RA 
 
 e.4 3 
 
 SiSS 
 
THE CONTROL 
 
 COMMUNICABLE DISEASES 
 
 SOUTH AUSTRALIA. 
 
 W. RAMSAY SMITH, M.D., D.Sc.. F.R.S. (Edin.), 
 
 \ Permanent Head of the Department of Public Health of South Australia;, 
 Fellow of the Royal Institute of PuSlic Health of Great Britain; Chairman of the 
 Board of Examiners for South Australia of the Royal Sanitary Institute ; Member 
 of the Association of Military Surgeons of the United States, S'c. 
 
 THIBD EDITION. 
 
 B. E. E. R0GEK8, GOVERNMENT PBJNTEK, NOSTfl TEER4CE. 
 
 1919. 
 
Ncuj fork 
 
 ^ttAt (^allege of Agricultutc 
 
 At ajorneU Iniucraits 
 atl)aca. £7. %. 
 
 3Cibrarg 
 
With Compliments 
 
 FROM 
 
 The Board of Governors 
 
 OF THE 
 
 Public Library, Museum, & Art Gallery 
 of South Au^ralia. 
 
 Adki,aidk, 
 
 South Australia. 
 
THE CONTROL 
 
 COMMUNICABLE DISEASES 
 
 SOUTH AUSTRALIA. 
 
 W- RAMSAY SMITH, M.D., D.Sc. F.R.S. (Edin.), 
 
 Permanent Head of the Department of Public Health of South Australia ; 
 
 Fellow of the Royal Institute of Public Health of Great Britain ; Chairman of the 
 
 Board of Examiners for South Australia of the Royal Sanitary Institute ; Member 
 
 of the Association of Military Surgeons of the United States, &rc. 
 
 THIBD EDITION. 
 
 R E. E. ROGERS GOVERNMENT PRINTER, NORTH TERRACE. 
 
 1919. 
 
The original of this book is in 
 the Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924080085065 
 
PREFACE TO THE THIRD EDITION. 
 
 THE first edition of this pamphlet was written in 1909, in 
 accordance with a resolution of the Central Board of 
 Health that I should prepare a statement about modern 
 methods of isolating- cases of infectious diseases, and in 
 response to a request of the Director of Ediication that 
 some instructions regarding communicable diseases should 
 be available for thd use of public school teachers in the 
 State. The health and well-being of school children had 
 then come to be recognised as prime considerations in any 
 system of education. 
 
 The present edition has been carefully reivised. A chapter 
 on influeiiza has been substituted for the chapter on plague 
 in the former editions. The statistical and administrative 
 information has been brought up to date, and the experience 
 of the past ten years has been used as a guide for future 
 action. 
 
 I gratefiiUy acknowledge my special obligations to many 
 American sources of information, including opportunities 
 afforded me for personal observations in the States and 
 Philippines, and the numerous Federal and States publica- 
 tions regularly received. The lessons these have taught 
 prove very helpful here, where so many conditions are 
 similar. 
 
CONTENTS. 
 
 PAQE. 
 
 "Recent Knowledge about Communicable Diseases . . . . 5 
 
 ■General Characters of Communicable Diseases . . . . 7 
 
 Measures Necessary to Control Communicable Diseases . . 11 
 
 Legal Aspects of Control . . . . . . . . . . 13 
 
 Local Administration . . . . . . . . . . . . • • 1 5 
 
 A Model Lesson in Health Administration . . . , . . 22 
 
 Present Position in South Australia . . . . ..26 
 
 Control of Various Communicable Diseases .... . . 27 
 
 Whooping Cough . . .. .. .. .. .. ..30 
 
 Measles. . . . . . . . . . . . . . . . 35 
 
 Scarlet Fever . . . . . . . . . . . . ■44- 
 
 Diphtheria . . . . . . . . . . . . . . ^9 
 
 "Contact Diseases" or " School Diseases".. .. ..S3 
 
 Typhoid Fever . . . . . . . . . . . 51 
 
 Influenza . . . . . . . . , . . . 65 
 
 Consumption.. .. '^.. .. .. .. .. yi 
 
 The Sick Room and Disinfection .. .. .. .. .. 8f 
 
COMMUNICABLE DISEASES. 
 
 Recent Knowledge about Communicable Diseases. 
 
 In 1870 an observant physician, writing of smallpox, chicken- 
 pox, scarlet fever, measles, and some similar diseases, said:^ — "As 
 yet we know absolutely nothing of the way by which these com- 
 plaints have originated, and how, when once produced, they 
 spread. There is no problem in medicine that has received more 
 attention than this ; yet it remains unsolved. All that we think 
 that we know is this. That each disease does not now arise spon- 
 taneously, that the infection is of human origin, that each is 
 frequently epidemic and far more severe at some time than at 
 another, that children are more susceptible than adults, and that 
 some people escape altogether, whilst others suffer every time they 
 are exposed to fresh infection. ' ' 
 
 As to how the diseases, commonly called infectious, contagious, 
 or communicable, first appeared in the human race, we can only 
 speculate or theorise. We know, however, something definite 
 about how these diseases spread from person to person and from 
 place to place. And this knowledge, although in many cases 
 limited and fragmentary, is of the sort that proves of very great 
 practical value, since it enables us to control, to a greater or 
 lesser extent, the spread of these maladies. 
 
 Formerly these diseases, like hurricanes, or earthquakes, or 
 inundations, devastated a country and defied control, because 
 people had no knowledge as to \viiether there was any regularity 
 in the way in which epidemics of them appeared, waxed, waned, 
 died out, and reappeared. Now, however, we have the means of 
 finding out something about the infective material, how and 
 where it grows, how it is conveyed from person to person and 
 from place to place, and how it can be destroyed or limited in its 
 action. We can deal with some diseases in much the same way as 
 we deal with plants. We can cultivate them in human beings 
 or other animals, regulate their distribution, modify their viru- 
 lence, or so change the human soil in which they are accustomed 
 to grow that they can no longer fiourish or even take root in it. 
 Like many other processes of fermentation — for they are really 
 so — ^they have ceased from being our masters and have become 
 subject to us. 
 
The human mind, in its attitude towards communicable 
 diseases, has long oscillated, and even now on occasion alternates, 
 between panic and apathy. A knowledge of the modes in which 
 these diseases spread, and of the means and methods of prevent- 
 ing or controlling them should go far, very far, to remove the 
 unreasonable fears that so long possessed people in the presence 
 of an epidemic, or even of a single case of illness. We do not, 
 like some savage races, kill the victims who are attacked by the 
 disease and burn the bodies and the belongings. "We need not 
 prohibit all commerce, or forbid all intercourse with a cholera- 
 infected or a plague-stricken country, or even impose a 40-days' 
 imprisonment or isolation on all persons coming from it. There 
 is no occasion to become alarmed for our own or other people's 
 safety when we read of persons suffering from infectious disease 
 being taken through the public streets in ordinary conveyances 
 without any special precautions, so far as alarmists can see. In 
 these days of effective disinfection, and of Health Acts which' 
 permit efficient isolation and control, we do not need to resort to 
 shot-gun quarantine, nor need we clamor for general and com- 
 pulsory cremation of the dead and imprisonment of the living. 
 
 In most of the communicable diseases the active infective agent, 
 the germ or virus which spreads the disease, has its own dis- 
 tinctive characters and peculiarities, and each disease has there- 
 fore to be dealt with in the light of what is known, or a considera- 
 tion of what is unknown, regarding these characteristics. The 
 measures for disinfection in whooping cough differ as much from 
 those necessary in typhoid fever as the fencing-in of ostriches 
 differs from the caging of canaries. As our knowledge and ex- 
 perience of each disease increase, the really essential measures of 
 control become simpler and more exact in their application ; more 
 intelligible and therefore more interesting; more reasonable and 
 therefore more tolerable. 
 
7 
 
 General Characters of Communicable Diseases. 
 
 The communicable diseases, commonly called zymotic on 
 account of their being supposed to be due to fermentation set up 
 by microbes, have certain characters in common. They have a 
 definite natural history, running a course which is variable in 
 length in the case of each disease, from origin to extinction, 
 and usually showing, during their existence, several stages, 
 viz., a stage of incubation, before symptoms appear; a 
 stage of invasion, during which general symptoms begin to be 
 evident ; a stage of advance, in which certain characteristic skin 
 symptoms may show themselves ; and a stage of decline and con- 
 valescence. Most of them usually occur only once in the same 
 person, i.e., one attack confers a lasting immunity. Cases are 
 generally supposed to be traceable to a previous case of the same 
 disease. The diseases that feoncern us most intimately are whoop- 
 ing cough, measles, scarlet fever, diphtheria, and typhoid fever. 
 Consumption, though in some respects in a different category, will 
 also be considered. 
 
 About 2,300 years ago Hippocrates, "the father of medicine," 
 said : — ' ' The physician who cannot inform his patient what would 
 be the probable issue of his complaint, if allowed to follow its 
 natural course, is not qnalifie'd to proscribe ajiy rational plan of 
 treatment for its cure. ' ' The truth therein set forth regarding 
 disease in the individual requires to be kept in view when we 
 speak of the nature and course of epidemics. It is highly desir- 
 able that we should know the natural history of an epidemic 
 before we attempt to estimate the value and the effect of the 
 measures we employ to check it. We know that individuals differ 
 greatly in their constitution and habits ; yet scarlet fever, measles, 
 smallpox, or typhoid fever will show a general similarity in all 
 as regards incubation,' invasion, symptoms, decline, and period of 
 convalescence. • Some of these features of the disease can be 
 altered in a greater or less degree by treatment ; but the point to 
 remember is that each of these incurable diseases runs a natural 
 course, ending normally, if not usually, in a natural and complete 
 recovery. Speaking generally, one can no more cure typhoid 
 fever or any similar disease than one can cure a storm ; but, just 
 as the shipmaster can manage and manoeuvre his vessel till the 
 storm has spent itself, so the physician can guide his patient 
 through the disease and its complications to a successful issue. 
 The question then arises — Is the same true in relation to epidemics 
 of disease ? Has an epidemic a natural course ; and can we fore- 
 cast the rise, the acme, the decline, and the death of any epidemic 
 in the community? 
 
8 
 
 Very little has beeu done in connection with this subject, but 
 the little that has been done may be set forth briefly in the follow- 
 ing short historical account— In 1866 the late Dr. Parr wrote a 
 letter regarding cattle plague in the United Kingdom, at a time 
 when the disease was making most extensive ravages, and when, 
 there seemed to be no limit to the damage it might do. He showed 
 that as the rate at which the disease was extending was already 
 lessening, the acme and the decline of the epidemic might besoon 
 expected. Later on he applied his method to an epidemic of 
 smallpox in 1871-2. Afterwards Dr. G. H. Evans worked out 
 mathematically the method that Dr. Farr had employed in mak- 
 ing his forecasts. Dr. Brownlee, in 1906, applied Dr. Farr's 
 method to a large variety of epidemics. 
 
 The point of general interest in connection with Dr. Brownlee .'s 
 work is that he compares the actual figures of known epidemics 
 in ancient and recent times with the theoretical course as marked 
 out by Parr's mathematical curve. He takes, for instance, an 
 epidemic of miliary fever that occurred in 1821 at Oise, in the 
 north of France, and shows that the two agree in a manner that 
 is very surprising. ' This disease is very well fitted to test the 
 theory, because its cause and the means of its propagation are 
 absolutely unknown, and it is therefore one which spreads as 
 nearly as possible in natural conditions. Further, it is an ex- 
 plosive disease, so that there is no.diiBeulty about knowing the 
 beginning and the end of the outbreak. 
 
 Dr. Brownlee shows that, as the number of persons exposed 
 increased from the start to the finish of the epidemic, the decline 
 in the number of cases must have been due to the loss of infec- 
 tivity in the germ of the disease itself, and not to the lack of 
 individuals who might be supposed to be open to contagion. He 
 then takes up the great plague of London, in 1665. The number 
 of cases is estimated from the London Bills of Mortality, and the 
 particulars given in Pepys's Diary. Pepys speculated on the 
 possibility of a recurrence or a recrudescence of the malady, on 
 account of the number of people who were returning to London. 
 In truth, however, the infective power of the disease organism 
 was exhausted, and though great numbers of susceptible persons 
 came from the country into the zone of infection — even, it is said, 
 occupying the beds of those who had been afflicted — no further 
 extension of the plague ensued. It is a popular historical belief, 
 but nevertheless an unfounded one, that the Great Fire of London 
 stopped the plague. An examination of the statistics of the 
 time will show that there is no foundation for the statement. 
 
 Dr. Brownlee makes some very interesting remarks on the 
 subject of smallpox. At first sight, in epidemics where all the 
 machinery of modern sanitation has been brought to bear, it 
 
might be expected that the form or the course of the epidemic 
 would in some way be altered. Dr. Brownlee, however, finds that 
 the course of recent epidemics — say, that of London in 1902 — 
 varies little from that of epidemics in pre-sanitary days. That 
 does not mean that there is no difference in the amount of disease 
 present in a given epidemic; but it does mean that a uniform 
 force, acting towards the limitation of an epidemic, produces no 
 perceptible effect on the form of the curve. 
 
 Dt. Brownlee not only includes a large variety of epidemics in 
 his investigations, but he turns his attention to the subject of the 
 recrudescence of epidemic diseases, and also to outbreaks and 
 increase of violence of endemic diseases, or those which, affecting 
 a number of persons simultaneously, seem to show a distinct con- 
 nection with certain localities. He demonstrates that the mathe- 
 matical forecast is also very accurate as applied to these. 
 
 Some of his remarks in reference to smallpox are worthy of 
 serious study. It is generally stated that there is a larger amount 
 of smallpox in the vicinity of smallpox hospitals than anywhere 
 else in the cities, and a large amount to the leeward of the pre- 
 vailing winds. It has to be remembered, however, that a small 
 amount of infection placed anywhere in a suitable locality is 
 capable of producing an extensive epidemic ; and though all the 
 cases be promptly removed from the district, the disease may 
 continue to spread, and an epidemic develop with the typical dis- 
 tributions in time and space. Secondly, some centres of a town 
 are, for reasons more or less known, more suitable for the spread 
 of an epidemic than are others; and, though the disease may 
 first start in a part at some distance from these, yet as the 
 epidemic proceeds and infection is introduced into these districts 
 the cases therfe may so increase as to make those portions ulti- 
 mately the chief centres of the outbreak. It must therefore be 
 borne in mind that a local outbreak in the neighborhood of a 
 hospital may be as much an accident of place as a result of the 
 proximity of the hospital. Statements made in books of sanitary 
 science regarding the relation of infection to the prevailing wind 
 in the neighborhood of hospitals have too often been founded 
 upon a single observation, and they require to be retested. 
 
 The great lesson to be learned from all this is the one urged by 
 Ovid — "Principiis ohsta; sero medicina paratur" — "Withstand 
 the beginnings, for an after remedy comes often too late." If 
 we give the organism of the disease no chance, we prevent or stop 
 the epidemic. Therein lies the importance of sanitary pre- 
 cautions. Nothing should knowingly be permitted that will allow 
 an epidemic the opportunity to start ; but if it does gain a footing, 
 every effort should be made to prevent its spreading from new 
 centres of infection. 
 
10 
 
 A knowledge of these facts regarding epidemics is very neces- 
 sary, because without it we may be misled in two ways. "We may, 
 on the one hand, unwarrantably assume that certain measures of 
 prevention and isolation have effectively checked the spread of an 
 epidemic, when, as a matter of fact, these measures were probably 
 ineffective or useless, and the epidemic had actually burned itself 
 out, become self-limited, or exhausted. On the other hand, we 
 may be unnecessarily disheartened at the spread of an epidemic 
 in spite of preventive measures which have apparently been suc- 
 cssful in other cases. 
 
 Bacteriological discoveries have given direction and precision to 
 the work of preventing disease or checking its spread by means of 
 isolation and disinfection, with a resultant economy of time, 
 effort, and expense. Each disease to a certain extent presents a 
 special problem ; but certain principles are of general application. 
 
 In many cases it is easier, and in the long run more economical, 
 to stamp out a disease than to control it. To extinguish an 
 epidemic, however, demands (1) an intelligent co-operation of a 
 people who have been educated in the simple principles of health; 
 (2) a certain amount of individual sacrifice for the benefit of the 
 whole; (3) prompt, intelligent, and effective administration; and 
 (4) sufficent appliances for the requirements. 
 
 In 1914 a committee of the Massachusetts Association of Boards 
 of Health, in presenting a very complete and carefully considered 
 report upon the period of isolation and exclusion from school in 
 cases of communicable disease, said: — "Your committee has 
 approached this task with an earnest desire to annihilate the 
 superstitions which have surrounded the theory of the trans- 
 mission of disease; to eliminate the hardships attendant upon 
 unreasonable isolation and to educate the public in the methods 
 of contracting disease. ' ' 
 
 With the increase of knowledge we realise in the case of several 
 diseases how very little is necessary for protection, but how very 
 necessary that very little is. Not a few people, however, think 
 that the very little is so little that it cannot be worth while. 
 
11 
 
 Measures Necessary to Control Communicable 
 Diseases. 
 
 In 1877, at a time when preventive medicine was in its infancy, 
 and when the role of germs in the cause and spread of diseases 
 was unknown, Sir Thomas Watson wrote in the Nineteenth 
 Century: — "We cannot indeed slay the human subjects of 
 zymotic disease and those suspected of it, but we may destroy the 
 poison which they bear within and about them. To this end 
 the requisites are, first, the unfailing and immediate notification 
 to the proper authorties of the occurrence of every case. Second, 
 the instant isolation of the sick person. Third, the thorough 
 disinfection of his body, clothes, furniture, and place of isolation. 
 Fourth, vigilant and effectual measures to prevent the importation 
 of disease from abroad, and to strangle it should it by mischance 
 return. ' ' 
 
 In 1868 Sir J. Y. Simpson had made a strong appeal to the 
 public to stamp out smallpox. As measures that had been, or 
 were likely to be, effective, he urged the earliest possible notifica- 
 tion, isolation of the sick at home or in a hospital during the whole 
 of the infective period, the employment of nurses and attendants 
 who were immune to the disease, and effective disinfection during 
 and after the disease. He believed that by applying the same 
 principles to scarlet fever, measles, and whooping-cough, now 
 generally known as the "school diseases," these diseases would 
 become greatly reduced, if not extirpated. In putting very 
 strongly the case for legislative and administrative control, Simp- 
 son said — "A rattlesnake or a tiger escaping from a travelling 
 menagerie into a school full of children would, in all probability, 
 not wound and kill nearly so many of these children as would a 
 boy or girl coming among them infected with, or still imperfectly 
 recovered from, smallpox, or scarlet fever, or measles, or hoop- 
 ing-cough. Most properly the cobra and the tiger — because they 
 are always dangerous — are always, as far as possible, prohibited 
 from making such visitations ; and the infected boy or girl should 
 be prohibited also, during the time that they are dangerous, by 
 running through the course and convalescence of such contagious ' 
 diseases ; or, in other .words, while they exhale from their bodies 
 a virus of disastrous and deadly potency. ' ' 
 
 It is notable that the precautions recommended by Simpson and 
 Watson were founded, as all trustworthy medical treatment 
 during the past 2,000 years or more has been founded, upon ex- 
 perience. The discovery by scientific experiment and observation 
 
12 
 
 of the manner in which most, if not all, of these diseases are pro- 
 pagated by germs (known also as microbes, micro-organisms, and 
 bacteria), has confirmed the belief that control is possible, and 
 has supplied us with the means of checking their spread. Nowa- 
 days experience and experiment go hand in hand in the effort to 
 abolish these deplorable scourges of humanity; for they are de- 
 plorable when one considers the large number of preventable 
 deaths recorded with almost unfailing regularity in every civilised 
 community. And, as Sir Thomas "Watson pointed out, the 
 records enumerate the killed alone. Far greater, he said, and 
 indeed innumerable, is the multitude of the wounded, the maimed, 
 the disabled, the impoverished, by the stroke of these dread 
 diseases, which thus bring widespread ruin and misery upon 
 whole families at once. 
 
13 
 
 Legal Aspects of Control. 
 
 In a free country every individual has his rights, and he should 
 be free to exercise them. But in a free community he must also 
 respect the rights of others. Under the common law a man has a 
 right to take down his house, but he must not throw the stones 
 recklessly on the pavement where the public pass by, for another 
 person has a right to walk on the public pathway without being 
 subjected to the danger of death or injury. He has also a right 
 to be in a public place or a public conveyance without being com- 
 pelled to run the risk of contracting disease from persons or 
 things in the conveyance that may be in a condition to spread it. 
 
 It is therefore a nuisance at common law, and an indictable 
 oifence, for a person knowingly to expose another in a public 
 high.way who is sufiEering from an infectious disease. 
 
 It would be a mistake to imagine that protection by statute 
 law from infectious disease is a peculiar development of present 
 or recent times. In the second year of the reign of James I. a 
 law was passed giving power to the officials of a plague-stricken 
 town to levy a rate for the relief of the sufferers and to make 
 regulations to prevent the spread of the disease. People attempt- 
 ing to leave an infected house might be detained by force ; and if 
 an infected person went into company he was liable to be put to 
 death for felony. If he left an infected house, though not him- 
 self infected, he was punishable as a vagabond by whipping and 
 to be bound to his good behavior. 
 
 These laws are founded on the principle that the public health 
 is paramount, and that it is the first duty of every State to pro- 
 tect the public, particularly the poorer classes, since it is the 
 poor who suffer most. They also assume the principle that 
 individual liberty may be restrained or restricted for the benefit 
 or protection of the general community. The question arises: 
 How far is it justifiable for the community to restrain a person's 
 liberty of action in health matters or in any matter ? 
 
 John Stuart Mill says : — ' ' The sole end for which mankind are 
 warranted, individually or collectively, in interfering with the 
 liberty of action of any of their number is self -protection. That 
 the only purpose for which power can be rightfully exercised 
 over any member of a civilised community, against his will, is to 
 prevent harm to others. His own good, either physical or moral, 
 is not a sufficient warrant. He cannot rightfully be compelled 
 to do or forbear because it will be better for him to do so, because 
 it will make him happier, because, in the opinions of others, to do 
 
14 
 
 so would be wise or even right. These are good reasons for re- 
 monstrating with him, or reasoning with him, but not for com- 
 pelling him, or visiting him with any evil in case he do other- 
 wise. ' ' He says, further — ' ' The only freedom which deserves the 
 name, is that of pursuing our own good in our own way, so long 
 as we do not attempt to deprive others of theirs, or impede their 
 efforts to obtain it. Bach is the proper guardian of his own 
 health, whether bodily, or mental and spiritual. Mankind are 
 greater gainers by suffering each other to live as seems good to 
 themselves than by compelling each to live as seems good to the 
 rest." 
 
