- Email: [email protected]
Common infections of the gastro intestinal tract
I922.
PUBLIC HEALTH.
precautions were taken. Now we have to report direct to the Ministry of Health, and they pass it on to the M.O.H. This appears to be a procedure likely to cause delay and to be detrimental for the men and their families when returning to a poor home, generally overcrowded and often badly ventilated; though every man is informed of the danger of disseminating the disease, and what to do. Even now we all recognise that our first duty is to prevent the men, who are admitted as firstclass lives, from becoming ill; our second to relieve this should they unfortunately do so, employing all known chemical and bacteriological methods to come to a diagnosis, and to antagonise the infecting agent or agents. Though the science of Preventive Medicine has advanced far in the Naval Service I look forward to the time when the work will be put on a still firmer basis by the introduction of a scherne on the lines of that now developed in the Army Medical Service, namely, that the Professors at Greenwich shall both be of the high rank of SurgeonJCaptain (which, however, is a very equivocal title to the non-naval person), and be given pay and special allowances, for as the responsibility is great it should be suitably recognised financially, and they should be, respectively, Director of Hygiene and Pathology. Each should have an efficient understudy training to take his place when emergency arises. Each should be responsible to the Medical Director General for the special work at all naval laboratories throughout the country, and they should inspect their efficiency of personnel and apparatus. All returns should be sent in from the laboratories to them so that co-ordination and statistical results would be comparable. Each laboratory of a large hospital should have a trained Pathologist who would be able to give his whole time to the work, and these specialists should t)e eligible for higher promotion, without prejudice, as a recognition of ~cheir skilled work. The steps which have been taken to provide t 9 o~ur greaf ~aval eentres Navaloffieers ciu~-~fied in Public Health work have been of very great use in the establishment of that interchange of ideas and co-ordination of work so necessary for the public good lJetween the Services and the civil officers on shore. S~rgeon-Commander R. J. MaeKeown, as President of the local branch, has lately given at Portsmouth a very interesting address in which he has shown the wide scope of their duties. These officers will be of the utost importance in
I75
providing early information on local sanitary matters should we ever have to face another great war, acting in co-operation with officers of the W a r Office, Territorial Force, Air Force, and Ministry of Health. " The experience in this work of Surgeon-Commander Bond, now at Greenwich, must assist materially in those Public Health problems, as adviser to the Admiralty. I have had the great honour and pleasure of being associated with all the Medical Officers of the Navy in instructional work, first at Haslar, then at Greenwich, since 1900, have watched their progress and noted the zeal and excellence of the work done by many of them, and now when my day is over, I shall continue to watch their further successes dnd assist still in any way possible. The association of hygiene and bacteriology in preventive medicine is very close, but as years go by the dependence of the Physician and Hygienist for facts from the bacteriologist on which to base conclusions becomes more and more marked. The aphorism " The fallacy of finality " should never be forgotten. There is no finality. A fact discovered, which may seem final, should only stimulate to further investigations, but we should also bear in mind the wise words of Confucius, the greatest Chinese philosopher, who lived 550 B.c., that " Learning without thought is labour lost : thought without learning is perilous."
COMMON GASTRO
INFECTIONS INTESTINAL
OF THE TRACT.
BY
WL HUDSON, M.D., D . P . H . , M.O.H., Bedlington. T h e subject chosen is one which is familiar to you all, a n d is not put f o r w a r d with any claim' to originality, but with the view of inviting discussion on the preventati,ve, a n d to a certain extent on. t h e curative, measures which m i g h t be a d o p t e d in dealing with some of the cgmmo~vejr .affections of the alimentary canal. I t is considered advisable to confine attention to zymotic enteritis a n d enteric fever, whilst omitting such conditions as tuberculosis, dysentry, ~aundice a n d f o o d poisoning. T h e former diseases have been chosen seeing that they are more prevalent t h r o u g h o u t the country, and that we are now a p p r o a c h i n g tb.e close of the seasonal prevalence of zymotic enteritis, 'and entering the period in which enteric fever ia usually prevalent.
~75
PUBLIC HEALTH.
