TYPHUS FEVER EPIDEMIC AMONG THE GREEK REFUGEES.

153 It is superfluous to state that the infected human louse is the intermediary in the transmission of typhus ; ordinarily there is no direct communication of the disease from man to man. If it were possible to exterminate human lice in an infected area the disease would cease. All our radical preventive measures are based on this knowledge. ExperiTYPHUS FEVER EPIDEMIC AMONG THE enced local medical administrators act on the principle that GREEK REFUGEES. if there are no lice on the people themselves and their clothes they cannot give the disease to others. Somehow it has got BY SIR PATRICK HEHIR, K.C.I.E., C.B., C.M.G., abroad that it is only the body-louse that acts as a carrier. I am all but morally certain that this is not the case, and that M.D. BRUX., F.R.C.S., F.R.C.P. EDIN., the exculpation of P. capitis is a dangerous theory. I.M.S. MEDICAL BRITISH MAJOR-GENERAL, (RET.) ; ADVISER, The micro-organism of typhus passes through a developRED CROSS SOCIETY IN GREECE. mental stage in the louse ; in that insect it is intracellular, develops, is set free, and is finally discharged into the oral IT has fallen to my lot to see a great deal of typhus apparatus, from which it is introduced into man. In man it becomes intracellular, and from the infected cells it among the Greek refugees during the last four and a half again months. As the outbreak presents many points of difference, is thrown into the blood with its toxins. The louse does not epidemiologically and otherwise, from the disease as ordinarily transmit the virus until four days have elapsed from the time met with elsewhere, an account of it may be of interest. The of its infection ; infection of man is in the vast majority of Greek refugees primarily brought the infection with them, cases through the bite of the louse, and the insect’s excreta and have been moving from one place to another carrying rubbed into scratches of the skin is also believed to give rise the disease, either in the incubating stage or in a mild ambu- to infection in a small number of cases. So far as I can discover, no original work is being done during this epidemic latory form. The serious cases are, of course, incapable of in regard to the relation of the louse to typhus. movement with the masses. The infectious diseases hospitals for typhus cases in refugees Epidemiology. are not ideal institutions, but they might be worse. There The epidemiological history of the present outbreak is is usually a sufficient number of sick attendants, nurses, easily understood if one pictures the conditions, economic, and doctors, but want of experience as to how to deal with political, and military, that have been in existence in relation the disease has been evident in several local epidemics. to these refugees since last autumn. Apparently there is a The arrangements for protecting the hospital staff from gradual rise in the intensity of the epidemic until it reaches infected lice was one of the most serious defects I came across. its acme ; this continues for a few months and then the When I visited an infectious diseases hospital some weeks epidemic gradually subsides. There are, however, oscilla- ago a long white coat was given me to wear in the wards. tions in the intensity which, I believe, are mainly associated After I had put it on one of the hospital orderlies picked off with variations in meteorological conditions, but doubtless a louse from the neck, remarking that it was seldom he found other accidental factors are concerned. With us it began at one on the assistant director’s gown which I was wearing. the end of January, gradually rose in numbers and severity In one infectious diseases hospital the arrangements for of attacks, reached a maximum about the first fortnight in delousing patients admitted were of the most elementary March, remained stationary for a month or so, and is now kind, except that a steam-disinfector was occasionally used for the clothing when water was available. There was no undergoing a marked abatement. It is noteworthy that in areas where refugees have been bathing of patients on admission, but the hair was cut short. widely dispersed on the land there has been no typhus, or I found that the sanitary arrangements in wards and latrines it has not become epidemic when introduced. Other things called for serious improvement-some of the wards were being equal, the intensity of the epidemic appears to depend offensive, as several cases of incontinence of urine and faeces largely upon the economic conditions in existence. The were present and the nursing and cleanliness were unsatisrelation of typhus to overcrowding, long misunderstood, is factory. In our own camp one day I found that three cases now known to be easily explained by the part that-human which the Greek medical officer (himself a