 Farrar says : — ' ' Man 's liberty ends, and it ought to end, when 
 that liberty becomes the curse of his neighbors. ' ' 
 
 The common law, and most if not all statute laws dealing with 
 health, are based on these principles. A man who unfortunately 
 has contracted smallpox or erysipelas or some disease which may 
 be communicated to another, is not allowed to comport himself 
 in such a way as to infect that other. The common law has for 
 many hundreds of years made it a criminal offence for such a 
 person to infect another either wilfully or carelessly. For ages 
 administrators were ignorant of the precise ways in which certain 
 diseases could be communicated; and the methods of control in 
 some instances weighed heavily on the afflicted, and even on the 
 healthy, where control was attempted. It is only in very recent 
 times that medical knowledge has increased to such an extent as 
 would .justify comprehensive action in the control of that whole 
 class of diseases known as communicable. Since fairly complete 
 control may be effected without great inconvenience or loss, one 
 disease after another has passed from the category of ' ' the secret 
 things of God" into the list of things capable of being known 
 of all men, and of being controlled by human effort wisely 
 directed. 
 
 In proportion as people learned more about the way in which 
 certain diseases were propagated, and the measures by which 
 their spread could be prevented or controlled, statute law gave 
 powers to local authorities (i.e., to the people's representatives 
 elected by the people themselves) to interfere still more with indi- 
 vidual liberty for the sake of protecting the whole community. 
 
15 
 Local Administration. 
 
 At different times and in various ways I liave set forth what 
 these powers are in this State, and how they might be exercised 
 and applied so as to give the community the fullest protection pos- 
 sible, consistently with the recognition of individual rights. I 
 have also endeavored to set forth from time to time the facts we 
 have learned regarding the appearance and course of various 
 diseases in this State. In the following pages I shall try to 
 gather together in compact form the information scattered 
 throughout numerous reports, memoranda, and pamphlets, and 
 to supplement and illustrate this by the results of investigations 
 and observations in other places. 
 
 In South Australia every municipal council is a local board of 
 health for its municipality, and every district council is a local 
 board of health for its district. Where there is no council the 
 Central Board of Health exercises the powers of a local board of 
 health. The special powers conferred on local boards of health to 
 control infectious diseases are set forth in the Health Act, 1898, 
 and the regulations made under that Act. The diseases defined 
 as infectious in the Act are leprosy, plague, yellow fever, small- 
 pox, cholera, diphtheria, membranous croup, erysipelas, scarlet 
 fever, searlatiaa, and the fevers known by any of the following 
 names or descriptions: — Typhus, typhoid, enteric, relapsing, or 
 puerperal (including all puerperal conditions depending on in- 
 fection). Since the Act was passed- the following have been 
 added to the list by Proclamation : — Anthrax, trichinosis, cerebro- 
 spinal meningitis, cerebro-spinal fever, epidemic cerebro-spinal 
 meningitis, intermittent, remittent, paludal, or malarial fever, 
 whooping cough, measles, chicken-pox (temporarily), favus, bil- 
 hariosis, and influenza. Pulmonary tuberculosis is not an "in- 
 fectious disease" within the meaning of the Health Act of this 
 State, but the law gives local authorities certain powers of control 
 over infected persons and infected articles. 
 
 The reason, or reasonableness, underlying the law with respect 
 to the control of communicable diseases may be briefly referred 
 to. 
 
 The chief feature which all the diseases classifled as "infec- 
 tious" under the Health Act possess in common is that they are 
 preventable. It is this feature that gives any legislature a suffi- 
 cient reason for so far interfering with the liberty of the subject 
 as to cause him to notify his disease, and that gives a right to 
 put him under necessary restraint in the matter of spreading 
 infection among his neighbors. The State does not make legal 
 provision for an individual being isolated because he has had his 
 
16 
 
 arm broken, or is suffering from heart disease. Such an injury or 
 disease will not spread by contact of persons, or be carried by 
 clothing, or otherwise, to the houses of his neighbors ; but scarlet 
 fever, diphtheria, and typhoid fever may so spread; and the 
 ravages of these may mean a considerable loss of time and money 
 to the man who has a commercial business to attend to or a pro- 
 fession to follow, unless he has some means of protecting himself, 
 at a reasonable limitation of liberty, and a moderate expenditure 
 of money against the ravages of diseases that are preventable. 
 Apart from the Health Act, speaking generally, there is no such 
 power. What the Health Act does is this: it gives the people 
 living in any particular district the right to form themselves into 
 a large "health insurance association" for preventing disease 
 from appearing among them, and for checking its spread by iso- 
 lating and otherwise dealing with cases of the disease if it does 
 appear. The rate which is levied for health purposes by the local 
 board is the premium which every ratepayer pays for this pro- 
 tection. The local board elected by the ratepayers is the local 
 authority for carrying out all the provisions of this insurance 
 scheme. 
 
 In administering the Health Act the local boards have at their 
 disposal the following means of becoming aware of the existence 
 of infectious disease in the district and for preventing its 
 spread : — 
 
 Notification. 
 
 Notification is made to the local authority by the head of the 
 family or other responsible person, and by the medical practi- 
 tioner called in to attend. No medical practitioner has any right, 
 apart from the Health Act, to give the authorities or anyone else 
 any information about a patient he is attending ; and the Health 
 Act, or the direction of a judge in a court, is his only legal pro- 
 tection when giving such information as he is required to give. 
 
 Visitation and Inspection. 
 
 On receiving notification of the case, the officer of health begins 
 his duties. It has to be noted that the medical attendant is con- 
 cerned chiefly or solely with the health of his patient, and that, 
 having notified the case to the local board of health, his duty to 
 the public has been performed. On the other hand the first con- 
 cern of the officer of health is, not the well-being of the patient, 
 but the health of the community, and how infection can be kept 
 from spreading from that particular case to other persons. He 
 does not, as a rule, require to see the patient; but if circum- 
 stances occurred in which it were necessary or desirable that he 
 should do so for the purpose of measures of isolation or disinfee- 
 
17 
 
 tion, he would communicate with the medical attendant, and see 
 the patient only in conjuiiction with him. In all visitation for 
 the purposes of isolation of the patient or the check of the disease, 
 promptness is of prime importance. A broken arm can wait with- 
 out detriment to the health of the community ; but, if isolation 
 of an infectious case and disinfection are to be of any use, the 
 person and the contaminated materials must be attended to at 
 once by the ofScers of the board. 
 
 Isolation at Home. 
 
 In many cases, especially m the country and in the summer 
 season, isolation may very well be carried out at home. Local 
 boards should order disinfectants to be used in and about the 
 sick room, and they may, either by their officer of health, trained 
 nurse, or inspector, supervise the use of disinfectants and remove 
 for disinfection articles that cannot be properly disinfected at the 
 house. 
 
 CoMPLTi;SOEY Removal. 
 
 In towns isolation at home is usually unsatisfactory, especially 
 where there are families of any size, or where the house contains 
 more than one family. In cases where proper isolation is imprac- 
 ticable, or where the sick person is lodged in a room occupied by 
 others of more than one family, or on board any ship or vessel, 
 or in a common lodging-house, or in a boarding-house, the patient 
 can be removed upon the certificate of a legally qualified medical 
 practitioner to any hospital or other place for reception of the 
 sick, subject to the consent of the hospital or other authorities. 
 Such compulsory removal should seldom be resorted to; for a 
 hospital ought to be looked upon as a place to which a patient 
 naturally wishes to go (and all proper inducements should be 
 held out to persuade every patient to go), both for his own sake 
 and for the sake of others. 
 
 Isolation in Hospitals. 
 The section of the Act which allows local boards to build hos- 
 pitals, or to contract for hospital accommodation, is one of the 
 most important in the Act, and one which requires the greatest 
 care and tact for its proper administration. If the section is pro- 
 perly administered it ought to be a most effective means of check- 
 ing the spread of infectious disease in the district. An isolation 
 hospital, or some place to receive and seclude the sick, should be 
 in readiness before the necessity to use it arises. If such a place 
 is not provided until the need for it has arisen, it is usually use- 
 less as a means of checking the spread of infection, and is of use 
 merely for the treatment of particular patients, and not for the 
 protection of the general community. If infection has already 
 
18 
 
 spread from the first cases a hospital is useless for its primary- 
 purpose as a means of isolation, and becomes merely an aid in 
 the treatment of patients, whether paying or non-paying. 
 
 Isolation hospitals should be free to all the inhabitants of the 
 district in which the hospital is situated. The district has paid 
 for it ; the district keeps it up, and is entitled to all the benefits 
 which it is capable of conferring. Since it is desirable to have all 
 the cases of infectious disease isolated in a hospital or other house 
 at once, and since there is no authority to compel patients in 
 ordinary circumstances to go to such places, every inducement' 
 should be made to prevail upon them to go. Under the Health 
 Act the only resemblance places of isolation bear to public hos- 
 pitals is the similarity of name, and this should be avoided, if 
 possible. Public hospitals usually exist for the benefit of the 
 sick poor who cannot afford treatment at home, and are, there- 
 fore, dependent on charitable individuals or the Government for 
 admission and treatment. Isolation hospitals, on the contrary, 
 are places provided and supported by the ratepayers of a district 
 for their own defence and treatment, and should be open for the 
 reception of everyone in the district who suffers from an infec- 
 tious disease and goes there at the sacrifice of so much liberty and 
 home comfort, and as a concession to the wishes of his neighbors. 
 When a man receives money under the terms of an accident in- 
 surance policy on which he has paid his premiums, we do not call 
 him a pauper any more than we regard him as a gambler. There 
 should not be the slightest semblance of poverty connected with 
 these hospitals. No fees whatever should be charged, however 
 small. 
 
 There is only one exception to this general principle of free 
 treatment, and the Act provides for it, viz., by section 145, which 
 says that expenses may J)e recovered from a patient. This clause, 
 which is copied in this connection from the English Public 
 Health Act, was inserted into that Act because in countries where 
 no such rule was in force the local boards were unable to recover 
 fees from well-to-do people who went to isolation hospitals and 
 demanded suites of rooms and superior attendance and food, 
 special nurses, and additional comforts. But the section is not 
 intended to apply to people going there in the ordinary course for 
 isolation purposes. 
 
 The English Local Government Board has stated the position 
 thus: — "While the means of isolation afforded by the hospital is 
 of considerable benefit to the individuals, such means should be 
 regarded as directed to the attainment of the larger benefit of the 
 protection of the general public health, and therefore it is, in the 
 Board's opinion, undesirable that admission should be subject to 
 any charges and conditions which, by operating restrictively, may 
 
19 
 
 tend to prevent the use of the hospital by the poorer portion of 
 the community, that is to say, by those who have the least 
 facilities for isolation and treatment at their own homes." 
 
 If a local board has no hospital of its own, then it may under 
 the Act make terms with the managers or superintendent of any 
 hospital, public or private, within its bounds, or outside of its 
 bounds, on such conditions as will ensure good maintenance, nurs- 
 ing, and medical attendance ; and the contract might be made at 
 so much p^r case or at so much per annum for all cases. The 
 distance at which a hospital is situated need not be a bar to the- 
 removal of patients from even far outlying districts, since the- 
 advantages of careful and continued nursing and the complete- 
 removal of an active source of infection from the district more- 
 than counterbalance the risk that arises from conveyance by rail,, 
 ship, or ambulance, now that such modes of conveyance can be- 
 made so convenient, comfortable, and rapid. 
 
 Disinfection. 
 Disinfection, in order to be thoroughly effective, should be done- 
 by trained officers of the local board. A certain amount of disin- 
 fection of bedding and of articles of clothing may be done at the 
 infected house ; but it is preferable to have these removed to be- 
 treated in a proper disinfector. Distance should be of compara- 
 tively little account if proper air-tight containers are used for- 
 conveying the articles ; and there is no reason why two or three 
 municipalities should not contract with almost all of the other- 
 local boards in the State to undertake all their disinfection. The 
 procedure introduced by the Central Board about 10 years ago- 
 has proved the most convenient, effective, and economical yet 
 tried. It consists in sending, when requested, a trained nurse- 
 inspector of the Board's to carry out disinfection of houses and 
 materials on the spot, the local board not being asked to defray 
 more than the actual expenses. 
 
 Penal Clauses Against Exposure. 
 
 These should be strictly enforced. The section is very compre- 
 hensive, and refers not only to persons who are actually suffering,, 
 but to those who, having suffered, have not sufficiently recovered 
 to prevent infection. Proceedings may be taken by a local board 
 of health under the Health Act, or by the police under the 
 Criminal Law Consolidation Act, as may best suit the circum- 
 stances. 
 
 Where these various provisions for dealing with preventable- 
 diseases have been carried out in the complete form here indicated 
 they have been the means of saving much time and money to- 
 the local boards, and also of preventing a great deal of unneces- 
 sary sickness within their districts. 
 
20 
 
 In order to deal in any way that migM be deemed necessary 
 with epidemics in this State or threatened epidemics, an Act was 
 passed in 1918 enabling the Governor, in case of an outbreak or 
 danger of an outbreak, to authorise the Central Board of Health 
 to stop all or any traffic and to limit and prevent the ingress, 
 egress, and regress of any person to or from any house or 
 premises, or to limit and prevent the carriage of any persons in 
 any vehicle for such time and in such manner as the Governor 
 may think necessary. 
 
 Since the days when things relating to human health were sup- 
 posed to concern human beings only as matters of prayer and 
 resignation, health administrators who have urged people io work 
 out their own safety have been charged with impiety, unbelief, or 
 materialism. Although such theological bias, as Herbert Spencer 
 called it, is disappearing under the influence of education and 
 saner beliefs, another sort of bias exists, which is all the more 
 ■detrimental to well-being on account of its assuming the garb of 
 scientific criticism. This bias sometimes shows itself, un- 
 consciously it may be, but it does show itself. An American 
 Health Commissioner, addressing public health officials, said: — 
 "We have to contend against the insincerity and the lack of 
 ■earnest co-operation of a certain class of physicians. It is 
 almost a daily experience in my department, and I am. sure that 
 all health officers are confronted with the same conditions, where 
 physicians will advise the families and patients along lines 
 directly antagonistic to the policies of the Health Department. 
 'They say that we are faddish and hobby riders, and that this, and 
 that, is not at all necessary, and assisting the family and patient 
 to evade, violate, and set aside, the rules and regulations of your 
 department, to the detriment of the public at large. ... I am 
 glad to say that we haven't many" doctors in our community that 
 ■do not co-operate with the Health Department, but there are some, 
 as there are in every community, and they do great harm to the 
 progress of your preventive work. ' ' 
 
 In a case where a patient or his friends may wish to do some- 
 thing pleasant or profitable to them, but inimical or risky to the 
 public health, the family physician has not much inducement to 
 say: "You mustn't," or "You shouldn't." It is not his interest 
 to do so. Strictly speaking, it is not his business. He is paid 
 by the individual for certain services which the State does not 
 undertake, at least not as yet ; and the health officer is paid by the 
 State for other services to the community which undoubtedly 
 may conflict with the interests of the patient and his physician. 
 Such conduct and the criticism that often accompanies it is not 
 new. One cannot help remembering the bitter personal abuse to 
 which Dr. Oliver "Wendell Holmes was subjected when he 
 
21 
 
 endeavored to save women fi-om puerperal infection ; the strong 
 theological opposition to Professor Simpson when he gave chloro- 
 form to women in childbirth ; and the professional ostracism of 
 Sir Benjamin "Ward Richardson when he challenged the practice 
 of the indiscriminate employment of alcohol in medicine. .The 
 attitude of some individuals and of some communities to the 
 public administration varies from active and loyal co-operation to 
 apathy or active hostility, including misrepresentation of scien- 
 tific facts and of administrative principles, appeals to the avarice 
 of individuals and to the passions of the community, and 
 assertions that are really excuses for neglect, ignorance, and 
 incompetence. This attitude will no doubt exist until public and 
 private interests cease to be antagonistic and become recognised 
 as being one. 
 
22 
 
 A Model Lesson in Health Administration. 
 
 I may refer to what has been a model lesson to the world in 
 sanitation. From all I can gather by personal observation and 
 inquiry, it seems to me that in Manila the most complete and 
 ■effective system of administration extant is to be found. The 
 Americans had to deal with a city of about 220,000 inhabitants, 
 ■comprising Filipinos, Chinese, Spanish, other Europeans,' and 
 Americans. The ignorance and apathy of the natives were ex- 
 treme ; the natural difficulties connected with practical sanitation 
 were unusually great; and the insanitary conditions for many 
 years were almost unspeakable. An administration by a central 
 board and local boards was tried, but proved unsatisfactory. 
 
 The following account, which was written in 1908, describes the 
 system of medical relief and control of infectious diseases as then 
 existing, and as suited to the special circumstances of the Philip- 
 pines at the time : — 
 
 There is a Bureau of Health, the only one of its kind under the 
 American Government. The director, as head, has very extensive 
 powers. He is personally responsible for all financial matters. 
 There are 11 different divisions, each having an administratjve 
 ■chief. An assistant director is head of the inspection division. 
 The abolition of a central board has recently been followed by the 
 abolition of, provincial boards and the establishing, of district 
 health officers appointed by the Governor-General. The district 
 health officer is responsible to the Director of Health for the 
 general sanitary condition of his district, and he has control over 
 municipal boards of health. This control is by no means nominal ; 
 if the president of a municipality should neglect or refuse to per- 
 form his duty, the district health officer will take proceedings 
 against him, and he may be subjected to a fine or imprisonment, 
 or both, and be removed from his office. It is recognised that 
 organisation and system mean everything in health work. The 
 director says that experience has amply justified the change from 
 the board to the bureau system. The saving of time alone, to say 
 nothing of money and annoyance, has in itself fully warranted 
 the reorganisation so far as the Bureau of Health is concerned. 
 
 The city of Manila is divided into five health districts, each 
 being under a district health officer, who acts as coroner's 
 physician, renders help in emergency cases, and is surgeon to the 
 police and firemen. He supervises inspections of food and water, 
 and advises on all sanitary matters. Each station has its staff of 
 American and native sanitary inspectors, disinfectors, and sani- 
 tary police ; and has its dispensary, where free medical advice is 
 
23 
 
 given by one or more municipal physicians, and where prescrip- 
 tions of other physicians are, dispensed free of charge when 
 marked "for the poor." There is a municipal midwife for 
 attending the poor. Forty native police of the. City Police 
 Department are engaged under the direction of the Bureau of 
 Health as special sanitary inspectors. 
 
 Each station is responsible for the health and sanitary condi- 
 tions of the district in w^hich it is located. "This involves the 
 sanitary inspection of buildings, schools, bottling works, tiendas, 
 hotels, restaurants, yards, alleys, latrines, vaults, stables, sewers, 
 and similar places and conveniences, and the preparation of orders 
 for repair, or, in the case of sewers, the notification of the proper 
 authorities." The form of order served is simple, and runs 
 thus : — 
 
 ' ' The occupant or owner of property No. , Street, 
 
 is hereby ordered to Within days from date 
 
 •of notice. 
 
 ' ' Chief Sanitary Inspector. ' ' 
 
 To an Australian, perhaps the most outstanding feature in 
 this administration is the system of house inspection. In every 
 house there is posted up in a conspicuous place a "Sanitary 
 IReport" card, lO^in. by 6in. in size. An inspector visits the 
 house two or three times a week, and enters on the card the date 
 •and hour of his visit, the condition o£ the premises, and his name. 
 The instructions on the card, printed in English on one side and 
 in Spanish on the other, are as follows: — (1) The attention of 
 the owners of this house is called to their duty of keeping the same 
 in a clean and sanitary condition, especially the drains, closets, 
 stables, and the interior of the same. (2) All refuse and sweep- 
 ings should be gathered in boxes or baskets and dumped into the 
 refuse carts which pass daily to remove them. (3) All repairs 
 of the house should be promptly attended to and the same painted 
 ■or whitewashed. (4) The Bureau of Health must be notified of 
 any case of bubonic plague, smallpox, cholera, or any other con- 
 tagious disease occurring in this house. (5) Any person who fails 
 to carry out these instructions will be arrested and brought be- 
 fore the Courts. Note. — Please notify the Bureau of Health of 
 any discourtesy on the part of the sanitary inspectors. 
 
 Every sanitary inspector is required to send in a daily report 
 to the Bureau of Health, giving details of houses inspected and 
 reinspected; of houses ordered t6 be cleaned, painted, or white- 
 "washed, and the number so cleaned ; of the number of cesspools, 
 vaults, yards, &c., ordered to be cleaned ; of rats caught, poisoned, 
 or purchased ; and of the number of persons sick reported to the 
 municipal physician. 
 
24 
 
 This system of frequent inspection of all houses may seem 
 very drastic; but one must remember the circumstances of the 
 inhabitants of a city whose streets and tenements are in many 
 eases built after the pattern of Spanish towns of 300 years ago. 
 Many of the conditions were unspeakable. We can hardly 
 imagine "privy vaults" two stories high in houses, yielding 
 8,500galls. of human excreta at a single cleaning, as the Ameri- 
 cans found in some instances when they began operations. 
 
 1. Discovery. — Private medical practitioners attending cases of 
 infectious disease are required to report verbally at the Health 
 Station. The particulars are taken down by the municipal in- 
 spector, who sees the case and fills in a regulation form. The 
 definition of infectious disease includes cholera, smallpox, chicken- 
 pox, plague, diphtheria, including membranous croup, ship or 
 typhus fever, typhoid, spotted, relapsing, yellow, and scarlet 
 fevers, measles, glanders, leprosy, anthrax, and any other diseases 
 of an infectious, contagious, or pestilential nature, or any disease 
 declared to be dangerous to the public health. 
 
 2. Isolation. — Persons suffering from infectious diseases are re- 
 moved by ambulance to hospital compulsorily, where a hospital 
 exists. The activity of the officers may be judged from the fact 
 that orders have had to be made to prevent furious driving by 
 ambulance conductors. 
 
 In Manila all eases of infectious diseases are isolated and 
 treated at a central hospital within the city bounds. This con- 
 sists of a series of wooden wards, each one story in height, and 
 standing singly, but connected by a short covered way with a 
 common corridor. Here also -cases of smallpox and cholera are 
 received. 
 