The subject of tuberculosis is too expansive for a paper of this nature, and although dysentery is a rare disease in this country yet some of you must have experienced cases amongst the civil population where the disease has been corn tracted from men coming back from the army, and still remaining infective. It may be considered that this had some bearing on the high degree of prevalence of zymotic enteritis during the present summer, but the evidence is t:ardly corroborative, since few cases of true dysentry have occurred in adults, and the en.teritis was chiefly confined to children. With regard to jaundice it may be desirable to mention six cases which have recently come to my notice amongst children, occurring in two families, four in one, and two in the other. The water supply was derived from a well, and all children were simultaneously attacked On cleansing the well there were no further cases. On the evidence there was every reason to believe the infection was water-borne, but unfortunately no bacteriological examination was conducted, whereby the causative organism might have been demonstrated. \Ve will now turn to the subject of epidemic enteritis. It is unnecessary to discuss the clinical aspects of zymotic enteritis as they are so well known to you all, and we will confine ourselves to a study of the disease from a hygienic standpoint under the following headings: (I) Epidemiology. (2) Bacteriology. With regard to the epidemiology of this disease the following facts which are well recognised, might be briefly mentioned: (~) The seasonal incidence is from luly to September. (2) The prevalence is dependent upon three factors--(a) a suitable earth temperature; (b) favourable conditions of rainfall; (c) the presence of flies. it was shown by Ballard and other observers that when the four feet earth thermometer registere d fifty-six degrees F the mortality wave began to rise and continued to do so in conjunction with the temperature. I think that from your own experiences you will agree that a wet summer or a very hot summer is accompanied by a low incidence of summer diar-rhoea, whereas a moderately wet summer with considerable heat is usually productive of a large number of cases. The conditions of tern-
APRIL,
perature and moisture are favourable to the multiplication of the house fly, and there is evidence to show that the mortality rate increases as the flies become more numerous, and although there is no consensus of opinion these conditions of heat and moisture also favour multiplication of the infecting organism. The disease is more prevalent in congested areas with the privy-midden system of excrement disposal. The promiscuous defaecation of the children of the lower classes who are able to move abou: whiIst suffering from the disease, and the negligence on the part of the mothers is a very potent factor in the fly-borne nature. From a study of cases notified in Bedlingtonshire there is usually a few sporadic cases foI'Iowed by clumps which are in all probability secondary to those already notified. The virulence appears to increase as the season advances, which may be accounted for by the fact that the organism attains a greater virulence in its passage from person to person and this obtains until climatic conditions gradually produce a cessation of the disease. The probable source of infection is through the agency of milk and other foods, but in one's experience of general practice where flies are too frequently seen around the mouths of infants there is every reason to believe that the infection may be directly transmitted, and this may account for cases occurring in breast fed children. Although epidemic enteritis is essentially a disease of summer, still one invariably sees cases occurring in winter. This was strikingly brought to my notice during the extensive epidemic of enteric fever in Bedlingtonshire in I918, when during the winter months cases of enteritis occurred in children previous to, and simultaneously..with the occurrence of enteric fever. This was probably due, as the water analysis suggested, to an infection with the bacillus enteriditis sporogenes, seeing that the organism was present in tt%e w~tter, supply. Bacteriology. Up to the present the infective agent of summer diarrhoea has not been identified with certainty. Different organisms have been reported as the causative agent. Examination of the faeces of cases, and experiments on flies would seem to show that morgans No. 1 baeiltus is the most common organism present. It is unnecessary to dwell further over this subject.
I922.
PUBLIC H E A L T H .
Enleric Fever. tn dealing with summer diarrhaea in children the practitioner must never forget the possibility of enteric fever, and any case of intractable diarrhoea in a child should arouse suspicion and demand a blood examination for widal reaction, or removal to hospital for observation. Within the past two weeks four cases of enteric have come to my notice, all occurring in close proximity to one another, and after investigation I am led to believe that all four cases are secondary to a case of long continued diarrb.oea with recovery in a child, which was possibly unrecognised enteric. The mode of infection in these cases has probably been by the agency of flies, the privy-midden system being in use in that area. Three cases each serologically negative on three examinations have now been proved positive. Examination of faeces showed B Typhosus present. In Bedlingtonshire during the pa~t forty years, with the exception of an extensive waterberne outbreak in I918 , which was productive of I65 cases and a marked falling off in the succeeding years, there has been an average at.,. nual incidence of approximately 16 cases. Many of these were probably water-borne in nature, although a proportion would certainly arise from chronic carriers during t h e fly season or even be transmitted by inhalation if such does occasionally occur as suggested by some observers. We cannot ignore tne fact that the early symptoms of the disease closely resemble those of influenza. The large number of cases of eholetithiasis and cholecystitis in this district bears out the evidence of long-standing enteric fever. With such a large number of chronic carriers which certainly must exist, under favourable climatic conditions o.f heat and moisture such as has recently been present, one can anticipate a number of sporadic cases e~en.thougti the water supply has been altered. Preventative measures. The only efficient means of dealing with these two diseases is the abolition of the privy-midden sys.tem and adoption of the water carriage system. With the preponderance of the privy-midden system in many urban .and rural districts one can only expect limited success by palliative measures. Regarding enteric fever little can be znticipat~.,d in this respect seeing that the isolation and treatment of chronic carriers is almost impossible. More success may be expected with summer diarrhoea by making the notification of the
