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County Council of Kirkcudbright.
PUBLIC HEALTH DEPARTMENT.
YEAR ENDING 31st DECEMBER, 1891.
FIRST
ANNUAL COUNTY REPORT
BY
W. LESLIE MACKENZIE, M.A., M.B., C.M., D.P.H.,
MEDICAL OFFICER OF HEALTH
FOR COMBINED COUNTIES OF KIRKCUDBRIGHT AND WIGTOWN. |
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County Council of Kirkcudbright.
PUBLIC HEALTH DEPARTMENT,
Year ending 31st December, 1891.
ANNUAL COUNTY REPORT.
PART 1.
TO THE HONOURABLE THE BOARD OF SUPERVISION AND TO THE
COUNTY COUNCIL OF KIRKCUDBRIGHT.
My Lords and Gentlemen,
According to the regulations of the Board of Supervision,
under the Local Government (Scotland) Act, sec. 53, I now have the
honour to present my Annual Report on the County of Kirkcudbright.
As Medical Officer for the Districts, I have already had to sketch
the general sanitary state of the county in its main divisions. In the
County Report the District Reports for this year are reprinted in full;
because, being written by a single officer, they form as a total really one
report, and at the same time contain nothing that the County Council
may not consider. Rather, therefore, than summarise those condensed
and comparatively brief documents, I here constitute them part of my
County Report and devote the County Report proper, first, to certain
general remarks on administration; and next, to a preliminary system-
atizing of vital statistics for the County.
1. - ADMINISTRATION.
First. - The present Sanitary Staff for the County is insufficient.
This opinion is based on the following facts:- The County Sanitary |
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Inspector, single-handed, has three kinds of work to do - he is Inspector
of Nuisances, etc., under the Public Health Acts; he is Inspector of
Dairies under the Dairy Regulations; and, under the Infectious Diseases
(Notification) Act, he is required to assist the Public Health Office in
the isolation of infectious cases and the disinfection of premises. In
these three kinds he acts for the County as a whole, for each of four
Districts, and for each of three Burghs. As County Inspector he must
advise proprietors and others on the sanitary reconstruction of premises;
as District Inspector he is provisional surveyor, draughtsman, and clerk
of works for all structural works under the Local Authority; and as
Burgh Inspector he must likewise work under the same Acts and Bye-
laws. As County, District, and Burgh Inspector of Nuisances, Dairies, and
Infected Premises he must traverse an area of some 900 square miles; he
must be available for infectious epidemics as the unforeseen incidence of
disease may determine; and he is required to inspect the dairies four
times a year. In a small county where dairies are few, the last item
might not be considerable; but in this county the dairies number about
200, and their inspection means 200 visits per quarter, or 800 visits a
year. The first year of this work is unquestionably the heaviest, for a
minute record has to be taken of cubic air space, drainage, and structure
generally; but always it must absorb a large part of the Inspector's time.
Add to this the time necessary to visit, isolate, and disinfect premises
when infectious cases number some 150 in the year, and it will be
obvious at once that the time left for special district work, for reports on
villages, systems of drainage, water supplies, and housing must be small.
Second. - I offer the following suggestions from the Public Health
standpoint, for nine months' experience of work in the county has
persuaded me that the efficient administration of the Public Health
Acts now operative in the county requires a certain minimum of
assistance to the Sanitary Inspector.
(a.) A large part of the Inspector's time is consumed in re-visiting
the site of notified nuisances in order to see that the nuisances have been
removed. If a definite arrangement could be made with the police
officials to supply information even on this one matter, a large per-
centage of time would be saved for other and more fruitful work. (See
Supplement to Skelton's Handbook of Public Health, p. 25.)
(b.) For the ultimate suppression and extinction of infectious
disease within the county it is essential that for some time every infected
house be disinfected by the Sanitary Inspector, or by an official directly
responsible to him. It is rare that private disinfection is really adequate.
In occasional instances it has been possible to secure a man in the
locality; but at least one such man should be available in every district,
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and one in every main aggregation of people. Two districts have
already given power to the Public Health Office to secure such
assistance. It is important that the assistance should be constantly
available at need in all districts. The result within a short time would
be fewer cases, and ultimate reduction of expense.
(c.) The dairies are a constant possible source of disease, and the
thoroughness of dairy regulations is an admirable feature of county
administration. But the regulations leave it unessential for very small
milk-sellers to register. This is an administrative mistake; the possible
dangers are admirably illustrated in the cases of fever at Bridgestone, in
Balmaghie (see appendix). Registration costs nothing, and ought to be
compulsory on every milk-seller whatsoever. If registration means
anything, it means a sharpening of responsibility for cleanliness and
avoidance of possible contamination, and it is precisely the minor byres
that most need a stricter supervision.
II. - VITAL STATISTICS.
A. - DEATH-INCIDENCE.
In the District Reports I have given the details of deaths and rates
for the year 1891. Those deaths and rates by themselves, however,
give little information.
In the County Report, therefore, my design is so to tabulate the
facts of past years as to provide a system for a critical estimation of
the present. This year neither the matter at my disposal nor the time
for its elaboration permitted more than the part realisation of such a
system, which, however, as a system must embody in its parts the main
principles of the whole. This is not the place to give a full exposition
of the plan that governs the details of a public service. I expound only
that part of it concerning the vital statistics of the year.
The tables that form the body of the report are designed to exhibit
in serial exposition the varying populations, the incidence of death, and,
through deaths, the incidence of disease within the county. The last
ten years have been chosen for a basis of averages, and for beginning
the construction of a system that shall gather in new facts to itself, and
give them their scientific meaning. Unrelated facts are meaningless
and worthless. A careful study even of these tables will show whether
things are going forward or backward, how the case stands with the
divisions of the county relatively to each other, and how the case for the
whole county stands in the general comparison with all Scotland.
In the arrangement of this table-series I have followed the great
generalities of Time and Space. In the time-incidence of deaths certain |
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facts, as the part that climate plays, are to be learned from the monthly
deaths; certain others again from averages over longer periods. I have,
therefore, followed the division into months, into years, and into
decennial periods. Yet other facts are to be learned within the county
itself, others from the comparison with larger areas. Tables, therefore,
are given to show the local deaths and rates, and others to show the
comparative deaths and rates. Once more, deaths arranged according
to age give us many important indications of the health or dishealth of
a people, but tables for this purpose are not yet ready.
Similarly, in the space-incidence of deaths, tables are designed to
show local and comparative facts and averages. The local tables give
the facts within the major and minor divisions of the county, showing,
so far as the death-rate can, the relative healthiness or dishealth of the
areas. Each major division or district has a table showing population,
deaths, and averages within its parishes. For a full estimate of the case
the Burghs should be calculated separately, but for the ten years this is
yet to do. But the figures for each Registration District are given, and
those districts where a burgh or royalty is the chief contributor of
deaths I print in larger letters. A little manipulation will, therefore,
quickly discover any contrast between burgh and landward figures. In
this county the contrast is seldom so marked as where burghs are larger,
for the conditions that tend to make burghs unhealthy in the specific
way of large towns as yet hardly exist in this county. For the burghs are
essentially small rural towns, only better organised than the villages.
Lastly, under the Local space-head I give a small table to show the rates
in the districts. The comparative facts for Space are readily got from
the comparative table for Time.
B. - DISEASE-INCIDENCE.
The assumptions at the basis of all inference from death-rates are
these:-
First. - Death-rates are disease-rates; for the causes of death may
all be classed as specific diseases or not, and, therefore, causes of disease
are à fortiori causes of death. Second. - It is also true that disease-rates
are death-rates; for some diseases are directly fatal, and the prevalence
of others not directly fatal always accompanies a high death-rate. The
tables for Disease-incidence, then, follow the same plan as those for
Death-incidence.
INDEX TO TABLE-SERIES.
1. - DEATH-INCIDENCE.
A. IN TIME.
(1) MONTHLY AND YEARLY.
(a) LOCAL. - Confined to two Counties:
TABLE I. - Actual Deaths for Ten Years (Kirkcudbright)
TABLE II. - Actual Deaths for Ten Years (Wigtown).
TABLE III. - Rates per 1000 (Kirkcudbright and Wig-
town).
(b) COMPARATIVE. - Including all Scotland, Mainland-Rural,
Small Town and Principal Town Districts:
TABLE IV. - Annual Rates per 1000 of Average Popula-
tions (Kirkcudbright and Wigtown).
(2) DECENNIAL - at four Census periods.
(a) LOCAL. - Confined to two Counties:
TABLE V. - Births, Deaths, Birth-rates, Death-rates
(Kirkcudbright and Wigtown).
(b) COMPARATIVE. - Tables incompleted.
(3) ACCORDING TO AGE. - Incompleted.
B. IN SPACE - FOR TEN YEARS.
(1) LOCAL. - Confined to two Counties.
