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LOCAL OUTBREAKS OF TUBERCULOSIS
805
by the committee had seen patients with corneal opacities and permanent scarring following the wearing
out
of contact lenses. Moreover, almost 8000 of the 50,000 wearers of lenses had sustained some form of reversible damage to their eyes. The committee found that complications were more common in patients with aphakia, in older patients, in patients who had worn their lenses for long periods and at night, and in patients who had had previous injury or disease of their eyes. Ophthalmologists have a duty to impress upon patients the need for scrupulous cleanliness, for resting the eyes, and for follow-up visits. It goes without saying that ophthalmologists should ensure that patients get properly fitting lenses and are made aware of the importance of reporting even slight discomfort when this is present. Newer types of soft, water-absorbing, plastic lenses are under investigation. They may prevent some of the complications described in the American report.
NURSERY SCHOOL FOR DEPRIVED CHILDREN
YourrG children from large problem families have no encouragement to develop warm relationships, habits of cleanliness and obedience, and social skills at homethese are the very ones who should have priority for nursery-school education. Otherwise, when they reach schoolage it is impossible for them to meet the demands made on them. Feeling themselves inadequate they dislike school, and habits of truancy and delinquency are set up. To fill in the gaps in their social education, Dr. Harriett Wilson set up an experimental nursery school in Cardiff in 1960 " specifically for the child from large low-income families."1 These families had usually moved away from their relatives or had quarrelled with them, and their low living-standards provoked hostility among their neighbours. Not unnaturally children brought up in this atmosphere were deprived of the ordinary friendly giveand-take of a wide circle. The nursery school tries to give them a chance to learn how to fit in with a group before they reach school-age. The school is run by 2 trained nurses and a rota of voluntary helpers, with financial help from a group of Quakers and from the Cardiff public-health department. Families with at least 5 children are eligible, and children are sent by health visitors, teachers, the National Assistance Board, probation officers, and others. The tactful official name " play-centre for large families " avoids any possible stigma. Transport and even extra clothes and shoes help to ensure regular attendance. Although toys are provided, supervised activities-such as modelling, painting, and singing-are encouraged, because it was soon discovered that these children do not know how to amuse themselves creatively and have to be taught to play. Speech, and thereby reasoning powers, too, must be fostered. " The eternal question ’Why? ’ is dealt with respectfully and in the knowledge that at home it is probably brushed aside." Treatment for sores and lice, which is not today normally included in the curriculum of an ordinary school, at the nursery school is accepted as part of the daily routine, as is cuddling-both usually being neglected by the inadequate mother. A study is now being made of the mental and social development of the 100 children who have passed through this play-centre, and the results will doubtless influence 1.
Wilson, H. New Society, March 24, 1966, p. 14.
future
experiments. There seems no doubt that these deprived children can benefit from " an experience of someone caring and not condemning ".
DIET OF ELDERLY WOMEN
THE diet of 60 women, all aged over 70, and living alone in the London boroughs of Hornsey and North
Islington, was the subject of an inquiry lately published1 by the King Edward’s Hospital Fund. 44 of the women were given a full clinical examination. The dietary findings have been thoroughly worked out, and the intake of essential nutrients by most of the women was satisfactory. The clinical gradings of their general condition were: excellent 25%, good 50%, fair 23%, and poor 2%. All doctors and social workers are aware of old people living alone under poor circumstances and with inadequate food, but there does not seem to be much reliable information about how many people are in this plight. Do they represent a national problem ? Is their care within the capacity of the local health services, social organisations, and charitable workers ? This report suggests that, in North London at least, most old women get along quite well. Since the numbers studied were small and their selection was not random (the Islington group was selected from a list of women whom the medical officer of health thought might be malnourished), no general conclusion can be drawn. The report emphasises the value of the help that can be given to old people by a known and trusted person, such as a health visitor or dietitian, in advising what foods to buy and in budgeting. Moreover, the benefits offered by those who provide meals on wheels, club meals, and invalid meals should be greatly extended.
