Enteric fever and the dry-closet system

56

PUBLIC

A specific organic poison was described as peculiar to mussels as long ago as I886, and the n a m e " m y t l e t o x i n " was given to it. It appears doubtful in the light of present bacterial investigation w h e t h e r such a toxin is produced by the mussel itself. T h e toxins are often present, irrespective of harmful bacteria, appears to be well s u p p o r t e d b y clinical observation. F r o m the nature of the mud in which these shell-fish live, it seems likely t h a t such poisonous p r o d u c t s arise from it r a t h e r t h a n from the shell-fish. S y m p t o m s d e p e n d e n t on these toxins are usually seen within a few hours of eating the fish. T h e next class of illness is associated with bacterial invasion, and is later in its onset and rarely seen until after twenty-four hours, t h o u g h this class :nay be c o n s e q u e n t upon the preceding. It a p p a r e n t l y depends on a disturbance of balance between the putrefactive powers of the intestine and the inhibitory or controlling action of the mucous membran.e. I n an experience of my own, after accidentally swallowing about half a g r a m m e of mud, the consequent attack of diarrhcea c o m m e n c e d thirty-six hours later, and lasted for a period of three days, the seat of the disturbance being mainly in the large intestine, but b e y o n d a feeiing of malaise there were no o t h e r constitutional s y m p t o m s . T h e specific bacterial infections are longer in their incubation periods, and constitute the group of conditions included under the generic name " enteric fever." It is quite possible t h a t a toxic poisoning may pass on to a disturbance of the general bacterial balance of the intestine, and then in its turn to a specific bacterial invasion ; in fact, the preceding conditions r a t h e r predispose than protect against the more serious disturbances. A suggestion of Mr. J o h n s o n , B.Sc., in the L a n c a s h i r e Sea Fisheries Report, 19o9, is w o r t h y of c o m m e n t . H e points out that in most estuaries it is possible to find some area which at least during the flood tide may be regarded as unpolluted. H e suggests that at this point a small salt-water lock should be made where all mussels collected for m a r k e t must be placed for at least four days. It is found that u n d e r these conditions the risk of mischief falls e n o r m o u s l y and is practically confined to the possibility of a dead mussel being accidentally eaten. B y this device the toxins derived from the e n v i r o n m e n t are removed and the bacterial fauna greatly reduced, and the possibility of specific bacterial invasion becomes practically ~Kl.

NOVEMBEt*,

HEA LTH.

ENTERIC

FEVER AND THE DRYCLOSET SYSTEM.* By PHILIP BOOBBYER, M.D., Medical Of-ricer of Healtb, Nottingham.

H E sections en enteric fev~r and diarrhoea in my annual reports have, for many 3;ears, been little more than one long indictment of the dry-closet system--pail or privy--and all I need urge by way of excuse for this is the practically undiminished continuance of the dry-system in the City. The public, and even members of the medical profession, have been so long accustomed to look to certain definite channels of infection, like watersupplies and shell-fish, for the conveyance of the typhoid poison to the human intestine, that they are apt to forget the obvious fact that by far the greater part of the enteric fever occurring in this and other countries is not propagated in this manner, and that, provided the poison be swallowed in sufficient dose, it matters little with what vehicle it is taken in. Not the most thorough and scientifically devised precautionary measures can effectually protect against infection a certain proportion of those who--like the nurses of enteric fever hospitals--are closely associated with persons suffering from the disease. In such towns as Nottingham, and in other places--like military camps, for instance--wt_~ere dry-systems of excrement disposal are in use, the urine and fceees of all cases of enteric fever before diagnosis, and of all undetected cases, ate dispcsed of without special precautions ; and the resulting contamination of soil and atmosphere, of the human clothing and persons, and of food and habitation, through the agency of dirty, careless habits, and through flies and dust in warm weather, explains the spread of infection when once the fever has obtained a footing. However much we may improve the methods and increase the efficiency of our public scavenging, and we have done both to a very large extent in recent years, we cannot entirely obviate the risk of infection by such means as those i have just mentioned; and a town, therefore, with pailclosets and privies must be subject to endemic extension of enteric fever so long as the disease exists within its borders, or invades them occasionally from without. It will be interesting now to compare the past and present enteric fever death-rates of Nottingham, which retains its dry-closets, with those of the other great towns which have either already converted theirs, or are engaged in doing so. The death.rate of Nottingham from .enteric fever was rather below the mean rate of the other large cities taken together in the seventies--the

T

* Annual Report, ~9o8,

1909.

