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Summer diarrhœa
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SUMMER DIARRH(EA.* By A. E. NAISH, M.A., M.D., Assistant Physician to the Sheffield Royal Hospital. I bring before you to-night T H Eneedssubject no apology on account of its importance or general interest. I do not, however, attempt its introduction in the hope of being able to say anything new or startling, but rather with the object of stimulating interest in the causation and the means of prevention of this terrible disease. Last year, in spite of the comparative coolness of the summer and consequent low death-rate, acute diarrhoea was responsible for more than ten times as many deaths as scarlet fever or diphtheria, and for nearly fifteen times as many as typhoid; and the after history of those that recover is, perhaps, the gravest feature of all--for months often the weight remains nearly stationary, and if the child does not fall a victim to some intercurrent disease, it tends to suffer permanently from malnutrition. With a disease of such gravity it would be remarkable that so little is known about its mode of origin and spread were it not that the subject is one of considerable complexity, and that probably under the one name we have grouped a number of different, even if closely allied, diseases. Among the theories that have been advanced as to the causation of this disease, one may be justified, I think, in putting aside all but the three most important. The first is that it is due to the action of heat on the cerebral heat centres--in other words, that the cases are examples of heat stroke strictly comparable to the heat stroke of adults, in which diarrhoea and vomiting are not infrequently met with. A number of authorities, especially in America and Germany, have expressed themselves in favour of this theory, but although certain cases may be, and probably are, due to this cause, I think it can hardly be contended that the bulk of summer diarrhoea can be attributed to it. In the first place, if heat were the main cause we should expect that sudden rises of temperature would be followed by the greatest number of cases--in other words, that the curve of incidence would correspond closely to the curve of the maximum temperature--whereas *A paper read before the Sheffield Medico-Chirurgical Society, October ~8th, I9o9. This paper and the following discussion have been kindly communicated by Dr. Harold Seurfield, Medical Officer of Health, Sheffield.
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in reality a rise in the average mean temperature, or the temperature of the ground at three or four feet, corresponds more closely to the incidence of the disease. Further than this, it is found that the maximum incidence generally falls some weeks after the maximum ground temperature. It might be said that this is due to the interval between onset and death, but in Woolwich, where notification is carried out, the same phenomenon is noticed. On the average of four years the highest ground temperature was in the fifth week of the summer quarter (July, August and September), whereas the largest number of cases was in the eighth week. Other arguments against the heat theory are of the nature of positive evidence of the infectivity of the disease, which I shall touch on later. It is well to remember, however, that heat often causes loss of appetite and nausea even in adults, and, acting on an infant whose digestion has been deranged for some time and who has perhaps been suffering from chronic looseness of the bowels, may well be the determining factor in the production of an acute and even fatal diarrhoea. The next theory is that the products of the decomposition of milk (or other food) act as poisons--in short, that the disease is comparable to the ptomaine poisoning of adults. This theory has unfortunately been confused with the theory of the transference of pathogenic organisms by milk, and in certain text books and writings it is not clear whether the authors distinguish between them. With regard to the decomposition theory, however, neither the bacillus nor the toxin have been demonstrated, and it is a notable fact that no connection has been traced between diarrhoea incidence and the supply of milk from particular farms. I shall, however, discuss the question of milk in connection with the third theory, which I n o w bring forward. This is that the disease is due to the invasion of the body by bacteria. Assuming this to be so, we have further to enquire whether the organism is one of those normally present in the intestine, which under normal circumstances has taken on pathogenic functions, or whether it has been introduced from some foreign source, and in what way it is conveyed to the child'~ intestine. The gaps in our knowledge are so great that I may perhaps be forgiven if I do not discuss the matter in its logical sequence. In America a considerable proportion of the
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cases of diarrhoea occurring in summer has been proved by Flexner and others to be due to infection by bacilli of the dysentery group; these cases always have blood and mucus in the stools. The type which is commonest in England is not clinically the same, and the pars-dysentery bacillus cannot be isolated. Morgan and others of the Lister Institute have for the last four years found one bacillus of the non-lactose group to predominate over all others in cases from London hospitals. They have isolated it from f~eces and postmortem material in over 5° Per cent. of cases, and have found it nearly always absent in healthy children, or in those suffering from other diseases, even if complicated by diarrhoea. Williams and Murray in Liverpool have also isolated a bacillus closely allied to para-typhoid B. Certain epidemics have been shown by Escherich to be associated with the presence of a modified colon bacillus, and others with a streptococcus. All these bacteria have been isolated from post-mortem material as well as from the f~eces, and have frequently given agglutinative reactions. So far, then, as this evidence goes, it seems to point to the invasion of the body by bacteria, especially by those of the colon group, being frequently the cause of summer diarrhcea. I have myself noticed in many cases a distinct period of malaise often accompanied by an urticarial rash before the onset of acute diarrhoea. The close relationship of many of the bacteria found to one another and to the colon bacillus makes us wonder whether the latter and its family in the character of Jekyll and Hyde are not responsible for most of the mischief. With regard to the mode of transmission it has been widely held both among medical and lay men that milk is the main, if not the only, source of infection. It is natural, I suppose, to attribute all diseases that manifest prominent intestinal symptoms to the action of food or drink, and in this instance the theory receives strong support from the well-known relative immunity of infants fed at the breast. However, if we look a little further into the matter, we find certain facts which must make us pause before we ascribe to milk such a position of importance as a transmitter of this disease. Following upon the discovery of the comparative immunity of breast-fed infants, there was a rush towards the sterilization of cows' milk for bottle-fed babies, especially in certain Conti-
