REPOET OP A SPECIAL OOM.MITTEE TO THE BOARD OF HEALTH OF THE iX fflitjt at §£tr£iL_.. Suggesting Measnres for the Prevention of ASIATIC CHOLERA. AND THE PROMOTION OF THE PUBLIC HEALTH. ALSO, CONTAINING A PLAN AND OPERATIONS OF A CITY DISPENSARY. By Obdeb of the Common Council, December 12, 1865. DETROIT: WALKER, BABH8 & CO., CITY PRINTERS, 1865. BOARD OF HEALTH. Detroit, Nov. 10, 1865. The Board was called to order by the President, Hon. William Brodie. <■ —~- By Dr. Pitcher : Resolved, That a committee of five be appointed, of whom the Presi- dent of the Board of Health shall be a member, to take into consideration the sanitary condition of the city, and whose duties it shall be, also, in view of the general apprehension of an impending visitation of Asiatic cholera, to suggest for adoption such measures as, in their judgment, will most effectually promote the public health, and prevent the introduction and spread of that appaling disease. Said committee to report at the earliest practical period. Adopted. The President appointed Drs. Pitcher and Brumme, and Alder- men Weir and McGinnis as such committee. By Alderman Brodie : That so much of this report to the Board of Health, as relates to a City Dispensary, be referred to the same committee. Adopted. Detroit, Nov. 23, 1865. The Board Of Health being in session, Dr. Pitcher, of the com- mittee appointed Nov. 10, reported as follows : To the Honorable, the Board of Health : Gentlemen :—In the discharge of their duty, your committee have deliberately formed the opinion that the best way to meet the responsibilities, and accom- 4 plish the objects of their appointment, is to state at once, on the strength of what they believe to be the best medical testimony, that cholera is essentially a disease of miasmetic origin; that its development is due to, or dependent upon, terrestrial and atmospheric agencies; that it is in some way propagated by hu- man intercourse, more generally in the milder seasons of the year, and that it may, when associated with the poison of typhus fever, traverse in winter the colder regions of the country, as it did the northern part of Russia in 1831. Whilst we admit, without discussion, what the history of the disease so clearly establishes, that sporadic cases of cholera do originate in domestic causes, especially with the coincident influence of a high temperature and a high dew point, we also (es- pecially the medical members of the committee) feel bound to state, what we think must be known to all intelligent medical observers, that there are premoni- tions or fore warnings in all great communities, given through the prevailing diathesis of their current diseases, by which the approaches of grave epide- mics are silently heralded, showing how a beneficent Providence tempers, by kindness, the judgments by which He afflicts the children of men. This view of epidemic visitations, whilst it in no degree lessens the obligations of the people to study the principles of hygiene, so that they may learn how to live in conformity to the requirements of natural laws, has a salutary influence upon the public mind by constantly reminding it that we all are the subjects 5 of a Divine Government, embracing alike the moral and the natural world. We make these general remarks for the purpose of inducing our fellow-citizens to look at home for the existence of those causes which give virulence and force to epidemic diseases3 which will be found to be the concomitants of poverty, the fruits of intemper- ance, the results of imperfect sewerage, including the overflow of latrines, and to show them that if they expect to purchase immunity from the invasion of pestilence, it must be done by the adoption of such sanitary rules, and the enforcement of such judicious measures .as shall remove from our own premises all the sources of insalubrity, when it will be in season to pass ordinances for the purpose of keeping inward bound railway trains and vessels at quarantine, and making regulations for admitting them to pratique after having been so detained. Detroit, notwith- standing its relations to commerce, which often carries pestilence as well as wealth on its wings, has more than ordinary facilities for promoting the health of its citizens, and preventing the spread of malarious diseases among them. It is abundantly supplied with pure water, and has an extensive system of public sewerage. It is, to a great extent, exempt from the pestilential influence of tenement houses, as a large proportion of its population live in dwellings and upon lots owned by themselves, and has also such an elevation of surface above the level of the river, that all the moisture precipitated in the form of rain and snow, can be readily conducted into it. These 6 natural and artificial advantages leave us without excuse for the toleration of nuisances known to exist in many parts of the city. Notwithstanding the possession of these facilities for securing cleanliness, this committee have learned from the sanitary inspectors of wards, and from their own observations, that there are in many parts of the city alleys filled with decaying compost and human ordure, and alleys and gutters