, but nothing has as yet 
been decided. 

3. Your Council devoted a large amount of 
time to the consideration of the various altera- 
tions suggested to be made in the Articles of 
Association, and they are gratified that the matter 
terminated to the satisfaction of all by the making 
of a new set of Articles which have been sanctioned 
by the Board of Trade. The thanks of the Council 
are due to the Metropolitan Branch for the sugges- 
tions put forward, which formed the basis of the 
new Articles, and to the Hon. Solicitor of the 
Society for the trouble he took to secure a satis- 
factory ending of the matter, and the prompt regis- 
tration of the new Articles. The Council for the 
year 1895-96 has been elected under the new 
Articles, and is composed of Representatives elected 
by the several Branches. 

4. In their annual report for 1893-94 the then 
Council referred to the fact that Dr. T. Orme 
Dudfield was, at their request, representing the 
Society on the Committee formed by the Local 
Government Board to draft a scheme for a Conjoint 
Board for the examination of persons desirous of 
qualifying themselves for the office of a Sanitary 
Inspector. The scheme at the date of the last 
report had been drafted, but the Council, deeming 
the Society to be inadequately represented on the 
Board, were in communication with the Local 
Government Board, with the view of securing an 
increased representation. Your Council have now 
to report that the Local Government Board felt 
unable to sanction any increase, and that they 
approved the draft scheme and authorised Dr. 
Dudfield to sign the same on behalf of the Society. 
Your Council regret to have to add that the pro- 
posed " Sanitary Inspectors' Examination Board " 
has not yet been incorporated. 

5. Your Council have had the " Midwives' 
Registration " and the " Poor Law Officers' (Super- 
annuation) " Bills under their consideration during 
the Session. Both Bills fell through on the dis- 
solution of Parliament. Should they be re-intro- 
duced in the coming year, the new Council will 
doubtless take them into their consideration. Your 
Council forwarded to the Home Secretary the 
suggested amendments received from the Metro- 
politan Branch, to the Factories and Workshops 
Bill, which has since become law. 

6. Your Council having had the question of the 
tenure of Extra-Metropolitan Medical Officers of 
Health under consideration, invited the British 
Medical .Association, the British Institute of Public 
Health, and the Sanitary Institute to join with 



EDITOR'S REPORT. 



them in a deputation to the Local Government 
Board on the subject. The deputation was received 
by Sir Walter Foster, Parliamentary Secretary to 
the Board, on the 8th March last. A full report 
of the proceedings on the occasion appeared in the 
April issue of Public Health. 

7. In consequence of the alterations in the 
Articles of Association, the Society will in the 
future hold fewer meetings than heretofore; and in 
order to avoid unnecessary expense, your Council 
have decided to retain only a registered address 
at 20, Hanover Square. The meetings of the 
Society in the coming session will be held at 197, 
High Holborn, by the courtesy of the Board of 
Works for the District of St. Giles, Bloomsbury. 

8. During the past Session 11 meetings of the 
Society have been held, viz., the Annual Meeting in 
October last, 6 Ordinary Meetings, 3 Extraordinary 
Meetings for the revision of the Articles of Asso- 
ciation, and the Provincial Meeting at Portsmouth 
in July last. The Presidential Address was given 
at the November meeting, the subject chosen being 
that of " The Past, Present, and Future of the 
Society." 

9. Four papers were read during the Session, 
viz., on " Some Points of Difiference between 
English and Continental Methods of Municipal 
Sanitary Administration," by Dr. Legge; on "The 
Limits of Infection by Phthisis," by Dr. Ransome, 
F.R.S. ; on " Preventable Infantile Mortality," by 
Dr. Porter; and on "Sewers and Drains," by 
H. C. Jones, Esq., Hon. Solicitor to the Society. 
Dr. F, Vacher, F.R.C.S., was elected President 
for the Session 1895-96 at the April Meeting of 
the Society, the other officers having been elected 
by the Council on the same day. 

10. In conclusion, your Council submit the 
reports of the Hon. Editor, the Hon. Treasurer, 
and the Auditors, and beg to state that, after due 
consideration, they have decided to carry out the 
recommendations contained in the last-mentioned 
report. 



{Signed) J. C. Thresh, 

Reginald Dudfield 
August 2,'^st, 1895. 



.1 



Hon. Sees. 



Editor's Report. 

Of the numbers of Public Health published 
during the last twelve months, six have consisted 
of eighty columns, the remainder of sixty-four or 
seventy-two columns. The total number of columns 
of printed matter for the twelve months was 884, 
of which 35 per cent, consisted of official announce- 
ments and proceedings of the Society and its 
branches; about 22 per cent, were furnished by 
contributors paid by the Society ; and about 43 per 
cent, consisted partly of original signed articles, but 
chiefly of extracts from annual and other reports of 
medical officers, condensed and arranged by the 
Editor. This latter work, though laborious, is very 



necessary in the interest of Public Health, and 
I therefore trust that all members of the Society 
will continue to send me, not only marked copies 
of their annual reports, but of any special reports 
which they may present to their local authorities. 
{Signed) Arthur Newsholme, 

Hon. Editor of ''Public Health." 



Report of the Honorary Treasurer. 

In consequence of the alterations in the 
Articles of Association, I have been compelled 
to close the accounts of the Society six weeks 
earlier than hitherto. The financial statement and 
balance-sheet, which I submit herewith, are for the 
period commencing October ist, 1894, and ending 
August i6th, 1895. 

I am glad to be able to report a balance in hand 
of ^616 i8s. 4d.; this sum, of course, being 
irrespective of the capital amount of four thousand 
pounds. There is, moreover, a substantial amount 
of assets due to the Society, in the shape of unpaid 
subscriptions for the present year, which will prob- 
ably be more than sufficient to satisfy any out- 
standing liabilities of the year. 

{Signed) W. H. Kempster, 

August 2,\st, 1895. Hon. Treasurer.' Z 



The Incorporated Society of Medical 

Officers of Health. 

RECEIPTS AND EXPENDITURE. 

October is(, 1894, to August i6tk, 1895. 

Expenditure. £ s. d. £, s. d. 

To Rent, 20, Hanover Square, Three 

Quarters to Midsummer, 1895 ^5 ^5 o 

,, Attendant at ditto 100 

,, Expenses of Annual Dinner ... 6 15 

,, Printing and Stationery — 

Roberts and Leete o 17 10 

Per Hon. Solicitor (deed 

box, etc.) ; i 10 o 

W. H. and L. CoUingridge ... 150 

Farmer and Son 3 10 9 

Lowe Bros. ... ... ... i 18 o 

9 I 7 

„ Mr. E. Kent (salary) 16 o 

,, Mr. T. P. Scrivener, Auditor — 

Audit Fee 5 5 o 

Clerk's Time 3 3 o 

CostofBooks o 15 o 

930 

,, Postages, Telegrams, etc. ... 9 10 o 

,, Journal Account — 

W. H. and L. CoUingridge— 

January, 1895, * ^^^- to date 78 li 10 

April, „ „ „ 52 8 3 

June, ,, ,, ,, 45 7 9 

Southern Publishing Company 

(diagrams) 17 1° o 

Gavin and Watson (diagrams) 3 10 o 

Kmg and Co. (Parliamentary 

Papers) 2 13 7 

Albion Printing Works (dia- 
grams) 096 

Truscott and Co. (diagrams)... 4 14 o 



Carried forward 



203 4 II 

.. 272 9 6 

B 2 



THE RELATION OF DIPHTHERIA TO INSANITARY CONDITIONS. 



Expenditure — contimud. £ 
Brought forward 
To Hon. Editor (half-year's expenses) — 

Clerk 

Index (preparation of) 
Postages, Telegrams, etc. 
Contributions inserted in 
Public Health ... 



272 



s. d. 
9 6 



23 I 



Hon. Solicitor (disbursements) — 
Annual General Meeting 
Alteration of Articles of 
Association ... 

Hon. Secretaries (petty cash) — 

Dr. J. C. Thresh 

Dr. K. Dudfield 

Expenses connected with Annual 

Provincial Meeting 

Amount refunded to Metropolitan 

Branch ;■£ Alteration of Articles 

of Association... 
Funeral Wreath (the late Sir 

George Buchanan, F.R.S.) ... 
Branch Accounts (proportion of 
Subscriptions) — 

Metropolitan 

Midland 

Northern 

North Western 

Yorkshire 

West of England 

Home Counties 

Southern 

Bank Commission 

Balance 



40 15 o 



35 13 6 



16 



3 8 
8 6 



Total 



Receipts. 



By Balance brought forward 

,, .Subscriptions 

,, Publisher, balance of Account .. 
„ Dr. Adams, part cost of Diagrams 
,, One year's dividend on jC4,ogg 17s 
India Three per Cent. Stock ... 

Total 







— 5 

2 


12 

3 


2 

2 






12 


II 









I 


I 





29 

20 


2 
2 


6 
6 






18 


17 


6 






17 


12 


6 






16 


10 









13 


2 


6 






lb 


10 









12 


7 


6 











— 144 


■; 










616 


6 
18 


4 
4 




£1,139 


16 







£ 


s. 


d. 




... 


404 
569 


II 
15 


I 
6 






42 
4 


3 
7 


II 

6 



5d. 



BALANCE SHEET. 

August i6tk, 1895. 

Liabilities. 

To Capital Account — 

Mr. Berridge's Bequest 
,, Receipts and Expenditure Account — 
Balance as per Account 



By value of ;^4,099 17s. 
f)er Cent. Stock, 
names of Messrs. 
and Wightwick 
,, Cash 



Assets. 

5d. India Three 
standing in the 
Lovctt, Murphy, 



118 18 o 
;^i,i39 16 o 



£ s. d. 

4,000 o 

616 18 4 

;^4,6i6 18 4 

£ s. d. 



4,000 o 

616 18 



;^4,6i6 18 4 



We have examined the foregoing accounts with the 
vouchers, and certify them to be correct. 

{Sigtud) E. GwYNN, \ A , . 

T. P. Scrivener, F.C.A.,)^"^"'"''- 



Report of the Auditors. 

We beg to report that we have examined the 
accounts of the Society with the vouchers and 
books, and certify them to be correct. 

We recommend that in future an additional 
book be kept, viz., a subscription book, ruled 
to show — (i) a full list of subscriptions payable, 
alphabetically arranged, with the amount of 
subscriptions due ; (2) date when such subscrip- 
tions are paid or otherwise determined ; (3) amount 
of such subscriptions allocated to branches, and 
the branch to which such allocation is made ; and 
(4) the arrears standing unsatisfied to be carried 
forward to the next year's account. 

We also recommend that the Trustees under 
the Berridge Trust be requested to sign an authority 
to the Bank of England for the payment by the 
Bank of England direct to the Society's bankers 
of the dividends on the ;^4,o99 17s. 5d. India 
Three per Cent. Stock as they fall due. 

{Signed) E. Gwvnn, \ . ...^„. 

T. P. Scrivener, F.C.A., j ^"^^''''^^• 



THE 



RELATION OF DIPHTHERIA 
INSANITARY CONDITIONS.* 



TO 



T. G. Nasmyth, M.D., D.Sc, M.O.H. of the County of 
Fife. 

An outbreak of diphtheria associated with well- 
marked insanitary conditions is of considerable 
importance, as at the present time too much im- 
portance is apt to be attributed to the bacterial 
equation, and too little to the insanitary conditions 
under which the disease frequently arises. The 
reaction that has set in in this respect, depends 
on the fact that diphtheria is found to prevail even 
under the most favourable, or at least, what appear 
to be favourable, sanitary conditions. The terms 
favourable sanitary conditions are merely relative, 
and are used to indicate that the grosser forms of 
nuisances, so commonly associated with outbreaks 
of enteric fever, diarrhoea, etc., are absent. The 
virus, which is the exciting cause of diphtheria, is 
a micro-organism. All micro-organisms have 
special selective affinities in relation to the con- 
ditions under which they grow and develop, 
whether the organisms find these in air, water, or 
soil, or in the solids or liquids of the bodies on 
which they act as parasites, ^\'hat are the special 
chemical and physical conditions under which the 
diphtheria bacillus thrives outside the body are so 
far unknown, and what may be considered fairly 
sanitary conditions, under our current ideas of the 
causation of diphtheria, may yet be found to repre- 
sent highly insanitary conditions, in so far as they 
are the necessary conditions for the growth of 
diphtheria bacilli. The chemistry of soils is a 

• From Dr. Nasmyth's Annual Report for 1894. 



EPIDEMIC OF SMALL-POX IN BIRMINGHAM. 



complex question in its application to agriculture ; 
and a new science is being gradually built up, so 
that the agriculturist is getting to know what soils 
want for the growth of a particular plant. The 
pathology of the living earth, as it is sometimes 
called, will yet show what diseases may be expected 
to arise under certain chemical and physical con- 
ditions of the soil. The outbreak of diphtheria in 
the present case was associated with very marked 
insanitary conditions, which some time ago would 
have been called characteristic of the disease. 

The cases occurred in a small colliery village, 
the houses consisting of two rows situated on 
ground sloping to the west. The ground still 
further west had a very steep fall. At the bottom 
of this fall, about 150 yards away from the nearest 
house, was situated a cesspool, into which the 
sewer from the houses drained. The cesspool 
was covered up and unventilated, and there was 
no disconnecting trap between it and the sewer. 
The sewer itself was unventilated. At the houses, 
near to the doors, were placed gully traps, which 
received surface slop waters from the houses. It 
will be easily understood that with gases thus held 
under pressure much greater than of the atmos- 
phere, there would be a great tendency for them 
to escape, and the situations offering least resist- 
ance were the gully traps, which could easily be 
forced. In these ways sewer gases of a very foul 
description could gain access to the houses, and 
the atmosphere surrounding the gully traps would 
always be foul. It can readily be understood how 
children would breathe this, playing about the 
gutters as they do. 

Whether the part that sewer gas plays in the 
causation of diphtheria is secondary or primary 
matters very little, as without the influence of the 
secondary cause, the primary — the micro-organism 
— would not develop, or would only do so with 
great difficulty, and few cases of diphtheria would 
ensue. 



THE EPIDEMIC OF SMALL-POX IN 
BIRMINGHAM. 

BY 

Alfred Hill, M.D., M.O.H. of Birmingham. 

The small-pox epidemic which had existed all 
through 1893 manifested increased severity in 
1894, more particularly in the first part of the 
year. All Saints' Ward suffered far more than any 
other part of the town, the cases there being equal 
to the very high rate of 14*5 per 1,000 of the 
population. Next in order came Rotton Park 
with 8*5, St. Paul's with 8-3, St. George's with 5-5, 
and St. Stephen's with 5*1. In the southern and 
eastern parts of the town the rates were quite 
insignificant in comparison with those just quoted, 
being I'l in Edgbaston and Harborne, 0*9 in 
Balsall Heath, i*o in Bordesley, and 07 in Saltley; 
in fact the disease was almost confined in its 



epidemic character to the north-west corner of the 
city, the neighbourhood in which the Small-pox 
Hospital is situated. 

A comparison with the figures for previous years 
shows that the present epidemic has been much 
more severe than that of 1883-4, but less so than 
the one which culminated in 1874. I am pleased 
to say, however, that towards the end of the year 
a diminution in the number of cases set in, and at 
the time of writing the disease had practically died 
out, only twenty-two known cases existing in the 
city. 

Of the 2,074 cases notified during the year 1,769 
were vaccinated, 224 unvaccinated, and 81 doubt- 
ful as to vaccination. Either during the year or 
after its close there were 165 deaths amongst them, 
the mortality being distributed among the three 
classes as follows : — 

No. of No. of Proportion of Deaths 
Cases. Deaths. to Cases. 



Vaccinated ... 


1769 


77 


4'4 per cent. 


Unvaccinated.. 


224 


75 


33-5 ,. 


Doubtful 


81 


13 


i6-o „ 



The following table shows the incidence of the 
disease at different age periods amongst the three 
classes of patients : — 





Vaccinated. 


Unvacci- 
nated. 


Doubtfiil. 






1 


>. 






>. 






>. 


AGES. 


4) 


j: 


4) 


V 


Jc 


C c 
V 


« 


j: 


3^ 




n 
U 


a 


St: 

« a 



a 











Q 


« a. 



Under i year 











41 


32 


78 











Between i and 5 years 


S 








3« 


13 


34 


b 





— 


„ 5 and IS „ 


236 


I 





73 


6 


8 


14 


I 


7 


„ 15 and 25 „ 


707 


13 


2 


3« 


8 


21 


19 


I 


5 


„ 25 and 45 ,, 


689 


.S2 


8 


25 


12 


48 


28 


8 


29 


,, 45 and 65 „ 


119 


9 


8 


7 


2 




12 


2 


17 


At 65 years and upwards 


13 


2 


15 


2 


2 




2 


I 





I have not calculated any percentages on less 
than ten cases, as conclusions based on a very 
small number of observations are of no value, and 
indeed are misleading. 

The chief point to be noted in the above figures 
is the different incidence of the disease upon 
vaccinated and unvaccinated subjects. Amongst 
the vaccinated less than one-seventh of the attacks 
were in children under fifteen, or in other words, 
amongst those who had been vaccinated within the 
last fifteen years. On the other hand, of the total 
number of unvaccinated persons who were attacked 
by small-pox no less than two-thirds took the 
disease before reaching the age of fifteen years. 
Amongst the 241 vaccinated patients under fifteen 
years of age only one died, this being a boy who 
was suffering from scarlet fever at the time he con- 
tracted small-pox. But amongst the 152 unvacci- 



THE WATER SUPPLY OF GLAMORGANSHIRE. 



nated cases at the same age period there were 
fifty-one deaths ; in other words, while less than 
•5 per cent, of the vaccinated children died, 
amongst the unvaccinated the mortality was 33 per 
cent., or sixty-six times as great. 

THE WATER SUPPLY OF 
GLAMORGANSHIRE,* 

BY 

William Williams, M.A., M.D. , 

D.P.H. Oxon, 
County Medical Officer of Health. 

The nature of the water and the sources of supply 
for drinking purposes is of the greatest importance. 
In the southern area, in addition to river supply 
(usually dangerous from pollution), there are 
numerous springs thrown out by the shales and 
clays of the Lias Limestone series. The quantity 
is generally small, and the water contains much 
lime and salt {e.g., the Barry and Porthcawl 
supplies). 

The Keuper Sandstones and Marl series, 
especially the junction with the Dolomitic Breccia, 
give a constant supply to the wells of the Cardiff 
breweries and the Ely district. 
The water is usually very hard, 
containing sulphates and carbo- 
nates of lime and magnesia, also 
sodium chloride. 

From the carboniferous lime- 
stones, especially along the lines 
of faults, we often have springs 
of considerable volume, thus : — 

Githerinp grouna. 



Sometimes ordinary underground streams are 

formed by percolation. The water from the 
carboniferous limestone is always hard. 

Within the coal basin the watersheds of the 




Fig. 2. 



N.E. of Cefn, near Merthyr. 
'I'he rock is Carboniferous Limestone. 
(Different shading adopted to indicate fault) 



various rivers form the principal supplies. Besides 
these the Pennant sandstones are full of water, and 
give rise to strong springs where percolation is 
hindered by the presence of clay bands, e.g., fire- 
clays, thus : — 







Clay bunrfs oft^'ft beiunth 
a CuaJ tivuuL 




Rg. 1. 

Carboniferous 

Limestone, 



Cftrhoniferous 
Limestone 



Limestone Sh&Ie. 



A Sertion across thr fnult nenr Ewfnny, showing; the relation thereof 
to the Spring which supplies Uridgcnd. 



These springs are occasionally the outflow of sur- 
face springs which had disappeared below the sur- 
face for a while. Such an instance is to be found 
north-east of Cefn, near Merthyr, as in Fig. 2. 



shire 



From Dr. Williams' " Sanitary Survey of Glamorgan* 



Cliagnm to show the eOeot of Cl«y hnnJs in tlie Poniwnt Or 
n foiining Springs by prevpntinjr porcoliliun 
lQ£tances numeruuit in every vjUli-v 



This water is soft, usually 
ferruginous, and occasionally 
slightly acid from the presence 
of coals. From one of these 
springs at least free nitrogen gas 
is evolved (TafPs Well). Very 
little of the supply of the 
northern area is obtained from 
the rocks. Water from the car- 
boniferous limestone is hard, 
whereas the millstone grit above 
and the old red sandstone 
below yield softer water. The 
water from the surface of the hills is extremely 
soft, and in running over their peaty slopes it 
gathers much organic impurities, and when ob- 
tained from the high ground within the coal basin 
is still more impure, since it collects the particles 
of the atmosphere. 



THE WATER SUPPLY OF GLAMORGANSHIRE. 



The most useful supply, therefore (balancing the 
commercial gain of pure water for engines against 
the possible injury to health by too soft water, and 
also the loss to breweries), is the rain supply 
collected on the northern area. Cardiff and 
Merthyr obtain their supplies from this area, and 
Swansea is about to be supplied from the same. 

On the hills the surface soil consists of a con- 
siderable thickness of peat, and in the smaller 
tributary valleys there is much boggy ground. 
This condition is produced by water, after heavy 
rain and from springs, flowing down along their 
steep slopes and constantly soaking into the peat, 
the result being a quagmire. Naturally, the soil is 
derived in most cases by mere disintegration of the 
rocks below. Such a soil is common on the higher 
ground, and the rocks being pervious the soil is 
also pervious, or it may be due to glacial action, 
e.g., Pwllypant old station is built on an esker. 
Along some of the valleys, e.g., the Taff and its 
tributaries, also the Loughor, there are heaps and 
lines of clay and gravel, as well as scattered blocks, 
accumulated by this agent. It usually implies the 
shifting of the material further south than its 
natural outcrop, e.g., on the flat north of the Cardiff 
Silurian outcrop we get blocks, etc., from the old 
red sandstone, carboniferous hmestone, and coal 
measures, brought from the north. In the majority 
of cases these beds are porous, but they are very 
variable, and pass into impervious clays. 

From the river Rhymney to the Ely there is a 
tract of alluvium, and such a condition is also 
found for some distance up along the banks of the 
principal rivers. West of the Ely tracts of alluvium 




permanent 

a— Level after much rein. b— CeveJ after dry »9atber, 

c — Level reduced by mine pumpiag. 

Cases are numerous, t.g. at LlaiJjraAich io tho Bhymney 
Volley. 



also occur. Wind has done much along the shore 
west of the Ewenny to beyond Neath by spreading 
sand over the surface and accumulating large sand- 
dunes. These beds are very porous, and well 
adapted for the treatment of sewage, though so far 
they are not used for that purpose. 

In the minor folds (already noticed) water was 
formerly naturally collected as in a basin, and the 
surplus got rid of by local springs. These have 
been weakened or destroyed by underground 
workings, which discharge large volumes of water 
contaminated with impurities due to man and beast 
and the chemical products of the oxidation of 
the coal and associated minerals, and is no longer 
fit for drinking springs. 

The bulk of the population withdraw from the 
Vale and accumulate in the valleys, the rivers have 
become too polluted for use, and the natural flow 
of the underground water is disturbed, so that the 
water supply of the present and the anticipated 
future of the coalfield is most important. 

Llanbradach Colliery in the Rhymney Valley 
pumps about 32,000 gallons an hour from under- 
ground. This is most likely the supply from the 
hill country to the west — the eastern side of 
Mynydd Eglwysilan. 

If the water level is permanently reduced in this 
way houses and villages situated on the ground 
above the valleys are in danger of losing their well 
water, especially during dry weather. 

In the valleys shallow wells are possible occa- 
sionally in the gravels formed by rivers and ice. 
These deposits are irregular in thickness, and not 
likely to give a continual supply, and from their 
porous nature are certain to take 
in impurities from sewage, etc. 
i^i^gpf Even in the lower parts of some 

Valley. of the vallcys care is needed 

I with the springs from the lime- 

} stone, since the water may not 

be pure spring water, but merely 
the river supply, with all its ob- 
jectionable soluble contents tra- 
velling underground for a while. 
Such a case is recorded at Pwl- 
loffeiriad in the Ogmore Valley. 
The chief source of danger 
arises from disturbances of sur- 
face produced by underground 
workings. As far as possible 
mining officials seek to cause 
merely a gentle and even sub- 
sidence by stowing. This, how- 
ever, was not done in past 
time. Subsidences do and must 
occur, and the greater the num- 
ber of seams worked the greater 
the effect, thus : — 

{a) Fault lines are disturbed, 
and since they frequently form the 
boundaries of a royalty, working 



8 



THE WATER SUPPLY OF GLAMORGANSHIRE. 



tends to exaggerate the surface effect, producing in 
some cases a fall of the surface to the extent of ten 
to twenty-five feet. This may cut off the water 




\<lit Level. 



Fig 5. • 'A Diagram to show effect of a level driven into, the hill from 
the valley, slightly rising and crossing several coal 6eauis. The 
Working thereof entirely upsets the water circulation. It i.-j 
dmined out along the level, which is made to slope for that 
purpose. There are numerouo esaiuplea of this, e.g. at lUidry. 

supply obtained from springs along the line of fault 
and divert it underground (Fig. 6). It may also 
cause contamination. Smartt proved that a fault 
in the chalk under Woolwich contaminated the 
water supply, and there is reason to believe that 
faults under the Thames suck in the water when 
the porous beds beneath are pumped out, or if the 
water level gets low. 

{b) Workings being local, the subsidence is far 
from regular over a wide area. When a sudden 
subsidence takes place, the drainage and water 
supply are apt to be disturbed by the breaking of 
pipes, and even when gentle it destroys the 
gradient, and thus produces stagnancy as well as 
danger of breakage. The danger of leaking wattr 
pipes is well known. (See Dr. Spear's Report on 
Typhoid Fever Epidemic at Mountain Ash in 
i888.) 




A fault commonly formn tlie limit .,f a royalty. A fault na 
iiiown m di«Krarn ■• often a linn of .tronfr Spnngs. Under- 
ground workinp. c«u« the w,t*r fre^uentlv to run in a diff.rent 
dinwtion. The Sprinp (S) c«ui«.. nn^ the water runs down >\,e 
level* leii uniha/W and ■« piim|K«l in an impure nt^te from th« 
pit. Th" uru'hsle.) |^rta »« supiosed to \h- worked out coat 



The water supply of the mineral districts of 
Glamorgan is a matter of the greatest importance. 
During the drought of last summer there was a 



great scarcity in many localities, a condition almost 
bordering upon a water famine. Now, at present, 
a great alarm is felt that there may be an absolute 
water famine in the near 
future, if some means are not 
taken to provide an adequate 
supply. There are several 
water companies, but the sup- 
ply provided by some of them 
is very defective, and inade- 
quate to meet the needs of the 
inhabitants. 

It has been proved that we 
cannot rely on obtaining a con- 
stant supply from the mineral 
districts, though now most of 
it is obtained from watersheds 
situated over this area. This 
IS the experience of Swansea, 
where some years ago an 
attempt was made to construct reservoirs and collect 
water within the mineral basin, with the result that 
it proved a failure, or at any rate the supply, if 
obtained, was very inadequate for the purpose. 
In former pages I have endeavoured to show how 
underground working may disturb or crack the 
surface, thereby producing loss of water. Cardiff 
and Merthyr are supplied from areas north of the 
coalfield, but the remainder of the population 
obtain their water from watersheds over the mineral 
basin. 

The population of the county in iSSi was 
511,433, in 1891 it was 687,218, showing an 
increase of 175,785 in ten years, t.e , about 34 per 
cent. This increase was larger than that of any 
other county in the United Kingdom, except 
Essex, representing the Eastern population of 
London. These figures refer to the whole county, 
but excluding the two county 
boroughs of Cardiff and Swan- 
sea, they are 352,242 in 1881, 
and 467,954 in 1891, being an 
increase in the administrative 
county alone of 115,652. This 
increase has mainly taken 
place over the mineral area. 
In 1 80 1 the population of the 
whole county was only 70,879, 
in 1891 it was 687,218, so that 
in ninety years the increase 
has been nearly ten times. If 
it increases at the same rate 
as during the past decade, it 
would reach over 11,000,000 
in one hundred years hence. 
The above figures show what 
the population may become, 
and how absolutely necessaiy 
it is to be in readiness to supply it with a sufficient 
water supply. The question naturally arises. Will 
the county be able to sustain such a population ? 



OYSTERS AND TYPHOID FEVER. 



The Coal Commission appointed in 187 1 reported 
that there was in the South Wales coalfield 
32,241,472,740 tons of available coal for use, and 
it has been estimated that whatever the increase of 
population may be, there will be ample mineral 
wealth to sustain it. The large populations of 
Ystradyfodwg and Pontypridd districts, some 
140.000, dependent upon local companies, have at 
present no adequate supply ; last summer they were 
actually in want. 

In June, 1893, deputations from the Local Boards 
of the above districts waited upon the Water 
Committee of the Glamorgan County Council, and 
represented that then a serious deficiency of water 
existed in their districts, and that the prospects for 
the near future were alarming. The Committee 
recommended that a deputation consisting of 
members of the Water Committee and of the Local 
Authorities be sent to the Local Government 
Board, urging it to introduce into Parliament a 
measure repealing the clause prohibiting local 
authorities from competing in water supply with 
private Water Companies within their districts, and 
also to authorise the County Council to promote a 
Bill for providing a general water supply for the 
county. Such powers, however, were not granted, 
and matters must of necessity, for the present, 
remain in statu quo. 

Populations spring up so rapidly within the 
mineral area, and they have no power of obtaining 
a proper water supply except by means of sanitary 
authorities, who cannot afiford to go to Parliament 
for large and costly scheme or schemes that are 
necessary to supply the wants of their growing 
populations. 

And now, since the supply given by the various 
local companies is inadequate, and in danger at 
any moment of being disturbed, it is absolutely 
necessary that the supply of the districts should be 
obtained by a large and general scheme created by 
the County Council, or a combination of local 
authorities, from the mountain ranges lying to the 
north of the coalfield, Cardiff and Merthyr 
already obtain their supplies from this area, and 
Swansea has also promoted a Bill in Parliament to 
obtain their water from the collecting ground of the 
Cray, the upper watersheds of the Usk. Until 
such another scheme is provided for the mineral 
districts of Glamorgan their present and anticipated 
future population cannot be said to be adequately 
provided with a constant and a sufficient quantity 
of pure and wholesome water, which is the first 
necessity of life. 



i^ubltc Icaltlj. 



Dr. Jno. F. J. Sykes, M.O.H. of St. Pancras, 
has been appointed Lecturer on Public Health at 
Guy's Hospital Medical School. We heartily con- 
gratulate Dr. Sykes, and still more the Medical 
School at Guy's, on the new appointment. 



OYSTERS AND TYPHOID FEVER. 

Professors Herdman and Rubert Boyce, of 
Liverpool, contributed to the Ipswich meeting of 
the British Association the results of an incomplete 
experimental inquiry into the effect upon the 
oyster of various external conditions, including 
pathogenic organisms. One point established was 
the tolerance of sewage displayed by oysters. They 
could live for a prolonged period in water rendered 
completely opaque by the addition of fsecal matter. 
It hardly needed an experimental inquiry to 
demonstrate this point. Is it an accidental cir- 
cumstance that oyster-beds, and particularly the 
market-ponds attached to them, are so commonly 
placed at the mouth of tidal rivers, in suspicious 
contiguity to the sewage outfalls ; or have 
oyster-growers realised that under these conditions 
the oysters fatten more readily than in purer 
streams ? 

As regards the infection of the oyster by micro- 
organisms, the bacteriological examination of the 
water of the pallial cavity of the oysters and of the 
contents of the rectum showed that when oysters 
were laid down in the open water of the bay, there 
were but few colonies present, but when laid down 
near a drain-pipe, the number was enormous. 
Oysters were grown in water infected with the 
bacillus typhosus ; and the latter could be identified 
in cultures taken from the water of the pallial 
cavity and rectum fourteen days after infection. 
The authors suggest that by methods similar to 
those employed in the " Bassins de degorgement '' 
of the French ostreiculturist, where the oysters are 
carefully subjected to a natural process of cleaning, 
oysters previously contaminated with sewage could 
be freed of pathogenic organisms or their products 
without spoiling the oyster for the market. This, 
no doubt, will be good news for the oyster trade 
(though we doubt if they will avail themselves of it 
in practice until the pressure of public opinion is 
greatly increased) ; but what of the long-suffering 
public, who will continue to be experimented on ? 
Probably they would prefer not to eat oysters 
freed (?) from previous sewage contamination if 
they had a choice in this matter, which, it would 
appear, is to be- settled between bacteriologists and 
the oyster trade, the persons most concerned being 
left out of the consultation I 

We welcome the researches of Professors 
Herdman and Boyce on this important subject, 
and hope they will be continued. It is desirable, 
however, that medical officers of health should state 
very emphatically that they do not on this or on 
any other public health problem intend to allow 
themselves to be bound hand and foot by ex cathedra 
statements of bacteriologists. Bacteriology is as 
yet but a young science ; it has still much to learn 



THE EXCESSIVE MORTALITY FROM PHTHISIS IN IRELAND. 



about its own subject ; and when it has learnt it, 
can only enlighten us on a limited portion of public 
health problems. At present its negative verdicts 
are almost valueless, and its positive verdicts can 
only be accepted when they fit in with what we may 
call the clinical experience of preventive medicine. 
It is obvious that, given — as has happened recently 
— oyster ponds placed close below the sewage out- 
fall of towns or villages in which typhoid fever is 
endemic ; and given that a bacteriological exami- 
nation of the oysters and their environment has not 
detected the presence of the bacillus typhosus ; and 
given, that case after case of typhoid fever occurs, 
in which other causes are eliminated, and the only 
common factor is the eating cf these oysters, we 
must reject the bacteriolog'cal evidence, and 
accept the conclusion forced upon us by a careful 
investigation en the spot. 



THE EXCESSIVE MORTALITY FROM 
PHTHISIS, Etc., IN IRELAND. 

BY 

Henry Whitaker, M.D., Superintendent M.O.H. of 
Belfast. 

Of the deaths registered in Belfast during the year 
1S94, considerably more than one-third are attri- 
butable to phthisis and diseases of the respiratory 
organs ; of these more than one-seventh were 
caused by the former, whilst about one-fourth were 
caused by the latter. The deaths from these 
causes seem slowly but gradually becoming less 
numerous. This terrible loss of life, beside which 
that from zymotic diseases sinks into comparative 
insignificance, occurs not only with us, but quite 
as severely in Dublin and Cork, though both these 
cities have more healthy surroundmgs, a more 
equable temperature, and less unhealthy industries 
than we have. A great deal has been written in a 
highly sensational manner about the " martyrdom " 
of the linen and flax workers in our city, and I, 
myself, in every yearly report, have referred again 
and again to the regrettable condition under which 
so many of our operatives, more especially women 
and children, have to work. In my report for the 
year 1891, I stated that, "breathing as they must 
do a close, heated atmosphere, laden with jjarticles 
of flax dust, fibrous and other matters irritating to 
the lungs ; going from thence, directly it may be, 
into the cold, damp, or frosty air, poorly and lightly 
clad, often too young (especially the female 
workers), to bear the exposure to which they are 
subjected, it is scarcely to be wondered at that 
mortality from these diseases is as great as it is." 
Since then I have repeatedly called attention to 
this very important subject, which years ago 
engaged the special notice of the late r3r. Charles 
D. Purdon, for many years the certifying surgeon 
to the mills in our city, who, taking a warm interest 
in the health of the workers, carefully investigated 
and reported thereon. I believe that changes have 



been, and are being, introduced into our mills and 
factories, by which the health of the operatives 
employed therein will be materially benefited. 
Apart from any humane considerations, it is the 
direct interest of the employer to keep f his 
employes in good health, and it has been calcu- 
lated that in Belfast alone there is a "waste of 
p^8i,7 7o a year in preventable serious illness." As 
the matter is of so much importance, I have taken 
the trouble to compile a table showing the death 
rate from these diseases in the sixteen principal 
urban districts of Ireland. 
Deaths per 10,000 from — 

Diseases of the 
Phthisis. Respiratory Organs, 

Dublin City 387 51 '6 

Belfast 34*3 54*0 

Cork 394 56*8 

Limerick ... ... 32 '4 56*2 

Londonderry ... ... 284 48 "5 

Waterford 29-3 2 1 '6 

Galway 225 4$ 6 

Newry .. 23*8 30'0 

Dundalk ... 13-0 35*5 

Lisburn 377 3i'2 

Drogheda ... ... 24"6 30*0 

Wexford 23*4 40" i 

Lurgan ... .. ... 333 40*0 

Kilkenny ... .. 14-5 SVS 

Sligo 48-0 25-0 

Armagh i6'2 2S'3 

Dublin Eegistration Dis- 



trict 



45 'O 



The foregoing table is well worthy of your con- 
sideration. It does not show Belfast in a very bad 
light when compared with the other large Irish 
towns. Notwithstanding the large number of mill- 
workers, the majority of them women or children, 
spending a large proportion of their life in the mill 
or factory, going to their work at half-past five in 
the cold winter morning, careless as to frost, snow, 
or rain, indifferently clad, with but little nutritious 
food, and working at high pressure in the heated 
atmosphere of the mill, our death rate from chest 
aff'ections contrasts favourably with that of those 
towns in which the black smoke of the mill 
chimney, or the noise of the spinning jenny is un- 
known. If our mills and factories are to any large 
extent potent factors in increasing our death rate, 
were they introduced into Dublin, Cork, or 
Limerick, disastrous results would surely follow 
therefrom. As it is, Cork has a much higher 
death rate than we have, both from phthisis and 
diseases of the respiratory organs, whilst Dublin 
beats us in the former, and Limerick in the 
latter respect. As you will observe, Sligo, a 
non-manufacturing town, has much the highest 
death rate from phthisis, whilst Cork heads the 
list of deaths from diseases of the respiratory 
organs. Armagh, Newry, and Lisburn, all towns, 
more or less manufacturing, have a low death rate 
from these causes, though unfortunately the death 
rate from phthisis in the latter town is much higher 
than with ourselves. In my report for the year 



THE SIGNIFICANCE OF THE "ZYMOTIC DEATH RATE." 



II 



1893 I attributed the marked decrease in the 
deaths from these diseases which I then reported 
to the exceptionally warm and dry summer which 
we had experienced. I am happy, however, to be 
able to point out that the improvement still con- 
tinues, notwithstanding that during the past year 
the -weather was, during the summer at least, in 
marked contrast to that of the year preceding it, 
with much moisture and a comparatively low tem- 
perature. The chart (given in the original report) 
shows that the deaths from phthisis seem to be but 
little influenced by the state of the weather or the 
season of the year. The deaths from this cause 
were most numerous (33) in the first week in 
April, and lowest (8) in the fourth week in 
September ; in the last week in December the 
number was only 1 1 ; whilst, on the other hand, 
the severe, inclement, and very cold weather told 
heavily in increasing our mortality from diseases of 
the respiratory organs. There seems to be but 
little relation between the mortality arising from 
these diseases. I regret that I cannot give even an 
approximate idea of the number of cases of diseases 
of the respiratory organs occurring amongst us, nor 
can I specify the form of lung affection which they 
assume, or which of them causes the greater 
number of deaths. I think, however, that bron- 
chitis, both acute and chronic, is accountable for 
the majority thereof. The nature of the employ- 
ment of a large number of our people, the sudden 
transition from the heated mill or factory into the 
damp, cold outer air, with often insufficient clothing 
and but little heat-producing food, rendering them 
most susceptible to this disease ; and when to these 
is added the irritation of the air passages produced 
by the particles of textile matter suspended in the 
air of the factory, it is not to be wondered at that 
bronchitis is so prevalent with us, as it undoubtedly 
is ; and I believe that it is the cause of the great 
majority of the deaths attributable to diseases of 
the respiratory organs. 

Phthisis is essentially a disease of overcrowding 
and bad ventilation. The public generally do not 
seem to realise this fact, nor do they consider the 
somewhat infectious nature of the disease. It is 
the scourge of the working classes, and is mainly 
due to unsanitary surroundings and ill-ventilated 
dwellings. The ventilation of the working man's 
dwelling is the least and last consideration of the 
builder, and light and air strive too often in vain 
for an entrance therein. The effect of good sani- 
tary work in reducing the death rate from this 
disease has been very marked, not only on the 
Continent, but in the sister countries. Unfortu- 
nately, in this country but little sanitation has been 
thought of, and matters remain, at present, in much 
the same unsatisfactory condition in which years 
ago we found them. Want of exercise, improper 
food, and impure air, more especially that rendered 
so by respiration, or exhalations from the body, 
have a most material effect in the causation of this 



disease, and increasing its mortality. Naturally, 
those working in close rooms are affected most, 
whilst those who pursue their avocations in good, 
fresh, open air. are least liable to suffer from it. In 
the army an increase of cubic space to each man, 
and the removal of foul air, caused a notable 
decline in the number of deaths from this cause. 
No other remedy was employed. In many of the 
sanatoriums, where invalids suffering irom this 
disease resort with much benefit, the cold, though 
very great, does not injuriously affect them, accom- 
panied, as it generally is, with dry air and much 
sunlight. We, unfortunately, have the disadvantage 
so common to Ireland, of a copious rainfall, a 
constant moisture in the air, and the sun only too 
rarely shines brightly upon us. Our heavy clay soil 
is very retentive of damp, and there can be but 
little doubt that the drying of the soil and air 
which more or less always accompanies efficient 
drainage, would tend considerably to the diminution 
of this disease, so prevalent in our midst. 



THE SIGNIFICANCE OF THE " ZYMOTIC 
DEATH RATE."* 

BY 
T. Orme Dudfield, M.D., M.O.H. of Kensington. 

Zymotic diseases have a special interest for sani- 
tarians, being of a more or less preventable 
character ; the absence or the prevalence of certain 
of them therefore, is regarded as a test of the 
sanitary condition of a district. But, without 
underrating the importance of this test, it must be 
said that there are limitations to its applicability 
necessary to be borne in mind in drawing inferences 
from mere numbers. What I mean may be best 
explained by illustrations, founded on our own 
local experience within the last few years. Thus, 
measles was very prevalent in 1888, 1890, 1892, 
and in 1894, the deaths being considerably above 
the average. In 1889, 1891 and 1893 on the 
other hand, the deaths from this cause were greatly 
below the average ; but the lowered mortality, 
regarded as evidence of the diminished prevalence 
of the disease, was the natural consequence of its 
excessive prevalence and fatality in the preceding 
years. In saying this, I must not be thought to 
ignore the fact that the type of one epidemic of a 
zymotic disease may be more severe than that of 
another ; or that the relative severity of an epidemic 
may be influenced by the measures taken, or the 
neglect to take measures, to check the spread of 
infection. Again, the number of deaths from 
whooping-cough in 1889 was the lowest on record; 
it is not surprising to find, therefore, that in the 
immediately preceding and succeeding years this 
disease was fatal above the average ; the large total 
of 185 deaths in 1878, moreover, followed the then 
minimum return of thirty-four in the previous year. 

* From Dr. Dudfield's Annual Report for 1894. 



12 



TENEMENT DWELLINGS IN NEW YORK. 



Diarrhoea may be cited as an illustration of quite 
another kind. The mortality from this disease 
amongst infants was excessive in 1887 ; the mor- 
tality in 1888 was much below the average; but 
the diminished mortality in 1888 had no relation 
to the excessive mortality in 1887. The conditions 
were altogether different; the summer of 1888 was 
cold and wet, and, as always happens in these 
circumstances, the mortality from infantile diarrhoea 
was low — just as it is always high when the summer 
is hot and dry, as in 1887. Again, the significance 
of a high rate of prevalence of enteric fever varies 
widely in different circumstances. This disease 
may be constantly present in one district, as a 
result of drainage defects or of a polluted water 
supply ; whilst in another district its introduction 
may be wholly accidental, as when it is due to 
casual pollution of water, or to a specifically con- 
taminated milk supply introduced from without. 
These and like circumstances must be kept in view, 
if we would draw sound conclusions from a high or 
a low rate or prevalence of zymotic diseases, par- 
ticularly in relation to the sanitary condition of a 
district. Subject to corrections for local circum- 
stances, for climatic influences, and for high rates 
in previous years, the concurrence of a low zymotic 
death rate with a low general death rate, furnishes 
just ground for satisfaction. For some years past 
the general rate and the zymotic rate had both 
been below the decennial average in Kensington. 
In 1894 the general rate was (as in London also) 
below the average ; the zymotic rate was average. 
It need hardly be said that a persistently high rate 
of mortality from zymotic diseases furnishes matter 
for serious consideration. Kensington has hitherto 
been fortunate in having a death rate from these 
diseases much below that of the metropolis 
generally. 



TENEMENT DWELLINGS IN NEW YORK. 
An attack has been recently made on the sanitary 
condition of the Tenements of Trinity Church, in 
New York. An able defence of these Tenements 
has been published by Mr. F. L. Hoffman, who 
evidently speaks with actuarial knowledge and 
skill. 

The charge made against the sanitary condition 
of the Trinity Tenements consists in the main in 
the statement that the death rate in them was 
35 per cent, in excess of the general death rate of 
the City of New York. This method of comparison 
is rightly objected to. " The fallacy involved in 
the comparison of two populations so essentially 
different in numbers, is plain. The law of large 
numbers eliminates the possibility of accidental 
occurrences and accidental influences in the death 
rate of the population at large, which is not the 
case in the calculation of a death rate based on 
small populations. If, for instance, the 326 
suicides that occurred in the City of New York 



during 1894 were omitted in the calculation of the 
general death rate, this would only affect the rate 
per 1,000 by o'i7, but if the one suicide that 
occurred in 1894 among the population of Trinity 
Tenements were omitted, this would affect the 
Trinity death rate by 0*43 per 1,000. Or, in other 
words, 843 deaths could be omitted from the total 
mortality of the city before such an omission or 
element of error would affect the general death 
rate to the same extent as the accidental omission 
or addition of one death would affect the Trinity 
Tenement death rate." Mr. Hoffman then pro- 
ceeds to quote various English and other autho- 
rities in support of his contention that the above 
method constitutes a violation of the fundamental 
principles of vital statistics. He further shows 
that a considerable proportion of the excess in the 
death rate of the Trinity Tenements over that for 
New York as a whole is caused by the latter being 
based on an erroneously estimated population, 
while the former is based on a rigidly enumerated 
population. 

Having shown the fallacies of the methods em- 
ployed, Mr. Hoffman proceeds to show that four 
methods of comparison might have been legiti- 
mately employed, {a) The Trinity death rate 
might have been compared with that of District A, 
Ward 8, within which the tenements are situate. 
Such a comparison shows in 1891 a death rate of 
28*5 for the whole ward, and of 217 for the Trinity 
Tenements, {b) Other tenement dwellings might 
have been compared with the Trinity Tenements. 
Such a comparison when made is very favourable 
to the latter, {c) A modification of («), using the 
comparative statistics of six years, shows a mean 
death rate of 31 "39 in District A, Ward 8, as com- 
pared with 2873 in Trinity Tenements, id) The 
fourth method being dependent on a knowledge of 
special local considerations need not be further 
considered. 

Having shown by these methods, that the general 
death rate of the Trinity Tenements is not so high 
as that of fairly comparable populations, Mr. 
Hoffman makes a detailed comparison for certain 
diseases. Comparing Ward 8 with the Trinity 
Tenements, it is jilain that the death rates from 
scarlet fever, diphtheria and croup, typhoid fever 
and diarrhceal diseases, are very much lower in the 
latter than in the former, while that from measles 
is considerably higher. These results coincide 
very closely with the results of a similar investiga- 
tion of Peabody Buildings in this country. So 
also does the fact that the death rate among 
children under five years of age is considerably 
lower than that in Ward 8, District A, and some- 
what lower than that in the whole city. Mr. 
Hoffman has not gone fully into the influence of 
age-distribution of the special pojiulation of the 
Trinity Tenements; but he promises this in a 
later and fuller report. This will be of great 
value, and will be looked for by all who are 



THE LUMLEIAN LECTURES ON ETIOLOGY. 



13 



interested in this important subject, and are more 
anxious to ascertain the truth than to bolster up 
preconceived notions. Mr. Hoffman concludes 
his remarks with the following extract from the 
Lancet : — " We have so strong a conviction of the 
powerful influence that our national system of 
mortality statistics has exercised on the progress of 
public health in England, that we think it to be 
of the first importance that public faith in these sta- 
tistics should not be weakened by ambiguous terms, 
by false methods, and by unsound deductions." 



THE LUMLEIAN LECTURES 
ETIOLOGY.* 



ON 



Dr. Pye-Smith's brilliant lectures on aetiology 
were doubtless read by many health officers when 
they first appeared in the medical journals. We 
have great pleasure now in welcoming them in 
permanent book form, and in claiming for them a 
place in the study of every hygienist. Every page 
contains some fertile suggestion or philosophical 
generalisation, which must stimulate further 
thought and investigation. The old notion that 
disease is an entity is first combated. " It is as 
natural, as physiological, as health." Similarly to 
regard filarise and bacilli as merely '* causes of 
disease " in man is to take too narrow, too human 
a view. Every kind of beast harbours parasites 
habitually. It is only in the minority of instances 
that they prove destructive to their host. "The 
fact is, that if we call 'disease' whatever is 
abnormal, then the * pathological ' condition is to 
be free from parasites." Here follows a noble 
tribute to the value of preventive medicine. " If 
inquiry into the origin and conditions of disease 
helps treatment, it is indispensable for the still 
better art of prevention. That depends entirely 
upon the extent of our knowledge of aetiology ; and 
I venture to believe that more human suffering has 
been relieved, and more lives have been saved, 
by the studies in natural history, which have 
taught us the origin of infectious fevers, of scurvy, 
of lead colic, of erysipelas and pysemia, than by the 
best results of pharmacology." 

In the following sentence on hereditary diseases, 
Dr. Pye-Smith has summed up the entire difficulty, 
at present unsolved, which Weismann's views have 
introduced into the science of heredity. " If, as 
some naturalists hold, acquired properties are not 
transmitted to the offspring, it is very difficult for 
us to explain the undoubted hereditary trans- 
mission of gout, haemophilia, and phthisis." A 
few sentences further on a suggestion is made, 
which, if adopted, would save some medical men a 
vast amount of useless labour, and would save 
others from the irksome, because so common, task 

* " The Lumleian Lectures on Certain Points in the 
Etiology of Disease ; to which is added the Harveian 
Oration." By P. H. Pye-Smith, M.D., F.R.S. (J. and A. 
Churchill, 1895 ; 7s. 6d.) 



of pointing out the fallacies of the method 
adopted. " All very common diseases will appear 
to be hereditary by mere coincidence. Hence 
statistical statements as to the frequency of rheu- 
matic fever, cancer, or phthisis in the children of 
parents subject to these diseases, ought to be 
checked by control figures showing its frequency 
in others." 

Dr. Pye-Smith's sensible remarks on " The 
Supposed Pressure of Modern Life " may be 
commended to the attention of those who talk 
and write so much inflated nonsense on this 
subject. He thinks it has been proved that 
cancer is not really on the increase, and on 
similar grounds doubts the enormous increase of 
nervous disorders. " The vanity of human nature 
is tickled by ascribing its disorders to such 
respectable antecedents as industry, energy, and 
intellectual activity. There is no fear of any one 
of us using our brains too much for our health ; 
nor do I believe that any amount of mental labou-" 
or business, or honest work of any kind, interferes 
with health, or shortens life a day. Even if it did, 
who would not rather be worn in use than rust in 
idleness ? " 

We have only touched on a few of the many 
points of interest and value in Dr. Pye-Smith's 
lectures, and we perhaps owe the author an 
apology for extracting the tit-bits already quoted. 
Our intention, however, is but to whet the appetite 
of the reader, so that he may be prepared slowly 
and carefully (as it deserves) to consume the whole 
volume. 



THE BACTERIOLOGICAL DIAGNOSIS OF 
DIPHTHERIA.* 

A Preliminary Report. 



D. S. Davies, M.D. Lond., M.O.H. of the City and Port 
of Bristol. 

As the examination of diphtheria cultures in the 
Public Health Laboratory was, at my suggestion, 
undertaken by your committee somewhat by way 
of experiment, it is due to your enterprise in 
following the lead of the New York Bacteriological 
Department, that your medical officers should 
present a report setting forth the results obtained 
and showing, if possible, some justification for the 
new departure. I have, therefore, asked Dr. 
Dowson to prepare a statement of our experience 
up to the present in the laboratory determination 
of diphtheria, and I trust that his carefully stated 
and concise conclusions will meet with your 
committee's sanction and approval. The exact 
nature of the work done and the reasons for doing 
it are briefly as follow : — 

I. There are many throat affections attended by 
the formation of patches of false membrane, some of 

* From a special report of Dr. Davies to the Sanitary 
Committee of the Bristol Town Council. 



14 



THE BACTERIOLOGICAL DIAGNOSIS OF DIPHTHERIA. 



•which are communicable and very fatal, others are 
less communicable, and are not so dangerous or 
not at all dangerous to life. To the naked eye 
these very different varieties are occasionally in- 
distinguishable. 

2. In the communicable and fatal form of 
diphtheria (bacillary diphtheria — Lennox Browne)* 
a special and recognisable bacillus is invariably 
present (Bacill. Klebs — Lceffler). 

3. By implanting a rubbing from the throat upon 
a suitable medium {Agar ^' Brof/i" or Blood 
Scnnn) " colonies " of the bacillus can be 
separated out in twenty to twenty-four hours, and 
examined by the naked eye, and also, when 
suitably stained, microscopically, and may thus be 
recognised. 

4. In this way attention is usefully directed to 
he cases needing most careful isolation, and an 

indication is also given as to the cases in which 
'* immunised serum," which re-acts favourably on 
those cases alone where the Lceffler bacillus is 
present, may be used with the prospect of success. 
{No direct recomvtotdation as to the therapeutic use 
of this serum is, hotvez'er, issued from the Labora- 
tory, as the question of treatment after i?ifection is 
entirely outside the scope of the work of the Health 
Department). 

5. Two culture tubes containing respectively 
solidified Agar broth and a swab are, on request, 
supplied to medical practitioners, with full 
directions for use, from any one of three local 
depots, or from the office. On return they are 
examined, and a report is forwarded within twenty- 
four hours. 

6. In cases where no bacilli are found, it is a 
valid argument that by some error of inoculation 
or of observation, they may have been overlooked. 
Attention is therefore called to this point in every 
negative certificate, and the suggestion is made to 
treat the case, if clinicalfy suspicious, with the 
care usual in infectious disease. 

The cost of each culture outfit is about 4d., a 
very small price to pay for some increase of 
certainty in dealing with this dangerous and 
obscure disease. 

During the half-year's work in these examina- 
tions, two points have seemed to call for special 
comment — one, the very frequent association, 
apparently causal, of throat or other illness, 
amongst domestic animals, with diphtheria in 
human beings ; and the necessity thus indicated 
for further and more stringent control over the 
keeping both of cats and poultry within the cur- 
tilage of town houses. Many previously-recorded 
experiences have pointed to this conclusion, and 
quite recently Dr. Newsholme, of Brighton,! had 

• Diphtheria and its Associates : V>y Lennox Browne, 
F.R.CS. Edin., Illustrated by the author. London : 
Raillicrc, Tindall and Co.r, 1895. 

t Report for 2nd Quarter of 1895 ; British Med. /ourn., 
June 2Cih, 1S95. 



his attention called to cats by the notification of a 
group of cases of diphtheria in the course of a 
single fortnight, which pointed distinctly to the 
operation of some local cause. The patients com- 
prised both children and adults. They did not 
attend any particular school ; there was no com- 
munity ot milk supply ; personal infection from 
case to case could not be traced, and no sanitary 
defects were found in the affected houses. But in 
each instance there was a history that the house- 
hold cat had been ill ; and in several families the 
child who was specially fond of the cat was the sole 
victim of diphtheria. The illness of the affected 
cats had not been carefully observed, but it 
included one or more of the following symptoms: 
a bad cough, difficulty in swallowing, discharge 
from the nose, and marked emaciation. In some 
cases the cat was simply observed to be wasting, 
leading to the surmise by the owners that it had 
been poisoned. In one house in the centre of the 
affected neighbourhood nine live cats were found, 
and the neighbours stated that in the previous 
week a dead cat lay in the yard attached to this 
house, with discharge oozing from its nostrils. 
Necropsy and bacteriological examination in the 
case of four of the emaciated cats gave negative 
results, but the illness dated from a month previous 
to the opportunity for examination ; and it must 
also be borne in mind that the diphtheria infection 
in cats may result in no throat exudation, but may 
produce " an acute lung inflammation, the kidneys 
becoming degenerated in a manner known in man 
as the ' large white kidney.' " * 

Klein's own words, in his article in the " Treatise 
on Hygiene," edited by Shirley Murphy, Vol. II., 
are as follow : — 

"Cats have unquestionably been observed! to 
show disease in connection with human diph- 
theria. In houses where human diphtheria 
obtained, cats have been known to become ill, 
either antecedently, or coincidently, or subse- 
quently ; they appear to have some kind of throat 
illness, and cannot swallow ; they sneeze and their 
eyes water. As a rule, bronchial mischief is 
noticed early; and if the disease is protracted 
through several weeks, as it sometimes is, they 
become much emaciated, and die. On post-mortem 
examination, the lungs are full of grey consolidated 
lobular patches, and the kidneys are always 
enlarged and white. . . . Further, the writer has 
ascertained that an infectious disease with the same 
symptoms, and leading to the same result, exists 
naturally among cats ; the animals have severe 
lung trouble, become emaciated and die, with the 
same pathological appearances, notably on the 
part of the kidney. In one case the writer has 

* Klein — Proceedings of the Royal Society, 1890. 

t Dr. George Turner. Dr. Bruce Low, Dr. C. T. Ren- 
shaw, Dr. Thursficld ; Report by Dr. Klein, in the vol. of 
the Medical Officer of the Local Government Board, 1889, 
p. 162. 



THE BACTERIOLOGICAL DIAGNOSIS OF DIPHTHERIA. 



15 



seen such a cat, after several weeks' illness, 
showing paresis of the hind extremities." 

Much of our own experience tends to support 
these observations. 

The second point of great importance is the 
evidence of persistence of the Loeffler bacillus in 
the throat or nasal passages of patients apparently 
convalescent, a condition furnishing a possible clue 
to the elucidation of some obscure outbreaks, and 
forming, perhaps, one effective factor in the 
steadiness of the observed increase of urban 
diphtheria. 

B. Report of Work in the Public Health 
Laboratory in Connection with the 
Bacteriological Diagnosis of Diphtheria 
during the Six Months, January — June, 
1895. 

BY 

W. Dowson, M.D., 
Assistant Medical Officer of Health. 

The term diphtheria, introduced by Bretonneau 
in 1826, is an anatomical term, and therefore may 
properly be applied to any disease in which a skin 
or false membrane is formed on the affected part. 
It is true that Bretonneau himself appears to have 
had a keen eye for that kind of diphtheria which 
we indicate by the expression " true diphtheria " ; 
but unfortunately for chnical diagnosis, a descrip- 
tion of the membrane, or skin formed in this 
disease, would do sufficiently well for that found 
in any angina where the microbes present produce 
a toxin sufficiently virulent to cause necrosis 
of the cells of the part upon which they are im- 
planted ; and this is why, in many instances, false 
membranes, and so the disease with which they 
are associated, can only be distinguished from each 
other by the character of the bacteria which are 
found in them. 

Most of the sore throats in which membrane is 
formed, are due to mixed infection, that is, to the 
presence of more than one kind of microbe, 
though, as a rule, some one of these is found in 
greater abundance than the others. 

The object of the bacteriological examination of 
vhe exudate, which can generally be observed in 
the throat or other parts of the persons suffering 
from diphtheria, is to demonstrate the presence or 
absence in this, usually called the false membrane, 
of the Klebs-Loeffler bacillus, which is now 
generally acknowledged by those competent to 
form a judgment in the matter to be the cause of 
the disease which is indicated by the expression, 
"true diphtheria." There are other kinds of 
diphtheria, but in none of them is the property of 
infectivity so marked, nor the fatality so high as in 
"true diphtheria." 

During the past six months, ending June 30th, 
seventy-three cases of diphtheria have been notified 
to the medical officer of health. Two of these 



cases were subsequently decided on clinical grounds 
not to be diphtheria by the medical practitioner in 
charge of the case. The net total of notified cases 
for the half year is therefore seventy-one. Eighteen 
of these cases were suspected to be diphtheria, but 
were not notified as such until the specific bacillus 
had been demonstrated by bacteriological examina- 
tion. In twenty other suspected cases the bacillus 
was not found. 

Of eleven previously notified cases from which 
a culture was submitted to examination in the 
laboratory, the bacillus was demonstrated in six — 
in five it could not be found. 

As failure to find the Loeffler bacillus does not 
necessarily imply its absence, the five previously 
notified cases in which this happened, were still 
reckoned as diphtheria. Thus 24+5 = 29 cases 
out of seventy-one were submitted to microscopical 
test. It is much to be regretted that omission of 
the medical attendants to inoculate culture tubes, 
prevented a similar examination of the remaining 
forty-two notified cases ; especially as of the eleven 
examined five gave negative results. At the same 
time it is highly improbable that these numbers 
give anything like the ratio which would be ob- 
tained by the application of this test to a greater 
number of cases ; the figures are too small. Out 
of eighty notified cases admitted to the hospitals 
of the Metropolitan Asylums Board, the bacillus 
was found in sixty-one.* In a disease like 
diphtheria mistakes of diagnosis are unavoidable ; 
but there is little doubt that the number of mild 
cases of the disease which are either unrecognised 
or overlooked altogether, considerably exceeds 
those which are incorrectly returned as "true 
diphtheria," 

In addition to the total of forty-nine primary 
examinations, twenty-four further examinations 
were made in fifteen of the cases during the pro- 
gress of the illness, to ascertain when the throat 
was clear of the specific bacillus, and so determine 
the period of isolation necessary in each case, 
thus : — 



No. of 2nd 


examinations in positive cases .,. 


... 14 


» ,, 3rd 


)5 J> »> >> 


... 8 


„ „ 4th 


)> J» )) it 


I 


„ „ 2nd 


„ „ negaave „ ... 


I 
24 


Primary ( 


examinations ..- 


... 49 



Total examinations 



73 



Of the twenty-five cases which gave negative 
results to bacteriological examination, one was a 
case of measles, in which a dirty-coloared membrane 
appeared on one tonsil on the fifth day of illness. 
A culture tube inoculated from this yielded a per- 



* Paper by Drs. Washbourne, Goodall, and Card. Brit. 
Med. /ourn., Dec. 22, 1894. 



i6 



THE BACTERIOLOGICAL DIAGNOSIS OF DIPHTHERIA. 



fectly pure growth of staphylococcus aureus. This 
case was associated from the first with acute 
tonsiUitis and unusual swelling of the palate and 
pharynx. Septic broncho-pneumonia supervened, 
and altogether the illness ran a very severe course. 
The attack came on after a cistern in the house, 
which received the washings of a slaughter house, 
had been cleared out, causing what was described 
as " a horrible stench." 

A second negative case was associated from the 
first with acute lollicular tonsillitis and enlarged 
glands at the angle of the jaw. Cultures from the 
tonsils yielded chiefly a diplococcus. A consulta- 
tion was held in this case, and the diagnosis 
(clinical) of diphtheria was confirmed. At the end 
of a week an abscess had formed on one side of 
the neck in connection with the glands at the angle 
of the jaw. As soon as this was opened, the 
patient, who had suffered severely, rapidly recovered. 
The pus from the abscess yielded nearly a pure 
culture of a diplococcus ( ? Fraenkel's). 

As stated above, subsequent examinations were 
made in fifteen cases, fourteen positive and one 
negative, with a view to determine the period at 
which the affected part became free from the 
specific bacillus. 

Two of the cases were instances of fibrinous 
rhinitis, and were remarkable in many ways. 
Their history is as follows : — L. H. and S. H. 
went to a childien's party on December 17th, 
1894, at the house of a lady who had a tendency 
to suffer from sore throat, and who, about three 
weeks before the party, was under the care of a 
medical man, the father of L. H. and S. H., for a 
somewhat indefinite ailment of the throat, attended 
with slight difficulty in swallowing. 

Both the children were kissed by this lady, and 
on December 19th, L. H., a healthy boy of four 
and a half years, had a slight nasal catarrh, 
but was apparently quite well otherwise. On 
December 28th his right nostril was noticed to be 
blocked by a tough white membrane which, when 
detached, did not cause bleeding, although an 
abraded, vascular surface was thus exposed. On 
January 2nd, S. H., the sister, aged six vears, was 
noticed to be affected in a similar manner in the 
• left nostril. 

Culture tubes were now inoculated from the 
affected parts in both the children, and in the 
resulting growths diphtheria bacilli were recognised 
in considerable numbers the next day. As the 
general health of the children had, apparently, not 
been in the least affected, it was thought desirable 
to have this observation confirmed ; and accord- 
ingly a portion of the membrane was sent to Dr. 
Klein, who reported that, without doubt, we had 
to deal with the diphtheria bacillus, and, what was 
more important still, that his cultures of it were 
virulent to guinea-pigs. 

At the end of two months so very few bacilli, 
and these chiefly involution forms, could be 



recovered from the children's noses by culture 
methods, that they were considered harmless to 
others ; and the fairly strict quarantine which had 
been observed was removed. Active locil anti- 
septic treatment had been employed during the 
whole of this time. 

At the end of May, the mother of the children, 
the third day after playing with and kissing the boy 
to quite an unusual extent, complained of sore 
throat, which on inspection proved to be a mem- 
branous pharyngitis presenting all the appearance 
of true diphtheria. This was confirmed by inocu- 
lating a culture tube from the membrane, the 
resulting growth being almost a pure culture of the 
diphtheria bacillus. 

It was at first thought that the mother's attack 
was due to some oversight in disinfection, but an 
examination of the children's noses showed that 
membrane resembling that first observed was 
again present. The diphtheria bacillus was again 
found, and again the observation was confirmed by 
Klein. 

The mother and both the children were now 
removed to hospital, and the house and all possibly 
infected clothing, bedding, etc., thoroughly disin- 
fected. By the end of a month the bacillus, after 
repeated trial, could not be recovered from any of 
the three patients: The mother's illness ran a mild 
course, and neither of the children developed at 
any time during their illness any constitutional 
symptoms, nor did they suffer beyond the local 
discomfort of " stuffiness " in the nose. 

Another case, that of a boy of eleven, was scarcely 
less interesting and important. The medical man 
in attendance had no suspicion of diphtheria, and 
states that he noticed a " patch " on one of the 
tonsils almost by accident. As his patient was 
hardly at all ill, he inoculated a culture tube from 
this patch more out of curiosity than in anticipation 
that the result would prove of any importance; 
and consequently the laboratory certificate that 
almost a pure culture of the diphtheria bacillus 
had appeared after twenty hours' incubation was 
received with considerable surprise, if not incre- 
dulity. 

As this was the finest growth, both in the tube 
and under the microscope, that I had up to this 
time seen, I sent a sub-culture (No. i) of it to the 
Pathological Laboratory, Camb., where antitoxic 
serum was being prepared for Professor Roy by 
Dr. Louis Cobbett, with the result that it was 
found to be one of the most, if not the most, 
virulent bacillus which they had up to that time 
worked with. Dr. Cobbett has very kindly fur- 
nished me with the following data u[)on which this 
statement is founded, with permission to reproduce 
them : — 

" From this culture I obtained two varieties : — 

" a — formed large white colonies \on a certain kind 
" b — „ small colourless colonies/ of gelatine. 



THE BACTERIOLOGICAL DIAGNOSIS OF DIPHTHERIA. 



17 



With 48-hours-old broth-cultures of the two I made 
the following experiments [on guinea-pigs] : — 



.:-iv 


Weieht 


Dose. 


Result. 


(grati... ««>. 


Per Kilo. 


Actual. 




a 


760 


•067 


•OS 


Died in 48 hours. 


b 


770 


•067 


•05 


Died in less than 48 
hours. 



" For comparison, take these experiments with 
the culture I have been using for my horses. . . . 
It came from a very bad case, has yielded a very 
powerful filtrate, and I have always regarded it as a 
virulent culture." 



Body Weight 


Dose. 


Result. 


(grammes). 


Per Kilo. 


Actual. 




a + b 


620 


•05 


0-325 


Died in 54-68 hrs. 


a + b 


No Note 


•05 




Died in 96 hrs. 


a 


340 


•06 


•02 


Died in less than 48 hrs. 


b 


315 


•06 


•oz 


Died in less than 48 hrs. 


a 


410 


•07 


0-28 


Died in 60 hrs. 


b 


350 


•08 


0*28 


Died in 60 hrs. 



As Dr. Cobbett goes on to remark, this boy's 
case " affords a good example of the fact that the 
resistance of the individual is an important element 
in determining the severity of the disease." In 
order that this observation may not be misinter- 
preted, it is necessary to state here the equally 
important fact that "resistance of the individual" 
in this connection does not mean bodily vigour or 
good health. It is a striking fact, and one well 
known to medical men, that infectious disease not 
unfrequently passes by altogether or but lightly 
touches weakly children, at the same time thbt it 
attacks with great severity others in apparently the 
best of general health. The great difference 
commonly observed amongst persons in respect of 
their natural susceptibility to take a given disease, 
may be compared to the circumstances of the 
infection itself. The cleanliness which alone can 
be relied upon to ward off infectious disease is not 
housemaids' cleanliness, or ordinary personal 
cleanhness,* but a special kind of cleanliness which 
has to deal with air, water, food, clothing, houses, 
and infected persons, with the object of excluding, 
or removing, or destroying the invisible specific 
dirt ("germs") of these diseases; and it is 

* I trust that this may not be taken to mean that I under- 
value these necessary foundations for the complex super- 
structure of present-day methods of controlling disease in 
communities of people. — W. D. 



the impossibility of effecting this by ordinary 
domestic methods which makes isolation hospitals 
necessary. In the same way the resistance which 
protects a person against the invasion of infectious 
disease microbes is not the general bodily vigour 
which is implied by the term good health*; it is 
a special quality of refractoriness, different for 
different diseases, which, in the form of natural 
resistance, is but little understood at present, though 
the experimental work of the last five years has 
gone far to make less mysterious that kind of 
refractoriness which is called acquired immunity, 
as for example the protection afforded against a 
second attack by a previous attack of the same 
disease. 

It is desirable that it should be distinctly under- 
stood that the culture method is not undertaken 
with the object of correcting the diagnosis of the 
medical man in charge of a case, but in order to 
confirm by a demonstration of the presence of the 
Loefifler bacillus, the diagnosis of those of the 
notified cases which are true diphtheria, to discover 
true diphtheria amongst suspected cases, and, 
collaterally, to make possible an intelligible trial 
of the therapeutic value of antitoxic serumf together 
with the compilation of correct statistics as to the 
prevalence and fatality of the disease. 

The negative certificate does not, therefore, 
carry with it a reversal of the diagnosis on the 
notification form, not only for the reason that a 
diagnosis of diphtheria, of some sort, is sufficiently 
correct if a distinct and unmistakable false mem- 
brane is observed, but because there is always the 
possibility in bacillary diphtheria, as Dr. Lennox 
Browne:]: would term the Lceffler bacillus disease, 
either that a swab, even when applied directly to a 
diphtheria patch, may occasionally fail to carry 
away on it any of the specific microbes ; or that 
these if removed may, for some unknown reason, 
fail to grow in the culture tube. 

It must at the same time be conceded that if 
within a certain time, say twelve hours at least, no 
antiseptic preparation has been applied to the parts 
touched by the swab, the negative certificate means 
that in all probabihty no Loeffler bacilli were present 
at those particular parts ; § and if the diphtheria 
process were always confined to one spot easily 

* Neither vigorous health nor any degree of personal 
cleanliness will protect the majority of children from 
"catching" measles, for instance, if exposed sufficiently 
long to infected persons or things. — W. D. 

t Lojffler bacillus antitoxic serum should only be used in 
cases of Lceffler bacillus diphtheria. 

X Op. cit. 

\ In each of two cases of severe diphtheria, a swah 
rubbed over the surface of the greenish yellow sloughs 
covering the tonsils and soft palate failed to set up a growth 
of the diphtheria bacillus in the culture tube, although an 
abundant growth of pyogenic cocci resulted. A second trial, 
in which the swab was pushed under the edge of the slough 
sufficiently far to cause slight bleeding, was followed by the 
appearance of numerous diphtheria colonies. 



i8 



WATER CLOSETS FOR COTTAGE PROPERTY. 



accessible to the swab, this would in the majority 
of cases exclude '' true diphtheria," for the bacilli 
are disposed ver}- superficially, and when transferred 
alive, readily grow in the artificial media used in 
the laboratory. As a matter of fact, the primary 
local lesion of this disease may occur in the trachea, 
the larynx, or in the cavities of the nose, not to 
mention other places, and in such cases a swab 
inoculation from the pharynx would only 
accidentally result in the transference of bacilli to 
the culture tube. 

( To be continued^ 



WATER CLOSETS FOR COTTAGE 
PROPERTY* 

BV 

J. H. Crocker, M.D., D.S.Sc, M.O.H. of Eccles. 

In connection with the water carriage system, the 
question, " Which is the best form of water closet 



Ordinary Water Closets. — These are flushed 
with fresh water from a cistern holding about three 
gallons, the closet having a water seal. 

Trough Closets, or Latrines.. — These are of use 
where several closets are wanted in a row; they are 
flushed with fresh water by means of automatic 
syphons, action cisterns, or tippers. 

The Frost of Last Winter. — The cold period 
commenced on December 30th, 1894, and termi- 
nated in the third week of March, practically a 
continuous frost of about seventy days. 

The severity is evident from the published 
results of records taken at the observatory of our 
adjoining borough, Salford ; the mean temperature 
in January being 34'4 deg., which is 4*5 deg. below 
the average for that month, and in February 
3 1 '6 deg., or 8*3 below the average.* 

The following shows the temperature in the 
shade for the first eleven weeks of the year : — 



Month 




January. 




February. 


March. 


Week ending 


5 


12 


19 


26 


2 


9 


16 

40*0 
i8-8 


23 


2 


9 


16 


Maximum 

Minimum 


42-2 
280 


39-2 

22*2 


44 "2 
26-2 


42-8 
25 


38-6 

22-0 


39-4 
i6-8 


42-5 
270 


45-8 
310 


481 
28-2 


551 
322 



to advise in cottage property," often arises, not 
only in the case of new property, but also in that 
already in existence, there being many streets in 
this district laid out with a privy midden situated 
at the back of each house, and in the majority of 
cases about six feet from it. 

The particulars given below concerning the water 
closets already existing in this class of property in 
the borough of Eccles, I trust, will be of some 
assistance in answering the above question. 

Slop Closets. — By the term slop closet is meant 
one in which the waste water from the slop stone, 
etc., is used to flush the closet ; in the majority of 
cases — and preferably — a tipper holding about 
three gallons is interposed between the slop stone 
pipe and the closet, as in Duckett's, etc., or in the 
closet, as in Day's. 

It has been claimed for this class of closet, which 
is meant for out-of-door use only, that they act 
automatically, are inexpensive, not likely to get out 
of repair, provided they are systematically in- 
spected, and that during periods of frost they do 
not give rise to any trouble. As a system it 
economises the water supply and diminishes the 
volume of sewage to be disposed of — an important 
condition when the sewage has to be pumped, as 
it has to be at our sewage farm. 



• From a special report by the Medical Officer of Plealth 
to the Sanitary Committee of the Borough of Eccles. 



Slop Closets. — There are over 280 of these in 
use in this district. 

1. Freezing. — In no case was there any history 
of obstruction due to the frost. 

2. Tipper out of Order. — In five cases the tipper 
had been out of order. 

3. Out of Order through Obstruction.— Cause. — 
Of the 6 which have been fixed 6 months, 2 have 
been stopped owing to bricks thrown down. 

Of tht: 13 which have been fixed 9 months, 
none have been stopped up. 

Of the 5 which have been fixed 12 months, 
none have been stopped up. 

Of the 5 which have been fixed 15 months, 
none have been stopped up. 

Of the 62 which have been fixed 18 months, 7 
have been stopped up : — 

I case the main drain was stopped. 

4 were stopped with wood or sticks. 
I with rags. 

1 with a tin can. 

Of the 93 which have been fixed 2 years, 15 
have been obstructed : — 

5 cases main drain was stopped. 

2 cases stopped with floor cloth. 

5 cases stopped with wood or sticks. 
I case stopped with rajs. 
I case stopped with a salm 'n tin. 
I case stopped with rags and paper. 

• County Horough of Salford Health Bulletin, first 
quarter, 189S, by Dr. C. E. Paget, M.O.H. 



i 



WATER CLOSETS FOR COTTAGE PROPERTY. 



19 



Of the 19 which have been fixed 2i years, in i 
case the main drain was stopped. 

Of the 57 which have been fixed 3 years, 9 have 
been obstructed : — 

2 cases main drain stopped. 

2 cases stopped with brushes. 

I case stopped with floor cloth. 

1 case stopped with old bonnet. 

3 caes stopped with rags. 

Of the 14 which have been fixed 4 years, there 
is no record of any obstruction. 

Of the 12 which have been fixed an unknown 
time, 3 were obstructed : — 

2 with sticks. 
I with rags. 

Total, 284. Total obstructed, 37 ; or 13 per 
cent. Deducting stoppages of main drain, less 
than 10 per cent. 

Several of these closets are amongst the lowest 
classes in the borough. It is a general experience 
that a larger proportion of closets are stopped up 
when first adapted in a town than is subsequently 
found, and in support of this is the fact that of 
those which have been fixed for four years the 
present tenants cannot remember any time when 
the closets were stopped up. 

4. Offensiveness . — In several cases the closets 
were not clean. This is easily remedied by pouring 
down a bucket of clean water once a week. 

Ordinary Water Closets. 

1. Since when Adopted : — 

3 months ... ... ... = 15 

4, 5, and 6 months ... ... = 30 

7 and 8 months ... ... = 10 

9 months ... ... .. ^= 11 

12 months ... ... ... = i^ 

14 and 15 months ... ^ 7 ' 
18 months ... ... ... = 66 

2 years... ... ... ... = 3.S 

3 years = 13 

4 years... ... ... ... ^ 10 

7 years ... ... = 4 

12 years ... ... ... = 2 

15 years = 4 

Total 223 

2. Freezing. — {a). Cistern. Particulars con- 
cerning freezing of the cistern during the last frost 
were obtained in 126 of above : — 



Time frozen. 
Haifa day 

1 day ... 

2 days ... 

3 days ... 

4 days ... 

1 week . . . 

2 weeks 

3 weeks 

4 weeks 

5 weeks 

6 weeks 

7 weeks 



Total 



Number of cisterns. 

••• 3 
... 9 
... 29 
... 16 
I 

••• 3 

... II 

... 14 

... 19 

... 14 

... 6 
I 

... 126 



3 


Main frozen. 




Frozen I day. 
,, 2 days. 
,, 2 weeks. 




„ 3 ,. 


13 


4 ., 
No freezing. 
Frozen i day. 
,, 2 days. 


2 


>» 3 '> 



3. Water in Pan Frozen = 21. 

1. Bursting of Service Pipe through Frost =^ 34. 

5. Pan Cracked = 6. 

6. Position of Closet. — All built against the house 
excepting in 43 cases. 

7. Position of Cistern. — All in the closet and 
not cased in, excepting in the following 46 : — 

In closet and cased over = i No freezing. 
In the house and not cased =18 ,, 



In the house and cased in = 



Total ... 46 

8. Obstruction in the Pan or Drain : — 
In 16 cases the main drain had been stopped. 
In I case the pan had sunk out of.place. 
In 4 cases obstruction was due to neglect in flushing. 
In I case the pan had been stopped up with tin can. 
In I case the pan had been stopped up with floor cloth. 
In 3 cases the pan had l^een stopped up with paper. 
In I case the pan had been stopped up with brush. 

Trough Closets., or Latrines. — At present there 
are two of these in the borough, and they work 
very satisfactorily. During the last frost there was 
no obstruction due to freezing. 

Remarks. — In most of the cases where the main 
drains were stopped it was due to fine ashes, which 
had been carried in from drained privy middens. 

From the point of cleanliness the ordinary water 
closet is preferable, and from the foregoing evidence 
if the closet is built against the house and the 
cistern placed inside in the kitchen or scullery and 
properly cased in, there is little fear of freezing. 
The closet should be of the short hopper, or wash- 
down type, with a good water seal, and the cistern 
should hold at least three gallons, and be of 
syphon action, one pull of the lever ensuring com- 
plete emptying ; the supply pipe should be at least 
of i^^ inches calibre. 

In dealing with those cases where the closet is 
situated away from the house, or where the class 
of tenant is unfortunately ignorant, careless, negli- 
gent, or destructive, the slop closet is decidedly 
preferable. 

In Nottingham*, where they are about to enter 
upon a wholesale conversion of pails into the water 
carriage system, they have decided to put ordinary 
water closets in all houses of more than £,i?> 
annual rental value, and slop closets in those of a 
lower rental. 

In the case of the few blocks of closets in our 
district, and also for mills and schools, the trough 



* Public Health, May, 1895. 



C 2 



RECENT RESEARCH. 



closet or latrines, where the contained water is a 
foot below the ground level, is to be recommended. 
A regular inspection of the closets in this class 
of property should be made by the sanitary in- 
spector to ensure cleanliness and avoid neglect, 
and the keys for the regulation of the fresh water 
supply to the latrines should be under his charge. 



RECENT RESEARCH. 

The Microscopical Counting of Plates, and Its 
Special Use in the Counti?ig of JVater Plates. 
By Dr. Max Neisser. Zeitschrift fier Hygiene. 
Vol. XX., p. 119. 

The author begins his article by referring to the 
fact that the counting of plates is the only means 
used for ascertaining irregularities in the working 
of sand filter beds. The methods of counting have 
not altered much in the course of years. Usually 
a definite quantity of the fluid to be examined is 
taken, mixed with gelatine, and poured on to a 
plate or Petri dish. When the number of bacteria 
in the liquid is great, a definite quantity is taken 
and diluted with sterile water before it is mixed 
with the gelatine. 

The counting has up till now usually been done 
with the naked eye, or with a magnifying glass, 
with the aid of Wolffhiigel's counting apparatus. 
Buchner was one of the first to describe the method 
of counting the colonies upon a gelatine plate by 
the number appearing in a microscopical field of 
known size. Giinther in his text-book recommends 
this method for plates that are thickly sown with 
colonies. The average number of microscopical 
fields counted would be from 10 — 20. In plates 
very thickly sown, an eye-piece i)rovided with a 
micrometer would have to be used. 

The object of the present paper is to show how 
far the microscopical counting of plates gives 
accurate results, and further, up to what maximum 
and minimum in the number of colonies can 
microscopical counting be employed, and, finally, 
how many microscopical fields should be counted 
as a rule to give an accurate average. 

Experiments were made to determine these 
points in plates made from pure cultures, and 
also from mixed sources, as, for instance, water. 

Amongst the objections to counting colonies 
with the magnifying glass are that very often the 
colonies cannot be seen, so small are they ; they 
may be so close to others as to be indistinguishable 
from them ; more than 20,000 colonies on a plate 
cannot be counted without introducing great errors 
in the calculations. Further, since plates but 
sparsely sown with colonies arc best fitted for 
counting in this way in order to arrive at that 
result, dilutions are made which tend to introduce 
other sources of error, as the total number found is 
multiplied by the factor of dilution. 

Experiments were made by (i) comparing the 



result of counting plates with the hand lens and 
with the microscope ; (2) comparing the numbers 
found in different plates which had been inoculated 
with definite known cjuantities of a pure culture ; 
and (3) several microscopical countings of the same 
plate were made on different days with the view of 
finding out whether the results harmonised 
sufticiently with one another. 

The conclusions are : — 

(i) In pure cultures with 1,500 or more colonies 
to a plate, the microscopical counting is decidedly 
to be preferred to that of the hand lens. When 30 
microscopical fields are counted, the error does not 
exceed +Jth or — ^th. 

(2) In pure cultures, when the number of 
colonies varies between 600 and 1,500, the errors 
of the microscopical method of counting are greater, 
and rnay, when 60 fields are counted, be as high 
as +ird or — |th. But in these cases the errors 
from counting with the hand lens may be even 
greater. 

(3) In pure cultures where the colonies number 
300 — 600, when 90 fields are counted, the error may 
be as much as +^. Counting with a hand lens 
gives similar results. 

(4) Where less than 150 colonies occur, the 
microscopical method is not indicated. 

(5) All these errors are diminished by increasing 
the number of microscopical fields counted. 

(6) In quantitative experiments, for the sake of 
accuracy, it is not advisable to carry dilutions so far 
that such low numbers are obtained. 

(7) Mixed plates {i.e., those not made from pure 
cultures) should always be counted by means of 
the microscope, because of the presence usually of 
small colonies. 

(8) Whether the results obtained by counting 
with the hand lens give an accurated measure of 
the number of bacteria in water has still to be 
proved. 

(9) If it is necessary to count a plate by means 
of a hand lens, then it should always be subjected 
to a microscopical examination first to see whether 
it is suited to the first-named method. 

(10) In every counting it should be stated 
whether it was done with the hand lens or micro- 
scojje, and after how many hours. In every 
microscopical counting, the size of the field should 
be given, and especially the number of separate 
fields that were counted. 



Bacteriologischc Studien iibcr Margarin und 
Margarinproducte. By Drs.Jolles and Winkler, 
/.eitschrift fitr Hygiene. Vol. XX., p. 60. 

The experiments were undertaken with the view 
of seeing whether the same conditions hold good 
for margarine as are found in butter. Butter con- 
tains on the average an enormous number of 
bacteria (10 — 20 millions in i gram.). There can 
be no question that inflammations ot the mucous 



THE INITIAL RASHES OF SMALL-POX. 



21 



coats of the stomach and intestines has been not 
unfrequently induced by the ingestion of fats, and 
especially of butter fat. Nor is the possibility of 
butter containing pathogenic microbes excluded. 
Ostertag has recorded a case in which a student 
became ill after the consumption of butter made 
from the milk of cows suffering from foot and 
mouth disease. The development of tubercle it 
is suspected may occasionally originate in a 
similar way. 

The substances on which the authors experi- 
mented were margarine and its products, margarin- 
butter (made by adding diluted cow's milk to the 
margarine), and margarinscJwialz (made by add- 
ing lo — 15 per cent, cotton seed oil to the raw 
margarine). The results of the inquiry are summed 
up as follows : — 

In comparison with ordinary butter the number 
of bacteria in margarine and its products is small. 
During the first forty-eight hours the average 
number of bacteria per gram of margarine was 
about 2,000, after three weeks 7,000, and after two 
months, when left in contact with the air, about 
10,000. In the margarine products the numbers 
vary from i — 6 millions in i gram, of the substance. 

The number of bacteria found in the margarine 
products is much greater than the number in the 
margarine itself 

During the manufacture of the margarine the 
number diminishes. 

The number of microbes is less in margarin- 
schmalz than in margarinbiitter. 

In margarine the bacteria increases with the 
length of time that this is kept, and on the surface 
there are far more than in the interior. As an 
example of this, after three weeks, 10,568 bacteria 
were found in i gram of the outside of , the 
margarine, and only 3,464 in a similar quantity 
from the inside. 

The rancidity of butter has a direct connection 
with the increase in the number of bacteria, and 
this increase is proportional to the advance of this 
rancidity. 

Cold exercises a marked influence in killing the 
bacteria in the case of the margarine products. 
Thus, in margaritibutter, with 3,642,400 bacteria 
in I gram, the effect of cold acting for four weeks 
was to reduce this to 2,900. No sterilization of 
the substances can, however, be brought about by 
the action of cold. 

Although in margarine the external portion is 
richer in bacteria than the internal, yet in the i)ro- 
ducts made from margarine the outside is poorer 
in bacteria than the inside, but this deficiency in 
bacteria is compensated for by the increase in the 
moulds. 

Fat derived from sick animals, or fat that has 
been spoilt in any way, ought not to be utilized for 
the manufacture of margarine. 

The use of centrifugalised milk and of water as 
free from bacteria as possible help to keep down 



the number of germs in margarinbutter. The 
authors could not detect any pathogenic bacteria, 
nor could they find any trace whatever of tubercle 
bacilli, for which they searched carefully. The 
species that they found were one and all sapro- 
phytes belonging either to the air, water, or milk. 

Two kinds of bacteria were found in margarine 
(not hitherto identified) which were met with 
greater frequency when rancidity had been de- 
veloped, and they are inclined to regard them as 
standing probably in some casual connection with 
this process. In margarinbutter four hitherto 
undescribed organisms were found. 



THE INITIAL RASHES OF SMALL-POX. 

BY 

W. Arnold Evans, M.D. Lond., M.O.II. Bradford. 
During the epidemic of small-pox which occurred 
in Bradford in the year 1893, many examples of 
the prodromal eruptions which occasionally appear 
in small-pox came under the notice either of my 
colleague, Mr. Foster, Medical Superintendent of 
the Fever Hospital, or myself. But to the great 
majority of medical practitioners who, during a 
lifetime, see only a few cases of small-pox, they 
are, I believe, little known, for their occurrence 
has been noted only in a small percentage of cases 
of the disease. Until a few years ago the existence 
of a prodromal rash in small- pox was not generally 
recognised, although it was fully admitted that 
two exanthematous diseases, e.g., small-pox with 
scarlatina or measles, might, and occasionally did, 
exist concurrently. The information derived from 
a study of the Bradford epidemic points strongly 
to the conclusion that the initial rashes occasionally 
seen in small-pox are symptomatic of the disease, 
and not due to the co-existence of any other 
exanthem. At the same time, I do not wish to be 
understood to say that the initial eruptions in 
small-pox are never imitated by the simultaneous 
existence of some other zymotic disease. Those 
who are intimately concerned in the administration 
of fever and small-pox hospitals sometimes see 
undoubted examples of such perplexing com- 
binations. 

Careful observation of a few cases of small pox 
accompanied by an initial rash would, I think, 
often enable a practitioner to observe a discreet 
silence in reference to the diagnosis of some 
doubtful eruption, and occasionally to correctly 
diagnose a case of small-pox before the appearance 
of the papular eruption, which usually appears on 
the third day. It is on this account that I 
venture to make a few observations on such a 
comparatively obscure subject — one that cannot be 
said to have a burning interest to the great majority 
of medical men. It is quite unnecessary to point 
out the advantages of early diagnosis in cases of 
small-pox. The disease being so virulently 
infectious in its earliest stage, any practitioner who 



THE INITIAL RASHES OF SMALL-POX. 



failed to make use of every point that could help 
him in its detection would incur a very serious 
responsibility, and might perhaps allow to slip by 
the golden opportunity of protecting, by vaccina- 
tion, those who had been in contact with the 
infected person. A patient, too, who has an idea 
that all diseases are distinctly labelled from their 
onset would have a poor idea of his doctor, who, 
after having watched the progress of an eruption 
for four or five days, finally told him that he was 
attacked with small-pox. 

The varieties of the initial rashes are not 
numerous, and a simple classification will answer 
all practical purjjoses. In apai)er published in the 
St. Thomas's Hospital Report for 1880, Dr. 
Sharkey gave the one which is here adopted, viz.: — 

(a) — General Erythema. 

I. — Scarlatiniform. 
2. — Morbilliform. 

(d) — Partial Erythema. 

I. — On Exterior surfaces. 
2. — On Flexor surfaces. 

The first variety of the general group often 
strongly resembles a typical rash of scarlatina, and 
in reference to this eruption Dr. Liveing makes 
the following statement: — "The eruption of small- 
pox, as is well known, may be preceded by a 
copious erythematous rash or roseola which may be 
easily mistaken for scarlatina. The characteristic 
position of this rash is the lower half of the 
abdomen and the anterior aspect of the thighs, and 
when the rose rash is confined to this region we 
should be on our guard, and suspect that we have 
to deal with a case of small-pox. The red rash is, 
however, by no means limited to these spots, but 
may exist on other parts of the body ; and I have 
on several occasions known it mistaken for scarlatina 
by experienced medical men even during an 
epidemic of small-jjox, and in truth the mistake is 
a very excusable one. It is well to remember that 
the eruption in scarlatina first appears on the neck, 
and that this is not the case in the rose rash which 
precedes small-pox." 

But every case of rose rash referred to by Dr. 
Liveing does not come under the heading of 
scarlatiniform ; I should include only those case- 
in which the eruption is general, and presents a 
striking similarity to scarlatina ; those in which the 
eruption is limited to the inner aspects of the 
thighs and lower part of the abdomen fall more 
appropriately under the second general heading of 
IKirtial erythema. 

Out of a total number of 42 cases of small-pox 
with prodromal eruption, I noticed the scarlatiniform 
variety in seven, four of which were in females and 
three in males. The ages of the patients varied 
from 15 to 36. They had all been vaccinated in 
infancy, and all recovered. 

Ot the mobilliform variety only four cases were 
described in the hospital records, but in addition I 
had several under observation at their own homes 



for a few days in company with the medical 
attendant. The eruption is such a complete 
counterfeit of measles that one is not inclined to 
remove such a case to the small-pox hospital until 
the papular rash has commenced to appear. The 
four cases referred to were admitted to hospital be- 
tween the third and sixth day of the disease. It 
was noticed that on the appearance of the papular 
eruption the prodromal rash rapidly faded away. 
Two of the patients were males and two females, 
their ages varying from 13 to 38. Recovery 
occurred in each case. 

But the erythematous form of initial rash, usually 
affecting only certain parts of the body, seems to be 
the most common. The great bulk of our cases 
which presented any prodromal rash at all came 
under this heading. Generally the rash was most 
marked in the groins, on the lower part of the 
abdomen, and inner aspects of the thighs, but in 
some few cases was present also on the limbs and 
greater part of the body. It varied from a slight 
rose rash to a dark purplish petechial eruption. 

During the period of the epidemic I frequently 
noticed this form of initial eruption, and formed 
the opinion that when present, especially if in 
addition it be continued along the flanks into the 
axilla, a diagnosis of small-pox could safely be 
made before the appearance of the characteristic 
popular eruption. 

Regarding the significance of the eruptions now 
under consideration, my colleague, the Superin- 
tendant of the Fever Hospital, observes that those 
parts of the body covered by an initial rash are 
rarely invaded by the subsequent papular eruption 
of small-pox. From which it would apparently 
follow that the more extensive the initial eruption 
the less likely is there afterwards to be a serious 
crop of pai)ules. But on this point my experience 
is not confirmatory, for I distinctly recollect two 
severe cases following upon an extensive initial 
rash. However, the curious fact remains, that each 
of the forty-two cases, upon an examination of 
which this communication is based, ended in 
recovery, whereas if the ordinary case mortality of 
the epidemic — 11 "2 per cent. — had obtained 
amongst them there would have been four or five 
fatal cases. It would therefore appear that an 
initial rash is not an unfavourable sympton. 

In a small publication, " On the Diagnosis of 
Small-pox in its Early Stages," Dr. Savill, of the 
Marylebone Infirmary, from an examination of 
1,375 cases of small-i)Ox, states that in his opinion 
these initial rashes arc " comparatively rare." My 
observations arc founded upon an examination of 
1,055 cases, and I noticed that in 3*9 per cent, of 
them an initial eruption was present. Although 
this may be called a small per ccntage, I think it 
sufficiently large to be borne in mind when investi- 
gating the character of some suspicious exanthem. 
The prompt recognition of such an eruption will be 
found to be a most useful adjuvant in diagnosis. 



A MUNICIPAL NIGHT SHELTER IN PARIS. 



23 



A MUNICIPAL NIGHT SHELTER IN 
PARIS. 

(By a Special Correspondent.') 

In the Xlllth arrondissement, far from the Champs 
EIys6es and the Louvre, and all the pleasant places 
of Paris, is the Rue du Chateau des Rentiers. 
The street opens out of a broad boulevard, in the 
making of which numberless families must have 
been displaced, to judge by the crowded condition 
of the narrow courts and alleys in its immediate 
neighbourhood, recalling the worst features of the 
mean streets of our own East-end. Blear eyed 
dishevelled women guard the tunnel-like entrance 
to these courts, children sprawl in the mud every- 
where, rendering it hard to believe that in point of 
squalidness the district is beaten by the XXth 
arrondissement, M^nilmontant. The Rue du 
Chateau des Rentiers is a long winding street, one 
< f the least typical in Paris, containing houses of 
all sorts and conditions. Houses six stories high 
adjoin tumble down cabarets of but one story and 
an attic. It is as though all the varieties of houses 
met with in the city were brought together — a few 
good, most bad or indifferent — and jumbled up 
anyhow. Every other house nearly has the sig- 
nificant inscription, " Vins et Liqueur?," with the 
tempting offer to the wayfarer of absinthe at 
fifteen centimes the glass. Grands hotels meub!es 
seem to flourish, although the panes of glass in 
the windows are often broken, and what would 
seem an inefficient substitute found in a sheet of 
newspaper. The only bright feature in the street 
(if one excludes the shining nickel-plated bars of 
the wine shops) are the windows of the bakers' 
shops, with the long crisp brown loaves of bread 
slashed diagonally in them. Tall chimneys are ^ 
dotted about, which mark the cheery business done 
by candle and manure manufactories in the neigh- 
bourhood. A few ragged tricolor flags looped up 
mark the fact (which might otherwise be overlooked) 
that Liberte, Egalite, and Fraternite, flourish and 
abound in the street. One of these is over the 
door of the Commissaire de Police ; another over 
the gate in a long high wall is more interesting, as 
it indicates the Asile de Nuit of the Prefecture of 
the Seine. 

About six o'clock in the evening is the best 
time for a visit, as then the courtyard will be found 
filled with some two hundred wretched specimens 
of humanity, who have come for a night's lodging. 
Some are vagrants, others are merely men down on 
their luck — stonemasons, carpenters, compositors, 
or labourers, who have come to the capital, hoping 
to secure higher wages, only to find that they do 
not always better themselves there. 

They form a queue, and enter the building in 
single file. Everyone has to take a bath ; five at a 
time they strip, and are made to stand in a foot 
bath under a shower of warm water, soft soap 
being ladled out to each one. Meanwhile, their 



clothes are hung on a bar, and carried to a steam 
disinfecting machine. They need the bath, many 
of them, but the stripping also serves incidentally 
another useful end, in enabling the attendant to 
see whether there is any suspicious rash, as that of 
smallpox, for instance, out on their bodies. The 
bath completed they put on, until their clothes are 
returned from the disinfector, a linen suit, provided 
by the refuge, and pass into a large room where 
they are regaled with a basin of bread and lentils, 
which nourishes them without pampering their 
appetites. By the time the meal is ended, their 
clothes have been disinfected, and after putting 
them on, they are allowed, if the weather is fine, 
to go into the garden and smoke for an hour. 

In each of the two long dortoirs there are one 
hundred and three beds, placed pretty close to- 
gether, it is true, and provided each with a mat- 
tress, sheets, and two blankets. Everything about 
the dortoirs and lavatories was very clean and well 
kept. At six o'clock in the morning, after a wash 
and a bowl of food, they must go out in search of 
work. Each person is allowed to sleep in the 
refuge for three successive nights once every two 
months. Where many of them sleep in the 
interval is known probably only to themselves and 
the Commissaire de Police. 

Perhaps the most important point in this shelter, 
and in the exactly similar one on the Quai de 
Valmy, is the disinfection of the clothing of the 
men that is practised. Adjoining the night refuge 
is one of the stations of the Etiwes Municipales 
of Paris, or public disinfecting stations, in which 
there are two large steam disinfecting machines, 
made by G^neste and Herrscher. The building is 
divided into two halves by a brick wall, and built 
into the middle of the wall are the disinfecting 
ovens. One side is exclusively devoted to the 
reception of infected articles, and the other for 
the same when they have been disinfected by 
passing through the machine. The persoinel on 
the two sides is absolutely distinct. 



A NEW DISINFECTING APPARATUS. 

Dr. J. C. Thresh, D.Sc. Lond., M.O.H. of 
Chelmsford, etc., has devised a new steam dis- 
infector, which will shortly be placed upon the 
market. In this apparatus disinfection is accom- 
plished by means of " current " steam at a few 
degrees above 212*^ F., and perfect drying by hot 
air, which is introduced instead of the steam by 
the movement of a lever. The apparatus has been 
tested, and favourably regarded by well-known 
experts. Its further development will be watched 
with interest, as there can be no doubt that a 
cheaper form of disinfecting apparatus (as this is 
intended to be) than the English forms at present 
in use is one of the great desiderata in EnghsK 
sanitary practice. 



24 



LAW REPORTS. 



SUPPOSED ETIOLOGY OF DIPHTHERIA. 

Croydon. 
Dr. Leonard Wilde remarks : — " It seems clear 
that the supposed relation of diphtheria to drainage 
defects is quite unconfirmed as far as Croydon is 
concerned, the main local factor in its dissemina- 
tion being undoubtedly school attendance. It has 
also been observed that a prevalence of sore throat 
among school children frequently precedes the 
notification of cases of diphtheria, and seems to 
pave the way for its development. A large number 
of cases still remain, particularly in certain locali- 
ties, which cannot be ascribed to either school 
attendance, pre-existing throat illness, or drainage 
defects, and these would appear to have an entirely 
de novo origin, and the chief causes of their 
evolutionary development are possibly darkness, 
dampness, and decomposition, and the contamina- 
tion of the surrounding soil with effete products." 

Bristol. 
Dr. Davies notes : — " The tendency shown by 
diphtheria of late years to increase as a cause of 
sickness and mortality in the large urban districts 
of England and Wales, is unfortunately now shared 
by Bristol. The notified cases, which rose from 
70 in 1891 to 106 in 1892, show-ed a further 
increase in 1893 to 141, and this year numbered 
128 ; while the deaths, which numbered 16 in 1891, 
rose to 38 in 1892 and 53 in 1893, and numbered 
50 in this year. No widespread outbreak trace- 
able to any common cause, school association, or 
other conditions occurred during the year." 

Salford. 
Dr. C. E. Paget reports : There were 203 cases 
of diphiheria and 39 of membranous croup during 
the year 1894, as against 207 of diphtheria and 54 
of membranous croup during the year 1891, as 
against 204 and 27 respectively in the year 1892, 
as against 222 cases of diphtheria in 1891, and as 
against 694 cases in 1890. The stationary character 
ot this disease, therefore, in the borough, to which 
I have before called attention, has now been main- 
tained during a j^eriod of about four years, and 
none the less it cannot be denied that the amount 
of prevalence is too high. It is much higher than 
it was in the years preceding the great epidemic of 
the disease, which commenced in the year 1888, 
and which did not subside until the close of the 
year 1890. A comparison with the figures of those 
earlier years shows this clearly, since in 1883 there 
were only 81 cases ; in 1884, 99 cases ; in 1885, 54 
cases ; in 1886, 42 cases ; in 1887, 83 cases ; and 
in 1888, 176 cases. I am still hopeful, however, 
that the measures of disinfection and general sani- 
tation, which are continuously being carried out in 
the borough, may yet bring the annual prevalence 
of the disease to a lower level than has been the 
case during the past four years ; and that the 
nearer approach to the condition of things existing 



before the great epidemic period mentioned, may 
yet be attained. 

The number of notifications during the year 
1894 shows that the disease was very evenly main- 
tained throughout the year, the numbers for the ■ 
consecutive quarters having been 58, 46, 46, and I 
53. Of the whole number of cases, 79, or 38-9 
per cent, were of children under five years of age, 
as against 34-8 per cent, in 1893, 30*4 per cent, in 
1892, and 34'2 per cent, in 1891. 

Preston. 

Dr. Pilkington remarks : Diphtheria is a disease 
which is happily not common, and certainly not 
prevalent, in Preston, and as regards the amount 
of sickness and the number of deaths caused by it, 
the town compares very favourably not only with 
other large towns, but also with many country dis- 
tricts, because it is in the rural districts that 
diphtheria not unfrequently assumes epidemic pro- 
portions. 

It is a question whether or not diphtheria can 
actually be created from sewage matter, but it is 
certain that in country districts it is most frequently 
met with in those situations where stagnant sink 
ditches most abound, and in those towns where 
there is a heading back of the sewage, with the 
result that the traps are forced, and the sewage 
matters find entrance into the houses. 

The death rate from this cause only amounted 
to 07 per thousand, Sunderland being the only 
one of the other large towns which showed a lower 
mortality. 



LAW REPORTS. 



BaDLEY V, CUCKFIELD UnION RuRAL DISTRICT 

Council. 

Public Health — Building Bye- Laws — Construction 
of IValls — " Hard and IncomlnistibU Materials " 
— Slieets of Galvanised Iron supported by Wooden 
Posts and Frames. 

By one of the Building Bye-Laws made by the 
Cuckfield Union Rural District Council, under 
Section 158 of the Public Health Act, 1875, it was 
provided that " Every person who shall erect a new 
building shall cause such building to be enclosed 
with walls constructed of good bricks, stone, or 
other hard and incombustible materials properly 
bonded and solidly put together." 

In pursuance of the bye-laws, the Plaintiff sub- 
mitted for the approval of the District Council 
plans of a building which he proposed to erect for 
the purposes of a sanatorium in connection with a 
boarding school of which he was the proprietor. 
The proposed building was to be constructed of 
external sheets of corrugated galvanised iron, one- 
thirty-sccond part of an inch in thickness, lined 
with a layer of felt three-sixteenths of an inch in 
thickness, and with an inner lining of match- 



LAW REPORTS. 



25 



boarding, and fixed to the outside of a framework 
of wooden posts and rails. The District Council 
refused to approve these plans, on the ground that 
the building contravened the above bye-law re- 
lating to the mode of construction of the walls of 
new buildings. 

A special case for the opinion of the High 
Court was thereupon stated by arrangement between 
the parties, and this case was argued before a 
Divisional Court of the Queen's Bench Division, 
consisting of Lord Russell, C.J,, and Charles, J., 
on the 22 nd May last. 

The Court held that the walls of the proposed 
building must be taken to consist of the wooden 
posts and rails as well as of the sheets of corrugated 
iron, and that the walls would, therefore, not be 
constructed of "hard and incombustible materials,'' 
and that the proposed building, not being in 
accordance with the bye-law, the District Council 
were justified in refusing to approve the plans. 



The case is reported in 72 Law Times (N.S.)> P- 775- 



Kershaw v. Taylor. 

Metropolis Management Acts — Sewer — Drain — 
Liability to Repair — Effect of Builders Dis- 
obeying Order of Sanitary Authority. 

This is another case illustrating the difficulties 
arising in connection with joint drains and the 
unsatisfactory state of the law on that subject. 

Under the Metropolis Local Management Act, 
1855, the duty of repairing sewers lies on the 
Sanitary Authority, and that of repairing drains on 
the owner of the premises. 

By Section 250 of the Act, the word "drain" is 
defined to mean any drain of and used for the 
drainage of one building only, and to include any 
drain for draining any group or block of houses by 
a combined operation under the order of any 
vestry or district board ; and the word " sewer " 
is defined to mean and include sewers and drains 
of every description, except drains to which the 
word "drain " as above defined applies. 

In the present case it appears that in 1887 a 
builder deposited with the Board of Works for the 
Wandsworth District a plan showing the proposed 
means of drainage of six semi-detached houses 
which he proposed to erect in Tankerville Road, 
Streatham. This plan showed a scheme of 
drainage by which the sewage from each pair of 
houses was carried into the public sewer by 
means of a single drain. The plan of drainage 
was sanctioned by the Board, and the builder 
proceeded to erect the houses, but improperly, 
and without the sanction of the Board, connected 
the drainage of two pairs of the houses, and from 
the point of junction carried the drainage of the 
four houses into the sewer by means of a single 
drain wholly situated within the premises of 



one of the houses. The builder afterwards sold 
these four houses to different purchasers without 
notice that the system of drainage had been con- 
structed without the consent of the Board, The 
Respondent subsequently became the owner of the 
house through which the single drain ran. In 
1894 a nuisance arose upon the premises, and the 
Sanitary Inspector for Streatham served a notice 
upon the Respondent, requiring him to abate the 
nuisance, and to execute certain works for that 
purpose. 

On opening the ground for the purpose of doing 
the work, the Respondent discovered that the 
drain running through his premises also received 
the drainage of the other three houses, and he 
thereupon refused to repair the drain beyond the 
point where it received the drains from the other 
houses, contending that from that point it was a 
sewer and as such vested in the Board, and that 
he was consequently not liable to repair it. 

Shortly after this the owner of one of the other 
houses disconnected his drain from the joint 
system of drainage, and caused his house to be 
redrained directly into the public sewer. The 
other three houses, however, continued to be jointly 
drained as before. 

