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Diphtheria in Cardiff
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Diphtheria in Cardiff
DIPHTHERIA
IN
89
CARDIFF.*
BY E. WALFORD, M.D., D.P.H., Medical Officerof Health of Cardiff (C.B.). THE following notes are intended to present a few facts connected with the distribution of diphtheria in Cardiff which may, I hope, be of some interest to the members of this Branch of our Society : The number of notified cases of diphtheria, which rose from 235 in the fourth quarter of 1897 to 357 in the first quarter of 1898, declined to 218 in the second quarter in this year. The mortality from diphtheria in Cardiff was below the average in the large towns of England and Wales during the ten years ending 1896, being at the rate of 0"27, as compared with 0"29 per thousand, but was above that average in the year 1897, being at the rate of 0"53, as compared with 0"31 per thousand in the large towns. In the first quarter of 1898 the death-rate from diphtheria was at the rate of 1"17 per thousand, being 0"84 above the average in the large towns for the same period, and 0"69 above the London rate ; in the second quarter the rate fell to 0"83. In considering the complex causes which may have contributed to the recent prevalence of this disease in Cardiff, it is necessary to bear in mind the very rapid increase in the population of this locality, which, by producing a greater aggregation of persons, must of necessity have increased the opportunities for the extension of a disease which spreads mainly by the influence of personal infection. The following table shows the increase in the density of the population in the Borough of Cardiff ~since 1888 : TABLE
A.
Density of Population. Year.
1888 1889 1890 1891 1892 1893
......... ......... ......... ......... ......... .........
Persons p e r Acre.
14"7 15"3 15"9 17"7 18"5 23"5
Year.
1894 . . . . . . . . . 1895 . . . . . . . . . 1896 . . . . . . . . . 1897 . . . . . . . . . 1898 . . . . . . . . . .
Persons p e r Acre.
24"6 25"7 26 8 28"1 29"3
Again, it is obvious that the spread of a disease in this way is favoured by the facilities of communication which now exist between all parts of the kingdom. A distinct relation, therefore, is to be expected between diphtheria prevalence in Cardiff and the prevalence * Read before the West of England and South Wales Branch of the Incorporated Society of MedicalOfficersof Health, July, 1898. 7
90
Diphtheria in Cardiff
tPub~eae~t~
of the disease in neighbouring localities having a constant railway communication with this town. Assuming that personal infection is the most important factor in the spread of diphtheria, it is difficult to understand why this factor should be so much more potent at one time than another, producing at irregular intervals extensive epidemics. Although the steady increase which has been so marked in London and the large towns since about 1875 may be due to increased density of population, and the greater aggregation of children at ages susceptible to the infection, the excessive increase which occasionally takes place in some years seems out of all proportion to the natural or estimated increase in the population. These epidemic extensions of diphtheria seem to be due to some influence operating in many parts of the country at the same time. We notice, for instance, that the maximum mortality occurred in London, in Cardiff, and in many other large towns in the same year--1898. A certain peculiarity is noticed in the distribution of the diphtheria mortality in England. The increase in the whole country is due solely to an increase in the large towns. In the country districta fatal diphtheria has diminished in amount. In 1855-60 the rate was 123 per million in the large towns, as compared with 9.49 in the rural districts. In 1861-70 the large towns still have proportionately less fatal diphtheria than the country districts, the rate being in the large towns 163, as compared with 59.3 per million ; but in 1881-90 the relation is entirely changed, the death-rate being 190 in the large towns, as compared with 159 in the rural district. Coincident with the increase in diphtheria, there has been a decrease in other diseases known to be associated with bad sanitation. The conditions which influence the spread and develop. ment of diphtheria are apparently quite dissimilar from those which favour the spread of enteric fever, a disease regarded by most authorities as essentially a filth disease. In comparing the mortality from these two diseases in England and Wales, we find that in the decennial period--1871-80--the diphtheria death-rate was 19.1 per million of the population, as compared with 168 in the period 1881-90, whereas during the same period the enteric fever deathrate decreased from 39.9. to 196. TABLE B. A n n u a l D e a t h s per M i l l i o n - - E n g l a n d and W a l e s . A n n u a l Increase 1871-80.
All
causes
. . . . . .
Diphtheria Enteric f e v e r
1881-90.
19,080
o r D e c r e a s e , 1881-90L
21,2'/2
...
...
...
121
...
163
...
- 2,192 q-42
...
322
...
196
...
- 126
November, 1898]
Diphtheria in Cardiff
91
A n n u a l D e a t h s p e r Million--London. Diphtheria Enteric fever
1871-80. 122 244
... ...
... ....
1881-90. 259 189
1886-95. 410 150
... ...
... ...
1896. 600 140
Annual D e a t h - r a t e per Million--Diphtheria.
1855-60. Large towns ...... Rural Districts
...
123 249
1861-70. ... ...
1885-94. England London Large towns
...... ...... ......
202 889 250
163 223
1881-90. ... ...
1895. ... ... ...
260 536 350
190 159
1896. ... ... ...
292 600 380
If defective sanitation were responsible for the development and spread of diphtheria, we should expect that its influence would be shown upon the general health of the community, and that a high general death-rate would result, particularly an increased prevalence of enteric fever. So far as Cardiff is concerned, the reverse has been the case. The general death-rate (14"9) in the very year (1897) in which diphtheria was so prevalent was, as compared with other large towns, the lowest, with the exception of Croydon. Since 1892 the general dearth-rate in Cardiff has been considerably below the average rate in the thirty-three large towns, and the mortality from enteric fever has been exceptionally low. The following table gives the death-rate from fever (including typhus, typhoid, and continued fevers) in England and Wales, the thirty-three large towns, and in Cardiff, from 1887-97. F e v e r Mortality (including Typhus, Typhoid, and Continued F e v e r s ) . - - D e a t h - r a t e s p e r 1,000 of the Population. TABLE
C.
1887. ] 1888. 1889.i 1890. 1891. 1892.I 1893. 1894. 1895. ~
33 l a r g e t o w n s Cardiff ......
1897.
.., / 0"22 [ 0"201 0"20 ~0"19 0"20 0"15 0"24 / 0"19 / 0 " 2 0 0"19 ] 0"18 I 0"16 t 0"33 t 0"25 0"19
I0"190'190"1210"0410"I00'0810"II1
Table D gives the death-rates from diphtheria, enteric fever, and scarlet fever respectively in Cardiff since 1881, showing the increasing rate in the case of diphtheria, and the decreasing rate in the case of scarlet fever and enteric fever: 7--2
D i p h t h e r i a in Cardiff
92
TABLE Death-rate
per
1881-90. 1886-95__ 1891.
260 190 270
Diphtheria... 410
/ 210
[Public Health
D.
MilHon--Cardiff. 1892.
