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On an outbreak of diphtheria connected with school attendance
18o
DIPHTHERIA
AND
SCHOOL
ON AN OUTBREAK OF DIPHTHERIA CONNECTED WITH SCHOOL ATTENDANCE. By J. SPOTTIS~,VOODE CAi~IERON, M.D., B. Sc., M.O.H. for Leeds.*
I PROPOSE to say a few words about a limited outbreak of diphtheria which occurred in Headingley. The first case which came to our knowledge was fatal at Heathfield Terrace. T h e inspector, having heard of it, visited the house on November 26tb. On the 28th the sub-registrar informed us that he had the previous day registered this death as due to diphtheritic tonsilitis. The district inspector, on visiting the house, had found that Of five remaining inmates, three wexe suffering from an analogous disease, and that two of these children and the patient who had died were in attendance at the elementary school attached to St. Chad's Church. On the 3oth we were requested by a medical man to remove a patient suffering from diphtheria from HiRhbury Street. This patient was also attending St. Chad's School. Thirteen other cases of sore throat of a diphtheritic character ~ere heard of in the course of a few days. These all occurred in six families, from each of which some members were attending St. Chad's School. Of the 18 patients, i i had been themselves attending this school, and of these three died. T h e vicar promptly closed the schools, and communicated with us . . . . The condition of each patient's house, and of the milk supply, was carefully gone into, and several visits were paid to the school . . . . There was in almcst every case something locally wrong, but the most serious defects evidently lay in the school-house. T h e children attacked were principally associated in the infant department, and occupied a small room, at the end of the building, very inadequately ventilated. Communicating with this badly.ventilated room was a staircase into a small cellar, and in this cellar was a dry gully trap passing into the sewer.
I t seemed probable that some case originating at home, the exact nature of which had not been ascertained at the commencement, had caused the infection of this little community, brought together under insanitary conditions. Prompt measures were taken on the part of the school authorities to remedy the more urgent of the defects, and for some weeks the school remained closed. During this period altogether 18 cases seemed traceable to infection from this school, i i in patients actually attending the schools and seven in members cf their families. In addition to these, some other cases not attending this school seemed to have received the infection from children who were. T h e drainage was thoroughly overhauled, the trap already spoken of removed, and a certain amount of cleaning dcne. * From Dr. Cameron's Annual Report for x89 r.
ATTENDANCE.
The school was r e o p e n e d on January 12th. A boy, G H., aged four, came to the school on the I2th, was noticed to be ill on the t6th, and died on the 2oth. His death was certified as due to diphtheria. T h e house in which he died contained five inmates and two rooms, and had an ordinary midden, used by two families, 25 yards away from the house. There was no sink or other inside drain within the house. T h e r e was a trapped gully opposite the door about 3{ ~ards distant. On February i8th two other children, aged eight and five respectively, and in attendance at St. Chad's School, were sent by their medical attendant into hospital. A further case, a child of eight, also at the same school, was reported to us next day, and a third child, from the family mentioned before, was reported on the 2ist. On the 23rd a girl of four, on the 25th a girl of ten, on the 28th a girl of eight, were all reported to us from different houses as suffering from diphtheria. T h e y were all attending St. Chad's School. On the lastmentioned date the inspector, on visiting the house where the child of eight was ill, found the mother, aged 33, suffering flom sore thioat, It was ascertained that she had been sufferit~g, more or less, since December 9th, and that her children had remained away from school until January Igth. T h e dates of the commencement ot illness in the cases last mentioned were : One on February 7th, three on February i Ith, one on the 2oth, a case which proved fatat on February Igth, and the remaining case on the 22nd. T h e case reported on the 28th had been ill from February 7th, and was one of the patients who recommenced their school attendance on January I9th , and whose mother had had a sore throat at the time of the previous outbreak. I t would seem that this child had returned to school without any certificate of disinfection from the-department. The previous case in this house had come to our knowledge on December 2nd, and had been visited at that time, but disinfection was not completed then as the mother was ill. It seems not unhkely that the poison of the disease may have been lurking about this child's clothes, for she herself took ill on February 7th, and others ot her schoolfellows on the i ith. U n d e r these circumstances the vicar judiciously re-closed the school. Some further measures of cleaning and ventilation, which had not been carried out in the first in.~tance, were now completed . . . . . At the same time a new inquiry was set up at the houses of all the children in attendance at the schovl, and I am happy to report that no further cases came to our knowledge in connection with this outbreak after March 17th. I have gone somewhat into detail in this case, as it seems to illustrate in regard to diphtheria the great importance of being able to diagnose and isolate the early cases, especially when they occur in children of school-going age. T h e cases which were first noticed were not regarded to begin with
ISOLATION as diphtheria at alI; it was not till one or two had proved fatal that suspicion was aroused that the disease was really of this nature, and even after the closing and re-opening of the school, there seemed difficulty in recognizing all the infective cases. I was largely indebted to the medical men of Headingley for the prompt manner in which they informed me of the cases about which they felt sure. But it would almost seem as if it were necessary to regard every case of sore throat as a possible case of diphtheria, until the contrary is proved. It is the experience, I believe, of all medical officers that the early cases in outbreaks of this kind are frequently regarded as ordinary cases of tonsili~is.
