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A RURAL OUTBREAK OF SCARLET FEVER DUE TO A NON-NOTIFIABLE CARRIER
mitted no 6ffen,.-,e,;: he was merely describing himself as what he was. (The facts indeed, if one may interject the comment, were not unlike those in Ellis v. Kelly where Baron -Wilde remarked : " The defendant had a German diploma which he might reasonably believe entitled him to describe himself as he did." Mr. Justice Humphreys, during the hearing of- Jutson v. Barrow in 1936, commented that it was hard to understand why Mr. (or Dr.) Kelly was ever prosecuted.) To return, however, to Dr. Luftig’s case, the real difficulty was his " use of the abbreviation BLN." But, said Lord Goddard, it was for the Brighton justices to decide whether he was " wilfully and falsely " pretending to take or use the name or title of a doctor of medicine ; their decision was that he did not do so. Then came the further point-had Dr. Luftig used a description " implying that he was registered " ? Counsel argued against him that the title of " doctor of medicine " could only be used by a person who was
931 In the Luftig case Lord Goddard emphasises the significance of "wilfully and falsely" in section 40. Mens rea, the guilty mind, is-an element in the offence, and the presence or absence of that state of mind must be tested on ordinary principles and in the light of "
sense." ’Lord Goddard rejected counsel’s contention that " doctor of medicine "could be used only by a person who was registered. He also rejected an alternative contention that the Medical Act at least prevented a man from using the- title unless he was qualified to be registered ; the court could find no basis for this argument in the statute. The cardinal fact was that the justices had found that the description " M.D. BLN" did not imply that Dr. Luftig was registered. They could, said Lord Goddard, have decided the other way. They had found that Dr. Luftig had not acted wilfully and falsely ; it could not be said that there was no evidence to support this finding ; the appeal against their finding must therefore be dismissed. :’ In the " complete fog " of cases under section 40 one registered. In Jutson v. Barrow, where Captain Horace Barrow,.having point seems clear. - If an unregistered practitioner really wishes to avoid confusion with registered practitioners, had no professional training, displayed the description " " manipulative surgeon " and seemed to assert that the ’word he can find means of doing so. BLN is not a familiar him was chosen order to abbreviation of Berlin ; to avoid the threatening letters " manipulative " distinguish in from duly qualified surgeons whose names were on the and the swastikas some hieroglyphic was presumably Register, Lord Hewart said that the words " implying that sought which would not- suggest Berlin very readily. he is registered " were not words describing the individual’s Whatever " BLN " may convey to the uninitiated, the intent but describing the effect. " The section is to protect Lord Chief Justice remarked that "it was to be the public, and what is regarded is not the mind of the individual but the meaning likely to be conveyed by the hoped that Dr. Luftig would not in future use"that abbreviation." words that are used." common
"
’,,’
’
,
the milk, and the
Public Health A RURAL OUTBREAK DUE TO
OF
SCARLET FEVER
A NON-NOTIFIABLE CARRIER
FRANK T. MADGE M.D. MEDICAL
OFFICER
OF
Lpool,
HEALTH
DISTRICTS
D.P.H. TO
THE
COMBINED
set for
the, advent
of
’ , ,
,
infected one,
COUNTY THE
MILKER
,
1. The initial illness of the milker in January, 1948, and other reputed cases of tonsillitis in the village. 2. A probably milk-borne spread in early April, with7 cases of clinical scarlet fever and 4 cases- of other suspicious
infections. 3. The third
was
The milker was a member of the family living in the farmstead and certainly intermittently if not all, of the other occupants, who were apparently non-susceptible. The family also let a portion of the farmhouse for board-residence to holiday visitors, several of whom were infected.
OF WESTMORLAND
and roundsman with chronic subacute rheumatic fever was responsible for an epidemic of hæmolytic streptococcal infections during the spring and summer of 1948 in a small remote village of the English There were 13 clinical cases of scarlet Lake District. fever and 12 reported cases of other streptococcal illnesses. The epidemic was interesting for two reasons : first, limitation of the infection to this village and its visitors ; and secondly, the difficulty of controlling a non-notifiable carrier of a notifiable disease. The outbreak occurred in four separate phases : A
stage
trouble.
phase, which occurred in May, was also probably milk-borne, comprised 4 cases of notified scarlet fever and 4 cases of suspicious infections, and was limited to persons who did not adopt the precautions advised. 4. The fourth phase was in July, consisting of 3 cases of notified scarlet fever and 1 case of tonsillitis, possibly milkborne or possibly by direct contact.
