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DIPHTHERIA OUTBREAK ASSOCIATED WITH ICE-CREAM
837 to abolish murmurs, and that in any case an expected murmur may be unaccountably absent. If the bronchial arteries are enlarged the patient may lead a fairly active life well into adult years. The part they may play in providing a collateral circulation to the lungs when the pulmonary artery and ductus arteriosus are closed needs further attention. SUMMARY
Two
cases
of
complete pulmonary
atresia
reaching
adult life are described. -In these patients the bronchial arteries were the only channel for the blood to the lungs, for the ductus arteriosus was closed. Two other published cases are quoted for comparison. The possibility of the diagnosis of pulmonary atresia on the physical signs is suggested.
affected ward. Complete information about recent illness in the shopkeeper’s family was not provided till a later date ; but the three persons found in the shop were swabbed on August 20th and one of these, the shopkeeper’s daughter, was excluded from the shop as she showed a clinical abnormality in the form of nasal excoriation. Next day she was sent to a fever hospital as nose and throat swabs had been reported positive; the shopkeeper, whose throat swab was negative, was instructed to live away from home and to arrange to buy in his ice-cream ; the shop assistant, whose throat had yielded a positive swab, returned SUMMARY OF CASES
REFERENCES
Abbott, M. (1936) Atlas of Congenital Cardiac Disease, New York. Bach, F. (1928) Lancet, 1, 1009. Lundsgaard, C., and van Slyke, D. D. (1923) Medicine, 2, 1. Myers, B. (1925) Proc. R. Soc. Med. 19, 43. Tabul. biol., Berl. 1926, 3, 713, 715. Vierordt, H. (1906) Anatomische u. Physikalische Tabellen, 3ED, Jena, p. 175.
DIPHTHERIA
OUTBREAK ASSOCIATED WITH ICE-CREAM
BY E. BLOCH, M.B. DIVISIONAL MEDICAL
OFFICER,
Glasg.,
D.P.H.
PUBLIC HEALTH
DEPARTMENT,
GLASGOW
OUTBREAKS of illness have frequently been attributed to infected ice-cream but it is uncommon for diphtheria to be the disease reported. In the Ministry of Health (1935) records of 20 outbreaks and in one reported since (1936) other conditions have been responsible. Infections other than diphtheria were also concerned in outbreaks recorded in Glasgow in 1931, 1933, and 1936, in a county outbreak investigated by the city bacteriologist in Glasgow in 1931 and in the Aberdeen epidemic which involved some visitors from Glasgow and was reported by Kinloch (1925). When diphtheria is food-borne the vehicle is practically always milk or a milk product. During the period 1907-36 five outbreaks of milk-borne diphtheria involving 77 cases have been recognised in Glasgow as follows : 15 cases and 20 cases in 1912, 30 cases in 1913, 5 cases in 1926, and 7 cases in 1936. Glasgow records for the same period also illustrate the fact that the frequency of diphtheria infections due to milk is less than that of scarlet fever infections. Scarlet fever infections recognised as milk-borne involved 434 persons comprised in nine outbreaks described in the annual medical and sanitary reports for Glasgow (1908, 1912, 1913, 1923,
1925, 1931, 1932). THE
In
OUTBREAK
August, 1937, the first Glasgow epidemic of
attributed to ice-cream occurred in connexion with an ice-cream shop in a south-side industrial ward. It involved 13 persons, including one secondary case. A striking feature was the severity of the primary cases, 6 of whom died. The Table shows that all but one of the cases infected were children, that 9 were infected on one day, and that the majority sickened two days after consuming the ice-cream. The opportunity for administrative action thus arose on August 20th, the removal to hospital of several cases of diphtheria from a restricted area having then been reported. Special inquiries made on that day regarding the consumption of ice-cream pointed to one of the 13 ice-cream shops in the
diphtheria
*
Tracheotomy.
