of puerperal septicemia are rarely met with now where the principles of asepsis and antisepsis are strictly carried out, and the great terror of the midwife now is not in the after treatment of the parturient woman, nor of the diseases resulting therefrom, but his anxiety is that he observe all the precautions against causing or allowing infection.

Because it is now well understood that the attendants are largely by their ignorance or carelessness, responsible directly or indirectly for the occurrence of the disease.

PREVENTIVE MEDICINE, WITH A STUDY OF THE INFECTIOUS DISEASES PREVALENT IN VERMONT.

BY C. S. CAVERLY, RUTLAND, VT.

I do not know that our experience in Vermont with infectious diseases has differed from that of other States in our latitude and with similar topography. But it has occurred to me that no definite study has been made of these diseases by our society, and I ask you to consider the status of Vermont as regards the prevalence of such diseases here, based on the most reliable data at hand, and what it behooves us, as modern medical men, to do in preventing them.

"

It may not be generally known that one of the earliest books on the subject of infectious diseases, was written by a member of this Society and published in Woodstock in 1815. 'A Sketch of Epidemic Diseases in the State of Vermont," with a consideration of their causes, phenomena and treatment, by Jos. A. Gallup, M. D., was for years I am told, authority not only in Vermont but throughout the country. From this work I find that our forefathers' diseases were very much the same as ours, even to hydrophobia and the influenza. The words typhoid and typhus were used interchangeably and the fever was very prevalent. Measles and small pox were the two diseases most dreaded for their contagious properties. Canker-rash and malignant and ulcerous sore throat are mentioned as the same disease and are not considered conta. gious, while other diseases considered are, spotted fever, dysentery, croup and consumption. At a distance of 75 years, Dr. Gallup and his theories look primitive enough, but who shall say that our own now modern theories, in which hydrophobic inoculations, tuberculin injec tions and the elixir of life, play prominent parts, will not look even more ridiculous to our professional descendants.

In 1857 our State inaugurated a system of gathering vital statistics,

which seeks to give the number of marriages, divorces, births and deaths yearly. These statistics are gathered as you are probably aware, by school district clerks, and are compiled and tabulated by the Secretary of State. I feel that an apology is due this Society for making use of them here, but since they are the only statistics on this subject which we have, I am compelled to use them, incomplete and inaccurate as they are. That they are incomplete and inaccurate, any casual observer can see, and all I claim for the figures I gather from them, is that they are approximately and relatively correct: that they may show approximately the number of deaths from certain diseases and consequently the prevalence of those diseases; and that the errors in the matter of one disease may possibly be offset by like errors in another, and thus their relative prevalence be substantially correct.

From these Registration Reports I have prepared charts showing the mortality year by year from most of our infectious diseases. These are so arranged that a glance will show the number of deaths recorded each year from each disease, and a hasty comparison can be made. The Report for one year (1881) is missing and a copy of it cannot be found. I have selected those diseases of well known infectious character, and against which as a profession, we are bound to adopt preventive measures, viz., small pox, measles, scarlet. fever, diphtheria, typhoid fever and consumption.

Others, such as whooping-cough, cerebro-spinal meningitis and erysipelas, might properly be included, but I take only such as are now generally recognized as infectious and preventable, and at the same time important causes of mortality.

It will be seen at a glance that small-pox and measles do not figure conspicuously as destroyers of life: that deaths from scarlet fever, diphtheria and typhoid fever are very numerous, while consumption in nearly every year, maintains a commanding lead. The deaths from consumption during these 32 years, range from 650 to 850 yearly; from typhoid fever, from 100 to 550; from diphtheria as high as 1200 in a single year; from the others, a much smaller number.

The death rate from consumption has fallen off slightly during the past decade; that of typhoid fever has had a decided decline; and that from diphtheria, while subject to greater fluctuations, has not declined during the past 10 years.

Thus much for the relative mortality of these diseases. Their prevalence can be roughly computed from these figures and may be supposed to follow much the same curves. Studying the statistics in regard to consumption from another standpoint, I find that the death rate of the different counties does not vary markedly. During the period covered by these records, I find that there has been 2.7 deaths per 1000 of population in Caledonia Co., which has the largest percentage, and 1.9

per 1000 in Grand Isle Co., which has the smallest. Orange and Washington are among those having the largest death rate from consumption, and Franklin, Essex and Addison those having the smallest. I do not know that any significance attaches to these figures, beyond perhaps the fact that there is a slight difference in favor of those counties bordering on Lake Champlain. Of the five counties bordering on this lake, I find that there have been 2.1 deaths per 1000 of population in the State as a whole. It would be interesting to note how these figures compare with other parts of the world, but reliable figures on the subject are scarce. In a paper by Dr. Bryce of Canada, I notice that for the period 1857 to 1887, the average rate per thousand in England was 1.97 with a steady decline from 2.67 in the former year to 1.59 in the latter. The figures for the State of Rhode Island during the past 35 years are 2.49 per thousand. The rate for Massachusetts in 1886 was 2.69, which was stated as the lowest for many years. The rate for New York State is 3.56; for rural New England, as a whole, 2.30; for Switzerland 1.80 (Aimee Raymond, Medical Record, Oct. 17, 1891.)

Of the 23.619 deaths, of which I find records during the past 32 years in Vermont, I find 3765 or 16 per cent were under 20 years of age; 5393 or 24 per cent between 20 and 30 years of age, and 3598 or 15 per cent between 30 and 40 years. Nearly 14 the deaths from this disease occur between 20 and 30 years and more than 11⁄2 under 40 years.