(a) KIRKCUDBRIGHT - District and Parochial:
TABLE VI. - Northern District.
TABLE VII. - Southern District.
TABLE VIII. - Eastern District.
TABLE IX. - Western District.
(b) WIGTOWN - District and Parochial:
TABLE X. - Lower District.
TABLE XI. - Upper District.
(c) BURGHS. - Incompleted separately, but included in above
Tables.
(d) DISTRICTS. - Rates per 1000:
TABLE XII.
(2) COMPARATIVE. - See TABLE IV. |
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INDEX TO TABLE-SERIES.
II. - DISEASE-INCIDENCE.
A. IN TIME.
(1) MONTHLY - Incompleted.
(2) YEARLY - In Decennial Averages.
(a) LOCAL - Confined to two Counties:
TABLE XIII. - Zymotics and Tubercular Diseases.
(b) COMPARATIVE. - Including all Scotland and Mainland-
Rural Districts:
TABLE XIV. - Rates and Per Centages.
B. IN SPACE. - Tables incompleted.
III. - OTHER HEALTH INFLUENCES.
A. METEOROLOGICAL:
TABLE XV. - Barometer, Thermometer, Winds and Rainfall
(Kirkcudbright).
TABLE XVI. - Annual and Monthly Rainfall for Ten Years (Kirk-
cudbright).
B. SOCIOLOGICAL. - Including Profession, Trade, Housing, Soil, Situation
Drainage, &c. - Table incompleted.
IV. - DISTRICT TABLES FOR 1891.
See end of District reports.
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TABLE I. - KIRKCUDBRIGHT.
Showing Monthly and Yearly Death-Incidence for Ten Years.
[Table inserted] |
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TABLE II. - WIGTOWN.
Showing Monthly and Yearly Death-Incidence for Ten Years.
[Table inserted]
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TABLE III. - KIRKCUDBRIGHT AND WIGTOWN.
Showing Monthly and Yearly Death-Incidence in Annual Rates per 1000 population living.
[Table inserted] |
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TABLE IV. - KIRKCUDBRIGHT AND WIGTOWN.
Showing Annual Rates per 1000 of Average Population.
[Table inserted]
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TABLE V. - KIRKCUDBRIGHT AND WIGTOWN.
Showing Births and Birth-rates, Deaths and Death-rates at Four Census Periods.
[Table inserted] |
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TABLE VI. - KIRKCUDBRIGHT - NORTHERN DISTRICT.
(INCLUDING BURGH OF NEW-GALLOWAY).
Showing Actual and Average Deaths for Ten Years.
[Table inserted]
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TABLE VII. - KIRKCUDBRIGHT - SOUTHERN DISTRICT.
(INCLUDING BURGHS OF KIRKCUDBRIGHT AND CASTLE-DOUGLAS).
Showing Actual and Average Deaths for Ten Years.
[Table inserted] |
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TABLE VIII. - KIRKCUDBRIGHT - EASTERN DISTRICT.
(INCLUDING BURGHS OF MAXWELLTOWN AND DALBEATTIE).
Showing Actual and Average Deaths for Ten Years.
[Table inserted]
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TABLE IX. - KIRKCUDBRIGHT - WESTERN DISTRICT.
(INCLUDING BURGH OF GATEHOUSE).
Showing Actual and Average Deaths for Ten Years.
[Table inserted] |
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TABLE X. - WIGTOWN - LOWTHER DISTRICT.
(INCLUDING BURGHS OF NEWTON-STEWART, WIGTOWN AND WHITHORN).
Showing Actual and Average Deaths for Ten Years.
[Table inserted]
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TABLE XI. - WIGTOWN - UPPER DISTRICT.
(INCLUDING BURGH OF STRANRAER).
Showing Actual and Average Deaths for Ten Years.
[Table inserted] |
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TABLE XII. - KIRKCUDBRIGHT AND WIGTOWN DISTRICTS.
Showing Deaths per 1000 at two periods and per 1000 of
Average Population.
[Table inserted]
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TABLE XIII. - KIRKCUDBRIGHT AND WIGTOWN.
Showing Average Zymotic and Tubercular Deaths.
[Table inserted] |
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TABLE XIV. - KIRKCUDBRIGHT AND WIGTOWN.
Showing Comparative Rates and Per Centages at Different Periods.
[Table inserted]
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TABLE XV. - KIRKCUDBRIGHT.
Showing Barometer, Temperature, Prevailing Winds, and Rainfall, 1891.
[Table inserted] |
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TABLE XVI. - KIRKCUDBRIGHT.
Showing Monthly, Actual, and Average Rainfall for Ten Years at Two Places.
[Table inserted]
PART II.
ANNUAL DISTRICT REPORTS.
1. - NORTHERN DISTRICT.
According to the requirements of the Board of Supervision, I now
present my annual report with regard to the Northern District of the
Stewartry of Kirkcudbright.
For certain general remarks applicable, with verbal changes, to all
four districts equally, I would refer to my report on the Western
District, where I have given a typical sketch of the sanitary condition
of farm-houses, cot-houses, and villages. In the present report I
include only matters prominent in the Northern District.
1. - GENERAL SANITARY CONDITION.
A. - DISTRIBUTION OF POPULATION.
The district includes the parishes of Balmaclellan, Carsphairn,
Corsock Bridge (quoad sacra), Dalry, Kells, and Parton. The total
acreage is 178,575 acres. The total population by the census of 1891
is 3846. This gives an average of 0·021 persons to the acre, or other-
wise, on round numbers, one person to every 50 acres. The greater
part, however, of Kells, Carsphairn, and Dalry are uninhabited moun-
tain lands, and the population naturally gravitates towards the valley
of the Ken. The principal aggregations are at Carsphairn Village,
Dalry Village, Balmaclellan Village, the Royal Burgh of New-Galloway,
and Parton Village. The rest of the population spreads itself variously
among the farms.
B. - OCCUPATION, INDUSTRIES, AND SANITARY STATE.
The sole productive industry of the Northern District is farming,
and all that depends on it. The sanitary question, therefore, is
essentially the same as in the Western District, to the report on which |
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I must refer. The same general defects of situation, water supply,
drainage, and scavenging are common. The one point calling for
special remark is the water supply.
The difficulty of finding a good and constant water supply is
greater in the high lands of the Northern than in the low lands of the
other districts. The summer of 1891 has put every locality to the test.
Lochs there are, but for the main centres not available without great
relative expense, and when available not without need of filtration
from peaty extract and débris. Springs there are, too, in plenty; but,
unfortunately, they have been, as a rule, little protected; and in one
village, where need was of the greatest, the wells had been polluted by
sewage, proximity to dung-heaps, or other contamination. This village
- Dalry - was early after my appointment made the subject of a special
report, and was ultimately formed into a special Water and Drainage
District. A plan for water and sewage was submitted to the District
Committee, but rejected on financial grounds; and now the matter is
again in the hands of a sub-Committee, which is instructed to make
further research into the available water sources of the district, and
prepare a further report. It is my hope that in the next annual report
for the district I shall be able to put on record an accomplished scheme.
Some time ago the Royal Burgh of New-Galloway completed a
scheme for a gravitation supply. This burgh has just appointed me as
their Medical Officer; but I am not yet in a position to report on any-
thing connected with the burgh.
If the difficulties at Dalry can be successfully overcome, the
District Committee will be encouraged to proceed with the lesser
places.
C. - MEASURES FOR IMPROVEMENT.
The District Committee should forthwith order reports on the
following:-
(a.) Housing of the working classes in each parish, exclusive of
villages.
(b.) The health and sanitation of every village in the district.
(c.) The school and public institutions in the district.
The reports should be given in month by month, and after
approval by a small committee, should be made public. In no other
way will the inhabitants of the district be better roused to do all that
individuals can to better the sanitary state of the district, and
ultimately to relieve the Committee of responsibility. There is
much that can be done by the small localities, if only the facts are
brought home to them. My primary object in urging this mode of making
reports public is the education of the people. A secondary result will
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be the economising of time and labour to the District Committee. I
propose, therefore, a drafting of a programme of special reports in the
above sense.
II. - INQUIRIES DURING THE YEAR.
(a.) General. - I have made a general inspection of part of the
parishes of Parton, Balmaclellan, Dalry, and Kells. Carsphairn I
propose to visit early in the present year.
(b.) Special. - I have made special inquiries regarding the follow-
ing: - The Ringbane scarlet fever outbreak, which had almost passed
away when I began duty; water and drainage of Dalry, referred to
above; whooping cough in parts of the parishes of Balmaclellan, Dalry,
and Kells.
III. - CERTIFICATES GRANTED.
There is nothing to report under this head.
IV. - BAKEHOUSES.
I have not found any condition demanding the interference of the
law.
