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Etiology of diphtheria
96
ETIOLOGY
OF
about two and a half years old fondled it. Four days later the child was takensick, apparently with diphtheria, from which it died. There were no other cases in the neighbourhood, and the affected chicken was the only possible source of infection. " T h e diphtheritic disease of fowls, reported by Loir and Ducloux (/oc. cir.), in Tunis, in I894 , spread to the people of that place, resulting in an epidemic of serious proportions. M6nard refers to the fact that men employed to feed young squabs contracted diphtheria by blowing the masticated food into the mouth and crop of squabs (or young unfledged pigeons)suffering with that disease. Schrevens (Bulletiz de l'Acad. Roya/.e de M'~d. de J3elgifue, V I I I . (I894), p. 380) reports several cases of diphtheria in children, in which he traces the source of infection to certain poultry. "Although the number of reported cases of the transmission of fowl diphtheria to the human species, and vice versa, is small in comparison with the extent of the disease in poultry, the evidence that such a transmission is possible is quite sufficient to discourage the careless handling of diseased fowls. It is a quite common practice, especially in the rural districts, to bring the sick chickens into the house for treatment, where the children of the household are allowed to fondle them at will. It is not improbable that when this disease is thoroughly investigated, the number of cases of direct infection from this source will be found to be much larger than it is at present supposed. Until such investigations are satisfactorily completed, the indiscriminate handling of diphtheritic chickens, especially by children, and the exposure of fowls to the infection of diphtheria in the human species, whereby they may become carriers of the virus, should be strenuously avoided." E T I O L O G Y OF D I P H T H E R I A . ST. PANCRAS.
DR. J. F. I. SYKEs, in his annual report, brings up to the present date his interesting study of the metropolitan mortality from diphtheria, which was published in PUBLIC HEALTH~ Vol. VI. pp. 331 334. H e states :--"Contrary to our experience up to 189o , the last four years show that the mortality of diphtheria has taken to epidemic fluctuation like scarlet fever, and is no longer comparatively steady like enteric fever. Further, unlike previous years, the rise and fall of the mortality of scarlet fever and diphtheria have occurred simultaneously. Again, in reference to the proportion of the mortality from throat diseases caused by diphtheria, t h e experience of the past four years is not quite according to previous experience. Previous experience has shown that the fall in the number of deaths from throat diseases other than diphtheria corresponded with the rise in the number of deaths from diphtheria ; but the last four years show that
DIPHTHERIA.
there is -no longer a correspondence between the two sets of figures, the deaths from diphtheria having increased in nmnber out of all proportion to the diminution in the number attributed to other throat diseases, and this is specially observable in 1893, and in a lesser degree in 1892. An enormous increase in the mortality from al/ throat diseases has taken place in t h e last four years, and this mortality is wholly and solely due to diphtheria." Dr. Sykes sums up his further conclusions as follows : - i. That there appears to be little doubt that a distinct change of type has taken place in a large proportion of disease affecting the throat, accounting in the first place for the diminution in the mortality from other diseases of the throat and its displacement by diphtheria. 2.--That it is very evident that the change of type is from a non-infectious to an infectious form of disease, accounting for the enormous increase of diphtheria mortality over and above the diminution of that of other throat diseases during the last few and quite recent years. 3 . - - T h a t diphtheria has become an acute epidemic disease with far more sudden variations in extent and intensity of prevalence than formerly, and that we may expect epidemic and non-epidemic years with marked seasonal prevalence in the future. WEST HAM. Dr. Sanders remarks : " A p a r t from two localized outbreaks in connection with schools, diphtheria showed a phenomenal tendency to increase in the borough during x894 , to an extent greater in my opinion than the increase shown in the other large towns. Doubtless this increase is due to a variety of causes, the special characters and varying conditions of which are not at present recognized, but of this I feel sure, that although, owing to the virulence of the disease in many cases, and the consequent publicity given to the anti-toxic treatment of the disease, diphtheria has had much public attention given to it in recent times, yet there is not the same care and rigour devoted to the prompt and continued isolation of the slighter cases of diphtheria as in many other infectious diseases; a laxity due possibly to the frequent absence in this disease of objective symptoms which, as in the desquamation of scarlatina and the diarrhoea of enteric fever, force themselves on the notice of both medical attendant and friends. In this way children in a still infectious condition are allowed too early to associate with the unprotected, with the natural result of many unnecessary secondary cases." BEDFORD. Dr. Prior says : "Diphtheria and scarlatina are diseases which have, in some particulars, a strong similarity ; both are infectious, though the one with
ANALYTICAL NOTES. much less regularity than the other; both are characterised by a throat affection occasionally very severe ; both are apt to be attended with severe constitutional disturbance. In the course of an epidemic of scarlatina, many cases are to be met with in which the eruption has been slight or almost ~dl, while the throat symptoms have been severe, and these, I believe, are occasionally certified as diphtheria. Under the circumstances it is often very difficult, almost impossible, to distinguish; but, on the other hand, in an outbreak of genuine diphtheria, it is very rarely, if ever, that cases of scarlatina are to be met with." POPLAR.