FIRST
PHASE
The milker and roundsman, aged about 23, developed a severe sore throat in January, 1948, but there was no rash. He’made rather a slow recovery from this illness, and his convalescence was complicated by polyarticular synovitis and muscular pains: He- resumed work on the farm but could walk only with difficulty and -was ’obviously suffering considerable discomfort. He continued in this state of malaise for about three months and did not obtain real relief until the warmer weather airived about midsummer. There had been many sore throats in the village since Christmas, but no serious case was traced, and there had been no notification of scarlet fever for many
months.
’
THE .SECOND PHASE
’
’,’, ’ ’
,
,
CASE 1.—A man, one of a party of five adults and five children who had arrived in the village on March 25 and taken a furnished house next to the farm, fell ill on March 29 and went next day to Batley, where he was found "to have scarlet fever. CASE 2.—-A- girl, aged 6 years, daughter of case 1, developed scarlet fever on April 4, whereupon the rest of the, party left the district next day. ’
,
The farm was a small one, about half a mile above the As no other cases of scarlet fever had been iiotifi46d in village, and the dairy herd was limited to five cows in the district, it was felt that the father had probably milk. The shippon was dark, low, and old-fashioned, brought the infection with him, and that the daughter, with cobbled floors, and a barn overhead. A portion of being a close contact, -had been infected by him. the farmhouse was used as a dairy and technique was CASE 3.-In the village a girl, aged 4 years, developed a primitive. The water-supply was surface drainage. The temperature on April 8 anda scarlatinal rash on April 9. high to the and -the was confined local, village, Since -a maid from the furnished house -where leases 1 The - adverseeffect of-these milk was retailed conditions was reflected in the bacterialcontent, of and 2 had occurred had visited ’13his ’ patient’shome, on
milk-supply
loose.
1
932
March 31, it seems possible that this child had become infected from the holiday party ; but eight days from
contact to
onset
appeared rather long.
’
CASES 4 and 5.—On April 14 a letter was received from the medical officer of health of Croydon reporting that 2 young women had returned home after a holiday in the village and had been admitted to hospital on April 10 and 12 with scarlet fever. These young ladies had volunteered the information that the village milkman had a sore throat. This disclosure considerably shortened the investigations. It was found that the source of the milk-supply was identical ’in The farm was visited and the milker and cases 1-5. roundsman was questioned and examined. He denied any recent recurrence of tonsillitis, but his tonsils were dirty. From. a, throat-swab the laboratory reported the presence of group-A hæmolytic streptococci, subsequently ascertained to be type 25 by the streptococcal reference laboratory of the Central Public Health Laboratory, London. The other members of the farm household were examined and found to be healthy. On April 15, by a notice issued under Article 19 of the Milk and Dairies Regulations, 1926-43, the carrier was prohibited from taking part in dairying. The milk cows were found to be free from mastitis by the divisional veterinary inspector of the Ministry of Agriculture and Fisheries. Bulk samples of milk were taken and, though there was a profuse growth of contaminants, no hsemolytic streptococci were isolated. All householders on this milk-round were visited and warned to boil all ’
,
milk,
News
of further
cases
then came to light. who stayed as a boarder on the 10, went to bed with severe ton-
CASE 6.-A young man, farm from April 5 to April sillitis on April 9, and went home to Bristol next day. He had a rash which subsequently peeled, and his convalescence was complicated by rheumatic polyarthritis and acute nephritis. This case was not notified. CASE 7.-A young man developed scarlet fever He was on the same milk-round as the others.
on
April
13.
The landlady of the house in the village where the two Croydon girls had stayed developed a sore throat, but her swabs were negative. There were also rumours of other sore throats and strange rashes in the village, but no further notifications were received. The carrier was committed to the care of his own doctor, and the control measures checked the outbreak with a dramatic suddenness which was surprising.
members of the farmer’s family, and the milk was still contaminated. Appeal was made t6 the moral of the farm household to ensure that unwitting holiday visitors should not be given unboiled milk, and that proposed boarders at the farm should be advised of the prevalence of scarlet fever. It is doubtful whether this appeal.convinced the sceptical.farm folk, but seven weeks’ peace ensued. The carrierwas still positive under his doctor’s treatment, and the notice was kept in force.
being sense
THE FOURTH
PHASE
CASES 12 and 13.-On July 22 it was reported that the carrier’s sister and her little girl, who lived outside the area, had developed scarlet fever on July 15, four days after visiting the carrier, This infection was presumably by direct contact.
