- Email: [email protected]
CONVALESCENT HOMES
539 Dublin. Such variations in severity and age-incidence have been observed by Deicher and Agulnik2 and by others. They were observed even before C. diphtherice was
Public Health
Smallpox
discovered.
One further
Colonel Walker says that
although Oldenburg during the diphtheria was common in Land it did not reach epidemic properiod of observation, incidence averaged about its He weekly says portions. 20 per 100,000 of the population. An incidence of that order in Dublin would certainly be regarded as reaching epidemic proportions. J. C. GAFFNEY. point.
School of Pathology, Trinity College, Dublin.
ANKYLOSING SPONDYLITIS AND FLUOROSIS
SiB,—Mr. Eric Lloyd’s interesting letter in your last issue draws attention to the possibility of fluorosis playing a part in the aetiology of ankylosing spondylitis. Since reading Dr. Oliver Lyth’s paper (Lancet, 1946, i, 233) I have been at pains to find anything to suggest fluorosis on examination or history-taking of cases of ankylosing spondylitis, but I have drawn a complete blank in the 15 cases I have examined since then. The last 60 cases attending this hospital have come from all parts of the United Kingdom ; nearly all were towndwellers drinking the same water and breathing the I have one patient same air as their normal neighbours. with ankylosing spondylitis of thirty years’ duration, but the radiological picture is not that of fluorosis. Were there an association one might expect radiological changes more frequently in the aged. At the most, fluorosis could only be one factor at work in these cases, and the reason why one man suffered while all his neighbours went free would still be lacking. And why the difference in sex incidence ? The progress in the development of the bony changes differs largely in the two conditions, and most of the apparent similarities disappear on closer inspection. Nevertheless, association there may possibly be, and Mr. Lloyd has done a service in drawing attention to the fact. Westminster Hospital, London, S.W.1. F. DUDLEY HART. CONVALESCENT HOMES
8m,—The convalescent-home service in this country has developed in a somewhat haphazard way, mainly outside the hospital framework, with the resulting advantage that the main emphasis is laid on the return to normal
life rather than the continuation of medical treatment. But it is, perhaps, in consequence of this independence that convalescence does not, even now, receive adequate recognition as an extension of hospital treatment, but is often regarded as a pleasant but unessential extra. The attitude of the homes themselves is not always helpful. Some, often those belonging to organisations covering large sections of the community, are reluctant to give details of the care they provide, or to allow visitors from hospitals which send them patients. They regulate the admission of patients through a committee of laymen; and they restrict stay to two weeks, irrespective of medical requirements. The standards in some homes today are still below those laid down by Florence Nightingale in 1863, and the regimen is by no means always adapted to the mental needs of the patient, which, in the convalescent, are often as great as the physical. Use is rarely made of occupational therapy or recreation under expert supervision. Little interest is taken in the possibilities of research. Scientific knowledge about diet is the exception rather than’ the rule, and the services of a dietitian are rarely sought. Many homes work in isolation without any yardstick by which to measure their standards, and without means of exchanging ideas. There is need for greater curiosity on the part of homes, but the absence of any reliable pool of information and advice has been a great drawback. Action now being taken by King Edward’s Hospital Fund (Lancet, April 5, p. 454) to remedy this in the London area needs to be extended over the whole country. In this way standards could be raised and gaps in_ provision filled; whereas coercion and regimentation might well destroy many of the smaller homes, which, whatever their faults, are a valuable part of the convalescenthome service in Great Britain. MARJORIE L. WARD. London, S.BB’.1. 2. Dtsch. med. Wschr. 1927, 53, 825.