LOCAL OUTBREAKS OF TUBERCULOSIS
WHEN a teacher or pupil has open tuberculosis, the schoolroom becomes an infectious milieu. Hyge 2-4 described how a teacher with two small lung-cavities taught during the war in a basement room which was permanently blacked out and also served as an air-raid shelter. More than half the children who became tuber-
culin-positive showed X-ray evidence of primary tuberculosis, and 11 had progressive pulmonary disease, of But Lincoln,5 reviewing outbreaks whom 1 died. in several countries, illustrated how often a fellow pupil was the source. While lesions of the primarycomplex type in children are practically non-infectious, a primary lung-focus may cavitate, and adult-type disease with cavitation in children aged 10-15 is not altogether a rarity. Moreover, an infectious child in constant and intimate daily contact with his fellows can be a more highly potent source of bacillary dissemination than the teacher, with whom the pupils may be in the same room for only an hour a day. Thus, in a new Staffordshire grammar school, a 13-year-old girl seems to have infected all children in her form.Of 423 children
the school 24
Smith, A. N., Stanton, B. R. Report of an Investigation into the Dietary of Elderly Women Living Alone. King Edward’s Hospital Fund for London, 1965. Hyge, T. V. Acta. tuberc. scand. 1947, 21, 1. Hyge, T. V. ibid. 1949, 23, 153. Hyge, T. V. ibid. 1956, 32, 89. Lincoln, E. M. Advanc. Tuberc. Res. 1965, 14, 157. Aspin, J., Sheldon, M. Tubercle, Lond. 1965, 46, 321.
1. Exton 2. 3. 4. 5. 6.
at
806
(6%) were found to have active tuberculous lesions, mainly hilar adenitis; but 4 had pleural effusion, and 2 others miliary tuberculosis, in 1 of whom meningitis also developed. During the next two years tuberculous lesions appeared in 2 more children, making 26 in all. The source of infection may not be in the school itself. In June, 1958, the driver of a school bus in a country district in the State of New York was found to have active pulmonary tuberculosis.’7 He had been unwell from January onwards with night sweats, fatigue, and a troublesome cough. Of 266 children who travelled in the bus, 85 (32%) were found to be tuberculinpositive compared with only 51 (2%) of 2296 other children in the five schools it served; and 52 (19%) of the passengers showed evidence of active primary tuberculosis, against 3 (0-1%) of the others. The proportion of reactors varied directly with the time spent in the bus, ranging from 22% in those with less than ten minutes’ travelling per day to 62-5% in those with fifty minutes’ or more. No other source of infection in the schools was uncovered by an intensive search, and no increased incidence of tuberculosis was observed among the families of the infected children. The bus had two fan-type heaters, a defroster at the base of the windshield, and two six-inch fans, one on either side of and directed at the windshield. These devices, plus frequent opening of the door, undoubtedly deflected air from the front to the rear of the bus. Interestingly enough, a crippled girl who regularly travelled beside the driver in her wheelchair remained tuberculin-negative: presumably it was safer to sit beside him than behind him. The interior of this bus must have contained many infectious droplets circulating around head level. Thus, the infectiousness of tuberculosis in certain circumstances can be quite striking. Gedde-Dahl 11 mentioned a young Norwegian seaman who, during a month at home at Christmas, probably infected 15 people, of whom 4 got progressive pulmonary tuberculosis and only 1 remained free of symptoms. At a Christmas party in a small and overcrowded schoolroom in another district nearby, he infected 7 more, in 1 of whom, a 16-year-old girl, progressive pulmonary disease developed. Taylor and Mein 9 now report from New Zealand a local epidemic in a country district where one man produced notifiable disease in 15 others; and 3 more infections were attributed to a patient originally infected by him. Rees 10
uncooperative family was responsible for an cases of tuberculosis in an Anglesey village. epidemic Not all patients with open tuberculosis are equally infectious. Indeed, tuberculosis seems to be mainly spread by a small number of highly infectious individuals.ll The young patient who is still mobile in spite of active disease may be extremely infectious over the course of a tells how
one
of 16
month or two, and may infect many more of his contacts in this short time than an older patient with a fibrotic lesion and fewer susceptible contacts who goes on producing a small amount of positive sputum over many years. A recent relapse in a patient with chronic disease, however, can certainly result in a high degree of infectivity. Gedde-Dahl8 points out that many of his " good chronics ", although sputum-positive, had a low infectivity, and he suggests that we should refer to benign 7. 8. 9. 10. 11.
