THE ANTICIPATORY TREATMENT OF LOCAL EPIDEMICS. BY H. R. STOKER, M. D., OF NEWPORT. You will pardon me, gentlemen, if in the very practical remarks that I am about to make, I shall seem to be almost insulting science b}T begging that it may be more frequently allied with plain and simple common sense. In what way, I shall explain. That prevention is better than cure, though ax- iomatic, has been acknowledged by our profession virtually only within the last twenty-five years ; and even now, coinci- ding as we really all do in the dogmata that conservative sur- gery is far more creditable and implies a higher skill than de- structive surgery, and that prevention of illness is a more beneficent work, often requiring indeed more strictly scien- tific attainments, than attempting, so often in vain, its cure, we find in practice that however intelligent the surgeon or physician, he is handicapped everywhere by a very universal popular ignorance, which applauds the dashing feats of the old-fashioned heroic cutter and carver, which values the family attendant in proportion as he is an adept in the equally old- fashioned art of drugging, or which, but imperfectly appre- ciating the motive of the skilful practitioner who has learned that most valuable of Nature’s lessons, when to withhold his hand, rushes headlong into the net of the wiliest of med- ical sophists, those prescribers of infinitesimals, who but il- lustrate anew the old axiom that history merely repeats itself. The mediaeval application of rust from the sword or 2 spear that had wounded, the employment of hair from the tail of the dog that had bitten (they had not then progressed so far as to inoculate hydrophobics with potentialized bits of spinal marrow as now advised by Pasteur), were but essays towards the doctrine that sim. sim. curantur ; though the first of the practices instanced had at least a grain of sense upon which to base its claim, for rust, whether upon a spear or elsewhere, is a good chalybeate, and locally used would ex- ert an astringent, stimulant or even antiseptic influence. Well would it, be just now for the National Medical Asso- ciation, and indeed for the whole profession, had no sordid specialists endeavored to disinter the heresies of Hahne- mann, for their own selfish purposes, from the oblivion into which they were sinking, side by side with the dead and for- gotten theories combatted by our medical ancestors. The popular ignorance of which I have spoken but few practitioners have the courage, or more properly speaking can afford, to persistently withstand, save by withdrawing themselves, very seriously and solemnly, within the shell of professional dignity; and particularly does this seem the case in Rhode Island. It is not necessary to refer to the in- stances, almost innumerable, of fractures and luxations that in this State are placed almost as a matter of course under irregular practice, and to the unfortunate results of which I, though a comparative new comer among you, have myself seen so many illustrations that I do not hesitate to say that I doubt if another city exists in this country where, with the same population, there are as many cripples as in Newport. Lame myself, I daily find more than enough with whom to sympathize. Aside from this, however, there obtains a pe- culiar and almost laughable apathy, slowness of comprehen- sion, inertness, disinclination to progress, call it what you will except by the misnomer “ conservatism,” so often wrongfully applied to it by local pride, which in professional matters must often have evidenced itself, upon the part of their clients and townspeople, to every gentleman present. I have lived in other communities, and can therefore fairly draw comparisons ; I speak besides in the moderate language of one who has left his youth behind him, and I frankly say that the study of the peculiarity of which I am speaking has added a constant interest and fascination to ray now nearly nine years of Rhode Island life. There has been in the past a perfect glut of this sort of thing in Newport, dating back 3 to the lethargy of its first loss of commerce, and of all business movement and energy. I had almost said indeed of all ac- tive communication, for at least six months each year, with the outside world. The recent city election, with its complete breaking down of precedents, plans and partizan methods, is perhaps in evidence that the ice pack of preju- dice is at last moving out of the lower bay. It is not five years, since two of those most active in securing the health board that is now doing so much for Newport, were deliberately and in earnest threatened by the “ Newport Mercury ” with suspension from a street lamp-post; and now, another instance of the repetition of itself by history, that very journal is praising what a more enlightened public sen- timent has come to perceive is for its highest good. Such being the case, and deliberate little Rhode Island, as a State, having been almost as slow in throwing its weight in favor of protecting the public health, as it was in joining the Federal Union, you who are natives of her soil will ex- cuse my warmth when I urge you, as a society, to greater, more intelligent and more conjoined efforts to