’
CASE 14.-A young man, who, with his
wife, had been
boarding on the farm since July 17, developed a sore throat on July 19 and a typical scarlet-fever rash on July 22. His wife had a mild sore throat. These visitors said that they had been given unboiled milk in the farmhouse, and that they had no direct contact with the carrier. These were the last notified cases in the village, and the main holiday period of August passed offwithout’ any further troubles except a case of measles in the ill-fated furnished house next to the farm. The carrier continued to undergo treatment, but -he was intermittently positive and still worked at the farm. Dr. V. D. Allison, of the Central Public Health Laboratory, suggested a course of penicillin (100,000 units intramuscularly morning and evening for six days), but, before the patient’s doctor had time to arrange this, the carrier decided to seek a job in another area. He was becoming very worried by all this attention and felt unfairly persecuted, so he went over the county border and resumed dairying once more. The medical officer of health of that area was informed of the outstanding notice against the carrier, and he eventually persuaded him to seek another type of occupation until he is cured. ’
DISCUSSION
The clinical aspects of the cases were not unusual, In 5 of the cases of scarlet fever it was possible to ascertain clearly the time between exposure to infection and the appearance of the rash. This was four days. The conception of scarlet fever as a clinical entity which is notifiable under the Public Health Act, 1936, THE THIRD PHASE bears little relation to its epidemiological significance. CASE 8.-A notification was received on May 14 of scarlet Our carrier harboured in his throat, and transmitted fever in a little girl staying with her parents in the same to other persons, virulent h2emolytic streptococci. The furnished house next to the farm. Of the other members of entirely unsusceptible recipients experienced no ill effects. the household a doctor, his wife, and the maid all had sore Those who were unsusceptible only to the erythrogenic a was but unaffected. These throats, visitors, having baby only recently arrived, had not been warned to boil all factor developed a simple uncomplicated tonsillitis which milk, and the same farmer who supplied them did not tell was not notifiable. The susceptible recipients exhibited the classical syndrome and were notified. them. This anomalous situation creates difficulties both in CASE 9.-On May 16 a man in the village developed scarlet to the boil all milk, epidemiological control and in general practice, particufever. He had disregarded warning which he obtained from this same source. larly in an area which receives a seasonal influx of susceptible youngsters, and in which hygienic standards are CASES 10 and 11.—On May 18 a young girl, aged about 16, still primitive. boarding on the farm, developed scarlet fever four days after The laboratory isolation of hæmolytic streptococci her arrival. Her mother followed suit on May 26. Both these patients said that they had drunk unboiled milk in the from the milk was hampered by the overgrowth of confarmhouse, but -that their accommodation was separate from taminants. Poor shippons, improvised cooling, and the that of the farmer’s family. absence of a proper dairy and sterilising facilities rendered contamination almost inevitable ; and, since the main all cultures but of milk were taken, Repeated samples outbreak to the milk-round and was checked confined was At were heavily overgrown with contaminants. this control it is not unreasonable to of the the other for by milker result milk-supply, a swab stage gave positive group-25 hæmolytic streptococci, but subsequent tests accept the circumstantial evidence that heemolytic were negative. - 11"’-streptococci were intermittently present in the milk. The inference was that the carrier, though taking no The provisions of article 19 of the Milk and Dairies part in. dairying, was intermittently infecting the other Order, 1926, included in the Milk and Dairies Regula-
’
933 tions, 1926-43, are effective insecuring the physical removal of the infected person from dairying operations, provided that the terms ofthe notice are conscientiously observed. The domestic difficulties of running a small family farm, and the impossibility of constant official
supervision,
somewhat detract from the force of the ’
notice.
-
Moreover, even if the infected person does observe the spirit and letter of the notice, he still lives in the farmhouse, and must from time to time infect the other members of the into the milk.