Rogers, E. F. H. Publ. Hlth. Rep., Wash. 1962, 77, 407. Gedde-Dahl, T. Am. J. Hyg., 1952, 56, 139. Taylor, A. J., Mein, J. R. Tubercle, Lond. 1965, 46, 345. Rees, T. A. I. Med. Offr. 1966, 155, 74. Pagel, W., Simmonds, F. A. H., Macdonald, N., Nassau, E. Pulmonary Tuberculosis; p. 476. London, 1964.
and malignant phases of the disease. The outcome is determined by the number, size, and bacillary content of the droplets produced; and also by the physical circumstances, such as lack of ventilation or overcrowding, to which contacts are exposed. Their existing level of resistance, natural and acquired, will then be put to the test. The danger nowadays is that, as tuberculosis declines, more tuberculin-negative children are at risk. Inherited resistance, however, is for the most part reasonably good, and a significant extra protection is conferred at the age of 13 by B.C.G. vaccination, although by no means all children of this age receive it. Fortunately, too, in this country outbreaks of tuberculosis are uncommon. But the unexpected appearance of primary-type lesions in several schoolchildren or adolescents, either simultaneously or at short intervals, or occasionally a small crop of young patients with erythema nodosum,12 or the finding of infectious disease in a pupil, teacher, or school employee, will usually indicate the need for a complete tuberculin survey of the school and X-ray examination of reactors, on the lines pursued by Aspin and Sheldon.5 Again, the routine tuberculin survey at age 13 for B.c.G. vaccination may reveal too high a prevalence of strongly positive reactors in a school. In theory, annual X-ray examination of teachers and other school staff is the ideal, but in this country it has proved hard to achieve. And the infectious child would still escape. A case could be made out for more regular tuberculin testing in earlier years and for B.c.G. vaccination at the age of 11; but this would involve a big reorganisation of the school health programme which, now that tuberculosis is on the decline, might not appeal to local authorities. Perhaps the introduction of comprehensive schools might provide a suitable opportunity for reassessment.
UNIVERSITY AND HOSPITAL
forty years the role of the university in the teaching hospital has been to occupy an academic area of beds and laboratories staffed by full-time university staff and headed by a professor. This arrangement has been inclined to divide the medical side of a hospital into two estates, though the invasion by medical science is obscuring any distinction between the approach of the academic and the non-academic. A chair of medicine has long ceased to denote someone who can profess the whole of the practice of medicine, and the needs of today can perhaps best be met by a group of physicians, working as a team, most of whom will have special interests. There are good arguments for grouping all the physicians of a teaching hospital and recognising them as a university department of medicine, with a chairman elected annually. This type of academic organisation is now to be tried out in Edinburgh for an experimental five years.13 Though the advantages in widening the influence of the university and giving each physician a responsibility in the affairs of the department are clear, dangers may arise in the diffusion of academic resources which are already strictly limited. But the day of the individual charge, immutable from appointment to retirement, is passing and some more adaptable structure must take its place. Edinburgh is to be congratulated on a bold experiment, which will be FOR
some
watrhf*r) with itltf*r<*<:t 12. Stronge, R. 13. See Lancet,
F., Balmer, S. V. Br. med. J. 1961, 2, 1319. April, 2, 1966, p. 776.
