1137 rather than patronise a low status and ineffective auxiliary whose training may have included almost no curative care. (A recent study in Northeast Thailand9 indicates that the widespread and uncontrolled sale of dangerous drugs there constitutes an important health
Points of View HOW BAREFOOT? NEXT STEPS FOR THE MEDICAL AUXILIARY E. MAURICE BACKETT
ROGER ENGLAND
University Department of Community Health, Nottingham NG7 2RD
The arguments for and against medical auxiliaries are over and interest must to shift now ways of maximising their effectiveness. An important issue is to what extent the findings of hightechnology medicine can be successfully combined with the barefoot concept of delivery. An important question for the future is to what extent they can be applied by the individual to himself.
Summary
of the medical auxiliary writings of the Director General ofW.H.O.,l Fendall,Morley,3 Taylor,4 King,’ Newell,and many others. The development of what amounts to a new discipline of health manpower planning has also helped’ to challenge "classical" assumptions about the doctor as the only health professional fit to deliver primary care. The reasons for the new preoccupation are obvious: first, few doubt that the world’s greatest contemporary health-care problem is how welltried and understood disease control measures (both curative and preventive) can be delivered to those who The be
can
increasing importance seen
from the
recent
need them. There is little
reason to
think of this
as ex-
clusively or even primarily a medical task. Next, the costeffectiveness of doctor-delivered care is low-especially in rural areas. It is expensive, episodic, and often too late. When to these reasons is added the sheer impossibility of training enough doctors and growing doubts about the relevance of much of this training anyway, the case for the medical auxiliary is overwhelming. Just as "intermediate technology" attempts to identify and utilise technological processes appropriate to available skills and resources,8 so in medical manpower the parallel is the medical auxiliary. The same notions of simplicity and economy are there and so is the rational objective of a high cost-effectiveness. But the same dangers are there also. Such an approach may slip into supporting simplicity or economy for its own sake regardless of its effects, or we may find ourselves in the abhorrent position of advocating low technology for them while we continue
to
pre-empt the
specialist manpower.
How Effective is Care by the Auxiliary? The low cost of auxiliary medical care can easily conceal what, from a medical point of view, is today an unacceptably small effect upon health. Thus the useless placebos and ineffective expectorants and balms in the medical assistant’s pack, though very cheap, are soon recognised for what they are. As a result, in the developing world patients will often struggle 30 or 40 miles to a health centre (where there is sometimes a doctor) or may turn to the commercial drug industry for a product at great expense and often at considerable danger,
risk.) There are other, related problems since, often, -the lack of training in curative care received by the auxiliary stems from doctor-imposed legal constraints upon his use of more active drugs. (Many of these constraints appear unnecessarily restrictive and are perhaps designed to ensure that real treatment remains the prerogative of the doctor.) Instead he is taught little but preventive and promotive work which he is unable to implement effectively because of his low credibility and standing-the result of his inability adequately to assist people in need of simple curative services. In short, our attachment to medical auxiliaries as an idea may lead us to an uncritical appraisal* of their actual effectiveness or to no appraisal at all. Whilst the need for new health manpower policies is obvious and great, the need for studies of the effectiveness of the initial stages of the referral chain where the medical auxiliary works may be even greater and is often overlooked. The Barefoot Idea The beginning of the referral chain has been transformed by the barefoot concept.’o-i3 Although it may be highly China-specific, parts of the idea (participation of the village, incorruptibility and pride, comprehensiveness of care, etc.) are found elsewhere and inform many of the experiments in progress.However, with one or two exceptions14 experiments so far have of necessity been aimed at the provision of a service more often than at its improvement. If the improvement of care is to be the next objective, then investigation and experiment are needed in two important areas: one concerns the ways in which individuals can be mobilised along barefoot lines; the other concerns the methods to be made available to the auxiliary. The first demands investigation into the more extensive use of existing status systems and the recruitment of, for example, monks and priests, schoolteachers, adolescent pupils, students, and the military as auxiliaries and the testing of their effectiveness against existing cadres. It will involve too, actionoriented studies of how existing social incentives operate so that efforts to improve health-care delivery work with, rather than against, these incentives (why should a traditional "doctor" refer a patient to the Government care system if all it means to him is a loss of income?). The second experiment is equally complicated and has as its objective the effective use of relatively high medical technology (or the ideas which support it) at village level-the production of simple scoring systems (e.g., for high risk), nomograms, clinical tests, and measuring apparatus (to decide what is "normal"). This "crossing of the technology bridge" or making advanced knowledge available for use in a simple way is demonstrably a very high priority for medical research and is quite different from the intermediate technology or "small is beautiful" approach.s An obvious medical challenge and field for experiment is reproductive performance, where the social costs of failure (or poor performance) are very high and much is known of the predictive value of events in the reproduc-