Case 13, a boy aged 10, who sickened direct contact and playmate of Case 7.
on
August 18th,
was a
to her home in another town. On August 21st also the utensils were sterilised and 24 gallons of ice-cream and " mix " found in the shop were rendered unsaleable by the addition of soap powder pending removal for destruction. On August 24th the shopkeeper was
excluded from the shop because a nose swab had been found positive although this throat remained negative. The business was thereafter conducted by a friend. It will be noted that although 2 further cases were admitted to hospital during the investigations they had been infected before these began. Further details regarding the three persons present in the shop when the cases occurred are as follows : The shopkeeper had until July owned a sweet-shop in a small town in an eastern county where he had sold ice-cream, bought in, at the week-ends only. There had been no undue prevalence of diphtheria in that town. He opened the Glasgow shop on Sunday, August lst. He proved to be a virulent nasal carrier (Type IV). A heavy pipe and cigarette smoker, he appeared to suffer from mild chronic pharyngitis, and on inquiry said that he had had a slight cold on or about August 17th. Early in September he was sent to a fever hospital after a throat swab had been found positive. His daughter, aged 12, who was sent to a fever hospital on August 21st, was suspected of being a virulent carrier (Type If) as the second of four guinea-pig inoculations gave a positive result for virulence.- Her tonsils had been removed when she was aged 4, and in February, 1937, she had received one
prophylactic antidiphtheria injection.
The shop assistant, aged 19, had come from a town in a Midland county on August 12th to work in the proprietor’s shop and to live in his household. She
838 had remained in normal health.
Her throat swab
positive (morphologically only) and it was not further investigated. The shopkeeper’s home, which was situated at a different address from the shop, was first visited on was
21st. Full information about familial illness still withheld, but three of the four persons found there were discovered to be infected. They had arrived in Glasgow on August 19th. Information regarding these four persons became available later as follows :-
August was
Daughter, aged 2, in spite of one prophylactic injection in February, 1937, had been a diphtheria patient in a county fever hospital from June 29th until July 24th, when she had been dismissed after two negative swabs. In Glasgow in August a second and subsequent throat swabs proved positive, and in . September she was sent to a fever hospital as a convalescent carrier on morphological grounds. Her tonsils were enlarged. Son, aged 5, was found to be a case of missed nasal diphtheria (Type IV) and was sent to a fever hospital. His tonsils had been removed when he was aged 2, and on July 14th, 1937, he had received one prophylactic injection. Daughter, aged 9, gave four negative throat swabs. Her tonsils had been removed when she was aged 7. She had received two prophylactic injections in February, 1937. The shopkeeper’s wife proved to be a virulent throat carrier (Type IV). Her tonsils were slightly
enlarged but not inflamed and she had been liable to sore-throat since 1920.
Information was also obtained later regarding the absentee from the home :Daughter, aged 16, had been admitted as a positive
following
diphtheria case to a county fever hospital on August 2nd, having sickened the previous day. She had previously had her throat swabbed with negative result on July 1st as a contact of the first case of diphtheria in the household, her sister aged 2. At the beginning of August when this second case of diphtheria was detected the movements and activities of the shopkeeper had not been reported to the
of organism and Type IV had been reported. Only 1 of the 8 September cases died. It is probable that few, if any, cases infected in the shop remained untraced. Inquiries regarding consumption of ice-cream were made in August and the early part of September concerning over 100 other cases of diphtheria notified during that period from No further an extensive south-side area of the city. cases connected with the outbreak were discovered. Excluding the affected ward the number of cases and their fatality were registered in Glasgow in exceeded in other months during the year. With regard to the bacteriological findings, Carter (1936) had found only 10 Type IV strains in 1614 positive swabs examined in Glasgow between May, 1934, and January, 1936. One learned, however, that in 1937 this type had been more often encountered in the City Laboratory and that in the autumn it was recovered from several cases besides those mentioned above. Clinical reports from hospital stated that 11 of the primary cases showed disease of the tonsils, uvula, and soft palate, and that one of these cases had also laryngeal disease ; in one case membrane was limited to the tonsils. All the primary cases were severe. The secondary case was of moderate severity.
August
I wish to thank the city bacteriologist for the information readily supplied by his department. REFERENCES
Carter, H. S. (1936) J. Hyg., Camb. 2, 147. Kinloch, J. P. (1925) Med. Offr, 18, 191. Ministry of Health (1935) Ann. Rep. Chief Med. Offr, (1936) Ibid, p. 149.
EPIDEMIOLOGY
It is of epidemiological interest to record that in August 6 other cases and in September 8 cases were registered from the affected city ward. No other connexion could be established between these and the outbreak. During the previous twelve months the number of cases from this ward had averaged 2-3 monthly ; and the numbers returned to this level in October and November when 2 and 3 cases respectively Three of the 6 August cases died. were notified. Two of these fatal cases had been examined for type
p. 138.
