MEMOBANDUM OF A PLAN OF UNITED ACTION IN THE CASE 01? AX EPIDEMIC OF CHOLEKA: TO BE COMMUNICATED TO VESTRIES AND DISTRICT BOARDS, UY THE METROPOLITAN MEDICAL OFFICERS OF HEALTH. PRINTED AT THE "MARYLEBONE MERCURY" STEAM PRINTING OFFICES, 6, North Street, Manchester Squabe. Dr. Aldis, 1. Chester Terrace, Chester Square, S.W. St. George's, Hanover Square Dr. Auo. W. Allinson, Beresford Square, Woolwich, S.E. Plumstead Dr, Ansell, Harley Place, Bow, E. Bow Dr. Ballard, 7, Compton Terrace, Islington, N. Islington Dr. Barclay, 23a, Bruton Street, Berkeley Square, W. Chelsea Dr. Barnes, 12, Finsbury Square, E.C. Shoreditch Dr. H. Bateson, 1, Gladstone Place, Bs. George's Road, S. St. George's, Sottthwark Mr. L. Beale, 108, Long Acre, "W.C. St. Martin? s-in-the-Fieldt Mr. R. Bianchi, 13, Stamford Street, Blackfriars Road, S. St. Saviour's, Southivark Dr. Bristowe, 2, Queen's Square, Westminster, S.W. Camberwcll Dr. Buchanan, 63, Harley Street, W. 8k Giles and St. George, Bloomsbury Mr. F. J. Buuoe, New Uoad, Hammersmith, W. Fuiltam Mr. J. S. BuaTON, Blackheath Terrace, Blackheath, S.E. Lee and Kidbroke *Dr. W. Connor, St. John's Hill, Battersea Eise, S.W. Wandsworth Dr. Dhuitt, 37, Hertford Street, May Fair, W. St. George's Hanover Square • Mr. S. K. Ellison, Carlton House, East India Koad, E. Poplar Dr. Conway Evans, 56, Russell Square, "W.C. Strand Dr. Finch, Stainton Lodge, Blackheath, S.E. Clmrlton Mr. J. H. Freeman, 1, Gardner's Terrace, Mile End Road, E. Mile End, and also St. George's Eatl Dr. S. Gibbon, 3, Finsbury Square, E.G. Holborn Mr. F. Godrich, Jun., 12, Sidney Place, Onslow Square, S.W. Kensington •Dr. Griffith, 6, Wrotham Road, Camden New Town, N.W. Clerkenwell Dr. Hillier, 32, Queen Anne Street. W. St. Pancras Mr. B. Holt, 14, Savillc Row, W. Westminster Mr. Kino, Eltham, S.E. Eltham. Dr. W. T. Iliff, 37, Kcnniugton Park Road, S. Newington Dr. Lankksteb, F.R.S., 23, Great Marlborough Street, W. St. James's, Westminster Dr. Lethebv, 17, Sussex Place, Regent's Park, N.W. City of London Mr. J. Liddlk, 8, Campbell Terrace, Bow Road, E. Whitechapel Mr. C. F. J. Lord, 1, College Terrace, Hampstead, N.W. Hampstead •Mr. J. M'Donovoh, Clapham, S. Clapham Dr. Mcudock, James Place, Lower Road, Rotherhithe, S.E. Botherhithe Mr. G. E. Nicholas, Church Row, Wandsworth, S.W. Wandstsorth •Mr. D. C. Noel, Upper Tooting, S. Strcatliam, Tooting, and Balham Mr. T. Orton, 5, Regent's Terrace, Commercial Road East, E. Limehonec Dr. W. Parker, 49, Great George Street, Bermondsey, S. Bermondsey Dr. Pavy, 33, Bedford Place, Russell Square, W.C. St. Luke's, Middlesex Dr. T. Sarvis, 135, Bcthnal Green Road, N.E. Bethnal Green Mr. H. N. Pink, Crooms Hill, Greenwich, S.E. Greenwich Dr. G. Puckle, Denmark Hill, S. Lambeth Dr. Sanderson, Queen Anne Street, W. Paddington Dr. Whitmore, 15, Wimpole Street, W. St. Marylebone Dr. Tripe, 7, King's Place, Commercial Road East, E. Hackmy Dr. J. N. Vinen, 5, Church Row, St. John's, Southwark. S.E. St. John's and St. Olave's Southivark Mr. R. H. Whiteman, High Street, Putney, S.W. Wandsworth Mr. J. E. Wilkinson, Sydenham, S.E. Lewisham N.B.— Those names to which an asterisk is prefixed are not members of tlie Association of Medical Officers of Health. MEMBERS Who are not now Metropolitan Officers of Health< W\ Odi-ing, Esq., M.D., F.E.S., St. Bartholomew's Hospital. "W. Kendie, Esq., 40, Newington Causeway, S.E. J. Simon, Esq., F.R.S., Privy Council Office, 8, Richmond Terrace, Whitehall, y.W. PREFACE. The following short notes are intended to give a sketch of the various things which the Medical Officers of Health recommend to be d6ne in the case of a threatening or actual invasion of cholera. The same measures, whether cholera visit us or not, would tend to suppress the scarlet fever and typhus, whose continued presence in London causes more mortality than a passing epidemic might do. They are intended for the consideration of Vestries and District Boards, and of the public generally, as an exposition of what the Medical Officers of Health recommend. They are believed to be founded on common sense and experience, and aim at nothing extravagant ; and, if attended to now, much future suffering, panic, and cost will be avoided. They do not aim at absolute perfection, but only at such limited measures of precaution as the present state of the law and the present state of society make it possible to carry out by