Notes on epidemics. For the use of the public

Front matter

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Introduction

A book such as Br. Anstie's little volume, which is uow presented to the American public, has long been a desideratum. Written as it is by one distinguished for his scientific acquirements, it cannot fail to be of great service to the people wherever it is circulated. Medical men have been charged with a reluctance to instruct the great mass of mankind in those truths which are capable of being understood and acted upon by all intelligent and moderately educated persons. "Without admitting the full force of this allegation, there is no doubt that if the great men of the profession had written more for the people than they have, quackery would not be so rampant and wide-spread as it is at present. In the belief that our people will gladly re-

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IV INTRODUCTION.

ceive instruction in the important matters contained in the present volume, it is submitted for their consideration and guidance at a time when the knowledge it contains will prove more than ordinarily useful.

WM. A. HAMMOND, M.D.

New York, August 17th, 1866.

Preface

The following short treatise is an expansion of an article which appeared in the January number of the British Quarterly Review, and I have naturally experienced some difficulty in adapting it to its present form. As the publishers, however, thought that some of the facts and arguments of the original paper were of sufficient public importance to deserve a more general circulation than could be obtained by a review article, I have willingly done my best to make this volume of use to general readers.

No one who lives in one of our great cities— and especially no Londoner— can have failed to notice the increased attention which is everywhere being given to the subject of Epidemic Diseases. As yet, however, this interest is but a vague sentiment with the majority ; and I have been particularly struck, when conversing even with those gentlemen whose daily avocations bring them into constant contact with the classes among whom these maladies are chiefly developed and fostered, with the fact that, as yet, the bearing of sanitary laws upon the practical questions connected with

VI PREFACE.

prevention and mitigation is so ill understood that it can scarcely be said to be known at all. Without pretending to write what the medical profession would receive as a valuable original work, a physician may supply the public with very useful information. The special source of my own interest in this matter is the great prevalence of typhus fever — one of the most deadly forms of epidemic disease in London at the present day — in the immediate neighborhood of the hospital of which I am an officer; a prevalence which is so plainly artificial and needless that no medical man can observe it without mingled feelings of regret and iDdignation. The opportunity now offers itself for appealing to the public against that supineness which, fostered by a habit of overweening confidence in our powers of local self-government, has induced Englishmen to neglect problems which are daily becoming of more vital consequence to the well-being of the State. No mistake can be more serious in its consequences than is the error of regarding the growth of infectious diseases as a matter of mere local or personal interest. That which is happening in the low "slums " of Westminster is happening also in hundreds of places where the conditions of daily life are similarly unwholesome ; and, unfortunately, the progress of those incidental evils which inevitably accompany a certain stage of civilization is daily multiplying the centers from which infectious disease spreads through the whole community, and aggravating the evil where it already ex-

PREFACE. Vll

isted. To meet and check the mischief requires a national effort; but until the nation understands the elementary facts of the history of preventable disease its efforts will be wasted. How miserably ineffective our collective attempts at improvement have been will be shown in the following pages; nor can we wonder at the result when we find official bodies, which are charged with the gravest responsibilities as to the care of the public health, ignoring so simple a fact as the distinction between the contagious typhus of the destitute classes, and the utterly different fevers which depend upon insanitary conditions affecting rich and poor almost equally.

The main object of this essay is to furnish information which may assist the non-medical public to do their part in the work of prevention. For the purpose of insuring that early isolation of patients which is absolutely necessary if infectious diseases are to be cut down at the roots, it is necessary that a knowledge of the value of the principal premonitory symptoms should be widely diffused among the public ; and, accordingly, I have endeavored to supply this want in the briefest and most intelligible manner. As far as possible, the descriptions have been limited to simple physical facts, and I have gladly availed myself of one important set of phenomena which especially bear this character, namely, the changes of animal temperature, as tested by the thermometer, which have lately been found to furnish most valuable information. It would

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be idle to attempt to convert the public into a body of skilled medical observers ; but it is possible, and in regard to the present subject most important, to teach them to perform, scientifically, those duties which devolve on the friends of patients, even before medical advice can be summoned ; and, above all, to inform them of the real value of those symptoms which make it necessary that medical assistance should be at once obtained. F. E. A.

