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Epidemic jaundice in school children
1935.
PUBLIC HEALTH.
391
Epidemic Jaundice in School Children. By GERALD RAMAGE, M.D., D.P.H., Assistant County Medical Officer of Health , Holland, Lines. In this paper, submitted at a meeting of the East Midland Branch of the Society on June 6th, 1935, is noted a series of blood counts taken during an outbreak of epidemic jaundice. Two cases are of unusual interest as specimens of blood were obtained before and during their illnesses. P IDEM I CS with jaundice as a feature E have been recorded since the time of Hippocrates. In 1889, Quineke and Hoppe Seyler pointed out an epidemic jaundice which was distinct from spirochetal jaundice. In 1912, Cockayne called the disease epide.mic catarrhal jaundice and this name per~~sts, though it erroneously suggests that biliary catarrh is present. Epidemic jaundice was noted during the W~r at Mesopotamia and the Dardanelles, but It was not until 1920 and after, that numerous epidemics were described. These occurred in France, Portugal, Germany, China, Africa and U.S.A. As far as I can find, there are some six to seven large epidemics described in England, starting with 1925. These occurred in the Midlands, Oxford, Ayrshire, Wensleydale and Surrey. There have, of course, been other epidemics of spirochetal jaundice, notably that investigated by Buchanan in 1924, and Alston (London) in 1934. Catarrhal Jaundice in Holland, L£ncs.-In 1929 an outbreak occurred in Moulton, and in 1930' another in a village four miles away. In 1933, 13 cases were recorded in Moulton Chapel, half of whom were adults. The present epidemic has been centred at Kirton Holme School, and a few cases have occurred at Swineshead Infants' School, three miles away. Kirton Holme School is in a rural district and the scholars live within an area of about Ii miles. There are 124 scholars at the school, and 15 have been affected so far. It is a wellventilated school and not overcrowded. The first case brought to our notice was that of a girl L.M. (ret 10 years). Her illness started on December 24th, 1934, with headache and vomiting. She was kept in bed by her own doctor for two weeks. (His certificate to the school started the investigations.) She was seen by me on January 30th, 1935, when the conjunctives were still yellow, but no other symptoms or signs remained. There were four
other children at home, three of whom attended school. The family live in a hamlet 1 to Ii miles away from the school. Second case.-E.G. (ret 13 years), taken iII on January 21st, 1935. She is a friend of the first case, though had not been in contact with her for three weeks. The jaundice was ushered in by headache and vomiting; three family contacts were attending school. Third case.-I.N. (ret 9 years), sister to first case, was ill on January 28th. The fourth and fifth cases were brothers of the second case, and started their illnesses on March 2nd and 5th, 1935, six weeks after their sister (? home contact). Between March 28th and 31st, seven further cases occurred in Kirton Holme School. On April 4th and 8th, three further cases occurred, and a suspected case on April 16th who has since left the district. All these cases attend the school. The first fivecases live in the same hamlet, and the children were friends and played together. As the second case continued at school the disease spread. Later cases were scattered in their homes and met at school. After the first three cases, contacts were excluded for three weeks. Observation of Swineshead School was not so close as that of Kirton Holme. The first case was reported on March 30th, 1935, and this date coincides with the second case at Kirton Holme. No direct contact was traced. Four cases were reported and visited. It was not possible to get blood samples from them, and no further cases have been reported. Two sporadic outbreaks were reported: one, 10 miles away where three of a family were affected, and the second 7 miles away where one case only occurred. So far 26 cases have occurred altogether, the ages of the patients varying from 8 to 14 years (average 11 years).
Analysis of Symptoms.-Symptoms are similar to those described in other outbreaks, and they are arranged in order of their frequency.
392
PUBLIC HEALTH.