~77
disease compulsory in children under two years of age, during the months of July, August and September, with an extension if necessary. By this means the hea.lth visitors are enabled to get in touch with every case, and instruct the mother in dietetic and preventative measures, which are so essential. Furthermore, there is an opportunity afforded of dealing with the early cases, and to a certain degree controlling the spread of the infection. it is well recognised that eliminatbn and starvation are the essential means in treating the disease, and medicinal treatment takes a secondary, position. This system of home visiting and individual instruction is certainly more efficacious than the distribution of leaflets during the seasonal prevalence, or talks to mothers at the Maternity and Child Welfare Centres. The full measure of success can only be an-. ticipated if medical practitioners would notify all cases as early as possible instead of notifying those which are serious, and in some cases in a moribund state. Fortunately a proportion of cases come to the notice of the health visitors during their routine visiting, although it is desirable that all cases, mild or otherwise, should be notified by the medical attendant as early as possible. Compulsory notifications has been in operation in Bedlingtonshire during the past four years, and has been the means of reducing the mortality rate from zymotic enteritis. I must again admit that the paper presents nothing scientific or original, but still I hope some discussion may arise therefrom. Discussion. Dr. Hislop said that he also had had recently undoubted cases of enteric fever with negative widal reactions. "He suggested that with "the return of the army from France a new strain'of the bacillus typhostis had been introduced into the country, which migh¢ account for the absence of the reaction. Until about two years ago, t~'ie -serum used for inoculation had given good results, but it did not seem now to have the same effect. Dr. Bruce thought that economic conditions had conduced to a smaller consumption of cockles and other shell-fish, and of cooked meats from the porkshop, which would tend to reduce the prevalence of the conditions referred to by the ~'riter of the paper. He had found notification of summer diarrhoea during the season of its prevalence most valuable, as
i7 8
PUBLIC HEALTH.
it enabled the health visitor to visit the cases, and much good certainly resulted. The cost was small. He had found little diarrhoea among children fed on dried milk. Dr. Dickinson suggested that blood cultures would probably have shown the bacillus typhosus. These could be taken up to the second week. Dr. Mostyn said he usually found diarrhoea to prevail from August to October, and often into November, and not during what were generally regarded as the summer months. Dr. Taylor agreed with Dr. Mostyn. There might possibly be a greater case .incidence towards November, but the deaths were fewer. He thought there was a relation between the incidence of the disease and small houses and oyercrowding. Carriers were probably re, sponsible for the spread of enteric fever in privy-ashpit areas. Inoculation, he thought, scarcely accounted for the great reduction in enteric fever. Dr. Gibson pointed out that the decline in enteric fever was general prior to the war, and before there was any general inoculation, and it would appear therefore that army inoculation had not a large share in the reduction in its prevalence. It might be that public education as to the fly peril had had some effect in this respect. It was disappointing t~ find sporadic cases occurring in houses on the watercarriage system. Dr. Lyor~s said he had found voluntary n o t i fication of diarrhoea useful. In his experience the season of incidence was much longer than the period usually quoted. Babies reared on dried milk suffered little from diarrhoea. He had obtained good results from the acetozone treatment. Dr. Mabel Brodie found more diarrhoea in October than July. She doubted that the prolonged cases of diarrhoea quoted by Dr. Hud-. son were enteric fever. More probably they were due to lack of proper treatment on the part of the mothers. In her experience diarrhoea was common enough in babies fed on dried milk. Notification would be of little use unless there was adequate staff to deal with the cases when reported. Dr. Kerr said it was interesting to see how the big enteric group of organisms was beginning to be divided up, and how the various organisms were shown to be related. Food poisoning had been supposed to be .the peculiar ground of the Salmonella group, but now there
APRIL,
was atso the Aertrycke, and in an outbreak of tood poisoning in the United States recently, tile paratyphoid organism was found. Was this organism not the actual cause of many of the outbreaks of food poisoning, or had it clianged its function in passing through various hosts ? Diarrhoea did occur in children reared on dried milk, though relatively seldom. The four-foot thermometer theory was a tradition with some people, but other observers maintained that it was pure coincidence. The acetozone treatment gave very wonderful results in a hospital, but was not nearly so successful in the out-patient department, or at home, owing probably to the fact that the mother could rarely be persuaded to withhold all food from the patient. The President (Dr. Hill) said it was an undoubted fact that there had been an extraordinary reduction in the incidence of enteric fever and in the mortality from diarrhoea. All the climatic conditions during the present year seemed to point to an epidemic of diarrhoea, such as occurred in I9I I, yet in his own county, in I92I, there had been I,OOO fewer deaths than in 1911. Other theories notwithstanding, he considered that there was some connection between organic pollution of the soil and diarrhoea. Most authorities agreed that at a certain temperature there appeared to be some condition in the soil which caused the organism to become active, and diarrhoea occurred at a period of the year when temperature conditions were most favourable. Itot years showed high diarrhoea attack rates, and cold and wet years the opposite. One of the reasons for the reduction perhaps was the education of the people. With regard to enteric fever, he rather favoured the idea that a new strain of organi.sm was responsibt6 for tee absence of tile wi~dal reaction. Dr. Hudson, replying to the discussion said that the spread of enteric°'fever is probably largely due to chronic carriers. He understood that in the third week of the disease the bacillus was more certainly found in the faeces than in the blood. Access of flies to the child's mouth, he thought, was a prolific cause of diarrhoea in infants fed on dried milk, and it was a wise precaution to cover the face of a very young child with muslin. Overcrowd;.ng and congestion probably had some connection with both diarrhoea and enteric fever. Hot moist
.922.
