1349 autumn of 1927. Again, as in 1927, the cases occurring in the winter and spring and even up to early in July, 1928, were diagnosed as typhoid or paratyphoid fever. In retrospect they are seen to have been typical cases of dengue fever.. The epidemic reached its peak in the second half of August, and from then progressively diminished, but not before nearly every inhabitant of Athens and Piraeus had been stricken. The comparatively few who had been infected in the previous autumn escaped with few exceptions. From mid-August the infection was carried by incubating cases to the provinces outside Athens. It raged in the centre and south of Greece ; the north was less affected, and in the northern mountains the only cases were refugees from Athens. Altitude by itself, however, is of uncertain protection, for in Syria dengue has occurred at 5000 ft. above sea-level. Clinically the illness presented its typical features-sudden onset, slight rigor, headache, increasingly severe bone and muscle pains, and fever rising to 40° C. In most cases during the first two days there was an intense erythema of face and thorax, becoming scarlatiniform on third and fourth days. At this point the temperature fell, to rise again to a maximum on sixth and seventh, or rarely eighth day, and then dropping sharply with profuse sweatings. In some the exanthem was terminal. Gastro-intestinal disturbances were frequent. In not a few there was slight albuminuria and slight pulmonary congestion. During recovery there was bradycardia. At first the epidemic was benign in character ; later it became clinically severe, so that deaths occurred not only in the aged and previously diseased, but a few also in the young and previously healthy. Among these severe cases there occurred haemoptysis, hoematemesis, intestinal and uterine haemorrhages, severe albuminuria and haematuria, cerebral haemorrhage, convulsions, syncope, nervous and psychic troubles. The great majority of fatal cases, however, were among the aged. Relapse appeared only among those who left bed and returned too soon to everyday work, the relapse being in every feature more severe than the primary attack. Autopsies were few. They revealed no inflammatory lesions, but rather a cellular degeneration in liver, kidney, and heart. The stomach and intestines showed submucbus petechiae or larger haemorrhages. The suprarenals were apparently unaffected. There were certainly many more than 800,000 cases : 1240 deaths were recorded. Treatment was symptomatic. The blood of infected persons showed a leucopenia with relative lymphocytosis: no spirochaete was found. Investiga- tions undertaken by the Pasteur Institute in Athens confirmed the findings of Ashburn and Craig. Filtered and unfiltered blood conveyed the disease by direct transmission to healthy persons. The disease was also experimentally transmitted by Aedes egypti 12 days after their feed on infected persons, and the aedes remained infected during their life. Atmospheric temperature during the summer of 1928 in Athens and generally all over Greece was high. In 1927 and throughout the summer of 1928 an astound- ing increase in the numbers of Aëdes egypti was noted. The untidy sloppiness of most Greek houses and yards provided innumerable and ideal breeding places for aedes. It was noted at Salonika in September, 1928, I that aedes abounded in the small hutments where lived ’ " refugees "-dengue fever smote all these families- and was entirely absent from the households of better dwellings not far off where aedes was very scanty. Prevention obviously lies primarily in the destruction of aedes. The community that suffers from dengue fever has deserved the visitation. Annotations. " Ne quid nimis." BACILLUS ABORTUS IN MAN. THE diagnosis of new human diseases is always an interesting process. It needs a particular genius to recognise that things which were thought to be the same are really different, and men like Addison and Bright are few and far between. But ordinary curiosity will often find a thing if it is looking for it, and it seems likely that infection with the organism which causes contagious abortion in cattle may now be definitely added to the list of our endemic human diseases. The evidence is summarised in the papers by Dr. Theodore Thompson and by Dr. H. Harrison and Dr. G. S. Wilson, which will be found in our present issue. It is not finally complete and