V. - HOSPITAL SUPERVISION.
The only hospital available for the district is the Dumfries Royal
Infirmary. Apart from the inadequacy of the accommodation there,
the impossibility of safe transit would make this hospital practically
useless. The experience of the last year points to the desirability of a
special hospital for the district, and the sooner the matter is seriously
grappled with the better. I do not here propose any special place, but
I advise the District Committee to appoint a sub-Committee to inquire
into the whole case for hospital isolation, and to report. This sub-
Committee might consult with the Royal Burgh of New-Galloway, with
a view to organising a conjoint hospital. I shall advise the Local
Authority of New-Galloway to the same effect. I may add that scarlet
fever has again broken out in the burgh of New-Galloway. With
the present district sanitary staff it is simply impossible to grapple
effectively even with minor outbreaks of fever, and I, therefore, set
down this matter of an isolation hospital as urgent.
VI. - ACTION TO PREVENT SPREAD OF INFECTIOUS
DISEASE.
With the object of more efficient service, the District Committee
has empowered the Public Health Office to employ assistance in the |
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actual work of washing and disinfecting. But since the Ringbane out-
break there has been no scarlet fever or any other infectious disease
except whooping-cough in the district. And whooping-cough, which
has over-run the upper part of the district, exceeded at an early stage
any effort at prevention. The cases reported have been nearly 100,
but this does not more than indicate the prevalence of the epidemic.
Fortunately the type has been mild, and the deaths recorded are only
six. Of these three are returned as 'whooping-cough and over-crowd-
ing.' On investigation I found that the over-crowding was due, not to
defective house room, but to a mistaken anxiety to have all the sick
children in one room. This, with the addition of one or more adults,
undoubtedly amounted to over-crowding, and became an active cause of
death. It has been found hopelessly impossible to follow up all the
cases reported, much less those unreported. In the course of this year
I propose to use all the means available to forestall any such epidemic
in the district, in which such extensive epidemics are happily rare.
The treatment of whooping-cough, however, is so various, the chances
of its spread are so enormous, the fatalistic ideas regarding its necessity
are so deep-rooted, that only by a process of slow and gradual educa-
tion, guided by facts such as the present, is there any hope of its
ultimate extinction. I have already advised the District Committee to
arrange with the various School Boards against the return to school of
children that are uncertified.
VII. - CAUSES, ORIGIN, AND DISTRIBUTION
OF DISEASE.
The vital statistics of the past year are too imperfect and too
limited in range to justify a discussion here of cause, origin, or distri-
bution. The present year's facts will better fall in with the general
comparative view of the County Report, into which also I hope to gather
up in digest the important facts in the recent history of the district.
In general the district is healthy. The death rate is 17·2 per 1000;
but it is well understood that where numbers are small very slight
variations on the absolute numbers make large variations in the rates.
The death rate, though it is low, affords less indication of the healthy
nature of the district than the proportion of adult to post-mature
deaths - that is, the proportion of deaths between 25 and 60 and deaths
over age 60. Thus for 32 deaths over 60 there were only 15 between
25 and 60, adult deaths showing rather less than half in amount. This
means that the average age at death is high, which in turn means that
so far as quantity as distinct from quality of life is concerned, the
district stands well. Personally, however, I reckon quality higher than
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mere quantity; but on the quality of life in this district I have as yet
no organised data. There have been ten deaths from zymotic (that is,
infectious) diseases; that is, one-sixth of all the deaths. Six of these
zymotic deaths were due to whooping-cough, three occurring from
more or less preventable causes. Two were from scarlet fever; one to
my own knowledge was due to the merciless insalubrity of an excep-
tionally damp house. Five deaths were due to consumption, and none
to other forms of tuberculosis. This is a good record, and quite in
accord with the bracing hill-air of the district generally. Another
satisfactory feature is the small number of deaths from circulatory and
respiratory causes, and the large number of deaths over 60. Of the
latter many are over 70 and 80.
It is right to add that the population shows a fall from 4299 in
1881 to 3846 in 1891; that is a fall of 453 or about 10·5 per cent.
The fall for the whole county has been only 5·1 per cent. The parishes
of Carsphairn and Balmaclellan show a fall of 18·8 and 17·4 per cent.
respectively. The least fall has been in the parish of Kells, which fell
only 4·2 per cent. These facts must qualify any inferences from the
death-rates. The low death-rate between ages 25 and 60, instead of
being a subject for congratulation, may mean the swift emigration from
the district of adults between those ages - a fact that cannot be fully
understood till the complete census returns are published.
II. - SOUTHERN DISTRICT.
According to the requirements of the Board of Supervision, I now
present my annual report on the Southern District of the Stewartry of
Kirkcudbright.
I. - GENERAL SANITARY CONDITION.
A. - DISTRIBUTION OF POPULATION.
The Southern District, which includes the parishes of Balmaghie,
Borgue, Buittle, Crossmichael, Kelton, Kirkcudbright, Rerwick, Tong-
land, Twynholm, is one of the most populous districts. The total
acreage is 127,070 acres. The total population at the last census was
14,557; the number of persons per acre, therefore is 0·114, or other-
wise about one person to every ten acres. The population, too, is
distributed with fair equality over the various parishes; but here and
there tracts of hill land are little or not at all inhabited. The largest |
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parishes are Kelton (pop. 3692) and Kirkcudbright (pop. 3476), the
first containing the burgh of Castle-Douglas, the second containing the
Royal Burgh of Kirkcudbright. There are nine considerable villages in
the district, viz. - Crossmichael, Ringford, Rhonehouse, Laurieston,
Twynholm, Borgue, Auchencairn, Dundrennan, Palnackie. The rest
of the population is distributed over farms, which here, as elsewhere in
the county, are practically the sole productive industry.
B. - FARMHOUSES, COTHOUSES, AND VILLAGES.
In this district, as in the others, the sanitary question always
resolves itself into the same thing - the healthy housing of a population
depending for its livelihood on agriculture. Certain general remarks,
applicable equally with the necessary change of instances to all four
districts, I have embodied in the report on the Western District. In
this report I confine myself to the features special to the Southern
District.
First. The large number of villages makes the sanitary condition
of villages a question of primary importance. Already three of them
have had the special attention of the District Committee, but in all of
them the same defects of water and drainage exist in varying degrees.
As to water, quantity as a rule is less to complain of than quality; as
to drainage, what public drains there may exist, are as a rule the patch-
work of generations. Scavenging is as yet hardly anywhere organised.
Second. The cothouses present here much the same features as
elsewhere. But everywhere there are signs of a growing wish to have
them made as good in every sanitary regard as the circumstances allow.
C. - MEASURES FOR IMPROVEMENT.
The chief difficulty of sanitary and health administration has
hitherto been the unwieldy character of the administrative bodies.
To be effective, public health action must be prompt and continuous -
two conditions not attainable under present arrangements. Thus the
village of Borgue was reported on for drainage and water supply about
six months ago. Certain conditions then reported are still unremoved;
but circumstances are such that the ordinary action of the sanitary
office is ineffective without farther discussion by the District Com-
mittee. Meanwhile an important public institution - the Borgue
Academy - is exposed to further risks from contaminated water, and
the whole case will again become the subject of a special report. It is
obvious that the appointment of a small sub-committee for public health
would here be a great improvement in procedure. Further, it is
important that in epidemics or isolated cases of infectious disease
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originating in defective sanitation, the public should be apprised of the
facts at the earliest possible moment. The educative effect of such
information is enormous. Thus a report, now some months old, dealt
with an outbreak of typhoid in a certain parish, but it has to await a
meeting of the District Committee before it can become public. For
these and such reasons then I propose the following:-
First. That the District Committee appoint a small sub-committee
for purposes of public health.
Second. That the District Committee order special reports on all
the villages in the district that have not already been reported on.
These reports should be sent in month by month, as occasion serves,
to the sub-committee above named, and if this Committee sees fit, the
reports should, in special cases, be made public forthwith. This
procedure would tend to organise public health much more effectively.
Third. That this sub-committee consult with the Public Health
and Sanitary Offices in order to construct a detailed programme of
work for the year.
Fourth. That all public institutions where large numbers of people
are concerned be made the subjects of special reports.
These proposals I make from the standpoint of public health.
II. - INQUIRIES DURING THE YEAR.
The facts above generalised indicate the general inquiries I have
made during the six months I have been in office. A full and system-
atic inspection of premises, water, and the like through the whole
district has been neither possible nor called for. No general question
affecting the whole district has yet been raised.
