- Email: [email protected]
The Milroy Lectures ON CHANGES OF TYPE IN EPIDENIC DISEASES.
MARCH 4, 1893. Nottingham notification began in 1882 after a severe epidemic which reached its height in 1881. The record is not long enough to show how the case mortality curve would run at the outset of a fresh epidemic, but it does show that ON with the decline of mortality there has been a decline in the CHANGES OF TYPE IN EPIDENIC DISEASES. average severity of attack. From 1858 to 1882 epidemics At
The Milroy Lectures
Delivered at the Examination Hall, Victoria Embank-
ment,
BY B. A.
on
Feb. 23rd, 1893,
WHITELEGGE, M.D.,
B.Sc. LOND.
occurred at the usual interval of five or six years, but since 1882 there has been no year of high mortality and the epidemic rhythm has abruptly ceased. These changes have been accompanied by a uniformly mild and non-fatal type of disease, although the prevalence has in some years been considerable. The Christiania records of cases and deaths are given by Johannessen for the years 1863 to 1878 :-
LECTURE II. Stable of Type.-Evideilce of G"rccclrml Chtt)le.Scarlet -Zt;. —M-o.c. —J/M.’<".s. Table rf Cages and Death from, scarlet ]t’fJ’I’(’r it Christiania fr o0 1863 to 18’,8. * MR. PRESIDENT AND GENTLEMEN, -It has long been cecognised that scarlet fever changes greatly in character, and that while some epidemics are mild others are severe. In Sydenham’s time it was persistently mild. 1n Dublin, from 1804 to 1834, the epidemics of scarlet fever were of a non-fatal type, but after as well as before this period they .assumed a malignant form. In New York the scarlet fever death-rate, after being low for thirty years, suddenly in,creased tenfold in 1828-29, and remained high for sixteen years. Very many instances of this kind are on record, but nevertheless they are exceptional, and as a rule the changes in type, which are neither rare nor unimportant, are of slower and more orderly character. The scarlet fever deathjate in London for the last fifty years presents many points of interest. At intervals of about five or six years wave after
Diseases
more
wave of high mortality is seen alternating with depressions corresponding to years of low mortality. The rise and fall - are gradual, a maximum in one year being rarely followed by
Johannessen : Die Epidemische
Verbreitung des Scharlachfiebers in
Norwegen.
This at once suggests that the The mortality curve ran high in 1867 and 1875-76, with minor P, minimum in the next. ’variable factor, whether prevalence or severity, is not capricious elevations in 1863 and 1870. The attack curve is irregular. :in action, but rises by degrees to a maximum, and then falls There was great prevalence in 1867 and 1865-66, as would be by similar degrees to a minimum, usually to rise again inferred from the death curve, but there was also an excess of But there is a further point. There are indica- attacks in 1870, which produced comparatively little effect on as before. tions of a tide in the series of waves : the highest mark was the death-rate. The case mortality curve is much more orderly reached in the " sixties," and since that time the successive and shows a maximum severity in 1867-68 and 1865-66-67. -crests have been lower and lower. During the last ten years Between these periods it fell and the intercurrent prevalence ’the mortality has been persistently low, and the orderly of 1870 was attended with a lower case mortality than It was therefore -sequence of epidemics is scarcely traceable. Presently we the years preceding or following it. shall see that the average case mortality rose and fell with a wave of prevalence merely, due perhaps to excepthe recorded death-rate, so that the type was most severe tional meteorological conditions ; not due, at all events, when the recorded mortality was highest. A study of the to any increased potency of the disease or intensificarecords of other parts of the kingdom shows that whilst tion of type. Under such conditions the case mortality &’
No. 3627.
I
DR. B. A. WHITELEGGE ON EPIDEMIC DISEASES.