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nental countries and America. Many towns set up machinery for sterilization on a large scale, and supplied the milk in sealed bottles. We have now the opinion expressed by many authorities who have been in a position to judge of the results, that sterilization of milk has had little effect on the general or diarrhoea mortality of infants (after making due allowance for the variation in mortality according td temperature). This has been attributed by some to contamination taking place in the houses, but often the milk has been supplied in such a way as to render such contamination very difficult : for instance, in narrow-necked bottles, which may be left uncorked for two or three days in an incubator without decomposition occurring. Occasionally we have even more evidence : for instance, in the town of Halle the illegitimate infants were put on sterilized milk from the year I9O4 without any reduction of the mortality amongst them, which still remained high in proportion to the general town rate, and was chiefly from gastro-intestinal disease. Where sterilization of milk has been undertaken hand in hand with its modification to suit the rieeds of the different ages, or with dep6ts for the instruction of mothers, excellent results have been reported; but these can hardly be attributed to the sterilization. Our own experience at the dep6ts in Sheffield is confirmatory of the above. If milk were the chief carrier of infection the use of a sterilized dessicated powder kept in tins, and mixed freshly with water for each feed, should act largely as a prophylactic. W e have no means of comparing the attack-rate of these babies with the general attack-rate of bottle-fed babies, but I think there is not much difference in favour of the former. There are other general considerations which tend to point in the same direction. The W e s t Riding enquiry into the bacteriology of milk showed that the greatest number of bacteria were added a t the farm. Now, as the milk supply of rich and poor does not differ largely, and a greater proportion of children of the rich are hand fed, we should expect, if the milk bacteria were the main cause of diarrhoea, to have a larger proportion of cases among them than among the poor, whereas it has been proved that the higher i n t h e social scale one goes the less acute diarrhoea is found. Further, the workers at the Lister Institute found that, out of twenty-nine samples of milk taken from houses affected, only one contained
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Morgan's bacillus, whereas out of eight batches of flies six contained it. How, then, can we explain the immunity of breast-fed infants ? In the first place, there has been a tendency to exaggerate this immunity ; more breast-fed infants are attacked than would be gathered from the death-rate figures; in other words, the disease tends to be milder. In the next place, it is a well-recognized fact that the catarrhal condition resulting from repeated " insults to the intestinal m u c o s a " acts as a powerful predisposing cause of true infective diarrhoea, and these insults are far less frequent in breast-fed infants. In the third place, freshly drawn milk has been shown to have an inhibitory effect on the growth of many bacteria, and it is quite possible that maternal milk may in this w a y act as a mild antiseptic. In this connection it may be mentioned that under normal conditions the flora of the breast-fed baby's intestine differ markedly from those of the hand-fed baby's. Is the disease communicable from person to person ? I think there can be little doubt on this point. Firstly, the disease used to be very prevalent in institutions where children were aggregated closely. Finkelstein observed in the infants' ward that the epidemics were preceded by one child being taken ill first, the others following after an interval. After antiseptic precautions had been instituted there was a fall in mortality from about 8o per cent. to 22 per cent. Secondly, investigations made in towns seem to establish the fact that overcrowding has a closer relation to the prevalence of the disease than any other factor. Thirdly, similar investigations show a marked grouping of the cases in certain streets and areas, and a tendency for the disease to spread from the backs of houses to the backs of those in an adjoining street. Fourthly, a spread throughout a family is very common, if not the rule. Dr. Davies, the medical officer of health of Woolwich, says :-" I t was common to find the baby notified was not the first case in the family, and frequently it was found that most members of the family had been affected one after another within a few days' interval. Probably the usual incubation period is from two to seven days, as the interval between the commencement of successive cases varied between these limits." I have not attempted to exhaust all the evidence that has accumulated with regard to the transmission of this disease~ for time has
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allowed me to touch here and there only a few fragments of its etiology. I should like, how: ever, to bring forward one or two provisional suggestions as to its prevention. In the first place, probab]~y too much attention has been directed to the milk supply, and not enough to housing conditions. The following rather striking account was given me by a lady who was an Army nurse at Aldershot for five years, and afterwards at Bulford. In the Old Lines (at Aldershot), where the houses were small, dark and low lying, diarrhoea was v e r y prevalent among the children; but in the New Lines, which stood higher, with houses larger and lighter, it was much less so. The milk supply was the same. At Bulford, where the houses were in long straight lines, with free through ventilation, diarrhoea was almost unknown. The betterment of housing conditions is, however, a big thing, and one which will probably take many years to make much head-" way in, but there is one thing which I think may be done without much delay. The mortality in infants' institutions has been much reduced by the introduction of antiseptic precautions. Last summer I suggested to Dr. Scurfield that it might be possible to educate mothers, even in poor houses, to a recognition of the infectivity of diarrhoea. Dr. Scurfield took up the proposal with enthusiasm, and representative poor streets were chosen by each of the women sanitary inspectors. The object was to teach the mothers by written and verbal instructions that the stools and possibly the urine of infected cases were a source of danger to others, and to help them towards the routine disinfection of the same and the cleansing of the infants' bodies, whether in infected or non-infected cases, during the hot months. I had hoped to have some figures to give comparing the diarrhoea mortality in these districts with the gefieral diarrhoea mortality, but the numbers are too small to draw any conclusion from. Among 417 infants under one year, seven died from diarrhoea, but of these one was brought from another district while suffering from the disease ; in another case measles had ushered in a prolonged diarrhoea of ten weeks, which was not improbably tubercular; and in a third the diarrhoea was only the terminal e v e n t - lasting two days--in an illness of three weeks' duration. I think the effect of the instructions has been of value. There has been striking