ISOLATION HOSPITALS. By Dr. JosEel~ PRIESTLEY, Leicester. (Read at t~e ~anuary Meeting of the Birmlngham and Midland Branc~ of the Zncor2~oratedSociety of Medical Officers of Z-Zeatt/~.)
FOR the purposes of my paper I shall restrict myself to scarlet fever, and endeavour to show from Leicester's statistics certain facts, and to draw therefrom certain conclusions. Starting from the end of the year 1879 , scarlet fever has been endemic in the town. In :885 there were r,8r6 cases notified and rl 3 deaths. Since then the disease deelined, until 1888 when there were only 132 cases and four deaths. The disease again began to increase until the last year, 1892 , during which there have been notified 1,33 t cases, of which 4I have died. Though it is undoubtedly true that scarlet fever is both infectious and contagious, and that many of our cases can be exphined by one child having caught the fever from contact with another, I would point out that between 50 and 60 per cent. (roughly) of the cases have been removed to our hospital and thoroughly isolated. # Leicester has a high birth-rate, and, after allowing for the large number of children who die before attaining the age of five years, there still remains an enormous number of children who offer a suitable soil upon which the contagion of scarlet fever witl thrive. All these susceptible children we may call the "infectible material," and until this " i n fectible material" is exhausted, the epidemic continues. Roughly calculated, we may say that during the six years from 1885 (a year of maximum outbreak) until the end of 189 r, the "infectible material" has got up to the large number of 20,000, This number is arrived at by taking the number of births during the six years and subtracting * This 60 per cent. is the average removed during the last ten years; during the last few years we have been removing 9o per cent., and during the Ia~t few months as many as 95;per cent.
HOSPITALS.
I81
therefrom the numbers of deaths under five years of age, allowing margins for children l_~aving, and coming to, the town, etc. At the beginning of r892, then, the "infectible ma:erial" was 2o,ooo, but the number of cases notified during the same period has only been 4,27i (including 1,53o children under five), giving us an enormous surplus of children under five, the majority ot whom are a suitable soil upon which the bacilli scarlafime wilt grow. I n :885, of the total 1,816 cases notified, no less than 1,595 were children under ten years of age, and 933 were under five. Again, from i88o to t885 there were registered z8,78z births, and, calculating in the same way as before, we find (roughly) the "infectible material" at the beginning of I885 as equal to I5,OOO. Looking at the subject from this point of view we as medical officers of health, and our committees as health authorities, must all admit that some material good is being effected by the precautions we are taking in isolating cases and disinfecting houses, bedding, clothes, etc. I calculate that in Leicester the epidemic would have swelled during the last six years to at least ten times the size had isolation not been practised. Unfortunately, owing to the fact that .-mall.pox appeared in our scarlet fever wards)and the hospital had, as a consequence, to be shut up against all scarlet fever cases, I am able to show you by a few figures the actual difference. The hospital was closed on October 3ist, 1892 ) and since then there have been 408 cases notified, whereas in the previous io months (with meres of isolating) there were only 956 cases, i.e., since the closing of the isOlation hospital the number of cases has increased ioo per cent. The importance of saving young children from attacks of scarlet fever is of special interest. Every year a child remains unattacked is a distinct gain, for as the child's age increases, its susceptibility to scarlet fever decreases. Again, as age increases (after five years), the mortality rate decreases. Of the 4,4t 3 cases admitted to hospital during the last IO years, I64 have died, givinga deathrate of 3'7 per cent., as compared with the death-rate (8"06 per cent.) of those cases treated outside. Then, again, scarlet fever is, as all medical men know, likely to be followed by sequehe (e.g. nephritis, otitis, glandular enlargements, etc.) during the peeling stage, and these sequelze are less likely to arise in hospital where the patients are well looked after and cared for--better cared for than they are, as a rule, at their own homes. The average length of stay in bed is about three weeks, and the average stay in hospital seven to eight weeks, during all of which time the patients are carefully watched. I do not look to our isolation hospitals as a means of stamping out scarlet fever, but merely as a means of lessening the scarlet fever mortality, and keeping an epidemic from bursting forth. What we have apparently been
DIPHTHERIA
AND
SCHOOL
ON AN OUTBREAK OF DIPHTHERIA CONNECTED WITH SCHOOL ATTENDANCE. By J. SPOTTIS~,VOODE CAi~IERON, M.D., B. Sc., M.O.H. for Leeds.*