Of special inquiries I have to record the following, which do not
include several individual visits under the Infectious Diseases (Notifi-
cation) Act:- Examination and report of Borgue Village; examination
of certain farms and premises in connection with an outbreak of scarlet
fever in Borgue Parish; detailed investigation of Balmaghie typhoid
fever cases; inspection of certain farms in connection with scarlet fever
cases in Kelton and Tongland parishes; inspection of four schools, of
several cothouses in various parishes, of Rhonehouse, Crossmichael,
Ringford, Dundrennan, and Auchencairn villages. For a large part of
the time I have visited in company with the Sanitary Inspector, with
a view to determine - first, how much had already been done; and,
second, what parts of the district are most in need of attention. The
result is embodied in the practical proposals I have already made. |
| HH62/1/KIRKCU/33 |
[Page] 32
III. - CERTIFICATES GRANTED.
Beyond the certificates necessary under Public Health (Scotland)
Act, 1867, sec. 40, I have been asked for no certificates.
IV. - BAKEHOUSES.
No proceedings have had to be taken in connection with bakehouses.
V. - HOSPITAL SUPERVISION.
(See report on Eastern District.) I advise the Committee to
appoint a sub-committee of inquiry.
VI. - PREVENTION OF INFECTIOUS DISEASE.
(a) In September, 1891, the District Committee adopted the
Infectious Diseases (Notification) Act, adding measles and whooping-
cough to the statutory list. The district has since afforded an
admirable example of the benefits to be derived from that Act. Thus,
in the Parish of Borgue, scarlet fever, as I afterwards discovered, had
been cropping up from time to time since March, or at least early
summer. Private notice called my attention to certain cases still
going on. A visit to the parish discovered nine cases. Most of them
had spread through the school, whither one case, if not more, had been
allowed to return without any attempt at disinfection. These nine
cases were isolated as well as private accommodation could allow. The
school at Borgue village was closed, but only for a fortnight, and this
without any knowledge of the Public Health or Sanitary Offices. The
result was one or two fresh cases. But the prompt intimation, due to
the Infectious Diseases (Notification) Act, has now put the officials in
full supervision, probably of all existing cases. As a consequence the
last case may soon be looked for. The type of fever, however, has
been so mild that in several instances no medical attendant has been
consulted. This will necessitate another thorough overhauling of the
parish at an early date.
The same Act has enabled the Public Health and Sanitary Offices
to isolate and stop a case of scarlet fever at one dairy farm; typhoid
fever, at two other farms.
(b) Over and above the administrative assistance due to this Act,
which enlists every medical practitioner and every householder in the
public service, the ordinary means of private isolation and disinfection
have been employed. The Sanitary Inspector has himself superin-
tended disinfection where such superintendence has been considered
necessary.
[Page] 33
(c) The want of a suitable hospital has been felt in the Borgue
outbreak. Private isolation cannot always be relied on. The super-
stition is still current that scarlet fever, like small-pox a century ago,
is a necessary incident of child life, and the indifference so generated
is certain sooner or later to result in prosecutions under the Public
Health (Scotland) Act, 1867, (sec. 59).
(d) I shall advise the District Committee to arrange with the
School Boards in terms of this section.
(e) The other infectious diseases notified have been efficiently dealt
with in the ordinary way.
VII. - CAUSES, ORIGIN, AND DISTRIBUTION
OF DISEASE.
Of these the only index yet available, except for infectious
diseases, is the death-rate, which in almost no disease bears any constant
relation either to the living population as a whole, or to the number
affected by the disease. So far, however, as the death-rate is an index,
I here direct attention to it, giving first the general and then certain
special death rates.
A. - GENERAL.
The total of deaths for the year was 206. This is equivalent to a
death-rate of 15·450 per 1000. There are, however, special variations
from this. In Kelton, the largest in population, 55 deaths occurred,
giving a rate of 14·850 per 1000 - slightly below the average. In
Kirkcudbright 70 deaths occurred, giving a rate of 20·090 per 1000 -
decidedly above the average.
B. - SPECIAL.
(a) Zymotic Diseases. - The death-rate from zymotic diseases is
very low, amounting only to 0·525 per 1000. Of two deaths from
enteric fever, one occurred in the burgh of Kirkcudbright, one in the
parish of Balmaghie. There have been no deaths from scarlet fever,
which, however, has had a record in the district of some 25 cases since
May. One death was due to diphtheria, which this year seems to be
exceptionally rare in the district; none to measles or whooping-cough,
neither of which has been recently in the district; 4 were due to
diarrhœa.
Of the enteric fever cases one was imported from Manchester; one
along with another, and several cases of doubtful nature were traced to
contaminated milk. There is no reason to look on the district as specially
favourable to the growth and propagation of infectious disease. |
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[Page] 34
(b.) Tubercular Diseases. - These are more serious in amount.
Twenty-eight deaths have been due, to phthisis; seven to other forms
of tuberculosis. This gives a total rate of 2·625 per 1000 of population,
or about 260 per 100,000. This is above the average for Scotland,
which the rate in 1888 being 243 per 100,000. This high rate for
tuberculosis may indicate either a larger proportion of cases to pop-
ulation in the district or larger proportion of deaths to cases;
either way the rate is undesirably high. It is remarkable, too, that
the deaths indicate a special distribution of the disease. Thus Kelton,
which has the largest population, records only 5 deaths; Kirkcud-
bright, has the next largest population, records 16 deaths. This is
equivalent to 135 and 459 deaths per 100,000 respectively. On the
other hand, for respiratory diseases Kelton has a record of 15, equivalent
to 405 per 100,000; Kirkcudbright, only 1, equivalent to 28 per
100,000. The remarkable difference in these two classes of disease
will lead to a special investigation.
At the present time there is no systematic effort to mitigate
tuberculosis, which is essentially an infectious disease. If by any
means tuberculosis could be made to generate in the public the same
terror-stricken exclusiveness of treatment as small-pox or as leprosy
and even typhus already receive, I am satisfied that in ten years
tuberculosis could be reduced to one-third of its present prevalence.
The drying of damp soils and the improvement of damp houses will
become to a certain extent preventive; but sanitation with present
resources in the counties is powerless without the emotional support
of the public.
(c.) Cancer and Malignant Diseases. - These will also form the
subject of special research, though there is not the same interesting
distribution. Of 16 cases, including cancer and other malignant
diseases, seven (chiefly cancer) occurred in Kirkcudbright; 5 in the
parish of Rerwick; 3 in Kelton.
(d.) Circulatory Diseases. - These show a record of 36 deaths,
chiefly heart disease.
(e.) Respiratory Diseases. - These show a record of 32 deaths.
Until checked by the more extended figures of the past ten or
twenty years, these facts must be taken as indicating roughly the
condition of health in the district. The population has remained on
the whole very constant; the last census showed a fall of only 74 over
the whole area; Crossmichael, Kelton, Tongland, and Twynholm showed
a slight rise; the other parishes, a slight fall. The greatest rise has
been in Kelton, where the population rose from 3458 in 1881 to 3692
in 1891. Note. - In these figures, as to deaths, &c., the parish of Cross-
[Page] 35
michael is purposely omitted; a mistake arose regarding the returns
from the registrar. This correction will be made in the county report.
Prevention or Mitigation. - The only specific proposals I have to
make are indicated under the first head of the report - viz., special
inspections of the water, soil, and drainage of the chief centres of
population. These inspections should begin with the most unhealthy
areas, which are shown in the figures I have given. The detailed pro-
gramme to be drawn up by the Health Committee proposed should be
guided by the facts now submitted. Those facts that specially affect
the burgh of Kirkcudbright, I shall bring before the burgh authorities
in a special report.
III. - EASTERN DISTRICT.
According to the requirements of the Board of Supervision, I now
present my annual report regarding the Eastern District of the
Stewartry of Kirkcudbright.
I. - GENERAL SANITARY STATE.
A. My position as medical officer for each of the four districts has
enabled me to develop one point in one report and another in another.
The description of sanitary conditions made in the Western District
report is applicable in general terms to the Eastern District. To
the Eastern District Committee I have the same recommendations
to make, since I consider it advisable to unify the work all over the
county. My main recommendations I have detailed in the Southern
District report, to which I now refer the Board and the County Council.
Especially would I suggest that the villages of Newabbey, Crocketford,
Springholm, and Barnbarroch, be forthwith inspected and reported on
in the sense I have indicated.
B. This district includes the following parishes:- Colvend, Irongray,
Kirkbean, Kirkgunzeon, Kirkpatrick-Durham, Lochrutton, Newabbey,
Terregles, Troqueer, and Urr. The total acreage is 142,750; the total
population, 16,463; persons per acre, 0·115, or about one person to 11
acres. The chief centres of population are the burghs of Dalbeattie
and Maxwelltown. I have not been appointed medical officer for either
burgh. |
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[Page] 36
II. - INQUIRIES DURING THE YEAR.
There has been no matter demanding any general inquiry over the
whole district, but I have made a beginning with the question of village
housing and health generally.
