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J. A. (Joel Asaph) Allen.

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the mortality rate from this disease is much less, and more
uniform than that of most of the infectious diseases. Its variabil-
ity is seen by the foregoing table, where there is a difference of
1,200 per cent, in two consecutive years. In 1886, there were only



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gram: statistics of infectious diseases. 199

five deaths from measles in this city, while the following year this
number jumped to sixty ; in 1888, it dropped to thirty-five, then
eame down to where it was in 1886, then jumped to fifty-six in
1890, and represented forty-seven and eighteen deaths, respectively,
in the two succeeding years. Of those dying from measles at
different periods, from ninety to 100 per cent, were below the age
of five years.

Scarlet fever prevailed to the greatest extent in 1887, when a
general increase in its mortality was noted throughout the State.
It reached its minimum point in 1890, and continued at an
unusually low rate throughout that year, when only twenty-one
deaths, out of a total of 5,117, were ascribed to that cause in this
city. It again began an upward tendency the following year,
giving a total of eighty-four deaths last year, while the statistics
for this year will doubtless exceed that point.

Diphtheria stands third on the list of infectious diseases, and
omitting cholera infantum from this class, as is done by some
authorities, it ranks second. It has constituted a considerable
part of the mortality of this as well as other localities, being
almost constantly present. Comparing diphtheria, croup, scarlet
fever, whooping cough, and measles, we find that the ratio between
diphtheria and scarlet fever is more proportionate in each year
than that of the others. Whenever the ratio of one increases, the
other does likewise. The greatest mortality from this disease^
during the past seven years, was reported in 1887, when it reached
183 deaths out of a total of 4,688, and the smallest in 1890, when
the number was lowered to 111. Of those dying, about ninety-five
per cent, were under ten years of age. The average mortality for
the seven years shows a rise of one-third in the mortality of Octo-
ber over that of September, from this cause, clearly indicating
that the closing up of buildings and exclusion of fresh air from
cellars are important factors in the causation of this disease. A
study of the statistics in the various reports of the State Boards
shows a much larger proportion of deaths from this disease in the
cities than in the country.

Croup ranks next to diphtheria as regards mortality. I use
the simple term << croup " because in the reports no distinction is
made of the various kinds ; and, right here, I beg permission to
call the attention of physicians to the importance of giving all the
information at their command when filling out death certifi-
cates.



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200 gbam: statistics of infectious diseases.

Tiie mortality from whooping cough is slightly in excess of
that from measles, having been greatest in 1889 and 1892.

Cerebro-spinal meningitis and erysipelas show a greater uniform
ity in their death-rates than most of the other infectious diseases.

Cholera infantum, with all its terrors, does not claim as many
victims as consumption. The former is found almost exclusively
in the statistics of the hottest months of the year, but the latter
we have always with us. My short experience in the Registrar's
office happens to cover the cholera infantum period. A careful
study of the death returns convinces me that the term ^' cholera
infantum," as used by many practitioners, is about as indefinite as
the term << heart disease," and in discussing the subject with some,
I found that they made no distinction between gastric catarrh^
dysentery, colitis, enteritis, entero-colitis, gastro-enteritis, and
cholera infantum, but called any one of these by the latter name.
This would indicate that the statistics on cholera infantum are
misleading, caused by the fact that there is a diversity of opinion
as to what really constitutes that dfsease.

Enteric, or typhoid, fever shows its greatest mortality between
the ages of twenty to thirty, the next in rank being the ages of
thirty to forty, while the period between fifteen to twenty comes
third.

I added syphilis to this table, at the request of one of the gen-
tlemen who is to discuss the subject tonight. Looking at the
summary as here shown, and comparing it to the large number of
cases of syphilis known to be extant, it would appear that this dis-
ease is not always stated as the cause of death when it ought to
be. Taking the summary for last year, I find that out of a total
of fifteen deaths five occurred in children under one year, three
between the ages of twenty to thirty, four between the ages of
thirty to forty, one between forty to fifty, one between fifty to
sixty, and one between sixty to seventy years. There is very little
variation between this and the tables for the previous years. But
in this table I also find that no distinction is made between heredi-
tary and acquired syphilis, so we are left to draw our own infer^
ences by studying the ages. Perhaps one of the reasons for this
is that if a young man, between the ages of twenty to thirty,
would give a history of hereditary syphilis he might be suspected
of not telling the truth as regards himself.