convincing, for the organism has not been actually isolated from any of the British cases which have been identified by agglutination reactions ; but it constitutes a strong case, and a wider ventilation of the possibility should soon lead to the discovery of more and conclusive examples. It is perhaps significant that the new evidence relates to the north-western counties ; the disease may be commoner in some parts than others. Clinically it belongs to the large class of disease known to the honest practitioner as G.O.K. The onset is gradual and the general illness often too slight to send the patient to bed, the main symptoms being lassitude, headache, and joint pains with a certain amount of fever, which may be irregular, continuous, or paroxysmal. This goes on for weeks or even months, and there is nothing obviously diagnostic. What is so much needed is that suspicious cases should be investigated in detail and the first thing to do is to test the serum against Bacillus (Brucella) abortus. If a positive result is obtained the cultivation of the organism from the blood and urine should be attempted. As Dr. R. A. Kern points outl in an admirable article on the clinical aspects, the more the disease has been looked for in the United States the more it has been found, and the same will probably prove true in this country. He also mentions, which we very much regret, that Dr. Alice Evans, to whom so much of our knowledge of the bacteriology is due, has herself caught the infection. We wish her a speedy recovery. THE HEALTH PROBLEMS OF A SCOTTISH BURGH. I’ THE translation of Dr. J. Parlane Kinloch in the coming year to the Scottish Board of Health adds a special significance to the report which he has issued as chief health officer of the royal burgh of Aberdeen. Dr. Kinloch tells us that in the course of the year 1927 the parish council and the town council unified the statutory hospital services of the city, and thus took the first step in a great project of hospital reform. The former poor-law hospital, reconditioned as a general hospital of modern type with 220 beds and an orthopaedic hospital of 160 beds, was formally opened as " Woodend Hospital " on Oct. 14th, 1927, by Sir John Gilmour, Secretary of State for Scotland. The hospital has been recognised as a complete training school for nurses. Under the new arrange- ment the town council have taken over all the poor- law medical buildings and have undertaken the treatment of all poor-law patients, thus anticipating the proposed poor-law reforms. An extension of the city fever hospital at a cost of 57,000 is in full progress. The new Royal Hospital for Sick Children is approaching completion, and the success of the Lord Provost’s appeal for 400,000 for the provision of a new Royal Infirmary and a new maternity hospital on the same site is assured. Every effort is being made by the town council to cooperate with 1 Amer. Jour. Med. Sci., 1928, clxxvi., 405.
Transcript
1349
autumn of 1927. Again, as in 1927, the cases
occurring in the winter and spring and even up toearly in July, 1928, were diagnosed as typhoid orparatyphoid fever. In retrospect they are seen tohave been typical cases of dengue fever..The epidemic reached its peak in the second half of
August, and from then progressively diminished, butnot before nearly every inhabitant of Athens andPiraeus had been stricken. The comparatively fewwho had been infected in the previous autumn
escaped with few exceptions. From mid-August theinfection was carried by incubating cases to the
provinces outside Athens. It raged in the centre andsouth of Greece ; the north was less affected, and inthe northern mountains the only cases were refugeesfrom Athens. Altitude by itself, however, is ofuncertain protection, for in Syria dengue has occurredat 5000 ft. above sea-level. Clinically the illness
presented its typical features-sudden onset, slightrigor, headache, increasingly severe bone and musclepains, and fever rising to 40° C. In most cases duringthe first two days there was an intense erythema offace and thorax, becoming scarlatiniform on thirdand fourth days. At this point the temperature fell,to rise again to a maximum on sixth and seventh, orrarely eighth day, and then dropping sharply withprofuse sweatings. In some the exanthem was