458
is of most virulent and most highly infectious type ; but, as other things are not always equal, epidemic extension occurs at other times too. Similar evidence upon a smaller scale is to be found in the hospital record of Hull, Birmingham and other towns. It may be suspected that the epidemic rhythm is still maintained, though too faintly to be detected by such crude tests as case mortality or death-rates, and that it will reassert itself if and when the type of disease again becomes more severe. On the other hand it seems clear that there is nothing essential or permanent in the length of the five or six years cycle, since it is often shortened or lengthened, and there are no grounds for fixing limits in either direction. It is possible too that the persistent removal to hospital of the most virulent cases has had something to do with the present low average of case mortality, not merely by increasing the chances of recovery, but also by leaving only the milder attacks to propagate their kind by diffusing infection. But here, again, it must be remembered that the attenuation began before isolation assumed large proportions and has not been altogether limited to the towns in which isolation has been practised. In former years, too, long intervals of low intensity have been recorded, but have not proved permanent. Table
of
Scarlet Feve?’ Death-rate in London. Case mortality.
tion had to
extent been reinforced during the years of freedom from scarlet fever. After reaching its. acme, the death-curve descends again for a year or two to a new minimum. It descends because there is a less susceptible population, less infectiveness and less fatal type. The attacks, while lessening in number, lessen in severity also;. and as they are both fewer and milder the death-rate falls in compound ratio. Vaccination has profoundly affected the epidemic course of small-pox, but changes of type are evident. In the latter part of the last century small-pox contributed on an average about one-tenth of the whole death-rate of London, and in 1796 no less than 18 ’3 per cent. After this, and coincidently with the introduction of vaccination, its ravages lessened until 1830. From 1830 to 1838 the records are missing, butin 1838 the mortality was again comparatively high, though below even the average which prevailed half a century before. After 1838 we can measure its course by actual death-rates, and a considerable degree of order and even rhythm becomes apparent. Every few years-usually four or five, but sometimes two or three only-it recurred as an epidemic, but with somewhat reduced destructiveness each time until 1855, which happened to be halfway between 1838 and 1871. After 1855 minor epidemics continued to, recur at about the same interval, but the loss of life on each occasion increased rather than otherwise. Then came the great epidemic or pandemic of 1871, killing a larger proportion of the population than in 1838. The course of events for twenty years after 1871 was not unlike that which followed the 1838 epiclemic-successive outbreaks at intervals of four or five years, decreasingin. mortality, and subsiding after 1885 to a much lower level than was ever before reached. Amongst unprotected persons the case mortality even now runs high, but the small-pox of to-day is evidently different from that of 1871-different in virulence of attack and still more so in infectiveness and power of epidemic diffusion. The last-named tendency especially seems to have been at a low ebb in 1888-90, as in the fifties," and wemay not unreasonably anticipate in the "nineties" the same sort of’ gradual intensification as occurred in the " sixties." In considering the English epidemic of 1871 as part of the. great pandemic which about that time overran Europe, we must not lose sight of the fact that for several years previously there had been indications of increasing intensity in London-i. e., a tendency to slightly greater destructiveness in each successive minor epidemic. The same may be said of Prussia and Austria.1 In Russia small-pox was epidemic io. 1841-42-43, 1853-54 and 1864-65-66-67, recurring at intervals of about eleven years and with steadily increasing intensity. Then after an interval of only five years came the pandemic. of 1871-72, which (as in England) was much more destructive: than the other terms of the series would have led us to anticipate ; but, apart from the pandemic, a formidable outbreak would have been due in 1876. Whether the minor epidemics which occurred in London at intervals of four or five years were attended with any temporary increase ot’ severity, as in scarlet fever, is a point of considerable doubt. Some indication of such a change is afforded by hospital stasome
comparative
tistics, though not very clearly. It has been observed that during NOTE.-The death-rates are taken from the Registrar-General’s Annual Reports ; the Metropolitan Asylums Board Hospitals’ case mortality from the Statistical Reports of the Metropolitan Asylums Board; and the London Fever Hospital data were kindly furnished by Dr.
