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Rural Sanitation.
RURAL SANITATION.
840
the medical officer of health holds some other public appointment, and that in 504 he engages in other work, usually in private practice. Among the inspectors of nuisances there are 597 instances in which the officer has other appointment?, such as surveyor of highways, or building surveyor, under the same or some other council, and 140 in which he follows
THE LANCET.
some
LONDON :SATURDAY, SEPTEMBER 21,1907.
recognition among rural councillors of the moral obligations of their official position, and WALPOLE’S maxim, Quieta non movere, expresses, also as a rule, their highest conception of their duties. They regard their health officers in most cases as our grandparents are is,
Rural Sanitation. EARLY in the last session of Parliament Sir JOHN DICKSONPOYNDER moved in the House of Commons for
a
private occupation.
The arrangements thus described in numerical outline work practically much as might be expected and in the There manner only too well known to most of our readers.
return of
as a
rule, little
or no
said to have regarded children-that is to say, as creatures inspectors of nuisances in that should be seen and not heard. The councillors are the rural districts of each county in England and Wales, usually men holding respectable business positions in the showing the area and population of each district and, as district, tradesmen or farmers, or in some similar station, able regards each officer, the amount of his remuneration, to read their favourite newspaper and to re-echo its views on whether repayment is made in respect of it by the county local or general politics, but almost as ignorant as their own council, and whether he holds any other appointment or cattle with regard to the protection of the public health, carries on any other occupation." This return has now been or with regard to the public importance of insanitary condiissued as a Parliamentary paper and it displays several of tions. They are slenderly endowed with imagination and the pieces which form the curious mosaic that may be are absolutely unable to realise the consequences likely to collectively described as our system (or want of follow from leaving a case of infectious disease in one of a system) of rural sanitation. It tells us that the group of overcrowded and undrained cottages. They are appointments in question are made by the councils sensitive to expenditure, especially to expenditure the of 659 rural districts but that, on account of combina- objects of which they are unable to appreciate or to undertions and of divisions of districts and of cases in which stand ; and they have a deeply-rooted conviction that it is more than one appointment is held by a single person, this unneighbourly to devote too much consideration to the number does not coincide with the number of officials. For dunghills and other appliances of their own congeners in the 659 rural districts there are 682 appointments of medical the vicinity. They have never seen a typhoid bacillus officers of health and 739 appointments of inspectors of which they would suppose to be something visible and nuisances. There are 30 combinations under the Public tangible, like a pigeon or a sparrow. They have never Health Act comprising rural districts for the appointment seen it go into the water of the village stream, they of a medical officer of health, and two comprising a rural have never seen it emerge, and they have no assured district for the appointment of an inspector of nuisances. ’, belief in its existence. They individually would not like There are cases in which, without formal combination, to be put to expense for the sake of rendering any cottages officers hold more than one appointment, and others in belonging to them fit for human habitation, and they wish which the officer for a form?! combination holds additional to extend to other proprietors, and especially to their separate appointments. In this way 64 medical officers of colleagues on the council, the same indulgence that they health act for 237 rural districts and one inspector of would expect to receive themselves. They are very tolerant nuisances acts for two rural districts. When the qualifica- of the medical officer of health so long as he meets them tions and conditions of office of a medical officer or inspector with a pleasant smile and keeps his duties as much as are in accordance with the regulations of the Local Governpossible in the background. If he be not satisfied with this is to to ment Board, the county council the position and displays too much consciousness of the required repay district council one-half of the officer’s salary. Under this responsibilities of his office, he will receive a friendly provision repayment is allowed in respect of 645 of the 682 private intimation that he had better hold his tongue, and appointments of medical officer of health for rural districts, if this be disregarded he will find that his practice and in respect of 656 of the 739 appointments of inspector suffers and that his re-election at the expiration of of nuisances, or in 94’ 5 per cent. of the fcrmer and his term will be more than doubtful. As for the inspector of 89 per cent. of the latter. In four single rural districts the nuisances, the best way to hinder him from being meddlemedical officers of health give their whole time to the some is to give him some more profitable occupation, and he duties of the office, and in 23 combined districts they do the is therefore permitted or encouraged to undertake other same, either strictly, or in combination with other work of a duties. We observe one case in which the inspector for two public character. These 23 cases comprise 127 rural districts in adjoining counties, respectively of 95,873 and of districts, but, with one exception, they also include urban 35,760 acres, and with populations of 9950 and 5803, being districts. There are but 98 cases in which the inspector of paid £55 a year for one of them and £30 for the other, but nuisances gives his whole time to his duties. The return with no contribution from the county council in either case, further shows that in 599 instances, including combinations, is at the same time a practising veterinary surgeon and
the medical officers of health and
I
MEMBRANOUS COLITIS.