First dayVomiting occurred in 22 out of 26 cases. 15 26 Headache Pain in epigastrium " 12 26 8 26 Bradycardia 7 26 Loss of appetite ... Lassitude 5 26 " 26" Di zziness ] Rambling... 2 26 ,,2 26 Sleepiness Diarrhcea . .. 2 26 3 26 T emperature Epistaxis .. . 1 26 ,,1 " 26 Sore throat Second to ninth day (even distribution)Jaundice '" occurred in 23 out of 26 cases. (2 urine dark; 1 moved out of district.) Urine dark occurred in 19 out of 26 cases. Fseces pale 16 " 26 Itching 5 26
In one to three weeks the patient feels better, or when jaundice appears if it is not severe. Information was obtained from parents and teachers, and so many points were missed, particularly with reference to pyrexia. Findlay, Dunlop and Brown found diarrhcea to be a common accompaniment of epidemic jaundice in the Surrey outbreak. Frazer describes sore throat as being a constant symptom. This was not seen in Holland nor traced in the literature. Montford (Castle Donnington) had one case (ret 4 years) who complained of seeing green (Xanthopsia). Laboratory Work.-In nearly all the epidemics looked .np, every endeavour had been made to trace the spirocheta ictero-hremorrhagica, and always without success. Using blood and urine, Findlay, Dunlop and Brown in 1931 inoculated 100 guinea-pigs and 10 monkevs-rabbits, mice and rats were all tried in thei~ turn. Nasal washings of cases were sprayed on two monkeys. Bacteriological examination of freces and nasopharynx were made, and all their work gave negative results. Drinking water was examined and eliminated in the Surrey outbreak described by Booth and Okell in 1927, where completely negative findings for pathological material again resulted. Definite changes in the blood counts were found by several workers (below) and here attention has been restricted to the blood picture. Blood Counts.-Sixteen samples were taken and counts were made by the county pathologist: 200 to 300 cells were counted for the differential count. In two cases bloods were obtained before the jaundice appeared, and a
AU(illST,
second specimen when it came on. In a third case blood was taken when the jaundice was present and again when the patient had recovered. No control was possible over the other factors affecting the blood count. Most of the patients were starving when the samples were taken. Summary of Blood Counts.-In general, lymphocytes are increased in numbers while the polymorphonuc1ears are decreased or not affected. Changes in two cases with onset of jaundice: (I) Leucocytosis. (2) Absolute and relative increase of lymphocytes. Changes in one case after jaundice cleared up:(1) Slight leucocytosis. (2) Relative lymphocytic leucoprenia. Insufficient cases were seen to show any difference in lymphocyte count at different days of illness. Figures suggest that lymphocytes increase slightly in later days of illness. Other Work on Blood.-In spirochretal jaundice, several workers note a leucocytosis with absolute and relative increase in polymorphonuclears (up to 93 per cent.), lool.-Archard and Toeper noted slight polymorphonuclear leucocytes at onset of illness and then a rapid leucopenia with an increase in mononuclear count; 3 to 4 per cent. mylocytes were present. 1923.-Jenes and Minot (America) observed in 23 cases a primary leucocytosis for three days with normal differential count. Then when jaundice appeared leucopenia occurred. There was a drop in the polymorphonuclear count and rise in lymphocytes to 50 and 60 per cent. and large mononuclear were counted up to 10 per cent. Immature cells were common . 1925. -Thewlis and Middleton working in America concluded that an initial leucopenia was present in some cases. The increase in lymphocytes was relative only while the increase in mononuclear was absolute. 193I.-Findlay, Dunlop and Brown, using controls of similar aged children, made differential lymphocyte counts. They found a fall in polymorphonuclears and a rise in lymphocytes when the disease was established, and usually even in the preicteric stage. In one case an initial polymorphonuclear leucocyte was noted, and nasopharynx was engorged for the first three days of the illness.
1935.
PUBLIC HEALTH. TABLE
393
I.
BLOOD COUNTS TAKE N WITH JAUNDICE PRESENT
I
Day No. Erythroof of cytes . Illness . Cas es. , 1
2
3 5
6
{: 1 {:
7
9 10 13 14 16
1
~!
I 1 1
Leucocytes.
4,800 6,000 5, 200 5,000 5,200 5,600 4,400 5,600 4,600 4,800 4,600 5,6 00 5,600 5, 000
I
98 92 80 92 96 102 78 106 96 90 98 100 110 100
4,600 11,600 9,600 5,600 5,000 7,400 10,000 10,800 4,800 10,200 8 ,600 10,200 10,400 7,600
Polymorphonuclear HyaLyrnpholeu cocyt es . cytes. lines. Per cent. Pe r cent. Per cent.
Hserno- Colour globin. Index.