"PUBLIC HEALTH,
weather was particularly favourable for diarrt:cea, and it might well h a p p e n that an epidemic continued into November. H e strongly f a v o u r e d notification. V A R I A T I O N S IN V I T A L S T A T I S T I C S O F ADJOINING D I S T R I C T S . BY
C. R. GIBSON, M.A., M.B., Ch.B., D.P.H., M.O.H, Guisborough Combined District I f we are i n f o r m e d that the death-rate in a certain district one year is I3.O per thousand, and in the n e x t year 14.5, we can assert with seme confidence that the conditions as regards health and life were not so favourable in the second year as in the first. If, on the other hand, we are told that the death-rate in one district is I3.O, while in am immediately adjoining district in the same year it is I4. 5, we can offer no opinion as to the relative salubrity of the two districts; the rate of death, and therefore presumably the rate of sickness, has been higher in one than in the other, but the populations o f the two districts m a y have differed in their natural susceptibility to disease a n d death. A high death-rate m a y be no blot on the sanitary scutcheon of an area, but merely the visible sign o f the special composition of its population, containing a large proportion o f individuals who, under the conditions subsisting generally to-day, are subject to a high deathrate wherever they are found. Such classes have been distinguished as the very young and the v e r y old, and also males as compared to females, and it has consequently been the practice to a p p l y corrections for the age and sex constitution of the populations before comparing cIeath-rates of different p l a c e s . But even then the-comparison is difficult : can we compare, -for example, tl~ corrected or standardized deathfate o f H a r r o g a t e with -that of B r a d f o r d ? T o do so would be to neglect the differences in social compositi6n of the two localities, differences which are vital to the question. I f we cculd compare the death-rates in the artisan pol~ulations, or the shop-keeping populations separately of the two places, we would be well on our way to a fair comparison, a n d it is the purpose of this note to suggest a method by which this may be done.
i79
As a medical officer of health o,f six adjacent sanitary districts, geographical variation in vital rates, as distinct from historical variation, has frequently thrust itself on my notice. These six small districts in north-east Yorkshire, on the iron-bearing south shore of the mouth of the Tees, have common characters in climate, soil, style of housing, a n d industry, a n d yet their vital statistics exhibit steady differences which m a y be t y p i c a l l y seen in the rates given in th~ accompanying table. W h y should Saltburu U r b a n District have a s t a n d a r d i z e d death-rate of I 1.7, while the neighbouring urban district o f Skelton and Brotton exhibits one of 13.2 , with a still greater divergence in birth-rate, from 18.o in Saltburn to 31.3 in Skelton a n d Brotton ? One acquainted with the localities would answer that the differences in social composition of the two districts might explain the major part at least of the variation in vital statistics. T o assess the social Grade of a district b y file occupation of its inhabitants is an arduous task of d o u b t f u l utility. But size o.f house is associated witl¢ social class at least as closely as is occupation, a n d the requisite information as to housing can be readily f o u n d in the census retunics. In the districts with which I am concerned an obvious division exists between the inhabitants o f dwellings containing five or fewer rooms (which elsewhere in this paper I shall designate briefly as "cottages," and those of dwellings with six or more rooms (to be hereafter referred to. as " h o u s e s " ) . T h e cottages contain the artisan population, the houses the shopkeeping a n d middle-class. Comparing the six districts in the table, tile vital statistics are seen to' vary along with the percentage of the popuLatiol~ living in cottages.. It is an easy inference that the vKal rates are possibly uniform Within the cottage population o f the veho.le area, .:and again ia the'house population, and that the differences in r,ates exhibited b y the districts are due merely to the varying proportions of these two g r o u p s : on this hypothesis a simple calculatio.n @ill soon fix these class-rates, and, as there are more t h a n two districts, the agreement ci rates calculated from them for the various districts with the actual values will test the hypothesis. H o w close the agreement is can be seen in the table, rows 6 and 7, Io and II, 13
PUBLIC HEALTH.
