- Email: [email protected]
SANITATION IN INDIA. THE PREVALENCE OF ENTERIC FEVER AMONGST BRITISH TROOPS IN INDIA.
721 FIG. 4.
Mechanical
beef-dressing table.
The leaves
as
they revolve pass through a trough scoured by water jets.
of hot water and caustic soda and are further
is immersed in a long tank of hot water placed under the different principles such special care over this one detail table and in which caustic soda has been dissolved. Just as would not be necessary, but this would be a grudging each leaf of the table emerges from this bath jets of waterrecognition of the fact that the complaints published have play upon it and give it a final scour. Undoubtedly this is aborne fruit and that efforts are being made towards genuine remarkable piece of machinery. The very critical mightimprovement. (To be continued.) suggest that if the entire premises were constructed on
SANITATION IN INDIA. THE PREVALENCE OF ENTERIC FEVER AMONGST BRITISH TROOPS IN INDIA.
(FROM
A
SPECIAL
IX.1—Clothing, Blankets, &c.,
CORRESPONDENT.) as
Carriers
of Infection.
of fabrics may be considered as possible sources or carriers of infection all kinds of clothing, bedding, blankets, sheets, and cleansing cloths for wiping either the utensils in which food is cooked or served at table, as well as glass cloths and ordinary dusters. If any of the fabrics included in this category become infected from the excreta of either enteric fever patients, ambulant cases, or " carriers" it has been proved that not only are they capable of conveying enteric fever but also that such infection may remain active and virulent for a very considerable time. Owing to certain outbreaks being attributed to the infectibility of army blankets at the close of the South African war, Firth and Horrocks carried out a series of most interesting and valuable experiments in the laboratories of the Army Medical School at Netley. These observers found that they were able not only to recover the bacillus typhosus from uniform soiled with typhoid bacilli up Lo 87 days after infection, but that clothes soiled with enteric faecal matter contained active infection up to 17 days. They also found UNDER
the
heading
1 Nos. I., II., III., IV., V., VI., VII., and VIII. were published in THE LANCET of Jan. 2nd (p. 62), 9th (p. 134), 16th (p. 197), 23rd (p. 277), and 30th (p. 353), and Feb. 6th (p. 427), 13th (p. 501), and 20th, 1909 (p. 575), respectively.
bacillus could survive on uniform serge up for 50 hours of this period the cloth was exposed to direct sunshine at Netley. The latter observation is of importance owing to the popular belief in the efficiency of sunshine as a bactericidal agent. Pfuhl working independently on the same lines has recovered the bacillus typhosus on linen up to 97 days after infection. Reinche has also proved bacteriologically instances of infection from the same source. For these reasons the danger of infection from any kind of fabric should be apparent not only in tropical climates but also in the United Kingdom. At Bareilly in India during 1901 an outbreak of some 19 cases of enteric fever for a time baffled the military authorities, until attention was directed to the outdoor washing grounds where the garrison were having all their clothing washed by native washermen. It was noted that some ground in close proximity had recently been utilised for trenching the night soil, which consisted of fascal matter and urine, and that this ground had been taken into some use 43 days prior to the occurrence of the first case of enteric fever in barracks. The soldiers’ clothing were found drying within 100 yards of these trenches. From a damp sterilised cloth experimentally exposed Aldridge isolated the bacillus coli and the bacillus enteritidis. The washing grounds were closed as a result and the outbreak disappeared. The whole system ofwashing of clothing in India is open to grave sources of infection. In most stations the native washermen take private clothing to their homes for several days to do the making up "-starching and ironing, and that the to ten
typhoid
days, notwithstanding that
722 many cases of small-pox have been traced to such clothing store, common to all clothing of the patients in hospital, from their hovels. The infection to clothing by ambulant ur)less his disease is diagnosed or suspected to be enteric fever cases of enteric fever and also the infective clothing of be;fore admission, when his complete outfit is disinfected. " he clothing of a "typhoid carrier" or an ambulant case is. carriers" are quite unprovided against, and this clothing can readily infect the general washing water during the qxute likely to get into a general store of such a nature and period such cases continue out of hospital in the case of the in.feet the room. Or again, patients with fever which may former. In the case of "carriers"" strenuous attempts have af’terwards develop into enteric fever may have their clothing lately been made to detect as many as possible, but even when ut in the general store. Some arrangement is necessary to rovide against such exigencies until the diagnosis is condiscovered one is at a loss to know what to do with them. rmed and a small room set apart for the clothing of