1·02 0 ·75 0 '77 0 ·92
54 46 50 37 46 46 60 46 -12 53 51 40 44 46
O·g 0 ·9 0· 88 0· 9 0 ·98 0 ·93 1·0 0 ·9 0·98 0 ·99
41 49 47 57 51 50 38 56 57 44 47 51 51 52
I
Eosine-
Baso-
phils. Per cent.
phils. Per cent.
3 I I 2
-
2 2 1·5 4 2 3 2 2
2 1
-
1
I
-
-
-
-
-
-
-
I 1
2 2
-
4 3
1 2
2 I
14 (2 others Without Jaundice). TABLE
No. of Ca ses .
I
General Average.
...
14 14 14 14
Erythrocytes Leucocytes Heemoglobin Colour index
14
Polymorphonuclear leucocytes ... Lymphocytes'[ ... Large mononuclear or hyaline cells . ..
14 8
6 4
II.
ROUGH AVERAGES OF ALL COUNTS TAKEN WHILE PATIEN TS WERE JAtJNDlCED .
... ...
...
...
Eosinophils Basophils . . .
7,500
-
Present Average .
Maximum.
5,240,000 8, 500 95 per cent. ·9
11,600 110 per cent. 1'0
4,800 78 per cent. '75
45 per cent. 48 per cent.
60 per cent. 57 per cent.
42 per cent. 38 per cent.
2 per cen t .
3 per cent.
60-65 per cent. (4 ,000) 25-35 per cen t . (2,000) 3-5 per cent.
Minimum.
-
-
nil
2-3 per cent. 0 ·5 per cent.
nil 2 per cent. 4 pe r cent. nil 1·5 per cent. 2 per cent. • The lymphocytes were not differen tiat ed Into large and small cells. The figur es in brackets are the number of cells per cubic millimetre, The table shows an increase in the lymphocyte count.
...
TABLE
III.
D IFFERENTIAL COUNT.
Day.l Leucocytes·1
2 3 3 5 6 6 7 9 9 10
10 13 14
16
4,600 11,600 9 ,600 5,600 5,000 7,400 10,000 10,800 4,800 10,200 8,600 10,200 10,400 7,600
Polymorphonuclear leucocytes.
Lymphocytes.
Per cent.
Count per cu . mm,
Per cent.
Count per cu. mm,
54 46 50
2,484 5,336 4,300 2,072 2,300 3,404 6,000 4,860 2,016 5,406 4,386 4,080 4,576 3,496
41 49 47 57 51 50 38 56 57 44 47 51 51 52
1,886 5,684 3,712 3 ,192 2,550 3,700 3,800 6,048 2,736 4,488 4,20 2 5,202 5,304 3,952
37 46 46 60 46 42 53 51 40 44 46
I
L ymphocytes per 10,000 Leucocytes.
4,000 4,900 3,860 5,700 5,100 5,000 3,800 5 ,600 5,700 4,480 4,900 5,200 5,250 5 ,200
PUBLIC HEALTH.
394
CASE
Day of Illness. Erythrocytes .. . Leucocytes Heemoglobin
. Colour index . Polymorphonuclear leucocytes Lymphocytes .. . Hyalines Eosinophils Basophils
AUGIlST,
1 (RT.).
2nd day (no jaundice).
6th day (with jaundice).
4,800,000 4,600 98 per cent. 1002 54 per cent. (2,484) 41 per cent. (1,886) 2
5,200,000 5,000 96 per cent. 0·9 46 per cent. (2,300) 51 per cent. (2,550) 2
3
This case shows an absolute and relative increase in lymphocytes and reduction in polymorphonuclear leucocytes when jaundice appeared. CASE
Erythrocytes ... Leucocytes Heemoglobin . Colour index .. Polymorphonuclear leucocytes Lymphocytes ... Hyalines Eosinophils Basophils
2 (J.N.).
Without jaundice (weeks before).
With jaundice (9th day of illness).
5,200,000 4,800 98 per cent. 0·9 46 per cent. (2,168) 51 per cent. (2,448) 2
5,600,000 10,800 106 per cent. 0·9 46 per cent. (4,968) 56 per cent. (6,048) 2
1
Here there is an initial small polymorphonuclear count with onset of jaundice: a leucocytosis occurred with an absolute and relative increase in the lymphocyte counts. CASE
3 (H .G .).
