INFECTIOUS DISEASES.

BY CHARLES S. CAVERLY, M. D., PRESIDENT VERMONT STATE BOARD OF HEALTH.

The functions of health boards, state and local, are becoming more varied every year they have to do with the registration of vital statistics, water supplies, sewage disposal, nuisances injurious to health, food supplies, and the disposition of the dead. So that the practical work of health officials covers a wide range of activity, and calls for knowledge of various kinds.

It is true, however, that the end sought, by health laws and regulations, whatever they may directly deal with, is the prevention of disease, the conservation of physical health. So the success or failure of our health laws and health boards, in the end, will usually be measured by this standard: Do they or do they not prevent disease?

It behooves us, as public officials, to prove that the laws the public has given us and the expenditures it authorizes for enforcing them, are justified by smaller death rates and sickness rates from preventable disease. There is no more important subject for discussion, in a School of Health Officers, than infectious diseases.

I appreciate this. I appreciate the responsibility placed on me here of treating this subject before you, but I have the mandate of the majority of the State Board, from which you know there is no appeal.

It is proper that you, who are compelled to listen to my remarks, should know at once where the responsibility rests.

Preventive medicine has come into wide prominence during the last quarter century. By the most painstaking research and perfected technique, science has made a beginning in the solution of the subtle problem of disease causes. While we are warranted now in saying only this, the beginning that has been made is full of promise. Legislative bodies, state and national, have everywhere kept in touch with scientific research, and statutory laws have been made to harmonize with scientific laws on these subjects. Thus is it sought to give the people the benefits of medical discoveries.

The brunt of preventive work actually falls on the local health officer. He needs the cooperation of the medical profession to make his office the most useful to the public. The local health officer, and incidentally, the general practitioner should be men of vigilance and brains. They must have their wits about them, when dealing with preventable disease. Epidemic disease comes unexpectedly, at inconvenient times, and in the most deceptive guise. It comes unheralded, with no noise or pyrotechnics. The laws expect much of the physician and the general public.

The head of a family, in whose home there occurs a case of infectious or contagious disease dangerous to the public health shall immediately give notice thereof to the local health officer of the town in which he lives. A

physician who knows or suspects that a person whom he has been called to attend is sick or has died of a communicable disease dangerous to the public health shall immediately quarantine and report to the health officer the place where such case exists, and the name, degree of virulence and cause or source of the disease, and such other facts relating thereto as may be necessary for the health officer to make examination and act in the premises. [Ext. Sec. 5454, Vt. Statutes.

The duty imposed by law on the public in these matters is not generally understood. Every newspaper in Vermont might to public advantage carry this extract from the laws over its local columns the year around.

You will notice, furthermore, that the duty imposed on physicians is sweeping as well as peremptory. They are required to report their suspicions, as well as what they are sure of. There are three well-recognized steps in the handling of epidemic disease.

The first of these is securing reports of these diseases to the local health officer. There is little difficulty, I believe, now in securing reports of most of the contagious diseases which are generally rated as "dangerous to the public health," within the meaning of the statutes. This list is as follows:

Typhoid (enteric) fever.
Typhus (ship) fever.

Smallpox (variola, varioloid).
Chicken-pox (varicella).

Measles (rubeola, morbilli).

Scarlet fever (scarlatina, canker-rash).

Whooping cough (pertussis).

Diphtheria (croup, membranous croup).

Cholera (Asiatic cholera, epidemic cholera).

Yellow fever.

Bubonic plague.

Mumps (epidemic parotitis).

German measles (rotheln).

Glanders.

Hydrophobia (rabies).

Epidemic cerebro-spinal meningitis (spotted fever).

Pneumonia (lobar or croupous pneumonia).

Puerperal fever (puerperal septicæmia).

Epidemic dysentery.

Erysipelas.

Leprosy.

Tetanus (lockjaw).
Anthrax.

Actinomycosis.

Physicians generally report most of these diseases, although pneumonia, puerperal fever, and perhaps tetanus are often overlooked.

Pneumonia is now reportable in most states, I believe, and that step should be seriously undertaken in Vermont. It stands at the head of our mortality tables, and this first step in its control should be taken by all local health officers. Puerperal fever is not often reported, because the disease is usually allowed to pass with a name less harsh, or one less suggestive of possible professional negligence; and tetanus is rather rare, and probably

most physicians have forgotten that it is a reportable disease. Tonsilitis should be added to this list of reportable diseases, for the intimacy it maintains with diphtheria.