In January, 1895, the Appellant (the Sanitary 
Inspector for Streatham) issued a summons against 
the Respondent in respect of the nuisance. Upon 
the hearing of the summons, the Magistrate held 
that inasmuch as the drainage system existing 
upon the premises had never been approved by 
the Board, the drain in question was a sewer from 
the point where it received the drainage of the 
other premises, and he therefore dismissed the 
summons subject to a case for the opinion of the 
Court on the question of law involved. 

The case was argued on the 17th June last, 
when it was contended for the Appellant (the 
Sanitary Inspector) that the wrongful act of the 
builder in laying out the drains of the houses in 
contravention of the plan approved by the Board 
could not impose on the pubhc the obligation to 
repair such drain, which obligation would, if the 
builder had obeyed the Board's order, have lain 
upon the owner. 

For the Respondent (the owner) it was argued 
that the appeal could not succeed unless the 
system of drainage was proved to be a drain within 
the meaning of the Act, and that to bring it within 
that definition the drainage must have been executed 
under an order of the Board. Here what the 
Board had approved was very different from what 
was done. The Board might be without remedy, 
but the argument of hardship was of no value. 

The Court (Wright and Kennedy, J.J.) held 
that the system of drainage was a sewer within the 
meaning of the Metropolis Management Acts, and 
that the act of the builder, in constructing the 
drain otherwise than in the manner authorised by 
the Board, did not debar the owner from setting up 



26 



REPORTS OF MEDICAL OFFICERS OF HEALTH. 



the defence that ihe system of drainage was a sewer, 
and therefore repairable by the Local Authority. 

The case is reported in Law Reports (1895), 2 Queen's 
Bench, p. 20S and in 64 Law Journal Reports, p. 222. 



The Queex v. Slade; ^'a- parte Saunders. 
Public Health {London) Act, 1891, Section 5, Sub- 
section ()^ Summary Jurisdiction Act, 1848, Sec- 
tion II. — Closing Order — Conviction — Limita- 
tion of Time. 

This was an application for a certiorari to quash 
a conviction made by a Metropolitan Police Magis- 
trate in respect of the failure of the Defendant to 
obey a closing order made in respect of certain 
premises of which he was the owner. 

By the Public Health (London) Act, 1891. 
Section 5, Subsection 9, it is provided that if a 
person knowingly and wilfully acts contrary to a 
prohibition or closing order he shall be liable to 
a fine not exceeding 40s. a day during such con- 
trary action. 

By the Summary Jurisdiction Act, 1848, Sec- 
tion II, it is provided that any complaint or 
information (except where otherwise provided) 
shall be laid or made within six calendar months 
from the time when the matter of such complaint 
or information arose. 

In the present case, the Prosecu'ors, a District 
Board of Works, had served on the Defendant a 
notice calling upon him to abate a nuisance exist- 
ing on certain premises, and on his failing to 
comply with the notice the Defendant had been 
summoned and fined, and a closing order had 
been made against him. 

The Defendant had, further, failed to comply with 
the closmg order, and was summoned for having 
knowingly and wilfully acted contrary to the order. 
The Magistrate convicted the Defendant and im- 
posed a fine of IS. per day for a period of 193 days 
during which the Defendant had acted contrary to 
the order. 

Application was made on behalf of the Defendant 
for a certiorari to quash this conviction on the 
ground that by reason of the limitation of time 
prescribed by Section n of the Summary Jurisdic- 
tion Act, 1848, the Defendant could not be liable 
to a fine in respect of a period exceeding six 
calendar months. 

The Court (Wills and Wright, J.J.) held that the 
conviction was wrong on the ground that it was 
for an offence extending over a period of time 
which comprehended eleven days in excess of the 
period of six months limited by the Summary 
Jurisdiction Act, 1848, and they decided that as 
they could not take the conviction to pieces so as 
to reduce the amount of the penalty by the amount 
imposed in respect of those eleven days, the con- 
viction must be quashed. 

The case is reported in Law Reports (1895), 2 Queen's 
Bench, p. 247, and in 56 Justice of the Peace, p. 471.^ 



REPORTS OF MEDICAL OFFICERS OF 

HEALTH. 

Belfast. 

Notification of Disease. — Dr. Whitaker pleads 
for the extension of this to Belfast as follows : — In 
every annual report which I have presented to you, 
I have called your attention to the fact, that I 
have no means of knowing, except to a very limited 
extent, when or where disease exists amongst us. 
In every other large city or town in the United 
Kingdom the medical officer of health is officially 
informed, and can report to his committee the 
occurrence of infectious disease when it appears, 
and take the necessary steps to prevent its spreading 
amongst the community. This is a most impor- 
tant matter, as it is only by prompt care and 
vigilance, in the first few cases of many of these 
diseases, that an epidemic entailing much suffering 
and loss of life may be averted. I should also 
know where, when, and from what causes, our 
deaths occur. It is impossible to take measures 
to counteract disease when I neither know the 
causation, nor the locality in which it occurs. I 
should be able to keep you regularly informed on 
these matters, both as to the nature and extent, as 
also the locality of the diseases occurring amongst 
us. Maps of Great Britain and Ireland are pub- 
lished from time to time, on which are shown the 
rocks, reefs, and sands round our coasts, upon 
which shipwrecks occur and mariners' lives are 
lost ; so should I be able, with my report, to place 
before you a map of our city, upon which you 
would see marked, the streets, lanes, and alleys in 
which disease and death prevails to an abnormal 
extent, and where it would be the duty of your 
officers to thoroughly examine into the causes 
therefor, and report to you, as to the remedies to 
be a<iopted to remove them, if possible. The 
public would then know the unhealthy districts, 
and the landlords, in self defence and in their own 
interests, would only be too ready to co-operate 
with you in providing for the sanitary defects, a 
remedy whereby their property would be improved, 
and the health of the people living therein placed 
in a better and more satisfactory condition. Did 
we go into court to compel sanitary work to be 
carried out, as we often have to do, there could be 
no defence, were we able to show an extra amount 
of disease and death in the locality of which we 
complain. 

Chester (County of). 

Midden- Generated Enteric Fever. — Dr. Vacher 
asks : What is it that causes outbreaks of typhoid 
fever so frecjuently ? Without doubt it is the 
usually ne\:;lected condition of the closets and middens. 
This is the predisposing cause. As soon as the 
disease is imported, at the back of three-fourths of 
the dwelling-houses is a hotbed ready, where the 
seeds of the disease are received,- to grow and 
multiply. The same story is told in report after 



REPORTS OF MEDICAL OFFICERS OF HEALTH. 



27 



report with wearisome reiteration. What was to 
all intents and purposes the same event is recorded 
in respect of eight urban districts and six rural 
districts. Even in the districts where there was 
no typhoid fever in 1894, the immunity was pro- 
bably not due to the absence of the predisposing 
cause, but the absence of the exciting cause — that 
is, the disease not having been imponed. 

What is the remedy for this evil ? The answer 
is simple enough. Wherever it is possible abolish 
the ubiquitous midden-privy, arrange for the pro- 
vision of water-closets, and educate householders 
to burn their house-refuse on the kitchen fire. 

Durham (County of). 

Dust-boYne Enteric Fever. — Dr. Eustace Hill 
reports that the medical officer of health for 
the Sunderland rural district suggests that the 
disease is sometimes spread by infected dust 
from the contents of midden-privies being 
carried into the open reservoirs used for storing 
drinking water, which are frequently placed in 
proximity to centres of population ; and in fact in 
nearly all the health reports the cause of enteric 
fever is attributed to the existence of insanitary 
conditions, which have long been recognised as 
such, and to remove which every endeavour should 
be made. 

Essex (County of). 

Dr. Thresh calls attention to the " frightful 
mortality among children under five years of age " 
in certain parts of the County of Essex. The method 
of comparison of the different urban and rural dis- 
tricts in the county adopted by Dr. Thresh is to 
" take the percentage of deaths of children under 
five years to the total deaths." The differences 
thus shown are very startling. Out of 100' total 
deaths in the respective districts, only 16 occurred 
among children under five years of age in Chelms- 
ford, at one end of the scale, while 58 occurred at 
Grays at the other end of the scale. How far this 
represents the real facts must remain for the pre- 
sent uncertain. Probably the true death rate of 
children under five (per i,coo children living at 
the same age) is higher at Grays than at Chelms- 
ford ; but there can scarcely be such a difference 
as the above figures would imply. It may be im- 
practicable to discover the true death rate of 
children for small districts, the true population 
under five years of age not being known. Judging 
by infantile mortality, the true proportion between 
Grays and Chelmsford is, probably, more nearly 
32 to t6 than 58 to 16, as in 1894 the infantile 
mortality (per 1,000 birtns) was 78 in Chelmsford 
and 154 in Grays. 

Birth Rates. — Dr. Thresh remarks : — There is 
no doubt that the great factor influencing the 
birth rate in the various districts is the proportion 
of young adults to the total population. In the 
purely agricultural districts, the girls migrate as 



soon as they are of age to act as domestic servants, 
and the lads remove to manufacturing districts to 
find employment. Here they marry and increase 
the birth rate, whilst in the districts they have left 
the birth rate is correspondingly lowered. Compare 
the rates for Chelmsford (22*9) and Dunmow (23*0) 
with those for Orsett (34'i) and Romford (33*0). 
In the towns, also, the birth rates vary very con- 
siderably ; but, as a rule, we find the highest rates 
where there is the greatest working-class popula- 
tion, as in Barking, with a birth rate of 42* i per 
1,000 population. 

One medical officer remarks that the number of 
premature and still-births appears to be increasing, 
and that this in some measure accounts for the 
continuous decline in the birth rate. Unfortu- 
nately, in this country, such births are not 
registered, and it is impossible to ascertain whether 
this view is correct. However, so long as the births 
number twice as many as the deaths, there cannot 
be much cause for alarm. There is a general dis- 
position to view the decline of the birth rate with 
satisfaction, without enquiry as to its cause, the 
fact that the cause or causes may be anything but 
satisfactory being entirely ignored. 

Nottingham. 

Cancer. — Dr. Boobbyer remarks : The Registrar- 
General, in his annual report for i88q, estimated 
that, according to the records of. 1887-8-9, i in 
12 women, and i in 20 men in this country 
who survive thirty-five years would succumb to 
cancer {i.e., some form of malignant growth) ; and, 
by the law of probabilities it must follow, that on 
an average in one of three cases either a parent, 
or a grandparent, if he or she survived thirty-five 
years, will have died of such an affection. But it 
must not be forgotten that a large part, if not all, 
of the apparent increase in the cancer mortality of 
recent years is undoubtedly due to more accurate 
diagnosis and classification. 

Slaughter-houses. — The number of slaughter- 
houses upon the borough register at the end of 
1894 was 150. Seven existing slaughter-houses 
were closed during the year, but none re-opened. 
Six transfers of permits were granted. Six appli- 
cations for permits to open new slaughter-houses 
were received ; three were granted, and three 
refused. The slaughter-houses of the borough are 
not increasing in number, and their general con- 
dition is now for the most part much better than 
it was a short time ago. But this is all that can 
be said from the health standpoint in favour of 
these private slaughter-houses. Effective official 
supervision is practically impossible under the 
present system, and can only be looked for when 
all the slaughtering of the borough is carried out 
in a public abattoir. I have stated elsewhere that 
the amount of butchers' meat seized during one 
month in Edinburgh, which is not greatly larger 
than Nottingham, but is provided with abattoirs, 



28 



REPORTS OF MEDICAL OFFICERS OF HEALTH. 



frequently exceeds that taken during a whole year 
in this town. I find, upon again consulting the 
returns of both places, that the amount of meat 
annually seized during recent years in Edinburgh 
has averaged considerably over 150,000 lbs. ; 
whereas that taken in Nottingham has never 
reached 10,000 lbs. in any year of which the 
records have been kept, and has once recently 
(1S92) fallen as low as 2,534 lbs. I leave the^^e 
figures to speak for themselves ; the inference to 
be drawn from them is obvious. 

Surrey (County of). 

District Medical Officers' Reports. — From Dr. 
Seaton's report we extract the following : — On the 
other hand it is expected of me that I should 
indicate from time to time the reports which are 
notably deficient. One such report I indicated 
last year. It may become my duty (however dis- 
agreeable the task may be) to indicate another 
notoriously defective report from an important 
district. There is reason to think that in this 
instance the scrutiny of the death returns made by 
registrars to the District Sanitar}' Authorities, which 
forms the basis of the estimation of death rates on 
which so much action is founded, is left almost 
entirely to the sanitary inspector, who, although a 
most excellent officer in his own department, is, of 
course, not qualified for this duty. It would be 
misleading if I were to report the conditions of 
public health administration in the county as every- 
where satisfactory. There is yet a great deal to be 
done, and I do not see how substantial improve- 
ment can be brought about except on the lines I 
have suggested in a previous report, viz., the com- 
bination of two, three, or even four districts of 
suitable size for the purposes of the appointment 
of a medical officer of health, even as they are now 
joined in some cases for the purposes of hospital 
provision. 

Preventive Measures — Their fans et Origo. — 
The preventive measures which are adopted in the 
county must obviously arise mainly from the en- 
quiries, information, advice, and action of the 
medical officer for the district. In my last annual 
report, I referred esi)ecially to the growing import- 
ance of this work, and to the fact that its value is 
by degrees coming to be more generally recognised. 
It is with pleasure that I am able now to refer to 
the rejjorts of medical officers of health in the 
county, showing that their respective authorities 
look to the medical officer of health as the person 
who is best able to advise them as to the direction 
in which they should take action. It is plainly 
laid down under the orders of the Local Govern- 
ment Board, that the principal duties of the 
medical officer of health are that he should inform 
himself as far as practicable, respecting all influences 
affecting the public health within the district, and 
that he should inquire into and ascertain by such 
Hicans as are at his disposal, the cause, origin, and 



distribution of these diseases within the district, 
and ascertain to what extent the same have de- 
pended on conditions favourable to removal or 
mitigation, and subsequently that he shall advise 
the Sanitary Authority thereon. If sanitary autho- 
rities will bear in mind that these are the principal 
functions of a medical officer of health, more rapid 
advances will be made in the adoption of measures 
for preventing illness which is of a disabling, and, 
at the same time, preventable character. 

West Sussex. 

Suicides. — Dr. Kelly notes that — Two hundred 
and seventeen persons committed suicide in the 
nineteen years 1876-94, and of these 178 were 
males and 39 were females, or in the proportion of 
4' 5 male to i"o female. The death rate is equal to 
114 per million of the population against a rate in 
England and Wales of 87 in the three years, 
1891-93. Each district contributes in about 
similar proportions, and there is no special inci- 
dence in any particular area. The numbers vary 
but slightly from year to year, but they are much 
in excess of the general average throughout the 
country. This mode of death is very rare in youth, 
but it is now and then met with in persons from 51 
to 25 years of age ; it is uncommon up to 40 years 
of age when it becomes more frequent, and it 
reaches its highest point at the ages of 60 to 80 
years. 

Accidents. — In 1893 the deaths in England and 
Wales from accidents were 12,083 among males, 
and 5,041 among females. The deaths from 
suicide were 1,940 among males, and 659 among 
females. The deaths from these two causes were 
equal to a rate of 644 per million living, against a 
rate of 466 in this district. The deaths from acci- 
dents might be expected to be lower in an agricul- 
tural district than in the whole country which 
includes so many large towns, but it is not clear 
why the deaths from suicide should be so high in 
this area. 



Croydon Isolation Hospital. — Dr. Leonard 
Wilde, Assistant Medical Officer of Health of the 
Borough, has presented a most comprehensive and 
complete statement of the hospital department of 
the Corjioratinn of Croydon during 1894. This 
includes a description of the new buildings rapidly 
approaching completion, and of the administration 
of the old. The analysis of expenditure is drawn 
up on the lines recommended by the Metropolitan 
Hospital Sunday Fund. It appears from this 
statement that the average annual cost per head 
per week, including staff, was jQi 2s. 4d. ; not in- 
cluding staff, jQ\ 17s. The cases of diphtheria 
admitted during the year were subjected to a special 
etiological analysis, the supposed origin of each 
case being given in tabular form. 



SANITARY PROSPECTS UNDER PARISH COUNCILS ACT IN SCOTLAND. 29 



SANITARY PROSPECTS UNDER THE 
PARISH COUNCILS ACT (LOCAL 
GOVERNMENT SCOTLAND ACT, 1894) 
IN SCOTLAND * 

BY 

JNO. C. M'Vail, M.D., D.P.H. 

In concluding this Report, it may be convenient 
to notice this new enactment, which contains some 
important sanitary provisions. In particular, it 
extends the power to form special districts for 
special health purposes. Up till now only water 
and drainage could be dealt with in this way, but 
in future three other matters may be included, 
viz. : — (a) lighting; {d) scavenging and removal of 
dust, ashes, and refuse, not only from roads and 
footpaths, but from lands and premises ; (c) the 
provision and maintenance of public baths, wash- 
houses, and drying grounds. The most important 
by far from a purely public health point of view is 
likely to be the second — that relating to scavenging. 
In nearly every village in Scotland, the air and 
the soil are polluted by heaps of decomposing filth, 
collected behind almost every house. These 
accumulations are often the means of spreading 
infectious disease, and in many places they cause 
contamination of the water supply. Nor is it to 
be doubted that, independently of infectious 
disease, there is much injury to the health of 
children who are in the habit of using as play- 
grounds the backyards, whose soil and air are 
specially affected. The removal of these abomina- 
tions is a matter of first-rate sanitary importance, 
yet their existence has been almost sanctified by 
immemorial custom. Seeing that, in many towns 
of considerable size, it is still the habit to permit 
ashpit and privy refuse to accumulate for weeks, to 
think of a daily removal of filth from country 
villages may seem almost Utopian — may be looked 
on as an evidence of sanitary insanity. Until 
recently, this was the view taken in Perthshire, 
but, as a matter of fact, in some villages in that 
county, a daily removal is now being carried out 
under the supervision of the county sanitary 
inspector. It may be said that, looking to the very 
small valuation of many villages, consisting mainly 
of labourers' cottages, the total additional rating 
powers conferred on special districts by the Act of 
1894 can be productive of very little good. It is 
true that the amount may be small, but if the main 
requirement of such a village consists in two or 
three hours' daily work by a scavenger with a 
barrow, the simple powers conferred by the Act 
may be of the greatest value. If, in a village of, 
say, two hundred houses, no heed is given to the 
powers conferred by the Act, then from year's end 
to year's end there will be about two hundred heaps 
of reeking filth dotted all through the populated 

* From Dr. M'Vail's Annual Report for 1894 to the County 
Council of Dumbarton. 



area, polluting the atmosphere and the soil and the 
water, and insensibly, yet surely, causing and main- 
taining a general deterioration of the health of the 
inhabitants. On the other hand, in a similar 
village, wise enough to take full advantage of the 
new Act, there will be a very frequent, perhaps 
even a daily, removal of all household refuse and 
filth. The removal will take place before decom- 
position has had time to occur, and the village 
will be protected against probably the principal 
insanitary influence to which it has previously been 
subjected. Along with the county medical officer 
and sanitary inspector of Perthshire, I have had 
the pleasure of visiting some of the villages above 
referred to, in which regular scavenging is carried 
out and where ashpits are practically abolished, 
and I cannot conceive that any one can complete 
an inspection of these villages without being con- 
vinced of the very great value of the results 
achieved. 

My chief fear is that, with the partial return to 
the parish unit of administration, there may be a 
risk here and there of the manifestation of the 
old parochial narrowness, with the result that the 
village may continue to be a dumping ground for 
every kind of refuse and a breeding ground for 
every resulting disease rather than that the villagers 
should each be called on to expend annually the 
amount required to pay for an environment of 
cleanliness. The Act of course provides that 
petitions for the formation of scavenging districts 
may come not only from the Parish Council, but 
from any ten parish ratepayers, and the District 
Committee will have to consider the one as well as 
the other, but it is natural to suppose that it would 
be preferred that such petitions should emanate 
from a representative body, rather than from in- 
dividuals, and it is to be hoped that the Parish 
Councils will seriously face the question, so that 
petitions from ratepayers may not be required. 

The special districts should consist mainly of 
villages. Isolated houses and farm steadings are 
out of their scope. Often it may be convenient 
that several adjoining villages should constitute 
one scavenging district. Wherever possible, the 
district should be large enough to occupy the whole 
time of at least one scavenger. In some places, 
however, villages are so far apart as to render this 
inconvenient, and then, no doubt some labourer 
could be got for the fnecessarj- daily time. In 
connection with most special districts there should 
be one or more depots for the collection of the 
ashpit and other refuse from which the material 
would be disposed of to farmers. Something would 
depend not only on the value or want of value of 
the refuse as manure, but on the nature of the 
farm land in the neighbourhood. With a stiff clay 
soil there would be more chance of disposing of 
refusq, largely made up of ashes, than where the 
farm land is light and open. But at the worst, 
it would probably not be difficult to get a farmer 



30 



DIPHTHERIA IN SCOTLAND. 



to give a corner of a field as a coup, in return for 
the right to use the refuse. At present the difficulty 
is that it is only at some periods of the year that 
farmers can cart manure, which, in consequence, 
remains in the village ashpits, a nuisance to every- 
body ; but the setting up of depots should 
remove this difficulty. In districts of any size the 
scavenger will have to be provided with a horse 
and cart. One regulation which must be enforced 
on all such districts is that the receptacles, whether 
fixed or movable, shall be so placed as to be con- 
venient fjr the work of the scavenger. Wherever 
possible, the best course would be the entire 
abolition of ashpits, and the substitution of 
movable receptacles. In one Perthshire village 
— Bridge of Earn — this is carried out on very 
simple lines. Each household provides its own 
box — usually a small coal box — and this is placed 
at the street kerb every morning by eight o'clock, 
and emptied by the scavenger into his barrow. 
Metal pails are placed below every privy seat, the 
seats being hinged to allow of similar daily empty- 
ing of the pails. In another village— Scone — daily 
removal is practised for some tenements, and for 
others the interval is rather longer, while in a few 
houses the refuse is used on the garden ground. 
A little grass or ashes are put into the empted pail 
to allow of soakage of urine, and to prevent 
adhesion of the contents to the sides of the pail. 
I look forward with much hope to the exercise of 
the powers conferred by the new Act as likely to 
have a most beneficial effect on the health of the 
villages of Scotland. 



had been no increase of diphtheria in Scotland 
since the introduction of compulsory education, 
though it was not denied that school attendance 
was sometimes a means of spreading the disease. 



DIPHTHERIA IN SCOTLAND. 

Dr. a. K. Chambers, Assistant Medical Officer 
of Health of Glasgow, in introducing a discussion 
on the subject at a recent meeting of the Glasgow 
Medico-Chirurgical Society, stated that the ex- 
perience of Scotland seemed to differ widely from 
that of England in recent years as regards pre- 
valence of diphtheria. Whereas in England there 
bad been a great increase in the prevalence of the 
disease, in Scotland the curve of death rate from 
diphtheria between 1865 and 1890 showed a 
movement which, although fluctuating, was on the 
whole downward. There appeared to be evidence 
that, until recent years, there had been a greater 
prevalence of diphtheria in Scotland than in 
England. "Now the position was being reversed, 
and a wave of diphtheria [trevalence, beginning 
so ne years ago in the towns of England, had now 
spread throughout the rural districts." The wide- 
spread prevalence of diphtheria in England, which 
occurred in the years 1858-59, was followed by 
a similar epidemic prevalence in Scotland in 
1862-64, and this seemed to suggest the likeli- 
hood of a similar sefjuence in the near future. So 
far as could be judged from the death rate, there 



THE USE OF STERILIZED MILK. 

In connection with what appeared in the August 
number of Public Health on the "Preventive 
Measures against Infection from Tubercle in Milk," 
an article by Dr. Blasius, Professor of Hygiene at 
Brunswick, and Dr. Beckurts in the last number 
of the Deutsche Vierteljahrsschrift fi'ir nffentliche 
Gesuiidheitspflege is of interest. It treats of the 
use to which sterilized milk may be put as a food 
for infants and convalescents, from investigations 
which they carried out on the sterilized milk pre- 
pared by a large company in Brunswick. 

In this establishment the milk of 350 to 400 
cows from three different farms receiving all the 
year round much the same food was mixed together 
and sterilized. The milk on its arrival from the 
farms in the early morning is first placed in a cen- 
trifugalising machine in order to get rid of the 
smallest particles of dirt which manage to pass 
through the finest sieve or cloth, and consist very 
often of scales of epidermis from the skin of the 
udder or hands of the milker. In the removal of 
the dirt the number of the bacteria is also reduced 
by about one-third. The milk is placed in one- 
third liter bottles with a patent stopper made of 
porcelain fitting into an indiarubber collar. These 
are then submitted to steam at a temperature of 
103° C., the bottles being constantly agitated to 
prevent any inequality in the amount of fat. 

The chief changes effected by this sterilization 
are that all the albumen is converted into peptone, 
and the micro-organisms are destroyed. Such milk 
is eminently suited to infants, as the mixing of the 
milk of 400 cows causes it to have a great chemical 
uniformity in composition, while the absence of 
micro-organisms enables it to be kept for a long 
time. Its specific gravity was 1,030, and the fats 
3*4 per cent. The authors found that only small 
quantities of fat sei)arated from the emulsion by long 
keeping when the milk was sterilized in this way. 

Papers asking questions of the consumers as to 
how far such milk was satisfactory were circulated. 
Of 209 answers to these questions in the case of 
children under two years of age, it was found that 
201 were entirely satisfactory and 8 were not. In 
183 cases absolutely no digestive disturbances had 
occurred, in 16 there had been diarrhoea, in 9 con- 
stipation, and in i vomiting. Only 9 out of the 
200 samples of milk showed any change either in 
appearance or taste. The percentage of bottles 
which did not remain sterile, so far as the authors 
could ascertain, was 0*09. The practitioners in the 
town had expressed themselves as highly satisfied 
with the results of the milk in the cases in which 



ANNOTATIONS. 



31 



they had ordered it. The price of the J-litre 
bottle was one penny. 

They consider the following conclusions 
justified : — 

(i) Such sterilized milk possesses an extra- 
ordinary uniformity of composition, and will keep 
for a long time. 

(2) So little fat separates from the emulsion that 
any danger to a child from this cause may be 
disregarded. 

(3) It offers an excellent substitute for human 
milk, can be delivered at a comparatively cheap 
rate, and is, therefore, admirably suited as a food 
for the children of the poor. 

(4) Owing to its power of keeping good a long 
time, it offers the possibility for children, who cannot 
get human milk on journeys or change of abode, to 
have the same diet constantly. 

(5) Convalescents find it a strengthening and an 
easily assimilable article of diet. 



ANNOTATIONS. 

Experimental Malaria. 

Dr. Mattel, as the result of elaborate investigation 
{Archiv fiir Hygiene, Bd. XXII., Heft 3) comes to 
the following conclusions : — Malaria can be pro- 
duced in man by both intravenous and subcutaneous 
injection of blood from malarious patients. The 
period of incubation is usually ten to fourteen 
days. Tertian, quartan, and irregular fevers are, 
in his opinion, due to different parasites, and the 
injection of blood containing one variety re- 
produces the same variety in the infected person. 
Attempts on all kinds of animals, including 
monkeys, have failed to produce malaria by in,ocu- 
lation with the blood of a malarial man. The 
parasites found by Danilewsky in birds are not 
identical with human malarial protozoa, though 
they have analogies with the latter. They cannot 
be grown in the human body, and they are not 
affected by quinine or arsenic. 

Inheritance of Bacilli. 

It is too often lost sight of that the inheritance 
of phthisis may mean the direct transmission of 
the tubercle bacilli from parent to child. This is 
brought out by Whittredge ^Villiams in the John 
Hopkins' Hospital Reports, Vol. III., Nos. i, 2, 
and 3. He states that during the past few years 
systematic examinations of all pathological speci- 
mens relating to the diseases of women coming 
within their reach at the hospital have been made. 
This, he writes, has served, " among other things, 
to demonstrate that tuberculosis of the female 
generative organs is of far more frequent occur- 
rence than is generally supposed, and that instead 
of being merely a pathological curiosity, it should 
be regarded as a disease of practical interest and 



importance." The Hospital Reports show, among 
other things, how the tuberculosis in the mother 
may be strictly limited to the genital organs. The 
direct transmission of bacilli from the mother to 
the foetus has been proved by Birch-Hirschfeld and 
others. 



REVIEWS. 

Disin/ulion and Disinfectants (An Introduction to the 
Mudy of). Together with an Account of the Chemical 
Substances used as Antiseptics and Preservatives. By 
Samuel Rideal, D.Sc. Lond. (Charles Griffin and Co., 
Exeter Street, Strand. 1895 ) 12s. 6d. 

Notwithstanding the advance of sanitary science in this 
country, there is no English book dealing exclusively with 
the composition of disinfectants. The present work, there- 
fore, deserves a warm welcome ; while a perusal of its 
contents shows that it more than fulfils the promise of its 
title-page and table of contents in fulness and accuracy of 
information on nearly every question connected with 
disinfection. 

The chapter on Disinfection by Heat occupies thirty-sevea 
pages, and gives a complete account of the chief appliances 
in use in this and other countries. It contains also a plan 
of a disinfector house and incinerator at present being 
erected for the Vestry of St. Mary's, Newington. 

In the chapter on Chemical Disinfectants, the Hermite 
Process, tried at Worthing, is passed under review in a 
somewhat unsatisfactory maimer. The author has evidently 
n >t criticised the process from his individual standpoint, but 
only collated the somewhat contradictory opinions on the 
process. Sir II. Roscoe is mentioned as reporting both 
tavourably and unfavourably. Thus on page 67 we learn 
"Dr. Ruffer and Sir H. Roscoe have reported more 
favourably " (than Dr. Kelly) " on the process, and it has 
been further tried at Havre," etc. On page 69 it is stated : 
" Sir Henry Roscoe and Lunt have also criticised the 
Hermite process unfavourably " {^Journal Soc, Chein. Ind., 
1895). 

Dr. Rideal summarises the evidence for and against the 
use of boric acid and borates as preservatives of food. He 
advocates the use of carbonic acid instead of boric or salicylic 
acid. According to Slater this gas has a remarkable power 
of killing pathogemic bacteria in mineral waters. It 
can also be used for preserving milk, the milk being first 
boiled and then saturated with carbonic acid. Butter in an 
iron vessel subjected to carbonic acid under a pressure of 
six atmospheres, remains fresh for four or five weeks without 
losing flavour or consistency. It is unfortunate that the 
suggestions made by the Society of Medical Officers of 
Health for disinfection, etc. , are quoted as recent suggestions. 
Tney are quite out of date, having been made some ten or 
more years ago. The chapters on Preservation of Food are 
full and interesting. A final chapter deals with Methods of 
Analysis ; and a useful bibliography and index bring it to a 
close. The book will be of groat value for reference, as it 
focusses in a manageable compass our present knowledge on 
its important subject. 

Les Maladies Vhierientus dans les A/y/iees Anglaise, 
Fran<;aise, and Russe. Par Dr. O. Commence. (Paris, 
120 Boulevard Saint-Germain, G. Masson. 1895.) 

This is a pamphlet of forty-seven pages, which reviews 
the condition as to venereal diseases in the English, French, 
and Russian armies, in connection with their different 
systems of regulation of prostitution, or of *' la libeite de la 
prostitution " as in England. The main conclusions of Dr. 
Commenge's careful study of the subject are : — 

I. That venereal diseases are much more abundant in the 
countries where prostitution is unrestricted than in those in 
which it is regulated. 



32 



REVIEWS— APPOINTMENTS. 



2. That the regulation of prostitution produces an 
attenuation of venereal diseases and prevents their increase. 

3. That these results are in accordance with the resolutions 
of the Academy of Medicine in 1888, when it drew the 
attention of the Authorities to the dangers of prostitution, 
particularly clandestine prostitution, and to the measures 
necessary for safeguarding the public health. 

The Truth Ahout Vaccniatioti. Being a Report on 

Vaccination as a Branch of Preventive Medicine. By 

Ernkst Hart, D.C.L. 2nd Edition. (Smith, Elder 
and Co. 1895.) 

This work will be of value to medical officers of health 
and others, because it presents a convenient summary of the 
more recent statistics of small-pox, for which otherwise 
various reports and journals would reed to be ransacked. 
On pages 14 and 15 is a valuable table summarising the 
experience of a number of large towns between the years 1887 
and 1894. The table deals altogether with 11,064 cases of 
small-pox, among whom the total fatality was 9*2 per cent. 
Of the total cases 9,343 were under ten years of age, 9,343 
over this age. Arrong those under ten years of age, the 
vaccinated bad a fatality of i'2 per c^nt., the unvaccinated 
of 32'4 per cent., the doubtful of 428 per cen'. (only four- 
teen doubtful cases), while among those over ten years of 
age the vaccinated had a fatality of 4*5 per cent., the 
unvaccinated of 40*6 per cent., and the doubtful of I4'5 
per cent. 

Microbes and Disease Demons. By E. Berdoe, M.R.C.S. 
(Swan Sonnenschein and Co. 1895.) is. 

It is a sorry task to review so incompetent and unsatis- 
factory a brochure ; and it is regrettable that its author has 
succeeded in securing a publisher. The author's mind is 
so biassed by his views on the experimentation on animals, 
that it is questionable if even his statement of facts can be 
trusted. The chief burden of the work is against anti-toxin 
treatment of diphtheria. It is a pity that the author troubled 
the world with his book ; the antitoxin treatment of diph- 
theria is still admittedly on its trial, then let it have a fair 
field and no favour. There is some satisfaction in finding 
that one scientific authority of undoubted eminence is quoted 
with approbation ; need we say that we refer to the Star 
newspaper, quotations from which form no inconsiderable 
part of the book. 

A Text Book of the Science and Art of Bread- Making ; 
including the Chemistry and Analytic and Practical Tests 
of Wheat, Flour, and Other Materials Employed in 
Baking. By Wm. JAGO, F.I.C., etc. (Simpkin, Marshall 
and Co. 1895.) 

The Science and Art of Bread-Making is dealt with in 
this portly volume by Mr. Jago in a more complete and 
systematic manner than anywhere else in the English 
language. Mr. Jago has made an almost lifelong study of 
his special sul)ject ; he is well known as a consultative 
authority upon it, and he is thoroughly competent to speak 
on all aspects of the question. 

The introductory chapters deal with general chemical and 
physical principles, an 1 with the methods of investigation 
and analysis. Then follow chapters on the different con- 
stituents of bread and the methods of fermentation. The 
chapter on fermentation gives a masterly summary of the 
subject from a chemical, botanical, and physiological stand- 
point. The chapters on the structure anrl composition of 
wheat grain contain elaborate analyses of the chief varieties 
of grain, a large proportion of them original analyses, made 
by the author himself. While discussing the different 
methods of bread-baking, Mr. Jago points out that by a 
curious anomaly of the law on adulteration, " while the 
addition of alum to bread is considered to be an adulteration 
and therefore penal ; yet, because baking powder is not in th 
eyes of the law a" article of food, its preparation from alum 



is not a legal offence." The famous case of alumed baking 
powder, at the Glamorganshire Quarter Sessions is fully 
discussed ; and Mr. Jago details some experiments made by 
him on the question at issue. These tended to show some 
retardation of proteid digestion in artificial digestion of 
bread made with alumed baking powder, and a smaller 
retardation of starch digestion. 

Mr. Jago remarks respecting the Dauglish process of 
making aerated Ijread that it is possible to use flours of 
inferior quality, though he does not suggest that this is done. 
There is no doubt that the aeration process is specially suited 
for the manufacture of whole-meal bread. One of the 
arguments in favour of the aeration process, is that it retains 
the cerealin in the bread. This overlooks the fact that 
diastasic action is destroyed by the subjection of proteids to 
a temperature approaching 212° F, The same remark 
applies to malt bread, much advertised varieties of which are 
at present having a large sale, largely on the supposition 
that the diastase of malt in the baked bread retams its 
digestive properties. 

The chapters on Bakehouse Designs will be of great 
interest to all practical men. These are illustrated by ten 
large plates of designs of bakehouses of various sizes and 
kinds. The last chapters deal with analytical details. We 
have given a brief survey of the chief contents of this 
valuable work. Jt is one, we are sure, which ought to be 
on the shelves of every practical baker, and can be consulted 
with advantage by public analysts and others interested in 
bread. 

Catalogue of Sanitary AppUauics. (Thomas Crapper and 
Sons, Marlboro' Works, Chelsea.) 

Messrs. Crapper and Sons have issued a new edi'ion of 
their illustrated catalogue, which contains a large number of 
well-known approved sanitary appliances. 



APPOINTMENTS. 



Medical Officers of Health. 

Bekesford, Robert de la Poer, M.D. Glasg., 
L.R.C.P., L.R.C.S. Edin., re-appointed M.O.H. to the 
Oswestry Town Council. 

Fegen, C. M., M.R.C.S., L.R.C.P.,and Diploma in 
State Medicine, appointed M.O.H. to the Ampthill 
Rural District Council. 

Glendinnkn, W. M., M.R.C.S. Eng., L.R.C.P. 
Lond., appointed M.O.H. to the Covely Urban District. 

Gould, J. E., M.D., L.R.C.P. Lond., re-appointed 
M.O.H. to the Chesterfield Town Council. 

Hill, G., L.R.C.P. Edin., L.R.C.S. Edin., appointed 
M.O.H. to the Holme Cultram Urban District Council. 

Jago, E. O., M.R.C.S. Eng., L.S. A. Lond., appointed 
M.O.H. to the Tream Urban District Council. 

Jenkins, Dr., re-appointed M.O.H. for Lytham. 

Orchard, Edward, M.B.C.M., Al>erd., appointed 
M.O.H. to the Kingussie and Iri.sh Parish Council. 

Smailes, Thomas, M.D. St. And., L.R.C.P. Edin., 
M.R.C.S. Eng., re-appointed M.O.H. to the South Cros- 
land Urban District Council. 

Templeman, Chas., M. D., D..Sc., appointed M.O.H. 
for the City of Dundee. 

Taylor, Dr. J., appointed M.O.H. to the Chester-le- 
Street Rural District Council. 

Watkins, J. W., M.D. Edin., M.R.C.S. Eng., re-ap- 
pointed M.O.H. for the Newton Urban District. 

Winn, John, L.R.C.P,, L. R. C.S.I. , appointed M.O-H. 
for Clayton-lc-Fylde. 



Public Health, 

Efje Journal of tfje Incorporateti Societg of IHetiical ©fiDtcers of l^ealtlj. 



SUBSCRIBERS' COPIES of Public Health are 
supplied at \os. dd. per annum. Single copies One Shilling. 

BOUND VOLUMES.— C<7/zVf of Volume VI. are now 
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CLOTH COVERS for Binding the Volumes, price is. 6d., 
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Orders should be addressed to E. W. Allen, 4, Ave Maria 
Lane, E.G. 

ADVERTISEMENTS. — Co/«;«M«?Va(rw?j relating to 
Advertisements should be addressed to Messrs. W. H. S' L. 
Collingridge, 148 and i^g, Aldersgate Street, E. C. 

Every Reader of a Paper before the Society, or Contributor 
of a Signed Article, is entitled to twenty five copies of the 
issue oj Public Health containing the contribution in 
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must be made to the Editor not later than the TWENTY- 
FOURTH day of the month previous to insertion of the 
Contribution. 

Medical Officers of Health and other Correspondents are 
requested to send regularly all published reports and 
matters of interest bearing upon Sanitation to the Editor, 
1 1 , Gloucester Place, Brighton. 



NOTICES, 



The 



ALTERED SUBSCRIPTION FOR MEMBERS OF 
THE INCORPORATED SOCIETY M.O.H. 

The attention of Fellows and Members of the Incorporated 
Society is called to the fact that dating from October, 1894, 
the subscription to the Society will be one guinea instead of 
half-a-guinea as hitherto. It must be noted that this will 
include the subscription as members of a branch of the 
Society, the guinea subscription being inclusive for all 
purposes. 

It will be seen from this that there will be no very 
material increase in the subscription for those who are 
members of the parent Society and of one of its branches. 
There will, however, be considerable saving of trouble in 
collecting subscriptions, etc., as one subscription only will 
be payable. The subscriptions (and those for Associates, 
which remain half-a-guinea) should be sent to the Trea- 
surer, Dr. Kempster, Chesterfield, North Side, Clapham 
Common, London, S.W. 



Special attention is called to the fact that 
the meetings of the Incorporated Society of 
Medical Officers of Health are now held at 
No. 197, High Holborn, and not at 20, 
Hanover Square. The next meeting is on 
Thursday, 21st November, at 7.30 p.m. 

No. gi. November, 1895. 



Incorporated Society of Medical 
Officers of Health. 

20, Hanover Square, London, W., 

ist November, 1895. 



Notice is hereby given that an Ordinary Meeting 
of the Society will be held. on Thursday, the 21st 
day of November, 1895, at 197, High Holborn, 
W.C, at 7.30 p.m. for the transaction of the 
following business : — 

AGENDA. 

1. To read and confirm the Minutes of the 
Ordinary Meeting held on Monday, April 8th. 

2. To receive the Report of the Council (if 
any). 

3. To elect Fellows, Ordinary Members, and 
Associates. The following have been duly 
nominated : — 

As Fellows. 
Dickson, John Dunbar, M.D., M.Ch., The Gables, 

Marlow, Bucks, M.O.H. Wycombe R.S.D. ; proposed 

by Reginald Dudfield ; seconded by J. C. Thresh 
Haworth. F. G., M.B., CM., D.RH., Vale House, 

Darwen, M.O.H. Darwen U.S.D. ; proposed by 

James Wheatley ; seconded by A. Jasper Anderson. 
HORNE, Thomas, M.D., Stockton-on-Tees, M.O.H. 

Stockton-on-Tees U.S.D. ; proposed by T. Eustace 

Hill ; seconded by J. C. Thresh. 
Pearce, J. P., M.R.C.S., L.S.A., St. Anne's, Lewes, 

Sussex, M.O.H. Lewes U.S.D. ; proposed by Reginald 

Dudfield ; seconded by J. C. Thresh. 
Taylor, John, M.D., D.P.H., Chester-le-Street, M.O.H. 

Chester-le-Street R.S.D. ; proposed by T. Eustace 

Hill ; seconded by J. C. Thresh. 
VissER, Thomas Christoffel, M.B., B.S., Private Box 

No. 983, Johannesburg, South Africa, M.O.H. 

Johannesburg, South Africa ; proposed by Henry E. 

Armstrong ; seconded by Reginald Dudfield. 

As Ordinary Members. 
Armstrong, Henry George, M.R.C.S., L.S.A., Crow* 

thorne, Berks, Medical Officer to Wellington College ; 

proposed by W. T. G. Woodforde : seconded by T. C 

Thresh. 
Manby, E. Petronell, M.D., D.P.H., Fountain 

Hospital, Tooting ; proposed by S. R. Lovett ; 

seconded by J. C. Thresh. 

As Associate. 
LiVY, John, M.D., F.R.C.S.Ed., 44, St. George's 
Terrace, Bolton ; proposed by James Wheatley ; 
seconded by A. Jasper Anderson. 

4. To receive nominations for election of 
Fellows, Ordinary Members, and Associates. 

5. To read correspondence (if any). 

6. At 8 o'clock, Dr. A. Newsholme will open a 
discussion on " A National System of Notification 
of Sickness." 



34 



THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. 



The following points will be presented for con- 
sideration : — 

(a) Mortality statistics have been the founda- 
tion on which the past progress of public health 
has been built. Further and rapid progress can 
only be obtained by means of sickness statistics on 
a much larger scale than has yet been contem- 
plated. 

{b) Preventive measures are not to be limited to 
diseases of an infectious character. 

{c) How can the necessary information as to 
sickness be obtained ? 

{d) Should payment of a fee for notification of 
sickness be continued ? or, assuming that the 
Government is prepared to give the medical pro- 
fession more efficient protection against the 
practising of medicine by unqualified men, may 
not the notification of sickness be regarded as 
a duty owed by the medical practitioner to the 
State? 

7. To transact any other business. 

{Signed) John C. Thresh, 

The Limes, Chelmsford. 
Reginald Dudfield, 
19, Blomfield Road, 

Maida Vale, W 



Sees. 



THE INCORPORATED SOCIETY OF 

MEDICAL OFFICERS OF HEALTH. 
Annual Meeting. 
The Annual General Meeting of the Society was 
held on Thursday, October 17th, 1895, ^t No. 197, 
High Holborn, W.C. Present :— Dr. S. R. 
Lovett (President) in the Chair ; F. Vacher, W. H. 
Kempster, W. T. G. Woodforde, O. Field, J. Row- 
Idnd, VV. R. Smith, W. Gruggen, A. Ashby, T. O. 
Dudfield, E. Gwynn, B. H. Mumby, H. W. 
Roberts, W. Collingridge, J. N. Cook, S. Barwise, 
J. C. Thresh, \V. G. Willoughby, T. M. Legge, 
E. F. Willoughby, H. E. Armstrong, R. Dudfield, 
b. F. Murphy, and S. Gibbon. 

Dr. LovETT, the retiring President, congratu- 
lated Dr. F. Vacher on his election, and formally 
inducted him to the Presidential Chair. 

Dr. F. Vacher in the Chair. 

The Secretary being about to read the minutes 
of the last annual meeting, 

It was proposed by Dr. T. O. Dudfield, 
seconded by Professor Smith, " That the bye-laws 
be suspended," which resolution was carried 
unanimously ; and it was thereupon proposed by 
Professor Smith, seconded by Dr. W. T. G. 
Woodforde, that the minutes of the annual 
general meeting of October, 1894, having been 
printed and circulated in Public Health, be 
taken as read. (Carried.) 

The same were then apjjroved, and signed by 
the Chairman. 



Election of Candidates. 

The meeting then proceeded to the election of 
Fellows, Members, and Associates. 

The following gentlemen having been duly 
nominated as candidates, a ballot was taken, and 
they were declared by the Chairman to have been 
unanimously elected. 

Nominated at Meeting of 8th April. 
As Fellows. 

Rayner, Edwin, M.D., &c., Tiviot Dale, Stockport, 
M.O.H. Stockport (retired) ; proposed by J. C. Thresh ; 
seconded by Reginald Dudfield. 

Rogers, G., M.R.C.S., L.R.C.P., 24, High Street, Sheer- 
ness-on-Sea, Ass.-M.O.H. Port of London; proposed 
by W. Collingridge ; seconded by the President. 

Simpson, Reginald Palgrave, M.D., 11, Gloucester 
Row, Weymouth, M.O.H. Weymouth Port S.A. ; 
proposed by B. H. Mumby ; seconded by Reginald 
Dudfield. 

Stephens.Lockart Edward Walker, M.R.C.S.,L.S. A., 
White House, Emsworth, Hams, M.O.H. Wartlington 
U.S.D. ; proposed by George Turner; seconded by 
J. C. Thresh. 

As Associates. 

Hunt, Gilbert J., Weymouth, Borough Surveyor, Wey- 
mouth ; proposed by G. H. Mumby ; seconded by 
Reginald Dudfield. 

Laurie, McPiierson (Dr.), Greenhill, Weymouth; 
proposed by B. H. Mumby ; seconded by Reginald 
Dudfield. 

Matthews, William, C.E., Municipal Offices, South- 
ampton, Water Engineer to Borough of Southampton ; 
proposed by B. H. Mumby ; seconded by Reginald 
Dudfield. 



Nominated at the Provincial Meeting, July 27TH. 
As Fellows. 

Elias, James, D.P.H., Neath, M.O.H. Neath U.S.D. ; 
proposed by the President ; seconded by Reginald 
Dudfield. 

Legate, Robert Lloyd, L.R.C.P, Bridge House, Christ- 
church, Hants, ^LO.H. Christchurch U.S.D. ; pro- 
posed by B. H. Mumby ; seconded by Chas. Kelly. 

Peskett, Alfred P., M.R.C.S., Leyton, M.O.H. Leyton 
U.S.D ; proposed by St. Clair Shad well ; seconded by 
John C. Thresh. 

Skegg, John Joseph, L.R.C.P. Edin., M.R.C.S. Eng., 
29, Craven Street. Strand, M.O H. St. Martin's-in-thc- 
Fields Metropolitan S.D. ; proposed by the President ; 
seconded by Reginald Dudfield. 

Waters. Avery Clough, M.B.,Southend-on-Sea, M.O.H. 
Southend-on-Sca U.S.D. ; proposed by John C. Thresh ; 
seconded by J. .S. Tew. 

As Ordinary Members. 

Eraser, A. Mearns, M.B., D.P.H. Camb., 277, Cold- 
harbour Lnne, Brixton, S. W. ; Assist.ant to Dr. Thresh, 
M.O.H. Chelmsford ; proposed by John C. Thresh ; 
seconded by Reginald Dudfield. 

O'Connor, Michael, M.B., Perth, Western Australia ; 
proposed by John C. Thresh ; seconded liy the 
President. 

Nominations. 

A mimbcr of candidates were then nominated 
for election at the next meeting. 

The Hon. Secretaries submitted the Report of 
the Council for the year ending September 30th 
last, and rejiorted that the same had been published 
in the October issue of Public Health. 



THE PREVENTION OF EPIDEMICS. 



35 



It was moved by Dr. Lovett, seconded by Dr. 
T. Orme Dudfield, and resolved unanimously, 
that the same be received and adopted. 

The Hon. Secretaries submitted the Report of 
the Editor, and stated that the same had been 
pubhshed in the October issue of Public 
Health. 

Resolved, on the motion of Dr. Dudfield, 
seconded by Dr. Gwynn, that the same be re- 
ceived and approved. 

The Hon. Secretaries submitted the Reports of 
the Treasurer and Auditors, and reported that the 
same, together with an account of receipts and 
expenditure, and balance-sheet for the year 1894 95 
had been inserted in the October issue of the 
journal. 

Resolved, on the motion of Dr.T. O. Dudfield, 
seconded by Dr. Lovett, that the same be received 
and adopted. 

The President then read his Inaugural 
Address as follows : — 

The Prevention of Epidemics. 

BY 

Francis Vacher, F.R.C.S. EJin., President. 
Gentlemen, — By your courtesy, I appear before 
you this evening as President of the Incorporated 
Society of Medical Officers of Health, a position 
any medical officer of health in the Kingdom 
might be proud to occupy. Perhaps my principal 
recommendation for this high office is length of 
service (I received my first public health appoint- 
ment in 1873); and another recommendation is 
that it fell to my lot to take an active part in 
the work of the first Society of Medical Officers of 
Health founded in the Provinces. Whatever led 
to my selection for this position, and notwith- 
standing the misgivings I had as to my entire 
fitness for the post, my duty at least appeared 
obvious — to acquiesce in your decision. I thank 
you from my heart for the honour you have done 
ine. I trust to be able during my term of office 
to be present regularly at the meetings of the 
Society, to preside over its deliberations im- 
partially, and to give my full mind to all busi- 
ness connected with the Society brought before 
me. 

The initial function required of me to-day is as 
important as any I shall be called upon to fulfil. I 
have to deliver an address to men of my own voca- 
tion on some pubhc health topic. It would scarcely 
become me to attempt to say anything new, and I 
shall be quite satisfied if I can hold your attention 
for half an hour, while we think together on a 
perfectly common-place subject. What more 
common-place, what more familiar to us as 
medical officers of health, than epidemics ! They 
are like poverty and vice — with us always. We 
are perpetually engaged in an unequal strife with 
them when they are on all sides of us ; an unequal 
race with them when they have a long start. 



Let me consider then, with you, for such time 
as we have, epidemics and their prevention : for 
assuredly they should not be the familiar occur- 
rences they are, and certainly their prevention is 
possible. What is an epidemic, using the word in 
its ordinary sense ? It is an outbreak of disease 
which has not been checked, and consequently 
spread till many persons are affected. Wherever 
it occurs, it is local proof of the failure of 
preventive medicine. Local authorities have 
means of "coming before," and if they neglect 
these means, or use them inadequately, they must 
be held responsible for the inevitable results. I 
propose, briefly, as the simplest way of dealing 
with this subject, to go over the preventive means 
available, and to inquire what use is made and 
might be made of these. The principal means are 
four, viz : — 

1 . The Rapid Removal of Decomposing Refuse 
Material. 

2. Notification of Infectious Cases. 

3. Isolation of Infectious Cases. 

4. Disinfection of Infectious Persons and 
Things. 

The Rapid Removal of Decomposing Rf-fiise 
Material. — From a sanitary point of view, decom- 
posing refuse is of three kinds — (i) human 
excreta, {2) house refuse, and (3) trade refuse. 
Will anyone assert that the ordinary way of dealing 
with this material secures its rapid removal ? 
Commonly, the first two kinds are hoarded up in 
middensteads, in close proximity to inhabited 
houses ; and the third is deposited on waste land, 
or turned into a running stream. JMuch, doubtless, 
has been done of late to induce manufacturers to 
use or consume their decomposable waste, and 
much is still being done. But as for the ubiquitous 
midden, it is yet supreme. Sanitary authorities 
rarely attempt its abolition, dissipating their 
strength in projects for its improvement. It is to 
be made smaller and shallower ; is to be cemented 
over, and roofed and ventilated, etc., etc. Cer- 
tainly, you may make it less offensive in this 
manner, but storing decomposable stuff is an in- 
sanitary practice per se, and therefore any recep- 
tacle for its storage is bad ; and improvements, 
making it a little more tolerable, continue it in 
existence from year to year. Some recently- 
altered middens are scarcely more tolerable than 
the most primitive. There are districts where 
these receptacles are being divided, converting 
each compound midden into a midden and cess- 
pool ; and other districts where pails (to be emptied 
weekly) have been placed under the seats. I can 
find no smooth word for the midden, no excuse for 
those who are content with it. In all its pristine 
foulness, it is execrable ; and, as metamorphosed 
and modified in various ways, it is yet altogether 
abominable. Wherever it exists, conditions are 
present which assist in the spread of many diseases, 
epidemic and endemic. Where it nestles in the / 

D 2 



36 THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. 



narrow yard of each little dwelling in the poor 
quarter of a town, who can wonder that the visits 
of such disease are frequent, and their stay pro- 
longed ? 

When the invited epidemic comes, attempts are 
made to discover the cause. It is ascribed to " the 
usually neglected condition of the middens," 
" defective construction of the middens," " foul 
water in the middens," " overflowing middens," 
etc. And what is implied, if not expressly stated, 
is, that were the middens altered somewhat, or the 
scavenging improved, all would be right. So the 
middens are altered, and the scavenging improved. 
However, when the next outbreak of disease occurs, 
it spreads. All was not right, and never will be, 
as long as the middens remain. 

The desideratum, as just stated, is the rapid 
removal of decomposing refuse material. How is 
this to be accomplished ? Wherever at all prac- 
ticable, the quickest and best way of removing 
excreta is by water-carriage — should the supply be 
plentiful, by water laid on to separate-service 
cisterns ; should the supply be scarce, by slop- 
water, delifered from tumblers? Where water- 
carriage is impossible, the one admissible 
alternative is a properly - constructed dry-earth 
closet, well supplied, and attended to daily. As 
regards house-refuse, the system adopted in parts 
of many towns (and proved by long experience to 
be easy, simple, and satisfactory \ is to provide 
each house with a small covered dust-box or pail, 
and arrange for its being emptied — if it needs 
emptying — by the dustmen every morning before 
eight o'clock. It is scarcely possible to imagine a 
more perfect method of collecting house-refuse 
than this. However, there is no getting the British 
housewife to burn decomposing refuse at the 
back of the kitchen fire, so the Authority 
(the Urban Authority, at least), must arrange 
for its combustion. The contents of the little 
pails or boxes, besides cinders and ashes, are 
found to be mainly — (i) potato peeling and 
trimmings of fruit and vegetables ; (2) bones, 
offal of fish and poultry, and egg-shells ; and (3) 
dirty tins, potsherds, rags, and paper. The only 
effectual way to render all this innoxious as soon 
as gathered is for the authority to erect a destructor 
and shoot it therein. All that is combustible is 
forthwith cremated, and the remainder is drawn as 
slag and clean iron waste. Trade refuse from 
fishmongers, poulterers, greengrocers, fruiterers, 
etc., should be collected and dealt with daily in 
the same way. 

It is unnecessary for me to point out to medical 
officers of health that there should be no difficulty 
about the abolition of compound-middens. If a 
house having this form o*" sanitary accommodation 
appears to the local authority, on the report of their 
surveyor or inspector of nuisances, to be without a 
sufl^cient water-closet, earth-closet, or ashpit, etc., 
the local authority shal/, by written notice, require 



the owner or occupier, within a reasonable time, to 
provide a sufficient water-closet or earth-closet and 
ashpit. What is " sufficient " is for the local 
authority to specify in precise terms, and when the 
new accommodation is ready, any hoarding in the 
old midden could be proceeded against as a 
nuisance. As to the daily removal of refuse, every 
local authority may undertake or contract for the 
removal of ashpit refuse, etc., at such intervals as 
they think fit. 

It may be said that much of this does not apply 
to rural districts. Certainly, the daily collection 
and burning of refuse would not ordinarily be 
necessary in country places, but checking the 
practice of hoarding decomposing refuse in con- 
tiguity to dwelling-houses is necessary, and can be 
effected. A compound-midden here and there in 
the country will not be powerful for harm like long 
rows of them in crowded towns ; but a compound- 
ihidden is an odious thing wherever it exists, and 
should not be tolerated by any sanitary authority. 

Notification of Infectious Cases. — All will admit 
that one of the most important means sanitary 
authorities possess for checking the spread of in- 
fectious disease, is the power to require notification 
of the same. This power (previously obtained in 
many districts under local Acts) was given to 
authorities in England and Wales, and compulsory 
notification itself was given to the metropolis by 
the Infectious Disease (Notification) Act, 1889; 
yet even now the authorities in many districts still 
decline to adopt the Act, and thus appropriate the 
powers offered. I find that on March 31st, 1894, 
the aggregate population in England and Wales 
placed under compulsory notification amounted to 
upwards of 26,400,000 — somewhat over 91 per 
cent, of the entire population of the country. 
Probably the proportion is 93 per cent, at present, 
or even more, but the remainder represents the 
population of many districts, urban and rural, 
scattered throughout the counties, and a continual 
source of danger to neighbouring districts. It may 
be said that notification will soon be made com- 
pulsory all over the kingdom. Possibly so, but 
the fact that many districts do not want notification 
justifies the belief that it will not be enforced 
vigorously even then. 

Now, as to how notification is carried out in 
many districts where it is compulsory. According 
to the provisions of the Infectious Disease (Noti- 
fication) Act, the certificate must (under a penalty 
not exceeding forty shillings) be sent to the 
medical officer of Health /w//?/'////, on the medical 
practitioner attending on or called in to visit the 
patient becoming aware that the patient is suffering 
from an infectious disease to which the Act applies. 
The householder is also under an obligation to 
notify. The refjuirements in local Acts, in these 
respects, are for the most part similar. I have had 
many years' experience of compulsory notification, 
and noted how it works in many districts. The 



I 



THE PREVENTION OF EPIDEMICS. 



37 



outcome of my experience and inquiries is to con- 
vince me of two tilings . First, that dual notifica- 
tion does not exist — what passes for it is a travesty — 
as in most districts it is quite a rare occurrence for 
a householder to notify ; and secondly, that the 
word " forthwith " is by many practitioners habit- 
ually ignored- It is the simple truth that there 
are practitioners who send in their certificates in 
batches — twelve or twenty or more at a time, the 
dates thereon ranging over a period of a week or 
a fortnight. Surely the local authority is war- 
ranted in protesting against this. In nine cases 
out of ten such certificates are worthless. In 
support of what I state, I should like to cite 
instances giving the names of the districts referred 
to, but this would be obviously inexpedient. 
However, I may say that in one report it is 
recorded that out of 1,007 notifications, one only 
was by the house-occupier ; and in another report 
it is recorded that out of 2,166 notifications, not 
one was by the house-occupier. In several instances 
the number of fatal cases of puerperal fever exceeds 
the number notified. In several districts the 
mortality from croup is cent, per cent. ; and in one 
district two cases were reported and seven died. 
I may add, that the evidence submitted to me 
shows that neither puerperal fever nor croup are 
notified to the extent of their occurrence, and that 
there is frequently needless delay in notifying scar- 
latina and typhoid fever. 

I am not going to maintain that it is reasonable 
to expect much assistance from occupiers, but far 
more assistance than is now given might be looked 
for, if in every district steps were taken to intimate 
to occupiers what are their obligations in regard 
to notification. The bulk of reliable notification 
coming to the medical officer of health must neces- 
sarily be by medical practitioners ; but if iri any 
district certificates are sent in late without excuse, 
and received late without protest, the end in view 
when the Act was adopted must be defeated. 

The diseases required to be notified in the 
general Act (as is well known), are small-pox, 
cholera, diphtheria, membranous croup, erysipelas, 
scarlatina, and typhus, typhoid, relapsing, continued, 
and puerperal fevers. Whether it is wise for local 
authorities to add to this list, in the manner pro- 
vided by the Act, has been often debated. On 
this I wish to offer no opinion here. Upwards of 
seventy authorities have added measles to the 
list, and some have taken it off" again ; about twenty 
authorities have added whooping-cough, several 
have added diarrhoea in the autumn, a few German 
measles, a few chicken-pox, and one hydrophobia. 
I think it is of infinitely more importance to obtain 
the prompt notification of all the diseases named 
in the Act, than to add to the list. 

Isolation of Infectious Cases. — Many years' ex- 
perience at the London Fever Hospital and the 
Hospitals Inquiry of 1863, by Drs. Bristowe and 
Holmes, showed the need of isolation hospitals 



and the conditions of their usefulness. Accordingly, 
the Sanitary Act, 1866, gave local authorities 
powers to erect and maintain such hospitals. 
These powers were given afresh to Urban and 
Rural authorities alike by the Public Health Act, 
1875. ^s» however, a large number of authorities 
neglected to use the powers conferred, or used them 
inadequately, it seemed that further legislation was 
needed, and this is supplied by the Isolation Hos- 
pitals Act, 1893. This Act, as you all know, gives 
important powers to County Councils, in particular, 
enabling them to take an active part in obtaining 
the provision of efficient hospitals for the isolation 
and treatment of cases of infectious disease. 

County Councils and District Councils have thus 
ample powers to provide all required accommo- 
dation for the infectious sick. Would that these 
powers were used to the full. Early in the present 
year I made a report on the isolation hospitals in 
my own county, and in 1893 I made a report 
to the International Congress of Charity, on the 
cottage hospitals in this country. I have there- 
fore recently inspected many hospitals, and what I 
have seen of the existing provision for infectious 
cases enables me to assure you that it is very 
inadequate and unsatisfactory. The permanent 
accommodation is partly in special hospitals 
provided by sanitary authorities, partly in hos- 
pitals provided by the guardians of the poor, 
partly in buildings endowed or supported by volun- 
tary contributions (often in connection with 
general infirmaries), and partly in private hospitals. 
Of these it may be said that the best hospitals are 
to be found among those erected by sanitary 
authorities. The provision of special isolation 
hospitals for paupers has been discouraged, and is 
not likely to be increased ; nor is there any prospect 
of endowed hospitals or voluntarily supported 
hospitals being added to appreciably. 

The large amount of isolation hospital accom- 
modation needed, if it is to be obtained at all, will 
have to be provided by local authorities. As has 
been shown, they have the power to make pro- 
vision ; they can borrow capital for the purpose on 
favourable terms, and have been well advised by 
the Local Government Board as to construction, 
arrangement, site, etc. What have they done ? 
Not one- fifth of the permanent accommodation 
required has been supplied, and this has been 
supplemented (frequently under pressure of 
epidemic disease) by temporary accommodation 
the most miscellaneous. I have seen neat military 
huts, rough wooden shanties, corrugated iron sheds, 
light wooden frames covered with weather-proof 
paper or tarred felt, canvas tents, old houses, 
workshops, offices, cottages, etc. Some of these 
serve there purpose fairly well, some very badly. 
None of them would have been needed had per- 
manent hospital accommodation been made, and 
nearly all of them help to postpone the making of 
permanent provision. For instance, a district 



38 THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. 



having upward of 10,000 population, after spending 
jCs5 or j€4° o'^ 2. tent or a small wooden erection, 
reports that it has made sufficient provision. 
Among the objections to most temporary hospitals 
is the impossibility of regulating the temperature 
therein (especially in winter), and the difficulty of 
having the nursing efficiently done. Some of the 
old pest-houses and lazarets might rise up in 
judgment against the temporary shelters for 
infectious cases which not a few districts provide. 

To be in a prcper state of preparedness to 
isolate the initial cases of dangerous infectious 
disease notified, the whole country should be 
divided into hos])ital districts, and every district 
should be provided with at least one sinall-pox 
hospital and one hospital for other infectious 
diseases. It seems to me it would greatly simplify 
matters to make these districts co-terminous, or 
nearly co-terminous with the old union districts. 
The model plans in the official memorandum on 
" Isolation Hospital Provision " indicate the lines 
on which provision should be made, and the 
extent of the provision should not be less than at 
the rate of one bed for each 1,000 of the popula- 
tion. When once a good permanent hospital is 
open free of charge, there is little difficulty from 
the first in getting patients to use it, and what 
difficulty there may be yearly decreases. It is not 
necessary to point out that it is a great advantage 
for a hospital to have an observation ward, or that 
every authority should provide shelters for house- 
holds which have to leave their homes on account 
of necessary dismfection. This introduces the next 
topic. 

Disinfectioji of Infectious Fersojis and Things. — 
Compulsory notification, isolation hospital pro- 
vision, and efficient disinfection, are complemental 
to each other — for the prevention of epidemics all 
are absolutely necessary. I have complained that 
compulsory notification is refused by many 
authorities, enforced half-heartedly by others, that 
hospital provision is frequently unsatisfactory or 
neglected altogether. What can I say of disinfec- 
tion ? I find that in most districts those who are 
responsible for disinfection pin their faith to SO2. 
Some use the anhydrous acid supplied in tubes 
and lauded in many printed encomiums ; but the 
greater number adhere to the " good old l)lan," and 
stove the room with burning sulphur. I admit 
that the ownci or occupier of the infected room is 
commonly enjoined to lime-wash the ceiling, to 
wash the floors and woodwork with water contain- 
ing carbolic acid, and rub down the walls with 
dough or bread-crumb. However, the sul])hur 
fumigation appears to be considered of paramount 
importance, and the other measures supplemental 
— the inspector is instructed to see to the fumiga- 
tion himself, while the remainder of the disinfect- 
ing process is left to be done by others, or 
neglected. Now, is it not a fact that the stoving 
leaves the room /;/ stafu quo 7 If the ceiling be 



lime-washed, if the floor and wood-work be pro- 
perly washed with carbolic acid and water, and if 
the walls be stripped and cleansed, the room will 
be efficiently disinfected. But^ say the advocates 
of SO2, " the fumes were for the purpose of dis- 
infecting the air." Is it a very shocking heresy to 
allege that the air does not need disinfecting ? 
When outbreaks recur in a house, it is not because 
the air was not disinfected, but because the walls, 
floor, furniture, bedding, clothing, etc., were not 
disinfected. However, if the air must be disin- 
fected, there are many effective ways of doing it, 
e.g., by the disinfecting spray used in France — 
water containing i per 1,000 perchloride of mercury 
and 2 per 1,000 of sea salt. 

A few words now on disinfection of the room- 
contents. No large proportion of rural districts 
and small urban districts has provided steam dis- 
infectors. In some localities a hot-air disinfector 
(Ransome's, Eraser's, or similar apparatus) is still 
in use ; in others, bedding and things which can- 
not be boiled are subjected to no treatment beside 
fumigation. Yet a good steam disinfector, such as 
Reek's, may be obtained for, I believe, under ^^70. 
Again Esmarch's experiments (of seven years ago) 
on steam-disinfection seem to be unappreciated or 
forgotten. Apparatus in which the steam is super- 
heated by various methods seems to be specially in 
favour, yet Esmarch proved that steam thus super- 
heated had the disinfecting power of hot air only. 
i.e., that it could not sterilize organisms except at 
temperatures higher than any ordinary material, 
save horse-hair, could endure, and had no power 
to penetrate such articles as mattresses. As a 
matter of experience, such apparatus often acts 
better in practice than might be expected — the 
superheated steam brought in contact with cold 
objects is cooled, and the process goes on with 
saturated steam, till the difference in temperature 
between the objects and the steam is insufficient to 
reduce it thus. But whether efficient disinfection 
is taking place should not in this way be left in 
doubt. The practice of using superheated steam 
should be abandoned. It is not a reliable dis- 
infectant, and any assistance it gives in the drying 
of articles can be effected by other means. 

As regards arrangements for disinfecting infected 
persons, much remains to be done. It might be 
thought that at least every isolation hospital would 
provide the means of discharging patients in a dis- 
infected state; but it is not so. There should be 
an undressing-room, in which the patient leaves the 
clothes he has been wearing ; a bath-room adjoin- 
ing, where he receives a disinfecting bath; and a 
dressing-room beyond, where he puts on clean 
clothes. A large hospital should provide several 
such sets of discharging-chambers ; and there is no 
reason why a set, or more than one, should not be 
furnished at every well - equipped disinfecting 
station. Members of infected families could then 
be bathed while their wearing apparel was being 



THE PREVENTION OF EPIDEMICS. 



39 



disinfected ; children recovered from an infectious 
disease would be disinfected before returning to 
school, etc., etc. 

Certainly more systematic and thorough disin^^ec- 
tion of persons and things is an urgent need. 

Co?idusion. — What shall I add ? I would there 
were means of keeping in check the wanderings 
of vagrants, who carry infection from place to 
place ; I would that vaccination, as efficient as at 
the public vaccination stations, were insisted 
on generally ; but these and other desiderata in 
the interest of public health are not within the 
power of local authorities. I have confined my 
attention to the consideration of the four principal 
means local authorities have for preventing 
epidemicSj and I think I have shown that these 
means are not used as fully and intelligently as 
they might be. What I have said is so obvious, 
so trite, it is strange there should be occasion 
to say it at all. Yet there is occasion. 

Local authorities are charged with the duty of 
preventing epidemics. They can procure prompt 
information of initial cases of infectious disease ; 
they can order cleanliness, isolation, and disin- 
fection; they have, or may obtain, excellent 
advice what to do. If they use the means of 
prevention available, and epidemics are still to 
the front, authorities deserve commiseration and 
further State aid. But if, on the other hand, 
early notification of infectious disease is lightly 
esteemed — if cleanliness lies smothered in the 
midden, if isolation hospitals are few and poor, 
if disinfection is done by rule of thumb, or left 
undone — who can marvel should the advance of 
epidemics be like a royal progress, and who will 
dare commiserate with the local authority ? 

We are too ready to regard our system of public 
health administration in England as a brilliant 
success. Perhaps it is, as a whole. Undoubtedly 
much has been accomplished under it. It is com- 
prehensive and practical, and has many good 
qualities ; but it would be fatal to allow these to 
lead us into blind optimism. The triple line of 
defence against epidemics is admirable in theory, 
and might be made a briUiant success. Alas! that 
in practice it should ever prove a prodigious failure. 

Gentlemen, I hope I have not said too much ; 
I am sure I have not said too little. Those of 
you who do not estimate as poorly as I do the 
actual existing defence against epidemics, will at 
least admit that the results of the defence have 
often been far from satisfactory, and that I am 
justified in asking for something more, something 
different to be done. Let this be recognised and 
acted upon with zeal and knowledge, and I shall 
be content. 

A vote of thanks to the President for his address 
was moved by Dr. Lovett, and carried by acclama- 
tion. 

The President having rephed, 

Dr. WooDFORDE said he had a very agreeable 



task to perform in moving that the best thanks of 
the Society be given to their late President, Dr. 
Lovett, for the valued, courteous, and able services 
he has rendered in the Chair during the past year. 
They had seen him do a lot of valuable work for 
the Society for many years, but his action in the 
Presidential Chair had been a crown to his efforts. 
The motion having been carried unanimously, 
Dr. Lovett briefly thanked the Society for their 
thanks and the support they had given him during 
his year of office. 

Thanks to the Officers. 

Dr. T. Orme Dudfield m.oved that the thanks 
of the Society be given to their Officers, to whom 
they were so greatly indebted ; to Dr. Newsholme 
for his valued services as Editor of the Journal ; 
to Dr. Kempster, whom they could congratulate 
on the very handsome balance he had been able 
to show them ; to the Honorary Secretaries (Dr. 
Thresh and Dr. R. Dudfield), on whom a very 
large part of the burden of the work of the Society 
had fallen ; to Dr. Gwynn for his services as 
Auditor, and, finally, to that gentleman, who since 
the date of the Society's incorporation, had rendered 
them such valuable service and advice, he referred 
to Mr. Henry C. Jones, the Honorary Solicitor. 

The motion having been seconded by Dr. 
Woodforde, was put to the meeting, and carried 
unanimously. 

At the conclusion of the meeting, the Members 
adjourned to the Holborn Restaurant, when the 
Annual Dinner of the Society took place. 

The following toasts were proposed during the 
evening :— " The Queen " ; " The Prince of Wales 
and Rest of the Royal Family " ; "The Society" 
(proposed by Dr. T. Orme Dudfield, responded to 
by the President) ; " The Honorary Officers " 
(proposed by Dr. H. E. Armstrong, responded to 
by Drs. R. Dudfield and Kempster); and "The 
Branches of the Society " (proposed by Dr. Lovett, 
responded to by Dr. Yarrow). 



Dr. Leonard Wilde has been appointed to the 
post of Consulting Medical Officer to the East 
Sussex County Council. 

Dr. T. M. Legge has in the press a book on 
" Public Health in European Capitals," which will 
be published this month by Messrs. Swan 
Sonnenschein and Co. The capitals described 
will be Paris, Brussels, Berlin, Copenhagen, Stock- 
holm, and Christiania. From a persual of proof- 
sheets, and from a knowledge of the fact that 
Dr. Legge has secured the materials for this work 
by months of hard work in these European capitals, 
we can state that the book will be of great impor- 
tance as a survey of international sanitation, and 
one that the health officer who means to be fully 
equipped for his duties cannot afford to neglect. 



40 



PROCEEDINGS OF THE METROPOLITAN BRANCH. 



PROCEEDINGS OF THE METROPOLITAN 

BRANCH OF THE INCORPORATED 

SOCIETY OF MEDICAL OFFICERS OF 

HEALTH. 

A MEETING of the Branch was held on Friday, Octo- 
ber I ith, 1895, at 197, High Hoiborn, to consider 
" the question of the necessity or desirability of the 
provision of storage cisterns for sanitary purposes 
in occupied dwelling-houses on 'constant supply.'" 
Dr. Yarrow, the President, occupied the chair, and 
there was a large attendance, including the follow- 
ing Fellows : — Drs, W. H. Kempster, J. Dixon, 
R. Dudfield, P. C. Smith, Louis C. Parkes, R. M. 
Talbot, A. E. Harris, J. C. Jackson, J- Edmunds, 
W. A. Bond, E. F. Willoughby, S. R. Lovett, L. F. 
Bryett, G. Millsom, F. J. Allan, G. A. Rogers, 
E. Gwynn, J. Heron, S. Gibbon, T. O. Dudfield, 
W. R. Smith, and O. Field. 

The President called upon Dr. T. Orme Dudfield 
(Kensington) to open the discussion. After some 
introductory remarks directed to show the desira- 
bility of the subject being discussed, and of some 
opinion thereon being expressed, by the Branch, 
Dr. Dudfield avowed his belief in the necessity of 
retaining storage cisterns in houses on constant 
supply, for a variety of purposes, such as the flush- 
ing of ^drains and the service of water-closets. 
Siorage was needed, moreover, for the supply of 
feed-cisterns to kitchen boilers, and also when there 
was a hot-water circulating system. At the same 
time he urged the desirability of means being pro- 
vided so that water for dietetic uses might be ob- 
tained without the intervention of a storage cistern, 
viz., by affixing a tap or taps to the rising main or 
service-pipe. Referring to the late trouble at the 
East End of London, he observed that the people 
would not have been deprived of water had there 
been any means of storage, for the water was ad- 
mittedly turned on for never less than two hours a 
day, which was a longer time than was general in 
those large districts in London which were still 
supplied on the intermittent system. He had been 
unable to find any power enabling the Sanitary 
Authority to abolish cisterns, excef)ting, in the case 
o nuisance, under Section 2 of the Pubhc Health 
(London) Act, 1891. On the other hand he 
thought that there was ample power in that Act, 
and under the Water Acts, and the Regulations, to 
require the f)rovision of cisterns ; and he was 
under the impression that a water company might 
refuse to supply water to a house not possessing 
means of storage. Where storage was not i)rovided, 
a house, or a whole district, might be dc[)rivcd of 
water, suddenly, when it became necessary to shut 
off the water for repair of pipes, or in case of frac- 
ture of a main or 01 her cause. In such a case the 
people were at onrc deprived of water not merely for 
potable use, but (or all sanitary purposes whatever. 
In the event of frost closing the service-pipe, the 



house which possessed storage would be supplied, 
it might be, for several days, with water to flush 
the closets and drains, and so the cistern became a 
valuable reserve in case of emergency. Dr. Dud- 
field stated that he had been in communication 
with the medical officers of some of the chief cities 
in the three kingdoms, to ascertain their views, and 
the practice adopted in their several districts, and 
he read letters he had received from Sir Charles 
Cameron, of Dublin, Sir Henry Littlejohn, of 
Edinburgh, Dr. Niven, of Manchester, Dr. Hope, 
of Liverpool, Dr. Alfred Hill, of Birmingham, and 
Dr. Russell, of Glasgow. These gentlemen were 
not all of the same opinion, but the general view- 
was that storage should be provided, notwithstand- 
ing constant supply might be given, provision 
being made to enable people to obtain water for 
dietetic uses direct from the main. Dr. Dudfield 
observed that his opinion on the subject was 
no new one, for in every one of his annual 
reports since 1883, he had urged the necessity 
for storage, and for a draw-off tap on the main. 
He considered that, as the companies had no 
objection to the provision of such a draw-off tap 
on the main, it would be a wise thing to require it 
by a new regulation. He thought that any decision 
the Branch might arrive at should be sent to the 
Local Government Board, and with the view of 
ascertaining the feeling of the Branch with regard 
to this important question, he concluded by moving 
a resolution as follows : — 

" That the Branch is of opinion that storage 
cisterns should be retained, for sanitary purposes 
only, in occupied dwellings supplied with water on 
the constant supply system, and that draw-off taps 
should be affixed to the rising main for the supply 
of water for dietetic uses." 

The President read a letter he had received 
from Dr. Sykes (St. Pancras), advocating the reten- 
tion of cisterns and separate supply of drinking 
water from the main. 

Dr. Septimus Gip.bon (late of Holrorn) 

seconded the resolution. There was as much 
need, he said, for storage in private houses as for 
the storage the companies were required to pro- 
vide. He could not call to mind any case of ill- 
ness which had been traced to the use of cisterns, 
or any illness, other than cholera, many years ago, 
which had resulted in London, for which the water 
could be blamed. He would recommend a her- 
metically sealed cistern, to contain some 50 or 
more gallons, and which should be so constructed 
as to be practically a dilatation of the service pipe. 

Dr. Rogers (Limehouse) 

assured the meeting — with regard to a suggestion 
by Dr. Gibbon, that the trouble at the East End 
had been somewhat exaggerated — that the inhabi- 
tants of that district had suffered very much indeed 
from the want of water. He, himself, could get 



PROCEEDINGS OF THE METROPOLITAN BRANCH. 



41 



water at his surgery, for some weeks, only during a 
limited time every day. With respect to Dr. Dud- 
field's remarks on the abolition of cisterns, he 
detailed his experience as to the bad character of 
the storage receptacles, which he described as old 
and unlined water-butts, filthy, uncovered, and 
never-cleansed cisterns, which were often placed 
over the waterclosets they supplied direct, and 
with waste-pipes in connection with the drain. 
Consequently the sanitary authorities had served 
notices upon the owners of houses to affix draw-off 
taps to the mains, to provide waste-preventers, with 
the result that the cisterns had gradually fallen into 
a state of decay, and ultimately been done away 
with. He confessed that he was somewhat hazy 
as to any power that the sanitary authority might 
have for ordering the removal of a cistern, unless, 
as Dr. Dudfield had stated, when it was in such a 
state as to be a nuisance, or injurious, or dangerous 
to health. As a justification for the action of the 
local sanitary auihonties, he stated that when the 
East London Water Company promised them a 
constant service, they made a great point of the 
boon it would be to have no cisterns, but he was 
now satisfied that domestic storage was necessary, 
for they could not again go through such privation 
as they had had to endure during the past summer. 
With regard to the question of hot water supply, 
he expressed the opinion that at the East End 
kitchen boilers were mainly filled by hand and not 
through feed-cisterns. 

Dr. p. C. Smith (Wandsworth) 

expressed himself as being averse to cisterns, for 
which he could not see any necessity where there 
was a constant service. 

Dr. Harris (Islington) 

avowed that he had been strongly opposed to 
cisterns when he came to Islington, but he had 
since arrived at the conclusion that in London, 
where, owing to the inadequacy of the supply or 
other causes, there was liability to a breakdown of 
the water supply, some amount of storage was 
indispensable. He had had his attention much 
directed to the matter in connection with artizans' 
dweUings, and, whilst not prepared to go as far as 
the resolution of Dr. Dudfield, he hoped some 
modification of it might be arranged, so that they 
should be unanimous. He produced and explained 
a plan he had devised to enable water to be 
obtained from the rising main in ordinary circum- 
stances, with storage arrangements which could be 
brought into use when required. 

Dr. Parkes (Chelsba) 

suggested that the application of the resolution 
should be limited to London, as they did not 
desire to dictate to the authorities of other parts 
of the country. They needed storage in London 
for special reasons. When the constant supply was 



so abundant that it was not likely to fail, he could 
not see any advantage in storing water on the 
premises ; but in London the supply might fail, and 
therefore it was necessary to have storage. 

Dr. Dudfield 

said he had no difficulty in accepting Dr. Parkes's 
suggestion, it having been his intention to limit 
the application of the resolution to London 
exclusively. 

Dr. Reginald Dudfield (Paddington) 

referred to his experiences as to the misplacing of 
cisterns, and agreed as to the necessity of storage 
cisterns for the supply of water-closets and other 
sanitary purposes ; but there should be, he said, 
no means of drawing-off water from such cisterns 
for drinking purposes. This was the practice he 
had advocated, and which was in use, at Eastbourne. 

Dr. Gwynn (Hampstead) 

also agreed that it was undesirable to fix taps to 
cisterns intended for common sanitary purposes, 
to enable water to be obtained for dietetic uses. 
But if such cisterns were accessible, women and 
children would be sure to bale water out of them 
for any use. He gave his experience of the 
extraordinary situations in which cisterns were 
placed, as under bedroom floors, etc. It was 
surprising how clean such receptacles had been 
found, after long intervals, when properly covered. 
No doubt the unfitness of cisterns for dietetic uses 
was aggravated by inattention to cleanliness, and 
this was often due to the ditificulty of getting at 
them. 

Dr. Talbot (Bow and Bromley) 

did not think that the proposed resolution would 
help them much. What they wanted at East 
London was storage of a proper kind for water for 
drinking purposes. He had patented a cistern 
designed to secure this desideratum. It was made 
of stone, was acorn-shaped, and the tap was 
at the apex ; the lid was water-sealed. No dirt 
could accumulate in the cistern, for none could 
get in from the top, and it was self-cleansing. He 
admitted the justice of Dr. Dudfield's criticism of 
his plan of water supply, as shown in the sketch 
produced, because if a waste-preventer was supplied 
direct from the main pipe for the use of the water- 
closet, the flush of the closet could not be effected 
when the water was turned off. But it was quite 
easy, as Dr. Dudfield suggested, to supply the 
water waste-preventer from a storage cistern, and 
to use such a cistern as he had devised for drinking 
purposes only. 

Professor Smith (Woolwich) 

thought it undesirable at the present time to pass a 
resolution which, he said, could have no practical 
effect, or to forward to the Local Government 



42 



PROCEEDINGS OF THE NORTH-WESTERN BRANCH. 



Board any expression of opinion which might seem 
to forestall the report of their Inspectors arising out 
of the recent inquiry. At the same time, he was 
entirely of the opinion that storage cisterns should 
be provided. 

Dr. Dixon (Bermondsey), Dr. Lovett (St. Giles), 
President of the Society, and other fellows having 
spoken, Dr. H.\rris moved, and Dr. T.'VLkot 
seconded an am.endment to the resolution, to the 
effect : — 

That " a storage cistern should be provided, so 
arranged with taps that it should be only possible 
to use it when the water supply became inter- 
mittent; and that at other times water should be 
drawn directly from the main." 

After some further discussion the amendment 
was put to the meeting, and declared by the 
President to be lost. 

The resolution being about to be put to the 
meeting, Dr. Edmunds (St. James's, Westminster) 
deprecated any sweeping condemnation of the 
use of cisterns for potable water, when kept in 
a proper condition, as would generally be the 
case, certainly at the "West End. After further 
debate, in which several fellows took part, the 
resolution moved by Dr. Dudfield was amended to 
read as follows : — 

'' That the Branch is of opinion that in London 
storage cisterns should be retained for domestic 
purposes in occupied dwelling-houses supplied with 
water upon the constant service system, and that a 
draw-off tap should be affixed to the rising main 
for the supply of water for dietetic uses." 

The resolution having been put to the meeting, 
was declared by the President to be carried nem. 
con. It was then resolved that a copy of the reso- 
lution should be forwarded to the Local Govern- 
ment Board forthwith. 

The Water Regulations. 

Reference was made to the approaching inquiry 
by Colonel Ducat, R.E., one of the Inspectors of 
the Local Government Board, who had been 
appointed by the Board, as " a person of engineer- 
ing knowledge and experience," to report to them 
on certain alterations in the water regulations 
proposed by the London County Council, the water 
authority under the Metropolis Water Acts. One 
of the proposals of the Council relates to the 
2ist regulation, which requires water-closets to be 
supplied with water through a flushing-tank " not 
capable of discharging more than two gallons 
at a flush.'* The Council's proposal is to sub- 
stitute thre<' for two gallons. The P>ranch, being 
of opinion that the proposed alteration is 
desirable, requested Dr. Parkes to attend the 
mquiry on the 31st Inst., and to give evidence 
on the part of the Branch in support of the 
views of the Council. Dr. Parkes consented to do 
as requested. 

The meeting then adjourned. 



PROCEEDINGS OF THE NORTH-WESTERN 
BRANCH OF THE SOCIETY OF 
MEDICAL OFFICERS OF HP:ALTH. 

The adjourned annual meeting of this Branch was 
held in the Rooms of the Chemical Club, Man- 
chester, on Friday, October nth, at 4 p.m. The 
following members were present : — Drs. Vacher 
(President), Adams, Barr, Gornall, Graham, 
Kenyon, Marsden, Niven, Paget, Pilkington, 
Porter, Robertson, and Wheatley. 

It was proposed by Dr. Paget, seconded by 
Dr. Adams, and carried, that the alteration of rules 
approved at the June meeting be confirmed. 

Letters were read from Dr. Harvey Littlejohn 
and Dr. Eustace Hill. 

It was proposed by Dr. Paget, seconded, and 
carried, that the present ollficers and committee be 
re-elected until October, 1896, and that Dr. 
Robertson be elected a member of the committee. 

Dr. Vacher referred to the death of Dr. J. M. 
Fox, and proposed the following resolution, which 
was seconded by Dr. Gornall and carried : — 
" That the North-Western Branch of the Society 
of Medical Officers of Health takes the earliest 
opportunity of expressing its sense of the loss it 
has sustained by the death of Dr. John Makinson 
Fox, who had been a member of the Society since 
1878, and who served as President of the Branch 
during the year 1883-84. Dr. Fox was much 
esteemed as a colleague, and enriched the proceed- 
ings of the Branch with several highly-valued con- 
tributions. The Branch expresses its sincere 
sympathy with the family of the deceased in their 
bereavement." 

A committee, consisting of Drs. Vacher, Adams, 
Graham, Wheatley, and Paget was formed to draw 
up as far as possible a list of papers for the 
ensuing year. 

Address by the President. 

Gentlemen, — The opening of what we may call 
our Winter yession affords me an opportunity of 
saying a few words to you, which I should be un- 
willing to let pass. 

First, I welcome you back to these rooms and 
our monthly meetings, after an interval, part of 
which 1 hope has been spent by every one of you 
in taking a holiday. If it be true (and who doubts 
it ?) that the general practitioner needs an annual 
holiday, it is surely not less true that the medical 
officer of health needs one. The worry and strain 
of public health work are as severe as in the case 
of any work, and getting right away from these for 
three or four consecutive weeks yearly is almost 
essential if a man is to maintain himself in good 
form — mens scuia in corporc sano. Taking two or 
three days off now and again is often so much 
easier than getting away for an extended period, 
that many are content with such brief absences ; 
but the bcnelit derived is nothing like as great, as 



CLOSING OF SCHOOLS IN RELATION TO SPREAD OF MEASLES. 



43 



many of us have proved by experience. My 
advice therefore is, make a practice of taking an 
annual holiday, and I am quite sure that your 
districts will get better work out of you if you do. 
Having thus begun with a note on holidays, I 
proceed to discuss work — the work of this Branch. 
While fully convinced of the good work done in 
the past year by year, I cannot help thinking that 
with a little more method better might be accom- 
plished. We have so many monthly meetings be- 
fore us — could we not arrange something in the 
nature of a programme concentrating our attention 
on a series of six or seven subjects. There is no 
necessity that these subjects should be intimately 
related, though it might be well that they should 
have some slight connection to each other. The 
main point is to select topics in which we as 
medical officers of health are personally concerned 
in our daily routine. Some of you may remember 
that about this time last year the Incorporated 
Society in arranging discussions suggested four 
subjects, all of which were in due course debated, 
viz. : " Vaccination and the Laws Relating There- 
to," "Death Certification and Registration," " The 
Training and Qualification of Medical Officers of 
Health," and the " Etiology of Puerperal Fever." 
Now, no one will deny these are all subjects in 
which medical officers of health take a general 
interest, but not one of them has any direct 
relationship with our ordinary work. If we 
arrange a programme, as I trust we may, I should 
like the subjects therein to be those with 
which we are dealing daily, on which we are 
frequently asked advice and give opmions. I 
am reminded of a story of Lord Melbourne. At 
the end of the Cabinet Council at which it was 
agreed to propose a fixed duty on corn, his lordship 
put his back to the door, and said, " Now, is this 
to lower the price of corn, or isn't it ? It does not 
much matter what we say, but mind, we must all 
say the same." This may serve to point a moral 
to medical officers of health. Local authorities 
and the public look to us for direction, and we 
often take counsel together; yet when the time 
comes for us to give advice, we do not all " say the 
same." Whether Lord Melbourne and his Cabinet 
said the corn duty would lower the price of corn or 
not was of no importance, but when simple, direct 
questions are put to us, I think we ought to be 
able to " say the same," or something near it — 
i.e., we ought to give the best answer modern 
experience and research permits of. Some questions 
put to us, I might almost say, receive a different 
answer in every d\?>mcl— tot homines, tot sententice — 
such a question, for instance, as. What constitutes 
efficient disinfection ? Some questions put to us, 
or occurring to us, are for the most part left 
unanswered ; such a question is, How can animal 
food be systematically inspected ? Now, could 
not a programme of half a dozen subjects, to be 
stated as simple, practical questions such as these, 



be drawn up, and a question or subject assigned 
to each monthly meeting? Someone should be 
asked to open the debate, and all should think 
over the matter and contribute more or less. I am 
not prepared to suggest the subjects, but I am sure 
that a small committee, with the help of the 
honorary secretary, could draft a satisfactory 
programme in a few days. 

There is only one other matter I desire to re^er 
to now, and that is the importance of increasing 
our membership. The measure of our usefulness, 
other things being equal, must increase with the 
membership. The Branch, doubtless, has a fairly 
representative membership at present, but having 
regard to the area covered by the Branch, the sum 
of the fellows belonging to it, instead of being 
about 50, should be about 100. On this, the 
twenty-first year of our association, a united effort 
should be made to bring the membership up to the 
full strength attainable. I will promise to take my 
share in this united effort, and trust that every 
other fellow belonging to the Branch will do his 
best also. 

The Closing of Schools in Relation to the 
Spread of Measles. 

BY 

R. Sydney Marsden, M.B., D.Sc, F.R.S. Edin., etc.. 
Medical Officer of Health for Birkenhead. 

The question as to the advisability of the noti- 
fication of measles is at present receiving a 
considerable amount of attention from -Sanitary 
Authorities ; any statistics, therefore, which bear 
upon the subject must be of interest and value. 

One advantage which I have always claimed in 
connection with the notification of measles has 
been that of giving us data for the closing of 
schools, which in the commencement of an out- 
break I regard as of considerable importance in 
checking the spread of the disease. 

But we are repeatedly told that such a procedure 
as school closure has no appreciable effect in 
stopping the spread of measles. This, however, is 
not my experience, as the following statistics 
show : — 

In the middle of January, 1893, an outbreak of 
measles occurred in the northern district of Birken- 
head, and by the beginning of March it was 
spreading so rapidly that I advised the Sanitary 
Authority to close the public school (St. James') in 
the district for fourteen days. This was done from 
March 4th to the 21st, 1892 (inclusive), with the 
following results, viz. -.—The number of cases 
notified m the district during the six weeks precedmg 
the closure and the first week of closure,* that is, 
from the 2 2ndof January to the iithof March, 1892, 
was 99. The number of cases notified during the 
five weeks following, that is, from the i ith March to 
the 15th of April, was 32. The disease then died 

* This week must be included, as the infection wouM 
have taken place before closure. 



44 



THE EAST LONDON "WATER FAMINE. 



out — a reduction of 66 per cent. ; the notifications 
for the different weeks being as follows : — 

1st week, from January 22 to January 29, i cases. 

2nd ,, ,, ,, 30 ,, February 5, o ,, 

3rd ,, ,, February 6 ,, „ 12, 4 ,, 

4th ,, „ ,, 13 ,, ,, 19, 27 ,, 

5th M .. ,. 20 ,. ,, 26, 17 „ 

bth ,, „ ,, 27 ,, March 4, 33 ,, 

7th „ ,, March 5 „ „ 11, 17 ,, 



Sth 

9th 

loth 

nth 

1 2th 



April 



12 ,, 

19,, 
26 „ 



April 



99 

18, 15 
25, 10 

I. 3 
8, 2 

15. 2 
32 



At the time of closing the school there were 85 
cases out of 450 on the rolls. 

Another outbreak of measles occurred in the 
Oxton District of Birkenhead in September, 1893, 
and by the middle of October the cases were 
becoming so numerous, particularly amongst the 
children attending the Infants' Division of the 
Oxton National Schools, that I again advised the 
Sanitary Authority to close the school, which was 
done from the 17 th of October to the ist of 
November, 1S93 (inclusive), with similar results 
to those obtained from the closing of the St. 
James' schools in 1892, recorded above. 

At the time of closing this school there were 43 
cases out of 114 on the rolls. 

Thentimber of cases notified in the district during 
the six weeks previous to the closing and the first 
week after the closing, i.e., from the 5th September 
to the 24th of October, 1893, was 53. The number 
of cases notified during the five weeks following, 
i.e., from the 25th of October to the 28th of 
November, 1893, was 9, a reduction of 60 per 
cent. ; they then died out, the notification for the 
different weeks being as follows, viz. : — 

1st week, from September 5 to September I2, o cases. 

2nd M ,, ,, 13 .. „ 19, o ,, 

3''d „ ,, ,, 20 ,, „ 26, 12 „ 

4th ,, ,, ,, 27 ,, October 3, i ,, 

5th ,, ,, October 4 ,, ,, 10, 7 ,, 

6>h „ „ „ II ,, ,, 17, 8 „ 

7th ,, ,, ,, 18 „ ,, 24, 25 ,, 

8th „ ,, ,, 25 ,, ,, 31, 6 ,, 

9th ,, ,, November i ,, November 7, i „ 

loth ,, ,, ,, 8 „ „ 14, 2 ,, 

"'h ,, ,, ,, 15 ,, ,, 21, o ,, 

I2lh ,, ,, ,, 22 ,, „ 28, o ,, 



The closing of the schools, therefore, had a 
most appreciable effect in stopping the spread of 
the disease in these two cases, but if notification 
of measles had not been in operation in the 
borough we could have had no data on which to 
table so important a step. 



A discussion followed, in which Drs. Paget, 
Kenyon, Robertson, Wheatley, Gornall, Oraham, 
and Porter took part, and Dr. Marsden replied. 

Dr. Niven showed specimens of meat, which 
clearly demonstrated the value of very careful 
inspection of meat for tubercle, even although all 
the organs have been removed. 

( The Reports of the Odober meeting of the Birmingham 
and A/idland Branch, the West of England Branch, and 
the Yorksliire Branch are unavoidably held over until 
next month.) 



THE EAST LONDON "WATER FAMINE,'' 
AND ITS EFFECTS AS REGARDS THE 
PUBLIC HEALTH. 
In another part of the present issue we report the 
proceedings at a meeting of the Metropolitan 
Branch, convened to consider the question, arising 
out of the recent trouble in connection with the 
water supply in East London, Whether storage cis- 
terns are necessary or desirable in houses supplied 
with water on the constant service system ? This 
question has lately received attention in our contem- 
poraries, the Lancet and the British Medical Journal, 
and we may have something to say on it on another 
occasion. But at present we confine our observations 
to the intjuiry, What were the effects, as regards 
the public health, ^ua mortality, of the alleged 
deficiency in the water supply during the third 
quarter of the year ? And here it seems only right 
to mention that the supply, so far as we can gather, 
was deficient only in houses unprovided with the 
means for storing the water pumped into the 
district by the delinquent Company — the East 
London — who claim to have supplied, during the 
" famine " months, July and August, upwards of 
thirty gallons a day per head of the population, or 
nearly three times as much as the Medical Officer 
of Health for Bethnal Green considers necessary 
for the domestic requirements of the people. This 
question — of the effects of the short supply as 
regards the public health, to whatever cause due, 
naturally received attention at the inquiry opened 
at the Hackney Town Hall, on the ist October, 
by the Inspectors of the Local Government Board, 
and evidence with regard to it was given by the 
Medical Officers of Health for the Sanitary 
Districts of Hackney, Bethnal Green, Mile End 
Old Town, Poplar, St. George's-in-the-Kast, and 
Limehousc, these districts, and Shoreditch, 
apparently, being those mainly affected. The 
allegation made was to the effect that in these 
seven districts there was an increase in the general 
death-rate, and in the dinrrhteal death-rate, during 
a period of five weeks ending August 17th, the 
comparison being made with the corresponding 
weeks of the third quarter of 1893 — the two 
(|uarters being fairly comparable, their rainfall 
(5'88 inches in 1893, and 6*50 in 1895) and mean 
temperature (61-9'' in 1893, and 62*3^ in 1895) 



WEATHER AND DISEASE 



45 



having been almost identical. Accepting^ the 
statements of the medical officers as entirely 
accurate for the period in question, we are yet glad 
that the "Analysis of the Mortal Statistics of the 
Sanitary Districts of the Metropolis," for the third 
quarter of the year, which appeared in the British 
Medical yournal of the iQth of October, has 
enabled us to extend the comparison to the entire 
period of thirteen weeks, with results that are 
somewhat surprising. Time does not permit now 
of a statement of the figures for each of the 
sanitary districts named ; it must suffice to say that 
their combined death-rate, which had been 23'i5 
per 1,000 in the third quarter of 1893, was 21 "38 in 
1895.* The Hackney Vestry, in particular, which 
appears to have taken the lead in promoting the 
inquiry, may be congratulated on a reduced 
mortality of 2'8, viz., from 187 to 15*9 per 1,000. 
Nor IS the state of matters very different as regards 
diarrhoea. This disease was no doubt more fatal 
in the selected five weeks in 1895 than in the cor- 
responding weeks in 1893 ; but on comparing the 
rate of mortality for the entire quarter, we find no 
great excess in the seven East End districts, whether 
considered separately or m the aggregate, the un- 
corrected number of deaths in 1895 having been 
only 75 more than in the third quarter of 1893, in 
a popualtion of some 885,000. The diarrhoeal 
death-rate was 3 '09 per 1,000, compared with 2*89 
in 1893, and ranged from 2*47 in Hackney to 3*72 
in Shoreditch, the range in 1893 having been trom 
I "86 in Hackney to 3*98 in St. George's-in-the- 
East. In the Metropolis, as a whole, the rate, 
which had been 2*02 in 1893, was 2"4i in the third 
quarter of 1895 — ^ proportional increase greater 
than obtained in the seven East End sanitary areas. 
The diarrhoeal deaih-rate in the aggregate of these 
area^, moreover, compares favourably with that in 
our large provincial towns; for no fewer than 16 
of the 32 dealt with by the Registrar-General, have 
diarrhoea rates exceeding the East London rate, 
and the mean rate in the 32 towns (4" 10 per 1,000) 
was considerably higher than in East London 
(3"o9 per 1,000). Diarrhoea was, essentially, the 
only zymotic disease referred to at the inquiry, but 
we are now in a position to speak with respect to 
the " seven principal diseases " of the zymotic 
class ; and we note that the rate for the East End 
sanitary areas, which had been 5" 71 in 1893, was 
6 00 in the third quarter of 1895 — an increase of 
©•29 per 1,000 — there having been a net un- 
corrected increase of 86 in the deaths from these 
diseases in 1895. This excess, however, was 
entirely due to measles, which shows an increase 
of 179 deaths compared with the third quarter of 
1893. Of deaths due to diarrhoea, as already 

* Since 1893 the parish of Stoke Newington, with a present 
population of less than 36,000, has been separated from 
Hackney ; but we have thought it proper, for the sake of 
accuracy in comparison, to group the statistics of that sanitary 
area with those of Hackney, for the third quarter of 1895. 



Stated, there was an excess of 75 in 1895. All of 
the other diseases show more or less considerable 
decreases, viz., small-pox, 8 ; whooping-cough, 63 ; 
scarlet fever, 26 ; diphtheria, 43 ; and enteric fever, 
28. The decrease in diphtheria and enteric fever 
is specially significant. We may add that, speaking 
generally, the several decreases are fairly spread 
over the whole of the seven sanitary areas referred 
to. It would thus appear that little, if anything, 
can be made out against the water supply of these 
areas from the zymotic mortality, and that their 
general death-rate was considerably less than in 
1893. We realize to the full the grave incon- 
venience to which so large a proportion of the 
people at the East End were subjected by the 
failure of the constant supply, but we cannot 
resist the conclusion, which appears to be shared 
by the Metropolitan Branch, that this was due to 
the abolition of the means of domestic storage. 
Perilous, moreover, as the deficient supply of water 
undoubtedly was, it is satisfactory to note, as the 
unexpected result of this brief examination of 
the statistics of mortality, that no special incid- 
ence of disease appears to have resulted — a fact on 
which we heartily congratulate our colleagues at 
the East End of London, and for which, in our 
judgment, they are entitled to great credit. 



WEATHER AND DISEASE.* 

The influence of weather upon disease is of the 
highest hygienic importance \ and Mr. MacDowall's 
contribution to the subject is both timely and 
valuable. It possesses, in fact, an almost unique 
value, as its teaching is effected almost entirely by 
curves, the printed matter of the book occupying 
less space than its full-page diagrams. The graphic 
method has been very insufficiently employed in 
hygienic investigations. It is, however, incompar- 
ably superior to any other method, both in real 
accuracy and in the ease and rapidity with which 
deductions can be made. 

The first curve deals with the rainfall of England 
in the last ninety-five years, and illustrates very 
well the system of smoothingdi^Q'^Xtd. by the author. 
By means of this smoothing, the variations for long 
series of years are clearly bought out, which might 
have been lost in the violent oscillations of the 
annual curves. Then follow curves showing the 
wettest and the driest month, the best ten days in 
summer, the winters of this century, the occurrence 
of very cold days, and long frosts. The eighth 
curve, showing the mean temperature of the first 
plus the last quarter of each year at Greenwich 
since 1830, is interesting. It shows a maximum in 
1880, and a subsequent minimum reached (in the 

* " Weather and Disease : A Curve History of their 
Yariations in Recent Years." By Alex. B. MacDowall, 
M.A., F.R. Met. Soc. (The Graphotone Co., i, Maclean's 
Buildings, E.G. 1895. 2s. 6d.) 



46 



THE TYNE PORT SANITARY AUTHORITY AND THEIR M.O.H. 



smoothed curve) by steady graduations in 1889. 
It is not possible for us to discuss the curves of 
sunshine, sunspots, and thunderstorms, early and 
late seasons, and fogs ; but must pass on to the 
second part of the book, which has a more directly 
medical interest. The first curve in Part II. deals 
with measles in London since 1838. Its smoothed 
curve shows several long waves having maxima 
in 1843, 1862, and 18S5. The whooping curve 
shows no si'ch long waves, but a fairly steady 
though not great dechne. Scarlet fever the same. 

The curve of progression in the summer death- 
rate wave is interesting though anomalous. Thus, 
in 1893, the highest death-rate was reached in the 
25th week at Plymouth, in the 26th at Cardiff, in 
the 29th at Portsmouth, the 34th at Brighton, and 
the 35th at Hull. 

The curve of weekly deaths from influenza in 
London in each of the five epidemics from which 
it has suffered is excellent, illustrating very well 
the more explosive character of the third and fifth 
of these epidemics. 

We should like to see some more specimens of 
curves like those given on p. 75. It is interesting 
to note the different dates of incidence of whoop- 
ing-cough IP, Bristol and Portsmouth, of scarlet 
fever in Leeds and Bristol. Much light might be 
thrown on certain infectious diseases by an exten- 
sion of this method of bringing the facts into 
rehef. 

An attempt is made in the last rurve to 
work out the relationship between the amount 
of " zymotic disease " in severe and mild win- 
ters. The conclusion drawn is that, on the 
whole, winter cold is unfavourable to the mor- 
tality from zymotic disease, and mild winter 
weather favourable. The fallacy lies, however, 
in classing all zymotic diseases together. We 
may in th's have the concealed operation of 
divergent causes. 

We conclude our somewhat cursory review of 
this work by expressin^^ our delight with it. To 
those interested in statistics, and to that larger 
number who, without being interested in statistics 
themselves, desire to have their general results 
before them, the work can be heartily commended. 
It is refreshingly novel in character, extremely sug- 
gestive and original, and will, if we mistake not, 
provoke some imitators. 



JPufalic Iraltlj. 



In the last number of the Deutsche Vierteljahrs- 
schrift fur offentliche Gesundhcitspflege^ Dr. M. Pistor 
pays a tribute to the memory of the late Sir 
CJeorge Buchanan : — " liuchanan was distin- 
guished," he says, "by wide knowledge and 
marked ability in administrative work, combined 
with great amiability and genuine English hos- 
pitality. His well-earned rest he has, alas! not 
long enjoyed, but his memory will also in Germany 
be held in honour." 



THE TYNE PORT SANITARY AUTHORITY 
AND THEIR MEDICAL OFFICER OF 
HEALTH. 
The letter addressed by Dr. Armstrong to the 
River Tyne Sanitary Authority, which appears 
in another column, will be read with regret 
by all interested in the cause of port sanitary 
administration. For over thirteen years Dr. 
Armstrong has been responsible for the sanitary 
administration of this most important English 
jjort, and the brilliant and continued success of 
his administration is well known throughout the 
land. The history of cholera and its unsuccessful 
attempts to obtain a footing in this country, via the 
river Tyne, are more than sufficient evidence of 
this. The splendidly organised disinfecting 
arrangements and the infectious diseases hospital 
for the port are also due to Dr. Armstrong's power of 
organisation and initiative. The Port Sanitary 
Authority is a combined body representing a 
number of local authorities contiguous to the 
Tyne, and it appears to be the recalcitant action 
of the Town Council of South Shields that 
has caused the present iinpasse. We do not envy 
South Shields its invidious position in this matter, 
which threatens to break up a combination that 
has been invaluable in the interests of the common- 
weal. It is obvious that there must be mutual 
concessions in such a combination, but outsiders 
will have no difficulty in saying indignantly that no 
one member of the combination ought to be 
allowed to render joint action impossible. This is 
a case in which the hands of the Local Government 
Board ought to be greatly strengthened. The 
health of the community is of greater importance 
than the complete freedom of any local authority, 
and it ought to be possible for the Local Govern- 
ment Board to intervene, and prevent the evil 
consequences resulting from the petty and obstruc- 
tive action of a single local authority. 