 This method of hospital administration has much to commend 
 it. Centralising saves expense, time, attendants, nurses, 
 physicians, clerical work, and ambulances; and it is effective. 
 
 It is gratifying to find a people who give practical effect to 
 their scientific belief in modern modes of disinfection. Too often 
 in many communities one finds people in authority, or whose duty 
 it is to advise, expressing themselves as ardent sanitarians and 
 firm believers in the efficacy of up-to-date disinfectants and 
 methods of preventing infection, but who, nevertheless, at the 
 first suspicion of plague or smallpox or other similar disease, cast 
 aside all their professed belief in medical isolation, and go panic- 
 mongering for a geographical isolation that means expense and 
 inconvenience without being correspondingly efficient, or efficient 
 at all. 
 
25 
 
 All this public health machinery is augmented by a scheme of 
 scientific investigation on a scale that we would probably charac- 
 terise as lavish, and by a system of education and instruction in 
 schools and other educational institutions. Probably nowhere in 
 the world is there to be seen such a combination of commercial 
 interests and scientific investigation as in Manila. This operates 
 for the mutual benefit of science and commerce, and contributes 
 to the well-being of the whole community. The Americans realise 
 that the greatest national asset is not wealth, but health ; and they 
 are not slow to declare that their national prosperity would be 
 more securely established were there more health and less 
 immediate pursuit of wealth. 
 
26 
 
 Present Position in South Australia. 
 
 A system of notification and isolation on similar lines of 
 immediate Government control is not possible in this State under 
 the existing laws. At present the powers are vested in the first 
 instance in local boards of health. As yet no local board has an 
 officer of health devoting his whole time to public health work. 
 Not many have a trained sanitary inspector, although recently 
 there has been a great improvement in this respect. In country 
 places the maintenance of numerous special hospitals is out of 
 the question. Even in the case of municipalities, no single city or 
 town has as yet built a hospital or maintained an administrative 
 staff to be employed solely in health work, after the models fol- 
 lowed in European and American cities. 
 
 The position in Australia is that the bulk of the population is 
 massed in and around the capital cities. In South Australia, 
 which is perhaps the extreme instance of this phenomenal metro- 
 politan concentration, over 50 per cent, of the total population 
 is so located. Of recent years a good deal has been done with a 
 view to general isolation and disinfection under the Health Act. 
 The majority of local boards in the metropolitan area have made 
 arrangements with the Adelaide Hospital to receive and isolate 
 and treat their cases of infectious disease under legal agreements. 
 
 One difficulty connected with the present permissive powers 
 of local boards is that, while one board may exercise its functions 
 actively and intelligently, its efforts for the safety of its own com- 
 munity are frustrated or nullified by the apathy or the unwisely- 
 directed efforts, or spasmodic and intermittent attempts, on the 
 part of neighboring local boards. Further, the conflicting powers 
 and duties of various departments enter as disturbing elements in. 
 administration. A school building, for example, is under the 
 Education Department, the Department of Public Works, and 
 the local board of health. All these things, plus cumbersome and 
 possibly costly legal machinery, have to be kept in mind in con- 
 nection with the efforts made to introduce a complete, uniform, 
 economical, and effective system of controlling communicable 
 diseases in this State. 
 
27 
 
 Control of Various Communicable Diseases. 
 
 The following remarks are limited almost entirely to the sub- 
 ject of preventing the occurrence and' limiting the spread of 
 certain diseases. There is little or no reference in them to 
 medical treatment. There are no scientific speculations nor any 
 useless directions about appliances or means that are not available 
 here. In dealing with these subjects I have been careful to sift 
 all obtainable facts and to draw logical conclusions. I have tried 
 to render local observation fruitful by comparative study. When 
 writing these pages I have kept in view the special requirements 
 of this State. I have endeavored to make the observations useful 
 to school teachers, parents, and householders ; and I am not with- 
 out hope that they may prove of service as a guide to local boards 
 of health when they exercise well-directed sanitary activity. If 
 our cities and State could possibly be sanified by waves of talk 
 they would have been disease-proof long ago. 
 
 "When considering and describing some of these diseases I 
 vividly recall circumstances in the home country in which scores 
 and hundreds of children died from scarlet fever and measles in 
 the midst of insanitary surroundings and active neglect, if one 
 may use such an expression, by the local authorities, who deter- 
 minedly resisted all attempts at isolation, refused to adopt the 
 compulsory notification of diseases because of the expense it 
 would entail in paying the medical fees for it, and shut their eyes 
 to the spreading epidemics, or denied their presence until the 
 death rate had become appalling. Then, by well-directed public 
 and individual effort there came a hygienic upheaval, and in four 
 or five years' time the community was in the van of public health 
 reform and effective municipal administration. 
 
 The following table, which shows the number of deaths in the 
 various States of the Commonwealth from certain preventable 
 diseases during the 37 years ending 1917, will give some idea of 
 the enormous number of lives that might have been saved by well- 
 directed efforts for prevention : — 
 
 Commonwealth — Deaths for Thirty-seven Years ending 1917. 
 
 btate. 
 
 Small- 
 pox 
 
 Measles. 
 
 Scarlet 
 FeTev. 
 
 Diph- 
 theria. 
 
 WhoopinK 
 Cough. 
 
 Typhoid 
 Fever. 
 
 Tubercu- 
 losis. 
 
 Total. 
 
 New South Wales 
 
 Queensland 
 
 South Australia. 
 
 Tasmania 
 
 Victoria 
 
 Western Australia 
 
 71 
 1 
 2 
 30 
 12 
 13 
 
 3,364 
 1,138 
 1,006 
 
 192 
 2,752 
 
 393 
 
 2,269 
 347 
 363 
 142 
 
 1,076 
 29 
 
 8,049 
 2.669 
 3,214 
 
 836 
 7,536 
 
 918 
 
 6,441 
 2,153 
 1,680 
 
 619 
 4,644 
 
 618 
 
 12,106 
 5,508 
 2,863 
 1,392 
 
 11,112 
 3,499 
 
 39,091 
 15,276 
 11,771 
 
 4,163 
 48,444 
 
 4,476 
 
 71,391 
 27,082 
 20,879 
 
 7,373 
 76,575 
 
 9,945 
 
 Totals 
 
 129 
 
 8,845 
 
 4,216 
 
 23,213 
 
 16,157 
 
 36,471 
 
 123,284 
 
 212,316 
 
28 
 
 According to a computation, on a basis accepted as fairly accu- 
 rate, this number of deaths represents a money loss of about 
 £75,000,000 caused by deaths from a certain number of the com- 
 municable and controllable diseases. If one estimates the loss 
 due during that period to general sickness among the earning 
 population of Australia, on a basis generally assumed as approxi- 
 mately accurate, it would amount to about £74,000,000, i.e., a total 
 of about £4,000,000 a year from deaths and general sickness alone. 
 In addition to this, one has to take into account in the case of the 
 damaged survivors that their tools, their health, their stock in 
 trade, their working power, or whatever we may regard as their 
 capital, is diminished, their entailed estate is depreciated, their 
 handicap is increased, temporarily or permanently. One might 
 imagine that this subject would be inquired into and found 
 worthy of being treated even from the point of view of mere 
 economies apart from any questions of charity, philanthropy, 
 Christianity, or religion of any sort, science, socialism, or 
 humanity. 
 
 The total number of deaths in Australia from communicable 
 diseases during 37 years ending 1917 — not so very much more 
 than a single generation — was 212.316. These figures include the 
 dead only, not the damaged. The deaths were preventable. The 
 diseases are controllable and eradicable. During that period the 
 deaths from tuberculosis alone numbered 123,284, the number of 
 males and females being not greatly unequal — about 17 to 13. All 
 things considered, it may be agreed that a human pair, a man and 
 a woman, are of more value to the State and the race than two 
 men. Think of 123,284 sons and daughters dead from tubercu- 
 losis alone — a preventable disease. If an enemy had done this to 
 us! Since we did it ourselves we say, "God's will be done" — if 
 we say anything at all. 
 
 The deaths from measles and whooping-cough numbered 25,002, 
 and were all the more deplorable since these were of young people 
 who were presumably of more value to the State than an equal 
 number of dged people would have been. For, be it noted, those 
 who escaped death or injury were not the fittest ; in many cases 
 they were not even fit ; they were merely the non-exposed. The 
 action of these diseases has no more beneficially selective in- 
 fiuence than war has on communities, on nations, or on the race. 
 About 40 years ago Pasteur said: — "It is within man's power 
 to wipe infectious diseases off the earth. ' ' 
 
 A recent writer says that these diseases, if they still exist 
 among civilised people, do so with the consent of the people in 
 the face of a full knowledge of the manner of their prevention. 
 
 Rosenau says : — ' ' It is plain that man is the great source and 
 reservoir of human infections. Man is man's greatest foe in this 
 regard. The fact that most of the communicable diseases must 
 be fought in the light of an infection spread from man to man 
 
29 
 
 is one of the most important advances im preventive medicine. 
 . . The knowledge that most infections are spread rather 
 directly from man to man brings in all the forces of sociology to 
 that of preventive medicine. The task of preventive medicine is 
 thereby rendered much more difficult from the fact that most in- 
 fections depend upon the control of man himself. We ruthlessly 
 wage war against insects or against infected food or water. In 
 other words, we can arbitrarily control our environment to a very 
 great extent, but the control of man himself requires the consent 
 of the governed. . . . The fact that man is the chief source 
 and reservoir of most of his own infections adds greatly to the 
 scope and difficulties of public health work and often makes the 
 prevention of disease depend upon social changes. In this sense 
 preventive medicine is the true sociology. ' ' 
 
 When epidemics of diphtheria, typhoid fever, or scarlet fever 
 occurred, people thought a general clean-up of insanitary condi- 
 tions was the one necessity and they salved their consciences 
 accordingly. Now it is known that general sanitation is a secon- 
 dary element in the spread or prevention of such diseases. There 
 is something else to be attended to, something very different, a 
 very personal element. For the prevention of infection in many 
 diseases is literally in the hands of the public themselves. Money 
 grants, medical officers, inspectors, isolation hospitals, visiting 
 nurses, quarantine, disinfection, do not amount to much so long 
 as people cannot keep their fingers from their mouths and noses. 
 If nothing touched or passed the nose or lips except what we 
 knew to be clean, it is safe to say that epidemics would be un- 
 known. 
 
 Every true citizen is, or should be every day personally con- 
 cerned Avith this subject from the point of view of his own well- 
 being and of State efficiency. If 6,000 lives are lost annually in 
 Australia through apathy, stupidity, ignorance or avarice, or all 
 combined, and that, too, with scarcely a passing thought of State 
 or individual responsibility, one wonders what catastrophe will 
 be required to awaken the people of the Commonwealth to the 
 gravity of the situation. 
 
30 
 WHOOPING COUGH. 
 
 Whooping cough in this State, judged from the death rate 
 alone, is a dangerous disease. And it is all the more dangerous on 
 account of the indifference with which people regard it. During 
 the past 30 years 1,248 persons have died from this painful and 
 distressing malady — more them six times as many as have died 
 from scarlet fever within the same period. In the 10 years ending 
 1918, during which the disease has been notifiable, 9,064 cases 
 have been reported, with a mortality of 289 — over 3 per cent. 
 The number of deaths from this disease alone has been more than 
 30 per cent, greater than from measles and scarlet fever combined 
 for the same period. During the 20 years before notification the 
 deaths average 47.9 yearly ; while during the 10 years in which 
 notification has been in force they averaged 28.9; the increase of 
 population during the period being about 25 per cent. 
 
 Investigations, founded upon observations made by teachers 
 in the public schools here, show that the disease in this State has 
 very much the same characters as in other countries. It is said 
 that in Great Britain whooping cough and measles kill more chil- 
 dren than all the other zymotic diseases put together, and not 
 uncommonly one is the sequel of the other. "Whooping cough 
 occurs very frequently during convalescence from measles. 
 There is a view that epidemics of whooping cough and measles 
 alternate with each other, and that the diseases are therefore 
 mutually exclusive. Observations in this State do not support 
 this view. 
 
 The disease is very infectious from the very first appearance 
 of symptoms of catarrh, cough, or sneezing ; and this may be one 
 or more weeks before the characteristic cough begins. It is this 
 fact that constitutes the peculiar difficulty in the control of this 
 disease and measles. It is a difficulty that requires to be met by 
 special and definite measures of administration, not a difficulty 
 that makes control impossible. In the later stages of the disease 
 the infectiveness diminishes. The infective material, which 
 exists in the sputum, and is discharged from the mouth and nose, 
 is passed on to other persons by direct contact or in droplets of 
 moisture sprayed off, even in the open air at short range, in 
 coughing, sneezing, laughing, or talking. These droplets carry it 
 into the air passages of other people. The disease may also be 
 communicated by means of roller-towels, handkerchiefs, drinking 
 cups and other articles used by children in common ; and it may 
 possibly be conveyed through the medium of a third person. It is 
 communicable to oertain of the domestic animals such as dogs and 
 cats, and it may be acquired from them. 
 
31 
 
 There is no other communicable disease to which children dur- 
 ing the earliest years of life are so susceptible, as they are to this. 
 There appears to be no immunity from the disease. Almost every 
 one exposed acquires it. The most common age for children to be 
 attacked is from 2 to 5 years, but younger children and adults 
 may also suffer. It is most fatal in infants under 1 year, but in 
 any child under 5 years of age it is serious. Girls appear to be 
 more susceptible than boys, and to suffer more. The proportion 
 of cases among girls and boys is about almost five to four. Feeble 
 children are more likely to be attacked than the strong, and they 
 suffer more severely from the disease itself and from complica- 
 tions. Nervous and excitable children have more severe 
 paroxysms than those of robust constitution. A second attack of 
 the disease is very rare. "The spread of whooping cough is 
 limited to no definite time, no season, no weather conditions ; yet 
 the severity of the disease may change with these circumstances. ' ' 
 Epidemics are rarest in summer. 
 
 Infection. 
 
 Only a very short exposure to the infective matter or in the 
 neighborhood of a sick person is necessary. Overcrowding in 
 rooms, houses, or streets, helps the spread of an epidemic. There 
 seems to be no possibility of predicting when or where the disease 
 will be fatal, severe, mild, complicated, or simple. But it does 
 appear possible to escape the disease by avoiding contact and 
 personal intercourse with patients and infected materials. 
 
 Incubation. 
 
 After exposure to infection there is a period of incubation of 
 from two or three days to two or three weeks, but usually about a 
 fortnight, during which nothing noticeable occurs. 
 
 Invasion. 
 
 The stage of invasion follows, during which the child is sicken- 
 ing for the disease. The symptoms of an ordinary cold appear — 
 slight rigors or chills, slight redness and watering of the eyes, 
 running from the nose, sneezing, a feeling of tightness in the 
 chest, hoarseness, more or less severe cough, not to be distin- 
 guished from the ordinary cough of bronchitis, unless it be more 
 sonorous and more acute. The expectoration is limited and 
 scanty. 
 
 Fever is sometimes present for a day or more, and it may 
 assume the intermittent or remittent type. There may be some 
 constitutional disturbance, such as heaviness, depression of 
 spirits, restlessness, moroseness, and loss of appetite. During this 
 
32 
 
 time the disease both in children and in adults resembles an ordi- 
 nary catarrh, only the cough is more frequent and obstinate, and 
 the patient is more troubled with a feeling of tickling in the 
 throat and windpipe. 
 
 This stage usually lasts from five to 12 days, but may extend 
 to a month, or longer. 
 
 Stage oe Spasm or Convulsive Cough. 
 
 The fever, if it has been present, now decreases or ceases. The 
 cough begins to be more marked and characteristic. It occurs in 
 paroxysms that increase in length and severity. The child 
 appears frightened or anxious, and may cry. He remains 
 motionless and holds his breath. Repeated violent expirations, 
 perhaps from six to 20, are rapidly made, with the body bent for- 
 ward and the hands holding on to the knees or to something 
 firm to steady the body during the convulsive movements ; and so 
 rapidly are the expirations repeated that the child's face and 
 neck are swollen and livid, the veins stand out like cords, the 
 eyes protrude and are suffused, and saliva flows from the mouth. 
 The patient appears in danger of suffocation from stoppage of the 
 breath ; then the convulsive movements of the muscles of breath- 
 ing abate, and a deep, loud, long-drawn crowing or whistling in- 
 spiration or "whoop" occurs. This may be repeated three or 
 four times consecutively during each paroxysm* and the tem- 
 porary attack ends with the discharge of mucus, either scanty or 
 profuse, from the lungs, or by vomiting, or by both. Sometimes 
 bleeding occurs from the ears, mouth, nose, and lungs, and 
 the urine or faeces may be discharged. Bleeding may occur in 
 the "white of the eye." The skin is bathed with perspiration, is 
 cool, pale, and sensitive to cold. 
 
 An attack usually lasts from two to two and a half minutes. 
 Then the child quickly recovers, may become cheerful, wishes to 
 eat, and goes about playing as usual, if the attack be mild; if 
 severe, it may be followed by drowsiness or prostration, or pains 
 in the muscles of the chest, abdomen, and limbs. Convulsions 
 may occur. 
 
 Violent efforts, running, much speaking, mental excitement, 
 will bring on an attack or lengthen it, or make it more severe. 
 An attack in one patient will start off an attack in another. 
 Attacks are often more frequent and more severe during the 
 night and towards morning, but after every attack the child falls 
 asleep again almost immediately. This may occur only during 
 the night. Sometimes the paroxysms consist of sneezes instead 
 of coughs. It is doubtful if death ever occurs during a paroxysm. 
 
 The number of paroxysms during the day varies with the 
 severity of the disease. They may be few ; usually they average 
 
about 20 in the 24 hours, but they may amount to a hundred 
 within that time. If the number exceeds 40 the condition is very 
 serious ; if over 60 the patient will almost certainly die of some 
 complication. The violence of the paroxysm decreases as the 
 cough becomes looser. Some persons may have the disease, and 
 may infect others, without suffering from these paroxysms. 
 
 This stage usually lasts from three to four weeks, but it may 
 be longer or shorter. 
 
 Stage of Decline. 
 
 The stage of decline follows. The paroxysms are fewer and 
 less severe, the cough loses its characteristic features, and within 
 about six weeks usually disappears, and the child recovers its 
 normal health. 
 
 The cough, however, may return on account of exposure to cold, 
 or from other causes, and may assume the characteristic whoop ; 
 but during this recurrence the disease is usually not actively in- 
 fective ; the whoop is very much a habit, and may continue for 
 a long time. A complete change of air usually helps or hastens 
 recovery. If the stage of invasion is short,"" the convulsive stage 
 wiU usually also be short; the sooner the whoop appears the 
 sooner will it disappear. 
 
 Complications. 
 
 These are not uncommon. The severity of paroxysms and the 
 vomiting may interfere with the nutrition of the chid, and cause 
 exhaustion, prostration, and loss of flesh. Other diseases may 
 follow, such as bronchitis, emphysema, pneumonia, marasmus, 
 and cerebral haemorrhsige, and deaths are certified as being due 
 to these and not to the original cause, whooping cough. Other 
 and non-fatal troubles may follow, such as weakness of the heart, 
 disturbance of the nervous system, weak intellect, defective 
 memory, defects of sight, dea&ess, asthma, hernia, permanent 
 deformity of the chest. Latent tuberculosis is often lighted up. 
 
 Isolation. 
 
 Every effort should be made to isolate every case of whooping 
 cough, so that other children may not acquire the disease. Every 
 year that a child passes without taJiing the disease adds to the 
 probability of avoiding it, and to the likelihood of recovery should 
 it unfortunately contract it. If possible, isolate the child whom 
 you wish to protect from the disease. 
 
 It is unfortunate that hospital isolation is too often out of the 
 question in cases where the patients require it most, viz., in the 
 case of very young children, since provision must be made for the 
 mothers to attend them. 
 
34 
 
 At home the patient should be strictly separated from others so« 
 long as the paroxysms last, and for a few days after they havfr 
 ceased. If the cough should recur after having once ceased, it is. 
 not necessaory to isolate the patient again. 
 
 The prevention of contact with other children is the object 
 aimed at ; seclusion or isolation in the house is a means, but not 
 the only means of attaining this object. In some places, even 
 infected children, while' in a condition to spread infection, are- 
 allowed to go about if they bear on the breast or arm some dis- 
 tinctive notice that they are suffering from the disease, and are- 
 to avoid close contact with others. If this could be carried out 
 under proper supervision it might prove much more effective- 
 than the "isolation" that is usually attempted, or supposed to- 
 be attempted, at home. "Isolation of disease" is not a matter 
 of mere location of a patient. 
 
 In school a watch should be kept on all children for symptoms, 
 of cold, and everyone showing symptoms should be isolated at 
 home. Any child with a cough accompanied by vomiting, or with 
 a long-continued cough occurring in paroxysms, should be ex- 
 cluded from school. 
 
 Disinfection. 
 
 Everything used by the patient — ^handkerchief, clothes, towels,, 
 bedding, dishes, spoons, toys, furniture — should be disinfected 
 before being removed from the room where the patient is, and 
 aU remnants of food should be destroyed by burning. The- 
 material coughed up should be received in gauze, or handker- 
 chiefs or similar cloths, which should be disinfected or burned. 
 After the patient has recovered it is well to disinfect the room, 
 although free ventilation, with exposure of infected articles to- 
 sunlight and fresh air, will generally be sufficient. 
 
 Return to School. 
 
 As a rule, children will be able to return to school in from 
 eight to 10 weeks from the beginning of the whooping stage ; or 
 two weeks after the characteristic spasmodic cough has quite: 
 ceased. , 
 
 Quarantine op the Exposed. 
 
 This should extend to 21 days. 
 
MEASLES. 
 
 Measles is by far the most common of all the eruptive diseases 
 of school life, and is therefore a -most important disease from 
 the State point of view. It demands many lives, and entails much 
 suffering as well as great actual loss. In this State during the 
 past 30 years 762 deaths have occurred from it — nearly four 
 times as many as from scarlet fever. In the 10 years ending 
 1918, during which the disease has been notifiable, 22,989 eases 
 were reported, with a mortality of 121 — a little over 0.5 per cent. 
 During the 20 years before notification the deaths averaged 30.2 
 yearly ; while during the 10 years in which notification has been 
 in force they averaged 10.1, the increase of population during the 
 period being about 25 per cent. It is difficult to §ay how many 
 more deaths due to the disease appear in the statistics under the 
 headings of bronchitis, pneumonia, or tuberculosis. Extensive 
 statistics of various countries show that the fatal cases amount 
 to from 1 to 6 per cent, or more. Overcrowding in houses has a 
 very marked influence on the mortality. In one city in Great 
 Britain it was found that the case-mortality was eight times 
 higher in one-roomed tenements than in those of four or more 
 rooms. It is true that attacks are often mild ; but it is also true 
 that very grave complications may occur during their course; 
 that uncomplicated cases may be severe, or even malignant ; and 
 that, even if a patient recovers, serious after-effects may remain. 
 