—
ABDOMINAL AORTIC ANEURYSM ASSOCIATED WITH GENERAL PARALYSIS OF THE INSANE BY E. L.
HUTTON, M.B. Lond., D.P.M. AND
county authorities. It is thus obvious that the shopkeeper and his family provided an abundant source for diphtheria infection. It was also obvious that his business exposed a considerable number of persons to infection. His shop sold 8 gallons of ice-cream daily on weekdays and 12 on Sundays. Children formed a majority of the customers and usually bought a halfpennyworth weighing It oz. Adult customers usually bought a quantity weighing 4 oz. It was calculated that an average of 70 customers would partake of a gallon of the ice-cream. It was of the " custard ice " type and was manufactured by the " hot mix" method. During the early part of the week the proprietor would make" mix " and freeze it daily, but towards the end of the week he would make a large " quantity of mix " and store it for the week-end in uncovered pails on open shelves in the scullery at the rear of the shop.
special
A. J. GALBRAITH, M.D. Edin., D.P.M. (From the Malaria Treatment Centre, Horton
Hospital (L.C.C.), Epsom)
Kampmeier (1936) has recently published a paper dealing very fully with the symptomatology and findings of 73 cases suffering from abdominal aortic aneurysm, together with a comprehensive review of the relevant literature. We therefore propose to confine ourselves to the description of a case which recently came under our care. CASE REPORT
The patient acquired syphilis in 1916 when aged 27, for which he said he had received injection treatment in Australia ; the details of this treatment we have’ not been able to obtain. In May, 1927, he was admitted as an in-patient to Brompton Hospital for four weeks ; he complained of pain in the right side of the chest, backache for the past fifteen months, lassitude, and occasional cough with scanty expectoration. The pain was a constant dull ache with occasional sharp exacerbations unrelated to food, exertion, or breathing, and situated in the right loin. There was a family history of tuberculosis. On examination the only abnormal findings were diminished knee-jerks, obtained only on reinforce-
ment, and in the radiogram
of the chest and heart noted scoliosis with dorsal convexity to the right, the heart lying in the concavity of the curve. From July, 1927, to February, 1928, he attended the out-patient department of the National Hospital was
Two
cases
of
complete pulmonary
atresia
reaching
adult life are described. -In these patients the bronchial arteries were the only channel for the blood to the lungs, for the ductus arteriosus was closed. Two other published cases are quoted for comparison. The possibility of the diagnosis of pulmonary atresia on the physical signs is suggested.
affected ward. Complete information about recent illness in the shopkeeper’s family was not provided till a later date ; but the three persons found in the shop were swabbed on August 20th and one of these, the shopkeeper’s daughter, was excluded from the shop as she showed a clinical abnormality in the form of nasal excoriation. Next day she was sent to a fever hospital as nose and throat swabs had been reported positive; the shopkeeper, whose throat swab was negative, was instructed to live away from home and to arrange to buy in his ice-cream ; the shop assistant, whose throat had yielded a positive swab, returned SUMMARY OF CASES
REFERENCES
Abbott, M. (1936) Atlas of Congenital Cardiac Disease, New York. Bach, F. (1928) Lancet, 1, 1009. Lundsgaard, C., and van Slyke, D. D. (1923) Medicine, 2, 1. Myers, B. (1925) Proc. R. Soc. Med. 19, 43. Tabul. biol., Berl. 1926, 3, 713, 715. Vierordt, H. (1906) Anatomische u. Physikalische Tabellen, 3ED, Jena, p. 175.
DIPHTHERIA
OUTBREAK ASSOCIATED WITH ICE-CREAM
BY E. BLOCH, M.B. DIVISIONAL MEDICAL
OFFICER,
Glasg.,
D.P.H.