PUBLIC HEALTH.

N o t t i n g h a m rate was then a b o u t 45 per ioo,ooo, as c o m p a r e d with 48 per lO%OOO in t h e t h e n great towns. T h e e n t e r i c fever d e a t h - r a t e s of the great t o w n s all declined from this p~riod o n w a r d s , but, whereas the m e a n rate of the great t o w n s h a d fallen to 20 per lO%OOO in the last year of the century, the rate of N o t t i n g h a m h a d only declined to 29--i.e., the m o r t a l i t y was 45 per cent. more in N o t t i n g h a m t h a n in these towns as a whole. D u r i n g the decade ended with 19o 7 the a v e r a g e enteric fever death-rate per too,coo in N o t t i n g h a m was 24 , as c o m p a r e d with IO in the great towns, a n d d u r i n g 19o8 the rate in N o t t i n g h a m ( i i per IOO,OOO)) t h o u g h the lowest rate b u t one on record for N o t t i n g h a m , was still 36 per cent. in a d v a n c e of t h a t in t h e great towns (8 per IOO,OOO). T h e case of Leicester in this c o n n e c t i o n affords a n excellent object-lesson to N o t t i n g h a m . L e i c e s t e r formerly h a d a large n u m b e r of dry closets like N o t t i n g h a m , b u t it b e g a n their c o n v e r s i o n to w.c.'s m a n y years ago, and has n o w completed it. I n the seventies the a v e r a g e enteric fever deathrate of L e i c e s t e r was slightly below that of Nottit~gham, a n d its diarrhoea d e a t h - r a t e was twice as high. D u r i n g 19o8 the enteric fever deathrate of Leicester was only 3, while ours was i i per IOO,OOO, and d u r i n g the previous IO years (1898-19o7) the average enteric fever rate of Leicester was 8, whereas ours was 24 per IOO,OOO. T h e average diarrhoea m o r t a l i t y of Leicester is now c o n s i d e r a b l y below that of N o t t i n g h a m . T h e r e are m a n y who believe that m u c h of the e n t e r i c fever in our city is caused b y s h e l l fish. I would call the a t t e n t i o n of such people to the a b o v e figures, a n d also to the further fact t h a t the shell-fish supplies of N o t t i n g h a m a n d L e i c e s t e r are p r a c t i c a l l y identical, alike as to source a n d quantity. T h e n u m b e r of cases of enteric fever notified to me d u r i n g 19o8 was a37 , as c o m p a r e d with 231 in 19o 7 , a n d a n a n n u a l average of 286 d u r i n g the p r e c e d i n g five years. T h e a t t a c k rate per I,OOO of p o p u l a t i o n was equal to o'91 (91 per ioo,oco). T h i s is a very low rate for N o t t i n g h a m , lower, in fact, t h a n a n y previous a n n u a l rates excepting those of 19o 7 (o.897) a n d 19o 3 (o'81). T h e disease was, as usual, very generally dist r i b u t e d over most o f , t h e poorer districts of tim City, b u t g r o u p s of cases occurred m a r k i n g loci of local infection. T h e d e a t h s registered as due to enteric fever in N o t t i n g h a m , as a l r e a d y stated, n u m b e r e d 29 , a n d c o r r e s p o n d to a d e a t h - r a t e of o-11 per i,ooo ( i i per Ioo,eoo). T h e rates for the p r e c e d i n g five ydars h a d been respectively o.15, o ' I 6 , 0"09, 0"23, a n d o.I 4 per I,OOO. T h e rate for 19o8 is only 0"02 per I,OOO above the lowest r a t e on record (0.09 in 19o5). T h e d e a t h - r a t e from enteric fever d u r i n g 19o8 was equal to 0'o8 in the 76 great towns, o'o 5 in