guard your patients’ families and your own against outbreaks or the ex- tension of preventable disease. You have a State Board of Health, composed in the main of unexceptionable material, but it is, as its chairman, my colleague at the Newport Hospital and friend, Dr. Turner, has repeatedly impressed upon me, without the necessary power. You have in Providence, as we still have in Newport to a great extent, your public health controlled by city officials who are unprofessional persons, and therefore, however well meaning they may be, to this extent unfit and incompetent for such a responsible, and so strictly medical a trust. Superintendents of Health may be admirable in their way, City Registrars may be the most conscientious and assiduous of men, Secretaries of State Boards may be masters of sanitation, far sighted, skilled in statecraft, the very men for the place ; but what can Dr. Chapin, or Dr. Snow, or Dr. Fisher accomplish, in compar- ison with what still remains to be done, unless they are backed by public intelligence in these matters, and unless they have confided to them sufficient authority to enforce their own decrees, or those that have been made in accord- ance with their advice by the State or civic legislative bodies. The medical profession may be of one mind, as they now practically are, as regards preventing and controlling zymotic 4 disease, but unless they have secured the attention, the belief and co-operation of the great public, whose lives it is their own life study to prolong, they can effect, and they do effect, very little indeed in the way of increasing vital ex- pectation, and of throwing out from the mortuary list cer- tain constant series of premature deaths which are at once a menace to every community and a disgrace to those that are highly civilized. There occur yearly, almost monthly, in Rhode Island local epidemics of zymotic disease, slight perhaps in comparison with those of a century ago, but still, as I have said, discred- itable in view of what is known concerning the origin of such maladies, their methods of progression, and the means by which they might be not merely arrested, but prevented. At one time it may be typhoid, I will not say in Providence ; at another scarlet fever, in Newport for instance ; at a third diphtheria, as a year or two ago, and again very recently, in Middletown and Portsmouth, and, I regret to say, domiciled there at this very moment, if not indeed also in the city of Newport. It is bad practice, I think, not necessarily upon the part of local medical attendants, but decidedly so upon that of the State, that these preventable diseases, for such in very great measure they are, should ever be allowed to gain a foothold, no matter whether in city, town or village. The first case may be unavoidable, but having come, whether through dis- ease germs wafted by the wind, conveyed by water, or brought by personal importation from abroad, it is like the flying and flaming cinder that may strike upon dry roof or hay-rick, which it is the duty of each person, whether seem- ingly directly concerned or not, to use his every effort, individually and in concert with others, to arrest and extin- guish. Now there are difficulties, and very grave difficulties, often confronting the family attendant, should he endeavor to use his best judgment, to the very uttermost detail thereof, whether in treating an individual case of infectious or conta- gious disease, or in endeavoring to protect the remainder of the family, the neighbors or the community, and it is from repeated personal knowledge and observation of these diffi- culties, especially in connection with my duties as one of the officers of the Sanitary Protection Association of Newport, and from having had charge myself of two of the at least six 5 fatal cases of diphtheria that have just occurred in that city, that I have thought that this brief communication upon the Anticipatory Treatment of Local Epidemics might not only be of interest to you, but perhaps also of some actual ser- vice. We have found, decidedly, that no matter what the knowledge, skill, public spirit or good will of the attending physician, he requires in these cases to have behind him the moral support of the law; and this in turn is but the reflec- tion of public opinion. Where contagious and infectious disease has appeared, there is necessary, for the protection of others, a strict local quarantine, or removal to isolation house or hospital. This removal applies not only to the patient but to his immediate family, for at times it is not only cruel but sanitarily useless to separate them. There is required more or less expenditure for disinfectants, often thought needless by ignorant or parsimonious persons; and in addition, fre- quently the destruction of property, such as bedding and the like, that has become infected. To carry out these rules is not only at times beyond the power of any mere physician, but even to advise them simply, may occasion the loss of his most valuable patronage, perhaps indeed the main source of his support. In these cases a competent and properly selected official, for obvious reasons better to be designated by the State than by the city or town that he may be called