JOURNAL op THE ROYAL SANITARY INSTITUTE

REMARKS ON THE QUESTION OF THE AERIAL DISSEMINATION OF SMALLPOX INFECTION ROUND SMALLPOX HOSPITALS.

By HENRY E. ARMSTRONG, D.Hy., Medical Officer of Health, Newcastle-upon-Tyne. (FELLOW.)

Read at Sessional Meeting, Newcastle-upon-Tyne, March 4th, 1905.

HE issue in November last by Dr. G. S. Buchanan of his Report to T the Local Government Board on smallpox in and Felling in relation to Smallpox Hospital, has very naturally been a matter of great interest, not only to the sanitary districts immediately concerned, but tu the nation at large. For if the conclusion of Dr. Buchanan &dquo; that the use of this hospital has been responsible directly or indirectly for a material portion of the epidemic&dquo; in Gateshead and Felling be justified, and his recommendation &dquo;that Sheriff Hill Hospital shall no longer be used for the isolation of smallpox&dquo; be accepted and acted on, then every smallpox hospital placed under similar circumstances is a danger to its surrounding population~ which ought not to be permitted to exist. It is not the intention of the writer to criticise the details of a report on matters occurring outside of his own district, which he has nut But had some as to the effect personally investigated.Downloaded from rsh.sagepub.comhaving at Bobst Library, New Yorkexperience University on July 8, 2015 of smallpox hospitals on popuations living at different distances from 194 them, he ventures to offer the results of this, together with certain observations on the general question at issue. At the time of the great smallpox epidemic of 1870-72, the principal hospital in Newcastle for the reception of cases of that disease was the old Fever Hospital in Bath Lane, supplemented by a wooden block in the same curtilage, which together contained fifty-six beds. These beds, during the chief part of the epidemic, were filled with acute cases, the . convalescents being drafted to a Home at South . One of the hospital blocks was only fifty feet from the densely populated dwell- ings of Stowell Street, and the hospital mortuary was only thirty-four feet from the same houses. The writer was medical officers of the hospital throughout the epidemic. He does not remember a single cumplaint against the hospital by the residents of the street during that period, except as regarded the smell of carbolic acid; and speaking without the hospital admission books before him, he believes that there was very little, if indeed any, smallpox among tlue inhabitants of the street throughout that period. The sectional diagram (1~. 197) shows the relative positions of tlle houses of Stowell Street and the old hospital. The two sets of buildings are sepa- rated by the old town wall, nine feet high on the hospital side, and rising to a considerable height above the eaves of the houses of the street. It may be that to this circumstance the street largely owed its immunity from infection during the epidemic. The facts were brought by the writer to the notice uf Dr. R. Thorne Thorne, then a medical inspector of the Local Government Board, on llis inquiry in 1882 into the &dquo; Use and Influence of Hospital for Infectious Disease.&dquo; An experience such as the foregoing could not well be without effect on the mind of an observer, and the lesson the writer then learnt made a deep impression. That impression still remains, but it has been somewhat modified by recent events in relation to a sharply defined group of twelve cases of smallpox at St. Petc~r’s, in the eastern end of Newezstlc.>, notified between the 27th June and tlie 16th July in last year. Ten of tliese cases occurred in one street of tenement dwellings (High Chapel Street); the remaining two cases were in closely adjoining streets. As careful inquiry failed to trace the origin of any of these twelve cases, attention was drawn to the possibility of infection having been conveyed through the air from Gateshead or Felling. The dates of firstDownloaded feeling from rsh.sagepub.comof illness at Bobstwere Library, in New each York University of the on July cases 8, 2015 compared with the directions of the wind on tllc 14th, 13the, 12th, I I th, and 10th days before 195

dates of catching of infection). Tlie arl’ t!ll’ (i.e., the’ probable folluwing’ results ,-

’ Cuses Ot Smallpox at St. Pete?>’8 ntoti fiecl f rom ’ June 97tfi to July 16th, 190i,

Of the 12 cases of smallpox in question the possible infection-period occurred on days when the wind was blowing- From the south-east, in five cases (viz., on one day in each of three cases, and on two days in each of 2 cases) ; From the in one case on one south-west, day; . From the south, in six cases (fur 1 day in each case, one of these cases having also a date of possible infection on another day with a south-east wind). In one instance only was the disease likely to have been contracted when the wind was in a northerly direction on days of possible infection. The significance of the foregoing particulars will be understood when it is explained that a south-cast wind blows directly from the Felling Smallpox Hospital, and a south-by-west rvind directly from the Sheriff Hill Hospital across the river to St. Peter’s, Newcastle, where the above cases of smallpox occurred. The former huspital is a little under a mile, and the latter a little under two miles distant from the site of the outbreak of smallpox. It is not to be assumed that infection was absolutely blown across the river through the air to Newcastle, but it may Icccve úeen sc~ conveyed. There is one possible explanation of the convection of the variolous poison to a great distance which has hitherto, I believe, received little or