841
Similar instances may be found on almost every Membranous Colitis. page of the return. WE publish this week an interesting paper by Dr. E. H. Under such conditions as those which we have described HARRISSON upon Mucous Colitis, which affords a useful all goes on smoothly for a time or until the mortality returns contribution to our present knowledge of the disease. of the district show, perhaps in successive years, a remarkable to the Considerable confusion still exists in prevalence of typhoid fever or of diphtheria or an infantile classification of diseases of the colon and regard there are many death-rate much in excess of the average for the county. Recent matters in dispute concerning their pathology. The Local Government Board then takes note of the facts researches have established the frequency with which the and sends down an inspector to ascertain the explanation of intestine is the seat of disease, either primary, as in them. He makes a report which in the majority of cases he large dysentery and ulcerative colitis, or secondary, as in tubermight make without investigation, so closely does one renal disease, and syphilis, while the part played by resemble all the rest. He finds overcrowding of dwellings culosis, disorders of the putrefactive processes occurring in it in upon area, overcrowding of inmates in dwellings, dwellings the genesis of various conditions of ill-health resulting from saturated with damp by reason of defective construction, an chronic constipation and stasis, though well recognised, is absence of drainage, an accumulation of fæcal matters in all even yet imperfectly understood. Among the most interestsorts of places, a defective water-supply, an abundant conobscure and at the same time most conditions affecting tamination of that which exists, an absence of provision for ing the colon is that to which the names of mucous colic, mucoisolating infectious disease, and a total neglect of cleanliness in dairies and slaughter-houses. These are the ordinary con- membranous or mucous colitis, and tubular diarrhoea have ditions which in each locality may be supplemented by others been applied. This disease has been variously regarded as peculiar to itself. The report is published, is a nine days’ an inflammatory condition-i.e., as a chronic catarrh of the wonder, and is forgotten, and things continue as before. mucous membrane, hence the application of the term colitis, There is no power anywhere to enforce the recommendations or since, in at any rate some cases, no sign of inflammation of the inspector and they are quietly ignored. Many of the has been discovered after death it has been regarded by reports contain references to earlier inspections of the same LEUBE and NOTHNAGEL as a neurosis of secretion, or a localities and say that the conditions then described are still "myxo-neurosis," to adopt the word invented by EWALD existing. The medical officer of health not only has no to describe the condition. More recently it has been sugauthority but is liable to be displaced if he is what his gested, among others by Mr. J. P. LoCKHART MUMMERY, council would describe as " troublesome," and the powers of that this condition has no claim to be regarded as a inaction of the council are unlimited. There is probably less clinical entity, but that it is in point of fact a syndrome, in rural than in urban districts of deliberate office-seeking or collection of associated symptoms found in a number of for the express purpose of protecting nuisances and of pre- diseases of the colon of widely different character. In an venting such laws as the Sale of Food and Drugs Acts from interesting paper read before the Royal Medical and
farrier.
