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ETIOLOGY OF DIPHTHERIA, WITH SPECIAL REFERENCE TO TWO LOCALISED OUTBREAKS IN WANDSWORTH.
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DR. P. CALDWELL SMITH : ETIOLOGY OF DIPHTHERIA.
ruptured incision on the eleventh day. But in this case the patient was a strong woman ; her wound gave way suddenly during the night, and when I examined it some hours later I found the protruding bowel firmly adherent to the divided edges of the incision. I cleaned the parts, returned the viscus, and sewed up the wound, which did not give any
further trouble. CASE 24.-I was asked to see a patient about two hours after a hysterectomy had been performed. She had suddenly become very pale and faint whilst in the act of retching. When I saw her she had every appearance of severe haemorrhage. As the gentleman who had operated was not at hand I opened the abdomen, found that its cavity was full of blood, and that the right broad ligament had slipped completely from its ligatures. I re-secured the divided broad ligament and removed large quantities of blood, but I did not wash out the abdominal cavity because healthy blood-clot is not likely to do harm. A glass drainage tube was placed in the pouch of Douglas. It was doubtful for many hours, indeed for days, whether the patient would survive ; but she gradually rallied and made a perfect, though slow, recovery. She was alive and well five years after the operation. CASE 25.-In this case the inverted fundus of the uterus simulated a polypus, and had been removed by means of scissors, the nature of the operation being discovered by examination of the specimen. I saw the patient within an hour, and although her condition did not appear serious I thought it best to ensure against hæmorrhage by opening the abdomen and securing all the bleeding points. The second operation was begun within two hours of the first. Very little bleeding had taken place, but the disturbance of the parts set up free haemorrhage, and there can be little doubt that the patient would have run a very serious risk when reaction set in if the hmmostatic power of nature had been trusted to. I tied the uterine arteries and broad ligaments and sewed together the divided uterine surfaces so as to close completely the opening from the vagina to the peritoneum. The patient made a perfect recovery. CASE 26.-The accident that occurred in this case is, I believe, very rare. In dressing a patient whose pelvis was being drained I discovered on the fourth day after operation that the glass drainage-tube was fractured. I removed some sutures and fished up the lower half of the tube with a pair of forceps, the blades of which were guarded by rubber tubing. The two pieces of glass accurately completed the tube. Another tube was inserted for twenty-four hours. Beyond a sharp rise of temperature and pulse, which was recovered from next day, the accident caused no trcuble and it did not delay convalescence. The two great dangers in operating on the abdomen are the introduction of septic mischief during the operation and the occurrence of obstruction of the bowels or of pseudo ileus after the operation. In the foregoing cases I have succeeded in avoiding a fatal issue from these conditions, although in all the fatal cases septic mischief was primarily If a patient has or secondarily an important cause of death. to be operated on when the blood is already saturated with the products of septic mischief, as in Cases 16, 22, 11, 15, and 19, it is very difficult to avoid a fatal issue from septicaemia. But besides septicaemia and bowel complications there are many dangers and accidents which may The bowel occur in connexion with an abdominal section. conditions in Cases 14, 15, and 16 indicate remote dangers. The cancerous recurrence in Case 7 is a condition of great importance. Many accidents and mistakes are illustrated in my paper-injury to the bladder, Case 12 ; rupture of the abdominal wound, Cases 21 and 23 ; slipping of ligatures, Case 24; and mistaking of an inverted fundus for a polypus, Case 25. All these accidents have occurred before, and doubtless they will occur again ; but I think that by bringing these together I may impress on operators the necessity for the greatest care during and after operations so that these and other dangers may be avoided. Portman-street, W.
ETIOLOGY OF DIPHTHERIA, WITH SPECIAL REFERENCE TO TWO LOCALISED OUTBREAKS IN WANDSWORTH. SMITH, M.A., M.D. GLASG., D.P.H. CAMB.,
BY P. CALDWELL
MEDICAL OFFICER OF HEALTH OF THE PARISH OF WANDSWORTH.