My special inquiries have been directed more or less by the
necessities of infectious cases. I have made special inquiries at the
following places:- Crocketford, regarding typhus fever, diphtheria,
several nuisances, and general drainage; at Southerness, Carsethorn,
Kirkbean, Mainsriddle, and certain farms in the same region, all regard-
ing water. Carsethorn has been made into a special water supply
district. At Newabbey village I have investigated certain houses, and
this whole village will form the subject of a special report. I have
investigated regarding typhoid fever at the Scar, Irongray; regarding
complaint of dampness and unhealthy proximity to a churchyard at
Terregles Schoolhouse; regarding nuisances, structural, and other, at
Cargen Bridge; regarding scarlet fever at Barnbarroch village and
Barclosh farm; and regarding diphtheria at certain farms in the
neighbourhood of Dalbeattie. These inquiries have followed no organised
programme such as I wish to lay down for the coming year: they were
dictated by the necessities of the time. Had my office been in full
working order I should have had to report the analysis of several waters.
This, along with the life in villages, will constitute one of my general
inquiries during the coming year. And in regard to this, I may here
report that a grant of £60 has been made to the Public Health Office of
the combined counties with a view to my carrying out such work.
III AND IV.
Under these heads I have nothing special to report, beyond
certificates granted in connection with two groups of nuisances and
in connection with the disinfection of premises. No proceedings have
been taken in regard to bakehouses.
V. - HOSPITAL SUPERVISION.
The Eastern District, like the other three districts of the county,
has arranged with the managers of the Dumfries Royal Infirmary to
send to the Infirmary infectious cases at reduced rates. This hospital I
visited officially in September - first, in order to gain a general notion of
its adequacy according to the minute of agreement put in my hands by
the District Clerk; second, in order to arrange with the managers
anent the washing and disinfection of clothing of patients that live in
the district, but that have not been sent to the hospital.
[Page] 37
First. Adequacy of Hospital. - The Infirmary places at the disposal
of the District sixteen beds for infectious cases. This is a minimum.
I was given to understand that in great urgency 25 to 30 beds could be
provided, and in case of a small-pox outbreak special accommodation
would be extemporised. The wards through which I was taken were
not constructed on the most modern principles of fever hospital
construction; for obviously they were simply a well removed part of
the Infirmary buildings. I did not take exact measurements of the
cubic capacity, not considering the same necessary. For the patients
then in the wards the cubic capacity was ample; it is equally clear that
if 16 or 20 fever patients had to be accommodated, the cubic capacity
per head would fall short of modern requirements. For the Eastern
District, however, so far as numbers go, this hospital might be regarded
as sufficient. But when to the Eastern District the other three Districts
of the Stewartry, all the Districts of Dumfries, and the town of Dumfries
itself, are added, any one may foresee that in the event of serious out-
break (say of typhus or severe scarlet fever) sixteen or even 30 beds
are totally inadequate. Add to this the distances that patients must be
driven - 14 miles from Carsethorn, farther from Rockliff, farther again
from certain parts in the north, and no farther argument is needed to
demonstrate the inadequacy of the hospital accommodation for the
district. At the same time, for the parishes within easy distance of
Dumfries I consider this hospital suitable. The amount of severe
infectious disease in the district is not great, and if the western part of
the District could be provided with a hospital to serve conjointly for
Dalbeattie and neighbourhood, the District might be considered well
protected.
On these grounds I would suggest that this whole question should
be remitted to a sub-committee for full inquiry and report.
Second. The managers of the Infirmary agreed to disinfect and
wash any clothing sent to them for that purpose, and accompanied by a
certificate from the Public Health officials; the washing to be done at
the expense of the private individuals. The District Committee has
empowered the Public Health and Sanitary Offices to procure proper
boxes for transmission of such infected clothing. So far this arrange-
ment has worked well, and will be sustained until further arrangements
can be made for proper centres of disinfection in the various districts.
The difficulty of finding suitable persons to undertake such work has
been hitherto insurmountable. In one instance, where a case of typhoid
and one case of probable typhus had occurred, no one could be found
for months, and that even after all the rooms had been fumigated and
lime-washed and all clothing steeped in disinfectants. This case may |
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[Page] 38
probably come before the Board. I mean to use every means, such as
leaflet instruction, public lectures, and practical demonstration, to over-
come the utterly irrational and disproportionate terror inspired by
certain zymotic disorders. With a little judicious expenditure in the
formation of a sound public opinion, the difficulties of disinfection will
be considerably reduced.
VI. - PREVENTION OF INFECTIOUS DISEASE.
The prevention of infectious disease may be divided into two:-
(a) Administrative Mechanism. - In June, 1891, the District Com-
mittee adopted the Infectious Diseases (Notification) Act. This has
worked admirably in the district. It has enabled me to catch in the
beginning what threatened to become a serious outbreak of typhus
fever; to have three groups of enteric fever cases dealt with by isolation
and disinfection, two cases being sent to hospital; to follow up a pretty
extended outbreak of scarlet fever in the parish of Newabbey. No
fresh cases have been reported from this parish since early in December.
At the earliest possible opportunity I propose to visit the site of every
case, to make certain that, so far as our means permit, we may prevent
a fresh outbreak. The cases have been mild.
(b) Executive. - In all cases where it was considered necessary the
Sanitary Office superintended the actual work of disinfection. Every
effort has been made to isolate the cases in their private houses. Success
has not been universal, but not discouraging. No schools have had to
be closed in the district.
VII. - CAUSES, ORIGIN AND DISTRIBUTION OF
DISEASE.
The methods as yet available for ascertaining the cause and
distribution of disease in the district are two:- First, the Infectious
Diseases (Notification) Act, which applies only to one class of diseases;
second, the death-rates, which, however, bear no constant relation to the
number of cases of any one disease. I deal with the death-rate first.
(a) Death-rate for District. - In all the calculations here given the
Burgh of Maxwelltown (population, 4961) is excluded. The Burgh of
Dalbeattie offers certain contrasts that are instructive; the Dalbeattie
figures are therefore given - first, as part of the district; second, as a
separate calculation.
The total of deaths for the year has been 218, giving a death-rate
for the year of 18·748 per 1000 of population. If the burgh of
Dalbeattie is also excluded the death-rate becomes 17·890 per 1000.
This rate represents on the whole, fairly the rates for the lesser
[Page] 39
localities. All the parishes except Colvend, Dalbeattie (district), and
Urr have populations less than 1000. It would be misleading to give
rates for these separately, because the separation is nothing more in
most cases than a mere administrative convenience; there is no great
change in situation or climate, or social condition, or mode of life. The
parishes with considerable villages, however, show a higher figure.
Thus Kirkpatrick-Durham has a record of 21 deaths, and the parish has
one village of its own name and part of Crocketford, which has more
than its fair proportion of disease and death. But in all of these
parishes calculations are of little value for comparison, because the
variations in the absolute numbers make too large a variation in the
rates per 1000.
For a mainland-rural rate 17·690 per 1000 constitutes a satisfactory
average. Thus, for instance, in the quarter ending June 20, 1891, the
mainland-rural rate for Scotland was 16·7 per 1000; in the preceding
quarter it was 19 per 1000. The rate for the Eastern district is, there-
fore, neither exceptionally high nor exceptionally low.
(b) Age Incidence. - One of the least satisfactory features is the
high death-rate of children under one year. For every 100 births 13
die under one year. This, compared with many other localities, is not
a high rate, but the large number of deaths under five from diseases of
the respiratory organs leads one to conjecture that the district, from
whatever cause is not favourable to early childhood. A less unsatis-
factory feature, though not strikingly good, is the proportion of deaths
between ages 25 and 60 to ages over 60. Other things equal, and given
a fairly stationary population, this ratio indicates a high average age at
death. But this is only when we choose ages over one year. Such an
average is satisfactory for quantity of life (quality is not in any wise
indicated thereby) and I hope to make quality of life in rural districts
the subject of special research in future reports.
(c) Disease Incidence. - No one locality shows a striking preponder-
ance of any one disease.
(a) Zymotic Deaths. - The zymotic death is strikingly low. In this
I do not include deaths from influenza, which, as a cause of death, is
more properly regarded as a complication of other diseased conditions.
Deaths registered from influenza are 13. These have been in greatest
proportion in the villages of Kirkpatrick-Durham, Crocketford, and
Springholm, and all except one occurred within the months of November
and December.
(b) Tubercular Diseases. - These show a death rate of 232 per 100,000
of population This - which is rather less than the average for Scotland -
does not indicate the existence of any exceptionally unhealthy conditions. |
| HH62/1/KIRKCU/41 |
[Page] 40
But here, too, an organised effort to treat tuberculosis with the same
vigour as certain other diseases would result in a serious reduction of
cases.