being carried
into
effect,
but there is
an
amount of
steady Chirurgical Society
obstruction which only health officers themselves can realise to the full extent. In the meanwhile, the conditions of rural life are becoming as prejudicial to health as those of life in towns, and under a combination of noxious influences in both the health and the physique of the industrial sections of the community are suffering in the manner and degree recently set forth by the returns of the recruiting officers. The political exchange of votes for gabble goes on merrily, and schemers or visionaries are loud concerning projects of reform, while they leave untouched and unheeded the evils which are lying at their doors and which are certain, sooner or later, to entail due punishment upon the nation which permits their continued existence. The reform which is really needed, and which it would be the work of a true statesman to accomplish, would be to extend the protection of the laws to the thousands of poor and helpless who now suffer in health and strength from insanitary conditions which they cannot prevent and the existence of which they are frequently too ignorant either to recognise For this purpose the first necessity would be or to deplore. to give health officers security of tenure during good behaviour, to render them independent of other work, to combine districts in such a manner that needful expenditure should be spread over sufficiently large areas of taxation, and to commit, primarily to county councils and ultimately to the Local Government Board, the duty of making good the neglects and malfeasances of smaller and inferior authorities.
passive
on
June
lltb, and published in
15th, Mr. MUMMERY gives a careful of disease of the colon observed by analysis himself. He points out that owing to the application of the electric sigmoidoscope to the investigation of these cases it is possible to study directly the condition of the lower part of the colon, and by such means he has been enabled to prove the existence of local inflammatory lesions in 24 out of his 36 cases. The condition most often seen was an injection of the mucous membrane with a granular appearance like that seen in granular pharyngitis. Irregular patches of whitish-yellow adherent mucus were often observed on the surface of the membrane. In seven cases there was in addition definite ulceration, the ulcers being irregular in outline and shallow with a granular base. In four cases there was a chronic hypertrophic catarrh associated with oedema of the submucous tissue, while in seven cases the cause of the colitis appeared to be the presence of Other conditions found in association cancer of the colon. with the colitis were acute pericolitis, uterine displacements, and appendicitis. Mucus was present in the stools in all the cases and in eight of them large mucous casts were passed. Mr. MUMMERY therefore concludes that mucous colitis is not a distinct disease and also that NOTHNAGEL’S explanation of the condition as a secretory neurosis is untenable. A study of Mr. MUMMERY’S cases, however, shows that many of them hardly conform to the clinical type of the condition usually known as mucous colitis ; moreover, the greater number of his cases were in men, THE LANCET of June
of 36
cases
840
the medical officer of health holds some other public appointment, and that in 504 he engages in other work, usually in private practice. Among the inspectors of nuisances there are 597 instances in which the officer has other appointment?, such as surveyor of highways, or building surveyor, under the same or some other council, and 140 in which he follows
THE LANCET.
some
LONDON :SATURDAY, SEPTEMBER 21,1907.
recognition among rural councillors of the moral obligations of their official position, and WALPOLE’S maxim, Quieta non movere, expresses, also as a rule, their highest conception of their duties. They regard their health officers in most cases as our grandparents are is,
Rural Sanitation. EARLY in the last session of Parliament Sir JOHN DICKSONPOYNDER moved in the House of Commons for
a
private occupation.
The arrangements thus described in numerical outline work practically much as might be expected and in the There manner only too well known to most of our readers.