Hopwood. In manufacturing and mining districts it intensity has prevailed, often for a long
seems
that
high
term of years,
the rise of a minor epidemic malignant and hssmorrhagic cases are more often met with than they are later on, and at the decline of these outbreaks infectiousness appears sometimes to be almost lost, even though virulence shows but little. change. In May, 1884 (as in January, 1881) acute cases of£ small-pox were aggregated at the Fulham Hospital. Mr. Power found that this was followed by excessive incidence of small-pox upon the surrounding population, that the infection. was in all probability air-borne, and that the meteorologicaf records were of a character which seemed favourable for the aerial diffusion of particulate contagia ; but in June and July, 1884, with greater accumulation of acute cases in hospital and apparently similar weather indications, there was little if any evidence of diffusion. Hence Mr. Power infer& that the quality or infectiveness of small-pox itself may havechanged in the interval. Another possibility would seem try be that the atmospheric states suited for such diffusion may include as an essential element some detail (perhaps purely local) not indicable in the rough data of ordinary meteorological readings, which are in truth only daily averages or
some indication of the usual rhythm. districts the centres of population are near together, the intercommunication is free and the birthrate is high. These circumstances may be regarded as conducive to sustained prevalence of scarlet fever. It seems, then, that when the scarlet fever mortality curve rises at more or less regular intervals it does so for two reasons-because the attacks are more numerous and because they are more fatal in type. They are more numerous because there is increasing power of overcoming resistance, whereby those who were safe during the interval become more and more liable to attack ; because the severer cases are more capable of diffusing infection ; because the wider 1 Report of the German Vaccination Commission, 1884 ; a summary diffusion thus brought about lessens the chance of susceptible is given by Dr. E. J. Edwardes, Epidemiological Society’s Transactions, persons escaping; and, lastly, because the susceptible popula- 1885-86.
although In
such
not without
MR. H. SMITH ON HEMORRHOIDS AND PROLAPSUS OF THE RECTUM.
459
daily samples of conditions incessantly changing. Some limitation of the power of diffusion of infection must occur normally about June, for the average seasonal curve of mortality begins to decline sharply at that time. Presently it will be seen that this decline is attended with increased case
per cent. Looking to the records of former years, it is seen that from 1875 onwards there were biennial explosions increasing progressively in destructiveness and culminating in the exceptionally malignant outbreak already referred to. Since 1885 epidemics on a declining scale have occurred at similar intervals. It would seem that the quality of measles underwent mortality. There has been some prevalence of small-pox in Yorkshire progressive changes from a minimum intensity in 1875 to a during the past two years, attended in many districts with maximum in 1885, and that the course from 1875 to the precertain anomalies of type-for example, an occasional interval sent time is in a sense one great wave, interrupted repeatedly of only twenty-four hours between a definite onset and the in a mechanical fashion by the temporary exhaustion of conappearance of the rash, and sometimes an equally shortinterval ditions of susceptibility and by other external conditions. In between the first appearance of the rash and its attaining the 1888-89 a severe epidemic prevailed at Hanley and was vesicular stage. For the most part the aberrant types were investigated by Mr. Spear.5 He found that the symptoms slight and non-fatal. But this was not always so, nor were were of aggravated type and the case mortality not far short they limited to vaccinated persons. In one district at least of 9’0 per cent. On reference to the Registrar-General’s the comparatively rare complication of pneumonia was met returns for previous years we find that in the districts most with in a considerable proportion of the attacks. It would be severely affected there had been a succession of outbreaks interesting to know whether irregularity of type has been at not very regular intervals, but steadily increasing in morobserved in other parts of the country recently, and whether tality, until, as already seen, there came an epidemic conanything of the kind was noted at the corresponding period spicuous above the rest for its severity of type as well as high of forty years ago. To sum up : the type of small-pox seems mortality. A third example-in one respect more complete-is to be stable, rising and falling in intensity if traced through afforded by Barnsley. An exceptionally severe epidemic took long periods of years, the intensity being indicated even more place there early in 1891. It had been preceded by other outby power of epidemic diffusion than by severity of attack ; breaks in 1881, 1883, 1886 and 1888 at intervals of about two but apart from these long cycles there is a tendency to shorter years and a half. The measles death-rate increased with cycles of four years or so, which may or may not prove to be each successive epidemic, and Dr. Sadler, medical officer of accompanied by temporary increase of intensity and are pro- health for the borough, observed that, at all events in the bably governed by the accumulation of susceptible persons last three epidemics of the series, the type grew more and and other