persuasion or legal compulsion. The Jirst section treats of water, which, when impure, "is a great source of peril ; the second, of the measures requisite to check the spread of the disease in any given house which it may invade; the third, of the disinfection of clothes, &c. ; and the fourth, of the speedy burial of the dead. 240&+ f ] < ] 4 Section fifth has reference to the helpless and dependent classes and Section sixth mentions some general sanitary precautions, always necessary, but now more than ever. Appended are Hints for handbills for distribution, if thought expedient, to the owners or occupiers of houses, and to the population generally. I,__WATER. All experience shows that water is a most common and most dangerous vehicle of cholera, and that it may actually convey the discharges of the sick to the stomachs of the population. Should cholera be imported into any of those towns and villages which drain into the upper Thames, there can be no doubt that London would be in great danger. Hence it will be expedient, as regards the supply of water — i. To communicate with the water companies, urging them to make sure that no water is delivered into their mains which has not undergone nitration ; to take double care in delivering their water clear, for it has been shown that the sediment is the most dangerous part of foul water ; and to have their filtering beds thoroughly washed and cleansed from organic matter. So much for the quality of the water. Next as to quantity. 5 li. A daily supply should be given to the courtsinhabited by the poor, guarded by a "water-waste preventer," 3. A, supply on Sundays is absolutely necessary,, for the greater washing and cooking on Sunday mornings, when working men are at their own homes. 4. As regards Storage of Water The public must be cautioned as to the condition of their water receptacles, which should be thoroughly cleansed. Drinking water ought not to be taken from butts or cisterns connected with water-closets. 5. All surface wells should be absolutely closed for drinking purposes. lI.— AGAINST THE SPREAD OF CHOLERA. Let us suppose that cholera is actually imported. This will probably be by some sea-faring person coming from an infected port or ship, or by some person bringing the disease with him from one of the outports. In order to stop the spread of cholera in houses — 1. It is absolutely necessary to decompose and get rid of the excretions of the patient, in all manners and in all places whither their influence can reach. a. Some disinfectant should be put into the vesselsor receptacles in which the excretions are received before the vessels are used, or at all events before they are taken out of the room. 6 b. The closets and sinks should be treated in like manner, and be well flushed, and a little disinfectant be put into the chamber vessels after emptying them. c. The air of the sick chamber should be kept pure by free ventilation, and by sprinkling the floor with chloride of lime. d. The body clothes, bed clothes and bedding, towels, and any other things contaminated with the discharges of the sick, should be disinfected. (See section III.) If possible, no one should take food in the sick chamber j certainly not without washing the hands. c. The poison must be followed — the house drains be flushed with water and disinfectant j the gulleys by the street pavement be also flushed out with water and chloride of lime, and the ventilating openings of seivers in the middle of the streets be protected, if possible, by charcoal boxes. f. It is presumed that the drains of houses are efficient, and well trapped from the sewer and from the house. It will be too late to attend to this when the disease is within our doors. g. The areas, yards, basements, cellars, and all damp and dark places in which moisture can collect, •or mould or mildew grow, should be thoroughly coated with quicklime and water. The rooms in which the sick person has been treated should be cleansed, together with the carpets, &c. 7 111. -DISINFECTION & DISINFECTANTS. For the disinfection of the discharges from the body, a solution of chloride of iron, or chloride of zinc (Sir W. Burnett's fluid), is the most powerful agent, and either should be used in the quantity of about a wineglassful on each occasion. But for the disinfection of the atmosphere of a room, chloride of lime is the best, in the proportion of a