by the committee had seen patients with corneal opacities and permanent scarring following the wearing
out
of contact lenses. Moreover, almost 8000 of the 50,000 wearers of lenses had sustained some form of reversible damage to their eyes. The committee found that complications were more common in patients with aphakia, in older patients, in patients who had worn their lenses for long periods and at night, and in patients who had had previous injury or disease of their eyes. Ophthalmologists have a duty to impress upon patients the need for scrupulous cleanliness, for resting the eyes, and for follow-up visits. It goes without saying that ophthalmologists should ensure that patients get properly fitting lenses and are made aware of the importance of reporting even slight discomfort when this is present. Newer types of soft, water-absorbing, plastic lenses are under investigation. They may prevent some of the complications described in the American report.
NURSERY SCHOOL FOR DEPRIVED CHILDREN
YourrG children from large problem families have no encouragement to develop warm relationships, habits of cleanliness and obedience, and social skills at homethese are the very ones who should have priority for nursery-school education. Otherwise, when they reach schoolage it is impossible for them to meet the demands made on them. Feeling themselves inadequate they dislike school, and habits of truancy and delinquency are set up. To fill in the gaps in their social education, Dr. Harriett Wilson set up an experimental nursery school in Cardiff in 1960 " specifically for the child from large low-income families."1 These families had usually moved away from their relatives or had quarrelled with them, and their low living-standards provoked hostility among their neighbours. Not unnaturally children brought up in this atmosphere were deprived of the ordinary friendly giveand-take of a wide circle. The nursery school tries to give them a chance to learn how to fit in with a group before they reach school-age. The school is run by 2 trained nurses and a rota of voluntary helpers, with financial help from a group of Quakers and from the Cardiff public-health department. Families with at least 5 children are eligible, and children are sent by health visitors, teachers, the National Assistance Board, probation officers, and others. The tactful official name " play-centre for large families " avoids any possible stigma. Transport and even extra clothes and shoes help to ensure regular attendance. Although toys are provided, supervised activities-such as modelling, painting, and singing-are encouraged, because it was soon discovered that these children do not know how to amuse themselves creatively and have to be taught to play. Speech, and thereby reasoning powers, too, must be fostered. " The eternal question ’Why? ’ is dealt with respectfully and in the knowledge that at home it is probably brushed aside." Treatment for sores and lice, which is not today normally included in the curriculum of an ordinary school, at the nursery school is accepted as part of the daily routine, as is cuddling-both usually being neglected by the inadequate mother. A study is now being made of the mental and social development of the 100 children who have passed through this play-centre, and the results will doubtless influence 1.
Wilson, H. New Society, March 24, 1966, p. 14.
future
experiments. There seems no doubt that these deprived children can benefit from " an experience of someone caring and not condemning ".
DIET OF ELDERLY WOMEN
THE diet of 60 women, all aged over 70, and living alone in the London boroughs of Hornsey and North
Islington, was the subject of an inquiry lately published1 by the King Edward’s Hospital Fund. 44 of the women were given a full clinical examination. The dietary findings have been thoroughly worked out, and the intake of essential nutrients by most of the women was satisfactory. The clinical gradings of their general condition were: excellent 25%, good 50%, fair 23%, and poor 2%. All doctors and social workers are aware of old people living alone under poor circumstances and with inadequate food, but there does not seem to be much reliable information about how many people are in this plight. Do they represent a national problem ? Is their care within the capacity of the local health services, social organisations, and charitable workers ? This report suggests that, in North London at least, most old women get along quite well. Since the numbers studied were small and their selection was not random (the Islington group was selected from a list of women whom the medical officer of health thought might be malnourished), no general conclusion can be drawn. The report emphasises the value of the help that can be given to old people by a known and trusted person, such as a health visitor or dietitian, in advising what foods to buy and in budgeting. Moreover, the benefits offered by those who provide meals on wheels, club meals, and invalid meals should be greatly extended.