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evidence t h a t m o s t of the m o t h e r s h a v e tried to c a r r y out the instructions, and in doing so h a v e c o m e to realize m o r e fully t h e seriousness as well as the infectivity of the disease, and t h a t as one consequence t h e y h a v e t a k e n their children for t r e a t m e n t at an earlier stage. In conclusion, I should like again to d r a w a t t e n t i o n to t h e n u m b e r of t y p e s t h e r e are of this disease, d e p e n d e n t p r o b a b l y on different bacteria, a n d t h a t our only guide to future rational t r e a t m e n t will be t h r o u g h differentiation of these types. T h i s can only be d o n e b y a c c u r a t e observations, a n d recording of their o b s e r v a t i o n s b y a large n u m b e r of medical men. DISCUSSION. DR. GEORGE \VILKINSON, Honorary Surgeon to the Sheffield Royal Hospital, asked if Dr. Naish could explain the connection between rise of ground temperature and incidence of epidemic diarrhoea. W i t h regard to spread of infection by flies, did he understand Dr. Naish that flies carried the infectious organisms from the f~ecal discharges to food, s u c h as milk, from which source other inmates of the house became infected ? DR. V~[ADDY,District Medical Officer, Sheffield Union, rose to offer one or two practical suggestions. One difficulty which he encountered in his houseto-house work was the practice of keeping milk warm on the hob. After milk had been sterilized by boiling, it was liable to subsequent infection. By keeping the milk warm any micro-organisms present were incubated, and the degree of infection of the milk was enormously increased. Milk which had been boiled should be set to cool quickly. Only sufficient for one feed should be made warm at a time. T h e chief difficulty was with regard to feeding bottles. It seemed impossible to make people understand the difference between keeping a bottle always clean and keeping it always dirty. Mothers assert that they clean the bottle before filling it. If "this were so, then one would expect, in a definite proportion of visits, to find a bottle in the condition of being cleaned ready for use. But such a discovery is of the utmost rarity. E v e n in those cases in which this course is adopted it is quite inadequate. It is perfectly easy to keep a bottle clean by rinsing it out with cold water immediately after it has been used. It is very difficult to clean a bottle which has once become dirty; indeed, the bottle which is kept dirty never is clean. In this respect the provision of two bottles only increases the danger. The cleaning of the dirty bottle is all the more easily neglected and postponed. There are two dirty bottles to contend with instead of one. It is quite usual for milk to be put into a bottle and left in the child's cradle all night, and perhaps even all
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the next day, if two bottles are in use. T h e instructions issued by the medical officer of health are superior to those which have been published previously; but on this point there is room for further amendment. Instead of taking for granted that bottles are dirty, and telling people how to clean them by boiling them in soda, they ought to insist on the importance of never allowing the bottle to become dirty. The only way to keep a bottle clean is to keep it clean. Da. A. E. BARNES thanked Dr. Naish for his interesting paper, and thought that all the members must agree with his conclusions. H e agreed with Dr. Naish that it was necessary to set to work to differentiate the various types of disease, or perhaps different diseases. H e had seen two cases where apparently adults had been infected from children. As regards the statement that the child was often not the first in the family to be infected, he had seen an interesting case where the child during the summer epidemic suddenly began with acute colitis. The diagnosis of colitis was made in the laboratory, and on communication with the family doctor it turned out that the father had been affected with colitis for some years. Too much reliance should not be placed on the work in regard to Morgan's bacillus, as the original paper of Ledingham and Morgan was severely criticised by Dr. Thwort on grounds that appeared to be very sound--namely, that the differentiation of the bacillus depended on fermentation reactions, and it had been shown that by appropriate cultivation any bacillus of the group could be made to give any particular fermentation reaction, and that the agglutination reaction which was obtained by Morgan might be due to some other cause, as some of the sera agglutinated other bacilli in high dilution. It should also be remembered that only the non-fermenters of lactose were investigated. Dr. Barnes also wished to refer to some Breslau statistics which went to show that the incidence in cellar dwellers was less in proportion than those dwelling in upper rooms. JAMES MARTIN BEATTIE, M.D., Professor of Pathology and Bacteriology at Sheffield University, said: I quite agree with Dr. Naish that too much stress has been laid on the carriage of infection by milk alone. The disease is an infective one, and a look at the home in which the disease occurs shows how easily the causal organisms can be carried by flies to all kinds of food, to the hands of the child, and even to its mouth. Recent work has brought out very strongly the important part played by flies in the carriage of disease-producing organisms. In regard to the causal organism, I do not think there is sufficient evidence to justify any very definite conclusions. There is a good deal to be said in favour of Morgan' s bacillus, and the work he and Ledingham have done is extremely valuable ; but my own observations lead me to regard with suspicion the classification of bacteria into separate
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groups simply because one ferments a special sugar and another does not. Certainly with streptococci the same organism at different times and in different stages of virulence gives different reactions with the various sugars, and I see no reason to doubt that other organisms act in the same way : it m a y yet be proved that Morgan's bacillus is merely a modified colon, typhoid or dysentery bacillus. Dr. Naish has referred to the conclusions given in the Report on the Contamination of Milk of the West Riding County Council--that the main contamination is at the cowshed, and that the contamination in the houses of the consumers is not great. I feel that in this Report the evidence is not strong enough to justify the conclusions. Too little attention has, in my opinion, been given to the milk at the consumers' houses. Many more samples will require to be examined, and the examination will require to be much more thorough and exhaustive. MR. ARCHIBALD CUFf', F.R.C.S., Honorary Surgeon, Sheffield Royal Infirmary, after thanking Dr. Naish for his very interesting paper, said that he quite agreed with the writer that it was most important to teach the mothers the immense importance of cleanliness in attending to their children, and also impressing them with the fact that diarrhoea was infectious, and that by carelessness they could infect other children, or perhaps keep up the disease in the patient. Professor Beattie had in his remarks emphasized this, and had probably mentioned a very important factor when he said that the condition of the milk when in the house was probably of more importance in the spread of the disease than the condition of the milk before delivery. Mr. Cuff said t h a t anyone who had been on the staff of a children's hospital must have been struck with the uncleanliness of the mothers in dealing with the evacuations of the little c h i l d r e n - - a carelessness due in part to ignorance, and in part to poverty. Not only were the mother's clothes often accidentally soiled by the child, but the apron and even the mother's skirt is used to complete the cleansing of the child, and her soiled hands used immediately afterwards to put the dummy teat into the child's mouth. It was probably the same at home, and with the lack of linen and towels in the cottages of the poor it seemed more than probable that infection was carried by the mother-from one child to another, food and milk were infected-nay, it was even possible that the organisms, transferred to nutrient media, such as milk, food, etc., from a normal child's stool, might under suitable conditions of warmth, etc., become so virulent as to start an enteritis in another child. It would be a n ' i n t e r e s t i n g thing to examine bacteriologically some of the milk, food, and articles coming into contact with the small children in some of the houses in the diarrhcea
