May 13, 1896.]
medical attendant, without fee, while in the absence of a medical practitioner "of any nationality," which included therefore the Chinese so-called "doctors," this duty was imposed upon the nearest male adult relative or the occupier or keeper of the premises. The present by-laws apply to smallpox, bubonic plague, cholera, diphtheria, scarlet fever, typhus fever, enteric fever, relapsing fever, and puerperal fever, and a fee of one dollar is payable to legally qualified and registered medical practitioners for every such certificate, while in the absence of a medical attendant the occupier or keeper of the premises, or in default the nearest male adult relative, or the attendant npon the sick person, is required to notify the existence of the following diseases, namely, smallpox, cholera, and bubonic plague. penalty of 850 is recoverable for any contraven- tion of these by-laws, but in practice it is found, as at home, that where a medical practitioner is not in attendance the case is rarely notified, and as it is almost impossible to prove, in a court of law, that any of the above named persons actually knew that the disease was either smallpox, cholera, or bubonic plague, a prosecution is seldom undertaken.
A
It will be noticed that, actuated by experience of the working of the Imperial Act, I recom- mended the omission of erysipelas from the notifiable diseases.
DEATHS FROM THE INFECTIOUS DISEASES. 1.-Bubonic Fever.
The statement made by Dr. Lowson, in his able report upon the epidemic of bubonic fever (so-called plague) in 1894, that the public latrines were one of the most potent factors in the spread of the disease, is of serious moment to the health of the colony, for if this assertion can be substantiated by facts the Sanitary Board must, without delay, devise some other means of conservancy than that in vogue at present. None of the Chinese houses in the colony are provided with any latrine or closet accommodation, and it is the custom for the men to visit a public latrine for this purpose, while the women almost invariably use pots which are kept in the back yards or kitchens of their houses; both the pots and the latrines are emptied daily by night-soil coolies, and the night soil is removed from the colony at once by boat. Fora city such as Victoria, with a tropical climate, and a limited water supply, this appears to me a perfect system, but if the use of public latrines by the men can be proved to be the main cause of spreading such a disease as bubonic fever throughout the colony, then the sooner they are abolished the better. I contend, however, that there is no evidence to justify such an asser- tion, and in support of this contention I would point, in the first place, to the relative incidence of the disease during 1894 upon the two sexes. The Registrar-General's report for that year shows that, out of 2,508 deaths, 1,565 were men and 943 were women; that is to say, the propor- tion of cases in the two sexes was as 1.7 to 1, and as I have already pointed out that the population of the colony is composed of thrice as many men as women, it would appear that the women suffered from this disease to about double the extent that the men did, and as it is the men alone who use the public latrines I fail to see how these can be held in any way re- sponsible for the spread of the disease. It is true that the disease was more prevalent in the neighbourhood of these public latrines than elsewhere, but it is also true that the latrines are, for reasons of convenience, invariably located in the most densely populated quarters of the city, and as the predisposing causes of bubonic fever are undoubtedly, as in typhus, overcrowding, want of ventilation, filth, de- bility, and privation, we have here far more petent factors in the causation of an epidemic than the mere location of the public latrines. I do not wish to assert that bubonic fever cannot be communicated by the excreta, al- though our information as to the existence of the specific bacilli in the intestinal canal is not as positive as one could wish, but I am most strongly of opinion that the infection is dis- seminated chiefly by the emanations from the breath and skin, and only to a minor extent by the excreta.
Much has been written about the preponder ance of femoral buboes, and Dr. Lowson, in his report, explains this by asserting that in the
CHINA OVERLAND TRADE REPORT.
Chinese, who usually go barefooted infection by inoculation was the usual condition, but he fails to explain why the men of the Shropshire regiment also had femoral and inguinal buboes. To my mind the explanation of their occur- rence, in either case, is a very simple one; the disease is essentially one of the lymphatic system, and post-mortem examinations have abundantly shown that all the lymphatic glands of the body are more or less implicated, and all exhibit a greater or less tendency to enlargement; there- fore any special source of irritation will be sure to produce marked enlargement of certain glands, and such irritation would naturally occur in men, whether barefooted or booted, by much walking, especially if carry ing heavy weights at the same time, and by climbing up and down narrow flights of stairs, as was done by the soldiers; women on the other hand exhibit mostly enlargements of the axillary glands con sequent upon their ordinary household avocations, while the femoral and in guinal glands are not usually very enlarged, for the ordinary Chinese woman, even of the coolie class, does very little walking. It is an admitted fact that patients suffering from bubonic fever are able to walk about, and even in some cases to follow their usual employment, for the first day or two of their illness, and then succumb rapidly from heart failure, so that there is ample time for the development of the irritative enlargement of any special chain of glands.
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urgently need resumption, and when the clear- ing and laying out of Taipingshan has been completed others could be taken in hand with- ont producing further congestion of the re- maining portions of the city.
The number of cases of bubonic fever reported during the year was 45, of whom 14 were women and 31 were men; 14 of these were taken to hospital after death. Thirty-six deaths were registered during the year; the first case occurred on April 29th, and the disease con. tinued to recur sporadically during the remainder of the year. No less than twelve of the cases originated in No. 7 Health District, where the houses are in a very dirty and insanitary con dition, and many of the inhabitants of "which are said to have come from the resumed area of Taipingshan. Four cases were clearly imported from the mainland, while eight came from two houses in a small lane in No. 6 Health District (Heung Lane), but the origin of these cases was anexplained.
