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The croydon typhoid outbreak
1939
PUBLIC
THE CROYDON TYPHOID OUTBREAK. (A Summary of the Chief Clinical Features) By OSCAR M. HOLDEN, M . D . D . P . H . ,
Medical O.~cer of Health, County Borough of Croydon.
The Incidence of Cases An outbreak of typhoid fever occurred in the southern part of Croydon in 1987. It commenced during the last week in October, and continued throughout November and December. The total number of real or suspected cases which came to my notice and which resided in Croydon was 317. Of these 299 were notified and 18 were not notified. Of the notified cases 15 were secondary, and of the not notified 1 was secondary. Seven of the 299 notified cases were ultimately considered not to have suffered from typhoid. In addition to the a b o v , 28 primary cases and 8 secondary cases were brought to my notice by the medical officers of health concerned these were not resident in Croydon but were definitely connected with the outbreak, either by working in the town, or having resided therein during the relevant period. Of these 18 were in the neighbouring borough of Purley and Coulsdon, 1 in Wallington, 1 in Caterham, 1 in Merton, 1 in Carshalton, 1 in Horsham, 1 in Brighton, 1 in Camberwell, 1 in Liverpool, 1 in Great Yarmouth and 1 in Newport (Mon.). The 8 secondary cases were nurses who had been nursing in Croydon. The total cases, therefore, known to me, were 841 including 19 secondary cases. The graph overleaf shows the age and sex incidence in five-year age groups for both sexes. CROYDON
EPIDEMIC
SPECIFIC
OF TYPHOID.
AGE
FATALITY P.ATES.
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In the area there are a number of residential and day schools. The largest of these was a day school of some 750 boys, but it was early ascertained that this school obtained its water supply direct from the Low-Level mains, an entirely separate supply. Nine cases occurred in boys attending this school, of whom 6 lived on the High-Level supply at home, and 1 master, who also lived on the same supply. The largest residential school is situated in the Addington Hills and nearby the HighLevel Reservoir. It got the full force of the infection, 16 boys and 1 maid contracted the infection, one of the cases being secondary. The usual number of boys in residence is 150. The incidence rate was therefore 10.6 per cent. None of the teaching staff became ill. The other schools affected were private schools. In one, a boys' school, 5 cases, including a master, contracted typhoid; whilst in a girls' school--average attendance 180--9 cases occurred including a teacher. Among the public elementary schools in the district 15 cases occurred. The average attendance at these schools is 2,878. The incidence rate was therefore 0.52 per cent. One case occurred in a convalescent home for children, containing an average of 30 children, but no cases occurred in any of the private nursing homes in the area ; 1 case occurred in a residential hotel. It is extremely difficult, in view of the ramifications of the water supply, to give anything other than a very approximate estimate of the population at risk. It was possibly between 40,000 to 45,000. Even with the lower figure the incidence rate is only 0.75 per cent. This is rather a characteristic of water-borne outbreaks and would certainly appear to show that the infecting doses in the water were not heavy. The proximity of the residential school to the source of supply and the fact that the boys had a habit of using a tap for drinking in the changing room and in close proximity to the W.C.s would account for the high incidence at this school as compared with other schools and the rest of the population. More than 1 case occurred in 8 families, and of these 1 family had 8 cases--all children under ten years of age and nursed at home. There was, however, some evidence to show that the later 2 were secondary in that the dates of notification were (1) 10/11/87; (2) 26/11/37 ; (3) 29/11/87. The date of onset of the first case was given as 3/11/87, that of the two subsequent cases was indefinite. In the families with two cases, the second case in all was considered to be definitely secondary. CROYDON T Y P H O I D . - - A Q E AND SEX FATALITY PER CENT.
25 20
AND SEX
~OrH s ~ x ~ s MABI~5 . . . . . ~E.r,U~LES . . . . . . .
HEALTH
~
;o'
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Age Groups. O--
Males. 0.00
10-20-30-40-50-60-70--79
8.98 18.52 16"67 9-09 33-33 0-00 0.00
Females. 0.00 8-82 6.52 22.22 20-00 21.43 41-67 50.00
Both Sexes. 0.00 8-89 10.96 20.00 16.13 26.09 29.41 40.00
The number of houses on the High-Level supply is difficult to determine but probably a fifth to a sixth of the total houses in Croydon might have received the 135
PUBLIC HEALTH
FEBRUARY
supply at relevant times. The figure is probably in the neighbourhood of 1:],000. The district most heavily attacked was residential with houses of rateable value from £50 to £90 or over. A total of ~39 patients were admitted to the Corporation's hospitals ; 54 were treated at home and 17 were treated in London hospitals. At no time was any pressure exerted to force admissions to hospital; on the other hand admission was never refused. A considerable proportion of the cases occurred in relatively well-to-do families, in which the conditions laid down, that there must be a day and a night nurse and absolute seclusion of the patient, could be carried out without much difficulty. These cases remained under their private medical practitioners and the public health medical staff were not asked to assist beyond, in the first place, in certain of the cases, to afford a second opinion upon diagnosis, to carry out bacteriological tests, and,
CROYDON
when the case was free from infection, to arrange terminal disinfection. Three consecutive negative urine and faeces results was the criterion laid down, and as the tests were carried out in the Corporation's laboratory, a useful check could be kept upon it. At least three consecutive negative results of urine and faeces was also the rule in the Corporation's hospitals, before a patient was discharged. Of the '389 patients admitted to the Corporation hospitals, 174 were admitted to Mayday Hospital (the Corporation Public Health Hospital)--87 females, 87 males (one of the males was a paratyphoid B. infection) --and 65 to the Borough Fever Hospitai--45 females, 20 males. In the statistics which follow the figures for the two hospitals are kept separate. By so doing information of value isdicative of the influence of the personal factor of the attendant physician upon the incidence of signs and symptoms is obtained. The cases in the two
EPIDEMIC OF TYPHOID.
DISTEIBUTION
OF
CASES
AGE
AND
P~I M A ~ y
SECONDARY
MALES
80- 84
SEX
F----']
FEMALES
75-
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70-
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1939
PUBLIC HEALTH
hospitals were all victims of the same infection and were indeed, from time to time admitted to one or other of the hospitals, without at any time any differentiation being made. As the earliest cases which arose were, however, the most severe, the Borough Hospital, into which they were admitted, had for a time a higher relative proportion of severe cases than Mayday Hospital. This after the first fortnight did not continue as the available accommodation at the former hospital was by that time filled, and all new cases arriving were admitted to Mayday Hospital, until further accommodation was made available at the Borough Hospital. The average economic level of the cases nursed at home was considerably higher than those admitted to the Corporation hospitals, whilst those admitted to London hospitals were all sent as private patients and were economically on a higher level than the majority of the Corporation hospitals cases. Table I gives in summary form the cases and deaths.
Initial Symptoms and lneubation Periods The incubation period could be very accurately determined in two cases. In one the patient had stayed with a friend ira a house upon the incriminated water supply for three days, viz., on October 27th, 28th and 29th. He then returned to his home in Bournemouth. On Saturday, November 20th, he was taken ill whilst on a visit to Morden and was admitted to the Mitcham Isolation Hospital where he unfortunately died from typhoid on December 8rd. An incubation period of maximum 24 days, minimum 21 days. The second case was admitted from Adding'ton, from a house on the infected water supply, for her confinement on October 22nd. She was in good health and the confinement w.as normal. She returned home on November 6th and began to feel ill on November 7th. She was readmitted to Mayday Hospital on November 12th with typhoid fever. A minimum incubation period of 15 days.
T ~ L ~ I. Hospitals. Mayday Hospital.
Private Address.
Borough Hospital.
Cases.
Deaths.
Cases.
174
21
65
Deaths. 14
Other Hospitals. Cases. 17
Deaths.
Cases.
Deaths.
3
54
5
It is recognised, and has been illustrated in previous Of the cases treated in the Borough Hospital, g were definitely not typhoid ; 1 was a tuberculous meningitis ; water-borne outbreaks, that the incubation period is 1 a mild attack of influenza, and 1 showed no symptoms longer than in food-borne outbreaks. This is possibly at all but was sent in because his Widal showed a 1/50 due to the smallness of the infecting dose in the former agglutination. After a fortnight's stay ill hospital the as compared with the more concentrated dose in the Widal became negative and remained so. One case in latter. Water, moreover, is not a medium particularly the Borough Hospital was a urinary carrier on admission favourable to the life of the organism, though it probably suffering from cystitis and mild orchitis. This patient survives longer in a pure water, than in one grossly may have suffered a few weeks previously from a mild contaminated with other intestinal organisms of a more ambulant attack. He was detected owing to his daughter, robust habit. The most usual food conveyors, e.g., aged 13 years, developing typhoid on 16/12/37. She milk, are on the contrary, favourable media in which was admitted to a London hospital on 28/12/87, and the organism will multiply. after a severe illness, recovered. Seven cases in Mayday Table I I gives in summary the symptoms noted at Hospital were very doubtful, and, if in fact typhoid, the time of the history taking on admission to hospital. were clinically and bacteriologically of a very atypical The symptoms most frequently complained of were, kind. .headaches, lassitude, constipation, shivering attacks, In both Corporation hospitals, treatment was carried pains in the abdomen, nausea or actual sickness, diarout on very similar lines as regards methods of dieting-rhoea, epistaxis, backaches and insomnia. this being that of small fluid feeds of milk or modified The history of symptoms such as anorexia or cough milk at two-hourly intervals. No attempt was made to commence early feeding with solid food. In both show such wide divergence as between the two hospitals hospitals serum supplied by Dr. Felix of the Lister that one is forced to conclude that the complaint by Institute was used, though the cases so treated at the the patients of these symptoms depended upon the nature Borough Hospital were, on the whole, more severe than of the questions put to them. In 413 cases the patients those treated at Mayday. This was because the earliest thought they had contracted a severe cold, or influenza cases were admitted to the former hospital before with coryza and in 6 cases a stiff neck. It was noticeable, supplies of serum had been obtained, and the first cases however, that a number said they had no initial sympso treated had already been in hospital some days, and toms other than a feeling of tiredness and of being " off were indeed in the majority of instances, extremely ill, colour." No relationship was established between any at the time of administration. At Mayday Hospital, on initial symptoms and the subsequent trend of the attack. the other hand, the cases received serum on, or shortly Initial constipation might give way later to diarrhoea, or after, admission. This may account for the better more usually initial diarrhoea was replaced by constiresults obtained at this hospital. The method of pation. The reputed day of disease on admission in the cases administration was the same as both the medical officers is given in Table I I I . in charge had the benefit of Dr. Felix's guidance. 137
PUBLIC HEALTH TABLE
........