We owe an apology to Dr. F. W. Alexander, M.O.H. for Poplar and Bromley, for not having earlier drawn attention to his valuable report on " T h e Cause of Diphtheria : its suggested relation to the Main Drainage of London." The report in question had been accidentally misplaced. The whole report is worthy of careful consideration. Dr. Alexander summarises his report as follows : m i. Diphtheria was first recognised in this kingdom in the year i845. 2. Water-closets, invented about i813, became general in the better class of houses about 1828-33. 3- On January ist, z849, within the City of London, an Act was enforced compelling persons to drain into sewers. 4. I n 1856 the Metropolis Management Act enforced that all houses in the Metropolis should be drained into sewers. 5. I n 1855 the Registrar-General distinguished the diphtheria and scarlet fever deaths. In the London tables the deaths from these two diseases were not separated until 1859 , three years after the enforcement of the Metropolis Local Management Act. 6. The mortality from diphtheria, in proportion, has diminished in England and Wales, and increased in London, more especially during the years 1881 to 189o. 7. The Bye-laws to the i875 Public Health Act for England and Wales, except the Metropolis, were enforced in the year 1877 or thereabouts; consequently, the Provinces in sanitary work were in advance of the Metropolis. 8. The tests which are most commonly used for testing drains will not always reveal defects in drains laid under the earth ; consequently, many drains may be declared sound which are really unsound. The joints of drain pipes were not made in past years with the same care as in recent years. 9. Diphtheria prevails more in the colder than in the warmer months, through the interchange of the soil and atmospheric airs, and also on account of the ground-air being drawn into thehouses by fires. xo. The County Council's main sewers of the
97
Metropolis are inadequate for their present-day requirements. The Poplar District, through which the three Middlesex main sewers run, suffers from diphtheria to a greater extent than the other London districts north of the Thames, and more especially in the immediate vicinity of London County Council's main sewers and their main and tributary branches. i i . The Isle of Dogs, which is exceedingly damp, and was liable to sewage fioodings, suffers less from diphtheria since increased pumping accommodation has been afforded. I am of an opinion that when increased sewage accommodation is afforded in the Metropolis, and when all drains have been made watertight--as they no doubt will be on account of the work carried out by the Metropolitan local authorities, - - a n d when the West Ham sewage is pumped on to the Northern Outfall instead of being discharged into the rivers Lea and Thames, then the "microbic nitrifyin~ earth" in course of time, by natural processes, will get rid of the harmful matter deposited through the floodings and faulty drains, and diphtheria will cease to exist.
ANALYTICAL
NOTES.
