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A contribution to the etiology of diphtheria
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A CONTRIBUTION T O T H E ETIOLOGY OF D I P H T H E R I A .
A C O N T R I B U T I O N TO T H E ETIOLOGY OF D I P H T H E R I A . By MATTHEWA. ADAMS,F.R.C.S., F.C.S., F.I.C. The 31raldstone )Zpidem~c.__Th e following is an outline of an epidemic of diphtheria that prevailed in Maidstone during 1888 and 1889. On December 24th, 1887, after a whole year's all but entire immunity, the first of a series of eight disconnected sporadic cases of diphtheria appeared in the East end of lViaidstone, followed by seven others in different localities of the town, situated widely apart ; these cases occurred at various intervals until the seventeenth week of 1888, after which there was again absolute immunity for a further period of seventeen weeks, when another series of five sporadic cases commenced in the thirty-fifth and continued till the thirty-ninth week ; inthe forty-second, after a fortnight's halt, there came a single sporadic case; then between the fortythird and forty-fifth, a localized outbreak attacked eight persons in a part called Tovil, in the extreme west of the borough ; this was quickly followed by another localized outbreak in the extreme east, between the forty-seventh w~ek of 1888 and seventh week of 1889 . At this time the disease took its departure from Tovil. Between the eighth and seventeenth week, a third locality, Fant on the North West, became affected, and finally, during the seventeenth week the disorder reappeared in Tovil, and continued epidemic there until the thirty-fourth (strange to say, another seventeen weeks), and during the forty-first week returned to Fant, where it has continued in a sporadic fashion for some time. The total number of cases up to the end of 1889 amounting altogether to ninety-nine. ZocalDistribution.--As regards locality, previous to x888 the distribution of the few cases that are recorded seems to have been pretty general, but during 1888-89 the disorder fastened itself chiefly upon three several parts, Wheeler Street, Fant, and ToviL My inquiries have been directed to all such points as appeared to me likely to throw light upon the etiology and mode of propagation, and include milk and water supply, school attendance, concurrent diseases among brute animals and persons, the ordinary sanitary conditions of the houses and their surroundings, and the various meteorological passing events. Milk ,S'upp/y.--An analysis of the milk distribution shows that the supply was derived from twentynine different vendors ; in nine instances the vendors were dealers only, obtaining their supply from four cowkeepers already enumerated, this reduces the actual sources of the milk supply to twenty-four. In seven instances condensed milk only was used, in four others breast milk alone, and eight others none at all. So that in 1 9 = 19"2 per cent. of the whole
number, the possibility of milk-conveyed infection is out of the question. Eleven cases were supplied by W. Nine ,, ,, F. Eight ,, ,, S. Eight ,, ,, M. The remaining forty-four cases were distributed among twenty sources. There seems no reason to impute any special importance to the four who were the most concerned in the milk supply, they are the tradespeople in that line of business of the localities affected. Schools.--As regards schools, 4 ° = 40'4 per cent. of the cases, attended no school whatever, yet it is probable that Tovil schools were concerned in the spread during a late stage of the epidemic. The possibility of infection from brute animals was never lost sight of, but no distinct evidence of any importance of this kind was discovered. .Dwdlings.--As to the sanitary condition of the dwellings, it is difficult to classify, but I find by my notes that the sixty-nine houses are described as follows : Clean, eighteen ; fair, twenty.eight ; dirty, twenty-three. The division is very arbitrary, and in only a few instances could the houses be reckoned unimpeachable--this refers to inside of the houses. All those invaded by diphtheria are situated on the Ragstone with three exceptions, and these three are on clay. As regards the structure of the houses, they are for the most part of brick, some are stone, and some are wooden, but in many cases the brick houses have stone foundations, frequently the inner lining of the basement is of Hassock, so that they am liable to damp by capillary attraction. The immediate surroundings of the houses are often simply garden soil, without any paving whatever, so that in wet weather the approaches become converted into mud ; in other cases, paths, etc., are of brick or irregular pieces of ragstone, the interstices between these get filled with filth, and in wet weather produce a sloppy surface. The keeping of animals, such as pigs, poultry, rabbits, etc., is very common, and in many cases a veritable nuisance. The house refuse, when not disposed of on the premises, is sometimes allowed to collect in large pits that are uncovered, often too near the houses, and far too seldom emptied. I have often had to complain of collections of dung deposited within a few yards of the houses. The common, and one might almost say the universal, custom with regard to the disposal of w.c. sewage, is by hand-flushed hopper closets, which, for the want of sufficient flushing, are very often extremely foul. In Tovil, in particular, owing to the fact that but few of the houses are provided with a supply of water, except what is obtained from pumps, often at a considerable distance from the houses, flush-
A CONTRIBUTION TO THE ing is habitually neglected, and as a consequence the house drains become blocked with horribly offensive sewage, the soil sodden from escape at the badly-constructed joints of drains, and discharge of most offensive gases at the street ventilators ; these together constituting, as I quite believe, and shall endeavour to show, a real danger, and not untie. quently the starting point of diphtheria outbreaks. The above recital embraces the conditions that are usuaUy considered favourable to the origin and spread of diphtheria, yet it must be confessed that the greater number of the cases cannot be brought into line with either of them. It is all but certain that neither milk nor water had any share in the matter, nor the diseases of lower animals.
Infection through the Agency of Schools.--School attendance at Tovil, so far as spreading is concerned, seems to have played an important part, but as regards the other districts, there is no evidence of school attendance having been at work ; indeed, when we come to look into the matter more closely, we shall find that in Tovil even, it was not until the twenty-third week of I889 , that is to say, seventy-five weeks after the commencement of the outbreak, that the school had anything to do with it, and after all said and done, no one can suppose that school attendance is likely to originate the disorder of itself, or have any influence beyond affording opportunity for its spread by personal contagion, after it has been set a going by some other cause; that it did come into existence again and again, fresh and fresh, quite independently of any of the ordinary channels of contagion, is to me quite clear, and I think the nearest approach we have got to the discovery of a fundamental cause is to be found in the insanitary conditions of houses or their surroundings, more particularly in the foul states of the house drains, etc., the soil adjacent thereto, and the noxious effluvia escaping by the sewer ventilators, and given off from the retained sewage. This belief has been forced upon me by a variety of independent circumstances ; some of a kind that have often been noted by previous observers, and others, so far as I know, that are entirely new. In what follows I take i t for granted that diphtheria is due to a specific microbe, and it will be my endeavour to show that its natural habitat is polluted surface soil and siinilar situations ; that its propagation in the soil is due to suitable meteoro. logical conditions, and that its reception in the animal body at least is favoured by certain coincident pathological states, and perhaps other life conditions of environment, special to the organism itself, determining its development and activity ; this last point, though a matter of inference, only seems necessary to account for the periodical seasons of abated or augmented prevalence, and if the inference be false, some other explanation that ean take its place remains to be discovered, for whatever the true cause of the fact may be, we all
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know that these varigtions do occur, and that at the present time, and for some time past, there has been a steady increase of diphtheria, not .only in Maidstone, but throughout the country. As I have already said, our troubles began during the fiftyfirst week of ~887, after a whole year's exemption, causing the death of Case No. i on January 3rd, x888, and this death was certified as being the result of "DiphtheritismConfinement." The woman was thirty-four years of age, and the circumstances of her fatal illness did not come to my knowledge till after she wan dead and buried, and I was unable to obtain much information about it. It appeared to be a primary case, and certainly was not due to personal contagion, or other discoverable mediate agency. She lived in an eastern part of the borough, which I shall call the Wheeler Street part of the town, the disease did not appear likely to spread, and, as far as I know, did not. Seven weeks passed before we heard anything more of diphtheria, when case No. z, a child of five years, occurred in the fifth week of i889, in Tovil, an extreme western part of the town ; this also was a primary case. Sq far as I know, nothing of the sort had occurred in Tirol since the death of a child from laryngitis in the first week of I88z. Three weeks later, that is to say nine weeks after the first case, the disease returned to Wheeler Street district, and in another three weeks to Tirol, and so the thing went on for a space of nineteen weeks, alternately appearing in east and west districts, attacking eight persons, none of whom had any known communication with one another ; they alt died, and then came a time of seventeen weeks, between the eighteenth and thirty-fifth week of the year, of perfect immunity. In the thirty-fifth week a case occurred in Fant, a fresh and distinct part of the town, so that by this time s e had had three districts separately invaded. To the best of my belief up till then all the cases were primary, but after that secondary cases occurred, due to personal infection. Sewer Gas.mThat sewer gas acts as an agent in the production of diphtheria I have several cases to show, a child (No. 9), ~ for example, may be taken as a typical case. This was the first appearance of diphtheria in Fant, the district in which she lived, and tkere had been no case, so far as is known, in any other part of the town for seventeen weeks. The facts as related to me by the mother were as follows : ~ " O n Friday night Mary and I were together passing Fant Holme when I experienced a most diabolicalsmell issuing from the sewer manhole, and I said to Mary, ' Do you smell it, let us hurry by,' she answered, 'Yes, mother, I do.' I said, ' I feel it down here, Mary,' placing her hand on her * The numbers refer to a table giving details of each separate ease. This table is not inserted.