refugee) had lice play in the disease. The brunt of the epidemic has been diagnosed as " fever " had been allowed to remain in the borne by the larger towns-e.g., Athens and its environs, main blocks. All three had lice on their clothes ; they were Salonica, Patras, Corfu-the smaller towns escaping to a all cases of typhus and two of them already had the rash. considerable extent, the incidence being related to the In one town a severe epidemic of influenza was reported to density of population on the occupied area. Whole rural exist, but the high mortality aroused suspicion and inquiries districts in Macedonia and Western Thrace have escaped by experts were made ; it was found that influenza was the altogether. The housing conditions of the refugees, their minor disease and typhus the real epidemic. The same history hardships-especially insufficient food and exposure-have was given me by the controlling medical authority in regard considerably lowered their resistance to disease, which, except to two other towns. As the result of this want of experience in the case of minor maladies, runs a serious course and is several doctors and nurses taking no precautions got the frequently fatal. This high mortality is important, as it has disease and died. It is all but morally certain that anyone aroused antipathy to the hospitals ; early cases of sickness attending typhus cases without a knowledge of the nature are hidden, and often hospital relief is only sought when the of the disease will become infected himself sooner or later. patient is dangerously ill, this being one of the ways in which It is important to educate the subordinate staff of these typhus is being spread. ’ hospitals in the aetiology of typhus and the principles The outbreak attained its maximum of intensity in mid- adopted in the prevention of infection. winter. In colder weather the people are more crowded (To be continued.) together ; they wear thicker clothes, which foster lice, and bathe less frequently. Throughout the winter refugees were packed with the ordinary civil population in the waiting MEDICAL WORK OF THE MISSION TO LEPERS. rooms of railway stations and in other places ; contact cases As I write this in the British were therefore more frequent. THE forty-eighth annual report of the Mission to Lepers,l Red Cross train at Salonica railway station, a refugee-train presented at the annual general meeting of members of the is in a siding ; in and around the station yard are, roughly, mission at the Central Hall, Westminster, on May 10th, 500 refugees, all on the way to Seres (Thrace) to take up contains a chapter devoted to the medical work of the work on the land. The same sort of arrivals and distribu- mission, in which short statements by various medical men tions are occurring in many large railway stations ; it is easy and women are quoted. The mission cares for 7735 leper to see how communicable disease spreads rapidly among inmates in its own and aided institutions, and also for over them, and also reaches the stationary populations of towns. 600 untainted children, who are educated and trained in Overcrowding is, however, only one of the factors that enter separate homes to become useful members of the healthy into the epidemiology of typhus. Other hardships exist : A community. At Dichpalli, near Nizamabad, Deccan, India, very large percentage of the. refugees get only a bare subsis- improved results have been obtained by intravenous injection tence allowance of food. In some districts men who can of the ethyl esters of chaulmoogra or hydnocarpus oils, as work get no food dole, and out-of-work women get only opposed to intramuscular injection. " This means that very 6 to 8 ounces of bread or flour a day. Until a few months ago much more of the drug is administered, with consequent signs few refugees had a change of clothing ; undergarments were of improvement. In nodular cases an auto-vaccine is especially scarce. A great deal of help has been given them prepared for each patient." In some cases the two methods now in this respect, and I know of no camp of any duration are combined. The conditions of unrest in China militate that has not been relieved. With only one suit of clothes against the handling of the leper problem : " In Siao Kan the practical difficulties of delousing are obvious ; the suit (Central China), since the middle of the war period, we have is put through the steam disinfector and dried while the only encouraged the more pronounced, or chronic, cases to refugee is having his bath. The sanitary condition under come into residence. This means that we have turned away which refugees lived for months after their return to Greece 1 was indescribably bad ; it has, in the last two months or " A Fruitful Field." Mission to Lepers, 33, Henriettabeen greatly ameliorated. street, Covent Garden, London, W.C. 2. 6d.

