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Typhus
PUBLIC HEALTH
JANUARY
of ~ determining matters of fact must be upon the stuffs is universal and causes a deterioration in milk, magistrates, who had accepted the evidence that lack it will apparently be sufficient for any dairyman to of dairy cake had produced deterioration in the milk. urge that as a defence, and the prosecution must fail, T o require it to be shown also that there was no possi- even though it were shown that there was ample opporbility of access by any evil-minded person who would tunity for someone to tamper with the milk. It is well dilute the milk seemed to him to lay down a standard that medical officers of health and public analysts should of proof which went a good deal further than was be aware of the defence set up successfully in this case. necessary. One thing that should immediately be done, if it has "... if the magistrates hear evidence that not been done already, is to establish whether a defithere has been inadequate food and accept the ciency in certain feeding stuffs has a bearing on the evidence to that effect and also evidence to the quantity and quality of the milk, and, if so, exactly effect that lack of dairy food leads to a deficiency what is the relation between lack of feeding stuffs and in milk solids other than fat, I see no reason why, milk deterioration. It appears that the cryoscopic test apart from any evidence at all as to non-access, was not used by the analyst in testing the samples in they should not come to the conclusion that the question. This test is regarded by analysts and has milk was genuine milk." been accepted in courts of summary jurisdiction as Mr. Justice Humphreys, who agreed that the appeal proving whether milk is or is not genuine, whereas should be dismissed, said that the onus was upon the deficiency in solids not fat is not determinative. This respondent to disprove the allegation of the prosecution is an argument which it would have been much more that the milk sold was not genuine milk, which pre- interesting to carry to a higher court. Owing to this sumption arose from the facts and conclusions stated judgment matters are left in an extremely unsatison the analyst's certificate. It was the duty of courts factory position from the point of view of public health. of summary jurisdiction to decide the evidence as to facts. The defendant before the local justices must Typhus first prove that the milk had not been tampered with The Ministry of Health, because of the risk that by himself or his employees, and that there had been typhus may be introduced into large aggregations of no opportunity for anyone else to tamper with it. All population, have asked a number of the principal towns such matters should be present to the minds of the to organise teams for dealing with an outbreak. The justices. That had evidently been so in the present team* is to consist of one medical officer, four nurses, case, and the Court should not interfere with such a an ambulance driver, and an ambulance attendant. It finding when it was shown that the local bench had is suggested that one or more sanitary inspectors and applied their minds to the real question at issue. His trained disinfectors should also be included, and that lordship added a few observations on the case of the team should be duplicated. Members of the team Jenkins v. Williams. He said that if a defendant chose should be provided with protective clothing and be to base his defence upon the evidence of what was offered preventive inoculation. done to the milk or could have been done to it from Typhus is compulsorily notifiable, and the medical the time it came from the cow, his evidence must officer of health must immediately report every case to show that throughout there was no opportunity for the Ministry of Health by telegram or telephone. anyone else to interfere with it. That was the issue Medical officers of health can obtain the services of one in Jenkins v. Williams, and there was no other issue, of the medical staff of the Ministry of Health (or, in and that case could not be cited, in Mr. Justice London, of the L.C.C.) for help in diagnosis. A mobile Humphrey's opinion : - team from the American Red Cross-Harvard Field " as an authority for the proposition that where Hospital Unit will be available for assistance in diagnosis the defence is that there are natural causes which and control in any part of England and Wales. The account for the apparent excess of water in the Ministry urges Medical Officers of Health to consider milk, nevertheless, and after that has been proved, at once the provision of hospital accommodation, and there must in addition be given evidence excluding state that in practice it will probably be advisable to every possibility, however remote, that someone make arrangements