external conditions. Lastly, there are seasonal more severe, each occurrence exhibiting higher infectiveness changes regulated by the facilities for diffusion and not and wider extension than its predecessors. attended by any change of intensity. The change of quality in these instances seems clear, and Measles presents many points of analogy with small-pox. a similar change may be inferred with more or less probability They are alike in their independence of soil, water infection, from the course of the measles death-curve in London, and milk infection ; in their relation to age and sex ; in the Wolverhampton and many other towns. The case mortality duration of the intervals between infection and attack, and in measles is greatly influenced by surroundings, the severity also between the onset and appearance of the rash ; and in the and fatality being greatest among the poor. The experience primary seat of eruption. As regards the seasonal curve of epidemics amongst soldiers in time of war seems to confirm they have at all events the autumnal minimum in common. ’ this. In Fiji in 1875 the case mortality was enormous, and They are not unlike in the evidence which they afford of almost all the population, young and old, were attacked; comparative constancy of type. Notwithstanding the scanti- but here not only neglect and exposure of the sick but excepness of the records, alternate increase and decrease in tional susceptibility of a population never before invaded by virulence can be traced in many localities, each wave lasting measles have to be taken into account. The resistance was often twenty years or more in this country, although perhaps therefore lessened in two ways. Whether the destructiveless elsewhere. As in small-pox, the rise and fall of the ness of the pestilence was to be attributed entirely to this broad primary curve is interrupted (in a sense mechanically) lowered resistance, or whether there was an increased intensity at short intervals by explosions occurring when the accumu- of the contagium-in other words, a true change of typelation of susceptible persons is sufficient and the climatic remains to be proved. and other external conditions offer sufficiently small resistance. These outbursts of measles are often of brief duration and terminate as soon as the balance among the conditions ON THE TREATMENT OF HÆMORRHOIDS promoting and inhibiting the spread of infection inclines AND PROLAPSUS OF THE RECTUM sufficiently far in the direction of the latter. The interval BY CLAMP AND CAUTERY. is variable, but in English towns is usually about two years. The exact time of outburst is evidently affected by climatic BY HENRY SMITH, F.R.C.S. ENG., conditions, and as the mean seasonal curve shows two maxima CONSULTING SURGEON TO KING’S COLLEGE HOSPITAL. -two points of least resistance six months apart-it is not surprising to find that the interval, when not exactly two years, As some years have elapsed since I brought before the is frequently one and a half or two and a half years. There is, however, no assured constancy in the balance of influences upon profession any further experience of. the treatment of which the interval depends, and it is often reduced to one haemorrhoids and prolapsus of the rectum by means of the In Sweden2 and Norway3 year or extended to three or four. and cautery, and as some important improvements six or seven years usually elapse between successive out- clamp were suggested and have since been carried out on a somebreaks, and in Norway at all events there is evidence of extensive what case each The scale, I think it may be useful to give some of higher epidemic. mortality accompanying brief biennial explosions familiar in this country do not the results of my later practice having reference to the appear to be attended by increased case mortality. Their alterations just mentioned. Before going into details I may type is that of the prevailing phase of a broader wave. The say that these results have been such that my confidence bills of mortality show that about 1800 the average measles in the use of the clamp and cautery has been established mortality in London began to increase, reaching a maximum with greater firmness than ever. The objections which have about 1815. The Registrar-General’s reports from 1838 been urged against the treatment in question, and which in onwards show a distinct rise and fall in London measles its earlier history did exist, have been done away with, and, mortality, with maxima in the early "forties,"inthe "sixties" so far as my own experience has enabled me to judge, there and in the’’ nighties,’’ over and above the biennial rhythm are few surgical procedures attended with more satisfactory already referred to. It is difficult to account for these long results as regards the relief and cure of disease and the waves without assuming some altered quality of measles, and restoration of the patient to health and comfort. When the more detailed records of certain provincial towns leave this mode of treatment was originally prominently brought little room for doubt upon this point. At Sunderland4 in before the profession the objects I had in view were to adopt 1885 a virulent epidemic prevailed, causing in one quarter a a practice which would be attended with more safety to life mortality equal to an annual rate of nine per thousand from and with less of the inconveniences which were liable to happen measles alone. The recorded case mortality was twenty-nine after the usual modes of treatment of haemorrhoids and prolapsus, and which I had often witnessed in my own practice 2 Arthur Ransome, M.D., Epidemiological Society’s Transactions, ’
’
1881-82.
