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The health of London in 1927
19s8.
PUBLIC HEALTH.
During recent years paratyphoid fever has been more or less endemic in this country, and in several districts in consequence of the association of a carrier or carriers with milk or other food somewhat serious outbreaks have occurred. The subject is specially apposite at the present time in view of the occurrence of the disease in London, and a study of Dr. \~ernon Shaw's informing report and of the paper which appears in this number will serve to focus attention on several important points in relation to the mtiology of the disease. One of the most striking clinical features of the present type of paratyphoid B fever in relation to its mtiology and to public health administration is the extreme mildness which characterises quite a considerable percentage of cases. T h e attack, indeed, may be so mild that the individual is quite ignorant of the fact that a n y serious departure from normal health has occurred., and in consequence medical advice is not sought. A further feature of the disease specially noticeable in children is the tendency which it displays to simulate some other morbid condition, such as pneumonia or broncho~pneumonia. And lastly, and most important of all in relation to the causation of serious outbreaks, there is the frequency with which the bacillus paratyphosus tends to persist in urine or faeces for extended periods long after any evidence of constitutional disturbance has disappeared. These features of paratyphoid fever are no doubt directly responsible for the endemicity of the disease in E n g l a n d since the conclusion of the W a r , and they explain the periodicity of local .outbreaks of a more serious and epidemic character. Indeed, so long as it is impossible to. prevent the association of masked cases of the disease or of carriers with milk and other foods, so long will the risk remain of local epidemic outbreaks of paratyphoid fever. T h e outbreak which forms the subject of Dr. Vernon Shaw's report, and which is also described in Dr. Hyslop Thomson's paper, is a striking example of a sudden and somewhat extensive outbreak of paratyphoid fever through infection by milk. The ]ons et origo was no .doubt the child at the farm, whose illness presented symptoms of pneumonia, and the mother who. nursed h e r - - a carrier who handled milk. The fact that several of the roundsmen employed by the retailer who obtained milk from the farm were carriers of the
381
bacillus paratyphosus without any history of previous illness emphasises the ease with which milk may be contaminated with this organism and so provide a medium for the rapid dissemination of infectio.n. One of the patients in whom the bacillus persisted for over three months was the wife of a confectioner, a n d a further somewhat disturbing" feature whichl does not tend to render less difficult the control of this disease is the fact that in testing patients for carriers two or three negative results m a y be folio.wed by a positive result. One definite conclusion is to. be drawn from a perusal o.f the report and paper, and it is that every case of illness occurring in those who handle milk and other forms of uncooked food should be reported to. and investigated by the medical officer of health and, further, that a periodical medical examination of those who handle milk should be tecognised as an essential part of public health administration.
The Health of London in 1 9 2 7 . HE report of the Medical Officer of Health T and School Medical Officer of the London County Council, on the public health and school medical service for the year 1927,* provides a wealth of food for thought to health officers. It is, of course, a voluminous document, but upon each of its 172 pages is to be found most interesting reading or statistical matter. The statement that the infantile deathrate for the year (59 per 1,000 births) is the lowest recorded in London is one of the most gratifying features in the report. This reduction is chiefly attributable to the decreased mortality from diarrhoea, due to a cool summer. As a result of an analysis of the incidence of cancer mortality in the London population, Dr. Menzies reaches the following interesting conclusions : - (i) That among persons over 35 years of age the movements of the mortality from 1850 onwards are, in the main, correlated with the year of birth and not with progressive changes in conditions of life. (ii) That, assuming the same correlation to hold in the future, the female mortality rate will continue to decline, while that of males wili increase further for some time. (iii) That these variations in the total cancer mortality rates, considered in conjunction with (a) the complementary ~ANNUAL REPORT OF THE LONDON COUNTY COUNCIL. 1927. Vol. III. Public Health (including the Reports for the year 1927 of the County Medical Officer of Health and School Medical Officer, Main Drainage and Housing), No. 2588. London : P. S. King & Son, Ltd., 14, Great Smith Street, S.W.1. Price 2s. 6d.