upon to serve, may often in a single day save to the community in the lives preserved, a money value of productive labor, else sacrificed, far surpassing, perhaps many times over, the most generous annual salary that he may receive. Look for instance at last year’s epidemic at Plymouth, Pa., so much like the water-course from which it derived the fatal germs that gave it birth. At the outset, it resembled the single little isolated spring. As it went on and on, it increased in volume and in force, until it became the overwhelming torrent which decimated a prosperous community, and by its ravages put it back, in comparison with what it would have become in wealth and influence, a full score of years. Who can doubt that if at the Plymouth outbreak a skilled sanitary detective, preferable by far to the wisest assembly of experienced prac- tising physicians, had been earlier set to work, the ap- palling result would have been averted. The first case or two might have been perplexing, but the very moment, after 6 inspection of their local conditions and surroundings, and if you please analysis of the drinking waters, had taken place, the next step, that of synthesis, had been made, that mo- ment the mystery would have been solved. A hundred dol- lars, thus intelligently expended, would have saved hun- dreds of thousands, to say nothing of the frightful loss of life. If, as is so easy in these local epidemics, whether comparatively slight or severe, effects that are similar to each other can be traced to a common origin, he is simply an empiric, and no physician, who will not, by endeavoring to remove or destroy the cause, tend to arrest its conse- quences. I have implied that I believe very fully that it is the busi- ness of the State, in health matters, to protect its people, and I have declared that it is my conviction that the State health officials should be directed to investigate into, and should be expected to cut short, every local epidemic of zymotic disease that may be reported to it as existing within the borders of Rhode Island, It is well enough, it is indeed very necessary, that there should be local health officers and local boards of health. The beneficial effects of the hitter were never in any place made more manifest than they have been in the city of Newport during the last year, and there never was prepared a more convincing Annual Report than, that presented on the second of the present month by its secretary, Dr. Rives. The experience of that city, however, has shown that even were the executive powers of the Board all that they should be, and as yet they are very far from this, they would still be insufficient to cover very important ground. Take, for example, the present occurrence of diphtheria at Middletown, Portsmouth and Newport, during which there have been at least a dozen deaths. The only physician res- ident in the first of the communities named, a very worthy gentleman, whose personal acquaintance in all other respects I value, is so disqualified by the code of the National Associa- tion, through holding to an exclusive dogma, that no mem- ber of the Newport profession can meet him in consultation consistently with the rules of the code, or indeed with those of this State Society, which has accepted them. The Board of Health of Newport has had no authority whatever, either of investigation or of relief, beyond its own corporate limits. There has existed therefore no check, not even the slightest,. 7 save through the private efforts of our fellow member of the society, Dr. Benjamin Greene, the physician who lives in the adjoining town of Portsmouth, or of those from New- port or Fall River, who may have chanced to be called to individual patients ; and were a practitioner recently de- ceased yet living (we unfortunately still have another of the kind), with whom it is said that every case of throat disease he was called upon to treat, whether tonsillitis, simple or follicular, bronchitis or slight nasal catarrh, was always true diphtheria, and whose local reputation was in accordance with that assumption, it is not improbable that patients with the genuine disease would again have intentionally been imported into Newport, in the dead of night, as is said to have occurred in the former epidemics, that they might be under his immediate care. The following has been the sequence of the cases of death from diphtheria to which I have referred : I. Middletown. 1. Dec. 3, 1885. Jas. L. Heath ; 4 years, 7 months. 2. Dec. 12, “ Bertha E. Heath ; 9 years, 11 months. 3. Dec. 17, “ Peleg Albro, 2d; 35 years. 4. March 6, 1886. Child of Jas. R. Sherman ; 7 or 8 years. 5. March 7, 1886. Mrs. Jas. R. Sherman; age unstated. 11. Portsmouth. 6. March 11, 1886. An infant named Sylvia; 11 months. 111. Newport. 7. Jan. 3, 1886. Eliz. Kent Palmer; 8 years, 7 months, (Dr. Squire.) 8. Feb. 3, 1886. Chr. B. Ehrhardt-, 1 year, 3 months, (Dr. Turner.) 9. Feb. 21, 1886. Annie Morrissey; 3 years, 2 months, (Drs. Storer and Parker.) 10. Feb. 26, 1886. Maurice Morrissey; 1 year, 3 months, (Drs. Storer and Parker.) 11. Feb. 28,1886. Richard Pollitt; 5 years, 9 months, (Dr. Squire.) 12. March 5, 1886. Mary C. Kelly; 2 years, 5 months, (Dr. Turner.) 