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districts during an epidemic. Mr. Cuff was certain that the convincing of the parents of the highly infectious nature of the disease was one of the most important factors in the prevention of this scourge. MRS/ L u c y NAIsH, M.B., said: In this discussion on summer diarrhaea you m a y be interested to hear of the value of antiseptic treatment of the baby's buttocks and diapers, coupled with the value of fresh air, as evidenced by the babies at the nursery block at the Sheffield Union Workhouse. W h e n I first became a Guardian about three years ago I was distressed to find about thirty children, whose ages varied from one month to three years, in one quite small day nursery, which seemed to me quite inadequate as regards fresh air. Also there was only one paid attendant, and she was assisted by any female inmates other than the mothers of the babies. Some of the inmates were quite old women, or often umnarried girls awaiting their confinements. The mothers of the suckling babies slept with them and came across from the laundries or other places where they were employed in the day time at regular intervals to feed them, but they were not allowed in any way to attend to the baby by bathing or even changing its napkin. In fact, they were just a herd of human cows. W h e n I first called attention to the s m a l l size of. the nursery I was told that a new block was being built, and all my schemes for improvement were deferred until the babies got into the new block: Meanwhile diarrhrJea was very prevalent among these children, and they had to be sent up to the Union hospital for treatment, and I was frequently told by the medical officers there that a lot of children were admitted with diarrhcea from the nursery block. T h e milk of the bottle-fed children comes from a farm controlled by the Guardians. After eighteen months' dilly:dallying with first one authority and then another, at last the babies were really removed into the new block. The change to new quarters did not, however, stop the diarrhcea, and many cases were sent to the Union hospital during the summer of 19o8. Soon after a new master and matron were appointed, and I took the first opportunity of going to the matron and explaining to her that I should like to see the mothers of the suckling children doing more for them than merely feeding them, and suggested that each one might bath her own b a b y before she went to her other work. T h e matron fell in with the idea, and the result is that now each mother baths her own baby in the morning, and each one has a numbered peg with her own towel and little bag containing sponge and soap, and by this means the baby is ensured one good bath a day ; and as the mothers always work under supervision, they leave the workhouse having learnt something by their stay there. I
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ought to say here that I succeeded in persuading the Guardians to appoint another attendant, whose work is chiefly night work and superintending the morning baths. Also each mother, when she comes to feed her baby, takes it up from the cot and changes its napkin, and leaves it comfortable in its cot again when she goes back to tier work. I then turned my attention to the care of the napkins. When I asked what wasdone with them I was told that they went to thelaundry every day, but I wanted to find out what was done with them immediately after they were taken off. I found out that they were supposed to be taken into the basement and put into a tub of water there. The actual facts were that they were thrown down the stairs into the basement. If they managed to fall into the tub well and good, otherwise they lay on the floor or the steps until they were gathered up to go to the laundry. As the hot cylinders of the block were also in the basement, it was a nice incubator for any diarrhoea bacilli. On investigating the tub I found that there was neither sink nor tap in the basement, so you can imagine how often the water was really changed. I found two outside waterclosets in the large airing c o u r t ; the tubs were taken out there and filled with a weak solution of disinfectant, the soiled napkins were put in, and as it only meant tipping the tub to empty it into the proper drains, there was reasonable hope of the water being emptied daily. As the smnmer drew on I was struck by the fact that the little babies hardly ever got outside, and then on making another tour of investigation I found a lot of old disused swing cots in the basement, and I had these brought up and put into the big shed in the airing court. It was then only necessary for the bedding to be carried out every day; and the children were eventually taken out first thing in the morning, and lived out in the court all day long. The mothers had chairs out there and fed them, and the elder children had all their meals served out in the open air. I made a point of visiting the nursery whenever I was able at odd times, took every opportunity of impressing cleanliness as regards the changing of the napkins, and I also taught them how to put on napkins properly--a thing which even nine out of ten trained nurses don't do correctly--and by this means saved many a petticoat or blanket from being soiled. The milk supply of the bottle-fed babies was exactly the same as in previous years. I am happy to say that this year the medical officer of the workhouse had not had to send a single case up to the Union hospital for diarrhoea. DR. A. E. NAISH, in reply to Mr. Wilkinson, said that at present he supposed the relation between ground temperature and diarrhceal incidence could not be entirely explained. It might be, however, that the colon bacillus evacuated from the intestine was, if kept at a high tempera-
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ture for a sufficient length of time, capable of producing "strains" which were pathogenic. This would explain w h y a rise of temperature for a short time was less efficacious in the production of the disease than one more prolonged. With regard to the spread of infection by flies, it was not even necessary that they should infect the milk, since, as Professor Beattie had pointed out, it was quite sufficient they should infect tile hands Or the mouth, or even articles which came into daily contact with the hands of the mother or child. Infection might "well be carried between the different members of one family without the intermediate agency of flies; it was well to remember how many people a " typhoid carrier " might infect, and the passage from rectum to mouth was much easier in a child than in an adult. He quite agreed with Dr. \ V a d d y that the cleansing of the bottle immediately after each feed was seldom carried out, and that two bottles were more dangerous than one. He welcomed the criticisms by Professor Beattie and Dr. Barnes as to the lack of absolute distinction of Morgan's and other bacilli. Their close relationship to others of the colon group seemed to go hand in hand with clinical observations on the types met with. He thanked Mr. Cuff for his graphic description of the conditions prevailing in many of the homes. A RETURN CASE OF ENTERIC FEVER.--On May 6th, I9o8 , a male patient was dismissed from Belvedere Hospital, recovered from enteric fever, for which he had been under treatment from March i3th. His household consisted of his wife and two children, and on June I3th the former sickened of enteric fever. The circumstance l e d to a bacteriological examination of the first patient's condition, with the result that the organism of the disease has been recovered from his urine. The possibility of infection by this means has for some years been recognized, but it rarely happens that a concrete illustration is obtained. This patient has been kept under observation, and at the present time (July, 19o9) the organism is still recoverable from his urine. A vaccine is being prepared therefrom, with the object of ascertaining whether its administration may )cad to an amelioration of the symptoms indicated. It may be observed as Of some interest that no case has uccurred among the patient's fellow employees, nor (save in the instance of his wife) among the other inmates of the tenement in which he lives. W h e n first recognized there was a definite degree of pyuria also present, but now there are only a few leucocytes in the
urine.--Annuat Report of Dr. Offcer of Health, Glasgow.