with one of the larger isolation other than the defendant or his servants may have hospitals. The patient should be removed to hospital tampered with the milk." in a vehicle easy to free from lice and be enveloped in He added that whether, in the light of the argument a large sheet. The greatest care should be t a k e n t o which he had heard in the present case, he would have protect the staff admitting the patient, who should be arrived at the same conclusion in the case of Jenkins taken to a special bathroom, stripped, de-loused, and v. Williams was a matter of no interest to anyone, clad in hospital garments by protected attendants before perhaps not even to himself. Mr. Justice Lewis was being admitted to the special ward. (The memorandum of the same opinion ; he believed that there was some gives a description and illustrations of the protective evidence upon which the magistrates could find as they clothing.) did. T h e appeal, therefore, was dismissed with costs. Louse-borne typhus fever is an acute infectious Thus in fact the defence of deficiency in feeding disease lasting from twelve to sixteen days. Toxaemia stuffs held good, and the question of tampering with and nervous symptoms are pronounced, t The characthe milk was set aside. But surely there might be other cases in which both factors operated. A farmer might * Memorandum on Louse-Borne Typhus Fever. Ministry have a milk deficient because of lack of feeding stuffs of Health Memo. 252/Med. and also improperly diluted. I f a deficiency in feeding t Brit. reed. y., 1941, 2, 886. 78
1942 teristic maculo-papular rash appears on the fourth or f i f t h day, never involves the face, and may become haemorrhagic. It appears as small red papules in the axillae, on the abdomen, chest, and back, and later spreads to the extremities. For a day or two they fade on pressure, but fail to do so after that and become dull red. The papules closely resemble the rash of typhoid, but do not come out in fresh crops. The onset of the disease is sudden and common initial symptoms are rigors, headache, pains in limb and back, vomiting, and epistaxis. According to Dr. M. D. Mackenzie$ two constant symptoms at the onset are headache (frontal or occipital) and bronchitis. Delirium begins early, and the patient gradually slips into the " typhoid state," which is usually fully established between the third and .fifth day. Terrifying delusions are common, and transient delusions may recur during convalescence. It is thought that the excreta, as well as the blood, are infective. By about the end of the first week the patient's serum will agglutinate the so-called Proteus X strains (Weil-Felix reaction). Agglutination of Proteus OX 19 seems to be specific for louse-borne (epidemic) typhus and flea-borne (endemic or murine) typhus. The OX 19 suspension issued by the Oxford Standards Laboratory should be used : a strong reaction (observed by naked eye) in a dilution of 1 in 80 or 1 in 100 may be looked upon as positive. At a recent discussion at the Royal Society of Medicine Dr. G. W. M. Findlay said that the rickettsia virus could be isolated by inoculating the patient's blood into guinea-pigs and rats. It was possible to obtain rickettsiae in this way after the first week and not only during it. As to treatment, Findlay pointed out that the sulphonamide drugs had no effect on human typhus, and immune serum was, in the opinion of most observers, useless. More promising results had been obtained with hyperimmune serum. Findlay was not optimistic about the prophylactic use of vaccines. $ Brit. reed. ft., 1941, 2, 886.
The Ministry of Food propose to institute a system of priority by which it is hoped to ensure that a fair proportion of the eggs available shall go to those persons who need them most. In devising this scheme the Ministry have been guided by the advice of the Food Rationing (Special Diets) Advisory Committee of the Medical Research Council. This Committee have advised that priority should be granted to children under 6 years of age, to expectant mothers, to nursing mothers, and to certain classes of invalids. The Committee recognise that, while the food value of an egg is small, the psychological effect of including an egg in the diet of a patient whose treatment confines him to a limited number of monotonous dishes far outweighs its nutritive value. (The " Schedule of Illnesses Qualifying for Priority Claims on Eggs," is marked " Confidential. Not to be diwdged to the public.") A pamphlet giving particulars of films dealing with the many aspects of physical recreation and health education, which it is hoped will prove a helpful guide to those arranging film shows in clubs, colleges, youth centres, etc., has been published by the Central Council of Recreative Physical Training, 58, Victoria Street, London, S.W.1, price 9d., post free.