Wimpole Street, March, 1866.

Chapter I. Introductory

Ignorance of the public, a source at once of unnecessary panic and of mischievous neglect with regard to epidemic diseases — Essentially preventable character of these maladies — Definition of the phrase "Epidemic Disease" — List of British epidemics — General causes of epidemic disease — Mortality from epidemic diseases in London — Premonitory symptoms of epidemic diseases, with remarks on the use of the thermometer for the purposes of diagnosis Page 11

Chapter II. Fevers Of Destitution — Relapsing Fever And Typhus

Relapsing fever: its genesis simply from circumstances of destitution ; its spread by contagion ; its early symptoms. Typhus fever; caused by destitution plus overcrowding in dwellings; its intense contagiousness within a small area; the chief means of its propagation; pre-eminently a disease of cities; its early symptoms Page 24

Chapter III

EPIDEMIC DISEASES DEPENDENT ON INSANITARY CONDITIONS IN- DEPENDENT OF DESTITUTION — TYPHOID FEVER, CHOLERA, AND EPIDEMIC DIARRH03A.

Typhoid fever, formerly confounded with typhus; really quite distinct — Predisposing causes — Exciting causes, chiefly arising from defects of drainage — Early symptoms of typhoid.

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Asiatic cholera: an opprobrium of medicine, but really more comprehensible, as to its causation, than some much commoner epidemic diseases — Place of origin — Atmospheric influences — Propagation by sewage matters in drinking-water, and by sewer-gases — Early symptoms of cholera. Epidemic diarrhoea; its relations to cholera; its causes: "dysenteric" form of epidemic diarrhoea. Measures of disinfection..PAGE 41

Chapter IV

INFECTIOUS EPIDEMIC DISEASES WHICH ARE COMPARATIVELY INDEPENDENT OF DEFECTIVE SANITARY ARRANGEMENTS.

Unsatisfactory state of our knowledge as to the causation of those diseases — Scarlet fever; a disease never known to originate de novo — Mode of propagation — Intense contagiousness—Precautionary measures — Early symptoms. Diphtheria; predisposing causes mostly personal; peculiar nature of contagion; early symptoms. Measles; cause not known; bad ventilation a source of great aggravation — Early symptoms of measles. Early symptoms of small-pox. Whooping-cough; obscurity of original causes; mode of propagation — Non-febrile character of early symptoms; dangerous effects on weakly constitutions; danger of contagion. Influenza; uncertain origin ; rapid propagation ; infectious nature ; early symptoms; essentially distinct from common catarrh; is often followed by serious constitutional diseases in weakly subjects. Brief note on yellow fever. General conclusions on the subject of epidemic disease Page 68

Chapter I. Introduction

The British public has just undergone one of those panics which it suffers, at certain intervals, from the apprehension that epidemic disease of a terribly fatal kind is about to devastate the kingdom. The approach of the dreaded cholera raised in almost every mind vague terrors which the experience of exceptional years of pestilence has rendered traditional; and we were not unlikely to drift helplessly into mere paralysis at the very time when we needed to have all our wits about us. Nothing is so effectual in calming the unreasoning fears of a time like the present as the investigation of our real knowledge of the evils which we dread; it is no slight gain if we learn to view the plague with which we are threatened as a scientific problem for inquiry rather than a subject for unreasonable terror. In the following pages, we shall endeavor to show that public sentiment has been unduly excited by the prospect of one kind of danger, at the very time when other matters of equal, and indeed of far greater importance to the national health, are neglected or ill understood. We propose to review briefly such conelusions as medical science has been able to announce with some confidence, with regard to the special forms of epidemic disease to which this country is liable ; and it is needless to say that, in a popular treatise such as this is designed to be, we must limit ourselves to those practical considerations, as to prevention and mitigation, in respect of which the general public have duties and responsibilities of their own to fulfill.