teacupful of chloride of lime to a gallon of water, kept in saucers or sprinkled over the room j or the same may be used as a wash to infected bedding and particular parts of the floor, etc. Disinfection of Clothes. — This is a most vital matter, not only as regards cholera, but scarlet fever, measles, small pox, and typhus. No infected clothes ought to be washed at home, or in public or private laundries, without preliminary disinfection. The best disinfectant is dry heat, at 550 deg. Fahrenheit, where it is possible, for woollen fabrics ; linen should be boiled in water, or plunged into boiling water. IV,— SPEEDY INTERMENT OF THE DEAD. In the event of death, the corpses should be at once deposited in a shell, and be covered with Falcony's Powder (sawdust, sprinkled with a saturated solution of sulphate of zinc), or with charcoal, in small bags, and be quickly buried. This matter will probably in the case of an epidemic, be provided for by an Order in Council, under the 18th and 19th Vie, €. 116, s. 6. 8 In any case, where practicable, it is desirable that deceased persons should be speedily removed from inhabited houses. V.-SPECIAL PROVISION FOR POOR DISTRICTS. Heretofore we have spoken on the supposition that the persons concerned belonged to the classes that take care of themselves. But in the case of the helpless classes there is some further provision necessary. i. — Special Sick Wards For the reception of cholera patients must be provided- It may be said truly that the safety of a whole parish may depend on the energetic treatment of the first twenty sick persons. If these be removed from crowded dwellings, and their dwellings be disinfected,, in the manner before mentioned, the mischief may stop. Hence, it is expedient to provide for the reception of a certain liberal number at first. This number should be determined by each District Board/ according to the circumstances of each. Of course there are limits beyond which the sick must be left at home; but all depends on the extinction of the disease by energetic treatment at first. 9 a. House to House Visitation (18 & 19 Vie, c. 1 16). In every parish or district the number of houses inhabited by the helpless dependent part of the population, and the number of the families should be estimated, and arrangements made for house to house medical visitation. A sufficient number of assistants acting under the orders of the parochial medical officers should, at least once a week, visit thoroughly every family in every such house. In this climate diarrhoea usually precedes cholera for some days ; and this diarrhoea should be checked by appropriate medicines which the visitor should carry in a portable form. All experience shows that the surest way to limit the ravages of cholera is to find out and treat at once every person whose bowels are in the least disturbed. The visitor may also distribute handbills and give information as to disinfection, purification of water, etc. 3. — Dispensing of Medicines (18 & 19 Vie, c. 1 16). These should be accessible to all classes night and day, at some places to be made known by the local authority. VI. —GENERAL MEASURES OF PRECAUTION. It is highly important that a sufficient number of sanitary inspectors be appointed at once, if necessary, so that an inspection of the houses of the helpless classes may be made once a fortnight, for the purpose 10 of carrying out the ordinary means of precaution to the fullest extent ; and even if no cholera visit us, the effect in diminishing diarrhoea and fever will be great. Attention should be particularly directed — a. The state of closets, sinks, and dustbins. Even when the apparatus is in good order, and the water supply fair, closets in poor houses require to be daily flushed with water and chloride of lime to prevent them from being offensive. Sinks always require to be seen to, that they are not stopped up, nor the trap displaced. Emptying of dust, and lime-whiting, should also be attended to. b. Existence of rotten brick drains or cesspools. c. Underground dwellings inhabited contrary to law. d. Prompt legal proceedings should be taken against persons permitting nuisances on their premises. c. Each District Board is recommended to ask its surveyor for a formal account of the state of the public sewers in his district. Removal of Dust, etc. In anticipation of a cholera outbreak, contracts made with dustmen and scavengers should provide for the more frequent removal of house refuse, and for the more efficient cleansing of streets. All refuse, dust, and dirt, ought to be looked upon as containing possible germs of disease, which may be lifted in vapour or blown about by the wind, and so be inhaled or swallowed. It would be wise economy this summer to have the streets kept more cleanly. 