977] DIFFICULTIES OF MEDICAL MEN IN RELATION TO CASES OF DIPHTHERIA.

by leakage from its main outfall sewer the springs which

supply certain villages in an adjoining rural district, that of f

Crickhowell, with drinking water. The circumstance has led t

to paragraphs with alarming headings in the local press, from a

which, together with certain Local Government Board reports e

which are in our library, the facts appear to be as follows. B

The Brynmawr urban district council conducts its sewage to 1

a spot in its own district where some preliminary treat- ment, such as screening, is undertaken, and where, too, (

there seems to be a device by means of which, in certain

circumstances, the sewage may be diverted to a neighbour- ing stream. But as a rule the sewage is carried from ]these works by a sewer which passes through part of the Crickhowell rural district and thence to the sewage farm

which is situated in the Brynmawr district. This sewer, as

it traverses the Crickhowell district, skirts the edge of adecline which runs down to the small village of Llanelly, andwhen this sewer leaks, as it has on many occasions done, thesewage trickles through the porous limestone in which thepipes are laid and so, it is alleged, finds its way to a groupof springs which, issuing from the limestone below, supplythe village of Llanelly with water-and, according to Mr.P. E. HILL, the medical officer of health of Crickhowell,with enteric fever. In order to remedy this state of affairsthe Crickhowell rural district council has invoked the

assistance of the Local Government Board and within

recent years that of the Brecon county council. Bat to

judge from a recent report by Mr. HILL the leakage abovereferred to still exists, for this is what he writes :—

Typhoid fever has been endemic amongst the populationof Llanelly (Breconshire) for over 30 years and an epidemicis still in progress, as demonstrated by the fact that 14 caseshave been notified during the present year, 11 out of thisnumber since June 28th. A water poisoned by typhoid bacillihas been allowed to flow as from a fountain during the wholeof this period from time to time and has been the directsource of disease, suffering, and death to hundreds."

This is a strong and direct accusation and by way of

estimating its weight we have consulted a joint reportwritten by Dr. R. J. REECE and Mr. SANDFORD FAWCETT,M.LC.E., two inspectors of the Local Government Board,which was issued in 1902.1 From this report we gatherthat the facts are to a certain extent as stated and

that the sewer in question does frequently leak in

such fashion as seriously to threaten the water of the

Llanelly springs. But we also incidentally learn that

the Crickhowell rural district council is very far from

being an ideal body from an administrative standpoint ;that the village of Llanelly is, on its own merits, a some-what unwholesome spot ; and that the springs which arestated to be polluted by the Brynmawr sewage are also

liable to pollution by the contents of the Llanelly privies.There is no system of drainage in the village and the " slopwater is thrown on the ground or down drains of primitiveconstruction to find its way with the storm water over the

land or by channels furrowed along the roadside to ulti-

mately reach the Clydach brook." There is no isolation

accommodation in the distiict and the disinfection per-

formed at the time of the inspection, which led to Dr.

REECE’s and his colleague’s report, wa little other than afarce.

1 The report can be obtained from Messrs. Eyre and Spottiswoode,East Harding-street, London, E.C.

So far, therefore, as we can gather there is still much

for both the authorities in question to carry out before

they waste their time in discussing the responsibility foran admittedly serious condition of affairs. Clearly, it is the

elementary duty of the Brynmawr council to provide a

watertight sewer, and it is equally the duty of the Crick-howell council to see that Llanelly is provided with awater-supply which is not liable to pollution by, amongstother things, the contents of its own privies. But in

place of performing these elementary acts of justice to the

people over the health of whom they have been elected to

preside each district council would appear to be pro-

crastinating indefinitely. For ourselves we should like to

see both these authorities vigorously dealt with. The efforts

of the medical officers should be seconded at headquarters,and if reform does not follow the districts, if possible,might be dissolved. A perpetuation of this unedifyingbickering and ineptitude is not fair to local government.Dr. REECE’s and Mr. FAWOETT’S report is instructive in

many ways and its broad lesson is that if recurrences

of this nature are to be avoided a new Public Health Act

should be introduced conferring greater powers upon

the Local Government Board and upon county councils,enabling them to deal in a summary fashion with authoritieswhich neglect the health of the public under their care.