In one point of view these epidemic scourges of the earth, so far from presenting a specially gloomy aspect to the physician, are among the most tangible proofs to him of the reality and importance of his work. He boldly names them Preventable. He tells the impatient generation, which sees its ranks thinned by what seems an anomalous, incomprehensible, and irresistible power of destruction, that the time will come, and indeed is visibly coming, when the diseases which form the largest sources of mortality will be extinguished, or confined within narrow limits, by the enlarged resources of science. It may not be the lot of this generation, or of the coming one, to see this consummation ; but the student of medicine gathers omens of success in the future from past victories in this field, which it is impossible for a layman rightly to appreciate; and his faith never wavers, even under the severest pressure of present disappointment. No one who is not imbued with the spirit of modern medical inquiry can understand the grounds of this confidence. For example, let us consider for a moment the now familiar phenomenon of the disappearance of intermittent fevers, in consequence of the drainage and cultivation of the marshy districts, which are their proper habitat and place of birth. To the public, the disappearance (in England, for instance) of these diseases, though in itself gratifying, suggests no increased confidence in the resources of medicine ; for the local annihilation of the pest seems to have been as purely accidental as we dare call anything. The physician views the matter very differently. He looks upon the whole series of facts observed in the case as a most useful piece of analysis, ready performed to his hand, of which he eagerly avails himself in speculating upon epidemic disease in general; and, in fact, there is no single recorded circumstance in medical history which has been more fruitful in suggesting thoughts which have led to practical results in preventive medicine. It is impossible to say how much of our improved knowledge of the mode of propagation of many diseases, and specially of typhoid fever and cholera, is not, directly or indirectly, due to the important considerations forced upon medical men by the events which have happened in regard to the extermination of ague by drainage. Certain it is, that reflection upon this circumstance had the greatest share in leading to what we shall hereafter notice as one of the very few thoroughly valuable observations which have been made in regard to the propagation of cholera — the discovery by Dr. Snow of the frequent propagation of the disease by impure drinking-water.

Often, indeed, it has happened, that from the seemingly most desperate features of modern epidemics, there has directly originated the one all-important observation which has made possible a whole system of preventive regime. It needs but to study the history of the Irish Famine fevers, and the subsequent epidemics of typhus, to find an instance in point. We may safely say that the greatest discovery of this century, in regard to the causation of epidemic disease, as witnessed in Great Britain, arose out of the terrible circumstauces of the dreadful Irish famine-pestilence of the years 1846 and 184*7. Upon the persons of the unfortunate Irish there were worked out, first, the great problem of the nature of true starvation fevers ; and secondly, the differentiation of the true contagious typhus from the former. Such results as this, and the discovery of the propagation of typhoid fever through the medium of decomposing organic matters, are far more than mere medical curiosities ; indeed, as we shall hope to show in the proper place, they form the true basis, not only for a greatly improved medical treatment of some of the most important British epidemics, but also for a most promising system of sanitary legislation, which can hardly be much longer delayed.

It seems necessary, in commencing the discussion of our subject, to clear up some elementary points with regard to the definition of terms. At the risk, therefore, of appearing to be superfluously minute, we must premise that by epidemic diseases we mean to specify those maladies which, whether they habitually form part of the catalogue of the diseases of any country or not, are at intervals imported afresh from without, and take, more or less suddenly, a greatly increased development, both as to the number of individuals whom they attack and the proportionate mortality.

Of the human diseases of this class which have infested Great Britain and Ireland, the following is, for practical purposes, a complete list: Plague, typhus fever, typhoid fever, relapsing fever, malarial fevers (including intermittents and remittents), sweating sickness, scarlet fever, measles, small-pox, chicken-pox, diphtheria, whooping-cough, influenza, erysipelas, puerperal fever, cholera, and epidemic diarrhoea.