PUBLIC HEALTH OBITUARY ELWIN HARRAL THOMAS NASH, M.R.C.P.~ D.P.H. We much regret to record the death on November 28th of Dr. Elwin Nash, formerly President of the Society of Medical Officers of Health and Medical Officer of Health for the Borough of Heston and Isleworth. Elwin Harral Thomas Nash was educated at Manchester and St. Thomas's Hospital, qualifying M.R.C.S., L.R.C.P., in 1896. He took the M.R.C.P. in 1936. He won the Solly medal and prize at St. Thomas's Hospital. He was at one time Senior Assistant Medical Officer of Health for Derby, and Medical Officer of Health and School Medical Officer for Wimbledon. Nash's vigorous personality found expression in many public activities. He was, for example, President of the Medical Officers of Schools Association, a member of the Joint Commission on School Lighting, and a member of the International Medical Society, New York. He was an active supporter of the Society of Medical Officers of Health, and in addition to being its President he was President of the Home Counties Branch and of the Maternity and Child Welfare Group. We are indebted to a colleague for the following a p p r e c i a t i o n : In the passing of Elwin Nash, the public health service has lost a man of outstanding gifts and personality. In his young days at St. Thomas's he achieved fame in the athletic world as a swimmer, a cricketer and a tennis player, and when he was in practice at Accrington he played regularly for the town in Lancashire League cricket. No one who had the privilege of knowing him could doubt his enthusiasm for preventive medicine. Not many would have decided, as he did, to abandon a good private practice and take the risk of achievement in local government service. When I first met him in 1908 he had just completed a term of office as resident medical officer at the Derby Isolation Hospital, where I succeeded him. He had been appointed to the then new office of school medical officer in the same town, and as a colleague I was admitted to the friendship of Mrs. Nash and the four small children. The first part of his service was under the late W. J. Howarth, who subsequently became medical officer of health for the City of London: Howarth was a man of decided vmws. Nash's next chief was the late A. E. Brindley, one of the gentlest and most beloved men of his day. After eighteen months as school medical officer at Derby Nash was appointed medical officer of health for Wimbledon; he stayed there until 1915, when he was appointed medical superintendent to the newly opened Preston Colony for tuberculous ex-soldiers. Finding himself unable to p.ersuade the Committee of Management to adopt his views, he gave up this post and for a time worked in the school medical department of the L.C.C. He was then appointed medical officer of health to the rapidly expanding Borough of Heston and Isleworth, where his extensive experience in organisation, especially in school medical and infant welfare work, found full scope. In the later years of his work there he threw himself with characteristic ardour into the preparation of D r . N a s h ' s C o o k e r y B o o k . This involved a great deal of practical 79
JANUARY
of ~ determining matters of fact must be upon the stuffs is universal and causes a deterioration in milk, magistrates, who had accepted the evidence that lack it will apparently be sufficient for any dairyman to of dairy cake had produced deterioration in the milk. urge that as a defence, and the prosecution must fail, T o require it to be shown also that there was no possi- even though it were shown that there was ample opporbility of access by any evil-minded person who would tunity for someone to tamper with the milk. It is well dilute the milk seemed to him to lay down a standard that medical officers of health and public analysts should of proof which went a good deal further than was be aware of the defence set up successfully in this case. necessary. One thing that should immediately be done, if it has "... if the magistrates hear evidence that not been done already, is to establish whether a defithere has been inadequate food and accept the ciency in certain feeding stuffs has a bearing on the evidence to that effect and also evidence to the quantity and quality of the milk, and, if so, exactly effect that lack of dairy food leads to a deficiency what is the relation between lack of feeding stuffs and in milk solids other than fat, I see no reason why, milk deterioration. It appears that the cryoscopic test apart from any evidence at all as to non-access, was not used by the analyst in testing the samples in they should not come to the conclusion that the question. This test is regarded by analysts and has milk was genuine milk." been accepted in courts of summary jurisdiction as Mr. Justice Humphreys, who agreed that the appeal proving whether milk is or is not genuine, whereas should be dismissed, said that the onus was upon the deficiency in solids not fat is not determinative. This respondent to disprove the allegation of the prosecution is an argument which it would have been much more that the milk sold was not genuine milk, which pre- interesting to carry to a higher court. Owing to this sumption arose from the facts and conclusions stated judgment matters are left in an extremely unsatison the analyst's certificate. It was the duty of courts factory position from the point of view of public health. of summary jurisdiction to decide the evidence as to facts. The defendant before the local justices must Typhus first prove that the milk had not been tampered with The Ministry of Health, because of the risk that by himself or his employees, and that there had been typhus may be introduced into large aggregations of no opportunity for anyone else to