397SOCIETY OF MEDICAL OFFICERS OF HEAIjTTT.

SOCIETY OF MEDICAL OFFICERS OFHEALTH.

AT a meeting of this Society on Feb. 15th the chairwas taken by Dr. J. HOWARD-JONES, the President,and a discussion on the

CONTROL OF SMALL-POX

was opened by Dr. A. F. CAMERON. He said hepreferred the word " prevention " to " control"because the latter had no ideal before it and the wholeobject of the medical officer was to prevent the spreadof disease from a focus of infection. If he preventedsecondary cases he had done all that could be askedof him. The present discussion might be said toindicate an uncomfortable feeling that our methodswere not to be relied on and that their failure layin the system of control as laid down in public healthlegislation. The law gave to medical officers ofhealth power to acquire information, to segregate ’,

infectious patients, and to carry out disinfection. The schedule of diseases for which this power wasgiven illustrated the lack of elasticity in the law andwas one of the causes of the trouble with existingsmall-pox. The Acts had come into force in 1889and 1891, when it was believed that destruction ofthe materies morbi was essential to stop the spreadof infection. The method by which the process ofinfection was naturally brought to an end had notthen been understood. Disinfection was the funda-mental principle upon which the law was based, ’,and in treatment the greatest attention was paidto the locale of the disease in order to kill the organism.If the poison could not be killed because it washidden in a living individual, that individual wassegregated in hospital until the disease was at anend. Knowledge had progressed but the lawremained. Failure of secondary cases to appearwas due to a pre-existing immunity in those whocame into contact with the patient. In hospitala zone of control was set up around the patient, andin this zone the immunised workers carried outdisinfection. The two factors in segregation were,therefore, disinfection and immunity. of which thelatter was the variable factor. The efficiency ofsegregation varied proportionately with the degree Iof immunity in the zone of control. This might benatural or artificially produced. If the latter wereavailable, perfect immunity in the zone of control could be guaranteed, and for this reason segregation must be more effective in small-pox than in scarletfever or other diseases against which certain immunitycould not be produced artificially. In effect, therefore,segregation was only effective as a preventive of Ispread when immunity could be guaranteed-i.e., Iwhen spread could be prevented without it. Theminimum degree of immunity required to prevent Ithe spread of infection was immunity of contacts,and this could be guaranteed to prevent spread Ionly if it had been secured before the advent of Iinfection. Removal to hospital was only useful if Ithe temporary respite from spread thus obtained wereactively used to build up a zone of control.The legal preventive measures were fundamentally

defective and out of date, and there was little hopeof improvement until the law definitely recognisedthat immunity of those in contact with the focusof infection was the primary factor in the preventionof spread. It was a disadvantage that immunisationagainst small-pox depended on a living virus whichhad a pathology of its own. The people of thecountry must, however, choose between continuedvaccination-until the bacteriologists produced a

better immunity method-and having small-pox asone of our commonest diseases. The single-insertionvaccination had no advantages except that parentsmight accept it more readily for infants, and itsprotective power was quite unknown ; it reduced thechance of a take by 50 per cent. The mild diseaseprevalent in this country now was indistinguishable,

clinically and experimentally, from the more severetype, so that the name given to it did not matterand it must be dealt with administratively as small-pox. If compulsory power were applied to theimmunisation of contacts the vicious circle would bebroken. The mild type of small-pox had bred truefor ten years and was of very little importance tothe patient or the public health, but had been con-verted into a dangerous disease by a defective law.Its one important feature was its detrimental effecton trade and commerce, but that was a matter forbusiness men and trade conferences to discuss.Doctors could show them how to prevent the diseaseif they thought it worth while ; otherwise it was ofno more importance than chicken-pox or rubella.

Synall-pox and Small-pox Administration at the PresentT2me.

