USA > Massachusetts > Middlesex County > Somerville > Report of the city of Somerville 1879 > Part 13
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The following quotation illustrates the influence of contagion in spreading the disease : -
" A farmer living several miles from Woodstock, Vt., on a
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by-road which was not a thoroughfare, had but a single neighbor. He visited, with his family, some friends at a town some twelve miles distant. Scarlatina existed in the families with whom he visited. After his return home, all his children (the precise num- ber is not noted) had, in succession, scarlatina. The children of his only neighbor contracted it. Five children in these two fami- lies died with it. The cases were under the care of a physician living at Woodstock, distant some six or seven miles. Scarlatina did not previously exist in Woodstock. Shortly two children in the physician's family were attacked, and one died. A family in Woodstock was related to one of the families in which the disease first appeared, and the husband and wife watched one night with the children of their relatives. Shortly afterward their children were attacked. Communication with this family and the family of the physician was suspended throughout the village, and the only additional person affected was a boy who was exposed by going to the physician's house during the time his children were ill." - Flint, " Practice of Medicine."
The use of clothing worn by persons sick with the disease has frequently been the cause of its spread. In one instance " a child had died from scarlet fever. A relative of the family several miles away borrowed or bought a blanket and a coat, several weeks after the death of the child, to use for her own child ; and in a few days, this last child was taken sick with the disease and died. It had been exposed to the contagion in no other way. The garments had been used about the first child while it was sick." A case is reported " where the dress of a child that had been sick with scarlet fever lay in a bureau drawer for eight months ; this dress was sent to a relative twelve miles distant, and as the result, a fatal case of scarlet fever occurred in the family which received the clothing." "Maclagan saw a case in which the medium of communication was a woollen shawl, in which a scarlatinous patient had been wrapped. .. . Accord- ing to Ogle, the contagion which gave rise to a case after the epi- demic had subsided was spread by soiled linen. . V. Hil- denbrand, without the agency of scarlatinous surroundings, became infected by wearing a coat which had been worn formerly upon visits to scarlatinous patients, and had been stored away." Dr. John- son, of Salem, cites several cases in which beds, lounges, carpets, and upholstered furniture were the means of spreading the disease : one was " where a carpet, removed from a house where the family
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had had scarlet fever to another part of the town, communicated the disease to other children"; another in which his informant thinks the disease was contracted " by sleeping on a feather bed two months after it had been used by a previous patient. The bed had not been fumigated, but had been kept in the open air several days." - Massachusetts Board of Health, Ninth Annual Report. "V. Tscharner saw a case in which the medium was a piece of bedding. Heslop calls attention to the neces- sity of separating the ordinary washing in a hospital from that which is infected, as he has seen a non-observance of this rule fol- lowed by a spread of scarlatina through the whole house, and has also seen it disappear as soon as this rule was obeyed." - Thomas. Examples of this kind might be multiplied ; but enough has been said to prove that it is a contagious disease, that anything that has been used in the sick-room may be the means of spreading the con- tagion, that although some healthy individuals who visited persons sick with the disease escaped contracting it, they were the car- riers of the contagion to others who did contract it.
A very dangerous belief is held by many people, that children must necessarily take the disease some time, and that consequently it is useless to attempt to check its spread among them. Although it is mainly a disease of childhood, it does not follow that all children must take it. On this point Thomas writes : " However, if the mor- tality from scarlatina is calculated at only six per cent, a very low figure, we find, as Murchison says, that the number of individuals attacked with scarlatina in England and Wales is considerably less than one half the births, so that consequently a large number of peo- . ple must remain exempt and attain middle age without being pro- tected by a previous attack. Observations of epidemics in isolated regions, where scarlatina seldom prevails, give the same results." Although it is not confined to any age, it will be seen by reference to the following figures, presented by Murchison, that by far the greater number of victims were under five years of age: In 148,- 829, he found that 9,999 were under one ; 30,974 were under two ; 95.070 under five ; 38,591 were from five to ten ; 8,676 from ten to fifteen ; 3,871 from fifteen to twenty-five; 1,306 from twenty-five to thirty-five; at all ages above thirty-five, 1,315. Of the 16 deaths in this city in 1879, 14 were under 5. These figures con- firm the medical opinion that the liability to contract the disease diminishes with the increasing years of childhood.