tamper with it. All population, have asked a number of the principal towns such matters should be present to the minds of the to organise teams for dealing with an outbreak. The justices. That had evidently been so in the present team* is to consist of one medical officer, four nurses, case, and the Court should not interfere with such a an ambulance driver, and an ambulance attendant. It finding when it was shown that the local bench had is suggested that one or more sanitary inspectors and applied their minds to the real question at issue. His trained disinfectors should also be included, and that lordship added a few observations on the case of the team should be duplicated. Members of the team Jenkins v. Williams. He said that if a defendant chose should be provided with protective clothing and be to base his defence upon the evidence of what was offered preventive inoculation. done to the milk or could have been done to it from Typhus is compulsorily notifiable, and the medical the time it came from the cow, his evidence must officer of health must immediately report every case to show that throughout there was no opportunity for the Ministry of Health by telegram or telephone. anyone else to interfere with it. That was the issue Medical officers of health can obtain the services of one in Jenkins v. Williams, and there was no other issue, of the medical staff of the Ministry of Health (or, in and that case could not be cited, in Mr. Justice London, of the L.C.C.) for help in diagnosis. A mobile Humphrey's opinion : - team from the American Red Cross-Harvard Field " as an authority for the proposition that where Hospital Unit will be available for assistance in diagnosis the defence is that there are natural causes which and control in any part of England and Wales. The account for the apparent excess of water in the Ministry urges Medical Officers of Health to consider milk, nevertheless, and after that has been proved, at once the provision of hospital accommodation, and there must in addition be given evidence excluding state that in practice it will probably be advisable to every possibility, however remote, that someone make arrangements with one of the larger isolation other than the defendant or his servants may have hospitals. The patient should be removed to hospital tampered with the milk." in a vehicle easy to free from lice and be enveloped in He added that whether, in the light of the argument a large sheet. The greatest care should be t a k e n t o which he had heard in the present case, he would have protect the staff admitting the patient, who should be arrived at the same conclusion in the case of Jenkins taken to a special bathroom, stripped, de-loused, and v. Williams was a matter of no interest to anyone, clad in hospital garments by protected attendants before perhaps not even to himself. Mr. Justice Lewis was being admitted to the special ward. (The memorandum of the same opinion ; he believed that there was some gives a description and illustrations of the protective evidence upon which the magistrates could find as they clothing.) did. T h e appeal, therefore, was dismissed with costs. Louse-borne typhus fever is an acute infectious Thus in fact the defence of deficiency in feeding disease lasting from twelve to sixteen days. Toxaemia stuffs held good, and the question of tampering with and nervous symptoms are pronounced, t The characthe milk was set aside. But surely there might be other cases in which both factors operated. A farmer might * Memorandum on Louse-Borne Typhus Fever. Ministry have a milk deficient because of lack of feeding stuffs of Health Memo. 252/Med. and also improperly diluted. I f a deficiency in feeding t Brit. reed. y., 1941, 2, 886. 78
1942 teristic maculo-papular rash appears on the fourth or f i f t h day, never involves the face, and may become haemorrhagic. It appears as small red papules in the axillae, on the abdomen, chest, and back, and later spreads to the extremities. For a day or two they fade on pressure, but fail to do so after that and become dull red. The papules closely resemble the rash of typhoid, but do not come out in fresh crops. The onset of the disease is sudden and common initial symptoms are rigors, headache, pains in limb and back, vomiting, and epistaxis. According to Dr. M. D. Mackenzie$ two constant symptoms at the onset are headache (frontal or occipital) and bronchitis. Delirium begins early, and the patient gradually slips into the " typhoid state," which is usually fully established between the third and .fifth day. Terrifying delusions are common, and transient delusions may recur during convalescence. It is thought that the excreta, as well as the blood, are infective. By about the end of the first week the patient's serum will agglutinate the so-called Proteus X strains (Weil-Felix reaction). Agglutination of Proteus OX 19 seems to be specific for louse-borne (epidemic) typhus and flea-borne (endemic or murine) typhus. The OX 19 suspension issued by the Oxford Standards Laboratory should be used : a strong reaction (observed by naked eye) in a dilution of 1 in 80 or 1 in 100 may be looked upon as positive. At a recent discussion at the Royal Society of Medicine Dr. G. W. M. Findlay said that the rickettsia virus could be isolated by inoculating the patient's blood into guinea-pigs and rats. It was possible to obtain rickettsiae in this way after the first week and not only during it. As to treatment, Findlay pointed out that the sulphonamide drugs had no effect on human typhus, and immune serum was, in the opinion of most observers, useless. More promising results had been obtained with hyperimmune serum. Findlay was not optimistic about the prophylactic use of vaccines. $ Brit. reed. ft., 1941, 2, 886.