 Epidemics occur at intervals, apparently when there is a suf- 
 ficient number of susceptible persons to be affected. Overcrowd- 
 ing in rooms, houses, or streets, in addition to increasing the case- 
 mortality, also helps the spread of an epidemic. In one city in 
 Scotland it was found that the attack-rate of measles among in- 
 fants and young children was ten times higher in families living 
 in one-room tenements than in families living in tenements of 
 four or more rooms. Schools are fertile breeding-grounds for 
 the disease. Judging from the number of deaths recorded, it 
 would seem that during 20 years epidemics in this State occurred 
 about once every five years ; but that for the past 10 years, the 
 disease has been almost endemic. 
 
 During some of these epidemics it was not uncommon for 
 persons to suffer from a second and even a third attack. In 1901 
 returned soldiers from South Africa, who brought the disease 
 with them, suffered very severely. The rash on the face at 
 first looked very like the rash of smallpox, and the patients 
 almost invariably suffered from temporary loss of voice when 
 they began to recover. 
 
36 
 
 Much might be done to save children from death or from the 
 permanent evil effects of this disease if parents' only knew. 
 Speaking nowise too strongly of the criminal procedure of ex- 
 posing children purposely to the so-called "harmless" diseases, 
 an American writer says, regarding measles: — "Experience 
 shows that the public needs instruction, and that it complies with 
 reasonable restrictions as soon as it learns the necessity. Laymen 
 are not fools, and will not intentionally kill their own offspring, 
 nor will they deliberately inurder other children. ' ' 
 
 The State Board of Health of Pennsylvania, many years ago, 
 said: "In view of the mortality and disability, with which this 
 disease is justly chargeable, and of the fact that preventive 
 measures have been so generally adopted in the case of these other 
 diseases which do so much less harm, can we longer afford to 
 regard with indifference this serious menace to the life and health 
 of the rising generation? 'Measles and its death toll' in this 
 country, as abroad, may well be said to have become a question 
 of national importance." 
 
 Efforts to check epidemics of measles proved disappointing, 
 possibly because, as is now believed, the requirements in force 
 failed to steer between the Seilla of excess and the Charybdis of 
 inadequacy. The fact that infection of a number of children 
 may occur in a school from one child who, presents the symptoms 
 of only a slight cold shows how difficult it is to control the spread 
 of this disease, as compared with some others. Further, a school, 
 as a rule, was closed on account of measles only when the atten- 
 dance had dwindled so that it became hardly worth while to keep 
 it open. If an epidemic of measles is to be stamped out a school- 
 room should be closed as soon as the first case has been found 
 among the pupils, and every suspicious case should be isolated. 
 It is easier to check the spread of smallpox than of measles ; and 
 yet our attempts to prevent the large loss of life from measles that 
 occurs every few years cannot compare in activity with our 
 endeavors to prevent plague or smallpox — diseases which are 
 hardly ever likely in this State to cause so many deaths or so much 
 permanent misery as measles is. If we were reasonable, logical, 
 patriotic, or humane, we should make even greater efforts to check 
 an outbreak of measles than one of smallpox. 
 
 That measles can be checked by prompt measures has been 
 shown practically by Dr. McVail, in .connection with an outbreak 
 in the village of Larbert, in Scotland. He gives the following 
 account^ — -"In the somewhat straggling and scattered town of 
 about 10,000 inhabitants there are two schools — one with about 
 700 pupils and the other with about 1,000. Measles had pre- 
 vailed amongst the children attending Larbert village school, and 
 had practically spent itself. The distance between the schools is 
 
37 
 
 about a mile, and the population along the connecting road is not 
 at all dense. Bach school, therefore, has a pretty well-defined 
 area from which it draws its pupils. And, as it happened, the 
 disease did not attack any school children living in the east area 
 until it had nearly died out in the west. Then a single case 
 occurred in the infant department of the Central school, and 
 the child attended school for two or three days whilst in the 
 acutely infectious catarrhal stage. When the disease was recog- 
 nised the child was kept at home. Now, it happened that, 
 through the teacher and the local sanitary inspector, this case 
 came to my knowledge within three or four days of the appear- 
 ance of the rash. I immediately visited the school, and after 
 explaining the rationale of the proposed procedure to the teacher 
 and to the convener of the school committee, I closed the infant 
 department for a fortnight. During that fortnight about a dozen 
 chiljiren of this department developed measles. They were the 
 first crop from the seed planted in the school. Before the depart- 
 ment was reopened, all the households sending children to it were 
 visited, and a list made of those who had by this time been at- 
 tacked. The children of these houses were excluded from atten- 
 dance, and the result was that the epidemic was nipped in the 
 bud. There was no second crop in the school. Three or four 
 children were attacked who lived near those of the first crop and 
 played with them during their catarrhal stage; but the propin- 
 quity of the other cases, and the publicity resulting from school 
 closure and the visitation of infected houses, had warned the 
 parents to be on the lookout, and these three or four children were 
 kept at home from the beginning of the catarrhal stage. ' ' 
 
 This shows how the disease, universally recognised as the widest 
 spreading and most uncontrollable of all infectious diseases, can 
 be kept within bounds by an officer of health who knows his work 
 and does his duty promptly, and has faith in modern methods of 
 isolation. 
 
 An illustration of the possibility of checking the spread of 
 measles was furnished in 1875, in connection with an epidemic in 
 the Faroe Islands. In this connection the historian says: — 
 ' ' Quarantine is beyond a doubt the most reliable measure for pre- 
 venting the spread of measles. Even in case of a house in an 
 infected villeige, the family found it possible to keep out the 
 disease by avoiding any contact with the other villagers, and it 
 was still "less difficult to exclude contagion from a whole village 
 by isolating it. About 1,500 of the inhabitants, who tried this 
 plan on their own initiative, remained free from infection. Dur- 
 ing the epidemic the authorities succeeded, with the assistance of 
 the people, in maintaining a quarantine which entirely sufficed to 
 protect a considerable number of the islands from the disease. ' ' 
 
38 
 
 Newman says: — "The prevention and control of measles, like 
 that of whooping-cough and tuberculosis, is largely in the hands 
 of the public themselves." The failures to stamp out measles 
 in Great Britain have been ascribed to several specified condi- 
 tions, some of which, however, do not exist in this State; and 
 from the way in which local outbreaks have from time to time 
 been controlled here, and also from experience gained from sea- 
 quarantine on a large scale, we have reasonable assurance that 
 the disease can be kept in check. 
 
 Colonel Munson, Divisional Surgeon in the United States 
 Army, has given an account of the most extensive, detailed, and 
 scientific epidemiological study yet made of an outbreak of 
 measles, including an account of the successful control of the 
 disease by appropriate measures. In January, 1917, there were 
 23 regiments, numbering in all 13,773 troops, at Wilson Camp, 
 San Antonio, Texas, when an outbreak of measles occurred. , In 
 two of the regiments, totalling 2,411 personnel, the disease be- 
 came epidemic through neglect, inertia, and disobedience of 
 orders. There never was open opposition to sanitary measiires; 
 some interest in them was manifested; and there was a steady 
 succession of excuses as to why certain things were not done, with 
 promises of immediate improvement, which were not fulfilled. 
 The officers were pleasant gentlemen, whose highly limited mili- 
 tary experience had not given them the faculty of maintaining 
 sanitary discipline and enforcing their own orders thereon. They 
 were not organizers, and could not see that an order issued was 
 not necessarily an order carried out. 
 
 In 21 of the 23 regiments the outbreak was absolutely controlled 
 by the observance of simple preventive measures. Colonel 
 Munson states that the studj"^ of this outbreak has resulted in so 
 much new information about the spread and control of measles 
 that outbreaks need no longer be apprehended, and the death 
 rate from this cause may be reduced to a practically negligible 
 factor. He says. — "The prevention and control of measles here- 
 tofore has been attempted by measures of which the purpose was 
 usually only partly understood, and which were incomplete in 
 application. Consequently the results were unsatisfactory. 
 Measles, once started, tended to persist either until all the sus- 
 ceptible material had been attacked and immunised or new 
 seasonable environment created conditions unfavorable to the de- 
 velopment and spread of the measles virus. In other words, 
 measles tended to continue until brought to an end by factors of 
 self limitation. While with precise measures of prophylaxis we 
 expected to bring smallpox, malaria, and some other diseases 
 under absolute control, the same expectation was not entertained 
 with respect to measles. 
 
39 
 
 "But the writer believes that, as a result of the present epidemic 
 and its study, so much light has been shed on 'the epidemic causa- 
 tion and development of measles as to make its control, except as 
 to scattered cases in individuals, a matter of almost absolute cer- 
 tainty. He would simply apply and enforce the preventive 
 measures outlined for this camp, carried out in the 21 organisa- 
 tions which escaped epidemics of this disease, and which were 
 ignored or largely nullified in the two organisations that became 
 generally infected. He believes not only that measles epidemics 
 are preventable, but that hereafter they should be prevented. He 
 believes that they can be quite as well controlled in recruit depots 
 and barracks as in the field, provided that suitable ventilating 
 and other facilities are provided." 
 
 After setting forth "'Points to Observe in Measles Prevention 
 and Control," Colonel Munson continues: — "Measles is a 
 thoroughly preventable and controllable disease. A few scat- 
 tered cases will occur, and in the absence of definite knowledge 
 as to the causative agent, are necessary to making the diagnosis 
 of the presence of the infection. But if the foregoing rules, 
 based on the experience in this camp, are carried out, the writer 
 does not hesitate to state his firm conviction that measles need 
 not occur in epidemic form. He considers the preventive 
 measures which the above rules embody as effective against it as 
 are the preventive measures employed against any other disease, 
 except those in which immunity is conferred by protective inocu- 
 lation. He considers that this great cause ftf military inefficiency 
 is removable, that its existence hereafter as an epidemic should 
 be a reproach to the commander or medical officer concerned, a 
 reflection on their efficiency and a cause for official investigation 
 and discipline. 
 
 "While the present outbreak was regrettable from the stand- 
 point of the individuals and organisations concerned, it is be- 
 lieved that from the larger viewpoint of general military welfare 
 it is a public benefaction of the greatest value, inasmuch as it 
 has afforded opportunity for the formulation of simple, exact 
 preventive measures, which, in the future, should in the aggregate 
 save a vastT amount of inefficiency, sickness and death from what 
 has heretofore been regarded as inseparable from the recruitment 
 of military forces and the aggregation of troops. ' ' 
 
 The foregoing narratives of experiences have been given at some 
 length, because they show how a disease that has generally been 
 declared to be a typical instance of a dangerous and uncon- 
 trollable infectious disease may be completely controlled in 
 schools, military camps, quarantine stations, and elsewhere by 
 simple measures promptly, carefully, and faithfully carried out. 
 
40 
 
 Infection. 
 
 Measles is infectious from, if not actually before, the beginning 
 of the visible symptoms, that is, for some days, even as many as 
 five, before the rash appears. The infective material, the exact 
 nature of which is not known, is contained in the blood and in the 
 secretions of the nose and mouth. These secretions are the usual 
 means of transmitting the disease, both directly in the actual 
 contact of individuals, and indirectly, if persons are in the same 
 room or near each other, through particles of moisture floating in 
 the air. The infective matter is diffused rapidly and extensively. 
 A very small quantity is sufficient to transmit the disease ;. and a 
 short exposure in the same room with a patient will usually in- 
 fect a susceptible person. It is possible that infection may be 
 conveyed by infected materials and by means of a third person; 
 but this mode of transmission is very rare. The infective material 
 is more diffusible than in the ease of scarlet fever, but it does not 
 cling to houses and articles as in that disease. Outside the body 
 it is short-lived ; and it would appear that infection is not usually 
 transmitted after seven days from the appearance of the rash, 
 nor after the patient's temperature has become normal. 
 
 There seems to be no natural immunity to this disease ; nearly 
 every exposed individual takes it at one time or other of life; 
 adults who have not previously had the disease acquire it as 
 readily as children do; but young infants usually are not in- 
 fected. There appears to be no " sex-pref erenee ' ' in this disease. 
 ♦ 
 
 Incubation. 
 
 The length of the incubation period of this disease appears to be 
 fairly constant. For nine or ten days after exposure to the in- 
 fection there are few symptoms. Sometimes there is languor, 
 lassitude, malaise, or headache. Then the symptoms come on 
 gradually. 
 
 Invasion. 
 
 The child suffers from a "cold," or "influenza." The throat 
 is congested. There is an acrid discharge from the nose, and 
 frequent and violent sneezing. The eyes are red and watery, and 
 intolerant of light. The face may be swollen and puffy. Fre- 
 quently there is hoarseness and a hard, dry, painful, and high- 
 pitched cough. Rarely, there may be convulsions or vomiting. 
 Bleeding from the nose is not uncommon, but is rarely severe. 
 A false croup sometimes occurs in young children. These local 
 symptoms vary much in intensity. 
 
 The constitutional symptoms consist of more or less fever; 
 irregular chilly sensations, although actual chills are rare ; im- 
 paired appetite ; pain in the head and limbs ; lassitude, drowsi- 
 ness, irritability, and debility. 
 
41. 
 
 This stage lasts, on an average, for four days ; but it may vary 
 from a single day to seven days, and occasionally extend to ten. 
 
 In measles, about the second day of the stage of invasion, an 
 eruption occurs on the palate and the inside of the cheeks. This 
 consists of small irregular spots of a bright red color. In the 
 centre of each spot there is seen in strong daylight a minute 
 bluish-white speck. There are usually no more than two or 
 three spots on the palate ; on the lining of the cheeks there may 
 be upwards of half a dozen ; and in marked cases they may cover 
 the whole surface. They occur in nearly every case of measles, 
 and -are found in no other disease.. For these reasons, and since 
 they appear, two or three days before the general skin rash, they 
 are of particular value when found, because their presence enables 
 one to say positively that the child is sickening for measles. 
 
 Stage of Skin Eruption. 
 
 This usually commences on the thirteenth or fourteenth day 
 after exposure. The characteristic skin rash is seen about the 
 face and neck. Its starting points most commonly are the side 
 of the neck, temples, the forehead (near the hair), the cheeks, the 
 chin. From these centres it spreads over the he'ad and neck. 
 The eruption not uncommonly becomel confluent, and makes the 
 skin dusky and turgescent. Within 36 or 48 hours it has spread 
 successively ovpr the back, forearms, front of the trunk, lower 
 limbs, and the body generally. 
 
 At first the eruption appears like small red dots or specks, re- 
 sembling, in the early stages, flea-bites, which grpw larger, become 
 slightly raised, and form crescentic patches — in size from a pin- 
 head to a bean — of a dull or deep reddish-purple color, and of 
 velvety smoothness, between which portions of normal skin can be 
 seen. There is not the bright red or scarlet appearance seen in 
 scarlet fever. The color disappears on pressure. The skin is 
 sometimes very itchy, and papules, sometimes vesicles, may 
 appear. 
 
 On the fourth day the rash commences to fade from the face, 
 and later from the trunk and limbs. Then peeling begins. The 
 skin looks as if it were powdered over with flour, and it is usually 
 shed off in fine branny scales or scurf — ^not in large shreds, as in 
 scarlet fever. 
 
 In some cases the distinctive rash of measles may be preceded, 
 by a rash of a different character. There may be a general 
 faint reddish rash, not unlike rash of measles, but confined to the 
 body and limbs. Not infrequently there may be a general rash, 
 resembling the eruption of scarlet fever, but more transient and 
 more diffuse. This may lead to a diagnosis of scarlet fever; and 
 
 F 
 
42 
 
 it is not uncommon for eases of this sort to be sent to hospital as 
 •cases of scarlet fever instead of measles. 
 
 "While the rash is coming out the symptoms already mentioned 
 ■continue and increase in intensity. There is fairly high fever; 
 i:he tongue is coated and marked by red points ; and deafness may 
 occur. When the rash is fully established the fever abates. 
 
 Peeling of the skin goes on for from four to eight days. In 
 some cases it may not be visible. 
 
 Sometimes the rash suddenly recedes, usually because some 
 lung complication or other cause affects the heart and circulation. 
 The eruption then may resemble bluish spots on the pale skin, 
 ■or it may disappear entirely. 
 
 There is reason to believe that the disease is most highly in- 
 fectious at the time of the appearance of the rash. 
 
 Complications. 
 
 Under proper care and with proper attention few people need 
 ■die from measles. 
 
 The patient should be carefully protected. A chill may give 
 rise to serious consequences. On the other hand, ventilation 
 should be good. In an epidemic occurring in a cold winter, I have 
 known many children die from measles complicated with bron- 
 chitis because the mothers would insist on keeping them in front 
 of the fire in a close room where the air was almost unbreatheable. 
 
 In young people lung complications are specially common, and 
 they' not infrequently lead to consumption. A most dangerous 
 complication is membraneous laryngitis. In one hospital in Paris, 
 in 1,633 cases of measles, 235 patients suffered from this malady, 
 and 218 of these died. Grangrene of the mouth is a rare but 
 frightful complication. The most common evil effects of measles 
 are bad eyes and diseases of the ears. There may be a sort of 
 satisfaction in knowing that in some eases measles seems to have 
 effected a cure in cases of chronic skin disease, epilepsy, mania, 
 and joint disease. 
 
 Isolation. 
 
 As in whooping cough, so in measles, every effort should be 
 made to isolate every case and to prevent other children from 
 taking the disease. Every year passed without acquiring the 
 disease adds to the probability of escaping it, and to the likeli- 
 hood of recovery should it be acquired. Almost everywhere the 
 case-mortality is higher in children under one year of age and 
 remains high during the second and third years, after which it 
 falls rapidly until at the age of 15 it is practically negligible. 
 
43 
 
 Isolation of a case implies also the withdrawal of all the other 
 children of the family from the day school and from the Sunday 
 school and from contact with other children outside. A watch 
 ■should be kept on all children — especially those in infant classes 
 — for symptoms of colds ; and every one showing signs of a cold 
 •or languor should be isolated at home and excluded from school. 
 
 Disinfection. 
 
 Evidence is by no means conclusive that the infective material 
 •of measles clings to furniture and other articles ; in fact children 
 in schools, after the lapse of a certain time, have used the same 
 seats, desks, and materials as other children who suffered from 
 measles without acquiring the disease, so long as they did not 
 ■come into actual contact with, or within the range of droplet in- 
 fection by, the sufferers. At the same time it is well to disinfect 
 the room and its contents where a patient has been isolated, as 
 in the case of whooping cough, and to ventilate it freely and to 
 ■expose the possibly infected articles. During illness all dis- 
 ■charges from the mouth and eyes should be re<;eived in gauze, or 
 handkerchiefs, or in similar cloths, which should be disinfected 
 ■or burned. 
 
 Return to School. 
 
 As a rule children may return to school after three weeks of 
 Ihe appearance of the rash. 
 
 Quarantine of the Exposed. 
 This should extend to 16 days. 
 
44 
 
 SCARLET FEVER. 
 
 Scarlet fever, or scarlatina — for these are two names for the 
 same thing — is a very common and a very serious disease. It is 
 not so universally distributed as measles, being found but rarely 
 in certain parts of the world. It is more variable in its forms 
 and symptoms than any other of the eruptiye fevers, and its 
 dangers are more difficult to foresee. 
 
 During the past 30 years in this State 199 deaths have occurred 
 from it — about one-fourth as many as from measles. In the 20 
 years ending 1918, during which the disease has been notifiable, 
 the annual average of deaths was 5.6, while during the previous 
 10 years, when notification was not compulsory, the annual 
 average was 8.6. Certain facts show that it would not be logical 
 to ascribe the entire decrease in" the death rate to notification and 
 its consequences. 
 
 The number of cases of scarlet fever reported during the past 
 20 years was 7,402, with a death rate of 0.7 per cent. 
 
 The number of deaths alone gives little information regarding 
 the total mischief caused by the disease. Many other diseases 
 which have proved fatal or have caused great suffering oi* loss 
 have had their origin in attacks of scarlet fever, perhaps many 
 years previously. 
 
 Some epidemics are very mild, scarcely a fatal case or even 
 a severe one occurring. AH at once, however, a mild epidemic 
 may take on a severe form, or single severe cases may occur in the 
 midst of the mild ones. It is impossible to predict whether any 
 given case will be mild, severe, or malignant. 
 
 "While few, if any, escape an attack of measles when exposed 
 thereto, not half the people in a community — usually less than 
 40 per cent. — take scarlet fever ; and while the liability to acquire 
 measles continues throughout life, the susceptibility to scarlet 
 fever, which increases from birth, diminishes after the fifth year. 
 The disease shows itself most commonly in children from three 
 to six years old. The immunity from scarlet fever, on the part 
 of a large numbet" of the population, may be due to the particular 
 methods in which the infection is conveyed rather than to any 
 definite insusceptibility. A study of nearly 150,000 deaths in 
 England and Wales showed, that over one-half of the deaths 
 occurred in children under five years of age, about 90 per cent, 
 occurred in those under 10 years, and over 95 per cent, in those 
 under 15 years of age. Statistics of the disease in other countries 
 show a similar age mortality. 
 
45 
 
 As regards families, some show a relative immunity from the 
 disease ; others exhibit a special susceptibility to it not noticed in 
 any other similar disease; and in some the disease is so severe 
 as to lead to their total and sudden extinction. 
 
 Grown-up persons may, for some unknown cause, resist the 
 disease during several exposures, and then on the occasion of 
 another exposure may acquire it. Careful research has not shown 
 that women after childbirth are more susceptible to true scarlet 
 fever than other persons are. 
 
 In children under one year the disease is uneomtnon ; in those 
 under six months it is more rare ; in those under three months- it 
 is extremely rare. It has been observed, however, in a child of 
 two weeks old. 
 
 A second attack of the disease seldom occurs; but Dr. Ben- 
 jamin Ward Richardson states that he himself had the disease 
 three times. It is said that second and third attacks are never 
 fatal. It is stated, however, that in some cases they have never- 
 theless been more severe than the first attack. 
 
 Infection. 
 