1893.
1894.
260 190 620
680
1460
270
50
loo l 5o
1895.
1896.
360 100 50
370 80
1897.
110 100
170
i
The local incidence of scarlet fever appears to bear some relation to that of diphtheria. Taking the year 1896, the notifications from scarlet fever and diphtheria are seen to increase coincidently, as shown in the following table : Number of Notifications,
1st 2nd 3rd 4th
Quarter Quarter Quarter Quarter
Scarlet Fever. 130 149 262 333
...... ...... ...... ......
Number of Noti~cations,
Diphtheria. 56 60 71 109
...... ...... ...... ......
Calculated on the estimated population, the attack-rate or proportion of notified cases per thousand was for each registration sub-district as follows : Attack Rates per 1,000 of Estimated Population. 1898. 1896. Registration Sub.district.
W e s t Cardiff ... E a s t Cardiff ... C e n t r a l Cardiff
1897.
let Quarter.
2nd
Quarter.
Icarlet DiphScarlet I DiphScarlet I Diph- I Seariet I Diph. theria. _ F e v e r . theria. Fever__ t h e r i a . _ 'e'er' I t~°ria' i _Fever.
5'9
2"4
7"6
I 5"0
5.5 j r8 t 8.4 9.~ 8"4 / re t r8 I x'8
7-0 2.5 14-o
4.s tla.4 8.3 18"8
8.0;
2'2
1'0
/
/
3"3
] 3"4
With respect to the foregoing figures, it will be noticed that the relative position of incidence of both diseases with regard to the districts remains in each case the same--the highest rate in the Western District and the 1Qwest in the Central. Cardiff is divided by a natural boundary--the river Taft--into East and West Cardiff, and artificially into three registration sub. districts, West Cardiff sub-district being entirely on the western side of the river, the Eastern and Central Sub-districts being both on the eastern side. The sewers in the East and Central Districts discharge by outfalls directly into the Bristol Channel near the eastern boundary of the
Sovombor,lS~81
D i p h t h e r i a in Cardiff
93
borough, and have no connection whatever with those on the western side of the river, which discharge into the tidal estuary of the Taft. Both systems are tide-locked at the outfalls twice in the twenty-four hours. The western outfall is somewhat unsatisfactory, both as regards situation and capacity, and at times the lower parts of this district have suffered from this defect. With this exception both systems are very similar in construction, the sewers are well ventilated and flushed, but owing to the physical conformation of the locality the gradients are for the most part low. On the whole, the complaints of smells from the ventilators, which, with one or two exceptions, open on to the surface of the road, are not numerous, and not more so on one side of the town than on the other. I see no reason, therefore, for attributing the peculiar distribution of diphtheria to any insanitary condition of the districts chiefly affected. There is nothing to indicate that the higher attack rates in the western and eastern districts are connected with drainage defects, or that the comparatively low attack-rate in the central district is due to any superior sanitary conditions. The fact that scarlet fever has, since 1896, shown the same relative local distribution as diphtheria suggests an entirely different explanation. The spread of scarlet fever is reeognised on all hands to be entirely due to personal infection. No case can occur unless through the direct or indirect medium of a pre-existing case. Its spread will thus depend upon the facilities for the transmission of infection from person to person. Diphtheria, like scarlet fever, is essentially a disease of childhood. The facilities for the spread of infection will be increased, therefore, in communities in which the proportion of young children is high, and especially where such proportion has rapidly increased. There is good reason for believing that the western and eastern sub-registration districts of Cardiff offer, by the age distribution of their population, special facilities for the spread of diphtheria, a disease which, like scarlet fever, depends largely, if not entirely, upon personal infection for its extension. From their position these districts would naturally contain the greater part of the new and constantly increasing localities, whereas the central district has comparatively limited opportunities for extension. In evidence of this, it may be mentioned that during recent years the birth-rate has been higher in the western and eastern districts than in the central, and that in these districts the increase in the number of inhabited houses has been much greater.
94
D i p h t h e r i a in C a r d i f f
[Pubno aealth
The following tables show the relative position of the bir~h-rate in these districts in the year 1897 • Birth-rate, 1897. West Cardiff Sub-Registration District East Cardiff ,, ,, Central Cardiff . . . .
... ... ...
38"6 per 1,000. 30"5 ,, 27"7 ,,
The increase in the number of inhabited houses in each district since 1891 is given below : N u m b e r of Inhabited Houses. West Cardiff East Cardiff
Census in 1891.
189/.
Increase.
...
6,586 5,888
9,214 9,041
2,678 3,203
...
S,102
8,~0V
......
Central C~rai~ :::
~05
Unfortunately, the tables pi~blished in the census returns do not contain the age distribution of the population in the municipal wards, or in the registration sub-districts, so that it is impossible, from the available data, to estimate the proportion which the juvenile population bears to the entire population in any of these divisions of the town at the present time. But through the courtesy of Dr. John Tatham, of the General Register Office, Somerset House, who was good enough to furnish me with some unpublished ~ables, I was able to obtain the age distribution in groups of enumeration districts according to the census of 1891. These groups are not, however, coterminous with the wards, but consist each of parts of different wards. Taking one group, which consists of 12,955 persons at all ages living in the central registration subdistrict, and another group of 14,677 persons living in the west registration sub-district, I find tha~ the proportion of persons under fifteen years of age was 33"5 per cent. in the former, as compared with 41"5 per cent. in the latter district. As none of the enumeration districts consist entirely of inhabitants of the east registration sub-district, it is impossible to give the proportion in ,this division, but in any case it is clear that the proportion of children under fifteen years of age is greater in the western than in the central district, and, therefore, that the opportunities for the spread of infection would be greater in the former than in the latter district. There is an impression that diphtheria has always been more prevalent in the western part of the town. The following tables, which refer to the years 1893-97 inclusive, will show that this is
:No,e,-~r, x89S]
Diphtheria in Cardiff
95
not the case. They give the attack- rate and death-rate from diphtheria in each district per thousand persons living, calculated on the census population of 1891 : West Cardiff.
East Cardiff.
Central Cardiff.
Year.
1893 1894 1895 1896 1897
...... ...... ...... ...... ......
Death Rate.
Attack Rate.
Death Rate.
0'2 0"4 0 "4 0"9 1 "4
0"7 1'6 1 "4 3"4 7 "3
1"3 0"6 0'5 0"2 0"3
Attack Rate. •
5"5 4"8 3"6 2"6 3"3
Death
Ral~
0"6 0"3 0"1
0"1 0"8
Attack Rate.