NOTES ON AN OUTBREAK OF TYPHOID 
FEVER, DUE TO CONTAMINATED 
WATER SUPPLY. 

BY 

Trafford Mitchell, M.D., M.O II. (lorscinon. 
During the months of July and August last, a 
virulent outbreak of typhoid fever took place in a 
house situated in the town of P., six out of the 
seven inmates being attacked, and three dying of 
the disease. 

The first case occurred on 24th July, and was so 
obscure that its nature was only asceitained when, 
after a few weeks' interval, five other cases of fever 
occurred, all of which presented the typhoid rash, 
anrl some of them intestinal hemorrhage. 

The fever did not spread beyond the house first 



RECENT RESEARCH. 



47 



invaded, and there had been no other known cases 
of that disease in the town for a year. 

The milk supply was free from all suspicions of 
contamination, and there were no cases elsewhere 
of typhoid fever amongst consumers of m>.lk from 
the same dairy farm. 

The house and its surroundings were kept in a 
thoroughly clean state. Slop-water and the excreta 
from two w.c.'s were conveyed by glazed earthen- 
ware pipes to a cesspool situated a long way from 
the house ; and the pipes were efficiently trapped 
and ventilated. 

The family obtained their water supply from a 
private well, situated in close proximity to the w.c.'s, 
and to the soil-pipe leading from them. The well 
was 1 6 feet deep, and its walls consisted entirely of 
loose, dry stones, with the exception of two courses 
of bricks at the top, set in cement. The well was 
securely covered, and the pump was placed in the 
kitchen. Suspicions as to the purity of this water 
were soon confirmed by the discovery of a defec- 
tive joint in the soil-pipe, v/hich permitted free 
leakage. This broken joint was situated i8 inches 
below the surface of the ground, and at a distance 
of 6 feet from the well ; so that, as the soil was 
porous and gravelly, contamination of the well was 
inevitable. The water had, at frequent intervals 
during the last three years, given off a most offen- 
sive stench, and the family had often talked of 
a-iandoning its use and employing water from a 
pubHc pump situated fifty yards off. 

A sample of water from the private well was 
submitted to a public analyst, and his report con- 
tained the following : — 

" As regards organic matter, the water is of 
normal quality. Tne amount of oxidised nitrogen 
compounds is, however, rather high, and the 
presence of nitrites distinctly suspicious. I am of 
opinion that the surroundings of the well should be 
inspected, as the nitrogen compounds are originally 
derived from animal organic matter." 

That the contamination of the well had been 
going on for a long period is evident from the 
character of the broken joint in the soil-pipe, and 
the fact that the offensive odour already mentioned 
had been observed, at intervals, for years. 

No case of typhoid fever had occurred in the 
house previously, but the inmates had not enjoyed 
robust health. 

Why did the sewage-contaminated water cause 
typhoid fever this autumn, whilst previously it had 
only produced a feeling of malaise and general 
weakness? Whitelegge states that, "While water, 
poUuttd even with excremental filth, has often been 
drunk for years by numbers of people with per- 
fect impunity, so far as the appearance of enteric 
fever is concerned, the slightest contamination 
with the excreta of a case of enteric fever has, 
over and over again, been found to result in wide- 
spread outbreaks of the disease, the incidence of 
which, in such instances, exactly follows the dis- 



tribution of the water, and affects only those per- 
sons who drink it." 

In the present outbreak, six of the seven persons 
drinking this water were attacked by typhoid fever ; 
and the most reasonable explanation seems to be 
that the last five cases were due to excreta from 
the first typhoid patient obtaining access to the 
well. The dates of the primary and secondary 
cases seem fully to confirm this view. The first 
case occurred on 24th July ; the second, third, and 
fourth cases on 15 th, i6th, and 17 th August 
respectively; the fifth on 26th August; and the 
sixth on loth September. The interval that 
elapsed between the first case and the appearance 
of the next three is such as would allow a reason- 
able time for the passage of the specific poison into 
the well, and the subsequent period of incubation 
in the bodies of the patients. The later appearance 
of the fever in the fifth case is satisfactorily ex- 
plained by the fact that this paiient made it a rule 
never to drink water unless it had been previously 
boiled; but one night, about 15th August, finding 
no hot water available, he drank more than a pint 
of water taken direct from the pump, and to that 
he himself attributed his illness. The late occur- 
rence of the sixth case is clearly due to the fact 
that this patient had only returned home on 24th 
August, after many months' absence. 

Whence the first patient derived the infection 
has not been ascertained ; but, as his duties 
were of such a nature as to entail frequent absences 
from home, and the consequent use of water and 
food from innumerable sources, it is fair to infer 
that he imported the infection from some distance. 

I have to acknowledge the invaluable assistance of 
the county medical officer (Dr. Williams) in the 
investigation of the outbreak. 



RECENT RESEARCH. 

The Prep.\ration of Sterile Drinking Water 

P,Y MEANS OF ChLORIDE OF LiME (ChLOR- 

kalk). By Marine Staff-Surgeon Dr. Bassenge. 

{Zeitschrifi fiir Hygiene, Vol. XX., 3.) 
The conclusions of this very practical investigation 
are : — 

1. That an addition of 0*09 7 8 of a gram of active 
chlorine, corresponding to about o"i5 of a gram 
of ordinary chloride of lime, is sufficient to render 
absolutely sterile in ten minntes a litre of water 
very strongly affected with pathogenic organisms. 
If the action is allowed to continue for a longer 
time, the amount of chlorine necessary is cor- 
respondingly diminished ; so that if two hours be 
allowed, o'oioS of a gram suffices. 

2. The excess of chlorine not used in the work 
of disinfection can be removed by bi-sulphite of 
calcium Ca(HS03)2, which throws down a slight 
precipitate of sulphate of lime. The water so 
treated is harmless, has no perceptible taste, and 



48 



RECENT RESEARCH. 



increases in hardness. It can be enjoyed for a 
long period without exerting any deleterious effect 
on the health, as, owing to the above treatment, 
the water contains no constituents other than 
those found in ordinary drinking water. 

3. The [)roof that all excess of chlorine has 
been removed is given by the absence of taste and 
smell from the water. 

4. This fact, that by chemical means a sterile 
drinking water can be with certainty produced, is 
easily verified, and under certain circumstances it 
may have very important practical bearings. 

The author describes how in some of his 
experiments, when the cultures remamed sterile 
after addition of the chlorine, the control cultures 
developed as many as from 314 to 2,500,000 
microbes per c.c, according to their origin. 

That the chloride of lime (chlorkalk) has the 
same disinfecting power when added to the water 
in the solid form as when in the form of solution 
of chlorinated lime, has the great practical advan- 
tage that it can be kept for any length of time, if 
securely corked. The author suggests the fol- 
lowing way of putting his method into practice : — 
Put as much chloride of lime as will lie on the end 
of a small knife (about one gram) into five litres 
of the water in question. Shake it up well, and 
let it stand for from twelve to fifteen minutes. 
Then add, drop by drop, solution of bi-sulphite of 
calcium until there is neither taste nor smell of 
chlorine. 

The author thinks that this method of obtaining 
a germ-free water will be found of great utility in 
the Navy, especially on small survtying expeditions 
in tropical regions. For small encampments of 
troops, too, or for small settlements, the uses to 
which it might be put are obvious. 



On the Presence 
Market Milk. 



OF TuiiERCLE Bacilli in 
By Dr. Obermuller, 



{Uygienische Rundschau^ October ist, 



;•) 



Milk that is bought in the market is nearly always 
a mixture of milk from many different cattle. 
Owing to the prevalence of tubercle amongst 
cattle, the probability is that not unfrequently 
tubercle bacilli pass into such milk. The author 
describes the results of expermients made by 
inoculating forty healthy young guinea-pigs with 
milk purchased in the open market. The milk 
was bought in half litre bottles provided with 
a patent india-rubber fastening. Four of the 
animals died of advanced tubercle, and post 
inortevi examination showed that this was peri- 
toneal. Eight of the animals, further, died within 
eight to ten hours, not from tubercle, but from 
another organism (which the author isolated) 
peculiarly pathogenic to guinea-pigs. 

In another series of experiments, guinea-pigs 
were inoculated with the cream, and 38 per cent, 
of them became affected with tubercle. CJeneral 



experience shows that there are districts where 
tubercle amongst cattle is rare. For instance, 
where the animals are much in the fields, the 
disease is much rarer than it is amongst those that 
are stall fed. When, however, tubercle has once 
taken root in a district or cowshed, it is difficult to 
get rid of Boiling the milk is a sufficient pro- 
tection against infection from the milk itself, but 
does not go to the root of the matter. The use 
of animals affected with tubercle must be fought 
against by introducing rational methods of feeding 
and better housing, and, above all, by employing 
tuberculin as a means of diagnosing the disease, 
as is being done now so largely in Denmark, 
Holland, and France. 



The Self-Purification of Rivers. 

Dr. Draer, Assistant at the Hygienic Institute 
of Konigsberg, in an article in the Zeitschrift filr 
Hygiene, Vol XX., 3, refers at some length to the 
question of the self-purification of rivers. His 
attention was directed to the subject in a careful 
inquiry made by him on the bacteriological and 
chemical condition of the River Pregel, and its 
suitability as a drinking water supply for the large 
town of Konigsberg, in Prussia. 

The conditions influencing this phenomenon 
are: — 

1. The Movement of the Water. — According to 
some authorities, however, the importance of this 
has been exaggerated, as laboratory experiments 
have shown that the vigorous shaking of water by 
hand, or by mechanical means, does not affect the 
number of micro-organisms. 

2. 7he Pressure Exerted hy the Water. — This 
is believed to destroy or weaken the virulence of 
certain microbes, and in support of this it is urged 
that the number of bacteria capable of developing 
is less the greater the depth from the surface of 
the water a sample is taken. Opposed to it is the 
fact that in the ground at the bottom of water- 
courses, despite the weight of water lying above, 
an increase in the number of bacteria is found. 

3. Light. — Buchner's experiments on the effect 
of direct sunlight, as well as of diffuse daylight, on 
the bacteria suspended in water, showed that an 
enormous reduction in their number occurred after 
an exposure of some hours to their influence. 
Indeed, he could with certainty make out a varia- 
tion between the number present during the day 
and during the night, which was brought about 
by the sterilising influence of the light. 

4. Vegetation in Water. — Pettenkofer, more 
than anyone else, has shown the importance of 
this factor, and especially of that of algai. It has 
been proved that algio bring about a marked 
reduction in the organic matters in the water. 
For instance, in the waters of the Iser, imme- 
diately below Munich, whtre the organic matter is 
[)rcsent in excess, there is an abundant growth of 



DESTRUCTION' OF TOWN REFUSE BY HEAT. 



49 



algae ; but above the city, and far below it, there 
is none at all. According to Pettenkofer, who 
believes that the views held as to the danger of 
allowing sewage to flow into streams are ex- 
aggerated, the following are the signs of the 
pollution of a river : — Cloudy appearance of the 
water, unpleasant taste and smell, death of water 
plants and fish, increase in organic matter, altera- 
tion in the amount of oxygen, and the detection of 
poisonous matters. 

6. Sedimentation. — Pettenkofer attributes to this 
factor but a very small role, thinking that the 
agency of oxygen and vegetation are sufficient to 
account for the phenomenon. Others, however, 
regard the self-purification of rivers as due, in the 
main, to the subsidence of impure matters, and to 
their subsequent disintegration at the bottom of 
the river. 

Currier, of New York, was able to show that the 
number of bacteria in a river steadily diminishes 
as it flows along, provided others are not added 
to it from fresh pollutions. This diminution he 
attributes to dilution from additions of fresh pure 
water from springs, to oxidation through the ozone 
present in the water, and lastly, to the sedimenta- 
tion where it is a question of a slowly-flowing 
stream. Other agents, but to a lesser degree, are 
the antagonism of the various forms of bacteria, 
and sunlight. 

Although the views held as to the self-purifica- 
tion of rivers by different authorities are very often 
strikingly opposed to one another, yet almost all 
are agreed that twenty to thirty kilometers below 
the entrance of sewage matter the water is just as 
pure as it was above. 

The probability is, that no definite laws on the 
question can be laid down, but that, just as in the 
case of the treatment of the sewage in towns, each 
case must be judged by itself; so in the self- 
purification of rivers, in each instance a number 
of external influences come into play, which must 
be taken into consideration. 



DESTRUCTION OF TOWN REFUSE 
BY HEAT.* 

BY 

J. Spottisvvoode Cameron, M.D., B.Sc, etc., M.O.H., 
Leeds ; Consulting Physician to the Huddersfield 
Infirmary, etc. 

It is not perhaps necessary at all to elaborate the 
disadvantage in populous places of tipping the 
putrescible and putrefying refuse from our dust 
bins into old quarries, or of using it for the pre- 
paration of new streets. The mere fact that collec- 
tions of the kind frequently take fire shows to some 
extent the nature of their contents. Such fires, 
however, though doing something to lessen the 

* A Paper read before the Public Medicine Section of the 
British Medical Association, August 2nd, 1894. Printed by 
permission of Editor of Bnt. Med. Journal. 



evil, are nuisances in themselves. In default of 
tipping, the difficulty is how to dispose of the 
rubbish, and the experience of Leeds in burning 
this material — going back as it does for a period of 
eighteen years — may be of value to some. 

In 1876 the Council determined to experiment 
with the destruction of refuse by heat, and began 
to lay down a plant on Mr. Fryer's principle for 
this purpose. A destructor of six cells was opened 
at Burmantofts, at that time a thinly populated 
suburb of Leeds, in October of the following year, 
and at the same time a carbonizer of eight. The 
primary object in view in the former was the 
destruction of what was called wet ashpit rubbish ; 
that is to say, of that portion of the contents of the 
privy middens rejected by the farmers as valueless, 
and which up to that time it had been the custom 
to tip. The carbonizer was intended to convert 
market refuse into a saleable charcoal. The latter 
was worked for about four years, but, proving both 
costly and inefficient, was given up. The destruc- 
tor, on the other hand, has been enlarged from six 
to fourteen cells, and is working at the present 
time. It was very soon found, however, that the 
" rubbish " alone was not sufficiently combustible, 
and it was mixed with about its own volume of the 
refuse from dry ashpits ; that is to say, from ash- 
pits attached to houses where water-closets of some 
kind were in use. There was no difficulty about 
burning this mixed, but by no means "dry," 
material without the addition of any coal, and the 
Corporation were so pleased with the results that a 
year after the opening of the Burmantofts' destruc- 
tor they built one, also of six cells, in another part 
of the town (Armley Road), much nearer the 
centre of the population. Both these six-cell 
destructors were on the principle originally sug- 
gested by Mr. Fryer, and the cells then built are 
all working at this day. 

About 1883 four other, but similar, cells were 
added at Burmantofts, and the following year four 
more at Armley Road, followed two years later by 
two more ; making the Armley Road destructor into 
one of twelve cells. In 1888 four additional cells 
were erected at Burmantofts. The number of 
cells there at this time, all on Fryer's principle, was 
thus fourteen, and there were also twelve at 
Armley Road. 

Complaints, however, were not unfrequently 
received, more especially from the neighbourhood 
of the first destructor at Burmantofts, and the 
Council, feehng that possibly some of these had a 
foundation in truth, requested their engineer, Mr. 
Hewson, to experiment with a view of removing 
any real cause of complaint. He engaged Mr. 
Horsfall to assist him, and together they introduced 
an arrangement of steam jets which were put in 
operation at Burmantofts in 1888, about the date 
of the completion of the new cells just referred to. 
It was found that a very much higher temperature 
was obtainable under the forced draught thus 



5° 



DESTRUCTION OF TOWN REFUSE BY HEAT. 



produced, and from that time to this it has been 
noticed at this destructor that if we allow the 
temperature to fail by not using the jets, we have 
complaints from the neighbours, whereas as long as 
we keep the temperature high, we hear nothing 
about any nuisance. This has happened twice 
within my own knowledge — in the beginning of 
1893, and again in the early months of the present 
year. Although these experiments with steam jets 
were on the whole satisfactory, Mr. Hewson felt 
there was room for improvement in the construction 
of the destructor cell. It had been proposed by 
Mr. Jones, of Ealing, to take the fumes from the 
rubbish destructor to a cremator, and this fume 
cremator was in actual use not only at Ealing, 
but at Bradford and in other places. Fryer's 
destructor, it will be remembered, allows the fumes 
and gases from the burning material to pass away 
alongside the fresh material with which the cell is 
being fed. Mr. Jones' cremator is a separate 
furnace of burning coke at a temperature of not 
less than 1,000° F., through which the gases and 
vapours pass on their way to the chimney. 

Mr. Hewson conceived the idea of taking the 
fumes and gases of the destructor cell itself away 
at a part further from the feed hole. He intro- 
duced a flue, in communication with the main 
flue, on each side of the cell, and the opening into 
this he placed well forward. In 1891 ten cells, 
constructed on this principle, were erected at 
Kidacre Street. They were supplied also with 
steam jets. Two years later two more were added, 
and about this time a modification as to the 
position of the exit holes for the gases was intro- 
duced. These apertures were now placed as 
before, one on each side of the cell, but about a 
third of the way between the front and back of the 
fire bars, the lower part of the opening being about 
one foot above the bars.* In 1894 four cells of 
this new type were added to the twelve on Fryer's 
type already existing at Armley Road. 

These cells, with some slight modifications, are 
on the same plan as those at a destructor at 
present in course of erection at Meanwood Road. 
A description of the latter will suffice for both. 
They are back to back, and fed from the top. The 
material, passing over a bull-nose division to the 
two sets of cells, passes on to the concave side of 
an arc of a circle of fire brick. At the lower part 
of the curve the material reaches the fire bars. 
These are sloped at an angle of about 30*, and 
have an area 7 ft. wide by 5 ft. long. The walls of 
the furnace are lined with fire brick, and just above 
the bars a strip of iron is fixed, but not m contact 
with the brickwork, to prevent the clinker from 
fusing into the latter. The space in front of the 
fire bars is closed by two doors. In these are a 
few apertures communicating with a space between 

• See drawing of Kidacre Street cells, as first planned, in 
Pdblic Health, Vol. IV., page 38. 



the inner and outer surfaces of the door, thus 
keeping the latter cool. The space beneath the 
fire bars is closed by two iron plates, each pierced 
by a round hole 9 inches in diameter for a steam 
jet, and leading to a tube 3 feet long. The 
space between the two iron plates is closed by 
an iron door. The main flue runs under the 
centre of the whole arrangement. The bottom of 
it is a little below the level of the ground in front 
of the furnaces. The roof is arched, and a pair of 
flues from each cell enters the main flue with a 
slight inclination downwards. Each cell has, 
therefore, two communications (not used by any 
other cell) with the main flue. 

We have thus in Leeds at the present rime three 
destructors containing respectively fourteen, six- 
teen, and twelve cells each, and a fourth, to con- 
tain eight cells, is nearly complete. Of the forty- 
two cells already existing twenty-six are on the old 
or Fryer's type, sixteen on Mr. Hewson's modifica- 
tion. The eight which are in course of construc- 
tion are all upon this new plan. Steam jets, as 
already said, were added to the Fryer's cells at 
Burmantofts in 1888. In 1891, when the new 
Kidacre Street destructor was built they were in- 
cluded in the plant, and of course in the two extra 
cells which have been built there since. They 
have been added more recently to the Armley 
Road destructor, so that at present all the cells, 
both of the old and new form in Leeds, and the 
eight which are in course of construction, are fitted 
up with steam jets. 

An experiment was, however, made in September, 
1 89 1, shortly after the Kidacre Street destructor 
was opened, to ascertain amongst other things what 
the difference in temperature was, with the steam 
jets and without, with the following result : — The 
experiment extended over two periods of twenty- 
four hours each, similar material being used on 
each occasion (nineteen hours dry ashpit refuse 
and five hours wet ashpit rubbish), and tempera- 
tures taken hourly. It was found that the ten 
cells burned 6*2 tons per cell without and 6"7 per 
cell with the steam jets — the same number of men 
working in each case. The temperature without 
the jets averaged i,t 18° F., counting three observa- 
tions when the pyrometer index touched its maxi- 
mum as 1,500° F. With the jets the average was 
1,464° F., but these included seventeen observa- 
tions, when the pyrometer could register no higher. 
It is possible that the excess of temperature of 
346" F. would have been more like 500** F. if we 
could have registered it. 

The amount of work done by our destructors in 
1894 was equivalent to the burning of 63,132 loads 
of rubbish, weighing 65,151 tons. Some of the 
cells were not working full time, but the quantity 
named was burned in 11,644 cell days, which is 
equivalent to nearly 5*6 tons per cell i)er day. At 
the two destructors, Armley Road and Kidacre 
Street, which are more convenient of access, and 



DESTRUCTION OF TOWN REFUSE BY HEAT. 



51 



which were not interfered with by the temporary 
tip for garden purposes in the East End Fark, the 
average was winter and summer nearly 6'6 tons 
per cell day. Even these figures, covering as they 
do a whole year, do not show the work which a 
cell is capable of doing when worked by three 
shifts of men with an abundant supply of material. 
For weeks together working three shifts of men we 
have burned eighty tons per day in the ten cells at 
Kidacre Street, but the cost per ton in wages is 
thus considerably increased. 

Before erecting our new plant at Meanwood 
Road the committee in charge made two visits to 
Manchester to see Mr. Wiley's automatic feeder. 
When it was fully in work Mr. Darley, the super- 
intendent of our Refuse Removal Department, 
went over and tested the amount burned in twenty- 
four hours. The result did not induce the com- 
mittee to adopt the patent. Subsequently Mr. 
Darley and Mr. Carter, one of the City Engineer's 
staff, went to Warrington and were satisfied that 
there nearly twenty- four tons per cell could actually 
be consumed in twenty-four hours. The conditions 
of work, however, were not such as could be 
recommended, and the cost in wages per ton was 
excessive. 

Mr. Hewson thereupon asked Mr. Darley, with 
the help of Mr. Putman, another of his staff, to 
experiment under similar conditions on the four 
new cells recently added to our destructor at 
Armley Road. The following conditions apply to 
all these experiments. The furnaces which, as 
already said, had a grate area per cell of thirty-five 
square feet, were in full go, and were clinkered 
immediately before the commencement of the test. 
The tipping floor was cleared ; all the material 
placed upon it afterwards was weighed, the material 
left at the end of the experiment being weighed 
and deducted from the gross amount placed there. 
The clinker removed was also weighed, but no 
computation was made as to the increase or 
decrease in the amount of flue dust. The experi- 
ment lasted for twelve or twenty-four hours, and 
ended with a clinkering of the cells. The wages 



were calculated at the rate of 5s per working day 
of eight hours. The steam jets (used in all the 
experiments but one) were two for each cell. Each 
air aperture is nine inches in diameter, equal for 
the two to 127 square inches for each ceil. The 
tubes into which the jets discharged are three feet 
long. Beginning as just said with a diameter of 
nine inches they are in the course of nine 
inches gradually narrowed to one of six, from 
which size they expand to the original diameter at 
the other end of the tube. The steam pressure on 
the jets in each case approximated to 60 lbs. per 
square inch in the boiler. 

Experiment I. (June 12th, 1894), made with all 
four cells, for twelve hours, using two jets, each 
|-inch in diameter. The cells were clinkered 
every two hours. The total quantity burnt was 
20-4 tons. The temperature in the side flue, taken 
hourly, was never less than 1,500'' F. ; how 
much more it is imposible to say. The number 
of men employed was three*; their wages 15s. 
For each cell in twenty-four hours the quantity 
consumed was therefore 10*2 tons ; the number 
of men one and a half ; their wages 7s. 6d. 
The amount of wages paid per ton consumed, 
neglecting cost of management and interest on 
plant, was 8*82 pence per ton. The chnker 
weighed 36"5 per cent, of the original refuse. 

Experiment II. (June 13th, 1894), made on 
four cells for twelve hours, without jets, clinkering 
again every two hours. Quantity burnt, 16-5 tons ; 
average temperature in side flues, 1,050'^ F., 
counting 1,500° as the maximum registrable. 
Men and wages as in the last experiment. Con- 
sumed per cell day, 8*25 tons ; wages per ton, 
lo'pi pence ; clinker left, 35*5 per cent. 

Experiment III. (June 25th and 26th, 1894). — 
Four cells for twenty-four hours ; ^-inch jets ; 
clinkering every hour. Quantity burnt, d^Y 
tons ; temperature in the flue frequently enough 
to melt copper (1,990°). Men employed, 12 ; 

* Two men working each twelve hours — that is, a day and 
a half — and paid 7s. 6d. each. 



EXPERIMENTS ON WORK DONE BY DESTRUCTOR CELLS AT LEEDS, BY 

Messrs. DARLEY & PUTMAN. 

Area of Grate Bars, 7x 5 ft. ; Jets, 2 each Cell; Pressure, 60 lbs. ; Wages at Rate of 5/- for Eight Hours. 













ir- 










Per Cell dav. 


Cost per 








No. 


Duration 


Diam. of 


Frequency 


Tons 


Temp, of 
flue. 


Men 


Wages 




Men 




ton burnt. 


Clinker 




Date. 


of 
Cells 


of ex- 
periment. 


steam 
jets. 


of 
Clinkering. 


burnt. 


cm- 

ployed. 


of 
Firemen. 


Tons 
burnt. 


em- 
ployed. 


Wages 
paid. 


Wages. 
Pence. 


per cent. 


I 


June 12, 1894 


4 


12 hours 


J-inch 


Every2hrs. 


20 '4 


1,500° F. 


3 


15;- 


I0*20 


1-5 


7/6 


8-82 


36-5 


II 


„ 13 •, 


4 


12 „ 


No jets 


» 2 „ 


i6-5 


I,050« F. 

Frequently 


3 


15/- 


8-25 


1-5 


7)6 


10-91 


35-5 


III 


„25&26„ 


4 


24 .> 


i-inch 


,, hour 


631 


2,000° F. 

i.^.mltd.copp. 


12 


60/- 


15-78 


3 


15/- 


II-4I 


35-4 


IV 


,,26&27„ 


4 


24 .. 


i „ 


)> >f 


60*15 


ditto 


12 


60/- 


1504 


3 


15/- 


11-97 


32-2 


V 


„27&28„ 


4 


24 „ 


5 )> 


>> j> 


54'35 


1,500" F. 
Frequently 


12 


60/- 


i3'59 


3 


15/- 


i3'2S 


37-0 


VI 


„28&29„ 


2 


24 .. 


\ ,. 


., \„ 


53-5 


2,000° F. 


12 


60/- 


26-75 


6 


30/- 


1340 


359 



52 



THE BACTERIOLOGICAL DIAGNOSIS OF DIPHTHERIA. 



wages, 60s. Per cell day: — Consumed, 1575 
tons, by three men at 15s. ; cost per ton (in wages 
only), 1 1 '41 pence; clinker, 35-4 per cent. 

Experiment IV. (June 26th and 27th, 1894). — 
Four cells again for twent>--four hours ; jets }-inch 
(instead of i^-inch) ; clinkering every hour, as in 
last experiment. Quantity, 60-15 tons; tempera- 
ture similar ; men and wages the same. Amount 
burnt per cell, i5"04; cost in wages, ii"97 pence 
per ton ; clinker, 32*2 per cent. 

Experiment V. (June 27th and 28th, 1894). — 
Four cells for twenty-four hours ; i-inch jets ; 
clinkering ever)' hour. Quantity, 54*35 tons ; 
temperature not less than 1,500° F. ; number of 
men and wages the same. Quantity consumed 
per cell day, i3'59 tons, at a cost in wages of 
1 3*25 pence per ton ; clinker, 37 per cent. 

Experiment VI. (June 28th and 29th, 1894). — 
Final experiment, made with only two cells for 
twenty-four hours, with ^inch jets ; clinkering 
every half-hour instead of every hour. The 
quantity consumed was 53-5 tons; the tempera- 
ture in the flue repeatedly high enough to melt 
copper. Number of men employed for the two 
cells, 12 : wages, 60s., giving an average per cell- 
day of 2675 tons burned by six men, at a cost of 
30s. in wages. The cost in wages per ton is 
therefore 13 "46 pence. Amount of clinker left 
was 35*9 per cent. 

The general lesson from these experiments, not 
carried out for the purpose of exploiting any 
patent, but merely to test our own existing plant, 
is to the following effect : — The amount consumed 
per cell increases with the frequency of clinkering, 
but the cost per ton burned is increased at a more 
rapid ratio. The frequency of clinkering can be 
rendered practicable by increasing the rapidity of 
combustion. This can be done by steam jets, and 
the most frequent clinkering and greatest amount 
burned per cell was accomplished with two ^-inch 
jets at 60 lbs. boiler jiressure. The cost in firemen's 
wages, however, in obtaining these tremendous 
results (26J tons per cell) was nearly 53 per cent, 
higher per ton burned than when the clinkering 
was every two hours, and the consumption ten 
tons per cell day. It must also be added that the 
wear and tear of the plant is much greater at the 
higher out-put, though exactly in what proportion 
the experiments do not enable us to say. On the 
whole the high out-put method of working the 
destructors is not economical. 

In considering the question of erecting destruc- 
tors it has to be remembered that the cost of burn- 
ing is considerable — probably with sinking fund on 
plant and everything else, not much under 2s. a 
ton. Against this has to be put the distance to 
which the rubbish would have to be carted to a 
tip. No fuel is necessary, but a large amount of 
heat is developed, and it would be well so to place 
a destructor that this heat could be made available. 
It is also desirable that the site selected should be 



so situated as to necessitate as little collar work in 
carting as possible. Finally, it has to be remem- 
bered that thecoUection of material at the destructor, 
and the carting it there, may be itself a nuisance. 
The daily emptying of ash bins would do much to 
prevent this. 



THE BACTERIOLOGICAL DIAGNOSIS OF 
DIPHTHERIA.* 
A Preli.minarv Report. 

BY 

D. S. Davies, M.D. Lond., M.O.H. of the City and Fort 
of Bristol. 

{Continued from page 18, October No.) 

It follows from the above consideration that 
there exists no necessity for any medical man to 
suddenly alter his customary use of the term 
diphtheria in his practice, or his interpretation of 
notifiable disease in this connection. Those who 
have accustomed themselves to limit, so far as 
clinical diagnosis in an early stage of the disease 
permits, their use of the term to the more fatal 
disease, may, in proportion to the use they make 
of the culture tubes for the diagnosis of suspected 
cases, not unfrequently be surprised to receive a 
certificate of the presence of the Lceffler bacillus in 
some very mild cases ; while those who have 
habitually used the term in its widest signification, 
will be enabled to classify the great majority of 
their cases, and so to avoid the awkward con- 
sequences to their patients arising from the 
notification of what in the Public Health Act is a 
dangerous infectious disease, requiring under 
penalty not only " proper precautions against 
spreading .... the disorder " by the exposure of 
infected persons and things, but also the sub- 
sequent disinfection of all rooms occupied during 
the illness, and of all possibly infected clothing, 
bedding, or other articles to the satisfaction of the 
medical officer of health. 

If it is to be assumed that the majority of the 
thirty-eight suspected cases would not have been 
notified unless the bacillus had been found, the 
fact that so many as eighteen, or nearly half of 
these, were proved to be " bacillary diphtheria," 
points distinctly to the desirability of encouraging 
medical men to inoculate culture lubes from all 
membranous sore throats, no matter how mild the 
symptoms may be. 

There can be no question that diphtheria should 
be isolated ; and those cases, therefore, which 
cannot effectually be so dealt with at home, should 
be removed to hospital. Children suffering from 
the disease not unfrecjuently vomit their food, 
which is necessarily contaminated by the specific 
microbe ; and if the cat happens to lick some of 

* From a special report of Dr. Davies to the Sanitary 
Committee of the Bristol Town Council. 



THE BACTERIOLOGICAL DIAGNOSIS OF DIPHTHERIA. 



53 



this,* it will very probably contract the disease, 
and infect other cats, or any children who may 
nurse it. Moreover, portions of rejected food 
which have been handled by diphtheria patients 
-are often flung out of the window for birds, and so 
may be the means of infecting cats and fowls. In 
all probability, too, the excreta of diphtheria 
patients contain the " germs " of the disease. 

And hospital isolation, let it be noted, is none 
the less desirable, in that the diphtheria bacillus is 
more than suspected by many authorities of being 
able to live as a saprophyte under some unknown 
conditions, drains and sewers mostly falling under 
suspicion, though, as a matter of fact, the bacillus 
has never yet been found outside the animal body. 
Granting, however, that this does take place, the 
fairly complete separation of the cases into those 
of saprophytic origin and those due to direct 
personal infection, which would result from the 
prompt isolation of all cases, would probably bring 
into high relief the saprophytic factor, and so 
afford an opportunity of studying the natural 
history of the microbe in a direction confessedly 
obscure, and the subject of much disputation. 

There is, moreover, the probability that a great 
many more of the cases which have been attributed 
to saprophytic infection may be found to have 
their beginnings in chronic and mild cases of the 
disease than has hitherto been thought possible. 
The existence of such cases is now beyond 
question, and it is quite possible that a number of 
these scattered over the country constitute a 
floating capital of the disease which has few, and 
these accidental, reserves in sewers and filth 
collections. 

Culture tubes were inoculated from filth and 
soil taken from situations detailed in the following 
list. All the drains mentioned were defective, 
and admitted sewer gas into the house except in 
one instance, the first on the list, where the drain 
ran under the playground from the children's 
w.c.'s, just opposite and close to one of the 
entrances to the school-house, to the sewer in the 
adjoining road. All the joints in this drain were 
pervious, and the surrounding soil was very foul. 

Two manure heaps, containing blood and 
slaughter-house offal in allotment grounds, St. 
John's Lane, Bedminster. 

Drain and surrounding soil, St. Barnabas School, 
City Road — cases of diphtheria amongst the school 
children. 

Drain and surrounding soil of 56, Prince Street — 
an obscure case of intestinal trouble in the house. 
Drain and surrounding soil of 9, Clifton View, 
Totterdown — diphtheria in the house. 

Drain (old and defective) of 11, Clarence Street, 
St. Phihp's — no disease in the house. 

Drain (main, and very old) Upper Street, 
Temple. 

'^ Once observed by the writer. 



Drain from urinal at a public-house in West 
Street, St. Philip's. 

In every instance the resulting growths were 
carefully searched for the diphtheria bacillus, or for 
any organism sufficiently resembling it in appear- 
ance and in culture, to justify the expense of sub- 
mitting it to confirmatory experimental tests, but 
without success. 

One turkey, two fowls, and three cats, which 
had either died or were killed in consequence of 
disease, came under my notice. They all came 
from diphtheria-invaded houses. A post-mortem 
and subsequent bacteriological examination were 
made in each case. One of the fowls came from a 
poor neighbourhood, and had died in the small 
backyard of a house which smelt badly of sewer 
gas, and in which two cats had been destroyed in 
consequence of illness three weeks previously. 
Several other fowls died in the same backyard 
shortly after the cats were killed. This fowl was 
extremely emaciated, and had been ill some weeks. 
The nares, throat, larynx, oesophagus, lungs, liver, 
and kidneys, were apparently normal ; but the 
spleen was very dark, soft, and studded with 
numerous whitish miliary bodies, suggesting acute 
tuberculosis. No growth on agar could be obtained 
from them, nor could tubercle bacilH or any other 
well-known pathogenic organisms be demonstrated 
in them. 

The turkey, dead twenty-four hours, the remain- 
ing fowl in a dying condition, and one of the cats, 
purposely killed, came from a semi-detached house 
in Kent Road, Ashley, in which there were three 
cases of diphtheria at the time, one acute and two 
convalescent, and where a remarkable epidemic of 
fowl disease had been experienced. The facts 
came to the knowledge of the Public Health 
Department at the beginning of January, 1895, in 
the course of an enquiry into the cases of diph- 
theria in the house, the occupier stating that during 
the past eighteen months she had lost about two 
hundred head of poultry by what appears to have 
been an infectious throat and lung illness. And 
not only poultry had suffered — four cats and one 
dog were included in the fatal list. The conditions 
observed in the fowls were described as swelling of 
the throat and face, sanious discharge from the 
eyes, mouth, and nostrils, white patches in the 
mouth, and blackening of the comb. Food was 
refused from the first, and the illness ran an acute 
course, death occurring in three or four days. 
Before death they appeared to lose power in the 
limbs, and lay about without attempting to move. 

The hen which I had the opportunity of 
examining before death presented the following 
appearances. The comb was almost black, due to 
a hcemorrhagic rash. The eyes were closed by an 
intense swelling of the conjunctiva, from which 
issued a dirty- looking, purulent discharge. The 
mouth contained a considerable quantity of 
coagulated blood ; and two or three small white 



54 



THE BACTERIOLOGICAL DIAGNOSIS OF DIPHTHERIA. 



patches, which could easily be detached, were 
observed on the floor of the mouth and one side of 
the tongue. The lar)'nx and trachea appeared to 
be normal, with the exception that the latter con- 
tained a large blood clot, which could be traced to 
the lungs, and was plainly the result of pulmonary 
haemorrhage. The lungs on section presented 
numerous hemorrhages, and ap[)eared to be in the 
first stage of an intense pneumonia. 

During the preliminary examination of this hen, 
it was ascertained that in this particular instance 
the legs were not paralysed as the owner had 
thought. On attempting to move them, they were 
found to be held rigidly to the body, and were 
quickly retracted after sufficient force had been 
exerted to move them. The same was true of the 
wings, though to a less degree. It was inferred 
from this that the creature lay so still because any 
movement caused it pain. The turkey, post- 
viortetn, i>resented much the same appearances as 
the fowl ; inflamed eyes, blood in the mouth, 
larjnx, and trachea, and lungs studded with 
hajmorrhages. 

Cultures on blood serum and other media were 
made from various situations, including the purulent 
discharge from the eyes, the white patches in the 
mouth, the heart's blood, and the lungs, without 
finding any organism resembling the diphtheria 
bacillus, although a very large number of different 
organisms were met with. The white patches in 
the mouth were composed of a mixed growth of a 
torula and a large sarcina, chiefly the former. The 
house drain was subsequently exposed, and cultures 
made from its contents and from the surrounding 
soil, but the diphtheria bacillus was not found. 
The cat, a young one, was killed for the purpose 
of examination, and was found to be affected in a 
slight degree with some kind of mange. All the 
organs appeared healthy. It, unfortunately, never 
occurred to me at the time to endeavour to obtain 
cultures from the aff"ected skin. 

The second of the cats examined was undoubtedly 
suffering from diphtheria. It came from a com- 
mercial hotel in Clifton, where just previous to the 
onset of the cat's illness, a boy, S. P., aged fourteen, 
had died from diphtheria. The history of this case 
was thus noted by the inspector in charge : — 



Dec. 8th, 1894 
,. loth, 1894 
,, 17th, 1894 
„ 28th, 1894 

Ian. 1st, 1895 
8th, 1S95 



S. P. at school as usual. 
S. I', taken ill. Diphtheria. 

S. P. died. 

... Drains opened. 

Cat noticed to 1^ ill. Cough. 

Cat killed. 



The boy slept in a room which was exposed to 
"dram air" not only from the soil pipe of the 
house m which he lived, but from that of the house 
next door : both were found to be defective. A 
p<>st-m<yrt€in examination of the cat, a fine well- 
nourished animal, showed all the organs — the 
kidneys were unfortunately not examined — to be 
healthy excejjt the lungs, both of which presented 



the appearances of disseminated pneumonia. The 
mouth, nares, larynx and trachea were quite clean 
and normal in- appearance. Agar tubes inoculated 
from both lungs with the usual precautions pre- 
sented next day pure cultures of what I took to be 
undoubtedly a variety of the dijjhtheria bacillus. 
The wedge-shaped forms predominated, and very 
few of the longer forms showed segregation of the 
protoplasm. All the longer forms and many of 
the wedge-shaped forms were more or less curved. 
Club-shaped forms were fairly common. 

The third cat came from a house near St. 
Andrew's Park, and had to be exhumed after being 
buried two days. At the end of about the second 
week of its illness, its owner, making sure it would 
die, had killed it and buried it in the Park. There 
was a child suffering from diphtheria in the house 
at the time, but it could not be definitely ascertained 
whether the child or the cat had first shown 
symptoms of illness. No drainage defects in the 
house were discoveied. 

Post-mortem^ much the same condition was 
found as in the second cat, e.xcept that in this case 
suppuration had commenced in the lungs, from 
which a large number of different organisms was 
recovered, including a few colonies of bacilli, 
exactly resembling those obtained in pure culture 
from the former. The kidneys were not overlooked 
this time, and were, I should say, striking speci- 
mens of the large white kidney described by 
Dr. Klein. 

The existence of a relation between animal 
disease and some cases of diphtheria, is still 
further sustained by the circumstances attending 
the following case, that of a boy of nine, residing 
in Bedminster, who was notified, on June i8th 
last. The medical man in charge of the case 
inoculated one of our culture tubes from the boy's 
throat, and in this, after the usual incubation, we 
found the diphtheria bacillus. The inspector's 
notes in connection with this case were to the 
following effect : — The boy's father kept two 
fowls, and of one of these the boy had made a pet. 
About three weeks before the boy's illness this 
fowl fell ill with swelling of the neck and eyes and 
a discharge from the mouth. The boy used to 
open the fowl's mouth to clean out the discharge 
with his finger, and after its death kissed it. A 
few days after this the boy fell ill. When the 
circumstances came to our knowledge the fowl had 
been buried too long to render advisable any 
attempt at examination. 

I should like to take this opijorlunily of stating 
that, after nine years' work as one of the medical 
officers of the Bristol Dispensary, amongst the 
poorer inhabitants of the city, none of the many 
impressions which were formed during that experi- 
ence have fixed themselves so firmly in my mind as 
these two — the desirability that the Sanitary Autho- 
rity should acquire an exact knowledge, so far as 
possible, of the number, kind, and conditions under 



THE BERLIN NIGHT SHELTER. 



55 



which they are kept, of domestic animals in the 
city ; and the conviction that the knowledge gained, 
though at the expense of much time and trouble, 
would make it plain that the keeping of these 
animals, which would be found to be largely 
involved with the very unsuitable stabling accom- 
modation on the premises of small tradespeople — 
e.g., greengrocers, coal dealers, hauliers, hawkers, 
etc. — should in all cases be under the direct control 
of the Sanitary Authority, and in the majority of 
cases should be prohibited altogether. 



THE BERLIN NIGHT SHELTER. 

(B}' a Sj>tria/ Correspondent). 

The question of the housing of the working 
classes in Berlin and other great cities of the 
Empire is very much to the fore just now in 
Germany. It is difficult to understand why the 
subject has been neglected so long. Probably tbe 
many wars and the state of unrest consequent 
thereon have prevented the attention being paid to 
it that the subject deserves, and the expenditure of 
the necessary funds that it requires. The feeling, 
however, is growing stronger in Germany every 
day, that the conditions under which the poor live 
seriously endanger the maintenance of family life, 
and may be a powerful lever in upsetting existing 
institutions. Unfortunately, except in the country 
districts, the admirable system that prevails with 
us of single families Hving m their own cottage 
hardly exists in Germany, most of the famihes 
living in large houses let in tenements. Yet it 
must be admitted that the most diligent search 
fails to reveal the existence of slums in Berlin, 
such as are to be seen in London, in Paris, or in 
Brussels. The city is too modern for that. , The 
streets are broad, and in the suburbs might be 
dignified with the name of boulevards, taken in 
the Parisian sense of wide streets planted with 
trees. Flanking them on either side are the houses 
of that hideous style so dear to the heart of dwellers 
in towns abroad, five or six stories high, presenting 
outwardly a florid, grandiose appearance, with 
btucco decorations and elaborate cornices. But 
the eye looks in vain for some break in the monotony 
of the bky line, which is carried perfectly straight 
from one end of the long street to the other. Few 
cities leave a more monotonous impression on the 
mind that Berlin, and it may be characterised in 
general as a tableland of bricks and mortar seventy- 
two feet high, cut up by intersecting valleys repre- 
senting the streets. 

In these long rows of sumptuous-looking houses 
to the north, south, and east of the city, one hardly 
expects to find the poor ; and yet their presence 
is soon detected by the unkempt appearance of 
many of the women, and, surest sign of all, the 
number of children playing on the flagstones in 
the street. Although the first and second floors in 



the houses may be occupied by the fairly well to 
do, the cellars and uppermost stories are all filled 
by the poorer classes. The great evil that prevails 
as regards the dwellings is overcrowding combined , 
with very high rents. One hundred and two out of, 
every i,ooo dwellings consist only of one room, 
which serves as kitchen, sitting-room, and bed- 
room for a whole family. Three hundred and 
thirty-five' per i,ooo of the dwellings, containing 
nearly the half of the total population of BerHn, 
must be deemed overcrowded. To make matters 
worse, in order to eke out the high rent they have 
to pay, many of the families are in the habit of 
taking in night lodgers {schlafleute). In 1890, 
there were nearly 100,000 such persons, who, 
during the day are out seeking work, and at night 
help to still further overcrowd the dwellings, to the 
detriment of both health and morality. 

The municipality of Berlin has, within the last 
few years, built many very handsome buildings for 
public health purposes, such as hospitals, asylums, 
and infirmaries. One of the most remarkable of 
these is the " Obdach," or shelter, in the Danziger 
strasse. It was built in 1887, and added to two 
years ago. The main block, consisting of a central 
portion four stories high, with four large wings, is 
intended for the reception of whole families, who, 
for some reason or other — whether it be bad times 1 
or what not— are homeless, provided they have a 
recommendation from the President of Police or 
relieving oflicer. At the time of my visit, there 
were two hundred and eighty-two families located 2^i 
in it, representing about eight hundred persons. 
The rooms were large, light, and airy ; the floors 
were of perfectly smooth woodwork, and the whole 
was warmed throughout by hot-water pipes. The 
dormitories were well arranged, each containing 
twenty beds. All the belongings of these families — 
their bed-linen, furniture, etc. — are stored at the 
shelter, and everything is disinfected ; the linen, 
etc., by steam under pressure, and the furniture by 
a dilute solution of carbolic acid. 

Another part of the shelter is intended for the 
reception of single men and women, who merely 
pass the night there. They are housed in forty o-y 
wards, each containing seventy beds. As in Paris, // 
every person, on entering, must have a bath, and 
during this operation their clothes are removed, 
and passed through a steam disinfector. After the 
bath, they pass into the dormitories, and receive 
soup and bread. As the dormitories are warmed 
with hot-water pipes, only one linen coverlet is 
supplied to each plank bed. All the coverlets, 
before being used again the following night, are 
disinfected by steam. Accommodation can be ^ 
given here to over three thousand persons every 
night ; and this number is often reached in the 
winter months. The cost per head per day is about 
one penny ; whereas, in the case of the families 
who reside temporarily in the other portion of the 
shelter, it amounts to about fivepence. 



56 



ANALYTICAL NOTES. 



There are in Berlin other shelters, conducted by 
private benevolent effort ; but the accommodation 
provided, and the general sanitary arrangements 
(as is the case with many similar private shelters in 
London) leave a good deal to be desired. 



ANALYTICAL NOTES. 

WiLHELM Thorner has estimated the amount of 
gaseous matters in milks of different age and com- 
position. Fresh milk contains from 57 to 80 ex. 
of gas, while "separated" has only 27 to 54 c.c, 
the deficiency being chiefly due to the loss of 
carbonic anhydride. He found that milk still 
retained from 15 to 19 c.c. per litre after from five 
to ten minutes boiling, and attributes the taste of 
boiled milk chiefly to the loss of carbonic acid, and 
states that the original taste may be restored by the 
addition of sterilized carbonic acid and air. It 
must be remembered, however, that the well-known 
taste of boiled or milk sterilized by heating is 
largely due to the " caramelling " of the milk 
sugar, and this flavour cannot be removed by any 
process of aeration. 



A simple method for the detection of " Poivrette " 
in ground pepper has been devised by D. Martilli. 
Digest for two or three days i gramme of phloro- 
glucol in 50 to 60 c.c. of hydrochloric acid sp. gr. 
ri, and decant the clear solution. To about 
half gramme of the pepper to be examined add 
enough of the reagent to cover it, and heat 
cautiously till fumes of hydrochloric acid begin to 
be evolved. '* Poivrette " and like substances 
(e.g., ground-up shells of almonds, walnuts, nuts, 
etc.) give a very intense cherry-red colour, which 
is sharply distinguished by the naked eye from the 
yellow or faintly red-brown colour of the pepper. 
On adding to the mass a little water, and decanting 
the liquid, a violet-red powder is left, which con- 
sists almost entirely of " Poivrette," etc., stained 
by the reagent. 



Analyses made by G. Adolphe Chatin and 
Achille Muntz of oyster shells obtained from 
different sources, show their composition to vary as 
follows :—N, 0-05 — 0-14; SiOj, o'44 — r6o; CaO, 
48-44— 53-70; PjOj, 0-019— 0-089; SO3, 0-779— 
11-004; MgO, 0-340— 0-570 ; Fe, 0-011-0-037; 
Mn, 0-009 — 0017 ; S (as sulphide), 0-015 — 0.020; 
organic matter, 0-90 — i-oc; F, 0-015 — 0-020; 
I, 0003; Br, 0005; CO2, 43-329—48-122. It is 
apparent from these results that the shells of 
oysters are of considerable value as a manure. 



F. Scheiding has proved by a series of experi- 
ments that the f)resence of carbonic anhydride is a 
source of appreciable error when estimating acid 
by titration. An excess of normal soda is required 



in consequence of its presence. He advises that 
when titrating with phenol-pthalein as an indicator, 
the "neutralised" solution should be again acidified 
with about 0-2 of acid, and boiled for ten minutes, 
and then re-titrated with alkali. He also found 
that methyl-orange is quite as efficient as an 
indicator in hot as in cold solutions, and although 
not affected by carbonic anhydride in small 
quantities, is somewhat so when present in large 
amount. 



F. Gantter proposes the use of hydrogen peroxide 
as a reagent for the detection of blood stains in 
forensic cases. He applies it as follows : — A small 
particle of the blood-material (rust, fabric, or a 
solution) is placed on an object-glass with a black 
background, and moistened with a drop of water 
made faintly alkaline. A drop of hydrogen 
peroxide is now added, and if the slightest trace of 
blood-substance is present, numerous comparatively 
large bubbles of gas are developed, which after a 
short time unite, forming a fine snow-white scum, 
which remains for some hours. The reaction is, 
unfortunately, not absolutely characteristic of the 
presence of blood, since pus behaves in a similar 
way. The peroxide test is also useful in identify- 
ing hsemine crystals. The age of the stain appears 
to make no difference, as spots six months old 
responded as sharply as fresh. 



A set of "vegetable" colours, sold for use in 
confectionery, etc., has been analysed by ^L 
Autenrietts. They consisted of pastes insoluble in 
water and alcohol, and were found to be tin lakes. 
They contained, on an average, 70 per cent, of 
water, and the dried powder contained 72 to 80 
per cent, of tin oxide. Therefore, in the moist 
condition, the amount of tin present was at least 
20 per cent. The blue paste was pure indigo- 
carmine, with 2-5 per cent, of ash, chiefly sul- 
phates. 

The following process is recommended for the 
complete drying of substances which tenaciously 
retain water, such as molasses, invert sugar, etc. : — 
10 grains of the sample is mixed with 50 cc. of 
methylic alcohol in a flask connected with an air- 
I)ump, and then heated. As the alcohol boils, it 
carries with it the water. The last traces of spirit 
and moisture are removed by passing a current of 
dried air for about half an hour. 



H. Moreigne uses the following method for the 
estimation of sulphur in urine. The urine is 
evaporated to dryness in a porcelain crucible, and 
the residue fused with a mixture of sodium nitrate 
and carbonate, and the sulphate in the product 
estimated in the usual way by precipitation with 
barium chloride. It is necessary to use sodium 



SUPPOSED ETIOLOGY OF DIPHTHERIA. 



57 



nitrate for the oxidation, as, when potassium 
nitrate is used, the crucible is liable to crack on 
cooling. 



Luteol or chlorhydroxydiphenyl-quinoxaline is 
now used as an indicator where litmus or phenolp- 
thalein is inapplicable. In acid solutions it is 
colourless, but intensely yellow in alkaline. 



SUPPOSED ETIOLOGY OF DIPHTHERIA. 
Dumbartonshire. 

Dr. McVail remarks : — " Where no obvious 
connection can be ascertained between cases 
of diphtheria, it is sometimes possible to supply 
the wanting links by making house-to-house visi- 
tation in search of sore throats, which, though 
slight and unnotified, are yet diphtheritic in 
nature. Towards the end of April and in May 
and June there had been seven notified cases in 
Alexandria and Bonhill, without any evidence of 
close relationship. I accordingly had a house-to- 
house visitation made in the neighbourhood of the 
cases, but, as a matter of fact, no sore throats nor 
other suspicious illnesses were found. In many of 
the houses invaded there were defects in drainage, 
&c., but in others no insanitary conditions of any 
kind could be discovered. This is no unusual 
experience with regard to diphtheria. One case 
may be discovered where there is every appearance 
of connection with existing nuisances, and the next 
case may be found in a modern villa with its drains 
and water supply perfect. School attendance 
appears to be to a great extent responsible for the 
spread of the disease. The whole subject of 
diphtheria presents many points of difiiculty. 
While it is a fact that the disease not uncommonly 
appears where no sanitary defects can be found, 
there seems little doubt that it is often propagated 
by dirt of some sort, whether in drains or refuse 
heaps, or filth-polluted soil. In dirty houses, and 
wherever dirt is found, the policy of a local 
authority must be to have it removed, leaving 
obscure questions as to the causation of infectious 
disease to be settled by growing experience." 

County of Durham. 

Dr. Eustace Hill remarks : — " Very little informa- 
tion is given in the majority of the health reports 
as to the probable origin or cause of diphtheria. 
In West Hartlepool the cases most commonly 
occurred . in newly-built and apparently sanitary 
houses. At Byers Green, in the Auckland rural 
district, there have been several fatal epidemics 
during the last few years, and their spread is 
attributed to the attendance at school of children 
suffering from the disease in a mild form, and the 
closing of the village schools had the effect of 
checking their prevalence. The cases which 



occurred in the Houghton urban and rural districts 
and in the Stockton rural district were mostly 
associated with insanitary conditions, such as bad 
drainage or dampness of the dwelling-houses. As 
I stated in my last annual report, school attendance 
appears to be one of the chief factors in the spread 
of the disease, and no children should be allowed 
to attend school from houses where cases of 
diphtheria or crou[) are being treated, while all 
children who are obviously suffering from ' bad 
throats ' should also be excluded from school. 
Damp, dark houses appear under certain circum- 
stances to be favourable for the development of 
diphtheria, and exposure to foul smells from drains 
and sewers has frequently been stated to have 
caused the disease." 

Providence, U.S.A. 
Dr. Chas. V. Chapin, the Superintendent of 
Health and City Registrar (in the 12th Annual 
Report of the Superintendent of Health, for 1894) 
says : — "As is well known, diphtheria first appeared 
in Providence in 1858. From that time it varied 
considerably in prevalence until 1877-78, when 
there was a great increase, causing in 1877 as many 
deaths even as phthisis. Since that time there has 
been much less of it, but still more than in the first 
few years following its advent. The appended 
chart best shows these changes. 

Chart Showing the Number of Deaths from 
Diphtheria per 100,000 Living, for the 
Forty Years, 1855 to 1894. 



1856 

1857 
1858 
1S59 
18C0 

iSfii 

186a 
1863 
18(14 
1865 
1868 
1867 
1866 
1869 
1870 
1871 
1872 
18-3 
1874 
187J 
1876 
1877 
1878 

\l& 
1B81 
188a 
1883 
1884 
1885 
1886 



1889 
1890 
1891 
1892 
1893 
1894 



Cape Colony. 

Dr. Gregory, the Acting Medical Officer of 
Health for Cape Colony, draws attention to the 
excessive death rate from diphtheria in that 
colony. 



58 



REPORTS OF MEDICAL OFFICERS OF HEALTH. 



The death rate from diphtheria in England and 
Wales was, during 1S92, 222 per million of the 
population living ; the highest rate being in the 
case of London, with 459 per million ; and the lowest 
in that of Dorsetshire, with only 74. 

Taking, now, some of the South African towns, 
we find the following rates obtaining; : — 



Cape Town 

King William': 

Worcester 

Malmesbury 

Beaufort West 

Murraysburg 

Aberdeen 



Town 



804 
830 

925 
1,625 

1,791 
3,828 

3.984 



REPORTS OF ^lEDICAL OFFICERS OF 
HEALTH. 

HUDDERSFIELD. 

Still-born Children. — Dr. Kaye remarks : — " An 
investigation into the decline of the birth-rate led 
me, during the past year, to make inquiries into 
the number of still-born children. This inquiry has 
been surrounded with difficulties owing to various 
reasons. In some churchyards no record is kept 
of the interment of still-born children, because the 
English law enacts that those children born alive 
shall only be registered. On the Continent regis- 
tration of still-borns is provided for, with the excep- 
tion of Russia ; so that in this country, so far 
advanced in all questions relating to the welfare 
of the public, we should not lag behind in this 
matter. I am informed also that sometimes the 
bodies of still-born children are disposed of sur- 
reptitiously by the relations during the night time 
in the burial ground. In other cases a fee of one 
or two shillings is charged, which goes to the sexton, 
and no record of any kind whatever is kept, while 
in some instances the fee goes to the minister, and 
there a register is generally maintained. So far as 
I have been able to ascertain, a yearly average of 
119 interments of still-born children took place in 
five burying grounds during the decade 1884-1893 
in this borough — that is to say, six to eight percent, 
of the total births, or one to every fourteen living 
births. These proportions are much in the same 
ratio as reported by several investigators on this 
subject. From the figures at my disposal, there is 
little, if any, ground to believe that there has been 
any apparent increase in the number of still-born 
children. To show the necessity of registration in 
those cases, it has been brought to light in a Par- 
hamentary return for 1890 that no less than 17,335 
supposed to be still-borns were interred in 1,133 
burial board cemeteries, and of this number 4,569 
were interred without any medical certificate as to 

the cause of still-birth Under the present 

system, there is every opportunity for the conceal- 



ment of illegal means, and for the disposal of 
children as still-born who had survived an hour or 
two, it may have been a day or so.'* 



CERTAIN POINTS IN THE 


ETIOLOGY 


AND PREVENTION OF 


SCARLET 


FEVER. 





Charles V. Chafin, M.D., Superintendent of Health of 
tne City of Providence, U.S.A., and City Registrar. 

Scarlet fever tends to recur in epidemics 
every few years. Thus during the last forty years 
there have been eight of these exacerbations. This 
is well shown by the diagram. It will be seen that 
there is a decided diminution in the magnitude of 
the last two epidemic waves. It is only since 1885 
that active measures have been taken by the health 
department to prevent the spread of this disease. 
The methods referred to are the placarding of 
houses, exclusion of children from school, frequent 
inspections, disinfection, etc. It can hardly be 
doubted that scarlet fever is much more generally 
reckoned a contagious disease than it was twenty 
years ago, and it is extremely probable that it is 
chiefly to the recognition of this fact and the con- 
sequent precautions that are taken that the disease 
has been so considerably diminished during this 
period. 

Chart Showing the Number of Deaths from 
Scarlet Fever per 100,000 Living, for the Forty 
Years, 1855 to 1894. 



295 

64 

55 



1855 
1856 

1858 
1859 

1863 
i86i 
186a 
l8«3 
i86i 
1865 
18M 



1869 
1870 
1871 
187a 

>f74 

th 

5? 



18S1 
itts 

i8>3 
1884 

1885 
i88i 



1889 
itee 

1891 
189a 
49} 
««9« 



The following table gives the results of my 
observations during the past eight years concerning 
certain points in the etiology and prevention of 
scarlet fever. This table docs not include all the 



ETIOLOGY AND PREVENTION OF SCARLET FEVER. 



59 



families and cases, as some pass from observaciozi 
through removal or otherwise ; but for 1893 and 
1894 all cases are included : — 



5S 



I 



Number of families ia which there was more than one 

susceptible child ... 
Number of these in which there was a second case ... 
Number of susceptiUe children in all the above families 
Number of these children who were attacked 
Number of additional families with susceptible 

children in the house where the disease appeared 
Number of susceptible children in these families ... 
Number of these additional families attacked 
Number of children in these families who were 

attacked 
Number of tenements disinfected where there were 

other families with susceptible children in the 

house ... 

Number of above where the disease spread to other 

families in the house ... 

Number of susceptible children who were at once 

removed 
Number of these who were attacked on their return 
Number of children who were exposed and who had 

previously had scarlet fever 
Number of these who were attacked a second time 
Number of adults who were exposed and who hsd 

previously had scarlet fever .... 
Number of these who were attacked a second time 
Number of above with susceptible Children where 

there was isolation. . . 
Number of families where more than one child was 

attacked 
Number of susceptible children in families where 

there was isolation 
Number of the above who were attacked ... 



The following table shows the number and 
percentage of persons of different ages exposed to 
scarlet fever who contracted it, and also the number 
who did not. When I began to collect these facts 
the inspector was not careful to obtain the age in 
every case, so that until 1890 only a portion of the 
cases are contained in the table, and it was only in 
1894 that the facts in regard to all adults in the 
family were obtained. 



Ages. 



Under i year 



I 

2 

3 

4 

5 
6 

7 
8 

9 
10 
II 
12 
13 
14 
IS 
16 

17 
18 

19 

20 



years 



Adults 



Total. 





Number 


Ratio of Case -i 


Cases. 


Exposed. 


to Numbei 


I3S7-94- 


1887-94. 


Exposed. 


. 96 . 


. . 264 


... 263 


. 161 . 


.. 308 


52 '2 


■ 293 


,.. 486 


6o*2 


■ 327 . 


.. 501 


65-2 


• 335 . 


... 489 


68-7 


. 3bS . 


• • 57S 


64'o 


• 370 . 


.. 52S 


70-0 


■ 327 ■ 


.. 49S 


656 


• 253 ■ 


... 446 


.. 567 


. 215 • 


.. 402 


53 4 


157 . 


.. 301 


52- ( 


129 . 


. 274 


470 


, 108 . 


.. 272 


397 


, 80 . 


.. 2C8 


3^'4 


, ■ 72 . 


.. 20( 


... 35-8 


. 47 • 


.. 161 


29-1 


. 35 • 


133 


... 26-3 


, 27 . 


.. 96 


28-1 


18 . 


.. 68 


... 26-4 


18 . 


.. 65 


... 276 


21 


.. 64 


... 32-8 


169 


.. i,68i 


lo-o 


3,624 


S.131 


44*5 



From the data given on the preceding pages. 
I think several interesting conclusions can be 
derived. In the first place, the relative value of 



1SS7 1888 1889 1890 1S91 1S92 1S93 1S94 Total. 



232 


244 


73 


66 


198 


220 


.345 


359 


1,737 


130 


147 


30 


27 


78 


90 


150 


«77 


829 


98b 


827 


242 


215 


605 


711 


1,212 


1.293 


6,09; 


452 


5" 


126 


105 


341 


3^9 


642 


687 


3,253 


112 


1 28 


18 


15 


98 


154 


1 98 


244 


967 


3«i 


354 


34 


30 


238 


369 


493 


.587 


2,480 


27 


i6 





2 


10 


21 


16 


20 


112 



44 



34 



34 



49 


56 


ic 


4 


20 


26 


42 


109 


31 G 


5 


5 








2 


I 


2 


2 


17 


23^ 
3 


iS 

I 


10 



9 



27 



42 

2 


86 
8 


102 

4 


317 
lb 


— 


— 


— 


- 


— 


— 


- 


100 
13 


100 
13 


— 


— 


— 


— 


— 


— 


— 


230 
8 


23c 
S 


— 


— 


— 


— 


41 


27 


127 


37 


232 


— 


— 


— 


— 


23 


13 


32 


14 


82 


— 


— 


■ — 





130 
52 


69 
23 


291 

loS 


96 
52 


586 
235 



the figures (with a few exceptions to be explained) 
varies little from year to year. Hence, conclusions 
drawn from a single year are verified by com- 
parison with other years, and there is little likeli- 
hood that the numbers in the totals are not large 
enough for generalisation. 

It is clear that susceptibility varies very much 
according to age. The only way to really get at 
age susceptibility is to take under consideration 
a large enough group of children who have been 
actually exposed to the disease. It is certainly 
fair to assume that the children of a family where 
the disease exists are thus exposed. The one who 
first takes it certainly is ; and from what I have 
seen, I know that in this city, in the majority of 
cases, there is not the slightest attempt at isolation : 
and I am also sure that when the attempt is made 
it is very often entirely inadequate. An examina- 
tion of the table will show that there is much less 
susceptibility during the first year of life than 
during the second, and less during the second 
than the third. The third to the fifth years, 
inclusive, are the most susceptible, for of 2,591 
children of these ages exposed, 1,728, or 66"6 per 
per cent., were attacked. From this age on, the 
liability to contract the disease diminishes. It is 
probable that the fifth and sixth years are the 
most susceptible. At first sight the table referred 
to looks odd, for there are many more children 
between the ages of two and eight than at either 



6o 



ANNOTATIONS. 



earlier or later ages, while we know that in the 
general population there must be a continuous 
diminution in the number of children from birth 
onwards. But as the average family does not 
contain over three children, and as the enquiry 
itself presupposes one, and in most cases more 
than one susceptible child, it is evident that we 
are dealing with selected families (selected by 
scarlet fever), and therefore it is no surprise that 
an unusual age distribution is seen. Yet it is not 
claimed that the figures given are absolutely 
accurate, especially as regards the ages over four- 
teen, for until within a year or two the inspector 
was not careful to enumerate all over that age. 
Yet as the proportions, except as just noted, vary 
very little each year, it is probable that the con- 
clusions are justified. Taking the total number of 
persons under twenty-one years of age, it is seen 
that 53'6 per cent., or a little more than one-half, 
are liable to attack if exposed. Below the age 
of one, the chance of attack is, roughly speaking, 
one in four ; between the third and fifth years it is 
three in four ; and after thet welfth year it sinks to 
one in four again. 

As regards the immunity conferred by one 
attack of scarlet fever against a subsequent in- 
fection, data were gathered only during the year 
1894. They are not, therefore, numerous enough 
to base very certain conclusions upon, but I shall 
be surprised if in subsequent years they are not 
fairly well confirmed. The greatest chance of 
error is in regard to the fact of the first attack. 
The diagnosis is not always to be relied upon, and 
the memory also is uncertain. But the figures as 
obtained show that of roc children who had had a 
previous attack, 13 percent, were attacked again; 
while, as I have shown above, if there was no 
immunity, 53 per cent, would have yielded. Of 
230 adults who had previously had scarlet fever, 
3"4 per cent, were attacked, while of the adults 
who had never had it, 5 "6 per cent, were attacked. 
These figures, if correct, would show that age 
conferred greater immunity than a previous attack. 

It has been shown that when families with more 
than one susceptible child are attacked with scarlet 
fever, and no pretence at isolation is made, the 
disease spreads beyond the first ca.se in about 55 
percent., involving 54"8 per cent, of the children 
in these families. When isolation is fairly main- 
tained, however, it spreads beyond the first case in 
35'3 PC cent., and involves 40-1 per cent, of the 
children. Thus it will be seen that isolation, as 
ordinarily carried cut, has a very considerable pro- 
tective power, considerably more than the above 
figures would indicate, for quite a [)roportion of 
the "secondary" cases are not really secondary, 
but were exposed to the same contagion as the 
primary case, and, of course, could not have been 
protected by any isolation. It is very rare indeed 
that perfect isolation is maintained when sick and 
w-ell are kejjt in the same house. Yet the some- 



what imperfect attempts that are made are, I think, 
of undoubted value. 

It is only by the removal of the well children 
from the house, or the placing of the sick person 
in a hospital, that real isolation can in most cases 
be secured. The value of such removal of well 
children is shown by the fact that of 317 children 
who were at once removed, only eighteen, or 5*6 
per cent., were attacked on their return. If these 
children had remained at home, doubtless half of 
them would have yielded to the disease. 



ANNOTATIONS. 



The Bradford Licensing Committee recently 
refused the renewal of the license of the Napier 
Inn in that town on the ground that certain altera- 
tions had been made in the premises which 
increased the internal area. It appears that the 
alterations thus made use of to abrogate the license 
were ordered by the Local Sanitary Authority ; 
and the case, therefore, is of interest from a public 
health standpoint. The alterations were made on 
the recommendation of Dr. Arnold Evans, the 
Medical Officer of Health. They consisted chiefly 
in the removal of a urinal, the widening of a 
passage, and the substitution of one room for 
another for the purpose of a drinking bar. The 
carrying out of these works has rendered the inn 
more sanitary, and unless the revocation of the 
license was justified by other considerations not 
contained in the local report of the proceedings, it 
is unfortunate that the difficulties connected with 
obtaining the execution of sanitary work should be 
thus increased. A partially successful appeal has 
been made against the decision of the Licensing 
Committee, but we suppose the moral is that in future 
any proposed structural alterations should, before 
being made, be submitted to the bench of 
magistrates. 

Insufficiency of Hospital Accommodation 
IN London. 

In July the Managers (Metropolitan Asylums 
Board), not for the first time, addressed a com- 
munication to the sanitary authorities, suggesting 
that in the selection of cases for removal to 
hospital, preference should be given to those 
patients " who, as a consequence of their sur- 
roundings and conditions of life, are most in need 
of hospital treatment." This advice sounds 
reasonable, and clfect is given to it as far as prac- 
ticable. But a sanitary official finding a non- 
isolated patient to-day, could not properly neglect 
to take steps to remove the case to hospital 
because, perchance, a worse case might crop up 
to-morrow. If he did, he would probably find that 
some other parish had benefitted by his inaction, 
and obtained the bed which would not be at his 



ANNOTATIONS. 



6i 



disposal when his suppositious worse case turned 
up. No, there is nothing for it, as things are, but 
for sanitary officials to remove the cases as they 
crop up day by day, and for the managers to go on 
increasing their accommodation to whatever extent 
may be necessary to meet the requirements of the 
sanitary authorities. And this they are doing, for 
they have acquired sites for three additional 
hospitals for i,6oo patients, and two of these 
hospitals are now in course of erection. — From 
Dr. Dudfie/d's Report for September, 1895. 

Failure to Close a Polluted Well in 

Epping. 

The strict interpretation of the 70th Section of the 
Public Health Act, 1875, ^^^ again led to another 
failure. In I he town of Epping, a few water 
supplies obtained from surface wells continue to 
exist. Many of these are polluted. One of the 
wells was found by Dr. Fowler, the Medical 
Officer of Health, to be impure, and he had his 
analysis confirmed by the County Analyst. The 
water, indeed, contained 146 •3 grains of solid 
residue to the gallon, chlorine equal to 29 grains 
of common salt, and a large amount of nitrates 
and nitrites. The water also contained roving 
organisms. A closing order was asked for. The 
defendant (Mr. Lawrence) opposed the application, 
affirming that 90 persons drank the water, and 
during five years there had only been five deaths, 
one of the deaths being that of a stillborn child. 
He also stated that it was impossible for there to 
be contamination to the depth of twelve feet, but 
admitted that the well was within ten feet of a well 
closed eleven years ago by the same Court. The 
Bench dismissed the case. The reasons for this 
decision, in the face of the evidence, are not 
obvious, nor are they given in the press reports. 
It may be presumed, however, that the magistrates 
considered that the words " injurious to health " 
must be interpreted strictly, and that the prosecu- 
tion had failed to show that anyone's death or 
illness had been caused by drinking the water. 
Should this be the true interpretation the practic- 
ability of closing the thousands of polluted supplies 
throughout the country, until cholera or enteric 
fever has been propagated through their agency 
seems remote. It will be remembered that the 
corresponding section in the Public Health 
(London) Act, 1 891, adds the words "or dangerous 
to health," a wise amendment, removing all ambi- 
guity, and enabling the Metropolitan Local Authori- 
ties to close a supply if there is sufficient evidence 
to show that if not positively " injurious," yet the 
supply may be " dangerous." It is hoped that 
either a case may be taken to the Superior Courts, 
and an interpretation of the 70th Section obtained 
more favourable to its undoubted intention, or 
that the 70th Section will be amended in the next 
session. 



Sterilised Milk. 

In a recent number of the Antiales de Vlustiiut 
Pasteur (Tome IX., No. 4), Dr. E. Ducleaux 
makes an exhaustive examination of the objections 
against the use of sterilized milk, stated by Fliigge 
in the Zeitschrift f. Hyg., T. XVII., 1894, p. 272. 

Fliigge states that the liquid often sold in flask 
as sterilised milk contains a liquid which has 
become materially changed. In order to under- 
stand how this change is brought about, it is 
necessary to review the action of ferments on 
caseine. It is well known that ordinarily the forma- 
tion of lactic acid from sugar precedes the coagula- 
tion of caseine in milk by a special ferment. Pasteur 
first showed that milk may coagulate under the 
influence of ferments in a neutral medium. The 
ferments of caseine secrete a second diastase an- 
tagonistic to the first, which reduces the coagulum 
formed by the former. Then the coagulum again 
becomes liquid, and the passing coagulation may 
have been overlooked ; this transformation, 
although hidden, is very great. In milk, caseine, 
we know, is not in true solution, but in suspension, 
forming with the serum a stable emulsion, of which 
the elements are fine enough to pass through filter- 
paper, but too gross to pass through porcelain. 
When the second diastase has acted, the albu- 
minoid matter is completely dissolved. Further- 
more, a portion has been decomposed into the 
intermediary products which lead on to leucin, etc. 

The hygienic question in connection with milk 
is the determination of the microbes causing it to 
produce infantile diarrbcea. It is notorious that 
such diarrhoea is diminished, or even prevented, by 
the use of boiled milk. Is it the ferments of lactose, 
or those of caseine which are inimical ? M. 
Duclaux thinks it is the former — among other 
reasons, because experience shows that it suffices 
to render milk harmless (so far as diarrhoea is con- 
cerned) for ingestion to Pasteurise it, i.e., to heat it 
70 degs. to 75 degs., a temperature at which the 
lactic ferments are killed, but which the ferments 
of caseine and bacilli resist. 

Variable Milk Standards. 
In a case heard on September 26th, at the 
Harlesden Police Court, the Middlesex County 
Analyst, Mr. Bevan, working to a standard of 3, 
certified that 10 per cent, of the milk fat had been 
abstracted. The milk also contained boracic acid. 
The defendant had his third of the sample analysed 
by another analyst, who certified to dilution with 
8 per cent, of water, but disagreed as to the 
removal of milk fat. The same milk was sent to 
Somerset House, and a certificate received to 
the efifect that the Government chemists were 
unable to say fat had been removed. At the 
hearing, Mr. Richard Bannister, on behalf of the 
Somerset House chemists, stated the Umit now 
adopted was 2' 75, and that the difference was 
so small between 2-69 and 275 that they could 



62 



REVIEWS. 



not say any fat had been abstracted ; moreover, this 
year had been a bad season, 2nd they had found 
the milk-fat somewhat lower than usual. The 
Bench, on Mr. Bannister's evidence, dismissed the 
case. It is generally known that some few years 
ago the Somerset House chemists never supported 
an analyst's certificate for fat removal, unless the 
fai found was under 2 '5 per cent. : latterly, as Mr. 
Bannister says, the limit has been raised to 2- 75 
per cent Nothing can show more clearly the 
great public inconvenience of variable standards 
than the above case. Mr. Bevan works to a 
standard of 3 ; another analyst, as stated in the 
evidence before the Food Products Adulteration 
Committee, works to 2*5 ; the Somerset House 
chemists -.vobble round 2' 75, allowing in practice a 
few hundreds for differences in season. It is to be 
hoped that the voluminous evidence taken before 
the Committee of the last Parliament will be 
utilised, added to, and a Bill next session 
brought in, codifying, enlarging, and amending the 
existing law, and laying down definite standards, so 
as to render it impossible for any wide divergence 
of opinion on identical facts to interfere with the 
administration of the law. 



REVIEWS. 



Rural Water Supply. A Practical Handbook on the Supply 
of Water and Constniciion of Waterworks for Small 
County Districts. By A. Greenwell, A.M.I.C.E., and 
W. T. Curry, F.G.S. (Crosby Lockwood and Son, 
Ludgate Hill. 1S96.) 

The title of this work almost sufficiently indicates its 
purpose. It deals with the subject of water supply from the 
standpoint of the surveyor and engineer rather than from 
that of the medical officer. Sc far as hygienic points are 
touched upon, their treatment is accurate and concise. The 
whole work is well illustrated and carefully arranged, so that 
its contents are easy of reference. 

TTic Vofdnaiioi! Qiusticn. By A. H. HOTFON, M.A. 

(.Methuen and Co., 36, Essex btreet, W.C. 1894. is. 6<i.; 

.A.fter ha%-ing, in an editorial capacity, been obliged to 
wade through the already too numerous volumes of evidence 
issued by the Koyal Commission, which, with the exception, 
ala-s \ of those members of it who have died, is still in 
existence, it is a wearine<;s to the fiesh to have to wade 
through this brochure. It ha5, however, been done, without 
the discovery of a single new fact against vaccination. Many 
old "facts " are here served up as though they had never 
prrrviously appeared and been answered. l>r. .\Ifred Russell 
Wallace is still quoted as an authonty against vaccination, 
though we confess that we should have expected him to be 
tjuietJy dropped even by the anti-vaccinators, after the 
merciless expose of his statistics in cross-examination by Dr. 
Bristowe and .Mr. Savory. But the public memory is very 
short. 

Dia^ramdlt: for the Ttachinf^ cf Hygietu — Mr. Knight, 
the Curator of the Parkes Museum, has issued a capital 
series of diagrams relatmg to the various branches of 
hygiene. These will, we duubt not, be of great value 
to all teachers of hygiene, and we strongly recommend 
them to their notice. They can also be obtained in the form 
of magic-lantern slides, which will he of great value for 
lecture purposes. Among the best of the diagrams vf, per- 



haps, the one showing Knight's model of house sanitation, 

and showing how tnsyphonage, etc., can be effected. But 
all the diagrams are good, and their circulation will be of 
great educational value. 

Did in Sicktuss and in Health. By Mrs. Ernest Hart. 
With an Introduction by Sir Henry Thompson. (The 
Scientific Press, 428, Strand, 1895. 3s. 6d.) 
This is certainly a useful, though a somewhat sketchy 
book. It first deals with foods and stimulants from a general 
standpoint, and the dietetics of special diseases are con- 
sidered. The advice given under each disease is sound, and 
in accordance with medical knowledge, and the book is 
likely to be useful both to medical practitioners and to the 
many patients who like, independently, to have advice as to 
the dieting of their known ailments. The book is well 
illustrated, handsomely printed and bound. 

On the Natural Immunity against Cholera, and thi Preven- 
tion of this and other Allied Diseases by simple Physiological 
Mean-. By C. GODFREY GuMPEL. (Williams and 
Norgate, 14, Henrietta Street. 1894.) 
Admitting that an attack of cholera is caused by the joint 
operation of (j:) the cholera bacillus, (/) favourable environ- 
ment, and (:) the individual predisposition, the object of the 
author appears to be-little the importance of x and y, and to 
magnify that of z. He states that in the most violent 
epidemic?, over 90 per cent, of a population are already 
protected through a natural constitutional immunity, and he 
sets about the discovery of the nature of the immunity, thus 
anticipating that he will save the remaining 10 f)er cent. 
Giimpel believes that the essential pathological condition in 
cholera is the swollen and morbid condition of the red cor- 
puscles, rendering them unable to take up oxygen, and that 
a deficiency' of sodium-chloride in the blood is the cause of 
individual predisposition to cholera. He is, further, of 
opinion that an abundant supply of food rich in potash salts, 
without a corresponding supply of common salt, will develop 
a predisposition for cholera. Such an excess of potash salts 
is present in vegetable as compared with animal foods. If 
a liberal, systematic supply of common salt to the human 
organism would really confer upon it an immunity against 
cholera, Herr Giimpel, in publishing this fact to the worM, 
would be the greatest benefactor to the human race of the 
present century. But there are no facta to support this 
carefully-woven theory, and we must confess we regard it 
with incredulity. 

Seventh Special Report of the Commissioner of Labour. The 
Slums of Baltimore, Chicago, New York, and Philadel- 
phia. By Carroll D. Wright. (Washington : 
Government Printing Office. 1894.) 

From the preliminary part of this report we cull the 
following particulars. The pjercentage of males is greater in 
the slum districts of each city than cf females. They also 
contain a large excess of the foreign element. Thus, in New 
York, the foreign-bom is 42 per cent, of the total population ; 
in the slum districts it is 625 percent. The canvassers 
found much less sickness than they had expected, notwith- 
standing the most wretched conditions here and there. In 
Chicago the slum population averaged 15 5 persons to each 
dwelling ; in New Ytjrk, 368 persons. The remainder cf 
the volume contains most elaborate tables as to race, sex, 
age, occupations, earnings, etc., in each set of slums. 

The I'ital Statistics of Massachusetts for 1893. (From the 
Twenty-sixth .\nnual Report of the State Board of Massa- 
chusetts for 1894.) 

This annual report increases in value every year. Among 
other inteiesting items, is an interesting curve of the death- 
rate from phthisis in Massachusetts since 1851. This show 
a steady decline in the disease. We have no doubt that 1: 
is really declining, but we wonder whether there is the same 
tendency in New England, as in OUl England, to return 
deaths in an increasing number as " Tuberculosis " simply 



CORRESPONDENCE. 



63 



without allocating the disease. This, obviously, opens the 
door for a serious fallacy. The whole report bears evidence 
of careful and accurate work. 

A Summary of the Vila! Stathtics cf the New England 
States. (P. S, King and Son, 12, King Street, West- 
minster. ) 

The compilation of this summary of the vital statistics u\ 
the six New England States, which now have an accurate 
system of registration of causes of death, is a new departure, 
ard we congratulate Dr. Abbott on the masterly first report 
which he has issued. The tables and information are very 
full and complete, and we look forward with interest to 
further numbers of this series. We note that some of the 
New England States have long had accurate death returns. 
The value of the next volume of this series would be greatly 
increased by a tabular statement of the death-rate for each 
chief infectious disease for as long a series of years as is 
practicable. 



CORRESPONDENCE. 



THE RIVER TYNE PORT SANITARY 
AUTHORITY. 

To the Editor t?/ Public Health. 

River Tyne Port Sanitary Authority, 
Town Hall, Newcastle-upon-Tyne, 

2ist October, 1895. 
Sir — I beg to forward the subjoined copy of letter which 
I have addressed to the River Tyne Port Sanitary Authority, 
The resignation has, I hear, been accepted. 

I am, your obedient servant, 

Henry E. Armstrong. 

"To the Chairman and Members of the River Tyne Port 
Sanitary Authority. 
" Gentlemen, — In order to leave you as free as possible 
in your consideration of the resolution of the Town Council of 
South Shields, as to the residence of the Medical Officer of 
Health to the Port, I beg leave to place my resignation in 
your hands for you to deal with as you think fit in the interest 
of the community. 

" In taking this step, the necessity of which (for reasons 
I need not enter into here) has been on my mind fo^r a con- 
siderable time, I desire to acknowledge my deep sense of the 
importance, national and local, of the work carried out in 
the service of your Authority, and the honourable nature of 
the office I have now held under you for above thirteen years. 
*' I am, your obedient servant, 

"(Signed) Henry E. Armstrong, D.Hyg,, 

"Medical Officer of Health. 
"21st October, 1895." 



QUARANTINE REGULATIONS AT MAURITIUS- 

To the Editor of Public Health. 
Dear Sir. — You may have seen in Truth how, a short 
lime ago, the quarantine regulations at Mauritius prevented a 
man with a fractured skull getting medical help for twelve 
hours ; or in other papers what iniquities are committed 
under the guise of keeping out infectious disease. Ships 
have arrived at that island with disease on board, and have 
been unable to get a medical man often for days ; in one 
case, though there was no infectious disease and a person 
was dying, not at all. A recent quarantining of 400 coolies 
for an epidemic of measles {sic), of whom none died, has 
just cost the island 45,oco rupees. An epidemic of small- 
pox took place about four years ago, owing to the conceal- 
ment of a case by a ship's captain, who wished to avoid the 
regulations. This cost a large sum of money. A ship has 
gone from Calcutta to Mauritius in twenty-two days ; on the 
iiill of Health were given seventeen cases of cholera at 



Calcutta ; she got forty-eight hours. Four months later a 
ship did the same voyage in twenty days, and though there 
were eighty-five cases of cholera at Calcutta, she was only 
quarantined for nine hours ; but in this case a member of the 
Board of Health was on the ship, and another member did 
-not turn up until the meeting was over. The medical 
officer is not allowed to in-pect the ship until the Board have 
decided what to do ; the ship is then disinfected and the 
medical officer inspects. The disinfection is by means of 
SO2 for three hours, the ventilators being covered with old 
canvas, the clothes beina dipped in a 1-500 solution of 
perchloride of murcury, further diluted to about 1-5000 with 
sea water. The death rate was as follows : — 

Whole Population for 1893 was 40*9 per 1000 
Port Louis ,, ,,56-5 

Pamplemousses ,, ,, 68 "4 ,, 

Infants under I year old ,, ,, 517 ,, 

» )i 5 years old,, ,, 33^of whole mortality. 

Average of Port Louis for 6 

years, was ... 48 per looo. 

Average of Calcutta for same 

6 years was ... 26 ,, 

The death rate is higher than the birth-rate. 

There was some correspondence between the late .Secretary 
of State for the Colonies and the Governor, which resulted 
in the Secretary of State being told that the Mauritians were 
quite satisfied with their present arrangements, and firmly 
convinced that there was no other method of keeping out 
disease. This was the principal medical officer's opinion. 

They have just come to the conclusion that all the 
mistakes and objectionable parts of the process can be got 
rid of by giving the General Board of Health another name ; 
which, I am told, they are going to do. 

England asks the continental nations to give up quarantine. 
Others can comment. 

Yours, etc., 

J. Tertius Clarke, 
fSurg. B. I. S. N. Co., Mauritius Run). 

September 20th, 1895. 



ENTERIC FEVER AND THE PAIL SYSTEM. 
To the Editor of rvBhic Health. 

Sir, — In the August number of Public Health (page 
398) there appeared a paragraph headed, "Enteric Fever 
and the Pail System," in which the statement is made that 
in Newcastle in 1893, of houses on the water-closet system 
3 per cent, were affected with enteric fever, while 6 per cent. 
of houses having the pail system were affected. 

The inference to be drawn from this is, that the pail system 
does in some way produce enteric fever. Such a statement, 
coming from so eminent an authority as Dr. Armstrong, will 
doubtless be quoted elsewhere by medical officers of health 
and others. Some explanation of the statement is, I think, 
necessary — for either the pail system must be worked on bad 
principles in Newcastle, or else it has been put down in 
those districts whose general sanitary condition is much 
inferior to the districts where water-closets are in vogue. 

I cannot conceive of a properly worked pail system being 
productive of typhoid fever. 

I am certainly of opinion that the pail system for large 
towns is a most disgusting one, one which all experience 
goes to prove is most expensive, and one which ought not to 
be extended. To be strictly accurate, however, I do not 
think that this charge of producing enteric fever ought to be 
laid against it. 

I am, yours faithfully, 

John Robertson. 

St. Helens, Oct. 4th, 1895. 

[The paragraph in question was extracted from its contekt 
in Dr. Armstrong's report by us. It was an interesting 
statement of fact, no inference being drawn in the report. 



64 



APPOINTMENTS. 



We must, however, differ from Dr. Robertson's expression of 
opinion ; as we think that in two districts, otherwise coni- 
pletely comparable, the substitution of water-closets for pail 
closets (however careful the precautions taken with the latter 
during the prevalence of typhoid fever) would almost 
certainly be followed by a consideralile reduction in the 
incidence of typhoid fever. — Ed. P. H.]. 



MOXTHLY LIST OF PARLIAMENTARY 

PAPERS, Etc., 

Relating to Sanitary Matters. 

(To lie obt.iined from P. S. King and Son, 12 and 14, 
King Street, Westminster, S.W.) 

Papers. 

Food Products— Adulteration. Report of Select Com- 
mittee. Evidence, Appendix, and Index. 3s. lod. 

India — Sanitary Measures. Report for 1893-94. is. lod. 

London Water Transfer Bills. Report of Select Com- 
mittee, with Evidence, Appendix, and Index. 3s. 4d. 

Public Health. Report of the Medical Officer of the 
Local Govcrment Board for 1893-94. (Supplement to the 
Twenty-third Annual Report of the L.G.B. ) Plates and 
Coloured Maps, etc., ^■^. 560. 13s. 4d. 

Vaccination — English Cholera Administration — Inter- 
national Sanitary Conference of Dresden — Abstract of 
Medical Inspections made in 1813 with regard to the 
Incidence of Disease on particular places, and to questions 
concerning Local Sanitary Administration — Reports on 
Outbreaks of Enteric Fever, Diphtheria, and Epidemic 
Skin Disease in various districts — Lead Poisoning in 
Public Water Supplies. 

Reportsof ScientificInvestigations. — Dr. Klein 
on the Etiology of Typhoid Fever, on the Antagonisms of 
Microbes, and on the Etiology of Vaccinia — Dr. Edmund 
Cautley on the Micro-Organisms found in the Bronchial 
Glands, etc., etc. 



APPOINTMENTS. 



Medical Oikiclks of Health. 

AspiNALL, J., M.R.C.S. Eng., L.S.A., appointed 
M.OH. for the Smallthorne Urban Sanitary District. 

Adams, Dr. J., re-appointed M.O. H to the Runcorn 
Rural District Council. 

Addenbkooke, E. H., M.R.C.S. Eng., re-appointed 
M.O. H. to the Kidderminster Rural District. 

Beaimont, Albert Wm., H.A. Camlj., L.R.C.S. Edin., 
re-appointed M.O.H. to the East Ham District Council. 

Barr, John, M.B.. CM. Glasg., re-appointed M.O.H. 
to the Rishton Town Council. 

Boui.roN, A. E., M.R.C.S. Eng., L.S.A., appointed 
M.O.H. to the Horncastle Rural District Council. 

Browninc;, B., M.D., D.P.H., reappointed M.O.H. 
for the Weymouth and Melcomln; Regis Urban District 
Council. 

Colby, J. G. £., M.A. Oxon., M.B., B.Ch., ap- 
pointed M.O.H. for the Malton and Morton Rural Sanitary 
Districts. 

Fletcher, James, M.B., CM. Ivlin., appointed 
M.O.H. to the South Darley Urban District. 



Fitch, Frederick, M.D. St. And., M.R.C.S. Eng., 
re-appointed M.O.H. to the Kidderminster Rural District. 

Fostf.r, William, B.A., M.B., D.P.H. Camb., 
M.R.C.S. Eng., appointed M.O.H. for the Shipley Urban 
District. 

GARLAND, E. C, L.R.C.P. Edin., M.R.C.S. Eng., 
appointed M.O.H. for the Borough of Yeovil. 

Groom, H., B.A. Camb., M.D.. M.R.C.S. Eng., 
re-appointed M.O.H. to the Walsoken Urban District 
Council. 

Haswell, N. Richard, M.R.C.S. Eng., L.S.A., re- 
appointed M.O.H. to the Helston Rural District Council. 

Howard, Jones J., D.Sc. Pub. Health, M.B.C.M. 
Edin., appointed M.O.H. to the Port Sanitary Authority, 
etc., of Newport Town Council. 

Jones J. Howard, appointed M.O.H. to the Newport 
County Council. 

Morgan, H. de, R.M.A. Oxon., L.R.C.P. Lond., 
M.R.C.S. Eng., re-appointed M.O.H. to the Coclcington 
Urban District Council. 

Monk, H. G. H., M.R.C.S., D.P.H. Eng., appointed 
M.O.H. and Public Analyst to the Leicester Town 
Council. 

McNaught, James, M. D., appointed M.O.H. to the 
Rawtenstall Town Council. 

Mac Donald, James, M.A., M.B.,C.M. Edin., appointed 
M.O.H. for the Carlisle Rural District. 

Morsk, Edward, L.R.C.P., L.R.C.S. Edin., re- 
appointed M.O.H. to the Torrington Town Council. 

MacGregor, Duncan, A.M., B.Cm., Edin., re- 
appointed to the Clayton West Urban District Council. 

Pern, Dr. Edgar C, appointed M.O.H. to the 
Droxford Rural District Council. 

Partridge, Samuel, M.R.C.S. Eng., L.S.A., re- 
appointed M.O.H. to the Darlaston District Council. 

Pf.arck, John P., M.R.C.S., re-appointed M.O.H. to 
the Lewes Town Council. 

Phillips, J. N., L.R.C.P. Lond., M.R.C.S. Eng., 
appointed ^I.O. H. to the Cannock Urban District Council. 

Robertson, J. A., M.D. Glasg., appointed M.O.H. for 
Peterborough. 

Reynolds, H. D., L.R.C.P. Edin., M.R.C.S. Eng., 
re-appointed M.O.H. to the Pembroke Dock Town 
Council. 

Rouse, E., L.R.C.P. Edin., M.R.C.S. Eng., re- 
appointed M.O.H. to the Bideford Rural District Council. 

Sandford, H. v., L.R.C.P. Lond., L.F.P.S. Glasg., 
re-appointed M.O.H. for Herefordshire. 

Skinner, E. W., M.D. Edin., re-appointed M.O.H. to 
the Rye Rural District Council. 

Thomas. Dr. J. T., appointed M.O.H. and Port 
Medical Officer at Lowestoft. 

TuxFORi), James E., L.R.C.P., L.R.C.S. Edin., 
appointed M.O.H. to the Boston Town Council. 

Tkmpleman Charles, M.D., D.Sc. Edin., appointed 
M.O.H. for Dundee. 

Tew, J. Scott, M.D. , D.P.H., appointed M.O.H. for 
the West Kent Combined .Sanitary District. 

Walker, Allan, M.B., CM. Glasg., appointed 
M.O.H. for the Weetsladc Urban District. 

WiiKiNSON, J., M.B., CM. Edin., appointed M.O.H. 
to the Boston Rural District Council. 

Wilson, J. H., M.B., CM. Edin., appointed M.O.H. 
for the Standish with Langtrec Urban Sanitary Distric', 
nd Medical Officer for the Standish District of the Wigan 
Union. 

WoRSLEY, H., M.B., CM. Edin., appointed M.O.H. 
for the Church Urban Sanitary District. 



Public Health, 

Eiit Journal of the Incorporateti Societg of fHctiiral ©rTicers of j^ealil}. 



SUBSCRIBERS' COPIES of PauLic Health are 
supplied at \os. 6d. per annum. Single copies One Shilling, 

BOUND VOLUMES.— Co/z>j of Volufne VI. are now 
ready, bound in cloth, silt lettered, trice \os. 6d. A 
fe'M copies of Vols. /., //., IV., and V. are also oit hand. 

CLOTH COWERS for Biiidincr the Volumes, price li.6d., 
may be had by order of any Bookseller. 

Orders should be addressed to E. W. Allen, 4, Ave Maria 
Lane, E. C. 



ADVERTlSEMKliTS. — Communications relating to 
Advertisements should be addressed to Messrs. W. H. S' L. 
Collingridge, 14.8 and, i^g. Alder sgaie Street, E. C. 



\ 



Every Reader of a Paper before the Society, or Contributor 
of a Signed Ariicle, is entitled to twenty -five copies of the 
issue of Public Health containing the contribution in 
question ; but application for this- or any smaller number 
must be made to the Editor not later than //^e TWENTY- 
FOURTH day of the month precious to insertion of the 
Contribution. 

Medical Officers of Health and other Correspondents are 
requested to send regularly all published reports and 
matters of interest bearing upon Sanitation to the Editor, 
II, Gloucester Place, Rri-^hton 



NOTICES, 



ALTERED SUBSCRIPTION FOR MEMBERS OF 
THE INCORPORATED SOCIETY M.O.H. 

The attention of Fellows and Members of the Incorporated 
Society is called to the fact that dating from October, 1894, 
the subscription to the Society will be one guinea instead of 
half-a-guinea as hitherto. It must be noted that this will 
include the subscription as members of a branc h of the 
Society, the guinea subscription being inclusive for all 
purposes. 

It will be seen from this that there will be no very 
material increase in the subscription for those who are 
members of the parent Society and of one of its branches. 
There will, however, be considerable saving of trouble in 
collecting subscriptions, etc., as one subscription only will 
l)e payable. The subscriptions (and those for Associates, 
which remain half-a-guinea) should be sent to the Trea- 
surer, Dr. Kempster, Chesterfield, North Side, Clapham 
Common, London, S.W. 



Attention is called to Dr. Reginald Dudfield's 
request on page 104. A\'e are confident that those 
having information on the subject of "Aerial Con- 
vection of Small-pox '" will furnish Dr. Dudfield 
with the necessary references. 

No. ga. DiiCiiMBEK, iSg;. 



PROCEEDINGS OF THE INCORPORATED 
SOCIETY OF MEDICAL OFFICERS OF 
HEALTH. 

A MEETING of the Incorporated Society of Medical 
Officers of Health was held at No. 197, lii_h 
Holborn, on Thursday, November 2Tst, 1893. 
Present: The President (Dr. F. Vacher) in l^e 
chair, and the following Fellows and Members — 
Drs. W. T. G. Woodforde, S. R. Lovets J. F. [. 
Sykes, J. J. Skegg, T. M. Legge, M. A. Taylor, A. 
Newsholme, G. E. Yarrow, R. Dudfield, L. W. 
Darra Mair, Oliver Field, and E. T. Willoughby. 

The minutes of the adjourned ordinary meeting 
of the Society, held on April 8th, were read, 
approved, and signed by the Chairman. 

Rkport of COUN'CIL. 

The Hon. Secretary read the report of the 
Council, as follows : — 

Your Council beg to report — 

1. That they have appointed the President, Dr. 
F. Vacher, to attend the funeral of the late Mons. 
Pasteur in Paris. 

2. That they have decided to jDresent a petition 
to the Local Government Board, urging upon that 
Board the desirabihty of obtaining information as 
to the sex and age constitution of the populatior ,, 
at the forthcoming quinquennial census in London, 

3. That they have appointed Drs. F. Vacher, 
A. Newsholme, and R. Dudfield to represent 
the Society, at a Conference convened by the 
Municipal Officers' Association, to consider the 
matter of Superannuation Allowances. 

4. That they have, in accordance with the 
Articles of Association, formed a Scottish Branch 
of the Society. 

5. That they have authorised the sealing of the 
contract with :\Iessrs. W. H. and L. Collingridge, 
for printing the journal of the Society for the 
ensuing three years. 

Election ok Candidates. 

The meeting then proceeded to the election of 
Fellows, Members, and Associates. 

Theiollowing gentlemen having been duly nomi- 
nated as candidates, a ballot was taken, and they 
were declared by the Chairman to have been 
unanimously elected. 

As Fellows. 

Dickson, John Dunbar, M.D., M.Ch., The Gables, 
Marlow, Bucks, M.D.H. Wycombe, R.S.D. ; proposeu 
by Reg'nald Dudfield : secc nded by J. C. Thresh. 



66 



procei:di.\gs of the west oi i-nclaxd branch. 



IlAWOKiii, 1. 1... M.B. CM., D.P.II , Vale Hou»c, 

Darwcn, M.O.II. Darwen U.S.D. ; proposed by 

James Whcatley : seconded by A. Jasper Anderson. 
HORNK, Thomas, M.D., Stockton-on Tees, MO.H. 

Stockton-on-Tees U.S.D. : proposed h>y T. I'.iHlace 

Hill: -.econded by J. C. Thresh. 
Pear. E, J. P., M.R C.S., L.S A., St. Anne>, Lewes, 

Su-sex, M.O.H. Lewes U.S.D. ; proposed by Kei;inal(t 

Diidfield ; seconded by J. C. Thresh. 
Taylor, John, M.D., D.l' H., Chesterle-street, M.O.H. 

Chester-le-st'eet K.S. D. : proposed by T. Eustace 

Hill ; >econded liy J. C. Thresh. 
VissER, Thomas Christoffkl, M.P.., B.S., Private Box 

No. 9S3, Johannesburg, South Africa, >LO.H. 

Johannesburg, South Africa; proposed by Henry K. 

Armstrong; seconded by Reginald Uudfield. 

.Is Onitnaiy Members. 
.NL\S):v, E. I'tTKONELl., M.D., D.P.H., Fountain 
Hospital, Tooting ; proposed by .S. R. Loveit ; 
seconded by J. C. Thresh. 

As Associate. 
AR.MsrRO.NG, Hknry George, M.R.C.S., L.S A., Crovv- 

thorne, Berks, Medical Officer to Wellington Collegi- : 

proposed by W. T. ti. \Voodfoidc ; seconded by J. C. 

Thre.-;h. 
LiVY, John, >LD., I'.R. C.S.Ed., 44, St. George's 

Terrace, Bolton ; proposed by James Whcatley ; 

seconded by A. Jasper Anderson. 

No>riNATIOXS. 

A number of candidates \vere then nominated for 
election at the next meeting. 

A paper was then read by Dr. .\. Newsholme, on 
" A National System of Notification .Sickness," 
which will be published next month, together with 
the discussion thereon. 



PROCEEDINGS OF THE WEST OF ENCi- 
LAND AND SOUTH WALES BRANCH 
OF THE INCORPORATED SOCIETY OF 
MEDICAL OFFICERS OF HEALTH. 

Annual Meetinc;. 
The annual meeting of the above Branch was held 
on Thursday, October 24th, 1895, at the Offices 
of the Sanitary Authority, 51, Prince Street, 
Bristol, at 4 30 p.m. Present : Drs. D. S. Davies, 
H. J. .\lford, Crossman, Walford, and Heaven ; 
and J. Cooke-Hurle, Esq. 

The minutes of the last annual meeting were 
•■ad and confirmed. Letters were read from the 
Secretary of the Central Society, acknowledging; 
the receij)! of the Branch's letter containing the 
names of the members chosen as Branch Rejjre- 
sentatives on the Central Council, and from Dr. 
l>ivett, of W ells, stating that being no longer a 
medical officer of health he had resigned his mem- 
bership of the Society. 

The Treasurer's Report and .\ccount were then 
presented and read. The Report, after alluding to 
the alteration in the method of payment of sub- 
scriptions, and the consefiuent necessity for mem- 



bers to pay their subscriptions yearly before 
June 30th, or the funds of the Branch would 
suffer, proceeded to state that the year 1894-95 
was begun with a balance in hand of ;^5 9s. 2^d. ; 
that 14s. were received in the shape of subscrip- 
tions due to the Branch for ])a5t years, as well as 
the sum of ,7.13 2s. 6d. from the Central Society. 
The total receipts had therefore been ^13 i6s. 6d., 
while the expenses were jQi 9s. 6d. The Branch 
therefore had to its credit at the beginning of the 
year a balance of ^^17 16s. 2 id. The account 
was audited and adopted with the report. 

The Secretary next presented his Annual Report, 
showing that the Branch consisted of fifty-one mem- 
bers, and reviewing the proceedings of the Branch 
during the past year. The report was adopted. 

The next business was the election of Council 
and Officers of the Branch. The names selected 
by the retiring Council for the Council and Officers 
for the year 1895-6 were as follows : — 

Council — Dr. Walford, of Cardiff; Dr. Brabazon, 
of Bath ; Dr. D. S. Davies, of Bristol ; Dr. W. 
Williams, County -M.O.H. Glamorgan; and Dr. 
Walter Dowson, of Bristol. Vice-President — Dr. 
Bond, M.O.H. Gloucester Combined District. 
Secretary and Treasurer — Mr. John C. Heaven, 
Clifton, Bristol. 

The above names were duly submitted to the 
meeting, and their election for the above offices 
confirmed. 

Dr. H. J. Ali ORD, of Taunton (the President), 
then delivered the following address : — 

A Twenty Years' Retrospect. 

Gentlemen, — Allow me in the first place to thank 
you for the compliment you have paid me in electing 
me the President of the Branch for the ensuing year. 

As I feel that this compliment is rather due to 
long service than anything else, and as it is usual 
tor the President to deliver an address, I do not 
think I can do better than take a short retrospec- 
tive glance at the past twenty years, and compare 
our position then with the present. 

I speak as a provincial health officer, having 
had a large urban and rural district under my 
charge since 1873, Should my remarks be too 
autobiographical, you must forgive me. And first, 
as regards the a[ipointments of medical officers ot 
health — these were made in a most haphazard 
fashion. There was no method adopted by the 
Central Authority, and they varied from a com- 
bination of many districts with good salary, and 
the devotion of the whole time of the officer, to a 
paltry pittance unworthy of acceptance. As an 
illustration, I may jioint to my own case, where 
^600 a year was given, and that of a friend of 
mine who had J^,20 a year, and a vast rural district 
to look after. 

liut if there was this great divergence in the 
salaries given, there was one point which was fixed 
and inmiutable— the appointment was ui the first 



A rWENTY YEARS' RErROSPECT. 



67 



place only for live years. At the end of that time, 
where large salaries were given, an attempt was 
made by authorities to reduce them. In my case 
it was cut down to ^-£?2oo a year, and I was told 
I might again begin private practice. The only 
action taken by the Local Government Board was 
a sympathetic letter from the then President of the 
Board, and a cry of non possi/iiius when asked to 
mterfere. But poor encouragment this to devote 
one's best energies to the advancement of the 
sanitary condition of one's districts ! 

A different state of things now exists. The 
Local Government will sanction life appointments, 
as the following extract from a communication to a 
local authority shows : — ''The Board, at the same 
time, direct me to point out that they do not now 
think it necessary to impose any restrictions as 
regards the period for which medical officers of 
health and inspectors of nuisances should be ap- 
pointed, when the arrangements proposed are such 
as appear to the Board to be satisfactory ; and if 
the Council should think it desirable to submit a 
proposal for the re-appointraent of the medical 
ofificer of health for their district for a term of 
years, or permanently, the Board would be pre- 
pared to give it consideration." 

The " Inspectors of Nuisances " — or, as they 
now term themselves, " Sanitary Inspectors " — in 
those days were often of a very indifferent type, and 
in many cases utterly unlit lor the post. An ex- 
farmer, who had seen better days, was not un- 
frequently appointed out of compassion by his 
better-to-do confnres on the board of guardians. 
Now that an examination and qualification is pro- 
vided, I need hardly say that the class of inspectors 
is, as a rule, of the character which is needed. 

One cannot blame the local authorities in these 
matters, especially the rural authorities. ■ The 
Acts were quite new to them, and generally by 
them considered unnecessary, and to entail an 
outlay which was needless. It was the free hand 
given them by the central authority that was 
answerable for most of the difficulties that arose. 

But the anomalies did not cease here.. One of 
the first undertakings that I urged upon my 
authorities was the providing a hospital for the 
isolation of cases of infectious diseases. Plans 
were accordingly made, and four acres of land 
purchased in the suburbs of the town. The hospital 
was to be on the pavilion system — four wards and 
an administrative block. Everything was ready 
to begin the building, when a notice to rescind all 
former resolutions was given by a member of the 
rural sanitary authoritys on the ground that it was 
only '* an expensive fad of the doctor's,'' and would 
never be required for the rural district. It so 
happened that when this resolution came before 
the Board for discussion, the Poor Law Inspector 
of the district was present, and he forthwith pro- 
ceeded to give his ideas of an isolation hospital. 
It should be a one-roomed building of the stable 



type. The door sliould be provided with a lock 
and key. ^Vhen not wanted it should be kept 
closed ; when it was required for use a nurse was 
to be provided, the door unlocked, and the patient 
deposited in one of the beds. The plan was 
simplicity itself, and the cost so small (I) The 
delight of the obstructives on the Board was 
intense. Unhappily, however, no provision was 
made for the varieties of disease and sex. How- 
ever, the mischief was done, and it was necessary 
for the Local Government Board to send down one 
of their medical inspectors (the late Mr. Netten 
Radcliffe) to undo ut, and to persuade the Board 
of the absurdity of the scheme. 

At length the work was commenced, but the 
" penny wise and pound foolish " policy still had 
sway. The hos[)ital, instead of being placed in the 
centre of the land, wa<^ built at one end, in order 
that the other half might be let, and so money be 
saved. It was let, but after two years' tenancy and 
no rent, the tenant became bankrupt (!) However, 
a substantial tenant was then found, and the land 
was well stocked ; but shortly after, owing to an 
outbreak of small-pox, one half had to be sum- 
marily taken to erect an additional hospital, and 
very considerable compensation given. 