57

L o n d o n , 0"08 in the 142 s m a l l e r towns, a n d 0"07 in E n g l a n d a n d W a l e s . T h e r e were six c a s e s - - t w o each in J a n u a r y a n d F e b r u a r y a n d one each in J u l y a n d A u g u s t - - i n which there was a definite history of the e a t i n g of shell-fish (mussels) prior to a t t a c k ; a n d as Dr. F. H. Jacob isolated from mussels b e l o n g i n g to ttle same c o n s i g n m e n t as those which had been eaten b y two of the p a t i e n t s a bacillus which gave the reaction of the typhoid bacillus, it seems very p r o b a b l e that the disease in these cases at a n y rate was caused b y the mussels. E x c e p t in these few cases, however, there was no definite antec e d e n t history of the i n g e s t i o n of shell-fish or other suspected article of food or drink, a n d I was c o n s t r a i n e d , as stated in the earlier part of this article, to falt back for c a u s a t i v e theory u p o n what I believe to be the u s u a l m e t h o d of propag a t i o n for e n t e r i c fever infection in cities like N o t t i n g h a m , viz., the fouling of all the physical s u r r o u n d i n g s of h u m a n life w i t h the c o n t e n t s of our pail-closets. I give once more with this article a t a b l e showing the actual and proportional incidence of enteric fever u p o n h u m a n dwellings f u r n i s h e d with v a r i o u s types of closet from 1887 to 19o8 inclusive. T h e table speaks for itself as a n a r g u m e n t in support of m y c o n t e n t i o n that the dry-closet plays a very i m p o r t a n t part in s p r e a d i n g the disease. INCIDENCE WITH FROM

OF

ENTERIC

PAIL.-CLOSETS~ 1887

TO

FEVER

19o8 ) AND

CLOSETS

CASKS

~v'IIDDEN-PRIVIES~

DURING

UPON

UPON

HOUSES

AND

W.C?S)

WASTE-WATER-

I9o5-o8.

1887 to 1808 (average). Houses. Houses with pail-closets 1 case of enteric fever in I2o ,, midden-privies I ,, ,, ,, 37 ,, water-closets I ,, . . . . 558 1899. Houses. Houses with pail-closets ... ... I case in 70 ,, midden-privms ... I ), 18 ,, water-closets ... ... I ), 296 1900. Houses with pail-closets ... ... 1 case in 92 , midden-privies •.. I ,) 20 ,, water-closets ... ... t ,) 407 1901. Houses with pail-closets ... ... t case ill 84 ,, midden-privies • .. I ), 12 ,, water-closets ... ... I ,, 255 1902. Houses with pail-closets ... ... I casein I29 midden-privies ... I ), 21 water-closets ... ), ... I ,, 294 1903. Houses with pail-closets ... ... I case in 267 midden privies ), ... I ,, 5o water-closets ... ... I ,, 504 1904. Houses with pail-closets ... ... I casein 166 midden-privms ,) ... I ,) 50 water-closets ... ... I ,, 407

5~

P U B L I C t l I ~ A Z Ttl.

Houses. 37,048 with 4oa ,, I2,OOO , 6,785 ,,

1905. pail-closets ... 204 cases midden-privies 4 ,, water closets... 2I , waste-w.e.'s ... 26 ,, 1906. 36,886 with pail-closets ... :z31 cases 300 ,, midden-privies 3 ,,

T case in ISr 1 ,, IOO I ,, 57I 1 ,, 26I

14,ooo

,,

water-closets~..

2I

,~

I case in 16o I ,, IOO cir. I ,~ ~67

6,7~5

,,

waste-w.e.'s

3°

,

I

~,

226

I I I I

,,

207

,, ,. ,,

I8 cir. 736 377

I I 1 1

,, ,, ,, ,,

I85 33 cir. 798 565

...