The First Report of the Board of Health contains many valuable
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suggestions for the prevention and restriction of the disease. I shall briefly allude to the most important. The first and most important is the complete isolation of the patient from the rest of the house- hold. This is absolutely necessary ; and unless faithfully adhered to, other cases will probably follow. A room should be prepared for the patient, from which all unnecessary furniture and clothing should be removed. Into this room no one should be admitted except the nurse and physician. The nurse should be provided with cotton or linen wrappers for use in the sick-room. These should be laid aside, if at any time she passes from the patient's room into any other part of the house. Before leaving the room the hands should be washed in some disinfecting solution. Un- eaten portions of food should be put with the slops, to which a liberal quantity of disinfecting fluid should be added. A tub containing disinfecting solutions should be in the room, into which all cloths, bed and body clothing, and towels, which require cleans- ing should first be put, after which they should be boiled for a couple of hours. Dishes, cups, and spoons, used by the patient, should be washed in a like solution before removal from the room. The discharges from the throat, nose, and mouth may be put in a vessel containing disinfectants This vessel should be frequently washed with hot water. The discharges from the kidneys and bowels should be treated in the same manner. After recovery the patient should not mingle with other persons until all roughness of the skin has disappeared, and he has taken warm baths for several days. Our attention should now be directed to the room in which the patient was confined. It should be closed as tight as possible, particular attention being paid to the doors and windows. To an ordinary room (about ten feet long, ten feet wide, and ten feet high), one pound of sulphur will be sufficient. The sulphur, in powder or fragments, should be burned on live coals. To guard against fire, it would be advisable to place the coals in a pan of ashes. The room should remain closed for twenty-four hours, after which it should be thoroughly ventilated. The floor and wood-work should then be thoroughly washed with soap and hot water. Should a death occur, arrangements should be made for a private funeral. The body should be washed in a solution of chlorinated soda, and buried as soon as possible ; and in no case should children be permitted to attend the funeral.
Complete isolation was insisted upon as the most important of the restrictive measures suggested. `In the majority of families in
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which scarlet fever appeared during the past year, it was not a practical measure. Let us take Mr. B.'s family as an example. It consists of himself, wife, and four children, the oldest six years old, and the youngest a nursing child. The two-year-old child was taken sick. They had but two rooms, one of which was used as a bedroom. The mother was the only nurse, and had to attend to the sick child, and the other members of the family as well. Iso- lation in the case of this family could not be carried out at home, and it were idle to suggest it. What is to be done when we meet with such cases? Believing as I do in the necessity of carrying out this measure, and also in the fact that its non-observance entails more sickness and suffering upon the poor than upon any other class in the community, I claim that it is the duty of our city government to provide a hospital in which this and other con- tagious diseases could be treated. In such an institution the patients would be placed under better hygienic conditions than at their homes, and have more constant medical attendance, thereby materially lessening the dangers of the disease.
The item of expense should not be considered in this connection. If we fail to provide a hospital for such cases, we shall continue to have them reported weekly. If it were necessary to discuss the question of the cost of such an institution, it could be shown that it would pay the city to possess one. Many of the victims of the disease are buried at the public expense, and fumigating the rooms is also paid for by the city. We should not look at Boston or New York or other large cities, and ask what they have done ; but, knowing what we need, supply it. The following disinfectants are recommended : -
For cloths and clothes, and to put into vessels which are to receive slops or discharges of the patient, or to turn down water- closets and privies, eight ounces of sulphate of zinc and one ounce of carbolic acid dissolved in three gallons of water. For the hands, one or two drams of permanganate of potash in a pint of water ; a little of this solution should be added to the water in which the hands are washed.