FIFTEEN separate introductions of Asiatic smallpox occurred during 1946. Fortunately, on each occasion vaccination and surveillance of contacts brought the disease under control with remarkable speed, and only 40 persons became infected during the year. In mid-February, after an interval of seven months, the disease again appeared, and since then 33 cases have been notified up to April 15 (15 at Grimsby, 2 at Stepney, 7 at Scunthorpe, 1 at Doncaster, and 8 at Bilston). The disease was introduced from an unknown source into a common lodging-house at Grimsby, where 2 old men sickened on Feb. 13 and 16. Subsequently, 13 further cases arose, all of which were in the direct line of contact with the 2 original cases. 1 was in a man who had spent the night of Feb. 16 at the lodging-house, and subsequently developed smallpox at his home in Grimsby. 2 members of the staff of the Public-health department who had been concerned with the disinfecting of the lodging-house developed smallpox while living at home. With the exception of these 3, all the secondary cases occurred among the contacts either at the common lodging-house (4) or in the ward of the public-assistance infirmary (6) into which the original patient was unfortunately admitted. The total number of cases in this outbreak was thus 15. There were 6 deaths ; the high mortality was associated with the advanced age of the patients, and in 4 with previous debilitating disease. The last case at Grimsby was removed on March 9, and the town is now believed to be free from infection. It is probable that an unidentified contact at Grimsby infected an attendant at a hostel for seamen at Stepney ; fortunately, this man was admitted early in the disease to a general hospital, where he infected only 1 patient. Since the removal of this secondary case on March 21 no further case has been notified in the London area. The disease next appeared at Scunthorpe, 28 miles by road from Grimsby. The first patient resided in acommon lodging-house where 2 contacts who had absconded from surveillance at Grimsby were staying. Initially this man was diagnosed as having varicella and he was admitted to an infectious-disease hospital. 6 cases in the second generation have been notified, the first developing the rash on April 4. They include a doctor, vaccinated in infancy only, and an unvaccinated nurse, both of whom were attending the patient; the others were residents at the common lodging-house. 5 contacts (Kenny, McGennity, Finegan, Ancliffe, and Andrews) have absconded from this lodging-house while under_ surveillance ; their whereabouts are unknown and they may be incubating or suffering from smallpox. There is no further information concerning the source of infection at Doncaster. The disease there, in a schoolmaster (rash March 27, removed March 31), was detected early, and prompt vaccination appears to have prevented further spread. Surveillance of contacts has now ceased. The above series appears to be Asiatic smallpox or moderate severity. In contrast, the disease at Bilston, Staffordshire, is said to be variola minor although it originated in India or Cairo, more probably the former. The third generation of cases (onsets April 3-9, rashes April 5-10) numbers 5, of whom 1, a woman, aged 79, died during the prodromal period. The initial case and the second generation (2), although confidently diagnosed as chickenpox until variola virus was isolated in the laboratory, remained confined to their beds from onset ; and the infection is believed to be limited to a circle of relatives and friends in three households. The clinical picture has been misleading. In 2 of the patients there were less than half-a-dozen lesions, and the illness is described as being like " influenza with a few spots." A further patient is under observation, awaiting
diagnosis (April 15),
at Rubery, Birmingham. Because of the difficulties in diagnosis, and, more important, because ambulant cases of variola minor, which are sometimes relatively numerous, if missed, may bring about a wide dispersal of infection, the reappearance of mild smallpox should be viewed with apprehension,
_
Public Health
Smallpox
discovered.
One further
Colonel Walker says that
although Oldenburg during the diphtheria was common in Land it did not reach epidemic properiod of observation, incidence averaged about its He weekly says portions. 20 per 100,000 of the population. An incidence of that order in Dublin would certainly be regarded as reaching epidemic proportions. J. C. GAFFNEY. point.
School of Pathology, Trinity College, Dublin.
ANKYLOSING SPONDYLITIS AND FLUOROSIS
SiB,—Mr. Eric Lloyd’s interesting letter in your last issue draws attention to the possibility of fluorosis playing a part in the aetiology of ankylosing spondylitis. Since reading Dr. Oliver Lyth’s paper (Lancet, 1946, i, 233) I have been at pains to find anything to suggest fluorosis on examination or history-taking of cases of ankylosing spondylitis, but I have drawn a complete blank in the 15 cases I have examined since then. The last 60 cases attending this hospital have come from all parts of the United Kingdom ; nearly all were towndwellers drinking the same water and breathing the I have one patient same air as their normal neighbours. with ankylosing spondylitis of thirty years’ duration, but the radiological picture is not that of fluorosis. Were there an association one might expect radiological changes more frequently in the aged. At the most, fluorosis could only be one factor at work in these cases, and the reason why one man suffered while all his neighbours went free would still be lacking. And why the difference in sex incidence ? The progress in the development of the bony changes differs largely in the two conditions, and most of the apparent similarities disappear on closer inspection. Nevertheless, association there may possibly be, and Mr. Lloyd has done a service in drawing attention to the fact. Westminster Hospital, London, S.W.1. F. DUDLEY HART. CONVALESCENT HOMES
8m,—The convalescent-home service in this country has developed in a somewhat haphazard way, mainly outside the hospital framework, with the resulting advantage that the main emphasis is laid on the return to normal
life rather than the continuation of medical treatment. But it is, perhaps, in consequence of this independence that convalescence does not, even now, receive adequate recognition as an extension of hospital treatment, but is often regarded as a pleasant but unessential extra. The attitude of the homes themselves is not always helpful. Some, often those belonging to organisations covering large sections of the community, are reluctant to give details of the care they provide, or to allow visitors from hospitals which send them patients. They regulate the admission of patients through a committee of laymen; and they restrict stay to two weeks, irrespective of medical requirements. The standards in some homes today are still below those laid down by Florence Nightingale in 1863, and the regimen is by no means always adapted to the mental needs of the patient, which, in the convalescent, are often as great as the physical. Use is rarely made of occupational therapy or recreation under expert supervision. Little interest is taken in the possibilities of research. Scientific knowledge about diet is the exception rather than’ the rule, and the services of a dietitian are rarely sought. Many homes work in isolation without any yardstick by which to measure their standards, and without means of exchanging ideas. There is need for greater curiosity on the part of homes, but the absence of any reliable pool of information and advice has been a great drawback. Action now being taken by King Edward’s Hospital Fund (Lancet, April 5, p. 454) to remedy this in the London area needs to be extended over the whole country. In this way standards could be raised and gaps in_ provision filled; whereas coercion and regimentation might well destroy many of the smaller homes, which, whatever their faults, are a valuable part of the convalescenthome service in Great Britain. MARJORIE L. WARD. London, S.BB’.1. 2. Dtsch. med. Wschr. 1927, 53, 825.