1907. 36,697 with pail-closets ... 177 cases 2oo ,, midden-privies II ,, I8,395 ,, water-closets... 25 ,, 6,785 ,, waste-w.c.'s ... I8 ,, 1908. 36,531 with pail-closets ... I97 ,, too ,, midden-privies 3 ,, I9,944 ,, water-closets... 25 ,, 6,785 ,, waste-w.c.'s ... 12 ,, LOCAL

AUTHORITIES REMOVAL OF

AND SNOW.

THE

THE T o w n Clerk of L a m b e t h h a s recently l issued a v a l u a b l e r e p o r t on t h e use of salt in t h e r e m o v a l of snow. I t a p p e a r s t h a t the following I2 B r i t i s h cities do not use salt to assist the r e m o v a l of t h e snow from the c a r r i a g e - w a y s : A b e r d e e n , B r a d f o r d , Bristol, D u n d e e , G r e e n o c k , Inverness, Leeds, Leicester, Leith, Newcastle, N o r w i c h , a n d P a i s l e y . At G r e e n o c k the snow is c a r t e d a w a y i m m e d i a t e l y . A t D u n d e e it is c a r t e d a n d deposited in t h e r i v e r or sewers or on v a c a n t ground, a n d a m i x t u r e of salt and s a n d is used in t h e m a i n t h o r o u g h f a r e s to p r e v e n t horses fronl slipping d u r i n g frosty w e a t h e r . T h e use of salt in I n v e r n e s s is forbidden u n d e r a p e n a l t y by the B u r g h P o l i c e Act, 1892. Salt is used on the carriage-ways in Birmingham, Edinburgh, Glasgow, Hull, Liverpool, Manchester, Nottingh a m , and Sheffield. T h e following C o n t i n e n t a l Cities do not use salt for the p u r p o s e of g e t t i n g rid of a snowfall : Berlin, B e r n e , B r e s l a u , C h r i s t i a n i a , Cologne, C o p e n h a g e n , F r a n k f u r t , H a m b u r g a n d Munich, whilst D r e s d e n only does so in e x c e p t i o n a l cases. S n o w p l o u g h s a r e e m p l o y e d a t B r e s l a u , Cologne, D r e s d e n , a n d F r a n k f u r t . S a l t is used in A m s t e r dam, Antwerp, The Hague, Leipzig, and Paris; t h e s t r e e t s of P a r i s a r e g r o u p e d in t h r e e classes of " u r g e n c y , " a n d the salt is s p r e a d t h e r e o n in o r d e r of class. I n r e g a r d to f o o t p a t h s E d i n b u r g h is t h e only B r i t i s h city w h e r e salt is u s e d to a n y g r e a t e x t e n t for the r e m o v a l of snow. A t H u l l it is e m p l o y e d for this p u r p o s e , b u t o n l y to e x p e d i t e m a t t e r s when the snow is a l r e a d y t h a w i n g . I t is used on t h e f o o t p a t h s at L i v e r p o o l d u r i n g the n i g h t only, t h e slush b e i n g flushed a w a y b y 8 a.m. I t is also used o c c a s i o n a l l y at D u n d e e and G r e e n o c k , b u t w i t h t h e s e exceptions, n o n e of t h e B r i t i s h cities use salt on the footways.