I PROPOSE to say a few words about a limited outbreak of diphtheria which occurred in Headingley. The first case which came to our knowledge was fatal at Heathfield Terrace. T h e inspector, having heard of it, visited the house on November 26tb. On the 28th the sub-registrar informed us that he had the previous day registered this death as due to diphtheritic tonsilitis. The district inspector, on visiting the house, had found that Of five remaining inmates, three wexe suffering from an analogous disease, and that two of these children and the patient who had died were in attendance at the elementary school attached to St. Chad's Church. On the 3oth we were requested by a medical man to remove a patient suffering from diphtheria from HiRhbury Street. This patient was also attending St. Chad's School. Thirteen other cases of sore throat of a diphtheritic character ~ere heard of in the course of a few days. These all occurred in six families, from each of which some members were attending St. Chad's School. Of the 18 patients, i i had been themselves attending this school, and of these three died. T h e vicar promptly closed the schools, and communicated with us . . . . The condition of each patient's house, and of the milk supply, was carefully gone into, and several visits were paid to the school . . . . There was in almcst every case something locally wrong, but the most serious defects evidently lay in the school-house. T h e children attacked were principally associated in the infant department, and occupied a small room, at the end of the building, very inadequately ventilated. Communicating with this badly.ventilated room was a staircase into a small cellar, and in this cellar was a dry gully trap passing into the sewer.
I t seemed probable that some case originating at home, the exact nature of which had not been ascertained at the commencement, had caused the infection of this little community, brought together under insanitary conditions. Prompt measures were taken on the part of the school authorities to remedy the more urgent of the defects, and for some weeks the school remained closed. During this period altogether 18 cases seemed traceable to infection from this school, i i in patients actually attending the schools and seven in members cf their families. In addition to these, some other cases not attending this school seemed to have received the infection from children who were. T h e drainage was thoroughly overhauled, the trap already spoken of removed, and a certain amount of cleaning dcne. * From Dr. Cameron's Annual Report for x89 r.
ATTENDANCE.
The school was r e o p e n e d on January 12th. A boy, G H., aged four, came to the school on the I2th, was noticed to be ill on the t6th, and died on the 2oth. His death was certified as due to diphtheria. T h e house in which he died contained five inmates and two rooms, and had an ordinary midden, used by two families, 25 yards away from the house. There was no sink or other inside drain within the house. T h e r e was a trapped gully opposite the door about 3{ ~ards distant. On February i8th two other children, aged eight and five respectively, and in attendance at St. Chad's School, were sent by their medical attendant into hospital. A further case, a child of eight, also at the same school, was reported to us next day, and a third child, from the family mentioned before, was reported on the 2ist. On the 23rd a girl of four, on the 25th a girl of ten, on the 28th a girl of eight, were all reported to us from different houses as suffering from diphtheria. T h e y were all attending St. Chad's School. On the lastmentioned date the inspector, on visiting the house where the child of eight was ill, found the mother, aged 33, suffering flom sore thioat, It was ascertained that she had been sufferit~g, more or less, since December 9th, and that her children had remained away from school until January Igth. T h e dates of the commencement ot illness in the cases last mentioned were : One on February 7th, three on February i Ith, one on the 2oth, a case which proved fatat on February Igth, and the remaining case on the 22nd. T h e case reported on the 28th had been ill from February 7th, and was one of the patients who recommenced their school attendance on January I9th , and whose mother had had a sore throat at the time of the previous outbreak. I t would seem that this child had returned to school without any certificate of disinfection from the-department. The previous case in this house had come to our knowledge on December 2nd, and had been visited at that time, but disinfection was not completed then as the mother was ill. It seems not unhkely that the poison of the disease may have been lurking about this child's clothes, for she herself took ill on February 7th, and others ot her schoolfellows on the i ith. U n d e r these circumstances the vicar judiciously re-closed the school. Some further measures of cleaning and ventilation, which had not been carried out in the first in.~tance, were now completed . . . . . At the same time a new inquiry was set up at the houses of all the children in attendance at the schovl, and I am happy to report that no further cases came to our knowledge in connection with this outbreak after March 17th. I have gone somewhat into detail in this case, as it seems to illustrate in regard to diphtheria the great importance of being able to diagnose and isolate the early cases, especially when they occur in children of school-going age. T h e cases which were first noticed were not regarded to begin with
ISOLATION as diphtheria at alI; it was not till one or two had proved fatal that suspicion was aroused that the disease was really of this nature, and even after the closing and re-opening of the school, there seemed difficulty in recognizing all the infective cases. I was largely indebted to the medical men of Headingley for the prompt manner in which they informed me of the cases about which they felt sure. But it would almost seem as if it were necessary to regard every case of sore throat as a possible case of diphtheria, until the contrary is proved. It is the experience, I believe, of all medical officers that the early cases in outbreaks of this kind are frequently regarded as ordinary cases of tonsili~is.