I Erythrocytes .,. Leucocytes Heemoglobin . Colour index .. Polymorphonuclear leucocytes Lymphocytes ... Hyalines Eosinophils
Basophils
With jaundice (Bth day of illness).
After jaundice (13th day of illness).
5,200,000 9,600 80 per cent. 0·77 50 per cent. (4,300) 47 per cent. (4,112)
4,800,000 10,220 90 per cent. 0·93 53 per cent. (5,416) 44 per cent. (4,496)
I I I
2 1
This case shows a relative lymphocytic leucopenia after the jaundice had cleared up. Actually there is a leucocytosis of both polymorphonuclear and lymphocyte cells.
In conclusion, the following points emerge :(1) Symptomatology is fairly uniform. (2) No specific causal agent found-virus infection suggested . (3) Patients are mostly children (80 per cent. -Findlay, Dunlop and Brown), and rural districts are mostly affected (Bashford, 1934, reports an outbreak amongst adult workers
in a general post office headquarters in a townno home contacts.) (4) No sex differences. (5) Fairly close contact is necessary for infection (Bashford, Findlay, Dunlop, Brown and Blumer). School master at Kirton Holme states that cases occurring in the classroom had always been sitting close to a previous case.
PUBLIC HEALTIL
1935.
(6) Some evidence that it is infectious only in the early stages (Findlay, Dunlop and Brown). (7) Incubation period is three to five weeks (eight workers' figures). (8) Blood changes are constant and distinct from those in spirochetal jaundice. I wish to thank Dr. W. G. Booth, County Medical Officer of Health, for suggesting this investigation and for the help and facilities he has given. REFERENCES .
Alston, J. M. II Leptospiral Jaundice amongst Sewer Workers." Lancet, April 6th, 1935. Bashford, H . H. "Epidemic Catarrhal Jaundice." Lancet November 3rd, 1934. Booth, W. and Okell, C. C. "Epidemic Catarrhal Jaundice." PUBLIC HEALTH, May, 1928.
G.,
395
Findlay, Dunlop and Brown. "Observations on Epidemic Catarrhal Jaundice." Trans. Roy. Soc. Med, & Hyg., vol. xxv, 1931-2. Frazer, E. M. R. II Epidemic Catarrhal Jaundice in Children." British Medical Journal, April, 1935. Halstead, E. A. M. .. Spirochaetal Jaundice in a London Sewer Worker." British MedicalJournal, May 25th, 1935. Klein , N., Szentmihaleye, S . .. Die Veranderungen des qualitativen Blutbilder bei der Ge1bseicht." Zeitschr. fur Klin. Medz. ] 24 Bd. ]933 . Medical Research Council. .. Spirochretal Jaundice." Special Report Series, No. 1]3, 1927. Montford, T. M. .. Epidemic Jaundice in North Leicestershire." British Medical Journal, February 24th, 1934. Watson, G. W., McLeod, J. W ., Stewart, M. J. .. A Fatal Case of Leptospiral Jaundice of Obscure Origin." British Medical Journal, March 30th, ]935 .
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PUBLIC HEALTH.
