Etiology of diphtheria

32o

ETIOLOGY

OF DIPHTHERIA.

tained by others using Elsner's method. He collected statistics of thirty-two cases o f typhoid fever in which Elsner's method was app!ied during the febrile stage, and in every instance the bacillus of typhoid was found. Also in thirteen out of eighteen patients in the c~nvalescent stage it was found. H e also mentions that it was found in the faeces of a male attendant in a typhoid ward who was not himself suffering in any way from typhoid fever. Chantemesse points to the great value of this method in the early diagnosis of typhoid fever, and that, as a consequence of this early diagnosis, two important results will follow : - Ist. The patient will be able to submit to the serum treatment at an early period, before any secondary streptococcal infe ctions have occurred. 2nd. The early diagnosis ot all cases, and the confirmation of diagnoses in difficult cases, will be of great value in preventive medicme. Another, and perhaps the most important result of all, would be that any method which is so easy of application and so accurate as Eisner's, could be used in studying tt~e life history of the bacillus outside the body. E!sner's method has not yet been put to a sufficient test in this country, but already there is ample evidence that it is one of our most valuable methods for the separation and identification o f the 15'. Ty~hosus. It requires considerable technical skill, but it is not, however, a difficult method. ETIOLOGY OF DIPHTHERIA. DR. COOPER PAT'I'IN, in his report for 1894 to the Norfolk County Council, remarks : - - T h e county of Norfolk has for a very long time attained to an undesirable reputation as one of the portions of the country having a high diphtheria death-rate, and in 1894 it has maintained its position : diphtheria having caused no less than i 6 i deaths out of a total of 458 for the seven principal zymotic diseases. It must not, however, be supposed that this disease was equally spread all over the administrative county. As a matter of fact, large areas were relatively free from it . . . . Great variations in the mortality rates from this disease are recorded within the limits of the county, variations which are due in part to differences in the intrinsic virulence of the disease, and to the circumstance that in some districts more mild cases come under notice than in others, and so get reported, which latter fact should give us occasion to make careful enquiry before forming our conclusions . . . . I t is the mild unobserved type which is so insidiously dangerous, not to the spee M individual, but to the community, diphtheria appearing to frequently progress through stages of increasing virulence until i t reaches a very high potency indeed. Bearing these things in mind, it is easy for us to understand how schools become great

propagating agencies when once the disease has been accid~ ntally introduced, and how necessary it is to keep a vigilant eye on the eff, ctive ventilation of our schools. It is the crowding together of children within ill-ventdated rooms that causes so many to contract any infectious ailment that may be present (it may be of so mild a type as to escape notice) in any one of the scholars. I n the same report the following remarks by the Medical Officer for Erpingham are quoted : - - F o r purposes of prevention, I a d o p ' e d the policy of closing the public eLemefitary schools. As in rural districts, I am quite convinced that they largely aid i n the spread of infectious disease, by bringing children together to a common focus from outlying districts, who but for the school would not be brought into contact with one another. H o w much the compulsory aggregation of children in our rural schools may have had to do with the wave o f d:phthe~ia which has recently passed over the country is a fair question for debate. My own experience leads me to think that in ill-ventilated schools, coupled with neglected and stinking privies, without any ventil~ttion for either the vaul~ or the privy itse'f~ the disease is absolutely m a n n factured in the place. T h e Medical Officer for Mitford and Launditch says : The prime cause of diphth¢ria still seems to elude our grasp, but the inference to be drawn from the outbreaks in this union points to the fact that the incidence of the disease is chiefly amongst children of the school age, and generally commences during the school term ; consequently, !he. compulsory aggregation of children in schools is, m my opinion, a very important factor in the etiology o f the d~sease. Next, inspection reveals another important factor, namely, that the ventilation of most of the public elementary schools is very far from what it ought to be. T h e next causative element has to do with breathing the bad gases generated in privy pits which are d a m p and totally devoid of ventilation ; this predisposes the throat to a low form of inflammation, which forms a snitable soil in which the bacilZiof diphtheria can spread a n d propagate with extreme facility. It is possible that the decomposing faecal contents of these ill-ventilated privies may be the breeding ground of the di2~ht~eria bacillus. T h e condition of the subsoil water is a factor in the genesis of this disease. I ventured to predict, early in 1894 , that in consequence of the deficient rainfall of previous years, the subsoil water had sunk very low, and that consequently, when a heavy fall took place, much surface impurity must be carried down into the drinking-water, and there-by much disease engendered.