(c) Circulatory and Respiratory Diseases. - These constitute a large
proportion of the total deaths - no less than 41·3 per cent. This indicates
certain defects of climate, which may operate on constitutions that are
pre-disposed to respiratory disorders by defective housing. The deaths
from bronchitis and pneumonia are proportionally many. From the
standpoint of public health the only effective remedy or mitigation of
such a condition of the death rate is to improve the houses by means of
drainage, and to inculcate better ventilation of the homes.
IV. - WESTERN DISTRICT.
According to the requirements of the Board of Supervision I now
present my annual report on the Western District of the Stewartry of
Kirkcudbright.
My duty as District Medical Officer began only towards the end of
June, 1891. My report, therefore, is in many respects imperfect; for my
time has been disproportionately spent in attending to irregular cases as
they happened to arise, and in organising the mere mechanical
preliminaries of an entirely new office. The time for systematic
inquiry and inspection has been very limited, and in this report my
chief aim is to direct attention to certain cardinal facts in the public
health, from these to frame a general programme of work for the com-
ing year, and, lastly, to indicate what practical steps the realisation of
my programme may involve.
I. - GENERAL SANITARY CONDITION.
With the sanitary condition of the district I deal from one definite
stand-point - viz., the stand-point of public health. The details of
sanitary arrangement, the record of nuisances, the steps taken for
removal, the proposals for betterment, all find their place in the
Sanitary Inspector's report. What I concern myself with are those
facts in the sanitary state that have a direct and palpable bearing on
the question of health in the district.
[Page] 41
A. - DISTRIBUTION OF POPULATION.
The district, which includes four parishes - Anwoth, Girthon,
Kirkmabreck, Minnigaff, and the quoad sacra parish of Bargrennan - is
in space large, in population small. The total acreage is 162,318 acres;
the total population by the census of 1891 is 5295, and therefore the
number of persons to the acres is decimal 032, or about one person to
thirty acres. Such a way of putting the fact, however, little indicates
the real distribution of people, for the people are not equally distributed
over the land. Large tracts of all four parishes are uninhabited or
uninhabitable moorland or mountain. The chief inhabited parts are
towards the sea, along the fertile valleys of the rivers Cree and Fleet.
Thus on the Fleet there is the considerable burgh of Gatehouse; on the
Cree there are the villages of Minnigaff, Creebridge, and Creetown.
In these, in a few minor villages and hamlets, and on the farms, the
people are housed. It follows that, for the purposes of health other
than those of a remote though possible future, this large area may be
reduced to a very few thousand acres.
B. - OCCUPATION AND INDUSTRIES.
The whole population is essentially agricultural; mining, once a
considerable industry in the district, is now extinct, and the amount of
manufacturing is too insignificant to reckon as a source of dishealth.
The farms, too, are mainly for stock-raising and milk produce. Accord-
ingly the sanitary question resolves itself almost entirely into this - the
proper housing of five thousand people that depend for their livelihood,
directly or indirectly, on agriculture. The full discussion of this would
involve important social questions, which, however, must be reserved
for discussion elsewhere. The practical ends of the District Committee
demand only a brief indication of sanitary features in the housing of
farmers, cotmen, labourers, and other dwellers in village or hamlet.
For clearness I touch, first, on the farmhouse, cothouse, and labourers'
houses, and these three under the heads of situation, water supply,
drainage, scavenging, ventilation; next on the general state of the
villages.
C. - FARMHOUSES, COTHOUSES, AND LABOURERS' HOUSES.
(a.) Situation. - The farmhouses generally are well situated, but
even in the better order there is sometimes a complaint of damp. It is
due less to situation as a rule than to atmosphere and soil. For example,
in such a triangle of fertile land as the Cree valley for some ten miles
up, the nature of the soil, which is mainly river and sea mud, and the
exposure to tidal rises and falls, must affect considerably the dampness |
| HH62/1/KIRKCU/43 |
[Page] 42
of the buildings, and what applies to farmhouses applies more forcibly
to cothouses and the like; for these are in large proportion built either
on a level with the soil or below the level, and in neither case are they,
as a rule, drained. I have been struck again and again with the custom
of placing house floors below the level of the ground. The floor itself
is often little else than bare earth. There is usually little means of
drying even where the situation allows it. The relation of the condition
to disease is referred to under its proper head.
(b.) Water Supply. - This year general complaint arose of the scarcity
of water. The water supplies are mostly from wells, and competent
authorities declare that a year so dry in its earliest part has not visited
the district for nearly half a century. The wells as a rule are poorly
protected, often in dangerous proximity to midden heaps, and often to
other contaminations.
(c.) Drainage. - The greatest failure is the soil drainage of house
foundations, which thus to the natural damp of the soil add the damp
incident to inhabited houses. Sewage drainage on a small scale is not
well understood or much applied.
(d.) Scavenging. - The cleansing of ash-pits and privies where either
exist is ineffectively attended to, and in general there is a lack of
sensitiveness to accumulations of dirt. This probably arises from the
reduced vitality due to bad housing, infrequent ablution, and the general
monotony of the average country life. The farms are on the whole
better in this respect, but everywhere there is room and need for
improvement.
(e.) Ventilation. - In the poorer houses ventilation is an unknown
art. Usually there is no structural provision for it in the house, and in
the tenant no effort after fresh air - a state of mind that operates very
effectually even where the provision is ample. The plain man has not
yet begun to distinguish between ventilation and draughts.
D. - VILLAGES.
(a.) Housing. - So far as the housing goes the same facts of damp-
ness and defective drainage are equally prominent. It has not been
possible to make a detailed examination of more than a few typical
premises; but generally the tale is everywhere the same - primary and
fundamental defects of structure unrelieved by any well-informed
usage.
(b.) Water Supply. - The water supplies in the villages are begin-
ning to be better looked to. In Minnigaff a central pump supplies most
of the village. In Creebridge, which also benefits to a certain extent by
its proximity to Newton-Stewart, there are several pumps. In Cree-
[Page] 43
town part of the supply is from the wells, part from a small gravitation
supply. In the other villages much the same condition holds. The
burgh of Gatehouse enjoys the distinction of a good gravitation supply.
(c.) Drainage. - The drainage of most of the villages is of the most
irregular kind. The ordinary village has no corporate life; it is simply
a cluster of individual houses, which to all the defects of isolated dwell-
ings add the necessary complications of life in groups. With this aspect
of village life I hope to deal in future reports. It is obvious, however,
that feeling is beginning to organise itself towards public control of
common advantages; and on the basis of present arrangements, such as
they are, we may look for much and rapid improvement.
(d.) Scavenging. - As elsewhere, no effort is made at systematic
scavenging. Other nuisances than street gratings are left very much
to the variations of private taste. Privy accommodation is the exception;
suitably-sized and situated ashpits are comparatively rare. Any indica-
tion of system there is confines itself to jawholes for house water.
Trapping is not unknown, but usually antiquated; and ventilation of
drains, like ventilation of houses, is almost an unknown art.
E. - MEASURES FOR IMPROVEMENT OF SANITARY CONDITIONS.
The basis of action is a knowledge of facts. For the improvement,
therefore, of the conditions indicated, I have to suggest the following:-
First. A special inspection of the working-class houses in each of
the four parishes. This inspection should be specially ordered by the
District Committee; for a feature of health administration everywhere
is the unwillingness of private persons to complain. A publicly ordered
inspection removes the difficulties due to such unwillingness. The
report should emphasize situation, soil, drainage, house accommodation,
and water supply. The district is small enough to make it possible for
the Public Health Office to overtake a large part of this work within the
present year.
Second. Each village in the district should be made the subject of a
special report, which should detail the conditions of drainage, water
supply, and the needs of scavenging. For example, the village of
Creetown has reached the stage when an effective system of drains and
scavenging would be an immense improvement. The District Committee
would thus forward the general movement of instituting an effective
sanitary control over the villages, a thing at present impossible.
Third. All such reports, in whole or in part, as occasion serves,
should be made to the committee from month to month throughout the
year; and for the better education and instruction of the public in
matters of health such reports should, after approval by a small com- |
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[Page] 44
mittee appointed for the purpose, be made public in the local news-
papers. This suggestion I make for two reasons - first, because cases
have arisen where public interest would have been an effective aid to
the authorities; second, because in this way a continuous train of health
work can be laid for each important meeting of Committee, disposed of
more rapidly and discussed more satisfactorily when all the facts are
known beforehand.
Fourth. I propose to make, as my other duties permit, a special
inspection of the schools and other public institutions in the district.
II. - INQUIRIES DURING THE YEAR.
The result of my general inquiries during the year is given in the
above statement and in the tables of mortality. The general question of
rainfall, temperature, and geographical conditions, with their relation to
health, I have as yet obtained no data adequate for elucidating.
I have made certain preliminary inquiries at the following places:-
At Minnigaff village, relative to water and housing; at Creebridge,
relative to certain nuisances of long standing; at Palnure and Creetown,
relative to water supply and house accommodation. Minnigaff, Cree-
bridge, Blackcraig, and Creetown, will, at an early date, be the subject
of special reports.