\Vhen the drains were laid and connected to the 
town sewers (nearly a quarter of a mile off), I urged 
that gas and water should also be supplied. But 
this was but another example of my extravagance. 
Oil lamps and a well were quite sufficient (!) So the 
roads were broken up for drains only. Some 
months elapsed, when a fire occurred by the up- 
setting of a lamp, and gas was ordered to be laid 
on. Again I suggested laying a water main at the 
same time, but it was refused as useless. Some 
time afterwards (in the midst of the small-pox ou' - 
break already mentioned) the well ran dry, and 
then for the third time was the road broken u;) 
and a water main laid. 

But notwithstanding these examples of false 
economy, we have had a very excellent hospital, 
which has been the greatest boon to both urban 
and rural districts, notwithstanding the prophecies 
to the contrary. Since it was opened in 1879 I 
have had 1,380 patients in the institution — 190 
cases of small-pox, 716 of scarlet fever, 330 of 
diphtheria, 128 of enteric fever, 13 of measles, and 
2 of erysipelas. 

The number of outbreaks that have thus been 
checked by isolation have been very great. The 
proportion of urban to rural cases has been, as 
might be expected, about two to one. 

Of course, in these early days, we had no 
"Notification Act" in force : but being on good 
terms with my professional brethren, I was, as a 
rule, kept informed of such cases. The Act was 
adopted by both my authorities at the earliest 
possible date, and has proved of great value. But th^ 
number of mistaken diagnoses has greatly increased, 
the cause of which I will not try to account for. 



68 



PROCEEDINGS OF THE WEST 01 ENGLAND BRANCH. 



As regards the general condition of water supply, 
drainage, and dwellings, I need hardly say they 
were about as bad as they could be twenty years 
ago. Before this period, enteric fever was 
endemic in my urban district. Cesspits and open 
sewers had in olden time polluted all the wells; and 
it was not until (thanks to an excellent water supply 
from some neighbouring hills) I was enabled tc 
close them, that the disease disappeared. 

Of course, water supply, sewage disposal, and 
nuisance removal, is much more easily carried out in 
urban than in rural districts. The compactness 
of the area, the various means provided, and the 
better supervision in urban districts, all tend to 
this end. 

In my rural district the inspectors of nuisances 
are also surveyors of highwa>s; and I find the 
latter occupation, being the pleasanter, supplants 
the former, and the sanitary work is but imper- 
fectly done. 

A great ditiicuity one has had to combat in rural 
districts is the surreptitious conversion in past 
years of road drains into sewers. No one knows 
when the connections between cesspit and pump- 
trough and road drain were made ; but wherever 
practicable it has been done. As these road drains 
(intended originally only for rain-water) end, as a 
rule, in river or stream, the authority finds itself on 
the horns of a dilemma. If they are sewers within 
the meaning of the Act, they cannot compel 
owners to cut off their sewage ; and, on the other 
hand, as sewers they cannot allow their contents to 
be poured into stream or river ; and furthermore, 
road drains are not fit recipients cf sewage, being, 
as a rule, roughly constructed of stone. 

My experience has convinced me that in country 
villages, with (as is generally the rule) a restricted 
water supply, a water-carriage system of sewage is 
a great mistake. The " pail" system, in its various 
modifications, is by far the best, as it protects the 
water supply, and reduces the nuisance to a 
minimum. 

But still the old affection for large cesspits lingei -. 
on, and one cannot wonder at the hold it has 
gained on the rural poi>ulation. It is not confined 
merely to the poorer tenements. I well remember, 
some years ago, whilst tracing an outbreak of 
diphtheria, I found the water supply of some new 
schools contaminated with sev.age, due to the close 
proximity of the cesspit, which, uncemented, 
allowed the free {jtrcolation of sewage into the 
well, only a few feet distant. And this was the 
handiwork of an architect in large practice ! 

As regards the dwellings of the poor, grea 
improvement is discernible. I had, early in my 
experience, to deal with a mud hovel by a river's 
bank, which had no window, only a small door and 
chimney, the one small room being divided into 
two by a ragged curtain : and here lived a man, his 
wife, and seven children— nine in all. The houses 
of the present dny, although often leaving much to 



be desired, are, as a rule, very much improved^, 
and kept much cleaner than heretofore. 

Thus, then, both as regards tenure of appoint- 
ments, the action of local authorities, and the 
sanitation of districts generally, matters have, if 
-slowly, still steadily, advanced. Permissive legis- 
lation, however, still unhappily exists. 

It was not until 1875 ^^at we had the Public 
Health Act to guide us ; but the unfortunate use 
of the "may" for the " shall " tended to thwart 
much of the good that might have been done. 

More recent legislation is tainted by the sam» 
flaw. For instance, the Infectious Diseases 
Notification Act, 1889, says: — "The Act shall 
extend after the adoption therefore " — the effect of 
which is spoilt by the following : — " The local 
authority of any urban, rural, or port sanitary 
authority may adopt this Act." So that although 
a considerable percentage have adopted the Act,, 
others still remain without it. Then, again, the 
Isolation Hospital Act, 1893, is hampered in the 
same way. " A County Council may, on an appli- 
cation being made to them," and so on. One 
cannot, therefore^ be surj.rised that in the County 
of Somerset we find only eight out of eighteen 
urban districts, and six out of twenty-two rural 
districts, provided with such institutions. 

One word I would say in conclusion, on the Local 
' lovernrnent Act, 1894. It is as yet, perhaps, too 
early to speak of the utility or otherwise of Parish 
Councils, but in my district I find many of them 
of great value. They enter with lively interest into 
the sanitary shortcomings of their parishes, and by 
reporting to the District Council or to me. bring 
pressure to bear of a valuable kind. 

Only this week I have received a lengthy report 
from one parish, giving a long list of nuisances 
requiring abatement, and overlooked by the 
Inspectors of Nuisances. They form a valuable 
propelling force to this sometimes laissez-faire 
officer, and so are of great use to the parish. 

I cannot help thinking that if parishes will only 
utilise the Act, and put good men on the council, 
it may be fraught with great value to the community . 

The conclusion then, gentlemen, of my retrospect 
is this : the chaotic, unsatisfactory condition of 
twenty years ago is i)assing away. Sanitary 
authorities and the public generally are more alive 
to the needs of sanitation ; but at the same timf. 
during all that period to the present day, a drag 
has been ke|)t on sanitary progress by the very 
-ermissive character of legislation. 
Discussion. 

Dr. I). .S. Davit.s tlianked the Presidtnt forhisiaterestin: 
address. Alluding to improvement in the knowledge of mei^ 
appoinitd now .as i. .-.pectors, he staled that sanitaiy 
authorities even nf>w did not always choose the best in- 
formed man, and instanced a case where one authority 
refused to re-elect a cerliticated man who liad served thtir 
district well for some years, and knew it thoroughly, bi t 
chose a man who had no certificate, and ahsolutcly no 
knowledge of the work required. Insult was ad<<ed to 
injury in this case, by the authority asking the displace>l 



EFFECTS OF SEWAGE AND SEWAGE-GROWN PRODUCE UPON AXIMAI.S. 69 



inspector lo ins-truct his successor in his duties. He also 
touched upon the advantage of having one hospital to serve ai; 
urban and surrounding rural districts, where that is possible. 

Mr. J. t. . Heaven alluded to the question of highway 
drains as sewers. He thought there could be no question 
among medical officers of health of the unsuitability of such 
channels for carrying sewage. As to their ownership, he 
believed the sanitary authority had no claim upon them, 
and could not call upon a householder to connect to them, as, 
under the Public Health Act, a sewer does not include 
" drairts vested in or under the control of any authority 
having the management of roads, and not being a local 
authority under this Act." He mentioned a case where a 
highway authority called upon a sanitary authority to cut 
off all house drains in a certain village which connected to 
the highway drains. He agreed with Dr. Alford, that in 
small hamlets or villages which were dependent on wells for 
water supply, the dry privy is the best mode of excrement 
disposal, provided the people will use them with care and 
intelligence. The slops might l)e disposed of by sub- 
irrigation, or by an impervious slop-pit furnished with z 
pump, so that the contents might be used on the gardens. 
Where a public supply of water is available, and the place is of 
any size, he considered the water carriage system preferable. 

Dr. Walford was much interested in the letter of the 
Local Government Board, mentioned by Dr. Alford, with 
regard to the appointment of medical officers. If it was not 
intended to apply to a particular case, it seemed to him a 
new departure, and a reversal of their previous policy as to 
such appointments. 

Dr. Grossman stated that in his district, disposal of 
slops by sub-irrigation had not proved successful, owing to 
the rapid choking up of the irrigation pipes. His experience 
was, that the better plan was to apply the slops to the 
garden surface. 



PROCEEDINGS OF THE YORKSHIRE 
BRANCH OF THE INCORPORATED 
SOCIETY OF MEDICAL OFFICERS OF 
HEALTH. 

The quarterly meeting of the Yorkshire Branch 01 
the Incorporated Society of Medical Officers of 
Health was held at the Memorial Hospital, Mir- 
field, on Friday, October i8th. The Presiden: 
(Dr. Ramsden) occupied the chair. The following 
members were present : — Wm. M. Burman, Thos. 
B. Fairclough, R. Holgate Shaw, D. Ainley, B. 
Kemp, W. A. Hunter, G. Hodgson Higgins, 
Meredith Young, and James R. Kaye (hon. sec.\ 
There were also two visitors — Mr. Roberts, of the 
District Council, and Mr. F. H. Hare, engineer. 
Town Hall, Mirfield. After the election of eighteen 
new members and two associates, 
The President delivered his address. 

On the Re.medial Evils attendant upon the 
Lives of the People. 

After some introductory remarks, he went on to 
say that many evils capable of remedy have 
occupied and are occupying the minds of all 
thoughtful lovers of their fellow-men, and although 
much has been done, there is yet much to do. 
Subjects such as the distribution cf pure water, the 
closure of polluted wells, and the imperfect purilv 
■cation of water, believed not long since to be 
perfectly purified by filtration, are of immense 
importance to the public health. There are many 



v/ho believe that the use of the domestic filter meets 
every want and ensures perfect safety, while it has 
been abundantly proved that ordinary filtration is 
frequently more dangerous than drinking an ordi- 
nary well water supply, because the false sense of 
security prevents the householder from taking the 
natural precaution of boiling the water when thr: 
supply happens to be of a suspicious nature. A 
reference was then made to the laws relating to our 
food supply and its adulteration, and he advocated 
very strongly the boiling of milk. On detailing the 
methods of sterilising milk, he referred to the able 
address given by Sir Albert Rollitt at Hull, when 
he said, " He was astounded, when at Copenhagen, 
to see the processes to which milk was subjected, 
and the highly organised collective system of its 
supply to the public. Knowing milk to be the 
raedium of the microbes of many diseases, the 
Danes (like the Germans in Berhn^ sterilise it as 
far as possible by filtration through [)repared gravel 
in cylinders, this removing the bulk of the living 
germs — bacilli-cyanogeni (the blue milk bacilli) 
and the rest of them — and with them a prodigious 
quantity of solid refuse, hair, dirt, etc., of which 
he brought home a small sample in the bottle 
before him." Dr. Ramsden then reviewed the 
question of smoke abatement : the prevention of 
blindness from contagious ophthalmia ; and the 
interment of stillborn children without registration ; 
the danger from the explosion of paraffin lamps, 
and overcrowding in factories. He then criticised 
the delay in ttie issue of the report of the Royal 
Commission on ^'accination. It was his desire to 
press upon our future medical men the importance 
o{ the questions he had touched upon. Xoble as 
the work of curing disease undoubtedly is, that of 
preventing disease is nobler, and there are many 
•nousands in our great manufacturing cities the 
victims of our industrial conditions, living lives of 
hopeless ill-health, who are looking for deliverance 
vv'hich is only to be obtained for them by men who 
combine the clear intellect of the men of science 
with the compassion for the sufferings of their 
fellow-men, a combination of qualities which are 
to be found most frequently in the men of the 
medical profession. 

The Effect.s of Sewage and Sewage-Grown 
Produce upon Animals, and through 
THEM upon Man. 

l:V 

Meredith Vou.ng, M.B., CM. (Iniv. Edin.), M.O.H. 
Brighousc Corporation and IIalifa\ Rural District 
Council. 

My reason for bringing this subject before your 
meeting to-day, is that it involves questions which 
are continually coming to the fore, especially in 
rural districts. 

In such districts, and also on the fringes of 
urban districts, there are to be found often isolated 
dwellings, and blocks of dwellings, which cannot be 
included in a complete drainage scheme. 



PROCEKDIXGS OF THE YORKSHIRK BKAXCH. 



The construction of tanks, besides being expen- 
sive, means a multiplication of potential nuisances, 
and an easier way out of the difficulty is sought by 
simply turning the sewage on to the fields. In some 
places this can be managed so as in no way to 
cause a nuisance or injury to health, and without a 
risk ot" polluting any water supply. But, as the 
fields are frequently being u.^ed as pastures, a fresh 
possible danger suggests itself at once — will the sew- 
a^re, or the contaminated pasture, in any way injure 
the cattle ? This question has been put to me a great 
many times, and opinions being so varying on the 
different points concerned. I have had simply to 
advise a kind of " keep on the safe side " policy, 
and suggest the tanking of the sewage, or, at least, 
the fencing off of the 'and >>n which it ran. Again, 
I have met with very many cases where farmers have 
lost cattle which were grazini; in fields to which 
sewage gained access, or serious accidents have 
happened to their cattle which they have ascribed 
to '■ poisoning by sewage." And many of these 
farmers have threatened to take legal proceedings 
against the Sanitary Authority, to recover the cost 
of the cattle thus lost or injured. 

Vou will readily see, taerefore, the importance 
of the subject which I wish to bring before you. 

I do not claim any originality in the opinions I 
put forward, as they are almost all gleaned from 
books, or from communications received from 
Professor W alley. Professor Fred Smith, Sir Henr>- 
Littlejohn, Mr. Alexander Cope and others, which 
I will endeavour to acknowledge afterwards. 

I. — The first question is, whether the common 
notion that cattle drink polluted, in preference to 
pure water, is correct ? 

With the exception of Mr. Alexander Cope, of 
the Board of Agriculture, and Professor Fred 
Smith (Army Veterinary School, Aldershot), I 
think all the authorities I have consulted are agreed 
that cattle do drink polluted water in preference to 
pure water. Sir Henry T.ittlejohn remarking that 
"fresh sewage diluted is rather pleasant than other- 
wise, and is taken with relish by cows. Sec." 

The general explanation given by the supporters 
of this notion is, that polluted water is almost 
always softer than pure water, and is liked on that 
account by cattle. 

Though I may say I fali m with the supporters 
of this view, I strongly object to this preference of 
cattle being used as an excuse for supplying them 
with any sort of water. 

I have questioned many of the farmers in my 
districts, and have learned three things from 
them : — 

1. That cows, during the period of menstrua- 
tion, suffer often from depraved aj^petite, and at 
such times they will drink foully polluted water. 

2. 'J'hat lome cows iiave a special fondness for 
polluted water, and will pass by pure on their way 
to get to the polluted water. 

One farmer told nic of i cow which, when driven 



to the watering-[»lace along with the rest, refused 
to touch the water : on being driven through the 
fields, it passed two other jjure sources of water, 
and wont straight down to the side of the Rivtr 
Calder, where it drank with avidity. 

3. Once cattle have commenced drinking pol- 
luted water, it is extremely difficult to break them 
of the habit. 

I think all authorities are agreed that cattle 
graze on sewaged meadows, and eat the produce 
grown upon sewage-farms eagerly. 

n. — The next question is, whether the drinking 
of sewage, or sewage polluted water, or the eating 
of sewage-grown produce is injurious to cattle, and 
the directions in which it is said to be injurious. 

This question I propose to deal with as far as 
possible, leaving specific disease out of count. 

I regret to say that opinions are very much divided 
on this important point, and it is extremely difficult 
to say which side of the balance will sink. 

Though the majority of the experts give a 
negative reply to the question, the negatives are so 
quahlied as to considerably lessen their weight. 

I give you the main ones verbatim, so that you 
may use your own judgments. 

]SIr. Cope knows of no evidence as to the ill 
effects of sewage on cattle, provided such sewage 
" is free from poisonous compounds." He writes,, 
further, that " thousands of cattle, horses, and 
sheep are reared, or fattened, upon the grass raised 
upon sewage farms, without any deleterious effects.'* 

Professor Fred Smith, in a paper read before 
the Seventh International Congress of Hygiene, 
says : — 

" We are aware that there are forms of organic 
matter in water which appear to produce no ill 
effects in animals, probably for the reason that they 
are not susceptible to any fever resembling typhoid : 
but sewage in water, without doubt, affects them, 
producing abortion in pregnant animals, and malig- 
nant and other forms of sore throat in cattle. 

" I have never, however, witnessed any ill effects 
in the horse, probably for the reason that the 
amount taken was insufficient to produce harm. 

" Animals have been known to suffer from diar- 
rhoea when partaking of water from a well within 
100 yards of a place where diseased animals had 
been buried the previous year. 

" Sulphurous acid finds its way into water in 
certain manufacturing districts : its effect on animals- 
is to give rise to diseases of the bones. 

"Water charged with lime has been known to 
produce bon) enlargements in horses ; and in the 
form of sulphate and carbonate of lime, it produces 
certain changes in the digestive canal, resulting in 
loss of condition and indigestion. 

" Cystic calculi, particularly in sheep, have been 
attributed to hardness of the water." 

In a recent letter, however, he writes : — " We 
have no positive evidence of the ill effects of sewage 
on cither horses or cattle. Abortion has been 



EFFECTS OF SEWAGE AND SEWAGE-GROWN PRODUCE UPON ANIMALS. 



attributed to it, but, in the light of recent research, 
is probably not correct." There is also no evidence 
that he is aware of as to the harmfulness of sewage- 
grown produce. But his final sentence again partly 
undoes us : — 

"Though I have had to give negative replies to 
your questions, I should not like to convey the 
impression that I consider sewage harmless to 
cattle." 

Professor Walley, on the other hand, remarks 
of dysentery or bloody flux, which is frequently 
seen in cattle, sheep, and pigs, that it is "pro- 
duced by contamination (especially by sewage) of 
pastures or of water ; by decom})osing or ferment- 
ing vegetable matter, and by stagnant water." Those 
are his words. 

Drs. CoRFiELD and Parkes, in their joint article 
on Refuse Disposal, in " Stevensons and Murphy's 
Hygiene and Public Health," write thus : — 

"As regards the feeding of cattle on irrigated 
meadows, it certainly seems more cleanly to allow 
the sewage to sink away into the soil before ad- 
mitting them on to the land, though there seems to be 
110 appreciable risk incurred by a cojitrary practice" 
(Vol. I. p. 886.) 

Though I proposed excluding the question of 
specific disease, I have already just trespassed on 
my resolution, and must do so still further, in order to 
relate to you a somewhat curious case, communi- 
cated to me by Dr. Arthur Roberts, of Harrogate, 
formerly Medical Officer of Health for Bingley and 
Keighley. Briefly it is this : — 

At a place called Harden, in 1879, there were 
several cases of woolsorter's disease in a mill, and 
two of the hands died from this. The poison 
further got into the water used for washing the wool, 
and several cattle grazing in the field on to which 
the sewage was turned, develo[)ed anthrax, and died 
from it. 

At the present day, when disinfectants are being 
boomed so much, there is always a possibility of 
poisoning by this means. The objection at once 
arises, that disinfectants being possessed, as a rule, 
of strong odour and strong taste, cattle will avoid 
water so poisoned. The answer is, that the odour 
and taste will not be so apparent in large dilution ; 
and we have no positive proof that animals will 
reject a water which is possessed of a marked 
odour and taste. Besides, have we not very 
poisonous disinfectants, such as the chlorides of 
mercury and zmc, for example, in common use, 
which have no odour, and in dilution have only a 
metallic or astringent taste ? 

Again, may not almost any poison, odourless or 
tasteless or not, gain access even to domestic 
sewage, to say nothing of sewage containing trade 
refuse, or the drainage from metalliferous mines ? 
Is it not a common thing, for example, for the 
housewife to pour the ccjntents of old medicine 
bottles down the sink ? Taking this into considera- 
tion, and bearing in mind how delicately those 



people walk who assert that sewage is not injurious 
to cattle, I venture to submit that there are grave 
possibilities of danger attendant on the drinking of 
sewage by cattle, and I think that it is our duty to 
advise our authorities, and all concerned, to pre- 
vent cattle gaining access to sewage or sewage- 
polluted water, and, in fact, to look as carefully to 
their l)eabts' water supply as they would to their 
own. 

But the question of the contamination of pasture 
land and farm produce by sewage is diff'erent. 
Here, I submit, we have no evidence as to harm- 
fulness, and we have no more right to condemn 
produce grown on sewage, than produce grown 
on manure of any other kind. The plant only 
absorbs from the sewage, or from the manure, those 
constituents which are necessary for its life and 
growth, and the only pollution to which such pro- 
duce is liable, is accidental or external pollution, 
and this is common to produce grown with all 
kinds of manure. 

I do nut mean, however, that this clean bill of 
health should apply to pasture lands, which have 
sewage turned on them until they are " sick," and 
on which the sewage lies in stagnant pools, often 
covering the roots and the grass to some depth. 
These are objectionable and dangerous : firstly, 
because the risk of accidental pollution is much 
greater ; secondly, because of the possibility of the 
cattle drinking from these pools of sewage ; and. 
thirdly, because of the peculiar manner in which 
cows and sheep, for instance, eat grass. Not being 
provided with upper incisors, they are unable to 
nibble or nip the blades of grass off" as horses do, but 
grasp them, as it were, between the tongue and the 
lower mcisors, and drag them off. It can readily be 
imagined, then, that there is a danger that cows and 
sheep, eating on sewage-sick pasture land, may get 
a good portion of the softened and sewage-sodden 
roots of the grass into their stomachs, with the 
results mentioned previously. 

III. — The next question is, whether it is possible 
for any disease to be conveyed from human beings 
to cattle by means of sewage ? 

The possibility of this occurring is denied by most 
authorities. But I have one or two pieces of evi- 
dence to bring before you, which, I think, will con- 
vince you, that this denial, at the least, ought not 
to be unqualified. 

Professor Walley, after complaining that it is 
becoming fashionable to charge cows with being 
the progenitors of many of the diseases flesh 
is heir to, quotes two cases where cows and pigs 
had been infected with diphtheria by the ingestion 
of materials which had been used for poulticing 
the throats of the infected persons. (Meat Inspec- 
tion, p. 114.) 

It is obvious that there are many other similar, 
or even easier, channels along which the infection 
of diphtheria might pass from human beings to cattle, 
and domestic sewage is one of these channels. 



J'ROCKRIMXr.S OF THE YORKSHIRE BRANCH. 



Again, Dr. Svkes. in his excellent and suggestive 
book " Public Health Problems," writing on tuber- 
culosis, says : — 

'' Many w.iys exist for the communication ot" thi- 
disease to animals from man, but one in particular 
deserves mention. It is no uncommon thing for 
cattle tog tin access to and drink the water used 
in househ 'Id washing, but Guinard states that some 
ot the French peasantry reguLirly give the washing 
water to the cattle to drink, and records observing 
that the handkerchiefs of a phthisical patient, 
saturated with tubercular sputum, were washed in 
water so used, doubtl-.ss leading to the transmission 
of the disease to the animals. As polluted drinking 
water is the means of the introduction of many 
diseases to man, there is some reason for assuming 
that similar results may follow its consumption by 
jnimals." (P. 273.) 

It is an established fact, that animals can be 
infected with tubercle by feeding, and, to my mind, 
tnis puts the possibility of transmission of the dis- 
ease by drinking infected sewage beyond doubt. 

As a lurther point in this connection, I may 
mention a case that came under the observation of 
Professor Law, of the Cornell University, in which 
the milk of some cows, which were in the habit of 
drinking from a polluted well, was found to contain 
microbes identical with those found in the drinking 
water. I give you this case for what it is worth, for I 
can find no mention of the nature of the microbes, 
and there are so many other ways in which the 
microbes might have gained access to the milk 
without passing from the water through the system 
of the cow. 1 thmk, however, that Professor Law- 
would not have mentioned the case, in the con- 
nection he did, had not such possibilities been 
excluded. 

IV. — Let me now briefly draw your attention to 
what I may, perhaps, call the converse of the last 
question. Is it possible for any disease to be con- 
veyed from cattle, drinking sewage polluted water 
or eating sewage grown produce, to human beings? 

Apart trom the entozoic diseases, I find that the 
evidence on this question is against this possibility. 
This, however, with one exception, which I wili 
quote to you from Dr. .Sykes' book, mentioned 
above : — 

" An outbreak of disease amongst cows at a 
dairy near Glasgow, causing diarrhoea amongst the 
consumers of the milk, was considered by Dr. 
Russell to be caused by the sewage-polluted water 
drunk by the cowf." (P. 277.) 

Here we have a double charge implied against 
the sewage-polluted water— that it caused "disease' 
in the cows, and thereby caused disease in man. 

Most authorities are, as I have said, of o|>inion 
that the only di>e iscs which are likely to be spread 
in such a way, are parasitic or, rather, macroi)arasitic 
diseases, namely, the various tapeworms, etc. 

In this connection, however, let me rjuote to you 
from the experiments of the British Association 



Sewage Committee. They examined the slime and 
mud from the bottom and sides of some carriers 
at a sewage-farm. "It was found that, although 
these matters contained a considerable amount of 
animal life, there were no ova of entozoa among 
them. Dr. Cobbold assisted in these experiments. 
And more than this, the carcase of an ox, which 
had been fed for twenty-two months upon sewaged 
produce, was examined by Dr. Cobbold, Professor 
Marshall, and Dr. Corfield in the presence of several 
members of the committee, the result being that no 
trace of parasitic disease could be found in any 
part of the body by the most careful examination." 

Still, one cannot argue from a single instance. 
The ova of tapeworms have been found in water ; 
if they exist in water, they will get into domestic 
sewage ; once in sewage, they may find their way 
to their next host, and, being eaten in the form of 
measly pork or measly beef, eventually complete 
the cycle of their existence again in man's intestinal 
canal. 

Indirectly, also, sewage may act the part of a 
carrier of tuberculosis to man. If Dr. Sykes' state- 
ment be recalled, it will be obvious that where 
sewage is infected by tuberculous matter, cattle 
may be infected from this sewage, and man, again, 
from the flesh or milk of the infected cattle. 

With these two exceptions, then, of macro and 
microparasitic disease, I think we may safely conclude 
that disease is not likely to result in man from the 
ingestion of meat, milk, or dairy produce derived 
from cattle which have drunk sewage-polluted 
water or eaten sewage-grown produce. For just 
as in the case of the sewaged pasture, the animal 
organism only takes certain matters necessary for 
nutrition and development, and these matters have 
to pass through one organic filter, at least, in the 
shape of the intestinal villi, before they can be 
available for transmitting disease to man. 

V. — Finally, I will deal briefly with the question 
— Is the milk, meat, or dairy produce of animals 
which have drunk sewage-polluted water or fed on 
sewage-grown produce in any way deteriorated in 
itself.? 

Let me give you a few opinions first. 

Sir Henry Littlejohn says that their experience 
in Edinburgh (100 years at least) is, that it is not 
in any way deteriorated. 

Dr. L. C. Parkes is emphatic. "The meat 
and milk from animals fed on sewage-grown pro- 
duce, /;/ fit) way differs from meat and milk pro- 
duced on ordinary farms," {Hygiene and Public 
J lea [ill, 3rd edition, p. 197.) 

Professor I'red Smith says, in 1 891, "The flesh 
and milk of animals receiving a polluted or foul 
water supply, has often a bad taste and odour." 
I Trans. 7th Int. Cong. Hyg. and Demog.) In a 
letter received a few days ago, however, he says 
that he knows of nothing definite. 

The common notion amongst firmers is that 
the milk has a bad taste when taken from cows 



EFFECTS OF SEWAGE AND SEWAGE-GROWX PRODUCE UHON ANIMALS. 73 



fed on se\\Mj.(jd produce ; and many say that when 
■the milk is warm a distinct heavy odour is perceptible, 
and the keeping qualities of the milk are impaired. 
'J'nis, I think, is easy to believe, when we consider, 
for example, how readily one can detect the smell 
of turnips in milk when cows have been fed on 
them even for a short time. 

I have heard farmers and others go even a step 
further than this, and say that when hens have had 
''fish heads" thrown to them for food, the eggs 
have tasted fishy. And are we not all acquainted 
with the fishy taste of ham and bacon, due to pigs 
having been fed on fish : and the offensive taste of 
potatoes which have been over-manured ? It is 
also a well-known fact that certain drugs given to 
an animal not only affect the flesh, and in some 
cases render it poisonous, but the milk is also in 
many cases affected. 

I need but remind you that the milk of some 
American cows suffering from " the trembles," 
(supposed to be due to their eating rhus toxico- 
dendron) causes in children vomiting, swelling of 
tongue, and great prostration ; and that the milk 
of goats, which have eaten meadow saffron or col- 
chicum, may cause severe diarrhoea. And as the 
way seems open for the passage of such chemical 
compounds, is it too much to say that it is also 
open to ttie passage of disease germs, or at least 
of the poisonous products of such germs ? 

All these things point to the fact that, in some 
cases, certain chemical substances contained in 
food material can pass through the so-called biolo- 
gical filters, and be detected by man after absorption 
in the food products of the animals, whose systems 
they have entered. 

1 think this demonstrates the possibility, at least, 
•of the flesh and other food products being de- 
teriorated by sewage and sewage-polluted wa,ter. 

The flesh of animals is difficult to trace, but it is 
quite possible, however, for a kind of septic or 
malignant catarrh of the stomach to be caused in 
cattle drinking sewage-polluted water, and dysentery 
is frequently caused by the same thing. 

The former of these diseases indicates a very 
possible source of danger should the stomach or 
intestines be used for tripe or sausages, whilst the 
latter disease renders the flesh unfit for human 
food, unless the animal be killed in the very 
■earliest stages. 

Having regard to all these matters, I have no 
hesitation in saying, that the flesh and milk of 
animals which have drunk sewage in any form, 
should not be consumed by human beings until 
the deleterious effects have had time to pass away 
at least. 

As regards the milk, etc., of cattle feeding on 
sewage-grown produce, however, the case is sii\i^htly 
different. Here the possible contamination has to 
pass through at least two kinds of biological 
filters — through one when the sewage is being 
absorbed by the plant, and through another when 



the sewage-grown produce is being absorbed from 
the alimentary canal of ihe animal ; and in the 
case of the milk, ])ossibly through still another 
during the process of secretion of the milk. This 
filtration, if one may so term it, at all events 
materially lessens the risk of transmission of hurt- 
ful products. I would feel inclined to say, there- 
fore, on this ground alone, that the consumption of 
the flesh or milk of animals fed on sewage- 
grown produce, is not attended with such risks as 
attend the same materials from animals which 
have drunk sewage contammated water. 
Further than this, I do not think I can go. 

AdT)KXI)UM. 

Since the above paper was written I have received 
the following interesting communication from Dr. 
Henry E. Armstrong, M.O.H., Xewcastle-upon- 
Tyne : — 

'* Dear Sir, — I have communicated with Mr. 
Clement Stephenson, F.R.C.A'.S., chief veterinary 
inspector to the County Council of Northumber- 
land and the City of Newcastle-upon-Tyne, whose 
position as an authority on this subject is excep- 
tional. He replies to me as follows : — 

'' ' Healthy cows do not prefer dirty to clean 
water. 

" ' In 18S1 I had an expensive experience caused 
by my cows drinking water from a burn into which 
sewage was discharged. Within thirty-two days 
ten uf my pedigree cows cast their calves. My 

landlords joined me in an action against the 

Rural Sanitary Authority. It was before the 
Chancery Court for some time, and finally verdict 
was given for plaintiff. 

" ' The Sanitary Authority had to fence the 
burn where it passes through my fields, and to 
find me with Whittle Dene water (as suppHed 
to Newcastle) until further orders. The above 
holds good yet. 

'• ' I am very particular as to pure water for my 
cattle, yet at the same time I believe cattle do well 
on sewage farms. 

'' ' Mr. G. T., Norwich, has over 200 head of 
cattle, 100 of which are dairy cows. These are 
largely fed on sewage grown grass, and do well. 
I distinctly remember the late Dr. Luke Armstrong 
consulting me re a continued fever illness amongst 
the children of a certain farmer, and he was strongly 
of opinion that the illness was due to the milk from 
cows that drank from a filthy pond. 

'" I am perfectly certain that the supply of pure 
water is of equal importance to cattle and to human 
beings.' " 

Dr. Armstrong continues : — "In a report to my 
sanitary authority on an outbreak of scarlet fever 
in Newcastle in connection with a milk supply 
during the year 1879, I made the following re- 
mark :—' Contaminated water may on 

recorded testimony, so contaminate indirectly the 
milk they (the cows) yield, as to give rise to 



74 PROCEEDINGS OF THE BIRMINGHAM AND MIDLAND BRANCH. 



serious and fatal illness in the human beings who 
use it as food.' (If I remember rightly the 're- 
corded testimony ' is that of an American author 
whose name I do not at present recollect.) During 
the inquir}- which led to the report above quoted, 
being desirous to ascertain whether the contagion 
of scarlet fever could be conveyed to milk through 
the cow by means of the water she consumed, I 
addressed a circular letter to the principal medical 
officers of health of the country on the subject, and 
elicited that the prevalence of professional opinion 
was then against such a transmission of disease. 
I am not aware that that opinion has been altered." 

Discussion. 

Dr. HiGGlNS alluded to several inst.inces in his experience 
of the effect of contaminated water producing fatal effects on 
cows. 

Dr. BuRMAN referreii to the deleterious effects by cow? 
eating various plants. He mentioned a case of cows eating 
saffron or colchicum, which produces diarrhoea in them, but 
he had not followed up his investigations as to the effect of 
the milk of these cows on the consumers. 

Dr. Kaye said that we ought to be cautious in ascribing 
fatal results in cows to sewage drinking, because in several 
instances in his experience fatal results which mi§ht have 
been ascribed to polluted water were discovered to be due to 
mechanical injury by the presence of pieces of wire in the 
stomach. He quite agreed that cattle did prefer sewage 
polluted water to pure water, and this he ascribed to the 
presence of salt. While recognising the advantages of the 
disinfection of sewage on i)ro])erly conducted sewage farms, 
he could not help thinking that the greatest danger was due 
to what has been termed external pollution of the produced 
either from the land or from the cow. It was now admitted, 
especially with regard to enteric fever, that the specific 
poison was contained in the diarrhccal discharges of the 
patients, that the poison of germs was capable of being pre- 
served by drying, and that the germs can live outside the 
human body. That being so, it i> not difficult to understand 
that the germs of enteric fever reaching a farm in the sewage 
might become dried up en the land, and be blown hither 
and thither, settling on the cow or on the produce, and ulti- 
mately gaining an entrance into the alimentary canal of the 
human being, either by the produce or by the milk from 
sewage farms acting as carriers or vehicles of the disease, 
especially on those farms where little or no precaution is 
taken with regard to the teats and udders. The suspicion 
that watercress and oysters have acted as the vehicle of the 
disease he considered in the same light : that is to say, the 
germ is not necessarily a part of the material, but is simply 
carried by them to the victim. 

Several of the meml)ers took advantage of the kind 
invitation of Dr. Fairclough, Medical Officer of Health, 
Mirfield, and made an interesting visit to the reformatory. 



Thf. County Mkdical Officer of Chf:shire. 
— The County Council have decided to retain the 
entire services of Dr. Vachcr, the County Medical 
Officer for Cheshire, at a salary of ;^6oo per 
annum, with additional first-class travelling and 
out-of-i>ocket hotel and clerical expenses. We 
welcome this addition to the list of county medical 
officershifis, and have no doubt that it will be most 
conducive to the public advantage. 



PROCEEDINGS OF THE BIRMINGHAM 
AND MIDLAND BRANCH OF THE IN« 
CORPORATED SOCIETY OF MEDICAL 
OFFICERS OF HEALTH. 

Annual Meeting. 

The annual meeting of this Branch was held at 
the Council House, Birmingham, on Thursday, 
October 3rd. Present : — Drs. Manley (President), 
Barwise, A. Hill, B. Hill, Reid, May, Fosbroke, 
Hollinshead, Fenton, Underbill, Malet, Biggam,. 
Bailey, Meredith Richards, Clark, and Clendinnen. 
The minutes of the preceding meeting were read 
and signed. Messrs. Hollinshead and Underbill 
were appointed auditors. 

The Secretary then read his report on the pro- 
ceedings of the Branch durmg the past session, 
and expressed the congratulations of the members 
to Drs. Priestley and Tew on their new appoint- 
ments. There have been five meetings, at which 
the average attendance had been sixteen. Allusion 
was made to the duties of the representatives on 
the Society's council, and to change in the articles 
of association, and also to the deaths of Drs. 
Clendinnen and Thompson. 

The Treasurer presented a report on the finances 
of the Branch, which was approved and adopted. 

The election of officers and Council resulted 
as follows : — President, Dr. S. Barwise ; Vice- 
presidents, Drs. A. Hill and May; Treasurer,. 
Dr. Bostock Hill ; Secretary, Dr. H. Manley 
(West Bromwich;. Council: Drs. Bailey, Boobyer, 
Fenton, Hollinshead, Reid, Thursfield, and Under- 
bill. 

Dr. Barwise then took the chair, and the cus- 
tomary votes of thanks to the retiring officers were 
duly passed. 

Dr. Barwise then delivered the presidential 
address : — 

On the Necessiiv for, and ihe Means of, 
Reuucing the Death Rate of Children, 

MORE especially BV THE BeITER VeNTIL.VTION 

OF Pui'.Lic Elementary Schools. 



SiHNF.v Barwise, M.D. Ixmd., County Medical Officer 
of Derbyshire, President of the Branch. 

I r has been the custom at our Annual Meetings 
for the President to bring before this Society the 
ideas that have occurred to him during the pre- 
ceding year as likely to be of general interest, and 
in looking round for a subject upon which to 
address jou, the fact that last year the lowest birth 
rate and death rate yet recorded were registered, 
namely, 29'6 and i6-6 respectively, leads me to 
call your attention to what, to my mind, is one of 
the most significant facts in the hibtory of our 
times. 

The following table shows the births and death 



\'EN'1ILATI0N OF PUBLIC ELEMENTARY SCHOOLS. 



75 



per 1,000 living in England and Wales since the 
passing of the Public Health Act in 1875 • — 

1S76-S0 iSSi-85 1886-90 1891-94 
Birth Rate 35-3 33-5 31-4 30-5 

Death Kate ... zo-b, 19-4 iS'S 187 

It will be seen that, although the death rate has 
fallen steadily, the birth rate has fallen in a still 
more remarkable manner ; but while we cannot 
expect our death rate to fall much lower than the 
rate registered in 1894, there is no reason why the 
birth rate, which is not like the death rate governed 
by any natural law, should not fall below this 
figure, and the population actually decrease, as has 
already happened during the last three years in 
France. 

We must regard the fall in our birth rate as of 
most serious consequence to our country ; it was 
by the rapid increase of the population that the 
English race spread itself and carried with it the 
British flag into all quarters of the globe, and if 
we are to maintain our position as a colonising 
power amongst the nations of the earth, the fall in 
the birth rate will have to be compensated for by a 
corresponding diminution in the death rate of 
children — in other words, as fewer children are 
born, it is of paramount importance that fewer 
should be permitted to die. 

Our birth rate for the five years ending 1875 was 
35*4, while that of Germany was 37*4 — two per 
1,000 higher; during the five years ending 1890 the 
English birth rate had fallen to 31*4, while the 
German rate was 36' 7, or more than five per 1,000 
higher. The high international importance of this 
subject is, perhaps, best brought out by comparing 
France with Germany. The statistics of the last 
three years, which are published, show that while 
Germany has in that period increased by 1,800,000, 
France has actually decreased nearly 70,000. 
Although we are not in such a bad way as France, 
still, in the face of the figures I have quoted, I 
think it must be admitted that we can no longer 
afford the present fearful loss of life of infants and 
young children, and the question arises, "What 
should be done ? " 

The reduction in the death rate that has already 
been effected has been due to causes which may be 
grouped under the following headings : — 

1. Obtaining pure water supi^lies. 

2. Sewerage works and improvements with 
regard to excrement removal and disposal. 

3. Special action with regard to special diseases, 
such as small-pox and scarlet fever, by means of 
notification, isolation, and disinfection. 

We have done a great deal to get pure water, 
pure food, and clean soil, but very little has been 
done with regard to the important question of 
maintaining pure air, ;jarticularly in schools, and 
as a result those diseases which are conveyed by 
infected breath, such as measles, whooping cough, 
and diphtheria, are e:tber increasing or maintaining 
their ground 



The diseases which have been reduced, perhaps 
chiefly through the first sanitary works quoted, are 
typhoidal fevers, cholera, and diarrhoea, while to 
sewerage works and the lowering of the subsoil 
water, which has followed them, besides the 
lessened mortality from filth diseases, the diminu- 
tion of the death rate from phthisis is partly due. 
Restricting our attention to the zymotic diseases, 
we find that in 1893 the deaths from measles in 
England amounted to it, no, and this was the 
smallest number which had been registered from 
this cause for five years, while the deaths from 
scarlet fever were only 6,982, and this figure was 
the largest that had been registered for five years. 
In the same year whooping cough caused 10,476 
deaths, and diphtheria 9,466. Diphtheria, measles, 
and whooping cough are now, therefore, the three 
principal contributing causes to the zymotic death 
rate. Measles and whooping cough both cause 
between five and six times as many deaths as 
small-pox, yet, practically, nothing is done by the 
Sanitary Authorities to prevent these diseases 
spreading. 

Besides the deaths caused by measles and 
whooping cough, they are essentially diseases 
which are important to the community on account 
of the many serious permanent injuries which 
they cause, such as phthisis and other lung dis- 
eases, blindness, and deafness. In the face of the 
rapidly falling birth rate, I repeat that, as a nation, 
we can no longer afford to permit the fearful waste 
of life from whooping cough and measles to con- 
tinue, and we ought not to hesitate to make 
it perfectly plain that the deaths from these 
causes can be reduced at least by one-half if the 
public are prepared to find the necessary funds. 
Speaking from my personal experience as a late 
district medical officer in this city (Birmingham), I 
maintain that at least half the lives lost from these 
causes occurring in the homes of the poor would 
be saved if the cases merely received skilled 
nursing, warmth, and proper food in hospitals. 
Measles amongst the well-to-do is a disease of 
very small mortality ; amongst the very poor it is 
one of the most fatal disorders we come in contact 
with. If at any time hospitals are provided for 
measles, we must not blink the fact that they 
are provided, not as an ordinary isolation 
hospital to prevent the disease spreading to 
other nieinhers of the community^ but chiefly 
to save the lives of the children sent in. 
Personally, I would not advocate that whooping 
cough and measles should be tackled at the 
same time ; but I am strongly of the opinion 
that the time is ripe for energetic action to 
be taken with regard to measles. I say this after 
having had experience of the Notification of 
Measles. When Medical Olihcer of Health of 
Blackburn, I advised the Corporation to add 
measles to the list of diseases notified, and although 
the information obtained enabled me to hear of 



76 



PROCEEDINGS OF THE BIRMINGHAM AND MIDLAND BRANCH. 



nearly all the cases, yet 1 found that it was impos- 
sible to prevent the disease spreading while the 
patients remain at their homes. My Blackburn 
experience has been strengthened by knowledge of 
what has taken j)lace in one of the urban districts 
of Derbyshire which added measles to the list, and 
although once an advocate of the notification of 
this disease, I now am quite clear that its notifica- 
tion, without the means of isolation, is absolutely 
of no value. In the face of the large sums that 
have been spent, and are being spent, on small- 
pox and scarlet fever hosjjitals, I know it would be 
difficult to get the public to entertain any great 
expenditure for hospital purposes ; bat a measles 
hospital would be quite in another category to the 
scarlet fever and small-pox hospitals ; the children 
would remain in them, on the average, for only four 
weeks, and if the patients were classified in wards 
according to the stage of the disease, the cost of 
nursing would be infinitely less than in an ordinary 
isolation hospital. Again, if the hospital was 
designed specially for this purpose, and was 
mechanically ventilated, as the cubic space per 
head would be so small, the cost of construction 
need not be one-fourth of that of an ordinary 
isolation hospital. 

With regard to diphtheria, Dr. Thome Thorne 
first drew attention to the connection between the 
increase of this disease and the compulsory aggre- 
gation of children in elementary schools. Dr. 
Thorne Thome's suggestions have received a tre- 
menaous confirmation by Mr. Shirley Murphy's 
report to the London County Council for 1893, 
which shows that both in the case of scarlet fever 
and diphtheria in the month of August, when the 
schools were closed, there was a depression in the 
number of children between three and ten attacked 
with these diseases. This evidence coming on the 
top of the sudden increase in the number of cases 
of diphtheria at the ages three to ten, which has 
occurred since 1871, when education became com- 
pulsory, has directed attention to the condition of 
the public elementary schools. There is hardly a 
medical officer of health who could not give many 
instances of outbreaks of infectious disease entirely 
due to school influence, and in many instances 
where there is an unexplained outbreak, I am con- 
vinced that patient investigation would fretjuently 
trace it to this cause. I have known children 
wrapped up in blankets, and taken from their beds 
whilst suffering from inlectious disease, and carried 
to the school so as to be present at the Govern- 
ment examination, with the result of a wide-spread 
epidemic. Each year in the reports I receive from 
the different parts of Derbyshire, outbreaks entirely 
due to school influence are reported. A year or 
two ago, there was a serious outbreak of diphtheria, 
which was only cleared up by the return of a i)Ui)il 
teacher from the seaside still suffering from diph- 
theriatic paral)5is ; so that not only do the national 
statistics make a serious indictment against our 



public elementary sclioois, but ucar.y every medical 
officer of health can support the indictment by his 
personal experience of outbreaks being caused 
through re-infected schools, and being slopped by 
the closure of the schools. 

I will now ask you to consider what the condition 
of the schools themselves is. From the Codeof 
Regulations for day schools issued by the Educa- 
tional Department this year, it is laid down that 
7iew schools shall provide a minimum floor space 
of 10 square feet per child (I believe existing 
schools are allowed to have 8 feet), if we take the 
available air space as that within 12 feet of the 
floor, the cubic space per head is 120 feet ; so 
that, to give 2,000 cubic feet of air per child per 
hour, the air would have to be changed sixteen 
times. Let us see how the advisers to the Educa- 
tion Department suggest this should be done. 
They have at the end of their Code, a number 
of suggestions to architects. No. 1 1 deals with the 
question of ventilation. It runs as follows : — 

" Apari from open windows and doors, there should be 
provis^ion for copious inlet of fresh air ; also for outlet of 
/'oitl air at the highest point of the room. The best way of 
providing the latter is to Imild to each room a separate air- 
chimney, carried up the same stack with smoke flues. An 
outlet should have motive power by heat or exhaust, other- 
wise it will frequently act as a cold inlet. The principal 
point in all ventilation is to jirevent stagnant air ; particular 
expedients are only subsidiary to this main direction. Inlets 
should provide a minimum of 2h square inches per child, and 
outlets a minimum of 2 inches." 

I will call your attention, first of all, to the fact 
that the Regulations do not distinguish between 
artificial ventilation and mechanical ventilation. 
The same cubic space is permitted, whether the air 
is changed once an hour or twenty times. Appa- 
rently, those who drew up the regulation had never 
heard, or, at any rate, had never seen, a school 
mechanically ventilated on the Plenum system, 
at any rate that there is such a system is not even 
hinted at. The best way, suggest the instructions, 
for providing an outlet is from the highest point of 
the room. If the air is warmed — and it should be 
before admitting it — the top of the room is the 
very worst place for the outlet. 

The size of the air inlet is given at about 
2^ inches per child, so that to provide 2,000 cubic 
feet per hour the air will have to rush into the 
room through the ventilators at no less a velocity 
than 32 feet a second, a rate that would be 
dangerous and utterly impossible. But ])erhaps in 
my calculations I have not taken into considera- 
tion the full importance of the second and last 
section in the Code, which is so delightful in its 
simplicity that I will give the exact words. It runs 
as follows : — 

" Although lighting Ironi the left hand is considered so 
import int, ventilation in summer demands also the provision 
of a small swing window n~ far from the lighting as possible, 
and near the ceiling." 



VENTILATION OF PUBLIC ELEMENTARY SCHOOLS. 



77 



I have nothing against the small swing window, 
but to say that ventilation in summer demands one, 
and to dismiss the subject without anything 
further but two holes with an area 2! inches per 
head, shows that whoever drafted these Regula- 
tions had utterly failed to grasp the remotest idea 
of the quantity and the weight of the air that is 
required by several hundred children for the main- 
tenance of their health. 

Knowing what the regulations of the Educational 
Department are. the small amount of cubic sjjace, 
and, as a rule, the entire absence of any adequate 
means of ventilation, we cannot be surprised at the 
fearful results obtained on the examination of the 
air in schools in different parts of the country. In 
a report to the North-Eastern Sanitary Association 
by Dr. Bedson and Messrs. Lovibond and Severn, 
the carbonic acid in the Newcastle Grammar 
School is given at "915 per t,ooo. The Gateshead 
High School for boys gave "885, while the girls' 
school gave "82; the Orphan House gave i'i6 : 
the Jubilee Board School gave "723, and the 
number of bacteria to a litre was 18, while in the 
outside air they were only -2. In the Snow Street 
Board School (with four ventilators in the ceiling) 
the carbonic acid was 2 "41, and the number of 
bacteria i8*3. At the Industrial School the car- 
bonic was '83, and the bacteria 38 "2. Dr. Reid, 
in his " Practical Sanitation," page 38, gives the 
following analyses of air in public elementary 
schools in Staffordshire : — 



School. 



School. 



CO2 

per 1,000. 



LO2 
per 1,000. 

1'4 Texall ... ... ... 2*2 

15 Gt. Haywuod (Catholic) 2'2 

... 17 Ranten 24 



- -T 

2VS 



Seighford 
EUenhall 

Salt 

Hyde Lea ... ... 18 Hixon ... 

Gt. Haywood (Naiion.il; 1-9 Colwich 

Fradswell ... ... 20 Haut;hion 

Weston ... ... 20 l\.cckersc(Jie 

Stowe ... ... ... 2'l Bradvvell 

Gaytoii ... ... 2'2 Berkswich 



When we bear in mind that "9 per [,000 of COo 
is a poisonous atmosphere, and that the air in the 
above schools contained, on the average, 5 percent, 
of air which had previously been exhaled, we can 
understand how easy it is for epidemics to spread 
through schools. 

Perhaps no medical officer of health has done 
more to call attention to the necessity for the 
mechanical ventilation of elementary schools than 
Dr. Wheatley, of Blackburn. In his report for 
1893 he writes : — "The openings for ventilation in 
most schools require increasing to the extent of 
four or five times their present area. The inlets 
especially are very defective. Where hot water 
pipes are in use they can be utilized for warming 
the incoming air." He then gives the following 
table of the amount of carbonic acid in the air, and 



of the size of the inlets and of the outlets in seven 
of the public elementary schools : — 

Square inches of inlet CO2 per i,occ. 

and outlet per heal. of air. 

School No. I ... 6'4S 2-0 

,, 2 2-8S i-o 

3 ••• 2-S8 2-3 

,, 4 ... 2'iG i'6 

5 ••• 7-92 1-5 

., 6 ... — ... 2"I 

7 ■■• <'J"4'^ I 4 

In his report for 1S94 he calls attention to an 
infant school, the air in two class rooms of which 
contained 2 -6 and 2*3 parts of CO, per 1,000 
respectively, and in connection with which there 
was an outbreak of diphtheria. It is satisfactory 
to read that the Health Committee have so far 
taken the matter in hand as to order that the neces- 
sary proceedings, under the Public Health Act, 
1875, be taken to remedy the nuisance caused by 
the want of ventilation in the schools. 

If natural ventilation is to be retained for the use 
of new schools, a minimum air inlet of 30 inches 
per head sectional area should be insisted upou, 
and the air which is admitted should be warmed 
by passing it over a radiator of some kind. Unless 
this is done in cold weather, the inlets will have to 
be closed. But with an available cubic space of 
120 feet (it is no use counting the cubic space 
above 12 feet from the floor) it is necessary that 
the air should be changed sixteen times an hour, 
and as this can only be done by mechanical means 
the suggestions to architects issued by the Educa- 
tion Department should at least contain some 
intimation of this fact, and schools for over 500 
children should not be approved of u uess properly 
mechanically ventilated. 

I know schools can be found in which mechanical 
ventilation has not been a success, but these are 
ventilated on the viuva/zi system. The reason for 
the early adoption of this method was that 
architects could, with httle difficulty, make this plan 
fall in with the suggestions of the Education 
Department, with their outlec at the top provided 
with an exhaust. No wonder, therefore, that in 
1889 one of Her Majesty's Inspectors of Schools 
reported — "^^'e are practically ignorant — we might 
say, helpless — in respect to the right ventilation of 
our schools." To account for these failures let us 
briefly consider what happens in a school venilated 
on the system recommended by the Education 
Department : — 

I, The exhaust fan is placed somewhere in the 
ceiling; fresh air inlets, in the shape of open 
windows and Tobin's tubes, admit the air directly 
from the outside ; the direction of the current of 
air is, as a rule, pointed upwards, so as not to blow 
directly on the children in the school. In the 
older schools no arrangements were made for 
warming the air admitttd, so that windows and 
ventilators are kept as much closed as possible in 
the winter months, and no ventilation takes place ; 



78 



PROCEEDINGS OF THE BIRMINGHAM AND MIDLAND BRANCH. 



but if the air is warmed, what generally takes place 
under these circumstances is very well shown by 
Professor ShaT in his article on warming and 
ventilation in Stevenson and Murphy's " Treatise 
on Hygiene." In Fig. 40 he represents a lecture 
room at Cambridge with the outlet near the 
ceiling ; the fresh air passes at once to the outlet, 
the air in the part of the room below the inlet 
remaining stagnant. I am glad to find that no 
less an authority than Sir Douglas Galton condemns 
the suggestion of the outlet for foul air being at the 
highest point of the room. On page 137 of his 
*' Observations on the Construction of Healthy 
Dwellings," he writes : " The effect of introducing 
warm air at the lower part of a ward on each side, 
and allowing it to escape at the top, was illustrated 
by Professor E. Wood, of Harvard University, 
upon the various currents |)revailing at the same 
time in a hospital ward in P.oston, U.S."^'-The 
hourly supply of air per bed was 9,000 cubic feet. 
The high temperature of the inflowing air caused it 
to enter with velocity. This velocity was soon lost. 
There was an upward movement of air throughout 
the ward, but a comparative stagnation in the 
centre for a height of about eight feet from the 
floor, and also a comparative stagnation com- 
mencing over the bed-heads and extending to the 
upper pait of the ward, as shown in the diagram." 
The CO2 was also found to be increased in the 
stagnant spaces. "This example," continues Sir 
]Jouglas, "shows that extraction shafts should be 
so placed as to cause a circulation of air such as 
effected by a fireplace." Fig. 2 7 in the work quoted 
shows very well the objections to the roof outlet ; 
and on page 142 the same authority writes : 
" Extraction should generally take place from the 
lower part of the room." I might here remind 
you that there is nothing new in this extraction 
near the floor level. Sylvester, who ventilated 
the Derbyshire County Asylum about fifty years 
ago, exhausted the air from near the floor level, 
and admitted the fresh air at the top. Sir Joshua 
Jebb and General Morin both adopted low outlets, 
the latter in the French Chamber of Deputies, and 
the former using it for prisons. In fact, it is 
impossible to obtain anything approaching perfect 
diffusion in rooms ventilated on the vacuum 
principle with top outlets, as the fresh air is thereby 
passed direct to the outlet, leaving the vitiated air 
behind. 

2. Not only docs a powerful exhaust in the 
ceiling run off with the fresh air admitted above 
toe heads of the scholars, but unless the air inlets 
are kept wide open and are adequate in si/.e, the 
exhaust will cause an inrush of cold air under the 
doors and through the crevices in the windows, 
thereby causing dangerous draughts. 

3. Another objection is that, as the school is 
under a pirtial vacuum, ground air, air from 
defective drains, from itdjoining lavatories and 
other objeclional sources is drawn in. 



Attempts have been made to get over some of 
these difficulties by providing numerous air inlets 
with radiators, but apart from the impossibility of 
satisfactorily regulating by these means the tem- 
perature and ihe relative amount of air to the 
different parts of the room, in jjractice it has only 
resulted in the fresh air passiuj;, as I have said, 
direct to the outlet in the ceiling, the room 
remaining iinwarmed in addition to being un- 
ventilated. It does not affect the argument against 
ventilating a school on the vacuum principle, 
whether the vacuum is created by a fan or by a 
heat extraction tower ; but in the latter case it is 
impossible to get the flues large enough to cause a 
sul^cient circuLition of air in the summer months. 

I will, however, admit, that by means of exhaust 
fans connected with outlets at the floor level, and 
steam radiators in the inlets, under special circum- 
stances it is possible to properly ventilate a school 
on the exhaust system. 

I think we may, therefore, take it that the 
following propositions are proved up to the hilt : — 

1. That mechanical force is necessary for 
adequately changing the air in schools. 

2. That in the winter months the air admitted 
must be warmed. 

3. That, granting the above propositions, the 
outlets should be near the floor level. 

If we are satislied of the truth of the above three 
propositions, it will, I think, be admitted that to 
force the air into the schoolroom is a much simpler 
plan than to draw it out at the floor level, and 
possesses a number of advantages. To explain 
what these are I cannot do better than describe the 
arrangements at one of the schools that I am 
acquainted with, which is ventilated on the Plenum 
system. The school which 1 shall select for my 
purpose is at the model colliery village, built by 
Mr. Emerson P>ainbridge, M.P., at Bolsover, 
Derbyshire. 

The Bolsover Colliery Company's Schools : 
Ventilatio7i and Jfeating. — The ventilating and 
heating system was carried out by Messrs. Ashwell 
and Nesbitt, of Leicester. The fresh air is forced 
into the various class rooms, etc., in the building 
by means of a fan 4 feet '> inches in diameter, 
driven by a small horizontal steam engine. The 
fan runs at the rate of about 300 revolutions per 
minute, and forces the air through air passages 
under the main hall lloor, from which the wall 
flues in the class rooms are fed. The air forced 
into the building comes down a fresh air shaft, 
about 30 feet high, but before entering the wall 
flues in winter it passes over steam radiators. 
These arrangements will be understood by referring 
to the diagram opposite. 

By an arrangement of shutters, all the air for each 
room can pass through a battery, or only part, the 
remainder going in cold. By these means the tem- 
perature of the rooms can easily be regulated. 

T^f. steam for the fan is generated by a small 



I 



V 

VI 






^ 

^ 

^ 

^ 

^ 






^^ 







Si 



8o 



PROCKEDIXGS OF THE BIRMINGHAM AND MIDLAND BRANCH. 



4 feet 6 inch Cornish boiler, fixed in basement 
below the large hall. The boiler also feeds the 
various steam batteries, and works at about lo lbs. 
steam pressure per scjuare inch. In the large hall 
the radiators are n.xed on the floor at the wall 
sides, the air coming up flues from trunks belo\\, 
and blowing through them. 

The vitiated air is extracted by Louvre ven- 
tilators, fixed on the ridge and connected with 
outlets in the class rooms at the floor level, and 
also others 8 feet froiri the floor, which are opened 
when the gas is lighted at night. Of course, if 
ventilating gas burners or the electric light were 
adopted, this extra outlet would not be necessarj-. 
The outlets are formed in the walls and in the 
false roof connecting up to the Louvre extractors. 
It is intended in the summer time to run the idn 
with a small gas ei gine. The position of the out- 
lets was arrived at after careful experiments, and 
that best results are obtained by taking ths air off 
at floor levels will be understood when one 
bears in mind the amount of filth, dust, and dirt 
that accumulates on the lloor of a public elemen- 
tary school. The vitiated air is therefore with- 
drawn just above the floor level, and conveyed to 
upright exhaust shahs above the building. 

With regard to the incoming air, it is warmed 



Each class room is intended for fifty children. 
It has a floor space of 528 feet, and a cubic space 
of 8,400 feet. The air inlet is 6 feet 6 inches 
from the floor level, and is 23 inches square. 
After deducting the space taken up by the grating 
over the register, the available inlet is over 2 "8 square 
feet. This gives over 8 square inches of inlet per 
child. Without informing anyone of my intention, 
I paid a visit to these schools, and measured the 
air being pumped in. I found it was entermg 
through the inlet at the rate of 380 lineal fett a 
minute. This works out at 1,276 cubic feet of air 
per head per hour. A sample of the air in the 
same room, which was taken at 12 noon, when the 
children had been in since 9 a.m., gave "57 parts 
of carbonic acid per 1,000, the outside air 
yielding "4. Another similar class room, which 
had contamed fifty bigger children, yielded '^g- 
parts of carbonic acid per i.ooo. Parkes givts 
the carbonic acid given off by a child as from 
•25 to "34 of a cubic foot per hour. If we take it 
as "3, and the teacher at "6, the carbonic acid at 
12 o'clock should have been '61 per 1,000. 

Mr. P. T. Houfton, the manager of the Bolsovt r 
Colliery Comj)any, also thoroughly tested the ven- 
tilation of the school on November 29th last year,, 
and has kindly given me the following results : — 



Ventilation in Bolsover Colliery .'Schools. 



No. of 
Class Room 



I Velocity in 
Ifeet permin. 
by B.C.Co.'s 
j Ltd., Ane- 
momettr. 



Net Area of| 

Inlets, Cubic feet 
Deduct of air 

10 % for per hour. 
.Mesh. 



360 
400 
320 

3P 
310 

2/5 



babies room < i9^ . 7 



, class 
room 



111 fret. 
2S 

2 S 

28 
28 

2 S 
2-S 



67,200 
53,760 

57, ■2''' 
52,080 
46,200 

119,: 80 

58,800 




No. of 
Children 



57 



50 
50 
50 



Air per 

Child 

per Hour. 



1x76- 

1074- 

1140" 

1038- 

924- 

iiSS- 
1176- 



Remarks 



1 1 Windows open, 7 childrt.ni 
^^ more than 50 built for. 
Windows closed. 



Two inlets, windows closed. 



I'aii 4 ft. 6 in. diameter running at 315 revolutions per minute. 



above 60 degrees, and being warmer than the air in 
the room, it spreads out over the upper part, where 
It is cooled by contact with the walls, and still more 
by the windows, and gradually descends down these 
cooler surfaces, and eddies across the room to the 
outlets. The whole air of the room is in a steady 
motion of about half an inch a second — a rate that 
cannot be felt, but which can be seen by blowing 
smoke or chloride of ammonia fuines into the air 
outlets. TAe importance nf utilising the cooling 
action of avindmvs in causing an internal circula- 
tion of air in all rooms cannot be cxaj^ge rated. In 
winter it is the one important motive force that can 
ahvays he relied i/pon, and by having the outlets at 
the floor level, it is utilised to the utmost. 



Perhaps the best examples I have ever seen of a 
mechanically ventilated school are the Melboun e 
Road and Clarendon Park Board Schools at 
Leicester. The former school has accommodation 
fur 1,700 children. The fresh air is taken in at a 
shaft 12 feet high ; it is then filtered through jute 
cloth, and i)ropelled by an open-bladed fan, five 
feet in diameter, driven by a five-horse power gas 
engine, through the main air-conduit, which is six 
feet six inches high, five feet wide. This flue, 
which has been purposely made absolutely imper- 
vious (being constructed of concrete, with a cement 
face), is regularly cleaned and limewashed as scon 
as any signs of dirt appear. From the main duct 
up-cast shafts, in connection with which there aie 



VENTILATION OF PUBLIC ELEMENTARY SCHOOLS. 



8i 



steam radiators, branch off, and enter the class- 
rooms eight feet from the floor. The outlets are 
near the floor, other outlets near the ceiling being 
provided for use during the short time the gas is 
lighted at night. 

The cost of the gas, the oil, and the waste in 
working the fan is 6s. a week. I have me.isured 
the air passing into this school, and found it was 
about I, coo cubic feet per head per hour. The 
carbonic acid in a class-room built for 60, but 
which contained 67 boys, was at 12 o'clock "63 per 
1,000. 

At the Clarendon Park Infant School, the air 
suppHed to each child worked out at over 1,000 
cubic feet per hour ; at 1 1 o'clock the carbonic 
acid was '5 per 1,000. At both schools the 
amount of inlet per head is about eight inches. 

One of the latest schemes that I have heard of is 
for the ventilation of the City Road Board School 
in Birmingham, which is being ventilated by Mr. 
Key, of Glasgow; the contract here is to change 
the air eleven times each hour. 

The first important work I had to do in Derby- 
shire, was to report on the sanitary condition of the 
County Asylum, the ventilation of which I found 
grossly inadequate. The cubic space per head 
being in some of the rooms 540 feet, and in others 
460. As some of the patients were bedridden, the 
air literally .stank, and I was not surprised to find 
the carbonic acid in samples collected at five 
o'clock in the morning, when gas had been burning 
all night, varied from i"8 up to even in one 
instance 4 parts per 1,000. A contract was made 
for pumping into the Asylum 1,600 cubic feet of air 
per head per hour, in addition to what was already 
passing into the building ; at the same time, fresh 
wards have been made, with the result that the 
air is now everywhere quite sweet, and the carbonic 
acid present is very little above that in the outside 
air. Dr. Murray Lindsay, the medical superin- 
tendent, in his last report, writes : " It is worthy of 
note that there has been a marked decrease in the 
proportion of deaths from pulmonary consump- 
tion, which has only been one-ninth of the total 
mortality, whereas it was one-quarter for the 
previous year." Of course. Dr. Lindsay points out 
it is premature to attribute this to the improved 
ventilation, but at any rate it is suggestive. A 
similar change was noticed at the Nottingham 
Boro' Asylum, after mechanical ventilation on the 
Plenum system was adopted. The medical superin 
tendent, Dr. Evan Powell, writes : " For the three 
years previous to the introduction of the system, 
the d-ath rate was i5'i per cent, of the average 
number resident ; for three years after it was 12-4. 
I may say that two of the last three years have been 
influenza years, and this has told against us." 

I cannot conclude this subject without referring 
to Dr. Carnelly's classical report to the School 
Board of Dundee on the ventilation of schools. 
He points out as indirect evidence of the better 



health of teachers and scholars in mechanically 
ventilated schools than those in naturally ventilated 
ones, that the grant earned per head is more than 
2s. 6d. higher in the former than the latter.* 
The following table is condensed from Dr. 
Carnelly's report : — 



Mechanically venti- 
lated Schools ... 

Naturally ventilated 
Schools ... 



No. of ^Grrnf' IZ' ConduionofAir 
Schools. Earned i.ooo M.cro-organ.sm. 
per head par>f. P" lure. 



95 



21/- *r2 


•17 


i8/3i t2-i 


t97 


t 33 schools. 





* 5 schools. 

The carbonic acid in the mechanically ventilated 
schools is about half that in the naturally ventilated 
ones, and the micro-organisms per litre are only 
17^ per cent, in the mechanically ventilated schools 
what they are in those naturally ventilated. 

Carnelly sums up the question with the following 
recommendations : — " For new schools mechanical 
ventilation should be employed (i) because it is 
more comfortable, the rooms being kept warmer 
and the temperature more uniform, whilst draughts 
are as far as possible avoided ; (2) because it is 
much healthier, and prevents the spread of in- 
fectious diseases, owing to the children being 
supplied with purer air; (3) because by it the 
children are enabled to derive greater benefit from 
their education ; (4) because it increases their 
grant-earning power without increasing the labour 
of earning the grant ; and (5) because it increases 
the teaching power of the teacher." 

The question is one of vast importance at the 
present time, when the educational system of this 
country is entering upon a critical phase, and before 
the State is committed to the poHcy of maintaining 
or further assisting the voluntary schools, the 
Government should cause an inquiry to be held 
by competent experts into the sanitary condition, 
including the ventilation, of all elementary schools; 
and their being in a proper sanitary condition 
should be made a sine quA non to their receiving 
any further aid from the State. 

I am aware that the school inspectors have to 
report upon the sanitary condition of the schools, 
but the inquiries I have suggested ought to be 
made by a properly qualified health officer, and 
his examination should include a bacteriological 
and chemical examination of the air in the schools. 
These examinations should also be made periodi- 
cally, and the Government grant should depend not 
only upon the percentage of passes, but also upon 
the general hygienic condition of the schools. 
Were this done, we should hear far less of the 
influence of schools in distributing disease. 

*I also found when at Blackburn a case where, by ade- 
quately ventilating his weaving sheds, a large manufacturer 
increased his output 2| per cent. This he attributed entirely 
to the improved ventilation, and informed me that his 
expenditure on this head had been a wonderful investment. 



82 



PROCEEDINGS OF THE NORTH-WESTERN BRANCH. 



If you agree with me that the reduction in the 
birth rate makes it imperative that there should be 
a further reduction in the death rate of children, I 
think I shall have your support in my conclusion 
that by no one act of sanitation can the health of 
children be more improved, and the scourges of 
diphtheria, measles, and whooping cough be 
mitigated, than by improving the condition, more 
especially as regards ventilation, of our public 
elementary schools. 

A most cordial vote o{ thanks was accorded to 
Dr. Barwise for his address and the interesting 
diagrams with which it was illustrated. 



/ 



PROCEEDINGS OF THE NORTH-WESTERN 
BRANCH OF THE INCORPORATED 
SOCIETY OF MEDICAL OFFICERS OF 
HEALTH. 

The ordinary monthly meeting of this Branch was 
held in the rooms of the Chemical Club, Man- 
chester, on November 8th, at 4 p.m. The 
following members were present :- — Drs. \'acher 
(president), Anderson, Gornall, Graham, Kenyon, 
Niven, Paget, Pilkington, Posted, Sergeant, 
Stephenson, Tattersall, and Wheatley. 

Letters were read from Dr. Wills and Dr. 
Dudfield. 

The report of the committee was adopted. 
The following nominations were then read : — 
F. P. Moles, L.S.A., M.O.H. for Urmston Urban 
Sanitary District; J. A. Harold, L.R.C.P., L.R.C.S., 
M.O.H. Chadderton Urban Sanitary District; 
J. B. Wilkinson, M.D., D.Sc. (as a Member), pro- 
posed by Dr. Tattersall, and seconded by Dr. 
Paget. 

Remarks on the Feasibility of Examining all 
Carcases for Tuberculosis. 

BY 

James Niven, M.A., M.B., M.O.H. Manchester. 

At our last meeting I showed specimens of prime 
meat from the carcase of a cow affected with exten- 
sive tuberculosis of the internal organs. Examina- 
tion of the presternal, posterior thoracic, lumbar, 
pelvic, and other lymphatic glands, revealed that 
they were ^studded with tubercles. I have to-day 
(November 8) again seen a magnificent carcase of a 
two year old heifer in the same condition. It is a 
matter of common experience that such is fre- 
quently the case. The finest carcases may belong 
to tuberculous animals, and contain tuberculous 
glands. 

In the Manchester abattoir all the carcases are 
examined by the veterinary surgeon, Mr. King, who 
assures me that he has no difficulty, from examina- 
tion of a carcase, almost at a glance, in telling when 
an animal is tuberculous. Examination of the 
glands can be conducted, when required, in such a 



manner as in no way to injure it. Of course, an 
animal may have been tuberculous, and yet the 
lymphatic glands may reveal no sign of the presence 
of the disease. But I submit that where such 
tuberculous glands are present the meat is certainly 
unfit for human consumption, and that* their 
presence should of itself be taken as a condemna- 
tion. Moreover, this is a test ec^ually applicable to 
foreign and to domestic meat, to dressed and to 
undressed carcases. 

It is therefore a convenient point at which those 
who oppose the condemnation of carcases belong- 
ing to all tuberculous animals, and those who 
advocate that rigour of proceeding, may meet, both 
from a scientific and from a jjractical point of view. 
All would be agreed, one may hope, in condemning 
meat when these diseased glands are found. 

Now, I am informed by our veterinary surgeon 
that something like 20 per cent, of all English 
dairy cows slaughtered at the abattoir are more or 
less tuberculous. There are, however, 105 private 
slaughter houses in this city which cannot be sub- 
jected to anything like the strictness of inspection 
which the Manchester abattoir undergoes. I do 
not propose to-night to approach the subject of the 
abolition of private slaughter houses. But it is fair 
to assume, I think, under the circumstances 
existing in Manchester, that a higher percentage of 
the total animals killed in these will be found 
tuberculous than is ascertained to be so at the 
abattoir. 

It is clearly urgent that the carcases in such 
private slaughter houses should all be examined, 
and that meat such as I have shown you should 
not be allowed to go to the butchers' shops. Now, 
Mr. King informs me that with the aid of two 
young veterinary surgeons he would be able to 
examine all carcases, and also to inspect the meat 
sold in the shops. The matter is thus clearly 
within the range of practical politics. What I 
would wish to urge on the Society is the feasibility 
of examining all carcases of animals killed in our 
slaughter houses. 

As regards tuberculosis it is easy, after a little 
practice, for any intelligent trained man to examine 
carcases for the presence of tuberculous lymphatic 
glands. It should, therefore, be a part of the 
ecjuipment of every meat inspector to be able to 
make such an examination. Especially in our 
populous centres is it that this requirement is easy 
of fulfilment. 

I now show a piece of meat from an animal 
which has been choked and bled while dying. 
The pale condition of the meat is, I am informed, 
uniform in these cases, and in animals which have 
been drowned. The separation of the meat from 
the ribs is not unusually found. 

A discussion followed, in which Drs. Kenyon, 

• It is not intended by this to imply that, in ihe absence 
of such tuberculous (glands, the carcase of an animal affected 
with extensive tuberculous disease is to be passed. 



SANITARY DIFFICULTIES WITH THE LOWER WORKING-CLASSES. 83 



Sergeant, Anderson, Pilkington, Wheatley, 
Stephenson, and Vacher took part. 

Sanitary Difficulties in Connection with 
THE Personal Cleanliness of the Lower 
Working-classes and of the Submerged 
Tenth, 

BY 

R. Sydney Marsden, M.D., CM., D.Sc, F.R.S., Edin., 
M.O.H. for Birkenhead. 

In asking your attention to the following remarks 
on the subject of personal cleanliness amongst the 
lower classes of society, I feel that I need give no 
apology to my present audience for treating of a 
subject so intimately connected with the people's 
health. I am aware that it is one which is 
surrounded with difficulties, and that public 
opinion is not yet ready to deal with it in such a 
spirit as I should wish ; but increasing experience 
nevertheless convinces me that, however hopeless 
the task of reform in this direction may appear, we 
may still be able to do something in the right 
direction by putting existing facts before our 
sanitary authorities, and gradually educating them 
in the idea of reform. 

It is, therefore, in the hope of awakening some 
degree of active sympathy in this work that I 
venture to ask your consideration for a few 
moments to the agencies at present in operation, 
with a view to our getting some improvement of 
the local sanitary condition of the dwellings of the 
very poor. 

I am afraid there is no denying the fact that by 
far the greater proportion of our lower working 
class population pass their lives from year to year 
without washing themselves in any way except, 
perhaps, their hands and faces daily. All of us 
who have public hospitals under our control are 
constantly meeting these cases, and only the other 
day I had in hospital the wife of a fairly well-to-do 
working man, a comparatively young woman too, 
who admitted she had not had a bath or been 
properly washed for over fourteen years. What 
her children would be like you can imagine, yet 
this is not an isolated or uncommon instance ; and 
I will guarantee that if house to house inquiries 
were made, and true answers could be got, that the 
same story would be told by eighty per cent, of 
these people. Nor is it to be wondered at when 
we consider the sanitary conveniences of their 
houses, as we now find them existing in this country ; 
indeed, on the contrary, it is easy to understand 
how such dirty habits are fostered and grow. 

When we look at the houses in which such 
people live, consisting as they often do of only one, 
two, or at most four rooms, without any con- 
veniences whatever in the form of baths, or indeed 
frequently not even a sink and proper water supply, 
the difficulties to be overcome before a bath or 



proper cleanliness can be obtained are almost 
insuperable ; and these evils, which appear to have 
become almost inherent in the social life of the poor, 
depend far less on their depravity than on their 
ignorance, and the total lack of any handy means 
for personal washing, 

A family will probably consist of the father, 
mother, and perhaps four to seven children of all 
ages and both sexes ; it will be readily imagined, 
therefore, with what difficulty a man or his wife, or 
a grown-up son or daughter, would obtain a proper 
bath in a one or two-roomed cottage, or even a 
four-roomed house, under such circumstances, with 
any pretence to the commonest laws of decency ; 
whilst it is a fact that in very few instances will they 
be in possession of any suitable vessel in which a 
bath can be obtained. Is it surprising, therefore, 
that -they get out of the habit of washing, until in 
the end they get, as we know they do, positively 
afraid of a bath, lest it should kill them. 

The sequel to all this, of course, is filthy persons, 
filthy clothes, beds and bedding, and all the 
resulting filth diseases, such as typhus fever, which 
thrive so splendidly amongst this class of population. 
It is difficult to ascertain the extent to which the 
health of the people suffers from this want of proper 
cleanliness ; but one must believe that life under 
such conditions cannot be conducive to health, 
either of mind or of body. It becomes therefore a 
question of economics, not less than, of sanitary 
importance, for it is obvious that the remote effects 
of such sickness as this filthy condition engenders, 
must be disastrous to the health and physical well- 
being of the people, and more especially of the 
children brought up under such conditions, and 
must seriously impair their capacity for labour. 

How, then, are we going to combat the persis- 
tence of these adverse influences ? They are not 
like ordinary nuisances, summarily removable by 
legislative procedure, and it seems to me tnat pubhc 
baths and wash-houses, easily accessible, and at 
little or no cost to the poor, is the only way in 
which at present we can hope to get improvement 
in this condition of personal cleanhness. 

Of course, at first there would be considerable 
difficulty in getting the persons for whom they are 
intended to avail themselves of them ; but time 
would gradually remove difficulties of this 
description. 

In Edinburgh, where a system of public wash- 
houses has been started, which has proved emi- 
nently satisfactory, they have apparently solved two 
of the most difficult problems of the present day, 
viz., how to get people to use public wash-houses, 
and how to get them to wash themselves. 

In their first attempts, the Edinburgh Council 
were unsuccessful, because they went on the usual 
lines of providing a wash-house with apparatus for 
washing clothes and nothing more, and the scheme 
had to be abandoned. Their second attempt, 
however, has been a great success. My friend, Sir 

G 2 



84 



PROCEEDINGS OF THE HOME COUNTIES BRANCH. 



James Russell, Chairman of the Sanitary Com- 
mittee of the City Council, and recently Lord 
Provost, has given me the key to the secret of their 
success. 

He says, "in their present washing-houses, 
which are placed in the midst of a poor population, 
they have a large hall, round which there are cells 
containing earthenware basins let into a concrete 
floor, with discharge plugs, and hot and cold water. 
The people can here undress, and stand in these 
basins to have a wash, the hall being filled with warm 
air — a very important feature, as they would not be 
got to undress and bathe in a cold room." 

At present these places are only connected with 
the general wash-houses for clothes washing, the 
charge per hour paying; both for the use of the 
clothes-washing apparatus, and for the baths after- 
wards. They find the women readily avail them- 
selves of the opportunity for washing, and there 
seems to be no reason why the bath should not be 
allowed to be taken quite irrespective of the clothes 
washing ; and in my opinion such places ought to 
be provided free to the poor, and every induce- 
ment given them to come and make themselves 
and their children clean. 

In Edinburgh, also, there is an association for 
improving the dwellings of the poor, of which, also. 
Sir Jame Russell is chairman. In the tenements 
built by this association, each flat has a proper 
wash-house with all necessary apparatus at the 
disposal of the families living in the flat in rotation. 
The tenants prefer this arrangement to using the 
more distant public wash-house, and they save the 
charge per hour made in them. The tenants are 
mostly very poor — in fact, were slum-dwellers. In 
connection with and adjoining each wash-house 
there is a wooden plunge-bath, which is in much 
request. The keys of these washing places pass in 
rotation to the next tenant, or to the tenant who is 
caretaker, as the case may be. 

Here, then, we have the germ of reform which, 
if steadily nurtured, may lead in the future to a very 
great improvement in the personal sanitation (if I 
may so call it) of the lower classes. I think that in 
the case of new houses, it should be made com- 
pulsory in all building regulations, that to every 
house, or to all terraces or blocks of houses, 
builders should provide, either by outbuilding or 
by proper additions to the ordinary requirements, 
suitable places in which cleanliness, not only of the 
person, but of the household necessaries, can be 
obtained. 

Of course, we shall have to meet the difficulties 
as we now find them existing in the homes of the 
working-classes to-day, and the only way in which 
this can be done for old houses, seems to be 
the establishment of public wash-houses on lines 
similar to those at present so successfully carried 
out in Edinburgh, and I would therefore strongly 
advocate the adoption of .such places for all our 
large towns. 



PROCEEDINGS OF THE HOME COUNTIES 

BRANCH OF THE INCORPORATED 

SOCIETY OF MEDICAL OFFICERS OF 

HEALTH. 

At the meeting of this Branch, held in October, 

the following inaugural address was given by 

Dr. Seaton : — 

"The Physician's Work in Public Health 
Administration." 

liY 

Edward Seaton, M.D , F.R.C.P. 
It was shortly after the Public Health Act of 1872 
came into operation that I thought of applying for 
one of the posts of medical officer of health then 
advertised by local sanitary authorities for the first 
time. A famous physician and former teacher (the 
late Dr. Bristowe) with whom I discussed my pro- 
position, agreed that the opportunities afforded by 
the new Act should, even in the existing state of 
public opinion, afford ample scope for an honour- 
able and useful career. " But," added he, " keep 
up your connection with practical medicine, which 
must always be the basis of a sound system of 
public health administration." In accordance 
with this advice I took the membership of the 
London College of Physicians a few months 
later, and afterwards became connected with a 
provincial dispensary and a hospital as consulting 
physician, in after years serving on the Asylums 
Board of the Metropolis at a time when their 
hospitals and asylums first became available 
generally for the purposes of medical education. 
I mention these facts to you, not as being of 
any interest personally, but as explaining that 
my own bias has always been in favour of 
keeping the bond between public health adminis- 
tration and the work of physicians as close as 
possible. The local medical officer of health 
for a large town should be placed by his salary 
and tenure of office, in a position equal to that ot 
the principal town officials ; and while by the terms 
of his appointment, he should be debarred from 
private practice, he should at the same time be not 
only free, but in every way encouraged to accept 
positions of medical responsibility in connection 
with hospitals and dispensaries. The character of 
the office and its proper sphere of usefulness would 
thus be better suited than by any other arrange- 
ment as yet proposed or tried. 

It is well for us to have an ideal before us; but 
it must be admitted that up to now circumstances 
have not enabled us to realise it. In the first 
|)lace the public have not as yet come to fully appre- 
ciate the value of medical advice or services as 
applied wholly to the prevention, rather than the 
cure or treatment of illness. The subject of the 
appointments of medical officers of health, and their 
frequently unfavourable conditions of tenure, has 
received a large share of attention lately, not only 
in this Society and its branches, but in that section 
of the British Medical .Association which is devotei 



I1 



THE PHYSICIAN'S WORK IN PUBLIC HEALTH ADMINISTRATION. 



85 



to the consideration of questions relating to the 
public health. But of all those who have addressed 
us on this subject, it seems to me that Dr. Wood- 
forde, late President of the Society, indicated the 
main and essential difficulty in the way of improve- 
ment. It is that in a large proportion of instances 
the appointments are held by gentlemen in general 
medical practice, I am not about to enter into 
any controversial matter. I am fully aware that 
among those I have the honour to address are 
some who may think that under existing circum- 
stances the " specialist or whole-time " system is 
undesirable, and that until better initial conditions 
of appointment can be secured, it is not in the 
public interest that it should be generally recom- 
mended. I am not disposed at present to discuss 
this important question, but I desire to call atten- 
tion to a fact that cannot be gainsaid. It is that, 
notwithstanding what has been accomplished, the 
public do not as yet seem fully convinced of the 
practical utility of preventive medical work. 

Let me take a typical example of my meaning 
— viz., the case of an outbreak of scarlet fever 
or diphtheria associated with a particular milk 
supply, in which the medical officer of health 
happens also to be the practitioner attending on 
the cases. Here he has to choose between the 
attendance on the suffering sick, his anxious patients, 
and an investigation taking time, thought and care, 
for which his reward in most cases can only be an 
approving conscience. If his object be to secure 
reward and thanks for his pains, there can be no 
doubt in which direction his interest lies. Indeed 
— strange, but nevertheless true — unless the out- 
break assumes the proportions of an epidemic 
receiving wide attention, and unless it be of such 
a nature that it constitutes an object lesson, not 
even kudos attaches to the investigation. 

Again, in illustration of my meaning, I may refer 
to institutions where the cure and prevention of 
illness are carried on side by side. As you may 
know, I have had opportunities of observation at 
many rate-supported hospitals. There blame is 
almost entirely confined to matters relating to 
treatment and cure of the sick, and not to those 
concerned in the prevention of illness. Hospital 
" scandals " almost invariably relate to real or 
alleged neglect of the sick, not to the prevention of 
the spread or occurrence of preventable illness*. 

The practice of vaccination abounds with in- 
stances of my meaning. Who is there among us 

*In this respect there is a great difference between the 
voluntary hospitals in the management of which medical 
knowledge is supreme, and the rate-supported hospitals, 
where it is subordinate to "public opinion." Indeed, 
it seems to me the most powerful argument against 
making our hospitals " state " or " rate "-supported, is that 
hitherto the great advances in preventive surgery and 
medicine hive been carried out in voluntary hospitals, and 
that, humanly speaking, these great triumphs would have 
been impossible of achievement in hospitals supported by 
the rates, and subject to the sort of control usually exercised 
n such establishments. — E. C. S. 



that has ever been thanked for vaccinating sus- 
ceptible persons, even in households immediately 
threatened with smallpox ? 

In mentioning the above examples I have 
chosen those in which the close connection of 
prevention and cure is apparent to the medical 
profession, though not always to the general 
public. If, in such cases, the preference is 
usually given to the latter — to the cause of 
actually suffering humanity as some would put 
it— is it to be wondered at that the compara- 
tively far away preventive work in which we are 
daily engaged so often fails to win appreciation ? 
The indication of nuisances injurious to health, 
which may be remedied by money expenditure, 
and the estimation of the probabilities of their 
proving so injurious ; the institution of a system 
of notification of preventable illness, which 
may furnish the basis of a sound public health 
organisation ; the skilful analysis of sickness or 
vital statistics, so as to ascertain some fact con- 
nected with the habits or customs of a population 
tending to the development or increase of some 
disease ; the cultivation of the art of diagnosis ; 
the study of micro-pathology— these, to mention 
no other, are examples of the physician's work in 
public health administration, the fundamental 
importance of which we, in the medical profession, 
recognise. When will its importance be fully 
recognised by the public? 

Thus far it might seem that I am presenting an 
aspect of the physician's work which, if not deter- 
rent, is certainly not encouraging to those who 
have to earn a living and make a career in their 
profession. But there are hopeful signs that, with 
the progress of education, by the gradual extension 
of the sphere of local government, together with 
a large increase in the number of persons actively 
interested or engaged therein, the work for which 
we claim a high position will come more and more 
to be appreciated. 

In order to promote this end, it is desirable 
from time to time to recapitulate some of the prin- 
cipal achievements of preventive medicine. This 
has already been done, with co-ordinative skill 
and literary ability, by Dr. Thome Thome, in his 
book on "The Progress of Preventive Medicine 
during the Victorian Era." It is no detraction 
from his interesting and valuable record to say 
that it is incomplete, for in such a comprehensive 
subject there is ample field for work for physicians 
in the service of local authorities, as well as those 
attached to Her Majesty's Local Government 
Board. I would, moreover, specially remark that 
the labours of those who are officially unattached, 
but who work at public health problems as earnestly 
as the time they can spare from their practice 
permits, is valuable mainly on account of its inde- 
pendence of official bias. My own brief recapitu- 
lation shall relate entirely to matters within my 
own experience, and if I give you more of my own 



86 



PROCEEDINGS OF THE HOME COUNTIES BRANCH. 



opinions than those of other people, I will ask 
you to excuse me on account of the position in 
which you have placed me this evening. 

I. The Housing of the Poor. — It would form an 
interesting chapter in the history of sanitary pro- 
gress during the latter half of the Victorian era to 
trace the influence of the medical profession in pro- 
moting the greatest humanitarian movement of the 
nineteenth century — a movement which has made 
enormous strides in a comparatively very short time. 

This I cannot attempt to do now, but it is par- 
ticularly interesting to note the action taken by the 
College of Physicians in initiating or promoting 
this great work. 

Extraordinary Meeting of the College, 
February iglh, 1S74. 
Annals XXXI., /. 93. 

The committee appointed at the last college meeting to 
prepare a Memorial to the First Lord of the Treasury, laid 
before the college the draft of a memorial, which was 
amended, and on the motion of Ur. Anstie, seconded by 
Dr. Basham, was adopted as follows : — 

"The Memorial 

'* Of the Corporation of the Royal College of Physicians of 

London 

"To 

" First Lord of the Treasury 
•' Shkweth 

" That your memorialists in the daily exercise of their 
profession as physicians are brought much into contact with 
the poorer classes of the population, and are deeply interested 
in anything that concerns the welfare of these classes, noi 
only ( n account of the poor themselves, but also because the 
evils engendered among them affect the whole of society. 

"That it is well known to your memorialists that over- 
crowding—especially in unwholesome and ill-constructed 
habitations — originates disease, leads to drunkenness and 
immorality, and is likely to produce discontent among the 
poorer portion of the population. 

" That it is within the knowledge of your memorialists that 
the wholesale demolition of the houses inhalnted by the 
poor, which have been carried on of late years under various 
Railway and Improvement Acts, while it has been service- 
able in removing many very bad streets and dwellings, has 
incidenially caused much distress to the persons displaced, 
and has almost uniformly driven them to crowd into neigh- 
bouring quarters which were already as full as or fuller than 
was consistent with healthiness. 

" That private enterprise is powerless to provide the fresh 
air and improved house accommodation which is required 
for those who have been expelled from their former habita- 
tions, in addition to that which is called for by the constant 
increase of the population, by reason of the impossibility of 
securing suitable sites for building. Even so rich and 
powerful a body as the trustees of the Peabody Fund has 
been repeatedly foiled in particular attempts to obtain land 
to build on. 

"'Ihat your memorialists believe that the mere enabling 

Eowets which are at present entrusted to various authorities 
ave proved, and must prove, insuflicient to effect the 
desired object. 

"That in the opinion of your memorialists a remedy for 
these evils is urgently needed. They therefore venture to 
express the hope that you will favour them by holding out 
some prospect that this question of the Dwellings of the 
London Poor, upon which the health and morality of the 
pe iple so much depend, will be taken up by Government in 
the present session of Parliament. 

" And your memorialists will ever pray," etc. 

The president, censors, and registrar were appointed a 
deputation to present the memorial. 



One of the ways in which medical influence has 
been most usefully exercised has been in keeping 
to the front principles which should guide states- 
men in their method of dealing with this intricate 
question — principles which have been so ably 
expressed by Sir John Simon in his " English 
Sanitary Institutions.' 

Not less influentia has been the inhibitory 
influence of the profession. I refer to the cau- 
tious utterances of eminent physicians, such as 
Dr. Bristowe, in correcting exaggerated state- 
ments. It is ten years ago now that I conferred 
with my old teacher on the subject of diphtheria 
and its relation to insanitary conditions. I was 
about to read a paper at our Metropolitan Society, 
and I then took the opportunity of proclaiming the 
facts respecting this disease, which were and are 
very much in contradiction to what our respected 
friends, the sanitary engineers and inspectors, were 
teaching at that time. 

2. Industrial Hygiene. — This subject especially 
comes within the scope of physicians, whether prac- 
tising as such, or whether wholly engaged in 
official work, as was Dr. Ballard. The Milroy 
lectures of Dr. Arlidge, and the admirable series of 
lectures in the Transactions of the Sanitary Insti- 
tute, should mark a new era in public health 
administration. The way has been paved for 
fresh legislation and administrative reform, which, 
it is hoped, will soon lead to practical results com- 
parable with the enormous improvements which 
have taken place in the dwellings of the poor. 

3. Among the notable achievements, I place the 
Systematic Notification of Infectious Diseases. I 
do this not so much because of the immediate 
benefits to be derived from it (although I think 
these are already by no means small in the case of 
some diseases, such as small-pox and scarlet fever), 
but on account of the opportunities it affords for 
systematic local sanitary administration, and the 
scientific observation of epidemic diseases. Local 
sanitary authorities have the entire credit of 
initiating the system — a by no means easy achieve- 
ment, as some of us well know. 

4. In the field of scientific research we owe 
much to the labours of the Medical Department of 
the Local Government Board, especially as Dr. 
Thome has shown in that department which deals 
with Epideniiolog}'. In coiniection with small-pox, 
he dwells on the importance of Mr. Power's 
opinions as to the spread of the disease through the 
general atmosphere, which he says now meets with 
the almost unanimous support of competent 
scientific judges. In the same interesting volume, 
published in 1888, he discusses in detail the same 
observer's discovery of what is known as the 
Hendon disease, which some of us thought likely 
to constitute, and which may still prove to be, a 
material part of the etiology of scarlet fever. The 
great respect entertained for the scientific accuracy 
and conscientiousness of Mr. Power, and those 



THE PHYSICIAN^S WORK IN PUBLIC HEALTH ADMINISTRATION. 



associated with him at the Local Government 
Board, commanded the earnest and careful atten- 
tion of unprejudiced observers to the latter 
discovery. It will, I think, be generally held that 
the absence of similar independent observations 
during the last ten years makes it necessary to 
review with very great caution the position to be 
assigned to these very important observations. 

In his address. Dr. Thorne spoke of "an exag- 
gerated trust in," or "an over-estimation of the power 
of vaccination." May we express the hope that 
there may not arise an exaggerated fear of small-pox 
hospitals, which would seriously impede the further 
control of this eminently preventable disease. 

The work of Snow, of Stewart, of Parkes, ot 
Jenner, of Buchanan, and Bowditch, which had 
begun to produce these results before the time 
which I cover in this address, have furnished a 
basis for practical work in the prevention of cholera, 
typhoid, typhus, and phthisis, in which there has 
been no important change. There has, however, 
been some valuable addition to our knowledge in 
the contributions of Dr. Charles Kelly and Dr. 
Arthur Ransome, which will probably help to 
explain the law relating to phthisis distribution and 
soil moisture. 

The subject of phthisis and tuberculosis is at the 
present time attracting attention in another direc- 
tion. The Tuberculosis Commission has by its 
report established certain facts which should 
influence pubhc health administration in an 
important degree, viz., by altering our present 
system of the slaughter of animals, and their 
preparation for food, which so urgently needs 
improvement. I purposely refrain from entering, 
in this address, into the subjects of laboratory 
research which have sprung from the work of the 
great Pasteur, and which constitute a large share 
of the preventive medical work of our time, pre- 
ferring to dwell on important matters not generally 
receiving attention. I would, however, refer 
especially to the momentous discovery of the 
tubercle bacillus by Koch, and to the wonderful 
efficiency of tuberculin in detecting tuberculosis. 
Lectures, articles, and letters occasionally appear 
on this subject in the columns of leading journals. 
The Tvnes of September 30th contains an excellent 
letter on " Fresh Aspects of the Tuberculosis 
Question," setting forth the arguments which 
logically prove our present system of slaughter- 
houses in England to be as bad as possible. But 
the writer probably hardly realises that which • 
would be only too well known to his neighbours, 
our experienced colleagues, Drs. Woodforde and 
Ashby, viz., the enormous difficulty of altering the 
long established customs of the meat trade. This 
is a case for constant reiteration of indisputable 
facts, and explaining from the physician's point of 
view their full significance. 

Lastly, in the field of scientific research, which by 
way of contrast to laboratory research has been 



termed "field observation," or epidemiology, I 
have to say a few words on diphtheria, and those 
simply in illustration of what I have been saying 
this evening upon the imj^ortance of the physician's 
work in prevention as well as cure. The discovery 
of antitoxin may or may not make a very material 
difference in the mortality statistics of diphtheria. 
Be that as it may, the diagnosis and the prevention 
of the disease should rank as of even greater im- 
portance than its treatment or cure. It is much 
more important, in our estimation, that medical 
officers should be appointed under conditions 
which enable them to watch and arrest the de- 
velopment of epidemic disease at schools, or 
wherever they may arise (also, that aids to 
diagnosis and opportunities of isolation should be 
afforded), than that medical talents should be 
directed almost exclusively to the treatment of the 
disease when it has arisen. This may not be the 
popular view, but it is that which we must con- 
stantly endeavour to keep to the front. Certainly, 
though it may not be showy work, the study of the 
natural history of the disease as carried on for 
several years by the medical officers of the Local 
Government Board and Dr. Longstaft' and Dr. 
Adams, of Maidstone, and others, has already and 
will continue to produce the most valuable results. 

Here let me refer to the highly important 
lectures of Dr.Newsholme, on acute rheumatism, and 
to the hypothesis which he has advanced, and which 
will require careful attention of epidemiologists 
and all who are interested in preventive medicine. 

Having so far spoken of the achievements in 
preventive medical work, let me now briefly speak 
of some of the openings for further progress. 

The duty of a medical officer of health includes 
inquiry into the causes, origin, and distribution of 
diseases within a district, and ascertaining to what 
extent the same have depended on conditions 
capable of removal or mitigation. 

Hitherto such inquiries have been chiefly con- 
fined to diseases of the zymotic class, and to those 
directly connected with what are called sanitary 
conditions. There is undoubtedly a wide field of 
labour still before us, even in this direction. But 
even if we take such a subject as the housing of the 
working classes, it is becoming evident that the 
subject has come now to be mainly a question of 
local government and economics, and that the 
sphere of the medical officer will in the future be 
rather that of an executive officer, whose reports 
will form a necessary basis of action in securing 
improvements. Far-reaching as such improvements 
may be expected to be in the future, they cannot 
be said to touch even remotely the causes of illness 
into which it is our duty to inquire. Insanity alone 
accounts for a large proportion of disabling illness 
—often permanent— the control or prevention of 
which should be a subject of discussion in the 
reports of medical officers of health. It is im- 
possible to read the Lumleian Lectures by Dr. 



88 



THE TENURE OF OFFICE BY MEDICAL OFFICERS OF HEALTH. 



Blandford — especially that delivered on April 4th, 
which appeared in the British Medical Journal z.nd 
Lancet of April 20th — without being impressed 
with the need for calling public attention to the 
subject of insanity, especially its prophylaxis. 

The question whether insanity is increasing may 
be difficult to decide, but Dr. Blandford gives many 
reasons for thinking that it is. But even if it be 
not so, surely there is sufficient reason for anxiously 
considering whether its prevalence may not be 
reduced. 

The insanity that may be said to be produced by 
alcoholic indulgence, and which, in a remote way, 
may be influenced by the character of dwellings, 
is not at all equal (Dr, Blandford says) to heredity 
as a producer of mental disorder. 

"If," says he, "we wish to save our race from 
gradual mental decay, and not only to preserve 
life from such ills as zymotic diseases, but to raise 
up a strong and vigorous breed of healthy men and 
women, it is absolutely necessary that more atten- 
tion should be paid than has been hitherto to the 
selection of individuals who are about to marry and 
reproduce." 

I would wish to quote more from these valuable 
and suggestive lectures. I would also desire to 
speak of the necessity for bringing about a closer 
connection between the treatment of insanity and 
our existing system of public health administration. 
But as the limit of this short address will not allow 
of this, permit me to express the hope that the crude 
remarks I now make will be presented to yoa later 
on in maturer form and more definite shape. 



MEMORANDUM ON THE TENURE OF 
OFFICE BY MEDICAL OFFICERS OF 

HEALTH. 

prepared by 

Dr. T. Orme Dl'dfield. 

The first Public Act enjoining upon sanitary 
authorities the duty of appointing medical officers 
of health was the Metropolis Local Management 
Act, 1855 (18 and 19 Vict., c. 120, section 132). 
In London the medical officer was, prior to the 
passing of the Local Government Act, 18S8, 
appointed during, and removable at, the pleasure of 
the sanitary authority. The custom of appointment 
for a limited period only did not obtain, so that, 
practically, the appointment was made during good 
behaviour. The officers so appointed have in 
many cases been pensioned under the provisions 
of the Superannuation Allowances Act, 1866 (29 
Vict., cap. 31); an Act "to provide for super- 
annuation allowances to officers of vestries and 
other boards within the area of the Metropolis 
Management Act." Several retired medical officers 
of health are at the present time in the receipt of 
pensions granted under the provisions of this Act. 



The Public Health Act, 1872 (35 and 36 Vict., 
cap. 79, section 10) m.ade provision for the 
appointment of medical officers of health in the 
country generally by the several urban and rural 
sanitary authorities. Unfortunately, it was enacted 
that " the appointments yfry/ madea.{teT the passing 
of this Act shall be for a period not exceeding five 
years." It would appear to have been intended 
by the Legislature that subsequent api)ointments 
should be permanent, for the section further enacts 
that " the Local Government Pjoard shall have the 
same powers as they have in the case of a district 
medical officer of a union with regard to the 
qualification, appointment, duties, salary, and 
tenure of olfice of a medical officer of health . . . 
any portion of whose salary is paid out of moneys 
voted by Parliament." 

The Public Health Act, 1875 (S^ and 39 Vict., 
cap. 55), which repealed the Public Health Act of 
1872, re-enacts the provisions with regard to the 
appomtment of medical officers, and to the powers 
of the Local Government Board with respect to 
their tenure of office. 

The " powers " of the Local Government Board 
with respect to tenure of office were conferred by 
the 4th and 5th Will. IV., cap. 76, sec. 46. 

Prior to the year 1855, the Poor Law Medical 
Officer did not enjoy security of tenure of office. 
In 1854, however, the Select Committee of the 
House of Commons, appointed to consider the 
mode in which medical relief was administered to 
the poor, adopted, by a very large majority, the 
following resolution : — " Your Committee recom- 
mend that every medical officer to be appointed 
after the 25th of March, 1855, should continue in 
office until he may die, resign, or become legally 
disqualified to hold such office, or be removed 
therefrom by the Poor Law Board." 

This resolution, adopted alter a very careful 
investigation, was subsequently reported by the 
Committee to the House of Commons. With the 
view of giving it effect, the Poor Law Board, in 
February, 1855, issued a General Order relating to 
medical officers. In lieu of that Order, however, 
and in consequence of it not being found to give 
full effect to the recommendation of the Committee, 
the Board i)Ut forth a further Order, dated the 25th 
of May, 1857, on the subject of the tenure of 
office by medical officers. This last-named Order 
came into force on the 24th of June, 1857. It 
prescribes as follows : — 

" Art. I. — Every medical officer of a workhouse, 
duly qualified at the time of his appointment, 
according to the regulations of the Poor Law 
J'.oard then in force, shall hold his office until he 
shall die, or resign, or be proved to be insane, by 
evidence which the Poor Law Board shall deem 
sufficient, or become legally dis(}ualified to hold such 
office, or be removed by the Poor Law Board." 

" Art. 2. — Every district medical officer duly 
qualified as aforesaid at the time of his appoint 



h 

J 



THE TENURE OF OFFICE BY MEDICAL OFFICERS OF HEALTH. 



89 



ment, and then being, or within two months after 
his appointment, becoming resident within the dis- 
trict for which he shall be appointed to act, shall 
hold his office until he shall die, or resign, or be 
proved to be insane, in the same manner as in the 
previous Article ; or become legally disqualified to 
hold such office, or be removed by the said Board, 
or cease to reside within such district." 

It is hardly necessary to state that, under this 
beneficent General Order, all Poor Law Medical 
Officers (subject to the limitation as to residence in 
the case of the district medical officer) enjoy fi.xity 
of tenure ; and in this connection it is worth men- 
tioning that the loth section of the Act of 1872 
(already cited) enacted, and the 191st section of 
the Public Health Act of 1875 enacts, that, with 
the sanction of the Local Government Board, " Any 
district medical officer of a union may be appointed 
a medical officer of health." It is hardly necessary to 
add that many district medical officers who, as such, 
, enjoy life tenure of their appointments, hold their 
appointments as medical officers of health subject to 
the insecure tenure of appointment and re-appoint- 
ment for a limited term, because the Board have 
not availed themselves of the power conferred 
on them by the Act of 1875 (^"d previously 
by the Act of 1872) to give permanence of 
tenure to medical officers of health ; and, in fact, 
have dechned to sanction the proposals of sanitary 
authorities, who had been willing to place their 
medical officers of health, in respect of tenure of 
office, in the same position as the district medical 
officer of a union. 

The latest General Order applying to urban and 
rural sanitary districts was issued in 1891. The 
loth Article of the "Regulations as to Medical 
Officers of Health " reads as follows : — 

" Tenure of Office. — Every officer shall continue 
to hold office for such period as the local authority 
may^ with our approval., determine, or until he die, or 
resign, or be removed by such authority with Our 
assent, or be removed by Us, or be proved to be in- 
sane by evidence which We shall deem sufficient." 

The Local Government Act, 1888 (51 and 52 
Vict., cap. 41), by section 88 {c) made section 191 
of the Public Health Act, 1875, to apply to the 
Metropolis as if each sanitary authority were a local 
authority within the meaning of that section, and any 
medical officer of health subsequently appointed 
prior to 1892 has been appointed under the said 
Act. In virtue of this legislation, the Local 
Government Board, in 1889, issued a "General 
Order (Metropolis)," making " Regulations as to 
Medical Officers of Health," the 8th Article of 
which is identical with the loth Article of the 
General Order of 1891 above cited, with respect to 
provincial medical officers of health. 

The Public Health (London) Act, 1891 (54 and 
55 Vict., cap. 76), subsequently, and once for all, 
determined the position, as to tenure of office, of the 
medical officers of health acting within the Metro- 



polis, for section 108, sub-section 2 {h), enacts 
that " A medical officer of health shall be remov- 
able by the sanitary authority with the consent of 
the Local Government Board or by that Board, and 
not otherwise " ; and that {c) " any such medical 
officer shall not be appointed for a limited time 
only." 

The Local Government Board have given effect 
to these provisions of law by the issue of a General 
Order, entitled "The Sanitary Officers' (London) 
Order, 1891," which, as resp8cts officers appointed 
or re-appointed after the ist day of January, 1892, 
reads, in Article 9, as follows : — " Every medical 
officer of health shall continue to hold office until 
he die, or resign, or be removed by the sanitary 
authority, with Our consent, or be removed by Us, 
or be proved to be insane by evidence which We 
shall deem sufficient." 

It will be observed that in this Article the words 
italicised in the Provincial General Order of 1891 
above cited have been omitted. 

A considerable number of medical officers of 
health have been newly appointed since this Order 
took effect, and a still larger number of existing 
medical officers have been re-appointed by their 
respective sanitary authorities by resolution under 
the provisions of Article 8, which reads as 
follows : — 

" If, in the case of an officer holding office on 
the ist day of January, 1892, the sanitary authority 
desire to re-appoint him .... it shall not be 
ne:essary for notice of the proposed re-appoint- 
ment to be givea by advertisement, if notice be 
given at one of the two ordinary meetings of the 
sanitary authority next preceding the meeting at 
which the re-appointment is to be made." 

It would thus appear that the main point that 
the Council will have to consider is, What steps 
should be taken to obtain the enactment of an 
Act in the terms of section 108 of the Public 
Health (London) Act, 1891, or the submission to 
the House of Commons of a Resolution with 
respect to the tenure of office by extra Metro- 
politan medical officers of health, in the terms of 
the Resolution of 1854, with respect to the tenure 
of office by Poor-Law Medical Officers? 

It may be thought worthy of consideration, 
moreover, Whether the time has not come when an 
effort should be made to secure the appointment of 
all medical officers of health, so that a moiety of 
their salaries should be paid out of the Exchequer 
Contribution Account by the County Councils, 
and powers be given to the Local Government 
Board with regard to the qualification, appoint- 
ment, duties, salary, and tenure of office of every 
medical officer of health, in accordance with sec- 
tion 24 of the Local Government Act, 1888, and as 
in the case of Metropolitan medical officers of 
health, appointed or re-appointed under the Public 
Health (London) Act, 1891, and the Sanitary 
Officers (London) Order of the same year ? 