1I.
FEBRUARY INITIAL
Symptom.
SYMPTOMS
AS E L I C I T E D
Borough Hospital.
Lassitude ...... Headache ...... Backache ...... Shivering ...... N a u s e a o r s i c k n e s s ... Epistaxis ...... Diarrhoea ...... Constipation ...... Generalised limb pains Pain in abdomen ... P a i n in c h e s t . . . . . . Anorexia ...... Insomnia ...... Sore throat ...... Cold in the head ... Deafness ...... Cough ...... Influenza ...... Stiff neck ...... Dizziness ... ... Excessive thirst Difficulty of micturition
.., .i.
62 53 29 39 30 13 23 25 22 26 9 3 10 13 6 1 3 4 I 0 0 I
Per cent. 95 -38 81"54 44.62 60 "00 44. t 6 20.00 35-38 38.46 33.85 40.00 13-85 4-62 15-38 20.00 9-23 1.54 4 "62 6.15 1-54 --1-54
FROM
INTERROGATION
2'--3
4-5 ...... 6-7 ...... 8--9 . . . . . . 10-11 ...... 12-13 ...... 14-15 ...... 16-17 ...... 18-19 ...... 20-21 ...... O v e r 21 Uncertain
Borough Hospital.
... ...
1 3 12 7 8 7 5 2 4 1 6 9
.°.
PATIENTS.
105 133 22 31 35 45 40 61 9 44 9 63 31 5 8 10 5q 1 5 4 5 0
Total.
Per cent. 60"69 76-88 12.72 17.92 20"23 26 "01 23.12 35-26 5.20 25.43 5.20 36-42 17"92 2-89 4-62 5.78 32.37 0-58 2-89 2.31 2"89 --
Per cent. 70" 17 78"17 21.43 29.41 27.31 24.37 26.47 36-13 13.03 29,41 7.56 27.73 17'23 7"56 5-88 4.62 24,79 2.10 2.52 1.68 2.10 0-42
167 186 51 70 65 58 63 86 31 70 18 66 41 18 14 11 59 5 6 4 5 1
naturally often complained of more than
REPUTED DAY OF DISEASE ON ADMISSION TO HOSPITAL.
Day.
. . . . . .
i
Mayday Hospital.
T h e p e r c e n t a g e s are b a s e d o n t h e n u m b e r o f p a t i e n t s a d m i t t e d - - p a t i e n t s one symptom.
TABLE l l I .
OF THE
Per cent. 1.54 4.62 18.46 10.77 12.31 10.77 7.69 3-08 6"15 1-54 9.23 13-85
65
Mayday Hospital.
7 23 45 27 16 13 15 -1 2 4 20
Per cent. 4.05 13.29 26.00 15.61 9.25 7.51 8.67 -0"58 1.16 2.31 11.56
173
Total. Per cent. 3.36 10-92 23.95 14.29 10-08 8.40 8-40 0-84 2.10 1.26 4.20 12-18
8 26 57 34 24 20 20 2 5 3 I0 29 238
TABLE IV. DOMINANTSIGNSDISCOVERED ON FIRSTEXAMINATION OF PATIENTS. Sign. Distention of Abdomen ... Rash ...... ...... Constipated stools ...... Mental hebitude ...... Palpable spleen ...... Cyanosis . . . . . . . . . D i a r r h o e i c stools ...... B r o n c h i t i c s i g n s in c h e s t ... Restlessness . . . . . . . . .
138
Borough Hospital. 47 34 11 22 54 29 18 21 1t
Per cent. 72.31 52-31 16.92 33.85 83-08 44-62 27-69 32,31 16-92
Mayday Hospital. 70 121 69 51 29 14 20 41 8
Per cent. 40"46 69-94 39.88 29.48 16.76 8-09 11.56 23.70 4-62
Total. 117 155 80 73 83 43 38 62 19
Per cent. 49.16 65-13 33.61 30 "67 34-87 18.07 15.97 26.05 7-98
1939
PUBLIC HEALTH
T h e most usual duration was between a week and ten days. I n about 12 per cent. of the total cases, however, the onset was so vague that it was not possible to determine with any degree of certainty. T h e dominant signs discovered at the first examination are given in Table IV. I n these figures the influence exerted in the compilation of data by the proclivities of the examining medical man is once more illustrated. More especially is this seen in the note as to the presence of splenic enlargement. I n one hospital over 80 per cent. of the patients were noted to have a palpable spleen on admission, whilst in the other the percentage is only 17. Again, there is apparent a divergency of opinion as to what constitutes a distended abdomen, or a constipated stool. T h e presence of rose spots was the most frequent sign observed but the extent of the rash varied widely from a few scattered spots on the abdomen or flanks, to a fairly profuse eruption. I n no case were rose spots noticed on the face, arms or legs; they did occur on occasion on the upper part of the thighs, the back, and the front of the chest. T h e n u m b e r of rose spots bore no ascertainable relationship to the severky of the attack. T h e rash was usually most marked during the end of the second and third weeks of illness. Persistence, in some cases, was over a period of two or three weeks but in the great majority the rash had disappeared before defervescence. Diarrhoea was not usual, and the classical pea soup stools were the exception. Possibly this was due to the strict dieting. Abdominal distention was present in the more severe cases but was never excessive and in no case sufficient to cause untoward symptoms. I n some 30 per cent. of the fatal cases distention became pronounced before death. Six patients were women who had recently been confined. The first case probably contracted the infection immediately before her admission on 22/10/37 for her confinement. She was discharged from the Maternity Block on 6/11/37 and was re-admitted as a case of typhoid fever on November 12th. There were no cases of typhoid in the hospital during her stay for her confinement. This patient recovered after a moderate attack. T h e baby admitted with the mother, however, died eight days after admission ; the cause of death was certified as enteritis and broncho-pneumonia. Typhoid bacilli were not found in the f~ces. Two other patients were transferred direct from the Maternity Wards of Mayday Hospital to the Typhoid TABLE VI.
Wards, following on positive Widal tests on the 12th and on the second day of the puerperium. Both babies did well and exhibited no symptoms. Both mothers recovered. Three other patients had been confined shortly before admission, namely 12, 5 and 20- days before. Two of the mothers and all the babies did well, the third case died. This case was anomalous as on the 17th day from the date of onset of symptoms she gave a negative Widal, but three days later was reported to give an agglutination of 1 in 1,000 dilution. F~eces and urine were negative to search for B. tvphosus. This case ran a course more typical of a streptococcal septicmmia than of typhoid fever. A post-mortem was unfortunately not obtained.. I n practically every case, pyrexia was present on admission to hospital, and the clinical picture was that of the second or third week of the disease. Sixty-six cases occurred in which at some stage of the disease the temperature recorded was over 104 ° F., and in 12 cases it was over 105 ° F. Of these 12 cases, 2 died and in one the temperature rose to 106.8 ° F. before death. I n another case, which recovered, the temperature reached 106-2 ° F. on one occasion but was rapidly reduced by sponging. There were 47 cases of relapse, in 40 there was only one relapse, in 7 there were two. T h e severity of symptoms and height of temperature were less with one exception during the relapse than during the primary attack. T h e pulse rate varied and did not keep pace with the temperature. TABLE V.
HIGHF~T TEMPERATURE REACHED.
Range of Temperature.
Borougli Hospital.
Mayday Hospital.
Total.
9 10 10 23 I1 -2
7 11 35 66 45 8 1
16 22 45 89 56 8 3
Under 101 ° F . . . . 1012-102 ° F . . . . 109'-103 ° F . . . . 1033-104 ° F . . . . 1042-105 ° F . . . . 105~-106 ° F . . . . Over 106° F . . . .
In no case was a pulse rate of over 120 found during the first week. I n the fatal cases, as would be expected, the pulse rate rose as the end approached. The cases showed the characteristic relative slowness of pulse
DURATION OF PYREXIA (TEMPERATURE OVER 99 ° F. AT LEAST ONCE IN 24 HOURS) EXCLUDING
FATAL CASES AND RELAPSES.
None 0-7 8-14 15-21 22-28 29-35 36-42 43-49 50-56
Number of Days.
Borough Hospital.
... ... ... ,., ... ... ... ... ...
3 9 15 9 5 2 1 ---
Per cent. 6.82 20.45 34.09 20"45 11.36 4-55 2.27 ---
Mayday Hospital. 2 9 30 35 14 14 7 1 1
Per cent. 1.77 7"96
Total. 5 18
26"55
45
3(1-97 12.39 12-39
44 19 16
6.16 0'88 0.88
8 I 1
Per cent. 3.18 I 1"47" 28"66 28-03 12.10 10-19 5"09 0-64 0 -64
139
PUBLIC HEALTH
FEBRUARY
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1939
YPH01D OUTBREAK. onset of symptoms with those of notifications, etc.