2"6 1"6
0"8 1"1 1"8
With respect to the above rates, it must be noticed that, as they are calculated on the census population of 1891, they are, in the case of the western and eastern districts, probably too high, owing %0 ~he more rapid increase in the population in these districts than in the central district. But even if calculated on the estimated population for these years, the rates would mainrain the same relative position, although the increase in those districts would be less marked. This is shown in the preceding tables giving the attack-rate for diphtheria and scarlet fever for 1896 and 1897, calculated on the estimated population. In the foregoing tables the relative prevalence of diphtheria in each division of the town is indicated by the attack-rate and death-rate per thousand of the population. In the following tables the variety of the type of the disease is shown as it occurred in different localities by the percentage mortality of the cases--that is, by the proportion of deaths to cases notified. It is somewhat strange to find the extreme variation in the fatality of the cases which occurred in some of the municipal wards. The explanation of this diversity is to be found in the difference of the ages of those attacked in the various districts (diphtheria being a disease in which 95 per cent. of the total deaths occur amongst children under fifteen years of age). But I am unable to offer any explanation as to the remarkable preponderance of mild and adult cases in one particular municipal ward. Why, for instance, in 1896 should 42"0 per cent. of the cases notified in the Splott Ward be over thirteen years of age as compared with 14"8 per cent. in the Canton Ward, and in 1897 54"0 per cent. as compared with 22 per cent. in the Grangetown Ward ?
96
Diphtheria in Cardiff
E~bUeSealta
Case Mortality, or P r o p o r t i o n of Deaths to Cases of D i p h t h e r i a Notified. 1894. Canton Ward Splott Ward ......
...
Mortality. 45"4 p e r c e n t . 7"5 ,,
1896. Canton Ward Splott Ward ......
37"0 6"0
Grangetown Ward Splott Ward ......
1895. Grangetown Ward Splott Ward ......
...
Mortality. 31"5 p e r c e n t . 9-6 ,,
1897. ...
,, ,,
...
26"7 6"6
,, ,,
The peculiarity in the age-distribution of the disease which brought about this varying mortality is shown in the following table, which gives the proportion of cases of diphtheria notified under thirteen years and over thirteen years respectively, in each of the above wards, for the same periods : 1894. Canton Ward
Sic
Splott Ward
......
"'"
] C a s e s u n d e r 13 y e a r s , 82"0 p e r c e n t . ~ ,, o v e r 13 ,, 18"0 ,, {
,,"
underover1313
,,"
38"061"0
,,"
1895. Grangetown Splott Ward
Ward
400
......
[ C a s e s u n d e r 18 y e a r s , 78"0 p e r c e n t . ~ ,, o v e r 13 ,, 22"0 ,, {
" ,,
u n d e r 13 o v e r 13
,, ,,
58"0 42"0
,, ,,
1896. C a n t o n W a r d ... "-
) - C a s e s u n d e r 13 y e a r s , 85"0 p e r c e n t . L ,, o v e r 13 ,, 14"8 ,, f
Splott Ward
,, ,,
u n d e r 13 o v e r 13
,, ,,
58"0 42"0
,, ,,
) ' C a s e s u n d e r 13 y e a r s , 78"0 t ,, o v e r 13 ,, 22'0
,, ,,
(
,, ,,
1897. GrangetownWard Splott Ward
......
...
" ,,
u n d e r 18 o v e r 13
,, ,,
46"0 54"0
The following tables show the age- distribution of cases of diphtheria reported in each ward in Cardiff in 1897, and it is important to notice that the greatest incidence of the' disease falls upon persons between the ages of three and thirteen--that is, at ages when children are attending school, and when the facilities for transmitting the infection from person to person are great~st. It has been pointed out by observers that this does not of necessity imply that children are more likely to become infected in the classrooms of the school, but rather that the infection is spread at the Limes of entrance and of' leaving school and in playgrounds, when
Diphtheria in Cardiff
Sove,-ber, 18981
97
the scholars are more intimately associated and mix more closely than during the hours of study. It is interesting to notice in this connection the drop in the weekly notification of diphtheria which occurs during the August holidays. TABLE
E.
Diphtheria,
1897.
Age Periods of reported Cases.
First Quarter.
Second Quarter.
Third Quarter.
Fourth Quarter.
Under three years ...... Three and under thirteen Thirteen and under twenty-five Twenty-five and upwards ...
19 47 12 13
15 50 19 14
11 48 20 9
153 32 25
70 298 83 61
Total
91
98
88
235
512
......
TABLE
25
Year.
F.
Diphtheria, 1897.--Percentage of Cases a t Age Periods to Cases reported in each W a r d . Total Number Under of Cases of Three Years. all Ae~es.
Ward.
C e n t r a l ... South ... C a t h a y s ... Park Adamsdown R i v e r s i d e ... Canton ... Roath ... Grangetown Splott ...
° . .
. . °
. . °
. . .
D@I
. ° .
. ° .
16 21 47 62 17 105 103 25 86 30
Per cellt. 12"1 28"4 10"6 11"2 17 "6 9"8 19 "4 . . .
22 '1 6"6
Three and under Thirteen.
Thirteen and under Twenty-five.
Twenty.five and upwards.
Per cent. 68 "3 66 "9 55"3 56"4 52'9 51"9 53 "4 64"0 55"4 40 "0
Per cent.
Per cent. 12"1 9"5 6"3 20"9 11"7 12 "7 8"7 16"0 10"4 26"6
6'25 . . ,
23"4 11"2 17"6 25 "4 18"4 20 '0 11"6 26"6
The foregoing data, without altogether excluding other influences, point, I think, conclusively to personal infection as the most important factor in the spread of diphtheria. A noticeable circumstance, and pointing to the same conclusion, is the close connection which diphtheria prevalence in Cardiff bears to the prevalence of the disease in neighbouring localities, especially to those having an extensive communication with this town by means of railway passenger traffic. At ordinary times the inhabitants of the Rhondda Valley and South Wales colliery districts are passing constantly and in large
:98
D i p h t h e r i a in Cardiff
~eubuc Health
numbers to and from Cardiff, and one might naturally expect that this would lead to the dissemination of diseases which may be communicated from person to person. A study of the health statistics relating to the urban sanitary districts of Rhondda, Merthyr Tydfil, and Aberdare, in conjunction with those of Cardiff, show a relationship in the diphtheria p~:evalence in these districts which is, I think, too marked to be altogether accidental. The amount of diphtheria in these districts in 1897 may be judged by the fact that, whereas the mortality in this year in Cardiff was high, being, in fact, higher than that in London, and considerably higher than the average in the large towns, it was still higher in these colliery districts. In the Annual Summary of the Registrar-General for 1897 relating to the statistics of 100 large towns in England and Wales, it is stated that " the highest diphtheria death-rates were 0"62 in Rhondda and in Merthyr Tydfil, 0"63 in Great Yarmouth, 0"64 in Willesden, 0"76 in Worcester, 0"82 in Aberdare, 0"87 in Gloucester, and 2"62 in Longton." The diphtheria death-rates were as follows, as compared with London and the thirty-three large towns :
Diphtheria Death-rates. 1898. 1897. First Quarter. Second Quarter.