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abdomen, and the child apswered, So do I, mother ; ' this was a quarter-past six p.m. When we got home she had her tea, was bathed, and went to bed, and at two a.m. she awoke, was violently sick, and on Saturday was so ill that she had to return to her bed after mid-day, and on the next day, Sunday, her mother saw spots in her throat, and she was seen by the doctor on Monday, who pronounced it to be diphtheria." The following case (No. 8) is indirectly connected with the foregoing, the victim was a little child fifteen months old, living at a small cottage beside a rope-walk near the river, right away from any other dwellings ; as a matter of fact the child had never been away from its home for a tong time previous to its fatal illness, it had no children companions, and there had been no diphtheria near it. At first I could find no explanation to account for the illness, till, by accident as it were, I learnt that a great nuisance frequently occurred, arising from the escape of gas from a ventilating man-hole connected with the main sewer which brings the Fant sewage, that is to say the sewage concerned in the previous case, down to the riverside, a circumstance unknown to me up to that time. This sewer, as it reaches the riverside, turns sharp upon itself at a right angle, and it is at this angle the ventilator is placed, at a point just out of sight of, but close to, the cottage where the child dwelt, and frem the information given me there is no doubt that the child had been exposed to this sewer gas, and it is to that circumstance I attribute its fatal illness. Cases 35 and 46 illustrate another point in connection with this subject. The street where they occurred is a new street adjacent to Wheeler Street, and consists of about seventy-five small houses, they all have modern sanitary appliances, and are good specimens of the better class of artizan's dwellings. Those in particular where the cases occurred were beautifully dean, without a single cause for complaint, except the vile stenches proceeding from the sewer ventilators, of which there are three, one at the top, one in the middle, and another at the bottom, in the centre of the road, at the road level ; the top and the middle ventilators have beon especially complained of, and the explanation is simple enough; owing to the sewer being a tributory one only, and not a thoroughfare sewer, it terminates with a " d e a d e n d " at the top, and receives, especially at the upper portion, only the trifling amount of flushing which is derived from the small contributions of the small houses, there being but very little chance of neighbouring contributions acting jointly in respect of time so as to swell the stream, and so constitute an efficient flush, and there is none whatever of help from behind ; the consequence is, the sewage current is never large enough to maintain a self-cleansing of the sewer; this leads to a deposit in the sewer of the solids which decompose and stink ; such cases can best be met by auto-
ETIOLOGY OF DIPHTHERIA. marie flush tanks at the dead ends. It is my belief these cases 35 and 46 were caused by the gases coming from these ventilators. Cases z6, 27, and 29, are even more convincing as to the direct connection of sewage-borne or created infection. These three cases occurred in three old-fashioned cottages in Wheeler Street, adjacent to one another, and built upon the same plan ; they have sunk basements, with drains that pass from house to house, underneath the floor of the basements, and having trapped gulleys within the houses, and this drain, after picking up the drainage of each of the several houses of a block of six, finally passes from back to front to discharge into the main sewer in Wheeler Street. Case 26 was a little child, eighteen months old ; it was certified to have died of pneumonia, but there can be little or no doubt it was really diphtheria. Case 27, another child, also eighteen months, soon followed, and her death was certified as from croup ; and Case 29, the third child's death, was also certified as croup. Now there were these strange facts concerning these three cases--each of the three houses, where these children dwelt, had their drains blocked and their cellars flooded by sewage ; none of the adjacent houses had either flooded cellars or cases of croup. The nuisance caused by the floods of sewage was very gross, and several other of the inhabitants, especially the mother of 26, were very ill. Another fact that should be mentioned, Nos. 26 and 27 were the widest asunder ; they occupied two distinct blocks of houses, although the houses were of similar construction ; moreover, a party wall divided the back premises of the separate blocks occupied by the two families, and there had been no social intercourse between them, and it will be remembered the two children were each only eighteen months old, there is little or no likelihood of personal contagion from their having played together. Case 61 is essentially of a similar nature, though differing in detail; it relates to the death by diphtheria of a clergyman who lived in a large detached modem-built house in an eastern suburb ; the house had originally been drained into a cesspool, but recently had been connected with the main sewer, the drain conveying the w.c. and chief part of the house sewage, going round one side of the house, that from the scullery on the other ; the scullery drain discharged over a gully, and this gully also received the overflow from the rain water tank ; as time went on, the rain water became offensive, and on examining into the cause, it was discovered that through blockage of the drain by fat, regurgitation of scullery sewage had taken place into the rain tank, so that the rain Water in time became so foul it could no longer be used for household purposes, but was employed for watering the garden ; but at last the stench from the rain water tank became so bad, the gardener called his
A CONTP~IBUTION T O T H E master's attention to it, and they held a consultation about the matter at the place where the nuisance was. This was on a Saturday afternoon. The master ridiculed all idea of harm coming of the nuisance, but was prevailed upon to have something done, and gave instructions for the rain tank to be emptied on the following Monday. Next day morning, Sunday, though not feeling quite well, he performed his ministerial duty and preached a sermon, but in the evening he was not equal to this ; still, he managed to take some small part in the service ; before night he had to send for the doctor, and next day he died of most acute diphtheria. No. 4z is a case much to the same point, but not so tragic. It is of a woman washing in an outhouse, exposed in a most flagrant fashion to the escape of gas from a cesspool ; the immediate effect was to make her feel very unwell, and shortly after to have a severe attack of diphtheria. No trace of contagion from other source could be discovered, and she lived outside of the districts that had been infected. Disturbing Polluted Soil.--I have another point of a similar nature that I think deserves notice ; this refers to the risk of disturbing polluted soil. No. 68 was a woman living in a part that had not been attacked by diphtheria. She was the wife of a beerhouse keeper, and her duties called upon her to undertake washing of clothes ; this was done on a sink opposite to an open window that looks upon a small enclosed yard at the back of a public-house ; in this yard was a small urinal, and at that time the yard itself was paved with irregular squares of ragstone, leaving large interstices between the adjacent stones ; the urinal was unequal to the services required of it, and consequently the whole yard had been more or less put into requisition; this made it necessary for improvements to be undertaken, and in the course of these alterations the yard had to be " p e c k e d " up. Whilst this was being done, the wife was washing at the tub opposite the open window. I am told that whilst so engaged there was a great stench from the operations in the yard, and within a few hours she sickened with diphtheria. No. 97 was a child that would hang about watching the workmen employed upon the emptymg of a very foul cesspool and the relaying of drains connected therewith. No. 63 was a similar case. For the same, and other reasons, No. 86 is of the greatest interest and importance. To remedy gross sanitary defects, a renewal of the drainage was undertaken at the back of a house in Tovil, where a child, Gertrude, aged six years, pupil in the girls' department at Tovil Schools, lived. She watched the progress of the work, attended as it was by the usual offensive operations. She took the disease very severely August x4th, and died August I9th ; then for the first time it cameto
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my knowledge that four other children of this family had suffered from diphtheria between the 7th and I9th of June m Emily, nine years; Nelly, eight; Ernest, three ; and Harry, ten months. No doctor had been called in, the parents effectually concealed the occurrence ; the mother's description leaves not the shadow of a doubt of the nature of the illness of her children. She observed the " w h i t e " membrane in all their throats except Harry's, whose throat was so swollen she could not get a sight of it. At this time Gertrude also had sore throat, but her throat never had a white deposit upon it, and she continued to go to school, and so did Emily and Nelly, as soon as the severity of the disorder had passed off. Now immense importance attaches to these cases, for it is found that the commencement of the outbreak among the Tovil scholars, after perfect immunity during seventeen weeks, dates from almost the very day (June roth) of the commencement of the illness in this fsmily, and significantly enough after the thirty-third week, the date of Gertrude's case, and the discovery of the infective condition, and the consequent quarantine that was enfo~rced upon the family, only one other case appeared in the schools, though during the ten weeks (twenty-third to thirty-third) covered by the occurrences mentioned, no less than thirty cases of diphtheria appeared in Tovil ; and only two, one in the thirty-fourth week, and the final one in the forty-ninth week, have occurred since. The consideration of the cause of the delay of the manifestation of the disorder in this child brings up another point ot great interest. How comes it that this child, herself in the very thick of the disorder during June, and by implication she herself or her sisters acting as carriers of the complaint, for ten whole weeks escaped contagion until the middle of August ? Is it possible that she lived a charmed life, and whilst treading her perilous course had she passed through a cloud of dangers without having once exposed herself to actual danger? or can the disorder have been latent in her system for a whole ten weeks ? Or is it not more likely that something happened to make her system receptive of the poison at the later date that was absent in June ? It is even possible that the microbes set at liberty during the drainage operations above mentioned, may have been more plentiful, vigorous, or aggressive; in the present state of knowledge, I take it, it would be rash to venture to answer this question ; my belief inclines to the idea that something in the state of the body is developed that is attractive to the microbe by making provision for its reception, either in the way of food, or the suppression of something that is naturally antagonistic and a hindrance to it ; and this idea seems to have support by the following case. Nos. 79 and 80 were sisters, and both died of diphtheria in the thirtieth and thirty-first week of 1889, after which their mother, who had nursed