1138 tive cyclels-17 which could be utilised to prevent that failure. The problem, therefore, is to convert this knowledge into check-lists and score-sheets in which treatment and prevention are related to risk scores.18 A high-risk score-obtained for those with higher chances of future
abnormality-would initiate priority action. Scores would be related to simple strategies of packaged information and resources made available up to the level the village is able to afford. Risk scoring using the previous history alone seems reasonably accurate when carried out by almost untrained personnel,19 but if to the history is added the weighted scores resulting from a few simple measures based on local norms (2 or 3 point scales for blood-pressure, height and weight, dip-sticks for blood and urine where acceptable, &c.) some of the disasters of morbidity, and of course mortality, will be prevented. In general medical care the auxiliary can take short cuts to surprisingly accurate diagnosis and treatment using an algorithm type of scoring system.2O 21 With such a check-list he can arrive at the same diagnosis as a physician often enough to make correct treatment probable for a wide range of common conditions or, of course, identify those situations beyond his treatment abilities. Lessons for the Developed Countries Constraints upon the use of health manpower and doubts about the effectiveness of care are also found in industrialised countries and challenge current manpower policies and the relevance of medical education to contemporary need. In particular they suggest experiments with a new medical auxiliary for Western societies and with the ultimate extension of the barefoot idea-the improvement of self-care. The nurse practitioner.-As chronic disease increases its contribution to morbidity so the late and episodic care provided by the hospital, and the hospital-trained doctor, decreases in effectiveness. (Though it is logical and biologically probable, "earlier" does not necessarily mean "better" in the treatment of all chronic diseases.) Chronic disease suggests surveillance as part of care and thus a new role for someone earlier and with more continuity than the doctor in the professional referral chain. A nurse practitioner could meet this need ’21-25 and some operational experiments (particularly within the British National Health Service) are overdue. The nurse practitioner has some special advantages other medical auxiliaries who often consider themselves "half doctors" and struggle to attain the extra qualification and status. The relationship between nurse and doctor is not subject to this strain, and traditional work relationships are complementary. Meanwhile the nurse’s training may be changing more rapidly than is that of the doctor, and the multi-role nurse, with considerable responsibility, is already well accepted in primary care. There is therefore some support for the fact that changing need in the developed countries will make the nurse as successful a first contact in, for example, the Midlands of England as they have been (for quite different reasons) in the turbulent South Bronx of New York City or as they will be in Thailand, where a new training scheme for nurse practitioners is under way at the School of Public Health, Mahidol University, Bangkok, and, though they are not yet called nurse practitioners, at Khon Kaen University Faculty of Nursing. over
Self-care.-A further logical extrapolation from our thinking about the medical auxiliary concerns the effectiveness of the lay referral system and particularly of the self care of the individual. It may be assumed that the consumption of medical care by doctors more closely matches their "needs" for it than is the case with those whose understanding of health matters is less. Inasmuch as it is true, therefore, that doctors consume less medical care than comparable groups and for preventable conditions have long been recognised as healthier,26 then it may be inferred that
current
the most effective front-line care comes from the well-informed individual himself. (The question of the consumption of services by doctors is not as well studied as it might usefully be and our assumption here is by no means established. Certainly their mortality from some diseases is excessive.27) Informed self-care might also go some way to solving the dilemma raised by Illich,28 though true iatrogenic damage must be greater where powerful drugs are sold for self-care without sufficient understanding of their dangers. A systematic attempt to improve the quality of the patients’ own decision-making in health matters presents formidable research, ethical, and of course iatrogenic problems, yet the tenuous analogy with the work of the rural medical aide in the Third World is real. At best the aide makes a simple series of decisions,
gives elementary advice and usually How many of these decisions
some
simple treat-
be made by an informed and educated patient himself has yet to be demonstrated. There is at least the chance that in the industrially advanced world investment in self-care might, over the years, make a dramatic difference to our medical manpower and other resource needs and perhaps to our health. ment.