To all sanitarians as well as to medical men generally the increased prevalence of diphtheria in London is a subject of the greatest importance, and any addition, however small, to our knowledge of the etiology of this disease ought to be carefully studied for future guidance. It has been well said by Dr. Creighton in his admirable book on the History of Epidemics in Great Britain that ’’diphtheria is, perhaps, themost obscure and complex of all the infectious diseases iri its causes and favouring conditions" and its continued’ prevalence in the metropolis has verified the above statement. The death-rate for diphtheria in London for the ten years. 1871-80 was 120 per million living; in 1881-90 260 per million:, while in the year 1893 this rate was 740 ; in 1894, 610; in 1895, 520 ; and in 1896, 602 per million. On the continent. the death-rate is in some towns higher than the 1895 rate, it being in St. Petersburg 590 per million and in Berlin 540; while in Paris, Brussels, Amsterdam, Vienna, and Rome the rate was in the same year lower, in the latter city being only 80 per million. The above statistics tend to modify the view that insanitary conditions in dwelling houses are the cause of diphtheria, nor do they altogether agree with the statement of Sir R. Thorne Thorne that sewage gas produces a morbid condition of the fauces rendering the patient more liable to the reception of the diphtheria poison." In, the first place there is no doubt that in London the sanitary condition of the houses of the working classes is much better than it was in the decennium 1871-80, when the diphtheria mortality was 120 per million, as compared with 602 per million in 1896 ; and in. the second place it is certain that the general sanitary arrangements in London are superior to those existing, not only in continental towns, but also in provincial towns in England and Scotland, which have a much lower diphtheria mortality. That it is even a predisposing cause. would also seem to be negatived by the same statistics, so that for practical purposes we are confronted with the only other possible sources of infection-viz,, infection by milk In this regard the and infection from person to person. remarks made by Bristowe in his Theory and Practice of Medicine" may be quoted. He says that" there is reason to believe that the sanitary state of houses and localities and the condition of health of those who are exposed to its poison have much influence over its development." That was the general and accepted professional opinion twenty years ago, and even yet it is maintained that sanitary defect& play an important part in its causation. Again, we know that the zymotic disease most intimately related to insanitary conditions is enteric fever, although even in this the specific organism must be present before infection can occur. Specifically polluted milk, water, and other articles of food are of course the most common causes of outbreaks of enteric fever, but, as has been stated by Dr. Theodore Thomson, "there is no doubt that the air of sewers and drains which has become specifically contaminated may, if allowed to find its way into dwellings through defective house connexions, cause from time to time enteric fever among the inhabitants of such dwellings." If, then, the sanitary condition of the metropolis has beers improved we would expect a gradual diminution in the typhoid fever death-rate, and this is what has taken place. The death-rate which was in the decennium 1871-80 240 per million fell to 190 per million in 1881-90, 140 per million in 1895, and 127 per million in 1896. These figures would lead one to believe that the sanitary THE NEWPORT WATER-SUPPLY. - A condition of the houses in the metropolis is better now special meeting of the County Council was held on than it has ever been, and yet we see that the diphtheria Sept. 28th to consider the present condition of the Went- mortality has increased from 120 to 602 per million in worth Scheme for the water-supply of Newport. Many twenty years. Seeing, then, that insanitary conditions do failures have from time to time occurred during the course not explain the great rise in diphtheria mortality some other of the work, and the chairman mentioned that the cost of method of infection must be looked for. Dr. Klein, after the undertaking up to the present had been £100,408. i elaborate research and experiment, came to the conclusion
(MON.)
DR. P. CALDWELL SMITH: ETIOLOGY OF DIPHTHERIA.
that cows can be infected with the diphtheria bacillus, ani 1 while the other four children attended tlboard school in Ward 1 of this parish. During the month of February 20 that the milk from these cows, if drunk, would produc diphtheria in the hu, man being. It is not denied by sani cases were notified with 7 deaths, and in March 17 with 2 deaths. The total number of cases in the ward was 45, 25 tarians that milk, if infected from a human source with th diphtheria bacillus (for milk is a good medium for th, males and 20 females, with 12 deaths, a percentage of 26’5. growth of this bacillus), will produce the disease in person I These 45 cases occurred in twenty-three households ; in four drinking it; but whether this disease of cows is true diph households 5 cases occurred in each ; in six, 2 cases ; and in theria, or the bacillus described by Klein is simila . thirteen, 1 case. In this ward there are two schools, one a board school and the other a national school, and of the to the Klebs - Löfller bacillus, has not, as far as am aware, been definitely determined by other authori twenty-three households affected the first cases occurred ties. The only animal in which it is probable tha j in thirteen households in children attending the national diphtheria occurs is the domestic cat, and severa school, in nine the board school, and in two households the children infected had not been to any school. cases have been traced to infection from this source in the cat no membrane has ever been observed on th i At first it was difficult to localise the school in which fauces or larynx, and the principal organs affected are thl i infection took place, as in a preliminary inquiry it was found Yungs and kidneys. No doubt the bacilli are exhaled anc that the cases occurred in both schools at varying intervals 02xpelIed in the mucous discharge, and in this way infectior and among children who did not in school associate with one of human beings may take place. It is important to notE another. In the board school an examination of the cases rin this connexion that it is now decided that the affection oj showed that 10 attended the infant department, 3 the fowls and pigeons in which a membranous growth occurs it girls’ and 2 the boys’ departments. In the infant departthe throat has no connexion with diphtheria in human ment the first three cases were members of the same family, Mags. One certain mode of infection is by fomites, and and none of them had been in attendance at school for although this will not explain all cases yet many have been over seven days. The next two cases in that department {recorded proving that the virus can be conveyed by persons did not occur for three weeks, the first on Jan. 21st and the second on Jan. 26 ch, but they did not attend or things. I know of one case, or rather one household, that was infected in which the poison was conveyed by a letter, the same class at school, although they, on entering and Jacobi is leaving school, passed through the same corridors. In this as has often happened in the case of scarlet fever. of opinion that diphtheria is exquisitely contagious, that the department all the children have a common playground. germ clings to body-linen, bed-linen, clothes, and wood-work, In the girls’ department the cases occurred in separate