AuG-KHAK, a Chinese purple dye, is now used on the Continent for colouring articles of food. It is the product of a particular ferment on cooked rice, but the exact method of preparation is unknown. Its presence in red wine may be detected by agitating a few c,c. of the wine with chloroform, which will be at once tinged red if Aug-Khak has been used. As a confirmatory test, distinguishing it from analine dye, it may be precipitated with mercuric oxide. Aug-Khak coloured wine is also turned brown by adding solution of ammonium hydrate (1"2oo) in excess. For the detection of martius yellow in macaroni F. Schaffer uses the following method. About twenty grams of the macaroni reduced to small pieces are shaken with 40 c.c. of warm 5o-6o per cent. alcohol. If colouring matter is present the alcohol will be yellowed. On adding hydrochloric acid, if the colour is due to martius yellow, it will be discharged; if metanil yellow, it is changed to red ; and if saffron, it will remain unchanged. As a means of detecting whether the poorness of a milk is due to fat abstraction or added water, Dr. Lesc~eur advocates the determination of the specific gravity of the serum. The casein is coagulated by adding rennet and the serum separated by filtration. The density of the serum is found to average from 1'o31 to I'O29, but certain genuine samples have been met with as low as 1"o27, and this is taken as the standard from which is calculated the percentage of added water. The casein H
ETIOLOGY
OF
about two and a half years old fondled it. Four days later the child was takensick, apparently with diphtheria, from which it died. There were no other cases in the neighbourhood, and the affected chicken was the only possible source of infection. " T h e diphtheritic disease of fowls, reported by Loir and Ducloux (/oc. cir.), in Tunis, in I894 , spread to the people of that place, resulting in an epidemic of serious proportions. M6nard refers to the fact that men employed to feed young squabs contracted diphtheria by blowing the masticated food into the mouth and crop of squabs (or young unfledged pigeons)suffering with that disease. Schrevens (Bulletiz de l'Acad. Roya/.e de M'~d. de J3elgifue, V I I I . (I894), p. 380) reports several cases of diphtheria in children, in which he traces the source of infection to certain poultry. "Although the number of reported cases of the transmission of fowl diphtheria to the human species, and vice versa, is small in comparison with the extent of the disease in poultry, the evidence that such a transmission is possible is quite sufficient to discourage the careless handling of diseased fowls. It is a quite common practice, especially in the rural districts, to bring the sick chickens into the house for treatment, where the children of the household are allowed to fondle them at will. It is not improbable that when this disease is thoroughly investigated, the number of cases of direct infection from this source will be found to be much larger than it is at present supposed. Until such investigations are satisfactorily completed, the indiscriminate handling of diphtheritic chickens, especially by children, and the exposure of fowls to the infection of diphtheria in the human species, whereby they may become carriers of the virus, should be strenuously avoided." E T I O L O G Y OF D I P H T H E R I A . ST. PANCRAS.
DR. J. F. I. SYKEs, in his annual report, brings up to the present date his interesting study of the metropolitan mortality from diphtheria, which was published in PUBLIC HEALTH~ Vol. VI. pp. 331 334. H e states :--"Contrary to our experience up to 189o , the last four years show that the mortality of diphtheria has taken to epidemic fluctuation like scarlet fever, and is no longer comparatively steady like enteric fever. Further, unlike previous years, the rise and fall of the mortality of scarlet fever and diphtheria have occurred simultaneously. Again, in reference to the proportion of the mortality from throat diseases caused by diphtheria, t h e experience of the past four years is not quite according to previous experience. Previous experience has shown that the fall in the number of deaths from throat diseases other than diphtheria corresponded with the rise in the number of deaths from diphtheria ; but the last four years show that
DIPHTHERIA.
there is -no longer a correspondence between the two sets of figures, the deaths from diphtheria having increased in nmnber out of all proportion to the diminution in the number attributed to other throat diseases, and this is specially observable in 1893, and in a lesser degree in 1892. An enormous increase in the mortality from al/ throat diseases has taken place in t h e last four years, and this mortality is wholly and solely due to diphtheria." Dr. Sykes sums up his further conclusions as follows : - i. That there appears to be little doubt that a distinct change of type has taken place in a large proportion of disease affecting the throat, accounting in the first place for the diminution in the mortality from other diseases of the throat and its displacement by diphtheria. 2.--That it is very evident that the change of type is from a non-infectious to an infectious form of disease, accounting for the enormous increase of diphtheria mortality over and above the diminution of that of other throat diseases during the last few and quite recent years. 3 . - - T h a t diphtheria has become an acute epidemic disease with far more sudden variations in extent and intensity of prevalence than formerly, and that we may expect epidemic and non-epidemic years with marked seasonal prevalence in the future. WEST HAM. Dr. Sanders remarks : " A p a r t from two localized outbreaks in connection with schools, diphtheria showed a phenomenal tendency to increase in the borough during x894 , to an extent greater in my opinion than the increase shown in the other large towns. Doubtless this increase is due to a variety of causes, the special characters and varying conditions of which are not at present recognized, but of this I feel sure, that although, owing to the virulence of the disease in many cases, and the consequent publicity given to the anti-toxic treatment of the disease, diphtheria has had much public attention given to it in recent times, yet there is not the same care and rigour devoted to the prompt and continued isolation of the slighter cases of diphtheria as in many other infectious diseases; a laxity due possibly to the frequent absence in this disease of objective symptoms which, as in the desquamation of scarlatina and the diarrhoea of enteric fever, force themselves on the notice of both medical attendant and friends. In this way children in a still infectious condition are allowed too early to associate with the unprotected, with the natural result of many unnecessary secondary cases." BEDFORD. Dr. Prior says : "Diphtheria and scarlatina are diseases which have, in some particulars, a strong similarity ; both are infectious, though the one with
ANALYTICAL NOTES. much less regularity than the other; both are characterised by a throat affection occasionally very severe ; both are apt to be attended with severe constitutional disturbance. In the course of an epidemic of scarlatina, many cases are to be met with in which the eruption has been slight or almost ~dl, while the throat symptoms have been severe, and these, I believe, are occasionally certified as diphtheria. Under the circumstances it is often very difficult, almost impossible, to distinguish; but, on the other hand, in an outbreak of genuine diphtheria, it is very rarely, if ever, that cases of scarlatina are to be met with." POPLAR.