precautions were taken. Now we have to report direct to the Ministry of Health, and they pass it on to the M.O.H. This appears to be a procedure likely to cause delay and to be detrimental for the men and their families when returning to a poor home, generally overcrowded and often badly ventilated; though every man is informed of the danger of disseminating the disease, and what to do. Even now we all recognise that our first duty is to prevent the men, who are admitted as firstclass lives, from becoming ill; our second to relieve this should they unfortunately do so, employing all known chemical and bacteriological methods to come to a diagnosis, and to antagonise the infecting agent or agents. Though the science of Preventive Medicine has advanced far in the Naval Service I look forward to the time when the work will be put on a still firmer basis by the introduction of a scherne on the lines of that now developed in the Army Medical Service, namely, that the Professors at Greenwich shall both be of the high rank of SurgeonJCaptain (which, however, is a very equivocal title to the non-naval person), and be given pay and special allowances, for as the responsibility is great it should be suitably recognised financially, and they should be, respectively, Director of Hygiene and Pathology. Each should have an efficient understudy training to take his place when emergency arises. Each should be responsible to the Medical Director General for the special work at all naval laboratories throughout the country, and they should inspect their efficiency of personnel and apparatus. All returns should be sent in from the laboratories to them so that co-ordination and statistical results would be comparable. Each laboratory of a large hospital should have a trained Pathologist who would be able to give his whole time to the work, and these specialists should t)e eligible for higher promotion, without prejudice, as a recognition of ~cheir skilled work. The steps which have been taken to provide t 9 o~ur greaf ~aval eentres Navaloffieers ciu~-~fied in Public Health work have been of very great use in the establishment of that interchange of ideas and co-ordination of work so necessary for the public good lJetween the Services and the civil officers on shore. S~rgeon-Commander R. J. MaeKeown, as President of the local branch, has lately given at Portsmouth a very interesting address in which he has shown the wide scope of their duties. These officers will be of the utost importance in
I75
providing early information on local sanitary matters should we ever have to face another great war, acting in co-operation with officers of the W a r Office, Territorial Force, Air Force, and Ministry of Health. " The experience in this work of Surgeon-Commander Bond, now at Greenwich, must assist materially in those Public Health problems, as adviser to the Admiralty. I have had the great honour and pleasure of being associated with all the Medical Officers of the Navy in instructional work, first at Haslar, then at Greenwich, since 1900, have watched their progress and noted the zeal and excellence of the work done by many of them, and now when my day is over, I shall continue to watch their further successes dnd assist still in any way possible. The association of hygiene and bacteriology in preventive medicine is very close, but as years go by the dependence of the Physician and Hygienist for facts from the bacteriologist on which to base conclusions becomes more and more marked. The aphorism " The fallacy of finality " should never be forgotten. There is no finality. A fact discovered, which may seem final, should only stimulate to further investigations, but we should also bear in mind the wise words of Confucius, the greatest Chinese philosopher, who lived 550 B.c., that " Learning without thought is labour lost : thought without learning is perilous."
COMMON GASTRO
INFECTIONS INTESTINAL
OF THE TRACT.
BY
WL HUDSON, M.D., D . P . H . , M.O.H., Bedlington. T h e subject chosen is one which is familiar to you all, a n d is not put f o r w a r d with any claim' to originality, but with the view of inviting discussion on the preventati,ve, a n d to a certain extent on. t h e curative, measures which m i g h t be a d o p t e d in dealing with some of the cgmmo~vejr .affections of the alimentary canal. I t is considered advisable to confine attention to zymotic enteritis a n d enteric fever, whilst omitting such conditions as tuberculosis, dysentry, ~aundice a n d f o o d poisoning. T h e former diseases have been chosen seeing that they are more prevalent t h r o u g h o u t the country, and that we are now a p p r o a c h i n g tb.e close of the seasonal prevalence of zymotic enteritis, 'and entering the period in which enteric fever ia usually prevalent.
~75
PUBLIC HEALTH.