can
REFERENCES
Mahler, H., in The Medical Assistant: An Intermediate Level of Health Care Personnel (edited by D. M. Pitcairn and D. Flahault), Publ. Hlth. Pap. W.H.O. no. 60, 1974. 2. Fendall, N. R. E. Auxiliaries in Health Care: Programs in Developing Countries. Baltimore, 1972. 3. Morley, D. Pædiatric Priorities in the Developing World. London, 1973. 4. Taylor, C. E. New Engl.J Med. 1974, 290, 1376. 1.
M. (editor) A Primer on the Medicine of Poverty: A Symposium from Makerere. London, 1966. 6. Newell, K. W. in Health by the People (edited by K. W. Newell) Geneva, 1975. 7. The Development of Studies in Health Manpower. Tech. Rep Ser. Wld. Hlth. Org. no. 481, 1971. 8. Schumacher, E. F. Small is Beautiful. London, 1973. 9. England, R., Backett, E. M., Darke, L. University of Khon Kaen Health Sciences Centre Context Study. London, 1975. 10. Sidel, V. W., Sidel, R., Serve the People: Observations on Medicine in the People’s Republic of China. Boston, Mass., 1974. 11. Quinn, J. R. (editor) Medicine and Public Health in the People’s Republic of China. Washington D.C., 1973. 12. Cheng, Chu-Yuan in Public Health in the Peoples Republic of China (edited by M. E. Wegman, T. Lin, and E. F. Purcell). New York, 1973. 13. New P. K., New, M. L. Dartmouth Alumni Magazines, 1974, 66, 22 14. Silver, H. K. in The Medical Assistant: An Intermediate Level of Health Care Personnel (edited by D. M. Pitcairn and D. Flahault). Publ Hlth 5.
King,
Pap. W.H.O., no. 60, 1974. 15. Siegel, E., Morris, N. M. Am.J. Obstet. Gynec. 1974, 118, 995. 16. Fedrick, J., Butler, N. R. JBiol. Neonate, 1970, 15, 229; 1970,
1971, 17, 458; 1971, 18, 243; 1971, 18, 321. 17. Holley, W. L., Rosenbaum, A. L., Churchill, J. A
15, 258;
in Perinatal Factors Human Development. Pan American Health Organization, Scientific Publication no. 185, Washington D.C., 1969. 18. World Health Organisation, High Risk and Resource Allocation in Mother and Child Health Services. Unpublished Report of a Consultation on Identification and Assessment of High Risk for Development of Intervention Strategies in Maternal and Child Care, including Family Planning. Geneva, 1974. 19. Essex, B. J. Personal communication. 20 Essex, B. J. Br. med.J. 1975, iii, 34. 21. Sox, H. C., Sox, C. A., Tompkins, R. K. New Engl.J. Med 1973, 288, 818