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them, removed into another house, and was attacked in the forty-eighth week, seventeen weeks after her children's illness ; how else can we explain the reason why she escaped when her children were taken ? Connection bttween Diphtheria, Scarlet lever, and Measles.--This consideration naturally leads to the last point to which I have to refer under this head, namely, the association between diphtheria, scarlet fever, and measles. Frequently it has been noticed by others as well as myself that diphtheria is likely to be mixed up in a confused way with both scarlet fever and measles ; it was so in the case of No. 12, for the sister of this child had scarlet fever, and she herself was at first supposed to be sickening for the same disease, but'it developed into what was finally set down to diphtheria, and of which she died. (I ought perhaps to have mentioned earlier that during ~887, before the diphtheria began, mild scarlet fever had been very prevalent, and during i888 measles largely prevailed.) To return to the instances of assoclat i o n - - a next door neighbour of No. 24 had scarlet fever, and No. 24 died of a gangrenous sloughing sore throat, without rash, that was more like diphtheria than anything else ; an aunt to this latter child assisted in her nursing, and shortly after No. 28, the aunt's own child, that is a cousin of No. 24, died of undoubted diphtheria ; by the way, the mother of No. 28 borrowed clothes to attend the funeral of her own child of a neighbour, who was the mother of No. 3~, a child of eighteen months, and this child fell ill a very short time after the return of the clothes, and died of diphtheria. Case z 5 was the sister of two others ill at the same time as herself of ,scarlet fever, but No. 25 had diphtheria, and nearly died of it. Nos. 40 and 4 ' were both out in the rash of measles, when undoubted diphtheria set in. What can be the explanation of these, if indeed the association is other than fortuitous ? I can only imagine that the diseased condition of the faucial mucous membrane brought about by scarlet fever or measles may provide the pabulum in which the diphtheria microbe can flourish. Again and again it has been "observed that diphtheria epidemics arise as it were out of a cloud of ordinary and apparently nonspecific sore throat. Is it not possible that even ordinary catarrh may in some way render the mucous surface receptive? possibly by some chemical or biological change. M y idea is that the microbe lives a very precarious life, and the least thing is sufficient to turn the tide for or against its existence--a trifle too much or too little acidity or alkalinity, the presence or absence of a few benign micro-organisms may be all that is necessary to attract or repel the invasion, and determine the result. These cases seem to throw some little light upon the curious fact that the same person at different
E T I O L O G Y OF D I P H T H E R I A . times may at one time be receptive of the disease and another time not, and if they teach us nothing else, they indicate how very slight the differences may be that decides the balance whether the diphtheria organisms shall flourish or not, and encourage a search for more fundamental knowledge of its life history. The observations now about to be described are offered as a contribution in this direction. From all we know of diphtheria, it does not appear to be water-borne, nor to be easily air-borne, for though infectious, it seems to be so at close quarters only, and probably it is then communicated by particulate matter, such for instance as may pass from one individual to another in the acts of coughing, sneezing, or speaking; and so far as my experience goes there is nothing to encourage the belief that it is ever conveyed by water (in this respect differing widely from typhoid). Milk, and perhaps some other foods, though I have not found it so, may serve as vehicles, and if so, probably because they supply suitable pabula for the organism. I n short, everything goes to show that diphtheria is due to a microbe that lives a parasitic life upon dead or decaying animal matter, and that the animal body is liable to be attacked by it, just as it is by various other parasitic organisI'ns, the special phenomena of the disease being the result of the poison of its excretion, and there is nothing to forbid the belief that this organism, which neither air nor water appears to cherish, may live in the soil, and some observations that I have accumulated in recent years on subsoil water inferentially favour the belief. Influence of Subsoil IFater.--The observations I allude to were commenced during the year, ~884, and have been continued daily ever since, so that we now have a continuous record, extending over five years, of the depth in feet from the surface of the ground at which the subsoil water stood day by day throughout each of the five years, x885--i889 inclusive. T o bring these five years' records collectively under the eye for the purpose of comparison, the daily observations have been compressed into weekly periods, as set forth in the diagram, page x xi, which shows the range of movement of the subsoil water during each successive week, so that one can see at a glance when the alterations have been, how much or how little they have been, and whether rapid or slow. The maximum depth of water from surface .............................. = 17.7 feet. The minimum depth of water from surface ............................... ~ 15 ,, Total range ........................... = 2.7 ,, Average . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
~6.68 feet.
The first thing that strikes one is a similarity between the curves for x885 and r886 and x887 ;
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ETIOLOGY OF DIPHTHERIA.
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this is very obvious, in each year we find a high and a low tide, the high tide coming at the early part of the year, and the low tide sometime about the junction of the third and fourth quarter ; far different, however, the curves for x888 and x889, in those years all order seems to be lost, each year ~c~ 3 presents several high and low tides, the maximum never being so high nor the minimum so low as in the three former years, from which we may infer that the soil during the three earlier years must h a v e b e e n more thoroughly washed during the colder seasons, and better drained and dried and aerated during the hotter seasons, whilst on the other hand, during the last two years the soil must have been kept in a condition of more or less stagnant saturation ; moreover, it is to be • observed that the coincidence of tide and season oO oo that prevailed in earlier years, was more or less reversed in the latter ; for examples in the middle of the first quarter of ~888 there is low tide when we should have expected high tide, and in the middle of the third quarter, the highest tide of the year where we might have looked for the lowest, and this was followed by nearly twelve months of comparative stagnation. By the way, it may be as well to remark that the rainfall is not the only factor concerned in the maintenance of the subsoil water level; surface evaporation has very &-- much to do with it, and consequently wind and sunshine are very important agents in the matter ; as a rule, heavy rainfall is soon followed by a rise in the subsoil water, but the full effect is often delayed some two or three months ; in illustration of this the 7.7 inches of rain that fell in the fourth quarter of x885 made no great show till the middle of the first quarter of x886, when there was less rain than the average ; this only shows how long a time it takes for the soil to get thoroughly dry, for of course the water for all ,o these months was in the soil, though it had not oo sunk to its proper level, this gives us a good idea oO .of the relative dryness of the soil in different seasons. So far as concerns the subsoil water level, these are the facts, and if we turn to those relating to the prevalence of diphtheria we find equally remarkable distinction between the three earlier years and the last two ; with the former there was very little diphtheria, with the latter much. Whilst the single high and low tides, in correspondence with the cold and hot seasons lasted, diphtheria m was scarce ; as soon as this favourabte order of oO things was interrupted, diphtheria began to prevail, and it is seen that there was least diphtheria when the correspondence between the high tide and coldest seasons and vice v e r s a was most exact; as for example, in I887, when there was the least diphtheria, on the contrary, every departure from this type seems to be attended by an increase of the prevalence of diphtheria ; for iustance~ the beginning of our epidemic was during the middle
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of the first quarter of ~888, when a low tide usurped the place of a high one; and when the misplaced high tide did come to purge the soil, there was a pause in the prevalence, but again at the end of the year, and beginning of I889, when the annual washing of the soil ought to have taken place, and did not, and the accumulated pollution of the soil must have increased, the more serious outbreak occurred. Now what is the explanation of these occurrences ; was the diphtheria in any sense a consequence of, or only a coincidence with, the state of the soil and subsoil ? From all that has been written, one finds dampness of soil, defects of sewage, and other grave sanitary faults, always cropping up in reports on outbreaks of diphtheria; for example, in Mr. Power's valuable report on the North London epidemic he traced the chief incidence to a serious defect in a special sewage area, and by the way he draws attention to the effect of dead ends of sewers, such as I have already spoken of ; again, the same observer, in his report on Whitstable, describes a state of drainage faults, especially with respect to hand-flushed closets exactly parallel with our own case. The same again may be said of Aylesbury, as reported by Dr. Gresswell; and later on, concerning the same place, in a very valuable report by Mr. Spear, attention is specially called to recurring outbreaks occurring " i n damp houses exposed to draining defects and sewage effluvia," "closet nuisances," "foul sewer ventilators," and the association of localized outbreaks, in almost every case with grave defects of sewers and drains. I am afraid, when speaking of sewerage, hardly sufficient stress was laid upon the facts concerning the ventilator nuisance in Tovil. In Tovil, owing to the want of water, and the shockingly neglected state of the drains, this nuisance occurred habitually, and in a most serious manner, for it so happens the chief and most offensive ventilator in this line of sewer is situated just opposite the school gates consequently every child attending Tovil Schools must pass close to it, and from time to time must be assailed by a most horribly polluting stench. This makes it exceedingly difficult, if not impossible, to correctly assign the cause of each of the cases that occurred among the children of these schools from June xoth to August 21st, I889, as between contagion conveyed by Gertrude and her sisters on the one hand, and the ventilator nuisance on the other. Again to refer to Dr. Spear's report. In it there occurs a hypothesis whicb, as respects the views I am upholding, is of special interest; it " c o n t e m plates the operation of some extrinsic agent upon a miasmatic, as opposed to a purely contagious principle in diphtheria infection." If these observations on subsoil water are worth anything, they supply a link in the chain of causation which is contemplated in the above hypothesis.