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SUMMER DIARRH(EA.* By A. E. NAISH, M.A., M.D., Assistant Physician to the Sheffield Royal Hospital. I bring before you to-night T H Eneedssubject no apology on account of its importance or general interest. I do not, however, attempt its introduction in the hope of being able to say anything new or startling, but rather with the object of stimulating interest in the causation and the means of prevention of this terrible disease. Last year, in spite of the comparative coolness of the summer and consequent low death-rate, acute diarrhoea was responsible for more than ten times as many deaths as scarlet fever or diphtheria, and for nearly fifteen times as many as typhoid; and the after history of those that recover is, perhaps, the gravest feature of all--for months often the weight remains nearly stationary, and if the child does not fall a victim to some intercurrent disease, it tends to suffer permanently from malnutrition. With a disease of such gravity it would be remarkable that so little is known about its mode of origin and spread were it not that the subject is one of considerable complexity, and that probably under the one name we have grouped a number of different, even if closely allied, diseases. Among the theories that have been advanced as to the causation of this disease, one may be justified, I think, in putting aside all but the three most important. The first is that it is due to the action of heat on the cerebral heat centres--in other words, that the cases are examples of heat stroke strictly comparable to the heat stroke of adults, in which diarrhoea and vomiting are not infrequently met with. A number of authorities, especially in America and Germany, have expressed themselves in favour of this theory, but although certain cases may be, and probably are, due to this cause, I think it can hardly be contended that the bulk of summer diarrhoea can be attributed to it. In the first place, if heat were the main cause we should expect that sudden rises of temperature would be followed by the greatest number of cases--in other words, that the curve of incidence would correspond closely to the curve of the maximum temperature--whereas *A paper read before the Sheffield Medico-Chirurgical Society, October ~8th, I9o9. This paper and the following discussion have been kindly communicated by Dr. Harold Seurfield, Medical Officer of Health, Sheffield.
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in reality a rise in the average mean temperature, or the temperature of the ground at three or four feet, corresponds more closely to the incidence of the disease. Further than this, it is found that the maximum incidence generally falls some weeks after the maximum ground temperature. It might be said that this is due to the interval between onset and death, but in Woolwich, where notification is carried out, the same phenomenon is noticed. On the average of four years the highest ground temperature was in the fifth week of the summer quarter (July, August and September), whereas the largest number of cases was in the eighth week. Other arguments against the heat theory are of the nature of positive evidence of the infectivity of the disease, which I shall touch on later. It is well to remember, however, that heat often causes loss of appetite and nausea even in adults, and, acting on an infant whose digestion has been deranged for some time and who has perhaps been suffering from chronic looseness of the bowels, may well be the determining factor in the production of an acute and even fatal diarrhoea. The next theory is that the products of the decomposition of milk (or other food) act as poisons--in short, that the disease is comparable to the ptomaine poisoning of adults. This theory has unfortunately been confused with the theory of the transference of pathogenic organisms by milk, and in certain text books and writings it is not clear whether the authors distinguish between them. With regard to the decomposition theory, however, neither the bacillus nor the toxin have been demonstrated, and it is a notable fact that no connection has been traced between diarrhoea incidence and the supply of milk from particular farms. I shall, however, discuss the question of milk in connection with the third theory, which I n o w bring forward. This is that the disease is due to the invasion of the body by bacteria. Assuming this to be so, we have further to enquire whether the organism is one of those normally present in the intestine, which under normal circumstances has taken on pathogenic functions, or whether it has been introduced from some foreign source, and in what way it is conveyed to the child'~ intestine. The gaps in our knowledge are so great that I may perhaps be forgiven if I do not discuss the matter in its logical sequence. In America a considerable proportion of the
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cases of diarrhoea occurring in summer has been proved by Flexner and others to be due to infection by bacilli of the dysentery group; these cases always have blood and mucus in the stools. The type which is commonest in England is not clinically the same, and the pars-dysentery bacillus cannot be isolated. Morgan and others of the Lister Institute have for the last four years found one bacillus of the non-lactose group to predominate over all others in cases from London hospitals. They have isolated it from f~eces and postmortem material in over 5° Per cent. of cases, and have found it nearly always absent in healthy children, or in those suffering from other diseases, even if complicated by diarrhoea. Williams and Murray in Liverpool have also isolated a bacillus closely allied to para-typhoid B. Certain epidemics have been shown by Escherich to be associated with the presence of a modified colon bacillus, and others with a streptococcus. All these bacteria have been isolated from post-mortem material as well as from the f~eces, and have frequently given agglutinative reactions. So far, then, as this evidence goes, it seems to point to the invasion of the body by bacteria, especially by those of the colon group, being frequently the cause of summer diarrhcea. I have myself noticed in many cases a distinct period of malaise often accompanied by an urticarial rash before the onset of acute diarrhoea. The close relationship of many of the bacteria found to one another and to the colon bacillus makes us wonder whether the latter and its family in the character of Jekyll and Hyde are not responsible for most of the mischief. With regard to the mode of transmission it has been widely held both among medical and lay men that milk is the main, if not the only, source of infection. It is natural, I suppose, to attribute all diseases that manifest prominent intestinal symptoms to the action of food or drink, and in this instance the theory receives strong support from the well-known relative immunity of infants fed at the breast. However, if we look a little further into the matter, we find certain facts which must make us pause before we ascribe to milk such a position of importance as a transmitter of this disease. Following upon the discovery of the comparative immunity of breast-fed infants, there was a rush towards the sterilization of cows' milk for bottle-fed babies, especially in certain Conti-