family,
who in turn may pass infection
Stoppage of the entire milk-supply under article 18 of the Milk and Dairies Order, 1926, requires such strong proof of contamination, and is beset by such time restrictions, that it is impracticable in a situation of this kind. Heat treatment of the milk in bulk is also impracticable in a remote rural area, and even advice to consumers to boil their milk has to be given with due regard to the avoidance of defamation, and in the face of rural prejudice against the heresy of questioning the sacrosanct qualities of milk. The peculiar position of a non-notifiable carrier of a notifiable disease evades the removal powers of section 169 of the Public Health Act, 1936, whereby a justice may order the removal to hospital of a person suffering from a notifiable disease where the circumstances are such that proper precautions to prevent the spread of infection cannot be taken and that serious risk of infection is caused to other persons. Similarly there is no power to proceed under sections 148 and 149 of the Public Health Act, 1936, which penalises a person who, knowing that he has a notifiable, disease, exposes other’persons or articles to infection, or carries on an occupation to the danger of others. The position of the boarding-house business of the farm also revealed anomalies in the law. Section 157 (2) and (3) of the Public Health Act prohibits the letting of lodgings, after a case of notifiable disease, until disinfection has been carried out. There was no contravention of these provisions at the farm. Section 157 (1) of the Public Health Act, 1936, imposes a penalty upon a boarding-house keeper for making a false answer to a question of an intending lodger as to whether there has been any case of notifiable disease in the house during the preceding six weeks. The onus of raising this question rests upon the intending visitor, and it is not usual for holiday-makers to take such F-
morbid
precautions. is undoubtedly
There
moral obligation upon the landlord to disclose such known risks as the occurrence of recent cases of infectious disease or the presence of a known carrier in the house, and in default an action might possibly lie for civil damages. Hard cases may make bad law, but the medicolegal aspects of the case were cold comfort in the epidemiological control of the
outbreak.
a
’
There remains now the problem of keeping track of this rather dangerous young man. He is a free subject to go at liberty where he pleases ; and, as his new occupation is normally limited to the winter season, he may wish to revert to farming again next summer. Very understandably he feels persecuted by officialdom) and it will require a very high sense of moral duty to resist the temptation of escaping from the notice. In a smaller way his position is not unlike the case of " Typhoid Alary," except that his personal cure seems even more desirable to save him from possible cardiac complications. His return to the family circle in a dairy farm and boarding-house in a popular holiday district is too potentially dangerous to be viewed with an easy mind. . ’
,
SUMMARY
’
-
An outbreak of 25 streptococcal illnesses,including cases of scarlet fever, in a remote Lakeland village during 1948 is described. The position of a milker who was a non-notifiable throat carrier of group-25 hæmolytic streptococci, living on a dairy farm which was also a boarding-house, is discussed in relation to epidemiological control and the 13
medicolegal aspects. I am indebted to the local general practitioners, the other medical officers of health, and the Public Health Laboratory Service for their assistance and cooperation.
Smallpox
,
smallpox have now been notified in Liskeard, Cornwall-the original case admitted on May 7 and the 3 close family contacts who had been isolated in hospital as a precautionary measure. On the sixteenth day of surveillance none of the other contacts showed any sign of the disease. ; A case of suspected smallpox has been reported on board the liner Mooltan, now outward bound for Australia. The patient sickened on May 18, the liner having left this country on April 28. Altogether
4
cases
of
Estimate of Births Registrar-General1 estimates that births in England and Wales will number 190,000 in the quarter ending June 30 this year, and 178,000 in the quarter ending Sept. 30. In these estimates regard has -been had to : (1) sample returns of the number of special rationbooks issued to expectant mothers by the Ministry of Food, and (2) the recent trend of registered live births. .
The
Boundary Commission’s Annual Report The report of the Local Government Boundary Commission for 19482 reports a decision by the Government that it will not be practicable to introduce comprehensive legislation on local government reconstruction in the near future." Under the Local Government (Boundary Commission) Act, 1945, the commission have a continuing duty to keep under review the " circumstances of the areas into which England and Wales (exclusive of the administrative county of London) are divided for the purposes of local government," and to alter those areas " where it appears to the Commission expedient so to do " ; and the commission intends to make formal statements of proposals for a number of areas, leading up to formal Orders. The major changes proposed in the commission’s report for 19473 would require fresh legislation. .
Hazards With unvanquished faith in the British -summer; many will now be turning their thoughts to a camping holiday. Those unversed in this way of life would do well to arm themselves with an article written by Dr. C. G. Learoyd,*who discusses the medical risks with humour and insight. Dr. Learoyd views with unconcern the more common discomforts of a holiday in the open. " I do not believe " he says, " that damp blankets, occasional lack of groundsheets, and cold sleeping, although uncomfortable and undesirable, do any harm, but it is the instinct of mothers to attribute all subsequent disasters to them." Of water-supplies he takes a more serious view, for " it is a fallacy to suppose that-because inhabitants have been drinking a water for years it is bacteriologically safe." As to bathing : " Man is essentially a terrestial animal ; under water he is- much inferior to the alligator who can close his nostrils by sphincteric action. It is not fussy to exclude children with running ears from swimming in pools, both from their own and their friends’ points of view."