Affecting
1139 DIFFERENTIAI DIAGNOSIS OF RABIES AND RABIES HYSTERIA
Public Health
I
I
PRESENTING FEATURES AND DIAGNOSIS OF RABIES
J. M. WILSON St Mary’s Hospital Medical School, London
W2
J. HETTIARACHCHI University Department of Medicine, Western Infirmary, Glasgow G11 6NT L. M.
WIJESURIYA
General Hospital, Colombo, Sri Lanka The early clinical features important in the establishment of a diagnosis of rabies are described from experience of 23 fatal cases in Sri Lanka. The importance of the "fan test" as a diagnostic sign is stressed. The earliest features of the disease may
Summary
suggest hysteria if a history of a bite from a rabid animal is not obtained. In a district in which there is an outbreak of rabies cases of rabies hysteria may also develop. seen by doctors working in the United The eight fatal cases reported between Kingdom. 1946 and 1969 were in immigrants who acquired the disease abroad,’ and earlier this year two patients who were infected and diagnosed overseas were brought to Britain for treatment. No-one has contracted rabies in Britain since 1921 but animal rabies, found mainly in the fox, is spreading across France at a rate of 30 miles (48km) a year.3-5 To support enzootic rabies, the density of the fox population must be at least 1/km2; in Southern England a recent estimate6 put it as high as 4/km2, and foxes are now often seen in towns. Although there are strict quarantine regulations these are sometimes evaded, and there is a real danger that both foxes and dogs may become infected. Since rabies may be encountered more frequently in Britain, doctors should be familiar with the main presenting features. During the life of the patient the diagnosis can generally only be made on clinical grounds; confirmation may sometimes be possible by brain biopsy, and viral and antibody tests." We review here the presenting features in a series of 23 fatal cases seen in Sri Lanka where the disease is endemic, the main reservoir of infection being the dog. There were 16 men and 7 women in the series and the age ranged from 5 to 71 years. There was a history of a bite in 21, in 1 case from a monkey and in 20 from domestic dogs. In the 2 not bitten there was definite exposure; 1 patient worked in a dog pound and the other
RABIES is rarely
22
Spitzer, W. O., Sackett, D. L., Sibley, J. C., Roberts, R. S., Gent, M., Kergin, D. J., Hackett, B. C., Olynich, C. A. ibid. 1974, 290, 251. 23. Sackett, D. L., Spitzer, W. O., Gent, M., Roberts, R. S., Ann. intern. Med. 1974, 80, 137. 24 Merenstein, J. H., Wolfe, H., Barker, K. M. Med. Care, 1974, 12, 445. 25 Skroran, C., Anderson, E. T., Gottschalk, J. Am. J. publ. Hlth. 1974, 64, 847.
26 27 28
Dublin, L. I., Spiegelman, M. Am. med. Ass. 1947, 134, 1211.
King, H.J. chron. Dis. 1970, 23, 257. Illich, I. Medical Nemesis: the Expropriation of Health. London, 1975 PROF BACKETT, MR ENGLAND REFERENCES continued
had kept a dog which had died from a disease thought to have been rabies. Of the dogs, five were killed immediately, six died within 10 days, and in eight the outcome was unknown. One dog was still alive at the time of admission of the patient 3 months after the bite. The mean incubation period was 25 weeks with a range of 2-150 weeks, the longest being associated with the monkey bite. The patients commonly arrived in a hyperexcitable state with overbreathing and pain and tightness in the chest (52% of cases). Fever was present in a third and dysphagia in a fifth. Hydrophobia was less commonly an initial feature (17%). Pain at the site of the bite, often described as an early symptom was noted in only 16%. Aerophobia, as demonstrated by a positive "fan test", was present in all cases. This was elicited by fanning a current of air across the face which causes violent spasms of the pharyngeal and neck muscles. The illness lasted from 2 to 9 days. The male preponderance seen in our study is probably due to more men being exposed to the bite of stray dogs than women who in most Asiatic countries lead a comparatively sheltered life in the home. The incubation period varies greatly, and not enough information is available to correlate it with the site and severity of the bite. The longest was seen with the monkey bite and confirms the previous observation that disease acquired from wild animals has a lengthy incubation period.9 However, in the case of unusual incubation periods minor bites or other exposure to infection may have been overlooked. The virus may enter through a skin abrasion. Although the majority of dogs were dead within 10 days, an animal living longer than this does not exclude the diagnosis, as shown in one of our patients where the dog was alive at the time of its victim’s death. Rabies virus has been demonstrated in the saliva of symptomless animals, including dogs and bats,’° and the possibility of a carrier state should be taken into account in making a clinical diagnosis. The British physician who may unexpectedly encounter rabies might easily regard the presenting features of hyperventilation and hyperexcitability as hysterical if the history of a bite from a rabid animal was not forthcoming. The most difficult differential diagnosis in a country where the disease is endemic may be rabies hysteria. In a district where there has been an outbreak of rabies, hysterical features may develop following any animal bite through fear of the disease. The distinction between this and the true condition is outlined in the table. The extent to which the hysterical
Points of View HOW BAREFOOT? NEXT STEPS FOR THE MEDICAL AUXILIARY E. MAURICE BACKETT
ROGER ENGLAND
University Department of Community Health, Nottingham NG7 2RD
The arguments for and against medical auxiliaries are over and interest must to shift now ways of maximising their effectiveness. An important issue is to what extent the findings of hightechnology medicine can be successfully combined with the barefoot concept of delivery. An important question for the future is to what extent they can be applied by the individual to himself.