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PUBLIC H E A L T H
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associated with the condition. There was no distinctive feature of the pulse apart from the influence exerted upon it by complications such as haemorrhage and perforation. In the latter complication the picture rapidly became that of an acute peritonitis. As it is impossible to give the charts of cases in detail, Table VI, it is hoped, will help to convey some idea of the temperature charts. I n very few cases, other than relapse cases, was the temperature sustained for longer than 28 days, the usual duration being from 14 to 21 days. In practically every case determination was by lysis, sometimes extending over 14 days, but usually being complete in from 7 to 10 days. Complications
T h e complications most frequently met with, in both hospitals were relapse, urinary or f~ecal incontinence, haemorrhage from the bowel, vomiting, persistent epistaxis, phlebitis and pneumonia. Seven cases perforated, 4 at the Borough Hospital, a percentage of 6"15, and 8 at Mayday Hospital, a percentage of 1.78. Six were operated upon without delay as soon as diagnosed and one case at the Borough Hospital recovered after a prolonged and stormy period, complicated by pneumonia. One case was not operated o n ; this was a woman of 61 years who had been ill for 45 days and who was rapidly sinking before the perforation took place. Table V I I gives the various complications noted, and the percentage incidence at the two hospitals concerned. TABLE VII.
Relapse ...... ... Haemorrhage from bowel ... Incontinence of urine or faeces Vomiting ......... Pneumonia Retention of urine . . . . . . Persistent epistaxis ... ... Perforation of bowel ... Bed sores, heels and sacral ... Serum rash Hyperpyrexia (Temperature over 104° F.) ...... Otorrhoea Abscess (serum injection) ... Parotitis ......... Phlebitis ...... .., Herpes labialis ...... Periostitis (tibia) ...... Tender toes and soles of feet Difficulty of speech . . . . . . Secondary streptococcal septicemia ... Disturbances of C.NIS". . . . Epididymitis . . . . . . . . . Jaundice .........
142
...... ......
6 cases
Case No. 1 . - - I n the terminal part of the ileum. This case recovered. Case No. 2.--Caecum, near the root of the appendix. Case No. 8.--Lower anterior aspect of the caecum. Case No. 4.--Just above caecum in the ascending large intestine.
,~ayday Hospital Case No. 1 . - - A perforation the size of a shilling in the terminal part of the ileum. Case No.: 2 . - - A perforation about 8 mm. in caecum near the appendix. Case No. 8 . - - A perforation 9 in. from the ileocaecal valve in the ileum. Administration
of Serum
Sixty cases in the Corporation's hospitals had serum supplied by Dr. Felix from the Lister Institute. T h e serum was given in doses of 80.g c.c. on three successive days. It was given intravenously (?). The majority of the cases who had serum were severe, and in some of the cases treated at the Borough Hospital it was administered as a last resort in an endeavour to counteract the profound toxaemia already established. At the head of the next column are the statistics of the results obtained from the use of Felix Serum.
COMPLICATIONS ARISING AND NOTED DURING THE COURSE OF THE ILLNESS.
Nature of Complication.
Relapses--One Two
The Sites of Perforation found at operation in post-mortem in 1 case were as follows : Borough Hospital.
and at
Borough Hospital. 7 7 11 7 8 -6 4 1 2
Per cent. 10.77 10.77 16.92 10.77 12.3 I 9.23 6.15 1.54 3,08
1 1 1 3 3 I 1 1
1.54 1.54 1-54 4.62 4-62 1-54 1.54 1.54
3 ----
4'62
5 2
7.69 3.08
Mayday Hospital.
Total.
40 24 24 11 6 10 7 3 6 7
Per cent. 23.12 13.87 13.87 6-36 3.47 5.78 4.05 1"73 3.47 4.05
47 3l 35 18 14 10 13 7 7 9
5 7 2 9
2.89 4.05 1.16 5.20
6 8 3 12
2.52 3"36 1.26 5.04
I
---0.58
3 1 I 2
1.26 0.42 0.42 0.84
2 7
1.16 4.05
5 7
2.10 2,94
----
Per cent. 19.75 13.03 14.71 7.56 5.88 4.20 5.46 2.94 2.94 3.78
t
0-58
1
0.42
2
1.16
2
0.84
35 5
20.23 2.89
1939
PUBLIC HEALTH
Case 1.--Act. 89. This case was admitted to hospital on 20/11/'37 and gave the date of onset as 12/11/87. Total. She had received two inoculations of anti-typhoid Borough. Mayday. vaccine at home on 12/11/87 and 16/11/87. She died on 8/12/87, with cerebral symptoms for which L.P. was No apparent effect ... t2 19 31 done--fluid normal in appearance and not under Slight improvement ... 1 16 17 pressure. There was hyperpyrexia before death, the Moderate improvement 2 6 8 temperature rising to 106.6 ° F. Marked improvement 2 2 4 Died . . . . . . . . . 5 4 9 The post-mortem revealed some bronchitis and old pleurisy. T h e heart was dilated, the liver showed The case mortality in serum-treated cases was there- cloudy swelling and the same was present in the kidneys. The spleen was firm and enlarged to about twice its fore 15 per cent. The case mortality of all cases treated in the Corpora- normal size. There was h~emorrhagic inflammation of tion Hospitals was 14-6 per cent. ; of all the primary the lower 8 feet of the ileum with typical ulcers. Case ~.--This case, a female aged 48, was admitted cases known in the outbreak, 18-26 per cent. ; and of the secondary, 25 per cent. ; a combined mortality of to hospital on 2/12/87 and gave the date of onset as 17/11/87. She died on 5/12/37, from intestinal h~emor18-87 per cent. Tables V I I I and IX show the effects observed and rhage. She had a slight degree of exophthalmic goitre the reaction and calculated day of disease when the with a pulse rate of 180. Thepost-mortem showed a thin exsanguinated subject. serum was administered. Of Table V I I I cases, in 12 no effect was observed. In There was considerable enlargement of both lobes of 5 there was a good effect, and in 1 a temporary improve- the thyroid, the condition being one of toxic diffuse ment followed by decline and death. Five cases died. goitre. The lungs showed some bronchitis, the heart Summarised for both hospitals, the results of serum was normal; the liver showed cloudy swelling; the spleen was enlarged to 2½ times the normal size and was administration appear to be as follows : deep red in colour, soft with a diffluent pulp. There was No apparent effect ... 81 much blood in the large intestine, and typical typhoid Some improvement ... 25 ulceration in the lower part of the ileum, the caecum and Marked improvement ... 4 ascending colon. Died . . . . . . . . . . . . 9 Case 8 . - - A female aged 44 years, who gave a history This gives a case mortality of 15 per cent. Three of the eases who received serum were secondary eases; of onset on 11/11/87. She was admitted to hospital on 20/11/87 and died from tox~emia and heart failure on all recovered. 4/12/87. The temperature range until four days before death was 98 ° to 104.6 ° F., during the last four days the Case Mortality of Hospital Cases. temperature did not rise above 99.8 ° F. Death was conBorough Hospital : 65 cases, 14 deaths, 28.8 per cent. sidered to be due to tox~emia and heart failure. mortality. The post-mortem showed in the lungs, bronchitis; Mayday Hospital: 178" cases, 21 deaths, 12.1 per the heart muscle was very flabby; the liver showed cent. mortality. striking fatty change ; the spleen was enlarged to twice Combined Hospitals : 288 cases, 85 deaths, 14.6 per the normal size with a soft and diffluent pulp. The cent. mortality. kidneys were soft and friable. There was typical typhoid The mortality of the outbreak of 810 eases and 48 ulceration in the lower part of the ileum, and the c~ecum deaths is 18.8 per cent. (Males 12-1 per cent. ; Females with yellow sloughs in situ. There was some altered 15-8 per cent.). blood in the large intestine which was greatly distended. The urinary bladder showed cystitis. C a u s e s of D e a t h Case 4.--A female aged 78 years who gave the onset Tables X and XI (overleaf) show the causes of death of illness as 18/tl/87. She was admitted to hospital on at the two hospitals and Table X I I summarises the 24/11/87 and died on 26/12/87. She was a frail old combined figures. woman with pronounced senile kyphosis. During her The death rates for the two sexes were (1) For the illness she had progressive phlebitis and thrombosis, Borough Hospital : Males 80 per cent., Females 17 per first of the right leg and then both legs. Death was cent. ; (2) For Mayday Hospital : Males 9 per cent., considered to be due to tox~emia, thrombosis and heart Females 14-9 per cent. failure. The temperature range during her illness was The fatality rate based on the incidence of cases of 97 ° to 101 ° F. for the first few days and then it fell to the three causes of death was : below 98"6 o F. and remained below that level until the Males. Females. end. Tox~emia ... 8.4 per cent. 12.1 per cent. T h e post-mortem showed a small, soft diffluent spleen, Perforation ... 2.8 ,, 2.27 ,, enlarged mesenteric glands, and typical typhoid ulceraH~emorrhage 1-9 ,, 1-5 ,, tion of the lower 4 feet of the ileum, and the c~ecum with Post-mortem examinations were made in five cases and injection and cedema of the bowel wall. Case 5 . - - A female, aged 61 years, whose date of onset the following are summaries of the reports : - of illness was given as 14/10/87. She was admitted to hospital on 28/10/87 and died on 10/12/87, the cause of # A case of paratyphoid B is not incluuea. Medical Officer's Observation.
Hospital.
143
PUBLIC H E A L T H
FEBRUARY
death being considered to be tox~emia, and perforation. This case had repeated haemorrhages between 27/11/87 and 4/12/87. Her temperature range for the first three weeks was between 97 ° and 108.4 ° F., it then fell and varied between 97 ° and 101.4 ° F. until death. T h e post-mortem showed an exsanguinated and emaciated woman ; no observable splenic enlargement. Cloudy swelling of liver and kidneys; general periTABLE V I I I .
tonitis from a perforation in the upper part of the c~cum with free pus in the abdomen. I n conclusion, I would like to thank the medical officers of the two hospitals for the way in which the clinical records were kept in face of an overwhelming rush of work. T h e i r devotion to duty and the shouldering of burdens far in excess of their normal work I cannot commend too highly.
BOROUGH HOSPITAL: SERUM-TREATED CASES.
No.
Sex.
Day when Administration commenced.