391
Epidemic Jaundice in School Children. By GERALD RAMAGE, M.D., D.P.H., Assistant County Medical Officer of Health , Holland, Lines. In this paper, submitted at a meeting of the East Midland Branch of the Society on June 6th, 1935, is noted a series of blood counts taken during an outbreak of epidemic jaundice. Two cases are of unusual interest as specimens of blood were obtained before and during their illnesses. P IDEM I CS with jaundice as a feature E have been recorded since the time of Hippocrates. In 1889, Quineke and Hoppe Seyler pointed out an epidemic jaundice which was distinct from spirochetal jaundice. In 1912, Cockayne called the disease epide.mic catarrhal jaundice and this name per~~sts, though it erroneously suggests that biliary catarrh is present. Epidemic jaundice was noted during the W~r at Mesopotamia and the Dardanelles, but It was not until 1920 and after, that numerous epidemics were described. These occurred in France, Portugal, Germany, China, Africa and U.S.A. As far as I can find, there are some six to seven large epidemics described in England, starting with 1925. These occurred in the Midlands, Oxford, Ayrshire, Wensleydale and Surrey. There have, of course, been other epidemics of spirochetal jaundice, notably that investigated by Buchanan in 1924, and Alston (London) in 1934. Catarrhal Jaundice in Holland, L£ncs.-In 1929 an outbreak occurred in Moulton, and in 1930' another in a village four miles away. In 1933, 13 cases were recorded in Moulton Chapel, half of whom were adults. The present epidemic has been centred at Kirton Holme School, and a few cases have occurred at Swineshead Infants' School, three miles away. Kirton Holme School is in a rural district and the scholars live within an area of about Ii miles. There are 124 scholars at the school, and 15 have been affected so far. It is a wellventilated school and not overcrowded. The first case brought to our notice was that of a girl L.M. (ret 10 years). Her illness started on December 24th, 1934, with headache and vomiting. She was kept in bed by her own doctor for two weeks. (His certificate to the school started the investigations.) She was seen by me on January 30th, 1935, when the conjunctives were still yellow, but no other symptoms or signs remained. There were four
other children at home, three of whom attended school. The family live in a hamlet 1 to Ii miles away from the school. Second case.-E.G. (ret 13 years), taken iII on January 21st, 1935. She is a friend of the first case, though had not been in contact with her for three weeks. The jaundice was ushered in by headache and vomiting; three family contacts were attending school. Third case.-I.N. (ret 9 years), sister to first case, was ill on January 28th. The fourth and fifth cases were brothers of the second case, and started their illnesses on March 2nd and 5th, 1935, six weeks after their sister (? home contact). Between March 28th and 31st, seven further cases occurred in Kirton Holme School. On April 4th and 8th, three further cases occurred, and a suspected case on April 16th who has since left the district. All these cases attend the school. The first fivecases live in the same hamlet, and the children were friends and played together. As the second case continued at school the disease spread. Later cases were scattered in their homes and met at school. After the first three cases, contacts were excluded for three weeks. Observation of Swineshead School was not so close as that of Kirton Holme. The first case was reported on March 30th, 1935, and this date coincides with the second case at Kirton Holme. No direct contact was traced. Four cases were reported and visited. It was not possible to get blood samples from them, and no further cases have been reported. Two sporadic outbreaks were reported: one, 10 miles away where three of a family were affected, and the second 7 miles away where one case only occurred. So far 26 cases have occurred altogether, the ages of the patients varying from 8 to 14 years (average 11 years).
Analysis of Symptoms.-Symptoms are similar to those described in other outbreaks, and they are arranged in order of their frequency.
392
PUBLIC HEALTH.
First dayVomiting occurred in 22 out of 26 cases. 15 26 Headache Pain in epigastrium " 12 26 8 26 Bradycardia 7 26 Loss of appetite ... Lassitude 5 26 " 26" Di zziness ] Rambling... 2 26 ,,2 26 Sleepiness Diarrhcea . .. 2 26 3 26 T emperature Epistaxis .. . 1 26 ,,1 " 26 Sore throat Second to ninth day (even distribution)Jaundice '" occurred in 23 out of 26 cases. (2 urine dark; 1 moved out of district.) Urine dark occurred in 19 out of 26 cases. Fseces pale 16 " 26 Itching 5 26