classrooms. In the boys’ department the first case was notified and furniture of rooms in which a case had occurred. Far more important than the probable causation by on Feb. 4th and the second on March 2nd. Attention was defective sanitary arrangements, specifically infected milk, then directed to the national school, which was attended by domestic animals, and fomites is the causation and spread a little over 100 scholars, and here, also, it was in the earlier of the disease by personal infection, and it is this, I cases difficult to say that school attendance was the sole loelieve, that is the cause of the great increase in urban cause of the outbreak. Five out of ten cases occurred up to districts, and especially in London, in recent years. When Feb. 27th in which the infection was caught at school, two one remembers the opportunities now existing for close perof these being members of the same family. These cases aonal contact among children in public and private schools, were notified, one on Feb. 16th, two on Feb. 18th, one on Sunday-schools, and private gatherings, as compared with Feb. 20th, and one on Feb. 22nd. It was then thought that what was the case even twenty years ago, it is not to be the outbreak had abated as far as this school was wondered at that such increase in diphtheria has taken concerned, but on March 3rd three notifications were place. The wonder is that it is not greater and that out- received, in one of which the first symptoms appeared breaks such as recently occurred in the parish of Wands- on Feb. 22nd, in another on the 24th, and in worth have not been more numerous. In these outbreaks the third on the 27th. On March 4th two notifications were ’there is no doubt that in every case personal infec- received, in one of which the symptoms were said to have tion was the only cause in operation, although it appeared on Feb. 20th, and in the second on the 27th. On was not in every case that such could be definitely proved. March 5th four notifications were received, three of these These outbreaks occurred in Wards 1 and 3 of the parish being with respect to two children and one adult in a of Wandsworth, which had a population, principally working previously infected house, while the fourth case did not go to dass, of 8670 and 11, 817 respectively at the census of 1896. the day-school at all, but to the Sanday-school. All the first Thewards are not adjacent to one another, and the outbreaks children infected had been in close contact in the above dayhad, as far as could he ascertained, no connexion, although school or Sunday-school, and it was also ascertained that of the ’Jn both school infection was proved to have been the means earlier cases several were in attendance on the Sunday-school, of spread, and this most definitely in the outbreak in Ward 3. which was held partly in the same building as the dayThat school attendance is a prominent factor in the dis- school. The board school, although attended by over 800 *Semination of diphtheria has long been known, and Sir R. scholars, was excluded as the cause of the disease, but Thorne Thorne, in his Milroy Lectures, has summarised all the national school was closed on my instructiors The conclusions arrived at by on March 5th for fourteen days, with the almost immediate our knowledge of the subject. Sir R. Thorne Thorne are so generally known that it is effect of checking the outbreak. After that date six notifiunnecessary to recapitulate them, but there is one state- cations were received, only one of these from a household ment that, in view of the recent outbreaks in this district, not previously infected. This child had been to school on ’is specially noteworthy. Sir R. Thorne Thorne states that March 5th, the first symptoms appearing on the 7th. The "there are ample grounds for believing that the aggrega- other five were secondary cases. Out of the twenty-three tion of children in elementary schools constitutes one of households infected in only six were there any sanitary the conditions under which a form of disease of particular defects, and these were of a minor character. In four the potency for spread and for death may be, so to speak, connexion between the water-closet and the drains was manufactured"; or, in other words, that in diphtheria defective. there is a " progressive development of the property of In this outbreak it was at first difficult to arrive at a ’infectiveness." leflnite conclusion as to its causation, owing to delay in Before proceeding to discuss this as a cause of the virulence notification of the cases. In four of the cases no medical oi the outbreaks it will be necessary to give some particulars nan was called in until some time had elapsed, and children with reference to them. In Ward 1 sporadic cases of ’rom the infected households were meanwhile attending diphtheria had occurred during 1896, 27 cases having school. In one or two cases there was difficulty in diagnosis, been notified in that year at intervals of from fourteen ts some of the attacks were mild and not well-marked, to thirty days. Most of the cases were exceptionally vhereas others were of a severe and virulent type. The fact mild. In January, 1697, however, 8 cases were notified 1 ,hat the outbreak was checked by the closure of the school with 3 deaths, 5 of the cases occurring in one family, ; affords strong grounds for the belief that, at any rate in the 2 of these proving fatal. The causation of these 5 1 ater cases, the infection was received at school, and princases is important as showing a certain connexion< ;ipally at Sunday-school, where the same control is not between this outbreak and the one at Roehampton 1 lossible as far as overcrowding is concerned. in the adjoining parish of Putney, which had occurred The outbreak in Ward 3 was of a very malignant character, in the months of October and November, 1896. OneE ,nd this was specially marked in the primary cases. This of the children affected attended a school in Roehamp- ( utbreak was limited to children attending one school, and ton, at which all the children affected there were scholars, he infection was traced to the attendance of a child suffering .
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DR. C. D GREEN: APPENDICITIS WITH SOME ITNUSUAL SYMPTOMS.
from the disease at school on the afternoon of March 2nd. For some months previous to this no cases had occurred in this neighbourhood, and the school had always remained very free from diseases of an infectious nature. Inclusive of the above case, 3 notifications were received between March 6th and 18’.h, and 13 deaths resulted, a percentage of nearly 43. The first case which was the cause of the outbreak proved fatal, and of the 11 case9 primarily infected by this 7 died. In 7 caes the first symptoms appeared on the evening of March 4th, and of tho.e 6 died ; in 4 on March 5tih, with 1 death ; and in 4 on March 6th, with 1 death. These 15 cases were all infected at school on March 2nd, 3rd, and 4th, and, as might have been anticipated, were the cause of other cases, not only in the same households, but in others. One monitor, a girl aged fourteen yearp, was infected on March 5th ag on that date in school she nursed one of the previously infected cases who had turned ill, and the first The type of disease in ympt Ims appeared on March 8<’h. the early cases was more virulent, but the secondary and tertiary cases were of a mildtr type. Ia all, twenty-five households were infected, but owing to prompt diagnosis, notification, and isolation the outbreak did not last long. The disease was so virulent and the symptoms in the early stages were so definite that prompt isolation was at once carried out, with the result that in these households only two had secondary or tertiary cases. The school was