ISOLATION HOSPITALS. By Dr. JosEel~ PRIESTLEY, Leicester. (Read at t~e ~anuary Meeting of the Birmlngham and Midland Branc~ of the Zncor2~oratedSociety of Medical Officers of Z-Zeatt/~.)
FOR the purposes of my paper I shall restrict myself to scarlet fever, and endeavour to show from Leicester's statistics certain facts, and to draw therefrom certain conclusions. Starting from the end of the year 1879 , scarlet fever has been endemic in the town. In :885 there were r,8r6 cases notified and rl 3 deaths. Since then the disease deelined, until 1888 when there were only 132 cases and four deaths. The disease again began to increase until the last year, 1892 , during which there have been notified 1,33 t cases, of which 4I have died. Though it is undoubtedly true that scarlet fever is both infectious and contagious, and that many of our cases can be exphined by one child having caught the fever from contact with another, I would point out that between 50 and 60 per cent. (roughly) of the cases have been removed to our hospital and thoroughly isolated. # Leicester has a high birth-rate, and, after allowing for the large number of children who die before attaining the age of five years, there still remains an enormous number of children who offer a suitable soil upon which the contagion of scarlet fever witl thrive. All these susceptible children we may call the "infectible material," and until this " i n fectible material" is exhausted, the epidemic continues. Roughly calculated, we may say that during the six years from 1885 (a year of maximum outbreak) until the end of 189 r, the "infectible material" has got up to the large number of 20,000, This number is arrived at by taking the number of births during the six years and subtracting * This 60 per cent. is the average removed during the last ten years; during the last few years we have been removing 9o per cent., and during the Ia~t few months as many as 95;per cent.
HOSPITALS.
I81
therefrom the numbers of deaths under five years of age, allowing margins for children l_~aving, and coming to, the town, etc. At the beginning of r892, then, the "infectible ma:erial" was 2o,ooo, but the number of cases notified during the same period has only been 4,27i (including 1,53o children under five), giving us an enormous surplus of children under five, the majority ot whom are a suitable soil upon which the bacilli scarlafime wilt grow. I n :885, of the total 1,816 cases notified, no less than 1,595 were children under ten years of age, and 933 were under five. Again, from i88o to t885 there were registered z8,78z births, and, calculating in the same way as before, we find (roughly) the "infectible material" at the beginning of I885 as equal to I5,OOO. Looking at the subject from this point of view we as medical officers of health, and our committees as health authorities, must all admit that some material good is being effected by the precautions we are taking in isolating cases and disinfecting houses, bedding, clothes, etc. I calculate that in Leicester the epidemic would have swelled during the last six years to at least ten times the size had isolation not been practised. Unfortunately, owing to the fact that .-mall.pox appeared in our scarlet fever wards)and the hospital had, as a consequence, to be shut up against all scarlet fever cases, I am able to show you by a few figures the actual difference. The hospital was closed on October 3ist, 1892 ) and since then there have been 408 cases notified, whereas in the previous io months (with meres of isolating) there were only 956 cases, i.e., since the closing of the isOlation hospital the number of cases has increased ioo per cent. The importance of saving young children from attacks of scarlet fever is of special interest. Every year a child remains unattacked is a distinct gain, for as the child's age increases, its susceptibility to scarlet fever decreases. Again, as age increases (after five years), the mortality rate decreases. Of the 4,4t 3 cases admitted to hospital during the last IO years, I64 have died, givinga deathrate of 3'7 per cent., as compared with the death-rate (8"06 per cent.) of those cases treated outside. Then, again, scarlet fever is, as all medical men know, likely to be followed by sequehe (e.g. nephritis, otitis, glandular enlargements, etc.) during the peeling stage, and these sequelze are less likely to arise in hospital where the patients are well looked after and cared for--better cared for than they are, as a rule, at their own homes. The average length of stay in bed is about three weeks, and the average stay in hospital seven to eight weeks, during all of which time the patients are carefully watched. I do not look to our isolation hospitals as a means of stamping out scarlet fever, but merely as a means of lessening the scarlet fever mortality, and keeping an epidemic from bursting forth. What we have apparently been