The distribution of the cases was as follows April 3, May 2, June 13, July 2, August 4, September 3, November 6, December 12.
The steps adopted upon the report of each case have been to at once remove the patient to the Kennedytown Hospital, to place a police guard upon the premises persons leaving, to disinfect all clothing, bedding, and other fomites found upon the premises (including the cloth- ing actually worn by these persons, suits of Yet another argument against this theory of Government clothing being lent to them, in infection by inoculation is that wound reaction
the meantime), and then to give these persons is not present, in ordinary cases of the disease, the option of leaving the colony for a period but that when we get a genuine case of acci- of not less than ten days, or of remaining isolated dental inoculation, as from a post-mortem upon a quarantine boat, for a like period, at wound, it is most marked, both at the seat of
the Government expense. The great majority the wound and along the track of the lymphatic elected to leave the colony, and they were ac- vessels. This is well shown in the case of Pro-cordingly escorted to the boats by a police fessor Aoyama, as described ou page 38 of Dr.
officer, and their return fares to Canton paid Lowson's report, for he had two inoculation by the Captain Superintendent of Police. In wounds, one on the left third finger and the all cases the premises recently occupied by the other on the right thumb; both of these wounds patient have been stripped, disinfected, scrubbed, became so inflamed and intensely painful that and limewashed. they had to be freely incised, while lymphangitis occurred in both arms, and buboes formed in each axilla; it is worthy of note that the first bubo formed in the left axilla, while the lymphangitis appeared first in the right arm. Case X., Chinese, also illustrates this point, and in my opinion serves to accentuate the rarity of infection by inoculation under ordinary circumstances.
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A I have said; the infective material will breed in premises which are filthy, ill-ventilated, over- crowded, and dark, and the disease is contracted by prolonged breathing of such atmosphere as is found under these conditions, and the attention of the Board should therefore be directed not to the substitution of other methods of conservancy for that at present in vogue, but to the speedy improvement of the general sanitary condition of the colony. the prohibition of back-to-back houses, the opening out of narrow lanes and passages, at present occluded by filthy hoardings, awnings, and other coverings, the provision of an abundant supply of pure water, and the prevention of that overcrowding which has unhappily been permitted to continue unchecked for so many years past.
It is a significant fact that only about 26 per cent. of the cases occur on the ground floors of houses, although nearly half the tenement houses of the colony are still but two-storey buildings, and the proportion of occupied ground floor rooms to upper floor rooms is as 65 to 100. This is, I think, another argument favour of the theory that overcrowding and want of ventilation are the more potent factors in the spread of the disease, for the ground floor rooms of most Chinese houses are open throughout their entire frontage during the daytime, being closed at night by wide doors, while the upper floor rooms have no such efficient means of ventilation.
The course to be pursued appears undoubtedly to take steps at an early date, in the direction indicated by the provisions of the Crown Lands Resumption Ordinance, No. 23 of 1889, which is much on the lines of the Imperial Housing of the Working Classes Act of 1890, and to resume certain insanitary areas, demolish the premises upon them, and then having laid out the land either re-sell the building lots, or build model dwellings thereon; there are a number of insanitary areas in the city which
2.-Cholera.
Four deaths from cholera are recorded for the year 1895, two being in Europeans belong- ing to the army (ct. 22 and 30 respectively), one an Asiatic at Kowloon (cet. 21), and one a Portuguese (cet. 19); it will be noted that the victims were all young adults. In no case did the disease spread, and I think we may take it that the cause of death was not, in any of these cases, genuine Asiatic cholera, but rather some form of non-infections cholera nostras, such as is met with in Egypt and elsewhere, or an acute choleraic diarrhoea induced by indis- cretions of diet or exposure to chill.
3.--Smallpox.
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In a colony having such close proximity to the mainland of China, we must expect to have smallpox constantly introduced, and yet the chances of its spreading are small, for most of the Chinese inhabitants are already protected by a previous attack, while the Vaccine Institute under the superintendence of the Colonial Surgeon supplies an abundance of pure lymph, which undoubtedly accounts for the remarkable immunity of the police and other officials from
this disease.
Thirty-two cases of the disease were reported during the year, and eight deaths were registered. Five of the cases occurred amongst Europeans, two being taken from steamers in the harbour and one from the Sailors' Home, while one was a woman removed from the McGregor Barracks. There was a small outbreak of the disease among the children at the Berlin Foundling Mission dur- ing the month of May, when five cases were recorded, and another small outbreak at the village of Hunghom at the latter end of the year, which accounts for other six cases, while one case is debited to each of the villages of Yaumati, Tsat Tsz Mui, and Quarry Bay. Twenty of the cases were men, and twelve women, and they were treated in the following institutions :- Government Civil Hospital 18, Kennedytown Hospital 3, Tungwa Hospital 6, at home 5.
4.-Enteric Fever. Fifteen deaths were registered during the year as having occurred from this cause, four of them being among the non-Chinese civil population and one a British soldier; the former comprised one British sailor, one German sailor, one Japanese sailor (all imported cases), and one Japanese prostitute. Of the ten deaths
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