Summary
of the medical auxiliary writings of the Director General ofW.H.O.,l Fendall,Morley,3 Taylor,4 King,’ Newell,and many others. The development of what amounts to a new discipline of health manpower planning has also helped’ to challenge "classical" assumptions about the doctor as the only health professional fit to deliver primary care. The reasons for the new preoccupation are obvious: first, few doubt that the world’s greatest contemporary health-care problem is how welltried and understood disease control measures (both curative and preventive) can be delivered to those who The be
can
increasing importance seen
from the
recent
need them. There is little
reason to
think of this
as ex-
clusively or even primarily a medical task. Next, the costeffectiveness of doctor-delivered care is low-especially in rural areas. It is expensive, episodic, and often too late. When to these reasons is added the sheer impossibility of training enough doctors and growing doubts about the relevance of much of this training anyway, the case for the medical auxiliary is overwhelming. Just as "intermediate technology" attempts to identify and utilise technological processes appropriate to available skills and resources,8 so in medical manpower the parallel is the medical auxiliary. The same notions of simplicity and economy are there and so is the rational objective of a high cost-effectiveness. But the same dangers are there also. Such an approach may slip into supporting simplicity or economy for its own sake regardless of its effects, or we may find ourselves in the abhorrent position of advocating low technology for them while we continue
to
pre-empt the
specialist manpower.
How Effective is Care by the Auxiliary? The low cost of auxiliary medical care can easily conceal what, from a medical point of view, is today an unacceptably small effect upon health. Thus the useless placebos and ineffective expectorants and balms in the medical assistant’s pack, though very cheap, are soon recognised for what they are. As a result, in the developing world patients will often struggle 30 or 40 miles to a health centre (where there is sometimes a doctor) or may turn to the commercial drug industry for a product at great expense and often at considerable danger,
risk.) There are other, related problems since, often, -the lack of training in curative care received by the auxiliary stems from doctor-imposed legal constraints upon his use of more active drugs. (Many of these constraints appear unnecessarily restrictive and are perhaps designed to ensure that real treatment remains the prerogative of the doctor.) Instead he is taught little but preventive and promotive work which he is unable to implement effectively because of his low credibility and standing-the result of his inability adequately to assist people in need of simple curative services. In short, our attachment to medical auxiliaries as an idea may lead us to an uncritical appraisal* of their actual effectiveness or to no appraisal at all. Whilst the need for new health manpower policies is obvious and great, the need for studies of the effectiveness of the initial stages of the referral chain where the medical auxiliary works may be even greater and is often overlooked. The Barefoot Idea The beginning of the referral chain has been transformed by the barefoot concept.’o-i3 Although it may be highly China-specific, parts of the idea (participation of the village, incorruptibility and pride, comprehensiveness of care, etc.) are found elsewhere and inform many of the experiments in progress.However, with one or two exceptions14 experiments so far have of necessity been aimed at the provision of a service more often than at its improvement. If the improvement of care is to be the next objective, then investigation and experiment are needed in two important areas: one concerns the ways in which individuals can be mobilised along barefoot lines; the other concerns the methods to be made available to the auxiliary. The first demands investigation into the more extensive use of existing status systems and the recruitment of, for example, monks and priests, schoolteachers, adolescent pupils, students, and the military as auxiliaries and the testing of their effectiveness against existing cadres. It will involve too, actionoriented studies of how existing social incentives operate so that efforts to improve health-care delivery work with, rather than against, these incentives (why should a traditional "doctor" refer a patient to the Government care system if all it means to him is a loss of income?). The second experiment is equally complicated and has as its objective the effective use of relatively high medical technology (or the ideas which support it) at village level-the production of simple scoring systems (e.g., for high risk), nomograms, clinical tests, and measuring apparatus (to decide what is "normal"). This "crossing of the technology bridge" or making advanced knowledge available for use in a simple way is demonstrably a very high priority for medical research and is quite different from the intermediate technology or "small is beautiful" approach.s An obvious medical challenge and field for experiment is reproductive performance, where the social costs of failure (or poor performance) are very high and much is known of the predictive value of events in the reproduc-