8 There are three other deaths upon the Mortuary Record at the Newport City Hall, that would probably be thought, from their certificates, and their coincidence with the cases of true diphtheria, should be included in the above list. These are Nov. 10, 1885, Albert E. Walsh, 15 years 8 months, a boy in the U. S. Training School, certificate of death, “tonsillitis”; Jan. 3, 1886, Ida L. Gray, 6 years 1 month, certificate of death, “probably membranous croup”; and Jan. 20, Lilia E. White, 2 years 6 months, certificate of death, “ diphtheritic croup.” With regard to the first, however, although there was true diphtheria a month subse- quently, upon the ship, Surgeon Drennan, U. S. N., of the “New Hampshire,” writes me “there was not the slightest trace of diphtheria. The disease was tonsillitis, accompanied by a retro-pharyngeal abscess,” Regarding the second, which occurred upon the very day of the first undoubted case of death from diphtheria in Newport, Dr. Barker, the President of the local Board of Health, in whose practice it was, assures me that he could not have been in error; and regarding the third, which was reported as diphtheria by the attending physician. Dr. Stanton, the partner of Dr. Squire, (both of them homoeopaths), who lost the cases 7 and 11, Dr. Bark- er is confident, from having seen the child previous to its death, that there was an error of diagnosis, and that the case was one of scarlet lever. Neither ol these three cases is in- cluded in an official list with which I have been furnished by Dr. Barker in behalf of the Board of Health, Besides the fatal cases in Middletown officially reported to me, there are believed to have been several more there and in Portsmouth, unreported to the authorities or of which I have been unable as yet to gain the particulars. Dr. Ben- jamin Greene writes to me that he has “kept no record of the several cases of diphtheria that have occurred in South Portsmouth and Middletown for the last two years, but can call to mind ten fatal cases, six of them since the first of January, I think, of 1886. Four of these cases were treated by the regular practitioners, and six by Drs. Rice and Chase of Newport.” My letter of inquiry to the Town Clerk of Portsmouth as yet remains unanswered, but my thanks are due to Mr. Albert L. Chase, Town Clerk of Middletown, for his prompt reply in writing, and for an interesting per- sonal interview. I should not omit to say that Dr. Charles H. Fisher, Secretary of the State Board of Health, has kindly 9 given me all the information, infinitesimal though it was, that he has had in his possession regarding the present local epi- demic. There were an equal number of cases with those that died, in Middletown, Portsmouth and Newport, where re- covery has occurred; probably to be followed, however, by more or less completely established invalidism, from paraly- tic and other organic disability, which so frequently super- venes upon diphtheria. Upon the ship “ New Hampshire ” there were four well defined cases, severally commencing upon Dec. 27, 1885, and Jan. 7 and 8, 1886. lam greatly obliged to Surgeon Drennan, U. S. N., for the full and con- vincing details of their specific character that he has been kind enough to send me, as distinguished from the many mild attacks of tonsillitis among the boys of the Training School. There is an important fact about the Middletown-Ports- mouth group of cases, which has been pointed out to me by Drs. Turner, Barker and Greene, and Town Clerk Chase ; namely, that they have all occurred in a limited region, in- habited by well-to-do people, in the neighborhood of Slate Hill, towards the East River, which had already, a year previously, been fatally infected by diphtheria. One of the cases, that of the Portuguese infant, Sylvia, which died at the house of Joseph W. Chase (the old Prescott place), had been visiting at that of David Albro, in which a diphtheritic patient had died on Jan. 1, 1885, and where, according to Dr, Greene, there had again been diphtheria four or five weeks ago. All the cases in the vicinity have been of a malignant type, and the disease now seems endemic. So far as yet examined, the Middletown, Portsmouth and Newport premises, whereon the zymotic has appeared, have all been found in an unsatisfactory sanitary condition. Dr. Greene writes: “ The first cases were in a very tidy, well- kept family, who are especially careful in regard to cleanli- ness about the premises. There was this fact though, that seemed to me might reasonably be assigned as a cause just previous to the breaking out of the disease there, they removed their sink vaults further from the house and left the earth, saturated with sink water, exposed for a number of days.” Now the first of the Middletown deaths occurred on Dec. 3, 1885, and the first of the cases on the ship “ New Hamp- 10 shire ” revealed itself on Dec. 27 ; the first of the Newport deaths, which had been preceded in the same house upon Bellevue avenue by a milder case, unreported to the health authorities, under the care of Dr. Mary Elizabeth Baldwin, took place on Jan. 3, 1886. So far as can yet be learned, the disease seems therefore to have been imported into Newport from Middletown, and very likely carried thence to the “ New Hampshire” also from the same origin, or it may have been transferred directly to the ship from Middletown, and from thence to Newport, in either case Middletown supplying the original local focus of dissemination. Two of the later Newport cases (in February) may possibly have been infected directly from the “ New Hampshire,” the father of Nos. 9 and 10, the Morrissey children, being the ship’s shoemaker, and yet the latest case on shipboard was on Jan. 8, while the first of the children referred to was not attacked until Feb. 20. As to the chain of connection of the other Newport cases, the Board of Health has been able to directly trace this in regard to several of them, and there can therefore be no possible doubt that they could have been prevented had there existed a proper isolation hospital, and the first one or two cases been removed thereto. Now who can reach such an evil as this that I have demon- strated, the unchecked and by ordinary measures uncontrol- lable progress of one of the most fatal of all diseases, so direct- ly, so promptly, and so effectively as our friend, Dr. Fisher, Secretary of the State Board of Health whose well-directed energy we in Newport had occasion to utilize, by bringing him personally upon the ground, for inspection of the plague spots of the city, at the very commencement of the Board of Health campaign, the existence, extent and great danger of every one of which have been officially verified in the first annual re- port of the new Board of Health, now on file at the City Hall. He would be able to enter upon the scene, as soon as informa- tion should reach him of a local epidemic, in the name of the law. He would know precisely what to look for, what to do at the moment, and what orders to give for the future. He would bring to the task that independence of local and ob- structive influence pertaining to his official position and au- thority, and he would be besides, as a skilled expert, at once judge, jury and executive, just what is required in such an emergency, where loss of time is most dangerous. It seems to me that there can be no subject more worthy the atten- 11 tion of this society, no action that it could take of more ser- vice to the community, than for it to appoint a suitable com- mittee to draft a memorial to the Assembly at the present session requesting it to enlarge the powers of the State Board of Health in the direction that I have indicated, and to appropriate the small additional sum that might annu- ally be necessary to make them effective ; said committee to be directed to attend to their duty at once, so that the statute may be passed during the brief period that remains before the adjournment of the Assembly. I have purposely retained from consideration of the vari- ous technical measures that are of avail towards the preven- tion and arrest of epidemics, always interesting as such a dis- cussion would prove, especially when, as here, intelligent men convene from both city and country, believing as I do that something beyond this is indicated. You already pos- sess the necessary means, the machinery, for the anticipa- tory and for the direct treatment of local epidemics, namely, the State Board of Health. That machinery is already in motion, though as yet hesitatingly and imperfectly, if never indeed jarringly. It merely requires more power, both be- hind it and within itself, and more oil to lubricate it; in other words, an annual appropriation sufficient to enable its executive officer to travel, as often and as freely as may be necessary, to the successive foci of zymotic disease. I have addressed you, gentlemen, as again an active prac- titioner, and not merely the meditative recluse that my in- validism forced me for a time to be ; as one of the profes- sion of Newport, a city which requires, if she is ever to be- come the health resort for which Nature has so well fitted her, the assistance of the State towards protecting her from, and removing, every form of preventable disease ; and as now a member of this State Society. I may add, may I not, in this city of Roger Williams, that I have also spoken as one of the long line of Massachusetts men who, whether from stress of religious, or political, or as in my own case, of climatic asperity, have come out from our old home on the shore of Massachusetts Bay, to find a new one upon Narragansett, where with freedom of conscience, and equal rights shall I say, we may with our families, as becomes true Rhode Islanders, hope for a ripe old age, such as New- port traditions would give to us all, unabbreviated by either general or local epidemic disease. 12 The Society will permit me to offer the following motion, and I urge its passage : That a committee of three be appointed by the chair to immediately memorialize the Assembly, upon behalf of this Society, requesting it to authorize the State Board of Health to personally investigate and restrain, through its Secretary, local outbreaks of zymotic disease, including cholera, yel- low fever, small-pox, diphtheria, scarlet fever, typhus and malignant typhoid, as they may occur within the State ; and to appropriate for such additional service during the ensuing year a sum not to exceed five hundred dollars.