Notes, Comments, and Abstracts.

so,

154 the very cases which the treatment would have best served, summarised, leading to the modern view that man’s power for undeniably the esters act most rapidly in the early stages of taking exercise, whether violent or prolonged, depends. of the disease." From the Fusan Leper Asylum, Korea, largely on his ability to run into debt for oxygen. In 1 i.e honorary superintendent writes : " Before we began the prolonged effort, such as that associated with climbing chaulmoogra oil treatment our death-rate was always as high the healthy man is limited not by the magnitude of " debt " The inmates had little or no hope of a cure ; into which his body can run-not, that is to say, by the as 25 per cent. it was with the greatest difficulty that they could lactic acid maximum of his muscles-but chiefly by the be got to do any kind of work. Now, with the exception of maximum rate at which he can take in oxygen. With regard those who are maimed or blind.... they form a hive of to the economical use of muscle by the trained athlete,Hill writes as follows :industry and are as happy a crowd as one can see anywhere. Prof. " We have already discharged nine cases in which no trace of Clearly if a given movement can be carried out more the disease could be found ; and there are. perhaps, double economically-i.e., at the expense of less energy-then less that number who have no active symptoms though they oxygen will be required for it, and its maximum duration still have some anaesthetic patches.... In the first year of can be increased.... This economy of effort can, in part, the treatment the death-rate was reduced from 25 to 15 be taught ; but just as all the practice in the world will per cent., though only about half the patients were given not turn some quite intelligent people into mathematicians,. the injections. Since then the percentage in successive so all the practice in the world may never turn some quite years came down to 9, 6, 6, 5, 4, and for the past year it powerful and well-developed people into first-class athletes. stands at 2½ per cent. ; but as half the deaths resulted from Training and practice are essential, but they can only buildi on an aptitude already there. If a subject uses his muscles. an epidemic of typhoid, it may be said that the death-rate he will need an excessive supply of from normal causes was only 1 per cent. This is specially uneconomically remarkable when it is remembered that only cases far on in oxygen. Consequently he will be an ineffective athlete ... the disease have been admitted for several years. These he is uneconomical. Athletic prowess depends not only Dr. Wilson’s method of intramuscular upon a large oxygen supply, but upon a low oxygen results areoffrom whole chaulmoogra oil, camphorated. The requirement." injections new Dean treatment with ethyl esters of chaulmoogra oil Skill, power, and economy of muscular effort result, gives promise of still better results." In a short article Prof. Hill says, from the effectiveness of the " quick, silent, appended to the report Dr. E. Muir, leprosy research worker overmastering, and generally unconscious reactions, dictated the nervous system on the receipt of urgent messages in the School of Tropical Medicine, Calcutta, states that the most hopeful feature in connexion with leprosy in India is from tendons, joints, and muscles, or from the little senser the increasing interest being taken in the problem by the organs associated with the ear.... The instinctive skill,. medical profession and the public alike. The leper beggars quickness, and economy of the gymnast or climber, of the in the streets have, he remarks, generally reached a stage at mechanic, airman, tennis-player, or athlete, depend upon a which the lepra bacillus has died out of the system ; although vivid and readily reproducible picture in the brain or nervous, there is danger from this source, the chief danger is from system,’a picture,’ as Pear puts it,’of muscular exercise those who mix in various grades of society, from the highest in terms of the sensations which effective and successful downward, who are either unaware of, or are concealing, the movements produce.’" fact that they are disseminating the disease. Dr. Muir These considerations are very pertinent to the climbing has " come across cooks and house-servants, schoolboys course at Klosters, and a timely study of them by the would....

...

by

attending school, students attending college, teachers of both be climber might sexes instructing the young, confectioners serving over the counter, and

position

to

men

spread

and women in other walks of life, all in the disease to those around them."

a

save

him

disappointment.

THE DRIVING GRIP IN GOLF. To the Editor of THE LANCET.