Downloaded from rsh.sagepub.com at Bobst Library, New York University on July 8, 2015 196 no attention, and which may help to reconcile conflicting theories. Hozise- flies are a pest in smallpox wards, settling on the faces and other exposed parts of the patient when the eruption is pustular or crusting. With feet and probosces laden with the poison, they presently reach the open air, and may be carried by the wind to any distance, to infect persons, food, clothing, etc. For many years the writer has used muslin netting over the upper half of the bed to prevent the access of flies to the patient in the wards. The ventilating outlets might probably with advantage be guarded in like manner. If the cases here described, or any one of them, resulted from infection carried bv the air from one or both of the Smallpox Hospitals on the other side of the , at what distance from such a hospital can safety be counted on ~1 In one of his reports on the spread of infection round Fulham Small- pox Hospital, the present Medical Officer of the Local Government Board, ]B1:r. li~. H. Power, records his conclusion &dquo; That the excess of smallpox in the neighbourhood of the hospital was quite and specially remarkable at a time when the total admissions to hospital had not exceeded nine.&dquo;* He subsequently stated his opinion that on one occasion there occurred a notable increase of the disease among the surrounding population when the number of acute cases in the hospital was only five. What are the practical lessons to be learnt from the foregoing? If the view be acted on that a hospital containing only five acute cases is a danger to everyone living within half a mile or a mile of it, and should be closed as such, then very few hospitals for smallpox can be left open. If those within a mile of dwellings are closed, suitable sites elsewhere will be difficult to meet with. In the event of smallpox breaking out in a district unable to provide itself with a hospital at the desired distance from dwellings, many of those dwellings would soon become more dangerous than the hospital before its closure. This raises the question, is the occurrence of a limited number of cases of smallpox round a hospital necessarily a reason for its closure ? In the past, liospitals have got the blame of spreading air-borne disease round about them, which has after- wards been traced to negligence on the part of hospital officials. Here tlie remedy is not the emptying of the wards. If infection is carried otherwise than by flies, etc., can the risk of its spread through the at- mosphere be prevented? It may at least be reduced by passing the

* Fourteenth Annual Report of the L. G. B., 1884-5. Report of the Medical Otficer for 1884, p. 26. t fifteenth Annual Report of the L.G.B. Report of the Medical Officer for 1885, p. 11.

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Downloaded from rsh.sagepub.com at Bobst Library, New York University on July 8, 2015 199 outgoing air of the wards through fire. Apparatus for this purpose is in the market. The Sanitary Committee of the Newcastle Corporation are fully awake to the desirability of having a hospital for smallpox in some other position than the present one on the Town 112oor. But after a prolonged search no suitable and available site has, up to the present, been found. In conclusion, whilst there can be no dispute as to the advantage of having a smallpox hospital as far removed from ordinary houses as is compatible with convenience of working and other practical needs, the hard and fast requirement of a half-mile radius of uninhabited space round it would, in many a district, be an absolute bar to its erection.

By T. MORRISON CLAYTON, M.B., B.Hy., D.P.H., Medical Officer of Health, Gateshead. (MEMBER.)

April 18th, 1903, to June 5t1, 1904, we had in Gateshead 513 FROMF cases of smallpox, and these are the cases which are dealt with in Dr. Buchanan’s report. Of these cases, nfty-six occurred in our district within half a mile of our hospital. In , which is part of Felling Urban District Council, Dr. Buchanan’s spot map shows twenty-four centres within half a mile of Sheriff Hill Hospital. I cannot say how many cases these represent. The report shows that the prevailing winds are S.~.W. to W.N.W. Of these, W.N.W. winds are usually and S.11’. winds often strong. The most pr evalent light winds are S. ’BT. and S. Gentle winds from S. and S.W. would blow from the hospital over the neighbourhoods of Blue Quarries and Windy Nook,. which lie to the east of the Old Durham Road. Gentle winds from the S.E. and E. would blow over part of , west of the Old Durham Road. As regards the number of houses attacked, the report shows six per cent. in the direction of Blue Quarries and Windy Nook, fourteen per cent. along the Old Durham Road, and about two per cent. in the Low Fell direction. Dr. Buchanan states: &dquo; When the half-mile area is split up in this way, the figures become too small for any certain inferences to be drawn

Downloaded from rsh.sagepub.com at Bobst Library, New York University on July 8, 2015 200 as regards effect of winds. So far as they go they are not inconsistent with an inference that aerial convection has operated to a greater extent to the north and north-east of the hospital than to the west of it. In other words, they accord with the suggestion in Dr. Eustace IIill’s report that tlle carriage of infection from the hospital into Felling may be associated with the direction of the most prevalent winds. If this was in fact the case, the circumstance would assist to explain the heavy incidence of smallpox on Coldwell Lane and High Felling, from half to one mile 1V.E. from Sheriff Hill Hospital,.&dquo; Speaking of Felling Hospital lie states: 11 there are 227 dwellings within a quarter of a mile, as against 330 within a quarter of a mile of Sheriff Ilill Hospital. Ten of these 227 dwellings were invaded with smallpox. The hospital stands in the North Ward, near the Tyne. A large proportion of the dwellings within half a mile of Felling Hospital (and especially those within a quarter of a mile) lie in deep, narrow gullies which traverse the low plateau on which the hospital stands. These gullies arc partly natural and partly made. The air in these gullies is almost always stagnant, and tlle houses in them are well screened from any light winds blowing from the direction of the hospital. Light winds from S. and S.li~. whicli appear to have favoured aerial convection round Sheriff Hill Hospital, would carry infected air rising from tlle wards of Felling Hospital across the T3-lle.&dquo; He concludes 11 by having no hesitation in recommending that Sheriff Hill Hospital shoulll no longer be used for the isolation of smallpox..&dquo; This is llis conclusion after stating on the same page of the report that the figures are too small to draw any certain inferences. There are four periods shown :-

. It will be noted that &dquo; the infected air &dquo; from Sheriff Hill Hospital, standing at an elevation of 520 feet, blows down to Felling, Gateshead, and Low Fell, whereas &dquo;the infected air&dquo; of the Felling Hospital, lying near the Tyne, blows rover the tops of the houses lying in gullies where the air is stagnant.

