Short Title.

ARTICLE XXI.—These Regulations may be cited as "The Public Health (Pneumonia, Malaria, Dysentery, Etc.) Regulations, 1919."

Given under the Seal of Office of the Local Government Board, this Seventh day of January, in the year One thousand nine hundred and nineteen.

(L.S.)

H. C. MONRO,

Secretary.

A. C. GEDDES,

President.

NOTICE.-Section 1 (3) of the Public Health Act, 1896, provides that if any person wilfully neglects or refuses to obey or carry out, or obstructs the execution of any regulation made under Section One hundred and thirty or Section One hundred and thirty-four of the Public Health Act, 1875, or in pursuance of either of those Sections as amended by the Public Health Act, 1896, he shall be liable to a penalty not exceeding one hundred pounds, and in the case of a continuing offence to a further penalty not exceeding fifty pounds for every day during which the offence continues.

MEMORANDUM OF LOCAL GOVERNMENT BOARD.

MEMORANDUM ON PNEUMONIA.

Pneumonia as a cause of national mortality has long been a matter of grave concern to public health authorities, and its importance is particularly emphasized in time of epidemics, especially of influenza, when it exacts heavy toll as a secondary complication.

In 1911 pneumonia in its various forms was responsible for 37,642 deaths in England and Wales, the equivalent of 1,040 deaths per million of population. Its proportional contribution to the death roll was 71.3 per 1,000 deaths from all causes. But not all parts of the country were equally affected. Mortality from pneumonia decreases from north to south in all areas, the position of Wales being intermediate between that of the North and of the Midlands. In London the mortality from pneumonia is higher than in Midland county. boroughs; lower than in Northern county boroughs. A considerable decrease in mortality is experienced with decreasing urbanization. These features appear in the mortality returns from year to year, and, as pointed out by the Registrar-General, they define the normal type of distribution of pneumonia in this country (Registrar-General's Annual Report, 1916, p. lxxv.).

Classification of Pneumonia.

Acute pneumonia may be defined as a febrile disease characterized by inflammation of the lungs, and due to one or more specific microorganisms. Two forms of the disease are generally recognized:

(a) Acute lobar or croupous pneumonia, and

(b) Acute lobular or broncho-pneumonia.

Either of these may be either primary or secondary to some other recognized disease.

In the young child, lobular pneumonia is often the equivalent of croupous pneumonia in the adult. Secondary broncho-pneumonia is commonly a sequel of the infectious fevers, and as such is more common in the early years of life. As age advances it becomes rare, except as a complication of influenza or bronchitis.

Bacteriology.

The chief aetiological factor in lobar pneumonia and the primary lobular pneumonia of children is the presence of the pneumococcus of

Fraenkel. In secondary broncho-pneumonia various organisms are implicated either singly or in association-but chiefly the haemolytic streptococci, the pneumococcus, and the Bacillus Influenza, more rarely staphylococci and the Bacillus of Friedlaender.

It has been shown that, as in the case of the meningococcus, various strains of the pneumococcus can be differentiated by the use of specific serums. Some of these, e.g., the Type I. of American workers, are rarely found in healthy individuals; they have high pathogenic potency, and appear to be responsible for a large percentage of the fatal cases of pneumonia. Others, such as the so-called Type IV., appear to be less potent; they are normally present in a large proportion of healthy throats, but may acquire pathogenicity under conditions as yet unknown, giving rise to a minority of cases of lobar pneumonia.

These findings are important from the point of view of prophylaxis and treatment. They cannot, however, be applied to this country without confirmation, in view of South African results, according to which the strain responsible for a large proportion of the pneumonia in Transvaal natives is not represented in America.

To the recognition of the ubiquity of the pneumococcus may be traced the autogenic view of infection in pneumonia, that it is due to invasion of the lungs by pneumococci commonly present in the normal mouth and not to contact, direct or indirect, with a previous case of the disease. In the light of the results referred to above, this view may require modification.

Outside the human body, the pneumococcus has been found in the dust of rooms occupied by patients or carriers and on their handker chiefs and eating utensils; from rooms not so occupied, organisms of the "saprophytic " class-e.g., Type IV. and the atypical forms of Type II.-have been recovered. Their viability under such conditions depends on the degree of drying to which they have been subjected and on the presence or absence of sunlight. Exposed dry to direct. sunlight, the pneumococcus survives only a few hours. In diffuse daylight or in the dark and protected by sputum, it may survive for several weeks.