London ... 33 large t o w n s ......... R h o n d d a U r b a n District ... M e r t h y r Tydfil ......... Aberdare . . . . . . . . . . . . Cardiff . . . . . . . . . . . .
0"51 0"31 0 "62 0"62 0"87 0"52
0'33 0"48 0"84 1"16 2 "09 1"17
i
0"33 0"24 0"27 0"23 1 "09 0"83
All r a t e s per 1,000 of populations.
The accompanying Chart A shows the number of notifications in each week of the first and second quarters of 1898 in the Rhondda, Pontypridd, Merthyr, Mountain Ash, and Cardiff urban districts respectively. From this will be seen a certain correspondence as regards time in the prevalence of diphtheria in these places, a marked fall in the notifications, commencing in March, following upon the rise in January and February. This fall in diphtheria prevalence in both cases may, of course, have been due to the natural termination of the epidemic from the exhaustion of susceptible material, but it is suggestive that it should closely correspond in point of time wi~h ~he interrupted railway communication
November,1898]
D i p h t h e r i a in Cardiff
99
between these localities, consequent upon the strike of the colliers in these districts. In this case the opportunities for infection must have been lessened by the reduction in the number of visitors from infected places. MOv~'~. dANUAI~. . ~ , , , . ,
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CHARTA. In the foregoing remarks I have indicated what I consider to be the most important factor in the spread of diphtheria, and although I have been unable to attribute any direct influence to special local insanitary conditions requiring attention, I do not consider the sanitary authority altogether powerless in this matter. Any further preventive measures which might be undertaken should be in the direction of checking the indiscriminate commingling of infected and non-infected persons. I have already pointed out that this probably takes place most extensively during the assembly of children at school. It is most desirable, therefore, that every possible means should be used to prevent the attendance at school of children suffering from any form of sore throat. This is, of course, done at present in those cases where diphtheria is notified to the sanitary authority. But diphtheria is a disease which often occurs in a mild form; it is then not recognised by the parents, who, in ignorance, allow
100
D i p h t h e r i a in Cardiff
rPublic Health
children who may be suffering slightly to attend school and mix with others, and so spread the infection. In this matter the school authorities might be urged to undertake an efficient system of medical examination of pupils, and a rigid exclusion of all those who would be likely to spread infection, working in this matter in co-operation with the sanitary authority. It is obvious that the prompt isolation of infected children would very often prevent a severe outbreak of disease, and lead in the long-run to the increase in the average attendance at school. Too little attention is paid to school hygiene generally, particularly as regards ventilation and overcrowding. The structural arrangements may be, as they generally are in the public elementary schools, satisfactory, but a more complete medical or sanitary supervision of the scholars themselves, and of class-rooms during school-hours, is much to be desired, and would, I think, be of advantage to schools in particular and to the public in general. It would be inconvenient and impossible in a large town for the medical officer of health to undertake himself the work of medically inspecting children on admission to school; but he could, I presume, act as adviser in health matters to 'the school authority, and such inspection could be performed by local medical practitioners acting under the direction of the medical officer of health. Such a joint system would bring the school authority and the sanitary authority into closer co-operation, and obviate any possible friction between the two authorities. With respect to any further preventive measures which might be undertaken independently by the sanitary authority itself, they should, I think, be in a position to assist medical practitioners in forming an accurate diagnosis of iufectious diseases by carrying out, as a part of the public health work of the district, bacteriological examinations in connection with such diseases. This important subject was recently discussed at the meeting of the British Medical Association at Edinburgh, where a resolution was passed "inviting the Council of the Association to take steps to press upon the Legislature the urgent necessity of providing each sanitary district with a bacteriological laboratory, available for gratuitous examination of morbid products for the purpose of the early diagnosis of infectious disease." I have already alluded to the difficulties that exist in the recognition by the general public of the early symptoms of diphtheria. The difficulty of diagnosing the disease by medical men is also often great, and can only be cleared up by a careful bacteriological examination. A case mortality, varying from 45 per cent. in one
Sovember,xsss~
Notification of Measles
101
part of the town to 6 per cent. in a n o t h e r part, indicates that the disease was very different in character in these different localities, and it is probable that a large proportion of the adult and mild cases which occurred in those districts in which the mortality was very low would, with a more extended use of bacteriological methods of diagnosis, have proved not to have been diphtheria a~ all. Hospital isolation in cases of diphtheria has not yet been tried on a scale which could give it a fair chance as a preventive measure, but much may be hoped for from the increased accommodation shortly to be provided in this district, which will allow of the proper isolation of a far larger proportion of cases than has hitherto been possible.
NOTIFICATION OF MEASLES. BY W. R. ETCHES, D.P.H. Medical Officer of Health of Macclesfield. IN considering the measures possible to a Sanitary Authority against this disease, notification by medical certificate is obviously of little use, because comparatively few of the eases are seen by medical men, and when medical assistance is called, it is usually in consequence of complications coming on after the disease is well marked and has already exerted its infection, too late for useful interference from a preventive point of view. The alternative is to rely on the schools for timely information of the occurrence of cases ; this, taken along with the intimation of deaths from measles made by the registrars, enabled me, though tardily, to know something of what was going on. It is manifest that by a little extension of existing arrangements i~ should be possible for the School Board to obtain cognizance in nearly all the schools as soon as infectious disease has appeared, and so at once to apprize the Health Office. As it is, we are indebted to the schoolmasters for information as soon as they become aware of a serious amount of infection in a school. Unfortunately, that is often somewhat late. During the year I have naturally had the question of the utility of school closure much before me, especially because, in spite of all the schools except one being closed this year, the disease spread through the whole town except Broken Cross. I believe it is useless to expect to check this infection by school closing even for a lengthy period. It exerts, however, a retarding influence upon it, and lessens the number of cases. When infection gets into an infant-school it spreads rapidly among the scholars. Upon two occasions one school was severely attacked, while another not far off was comparatively free; this can only be explained by a rapid infection running through the school. The policy which has been adopted was to close the school when there was sufficient evidence of a school infection. Generally speaking, if 15 per cent. of children are absent simultaneously on account of measles, a school infection may be inferred. Before this necessity for closing is reached, there is the useful measure of refusing admittance to all children from infected houses, and sending children home at once who show signs of commencing illness.--A./~., 1897.