For the sake of comparison, the mortality of infectious diseases
in the entire State, for the year 1890, is herewith 'presented. It is



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clabk: contagious akd infectious disbasbs. 201

taken from the last published report of the State Board, and is as
follows: Total deaths from all causes, 116,830; consumption
18,831 ; croup and diphtheria, 4,915 ; typhoid fever, 1,612 ;
measles, 1,161 ; whooping cough, 1,156 ; scarlet fever, 913 ;
oerebro-spinal fever, 476 ; erysipelas, 812 ; small-poz, 4.

I did not enter into any discussion of consumption because the
statistics speak for themselves.

In conclusion, I desire .to say that the true value of these
statistics will depend entirely upon the accuracy preserved by the
one who gathers the original information, namely, the practitioner.



CAUSES AND MODES OF* COMMUNICATION OF CON-
TAGIOUS AND INFECTIOUS DISEASES.*

Bt EDWARD CLARK, M. D.. Buffalo, N. Y.,
Ex-Health Physician.

The Causes and Modes of Communication of Contagious and
Infectious Diseases, the subject allotted me this evening, is one of
such vast importance, and so deserving of our best thought and
attention, that it will be impossible for me to do any sort of justice
to it in a ten-minute paper. This, together with the fact that I am
acting as a substitute tonight for our able Health Commissioner,
and have had only four or five days in which to prepare my
remarks, must be my apology to you for this, perhaps, somewhat
rambling and incomplete discourse. The words contagious and
infectious, as applied to disease, have given rise to no little confu-
sion among physicians, as to their proper scope and meaning.
That they are synonymous terms is held by many, while others
argue that each has a distinct and separate meaning.

Personally, I regard contagious as a more comprehensive term
than infectious, and believe it may even include the latter. The
difference in meaning, however, of the two words, has no practical
significance, for the efforts of physicians and sanitarians are called
frequently into requisition to check and conquer both forms of
disease. To indicate a typically contagious disease and a typically
infectious disease, I might mention small-pox, contagious, and
typhoid fever, infectious.

The chief and distinguishing characteristic of a contagious or
infectious disease is its specificity ; that is, the disease transmitted

1. Read before the Buffalo Academy of Medicine, Tuesday evening, September 18, 1893.



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1302 clabk: GOirrAGious and infectious diseases.

or caused by the particular virus of that disease is always the same
in its essential characteristics. It may be of a very mild type, or
of a very severe one, but, so far as quality is concerned, is always
the same disease from which it sprung.

<< Men do not gather grapes from thorns nor figs from thistles,'*
and small-pox always produces small-poz, scarlet fever always pro-
duces scarlet fever, and typhoid fever always produces typhoid fever.
No matter how light the attack may be^ of any of these diseases,
/the virus or contagion produced is such that it will give rise to the
same disease in another, and here the attack may be either very mild
or very severe, its character depending, no doubt, on some inherent
condition of the receptive party. A case of small-poz, scarlet
fever, or diphtheria, which is so mi^d that it does not confine the
patient to bed, may give rise to a form of the same disease in others
of the most malignant type. In fact, I regard these '< walking
cases," so-called, as the most dangerous, so far as the spread of
the disease is concerned, because, as a rule, the restrictions and
confinement imposed upon the patient are less complete, and the
precautionary measures less secure, than in cases where the type of
disease is more severe. From a large personal experience with
small-pox, I know that the mildest possible cases should be sub-
jected to a rigid isolation and complete quarantine until all dan-
ger is past, and 1 think the same rule should apply to other
contagious diseases, especially scarlet fever and diphtheria.