non-diaWashermen in India being natives are, like all unskilled nosed cases is necessary. The difficulty of disinfecting thick labourers in that country, very careless in the most elementary principles of sanitation. Cases are on record where after a]rticles like great-coats and blankets where steam sterilisers washing one’s clothes they let out shirts, &c., on hire in the a]re not provided has to be faced. Caldwell has found that bazaar to their friends to attend domestic functions. A case ITtomentary immersion in boiling water killed the bacillus oli in soldiers’ shirts, but that 30 seconds were necessary is reported of a corpse being laid out in " hired " sheets in this way which belonged to an officer of the garrison. iri the case of great-coats and blankets. He found Sawyer’s Clothing is seldom or never boiled owing to the cost s1ove or an ordinary camp kettle excellent disinfectors; of fuel. Kitchen cloths (jharans) are probably a most no damage was caused to the clothing. When availdangerous source of many kinds of disease, and they are able, he recommends carbolic acid 1 in 40 (boiling) as a usually washed in any dirty water when washed at all. A perfect disinfectant. He found five seconds’ immersion good example of cholera infection carried by these articles sufficient to kill all forms of life in blankets experimentally reported in THE LANCET of Jan. 25th, 1908, p. 270, may be soaked in sewage effluent. This carbolic acid solution did recalled. A commissioner of an Indian Province while on no damage to the khaki or 11 blue-black " shirts. He also tour stopped with his wife and some friends for luncheon at f,ound that immersion in boiling water for one minute of a Some few hours afterwards the majority bbanket soaked experimentally in sewage effluent failed to a Dak bungalow. of the party were seized with cholera and the commissioner, dlestroy completely either the bacillus coli or the bacillus his wife, and another lady died. The sanitary officer of the 1]nesentericus vulgatus. 60 seconds’ immersion in a solution district on inquiry found that the disease was directly cf boiling carbolic acid 1 in 40 appeared to destroy all caused by infection conveyed by jharans (plate cloths)cleveloped forms of bacillary life. The danger of blankets as which had been washed just before the meal in a stagnant ab source and carrier of enteric fever infection is a proven pool in which a cholera corpse (a native) was lying. These fact. Munson suspects that outbreaks of enteric fever on jharans had been used to wipe the plates off which the the so-called virgin soil of remote uninhabited places may 1)e due to soldiers carrying infection either in their party had eaten their food. There are thus at least three ways by which clothing and c)wn bodies or excreting it in their urine, on blankets, other materials are liable to become infected in India duringeeo. A case was recorded in India (1903) of a man acquiring the process of washing and being made up afterwards: (1) by infection by using a quilt which had covered a patient being washed in polluted water, the existing pollution of suffering from enteric fever. During the South African war the water being often added to by that of the clothes washed1blankets had of necessity to be passed from man to man, at the time or beforehand ; (2) by being hung up to dryvery many of whom were either developing or had already near infection ; and (3) by being stored before delivery in (leveloped enteric fever or dysentery. Disinfection was not the washermen’s houses. Under existing arrangements the (mly impossible but out of the question ; occasionally a provision of means for washing soldiers’ clothes is made 1blanket got a washing in a spruit when circumstances were bv the cantonment authorities from their funds and allfavourable for such a measure. When the war was over many these dangers should be avoided and not allowed toof these blankets were shipped home by dealers and sold by depend on the fluctuations of cantonment finance.auction and enteric fever broke out in various places in Rooms should be provided for storing and making upEngland. The origin of these outbreaks was traced to the the clothes which should never be allowed into the blankets. It is understood that washermen’s dwelling-houses. Bermuda, which had the highest admission ratio per 1000 a plan of such a building has been designed and that its of strength of any military station in the British Empire, adoption is under consideration. It will contain rooms for reduced its enteric incidence by introducing steam sterilisers boiling and steaming the clothes, and ironing and storing for disinfection of the clothing of all convalescents, "conA tacts," and suspects, and putting a stop to interchange of rooms will be located in the lines of each British unit. handcart has also been designed and is under trial for the blankets, &c., between individuals and units in charge of removal of all infected clothing and bedding to hospital station. During the South African war, vermin (lice, &c.) for disinfection. It is a metal-lined receptacle and its pro- were spread by the interchange of blankets, as they were all vision has been recommended by the Standing Committee mixed