Dr. G. F. BUCHAN reviewed the history of small-pox in this country. Associated with the prevalenceof mild small-pox since 1919 there had been smalleroutbreaks of the classical variety. Mild outbreakshad been observed from early times, and variationsin virulence were a constant feature of most epidemicdiseases-e.g., influenza and scarlet fever. Animalexperimentation seemed to prove that the virus ofmild small-pox was identical with that of the severedisease. Arguments in favour of identity were : thesame period of incubation, the same characteristicprodromal symptoms; the appearance of eruptionat the same time, and its typical appearance. Inthis country, however, the prodromal symptoms inthe mild form might be so trivial as to be overlookedeven by the skilled observer, and the eruption didnot conform to the classic description in its form ofdevelopment. It was not yet known whether onetype could give rise to the other or not. The Willesdenoutbreak did not support the hypothesis that themild form could become the classical, because itwas quite common in all diseases for an epidemicto start from one very mild case. The most importantevidence was that of R. P. Garrow, who had statedthat mild small-pox did not confer immunity againstvaccinia for more than 8 to 12 months. This,however, did not establish the view that the two weredifferent diseases, but rather that one was a variantof the other.

Present administrative measures included earlydiagnosis, removal to hospital, disinfection of premises,inquiries as to source of infection, prompt search for,and surveillance of, contacts, and vaccination.The " missed case

" was undoubtedly the chief

factor in the spread of small-pox, and facilities forskilled diagnosis were most important. There oughtto be enough hospital accommodation for isolationof the early cases with a view to checking an epidemic.When the disease had got a hold there was reason todoubt whether hospitalisation was worth while forthe mild form. No reliance could be placed on

disinfection of premises, which might well be abolishedfor all infectious illness. Inquiry as to the sourceof infection was very valuable but by no meansalways successful. All contacts should be registeredand visited daily for 16 days. Small-pox was notinfectious before the rash appeared, and sufferersfrom prodromal symptoms should be isolated as

suspects. Vaccination within three days of infectionwould prevent or modify an attack ; the importanceof finding and vaccinating contacts immediatelycould not be overestimated. Vaccination had hithertobeen exploited as the lesser of two evils, but theprevailing type of small-pox was so mild that vaccina-tion caused more absence from work than the disease.Headache and pain in the left abdomen, neck, andaxilla were common after vaccination, and a fewdeaths from it occurred every year, apart from theoccasional encephalitis associated with althoughprobably not entirely caused by it. Nowadayssmall-pox caused fewer deaths than mumps or chicken-pox and, under all the circumstances, the recom-mendations of the Vaccination Committee were theonly reasonable line to take. They advocated

H3

398 LONDON ASSOCIATION OF THE MEDICAL WOMEN’S FEDERATION.

three insertions, one in infancy, one between theages of 5 and 7, and one on leaving school, instead ofthe usual four insertions in infancy.

Dr. A. E. BRINDLEY urged the necessity for powerto obtain knowledge of intimate contacts ; an astound-ing amount of prevarication was encountered, andthe mischief was usually done before the case wasseen. In Derby there had been 2008 cases of small-pox without death or marked disfigurement. Somecases had no eruption and others had a rash which noone could have recognised as small-pox if the casehad not been a known contact. It should be anoffence to give false information to the healthauthority. Power to obtain information was held byport sanitary authorities, and had been recommendedby several conferences on small-pox. If the medicalofficer of health knew his contacts he had the reinsin his hands. The statutory four insertions deterredpeople from submitting to vaccination. Small ruralauthorities could not possibly deal with this disease,and their areas formed reservoirs of infection. Countycouncils should be made the responsible authority.

The Case against Hospitalisation and Vaccination.Dr. R. P. GARROW argued that the reason for the

discussion was that under the name of small-pox therewere to-day two diseases which were quite differentfrom the point of view of control. Their exactbiological relationship was a matter of academicimportance only. What were all diseases from theevolutionary aspect but fixed variants ? If mild

. small-pox remained mild small-pox, surely it could begiven a definite name, and until it was given a nameit could not be treated differently from classical small-pox. A disease sui generis was one that gave riseto itself and to nothing else. " Influenza " was aname given to an infinite variety of diseases, andpractically every case of mild small-pox had beenlabelled " influenza " in its first few days. The mostimportant measure for mild small-pox was to give uphospitalisation. People realised that three weeks inhospital was " worth it," and refused vaccination forthat reason.

Dr. R. W. JAMBSON said that the recommendationsof the Committee meant the immediate vaccinationof 30 million people, and the further vaccination offive million annually, which was manifestly absurd.Non-epidemic vaccination was ridiculous and createdantivaccinationists., Vaccination in infancy did notlast a lifetime. Vaccination involved a 1/40,000risk of encephalitis, erysipelas, and other compli-cations, while mild small-pox involved no danger andlittle discomfort. We had no right to vaccinateagainst variola minor. Contacts had every chance ojvaccination if severe small-pox arose. The publicrecognised the difference between the two diseasesand would not object to vaccination in a graveepidemic.