In the recent pandemic of influenza, hæmolytic streptococci have played an important part as pathogenic adjuvants of the influenza. virus: a large share of the fatality in cases of influenza complicated by pneumonia having been caused by secondary infection by these organisms.

Predisposing Causes.

Although no age-period appears to be specially susceptible to lobar pneumonia, almost 70 per cent. of the deaths from broncho-pneumonia occur during the first five years of life. During epidemics of influenza, deaths from broncho-pneumonia occur mainly in the adult. population.

Males are attacked by pneumonia more frequently than females, but this is probably largely a question of greater exposure to infection.

The influence of season is unmistakable, but probably in great part indirect by producing conditions which favour the spread of disease of the respiratory organs-crowding, closed doors and windows, and lack of free ventilation. From one-third to one-half the deaths from pneumonia occur during the first four months of the year.

Fatigue and exposure are factors in the history of many cases.

Poverty, malnutrition, lack of warm clothing, insanitary surroundings, overcrowded dwellings, all contribute to the spread and fatality of the disease.

The most active predisposing cause of pneumonia, however, is an attack of one of the infectious fevers and particularly measles, whooping cough or influenza. In 1911, 68 per cent. of the total deaths from measles, 31 per cent. of the total deaths from whooping cough, and 30 per cent. of the total deaths from influenza are stated to have been complicated by some form of pneumonia. Pneumonia is also an important cause of mortality in scarlet fever, diphtheria, enteric fever, gastro-enteritis and rickets.

Multiple cases of primary pneumonia occasionally occur in a household; but little is known of the circumstances under which pneumonia thus exceptionally shows tendency to spread from patient to patient. In pneumonia secondary to or complicating one of the other acute infectious diseases, such as measles or influenza, infectivity is often particularly marked.

Unlike most acute infectious diseases, one attack of pneumonia seems to render the patient more liable to a subsequent attack.

Prophylaxis.

In view of the varying degree of communicability shown by pneumonia at different times, and the difficulty of estimating the infectivity of individual cases, it is desirable that the precautions suggested below should be made to apply as far as possible to all cases; particularly, however, to those cases in which the pneumonia occurs as a complication of another acute infectious disease.

Effective prophylaxis depends on isolation of the patient, and on the adoption of measures calculated to reduce the risk to those in attendance on him of droplet infection. It has been shown that in ordinary conversation infected material may be projected four feet, and during coughing or sneezing as far as ten feet.

If the patient is treated at home he should have a separate room; if in a hospital ward, crowding must be strictly avoided, and only a few cases of pneumonia treated in one room, the patient's bed being

separated from others by screening. Where removal of pneumonia patients to hospital is necessary, it should be carried out with special precautions as to the maintenance of the recumbent posture, and only under medical advice.

The value to the patient of abundance of fresh air, free ventilation and sunlight cannot be too strongly insisted upon. All window curtains and unnecessary furniture should be removed from the sick

room.

Sputum and discharges from the nose and throat should be disinfected. For sputum a cup containing a strong solution of chloride. of lime may be used. Handkerchiefs should be boiled, or burnt if of paper.

Attendants on the patient should observe the ordinary precautions necessary in dealing with cases of infectious disease. Prophylactic gargling and douching of the nose are recommended. In nursing cases of pneumonia associated with influenza or some other acute infectious disease, the wearing of face masks is desirable. Face masks may be improvised from gauze or butter muslin three layers of butter muslin eight inches long by five inches wide sufficient to cover the mouth and nose and fastened at the back of the head with tapes.

Of general prophylactic measures the most important are the avoidance as far as possible of direct infection and of the predisposing conditions already enumerated which tend to lower resistance to infection.

The value of vaccines in prophylaxis is not yet established, but the results so far obtained seem sufficiently encouraging to justify further trial.

General Administrative Measures.

Aids to Diagnosis.-The Sanitary Authority should be prepared to provide facilities for the bacteriological examination of sputum.

Notification.-Pneumonia following whooping cough, diphtheria and the exanthemata is intentionally excluded from the scope of the Order for notification of pneumonia, as provision is already made, or may be made, for the notification of these diseases. It has been considered desirable, however, to include pneumonia occurring in influenza in view of its high fatality and of the possibility of a recrudescence of the primary disease during the coming year.

While it is not anticipated that in the present state of our knowledge notification and the action consequent thereon will result in any great immediate reduction in the total incidence of pneumonia,