Diphtheria, according to the death rate by months, shows the same characteristics as are observed elsewhere. The highest death rate is in cold weather, the lowest in warm. The distribution of this disease is perhaps more significant. There has been the greatest mortality from it in Caledonia Co., where there has been 1.1 death each year to each 1000 population, and Windam and Washington Counties come next in order, while the lowest fatality has been in Essex, Rutland and Franklin Counties. I find that the disease has been more fatal in the Eastern counties of the State than in the Western; by this difference, that while in the Eastern counties there has been .79 deaths per 1000 living population yearly, the figures for the Western are .72. As a whole, the Western part of the State is more thickly settled and has more populous centres than the Eastern. Perhaps this fact does not explain the difference in the fatalities from diphtheria, but it has lately been asserted on the authority of statistics, that diphtheria is essentially a disease of the farm and country. Dr. Longstaff, an English authority, has recently published figures that substantiate this view. The annual death rate from this disease in Rhode Island for the past 35 years has been .60 per 1000 living population. For Massachusetts in the year 1886, the figures were .80. This tends to show that our death rate in Vermont does not vary much from other New England states. Of 7428 recorded deaths in Vermont from this disease, 2808 or 37 per cent were under 5 years of

age, and 1977 or 27 per cent were between the ages of 5 and 10 years; about two-thirds of the deaths were accordingly under 10 years.

The records in regard to typhoid fever, are less reliable than in regard to other diseases. In these records occur many deaths that are tabulated simply "Fever," "Typhus fever," "Infantile fever," " Bilious fever" and "Gastric fever," which may possibly properly be classed under the name "Typhoid." However, as the records classify them, I find that 5748 deaths during these 32 years, have been attributed to typhoid fever. 11 per cent or 609 of these occurred in the month of August; 18 per cent or 1082 in September; 19 per cent or 1121 in October, and 12 per cent or 770 in December, Of these 5748 deaths, 2085 or 36 per cent, were under 20 years of age and 1326 or 23 per cent were between 20 and 30 years. These figures require no comment as they represent about what is generally known as to the season at which the disease prevails and the age of those most likely to suffer.

The moral to be drawn from this tale of figures, might almost be pointed in these words. The precautions that have banished small-pox from the State; that have made deaths from measles and scarlatina rare, should if well understood by the public and acted upon by the profession, greatly reduce the prevalence and mortality from typhoid fever, diphtheria and consumption. Theoretically, such diseases as these should be wiped out of existence. The happy millennial future will count among its chief causes of happiness, the absence of these diseases. As members of the medical profession in an age that is becoming acquainted with their characteristics, we are fortunate in being able to contribute to this end.

The first and great duty that devolves on us, is to instruct the public. We do not need to tell a family that small-pox is "catching," nor do we that scarlet fever or measles are the same. We are able to carry out correspondingly strict precautions against their spread. The result is seen in the small death rate attributed to these diseases. With diphtheria and typhoid fever it is different. While many know and acknowledge their infectiousness and are willing to observe rules restricting their spread, still there is a vagueness and uncertainty in the minds of many that make it harder for physicians to enforce restrictive measures. The people should hear the simple explicit truth from us on every proper occasion. No suspicious case of sore throat should be allowed to go half-diagnosed and consequently half-treated. "Diphtheritic sore throat" and "croup" and simple "sore throat" are evasive, unprofessional synonyms often for diphtheria. We should be fearless and honest. We should be sure we err on the safe side. If there is room for a fair doubt, we ought to say so and give the patient's friends the benefit of the doubt. It is in this direction that we commit more errors as a pro

fession in dealing with these diseases probably, than in any other, and give them a fatal start. We hear physicians accused of being alarmists and raising a stir for advertising purposes. Perhaps there are such, but they are exceptions, and that accusation should not make the great body of the profession lethargic and careless. If we sit back in an over modest attitude, these diseases will continue to baffle our art. Urdoubtedly one of the most dangerous cases of diphtheria, dangerous to the community, is the walking case. That the disease is often of so mild type as to allow its subject to frequent the streets and business places, there is little doubt and it should make us, and through us the public, careful of the most ordinary sore throat. Many of the so called isolated cases of Diphtheria have this origin.

Another common error is the ascribing of diphtheria and typhoid fever to simple filth. If the infectiousness of these discases mean anything, it means that they do not arise de novo. We may with propriety advise against uncleanliness and dirt, but when we see an isolated case of fever or diphtheria, we should set the people to seeking for the preceding case. This is what we do in cases of small-pox, of scarlatina and of measles, and if isolated cases of these diseases occur, cases in which the prior case is sometimes hard to discover, why may not the same be true of diphtheria and of typhoid fever. The vehicle of the infection in these diseases is different; the germs are different and have different natural histories, but it is a definite, distinct and unique germ in each case, and each germ propagates itself and not another. Cabbages or corn will not spring up spontaneously in a barn yard, and I know of no reason why we should expect a crop of diphtheria there, unless it has been previously sown. That filth furnishes good breeding ground for these germs, no one doubts, but that it originates them is more than doubtful. The typhoid patient may have lived in a hog pen, but that fact does not explain his sickness. Everyone should know that the most probable cause is to be found in his drinking water and back of that the inevitable other case.

These facts are slowly becoming public property and as slowly is the spread of these diseases being limited. Isolation and disinfection should be our key-note in dealing with the case in hand. Thoroughness in both these particulars, distinguishes the modern medical man and marks the degree of our success in preventing these diseases.

In regard to consumption, on which the wisdom of the medical profession is now focused, prevention still retains its value over any cure, and until more successful results are obtained in the treatment of the disease than any yet substantiated, and as long as the disease retains its pre-eminent position as a destroyer of human life, we are justified in discussing methods of prevention. Koch has certainly furnished a clue to this end if tuberculin does not cure. Here is a field for missionary