The fact that all contagious and infectious diseases are the
progeny of their own kind, and do not originate de novo, is, to my
mind, the most unanswerable and convincing argument in favor of
their germal or bacillary origin. I think I can affirm, without
fear of successful contradiction, that by far a large majority of
the best observers and experimenters, both at home and abroad,
believe, as I do,* that each and every form of contagious and
infectious disease is produced by a specific germ peculiar to that
disease, and to no other. << Hence, the one great fundamental idea,
which it is important for the laity, as well as the members of our
profession, to grasp, is that the " germ theory " of disease is now
established on a firm scientific foundation," and this supplies us a
basis on which to erect the grand superstructure of preventive
medicine. If this is so, it follows that all the diseases of the
above-named types are preventable, and we will be effective with
our preventive measures when we are fully able to recognize and
study the life history of their causative germs.



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CLABK : CONTAOIOUS AND INFECTIOUS DISEASES. 208

Among the diseases which physicians have to deal with, under the
head of contagious and infectious, we may mention : scarlet fever,
diphtheria, small-pox, measles, pertussis or whooping cough, paroti-
ditis, typhoid fever, cholera, yellow fever, typhus fever, glanders,
epidemic cerebro-spinal meningitis, and tuberculosis, lioth general
and local. As many of the above are somewhat rare with us, and as
my time is limited, I shall take up, for consideration tonight, only
:five of the above-named diseases, four of which — scarlet fever, diph-
theria, typhoid fever, and tuberculosis — are quite prevalent in our
climate, and one, cholera, which is attracting much attention at the
present time, and which we hope will not reach our city. Let us
first consider diphtheria. Perhaps no disease in modern times has
attracted more attention than this, and the clinical and experi-
mental studies of Brettonean, Trosseau,Yirchow, Oertel, Mackenzie,
Elebs, Wood, Formad, Sternberg, Loeffler, Prudden, Northrup,
Eoch, and many others of recent times, in and by strictly scientific
methods, have elucidated the fact that true diphtheria is caused
by a germ now known and described as the Elebs-Loeffler
bacillus.

The type of disease produced by this particular organism may
be either severe or mild, and in either case is liable to be followed
by constitutional symptoms, such as the various forms of paralysis,
^tc There is a type of pseudo-membranous disease, affecting the
throat and air passages, which is caused by the streptococcus and
other cocci. This disease has been called true diphtheria by many,
but it is not, and it is not followed by the sequelsB which we
often see in cases of disease caused by the Klebs-Loeffler bacillus.
This bacillus, the true cause of diphtheria, not only possesses
remarkable vitality, but remarkable powers of propagation.
Numerous instances are on record where objects infected months
and years previously, have communicated diphtheria. While
filth does not of itself cause diphtheria or any other infectious or
contagious disease, it affords the best possible soil for the develop-
ment and growth of their deadly germs. Currents of air, or
gases ascending from cess-pools, foul vaults and sewers, carry the
germs and propagate diphtheria. In any large city like ours,
where we have diphtheria, the many miles of underground sewers
afford a good place for the propagation of the germ, and sewer
gas, carrying the germ, and escaping into apartments, and
inhaled by children, has caused diphtheria in numerous instances.
This is why health officials are so particular about having good sew*



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204 CLABK : CONTAGIOUS AND INFECTIOUS DISEASES.

age and good plumbing, for the records of the health departments
of any large city teem with instances where death and sickness have
entered many homes through the avenues of untrapped pipes and
improperly ventilated sewers. In fact, the rules for the construction
of this class of work cannot be too severe or too rigidly enforced.
Whenever diphtheria is endemic or epidemic, we find a certain
number of mild cases — walking cases, so-called, which spread the
disease very largely ; they are not sick enough to be confined, and
are allowed to go about among other children, sometimes even to
school. The cases arising from these mild cases may be of the
most malignant type, the severity, no doubt, depending on the par-
ticular condition of the individual affected. The following instance,
showing a common mode by which diphtheria originates in cities,
is related by Mallin : A boy, ten years old, had diphtheritic angina,
followed by almost universal paralysis ; the room which he occu-
pied was found to contain an offensive odor, which was traced to
an untrapped and broken pipe communicating with a cesspool.
There was no diphtheria in the neighborhood, and no other cases
occurred in the family. It seemed certain that the bacillus came
from the drain. Domestic animals and fowls are subject to the
disease in question, and they undoubtedly convey the infection to
human beings to a greater or less extent. Dogs, cats, cows, calves,
swine, goats, rats, mice, and especially the feathered tribes, are said
to be subject to the disease, and they not only convey the disease
by direct contact, but are the carriers of the contagion in their hair
and feathers. Of these, the dog and cat exert the greatest influ-
ence for evil, as they are quite likely to be fondled by children
suffering from the disease.