Holiday
-
1.
-
Registrar-General’s Weekly Return of Births and Deaths for the Week ended May 7. H.M. Stationery Office. Pp. 20. 6d. H.M. Stationery Office. Pp. 7. 2d.
2. 3. See Lancet, 1948, i, 610. 4. Practitioner, 396. Also available as 1s., from the Practitioner, 5, Bentinck Street,
1949, 162,
a pamphlet, price London, W.1.
931 In the Luftig case Lord Goddard emphasises the significance of "wilfully and falsely" in section 40. Mens rea, the guilty mind, is-an element in the offence, and the presence or absence of that state of mind must be tested on ordinary principles and in the light of "
sense." ’Lord Goddard rejected counsel’s contention that " doctor of medicine "could be used only by a person who was registered. He also rejected an alternative contention that the Medical Act at least prevented a man from using the- title unless he was qualified to be registered ; the court could find no basis for this argument in the statute. The cardinal fact was that the justices had found that the description " M.D. BLN" did not imply that Dr. Luftig was registered. They could, said Lord Goddard, have decided the other way. They had found that Dr. Luftig had not acted wilfully and falsely ; it could not be said that there was no evidence to support this finding ; the appeal against their finding must therefore be dismissed. :’ In the " complete fog " of cases under section 40 one registered. In Jutson v. Barrow, where Captain Horace Barrow,.having point seems clear. - If an unregistered practitioner really wishes to avoid confusion with registered practitioners, had no professional training, displayed the description " " manipulative surgeon " and seemed to assert that the ’word he can find means of doing so. BLN is not a familiar him was chosen order to abbreviation of Berlin ; to avoid the threatening letters " manipulative " distinguish in from duly qualified surgeons whose names were on the and the swastikas some hieroglyphic was presumably Register, Lord Hewart said that the words " implying that sought which would not- suggest Berlin very readily. he is registered " were not words describing the individual’s Whatever " BLN " may convey to the uninitiated, the intent but describing the effect. " The section is to protect Lord Chief Justice remarked that "it was to be the public, and what is regarded is not the mind of the individual but the meaning likely to be conveyed by the hoped that Dr. Luftig would not in future use"that abbreviation." words that are used." common
"
’,,’
’
,
the milk, and the
Public Health A RURAL OUTBREAK DUE TO
OF
SCARLET FEVER
A NON-NOTIFIABLE CARRIER
FRANK T. MADGE M.D. MEDICAL
OFFICER
OF
Lpool,
HEALTH
DISTRICTS
D.P.H. TO
THE
COMBINED
set for
the, advent
of
’ , ,
,
infected one,
COUNTY THE
MILKER
,
1. The initial illness of the milker in January, 1948, and other reputed cases of tonsillitis in the village. 2. A probably milk-borne spread in early April, with7 cases of clinical scarlet fever and 4 cases- of other suspicious
infections. 3. The third
was
The milker was a member of the family living in the farmstead and certainly intermittently if not all, of the other occupants, who were apparently non-susceptible. The family also let a portion of the farmhouse for board-residence to holiday visitors, several of whom were infected.
OF WESTMORLAND
and roundsman with chronic subacute rheumatic fever was responsible for an epidemic of hæmolytic streptococcal infections during the spring and summer of 1948 in a small remote village of the English There were 13 clinical cases of scarlet Lake District. fever and 12 reported cases of other streptococcal illnesses. The epidemic was interesting for two reasons : first, limitation of the infection to this village and its visitors ; and secondly, the difficulty of controlling a non-notifiable carrier of a notifiable disease. The outbreak occurred in four separate phases : A
stage
trouble.
phase, which occurred in May, was also probably milk-borne, comprised 4 cases of notified scarlet fever and 4 cases of suspicious infections, and was limited to persons who did not adopt the precautions advised. 4. The fourth phase was in July, consisting of 3 cases of notified scarlet fever and 1 case of tonsillitis, possibly milkborne or possibly by direct contact.
FIRST
PHASE
The milker and roundsman, aged about 23, developed a severe sore throat in January, 1948, but there was no rash. He’made rather a slow recovery from this illness, and his convalescence was complicated by polyarticular synovitis and muscular pains: He- resumed work on the farm but could walk only with difficulty and -was ’obviously suffering considerable discomfort. He continued in this state of malaise for about three months and did not obtain real relief until the warmer weather airived about midsummer. There had been many sore throats in the village since Christmas, but no serious case was traced, and there had been no notification of scarlet fever for many
months.