382
PUBLIC H E A L T H .
relation of the male excess of cancer of t h e u p p e r a l i m e n t a r y tract to t h a t of t h e female cancers of t h e r e p r o d u c t i v e s y s t e m , and (b) with t h e contrasts in age-incidence of cancers o f the reproductive s y s t e m b y locality o f g r o w t h a m o n g single a n d m a r r i e d w o m e n , respectively, are c o n s i s t e n t with t h e h y p o thesis t h a t a cancer diathesls is t h e d o m i n a t i n g factor in t h e m o r t a l i t y f r o m c a r c i n o m a in t h e general p o p u l a t i o n , a n d t h u s t h a t t h e solution o f t h e cancer p r o b l e m m a y u l t i m a t e l y be f o u n d to d e p e n d u p o n the detection a n d modification of t h e cancer diathesis.
During the year the tuberculosis care committees in the boroughs of Kensington, Stepney, Wandsworth and Westminster have followed the example of the Lewisham Tuberculosis Care Committee in establishing a handicraft class for dispensary patients. It is easy to appreciate the value of these classes as a means of providing new interest and occupation for persons whose restoration to health is frequently retarded by depression. Special reference is made to the continued improvement in the personal cleanliness of school children; while attention is drawn to the fact that the school doctors have noticed " nervousness" among many of the children and attribute the condition, which varies from mere restlessness to actual chorea, to lack of restful sleep at night. An enquiry carried out at two schools shows that, in many cases, the housing conditions of the families are such that it must be a matter of impossibility for the children to obtain undisturbed sleep. Dr. Menzies devotes considerable space to a review of the data which are now available as a result of the commencement in November, 1926, of the working of the scheme under which the County Council has become the organising authority for the care of rheumatic children. From the investigation of the environmental factors it would appear that no one disadvantageous factor stands out, but rather that each and all of the concomitants of poverty, poor houses, dampness, unhealthy sites, overcrowding, lack of ventilation and of sunlight, poor feeding, poor clothing, irregular habits, etc., destructively converge on these unfortunate children who wilt along the lines their bias carries them, be it marasmus, rheumatism, tuberculosis, or the respiratory diseases generally. In London, the school doctors are paying special attention to rheumatism; a register of all cases has been established, school supervision is being carried out, and residential accommodation for acute and sub-acute cases is being organised. What is now chiefly required is the development o f local supervisory centres. Already in the north-western
SEPTEMBER,
division of London three rheumatism supervisory centres have been established, namely, in Kensington, Paddington and St. Marylebone. During the coming year it is hoped that five more centres will be established in connection with hospitals or treatment centres in the four divisions in which no provision of the kind as yet exists. All children dischargcd from residential treatment will be specially considered from the standpoint of the advisability of their future education in special day schools, while continued supervision will bc ensured. This sccond annual report from the pen of Dr. Menzies reaches the high level of excellence of the one published twelve months ago, and will bc read with interest both by London and provincial medical officers.
The Maternity and Child Welfare Conference. H E National Maternity and Child Welfare Conference, 1928, attracted to the Guildhall of the City of London in the first week of July, an eager crowd that thronged its historic chambers with a petulant disdain for any limit of numbers dictated merely b y the law. The chief consideration at the conference was the health of the mother and, save in the first session, when a short series of papers on various subjects marking recent advances in child welfare work were read, followed b y Sir George Newman, who in his introductory address was as interesting and encouraging as usual, attention was concentrated on the welfare of motherhood. Maternal ill-health, as apart from mortality, for once received logical treatment as the first and greater og these evils. The gynmcologists made it plain that the unconscionable waste and suffering involved in a poor level of maternal health should and could be checked. Two factors were stressed : the prevalence of abortive methods, barely realised, and the inevitable loss of health necessarily associated with repeated abortions, even when these were not artificially produced, demanded attention from those who professed to care for womankind; and secondly, experience of obstetrical cases confined in hospital under the best conditions had demonstrated that in every instance a post-natal examination of the mother was necessary to eliminate at the most favourable moment any possible cause for future gynmcological disability. A short
T
PUBLIC HEALTH.