Diphtheria in Cardiff
DIPHTHERIA
IN
89
CARDIFF.*
BY E. WALFORD, M.D., D.P.H., Medical Officerof Health of Cardiff (C.B.). THE following notes are intended to present a few facts connected with the distribution of diphtheria in Cardiff which may, I hope, be of some interest to the members of this Branch of our Society : The number of notified cases of diphtheria, which rose from 235 in the fourth quarter of 1897 to 357 in the first quarter of 1898, declined to 218 in the second quarter in this year. The mortality from diphtheria in Cardiff was below the average in the large towns of England and Wales during the ten years ending 1896, being at the rate of 0"27, as compared with 0"29 per thousand, but was above that average in the year 1897, being at the rate of 0"53, as compared with 0"31 per thousand in the large towns. In the first quarter of 1898 the death-rate from diphtheria was at the rate of 1"17 per thousand, being 0"84 above the average in the large towns for the same period, and 0"69 above the London rate ; in the second quarter the rate fell to 0"83. In considering the complex causes which may have contributed to the recent prevalence of this disease in Cardiff, it is necessary to bear in mind the very rapid increase in the population of this locality, which, by producing a greater aggregation of persons, must of necessity have increased the opportunities for the extension of a disease which spreads mainly by the influence of personal infection. The following table shows the increase in the density of the population in the Borough of Cardiff ~since 1888 : TABLE
A.
Density of Population. Year.
1888 1889 1890 1891 1892 1893
......... ......... ......... ......... ......... .........
Persons p e r Acre.
14"7 15"3 15"9 17"7 18"5 23"5
Year.
1894 . . . . . . . . . 1895 . . . . . . . . . 1896 . . . . . . . . . 1897 . . . . . . . . . 1898 . . . . . . . . . .
Persons p e r Acre.
24"6 25"7 26 8 28"1 29"3
Again, it is obvious that the spread of a disease in this way is favoured by the facilities of communication which now exist between all parts of the kingdom. A distinct relation, therefore, is to be expected between diphtheria prevalence in Cardiff and the prevalence * Read before the West of England and South Wales Branch of the Incorporated Society of MedicalOfficersof Health, July, 1898. 7
90
Diphtheria in Cardiff
tPub~eae~t~
of the disease in neighbouring localities having a constant railway communication with this town. Assuming that personal infection is the most important factor in the spread of diphtheria, it is difficult to understand why this factor should be so much more potent at one time than another, producing at irregular intervals extensive epidemics. Although the steady increase which has been so marked in London and the large towns since about 1875 may be due to increased density of population, and the greater aggregation of children at ages susceptible to the infection, the excessive increase which occasionally takes place in some years seems out of all proportion to the natural or estimated increase in the population. These epidemic extensions of diphtheria seem to be due to some influence operating in many parts of the country at the same time. We notice, for instance, that the maximum mortality occurred in London, in Cardiff, and in many other large towns in the same year--1898. A certain peculiarity is noticed in the distribution of the diphtheria mortality in England. The increase in the whole country is due solely to an increase in the large towns. In the country districta fatal diphtheria has diminished in amount. In 1855-60 the rate was 123 per million in the large towns, as compared with 9.49 in the rural districts. In 1861-70 the large towns still have proportionately less fatal diphtheria than the country districts, the rate being in the large towns 163, as compared with 59.3 per million ; but in 1881-90 the relation is entirely changed, the death-rate being 190 in the large towns, as compared with 159 in the rural district. Coincident with the increase in diphtheria, there has been a decrease in other diseases known to be associated with bad sanitation. The conditions which influence the spread and develop. ment of diphtheria are apparently quite dissimilar from those which favour the spread of enteric fever, a disease regarded by most authorities as essentially a filth disease. In comparing the mortality from these two diseases in England and Wales, we find that in the decennial period--1871-80--the diphtheria death-rate was 19.1 per million of the population, as compared with 168 in the period 1881-90, whereas during the same period the enteric fever deathrate decreased from 39.9. to 196. TABLE B. A n n u a l D e a t h s per M i l l i o n - - E n g l a n d and W a l e s . A n n u a l Increase 1871-80.
All
causes
. . . . . .
Diphtheria Enteric f e v e r
1881-90.
19,080
o r D e c r e a s e , 1881-90L
21,2'/2
...
...
...
121
...
163
...
- 2,192 q-42
...
322
...
196
...
- 126
November, 1898]
Diphtheria in Cardiff
91
A n n u a l D e a t h s p e r Million--London. Diphtheria Enteric fever
1871-80. 122 244
... ...
... ....
1881-90. 259 189
1886-95. 410 150
... ...
... ...
1896. 600 140
Annual D e a t h - r a t e per Million--Diphtheria.
1855-60. Large towns ...... Rural Districts
...
123 249
1861-70. ... ...
1885-94. England London Large towns
...... ...... ......
202 889 250
163 223
1881-90. ... ...
1895. ... ... ...
260 536 350
190 159
1896. ... ... ...
292 600 380
If defective sanitation were responsible for the development and spread of diphtheria, we should expect that its influence would be shown upon the general health of the community, and that a high general death-rate would result, particularly an increased prevalence of enteric fever. So far as Cardiff is concerned, the reverse has been the case. The general death-rate (14"9) in the very year (1897) in which diphtheria was so prevalent was, as compared with other large towns, the lowest, with the exception of Croydon. Since 1892 the general dearth-rate in Cardiff has been considerably below the average rate in the thirty-three large towns, and the mortality from enteric fever has been exceptionally low. The following table gives the death-rate from fever (including typhus, typhoid, and continued fevers) in England and Wales, the thirty-three large towns, and in Cardiff, from 1887-97. F e v e r Mortality (including Typhus, Typhoid, and Continued F e v e r s ) . - - D e a t h - r a t e s p e r 1,000 of the Population. TABLE
C.
1887. ] 1888. 1889.i 1890. 1891. 1892.I 1893. 1894. 1895. ~
33 l a r g e t o w n s Cardiff ......
1897.
.., / 0"22 [ 0"201 0"20 ~0"19 0"20 0"15 0"24 / 0"19 / 0 " 2 0 0"19 ] 0"18 I 0"16 t 0"33 t 0"25 0"19
I0"190'190"1210"0410"I00'0810"II1
Table D gives the death-rates from diphtheria, enteric fever, and scarlet fever respectively in Cardiff since 1881, showing the increasing rate in the case of diphtheria, and the decreasing rate in the case of scarlet fever and enteric fever: 7--2
D i p h t h e r i a in Cardiff
92
TABLE Death-rate
per
1881-90. 1886-95__ 1891.
260 190 270
Diphtheria... 410
/ 210
[Public Health
D.
MilHon--Cardiff. 1892.
1893.
1894.
260 190 620
680
1460
270
50
loo l 5o
1895.
1896.
360 100 50
370 80
1897.