11 SUGGESTIONS FOR HANDBJLLS. PREVENTION OF CHOLERA. I.— TO HOUSEHOLDERS. Tarish or District of- The Local Authority for carrying out the Nuisances Removal and Diseases Prevention Act, under the advice of the Medical Officers of Health, appeal to tho good feeling and public spirit of all householders, and especially of owners of houses inhabited bj r the poorer classes, and urge them to take such precautions as are likely to render their houses comparatively safe from the Cholera. These precautions are very simple, and consist Ist, In causing all areas, basements, cellars, kitchens, yards, and other damp and dark places to be cleared of all rubbish and well lime-whited. 2nd, In having all water-closets sinks and drains well flushed out with chloride of lime every day during the summer, taking care that the traps are good, and in their proper places. 3rd, All dustbins to be regularly emptied. 4th, All waterbutts to be cloaned and kept well covered. 2— TO THE PUBLIC GENERALLY. The inhabitants of are hereby cautioned by the Local Authority, under the advice of the Medical Officers of Health, as to the best measures for avoiding an attack of cholera. 1. Every person attacked by diarrhoea, especially if without pain, should attend to himself, and obtain proper medicine. Purgative medicine should only bo taken under the advice of a medical man. 2. All sudden checks to perspiration should be avoided, such as sitting in draughts of cold ah- when hot from exercise. It is always a good precaution to wear a belt of flannel round the stomach. 3. Every person should live regularly and temperately on those articles of food which ho is used to, and which agree with him. There is no objection to fruit or vegetables if good ; but all stale or over-kept fruit, fish, meat, and vegetables should bo shunned. Great care should be taken to givo no stale or sour food to children. 4. Intemperance and drunkenness are most dangerous. It is to bo feared that raoro cases of choleraic diarrhoea occur on Mondays, and days after a holiday, than at other times. 5. It is of the utmost consequence to avoid all foul smells, as of sinks, closets, drains, dustbins, and the like. It should be remembered that every closet and sink which lets water down to a drain may allow bad air to come back, so that the traps should be looked to regularly, and bo kept well charged with water, and a little of some disinfectant should bo put dowD daily. G. The house should bo kept sweet by opening windows and admitting plenty of fresb air. 12 7. If an inmate be attacked, and he cannot be pnfc into a"room by himself, it is better to send him to the hospital provided for the purpose. Infected clothes, and bedding, and apartments should be purified under the direction of the medical attendant. All that passes from the sick should b6 looked on as highly poisonous, and be got rid of at onco ; and every vessel, and sink, and cloth, or article of bedding or clothing that it touches ought to be disinfected. 8. The greatest pains should be taken to secure pure water for drinking purposes. None should be used that is not quite bright ; and this should be boiled and flavoured with tea, coffee, or burnt bread. If at all turbid or discoloured, it should be allowed to settle, or should be filtered, or both. No water should be drunk which comes out of a dirty butt, or that has been standing near a sink or closet. All cisterns should be cleansed, and wooden butts be charred or pitched inside. 9. Persons who attend upon the sick should wash their hands and face before any meal, and should not take any food in the room occupied by the patient. N.B.— The chief disinfectants are Chloride of Lime, Burnett's Liquid, 8olu» tion of the Chloride of Iron, and Condy's Liquid. Any respectable Chemist will supply a small quantity of any of them for sixpence, with directions for use. %? It will be observed that the gist of the foregoing advice is to breathe pure air, drink no impure water, and avoid everything that upsets the bowels.