Apparently the Brynmawr and Crickhowell districts have

been visited on numerous occasions by inspectors of

the Local Government Board and in each instance advice

has been given which, if followed, would have led to a

speedy remedy of a nuisance which has been obvious for

many years. Neither of these councils can therefore pleadthat advice has not been forthcoming and it is only matterfor regret that the central health authority is not able atthis stage to enforce the carrying out of the recommendations so frequently made by its own inspectors. We venture

to commend this case to Mr. GERALD BALFOUR whose un-

doubted ability should prove equal to the occasion.

Annotations."Ne quid nimis."

THE DIFFICULTIES OF MEDICAL MEN IN RELA-

TION TO CASES OF DIPHTHERIA.

In THE LANCET of Sept. 23rd, p. 907, we drew attention,under the title of "How Disease May be Spread," to thedifficulty which is liable to attend the diagnosis of diphtheriain cases where a medical man is consulted when the clinical

signs of the disease have disappeared and when the patientor the patient’s friends either by silence or positive mis-statements throw dust in the eyes of the practitioner.Curiously enough, a correspondent sends us this week

the particulars of a case the circumstances of which

are very similar to those to which we referred in our

issue of Sept. 23rd and as the facts are of interest toall practitioners we summarise them for the benefit of ourreaders. A notifies that a child is suffering from diphtheria,the diagnosis being founded upon satisfactory clinical andbacteriological evidence. The parents are duly informedby A who urges isolation which he suggests may probablyhave to be continued for about a month. The local medicalofficer of health visits the house and, supporting in every way

978

this medical practitioner, orders isolation. But the fatherof the child finding it convenient to doubt the diagnosispartly on account of the expense of prolonged isolation andpartly in consequence of interference with the holidayarrangements, ceases to call in A, and consults B and C

independently, both of whom see the child when the mem-brane and other clinical signs of diphtheria have pre-sumably disappeared. Without any attempt at bacterio-

logical examination the child is proncunced by them not tobe suffering from diphtheria and, consequently, in a fortnightfrom the onset of the illness the father, so far as we can

gather from our correspondent’s communication, takes thechild home by train, where the medical officer of health,who it is to be assumed has been informed of the circum-

stances, makes an independent examination and finds thata swab taken from the throat yields a positive result

quâ diphtheria. Having regard to the recent successful

prosecution in the North London police-court to which wereferred in our issue of Sept. 23rd our correspondent askswhether the urban district council and the railway companyconcerned ought to prosecute and, if so, whether a convictionwould be probable, and finally, whether if the districtcouncil declines to prosecute the Local Government Boardis likely to compel it to do so. In our view much

depends upon what was the attitude of the child’s fathertowards B and C. Did he inform them of the previousnotification or of the results of the bacteriologicalexamination ? If he suppressed both these facts we are

inclined to think that it might go badly with him in a courtof law. If, on the other hand, he apprised B and C of allthe circumstances B and C themselves would seem to us to

have failed somewhat in their duty alike to the patient,the public, and to A in not procuring a bacteriologicalexamination. At the same time it is an open questionwhether the law would regard it as incumbent upona practitioner to secure such an examination ; indeed,in the case of persons too poor to pay for it or

when there was no provision made by the local authori-ties for such examination it would obviously be impractic-able. But this fact hardly absolves B and C from their moralresponsibilities in this case. In our own view, no medicalman in face of the facts was in a position to assert that thechild was not suffering from diphtheria without a bacterio-logical examination. But we are not quite clear from ourcorrespondent’s letter whether when the second medicalofficer of health made a bacteriological examination of thethroat with a positive result there were also clinical signsof diphtheria. It is, of course, conceivable that in the intervalbetween the first and second bacteriological examinationthe throat may have been for a time free from the organismof the disease and the defence would probably develop thispoint. But as regards the chances of a successful prosecu-tion we think all depends upon the father’s attitude towardsB and C and we doubt whether the Local Government Boardwould regard the case as one in which it could usefullyintervene.