1138 tive cyclels-17 which could be utilised to prevent that failure. The problem, therefore, is to convert this knowledge into check-lists and score-sheets in which treatment and prevention are related to risk scores.18 A high-risk score-obtained for those with higher chances of future
abnormality-would initiate priority action. Scores would be related to simple strategies of packaged information and resources made available up to the level the village is able to afford. Risk scoring using the previous history alone seems reasonably accurate when carried out by almost untrained personnel,19 but if to the history is added the weighted scores resulting from a few simple measures based on local norms (2 or 3 point scales for blood-pressure, height and weight, dip-sticks for blood and urine where acceptable, &c.) some of the disasters of morbidity, and of course mortality, will be prevented. In general medical care the auxiliary can take short cuts to surprisingly accurate diagnosis and treatment using an algorithm type of scoring system.2O 21 With such a check-list he can arrive at the same diagnosis as a physician often enough to make correct treatment probable for a wide range of common conditions or, of course, identify those situations beyond his treatment abilities. Lessons for the Developed Countries Constraints upon the use of health manpower and doubts about the effectiveness of care are also found in industrialised countries and challenge current manpower policies and the relevance of medical education to contemporary need. In particular they suggest experiments with a new medical auxiliary for Western societies and with the ultimate extension of the barefoot idea-the improvement of self-care. The nurse practitioner.-As chronic disease increases its contribution to morbidity so the late and episodic care provided by the hospital, and the hospital-trained doctor, decreases in effectiveness. (Though it is logical and biologically probable, "earlier" does not necessarily mean "better" in the treatment of all chronic diseases.) Chronic disease suggests surveillance as part of care and thus a new role for someone earlier and with more continuity than the doctor in the professional referral chain. A nurse practitioner could meet this need ’21-25 and some operational experiments (particularly within the British National Health Service) are overdue. The nurse practitioner has some special advantages other medical auxiliaries who often consider themselves "half doctors" and struggle to attain the extra qualification and status. The relationship between nurse and doctor is not subject to this strain, and traditional work relationships are complementary. Meanwhile the nurse’s training may be changing more rapidly than is that of the doctor, and the multi-role nurse, with considerable responsibility, is already well accepted in primary care. There is therefore some support for the fact that changing need in the developed countries will make the nurse as successful a first contact in, for example, the Midlands of England as they have been (for quite different reasons) in the turbulent South Bronx of New York City or as they will be in Thailand, where a new training scheme for nurse practitioners is under way at the School of Public Health, Mahidol University, Bangkok, and, though they are not yet called nurse practitioners, at Khon Kaen University Faculty of Nursing. over
Self-care.-A further logical extrapolation from our thinking about the medical auxiliary concerns the effectiveness of the lay referral system and particularly of the self care of the individual. It may be assumed that the consumption of medical care by doctors more closely matches their "needs" for it than is the case with those whose understanding of health matters is less. Inasmuch as it is true, therefore, that doctors consume less medical care than comparable groups and for preventable conditions have long been recognised as healthier,26 then it may be inferred that
current
the most effective front-line care comes from the well-informed individual himself. (The question of the consumption of services by doctors is not as well studied as it might usefully be and our assumption here is by no means established. Certainly their mortality from some diseases is excessive.27) Informed self-care might also go some way to solving the dilemma raised by Illich,28 though true iatrogenic damage must be greater where powerful drugs are sold for self-care without sufficient understanding of their dangers. A systematic attempt to improve the quality of the patients’ own decision-making in health matters presents formidable research, ethical, and of course iatrogenic problems, yet the tenuous analogy with the work of the rural medical aide in the Third World is real. At best the aide makes a simple series of decisions,
gives elementary advice and usually How many of these decisions
some
simple treat-
be made by an informed and educated patient himself has yet to be demonstrated. There is at least the chance that in the industrially advanced world investment in self-care might, over the years, make a dramatic difference to our medical manpower and other resource needs and perhaps to our health. ment.