 The exact nature of the infective material cannot be said to be 
 known as yet. The infection clings pertinaceously to houses, 
 furniture, clothing, hair, and such things in a way very different 
 from the infective material of measles; but, for all this, the 
 disease is not nearly so infectious as measles. The infection of 
 scarlet fever is much less diffusible, and there is this great prac- 
 tical difference, that whereas a child sickening for- measles is in 
 a condition to infect others, all of whom are susceptible, for about 
 a fortnight before it is possible to* diagnose the disease, a child 
 with scarlet fever is not very likely to infect the less numerous 
 susceptible people until the symptoms are evident. 
 
 One would imagine from these considerations that the results 
 of attempts to control scarlet fever in populous communities 
 would be fairly satisfactory. It appears that they have not in- 
 variably been so; or, at least, that those people who have 
 inquired into or discussed them are not agreed on the subject. 
 
 The infective material is carried by the discharges from the 
 throat and nose, and also, later in the disease, by discharges from 
 the ears and from discharging glands. Infection occurs usually 
 from active contact with infected materials, either directly 
 through bodily contact with the patient by hand-touch or kissing ; 
 or indirectly by carpets, bed and body clothing, thermometers, 
 handkerchiefs, towels, food, toys, and such like articles that have 
 become contaminated. Droplet-infection is not such an impor- 
 tant factor as in the case of measles. Some articles may retain 
 the infection for months, and even for years. Infection may 
 
46 
 
 occur through the medium of third persons. Epidemics from in- 
 fected milk are not uncoiiimon, and they are sometimes very ex- 
 tensive. 
 
 It used to be thought that scarlet fever could be communicated 
 by means of the shreds of shed skin as in measles, but more effec- 
 tively and more commonly than in that disease. Experimental 
 evidence is against the view that the skin is a dwelling-place of 
 the infective material in either disease ; but it would appear that 
 in scarlet fever if not also in measles the skin, unless specially 
 cared for, can hardly escape contamination by the infective dis- 
 charges, and thus may communicate the disease. 
 
 A fairly large number of cases have been recorded in which the 
 disease has been spread by true carriers who have been perfectly 
 ' well, and Who have not themselves shown any symptoms of the 
 disease at any time. 
 
 In this State it is not uncommon for the disease to occur in 
 isolated cases far apart, and not to assume an epidemic form or 
 spread to any other individuals. 
 
 Only a very short exposure is necessary. The infection prob- 
 ably enters the system through the mouth and nose. 
 
 Incubation. 
 
 There is great difficulty in definitely determining the period 
 of incubation. For practical purposes we may assume that it is 
 usually from two to seven days; but it may be only 24 hours, 
 or even less. The commonest period is probably from two to four 
 daj'-s. Rarely, it may extend to 14 days. 
 
 Invasion. 
 
 The invasion is usually sudden. Vomiting occurs very fre- 
 quently as one of the earliest symptoms. Fever follows — sharp, 
 sudden, and severe — and is more noticeable than in any other 
 eruptive disease. It may or may not be preceded by a chill. Then 
 sore throat is noticed, accompanied, perhaps, by pain in swallow- 
 ing. The throat is very red ; the skin feels very hot and burning 
 to the touch, and may be itchy ; thirst is often very great ; the 
 eyes are dull and listless ; and the face is flushed. Headache and 
 giddiness are common, and sleepiness may alternate with rest- 
 lessness. Brain symptoms occurring early in the disease usually 
 indicate malignant scarlatina, which is almost invariably and 
 rapidly fatal. 
 
 Eritptive Stage. 
 
 In from 12 to 24 hours the eruption is noticed on the neck, 
 chest, or back. The cheeks may be red, but this is not due to the 
 characteristic rash. The nose, upper lip, and chin are not 
 
47 
 
 affected. It appears first as minute dots or specks. These coalesce 
 to form irregular patches, varying in size and shape and having 
 irregular margins. The color is vermilion, scarlet, or bright red 
 — ^like crushed raspberry, as contrasted with the crushed mulberry 
 color seen in measles. In severe cases it is darker. ' At times the 
 rash may resemble "goose-skin." The redness is most marked 
 and remains longest in places where the skin is most delicate, as 
 in the front of the arms and the inner sutface of the thighs. It 
 disappears momentarily on pressure. Usually on the third day 
 the rash reaches its maximum intensity and distribution, having 
 extended over the rest of the body in a more continuous form, 
 except, perhaps, on the extremities, where it appears in blotches 
 or patches. Then, within a period varying from the fifth to the 
 sixteenth day, it fades in much the same order as it appeared, 
 and afterwards the skin begins to peel off in strips or flakes or 
 large patches, or even in the form of gloves or slippers, from the 
 hands and feet; on rare occasions the nails may be shed. The 
 amount of peeling bears no relation to the intensity of the rash. 
 The peeling may be repeated several times. The rash, in its 
 appearance and spread, is not so regular as in smallpox and 
 measles. When the throat conditions are very severe the rash 
 may be mild, or even absent. 
 
 During this stage the tongue is almost invariably white or 
 greyish with red spots. Soon the tip and edges grow red and 
 present a roughness or granular appearance. The appear- 
 ance of the tongue is very characteristic of scarlet fever. The 
 coating disappears usually about the fourth day, leaving the sur- 
 face clean and reddened. When the papillae are enlarged, the 
 appearance is like a ripe strawberry. The "strawberry tongue" 
 is not always present ; but when it does occur it is distinctive of 
 the disease. 
 
 Mild cases of scarlet fever, with no perceptible eruption, but 
 with sore throat, may occur; and it is generally believed that 
 persons so affected may infect others with true scarlet fever of 
 the ordinary types. The discovery and management of mild cases 
 is a very important factor in the control of the disease. 
 
 Complications. 
 
 The most common and most serious complication is kidney 
 disease, which often ends fatally and quickly, or sometimes en- 
 tails lifelong trouble. This may occur as commonly in mild as in 
 severe cases, and is independent of catching cold. It has no re- 
 lation to the severity of the skin rash. Diseases of the ear are also 
 common, and rheumatic affections of the joints are by no means 
 rare. Swelling and suppuration of the glands of the neck may 
 
48 
 
 occur, and the condition is then usually serious. Diphtheria 
 sometimes develops during an. attack of scarlet fever. Eheuma- 
 tism and various affections of the heart may follow. 
 
 Isolation. 
 
 In some places where hospital isolation has been practised the 
 number of cases and the. death rate have both diminished. In this 
 State the conditions appear to be such as to lead one to expect 
 great general benefit from prompt isolation effectively carried 
 out. 
 
 At home, isolation should be complete. The sick-room should 
 be dismantled of all unnecessary furniture and other articles, 
 and no one allowed into it except the nurse or attendant. Other 
 children should be withdrawn from school and, if possible, sent 
 to some place where there are no other young people. Abun- 
 dance of fresh air is of immense value in the treatment of 
 patients, both in hospital and at home, and is very effective in 
 preventing the spread of the disease. 
 
 Disinfection. 
 
 During sickness all discharges from the mouth, nose, and eyes 
 should be received in gauze or handkerchiefs or similar cloths, 
 which should be burned immediately. All articles used by the 
 sick. person should be disinfected before removal from the sick- 
 room, and then washed separately from articles used by other 
 people. The disinfection of the sick-room after convalescence 
 should be thorough and even more extensive than in the case of 
 measles ; and to secure this it is necessary to call in the assistance 
 of experts in the work of disinfecting. 
 
 Return to School. 
 
 As a rule, children may return to school about six weeks from 
 the appearance of the rash, provided that there are no discharges 
 from the mouth, npse, eyes, or glands. It is well, however, to 
 keep a child strictly isolated from the children for eight or ten 
 days after all symptoms have disappeared. 
 
 Quarantine of the Exposed. 
 This should extend to 14 days. 
 
49 
 DIPHTHERIA. 
 
 During the past 30 years 1,751 persons in this State have died 
 from diphtheria. From the deaths recorded during that time, 
 and the cases notified during the past 10 years, one sees that it 
 is a disease that is always with us. Comjiared with scarlet fever 
 it has a very high death rate. "Within the past 10 years the 
 disease has greatly increased in this State as it has generally 
 throughout the Commonwealth. The cause of this does not appear 
 clear. The last 10-year period shows a reduction in the case 
 mortality from the preceding 10-year period. The case mortality 
 has been reduced from 87.7 to 43.7, but the actual deaths rose 
 from 197 to 677 — an increase of 243.6 per cent. More than one 
 factor may be concerned in this result ; and the subject is being 
 investigated. 
 
 An explanation is necessary here, in case the figures recording 
 the numbers of cases and deaths should be misinterpreted. For 
 some time it was customary for some medical practitioners to 
 notify as cases of diphtheria all contacts who have been found to 
 have the bacilli of diphthei-ia in their throats, whether they had 
 any symptoms of the disease or not. But such persons, although 
 notified, are not suffering from diphtheria, and they may not 
 aquire the disease. Careful investigations have shown that in 
 cities from 1 per cent, to 2 per cent, of all healthy persons among 
 the general public have genuine diphtheria baciUi in their nose 
 or throat, and from 8 per cent, to 50 per cent, of exposed persons 
 in families and schools. These persons, though not themselves 
 suffering from the disease, may infect others. They are known as 
 "carriers." The carrier problem is a very difficult one, both 
 scientifically and administratively, but it is one of great impor- 
 tance in connection with the control of the disease. At the same 
 time this should not divert attention from the spread by contact 
 which is probably of greater importance than is imagined. 
 
 A Committee on the Study and Prevention' of Communicable 
 Diseases reported to the American Public Health Association in 
 1913, that "it is not practicable to isolate well persons infected 
 with diphtheria bacilli, if such persons have not, so far as known, 
 been recently exposed to the disease."; also that "it is not 
 advisable as a matter of routine to isolate from the public all the 
 well persons in infected families, schools, and institutions." 
 
 Diphtheria occurs in country places as well as in towns. The 
 disease spreads more slowly than measles or scarlet fever. 
 
 Although, subject to a certain natural immunity in some 
 persons, the disease may occur in people of any age, it is prin- 
 cipally a disease of childhood. Most cases occur iu children 
 between the second and seventh year of age. It is rare in early 
 infancy, and is not common after the age of 10. It affects girls 
 
50 
 
 and boys alike, and children with enlarged tonsils and adenoid 
 growths in the throat are especially apt to acquire it. People 
 living in damp houses would appear to be predisposed to it. 
 There has not been found any immediate connection between this 
 disease and imperfect drainage or sewer gas. 
 
 Epidemics of dipht];ieria sometimes occur simultaneously with 
 epidemics of measles, or typhoid fever, or follow epidemics of 
 measles. A first attack of diphtheria does not confer any 
 immunity. 
 
 Infection. 
 
 Infection clinging to shreds of material from the throat, nose, 
 ear, or infected wounds, is carried usually directly by means of 
 touch, kissing, and droplet infection ; or less commonly indirectly 
 by contaminated clothing, handkerchiefs, books, toys, and such 
 like. It appears to enter the system by the lining of the throat 
 and upper air passages, and its entrance is favored by any local 
 disease or abrasion of the lining of these parts. Sometimes shreds 
 have been coughed into a person's eye or mouth, and so have 
 started the disease. The infected material clings very closely to 
 various articles, and may be conveyed to a great distance. Bad 
 sanitary conditions may favor its spread, but do not appear to 
 predispose people to the disease, except in so far as they lower 
 their general vitality. The disease may be conveyed by milk and 
 other foods. Pencils, pens, and other school apparatus will retain 
 this infection for 24 hours. In one instance, in an orphanage in 
 which diphtheria had occurred, a tooth-brush was found to con- 
 tain large numbers of diphtheria bacilli. The range of infection 
 is very linaited, apart from the conveyance by the agents men- 
 tioned. People can be safe a few feet from the patient. It is 
 therefore possible, with proper precautions, to treat a person 
 safely at home. 
 
 Incubation. 
 
 The period of incubation varies from about 24 hours to a week. 
 Most commonly it is from two to five days. It may be very short 
 when the infection is inoculated directly. During this period 
 there may be malaise and headache, and sometimes nausea and 
 vomiting and chilly sensations, but not commonly any distinct 
 chill. 
 
 Invasion. 
 
 There occur some sore throat, a slight fever, general weakness, 
 and a feeling of soreness of the muscles. The tonsils are seen to 
 be slightly swollen and reddened, and small greyish or yellowish 
 spots covered by a thin membrane may be seen on the surface 
 of one or both of the tonsils. In a few days these spots may 
 enlarge and coalesce, and the membrane may cover the whole of 
 the tonsils and spread to the palate and the back of the throat 
 and to the nose. There may not be much pain, but there is usually 
 
difficulty in swallowing. The breath is fcetid. The tongue is 
 coated and it may be swollen. Appetite disappears. There is 
 usually swelling of the glands on each side of the lower jaw. If 
 the membrane spreads downwards there is usually hoarseness, 
 obstructed and noisy breathing, and a harsh ringing cough. The 
 patient shows great distress, sits up in bed, or tosses about, gasp- 
 ihg for breath. If pieces of the membrane are coughed up, there 
 is a temporary relief. 
 
 The disease has no definite duration, like typhoid or scarlet 
 fever. It may last from 10 days to four weeks or longer. 
 
 COMPUCATfONS. 
 
 The commonest are diseases of the kidneys and paralysis. The 
 paralysis may occur during the course of the illness or after con- 
 valescence. 
 
 Isolation. 
 
 This has been referred to. If at home, the patient should be 
 strictly isolated. All children should be sent away if possible ; if 
 this is not possible, they should be kept away from the neighbor- 
 hood of the sick room. • 
 
 Disinfection. 
 
 Everything used by the patient should be disinfected before 
 removal from the room. The discharges should be received in 
 gauze, or handkerchiefs, or similar cloths, which should be disin- 
 fected or burned. The sick room and its contents should be dis- 
 infected by officers of the board of health. Cases of diphtheria 
 are very commonly removed to a hospital, and there is much to 
 recommend this course when one considers how treacherous the 
 disease is and how the necessity for surgical treatment' may arise 
 very suddenly. 
 
 Schools have been proved to play such a large part in the dis- 
 semination of diphtheria that it is doubtful if the disease will be 
 banished from the schools in the State until there is a complete 
 system of general inspection by teachers, followed up by a system 
 of special inspection of doubtful cases by medical officers and a 
 thoroughly trained staff of disinfectors whose services will be 
 available at the patients' homes. 
 
 Eeturn to School. 
 This will be possible after three weeks if the patient is strong 
 enough, and if there is no discharge from the nose, eyes, or ears. 
 Nowadays it is recommended that children should be kept from 
 school until materials from the throat and nose, t-aken not less 
 than 24 hours apart, show no cultures of the bacilli that cause 
 the disease. 
 
 Quarantine op the Exposed. 
 
 This should extend to 12 days, or until bacilli are not found 
 in the throat or nose. 
 
52 
 
 Table of Principal Communicable Diseases in South Australia, 
 1889-1918.* 
 
 Year. 
 
 Whooping 
 Cough. 
 
 Measles. 
 
 Scarlet Fever. 
 
 Diphtheria. 
 
 
 Cases. 
 
 Deaths. 
 
 Cases. 
 
 Deaths. 
 
 Cases. 
 
 Deaths. 
 
 Cases. 
 
 Deaths. 
 
 1889 
 
 1890 
 
 1891 
 
 1892 
 
 1893 
 
 1894 
 
 1895 
 
 1896 
 
 1897 
 
 1898 
 
 : 
 
 2 
 129 
 42 
 12 
 121 
 60 
 44 
 17 
 
 112 
 
 ~ 
 
 1 . 
 
 1 
 
 261 
 
 28 
 2 
 
 54 
 
 — 
 
 1 
 
 3 
 
 4 
 
 2 
 
 5 
 
 35 
 
 10 
 
 4 
 
 7 
 
 15 
 
 
 109 
 
 174 
 
 173 
 
 106 
 
 100 
 
 97 
 
 37 
 
 21 
 
 22 
 
 38 
 
 Ten Years— 
 1889-1898 
 
 — 
 
 539 
 
 — 
 
 347 
 
 / 
 
 86 
 
 — 
 
 877 
 
 1899 
 
 1900 
 
 1901 
 
 1902 
 
 1903 
 
 1904 
 
 1905 
 
 1906 
 
 1907 
 
 1908 
 
 — 
 
 106 
 29 
 51 
 36 
 60 
 25 
 6 
 16 
 73 
 18 
 
 — 
 
 27 
 
 2 
 
 5 
 
 235 
 
 5 
 
 1 
 
 5 
 
 14 
 
 986 
 254 
 115 
 120 
 749 
 529 
 451 
 852 
 403 
 75 
 
 16 
 
 1 
 
 19 
 10 
 
 8 
 12 
 
 5 
 
 624 
 400 
 313 
 267 
 292 
 302 
 126 
 150 
 132 
 213 
 
 40 
 32 
 19 
 27 
 21 
 18 
 
 7 
 
 12 
 13 
 
 8 
 
 Ten Years— 
 1899-1908 
 
 — 
 
 420 
 
 — 
 
 294 
 
 4,534 
 
 76 
 
 2,819 
 
 197 
 
 1909 
 
 1910 
 
 1911 
 
 1912 
 
 1913 
 
 1914 
 
 1915 
 
 1916 
 
 1917 
 
 1918 
 
 970 
 1,100 
 
 2,193 
 672 
 265 
 
 1,801 
 781 
 690 
 
 16 
 34 
 32 
 
 3 
 
 64 ' 
 49. 
 
 2 
 «5 
 29 
 
 5 
 
 261 
 
 227 
 
 8,589 
 
 564 
 
 1,063 
 
 2,023 
 
 6,163 
 
 4,490 
 
 321 
 
 288 
 
 17 
 
 17 
 
 23 
 
 8 
 
 34 
 
 20 
 
 1 
 
 1 
 
 128 
 134 
 75 
 679 
 300 
 169 
 214 
 266 
 238 
 665 
 
 2 
 
 2 
 
 12 
 
 7 
 2 
 1 
 1 
 1 
 9 
 
 430 
 1,604 
 1,076 
 1,141 
 1,185 
 996 
 651 
 1,669 
 1,257 
 1,469 
 
 15 
 37 
 61 
 55 
 70 
 58 
 64 
 144 
 87 
 86 
 
 Ten Years— 
 1909-1918 
 
 ' 9,064 
 
 289 
 
 22,989 
 
 121 
 
 2,868 
 
 37 
 
 11,378 
 
 677 
 
 * Note. — During these 30 years the population of the State 
 increased by 25 per cent. 
 
53 
 
 "CONTACT DISEASES" OR "SCHOOL 
 DISEASES." 
 
 The diseases whooping-oough, measles, scarlet fever, and 
 diphtheria constitute a group with certain features in common 
 that give them a peculiar interest. They are sometimes known as 
 contact diseases, not that they are transmitted solely by direct or 
 indirect contact, nor that other diseases are not also transmitted 
 in this way ; but because, on the whole, contact, either immediate 
 from person to person, or mediate by contaminated articles, plays 
 by far the largest part in their spread. Among all the diseases 
 that are spread by contact these possess for us by far the greatest 
 interest, and are the most entensive and deadly with which we 
 have to deal in daily life. 
 
 These diseases are sometimes also known as the school diseases, 
 not that they are limited in their occurrence to infection caught 
 in school or that they are the only communicable diseases that 
 occur among children attending school; but because in the vast 
 majority of cases they affect children of school age who may for 
 the first time in their susceptible lives be exposed to them, and 
 because even where, as in England, school conditions of living 
 are good compared with home conditions, schools are proved to 
 be the chief means in their spread, while in places where the home 
 conditions are good compared with overcrowded schools these 
 diseases are still more extensively spread through the medium of 
 public chools and similar institutions. 
 
 "Contact Diseases" or "School Diseases" in South Australia, 
 
 1889-1918.* 
 
 
 When Not Notifiable. 
 
 When Notifiable. 
 
 Disease. 
 
 Number of 
 Years. 
 
 Annual 
 
 Average 
 
 of Deaths. 
 
 Number of 
 Years. 
 
 Annual 
 
 Average 
 
 of Deaths. 
 
 Whooping Cough 
 
 Measles 
 
 .*^carlet Fever 
 
 20 
 20 
 10 
 10 
 
 47-9 
 
 320 
 
 8-6 
 
 87-7 
 
 10 
 10 
 20 
 20 
 
 28-9 
 
 10-1 
 
 .5-6 
 
 Diphtheria f 
 
 43-7 
 
 * Note. — During these thirty years the population of the State increased by 
 25 per cent. 
 
 t On the subject of Diphtheria death rates see p. 49. 
 
54 
 
 Neither the nomenclature nor the classification is strictly- 
 scientific, for there is no exact scientific classification possible of 
 any groups of diseases; but either of the designations, "con- 
 tact" or "school", has the practical advantage of keeping con- 
 stEintly before our minds the particular and prominent charac- 
 teristics that have to be reckoned with in all our attempts to deal 
 with these diseases. Briefly what has to be realised is that in each 
 of these four diseases the organism, or virus, as the case may be, 
 exists in the human body, that outside the body it does not 
 develop or grow but only lives, and that, too, for a relatively 
 short time, until it either dies or finds suitable soil in another 
 susceptible human body ; further that the organism or the virus 
 is given off in the secretions of the nose, mouth, and respiratory 
 passages, and enters other human bodies by these channels. 
 
 While schools usually form a ready field for the spread of 
 infection, they also in many instances may be made a very helpful 
 means in the prevention of epidemics. In Boston, Mass., in 1894, 
 Commissioner Durgin introduced school medical inspection in 
 order to check an epidemic of diphtheria. A few years later New 
 York City and Philadelphia adopted the same practice. The daily 
 visitation of every school by the school doctor or trained school 
 nurse, the inspection of the children, the inquiries into absences, 
 and the method of dealing with pupils from infected houses re- 
 ported by the Department of Health, and home isolation of 
 infected children, and the active disinfection connected with this, 
 are measures that have combined in New York to reduce 
 epidemics to an extent that is little short of marvellous. On an 
 average less than 1 per cent, of children per annum have been 
 necessarily excluded from school on account of infectious disease. 
 Dr. Josephine Baker, the Director of the Bureau of Child 
 Hygiene in New York, says: — "Such control may be exercised 
 in any community, and the school, instead of being the focus for 
 the dissemination of communicable diseases, may become, because 
 of its very adaptability to control, one of the most valuable 
 methods we have of limiting the spread of communicable diseases 
 in any community." It is to be noted that in New York the 
 medical inspection of schools is under the Department of Health, 
 and this is generally recognised as a necessary arrangement to 
 ensure satisfactory work. 
 