In one to three weeks the patient feels better, or when jaundice appears if it is not severe. Information was obtained from parents and teachers, and so many points were missed, particularly with reference to pyrexia. Findlay, Dunlop and Brown found diarrhcea to be a common accompaniment of epidemic jaundice in the Surrey outbreak. Frazer describes sore throat as being a constant symptom. This was not seen in Holland nor traced in the literature. Montford (Castle Donnington) had one case (ret 4 years) who complained of seeing green (Xanthopsia). Laboratory Work.-In nearly all the epidemics looked .np, every endeavour had been made to trace the spirocheta ictero-hremorrhagica, and always without success. Using blood and urine, Findlay, Dunlop and Brown in 1931 inoculated 100 guinea-pigs and 10 monkevs-rabbits, mice and rats were all tried in thei~ turn. Nasal washings of cases were sprayed on two monkeys. Bacteriological examination of freces and nasopharynx were made, and all their work gave negative results. Drinking water was examined and eliminated in the Surrey outbreak described by Booth and Okell in 1927, where completely negative findings for pathological material again resulted. Definite changes in the blood counts were found by several workers (below) and here attention has been restricted to the blood picture. Blood Counts.-Sixteen samples were taken and counts were made by the county pathologist: 200 to 300 cells were counted for the differential count. In two cases bloods were obtained before the jaundice appeared, and a
AU(illST,
second specimen when it came on. In a third case blood was taken when the jaundice was present and again when the patient had recovered. No control was possible over the other factors affecting the blood count. Most of the patients were starving when the samples were taken. Summary of Blood Counts.-In general, lymphocytes are increased in numbers while the polymorphonuc1ears are decreased or not affected. Changes in two cases with onset of jaundice: (I) Leucocytosis. (2) Absolute and relative increase of lymphocytes. Changes in one case after jaundice cleared up:(1) Slight leucocytosis. (2) Relative lymphocytic leucoprenia. Insufficient cases were seen to show any difference in lymphocyte count at different days of illness. Figures suggest that lymphocytes increase slightly in later days of illness. Other Work on Blood.-In spirochretal jaundice, several workers note a leucocytosis with absolute and relative increase in polymorphonuclears (up to 93 per cent.), lool.-Archard and Toeper noted slight polymorphonuclear leucocytes at onset of illness and then a rapid leucopenia with an increase in mononuclear count; 3 to 4 per cent. mylocytes were present. 1923.-Jenes and Minot (America) observed in 23 cases a primary leucocytosis for three days with normal differential count. Then when jaundice appeared leucopenia occurred. There was a drop in the polymorphonuclear count and rise in lymphocytes to 50 and 60 per cent. and large mononuclear were counted up to 10 per cent. Immature cells were common . 1925. -Thewlis and Middleton working in America concluded that an initial leucopenia was present in some cases. The increase in lymphocytes was relative only while the increase in mononuclear was absolute. 193I.-Findlay, Dunlop and Brown, using controls of similar aged children, made differential lymphocyte counts. They found a fall in polymorphonuclears and a rise in lymphocytes when the disease was established, and usually even in the preicteric stage. In one case an initial polymorphonuclear leucocyte was noted, and nasopharynx was engorged for the first three days of the illness.
1935.
PUBLIC HEALTH. TABLE
393
I.
BLOOD COUNTS TAKE N WITH JAUNDICE PRESENT
I
Day No. Erythroof of cytes . Illness . Cas es. , 1
2
3 5
6
{: 1 {:
7
9 10 13 14 16
1
~!
I 1 1
Leucocytes.
4,800 6,000 5, 200 5,000 5,200 5,600 4,400 5,600 4,600 4,800 4,600 5,6 00 5,600 5, 000
I
98 92 80 92 96 102 78 106 96 90 98 100 110 100
4,600 11,600 9,600 5,600 5,000 7,400 10,000 10,800 4,800 10,200 8 ,600 10,200 10,400 7,600
Polymorphonuclear HyaLyrnpholeu cocyt es . cytes. lines. Per cent. Pe r cent. Per cent.
Hserno- Colour globin. Index.
1·02 0 ·75 0 '77 0 ·92
54 46 50 37 46 46 60 46 -12 53 51 40 44 46
O·g 0 ·9 0· 88 0· 9 0 ·98 0 ·93 1·0 0 ·9 0·98 0 ·99
41 49 47 57 51 50 38 56 57 44 47 51 51 52
I
Eosine-
Baso-
phils. Per cent.
phils. Per cent.
3 I I 2
-
2 2 1·5 4 2 3 2 2
2 1
-
1
I
-
-
-
-
-
-
-
I 1
2 2
-
4 3
1 2
2 I
14 (2 others Without Jaundice). TABLE
No. of Ca ses .
I
General Average.
...
14 14 14 14
Erythrocytes Leucocytes Heemoglobin Colour index
14
Polymorphonuclear leucocytes ... Lymphocytes'[ ... Large mononuclear or hyaline cells . ..
14 8
6 4
II.
ROUGH AVERAGES OF ALL COUNTS TAKEN WHILE PATIEN TS WERE JAtJNDlCED .
... ...
...
...
Eosinophils Basophils . . .
7,500
-
Present Average .
Maximum.
5,240,000 8, 500 95 per cent. ·9
11,600 110 per cent. 1'0
4,800 78 per cent. '75
45 per cent. 48 per cent.