, On this arguing, it seems to me that the best place to build a smallpox

Downloaded from rsh.sagepub.com at Bobst Library, New York University on July 8, 2015 201 hospital is where thc air is stagnant, which would be best found in gullies and where there are several buildings; and conversely it would be most dangerous to build one where there are few houses unprotected by screening, natural or artificial. I ask if we, as the health advisers of . local authorities, have done our duty in allowing them to build houses where tlle air is stagnant, and consequently unfitted for eHicient ven- tilation ?2 But ventilation must and does take place. In the day time the air in gillies and valleys becomes heated and expanded, and the air, therefore, has a tendency to rise and mix with that above it so long as this heat action is maintained. At night tulle temperature in these places falls, and the air lying in them contracts, producing a partial vacuum. This causes the air to descend, so that a downward current is generated which lasts all through the night. The idea to me, therefore, that gullies would protect houses situate therein from pollution with smallpox-infected air blowing over them sinks into 111s1~111~1CFlllcc. Is it not true, also, and that on the explanation of heat, that during the day we have upward currents produced, and during the night downward currents ?l With gentle winds, then, blowing down the hill during the night, infection would be carried to Felling, but would not winds blowing up the llill also carry infection from the Felting low-lying hospital? I contend that what is true of one in this respect must be true of tlle other. Suppose that we disregard entirely these nocturnal and diurnal influences, and assume that currents over this small area blow horizontally (for be it understood that hitherto we have only lllstl’11111c11tS to record direction and velocity of horizontal currents), we neglect another very vital factor, and that is elevation. Take, again, Sheriff Hill Hospital, at its elevation and from it, winds blowing horizontally, and couple rvith it the striking distance of smallpox infection as half a mile on the level, and suppose that the energy of the contaglum prevents it being carried further; are we to assume that it now drops per pendicular ly, or by undercurrents is carried to repose at an angle? It would follow that the striking distance would be more probably three quarters to one mile, and the parts nearest the hospital would be the safest. Or, on tlle other hand, if the contaglum must be carried in horizontal planes, and strike in the same horizontal plane, Sheriff Hill Hospital would be more likely to infect Walker or Newcastle, each across the Tyne. I do not need, however, to theorise to find the explanation of the incidence in our own borough within half a mile of the hospital. When Dr. Buchanan was here, out of the fifty-six cases there were some eight or nine I could not trace, but by subsequent investigation I have traced

Downloaded from rsh.sagepub.com at Bobst Library, New York University on July 8, 2015 202 the origin by contact of fifty-two cases. Of the four remaining two are in one house and gave rise to no other ascertained case. A third I cannot as yet trace. The fourth gave rise to one other ascertained case. If, then, four unascertained cases out of fifty-six are enough to establish aerial convection, I fear its foundation is of weak resistance. The fact, of course, that these four cases only gave rise to one more, does not disprove an unusual source such as aerial convection; for any one case might have given rise to several cases, and what was the cause of the original one would necessarily have been the cause of all that followed, and this would be strong evidence in favour of the contention of an unusual source. So far as Sheriff Hill is concerned, however, it does disprove that any unusual cause has operated conspicuously. I am now of opinion that with few exceptions (such as mild cases of varioloid riding in tramcars, railway carriages, and so on) all cases could be traced to contact if we could only get the truth of the movements and associations of the sufferers. As regards those in Windy Nook, within half a mile of our hospital, the medical officer of health for Felling states that several cannot be traced. I venture to offer a source of several, and this will be found due to a tramp who was admitted to our hospital on October l~th, 1903, suffering from smallpox in the pustular stage. From this source in Gateshead we subsequently traced 81 cases, with 6 deaths. You will notice that of the 24 spots on the map 15 occurred in the period when we had so many cases following this man’s perambulations. Tlie tramp told me he had come from Catcleugh viä Otterburn, ~Yoodburn, Ridsdale, Tonepit, Hexham, Consett, Stanley, Birtley, , and , to Gateshead. A fortnight after liis admission the medical ofhcer of health of Felling wrote asking me if I had tliis man in hospital, and if it were true lie had slept at Oakley’s Farm, Windy Nook, where another case now occurred. Both questions were answered in the a~rmative. On the 29th November, 1903, I was notified of a case (tlic first during the epidemic) at Mount Pleasant, and in tracing tliis womau’s contacts I discovered a family of eight, all of whom were suffering from the disease. One boy had been ill of smallpox for some time; lie liad shaved the tramp at a hairdresser’s shop in Windy Nook the day before he came to hospital. Tlie boy developed a rash a fortnight after shaving the tramp. Not only had this tramp been shaven, but lie had, through the hinduess ,of the hairdresser, been supplied in the house with several meals two or three days before. As the shop is one room of the house the whole place must have been reeking with infection ; furthermore, a roller towel is used