 In country districts the method of control by constant and 
 continued daily inspection of school children is seldom applicable 
 on account of the cost it would entail. This illustrates the fact, 
 too often forgotten or ignored, that no one plan of control wiU 
 apply everywhere or at all times. Misconception or misrepresen- 
 tation of any plan of action, or single act, is unfortunately easy. 
 A classroom, for instance, is closed in a country school on account 
 of a case of measles, and the contacts are excluded for some 
 
55 
 
 •days. One is told that the eommittee of the Massachusetts 
 Association of Boards of Health reported that "Schools should 
 not be closed during an epidemic of diphtheria. ' ' The remainder 
 ■of the sentence in the report may not be quoted. It reads: 
 •* ' Daily inspection and culturing will achieve better results. ' ' 
 
 It must never be forgotten that not only do the precautions 
 and measures of control vary in the different diseases and in diffe- 
 rent places, but they may have to be changed during the course 
 •of an epidemic in one locality. A time may come, for example, 
 in the history of an outbreak of measles when the healthy may 
 "be excluded from school and the convalescents and the immune 
 allowed to return. 
 
 In dealing above with the spread of whooping cough, measles, 
 ■scarlet fever, and diphtheria, repeated reference has been made 
 to infection by direct contact with the patient and also to droplet 
 infection.* 
 
 It is difficult, however, to grasp the fact that infective material 
 may easily pass from one person to another by means of secre- 
 tions from the nose and mouth. Without inquiry we give a sort 
 ■of intellectual assent to the possibility of infection by the^e 
 means. But when we study and observe, what strikes us is not 
 the possibility that some persons may be so infected; we are 
 ■filled with wonder how any susceptible person can escape — if any 
 such person actually does escape. 
 
 There are other methods, however, by which infection can be 
 •conveyed by secretions of the nose and mouth. These demand 
 •careful consideration. 
 
 In writing on the subject of infection by contact with saliva, 
 Dr. Charles V. Chapin, Superintendent of Health, Providence, 
 E..I., urges that if contact infection is important in diseases like 
 typhoid fever, dysentery, and cholera, in which the infecting 
 material is not constantly at hand, and is usually strenuously 
 avoided, this mode of transference is of much greater importance 
 in diseases 'in which the specific germs are found in the secretions 
 ■of the nose and mouth or ia the sputum. The following extracts 
 will give an idea of the position : — 
 
 "Probably the chief vehicle for the conveyance of nasal and 
 ■oral secretion from one to another is the fingers. If one takes 
 the trouble to watch for a short time his neighbors, or even him- 
 self, unless he has been particularly traiued in such matters, he 
 
 * The subject of "droplet infection" has been mentioned above in con- 
 nection with the spread of infection in whooping cough, measles, scarlet 
 ^fever, and diphtheria. It is referred to at some length, with illustrative 
 facts, in Bulletin No. 1 "On Cleansing and Disinfection in the Control of 
 Infectious Diseases" (Adelaide: R. E. E. Rogers, Government Printer, 1917). 
 
56 
 
 will be surprised to note the number of times that the fingers ga 
 to the mouth and the nose. Not only is the saliva made use of 
 for a great variety of purposes, and numberless articles are for 
 one reason or another placed in the mouth, but for no reason 
 whatever, and all unconsciously, the fingers are with great fre- 
 quency raised to the lips or the nose. "Who can doubt that if 
 the salivary glands secreted indigo the fingers would continually 
 be stained a deep blue, and who can doubt that if the nasal and 
 oral secretions contain the germs of disease these germs will be 
 almost as constantly found upon the fingers? All successful 
 commerce is reciprocal, and in this universal trade in human 
 saliva the fingers not only bring foreign secretions to the mouth 
 of their owner, but there exchanging them for his own, distri- 
 bute the latter to everything that the hand touches. This- 
 happens not once, but scores and hundreds of times during the 
 day's round of the individual. The cook spreads his saliva on 
 the muffins and rolls, the waitress infects the glasses and spoons, 
 the moistened fingers of the peddler arrange his fruit, the thumb 
 of the milkman is in his measure, the reader moistens the pages 
 of his book, the conductor his transfer tickets, the 'lady' the 
 fingers of her glove. Everyone is busily engaged in this dis- 
 tribution of saliva, so that the end of each day finds this secretion 
 freely distributed on the doors, window sills, furniture and play- 
 things in the home, the straps of trolley cars, the rails and coun- 
 ter and desks of shops and public buildings, and indeed upon 
 everything that the hands of man touch. "What avails it if the 
 pathogens do die so quickly?' A fresh supply is furnished each 
 
 day Besides the moistening of the fingers with 
 
 saliva and the use of the common drinking cup, the mouth is put 
 to numberless improper uses which may result in the spread of 
 infection. It is used to hold pins, string, pencils, paper and 
 money. The lips are used to moisten the pencil, to point the 
 thread for the needle, to wet postage stamps and envelopes. Chil- 
 dren 'swap' apples, cake, and lollipops, while men exchange 
 their pipes, and women hatpins. Sometimes the mother is seen 
 'cleansing' the face of her child with her saliva-moistened hand- 
 kerchief, and perhaps the visitor is shortly after invited to kiss: 
 the little one. 
 
 ' ' Children have no instinct of cleanliness, and their faces, hands, 
 toys, clothing, and everything that they touch must of necessity 
 be continually daubed with the secretions of the nose and mouth. 
 It is well known that between the ages of two and eight y6ars 
 children are more susceptible to scarlet fever, diphtheria, measles; 
 and whooping cough than at other ages, and it may be that 
 one reason for this is the great opportunity that is afforded by 
 their habits at these ages for the transfer of the secretions. 
 Infants do not of course mingle freely with one another, and' 
 
57 
 
 older children do not come in such close contact in their play, 
 and they also begin to have a little idea of cleanliness. ' ' 
 
 Besides the saliva there is another source and mode of infec- 
 tion, and one that is generally overlooked in measles, scarlet 
 fever, and diphtheria. This is the discharge from the ear that 
 often occurs during the course of the disease, and remains after 
 the patient is regarded as convalescent, or even as quite well. 
 The discharge in these cases often remains virulent for a con- 
 siderable time. One instance is recorded in which a case was 
 discharged from hospital in the thirteenth week of the disease, 
 and a brother of the patient died of scarlet fever before the in- 
 fected child was a week home from the hospital. Discharges also 
 containing pus from other parts of the body than the ear, may 
 spread infection in these diseases. 
 
 From the facts here set forth it will be abundantly evident that 
 in schools, and especially in overcrowded schools, all the factors 
 are present for the facile spread of infection in the case of whoop- 
 ing cough, measles ,and scarlet fever. Diphtheria may also be 
 included. A careful study of recent statistics of "home infec- 
 tion" shows that the spread of infection in these diseases from a 
 sick person to other members of the family, or from one family to 
 another, except by actual contact with the infected person or the 
 infective material, is a rare event compared with the rapid and 
 wide spread of infection that occurs in schools, public institu- 
 tions, camps, public meetings, and similar congregations. 
 
 It is facts like these that are rousing educational and health 
 authorities to take stringent measures against the spread of 
 diseases that have now been proved to be controllable. Measles, 
 which was for a long time regarded as beyond the scope of almost 
 any practicable measures of control, is now receiving the con- 
 sideration that it urgently calls for, considered as a practically 
 universal disease with a high mortality and an extensive and 
 varied disablement of a permanent or temporary character. 
 
 In 1913 Dr. Frederick S. Crum, Statistician to the Prudential 
 Insurance Company of America, wrote: — "Authorities have in 
 the past been in disagreement as to the benefits of compulsory 
 notification of measles but those opposed to notification have 
 been so because of practical difficulties in the form of expense, 
 lack of sufficiently large health departmental staffs, lack of hos- 
 pital accommodation for isolation of patients, &c. Presumably, 
 however, there is quite general agreement that notification of 
 eases of measles must be a preliminary requirement, and a neces- 
 sary part of any complete program for the better control of 
 measles. The best modern practice seems to be that whereby 
 co-operation is effected between parents, school teachers, medical 
 inspectors of schools, visiting nurses and health departments." 
 Evidence of a sane and sanitary campaign on these lines is 
 
58 
 
 afforded in a recent report issued by the Local Government 
 Board, England (1919, New Series, No. 115), dealing with 
 "Measures for the Prevention of Mortality and Disablement due 
 to Measles and Pneumonia in Children." 
 
 When one understands (1) the possibility of an infected per- 
 son infecting another before he himself shows symptoms of ill- 
 ness; (2) the conditions under which the infection of measles- 
 spreads by contact and droplet infection; and (3) the frequent 
 serious and permanent consequences to the survivors, one sees the 
 necessity for prompt and effective measures in dealing with every 
 case of the disease. The following brief statement of administra- 
 tive action in England is bound to prove encouraging. 
 
 By a recent order of the Local Government Board, every local 
 authority is empowered to provide nursing as well as medical' 
 attendance for all necessary eases of measles in its district. 
 Further, the visiting of children suffering from measles is alsa 
 part of infant welfare work, and the Government Board is also 
 to give grants to help in providing health visitors for this pur- 
 pose; and if the arrangements are satisfactory the board allow 
 a grant of 50 per cent, for this work and for nursing. 
 
 The routine work of the nurse consists in prompt visiting, in- 
 quiring as to other eases, taking precautions, giving directions,, 
 instructing as to nursing, looking after clothing, ventilation, dis- 
 infection, healthiness of the house — in short, evers^thing that has 
 to do with the child's and family's welfare. She reports to the 
 medical officer, and continues her visits, twice daily at first, until 
 the child is convalescent. The board's memorandum says regard- 
 ing nursing provision : — ' ' There can be no doubt that this is of 
 first importance for preventing mortality and disablement result- 
 ing from measles. The mortality among the working classes from 
 measles is very much greater than among the middle and upper 
 classes, mainly on account of the absence of proper care of the 
 children during the acute stages of the disease. . . . The 
 cleansing of the skin, and the maintaining of the mouth and 
 throat in as aseptic a condition as possible are of the first im- 
 portance, also the nursing of complications such as bronchitis 
 and pneumonia." The memorandum points out that where the 
 children are not removed to hospital, nursing must be provided 
 at home. 
 
 The most convenient ways of providing nursing in England 
 have been the engaging the nurses of a District Nursing Asso- 
 ciation or employing the nurses of the sanitary authorities 
 isolation hospital staff; also by a number of adjacent local 
 authorities combining to engage the services of a permanent 
 nurse. In some epidemics the services of the school nurses are 
 
59 
 
 employed; in one case the workshop inspector, a trained nurse, 
 was engaged. Sometimes the teachers of schools that have been 
 closed have been employed as visitors to assist. In some cases 
 "mothers' helps" have been employed by the local authorities 
 to assist in the home nursing of measles cases. It is laid down 
 that every case of measles should be seen by a doctor, and that 
 he should advise and supervise the nurse or other attendant. 
 
 These and other measures of control and treatment are far from 
 being unnecessary when the serious nature of measles is con- 
 sidered. In the first place, measles is an almost universal disease 
 of civilisation. It can scarcely be said that any person is immune 
 to it. This means the vast majority of the population in present 
 conditions of administration will suffer from the disease. The 
 death rate from measles should cause even the most casual to 
 think. In public institutions the fatality is high. In one 
 epidemic in an institution affecting 294 children, nearly half 
 being under 2 years of age, the mortality was 30 per cent. In two 
 epidemics in an institution in New York the fatality was 35 per 
 cent. Apart from institutions the mortality is large. A study of 
 nine years' compulsory notification of measles in Edinburgh 
 shows that the "case mortality" for all ages was not less than 
 f fA per cent. The mortality in private houses varies in proportion 
 i to the crowded condition of the rooms and the lack of facilities 
 for isolation of healthy individuals. The mortality varies with 
 age, as has been noted above. 
 
 Desirable Remedial Measures. 
 
 The memorandum of the Local Government Board says the 
 following remedial measures stand out as likely to favor a 
 reduction in the mortality and disablement due to measles : — 
 
 1. Efforts to prevent the risk of infection amongst the young, 
 with a view to the postponement of the incidence of measles until 
 after 5 years of age. 
 
 2. The special guarding of all ailing and delicate children from 
 measles infection. 
 
 3. Precautions directed against the outbreak and spread of 
 measles in children's institutions. 
 
 4. Measures directed towards the improvement of housing 
 conditions with special reference to hygiene, ventilation, and the 
 diminution of overcrowding. 
 
 5. Measures directed towards the reduction of the general 
 infantile mortality. 
 
 6. The securing of skilled medical and nursing treatment for 
 cases of measles in the patients' own homes. 
 
 7. The provision of efficient hospital treatment for necessitous 
 cases of measles. 
 
60 
 
 8. The prevention of complications of measles. 
 
 9. Medical observation and treatment of the child after the 
 attack of measles, with a view to the prevention of sequelse. 
 
 The problem of the possibility of successful scientific and 
 administrative control of measles has been solved. Munson has 
 the best grounds for saying that the death rate may be reduced 
 to a practically negligible factor. In England and Wales alone 
 during the three years 1911-13 the notifiable diseases, viz., 
 smallpox, scarlet fever, diphtheria, typhoid fever, puerperal 
 fever, and erysipelas caused 31,641 deaths. Measles, which is 
 partially notifiable, killed 36,627 people, i.e., 15 per cent, more 
 than all the others together. The people are now thinking that 
 the problem of practical control is worth considering, from the 
 point of view of economics, if from no other. 
 
61 
 
 TYtHOID FEVER. 
 
 Typhoid fever is one of the most widely distributed of the com- 
 municable diseases. It ranges from the arctic regions to the 
 tropics. It may be looked upon as essentially a disease of youth, 
 as contrasted with whooping cough and measles, which are 
 characteristically diseases of childhood. About four-fifths of all 
 cases of typhoid fever occur between the fifteenth and the thirty- 
 fifth year of age, and more than half between the fifteenth and 
 the twenty-fifth year. After the fiftieth year and before the 
 end of the first year it is rare. Among children more boys are 
 attacked than girls. In England the disease occurs most 
 commonly in the summer months. The same is true of this 
 State. Most eases occur in February, March, and April; 
 occasionally a large epidemic may occur in May^ and also in 
 January. 
 
 Speaking generally, filth is the origin of typhoid fever; food, 
 flies, dust, and dirty hands are its vehicles of spread. It is a poor 
 satisfaction for a sufferer to know that it may have been his 
 neighbor's or somebody else's filth that gave him the disease. 
 The community must help the individual in his endeavors to 
 avoid this disease. 
 
 The infective material leaves the human body in the evacua- 
 tions of the bowels, in the urine, and exceptionally in materials 
 thrown out in vomiting, coughing, spitting, and sneezing. The 
 infection may directly, or through the medium of flies or dust, 
 contaminate water, ice, milk, butter, shellfish, vegetables, fruit — 
 in fact, all sorts of food and drink. When it is dried it will retain 
 its virulence for several months, so also when it is mixed with ' 
 boiled milk, aerated waters, distilled or sterilised drinking water. 
 In natural drinking water, especially when it is moving and 
 exposed to sunlight, the infective material usually loses its 
 activity. Infection derived from the excreta may cling to house- 
 hold articles, such as bedding, clothing, linen, and towels for a 
 considerable time. Third persons may also be the means of 
 conveying infection from the diseased to the healthy. 
 
 Lavatory railway ears have been blamed in America for 
 spreading typhoid fever, and the dry earth closet has been recom- 
 mended on the cars instead of the water closet. It would prevent 
 soiling of the road bed, and be inoffensive. 
 
 In hospitals the disease sometimes spreads from patients to the 
 nurses and other attendants through lack of attention to details 
 of cleanliness and disinfection. It is now recognised that the 
 frequency with which cases of typhoid • fever originate in a 
 hospital can be taken as an index of its hygienic arrangements 
 
62 
 
 and the organisation of the medical and nursing service. A single 
 inexperienced or careless attendant may upset the hest regula- 
 tions, with widespread and disastrous effects. The same remark 
 applies to cases in private houses. 
 
 Typhoid fever does not generally attack large districts at once, 
 or a whole city, unless, of course, the general water supply should 
 he contaminated. The disease usually shows itself in single cases 
 or small groups, or in street epidemics. 
 
 Typhoid fever occurs perhaps most commonly among well 
 nourished young individuals living in healthy surroundings. The 
 rich suffer quite as much as, and even more than, the poor. Once 
 the disease has broken out in an overcrowded locality, where 
 drainage and arrangements for the disposal of nightsoil are 
 defective, it will spread faster than where hygienic conditions 
 obtain ; but insanitary conditions in themselves do not predispose 
 to the occurrence of the disease. 
 
 People suffering from typhoid fever may be sufficiently well 
 to walk about, and may show few, if any, symptoms of illness. 
 Further, people who have passed through an attack and have 
 quite recovered may discharge the infection from their bodies for 
 months of even years. Only general sanitatipn will prevent an 
 outbreak from thede "ambulatory cases" and "typhoid carriers" 
 as they are called. , . 
 
 In this State typboid fever is spread by excreta from cesspools, 
 and leaking or overfilled privy pans percolating through the sub- 
 soil into wells and underground tanks; from contaminated dust 
 being blown into uncovered tanks, both under and above ground ; 
 and by flies, especially in houses near cattle-yards, carrying infec- 
 tion to food and drink. 
 
 Predisposing causes are recognised — such as illhealth, pro- 
 longed anxiety, lack of exercise, overwork, monotony of di^t, 
 ^indigestion, especially gastric disorders accompanied by a loath- 
 ing for fo&d and an absence of the natural acids of the stomach, 
 and exposure to foul air and other insanitary conditions in sub- 
 jects not accustomed to such. 
 
 The more healthily a person has lived in sanitary surroundings 
 the more likely he may be to suffer when he first comes into con- 
 tact with or lives in insanitary conditions. This is often evi- 
 denced in persons going from cities to the goldfields. 
 
 One attack very often confers immunity for a lifetime, but 
 second attacks are sometimes met with. It is not known whether 
 the mildriess of a first attack renders one more liable to a second. 
 Third and fourth attacks " occur, but are most exceptional. 
 
 Since typhoid fever attacks persons mostly at an age when 
 their economic value to the community is greatest, the economic 
 loss is immense. It has been Calculated that in America the 
 money loss through this disease is £20,000,000 annually. 
 
63 
 
 Infection. 
 
 The disease is eommunicable from the time of the first appear- 
 ance of symptoms, sometimes even before the fever, and until the 
 -typhoid bacilli are absent from the body discharges — ^usually, 
 at the time of convalescence; but they may continue to be dis- 
 charged in the faeces, the urine, and in pus from abscesses, even 
 for years after health is restored. Persons also may be "car- 
 riers" of the infection of typhoid fever who give no history of 
 laving ever suffered from the disease. The disease has been 
 produced experimentally through the medium of the bites of 
 laed bugs. 
 
 With the possible exception of infection by way of the lungs, 
 the infective material enters the system, only by one portal — 
 "the alimentary tract — by the agency of food and drink, by dust, 
 and by contaminated hands. 
 
 Incubation. 
 
 The period of incubation is usually from 10 to 14 days. It 
 may vary from seven to 23 days. During the incubation period 
 there may be languor, headache, disturbed sleep, night sweats, 
 and impaired appetite. 
 
 Invasion. 
 
 The stage of invasion, which is not sharply defined, is reckoned 
 to begin with the marked appearance of fever. It may last from 
 two or three days to two weeks. The symptoms usually appear 
 gradually. Slight chilliness, or repeated chilliness, is often 
 noticed; and this distinguishes typhoid fever from other 
 infectious fevers, in which a single chill usually marks the begin- 
 ning. Exertion causes fatigue, sleep is light and disturbed, the 
 appetite fails, there are occasional abdominal pains, nausea, a 
 coated tongue, which soon becomes dry, severe headache, weary 
 aching in the limbs, and sometimes dullness of hearing, and a 
 feeling of roaring in the ears. In children the symptoms of the 
 ■disease may appear suddenly. The patient is listless and 
 apathetic, and lies with eyes closed, as if asleep ; the cheeks are 
 reddened; the skin feels hot and dry; delirium may occur at 
 night; appetite is lost, but thirst is present; the abdomen is 
 -usually full. Sometimes there is cough, and not infrequently 
 Heeding from the nose occurs. 
 
 Towards the end of the first week, or at the beginning of the 
 second, the characteristic rose spots appear. They are to be 
 seen first upon the abdomen, the back, and the lower part of the 
 ■chest. They may also be found on the thighs and upper arms. 
 'They do not occur on the face. They appear in successive 
 ■crops, and the number varies greatly and bears no relation to 
 the intensity of the fever or the severity of the disease. Each 
 spot is small, slightly raised, and rose-oolored, and varies in size 
 from a pinhead to a lentil. The color disappears on pressure, 
 but returns almost immediately. Sometimes one finds instead 
 
64 
 
 of rose spots, blue spots about the size of a split pea. These 
 may be seen in the situations where the rose spots usually occur. 
 
 During the second week the symptoms are intensified. Torpor 
 and somnolence become more marked. Delirium continues, the 
 patient remains in a continuous stupor, the tongue becomes red 
 down the middle and at the sides, it is protruded slowly and is. 
 tremulous. The face looks drawn, it loses its former reddish 
 appearance and becomes pale. The mouth is partly open,, 
 exposing the upper teeth, which, like the lips, are covered with 
 "sordes" — dry, dark crusts. The voice is weak, and may be 
 hoarse. Dry cough is sometimes troublesome. 
 
 The symptoms persist during the third week, after which a 
 gradual improvement usually sets in. The mind clears up, the 
 tongue becomes moist, appetite returns, and about the fifth or 
 sixth week the patient is convalescent. 
 
 Complications. 
 
 Bed sores may occur and prove troublesome. Abscesses are not 
 uncommon in some epidemics. Hsemorrrhage from the bowels 
 may occur. Parotiditis, resembling mumps, is sometimes seen,, 
 and then suppuration oi the glands usually occurs. Perforation 
 of the intestines, when it occurs, is usually, though not invariably^ 
 fatal. 
 
 Isolation. 
 
 In hospitals, cases of typhoid fever are often treated in the 
 general medical wards, and there is no reason why this should 
 not be done. The custom gives nurses and students opportunities 
 of study that might not otherwise be available to them. If the 
 patient is treated at home he should be isolated in a room by 
 himself. The room should be cleared of all unnecessary furniture 
 and furnishings. The room should be fly proof. 
 
 Disinfection. 
 