’
THE .SECOND PHASE
’
’,’, ’ ’
,
,
CASE 1.—A man, one of a party of five adults and five children who had arrived in the village on March 25 and taken a furnished house next to the farm, fell ill on March 29 and went next day to Batley, where he was found "to have scarlet fever. CASE 2.—-A- girl, aged 6 years, daughter of case 1, developed scarlet fever on April 4, whereupon the rest of the, party left the district next day. ’
,
The farm was a small one, about half a mile above the As no other cases of scarlet fever had been iiotifi46d in village, and the dairy herd was limited to five cows in the district, it was felt that the father had probably milk. The shippon was dark, low, and old-fashioned, brought the infection with him, and that the daughter, with cobbled floors, and a barn overhead. A portion of being a close contact, -had been infected by him. the farmhouse was used as a dairy and technique was CASE 3.-In the village a girl, aged 4 years, developed a primitive. The water-supply was surface drainage. The temperature on April 8 anda scarlatinal rash on April 9. high to the and -the was confined local, village, Since -a maid from the furnished house -where leases 1 The - adverseeffect of-these milk was retailed conditions was reflected in the bacterialcontent, of and 2 had occurred had visited ’13his ’ patient’shome, on
milk-supply
loose.
1
932
March 31, it seems possible that this child had become infected from the holiday party ; but eight days from
contact to
onset
appeared rather long.
’
CASES 4 and 5.—On April 14 a letter was received from the medical officer of health of Croydon reporting that 2 young women had returned home after a holiday in the village and had been admitted to hospital on April 10 and 12 with scarlet fever. These young ladies had volunteered the information that the village milkman had a sore throat. This disclosure considerably shortened the investigations. It was found that the source of the milk-supply was identical ’in The farm was visited and the milker and cases 1-5. roundsman was questioned and examined. He denied any recent recurrence of tonsillitis, but his tonsils were dirty. From. a, throat-swab the laboratory reported the presence of group-A hæmolytic streptococci, subsequently ascertained to be type 25 by the streptococcal reference laboratory of the Central Public Health Laboratory, London. The other members of the farm household were examined and found to be healthy. On April 15, by a notice issued under Article 19 of the Milk and Dairies Regulations, 1926-43, the carrier was prohibited from taking part in dairying. The milk cows were found to be free from mastitis by the divisional veterinary inspector of the Ministry of Agriculture and Fisheries. Bulk samples of milk were taken and, though there was a profuse growth of contaminants, no hsemolytic streptococci were isolated. All householders on this milk-round were visited and warned to boil all ’
,
milk,
News
of further
cases
then came to light. who stayed as a boarder on the 10, went to bed with severe ton-
CASE 6.-A young man, farm from April 5 to April sillitis on April 9, and went home to Bristol next day. He had a rash which subsequently peeled, and his convalescence was complicated by rheumatic polyarthritis and acute nephritis. This case was not notified. CASE 7.-A young man developed scarlet fever He was on the same milk-round as the others.
on
April
13.
The landlady of the house in the village where the two Croydon girls had stayed developed a sore throat, but her swabs were negative. There were also rumours of other sore throats and strange rashes in the village, but no further notifications were received. The carrier was committed to the care of his own doctor, and the control measures checked the outbreak with a dramatic suddenness which was surprising.
members of the farmer’s family, and the milk was still contaminated. Appeal was made t6 the moral of the farm household to ensure that unwitting holiday visitors should not be given unboiled milk, and that proposed boarders at the farm should be advised of the prevalence of scarlet fever. It is doubtful whether this appeal.convinced the sceptical.farm folk, but seven weeks’ peace ensued. The carrierwas still positive under his doctor’s treatment, and the notice was kept in force.
being sense
THE FOURTH
PHASE
CASES 12 and 13.-On July 22 it was reported that the carrier’s sister and her little girl, who lived outside the area, had developed scarlet fever on July 15, four days after visiting the carrier, This infection was presumably by direct contact.