^o 



"RETURN CASES" OF SCARLET FEVER. 



MEMORANDUM PREPARED BY 

DR. W. T. G. WOODFORDE. 

Public Health Act, 1872 (35 and 36 Vict. c. 79). 

Extracts from Hansard^ 1872. 
In the Bill, as introduced by Mr. Stansfeld, nothing 
was said as to permanency of tenure or otherwise, 
in Clause 10, relating to the appointment "from 
time to time " of medical officers of health. 

When the Bill was in Committee, July 18, 1872, 
Colonel Barttelot moved as an amendment the 
addition of the words (Hansard, July 18, 1872, 
p. 1,391), "whose several appointments shall be 
for a period not exceeding five years, but nothing 
in this Act shall prevent such officers from offering 

themselves again for re-election." 

" This would enable boards of guardians to have 
some power over these officers of health, and would 
prevent them from doing as they pleased," etc. 

Mr. Stansfeld acceded to the amendment 
"on condition of its applying only to the first 
appointments under the Act. The functions of the 
officer being a matter of experiment, it was not de- 
sirable to make the first appointment permanent." 

Sir M. H. Beach objected to the amendment, 
" thinking that a five years' officer, like an Ameri- 
can President, would be afraid of displeasing those 
on whom his re-election depended," 

Colonel Barttelot " was not satisfied with the 
modification proposed by the right honourable 
gentleman ; was it to apply to the first five years of 
every officer's tenure, or to the first five years after 
the passing of the Act ? " 

Mr. CoRRANCE said the amendment " would 
reduce the Bill to a nullity by impairing the inde- 
pendence of the medical officer." 

Mr. Stansfeld "should have preferred at this 
moment not to have legislated on this subject, but 
was willing to accept the amendment "... 
" so modified as to make the first appointments 
under the Act tenable for five years only, leaving 
the question of their permanency open for future 
decision." 

Mr. Corrance would prefer the Bill as it stood. 

Colonel Barttelot would gladly accept the 
modification of the right hon. gentleman if it were 
understood that the first appointments under the 
Bill were not to be permanent. 

Amendment proposed, to insert the words in 
Clause 10: "The appointment of the medical 
officers of health first made after the passing of this 
Act shall be for a period not exceeding five years." 

After further remarks by Mr. Peel, Mr. Hibbe'\ 
and Sir Masscy Lopes pointing out that th:.Tinjad- 
ment should apply to the appointmer' ; ci inspectors 
of nuisances as well as to medi n! oliicers of health, 
the words " and inspectors of nuisances " were 
inserted after " medical officers of health." 

Amendment as amended agreed to. 

Clause as amended ordered to stand part of the 
Bill. 

Bill read third time, August 7th. 



iluijlit Italtl). 



We draw attention to the announcement on 
another page of the fact that the Council of the 
Incorporated Society of Medical Officers of Health 
have, in accordance with the Articles of Association, 
formed a Scottish Branch of the Society. The 
Society is to be congratulated on this important 
addition to its strength. The Society may now be 
accurately described as British in its constitution ; I 
and we hope that its strength will ere long be further 1 
increased by the formation of a Branch in Ireland, 
where already the Society has a number of mem- 
bers. While congratulating the Society on the 
formation of a Scottish Branch, it will be evident 
that the combination is advantageous to all 
the new members, as the larger and more 
completely representative the Society becomes, 
the more powerful will be its intervention in 
Imperial questions affecting the Public Health. 
This will, we trust, be seen to advantage in the 
course of the next few months, when the Society, 
through its Council, will be engaged in considering 
and deciding the action to be taken on the im- 
portant questions of Fixity of Tenure of Office 
and Superannuation. 



" RETURN CASES " OF SCARLET FEVER. 

This subject has lately attracted much attention, 
and two important recent utterances on the subject 
deserve notice. The first is a report of a Sub- 
Committee of Managers of the Metropolitan 
Asylums Board, which applied to the Metropolitan 
medical officers of health for information as to 
" return cases." The information supplied was 
obviously deficient, only twenty-six out of fifty-two 
medical officers having given exact returns. And 
yet the compiler of this report puts the 165 cases 
of alleged infection produced by patients dis- 
charged from the Asylums Board Hospitals in 
comparison with the total 30,227 pntients dis- 
charged from the same hospitals i'l : j years for 
which the return was made, vi.ig one alleged 
case of infection for cv y 285 discharges. No 
confidence can be ;>' rcu in such imperfect returns ; 
and theyalm-^ t certainly do not represent the total 
evil. I" i.i much more probable that the figures 
'k: led by Mr. T. W. Thompson in his paper on 
the same subject, at the last meeting of the 
Epidemiological Society, more nearly approach the 
truth for the metropolis. These figures are from a 
paper by Dr. Chalmers, which show that, in the 
year 1894, scarlet fever reappeared in 26 per cent, 
of the households to which the 2,953 scarlet fever 
|)aticnts belonged who were discharged from the 
three (Uasgow fever hospitals during that year. 

The Sub-Committee of the Metropolitan Asylums 
Board carry the war into the enemy's camp, when 



iPOVERTY IN RELATION TO SANITATION. 



91 



they suggest that some of the " return " cases 
are caused by imperfect disinfecting apparatus and 
arrangements of some of the metropohtan vestries. 
This probably does not account for more than a 
minute share ; nor will the bringing out on the 
return of the fever patient of clothing which had 
escaped disinfection, account for more than a small 
proportion of the " return " cases. 

All who have had experience of fever hospital 
administration will admit the serious difficulties 
which attend the discharge of patients. A slight 
nasal or ear discharge, or any eczematous condition 
of the scalp or elsewhere, appears capable of pre- 
serving the infectiousness of the disease for a con- 
siderable period beyond the usual time for dis- 
charge. We cannot, however, have much sympathy 
with the medical officers of health who appear to 
delight in publishing the details of cases in which 
desquamation, etc., has been found after the dis- 
charge of fever patients. Much friction might be 
avoided by abstinence from such publication, 
and by simply and solely sending a statement 
of the facts of each case to the medical 
superintendent of the hospital from which the 
patient has been discharged. It must be regarded 
as unfortunate that the administration of metropo- 
litan fever hospitals is so absolutely dissevered 
from that of the local sanitary authorities. Those 
medical officers of health who are also medical 
superintendents of the fever hospital in their own 
district are not unacquainted with "return cases," 
and can appreciate both sides of the subject. 

It cannot be denied tha*-, notwithstanding all 
precautions, returned patients from isolation hos- 
pitals are sometimes in a state of actual infective- 
ness. It is very doubtful if this continued infec- 
tiveness is caused by the scales of the secondary 
desquamation sometimes discovered after discharge. 
It appears more probable that catarrhal conditions 
of the nose, ears, and throat are the seat of the 
infection. Perhaps, also, as suggested by Mr. 
Thompson, there may be a seasonal influence as 
regards " return " cases, these occurring most fre- 
quently at the time of the year when scarlet fever 
is naturally most prevalent. Or they may be 
associated more closely with the greater infective- 
ness of scarlet fever, or the greater suscepti- 
bihty of the population during the rise of an 
epidemic. All these points require further in- 
vestigation. 

Mr. Thompson's very suggestive paper may be 
taken as the basis of this further investigation 
which is undoubtedly required. We quite agree 
with him that all the ordinary explanations of 
"return " cases, although they may account for a 
certain number, do not explain all the cases. 
There is something beyond careless or imperfect 
disinfection on the part of sanitary or hospital 
authorities, or protracted retention of infectiveness 
in the patient's person. Mr. Thompson concludes, 
from a special local investigation undertaken by 



him, that " on the whole it appeared to me pro- 
bable that some unknown proportion of the so- 
called ' return ' cases had in this instance been due, 
not to the return of the patients from hospital, but 
to the cause or causes which had contributed to 
the excessive incidence of secondary invasion 
generally upon households of the hospital isola- 
tion class," <?.f., school attendance." 

A further point, not mentioned by Mr.Thompson, 
should be borne in mind. During convalescence 
from scarlet fever, second attacks occur in a con- 
siderable percentage of cases. These secondary 
attacks are probably more common in some epi- 
demics than in others. They may be overlooked, 
and thus the patient be discharged before the 
infectiveness of the second attack is over. Further- 
more, scarlet fever patients are liable to "scarla- 
tinal sore throats " during convalescence. They 
may have these close to the time of discharge or 
immediately after reaching home. We know that 
nurses attending scarlet fever patients are liable to 
such sore throats, and that they are infective. May 
not such sore throats be the cause of some of the 
"return" cases ? 



POVERTY IN RELATION TO SANI- 
TATION.* 

BY 

Henry Malet, M.D., B.A., M.O.H. Wolverhampton. 

Among the more direct effects' of poverty! are 
insufficient food and clothing, shelter and firing. 
Such matters are beyond sanitation. So also 
in a measure is another effect of poverty, 
ignorance ; not only in respect of infectious disease, 
or management of illness generally, but even of 
how to live. Erroneous notions about feeding and 
cooking (especially child feeding) and ignorance of 
ventilation, and the value of pure air and sunlight 
and cleanhness, are all of them no doubt answer- 
able for much needless suffering and death amongst 
the poor. And teaching these things is hardly 
within our scope. But much of the insanitary con- 
ditions of Wolverhampton are also due to poverty, 
and do fall within our scope, and are dealt with, 
though not so fully as they ought to be were they 
less painful or more hopeful. Such are over- 
crowding, living in ill-ventilated or damp or 
draughty houses, or in houses in close unhealthy 
situations, or dirtiness in respect of yards, drains, 
and ashpits. When people are too poor to rent 
roomy and healthy houses we can serve notices on 
them t D cease overcrowding, or we could, within 
certain limits close dubious houses and turn their 
tenants adrift ; but the wisdom c.:\i kindness of such 
a proceeding is not always ce .ain, unlike the acute 

* From Dr. Malet's Annual ..epott for 1894. 

t I have not been able to yc:t ttie Poor rate of ten of the 
large towns ; o( the other 23 Wolverhampton is first, 2s. id., 
and actually 4d. higher than the next ; the average of the 
other 22 is only is. 22d, 



92 



ANTI-CHOLERA INOCULATION. 



hardship on the unfortunate poor. There are, in 
Wolverhampton, an enormous number of houses 
not strictly fit for habitation, and a considerable 
number quite unfit ; the latter must be closed by 
degrees, and the former eventually. But there it 
no use in so doing if there is nowhere else for the 
poor to go to, at least none that they can afford lo 
pay for. 

Again, a less excusable matter is the frequent 
filthiness of common yards, closets, etc. This ii 
generally due to the neglect of a few of the tenants 
who cannot be easily detected, and all we can 
usually do is to summon the innocent with the 
negligent, an irritating proceeding. 

Another very insanitary effect of poverty is the 
attempt to eke out a little extra living by keeping 
pigs, poultry, or other animals, or even by storing 
pig wash for sale. These matters we do deal 
with, but they are constantly recurring. There is 
no doubt, however, but that on the whole our 
condition is decidedly improving. 



of anti-cholera inoculation. As in the analogous 
case of anti-rabic inoculation, an enormous ex- 
perience must accumulate before the evidence can 
be said to prove the utility of the inoculation. 
There is this difference between the two cases- 
Patients do not have two attacks of hydrophobia, 
because the first attack is always fatal ; though it 
is conceivable that a person having been saved 
from hydrophobia by Pasteur's process, might fall 
a victim to a later bite from a rabid dog. Multiple 
attacks of cholera are, on the contrary, quite 
common, second attacks not infrequently occurring 
during the same epidemic as the first. On a priori 
grounds, therefore, can any protracted protection 
against cholera be expected to follow on anti- 
cholera inoculation ? At the same time anti- 
cholera inoculation would be justifiable, under 
certain conditions, if it can be shown to produce 
temporary immunity from the disease during a 
single epidemic. 



ANTI-CHOLERA INOCULATION * 

Dr. Haffkine has issued his report of the ex- 
perimental preventive inoculations against cholera, 
which have been performed in India between April, 
1893, and August, 1895, mclusive. He states that 
in the course of the first year 22,703 people were 
inoculated in the North-West Provinces and Oudh, 
and in the Punjab, including all classes of the 
population. From March, 1894, to July, 1895, 
19,473 persons were inoculated in some of the 
most affected locahties of India. The results in 
Dr. Haffkine's opinion " seem to indicate that in 
the inoculations we possess a means of effectively 
combating cholera epidemics." Dr. Haffkine finds 
himself obliged on account of ill-health to leave 
India temporarily, but recommends the initiation 
of medical officers in the Indian service into the 
technique of the operation, so as to be able to carry 
it out on a larger scale. 

The statistical part of Dr. Haffkine's report is 
somewhat badly arranged. There is no general 
summary of results, and it is necessary to wade 
through many pages to discover the results of the 
inoculations. Perhaps the most interesting are 
Dr. Simpson's observations at Calcutta. Cholera 
occurred in 36 houses among inoculated people. 
There were in these houses 521 people, of whom 
18 r were inoculated and 340 remained uninocu- 
lated. Among the uninoculated the deaths from 
cholera were 11 "6 per cent., among the inoculated 
2 "2 per cent, of the persons in each group. 

Other similar ex{)eriences are given. 

We cannot profess to be convinced of the utility 



RELATION BETWEEN DENSITY OF 
POPULATION AND MORTALITY. 

The effect of density or overcrowding is shown in 
the following table, which gives the density of 
population to the acre, and the corresponding 
death rate for all ages, and ages under five. The 
table and the subsequent remarks are taken from 
an interesting article in the October number of 
the American Spectator, by Mr. F. L. Hoffman. 







Under 


Dbnsity of Population to thb Acre. 


All Ages. 


5 Yean.» 


New York City, 1885-90. 






Under 100 persons per acre 


2276 


94-30 


100 to 200 „ ,, 


29'53 


12337 


200 to 300 ,, ,, 


2873 


11049 


300 and over ,, ,, 


27 57 


104-42 


Brooklyn, 






Under 40 persons to the acre 


•1941 


74 94 


40 to 80 ,, ,, 


21-99 


8699 


80 to 120 ,, ,, 


24^5 


96-21 


120 »nd over ,, ,, 


27-04 


103-88 


Boston. 






Under 50 persons lu the acre 


2153 


80-69 


50 to 100 ,, ,, 


22-37 


92-87 


100 and over ,, ,, 


2845 


117-63 


Philadelphia. 






Under 50 persons lo the acre 


20-23 


7314 


50 t(j 100 ,, ,, 


22-40 


86-96 


100 and oyer ,, ,, 


23-81 


93'3 



• " Report to the Government of India." 
Thacker, Spiak & Co.) 



(Calcutta : 



• Native whites only. 

For the three cities, Brooklyn, Boston, and 
Philadelphia, the increase in the mortality in pro- 
portion to the increase in the aggregation of the 
population is clearly shown there. The slight 



THE PREVENTION OF PHTHISIS. 



93 



variations in the rates for New York City must be 
attributed to the fact that under certain conditions 
the reverse may take place. This has been 
pointed out by Newsholme in his discussion of the 
vital statistics of the Peabody Fund dwellings in 
London, in which the actual mortality is less than 
the general mortality, although the density of 
persons to the acre is vastly greater. Newsholme 
proves that under certain conditions the density 
per acre is not the true test, but that the number 
of persons to a room must be taken into con- 
sideration in preference to the density per acre. 
That is to say, a building of ten storeys, with all 
sanitary improvements, with sufficient room space 
and a pure water supply, may harbour a very large 
number of people, have a very high degree of 
density to the acre, and still prove a far healthier 
abode than an ordinary tenement with overcrowded 
rooms, highly insanitary conditions in regard to 
sewerage and water supply, but with only a 
moderate degree of density of population to the 
acre. 



THE PREVENTION OF PHTHISIS.* 

BY 

Leonard Wilde, M.D., M.R.C.P. 

Several districts have from time to time proposed 
to include phthisis among the notifiable diseases, 
but as yet this has not received the sanction of the 
Local Government Board. The notification of 
acute phthisis, which runs a rapid course and is 
invariably fatal, may be theoretically desirable, 
but to include the ordinary or chronic form, 
which may last for years, and does not appear to 
be infectious from person to person, would probably 
be found impracticable. 

A knowledge of the etiology of tuberculosis is 
essential to its prevention, and the efforts of the 
sanitarian may well be directed towards securing the 
amehoration of those conditions which are known 
to favour its development. 

Among the chief causative conditions which may 
be said to be within the reach of sanitary preventive 
measures may be mentioned : — 

1 . Continued dampness of locality and dwellings. 

2. Direct infection by the inhalation of tubercle 
bacilli or their spores in a dry state. (Personal 
infection has been shown to occur only on some 
very rare occasions in cases of acute phthisis, and 
under circumstances of close intimacy and defective 
ventilation). 

3. Habitually breathing the vitiated stagnant 
atmosphere of ill-ventilated, uncleanly, or over- 
crowded workrooms, dwelling rooms, and bed- 
rooms. 

4. Consumption of the milk of tuberculous 
cows, or the meat of tuberculous animals. 

* From Dr. Wilde's Annual Report, 1894, to the Bedford- 
shire County Council. 



5. Certain trades and occupations in which dust, 
grit, or other irritants are constantly inhaled. 

Other causes, such as hereditary transmission, 
alcoholic intemperance, and certain predisposing 
diseases, hardly come within the range of practical 
sanitation. For their mitigation we must look to 
the spread of education and the advance of public 
opinion. 

All sanitary improvements tend to reduce the 
mortality from tubercle, but the special protective 
measures which have been advocated from time to 
time may be enumerated as follows : — 

1. The drainage of the subsoil. 

2. The ventilation of dwelling houses, factories, 
workshops and school rooms, and the provision of 
sufficient window space to admit of the free 
penetration of sunlight and air. 

3. The artificial illumination of workshops and 
offices by the arc electric light instead of gas. 

4. The prevention of overcrowding. 

5. Efficient sanitary supervision of dairy farms, 
dairies, and milkshops. 

6. The periodical veterinary inspection of milch 
cattle and the slaughter and destruction of tuber- 
culous animals. 

7. The penalisation of the sa!e of the milk of 
cows affected by tubercle. 

8. The boiling or sterilization of milk before 
consumption. 

9. A proper inspection of meat and the more 
stringent regulation of slaughter-houses. 

10. The dissemination among the working classes 
of information as to the causation of phthisis, and 
the precautions necessary to prevent its develop- 
ment and spread. 

11. The cleansing and disinfection of rooms in 
which phthisical persons have lived and died. 

12. The regulation of certain dusty trades. 



THE ANIMAL TUBERCULOSES AND 
THEIR RELATION TO HUMAN TUBER- 
CULOSIS.* 

This exceedingly interesting and altogether read- 
able book will be found very useful to medical 
officers of health, veterinary surgeons, and all con- 
cerned with the rearing of stock or the production 
of milk. Apart from the direct ami of the author, 
the work shows the inestimable advantage to man- 
kind, likely to result from the two professions 
(which are, in certain important respects, really 
one) working together. The reader has placed 
before him a clear, compact, up-to-date scientific 
treatise on the tuberculoses of cattle and other 
animals in domestication from the point of 

• By Ed. Nocard, Professor in the Alfort Veterinary 
College. Translated by Harold Scurfield, M.D., Ed. 
D.P.H., Camb. (Bailliere, Tindall, and Cox, 1895.) 8vo. 
pp. 143. 



94 



RELATION OF ANIMAL TO HUMAN TUBERCULOSIS. 



view of an eminent veterinary professor. Among 
many notable sections and parts may be specially 
mentioned — the lucid statement of the different 
stages and diagnostic signs of tuberculosis 
in cattle ; the observations on bacteriological 
diagnosis ; the description of the modes of pro- 
curing specimens of the bacillus ; the section on 
the heredity of the disease ; the historic accounts 
of the widely-spread views as to the contagiousness 
of phthisis in past times, and the vigorous measures 
formerly taken for its notification, isolation, and 
disinfection ; the proof of itsinoculability in 1865 ; 
the introduction of tuberculosis among Danish 
herds ; its former prevalence and present rarity in 
Parisian dairies, and the cause of its cessation ; the 
extent of bovine tuberculosis in different countries 
at the present time ; illustrations of the spread of 
the disease from man to cattle and vice versa ; the 
curability of tuberculosis by creosote, etc. 

For all of what the author so admirably tells 
us on these and many other divisions of the subject, 
we owe him nothing but praise and thanks. But 
his conclusions on two important practical points 
are, we submit, open to criticism. Firstly, he is a 
professed out-and-out (though, according to his 
own admission (pp. 89 and 95), a thoroughly 
unsuccessful) opponent of the practice of "total 
seizure " of the carcase in the case of beef affected 
partially with tuberculosis. Secondly (pp. 96 and 
97), he declares the milk of a tuberculous cow nc-t 
to be virulent so long as the udder remains free 
from tuberculous lesions. As arguments against 
these very dangerous (if unfounded) doctrines, let 
us examine the evidence afforded by the author's 
own statements and quotations from other sources 
in different parts of the book. 

With regard to the use for human food of the 
flesh of an animal affected in any degree with 
tuberculosis, in discussing the question " are the 
muscles of the tuberculous animal virluent ? " the 
author says (transl. p. 87), " Certainly it would 
seem that, as the experiments of Chauveau have 
shown the danger of the ingestion of tubercu- 
lous material, and as the custom of eating meat 
grilled, that is to say, insufficiently cooked in its 
central parts, is becoming common, the meat of 
the tuberculous animal ought to be forbidden as 
food." He then proceeds to state that three 
important Veterinary Congresses in Paris, held in 
1888, 1889, and 1891, "affirmed the necessity for 
the total seziure, however good the ajjjjarent quality 
of the meat, and however limited the tuberculous 
lesions might be." Yet M. Nocard protests against 
this measure as unjustifiable and severe, objecting 
(pp. 89 and 90) to the conclusions of the upholders 
of this resolution on the ground that in the experi- 
ments on which they are based, the rnuscle juice of 
only 10 or 20 per cent, of the tuberculous animals 
used proved virulent when injected into the peri 
toneal cavaties of not more than 30 per cent, of 
the guinea pigs experimented on ; arguing {n) 



that the failures prove that the meat of tubercu- 
lous cattle seldom contains tubercle bacilli, and 
then only in very small numbers; and (/') that the 
successful experiments with the peritoneum of 
guinea pigs do not justify the conclusion that the 
meat used as food would have tuberculized the 
person so consuming it. Are the latter conclusions 
of the author consistent with his admission as above 
quoted ? Even were we prepared to assume that 
they are justifiable, since it is admitted that the 
consumption of the flesh of a tuberculous animal 
is sometimes dangerous, what guarantee is there of 
safety in any given case ? The author says (p. 57), 
" The lymphatic gland plays the part of a barrier 
which the bacillus only succeeds in passing when 
the gland has been almost entirely destroyed ; '' 
and further on (p. 58) it is affirmed that tubercu- 
losis is primarily a local disease, and remains so, 
" in spite of the increase in number and importance 
of the foci of the disease as long as the bacilli, on 
their onward march, have not gained access to the 
bloodstream," What authority is there for either of 
these statements ? If the first be correct, how are 
we to account for acute general miliary tuberculosis 
without previous local lesion, or to explain the 
simultaneous ai)pearance of the disease in several 
parts of the body remote from each other without 
the occurrence of miliary tuberculosis ? The second 
proposition of the author might with equal reason 
be extended to scarlet fever, or any other infectious 
disease, but who would think of these diseases as 
local } 

The author's use of the term " successive 
multiple localizations," (p. 59) is, apart from its 
scientific aspects, for practical reasons objectionable, 
since it leads to the obvious conclusion that there 
is no need to destroy a carcase of meat, no matter 
how extensively tuberculized, so long as the disease 
has not taken the miliary form. Such a conclusion 
is both repugnant to all old-established ideas as to 
purity of the food we are to eat, and is opposed to 
the obvious teaching of the most recent scientific 
knowledge, since the re-action of tuberculin, if it 
proves anything at all, establishes beyond question 
the all-pervading nature of tuberculosis, even in an 
apparently healthy animal, no matter how minute 
the visible appearances of disease in the cat case. 

Happily, M. Nocard does not extend to pork 
his leniency towards beef, as regard tuberculosis. 
He says (p. 115), "The muscle-juice of the tuber- 
culous pig is very often virulent," and expresses his 
approval of the seizure of such animals. But to 
condemn in the one case what would be passed in 
the other will apjicar to most medical officers of 
health to be drawing too fine a line for publ c 
safety. 

We are unable to agree with M. Nocard in his 

views (p. 91 ) as to the incomjjleteness of the proof 

afforded by those experimentalists who have given 

tuberculosis to animals by the digestive tract. 

'^ hese exneriments, to our mind, leave less to be 



FOWL DIPHTHERIA AND PUBLIC HEALTH. 



95 



desired than his own, which, in addition to being 
entirely negative, are, at best, no argument as to 
\}c\Q. fitness of the flesh of tuberculous cz.\.Wt for food, 
but merely show it to be less certainly dangerous 
when swallowed than when injected into the 
peritoneum. 

M. Nocard admits (p. 95) the milk of tubercu- 
lous cows to be sometimes virulent, but, in his 
experience, never so when the udder is free from 
tuberculous lesion. But the negative results of his 
experiments on this point are overborne by those 
of Hirschberger, and some of those of Bang, both 
of which are quoted. In the author's illustration 
of the "fine children . . . put out to nurse in 
the country soon after their birth" (p. 71) who 
escaped from "the hereditary (?) tuberculosis to 
which their elder brothers had succumbed," what 
does this lesson prove — if not the infective 
character of the mother's milk when ingested ? 

Comparison with the original shows that in his 
translation of the book Dr. Scurfield has followed 
his author carefully and accurately, a by no means 
easy thing to do in the rendering of French 
scientific phraseology into the corresponding 
English. The only word which appears to have 
given him difficulty is *' m^decins,'' for which, as 
applied to the diseases of animals and man, there 
is no exact English equivalent. 

The valuable service rendered to hygiene by 
Dr. Scourfield in his self-allotted task will be 
fully appreciated by a large class of readers. Even 
to those who are fair French scholars this good 
translation of such a technical work will be found 
a great convenience. To others it is much more, 
introducing to them, as it does, an able treatise on 
a disease which has, perhaps, more than all others, 
a vital and widespread interest for mankind. 

X. 



FOWL DIPHTHERIA AND PUBLIC 
HEALTH. 

BY 

y. Lawrence-Hamilton, M.R.C.S. 

Among the many magnificent up - to - date in- 
dustrial monographs published by the Bureau of 
Animal Industry — one of the most useful branches 
of the U. S. Department of Agriculture — the 
exhaustive 1895 treatise on the Infectious Diseases 
of Poultry is specially worthy of attentive study by 
poultry breeders and hygienists. 

This book is artistically illustrated with numerous 
original plain and coloured bacteriological and 
pathological plates, admirably arranged by Drs. 
Theobold Smith and Veranus Moore, who have 
had the great advantage of working under the 
expert direction of Dr. D. E. Salmon, the chief of 
the Bureau of Animal Industry. 

It may be well to recall the summing up of the 
relationship of fowl diphtheria to public health, as 



expressed by Drs. Theobold Smith and VeranuS 
Moore in the following extract : — 

"A comparison of the bacillus of diphtheria in 
man (Klebs-Lceffler) with the one described by 
Lceffler as the cause of diphtheria in fowls, shows 
that morphologically and in their pathogenesis for 
experimental animals, the two organisms are in no 
way alike. There is also a marked difference in 
the nature of the exudates in fowls and in man. 
The non-identity of these diseases has been clearly 
pointed out by Menard {Revue (Tllygiene, tome 
XII. (1890), p. 410). Although these diseases are 
shown by several observations to be unlike in their 
etiology and the character of their lesions, the 
transmission of fowl diphtheria to the human 
species, and vice versa, is affirmed by several 
writers. 

" Gerhardt {Revue f Thierheilkunde u. Viehzucht, 
Bd. VI. (1883), p. 180) reports four cases of diph- 
theria among six workmen who had charge of several 
thousand fowls, many of which died of diphtheria, 
in Wesselhausen, Baden. There were no other 
cases of diphtheria in the neighbourhood, and the 
evidence was quite conclusive that the disease was 
contracted from the affected fowls. It is also 
stated that an island on the north-eastern coast of 
Greece had been free from diphtheria for at least 
one-third of a century, when a dozen turkeys, 
several of which were diseased, were introduced. 
Soon afcerwards diphtheria appeared in a house 
near the garden where the turkeys were kept. The 
disease became epidemic on the island, causing 
the death of 36 people, or over 40 per cent, of 
those attacked. 

" Debrie (reviewed in Centralblatt f. Bakterio- 
logie, Bd. XIII. (1893), p. 730) reports briefly the 
clinical history of six cases of diphtheria which 
occurred in the garrison of Sebdou, and states that 
while the sixth case (two were fatal) was still under 
treatment in the hospital, ten fowls kept in a 
house not far from the hospital were attacked with 
diphtheria, and exhibited symptoms strikingly like 
those present in the human beings. Five of the 
ten fowls died, and two heads were sent to Arloing, 
who confirmed the diagnosis of fowl diphtheria. 
The fowls were fed by a hospital attendant, and it 
was ascertained that an identical outbreak had 
occurred among the fowls at a neighbouring place, 
from which one of the six cases of human diph- 
theria had been brought. Debrie is inclined to the 
view that human diphtheria is transmissible to 
fowls, and fowl diphtheria to man. 

"Cole {Archives of Pediatrics, XL (1894), p. 
381) reports an interesting case near Jacksonville, 
111. A flock of fowls became affected with a 
disease characterized by an exudate on the mucosa 
of the head. Some of the exudates emitted a foul 
odour (Cole's description of the disease shows that 
it was undoubtedly the same as the one I have 
studied). As the weather was cold, one of the 
chickens was taken into the house where a child 



96 



ETIOLOGY OF DIPHTHERIA. 



about two and a half years old fondled it. Four 
days later the child was taken sick, apparently with 
diphtheria, from which it died. There were no 
other cases in the neighbourhood, and the affected 
chicken was the only possible source of infection. 

"The diphtheritic disease of fowls, reported by 
Loir and Ducloux {Joe. cit.), in Tunis, in 1894, 
spread to the people of that place, resulting in an 
epidemic of serious proportions. Menard refers to 
the fact that men employed to feed young squabs 
contracted diphtheria by blowing the masticated 
food into the mouth and crop of squabs (or young 
unfledged pigeons) suffering with that disease. 
Schrevens {Bul/etiti de I' Acad. Roy ale de Mid. de 
Belgique^ VIII. (1894), p. 380) reports several 
cases of diphtheria in children, in which he traces 
the source of infection to certain poultry. 

" Although the number of reported cases of the 
transmission of fowl diphtheria to the human 
species, and vice versa., is small in comparison with 
the extent of the disease in poultry, the evidence 
that such a transmission is possible is quite suf- 
ficient to discourage the careless handling of 
diseased fowls. It is a quite common practice, 
especially in the rural districts, to bring the sick 
chickens into the house for treatment, where the 
children of the household are allowed to fondle 
them at will. It is not improbable that when this 
disease is thoroughly investigated, the number of 
cases of direct infection from this source will be 
found to be much larger than it is at present 
supposed. Until such investigations are satisfac- 
torily completed, the indiscriminate handling of 
diphtheritic chickens, especially by children, and 
the exposure of fowls to the infection of diphtheria 
in the human species, whereby they may become 
carriers of the virus, should be strenuously 
avoided." 



ETIOLOGY OF DIPHTHERIA. 

St. Pancr.'^s. 
Dr. J. F. J. SvKES, in his annual report, brings up 
to the present dale his interesting study of the 
metropolitan mortality from diphtheria, which was 
published in Public Health, Vol. VI. pp. 331 - 
334. He states : — "Contrary to our experience up 
to 1890, the last four years show that the mortality 
of diphtheria has taken to epidemic fluctuation 
like scarlet fever, and is no longer comparatively 
steady like enteric fever. Further, unlike i)rtvious 
years, the rise and fall of the mortality of scarlet 
fever and diphtheria have occurred simultaneously. 
Again, in reference to the proportion of the mor- 
tality from throat diseases caused by diphtheria, 
the experience of the past four years is not quite 
according to previous ex{)erience. Previous ex- 
perience has shown that the fall in the number of 
deaths from throat diseases other than diphtheria 
corresponded with the rise in the number of deaths 
from diphtheria ; but the last four years show that 



there is no longer a correspondence between the 
two sets of figures, the deaths from diphtheria 
having increased in number out of all proportion 
to the diminution in the number attributed to 
other throat diseases, and this is specially ob- 
servable in 1893, ^"^ '" ^ lesser degree in 1892. 
An enormous increase in the mortality from all 
throat diseases has taken place in the last four 
years, and this mortality is wholly and solely due 
to diphtheria." 

Dr. Sykes sums up his further conclusions as 
follows : — J 

I. — That there appears to be little doubt that a 1 
distinct change of type has taken place in a large 
proportion of disease affecting the throat, account- 
ing in the first place for the diminution in the 
mortality from other diseases of the throat and its 
displacement by diphtheria. 

2. — That it is very evident that the change of 
type is from a non-infectious to an infectious form 
of disease, accounting for the enormous increase of 
diphtheria mortality over and above the diminution 
of that of other throat diseases during the last few 
and quite recent years. 

3. — That diphtheria has become an acute epi- 
demic disease with far more sudden variations in 
extent and intensity of prevalence than formerly, 
and that we may expect epidemic and non-epidemic 
years with marked seasonal prevalence in the 
future. 

West Ham. 

Dr. Sanders remarks : "Apart from two localized 
outbreaks in connection with schools, diphtheria 
showed a phenomenal tendency to increase in the 
borough during 1894, to an extent greater in my 
opinion than the increase shown in the other large 
towns. Doubtless this increase is due to a variety 
of causes, the special characters and varying con- 
ditions of which are not at present recognized, but 
of this I feel sure, that although, owing to the 
virulence of the disease in many cases, and the 
consequent publicity given to the anti-toxic treat- 
ment of the disease, diphtheria has had much 
public attention given to it in recent times, yet 
there is not the same care and rigour devoted to 
the prompt and continued isolation of the slighter 
cases of diphtheria as in many other intectious 
diseases; a laxity due possibly to the fiequent 
absence in this disease of objective symptoms 
which, as in the desquama'ion of scarlatuia and 
the diarrhoea of enteric fever, force themselves on 
the notice of both medical attendant and friends. 
In this way children in a still infectious condition 
are allowed too early to associate with the unpro- 
tected, with the natural result of many unnecessary 
secondary cases." 

Bedford. 

Dr. Prior says : "Diphtheria and scarlatina are 
diseases which have, in some particulars, a strong 
similarity ; both are infectious, though the one with 



ANALYTICAL NOTES. 



97 



much less regularity than the other; both are 
characterised by a throat affection occasionally 
very severe; both are apt to be attended with 
severe constitutional disturbance. In the course 
of an epidemic of scarlatina, many cases are to be 
met with in which the eruption has been slight or 
almost nil, while the throat symptoms have been 
severe, and these, I believe, are occasionally 
certified as diphtheria. Under the circumstances 
it is often very difficult, almost impossible, to 
distinguish ; but, on the other hand, in an out- 
break of genuine diphtheria, it is very rarely, if 
ever, that cases of scarlatina are to be met with." 

Poplar. 
We owe an apology to Dr. F. W. Alexander, 
M.O.H. for Poplar and Bromley, for not having 
earlier drawn attention to his valuable report on 
" The Cause of Diphtheria : its suggested relation 
to the Main Drainage of London." The report in 
question had been accidentally misplaced. The 
whole report is worthy of careful consideration. 
Dr. Alexander summarises his report as follows : — 

1 . Diphtheria was first recognised in this kingdom 
in the year 1845. 

2. Water-closets, invented about 1813, became 
general in the better class of houses about 1828-33. 

3. On January ist, 1849, within the City of 
London, an Act was enforced compelling persons 
to drain into sewers. 

4. In 1856 the Metropolis Management Act 
enforced that all houses in the Metropolis should 
be drained into sewers. 

5. In 1855 the Registrar- General distinguished 
the diphtheria and scarlet fever deaths. In the 
London tables the deaths from these two diseases 
were not separated until 1859, three years after the 
enforcement of the Metropolis Local Management 
Act. 

6. The mortality from diphtheria, in proportion, 
has diminished in England and Wales, and 
increased in London, more especially during the 
years 1881 to 1890, 

7. The Bye-laws to the 1875 Public Health Act 
for England and Wales, except the Metropolis, 
were enforced in the year 1877' or thereabouts; 
consequently, the Provinces in sanitary work were 
in advance of the Metropolis. 

8. The tests which are most commonly used for 
testing drains will not always reveal defects in 
drains laid under the earth ; consequently, many 
drains may be declared sound which are really 
unsound. The joints of drain pipes were not 
made in past years with the same care as in recent 
years. 

9. Diphtheria prevails more in the colder than 
in the warmer months, through the interchange of 
the soil and atmospheric airs, and also on account 
of the ground-air being drawn into the houses by 
fires. 

10. The County Council's main sewers of the 



Metropolis are inadequate for their present-day 
requirements. The Poplar District, through which 
the three Middlesex main sewers run, suffers from 
diphtheria to a greater extent than the other London 
districts north of the Thames, and more especially 
in the immediate vicinity of London County 
Council's main sewers and their main and tributary 
branches. 

II. The Isle of Dogs, which is exceedingly 
damp, and was liable to sewage floodings, suffers 
less from diphtheria since increased pumping 
accommodation has been afforded. 

I am of an opinion that when increased sewage 
accommodation is afforded in the Metropolis, and 
when all drains have been made watertight — as 
they no doubt will be on account of the work 
carried out by the Metropolitan local authorities, 
—and when the West Ham sewage is pumped on 
to the Northern Outfall instead of being discharged 
into the rivers Lea and Thames, then the " microbic 
nitrifying earth " in course of time, by natural 
processes, will get rid of the harmful matter 
deposited through the floodings and faulty drains, 
and diphtheria will cease to exist. 



ANALYTICAL NOTES. 

Aug-Khak, a Chinese purple dye, is now used 
on the Continent for colouring articles of food. It 
is the product of a particular ferment on cooked 
rice, but the exact method of preparation is un- 
known. Its presence in red wine may be detected 
by agitating a few c.c. of the wine with chloroform, 
which will be at once tinged red if Aug-Khak has 
been used. As a confirmatory test, distinguishing 
it from analine dye, it may be precipitated with 
mercuric oxide. Aug-Khak coloured wine is also 
turned brown by adding solution of ammonium 
hydrate (i"2oo) in excess. 

For the detection of martins yellow in macaroni 
F. Schaffer uses the following method. About 
twenty grams of the macaroni reduced to small 
pieces are shaken with 40 c.c. of warm 50-60 per 
cent, alcohol. If colouring matter is present the 
alcohol will be yellowed. On adding hydrochloric 
acid, if the colour is due to martins yellow, it will 
be discharged ; if metanil yellow, it is changed to 
red ; and if saffron, it will remain unchanged. 

As a means of detecting whether the poorness 
of a milk is due to fat abstraction or added water, 
Dr. Lescceur advocates the determination of the 
specific gravity of the serum. The casein is coagu- 
lated by adding rennet and the serum separated 
by filtration. The density of the serum is found 
to average from 1-031 to 1-029, but certain genume 
samples have been met with as low as 1-027, and 
this is taken as the standard from which is calcu- 
lated the percentage of added water. The casern 



98 



LAW REPORTS. 



is also weighed, and found to amount from 67 to 
71 grams per litre. The following results were 
obtained by experiment with a pure milk : 



Weight of 
Extract. 



Density of 
Serum. 

Pure milk ... 1030 ... 70 grams 

,, ,, + 10 per cent, water ... i"0275 ... 64 ,, 

„ „ + 20 „ , 1-0251 ... 59 „ 



+ ^o 



I -0230 



54 '5 



Naturally curdled milk may be examined in the 
same way, the results- being found to differ very 
slightly from the neutral serum obtained by 
precipitation with rennet. 



A simple method of proving whether a sample 
of acetone is anhydrous or not is by agitating 
equal volumes of it and petroleum ether (p.p. 40 
to 60'' c). If a trace of water is present the 
acetone and ether will separate into two layers. 



M. Dennstedt and T. Voightliinder have taken 
advantage of the blue compound starch forms with 
iodine in devising a process for the quantitative 
estimation of starch colorimetrically. They state 
that when very little starch is boiled with a large 
quantity of water, the emulsion formed behaves as 
a solution. A standard solution is made by boil- 
Jog o'5 gram of pure starch in water, and when 
cool making up to a litre. Any starch cellulose 
present is allowed to subside, and 5 c.c. of the 
supernatent liquid is pipetted into several 100 c.c. 
cylinders ; 0-5 gram of the starchy substance to be 
examined is treated in a similar manner, and 
different quantities of it also put into a series of 
cylinders. All are now made equal in volume by 
the addition of water, and the temperature of all 
being equal, one drop of a solution of iodine in 
potassium iodide is added, and the colour of a 
cylinder of the unknown quantity starch matched 
with one containing a known quantity. 



H. Fresenius and A. Shattenfroh find by experi- 
ment that iron, zinc, copper, and aluminium may 
be estimated by simply incinerating the oil. Lead 
is better estimated by first dissolving the oil in 
ether, and then shaking with dilute sulphuric acid, 
when the lead is precipitated as sulphate. All 
metals may be extracted by agitation with dilate 
nitric acid. 



Menthol Snuff.— Messrs. Burroughs, Well- 
come & Co. have issued a new preparation which 
is likely to be most useful. It is called menthol 
snuff, but contains not only menthol, but ammo- 
nium chloride, camphor, and one-sixth per cent, of 
cocaine, made up with lycopodium. The local 
anaesthetic and antiseptic action of this remedy is 
marked, and the form in which it is issued renders 
it convenient nnd attractive in use. 



LAW REPORTS. 

Moore v. Pearce's Dining and Refreshment 
Rooms (Limited). 

Adulieraiion of Food — Margarine Acf, 1887 — 
Exposicre for Sale by Retail — Label and 
Wrapper. 

This case raises a novel question under the Mar- 
garine Act, 1887 — the point being whether the 
provisions of that Act with reference to the sale of 
margarine by retail apply to the case of margarine 
spread upon slices of bread, and sold in that form. 

It appears that the defendants were keepers of 
refreshment rooms, and that among the articles 
sold by them were slices of bread, upon which was 
spread a mixture of butter and margarine. A 
notice was posted up in the shop, stating that 
nothing was sold there but a mixture of the best 
Danish butter and margarine. The complainant, 
an officer of the Butter Association, went to the 
refreshment rooms in question, and having par- 
taken of coffee and slices of breadand butter, asked 
the attendant for four dry slices and three-penny- 
worth of butter. He was informed by the attendant 
that they had only a mixture of butter and mar- 
garine, which was only sold spread on slices, or 
given away with haddocks (which were also sold 
by the defendants). The attendant, however, pro- 
ceeded to cut a piece off a lump of the mixture 
standing on a shelf, and weighed it. The lump 
referred to had no label of " Margarine " on it. 
The manager then came up, and asked the com- 
plainant what he wanted, and told him that the 
company did not supply any margarine to be taken 
out. The complainant said he wanted it for 
analysis, and offered threepence for it, but the 
manager refused to serve him. 

The complainant then summoned the defendants 
for having margarine exposed for sale and not 
marked " Margarine," and for selling margarine by 
retail without delivering the same to the purchaser 
in or with a paper wrapper on which was printed 
the word " Margarine," as required by Section 6 
of the Margarine Act, 1887. 

On the hearing before the magistrate, it was 
proved that it was no part of the business of the 
defendants to supply margarine by retail, although 
they were in the habit of giving away small pieces 
of the margarine to the purchasers of haddocks. 
The magistrate dismissed the complaint, being of 
opinion that the Act only applied to shops, such as 
butter shops or grocers' shops, where margarine 
was usually sold, and that the lump on the shelf 
was only there for the purpose of being used to 
spread on bread, and was not exposed for sale 
within the meaning of the Act ; and that therefore 
neither it nor the slices required a label. 

The magistrate.', however, stated a case for the 
opinion of the Queen's Bench Division upon the 
question of law involved. The case was argued or 
the 25th October last, before a Divisional Court, 



LAW REPORTS. 



99 



consisting of Lord Russell, L.C.J., and Cave, J., 
when the decision of the magistrate was upheld. 

Lord Russell, in giving judgment, observed that 
the provision in Section 6 of the Margarine Act, 
1887, requiring that every person selling margarine 
by retail should sell it either in a package or 
wrapper, showed that the words "exposed for sale 
by retail," where wholly inapplicable to the business 
as it was carried on in this case, and that it would 
be ridiculous to apply it to margarine that was put 
on the bread or eaten with the haddock. With 
regard to the lump of margarine upon the shelf, the 
Court were of opinion that it was not exposed for 
sale by retail, and that it did not require to be 
labelled. 

The case is reported in 12 Times Law Reports, p. 2 ; 
100 Law Times, p. 10 ; 40 Solicitors^ Journal, p. 12 ; 59 
fustice of the Peace, p. 692. 



ToLER V. Bishop. 
Adulteration of Food — Marg.irine Act, 1887, s. 6 — 
Selling by Retail — Paper Wrapper. 

This was an appeal by special case from the 
decision of a Metropolitan police magistrate, dis- 
missing a summons under Section 6 of the 
Margarine Act, 1887. 

It appears that the appellant, an officer in the 
employ of the Butter Association, went into the 
shop in which the respondent was employed, and 
asked for 2 lb. of a mixture of butter and mar- 
garine, known as " Le Dansk." The pieces of 
margarine from which that sold was taken were 
not exposed to the view of customers coming into 
the shop. The margarine in question was placed 
by the respondent in two cardboard boxes, each of 
which bore stamped on it, partly on the box itself, 
and partly on a paper band fastened round it, .the 
word " Margarine " in letters a quarter of an inch 
square. The two boxes were then wrapped up in 
brown paper by the respondent, and delivered to 
the appellant. This outer covering did not bear 
the word " Margarine " upon it. The appellant 
subsequently summoned the respondent for selling 
margarine by retail without delivering the same in 
or with a paper wrapper bearing the word " Mar- 
garine," as required by the Margarine Act. 

On the hearing of the summons, it was alleged by 
the respondent that the boxes were wrapped up in 
the brown paper cover at the request of the appel- 
lant, but this was denied. The magistrate dis- 
missed the summons, on the ground that no offence 
was disclosed, but stated a case for the opinion of 
the High Court upon the question of law involved. 

The case was argued before a Divisional Court 
of the Queen's Bench Division, consisting of Lord 
Russell, L.C.J., and Cave, J., on the 25th October 
last, when the Court affirmed the decision of the 
magistrates. 

Lord Russell, in giving judgment, stated that he 
should have hesitated long before holding that the 



box alone was not a wrapper, but that he had no 
doubt at all that the box and the paper band 
together amounted to a wrapper within the sec- 
tion. That the wrapping up of the boxes did not 
prevent the boxes from being wrappers in them- 
selves ; and, as they were in order, that was 
sufficient. 

Cave, J., on the other hand, stated that the 
paper wrapper mentioned in Section 6 of the Act 
meant outer wrapper. 

The Court dismissed the appeal, but without 
costs, since it did not appear how the brown 
paper came to be put outside the boxes. 



The case is reported in 12 Times Law Reports, p. 3 ; 
100 Law Times, p. 10 ; and 59 Justice of the Peace, 
p. 692. 

Kershaw v. Taylor. 
Metropolis Management Acts — Sewer— Drain — 
Liability to Repair — Ej^ectof Builder s Disobeying 
Order of Sanitary Authority. 

This case has been heard on appeal in the Court 
of Appeal, and the decision of the Queen's Bench 
Division (reported 8 Public Health, p. 25) has 
been affirmed. 

The facts of the case are fully set forth in the 
previous report. 

The Court (^Lord Esher, M.R., Kay and Smith, 
L.J.J.) held that the drain in question was not a 
drain for draining a group of houses by a combined 
operation under the order of a District Board, 
there being no order sanctioning the use of one 
drain for the four houses ; that, as it was used for 
the drainage of more than one house, without such 
order, it was a "sewer," and not a " drain," within 
Section 250 of the Metropohs Management Act, 
1855 ; and that a subsequent owner of one of the 
houses was not stopped by the misconduct of the 
builder, of which he had no knowledge, from setting 
up as a defence to a summons against him for a 
nuisance on his premises arising from such drain 
that it was a " sewer," and, therefore, repairable 
by the Board. 



The case is reported in La-iv Reports (1895), 2 Q.B., 
p. 471 ; 59 Justice of the Peace, p. 516 ; 73 Laxu Times 
Retorts (N.S.), p. 274. 



The British Insulated Wire Company 
(Limited) v. The Prescot Urban District 

Council. 
Contract by Urban Authority — Validity — Omission 

to specify Penalty — Public Health Act, 1875,5-. 174. 

This case illustrates the necessity for strict obser- 
vance by municipal corporations and other urban 
authorities having occasion to enter into contracts 
for the purposes of the Public Health Act, 1875, 
of the provisions of that statute as to the mode in 
which such contracts are to be framed. 

Section 174 of the Act provides that with 



A STUDY OF THE LAWS OF INCREASE OF POPULATION. 



respect to contracts made by an urban authority 
under that Act, the following regulations shall be 
observed: — (i) Every contract whereof the value 
or amount exceeds ^50 is to be in writing, and 
sealed with the common seal of such authority ; 
and (2) Every such contract is to specify the 
works, materials, matters, or things to be furnished, 
had, or done, the price to be paid, and the time or 
times within which the contract is to be performed, 
and shall specify some pecuniary penalty to be 
paid in case the terms of the contract arc not duly 
performed. 

In the present case, it appears that in November, 
1892, the plaintiffs and defendants entered into a 
contract in writing, duly sealed with the seal of the 
defendants, whereby the plaintiffs agreed to Hght 
the streets of the defendants' district by means of 
electricity for a period of five years. 

The contract contained stipulations as to the 
materials to be supplied, prices to be paid, etc., 
and also an arbitration clause ; but it did not con- 
tain any clause specifying pecuniary penalties to be 
paid in case its terms were not duly performed. 

The plaintiffs had duly performed their part of the 
contract, and would be entitled to the sums claimed 
in the action if the contract was valid and binding 
upon and enforceable against the defendants. 

The question for the Court was whether the con- 
tract was void, by reason that it did not specify 
some pecuniary penalty to be paid in case the 
terms were not duly performed. 

The Court (Pollock, B., and Wright, J.) held 
that the provisions of Section 174 of the Public 
Health Act, 1875, with respect to penalty, were 
not directory merely, but essential and obligatory, 
and that the contract could not be enforced against 
the urban authority. 



The case is reported in Law Reports (1895), 2 Q.B., 
p. 463 ; and in 11 Times Law Reports, p. 557. 



The British Insulated Wire Company 

(Limited) v. The Prescot Urban District 

Council. (On Appeal). 

Contract by Urban Authority— Validity — Omission 
to specify Penalty— Public Health Act^ 1 875, j. 1 74. 

This was an appeal against the decision of the 
Divisional Court in the last-mentioned case. 

Upon the hearing of the appeal, it was stated 
that the Local Government Board would sanction 
the payment of the arrears due under the contract 
which the Divisional Court had held to be invalid, 
and that it had been arranged that a new contract, 
containing a penalty clause, should be entered 
into in place of the invalid contract. 

The Court thereupon dismissed the appeal, 
without delivering any judgment. 

The case is rei>ortcd in Imw Reports (1S95), ^ QB., 
p. 538. 

H. T. 



A STUDY OF THE LAWS OF INCREASE 
OF POPULATION. 

By M. Joseph KorSsi, Director of the Municipal Bureau 
of Statistics in Budapest. 

It is of the utmost importance, both for statistical 
and general purposes, to know the limit of human 
fecundity and the rapidity with which the human 
kind propagates. The greater or less fecundity 
of a nation is one of the conditions of its political 
power and influence. On the other hand are 
produced the evils of over-population and deficient 
work for each. Thus are produced the misery of 
the masses, the great movements of socialism, 
communism, and anarchism which occupy to such 
an extent the attention of the present generation. 

The principal cause of the augmentation of 
population is conjugal fecundity. The exact 
statistical expression of this is very embarrassing. 
The most usual comparison is between the 
marriages contracted in the course of a year, and 
the infants born during the same year, the uncer- 
tainty of which, as a measure, is well known to 
statisticians. The uncertainty is increased when 
we come to inquire what changes in fecundity are 
produced by race, social position, well-being, and, 
above all, the decisive factor of age. The influence 
of the last factor must be measured in the most 
exact fashion, as we are here dealing with a purely 
physiological phenomena, which can be treated by 
the quantitative method. Fecundity is a function 
of age, reaching its maximum at a certain age, and 
terminating more slowly at zero. One might 
imagine, therefore, that the variations of fecundity 
produced by the advance of age, ought to follow a 
regular course, and that its graphic representation 
would describe a regular curve. To arrive at this 
law, observations should be for single years, rather 
than for quinquennia. Further, as every concep- 
tion is the product of two factors, and the potential 
power of one of the parents is modified by that of 
the other, particularly by age, the law according to 
which fecundity is modified by age can only be 
ascertained by combined observations of the age of 
the two parents. Assuming, then, the duration of 
the fecundity of the male is about 50 years, and 
that of the female about 40 years, the question as 
to the degree of conjugal fecundity, which at first 
appears so simple, can only be solved by a division 
into at least 2,000 questions, since each year of age 
of one parent ought to be combined with each year 
of the age of the other. 

Results of these observations are given in 
tables of tiatality, A similar table will give us for 
each year the probability of a birth for each com- 
bination of ages of fecundity. There has been a 
possibility of constructing such tables of natality 
in ]5udapcst since 1889, as the birth-returns state 
inter alia the ages of parents, previous births in 
same family, ^:c. 

What is still required, is to know the number 



A STUDY OF THE LAWS OF INCREASE OF POPULATION. 



lOI 



of couples living among the same combinations of 
ages, and then, by the comparison of these figures 
with the corresponding births, we learn the pro- 
bability of a birth for each combination of ages. 
This is possible by means of the census returns of 
1891. 

The observations have been continued through 
four years, and embrace 46,931 births. From these 
we learn that of 1,000 total marriages existing in 
Budapest, there were, in the course of a year, 163 
births. This result cannot be scientifically utilised, 
inasmuch as many of the total marriages have 
passed the period of prolificity. It is necessary to 
apply the same principle as in statistics of mortality, 
giving a separate statement for each year of life. 
I had the honour to present such tables to the 
Royal Society of London, just 200 years after the 
first tables of mortality, by Halley, first saw the light. 
(Phil. Trans.) 

The facts may be stated first mono-sexually. They 
show that the fecundity of the female reaches its 
maximum between the eighteenth and nineteenth 
year, descending thence in a regular line to the age 
of 45-50 years, when it ceases. Young mothers 
under 18 years of age do not seem to be yet in 
full possession of their reproductive power. Of 
100 marriages at these ages there are 36 to 38 
infants. From 18 to 20 years, fecundity reaches 
its maximum of 40 per cent. At 25 years it is 32 
per cent., at 30 years it is 24 per cent., at 35 years 
17 per cent., at 40 years scarcely 7 per cent., at 
50 years o'l per cent. 

Men attain the maximum of their fecundity at 
25-26 years, when it is 35 per cent., at 35 years it 
has fallen to 23 per cent., at 45 to 9*5 per cent., 
at 55 to t'2 per cent., and at 65 to 0-5 per cent. 
The figures relate to effective, and not to physiolo- 
gical fecundity. The fecundity of marriages newly- 
contracted will approach most nearly to physiolo- 
gical fecundity, prudential considerations frequently 
operating later in married life. At the last census 
in Budapest, inquiry was made as to the duration 
of marriage and the number of children. From 
these were obtained the following results as to 
fecundity of marriage : — 



probability of a birth varies with the age of the 
man as follows : — 

Age of Father. Age of Mother. 





For Women Newly 
Married, 


For all 
Women, 


Age 30—34 yeari 


32-9% 


20-6% 


•> 35—39 •> 


327% 


H'7% 


„ 40—44 » 


21-4% 


5-9% 



The two columns show a difference increasing 
with age. 

Thus, at the age of 40-45, it is a rare thing to 
see a woman with an infant ; but among newly- 
contracted marriages at this age the frequency of 
births is four times as great. 

The facts may be next considered bi-sexually, 
i.e., according to the change in age of both 
parents. 

For 100 females of the following ages, the 





y 




^ 




as years. 


30 years. 


35 years. 


25—29 years 


.. 35-6% . 


•• 25-0% . 


.. 21-2% 


30—34 >. 


.• 31*2% . 


.. 23-6% . 


•• 19-9% 


35—39 1. 


.. 27-5% •■ 


.. 21-8% . 


• • 19*4% 


40—44 „ 




.. i6-7% . 


.. i4'o% 


45—49 •> 


— 


.. 14-4% • 


•• 10-9% 


50-54 •• 


— 


— 


• • 109% 



On the other hand, the fecundity of the fathers 
varies as follows with the age of the mothers : — 

Aje of Mother. Age of Father. 

y ' V 

«5 yrs. 35 ys. 45 y". 5S yrs. 

Under 20 years ... 49'i% ••. — ••• — ••• — 

20—24 „ ... 43-0% ... 31-3% ... i6-o% ... — 

25—29 ,. ... 30-8% ... 27-3% ... 18-5% ... — 

30-34 „ ... 33-5% - 237% - 144% ". 8-1% 

35-39 ., ... - - i8-9% ... 11-8 % ... 67% 

40—44 „ .„ — ... 6-6% ... 6-1% ... 30% 

These probabilities of birth may in time be 
practically utilised in the same way as the pro- 
babilities of mortality tables. The latter are the 
basis of life assurance, the former may furnish the 
basis of a new branch of assurance. 

The same tables answer the question as to the 
appropriate age of the female to secure the 
greatest fecundity. Thus a man aged 25 years 
ought, from this standpoint, to choose a wife aged 
19 years ; a man aged 35 a wife aged 21 years ; at 
40 years a wife of 24 ; at 45 a wife of 29 years 
old. They may also be employed in ascertaining 
the difference between the ages of man and wife 
which is most conducive to fecundity. Thus, 
from this standpoint, a woman aged 18-19 years 
ought to marry a man 7 years older than herself ; 
a woman of 25, a man 3 years older. At 29 years 
of age the greatest average fecundity is obtained 
with a husband of the same age, beyond 30 years 
with a younger husband. 

In a contribution to the Royal Society on my 
tables, Mr. Francis Galton made an ingenious 
attempt to reduceto a single formula the probability 
of births for numerous combinations of ages, and 
made further combinations of ages of the same 
fecundity with geographical maps for places of 
the same temperature and altitude. These lines, 
analogous to his isotherms and isobars, may be 
described as isogenes. 

When one represents graphically the tables of 
natality, the diagrams being set out from left to 
right according to the age of the mothers, and 
from above downwards according to the age of the 
fathers, the following results will be seen. Each 
combination of age will be represented by a square 
like that shown on geographical maps by increase 
of degrees of latitude and longitude. If one 
marks on each square the height of each degree of 
fecundity, one obtains a mountain in relief, whose 
highest points are in the left upper angle, i.€., in 
the youngest ages, while it declines then in all 
directions. But as men of 24-29 years are at the 



102 



REPORTS OF MEDICAL OFFICERS OF HEALTH. 



apogee of their reproductive force, there will be 
formed at the upper part of the relief corresponding 
to these years a ridge crossing the relief. If one 
follows the female fecundity for each year of age, 
one ought to cross this ridge at the 24th year of 
masculine age. In descending, one arrives by 
degrees at the same point of apogee that has been 
crossed from the other side in ascent. This shows 
that the fecundity of the female reaches its 
maximum at various ages. For example, women 
of 23 years, have with men of 23 years, a fecundity 
of 36 per cent., and the same with men of 30 
years, whilst with men at intermediate ages they 
attain the maximum degree of fertility. For 
women aged 24 years, the same degree of fertility 
is found with men of 24 years and of 30 years of 
age, and soon; women 31 years old having a 
fecundity of 25 per cent., on the one hand, with 
men 26 years old, and on the other hand with men 
30 years old. 



REPORTS OF MEDICAL OFFICERS OF 
HEALTH. 

St. George, Hanover Square. 

Enteric Fever and the Use of Thames Water 
after Flood. — Professor Corfield states : — Of the 
sixty-five cases of enteric fever in 1894, no fewer 
than twenty-nine were certified in November and 
December, and only fourteen in the three previous 
months, when the seasonal prevalence of that 
disease usually takes place ; and, on investigation, 
I find that this is usually the case, as is shown by 
the following table : — 

Cases of Enteric Fever. 





Aug., Sept 


, and Oct. 


Nov. and Dec. 


Year. 












Number of 


Average per 


Number of 


Average per 




Cases. 


Month. 


Cases. 


Month. 


1891 


6 


2 


12 


6 


1892. „ ... 


15 


5 


IS 


7 "5 


1893 


16 


5'^ 


18 


9 


1894 


14 


4-6 


29 


MS 



This follows upon the delivery of insufficiently 
filtered Thames water when the river is in flood, 
which was especially noticeable last year, the 
samples taken in November being very bad 
indeed. Some cases of this disease in London 
and elsewhere were believed to have been traced 
to the consumption of sewage-polluted oysters, 
but this cause would apply eciually to September 
and October. 

Alkalised Gas Creosote as a Disinfectant. — At 

the retjuest of your committee of works, I had a 

series of bacteriological investigations made into 

he power of various disinfectants to destroy 



organisms, the result of which confirmed the 
advice I gave to the Vestry many years ago — to 
use alkalised gas creosote as the general dis- 
infectant, and not to distribute carbolic acid to 
the public. 



ANNOTATIONS. 



The Problem of Re-housing Persons Displaced 
BY Improvement Schemes. 
The great difficulty in all improvement schemes 
is re-housing the persons displaced. Demolition 
being for the purpose of opening up to light and 
air, it is often not desirable to re-house on all or 
even part of a site. To measure the amount of 
re-housing desirable by the number of persons 
displaced is very misleading, for whereas the old 
occupiers were housed in a minimum of cubic 
space, the new occupiers will demand a maximum ; 
the amount of re-housing should therefore be 
measured by cubic space rather than by number 
of persons. It would seem a reasonable course 
to pursue to ascertain the amount of inhabited 
cubic housing space to be demolished, and to 
replace as much of this cubic housing space 
upon as much of the area as is compatible 
with the London Building Act. If it is abso- 
lutely necessary for the Authority to provide 
the rest of the required re-housing space, it is 
placed in a difficult position. Surrounded on all 
sides by crowded areas this can only be accom- 
plished, either by building upon open spaces — 
such a remedy being worse than the disease — or 
by erecting dwellings out of town, and this can be 
done as well, if not better, by private effort as by a 
Public Authority. It might be lijorth considering 
whether a Public Authority could not contract 
wi'h a private individual to supply the requisite 
cubic re-housing space as near the site of demo- 
lition as possible, or, if need be, out of town. 
But, after all, however the accommodation is 
supplied, who is to undertake that the persons 
displaced shall go into any new buildings pro- 
vided ? The only reasonable conclusion that can 
be come to with regard to re-housing after demo- 
lition is that it should be made incumbent upon 
the Authority to utilise the space to the best advantage 
and to the fullest extent permitted by the London 
Building Act. To demand more than this is to 
demand the impossible. — From Dr. Sykes' Annual 
Report^ St. Pancras, 1894. 

The Removal of Offensive Matter. 
Dr. T. O. Dudficld, in his eleventh monthly 
report for 1895, draws attention to the practical 
difficulties arising in connection with the removal 
of fish offal and other offensive matter before 
10 a.m. This means that the offensive matter is 
often left on the premises from Saturday to Mon- 
day morning, thus causing a much more serious 
nuisance than would be produced by a Saturday 



ANNOTATIONS— REVIEWS. 



103 



evening removal. In practice there need, as Dr. 
Dudfield points out, be no nuisance whatever in 
connection with such an evening removal, if the 
refuse were removed in iron vessels and closely 
covered, no tipping of the contents into a cart 
being allowed. The Kensington Vestry have 
decided to communicate with the London County 
Council, pointing out the desirability of altering 
the bye-law as indicated above. 

Reports of the Medical Department of the 
Local Government Board. 

A report by Dr. Copeman has been issued on 
an outbreak of enteric fever at Loddon, in Nor- 
folk, in the early part of 1895. The disease, from 
which Loddon had previously been free for ten 
years, appears to have been imported by a servant 
who had probably acquired the disease in the 
Norwich Infirmary. Subsequently 29 cases were 
notified in Loddon and the neighbourhood. The 
majority of the cases were in houses in close 
proximity to the Green, in the centre of which the 
town pump stands. This water was subsequently 
shown to be seriously contaminated with sewage ; 
and it is probable that the infection was conveyed 
by this means. 

Dr. R. J. Reece reports an outbreak of diph- 
theria in the borough of Flint. 

The disease appears to have been conveyed by 
personal infection, partly by means of school 
attendance. 

The Aerial Transportation of Malarial 
Germs. 

The controversy as to whether malaria comes 
from the air we l^reathe or the water we drink, is as 
old as medicine itself. Professor Bemis, of New 
Orleans, has shown that the malarial poison may 
live in water an indefinite time, and be conveyed 
by water currents through immense distances. 
Dr. Richard C. Newton, Assistant-Surgeon in the 
United States Army, gives afn interesting contribu- 
tion in the International Medical Magazine for 
October, 1895, tending to show the aerial trans- 
mission of malaria. It is based oh his experience 
as post-surgeon, at Fort Sill, Indian Territory, in 
1883. The barracks at this station were four in 
number, the distance between a neighbouring creek 
and the furthest (northern) point of the barracks 
being 540 feet. Experience at these barracks 
showed that the number of cases of sickness and 
days of sickness increased in each company in 
direct ratio to its proximity to the banks of the 
creek, with the exception of one company. This 
exception is explained by the circumstance that 
the barracks of the exceptional company lay direct 
across the course of the north wind, and in con- 
sequence presented a greater surface to the air- 
currents than those buildings whose long axis was 
parallel with the direction of the prevailing winds 



{i.e., north and south). The conditions in these 
barracks, except as to position in relation to the 
creek, were identical ; there being the same class of 
men, eating the same food, drinking the same 
water, and performing the same duties. The 
banks of the creek afforded all the supposed 
factors for the production of malaria ; and there 
seems little doubt that the miasm was produced 
at the stream, and brought into the barracks by 
the prevailing north wind. 

Lowestoft Sanitation. 
The Chairman of the Sanitary Committee of 
the Lowestoft Town Council has no mean opinion 
of his own knowledge, but has a decided 
objection to full publicity for the reports of the 
Medical Officer of Health for the borough. A 
report of the Medical Officer for the four weeks 
ending the 19th October, drew attention to the 
almost unprecedented death rate of 50-18 (per 
annum) per 1,000 for this period. Of this amount 
19 per 1,000 was ascribable to measles, 10-34 to 
diarrhoea, 5' 17 to whooping cough, and 2 to diph- 
theria. Lowestoft has evidently been going through 
an excessively severe epidemic of measles,_ which 
does not, however, necessarily reflect in the 
slightest degree upon the sanitary condition of the 
town. As to whether the proposed inclusion of 
measles among notifiable disease would prevent 
the recurrence of so severe an epidemic there may 
be some difference of opinion, but the proposal 
is worthy of careful and deliberate consideration. 
The Chairman of the Sanitary Committee thinks 
otherwise. He would hke to tamper with the 
report of the Medical Officer " in the interests of 
the borough." Furthermore he objects to the 
Medical Officer's opinions as to the causes of 
the outbreak, and with the audacity which 
characterises ignorance, is certain, that " from his 
own experience, although not a doctor, he could 
trace a disease to its origin as clearly as any 
medical officer ! " 



REVIEWS. 



The Diseases of Children's Teeth : their Prevention and 
Treatment. A manual lor medical practitioners and 
students. By R. Denison Pedley, M.R.C.S., L.D.S. 
Eng., F.R.C.S. Edin. (Seg^ and Co., 289, Regent Street, 
W. ; and S. S. White and Co., Philadelphia.)— This is a 
most valuable and original handbook on a subject which has 
been greatly neglected by medical practitioners. If its 
perusal and study by medical practitioners could be secured, 
there can be little doubt that the health of the next genera - 
tion would be greatly benefited. The third chapter, on 
Caries, gives an mteresling account of its causation. " In 
order that such processes as fermentation may be carried out 
successfully, material is necessary, and also a chamber kept 
constantly moist, at a sufficiently high temperature, with free 
access to the air. The mouth is such an ideal chamber with 
all the conditions favourable for the action and propagation 
of micro-organisms, and the particles of food left upon, or in 
the neighbourhood of the teeth, are the material essential for 



I04 



CORRESPONDENCE— APPOINTMENTS. 



cultivation. It is now well recognised that the production 
of caries in teeth depends entirely upon the presence of 
micro-organisms in the mouth. Thirty species of these were 
isolated and cultivated by Miller, of Berlin, twelre of them 
being characterised by the formation of lactic acid." 

The sixth chapter, on Irregularities of the Teeth, is most 
exhaustive. It is copiously illustrated, the illustrations being 
original, and of a high merit. The next chapter, on the 
Hygiene of the Mouth, is, however, the most interesting 
from a preventive standpoint. The first point emphasised is 
the importance of cleansing the temporary teeth daily, a 
point most generally neglected. Next comes the importance 
of giving children foods which require chewing, rather than 
foods in which every mechanical difficulty is overcome. The 
necessity of attending to carious temporary teeth is obvious, 
when we remember that they " have to serve the purposes of 
mastication during the most important period of a child's 
existence," and that if neglected they often spoil their succes- 
sors, or interfere with their eruption. The author 
strengthens his argument in favour of the necessity of oral 
hygiene, and a more strict supervision of children's mouths, 
by a statement of the results of his personal examination of 
3,800 children between three and sixteen years of age. Of 
these, 2,972 children had among them 10,795 carious teeth. 
In none of the industrial schools examined were tooth- 
brushes used. 

The author then gives some interesting particulars of the 
condition of the teeth in 306 children suffering from various 
diseases in the Evelina Hospital for ChiHren. There was 
no excess of caries among rachitic children, though there was 
delayed dentition. The author gives an interesting scries of 
cases of Chorea, in which rapid improvement followed the 
removal of carious teeth. Stomatitis and chronic diarrhoea 
in children are not infrequently caused by foul carious teeth, 
numerous cases illustrating this being adduced by Mr, 
Pedley. The importance of attention to the teeth is further 
emphasised by the fact, to which attention has been called 
by Mr. Owen, that " septic infection of the glands beneath 
the jaw frequently takes place in children through carious 
teeth." 

The author found that in 251 sick children out of the 306 
examined, an average of five carious teeth were present in 
every mouth, a fact which cannot but be regarded as 
significant in the pathological history of the children in 
question. The whole of the chapter on Oral Hygiene is full 
of practical and valuable information, based on extensive 
clinical expeiience, and stated without the slightest 
exaggeration. 

With the last chapter on Treatment, we have as hygienists 
but little concern. We must content ourselves in conclusion 
with drawing special attention to this work, and claiming 
for it a wide circle of readers in the interests of the health of 
the community. 



CORRESPONDENCE. 



THE AERIAL CONVECTION OF SMALL-POX. 
To the Editor oj I'unLic Health. 

Sir, — I shall be greatly obliged to you if you will allow 
me to appeal to all medical officers of health for information 
on the subject of "Aerial Infection" of Small-pox. I am 
seeking for cases that have come to their knowledge within 
recent years, and shall be glad of any references to published 
facts. I shall especially welcome information from those in 
charge of small-pox hospitals. 

I have not been able to discover any literature on the sub- 
ject giving any account of similar spread of infection in 
connection with hospitals in foreign countries. Perhaps 
.some of your readers may be able to give me references 
hereon? — I am, Sir, yours faithfully, 

Reginald Dudfield. 

19, Blomfield Road, .Maida Vale, London, W. 
November 27th, 1895. 



APPOINTMENTS. 



Medical Officers of Health. 

Adams, F. E., M.D., R.U.I., D.P.II. Camb., appointed 
M.O. H. to the Ilereford County Council. 

BouLTO.N, A., M.R.C.S. Eng., appointed M.O.H. to the 
Horncastle Rural Sanitary District. 

Brown John, M.D., Vict. D. S. Sci., re-appointed 
M.O.H. for the Borough of Bacup. 

Burnett, W. E. S., L.R.C.P., L.R.C.S. Edin., ap- 
pointed M.O.H. to the Tintwistle Rural Sanitary District. 

Cooke, Mr. T., appointed M.O.H. to the Limehurst 
Rural District Council. 

Clendinnen, Wm. McEntire, M.R.C.S., L.R.C.P. 
Lond., appointed M.O.H. to the Coseley Urban District. 

Fraser, Peter, M.D., B.Sc, appointed M.O.H. to 
the Carnarvon Joint Sanitary Authority. 

Garstanc, Thomas W. H., M.R.C.S., M.O.H. to the 
Knutsford Urban District Council, appointed M.O.H. to 
the Bucklow Rural District Council. 

Hardy, C. M., M.B. Durh., B.S., appointed M.O.H. 
for the Darlington Rural Sanitary District. 

Hardwicke, E. W., B a. Camb., M.B., B.C., 
appointed M O.H. to the Quarry Bank Urban District 
Council. 

Hall, Dr. Alfred, appointed M.O.H. to the Mayfield 
Rural District. 

Hayward, J. W., M.R.C.S., L.S.A., appointed 
M.O.H. to the Whitstable Urban District Council. 

Jolly, R. W., M.R.C.S. Eng., appointed M.O.H. for 
Peterborough. 

Kf.mp, Benjamin, M.R.C.S. Eng., L.S.A., re-appointed 
M.O.H. to the Horbury Urban Distii-t Council. 

Keiffenheinn-Trurridge, L. W. A., M.D. Durh., 
M.R.C.S., L.R.C.P., appointed M.O.H. to the Hoo 
Sanitary District. 

Littlejohn, Herbert, M.B., D.P.H., CM., appointed 
M.O.H. for Scarborough. 

Moles, Frederick P., L.S.A., appointed M.O.H. to 
the Urmston District Council. 

Mackenzie, W, S., L.R.C.P., L.R.C.S. Edin., re- 
appointed M.O.H. to the Altofts Urban District Council. 

Nunn, p. W. G., L.R.C.P. Lond., M.R.C.S. Eng., 
appointed M.O.H. to the Popesdown Urban District 
Council. 

Nutting, E. S., M.B., CM. Edin., appointed M.O.H. 
to the Warsop Urban District Council. 

Pattinson, H. a., M.R.C.S. Eng., L.R.C.P.I., re- 
appointed M.O.H. to the Seaton Urban Sanitary District. 

Phillips, E. V., L.R.C.P. Lond,, M.R.C.S., appointed 
M.O.H. to the Oxenden Rural Sanitary District. 

Powell, Dr., appointed M.O.H. to the Llandyssul J 
Rural District Council. ^ 

Richmond, R., M.D., appointed M.O.H. to the Dun- 
mow Rural Sanitary District. 

RoitERTSON, J. A., M.D. Glasg., appointed M.O.H. for 
the town of Pctcrboro'. 

Stevens, F. J., B.A. Oxon., M.R.C.S., D.P.II., ap- 
jiointcd M.O.H. to the Camberwell Sanitary District. 

Senior, A., M.B., B.C. Camb., appointed M.O.H for 
the Esher and the Dittons Urban Listrict Council. 

TiiiHETTs, T. M., M.B. Lond., M.R.C.S. Eng., L.R.C.P. 
appointed M.O.H. for the Quarry Bank Urban Sanitary 
District. 

Thomas, Mr. D., appointed M.O.H. Ystradgynlais 
Rural District Council. 

TuxFORD, Arthur, M.D., appointed M.O.H. to the 
Boston Town Council Port Sanitary, and the Sebley Rural 
District. 

Wray, r.. B., M.R.C.S. Eng., L.S.A., D.P.H., ap- 
pointed M.O.H. to the Basford District Council. 



Public Health. 

Cfje Journal of t\}t Incorporateti Societg of fHetJical i^Klccrs of l^ealtij. 



SUBSCRIBERS' COPIES of Public Health are 
supplied at \os. 6d. pe?- annum. Single copies One Shilling. 

BOUND VOLUMES. — C<)/zVj of Volume VI. are now 
ready, bound in cloth, silt lettered, trice \os. 6d. A 
few copies of Vols. /., //., IV., and V. are also on hand. 

CLOTH COV'E.'RS for Binding the Volumes, price li.6d., 
may be had by order of any Bookseller. 

•Orders should be addressed to E, W, Allen, 4, Ave Maria 
Lane, E.C. 

ADVERTISEMENTS. — C(7ww?/wzVa/zV.-«.f relating to 
Advertisements should be addressed to Messrs. W. H. is' L. 
Collingridge, 148 and 14^, Aldersgate Street, E. C. 

Every Reader of a Paper before the Society, or Contributor 
of a Signed Article, is entitled to twenty -five copies of the 
issue of Public Health cojitaining the contribtttion in 
■question ; out application for this or any smaller number 
fuust be made to the Editor not later than the TWENTY- 
FOURTH day of the month previous to insertion of the 
Contribution. 

Medical Officers of Health and other Correspondents are 
requested to send regularly all published reports and 
vmtters of interest bearing upon Sanitation to the Editor, 
1 1 , Gloucester Place, Brighton. 

NOTICES. 



ALTERED SUBSCRIPTION FOR MEMBERS OF 
THE INCORPORATED SOCIETY M.O.H. 

The attention of Fellows and Members of the Incorporated 
Society is called to the fact that dating from October, 1894, 
the subscription to the Society will be one guinea instead of 
half-a-guinea as hitherto. It must be noted that this will 
include the subscription as members of a branch of the 
Society, the guinea subscription being inclusive for all 
purposes. 

It will be seen from this that there will be no very 
material increase in the subscription for those who are 
members of the parent Society and of one of its branches. 
There will, however, be considerable saving of trouble in 
collecting subscriptions, etc., as one subscription only will 
be payable. The subscriptions (and those for Associates, 
which remain half-a-guinea) should be sent to the Trea- 
surer, Dr. Kempster, Chesterfield, North Side, Ciapham 
Common, London, S.W. 



A New Departure.— An important new departure, in 
the form of a comprehensive policy providing for compensa- 
tion in the event of accident or disease, is now being made 
by the Accident Insurance Company, St. Swithin's Lane, 
E.C. Many who have not seen the wisdom of taking out 
policies covering accident alone will, no doubt, avail them- 
selves of the increased advantages now offered, and will insure 
themselves against the risks to which all, of whatever rank, 
profession, or occupation, are liable. The office instituted 
the system of general accident insurance, under which nearly 
A 1,000,000 has been paid in compensations, giving relief in 
thousands of cases of death or disablement, and providing 
help when most needed by the insured or their families. 

No. 93, January, 1896, 



The Incorporated Society of Medical 
Officers of Health. 

20, Hanover Square, London, W., 

2ist December, 1895. 
An Ordinary AIeeting of the Incorporated 
Society will be held at 197, High Holborn 
(offices of Board of Works, St. Giles's District), 
on Thursday, i6ih day of January, 1896, at 
7.30 p.m., for the transaction of the following busi- 
ness : — 

AGENDA. 

1. To read and confirm the Minutes of Ordinary 
Meeting of November 21st, 1895. 

2. To receive Report of Council. 

3. To elect Fellows, Ordinary Members, and 
Associates. The following candidates have been 
duly nominated for election : — 

As Fellows. 
Shillito, Wm. Alsope, M.R.C.S., L.S A., Wilsden, near 

Bradford, M.O.H. Wilsden U.S.D. 
Richardson, W. J., M.D., M.Ch.,Clonavon,Ravensthorpe, 

M.O.H. Ravensthorpe U.S.D. 
Mackay, J. D., B.A , M.B., CM., T/ie Cloisters, Knares- 

borough, M.O.H. Knaresborough U.S.D. 
Jones. \V. Makeig, M.R.C.S., L.S.A., D.P.H. Camb , 

Wath-upon-Dearne, M.O.H. Swinton U.S.D. 
Wiley, A. O., L.R.C.P. Ed., L.R.C.S. I., Newton House, 

Knaresborough, M.O.H. Knaresborough R.S.D. 
Stuart, J. A. Erskine, L.R.C.P., High Street, Heck- 

mondwike, Normanton, York-;, M.O.H. Batley U.S.D. 
Hillman, G B., L.S. a., Whitwood Mere, Castleford, 

M.O.H. Whitwood U.S.D. 
Hargreaves, J. A., M.B., O.M.,Wetherby,Yorks, M.O.H. 

Wetherby R.S.D. 
Ross, James A., M B., CM., St. Mary's, Penistone, 

M.O.H. Penistone U.S.D. 
Stevenson, Robert, L.R.C.P., L.RC.S., Marsh Villa, 

Rothwell, near Leeds, M O.H. Rothwell U.S.D. 
Buck, Joseph, L.R.C.P., L.R.C.S., Melbourne Hou?e, 

Rothwell, near Leeds, M.O.H. Hunslett R.D.C 
Shaw, R. Holgate, M.R.C.S., L.R.C.P., The Grove, 

Liversedge, M.O.H. Liversedge U.S.D. 
Nightingale, John, M.B., CM., The Green, Horsforth, 

M.O.H. Horsforth U.S.D. 
Spowart, J., L.R.C.P. Edin., D.P.H. Camb., 249, Pits- 
moor Rd., Sheffield, M.O.H. Woftley(2nd Div.) R.S.D. 
Wakelam, Edgar, L.R.C.P., L R.C.S., Walerhead, 

Oldham, M.O.H. Springhead U.S.D. 
(All the above proposed by W. H. F. Ramsden ; seconded 
by James Robert Kaye). 

Collins, Henry Beale, M.R.CS. Eng., L.S. A., D.P.H. 

Conj. Bd., Greenholme, Kingston Hill, M.O.H. 

Kingston U.S.D. 
Jolly, Robert William, M.R.CS. Eng., L.S. A., 5, 

Bridge St., Peterborough, M.O.H. Peterborough U.S.D. 
(The above proposed by Reginald Dudtield ; seconded by 
Francis Vacher). 



io6 THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. 



Alexander, John, M.D., D.P.H., F.T.S. G'asg., Wel- 
lington House, Wick, M.O.H.« Cailnness-shirc and 
Royal Burgh of Wick. 

Bruce, William, M.D., The Castle, Dingwall. M.0. 11. 
COS. Ross and Cromarty. 

Cameron, J. A., M.D., B.Sc, Firhill, Nairn, M.O.H. 
(retci.) Old Kilpatrick. 

Chalmers, A. K., M.D., D P H. Camh., 23, Kerslar.d 
Terrace, Hillhead, Glasgow, M.O.H. Glasgow. 

Duncan, Eben., M.D., Queen's Park House, Crosshill, 
Glasgow. M.O.H. (reld ) Burgh of Crosshill. 

Graham, J. T., M.D., 4, Alhole Crescent, Perth, M.O.H. 
Perthshire. 

LiTTLEjOHN, Sir Henry, M.D., City Chambers, Edin- 
burgh, M.O.H. Edinburgh. 

McVail, J. C, M.D., D.P.H. Camb., 24, George Square, 
Glasgow, M.O.H. cos. Stirling and Dumbarton. 

Na.smyth, T. G., M.D., D.Sc, D.P.H. Camb., St. 
Michael's, Cupar, Fife, M.O.H. Fife and Clack- 
mannanshire. 

Simpson, A., M.D., 4, King's Place, Perth, M.O.H. Perth 
City. 

Watt, J. P., M.A., M.B., 15, Albert Street, Aberdeen, 
M.O.H. Aberdeen. 

Templemax, Chas., M.D., D.Sc. (Pub. Health), 8, Airlie 

Place, Dundee. M.O.H. Dundee. 
(The above proposed by A. Campbell Munro ; seconded by 

Reginald Dudfield). 
Garstang, T. W. H., M.R.C.S., L.S.A., Headingley 
House, Knutsford, Cheshire, M.O.H. Knutsford 
U.S.D. and Bucklow R.S.D. ; proposed by Francis 
Vacher ; seconded by Reginald Dudfield. 

As Ordinary Members. 
Symonds, Wm. Henry, D.P.H., 43, Marlborough Hill, 

St. John's Wood, N.W. : proposed by J. C. Thresh; 

seconded by Ret,inald Dudfield. 
English, Edgar, D.P.H., Doncaster; proposed by 

W. H. F. Ramsden ; seconded by James Robert 

Kaye. 
Richardson, J. N., L.S.Sc, Ilkley ; proposed by W. H. F. 

Ramsden ; seconded by James Robert Kaye. 

4. To receive nominations for the election of 
Fellows, Ordinary Members, and Associates. 

5. Any other business. 



No paper will be read at this Meeting, the even- 
ing having been reserved for a full discussion of 
the Council's Report on *' Fixity of Tenure." 
Memoranda by Drs. T. O. Dudfield and W. T. G. 
Woodforde will be found in the December issue of 
Public Health. 



"1 



John C. Thresh, 
The Limes, Chelmsford 

Reginald Dudfieltj, 
19, Blomfield Road, 

Maida Vale, W.^ 



\Hon. 
I Sees. 



Mr. Hf.nrv C. Jones, Honorary Solicitor of 
the Incorporated Society of Medical Officers of 
HeiUh, is a candidate for the post of Cleric of the 
London County Council. Mr. Jones has for a 
number (if years done valuable honorary work for 
onr Society, and its members will wish him success 
in his present application. 



PROCEEDINGS OF THE INCORPORATED 
SOCIETY OF MEDICAL OFFICERS OF 
HEALTH. 

At the meeting of the Society, held on the 
2ist November, an address, of which the following 
is an abstract, was given : — 

A National System of Notification of 
Sickness, 

liY 

Arthur Newsholme, M.D. 

Dr. Newsholme prefaced his address by some 
remarks on the history of the subject. The names 
of B. W. Richardson, Rumsey, and Arthur Ran- 
some would always be honourably associated with 
the prolonged agitation in favour of such sickness 
registration. Dr. B. W. Richardson had for many 
years published in the journal of Public Health 
returns of sickness from districts as remote as the 
Scilly Islands and the Shetlands. The Sanitary 
Association of Manchester and Salford had also> 
for many years carried out a system of local 
registration of all sickness treated at the public 
expense, under the direction of, and inspired by^ 
the steady efforts of Dr. Ransome and his 
colleagues. Perhaps the most interesting experi- 
ment in this direction was that of the Metropolitan 
Association of Health Officers in 1857. It was 
specially interesting, because the then Board of 
Health undertook to print and circulate the weekly 
and quarterly tables of sickness. They were thus 
published for over a year, when the scheme lapsed. 
It was, however, significant that a department of 
the Imperial Government, thus early in the history 
of the subject, undertook the collation and publica- 
tion of returns. 

The subject was taken up by the Social Science 
and the British Medical Associations, and various 
attempts were made to thrust attention to it upon 
the Government. Gradually, however, it gave 
place to the more limited demand for Compulsory 
Notification of Infectious Diseases, the first town 
to adopt this being Bolton, in September, 1877. 
Now about five-sixths of the English population 
had adopted the Infectious Disease (Notification) 
Act. 

It was admitted that our system of registration 
of deaths, and the statistical facts which had thus, 
become available, were the foundation on which 
the progress of public health hitherto achieved 
had been built up. It soon, however, became 
evident that mortality statistics, as they ignored 
everything which preceded death, gave a very im- 
I)erfect representation of the jiublic health. A low 
rate of mortality was comiiatible with a high sick- 
ness rate, as witness the nresent incidence of scarlet 
fever. Considerations like these had caused the 
cnrly hygienists to advocate the general notification 
of sickness, and had produced the present limited 
notification of infectious diseases. 



A NATIONAL SYSTEM OF NOTIFICATION OF SICKNESS. 



107 



It might be asked whether any great advantage 
had accrued from such notification of infectious 
diseases. The answer was that — 

(a) Knowledge was always power, and it was 
self-evident that any local authority using the in- 
formation given it by notification, was in a better . 
position, and in fact was frequently compelled by 
the pressure of public opinion, to adopt early pre- 
ventive measures against the spread of disease, by 
provision of isolation hospitals, efficient disinfec- 
tion, supervision and detection of contaminated 
milk or water supplies, detection of special inci- 
dence of disease on the scholars fn any particular 
school, and so on. 

Notification was only a means to an end ; and 
to attempt, as some had done, to compare the in- 
cidence of special infectious diseases in one town 
before and after the adoption of notification, with- 
out knowing what use had been made of the 
information acquired by notification ; or, again, to 
compare notification towns with non-notification 
towns without knowing the relative activity or 
efficiency of their sanitary administrations was a 
gross misuse of statistics. Furthermore, such 
comparisons of the statistics of one town with 
another, or of the statistics of the same town at 
two different periods, were misleading, unless one 
had strict regard to the natural epidemic or inter- 
epidemic periods for each disease. 

(d) Even if it could be shown that notification 
had not been the means of preventing radiation 
from a single focus of infection, its continuance 
was highly desirable in the interests of the com- 
munity. By its means there was gradually being 
accumulated in this country a mass of information 
as to the seasonal, annual, epidemic, and cyclical 
prevalence of the chief infectious diseases, such as 
had never previously been possessed by epidemio- 
logists. The first condition of success in the pre- 
vention of disease being knowledge of its natural 
history, such knowledge must ere long bear a rich 
harvest of preventive measures. 

The local notification of sickness did not exhaust 
the possible utility of the returns. This had been 
perceived, and in 1889 ^^e Local Government 
Board, after voluntary efforts by Dr. Tatham and 
others had shown the practicability of the scheme, 
undertook to receive and print the weekly returns 
from all contributing notification-towns, and circu- 
late them to the contributing medical officers of 
health. Special attention was drawn to this ; as it 
was the second occasion on which a Government 
department had undertaken the publication of 
sickness returns, and constituted a valuable pre- 
cedent for further extensions of the system. 

The preceding considerations indicated the de- 
sirability of a vast extension of the notification 
of sickness. Not only ought erysipelas to be 
retained in the Hst of notifiable diseases, but 
measles, whooping-cough, epidemic diarrhoea, even 
chicken-pox and mumps, ought — apart from the 



pecuniary considerations involved — to be added to 
the list. It was not necessary that all these should 
be notified forthwith, but a system of weekly or 
monthly returns, like those in Germany and 
Scandinavia, might be introduced. 

The work of the medical officer of health was 
not limited to zymotic diseases. There were other 
fields of disease, in which the possibility of, and 
scope for, preventive measures was both vaster and 
more promising of result. Attempts were already 
in progress as to tubercular diseases, the annihila- 
tion of which was much more practicable than that 
of measles or scarlet fever ; and the annihilation of 
these diseases would produce a greater result on 
the death rate, and would add infinitely more to 
the aggregate of human happiness than that of 
scarlet fever and measles. Rheumatism was next 
in importance to phthisis as a cause of disablement 
and disease ; and there was little doubt that it 
would eventually come within the range of actively 
preventable diseases. 

Pneumonia and bronchitis again were worthy of 
more attention, especially in their relation to con- 
ditions of housing and occupation, than they had 
hitherto received. 

The diseases of special industries, as lead- 
poisoning, phosphorus poisoning, and anthrax, 
ought to be notified to the medical officer of health. 
Attention was here called to the obnoxious Sec. 27 
of the Factory and Workshop Act, 1895, requiring 
notification of certain diseases to the Chief In- 
spector of Factories, a layman ; and the important 
letter by Dr. J. B. Russell, in the British Medical 
J'oitrnal of August 31st, 1895, was quoted on the 
same subject. 

The systems of notification,of sickness in foreign 
countries were then briefly sketched. In Norway, 
Denmark, and Germany there was a double system 
of immediate notification of the more serious in- 
fectious diseases, and weekly returns of the minor 
infectious diseases and of certain other diseases, 
which the Scandinavian authorities, with somewhat 
remarkable foresight, had classified as "epidemic 
diseases." These included rheumatic fever, pneu- 
monia, bronchitis, follicular tonsillitis and many 
others. 

In the chief cities of Germany there was, in 
addition, a most important system of notification 
of hospital statistics, thus rendering it possible to 
contrast the hospital incidence of various diseases 
in different towns. 

Any extension of notification of sickness in this 
country involved the important difficulty of ex- 
pense. Local authorities could not reasonably be 
expected to increase the schedule of notifiable 
diseases, unless it could be shown that the increase 
would possess immediate or proximate practical 
utility. Doubtless a system of weekly returns for 
the majority of diseases would involve a smaller 
expense than immediate notification ; but even this 
expense would probably be prohibitive. The 

I 2 



loS THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. 



qucsticn arose whether it would be just to enforce 
a wider notification of sickness without remunera- 
tion to the medical practitioner. No fees were 
paid to Scandinavian or German doctors. In this 
country, no fee was paid for the compulsory death 
and vaccination certificates. If the protection 
given to medical practitioners in the discharge of 
their professional work were absolutely complete — 
as it was not — then it might be argued that the 
State was entitled, in return for the special privi- 
leges given to the profession, to receive such infor- 
mation as was desirable in the interest of the 
community. As matters now stood, the problem 
was beset with difficulty. 

The suggestions made might be summed up as 
follows : — 

1. Extend the schedule of notifiable diseases, 
and make notification universally compulsory. 

2. Make it compulsory on all friendly societies, 
and on all sickness insurance societies of every 
description, to furnish periodical returns to the 
medical officer of health of the number and age of 
their members, and of the cases of sickness 
occurring in their experience, giving particulars as 
to age, and the nature and duration of illness. 

3. Make it compulsory on all hospitals, dis- 
pensaries, etc., and on all poor-law medical officers, 
to make similar periodical returns to the medical 
officer of health. 

4. Establish a central office in London, probably 
in connection with the G.^neral Register Office, for 
the tabulation and publication of these statistics. 

DiSCU.SSION. 

Dr. WOODFORDE, referring to the returns of sickness 
among paupers, said that he used to receive such re- 
turns for all out-relitf cases, and had tabulated them. 
Lately this work had been dropped, as he doubted the value 
of the statistics. He had found that the entries in the 
returns were made in a loose way, but he thought they 
should endeavour to get such returns made more accurately 
rather than abandon them al'ogether. As to payment for 
notification?, it was his experience that very trivial cases 
were sometimes seen by three or four medical men, all of 
whom chargL-d for iheir notifications. The information he 
obtained, on the " prescribed " forms, was very meagre, and 
entailed much work on the sanitary ofSccrs. He thought 
that when any application was made for an extension of 
lbs system of notification, something should be done to 
remedy the defects he had referred to. Whilst endorsing 
the general principles enunciated by Dr. Newsholme, he 
though", that much consideration would have to be given to 
<letails. 

Dr. SvKES thought the Society should be grateful to Dr. 
Newsholme for introducing a sut>ject which was a founda- 
tion fur all their work, and was of very great importance. 
He had considered the subject very carefully for some time, 
an 1 whii-t agreeing with most of the remarks of Dr. News- 
holme, thought that they dealt with only one side of the 
question. Death certificates infcrnncd them of /a/a/ diseases, 
whilst notification dealt with the non-fatal as well as the 
fatal cases. Considering that all classes of disease were not 
of equal importance, he was of o[)inion that the " general " 
notification of diseases was undesirable, as it might injure 
"special" notification of those diseases which were of^ far 
more importance. As an example, he mentioned the " pre- 
ventable " diseases which are divisible into infectious and 
non-infectiou', the former being again divisible into 



"dangerous" and "non-dangerous." The former are 
either notifiable or non-notifiable, but he thought they 
wanted a " serious " class to include many diseases which 
wore at present not notified. He was of opinion that 
friendly societies, poor-law ofiicers, and others should send 
returns of their sickness, but h'n opinion was that many of 
the returns would probably be of but little value. He was 
not of opinion that the German system of statistics was 
wonhy of being copied, as it was far too elaborate. In this 
country there was theoretically no charge for death certifi- 
cates, but many practitioners charged for them, and letters 
had appeared in the British Medical foiirual stating that 
there was no legal prohibition against making such charge. 
In other countries there was no payment for notification or 
death certificates. He had little doubt that if the profession 
were protected in England as on the continent, fenced in to 
the same extent as the practice of the law, medical practi- 
tioners would gladly send in any reasonable certificates free 
of charge. 

Dr. Legge, in speaking in favour of the German system 
of statistics, reminded the meetmg that notification was in- 
troduced to this country from abroad. It was first initiated 
in France, when cholera was about ; but in that country com- 
pulsory notification, as now practised, was not introduced 
until two years ago. 

Dr. Yarrow could endorse all that Dr. Sykes had said 
as to charges being made for death ceriificates. He had 
l;nown deaths to l^e reported to the coroner, and inquests to 
lie held when no fees were paid. He doubted the value of 
returns from clubs, as it was a common practice to give a 
" few days' rest " for very tiivial complaints. He had come 
to the conclusion that ncrfification without the power to 
remove to hospital was almost useless, but he did not wish 
it to be thought that he would remove every case. 

Dr. Oliver Field, speaking on the alleged unreliability 
of statistics based on returns from friendly societies and 
others, called attention to the fact that, by careful handling, 
very reliable information could be obtained from these 
sources, as in a long series of returns the effect of ' ' average " 
would eliminate errors. Further, he did not think there was 
any great amount of malingering as had been suggested. 

Dr. WiLLOUGHBV asked what Dr. Newsholme would do 
with proposed notifiable diseases which usually ran a course 
of (perhaps) years? He did not see how such cases could 
be prevented from occurring in the returns on several 
occasions. 

The President, commenting on the statement that 
Bolton and Iluddersheld claimed to be the first towns to 
establish notification, explained that Huddersheld was the 
first to e>tablish a voluntary system without any penalty (or 
non-notificaiion. Owing to the fadure of a voluntary system 
at Crewe, the compulsory system had never been adopted. 
Dr. Jones had obtained a large number af returns from 
friendly societies at Crewe, which was a town of unique 
composition, rentals of more than £20 being practically un- 
known ; and from these returns, which included the day of 
" going sick," Dr. Jones had been able to determine where 
sickness was unduly prevalent and to get insanitary con- 
ditions remedied. In comparing the results of notification 
in ddTerent towns it was necessary to take into consideration 
the further steps taken, e.g., isolation, etc. He regretted 
that, under the new Factory Act, notifications were to be 
sent 10 the factory inspector instead of the medical officer of 
health. As to erysipelas, he had had a considerable number 
of cxses under treatment at the Birkenhead Isolation 
Hospital, as also cases of puerperal fever, and considered the 
notification of the former disease to be useful. 

Dr. Newsholme, in reply, referring to the fears eicpressed 
that sickness returns woukl be comparatively untrustworthy, 
said that he had had a large experience of the use of statistics 
basecl on imperfect data, and had shown that, with caul ion, 
perfectly valid conclusions might be drawn from them. He 
agreed with Dr. Sykes as to the advisability of selecting the 
more important diseases, and also that the Government ought 
to give more efficient protection to mcilical men before they 
required them to give notifications gratuitously. He had 



J 



CO-OPERATION, AND WATER SUPPLIES FROM THE CHALK. 



109 



included this under the heading (d) on the agenda, which 
read : — " (d) Should payment of a fee for notification of 
sickness be continued? or, assuming that the Government is 
prepared to give the medical profession more efficient protec- 
tion against the practising of medicine by unqualified men, 
may not the notification of sickness be regarded as a duty 
owed by the medical practiiioner to the State ? " He could 
not agree with Dr. Sykes and Dr. Yarrow that the statistics 
of friendly societies wojld be untrustworthy owing to the 
amount of malingering. In the aggregate they would be of 
great value, even if not with regard to the nature of the 
sickness, then as to its duratim, and gradually they wouUl 
become more accurate. The repeated rotificalion of cases 
of phthisis would doubtless occur, and there would thus be 
some apparent exaggeration of the prevalence of ihis disease. 
It should be noted, however, that notification of new cases 
of sickness was alone suggested, and that therefore, so far as 
each individual locality was concerned, the duplication of 
returns would not be very frequent. 



PROCEEDINGS OF THE SOUTHERN 
BRANCH OF THE INCORPORATED 
SOCIETY OF MEDICAL OFFICERS OF 
HEALTH. 

A MEETING of the Southern Branch was held at 
Weymouth on December 14th. 

Dr. Browning met the members at the railway 
station at twelve o'clock, and having entertained 
them with light refreshments at the Weymouth and 
County Club, conducted them to the Verne Barracks, 
Portland, and thence to the convict prison, over 
which the members were shown by permission 
which had been obtained from the Home Office, 
and in which they were much interested. 

A meetmg was held at the Town Hall at four 
o'clock. Dr. Kelly first took the chair, and after 
thanking the members of the Branch for the kind- 
ness which he had received from them during the 
past year, vacated the chair in favour of the new 
President (Dr. Groves), and reminded him of the 
first sanitary work in which they were associated, 
viz., the cholera epidemic of 1866 in London. 

Dr. Groves then took the chair ; there were 
also present Drs. C. Kelly, C. H. Watts Parkinson, 
W. Pridham, W. G. Willoughby, J. Moorhead, 
B. Browning, J. P. Williams Freeman, J. Comyns 
Leach, B. H. Mumby, P. W. G. Nunn, and Messrs. 
Montagu Luff, and Charles F. Hope. 

The minutes of the last meeting were read by 
the Hon. Secretary and confirmed and signed. 

It was proposed by Dr. Browning and seconded 
by Dr. Kelly, and resolved, that the following 
gentlemen be elected members of the Branch, 
viz. : — 

R. L. Legate, L.R.C.P., Bridge IIou e, Christchurch ; 
L. C. W. Stephens, M.R.C.S., White House, Emsworth, 
Hants ; J. Comyns Leach, M.D., B.Sc., The Lindons, Stur- 
minster Newton. 

Proposed by Dr. Parkinson, seconded by Dr. 
MuMBY, and resolved, that the following gentle- 
men be nominated for membership of the Branch 
as soon as they joined the parent Society, viz. : — 

Montagu Luff, M.A., clerk to the Wimborne Rural Dis- 
trict Council J Dr. Day, Medical Officer of Health, Dor- 



chester ; Dr. Lawson, Medical Officer of Hea'th, Portland ; 
Dr. Wcathcrall, and Dr. Snook, Weymouth. 

The accounts for the past year were submitted 
by the Hon. Secretary as follows : — 

/ s. d. 
Expenses of Branch for year 1 894- 1895 .« ... 633 
Expenses of Provincial Meeting of the Society... 13 10 2 

19 13 5 

... 12 7 6 



Contribution of Parent Society ... 

Due to Hor. Sec. 



7 5" 



Proposed by Dr. Groves, seconded by Dr. 
Browning, that the accounts be adopted and 
passed. Carried unanimously. 

Letters were read from Dr. Lovett, and also 
from Dr. Dudfield, Hon. Secretary of the Society, 
re the fixity of tenure of Medical Officers of Health. 

Proposed by Dr. Parkinson, seconded by Dr. 
Mumby, and resolved, "That in the opinion of the 
Southern Branch of the Incorporated Society of 
Medical Officers of Health, every appointment to 
the position of Medical Officer of Health should 
be, during good behaviour, in accordance with the 
terms of the Act of Parliament ; and that Dr. 
Kelly, the representative of the Branch on the 
special committee appointed for that purpose, be 
asked to request the Council to require that all 
appointments of Medical Officers of Health be 
made permanent. ' 

Dr. Groves then delivered his presidential 
address, and Dr. Browning read a paper on " A 
Recent Local Outbreak of Enteric Fever," with its 
lessons to rural and urban authorities generally. . 

Presidential Address on Co-operation of 
Health Officers, and on Water Supplies 
from the Chalk. 

BY 

Joseph Groves, B. A. ,M.B. Lend., F.G.S., M.O.H. Isle of 
Wight Rural District. . 

Our respected ex President, Dr. Kelly, in his 
introductory remarks upon the occasion of the de- 
livery of the first presidential address to the Southern 
Branch of the Incorporated Society of Med'cal 
Officers of Health last )ear, made some excellent 
suggestions as to the character of such addresses, 
and as to the subjects which should occupy our 
attention at our quarterly meetings. He said the 
lives of most of us were too full and too entirely 
taken up by attention to our responsible duties to 
admit of our occupying ourselves with original 
research; he pointed out that the renilts of the 
investigations of those who had more leisure ap- 
peared in the journals, and were read by most of 
u§, and that it was unnecessary, therefore, to form- 
ally reproduce them ; he expressed the opinion 
that our time would be most profitably occupied 
with subjects which appealed to the experience of 
all of us, and with which our ordinary everyday 
avocations rendered us familiar ; and he went on 
to illustrate his remarks by giving us a very clear 



PROCEEDINGS OF THE SOUTHERN BRANCH. 



and most interesting account of the Worthing epi- 
demic of enteric fever. I fully endorse Dr. Kelly's 
views ; and, I think, it will be wise of us to follow 
his suggestions as closely as circumstances permit. 
Gentlemen, we of the Incorporated Society of 
Medical Officers of Health, with our Scottish, 
Northern, North - Western, Yorkshire, Midland, 
MetropoUtan, Home Counties, West of England 
and South Wales, and Southern Branches, are bound 
together in bonds of comradeship unknown in other 
departments of our profession. We are, in fact, a 
veritable army always warring against ubiquitous 
foes. When we meet at the camp fires, so to speak, 
we compare notes and exchange experiences, not 
only about the incidents of the campaign and the 
methods of our warfare, but about the deficiencies 
of the commissariat, about the imperfect weapons 
placed in our hands, about the manner in which 
we are hampered by those we serve, about the terms 
of our enlistment, and the insecurity of our position. 
We receive sympathy and counsel from one another, 
and we go back to our posts with courage renewed, 
feeling assured that, standing shoulder to shoulder, 
we are strong enough to redress our grievances, and 
feehng confident that the time will come when not 
one among us will have to weigh his duty to wife 
and children against his duty to the public health. 
Although our individual experiences appeal to 
the sympathies of our brother medical officers of 
health, the sanitary features of different sanitary 
districts vary greatly by reason of climate, of physi- 
cal features, of the occupations, character, and con- 
dition of the people, and of energy of administra- 
tion, or the absence of it ; but, especially, they differ 
in their sources of water supply in accordance with 
the variations in geologic structure. In a large 
number of the districts of the Southern Branch 
we have in common, in great measure, that our 
water supplies are derived from similar sources. 

From Eastbourne to Weymouth, and north to 
Salisbury, and east and west and north of these, 
the upper secondary and lower tertiary rocks are at 
the surface. Our local superficial water sui)plies are 
obtained from gravel and sand deposited in 
pockets of the alluvial clay, or of clays of the lower 
tertiary strata. Our deeper local supplies come 
from porous beds, in which the water is held up by 
beds of clay beneath them, such as the Bembridge 
limestone, the Headon sands, and the still deeper 
Bagshot sands of my own district ; and from wells 
in the chalk, the upjjcr greensand, the lower 
grecnsand, and in the Portland beds above the 
Kimmeridge clay of the oolite. But the great 
source of water supply in the Southern district is 
the chalk, and to this formation we go, for the 
most part, for inde[)endent supplies for towns and 
populous villages. The chalk, then, is of the 
greatest possible interest to us. It is our constant 
aim to prevent the use for drinking of the water of 
surface wells, and of rivers and streams, which are 
liable to pollution, and to pipe to towns and 



villages, and to detached houses, water not so 
liable. We congratulate ourselves if we can so 
pipe chalk water derived from wells, or from 
springs which issue from the rock above the 
tertiary clays, for we know we then have an 
exceedingly pure water containing, perhaps, not 
more than ten micro-organisms to the cubic centi- 
metre ; and if we have to store it in reservoirs, and 
have to treat it with lime because of its hardness, 
we know this number will be reduced almost to 
sterility. 

But it must have occurred to every thoughtful 
medical officer of health who has seen the galleries 
in connection with deep chalk wells, how terrible 
would be the results if the poison of anthrax, say, 
or of enteric fever, were to gain access to one of the 
chasms or fissures out of which issue those cascades 
to form that river of life, the waters of which are 
distributed to every house in the district, and how 
quickly it may be converted into a river of death. 
And the remarkable and most interesting investiga- 
tions of Professor Percy Frankland of the bacteria 
of water will not tend to diminish his apprehen- 
sions. 