It would be waste of time, however, to dwell upon all these diseases, because there are a few of them which, from their prevalence or their fatality, altogether outweigh the rest in practical interest. The malarial fevers are now only represented in this country by the agues which infest some marshy districts: and the deaths from this class of disorders are but trifling in number. Small-pox has, it is true, not altogether ceased to be occasionally fatal to considerable numbers, but we all clearly understand that nothing hinders its extinction but the difficulty of enforcing the universal use of vaccination. The plague and the sweating sickness are happily never known here now, though formerly so destructive. Chicken-pox is a trivial complaint. Erysipelas and puerperal fever do not come under the head of serious and widely-spreading epidemics, and their outbreak in particular places (such as hospitals, etc.) is becoming less and less common now that the first principles of hygiene are well understood by medical men. The remaining diseases, which are to form the subject of this paper, will be divided into three groups : in the first, we shall place relapsing fever and typhus ; in the second, typhoid fever, cholera, and epidemic diarrhoea ; and in the third, scarlet fever, diphtheria, measles, whooping-cough, and influenza. We shall take as our text-books the learned works which represent the most recent medical science ; without pledging ourselves, however, to do more than indicate what seems to be the balance of probabilities derivable from a comparison of the opinions expressed therein.

Before speaking of special epidemic diseases, it will be well that we say a few words as to the general causes of this kind of sickness, among which we must seek for the special sources of particular epidemics. These are either constant or occasional in their operation. The first kind can be easily illustrated by the conditions which prevail where the low- lying delta of a slowly flowing river has become the depository of a great quantity of decaying organic matter, or by the state of things which exists when sewage matters habitually contaminate drinking water, or sewer gas always mixes in large quantity with the atmosphere. In all these examples we see elements (though not all the elements) of epidemic disease lying constantly in readiness for mischief. The occasional causes may be illustrated by the influence of changes in the atmosphere (particularly as regards temperature, moisture, and the rate of movement of the air), and by the various circumstances which may produce distress and privation of food among large numbers of persons at a particular time. But by far the most important of these occasional causes is that influence which is known by the name of contagion ; this word expressing the idea of the communication of a material substance which can excite the disease in the body. Our readers are probably aware that modern writers for the most part associate with the idea of contagion the further theory that the communicated poison is of the nature of a ferment, and that the characteristic disturbances which it sets up in the organism are due to a kind of fermentative movement; hence the name "Zymotic (or fermentative) diseases." During the fermentative process the secretions of the infected person become charged with matters, which in their turn are capable of setting up the zymotic process in healthy organisms : these matters are sometimes volatile, and sometimes not, or they may have very different degrees of volatility ; and upon these differences depends the distance to which the atmosphere round an infected person will be charged with the pernicious influence. But even in the case of the n on -volatile zymotic poisons, infection may be conveyed by the direct application of the morbid matter to a part of the body from which it can be readily absorbed into the blood ; as by the application of small-pox or cow-pox matter to a wound, or by swallowing the vitiated secretions from patients suffering from typhoid fever or cholera. Lastly, it must be noted that many of the best observers believe that some diseases which are not contagious are yet dependent on the action of a zymotic poison; as, for instance, the ordinary English agues.

As regards the nature of the several zymotic poisons, little more is known than that they are probably organic in their chemical composition ; but it may be said that the belief rather gains ground, that in their active state these morbid matters consist of or retain living organisms. This question, though far too little elucidated to permit of detailed argument, has most important relations to the question — whether all or any of the zymotic diseases are capable of being produced de novo, and in the absence of specific germs derived from existing cases of the particular disease. In a treatise like the present, it is impossible to do more than to point out, in treating of individual diseases, the evidence which bears most strongly on this disputed question.