closed on March 8th for twenty-one days, and after that date thirteen cases were notifiej, but of these four ca;es occurred in households previously infected. An analysis of the other nine cases showed that two in whom the first symptoms appeared on March 9th had been at school on the 50h and 8th, while the remaining seven were all ascertained to have come into direct contact with some of the previously notified cases. The last notification from this part of the district was received on March 22ad, the first symptoms having appeared on the 20th, and the outbreak subsided almost as rapidly as it had commenced. In nine of the houses where cases occurred sanitary defects were found after testing, but these, as in the outbreak in Ward 1, were of a slight character, mainly consisting of defective watercloset arrangements. In all the cases occurring in these houses a definite history of contact with a previous case was obtained. The milk-supply in all cases was the subject of careful inquiry, but no connexion between this and the outbreaks in either ward could be traced. The sanitary arrangements of the school in Ward 1 were carefully examined and the drains tested, but only a slight defect was found, this consisting of an untrapped rain-water pipe. In Ward 3 the sanitary arrangements of the school were excellent, the drains having only recently been laid under the supervision of the sanitary inspector. A review of all the circumstances attending the three outbreaks-the one at Roehampton and the two in Wandsworth-emphasises the fact that diphtheria may show varying degrees of virulence in different outbreaks. In the Roehampton outbreak out of 30 cases reported not one proved fatal. In the first’outbreak in this parish 45 cases were reported, of which 12 proved fatal, and in the second 31 cases with 13 deaths. Again, in Ward 1 of this parish diphtheria had been present, though in a mild form, during the previous year ; and it is a well-known fact that virulent outbreaks are frequently preceded by a prevalence of sore-throat or of true diphtheria of a mild character. It is difficult to say definitely whether the outbreak in Ward 3 arose out of that in Ward 1. Every inquiry was made into the history of the child first affected in Ward 3, but no definite information could be obtained as to contact with any of the cases in Ward 1. It is quite within the bounds of possibility that such contact did take place, and if so it would further verify the statement made by Sir R. Thorne Thorne as to the progressive power of infectiveness of this disease. The lessons to be drawn from these and similar outbreaks are, in my opinion-that all cases of sore throat should be immediately isolated, and that when possible a bacteriological examination should be made. Immediate notification should be made to the medical officer of health, not only of cases where the symptoms are on the first examination definite, but also in all cases which are at all suspicious. These measures would ensure the exclusion of alt infected children from school, and this is, in my opinion, the most important etiological factor in the dissemination of diphtheria in urban localities, and especially in the metropolis. Wandsworth, S.W
A CASE OF APPENDICITIS WITH SOME
UNUSUAL SYMPTOMS. BY CHARLES D. GREEN, M.D.
LOND., F.R.C.S. ENG.
AN ill-nourished and undersized lad, agfd fifteen years, on Sept. 27th, 1893, while employed in field work, obliged to return home on account of abdominal pain. !. saw him the same evening ; he gave no history of any previous bowel trouble. He had felt a little pain in theabdomen before starting for work, but went to work as usual, walking nearly two miles for the purpose. He continued at work during the morning, but was obliged to return early in the afternoon on account of increase in the pain. He had vomited once during the day. When I saw him he was lying on his back; he did not appear to be seriously ill; his abdomen was not distended, and no tenderness was elicited’ on examination ; his tongue was clean and moist, and his bowels had been open. He had eaten some raw turnip, amongst other things, during the day; no aperient was given, but absolute rest was enjoined. The next day some. tenderness was evident in the right iliac fossa. Onthe. 29th the temperature was 101° F. ; there was some exadation on the right side ; the abdominal walls were rigid ; ther& was a distinct tender spot two inches below, and one inch external to, the umbilicus, and at this spot there seemed to be a greater sense of resistance than elsewhere. The sense of resistance was, however, ill.defined and diffuse; there was. no dulness on percussion. The next day (the 30th) thetemperature was 102° and there was a little dulness over the, tender spot; the general condition did not seem grave. On Oct. lst and 2nd there appeared to be some amelioration;, the temperature on the latter date was 100°, the tongue was moist and clean, there had been no further vomiting since the onset, and the general condition remained about the same the signs of local exudation were more distinct. So far the case had appeared to me to have been a simple one of appendicitis, localised and threatening to suppurate, but not calling for immediate operation. On the night of the 2nd, however, a sudden and severe exacerbation of pain took. place. On the 3rd the temperature was 101°, there was considerable distension of the abdomen, and severe pain, referred to the right iliac region ; the dulness previously noticed had disappeared. On very light percussion, however, the note seemed somewhat damped over a small area the centre of which was about the middle of a line drawn from, the umbilicus to the middle of the right Poupart’s ligament There had been no vomiting. The treatment had hitherto been small doses of opium and enemata; these latter had,. however, only brought away a small quantity of hard fxces, evidently from the lower bowel, and it was stated that D(). flatus had been passed. It was now evident that operation was called for, and it seemed to me that perforation of the: appendix had taken place during the night and that if general. peritonitis had not already begun the risk of its occurrence would be materially increased by moving the patient. r therefore decided to operate on the spot, although the patient was a pauper and the surroundings far from favour-. able. On the morning of the 3rd, chloroform having been, administered, I made an incision three inches long in the right iliac region ; the peritoneum was thick and vascular, and on dividing it I came upon a thickened mass which I took to. be the edge of the great omentum. On separating the lower edge of this from its connexions about four ounces of foul-smelling fluid escaped ; this was thin and semi-purulent,. with flocculent material floating in it ; no actual pus was found. The finger inserted into the wound failed to define. clearly the appendix, it appeared to be curled up behind the. casoum; a mass of adherent small intestine could be felt at the upper and inner part of the cavity ; the finger brought away two fascal concretions of the size and shape of rice. grains, and four other similar concretions were subsequently found in the fluid that had been evacuated. The cavity. was gently irrigated with warm mercuric chloride solution (1 in 2000), the upper part of the wound closed with a silk-worm gut suture, and a rubber drainage-tube inserted. The patient rallied well from the operation, the pain was relieved, and there seemed at first every prospect of a quiet course. Thetemperature did not rise above 100°; the bowels, however, in. spite of enemata, were not opened, no flatus was passed, and only a small lump of hard fasces, evidently from the lowe7 was
DR. P. CALDWELL SMITH : ETIOLOGY OF DIPHTHERIA.