ETIOLOGY OF DIPHTHERIA. So far as we have yet gone, our facts meteorological and pathological have been set forth with a view of ascertaining whether there be any general principle to be discovered in the gross. And now believing we have discovered, in the behaviour of the subsoil water, an underlying general principle, if we could, by coming to close quarters with the question, and applying in detail a more delicate test, by bringing together the individual cases of disease and the separate occurrences in the meteorology ; in doing this we might hope to find some definite concordance. I n any attempt however to do so, it must not be forgotten that there are serious difficulties to he encountered. In the first place, it is a difficult matter to fix with certainty the moment of inception, and far more difficult to discriminate between secondary cases that originate through personal or other mediate contagion, and those that arise from initial primary sources, and it is probable that in so complex a matter as this it is safer to deal with cases in the abstract than in the particular ; however, the temptation is so strong, to make the attempt, I have constructed diagrams which show side by side the the daily record of barometric pressure, temperature, rainfall, and height of subsoil water, and the date of inception of each case of diphtheria, as near as it could be fixed. With regard to the last item, for reasons, some of which I have already given, my experience leads me to the opinion that the incubation stage of diphtheria is very short indeed, and I think that it we date from the first slight feeling of illness, or sense of something being wrong, we shall probably be within a few hours of the time when the disease was taken, and as I have already related, in some instances a definite event is spoken to by the patient, which on the face of it certainly deserves to be taken into account when searching for the precise time and cause of the illness that follows; the first appearance of the diphtheritic membrane may be about two days later, and in the absence of any premonitory guide, this space of time may be taken as the usual period of incubation. Just a word of explanation regarding the rainfalI and the water level. The rainfall is plotted against the day on which it actually fell, the height of the water level on the day ot reading, so the difference between it and the record of the day before represents the movement that occurred during the 24hours preceding the record. By the way, some points of paramount importance must be taken before we proceed with o~ consideration of the diagram. How can the behaviour of the subsoil water level be supposed to. act? Is it mechanically, by forcing the germ charged air out of the soil into the air we breath% or is there some more intimate biological connection between the two things promoting the activity of the germ? Probably both ideas are correct. There can be little doubt that a damp condition o f
A CONTRIBUTION
TO THE
the soil favours the development of the microbe; in all probability it cannot live actually submerged in water, immersion would drown it, for it does not appear that there is a tittle of evidence to indicate that diphtheria is ever water-borne ; we must therefore believe that if it exists in the soil it lives somewhere above the water level. It is equally probable that much drought will kill it, and there can be no doubt that decaling albuminous matter is absolutely necessary for its existence. I n short it is aerobic, requiring its just proportion of moisture, heat, air, and albuminous food, and it seems to me that at or near the surface of polluted soil is the most likely place to find these conditions best fulfilled, and when these conditions are conjoined with the fluttering fluctuation of subsoil water that we found to occur in i888-89 . The soil must have been in a condition peculiarly favourable to the vigorous development and rapid multiplication of the microbe ; in this way we can imagine the interstices of the soil, at or near the surface, thronged by colonies of spore-bearing microbes, ready at any moment for distribution in the atmosphere, by any disturbance of the soil or other mechanical means whereby they could be driven out of the soil air to mingle with the atmosphere we brtathe, such for instance as must necessarily attend the sudden fall of the barometer, which in effect causes the germ-charged air to be aspirated out of the soil and sewers; as a proof that this does take place we need only be reminded of the common enough forecast, one so often hears, that becau:e of the stinks fiom the drains rain may be expected. For the same reason a sudden fall of rain is an eff~ctive cause in producing a like resuit, and many observant persons no doubt have had evidence through the sense of smell of the truth of this. Among others, Dr. Gresswell has noticed the association between throat disorders and increase " o f rainfall and certain uther meteorological changes ; " and lastly there is the rise of the level of the subsoil water, which of necessity pushes the air out of the soil, and if the air is germ-charged the germ may go with it ; change of temperature, so far as movement of the air is concerned, can have but trifling effect, so that as regards our study of the diagram our attention ought to be fixt.d on three things--the barometer, the rainfall, and the subsoil water-level. T o begin with, let us take a rough glance through the diagram. Our attention is first attracted by the association of diphtheria cases with three typical instances of sudden decrease of barometric pressure occurring on January 3xst and March i i t h and xsth , i888. Next we may observe the rise of the sub-soil water in March and November, i~'88, in February, I889, and the sudden rise in June and October, ~889. The effect of sudden rainfall may be seen at the end of October, and throughout November, i888. Again, in February and April, 1889, and from
ETIOLOGY OF DIPHTHERIA.
xi3
June 6th to ioth, almost daily in July, and again in October and December. The fall on June 6th I remember particularly well, it was a sudden deluge that accompanied a thunderstorm, it lasted but a few minutes, and my memory is especially impressed by the occurrence, because a poor lad in Tovil, whose fatal illness began on June 7th, was out in that storm, in a field, playing cricket, by the side of the Tovil stream, near the sewer ventilator at the margin of the stream ; remember, this sewer ventilator has often been frightfully offensive, and it is easy to imagine what the effect of this sudden rain must have had upon the contents of the foul house drains connected with this sewer ; how it must have forced forward and stirred up the festering filth, causing a pouring forth of a perfect blast of poisonous sewer gas at the ventilator. At this time, June 6th, there had been an absolute pause in the prevalence of diphtheria since April 3oth, no case had occurred in the town, and I have not the least doubt in my mind that this thunderstorm of June 6th, and the heavy rains of the 9th and xoth, set all the subsequent mischief a going. Besides the positive evidence afforded b y the observation of barometer, raingauge, and water level, the arrest of prevalence of diphtheria during May, June, and July, i888, and in a less marked degree during May and September, I889, in conjunction with the lowering of the sub-soil water at those times, offers negative evidence of no mean order. If we analyse the 99 cases carefully, to ascertain what correspondence exists between those several circumstances and the occurrence of diphtheria, we find in 6I instances there is distinct evidence of such coincidence, in the remaining 38 cases, I6 are accounted for by direct contagion 15 by some special circun~stances, and seven only remain unaccounted for, of these seven, my notes taken at the time, record against five o f them either doubtful, or very doubttul, as to the exact nature of the malady. igo. of Cases.
17 9 6 5
9 9
6
Favouring Circumstance.
Barometer, Rain ar,d Water level. Ba.ometer an0 Rain. Barometer and Wa~er levd. Rain and Water level. Barometer. Ram. Waler level.
6I
Total Meteorologieal.
16 7 3 5 7
Contagion. Drain Overflow. Disturbance of Polluted Soil. Associat~onwith ScaIlet FeverorMe~sles. Unaee unted for.
99
Total.
xx4
NORTHERN
I am not in a position at present to carry the case further than this. Dealing with complicated and difficult questions of fact and inference, it is not to be expected that one could do so without more extended opportunities of observations. The most I can hope for is that the opportunities this epidemic have afforded, have not been altogether wasted, but that it may prove that the observations here recorded contribute something towards the discovery of the mysterious influences that govern the origin and spread of diphtheria. N O R T H E R N NOTES. THE Smoke Abatement Organization, which has its head-quarters at the office of the Manchester and Salford Sanitary Association, is drawing the attention of all good citizens to the duty of purifying the air of manufacturing districts, and when funds sufficient are provided a series of experiments on the best means of smoke prevention are to be made. The medical officers of health of Oldham and Blackburn and some other Lancashire towns have also been active in the cause of smoke abatement. Indeed, in many localities a great improvement has already been effected, e.g., let anyone compare the present state of the green fields round Widnes and Runcorn, for instance, with the stretches of barren plain alone to be seen a few years back. A memorial to the late Angus Smith has been proposed--let alI who wish to honour his memory carry on the work which he so well began; and then, when a foreigner comes to seek the old chemist's memorial, the Lancashire lad can point to pure air and blue sky and say eircuras~ice. This ifitroduces another subject. The smoke nuisance is what it is in northern towns simply owing to steam being almost universally used, although in many localities there is water power running to waste. I f only water were used for driving machinery where it is available, the change would effect a wonderful improvdment in the purity of urban air. When the Americans have shown us the way, perhaps we shall set to work in this direction. A syndicate is already formed for using a little of the waste power in Niagara. The actual fall of level is about 200 feet, and it is calculated that if about four per cent. of the water going over the falls is taken there might be utilized x2o, ooo horse.power. It is proposed to take the water by a short lateral canal, to allow it to descend vertically in shafts in which turbines will be placed, and to discharge it by a tunnel tail-race, passing beneath the present town of Niagara at a point below the falls. It is part of the plart to transmit a portion of the power to Buffalo, eighteen miles distant. Surely something might be done in this country to replace steam by water power. It is not always that economy and public health point in the same direction.
NOTES. Much interest is taken in northern towns in the coming census. The report of the committee appointed by the Treasury to inquire into certain questions connected therewith, is regarded on the whole as satisfactory. All are in favour of enumerations being made every five years instead of every ten years, and that special attention should be given to the careful selection of enumerators. The omission of the word " r a n k " from the column heading " rank, profession, or occupation," is quite in accord with modern views. A better classification of occupations is also needed. It is a useful r.ecommendation also that householders should give the number of rooms occupied if less than five. Since the promulgation of the dog muzzling order there has been little heard of hydrophobia. However, rabies has lately appeared at Fulwood, near Preston. A farmer named Eccles, and a labourer in his employ left Preston for Paris on the night of July x3th , having been bitten on the 9th by a sheep dog which was afterwards found to be suffering from rabies. The two men are to place themselves under the care of M. Pasteur. The dog attacked three other dogs, and all four were destroyed. The questions that suggest themselves in isolated cases of this kind are : Where could this sheep dog have got rabies from ? Did it arise de nova ?
Has anyone had a long experience of fever hospital management without losing some of his faith in the intuitive dexterity of practitioners to diagnose febrile disease ? The writer of these notes, with an experience of fourteen years in this direction, has'received some odd fever cases. He does not complain of eases of pneumonia being sent in as "typhus," because for all he knows to the contrary pneumonia may be an infectious fever, and is better in hospital than elsewhere. What first shook his childlike faith in the carefulness of practitioners was a case of primary syphilis sent in as "typhus," and a case of well-marked secondaries sent in as small-pox. Then arrived a case of itch, also sent in as small-pox. This is no place for a list of curiosities of diagnosis, amusing as it would be. All that is asked for is the exercise of a little more care before consigning a poor patient to an infectious diseases hospital. During the present year the writer has had four cases sent him as "typhus," in none of which was the temperature a hundred degrees ; and he is now treating a ease of delirium tremens which was sent in as enteric fever. What a worry the filling in of printed forms has become! Two or three times a-week the hardworked medical officer of health receives applications from town clerks and surveyors and secretaries of various societies for information on all sorts of subjects. A printed list of queries accompanies each application, and the receiver is requested to fill in his answers without delay. Many of the questions asked, such as, What was the population of your town at the last census ?
A CONTRIBUTION T O T H E ETIOLOGY OF D I P H T H E R I A .