During recent years paratyphoid fever has been more or less endemic in this country, and in several districts in consequence of the association of a carrier or carriers with milk or other food somewhat serious outbreaks have occurred. The subject is specially apposite at the present time in view of the occurrence of the disease in London, and a study of Dr. \~ernon Shaw's informing report and of the paper which appears in this number will serve to focus attention on several important points in relation to the mtiology of the disease. One of the most striking clinical features of the present type of paratyphoid B fever in relation to its mtiology and to public health administration is the extreme mildness which characterises quite a considerable percentage of cases. T h e attack, indeed, may be so mild that the individual is quite ignorant of the fact that a n y serious departure from normal health has occurred., and in consequence medical advice is not sought. A further feature of the disease specially noticeable in children is the tendency which it displays to simulate some other morbid condition, such as pneumonia or broncho~pneumonia. And lastly, and most important of all in relation to the causation of serious outbreaks, there is the frequency with which the bacillus paratyphosus tends to persist in urine or faeces for extended periods long after any evidence of constitutional disturbance has disappeared. These features of paratyphoid fever are no doubt directly responsible for the endemicity of the disease in E n g l a n d since the conclusion of the W a r , and they explain the periodicity of local .outbreaks of a more serious and epidemic character. Indeed, so long as it is impossible to. prevent the association of masked cases of the disease or of carriers with milk and other foods, so long will the risk remain of local epidemic outbreaks of paratyphoid fever. T h e outbreak which forms the subject of Dr. Vernon Shaw's report, and which is also described in Dr. Hyslop Thomson's paper, is a striking example of a sudden and somewhat extensive outbreak of paratyphoid fever through infection by milk. The ]ons et origo was no .doubt the child at the farm, whose illness presented symptoms of pneumonia, and the mother who. nursed h e r - - a carrier who handled milk. The fact that several of the roundsmen employed by the retailer who obtained milk from the farm were carriers of the
381
bacillus paratyphosus without any history of previous illness emphasises the ease with which milk may be contaminated with this organism and so provide a medium for the rapid dissemination of infectio.n. One of the patients in whom the bacillus persisted for over three months was the wife of a confectioner, a n d a further somewhat disturbing" feature whichl does not tend to render less difficult the control of this disease is the fact that in testing patients for carriers two or three negative results m a y be folio.wed by a positive result. One definite conclusion is to. be drawn from a perusal o.f the report and paper, and it is that every case of illness occurring in those who handle milk and other forms of uncooked food should be reported to. and investigated by the medical officer of health and, further, that a periodical medical examination of those who handle milk should be tecognised as an essential part of public health administration.
The Health of London in 1 9 2 7 . HE report of the Medical Officer of Health T and School Medical Officer of the London County Council, on the public health and school medical service for the year 1927,* provides a wealth of food for thought to health officers. It is, of course, a voluminous document, but upon each of its 172 pages is to be found most interesting reading or statistical matter. The statement that the infantile deathrate for the year (59 per 1,000 births) is the lowest recorded in London is one of the most gratifying features in the report. This reduction is chiefly attributable to the decreased mortality from diarrhoea, due to a cool summer. As a result of an analysis of the incidence of cancer mortality in the London population, Dr. Menzies reaches the following interesting conclusions : - (i) That among persons over 35 years of age the movements of the mortality from 1850 onwards are, in the main, correlated with the year of birth and not with progressive changes in conditions of life. (ii) That, assuming the same correlation to hold in the future, the female mortality rate will continue to decline, while that of males wili increase further for some time. (iii) That these variations in the total cancer mortality rates, considered in conjunction with (a) the complementary ~ANNUAL REPORT OF THE LONDON COUNTY COUNCIL. 1927. Vol. III. Public Health (including the Reports for the year 1927 of the County Medical Officer of Health and School Medical Officer, Main Drainage and Housing), No. 2588. London : P. S. King & Son, Ltd., 14, Great Smith Street, S.W.1. Price 2s. 6d.