Downloaded from rsh.sagepub.com at Bobst Library, New York University on July 8, 2015 203 by several customers. The hairdresser tells me the house was not dis- infected till after my discovery of the boy. It would be impossible to find out how many people had been infected from this shop. It is no discredit for the officials of a district under such circumstances to be unable to trace all contacts, but on the other hand, with such a doubt hanging over us, I contend it does not elevate our individual status nor that of our profession, to fall upon the wind as the probable cause of the spread and the shield of our shortcomings. If a. hospital which is generally well ventilated acts so seriously as a centre of infection by aerial convection, should not an ill-ventilated house of two, three, four, or even more rooms act equally as much in, of course, a size proportional manner. In some districts, when a patient suffering from smallpox is removed from a house, the contacts are quarantined in the house over the incubative period, that is to say, fourteen to seventeen days. These persons are breathing and re-breathing vitiated air which must necessarily be more foul than that of a hospital. I do not assume that in every house a second case occurs, but I am safe in saying that, owing to contacts refusing vaccination, and probably in some instances the primary case not being discovered till several days of the illness is passed, at least 12 per cent of such cases occur. Although there are not as many sufferers as in a hospital, yet in proportion to the difference of the allowance of cubic space in a dwelling-house and a hospital, I am under the impression that the air of such a house would be more dangerous than that from a properly kept and ventilated hospital with many cases. This being so, if aerial convection had the dangerous significance assigned to it, the spread of the infection would be entirely beyond reasonable control. As regards hospital influence within a quarter of a mile, I can point out at least three circles of a radius of a quarter of a mile each, right away from the hospital giving nearly double the cases we have in the hospital quarter-mile circle. It may be stated against this that there are more houses, but then on Dr. Buchanan’s reasoning as regards stagnant air, etc., we should expect fewer cases. I question very much whether in a smallpox epidemic the percentage of dwellings attacked is a sound guide. With all our ideas of the failings of the people with regard to vaccination-that is to say protection, we must not forget that in every community there are people whose whole household is protected against a visit of smallpox, and I contend, until we know how many houses have susceptible inmates, we cannot arrive at any true index. It is very different with an outbreak of typhoid fever. If we suspect a polluted water supply, it is only by enumerating the

Downloaded from rsh.sagepub.com at Bobst Library, New York University on July 8, 2015 204 houses actually supplied by that water in any district that we can arrive at a correct idea of its magnitude. In conclusion I have no hesitation in say ing that aerial convection of smallpox (except in the immediate vicinity of the patient) exists in theory only; a theory which has been built on iusuf~cient evidence, and one which is weakened more and more by the daily practical experience iu dealing with the disease.

DR. BUClIAKAK (Local Government Board) said that all would be grateful to Dr. Armstrong for his admirable introduction to the discussion of a very intricate subject. IIe need only deal briefly with the observations made by Dr. Clayton on his report regarding the Sheriff 11111 Hospital. The answer to nine- tenths of Dr. Clayton’s objections would be found in the report itself. Dr. Clayton had missed the principal point. The main evidence in favour of aerial convection from that hospital was the existence, throughout a thirteen months’ epidemic, of a graduated intensity of smallpox incidence on the dwellings in Gateshead and Felling which are in the neighbourhood of the hospital. Out of some 1,300 houses within half a mile, 61, or 4.7 per cent., were invaded by smallpox; in the rest of Gateshead and Felling, more than half a mile from the hospital, the proportion was 1-4 per cent. Subdividing the half-mile area, it was found that 8’2 per cent. of dwellings within a quarter of a mile were attacked, and 3’5 per cent. of those between u quarter and llalf a mile. In otller words, there had occurred in Gateshead and Felling the same characteristic incidence of smallpox in the neighbourhood of the hospital which had been observed in the case of many otller hospitals in many other epidemics. No doubt personal infection had operated in the neighbourhood of the hospital as else- where, but the hospital influence had still to be accounted for. He did not find it difficult to Imagine the way in which aerial convection could take place from hospital wards containing considerable numbers of acute smallpox cases. Patients in the vesicular and early pustular stages are capable of communicating infectious particulate matter to the air to a much greater extent, relatively, than patients in the early and papular stages uf the rash, which ordinarily is all that has developed before they are admitted to hospital. There is direct evidence of the extreme infectiousness to susceptible persons of a brief exposure to the air of a smallpox ward, an infectiousness relatively greater than in the case of diphtheria or scarlet fever. Large volumes of such infected air escaping from the hospital would rise on account of temperature differences, and later the infectious particulate matter would, in certain conditions of atmosphere, tend to settle in the neighbourhood of the hospital without great dispersion. If the hospital was in a desert, or if tlle persons living near it were all vaccinated and re-vaccina,ted, aerial convection would produce no smallpox. If there were susceptible peuple

Downloaded from rsh.sagepub.com at Bobst Library, New York University on July 8, 2015 205 living in the area round the hospital, but all dwelt in one small part of it (say in an institution or workhouse) the risk from the hospital would mainly depend upon the direction of prevalent light winds, and miglit often be small, though probably it would increase with the proximity of the population to the hospital: whereas if a. susceptible population were distributed over the whole area, or a. large part of the liospital area, then, if sufficient periods of time were taken, a graduated intensity of smallpox incidence might be expected, the percentage of houses invaded by smallpox. in the neighbourhood of the hospital becoming smaller as the distance from the liospital increased. If asked why assumptions of aerial convection are necessary, the answer was that they afford the only satisfactory explanation of the &dquo;graduated incidence.&dquo; This is a definite phenomenon which ppidemiologists liave to account for, and has been shown to occur under con- ditions which almost preclude the possibility of the spread of smallpox round the hospital having been due to hospital operations or to hospital maladministration. Its existence was first demonstrated by Mr. AV. II. Power in the case of Fullam hospital in 1881, and again in 1884. It was confirmed by -Air. Power’s masterly study of the distribution of smallpox, as judged by mortality returns, in different parts ot’ London during the years in which smallpox was treated in one after another of the Metropolitan Asylums Board hospitals in or near populous neighbourhoods. These observations showed how in these years the distribu- tion of smallpox in the Metropolis was again and again determined and dominated by the operations of the hospitals receiving acute smallpox cases. Graduated incidence had since be en demonstrated in many other instances : West Ham, 1SS~-5: Nottingham, 1887-8: 01dham,1892; ~Varrington, 1892-3; Bradford, 1893; and, during the recent epidemic ycars, in Glasgow, 1900-‘’, and nuw in Gateshead and Felling. Those who hesitated to accept aerial convection as tlie cause were bound, in his opinion, to advance an alternative and consistent theory in explanation of the facts. Negative instances had been reported, and no doubt aerial convection did not always happen under all circumstances. But he was struck by tlle absence oF evidence that tlu problem had been carefully studied in instances comparable to those he liad mentioned, with the result that no graduated incidence had been observed. Dr. Armstrong had mentioned the negative experience of Stowell Street and other houses in the neighbourhood of Batli Lane hospital, Newcastle, during the epidemic of 1870-2, and tliis was valuable. But apparently the Stowell Street area had not always enjoyed this immunity, as it was heavily hit in 1882, just; before the Bath Lane hospital was closed and the present hospital on the Town Moor was taken into use for smallpox. In conclusiun, he referred to tlie administrative recommendations of the Local Government Board as to the maximum populations which should be allowed in the neighbourhood of a small- pox hospital. These are intended to provide a useful working standard; no one claimed that they are in any sense definitions of conditions whicli will ensure absolute security.