up during the daytime in the carts they had been on Enteric Fever appointed by the Government of India. carried in on the march. If lice can be spread enteric fever In the military hospitals in India regulations are enforced can spread by the same means. I have now examined in these columns the less common whereby all the bedding, clothing, furniture, and utensils of the patients and enteric fever wards are conspicuously marked paths whereby enteric fever is spread because of their with a large capital "E,"to enable them to be carefully importance in being more often the channels that are overguarded and sterilised before further use ; the duster cloths looked and for this reason are probably the more dangerous. (jharans) are the only articles which occasionally might be There still remain for consideration the sources of infection carried away by the native servants, and these miht be due to "bacilli carriers," water, milk, food, conservancy, rendered more conspicuous if they were dyed a brilliant red, latrines, and urine, and I hope to deal with these at some whereby they could be more easily distinguished. The cloth- future date as space allows. ing worn by all attendants, nursing sisters, and orderlies in charge of enteric fever patients should be invariably changed THE RADIUM A. E. before the wearers leave their tour of duty and should not be I.M.S. late medical Pinch, Hayward (retired), superintendent removed from the hospital unless disinfected. Up to a few of the Medical Graduates’ College and Polyclinic, has been years ago the nursing orderlies carried out their daily work director of the Radium Institute. Captain Pinch, appointed the wards in in their ordinary khaki uniform, but on recognition of the dangers of infection spreading to barracks by the we understand, has started for the continent in order to medium of clothing special white suits for nursing purposes investigate the methods and technique in vogue at the various cont,inental radium institutes. have been provided on a fixed scale for nursing orderlies THE annual report of the medical officer ot fever is enteric Tents which cases. there attending any the Exeter Sanatorium, which has just been issued, shows reason to believe have been exposed to infection are disinfected by first spraying with 1 in 40 carbolic acid and that during 1908 208 cases were treated in the institution, afterwards by exposure (particularly the inner surfaces) to nearly half of the patients coming from the county of Devon. There were two deaths among the patients from the direct rays of the sun for at least four days. When a soldier is admitted to hospital, his complete kit the county and two amongst those from the city, giving a accompanies him and this (after having changed into the death-rate of 1-9 per 100 cases treated. The average stay special hospital clothing provided) is put by in a general of each patient was 50 03 days.
INSTITUTE.—Captain
Mechanical
beef-dressing table.
The leaves
as
they revolve pass through a trough scoured by water jets.
of hot water and caustic soda and are further
is immersed in a long tank of hot water placed under the different principles such special care over this one detail table and in which caustic soda has been dissolved. Just as would not be necessary, but this would be a grudging each leaf of the table emerges from this bath jets of waterrecognition of the fact that the complaints published have play upon it and give it a final scour. Undoubtedly this is aborne fruit and that efforts are being made towards genuine remarkable piece of machinery. The very critical mightimprovement. (To be continued.) suggest that if the entire premises were constructed on
SANITATION IN INDIA. THE PREVALENCE OF ENTERIC FEVER AMONGST BRITISH TROOPS IN INDIA.
(FROM
A
SPECIAL
IX.1—Clothing, Blankets, &c.,
CORRESPONDENT.) as
Carriers
of Infection.
of fabrics may be considered as possible sources or carriers of infection all kinds of clothing, bedding, blankets, sheets, and cleansing cloths for wiping either the utensils in which food is cooked or served at table, as well as glass cloths and ordinary dusters. If any of the fabrics included in this category become infected from the excreta of either enteric fever patients, ambulant cases, or " carriers" it has been proved that not only are they capable of conveying enteric fever but also that such infection may remain active and virulent for a very considerable time. Owing to certain outbreaks being attributed to the infectibility of army blankets at the close of the South African war, Firth and Horrocks carried out a series of most interesting and valuable experiments in the laboratories of the Army Medical School at Netley. These observers found that they were able not only to recover the bacillus typhosus from uniform soiled with typhoid bacilli up Lo 87 days after infection, but that clothes soiled with enteric faecal matter contained active infection up to 17 days. They also found UNDER
the
heading
1 Nos. I., II., III., IV., V., VI., VII., and VIII. were published in THE LANCET of Jan. 2nd (p. 62), 9th (p. 134), 16th (p. 197), 23rd (p. 277), and 30th (p. 353), and Feb. 6th (p. 427), 13th (p. 501), and 20th, 1909 (p. 575), respectively.