~"he Extra-£aboratary Researcfzof Di2~Mheria.~ On this subject Dr. Pattin remarks : There is just now, perhaps, a tendency to attach, and to rightly attach, so much importance to the researches of, the bacteriologists, that there is some risk of

THE

DURATION

OF INFECTIVITY

equally important extra-laboratory work being neglected i and after all it is not on what occurs to guinea-pigs in laboratories that medical officers must alone base their practical prophylactic measures, but on preventing those conditions from arising which their mutual experience and individual observations have shown them to favour the development of disease in human beings. THE

DURATION OF INFECTIVITY IN DIPHTHERIA.~" BY L. W. DARRANIAIR~M.D. Lond.m M.P.H. Croydon Rural District. THE " d i s i n f e c t i o n " of premises where cases of infectious diseases have arisen has been done upon the receipt, from the medical attendant, of a certificate of freedom from infection, except in cases of diphtheria, in which, since the commencement of 1895 , it has been the practice to prove the absence of the diphtheria bacillus, by bacteriological examination, after the recovery of the patient. This procedure has resulted in the continued isolation of the great majority of cases for much longer periods than was usual before these examinations were made. Thus, in 1894 , there were 2o cases of diphtheria, which neither died nor were removed from home, and their average d u r a t i o n - that is, the average period which elapsed between the date of attack and the receipt of the medical attendant's certificate of freedom from i n f e c t i o n - was I6"4 days. In I895, of I4 cases which neither died nor were removed, the average period which elapsed between the date of attack and the receipt of a certificate declaring the absence of the KlebsLoeffler bacillus, was 33 days. It may be useful to analyse the duration of these eases more fully. I n 1894 , of the 2o cases, the duration of 3 was less than i o days, that o f 5 was between i o and 15 days, that of 6 between i 5 and 2o days, that of 5 between 2o and 2!; days, and that of i only between 25 and 30 days. I n 1895 , of the 14 cases, no case lasted less than lO days,. 1 lasted between i o and 15 days, 3 between 15 and 20 days, 2 between 2'0 a n d 3 o days, 3 between 3 ° and 4o days, 3 between 4o and 5 ° days, I between 5 ° and 6o days, while i lasted as long as 6I days. If i t be a c c e p t e d that the presence of the Klebs.Lceffier bacillus denotes continued infectivity ~ a n d it would be dangerous at present to aver the c o n t r a r y - - i t is obvious that in 1894 , before these examinations were made, a considerable number Of persons were allowed to mix ~with their fellows before they had really cease(t "to be infectious ; and there can be little doubt that the institution of these examinations has largely determined the diminution in the total number of cases in 1895 as compared with I894. It must be confessed, however, that these From Dr. Moires Annual Report for I895.

IN DIPHTHERIA.

32r

examinations have occasionally led to considerable difficulty, and have resulted in creating a fresh cause of anxiety to the officers of the Health Department, while at the same time they have very materially increased the trouble which a case of diphtheria always causes, in any event, to the medical practitioner. It has been difficult to persuade parents that a child, perfectly well in itself, was, nevertheless, capable of conveying infection to othersj owing to the presence of an invisible organism, and, if it had not been for the almost universal support which has been accorded by the medical practitioners in the District, there is no doubt that the utility of these examinations would have been much impaired, if not rendered almost altogether nugatory The object of them, however, is of such great importance that every effort will be made to persevere with them in spite of difficulty ; and it may be confidently hoped that medical practitioners will continue their invaluable support, and thereby gradually educate the public to the necessity of enduring prolonged isolation of diphtheria, just as they have already done in the case of scarlet fever. LAW REPORT. COUNTY OF LONDON SESSIONS.

.4dulteration--Sale of Preserved Peas coloured with Su~hate of Cop~er-- Whether Injurious to Heallh--Sale of food and Drugs Act, 1875 , s. 3 . THIS was an appeal by Charles H e n r y Summers against a conviction under s. 3 of the Sale of F o o d and Drugs Act, 1875, for having sold certain bottled peas which were alleged to be injurious to health. T h e facts of the case appear sufficiently from the judgment of the Court delivered by Mr. Sprees, which was to the following effect: This is an appeal from a conviction under s. 3 of the Sale of F o o d and Drugs Act, 1875 , which is as follows : " N o person shall mix, colour, stain, or powder , . . any article of food with any ingredient or material so as to render the article injurious to health . . . and no person shall sell any such article so mixed under a penalty not exceeding .£50. '' T h e conviction is for seUing.a pound of bottled peas c01oured with sulphate of copper so as to cause injury to health. The facts to be considered are : ( i ) the quantity of sulphate of copper a d d e d ; (2) whether sulphate o f copper is of such a nature as to render peas t o which it has been a d d e d injurious to health. As to the quantity there is some difference in the results of three several analyses which have been made. Mr. Bodmer, the analyst t o t h e St. Savi0ui"s VeStry, who has for many years worked under Dr. "Stevenson, the aA