LOCAL OUTBREAKS OF TUBERCULOSIS
WHEN a teacher or pupil has open tuberculosis, the schoolroom becomes an infectious milieu. Hyge 2-4 described how a teacher with two small lung-cavities taught during the war in a basement room which was permanently blacked out and also served as an air-raid shelter. More than half the children who became tuber-
culin-positive showed X-ray evidence of primary tuberculosis, and 11 had progressive pulmonary disease, of But Lincoln,5 reviewing outbreaks whom 1 died. in several countries, illustrated how often a fellow pupil was the source. While lesions of the primarycomplex type in children are practically non-infectious, a primary lung-focus may cavitate, and adult-type disease with cavitation in children aged 10-15 is not altogether a rarity. Moreover, an infectious child in constant and intimate daily contact with his fellows can be a more highly potent source of bacillary dissemination than the teacher, with whom the pupils may be in the same room for only an hour a day. Thus, in a new Staffordshire grammar school, a 13-year-old girl seems to have infected all children in her form.Of 423 children
the school 24
Smith, A. N., Stanton, B. R. Report of an Investigation into the Dietary of Elderly Women Living Alone. King Edward’s Hospital Fund for London, 1965. Hyge, T. V. Acta. tuberc. scand. 1947, 21, 1. Hyge, T. V. ibid. 1949, 23, 153. Hyge, T. V. ibid. 1956, 32, 89. Lincoln, E. M. Advanc. Tuberc. Res. 1965, 14, 157. Aspin, J., Sheldon, M. Tubercle, Lond. 1965, 46, 321.
1. Exton 2. 3. 4. 5. 6.
at
806
(6%) were found to have active tuberculous lesions, mainly hilar adenitis; but 4 had pleural effusion, and 2 others miliary tuberculosis, in 1 of whom meningitis also developed. During the next two years tuberculous lesions appeared in 2 more children, making 26 in all. The source of infection may not be in the school itself. In June, 1958, the driver of a school bus in a country district in the State of New York was found to have active pulmonary tuberculosis.’7 He had been unwell from January onwards with night sweats, fatigue, and a troublesome cough. Of 266 children who travelled in the bus, 85 (32%) were found to be tuberculinpositive compared with only 51 (2%) of 2296 other children in the five schools it served; and 52 (19%) of the passengers showed evidence of active primary tuberculosis, against 3 (0-1%) of the others. The proportion of reactors varied directly with the time spent in the bus, ranging from 22% in those with less than ten minutes’ travelling per day to 62-5% in those with fifty minutes’ or more. No other source of infection in the schools was uncovered by an intensive search, and no increased incidence of tuberculosis was observed among the families of the infected children. The bus had two fan-type heaters, a defroster at the base of the windshield, and two six-inch fans, one on either side of and directed at the windshield. These devices, plus frequent opening of the door, undoubtedly deflected air from the front to the rear of the bus. Interestingly enough, a crippled girl who regularly travelled beside the driver in her wheelchair remained tuberculin-negative: presumably it was safer to sit beside him than behind him. The interior of this bus must have contained many infectious droplets circulating around head level. Thus, the infectiousness of tuberculosis in certain circumstances can be quite striking. Gedde-Dahl 11 mentioned a young Norwegian seaman who, during a month at home at Christmas, probably infected 15 people, of whom 4 got progressive pulmonary tuberculosis and only 1 remained free of symptoms. At a Christmas party in a small and overcrowded schoolroom in another district nearby, he infected 7 more, in 1 of whom, a 16-year-old girl, progressive pulmonary disease developed. Taylor and Mein 9 now report from New Zealand a local epidemic in a country district where one man produced notifiable disease in 15 others; and 3 more infections were attributed to a patient originally infected by him. Rees 10
uncooperative family was responsible for an cases of tuberculosis in an Anglesey village. epidemic Not all patients with open tuberculosis are equally infectious. Indeed, tuberculosis seems to be mainly spread by a small number of highly infectious individuals.ll The young patient who is still mobile in spite of active disease may be extremely infectious over the course of a tells how
one
of 16
month or two, and may infect many more of his contacts in this short time than an older patient with a fibrotic lesion and fewer susceptible contacts who goes on producing a small amount of positive sputum over many years. A recent relapse in a patient with chronic disease, however, can certainly result in a high degree of infectivity. Gedde-Dahl8 points out that many of his " good chronics ", although sputum-positive, had a low infectivity, and he suggests that we should refer to benign 7. 8. 9. 10. 11.