The subject of tuberculosis is too expansive for a paper of this nature, and although dysentery is a rare disease in this country yet some of you must have experienced cases amongst the civil population where the disease has been corn tracted from men coming back from the army, and still remaining infective. It may be considered that this had some bearing on the high degree of prevalence of zymotic enteritis during the present summer, but the evidence is t:ardly corroborative, since few cases of true dysentry have occurred in adults, and the en.teritis was chiefly confined to children. With regard to jaundice it may be desirable to mention six cases which have recently come to my notice amongst children, occurring in two families, four in one, and two in the other. The water supply was derived from a well, and all children were simultaneously attacked On cleansing the well there were no further cases. On the evidence there was every reason to believe the infection was water-borne, but unfortunately no bacteriological examination was conducted, whereby the causative organism might have been demonstrated. \Ve will now turn to the subject of epidemic enteritis. It is unnecessary to discuss the clinical aspects of zymotic enteritis as they are so well known to you all, and we will confine ourselves to a study of the disease from a hygienic standpoint under the following headings: (I) Epidemiology. (2) Bacteriology. With regard to the epidemiology of this disease the following facts which are well recognised, might be briefly mentioned: (~) The seasonal incidence is from luly to September. (2) The prevalence is dependent upon three factors--(a) a suitable earth temperature; (b) favourable conditions of rainfall; (c) the presence of flies. it was shown by Ballard and other observers that when the four feet earth thermometer registere d fifty-six degrees F the mortality wave began to rise and continued to do so in conjunction with the temperature. I think that from your own experiences you will agree that a wet summer or a very hot summer is accompanied by a low incidence of summer diar-rhoea, whereas a moderately wet summer with considerable heat is usually productive of a large number of cases. The conditions of tern-
APRIL,
perature and moisture are favourable to the multiplication of the house fly, and there is evidence to show that the mortality rate increases as the flies become more numerous, and although there is no consensus of opinion these conditions of heat and moisture also favour multiplication of the infecting organism. The disease is more prevalent in congested areas with the privy-midden system of excrement disposal. The promiscuous defaecation of the children of the lower classes who are able to move abou: whiIst suffering from the disease, and the negligence on the part of the mothers is a very potent factor in the fly-borne nature. From a study of cases notified in Bedlingtonshire there is usually a few sporadic cases foI'Iowed by clumps which are in all probability secondary to those already notified. The virulence appears to increase as the season advances, which may be accounted for by the fact that the organism attains a greater virulence in its passage from person to person and this obtains until climatic conditions gradually produce a cessation of the disease. The probable source of infection is through the agency of milk and other foods, but in one's experience of general practice where flies are too frequently seen around the mouths of infants there is every reason to believe that the infection may be directly transmitted, and this may account for cases occurring in breast fed children. Although epidemic enteritis is essentially a disease of summer, still one invariably sees cases occurring in winter. This was strikingly brought to my notice during the extensive epidemic of enteric fever in Bedlingtonshire in I918, when during the winter months cases of enteritis occurred in children previous to, and simultaneously..with the occurrence of enteric fever. This was probably due, as the water analysis suggested, to an infection with the bacillus enteriditis sporogenes, seeing that the organism was present in tt%e w~tter, supply. Bacteriology. Up to the present the infective agent of summer diarrhoea has not been identified with certainty. Different organisms have been reported as the causative agent. Examination of the faeces of cases, and experiments on flies would seem to show that morgans No. 1 baeiltus is the most common organism present. It is unnecessary to dwell further over this subject.
I922.
PUBLIC H E A L T H .
Enleric Fever. tn dealing with summer diarrhaea in children the practitioner must never forget the possibility of enteric fever, and any case of intractable diarrhoea in a child should arouse suspicion and demand a blood examination for widal reaction, or removal to hospital for observation. Within the past two weeks four cases of enteric have come to my notice, all occurring in close proximity to one another, and after investigation I am led to believe that all four cases are secondary to a case of long continued diarrb.oea with recovery in a child, which was possibly unrecognised enteric. The mode of infection in these cases has probably been by the agency of flies, the privy-midden system being in use in that area. Three cases each serologically negative on three examinations have now been proved positive. Examination of faeces showed B Typhosus present. In Bedlingtonshire during the pa~t forty years, with the exception of an extensive waterberne outbreak in I918 , which was productive of I65 cases and a marked falling off in the succeeding years, there has been an average at.,. nual incidence of approximately 16 cases. Many of these were probably water-borne in nature, although a proportion would certainly arise from chronic carriers during t h e fly season or even be transmitted by inhalation if such does occasionally occur as suggested by some observers. We cannot ignore tne fact that the early symptoms of the disease closely resemble those of influenza. The large number of cases of eholetithiasis and cholecystitis in this district bears out the evidence of long-standing enteric fever. With such a large number of chronic carriers which certainly must exist, under favourable climatic conditions o.f heat and moisture such as has recently been present, one can anticipate a number of sporadic cases e~en.thougti the water supply has been altered. Preventative measures. The only efficient means of dealing with these two diseases is the abolition of the privy-midden sys.tem and adoption of the water carriage system. With the preponderance of the privy-midden system in many urban .and rural districts one can only expect limited success by palliative measures. Regarding enteric fever little can be znticipat~.,d in this respect seeing that the isolation and treatment of chronic carriers is almost impossible. More success may be expected with summer diarrhoea by making the notification of the
