On the Cause and Prevention of Diphtheria. It is believed that the railway and steamboat passenger traffic plays no small part in the dissemination of the disease, and should demand careful attention from all health officers. Unquestionably, the early diagnosis in suspected cases is most important of preventive measures. A prompt detection cannot be made of all cases by a clinical diagnosis it matters not how skilful the diagnostician. To be ab solutely certain, the culture test must be applied. This is of equal importance in determining when the case has fully recovered and is no longer a menace to others. We are of the belief that if the above diagnostic methods were generally applied and uniformly executed, the ravages of this disease would be quickly stayed, and the disease itself become one of the least disturbing factors to the public health. Early notification of all cases of diphtheritic infection should be insisted upon. Prompt isolation of those sickeither domiciliary or hospital-private funerals, the nontransportation of corpses by train, should be enforced by law and practice. Isolation should also be made to include those who have been directly exposed to infection for a time sufficient to demonstrate their freedom from the infective agent. Those having the bacillus in their throats should be treated as cases of diphtheria. Great care should be exercised in the schools; they should be under the direct supervision and control of the health authorities, so far as their hygiene and sanitation is concerned. A daily medical inspection should be made of all of the schools in the larger cities. This may not be practicable or necessary in small towns and rural districts; but when a case has been detected, the inspection should then be maintained for several days. On the Cause and Prevention of Diphtheria. We shall now consider the prophylaxis and treatment. Our laws and ordinances against infectious disease have for their object the prevention and suppression. We prevent infection because the infected die; if the contrary were true, that the diseases were not so fatal, we would not be so concerned about them. If the ultimate object of these restricted measures is to prevent death, it behooves us to use every means in our power to combat the disease. It matters not in what way we direct our efforts, provided they are successful in suppressing or modifying the course of the disease. We have advocated the culture method for diagnosis for all cases of diphtheria. If this position is a correct one, and necessary, then we should advocate other measures of equal efficiency. Two years have now elapsed since the introductian of the new remedy for the treatment and prevention of diphtheria. It is believed that there has been sufficient evidence submitted to form an unbiased opinion of its true value. The consensus of opinion in all countries has been very favorable to its use. Its adherents now number thousands, while the opponents can be numbered as few. The reports from the Dominion of Canada state that there has been a gradual diminution of death-rate from diphtheria, and the ratio of disease has been proportional to the use of the remedy. One report from Mexico states that it has reduced the mortality of one city forty per cent. over previous years. In the United States the same is true. In those places where there has been the largest quantity of antitoxin used, there has been a decrease in the number of deaths over 1894, although there has been an increase in the number of reported cases. The published reports of one hundred physicians and twenty health boards show, for the year 1895, and the first On the Cause and Prevention of Diphtheria. three months of 1896, that there were 7,021 cases of diphtheria treated by antitoxin with seven hundred and fortyone deaths a death rate of ten and six-tenths per cent., as compared with 2,936 cases of diphtheria occurring synchronously with 1,110 deaths a death rate of thirty-nine per cent. The largest number of cases treated was in the cities of the East and Middle West. Of the reports of the physicians and health boards, fifty-three physicians and nine health boards were in the East, forty physicians and nine health boards in the Middle West and Northwest, two physicians and one health board in the West, and five physicians and one health board in the South. The above table in part bears out the statement that where the largest number of reports come from there have been more cases recognized as diphtheria and less as croup; while on the other hand, where the fewest reports are made the cases of croup preponderate. Antitoxin, while believed to be a remedy par excellence, is believed to have increased the number of cases in many instances; especially is this so in the smaller places and the rural districts. The reason assigned for this is that formerly, when a child had diphtheria, it usually died, and parents kept their children away from the infected premises; now, as a rule, the rapid recovery of a child causes doubt as to the correctness of the diagnosis, and it is allowed to resume its associations with the bacilli in the throat, thereby disseminating the disease. In the above statistics no attempt has been made to separate the cases into classes, or to exclude cases moribund when the treatment was given. They represent, it is thought, the average cases in age, duration, and severity. Care has been taken, however, to exclude from these, cases of laboratory diphtheria which are included in those who were given protective treatment. On the Cause and Prevention of Diphtheria. These same reports show, that during this time-1895 and 1896-2,867 cases which were exposed to infection, in many of which the bacilli were found, were given protective doses, with the result of forty mild cases, occurring from twelve hours to thirty days after the infection. In closing this report, your committee would recommend the following: I. That there should be uniform rules and regulations adopted by all the states and provinces for the prevention and control of diphtheria. The several governments should assume the responsibility and act in unison in preventing the spread of the disease from one country to another, and assume authority over interprovincial and interstate communication. II. That it should be the duty of the health authorities to provide facilities for determining the diagnosis in all suspected cases by the establishment of inexpensive laboratories for each health jurisdiction. To agree upon a system and means of transmission of material for diagnosis through the mails. III. Compulsory notification of all suspected cases and the abolition of the terms croup or membranous croup, unless diphtheria has been excluded by culture and microscopic examination. IV. Compulsory isolation of all cases, domiciliary or in hospital, until the recovered cases show the absence of the diphtheria bacillus. V. That the medical inspection of schools should be inaugurated under the direction and supervision of the health. authorities by making daily inspections in the larger cities of all school children, for the detection of infectious disease. In the smaller places and rural districts, the inspections, while necessary, need not be made daily, but at least once per week, and daily for several days after the appearance of a case of diphtheria. Some Thoughts Relative to Sanitary Legislation. The plan advocated by Dr. S. Durgin, of Boston, at the last meeting of this Association, is highly commended. VI. School buildings, books, etc., should be subjected to a reliable method of disinfection at least once per month, and oftener if suspected of being infected. VII. The early treatment of those ill with diphtheria with antitoxin, the administration of preventive doses to those who have been exposed to infection and have the bacilli in their throats. VIII. Prompt and effective methods of disinfection of infected articles and apartments to be carried out under the supervision of the health authorities. SOME THOUGHTS RELATIVE TO SANITARY Read by U. O. B. WINGATE, M. D., Milwaukee, at the meeting of the American Public Health Association held in Buffalo, N. Y., September, 1896. Professor Hygiene and Diseases of the Nervous System, Wisconsin College of Physicians and Surgeons, Secretary Wisconsin State Board of Health. There is no stronger evidence of the need of national health legislation than the heterogeneous mass of state and municipal sanitary laws and regulations which exist in the United States at the present time, and there is no more discouraging phase of sanitary administration than that which confronts the health officer when he attempts to enforce the laws intended to aid him in the performance of his duties, and finds that the courts will not sustain him. Lord Beaconsfield has been quoted as saying that "The health of the public ought to be one of the chief considerations of the statesman," but we are forced to conclude that this admonition is too often sadly overlooked. *From the Journal of the American Public Health Association, April, 1897. |