We owe an apology to Dr. F. W. Alexander, M.O.H. for Poplar and Bromley, for not having earlier drawn attention to his valuable report on " T h e Cause of Diphtheria : its suggested relation to the Main Drainage of London." The report in question had been accidentally misplaced. The whole report is worthy of careful consideration. Dr. Alexander summarises his report as follows : m i. Diphtheria was first recognised in this kingdom in the year i845. 2. Water-closets, invented about i813, became general in the better class of houses about 1828-33. 3- On January ist, z849, within the City of London, an Act was enforced compelling persons to drain into sewers. 4. I n 1856 the Metropolis Management Act enforced that all houses in the Metropolis should be drained into sewers. 5. I n 1855 the Registrar-General distinguished the diphtheria and scarlet fever deaths. In the London tables the deaths from these two diseases were not separated until 1859 , three years after the enforcement of the Metropolis Local Management Act. 6. The mortality from diphtheria, in proportion, has diminished in England and Wales, and increased in London, more especially during the years 1881 to 189o. 7. The Bye-laws to the i875 Public Health Act for England and Wales, except the Metropolis, were enforced in the year 1877 or thereabouts; consequently, the Provinces in sanitary work were in advance of the Metropolis. 8. The tests which are most commonly used for testing drains will not always reveal defects in drains laid under the earth ; consequently, many drains may be declared sound which are really unsound. The joints of drain pipes were not made in past years with the same care as in recent years. 9. Diphtheria prevails more in the colder than in the warmer months, through the interchange of the soil and atmospheric airs, and also on account of the ground-air being drawn into thehouses by fires. xo. The County Council's main sewers of the
97
Metropolis are inadequate for their present-day requirements. The Poplar District, through which the three Middlesex main sewers run, suffers from diphtheria to a greater extent than the other London districts north of the Thames, and more especially in the immediate vicinity of London County Council's main sewers and their main and tributary branches. i i . The Isle of Dogs, which is exceedingly damp, and was liable to sewage fioodings, suffers less from diphtheria since increased pumping accommodation has been afforded. I am of an opinion that when increased sewage accommodation is afforded in the Metropolis, and when all drains have been made watertight--as they no doubt will be on account of the work carried out by the Metropolitan local authorities, - - a n d when the West Ham sewage is pumped on to the Northern Outfall instead of being discharged into the rivers Lea and Thames, then the "microbic nitrifyin~ earth" in course of time, by natural processes, will get rid of the harmful matter deposited through the floodings and faulty drains, and diphtheria will cease to exist.
ANALYTICAL
NOTES.
AuG-KHAK, a Chinese purple dye, is now used on the Continent for colouring articles of food. It is the product of a particular ferment on cooked rice, but the exact method of preparation is unknown. Its presence in red wine may be detected by agitating a few c,c. of the wine with chloroform, which will be at once tinged red if Aug-Khak has been used. As a confirmatory test, distinguishing it from analine dye, it may be precipitated with mercuric oxide. Aug-Khak coloured wine is also turned brown by adding solution of ammonium hydrate (1"2oo) in excess. For the detection of martius yellow in macaroni F. Schaffer uses the following method. About twenty grams of the macaroni reduced to small pieces are shaken with 40 c.c. of warm 5o-6o per cent. alcohol. If colouring matter is present the alcohol will be yellowed. On adding hydrochloric acid, if the colour is due to martius yellow, it will be discharged; if metanil yellow, it is changed to red ; and if saffron, it will remain unchanged. As a means of detecting whether the poorness of a milk is due to fat abstraction or added water, Dr. Lesc~eur advocates the determination of the specific gravity of the serum. The casein is coagulated by adding rennet and the serum separated by filtration. The density of the serum is found to average from 1'o31 to I'O29, but certain genuine samples have been met with as low as 1"o27, and this is taken as the standard from which is calculated the percentage of added water. The casein H