Air, wat^r, and food, and especially milk, are the media through
which the virus enters the body, and the mouth, throat, and air-
passages are the localities where the germ lodges and develops,
although inoculation may occur through any wound or abrasion
on the body. It is not necessary that the germ be swallowed to
produce the disease, as is the case with the germs of cholera and
typhoid fever. A great variety of conditions increase the suscep-
tibility of some persons, such as nasal and pharyngeal catarrh,,
debility from any cause, age, etc. Some assert that scrofulous
children with light hair and eyes, contract the disease quicker and
suffer from its ravages greater than those having dark hair, eyes^
and skin. The disease is not caused by any agency within th&
body, but always comes from without.



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CI^AJIK : CONTAGIOUS AND INFECTIOUS DISEASES. 205

The paralysis and other sequelae are said not to be produced
by the bacillus invading the blood channels, but by the noxious
substances or ptomaines evolved by the bacillus. The ptomaines of
diphtheria are among the most deadly poisons. One great reason
why diphtheria prevails most during the cold, damp months of
Autumn and early Spring, is, perhaps, that catarrhs and other
throat troubles are more prevalent during these months, and the
germs of diphtheria find easier access to the system on account of
the already diseased conditions of the mucous membranes. In the
Annals of the Pasteur Institute, <^ Roux and Yersin state it as their
opinion that the Klebs-Loeffler bacillus is so specifically identified
as a cause of diphtheria, as to render it necessary that all practicing
physicians should be able to isolate and identify this bacillus.
They think that not until diagnoses are made in this way will
thoroughly scientific results be attained." '< In order to stain the
bacillus so that it can be readily 8een and studied under the micro-
scope, it is merely necessary to remove a small fragment of the false
membrane, by means of a piece of absorbent cotton wool, tied
firmly to a pair of forceps, or any other safe carrier, from which it
is transferred to a scrap of blotting paper, and thence to a cover
glass, when it is broken down as finely as possible, heated over a
flame and stained methyl olive or gentian violet, washing thor-
oughly with water before examining.''

Of the exact nature of the specific cause of scarlet fever, we have
not so thorough a knowledge as of that of diphtheria, but obser-
vation and research have given us much insight into its behavior.
The evidence is very strong that the disease in question does not
originate de novOy or that it does not spring from certain atmos-
pheric or telluric conditions, but is produced by a definite specific
principle, since countries have been free from it for centuries, till
it was imported by commerce. That it sometimes appears in cer-
tain localities and persons without any known exposure, can be
explained by the fact that the causative bacillus is so subtle and
transmissible that it is conveyed long distances in articles of mer-
chandise, even in very small packages. Reading-matter and letters
going through the mails can carry it ; the dry goods in the stores,
the fruits in the groceries, and the milk from the dairies, are looked
upon as carriers of the contagious principle. The newspapers
delivered at our doors, and the hand-bills thrown upon our door-
steps, may serve as vehicles for conveying the disease. The furni-
ture, carpets, and even the wall paper of a room used by a scarlet



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206 clabk: contagious and infectious diseases.

fever patient, have been known to hold and transmit the disease
even after a long period of time has elapsed. Domestic animals^
especially the dog and cat, may carry the germ in their fur. Doc-
tors in attendance on scarlet fever patients, unless extremely care-
ful, can carry the microbe in their hair, and beard, and on their
clothing. Currents of air and flies can also carry the contagion ;
in fact, the only way, perhaps, in which it cannot be conveyed, is
by telegraph or telephone. The specific cause of scarlet fever is
probably reproduced in the throats of patients, and in the des-
quamation from the skin. The sputa and other secretions from
the mouth and throat dry, and thus the germs are set free in the
air. The dried secretions, then, are just as dangerous in spreading
the disease as are the small scales or particles thrown off in the
process of desquamation. The disease is undoubtedly caused by
the inhalation and lodgement of these particular specific particles
in the throat of the victim.