Immediate Reaction.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
F. M. M. M. M. M. M. M. F. M. F. F. F. F. F. F. F.
17 24 24 3 11 7 4 5 9 6 10 10 19 11 7 20 8
Rigors : vomiting 2 hours after Profuse perspiration Vomiting and rise of temperature Rigors and rise of temperature Rigor and rise of temperature Rise of temperature Nil Nil Rise of temperature Rigors and rise of temperature Rise of temperature Rise of temperature Slight rigor and rise of temperature Nil Nil Profuse sweating Vomiting and rise of temperature TABLE IX.
Sex.
Day of Disease when Administration Began.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
M. ~{. F. F. F. M. F. F. F. F. F. F. F. F. M. M M. M. M. M. F. F. F. F. M. M. M. M. M.
18 17 12 18 13 16 17 l0 11 10 10 10 10 I1 ]2 9 9 8 8 15 12 6 10 10 10 8 7 9 10 10
144
Died from heart failure Died 10 days after last injection Good effect. Steady improvement No observable effect Good effect. Fall of Temp. 6 days later No effect No effect. Died 6 days after last injection. Good effect. Steady improvement No effect No effect No effect. Died No effect No effect No effect No effect No effect. Died Improved. Good effect
MAYDAY HOSPITAL: SERUM-TREATED CASES.
No.
M,
Result.
Immediate Reaction. None None None None Slight improvement Moderate improvement None None None Slight improvement None Slight improvement Moderate improvement Slight improvement None Slight improvement Marked improvement None None None None None Moderate improvement Slight improvement Slight improvement None Slight improvement Slight improvement Slight improvement Slight improvement
Result. Died Recovered Recovered Recovered Recovered Recovered Recovered Recovered Died Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Died Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered
PUBLIC H E A L T H
1939 TABLE I X
(Continued).
~'IAYDAY HOSPITAL: SERUIvI-TREATED CASES.
No.
Sex.
Day of Disease when Administration Began.
31 32 33 34 35 36 37 38 39 40 41 42 43
NI. M, F. ~'I. M, F. F. M. M. ~I. M. F. F.
15 13 17 14 17 16 15 J8 I1 15 12 24 15
TABLE X .
Age.
Sex.
13 16 24 28 10 *55 t6 *72 35 "31 64 61 17 *15
M. M. M. M. M. F. F, F. F. F. F. F. F, M.
Immediate Reaction.
Result.
Slight improvement None Slight improvement None None Slight improvement Moderate improvement Slight improvement (slight rigor) Marked improvement Moderate improvement None Slight improvement Moderate improvement
Recovered Died Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered
BOROUGH HOSPITAL : CAUSES OF DEATH.
Reputed Day of Disease on Admission. 5 11 14 12 13 lb 30 15 9 ? 25 33 14 9 13
N u m b e r of Days in Hospital.
Cause of Death.
10 10 12 23 9 t7 21 17 29 6 15 43 14 I0
Toxmmia Intestinal ha~morrhage Toxmmia Tox~emia Tox~emla Toxmmia Perforation Tox~emia and pneumonia Perforation Toxmmia--confinement Toxa~mia--sudden heart failure Perforation Toxmmia Toxtemia
* Secondary cases. TABLE XI. Age.
Sex.
15 34 20 15 31 39 43 44 63 40 55 26 30 38 29 26 54 78 63 45 54
M. F. ~ I. ~I. M, F. F. F. F. M, F. F. hi. F. M. F. M. F. F. F. F.
MAYDAYHOSPITAL; CAUSESOF DEATH.
Reputed Day of Disease on Admission. 14 7 7 6 10 8 15 9 ? 7 4 ? 7 21 10 10 21 19 6 7 14 16
Number of Days in Hospital. 11 13 I0 12 4 12 3 14 15 14 19 20 9 23 19 24 7 32 35 39 43
Cause of Death. Toxaemia Tox~emia Perforation Perforation Perforation Toxa~mia H~emorrhage Tox~emia Hmmorrhage Toxa~mia Tox~emia Toxmmia Hmmorrhage Tox~emia Toxaemia Toxa~mia-pneumonia Toxmmia Toxa~mia Tox~emia Toxmmia Toxa~mia
145
FEBRUARY
PUBLIC HEALTH TABLE X l I .
COMBINED TOTALS; CAUSES O F DEATH,
Borough Hospital.
Mayday Hospital.
Total.
Cause. Toxmmia . . . . . . Perforation ... Hgemorrhage ...
Male.
Female.
Male.
5 -1
5 3 --
4 3 t
11 -2
6
8
8
13
RECENT APPOINTMENTS IN THE PUBLIC HEALTH SERVICE T h e following are some recent appointments to the public health departments of various local authorities and to other bodies. The Editor will be grateful if members of the Society will notify him at once of any new appointments. ABERDEEN C.C.: Ophth. Surg. for Sch. Med. Service, Dr. J. R. Muteh (Asst. Ophth. Surg. Aberdeen Royal Infirmary). BIRMINGHAM C.B.: A.M.O.H., Dr. J. F. Warin (A.M.O.H. & A.S.M.O., Blackburn C.B.). BRECON COMBINED DISTRICT: M.O.H., Dr. David J. Jones (A.C.M.O.H. & S.M.O., Warwickshire). CENTRAL COUNCIL FOR HEALTH EDUCATION: Gen. Secretary, Mr. John Lee, Barr.-at-Law, LL.B., D . e . A . CORNWALL C.C.: C.M.O.H., Dr. Reginald N. Curnow (Dep. C.M.O.H., Derbyshire C.C.). COSELEY U.D.: M.O.H. and S.M.O., Dr. A. Watt (A.C.M.O.H., Staffs C.C.). DURHAM C.C.: Dep. C.M.O.H., Dr. John Walker (Divl. M.O., Central Div. of Glasgow). HAReENDEN R.D.: M.O.H., Dr. R. R. K. Paton (M.O.H., St. Alban's City and R.D.). HOVE M.B.: A.M.O.H., Dr. J. M. Erskine-Young (R.M.O., City Hospital, Edinburgh). HULL C.B.: Dep. Med. Supt., I.D. Hosp.s & San., Dr. C. D. Preston. ISLE OF ELY C.C.: Temp. C.M.O.H., Dr. J. F. Dawson. KENT C.C.: A.M.O. M. & C.W., Dr. Josie M. Oldfield (R.M.O., I.D. Hosp.). Salary £500 to
Female.
Male.
Female.
Both Sexes.
9 3 2
16 3 2
25 6 4
14
21
35
ROTHERHAM :C.B.: Dep. Med. Supt., I.D. Hosp's & San., Dr. A. C. Morrison (Dep. Med., Hull City & I.D. Hosp.s & San.). SALE M.B.: M.O.H., Dr. Frank Appleton (M.O.H., Brierley Hill U.D.). STONE U. • R.D.s: M.O.tI., Dr. R. A. Leader (in addition to present appointment of A.C.M.O.H., Staffs C.C.). SURREY C.C.: A.C.M.O.s H., Dr. C. A. McPherson (A.M.O.H., Leicester C.B.) and Dr. F. M. B. Dougherty. SWANSEA C.B.: M.O.H., Dr. R. H. Tighe (Dep. M.O.H. & S.M.O., Swansea). Salary, £1,200. WIMBLEDON M.B.: Dep. M.O.H., Dr. P. J. Doody (A.M.O.H., Luton M.B.). Commencing Salary, £650.
The National Conference on Maternity and Child Welfare will be held in the Great Hall, British Medical Association House, Tavistock Square, London, W.C.1, on Tuesday, Wednesday and Thursday, June 27th, 28th and 29th, 1939. President, the Rt. Hon. Walter Elliot, M.P. (Minister of Health. The general question underlying the discussions at the Conference is to be " T h e Needs and Problems of Parenthood." The following subjects will be discussed : - 1. Safety in childbirth for mother and child. 2. The encouragement of breast feeding. 3. Some problems of the nursery school, the nursery class and the day nursery. 4. The child in relation to the foster mother and the daily minder. 5. Problems of parents with a physically defective child. 6. Some problems of propaganda in the maternity and child welfare movement. The Conference is open to all who are interested in maternity and child welfare, whether representative of Local Authorities, or of Voluntary Organisations, or as individuals. £700. A Clinical Course for Medical Practitioners will be held LINDSAY (LINCS) C.C.: Sen. Asst. and Dep. C.M.O.H. on Sunday, June 25th, and Monday, June 26th (organised and S.M.O., Dr. H. C. Humphrey Butcher by the M. and C.W. Group, Society of M.O.H.). (A.M.O.H., Ealing M.B.). CONFERENCE FEES.--For full membership in the ConferMIDDLESBROUGIt C.B.: A.S.M.O., Dr. G. S. Clouston ence, including the receipt of al printed matter that may be issued in connection therewith:-(A.S.M.O., Liverpool C.B.). £ s.d. MIDDLESEX C.C.: A.C.M.O.H., Dr. J. O. F. Davies Per Member ...... 1 1 0 (A.M.O.H., Willesden M.B.) Per Member (if two represent the same Local MINISTRY OF HEALTH: M.O.s, Dr. W. D. T. Brunyate Authority or voluntary organisation) ... 15 0 Per Member (if three or more represent the (M.O.H., Stone U. & R.D.'s; A.M.O.H., Staffs same Local Authority or voluntary organiC.C.) and Dr. G. C. Kelly (Sen. A.M.O.H., sation) . .............. 14 0 Birmingham C.B.). A remittance should accompany all applications for tickets. NATIONAL ASSOCIATION FOR THE PREVENTION OF and should be sent to the Secretary, N.A.M.C.W.C. and TUBERCULOSIS: Gen. Secretary, Dr. J. H. Harley P.LM., 117, Piccadilly, London, W.t, using one of the forms attached. Williams (Med. Commissioner).
146
PUBLIC
THE CROYDON TYPHOID OUTBREAK. (A Summary of the Chief Clinical Features) By OSCAR M. HOLDEN, M . D . D . P . H . ,
Medical O.~cer of Health, County Borough of Croydon.