A C O N T R I B U T I O N TO T H E ETIOLOGY OF D I P H T H E R I A . By MATTHEWA. ADAMS,F.R.C.S., F.C.S., F.I.C. The 31raldstone )Zpidem~c.__Th e following is an outline of an epidemic of diphtheria that prevailed in Maidstone during 1888 and 1889. On December 24th, 1887, after a whole year's all but entire immunity, the first of a series of eight disconnected sporadic cases of diphtheria appeared in the East end of lViaidstone, followed by seven others in different localities of the town, situated widely apart ; these cases occurred at various intervals until the seventeenth week of 1888, after which there was again absolute immunity for a further period of seventeen weeks, when another series of five sporadic cases commenced in the thirty-fifth and continued till the thirty-ninth week ; inthe forty-second, after a fortnight's halt, there came a single sporadic case; then between the fortythird and forty-fifth, a localized outbreak attacked eight persons in a part called Tovil, in the extreme west of the borough ; this was quickly followed by another localized outbreak in the extreme east, between the forty-seventh w~ek of 1888 and seventh week of 1889 . At this time the disease took its departure from Tovil. Between the eighth and seventeenth week, a third locality, Fant on the North West, became affected, and finally, during the seventeenth week the disorder reappeared in Tovil, and continued epidemic there until the thirty-fourth (strange to say, another seventeen weeks), and during the forty-first week returned to Fant, where it has continued in a sporadic fashion for some time. The total number of cases up to the end of 1889 amounting altogether to ninety-nine. ZocalDistribution.--As regards locality, previous to x888 the distribution of the few cases that are recorded seems to have been pretty general, but during 1888-89 the disorder fastened itself chiefly upon three several parts, Wheeler Street, Fant, and ToviL My inquiries have been directed to all such points as appeared to me likely to throw light upon the etiology and mode of propagation, and include milk and water supply, school attendance, concurrent diseases among brute animals and persons, the ordinary sanitary conditions of the houses and their surroundings, and the various meteorological passing events. Milk ,S'upp/y.--An analysis of the milk distribution shows that the supply was derived from twentynine different vendors ; in nine instances the vendors were dealers only, obtaining their supply from four cowkeepers already enumerated, this reduces the actual sources of the milk supply to twenty-four. In seven instances condensed milk only was used, in four others breast milk alone, and eight others none at all. So that in 1 9 = 19"2 per cent. of the whole
number, the possibility of milk-conveyed infection is out of the question. Eleven cases were supplied by W. Nine ,, ,, F. Eight ,, ,, S. Eight ,, ,, M. The remaining forty-four cases were distributed among twenty sources. There seems no reason to impute any special importance to the four who were the most concerned in the milk supply, they are the tradespeople in that line of business of the localities affected. Schools.--As regards schools, 4 ° = 40'4 per cent. of the cases, attended no school whatever, yet it is probable that Tovil schools were concerned in the spread during a late stage of the epidemic. The possibility of infection from brute animals was never lost sight of, but no distinct evidence of any importance of this kind was discovered. .Dwdlings.--As to the sanitary condition of the dwellings, it is difficult to classify, but I find by my notes that the sixty-nine houses are described as follows : Clean, eighteen ; fair, twenty.eight ; dirty, twenty-three. The division is very arbitrary, and in only a few instances could the houses be reckoned unimpeachable--this refers to inside of the houses. All those invaded by diphtheria are situated on the Ragstone with three exceptions, and these three are on clay. As regards the structure of the houses, they are for the most part of brick, some are stone, and some are wooden, but in many cases the brick houses have stone foundations, frequently the inner lining of the basement is of Hassock, so that they am liable to damp by capillary attraction. The immediate surroundings of the houses are often simply garden soil, without any paving whatever, so that in wet weather the approaches become converted into mud ; in other cases, paths, etc., are of brick or irregular pieces of ragstone, the interstices between these get filled with filth, and in wet weather produce a sloppy surface. The keeping of animals, such as pigs, poultry, rabbits, etc., is very common, and in many cases a veritable nuisance. The house refuse, when not disposed of on the premises, is sometimes allowed to collect in large pits that are uncovered, often too near the houses, and far too seldom emptied. I have often had to complain of collections of dung deposited within a few yards of the houses. The common, and one might almost say the universal, custom with regard to the disposal of w.c. sewage, is by hand-flushed hopper closets, which, for the want of sufficient flushing, are very often extremely foul. In Tovil, in particular, owing to the fact that but few of the houses are provided with a supply of water, except what is obtained from pumps, often at a considerable distance from the houses, flush-
A CONTRIBUTION TO THE ing is habitually neglected, and as a consequence the house drains become blocked with horribly offensive sewage, the soil sodden from escape at the badly-constructed joints of drains, and discharge of most offensive gases at the street ventilators ; these together constituting, as I quite believe, and shall endeavour to show, a real danger, and not untie. quently the starting point of diphtheria outbreaks. The above recital embraces the conditions that are usuaUy considered favourable to the origin and spread of diphtheria, yet it must be confessed that the greater number of the cases cannot be brought into line with either of them. It is all but certain that neither milk nor water had any share in the matter, nor the diseases of lower animals.
Infection through the Agency of Schools.--School attendance at Tovil, so far as spreading is concerned, seems to have played an important part, but as regards the other districts, there is no evidence of school attendance having been at work ; indeed, when we come to look into the matter more closely, we shall find that in Tovil even, it was not until the twenty-third week of I889 , that is to say, seventy-five weeks after the commencement of the outbreak, that the school had anything to do with it, and after all said and done, no one can suppose that school attendance is likely to originate the disorder of itself, or have any influence beyond affording opportunity for its spread by personal contagion, after it has been set a going by some other cause; that it did come into existence again and again, fresh and fresh, quite independently of any of the ordinary channels of contagion, is to me quite clear, and I think the nearest approach we have got to the discovery of a fundamental cause is to be found in the insanitary conditions of houses or their surroundings, more particularly in the foul states of the house drains, etc., the soil adjacent thereto, and the noxious effluvia escaping by the sewer ventilators, and given off from the retained sewage. This belief has been forced upon me by a variety of independent circumstances ; some of a kind that have often been noted by previous observers, and others, so far as I know, that are entirely new. In what follows I take i t for granted that diphtheria is due to a specific microbe, and it will be my endeavour to show that its natural habitat is polluted surface soil and siinilar situations ; that its propagation in the soil is due to suitable meteoro. logical conditions, and that its reception in the animal body at least is favoured by certain coincident pathological states, and perhaps other life conditions of environment, special to the organism itself, determining its development and activity ; this last point, though a matter of inference, only seems necessary to account for the periodical seasons of abated or augmented prevalence, and if the inference be false, some other explanation that ean take its place remains to be discovered, for whatever the true cause of the fact may be, we all
E T I O L O G Y OF D I P H T H E R I A .
Io7
know that these varigtions do occur, and that at the present time, and for some time past, there has been a steady increase of diphtheria, not .only in Maidstone, but throughout the country. As I have already said, our troubles began during the fiftyfirst week of ~887, after a whole year's exemption, causing the death of Case No. i on January 3rd, x888, and this death was certified as being the result of "DiphtheritismConfinement." The woman was thirty-four years of age, and the circumstances of her fatal illness did not come to my knowledge till after she wan dead and buried, and I was unable to obtain much information about it. It appeared to be a primary case, and certainly was not due to personal contagion, or other discoverable mediate agency. She lived in an eastern part of the borough, which I shall call the Wheeler Street part of the town, the disease did not appear likely to spread, and, as far as I know, did not. Seven weeks passed before we heard anything more of diphtheria, when case No. z, a child of five years, occurred in the fifth week of i889, in Tovil, an extreme western part of the town ; this also was a primary case. Sq far as I know, nothing of the sort had occurred in Tirol since the death of a child from laryngitis in the first week of I88z. Three weeks later, that is to say nine weeks after the first case, the disease returned to Wheeler Street district, and in another three weeks to Tirol, and so the thing went on for a space of nineteen weeks, alternately appearing in east and west districts, attacking eight persons, none of whom had any known communication with one another ; they alt died, and then came a time of seventeen weeks, between the eighteenth and thirty-fifth week of the year, of perfect immunity. In the thirty-fifth week a case occurred in Fant, a fresh and distinct part of the town, so that by this time s e had had three districts separately invaded. To the best of my belief up till then all the cases were primary, but after that secondary cases occurred, due to personal infection. Sewer Gas.mThat sewer gas acts as an agent in the production of diphtheria I have several cases to show, a child (No. 9), ~ for example, may be taken as a typical case. This was the first appearance of diphtheria in Fant, the district in which she lived, and tkere had been no case, so far as is known, in any other part of the town for seventeen weeks. The facts as related to me by the mother were as follows : ~ " O n Friday night Mary and I were together passing Fant Holme when I experienced a most diabolicalsmell issuing from the sewer manhole, and I said to Mary, ' Do you smell it, let us hurry by,' she answered, 'Yes, mother, I do.' I said, ' I feel it down here, Mary,' placing her hand on her * The numbers refer to a table giving details of each separate ease. This table is not inserted.