 Everything used by the patient should be disinfected before 
 being removed from the room. All discharges should be received 
 into strong disinfecting solutions. Every precaution must be 
 taken to prevent any utensil from being used for other persons 
 without being disinfected. No person attending the sick, in fact, 
 no person living in the same house, should milk cows or have 
 anything to do with dairy work. 
 
 Eetuen to School. 
 
 As a rule children will be able to return to school as soon as 
 strength is recovered after convalescence, provided that no 
 typhoid bacilli are found in the body discharges. 
 
 Quarantine of the Exposed. 
 This should extend to 28 days. 
 
65 
 
 INFLUENZA. 
 
 For many hundred years past a strange disease has from time 
 to time appeared in various places on the habitable globe, has 
 spread_ widely and usually rapidly, has devastated whole 
 countries, killing multitudes, and causing much permanent iU- 
 Ihealth among jthe survivors, and then has seemed to die out, only 
 to re-appear, perhaps, several times in the course of the next 
 •century. No other disease has ever been so widely diffused. So 
 strange was it in its mode, or modes, of origin, so unaccountable 
 in fts methods of spread, and so often associated with strange 
 meteorological or other phenomena, that its cause was suspected 
 io be some peculiar stellar or telluric "influence." Hence it 
 was named "Influenza." 
 
 But it had, and still has, many other names. About 40 of 
 ihese might be enumerated. Some of these names have been 
 given to it on account of the way in which the disease seizes its 
 victims, e.g., La Grippe and Blitz-katarrh ; others on account of 
 the bodily symptoms to which it gives rise, e.g., Pebris eatarrhalis 
 (catarrhal fever) ; others because of the manner in which it has 
 T)een supposed to spread, e.g., Catarrhus ' a contagio — catarrh 
 from contact; others from certain peculiarities that have at- 
 tracted attention, e.g., Schaffhusten and Huhner-weh, from the 
 peculiar character of the cough; others from some incidental 
 feature seen during the epidemic, e.g., Coqueluche, because the 
 sick wore a close cap over their heads ; others from the name of 
 the country in which it appeared or from which it spread, e.g., 
 the Germans and Italians called it the Russian disease, a name 
 also given to it by the English in 1889; the Russians called it 
 €hinese catarrh ; the French call it Spanish catarrh or Spanish 
 influenza, the last being the general name by which it is known 
 in the present epidemic. 
 
 Although epidemics have shown great variation in their origin, 
 ■course, and minor manifestations, they have usually presented 
 much the same broad features since the time when the disease 
 T)ecame the subject of systematic study. No class of persons can 
 "be said to have been exempt from the ravages of 'this disease. 
 The very old have usually been the most severe sufferers, 
 ■although in some epidemics the disease has proved serious to very 
 young children. It would appear that certain types are 
 associated with patients at particular ages. Outbreaks may occur 
 suddenly and simultaneously in many isolated places, and have 
 occurred even in vessels that have been at sea for from three 
 to four weeks. The spread is usually rapid — as fast as the speed 
 of human traffic — and often mysterious. The complications may 
 
66 
 
 be dangerous. The mortality may be very great. The after- 
 effects of the disease may be many, various, severe, and long con- 
 tinuing. An attack confers no immunity on an individual; ia 
 fact, it would sometimes appear that a person when once affected 
 became more liable to another attack. The lower animals as 
 well as human beings may suffer from the disease. 
 
 An epidemic in any given locality usually subsides in a few 
 weeks, but it may light up again in a few months or reappear- 
 after a longer interval. 
 
 The discovery by Pfeiffer in 1892 of a germ associated with 
 the malady, promised to east light on many of the problems of 
 the origin and spread of the disease that formerly were insoluble. 
 Certain observations and investigations made during the present 
 epidemic, however, show that the bacteriology of the disease pre- 
 sents many difficulties. The association of Pfeiffer 's bacillus 
 with the disease is not the simple matter it appeared to be a few 
 years ago. It may be that Pfeiffer 's bacillus, when found in the 
 secretions of healthy persons, may resemble the diphtheria 
 bacillus in that it may spread the disease to others without 
 infecting the "carrier." It may be, again, that Pfeiffer 's; 
 bacillus, although not detectable by microscopic examination in,, 
 or in cultures from, the secretions of diseased persons, may still 
 be present in these secretions, but may be "masked" or "over- 
 grown" by other micro-organisms that are commonly found tO' 
 be present. And it may be that the germ, or virus, that causes, 
 influenza has not yet been isolated. 
 
 In a memorandum issued by the English Local Government 
 Board the position is set forth thus : — ' ' It is still an open question 
 whether Pfeiffer 's bacillus is the specific cause of Influenza, or- 
 whether in relation to this disease it occupies a position analogous 
 to that of the pneumoeoccus or streptococcus, though perhaps a 
 more important cause than these of the secondary complications: 
 of Influenza. In view of the above considerations, it is impossible 
 to set up an unerring bacteriological test for Influenza, and its; 
 clinical symptoms are so multiform as not to permit of a dif- 
 ferential clinical diagnosis in all cases. The one distinctive 
 feature of the disease is its occasional occurrence in epidemics: 
 and in world--wide pandemics. It is impracticable, however, to- 
 base a diagnosis of this characteristic ; for it would exclude cases 
 occurring in the intervals of an epidemic, and ordinary non- 
 influenzal cattarrhs would be included. For the present it must 
 remain uncertain to what extent severe catarrhs' or febrile 
 attacks without catarrh occurring in inter-epidemic J)eriods are 
 true Influenza ; and whether when Influenza becomes widely pre- 
 valent this occurs as the result of increased virulence of disease 
 already prevalent or by introduction from some unkno-wn focus 
 of a new strain of disease. Attack by Influenza enhances the 
 virulence of pneumococci and streptococci — previously present 
 
67 
 
 possibly as harmless saprophytes — and much of the mischief 
 caused by Influenza is due to this. We are ignorg,nt as to the 
 causes which lead to the occasional world-wide spread of In- 
 fluenza. ' ' 
 
 Prophylaxis.. 
 
 Until the true cause of the disease is scientifically known, the 
 employment of an;^ prophylactic would be founded on an em- 
 pirical basis. The difficulties of logical medical investigation in 
 any given case are' numerous and arduous, and rarely is the con- 
 clusion scientifically justified from the premises. In reference 
 to influenza it ought to be said that in not a few epidemics there 
 is ground for believing that quinine in doses of 2 grains every 
 morning has been useful in preventing people from taking the 
 disease. Apart from this, one cannot say that any other drug 
 has been really found useful, except in so far as the taking of it 
 gave the taker a quiet mind, and reminded him or her to avoid 
 infection by contact. 
 
 On the subject of vaccines against influenza, it is generally 
 acknowledged that until the true germ or virus of the disease has 
 been scientifically established, the use of any vaccine would be 
 altogether experimental. On this subject the Department of 
 Public Health of the United States in November, 1918, issued the 
 following cautionary advice : — ' ' In view of the exaggerated, and 
 in some respects misleading, statements that have jippeared In 
 the public press regarding the value of bacterial vaccines in the 
 prevention and treatment of infltienza and the pneumonias which 
 so often complicate it, the following statement is made: The 
 evidence that has been presented thus far does not warrant the 
 reposing of confidence in any infiuenza vaccine for either pro- 
 phylactic or therapeutic purposes. . . At present ^t can be 
 said that vaccines may be used in a purely experimental way, and 
 pains should be taken to collect data on the incidence of the 
 disease among both the vaccinated and the unvaccinated. ' ' 
 
 Infection. 
 
 Whatever may be the particular germ, or the special association, 
 of germs that gives rise to the disease, several facts may be deemed 
 settled, or several suppositions may be considered as highly pro- 
 bable regarding infection. The ipfective matter may be con- 
 veyed from one person to another by bed clothes, towels, 
 handkerchiefs, cups, spoons, and such-like means; by droplets 
 of moisture in the air which are being continually thrown off in 
 sneezing, coughing, , speaking, and singing; and by shaking 
 hands, kipsing, or other modes of personal contact. 
 
 Infection occurs most probably by way of the nose, throat, and 
 lungs. It may be made easier if the individual exposed is 
 suffering from an ordinary cough or cold. Persons living or 
 
68 
 
 working in overheated and badly ventilated rooms are predis- 
 posed to infection. 
 
 The .disease is spread by actual contact with, or by the 
 secretions of, persons who are sick, or who, though not sick, are 
 "influenza carriers"; and it is usually caught in overheated and 
 badly ventilated rooms, places of amusement, schools, churches, 
 factories, railway carriages, and tramcars. Climate in itself, 
 or season, does not appear to have much influence. Overcrowding 
 in homes, places of amusement, schools, churches, factories, 
 prisons, railway carriages, and tramcars is one of the most 
 powerful factors in the spread of the disease, even where- none 
 of the persons present may be obviously ill. In every epidemic 
 the dangerous and unrecognisable "influenza carrier" may be 
 everywhere about, and is all the more effective in spreading mis- 
 chief because he is a quite unconscious agent in the process. 
 
 Avoidance. 
 
 The practical advice to follow is: — Avoid all crowded places. 
 Breathe through your nose. "Within 3ft. of a person you are 
 decidedly in the danger zone. When coughing or sneezing 
 never, on any account, omit to turn your head aside and to put 
 a handkerchief before your face. Do not speak directly in a 
 person's face, or allow anyone to speak directly in yours, in case 
 the droplets of moisture in the breath should carry infection. 
 
 Wash your hands and face often, not so much to make them 
 clean as to keep them clean. Do not use another person's towel, 
 napkin, spoon, fork, drinking cup or glass unless it. has first been 
 washed. 
 
 Have your house and room well ventilated. Live always in 
 fresh air, and as much as possible in the open air and sunshine.. 
 Walk to your work if possible. Avoid fatigue. Bat good 
 nourishing food in proper quantity. 
 
 Avoid persons who may have been in a possibly infected place. 
 Keep away from any place that may be infected. 
 
 Avoid people who have ' ' a cold. ' ' Keep away from everybody 
 if you have a cold. 
 
 If you are struck by a chill, pains in the head, eyes, back or 
 elsewhere, aching, feverishness, giddiness, nausea, or prostration 
 — whether you have "a cold" or not, and whether or not there 
 is influenza about — go to bed at once, send for a doctor, and 
 until he comes f-emain as strictly isolated as possible. 
 
 Incubation. 
 
 The period of incubation, that is, the time between the entrance 
 of the "germ," or of its products, into the system and the first 
 manifestation of symptoms, is usually from three to four" days, 
 oftenest perhaps two ; but it may be no more than one day, and 
 
69 
 
 it may even be only an hour or two. There may be no symptoms 
 of any sort during this stage. 
 
 Invasion. 
 The invasion of the disease, that is, the appearance of 
 symptoms, is usually abrupt. It may be almost "apoplectic" 
 in its suddenness. The sufferer may be struck with chill and 
 acute frontal headache, with pains in the small of the back, or 
 with general aching with giddiness and nausea and depression. 
 Vomiting, diarrhoea, or abdominal pain may be present. There 
 may be running at the nose and eyes; suffusion of the eyes, 
 drooping of the upper eyelids, squint; cough, sore throat, high 
 temperature, sleeplessness, prostration, or great debility. Bleed- 
 ing from the nose may occur. In some very acute cases the 
 symptoms may subside in about three days. In most cases, how- 
 ever, th'ey persist for about a week, when the patient becomes 
 convalescent. Weakness, sometimes of a profound character, may 
 be experienced for several days after getting up. 
 
 Complications. 
 
 Almost every epidemic shows some peculiarities in its character 
 or in its complications during some period in its course. Like 
 the European epidemic of 1889, the present epidemic is charac- 
 terised by a large amount of cases in which pneumonia occurs, 
 and causes very serious symptoms. 
 
 In some epidemics a study has been made of the influence of 
 the disease upon patients in hospital who were under treatment 
 for other diseases. It was found that consumption made more 
 rapid progress; diabetes became intensified; chronic kidney 
 disease became acute; epileptics had more fits than usual; heart 
 disease became complicated by other conditions. 
 
 The after-effects, or sequelae, of influenza have often been veiy 
 pronounced, such as neuralgia, neuritis, heart weakness, sleep- 
 lessness, mental disorders with suicidal tendencies. Almost every 
 epidemic has been characterised by some dominant sort of 
 sequelfe, which may be more serious than the original or the 
 primary disease. One of the commonest, however, has been 
 muscular rheumatism, which may occur for the first time after 
 an attack of influenza, and may persist for many years. 
 
 Isolation. 
 
 The patient should be put to bed at once and the doctor called. 
 Isolation should be on the same lines as for diphtheria, and should 
 be complete. Early bed helps isolation, it means rest, and it 
 appears to be the best preventive of a "serious" or "dangerous" 
 form of the illness and of a relapse. The patient should be kept 
 
70 
 
 io ,lpe(i for at least three or four days after the fever has gone. 
 The sick room should be a warm, open room, with as much sun- 
 light and fresh air as possible. It should be forbidden ground 
 to everyone but the nurse and the doctor. All attendants on the 
 sick should wear masks. Isolation, it should be noted, does not 
 mean geographical separation so much as the establishment of 
 barriers against the passage of infected material from the patient 
 to other persons. Treatment in hospital is to be preferred, if 
 obtainable. If carried out at home, the patient's bed may be out 
 of doors, say, in a sheltered part of a verandah. Everything that 
 has been used by the patient should be disinfected before being 
 used by others or else destroyed. 
 
 Disinfection. 
 
 The directions for the management of the sick room and disin- 
 fection laid down in the chapter on "The Sick Room and Disin- 
 fection." Whether the patient is the "first case" in the house- 
 hold or not, every precaution should be taken against the spread 
 of the disease in the house and from the house. If it is the first 
 case in the district, the responsibility of effective control is all 
 the greater ; for in the case of an epidemic of disease of this sort 
 he is best his own friend who is his brother's keeper. 
 
n 
 
 CONSUMPTION. 
 
 A Notable Subject. 
 
 Consumption, or tuberculosis, has come to be known as "the 
 great white pla^e." It "claims more victims, produces more 
 misery, is destructive of more happiness, creates more poverty, 
 and interferes with the public weal to a greater extent than any 
 other disease ever known to man." But while it has been the 
 cause of so much mental and bodily suffering, it has, at the 
 same time, been the occasion of the display of such mental forti- 
 tude as almost to be one of the most potent moral forces in 
 ancient or modern times. Many of the world's most eminent men 
 and women have been consumptives — among writers, Laurence 
 Sterne, Smollett, Heine, J. Stuart Mill, Thoreau, Artemus Ward, 
 Eobert Louis Stevenson; among poets, Schiller, John Keats, 
 Henry Kirke White, Shelley, E. B. Browning, Thomas Hood; 
 among philosophers, Descartes, Spinoza; among "stage stars," 
 Rachel and many another ; among musicians, Chopin, Mozart, and 
 von Weber ; among physicians, Bayle, Andrew Combe, and An- 
 drew Clarke. When we think how much of the world's best litera- 
 ture and art we owe to the lives— and to the sufferings — of men 
 and women such as these, we must feel something else than pas- 
 sive contempt for persons — ^we can't call them men or women 
 — who would treat aU consumptives as worse than pariahs and 
 no better than lepers, granting them a right to die, with assis- 
 tance in the act if permissible, but denying them their right to 
 live except in physical and moral isolation. A strong antidote 
 is wanted to much of the fashionable medico-moral poison that 
 is being circulated at the present time regarding the rights of 
 consumptives. 
 
 Consumption — Ancient and Modern. 
 
 A disease like consumption could not avoid being the object of 
 much careful observation and inquiry. Hippocrates, the father 
 of medicine, who lived over 2,000 years ago, knew a great deal 
 about consumption from careful observation. He states that 
 the commonest age for its appearance is from 18 to 25 years. He 
 has described the spit, the locality of the pain, the characteristic 
 features of the breathing and the cough, the condition of the 
 skin and nails, the sweats, diarrhoea, emaciation, and post-mortem 
 appearances. He says it is curable if taken early. Aristotle 
 asserted it was communicable. Aretieus gives an excellent 
 description of the disease, and recognises two of the most potent 
 curative factors. Celsus recognised the necessity of getting a 
 
72 
 
 oonsumptive clear away from the surroundings in which he con- 
 tracted the disease. Perhaps the greatest observer, however, was 
 an Englishman, Dr. Bennet, who wrote and spoke from actual 
 experience of the disease in his own person. His book was pub- 
 lished in 1742. 
 
 The Seed. 
 
 It will thus be seen that the older writers had an extensive 
 acquaintance with consumption. It is interesting to find that the 
 writer of one of the newest books on the prevention of tuberculosis 
 culls so much of the medical part of the subject from the classical 
 works of authors who wrote more than half a century ago. In 
 modern times the subject has been very carefully studied, and 
 about 40 years ago almost every point in its nature, cause, dura- 
 tion, and treatment was abreast of present-day knowledge — ^the 
 bacillus excepted. In 1882, Robert Koch, a German physician, 
 showed from observation and experiments that consumption is 
 associated with and propagated by a minute bacillus ; and a great 
 many now believe, and here we may assume, that where there is 
 no bacillus there can be no consumption. When Koch found that 
 a bacillus existed in eases of consumption, and that this bacillus, 
 if suitably inoculated, could cause consumption in another, then 
 writers came forward with the apparently scientific advice, ' ' Kill 
 the bacillus in its lair, and so cure the disease," forgetful alto- 
 gether of the disposition of the individual, or of the fact that 
 there was an individual to be considered. The death of the 
 bacillus in the lung was the summitm boiium ; the life of the 
 person to whom, the lung belonged was a matter of secondary 
 importance. 
 
 Medical art for a time was influenced, and influenced for evil, 
 by the hasty theorising of people whose view was somewhat less 
 than one-sided, after the discovery of the bacillus of tuberculosis. 
 This short road to cure proved, in many instances, a short cut 
 to something else, and "killing the bacillus in its lair" — i.e., 
 administering "specifics" and quack medicines or much vaunted 
 cures — is no longer the approved method of treating consumption. 
 
 The Soil. 
 
 Undoubtedly too much was ascribed to the bacillus. The 
 bacillus will not cause consumption in everybody any more than 
 it will produce the disease in a piece of wood. A lighted match 
 will cause fire only when there is inflammable material. A seed 
 requires suitable conditions for its germination and suitable soil 
 for its grovTth. The bacillus is only one of the conditions, only 
 one factor in the cause of the disease. Where are we to look for 
 the other ? Only in one place — the body ; and it is the body, with 
 its varying conditions and predispositions, that determines 
 whether any process. shall occur, and, if so, what process, and to 
 
16 
 
 what extent. The recognition of the two factors, the soil and the 
 seed, the susceptible body and the inoculating germ, as being 
 necessary before consumption can lay hold on a human being, 
 is what puts the treatment and the prevention of the disease on 
 a rational basis. The bodily disposition to disease is to a large 
 extent in the hands of the individual, and often before the 
 disease has laid hold of its victim he has the choice between a 
 long life and a short one. 
 
 In 1901 a Tuberculosis Congress was held in London. The full 
 title of the congress, which we seldom see quoted, is very signifi- 
 cant. It was the "British Congress on Tuberculosis for the 
 Prevention of Consumption." No doubt the treatment of this 
 malady was discussed, as was also the cause; but in all con- 
 siderations of the cause and treatment, the one idea constantly 
 before the congress was prevention. In that one word is summed 
 up the whole problem of consumption — its communicability, its 
 curability, its heredity, its causation. 
 
 Consumption a Univeesal Disease, but Preventable. 
 
 Tuberculosis, geographically speaking, is a universal disease of 
 civilisation. It may affect every human being and at any period 
 of his life. It may show itself in any or every organ of the 
 human body. It is a communicable disease, but it is a curable 
 disease, especially in its early stages. The vast majority of those 
 attacked by it recover. Further, it is a preventable disease. 
 There is no reason nor any necessity why any particular 
 individual should acquire the disease if proper precautions are 
 taken. A study of the bacillus has given us the means of knowing 
 the doors of exit from one individual, the vehicles of distribution, 
 and the doors of entrance into another. And it is this knowledge 
 that has given us the power to control the spread of this dire 
 malady. 
 
 Consumption not Hereditary. 
 
 Many people — perhaps most people — believe that consumption 
 is hereditary. When asked on what evidence their belief is based 
 they will point to instances where a father or a mother, or both, 
 may have suffered f rom^ consumption, and where the children also 
 have been consumptives. But they have not considered whether 
 or not all the members of the family may have acquired the 
 disease in the same way from a common source. To call all such 
 cases indiscriminately instanced of heredity is an abuse of 
 terms. The question of heredity must be discussed from the point 
 of view of observations and statistics. 
 
 A very careful study of cases has yielded the following con- 
 clusions : — ^First, the percentage of consumptives having a tuber- 
 cular parentage is actually smaller than that having a non- 
 tubercular parentage, and much smaller than would be accounted 
 
74 
 
 for by the additional risk of infection to whicii the former class 
 is subjected; and second, tuberculosis in the parents renders to 
 no inconsiderable extent an immunity to the disease in the 
 offspring — ^an immunity which, of course, is but relative, and not 
 sufficiently protective, but still demonstrable, as is shown by 
 increased resistance to the progress of the disease, and increased 
 tendency to recover among this class. 
 
 The disease is not hereditary. Further, there is nothing in 
 medicine or in scientific observation to show that consumption 
 in the parent predisposes the offspring to contract the disease any 
 more than does any other general weakening cause that may affect 
 the progeny injuriously. 
 
 COMMUNICABILITY OF CONSUMPTION. 
 
 I have already said that consumption has been known to be a 
 communicable disease since the days of Aristotle. Most of the 
 modern study of communieability centres round the exciting cause- 
 — the bacilli or germs. Observation and experiment agree in 
 showing that if the exciting cause, the tubercle bacilli, be im- 
 planted in suitable soil and nourished under suitable conditions, 
 the disease we know as consumption will result. We may here 
 put aside the question of a non-tubercular consumption. 
 
 The recognised sources of these tubercle bacilli are two — con- 
 sumptive people and consumptive lower animals. The tubercle 
 bacillus is not known to "breed on its own" outside an animal 
 body. If bacilli were given off by all parts and in all secretions 
 of the body indiscriminately, the task of combating and con- 
 trolling the spread of this disease would be a hopeless one. What 
 gives hopefulness and practicability to the control of the disease- 
 is the fact that, although it is impossible to "kill the parasite in 
 its lair," or wage war against countless nlillions of bacilli else- 
 where, the channels of communication are accessible, and can be- 
 controUed. 
 