terminal. Gastro-intestinal disturbances were frequent.In not a few there was slight albuminuria and slightpulmonary congestion. During recovery there wasbradycardia. At first the epidemic was benign incharacter ; later it became clinically severe, so thatdeaths occurred not only in the aged and previouslydiseased, but a few also in the young and previouslyhealthy. Among these severe cases there occurred
haemoptysis, hoematemesis, intestinal and uterine
haemorrhages, severe albuminuria and haematuria,cerebral haemorrhage, convulsions, syncope, nervousand psychic troubles. The great majority of fatal
cases, however, were among the aged. Relapseappeared only among those who left bed and returnedtoo soon to everyday work, the relapse being in everyfeature more severe than the primary attack. Autopsieswere few. They revealed no inflammatory lesions, butrather a cellular degeneration in liver, kidney, andheart. The stomach and intestines showed submucbus
petechiae or larger haemorrhages. The suprarenalswere apparently unaffected. There were certainlymany more than 800,000 cases : 1240 deaths wererecorded. Treatment was symptomatic. The bloodof infected persons showed a leucopenia with relativelymphocytosis: no spirochaete was found. Investiga-tions undertaken by the Pasteur Institute in Athensconfirmed the findings of Ashburn and Craig. Filteredand unfiltered blood conveyed the disease by directtransmission to healthy persons. The disease was alsoexperimentally transmitted by Aedes egypti 12 daysafter their feed on infected persons, and the aedesremained infected during their life.Atmospheric temperature during the summer of 1928
in Athens and generally all over Greece was high. In1927 and throughout the summer of 1928 an astound-ing increase in the numbers of Aëdes egypti was noted.The untidy sloppiness of most Greek houses and yardsprovided innumerable and ideal breeding places foraedes. It was noted at Salonika in September, 1928, Ithat aedes abounded in the small hutments where lived ’"
refugees "-dengue fever smote all these families-and was entirely absent from the households of betterdwellings not far off where aedes was very scanty.Prevention obviously lies primarily in the destructionof aedes. The community that suffers from denguefever has deserved the visitation.
Annotations." Ne quid nimis."
BACILLUS ABORTUS IN MAN.
THE diagnosis of new human diseases is always aninteresting process. It needs a particular genius torecognise that things which were thought to be the sameare really different, and men like Addison and Brightare few and far between. But ordinary curiosity willoften find a thing if it is looking for it, and it seemslikely that infection with the organism which causescontagious abortion in cattle may now be definitelyadded to the list of our endemic human diseases.The evidence is summarised in the papers by Dr.Theodore Thompson and by Dr. H. Harrison andDr. G. S. Wilson, which will be found in our presentissue. It is not finally complete and convincing, forthe organism has not been actually isolated from anyof the British cases which have been identified byagglutination reactions ; but it constitutes a strongcase, and a wider ventilation of the possibility shouldsoon lead to the discovery of more and conclusiveexamples. It is perhaps significant that the newevidence relates to the north-western counties ; thedisease may be commoner in some parts than others.Clinically it belongs to the large class of disease knownto the honest practitioner as G.O.K. The onsetis gradual and the general illness often too slight tosend the patient to bed, the main symptoms beinglassitude, headache, and joint pains with a certainamount of fever, which may be irregular, continuous,or paroxysmal. This goes on for weeks or even
months, and there is nothing obviously diagnostic.What is so much needed is that suspicious cases shouldbe investigated in detail and the first thing to do isto test the serum against Bacillus (Brucella) abortus. Ifa positive result is obtained the cultivation of theorganism from the blood and urine should be attempted.As Dr. R. A. Kern points outl in an admirable articleon the clinical aspects, the more the disease has beenlooked for in the United States the more it has beenfound, and the same will probably prove true in thiscountry. He also mentions, which we very muchregret, that Dr. Alice Evans, to whom so much ofour knowledge of the bacteriology is due, has herselfcaught the infection. We wish her a speedy recovery.
THE HEALTH PROBLEMS OF A SCOTTISH
BURGH.