SIR,-Professional golfers should be grateful to Dr. Wm. Cuthbert Morton for the scientific confirmation in your CONSIDERABLE study has been devoted since the war to issue of June 30th of the fact long appreciated by profesgas warfare in the United States, and the Bureau of Mines of sionals, but difficult to convey to pupils, that the golf club Pittsburg in Pennsylvania has in consequence developed a must be held with the wrist slightly extended, " especially " universal gas-mask,"1which, with its harness, weighs the left one," if full power is to be exerted in the grip. 8½ lb., and protects, though for a short time only, against Can you explain why this should be ? I find golf pupils small doses of most noxious gases. It produces no oxygen, are much more ready to obey instruction when a logical so cannot serve as a protection in atmospheres deprived of explanation of the reason for a position can be given. The oxygen, and no atmosphere which extinguishes a candle can slanting grip of the fingers with extended wrist seems be entered with reliance on this mask ; a self-contained unnatural and uncomfortable to most beginners. One further point which Dr. Morton does not elaborate oxygen-breathing apparatus must then be used. In this " universal gas-mask " the entering air first passes through is the general impression among professionals that the (a) an activated charcoal, to remove organic vapours, thengrip is principally maintained by the forefinger and thumb through (b) a filter of cotton-wool to remove smokes, dusts, of both hands. The real gripping power is, of course, in the and mists ; next comes (e) caustic soda, fused on pumice flexion of the middle, ring, and little fingers, whereas the stone, to remove acid gases. These are followed by strain felt between or with the first finger and thumb is (d) another cotton-wool filter ; (e) fused calcium chloride, todue to the sharp contraction of the first interosseous muscle extract water vapour which would inhibit the action of the which approximates finger and thumb to prevent the handle next absorbent; (f) " hopcalite," a mixture of oxides of of the club from dropping into the groove or web between I am, Sir, yours faithfully, manganese and copper, with sometimes silver and cobalt, them. to destroy carbon monoxide ; and finally (g) silica gel for DAVID ANDERSON.. absorbing ammonia. This mask is considered to be safe for York Gate, Regent’s Park, July 12th, 1923. six hours of use. It has been used for 14 hours, but not without great risk, for when carbonic oxide absorption is PROFESSIONAL CLASSES AID COUNCIL. completed and that gas is coming through no warning is How the wearer have been must after Professional Classes Aid Council, reconstituted in THE given. thirsty inspiring air all that time through fused calcium chloride, April, 1921, to carry on and extend the work arising out of and in the dry atmosphere of the United States, tooI Athe Professional Classes War Relief Council, has now comsmaller equipment for firemen weighs 5½ lb., and gives pleted its second year of work. The council exists to relieve, protection for four hours.or assist in relieving, distress among the professional and other highly educated classes and their dependents, and that work has been steadily consolidated during the past 12 THE TRAINED CLIMBER. months. As a general rule the council does not give financial MANY medical men know the value of Swiss mountain airassistance to persons suffering from misfortune which could A NEW GAS-MASK.

l been naturally foreseen and reasonably provided against,. holidays after heavy work ; some make a point of have spending a month every year there. For the strenuous although in such cases helpful advice can frequently be ( The aim in giving financial assistance is to enable mountain-climbing is an attraction, and it is of interestoffered. 1 to learn that for the timid amateur who dreads being a the recipient to become independent of further help. drag on other climbers a scientific course of instruction,Doctors, nurses, and medical students were among those theoretical and practical, in mountaineering will be given lhelped directly and indirectly during 1922, the council of the at the end of July in the beautiful village of Klosters, in theassociation being careful to avoid usurping the functions of£ Grisons district, at a fee of .666s., including board. Full existing benevolent funds. The direct relief given is at

for

‘

present severely limited by want of funds. -The hon. particulars may be had from Gustav Walty, Klosters. 1 of the association (of which Sir Clifford Allbutt is Of importance in this connexion is an article on Muscular treasurer Exercise by Prof. A. V. Hill, F.R.S., in Nature of July 14th,a patron and Dr. G. Newton Pitt, representing the Royal in which recent work on muscle contraction and recovery is Medical Benevolent Fund, a member of the council) is Mr. E. W. Monkhouse, and the offices are at 251, Brompton1 The Military Surgeon, May, vol. lii., p. 555. road, London, S.W. 3.