3 Johannessen, loc cit.
4 Annual
Report of Medical Officer of Health for Sunderland, 1885.
5 Annual
Board, 1890.
Report
of the Medical Officer to the Local Government
The Milroy Lectures
Delivered at the Examination Hall, Victoria Embank-
ment,
BY B. A.
on
Feb. 23rd, 1893,
WHITELEGGE, M.D.,
B.Sc. LOND.
occurred at the usual interval of five or six years, but since 1882 there has been no year of high mortality and the epidemic rhythm has abruptly ceased. These changes have been accompanied by a uniformly mild and non-fatal type of disease, although the prevalence has in some years been considerable. The Christiania records of cases and deaths are given by Johannessen for the years 1863 to 1878 :-
LECTURE II. Stable of Type.-Evideilce of G"rccclrml Chtt)le.Scarlet -Zt;. —M-o.c. —J/M.’<".s. Table rf Cages and Death from, scarlet ]t’fJ’I’(’r it Christiania fr o0 1863 to 18’,8. * MR. PRESIDENT AND GENTLEMEN, -It has long been cecognised that scarlet fever changes greatly in character, and that while some epidemics are mild others are severe. In Sydenham’s time it was persistently mild. 1n Dublin, from 1804 to 1834, the epidemics of scarlet fever were of a non-fatal type, but after as well as before this period they .assumed a malignant form. In New York the scarlet fever death-rate, after being low for thirty years, suddenly in,creased tenfold in 1828-29, and remained high for sixteen years. Very many instances of this kind are on record, but nevertheless they are exceptional, and as a rule the changes in type, which are neither rare nor unimportant, are of slower and more orderly character. The scarlet fever deathjate in London for the last fifty years presents many points of interest. At intervals of about five or six years wave after
Diseases
more
wave of high mortality is seen alternating with depressions corresponding to years of low mortality. The rise and fall - are gradual, a maximum in one year being rarely followed by
Johannessen : Die Epidemische
Verbreitung des Scharlachfiebers in
Norwegen.
This at once suggests that the The mortality curve ran high in 1867 and 1875-76, with minor P, minimum in the next. ’variable factor, whether prevalence or severity, is not capricious elevations in 1863 and 1870. The attack curve is irregular. :in action, but rises by degrees to a maximum, and then falls There was great prevalence in 1867 and 1865-66, as would be by similar degrees to a minimum, usually to rise again inferred from the death curve, but there was also an excess of But there is a further point. There are indica- attacks in 1870, which produced comparatively little effect on as before. tions of a tide in the series of waves : the highest mark was the death-rate. The case mortality curve is much more orderly reached in the " sixties," and since that time the successive and shows a maximum severity in 1867-68 and 1865-66-67. -crests have been lower and lower. During the last ten years Between these periods it fell and the intercurrent prevalence ’the mortality has been persistently low, and the orderly of 1870 was attended with a lower case mortality than It was therefore -sequence of epidemics is scarcely traceable. Presently we the years preceding or following it. shall see that the average case mortality rose and fell with a wave of prevalence merely, due perhaps to excepthe recorded death-rate, so that the type was most severe tional meteorological conditions ; not due, at all events, when the recorded mortality was highest. A study of the to any increased potency of the disease or intensificarecords of other parts of the kingdom shows that whilst tion of type. Under such conditions the case mortality &’
No. 3627.
I
DR. B. A. WHITELEGGE ON EPIDEMIC DISEASES.
458
is of most virulent and most highly infectious type ; but, as other things are not always equal, epidemic extension occurs at other times too. Similar evidence upon a smaller scale is to be found in the hospital record of Hull, Birmingham and other towns. It may be suspected that the epidemic rhythm is still maintained, though too faintly to be detected by such crude tests as case mortality or death-rates, and that it will reassert itself if and when the type of disease again becomes more severe. On the other hand it seems clear that there is nothing essential or permanent in the length of the five or six years cycle, since it is often shortened or lengthened, and there are no grounds for fixing limits in either direction. It is possible too that the persistent removal to hospital of the most virulent cases has had something to do with the present low average of case mortality, not merely by increasing the chances of recovery, but also by leaving only the milder attacks to propagate their kind by diffusing infection. But here, again, it must be remembered that the attenuation began before isolation assumed large proportions and has not been altogether limited to the towns in which isolation has been practised. In former years, too, long intervals of low intensity have been recorded, but have not proved permanent. Table
of
Scarlet Feve?’ Death-rate in London. Case mortality.