ruptured incision on the eleventh day. But in this case the patient was a strong woman ; her wound gave way suddenly during the night, and when I examined it some hours later I found the protruding bowel firmly adherent to the divided edges of the incision. I cleaned the parts, returned the viscus, and sewed up the wound, which did not give any
further trouble. CASE 24.-I was asked to see a patient about two hours after a hysterectomy had been performed. She had suddenly become very pale and faint whilst in the act of retching. When I saw her she had every appearance of severe haemorrhage. As the gentleman who had operated was not at hand I opened the abdomen, found that its cavity was full of blood, and that the right broad ligament had slipped completely from its ligatures. I re-secured the divided broad ligament and removed large quantities of blood, but I did not wash out the abdominal cavity because healthy blood-clot is not likely to do harm. A glass drainage tube was placed in the pouch of Douglas. It was doubtful for many hours, indeed for days, whether the patient would survive ; but she gradually rallied and made a perfect, though slow, recovery. She was alive and well five years after the operation. CASE 25.-In this case the inverted fundus of the uterus simulated a polypus, and had been removed by means of scissors, the nature of the operation being discovered by examination of the specimen. I saw the patient within an hour, and although her condition did not appear serious I thought it best to ensure against hæmorrhage by opening the abdomen and securing all the bleeding points. The second operation was begun within two hours of the first. Very little bleeding had taken place, but the disturbance of the parts set up free haemorrhage, and there can be little doubt that the patient would have run a very serious risk when reaction set in if the hmmostatic power of nature had been trusted to. I tied the uterine arteries and broad ligaments and sewed together the divided uterine surfaces so as to close completely the opening from the vagina to the peritoneum. The patient made a perfect recovery. CASE 26.-The accident that occurred in this case is, I believe, very rare. In dressing a patient whose pelvis was being drained I discovered on the fourth day after operation that the glass drainage-tube was fractured. I removed some sutures and fished up the lower half of the tube with a pair of forceps, the blades of which were guarded by rubber tubing. The two pieces of glass accurately completed the tube. Another tube was inserted for twenty-four hours. Beyond a sharp rise of temperature and pulse, which was recovered from next day, the accident caused no trcuble and it did not delay convalescence. The two great dangers in operating on the abdomen are the introduction of septic mischief during the operation and the occurrence of obstruction of the bowels or of pseudo ileus after the operation. In the foregoing cases I have succeeded in avoiding a fatal issue from these conditions, although in all the fatal cases septic mischief was primarily If a patient has or secondarily an important cause of death. to be operated on when the blood is already saturated with the products of septic mischief, as in Cases 16, 22, 11, 15, and 19, it is very difficult to avoid a fatal issue from septicaemia. But besides septicaemia and bowel complications there are many dangers and accidents which may The bowel occur in connexion with an abdominal section. conditions in Cases 14, 15, and 16 indicate remote dangers. The cancerous recurrence in Case 7 is a condition of great importance. Many accidents and mistakes are illustrated in my paper-injury to the bladder, Case 12 ; rupture of the abdominal wound, Cases 21 and 23 ; slipping of ligatures, Case 24; and mistaking of an inverted fundus for a polypus, Case 25. All these accidents have occurred before, and doubtless they will occur again ; but I think that by bringing these together I may impress on operators the necessity for the greatest care during and after operations so that these and other dangers may be avoided. Portman-street, W.
ETIOLOGY OF DIPHTHERIA, WITH SPECIAL REFERENCE TO TWO LOCALISED OUTBREAKS IN WANDSWORTH. SMITH, M.A., M.D. GLASG., D.P.H. CAMB.,
BY P. CALDWELL
MEDICAL OFFICER OF HEALTH OF THE PARISH OF WANDSWORTH.
To all sanitarians as well as to medical men generally the increased prevalence of diphtheria in London is a subject of the greatest importance, and any addition, however small, to our knowledge of the etiology of this disease ought to be carefully studied for future guidance. It has been well said by Dr. Creighton in his admirable book on the History of Epidemics in Great Britain that ’’diphtheria is, perhaps, themost obscure and complex of all the infectious diseases iri its causes and favouring conditions" and its continued’ prevalence in the metropolis has verified the above statement. The death-rate for diphtheria in London for the ten years. 1871-80 was 120 per million living; in 1881-90 260 per million:, while in the year 1893 this rate was 740 ; in 1894, 610; in 1895, 520 ; and in 1896, 602 per million. On the continent. the death-rate is in some towns higher than the 1895 rate, it being in St. Petersburg 590 per million and in Berlin 540; while in Paris, Brussels, Amsterdam, Vienna, and Rome the rate was in the same year lower, in the latter city being only 80 per million. The above statistics tend to modify the view that insanitary conditions in dwelling houses are the cause of diphtheria, nor do they altogether agree with the statement of Sir R. Thorne Thorne that sewage gas produces a morbid condition of the fauces rendering the patient more liable to the reception of the diphtheria poison." In, the first place there is no doubt that in London the sanitary condition of the houses of the working classes is much better than it was in the decennium 1871-80, when the diphtheria mortality was 120 per million, as compared with 602 per million in 1896 ; and in. the second place it is certain that the general sanitary arrangements in London are superior to those existing, not only in continental towns, but also in provincial towns in England and Scotland, which have a much lower diphtheria mortality. That it is even a predisposing cause. would also seem to be negatived by the same statistics, so that for practical purposes we are confronted with the only other possible sources of infection-viz,, infection by milk In this regard the and infection from person to person. remarks made by Bristowe in his Theory and Practice of Medicine" may be quoted. He says that" there is reason to believe that the sanitary state of houses and localities and the condition of health of those who are exposed to its poison have much influence over its development." That was the general and accepted professional opinion twenty years ago, and even yet it is maintained that