bacillus could survive on uniform serge up for 50 hours of this period the cloth was exposed to direct sunshine at Netley. The latter observation is of importance owing to the popular belief in the efficiency of sunshine as a bactericidal agent. Pfuhl working independently on the same lines has recovered the bacillus typhosus on linen up to 97 days after infection. Reinche has also proved bacteriologically instances of infection from the same source. For these reasons the danger of infection from any kind of fabric should be apparent not only in tropical climates but also in the United Kingdom. At Bareilly in India during 1901 an outbreak of some 19 cases of enteric fever for a time baffled the military authorities, until attention was directed to the outdoor washing grounds where the garrison were having all their clothing washed by native washermen. It was noted that some ground in close proximity had recently been utilised for trenching the night soil, which consisted of fascal matter and urine, and that this ground had been taken into some use 43 days prior to the occurrence of the first case of enteric fever in barracks. The soldiers’ clothing were found drying within 100 yards of these trenches. From a damp sterilised cloth experimentally exposed Aldridge isolated the bacillus coli and the bacillus enteritidis. The washing grounds were closed as a result and the outbreak disappeared. The whole system ofwashing of clothing in India is open to grave sources of infection. In most stations the native washermen take private clothing to their homes for several days to do the making up "-starching and ironing, and that the to ten
typhoid
days, notwithstanding that
722 many cases of small-pox have been traced to such clothing store, common to all clothing of the patients in hospital, from their hovels. The infection to clothing by ambulant ur)less his disease is diagnosed or suspected to be enteric fever cases of enteric fever and also the infective clothing of be;fore admission, when his complete outfit is disinfected. " he clothing of a "typhoid carrier" or an ambulant case is. carriers" are quite unprovided against, and this clothing can readily infect the general washing water during the qxute likely to get into a general store of such a nature and period such cases continue out of hospital in the case of the in.feet the room. Or again, patients with fever which may former. In the case of "carriers"" strenuous attempts have af’terwards develop into enteric fever may have their clothing lately been made to detect as many as possible, but even when ut in the general store. Some arrangement is necessary to rovide against such exigencies until the diagnosis is condiscovered one is at a loss to know what to do with them. rmed and a small room set apart for the clothing of non-diaWashermen in India being natives are, like all unskilled nosed cases is necessary. The difficulty of disinfecting thick labourers in that country, very careless in the most elementary principles of sanitation. Cases are on record where after a]rticles like great-coats and blankets where steam sterilisers washing one’s clothes they let out shirts, &c., on hire in the a]re not provided has to be faced. Caldwell has found that bazaar to their friends to attend domestic functions. A case ITtomentary immersion in boiling water killed the bacillus oli in soldiers’ shirts, but that 30 seconds were necessary is reported of a corpse being laid out in " hired " sheets in this way which belonged to an officer of the garrison. iri the case of great-coats and blankets. He found Sawyer’s Clothing is seldom or never boiled owing to the cost s1ove or an ordinary camp kettle excellent disinfectors; of fuel. Kitchen cloths (jharans) are probably a most no damage was caused to the clothing. When availdangerous source of many kinds of disease, and they are able, he recommends carbolic acid 1 in 40 (boiling) as a usually washed in any dirty water when washed at all. A perfect disinfectant. He found five seconds’ immersion good example of cholera infection carried by these articles sufficient to kill all forms of life in blankets experimentally reported in THE LANCET of Jan. 25th, 1908, p. 270, may be soaked in sewage effluent. This carbolic acid solution did recalled. A commissioner of an Indian Province while on no damage to the khaki or 11 blue-black " shirts. He also tour stopped with his wife and some friends for luncheon at f,ound that immersion in boiling water for one minute of a Some few hours afterwards the majority bbanket soaked experimentally in sewage effluent failed to a Dak bungalow. of the party were seized with cholera and the commissioner, dlestroy completely either the bacillus coli or the bacillus his wife, and another lady died. The sanitary officer of the 1]nesentericus vulgatus. 