I’ THE translation of Dr. J. Parlane Kinloch in the
coming year to the Scottish Board of Health adds aspecial significance to the report which he has issuedas chief health officer of the royal burgh of Aberdeen.Dr. Kinloch tells us that in the course of the year 1927the parish council and the town council unified thestatutory hospital services of the city, and thus tookthe first step in a great project of hospital reform.The former poor-law hospital, reconditioned as a
general hospital of modern type with 220 beds andan orthopaedic hospital of 160 beds, was formallyopened as " Woodend Hospital " on Oct. 14th, 1927,by Sir John Gilmour, Secretary of State for Scotland.The hospital has been recognised as a completetraining school for nurses. Under the new arrange-ment the town council have taken over all the poor-law medical buildings and have undertaken thetreatment of all poor-law patients, thus anticipatingthe proposed poor-law reforms. An extension of thecity fever hospital at a cost of 57,000 is in fullprogress. The new Royal Hospital for Sick Childrenis approaching completion, and the success of theLord Provost’s appeal for 400,000 for the provisionof a new Royal Infirmary and a new maternityhospital on the same site is assured. Every effortis being made by the town council to cooperate with
1 Amer. Jour. Med. Sci., 1928, clxxvi., 405.
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the University Medical School and the voluntaryhospitals. It is intended that all the statutoryhospitals shall be used for teaching purposes, and itis hoped that the professors and heads of depart-ments of the medical school will become ex-officioconsultants to the municipal hospitals.The exact details of the working arrangements
between the town council and the medical schooland voluntary hospitals have yet to be settled. Thetown council have now to provide for the parishcouncil infants, and this has been done by the provi-sion of ten additional cots, free from the poor-houseenvironment, at Burnside Home for Mothers andChildren. This home now has accommodation for10 mothers and 42 children, and is mainly utilised forthe admission of married women after confinement,with the object of providing them with rest andinstruction in baby care. Unmarried mothers arealso admitted for their first pregnancy. Anotherhome with accommodation for 8 mothers and 10infants is mainly used for unmarried mothers bothbefore and after confinement. The marasmus wardin the city hospital provides 22 cots for infantssuffering chiefly from nutritional disorders. Asanother part of the hospital reorganisation schemearrangements have been made for the admission ofpost-encephalitics and epileptics as voluntary patientsto Kingseat Mental Hospital. In the new hospitalscheme the town council is working in full coöpera-tion with the county council and the authorities ofthe other North-Eastern counties. Dr. Kinlochvisualises ultimately a hospital organisation forScotland on a regional basis grouped mainly aroundthe four medical schools.The report contains a review of infant mortality,
undertaken by Dr. Hilda Menzies, who showsthat, whereas in 1856-60 the Aberdeen infantmortality was considerably lower than that ofEdinburgh, Dundee, or Glasgow, this superioritywas lost in 1886-95, and in 1921-25 the figureswere : Edinburgh 91, Glasgow 107, Dundee113, Aberdeen 115. From her investigation Dr.Menzies finds that the infant mortality from " develop-mental diseases " during these 70 years has increasedby 79 per cent. in Aberdeen, by 3 per cent. in Edin-burgh, and by 1 per cent. in Dundee, whilst in Glasgowit has decreased by 9 per cent. The increase appearsto be a real one in Aberdeen, and the reason whyAberdeen has lost its early advantage over the otherthree Scottish towns deserves the closest investiga-tion. It has been suggested by other observersthat the introduction of a foreign element hasadded to the vigour of the stock, and it is note-worthy that Glasgow, the town of the most hybridstock, has shown the steadiest rate of decrease ininfant mortality, whereas Aberdeen, the town of thepurest race, has come off worst for infant mortalityfrom " developmental diseases."
ANTERIOR POLIOMYELITIS.