sanitary defect& play an important part in its causation. Again, we know that the zymotic disease most intimately related to insanitary conditions is enteric fever, although even in this the specific organism must be present before infection can occur. Specifically polluted milk, water, and other articles of food are of course the most common causes of outbreaks of enteric fever, but, as has been stated by Dr. Theodore Thomson, "there is no doubt that the air of sewers and drains which has become specifically contaminated may, if allowed to find its way into dwellings through defective house connexions, cause from time to time enteric fever among the inhabitants of such dwellings." If, then, the sanitary condition of the metropolis has beers improved we would expect a gradual diminution in the typhoid fever death-rate, and this is what has taken place. The death-rate which was in the decennium 1871-80 240 per million fell to 190 per million in 1881-90, 140 per million in 1895, and 127 per million in 1896. These figures would lead one to believe that the sanitary THE NEWPORT WATER-SUPPLY. - A condition of the houses in the metropolis is better now special meeting of the County Council was held on than it has ever been, and yet we see that the diphtheria Sept. 28th to consider the present condition of the Went- mortality has increased from 120 to 602 per million in worth Scheme for the water-supply of Newport. Many twenty years. Seeing, then, that insanitary conditions do failures have from time to time occurred during the course not explain the great rise in diphtheria mortality some other of the work, and the chairman mentioned that the cost of method of infection must be looked for. Dr. Klein, after the undertaking up to the present had been £100,408. i elaborate research and experiment, came to the conclusion
(MON.)
DR. P. CALDWELL SMITH: ETIOLOGY OF DIPHTHERIA.
that cows can be infected with the diphtheria bacillus, ani 1 while the other four children attended tlboard school in Ward 1 of this parish. During the month of February 20 that the milk from these cows, if drunk, would produc diphtheria in the hu, man being. It is not denied by sani cases were notified with 7 deaths, and in March 17 with 2 deaths. The total number of cases in the ward was 45, 25 tarians that milk, if infected from a human source with th diphtheria bacillus (for milk is a good medium for th, males and 20 females, with 12 deaths, a percentage of 26’5. growth of this bacillus), will produce the disease in person I These 45 cases occurred in twenty-three households ; in four drinking it; but whether this disease of cows is true diph households 5 cases occurred in each ; in six, 2 cases ; and in theria, or the bacillus described by Klein is simila . thirteen, 1 case. In this ward there are two schools, one a board school and the other a national school, and of the to the Klebs - Löfller bacillus, has not, as far as am aware, been definitely determined by other authori twenty-three households affected the first cases occurred ties. The only animal in which it is probable tha j in thirteen households in children attending the national diphtheria occurs is the domestic cat, and severa school, in nine the board school, and in two households the children infected had not been to any school. cases have been traced to infection from this source in the cat no membrane has ever been observed on th i At first it was difficult to localise the school in which fauces or larynx, and the principal organs affected are thl i infection took place, as in a preliminary inquiry it was found Yungs and kidneys. No doubt the bacilli are exhaled anc that the cases occurred in both schools at varying intervals 02xpelIed in the mucous discharge, and in this way infectior and among children who did not in school associate with one of human beings may take place. It is important to notE another. In the board school an examination of the cases rin this connexion that it is now decided that the affection oj showed that 10 attended the infant department, 3 the fowls and pigeons in which a membranous growth occurs it girls’ and 2 the boys’ departments. In the infant departthe throat has no connexion with diphtheria in human ment the first three cases were members of the same family, Mags. One certain mode of infection is by fomites, and and none of them had been in attendance at school for although this will not explain all cases yet many have been over seven days. The next two cases in that department {recorded proving that the virus can be conveyed by persons did not occur for three weeks, the first on Jan. 21st and the second on Jan. 26 ch, but they did not attend or things. I know of one case, or rather one household, that was infected in which the poison was conveyed by a letter, the same class at school, although they, on entering and Jacobi is leaving school, passed through the same corridors. In this as has often happened in the case of scarlet fever. of opinion that diphtheria is exquisitely contagious, that the department all the children have a common playground. germ clings to body-linen, bed-linen, clothes, and wood-work, In the girls’ department the cases occurred in separate classrooms. In the boys’ department the first case was notified and furniture of rooms in which a case had occurred. Far more important than the probable causation by on Feb. 4th and the second on March 2nd. Attention was defective sanitary arrangements, specifically infected milk, then directed to the national school, which was attended by domestic animals, and fomites is the causation and spread a little over 100 scholars, and here, also, it was in the earlier of the disease by personal infection, and it is this, I cases difficult to say that school attendance was the sole loelieve, that is the cause of the great increase in urban cause of the outbreak. Five out of ten cases occurred up to districts, and especially in London, in recent years. When Feb. 27th in which the infection was caught at school, two one remembers the opportunities now existing for close perof these being members of the same family. These cases aonal contact among children in public and private schools, were notified, one on Feb. 16th, two on Feb. 18th, one on Sunday-schools, and private gatherings, as compared with Feb. 20th, and one on Feb. 22nd. It was then thought that what was the case even twenty years ago, it is not to be the outbreak had abated as far as this school was wondered at that such increase in diphtheria has taken concerned, but on March 3rd three notifications were place. The wonder is that it is not greater and that out- received, in one of which the first symptoms appeared breaks such as recently occurred in the parish of Wands- on Feb. 22nd, in another on the 24th, and in worth have not been more numerous. In these outbreaks the third on the 27th. On March 4th two notifications were ’there is no doubt