The Incidence of Cases An outbreak of typhoid fever occurred in the southern part of Croydon in 1987. It commenced during the last week in October, and continued throughout November and December. The total number of real or suspected cases which came to my notice and which resided in Croydon was 317. Of these 299 were notified and 18 were not notified. Of the notified cases 15 were secondary, and of the not notified 1 was secondary. Seven of the 299 notified cases were ultimately considered not to have suffered from typhoid. In addition to the a b o v , 28 primary cases and 8 secondary cases were brought to my notice by the medical officers of health concerned these were not resident in Croydon but were definitely connected with the outbreak, either by working in the town, or having resided therein during the relevant period. Of these 18 were in the neighbouring borough of Purley and Coulsdon, 1 in Wallington, 1 in Caterham, 1 in Merton, 1 in Carshalton, 1 in Horsham, 1 in Brighton, 1 in Camberwell, 1 in Liverpool, 1 in Great Yarmouth and 1 in Newport (Mon.). The 8 secondary cases were nurses who had been nursing in Croydon. The total cases, therefore, known to me, were 841 including 19 secondary cases. The graph overleaf shows the age and sex incidence in five-year age groups for both sexes. CROYDON
EPIDEMIC
SPECIFIC
OF TYPHOID.
AGE
FATALITY P.ATES.
50
,.,'+
45
,
35 li :
5O
/t / .]''"..
:1
/
/r,
/
/"
S.
. ..°: I
\
I
I
',l'
':
~ 'I
"1
:',/: ....../ h;," +++""" "':
1 It
,/,,, ¢:,
,o
,
~o
,
~o
,o
AGe
~'o
In the area there are a number of residential and day schools. The largest of these was a day school of some 750 boys, but it was early ascertained that this school obtained its water supply direct from the Low-Level mains, an entirely separate supply. Nine cases occurred in boys attending this school, of whom 6 lived on the High-Level supply at home, and 1 master, who also lived on the same supply. The largest residential school is situated in the Addington Hills and nearby the HighLevel Reservoir. It got the full force of the infection, 16 boys and 1 maid contracted the infection, one of the cases being secondary. The usual number of boys in residence is 150. The incidence rate was therefore 10.6 per cent. None of the teaching staff became ill. The other schools affected were private schools. In one, a boys' school, 5 cases, including a master, contracted typhoid; whilst in a girls' school--average attendance 180--9 cases occurred including a teacher. Among the public elementary schools in the district 15 cases occurred. The average attendance at these schools is 2,878. The incidence rate was therefore 0.52 per cent. One case occurred in a convalescent home for children, containing an average of 30 children, but no cases occurred in any of the private nursing homes in the area ; 1 case occurred in a residential hotel. It is extremely difficult, in view of the ramifications of the water supply, to give anything other than a very approximate estimate of the population at risk. It was possibly between 40,000 to 45,000. Even with the lower figure the incidence rate is only 0.75 per cent. This is rather a characteristic of water-borne outbreaks and would certainly appear to show that the infecting doses in the water were not heavy. The proximity of the residential school to the source of supply and the fact that the boys had a habit of using a tap for drinking in the changing room and in close proximity to the W.C.s would account for the high incidence at this school as compared with other schools and the rest of the population. More than 1 case occurred in 8 families, and of these 1 family had 8 cases--all children under ten years of age and nursed at home. There was, however, some evidence to show that the later 2 were secondary in that the dates of notification were (1) 10/11/87; (2) 26/11/37 ; (3) 29/11/87. The date of onset of the first case was given as 3/11/87, that of the two subsequent cases was indefinite. In the families with two cases, the second case in all was considered to be definitely secondary. CROYDON T Y P H O I D . - - A Q E AND SEX FATALITY PER CENT.
25 20
AND SEX
~OrH s ~ x ~ s MABI~5 . . . . . ~E.r,U~LES . . . . . . .
HEALTH
~
;o'
~o
Age Groups. O--
Males. 0.00
10-20-30-40-50-60-70--79
8.98 18.52 16"67 9-09 33-33 0-00 0.00
Females. 0.00 8-82 6.52 22.22 20-00 21.43 41-67 50.00
Both Sexes. 0.00 8-89 10.96 20.00 16.13 26.09 29.41 40.00
The number of houses on the High-Level supply is difficult to determine but probably a fifth to a sixth of the total houses in Croydon might have received the 135
PUBLIC HEALTH
FEBRUARY
supply at relevant times. The figure is probably in the neighbourhood of 1:],000. The district most heavily attacked was residential with houses of rateable value from £50 to £90 or over. A total of ~39 patients were admitted to the Corporation's hospitals ; 54 were treated at home and 17 were treated in London hospitals. At no time was any pressure exerted to force admissions to hospital; on the other hand admission was never refused. A considerable proportion of the cases occurred in relatively well-to-do families, in which the conditions laid down, that there must be a day and a night nurse and absolute seclusion of the patient, could be carried out without much difficulty. These cases remained under their private medical practitioners and the public health medical staff were not asked to assist beyond, in the first place, in certain of the cases, to afford a second opinion upon diagnosis, to carry out bacteriological tests, and,
CROYDON
when the case was free from infection, to arrange terminal disinfection. Three consecutive negative urine and faeces results was the criterion laid down, and as the tests were carried out in the Corporation's laboratory, a useful check could be kept upon it. At least three consecutive negative results of urine and faeces was also the rule in the Corporation's hospitals, before a patient was discharged. Of the '389 patients admitted to the Corporation hospitals, 174 were admitted to Mayday Hospital (the Corporation Public Health Hospital)--87 females, 87 males (one of the males was a paratyphoid B. infection) --and 65 to the Borough Fever Hospitai--45 females, 20 males. In the statistics which follow the figures for the two hospitals are kept separate. By so doing information of value isdicative of the influence of the personal factor of the attendant physician upon the incidence of signs and symptoms is obtained. The cases in the two
EPIDEMIC OF TYPHOID.
DISTEIBUTION
OF
CASES
AGE
AND
P~I M A ~ y
SECONDARY
MALES
80- 84
SEX
F----']
FEMALES
75-
! ID
70-
!
656055-
504,5403530252015IO--
5Oi'm'
~o
25
1
!
I
t
20
iS
10
5
5
N U M B E E OF C A $ E 5
10
~5
2o
25
~0
~5
1939
PUBLIC HEALTH
hospitals were all victims of the same infection and were indeed, from time to time admitted to one or other of the hospitals, without at any time any differentiation being made. As the earliest cases which arose were, however, the most severe, the Borough Hospital, into which they were admitted, had for a time a higher relative proportion of severe cases than Mayday Hospital. This after the first fortnight did not continue as the available accommodation at the former hospital was by that time filled, and all new cases arriving were admitted to Mayday Hospital, until further accommodation was made available at the Borough Hospital. The average economic level of the cases nursed at home was considerably higher than those admitted to the Corporation hospitals, whilst those admitted to London hospitals were all sent as private patients and were economically on a higher level than the majority of the Corporation hospitals cases. Table I gives in summary form the cases and deaths.
Initial Symptoms and lneubation Periods The incubation period could be very accurately determined in two cases. In one the patient had stayed with a friend ira a house upon the incriminated water supply for three days, viz., on October 27th, 28th and 29th. He then returned to his home in Bournemouth. On Saturday, November 20th, he was taken ill whilst on a visit to Morden and was admitted to the Mitcham Isolation Hospital where he unfortunately died from typhoid on December 8rd. An incubation period of maximum 24 days, minimum 21 days. The second case was admitted from Adding'ton, from a house on the infected water supply, for her confinement on October 22nd. She was in good health and the confinement w.as normal. She returned home on November 6th and began to feel ill on November 7th. She was readmitted to Mayday Hospital on November 12th with typhoid fever. A minimum incubation period of 15 days.
T ~ L ~ I. Hospitals. Mayday Hospital.
Private Address.
Borough Hospital.
Cases.
Deaths.
Cases.
174
21
65
Deaths. 14
Other Hospitals. Cases. 17
Deaths.
Cases.
Deaths.
3
54
5
It is recognised, and has been illustrated in previous Of the cases treated in the Borough Hospital, g were definitely not typhoid ; 1 was a tuberculous meningitis ; water-borne outbreaks, that the incubation period is 1 a mild attack of influenza, and 1 showed no symptoms longer than in food-borne outbreaks. This is possibly at all but was sent in because his Widal showed a 1/50 due to the smallness of the infecting dose in the former agglutination. After a fortnight's stay ill hospital the as compared with the more concentrated dose in the Widal became negative and remained so. One case in latter. Water, moreover, is not a medium particularly the Borough Hospital was a urinary carrier on admission favourable to the life of the organism, though it probably suffering from cystitis and mild orchitis. This patient survives longer in a pure water, than in one grossly may have suffered a few weeks previously from a mild contaminated with other intestinal organisms of a more ambulant attack. He was detected owing to his daughter, robust habit. The most usual food conveyors, e.g., aged 13 years, developing typhoid on 16/12/37. She milk, are on the contrary, favourable media in which was admitted to a London hospital on 28/12/87, and the organism will multiply. after a severe illness, recovered. Seven cases in Mayday Table I I gives in summary the symptoms noted at Hospital were very doubtful, and, if in fact typhoid, the time of the history taking on admission to hospital. were clinically and bacteriologically of a very atypical The symptoms most frequently complained of were, kind. .headaches, lassitude, constipation, shivering attacks, In both Corporation hospitals, treatment was carried pains in the abdomen, nausea or actual sickness, diarout on very similar lines as regards methods of dieting-rhoea, epistaxis, backaches and insomnia. this being that of small fluid feeds of milk or modified The history of symptoms such as anorexia or cough milk at two-hourly intervals. No attempt was made to commence early feeding with solid food. In both show such wide divergence as between the two hospitals hospitals serum supplied by Dr. Felix of the Lister that one is forced to conclude that the complaint by Institute was used, though the cases so treated at the the patients of these symptoms depended upon the nature Borough Hospital were, on the whole, more severe than of the questions put to them. In 413 cases the patients those treated at Mayday. This was because the earliest thought they had contracted a severe cold, or influenza cases were admitted to the former hospital before with coryza and in 6 cases a stiff neck. It was noticeable, supplies of serum had been obtained, and the first cases however, that a number said they had no initial sympso treated had already been in hospital some days, and toms other than a feeling of tiredness and of being " off were indeed in the majority of instances, extremely ill, colour." No relationship was established between any at the time of administration. At Mayday Hospital, on initial symptoms and the subsequent trend of the attack. the other hand, the cases received serum on, or shortly Initial constipation might give way later to diarrhoea, or after, admission. This may account for the better more usually initial diarrhoea was replaced by constiresults obtained at this hospital. The method of pation. The reputed day of disease on admission in the cases administration was the same as both the medical officers is given in Table I I I . in charge had the benefit of Dr. Felix's guidance. 137
PUBLIC HEALTH TABLE
........
