APPENDICES TO THE REPORT OF THE HEALTH OFFICER OF THE DISTRICT OF COLUMBIA. The publication of these reports as appendices to the report of the Health Officer is not to be construed to mean that the opinions and recommendations set forth in them have been adopted by the Health Department. 31 APPENDIX A. REPORT OF THE MEDICAL SANITARY INSPECTOR. SIR: I have the honor to submit the following report relative to the scarlet fever and diphtheria service for the fiscal year ending June 30, 1900: During the year 1,109 cases of diphtheria, with 197 deaths therefrom, were reported to this department. The proportion of cases to the total population was 39.17 per each 10,000. Of the whole number of cases only 211, or 19 per cent, were colored. While the number of cases occurring among this portion of our population is so very much smaller than among the whites the death rate is as usual very much higher. Of the whites 144 died, a mortality rate of 16 per cent, while 53 of the colored cases succumbed, making a death rate of 25.1 per cent. The mortality for all cases was 17.76 per cent. A comparison of Table I with that of the report of 1898-99 shows an increase of 50 in the number of cases of diphtheria reported; also an increase in the general mortality of 1.23 per cent. There has been a decrease of 93 in the number of colored cases, while the death rate has increased from 21.7 per cent to 25.1 per cent. Table II shows the ages of the patients, and, as in former years, that the largest number of cases reported was between the ages of from 3 to 12 years, 68.9 per cent of all cases occurring during that period of life. There was a decrease in the death rate of children under 1 year of age, but a marked increase in those over 12. In the bacteriological laboratory there were examined 3,157 cultures for diagnostic purposes and to determine the termination of quarantine. The number of primary cultures was 1,209, and of these 567, or 46.9 per cent, were positive. While the total number of cultures. examined was slightly increased (227) over the number for the previous year, it is not pleasing to note that the number of primary cultures decreased from 1,312 to 1,209. It is hoped this does not indicate carelessness on the part of the medical profession or a tendency to rely on the clinical aspect of the disease to the exclusion of the bacteriological. This particular branch of the service has been of inestimable value in the past in determining the presence of the disease germs where there were no other symptoms, and by the isolation of the persons in whose throats the organisms were found outbreaks in several institutions have been aborted. We hope the physicians will avail themselves more of its advantages. Of scarlet fever there were reported, as shown in Table III, 893 cases, of which number 23, or 2.57 per cent, terminated fatally. The number of cases reported was 101 less than during the year ending June 30, 1899. The death rate, however, was slightly increased from 2.11 per cent to 2.57 per cent. The cases occurred in the proportion of 32.13 7165-003 33 to each 10,000 of the population. Only 57 of the cases were colored, among whom the death rate was 8.77 per cent. The mortality of the white cases was 2.15 per cent. This is a slight increase in the mortality among the whites over the previous year, but a marked increase among the colored. The death rate among the latter last year was only 1.92 per cent. Table No. IV, showing the ages of those who were affected with scarlet fever, does not differ materially from that of other years, except that the deaths were not confined to those of early life, as two persons over the age of 12 died. These are the first at that age for over five years. This disease has continued its mild course, and to this is due in a great measure the large number of cases reported. It is a very common occurrence to be told on visiting a case of this disease that there had been others in the neighborhood which had not been treated by physicians, but which were allowed to go about while scaling. Our informants invariably decline to give the names of the persons, which renders it impossible to enforce the law or secure disinfection of the premises. The need of medical supervision of the public schools has been forcibly indicated by the fact that in two of them we accidentally discovered children who were attending school, although in the stage of desquamation. The cases had never been called or considered scarlet fever, but the parents when questioned gave a good clinical history of the disease, and the fact that other children in the school were taken with it demonstrated its nature. After they had been isolated and the school disinfected no other cases occurred. We have had again occasion to note an outbreak of this disease, due to milk infection. During the latter part of January, 1900, it was noticed that cases of scarlet fever were being reported with a considerable degree of frequency among the consumers of milk furnished from a certain dairy. The reports began to be sent in January 14 and continued until February 15, when 33 cases had been recorded in 29 different premises. The cases were reported as follows: At first little attention was paid to it, as