that in every case personal infec- received, in one of which the symptoms were said to have tion was the only cause in operation, although it appeared on Feb. 20th, and in the second on the 27th. On was not in every case that such could be definitely proved. March 5th four notifications were received, three of these These outbreaks occurred in Wards 1 and 3 of the parish being with respect to two children and one adult in a of Wandsworth, which had a population, principally working previously infected house, while the fourth case did not go to dass, of 8670 and 11, 817 respectively at the census of 1896. the day-school at all, but to the Sanday-school. All the first Thewards are not adjacent to one another, and the outbreaks children infected had been in close contact in the above dayhad, as far as could he ascertained, no connexion, although school or Sunday-school, and it was also ascertained that of the ’Jn both school infection was proved to have been the means earlier cases several were in attendance on the Sunday-school, of spread, and this most definitely in the outbreak in Ward 3. which was held partly in the same building as the dayThat school attendance is a prominent factor in the dis- school. The board school, although attended by over 800 *Semination of diphtheria has long been known, and Sir R. scholars, was excluded as the cause of the disease, but Thorne Thorne, in his Milroy Lectures, has summarised all the national school was closed on my instructiors The conclusions arrived at by on March 5th for fourteen days, with the almost immediate our knowledge of the subject. Sir R. Thorne Thorne are so generally known that it is effect of checking the outbreak. After that date six notifiunnecessary to recapitulate them, but there is one state- cations were received, only one of these from a household ment that, in view of the recent outbreaks in this district, not previously infected. This child had been to school on ’is specially noteworthy. Sir R. Thorne Thorne states that March 5th, the first symptoms appearing on the 7th. The "there are ample grounds for believing that the aggrega- other five were secondary cases. Out of the twenty-three tion of children in elementary schools constitutes one of households infected in only six were there any sanitary the conditions under which a form of disease of particular defects, and these were of a minor character. In four the potency for spread and for death may be, so to speak, connexion between the water-closet and the drains was manufactured"; or, in other words, that in diphtheria defective. there is a " progressive development of the property of In this outbreak it was at first difficult to arrive at a ’infectiveness." leflnite conclusion as to its causation, owing to delay in Before proceeding to discuss this as a cause of the virulence notification of the cases. In four of the cases no medical oi the outbreaks it will be necessary to give some particulars nan was called in until some time had elapsed, and children with reference to them. In Ward 1 sporadic cases of ’rom the infected households were meanwhile attending diphtheria had occurred during 1896, 27 cases having school. In one or two cases there was difficulty in diagnosis, been notified in that year at intervals of from fourteen ts some of the attacks were mild and not well-marked, to thirty days. Most of the cases were exceptionally vhereas others were of a severe and virulent type. The fact mild. In January, 1697, however, 8 cases were notified 1 ,hat the outbreak was checked by the closure of the school with 3 deaths, 5 of the cases occurring in one family, ; affords strong grounds for the belief that, at any rate in the 2 of these proving fatal. The causation of these 5 1 ater cases, the infection was received at school, and princases is important as showing a certain connexion< ;ipally at Sunday-school, where the same control is not between this outbreak and the one at Roehampton 1 lossible as far as overcrowding is concerned. in the adjoining parish of Putney, which had occurred The outbreak in Ward 3 was of a very malignant character, in the months of October and November, 1896. OneE ,nd this was specially marked in the primary cases. This of the children affected attended a school in Roehamp- ( utbreak was limited to children attending one school, and ton, at which all the children affected there were scholars, he infection was traced to the attendance of a child suffering .
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DR. C. D GREEN: APPENDICITIS WITH SOME ITNUSUAL SYMPTOMS.
from the disease at school on the afternoon of March 2nd. For some months previous to this no cases had occurred in this neighbourhood, and the school had always remained very free from diseases of an infectious nature. Inclusive of the above case, 3 notifications were received between March 6th and 18’.h, and 13 deaths resulted, a percentage of nearly 43. The first case which was the cause of the outbreak proved fatal, and of the 11 case9 primarily infected by this 7 died. In 7 caes the first symptoms appeared on the evening of March 4th, and of tho.e 6 died ; in 4 on March 5tih, with 1 death ; and in 4 on March 6th, with 1 death. These 15 cases were all infected at school on March 2nd, 3rd, and 4th, and, as might have been anticipated, were the cause of other cases, not only in the same households, but in others. One monitor, a girl aged fourteen yearp, was infected on March 5th ag on that date in school she nursed one of the previously infected cases who had turned ill, and the first The type of disease in ympt Ims appeared on March 8<’h. the early cases was more virulent, but the secondary and tertiary cases were of a mildtr type. Ia all, twenty-five households were infected, but owing to prompt diagnosis, notification, and isolation the outbreak did not last long. The disease was so virulent and the symptoms in the early stages were so definite that prompt isolation was at once carried out, with the result that in these households only two had secondary or tertiary cases. The school was closed on March 8th for twenty-one days, and after that date thirteen cases were notifiej, but of these four ca;es occurred in households previously infected. An analysis of the other nine cases showed that two in whom the first symptoms appeared on March 9th had been at school on the 50h and 8th, while the remaining seven were all ascertained to have come into direct contact with some of the previously notified cases. The last notification from this part of the district was received on March 22ad, the first symptoms having appeared on the 20th, and the outbreak subsided almost as rapidly as it had commenced. In nine of the houses where cases occurred sanitary defects were found after testing, but these, as in the outbreak in Ward 1, were of a slight character, mainly consisting of defective watercloset arrangements. In all