In order to give a general idea of the importance of those epidemic diseases which we propose to discuss, it may be well to quote here the evidence afforded by the Registrar-General's abstracts of the mortality in London for the thirteen years from 1852 to 1864 inclusive. These returns show that in that period of time the mortality in London, from all causes, was 719,958. In the same period, the mortality from " zymotic" dis- 2* eases was 218,998. Of these deaths, 41,664 were caused by scarlet fever or diphtheria (these two diseases are not accurately separated), 18,256 by measles, 26,892 by whooping-cough, 13,160 by cholera (10,708 of these in the single epidemic of 1854), 29,995 by diarrhoea, and 31,937 by " typhus" (including not only true typhus, but relapsing fever and typhoid), and only 1168 by influenza — no serious outbreak of the latter disease having occurred within the years specified.

We shall conclude the present chapter by mentioning some circumstances which may give warning of attacks of epidemic diseases, and may often enable friends of patients to form a rough but serviceable estimate of the probable gravity of the impending affection.

Of the diseases which we are about to discuss, some are, and some are not, febrile in the manner of their commencement : of the former class are typhus, typhoid, relapsing fever, scarlet fever, measles, and influenza ; diphtheria may be said to hold a half-way position; while cholera, epidemic diarrhoea, and whooping-cough belong to the non-febrile class, as regards the way in which they begin.

The febrile kind of epidemics usually announce their attack by striking premonitory symptoms. In all of them, if the affection run at all a typical course, there is a. period of greater or less duration, a few hours or a few days as the case may be, between the exposure to the infecting poison and the outbreak of distinct symptoms : but usually for some time before the latter event the patient loses his appetite, and experiences, and shows in his looks, an unaccountable depression. This culminates most commonly in a burst of shivering, not unfrequently accompanied or followed by vomiting; a chilly feeling lasts for some time, and then gives way to sensations of unusual and steadily-increasing heat, till that burning state of the skin is attained which is popularly thought to be typical of fever; there are the greatest differences, however, between different diseases, and even between different cases of the same disease, as to the degree of flushing of the face.

Whenever a patient shows such symptoms as these, he should be at once isolated in an apartment possessing not less than 1500 to 2000 cubic feet of space, and with the freest means of subsidiaiy ventilation : unless the weather be very hot there should be a fire, and the windows must be constantly open. No bed- hangings, curtains, or carpets should be allowed. This is more especially necessary if, among the symptoms, there has been sore throat, and the patient has never had scarlatina, — or severe pain in the back, and sickness, and the patient has been exposed to small-pox, — or if there be great nervous prostration or delirium, and the patient has been within the possible range of typhus contagion. The most anxious watch must now be kept upon the skin, and the appearance of anything like an eruption, especially if it comes out on several parts of the body, should be the signal for summoning medical advice, even in cases where the preliminary symptoms may have been ever so mild. The time of appearance of the eruption varies from twenty-four hours to nine or ten days, from the commencement of the febrile symptoms in the various febrile diseases; and, in relapsing fever, there is never any specific eruption at all. Besides this, there are many instances of the complete, or almost complete, absence of eruption, even in scarlet fever and other epidemic diseases, which are ordinarily accompanied by a rash. Some more early and certain criterion of the nature and seriousness of the disease is, therefore, a great desideratum for the friends of the patient, and, fortunately, we are now in a position to suggest one test of this kind, the value of which is very great.

Recent medical observation has placed in our hands a means of distinction between different febrile maladies, and a most useful calculus of the gravity of an existing disease, which we must here specify, viz., the thermometer.

It has long been known that the healthy human body possesses the remarkable property of retaining an almost complete equality of temperature in its deeper parts, under all the varying circumstances of external cold or heat. The temperature of the armpit, for instance, which is a part protected from the influence of external changes, remains always, during health, at the level of 98° to 99° Fahrenheit. And this is taken as the standard in the ordinary circumstances of life in temperate climates. In severe diseases of many kinds (not merely in fevers) this standard is exceeded, sometimes even to the extent of eight or nine degrees ; and it is a singular fact that this increased heat begins to be manifested to thermometric observation even in those early stages of acute diseases, when the patient's own delusive sensations would lead him to believe that there was a great reduction of animal heat, as, for instance, in the shivering fit which forms the first stage of an attack of ague.