Professor Frankland found that the bacillus of 
enteric fever introduced into chalk well water 
remained alive for thirty-three days, whereas in 
natural Thames river water it lived for only nine 
days, facts contrary to the preconceived notions of 
most of us. As regards the bacteria of river 
water, he examined those of the River Dee for a 
distance of over forty miles. Above Enxmar the 
Dee yielded only 88 micro-organisms to the c.c. ; 
after receiving the sewage of Brsemar, the number 
went up to 2,820 per c.c. ; some miles further 
down it had fallen to 1,139 ; below another point 
at which sewage entered the river the number rose . 
to 3,780, while some miles further down it again I 
fell to 938 ; with fresh access of sewage it rose to 
1,860 per c.c; and lower down again it fell to 
950 microbes per c.c. And, as showing the utter 
futility of the reliance of sanitary authorities in 
chemical examinations of water, I may say the 
presence of sewage in this river was not detectable 
by chemical analysis. 

These experiments of Professor Frankland 
clearly prove that if the same number to the 
c.c. of the bacilli of enteric fever were introduced 
at the same time into the water of a river contain- 
ing countless micro-organisms, and into under- 
ground water containing scarcely any, within a 
fortnight it would be safe to drink from the river 
so far as typhoid fever poison was concerned, and 
dangerous to drink from the well, the water of 
which the chemist would say was an excellent 
potable water quite free from impurity. The ex- 
planation of the difference must be that the 
chemical substances produced by the innocent 
water bacteria are inimical to the life of the 
bacillus of enteric fever, that their toxins immunise 
the water, so to speak ; while there are no bacteria 



CO-OPERATION, AND WATER SUPPLIES FROM THE CHALK. 



to speak of to produce toxins in deep chalk water. 
If this be so, why should not the toxins of innocent 
bacteria immunise the human blood ? 

The fissured character of the chalk formation 
— given to it when it was bent into anticlinal and 
synclinal curves, probably during miocene times, 
the period during which the Jura mountains were 
upheaved, and volcanoes were active in the west 
and north-west of what is now Britain — is a serious 
drawback to it as a source of water supply. It 
becomes us, therefore, as medical officers of 
health, to be ever alive to the risk of sewage dis- 
■charging into the chalk, and to the danger arising 
from leaking cesspits. For the custom in chalk 
districts is to make such cesspits, and if perchance 
a fissure is reached, it is thought to be a particu- 
larly fortunate circumstance, as it will save the 
annual cost of scavenging the cesspit. 

The disposal of the sewage in my own village is, 
to a considerable extent, by means of leaking cess- 
pits in the chalk, some of which reach the under- 
ground water-level, and two at least of which are 
disused wells. The interments of the large ceme- 
tery of a populous parish — situated on a hill in the 
immediate neighbourhood, but separated from the 
village by the chalk valley — are also made in the 
chalk. 

At the foot of the hill upon which Carisbrooke 
stands, and in close proximity to cesspits and a 
millpond which receives the polluted stream which 
drains the valley, are situated the waterworks of 
the borough of Newport, a town of over 10,000 
inhabitants, the boundaries of which extend to 
Carisbrooke. 

Last year a severe epidemic of enteric fever 
occurred at Newport, which reached its maximum 
in the middle of October. There had been 
" dropping " cases since the spring, but as notifica- 
tion was not in force, the extent of the epidemic 
was not at first known ; but, by the efforts of Dr. 
Theodore Thomson, of the Local Government 
Board — who, with the assistance of Mr. Evan 
Evans, of the same authority, ably investigated 
the outbreak — voluntary notification was instituted. 
Approximately about 440 persons were treated 
within the borough, or, roughly, about 44 per 1,000 
of the inhabitants. In the Isle of Wight Rural 
Sanitary District, which covers about i5-i6ths of 
the area of the Isle of Wight, and in which notifi- 
cation came into force on January ist, 1890, there 
were 117 cases connected with the epidemic, which 
were of two classes : those in which the poison was 
apparently taken at home, and those in which the 
poison .was taken in Newport, or from those who 
had contracted the disease there, and some of 
whom had been sent to their liomes in the country 
as suffering from influenza. Of the former there 
were 67, and of the latter 48, cases. Of those who 
contracted the disease in the neighbourhood of 
Newport, 23 cases occurred in Carisbrooke, 7 in 
the adjoining hamlet of Gunville, and 4 in other 



suburbs of the town. They were about 28 per 
thousand of the population : 18 cases occurred 
among the prisoners in Parkhurst Prison, and 8 
cases among the families of the warders, about 24 
per thousand ; and 9 cases occurred among the 
troops in Parkhurst Barracks, about 13 per thousand. 
On comparing the history of the epidemic in the 
rural sanitary district with that of the town of 
Newport, we find there were a larger number of 
cases in the rural district contracted at home dur- 
ing the second fortnight in October and the first 
fortnight of November, after which the number of 
fresh cases diminished, at first gradually, and then 
rapidly, until the close of the year. After the first 
fortnight of October the general features of the epi- 
demic in the two districts were similar, and it seemed 
probable there was some common cause. 

The Newport town water is supplied to the 
Government establishments at Parkhurst, and to 
Carisbrooke and Gunville, and other suburbs of 
Newport, and this circumstance alone was common 
to Newport and the surrounding district. The inci- 
dence of the disease was less severe in the rural 
district than in Newport, because the town water 
was not so universally used, and in the prisons and 
barracks orders to boil the water were issued early, 
and the waterworks water was quickly excluded from 
the barracks entirely. Every house in which a case 
arose in the rural district was supphed with town 
water, save two, and in these cases the children 
attended the Carisbrooke Board School, to which 
the Newport supply was laid on. 

The town water came from the waterworks of 
which I have spoken. There were three sources 
of supply : the low level reservoir, built of 9-in. 
brickwork, rendered in and lined with cement, over 
chalk springs, which bubble to the surface there ; 
and two wells, the old well and the new well, con- 
nected by a syphon, from which the water was 
pumped to a high level reservoir a quarter of a mile 
up the hill. The old well is 23 ft. deep, with a 
boring 20 ft. deeper in the chalk. It is of brick 
and stonework rendered in cement, and is within 
20 feet of the pond. The new well is 27 ft. deep, 
and has a boring of 80 ft. deeper. It is lined with 
iron cylinders, and has an iron bottom, and is 50 
feet from the millpond. The level of the water in 
the millpond is some seven feet above that in the old 
well and the low level reservoir, and about 18 in. 
above the top of the new well. 

Chemical analysis failed to detect any impurity 
in the reservoir or wells, the water of which was 
pronounced by the chemists to be an excellent pot- 
able water. Bacteriological examination discovered 
the bacillus coli communis in the water of both wells 
and reservoir and in that taken from a tap in Park- 
hurst prison, and the bacillus fiuorescetis putidus 
was found in the water of the low level reservoir 
and of that of the old well. The specific bacillus 
of enteric fever was said to have been found in the 
water of the new well on December loth. 



PROCEEDINGS OF THE SOUTHERN BRANCH. 



It \ras evident this excellent potable water con- 
tained sewage— or, rather, that the contents of the 
large intestines of man or lower animal had passed 
into the water: and the question was, wh-re did it 
come from ? Did it come from deep pollution or 
from the millpor d ? The engineer to the Corpora- 
tion of Newport, Mr. Baldwin Latham, having 
determined that lithia was not present in the miil- 
pond, or wells, or reservoir, placed a quantity of 
lithiu-n chloride in the pond, and it was subse- 
quently fjund to be present in the old well and in 
the reservoir. Upon pumping down the water in 
the old well, and lowering a light, water was seen to 
find its way in around the bricks, and where some of 
them had fallen out it was running in in a itream. 
On November 20th the old wei was disconnected 
and the reservoir water was cut off. Th" number 
of fresh cases, which were diminishing at this time, 
continued to decline, and rapicly decreased in 
December. 

In considering the question of the source of the 
poise n, too much weight must not be given to this 
circumstance. The bacillus of enteric fever was 
said to be present in the water of the new well on 
December loth, and it is common ex.erience that 
epidemics of enteric fever rapidly subside often, 
as if from exhaustion of the materies morbi. On 
the other hand, the flow of the underground water 
in the chalk is from south-west to north-east, and 
on its way to the waterworks it would meet with 
some of the leaking cesspits. Moreover, the pump- 
ing, which is known to have lowered the wells far up 
the valley, would tend to draw some of the \\ ater not 
in the direct line cf flow towards the waterworks. 
The question would be easier of solution if the origin 
of the contagion could be discoveied. There had 
been no case of enteric fever in this particular sec- 
tion of the rural district since 1890, and that, an 
imported case, was treated in a house situated be- 
low the waterworks. Carisbrooke, however, is 
visited by thousands of visitors during the year, 
who occupy its hotels and lodtiings. Tramps 
traverse the island in considerable numbers, and 
some of them sleep out in the field' in tummer ; 
and laundresses pursue their calling upon the 
banks of the stream which discharges its wattrs 
into the millpond, and in the vicinity of the mill- 
pond itself. The origin of the contagion in either 
cesspit or surface wa'er is conceivable, therefore. 

But it has always been p'estnt to my mind that 
although town water was distributed in the lural 
district, there was no case of enteric fever connected 
with the epidemic distinctly attributable to drink- 
ing water outside Newport until October. There 
was certainly a case of the disease in Newport in 
February ; it was known to the medical officer of 
health of that town that there were 3 cases in 
March, 7 fresh cases in June, 5 in July, 9 in 
August, and 14 in September. Several of these 
cases occurred in houses into which sewer gas 
found entrance, and some of them were aj.'gre- 



gated in particular sections of the town. Soiled 
linen from one of these cases may have been washed 
in Carisbrooke, or a deftccation in a ditch communi- 
cating with the stream, or into the stream itself, 
may have occurred there in connection with an 
inhabitant cf Newport suffering from enteric fever, 
while out walking. In this manner the poison 
may have reached the millpond and passed into 
the old well. Within a fortnight, according to 
Professor Frankland, the bacillus would have dis- 
appeared from the millpond, but it would have 
remained in the well nearly fivc- weeks, and may have 
increased there for a short time. This view would 
both account for the complete subsidence of the 
epidemic early in December, and would support 
the conclusions come to by the result of Professor 
Frankland's investigations on the water bacteria 
and their relation to pathogenic organisms. If the 
bacillus of enteric fever were in the millpond it 
would have increased there, according to former 
notions, and the height of the epidemic would not 
have been reached within two or three weeks, and 
fu ly a month before the old well and the low level 
reservoir were closed. 

In conclusion, I may say Carisbrooke is to be 
sewered, and the Corporal ion of Newport have 
placed a wall of puddled clay around their water- 
works, which they are about to remove to a site 
some three miles up the valley, and at the ultimate 
source of the stream beyond the region (-f millponds 
and aggregation of leaking cesspits. Even ihtre I 
fear they will not be beyond the region of farmyards 
or of possible fissures in the chalk. But the well 
may reach the upptr greensand, for the chalk is- 
much denuded in the valley ; and if it does not, it 
would be wi^cr to bore into that formation. Acting 
upon the skilled advice of their engineer, the 
authorities of Newport are doing all they can tO' 
retrieve the past, and to maintain the fair fame of 
the Isle of Wight, the sanitary icputation of which 
ought to be above suspicion. 

On a Recent Loc.vl Ouii'.reak oi" Enteric 
Fever, with its Lessons to Rural and 
Urban Auihorities gkni:rallv. 

1!V 

B. Browning, M.D.. D.P.II., &c., Medical Officer of 
Health to the Urban Di>tiict Council. 

Dr. Browning first welcomed the Southern Branch 
to Weymouth, and then said : — 

Resisting the temptation which so powerfully 
aft'ects most mtdical officers of health to plunge 
deei)'y into vital statistics, I will merely (juote our 
last ) ear's birthrate of 21,108 per 1,000 ; death- 
rate of 10 79 ptr I, coo ; child death-iate of 0697 
per 1,000; zymotic death-rate of 0*5 per 1,000;. 
recorded sunshine of 5'36 hours daily; and not 
comment on these figures. Vou may, if you please. 

I will now ask your attention to the paper I am 
credited with in the agenda of to-da)'s^meeting. 



RECENT LOCAL OUTBREAK OF ENTERIC FEVER. 



"3 



It is a tale well fitted for a lay audience to hear, 
and I trust some of you will convey it to one. 

I regret to state that both my friend Dr. Pridham 
and myself have recently been sorely exercised by 
an outbreak of enteric fever in our respective rural 
and urban districts : that occurring in his being 
directly traceable to importation from Portland ; 
that in mine being the natural sequence of my 
unfortunate proximity to him. 

In the second week of March, 1895, he attended 
a young woman for enteric fever, who, living at 
Portland, contracted the " island blessing" there, 
and was sent home sick to Charleston, a small 
village in his district surrounded by numerous dairy 
farms supplying Weymouth with milk and butter. 
This place presented the customary insanitary con- 
ditions of a Dorset village in a strongly-marked 
degree ; the water supply, scanty in dry weather, 
derived from surface wells in close proximity to 
overflowing cesspits and a water-course which 
watered some of the cattle and was practically an 
open sewer. These wells were therefore certain, 
in wet weather, to be contaminated by human and 
animal excreta, as well as manurial abominations 
washed in from the fields above, and as a matter 
of fact gave me, on subsequent analysis, undoubted 
evidence of sewage pollution. 

The patient died, and no more cases occurred 
until about September 3rd, when another girl 
staying there took enteric fever, and shortly after- 
wards three members of her family, in the same 
house, were attacked with it. A few days later 
more cases developed in the neighbouring houses, 
and by the end of October twenty-two cases in all 
were noted and two deaths. None were sent to the 
Infectious Hospital, but the wells were closed, 
water from Weymouth mains was sent out daily in 
carts to the districts, two trained nurses obtained, 
and the generous voluntary aid of the rector and 
two other gentlemen utilized as desirable. The 
plague is now, I believe, stayed, and certain 
remedial measures, which were urgently indicated, 
are being carried out, including a better water 
supply and some necessary house sanitation. 

Although from its commencement watching 
this wholesale manufactory of typhoid with con- 
siderable anxiety and interest, I was unable to 
take any preventive measures regarding Wey- 
mouth urban district, beyond giving advice to 
purveyors and people, until October 26th, when a 
case of typhoid was notified to me, which, on 
visiting, I found due to milk sent from Charleston. 

The next two days gave me three more cases, all 
of whom had taken Charleston milk. Of these 
four, who were all at once sent to the Infectious 
Hospital, three had milk from the same dealer, 
and neither he nor the other had used pure water 
for washing their milk cans, though their wells and 
drinking ponds were situated close to the infected 
premises, and the Weymouth water was carried past 
their doors. Another case was made known to me 



on November 8th ; here the water supply of the 
dairy where the milk was obtained was within 
thirty feet of a house in which a fatal case of 
typhoid, also caught at Portland, had occurred 
under my care in the rural district at the end of 
January last, though the well was situated just 
below an ancient and overcrowded churchyard, and 
received its drainage, but was not used for drink- 
ing. Since then I have witnessed four more cases 
of typhoid in my district, the last on December 
5th, which was at once sent to the hospital. 
The others were properly isolated and well 
nursed, but their removal would have been most 
injudicious. I could not so certainly trace the 
infection in these last four cases directly to milk, 
though all that had been used came either from 
Charleston or some farms near it, but as proper 
precautions have been recommended both to con- 
sumers and retailers of milk here, and as a rule, 
I believe, carried out, I did not feel justified in stop- 
ping the sale of milk from the parish of Chickerell, 
m which Charleston is situate, although I consider 
its milk supply of doubtful character and a possible 
source of danger for some time to come. 

No deaths due to enteric fever have yet hap- 
pened during the outbreak, either in my urban 
district nor in the Port Sanitary Hospital. My 
cases sent to hospital (five in all) were of a very 
severe character, as indeed were the others left at 
home. Those in Charleston were of a milder type. 

In spite of Dr. Pridham's presence here, I am per- 
force compelled to mention the zeal and devotion to 
the thorough discharge of his duty which he showed, 
both as rural medical officer of health and medical 
officer to the guardians; he spared himself in neither 
capacity, and it was only regrettable that his 
divided duties were somewhat antagonistic : the 
remarkably small mortality amongst his clientele 
is proof positive of the value of his services, which 
should be thoroughly recognised by his official 
superiors. Owing to his courtesy and kindness, I 
had ample opportunity of observing the rise, fall, and 
decline of the typhoid outbreak in Charleston, and 
am, as a result, convinced that it affords good 
object lessons in the prevention of similar pests 
elsewhere, to both rural and urban authorities, 
more especially rural. 

How does such a history appeal to rural authori- 
ties? It comes home to their "business and 
bosoms " ; for though they are too often invulner- 
able to arguments in favour of improved sanitation 
generally, fearing that the rates will be raised, it is a 
different matter when their monetary interests are 
vitally affected by an epidemic of preventable 
disease, and then they will gladly embrace the faith 
new to their fathers. 

This experience should teach them to support 
their health officers in every possible way, to give 
them a free hand in improving the districts, even if 
time-honoured and vested nuisances are thereby 
attacked and abolished. 



114 



PROCEEDINGS OF THE SOUTHERN BRANCH. 



It should induce them to adopt the more recent 
Amendment and Improvement Acts and the Local 
Government Board Orders following the Public 
Health Act, 1875, everywhere, so as to place rural 
and urban authorities in an equal position as to 
sanitar)' powers. 

More particularly should they most positively 
insist on the Dairies, Cowsheds, and Milkshops Act 
and the Bakehouses Regulation Act not being left 
in abeyance, but thoroughly carried out in the spirit 
as well as the letter of the law. 

Instead of, as too often is the case, gauging the 
value of their health officer by the minimum of 
work accomplished, they should realise the fact 
that, by keeping the district in the old typical in- 
sanitary state, they are running the risk of being 
placed by their more enlightened urban neighbours 
within a " cordon sanitaire," and having the sale of 
some of their most remunerative produce forcibly 
stopped. Also, that from their water supplies, wil- 
fully suffered to be polluted, they may by their 
neglect and apathy be the means of bringing into 
their neighbourhood such a pestilence as has lately 
raged in Worthing and Newport, Isle of Wight, and 
such as might have existed in this town had not our 
Local Improvement Actlbeen in force and carried out. 

Some here present may remember when typhoid 
fever was rampant in a village near the site of our 
present waterworks, which were not then existent, 
and how it decimated the neighbourhood. What 
might have happened lately had this Charleston 
outbreak occurred on the gathering grounds of our 
Weymouth Water Company } What may yet hap- 
pen if country dairymen are allowed "the option of 
the choice '* whether they shall use pure or sewage 
polluted water in their business, the former being 
within the reach of all? 

How can a town escape the risk of typhoid infec- 
tion from country-contaminated water and milk 
when the rural medical officer is paid a sweating 
wage, terminable annually, which, poor as it is, 
causes him to be the scapegoat, and held responsible 
for any lacheti'-s of his employer ? 

One more lesson may be learnt by rural autho- 
rities from such outbreaks as that in Charleston, 
/.?., that typhoid excreta may be disposed on earth 
more than 100 yards from the nearest water supply, 
and that the general water supply within a long 
distance — say, a radius of a mile at least — may be 
so poisoned in consequence, that not only persons 
drinking it will contract the malady, but that cows 
doing so may be the innocent means of giving it to 
people living in a neighbouring or remote locality. 

This appears to be proved by the bacteriological 
researches of Wright and Semple and the able sum- 
mary of Meredith, and I am endeavouring to verify 
the statement that the bacillus ty[)hosus can be 
detected both in the milk and urine of cows drink- 
ing water fouled with, or fed on grass contaminated 
by, typhoid sewage, as it is in those secretions of 
enteric patients. 



So much for lessons to rural authorities. What 
can we tell those in urban districts ? 

The lessons to be learnt by any urban authority 
from such experiences as these now related are : — 

1. The absolute necessity of keeping a watchful 
eye on their rural neighbouring authorities (I use 
the word authority instead of district for a reason) 
to see that neither the gathering ground of their 
water supply is allowed to be polluted owing to the 
" laissez faire " of their neighbours in office, nor that 
the dairy products in their vicinity shall be allowed 

to enter their urban district unless their health ■ 
officer is satisfied that no appreciable cause of » 
disease exists within a reasonable specified zone, 
which zone is to be determined on its merits. 

2. For this purpose, it must be made imperative 
on the rural authorities to notiiy fort/iwith to their 
urban neighbours all outbreaks of infectious 
disease, as they do now to the Local Government 
Board and to the Local County Council, the word 
" forthwith " meaning, not a fortnight or more after 
the occurrence, as is usual whilst the case is being 
treated, but an immediate report to the urban 
medical officer of health, supposing that the 
practitioner is somewhat doubtful as to the exact 
nature of the complaint ; so that the responsibility 
of removal or detention at home may be shared 
by two practitioners instead of, as now, being 
thrown on the shoulders of one only, to .his 
manifest disadvantage. 

3. The powers of the urban district officers 
should be largely increased by the efforts of their 
Council. At present they must sit out, as I and 
others have done, whilst endemic disease was 
raging near us, with folded hands, powerless to 
interfere till we had a case or cases in our dis- 
tricts. The interests of the few must always be 
subservient to the interests of the many ; and a 
small rural population, though with a large acreage, 
has no right to imperil the well-being of an urban 
population because the former, through the Parish 
Council, objects to being hindered from fatally 
injuring their neighbours through non-compliance 
with the letter and spirit of the many Sanitary Acts 
which have been passed since 1875. 

Lastly, this most important lesson of all must be 
learnt by urban and rural authorities — the absolute 
necessity of co-operation in general sanitation. The 
" penny-wise pound-foolish " policy of non-removal 
to hospital too often is upheld by both of them. 
For example, it was said at a meeting of a rural 
authority when I was present : " If these peop'e 
had been sent to hospital, it would have cost us 
us p^^ioo or more." Yes, but if the rural medical 
officer of health had had, like myself, a free hand 
in the matter, one or two at the utmost would have 
been sent to hospital, and no more cases would 
have occurred, and no such expenses would have 
been needed. I, with full permission from my 
Council to act according to my lights, sent five out 
of nine cases at once to the hospital, and, with a 



DISEASE COINCIDENT WITH INSANITARY CONDITIONS. 



"5 



much larger population (partly exposed to one of 
the most potent factors of enteric fever), have, for- 
tunately, recorded no more cases, and may claim 
to have stamped out an epidemic in a town of 
20,000 people, whilst one-third of the inhabitants 
of the hamlet which was t\\Qfo?is et origo mali were 
struck down in succession owing to the objection 
of the District Council to incur any increased ex- 
penditure. Comment is needless, but these lessons 
should be taught everywhere. 



PROCEEDINGS OF THE HOME COUNTIES 
BRANCH OF THE INCORPORATED 
SOCIETY OF MEDICAL OFFICERS OF 
HEALTH. 

A Meeting of the Home Counties Branch was 
held at the Holborn Restaurant on Thursday, 
December 5th, the following members being 
present : — Dr. Seaton (President), Drs. Barton, 
Child, Peskett, Shad well, Thresh, Woodgarde, 
Yunge Bateman, and the Hon. Sec. 

The minutes of the previous meeting were read 
and confirmed. 

The Honorary Treasurer's balance-sheet, show- 
ing a balance in handof;^!! 9s. 3d., was audited 
and passed. 

The question of changing the day of meeting 
was discussed, and it was resolved that the meetings 
be held on the second Thursday in the month 
instead of the first as heretofore. 

The following paper on " Diseases Coincident 
with Insanitary Conditions," was read by Dr. 
Shadwell : — 

Disease Coincident with Insanitary 
Conditions. 

By St. Clair B. Shadwell, M.D., D.P.H. 

In investigating the causes of disease, every medical 
officer of health must frequently have found some 
insanitary condition of the dwelling co-existing with 
the illness. The question naturally arises, whether 
the insanitary condition has caused the disease, or 
whether the two are simply coincidental ? 

To take an example. A case of typhoid fever 
was notified to me. The house drains, on being 
tested, were found defective. Defective drainage 
and typhoid have for so long stood in the relation- 
ship of cause and effect, that one is almost satisfied 
that the cause of the disease has been discovered 
when the defect in the drains has been demon- 
strated. But on pushing my investigations, it was 
found that the patient had been away from home 
for a month or more, and had returned out of 
health, and during her absence had been engaged 
in nursing a case of typhoid fever. Under these 
circumstances, one was justified in concluding that 
the defective drainage was not the cause of the 
disease, which in all probability had been con- 
tracted while away from home, the defective 



drainage and disease on this occasion being only a 
coincidence. 

If, on the other hand, after the most careful 
inquiries, no cause save the insanitary surround- 
ings can be found to account for the presence 
of disease, is it justifiable to regard the insanitary 
condition as the cause of the illness? 

Sewer and drain air has long been credited with 
being a potent cause of certain diseases. Recent 
investigations, however, tend to throw some doubt 
on the correctness of the old faith so long 
cherished by the sanitarian. 

Are we yet in a position to throw over the old, 
and unconditionally to accept the new doctrine ? 

It is with the object of obtaining an answer to 
this question, from those of a larger experience 
and greater scientific knowledge, that I have 
ventured to read a paper before this Society to- 
day, and bring to your notice instances of disease 
coincident with insanitary conditions which have 
excited my interest while prosecuting my duties 
as a health officer or general medical practitioner 
(a combination of duties which may have itsdis- 
advantages, but which also has some advantages), 
and which may, or may not, have resulted from 
exposure to sewer air. The first disease which 
I wish to bring forward for your discussion is a 
form of sore throat, which starts as a tonsillitis, and 
is followed by a series of symptoms more or less 
serious. 

In this class of disease the tonsils are inflamed, 
slightly enlarged, having a dusky red appearance, 
with a greyish or greenish grey deposit ; the 
throat, especially in children, is painful. The 
throat symptoms generally pass off in six or eight 
days, and are followed by pain and swelling of 
the joints, often complicated by heart and kidney 
inflammations. 

These throats have nothing to do with scarlatina 
or diphtheria, nor do they resemble the well- 
known quinsy in persons with rheumatic histories. 

The following is a short sketch of a few such 
cases which have come under my notice : — 

I, A father and daughter were attacked at about 
the same time with sore throats as above de- 
scribed, followed in both with acute arthritic pains 
(rheumatism). The male patient's illness was com- 
plicated with endo-carditis and albuminuria. The 
illness was a protracted one, and though ending in 
recovery, left the patient with damaged heart and 
kidneys. The house was a comparatively new one, 
and looked west over an open space of land. The 
sewer in the road terminated in a manhole, which 
was provided with a grid ventilator, and was 
situated immediately in front of the sitting-room 
window. During the prevalence of westerly winds, 
the presence of sewer air could most unmistakably 
be detected in the room. Beyond the fact that 
the drinking-water cistern also supplied the w.c, 
the sanitary arrangements of the house appeared 
to be satisfactory. 



ii6 



PROCEEDINGS OF THE HOME COUNTIES BRANCH. 



2. As in the above instance, a father and 
daughter suffered with sore throat, followed by 
pain and swelling of the joints ; the illness was 
further complicated with albuminuria. The elder 
patient suffered the more severely. The drinking- 
water cistern was placed over the w.c, and supplied 
it. A ventilating pipe discharged on a level with 
the top of the cistern, which was not covered. It 
is quite within the range of possibility that drain 
air was absorbed by the drinking water. 

3. A father, grandmother, and three childien 
suffered with sore throat, followed, in the case of 
the father, grandmother, and youngest child, with 
rheumatism, and terminating, in the case of the 
father, with hyperpyrexia (temp. iii'^)and death. 
The house had not been recently built ; the 
drains were defective, and almost choked with 
soil. The sewer in the road discharged at times, 
through a grid ventilator, a quantity of foul-smelling 
air in front of the house. This ventilator was the 
first opening in a long line of unventilated sewers. 
About twelve months later a second outbreak of 
sore throat occurred in the same house, a servant- 
maid who had recently come into the family being 
the first to be attacked on this occasion ; then two 
of the children who had escaped the disease on 
the previous occasion. By this time the house 
drains had been put in repair, but the sewer con- 
tinued to discharge offensive air in front of the 
house. This was subsequently remedied by pro- 
viding outlets in the unventilated sewer. 

4. A father, son, and daughter were ill at the 
same time with sore throats, followed, as in the 
former cases, with symptoms resembling acute 
rheumatism. In the case of the father the illness 
was very protracted, and the daughter developed 
severe heart trouble. The healthiness of the 
house — a very old one — 'Was suspected. On in- 
vestigating its sanitary arrangements, two cess- 
pools, the existence of which was quite unknown, 
were found urder the floor of the living-room. 
These cesspools had overflow pipes, which were 
connected with the sewer in the road, so that it had 
not been necessary to empty them for many years. 

Further examples of this disease might 
be given, but the four examples above 
mentioned are sufficient for the purposes 
of this paper. 

I have never met with this disease in an 
epidemic form, for though two or more 
inmates of a house have usually suffered 
at the same time, I have not known it to 
have affected nurses or others who have 
visited the infected houses. 

My cases have been spread over a con- 
siderable period of time. In a recent case, 
Dr. Thresh, Medical Officer of Health for 
the County of Essex, has made a cultiva- 
tion of the throat deposit, and I hope he 
will tell us something about this obscure 
but interesting disease. 



The next question proposed for discussion is> 
Whether the infection of diphtheria can be con- 
veyed (not produced) by sewer air ? 

In passing, I may mention a curious coincidence 
which came under notice while investigating an 
outbreak of diphtheria a few years ago. The 
incidence of the disease pointed to a certain 
school as being the chief factor in spreading the 
infection. On visiting the school, it was found that 
all the earlier cases had occurred among the 
children using one class-room. This class-room 
had been built quite recently, the main building 
being some twenty-five years old. Further in- 
vestigations brought to light the fact that the new 
room had been built over an old disused cesspool, 
connected to which was a brick drain, which 
passed directly under the class-room, and was 
supposed to terminate in one of the street sewers, 
as it received the waste water from the school 
lavatory. 

A still more interesting condition of things, and 
one which requires a satisfactory explanation, is the 
following : 

In a group of streets situated at one end of a 
district, one street had a large number of diphtheria 
cases, while the others were all but free from the 
disease. To put the facts clearly before you it will be 
necessary to give a description of the drainage 
system of the district. 

The district is drained on the " separate system," 
the rain-water from the backs of the houses only 
being allowed to find its way into the soil sewers. 

There are three systems of soil sewers, namely, 
the northern outfall, which provides for the 
sewage of the greater part of the district, the 
southern, and the low-level outfalls. 

The sewage finds its way by gravitation to a 
sewage farm by the first two systems, while that 
from the low-level has to be pumped up to the farm. 
To lessen the pumping operations extra drains 
were provided to take the rainfall from the backs 
as well as the fronts of the houses situated in that 
part of the district drained by the low level system 
of sewers. 




The Unshaded roRTioNS represent the .Streets draining 
INTO the Low Level System. 



PROCEEDINGS OF THE NORTHERN BRANCH. 



117 



The group of streets now under consideration 
drained some into the low-level, and others into 
the northern outfall ; while one street, which 
claims special attention, drained part into the 
low-level, and part into the northern main sewer. 

On examining the accompanying plan it will at 
once be seen that a large number of cases of 
diphtheria occurred in this one street, while the 
adjoining streets were all but free from the disease. 

On examining the sewers and drains in this and 
adjoining streets (A and B), it was found that the 
sewer in A was in fairly good working order, while 
in B the sewer was badly laid and the joints 
defective. It was further discovered, and this is a 
point to be taken note of, that the rain water sewers 
svhich had been provided for the houses in street 
A, were discharging into the soil sewers in street B. 

The drains in all these streets were provided 
with "bell traps." The summer, at the end of 
which these diphtheria cases occurred, had been a 
hot and dry one ; and as the " bells " were often 
broken, missing, or easily removed by children 
playing in the yards of the houses, it is evident 
that the rain water drains acted as ventilators to 
the defective and badly laid sewers in street B. 

A further point of interest is the fact that all the 
known cases of diphtheria in street A were limited 
to that portion of the street w^hich drained into the 
low-level system, while the portion draining into 
the northern main sewer remained free. 

One further example of disease coincident with 
insanitary conditions of the dwellings. 

In one of a row of sixteen houses there was a 
case of typhoid fever, the history of which was as 
follows : — A youth, the son of a bricklayer, was 
engaged with his father in some drain work, and a 
short time before being taken ill had to open a 
blocked drain. This may, or may not, have been 
the cause of his illness. During the next three 
weeks, cases of typhoid fever showed themselves in 
three other houses in this row. 

Some time previously I had found that the sink 
pipes in all these houses were directly connected 
with the house drains. Notices were served on 
the owners of the houses to disconnect the sinks, 
and with two exceptions the notices had been com- 
plied with. 

The fresh cases of typhoid fever occurred in these 
two houses, and in a third one where, though the 
sink pipe had been disconnected, the house drain 
had been left defective, so that sewer air found 
ready access into the house. 

I was unable to find anything in common with 
the persons living in these three houses, save air, 
water, and sewer gas; air and water were common 
to all the houses, but no other cases of enteric 
fever was found in any except the four houses 
mentioned. Did the sewer air convey the disease 
to the three houses, the infection having found its 
way into the sewer from the first case ? Or was 
this, again, only a coincidence? 



I am well aware that now-a-days whoever 
entertains the supposition that sewer air can 
produce disease, proves himself to have neither a 
qualitative nor quantitative idea of physical causa- 
tion, or at least some would have us believe so. 

And to suggest, which I must admit this paper 
does, that [sewer air may act as a vehicle for the 
transmission of disease germs, lays oneself open to 
the taunt of the supporters of the more scientific 
and newer faith. 

Thou prated here where thou are least ; 
This faith has many a purer priest, 
And many an abler voice than thou. 

This may be so, yet I cannot help feeling that 
before quite giving up the old belief we should 
pause awhile, and compare the results of careful 
observation with the results of scientific experi- 
ment, and see how far they are in accord. This is 
what I hope you will do to-day, and so, in some 
measure, remedy the many defects of this paper, of 
which I am only too conscious. 

An interesting discussion took place on the 
paper, in which most of the members took part. 

Note. — The next meeting of the branch will 
be held at the Holborn Restaurant, at 5.30 p.m., 
on Thursday, February 13th, 1896. 



PROCEEDINGS OF THE NORTHERN 
BRANCH OF THE INCORPORATED 
SOCIETY OF MEDICAL OFFICERS OF 
HEALTH. 

The annual meeting of this Branch was held at 
Newcastle-on-Tyne on November 8th, 1895, Dr. 
H. E. Armstrong in the chair. 

The minutes of the last annual meeting were 
read and signed. 

The Hon. Secretary read a letter from Dr. 
Sydney Hall, thanking the Branch on behalf of 
Mrs. Hall and himself for their kind sympathy 
with them in their recent bereavement. 

A letter was read from Dr. Gourley, ^Medical 
Officer of Health of West Hartlepool, inviting the 
Branch to hold its next meeting in January at 
West Hartlepool, when he would be glad to give 
the members an opportunity of inspecting the new 
public slaughter-houses, which were rapidly ap- 
proaching completion. It was resolved that Dr. 
Gourley's kind invitation be accepted, and that the 
next meeting of the Branch be held at We-t 
Hartlepool, on a date (preferably a Friday) suitable 
to Dr. Gourley. 

A letter was read from the Treasurer of the 
Incorporated Society, dated August 14th, 1895, re 
the amount of money due to the Branch from the 
Society, and enclosing a cheque for p^iS 17s. 6d. 

The Hon. Secretary stated that he had for- 
warded the resolution passed at the last meeting, 
asking for an increase in the grant from the 
Society to the Branch from 7s. 6d. to los. per 



ii8 



PROCEEDINGS OF THE NORTHERN BRANCH. 



member to the Hon. Secretary of the Society, and 
read letters dated October ist and November ist, 
1895, from the Secretary of the Society, which 
stated that the Council of the Society could not 
make any alteration in the present grant till next 
September (1896), but that they considered the 
request a reasonable one. 

A letter, dated October 24th, 1895, was read 
from the Hon. Secretary of the Society on the 
question of the Insecurity of Tenure of Medical 
Officers of Health. In connection with this 
subject the following resolution (moved by Dr. 
Eustace Hill) was seconded by Dr. Wood, and 
carried unanimously : " That the Northern Branch 
of the Incorporated Society of Medical Officers of 
Health is strongly of opinion that the present 
position of most medical officers of health in the 
Northern District is detrimental to the best 
interests of sanitation, as the proper performance 
of their duties frequently renders the tenure of 
their office insecure, especially when the appoint- 
ments are made for a limited period of time ; that 
in the opinion of this Branch medical officers of 
health should be appointed without limit of time, 
and should not be subject to dismissal by their 
authority, except with the sanction of the Local 
Government Board." 

It was resolved that a copy of this resolution be 
forwarded to the Society of Medical Officers of 
Health, with the request that it should receive 
their strong support. 

On the motion of Dr. Wood, seconded by Dr. 
Armstrong, it was resolved: "That the further 
consideration of the matter be referred to the 
Council of the Branch, who should report to the 
next meeting of the Branch, and that the Hon. 
Secretary be requested in the meantime to com- 
municate with the members of the Branch, asking 
them for instances of the present system acting 
prejudicially to them as medical officers of health." 

The Hon. Secretary read his annual report, as 
follows : 

Report of the Hon. Secretary for the 
Year 1894-5. 

The meetings of the Branch during the past year 
have been four in number, and were held at 
Newcastle-on-Tyne, Darlington, Morpeth, and 
Tynemouth. With the exception of the meeting at 
Tynemouth, there was a good attendance of mem- 
bers ; but it is noteworthy that the meetings held 
in Newcastle are always better attended than those 
held elsewhere, owing, probably, to its being more 
easy of access to the majority of the members. 

The following papers were read at the various 
meetings, and subsequently discussed : — " Enteric 
Fever in the Sunderland Rural District during 1893 
and 1894," by Dr. T. Coke Squance ; "Noise, 
Silence, and Sound," by Dr. C. S. Hall. 

An important discussion on " The Prevention of 
Phthisis " was opened by Dr. Henry Armstrong 



and Dr. Geo. Murray, and a discussion also took 
place on "The Form and Compilation of Annual 
Health Reports," the subject being introduced by 
Dr. W. W. Stanithorpe, and ultimately referred to 
a sub-committee of the Branch, which has not yet 
met. Resolutions were passed by the Branch 
respecting the notification of tuberculosis in 
animals, the condemnation of the meat of such 
animals obviously affected with the disease, with 
compensation to the owners ; but the resolutions 
did not receive the support of the Society. 

Three new members have been elected to the 
Branch, which, however, sustained a great loss 
during the year by the death of its esteemed Vice- 
President (Dr. C. S. Hall). Three members have 
resigned, and the membership of the Branch now 
stands at 60, or one less than last year. 

The proceedings of the meetings of the Branch 
have been regularly published in Public Health, 
the journal of the Society. 

The financial condition of the Branch is satisfac- 
tory, there being a balance in hand of ^i^ 4s. 3d. ; 
while outstanding subscriptions, amounting to 
^2 15s., remain to be paid. As a result of the 
recent alterations of the Articles of Association 
of the Society, the Subscription to the Society 
was increased from los, 6d. to ^i is., there being 
no longer any subscription payable to the Branch, 
which, however, receives from the Society the sum 
of 7s. 6d. as respects each of its Fellows and mem- 
bers whose subscription has been paid, and 2s. 6d. 
as respects each Associate. The subscription was 
increased partly with the object of the Society con- 
tributing such a sum to the Branches that the latter 
would be able to pay the travelling expenses of 
their representatives when attending the meetings 
of the Council in London. Owing to the great 
distance of the Northern Branch District from 
London, the travelling expenses of the Branch 
representatives cannot be fully paid out of the 
present grant made by the Society, and an applica- 
tion has therefore been made for an increase of the 
grant from 7s. 6d. to los. per member, and in fair- 
ness to the Branch, should be acceded to by the 
Society. 

The Hon. Treasurer presented his balance- 
sheet, duly audited, and showing a balance in 
hand of ^13 4s. 3d. 

The Hon. Secretary read the report of the 
Council meeting held October 29th, 1895. 

The following gentlemen, who had been 
nominated by the retiring Council, were unani- 
mously elected to form the Council for the ensuing 
year, the President, Dr. Armstrong, having been 
elected in accordance with the Articles of Associa- 
tion at the July meeting of the Branch. 

y/j Vice-Presideni.—T. Eustace Hill. 

As Hon. Secretary and Treasurer . — B. T. Stokoe. 

As Council.— Drs. R. J. Boustead, H. Frazer 
Hurst, J. E. Gofton, J. W. Hembrough, D. S. 



AN EPIDEMIC OF ENTERIC FEVER. 



119 



Park, T. Coke Squance, W. H. Turnbull, and 
J. Cundell Wood. 

The following gentlemen were elected as Fellows 
of the Branch: — Thomas Home, M.D., M.O.H., 
Stockton-on-Tees; John Taylor, M.I)., D.P.H., 
M.O.H., Chester-le-Street Rural District. 

The President, Dr. H. E. Armstrong in lieu of 
his presidential address, opened a discussion on 
" The Peculiarity of Type in Enteric Fever " (to 
be published in February number of Public 
Health). 

The discussion was continued by Dr. J. C. 
Wood, who referred to the recent severe epidemic 
of enteric fever in Sunderland, which, there were 
some suspicions, might have been caused by milk. 
The discussion was ultimately adjourned to a sub- 
sequent meeting of the Branch, at which Dr. Wood 
stated that he would give some interesting facts 
and statistics relating to the Sunderland epidemic. 

The annual dinner was held at the conclusion of 
the meeting, and was well attended. 



PROCEEDINGS OF THE METROPOLITAN 
BRANCH OF THE INCORPORATED 
SOCIETY OF MEDICAL OFFICERS OF 
HEALTH. 

A MEETING of the above Branch was held on 
Tuesday, December loth, at 197, High Holborn, 
at 8 p.m. Present — Dr. G. E. Yarrow (President) 
in the chair, Drs. Bute, Bryett, Davies, Lovett, 
Allan, Herron, Roberts, Field, Reginald Dudfield, 
Hamer, Willoughby, and Murphy ; and Messrs. 
Gould (Factory Inspector to the Home Office) 
aud Martinson, visitors. The minutes of the last 
meeting were read and signed as correct. 

Reports of Council. 

In reference to a letter from the Secretary of the 
Metropolitan Local Government (Officers) Associa- 
tion, suggesting that, in view of questions arising in 
Parliament and elsewhere, where a united body of 
officers would carry far more weight than can be 
effected under present conditions, it would be 
desirable to establish co-operation between the 
association and others of a like character by a 
joint committee or otherwise. It was resolved 
" That the Branch does not consider it advan- 
tageous at the present juncture to join such con- 
joint committee, as proposed by the Metropolitan 
Local Government (Officers) Association." 

In reference to the published report of the pro- 
ceedings of the General Medical Council, amending 
the regulations for examinations for diplomas in 
State Medicine, by which it appears that only 
Medical Officers of Health of districts with a 
population of 50.000 and upwards will be in 
future able to take pupils, it was unanimously 
resolved that letters be addressed to the General 
Medical Council, and to Dr. R. Thome Thorne, 
pointing out the hardships involved to many 



Metropolitan Medical Officers of Health, who now 
take pupils and will in future be disqualified. 

Election of an additio?ial representative to the 
Council of the Society^ to which the Metropolitan 
Branch has become entitled by the formation of the 
Scottish Branch. 

Dr. W. Collingridge was proposed, and, there 
being no other nomination, the chairman declared 
him duly elected. 

Dr. Sidney Davies then read the following 
paper : — 

An Epidemic of Enteric Fever, 

Sidney Davies, M.A., M.D., Oxon ; M.O.H. of 
Plumstead. 

I. Previous to May 9th, only six cases of 
enteric fever had been notified during the year in 
Plumstead. These all occurred in East Plum- 
stead, whereas the recent epidemic was mainly 
confined to West Plumstead. The number of 
cases notified in the three preceding years 
respectively was 22, 29 and 26. The first case of 
the epidemic was notified on the 9th May, at a 
public house in Plumstead Common Road, and 
two more on the nth. On this day I was informed 
by Dr. Clarke, of Plumstead Common Road, that 
he had several suspicious cases in his practice. I 
visited two of these, and had no hesitation in 
pronouncing them to be enteric fever. On the 
whole I had information on the nth of six recent 
cases of enteric, and five of them derived their 
milk supply from the same source, a dairy in 
Prince's Road. (I found afterwards that the sixth 
case also had milk from the same source, though 
from a different dairy.) I felt no doubt accord- 
ingly that I had an epidemic of enteric fever to 
deal with, and that in all probability it was con- 
veyed by the milk supplied from the Prince's 
Road dairy. I at once inspected this dairy. It 
contained thirteen cows, all apparently in good 
condition. The Kent Company's water was laid 
on. Although not kept in a very cleanly condition, 
the only thing which excited my suspicion was a tank 
about three feet square and two feet deep, situated 
under a tap, and used for watering the cows. 
Evidently this tank was seldom cleaned out, and in 
all probability was used for washing the cans into 
which the cows were milked, if not also the churns. 

All the milk supplied from the dairy was said to 
come from the cows in the cowshed. I could 
learn of no recent illness of any kind in anyone 
connected with the dairy ; but I was told that the 
manager and his wife and daughter living on the 
premises were frequently under treatment for 
alcoholism, and I knew one of the two employes 
as a lad of dirty habits. 

The information at my disposal, though occasion- 
ing strong suspicion, did not, I felt, justify me in 
asking the vestry to close the dairy. I waited 
accordingly two days till the 13th, on which day I 



PROCEEDINGS OF THE METROPOLITAN BRANCH. 



knewof i6 cases, 15 of which were found to have had 
milk from the Prince's Road dairy. The evidence 
now seemed sufficient to incriminate the dairy, 
and a special meeting of the Health Committee 
was summoned for the following day. This meet- 
ing decided, on my recommendation, to put in force 
Section 71 of the Public Health Act, London, 
and gave notice to the dairyman to appear the 
next day before them and show cause why the 
dairy should not be closed. 

In the meantime, in order to comply with the 
letter of the Act, although I had twice inspected 
the dairy, an order to inspect the same was ob- 
tained from a magistrate, and, accompanied by a 
veterinary surgeon, I again visited the dairy, but 
this time was refused admission and ejected from 
the premises with violence, the manager being 
under the influence of alcohol. When the com- 
mittee again met, the owner of the dairy appeared 
to answer the summons, the manager not being 
in a fit state. It was stated that one man owned 
the dairy, a second occupied it and managed it, 
and a third was responsible for the sale of the 
milk. An order was accordingly made requiring the 
occupier not to supply any milk from the dairy 
within the Plumstead district. This was on May 
15th, six days after the first case was notified, four 
days after the first indications of an epidemic, and 
two days after there was reasonable ground to 
attribute it to the milk supply. It might have 
been expected that there would have been no 
further trouble with the milk supply. But the 
event was far otherwise. I soon heard that the 
employes of the dairy were still selling milk. No 
doubt a good many of the customers had been 
frightened by what they had heard as to the 
epidemic, and the closing order made by the 
vestry, but it appeared that a large number were 
still willing to buy this milk. The vendors asserted 
that they were not selling the milk of their own 
cows, but milk they had bought elsewhere. I 
applied for a summons on this ground, but the 
magistrate considered it could not be called " sell- 
ing milk from the dairy." Accordingly, in order 
to obtain evidence for a prosecution, they were 
watched by the chief ins{)ector early in the morn- 
ing, and seen to bring the churns out of the dairy 
and proceed straightway and sell it to several 
houses. For this the occupier was summoned to 
the police court on May 20th, and fined the full 
penalty, ^5. I believe some milk was sold even 
after this, but probably not very much. It was, 
however, turned into butter, the sale of which is 
not interfered with by the Act. On the 28th the 
cows were sold. 

Up to May 15th, 25 cases were reported ; on 
the 29th the number had reached 92 ; in the fol- 
lowing fortnight 47 fresh cases occurred ; in the 
fortnight ending June 26th, 10 cases, since when 
there has been a slow but steady diminution. 
(See Table A.) 



The epidemic may be said to have declined 
rapidly from the 12th June, or about three weeks 
after the dairyman was summoned to the Police 
Court. In the cases that occurred after that date 
it was usually found that either the patient had 
been ill for two or more weeks before a diagnosis 
was made, or that there had been a previous case 
in the same house. 

It was to be expected that such an epidemic 
should cause for some months an increased pre- 
valence of enteric fever in the district, owing partly 
to direct conveyance of the infection to inmates of 
the same house, and partly to conveyance by unde- 
termined factors. Thus there were 13 cases re- 
ported in July. It is necessary, then, to fix an 
arbitrary date for the termination of the epidemic, 
and it is convenient to take the 30th June. Up to 
the 30th June 177 cases occurred, of which 159, 
or 90 per cent., were found to have had milk from 
the Prince's Road dairy, or from other dairies which 
supplied the same milk. 

2. Distribution of the Afilk. — The business of 
the implicated dairy was carried on without book- 
keeping, and not much reliance can be placed on 
the figures given by the dairyman, I obtained, 
however, from him a list of 141 houses in Plum- 
stead which he supplied regularly by cart. Sixty-five 
cases occurred in 44 of these houses. Many of his 
customers used to send to the dairy for milk. He 
also supplied all the milk sold by a large dairy situ- 
ated in Woolwich, and sold milk for retailing to two 
neighbouring shops. Seventeen of the Plumstead 
cases were supplied by the Woolwich dairy. All 
these are not included in the dairyman's list. As a 
result of a house-to-house inspection in Barnfield 
and Prince's Roads (the roads most affected by the 
epidemic), I found that, of 49 houses which had 
had milk from the Prince's Road dairy, only 20 
escaped having a case of enteric fever. On the other 
hand, only two had the fever out of 150 houses 
which were stated not to have had this milk. 
Altogether, this dairy must have supplied a very 
large number of people, probably, at least, 250 
houses. 

In May and June 33 cases of enteric fever 
occurred in Woolwich, nearly all of which, I under- 
stand, had milk from the Woolwich dairy referred 
to above, which was supplied by the Prince's Road 
dairy. 

3. The Dairy. — The dairy comprised a fair-sized 
cottage dwelling-house, situated in Prince's Road. 
Adjoining the back addition and water-closet cf the 
house was a small room, used' for keeping and 
washing the milk-churns. This was fairly clean, 
and had no separate water supply. It opened into 
the yard. On the opposite side of the yard to the 
house was the cow-shed, one side adjoining the 
yard, and the other being in Barnfield Road. This 
was well ventilated on both sides. Continuous 
with the cow-shed, and running along Barnfield 
Road, was a shed for the grains. In this, against 



i 



AN EPIDEMIC OF ENTERIC FEVER. 



the wall of the cowshed, was the tank of water 
above referred to, close to the door leading into 
the cowshed. The roof, being of loosely-laid tiles, 
and there being a window within a few feet, it 
would be easy for any filth existing in Barnfield 
P.oad to get into the tank water, and it would also 
be liable to contamination by the cows going in 
and out of the shed. Over it were stacked some 
cans used for receiving the milk as it was drawn 
from the cows. 

The house contained a cellar, where milk was 
put to stand for separating the cream. In the 
cellar was a cupboard full of old condensed-milk 
tins. 

4. Water Supply. — The dairy was supplied by 
the Kent Water Company. There was one tap in 
the house, and one situated over the tank. This 
tank consistedof cemented brickwork. From it the 
cows were watered by means of pails. There was 
a green deposit on the sides and bottom, and the 
water was cloudy, as seen in a bottle. This water 
was analyzed by Professor Smith, and pronounced 
unfit for drinking purposes, on account of vegetable 
debris. Professor Smith also examined it bacterio- 
logically, with a negative result, as regards the 
specific organism of enteric fever. The water from 
the tap was also analysed and found to be of the 
usual good quality of Kent Company's water. The 
water pipes supplying the dairy on both, sides were 
carefully tested by Mr. Duck, chief sanitary in- 
spector, but were found perfectly sound : the water 
stood in the pipes without leakage for two days. 
I was informed by the company's inspector that the 
water had not been shut off in this locality within 
the previous two months. 

There was no well or underground tank situated 
on the premises. 

5. Sanitary Condition a7id Drainage. — The cow- 
house was not in a very cleanly condition. The 
roof was full of cobwebs, and the cow-dung not 
swept back on any of my visits. It was well- 
ventilated and properly drained. The water-closet 
of the house was satisfactory, as regarded the ap- 
paratus. The drains of the house were tested 
with the smoke machine, and found very defective, 
but the defects were all outside the buildings. 
There was, however, escape of smoke in an area 
outside the window of the cellar, where the milk 
was creamed, and where the condensed-milk tins 
were found. The rain-water pipes were in direct 
connection with the drain, and there was a de- 
fective gully outside the can-house. 

6. Incidence of the Disease. — The disease attacked 
74 males and 103 females : 28 were under 5 years 
of age, 41 from 5 to 10, 57 from lo to 20, 45 from 
20 to 40, and 6 over 40. One patient was 71 years 
old. He had a slight attack, and was at his occu- 
pation (analyst's inspector) within four weeks. (See 
Table A.) 

In my house-to-house inspection of the streets 
most affected I met with several cases of infants 



and young children who were out of sorts, and 
had diarrhoea. I think, probably, some of them 
were mild cases of enteric, but they were not 
notified. The cases presented the ordinary symp- 
toms, and usually had diarrhcea. 113 went to hos- 
pital, and 64 were treated at home. Up to the end 
of July there were 13 deaths at hospital and 10 at 
home. 

7. Death-rate. — Thus the case death-rate was r i 
per cent, at hospital and 15 per cent, at home. 

The case death-rate for Plumstead in the three 
years (1892, 1893, and 1894) was 22 per cent. This 
lower death-rate at hospital is highly satisfactory, and 
is probably mainly due to the more careful feeding 
that hospital patients have. It is in marked con- 
trast to the higher hospital death-rate of scarlet fever 
and diphtheria. 

8. Hospital Accommodation, — Many of the cases 
were unable to be removed to hospital for several 
days after notification, on account of want of accom- 
modation. The accommodation at the South- 
Eastern Hospital was soon exhausted, and cases 
were taken to the more distant fever hospitals. 
Arrangements were also made with the London, 
Guy's, and other general hospitals to receive 
patients. It is certainly undesirable to move an 
enteric case, after the first week, so long a journey as 
was required to reach these hospitals ; but the re- 
sult does not appear to have been so unfavourable 
to recovery as I anticipated. 

It is hardly creditable that London should be so 
deficient in accommodation for fever cases, that, at 
a time when very little fever prevailed over the great 
bulk of the Metropolis, a small localized outbreak 
could not be satisfactorily dealt with. 

9. District N'urses. — Great and valuable assist- 
ance was rendered by the nurses of the Woolwich 
District Nursing Association in nursing cases before 
they went to hospital, as well as those who remained 
at home all through their illness. 

10. Infectiousness. — The great importance of hos- 
pital treatment for all who cannot afford to have a 
trained nurse in continued and exclusive atiendance 
on the patient is shown by the number of cases 
which appeared to have been transmitted from the 
first patient to another in the same house, viz., six, 
at least. A case attended by myself is instructive 

from th's point of view. Mrs. R , living with 

her husband (a carpenter) and baby in three very 
comfortable and well-furnished rooms, in a well- 
drained and in every way sanitary house, caught 
the fever by drinking the Prince's Road milk when 
calling at her mother's. Her own house had a dif- 
ferent milk supply. She was jJaced in a large, well- 
ventilated room (the husband occupied a separate 
one), and nursed by the district visiting nurse and 
an untrained nurse who remained in the house. 
The latter prepared the husband's food ; but she 
was given strict directions about rendering her 
hands aseptic. Nevertheless, the husband fell ill 
about a week after the wife got up. No other 



PROCEEDINGS OF THE METROPOLITAN BRANCH. 



source of infection besides his wife could be 
traced. 

Remarks. — The facts given above are, I con- 
sider, conclusive proof that this epidemic was 
caused by a particular milk supply. 

A. Source of Infection. — A considerable number 
of milk epidemics of enteric fever have been 
reported in recent years. Some of these have 
been clearly traced to the use (for washing the 
milk cans or diluting the milk) of water con- 
taminated with the excreta of a previous case of the 
disease. But in other cases— as in the present 
epidemic — there appeared no probability of con- 
tamination by a previous case. It has been 
suggested that, as is probably the case with scarlet 
fever, enteric fever may be communicated to man 
by the milk of diseased cattle. A third explanation 
is the contamination of the milk by sewer gas. 

Pre-cxistent Case of Enteric. — In the present case 
it seems unlikely that anyone with enteric fever 
had had any connection with the dairy. I enquired 
carefully from their medical attendants as to the 
recent ailments of all connected with the dairy, and 
could find nothing suspicious about them. May, 
too, is the month when enteric fever is least pre- 
valent. If there had been any case of the disease 
among the dairy people, the dirty and intemperate 
habits of these, and the existence of the tank of 
water, offered a likely means of the contamination 
of the milk. A comparison of the bacteria found 
respectively in the tank water and the milk shows 
that there was a close resemblance between them, 
and increases the probabilty that this water found 
its way into the milk. 

In the absence of any evidence of a pre-existing 
case of enteric, it is impossible to say more than 
that this offers a not unlikely explanation. 

The Beveridge Epidemic. — An almost parallel 
case reported by Dr. Beveridge, of Aberdeen, is 
referred to by Dr. Ernest Hart, in the British 
Medical Journal for July 13th, 1895. Here an 
epidemic affecting 322 people was traced to the 
milk from a farm. 

*' The cistern at the farm was situated in a 
corner of the cowshed, its contents being used for 
all dairy and byre purposes. Analysis showed the 
water to be pure prior to entry into the cistern, 
but to become highly polluted with organic matter 
while in the cistern. All the 322 cases of fever 
occurring in the month of April were in consumers 
of the milk from this dairy, and no condition of 
the milch cows could be discovered, after very 
careful examination, to account for infcctivity of 
the milk by the cattle. No one taking other milk 
was attacked, and persons whose cans were not 
washed in the cistern water escaped the fever." 

"The case is interesting as showing that despite 
the patent fact that the water was the vera causa 
of the epidemic, there is no knowing in what 
manner the water obtained its infective quality." 
In the case of the Plumstead dairy the use of the 



tank water, even for washing the cans, was denied. 
But in all other respects the two epidemics are 
analogous. 

Infection by Sewer Gas. — The possibility of the 
infectivity of the milk coming from sewer gas would 
be disregarded by many, but in spite of recent 
researches as to the absence of pathogenic germs 
in sewer gas there is no getting away from the 
multitude of evidence that disease (especially a 
enteric fever) is conveyed directly in this way, I 
and indirectly through the pollution of food. In 
the number of the British Medical Journal above 
quoted, Dr. Hart refers to an outbreak in Cornwall, | 
reported by Dr. Ballard of the Local Government \ 
Board. Typhoid dejecta found their way into "a 
drain which had aerial connection with the room of 
a dairy farm in which the milk was stored on 
shelves, with extension of the disease as a result in 
the dairyman's family and an unknown number of 
his customers." At the Plumstead dairy the sewer 
gas only had connection with the room where milk ; 
was stored through the window of a cellar or by 
the door of a can house. There was also no 
evidence or probability of the drain or sewers con- 
taining enteric dejecta, no case having been 
reported in the street for some years. So that on 
the whole I am inclined to regard sewer gas as 
a possible source of infection, though less probable 
than the tank water. 

The Colouring Fluid. — Another means by which 
it is just possible for the infection to have reached 
the milk is by means of the annatto dye used for 
giving a creamy colour to the milk. I have to 
thank Dr. Bernays, Medical Oflficer of Health, 
Charlton, for calling my attention to this. He 
informs me that the use of colouring matter is 
widespread. The dye was noticed in an empty 
milk can, and the bottle obtained. It came from 
manufacturers in the north of London. But if 
this had been the source, the epidemic would 
certainly not have been confined to Plumstead and 
^Voolwich, as was the case, so that this hypothesis 
may be excluded. 

Coxvs as the Source of Infection. — Finally, could 
the infection have been in the milk as it came from 
the cows ? Two veterinary surgeons pronounced 
the cows healthy. But as one of them was 
suspected to have drunk water contaminated with 
sewage, while out at grass about a month previously, 
it was killed, and examined pathologically and 
bacteriologically at the Brown Institute, but with a 
negative result. If cow malady can be excluded, 
the tank water remains as the most probable 
explanation of the epidemic. 

B. Closing the Dairy. — Procedure for Closing the 
Dairy. — The following appears from Section 71, 
Public Health Act, London, to be the procedure 
in London necessary for closing a dairy, (i) The 
Medical Officer must have evidence that dangerous 
infectious disease in his district is attributable 
milk sui)plicd from the dairy. (2) He must 



71, 
ire 

he ■ 

)US I 

to I 

ust ■ 



AN EPIDEMIC OF ENTERIC FEVER. 



123 



obtain an order from a justice to inspect the dairy. 
(3) If he wishes to inspect the animals he must be 
accompanied by a veterinary inspector (a term not 
defined) or veterinary surgeon. (4). He must 
inspect the dairy, and such inspection must 
lead him to form the opinion that the disease is 
caused by milk from the dairy. (5) A report is to 
be made to the Sanitary Authority. (6) Twenty- 
four hours' notice is to be served on the dairyman 
to appear before the Sanitary Authority. 

Finally, if the dairyman fails to show cause to the 
contrary, an order may be made requiring him not 
to supply any tnillc from the dairy within the 
district until the order has been withdrawn. 

Now, in the first place, why should it be neces- 
sary to obtain an order to inspect the dairy when 
Section 10 gives power of entry to any premises ? 
Secondly, why should not a Medical Officer have 
power to inspect the animals unaccompanied by a 
Veterinary Inspector or Surgeon ? These are 
minor anomalies of the Act ; but the terms in 
which the closing of the dairy is expressed seem 
to me to seriously cripple the usefulness of 
Section 71. There is actually no power to close 
the dairy. The water supply may still be used — 
the churns, cans, premises, and all appurtenances 
may still be used — provided only that no milk goes 
out of the dairy for sale in the district ; even the 
milk itself may continue to be sold if it is carried 
into an adjoining sanitary district ; e.g.^ the dairy- 
man of the Prince's Road dairy was in no way 
debarred by the closing order from selling his 
milk as before in Woolwich, nor from taking his 
churns after they had been washed in his tank 
and buying milk at the station and retailing it 
to his customers. Evidently what is required is 
power to prevent the use of the dairy or anything 
contained therein absolutely and entirely, and ' to 
destroy or in other way render innocuous all milk 
given by the cows in the dairy. To do this 
effectively it would probably be necessary to 
quarter an inspector on the dairy premises. 

Compensation. — In the present instance the 
•dairy people, by their intractable behaviour, 
alienated any sympathy which they might other- 
wise have received ; but, even in their case, their 
fault hardly justified such a severe punishment as 
the complete ruin of their business. It certainly 
would seem common justice that where a dairy is 
■closed by a sanitary authority, on account of 
■disease caused by the milk, and when it cannot be 
shown that the milk is injurious through any 
breach of the law, or neglect on the part of the 
occupiers, these should be compensated for the 
loss of their business by the sanitary authority out 
of the rates, or perhaps better by the County 
Council. The absence of provision for compensa- 
tion probably often deters an authority from closing 
a dairy, from unwillingness to ruin the dairyman. 

Fine for Disobeying the Order Insufficient. — On 
the other hand, where a dairyman sets the closing 



order at defiance, a maximum penalty of ^Q'^ on 
conviction is absurdly inadequate. No doubt it 
usually happens that fear of losing custom makes 
dairy proprietors submit meekly to any orders 
given by the sanitary authority ; but that is not 
always the case, as the Plumstead experience 
shows. Here the magistrate, on imposing the 
penalty, expressed his opinion that it should be 
much greater. And I think most people will 
allow that a fine of jQ^o would not be too large a 
penalty for doggedly persisting, after a closing 
order, in selling milk proved to convey disease 
wherever it went. 

C. Dairy Regulations. — The question of the 
proper control of dairies and the milk traffic is a 
most important one, and will soon have to be 
taken in hand by the legislature. They are now 
under the dual control of the County Council and 
Local Sanitary Authority. It would be better to 
make one only of these bodies responsible, and 
probably the local authority would be most satis- 
factory — at any rate, for executive functions. The 
County Council might with advantage have ex- 
tended powers of making regulations, and cer- 
tainly further regulations are needed. It seems 
to me most undesirable that tanks of water such 
as existed in Prince's Road should be allowed, but 
the dairy regulations do not forbid them. There 
is no law or regulation, I believe, to prevent the 
sale of milk from tuberculous cows, although I 
think this might be done by extending the term 
dangerous infectious disease to tubercle under 
Section 58 of Public Health Act (London), after 
which Section 71 would apply. Milk should not 
be kept in such a cellar as it was at the Prince's 
Road dairy, but probably this was unknown to the 
inspector. 

Conclusion. — On the whole, I think it must be 
said that, under the existing law, nothing was left 
undone by the authorities which, if done, would 
have prevented this epidemic. 

I consider the lessons of the epidemic are : — 

1. That under our present knowledge milk 
cannot be considered a safe food unless boiled or 
otherwise sterilized. 

2. That legal powers are required for more 
effectively closing a dairy which is shown to be the 
source of infectious disease. 

3. That more stringent regulations for, and 
more effective inspection of, dairies, are required. 

ENTERIC FEVER. 
A.— Cases Occurring Each Week of the Epidemic, 



Week ending 15th May 

„ „ 22nd „ 

» 29th „ 

,, ,, 5th June 

,. „ I2th ,, 

,. 19th „ 

„ „ 26th „ 

Four days ending 30th ,, 



Total 



25 
SI 
39 
28 

19 
7 

4 
2 

K 2 



T24 



PROCEEDINGS OF THE METROPOLITAN BRANCH. 



B.— Sex and Age Distribution. 
Cases. 



Death?. Deaths. 





Male. 


Female. 


Male ami 
Female. 


Per cent 
of cases. 


Under 5 .. 


. 17 . 


II 


2 


7.0 


5-10 . 


• 15 


.. 26 


4 .. 


10 


10 — 20 . 


• 23 


•• 34 


^ 


90 


20—40 . 


. 16 


.. 29 


9 •• 


2C.0 


Over 40 . 


3 • 


J 


J 


50.0 



Total 



74 



23 



I3-0 



The Factory and Workshop Act, 1895. 

BY 

Francis J. Allan, M.D., F.R.S.E., Medical Officer of 
Health for the Strand District. 

To the already complicated and unsatisfactory 
series of Acts of Parliament dealing with the con- 
ditions under which work is carried on, there has 
this year been added yet another Act which well 
maintains the reputation of its predecessors. This 
latest enactment has been received with much 
acclamation by political parties, as an excellent 
product of legislative ability : but I venture to 
think that it would have been of greater practical 
utility had the Bill been drafted and promoted by 
a governmental department which was more in 
touch with public health questions than is the 
Home Office. As an example of this, one has 
only to notice two departures which have unfortu- 
nately found place in the Act. By Section 3 the 
Sanitary Authority is placed in the position of having 
to report to the Government Inspector of Fac- 
tories what proceedings the Authority may have 
taken in consequence of any complaint made by the 
Factory Inspector to the Authority, in respect of 
the sanitary condition of any factory or workshop 
under Section 4 of the Factory Act of 1878. And 
where proceedings are not taken within one month, 
the Factory Inspector (who, as a rule, has no prac- 
tical knowledge of sanitary work) " may take the 
like proceedings for punishing or remedying the 
same as the Sanitary Authority might have taken, 
and is entitled to recover from the Sanitary Autho- 
rity all such expenses in and about the proceedings 
as the inspector incurs, and are not recovered from 
any other person, and have not been incurred in 
any unsuccessful proceedings." 

It is quite conceivable that a Sanitary Authority 
may disagree with a Factory Inspector, and that it 
may be the duty of the Authority's advisers to 
appear in court in opposition to the factory inspec- 
tion. In commenting upon this anomalous 
requirment, I would quote to you an extract from 
a statement submitted by the Police Commissioners 
of €rlasgow to Mr. Asquitb, durmg the Committee 
stage of the Bill, which points clearly and decidedly 
the danger of inserting such a requirement. They 
said* : — 

The Commissioners are, as local authority, responsible to 

• Vide letter from Dr. J. B. Russell, Medical Officer of 
Health for Gla<gow, dated September loth, 1895, in 
British Mtdical 'Journal, vol. ii. p. 684, 1895. 



the Local Government Board for Scotland for the due and 

proper performance of their duty. The Commissioners have 
observed with regret that in recent Factory Acts some con- 
fusion has been created between the jurisdiction of local 
authorities and factory inspectors as regards the general 
conditions of health in factories and workshops. In the 
Bill for the amendment of these Acts presently before the 
House there are proposals which, if passed into law, will 
increase this confusion. The Commissioners are at one with 
the Government in their desire to procure for those who 
labour in factories and workshops the physical conditions of 
health, but they do not thinli that the method hitherto 
followed, and now proposed to be extended, would eventually 
promote the interests of the community at large, or even of 
that limited portion of it to which these .Acts apply. In 
respect of cleanliness, ventilaticn, overcrowding, and con- 
veniences, they can discover no adequate reason foi 
excluding, on account of their employment, any part of their 
constituency from the scope of the powers they possess ; for 
conferring sanitary powers upon factory inspectors which 
the Commisssioners themselves do not possess, or for sub- 
jecting their actings to the review and control of the Home 
Office, instead of the Local Government Board. Further, 
they take exception to such interference with their functions, 
on the ground of the administrative difficulties which will, 
in their judgment, inevitably ensue. In applying a statute 
which deals with standard measurements of space, with 
precise durations of time, with definite conditions of struc- 
ture of machinery, etc., there can be no room for diflference 
of opinion ; but cleanliness, ventilation, overcrowding, and 
conveniences, all involve more or less matters of opinion. 
The Commissioners have been exercising the powers they 
possess in these regards in factories, workshops, warehouses, 
offices, dwelling-houses, etc., for many years, advised by 
competent experts ; principles have been laid down ; pre- 
cedents have been established. While they welcome from 
any quarter information as to places, whether dwelling- 
houses, factories, or workshops, which seem to require the 
application of these powers, they foresee frequent friction 
and unseenly conflict of opinion if they are required to 
submit their actings thereon to the review ot factory 
inspectors. If special control of their actings in these 
regards in factories and workshops is thought to be neces- 
sary, the Commissioners respectfully submit that it ought to 
be exercised by the Local Government Board. If special 
powers are required to deal with those elementary matters of 
health in factories and workshops, they respectfully suV)mit 
that these powers ought to be conferred upon them, and be 
exercised subject to the supervision of the Local Government 
Board. Although the Commissioners have stated their own 
case as against the Bill, they believe that their position 
represents a sound general policy — namely, that there ought 
to be no division of authority or responsibility as to the 
primary conditions of health. If local authorities have been 
found to neglect their duty as regards factories and work- 
shops, the presumption is that this is only a fraction of 
their negligence, and it is certain that no general reform 
can be effected by a system of transferring the proper 
functions of local administration to independent officials 
acting under Government control. Indeed, the Com- 
missioners believe that much of the indifference to the 
sanitary clauses of the Factory Acts, which is said to exist 
on the part of sanitary authorities, is confirmed, if not 
occasioned, on the cne hand, by the freedom with which 
matters for which they are responsible are from time to 
time interfered with, and so far taken out of their hands ; 
and, on the other, by the cultivation in the minds of 
a powerful section of the ratepayers of the idea that their 
health is .in affair of the central Government rather than of 
their local representatives. 

The second new departure, which finds a place 
in this Act, is that contained in Section 29, whereby 
" Every medical practitioner attending or called 
in to visit a patient whom he believes to be suffering 



THE FACTORY AND WORKSHOP ACT, 1895. 



125 



from lead, phosphorous, or arsenical poisoning, 
or anthrax, contracted in any factory or workshop, 
shall (unless the notice required by this section has 
been previously sent*) send to the Chief Inspector 
of Factories at the Home Office, London, a notice" 
of the fact. The local inspector and the certifying 
surgeon will then be informed from the head office, 
and the provisions of the Factory Acts with respect 
to accidents shall forthwith apply in any such case. 
But there is no mention of the local authority or of 
the medical officer of health, and, were the matter 
not so serious, one might smile at the absurd cir- 
cumlocutory method by which the principle known 
as "red tapeism " is here applied. Dr. Newsholme 
and Dr. J. B. Russell have already called attention 
to this matter ; and it is to be noted that the Secre- 
tary of State may order an extension of this parti- 
cular enactment to any other disease occurring in a 
factory or workshop. May I quote Dr. Russell's 
criticism, written when the Bill was before Com- 
mittee. According to this clause — 

The medical practitioner will form an opinion that his 
patient suffers from poisoning or anthrax before he arrives at 
any conclusion as to its cause. This presumes an inquiry 
into circumstances, and the conclusion may postibly not be 
one which will make the practitioner any more popalar in 
the locality if he promulgates it. Let every such case be 
notifiable to the medical ofilcer of health of the district, as if 
it was an infectious disease. Let the medi:al officer of health 
make the inquiry, and, if he believes the disease was " con- 
tracted in any factory or workshop," let him at once inform 
the local factory inspector. 

In regard to this piece of legislature he con- 
cludes — 

There never was a better illustration of the extreme danger 
to the best interests of the country when a Bill so comp i- 
Gated, and demanding so much absolutely dispassionaie dii- 
cussion, as the Bill under review happens to be, hanging in 
the bilance on the eve of a general elec'ion. Had any 
member raised any such discussion regarding any clause in 
this Bill, after the resignation of the Ministry, it would have 
been as much as his political life was worth. The woiking 
classes in his constituency would have been told that he had 
sacrificed their interests by making it impossible to pass the 
Bill. 

Turning now to a consideration of those require- 
ments which it will be the duty of local authorities 
to enforce, it may be well to state here what the 
expression "workshops" implies. 

A "workshop " is defined in the " Factory and 
Workshop Act, 1878" (known as the "Principal 
Act "), Section 93, as : — 

" (i) Any premises or places named in part two 
of the fourth schedule to this Act, which are not 
a factory within the meaning of this Act ; 

" (2) Also any premises, room or place, not 
being a factory within the meaning of this Act, in 
which premises, room, or place, or within the 
close, or curtilage, or precincts of which premises 
any manual labour is exercised by way of trade, or 
for purposes of gain, in or incidental to the follow- 
ing purposes, or in any of them, that is to say — 

* A phrase which might be usefully applied to the In- 
tecious Disease Notification Act. 



" {a) In or incidental to the making of any 
article ; or 

"((^) In or incidental to the altering, repairing, 
ornamenting, or finishing of any article ; or 

'• {c) In or incidental to the adapting for sale of 
any article ; 

" And to which or over which premises, room, or 
phce, the employer of the persons working therein 
has the right of access or control." 

The Act of 1895 defines a laundry (other than 
a steam or power laundry) as a " workshop." 
And, as pointed out by Dr. T. Orme Dudfield, in 
one of his valuable monthly reports (No. vii., 
1895), " It is further enacted that any premises or 
place shall not be excluded from the definition of 
a workshop by reason only that such premises or 
place are, or is, in the open air." 

It is by Section 2 (i)^ of the Pubhc Health 
(London) Act, 1891, already the duty of Metro- 
politan Vestries and Boards to deal with any work- 
place (not being a factory subject to the provisions 
of the principal Act relating to cleanliness, ventila- 
tion, and overcrowding), which 

" (i.) Is not kept in a cleanly state and free 
rom effluvia arising from any drain, water-closet, 
etc., or other nuisance, or 

" (ii.) Is not ventilated in such a manner as to 
render harmless any gas, vapours, dust or other 
uiipurities generated therein that are a nuisance, or 
injurious or dangerous to health, or 

" (iii.) Is so overcrowded while work is carried 
on as to be injurious or dangerous to the health of 
those employed therein." 

It is scarcely necessary to touch upon the first of 
these duties ; but I would just here note that, for 
the purpose of examining as to the existence of 
any nuisance, the sanitary authority has the right 
of entry into any premises at any hour by day, i.e.^ 
between 6 a.m. and 9 p.m., or, in the case of any 
business, then at any hour when that business is 
in progress or is usually carried on (Public Health 
(London) Act, Sections 10 and 141). 

In regard to Ventilation, Section 33 of the new 
Act gives power to the Local Authority, " where 
any gas, vapour, or other impurity is generated and 
inhaled by the workers to an injurious extent," to 
require, if need be, the use of a fan or other means 
of mechanical ventilation (1878 Act, Section 36). 
Mr. Lakeman, whose retirement from the office of 
Superintending Inspector of Workshops we must 
all regret, was good enough to give me his views 
on certain sections of this Act, and, in connection 
with this question of ventilation, pointed out that 
the contention that the introduction of mechanical 
power for this object would constitute the place a 
factory, was incorrect, as the use would not be 
" for iBanufacturing purposes." (See definition of 
the term "Factory.") 

Almost inseparably connected with the ventila- 
tion of workshops is the question of Temperature. 



126 



PROCEEDINGS OF THE METROPOLITAN BRANCH. 



Section 32 reads thus : — (1) In every factory and 
workshop adequate measures shall be taken for 
securing and maintaining a reasonable temperature 
in each room in which any person is employed ; 
(2) A factory, or workshop, in which there is a 
contravention of this section, shall be deemed not 
to be kept in conformity with the principal Act. 
It is not at all clear who is to take cognisance of this. 
Mr. Sprague Oram informs mc that he considers 
the responsibility to be on the factory inspectors, 
as this section has not been inserted in Part i, 
which deals with sanitary provisions. If Mr. 
Oram's argument holds good for Section 32, then 
it would apply also to Section t,^, dealing with 
ventilation; but we know that the latter is distinctly 
a sanitary provision. I contend that Section 32 
falls under the sanitary regulations of Section 3 of 
the 1 89 1 Act, and therefore comes within the duties 
of the Local Authority. Possibly the execution of 
this Section will devolve upon the Sanitary Autho- 
rity by day and upon H.M. Inspectors during over- 
time and by night. There may, however, be 
difficulties in deciding what " a reasonable tempera- 
ture" may be, and that is a point upon which 
members of the Branch might express an opinion 
with a view to securing some uniformity of action 
throughout the metropolis. It is evident that in 
coming to a conclusion on this point, while a mini- 
mum temperature may be fixed, say at 55°, it will 
be more difficult to say definitely what should be 
the maximum; probably in regard to this it will be 
necessary to take into account the temperature of 
the external air at different seasons of the year. 

Overcrowding. — The amount of air-space per 
head was not previously defined, although the 
limits now mentioned in Section i have been 
recognized for some time, both by Factory 
Inspectors * and Local Authorities. Each person 
employed in a workroom must have not less than 
250 cubic feet of space, and during overtime not 
less than 400 cubic feet of space. " Provided 
that the Secretary of State may by order modify 
this proportion for any period, during which 
artificial light other than electric light is employed 
for illuminating purposes, and may by like order, 
as regards any particular manufacturir g process or 
handicraft, substitute for the said figures of 250 
and 400 respectively any higher figures." 

As already pointed out, the Local Authority is 
responsib e for the prevention of over-crowding in 
workshops, but that responsibility ap[)arently 
ceases when overtime is worked. This may be 
gathered from Section 63 of the principal Act, 
which gives power to the Secretary of State to 
provide for the adoption of any special means for 
the health of the workmen. On December 20th, 
1882, Sir William Harcourt issued an order under 
this section, declaring it to be illegal employment 
after 8 p.m., where less than 400 cubic feet per 
head existed. So that under Section 53 of the 
• Redgrave's Factory .^cts. 



1878 Act, H.M. Inspectors would be responsible, 
and presumably they would also take cognisance 
of the temperature of the rooms during that 
period, but that does not appear to me to neces- 
sarily follow. In order to carry out Section i, it 
will be necessary to measure each workroom, and 
to ascertain the number of persons who may 
legally occupy it. The Act requires that a notice 
be affixed in each workroom, specifying the 
number of persons who may be employed therein. 
I was under the impression that it would be the 
duty of the Sanitary Authority to provide and fill 
in this notice, and had prepared a card on which 
was stated, " This workroom has accommodation 
for — hands. When this workroom is used 
during atiy period of overtime, it has accommoda- 
tion for — hands only." I learn now, however, 
from Mr. Sprague Oram that a form for this 
purpose has been prepared at the Home Office, 
and will be forwarded with an abstract of the new 
Act to each occupier of a workshop. I take it, 
therefore, that the Sanitary Authority, having 
measured up the room, will ask for the form, and 
will fill in the numbers who may occupy the room. 
Mr. Gould subsequently stated to the meeting that 
it would be the duty of each occupier to discover 
for himself the capacity of his workplace, and to in- 
sert on his form the number of persons he thinks 
may occupy it. This figure must, in many in- 
stances, be of little value until it has been checked 
by the Sanitary Authority. It then becomes the 
duty of the occupier to affix the form in such place 
as the Factory Inspector may direct (1878 Act, Sec- 
tion 78), and any default in affixing the notice or in 
keeping it properly displayed will be dealt with by 
that official. If the notice, which will be known as 
No. 46, is destroyed, it must be replaced by the 
occupier, who may obtain copies from the usual 
publishers. 

As regards "overtime," Mr. Oram says: — 
" When overtime is worked, the number to be 
employed will be embodied in Form No. 12, 
' Record of Overtime,' which will be purchased as 
heretofore by the various occupiers who work, 
overtime." Unless a new form has been prepared 
there is no place in Form No. 12 for entering the 
number who may be employed. 

There are one or two other points to which I 
would shortly refer. 

Section 22 deals with laundries, those in which 
"steam, water, or other mechanical power" is used 
being classed as non-textile factories, and the 
others as workshops. In the former class provision 
is to be made of fans for regulating temperature 
and carrying off steam, also for the separation of 
stoves for heating irons from ironing rooms, and 
for the good condition and drainage of the flooring. 
Laundries worked only by resident members of the 
same family, or in which not more than two 
persons dwelling elsewhere are employed, are 
exempt from the operation of this section, as are 



THE FACTORY AND WORKSHOP ACT, 1895. 



127 



also laundries conducted in good faith for 
religious or charitable purposes, and those in con- 
nection with prisons, reformatories, or other 
institutions subject to inspection under other Acts. 
With the exception of those last named, where 
laundry work is not done for gain, those laundries 
which are not reckoned as factories will be dealt 
with by the Local Authority under the powers given 
by these Acts, and the Public Health (London) 
Act, as ordinary workshops. 

Section 27 extends to every bakehouse, the 
provisions of former Acts hitherto restricted to 
those in towns of over 5,000 inhabitants. By the 
same Section (sub-section 3), "A place under- 
ground shall not be used as a bakehouse unless it 
is so used at the commencement of this Act," that 
is, after January ist, 1896. This is an important 
advance, and will go far to raise the standard of 
requirements in existing bakehouses. 

By Section 13 the occupier of a factory or work- 
shop becomes liable to penal compensation for any 
death, bodily injury, or injury to health which may 
occur in consequence of having neglected to 
observe any provision of the Factory Acts, or any 
special rule or requirement made in pursuance of 
the Act of 1891. The injury to health must, 
however, be caused directly by such neglect. It is 
probable that in such cases the Medical Ofificer of 
Health will be called as a witness, so that very 
exact notes should be kept of insanitary conditions 
discovered in connection with work-places. 

Many work-places exist of which it is difficult for 
an authority to become acquainted, therefore 
Section 41 provides that every person in occupa- 
tion of a workshop shall, during 1896, serve a 
notice on the Factory Inspector giving particulars 
of the same, and such notice shall be forwarded 
forthwith to the Sanitary Authority of the district 
in which the workshop is situate. 

Outworkers. — By the order of the Home 
Secretary (November, 1892), made under the 1891 
Factory and Workshop Act, Section 27, lists of 
outworkers had to be prepared in certain trades, 
and were open to the inspection of the Factory 
Inspectors and the Officers of Sanitary Authori- 
ties. By Section 42 of the new Act, these 
lists are to be sent twice a year (on or before the 
ist day of March and the ist day of September) 
to Her Majesty Inspector for the district. One, if 
not the chief, object of this order was to ensure 
the inspection of the homes of outworkers, and to 
prevent persons making clothing, etc., when 
infectious disease existed in their households ; now, 
however, the list will not be there for inspection ; 
but I take it that by Section 6 it will be a duty of 
the Sanitary Authority on becoming aware that 
scarlet fever or small-pox exists in a family, 
members of which take in wearing apparel to 
make, clean or repair, to send notice of the fact to 
the occupier of the factory, workshop, or other 
responsible person in whatever part of the county 



he may be. Notice need hardly be sent to the 
Sanitary Authority of the district, unless it were 
found that work was still being given out. It is 
probably in the experience of Medical Officers, 
that persons, in whose families infectious disease 
occurs, sometimes refuse to give the address of 
their employers. It will depend, in the future, upon 
the courtesy of Her Majesty's Inspectors whether or 
not Sanitary Authorities may send to the Home 
Office and take copies of the list of outworkers, in 
so far as they relate to their own district. It would 
be a better arrangement for the Inspector to send 
each Authority a list of outworkers resident within 
its jurisdiction. It is a matter of regret that only two 
infectious diseases are specified in the Act, as we 
know that other diseases may be similarly 
conveyed, and especially so as this was brought to 
the knowledge of the Committee. 

The intention of Sec. 6 is also to prevent work 
in connection with wearing apparel being carried 
on in any premises wherein either small-pox or 
scarlet fever exists, but the wording of the section 
is not quite so definite as one would like. 
On the other hand, there is nothing to prevent a 
person, in whose family there is a case of unisolated 
scarlet fever, continuing his employment at a work- 
place away from his house. 

The question of provision of means of escape in 
case of fire does not in London concern the 
vestries or boards ; the County Council, under 
whose jurisdiction it falls, has issued a notice 
calling attention thereto, and intimating that the 
Council's Inspectors will shortly make a tour of 
inspection in order to ascertain if the provisions 
of the Act have been complied with. In the case 
of workshops commenced after January ist, 1896, 
a certificate from the Council will be granted on 
satisfactory plans being submitted for approval 
before commencing to build. 

A discussion took place, principally as to the 
duties of Sanitary Authorities under the new Act, 
in which Mr. Gould took part, expressing his wil- 
lingness to co-operate, as far as possible, with 
medical officers of health in carrying out thsf. 
duties in that direction. 

The meeting then adjourned. 



Date of Issue of Annual Reports of 
Metropolitan Health Officers. 
The Branch has during the past year addressed 
several letters to the Local Government Board, in 
reference to the date of sending copies of the 
annual reports of medical officers of health to the 
Board, which they were directed by the memoran- 
dum, dated December, 1894, to do within a month 
or six weeks of the end of the year. The points to 
which attention was specially called were that the 
year of the vestries and district boards in London 
ends on the 31st of March, and that the Public 
Health (London) Act, 1891, Sec. 106, provides 



128 



ISOLATION HOSPITALS ACT, 1893. 



tint the reports shall be appended to the Annual 
Re|)orts of the Sanitary Authority ; and that the 
Registrar General's Annual Summary is not printed 
till May. 

The final answer of the Local Government 
Board is given below : — 

" Local Government Board, Whitehall, S.W. 
'• 29th June, 1895. 

" Sir. — I am directed by the Local Government 
Board to inform you that they have had under con- 
sideration the letters which you addressed to their 
medical officer, Dr. Thorne, with reference to the 
date when copies of the annual reports of medical 
officers of health in the metropolis are required to 
be forwarded to the Board, and I am to state that 
whilst the Board attach much importance to re- 
ceiving the reports of medical officers of health as 
early as practicable after the commencement of 
the year, they will not, having regard to the some- 
what exceptional circumstances in the case of 
London, certify the officer to be in default in cases 
where the reports are received by them not later 
than the month of May in the year following that 
to which the report relates. 

" This arrangement will, however, be subject to 
reconsideration by the Board if it should appear to 
them to be necessary. — I am, Sir, your obedient 
servant. 

(Signed) "C. N. Daltox, Assistant Secretary." 

"Oliver Field, E^q., M.D., 
" Honorary Secretary to the Incorporated 
Society of Medical Officers of Health 
(Metropolitan Branch)." 



Eni of Proc<cdingi of the Incorporated Society of Medical 
Officers of Health.) 



ISOLATION HOSPITALS ACT, 1893. 

Difficulties have arisen in the administrative 
County of Lancashire with respect to the borrow- 
ing of money under the Isolation Hospitals Act, 
The Local Government Board have decided that a 
hospital committee can obtain loans for the pur- 
poses of the Act only "through the County 
Council " ; and, further, the latter body will not 
obtain the sanction of the Local Government 
Board to the borrowing of money until they are 
satisfied that "the scheme, in its entirety, is one 
which would be generally acceptable." In order 
to get information on which the Board can act, an 
inspector has to hold a " conference " on the sub- 
ject, notwithstanding the fact that the County 
Council may have already issued an order, under 
section 7, for the constitution of a " hospital dis- 
trict." It is felt that the action of the Local 
(ioveroment Board causes unnecessary delay, 
and gives rise to complications which might be 
avoided. 

The high rate of interest — namely, 4 per cent. — 
required to be paid, under section 22, to county 



councils for hospital loans will create difficulties. 
When local authorities can borrow money readily 
at from 3 to 3^ per cent., why should a higher 
rate be paid to County Councils ? There is no 
desire on the part of the Lancashire County Council 
to make profit out of loans granted to hospital 
committees ; and, notwithstanding the section 
referred to, it has been decided to grant the first 
hospital loan applied for under the Act at the rate 
of 3^ per cent , the total amount being repay- 
able in twenty equal annual instalments, without 
the intervention of a sinking fund. Further loans 
for hospital purposes will be considered on their 
merits, and in some cases the rate of interest 
may be lowered, and the period of repayment 
lengthened. 

In a recent report on this subject. Dr. Sergeant, 
Medical Officer of Health, Lancashire, suggests 
that the difficulties might, perhaps, be more readily 
overcome by the County Council contributing a 
fixed sum per bed provided under the conditions 
of the Act. Assuming that the structural charges, 
etc., of a hospital average, say, ;^2oo a bed, the 
annual rate of interest, at 4 per cent., would 
amount to ^8. Therefore, a remittance of £,2 
per bed, in the form of a contribution provided for 
by section 21, would be equal to a reduction of 
I per cent, in the interest payable to the County 
Council. The question of contribution towards the 
establishment expenses of the hospital — apart from 
what may be taken as a remission of excess of 
interest — is not so easy to decide, and there are 
many who do not consider it desirable to tax dis- 
tricts in which hospitals are already established 
outside the Isolation Hospitals Act for the benefit 
of those districts only just awakening to a proper 
sense of their responsibilities. 



ISOLATION HOSPITALS ON CHALK 
STRATA. 
Dr. Seaton, in his annual report for 1894, states 
that in the Epsom (Rural), Sutton, and Carshalton J 
Districts the sources of water supply have received \ 
great attention in connection with the proposal to 
establish a " Joint Isolation Hospital " at Banstead, 
and the strong opposition to which that proposal 
gave rise, as well as in connection witli the agitation 
against the existence of any cemeteries in the chalk 
formation of this district. The following account 
is (juoted from Dr. Jacob's report to the Sutton 
Urban District : — 

*' In February the Local Government Board 
caused an inquiry to be held at Sutton into the 
ap[ilication of the Epsom (Rural), Sutton, and Car- 
shalton Joint Hospital Boards (on which the 
Authority of this District has five representatives), 
to sanction a loan for the purchase of eight acres 
of land in the Parish of Cuddington as a site for 
this hospital. The proposal was strongly opposed, 
among others, by the Sutton District Water Com- 



CLIMATE AND HEALTH. 



129 



pany, who contended, though the land is 2^ miles 
from their works, that the sewage of the hospital 
would rapidly find its way, through fissures in the 
chalk, down to the water-level (which is 150 feet 
below the surface of the site), and would pollute 
the springs or reservoirs in the chalk from which 
their water-supply is derived. In November, how- 
ever, the Board sanctioned the purchase of the 
land for this purpose on condition, first, that the 
surface-soil overlying the chalk on an acre of the 
land should be increased to a thickness of 4 feet, 
and that this acre should be devoted to the purifi- 
cation of the sewage." 

We drew attention to this important inquiry soon 
after it was held (Public Health, Vol. VI., p. 
300), expressing our disbelief in the possibility of 
there being any risk of contaminating the water- 
supply drawn from the chalk under the conditions 
named above. The decision of the Local Govern- 
ment Board is strictly in accord with common sense 
and hygiene. 



CLIMATE AND HEALTH. 

Thk first number of a monthly American publica- 
tion, having the above title, is before us. It is 
edited by Dr. W. F. R. Phillips, and is officially 
issued from the Weather Bureau of the United 
States' Department of Agriculture. In this publica- 
tion, by means of elaborate and beautifully-executed 
charts, the weekly mortality and morbidity statistics 
of the different States are placed in correlation with 
the corresponding weather data for each week. 
The publication promises to be a most important 
one as the statistics become more complete and 
accurate, and even such incomplete data as are 
already available will increase in value month by 
month. It is worth noting that the idea but of 
which this important publication has grown was 
derived from Mr. Trevail's monthly reports to the 
Cornwall County Council, as stated on the first 
page of the journal. The remarks made by the 
editor of this new journal as to the comparative 
value of mortality and morbidity statistics in 
relation to climate and health are so opposite — 
especially when associated with the paper in the 
*' Notification of Sickness " in the present number 
of Public Health — that we quote them in 
full :— 

Statistics of mortality, though easier to obtain than those 
of morbidity, are not so well adapted as the latter to show 
etiologic connections between sickness and weather changes 
and condition.^. It is very evident that a disease may termi- 
nate fatally, and most probably does so terminate, under 
decidedly different meteorological conditions from those 
prevalent at its inception. If the discovery should be made 
that deaths from any given cause may be expected to occur 
more frequently during the manifestation of certain atmos- 
pheric phenomena, it would probably be of considerable 
value to the physician in the treatment of the disease, but it 
is doubtful if this sort of knowledge could be of service in 
the prevention of the disease. On the other hand, if the 
prevalence of a given atmospheric condition should be 



found to be coincident with the greater or less frequency of 
a certain disease, the knowledge will be useful to both the 
physician and the general public in indicating an insistence 
upon the observance of more or less stringent preventive 
measures. 

Prevention is assuming in the medical thought of to-day a 
value co-ordina'e with, if not greater than, that of thera- 
peutics, and attempts, even though they appear but feeble 
efforts, tending to add something to our knowledge of the 
etiology and prevention of disease, may expect to receive 
considerate attention. Therefore, it is hoped that the 
medical profession will extend to this endeavour of the 
Weather Bureau to be of service to it in particular, and to 
mankind in general, a cordial co-operation, till time may 
show either the value of continuing the endeavour, or the 
advisability of abandoning it. 

The statutory organisation of the Weather Bureau confines 
its work to climate and meteorology, and it can employ its 
activity in other fields only in so far as they are directly 
related to, or affected by, these sciences. Therefore, it 
must not be expected, nor is it contemplated, that the 
Weather Bureau shall enter into competition with either 
State or Federal establishments on medical or sanitary 
affairs, nor duplicate the work done by them. The general 
aim of the W^eather Bureau in this new field of work will be 
to collect the meteorologic and hygienic statistics that may 
be considered by sanitarians and medical climatologists of 
the greatest correlative importance, and to publish them in 
the shapes most acceptable and useful to these professions. 



LEPROSY AS AN ENDEMIC DISEASE IN 
GREAT BRITAIN.* 

The Council of the National Leprosy Fund have 
done excellent service to the science of preventive 
medicine in publishing in book form Dr. Newman's 
most instructive and interesting prize essay. We 
have seen no other description of the prevalence of 
this disease, and of the conditions under which it 
declined and disappeared in this country as an 
endemic disease, that is so well written or con- 
vincing in statement and argument. 

It seems quite clear that leprosy was a pre- 
Norman disease in the British Islands, though in 
all probability it reached its zenith about the 
twelfth century. The view that the Crusaders 
" brought " leprosy back to England is now prac- 
tically discarded. Perhaps this view obtained 
currency because it was in the eleventh century 
that the first " hospitals " and pest-houses were 
built ; though this no more implies that leprosy 
was then a new, or even an increasing disease, 
than it can be concluded from the immense exten- 
sion of the provision of isolation-hospitals during 
the last ten years that infectious diseases are now 
increasing in our midst. 

The isolation usually maintained in the leper 
hospitals was but imperfect. A mayor of the city 
of Exeter, who, in 1454, having become infected 
with leprosy, submitted to be removed to dwell in 
the local lazarette and there end his days, was con- 

* " On the History of the Decline and Final Extinction 
of Leprosy as an Endemic Disease in the British Islands." 
By George Newman, M.D. ( Adlard and Son, Bartholomew 
Close, E.G., 1S95.) 



I30 



I.EPROSY AS AN ENDEMIC DISEASE IN GREAT BRITAIN. 



sidered to be an example of superlative goodness 
and piety. 

Scotland appears to have suffered severely 
from leprosy, and it appears to have continued 
prevalent in the northern islands of Scotland long 
after it had disappeared from the mainland, and, 
indeed, all other parts of Great Britain. 

Although other diseases were undoubtedly, in 
many cases, confounded with leprosy, there can be 
no doubt that true leprosy was very prevalent in 
Britain in the Middle Ages, and that it was for 
this disease that the numerous leper-houses were 
established. The lepers were under the special 
care of the Church, and the movement on their 
behalf was largely an ecclesiastical movement. 
Among the diseases confounded with leprosy, the 
chief was secondary syphilis ; and when, in con- 
nection with the wide epidemic of this disease 
(about 1490-1500), its distinctive characters became 
better known, the number of lepers diminished n 
a short period. There was, in the fifteenth and 
sixteenth centuries, much discussion as to whether 
syphilis was not in reahty the offspring of leprosy. 

The most interesting question is the cause or 
causes of the decline of leprosy in England. It is 
difficult to conceive the condition of Europe in the 
Middle Ages. Devastated by wars and plagues, 
agriculture was but little cultivated, and the people 
lived in hopeless filth, and partook of unwholesome 
and unvaried food. In the fourteenth century 
there were fourteen European plagues. The meat 
was chiefly salted, the bread black — usually rye. 
The streets of London were filled with common 
lay-stalls of all manner of filth and garbage, which 
the people were in vain ordered to remove from 
their own doors. The projecting houses almost 
met at the top. Soap, in the fourteenth and 
fifteenth centuries, was scarcely used at all. The 
labourer slept on rotting straw, and had no fresh 
vegetables to eat. There was a considerable fish 
trade in the Middle Ages all over the populous 
parts of the country. This trade declined in the 
sixteenth century, owing to increased exportation 
of fish, and the rise in the price of fish which fol- 
lowed the Black Death in 1349. It is not without 
significance that the decline of leprosy and the 
decline of excessive eating of salt, and bad, as well 
as fresh fish, were coincident in time, and that 
the endemic leprosy areas and the fish areas were 
largely identical. Even in 1509, Catharine, King 
Henry's Queen, could not procure a salad till the 
King sent to the Netherlands and engaged a gar- 
dener to come over and raise the necessary articles 
here. In the same century turnips, potatoes, and 
other vegetables began to be grown in England. 

After reviewing the social and hygienic condi- 
tions under which leprosy prevailed m medireval 
England, Dr. Newman cor, trasts them with those in 
Chma, India, and Iceland, in which leprosy still pre- 
vails. There is, obviously, no resemblance in cli- 
mate or physical conditions, or densityof population. 



In social conditions there is a striking resemblance. 
In all four the poverty is extreme, the environment 
most unsanitary, the diet insufficient. There is no 
evidence that the disease was spread in England 
by contagion. If so, it is wonderful how slowly it 
spread, although, as has been shown, isolation was 
not enforced in the lazarettes. Contagion may, at 
least, be excluded as a chief cause of the propaga- 
tion of leprosy. The idea that fish-eating caused 
leprosy was early entertained ; and this was pro- 
bably the reason why it was frequently stipulated 
that a servant or apprentice should not be obliged 
to dine on salmon more than once or twice a week. 
There is a striking analogy with leprosy in the 
Italian disease, pellagra, due to eating bread pre- 
pared from damaged maize. 

Apart from improved dietary, and improved per- 
sonal and general hygienic conditious, two events 
probably played an important part in exterminating 
leprosy in England — viz., the Famine (1315-16), 
and the Black Death (1349). These killed off 
more than half the population, and the after-effects 
of these and other similar events in the fourteenth 
century, led to an improved social and hygienic 
condition of England. 

Although Dr. Newman's summing-up appears to 
favour the view that fish — especially putrid and 
dried fish — was an important factor in causing 
leprosy, he does not commit himself to a very 
definite statement on this point, and still less to the 
view that such fish was the sole cause of leprosy, 
though he has no doubt that, " in conjunction 
with other dietaries and conditions, it played some 
part in the prevalence of the disease." In appen- 
dices to the book are given tabular statements of 
the international history of leprosy, and the names 
and dates of the leper-houses in the British 
Islands. 



Destruction of Tuberculous C.vttle in New 
South Wales. — From the report to the Legislative 
Assembly of New South Wales, on the administra- 
tion of the Dairies Supervision Act during 1894, 
we learn that many cattle have been destroyed as 
diseased, and the Board of Health are taking steps 
to impress upon the local authorities the urgent 
need for the immediate destruction of any cows or 
bulls that may be affected with tuberculosis, and 
for the cancellation of the registration of dairymen 
who object to carry out their directions in this 
matter. The report adds that while it is certain 
that the proportion of dairy stock suffering from 
this disease is much smaller here than m European 
countries, there are yet the strongest reasons for 
stamping out the cases that are discovered, not 
only to arrest the s[)read of the disease amongst 
the cattle, but also because of the serious risk of 
the tubercular matter contained in the milk causing 
consumption of the lungs in the human beings 
who use it. 



J 



DARWINISM AND THE MEDICAL PROFESSION. 



131 



5PutrUc lealtlj. 



DARWINISM AND THE MEDICAL 
PROFESSION. 

Dr. Gresswell's address on this subject, de- 
livered at the annual meeting of the Medical 
Society of Victoria, treats of medical and hygienic 
questions from an evolutionary standpoint. 

He points out that we, as a profession, are not 
concerned with man merely as an individual. 
" We are called upon to advise also concerning 
man considered as a community ; and State direc- 
tion in matters relating to the physical, the mental, 
the moral well-being and progress of communities, 
should proceed from a sound knowledge of man, 
such as that which the profession endeavours to 
obtain." In favour of the study of man from the 
evolutionary standpoint, he speaks as follows : — 
" For State-direction, it may be sufficient to know, 
if it has been so, that savagery preceded civilisa- 
tion ; from this more narrow basis to study the 
gradual development of man's higher functions — 
his habits, his aptitudes, his potentialities ; and by 
aid of such study to give counsel for man's further 
progress, by removal of obstacles to his further 
development, and by encouragement of those con- 
ditions that may tell in his favour. The history of 
man in process of civilisation — short though it may 
be in contrast with the complete history of his race 
— may, and no doubt will, teach lessons in State- 
direction, if there be any truth in the doctrine of 
descent, as applied to man. In this connection, 
we need but to reflect upon the influence which a 
knowledge of savage races has of recent years 
exercised upon questions of morality, or to reflect 
upon the protection of man against infections by 
clothing, by cooking, and by observance of clean- 
liness ; or, again, upon the increase of susceptibility 
to those same infections which man is probably 
thus gradually acquiring." 

Taking up the question of food, Dr. Gresswell 
asks the following questions, which will indicate 
the general gist of his remarks on this point : — 
*' If man has lived through millions of years on 
foods uncooked, what are we to say of the fact that, 
commencing shortly after birth, man lives at the 
present time on foods which, with but few excep- 
tions, are subjected to cooking operations ; though 
we must believe that the molecular constitution of 
the food is thus largely altered ? Cooking may, 
indeed, be essential, if the individual man is to 
pass a comfortable existence ; but can we suppose 
that the material itself is, by cooking, rendered a 
better food ? " He adds : " I think it may be at 
least suspected that assimilation in the case of 
cooked food is after the nature of crystallisation, 
and, in the case of uncooked food, is something 
more — something imperfectly denoted under the 
name spermatic." The remaining questions dealt 



with by Dr. Gresswell are rather of interest to 
therapeutical than to preventive medicine. We do 
not pretend to agree entirely with his remarks 
quoted above, but they possess considerable 
interest and freshness, and are deserving of atten- 
tion and further investigation. 



AN ACCOUNT OF THE SPECIAL INVES- 
TIGATION OF BOVINE TUBERCU- 
LOSIS ON BEHALF OF THE STATE 
BOARD OF HEALTH OF NEW YORK * 

EY 

James Law, Esq., of Cornell University, Ithaca, New York. 

It is to the honour of the States of New York that 
she has been the first to place on her statute book 
a law directing the State Board of Health to enter 
this new field, and organise effective measures 
against the spread of bovine tuberculosis. The 
appropriations made, though incommensurate with 
the magnitude of the undertaking, have been suffi- 
cient to show, to some extent, the vast proportions 
of this menace to life and health, and the need of 
adequate resources to intelligently meet and over- 
come it. 

We propose to review the work done since the 
passage of the law (chapter 487 of 1892), till its 
enforced suspension, by reason of exhausted 
means, and the creation of a special tuberculosis 
commission to make a care''ul study of the subject 
and report thereon. 

The law calls upon the State Board of Health : 

1. To ascertain whether or not there exists in 
the milch cows or other cattle in the State a cause 
of disease or danger to life. 

2. To devise means for averting the same, and 
for preventing all injury from tuberculosis in milch 
cows. 

It further calls upon the State Board to impart 
to local boards of health such information as may 
be in its possession respecting any such disease 
among cattle, and to offer useful suggestions for 
the removal of such sources of danger. The 
local boards are required to communicate to the 
State Board such facts in their possession regarding 
any infectious or contagious disease in milch cows. 
Power is given to employ and fix the compensation 
of medical and veterinary practitioners and other 
persons as may be necessary to discharge its duties, 
and to prescribe rules and regulations for the con- 
duct of the work. Power is also given to call 
upon sheriffs and deputy-sheriffs and officers of the 
peace in any neighbourhood where disease exists 
among milch cows or other cattle, and to enforce 
the orders of the State Board. Power is also given 
to make rules for the destruction of animals aff'ected 
with tuberculosis or other contagious or infectious 
disease. 

* From the Fourteenth Annual Report of the State Board 
of Health of New York (Vol. II., 1894). 



132 



BOVINE TUBERCULOSIS IN NEW YORK. 



Whenever tuberculosis is found to exist among 
milch cows or other animals, it is the duty of the 
State Board of Health to take measures to suppress 
it promptly and to prevent it spreading. 

In obedience to the mandate of law, the State 
Board of Health proceeded to organise the tuber- 
culosis branch of its service, and to appoint 
veterinaries. The following rules, for the guidance 
of the inspectors, were promulgated : — 

Rules and Rtgulations for Inspectors of Cattle 
Suffering from Tuberculosis or other Infectious 
and Contagious Diseases. — The State Board of 
Health, in pursuance of the powers conferred on 
it by chapter 4S7 of the laws of 1892, hereby 
makes and publishes the following rules and 
legulations for the guidance of all inspectors, 
or other persons employed by it in the inspection 
of milch cows and other cattle suffering from tuber- 
culosis or other infectious or contagious diseases. 

1. Inspectors or others shall use all reasonable 
means to discover tuberculous or other infectious 
or contagious diseases in cattle, and report in 
writing the result of their inspections not less than 
once in each month ; and as much oftener as may 
be called for by the president or secretary of the 
board. 

2 . All owners or keepers of cattle, and all persons 
having charge thereof, shall allow of such inspec- 
tion and examination as the employers of the 
board shall consider necessary, upon said employe 
presenting his authority to so examine, and all 
orders made as to destruction, isolation, disinfec- 
tion, or other care of cattle suffering from 
infectious or contagious disease, or suspected of 
so being affected, shall be obeyed by all owners, 
keepers, or other persons having charge of such 
cattle. 