Rogers, E. F. H. Publ. Hlth. Rep., Wash. 1962, 77, 407. Gedde-Dahl, T. Am. J. Hyg., 1952, 56, 139. Taylor, A. J., Mein, J. R. Tubercle, Lond. 1965, 46, 345. Rees, T. A. I. Med. Offr. 1966, 155, 74. Pagel, W., Simmonds, F. A. H., Macdonald, N., Nassau, E. Pulmonary Tuberculosis; p. 476. London, 1964.
and malignant phases of the disease. The outcome is determined by the number, size, and bacillary content of the droplets produced; and also by the physical circumstances, such as lack of ventilation or overcrowding, to which contacts are exposed. Their existing level of resistance, natural and acquired, will then be put to the test. The danger nowadays is that, as tuberculosis declines, more tuberculin-negative children are at risk. Inherited resistance, however, is for the most part reasonably good, and a significant extra protection is conferred at the age of 13 by B.C.G. vaccination, although by no means all children of this age receive it. Fortunately, too, in this country outbreaks of tuberculosis are uncommon. But the unexpected appearance of primary-type lesions in several schoolchildren or adolescents, either simultaneously or at short intervals, or occasionally a small crop of young patients with erythema nodosum,12 or the finding of infectious disease in a pupil, teacher, or school employee, will usually indicate the need for a complete tuberculin survey of the school and X-ray examination of reactors, on the lines pursued by Aspin and Sheldon.5 Again, the routine tuberculin survey at age 13 for B.c.G. vaccination may reveal too high a prevalence of strongly positive reactors in a school. In theory, annual X-ray examination of teachers and other school staff is the ideal, but in this country it has proved hard to achieve. And the infectious child would still escape. A case could be made out for more regular tuberculin testing in earlier years and for B.c.G. vaccination at the age of 11; but this would involve a big reorganisation of the school health programme which, now that tuberculosis is on the decline, might not appeal to local authorities. Perhaps the introduction of comprehensive schools might provide a suitable opportunity for reassessment.
UNIVERSITY AND HOSPITAL
forty years the role of the university in the teaching hospital has been to occupy an academic area of beds and laboratories staffed by full-time university staff and headed by a professor. This arrangement has been inclined to divide the medical side of a hospital into two estates, though the invasion by medical science is obscuring any distinction between the approach of the academic and the non-academic. A chair of medicine has long ceased to denote someone who can profess the whole of the practice of medicine, and the needs of today can perhaps best be met by a group of physicians, working as a team, most of whom will have special interests. There are good arguments for grouping all the physicians of a teaching hospital and recognising them as a university department of medicine, with a chairman elected annually. This type of academic organisation is now to be tried out in Edinburgh for an experimental five years.13 Though the advantages in widening the influence of the university and giving each physician a responsibility in the affairs of the department are clear, dangers may arise in the diffusion of academic resources which are already strictly limited. But the day of the individual charge, immutable from appointment to retirement, is passing and some more adaptable structure must take its place. Edinburgh is to be congratulated on a bold experiment, which will be FOR
some
watrhf*r) with itltf*r<*<:t 12. Stronge, R. 13. See Lancet,
F., Balmer, S. V. Br. med. J. 1961, 2, 1319. April, 2, 1966, p. 776.