 The flesh and milk of the lower animals are recognised as the 
 usual channels- of communication from them to the human being, 
 but in Australia the danger from these sources is not great. The 
 hximan subject gives off bacilli in the sputum. Many consump- 
 tives, however, do not spit at all. The spit of many others — 
 perhaps of the great majority — contains bacilli only now and 
 then. Pprther, millions and millions of bacilli may be expec- 
 torated, and few of them may be found virulent. Even the 
 virulent or disease-producing have but little vitality, except in 
 specially favorable circumstances. The one thing to fear, the 
 chief source of danger, is dried spit in dark places. Sunlight 
 and fresh air in certain quantity are fatal to the bacilli. The 
 fresh germs are also destroyed without much difficulty by certain 
 substances known as disinfectants or antiseptics. Finally, dried' 
 
sputum, discharges from the air passages, and the continued 
 presence of bacilli in unhealthy rooms, form the chief means bf 
 passing the disease on from man to man. Let us accept these 
 conclusions as widely admitted, and we may discuss the riieans 
 of prevention of the disease. 
 
 Notification. 
 
 If we are to deal with consumption in an effective way, we 
 must have the means of knowing where the consumptive is, and 
 what his physical, social, and sanitary circumstances are. This 
 means that compulsory notification is essential. It has often been 
 said, and widely repeated, that notification is impossible on account 
 of the great inconvenience and hardship it would entail on con- 
 sumptives. Such theoretical reasoning has been disproved in 
 practice. In South Australia, where compulsory notification has 
 been in force for upwards of 20 years, the system has worked 
 smoothly, and has been productive of very valuable scientific and 
 practical results. 
 
 On the subject of notification one must refer to a statement 
 by Dr. Newsholme, because it is likely to be quoted in part 
 only. He says — "At present it would be inexpedient, unwise, 
 and of relatively little use to advise the general adoption of com- 
 pulsory notification of phthisis. Public opinion is not ripe for 
 this step, and such notification would reman to a large extent a 
 dead letter. Local authorities are not ready to utilise the in- 
 formation thus received to the benefit of the patient and the 
 public." This is quite true. Local authorities in Australia are 
 much worse off in this respect than those in England. They are 
 not only not ready, but they have not the means, and it is not 
 possible that they will have the means for many a day. They 
 cannot be expected to undertake the control of consumption any 
 more than they can be expected to make and manage the railways. 
 When ordinary cleanliness and healthy conditions and the lives 
 and well-being of the community are put in the balance against 
 vested interests and permissive action and a halfpenny in the 
 pound health rate, the public weal scale kicks the beam every 
 time. The wise, the observant, the experienced, who know the 
 local conditions of health administration, and have considered 
 this subject of consumption, recognise that it is a State affair, 
 and it is with the State aspect of it that we have here to deal. 
 With notification in force, we not only discover the consumptive, 
 but we have the means of finding whence he comes, and we can 
 determine where he goes or where he ought to go. 
 
 Consumption and Housing. 
 Even the slightest practical experience of the working of 
 notification convinces one that consumption is a house disease. 
 Dr. Flick says: — "Without the house tiiberculosis would Wot 
 
76 
 
 exist. It depends upon the house for its implantation and pro- 
 pagation, and for the evolution of all its phenomena. The house 
 is the place where the tubercle bacillus lies dormant in wait for 
 its new host ; it is the place where the new host gets his implanta- 
 tion; it is the place where the tubercular subject gradually 
 becomes a consumptive ; and it is the place where the consumptive 
 dies. If man desires to free himself from the great white plague, 
 he will have to retrace his steps from some of what he considers 
 advanced points of civilisation. He will have to learn, among 
 other things, that fresh air is God's greatest gift on earth, and 
 that whoever shuts out fresh air shuts out health and happiness. ' ' 
 
 We hear a great deal about the possibility of persons acquiring 
 consumption in the streets, and the risk of taking consumption 
 has been made a reason, if not the chief reason, for passing 
 by-laws against spitting on the pavement. Now, spitting on the 
 pavement is a filthy and indecent habit, and laws should be passed 
 against it, provided they are likely to be enforced; but there 
 is no need to tell well-meaning scientific untruths to support such 
 legislation. It is true that one may acquire consumption in the 
 street, just as it is true that one may acquire pneumonia from 
 the evaporation if one should water it, or bronchitis from the 
 dust if one should omit to water it ; but the chances of acquiring 
 any of these diseases in this way are about equal, and, in the 
 majority of Australian streets, are so small as to be negligible. 
 
 The house, and especially the bedroom, yields the great 
 majority of our consumptives. Formerly, builders had difficulty 
 in keeping the breezes out, and people slept in curtained four- 
 posters in consequence. Now, architecture has improved so much 
 that in these days of burglar-proof windows and Tale locks the 
 air cannot get in, not even by the keyhole. 
 
 For every case of consumption acquired in the streets hundreds 
 and thousands are contracted in houses. Damp sites, damp soils, 
 damp vapors, damp filth, damp floors, damp walls, dark streets, 
 dark alleys, dark houses, closely-curtained rooms, unswept floors, 
 uncleaned walls, contaminated air, flies and vermin-infested 
 places, over-crowded bedrooms, food exposed to contamination in 
 dairies, milk-shops, greengrocers' stores, or in the houses of the 
 patients themselves — these are the conditions in which the 
 bacillus continues capable of existing, and the vehicles by which 
 it finds entrance to a human being, so as to produce the disease 
 should he perchance prove susceptible to it. And even then it is 
 recognised that protracted exposure to large doses of the infection 
 is usually required before the patient takes the disease. 
 _ Next to the dwelling-house, as a breeding ground of consump- 
 tives, comes the factory or the workshop, with its air kept from 
 stagnation only by the occasional stirring up of the infected dust. 
 Along with it comes the public-house, with its dark bar parlors, 
 with damp walls, and unswept and much-spat-upon floors. 
 
What are we to do with the breeding ground of the disease 
 when we have found it? If we were "heathen Chinese" we 
 would hold a street procession of the inhabitants, with a dragon 
 at its head, and conclude the ceremony by burning down the 
 house and every infected article in it. But, being Christians, we, 
 of our Christian charity, allow the owner, especially if he is a 
 town councillor, or the father, cousin, partner, or friend of one, 
 to go on drawing his rents from his uninhabitable house ; and then 
 we endeavor to fan the flame of philanthropic feeling in other 
 citizens by asking them to emulate this public-spirited man, whose 
 name appears in the subscription list as "donating" half-a-crown 
 to a sanatorium for consumptives! 
 
 We shall never act justly to our fellow mortals, or scientifically 
 in our attitude to the great plague, until we ensure equitable 
 administration of the health laws of the State, through officers 
 who are influenced neither charitably nor mercenarily, but only 
 by the knowledge that if they do not do their work they will 
 vacate their office promptly. The housing problem would then . 
 solve itself. Meantime, much might be done, not by the State, 
 not by the local authorities, not by philanthropists, but by private 
 individuals in a business way and on an 8 per cent, basis, along 
 the lines of the Edinburgh Social Union, by building new houses, 
 or buying up old ones and renovating them, and letting them and 
 looking after them in a sane, sanitary, and business fashion. Such 
 houses never lack tenants. 
 
 The Management op tAe Consumptive. 
 
 What, in the next place, is to be done with the consumptive 
 himself, the man who, through lack of knowledge, cannot inanage 
 himself, and is a perpetual or intermittent source pf danger to 
 his neighbors ? First of all, he does not require to be sent away 
 to some much-advertised region, where he will spend as much 
 money in the process of dying, or recovering to be a loafer, as 
 would keep his family in comfort and cure himself under proper 
 supervision at his own home. It is now recognised that climate, 
 per se, has practically nothing to do with the matter ; that t)ie 
 question is not where a consumptive is to live, but how he is to 
 live ; that consumption can be successfully treated anywhere ; that 
 it is pure air and sunshine, and not a particular climate, that is 
 the essential factor in the treatment; and that "the cures of 
 consumption accomplished in the home climate in which the 
 patients remain are more lasting and more assured than when 
 cures have been attained by temporary residence elsewhere." 
 
 There are, broadly speaking, two classes of consumptives to be 
 dealt with— the incapable, and the able to work. The consump- 
 tive incapables are proper objects of the State's care, just as all 
 the bodily and mentally feeble are, and all the more so since they 
 
78 
 
 are usually in the advanced stage of consumption, and likely to 
 be actively dangerous to their neighbors. They are to be kept 
 under constant and effective supervision in institutions or else- 
 where for so long and in such a manner as may be found neces- 
 sary. 
 
 The great majority, however, are those who are able to work 
 and earn the whole or part of their living. These have to be 
 instructed in the art of curing themselves at home, and of pre- 
 venting their disease from spreading to others. It is being found 
 that the most effective measures are short periods of sanatorium 
 treatment, and the provision of medical dispensaries associated 
 with home visitation and help of the patients. The sanatorium 
 is to be regarded as a school for instruction in the value of pure 
 air and cleanliness, sunlight, and suitable food, and the formation 
 of hygienic habits. . It is doubtful if a sanatorium serves any 
 other useful or necessary purpose. The training begun there will 
 be carried on at home and in the workshop by the consumptive 
 himself, under such supervision as may be required in order to 
 render him hygienically harmless. The patient 's conscience may 
 be appealed to, but his self-interest will form the most effective 
 lever' in dealing with him. He must be taught that even public 
 carriers are subject to regulations in such matters as the transit 
 of gunpowder, and that while consumptives have legal and. moral 
 rights, the general public, too, have theirs. 
 
 Education. 
 
 Tuberculosis, it has been said, is a disease of misery. It. is 
 also a disease of ignorance. People now realise the necessity of 
 educating the public, and especially school children, in the facts 
 of personal hygiene and the simple principles applicable to the 
 control of the disease. This education should not be of the 
 alarming or panic variety. Reasonable precautions will be tajcep 
 all the more readily if the facts concerning tuberculosis are fairly 
 and correctly stated, and if the conclusions are logically drawn 
 from the data. 
 
 Administrative Control. 
 
 In various places and very frequently, questions have been 
 raised as to how certain administrative measures of control would 
 be regarded by consumptives themselves, their relatives and 
 friends, medical practitioners, local authorities, the various 
 Governments, and the public generally. In South Australia we 
 learned much on these points in connection with the establish- 
 ment of a system of visiting nurse inspectors of the Central 
 Board of Health ; and the experience of 12 years of compulsory 
 notification of pulmonary tuberculosis in the State was set forth. 
 
ia 
 
 in an address delivered before the Fifteenth International Con- 
 gress on Hygiene and Demography at Washington, in 1912. The 
 system of visiting nurses has proved one of the most efficient 
 agencies of control and education. 
 
 The Economic Aspects op Consumption. 
 
 The machinery for all this work of dealing with consumptives 
 should be provided by the State, and should be under the imme- 
 diate direction of the State health authorities. The question most 
 likely to be asked is, ' ' Can we afford to do it ; what will it cost ? ' ' 
 The question that really demands an answer is, ' ' Can we afford 
 not to do it ; what are we paying now for not doing it ? " 
 
 Dr. Hermann Biggs estimates the total annual loss in the 
 United States from tuberculosis at £66,000,000. He first calcu- 
 lates the loss to New York City by putting a value of £300 upon 
 each life at the average age at which deaths from tuberculosis 
 occur. This gives a total of £3,000,000 for the lives lost annually. 
 To this has to be added the loss due to the fact that for at least 
 nine months before death these patients cannot work; and the 
 loss of service at 4s. a day, and the cost of food, nursing, medi- 
 cines, attendance, &c., at 6s. a day, result in a further loss of 
 £1,600,000, making a yearly loss to the city from tuberculosis of 
 £4,600,000. The estimated annual total of 150,000 deaths from 
 tuberculosis in the United States thus represents a loss of 
 £66,000,000. He shows that the £100,000 spent annually by the 
 city of New York in the care of consumptives does not exceed 2 
 per cent, of the actual loss by death, &c. ; and he adds, ' ' If this 
 annual expenditure were doubled or trebled, it would mean the 
 saving of several thousand lives annually, to say nothing of the 
 enormous saving in suffering. ' ' 
 
 On the same basis of calculation, the loss to the Australian 
 Commonwealth in 1917 was £1,480,160, and the total loss for 37 
 years ending 1917 was £54,216,800. The loss to the individual 
 States was— New South Wales, £17,200,040; Queensland, 
 £6,721,440; South Australia, £5,179,240; Tasmania, £1,831,720; 
 Victoria, £21,315,360; Western Australia, £1,969,000. This 
 refers to money alone, and takes no account of the sufferings of 
 the victims or of tlieir friends and relatives. 
 
 Ineffective Present Administration. 
 
 Another view of the subject has to be presented. In 1907, in 
 the Commonwealth, 3,858 persons died from consumption— 321 
 every month, 74 a week, more than 10 a day, from a single pre- 
 ventable disease, which we take no serious measures to control; 
 and we fold our hands and talk impiously of the will of God, or 
 piously theorise about the birth rate. If this tale of deaths, with 
 
»u 
 
 its baleful accompaniments of sickness and misery, occurred from 
 shipwrecks, or railway accidents, or mining operations, or other 
 similar causes that are really less subject to our control than con- 
 sumption is, the nation would rise and demand that somebody 
 should suffer for something; in other words, there would be a 
 general clamor for active measures of investigation and preven- 
 tion. 
 
 At present if a medical man, for some reason or other, refrains 
 from notifying a ease of consumption, his explanation is received, 
 or excuses are made for him. If an officer of health condemns 
 a consumption house as uninhabitable, the local authority wants 
 to know first of all who the owner is. If a consumptive is found 
 engaged in milking cows, and selling vegetables, or keeping a post 
 office, with a public telephone in it, p'eople say, ' ' Poor fellow, he 
 must make a living somehow. ' ' It does not follow, however, that 
 this particular "how" is the only possibility. Do we allow 
 regulations regarding shipping, railways, and mines to be 
 broken with impunity ? If not, why not ? Because such breaches 
 would involve companies in payments of pounds, shillings, and 
 pence, with costs, while breaches of the Public Health Acts, under 
 the present methods of administration, result only in ill health 
 and death. We still live and act as if we regarded money, even, 
 other people 's money, as of more value than health and lives,' even 
 our own lives. 
 
 The' Summing-up. 
 
 The whole management of consumption is summed up in — (1) 
 abolishing consumption houses and other insanitary conditions; 
 (2) checking the dissemination of the disease by controlling the 
 dangerous cases; (3) teaching people how to be consumption- 
 proof. For this we Require trained health administrators, who 
 will be adequately supervised by and held responsible to the 
 State. Five per cent, of the money at present annually lost on 
 account of consumption, if properly expended, would in a few 
 years establish a complete and effective system of control, and in 
 a few years more might banish the disease from the Common- 
 wealth. 
 
81 
 
 THE SICK ROOM AND DISINFECTION. 
 
 The sick room should be chosen from the point of view of its 
 natural isolation, or the possibility of its being cut olf from com- 
 munication with 'the rest of the house. To isolate a person is so 
 to care for that sick person or "carrier" that the infective 
 material of the disease will not be transferred from that person 
 to any other person either directly or indirectly. The necessary 
 precautions will depend on the particular disease and the con- 
 difion of the patient. Isolation is too often thought of as mere 
 geographical separation, which may not be isolation at all in the 
 medical sense. In this State, wooden houses with plenty of 
 windows may easily be placed temporarily at some distance from 
 the dwelling-houses. Tents, for infectious cases, have been used 
 very largely in connection with ordinary general hospitals, and 
 have proved satisfactory for emergency use. What is really 
 required in a sick room is plenty of air and light, and means for 
 regulating both, an open fireplace, and as little as possible for 
 dust to lie on or infective material to adhere to. 
 
 The room, if in the house, should be preferably at the end of 
 a passage, or at the top of the house. It. should be as far as 
 possible 'from the kitchen. The floor should be bare, although 
 strips of carpet that can be burned afterwards, may be used. If 
 it should be impracticable to remove the carpet it should be 
 covered with linen. If the room is to be used for a long period, 
 the flooring, as far as is possible,- should be made impervious by 
 having all the cracks filled in and then stained and varnished or 
 beeswaxed ; the wall paper should be varnished, or walls stripped 
 and painted, or limewashed; the ceiling should be cemented or 
 painted, or limewashed frequently. All curtains, pictures, 
 ornaments, and unnecessary furniture should be removed. 
 
 Something outside the door should warn people off. The sheet 
 one sometimes sees soaked with carbolic acid is useless, sometimes 
 harmful, from a hygienic point <of view ; but it is a good fetish 
 or a reminder that trespassing is forbidden.' The windows should 
 open, and usually be opened freely and widely for ventilation. 
 The room should always smell fresh. This is the best test of good 
 ventilation. Draughts should be avoided by choosing a good 
 place for the bed or by screens (a clothes horse covered by a 
 blanket or a shawl will do), or by a gauze blind so fixed over 
 the window as to divert the air current upwards. The old- 
 fashioned wide chimney, which is becoming common again in 
 many houses in this State, makes a good air extractor. In all 
 
82 
 
 sick rooms it should be the practice half a dozen times a day to 
 air the rooms thoroughly. The patient may be covered up 
 entirely or otherwise protected, and the room opened up com- 
 pletely for five or ten minutes. There is no danger of chills 
 from fresh air. 
 
 For heating, an open fire is best,, but kerosine stoves may be 
 used. It is often necessary in this climate to cool the sick room.. 
 This may be done by keeping out the sun by curtains outside the- 
 windows. Large sheets constantly wetted may be hung in front 
 of the windows. A block of ice may be kept in a strainer over a 
 basin in the middle of the room. The patient's own feelings, pro- 
 vided his nervous system is not abnormal, will usually be the 
 best guide as to the most suitable temperature for the room and' 
 for his body and the applications to it of heat or cold. 
 
 Artificial light at night may be obtained by a shaded oil lamp, 
 or a "night light," or a "floating light," or a "night candle."' 
 Small electric lamps are very convenient and can now be had 
 very cheaply. 
 
 The amount of moisture in the air may require to be regulated. 
 It can be increased by an ordinary kettle on the fire, or by a 
 "bronchitis kettle," or by dropping very hot bricks into water, 
 or by a hand atomizer. It may be reduced by exposing calcium 
 chloride or other similar substance in vessels in various parts of 
 the room. • 
 
 The furniture should be of the simplest kind. Wooden tables 
 should be varnished. Chairs should be made of wood, and have 
 wooden or cane bottoms. No rocking-chairs should be allowed. 
 The bed should be about 6ft. 6in. in length, about 3ft. wide, and 
 about 2ft. high. Metal beds are best, with wire mattresses, the 
 two legs at the top being mounted on casters. Bed means rest 
 for the patient, and materially contributes to isolation and thus 
 to the protection of others. The bed should not directly face a. 
 window, but should be so placed that the patient may have a 
 view through the window, and that the attendant may be able- 
 to reach it from all sides. The mattress should be made of horse- 
 hair. The sheets should be made of white bleached cotton, not 
 linen. The blankets should be warm, light in weight, and of a 
 white or light-yellow color. The -outer covering should be light 
 — ft light-weight honeycomb spread. Heavy cotton counterpanes 
 and down quilts should be avoided. The pillows should be of 
 horsehair, moderately firm, and properly covered. 
 
 Chamber utensils should be made of glazed white earthenware, 
 or enamelled iron. Bed pans should be made of the same 
 materials. Spit cups should be used, if possible, in all cases where 
 there is a possibility of infection from the sputum. All these- 
 
83 
 
 vessels into which discharges are to be received should contain 
 a solution of cyllin or other suitable disinfectant. If the patient 
 is unable to use a spit cup, then pieces of cloth or Japanese paper 
 should be used and burned immediately. Handkerchiefs and 
 towels which require washing should not be employed. 
 
 The hands of the nurse or attendant should frequently, and 
 after soiling always, be washed in a disinfecting solution. 
 
 For soiled clothes, linen, &c., a large covered vessel containing 
 a disinfecting solution should be kept in the sick room., and all 
 articles should be steeped in it for an hour or more before being 
 removed for further disinfection by boiling. All such articles 
 should then be washed separately from the household linen. 
 
 The daily routine of the sick room should be carefully carried 
 out. The floor should be sprinkled with some material like pre- 
 pared sawdust which gives off no dust, and then swept with a 
 soft hair-broom or floor brush. Pieces of carpet should be taken 
 outside and cleansed in the open air. All walls and furniture 
 should be dusted with damp cloths, not with feather dusters or 
 "whisks." 
 
 The weekly cleaning should consist of scrubbing the floor, 
 doors, window sills, and all other woodwork with hot water, soap, 
 and soda. All basins, bed pans, spit cups, and other utensils 
 should be washed with soap, soda, and water, and boiled for an 
 hour. 
 
 When the patient has recovered, the room should be thoroughly 
 disinfected. This may be done by the officers of the local board 
 of health. If not, the directions published for the cleansing and 
 disinfecting of schools may be followed with certain necessary 
 modifications. If fumigation is to be used the room' should be 
 prepared. The contents should be arranged so that the fumes 
 may reach all the surfaces possible ; at the same time things 
 should not be too much disarranged, since the surfaces that were 
 most exposed to infection should be most exposed to the disin- 
 fectant. All clothing, bedding, towels, and similar materials 
 should be hung on lines strung across the room. The furniture 
 should be, moved away from the walls. All drawers and doors 
 of closets, wardrobes, cupboards, &c., should be opened. The 
 fireplace should be closed up ; the windows sealed with strips of 
 gummed paper. Then the autan or formalin should be 
 generated according to directions, and the door closed and sealed 
 outside with strips of paper. The room may be left in this con- 
 dition for 24 hours. Then everything in it should be taken 
 outside and exposed to the fresh air and sunlight, and the room 
 itself thrown open and thoroughly aired. 
 
84 
 
 I^ the. formalin spray is to be used the room ought to be 
 thoroughly heated, unless the weather is warm. Prepare the 
 rpQm as for fumigation. Spray all walls and the contents of the 
 room,, then seal it up and deal with it as in fumigation. 
 
 Note. — In cohnfection with this subject attention is directed 
 to "The Cleansing and Disinfecting of Schools in South Aus- 
 tralia," C. B. Bristow, Government Printer. The principles and 
 practice of disinfection are dealt with at some length in Bulletin 
 No, 1 of the Departnient of Public Health of this State "On 
 Cleansing and .Disinfecticm in the Control of Infectious 
 Diseases."