tion had to
extent been reinforced during the years of freedom from scarlet fever. After reaching its. acme, the death-curve descends again for a year or two to a new minimum. It descends because there is a less susceptible population, less infectiveness and less fatal type. The attacks, while lessening in number, lessen in severity also;. and as they are both fewer and milder the death-rate falls in compound ratio. Vaccination has profoundly affected the epidemic course of small-pox, but changes of type are evident. In the latter part of the last century small-pox contributed on an average about one-tenth of the whole death-rate of London, and in 1796 no less than 18 ’3 per cent. After this, and coincidently with the introduction of vaccination, its ravages lessened until 1830. From 1830 to 1838 the records are missing, butin 1838 the mortality was again comparatively high, though below even the average which prevailed half a century before. After 1838 we can measure its course by actual death-rates, and a considerable degree of order and even rhythm becomes apparent. Every few years-usually four or five, but sometimes two or three only-it recurred as an epidemic, but with somewhat reduced destructiveness each time until 1855, which happened to be halfway between 1838 and 1871. After 1855 minor epidemics continued to, recur at about the same interval, but the loss of life on each occasion increased rather than otherwise. Then came the great epidemic or pandemic of 1871, killing a larger proportion of the population than in 1838. The course of events for twenty years after 1871 was not unlike that which followed the 1838 epiclemic-successive outbreaks at intervals of four or five years, decreasingin. mortality, and subsiding after 1885 to a much lower level than was ever before reached. Amongst unprotected persons the case mortality even now runs high, but the small-pox of to-day is evidently different from that of 1871-different in virulence of attack and still more so in infectiveness and power of epidemic diffusion. The last-named tendency especially seems to have been at a low ebb in 1888-90, as in the fifties," and wemay not unreasonably anticipate in the "nineties" the same sort of’ gradual intensification as occurred in the " sixties." In considering the English epidemic of 1871 as part of the. great pandemic which about that time overran Europe, we must not lose sight of the fact that for several years previously there had been indications of increasing intensity in London-i. e., a tendency to slightly greater destructiveness in each successive minor epidemic. The same may be said of Prussia and Austria.1 In Russia small-pox was epidemic io. 1841-42-43, 1853-54 and 1864-65-66-67, recurring at intervals of about eleven years and with steadily increasing intensity. Then after an interval of only five years came the pandemic. of 1871-72, which (as in England) was much more destructive: than the other terms of the series would have led us to anticipate ; but, apart from the pandemic, a formidable outbreak would have been due in 1876. Whether the minor epidemics which occurred in London at intervals of four or five years were attended with any temporary increase ot’ severity, as in scarlet fever, is a point of considerable doubt. Some indication of such a change is afforded by hospital stasome
comparative
tistics, though not very clearly. It has been observed that during NOTE.-The death-rates are taken from the Registrar-General’s Annual Reports ; the Metropolitan Asylums Board Hospitals’ case mortality from the Statistical Reports of the Metropolitan Asylums Board; and the London Fever Hospital data were kindly furnished by Dr.