FIFTEEN separate introductions of Asiatic smallpox occurred during 1946. Fortunately, on each occasion vaccination and surveillance of contacts brought the disease under control with remarkable speed, and only 40 persons became infected during the year. In mid-February, after an interval of seven months, the disease again appeared, and since then 33 cases have been notified up to April 15 (15 at Grimsby, 2 at Stepney, 7 at Scunthorpe, 1 at Doncaster, and 8 at Bilston). The disease was introduced from an unknown source into a common lodging-house at Grimsby, where 2 old men sickened on Feb. 13 and 16. Subsequently, 13 further cases arose, all of which were in the direct line of contact with the 2 original cases. 1 was in a man who had spent the night of Feb. 16 at the lodging-house, and subsequently developed smallpox at his home in Grimsby. 2 members of the staff of the Public-health department who had been concerned with the disinfecting of the lodging-house developed smallpox while living at home. With the exception of these 3, all the secondary cases occurred among the contacts either at the common lodging-house (4) or in the ward of the public-assistance infirmary (6) into which the original patient was unfortunately admitted. The total number of cases in this outbreak was thus 15. There were 6 deaths ; the high mortality was associated with the advanced age of the patients, and in 4 with previous debilitating disease. The last case at Grimsby was removed on March 9, and the town is now believed to be free from infection. It is probable that an unidentified contact at Grimsby infected an attendant at a hostel for seamen at Stepney ; fortunately, this man was admitted early in the disease to a general hospital, where he infected only 1 patient. Since the removal of this secondary case on March 21 no further case has been notified in the London area. The disease next appeared at Scunthorpe, 28 miles by road from Grimsby. The first patient resided in acommon lodging-house where 2 contacts who had absconded from surveillance at Grimsby were staying. Initially this man was diagnosed as having varicella and he was admitted to an infectious-disease hospital. 6 cases in the second generation have been notified, the first developing the rash on April 4. They include a doctor, vaccinated in infancy only, and an unvaccinated nurse, both of whom were attending the patient; the others were residents at the common lodging-house. 5 contacts (Kenny, McGennity, Finegan, Ancliffe, and Andrews) have absconded from this lodging-house while under_ surveillance ; their whereabouts are unknown and they may be incubating or suffering from smallpox. There is no further information concerning the source of infection at Doncaster. The disease there, in a schoolmaster (rash March 27, removed March 31), was detected early, and prompt vaccination appears to have prevented further spread. Surveillance of contacts has now ceased. The above series appears to be Asiatic smallpox or moderate severity. In contrast, the disease at Bilston, Staffordshire, is said to be variola minor although it originated in India or Cairo, more probably the former. The third generation of cases (onsets April 3-9, rashes April 5-10) numbers 5, of whom 1, a woman, aged 79, died during the prodromal period. The initial case and the second generation (2), although confidently diagnosed as chickenpox until variola virus was isolated in the laboratory, remained confined to their beds from onset ; and the infection is believed to be limited to a circle of relatives and friends in three households. The clinical picture has been misleading. In 2 of the patients there were less than half-a-dozen lesions, and the illness is described as being like " influenza with a few spots." A further patient is under observation, awaiting
diagnosis (April 15),
at Rubery, Birmingham. Because of the difficulties in diagnosis, and, more important, because ambulant cases of variola minor, which are sometimes relatively numerous, if missed, may bring about a wide dispersal of infection, the reappearance of mild smallpox should be viewed with apprehension,
_