1I.
FEBRUARY INITIAL
Symptom.
SYMPTOMS
AS E L I C I T E D
Borough Hospital.
Lassitude ...... Headache ...... Backache ...... Shivering ...... N a u s e a o r s i c k n e s s ... Epistaxis ...... Diarrhoea ...... Constipation ...... Generalised limb pains Pain in abdomen ... P a i n in c h e s t . . . . . . Anorexia ...... Insomnia ...... Sore throat ...... Cold in the head ... Deafness ...... Cough ...... Influenza ...... Stiff neck ...... Dizziness ... ... Excessive thirst Difficulty of micturition
.., .i.
62 53 29 39 30 13 23 25 22 26 9 3 10 13 6 1 3 4 I 0 0 I
Per cent. 95 -38 81"54 44.62 60 "00 44. t 6 20.00 35-38 38.46 33.85 40.00 13-85 4-62 15-38 20.00 9-23 1.54 4 "62 6.15 1-54 --1-54
FROM
INTERROGATION
2'--3
4-5 ...... 6-7 ...... 8--9 . . . . . . 10-11 ...... 12-13 ...... 14-15 ...... 16-17 ...... 18-19 ...... 20-21 ...... O v e r 21 Uncertain
Borough Hospital.
... ...
1 3 12 7 8 7 5 2 4 1 6 9
.°.
PATIENTS.
105 133 22 31 35 45 40 61 9 44 9 63 31 5 8 10 5q 1 5 4 5 0
Total.
Per cent. 60"69 76-88 12.72 17.92 20"23 26 "01 23.12 35-26 5.20 25.43 5.20 36-42 17"92 2-89 4-62 5.78 32.37 0-58 2-89 2.31 2"89 --
Per cent. 70" 17 78"17 21.43 29.41 27.31 24.37 26.47 36-13 13.03 29,41 7.56 27.73 17'23 7"56 5-88 4.62 24,79 2.10 2.52 1.68 2.10 0-42
167 186 51 70 65 58 63 86 31 70 18 66 41 18 14 11 59 5 6 4 5 1
naturally often complained of more than
REPUTED DAY OF DISEASE ON ADMISSION TO HOSPITAL.
Day.
. . . . . .
i
Mayday Hospital.
T h e p e r c e n t a g e s are b a s e d o n t h e n u m b e r o f p a t i e n t s a d m i t t e d - - p a t i e n t s one symptom.
TABLE l l I .
OF THE
Per cent. 1.54 4.62 18.46 10.77 12.31 10.77 7.69 3-08 6"15 1-54 9.23 13-85
65
Mayday Hospital.
7 23 45 27 16 13 15 -1 2 4 20
Per cent. 4.05 13.29 26.00 15.61 9.25 7.51 8.67 -0"58 1.16 2.31 11.56
173
Total. Per cent. 3.36 10-92 23.95 14.29 10-08 8.40 8-40 0-84 2.10 1.26 4.20 12-18
8 26 57 34 24 20 20 2 5 3 I0 29 238
TABLE IV. DOMINANTSIGNSDISCOVERED ON FIRSTEXAMINATION OF PATIENTS. Sign. Distention of Abdomen ... Rash ...... ...... Constipated stools ...... Mental hebitude ...... Palpable spleen ...... Cyanosis . . . . . . . . . D i a r r h o e i c stools ...... B r o n c h i t i c s i g n s in c h e s t ... Restlessness . . . . . . . . .
138
Borough Hospital. 47 34 11 22 54 29 18 21 1t
Per cent. 72.31 52-31 16.92 33.85 83-08 44-62 27-69 32,31 16-92
Mayday Hospital. 70 121 69 51 29 14 20 41 8
Per cent. 40"46 69-94 39.88 29.48 16.76 8-09 11.56 23.70 4-62
Total. 117 155 80 73 83 43 38 62 19
Per cent. 49.16 65-13 33.61 30 "67 34-87 18.07 15.97 26.05 7-98
1939
PUBLIC HEALTH
T h e most usual duration was between a week and ten days. I n about 12 per cent. of the total cases, however, the onset was so vague that it was not possible to determine with any degree of certainty. T h e dominant signs discovered at the first examination are given in Table IV. I n these figures the influence exerted in the compilation of data by the proclivities of the examining medical man is once more illustrated. More especially is this seen in the note as to the presence of splenic enlargement. I n one hospital over 80 per cent. of the patients were noted to have a palpable spleen on admission, whilst in the other the percentage is only 17. Again, there is apparent a divergency of opinion as to what constitutes a distended abdomen, or a constipated stool. T h e presence of rose spots was the most frequent sign observed but the extent of the rash varied widely from a few scattered spots on the abdomen or flanks, to a fairly profuse eruption. I n no case were rose spots noticed on the face, arms or legs; they did occur on occasion on the upper part of the thighs, the back, and the front of the chest. T h e n u m b e r of rose spots bore no ascertainable relationship to the severky of the attack. T h e rash was usually most marked during the end of the second and third weeks of illness. Persistence, in some cases, was over a period of two or three weeks but in the great majority the rash had disappeared before defervescence. Diarrhoea was not usual, and the classical pea soup stools were the exception. Possibly this was due to the strict dieting. Abdominal distention was present in the more severe cases but was never excessive and in no case sufficient to cause untoward symptoms. I n some 30 per cent. of the fatal cases distention became pronounced before death. Six patients were women who had recently been confined. The first case probably contracted the infection immediately before her admission on 22/10/37 for her confinement. She was discharged from the Maternity Block on 6/11/37 and was re-admitted as a case of typhoid fever on November 12th. There were no cases of typhoid in the hospital during her stay for her confinement. This patient recovered after a moderate attack. T h e baby admitted with the mother, however, died eight days after admission ; the cause of death was certified as enteritis and broncho-pneumonia. Typhoid bacilli were not found in the f~ces. Two other patients were transferred direct from the Maternity Wards of Mayday Hospital to the Typhoid TABLE VI.
Wards, following on positive Widal tests on the 12th and on the second day of the puerperium. Both babies did well and exhibited no symptoms. Both mothers recovered. Three other patients had been confined shortly before admission, namely 12, 5 and 20- days before. Two of the mothers and all the babies did well, the third case died. This case was anomalous as on the 17th day from the date of onset of symptoms she gave a negative Widal, but three days later was reported to give an agglutination of 1 in 1,000 dilution. F~eces and urine were negative to search for B. tvphosus. This case ran a course more typical of a streptococcal septicmmia than of typhoid fever. A post-mortem was unfortunately not obtained.. I n practically every case, pyrexia was present on admission to hospital, and the clinical picture was that of the second or third week of the disease. Sixty-six cases occurred in which at some stage of the disease the temperature recorded was over 104 ° F., and in 12 cases it was over 105 ° F. Of these 12 cases, 2 died and in one the temperature rose to 106.8 ° F. before death. I n another case, which recovered, the temperature reached 106-2 ° F. on one occasion but was rapidly reduced by sponging. There were 47 cases of relapse, in 40 there was only one relapse, in 7 there were two. T h e severity of symptoms and height of temperature were less with one exception during the relapse than during the primary attack. T h e pulse rate varied and did not keep pace with the temperature. TABLE V.
HIGHF~T TEMPERATURE REACHED.
Range of Temperature.
Borougli Hospital.
Mayday Hospital.
Total.
9 10 10 23 I1 -2
7 11 35 66 45 8 1
16 22 45 89 56 8 3
Under 101 ° F . . . . 1012-102 ° F . . . . 109'-103 ° F . . . . 1033-104 ° F . . . . 1042-105 ° F . . . . 105~-106 ° F . . . . Over 106° F . . . .
In no case was a pulse rate of over 120 found during the first week. I n the fatal cases, as would be expected, the pulse rate rose as the end approached. The cases showed the characteristic relative slowness of pulse
DURATION OF PYREXIA (TEMPERATURE OVER 99 ° F. AT LEAST ONCE IN 24 HOURS) EXCLUDING
FATAL CASES AND RELAPSES.
None 0-7 8-14 15-21 22-28 29-35 36-42 43-49 50-56
Number of Days.
Borough Hospital.
... ... ... ,., ... ... ... ... ...
3 9 15 9 5 2 1 ---
Per cent. 6.82 20.45 34.09 20"45 11.36 4-55 2.27 ---
Mayday Hospital. 2 9 30 35 14 14 7 1 1
Per cent. 1.77 7"96
Total. 5 18
26"55
45
3(1-97 12.39 12-39
44 19 16
6.16 0'88 0.88
8 I 1
Per cent. 3.18 I 1"47" 28"66 28-03 12.10 10-19 5"09 0-64 0 -64
139
PUBLIC HEALTH
FEBRUARY
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PUBLIC HEALTH
1939
YPH01D OUTBREAK. onset of symptoms with those of notifications, etc.