108
A CONTRIBUTION
TO THE
abdomen, and the child apswered, So do I, mother ; ' this was a quarter-past six p.m. When we got home she had her tea, was bathed, and went to bed, and at two a.m. she awoke, was violently sick, and on Saturday was so ill that she had to return to her bed after mid-day, and on the next day, Sunday, her mother saw spots in her throat, and she was seen by the doctor on Monday, who pronounced it to be diphtheria." The following case (No. 8) is indirectly connected with the foregoing, the victim was a little child fifteen months old, living at a small cottage beside a rope-walk near the river, right away from any other dwellings ; as a matter of fact the child had never been away from its home for a tong time previous to its fatal illness, it had no children companions, and there had been no diphtheria near it. At first I could find no explanation to account for the illness, till, by accident as it were, I learnt that a great nuisance frequently occurred, arising from the escape of gas from a ventilating man-hole connected with the main sewer which brings the Fant sewage, that is to say the sewage concerned in the previous case, down to the riverside, a circumstance unknown to me up to that time. This sewer, as it reaches the riverside, turns sharp upon itself at a right angle, and it is at this angle the ventilator is placed, at a point just out of sight of, but close to, the cottage where the child dwelt, and frem the information given me there is no doubt that the child had been exposed to this sewer gas, and it is to that circumstance I attribute its fatal illness. Cases 35 and 46 illustrate another point in connection with this subject. The street where they occurred is a new street adjacent to Wheeler Street, and consists of about seventy-five small houses, they all have modern sanitary appliances, and are good specimens of the better class of artizan's dwellings. Those in particular where the cases occurred were beautifully dean, without a single cause for complaint, except the vile stenches proceeding from the sewer ventilators, of which there are three, one at the top, one in the middle, and another at the bottom, in the centre of the road, at the road level ; the top and the middle ventilators have beon especially complained of, and the explanation is simple enough; owing to the sewer being a tributory one only, and not a thoroughfare sewer, it terminates with a " d e a d e n d " at the top, and receives, especially at the upper portion, only the trifling amount of flushing which is derived from the small contributions of the small houses, there being but very little chance of neighbouring contributions acting jointly in respect of time so as to swell the stream, and so constitute an efficient flush, and there is none whatever of help from behind ; the consequence is, the sewage current is never large enough to maintain a self-cleansing of the sewer; this leads to a deposit in the sewer of the solids which decompose and stink ; such cases can best be met by auto-
ETIOLOGY OF DIPHTHERIA. marie flush tanks at the dead ends. It is my belief these cases 35 and 46 were caused by the gases coming from these ventilators. Cases z6, 27, and 29, are even more convincing as to the direct connection of sewage-borne or created infection. These three cases occurred in three old-fashioned cottages in Wheeler Street, adjacent to one another, and built upon the same plan ; they have sunk basements, with drains that pass from house to house, underneath the floor of the basements, and having trapped gulleys within the houses, and this drain, after picking up the drainage of each of the several houses of a block of six, finally passes from back to front to discharge into the main sewer in Wheeler Street. Case 26 was a little child, eighteen months old ; it was certified to have died of pneumonia, but there can be little or no doubt it was really diphtheria. Case 27, another child, also eighteen months, soon followed, and her death was certified as from croup ; and Case 29, the third child's death, was also certified as croup. Now there were these strange facts concerning these three cases--each of the three houses, where these children dwelt, had their drains blocked and their cellars flooded by sewage ; none of the adjacent houses had either flooded cellars or cases of croup. The nuisance caused by the floods of sewage was very gross, and several other of the inhabitants, especially the mother of 26, were very ill. Another fact that should be mentioned, Nos. 26 and 27 were the widest asunder ; they occupied two distinct blocks of houses, although the houses were of similar construction ; moreover, a party wall divided the back premises of the separate blocks occupied by the two families, and there had been no social intercourse between them, and it will be remembered the two children were each only eighteen months old, there is little or no likelihood of personal contagion from their having played together. Case 61 is essentially of a similar nature, though differing in detail; it relates to the death by diphtheria of a clergyman who lived in a large detached modem-built house in an eastern suburb ; the house had originally been drained into a cesspool, but recently had been connected with the main sewer, the drain conveying the w.c. and chief part of the house sewage, going round one side of the house, that from the scullery on the other ; the scullery drain discharged over a gully, and this gully also received the overflow from the rain water tank ; as time went on, the rain water became offensive, and on examining into the cause, it was discovered that through blockage of the drain by fat, regurgitation of scullery sewage had taken place into the rain tank, so that the rain Water in time became so foul it could no longer be used for household purposes, but was employed for watering the garden ; but at last the stench from the rain water tank became so bad, the gardener called his
A CONTP~IBUTION T O T H E master's attention to it, and they held a consultation about the matter at the place where the nuisance was. This was on a Saturday afternoon. The master ridiculed all idea of harm coming of the nuisance, but was prevailed upon to have something done, and gave instructions for the rain tank to be emptied on the following Monday. Next day morning, Sunday, though not feeling quite well, he performed his ministerial duty and preached a sermon, but in the evening he was not equal to this ; still, he managed to take some small part in the service ; before night he had to send for the doctor, and next day he died of most acute diphtheria. No. 4z is a case much to the same point, but not so tragic. It is of a woman washing in an outhouse, exposed in a most flagrant fashion to the escape of gas from a cesspool ; the immediate effect was to make her feel very unwell, and shortly after to have a severe attack of diphtheria. No trace of contagion from other source could be discovered, and she lived outside of the districts that had been infected. Disturbing Polluted Soil.--I have another point of a similar nature that I think deserves notice ; this refers to the risk of disturbing polluted soil. No. 68 was a woman living in a part that had not been attacked by diphtheria. She was the wife of a beerhouse keeper, and her duties called upon her to undertake washing of clothes ; this was done on a sink opposite to an open window that looks upon a small enclosed yard at the back of a public-house ; in this yard was a small urinal, and at that time the yard itself was paved with irregular squares of ragstone, leaving large interstices between the adjacent stones ; the urinal was unequal to the services required of it, and consequently the whole yard had been more or less put into requisition; this made it necessary for improvements to be undertaken, and in the course of these alterations the yard had to be " p e c k e d " up. Whilst this was being done, the wife was washing at the tub opposite the open window. I am told that whilst so engaged there was a great stench from the operations in the yard, and within a few hours she sickened with diphtheria. No. 97 was a child that would hang about watching the workmen employed upon the emptymg of a very foul cesspool and the relaying of drains connected therewith. No. 63 was a similar case. For the same, and other reasons, No. 86 is of the greatest interest and importance. To remedy gross sanitary defects, a renewal of the drainage was undertaken at the back of a house in Tovil, where a child, Gertrude, aged six years, pupil in the girls' department at Tovil Schools, lived. She watched the progress of the work, attended as it was by the usual offensive operations. She took the disease very severely August x4th, and died August I9th ; then for the first time it cameto
E T I O L O G Y OF D I P H T H E R I A .
~o9
my knowledge that four other children of this family had suffered from diphtheria between the 7th and I9th of June m Emily, nine years; Nelly, eight; Ernest, three ; and Harry, ten months. No doctor had been called in, the parents effectually concealed the occurrence ; the mother's description leaves not the shadow of a doubt of the nature of the illness of her children. She observed the " w h i t e " membrane in all their throats except Harry's, whose throat was so swollen she could not get a sight of it. At this time Gertrude also had sore throat, but her throat never had a white deposit upon it, and she continued to go to school, and so did Emily and Nelly, as soon as the severity of the disorder had passed off. Now immense importance attaches to these cases, for it is found that the commencement of the outbreak among the Tovil scholars, after perfect immunity during seventeen weeks, dates from almost the very day (June roth) of the commencement of the illness in this fsmily, and significantly enough after the thirty-third week, the date of Gertrude's case, and the discovery of the infective condition, and the consequent quarantine that was enfo~rced upon the family, only one other case appeared in the schools, though during the ten weeks (twenty-third to thirty-third) covered by the occurrences mentioned, no less than thirty cases of diphtheria appeared in Tovil ; and only two, one in the thirty-fourth week, and the final one in the forty-ninth week, have occurred since. The consideration of the cause of the delay of the manifestation of the disorder in this child brings up another point ot great interest. How comes it that this child, herself in the very thick of the disorder during June, and by implication she herself or her sisters acting as carriers of the complaint, for ten whole weeks escaped contagion until the middle of August ? Is it possible that she lived a charmed life, and whilst treading her perilous course had she passed through a cloud of dangers without having once exposed herself to actual danger? or can the disorder have been latent in her system for a whole ten weeks ? Or is it not more likely that something happened to make her system receptive of the poison at the later date that was absent in June ? It is even possible that the microbes set at liberty during the drainage operations above mentioned, may have been more plentiful, vigorous, or aggressive; in the present state of knowledge, I take it, it would be rash to venture to answer this question ; my belief inclines to the idea that something in the state of the body is developed that is attractive to the microbe by making provision for its reception, either in the way of food, or the suppression of something that is naturally antagonistic and a hindrance to it ; and this idea seems to have support by the following case. Nos. 79 and 80 were sisters, and both died of diphtheria in the thirtieth and thirty-first week of 1889, after which their mother, who had nursed