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nental countries and America. Many towns set up machinery for sterilization on a large scale, and supplied the milk in sealed bottles. We have now the opinion expressed by many authorities who have been in a position to judge of the results, that sterilization of milk has had little effect on the general or diarrhoea mortality of infants (after making due allowance for the variation in mortality according td temperature). This has been attributed by some to contamination taking place in the houses, but often the milk has been supplied in such a way as to render such contamination very difficult : for instance, in narrow-necked bottles, which may be left uncorked for two or three days in an incubator without decomposition occurring. Occasionally we have even more evidence : for instance, in the town of Halle the illegitimate infants were put on sterilized milk from the year I9O4 without any reduction of the mortality amongst them, which still remained high in proportion to the general town rate, and was chiefly from gastro-intestinal disease. Where sterilization of milk has been undertaken hand in hand with its modification to suit the rieeds of the different ages, or with dep6ts for the instruction of mothers, excellent results have been reported; but these can hardly be attributed to the sterilization. Our own experience at the dep6ts in Sheffield is confirmatory of the above. If milk were the chief carrier of infection the use of a sterilized dessicated powder kept in tins, and mixed freshly with water for each feed, should act largely as a prophylactic. W e have no means of comparing the attack-rate of these babies with the general attack-rate of bottle-fed babies, but I think there is not much difference in favour of the former. There are other general considerations which tend to point in the same direction. The W e s t Riding enquiry into the bacteriology of milk showed that the greatest number of bacteria were added a t the farm. Now, as the milk supply of rich and poor does not differ largely, and a greater proportion of children of the rich are hand fed, we should expect, if the milk bacteria were the main cause of diarrhoea, to have a larger proportion of cases among them than among the poor, whereas it has been proved that the higher i n t h e social scale one goes the less acute diarrhoea is found. Further, the workers at the Lister Institute found that, out of twenty-nine samples of milk taken from houses affected, only one contained
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Morgan's bacillus, whereas out of eight batches of flies six contained it. How, then, can we explain the immunity of breast-fed infants ? In the first place, there has been a tendency to exaggerate this immunity ; more breast-fed infants are attacked than would be gathered from the death-rate figures; in other words, the disease tends to be milder. In the next place, it is a well-recognized fact that the catarrhal condition resulting from repeated " insults to the intestinal m u c o s a " acts as a powerful predisposing cause of true infective diarrhoea, and these insults are far less frequent in breast-fed infants. In the third place, freshly drawn milk has been shown to have an inhibitory effect on the growth of many bacteria, and it is quite possible that maternal milk may in this w a y act as a mild antiseptic. In this connection it may be mentioned that under normal conditions the flora of the breast-fed baby's intestine differ markedly from those of the hand-fed baby's. Is the disease communicable from person to person ? I think there can be little doubt on this point. Firstly, the disease used to be very prevalent in institutions where children were aggregated closely. Finkelstein observed in the infants' ward that the epidemics were preceded by one child being taken ill first, the others following after an interval. After antiseptic precautions had been instituted there was a fall in mortality from about 8o per cent. to 22 per cent. Secondly, investigations made in towns seem to establish the fact that overcrowding has a closer relation to the prevalence of the disease than any other factor. Thirdly, similar investigations show a marked grouping of the cases in certain streets and areas, and a tendency for the disease to spread from the backs of houses to the backs of those in an adjoining street. Fourthly, a spread throughout a family is very common, if not the rule. Dr. Davies, the medical officer of health of Woolwich, says :-" I t was common to find the baby notified was not the first case in the family, and frequently it was found that most members of the family had been affected one after another within a few days' interval. Probably the usual incubation period is from two to seven days, as the interval between the commencement of successive cases varied between these limits." I have not attempted to exhaust all the evidence that has accumulated with regard to the transmission of this disease~ for time has
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allowed me to touch here and there only a few fragments of its etiology. I should like, how: ever, to bring forward one or two provisional suggestions as to its prevention. In the first place, probab]~y too much attention has been directed to the milk supply, and not enough to housing conditions. The following rather striking account was given me by a lady who was an Army nurse at Aldershot for five years, and afterwards at Bulford. In the Old Lines (at Aldershot), where the houses were small, dark and low lying, diarrhoea was v e r y prevalent among the children; but in the New Lines, which stood higher, with houses larger and lighter, it was much less so. The milk supply was the same. At Bulford, where the houses were in long straight lines, with free through ventilation, diarrhoea was almost unknown. The betterment of housing conditions is, however, a big thing, and one which will probably take many years to make much head-" way in, but there is one thing which I think may be done without much delay. The mortality in infants' institutions has been much reduced by the introduction of antiseptic precautions. Last summer I suggested to Dr. Scurfield that it might be possible to educate mothers, even in poor houses, to a recognition of the infectivity of diarrhoea. Dr. Scurfield took up the proposal with enthusiasm, and representative poor streets were chosen by each of the women sanitary inspectors. The object was to teach the mothers by written and verbal instructions that the stools and possibly the urine of infected cases were a source of danger to others, and to help them towards the routine disinfection of the same and the cleansing of the infants' bodies, whether in infected or non-infected cases, during the hot months. I had hoped to have some figures to give comparing the diarrhoea mortality in these districts with the gefieral diarrhoea mortality, but the numbers are too small to draw any conclusion from. Among 417 infants under one year, seven died from diarrhoea, but of these one was brought from another district while suffering from the disease ; in another case measles had ushered in a prolonged diarrhoea of ten weeks, which was not improbably tubercular; and in a third the diarrhoea was only the terminal e v e n t - lasting two days--in an illness of three weeks' duration. I think the effect of the instructions has been of value. There has been striking
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evidence t h a t m o s t of the m o t h e r s h a v e tried to c a r r y out the instructions, and in doing so h a v e c o m e to realize m o r e fully t h e seriousness as well as the infectivity of the disease, and t h a t as one consequence t h e y h a v e t a k e n their children for t r e a t m e n t at an earlier stage. In conclusion, I should like again to d r a w a t t e n t i o n to t h e n u m b e r of t y p e s t h e r e are of this disease, d e p e n d e n t p r o b a b l y on different bacteria, a n d t h a t our only guide to future rational t r e a t m e n t will be t h r o u g h differentiation of these types. T h i s can only be d o n e b y a c c u r a t e observations, a n d recording of their o b s e r v a t i o n s b y a large n u m b e r of medical men. DISCUSSION. DR. GEORGE \VILKINSON, Honorary Surgeon to the Sheffield Royal Hospital, asked if Dr. Naish could explain the connection between rise of ground temperature and incidence of epidemic diarrhoea. W i t h regard to spread of infection by flies, did he understand Dr. Naish that flies carried the infectious organisms from the f~ecal discharges to food, s u c h as milk, from which source other inmates of the