60 per cent. 57 per cent.
42 per cent. 38 per cent.
2 per cen t .
3 per cent.
60-65 per cent. (4 ,000) 25-35 per cen t . (2,000) 3-5 per cent.
Minimum.
-
-
nil
2-3 per cent. 0 ·5 per cent.
nil 2 per cent. 4 pe r cent. nil 1·5 per cent. 2 per cent. • The lymphocytes were not differen tiat ed Into large and small cells. The figur es in brackets are the number of cells per cubic millimetre, The table shows an increase in the lymphocyte count.
...
TABLE
III.
D IFFERENTIAL COUNT.
Day.l Leucocytes·1
2 3 3 5 6 6 7 9 9 10
10 13 14
16
4,600 11,600 9 ,600 5,600 5,000 7,400 10,000 10,800 4,800 10,200 8,600 10,200 10,400 7,600
Polymorphonuclear leucocytes.
Lymphocytes.
Per cent.
Count per cu . mm,
Per cent.
Count per cu. mm,
54 46 50
2,484 5,336 4,300 2,072 2,300 3,404 6,000 4,860 2,016 5,406 4,386 4,080 4,576 3,496
41 49 47 57 51 50 38 56 57 44 47 51 51 52
1,886 5,684 3,712 3 ,192 2,550 3,700 3,800 6,048 2,736 4,488 4,20 2 5,202 5,304 3,952
37 46 46 60 46 42 53 51 40 44 46
I
L ymphocytes per 10,000 Leucocytes.
4,000 4,900 3,860 5,700 5,100 5,000 3,800 5 ,600 5,700 4,480 4,900 5,200 5,250 5 ,200
PUBLIC HEALTH.
394
CASE
Day of Illness. Erythrocytes .. . Leucocytes Heemoglobin
. Colour index . Polymorphonuclear leucocytes Lymphocytes .. . Hyalines Eosinophils Basophils
AUGIlST,
1 (RT.).
2nd day (no jaundice).
6th day (with jaundice).
4,800,000 4,600 98 per cent. 1002 54 per cent. (2,484) 41 per cent. (1,886) 2
5,200,000 5,000 96 per cent. 0·9 46 per cent. (2,300) 51 per cent. (2,550) 2
3
This case shows an absolute and relative increase in lymphocytes and reduction in polymorphonuclear leucocytes when jaundice appeared. CASE
Erythrocytes ... Leucocytes Heemoglobin . Colour index .. Polymorphonuclear leucocytes Lymphocytes ... Hyalines Eosinophils Basophils
2 (J.N.).
Without jaundice (weeks before).
With jaundice (9th day of illness).
5,200,000 4,800 98 per cent. 0·9 46 per cent. (2,168) 51 per cent. (2,448) 2
5,600,000 10,800 106 per cent. 0·9 46 per cent. (4,968) 56 per cent. (6,048) 2
1
Here there is an initial small polymorphonuclear count with onset of jaundice: a leucocytosis occurred with an absolute and relative increase in the lymphocyte counts. CASE
3 (H .G .).
I Erythrocytes .,. Leucocytes Heemoglobin . Colour index .. Polymorphonuclear leucocytes Lymphocytes ... Hyalines Eosinophils
Basophils
With jaundice (Bth day of illness).
After jaundice (13th day of illness).
5,200,000 9,600 80 per cent. 0·77 50 per cent. (4,300) 47 per cent. (4,112)
4,800,000 10,220 90 per cent. 0·93 53 per cent. (5,416) 44 per cent. (4,496)
I I I
2 1
This case shows a relative lymphocytic leucopenia after the jaundice had cleared up. Actually there is a leucocytosis of both polymorphonuclear and lymphocyte cells.
In conclusion, the following points emerge :(1) Symptomatology is fairly uniform. (2) No specific causal agent found-virus infection suggested . (3) Patients are mostly children (80 per cent. -Findlay, Dunlop and Brown), and rural districts are mostly affected (Bashford, 1934, reports an outbreak amongst adult workers
in a general post office headquarters in a townno home contacts.) (4) No sex differences. (5) Fairly close contact is necessary for infection (Bashford, Findlay, Dunlop, Brown and Blumer). School master at Kirton Holme states that cases occurring in the classroom had always been sitting close to a previous case.