DIPHTHERIA. - There were 170 cases of diphtheria in Somer- ville in 1879, 29 of which proved fatal. Medical writers are not agreed as to the cause of this disease. While some lay special stress on its contagious character, others claim that it depends upon some condition of soil, filth and moisture, defective drainage, overcrowding, etc. The following quotations will probably fairly
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represent medical opinion of the present day. In the report of an epidemic of diphtheria in Lowell, by Dr. Nickerson, and published in the Eighth Report of the Massachusetts Board of Health, I find the following : -
" The facts which are here brought together form only a part of the evidence which goes to show that in diphtheria, whose ulti- mate origin is unknown, its manifestations, although often erratic, are reducible to certain laws. Admitting that the cause is exter- nal in the individual, which appears reasonable, it seems to me that confirmation of the idea that the atmosphere is a carrier of the poison is obtained in the fact that we have on record four deaths from diphtheria in infants, whose diet consisted exclusively of the mother's milk. Of contagion, we have had such striking proofs that our physicians generally have testified their belief in it. The favorite haunts of the Lowell epidemic have been low levels in the midst of more or less insanitary surroundings."
In the same report there is a paper by Dr. Pinkham, of Lynn, on an epidemic of diphtheria in that city, in 1876. He says : -
" Diphtheria has been more prevalent near marsh lands, in the valleys of brooks, and near bodies of water, where the soil and sub- soil are naturally damp, than at a distance from such localities. Other things being equal, it has been more prevalent and relatively more fatal where air and soil have been polluted by house drainage, overflowing privies, decaying garbage, etc., than in places not subject to these conditions. It has presented in an eminent degree the characteristics of a contagious disease."
Of diphtheria in Salem in the same year, Dr. Johnson says, " The epidemic has been so wide-spread, and the failures to trace many cases to any contagion have been so numerous in the expe- rience of our physicians, that we are led to conclude that, like the distemper which afflicted horses in the year 1873, it spreads through some unknown miasm. Not only the uncleanly sections of the city have been visited, but families whose surroundings seemed unexceptionable have suffered by this disease. Therefore we do not find the source of diphtheria in filth and insufficient sewerage ; but one cannot help thinking that it has found its best nidus in localities and among people whose hygienic conditions were unfavorable." - Eighth Report Massachusetts Board of Health.
In the same report the board, commenting on the replies from their medical correspondents, say, "So far as these replies are
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concerned, the opinions of physicians agree, in the main, that the causes of the disease are in part telluric or meteorological, and at present unknown, and that it is contagious, infectious, and attended with the greatest mortality and severity where generally insanitary conditions, especially soil moisture and filth, prevail. Like all other diseases, it is prone to attack persons debilitated from any cause."
In the Sixth Report of the Michigan Board of Health I find the following remarks concerning the replies of medical correspondents relative to the cause of diphtheria : "Some of the evidence tends to the belief that among the elements in the causation or aggra- vation of the disease are insanitary conditions of cellars, privies, wells, or other surroundings of dwellings, and the location of dwellings on damp ground or near cesspools, privies, or swamps, etc. Indeed, the evidence of the frequent occurrence of diphtheria under such conditions, and of its aggravation by these conditions, is so strong as to make it a matter of common prudence that every householder and officer of health should assiduously guard against the occurrence of any of these conditions, and should earnestly work for their removal wherever or whenever they may chance to be present. Some, however, are inclined to believe that every case of diphtheria is derived from a previous case, through some source of contagion, known or unknown. Concerning the con- tagiousness of diphtheria, the weight of evidence in these commu- nications is strongly in favor of the belief that the disease is contagious."
Mr. W. H. Brine, inspector of the Board of Health, made an examination of the houses in which occurred the seventy cases reported in 1878. There were but four reported as "good." There were " drain pipes broken," "improperly trapped," " not trapped," "clogged," "not trapped, emptying into cesspools." The cellars were "filthy," "damp," "damp and offensive." Privies were filthy, and in several instances were found within five and seven feet of the houses. Cesspools were " overflowing," etc.