house became infected ? DR. V~[ADDY,District Medical Officer, Sheffield Union, rose to offer one or two practical suggestions. One difficulty which he encountered in his houseto-house work was the practice of keeping milk warm on the hob. After milk had been sterilized by boiling, it was liable to subsequent infection. By keeping the milk warm any micro-organisms present were incubated, and the degree of infection of the milk was enormously increased. Milk which had been boiled should be set to cool quickly. Only sufficient for one feed should be made warm at a time. T h e chief difficulty was with regard to feeding bottles. It seemed impossible to make people understand the difference between keeping a bottle always clean and keeping it always dirty. Mothers assert that they clean the bottle before filling it. If "this were so, then one would expect, in a definite proportion of visits, to find a bottle in the condition of being cleaned ready for use. But such a discovery is of the utmost rarity. E v e n in those cases in which this course is adopted it is quite inadequate. It is perfectly easy to keep a bottle clean by rinsing it out with cold water immediately after it has been used. It is very difficult to clean a bottle which has once become dirty; indeed, the bottle which is kept dirty never is clean. In this respect the provision of two bottles only increases the danger. The cleaning of the dirty bottle is all the more easily neglected and postponed. There are two dirty bottles to contend with instead of one. It is quite usual for milk to be put into a bottle and left in the child's cradle all night, and perhaps even all
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the next day, if two bottles are in use. T h e instructions issued by the medical officer of health are superior to those which have been published previously; but on this point there is room for further amendment. Instead of taking for granted that bottles are dirty, and telling people how to clean them by boiling them in soda, they ought to insist on the importance of never allowing the bottle to become dirty. The only way to keep a bottle clean is to keep it clean. Da. A. E. BARNES thanked Dr. Naish for his interesting paper, and thought that all the members must agree with his conclusions. H e agreed with Dr. Naish that it was necessary to set to work to differentiate the various types of disease, or perhaps different diseases. H e had seen two cases where apparently adults had been infected from children. As regards the statement that the child was often not the first in the family to be infected, he had seen an interesting case where the child during the summer epidemic suddenly began with acute colitis. The diagnosis of colitis was made in the laboratory, and on communication with the family doctor it turned out that the father had been affected with colitis for some years. Too much reliance should not be placed on the work in regard to Morgan's bacillus, as the original paper of Ledingham and Morgan was severely criticised by Dr. Thwort on grounds that appeared to be very sound--namely, that the differentiation of the bacillus depended on fermentation reactions, and it had been shown that by appropriate cultivation any bacillus of the group could be made to give any particular fermentation reaction, and that the agglutination reaction which was obtained by Morgan might be due to some other cause, as some of the sera agglutinated other bacilli in high dilution. It should also be remembered that only the non-fermenters of lactose were investigated. Dr. Barnes also wished to refer to some Breslau statistics which went to show that the incidence in cellar dwellers was less in proportion than those dwelling in upper rooms. JAMES MARTIN BEATTIE, M.D., Professor of Pathology and Bacteriology at Sheffield University, said: I quite agree with Dr. Naish that too much stress has been laid on the carriage of infection by milk alone. The disease is an infective one, and a look at the home in which the disease occurs shows how easily the causal organisms can be carried by flies to all kinds of food, to the hands of the child, and even to its mouth. Recent work has brought out very strongly the important part played by flies in the carriage of disease-producing organisms. In regard to the causal organism, I do not think there is sufficient evidence to justify any very definite conclusions. There is a good deal to be said in favour of Morgan' s bacillus, and the work he and Ledingham have done is extremely valuable ; but my own observations lead me to regard with suspicion the classification of bacteria into separate
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groups simply because one ferments a special sugar and another does not. Certainly with streptococci the same organism at different times and in different stages of virulence gives different reactions with the various sugars, and I see no reason to doubt that other organisms act in the same way : it m a y yet be proved that Morgan's bacillus is merely a modified colon, typhoid or dysentery bacillus. Dr. Naish has referred to the conclusions given in the Report on the Contamination of Milk of the West Riding County Council--that the main contamination is at the cowshed, and that the contamination in the houses of the consumers is not great. I feel that in this Report the evidence is not strong enough to justify the conclusions. Too little attention has, in my opinion, been given to the milk at the consumers' houses. Many more samples will require to be examined, and the examination will require to be much more thorough and exhaustive. MR. ARCHIBALD CUFf', F.R.C.S., Honorary Surgeon, Sheffield Royal Infirmary, after thanking Dr. Naish for his very interesting paper, said that he quite agreed with the writer that it was most important to teach the mothers the immense importance of cleanliness in attending to their children, and also impressing them with the fact that diarrhoea was infectious, and that by carelessness they could infect other children, or perhaps keep up the disease in the patient. Professor Beattie had in his remarks emphasized this, and had probably mentioned a very important factor when he said that the condition of the milk when in the house was probably of more importance in the spread of the disease than the condition of the milk before delivery. Mr. Cuff said t h a t anyone who had been on the staff of a children's hospital must have been struck with the uncleanliness of the mothers in dealing with the evacuations of the little c h i l d r e n - - a carelessness due in part to ignorance, and in part to poverty. Not only were the mother's clothes often accidentally soiled by the child, but the apron and even the mother's skirt is used to complete the cleansing of the child, and her soiled hands used immediately afterwards to put the dummy teat into the child's mouth. It was probably the same at home, and with the lack of linen and towels in the cottages of the poor it seemed more than probable that infection was carried by the mother-from one child to another, food and milk were infected-nay, it was even possible that the organisms, transferred to nutrient media, such as milk, food, etc., from a normal child's stool, might under suitable conditions of warmth, etc., become so virulent as to start an enteritis in another child. It would be a n ' i n t e r e s t i n g thing to examine bacteriologically some of the milk, food, and articles coming into contact with the small children in some of the houses in the diarrhcea