Dr. W. M. Dickie gives many interesting details Iof the epidemic of anterior poliomyelitis in Californiain 1927, and of the measures taken against it. Theepidemic was at its height in July and August, andof 1270 cases reported, 237 proved fatal. Howinadequate is the old name of
" infantile paralysis "for the disease is shown. by the fact that out of 1385cases in which the age was recorded, 145 (or over10 per cent.) of the patients were aged 20 or over.In this epidemic the average age at onset was perhapsunusually high, for nearly 70 per cent. of thoseaffected were 4 years old or more, whilst nearly40 per cent. were over 9. During the acute illnessserum treatment was tried in a small proportion ofthe cases, but does not seem to have been veryuseful. A large number of deformities and disabilitiesinevitably remains in the track of the disease, and theorganisation which deals with them largely resemblesthose existing in many parts of this country. Thirty-
1 Jour. Amer. Med. Assoc., Nov. 10th, p. 1417.
one hospitals throughout the State are open to
orthopaedic cases on a charitable or partly charitablebasis, nine of them in San Francisco, five in LosAngeles. Ten of those in rural communities are wellequipped, but the remaining seven in rural com-munities are stated to be not adequately equippedfor treatment. There are orthopaedic clinics in 13 ofthe counties of the State. By a recent Act of thelegislative assembly of California, called the CrippledChildren’s Act, children up to the age of 18 yearsmay obtain materials or appliances necessary fortreatment at the public expense, but the machineryby which this help is to be obtained seems to berather too elaborate for efficiency and likely to wastetime. The State department concerned is alsoauthorised to receive and administer gifts for therelief of cripples and to arrange through local agenciesfor diagnostic clinics or conferences. Since thepassage of the Act 20 patients have been hospitalised,the average cost being 1000 dollars. High though thiscost may seem, it has been only kept down to thislevel by a special hospital rate of 4 dollars a day anda special operating fee charged to the department bythe surgeons concerned. Dr. Dickie thinks that theCrippled Children’s Act is not entirely satisfactory.He advocates a plan whereby the State shouldpay one-third of the cost of treatment, charitableagencies and friends the remainder. He realises, ashas been done here and elsewhere, that the long after-treatment of many of these cases cannot be carriedon in hospital wards owing to its expense, andis impracticable in most homes. He thereforeadvocates the provision of convalescent homes.
ACID URINARY DISINFECTANTS.
INFECTIONS of the urinary tract are often treatedby administering salts which alter the reaction ofthe urine and thus discourage bacterial growth. Inacid urine hexamethylenetetramine may be given incombination with these salts for the antiseptic effectof the formaldehyde which is liberated from it in anacid medium. The results thus obtained are difficultto assess owing to wide variation in the type ofcases treated and differences of dosage. K. Kelstedand E. Schiodt,l of Copenhagen, have attempted toplace this acidosis therapy on a more accurate basisby finding the difference in pH of urine before andafter treatment, and in their preliminary reviewquote the work of Rostoski who showed that theaddition of acid urine to broth cultures of colonbacilli and staphylococci had an inhibitory effect ongrowth, this effect being proportional to the acidity.They describe their results of treatment in 28 casesof chronic pyelitis and 42 of chronic cystitis, all ofwhich were thoroughly investigated clinically andbacteriologically, and if necessary by cystoscopy andureteral catheterisation. The hydrogen-ion con-
centration of the urine was measured at intervalsboth before and during treatment. To acidify theurine they gave calcium or ammonium chloride intablet form in doses of from 3 to 8 grammes daily, andin 14 cases of pyelitis and 16 of cystitis these wereused alone for periods of from 8 to 35 days. In onlyone of them, a B. coli pyelitis, did the urine becomesterile, and this was the one in which the aciditywas greatest, reaching pH 4-7. In the next test theacid treatment was given together with urinary dis-infectants ; the 70 cases were treated for periodsranging from 16 to 120 days, hexamine or salol beinggiven in 1 g. doses, or hexylresorcinol in 0-3 g. doses,three times a day. Acidity of the urine was producedin nearly all the patients, but only in seven was itsufficiently strong to give a prospect of much inhibi-tion of bacterial growth from acidity alone, thoughall the samples were acid enough for the formaldehydeto be bactericidal. Five out of 28 cases of pyelitis-which were mostly long-standing-recovered com-pletely, and the urine was proved to be sterile. Ofthe 42 cases of cystitis six developed sterile urine.