NOVEMBER,

I n C o n t i n e n t a l cities salt is used s p a r i n g l y on t h e f o o t p a t h s at D r e s d e n , T h e H a g u e , a n d L e i p z i g , b u t not at all in the r e m a i n i n g cities. A t B r e s l a u a n d lbaris t h e i n h a b i t a n t s are r e q u i r e d to clear t h e p a v e m e n t s ; at t h e f o r m e r p l a c e salt is forbidden, and at t h e latter it is required t h a t sand, ashes, or slag should be s p r e a d . In the case of t e n B r i t i s h c i t i e s - - A b e r d e e n , B r a d f o r d , Bristol, G r e e n o c k , I n v e r n e s s , L e e d s , Leicester, Newcastle, Nottingham and Paisley-t h e o p i n i o n is t h a t a g e n e r a l use of salt for t h e r e m o v a l of snow is o b j e c t i o n a b l e from the p o i n t o f view of p u b l i c h e a l t h . In t h e m a j o r i t y of t h e s e t e n cases t h e cold slush t h a t is formed is r e g a r d e d as being a t least u n p l e a s a n t for if not d a n g e r o u s to p e d e s t r i a n s , a n d a s d i s t i n c t l y injurious to t h e feet of a n i m a l s . A t E d i n b u r g h and H u l l t h e m e d i c a l officers a r e s t r o n g l y of opinion t h a t t h e use of salt is o b j e c t i o n a b l e ; the city engineers, on the o t h e r h a n d , a r e in favour of its a p p l i c a t i o n . A t H u l l the city e n g i n e e r ' s opinion is t h a t w i t h o u t . a p p l y i n g salt it is i m p o s s i b l e to m a i n t a i n traffic on wood p a v i n g . T h e city r o a d s u r v e y o r of E d i n b u r g h considers t h a t salt does no a p p r e c i a b l e i n j u r y to p a v e d r o a d s , but t e n d s to b r e a k t h e surface of m a c a d a m i z e d roads. T h e m e d i c a l officers of D u n d e e , L i v e r p o o l , a n d M a n c h e s t e r consider t h a t no a c t u a l h a r m results from t h e m e t h o d of a p p l y i n g t h e salt in their r e s p e c t i v e cities, t h o u g h in the c a s e of M a n c h e s t e r it is s t a t e d t h a t no d o u b t people w i t h defective boots suffer severely. T h e a u t h o r i t i e s at A n t w e r p , Berlin, D r e s d e n , and H a m b u r g c o n s i d e r the use of salt p r e j u d i c i a l to p u b l i c h e a l t h . T h e reply from A n t w e r p s t a t e s t h a t if small q u a n t i t i e s of salt a r e m i x e d w i t h l a r g e q u a n t i t i e s of ashes the p r a c t i c e is not o b j e c t i o n a b l e when a p p l i e d to r o a d s first cleared of the snow. S o m e y e a r s ago at A m s t e r d a m c e r t a i n of t h e t r a m c a r horses' feet b e c a m e d i s e a s e d t h r o u g h t h e use of salt, but no c o m p l a i n t of i n j u r y to persons h a v e been r e c e i v e d . R e p o r t s from P a r i s , C h r i s t i a n i a , Cologne, a n d T h e t l a g u e do not r e c o r d a n y o b j e c t i o n s to the use of salt. T O O T H B R U S H E S FOR S C H O O L C H I L D R E N . - - T o o t h

b r u s h e s h a v e been p u r c h a s e d at wholesale r a t e s b y t h e c o m m i t t e e , and a l r e a d y i 5 o gross h a v e been r e t a i l e d to the c h i l d r e n at I½d. apiece. E a c h brush is enclosed in an e n v e l o p e with i n s t r u c t i o n s p r i n t e d thereon. A c i r c u l a r l e t t e r d e t a i l i n g some: e l e m e n t a r y facts a b o u t teeth h a s been c i r c u l a t e d a m o n g t h e t e a c h e r s , a n d a c a r d ( A p p e n d i x 13) c o n t a i n i n g i n f o r m a t i o n on the p r e s e r v a t i o n of t h e teeth, for wholesale d i s t r i b u t i o n a m o n g t h e school children, is used. The Continental experience has shown t h a t this is not enough, and, therefore, p r a c t i c a l m e a s u r e s m u s t be a d o p t e d for enforcing cleanliness a n d for p r o v i d i n g r e m e d i a l treat-

ment.--Ammal Report of Dr. Sidney Barwise, County Medical 02ricer of Health, and School Medical O~icer, Derbyshire.