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districts during an epidemic. Mr. Cuff was certain that the convincing of the parents of the highly infectious nature of the disease was one of the most important factors in the prevention of this scourge. MRS/ L u c y NAIsH, M.B., said: In this discussion on summer diarrhaea you m a y be interested to hear of the value of antiseptic treatment of the baby's buttocks and diapers, coupled with the value of fresh air, as evidenced by the babies at the nursery block at the Sheffield Union Workhouse. W h e n I first became a Guardian about three years ago I was distressed to find about thirty children, whose ages varied from one month to three years, in one quite small day nursery, which seemed to me quite inadequate as regards fresh air. Also there was only one paid attendant, and she was assisted by any female inmates other than the mothers of the babies. Some of the inmates were quite old women, or often umnarried girls awaiting their confinements. The mothers of the suckling babies slept with them and came across from the laundries or other places where they were employed in the day time at regular intervals to feed them, but they were not allowed in any way to attend to the baby by bathing or even changing its napkin. In fact, they were just a herd of human cows. W h e n I first called attention to the s m a l l size of. the nursery I was told that a new block was being built, and all my schemes for improvement were deferred until the babies got into the new block: Meanwhile diarrhrJea was very prevalent among these children, and they had to be sent up to the Union hospital for treatment, and I was frequently told by the medical officers there that a lot of children were admitted with diarrhcea from the nursery block. T h e milk of the bottle-fed children comes from a farm controlled by the Guardians. After eighteen months' dilly:dallying with first one authority and then another, at last the babies were really removed into the new block. The change to new quarters did not, however, stop the diarrhcea, and many cases were sent to the Union hospital during the summer of 19o8. Soon after a new master and matron were appointed, and I took the first opportunity of going to the matron and explaining to her that I should like to see the mothers of the suckling children doing more for them than merely feeding them, and suggested that each one might bath her own b a b y before she went to her other work. T h e matron fell in with the idea, and the result is that now each mother baths her own baby in the morning, and each one has a numbered peg with her own towel and little bag containing sponge and soap, and by this means the baby is ensured one good bath a day ; and as the mothers always work under supervision, they leave the workhouse having learnt something by their stay there. I
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ought to say here that I succeeded in persuading the Guardians to appoint another attendant, whose work is chiefly night work and superintending the morning baths. Also each mother, when she comes to feed her baby, takes it up from the cot and changes its napkin, and leaves it comfortable in its cot again when she goes back to tier work. I then turned my attention to the care of the napkins. When I asked what wasdone with them I was told that they went to thelaundry every day, but I wanted to find out what was done with them immediately after they were taken off. I found out that they were supposed to be taken into the basement and put into a tub of water there. The actual facts were that they were thrown down the stairs into the basement. If they managed to fall into the tub well and good, otherwise they lay on the floor or the steps until they were gathered up to go to the laundry. As the hot cylinders of the block were also in the basement, it was a nice incubator for any diarrhoea bacilli. On investigating the tub I found that there was neither sink nor tap in the basement, so you can imagine how often the water was really changed. I found two outside waterclosets in the large airing c o u r t ; the tubs were taken out there and filled with a weak solution of disinfectant, the soiled napkins were put in, and as it only meant tipping the tub to empty it into the proper drains, there was reasonable hope of the water being emptied daily. As the smnmer drew on I was struck by the fact that the little babies hardly ever got outside, and then on making another tour of investigation I found a lot of old disused swing cots in the basement, and I had these brought up and put into the big shed in the airing court. It was then only necessary for the bedding to be carried out every day; and the children were eventually taken out first thing in the morning, and lived out in the court all day long. The mothers had chairs out there and fed them, and the elder children had all their meals served out in the open air. I made a point of visiting the nursery whenever I was able at odd times, took every opportunity of impressing cleanliness as regards the changing of the napkins, and I also taught them how to put on napkins properly--a thing which even nine out of ten trained nurses don't do correctly--and by this means saved many a petticoat or blanket from being soiled. The milk supply of the bottle-fed babies was exactly the same as in previous years. I am happy to say that this year the medical officer of the workhouse had not had to send a single case up to the Union hospital for diarrhoea. DR. A. E. NAISH, in reply to Mr. Wilkinson, said that at present he supposed the relation between ground temperature and diarrhceal incidence could not be entirely explained. It might be, however, that the colon bacillus evacuated from the intestine was, if kept at a high tempera-
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ture for a sufficient length of time, capable of producing "strains" which were pathogenic. This would explain w h y a rise of temperature for a short time was less efficacious in the production of the disease than one more prolonged. With regard to the spread of infection by flies, it was not even necessary that they should infect the milk, since, as Professor Beattie had pointed out, it was quite sufficient they should infect tile hands Or the mouth, or even articles which came into daily contact with the hands of the mother or child. Infection might "well be carried between the different members of one family without the intermediate agency of flies; it was well to remember how many people a " typhoid carrier " might infect, and the passage from rectum to mouth was much easier in a child than in an adult. He quite agreed with Dr. \ V a d d y that the cleansing of the bottle immediately after each feed was seldom carried out, and that two bottles were more dangerous than one. He welcomed the criticisms by Professor Beattie and Dr. Barnes as to the lack of absolute distinction of Morgan's and other bacilli. Their close relationship to others of the colon group seemed to go hand in hand with clinical observations on the types met with. He thanked Mr. Cuff for his graphic description of the conditions prevailing in many of the homes. A RETURN CASE OF ENTERIC FEVER.--On May 6th, I9o8 , a male patient was dismissed from Belvedere Hospital, recovered from enteric fever, for which he had been under treatment from March i3th. His household consisted of his wife and two children, and on June I3th the former sickened of enteric fever. The circumstance l e d to a bacteriological examination of the first patient's condition, with the result that the organism of the disease has been recovered from his urine. The possibility of infection by this means has for some years been recognized, but it rarely happens that a concrete illustration is obtained. This patient has been kept under observation, and at the present time (July, 19o9) the organism is still recoverable from his urine. A vaccine is being prepared therefrom, with the object of ascertaining whether its administration may )cad to an amelioration of the symptoms indicated. It may be observed as Of some interest that no case has uccurred among the patient's fellow employees, nor (save in the instance of his wife) among the other inmates of the tenement in which he lives. W h e n first recognized there was a definite degree of pyuria also present, but now there are only a few leucocytes in the
urine.--Annuat Report of Dr. Offcer of Health, Glasgow.
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