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DR. T. EusT~c>; Hm.L (Durham C.C.) was very pleased to llear that Dr. Armstrong’s views on the aerial dissemination of smallpox were now somewhat modified, for unly two years ago that gentleman was a strong opponent of the air-borne theory and had stated that &dquo;aerial convectionists were virtually opponents of smallpox hospitals.&dquo; All medical officers of health were in theory opponents of smallpox hospitals, for they recognised that but for the neglect of vaccination there would be no necessity for separate hospitals for smallpox, as was proved by the experience of well-vaccinated Germany. As matters stood at present, though, tlle provision and maintenance of separate smallpox hospitals were a necessary evil in this country, and huge sums of money must be annually spent for that purpose. It was, he thought, admitted that the isolation of smallpox patients in hospitals situated in populous districts had resulted in an excessive incidence of the disease on the populations in the vicinity. That was shown to be the case, without doubt, at Fulham, Sheffleld, Warrington, Bradford, Glasgow, Gateshead, and many other places, and the negative evidence of spread from the Newcastle and old smallpox hospitals had in his opinion very little weight when compared with positive facts as to the influence of smallpox hospitals. Possibly the negative evidence in the case of Newcastle and Sunderland might be explained by the difference in the virulence of the infection, or by the epidemics not having been the subject of such searching inquiry a5 was the case at Fulham, Shef~eld, etc. In his opinion the most common agencies in the spread of smallpox around hospitals were maladministration, traflic to and from the hospital, and the air. Possibly also, flies, as suggested by Dr. Armstrong, nlight be a factor in the spread of the disease. He admitted that in some instances, such as Sheilield, the spread of smallpox in the nelghourhood of smallpox hospitals might be accounted for by contact as a result of defects of administration; but in several epidemics the only satisfactory explanation was that the infection was air-borne. This was especially so in the case of the epidemic at Purfleet, in the Orsett Union, in 1J01-’~, which was the subject of a most careful and searching inquiry by Dr. Buchanan. Personally he could not conceive that anyone reading Dr. Buchanan’s report on the epidemic in the Orsett Union could have any doubt that the air was an important factor in the dissemination of smallpox infection, and he was also convinced that the excessive incidence of smallpox at Windy Nook in the Felling Urban District was the result of infection having been carried by the air from the Gateshead smallpox hospital at Sheriff Hill. He entirely agreed with the deduction drawn by Dr. Armstrong from the conclusions in Dr. l3uchanan’s Gateshead lieport that hospitals so situated as that at Sheriff Hill were a danger to the surroundings population, for within a quarter of a mile of that hospital there was a population of 1,600, and within half a mile a population of li,‘?~0. The requirements of the Local Government Board that there should not be within a quarter of a mile of a smallpox hospital a population of more than 200 and within half a mile a population of 600 were reasonable, and even for a large town there should be no

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serious difficulty in obtaining a site which fulfillled those requirements. The surroundings of the Nottingham smallpox hospital to which reterence had been made entirely differed from those of the Gateshead hospital, for in che former the population within the quarter- and half-mile radius did not exceed the limit laid down by the Local Government Board, and he quite agreed that the risk of using a hospital so situated for smallpox patients was infinitely small compared with the danger of isolating the patients in their own houses or in a hospital with a large population in its vicinity.

SIR GEORGE HARE PIIILIPSON (~Tewcastle-upun-Tyne), stated that in his position of Professor of Medicine of the University of Durham, in describing to his students the mannur in which smallpox was communicated, lie had over a period of more than forty years taught that the disease was communicated by aerial convection. His statement was based upon his own personal observation, when, as remote as 1865, he held the office uf Visiting Physician to the Bath Lane Fever Hospital, lTewcastle-upon-Tyne, and from his consideration of the papers on the subject by eminent sanitarians. DR. J. C. M’VAiL (Stirling and Dunbarton C.C.) said lie had been surprised to learn not long ago how much doubt existed in regarding aerial con- vection of smallpox. The decision in the Nottingham case, to which much interest and some inlpurtance attached, had to be taken at its true value. In commenting on Dr. Thresh’s evidence as to the influence of the hospital 511ips on the Thames in spreading smallpox in the adjoining part of Essex, lVlr. Justice Farwell was reported as follows : &dquo; The plaintiff’s case depends on the inference to be drawn from an unbroken series of facts. In all cases wliere A has occurred B has followed, therefore A causes B. But the conclusion depends un the universality of the premiss, and a negative instance unexplained spoils the chain.&dquo; With all respect, it appeared to Dr. 3l’Vail that this dictum is not scientifically, though it seemingly is legally, applicable. to questions where 11 and B consist of variables like the smallpox poison and the human body, where there is indeed a third variable, namely, the atmosphere, as a medium for conveyance of infection. Indeed, measuring by such a standard, it would be im- possible to prove the existence of infectious disease of any kind. If 3 be a case of scarlet fever, or typhus, or diphtheria, or measles, or whooping cough, ur airy other such disease, there is nothing amounting almost to a moral certainty that A will be followed by B ; that a second case will result from a first, and we do not know why this should be so ; but, if the newspaper report is to be trusted, it would appear that a single case of scarlet fever not followed by another case would, unless in presence of an explanation of tlle failure to infect, be sullicient in the eye of the law to destroy the proof of the infectiousness of scarlet fever. In the intere5t of preventive medicine and sanitation, it was fortunate that , statute law differs from common law in these matters, and that ordinary public