covered with stagnant water; many cellars and privies not connected with the public sewers by private drains, and numerous premises kept wet by leaky hydrants. There are in the city, at this time, all t]ie organi- zations necessary to effect the abatement of these nuisances, if they are endowed with sufficient author- ity and inspired by a proper zeal in the cause of sani- tary reform. These are the Water Commissioners, who regulate the supply of water, and should prevent its waste ; the Sewer Commissioners, authorized to con- nect'private drains with the public sewers ; the Police Commissioners, acting as ministerial agents in the en- forcement of the decrees of the Mayor and Common Council; and the Board of Health, an advisory body, having initial authority to abate certain specified nui- sances, for that purpose co-operating with the Mayor. After making these general observations in relation to the approaches of cholera, which we believe to be a pandemic in so far as there are prodromous signs which may be detected by observing physicians before the outbreak of the more violent phenomena, by which its approaches are foreshadowed, and 7 after stating that poverty, intemperance, ill venti- lation, the poison of undrained latrines, stagnant water, filth and fear are active causes of cholera, either predisposing or exciting, it seems scarcely neces- sary for the committee to be more explicit in their recommendation of measures to be adopted for the prevention of its importation or development among us. We will, however, sum up as follows : 1. We would advise the appointment of a Health Physician, to co-operate with the Sanitary Inspectors, whose duty it should be thoroughly to 'explore the whole city, and keep the Board of Health and Com- mon Council fully informed of its sanitary condition. 2. It is recommended that the occupants of all premises contiguous to the sewers be required to drain them by making connections therewith. 3. It is suggested that the city authorities cause all hydrants, which allow water to escape upon the surface of the ground to be repaired. 4. We earnestly advise that the ordinance in relation to privies be rigorously enforced, by requiring them to be drained into the sewers or thoroughly cleansed. 5. Where occupants or owners of premises are known to be unable to incur the expense of draining or cleansing them, we would aid them by an appro- priation of the public funds or by making an appeal to private munificence for their relief. Whilst the subjects of water supply and city drain- age are under consideration, the committee would sug- gest to the Water and Sewer Commissioners the expe- 8 diency of making such a connection between the two systems as will render it practicable on extraordinary occasions, such as protracted drouth, to flood the main sewers. And as a means of carrying off" the effluvium from the sewers at all times necessary, we would rec- ommend the erection of wooden chimneys at the im- portant openings, especially as they approach the river. The practicability of the latter expedient the Board of Health, we presume, is aware, depends on the specific gravity of all the combinations of hydrogen in a gaseous state, which is much less than atmospheric air. There is one subject yet for the committee to bring to your notice, and through you we wish to invoke the co-operation of our fellow citizens, in the accom- plishment of the purpose we have in mind. As the measure we are about to suggest for public adoption, is not a preventive but remedial one, we have made it the concluding topic of this report. We allude to the establishment of a City Dispen- sary, as a means of supplying the indigent population of the city with medicines and medical attendance. These organizations in the older cities, from whence we derive our knowledge of their utility, are volun- tary, and are sustained in a great degree by the con- tributions of their members, the public authorities making appropriations for their support, on condi- tion that the city poor, under prescribed regulations, shall be supplied with medicines and receive medical treatment at the dispensaries. Such a system, well administered, would be of great value in the time of 9 a prevailing pestilence, and would also be the best and most economical mode of providing for the medical wants of the indigent portion of our population at all times. One function of the Dispensary is to vaccinate the poor and preserve pure vaccine matter for general use. In order that our fellow citizens may comprehend more fully the objects to be fulfilled by a City Dispen- sary, we adopt the remarks of Dr. Morse Stewart on this subject, made in a paper prepared for the Young Men's Benevolent Society, who had at one time this matter under consideration. The committee appointed to consider the subject of a Dispensary, submit the following report: Dispensaries have been in existence in the cities of New York and Philadelphia for about eighty years. In both cities the institution has been found to accomplish so fully the object for which it was founded, that it has grown steadily in favor with all classes of the community, not only, but especially with the