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PUBLIC H E A L T H
FEBRUARY
associated with the condition. There was no distinctive feature of the pulse apart from the influence exerted upon it by complications such as haemorrhage and perforation. In the latter complication the picture rapidly became that of an acute peritonitis. As it is impossible to give the charts of cases in detail, Table VI, it is hoped, will help to convey some idea of the temperature charts. I n very few cases, other than relapse cases, was the temperature sustained for longer than 28 days, the usual duration being from 14 to 21 days. In practically every case determination was by lysis, sometimes extending over 14 days, but usually being complete in from 7 to 10 days. Complications
T h e complications most frequently met with, in both hospitals were relapse, urinary or f~ecal incontinence, haemorrhage from the bowel, vomiting, persistent epistaxis, phlebitis and pneumonia. Seven cases perforated, 4 at the Borough Hospital, a percentage of 6"15, and 8 at Mayday Hospital, a percentage of 1.78. Six were operated upon without delay as soon as diagnosed and one case at the Borough Hospital recovered after a prolonged and stormy period, complicated by pneumonia. One case was not operated o n ; this was a woman of 61 years who had been ill for 45 days and who was rapidly sinking before the perforation took place. Table V I I gives the various complications noted, and the percentage incidence at the two hospitals concerned. TABLE VII.
Relapse ...... ... Haemorrhage from bowel ... Incontinence of urine or faeces Vomiting ......... Pneumonia Retention of urine . . . . . . Persistent epistaxis ... ... Perforation of bowel ... Bed sores, heels and sacral ... Serum rash Hyperpyrexia (Temperature over 104° F.) ...... Otorrhoea Abscess (serum injection) ... Parotitis ......... Phlebitis ...... .., Herpes labialis ...... Periostitis (tibia) ...... Tender toes and soles of feet Difficulty of speech . . . . . . Secondary streptococcal septicemia ... Disturbances of C.NIS". . . . Epididymitis . . . . . . . . . Jaundice .........
142
...... ......
6 cases
Case No. 1 . - - I n the terminal part of the ileum. This case recovered. Case No. 2.--Caecum, near the root of the appendix. Case No. 8.--Lower anterior aspect of the caecum. Case No. 4.--Just above caecum in the ascending large intestine.
,~ayday Hospital Case No. 1 . - - A perforation the size of a shilling in the terminal part of the ileum. Case No.: 2 . - - A perforation about 8 mm. in caecum near the appendix. Case No. 8 . - - A perforation 9 in. from the ileocaecal valve in the ileum. Administration
of Serum
Sixty cases in the Corporation's hospitals had serum supplied by Dr. Felix from the Lister Institute. T h e serum was given in doses of 80.g c.c. on three successive days. It was given intravenously (?). The majority of the cases who had serum were severe, and in some of the cases treated at the Borough Hospital it was administered as a last resort in an endeavour to counteract the profound toxaemia already established. At the head of the next column are the statistics of the results obtained from the use of Felix Serum.
COMPLICATIONS ARISING AND NOTED DURING THE COURSE OF THE ILLNESS.
Nature of Complication.
Relapses--One Two
The Sites of Perforation found at operation in post-mortem in 1 case were as follows : Borough Hospital.
and at
Borough Hospital. 7 7 11 7 8 -6 4 1 2
Per cent. 10.77 10.77 16.92 10.77 12.3 I 9.23 6.15 1.54 3,08
1 1 1 3 3 I 1 1
1.54 1.54 1-54 4.62 4-62 1-54 1.54 1.54
3 ----
4'62
5 2
7.69 3.08
Mayday Hospital.
Total.
40 24 24 11 6 10 7 3 6 7
Per cent. 23.12 13.87 13.87 6-36 3.47 5.78 4.05 1"73 3.47 4.05
47 3l 35 18 14 10 13 7 7 9
5 7 2 9
2.89 4.05 1.16 5.20
6 8 3 12
2.52 3"36 1.26 5.04
I
---0.58
3 1 I 2
1.26 0.42 0.42 0.84
2 7
1.16 4.05
5 7
2.10 2,94
----
Per cent. 19.75 13.03 14.71 7.56 5.88 4.20 5.46 2.94 2.94 3.78
t
0-58
1
0.42
2
1.16
2
0.84
35 5
20.23 2.89
1939
PUBLIC HEALTH
Case 1.--Act. 89. This case was admitted to hospital on 20/11/'37 and gave the date of onset as 12/11/87. Total. She had received two inoculations of anti-typhoid Borough. Mayday. vaccine at home on 12/11/87 and 16/11/87. She died on 8/12/87, with cerebral symptoms for which L.P. was No apparent effect ... t2 19 31 done--fluid normal in appearance and not under Slight improvement ... 1 16 17 pressure. There was hyperpyrexia before death, the Moderate improvement 2 6 8 temperature rising to 106.6 ° F. Marked improvement 2 2 4 Died . . . . . . . . . 5 4 9 The post-mortem revealed some bronchitis and old pleurisy. T h e heart was dilated, the liver showed The case mortality in serum-treated cases was there- cloudy swelling and the same was present in the kidneys. The spleen was firm and enlarged to about twice its fore 15 per cent. The case mortality of all cases treated in the Corpora- normal size. There was h~emorrhagic inflammation of tion Hospitals was 14-6 per cent. ; of all the primary the lower 8 feet of the ileum with typical ulcers. Case ~.--This case, a female aged 48, was admitted cases known in the outbreak, 18-26 per cent. ; and of the secondary, 25 per cent. ; a combined mortality of to hospital on 2/12/87 and gave the date of onset as 17/11/87. She died on 5/12/37, from intestinal h~emor18-87 per cent. Tables V I I I and IX show the effects observed and rhage. She had a slight degree of exophthalmic goitre the reaction and calculated day of disease when the with a pulse rate of 180. Thepost-mortem showed a thin exsanguinated subject. serum was administered. Of Table V I I I cases, in 12 no effect was observed. In There was considerable enlargement of both lobes of 5 there was a good effect, and in 1 a temporary improve- the thyroid, the condition being one of toxic diffuse ment followed by decline and death. Five cases died. goitre. The lungs showed some bronchitis, the heart Summarised for both hospitals, the results of serum was normal; the liver showed cloudy swelling; the spleen was enlarged to 2½ times the normal size and was administration appear to be as follows : deep red in colour, soft with a diffluent pulp. There was No apparent effect ... 81 much blood in the large intestine, and typical typhoid Some improvement ... 25 ulceration in the lower part of the ileum, the caecum and Marked improvement ... 4 ascending colon. Died . . . . . . . . . . . . 9 Case 8 . - - A female aged 44 years, who gave a history This gives a case mortality of 15 per cent. Three of the eases who received serum were secondary eases; of onset on 11/11/87. She was admitted to hospital on 20/11/87 and died from tox~emia and heart failure on all recovered. 4/12/87. The temperature range until four days before death was 98 ° to 104.6 ° F., during the last four days the Case Mortality of Hospital Cases. temperature did not rise above 99.8 ° F. Death was conBorough Hospital : 65 cases, 14 deaths, 28.8 per cent. sidered to be due to tox~emia and heart failure. mortality. The post-mortem showed in the lungs, bronchitis; Mayday Hospital: 178" cases, 21 deaths, 12.1 per the heart muscle was very flabby; the liver showed cent. mortality. striking fatty change ; the spleen was enlarged to twice Combined Hospitals : 288 cases, 85 deaths, 14.6 per the normal size with a soft and diffluent pulp. The cent. mortality. kidneys were soft and friable. There was typical typhoid The mortality of the outbreak of 810 eases and 48 ulceration in the lower part of the ileum, and the c~ecum deaths is 18.8 per cent. (Males 12-1 per cent. ; Females with yellow sloughs in situ. There was some altered 15-8 per cent.). blood in the large intestine which was greatly distended. The urinary bladder showed cystitis. C a u s e s of D e a t h Case 4.--A female aged 78 years who gave the onset Tables X and XI (overleaf) show the causes of death of illness as 18/tl/87. She was admitted to hospital on at the two hospitals and Table X I I summarises the 24/11/87 and died on 26/12/87. She was a frail old combined figures. woman with pronounced senile kyphosis. During her The death rates for the two sexes were (1) For the illness she had progressive phlebitis and thrombosis, Borough Hospital : Males 80 per cent., Females 17 per first of the right leg and then both legs. Death was cent. ; (2) For Mayday Hospital : Males 9 per cent., considered to be due to tox~emia, thrombosis and heart Females 14-9 per cent. failure. The temperature range during her illness was The fatality rate based on the incidence of cases of 97 ° to 101 ° F. for the first few days and then it fell to the three causes of death was : below 98"6 o F. and remained below that level until the Males. Females. end. Tox~emia ... 8.4 per cent. 12.1 per cent. T h e post-mortem showed a small, soft diffluent spleen, Perforation ... 2.8 ,, 2.27 ,, enlarged mesenteric glands, and typical typhoid ulceraH~emorrhage 1-9 ,, 1-5 ,, tion of the lower 4 feet of the ileum, and the c~ecum with Post-mortem examinations were made in five cases and injection and cedema of the bowel wall. Case 5 . - - A female, aged 61 years, whose date of onset the following are summaries of the reports : - of illness was given as 14/10/87. She was admitted to hospital on 28/10/87 and died on 10/12/87, the cause of # A case of paratyphoid B is not incluuea. Medical Officer's Observation.
Hospital.
143
PUBLIC H E A L T H
FEBRUARY
death being considered to be tox~emia, and perforation. This case had repeated haemorrhages between 27/11/87 and 4/12/87. Her temperature range for the first three weeks was between 97 ° and 108.4 ° F., it then fell and varied between 97 ° and 101.4 ° F. until death. T h e post-mortem showed an exsanguinated and emaciated woman ; no observable splenic enlargement. Cloudy swelling of liver and kidneys; general periTABLE V I I I .
tonitis from a perforation in the upper part of the c~cum with free pus in the abdomen. I n conclusion, I would like to thank the medical officers of the two hospitals for the way in which the clinical records were kept in face of an overwhelming rush of work. T h e i r devotion to duty and the shouldering of burdens far in excess of their normal work I cannot commend too highly.