110 100
170
i
The local incidence of scarlet fever appears to bear some relation to that of diphtheria. Taking the year 1896, the notifications from scarlet fever and diphtheria are seen to increase coincidently, as shown in the following table : Number of Notifications,
1st 2nd 3rd 4th
Quarter Quarter Quarter Quarter
Scarlet Fever. 130 149 262 333
...... ...... ...... ......
Number of Noti~cations,
Diphtheria. 56 60 71 109
...... ...... ...... ......
Calculated on the estimated population, the attack-rate or proportion of notified cases per thousand was for each registration sub-district as follows : Attack Rates per 1,000 of Estimated Population. 1898. 1896. Registration Sub.district.
W e s t Cardiff ... E a s t Cardiff ... C e n t r a l Cardiff
1897.
let Quarter.
2nd
Quarter.
Icarlet DiphScarlet I DiphScarlet I Diph- I Seariet I Diph. theria. _ F e v e r . theria. Fever__ t h e r i a . _ 'e'er' I t~°ria' i _Fever.
5'9
2"4
7"6
I 5"0
5.5 j r8 t 8.4 9.~ 8"4 / re t r8 I x'8
7-0 2.5 14-o
4.s tla.4 8.3 18"8
8.0;
2'2
1'0
/
/
3"3
] 3"4
With respect to the foregoing figures, it will be noticed that the relative position of incidence of both diseases with regard to the districts remains in each case the same--the highest rate in the Western District and the 1Qwest in the Central. Cardiff is divided by a natural boundary--the river Taft--into East and West Cardiff, and artificially into three registration sub. districts, West Cardiff sub-district being entirely on the western side of the river, the Eastern and Central Sub-districts being both on the eastern side. The sewers in the East and Central Districts discharge by outfalls directly into the Bristol Channel near the eastern boundary of the
Sovombor,lS~81
D i p h t h e r i a in Cardiff
93
borough, and have no connection whatever with those on the western side of the river, which discharge into the tidal estuary of the Taft. Both systems are tide-locked at the outfalls twice in the twenty-four hours. The western outfall is somewhat unsatisfactory, both as regards situation and capacity, and at times the lower parts of this district have suffered from this defect. With this exception both systems are very similar in construction, the sewers are well ventilated and flushed, but owing to the physical conformation of the locality the gradients are for the most part low. On the whole, the complaints of smells from the ventilators, which, with one or two exceptions, open on to the surface of the road, are not numerous, and not more so on one side of the town than on the other. I see no reason, therefore, for attributing the peculiar distribution of diphtheria to any insanitary condition of the districts chiefly affected. There is nothing to indicate that the higher attack rates in the western and eastern districts are connected with drainage defects, or that the comparatively low attack-rate in the central district is due to any superior sanitary conditions. The fact that scarlet fever has, since 1896, shown the same relative local distribution as diphtheria suggests an entirely different explanation. The spread of scarlet fever is reeognised on all hands to be entirely due to personal infection. No case can occur unless through the direct or indirect medium of a pre-existing case. Its spread will thus depend upon the facilities for the transmission of infection from person to person. Diphtheria, like scarlet fever, is essentially a disease of childhood. The facilities for the spread of infection will be increased, therefore, in communities in which the proportion of young children is high, and especially where such proportion has rapidly increased. There is good reason for believing that the western and eastern sub-registration districts of Cardiff offer, by the age distribution of their population, special facilities for the spread of diphtheria, a disease which, like scarlet fever, depends largely, if not entirely, upon personal infection for its extension. From their position these districts would naturally contain the greater part of the new and constantly increasing localities, whereas the central district has comparatively limited opportunities for extension. In evidence of this, it may be mentioned that during recent years the birth-rate has been higher in the western and eastern districts than in the central, and that in these districts the increase in the number of inhabited houses has been much greater.
94
D i p h t h e r i a in C a r d i f f
[Pubno aealth
The following tables show the relative position of the bir~h-rate in these districts in the year 1897 • Birth-rate, 1897. West Cardiff Sub-Registration District East Cardiff ,, ,, Central Cardiff . . . .
... ... ...
38"6 per 1,000. 30"5 ,, 27"7 ,,
The increase in the number of inhabited houses in each district since 1891 is given below : N u m b e r of Inhabited Houses. West Cardiff East Cardiff
Census in 1891.
189/.
Increase.
...
6,586 5,888
9,214 9,041
2,678 3,203
...
S,102
8,~0V
......
Central C~rai~ :::
~05
Unfortunately, the tables pi~blished in the census returns do not contain the age distribution of the population in the municipal wards, or in the registration sub-districts, so that it is impossible, from the available data, to estimate the proportion which the juvenile population bears to the entire population in any of these divisions of the town at the present time. But through the courtesy of Dr. John Tatham, of the General Register Office, Somerset House, who was good enough to furnish me with some unpublished ~ables, I was able to obtain the age distribution in groups of enumeration districts according to the census of 1891. These groups are not, however, coterminous with the wards, but consist each of parts of different wards. Taking one group, which consists of 12,955 persons at all ages living in the central registration subdistrict, and another group of 14,677 persons living in the west registration sub-district, I find tha~ the proportion of persons under fifteen years of age was 33"5 per cent. in the former, as compared with 41"5 per cent. in the latter district. As none of the enumeration districts consist entirely of inhabitants of the east registration sub-district, it is impossible to give the proportion in ,this division, but in any case it is clear that the proportion of children under fifteen years of age is greater in the western than in the central district, and, therefore, that the opportunities for the spread of infection would be greater in the former than in the latter district. There is an impression that diphtheria has always been more prevalent in the western part of the town. The following tables, which refer to the years 1893-97 inclusive, will show that this is
:No,e,-~r, x89S]
Diphtheria in Cardiff
95
not the case. They give the attack- rate and death-rate from diphtheria in each district per thousand persons living, calculated on the census population of 1891 : West Cardiff.
East Cardiff.
Central Cardiff.
Year.
1893 1894 1895 1896 1897
...... ...... ...... ...... ......
Death Rate.
Attack Rate.
Death Rate.
0'2 0"4 0 "4 0"9 1 "4
0"7 1'6 1 "4 3"4 7 "3
1"3 0"6 0'5 0"2 0"3
Attack Rate. •
5"5 4"8 3"6 2"6 3"3
Death
Ral~
0"6 0"3 0"1
0"1 0"8
Attack Rate.