~77
disease compulsory in children under two years of age, during the months of July, August and September, with an extension if necessary. By this means the hea.lth visitors are enabled to get in touch with every case, and instruct the mother in dietetic and preventative measures, which are so essential. Furthermore, there is an opportunity afforded of dealing with the early cases, and to a certain degree controlling the spread of the infection. it is well recognised that eliminatbn and starvation are the essential means in treating the disease, and medicinal treatment takes a secondary, position. This system of home visiting and individual instruction is certainly more efficacious than the distribution of leaflets during the seasonal prevalence, or talks to mothers at the Maternity and Child Welfare Centres. The full measure of success can only be an-. ticipated if medical practitioners would notify all cases as early as possible instead of notifying those which are serious, and in some cases in a moribund state. Fortunately a proportion of cases come to the notice of the health visitors during their routine visiting, although it is desirable that all cases, mild or otherwise, should be notified by the medical attendant as early as possible. Compulsory notifications has been in operation in Bedlingtonshire during the past four years, and has been the means of reducing the mortality rate from zymotic enteritis. I must again admit that the paper presents nothing scientific or original, but still I hope some discussion may arise therefrom. Discussion. Dr. Hislop said that he also had had recently undoubted cases of enteric fever with negative widal reactions. "He suggested that with "the return of the army from France a new strain'of the bacillus typhostis had been introduced into the country, which migh¢ account for the absence of the reaction. Until about two years ago, t~'ie -serum used for inoculation had given good results, but it did not seem now to have the same effect. Dr. Bruce thought that economic conditions had conduced to a smaller consumption of cockles and other shell-fish, and of cooked meats from the porkshop, which would tend to reduce the prevalence of the conditions referred to by the ~'riter of the paper. He had found notification of summer diarrhoea during the season of its prevalence most valuable, as
i7 8
PUBLIC HEALTH.
it enabled the health visitor to visit the cases, and much good certainly resulted. The cost was small. He had found little diarrhoea among children fed on dried milk. Dr. Dickinson suggested that blood cultures would probably have shown the bacillus typhosus. These could be taken up to the second week. Dr. Mostyn said he usually found diarrhoea to prevail from August to October, and often into November, and not during what were generally regarded as the summer months. Dr. Taylor agreed with Dr. Mostyn. There might possibly be a greater case .incidence towards November, but the deaths were fewer. He thought there was a relation between the incidence of the disease and small houses and oyercrowding. Carriers were probably re, sponsible for the spread of enteric fever in privy-ashpit areas. Inoculation, he thought, scarcely accounted for the great reduction in enteric fever. Dr. Gibson pointed out that the decline in enteric fever was general prior to the war, and before there was any general inoculation, and it would appear therefore that army inoculation had not a large share in the reduction in its prevalence. It might be that public education as to the fly peril had had some effect in this respect. It was disappointing t~ find sporadic cases occurring in houses on the watercarriage system. Dr. Lyor~s said he had found voluntary n o t i fication of diarrhoea useful. In his experience the season of incidence was much longer than the period usually quoted. Babies reared on dried milk suffered little from diarrhoea. He had obtained good results from the acetozone treatment. Dr. Mabel Brodie found more diarrhoea in October than July. She doubted that the prolonged cases of diarrhoea quoted by Dr. Hud-. son were enteric fever. More probably they were due to lack of proper treatment on the part of the mothers. In her experience diarrhoea was common enough in babies fed on dried milk. Notification would be of little use unless there was adequate staff to deal with the cases when reported. Dr. Kerr said it was interesting to see how the big enteric group of organisms was beginning to be divided up, and how the various organisms were shown to be related. Food poisoning had been supposed to be .the peculiar ground of the Salmonella group, but now there
APRIL,
was atso the Aertrycke, and in an outbreak of tood poisoning in the United States recently, tile paratyphoid organism was found. Was this organism not the actual cause of many of the outbreaks of food poisoning, or had it clianged its function in passing through various hosts ? Diarrhoea did occur in children reared on dried milk, though relatively seldom. The four-foot thermometer theory was a tradition with some people, but other observers maintained that it was pure coincidence. The acetozone treatment gave very wonderful results in a hospital, but was not nearly so successful in the out-patient department, or at home, owing probably to the fact that the mother could rarely be persuaded to withhold all food from the patient. The President (Dr. Hill) said it was an undoubted fact that there had been an extraordinary reduction in the incidence of enteric fever and in the mortality from diarrhoea. All the climatic conditions during the present year seemed to point to an epidemic of diarrhoea, such as occurred in I9I I, yet in his own county, in I92I, there had been I,OOO fewer deaths than in 1911. Other theories notwithstanding, he considered that there was some connection between organic pollution of the soil and diarrhoea. Most authorities agreed that at a certain temperature there appeared to be some condition in the soil which caused the organism to become active, and diarrhoea occurred at a period of the year when temperature conditions were most favourable. Itot years showed high diarrhoea attack rates, and cold and wet years the opposite. One of the reasons for the reduction perhaps was the education of the people. With regard to enteric fever, he rather favoured the idea that a new strain of organi.sm was responsibt6 for tee absence of tile wi~dal reaction. Dr. Hudson, replying to the discussion said that the spread of enteric°'fever is probably largely due to chronic carriers. He understood that in the third week of the disease the bacillus was more certainly found in the faeces than in the blood. Access of flies to the child's mouth, he thought, was a prolific cause of diarrhoea in infants fed on dried milk, and it was a wise precaution to cover the face of a very young child with muslin. Overcrowd;.ng and congestion probably had some connection with both diarrhoea and enteric fever. Hot moist
.922.