return of
as a
rule, little
or no
said to have regarded children-that is to say, as creatures inspectors of nuisances in that should be seen and not heard. The councillors are the rural districts of each county in England and Wales, usually men holding respectable business positions in the showing the area and population of each district and, as district, tradesmen or farmers, or in some similar station, able regards each officer, the amount of his remuneration, to read their favourite newspaper and to re-echo its views on whether repayment is made in respect of it by the county local or general politics, but almost as ignorant as their own council, and whether he holds any other appointment or cattle with regard to the protection of the public health, carries on any other occupation." This return has now been or with regard to the public importance of insanitary condiissued as a Parliamentary paper and it displays several of tions. They are slenderly endowed with imagination and the pieces which form the curious mosaic that may be are absolutely unable to realise the consequences likely to collectively described as our system (or want of follow from leaving a case of infectious disease in one of a system) of rural sanitation. It tells us that the group of overcrowded and undrained cottages. They are appointments in question are made by the councils sensitive to expenditure, especially to expenditure the of 659 rural districts but that, on account of combina- objects of which they are unable to appreciate or to undertions and of divisions of districts and of cases in which stand ; and they have a deeply-rooted conviction that it is more than one appointment is held by a single person, this unneighbourly to devote too much consideration to the number does not coincide with the number of officials. For dunghills and other appliances of their own congeners in the 659 rural districts there are 682 appointments of medical the vicinity. They have never seen a typhoid bacillus officers of health and 739 appointments of inspectors of which they would suppose to be something visible and nuisances. There are 30 combinations under the Public tangible, like a pigeon or a sparrow. They have never Health Act comprising rural districts for the appointment seen it go into the water of the village stream, they of a medical officer of health, and two comprising a rural have never seen it emerge, and they have no assured district for the appointment of an inspector of nuisances. ’, belief in its existence. They individually would not like There are cases in which, without formal combination, to be put to expense for the sake of rendering any cottages officers hold more than one appointment, and others in belonging to them fit for human habitation, and they wish which the officer for a form?! combination holds additional to extend to other proprietors, and especially to their separate appointments. In this way 64 medical officers of colleagues on the council, the same indulgence that they health act for 237 rural districts and one inspector of would expect to receive themselves. They are very tolerant nuisances acts for two rural districts. When the qualifica- of the medical officer of health so long as he meets them tions and conditions of office of a medical officer or inspector with a pleasant smile and keeps his duties as much as are in accordance with the regulations of the Local Governpossible in the background. If he be not satisfied with this is to to ment Board, the county council the position and displays too much consciousness of the required repay district council one-half of the officer’s salary. Under this responsibilities of his office, he will receive a friendly provision repayment is allowed in respect of 645 of the 682 private intimation that he had better hold his tongue, and appointments of medical officer of health for rural districts, if this be disregarded he will find that his practice and in respect of 656 of the 739 appointments of inspector suffers and that his re-election at the expiration of of nuisances, or in 94’ 5 per cent. of the fcrmer and his term will be more than doubtful. As for the inspector of 89 per cent. of the latter. In four single rural districts the nuisances, the best way to hinder him from being meddlemedical officers of health give their whole time to the some is to give him some more profitable occupation, and he duties of the office, and in 23 combined districts they do the is therefore permitted or encouraged to undertake other same, either strictly, or in combination with other work of a duties. We observe one case in which the inspector for two public character. These 23 cases comprise 127 rural districts in adjoining counties, respectively of 95,873 and of districts, but, with one exception, they also include urban 35,760 acres, and with populations of 9950 and 5803, being districts. There are but 98 cases in which the inspector of paid £55 a year for one of them and £30 for the other, but nuisances gives his whole time to his duties. The return with no contribution from the county council in either case, further shows that in 599 instances, including combinations, is at the same time a practising veterinary surgeon and
the medical officers of health and
I
MEMBRANOUS COLITIS.
841