2"6 1"6
0"8 1"1 1"8
With respect to the above rates, it must be noticed that, as they are calculated on the census population of 1891, they are, in the case of the western and eastern districts, probably too high, owing %0 ~he more rapid increase in the population in these districts than in the central district. But even if calculated on the estimated population for these years, the rates would mainrain the same relative position, although the increase in those districts would be less marked. This is shown in the preceding tables giving the attack-rate for diphtheria and scarlet fever for 1896 and 1897, calculated on the estimated population. In the foregoing tables the relative prevalence of diphtheria in each division of the town is indicated by the attack-rate and death-rate per thousand of the population. In the following tables the variety of the type of the disease is shown as it occurred in different localities by the percentage mortality of the cases--that is, by the proportion of deaths to cases notified. It is somewhat strange to find the extreme variation in the fatality of the cases which occurred in some of the municipal wards. The explanation of this diversity is to be found in the difference of the ages of those attacked in the various districts (diphtheria being a disease in which 95 per cent. of the total deaths occur amongst children under fifteen years of age). But I am unable to offer any explanation as to the remarkable preponderance of mild and adult cases in one particular municipal ward. Why, for instance, in 1896 should 42"0 per cent. of the cases notified in the Splott Ward be over thirteen years of age as compared with 14"8 per cent. in the Canton Ward, and in 1897 54"0 per cent. as compared with 22 per cent. in the Grangetown Ward ?
96
Diphtheria in Cardiff
E~bUeSealta
Case Mortality, or P r o p o r t i o n of Deaths to Cases of D i p h t h e r i a Notified. 1894. Canton Ward Splott Ward ......
...
Mortality. 45"4 p e r c e n t . 7"5 ,,
1896. Canton Ward Splott Ward ......
37"0 6"0
Grangetown Ward Splott Ward ......
1895. Grangetown Ward Splott Ward ......
...
Mortality. 31"5 p e r c e n t . 9-6 ,,
1897. ...
,, ,,
...
26"7 6"6
,, ,,
The peculiarity in the age-distribution of the disease which brought about this varying mortality is shown in the following table, which gives the proportion of cases of diphtheria notified under thirteen years and over thirteen years respectively, in each of the above wards, for the same periods : 1894. Canton Ward
Sic
Splott Ward
......
"'"
] C a s e s u n d e r 13 y e a r s , 82"0 p e r c e n t . ~ ,, o v e r 13 ,, 18"0 ,, {
,,"
underover1313
,,"
38"061"0
,,"
1895. Grangetown Splott Ward
Ward
400
......
[ C a s e s u n d e r 18 y e a r s , 78"0 p e r c e n t . ~ ,, o v e r 13 ,, 22"0 ,, {
" ,,
u n d e r 13 o v e r 13
,, ,,
58"0 42"0
,, ,,
1896. C a n t o n W a r d ... "-
) - C a s e s u n d e r 13 y e a r s , 85"0 p e r c e n t . L ,, o v e r 13 ,, 14"8 ,, f
Splott Ward
,, ,,
u n d e r 13 o v e r 13
,, ,,
58"0 42"0
,, ,,
) ' C a s e s u n d e r 13 y e a r s , 78"0 t ,, o v e r 13 ,, 22'0
,, ,,
(
,, ,,
1897. GrangetownWard Splott Ward
......
...
" ,,
u n d e r 18 o v e r 13
,, ,,
46"0 54"0
The following tables show the age- distribution of cases of diphtheria reported in each ward in Cardiff in 1897, and it is important to notice that the greatest incidence of the' disease falls upon persons between the ages of three and thirteen--that is, at ages when children are attending school, and when the facilities for transmitting the infection from person to person are great~st. It has been pointed out by observers that this does not of necessity imply that children are more likely to become infected in the classrooms of the school, but rather that the infection is spread at the Limes of entrance and of' leaving school and in playgrounds, when
Diphtheria in Cardiff
Sove,-ber, 18981
97
the scholars are more intimately associated and mix more closely than during the hours of study. It is interesting to notice in this connection the drop in the weekly notification of diphtheria which occurs during the August holidays. TABLE
E.
Diphtheria,
1897.
Age Periods of reported Cases.
First Quarter.
Second Quarter.
Third Quarter.
Fourth Quarter.
Under three years ...... Three and under thirteen Thirteen and under twenty-five Twenty-five and upwards ...
19 47 12 13
15 50 19 14
11 48 20 9
153 32 25
70 298 83 61
Total
91
98
88
235
512
......
TABLE
25
Year.
F.
Diphtheria, 1897.--Percentage of Cases a t Age Periods to Cases reported in each W a r d . Total Number Under of Cases of Three Years. all Ae~es.
Ward.
C e n t r a l ... South ... C a t h a y s ... Park Adamsdown R i v e r s i d e ... Canton ... Roath ... Grangetown Splott ...
° . .
. . °
. . °
. . .
D@I
. ° .
. ° .
16 21 47 62 17 105 103 25 86 30
Per cellt. 12"1 28"4 10"6 11"2 17 "6 9"8 19 "4 . . .
22 '1 6"6
Three and under Thirteen.
Thirteen and under Twenty-five.
Twenty.five and upwards.
Per cent. 68 "3 66 "9 55"3 56"4 52'9 51"9 53 "4 64"0 55"4 40 "0
Per cent.
Per cent. 12"1 9"5 6"3 20"9 11"7 12 "7 8"7 16"0 10"4 26"6
6'25 . . ,
23"4 11"2 17"6 25 "4 18"4 20 '0 11"6 26"6
The foregoing data, without altogether excluding other influences, point, I think, conclusively to personal infection as the most important factor in the spread of diphtheria. A noticeable circumstance, and pointing to the same conclusion, is the close connection which diphtheria prevalence in Cardiff bears to the prevalence of the disease in neighbouring localities, especially to those having an extensive communication with this town by means of railway passenger traffic. At ordinary times the inhabitants of the Rhondda Valley and South Wales colliery districts are passing constantly and in large
:98
D i p h t h e r i a in Cardiff
~eubuc Health
numbers to and from Cardiff, and one might naturally expect that this would lead to the dissemination of diseases which may be communicated from person to person. A study of the health statistics relating to the urban sanitary districts of Rhondda, Merthyr Tydfil, and Aberdare, in conjunction with those of Cardiff, show a relationship in the diphtheria p~:evalence in these districts which is, I think, too marked to be altogether accidental. The amount of diphtheria in these districts in 1897 may be judged by the fact that, whereas the mortality in this year in Cardiff was high, being, in fact, higher than that in London, and considerably higher than the average in the large towns, it was still higher in these colliery districts. In the Annual Summary of the Registrar-General for 1897 relating to the statistics of 100 large towns in England and Wales, it is stated that " the highest diphtheria death-rates were 0"62 in Rhondda and in Merthyr Tydfil, 0"63 in Great Yarmouth, 0"64 in Willesden, 0"76 in Worcester, 0"82 in Aberdare, 0"87 in Gloucester, and 2"62 in Longton." The diphtheria death-rates were as follows, as compared with London and the thirty-three large towns :
Diphtheria Death-rates. 1898. 1897. First Quarter. Second Quarter.