Hopwood. In manufacturing and mining districts it intensity has prevailed, often for a long
seems
that
high
term of years,
the rise of a minor epidemic malignant and hssmorrhagic cases are more often met with than they are later on, and at the decline of these outbreaks infectiousness appears sometimes to be almost lost, even though virulence shows but little. change. In May, 1884 (as in January, 1881) acute cases of£ small-pox were aggregated at the Fulham Hospital. Mr. Power found that this was followed by excessive incidence of small-pox upon the surrounding population, that the infection. was in all probability air-borne, and that the meteorologicaf records were of a character which seemed favourable for the aerial diffusion of particulate contagia ; but in June and July, 1884, with greater accumulation of acute cases in hospital and apparently similar weather indications, there was little if any evidence of diffusion. Hence Mr. Power infer& that the quality or infectiveness of small-pox itself may havechanged in the interval. Another possibility would seem try be that the atmospheric states suited for such diffusion may include as an essential element some detail (perhaps purely local) not indicable in the rough data of ordinary meteorological readings, which are in truth only daily averages or
some indication of the usual rhythm. districts the centres of population are near together, the intercommunication is free and the birthrate is high. These circumstances may be regarded as conducive to sustained prevalence of scarlet fever. It seems, then, that when the scarlet fever mortality curve rises at more or less regular intervals it does so for two reasons-because the attacks are more numerous and because they are more fatal in type. They are more numerous because there is increasing power of overcoming resistance, whereby those who were safe during the interval become more and more liable to attack ; because the severer cases are more capable of diffusing infection ; because the wider 1 Report of the German Vaccination Commission, 1884 ; a summary diffusion thus brought about lessens the chance of susceptible is given by Dr. E. J. Edwardes, Epidemiological Society’s Transactions, persons escaping; and, lastly, because the susceptible popula- 1885-86.
although In
such
not without
MR. H. SMITH ON HEMORRHOIDS AND PROLAPSUS OF THE RECTUM.
459
daily samples of conditions incessantly changing. Some limitation of the power of diffusion of infection must occur normally about June, for the average seasonal curve of mortality begins to decline sharply at that time. Presently it will be seen that this decline is attended with increased case
per cent. Looking to the records of former years, it is seen that from 1875 onwards there were biennial explosions increasing progressively in destructiveness and culminating in the exceptionally malignant outbreak already referred to. Since 1885 epidemics on a declining scale have occurred at similar intervals. It would seem that the quality of measles underwent mortality. There has been some prevalence of small-pox in Yorkshire progressive changes from a minimum intensity in 1875 to a during the past two years, attended in many districts with maximum in 1885, and that the course from 1875 to the precertain anomalies of type-for example, an occasional interval sent time is in a sense one great wave, interrupted repeatedly of only twenty-four hours between a definite onset and the in a mechanical fashion by the temporary exhaustion of conappearance of the rash, and sometimes an equally shortinterval ditions of susceptibility and by other external conditions. In between the first appearance of the rash and its attaining the 1888-89 a severe epidemic prevailed at Hanley and was vesicular stage. For the most part the aberrant types were investigated by Mr. Spear.5 He found that the symptoms slight and non-fatal. But this was not always so, nor were were of aggravated type and the case mortality not far short they limited to vaccinated persons. In one district at least of 9’0 per cent. On reference to the Registrar-General’s the comparatively rare complication of pneumonia was met returns for previous years we find that in the districts most with in a considerable proportion of the attacks. It would be severely affected there had been a succession of outbreaks interesting to know whether irregularity of type has been at not very regular intervals, but steadily increasing in morobserved in other parts of the country recently, and whether tality, until, as already seen, there came an epidemic conanything of the kind was noted at the corresponding period spicuous above the rest for its severity of type as well as high of forty years ago. To sum up : the type of small-pox seems mortality. A third example-in one respect more complete-is to be stable, rising and falling in intensity if traced through afforded by Barnsley. An exceptionally severe epidemic took long periods of years, the intensity being indicated even more place there early in 1891. It had been preceded by other outby power of epidemic diffusion than by severity of attack ; breaks in 1881, 1883, 1886 and 1888 at intervals of about two but apart from these long cycles there is a tendency to shorter years and a half. The measles death-rate increased with cycles of four years or so, which may or may not prove to be each successive epidemic, and Dr. Sadler, medical officer of accompanied by temporary increase of intensity and are pro- health for the borough, observed that, at all events in the bably governed by the accumulation of susceptible persons last three epidemics of the series, the type grew more and and other external conditions. Lastly, there are seasonal more severe, each occurrence exhibiting