Downloaded from rsh.sagepub.com at Bobst Library, New York University on July 8, 2015 208 health procedure is governed by the former and not by the latter, otherwise the prevention of inf·ectious disease in this country would be Impracticable. But there were a lH’iori reasons for thinking that the carrying po~-er of smallpox might readily be greater than that of other diseases. If half a dozen patients in the acute stage of their malady, one suftering from smallpox, one from typhus, one from scarlet fever, one from measles, one from whooping cough, and one from diphtheria, were placed in a row before even a layman, and if he were asked which of these cases he thought might be most likely to furnish material capable of being carried for a considerable distance through the atmosphere, he would almost certainly point to the smallpox patient. Atmospheric air was universally recognised as a powerful disinfecting agency provided it could get properly at the nmtenes morbi, but in the case of smallpox there seemed a 2)?’i))Ia ficcie likelihood that the disease poison might be protected from the air by lymph or pus, or epithelial debris, much more readily tlian in any of the other diseases. No doubt, in the areas round a smallpox hospital, other agencies besides aerial diffusion were at work and had to be taken into account, and hospital intercourse would be greater near the hospital than far from it. But it was surely not to be expected that people who had met unrecognised cases of smallpox or other infective media of any kind in streets, tramway cars, railway trains, work- shops, or elsewhere, should immediately begin to gather themselves into habi- tations in quarter- and half-mile zones round the hospital. The practical interest of medical officers of health in the whole question he took to consist in the difficulty of obtaining hospital sites to meet the requirements of the Local Government Board. But that difficulty would not be removed by denying the theory or working hypothesis of aerial convection. It mattered nothing to a man getting smallpox through hospital influence, whether the influence were aerial or by contact. What the man objected to was his catching the disease. Where a smallpox hospital in the course of an epidemic did not spread the disease around, either aerially or by intercourse, it was only human nature in those responsible for its management to attribute the result to excellence of administration, and on the other hand, where a hospital did spread the disease, it was equally human nature to attribute the result to unavoidable causes, aerial or otherwise. Assuming for the sake of argument that smallpox is not con- veyed aerially but only by intercourse, and assuming even further, that perfect administration is capable of absolutely preventing infective intercourse, would that be a sufficient reason for sanctioning the erection of smallpox hospitals in the midst of large populations ? Had they any right to assume that in any hospital managed by human beings there would be no failure of administration, not merely in ordinary times, but during all the hurry and bustle of a sudden epidemic of smallpox ? Surely not. The hospitals ought to be so situated that there would be very few people within likely reach of any evil influence they might exercise. Where the same hospitals treated smallpox, scarlet fever, diph- theria, and the like. the administration which had been sufficient to prevent

Downloaded from rsh.sagepub.com at Bobst Library, New York University on July 8, 2015 209 . the spread of these other diseases around the hospital, bad often been quite insufficient to prevent the spread of smallpox. Had they a right to rely on the management of a smallpox hospital being so much better than tha.t of a scarlet fever hospital where the whole work is so much more regular?E? No doubt the sanctioning of smallpox hospital sites in populous areas would temporarily relieve the minds of sanitary authorities. They would feel that they had done their duty and would thank God that they had at last got over that difficulty and had brought the Local Government l3oard to its senses. But the risk was that their mental relief would only be temporary. They would be all right so long as there was no smallpox in the hospital, but when an epidemic came thev might find themselves in the same position as many an authority had already done in the past. It would be no kindness on the part of the central authority to sanction sites for smallpox hospitals which would mean large expenditure or public money without removing the risk of tlle spread of smallpox, which removal it was the whole purpose of the hospitals to accomplisll.

TilE CHAIRMAN (D1’. Louis C. Parkes, Chelsea) remarked that it was not flattering to tlie common sense of the English nation that it should be possible to discuss such a subject as smallpox lcospitals at all, when the experience of Germany had abundantly demonstrated that a proper system of vaccination and revaccinatiun rendered smallpox hospitals absolutely unnecessary, because there were never any smallpox patients to bc treated. He suggested that the Local Government Board should appoint a small commission of experts to inquire intu all those cases where it was alleged that smallpox hospitals were in existence and were used for tin’ reception of patients, but no graduated incidence of smallpox in the area of a mile radius around the hospital had been observed. These alleged negative instances required careful investigation at the hands of competent observers, so that all the circumstances attending smallpox concen- tration might be recorded and compared, both those where aerial convection was suspected, and those where aerial convection was believed to be inoperative.