Health officers should all remember that the successful handling of outbreaks of disease is impossible, if they are not reported. Enforce the laws, if possible, and to that end enlighten the medical profession and the public, through the local press, on this part of our public health laws.

The second step in the management of an outbreak of contagious disease is to isolate the case or cases.

The law is specific and to the point.

"A health officer shall, upon receiving notice of infectious or contagious disease dangerous to the public health, investigate and ascertain if possible the source or cause of the disease, institute means of prevention or restriction in the name of the local board."

To allow epidemic disease of any kind to get a foothold and spread in a community is a reflection on the efficiency of the health department. To stop its progress is a matter of vital importance, as it means life and health or the opposite to a certain number of human beings. The public, I believe, is generally educated up to the idea that preventable diseases are really preventable, if properly handled by the medical profession and health officers. The public therefore is apt to be critical of looseness in the handling of these diseases.

The health officer shall "investigate and ascertain, if possible, the source or cause of the disease." You will pardon me if I mention some general propositions in this connection which underlie the whole science of infectious diseases.

The infection or poison of each disease has its origin in another, a preceding case. Smallpox does not arise de novo nor does it arise from filthy surroundings or from atmospheric conditions. When the disease appears in a town, it comes from another case. This is perhaps our beau ideal of an infectious disease. Yet the infection that causes it is probably no more a distinct entity and does not owe its propagation to a lineage of smallpox patients any more surely than does the infection or poison which gives rise to diphtheria, measles, plague, yellow fever, meningitis or even pneumonia, the grip and tonsilitis. The same poison, whether a germ or protozoan, produces the same disease in all these infections. Oats do not grow on wheatsown fields, nor potatoes where corn is planted. We have no right to think the preceding case a myth, because we cannot discover it.

There is, I fancy, some misconception on the part of a considerable number of health officers, as to the cause of epidemic disease. Let me cite some facts reported by health officers in the biennial reports to the secretary of the State Board for the years 1906 and 1907. One health officer says in re the origin or source of a case of chicken-pox, that the child had “not been out of the room for months." Nevertheless, we may not infer that this was a case of spontaneous generation or purely providential. There was surely

another case of chicken-pox back of this one. The medium of communication may have been the doctor, nurse, a letter or paper, or only the family

cat.

Again among the outbreaks of diphtheria, reported for 1906 and 1907, I find ten health officers report outbreaks as due to "sink drainage," or "unsanitary surroundings" and one ascribes the disease to "a cold."

These same reports in several instances state that typhoid outbreaks were due to "old cellars," "bad sanitation," or "privy drainage," and scarlet fever due to "bad sanitation" or "condition of house." Poor general sanitation may perhaps predispose to these infections: that they ever cause them is contrary to the fundamental principles of modern medicine. The health officer, upon receiving a report of a contagious disease, is directed to "institute means of prevention or restriction.".

The second step in the control of epidemic disease is

ISOLATION.

Each case of infectious disease is a human incubator, in which the specific poison of that disease is being grown, and from which, through various avenues, it is being spread about.

If we have scarlet fever to deal with, do not forget that the patient has the possibilities of producing the poison of that disease on a wholesale scale, and that that poison may be launched forth from his mucous surfaces and skin, to attack susceptible persons. In one way or another the same is true of all who suffer with any of the so-called infectious diseases.

The typhoid case is a culture medium for the Eberth germs, and they find exit from the body by the dejecta.

The diphtheria case, the case of measles, of whooping cough and even the case of pneumonia and the grip, is an infection manufactory, and distributes infection, each in its own devious way.

So, if you would control these infections, keep them within the closest possible limits. Hence we quarantine. We isolate the poison, and especially the individual who is producing the poison, within certain specified limits. The final destruction of that poison by disinfection, after death or recovery, is immensely simplified, if we know what house or what room in the house contains it.

Some of these infections are only spread by direct contagion from person to person, while others retain their virulence for varying times and may be held and carried by inanimate objects or human beings.

Measles and whooping cough are chiefly spread by direct contagion, while the poison of smallpox, scarlet fever, diphtheria and tuberculosis may cling to house furnishings, or personal clothing and even live in symptom-free human beings. I notice that one health officer, in the biennial reports referred to, says that scarlet fever was brought to his town by a