Under heads III. and IV. anent workshops and proceedings against
bake-houses I have this year nothing to report.
V. - HOSPITAL ACCOMMODATION AND INSPECTION.
The only hospital available for the district is the Royal Infirmary,
Dumfries. For all practical purposes the long distance of 50 miles will
render this hospital useless. The accommodation available for this and
the other three districts of the county is sixteen beds; but these are
also at the disposal of the county of Dumfries. It is obvious that in
case of need such accommodation is utterly inadequate. Details of my
visit to the Infirmary appear in the report on the Eastern District.
VI. - ACTION ANENT INFECTIOUS DISEASE.
The amount of infectious disease has been very trifling. Early in
the summer there occurred a somewhat serious outbreak of typhus and
typhoid fever in a common lodging-house at Blackcraig. This resulted
in two or three deaths. The prompt and persistent action of the local
medical attendants and the County Sanitary Inspector extirpated the
disease. The house is now in disuse. The original case, so far as after
the events I was able to ascertain, was imported from Stranraer.
Similar outbreaks will tend in future to be prevented, first, by the
[Page] 45
stricter bye-laws in regard to vagrancy, and next by the more efficient
inspection of Common Lodging-Houses. As a farther aid in the same
direction, the District Committee, in September last, adopted the Infec-
tious Diseases (Notification) Act, adding measles and whooping-cough
to the statutory list. The cases hitherto reported have been so few
that I entertain the hope of extirpating at least the main infectious
diseases in the district. Whooping-cough remains in the counties - as
in the towns - a disease with a high death-rate, yet rarely regarded as
serious; indeed, the idea everywhere to dislodge, in regard to whooping-
cough and measles, is that these diseases are not only too slight to need
any serious attention, but are also necessary incidents in child life and
a seasoning against the evil to come. I shall use every means in my
power to elevate these too diseases to the same grade of undesirability
in the public mind as diphtheria, typhus and scarlet fever already
occupy; so displacing a inexcusable apathy by an operative alarm for
the common safety.
VII. - CAUSE, ORIGIN, AND DISTRIBUTION OF DISEASE.
(a.) Cause. - In the tables of mortality I do not trace any prepon-
derating cause of death. But the district is too small, and the range of
time too limited to afford data for any extensive inferences, positive or
negative. The deaths, however, though in themselves few, yet exhibit
one or two striking relationships. Thus, perhaps, the least satisfactory
aspect of Table I. is the large proportion of deaths between 25 and 60
to deaths over 60. In this district for 36 that died between 25 and 60,
there died only 41 over 60. In the other districts, as the comparative
tables of the county annual report will show, this proportion is much
less. The inference is that, on the whole, the people of the western
part of the county tend to decay at an earlier age. The validity of the
inference is seriously qualified by the limited number of facts. At
present I offer this only as a fairly grounded conjecture, to be verified
or disproved by future research into the vital statistics of the parishes.
The fact as it stands, however, finds a certain support in the sanitary
state already described. To my mind the wonder has often been how
the occupants of certain kinds of houses resist for so long the miasmatic
influences of damp and changing soil. Perhaps the defective housing
drives men, women, and children unawares to be more in the open air
than where the houses are good; the life, too, is very often monotonous
and little exhausting to the most susceptible parts of the human organi-
zation. And yet, though the tables exhibit no direct connection of
dampness with mortality, I am satisfied from personal observation of
many cases that damp floors and walls coincide with a host of minor |
| HH62/1/KIRKCU/47 |
[Page] 46
ailments that may not be directly active causes of death, but are
unquestionably active in reducing the value of life - in debasing, as it
were, the life-currency. Such are chronic tonsillitis, laryngitis, diarrhœa,
dyspepsia, which all find in damp soils a most potent, fostering
condition.
It is at once obvious that, so far as this cause of premature decay
is concerned, the remedy lies in systematic sanitation, in the super-
seding of inadequate by more adequate, in modifying as far as possible
all existing structural defects, in teaching men how best to compromise
with what is unavoidable.
(b.) Origin. - There is nothing in these tables to throw light on
the origin of the diseases concerned.
(c.) Distribution. - Here again the facts are too few to be of much
value by themselves. No one place shows a great preponderance of any
one disease. Thus of 23 deaths in Gatehouse, 2 were from infectious
disease; 2 from respiratory diseases; 3 from heart disease; and 1 from
phthisis. Kirkmabreck parish, which includes Creetown, shows the
same nonpreponderance of any one cause of death. In Minnigaff
parish, 30 deaths occurred; of these 11 were in Creebridge and 12 in
the hamlet of Blackcraig. There needs no other fact to demonstrate
that, from whatever cause, Blackcraig is the most unhealthy spot in
the Western District. The hamlet is inhabited by the poorer classes;
the houses are very defective, and the situation is very exposed. At
an early date I propose to overhaul the whole place in detail.
TABLE I. - COUNTY OF KIRKCUDBRIGHT.
TABULAR STATEMENT of SICKNESS and MORTALITY referred to in the Regulations issued by the Board of Supervision
for Medical Officers of Districts of Counties.
Births and Deaths occurring in the Districts during the Year 1891.
[Table inserted] |
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[Page] 48
TABLE II. - COUNTY OF KIRKCUDBRIGHT.
Density of Population, Birth Rate, Infantile, and other Death Rates.
[Table inserted]
* To be calculated to three places in decimals.
[Page] 49
TABLE III. - COUNTY OF KIRKCUDBRIGHT.
Cases of Infectious Disease coming to the knowledge of the Medical Officer during the Year 1891.
[Table inserted] |
| HH62/1/KIRKCU/51 |
APPENDIX.
REPORT ON BALMAGHIE FEVER
CASES.
On the 8th of October the Public Health Office received a
notification of a case of typhoid fever at the parish manse of Balmaghie.
On the 9th of October the Medical Officer and Sanitary Inspector
visited the manse.
REPORT BY MEDICAL OFFICER AND SANITARY
INSPECTOR.
A. - SOURCE OF INFECTION.
The possible sources of infection in the present case were as
follows:- (a) The condition of the soil under and around the house;
(b) The condition of the house arrangements for water and sewage;
(c) The water supply; (d) The milk supply.
(a.) - THE SOIL.
1. - The rise and fall of ground water. - Pettenkofer of Munich has
long maintained that enteric or typhoid fever is causally connected with
the fall of ground water, and, in the absence of any other efficient cause,
one might suggest this as a probable cause in the Balmaghie manse case.
For the situation of the manse borders on the recent river mud and
sand formations of the Dee; the Dee is frequently in flood, and the
floodings must seriously affect the rise and fall of ground water. But in
a single case this, until the theory is further investigated, can properly
be assigned only as a probable predisposing cause.
[Page] 51
2. - The proximity to the churchyard. - This has obviously been a
matter for common remark. The churchyard occupies an eminence,
whose slope is pretty swift downwards towards the manse. It is possible,
though again the porous nature of the soil forbids one to lay too much
stress on the fact, that with the heavy rains and occasional floods the
soil round the manse may have become unhealthy. The soil, however,
to judge by the dryness of an underground cellar, is remarkably dry.
For the present, therefore, these two causes may be set aside. The
persistent recurrence of typhoid in the manse or near it, other causes
being absent, would justify a reopening of the question of soil and ground
water. In this regard it is to be remembered that some years ago a
well within a few yards of the manse was condemned as impure.
(b.) - ARRANGEMENTS FOR WATER AND SEWAGE.
The whole arrangements have the air of an incomplete transition
from antiquated to modern. The water closet is one of the ever popular
pan-closets, which, sometimes a source of disease, are always a source
of nuisance. In the closet itself there is no effort at through ventilation,
and the drainage, which on the whole follows a sound principle, is
inadequate both in ventilation and trapping. The situation of the closet,
which is over the larder, is eminently undesirable. To neither water-
closet nor drains, however, can one indubitably assign the present case.
At the same time such inadequate arrangements always tend to induce
an ever recurrent vital depression, which predisposes to most specific
diseases.
(c.) - WATER SUPPLY.
The water, which is from a gravitation supply from a hill some
half mile away, gave one suspicious indication. When run full from
the tap it came off turpid and sandy; on standing it showed a marked
deposit of coarse sand and earth. This alone indicated some defective
arrangements in the pipes, in the catchment cistern, in the cistern feeder,
or in the spring. Such a defect, if gross enough to admit coarse sand,
would, in special circumstances, readily admit materials of a more
soluble and absorbable nature. It was not surprising, therefore, to
discover that the water contained an amount of polluting material large
enough to justify its unconditional condemnation as a drinking water.