xxo
A CONTRIBUTION
TO THE
them, removed into another house, and was attacked in the forty-eighth week, seventeen weeks after her children's illness ; how else can we explain the reason why she escaped when her children were taken ? Connection bttween Diphtheria, Scarlet lever, and Measles.--This consideration naturally leads to the last point to which I have to refer under this head, namely, the association between diphtheria, scarlet fever, and measles. Frequently it has been noticed by others as well as myself that diphtheria is likely to be mixed up in a confused way with both scarlet fever and measles ; it was so in the case of No. 12, for the sister of this child had scarlet fever, and she herself was at first supposed to be sickening for the same disease, but'it developed into what was finally set down to diphtheria, and of which she died. (I ought perhaps to have mentioned earlier that during ~887, before the diphtheria began, mild scarlet fever had been very prevalent, and during i888 measles largely prevailed.) To return to the instances of assoclat i o n - - a next door neighbour of No. 24 had scarlet fever, and No. 24 died of a gangrenous sloughing sore throat, without rash, that was more like diphtheria than anything else ; an aunt to this latter child assisted in her nursing, and shortly after No. 28, the aunt's own child, that is a cousin of No. 24, died of undoubted diphtheria ; by the way, the mother of No. 28 borrowed clothes to attend the funeral of her own child of a neighbour, who was the mother of No. 3~, a child of eighteen months, and this child fell ill a very short time after the return of the clothes, and died of diphtheria. Case z 5 was the sister of two others ill at the same time as herself of ,scarlet fever, but No. 25 had diphtheria, and nearly died of it. Nos. 40 and 4 ' were both out in the rash of measles, when undoubted diphtheria set in. What can be the explanation of these, if indeed the association is other than fortuitous ? I can only imagine that the diseased condition of the faucial mucous membrane brought about by scarlet fever or measles may provide the pabulum in which the diphtheria microbe can flourish. Again and again it has been "observed that diphtheria epidemics arise as it were out of a cloud of ordinary and apparently nonspecific sore throat. Is it not possible that even ordinary catarrh may in some way render the mucous surface receptive? possibly by some chemical or biological change. M y idea is that the microbe lives a very precarious life, and the least thing is sufficient to turn the tide for or against its existence--a trifle too much or too little acidity or alkalinity, the presence or absence of a few benign micro-organisms may be all that is necessary to attract or repel the invasion, and determine the result. These cases seem to throw some little light upon the curious fact that the same person at different
E T I O L O G Y OF D I P H T H E R I A . times may at one time be receptive of the disease and another time not, and if they teach us nothing else, they indicate how very slight the differences may be that decides the balance whether the diphtheria organisms shall flourish or not, and encourage a search for more fundamental knowledge of its life history. The observations now about to be described are offered as a contribution in this direction. From all we know of diphtheria, it does not appear to be water-borne, nor to be easily air-borne, for though infectious, it seems to be so at close quarters only, and probably it is then communicated by particulate matter, such for instance as may pass from one individual to another in the acts of coughing, sneezing, or speaking; and so far as my experience goes there is nothing to encourage the belief that it is ever conveyed by water (in this respect differing widely from typhoid). Milk, and perhaps some other foods, though I have not found it so, may serve as vehicles, and if so, probably because they supply suitable pabula for the organism. I n short, everything goes to show that diphtheria is due to a microbe that lives a parasitic life upon dead or decaying animal matter, and that the animal body is liable to be attacked by it, just as it is by various other parasitic organisI'ns, the special phenomena of the disease being the result of the poison of its excretion, and there is nothing to forbid the belief that this organism, which neither air nor water appears to cherish, may live in the soil, and some observations that I have accumulated in recent years on subsoil water inferentially favour the belief. Influence of Subsoil IFater.--The observations I allude to were commenced during the year, ~884, and have been continued daily ever since, so that we now have a continuous record, extending over five years, of the depth in feet from the surface of the ground at which the subsoil water stood day by day throughout each of the five years, x885--i889 inclusive. T o bring these five years' records collectively under the eye for the purpose of comparison, the daily observations have been compressed into weekly periods, as set forth in the diagram, page x xi, which shows the range of movement of the subsoil water during each successive week, so that one can see at a glance when the alterations have been, how much or how little they have been, and whether rapid or slow. The maximum depth of water from surface .............................. = 17.7 feet. The minimum depth of water from surface ............................... ~ 15 ,, Total range ........................... = 2.7 ,, Average . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
~6.68 feet.
The first thing that strikes one is a similarity between the curves for x885 and r886 and x887 ;
A CONTRIBUTION d
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o ~t7
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TO THE
ETIOLOGY OF DIPHTHERIA.
III
this is very obvious, in each year we find a high and a low tide, the high tide coming at the early part of the year, and the low tide sometime about the junction of the third and fourth quarter ; far different, however, the curves for x888 and x889, in those years all order seems to be lost, each year ~c~ 3 presents several high and low tides, the maximum never being so high nor the minimum so low as in the three former years, from which we may infer that the soil during the three earlier years must h a v e b e e n more thoroughly washed during the colder seasons, and better drained and dried and aerated during the hotter seasons, whilst on the other hand, during the last two years the soil must have been kept in a condition of more or less stagnant saturation ; moreover, it is to be • observed that the coincidence of tide and season oO oo that prevailed in earlier years, was more or less reversed in the latter ; for examples in the middle of the first quarter of ~888 there is low tide when we should have expected high tide, and in the middle of the third quarter, the highest tide of the year where we might have looked for the lowest, and this was followed by nearly twelve months of comparative stagnation. By the way, it may be as well to remark that the rainfall is not the only factor concerned in the maintenance of the subsoil water level; surface evaporation has very &-- much to do with it, and consequently wind and sunshine are very important agents in the matter ; as a rule, heavy rainfall is soon followed by a rise in the subsoil water, but the full effect is often delayed some two or three months ; in illustration of this the 7.7 inches of rain that fell in the fourth quarter of x885 made no great show till the middle of the first quarter of x886, when there was less rain than the average ; this only shows how long a time it takes for the soil to get thoroughly dry, for of course the water for all ,o these months was in the soil, though it had not oo sunk to its proper level, this gives us a good idea oO .of the relative dryness of the soil in different seasons. So far as concerns the subsoil water level, these are the facts, and if we turn to those relating to the prevalence of diphtheria we find equally remarkable distinction between the three earlier years and the last two ; with the former there was very little diphtheria, with the latter much. Whilst the single high and low tides, in correspondence with the cold and hot seasons lasted, diphtheria m was scarce ; as soon as this favourabte order of oO things was interrupted, diphtheria began to prevail, and it is seen that there was least diphtheria when the correspondence between the high tide and coldest seasons and vice v e r s a was most exact; as for example, in I887, when there was the least diphtheria, on the contrary, every departure from this type seems to be attended by an increase of the prevalence of diphtheria ; for iustance~ the beginning of our epidemic was during the middle
iz2
A CONTRIBUTION
TO THE
of the first quarter of ~888, when a low tide usurped the place of a high one; and when the misplaced high tide did come to purge the soil, there was a pause in the prevalence, but again at the end of the year, and beginning of I889, when the annual washing of the soil ought to have taken place, and did not, and the accumulated pollution of the soil must have increased, the more serious outbreak occurred. Now what is the explanation of these occurrences ; was the diphtheria in any sense a consequence of, or only a coincidence with, the state of the soil and subsoil ? From all that has been written, one finds dampness of soil, defects of sewage, and other grave sanitary faults, always cropping up in reports on outbreaks of diphtheria; for example, in Mr. Power's valuable report on the North London epidemic he traced the chief incidence to a serious defect in a special sewage area, and by the way he draws attention to the effect of dead ends of sewers, such as I have already spoken of ; again, the same observer, in his report on Whitstable, describes a state of drainage faults, especially with respect to hand-flushed closets exactly parallel with our own case. The same again may be said of Aylesbury, as reported by Dr. Gresswell; and later on, concerning the same place, in a very valuable report by Mr. Spear, attention is specially called to recurring outbreaks occurring " i n damp houses exposed to draining defects and sewage effluvia," "closet nuisances," "foul sewer ventilators," and the association of localized outbreaks, in almost every case with grave defects of sewers and drains. I am afraid, when speaking of sewerage, hardly sufficient stress was laid upon the facts concerning the ventilator nuisance in Tovil. In Tovil, owing to the want of water, and the shockingly neglected state of the drains, this nuisance occurred habitually, and in a most serious manner, for it so happens the chief and most offensive ventilator in this line of sewer is situated just opposite the school gates consequently every child attending Tovil Schools must pass close to it, and from time to time must be assailed by a most horribly polluting stench. This makes it exceedingly difficult, if not impossible, to correctly assign the cause of each of the cases that occurred among the children of these schools from June xoth to August 21st, I889, as between contagion conveyed by Gertrude and her sisters on the one hand, and the ventilator nuisance on the other. Again to refer to Dr. Spear's report. In it there occurs a hypothesis whicb, as respects the views I am upholding, is of special interest; it " c o n t e m plates the operation of some extrinsic agent upon a miasmatic, as opposed to a purely contagious principle in diphtheria infection." If these observations on subsoil water are worth anything, they supply a link in the chain of causation which is contemplated in the above hypothesis.