DR. REXNEY (Sunderland) said that in 1883 and 1884 smallpox was epi- demic in Sunderland, and the smallpox hospital then eunsisted of a temporary wooden two-story building, certified by the Local Government Board as suflicient for sixty-four persons. Tllis building was 20 feet away from the fever hospital, 114 feet from the insane wards, 224 feet from the schools, 56 feet from tlie lock hospital, and 150 feet from the general body of the &dquo;house.&dquo; The total population at tlle workhouse was nine hundred. Three hundred smallpox cases were treated, forty-two being the largest number at any one time. Children and adults could conle to a distance of 10 tcc 22 feet c>E the building. The onlv vaccination was that uE the school children after the hospital had been in use twelve months. The medical officer. were most emphatic in stating that at no time during the two years did any spread of smallpox take place to the

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workhouse buildings. Before the present sanatorium was built, smallpox cases were treated in large numbers at a hospital in a very pour neighbourhood, closely packed with tenemented houses. Dr. Harris, a former medical ullicer of health for Sunderland (now of Islington), had stated that smallpox did not spread from tllis hospital to the surrounding neighbourhood. The cases which did occur near to the hospital were traced to direct ini’ection from other sources. In two other centres in the town the incidence of the disease was far greater than around the hospital. From lsScJ to 1904, a period of sixteen years, 131 cases ol’ smallpox had been treated at the sanatorium. During the last two years sixty-six cases had been treated there. He had attended forty of these himself from December, 1903, to .Tanuary, 1905. The isolation block in which they were placed was 40 feet from the administrative block. 58 from the laundry, 138 from the scarlet pavilion, 75 from a new typhoid pavilion, and l0i feet from another typhoid pavilion. Absolute isolation of everybody brought into contact with the patients bad been observed. lurses and wardmaids slept in the block. Food was carried across, and notliing left the block without previous disinfection. Nurses and wardmaids, when they take a day off duty, have first to go through a disinfecting bath and have their clothes disinfected. There had been no spread of infection to the other pavilions nor to any person in the neighbourhood, although there had been seventeen cases under treatment ;lt one time. DR. AVAUDY (~ln·flicld), referring to Dr. Clayton’s remarks about the infected atmosphere of a small house in a stagnant gully, suggested that perhaps even tllis might constitute .~, less menace to the community than that of a wc·11- ventilated 11«shital. The latter is widely difiuse4, whereas ill the houses of the working classes the vitiated a1 mosphere would rise to t h(~ upper story, and go no further; but it would deposit there its burden of ~~r«tc-ri~s ~nn~~l~i, which would frequently remain undiaurl~ed until it had become innocuous. Direct infection, Dr. lVadd3- cunsidered, was by far the most important factor to be reckoned with ; yet we must alsu acknowledge aerial convection as a real agency which could not be disregarded. 1 le agreed with Dr. 3IcQ’ail in observing that 1 here was room for great improvement in the construction as well as the administra- tion of certain statutes. The vaccination acts, in particular, might be made far more effectual lay embodying the following reforms, which were by no means novel or original suggestions : (i.) That the administration of public vaccination should be transferred from boards of guardians to the sanitary authorities ; (ii.) that every medical practitioner should be virtually constituted a public vaccinator by receiving a fee for successful vaccination, just as for notifying infectious diseases ; (iii.) that a definite standard of’ successful vaccination should be maintained, and enforced by efiicient inspection ; (iv.) that vaccination and revaccination should be made compulsory. DR. S. G. 1BIOSTY.N () said that the opinion of the meeting was that smallpox hospitals were a danger to the people in their neighbourhood,

Downloaded from rsh.sagepub.com at Bobst Library, New York University on July 8, 2015 211 but as convection by the air is proved by a process of exclusion, all possible causes should be considered. In addition to the three causes suggested, there was the fact that the curiosity of many of the public was (at any rate, on Tyne- side) stronger than their dread of the disease. People repeatedly climbed on the . walls round the hospitals to see the patients. Perhaps the fact that the wall round the Bath Lane Hospital was twelve feet high on the outside might explain the absence of infection in the neighbourhood.

DR. CIraLwrits (Glasgow) remarked on the desirability of having such incidents as had just been related by Dr. Renney published in some detail, iii order that the apparent immunity under specified conditions of persons resident in the neighbourhood of smallpox hospitals might be made the subject of definite

inquiry. Considerable importance, he thought, attached to the precise conditions . present where patients in fever wards escaped invasion wh’’n smallpox was being treated in adjacent wards, although he was disposed to think that for 1 he most part the experience was the other way. But, as they all knew, the majority of patients in fever hospitals were children, and it was among the child-population that the protective results of infantile vaccination were, of course, seen at their m,1ximum. Dr.Buchanan had quite reasonably given prominence to 1 he facts which the theory of aerial convection had been advanced to explain, because the tendency at the present time in some quarters undoubtedly was to suggest that if the theory of aerial convection of smallpox could be disproved, the facts them- selves, and which this theory was advanced to explain, would in consequence be discredited. On the other hand, lie believed that quite apart from any theory to explain the circumstance, it was a not Infrequent experience that smallpox hospitals did spread the disease in their neighbourhood. Nor was it necessary, lie thought, to show that this spread could only arise from maladministration or from failure to discover the point of contact of individual patients with infection. It was only a relatively small number, after all, of known contacts who ultimately sickened of the disease, because on the whole most cases were recognised in the earlier stages of the eruption, and vaccination was nowadays su vigorously pushed among them that it usually became operative soon enough to protect the contact from developing the disease. Speaking entirely from recollection of the recent prevalence of the disease in Glasgow, lie thought he was correct in saying that among many hundreds of known contacts the attack-rate did not exceed three per cent. Indeed, it was not the known, but the unkiiou.n, contact from whom danger was to he apprehended. It was well, therefore, that they should see that the facts of hospital influence were not lost sight of, whatever fate should befall the theory of aerial convection as an explanation of them. He need not refer to what was in the knowledge of everyone there, that the aggregation of the more ordinary infectious diseases in hospitals (such as scarlet fever, enteric fever, or diphtheria) had never given rise to any suggestion of injury to surrounding populations. It might, of course, be suggested that the infecting particle in