can
REFERENCES
Mahler, H., in The Medical Assistant: An Intermediate Level of Health Care Personnel (edited by D. M. Pitcairn and D. Flahault), Publ. Hlth. Pap. W.H.O. no. 60, 1974. 2. Fendall, N. R. E. Auxiliaries in Health Care: Programs in Developing Countries. Baltimore, 1972. 3. Morley, D. Pædiatric Priorities in the Developing World. London, 1973. 4. Taylor, C. E. New Engl.J Med. 1974, 290, 1376. 1.
M. (editor) A Primer on the Medicine of Poverty: A Symposium from Makerere. London, 1966. 6. Newell, K. W. in Health by the People (edited by K. W. Newell) Geneva, 1975. 7. The Development of Studies in Health Manpower. Tech. Rep Ser. Wld. Hlth. Org. no. 481, 1971. 8. Schumacher, E. F. Small is Beautiful. London, 1973. 9. England, R., Backett, E. M., Darke, L. University of Khon Kaen Health Sciences Centre Context Study. London, 1975. 10. Sidel, V. W., Sidel, R., Serve the People: Observations on Medicine in the People’s Republic of China. Boston, Mass., 1974. 11. Quinn, J. R. (editor) Medicine and Public Health in the People’s Republic of China. Washington D.C., 1973. 12. Cheng, Chu-Yuan in Public Health in the Peoples Republic of China (edited by M. E. Wegman, T. Lin, and E. F. Purcell). New York, 1973. 13. New P. K., New, M. L. Dartmouth Alumni Magazines, 1974, 66, 22 14. Silver, H. K. in The Medical Assistant: An Intermediate Level of Health Care Personnel (edited by D. M. Pitcairn and D. Flahault). Publ Hlth 5.
King,
Pap. W.H.O., no. 60, 1974. 15. Siegel, E., Morris, N. M. Am.J. Obstet. Gynec. 1974, 118, 995. 16. Fedrick, J., Butler, N. R. JBiol. Neonate, 1970, 15, 229; 1970,
1971, 17, 458; 1971, 18, 243; 1971, 18, 321. 17. Holley, W. L., Rosenbaum, A. L., Churchill, J. A
15, 258;
in Perinatal Factors Human Development. Pan American Health Organization, Scientific Publication no. 185, Washington D.C., 1969. 18. World Health Organisation, High Risk and Resource Allocation in Mother and Child Health Services. Unpublished Report of a Consultation on Identification and Assessment of High Risk for Development of Intervention Strategies in Maternal and Child Care, including Family Planning. Geneva, 1974. 19. Essex, B. J. Personal communication. 20 Essex, B. J. Br. med.J. 1975, iii, 34. 21. Sox, H. C., Sox, C. A., Tompkins, R. K. New Engl.J. Med 1973, 288, 818