Oertel, in Ziemssen's Cyclopædia, says, " The most important question in this whole chapter of etiology is that concerning the re- lution of certain vegetable organisms to diphtheria; whether their presence is determined by accident and by the existence of soil favorable to their growth, such as is found in the products of the disease, or whether they stand in a causal relation to the diphtheritic process. Of the vegetable organisms which Cohn classi-
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fies under the name of bacteria, and which he divides into four genera, with one or more species, there is one form in particular (the micro- coccus) which penetrates the tissues wherever a diphtheritic disease occurs, but is also accompanied by a second form (bacterium termo) in greater or less numbers." After describing the different forms of vegetable parasites, and the manner in which they act upon the tissues of the body and upon the blood, he continues, " There can no longer be a doubt, after the statement of such facts, that these vegetable organisms are not of accidental occurrence, but are inseparable from the diphtheritic process, just as the bac- teria of decomposition are necessarily connected with decay, and act as a ferment of it. Without micrococci there can be no diph- theria (Eberth)."
" At present the question of the etiology of diphtheria must be considered as sub judice, with enough probability in favor of the germ theory to warrant, on the part of the practical sanitarian, such measures of prevention as would probably be most efficacious if this theory were correct." - Billings, " Buck's Hygiene."
In the Fifth Annual Report of the Boston Board of Health I find the following summary of the results obtained from an inspection of the houses in which diphtheria occurred : "It thus appears, under the head of diphtheria, that nearly one half of the premises inspected (forty-seven per cent) presented nothing objectionable in point of drainage and general cleanliness ; in thirty-nine per cent the drainage was defective ; in the small proportion of three per cent . the yards and cellars were dirty ; and in the remaining eleven per cent sunken lots, stagnant water, or filthy dumps made the sur- roundings open to objection. It is, then, our duty, in view of the concurrent testimony, to reject the idea that filth fosters the origin and distribution of diphtheria."
It will be seen from these quotations how prominent a part in- sanitary conditions of man's surroundings play in the production and extension of this disease. Although it will be observed that in some instances the disease occurred where nothing objectionable could be found either in the house, the soil, or the condition of the family, there is a possibility that in these cases contagion was the cause.
Considering that the question of the primal cause of the disease is still an open one, it would not be wise for us to reject any of the testimony offered by these observers : it is all valuable, and from it we can derive many good suggestions. For my own part, I believe
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that diphtheria is a specific disease, depending for its existence upon a previous case, and that insanitary conditions in themselves will not originate it. It is highly probable that the germs of the disease, which are said to exist in unusual quantities in the dis- charges of the patient, seek those localities which are noted for their poor hygienic surroundings.
It is not my purpose in this paper to enter into an examination of the probable manner in which these conditions favor the exten- sion of the disease, - whether they act primarily in lowering the physical condition of those living under them, thus rendering them more liable to contract disease, or whether they present the neces- sary elements for the preservation and growth of the specific organisms which are said to be the cause of the disease ; but, recognizing the fact that they bear an intimate relation to each other, I would impress on the people the necessity of carefully inquiring into the condition of their houses. Particular attention should be paid to the house drains ; see that they are not leaky, and that they are properly trapped. Cellars should be kept dry and well ventilated, and at no time should decomposing vegetables or other substances be permitted to remain in them. The ground under and around the house should be well drained. Cesspools are dangerous nuisances, and should be removed as soon as pos- sible. He is not a wise man who persists in using a cesspool when, by the expenditure of a few dollars, he could connect his house drainage with a public sewer.
The suggestions made when treating of scarlet fever are appli- cable to this disease, and should be faithfully carried out.