The Ministry of Food propose to institute a system of priority by which it is hoped to ensure that a fair proportion of the eggs available shall go to those persons who need them most. In devising this scheme the Ministry have been guided by the advice of the Food Rationing (Special Diets) Advisory Committee of the Medical Research Council. This Committee have advised that priority should be granted to children under 6 years of age, to expectant mothers, to nursing mothers, and to certain classes of invalids. The Committee recognise that, while the food value of an egg is small, the psychological effect of including an egg in the diet of a patient whose treatment confines him to a limited number of monotonous dishes far outweighs its nutritive value. (The " Schedule of Illnesses Qualifying for Priority Claims on Eggs," is marked " Confidential. Not to be diwdged to the public.") A pamphlet giving particulars of films dealing with the many aspects of physical recreation and health education, which it is hoped will prove a helpful guide to those arranging film shows in clubs, colleges, youth centres, etc., has been published by the Central Council of Recreative Physical Training, 58, Victoria Street, London, S.W.1, price 9d., post free.
PUBLIC HEALTH OBITUARY ELWIN HARRAL THOMAS NASH, M.R.C.P.~ D.P.H. We much regret to record the death on November 28th of Dr. Elwin Nash, formerly President of the Society of Medical Officers of Health and Medical Officer of Health for the Borough of Heston and Isleworth. Elwin Harral Thomas Nash was educated at Manchester and St. Thomas's Hospital, qualifying M.R.C.S., L.R.C.P., in 1896. He took the M.R.C.P. in 1936. He won the Solly medal and prize at St. Thomas's Hospital. He was at one time Senior Assistant Medical Officer of Health for Derby, and Medical Officer of Health and School Medical Officer for Wimbledon. Nash's vigorous personality found expression in many public activities. He was, for example, President of the Medical Officers of Schools Association, a member of the Joint Commission on School Lighting, and a member of the International Medical Society, New York. He was an active supporter of the Society of Medical Officers of Health, and in addition to being its President he was President of the Home Counties Branch and of the Maternity and Child Welfare Group. We are indebted to a colleague for the following a p p r e c i a t i o n : In the passing of Elwin Nash, the public health service has lost a man of outstanding gifts and personality. In his young days at St. Thomas's he achieved fame in the athletic world as a swimmer, a cricketer and a tennis player, and when he was in practice at Accrington he played regularly for the town in Lancashire League cricket. No one who had the privilege of knowing him could doubt his enthusiasm for preventive medicine. Not many would have decided, as he did, to abandon a good private practice and take the risk of achievement in local government service. When I first met him in 1908 he had just completed a term of office as resident medical officer at the Derby Isolation Hospital, where I succeeded him. He had been appointed to the then new office of school medical officer in the same town, and as a colleague I was admitted to the friendship of Mrs. Nash and the four small children. The first part of his service was under the late W. J. Howarth, who subsequently became medical officer of health for the City of London: Howarth was a man of decided vmws. Nash's next chief was the late A. E. Brindley, one of the gentlest and most beloved men of his day. After eighteen months as school medical officer at Derby Nash was appointed medical officer of health for Wimbledon; he stayed there until 1915, when he was appointed medical superintendent to the newly opened Preston Colony for tuberculous ex-soldiers. Finding himself unable to p.ersuade the Committee of Management to adopt his views, he gave up this post and for a time worked in the school medical department of the L.C.C. He was then appointed medical officer of health to the rapidly expanding Borough of Heston and Isleworth, where his extensive experience in organisation, especially in school medical and infant welfare work, found full scope. In the later years of his work there he threw himself with characteristic ardour into the preparation of D r . N a s h ' s C o o k e r y B o o k . This involved a great deal of practical 79