60 seconds’ immersion in a solution district on inquiry found that the disease was directly cf boiling carbolic acid 1 in 40 appeared to destroy all caused by infection conveyed by jharans (plate cloths)cleveloped forms of bacillary life. The danger of blankets as which had been washed just before the meal in a stagnant ab source and carrier of enteric fever infection is a proven pool in which a cholera corpse (a native) was lying. These fact. Munson suspects that outbreaks of enteric fever on jharans had been used to wipe the plates off which the the so-called virgin soil of remote uninhabited places may 1)e due to soldiers carrying infection either in their party had eaten their food. There are thus at least three ways by which clothing and c)wn bodies or excreting it in their urine, on blankets, other materials are liable to become infected in India duringeeo. A case was recorded in India (1903) of a man acquiring the process of washing and being made up afterwards: (1) by infection by using a quilt which had covered a patient being washed in polluted water, the existing pollution of suffering from enteric fever. During the South African war the water being often added to by that of the clothes washed1blankets had of necessity to be passed from man to man, at the time or beforehand ; (2) by being hung up to dryvery many of whom were either developing or had already near infection ; and (3) by being stored before delivery in (leveloped enteric fever or dysentery. Disinfection was not the washermen’s houses. Under existing arrangements the (mly impossible but out of the question ; occasionally a provision of means for washing soldiers’ clothes is made 1blanket got a washing in a spruit when circumstances were bv the cantonment authorities from their funds and allfavourable for such a measure. When the war was over many these dangers should be avoided and not allowed toof these blankets were shipped home by dealers and sold by depend on the fluctuations of cantonment finance.auction and enteric fever broke out in various places in Rooms should be provided for storing and making upEngland. The origin of these outbreaks was traced to the the clothes which should never be allowed into the blankets. It is understood that washermen’s dwelling-houses. Bermuda, which had the highest admission ratio per 1000 a plan of such a building has been designed and that its of strength of any military station in the British Empire, adoption is under consideration. It will contain rooms for reduced its enteric incidence by introducing steam sterilisers boiling and steaming the clothes, and ironing and storing for disinfection of the clothing of all convalescents, "conA tacts," and suspects, and putting a stop to interchange of rooms will be located in the lines of each British unit. handcart has also been designed and is under trial for the blankets, &c., between individuals and units in charge of removal of all infected clothing and bedding to hospital station. During the South African war, vermin (lice, &c.) for disinfection. It is a metal-lined receptacle and its pro- were spread by the interchange of blankets, as they were all vision has been recommended by the Standing Committee mixed up during the daytime in the carts they had been on Enteric Fever appointed by the Government of India. carried in on the march. If lice can be spread enteric fever In the military hospitals in India regulations are enforced can spread by the same means. I have now examined in these columns the less common whereby all the bedding, clothing, furniture, and utensils of the patients and enteric fever wards are conspicuously marked paths whereby enteric fever is spread because of their with a large capital "E,"to enable them to be carefully importance in being more often the channels that are overguarded and sterilised before further use ; the duster cloths looked and for this reason are probably the more dangerous. (jharans) are the only articles which occasionally might be There still remain for consideration the sources of infection carried away by the native servants, and these miht be due to "bacilli carriers," water, milk, food, conservancy, rendered more conspicuous if they were dyed a brilliant red, latrines, and urine, and I hope to deal with these at some whereby they could be more easily distinguished. The cloth- future date as space allows. ing worn by all attendants, nursing sisters, and orderlies in charge of enteric fever patients should be invariably changed THE RADIUM A. E. before the wearers leave their tour of duty and should not be I.M.S. late medical Pinch, Hayward (retired), superintendent removed from the hospital unless disinfected. Up to a few of the Medical Graduates’ College and Polyclinic, has been years ago the nursing orderlies carried out their daily work director of the Radium Institute. Captain Pinch, appointed the wards in in their ordinary khaki uniform, but on recognition of the dangers of infection spreading to barracks by the we understand, has started for the continent in order to medium of clothing special white suits for nursing purposes investigate the methods and technique in vogue at the various cont,inental radium institutes. have been provided on a fixed scale for nursing orderlies THE annual report of the medical officer ot fever is enteric Tents which cases. there attending any the Exeter Sanatorium, which has just been issued, shows reason to believe have been exposed to infection are disinfected by first spraying with 1 in 40 carbolic acid and that during 1908 208 cases were treated in the institution, afterwards by exposure (particularly the inner surfaces) to nearly half of the patients coming from the county of Devon. There were two deaths among the patients from the direct rays of the sun for at least four days. When a soldier is admitted to hospital, his complete kit the county and two amongst those from the city, giving a accompanies him and this (after having changed into the death-rate of 1-9 per 100 cases treated. The average stay special hospital clothing provided) is put by in a general of each patient was 50 03 days.
INSTITUTE.—Captain