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smallpox had a longer striking distance or was more readily transported. Eitller or both might be true, yet the case against the hospitals was not miiiiiised thereby. In one way the experience of Glasgow had been unique. Tllirty years ago, during the prevalence of smallpox in the early seventies, their small- pox hospital had been situated in the northern part of the city, and there liad been a greater incidence of the disease at that time among the population of that part than elsewhere. Before the recent epidemic period, tlle liospital had been transferred to the eastern district of the city, and tlle major incidence during the recent outbreaks Ilad followed the hospital,. In is713, out of over 1200 cases in Glasgow, l14 per cent. occurred in the northern portion of the city; and again in the following year, when the number of cases was almost similar, the percentage had been 89. On the other hand’- during the prevalence of recent years, almost 62 per cent. of the cases had occurred in the eastern district, although only 211 per cent. of the population lived in tllis portion. Apart from these figures, winch might be said to represent the incidence over the whole epidemic period, evidence of hospitals influence was supplied by the move- ments of the diseases during the successive weeks of its prevalence. When the disease appeared in tlle sparing of 1900, it occurred in what might be called tulle east-central district of the city, and was for some time unrecognised. Tills illness occurred in tlie early days of April, and of 72 cases known to have occurred prior to the beginning of June, 1s3 were from tlie central and 18 from tlle eastern district of the but in the weeks a in tlie city; following change , distribution of the disease became manifest. Of 40 cases occurring during the fortnight ending 16th June, 27 were in the eastern district; and iu the next fortnight 34 occurred in tlie east out of 3<8 for the whole city. Then again, w hen tlle disease recurred in the winter of 1901-2, while tlie early cases were drawn from tlle northern district, in tlie fortnight ending 22nd February, 1902, of 147 cases registered, 102 were from the eastern district. During tlle more recent outbreak of 1903-4, the disease was introduced in the autumn months among the model lodging-house population on the south side of tlie river, so that of 131 cases occurring during tlle month of October, 27 occurred in lodging-houses, and only one might be said to be eastern. But during tlle following weeks a recur- rence to tlie old distribution became established; and when tlie outbreak ended, the attack-rate was found to be 1’5 per 1000 for the wliole city, and 4 per 1000 for the War d in which the hospital was situated. Facets like these convinced him that even were aerial convection shown to be untenable as a theory, the w hole question would require tu be discussed over again on the facts of hospital influence .

DR, AV. E. PEACOCK (Felling) said that ho would only refer to two points which liad been mentioned in the discussion, the 1Îrst being connected with Dr. Armstrong’s supposed air-borne cases at St. Peter’s, the sncond dealing with his own experience in regard to t.he incidence of the dis2ase around smallpox

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hospitals. At the time Dr. Armstrong’s cases developed at St. Petur’s, an isolated outbreak occurred at Felling, near the river and just within the quarter- mile radius of Felling Hospital. He was not in hossession of wind charts, but from Dr. Armstrong’s notes it appeared that at that date the prevailing winds were from the soutll-east, that was, from Felling Hospital towards St. Peter’s. A line drawn on the map from Felling Hospital to St. Peter’s would pasts directly through that portion of Felling in which those cases occurred. It seemed possible, therefore, that Felling Hospital might have been the cause of tlle outbreak at St. Peter’s, and that the infection had also been carried at the same time into dwellings nearer than those on the north side of the river. In regard to incidence of the disease around smallpox hospitals, in Felling tlie incidence ’ was greatest in the South Ward, whicll was near the Sheriff Hill Hospital, and next in the Nortll Ward, in which their own hospitals was situated. The attack-rate in the South Ward per 1,OU0 inhabitants was 1’?vG in 1904. In the North lVard, where l,~2 cases were treated cilring the year, it was s per 1,1)00. The at a distance from these hospitals were compare ivelv un- atfectcd.

DR. T. M. Cc:wr·w (Gateshead) said as regards Dr. 13LIellanail’s eyression tliat lle failed to touch on the real point, viz., the comparison of incidence round the hospital with other parts ot’ the town, he entirely denied. What did it matter if the incidence round a hospital were three times as great as in other parts of the town; if they could trace the cases to contact, it weakened the positive side of aerial convection. He quite agreed with what Dr. Ilill stated as regarded vaccination and re-vaccination, and had always held that no hospitals would be necessary if proper legislation for vaccination took place. He agreed with him also that we could not ignore tlle opinions of high authorities. We must be largely guided by tllem, but at the same time our education goes for little if we cannot think independently for ourselves. How many volumes had been written by great authorities on the miasmatic theory of malaria, only to be shown altogether wrong by the work of Professor Ronald Ross and Sir Patrick inianson on the mosquito. Might not even great authorities be mistaken in smallpox, Dr. Waddy did not quite catch his point; he (Dr. Clayton) did not state that air was more foul in gullies. He stated that it was impossible at all times for wind to blow over gullies without mixing with the air therein. DR. ARMSTRONG, in acknowledging the vote of thanks, expressed his admira- tion of the excellence of the work done many 3-ears ago on the question of the aerial dissemination of smallpox round hospitals, by DIr. ~V. H. Power, then a medical inspector, now the chief medical officer of the Local Government Board.

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