BOROUGH HOSPITAL: SERUM-TREATED CASES.
No.
Sex.
Day when Administration commenced.
Immediate Reaction.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
F. M. M. M. M. M. M. M. F. M. F. F. F. F. F. F. F.
17 24 24 3 11 7 4 5 9 6 10 10 19 11 7 20 8
Rigors : vomiting 2 hours after Profuse perspiration Vomiting and rise of temperature Rigors and rise of temperature Rigor and rise of temperature Rise of temperature Nil Nil Rise of temperature Rigors and rise of temperature Rise of temperature Rise of temperature Slight rigor and rise of temperature Nil Nil Profuse sweating Vomiting and rise of temperature TABLE IX.
Sex.
Day of Disease when Administration Began.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
M. ~{. F. F. F. M. F. F. F. F. F. F. F. F. M. M M. M. M. M. F. F. F. F. M. M. M. M. M.
18 17 12 18 13 16 17 l0 11 10 10 10 10 I1 ]2 9 9 8 8 15 12 6 10 10 10 8 7 9 10 10
144
Died from heart failure Died 10 days after last injection Good effect. Steady improvement No observable effect Good effect. Fall of Temp. 6 days later No effect No effect. Died 6 days after last injection. Good effect. Steady improvement No effect No effect No effect. Died No effect No effect No effect No effect No effect. Died Improved. Good effect
MAYDAY HOSPITAL: SERUM-TREATED CASES.
No.
M,
Result.
Immediate Reaction. None None None None Slight improvement Moderate improvement None None None Slight improvement None Slight improvement Moderate improvement Slight improvement None Slight improvement Marked improvement None None None None None Moderate improvement Slight improvement Slight improvement None Slight improvement Slight improvement Slight improvement Slight improvement
Result. Died Recovered Recovered Recovered Recovered Recovered Recovered Recovered Died Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Died Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered
PUBLIC H E A L T H
1939 TABLE I X
(Continued).
~'IAYDAY HOSPITAL: SERUIvI-TREATED CASES.
No.
Sex.
Day of Disease when Administration Began.
31 32 33 34 35 36 37 38 39 40 41 42 43
NI. M, F. ~'I. M, F. F. M. M. ~I. M. F. F.
15 13 17 14 17 16 15 J8 I1 15 12 24 15
TABLE X .
Age.
Sex.
13 16 24 28 10 *55 t6 *72 35 "31 64 61 17 *15
M. M. M. M. M. F. F, F. F. F. F. F. F, M.
Immediate Reaction.
Result.
Slight improvement None Slight improvement None None Slight improvement Moderate improvement Slight improvement (slight rigor) Marked improvement Moderate improvement None Slight improvement Moderate improvement
Recovered Died Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered Recovered
BOROUGH HOSPITAL : CAUSES OF DEATH.
Reputed Day of Disease on Admission. 5 11 14 12 13 lb 30 15 9 ? 25 33 14 9 13
N u m b e r of Days in Hospital.
Cause of Death.
10 10 12 23 9 t7 21 17 29 6 15 43 14 I0
Toxmmia Intestinal ha~morrhage Toxmmia Tox~emia Tox~emla Toxmmia Perforation Tox~emia and pneumonia Perforation Toxmmia--confinement Toxa~mia--sudden heart failure Perforation Toxmmia Toxtemia
* Secondary cases. TABLE XI. Age.
Sex.
15 34 20 15 31 39 43 44 63 40 55 26 30 38 29 26 54 78 63 45 54
M. F. ~ I. ~I. M, F. F. F. F. M, F. F. hi. F. M. F. M. F. F. F. F.
MAYDAYHOSPITAL; CAUSESOF DEATH.
Reputed Day of Disease on Admission. 14 7 7 6 10 8 15 9 ? 7 4 ? 7 21 10 10 21 19 6 7 14 16
Number of Days in Hospital. 11 13 I0 12 4 12 3 14 15 14 19 20 9 23 19 24 7 32 35 39 43
Cause of Death. Toxaemia Tox~emia Perforation Perforation Perforation Toxa~mia H~emorrhage Tox~emia Hmmorrhage Toxa~mia Tox~emia Toxmmia Hmmorrhage Tox~emia Toxaemia Toxa~mia-pneumonia Toxmmia Toxa~mia Tox~emia Toxmmia Toxa~mia
145
FEBRUARY
PUBLIC HEALTH TABLE X l I .
COMBINED TOTALS; CAUSES O F DEATH,
Borough Hospital.
Mayday Hospital.
Total.
Cause. Toxmmia . . . . . . Perforation ... Hgemorrhage ...
Male.
Female.
Male.
5 -1
5 3 --
4 3 t
11 -2
6
8
8
13
RECENT APPOINTMENTS IN THE PUBLIC HEALTH SERVICE T h e following are some recent appointments to the public health departments of various local authorities and to other bodies. The Editor will be grateful if members of the Society will notify him at once of any new appointments. ABERDEEN C.C.: Ophth. Surg. for Sch. Med. Service, Dr. J. R. Muteh (Asst. Ophth. Surg. Aberdeen Royal Infirmary). BIRMINGHAM C.B.: A.M.O.H., Dr. J. F. Warin (A.M.O.H. & A.S.M.O., Blackburn C.B.). BRECON COMBINED DISTRICT: M.O.H., Dr. David J. Jones (A.C.M.O.H. & S.M.O., Warwickshire). CENTRAL COUNCIL FOR HEALTH EDUCATION: Gen. Secretary, Mr. John Lee, Barr.-at-Law, LL.B., D . e . A . CORNWALL C.C.: C.M.O.H., Dr. Reginald N. Curnow (Dep. C.M.O.H., Derbyshire C.C.). COSELEY U.D.: M.O.H. and S.M.O., Dr. A. Watt (A.C.M.O.H., Staffs C.C.). DURHAM C.C.: Dep. C.M.O.H., Dr. John Walker (Divl. M.O., Central Div. of Glasgow). HAReENDEN R.D.: M.O.H., Dr. R. R. K. Paton (M.O.H., St. Alban's City and R.D.). HOVE M.B.: A.M.O.H., Dr. J. M. Erskine-Young (R.M.O., City Hospital, Edinburgh). HULL C.B.: Dep. Med. Supt., I.D. Hosp.s & San., Dr. C. D. Preston. ISLE OF ELY C.C.: Temp. C.M.O.H., Dr. J. F. Dawson. KENT C.C.: A.M.O. M. & C.W., Dr. Josie M. Oldfield (R.M.O., I.D. Hosp.). Salary £500 to
Female.
Male.
Female.
Both Sexes.
9 3 2
16 3 2
25 6 4
14
21
35
ROTHERHAM :C.B.: Dep. Med. Supt., I.D. Hosp's & San., Dr. A. C. Morrison (Dep. Med., Hull City & I.D. Hosp.s & San.). SALE M.B.: M.O.H., Dr. Frank Appleton (M.O.H., Brierley Hill U.D.). STONE U. • R.D.s: M.O.tI., Dr. R. A. Leader (in addition to present appointment of A.C.M.O.H., Staffs C.C.). SURREY C.C.: A.C.M.O.s H., Dr. C. A. McPherson (A.M.O.H., Leicester C.B.) and Dr. F. M. B. Dougherty. SWANSEA C.B.: M.O.H., Dr. R. H. Tighe (Dep. M.O.H. & S.M.O., Swansea). Salary, £1,200. WIMBLEDON M.B.: Dep. M.O.H., Dr. P. J. Doody (A.M.O.H., Luton M.B.). Commencing Salary, £650.
The National Conference on Maternity and Child Welfare will be held in the Great Hall, British Medical Association House, Tavistock Square, London, W.C.1, on Tuesday, Wednesday and Thursday, June 27th, 28th and 29th, 1939. President, the Rt. Hon. Walter Elliot, M.P. (Minister of Health. The general question underlying the discussions at the Conference is to be " T h e Needs and Problems of Parenthood." The following subjects will be discussed : - 1. Safety in childbirth for mother and child. 2. The encouragement of breast feeding. 3. Some problems of the nursery school, the nursery class and the day nursery. 4. The child in relation to the foster mother and the daily minder. 5. Problems of parents with a physically defective child. 6. Some problems of propaganda in the maternity and child welfare movement. The Conference is open to all who are interested in maternity and child welfare, whether representative of Local Authorities, or of Voluntary Organisations, or as individuals. £700. A Clinical Course for Medical Practitioners will be held LINDSAY (LINCS) C.C.: Sen. Asst. and Dep. C.M.O.H. on Sunday, June 25th, and Monday, June 26th (organised and S.M.O., Dr. H. C. Humphrey Butcher by the M. and C.W. Group, Society of M.O.H.). (A.M.O.H., Ealing M.B.). CONFERENCE FEES.--For full membership in the ConferMIDDLESBROUGIt C.B.: A.S.M.O., Dr. G. S. Clouston ence, including the receipt of al printed matter that may be issued in connection therewith:-(A.S.M.O., Liverpool C.B.). £ s.d. MIDDLESEX C.C.: A.C.M.O.H., Dr. J. O. F. Davies Per Member ...... 1 1 0 (A.M.O.H., Willesden M.B.) Per Member (if two represent the same Local MINISTRY OF HEALTH: M.O.s, Dr. W. D. T. Brunyate Authority or voluntary organisation) ... 15 0 Per Member (if three or more represent the (M.O.H., Stone U. & R.D.'s; A.M.O.H., Staffs same Local Authority or voluntary organiC.C.) and Dr. G. C. Kelly (Sen. A.M.O.H., sation) . .............. 14 0 Birmingham C.B.). A remittance should accompany all applications for tickets. NATIONAL ASSOCIATION FOR THE PREVENTION OF and should be sent to the Secretary, N.A.M.C.W.C. and TUBERCULOSIS: Gen. Secretary, Dr. J. H. Harley P.LM., 117, Piccadilly, London, W.t, using one of the forms attached. Williams (Med. Commissioner).
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