And the origin of the pollution was not far to seek. The water is
brought to the manse from a hill spring; the spring water is conducted
to a collecting tank about a hundred yards farther down the hill; the
tank water is in turn conducted to the manse in iron pipes. The spring
water was to be presumed pure; there was no reason to suspect the iron
pipes; the defect, therefore, was inferred to lie between the spring and |
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[Page] 52
the collecting tank. The inference was correct, at least in part; for
the water conduit between spring and tank is a hundred yards of
common field tile drain, which, probably draining a large area, excludes
neither the surface water nor the soluble matter of the soil. The
result, inevitable from the beginning, has been the pollution of the
water with artificial manure and animal excreta. And, further, to
judge by the full-bore rush of water from the drain, visible on opening
the tank, it is doubtful whether, in rainy weather, more than a minute
percentage of spring water ever lodged in the tank at all. Add to this
that the tank itself is of the most imperfect and inadequate kind, being
indeed only a common fire-clay trough, deepened by one or two layers
of perforated bricks (which merely strain out the larger masses of
earth), and on the surface protected almost not at all from the inrush
of surface washings.
In the light of facts set forth below, it is not permissible to regard
the water as the sole cause of the fever at the manse; but that it was
a powerful contributory cause, the evidence leaves no room to doubt.
Along with the milk, it probably also contributed to the super-normal
amount of disease in the cot-houses.
(d.) - MILK SUPPLY.
The milk supply to Balmaghie manse was from the neighbouring
farm of Bridgestone, where one fatal case of typhoid fever and two
cases of a nature suspiciously like typhoid have occurred. The onset
of the first case - that which ultimately was fatal - preceded the manse
case by about a fortnight; the other two cases must have begun about
the same time as the manse case. The two doubtful cases, though
certainly anomalous in character, are fairly to be regarded as springing
from the same causes and circumstances. These three cases, occurring
at a farm where milk was sold, justified the minute examination that
has since been made.
The question of cause now limited itself practically to this - is the
milk supplied from Bridgestone the cause of typhoid in the manse?
This involved another question - Is there any fair ground for believing
that the Bridgestone milk is contaminated? To both these questions
the following record is my answer.
First. The byre is badly lighted, badly ventilated, and floored in
part with wooden logs. The bad light makes cleaning difficult; the bad
ventilation concentrates dust and waste products of every kind; and
wooden log floors in a byre it is a physical impossibility to keep free
from unhealthy contamination and growth. These defects of structure
were aggravated by another circumstance. Just at the back door
[Page] 53
a large heap of byre manure lay in a pool of water, which, though
doubtless in part due to the unabsorbed recent rains, formed nevertheless
a stagnant and decomposing extract of manure. The requirements of
rigid proof forbid me to say that any one or all of these circumstances
could originate a specific fever such as typhoid; but by the general
consent of experts these are good circumstances for a fever-poison to
grow in, and at the least, to keep milk always pure where the possibility
of contamination is so great, would surpass the most systematic and
intelligent care even of a well-organised modern hospital.
Second. A scullery, opening directly on the kitchen, contains a sink
and a water grating. Sink and grating discharge into a tile drain which
passes the yard, under the buildings and opens on a field. The opening
showed very little evidence of recent or recurrent discharges. The
inference is that most of the water loses itself in the soil before ever
reaching the outlet - an inference verified by the recent necessary open-
ing of the drain. This drain has no ventilator; neither sink nor grating
has any trap; it follows that the drain ventilates freely into sink, scullery,
kitchen, and adjoining passages. It is obvious that the washing of
vessels at this sink, so exposed to the sloppy residue of many years,
constitutes a certain risk of contamination.
Third. From the scullery one passes through the kitchen along one
passage and across another to the milk-house. A servant's bedroom
opens off the first passage. At the head of the second passage stands a
larder. This last passage opens on the farm-yard. This amount of
isolation for a milk-house would certainly not satisfy many sanitary
authorities. One window the milk-house presents to the garden, another
to the yard. Each window is protected with perforated zinc. The floor,
which was relaid nine years ago, is of square fire-clay tiles. This is the
store-house for the milk of nine cows.
Fourth. Within eighteen feet of the garden window of the milk-
house (and the windows are the only ventilation) stands a privy, which
seems to have been long a source of nuisance. There is no opening to
the reception-pit; there are no facilities for emptying; there is in fine
no provision whatsoever against indefinite accumulations. Efforts
are made from time to time to diminish the inevitably offensive
condition of the closet; but these at the best are only feeble palliatives
of an unspeakable abomination. And, a thing almost incredible, but
told by a responsible person, this pit has not been emptied, certainly
for nine years, probably never since its erection some twenty-five or
thirty years ago. It follows that the ground between closet and milk-
house must be thoroughly impregnated with the sewage of all that period.
The milk-house atmosphere must be persistently contaminated with the |
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[Page] 54
exhalations from the soil and from the closet directly, the soil issuing its
impure vapours through the tile floor, the closet impurities entering by
the windows. In such a milk-house where air from one side may bring
impurities from such a closet, where air from the door may bring
impurities from the scullery, larder, and living rooms, where, finally,
vapours from the floor may bring impurities from the soil, milk, exposed
even for a short time, runs a serious risk of dangerous contamination.
The wonder is, not that typhoid and its congeners should be occasional
visitors, but that with so many chances of ingress they should ever be
absent. I should not be surprised to learn that depressed health, sore
throats, unaccountable dyspepsias, and many such minor ailments have
formed a long record among the inhabitants of this farm.
Fifth. Of the water, which comes from well a few feet from the
door, about twenty feet from the drain and about sixty feet from the
closet, no analysis has been made, and I cannot assert its purity or
impurity. It is possible that in such a soil pollutions may have spread
from the closet to the well. This would account in a rational way for
this, which at first seems to be an isolated, outbreak of typhoid; for it is
all but certain that in twenty or thirty years typhoid excreta have per-
haps more than once found their way into the closet. This, however,
which would finally account for all our facts, must for the present remain
a mere probable supposition. The subsequent analysis will confirm or
contradict.
Sixth. After I had satisfied myself that the milk was in all
probability contaminated, I proceeded deductively. The continued use
of such milk would be almost certain to give an appreciable per centage
of some sort of disease, whether the contamination were typhoid fever
or one of the innumerable varieties of sewage poison. With this for
guide, I ascertained all the persons supplied with milk. On the farm
itself there were eight; in cot-houses near at hand there were four
families, whose members made a total of nineteen, males eleven, females,
eight, ages varying from under five to over sixty; in a house at
Glenlochar, more than a mile away, there were two adults; and, lastly,
at the manse there were four adults. Total persons supplied, 33; males,
15; females, 18.
To follow now the same order with the disease:- At the farm,
three cases of illness occurred, one a fatal case of undoubted typhoid,
two cases of doubtful nature; in the cot-houses covering part of the
same time three children were ill with symptoms somewhat resembling
the farm cases; at Glenlochar one of the two inmates (and I am not
sure if the other used the milk) showed symptoms of the same character;
and lastly, at the manse, there has been one case of undoubted typhoid
[Page] 55
fever. Total cases yet discovered, 8; males, 5; females, 3. The follow-
ing table exhibits a very striking relation between the number of persons
exposed and the number affected:-
--- Males --- Females --- Under 25. --- Over 25. ---TL.
Persons exposed, --- 15 --- 18 --- 13 --- 20 --- 33
Persons affected, --- 5 --- 3 --- 5 --- 3 --- 8
Per cent. affected, --- 33·3 --- 16·6 --- 38·4 --- 15 --- 24·2
These cases include only the marked cases of illness. I do not
doubt that a careful and prolonged inquisition over a number of years
would unveil a number of minor and major ailments among the same
people and places. Thus in one of the four cot-house families, a careful
examination revealed at least five cases of illness that in the light of the
present facts it would be no great stretch of scientific methods to
assign to the same causes. These cases, however, occurred about the
same season last year, too distant a date to recover reliable information.
It is also to be remembered that the water supply to these cot-houses is
the same as to the manse. At the same time the occurrence of an
isolated case at Glenlochar is a strong argument in favour of the milk
hypothesis, which accounts both for the origin, for the spread, and for
the very definite limitation of the disease.
Course of Outbreak - 4th February, 1892. - Of the persons affected
one died; the others are now convalescent. The milk from Bridgestone
has been stopped. Another case of typhoid fever has been reported
from Nook of Balmaghie. This case is also convalescent. The boy
attended the school at Glenlochar; but there is no chain of evidence to
connect this case with the others. Disinfection of premises has been
attended to by the Sanitary Inspector; improvements are now in process
to remove offending conditions, and the outbreak, which has been so
typical in many respects, may now be considered at an end.
I may add that further investigation after the first part of this
report was written confirmed the hypothesis therein stated. Complaint
has since been made regarding the water at Bridgestone, and this in all
probability is contaminated. It will be further examined. |
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