municipal and State authorities. It is essentially a charitable institution. Its object is the medical relief of the indigent sick. This it accom- plishes by furnishing, gratuitously, the best medical advice, with medicine, both at the apothecary rooms and the houses of the sick. In order to a better understanding of the working of this system, your committee submit the following brief sketch of the plan of organization usually adopted: A society is formed under the name of a Dispen- 9 10 sary, and an act of incorporation obtained. Its by- laws require the payment of from five to ten dollars to constitute annual members, and fifty dollars for a life membership. A Board of Managers is annually elected by the members of the Society. This Board has its stated meetings monthly, and the presence of all the members at these meetings is rigidly enforced. It elects its own officers—a president, one or more vice-presidents, a treasurer and secretary -, also a number of standing committees, viz., a committee of finance, a committee of supplies, of real estate, a visiting committee, etc. — the president to be, ex- officio, a member of each. The Committee of Finance must devise and report to the Board the means for obtaining necessary and permanent pecuniary aid. The Committee of Supplies is required " to direct the procurement of all articles required for the Dispensary, and to register the same in a book, to be left in the Apothecary's apartment for that purpose." " They shall render, at each stated meeting of the Board, an account of the disburse- ments for the preceding month." It is required of the " Visiting Committee to meet at the Dispensary on the first week day of the month, for which they shall be appointed, and arrange with each other, so that the Dispensary shall be visited by some one of the number, at least three times in each week during the month. An entry of each meeting, and of the members attending it, shall be made by one of the committee in the minutes of the Visiting Committee, which shall be kept at the Dispensary, and it shall 11 be made the duty of said member, who makes a visit in pursuance of such arrangement, or otherwise, to enter in said minutes the day and hour the visit is made, what physician, if any, is in attendance, with such remarks as he may deem proper. In case any complaint may be made to him against any officers, members or employees of the Society; or in case any breach of the by-laws shall take place under his notice, he shall report the same to the Board, if, upon inquiry, he shall be satisfied there is reasonable ground for the complaint." " The Board of Managers appoint one or more Visiting Physicians, according to the number of dis- tricts into which the city is divided — one House Physician, one Apothecary, and twelve Attending Physicians, each of whom shall hold office during the pleasure of the Board." The Visiting Physician is required to take charge of all parties residing within the district, for which he is appointed, requiring medical aid at their dwellings. The House Physician shall attend at the Dis- pensary daily, (except Sundays), from 9 a. m. to 5 p. m., and on Sundays from 1 p. m. to 2 p. m. He is required to classify the diseases of patients apply- ing at the Dispensary, subject to the supervision of the Attending Physician. In the absence of an At- tending Physician, he shall treat and prescribe for such cases as need immediate relief; he shall bleed when it is prescribed by an Attending Physician; he shall daily register in a book, to be kept for. that pur- 12 pose, the hour at which each Physician attends at the Dispensary, which book shall be laid before the Board at each stated meeting. It shall be his duty to receive the names of applicants for the services of the Visiting Physician. " Each Visiting Physician shall daily enter in the register of patients treated in the several districts, the name, age, nativity, sex, condition and disease of each patient visited for the first time, and report monthly to the Board, the patients treated during the preced- ing calender month, at what place each call was registered, whether at the Dispensary or physician's office, with the results ; and also, what diseases have, during the same period, been prevalent in his district; * * * and one week previous to the annual meeting he shall make to the Board a statement of all patients treated during the year, giving the nativity, sex and results, with such remarks and observations regard- ing the diseases as he may think proper. " It shall be the duty of the House Physician to appoint a uniform hour in each day to vaccinate such persons as may call at the Dispensary for the purpose ; and between the first day of September, in each year, and the first day of April following, each Visitino- Physician shall call at each house in his own district, in which the inmates are likely to receive gratuitous vaccination, and tender the same—each physician registering in a book the street and number so called at, the name and residence of each person vaccinated, etc. j and there shall be kept constantly on hand at the Dispensary a supply of virus, which shall at all 18 times be furnished, free