PUBLIC HEALTH
DEPARTMENT,
GLASGOW
OUTBREAKS of illness have frequently been attributed to infected ice-cream but it is uncommon for diphtheria to be the disease reported. In the Ministry of Health (1935) records of 20 outbreaks and in one reported since (1936) other conditions have been responsible. Infections other than diphtheria were also concerned in outbreaks recorded in Glasgow in 1931, 1933, and 1936, in a county outbreak investigated by the city bacteriologist in Glasgow in 1931 and in the Aberdeen epidemic which involved some visitors from Glasgow and was reported by Kinloch (1925). When diphtheria is food-borne the vehicle is practically always milk or a milk product. During the period 1907-36 five outbreaks of milk-borne diphtheria involving 77 cases have been recognised in Glasgow as follows : 15 cases and 20 cases in 1912, 30 cases in 1913, 5 cases in 1926, and 7 cases in 1936. Glasgow records for the same period also illustrate the fact that the frequency of diphtheria infections due to milk is less than that of scarlet fever infections. Scarlet fever infections recognised as milk-borne involved 434 persons comprised in nine outbreaks described in the annual medical and sanitary reports for Glasgow (1908, 1912, 1913, 1923,
1925, 1931, 1932). THE
In
OUTBREAK
August, 1937, the first Glasgow epidemic of
attributed to ice-cream occurred in connexion with an ice-cream shop in a south-side industrial ward. It involved 13 persons, including one secondary case. A striking feature was the severity of the primary cases, 6 of whom died. The Table shows that all but one of the cases infected were children, that 9 were infected on one day, and that the majority sickened two days after consuming the ice-cream. The opportunity for administrative action thus arose on August 20th, the removal to hospital of several cases of diphtheria from a restricted area having then been reported. Special inquiries made on that day regarding the consumption of ice-cream pointed to one of the 13 ice-cream shops in the
diphtheria
*
Tracheotomy.
Case 13, a boy aged 10, who sickened direct contact and playmate of Case 7.
on
August 18th,
was a
to her home in another town. On August 21st also the utensils were sterilised and 24 gallons of ice-cream and " mix " found in the shop were rendered unsaleable by the addition of soap powder pending removal for destruction. On August 24th the shopkeeper was
excluded from the shop because a nose swab had been found positive although this throat remained negative. The business was thereafter conducted by a friend. It will be noted that although 2 further cases were admitted to hospital during the investigations they had been infected before these began. Further details regarding the three persons present in the shop when the cases occurred are as follows : The shopkeeper had until July owned a sweet-shop in a small town in an eastern county where he had sold ice-cream, bought in, at the week-ends only. There had been no undue prevalence of diphtheria in that town. He opened the Glasgow shop on Sunday, August lst. He proved to be a virulent nasal carrier (Type IV). A heavy pipe and cigarette smoker, he appeared to suffer from mild chronic pharyngitis, and on inquiry said that he had had a slight cold on or about August 17th. Early in September he was sent to a fever hospital after a throat swab had been found positive. His daughter, aged 12, who was sent to a fever hospital on August 21st, was suspected of being a virulent carrier (Type If) as the second of four guinea-pig inoculations gave a positive result for virulence.- Her tonsils had been removed when she was aged 4, and in February, 1937, she had received one
prophylactic antidiphtheria injection.
The shop assistant, aged 19, had come from a town in a Midland county on August 12th to work in the proprietor’s shop and to live in his household. She
838 had remained in normal health.
Her throat swab
positive (morphologically only) and it was not further investigated. The shopkeeper’s home, which was situated at a different address from the shop, was first visited on was
21st. Full information about familial illness still withheld, but three of the four persons found there were discovered to be infected. They had arrived in Glasgow on August 19th. Information regarding these four persons became available later as follows :-
August was
Daughter, aged 2, in spite of one prophylactic injection in February, 1937, had been a diphtheria patient in a county fever hospital from June 29th until July 24th, when she had been dismissed after two negative swabs. In Glasgow in August a second and subsequent throat swabs proved positive, and in . September she was sent to a fever hospital as a convalescent carrier on morphological grounds. Her tonsils were enlarged. Son, aged 5, was found to be a case of missed nasal diphtheria (Type IV) and was sent to a fever hospital. His tonsils had been removed when he was aged 2, and on July 14th, 1937, he had received one prophylactic injection. Daughter, aged 9, gave four negative throat swabs. Her tonsils had been removed when she was aged 7. She had received two prophylactic injections in February, 1937. The shopkeeper’s wife proved to be a virulent throat carrier (Type IV). Her tonsils were slightly
enlarged but not inflamed and she had been liable to sore-throat since 1920.