’
CASE 14.-A young man, who, with his
wife, had been
boarding on the farm since July 17, developed a sore throat on July 19 and a typical scarlet-fever rash on July 22. His wife had a mild sore throat. These visitors said that they had been given unboiled milk in the farmhouse, and that they had no direct contact with the carrier. These were the last notified cases in the village, and the main holiday period of August passed offwithout’ any further troubles except a case of measles in the ill-fated furnished house next to the farm. The carrier continued to undergo treatment, but -he was intermittently positive and still worked at the farm. Dr. V. D. Allison, of the Central Public Health Laboratory, suggested a course of penicillin (100,000 units intramuscularly morning and evening for six days), but, before the patient’s doctor had time to arrange this, the carrier decided to seek a job in another area. He was becoming very worried by all this attention and felt unfairly persecuted, so he went over the county border and resumed dairying once more. The medical officer of health of that area was informed of the outstanding notice against the carrier, and he eventually persuaded him to seek another type of occupation until he is cured. ’
DISCUSSION
The clinical aspects of the cases were not unusual, In 5 of the cases of scarlet fever it was possible to ascertain clearly the time between exposure to infection and the appearance of the rash. This was four days. The conception of scarlet fever as a clinical entity which is notifiable under the Public Health Act, 1936, THE THIRD PHASE bears little relation to its epidemiological significance. CASE 8.-A notification was received on May 14 of scarlet Our carrier harboured in his throat, and transmitted fever in a little girl staying with her parents in the same to other persons, virulent h2emolytic streptococci. The furnished house next to the farm. Of the other members of entirely unsusceptible recipients experienced no ill effects. the household a doctor, his wife, and the maid all had sore Those who were unsusceptible only to the erythrogenic a was but unaffected. These throats, visitors, having baby only recently arrived, had not been warned to boil all factor developed a simple uncomplicated tonsillitis which milk, and the same farmer who supplied them did not tell was not notifiable. The susceptible recipients exhibited the classical syndrome and were notified. them. This anomalous situation creates difficulties both in CASE 9.-On May 16 a man in the village developed scarlet to the boil all milk, epidemiological control and in general practice, particufever. He had disregarded warning which he obtained from this same source. larly in an area which receives a seasonal influx of susceptible youngsters, and in which hygienic standards are CASES 10 and 11.—On May 18 a young girl, aged about 16, still primitive. boarding on the farm, developed scarlet fever four days after The laboratory isolation of hæmolytic streptococci her arrival. Her mother followed suit on May 26. Both these patients said that they had drunk unboiled milk in the from the milk was hampered by the overgrowth of confarmhouse, but -that their accommodation was separate from taminants. Poor shippons, improvised cooling, and the that of the farmer’s family. absence of a proper dairy and sterilising facilities rendered contamination almost inevitable ; and, since the main all cultures but of milk were taken, Repeated samples outbreak to the milk-round and was checked confined was At were heavily overgrown with contaminants. this control it is not unreasonable to of the the other for by milker result milk-supply, a swab stage gave positive group-25 hæmolytic streptococci, but subsequent tests accept the circumstantial evidence that heemolytic were negative. - 11"’-streptococci were intermittently present in the milk. The inference was that the carrier, though taking no The provisions of article 19 of the Milk and Dairies part in. dairying, was intermittently infecting the other Order, 1926, included in the Milk and Dairies Regula-
’
933 tions, 1926-43, are effective insecuring the physical removal of the infected person from dairying operations, provided that the terms ofthe notice are conscientiously observed. The domestic difficulties of running a small family farm, and the impossibility of constant official
supervision,
somewhat detract from the force of the ’
notice.
-
Moreover, even if the infected person does observe the spirit and letter of the notice, he still lives in the farmhouse, and must from time to time infect the other members of the into the milk.
family,
who in turn may pass infection
Stoppage of the entire milk-supply under article 18 of the Milk and Dairies Order, 1926, requires such strong proof of contamination, and is beset by such time restrictions, that it is impracticable in a situation of this kind. Heat treatment of the milk in bulk is also impracticable in a remote rural area, and even advice to consumers to boil their milk has to be given with due regard to the avoidance of defamation, and in the face of rural prejudice against the heresy of questioning the sacrosanct qualities of milk. The peculiar position of a non-notifiable carrier of a notifiable disease evades the removal powers of section 169 of the Public Health Act, 1936, whereby a justice may order the removal to hospital of a person suffering from a notifiable disease where the circumstances are such that proper precautions to prevent the spread of infection cannot be taken and that serious risk of infection is caused to other persons. Similarly there is no power to proceed under sections 148 and 149 of the Public Health Act, 1936, which penalises a person who, knowing that he has a notifiable, disease, exposes other’persons or articles to infection, or carries on an occupation to the danger of others. The position of the boarding-house business of the farm also revealed anomalies in the law. Section 157 (2) and (3) of the Public Health Act prohibits the letting of lodgings, after a case of notifiable disease, until disinfection has been carried out. There was no contravention of these provisions at the farm. Section 157 (1) of the Public Health Act, 1936, imposes a penalty upon a boarding-house keeper for making a false answer to a question of an intending lodger as to whether there has been any case of notifiable disease in the house during the preceding six weeks. The onus of raising this question rests upon the intending visitor, and it is not usual for holiday-makers to take such F-
morbid
precautions. is undoubtedly
There
moral obligation upon the landlord to disclose such known risks as the occurrence of recent cases of infectious disease or the presence of a known carrier in the house, and in default an action might possibly lie for civil damages. Hard cases may make bad law, but the medicolegal aspects of the case were cold comfort in the epidemiological control of the
outbreak.