of charge, to physicians prac- cing in the State, who shall call or send a written order for the same. " All patients treated at the Dispensary other than vaccine patients, shall be arranged in classes. To each of said classes there shall be assigned by the Board of Managers two physicians, who shall be known as Attending Physicians, and whose duty it shall be to attend and treat patients at the Dispensary every day, except Sundays, at such hour as the Board may determine. " The Physicians shall have power to reject un- worthy applicants from the benefits of the Society, provided that the reasons for such rejection be registered, for the approval of the Board of Managers. " The Apothecary must have received a regular education as such. He is required to be in daily at- tendance at the Dispensary. He shall have charge of the Dispensary, shall compound such articles as are usually compounded in apothecary shops. He shall dispense no medicines except upon the physician's orders, except otherwise directed by the Board. It shall be his duty to cup and leech under direction of the physician. If needed, the Board may appoint an Apothecary's Assistant." The expense of maintaining such an establishment can only be determined approximately. By an exam- ination of the annual reports of the various Dispensa- ries of New York and Philadelphia, it is found to average from about $2400 to $5400 annually. This variation is owing to the extent of territory which 14 the district covers, and the corresponding number of patients had in charge. It is proper to state that this estimate is made upon reports rendered seven or eight years since. As to the source to which we are to look for the means of supporting such an institution, it must be here, as in other places, to our city, county and State authorities, as well as to the benevolent contributions of private individuals. With reference to this, we cannot better express our views than by quoting from a report of the Demilt Dispensary of New York: " There is a propriety in having the means of sus- taining this establishment derived from those various resources. The State should assist; hence by a fun- damental regulation, the Dispensary maintains a supply of recent and reliable vaccine matter, which it furnishes gratuitously to any physician practicing in the State of New York; thus promoting efficiently the general practice of vaccination, which, unfortu- nately, (as the bills of mortality show) has not yet become universal; and because a large part of the cases to which the Dispensary administers are inciden- tal to the great foreign immigration here making its first landing and pause, in which all parts of the State are alike interested. The city should aid •, because dispensaries save the city government, directly, the cost of medical relief, which, but for them, the city would have to afford by hospital and district physi- cians, an amount far exceeding the sums we ask at its hands ; and because the greatest protection against dangerous epidemics, the raging of which would be 15 fatal to the city prosperity, is found in the quiet, noiseless, but constant working of the Dispensaries. Above all, individual charities must be relied on for a portion of the necessary pecuniary means ; because annual contributors become members of the Society, elect its managers and watch over their proceedings, as well as serve the truest benevolence by this bes- towal of their money. The institution, therefore, is neither left to the political chances of official manage- ment by State or city authorities, nor to the irre- sponsible care of a close corporation, having sufficient permanent funds to stand indifferent to public opinion; but it is made at once the object of annual inquiry by the Governor and Legislature of the State, and the Mayor and Common Council of the city; and also of the constant notice of a large number of phi- lanthropic citizens, who will see to it that their liber- ality does not fail to be properly and judiciously dis- posed of and applied." In speaking of the means necessary to maintain a Dispensary, the economical aspect of the question arises. To some, the outlay of $2500 or $3000, against $800 now paid to District Physicians, looks unpromising. But to such we would say that true economy not only regards the cost of the thing, but still more the amount of good derived from it. That is an expensive article which promises much and proves valueless, though it costs little. Disappoint- ment, when our expectations and wishes have been raised, is only embittered by the recollection of the economical suggestions which have caused it, especi- 16 ally is this the case in medicine. In it the truest economy consists in first considering the end to be obtained and the means necessary for its accomplish- ment. Still, as regards the expenditure of dollars and cents merely, a close calculation will show an actual saving under the Dispensary system, as compared with that of the District Physicians and hospital relief now in use amongst us. The report was accepted and adopted unanimously. Z. Pitcher, M. D., Chas. Brumme, M. D., Jas. D. Weir, P. McGinnis, Wm. Brodie, M. D., Committee.