From the large number of observations which have been made by Wunderlich and many other continental observers, and in our own country by Dr. Sidney Ringer and Dr. Aitken, the following facts stand out as pre-eminently valuable in the appreciation of the character of acute diseases. If the thermometer rapidly rises as high as 101° to 105° Fahrenheit, the degree of fever may be known to be severe. When the temperature exceeds 105°, the complaint is dangerous to life, and the danger increases rapidly with every successive degree of added heat. On the contrary, if during the first two or three da}^s of illness the temperature never rises above 100°, the complaint is probably a trivial one, whatever its exact nature may be. On the whole, it is a good rule for the guidance of the public that a temperature exceeding 100°, however mild may be the general symptoms which the patient may present, is a proof of the necessity of immediately applying for medical advice.

These leading facts are sufficient to show the general importance of thermometric observations ; and we shall endeavor to show, in treating of particular epidemic diseases, the more special items of information which may be gained in this way. The thermometer is an instrument which for many important medical purposes is as necessary to non-professional persons as to medical men ; it remains for us now to indicate the precautions which must be observed in its application.

The kind of instrument which must be used is that with a naked bulb, and a white backing to its stem, on which the degrees are marked ; Mr. Cassella, of Hatton Garden, makes very good ones of this kind, which are generally adopted by medical men ; but cheaper instruments, of German make, can be obtained from Griffin, 22 Garrick Street, Covent Garden.

The "Self-Registering Maximum" form of thermometer is the most convenient for the use of non-professional persons, who are not accustomed to the daily employment of the instrument; the purchaser should obtain from the maker full instructions as to the adaptation of the index or register. No observation should be made till the patient has been quietly resting in bed for at least an hour. The bulb of the thermometer should then be placed deeply in the armpit, the arm being folded across the chest, and the bed-clothes so arranged to cover the projecting stem as high as the marking of 90°, or thereabouts. The patient must lie perfectly still for at least ten minutes ; the thermometer may then be withdrawn, when the register will remain stationary at the highest level which the mercury has reached.

A very slight amount of reflection will show the value of this mode of investigation, in assisting the friends of a patient who exhibits so-called " feverish " symptoms to a decision as to the propriety of taking some important steps, and particularly as to seeking medical help. It is absolutely necessary, however, that the application of the thermometer should first be practiced on the healthy body, before we venture to rely on its indications in disease, even for these limited purposes for which alone laymen could be recommended to use it. The mother of a family should always be skilled in the application of the instrument, since nothing is more uncertain and delusive than the sensations of young children who complain of feeling ill, and the application of the hand to the skin is a very poor and imperfect method of determining real temperature. In speaking of particular febrile diseases, we shall show that, besides the general information as to the gravity or triviality of a feverish disturbance which the thermometer can impart, it sometimes enables the observer, by its sole authority, to determine that a particular disease is or is not present.

The warning symptoms of those epidemic diseases whose commencement can hardly be said to present febrile phenomena at all, are so peculiar in the case of each individual disease, that we can lay down no general rules for determining their nature or severity, beyond the fact of the prevalence or non- prevalence of the disease in the neighborhood at the time. All other questions must be deferred to subsequent chapters.

Chapter II. Fevers Oe Destitution

Relapsing Fever and Typhus.

The three groups of epidemic maladies which we have already marked out have been arranged in the order in which we have placed them, on the principle of commencing with those which exhibit the simplest and the most intelligible phenomena. Our first group contains two diseases,— relapsing fever and typhus,— which owe their origin, or at least their developments, to scarcity of food, and to the various social miseries which follow necessarily in the train of such scarcity.

Relapsing Fever.* -Relapsing fever may be described as presenting the simplest type, as regards its mode of origin, of any of the epidemic diseases; for it has been almost certainly proved to result directly from privation of food. The evidence seems remarkably clear and satisfactory. Every epidemic of the disease which has been recorded was preceded by extreme destitution of the poor, produced either by the failure of crops, or by some artificial circumstances which tended to throw large numbers of the lower classes out of employment.