Similar instances may be found on almost every Membranous Colitis. page of the return. WE publish this week an interesting paper by Dr. E. H. Under such conditions as those which we have described HARRISSON upon Mucous Colitis, which affords a useful all goes on smoothly for a time or until the mortality returns contribution to our present knowledge of the disease. of the district show, perhaps in successive years, a remarkable to the Considerable confusion still exists in prevalence of typhoid fever or of diphtheria or an infantile classification of diseases of the colon and regard there are many death-rate much in excess of the average for the county. Recent matters in dispute concerning their pathology. The Local Government Board then takes note of the facts researches have established the frequency with which the and sends down an inspector to ascertain the explanation of intestine is the seat of disease, either primary, as in them. He makes a report which in the majority of cases he large dysentery and ulcerative colitis, or secondary, as in tubermight make without investigation, so closely does one renal disease, and syphilis, while the part played by resemble all the rest. He finds overcrowding of dwellings culosis, disorders of the putrefactive processes occurring in it in upon area, overcrowding of inmates in dwellings, dwellings the genesis of various conditions of ill-health resulting from saturated with damp by reason of defective construction, an chronic constipation and stasis, though well recognised, is absence of drainage, an accumulation of fæcal matters in all even yet imperfectly understood. Among the most interestsorts of places, a defective water-supply, an abundant conobscure and at the same time most conditions affecting tamination of that which exists, an absence of provision for ing the colon is that to which the names of mucous colic, mucoisolating infectious disease, and a total neglect of cleanliness in dairies and slaughter-houses. These are the ordinary con- membranous or mucous colitis, and tubular diarrhoea have ditions which in each locality may be supplemented by others been applied. This disease has been variously regarded as peculiar to itself. The report is published, is a nine days’ an inflammatory condition-i.e., as a chronic catarrh of the wonder, and is forgotten, and things continue as before. mucous membrane, hence the application of the term colitis, There is no power anywhere to enforce the recommendations or since, in at any rate some cases, no sign of inflammation of the inspector and they are quietly ignored. Many of the has been discovered after death it has been regarded by reports contain references to earlier inspections of the same LEUBE and NOTHNAGEL as a neurosis of secretion, or a localities and say that the conditions then described are still "myxo-neurosis," to adopt the word invented by EWALD existing. The medical officer of health not only has no to describe the condition. More recently it has been sugauthority but is liable to be displaced if he is what his gested, among others by Mr. J. P. LoCKHART MUMMERY, council would describe as " troublesome," and the powers of that this condition has no claim to be regarded as a inaction of the council are unlimited. There is probably less clinical entity, but that it is in point of fact a syndrome, in rural than in urban districts of deliberate office-seeking or collection of associated symptoms found in a number of for the express purpose of protecting nuisances and of pre- diseases of the colon of widely different character. In an venting such laws as the Sale of Food and Drugs Acts from interesting paper read before the Royal Medical and
farrier.
being carried
into
effect,
but there is
an
amount of
steady Chirurgical Society
obstruction which only health officers themselves can realise to the full extent. In the meanwhile, the conditions of rural life are becoming as prejudicial to health as those of life in towns, and under a combination of noxious influences in both the health and the physique of the industrial sections of the community are suffering in the manner and degree recently set forth by the returns of the recruiting officers. The political exchange of votes for gabble goes on merrily, and schemers or visionaries are loud concerning projects of reform, while they leave untouched and unheeded the evils which are lying at their doors and which are certain, sooner or later, to entail due punishment upon the nation which permits their continued existence. The reform which is really needed, and which it would be the work of a true statesman to accomplish, would be to extend the protection of the laws to the thousands of poor and helpless who now suffer in health and strength from insanitary conditions which they cannot prevent and the existence of which they are frequently too ignorant either to recognise For this purpose the first necessity would be or to deplore. to give health officers security of tenure during good behaviour, to render them independent of other work, to combine districts in such a manner that needful expenditure should be spread over sufficiently large areas of taxation, and to commit, primarily to county councils and ultimately to the Local Government Board, the duty of making good the neglects and malfeasances of smaller and inferior authorities.
passive
on
June
lltb, and published in
15th, Mr. MUMMERY gives a careful of disease of the colon observed by analysis himself. He points out that owing to the application of the electric sigmoidoscope to the investigation of these cases it is possible to study directly the condition of the lower part of the colon, and by such means he has been enabled to prove the existence of local inflammatory lesions in 24 out of his 36 cases. The condition most often seen was an injection of the mucous membrane with a granular appearance like that seen in granular pharyngitis. Irregular patches of whitish-yellow adherent mucus were often observed on the surface of the membrane. In seven cases there was in addition definite ulceration, the ulcers being irregular in outline and shallow with a granular base. In four cases there was a chronic hypertrophic catarrh associated with oedema of the submucous tissue, while in seven cases the cause of the colitis appeared to be the presence of Other conditions found in association cancer of the colon. with the colitis were acute pericolitis, uterine displacements, and appendicitis. Mucus was present in the stools in all the cases and in eight of them large mucous casts were passed. Mr. MUMMERY therefore concludes that mucous colitis is not a distinct disease and also that NOTHNAGEL’S explanation of the condition as a secretory neurosis is untenable. A study of Mr. MUMMERY’S cases, however, shows that many of them hardly conform to the clinical type of the condition usually known as mucous colitis ; moreover, the greater number of his cases were in men, THE LANCET of June
of 36
cases