"PUBLIC HEALTH,
weather was particularly favourable for diarrt:cea, and it might well h a p p e n that an epidemic continued into November. H e strongly f a v o u r e d notification. V A R I A T I O N S IN V I T A L S T A T I S T I C S O F ADJOINING D I S T R I C T S . BY
C. R. GIBSON, M.A., M.B., Ch.B., D.P.H., M.O.H, Guisborough Combined District I f we are i n f o r m e d that the death-rate in a certain district one year is I3.O per thousand, and in the n e x t year 14.5, we can assert with seme confidence that the conditions as regards health and life were not so favourable in the second year as in the first. If, on the other hand, we are told that the death-rate in one district is I3.O, while in am immediately adjoining district in the same year it is I4. 5, we can offer no opinion as to the relative salubrity of the two districts; the rate of death, and therefore presumably the rate of sickness, has been higher in one than in the other, but the populations o f the two districts m a y have differed in their natural susceptibility to disease a n d death. A high death-rate m a y be no blot on the sanitary scutcheon of an area, but merely the visible sign o f the special composition of its population, containing a large proportion o f individuals who, under the conditions subsisting generally to-day, are subject to a high deathrate wherever they are found. Such classes have been distinguished as the very young and the v e r y old, and also males as compared to females, and it has consequently been the practice to a p p l y corrections for the age and sex constitution of the populations before comparing cIeath-rates of different p l a c e s . But even then the-comparison is difficult : can we compare, -for example, tl~ corrected or standardized deathfate o f H a r r o g a t e with -that of B r a d f o r d ? T o do so would be to neglect the differences in social compositi6n of the two localities, differences which are vital to the question. I f we cculd compare the death-rates in the artisan pol~ulations, or the shop-keeping populations separately of the two places, we would be well on our way to a fair comparison, a n d it is the purpose of this note to suggest a method by which this may be done.
i79
As a medical officer of health o,f six adjacent sanitary districts, geographical variation in vital rates, as distinct from historical variation, has frequently thrust itself on my notice. These six small districts in north-east Yorkshire, on the iron-bearing south shore of the mouth of the Tees, have common characters in climate, soil, style of housing, a n d industry, a n d yet their vital statistics exhibit steady differences which m a y be t y p i c a l l y seen in the rates given in th~ accompanying table. W h y should Saltburu U r b a n District have a s t a n d a r d i z e d death-rate of I 1.7, while the neighbouring urban district o f Skelton and Brotton exhibits one of 13.2 , with a still greater divergence in birth-rate, from 18.o in Saltburn to 31.3 in Skelton a n d Brotton ? One acquainted with the localities would answer that the differences in social composition of the two districts might explain the major part at least of the variation in vital statistics. T o assess the social Grade of a district b y file occupation of its inhabitants is an arduous task of d o u b t f u l utility. But size o.f house is associated witl¢ social class at least as closely as is occupation, a n d the requisite information as to housing can be readily f o u n d in the census retunics. In the districts with which I am concerned an obvious division exists between the inhabitants o f dwellings containing five or fewer rooms (which elsewhere in this paper I shall designate briefly as "cottages," and those of dwellings with six or more rooms (to be hereafter referred to. as " h o u s e s " ) . T h e cottages contain the artisan population, the houses the shopkeeping a n d middle-class. Comparing the six districts in the table, tile vital statistics are seen to' vary along with the percentage of the popuLatiol~ living in cottages.. It is an easy inference that the vKal rates are possibly uniform Within the cottage population o f the veho.le area, .:and again ia the'house population, and that the differences in r,ates exhibited b y the districts are due merely to the varying proportions of these two g r o u p s : on this hypothesis a simple calculatio.n @ill soon fix these class-rates, and, as there are more t h a n two districts, the agreement ci rates calculated from them for the various districts with the actual values will test the hypothesis. H o w close the agreement is can be seen in the table, rows 6 and 7, Io and II, 13