London ... 33 large t o w n s ......... R h o n d d a U r b a n District ... M e r t h y r Tydfil ......... Aberdare . . . . . . . . . . . . Cardiff . . . . . . . . . . . .
0"51 0"31 0 "62 0"62 0"87 0"52
0'33 0"48 0"84 1"16 2 "09 1"17
i
0"33 0"24 0"27 0"23 1 "09 0"83
All r a t e s per 1,000 of populations.
The accompanying Chart A shows the number of notifications in each week of the first and second quarters of 1898 in the Rhondda, Pontypridd, Merthyr, Mountain Ash, and Cardiff urban districts respectively. From this will be seen a certain correspondence as regards time in the prevalence of diphtheria in these places, a marked fall in the notifications, commencing in March, following upon the rise in January and February. This fall in diphtheria prevalence in both cases may, of course, have been due to the natural termination of the epidemic from the exhaustion of susceptible material, but it is suggestive that it should closely correspond in point of time wi~h ~he interrupted railway communication
November,1898]
D i p h t h e r i a in Cardiff
99
between these localities, consequent upon the strike of the colliers in these districts. In this case the opportunities for infection must have been lessened by the reduction in the number of visitors from infected places. MOv~'~. dANUAI~. . ~ , , , . ,
=
~BI~4UL f i
tMAlt?..t¢. i i
i
,
, i
J4PRbm..
M^~',
i
J
,
, |
i
dUNE, i
,
i
i
~I'-'I~I
~
IIIII I IIII I .............. [ I I I I I Itll I .......... I . . . . . . . . . . . . . . IIIIIl . . . . . . . . . . . . . . . . . . . . . . . . . . IIllI~ "~I~.I I I II~II III IIIII I I I I ~ I Ill
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fill:iiiii; I IIIj
I i i i i I I I I I I I I I I I~
CHARTA. In the foregoing remarks I have indicated what I consider to be the most important factor in the spread of diphtheria, and although I have been unable to attribute any direct influence to special local insanitary conditions requiring attention, I do not consider the sanitary authority altogether powerless in this matter. Any further preventive measures which might be undertaken should be in the direction of checking the indiscriminate commingling of infected and non-infected persons. I have already pointed out that this probably takes place most extensively during the assembly of children at school. It is most desirable, therefore, that every possible means should be used to prevent the attendance at school of children suffering from any form of sore throat. This is, of course, done at present in those cases where diphtheria is notified to the sanitary authority. But diphtheria is a disease which often occurs in a mild form; it is then not recognised by the parents, who, in ignorance, allow
100
D i p h t h e r i a in Cardiff
rPublic Health
children who may be suffering slightly to attend school and mix with others, and so spread the infection. In this matter the school authorities might be urged to undertake an efficient system of medical examination of pupils, and a rigid exclusion of all those who would be likely to spread infection, working in this matter in co-operation with the sanitary authority. It is obvious that the prompt isolation of infected children would very often prevent a severe outbreak of disease, and lead in the long-run to the increase in the average attendance at school. Too little attention is paid to school hygiene generally, particularly as regards ventilation and overcrowding. The structural arrangements may be, as they generally are in the public elementary schools, satisfactory, but a more complete medical or sanitary supervision of the scholars themselves, and of class-rooms during school-hours, is much to be desired, and would, I think, be of advantage to schools in particular and to the public in general. It would be inconvenient and impossible in a large town for the medical officer of health to undertake himself the work of medically inspecting children on admission to school; but he could, I presume, act as adviser in health matters to 'the school authority, and such inspection could be performed by local medical practitioners acting under the direction of the medical officer of health. Such a joint system would bring the school authority and the sanitary authority into closer co-operation, and obviate any possible friction between the two authorities. With respect to any further preventive measures which might be undertaken independently by the sanitary authority itself, they should, I think, be in a position to assist medical practitioners in forming an accurate diagnosis of iufectious diseases by carrying out, as a part of the public health work of the district, bacteriological examinations in connection with such diseases. This important subject was recently discussed at the meeting of the British Medical Association at Edinburgh, where a resolution was passed "inviting the Council of the Association to take steps to press upon the Legislature the urgent necessity of providing each sanitary district with a bacteriological laboratory, available for gratuitous examination of morbid products for the purpose of the early diagnosis of infectious disease." I have already alluded to the difficulties that exist in the recognition by the general public of the early symptoms of diphtheria. The difficulty of diagnosing the disease by medical men is also often great, and can only be cleared up by a careful bacteriological examination. A case mortality, varying from 45 per cent. in one
Sovember,xsss~
Notification of Measles
101
part of the town to 6 per cent. in a n o t h e r part, indicates that the disease was very different in character in these different localities, and it is probable that a large proportion of the adult and mild cases which occurred in those districts in which the mortality was very low would, with a more extended use of bacteriological methods of diagnosis, have proved not to have been diphtheria a~ all. Hospital isolation in cases of diphtheria has not yet been tried on a scale which could give it a fair chance as a preventive measure, but much may be hoped for from the increased accommodation shortly to be provided in this district, which will allow of the proper isolation of a far larger proportion of cases than has hitherto been possible.
NOTIFICATION OF MEASLES. BY W. R. ETCHES, D.P.H. Medical Officer of Health of Macclesfield. IN considering the measures possible to a Sanitary Authority against this disease, notification by medical certificate is obviously of little use, because comparatively few of the eases are seen by medical men, and when medical assistance is called, it is usually in consequence of complications coming on after the disease is well marked and has already exerted its infection, too late for useful interference from a preventive point of view. The alternative is to rely on the schools for timely information of the occurrence of cases ; this, taken along with the intimation of deaths from measles made by the registrars, enabled me, though tardily, to know something of what was going on. It is manifest that by a little extension of existing arrangements i~ should be possible for the School Board to obtain cognizance in nearly all the schools as soon as infectious disease has appeared, and so at once to apprize the Health Office. As it is, we are indebted to the schoolmasters for information as soon as they become aware of a serious amount of infection in a school. Unfortunately, that is often somewhat late. During the year I have naturally had the question of the utility of school closure much before me, especially because, in spite of all the schools except one being closed this year, the disease spread through the whole town except Broken Cross. I believe it is useless to expect to check this infection by school closing even for a lengthy period. It exerts, however, a retarding influence upon it, and lessens the number of cases. When infection gets into an infant-school it spreads rapidly among the scholars. Upon two occasions one school was severely attacked, while another not far off was comparatively free; this can only be explained by a rapid infection running through the school. The policy which has been adopted was to close the school when there was sufficient evidence of a school infection. Generally speaking, if 15 per cent. of children are absent simultaneously on account of measles, a school infection may be inferred. Before this necessity for closing is reached, there is the useful measure of refusing admittance to all children from infected houses, and sending children home at once who show signs of commencing illness.--A./~., 1897.