382
PUBLIC H E A L T H .
relation of the male excess of cancer of t h e u p p e r a l i m e n t a r y tract to t h a t of t h e female cancers of t h e r e p r o d u c t i v e s y s t e m , and (b) with t h e contrasts in age-incidence of cancers o f the reproductive s y s t e m b y locality o f g r o w t h a m o n g single a n d m a r r i e d w o m e n , respectively, are c o n s i s t e n t with t h e h y p o thesis t h a t a cancer diathesls is t h e d o m i n a t i n g factor in t h e m o r t a l i t y f r o m c a r c i n o m a in t h e general p o p u l a t i o n , a n d t h u s t h a t t h e solution o f t h e cancer p r o b l e m m a y u l t i m a t e l y be f o u n d to d e p e n d u p o n the detection a n d modification of t h e cancer diathesis.
During the year the tuberculosis care committees in the boroughs of Kensington, Stepney, Wandsworth and Westminster have followed the example of the Lewisham Tuberculosis Care Committee in establishing a handicraft class for dispensary patients. It is easy to appreciate the value of these classes as a means of providing new interest and occupation for persons whose restoration to health is frequently retarded by depression. Special reference is made to the continued improvement in the personal cleanliness of school children; while attention is drawn to the fact that the school doctors have noticed " nervousness" among many of the children and attribute the condition, which varies from mere restlessness to actual chorea, to lack of restful sleep at night. An enquiry carried out at two schools shows that, in many cases, the housing conditions of the families are such that it must be a matter of impossibility for the children to obtain undisturbed sleep. Dr. Menzies devotes considerable space to a review of the data which are now available as a result of the commencement in November, 1926, of the working of the scheme under which the County Council has become the organising authority for the care of rheumatic children. From the investigation of the environmental factors it would appear that no one disadvantageous factor stands out, but rather that each and all of the concomitants of poverty, poor houses, dampness, unhealthy sites, overcrowding, lack of ventilation and of sunlight, poor feeding, poor clothing, irregular habits, etc., destructively converge on these unfortunate children who wilt along the lines their bias carries them, be it marasmus, rheumatism, tuberculosis, or the respiratory diseases generally. In London, the school doctors are paying special attention to rheumatism; a register of all cases has been established, school supervision is being carried out, and residential accommodation for acute and sub-acute cases is being organised. What is now chiefly required is the development o f local supervisory centres. Already in the north-western
SEPTEMBER,
division of London three rheumatism supervisory centres have been established, namely, in Kensington, Paddington and St. Marylebone. During the coming year it is hoped that five more centres will be established in connection with hospitals or treatment centres in the four divisions in which no provision of the kind as yet exists. All children dischargcd from residential treatment will be specially considered from the standpoint of the advisability of their future education in special day schools, while continued supervision will bc ensured. This sccond annual report from the pen of Dr. Menzies reaches the high level of excellence of the one published twelve months ago, and will bc read with interest both by London and provincial medical officers.
The Maternity and Child Welfare Conference. H E National Maternity and Child Welfare Conference, 1928, attracted to the Guildhall of the City of London in the first week of July, an eager crowd that thronged its historic chambers with a petulant disdain for any limit of numbers dictated merely b y the law. The chief consideration at the conference was the health of the mother and, save in the first session, when a short series of papers on various subjects marking recent advances in child welfare work were read, followed b y Sir George Newman, who in his introductory address was as interesting and encouraging as usual, attention was concentrated on the welfare of motherhood. Maternal ill-health, as apart from mortality, for once received logical treatment as the first and greater og these evils. The gynmcologists made it plain that the unconscionable waste and suffering involved in a poor level of maternal health should and could be checked. Two factors were stressed : the prevalence of abortive methods, barely realised, and the inevitable loss of health necessarily associated with repeated abortions, even when these were not artificially produced, demanded attention from those who professed to care for womankind; and secondly, experience of obstetrical cases confined in hospital under the best conditions had demonstrated that in every instance a post-natal examination of the mother was necessary to eliminate at the most favourable moment any possible cause for future gynmcological disability. A short
T