Information was also obtained later regarding the absentee from the home :Daughter, aged 16, had been admitted as a positive
following
diphtheria case to a county fever hospital on August 2nd, having sickened the previous day. She had previously had her throat swabbed with negative result on July 1st as a contact of the first case of diphtheria in the household, her sister aged 2. At the beginning of August when this second case of diphtheria was detected the movements and activities of the shopkeeper had not been reported to the
of organism and Type IV had been reported. Only 1 of the 8 September cases died. It is probable that few, if any, cases infected in the shop remained untraced. Inquiries regarding consumption of ice-cream were made in August and the early part of September concerning over 100 other cases of diphtheria notified during that period from No further an extensive south-side area of the city. cases connected with the outbreak were discovered. Excluding the affected ward the number of cases and their fatality were registered in Glasgow in exceeded in other months during the year. With regard to the bacteriological findings, Carter (1936) had found only 10 Type IV strains in 1614 positive swabs examined in Glasgow between May, 1934, and January, 1936. One learned, however, that in 1937 this type had been more often encountered in the City Laboratory and that in the autumn it was recovered from several cases besides those mentioned above. Clinical reports from hospital stated that 11 of the primary cases showed disease of the tonsils, uvula, and soft palate, and that one of these cases had also laryngeal disease ; in one case membrane was limited to the tonsils. All the primary cases were severe. The secondary case was of moderate severity.
August
I wish to thank the city bacteriologist for the information readily supplied by his department. REFERENCES
Carter, H. S. (1936) J. Hyg., Camb. 2, 147. Kinloch, J. P. (1925) Med. Offr, 18, 191. Ministry of Health (1935) Ann. Rep. Chief Med. Offr, (1936) Ibid, p. 149.
EPIDEMIOLOGY
It is of epidemiological interest to record that in August 6 other cases and in September 8 cases were registered from the affected city ward. No other connexion could be established between these and the outbreak. During the previous twelve months the number of cases from this ward had averaged 2-3 monthly ; and the numbers returned to this level in October and November when 2 and 3 cases respectively Three of the 6 August cases died. were notified. Two of these fatal cases had been examined for type
p. 138.
—
ABDOMINAL AORTIC ANEURYSM ASSOCIATED WITH GENERAL PARALYSIS OF THE INSANE BY E. L.
HUTTON, M.B. Lond., D.P.M. AND
county authorities. It is thus obvious that the shopkeeper and his family provided an abundant source for diphtheria infection. It was also obvious that his business exposed a considerable number of persons to infection. His shop sold 8 gallons of ice-cream daily on weekdays and 12 on Sundays. Children formed a majority of the customers and usually bought a halfpennyworth weighing It oz. Adult customers usually bought a quantity weighing 4 oz. It was calculated that an average of 70 customers would partake of a gallon of the ice-cream. It was of the " custard ice " type and was manufactured by the " hot mix" method. During the early part of the week the proprietor would make" mix " and freeze it daily, but towards the end of the week he would make a large " quantity of mix " and store it for the week-end in uncovered pails on open shelves in the scullery at the rear of the shop.
special
A. J. GALBRAITH, M.D. Edin., D.P.M. (From the Malaria Treatment Centre, Horton
Hospital (L.C.C.), Epsom)
Kampmeier (1936) has recently published a paper dealing very fully with the symptomatology and findings of 73 cases suffering from abdominal aortic aneurysm, together with a comprehensive review of the relevant literature. We therefore propose to confine ourselves to the description of a case which recently came under our care. CASE REPORT
The patient acquired syphilis in 1916 when aged 27, for which he said he had received injection treatment in Australia ; the details of this treatment we have’ not been able to obtain. In May, 1927, he was admitted as an in-patient to Brompton Hospital for four weeks ; he complained of pain in the right side of the chest, backache for the past fifteen months, lassitude, and occasional cough with scanty expectoration. The pain was a constant dull ache with occasional sharp exacerbations unrelated to food, exertion, or breathing, and situated in the right loin. There was a family history of tuberculosis. On examination the only abnormal findings were diminished knee-jerks, obtained only on reinforce-
ment, and in the radiogram
of the chest and heart noted scoliosis with dorsal convexity to the right, the heart lying in the concavity of the curve. From July, 1927, to February, 1928, he attended the out-patient department of the National Hospital was