higher infectiveness changes regulated by the facilities for diffusion and not and wider extension than its predecessors. attended by any change of intensity. The change of quality in these instances seems clear, and Measles presents many points of analogy with small-pox. a similar change may be inferred with more or less probability They are alike in their independence of soil, water infection, from the course of the measles death-curve in London, and milk infection ; in their relation to age and sex ; in the Wolverhampton and many other towns. The case mortality duration of the intervals between infection and attack, and in measles is greatly influenced by surroundings, the severity also between the onset and appearance of the rash ; and in the and fatality being greatest among the poor. The experience primary seat of eruption. As regards the seasonal curve of epidemics amongst soldiers in time of war seems to confirm they have at all events the autumnal minimum in common. ’ this. In Fiji in 1875 the case mortality was enormous, and They are not unlike in the evidence which they afford of almost all the population, young and old, were attacked; comparative constancy of type. Notwithstanding the scanti- but here not only neglect and exposure of the sick but excepness of the records, alternate increase and decrease in tional susceptibility of a population never before invaded by virulence can be traced in many localities, each wave lasting measles have to be taken into account. The resistance was often twenty years or more in this country, although perhaps therefore lessened in two ways. Whether the destructiveless elsewhere. As in small-pox, the rise and fall of the ness of the pestilence was to be attributed entirely to this broad primary curve is interrupted (in a sense mechanically) lowered resistance, or whether there was an increased intensity at short intervals by explosions occurring when the accumu- of the contagium-in other words, a true change of typelation of susceptible persons is sufficient and the climatic remains to be proved. and other external conditions offer sufficiently small resistance. These outbursts of measles are often of brief duration and terminate as soon as the balance among the conditions ON THE TREATMENT OF HÆMORRHOIDS promoting and inhibiting the spread of infection inclines AND PROLAPSUS OF THE RECTUM sufficiently far in the direction of the latter. The interval BY CLAMP AND CAUTERY. is variable, but in English towns is usually about two years. The exact time of outburst is evidently affected by climatic BY HENRY SMITH, F.R.C.S. ENG., conditions, and as the mean seasonal curve shows two maxima CONSULTING SURGEON TO KING’S COLLEGE HOSPITAL. -two points of least resistance six months apart-it is not surprising to find that the interval, when not exactly two years, As some years have elapsed since I brought before the is frequently one and a half or two and a half years. There is, however, no assured constancy in the balance of influences upon profession any further experience of. the treatment of which the interval depends, and it is often reduced to one haemorrhoids and prolapsus of the rectum by means of the In Sweden2 and Norway3 year or extended to three or four. and cautery, and as some important improvements six or seven years usually elapse between successive out- clamp were suggested and have since been carried out on a somebreaks, and in Norway at all events there is evidence of extensive what case each The scale, I think it may be useful to give some of higher epidemic. mortality accompanying brief biennial explosions familiar in this country do not the results of my later practice having reference to the appear to be attended by increased case mortality. Their alterations just mentioned. Before going into details I may type is that of the prevailing phase of a broader wave. The say that these results have been such that my confidence bills of mortality show that about 1800 the average measles in the use of the clamp and cautery has been established mortality in London began to increase, reaching a maximum with greater firmness than ever. The objections which have about 1815. The Registrar-General’s reports from 1838 been urged against the treatment in question, and which in onwards show a distinct rise and fall in London measles its earlier history did exist, have been done away with, and, mortality, with maxima in the early "forties,"inthe "sixties" so far as my own experience has enabled me to judge, there and in the’’ nighties,’’ over and above the biennial rhythm are few surgical procedures attended with more satisfactory already referred to. It is difficult to account for these long results as regards the relief and cure of disease and the waves without assuming some altered quality of measles, and restoration of the patient to health and comfort. When the more detailed records of certain provincial towns leave this mode of treatment was originally prominently brought little room for doubt upon this point. At Sunderland4 in before the profession the objects I had in view were to adopt 1885 a virulent epidemic prevailed, causing in one quarter a a practice which would be attended with more safety to life mortality equal to an annual rate of nine per thousand from and with less of the inconveniences which were liable to happen measles alone. The recorded case mortality was twenty-nine after the usual modes of treatment of haemorrhoids and prolapsus, and which I had often witnessed in my own practice 2 Arthur Ransome, M.D., Epidemiological Society’s Transactions, ’
’
1881-82.
3 Johannessen, loc cit.
4 Annual
Report of Medical Officer of Health for Sunderland, 1885.
5 Annual
Board, 1890.
Report
of the Medical Officer to the Local Government