this particular dairyman has a very large business, especially in the section of the city where the the cases occurred, but when the reports began to be received at the rate of two and four daily, steps were taken to ascertain the origin of the infection and to remove the cause if possible. Frequent visits were made by both the medical sanitary inspector and his assistant to the dairy. The premises and employees were examined thoroughly, but no evidence of the disease was found upon them. It was learned that the milk furnished these families came for the most part from two shippers. The farms of these two men were inspected by Drs. Lynch and Turner, but nothing of a suspicious nature was found. It was also noted that two drivers were principally employed in delivering the milk to the infected houses, but nothing could be detected about them or their families from which the cases could arise. Finally, February 9, the dairy was thoroughly cleaned and disinfected under the supervision of the assistant medical sanitary inspector and no more cases occured after allowing for the period of incubation in the cases already infected. The last case was reported February 15. Sometime after this it was learned that shortly before January 14, one of the employees had been under treatment for what was thought at first to be diphtheria, but a culture having been submitted showing the absence of the bacillus of that disease, he was allowed to go at large by the attending physician. It was discovered, however, that desquamation of the skin took place and had not entirely ceased when he sought and obtained employment at the dairy involved. It is more than probable that his case was one of scarlet fever and was the source from which the others came. The following correspondence in the case is submitted, the names of the persons being for obvious reasons omitted: WASHINGTON, D. C., February 7, 1900. DEAR SIR: I have the honor to report that since January 14, 1900, there have occurred among the consumers of milk from the dairy of Mr. 28 cases of scarlet fever, in 26 families. The milk furnished was distributed among the following dairy farms: F., 1 family; W., 1 family; M., 9 families, and D., 13 families. The drivers whose routes were affected are: S., 1 case; W. and R., 4 cases; M., 10 cases; Sr., 7 cases; R., 2 cases, and H. and L., 1 case each. The dairy farms of Messrs M. and D., from whom practically all the milk used by the infected families came, were inspected by Drs. Lynch and Turner and found to be in good condition, and no evidence of the disease among the help or their families. All the help at Mr. -'s dairy were examined and no evidence of scarlet fever was found upon them. In my opinion the cause of the spread of the infection is in the method of washing and filling the bottles at the dairy. In an apartment of about 18 by 12 feet, combining a boiler and engine room, washing and general utility room, the milk is handled. Each driver has his own bottles, for which he is responsible, and does not mix them with those of any other driver. On his return from his route he backs his wagon up to the door-which is being opened and shut constantly, allowing manure, etc., to blow into the milk, which is being bottled-brings his bottles in, and turns them over to the cleaners. The cleaning is done by means of a revolving brush and hot water. After being brushed out and rinsed, they are put in a rack over a cesspool to drain. By the time they get there the driver is ready with his milk to fill them. Without washing his hands he takes each bottle by the neck, and holding it over the can, fills it with a ladle. Frequently too much is poured in, and the milk runs over his dirty hands and sides of bottle back into the can. It is probable that one or more of the bottles might have the contagion of scarlet fever on the outside, as I often find them in the sick room. When they are drained in the rack some of the infection is washed down to the bottom, and when other bottles are placed there some of the contagion probably adheres to them and is washed into the main supply when being filled. Another source of danger is the brush for cleaning. The water in which the bottles are washed is only changed after the bottles of two or three drivers are washed. This brush and water is liable to become infected and contaminate the bottles. It seems impossible to ascertain just how the infection in the cases referred to occurred, but is probably due to one of these causes. I would respectfully recommend the following: First. That Mr. be required to have all the bottles now in use boiled for an hour, the racks washed with a solution of bichloride of mercury, 1 part to 1,000, and the brush cleaned with a 1 per cent solution of formaldehyde. Second. That a separate room be provided for filling the bottles, and the cans be not opened at all in the general room. The bottles in filling should be set on the floor or in a tray, so that the overflow milk may not run back into the can. Third. That the water used for washing the bottles be changed frequently and the brush be cleaned each day with a 1 per cent solution of formaldehyde. Very respectfully, Dr. WILLIAM C. WOODWARD, JOHN E. WALSH, M. D., Health Officer. |