Affecting
1139 DIFFERENTIAI DIAGNOSIS OF RABIES AND RABIES HYSTERIA
Public Health
I
I
PRESENTING FEATURES AND DIAGNOSIS OF RABIES
J. M. WILSON St Mary’s Hospital Medical School, London
W2
J. HETTIARACHCHI University Department of Medicine, Western Infirmary, Glasgow G11 6NT L. M.
WIJESURIYA
General Hospital, Colombo, Sri Lanka The early clinical features important in the establishment of a diagnosis of rabies are described from experience of 23 fatal cases in Sri Lanka. The importance of the "fan test" as a diagnostic sign is stressed. The earliest features of the disease may
Summary
suggest hysteria if a history of a bite from a rabid animal is not obtained. In a district in which there is an outbreak of rabies cases of rabies hysteria may also develop. seen by doctors working in the United The eight fatal cases reported between Kingdom. 1946 and 1969 were in immigrants who acquired the disease abroad,’ and earlier this year two patients who were infected and diagnosed overseas were brought to Britain for treatment. No-one has contracted rabies in Britain since 1921 but animal rabies, found mainly in the fox, is spreading across France at a rate of 30 miles (48km) a year.3-5 To support enzootic rabies, the density of the fox population must be at least 1/km2; in Southern England a recent estimate6 put it as high as 4/km2, and foxes are now often seen in towns. Although there are strict quarantine regulations these are sometimes evaded, and there is a real danger that both foxes and dogs may become infected. Since rabies may be encountered more frequently in Britain, doctors should be familiar with the main presenting features. During the life of the patient the diagnosis can generally only be made on clinical grounds; confirmation may sometimes be possible by brain biopsy, and viral and antibody tests." We review here the presenting features in a series of 23 fatal cases seen in Sri Lanka where the disease is endemic, the main reservoir of infection being the dog. There were 16 men and 7 women in the series and the age ranged from 5 to 71 years. There was a history of a bite in 21, in 1 case from a monkey and in 20 from domestic dogs. In the 2 not bitten there was definite exposure; 1 patient worked in a dog pound and the other
RABIES is rarely
22
Spitzer, W. O., Sackett, D. L., Sibley, J. C., Roberts, R. S., Gent, M., Kergin, D. J., Hackett, B. C., Olynich, C. A. ibid. 1974, 290, 251. 23. Sackett, D. L., Spitzer, W. O., Gent, M., Roberts, R. S., Ann. intern. Med. 1974, 80, 137. 24 Merenstein, J. H., Wolfe, H., Barker, K. M. Med. Care, 1974, 12, 445. 25 Skroran, C., Anderson, E. T., Gottschalk, J. Am. J. publ. Hlth. 1974, 64, 847.
26 27 28
Dublin, L. I., Spiegelman, M. Am. med. Ass. 1947, 134, 1211.
King, H.J. chron. Dis. 1970, 23, 257. Illich, I. Medical Nemesis: the Expropriation of Health. London, 1975 PROF BACKETT, MR ENGLAND REFERENCES continued
had kept a dog which had died from a disease thought to have been rabies. Of the dogs, five were killed immediately, six died within 10 days, and in eight the outcome was unknown. One dog was still alive at the time of admission of the patient 3 months after the bite. The mean incubation period was 25 weeks with a range of 2-150 weeks, the longest being associated with the monkey bite. The patients commonly arrived in a hyperexcitable state with overbreathing and pain and tightness in the chest (52% of cases). Fever was present in a third and dysphagia in a fifth. Hydrophobia was less commonly an initial feature (17%). Pain at the site of the bite, often described as an early symptom was noted in only 16%. Aerophobia, as demonstrated by a positive "fan test", was present in all cases. This was elicited by fanning a current of air across the face which causes violent spasms of the pharyngeal and neck muscles. The illness lasted from 2 to 9 days. The male preponderance seen in our study is probably due to more men being exposed to the bite of stray dogs than women who in most Asiatic countries lead a comparatively sheltered life in the home. The incubation period varies greatly, and not enough information is available to correlate it with the site and severity of the bite. The longest was seen with the monkey bite and confirms the previous observation that disease acquired from wild animals has a lengthy incubation period.9 However, in the case of unusual incubation periods minor bites or other exposure to infection may have been overlooked. The virus may enter through a skin abrasion. Although the majority of dogs were dead within 10 days, an animal living longer than this does not exclude the diagnosis, as shown in one of our patients where the dog was alive at the time of its victim’s death. Rabies virus has been demonstrated in the saliva of symptomless animals, including dogs and bats,’° and the possibility of a carrier state should be taken into account in making a clinical diagnosis. The British physician who may unexpectedly encounter rabies might easily regard the presenting features of hyperventilation and hyperexcitability as hysterical if the history of a bite from a rabid animal was not forthcoming. The most difficult differential diagnosis in a country where the disease is endemic may be rabies hysteria. In a district where there has been an outbreak of rabies, hysterical features may develop following any animal bite through fear of the disease. The distinction between this and the true condition is outlined in the table. The extent to which the hysterical