3. Should the inspectors or others employed by 
the State Board of Health find, upon examination, 
tuberculosis or other contagious or infectious 
diseases, existing in cattle examined by them, they 
are to direct such quarantine, sequestration, or 
other measures of protecting the public health or 
other cattle from the said disease, as may in the 
case then under examination be considered by 
them best. Should the killing of one or more 
cattle so affected be, in the judgment of the 
ins[>ector, necessary for the protection of the public 
health, or other cattle, the inspector, before 
directing such killing, shall first notify the presi- 
dent or secretary of the State Board, reporting 
the reason why he considered such killing 
necessary, the name of the owner or owners, the 
place where the said cattle are, and the number 
to be destroyed. The president or secretary 
shall then order the killing, or such other measures 
as both, or either of them may consider best. 

4. All owners, keepers of cattle, or other persons 
having charge thereof, shall, for the purpose of 
proper examination thereof, if requested by the 
inspector of the State Board to do so, place the 



animal to be examined in stanchions, or such other 
place as may be provided for their restraint, for the 
time necessary for such examination. 

5. To guard against the improper use or disposal 
of an animal or animals found to be suffering from 
tuberculosis or other contagious or infectious 
disease, the inspector may place on such animals a 
lock and chain, or other device for marking said 
animal or animals ; and all owners, keepers of 
cattle, or other persons having charge thereof, are 
cautioned against removing said lock and chain, or 
other device, without due permission in writing 
from an inspector of this board. And the in- 
spector, at the time of so marking an animal or 
animals, shall give, in writing, a note to the owner, 
keeper, or person in charge, said notice to set forth 
the description of said animal or animals, how 
marked, the reason for said marking, and a warning 
that the removal of the said animal or animals, or 
the removing or effacing of said marking, would be 
in violation of the provisions of chapter 487 of the 
Laws of 1892. And in case any owner, keeper, or 
person in charge of said animal or animals, shall so 
remove or efface said markings, or remove or other- 
wise dispose of said animal or animals, the in- 
s^jector shall report the same to the president or 
secretary of the State Board of Health, setting 
forth in said report all facts pertaining to the case. 

Physical examination by auscultation and other- 
wise was at first relied upon for the detection of the 
disease. Its insufficiency, however, was quickly 
demonstrated ; the need of tuberculin soon made 
itself manifest, and subsequently became the chief 
diagnostic agent. The previous rules were 
modified, and the following substituted : — ■ 

I. Physical examination will precede tests with i 
tuberculin. When entering a herd, enough are to 

be examined to determine the probability of tuber- 
culosis being present. If tuberculosis is decided to 
be present, all animals are to be tagged, preparatory 
to further tests. In general, before deciding upon 
the diagnosis, the tuberculin test will be used on all 
animals. It is discretionary with the inspectors to 
omit this test, however, if they can positively cer- 
tify, on physical diagnosis alone, the animal to be 
tuberculous. 

II. Initial temperatures will be taken before 
tuberculin is injected. Two temperatures will be 
thus taken, one an hour before feeding, and one 
an hour and a half after feeding. Experiments 
will be made as to the best time, morning or 
evening, for these initial temperatures. 

III. Tuberculin will be injected so as to allow 
of seven hours' interval between the injection and 
the taking of temjjeratures. 

After the injections, animals will neither be fed 
nor watered until the result of the test is known. 
Temperatures, beginning seven hours after injec- 
tion, will be taken until eighteen hours from the 
injection have elapsed, and they are to be taken 
at not less than two hours intervals. 



i 



BOVINE TUBERCULOSIS IN NEW YORK. 



^33 



IV. It will be considered for the purpose of this 
service, that the normal temperature of cattle 
ranges from g()° to 102^ Fahr. When the tem- 
perature under the tuberculin test rises two degrees 
above the initial mean temperature, the animal is 
to be considered a suspect, and a subject for 
quarantine. A rise from two degrees above the 
initial temperature and upwards, to be considered 
as showing the animal is tuberculous, and a subject 
for slaughter. Where doubt is aroused as to the 
action of the tuberculin test or other matters 
affecting the animal, discretionary power is with 
the inspector to hold the animal in quarantine for 
further examination, or to kill. 

V. In general, high grade cattle will be quaran- 
tined. The cases held may be incipient or 
advanced, where the conditions are such that 
perfect isolation can be maintained and proper 
experiments for future data made. In deciding 
what animals are to be thus held, and the method 
of quarantine, the inspector will exercise discre- 
tionary power. 

VI. The inspectors will state in the monthly 
reports, and also in the detailed reports of tem- 
peratures, the breed to which the animal belongs. 

Work was conscientiously begun in one or two 
of the great dairy centres of the State, and ex- 
tended gradually as experience dictated. 

Method of Operating with Tuberculin. — For an 
average cow, I employ about four drops ; for a 
very large animal (Shorthorn, Holstein, Hereford, 
etc.) a half more ; for a yearling, two drops ; for 
a six months' calf, one drop. A stoppered bottle, 
with water that has been thoroughly boiled, is 
provided for the dilution of the tuberculin, and a 
vessel with scalding water, or a watery solution of 
carbolic acid (i'2o) to wash the nozzle of the hypo- 
dermic syringe, between successive injections of 
different animals. By using the carbolic solution 
on the nozzle, one may be saved from the necessity 
of washing the skin and wetting it with this lotion. 
In hundreds of injections of tuberculin, I have not 
yet met with a resulting abscesr. The point of 
injection may be made as convenience may dictate, 
the abundance of subcutaneous connective tissue, 
the thinness and purity of the skin, and a position 
where the operator will be free from danger from 
the horns or hind foot, helping to a decision. 
Having an assistant to hold the animal by the nose, 
I have usually injected on the side of the neck, on 
the shoulder, or on the lower part of the chest. 
The tuberculin can be dropped into a scalded 
porcelain dish, and a hypodermic syringe, full of 
the boiled water, thoroughly mixed with it ; it is 
then drawn back into the syringe and injected into 
the subject, care being taken that it enters the 
loose, connective tissue. The conditions of life 
for the subject of the test should not be changed 
in any way, and the temperature taken imme- 
diately before or after the injection is to be taken 
as the standard with which to compare the subse- 



quent ones. The subsequent temperatures should 
be taken, by preference, from the eighteenth to 
the twentieth hour after injection, and at intervals 
of one hour. If this cannot be done, it may begin 
with the tenth or twelfth, and may be repeated 
every second hour up to the sixteenth. Cases are 
very exceptional that will not show the rise between 
the twelfth and the sixteenth. 

Sources of Fallacy in using Tuberculin. — Those 
who are most experienced in the use of tuberculin, 
as a test for tuberculosis are the most firmly con- 
vinced of its value. Nocard and others, who, at 
first, found a certain number of cases in which it 
appeared to mislead, by producing reaction, in the 
absence of tubercle, are now rather of the opinion 
that the apparent mistakes have been their own, 
and would not have been suspected as such had 
they sought more carefully for tubercles that really 
existed in secluded lymphatic glands, bones, etc. 
Indeed some, like Professor Eggeling, object to 
the test, because it is too certain in its results, and ) 
leads to the condemnation of animals with those 
secluded and circumscribed groups of tubercles, 
which do not seem to interfere with the general 
health, with the flow of milk, nor with the laying 
on of flesh. If the circumscribed tubercle is not 
in the udder, he would let such an animal be still 
utilized for the dairy or for the butcher's stall. 
This may do for an attempt at a partial restriction 
of the prevalence of tuberculosis ; but, if we aim 
at its final extinction, such a system of deliberately p/ 
preserving the germ of tuberculosis in our herds 
must render our efforts largely futile. No one can 
tell at what moment the latent and circumscribed 
tubercle is about to make a general extension 
through the body, and, as the germ travels through 
the blood, in many cases before it can form new 
tubercles at a distance from the original one, other 
animals are liable to be contaminated before this 
extension of the disease is suspected. No country 
has ever stamped out an animal plague on the basis 
of preserving in life those cases of the disease that 
may be expected to recover. This might be accom- 
plished, it is true, by a most expensive process of 
seclusion of the diseased and disinfection, but, in 
the case in hand, seclusion is not even proposed. 
One source of error is the absence of reaction under 
tuberculin in many of the worst and most advanced 
cases of the disease. 

But no man who should be trusted with tuber- 
culin can have even the desire to use it on such 
cases. The objective symptoms are more than 
enough to betray these aggravated cases. The 
system of the animal is already so surcharged with 
the poisons of tuberculin, that the small addition 
we make in the injection is without effect. This is 
an unanswerable argument against tuberculin in 
incompetent hands, but not at all against its use by 
a practitioner skilled in the diseases of cattle. 

Again, the supervention of oestrum after the 
injection of the tuberculin will cause a rise of tem- 



134 



BOVINE TUBERCULOSIS IN NEW YORK. 



perature in the healthy animal at the time, when it 
might justly be expected in the tuberculosis. This 
is another argument against the use of tuberculin 
by the careless or incompetent, but not at all against 
its use by the careful and skilful practitioner. 

Again, the temperature rises as parturition 
approaches, and under the action of tuberculin 
sometimes rises more than it would otherwise do. 
The parturient animal is, therefore, no fit subject 
for this test, but this is no ground for its disuse in 
suitable cases. 

Changes of diet or regime may cause a rise of 
temperature at the inopportune moment, and 
mislead the unobservant, as in the result of the 
privation of water in the case of Mr. Goodling's 
cows. Must we, therefore, condemn a valuable 
agent rather than the obstruseness of the operator? 
Certainly not. Even when reaction has ensued a 
full drink of ice-cold water just before the tem- 
perature is taken may prevent the record of the 
actual rise, and the tuberculous animal may be 
left as sound if the operator is too blind to see the 
source of his blunder. 

Once more, any casual febrile or inflammatory 
disease coming on after the injection of tuberculin 
may easily mislead the unskilled or the unwary 
into a condemnation for tuberculosis. But is 
tuberculin to be charged with an error like this ? 
Unless the operator is a skilful pathologist of 
cattle, and unless he scrutinizes his subjects care- 
fully for possible accidental causes of a rise of 
temperature, errors of this kind will arise. It is 
not enough that the operator is intimately 
acquainted with tuberculosis ; he must also be 
profoundly learned in other diseases of cattle and 
their diagnosis, if he would avoid an occasional 
blunder. 

The only conclusion is that tuberculin, however 
(infallible in its indications, when intelligently em- 
iployed, cannot be considered so if used as a popular 
[lest in lay hands, or even in the hands of profes- 
sional men who are not thoroughly acquainted 
with the hygiene, physiology, and diseases of cattle. 
The mistaken assumption has been that any rise of 
temperature, occurring ten hours or more after the 
application of the tuberculin test, is a certain 
indication of tuberculosis. If this is claimed, then 
truly tuberculin must be abandoned ; but if we 
qualify the claim so as to make it read "that any 
material rise of tempeiature occurring between ten 
and twenty hours after the application of the 
tuberculin test, in the absence of any other con- 
dition sufficient to account for such rise, is an 
indication of tuberculosis," then the claim may be 
sustained in the face of all opposition. But this 
demands that tuberculin shall be used only by 
practitioners who are skilful enough not to 
overlook such alternative causes of elevation of the 
body heats. 

Some Limitations of the Tuberculin Test. — In 
seeking to state succinctly some of the more 



obvious limitations of the tuberculin test, the 
following may be named : — 

I St. The tuberculin must be of nearly uniform 
potency, and absolutely sterilized. If living bacilli 
have been left in it, it will infect healthy animals 
with tuberculosis. 

2nd. It must be used in a dose proportionate to 
the size of the animal, and the susceptibility of the 
genus of animal tested. Weight by weight it is 
far more effective on some genera than on others. 

3rd. It should be used with due antiseptic 
precautions, otherwise other (septic) infectious 
diseases may occur to mislead the operator. 

4th. It should not be used on animals in certain 
physiological or pathological conditions, otherwise 
other causes of increasing temperature will com- 
plicate and invalidate the results. 

5th. It should not be used by anyone who is 
not fully competent to detect any contemporaneous 
disease of cattle, etc., other than tuberculosis, and 
which has set in since the injection of the 
tuberculin. 

6th. It should never be used as a test for tuber- 
culosis in any case, unless the single object is the 
remorseless destruction of every animal found to 
be tuberculous. As a test, therefore, it must not 
be upon man, nor upon any animal that cannot be 
slaughtered if found to be affected by tubercle. 
The value of tuberculin as a test depends largely 
on its power of increasing and extending the 
disease process in any previously-existing tubercle. 
In the case of a single, local, superficial tubercle 
(lupus), tuberculin may cure by causing the death 
and sloughing off of all diseased tissue, with 
all the living germs included in it ; but if there 
are, at the same time, any deeply-seated tubercles 
which cannot be thus thrown off, its action is 
dangerous in the highest degree. The physician 
who uses it on a man having internal tubercles 
assumes a fearful responsibility, and the veterina- 
rian who will use it as a test for tuberculosis, when 
there is no intention of destroying the animals that 
may be found affected, is simply contributing to 
the extension of the disease. 

7th. From the same standpoint, it may be said 
that the State is reprehensible for using this agent 
on animals, unless it is prepared to at once 
destroy, and pay for all that are j)roved to be 
tuberculous. The correlative of the use of tuber- 
culin by State agents, is that the State must stand 
ready to kill the diseased, and to indemnify the 
owners, with the single aim of the extinction of 
the disease germ in the herds. 

8th. State disinfection of contaminated premises 
and the exclusion of comsuni[)tive persons from 
attendance on the purified herds are further 
correlatives. 

Qth. Another condition of its use may be said 
to be a systematic movement to puiify the herds 
of an entire district, and finally of the entire state, 
for otherwise the still contaminated herds in the |,' 



1 



TUBERCULOUS CATTLE IN BOSTON, U.S.A. 



135 



vicinity of those that have been purged of the 
infection are Hkely to re-infect the latter sooner or 
later. 

loth. Another condition is that the purified 
herds shall not be permitted to receive renewed 
infection through the purchase or introduction of 
tuberculous animals. They should be left to their 
natural increase by generation ; or if new stock 
must he introduced, it should be guaranteed by 
the proper tests before it is allowed to mingle with 
the purified herd. There is no justice in charging 
on the commonwealth the cost of purifying a herd, 
and then leaving such herd open to renewed 
infection from outside sources. 

Family Susceptibility as Shown in the Groton 
Herds. — This group of cases furnishes an interest- 
ing illustration of the tendency of tuberculosis to 
run in susceptible families. The fact that the 
condemned animals were mainly Jerseys is not so 
much a condemnation of that breed of cattle as of 
the particular family of Jerseys here represented. 
The source of the trouble was traced to a cow 
bought by Mr. Burnham in 1888, at a sale in 
Binghamton, New York. Some years after this 
cow died consumptive. Her calves were con- 
sidered to have poor constitutions, and were 
mostly disposed of. One of these died consump- 
tive in 1892, in the herd of Mr. Gooding, and 
left the infection in his herd, two dying the same 
year. A second died the same year in the herd of 
Mr. Youmans, leaving the infection in his herd. 
The two killed tuberculous in the herds of Messrs. 
Pike and Sears were calves of the same Bing- 
hamton strain of blood. Here, the one diseased 
cow had her descendants practically wiped out of 
five herds into which I could trace them, besides 
conveying tuberculosis to other members of three of 
the herds in question. This fact of racial sus- 
ceptibility has been so long and so prominently 
before the minds of physicians, that it tended to 
obscure the no less important fact of contagion. 
Now, the sanitarian, in concentrating his attention 
on contagion, will do well to investigate along the 
family lines as well, as this will greatly assist in 
the discovery and the eradication of the infection. 



Enteric Fever in Sydney. — A return of the 
prevalence of enteric fever in Sydney and its 
suburbs, from 1876 to 1894, recently issued, shows 
that in the decennial period, 1876 to 1885, there 
was a very large increase in the mortality from this 
disease, viz., from 46"o7 per 100,000 in 1876, to 
io2'i7 in 1885. Between 1886 to 1894, the mor- 
tality from enteric fever underwent considerable 
diminution from 90*90 per 100,000 in 1886 to 
i8"oi in 1893, the lowest on record. In 1894 the 
rate increased slightly to 29-12 per 100,000. The 
same return shows the seasonal incidence of the 
disease, the greatest prevalence being from March to 
June in each year, and the minimum in September. 



THE METHODS OF DEALING WITH 
TUBERCULOUS CATTLE IN BOSTON, 

U.S.A. 

The Veterinary Inspector of the Health Depart- 
ment of the City of Boston, U.S.A., reports that, 
previous to June, 1894, the carcasses of animals 
slaughtered at the abattoir, showing the presence 
of very slight lesions of tuberculosis (as a small 
nodule in a lymphatic gland and the animal other- 
wise in good condition), had not been condemned. 

By an Act of the Legislature, passed during the 
month of June, it became compulsory that the 
carcasses of all tuberculous animals should be con- 
demned. Since that time all animals slaughtered 
at the abattoir have been condemned, without 
regard to the extent, size, or place of lesion of 
tuberculosis. 

Since November 20 the Massachusetts State 
Board of Cattle Commissioners has made a 
systematic examination of all cattle arriving at the 
different stock-yards. 

Such animals as were consigned direct to the 
abattoir, or were intended for immediate slaughter, 
were released from quarantine on being identified. 

All other animals have been tested with tuber- 
culin by the State Board of Cattle Commissioners, 
for the purpose of determining whether or not 
tuberculosis existed in such animals. 

xA.ll animals after such examinations as were sus- 
pected of being tuberculous were condemned as 
being unfit for sale. 

Such animals as did not show the presence of 
tuberculosis by such test were branded on the hip 
with the Commonwealth seal, and were then 
allowed to be sold for any purpose. 

Animals which were condemned by the Board 
of Cattle Commissioners as tuberculous were sent 
to the abattoir to be examined and destroyed. 

As the regular dead-house, where diseased 
animals are dressed, was at that time small and in- 
convenient, slaughter-house number eleven was 
turned temporarily into a dead-house, and the con- 
demned animals were killed and examined there 
by the Board of Cattle Commissioners, subject, at 
the same time, to the examination of the regularly 
appointed inspectors of the abattoir. 

Such animals as have been found to be free 
from disease on killing, have been sold for beef. 

The following table shows the number and kind 
of animals received, the number condemned, and 
the percentage found to be free from disease : — 



Animals. 


Number 
killed. 


Number 
tuberculous. 


Number 

not 

tuberculous. 


Percentage 

not 
tuberculous. 


Cows 


... 96 


76 


20 


— 


Bulls... 


- 5 


4 


I 


— 


Steers 


3 


2 


I 


— 


Total 


... 104 


o2 


22 


2I-I 



136 



THE MEDICAL INSPECTION OF SCHOOLS IN BOSTON, U.S.A. 



The following table shows the number of animals 
killed, which failed to react to the tuberculin test, 
and had been pronounced free from tuberculosis, 
the Commonwealth brand having been placed 
upon the right hip : — 



Animals. 



Number 
killed. 



Number 
tuberculous. 



Percentage 
tuberculous. 



Cows 


62 


4 


Steers 


I 


— 


Total 


63 


4 



6-34 



THE MEDICAL INSPECTION OF SCHOOLS 
IN BOSTON, U.S.A. 

The need of medical inspection of schools, for 
the purpose of detecting contagious and other 
diseases among the school children, was brought 
to the attention of the Mayor and City Council in 
1892, and for this purpose an appropriation was 
then secured. A delay for several months was 
occasioned in securing the approval of the School 
Committee, and 4;hen the Mayor withdrew hiS 
approval by objecting to the commencement of 
the work that year. In 1893, and again in 1894, 
the Board of Health asked for an appropriation for 
this work, and each time it was withheld, and the 
work was delayed, until diphtheria had assumed 
the proportions of an epidemic in September, 
1894, and was steadily increasing. Under these 
circumstances, the Mayor, in October, expressed 
a desire to have the Board of Health set in 
operation its plan for medical examination of 
school children. 

The Board of Health at once selected fifty 
physicians for this purpose, divided the city into 
fifty school districts, and began school inspection 
on November ist, 1894. These physicians are 
appointed Medical Inspectors of Schools and 
Agents of the Board of Health, and are authorised 
to visit each school daily, during the early part of 
the morning session, and to examine all i»upils 
who complain, or appear to the teachers to be ill. 
If an insjjector finds a pupil showing symptoms of 
any contagious disease, or is otherwise too ill to 
remain in school, he will advise the teacher to 
send the pupil home for the temporary observation 
of its parents or family physician. He will also 
give such professional advice as may be required 
by the teachers to aid them in carrying out all 
laws and regulations pertaining to contagious 
diseases, vaccination, and general school hygiene, 
whose enforcement belongs to the School Com- 
mittee or Board of Health. In the examination 
of throats, the Medical Inspectors will use only the 
wooden tongue-depressors which are furnished by 



the Board of Health, each of which is to be burned 
after a single use. 

No pupil is to be prescribed for or advised by 
the Medical Inspector, excepting such general 
advice as may be sought through the intervention 
of the teacher in behalf of poor children. 

The Medical Inspectors of Schools are also 
authorised agents of the Board of Health, and 
will, on notification from said Board, visit all cases 
of scarlet fever and diphtheria at the homes of the 
patients, for the sole purpose of examining the 
places and plans of their isolation ; and, as such 
agents, they will report to the Board of Health 
their approval or disapproval of such places and 
plans of isolation. Such medical agent will not 
prescribe advice or criticise anything beyond that 
which pertains strictly to the isolation of the 
patient, and will carefully avoid any word or act 
which may be construed as an infringement upon 
the rights of the family or attending physician. 
He will visit the patient as often as may be neces- 
sary to inform himself as to the continued isolation 
of the case. No case of scarlet fever or diphtheria 
will be discharged from isolation until its complete 
recovery is certified to the Board of Health by one 
of its medical agents ; and such certificates of re- 
covery will be based on the complete disappearance 
of desquamation in cases of scarlet fever, and 
on the absence of the Klebs-Lceffler bacillus in 
cases of diphtheria — the latter to be shown by 
bacteriological examination made satisfactory ta 
the Board of Health. 

The reports of the Medical Inspectors of 
Schools, for the months' of November and 
December, show that 4,962 pupils were presented 
to them for examination, and 564 were found to 
be too ill to remain in school for the time being, 
212 were suffering from contagious diseases, 43 
were suffering from diphtheria, and 131 were too 
ill from troubles in the ears and eyes to be at 
school. Diseases in the throat were most preva- 
lent, and were found in 1,749 pupils. Diseases of 
the eye, ear, and spine are found sufficiently often 
among the school children to warrant a more 
careful examination to find those who may be J 
suffering from mild forms or early stages of these \ 
diseases. It often happens that school children 
suffer serious and unrecognised disadvantages by 
reason of defective eyesight, deficient hearing, or a 
commencing deformity of the spine. The mild 
forms and early stages of these ills would not 
generally be seen and appreciated by the teachers, 
and it would be unreasonable to expect them to 
detect illnesses which require special skill on the 
part of the physician to recognise. 

The Board of Health will endeavour to pursue 
the inspection as far as it may be found to be 
agreeable to the school management and profitable 
to the highest interests of school hygiene. — From 
the 2'x,rd Annual Report of the City of Boston for 
the Year 1894. 



J 



SCARLET FEVER IN WOLVERHAMPTON. 



137 



SCARLET FEVER IN WOLVERHAMPTON ; 

RESULTS OF HOSPITAL ISOLATION 

IN 1894. 

By 
Henry Malet, B.A., M.D., M.O.H. of Wolverhampton. 

Scarlet fever has such natural variations, both in 
the amount of its prevalence and in its fatality, 
that it is difficult to estimate the value of preven- 
tive measures by noting results from year to year 
as regards numbers of cases or deaths. This has 
been especially the case with regard to hospital 
isolation in Wolverhampton. After it was first 
adopted in 1885, there was for some years a remis- 
sion of scarlet fever which mislead many, and gave 
very exaggerated hopes as to the efficacy of the 
measure. I drew attention to the many circum- 
stances (such as neglected and overlooked cases), 
that must always militate against any approach to 
suppressing this disease, and to the fact that by 
prevention a larger proportion of persons remained 
susceptible to attack ; and I anticipated such an 
experience as we have had in 1894, when our cases 
far exceeded any record since we began entering 
them in 1884, and our deaths were the highest 
since 1881. With general results so apparently 
against the utility of hospital isolation, it appeared 
well to contrast the actual spread of infection 
during the year in households where this measure 
had been adopted, and in those where it had not. 

In the following abstracts from our records, by 
children I mean only children who had not 
previously had scarlet fever, others being omitted 
as insusceptible to infection ; and I omit all 
instances, whether of removal or home care, in 
which the sick person was the only susceptible one 
in the house. 

During the year, hospital removal was resorted 
to for 564 households. In 443 of these, after one 
case was removed, there was no recurrence ; in 
these houses there remained 1,304 children. In 
61 houses, after two or more cases had occurred, 
removal was effected, and there was no further re- 
currence ; 157 children remaining. Thus there 
were 504 houses in which there was no recurrence 
after removal; 1,461 children remaining un- 
attacked. There were only 60 houses in which 
recurrence took place after hospital removal, 82 
secondary cases occurred at the following intervals 
after the removal of the last case : one day after, 
20 cases ; two days, 8 ; three days, 8 ; four days, 
3 ; five days, 6 ; six days, 2 ; seven days, 4 ; from 
eight to fourteen days after, 13 cases ; from fifteen 
to twenty-one days, 7 cases ; from twenty-five to 
thirty-five days, 11 cases. Of these 82 cases, the 
first 36 were almost certainly infected before the 
removal took place; and the last 11 were most 
probably due to some other source, leaving only 35 
cases that could be reasonably attributed to the 
failure of hospital removal (probably really due to 
failure of house disinfection). Of these 60 houses, 



in 49, after ultimate removal, recurrence ceased, 
although 119 children still remained. 

There were [44 cases treated at homes where 
there were no other children ; these I omit, as also 
12 instances in which other children were promptly 
sent away, and 8 instances of very early death. 
There were 45 houses in which cases were treated, 
other children being kept at home ; in 24 of these 
there was recurrence. There were 65 houses in 
which secondary cases occurred before hospital 
removal. Thus, independently of hospital removal, 
recurrence took place in 89 houses out of no. In 
these 89 houses there were 124 secondary cases, at 
the following intervals, after the preceding case had 
been taken ill : one day after, 34 cases ; two days, 
22 cases; three days, 11 ; four days, 12 ; five days, 
7 ; six days, 2 ; seven days, 3 ; from eight to 
fourteen days, 2 1 cases ; after sixteen, twenty 
three, twenty-eight, thirty-five, seventy-four, and 
eighty-one days, i case each ; after forty-two, forty- 
five, and fifty-eight days, 2 cases each. Of these, 
the first 56 would probably be infected from the 
same source as the primary case, and the two cases 
after seventy-four and eighty-one days would most 
likely be independent infection; the other 66 cases 
would probably be infected from the primary case 
in the house. Many of the secondary cases, which 
occurred in the 65 houses prior-to hospital removal, 
would be due to overlooked and neglected cases, 
so that it may be fairer to only take account of 
those 45 houses in which there was facility for 
home isolation, and in which it was supposed to be 
carefully carried out. In 21 of these, there was no 
spread, 44 children remaining unattacked. In 24 
instances, there were 39 secondary cases, at the 
following intervals, after the preceding case : one 
day after, 7 cases ; two days, 3 ; three days, i ; 
four days, 3 ; seven days, i ; eight to fourteen 
days, 12 cases; fifteen to fifty-eight days, 10 cases; 
and I case each at seventy-four and eighty-one 
days. Omitting the first 11 and the last 2, we 
have 26 cases probably due to failure of home 
isolation. Of the last 24 houses in 13 some 
children ultimately escaped infection — 30 in all. 

The following is a tabular comparison of the 
results of hospital removal and home care 
respectively : — 

Hospital. Home. 

Total households 564 45 

Children, per house 3'9 3'5 

No spread in (houses) ... ... ... 4^4 '• 

Children escaping J i,4'^i '4 

Secondary cases in (houses) ... ... 03 24 

Number of such cases ... ... ... S2 39 

Probably due to failure ... ... ... 35 ^^ 

All children attacked in (houses) ... H " 

Some escaped in (houses) ... . 49 '3 

Number of such children 119 3° 

Hospital, Hom;. 

Total number of children after 

primary case 1,662 113 

Number of the.se attacked .« 82, or 4-9% 39, or 34-5 % 
Number of these due to 

failure 35,or2-i% 26, or 23-0% 

L 



138 SUMMER DIARRHCEA IN RELATION TO EARTH TEMPERATURE. 



These figures are sufficiently striking, but they 
by no means fully indicate the practical value of 
hospital isolation. To appreciate this, it must be 
remembered that in every case in which home 
isolation was adopted, there was abundant facility, 
as regards house room and attendance, for carrying 
it out ; whereas, in the great majority of the cases 
removed to hospital, there was absolutely not the 
slightest chance of any home isolation at all. 
Further, the above figures only deal with the limi- 
tation of infection in the households attacked. 
Considering the free intercourse amongst the poor, 
and how soon healthy infectious convalescents from 
scarlet fever would be mixing with their neigh- 
bours, we may fairly conclude that the value of 
hospital removal in limiting home infection is far 
less than in limiting infection from house to house. 

We have had a serious experience in 1894, in 
having 55 deaths from scarlet fever to a population 
of 85,036 ; but there can be little doubt but that 
hospital isolation has been the main factor in 
averting such an epidemic as that of 1873, with 
121 deaths to 69,906 population, or of 1877, with 
27b deaths to 72,871 population. 



SUMMER DIARRHrEA IN RELATION TO 
EARTH TEMPERATURE. 

BY 

Joseph Priestley, B.A., M.D. Lond. 

The total number of deaths registered in Lei- 
cester during 1894, was 176, of which 153 were 
infants under one year of age, and 14 were between 
one and five years. Taking the registered number 
of births as the infantine population, we find that 
the diarrhcea mortality rate under one year of age 
is 2*5%, as compared with a total mortality rate for 
the same age-period of it'i^j^- There was the 
usual seasonal exacerbation of the disease during 
July and August, the largest number of deaths 
being registered during the week ending August 
15th, 1894. Id this connection it is interesting to 
note that the 4-foot earth temperature registered 
56^. for the first time on July 2nd, 1894, the fol- 
lowing 15 weekly registrations being 57'5°, 58'5"^, 

58•5^ 5«•5^ 58•5^ 58-5^ 58-5^ 57-5^ 57-5^ 
56-5^ 56<'F., 55-5". 54-, 537-, 52-7-. 

SCF. is stated to be the "critical" 4-foot earth 
temperature, i.e., the temi)erature at which certain 
changes (putrefactive, bacterial, etc.) take place in 
the pores of the earth, with the consequent develop- 
ment of the diarrhfeal poison. From the time 
that this " critical " temperature is first registered, 
we ought to allow about 14 days (seven for the 
average duration of the disease before death, and 
seven for the average interval between the death 
and its notification to the Health Department 
through the Registrar), after which the number of 
deaths ought rapidly to increase. During 1894, 
July 2nd saw the 4' earth thermometer first regis- 
tering 56*'?., and within 14 days from that date, 



the weekly immber of deaths from diarrha;a greatly 
increased. (The number of deaths from diarrhoea 
for the week ending June 27th was i, and in the 
following weeks the deaths were 4., 5, 8, 15, 20, 22, 
28, 16, 14, 8, 8, 4, the last being for the week 
ending September 19th.) 

On September 21st, the 4-foot earth temperature 
sank below 56°F. {viz., to SS'S^'F.), and with it the 
number of diarrhceal deaths rapidly declining 
(allowing, of course, the 14 days interval as before). 
The cause and effect relationship between the 4' 
earth temperature of 56°F. and summer diarrhoea 
deaths has therefore been well shown in Leicester 
during 1894 — the temperature being, apparently, 
the immediate existing cause. 



ON AN OUTBREAK OF SCARLET FEVER 
IN BRADFORD, DUE TO INFECTED 
MILK. 

1!Y 

W. Arnold Evans, M.D., M.O II. of Bradford. 

DuRiNf; 1893 scarlet fever was unusually prevalent 
in Bradford, no less than 1,445 cases of the disease 
having been reported to the Health Department. 
This exceedingly large number of cases was chiefly 
due to an epidemic in the month of July, brought 
about by the distribution of infected milk. The 
first half of the year had been more free than 
usual from scarlatina, but on July 3rd there was 
a sudden outburst, twenty-six cases coming to 
my knowledge on that day. I immediately set 
about to investigate the matter, and soon satisfied 
myself that the milk supply was the only factor 
common to the houses invaded by the disease. 
The farm in Bolton Woods, from which the great 
majority of infected houses procured their milk, 
was apparently free from infection, no case 
existing on the premises, and the cattle being in a 
healthy condition. It was, however, noticed that 
two boys who had assisted to deliver the milk 
were missing from their employment, and on 
visiting them at home I found one in the 
desquamatory stage of scarlet fever, with 
commencing dropsy ; at the time of my visit he 
was in bed with his younger brother, who had that 
day commenced with an attack of Scarlatina. 
The other boy had been detained at home on 
account of his having a "sore throat," which 
proved to be a mild attack of scarlet fever. All 
three cases were at once removed to the hospital. 
The milk-cans and all utensils used for the 
distribution of the milk were scalded and 
thoroughly cleaned under the supervision of the 
food and drugs insjjector. After the loth of the 
month there was a marked diminution in the 
number of fresh cases coming to my knowledge, 
until the 17th, when a fresh outbreak occurred, 
most of the families affected being supplied with 
milk from a farm contiguous to the one already 
referred to. I found that in this case the milk 



EXPOSURE OF INFECTED PERSONS. 



^^9 



was the source of the infection, and had most 
probably been contaminated on the farm by a boy 
who assisted in dairy work. I found this boy 
desquamating on the hands and feet. He was 
apparently convalescent from a mild attack of 
scarlatina, unknown to himself and his parents. 
The same preventive measures were taken as in 
the above-mentioned case, but the disease had 
now become so widelv spread that it was not until 
August was well advanced that the epidemic 
period could be considered at an end. In 
addition to the cases actually notified as scarlet 
lever, there were many others of a minor form, 
having for their chief symptom a sore throat of a 
more or less severe character. I am satisfied that 
many of them were scarlatinal in nature. The 
milk epidemic commenced on July 3rd from milk 
supplied by Mr. H. ; the second outbreak of 
the disease, beginning on July 17th, was due to 
milk supplied by Messrs. B. and Hd. Mr. B. was 
a farmer and close neighbour of Mr. H., Mr. Hd. 
being merely a purveyor, and obtaining his milk 
from Farmer B. 

At the commencement of the alarming prevalence 
of scarlatina above mentioned, a list of customers 
was obtained from the farmers and milk purveyors 
whose milk was suspected, from which it appeared 
that during the period July 3rd to August loth the 
three milk dealers already referred to delivered a 
daily supply at 367 houses, 130 of which during 
the same time became infected with scarlatina, 
equivalent to a rate of 35*4 per cent, of the total 
number of houses supplied. The proportion of 
houses infected in reference to each milk supply, is 
seen from the following table. 





Houses 


Houses 


Percentage 


Name. 


Supplied with 


Infected with 


of Houses 




Milk. 


Scarlatina. 


Infectec}. 


Farmer H. 


156 


59 


37-8 


Farmer B. 


123 


41 


33*3 


Purveyor Hd. 


88 


30 


34"o 


Total 


367 


130 


35-4 











EXPOSURE OF INFECTED PERSONS.'^' 

BY 

T. Orme Dudfield, M.D. 

A CASE of exposure of a person suffering from 
diphtheria has lately attracted a good deal of at- 
tention in the Press, due, not to the fact of such 
exposure, but to an accident in connection there- 
with, causing hardship to a cabman whose vehicle 
was employed for the conveyance of the sick per- 
son. The real point of the case, regarded from a 
sanitary point of view, viz., the unlawful use of the 
cab, appears to have been entirely overlooked. 
The facts, as reported in the newspapers, are shortly 
these : — A woman took her sick child to a Chelsea 
dispensary. Upon examination, the child was 

* From Dr, Dudlickl's Monthly Report for November, 
iS95. 



found to have diphtheria. The doctor told the 
mother to take the child home at once, and when 
she asked him to get the porter of the institution 
to call a cab for her, he did so, thus — as it is put — 
merely acting as her messenger But the cabman, 
who was not aware of the complaint from which the 
child was suffering, was directed to drive to the 
Town Hall, Chelsea. On arriving, his number 
was taken by a sanitary inspector, who told him to 
return to the hall after discharging his fare at home. 
He did so, and was then told that his cab would 
be detained, as the child he had carried was suffer- 
ing from diphtheria. He lost the use of his cab 
for two days whilst it was being disinfected, and, 
as neither the Sanitary Authority nor the dispensary 
doctor would compensate him, he took out a sum- 
mons at the Police-court against the latter — whom 
he appears to have regarded as the hirer of his cab 
— for the modest sum of one pound. The Magis- 
trate, whilst expressing sympathy for the cabman, 
held that the doctor was not liable, and dismissed 
the summons. All through the case no one ap- 
pears to have remarked on the fact that a serious 
breach of the law had been committed by the use 
of the cab for the conveyance of the sufferer. The 
law on the subject is explicit as set out in Section 
70 of the Public Health (London) Act, 1891, as 
follows : — 

"Section 70. — It shall not be lawful for any 
owner or driver of a public conveyance knowingly 
to convey, or for any other person knowingly to 
place, in any public conveyance, a person suffering 
from any dangerous infectious disease, or for a 
person suffering from any such disease to enter any 
public conveyance, and if he does so he shall be 
liable to a fine not exceeding ten pounds ; and if 
any person so suffering is conveyed in any public 
conveyance, the owner or driver thereof, as soon 
as it comes to his knowledge, shall give notice to 
the Sanitary Authority, and shall cause such con- 
veyance to be disinfected, and if he fails so to do, 
he shall be liable to a fine not exceeding five 
pounds, and the owner or driver of such conveyance 
shall be entitled to recover in a summary manner 
from the person so conveyed by him, or from the 
person causing that person to be so conveyed, a 
sum sulificient to cover any loss and expense in- 
curred by him in connection with such disinfection. 
It shall be the duty of the Sanitary Authority, when 
so requested by the owner or driver of such public 
conveyance, to provide for the disinfection of the 
same, and they may do so free of charge." 

With reference to this case, one may, perhaps, 
be allowed to remark that the child ought not to 
have been permitted to leave the dispensary in the 
way he did. He should have been isolated on the 
premises for the half-hour or so it would have taken 
to obtain one of the Asylums Board ambulances, 
which would have been sent on receipt of a 
message, by telephone, or telegram, or otherwise. 
In the circumstances, no charge, presumably, 



140 



A RESPONSIBILITY TO THE LYING-IN PATIENT. 



would have been made had the child been taken 
home ; none certainly had he been removed to the 
hospital. It is strange that no one at the dis- 
pensary appears to have known that a cab could 
not be lawfully used for the purpose of the 
removal. It is manifest, however, that the danger 
of using the vehicle was recognized, as the cabman 
was directed to go, not to the home of the sufferer, 
but to the head-quarters of the Sanitary Authority. 
Happily, no injury to the public health resulted, 
inasmuch as the vehicle was disinfected. But it 
might have been otherwise. 



A RESPONSIBILITY TO THE LYING-IN 
PATIENT, FROM A SANITARY POINT 
OF VIEW.* 

With Resolution. 

By 
G. Walter Steeves, B.A., M.D. 

That comprehensive term " Puerperal Fever," 
concerning which there has been so much discus- 
sion and difference of opinion in the past, is now 
included in the list of notifiable diseases under 
" The Infectious Diseases (Notification) Act, 
1889." 

So long as the medical attendant conscientiously 
submits his notification form, and the case is sub- 
jected to the rigid inquiry of the sanitary authority, 
we need not question the nomenclature or scientific 
value of the expression from a public health stand- 
point. 

It is not my intention to refer to the various 
forms of puerperal fever as they are usually classed 
in text-books, but I would ask you to confine your 
attention to that variety which undoubtedly exists 
as the result of defective sanitation. 

That puerperal septicitmia may arise through 
atmospheric infection by sewer gas is now an 
accepted fact, and many sad experiences have been 
related by the highest authorities on the subject. 
Dr. Playfair's address on " Defective Sanitation as 
a cause of Puerperal Disease," delivered a few 
years ago, deals with some very interesting and 
notable examples. From many instances, which 
time forbids to cite, it is j^retty certain that sewer 
gas is capable of conveying the micro-organisms of 
typhoid fever, di()htheria, and scarlet fever, 
possibly other zymotic diseases. Then, again, the 
removal of a patient suffering from puerperal fever 
to a cleanly atmosphere has often been followed 
by such a rapid recovery as to show that the sei)tic 
attack was not due to an ordinary zymotic infec- 
tion. Our esteemed medical officer of health (Dr. 
Hope) in answering my inquiries on the subject, 
writes to me as follows: — " I find, as the result of 
investigation into the reports, that about one-third 
of the cases of puerperal fever rej)orted in 1894 

• A •• Note " read at the Liverpool Medical Institution, 
December 12th, 1895. 



occurred in houses which come under the category 
of insanitary." 

The prevalence of puerperal fever is no safe 
index, and bears no necessary proportion to the 
amount of existing zymotic disease. Much proof 
could be adduced to demonstrate this. Let us 
take our own city of Liverpool. I find that during 
the year 1893, eighty-two cases of puerperal fever 
occurred, and sixty-eight cases in 1894. At the 
same time, I see a considerable increase in the 
number of notified cases of all the zymotics during 
the latter year ; in fact, the total in 1894 amounts 
to nearly 1,000 more than in 1893. 

We are forced to recognise the fact that, unless 
our puerperal patient is provided with pure, un- 
tainted air in her dwelling, her life will certainly be 
endangered. 

How do we stand as to this matter ? 

On booking a confinement, how many of us 
proceed to the house of the woman to ascertain 
those surroundings and conditions which may 
ultimately affect the case ? 

Is it not a fact that in very many instances the 
practitioner has never been inside the house till he 
is summoned to the labour. Though he may have 
been constantly visiting the family, he is usually 
ignorant of the sanitary condition of the house, 
unless typhoid fever or diphtheria may have 
directed the necessary inquiry. 

Presuming we are not only justified, but in duty 
bound, to ascertain those hygienic surroundings 
likely to influence the well-being of our obstetric 
case, what should be our method of procedure ? 

We would probably find little or no trouble in 
having our recommendations complied with where 
the occupant was the owner of the house, and in- 
deed few right-minded men would hesitate to carry 
out any structural reform when puerperal dangers 
were clearly pointed out ; but in the majority of 
instances, I grant, the problem is not so easy of 
solution. By far the greater number of midwifery 
cases — those with a remuneration of from one to 
two guineas — occur in small cottage property, the 
owners of which are not usually solicitous either of 
the health of the tenant or the healthiness of the 
premises. The recommendations of the attending 
physician and occupier are here frequently dis- 
regarded, till disease or death demand the . 
intervention of the sanitary authority. | 

Where the owner refuses to abate a nuisance 
under the circumstances we are considering, surely 
it is the duty of the physician to direct the atten- 
tion of the local authority to it, in order that the 
necessary notice might be served on him, by 
virtue of section 94 Public: Health Act, 1875. 

It may be argued that many practitioners have 
had no training or experience in public health or 
house sanitation, and therefore their investigations 
would be valueless. Admitting the truth of this, I 
would only answer that few doctors with such a 
sense of responsibility as is nnposed by the full 



LAW REPORTS. 



I4t 



confidence and dependence of their lying-in 
patients would hesitate to admit their incapacity, 
and seek a more skilled opinion in such matters. 

Again, it may be said that, after all, only a small 
proportion of lying-in women contract puerperal 
septicsemia. I am aware of this {i.e., acute 
puerperal septicemia), but I am also convinced 
that many a woman passes through a protracted 
period of ill-health after her confinement— the 
victim of chronic sewer-gas poisoning — usually 
more conveniently termed " general debility '' ; and 
this condition is only permanently got rid of by 
change of residence or alteration of sanitary 
arrangements. 

I now beg to propose the following resolution, 
viz.: — ''That, in the opinion of the Members of 
the Liverpool Medical Institution, it is the duty of 
every medical practitioner, when engaged to attend 
a confinement, to fortwith inspect, or cause to be 
inspected, the premises of the patient, with a view 
of having any sanitary defects which may exist 
corrected, and so further the stamping out of 
puerperal septicsemia by the methods of preventive 
medicine." 

The resolution was seconded by Dr. Imlach, 
and a discussion followed, in which Drs. Grimsdale, 
Campbell, Whittle, and others, took part. 

The resolution was lost by a large majority. 



LAW REPORT. 



HIGH COURT OF JUTSICE. 

Chancery Division. 

(Before Mr. Justice Romer.) 

The Attorney-General v. Stone and Others. 

From the " Times " Report. 

This was an action by the Attorney-General (at 
the relation of the Heston and Isleworth Urban 
District Council) and the said council against 
Mr. J. J. J. Stone and others. The council was 
the urban authority for the district under the 
Local Government Act, 1894, and the Public 
Health Act, 1875. The defendant Stone was the 
owner of a piece of land adjoining Kingsley Road, 
Hounslow, and not far from the High Street of 
Hounslow ; and the other defendants (who did not 
appear to defend the action at the trial) were some 
of the gipsies whose occupation of the land was the 
subject of the present action. The complaint of 
the plaintiffs was that Stone, since early in 1894, 
had been allowing his land to be used as a gipsy 
I ncampment, charging weekly sums for his permis- 
sion to the gipsies to keep their vans and tents on 
the land, in such a manner (by reason of the 
alleged insanitary state of the land, the absence of 
proper drainage, overcrowding, dirt, noise, and 
untidiness) as to be a nuisance to the inhabitants 
in the neighbourhood and injurious to health. 
The plaintiffs claimed a perpetual injunction 
against the nuisance. The trial lasted some days, 



and parts of the evidence were in direct contradic- 
tion of other parts. At the conclusion of the 
evidence and arguments, his Lordship reserved 
his judgment, which was delivered as reported 
below. 

Mr. Eve, Q.C, and Mr. Morton Smith were for 
the plaintiffs ; and Mr. Oswald, Q.C, and Mr. 
Bartley Denniss for the defendant Stone. 

Mr. Justice Romer delivered judgment as 
follows : — In this case the most important thing to 
be considered is how the defendant Stone allowed 
his land to be used between April, 1894, when he 
caused two water-closets to be provided, and 
April 5th, 1895, when the writ in this action was 
issued. There had been a conflict of evidence on 
the subject, greater even than what is unfortu- 
nately common in nuisance cases. And if a case 
could be won by the mere number of his witnesses 
then the defendant Stone ought to succeed, for he 
has called a great number. But a considerable 
proportion of these were of a class whose views on 
subjects concerning cleanliness and sanitation 
were likely to be of an abnormal character and 
opposed to the views of ordinary citizens, and 
whose evidence did not impress me favourably ; 
and some of the defendant's witnesses (as, for 
example, the defendant Stone himself and his 
son) were such partisans and so extreme in their 
evidence as to make it worthless to the Court. 
On the other hand, almost, all of the 
plaintiff's witnesses gave their evidence well, 
and I am sure are witnesses who can be trusted 
by the Court. And the effect of the evidence 
upon my mind at the trial was — and my then view 
has been confirmed by a subsequent perusal and 
consideration of my notes — that the plaintiffs are 
entitled substantially to the relief they ask for. 
During the period between the erection of the 
water-closets and April 5, 1895, the defendant 
Stone was in the habit of permitting for profit per- 
sons in vans and tents to stay on this land in such 
numbers, and under such surroundings, and in 
such manner as to make the land insanitary and 
offensive and dangerous to the health of the 
neighbourhood. No doubt at times, especially 
after complaints, the place would be cleared up 
and be more looked after and fewer people be per- 
mitted to dwell on the land, so that the land might 
temporarily cease to be a nuisance or injurious to 
health. But this state of things did not continue, 
and the defendant Stone persisted in permitting 
this land— which is an inhabited district and is not 
adapted by drainage or otherwise for the purpose 
of an encampment of a considerable number of 
dwellers in vans and tents— to be occupied and 
used in the manner and with the effect pointed 
out above. Since the writ was issued the de- 
fendant Stone has taken care to lessen the number 
of dwellers on the land and to improve its state 
and regulate its user ; but I am convinced that 
unless an injunction be granted the defendant will 



142 THE PREVENTION OF DIPHTHERIA IN BOSTON, U.S.A.— ANNOTATIONS. 



permit matters to go back to their old condition, 
and the insanitary condition and nuisance arising 
from the user of the land will probably be as bad 
as ever. But it is said that in any case I ought 
not to grant an injunction against the defendant 
Stone on the ground that the van and tent dwellers 
are alone responsible and that Stone is not. This 
is an idle contention. It would be impossible for 
the plaintiffs to get any real relief if they could 
only sue the temporary dwellers on the land, who 
have no estate or interest in any part of the land 
itself and are here to-day and gone to-morrow. 
Stone is the man who permits these dwellers to 
occupy the land in the way they do and who 
alone owns the land and is really responsible for 
the way in whi< h it is being used. It was further 
urged on behalf of the defendant Stone that the 
plaintiffs ought to have taken summary proceedings 
before a justice and were not entitled to bring this 
action. But, in the opinion of the plaintiffs, the 
Heston and Isleworth Urban District Council, 
being the local authority, summary proceedings 
would have afforded an inadequate remedy, and, 
therefore, under Section 107 of the Public Health 
Act, 1875, ^hey were entitled to cause these 
proceedings to be taken in the High Court ; and, 
in my judgment, the case was one which could 
not have been satisfactorily tried or dealt with by 
summary proceedings, and which the district 
council were well advised and justified in bring- 
ing before the Court by this action. I grant an 
injunction to restrain the defendant Stone from 
allowing this land to be occupied or used by 
dwellers in vans or tents, or others being his 
licensees, in such a way as to be a nuisance or 
injurious to the health of the neighbourhood, and 
I order him to pay the costs of the action. 



THE PREVENTION OF DIPHTHERIA IN 

BOSTON, U.S.A. 

DiPHTHF.RiA was morc prevalent in 1894 than in 
any previous year. It began a rapid increase in 
September, coincident with the commencement of 
the schools, and reached the highest point in 
November. 

The prevalence of the disease in epidemic form 
made it possible for the Board of Health to intro- 
duce three new forces for the suppression of the 
disease. 

One is the new remedy, "anti-toxine,"' which 
has been used to a limited extent, with excellent 
results, in reducing the percentage of deaths to the 
number of cases. It is also claimed for anti- 
toxine that it possesses the power of preventing an 
attack of diphtheria for a brief length of time wlien 
used during, or immediately after, exposure to the 
disease. To what extent this probable quality of 
the agent may in the future be made available 
remains to be seen, but thus far it catniol be said 



to have been an active agent in diminishing the 
number of cases. Another agent has been found 
in the use of the bacteriological laboratory, by 
which a large number of mild cases of this disease 
are found to exist. This has given rise to early 
treatment and isolation where the ordinary means 
of diagnosis have heretofore left such cases to go as 
ordinary sore throat. The laboratory test is prov- 
ing of great service also in determining the time 
when It is safe to discharge the diphtheritic patient 
from isolation. 

The third, and probably most potent, agency in 
controlling the spread of this disease, and that of 
scarlet fever, is the new force of fifty physicians for 
the daily inspection of the schools, in which there 
are more than 70,000 of the most susceptible sub- 
jects to these two diseases. This has set in practice 
the most active, constant, and skilled watchfulness 
for the earliest symptoms of these and other diseases 
among school children. This same agency has 
been used in watching and securing such isolation 
as might be possible of all cases of diphtheria and 
scarlet fever within the city, and certifying the time 
of their full recovery. 

By the latter means, the earliest appearances of 
the disease, its development, isolation, and disap- 
pearance are brought directly under the agency of 
the Board of Health. 

We regret to say that the hospital for contagious 
diseases, which was expected to be opened for the 
reception and treatment of i)atients in October, 
1894, is not yet available, and will not be for several 
months. It is but fair to say that, had an ample 
hospital been in readiness for cases of diphtheria 
and their inseparable connections, which required 
isolation and disinfection, added to the other means 
now in our hands, we could have broken up the 
epidemic in half the time which it has taken to 
reduce it to its present unsatisfactory proportions. 



ANNOTATIONS. 



Entkric Fever in Sheffield. 
Dr. H. Littlejohn. in an interestini:; report to the 
City Council, shows the excessive yearly prevalence 
of enteric fever in Sheffield. The milk and water sup- 
ply were carefully excluded as possible causes of the 
disease. In fact, no common cause for the origin of 
the disease was found, except the present system of 
refuse disposal. Dr. Littlejohn concludes that the 
chief cause of enteric fever in the city is the offen- 
sive and insanitary condition of the majority of the 
privy-middens, which permit of large accumulations 
of filth remaining in close proximity to dwelling- 
houses, combined with the pollution of the sur- 
rounding soil from these privy-middens. In previous 
reports he had pointed out the freciuency with 
which rases recurred in certain portions of the 
town, and also in yards having a privy-midden, 
used in common by several houses, and how, when 



REPORTS OF MEDICAL OFFICERS OF HEALTH. 



'4; 



the cases were not removed into hospital, but treated 
at home, the disease tended to spread from the 
house first infected to other famiHes using the same 
midden. It is obvious that, under such conditions, 
the treatment of cases in hospital is essential for 
preventing the spread of the disease. The desir- 
ability of removing patients to hospital is still 
further enforced by some interesting figures given 
by Dr. Littlejohn. In 1892, 15-5 per cent, of the 
cases treated in hospital died, while 2 3 8 per cent, 
of the cases treated at home died. In 1893, the 
corresponding percentages were i5"7 and 20-9; in 
1894, i2'4 and 248; and in 1895, 19*3 and 25*0 
per cent. 

The Limits of Chemical Analysis of Water. 

Chemical analysis will prove the presence of 
impurity in water but it will not prove its absence. 
Chemical analysis is a confirmatory test of the 
wholesomeness of water, it is not the test. The 
true test is the source of supply and its surround- 
ings. And yet it would seem that chemical analysis 
is actually regarded as a sort of fetish in this 

matter No chemist has a right to advise a 

sanitary authority that a given water is wholesome, 
if he does not know all about the source from 
which it is drawn. Water of a certain composition 
from one locality would be suspected, whereas if 
it came from another locahty no suspicion would 
attach to it. Bye-laws will be a great protection to 
the public health in your district as regards water 
supply ; but hitherto it has been an insult to 
common sense, a contempt of preventive medicine, 
and a trifling with the public health to certify 
water liable to contamination as wholesome because 
at the moment it is chemically pure.~(i^rc;;z Dr. 
y. Groves' Annual Report to the Rural Sanitary 
Authority of the Isle of Wight). 

The Low English Birth-rates. 
Dr. R. Dudfield, in his annual report for 1894, 
concludes, from an examination of statistics for 
1860-93, that — 

1. That the low birth-rate is in part, and 

chiefly, due to low marriage-rate ; 

2. That some of the reduction is due to 

diminished vigour of the population ; 
and — 

3. That there are indications that the latter 

cause is passing away. 
With these conclusions it is impossible wholly to 
agree. A lowered marriage-rate is, doubtless, 
followed by a lowered birth-rate. Thus between 
the maximum year, 1873, and the minimum year, 
1886, the marriage-rate of England declined 19 per 
cent., while between the maximum year, 1876, and 
the minimum year, 1890, the birth-rate declined 
20 per cent. This does not, however, express the 
whole truth. The mean age at marriage has been 
steadily rising since 1873, the mean age at marriage 
or 1893 being the highest on record. It is evi- 



dent, therefore, that two factors have been at work 
— a smaller proportion of marriages to population, 
and a postponement of such marriages as have 
occurred. Inasmuch, however, as the decline of 
the marriage-rate appears to be sufficient to account 
for nearly all the 20 per cent, decline in the birth- 
rate, without making any allowance for the reduc- 
tion of birth-rate caused by higher average age 
at marriage, it is highly probable that, after making 
allowance for the latter, there has not been so great 
a reduction as the low marriage-rate ought to have 
caused. 

It is almost certain that the temporarily 
diminished vigour of the population assumed by 
Dr. R. Dudfield is a phantasm. That this is so is 
confirmed by the further consideration that no 
allowance has been made in the preceding remarks 
for the notorious fact that artificial preventive 
measures against conception have become much 
more commonly used in recent years than they 
were at the time when the English birth-rate was 
at its highest. 



REPORTS OF MEDICAL OFFICERS OF 
HEALTH. 
Bradford. 
Enteric Fever and Discharge of Steam into 
Sewers.— Y)r. Arnold Evans records a small group 
of cases in the Dudley Hill district which seemed 
to have a common origin. His inquiries satisfied 
him that these cases were attributable to the sudden 
rush of steam from neighbouring factory boilers 
directly into the sewer : the practice of discharging 
steam into the sewers greatly increasing the pres- 
sure of the air in them and forcing noxious gases 
through the house traps. 

Manchester. 

Hospital Isolation in relation to Scarlet Fever 
Epidetnics. — Dr. Niven states : The death-rate 
from scarlet fever is greatly dependent on the type 
of disease prevailing in a particular year, but there 
can be no doubt that a high proportion of cases 
isolated in hospital tends to produce a milder type 
of disease, and to distribute the incidence of the 
disease in any locality over a longer period of time. 
In 1894 the proportion of the cases removed to 
hospital to all the cases notified was 66 per cent., 
as against 59 per cent, in the years 1891-93. The 
latter proportion was itself much higher than had 
prevailed in previous years. 

Interchange of School Books. — While inquiring 
into the extension which diphtheria had undergone 
in a particular school, I was much struck with one 
consideration — applicable to all diseases in which 
sputum or nasal discharge plays an important part, 
such as diphtheria, whooping cough, measles, 
influenza — viz., that the school books are all 
collected together into one common room at the 



144 



CORRESPONDENCE.— APPOINTMENTS. 



end of the day, and are distributed anew next day. 
Quite other children will have the books whirh on 
a previous day were used by children sickening 
with diphtheria, and on which infectious mucus 
may have been discharged. This seems to me a 
most dangerous arrangement, and one which 
requires entire overhauling. It is surely a larger 
evil than the re-issuing of infected library books. 

MONTRE.XL. 

Mali\::,iiant Scarlet Fever. — Dr. Louis Laberge, 
the medical health ofificer, reports a very severe 
epidemic of scarlet fever in that city during 1894. 
The deaths from scarlatina contributed more than 
any of the other infectious diseases to the excess 
of deaths from zymotic diseases in 1894; further- 
more, the mortality from this cause was the highest 
recorded smce the first annual report was published. 
The largest number of victims of this disease were 
carried off during the first half of the year, the 
maximum being during the month of March. The 
total number of deaths by scarlatina during the 
year was 497, or 304 more than in 1893, or 461 
more than the mean total number for the preceding 
six years. 

The type of the disease that prevailed was a 
most malignant one, being almost always, even 
during the prodromal stages, complicated with 
rapidly developing aphthous or rather gangrenous 
angina. The eruption being tardy, very slight or 
else entirely absent (the type frustre of Trousseau) 
might have decided some physicians to attribute 
cases resulting in early death to diphtheria or 
croup. We can thus conceive a sufficiently plau- 
sible reason for the increase in the number of 
deaths attributed to the two latter causes over 
the mortality from the same causes in 1893. 



CORRESPONDENCE. 



THE SL.\TE AS A PROBABLE MEANS OF 
TRANSMISSION OF DIPl ITIIERIA AND OTHER 
DISEASES AMONG SCHOOL CHILDREN. 

To the Editor of Public Health. 
Sir, — My attention has been directed to the following 
paragraph which appeared in Tlie Echo, dated December 
llth, 1895, which states, under the title "Dangers at 
School " :— 

•' It is now asserted that danger lurks in the slate used 
by children at school. The common practice which prevails 
in schools is to hand slates to the children without any 
attempt being made to insure that each child shall have the 
same slate time after time. The first thing which the child 
does is to clean the slate by means of ihe lingers wetted with 
saliva. In this process, of course, the finger travels many 
times from moutli to slate, and vice versa, and tliu.-> conveys 
to the mouth any material which may happen to be upon the 
slate. Thus, if a child happened to be suffering from 
tuberculosis, the disease might be steadily conveyed to the 
mouth of a healthy pupil, and the same contingency would 
fie likely to happen, fierhaps, in all prdliability with greater 
effect, if the disease were to be diphtheria. After all, there 
seems to Ix; some good ground for apprehension." 

The aliovc is the subslanre of an opininn which I expressed 
publicly before the Sani'ary Authority of the Borough of 



Maidstone, whilst acting as deputy and assistant medical 
officer for my father (Mr. M. A. Adams, the medical officer 
of health for the Borough referred to). I was led to this 
belief by reason rif some investigations and enquiries which I 
was then undertaking concerning an outbreak of diphtheria 
in a school, and it was the result of direct observation of the 
children, together with facts which appeared to support such 
an assumption, gleaned during my enquiries into similar 
outbreaks, my attention having been particularly devoted to 
this disorder by reason of my father's special research into 
the probable association of the incidence of diphtheria and 
certain fiuctuatic ns in the level of the subsoil water. In this 
easel directed that all the slaves should be boiled for half 
an hour in a so'ution of sodium carbonate. 

I am, sir, your obedient servant, 

Percy T. Adams. 



REVIEW 



Clinical Sketches, No. 12, Vol. II., price is. (Smilh» 
Elder and Co.), is a specially interesting number. It contains 
articles on Geology in Relation to Disease (Ilaviland) ; on 
a Sanitary Garden (Poore) ; on Pure Drinking-Water and 
Filters, not to mention others of less immediate interest 
hygienically. Each article is fully illustrated. With the next 
number, which begins a new volume, the price will be 
reduced to 6d. amon'h. The journal deserves support and 
a large circulation. 



APPOINTMENTS. 

Medical Officers of Health. 

Bevan, Richard, L.R.C.P. Lond., M.R.C.S., re- 
api^ointed M.O.H. to the Lydd Town Council. 

Belding, D. T., .M.R.C.S., L.R.C.P. Lond., appointed 
M.O.H. to the Dereham District Council. 

Cole, T. W., B.A. Dub., M.D., B.Ch., appointed 
M.O.H. to the Bolsover District Council. 

Easey, William, M.D. Brux., L.R.C.P., L.R.C.S. 
Edin., appointed ^I.O.H. to the Peterborough Rural 
District. 

Fulton, Dr., appointed M.O.H. to the Stevenston 
Parish Council. 

Graveley, H., M.R.C.S. Eng., re-appointed M.O.H. to 
the Chailey Rural Council. 

Hardy, C. M., M.B., B.S. Durh., appointed M.O.H. 
to the Croft Rural District Council. 

Harkek, W. E., M.D., McGill, L.R.C.P.L, appointed 
M.O.H. to the Tyne Port Sanitary Authority. 

Hardwick, a., M.D. .appointed M.O.H. to the Newquay 
Urban District Council. 

Heath, H. T., L.R.C.P. Edin., L RC.S.L, appointed 
M.O.H. to the Mansfield Woodhouse Urban District. 

Morton, A. C, M.R.C.S. Eng, appointed M.O.H. to 
tliu North Walsham Urban District Council. 

MacGregok, D.A., M.B , CM. Edin., appointed 
M.O.H. to the Skelmanthorpe Urban District Council. 

NOKKis, O., L.R.C.P. I., L.M., L.S.A., appointed 
M.O.H. for the Shcrburn Rural District. 

Patterson. G. II., L.R.C.P. Lond., M.R.C.S. Eng., 
le-appointed M.O.H. for the Dalton-in-Furness Urban 
District. 

Prin(;lf, Dr., appointed M.O.H. for the No. 3 District 
i)( the Bridgewatcr Union. 

RoiiKK'isoN, John A., M.D. Glas., M.B.C.M., ap- 
pointcd M O.H. to the Stilton Rural District. 

Tew, James Scott, M.D. Durh., M.B., M.R.C.S., 
appointed M.O.H. for the .Sevenoaks, Southlxirough, 
Tenterden and Tonbridge Urban .Sanitary District, and 
the Bromley, Cranbrook, Maidstone, Sevenoaks, Tenterden, 
and Tonbri<lge Rural .Sanitary District. 

Wachkr, Frank, M.R.C.S. Eng., L.S.A.. re-appointed 
M.O.H. for Canterbury Urban District. 



i 



Public Health, 

Eije Journal of tlje Jncorporatetj ^ocietg of Pletiical (©GBtcers of J^ealtlj. 



SUBSCRIBERS' COPIES of Public Health are 
supplied at \os. dd. per annum. Single copies One Shilling. 

BOUND VOLUMES.— Co/j« of Volume VI. are now 
ready, bound in cloth, gilt lettered, price lOs, 6d. A 
few copies of Vols. I., II., IV., and V. are also on hand. 

CLOTH COW'E.'RS for Binding the Volumes, price is.6d., 
may be had by order of any Bookseller. 

Orders should be addressed to E. W. Allen, 4, Ave Maria 
Lane, E.G. 

ADVERTISKMKKTS. — Communications relating to 
Advertisements should be addressed to Messrs. fV. H, &' L. 
Collingridge, 148 and 14^, Aldersgate Street, E. C. 

Every Reader of a Paper before the Society, or Contributor 
of a Signed Article, is entitled to twenty five copies of the 
issue of Public Health containing the contribution in 
question ; biif application for this or any smaller number 
must be made to the Editor not later than the TWENTY- 
FOURTH day of the month previojis to insertion of the 
Contribution. 

Medical Officers of Health and other Correspondents are 
requested to send regularly all published reports and 
matters of interest bearing upon Sanitation to the Editor, 
1 1 , Gloucester Place, Brighton. 



NOTICES. 



ALTERED SUBSCRIPTION FOR MEMBERS OF 
THE INCORPORATED SOCIETY M.O.H. 

The attention of Fellows and Members of the Incorporated 
Society is called to the fact that dating from October, 1894, 
the subscription to the Society will be one guinea instead of 
half-a-guinea as hitherto. It must be noted that this will 
include the subscription as members of a branch of the 
Society, the guinea subscription being inclusive for all 
purposes. 

It will be seen from this that there will be no very 
material increase in the subscription for those who are 
members of the parent Society and of one of its branches. 
There will, however, be considerable saving of trouble in 
collecting subscriptions, etc., as one subscription only will 
be payable. The subscriptions (and those for Associates, 
which remain half-a-guinea) should be sent to the Trea- 
surer, Dr. Kempster, Chesterfield, North Side, Clapham 
Common, London, S.W. 



Members of the Society will learn with great 
regret that Dr. Newsholme, the Editor of the 
Journal, has been laid up with an attack of enteric 
fever. We are pleased to be able to record that 
he is apparently out of danger and making very 
satisfactory progress towards recovery. It appears 
that the disease was most probably contracted in 
making a post mortefn examination. 

No. 94. February, 1896, 



The Incorporated Society of Medical 
Officers of Health. 
20, Hanover Square, London, W. 
An Ordinary Meeting of the Incorporated Society 
of Medical Officers of Health will be held at 
197, High Holborn, on Thursday, the 20th day of 
February, 1896, at 7.30 p.m., for the transaction 
of the following business : — 

AGENDA. 

1. To read and confirm the Minutes of the 
Ordinary Meeting held on January i6th, 1896. 

2. To receive the Report of the Council, if any. 

3. To read correspondence, if any. 

4. To elect Fellows, Ordinary Members, and 
Associates. The following have been duly nomi- 
nated : — 

As Fellows. 
J. Harold Ashton, L.R.C.P., L.R.C.S., Chadderlon, 
Lanes., M.O.H. Chadderton, U.S.D. 
Pri'pased by C. E. Paget, seconded by C. H. Tattersall. 

W. M. Clendtnnkn, M.R.C.S., L.R.C.P., Caseley, 
Staffs., M.O.H. Caseley, U.S.D. 
Proposed by B. S. U..derhill, seconded by H. Manley. 

John Tueb-Thomas, L.R.C.P., L.R.C.S., Town Hall, 
Lowestoft, M.O.H. Lowestoft U. and Port S.Ds. 
Proposed by E. Walford, seconded by R. Dudfield. 

Joseph Henry, M.D., Rochdale, M.O.H. Rochdale.U.S.D. 
Proposed by F. Vacher, seconded by C. E. Paget. 

E. F. Hall, M.D., Prescott, Lanes., M.O.H. Prescott 
U. and R.S.D. 
Propo.sed by J. Robertson, seconded byC. E. Paget. 

Herbert Peck, L.R.C.P., L.R.C.S., D.P.H., Wigan 
Road, Ormskirk, Lanes., M.O.H. Ormskirk, R.S.D. 
Proposed by E. Sergeant, seconded by C. E. Paget. 

Frederick Parker Moles, L.S.A. Lo^d., Croit's Bank 
Road, Urms^on, Manches er, M.O.H. Urmston, U.D.C. 
Proposed by C. H. TaUersall, seconded by C. E. Paget. 

Charles Edward Douglas, M.D., Winthank Bank, 
Cupar, Fife, N.B., M.O.H. Cupar, Fife. 
Proposed by A. Campbell Munro, seconded by R. Dudfield. 

William Berry, Applcton Cottage, Wigan, M.O.H. 
Wigan, D.C. 
Proposed by F. Vacher, seconded by R. Dudfield. 

George J. B. Hope, M. A., M.B., Scarborough, M.O.H. 
Scarborough, R.D.C. 
Proposed by J. R. Kaye, seconded by R. Dudfield. 

Thomas Herbert Littlejohn, M.B., CM.., D.P.H., 
Scarborough, M.O.H. Scarborough, U.S.D. 
Proposed by J. R. Kaye, seconded by R. Dudfield. 

Arthur Tuxford, M.D., 12, Wide Bargate, Boston 
Lines., M.O.H. Boston, U. and P.S.D., and Scossy 
R.D.C. 
Proposed by F. Vacher, seconded by R. Dudfield. 

M 



146 THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. 



Francis Stevens. M.R.C.S., D.P.II., 20, Nunhcad Lane, 
Peckham, S.E., M.O.H. Camberwell (Met.) Vestry. 

Proposed by F. Vacher, seconded by R. Dudfield. 
— . Adamson, M.O.H. Iletton-le-llole, U.D.C. 

Proposed by T. E. Hill, seconded by H. E. Armstrong. 
W. E. Harker, M.O.H, River Tyne, P.S.A. 

Proposed by R. Dudfield, seconded by H. E. Armstrong. 

As Ordinary Mcinhcrs. 
Groroe Newman, M.D., D.P.H., Camb., 20, Queen's 
Square, W.C. 
Proposed by F. J. Allan, seconded by R. Dudfield. 
T. B. Wilkinson, M.D., D.Sc. (Public Health) Ed., 
Westwood House, Oldham. 
Proposed by C. H. Tattersall, seconded by C. E. Paget. 
Edward Ferrand, M.D,, D.P.H., Brig. -Surg.-Lieut. -Col., 
67, Great Russell Street, W.C. 
Proposed by F. Vacher, seconded by R. Dudfield. 
Percy Targett Adams, F.C.S., M.R.C.S., D.P.H., 
Trinity House, Maidstone, Kent. 

Proposed by Matthew A. Adams, seconded by 
A. Newsholme. 

As Associates. 
William Hari'er Wioiiam, M.B., M.R.C.S., Muiivance 
House, Shre\vsl)ury. 
Proposed by F. J. Allan, seconded by R. Dudfield. 
H. Buckstone, Rev., Hope, Near Sheffield. 

Proposed by S. Barwise, seconded by R. Dudfield. 

5. To receive nominations for election as 
Fellows, Ordinary Members, and Associates. 

6. The adjourned discussion of the Report of 
the Council, re "Fixity of Tenure," will be re- 
sumed, when any Resolutions or other communi- 
cations from the Branches of the Incorporated 
Society will be considered. 

John C. Thresh, 

The Limes, Chelmsford. 
Reginald Dudfield, 
19, Blomfield Road, 

Maida Vale, VV 
j/^anuary 20///, 1896. 



Hon. 
Sees. 



The Hon. Secretaries have to announce that, at 
the Ordinary Meeting in March next, a Paper on 
" Diphtheria" will be read by Dr. Heaven, and at 
that of April there will be discussion on the Regu- 
lation of the Manufacture, etc., of Ice-cream. The 
Election of the President of the Incorporated 
Society for the ensuing session will take place at 
the April meeting. 

Provincial Meeting. — It is expected that the 
Annual Provincial Meeting will take place this year 
at Chester. The date has not yet been fixed, but 
will most probably be the second or third Saturday 
in June. It is hoped that by this early intimation 
a very large number of Members will be able to 
arrange to be present. 

In connection with an outbreak of enteric fever 
at Rennes, it has been alleged that the infection 
was conveyed by the ice used to cool the 
champagne. 



PROCEEDINGS OF THE INCORPORATED 
SOCIETY OF MEDICAL OFFICERS OF 
HEALTH. 

A meeting of the Incorporated Society of Medical 
Officers of Health was held at No. 197, High 
Holborn, on Thursday, January i6th, 1896. 
Present : The President (Dr. F. Vacher) in the 
chair, and the following Fellows and Members : — 
Drs. S. R. Lovett, Oliver Field, Sidney Barwise, 
W. T. G. Woodforde, J. Nield Cook, Henry 
Armstrong, Charles E. Paget, J. S. Tew, Reginald 
Dudfield, A. Bostock Hill, W. Gruggen, H. R. 
Kenwood, Alfred Ashby, and W. W. Stainthorpe. 
The minutes of the last meeting of the Society, 
held on the 21st November last, were read, 
approved, and signed by the Chairman. 

Correspondence. 

By permission of the meeting, the Hon. Secretary 
submitted a communication from the Hon. 
Secretary of the North-Western Branch, enclosing 
the following resolutions : — 

At a meeting of the North-Westem Branch of the 
Incorporated Society of Medical Officers of Health, 
held in Manchester on December 13th, it was resolved 
that in the interest of the public health an amendment 
of the law is urgently required so as to secure (i) A 
registration with local authorities of all persons carrying 
on the trade of manufacturers or purveyors of ice-cream; 
(2) An inspection of all places where ice-cream is 
manufactured or stored ; (3) A regulation of the light- 
ing, ventilation, cleansing, drainage, and water supply 
of such places ; (4) The cleanliness of ice-cream stores 
and shops, and of all vessels used for the manufacture, 
storage, or sale of ice-cream ; (5) Precautions to be 
taken for protecting ice-cream against infection or con- 
tamination ; (6) Power of local authorities to make 
regulations for the purposes aforesaid or any of them, 
subject to such conditions (if any) as the Local Govern- 
ment Board may prescribe. 

That the Council of the Incorporated Society of 
Medical Officers of Health be requested to make an 
application to the Local Government Board urging an 
alteration of the law so as to secure the objects intended 
by the previous resolution. 

Resolved, on the motion of Dr. Paget, seconded 
by Dr. R. Dudfield, that Dr. Jaspar Anderson be 
requested to open a discussion on the subject to 
which the resolutions relate, at a future meeting of 
the Society. 

Report of Council. 

Your Council beg to report — 

{a) That they have directed the Hon. Secretary 
to communicate with Mrs. Newsholme and express 
the great regret with which the Society has received 
the news of Dr. Newsholme's illness, and their best 
wishes for his speedy recovery. 

{/>) That they have requested Dr. Reginald 
Dudfield and Dr. Legge to undertake the temporary 
Editorship of the Journal, and have empowered! 
Dr. Dudfield to take all necessary action in thej 
matter. 



^^j.^ ii^ v^wxvx v^i\.n.i juiiy owv^xi^xx Kjr iy}.ii,LJi\^.t\u Kjrri\^ci^s KJr nUiAl^ l rl. 



147 



(c) That they have presented a petition from the 
Society to the President of the Local Government 
Board asking that the information to be obtained 
at the forthcoming quinquennial census may be 
extended so as to include particulars of age and sex. 

(d) That they have received a report from the 
Committee appointed by them to consider the 
question of " Fixity of Tenure," and recommend the 
following resolutions for adoption by the Society : — 

1. That in the opinion of this Society it is desirable 
in the interests of public health that medical officers of 
health in the provinces should, subject to the approval 
of the Local Government Board, have the same fixity of 
tenure as medical officers in the Metropolis. 

2. That in the opinion of this Society, the Local 
Government Board should be asked to make fixity of 
tenure dependent on such an arrangement of sanitary 
areas and salaries as will secure medical officers of health 
of suitable qualifications, and the carrying out of 
necessary sanitary improvements. 

3. That the Council be instructed to arrange for a 
deputation to the Local Government Board, similar to 
that which waited on the Board at the beginning of last 
year, and that the British Medical Association, the 
Sanitary Institute, and the British Institute of Public 
Health be invited to join in such a deputation. 

4. That the Council be instructed to ask the Branches 
of the Society to exert at the proper time all the 
influence they can bring to bear upon the Members of 
Parliament representing constituencies within their 
districts, for the accomplishing of the end in view as set 
forth in the preceding resolutions. 

(e) That the Council have decided to increase 
the grant for the payment of contributors to the 
Journal from ^50 to ;^62 los. for the ensuing 
year. 

Resolved, on the motion of Dr. Woodforde, 

seconded by Dr. Paget, that the same be received. 

Resolved unanimously that paragraphs {a), (d), 

(c) and {e) be approved and adopted. 

The meeting being about to consider paragraph 

(d) it was resolved that the remaining items on the 
agenda be first disposed of. 

Election of Candidates. 
The meeting then proceeded to the election of 
Fellows, Members, and Associates. 

The following gentlemen having been duly 
nominated as candidates, a ballot was taken, and 
they were declared by the Chairman to have been 
unanimously elected. 

As Fellows. 
Shillito, Wm. Alsope, M.R.C.S., L.S.A., Wilsden, near 

Bradford, M.O.H. Wilsden U.S.D. 
RicHARDS0N,W. J., M.D., M.Ch.,Clonavon,Ravensthorpe, 

M.O.H. Ravensthorpe U.S.D. 
Mackay, J. D., B.A., M.B., CM., The Cloisters, Knares- 

borough, M.O.H. Knaresborough U.S.D. 
Jones, W. Makeig, M.R.C.S., L.S A,, D.P.H. Camb., 

Wath-upon-Dearne, M.O.H. Swinton U.S.D. 
Wiley, A. O., L.R.C.P. Ed., L.R.C.S. I., Newton House, 

Knaresborough, M.O.H. Knaresborough R.S.D. 
Stuart, J. A. Erskine, L.R.C.P., High Street, Heck- 

mondwike, Normanton, Yorks, M.O.H. Batley U.S.D. 
HiLLMAN, G. B., L.S. A., Whitwood Mere, Castleford, 

M.O.H. Whitwood U.S.D. 



Hargreaves, J. A., M.B., O.M.,Wetherby,Yorks, M.O.H. 
Wetherby R.S.D. 

Ross, James A., MB., CM., St. Mary's, Penistone, 

M.O.H. Penistone U.S.D. 
Stevenson, Robert, L.R.C.P., L.R.C.S., Marsh Villa, 

Rothwell, near Leeds, M.O.H. Rothwell U.S.D. 
Buck, Joseph, L.R.C.P., L.R.C.S., Melbourne House, 

Rothwell, near Leeds, M.O.H. Hunslett R.D.C. 
Shaw, R. Holgate, M.R.C.S., L.R.C.P., The Grove, 

Liversedge, M.O.H. Liversedge U.S.D. 
Nightingale, John, M.B., CM., The Green, Hor-forth, 

M.O.H. liorsforlh U.S.D. 
Spowart, J., L.R.C.P. Edin., D.P.H. Camb., 249, Pits- 
moor Rd., Sheffield, M.O.H. Wortley(2nd Div.) R.S.D. 
Wakelam, Edgar, L.R.C.P., L.R.C.S., Waterhead, 

Oldham, M.O.H. Springhead U.S.D. 
Collins, Henry Beale, M.R.C.S. Eng., L.S.A., D.P.H. 

Conj. Bd., Greenholme, Kingston Hill, M.O.H. 

Kingston U.S.D. 
Jolly, Robert William, M.R.C.S. Eng., L.S. A., 5, 

Bridge St., Peterborough, M.O. H.Peterborough U.S.D. 
Alexander, John, M.D., D.P.H., F.P.S. Glasg., Wel- 
lington House, Wick, M.O. PI. Caithness-shire and 

Royal Burgh of Wick. 
Bruce, William, M.D., The Castle, Dingwall, M.O.H. 

cos. Ro.ss and Cromarty. 
Cameron. J. A., M.D., B.Sc, Firhall, Nairn, M.O.H. 

Banff, Elgin and Nairn, combined. 
Chalmers, A. K,, M.D., D.P.H, Camb., 23, Kersland 

Terrace, Hillhead, Glasgow, M.O.H. Glasgow. 
Duncan, Eben., M.D., Queen's Park House, Crosshill, 

Glasgow, M.O.H. (retd.) Burgh of Crosshill. 
Graham, J. T., M.D,, 4, Athole Crescent, Perth, M.O.H. 

Perthshire. 
Littlejohn, Sir Henry, M.D., City Chambers, Edin- 
burgh, M.O.H. Edinburgh. 
McVail, J. C, M.D., D.P.H. Camb., 24, George Square, 

Glasgow, M.O.H. cos. Stirling and Dumbarton. 
Nasmyth, T. G., M.D., D.Sc, D.P.H. Camb., St. 

Michael's, Cupar, Fife, M.O.H. Fife and Clack- 
mannanshire. 
Simpson, A., M.D., 4, King's Place, Perth, M.O.H. Perth 

City. 
Templeman, Chas., M.D., D.Sc. (Pub. Health), 8, Airlie 

Place, Dundee, M.O.H. Dundee. 
Garstang, T. W. H., M.R.C.S., L.S. A., Headingley 

House, Knutsford, Cheshire, M.O.H. Knutsford 

U.S.D. and Bucklow R.S.D. 

As Ordinary Members. 
Symons, Wm. Henry, D.P.H., 43, Marlborough Hill, 

St. John's Wood, N.W. 
English, Edgar, D.P.H., Doncaster. 
Richardson, J. N., L.S.Sc, Ilkley. 

Nominations. 
A number of candidates were then nominated 
for election at the next meeting. 

New Fellows. 
The Hon. Secretary reported that the follow- 
ing Members of the Society had, since their 
election, been appointed medical officers of health, 
and, ipso facto, became Fellows, viz. : — 
J. Howard Jones, M.D., B.Sc, M.O.H. Newport. 
E. P. Manby, M.D., D.P.H., Assist. M.O.H. Liverpool. 
S. NoY Scott, L.R.C.P., D.P.H., M.O.H. Plympton 
St. Mary R.D.C. 

M 2 



148 THE INCORPORATED SOCIETY OF MEDICAL OFFICERS OF HEALTH. 



Fixity of Tenure. 

The consideration of the Council's recommen- 
dations on this subject was then resumed. 

Resolved, on the motion of Dr. Bostock Hill, 
seconded by Dr. Armstrong, that the resolutions 
recommended for adoption be considered as a 
whole. 

It was moved by Dr. Facet, and seconded by 
Dr. WooDFORDE, that the recommendations be 
approved and adopted. 

Dr. BosTOCK Hill said that, although he had 
that afternoon been, before almost the same 
audience, in opposition, and had found a majority 
against him, he still felt it his duty to the Branch 
he represented to move that paragraph No. 2 be 
struck out. He agreed that it was desirable in the 
abstract for certain health appointments, as they 
at present e.xisted, to be modified ; but he sub- 
mitted they were not the body to originate such 
modifications. A very large number of medical 
officers of health in the country under this 
paragraph would be excluded from the benefits of 
fixity of tenure, and in their interests he felt 
bound to protest against the Society putting its 
seal on that resolution. It was a question which 
ought to be dealt with by the branches, exclusive 
of the Metropolitan Brancn. He did not say that 
from any disrespect to the Metropohtan Branch — 
one of the most important branches of the Incor- 
porated Society — but simply because their interests 
were already secured, and they were outside the 
scope of the resolutions. Therefore he thought 
they ought to look and see what were the inten- 
tions of those branches who had considered the 
question. Their intentions would be found 
in a series of resolutions which had been 
before the Council, and in those resolutions 
fixity of tenure alone was demanded. He was 
sorry that some of his friends thought he was 
obstinate in this matter, but he represented the 
members of one of the largest branches, and he 
knew that 90 per cent, of those members would be 
against this resolution. How could he, then, do 
otherwise than voice their opinions ? This resolu- 
tion was put in as the outcome of a communica- 
tion sent in by 07ie member of the Society — a 
member for whom they bore the highest respect — 
but only (?w member ; and he maintained that, that 
being so, they had no right to go beyond the reso- 
lutions actually passed by the branches. He was 
not going into the question of whether these small 
appointments were desirable or not. They repre- 
sented various interests there — the interests of 
those who held small appointments as well as those 
who held large ; and they had no right to send out 
to the world a suggestion that some of their 
colleagues held appointments which it was undesir- 
able to make permaiient. They were there, as 
shown by their Articles of Association, among other 
thmgs, to help forward the interests of all members ; 
and he maintained that the adoption of such a 



resolution as paragraph No. 2 would not only not 
do that, but would actually jeopardise the interests 
of a very large number of the members of the 
Society. The cases quoted in support of the 
Council's recommendations were, with one excep- 
tion, such as they would imply should 7iot be safe- 
guarded. He strongly objected to paragraph 
No. 2 being inserted as the opinion of the Society. 
He was certain it was not so. They were speaking 
as the mouthpiece of 1,200 public officials ; and, 
sitting round that board, they had not one man 
there who held one of these small appointments 
which, by implication, they would ask the Local 
Government Board not to sanction. If they 
adopted this resolution they would jeopardise the 
position of the Society. 

Dr. W. W. St.\inthorpe seconded the amend- 
ment. 

Dr. Barwise said since the meeting of the 
Council in the afternoon he had gone very fully 
into the question with Dr. Armstrong, and he 
thought it would have been better if No. 2 had 
been left out altogether. It was unnecessary, be- 
cause in No. I they said — 

I. That in the opinion of this Society it is desirable 
in the interests of public health that medical officers of 
health in the provinces should, subject to the approval of 
the Local Government Board, have the same fixity of 
tenure as medical officers in the Metropolis. 

He would move, as a further amendment, that in 
place of paragraphs Nos. i and 2 the following be 
substituted : — 

That in the opinion of this Society it is desirable in 
the interests of public health that medical officers of 
health in the provinces should have the same fixity of 
tenure of office as medical officers of health in the 
Metropolis, subject to the Local Government Board 
miking, when necessary, such arrangements as in their 
discretion they may see fit for grouping sanitary dis- 
tricts, as new medical officers of health are from time to 
time appointed, and that the resolution be sent to the 
several branches for confirmation. 

He thought paragraph No. 2, as worded in the 
Council's recommendation, was, he might almost 
say, offensive. It spoke of "suitable qualifications." 
Now, what was the most suitable qualification for 
a medical officer of health ? He would say tact, 
and salary would not get tact. The paragraph 
seemed to imply that there were a considerable 
number of medical officers of health who had not 
got the necessary qualifications to carry out their 
work, and that as a result the necessary sanitary 
improvements were not carried out. His amend- 
ment simply suggested that as fresh appointments 
became necessary the Local Government Board 
should, where they saw fit, make arrangements for 
grou])ing the districts. 

Dr. .'Vrmsironc; seconded Dr. Barwise's amend- 
ment pro formn. He would not have voted for 
paragraph No. 1 at the Council meeting if he had 
nut counted on No. 2 being passed also. The Com 
mittee who had considered the matter, after 



J 



FIXITY OF TENURE. 



149 



taking great pains, came to the conclusion that para- 
graph No. 2, which was proposed by Dr. Manley, 
was the best way out of a difficulty ; but he now 
thought Dr. Barwise's proposal would help them, 
and therefore for the sake of harmony he would 
agree. He did not like a member to assert that 
he came there as a mere delegate ; that put them 
too much on the level of a trade union. Ten 
or fifteen years ago he brought the subject of the 
status of medical officers of health before the 
Society, and he had since then consistently upheld 
his position, and he was not going to depart from 
it now. If Dr. Hill's amendment was carried, they 
would by their own act be confirming and helping 
to perpetuate a very bad system, viz., that of small, 
miserable appointments. 

Dr. Paget said the Local Government Board 
already had the power they proposed to give them. 
He could see nothing in the amendment which 
would give the Local Government Board power to 
act without an application from one or other of the 
districts asking for combination. The amendment 
did not go far enough. 

The amendment of Dr. Barwise was then put to 
the meeting, and there appeared : — 

In favour of same ... ... ... ... 3 

Against ... ... ... 5 

The Chairman declared the same to be lost. 

Dr. AsHBY thought it would be useless to take 
any action at present. They should wait until 
there was some legislation on public health, and 
then concentrate all their efforts to get a clause as 
to tenure inserted, and therefore he would move as 
a further amendment : — 

That the question of "fixity of tenure" be deferred 
until such lime as a Bill for amending or consolidating 
the Public Hea'th Acts shall be brought forward, when 
an attempt should be made by the locorporated Society 
of Medical Officers of Health to have a clause inserted 
in it similar to the one in the Public Health (London) 
Act, 1891, dealing with that subject. 

Dr. J. NiELD Cook. — For the sake of debate I 
will second that. 

Dr. Kenwood could not see that any great good 
was likely to come to them if these resolutions 
were passed. In resolution No. 3, it said : — 

That the Council be instructed to arrange for a depu- 
tation to the Loc?l Government Board, similar to that 
which waited on ihe Board at the beginning of last year, 
and that the British Medical Association, the Sanitary 
Institute, and the British Institute of Public Health be 
invited to join in such a deputation. 

He would like to know whether any fruit came 
from that deputation. The Local Government 
Board were very full of promises, and did very 
little indeed. He therefore supported Dr. Ashby's 
amendment. 

Dr. R. DuDFiELD said Dr. Kenwood must have 
forgotten that they would never get anything unless 
they worried, and every time they went to the 
T>ocal Government Board they gained a step, be- 
cause the Government would get so tired of them. 



that they would be given what they wanted to get 
rid of them ; but he thought they got a great deal 
last year, because the then Secretary of the Local 
Government Board stated he was entirely with 
them, so they had secured Sir Walter Foster's 
support. 

Dr. BosTOCK Hill said if they adopted Dr. 
Ashby's suggestion it would put them in a very in- 
vidious position. Were they to remain in the 
background while other bodies took action ? 

On Dr. Ashby's amendment being put to the 
meeting, there appeared : — 

In favour of same ... ... ... ... 3 

Against ... ... ... ... ... 6 

and the Chairman declared the same to be lost. 

Dr. Stainthorpe moved as a further amend- 
ment that the Council's recommendation, with the 
other information on the question that the Hon. 
Secretary had laid before the Council that after- 
noon, should be sent to the branches for their con- 
sideration, with a request that their opinions on 
the same might be forwarded to the Hon. Secretary 
in time for consideration by the Society at the 
meeting in February. 

Dr. LovETT seconded. 

Dr. BosTOCK Hill, by permission of the meet- 
ing, withdrew his amendment in favour of that 
moved by Dr. Stainthorpe, and 

Dr. Paget, by permission of the meeting, with- 
drew his motion for the adoption of the resolutions, 

Whereupon Dr. Stainthorpe's amendment became 
the substantive motion, and, on its being put to the 
meeting, it was declared by the Chairman to be 
carried fiem. con. 



PROCEEDINGS OF THE NORTH-WESTERN 
BRANCH OF THE INCORPORATED 
SOCIETY OF MEDICAL OFFICERS OF 
HEALTH. 

The ordinary monthly meeting of this Branch was 
held in the rooms of the Chemical Club, Man- 
chester, on December 13th, at 4 p.m. 

The following Members were present :— Drs. 
Vacher (President), Anderson, Barr, Edlin, 
Howarth, Graham, Jones, Marsden, Paget, 
Pilkington, Robertson, and Wheatley. 

The minutes of the last meeting were read and 
confirmed. 

Dr. F. P. Moles and Dr. H. Ashton were duly 
elected Fellows, and Dr. J. B. Wilkinson was 
elected a Member. 

The following nominations were then read : — 
Joseph Henry, M.D., M.O.H. Rochdale— pro- 
posed by Dr. Vacher, and seconded by Dr. Paget ; 
Herbert Peck, L.R.C.P., L.R.C.S., D.P.H., 
M.O.H. Ormskirk— proposed by Dr. Sergeant, 
seconded by Dr. Paget ; E. F. Hall, M.D., M.O.H. 
Prescott R. and U.D. — proposed by Dr. Robertson, 



ISO 



PROCEEDINGS OF THE NORTH-WESTERN BRANCH. 



and seconded by Dr. Paget ; T. W. H. Garstang, 
M.R.C.S., L.S.A., M.O.H. Knutsford— proposed 
by Dr. Vacher, and seconded by Dr. Paget. 

The Inspection of Food and the Places 
WHERE IT IS Manufactured and Stored. 

BY 

Dr. Anderson, M.O.H. Blackpool. 

The inspection of food is undertaken by the 
medical officer of health and the inspector of 
nuisances of a district, or by an inspector specially 
appointed as an inspector of nuisances, to carry 
out the duties of food inspection imposed by the 
Public Health Acts, and any officer of the local 
authority appointed by Section 12 of the Sale of 
Food and Drugs Act, 1875. Everyone, I think, 
will admit that at the present time inspection 
under the existing statutes is not carried out in the 
systematic and complete manner that it should be. 
This arises from the multifarious duties of the 
officials, and the difficulty in inducing sanitary 
authorities to enlarge the staff of inspectors. 
Bakehouses are regularly inspected in many places, 
but often the inspection is of a very perfunctory 
nature. The kitchens of hotels, restaurants, and 
such like places where food is prepared for public 
use, are not subject to any systematic inspection, 
though they may be situated in basements, and be 
in a very dirty and insanitary condition. I take it 
that the provisions of Sections 116 and 118 of the 
Public Health Act, 1875, ^"d of the Section in the 
adoptive Act (the Public Health Amendment Act, 
1890) are sufficiently wide to enable the officials 
to enter such places for the purpose of inspecting 
food in the course of preparation for sale, and 
intended for the food of man. The importance of 
this inspection I cannot enforce in better terms 
than in the concluding sentences of an able paper 
by Dr. Ballard, on "Meat Infections — Food 
Poisoning," read before the International Congress 
of Hygiene in 1891. After detailing the histories 
of fourteen cases of poisoning by food, and showing 
that in most cases the food obtained its poisonous 
properties after being cooked, he says : " But the 
grand precaution of all is the very commonplace 
one signified by the word cleanliness. Every 
factory where pork is converted into brawn or 
hams ought to be so arranged that light and a 
draught of air can penetrate freely everywhere; 
there should be no corner where refuse matter can 
lodge and become a centre for the cultivation of 
morbid micro-organisms in filth ; the rise of ground 
air should be obviated by cement under the pave- 
ment or flooring ; and the i)lace should be kept 
scrupulously clean and free from the incursion of 
seWer air, or putrid emanations of any kind. 
Kitchens and, above all, i)antrics, and places where 
fooi is stored in hotels, public refreshment rooms, 
or pastrycook's premises, and in private houses, 
should be similarly cared for. It should be held 
to be part of the business of conservators of public 



health to see that these rules are observed, as well 
as the business of every master or mistress of a 
family." 

It is not my intention, nor have I the time to 
treat exhaustively of the subject for discussion to- 
day, but before entering upon the portion of the 
subject which your Committee has been kind 
enough to allow me to open this discussion with, 
I wish you to permit me to allude to a case which 
occurred to me a few weeks ago. I mention this 
as showing one of the defects of the present , 
legislation. I seized the carcase of an animal 
which was admittedly affected with tuberculosis in 
a marked degree of the so-called generalised form, 
and though I gave evidence that in my opinion it 
was unfit for the food of man, and was backed up 
by the evidence of authorities like Drs. Sergeant 
and Vacher, yet without any medical evidence of 
the contrary kind, the magistrate — and that a 
medical man — gave the carcase back to the 
butcher, and only allowed me to retain the viscera. 
An action for the illegal seizure of meat is now 
threatened, under the 308th Section of the Public 
Health Act, and the damages which are claimed 
are made up partly of damage through loss of sale 
of meat, and partly of expenses in defending the 
case at the hearing before the magistrate. As far 
as I can find out from the Birkenhead case, which 
was taken to the Court of Appeal, we are only 
liable for the costs of the defence ; but I should 
like to have the opinions of members of the 
Branch on this point. But what I more particu- 
larly wish to bring out is that the medical officer 
of health should not be put in such a position that 
his action arising from special knowledge of the 
subject should be able to be over-ridden by a 
magistrate who is ignorant of the elements of meat 
inspection, and that in such cases of conflict of 
opinion there ought to be some expert who might 
be called in by the magistrate to give him his 
opinion upon the meat in question as an assessor. 
Such an opinion has, I believe, long been that of 
our esteemed President. 

To pass now to the immediate object of this 
paper. In connection with my official duties I 
had brought prominently under my notice the 
dangers to public health which might result from 
the present conditions under which ice-cream is 
manufactured, stored, and retailed. 

Through com|)laints received of diarrhcea and 
enteric fever having been caused by the con- 
sumption of ice-cream, I instituted an investigation, 
but was prevented from arriving at positive con- 
clusions by the lateness of the period when I was 
informed of the illnesses. However, I found that 
there was no evidence of enteric fever having_ 
resulted therefrom, and the complaint seems tc 
have been made under the impression that ice wa 
a component of this delicacy. I could not, or 
the other hand, assert that severe gastroenteritis 
had not been caused thereby, although I cam< 



THE INSPECTION OF FOOD. 



151 



across some people who were affected who had 
not had any of the commodity. Samples of ice- 
cream were analysed for metallic poisoning, but 
no traces of metals were found. The inquiry was 
made into the methods of conducting the business, 
and the premises where the manufacture and sale 
was carried on inspected. The business is largely 
in the hands of the Italians, and I must say that in 
all such cases the places were filthy, the habits of 
the people disgusting, and no proper safeguards 
had been thought of for storing the commodity 
after it was made until used. Then, again, there 
are a large number of people who, in the summer, 
add to their earnings by selling this article from 
stalls on the sands and elsewhere. 

They live in four-roomed houses mostly, which 
are at that period of the year not only occupied by 
the family, but often also by lodgers, so that there 
is a tendency for overcrowding to exist. I found 
that milk, eggs, sugar, and a little cornflour were 
used in every case, and in only one case was a 
little colouring matter added. The eggs used 
differed in their freshness, but as far as I could 
learn, precautions were taken to break each egg in 
a separate vessel, so that if it were rotten, it would 
not be added to the general mass. 

The mixture is gradually brought to a boiling 
temperature, and maintained thereat for about half 
an hour, until it has gained the requisite consistency. 
This boiling process is conducted in the kitchen, 
either on an open fire, or over a gas-stove in a 
brass vessel or cast-iron pan. The process is 
usually conducted in the evening, and the manu- 
factured product is allowed to cool during the 
night, generally in an earthenware mug, either in 
the kitchen, scullery, or front living-room. As a 
rule, the mug is left uncovered. In some instances, 
on my advice, a properly constructed safe was 
erected in the back-yard. Apart from the nature 
of the utensils, and their cleanliness, used in the 
manufacture and storage, the condition of those 
used in its consumption must be considered. 
Here I must comment upon the great danger of 
the spread of infection, especially diphtheria and 
stomatitis, from the manner of its consumption in 
the streets. The sight of the little urchins crowd- 
ing round the stalls, eating greedily the delicacy 
without any spoon, and licking out the glasses with 
the tips of their tongues, would alarm anyone 
alive to the possibilities of danger from such 
practices. 

Sometimes the glass is not even washed before 
it is again filled for another young customer ; and 
in the other instances it is rinsed in a small 
quantity of water taken out in a pail from the 
vendor's abode in the morning. The glass may be 
dried on a towel, which rapidly becomes dirty 
when business is brisk. The water in the pail will 
not be changed more than twice a day, and it like- 
wise becomes polluted, and very liable to become 
infected. 



Last summer I had the places of manufacture 
and the stalls inspected daily, with very beneficial 
results upon the cleanliness with which the business 
was conducted ; and also the speedy removal of 
any insanitary condition from the premises. A 
list of the dealers was obtained and kept in a 
register. The names of 56 vendors were entered, 
and besides shops there were 102 stalls from which 
the article was sold, 

I propose to give shortly the literature of the 
subject as far as I have had an opportunity of 
looking it up. In the Lancet (Vol. II., 1879, 
p. 590) a graphic description is given of the dirt 
and overcrowding which existed in the Italian 
quarter in London, where icecream was exten- 
sively manufactured, and some cases of the presence 
of infectious diseases on the premises whilst the 
business was being conducted were noted. Dr. 
Vaughan, who discovered tyro-toxicon and tyro- 
toxine in cheese, found a very similar substance in 
some ice-cream which had given rise to most acute 
poisoning. 

Apart from this danger, there is that pointed out 
by Hull {Medical News, Philadelphia, Vol. LVIIL, 
p. 713) that all kinds of ice-cream act on zinc, 
and especially so when two metals are exposed to 
it, so as to form a closed circuit. Thus, a tin 
container with a galvani/oed spoon would, with the 
ice-cream, form a galvanic cell, and zinc would be 
dissolved from the spoon. If the cream becomes 
sour, or is flavoured with acid fruit juices, this 
action is increased ; therefore a wooden spoon 
should be used in place of a metal one. 

Smith reports on an ice-cream poisoning case in 
one of the reports to the Board of Health, Con- 
necticut ; and another poisoning case is reported 
upon in the report of the Board of Health, Massa- 
chusets, for 1S89. 

In the Annales d! Hygiene (Tome XXX., p. 47) 
Riche reports upon the employment of ice in 
alimentation in Paris, and there collects the 
evidence of bacteriologists as to various micro- 
organisms withstanding the effect of extreme cold. 
Thus Prudden found that after ninety-two days of 
freezing a large number of the bacilli of typhoid 
fever were still active. This has been confirmed 
by Chantemesse and Vidal, whilst Anton and 
Rieder have established the same result for 
numerous pathogenic bacteria. 

YA€\w{Lancet, Oct. 13th, 1894) published some 
bacteriological examinations of ice-cream. For the 
British Institute of Preventive Medicine, Macfadyen 
and Colwell have made an inquiry into the com- 
position of ice-cream {Lancet, Nov. 9th, 1895). 
"The average chemical composition of an ice- 
cream according to these investigations is as 
follows :— Total soHds, 26-5 per cent, ; fats, 4 per 
cent.; sugar, 12 per cent.; starch, 6 per cent.; 
albuminoids, 4 per cent. ; and mineral matter, 
o*5 per cent. Microscopical examination revealed 
the following delectables :— Bed bugs, bugs' legs, 



152 



PROCEEDINGS OF THE NORTH-WESTERN BRANCH. 



fleas, straw (bed), human hair, cats' and dogs' hair, 
coal dust, woollen and linen fibre, tobacco, scales 
of epithelium and muscular tissfle." " Shop samples 
were, as a rule, better as regards their bacterial 
contents than the street-barrow supplies, the 
maximum number of organisms found in the 
former being just over a million per cubic centi- 
metre, and in the latter seven millions. The water 
used in making the creams teemed with micrococci, 
bacilli, and spirilla, one sample containing over 
5,000,000 bacteria in one cubic centimetre (about 
twenty-five drops)." 

The subject is alluded to by Mr. Albert Smith, 
Analyst for Islington, and in the report by the 
Medical Officer of Health for the County Council 
of Lancashire for 1894. 

Some time ago the authorities in Glasgow tried to 
bring ice-cream vendors under the Dairies, Cow- 
sheds and Milkshops Order as purveyors of milk, 
but on appeal the case was dismissed. I think the 
facts which I have stated above, prove the urgent 
necessity for legislation upon the subject. One of 
the prime necessities is the compulsory registration 
of all ice-cream vendors, so that the premises 
occupied by them may be inspected and put in a 
sanitary condition before the business is commenced, 
and the cleanliness thereof and of the utensils may 
be ensured by frequent inspections on the part of 
the sanitary officials, afterwards. With that object, 
the Town Clerk of Blackpool proposed a resolution 
in similar terms to that with which this paper con- 
cludes, at the last meeting of the Municipal 
Corporations Association. This was seconded by 
the Town Clerk of Birmingham, who brought 
forward the results of Mr. D. Stanley's bacterio- 
logical examination of samples of ice-cream, 
purchased in Birmingham. The resolution was 
unanimously adopted. I wish now to strengthen 
this appeal to the Local (Government Board for 
further legislation, by asking this branch to send up 
similarly worded resolutions to the Council of the 
Incorporated Society of Medical Officers of Health, 
in the hojjc that that body will approach the Local 
Government Board. 

I have now the pleasure in proposing the 
following resolutions : — 

.\t ameetingof the North-Western Branch of the 
Incorporated Society of Medical Officers of Health, 
held in Manchester, on December 13th, it was 
resolved that in the interest of the public health, 
an amendment nf the law is urgently required so 
as to secure (I) A registration with local authorities 
or all persons carrying on the trade of manufac- 
turers or [mrveyors of ice-cream. (II.) An inspec- 
tion of all places where ice-cream is manufactured 
or stored. (IH.) A regulation of the lighting, 
ventilation, cleansing, drainage, and water supply 
of such places. (IV.) The cleanliness of ice-cream 
stores and shops, and of all vessels used for the 
manufacture, storage, or sale of ice-cream. (V.) 
Precautions to be taken for protecting ice-cream 



against infection or contamination. (VI.) Power 
for local authorities to make regulations for the 
purposes aforesaid, or any of them, subject to such 
conditions (if any), as the Local Government 
Board may prescribe. 

That the Council of the Incorporated Society of 
Medical OfiFicers of Health be requested to make 
an application to the Local Government Board, 
uiging an alteration of the law, so as to secure the 
objects intended by the previous resolution. 

Discussion. 

Dr. Marsden referred to the Birkenhead meat case, and 
said that it is decided that a sanitary authority is only liable 
for the amount of damage meat has sustained whilst ih their 
hands, if a mistake has been made. He mentioned the 
danger of contamination of ice cream during actual sale in 
the streets. He considered that the existing law, if properly 
enforced, would prevent much of the danger connected with 
this trade. 

Dr. Robertson drew attention to the fact that adultera- 
tion of food and drugs is not nearly so harmful as contamina- 
tion during storage and handling. 

Dr. Herbert Jones sugg-sted that it would serve all 
useful purposes if ice cream shops and places where ice- 
cream is made were included in the Dairies, Cowsheds, and 
Milkshops Order. 

Dr. Sergeant drew attention to the insanitary condition 
of small cookshops and restaurants, and the danger arising 
from them. 

Dr. Paget seconded the proposition of Dr. Anderson, 
and referred to a case of an ice-cream maker which had 
come under his notice. He spoke particularly of a mischief 
in connection with food supply which required attention — 
namely, the storage of fruit and vegetables in the living- 
rot ms of hawkers — especially in summer time. This was an 
important matter, as it was a very common practice ; but it 
was difficult to say what further legislative powers than those 
we possess would be likely to prove useful in dealing 
with it. 

The resolution was carried unanimously. 

Dr. Vacher thanked Dr. Anderson for his interesting 
paper. 

Dr. Anderson replied, and the meeting terminated. 



The ordinary monthly meeting of this branch was 
held in the rooms of the Chemical Club, Manchester, 
on Friday, January loth, at 4 p.m. The following 
members were present : — Drs. Vacher (president), 
Anderson, Graham, Hayward, Jones, Moles, Niven, 
Paget, Porter, Robertson, Sergeant, Wilkinson, and 
Wheatley. 

The minutes of the last meeting were read and 
confirmed. 

Drs. Henry, Peck, Hall, Garstang, and Jenkins, 
who were nominated at the last meeting, were duly 
elected members. 

On iMK Inspection and Influence of Milk 
Supplies. 

IIV 

John Rohertson, M.D., B.Sc, M.O.H. St. IFclcns. 

Judging from the existing condition of cow- 
sheds, dairies, and milkshops throughout England 
and Scotland, and from an analysis of the mortality 
statistics having a bearing on milk supplies, it 
appears that this subject is one which has not j 
received the attention which it deserves. 



ON THE INSPECTION AND INFLUENCE OF MILK SUPPLIES. 



153 



The reason for this neglect is not far to seek ; 
for although everybody is convinced of the absolute 
necessity of a pure milk supply, yet there are few 
who have an opportunity of acquainting themselves 
with the amount of harm done by impure milk ; 
and it is well-nigh impossible for these few to pro- 
duce satisfactory statistics. 

One feature, which has specially attracted my 
attention, when perusing the reports of medical 
officers to county councils, is the frequency with 
which complaint is made as to the laxity with 
which the Dairies, Cowsheds, and Milkshops 
Order is administered in many districts. Again, 
it is in rural areas that the greatest amount of 
indifference is shown ; yet these are the areas 
from which the largest portion of our milk supplies 
and milk products is derived. 