As compared with other diseases, the one which must be rec-
ognized on every hand as being par excellence, that to which sani-
tarians and physicians must devote their special attention, is tuber-
culosis. This disease, or consumption, is produced by a bacillus
which behaves to a great extent very much as does that of scarlet
fever and diphtheria ; this is especially true of that form which
affects the lungs. The germs are coughed up with the sputa; these
dry and set the bacillus free in the atmosphere.

This is the greatest and most dangerous source from which the
disease springs. When we see a number of consumptive cases fol-
lowing each other in the same family, and where we see the husband
or wife of a consumptive marital partner developing the disease,
we may be quite sure that the disease came on through inhalation
of the specific germ. Swallowing the germ may sometimes pro-
duce tubercular trouble in the bowels and rectum, aud it is said to
occur locally through a process of inoculation, but by far the large
majority of cases are those of the pulmonary type, and are pro-
duced by drawing the bacillus into the lungs with the inspired air.
It is said that the germ is not so tenacious of life as the scarlet
fever bacillus, so that it cannot be so readily transported, but that
it is carried to a limited extent by the same agencies, and in same
manner is quite probable. Where the disease affects the intestines
and rectum, the discharges from the bowels may contain the
bacillus, and these, in consequence of improper drainage and
sewer facilities, may contaminate water supplies. Local lesions



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CLABK : CONTAGIOUS AND INFECTIOUS DISEASES. 207

of a tubercular character may also act as foci of infec-
tion.

Many of the lower animals suffer from tubercular disease^
especially the bovine species, and it is quite well established, or at
least beliered by many, that the disease from them can be trans-
mitted to the human family in their milk and meat. This, how-
ever, is such an exhaustive subject, that I can give it only a passing
allusion. Its importance, however, cannot be overestimated, and
it is being made a special study by many noted sanitarians of to^
day, as it has in times past. At the present day, almost all sanitary
authorities agree that the beef from tuberculous cattle and the
milk from tuberculous cows should be prohibited as unfit for food.
The milk which gives rise to tuberculosis is probably that from
oows suffering from tubercular disease of the udders, known as
tubercular mammitis. While exact statistics are not at hand, it is
asserted upon pretty good authority that over forty per cent, of
dairy cattle in this country are afflicted with tubercular disease,
and the finer grades of cattle are said to be the greatest sufferers.
If this is so, we have here a very powerful etiological factor, and it
behooves us as sanitarians and physicians to give this whole sub^
ject very serious attention. This subject is full of interest. But
time is hastening, and for fear that I am wearying you I will
hasten to briefly allude to typhoid fever and cholera before closing
this paper ; but before leaving this subject I wish to mention one
fact, which shows a decided difference in the character of such
infectious diseases as scarlet fever and diphtheria, and tubercu-
losis on the one hand, where the bacillus is inhaled, and such dis-
eases as typhoid fever and cholera on the other hand, where the
bacillus is swallowed and gains entrance into the intestinal canal.
This fact or proposition is that, as a rule, all inflammatory diseases
of the throat, air-passages, and lungs, are increased^by exposure to
a cold atmosphere ; that the same is true of all specific diseases
which generally enter the body by way of the throat, air-passages^
or lungs. On the contrary, diseases which generally enter the body
by way of the mouth and alimentary canal, increase during or fol-
lowing exposure in a warm atmosphere.

'< It is now pretty conclusively established that the speeific cause
of typhoid fever is reproduced in the intestinal canal, and some-
times in other parts of the body, having been found in the spleen
and other organs." The characteristic lesion found in the lower
part of the small intestine, indicates in what part of the body the



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208 clabk: coittagious and inpeciious diseases.

germ is most destructive of tissue. The glandular apparatus of
the small intestine is undoubtedly concerned somewhat in this ulcer-
ative process, for the destruction of tissue takes place only over
an aggregation of the solitary glands of the bowel, known as
Peyer's patches. The numerous experiments which have been



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 21 of 78)