a
’
There remains now the problem of keeping track of this rather dangerous young man. He is a free subject to go at liberty where he pleases ; and, as his new occupation is normally limited to the winter season, he may wish to revert to farming again next summer. Very understandably he feels persecuted by officialdom) and it will require a very high sense of moral duty to resist the temptation of escaping from the notice. In a smaller way his position is not unlike the case of " Typhoid Alary," except that his personal cure seems even more desirable to save him from possible cardiac complications. His return to the family circle in a dairy farm and boarding-house in a popular holiday district is too potentially dangerous to be viewed with an easy mind. . ’
,
SUMMARY
’
-
An outbreak of 25 streptococcal illnesses,including cases of scarlet fever, in a remote Lakeland village during 1948 is described. The position of a milker who was a non-notifiable throat carrier of group-25 hæmolytic streptococci, living on a dairy farm which was also a boarding-house, is discussed in relation to epidemiological control and the 13
medicolegal aspects. I am indebted to the local general practitioners, the other medical officers of health, and the Public Health Laboratory Service for their assistance and cooperation.
Smallpox
,
smallpox have now been notified in Liskeard, Cornwall-the original case admitted on May 7 and the 3 close family contacts who had been isolated in hospital as a precautionary measure. On the sixteenth day of surveillance none of the other contacts showed any sign of the disease. ; A case of suspected smallpox has been reported on board the liner Mooltan, now outward bound for Australia. The patient sickened on May 18, the liner having left this country on April 28. Altogether
4
cases
of
Estimate of Births Registrar-General1 estimates that births in England and Wales will number 190,000 in the quarter ending June 30 this year, and 178,000 in the quarter ending Sept. 30. In these estimates regard has -been had to : (1) sample returns of the number of special rationbooks issued to expectant mothers by the Ministry of Food, and (2) the recent trend of registered live births. .
The
Boundary Commission’s Annual Report The report of the Local Government Boundary Commission for 19482 reports a decision by the Government that it will not be practicable to introduce comprehensive legislation on local government reconstruction in the near future." Under the Local Government (Boundary Commission) Act, 1945, the commission have a continuing duty to keep under review the " circumstances of the areas into which England and Wales (exclusive of the administrative county of London) are divided for the purposes of local government," and to alter those areas " where it appears to the Commission expedient so to do " ; and the commission intends to make formal statements of proposals for a number of areas, leading up to formal Orders. The major changes proposed in the commission’s report for 19473 would require fresh legislation. .
Hazards With unvanquished faith in the British -summer; many will now be turning their thoughts to a camping holiday. Those unversed in this way of life would do well to arm themselves with an article written by Dr. C. G. Learoyd,*who discusses the medical risks with humour and insight. Dr. Learoyd views with unconcern the more common discomforts of a holiday in the open. " I do not believe " he says, " that damp blankets, occasional lack of groundsheets, and cold sleeping, although uncomfortable and undesirable, do any harm, but it is the instinct of mothers to attribute all subsequent disasters to them." Of water-supplies he takes a more serious view, for " it is a fallacy to suppose that-because inhabitants have been drinking a water for years it is bacteriologically safe." As to bathing : " Man is essentially a terrestial animal ; under water he is- much inferior to the alligator who can close his nostrils by sphincteric action. It is not fussy to exclude children with running ears from swimming in pools, both from their own and their friends’ points of view."
Holiday
-
1.
-
Registrar-General’s Weekly Return of Births and Deaths for the Week ended May 7. H.M. Stationery Office. Pp. 20. 6d. H.M. Stationery Office. Pp. 7. 2d.
2. 3. See Lancet, 1948, i, 610. 4. Practitioner, 396. Also available as 1s., from the Practitioner, 5, Bentinck Street,
1949, 162,
a pamphlet, price London, W.1.