PUBLIC HEALTIL
1935.
(6) Some evidence that it is infectious only in the early stages (Findlay, Dunlop and Brown). (7) Incubation period is three to five weeks (eight workers' figures). (8) Blood changes are constant and distinct from those in spirochetal jaundice. I wish to thank Dr. W. G. Booth, County Medical Officer of Health, for suggesting this investigation and for the help and facilities he has given. REFERENCES .
Alston, J. M. II Leptospiral Jaundice amongst Sewer Workers." Lancet, April 6th, 1935. Bashford, H . H. "Epidemic Catarrhal Jaundice." Lancet November 3rd, 1934. Booth, W. and Okell, C. C. "Epidemic Catarrhal Jaundice." PUBLIC HEALTH, May, 1928.
G.,
395
Findlay, Dunlop and Brown. "Observations on Epidemic Catarrhal Jaundice." Trans. Roy. Soc. Med, & Hyg., vol. xxv, 1931-2. Frazer, E. M. R. II Epidemic Catarrhal Jaundice in Children." British Medical Journal, April, 1935. Halstead, E. A. M. .. Spirochaetal Jaundice in a London Sewer Worker." British MedicalJournal, May 25th, 1935. Klein , N., Szentmihaleye, S . .. Die Veranderungen des qualitativen Blutbilder bei der Ge1bseicht." Zeitschr. fur Klin. Medz. ] 24 Bd. ]933 . Medical Research Council. .. Spirochretal Jaundice." Special Report Series, No. 1]3, 1927. Montford, T. M. .. Epidemic Jaundice in North Leicestershire." British Medical Journal, February 24th, 1934. Watson, G. W., McLeod, J. W ., Stewart, M. J. .. A Fatal Case of Leptospiral Jaundice of Obscure Origin." British Medical Journal, March 30th, ]935 .
The Society. Reports, Proceedings and Announcements. NOTICES.
THE ROLL OF ~lEMBERS.
The Roll of Members for the session 1935-36 is now being prepared for the Press. Members are asked to notify the Executive Secretary, if they have not already done so, of any changes which should be made in their entries, i.e., qualifications, appointments, etc. ANNUAL SIJBSCRIPTlONS.
Members who nave not yet paid their subscriptions for the current session (notices were sent out in this connection recently) are asked to make early payment and thus to save the staff at headquarters further labour in collecting these amounts before the annual audit. THE ANNUAL DINNER.
Members are again reminded that the Annual Dinner is to be held this year on Friday, November 22nd, at the Piccadilly Hotel, London, at 7.15 for 7.30 p .m, Tickets l~s. 6d. exclusive of wines. Sir Kingsley Wood, the Minister of Health, has accepted an invitation to be present, and Sir George
Newman is to be the guest of honour. The toast list is to be a short one, and arrangements are being made for members and their ladies who so wish to proceed to the hotel ballroom for the cabaret and dancing .
NomNATIONS.
Members who wish to nominate candidates for election at the beginning of the new session commencing in October are asked to do so before the end of August, so that the names of prospective members can be included in the new Roll of Members. The following nominations have already been received: Laurence David Adler, B.SC., sr.n., CH.B., D.P.H . j Ethel Browell, M.D. j Douglas Latham Brown, M.B., CH.B., D.P.H. i J. C. H. Browne, LoR.e.I'., M.R.e.S. j Norman Stuart Carruthers, r.n.c.s., D.L.O., M.R.C.S., L.R.C.P.; Francis Montagu Day, M.R.e.S., L.R.C.P., D.T.M., D.P.H.i Sibyl Dorothy Goodwill, M.B., B.S., III.R.C.S., t.a.c.r-., D.p.H. i Joseph Morrow Kennedy, IILB., D.P.H. i Adam Douglas Fraser Menzies, III.B., cn.s.j Violet Mizen, M.B., B.S., !\I.R.e.S., L.R.C.P.; Ernest Milford Ward, M.B., B.S., n .n.c.s., L.n.e.p.; Percy Denis Copeland, B.D.S.; Henry Francis Jones, t.,n.s. i Charles Reginald Knowles, L.D.S., George Oliver Wood, L.D.S., B.SC.