____

SIGHT TESTING.

WE have received from the secretary of the British OpticalAssociation a copy of a Bill which the association proposes" to present to Parliament " next year and which, if it everbecame law, would establish a recognised profession of

"sight testers " presided over by a body formed on the linesof the General Medical Council and, like the Council, havingsome control over the education and qualitications of the newlicentiates and some power of withdrawing licences in caseof misconduct. The Bill is avowedly framed as a countermove to one proposed by the British Medical Associa-tion and described as containing a clause which providesthat " testing the sight for spectacles must not be

practised by any person but a qualified medical man. We have no sympathy with either proposal because thesuggested prohibition could not pos6ibly be carried out inpractice. The spectacle seller would deny that he was

" testing sight " and would hand the customer any commonoptometer and would tell him to test " himself. We haveso often dealt with the dangers which would attend upongiving any appearance of ’’ qualification

" to spectacle sellersthat we need hardly now repeat ourselves upon the subject.There are many shoals and quicksands in Parliament andsufficient unto the day is the evil thereof. If the crazyscheme appeared at any time to be in danger of realisationwe should, of course, be bound to show cause against it and toask Parliament seriously to consider the consequences likelyto follow from the course proposed. In the meantime

nothing can be better for the promoters than a littlewholesome neglect. The Bill of the British MedicaAssociation has not yet become law and there is thereforeno immediate prospect that an "enormous number" of

"fully qualified (?) and certificated opticians" will be

deprived of their livelihood before the advent of winter.While waiting for the session of 1906 they may take comfort.in the thought that public attention is being seriouslydirected towards the misfortunes of the unemployed.

STRANGLED BY RED TAPE.

UaF of our Scottish correspondents informs us of an

unpleasant incident which has occurred at Burntisland inconnexion with the fifty-fifth section of the Licensing Act,1903, the particulars of which have just come to light.On a Sunday evening recently a medical man advisedthe parents of an infant that a mixture of brandyand water should be administered, the condition of the

patient being considered precarious. The practitionerwrote out a certificate to procure some brandy and

addressed the letter to a licence-holder in the town. The

father of the child requested that the immediate attentionof the licence-holder should be given to the order asthe matter was urgent but in view of the strictnessof the law the latter went to the police-office to obtain

the consent or assent of the police-sergeant to the order.

The latter declined to give the sanction on the ground thatthe certificate would require to be signed by the medicalofficer of health, as he could not recognise the medical man’ssignature as sufficient. It was found, however, that the

medical officer of the burgh was not at home and the

sergeant was again asked, in view of the urgency of the

case, to grant his consent to the order, but he declined andasked the parties to obtain the signature of the procurator-fiscal. This was in the end obtained and the brandy wasprocured after one and a half hours had elapsed. The childdied two hours afterwards. The cause of death might notinappropriately be described as "strangled by red tape."

HERB CALOMEL.

FROM an account which appeared in the Morning Post onSept. 23rd it would seem that some remarkable statementswere made last week at Hanley county court, when awholesale druggist named George Rowley, trading as Jamesand Co., sought to obtain an injunction against Cecil Pricewho, it was stated, imitated Rowley’s labels on his boxes.The labels alleged to have been copied bore the inscription"Dr. Astbury’s pure herbal pills, worth their weight ingold ; price two and nine per box." His honour JudgeMulholland elicited from the plaintiff that there never was aDr. Astbury, that the pills were made in London, and that theleading ingredients were soft soap and calomel. ThereuponJudge Mulholland seems to have taken a very definite line.He said that it seemed to him that the plaintiff’s description