the cases occurring in these houses a definite history of contact with a previous case was obtained. The milk-supply in all cases was the subject of careful inquiry, but no connexion between this and the outbreaks in either ward could be traced. The sanitary arrangements of the school in Ward 1 were carefully examined and the drains tested, but only a slight defect was found, this consisting of an untrapped rain-water pipe. In Ward 3 the sanitary arrangements of the school were excellent, the drains having only recently been laid under the supervision of the sanitary inspector. A review of all the circumstances attending the three outbreaks-the one at Roehampton and the two in Wandsworth-emphasises the fact that diphtheria may show varying degrees of virulence in different outbreaks. In the Roehampton outbreak out of 30 cases reported not one proved fatal. In the first’outbreak in this parish 45 cases were reported, of which 12 proved fatal, and in the second 31 cases with 13 deaths. Again, in Ward 1 of this parish diphtheria had been present, though in a mild form, during the previous year ; and it is a well-known fact that virulent outbreaks are frequently preceded by a prevalence of sore-throat or of true diphtheria of a mild character. It is difficult to say definitely whether the outbreak in Ward 3 arose out of that in Ward 1. Every inquiry was made into the history of the child first affected in Ward 3, but no definite information could be obtained as to contact with any of the cases in Ward 1. It is quite within the bounds of possibility that such contact did take place, and if so it would further verify the statement made by Sir R. Thorne Thorne as to the progressive power of infectiveness of this disease. The lessons to be drawn from these and similar outbreaks are, in my opinion-that all cases of sore throat should be immediately isolated, and that when possible a bacteriological examination should be made. Immediate notification should be made to the medical officer of health, not only of cases where the symptoms are on the first examination definite, but also in all cases which are at all suspicious. These measures would ensure the exclusion of alt infected children from school, and this is, in my opinion, the most important etiological factor in the dissemination of diphtheria in urban localities, and especially in the metropolis. Wandsworth, S.W
A CASE OF APPENDICITIS WITH SOME
UNUSUAL SYMPTOMS. BY CHARLES D. GREEN, M.D.
LOND., F.R.C.S. ENG.
AN ill-nourished and undersized lad, agfd fifteen years, on Sept. 27th, 1893, while employed in field work, obliged to return home on account of abdominal pain. !. saw him the same evening ; he gave no history of any previous bowel trouble. He had felt a little pain in theabdomen before starting for work, but went to work as usual, walking nearly two miles for the purpose. He continued at work during the morning, but was obliged to return early in the afternoon on account of increase in the pain. He had vomited once during the day. When I saw him he was lying on his back; he did not appear to be seriously ill; his abdomen was not distended, and no tenderness was elicited’ on examination ; his tongue was clean and moist, and his bowels had been open. He had eaten some raw turnip, amongst other things, during the day; no aperient was given, but absolute rest was enjoined. The next day some. tenderness was evident in the right iliac fossa. Onthe. 29th the temperature was 101° F. ; there was some exadation on the right side ; the abdominal walls were rigid ; ther& was a distinct tender spot two inches below, and one inch external to, the umbilicus, and at this spot there seemed to be a greater sense of resistance than elsewhere. The sense of resistance was, however, ill.defined and diffuse; there was. no dulness on percussion. The next day (the 30th) thetemperature was 102° and there was a little dulness over the, tender spot; the general condition did not seem grave. On Oct. lst and 2nd there appeared to be some amelioration;, the temperature on the latter date was 100°, the tongue was moist and clean, there had been no further vomiting since the onset, and the general condition remained about the same the signs of local exudation were more distinct. So far the case had appeared to me to have been a simple one of appendicitis, localised and threatening to suppurate, but not calling for immediate operation. On the night of the 2nd, however, a sudden and severe exacerbation of pain took. place. On the 3rd the temperature was 101°, there was considerable distension of the abdomen, and severe pain, referred to the right iliac region ; the dulness previously noticed had disappeared. On very light percussion, however, the note seemed somewhat damped over a small area the centre of which was about the middle of a line drawn from, the umbilicus to the middle of the right Poupart’s ligament There had been no vomiting. The treatment had hitherto been small doses of opium and enemata; these latter had,. however, only brought away a small quantity of hard fxces, evidently from the lower bowel, and it was stated that D(). flatus had been passed. It was now evident that operation was called for, and it seemed to me that perforation of the: appendix had taken place during the night and that if general. peritonitis had not already begun the risk of its occurrence would be materially increased by moving the patient. r therefore decided to operate on the spot, although the patient was a pauper and the surroundings far from favour-. able. On the morning of the 3rd, chloroform having been, administered, I made an incision three inches long in the right iliac region ; the peritoneum was thick and vascular, and on dividing it I came upon a thickened mass which I took to. be the edge of the great omentum. On separating the lower edge of this from its connexions about four ounces of foul-smelling fluid escaped ; this was thin and semi-purulent,. with flocculent material floating in it ; no actual pus was found. The finger inserted into the wound failed to define. clearly the appendix, it appeared to be curled up behind the. casoum; a mass of adherent small intestine could be felt at the upper and inner part of the cavity ; the finger brought away two fascal concretions of the size and shape of rice. grains, and four other similar concretions were subsequently found in the fluid that had been evacuated. The cavity. was gently irrigated with warm mercuric chloride solution (1 in 2000), the upper part of the wound closed with a silk-worm gut suture, and a rubber drainage-tube inserted. The patient rallied well from the operation, the pain was relieved, and there seemed at first every prospect of a quiet course. Thetemperature did not rise above 100°; the bowels, however, in. spite of enemata, were not opened, no flatus was passed, and only a small lump of hard fasces, evidently from the lowe7 was