Dr. J. T. NASH said that patients with mild small.pox would choose hospital instead of vaccinatiorevery time. He hoped the Society would seriouslyconsider whether vaccination was justifiable when i1was often worse than the disease against which i1

protected. He had noticed that the eruption o:

variola minor sometimes matured very rapidlyespecially in old people, so that after 16 hours thEpustules looked four days’ old.

Dr. R. M. PIcKEN said that it would be scientificallyunsound to describe the two forms by different namesalthough undoubtedly they were administrativelyquite different. He knew no other two disease:against which immunity could be produced by thsame procedure and which immunised against omanother. Many cases of the most virulent type mighbe missed because there was no eruption, and mil(missed cases might occur amongst the unvaccinate(as well as the vaccinated. Universal vaccinatimmust be advocated for classical small-pox, and theprocedure must be modified for the present typeThe public were quite intelligent enough to appreciat,this. There was something to be said for abandoninghospitalisation, but this mild disease had at any rat,

provided a valuable opportunity for making localauthorities bring their hospitals up to standard.When classical small-pox came again-as it undoubt-edly would-we should be better able to deal with itas a result of this mild type.The PRESIDENT spoke in favour of vaccination of

contacts and isolation of cases, and said that themethod of vaccination should be improved.

Dr. CAMERON and Dr. BUCHAN briefly replied.

LONDON ASSOCIATION OF THE MEDICAL

WOMEN’S FEDERATION.

A MEETING of this Association was held at theB.M.A. House on Jan. 22nd, Miss F. HUXLEY, thePresident, being in the chair.A paper was read by Dr. DOROTHY DOUGLAS on the

working of the

Mackenzie Institute of Clinical Research at St. Andrew’s.After outlining briefly the foundation of theInstitute, and commenting on the life and work ofits great originator, Dr. Douglas went on to explainthe aims of the organisation. These were, princi-pally : (1) to obtain a large series of accurate life-histories of the health of individuals, whose circum-stances, habits, and, if possible, antecedents wereknown ; and (2) by an intensive and minute studyof cases of disease, especially in its early stages, toarrive at a better knowledge of the meaning ofsymptoms, as opposed to physical signs.

Disease states might be divided into two groups:first, those in which there are symptoms only,without physical signs, and therefore only disorder offunction ; and secondly, those in which physical signscould be elicted, and therefore structural changemight be postulated. It was always Mackenzie’saim, by an early recognition of the first group, toprevent the occurrence of the second. St. Andrew’swas chosen as the site for such a research, chieflybecause it is a very small and somewhat remotetown. This makes it comparatively easy to followup patients and to discover facts about their familiesand circumstances ; moreover, it is there possible tokeep in touch with individuals over a large number ofyears, since the population is more or less stationary.For much the same reasons it was decided to staffthe Institute entirely from general practitioners ofthe town, since they would naturally be the firstto see the earliest symptoms of disorder. At thepresent time it was found practicable to employin addition a full-time pathologist and bacteriologist,a radiologist, and a pediatrist. The services of thegeneral practitioners were entirely voluntary, andthe general feeling locally, both among the doctorsand the general public, was that the work, besides

being part of a most necessary research, acts as astimulus to thought and discussion, and much’ increased the interest of the routine of generalpractice. Many important papers had been pub-lished by the Institute since its foundation, and acomprehensive mass of material in the shape ofaccurate clinical notes of a large number of cases ofspecial interest had been gathered together. Thismaterial was available to investigators following

, out a particular symptom or disease. It was to behoped that such unique opportunities for clinical

research as were offered at the Institute would be utilised to the full.

LBRISTOL EYE HOSPITAL.-The annual report shows

that last year 13,116 out-patients attended, an increase of> 1000 over the preceding year ; there was also a substantial

increase in the number of in-patients. The need of larger.

premises is urgent, and the number of beds needs to be doubled, but enlargement has been postponed until thewhole question of the Bristol hospitals has been considered. by a body which is in process of formation.