DIARRHEAL DISEASES. - The diarrheal group, under which term are included cholera morbus, dysentery, diarrhea, and cholera infantum, occupies a prominent position in our mortality table. Of the 398 deaths in 1879, these diseases were the cause of 34. Cholera infantum was by far the most fatal of these diseases, standing credited with 20. As but 4 of the fatal cases in the group were adults, I shall confine myself to a consideration of the influences at work productive of these diseases in young children. Among the predisposing causes of diarrhœal diseases in children are mentioned poverty, overcrowding, impure air, improper food, and a high temperature. It will not be necessary to examine each one of these causes separately, for it will be seen that several of them are at present intimately related to each other. The poverty of the parents of these children necessitates their living in cheap
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tenements, and, viewed from a sanitarian's standpoint, in the worst sections of the city. The rooms they occupy are small, and too few in number for the maintenance of health, and the inmates are exposed to all the evil influences of imperfect drainage, foul privies, cesspools, etc. In consequence of the inability of the head of the family to earn enough to support them, the mother often finds it necessary to lend her aid. To do this to advan- tage she must go out to work, and in the mean time the very young children are left practically to take care of themselves. It will be seen that under these circumstances, nursing children are brought under the influence of one of the causes, improper food. Nature's food for infants is the mother's milk, and no other aliment can take its place. Of this, in the case of the children of this class, they have but slight chance to partake, owing to the absence of the mothers. It is attempted to supply its place with various compounds from the nursing bottle, the use of which is one of the most prominent causes of these diseases. As we have at all seasons of the year many of these causes to contend with, and comparatively few cases of these diseases except in the sum- mer months, we are naturally led to inquire as to the cause of their relatively larger number during the heated term. This leads us to a consideration of the influence of a high temperature. In the months of July, August, and September of the past year, the diarrhæal diseases were the cause of twenty-nine deaths, while during the other months there were but five deaths from these dis- eases. The influence of a high temperature is more apparent when we examine the mortality table for the whole State. Of 2,540 deaths from these diseases in 1878, 2,094 occurred in the monthis of July, August, and September. Aside from the debilitating influence of heat, to which children succumb more readily than adults, it brings into activity poisonous gases, resulting from the decomposition of organic matters in cesspools, privies, blocked drains, etc. Under the influence of a high temperature, these changes in organic matters take place very rapidly, and the air is laden with the poisonous effluvia to a greater extent in our summer months than at any other time in the year.
Of the influence of filth in the production of diarrheal diseases, Simon says, " Nothing in medicine is more certain than the general meaning of high diarrhæal death-rates. The mucous membrane of the intestinal canal is the excreting surface to which nature directs all the accidental putridities which enter us. Whether they have
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been breathed or drunk or eaten or sucked up into the blood from the surface of foul sores, or directly injected by the physiological experiments, it is there that they settle and act. As · wine gets into the head,' so these agents get into the bowels. There, as their universal result, they tend to produce diarrhea, - simple diarrhoea in the absence of specific infections ; specific diarrhea, when the ferments of cholera and typhoid fever are in operation. And any such distribution of diarrheal diseases as has just been noticed, warrants a presumption - indeed, so far as I know, a practical certainty - that in the districts which suffer the high diarrhoeal death-rate, the population either breathes or drinks a large amount of putrefying animal refuse."
Those children who are so unfortunate as to be deprived of the maternal milk are particularly liable to these diseases. Dr. J. L. Smith, in his work on diseases of children, speaking of the effects of heat and indigestible food on infants, says, " Infants upon whom both causes are operative are most liable to cholera infantum in its severe form. Hence, bottle-fed infants of the city are especially liable to it, and infants whose food is carelessly and improperly prepared." Milk is very liable to change when exposed to the atmosphere ; and it is a well-known fact to medical writers, that the artificial food prepared for infants is open to the same objection. The results of a series of experiments conducted by Dr. Baginsky, for the purpose of ascertaining the degree of putrescibility of vari- ous kinds of food, are thus stated by Dr. Richardson : " After an exposure of these various articles of diet to a temperature of about 67°, for a period of twenty-four hours, he found that the human and the cow's milk remained almost unchanged ; the Swiss milk, the two varieties of the farinaceous food and of the artifi- cial food, although appearing still to be perfectly fresh and whole- some, yet exhibited on examination bacteria in motion.
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