ETIOLOGY OF DIPHTHERIA. So far as we have yet gone, our facts meteorological and pathological have been set forth with a view of ascertaining whether there be any general principle to be discovered in the gross. And now believing we have discovered, in the behaviour of the subsoil water, an underlying general principle, if we could, by coming to close quarters with the question, and applying in detail a more delicate test, by bringing together the individual cases of disease and the separate occurrences in the meteorology ; in doing this we might hope to find some definite concordance. I n any attempt however to do so, it must not be forgotten that there are serious difficulties to he encountered. In the first place, it is a difficult matter to fix with certainty the moment of inception, and far more difficult to discriminate between secondary cases that originate through personal or other mediate contagion, and those that arise from initial primary sources, and it is probable that in so complex a matter as this it is safer to deal with cases in the abstract than in the particular ; however, the temptation is so strong, to make the attempt, I have constructed diagrams which show side by side the the daily record of barometric pressure, temperature, rainfall, and height of subsoil water, and the date of inception of each case of diphtheria, as near as it could be fixed. With regard to the last item, for reasons, some of which I have already given, my experience leads me to the opinion that the incubation stage of diphtheria is very short indeed, and I think that it we date from the first slight feeling of illness, or sense of something being wrong, we shall probably be within a few hours of the time when the disease was taken, and as I have already related, in some instances a definite event is spoken to by the patient, which on the face of it certainly deserves to be taken into account when searching for the precise time and cause of the illness that follows; the first appearance of the diphtheritic membrane may be about two days later, and in the absence of any premonitory guide, this space of time may be taken as the usual period of incubation. Just a word of explanation regarding the rainfalI and the water level. The rainfall is plotted against the day on which it actually fell, the height of the water level on the day ot reading, so the difference between it and the record of the day before represents the movement that occurred during the 24hours preceding the record. By the way, some points of paramount importance must be taken before we proceed with o~ consideration of the diagram. How can the behaviour of the subsoil water level be supposed to. act? Is it mechanically, by forcing the germ charged air out of the soil into the air we breath% or is there some more intimate biological connection between the two things promoting the activity of the germ? Probably both ideas are correct. There can be little doubt that a damp condition o f
A CONTRIBUTION
TO THE
the soil favours the development of the microbe; in all probability it cannot live actually submerged in water, immersion would drown it, for it does not appear that there is a tittle of evidence to indicate that diphtheria is ever water-borne ; we must therefore believe that if it exists in the soil it lives somewhere above the water level. It is equally probable that much drought will kill it, and there can be no doubt that decaling albuminous matter is absolutely necessary for its existence. I n short it is aerobic, requiring its just proportion of moisture, heat, air, and albuminous food, and it seems to me that at or near the surface of polluted soil is the most likely place to find these conditions best fulfilled, and when these conditions are conjoined with the fluttering fluctuation of subsoil water that we found to occur in i888-89 . The soil must have been in a condition peculiarly favourable to the vigorous development and rapid multiplication of the microbe ; in this way we can imagine the interstices of the soil, at or near the surface, thronged by colonies of spore-bearing microbes, ready at any moment for distribution in the atmosphere, by any disturbance of the soil or other mechanical means whereby they could be driven out of the soil air to mingle with the atmosphere we brtathe, such for instance as must necessarily attend the sudden fall of the barometer, which in effect causes the germ-charged air to be aspirated out of the soil and sewers; as a proof that this does take place we need only be reminded of the common enough forecast, one so often hears, that becau:e of the stinks fiom the drains rain may be expected. For the same reason a sudden fall of rain is an eff~ctive cause in producing a like resuit, and many observant persons no doubt have had evidence through the sense of smell of the truth of this. Among others, Dr. Gresswell has noticed the association between throat disorders and increase " o f rainfall and certain uther meteorological changes ; " and lastly there is the rise of the level of the subsoil water, which of necessity pushes the air out of the soil, and if the air is germ-charged the germ may go with it ; change of temperature, so far as movement of the air is concerned, can have but trifling effect, so that as regards our study of the diagram our attention ought to be fixt.d on three things--the barometer, the rainfall, and the subsoil water-level. T o begin with, let us take a rough glance through the diagram. Our attention is first attracted by the association of diphtheria cases with three typical instances of sudden decrease of barometric pressure occurring on January 3xst and March i i t h and xsth , i888. Next we may observe the rise of the sub-soil water in March and November, i~'88, in February, I889, and the sudden rise in June and October, ~889. The effect of sudden rainfall may be seen at the end of October, and throughout November, i888. Again, in February and April, 1889, and from
ETIOLOGY OF DIPHTHERIA.
xi3
June 6th to ioth, almost daily in July, and again in October and December. The fall on June 6th I remember particularly well, it was a sudden deluge that accompanied a thunderstorm, it lasted but a few minutes, and my memory is especially impressed by the occurrence, because a poor lad in Tovil, whose fatal illness began on June 7th, was out in that storm, in a field, playing cricket, by the side of the Tovil stream, near the sewer ventilator at the margin of the stream ; remember, this sewer ventilator has often been frightfully offensive, and it is easy to imagine what the effect of this sudden rain must have had upon the contents of the foul house drains connected with this sewer ; how it must have forced forward and stirred up the festering filth, causing a pouring forth of a perfect blast of poisonous sewer gas at the ventilator. At this time, June 6th, there had been an absolute pause in the prevalence of diphtheria since April 3oth, no case had occurred in the town, and I have not the least doubt in my mind that this thunderstorm of June 6th, and the heavy rains of the 9th and xoth, set all the subsequent mischief a going. Besides the positive evidence afforded b y the observation of barometer, raingauge, and water level, the arrest of prevalence of diphtheria during May, June, and July, i888, and in a less marked degree during May and September, I889, in conjunction with the lowering of the sub-soil water at those times, offers negative evidence of no mean order. If we analyse the 99 cases carefully, to ascertain what correspondence exists between those several circumstances and the occurrence of diphtheria, we find in 6I instances there is distinct evidence of such coincidence, in the remaining 38 cases, I6 are accounted for by direct contagion 15 by some special circun~stances, and seven only remain unaccounted for, of these seven, my notes taken at the time, record against five o f them either doubtful, or very doubttul, as to the exact nature of the malady. igo. of Cases.
17 9 6 5
9 9
6
Favouring Circumstance.
Barometer, Rain ar,d Water level. Ba.ometer an0 Rain. Barometer and Wa~er levd. Rain and Water level. Barometer. Ram. Waler level.
6I
Total Meteorologieal.
16 7 3 5 7
Contagion. Drain Overflow. Disturbance of Polluted Soil. Associat~onwith ScaIlet FeverorMe~sles. Unaee unted for.
99
Total.
xx4
NORTHERN
I am not in a position at present to carry the case further than this. Dealing with complicated and difficult questions of fact and inference, it is not to be expected that one could do so without more extended opportunities of observations. The most I can hope for is that the opportunities this epidemic have afforded, have not been altogether wasted, but that it may prove that the observations here recorded contribute something towards the discovery of the mysterious influences that govern the origin and spread of diphtheria. N O R T H E R N NOTES. THE Smoke Abatement Organization, which has its head-quarters at the office of the Manchester and Salford Sanitary Association, is drawing the attention of all good citizens to the duty of purifying the air of manufacturing districts, and when funds sufficient are provided a series of experiments on the best means of smoke prevention are to be made. The medical officers of health of Oldham and Blackburn and some other Lancashire towns have also been active in the cause of smoke abatement. Indeed, in many localities a great improvement has already been effected, e.g., let anyone compare the present state of the green fields round Widnes and Runcorn, for instance, with the stretches of barren plain alone to be seen a few years back. A memorial to the late Angus Smith has been proposed--let alI who wish to honour his memory carry on the work which he so well began; and then, when a foreigner comes to seek the old chemist's memorial, the Lancashire lad can point to pure air and blue sky and say eircuras~ice. This ifitroduces another subject. The smoke nuisance is what it is in northern towns simply owing to steam being almost universally used, although in many localities there is water power running to waste. I f only water were used for driving machinery where it is available, the change would effect a wonderful improvdment in the purity of urban air. When the Americans have shown us the way, perhaps we shall set to work in this direction. A syndicate is already formed for using a little of the waste power in Niagara. The actual fall of level is about 200 feet, and it is calculated that if about four per cent. of the water going over the falls is taken there might be utilized x2o, ooo horse.power. It is proposed to take the water by a short lateral canal, to allow it to descend vertically in shafts in which turbines will be placed, and to discharge it by a tunnel tail-race, passing beneath the present town of Niagara at a point below the falls. It is part of the plart to transmit a portion of the power to Buffalo, eighteen miles distant. Surely something might be done in this country to replace steam by water power. It is not always that economy and public health point in the same direction.
NOTES. Much interest is taken in northern towns in the coming census. The report of the committee appointed by the Treasury to inquire into certain questions connected therewith, is regarded on the whole as satisfactory. All are in favour of enumerations being made every five years instead of every ten years, and that special attention should be given to the careful selection of enumerators. The omission of the word " r a n k " from the column heading " rank, profession, or occupation," is quite in accord with modern views. A better classification of occupations is also needed. It is a useful r.ecommendation also that householders should give the number of rooms occupied if less than five. Since the promulgation of the dog muzzling order there has been little heard of hydrophobia. However, rabies has lately appeared at Fulwood, near Preston. A farmer named Eccles, and a labourer in his employ left Preston for Paris on the night of July x3th , having been bitten on the 9th by a sheep dog which was afterwards found to be suffering from rabies. The two men are to place themselves under the care of M. Pasteur. The dog attacked three other dogs, and all four were destroyed. The questions that suggest themselves in isolated cases of this kind are : Where could this sheep dog have got rabies from ? Did it arise de nova ?
Has anyone had a long experience of fever hospital management without losing some of his faith in the intuitive dexterity of practitioners to diagnose febrile disease ? The writer of these notes, with an experience of fourteen years in this direction, has'received some odd fever cases. He does not complain of eases of pneumonia being sent in as "typhus," because for all he knows to the contrary pneumonia may be an infectious fever, and is better in hospital than elsewhere. What first shook his childlike faith in the carefulness of practitioners was a case of primary syphilis sent in as "typhus," and a case of well-marked secondaries sent in as small-pox. Then arrived a case of itch, also sent in as small-pox. This is no place for a list of curiosities of diagnosis, amusing as it would be. All that is asked for is the exercise of a little more care before consigning a poor patient to an infectious diseases hospital. During the present year the writer has had four cases sent him as "typhus," in none of which was the temperature a hundred degrees ; and he is now treating a ease of delirium tremens which was sent in as enteric fever. What a worry the filling in of printed forms has become! Two or three times a-week the hardworked medical officer of health receives applications from town clerks and surveyors and secretaries of various societies for information on all sorts of subjects. A printed list of queries accompanies each application, and the receiver is requested to fill in his answers without delay. Many of the questions asked, such as, What was the population of your town at the last census ?