That the consumption of cows' milk is a fairly 
frequent cause of sickness in the human subject 
need not here be discussed. The variety of ways 
in which milk becomes hurtful, and the probable 
amount of harm done, are points to which 1 would 
now specially draw your attention. 

First, milk may be unwholesome by reason of its 
containing constituents derived from the cow. It 
is well known that the milk of newly-calved cows 
does prove irritating to the alimentary tract of 
young infants. I have heard of several instances 
where such illness was attributed to this cause, and, 
I think, with some good reason. Recently a 
sample of milk was sent to me, which was said to 
have produced illness in a child. Analysis showed 
the sample to contain upwards of twenty per cent, 
of solids, over twenty-two times more milk albu- 
minoids than usual, and about one-half the amount 
of milk sugar which is usual. Microscopically, it 
contained very numerous colostrum corpuscles and 
other epithelial structures. Some dairy companies 
in this country, and many on the Continent, specify 
in their contracts that four to seven days shall elapse 
after calving before the milk be supplied to them ; 
or, what amounts to the same, that the milk 
supplied shall not coagulate on boiling. 

Again, there can be no doubt but that the 
ingestion of certain articles of food by the cow has 
the power ofrendering milk unsuitable for children. 
It is probable that the nature of the food of cattle 
has a far greater influence on the milk than is 
generally believed. The frequency with which 
breast-fed children are affected, as a result of some 
indiscretion on the part of the mother in regard to 
her diet, is, I think, very suggestive. It has become 
a fashion among medical men and nurses, when 
prescribing cows' milk as a food for infants, to 
advise, that mixed milk be supphed, thereby avoid- 
ing the variations in the quality of individual cows. 
Certain dairy companies specify that no sour 
brewers' grains, and such like foods, be given to 
the cows supplying them with milk. 

Certain diseases are undoubtedly conveyed from 
cows to the human subject by means of milk. 



I believe that the most serious of these is tubercle, 
from tubercular udder disease. This disease is 
by no means a rare one in the udder of milch cows. 
It, however, varies in frequency in different parts of 
the country. In a majority of such cases the 
tubercle bacillus can be demonstrated in the milk. 
Experimentally such milk has been found by many 
observers to be eminently capable of producing 
tuberculosis in animals. Dr. Martin, in his evidence 
before the Royal Commission on Tuberculosis, 
said : " The milk of cows with tuberculosis of the 
udder possesses a virulence which can only be 
described as extraordinary." Dr. Woodhead has 
spoken in similar terms, as a result of his very 
valuable work at Edinburgh, and later from his 
investigations undentaken at the request of the 
Royal Commission on Tuberculosis. 

Numerous continental experts have shown the • 
extraordinary virluence of such milk. In my own 
district, where, I am sorry to say, the inspection of 
cows is not as efficient as I should like it, two cows 
were found during 1895 with very advanced tuber- 
cular udder disease, and in both cases tubercle 
bacilli were found in the milk. The dairyman in 
both of these instances had the cows slaughtered. 

Tuberculosis, in situations other than the udder 
of milch cows, does not seem, either from physiolo- 
gical reasons, or the results of actual experiments, 
to be Hable to produce disease in the consumer of 
such milk. I am bound to admit that several 
authoriiies hold opposite opinions in this respect. 
It cannot be denied, however, that it is highly 
undesirable to have such cows in a cowshed, — ist, 
on account of possible danger to the milk ; and 
2nd, on account of danger to the rest of the herd, 
and consequent loss to farmer or butcher. 

Pleuro-pneumonia, diphtheria, and scarlet fever 
in man have been said to have been due to 
diseased conditions in cows. 

Many general and a few local diseases of milk 
cows render the milk not very wholesome. 

Our powers under Section XV. of the Dairies, 
Cowsheds, and Milk-shops Order are compara- 
tively limited ; yet I am satisfied that much 
can be done in the way of stopping the sale of 
unsuitable milk, were the cows in shippons 
inspected. This inspection need not necessarily 
be done, in the first instance, by a veterinary 
surgeon. The dairyman has usually too great an 
interest at stake to risk any exposure, and generally 
yields on a reasonable case being demonstrated to 
him. 

I believe that by proper regulations as to air 
space and ventilation, more can be done to 
diminish bovine tuberculosis than by any other 
known means, except the isolation or slaughter of 
diseased animals. When the enormous loss to this 
country every year is recognised, it seems difficult 
to understand why a determined effort has not 
been made before now to diminish its ravages. 

Our regulations, in St. Helens, insist on 800 



154 



PROCEEDINGS OF THE NORTH-WESTERN BRANCH. 



cubic feet of air space for each cow, with one 
square foot of inlet and outlet through ventilation 
for every i,ooo cubic feet of air space. 

As a result of this regulation several cow- 
keepers have left the district, and gone outside the 
boundary, where they can over-crowd their shippons, 
and where they can heat them up in a most un- 
wholesome way without being interfered with. 

Whatever amount of harm may be transmitted by 
the cow to her milk, I am satisfied it is absolutely 
trivial when compared' with the amount derived 
from the improper handling and storing of the milk. 

The harm I refer to is entirely due to the infec- 
tion of the milk by a large variety of micro- 
organisms, and its remedy is to be looked for in 
measures of cleanliness. 

I would like to insist on the teats and part of 
the udder, at least, being washed before milking. 
I think, too, that every milker should wash his or 
her hands before beginning to milk. I have 
examined the hands of many milkers and have 
found them often indescribably filthy,due to the dirty 
habit of not washing the hands, and of wetting the 
hands with milk before beginning. This custom 
of wet milking, as it is called, is said to be quite 
unnecessary by those whose opinions are most 
valuable. 

A cowshed should be kept scrupulously clean. 
It should be lime-washed twice a year ; it should 
have j)lenty of light ; a hard and impervious floor, 
with a gutter to take off liquid to an outside 
trapped gully. Some local authorities require the 
floor to be washed periodically, but this appears to 
me to be a little difficult of accomplishment. 

By such means, it is possible to keep the air in 
the cowshed sufficiently pure. I need scarcely 
point out how large a surface of the milk is 
exposed to the air of the shippon in the process of 
milking, nor how good a nutrient medium warm 
milk is for the development of microorganisms. 
I have had on several occasions strong evidence 
pointing to the fact that milk exposed to foul air, 
or probably specifically polluted air, does produce 
disease. Within the past three months, nine or 
ten cases of typhoid fever occurred in a milk 
.sujjply, and on examination it was found that four 
cows and twelve pigs were huddled together in a small 
shippon, the Hoor of which was covered with from 
one to three inches of liquid pig and cow manure. 
The cows were only taken into the shi[)pon to be 
milked, and the milk was taken directly to the < art 
for distribution. The evidence in this outbreak, as 
well as that in three previous ones, although n(;t 
absolutely conclusive, points to the probability 
of typhoid fever contagion occurring in dairy 
premises without the presence of any obvious 
contact with a patient suffering from typhoid fever. 

It is needless to add that the drainage of 
premises used for milk trade purposes should be 
efficient. It is well, too, that the manure heaj) 
should be removed some distance rom the cow- 



shed or dairy. In towns this is not possible, but 
the same object can be gained by reducing the 
size of the middenstead, so that no more than 
one or two loads can be stored, and by con- 
structing it so as to prevent percolation. 

There formerly used to exist in my district 
several middensteads, abutting on dairy premises, 
which contained eight or ten loads of manure, and 
which were so constructed as to facilitate decom- 
position. 

From the cowshed the milk should always be 
taken to the dairy or milk store, and there the 
cans should be cooled. The importance of this 
cooling is not recognised in this country. Such a 
cooling has a very marked effect in retarding the 
growth of micro-organisms of all kinds, and thereby 
enabling milk to be kept for much longer periods 
in a sweet condition. 

The question of water-supply is one of the most 
difficult in relation to country farms. It is essen- 
tial that it should be abundant and easily obtain- 
able, and that the source from which it is derived 
should be such as to preclude the possibility of 
pollution. A very considerable supply is necessary 
to enable the water in the cooling tank or refrige- 
rator to be changed often enough, and to enable 
milk vessels to be kept clean and well scalded. 

Milkers, or other dairy hands who are ill, should 
not be allowed to work. Every sanitary authority 
can, I think, effectively deal with notifiable infec- 
tious diseases occurring in dairy premises ; but in 
the case of some other diseases, such for instance 
as diarrhoea or phthisis, it is rather difficult to 
insist upon i)rcventive measures. 

The intermediate milkshop is often a source of 
danger to the milk. 

Here again the regulations regarding the cleanli- 
ness of milk vessels should be scrupulously carried 
out. In shops which are used for the sale of 
articles other than dairy produce, I have always 
insisted that the milk shall be so stored that no 
dust can fall into it. This is generally obtained 
by getting the occupier to erect an open cupboard 
having a sloping roof, the inside walls of which 
are regularly whitewashed. Such a sloping roof 
ensures that no other articles are stored over the 
milk. Many small milkshojis exist in my district 
in cottages, where the front room is used as a 
shop, where paraffin, vinegar, and a host of other 
incompatiblcs are sold. The room behind this is 
generally used as the living-room for the family, 
and this freely ventilates into the milkshop. 

But perhaps the greatest amount of harm to 
milk is derived in the house of the consumer, 
and is due to the fillhy vessels used for receiving 
and storing the milk, and the unsuitable places in 
which milk is often kej)t. Unfortunately we have 
very little control over this. 

I have made it a rule for many years past to 
examine, whenever an opportunity presented itself, 
the feeding-bottles for young children and other 



ON THE INSPECTION AND INFLUENCE OF MILK SUPPLIES. 



155 



milk vessels in the houses of the lower classes ; and 
I am quite certain that a large amount of harm is 
done by the carelessness displayed in the clean- 
liness of these vessels. 

From an inquiry into the sanitary condition of 
premises where 315 deaths from infantile diarrhoea 
occurred in my district during the past three years, 
it was found that of children under 3 months 
of age 85" 16 per cent, were bottle-fed, and 14*8 
breast-fed; between 3 and 6 months of age 85 "6 
per. cent, were bottle-fed, and 14*4 were breast-fed. 
These figures correspond very closely with those 
obtained by the Medical Officer of Health of 
Liverpool in his valuable investigation into fatal 
cases of diarrhoea. 

They are most suggestive, I think, of the influence 
which a dirty cow's milk exerts on the unfortunate 
infants, but they do not indicate the extent of the 
harm in such a forcible way as do the actual ob- 
servations made on the premises. This question of 
infant-feeding is, perhaps, outside the subject of this 
paper, but it is so closely bound up with the ques- 
tion of pure milk that I was tempted to refer to it. 

One method of preventing contamination during 
transit, which appears to work very satisfactorily 
on the Continent, is that of supplying milk in 
sealed bottles. Such an arrangement prevents all 
contamination during transit and delivering, and 
prevents storage in unclean vessels. It does not 
seem that it has been necessary in such cases to 
raise the price of milk. In many such towns the 
milk vendors also supply sterile milk in bottles, so 
Arranged that all that is necessary is that the milk 
should be diluted with boiled water, and the 
stopper replaced by a nipple. 

One great difficulty in the way of carrying out 
the Dairies, Cowsheds, and Milkshops Order- is the 
fact that in a large number of districts the 
Contagious Diseases (Animals') Act is worked by 
the police, who have not the interest or training 
necessary for the work of inspection of cowsheds 
and dairies. It appears to me that a specially 
trained sanitary inspector is the proper person to 
carry out this work, rather than a veterinary 
inspector. It will be necessary, of course, to 
obtain the assistance of a veterinary inspector 
when the case may require it. 

I am tempted here to refer to a fraud which is 
being perpetrated very extensively at present, and 
which is due mainly to the use of the milk 
separator. I refer to the condensing of skimmed 
milk, and its sale to the public as " condensed milk." 
Infants fed on such must of necessity suffer. In a 
recent article on the composition of condensed 
milks in The Analyst^ it is stated that of fifty 
different brands sold in this country, no less than 
twenty-four were of condensed skimmed or 
separated milk. 

For some time past I have felt that the inspec- 
tion of dairies, cowsheds, and milkshops was some- 
what imperfectly carried out in my distric*^. This 



was due to several causes, but among the chief of 

these was the fact that the inspector had so much 
to look after that his visit was often at long inter- 
vals ; and, when made, it was often a very hurried 
one. In order to make the inspection more 
complete, I intend to have pocket-books printed, 
so that the information may be obtained very 
much in the same way that the Canal Boats 
Inspector obtains his information ; and I hope 
that in this way the inspection of dairies, cowsheds, 
and milkshops will be more regularly carried out. 

The following is a copy of the proposed Instruc- 
tions to Inspectors, and of their Queries : — 

INSTRUCTIONS TO INSPECTORS. 

In examining and reporling on any cow whose milk is 
being sold, it must be understood that no opinion is to be 
expressed to the owner or his servants under any conditions 
whatever. 

The medical officer will, if necessary, direct the veterinary 
inspector to visit and report on any such cow. 

The inspector will notice specially whether the udder 
shows any signs of tubercular disease (usually to be felt as a 
hard lump or lumps in the back end of the udder). 2nd. 
Whether any ulceration or inflammation of the teats exist. 
Whether the glands under the skin of the groin or armpit 
are enlarged. 

He will also inquire whether any cow has calved during 
the previous seven days ; and if any such exist, he will 
inquire as to whether the milk is being sold. 

Careful observations and inquiries made with discretion 
will often elicit the fact that some of the cows are suffering 
from other diseases which render it undesirable that the 
milk should be sold. 



Situation of cowshed. 

Date and time of inspection. 

Number of cows for which registered. 

Number of cows at time of inspection. 

Number of other animals. 

Number of cows stated to be sick. 

Report on any stated or observed to be sick. 

Are cow's udders cleansed before milking ? 

Are hands of milkers washed before milking ? 

Is lighting sufficient ? 

Are ventilators in working order ? 

Condition of walls. 

Condition of floors. 

Condition of drainage. 

Is water supply sufficient and good ? 

Condition of middenstead. 

Has it been emptied sufficiently often ? 

Filth nuisances within fifty feet of a cowshed or dairy. 

Is milk cooled before being sent out ? 

Is milk store kept clean ? 

Has floor been washed daily? 

Condition of walls. 

Number of milk vessels which do not appear to have been 

" scalded " daily. 
Report fully any contravention of regulations, orders, or 
statutes. 

(Signed) 

inspector. 

Discussion. 
Dr. Sergeant emphasised the importance of securing the 
greatest cleanliness in cowsheds. The filth, want of sufficient 
cubic space, and b.id ventilation, so commonly found in such 
places — especially in rural districts — had a detrimental effect 
on the cows, and the milk obtained in a germ-laden air was 
more liable to be impregnated with bacterial life. The 
cleansing of the cow's udder and the hands of the milker 
should always be insisted on, and a special dress made of a 



iS6 



PROCEEDINCxS OF THE NORTH-WESTERN BRANCH. 



washable material should be worn during the process of 
milking. In an ouf^reak of milk typhoid twelve months 
ago which came under his notice, he suspected that the 
infection was derived from the dress, or possibly from the 
hands, of a maidservant who suffered from an ambulatory 
form of the disease. Certain urban authorities very properly 
satisfy themselves as to the sanitary state of the outside cow- 
sheds from which milk sold in their districts is supplied ; and 
in all cases dairymen ought to be in a position tosho*, when 
called upon, a reliable ctrtificat'e as to the sanitation of their 
cowsheds and the health of the cows. It was satisfactory to 
know that milk from tuberculous cows was not likely to give 
rise to disease unless the udder was affecicd, and the pro- 
portion of such cases was fortunately very small. 

Dr. NtVEN referred to the unsatisfactory condition of 
cowsheds in Oldham and Manchester. He mentioned the 
very excellent arrangements that exist in Copenhagen 
Ijetween the large milk companies and the farmers ; amongst 
which are the systematic inspection of the cattle, the isolation 
of diseased beasts and granting of compensation during isola- 
tion, and the treatment of the milk by cooling and filtration. 
He mentioned that he h.-id found infantile diarrhiea fifty 
times more fatal in hand-fed than in breast-fed children. 

Dr. Pjrter said that by means of handbills and placards 
milk vendors in Stockport had been made fully aware ol their 
obligations under the Diiries, Cowsheds, and Milkshops 
Order, and the Infectious Diseases Prevention Act. In 
addition, a special code of regulations had been recently 
adopted, and a careful survey effected, embracing the chief 
points referred to by Dr. Robertson in regard to all the cow- 
sheds. Overcrowding existed in more than half of these 
shelters, and nearly all were very low-roofed, the internal 
height not exceeding seven feet six inches, the object 
being lo keep the cows warm, and thus increase their milk- 
yield. The recent val la^le " Inquiry by the British 
Medical Journal's Commission into the Bacterial Flora of 
the London Milk Supply " had shown : (l) That the B. Coli 
Communis, which is specially diagnostic of fcecal contamina- 
tion, constituted 90 per cent, of all the forms found, being 
derived from the soiled cow, and manure-saturated cow- 
house. The presence of this organism in abnormal quan- 
tities in milk is regarded as a grave potential source of 
danger, especially to in'ants. (2) Gelatine liquefying organ- 
isms were present in every sample, and it is suggested that 
the extent of their prevalence is some index of the purity (?) 
of the milk. Varieties of (3) the bacterium tervio, which 
are found in putrefying organic matter, were very common, 
and were taken as indicating either direct contamination 
K^-g t by stale milk in improperly washed vessels), or care- 
less exposure to an atmosphere containing decomposing 
matter. Another noteworthy organism invariably found 
was (4) the aerobic /lacilliis Jluorescens, and as this form is 
frequently met with in potable water, the interestinjj sug- 
gestion is offere'l that its presence in milk might be taken as 
corroborative presumptive evidence of a</</<;^ a^a/cr. (5) In 
two samples examined, didiunt albicans was found. With 
regard to reforms, the Commission's recommendations were 
on the same lines as those suggested by Dr. Robertson, 
viz. : (i) That milking be carr ed on in the open air on an 
impermeable and easily-cleansed fl(jur, ^.^., concrete. (2) 
(ireater clean'iness of the cows. (3) Thorough washing of 
the hands of the milkers. (4) Greater cleanliness of, anfl 
l)ctt'-r means of storage in, milk vendors' shops. In re- 
gard to No. 3, Dr. Porter mentioned a milk outbreak of 
Scarlet fever in a country district in Kent, ascribed 
to the fact that one of the milkers was in the des- 
quamating stage of an unrecognized attack of the 
disease. Careless and improper storage of empty milk 
cans near an infectc 1 privypit had, he believed, caused 
some twelve cases of enteric lever in 1893 amongst the cus- 
tomers of a Stockport flairykeeper. The difficulty of getting 
even moderately suitable means of storage in small milk- 
shops was very great ; and milk vendors also appeared to have 
an unaccountable objection to cover their vessels over to 
keep out air-biirne impurities. In regard to sophistication <f 
milk, Dr. M. K. Robinson, of Dover, had recently reported 



an interesting and unusual occurrence ot poisoning by boracic 
acid, added to the milk as such, and also in the form of 
glacialene. Five out of seven adults in the affected house- 
hold, for two to four days afterwards, suffered from severe 
colic and vomiting, accompanied in the worst cases by sup- 
pression of urine, while five out of nine fowls fed with this 
m Ik mixed with blanc-mange had died, the oiher four 
showing sgns of poisoning. As regards tinned milks, the 
report of the British Meclical Journal's Commiss'on show 
that m St of what was sold cons'sted almost entirely of 
separated milk, and was therefoie quite unfit for infant feed- 
ing. The famous "Milkmaid" brand, however, contained 
10*92 per cent, of fat, and this might be taken as a fair 
standard for good condensed whole milk. 

Dr. Andi:kso\ said that it was an almost universal 
opinion amongst farmers that cows give more milk if kept _ 
in a warm atmosphere, and that this was always used as an ■ 
argument against increasing air space and ventilation. He ^ 
referred to a small epidemic of typhoid fever, which he 
attributed to washing the milk cans with water from a 
polluted surface well. 

Dr. Jones mentioned that it was principally the small 
farmers who were so difficult to deal with. He referred to 
the figures mentioned with reference to infantile diarrhoea 
and hand-feeding, and said he should like to have known 
what form of feeding-bottle was mostly used. 

Dr. Wheatley said that he thought it most important 
that farmers and farm hands generally should receive 
printed instructions as to the precautions that should be 
taken during milking. Much of the evil -arises through 
ignorance and thoughtlessness. Towns at present are under 
the disadvantage that the greater part of their milk supply 
comes from districts not under their inspection. A great 
advance would be made if towns could refuse to allow the 
importation of milk until they were satisfied as to the 
sanitary condition of the farm where it was gathered. 

Dr. Graham referred to the reliability of many forms of 
condensed milk, and also to the causation of summer 
diarrhoea by water polluted by manure spread on fields. 

Dr. Vacher referred to the danger of pollution of milk 
during storage in milkshops. Many of these milkshops 
are also greengrocers' shops, and the milk is liable to con- 
tamination in many ways. In others are stored such 
substances as paraffin and vinegar. He has found it 
necessary to insist on these trades being dissociated from 
the selling of milk. 

Dr. Robertson, in reply, said that tubercular udder 
disease was said to occur in i^ per cent, of cows suffering 
from tuberculosis. Dr. Woodhead found tubercle bacilli 
in the milk of six out of six hundred cows examined. As 
regards the filtration of milk as practised at Copenhagen, he 
thought that it acted as a more perfect seivc than that 
in general use rather than as a bacterial filter. The difficulty 
of cooling milk before delivery had been pointed out. It 
was satisfactory in this respect to note that a large number 
of milk producers did use a cooling apparatus, and that 
many such refrigerators were now in the market at com- 
paratively low prices. As to the comments made by several 
Fellows on the subject of air space per head of cattle, it 
seemed to him to be demonstrated beyond doubt that the 
old custom of keeping cows in crowded warm shippons was 
injurious and wrong. It was only necessary to visit any of 
the numerous modei dairy farms and to compare the results 
with those obtained from old-fashioned premises, to com- 
pletely disabuse one's mind as to the danger of having 
8cx3 cubic feet of air space for each cow, together with 
efficient ventilation. 



A REI'OK I touching the examinations in Salutary 
Science held at the various universities, &c., has 
been presented to the General Medical Council. 
The report appears to be one that the Council of 
the Incorporated Society should take into con- 
sideration. 



PROCEEDINGS OF THE MIDLAND BRANCH. 



157 



PROCEEDINGS OF THE MIDLAND 
BRANCH OF THE INCORPORATED 
SOCIETY OF MEDICAL OFFICERS OF 
HEALTH. 

A MEETING of the members of the above branch 
was held on Thursday, January 22nd, at the 
Council House, Birmingham. The chair was 
occupied by Dr. S. Barwise (President), and the 
other members present were Drs. Alfred Hill 
(Birmingham), Henry May (Aston Manor), Marsh, 
Jackson (Smethwick), M. Read (Worcester), A. S. 
Underbill (Tipton), Bostock Hill (Birmingham), 
H. Douglas (Leamington), Millard, and H. Manley 
(West Bromwich), Hon. Secretary. 

A letter was read from the Hon. Secretary of 
the Society re " Fixity of Tenure," and after some 
discussion the following resolution was unanimously 
passed : — " That in the opinion of this branch it is 
desirable, in the interests of the public health, that 
the same security of tenure should be given to all 
medical officers of health as is afforded to the 
Metropolitan medical officers of health under the 
Act of 1 89 1, and that a deputation of the Society 
should urge this upon the present Government." 

Dr. Underhill asked the advice of the mem- 
bers as to the best material to use for stuffing 
bedding in an infectious hospital. He had used 
the winnowings from oats and similar things. 

The President thought that the most common 
practice was to use wire-wove mattresses with 
ordinary felt, or a blanket on the top. 

It was thought by one member that cocoa fibre 
was too hard. 

The President said they could get wire-wove 
mattresses to fit any bed for about 5s. 

Dr. Manley favoured the opinion of the Pre- 
sident, but suggested that palliasses should be 
used on the top, and these could be burned after- 
wards. 

Dr. Underhill said he had been using the ears 
of corn and oats, but complaints had been made 
to his Board about it, and he had promised to make 
enquiries as to what was used in other districts. 

Dr. Jackson said at Smethwick they used wire 
mattresses with palliasses. 

Appointment of President-Elect. 

The President then proposed that Dr. Marsh 
Jackson be President-Elect. Dr. Jackson, he said, 
was an old friend of his, and gave him his pro- 
fessional baptism. It was a great pleasure to him 
to find that he was to be succeeded by one who 
had always been good to him, and he was sure Dr. 
Jackson would fill the chair with dignity. 

Dr. Alfred Hill had great pleasure in 
seconding the resolution, and expressed the opinion 
that Dr. Jackson would be very useful in the 
position. 



The resolution being carried unanimously. Dr. 
Jackson returned thanks. 

The Bye-L.\ws. 

On the motion of the Hon. Secretary, seconded 
by the President, it was decided that the bye-laws, 
as formed by the Council, should be printed, and a 
copy sent to each member of the branch, previous 
to their discussion at the next meeting 

Typhoid Fever at West Bromwich. 

Dr. H. Manley read a paper entitled, " Notes 
Upon an Epidemic of Typhoid Fever." The 
reason, he said, he brought this question before 
them was that for the past three years in the 
Borough of West Bromwich he had suffered from 
epidemics of typhoid fever. This had culminated in 
the demand for a Local Government Board enquiry, 
and Dr. George Buchanan had visited the Borough. 
He awaited the results of the enquiry with interest. 
In the course of his own investigations, certain 
facts had come before him, and he felt that he 
should Hke to take the counsel of his friends and 
colleagues. West Bromwich, he remarked, was a 
populous town, was a privy midden town, and 
possessed something like 13,000 houses, and 
between 6,000 and 7,000 privy middens, mostly of 
an old type, without proper doors and coverings. 
Typhoid fever was never entirely absent from the 
town. In a town so saturated with the products of 
excreta and sewage as a town which possessed 
7,000 privy middens, it was not to be expected 
that It would entirely disappear. They were apt, 
epidemically, to connect outbreaks of typhoid 
either with milk or water. There were one or two 
peculiarities in his outbreak that he wished to 
mention. The first was that the district which 
really caused the enquiry into the matter was, 
comparatively speaking, a sanitary district. That 
was a district which was well sewered, and in which 
the outbuildings were not exceptionally bad. With 
regard to the water, the whole of West Bromwich, 
with the exception of about 2 per cent., was sup- 
plied by the South Staffordshire Water Co., and he 
need hardly say that the disease was not dissem- 
inated by that means. The milk supply was of a 
very varied character, and after due enquiry he had 
abandoned the question of milk. Then they were 
told that it came from the privy midden nuisance, 
and the saturated soil ; this was rather his conten- 
tion. Another peculiarity was the tendency 
of the disease to return year after year to 
the same street, and in some instances to 
the same house. With privy middens they had 
a common yard, common excreta thrown into it, 
and the people exposed to the germs arising from 
that. They had people unclean in their habits, 
who in the stress of fever frequently passed their 
excreta beneath them, and polluted the bedding 
and blankets, which were imperfectly washed and 
disinfected. In the house, 22, Cross Street, for 



158 



PROCEEDINGS OF THE MIDLAND BRANCH. 



three years in succession, with different tenants, 
typhoid fever had appeared, and yet in that house 
there was nothing whatever to be found to account 
for it. In the construction — and he had examined 
it from floor to ceiHng— there was nothing to 
suggest a cause for its bad record. An ice-cream 
man had lived in the place, and he carried the 
disease half over West Bromwich. He (the 
speaker) thought that he had done with him, but 
the disease broke out again in the same house in 
1S94 and 1S95. There was another street in his 
borough (Long Square), and in 1890 typhoid fever 
broke out at No. 65, and he had eight cases in that 
one street. In that year the condition of the street 
got so bad that the Sanitary Commissioners met 
there, and went over every yard and property. 
They sewered it, water-closetted it, ducketted it, 
and for two years not one single notification was 
received from it In 1895 poverty, resulting 
from the closure of iron works and coal pits, 
descended upon it, and the people became more 
liable to disease. To give some idea of the 
condition of the people, he mentioned that in that 
street, which contained eighty houses, something 
hke j{^2oo was distributed. The people became 
liable to any latent attack of disease, and fever 
broke out again in the same house. He ventured 
to hope that Dr. Buchanan would think it was 
something to do with the privy-midden system 
and the saturation of the soil. Another thing 
which he was being constantly reminded of was 
the smells from the sewers, and whenever fever 
appeared people said "there is a smell in the 
locahty, and that causes it." One was at a 
great disadvantage in endeavouring to explain 
to the lay members that it was not their (the 
medical officers) opinion that the smells arising 
from the sewers caused typhoid. They read 
of classical outbreaks of typhoid caused by sewer 
gas — e.g., Caius College, etc.; and, on the other 
hand, one was met by the extremely interesting, 
and he must confess conflicting, opinion of Mr. 
Parry Laws, who, if he (the speaker) rightly under- 
stood him, showed that typhoid bacilli could not 
flourish for more than an extremely limited period 
in sewage or sewer air ; that sewer air, he might 
almost say, was not a suitable medium or home 
for the typhoid bacillus. If that were so, surely it 
was ridiculous to suppose that a smell from a sewer 
ventilator would cause an outbreak. He absolutely 
declined to believe it would, and he endeavoured 
to induce his Committee to decline to believe that 
a mere passing smell, caused by the displacement 
of sewer air, was going to produce an epidemic. 
He admitted that efficient and constant flushing 
was desirable. A sewer, if it was kept properly, 
should be flushed once a fortnight, and if it 
had a proper gradient and proper quantity of 
sewage he thought this sufficient. He went on to 
mention the influence of climate and meteorological 
conditions, which he thought were not sufficiently 



understood as regarded the causation and propaga- 
tion of typhoid, and then remarked that anyone who 
had received the weekly reports of the Local 
Government Board would notice that 1895 had been 
a year of exceptional outbreaks of typhoid fever from 
one end of England to the other. They would see 
that the increase was not a mere local increase, 
but an increase dependant upon certain chmatic 
conditions which went beyond the ordinary 
question of typhoid causation. He thought too 
little attention was given to this aspect of the 
question. 

In reply to a question by Dr. Read, Dr. Manlev 
said more than three parts of the houses where the 
outbreaks had occurred had privy middens. The 
number of houses in the Borough which had 
middens to those which had water-closets would 
be about seven or eight to one. 

Discussion. 

Dr. BosTOCK Hill said that at the present time they 
were in great danger of suffering at the hands of what he 
might term the bacteriologists. He did not wish to say a 
word against bacteriology, as he believed they were indebted 
to it to an enormous extent, and that it would be the chief 
instrument in the future in advancing sanitary science to the 
end it would eventually reach. Mr. Laws and his colleague 
came to the conclusion that as they were unable to find in 
the air of the London sewers any bacilli, typhoid was not 
produced by sewers, therefore it must be produced by water. 
This he believed was doing a great amount of damage. In 
the case Dr. Manley had dealt with, the disease could not 
have been produced by water, but inhalation was the cause 
of it. He had had many instances of an exactly similar 
kind. He had had typhoid cases in people who had lived 
by themselves in cottages, who had not been away for 
periods likely to exceed the period of incubation, and no one 
had visited them, and there were no means for producing it. 
He was of opinion that it was produced by other means than 
by water containing typhoidal germs or milk, viz., by air; 
and if they were to accept the views of the bacteriologists, 
they must say that it could not be produced so. With 
regard to Dr. Manlcy's assertion that 1895 was a typhoid 
year, he said it had been in one or two places in bouth 
Staffordshire, but generally he did not think it was. The 
year 1894 was, on account of the great drought, but he was 
inclined to think that they had had considerably less during 
the past year, owing to the altered climatic conditions, than 
they had in the years when the weather was hotter and 
drier. 

Dr. Read said there had been outbreaks of typhoid at 
Worcester, where they drank the Severn water. His first 
duty was to report to the Council upon the water. After a 
long time the members of the Council who wanted to keep 
on the supply from the river got into the majority, and 
decided to increase the filtering area. This came into force 
last year, and typhoid at Worcester fell from an average of 
70 cases to 20. This year (1895) there had not been so 
many — only 15. This, he thought, was due to the matter of 
filtration. They used to filter at about 8 or 10 inches an hour, 
but now they filtered at 4. He wanted them to increase the 
filtering area, so that it should be less than that. His 
experience in Worcester led him to the conclusion that if 
river water were filtered with sufficient care it might safely 
be drunk. 

In reply to a question, Dr. Manlev said his impression 
was that the conveyance of typhoid fever from the air to the 
patients was by means of food, and not inhalation. 

Dr. BosTOCK HiLi, did not thmk, of necessity, that the 
typhoidal poison, when carried by air, was always taken 
with food. 






ON A SCHOOL OUTBREAK OF DIPHTHERIA IN ASTON MANOR. 



159 



On a School Outbreak of Diphtheria in 

Aston Manor. 

BY 

Henry May, L.R.C.P., M.O.H. 

Diphtheria is a disease which has close relations 
with school attendance, and these require constant 
watchfulness on the part of a medical officer of 
health. I have been accustomed to record the 
school attended in all cases of infectious disease 
notified in children of school age ; and as there are 
about 15,000 children on the registers of the 
pubhc elementary schools in Aston Manor, these 
cases have been numerous — though not as regards 
diphtheria, until 1895. In April there was a 
series of seven or eight cases in connection with 
one of the schools, but that outbreak terminated 
satisfactorily. 

The Station Road mixed school of the Aston 
School Board is a modern school, situated close to 
the boundaries of the Handsworth and Erdington 
Urban Districts, and has accommodation for 495 
children. There were about 360 children in 
average attendance at the beginning of December. 
No case of diphtheria had been notified during 
the year in the neighbourhood, nor among 
children attending the school, until the evening of 
December 9th, when four notifications were 
received, which, on investigation, proved to be 
children who attended that school, and that one 
was dead and another dying. I also received a 
letter from the Clerk to the Aston School Board, 
on the loth (enclosing one from the mistress of 
the school, intimating the outbreak), requesting 
me to advise in the matter. I recommended the 
closing of the school forthwith, and it was closed 
at mid-day on the nth. 

The result of the inquiries made as to these and 
other cases subsequently notified, shows that the 
first recognised as diphtheria was taken ill' on 
December 4th, and that, in the fortnight following, 
twenty-one children who attended the school were 
taken ill with diphtheria, eleven of whom have 
died. 

At the end of the first week in January, the out- 
break appeared to have ended, but in the meantime 
forty-five cases were notified in Aston Manor, 
which were connected with the school, and living 
in its neighbourhood, out of fifty-eight diphtheria 
notifications in the district. 

Diphtheria in Aston Manor. 
(Five Weeks ending January 4th, 1896.) 

Total notifications ... 58 

,, deaths ... ... ... ... ... 18 



Connected with Station Road School : — 
Cases notified ... 
Deaths 

Taken ill in week ending 



45 
14 



Dec. 6. 
7 



IS- 
IS 



20. 
14 



27. 



Jan. 4. 
I 



Cases. Deaths. 

Attending school 28 11 

Absent one, two, or three weeks 5 i 

Brother or Sisters 7 2 

Mothers or Aunt 5 — 

J5 J4 

I have ascertained from the Medical Officer of 
Health for Erdington that six or seven children 
connected with the school, who lived in that dis- 
trict, were notified to him as suffering from 
diphtheria, one of whoin, a pupil teacher, died. I 
have also ascertained from the Medical Officer of 
Health for Handsworth that no cases of diphtheria 
connected with the school had been notified there. 
This is explained by the fact that all the Hands- 
worth children, about a hundred, had fortunately 
been discharged in the previous November, it 
being the end of the school year. 

The houses invaded were confined to a com- 
paratively small area, lying low near the river 
Tame, and having a wet sub-soil ; some land 
near has been raised gradually by tipping rubbish 
for some years, but this land is not built upon. 
The school is not upon it, and has a comp'ete 
layer of concrete below the foundations; the streets 
are sewered, and the houses are disconnected. 

I do not think there can be any doubt that this 
outbreak was caused by one or more unrecognised 
infectious cases of diphtheria attending the school 
at the beginning of December, for though no case 
had been recognised hving in the neighbourhood 
now attending the school, there is a history of 
previous sore throats in children belonging to the 
school. Only three or four children who actually 
attended the school appear to have been taken ill 
after the 14th inst. ; those which occurred after- 
wards were chiefly secondary cases. 

The School Board had adopted a recommenda- 
tion that " cases of sore throat should be referred 
to a medical man, as they are often mild cases of 
diphtheria which is generally spread from person to 
person, and is a very dangerous infectious disease," 
and the school will not be re-opened until 
cleansed, etc. 

The notification of diphtheria is indispensable in 
carrying out any measures for preventing its spread, 
such as withholding possibly infected children, 
disinfecting a house, or closing a school, but it 
does not work so satisfactorily in regard to it as to 
some other infectious diseases. The disease does 
not lend itself well to diagnosis, and so cases of 
ordinary sore throat are sometimes notified, or the 
notification may not be received until the disease 
is far advanced. 

Means of isolation might have been of some 
help in the later cases, but most of them were 
infected before the disease was recognised. When 
a first case occurs in a family living in a small 
house a situation of great danger is presented, but 
it is a disease in which medical and surgical skill 
treatment are relatively of greater importance than 



i6o 



THE SLAUGHTER-HOUSES OF BRISTOL. 



in small pox or scarlet fever, and I regret that the 
general hospitals here have discontinued to receive 
diphtheria cases, even in detached wards, except 
such as require operation. 

Considering the primary difficulties in diagnosis, 
the need for a skilled staff and the uncertainty as 
to its popularity I should not feel justified at present 
in recommending the provision by the sanitary 
authority of a special hospital for the isolation of 
diphtheria cases. 

The lesson has again been enforced by this 
outbreak, that children with sore throats or other 
suspicious symptoms must be excluded from school 
attendance, and teachers must watch for and report 
such cases for medical enquiry, and if necessary for 
the closing of the school, for which the 88th section 
of the Education Code affords ample powers. 

Discussion. 

Dr. A. Hill quite endorsed the view of Dr. May, of the 
school being the medium of the dissemination of diphtheria. 
All his facts pointed to that conclusion ; and his own 
experience certainly thoroughly supported it. A very 
marked case of "sporadic epidemic'" occurred about two 
months ago, at Harbome. In one school they had twenly- 
one cases. The first cases he enquired into were not 
.ittending Board Schools, nor was any child attending a 
Board School from the same house. The third case was of 
an attendant at a Board School ; and after that there were 
eighteen other cases, and, of these eighteen, only five died. 
Of the five who ricd, four of the cases occurred in a house 
where some children attended the Board School. It was 
very remarkable that the disease was entirely confined to 
the children attending the Board School, or of children of 
families where a member did attend the school. Nine years 
ago there was an outbreak of diphtheria in the very same 
school. It was found that there were drains passing under 
the school, and the sewer was cut off. In making some 
recent additions to the school, they came across some drains 
which, though they had been cut off, had been left in the 
foundation, and were filled with sewage matter. He did not 
know whether they had prompted the disease, but it was 
very likely that their presence, and the result of the decom- 
position, resulted in the spread of the disease. Schools 
were a great medium of transmission. They had not had 
a case since the school was closed. 

The President said at Blackburn they had practically no 
diphtheria until alter he was there. Since he left, his suc- 
cessor (Dr. Wheatley) had, he thought, twenty-three cases in 
1894, and of these seventeen were connected with one 
school. Where they had got virgin soil, such as they had 
at Blackburn, the spread and history of diphtheria was very 
beautifully illustrated ; and those who had the opportunity 
of seeing his report would have been struck with his able 
manner of treating the cases. He thought they were all 
agreed that the disease was spread through schools, and that 
was his opinion of the matter. 

Dr. MiLl.ARD related the experience at the City Hospital, 
where, he «aid, for the past two years, up to six or seven 
months ago, they had nevci had a case diagnosed as diph- 
theria. Alx>ut six or seven months ago they had a case 
bacteriologically diagnosed as diphtheria. Since then their 
record had fcen awfully bad. It was almost impossible to 
<liagnose the majority of these cases except by bacteriological 
investigation. They had done everything they could to 
stamp out the disease They had repeatedly closed wards, 
disinfected them, and started afresh ; l)ut still cases kept 
cropping up. One difficulty they had to face was that 
diphtheria was very |irevalcnf in Birmingham and outside. 
His experience wa« that it >v.is very difficult to stamp out the 
disease. 



Dr. Manley and Dr. Marsh Jackson made a few 
remarks upon the resolution of medical officers of health to the 
School Board, and the desirability of special payments being 
made for special school inspections and similar services — 
especially where reports are made to the School Board, and 
not to ths sanitary authority. 

Dr. BosTOCK Hill thought they would adopt the view 
that the first cases of epidemic of that sort were plain cases 
of sore throat and not diphtheria. 



THE SLAUGHTER-HOUSES OF BRISTOL. 

In a report on the slaughter-houses of Bristol, the 
authors, Dr. D. S. Davies, Medical Officer of Health, 
and Dr. W. Dowson, Assistant Medical Officer of 
Health, point out "that the condition of more than 
half the eighty-five city slaughter-houses is unsatis- 
factory," and " that this unsatisfactory condition is 
due chiefly to structural defects which are incapable 
of remedy." 

Most of the slaughter-houses " are disposed 
along .... two chief lines of approach from 
country districts .... and therefore conveniently 
situated for farmers and drovers. They occupy, 
as a rule, what was formerly the back yard or back 
garden of houses fronting the road. In the case 
of many of the smaller premises, the back yard has 
been converted into a slaughter-house by the simple 
expedient of raising the side walls unequally, and 
throwing across them a slanting roof, leaving a few 
feet of space between one end of this structure and 
the house to admit light to the parlour window. As 
one result of this method of adaptation, the yard 
pump, the privy, the yard sink, and the steps down to 
the cellar, are often one, or all, inside the slaughter- 
house, while the back door of the house and the 
parlour window open directly upon it." . . . "In 
many cases the lairs for the animals to be slaughtered 
are in the slaughter-house, being merely partitioned 
off from one end : and in these cases they drain by 
a shallow channel across the floor of the slaughter- 
house to the yard sink. One consequence of this 
common structural arrangement is that the meat is 
thus exposed for some time to the effluvia from the 
manure of the animals in the lairs. It is obvious 
that from common considerations of well-ordered 
cleanliness, the carcases of slaughtered animals 
should be kept from the moment they are dressed 
in places as well ventilated and free from effluvia as 
an ordinary larder.'' 

Only two of the Bristol slaughter-houses have 
been licensed under Part III. of the Public Health 
Acts Amendment Act, 1890, and the sanitary 
authority possess no special powers for the com- 
pulsory closure of those licensed before that enact- 
ment. Unless, therefore, the erection of a public 
abattoir, such as is contemplated by the authority, 
be supplemented by the acquisition of a Local Act 
empowering them to prohibit the slaughtering of 
cattle elsewhere, the extent to which the abattoir 
is used by the butchers will be regulated, in some 
degree, not by a sense of the general public interest, 
but by |jrivate considerations of convenience and 



"FIXITY OF TENURE." 



i6i 



expense. That some butchers would voluntarily 
use the abattoir is very probable ; but unfortunately 
there is reason to think that just those would be 
the last to come in who occupy premises the utter 
unfitness of which as slaughter-houses affords one 
of the main reasons for thi erection of a public 
abattoir. Some of the small butchers' shops in 
thickly populated districts retail a very large quan- 
tity ot meat ; and it no doubt keeps down working 
expenses to be able to kill on the spot, especially 
when one and the same room is made to serve all 
the purposes of slaughter-house, cooling-room, 
stable, lair, and manure receptacle. This may be 
convenient for a certain number of butchers, but it 
is a condition of things which should not be allowed 
to continue any longer. 

To what extent cattle bought at country fairs are 
walked into towns in the early hours of the 
morning, and are killed and dressed before a proper 
inspection of the living animal and of its organs 
after death, is possible ; and the result of such 
inspection if it were possible, is more or less guess 
work. It is quite sufficient to base the necessity 
for public abattoirs upon the admitted incompe- 
tence of men untrained m pathological observation, 
to determine, in the case of a carcase with a 
doubtful history, and presenting appearances 
indicative of possible disease, what is, or what is 
not fit tor human food. It is sufficient to know 
that animals, like human beings, may have mild 
attacks of infectious disease, and that in many 
rural districts from which the meat supply of towns 
is largely derived, serious disease of cattle is 
endemic. The following extract from the JVeskrii 
Daily Press is a fair specimen of the weekly returns 
of cattle disease in certain counties which supply a 
large quantity ot meat, not only to Bristol, but to 
London and other large towns: — "During the 
week ending December 14th [1895], there died, or 
were slaughtered as suffering from swine fever, the 
following numtjer of pigs : — In Gloucestershire, 7 
died and 27 were slaughtered; Somerset, 10 died 
and 191 slaughtered; Wilts, 11 died and 77 
slaughtered. Tnere were 10 fresh outbreaks of 
anthrax aflecting 19 animals. Twelve fresh cases 
of glanders were reported. There were 7 fresh 
cases of rabies." 



^Mk WM. 



In a communication to the British Medical 
J-ournaf, there appear the following suggestions 
as to the future of the Meiropoiitau As)lums 
Board, whose actions in coniRCtion with the 
prevalence of scarlet fever during the past summer, 
are just now being severely criticised. The 
suggestions are — (i) that the sanitary authorities 
should be represented on the Board ; (2) that the 
Board should be relieved of the restrictions im- 
posed on it as to the purchase of sites for hospitals ; 
and (3) that the sanitary authorities alone should 
decide what cases should be removed to hospital. 



"FIXITY OF TENURE." 

The letter from Dr. Seaton to Dr. R. Dudfield 
raises an issue which we venture to think is vital to 
the whole subject of " Fixity of Tenure." The 
question is, " Shall the Society seek to obtain 
permanency for all appointments ? or shall a limit 
be suggested, below which the tenure of office 
shall remain as at present?" The interests of 
public health are not, in our opinion, best served 
by a combination of health work with private 
practice ; and it that be granted, it becomes the 
duty of the Society to urge the Government to 
make it possible for men of high attainments and 
rank in the profession to devote themselves 
exclusively to the sanitary service. Such, indeed, 
is^ the gist of the reply given by the President of 
the Local Government Board to the Deputation 
from the British Medical Association in 1881. 
Further, such argument precludes any action on 
the part of the Society likely to crystallize the 
present system of small appointments at utterly 
inadequate salaries. It is imperative that the 
Local Government Board should use the powers 
they obtained in 1875 for the formation of com- 
bined districts able to pay salaries which shall 
induce medical men to devote their whole time 
to public work, and to prevent combined 
districts breaking up when once formed. 
Resolution No. 2, presented to the Society by 
the Council, really recommended the Society 
to urge such line of action to the Board. It 
will be useless to approach the Local Govern- 
ment Board if the Society be divided on this matter. 
If no suggestion be made in the direction fore- 
shadowed in Dr. Seaton's letter, it will be in the 
power of the Board to ask what is to be done with 
the smaller appointments, there being no reason to 
suppose that the Board would depart from the 
opinion expressed by Mr. Dodson. We believe 
the best solution of the difficulty will be to adopt a 
resolution on the lines of that of the Council, 
modified so as to safeguard the inteicsts of present 
officers. It must, however, be patent to all that 
the very insignificant salaries paid in many districts 
cannot be of any vital importance to the officers 
receiving them, who really depend on private 

practice. 

N 



l62 



"FIXITY OF TENURE." 



« FIXITY OF TENURE." 
In connection with the discussion on this matter 
at the last meeting of the Incorporated Society which 
stands adjourned until the next ordinary meeting, it 
has been thought that the following documents of 
historical value might prove to be useful and 
interesting. They have been found among the old 
papers of the Society, and indicate that the question 
is by no means one of recent growth. 

The earliest document is a portion of the British 
Medical journal for August 20th, 1881, contain- 
ing a report of a deputation to the President of 
the Local Government Board (Mr. Dodson, M.P.), 
when speeches were made in support of the depu- 
tation by Mr. Cropper, M.P., Dr. Tripe (M.O.H., 
Hackney), Mr. Ernest Hart (Chairman of the 
Parliamentary Bills Committee, B.M.A.), Dr. Far- 
quharson, M.P., and Dr. Bond (M.O.H., 
Gloucestershire). The attention of the President 
of the Board was directed exclusively to the case 
of extra-metropolitan medical officers, metropolitan 
officers being then appointed during good 
behaviour. 

It is interesting to note that Mr. Hart, in the 
course of his opening remarks, stated that the 
occasion was by no means the first on which he 
had appeared before the Local Government Board 
to urge the claims of medical officers of health to 
security of tenure. The advantages of large com- 
bined districts of sufficient area to engage the 
whole time of medical officers was strongly urged, 
and attention was called to the fact that the Board 
in 1875 obtained powers for compulsorily forming 
such districts, and for preventing the breaking up 
of suitable combinations already existing ; yet, 
with one or two exceptions, shortly after the pass- 
ing of the Public Health Act, 1875, the Act had 
not been put into force. Mr. Hart cited some 
twelve cases in which the appointment by tenure 
had been used to the disadvantage of officers of 
good repute, who had devoted themselves to the 
sanitary service. He claimed for medical officers 
of health the same permanency as was granted to 
poor law medical officers and relieving officers. 
The reply by Mr. Dodson appears to be worthy of 
being quoted at length. It was as follows: — 

" The only reply that I can make is this — 
that I am deeply sensible of the very great 
hardships which must fall upon the medical 
officer, in some cases, where the gentleman 
gives up private practice in order to devote 
his whole time to the duties of medical officer 
of health, and then finds his salary as medical 
officer cut ofi", and that he has to reconstruct a 
private practice. It has been, I may say, the 
policy of the Board to encourage and promote 
the appointment of medical officers of health, 
if not permanently, at all events in such a way 
as to secure to them such a fixity of tenure 
as inay be a sufficient inducement to men of 
high standing and position to accept these 



appointments. We can, however, only do so 
where the appointment is for a combined 
district, sufficiently large, and with a suffi- 
ciently good salary, to secure the services of a 
good and efficient medical officer ; and it is 
only in these cases that we can contemplate 
the desirability of these situations continuing 
permanent. Of course, now and then, in 
some cases, it may be that the districts are 
not such as we contemplate or desire to be 
permanent ; and therefore, in those districts, 
we could not desire to see an officer appointed 
permanently. I may mention the case of 
districts which extend into different counties, 
or, in other ways, cut into or overlap different 
areas, and that is not a thing we desire to see 
perpetuated. Another reason, I may mention, 
which has stood in the way of our compelling 
the local authorities to make these appoint- 
ments permanent, has been this : that we are 
not desirous of adding too much to the 
exercise of the centralising powers and 
authority of this Board, more especially when 
we have it in contemplation, as it has been for 
many years, of establishing in the different 
counties representative county authorities, to 
whom will be handed over powers which are 
now dealt with by the central authority. I 
will not now enter into the arguments as to the 
competitive advantages of permanent service, 
and service depending upon personal exertion. 
Of course, I am sensible — you will see that I 
am — of the advantages of permanent service 
in securing the expanse of views of gentlemen 
of high standing in the profession. On the 
other hand, it has, perhaps, been rather too 
broadly laid down that a permanent appoint- 
ment necessarily secures, to a great extent, 
efficienty and economy. We all know that a 
stimulus is necessary in some ca-ses, and I 
believe that is obtained by periodical re- 
election ; while economy is, of course, 
conducible to the public advantage. As 
regards the argument, complaining that the 
guardians are not desirous of having to re-elect 
their officers, I have only to say that we have 
no reason to complain in that matter. I can 
only add, that the observations that you have 
made to-day shall receive the most attentive 
consideration of my Board. We have to 
balance the advantages and disadvantages of 
exercising central against local authority ; and 
have to balance the advantages and disad- 
vantages of permanent appointments, against 
appointments which give the incentive to 
exercise, requiring re-appointment from time 
to time. I am deeply sensible of the hard- 
ships of the position in which the medical 
man of high standing is placed if he gives up 
his private practice, in order to give his 
position, as medical officer of health, his fullest 



FIXITY OF TENURE." 



163 



consideration and time, and then suddenly 

loses that position. All the arguments which 

have been used to-day shall receive the 

earliest consideration of the Board." 

In 1885, a Joint Committee was appointed by 

the Society of Medical Officers of Health, and the 

Yorkshire, the Midland, and the North-Western 

Associations of Medical Officers of Health. As a 

result of the deliberations of the Committee, a 

petition was prepared, in 1886, to Mr. Joseph 

Chamberlain, at that time President of the Local 

Government Board. In that petition the following 

paragraphs occur, and as they contain an argument 

which has been scarcely mentioned on the present 

occasion, they are given ifi extenso : — 

" The fact that in this respect {i.e., manner 
of tenure of office) your petitioners are in the 
same position as the constituent members of 
the Boards they serve, only accentuates the 
difficulty, inasmuch as the Boards themselves 
are for this reason liable to change in constitu- 
tion, and cannot be relied upon to afford the 
support which is necessary in moments of 
unpopularity. 

" Your petitioners would submit, that all 
experience shows that if the governing body 
is subject to change at popular caprice, the 
officials should be permanent ; and that if, on 
the other hand, the governing body is auto- 
cratic, officials may be left removable. When 
the governing body and the officials are alike 
subject to change at popular caprice, the 
highest service is not possible." 
At the present time no record has been found of 
the results of the deputation to the President of 
the Board. It is noteworthy that when the depu- 
tation was appointed to attend, a " Local Govern- 
ment Reform Bill " was under consideration, and 
the time, therefore, apparently ripe for action on 
the part of the officers affected. 



The Limes, Clapham Common, S.W., 

19th November, 1895. 

Incorporated Society of Medical Officers 
OF Health. 

Letter from Edward Seaton, M.D., Presi- 
dent OF THE Home Counties Branch of 
THE Society, to Dr. Reginald Uudfield, 
one of the Hon. Secretaries of the 
Society. 

Dear Dr. Reginald Dudfield, — I have 
received the notice of the meeting of the Council 
to be held on Thursday next for the consideration, 
amongst other things, of the memoranda on the 
question of " Fixity of Tenure " prepared by Dr. 
T. Orme Dudfield and Dr. W. T. G. Woodforde.* 

* These memoranda will be found in the December issue 
of the Journal. — Ed. Public Health. 



I have read these valuable memoranda with great 
interest. I need not say that I am heartily in 
accord with the principle of security of tenure as 
viewed by the authors of the memoranda, and I 
believe by most, if not all, of those who for many 
years have been associated with the active work of 
Medical Officers of Health. 

But inasmuch as the authors leave out of con- 
sideration for the time what appears to me an 
essential matter to be thought of in connection 
with this subject of security of tenure, I cannot, of 
course, signify my agreement with the argument as 
now used. You are probably aware that I have 
had some correspondence with Dr. Gruggen, 
Hon. Secretary of the Home Counties Branch, 
and I had a long interview with him on the subject 
a few days ago. I referred then to the fact that, 
so far as I know, this question appears lately to 
have been discussed entirely without any reference 
to the essential difference there must be, in the 
eyes of the whole medical profession at any rate, 
between Medical Officers of Health who are 
making "public health" their life work, and 
Officers of Health whose main work is that of 
general practice. 

The main question during the past ten or twenty 
years has been whether the policy of appointing 
medical officers who are making " public health '' 
their "life work " is to be encouraged or other- 
wise. There can be no doubt as to what the 
tendency has been in the metropolis and in large 
towns, but the question now indirectly brought 
before the Society is — What is the best plan for 
sanitary administration in the country generally ? 
Here I think there would probably be a good deal 
of division of opinion. Many would be m favour 
of the officer who resides in the locality and many 
would favour the combination system. 

I cannot help thinking that the question of 
security of tenure ought to be considered especially 
in relation to this question^ viz., whether it is 
desirable to encourage an expansion of the com- 
bination system, or, on the other hand, an 
extension of the system which is already most 
predominant throughout the country, viz. : That 
of having local practitioners to hold the office of 
Medical Officer of Health. By contending for 
security of tenure without reservation on this 
essential point, we shall, no doubr, stereotype the 
predominant system which now exists, and I think, 
as a consequence, the disintegration of the com- 
bination districts would be likely to follow in the 
end. This, however, is a matter of individual 
opinion of course, and a subject rather for debate 
and discussion. 

I desire to point out to the Council at the 
present time, that, in asking for security of tenure, 
we should undoubtedl)' have a very much stronger 
case with Parliamentary representatives if we could 
say that the security of tenure is asked for on such 
grounds as the following, viz. : That there are a 

N 2 



164 



ISOLATION HOSPITAL ACCOMMODATION. 



certain number of medical men who have educated 
themselves very highly and very specially with the 
view of serving the public in matters that relate to 
health administration; that they have cut their 
connection with practice, and they have done so 
with the expectation of being able to make a fair 
and honou'^able living ; and that under present 
conditions such is impossible, seeing that if they 
obtain a post in either a separate di^trict or a 
combination district they have no guarantee what- 
ever that there will be security of tenure. Under 
such circumstances it cannot be expec ed suffi- 
ciently highly qualified medical men will continue 
to devote themselves to this branch of public 
work, and that the interests of the public must 
consequently suffer. 

I would beg to say that, in urging the considera- 
tion of this point as being, in my opinion, the 
strong ground to be taken, I do not for a moment 
underrate the immensely important work that has 
been done, and is bemg done, by gentlemen m 
general practice, who, it seems to me, have in 
many cases sacrificed their interests very much to 
those of the public. Surely it must strike those 
who consider the subjec from an independent and 
public standpoint — statesmen especially — that we 
are asking for fixity of tenure for gentlemen whose 
salaries as local practitioners at the present time 
cannot be very high, and, generally speaking, in 
separate districts are extremely small ; and even if 
they were considerably increased, it could not, in 
the vast number of cases, recompense them for the 
sacrifice of their interests as general practit oners. 
This being so, their ostensible hving must be 
derived from sources quite apart from that con- 
nected with public administration, and on that 
ground it seems to me that, looking at the question 
as a whole, the question of security of tenure may 
well be associated with that of the specialist in 
"public health.'' 

I venture to express these views because, as 
president of one of the branches of this Society, I 
may be asked to support a pol cy which, so far as 
I see at present, I could not consistently advocate. 

Yours faithfully, 

Edward Seaton. 



Dr. Thorne Thorne, C.B., in a lecture on 
milk as a vehicle of disease, given before the 
National Health Soc ety. described the evidence 
of transmission of infection in connection with the 
foil wing diitases :— E'l'eric fever, f r m ante- 
cedent cases in man ; scarlet fcver and diphtheria, 
antecedent ca."5es in man, or disease in the cow ; 
cholera, by addition to the milk of water fouled 
with cholera dejecta ; foot and mouth disease and 
tuberculosis, from the cow direct. The infection 
being transmitted by organisms, becomes more 
efficient after the milk has been kept fur a time. 



ISOLATION HOSPITAL ACCOM- 
MODATION. 

A conference of representatives of the District 
Councils in tne County of Durham, convened by 
the Clerk to the County Council, at the instance 
of the County Health Committee, was held at the 
Shire Hall, Durham, in September, to consider 
the necessity of providing adequate accommoda- 
tion for the isolation of infectious diseases. 

Alderman Dr. Livingstone, Chairman of the 
County Health Committee, presided, and there 
was a large attendance. 

The Chairman, in opening the conference, 
referred to the chief provisions of the Isolation 
Hospitals Act, and specially to the fact that 
money expended in providing hospitals under 
this Act was to be provided by the County 
Council out of the county rates, the loan to 
be repaid to the County Council with interest 
at the rate of 4 per cent, per annum. This 
was a very high rate of interest to pay, but as 
the County Council had power also to make con- 
tributions to the expenses of the hospitals, any 
profit accruing to the County Council, as a result 
of their receiving a greater interest than they were 
paying for the money borrowed, might be paid as 
part of a contribution by the County Council to 
the expenses of the hospital. Dr. Livingstone 
pointed out that in their annual and other reports 
many of the district medical officers of health 
had referred to the deficiency of isolation hospital 
accommodation in the county. In 1893 there 
were 8,200 cases of infectious disease notified 
in the county of Durham, of which number 920 
died, and in i<594 there were 7,205 cases notified, 
with 589 deaths. Excluding the boroughs, to 
which the Act did not apply, and the rural 
districts of Darlington, Hartlepool, and Stockton, 
which had the use of borough hospitals, there 
were 520,000 inhabitants in the administrative 
county, and allowing one bed per 1,000 
popu ation, as recommended by the Local 
Government Board, the hospital accommodati<.n 
for this population should be 520 beds. This 
calculation excluded small-pox, for which separate 
isolation would be necessary, as that disease ought 
never to be treated in a hospital used for other 
diseases. But instead of 520 beds there were at the 
present time only 120, and many of these were 
not at all suitable. It was evident, therefore, that 
further isolation hospital accommodation was 
urgently needed. Another jioint to be con- 
sidered was that patients had a much better 
chance of recovery when isolated in a well-ap- 
pointed hos|iital than when nursed at home in 
small and frequently over-crowded houses where 
I)roper isolation was impossible. Dr. Livingstone 
concluded by referring to the requirements of a 
permanent isolation hospital, as regards site, 
construction, etc., and stated that the County 



ANALYTICAL NOTES. 



165 



Council would insist that the minimum require- 
ments of the Local Government Board should be 
carried out as respects any hospital erected under 
the Isolation Hospitals Act. 

Dr. Hill (County Medical Officer) said that there 
were seventeen sanitary districts in the adminis- 
trative county, having a population of 230,000, 
without hospital accommodation of any kind, while 
that provided in several other districts was quite 
unsuitable. He advocated the erection of joint 
isolation hospitals in several districts, and pointed 
out that there was already one joint hospital district 
in the county, that of Lanchester, which included 
the urban districts of Consett, Benfieldside, Lead- 
gate, Stanley, and Tanfield, and the rural district 
of Lanchester. This district was already provided 
with one excellent permanent h -spital of twenty- 
four beds, and two other hospitals were about to be 
provided, and it was worthy of note that there had 
never been any friction between the constituent 
authorities of this hospital board. The Auckland 
Union, with a population of 1 00,000, which was prac- 
tically without any isolation hospital accommodation 
whatever, would form an excellent hospital district, 
and the adjoining urban district of Willington should 
be included in it. The cost of construction of large 
joint hospitals, as compared with smaller institu- 
tions, was rela ively less, and they obtained greater 
efficiency of administration, and reduction in the 
cost iji maintenance— two very important points. 
A plea that was often advanced against the erection 
of isolation hospitals was that, if provided, they 
would always be empty, as people preferred to be 
treated at home ; but if the hospital was comfort- 
able, and the nursing good, the advantage of using 
such a hospital would soon be made evident to 
the people. The statistics of the county showed 
this to be the case, for in those districts where 
good comfortable hospitals had been provided, 
there was not the slightest difficulty in getting the 
people to make use of them. Everything should 
be done to make a hospital as comfortable and 
cheerful as possible, the nursing should be good, 
and not left, as was so frequently the case, to an 
old untrained caretaker ; and, what was equally 
important, there should be no charge for the use 
of the hospital. 

Mr. Bartlett (Darlington) said that at Darling- 
ton there was an excellent hospital, and he was 
not aware that there had ever been charged upon 
the rates, in regard to the hospital, more than 
id. or i^d. in the ^. There was no difficulty in 
getting the patients isolated, as was evidenced by 
the fact that 60 per cent, of the ijotified cascs of 
infectious diseases found their way into the 
hospital. 

Mr. W. Logan (Chairman, Lanchester Rural 
District Council) hoped the Conference would take 
a much higher aim than merely that of cost. But 
there was one view from which the provision of 
thes e hospitals could be made to suit the pocket. 



In Durham they had a mining prjpulation, 
which creat-d the wtalth of the county. Now, 
if they kept that population in a healthy condition, 
they wo'ild retain their wealth, but if they allowed 
the working people to be the prey of disease, and the 
bread winners to die, then they destroyed the means 
of producing that wealth. Looking at it from even 
a pocket point of view, he thought the building of 
infectious diseases hospitals would be a saving, 
instead of an increase to the rates. He did not 
think the cost of an hospital should much exceed 
^200 per bed. In his opinion there should be 
one bed for tvery 1,000 population. 

After much discussion, ttie following resolution was 
passed : — " That in the opinion of this Conference it 
is desirable that each local authority should provide 
isolation hospital accommodation for its own 
district, or that two or more districts should com- 
bine for that purpose." 



ANALYTICAL NOTES. 
The suggestion that an official analyst should have 
been sent out with the Ashantce Expedition, so 
that rapid analyses could be made of the water, as 
to its general fitness fur use by the troops, and the 
possibility of it having been poisoned by the 
enemy, is thoroughly practical, and breaks new 
ground for the analyst. It would, however, be 
desirable that his apparatus should be of the 
strongest possible description, and that he should 
stipulate that the "sampling" should be carried 
out by the reconnoitring party. The war analyst 
would be a valuable adjunct to the medical staff, 
and, being a trained scientific chemist, his advice 
would be very useful on many questions that arise 
from time to time, when troops are on active service 
in a strange country. 



Some recent researches by Eduard Kiilz, as to 
the amount of gases dissolved in human milk, 
showed that in 100 c.c. there is I'o; to i'44 c.c. of 
oxygen, 2*35 to 2-87 of carbonic anhydride, and 
3-37 to 381 of nitrogen. The higher amount of 
the two former gases than that found by other 
investigators is possibly due to aerial contamina- 
tion, as the method of collection used did not 
render this quite impossible. 

The ferric chloride test for salicylic acid, 
although giving satisfactory results with beer, is not 
so satisfactory with wine, as the ether used in 
extracting abo dissolves out sm dl quantities of 
organic acids, other than salicylic, which interfere 
with the colour reaction. Matteo Spica advocates, 
to avoid this,ihat the ethereal solution be evaporated 
to dryness, and the residue extracted with light 
petroleum, in which salicylic acid is soluble, but 
not tartaric acid. Ferric chloride is then added to 
the residue obtained by evaporation of the 
petroleum. Another delicate method — the results 



i66 



PECULIARITY OF TYPE IN ENTERIC FEVER. 



obtained by which are not affected by the presence 
of tartaric, tannic acids, etc. — is to evaporate a 
small quantity of the wine, and render it alkaline, 
then extract with ether, and evaporate the extract 
to dryness, and heat the residue with strong nitric 
acid ; then neutralise with ammonia, when any 
salicylic present is converted into picri^c acid. If 
this solution is now heated, and a piece of white 
cotton-wool, freed from grease, steeped in it, as 
small a quantity of salicylic acid as 0*02 milligram 
per litre, and if only 25 c.c. of the wine were 
taken, will dye it distinctly yellow. 



A rapid method of standardising sulphuric acid 
has been devised by Weinig, and is stated to be 
very accurate. He neutralises the acid with 
ammonia, then evaporates the solution of ammonia 
sulphate formed to dryness. As a little ammonia 
is lost during evaporation of the bulk, the residue 
is moistened with ammonia and finally dried at 
1 10-120 degrees. 



In estimating potassium sulphate in wine, 
L. Hogounenq has proved that the decomposition 
of the organic sulphur compounds which un- 
doubtedly exist in most wines, is a considerable 
source of error when the estimation is made on an 
acid solution of the ash. The error is found to 
amount to 30 to 40 per cent, in excess of the 
actual amount of potassium sulphate present. To 
avoid this, therefore, the estimation should be 
made on a portion of the original sample. The 
other matters in solution do not affect the accuracy 
of the result. 



Ralph Stockman has recently carried out some 
very careful researches in the amount of iron in 
food. The incineration 'in each case was made 
very complete by the aid of hydrochloric and 
sulphuric acids, extracting the residue with dilute 
sulphuric acid, reducing with zinc, and then 
titrating with potassium permanganate. The 
daily diet of the average person was found 
to contain from nine to ten milligrams of iron, but 
in chlorotic people who take little food was as low 



as three milligrams. The following is the amount 
found in some articles : — Milk from 2 to 4*3 milli- 
grams per litre. 

Per 100 grams (diicd). 
Oatmeal ... ... ... 3*5 

Bread ... .. ... o'6i — 

Yellow Ox Marrow ... 2'5 — 
Red Calf Marrow ... 76 — 
Beefsteak yg — 



0-85 

4 

87 



milligrams. 



]os(i Cosares, in analysing the sulphuretted 
mineral waters of Lugo and Guitiriz (Galicia, 
Spain), found an abnormal quantity of fluorine in 
them. Fresenius' method gave 0*02344, 0*02806, 
and 0*02277 gram of sodium fluoride per litre; 
Carnot's method 00 268 gram. He believes that 
fluorine in mineral waters is not so rare as is 
generally supposed. 



Mr. W. Lincolne Sutton has been appointed 
Public Analyst to Norwich. 



NOTES OF SOME CASES ILLUSTRATING 
PECULIARITY OF TYPE IN ENTERIC 
FEVER. 

BY 

Henry E. Armstrong, D.Hy., M.O.H. to Newcastle- j 
upon-Tyne, and Medical Superintendent of the City I 
Hospital for Infectious Diseases, Newcastle-upon-Tyne. ■ 

The remarkable prevalence of enteric fever in 
the north-eastern district of England during late 
years has been shown by the Registrar-General, 
and, quite recently, by Dr. T. W. Thompson, one 
of the Medical Inspectors of the Local Government 
Board. In this area, Newcastle enjoys, in 
common with the rural district of Hexham, the 
healthiest position as regards enteric fever. 
Indeed, the disease has never been a prominent 
one in the city during the twenty-three years I have 
held the appointment of Medical Officer of Health. 
The following are the death-rates per 1,000 from 
it, and the rates of mortality per cent, to cases 
since the notification of infectious diseases came 
into operation : — 



ENTERIC FEVER— NEWCASTLE-UPON-TYNE, 1883-94. 
Death-rates per 1,000 Population (incluoing Deaths in Hospital). 



Year ... 


1883. 


1884. 


1885. 


1886. 


1887. 


1888 


1889. 


1890. 


IS9I. 


1S92. 


1893. 


1894. 


Rate ... 


0*3 


0*3 


0*4 


0-2 


0*3 


0"2 


0*1 


0'2 


01 


o'07 


01 


o-i 





Mortality per 100 Cases 


) Notified (including 


Death ; 


in Hospital). 






Year ... 


1883. 


1884. 


1X85. 


i88'>. 


1887. 


1888. 


1 889. 


1890. 


1891. 


1892. 


1893. 


1894. 


Ra'e ... 


198 


I8-I 


22'I 


16 -6 


I2'9 


197 


13-9 


177 


17*9 


14*4 


17*7 


183 



PECULIARITY OF TYPE IN ENTERIC FEVER. 



167 



One point of interest in connexion with hospital 
experiences of enteric fevtr in Newcastle is that 
of the changes in type which have shown them- 
selves of late years. For a considerable time past 
several of the ordinary or " typical " symptoms 01 
the disease have been, until recently, conspicuous 
by their absence. Thus, during the last year or 
two, prior to 1895, diarrhoea was rarely met with, 
having been replaced, as it were, by constipation ; 
rose spots were frequently wanting ; often the 
temperature failed to fall at the characteristic 
period, but continued high during the fourth week 
or later. In other cases, genuine relapses 
occurred with much more than average frequency. 

In the present year the above condition ot 
things has, to a great extent, passed off, and a 
general reversion to type has predominated. 
During the past two months, however, we have 
had an unusual experience, viz., the occurrence of 
a considerable number of cases of both enteric 
and scarlet fevers in the same persons. In some of 
these cases the two diseases were simultaneous and 
concurrent ; in others the signs of scarlet fever 
appeared during the early stage of convalescence 
from enteric fever. 

There is nothing very remarkable in the 
occurrence of two infectious diseases in the same 
person, either at the same time or in rapid 
succession. Several of such cases were recorded 
by Mr. Marson, of the London Small-pox Hospital, 
in 1847. Only last year Dr. Caiger placed before 
the Epidemiological Society an extensive and 
valuable record of the numerous cases of com- 
pound infectious disease coming under his 
observation in the Stockwell Hospital of the 
Metropolitan Asylums Board.*" My own more 
limited experience includes, inter alia, one ex- 
ceedingly interesting simultaneous double case of 
scarlet fever and typhus in the person of a former 
resident medical officer of the Newcastle Hospital 
for Infectious Diseases, Dr. James Hindhaugh, in 
whose case the two diseases were ushered in by 
the same rigor, the eruptions of the two fevers 
appearing on the second and fifth days respec- 
tively. I have also frequently observed the 
development of one infectious disease during 
convalescence from another. But I have never, 
before the latter part of the present year, had 
under my care a succession of cases of simul- 
taneous or sequent enteric and scarlet fever. The 
cases are too numerous to be merely coincidental. 
They seem rather to indicate some special 
peculiarity of type. 

The following report of certain of these cases, 
kindly prepared by Dr. Cecil Willcox, resident 
medical officer of the hospital, illustrates, in 
different degrees, the occurrence of the double 
ailment simultaneously, or in succesbion, and in 

• "On the co-existence of more than one infectious 
disease in the same individual." Trans. Epidem. Society of 
Loadon, 1893-4. 



various members of the two different families, the 
presence of scarlet fever being indicated by the 
usual symptoms, except that of the scarlet rash, 
which was observed in only one of the cases in 
question. 

Report on several cases of Scarlatina and Enteric 
Fever occurring in the same persons treated in the 
City Hospital for Infectious Diseases, Newcastle- 
upon-Tyne. — The cases occurred in members of 
two families, viz , four in one family and two in 
another. AH of the cases were admitted as 
notified cases of enteric fever. 

First Family. 4 

Three brothers and a sister, admitted October 
ii-d, 1895. 

Alexander R , admitted on 27th day of 

illness ; aged 16. 

Robert R , admitted on 8th day of illness ; 

aged 8. 

Peter R , admitted on 5th day of illness ; 

aged 14. 

Ann R , admitted on 2nd day of illness ; 

aged 4. 

Details of Cases of Alexander, Robert, arid 
Peter R . 

All three commenced to be ill in a similar 
manner, though at different dates. The onset 
was said to have been gradual, with severe head- 
ache and anorexia. All had diarrhoea at the 
commencement, the motions in all being light 
yellow in colour and very loose, the average 
number of motions passed in twenty-four hours 
being from three to four. All have had some 
distension and tenderness of the abdomen. 
Alexander had epistaxis and cough, probably 
due to accompanying bronchitis, though none 
was found on admission. They all kept about 
for some days before taking to bed. In none 
had any eruption been noticed. The only point 
in their previous history in which the symptoms 
differed was that Alexander is said to have 
complained of sore throat at an early stage of 
his illness. 

On Admission. — Condition of the tongues com- 
pared. 

Alexander (27th day).— Tongue dry, with longi 
tudmal fissures and stripes of white fur at each 
side. The boy was emaciated, and his general 
condition was consistent with an attack of enteric 
fever at the date above named. 

Robert (8th day). — Tongue dry and glazed, a 
white stripe on each side. 

Peter (5th (?) day).— Tongue dry, a white stripe 
on each side. 

Abdominal Conditions — 

Alexander (27th day).— No distension or tender- 
ness of abdomen at present. 

Robert (8th day).— Slight distension and some 
tenderness. 



i68 



PECULIARITY OF TYPE IN ENTERIC FEVER, 



Peter (5th (?) day). — Abdomen distended and 
tender ; gurgling in right iliac fossa ; three rose 
spots marked. 

Temperatures on Admission — 

Alexander, io2*S°, became normal at night, 
34th day. 

Robert, ioo"2'', became normal loth day. 

Peter, i02"o''; became normal 21st day. 

There has been no diarrhoea in any of these 
cases since admission. Two days after admission 
Ale.xander was found to have a scarlatiniform 
rash out on the chest and abdomen. He was 
immediately isolated. 

The case of Ann R (the sister) must be 

taken separately. She was sent in with her three 
brothers as being feverish, and probably being a 
case of enteric fever, as were the rest thought to 
be. Her history before admission is as follows : — 
Onset sudden, with vomiting and headache ; slight 
sore throat, but no rash. 

On Admission. — Tongue uniformly coated, the 
papillae enlarged and prominent (strawberry 
tongue) ; no distension or tenderness of abdomen ; 
no diarrhcea ; no erufytion ; temperature, 101° F. 
She had no scarlet eruption afier admission. 
The four children were all isolated from the rest 
of the patients in the hospital, and on October 
22nd all were found to be desquamatmg. Five 
days after admission, papillae were noticed on the 
tongue of one of the boys (Peter). 

In the above cases at least two, and probably all 
three, of the boys appear to have had both enteric 
and scarlet fever before the girl sickened. She 
had scarlet fever only, apparently contracted from 
the brothers before removal to hospital. 

Second Family. 

Mary and John McG , admitted on 9th 

October, each on loth day of illness. 

History before Admission. — Onset gradual, with 
pain in abdomen. Both kept about for several days 
before taking to bed ; neither has had diarrhoea. 

On Admission {[ohn). — Tongue coated, no 
fissures, the papillae enlarged and prominent 
(strawberry tongue, very t>pica'); abdomen very 
considerably distended, with some tenderness ; 
several spots, regirded as being doubtful enteric 
spots; temperature, 102-8''; motions are natural; 
no history ot a rash ; has had sore throat ; no 
albumen in urine. 

Mary {on Admission). — Tongue heavily coated, 
no hssures, the papilla: rather prominent ; some 
distension and very marked tenderness of abdomen, 
especially over right iliac f;ssa, where gurgling is 
read.ly elicited ; some cough, but no physical 
signs of chest mischief on stellioscopy ; no eruption ; 
headache persistent; temperature, i04'6''; albumen 
in urine, as roughly estimated by the nitric acid 
method. 

John (Further Progress). — Morning temperature 
fell to normal on the nth day of illness, rose 



again at night, never remained normal all day, and 
on the i8th day of illnesss rose to 100-2°, on 
the 19th to 102", and on the 20th to 103-2**. 
It declined later on, and again fell to normal 
on the 2 7lh day of illness. There has been no 
diarrhoea, albuminuria, or rash. The throat 
was reddened on, and for some time after, 
admission. The tongue kept its strawberry ap- 
pearance for several weeks. On October 23rd 
desquamation was noted on arms and chest. 

Mary (Further Progress). — The albuminuria 
persisted; diarrhoea set in; stools light yellow in 
colour and loose ; several contained small clots of ■ 
blood. On October 13th (14th day of ailment), | 
diarrhoea excessive, fifteen times in twenty-four 
hours ; papillae on tongue very prominent. October 
15th, acute rheumatism of rij^ht shoulder and elbow. 
October 23rd (24th day of ailment), desquamation 
of arms and neck. October 27th, very severe 
haemorrhage from the bowel (four times repeated). 
Died October 29th. Post 7nortem revealed the 
usual changes in the small intestine due to enteric 
fever (swelling and ulceration of Peyer's patches ; 
intestine for several feet above caecum deeply in- 
jected ; several erosions of Peyer's patches ; clots 
of partly altered blood in bowel) ; spleen and 
liver enlarged ; the kidneys were swollen ; capsule 
stripped easily ; renal papillae engorged. 

Note. — Since the foregoing was brought before 
the Northern Branch of the Society, other cases of 
the same character have come under observation. 

Including the three boys of the R family, and 

the two McG 's above mentioned, the total 

number of cases of the double disease observed 
in hospital from October 3rd to date (December 
16th) is fifteen. The cases were all notified 
as enteric fever. The total includes three 

persons in a second family (T ) of four — 

father, mother, and two children — all admitted on 
December 3rd as cases of enteric fever — the 
children at the 5th and 4th weeks, the father at 
the 17th, and the mother at the nth day of 
ailment respectively. On admission the children 
had strawberry tongues and albuminuria ; they 
afterwards desquamated. The mother, who had 
symptoms of enteric fever on admission, soon 
afterwards developed a strawberry tongue and 
albuminuria, and was desquamating on or about 
December 13th. Up to date (December i6th — 
30th day of ailment), the father has shown 
symptoms of enteric lever only. In four of the 
ten remaining cases, the usual signs of enteric 
fever in hospital have not been characteristic. 
Tne febrile symptoms observed were thought by us 
at the time (but perhaps erroneously) to be due 
solely to other existent disease— meningitis or 
broncho-jineumonia respectively. Several of the 
ten cases suspected on admission on account of pro- 
minent tongue-papillrc, with or without ^ore t iroat, 
desquamated later on ; in others, desquamation 
was the first sign of scarlet fever noticed. Peeling 



THE BYE-PRODUCTS OF SLAUGHTER-HOUSES. 



169 



of the epidermis was marked in all of the fifteen 
cases. Albuminuria was present in four of the ten 
last named. In several instances tne scarlet fever 
succeeded the enteric fever; in others, the two 
diseases were apparently coincident, desquamation, 
albuminuria, etc., occurring before the increased 
temperature or other signs of the enteric fever had 
passed off. 

In connection with the foregoing account, it 
may be observed that scarlet fever has been very 
prevalent in Newcastle of late in a mild form, 
frequently with very little rash, which had quite 
disappeared by the time the patient had reached 
the hospital. 

One result of our recent hospital experience has 
been to cause us to view with suspicion the 
slightest prominence of the tongue-papilloe in any 
case admitted as enteric fever. 



THE BYE-PRODUCTS OF SLAUGHTER- 
HOUSES. 

[A Contributed Article.] 

Of the many advantages of a public abattoir^ not 
the least should be a certain amount of control 
over what may be called the bye-products of the 
slaughtering business. The blood, entrails, 
excreta, bones, hides, hoofs, and general offal, 
as soon as they leave the door of the slaughter 
house, enter upon a voyage the reckonings of 
which are by no means simple, even to the 
initiated ; and the history of this, viewed in the 
light of the known results of experimental 
pathology, is full of important problems to the 
Medical Officer of Health who is alive to the 
possibility that the pathogenic microbes, which 
necessarily become strewn over any area in which 
cases of infectious disease are occurring, may enter 
upon phases in their life-history which have, so far, 
escaped recognition. 

Take, for instance, some of the methods of dis- 
posal of the blood and intestines. A certain 
number of pau'iches, not always emptied of their 
contents, and not always cooked, are retailed for 
dogs' and cats' meat. The remainder, along with 
the guts and excreta, find their way, as a rule, into 
the blood-tub. In a certain number of msiances, 
there is an arrangement with a manure manufac- 
turer to remove this tub, with its contents, once a 
week, an empty tub being left in its place ; but if 
the butcher, as is often the case, possesses a field 
of his own on the outskirts of the town, the tub is 
removed once a week in the cart which is used in 
his ordinary business, and emptied on the manure 
heap in this field, the mixture being periodically 
strewn over the ground to raise a rich crop of grass 
for the animals which he puts out to graze from 
time to time. A few careful men cover each dis- 
charged tub load with road scrapings, but even a 



cursory inspection will generally discover half- 
decomposed guts exposed here and there on the 
heap, and covered, in warm weather, with swarms 
of fiies of various kinds, c jnspicuous amongst 
others being the cominon " blue-bottle." The 
picture of these blue-bottles, with their filth- 
covered legs, transferring their attentions from the 
manure heap to the neighbouring pantries and 
nurseries, is far from a pleasant one — particularly 
if the guts should happen to have come from an 
animal infected with '' tubercle " or " anthrax." 

A very large number — perhaps the majority — of 
these blood-tubs are regul irly removed by market 
gardene "s, who spread their contents, guts and all, 
over their plots ; and the possibility of growing 
vegetables, as they push their way upwards through 
the soil, becoming contaminated by this filth, may 
be indicated by the fact that in i^ig slaughter 
houses the mixture of dirt, epithelium, and bristles 
removed from the skin by scraping is carefully kept 
apart from the blood and offal, lest the bristles 
should be discovered on lettuces and other vege- 
tables when sent to market. 

If the butcher works a farm in connection with 
his business, the sheeps' guts, beasts' paunches with 
their contents, and coarse offal, are kept separate, 
and given, uncooked, to the farm pigs. It appears 
to be the usual plan to throw the guts and offal 
into a field, and let loose the pigs upon it ; and the 
spectacle of two pigs careering about a field, one at 
each end of a string of guts, is stated to be no un- 
common sight. Now, given the introduction of a 
pig suffering from swine fever into a mixed cattle 
and pig slaughter house, here is obviously a chain 
of events which might assist in the spread of that 
disease. Stray dogi are attracted by this offal, and 
foxes have been seen devouring it. The larger 
birds, too, such as crows and starlings, peck at it, 
and sometimes carry pieces away. It is only 
necessary to remember the circumstances which are 
already known to be associated with variation of 
the virulence of pathogenic microbes, and the 
effect upon the development and properties of 
these of grovvth on different medi.i and in various 
hosts, to recognise the possibilities which such a 
string of events may afford for the evolution of 
pathogenic organisms or the intensification of the 
harmful qualities of some already parasitic. A 
more suitable background for the picture of damp 
dwellings and rural diphtheria than the primitive 
methods of farmers in dealing with raw nitrogenous 
waste of various kinds could not well be imagined. 
Rats eat this raw offal, which is strewn about so 
recklessly ; starlings and hens pick at it ; cats eat 
rats, offal, and i>tarlings ; dogs worry cits ; and so 
on, witu the possible result that some of tlie many 
cats, which have a tendency to help themselves to 
the contents of the larder, may carry upon their 
teeih and claws a coating of microbes, whose 
genealogy is probably as remote and complicated 
as it is fall of possible danger. To any man given 



I70 SCIENTIFIC INVESTIGATIONS OF THE LOCAL GOVERNMENT BOARD. 



to the mildest speculation on the biology of para- 
sitic microbes, the spectacle of the many dirty, lean, 
ob\-iously unhealthy cats, which can be seen in the 
back streets of towns, is repulsive in the extreme, 
and none the less so when these are being caressed 
by children, as often happens. 

If it is necessary to prolong one end of the 
human alimentary canal into miles of expensive 
sewers, it would seem to be equally important that 
town and country alike should defecate raw nitro- 
genous bye-products into a destructor, igneous or 
other, wiih at least as much precision as an 
individual uses a water-closet. Indeed, the whole 
case for the necessity of public abattoirs may very 
well rest upon the not unreasonable claim that it is 
at least as important to provide for the wholesome 
intake of animal food as for the cleanly removal of 
faeces. 



SCIENTIFIC INVESTIGATIONS OF THE 
LOCAL GOVERNMENT BOARD, 1893-4. 

BY 

R. Thorne Thorne, M.B., F.R.S., 
Medical Officer to the Board. 

Etiology of Enteric Fever. 

The " Typhoid Bacillus," though it has come to 
be regarded as in all probability the essential 
cause of enteric fever, has never yet been experi- 
mentally proved capable of inducing that disease. 
Rodents inoculated, whether subcutaneously or 
intraperitoneally, with this bacillus, do indeed 
suffer fatal illness, but, as Dr. Klein has pointed 
out in the appendix to my report for 1892-93, the 
malady thus induced by him in the guinea-pig, is 
not of specific nature ; it is, moreover, just as 
easily produced by injection of other and various 
microbes. In 1893-94, he has further tested 
the ability of the typhoid bacillus to produce 
enteric fever, using for his purposes monkeys and 
calves. 

Dr. Klein's experiments on monkeys comprised 
two series ; feeding these animals with the typhoid 
bacillus, and inoculating the microbe into their 
groins. 

As to Jeeding^ two monkeys were made to 
swallow, on several successive days, milk and 
bread to which had been added broth culture of 
the tyi)hoid bacillus derived from the spleen of a 
person who had died of enteric fever. Neither of 
these monkeys suffered any illness whatever, and 
when they were killed, two or three weeks later, 
no pathological lesions were found in them. 
Moreover, attempt to recover, by culture, the 
typhoid bacillus from their heart - blood and 
spleens failed in both instances. 

As regards his inoculation experiments, however, 
Dr. Klein obtained results that were less un- 
equivocally negative. In all, eight monkeys were 
mcluded in tnis series, each of them being 



inoculated in considerable amount with gelatine 
culture of the bacillus derived, as before, from the 
spleen of enteric fever. Some, but not all, of 
these eight monkeys exhibited rise of temperature, 
and certain of them suffered more or less from 
loss of appetite and from diar.hoiia ; but none of 
them displayed any symp'om that could be de- 
finitely attributed to enteric fever. Of the eight, 
two (which had been accidentally inoculattd with 
a culture containing the streptococcus of erysipela<=, 
as well as the typhoid bacillus) died on the sixth 
and sixteenth day respectively, and other five 
were killed at intervals varying between eleven and 
sixteen days from ihe date of their inoculation. 
Examined post-mortem, none showed any in- 
testinal or other lesion parallel to those of enteric 
fever, except that in certain of them there was 
enlargement of the spleen, and in one enlargement 
of the mesenteric glands also. And bacteriologi 
cally, the evidence proved, in the main, negative; 
cultivation of the mesenteric gland-juice and ot 
the heart-blood in no instance yielded the typhoid 
bacillus, nor w-as this organism found, after death, 
in the intestinal contents of any one of these 
monkeys. As regards the spleen alone — and this 
only in those cases (three) in which that organ 
appeared enlarged — was there suggestion of 
positive bacteriological result. Thus, the spleen 
of one monkey (dead on the sixth day of mixed 
infection), yielded the typhoid bacillus in abun- 
dance and in pure culture ; from that of another 
was obtained bacillus coli ; while in a third in- 
stance, the monkey's enlarged spleen yielded a 
nondescript bacillus, exhibiting characters pertain- 
ing, some of them, to bacillus coli, others to the 
typhoid bacillus. j 

Whatever may be the interpretation of the above 
results as regards the monkey, they were too in- 
definite for Dr. Klein's purpose, and he proceeded 
next to inoculation of calves. Four calves were 
injected by him subcutaneously in their groins 
with broth culture of the typhoid bacillus derived 
from the spleen of enteric fever. In none was 
there observed any rise of temperature or other 
symptom of illness ; but in every one there 
occurred within three to four days of inoculation 
distinct enlargement of the inguinal lymphatic 
glands on the side operated on, which enlargement 
])ersisted until the calves were killed ten days to a 
fortnight from the date of experiment. Post- 
mortem, all the viscera were found normal ; the 
four calves presented absolutely no lesion, except 
that in each instance the lymph glands of the 
region inoculated were enlarged and juicy. Bac- 
teriologically the heart blood and spleen failed 
always on cultivation to yield micro-organisms, 
but the juice of the enlarged inguinal glands con- 
tained without exception the typhoid bacillus in 
abundance. The indication thus obtained that 
the tissues of the bovine animal can serve as 
multipl)ing ground for the typhoid bacillus 



SCIENTIFIC INVESTIGATIONS OF THE LOCAL GOVERNMENT BOARD. 171 



obviously deserves to be followed up by further 
experiments. 

Other study by Dr. Klein in 1893-94 of the 
etiology of enteric fever has had to do with the 
stability, as separate species, of the typhoid bacillus 
and bacillus coli, in culture under laboratory con- 
ditions and in the process of transference from 
animal body to animal body. On the one hand 
bacilli of both sorts, derived in each instance from 
human sources, were tested by him as to their 
vitahty, and as to retention of their differential 
characters, in w-aters of various composition or 
quality ; and on the other hand, the two sorts of 
bacillus obtained from outside the human body, 
namely, from excrementally polluted public water 
supplies, were transferred again and again from 
subculture to subculture, and were passed from 
peritoneum to peritoneum in separate series of 
guinea-pigs. But the resiilt was always uniform. 
Whatever the source of the one and the other 
bacillus, and whatever the experimental conditions 
in the laboratory or in the animal body to which it 
was exposed, each retained unimpaired the differ- 
ential features that characterised it at the outset. 
Incidentally it appeared in the course of the?e 
experiments that the persistence in a water medium 
both of the typhoid bacillus and of bacillus coli, is 
largely governed by the chemical constitution of 
the water of experiment. The fact is noteworthy, 
and in this connection these microbes are deserving 
of further study. 

Protective Inoculations. 

In his former report (1892-93) on protective 
inoculations. Dr. Klein insisted on the need for 
distinction between the protoplasm and the mt ta- 
bolic products of the microbe of a given disease. 
It is not, he pointed out, yet known in regard of 
many specific infectious diseases, how far the 
manifestations of the malady are due to the mere 
presence in the infected animal of a particular 
bacterium per se, or to the metabolic products 
which result from the life-processes of the microbe ; 
and further, he urged, differentiation of " proto- 
plasm " and of " product " is the more called ,for 
if, for the purpose of rendering the animal body 
proof against the virus of a disease, trustworthy 
materials are to be derived from the microbe 
associated therewith. Dr. Klein had been then 
working with a number of dissimilar microbes 
which each and all of them, when their intracellular 
substance was introduced into guinea-pigs, pro- 
duced in these animals one and the same malady ; 
and further, guinea-pigs thus made ill by inocula- 
tion with the intracellular poison of any one of his 
microbes were found by him to be protected 
against infection by any of the others. Dr. Klein 
inferred from this that the intracellular substances 
of all his microbes contained (physiologically) one 
and the same poison, and that the poison thus 
found common to all of them must needs be non- 



specific, and in no sense therefore related to the 
manifestation of the different diseases certain of 
these microbes have been found able to induce. 

The particular microbes with which he had 
been experimenting included not only the typhoid 
fever bacillus but also Koch's cholera vibrio, and 
in so far as results of the above sort obtained by 
him in regard of the latter microbe seemed to call 
in question the protective value of those anti- 
cholera inoculations of the human subject which 
were being practised abroad. Dr. Klein's inferences 
appeared of some considerable importance. Koch's 
vibrio, however, as also the typhoid fever bacillus 
and the other microbes with which Dr. Klein had 
been working, belong to a group of micro-organisms 
having, whatever their virulence for the human 
subject, but feeble pathogenicity for rodents ; large 
doses, whether of their protoplasm or of their 
metabolic products, being requisite for production 
of physiological effect in the guinea-pig. And 
accordingly it seemed desirable that judgment 
should at least be suspended until Dr. Klein's 
experimental observations of intracellular poisons 
had been extended to microbes which not only are 
pathogenic to man but also are virulent in small 
doses to rodents. 

Among the microbes studied in the latter sense 
in 1893-94 by Dr. Klein, the bacillus of anthrax 
and the diphtheria bacillus sufficiently well repre- 
sent bacteria pathogenic ahke to the human sub- 
ject and to the guinea-pig : and as to these Dr. 
Klein has some interesting facts to record. Bacillus 
anthracis and bacillus diphtheriae were, tested by 
him as to the presence within their protoplasm of 
any (intracellular) poison ; whether, that is, the 
protoplasm of the one and the other microbe is 
capable of inducing in guinea-pigs any definite ill- 
ness. Further, guinea-pigs that had been thus 
injected with the protoplasm, and protoplasm only, 
of the anthrax bacillus or of bacillus diphtheria, 
were tested by him as to their immunity against, or 
tolerance of, injection with the virus of anthrax and 
diphtheria respectively. And Dr. Klein found that 
neither the one nor the other bacillus included in 
its protoplasm any chemical poison ; that these 
bacilli, apart from their metabolic products, 
exercised no physiological effect whatever when 
injected into guinea-pigs ; and that guinea-pigs 
thus dealt with obtained thereby no immunity 
whatever against anthrax or against diphtheria. 

These results of Dr. Klein's further study of 
protective inoculations are of a sort to strengthen 
his doubts as to the ability of the protoplasm of a 
given microbe to inhibit, when antecedently in- 
jected into the human subject, the physiological 
activities of the same microbe qua its metabolic 
products. From Dr. Klein's point of view, there- 
fore, the more matured experience of India in 
the matter of the anti-cholera inoculations there 
being practised, will be looked for with particular 
interest. 



172 



LAW REPORTS, 



Etiology of Cancer. 

Concurrently with increase of late years in the 
mortality referred to cancer, special attention has, 
by aid of improved methods of staining and pre- 
paring specimens, been directed to the histology of 
this disease, and thus it has come about that not a 
few observers are attirming the presence of para- 
sites in cancerous tissue. Question has therefore 
arisen as to whether, in the interests of public 
health, cancer should not be regarded as coming 
within the domain of preventive, rather than of 
curative medicine, and accordingly preliminary 
investigation has been undertaken of the claim of 
cancer to be regarded as a parasitic disease. 

Dr. Klein, in a paper on " Psorosptrms in their 
Relation to the Etiology of Cancer," enters on a 
critical examination of epithelial cancer from this 
point of view, and his paper is perhaps the more 
deserving of attention smce he finds reason for 
abstaining from formulating any definite conclusion 
on the suDJect. He points out that as an essential 
condition of the problem to be solved, it is neces- 
sary to define, in regard of malignant growths in 
epithelial structures, what morphological appear- 
ances are peculiar to cancerous epithelium but to 
no other epithelial tissue in health or disease ; and 
he goes on to institute strict comparison of the 
)norphological elements of epithelial structures 
under various conditions normal and abnormal. 
As a result he deals with a number of appearances 
which, though they have been adduced as evidence 
of the presence in cancer of parasites (;r spores of 
parasites, are nevertheless to be fuund in epithelial 
structures in circumstances where cancer is alto- 
gether out of question. In this way Dr. Klein 
eliminates from consideration a number of alleged 
parasitic forms as not necessarily foreign to the 
tissues of the animal body, and finally retains one 
only, namely, an amceba, described and termed 
rophaloceplialus carcinomatosus by Korotneff, as 
unquestionably parasitic in nature. This amoeba, 
however, though diligently sought for by Dr. Klein 
in many cancers, has not been found by him in 
more than a single instance, and he hesitates, 
therefore, to accept the organism as having definite 
relation to cancerous disease. 

Bactfriology of Vaccine Lymph. 

Certain bacilli obtained by Dr. Klein indifferently 
from calf lymph, from human lymph, and from 
small-pox matter, were reported by him in 1892-93 
as possessing identical morphological characters. 
But inasmuch as these bacilli refused to grow and 
multiply on or in any of the artificial culture media 
employed by him to that end, Dr. Klein had not 
been able to ascertain in what way they differed — 
if, indeed, they differed at all — one from another, 
or to determine whether these microbes were dead 
or livmg. 

In 1893-94, he has engaged in further attempt 
at differentiation of these bacilli ; using lymph 



taken from the vesicles of the calf at intervals 
varying between 72 and 112 hours after vaccina- 
tion of that animal, and employirg as culture 
media certain nutriive materials not previously 
adopted by him. In all, his further attempts to 
grow the bacilli of calf lymph extended to above 
100 culture experiments, but in no single instance 
did growth result ; all his cultures proved sterile. 
He next sought to cultivate these bacilli in the 
living subcutaneous tissues of guinea-pigs and of 
calves. But here, again, he met with no success ; 
and, for the present, the question as to the identity 
of the bacilli found by him alike in vaccine lymph 
and in small-pox matter, mU:)t remain unde- 
termined, ^jr^ i,^ continued.) 



LAW REPORTS. 

Nuisance From Infectious Diseases 
Hospitals. 

[From the "Times" Report.) 

Attorney-General v. The Guildford, God- 
alming, and vvoking joint hospital board. 
Nuisafice — "Quia Timet''' Adioti — Erection of Small- 
pox Hospital — Injunctio7i Refused. 
This action, which was one of great interest and 
impo'tance to localities threatened with an invasion 
of hospitals for infectious diseases, was brought at 
the relation of certain persons living in the neigh- 
bourhood of Whitcmoor Common, near Guildford, 
to restrain the defendants from using a plot of land 
and cottage on the common for the purposes of, 
and bu Iding thereon, a small-pox hospital. The 
land in question was a little over two acres in 
extent and about a hundred yards across, and the 
plaintiffs alleged that if a hospital were established 
upon it it would create a serious private nuisance 
to themselves and a public nuisance to the in- 
habitants of the district, which was a large one, 
extending over a considerable area and with about 
50,000 inhabitants. The land was surrounded on 
all sides by the common, which consisted of 
marshy ground, and in wet weather access to the 
land was alleged to be very difficult. This circum- 
stance was relied on as increasing the danger of 
infection in the conveyance of patients to the site. 
It was contended that the small size of the plot of 
land rendered proper isolation of the proposed 
hopital impossible; that unless such isolation 
were effected there would be great danger of 
infection to the inhabitants of the district ; and 
that as the surrounding Lmd was common land, 
which the defendants had no power to acquire, it 
was impossible for them to remedy this objection. 
It was further contended that, in consequence of 
the character of the adjoining land, it would be 
impracticable efficiently to dispose of the large 
qu.intity of slop water and other objectionable 
matter which must proceed from a hospital 
intended for the accommodation of possibly 



LAW REPORTS. 



173 



numerous patients. It was proved that children 
were in the habit of playing on the common, and 
that it was frequented by the inhabitants of Guild- 
ford. It was also proved that cattle and geese fed 
on the common, and that the cattle were often 
tethered there. One of the plaintiffs kept cows and 
earned his livelihood by selling milk and butter, 
and he was apprehensive that his trade would fall off 
if he was known to come from the neighbourhood 
of a small-pox hospital. The plaintiffs wrre persons 
resident in the neighbourhood of the plot — one, a 
market gardener, having a house about 60 yards 
from it, and others residing at distances of 110, 
130, 300, and 335 yards from it. One of the 
plaintiffs was a gentleman of property, whose house 
was about 800 yards from the plot, and whose 
grounds came as near to it as about 250 yards. On 
behalf of the plaintiffs several eminent medical 
witnesses, including Dr. Alexander Collie, Dr. 
Russell, of Guildford, Dr. Wilson, of Hastings, and 
Dr. Thorne Thorne, of the Local Government 
Board, gave evidence as to the danger of contagion 
from the proximity of a small-pox hospital, and as 
to the nature of the precautions which were indis- 
pensable to obviaie such danger. There was a 
general concurrence of testimony that of late years 
the belief that the coiitagium of small-pox was the 
subjtct ot " aerial convection '' — i.e., was in some 
way, as yet undiscovered, carried through the 
atmosphere under certain circumstances — had 
gained ground among medical authorities. It also 
appeared that there was a general agreement that 
the distance to which the contagion was carried 
was much greater than had formerly been sup- 
posed, and Dr. Thorne Thorne stated that he was 
convinced that it might, under certain circum- 
stances, extend at least a mile. There was further 
a general consensus of opinion as to the necessity 
for isolation of the hospital by means of a " neutral 
zone," or belt — i.e.^ an area all round the hospital 
walled within and without, and from which patients 
and those attendant on them on the one hmd, and 
the outside public on the other hand should be 
wholly excluded, and the balance of opmion 
seemed to be that such zone should not be less 
than 100 yards. On the other hand it was stated 
by Dr. Thorne Thorne that, in the case of persons 
vaccinated and revaccinated, the risk of infection 
was practically non-existent, that the child com- 
munity of England, being vaccinated, enjoyed until 
ten years of age practical immunity from small-pox, 
which immunity continued throughout life if re- 
vaccination took place. It was stated that a large 
quantity of water, estimated at 30 to 40 gallons 
per head, would be required for the effective 
working of the hospital, and that the proper disposal 
of the refuse water and sewage was a matter of 
great importance. The trial of the action occupied 
several days. 

Mr. Warmington, Q.C, Mr. Warrington, Q.C., 
and Mr. Yate Lee were for the plaintiffs ; and Mr. 



Cozens Hardy, Q.C, and Mr. Reginald Bray for 
the defendants 

Mr. Justice Kekewich, in the course of a long 
and elaborate judgment, said some observations 
had been made as to want of judgment on the part 
of the defendants in selecting this site for a small- 
pox hospital. It had not been suggested that their 
judgment was otherwise than an ill advised one. 
It was not suggested that any member of the board 
had acted from any improper motive whatever ; but 
it had been brought out in evidence that there 
were other better sites that might be chosen, and 
the suggestion was that, because the defendants 
had selected one that was not the best, therefore 
by some mysterious process they had become 
amenable to the judgment of the Court. His 
Lordship put that aside altogether. The question 
he had to consider was whether a hospital on this 
site was and would be a nuisance to the plaintiffs, 
and not whether a hospital elsewhere would be less 
a nuisance. Then it was said that this common 
was a morass or swamp. Unless that could be 
made a ground of bad faith on the part of the 
board, which it was not, he could not see what he 
had to do with that. Whether the site was a con- 
venient one or not was not the question he had 
to try. So with regard to the road. It was said 
that the doctors cuuld not get there, that patients 
could not get there, and the ambulance might 
break down. With that he had no concern. What 
he had to consider was whether the plaintiffs had 
proved their case. They came and said, " This 
board has purchased this property for a small-pox 
hospital, and they intend, whenever occasion 
requires, to bring in small-pox patients and treat 
them in this ruinous cottage ; also they intend to 
build on this site a hospital with all modern 
appHances ; and this will be a danger to health 
and property." Nothing having yet been done, 
this was a qtiia thnet action, and the question was 
'• Is there here a real apprehension of a real danger, 
not a sentimental or fanciful one? " It had been 
proved that this cottage, as it stood, was not a 
proper place for the reception of patients ; there 
was no proper provision for the removal of excreta 
and linen and other matters. Then with regard to 
isolation, using that word in the strict sense of 
keeping the inmates of the hospital, whether 
patients, attendants, or nurses, from outside com- 
munication, there were at present no means of 
isolation at all, and even if a small-pox patient were 
to-day introduced into the hospital there would be 
serous d mger of infection being carried from the 
hospital into the neighbourhood by some means or 
other, and so entitle someone to say that this con- 
stituted a nuisance. His Lordship thought that 
the defendants failed on that part of the case and 
they must, therefore, so far pay the costs of the 
action. But the plaintiffs went on to ask to restrain 
the defendants from using any building hereafter to 
be erected on the plot as a small-pox hospital. He 



174 



LAW REPORTS. 



had it really uncontradicted on the evidence 
that there would be no difficulty in erecting 
on this plot a building of iron, wood, or 
brick capable of accommodating ten or twelve 
patients and providing everything necessary, accord- 
ing to the exigencies of modern science, for the 
attendance on these patients. But it was said this 
was not enough ; that there must be a neutral 
zone, by which he understood that there must not 
be any communication between those in the 
hospital in contact with the patients and those out- 
side. What was a sufficient zone was not for him 
to say ; but the evidence was conclusive that it 
was possible to make such a zone with outer and 
inner walls. Then with regard to the possibility of 
accidents, by nurses going out and carrying infec- 
tion, and so forth. Such accidents might occur 
notwithstanding every precaution ; but if the 
hospital was not properly administered, if the de- 
fendants allowed persons to come from the bed- 
side out into the world and to communicate with 
the neighbourhood, his lordship thought that there 
might be a good chance of success in an action to 
prevent the continuation of the hospital on the 
existing terms. But he would give credit to the 
board for paying attention to such matters, and 
exercising a proper administration. The question 
then was, " Is aerial convection a theory and 
hypothesis sufficiently established to enable the 
Court judicially to say this constitutes a source of 
danger against which the defendants have to pro- 
vide ? " If it was ever proved scientifically and 
beyond all reasonable doubt that infection could 
be conveyed possibly a quarter of a mile, half a 
mile, or even a mile, in spite of brick walls, doors, 
and windows, it might be a question whether 
something should not be done to deprive the 
public of the blessing arising from such a hospital 
as this, even though some persons might in that 
case suffer. But at present his Lordship was not 
satisfied that this had been established. What one 
medical witness had called "particulate matter" 
no one had seen and no one had analyzed. 
Whether it went half a mile or a mile, or how far 
it went, it was impossible to say. It was not 
traceable. Under such circumstances it would be 
entirely wrong to grant an injunction against the 
defendants erecting this hospital because some 
learned men whose opinions entitled them to great 
respect came to the conclusion, though they could 
not prove it, that small-pox was the subject of 
aerial convection. His Lordship found no re- 
f)orted case to assist him in coming to a conclusion 
at all ; the case came before him almost as res 
Integra. On these grounds he was of opinion that 
he should be going much too far in saying that 
there wts any real kind of apprehension of a real 
danger; and that being so the action so far failed, 
and the plaintiffs must pay the costs of that part of 
it. .\s each party had failed as to half the action, 
there would be an order that, the defendants 



disclaiming (as they had consented to do) to use the 
existing cottage or site as a hospital for small-pox 
patients until a proper hospital was built, the 
Court did not think fit to make any order as to 
costs or otherwise. 



Thompson and Norris Manufacturing Co. 
V. Hawes. 

Public Health {Londoft) Act, 1891 — Nuisance — 
Abatement — Works Executed by Occup