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EPIDEMIOLOGY OF A SMALL OUTBREAK OF ANTHRAX
1011 made up for it later on ; those who kept height and weight charts of infants knew that these were helpful for understanding week-to-week progress but were not necessarily an indication of what the child would be when grown up. To condemn a child to an institution life instead of giving it an opportunity to be brought up in a family was a very grave responsibility. The psychological problems in placement for adoption revolved round the personalities of the adopting parents, the ability of the mother to make her own decisions, and the need for the child to be adopted at the earliest possible moment. More study was required to determine the criteria for successful adoption, so that magistrates and others might have something valid to guide them. The problems of adoption required a considerable linowledge of the factors making for mental health and stability of personality as well as of physical sanitation.
A. T. DOIG M.D. St. And., D.P.H. H.M. MEDICAL INSPECTOR OF FACTORIES
J. S. GEMMILL SENIOR MEDICAL
HEALTH
DEPARTMENT,
GLASGOW
IN
early summer, 1950, three cases of anthrax occurred Glasgow. The first patient, who sickened in May, was a motor-van driver employed by a firm of purveyors and caterers in a southern area of Glasgow some four in
miles distant from his home in the east end. On May 16, 1950, the patient, aged 35, returned from work, and, before entering his home had his hair cut at the local
barber’s shop. While a towel was being adjusted he received scratch on the back of his neck which made him wince, and he remonstrated with the barber. Before leaving he felt the same spot again painful when having his hair brushed. On the following day there was a small pimple at the site of the injury which he covered with an adhesive dressing; the area, however, continued to itch for some days. On May 21 he suffered from anorexia, headache, generalised pains, and malaise, to which sweating was added on the 22nd, when he stayed in bed. On the 23rd his doctor visited him and treated him for influenza and a boil, the dressing having now been removed for the first time. On the 24th he had pain in his left shoulder and, now very ill, he was seen by another doctor who suspected anthrax from the appearance of the neck lesion and took a smear, in which the presence of anthrax bacilli was confirmed by animal inoculation. Penicillin treatment was begun and was at once effective. a
The
no
other
patient
notified
A visit to the hairdresser’s shop showed this to be of a low order of hygiene and management. The equipment was modern but the premises were generally dirty and untidy. Scissors, clippers, brushes, combs, &c., were said to be sterilised by heat every night. They were certainly not sterilised between each customer; the proprietor freely admitted that this was not practicable and was never done. He had not recently bought any new brushes; his present stock of shaving-brushes had been in use for a year, and of hair-brushes for
was seen at home on the 31st by one of us and was found to be convalescent. The lesion consisted of a healing ulcer on the left side of the back of the neck just above collar level ; the crater was covered by a dry black eschar which measured 1 in. horizontally by 3/4 in. vertically. The appearance was typical of a malignant pustule in the stage of resolution. There was also firm discrete adenitis of the posterior triangle and supraclavicular region on the left side, but none of the left axilla or on the right side anywhere. He had not recently bought or used any new
Many of this hairdresser’s regular customers were known to be employed at a nearby tannery ; and on June 1 two men employed at the tannery-neither of whom was a customer of this hairdresser-fell ill with anthrax. These two patients, aged 47 and 50, were seen by us several days after the onset of their illness. In one the lesion was on the left arm and was extremely severe, while in the other it consisted of a typical malignant pustule at the angle of the right jaw ; anthrax bacilli were isolated from both lesions. Both patients recovered. The severe case appeared to be penicillinresistant but began to make slow progress under treatment with anti-anthrax serum and ’Aureomycin’; the other case responded well to penicillin alone. On June 6 one of us (J. S. G.) visited the tannery and took samples for bacteriological examination. These were : (1) floor-sweepings from an area of the store on which a batch of suspected East African hides had been stacked since their arrival in the factory in February and March, 1950 ; (2) a sample of dry East African hide cut from the edge ; (3) a sample of dry East African hide cut from the centre. Sample 2 was negative for Bacillus anthracis, the guineapig having died of an intercurrent intoxication (Clostridium welchii). Samples 1 and 3 were both positive for B. anthracis on guineapig inoculation. Another batch of East Indian hides from the same cargo was responsible for a fourth case of anthrax occurring in another town. COMMENT
patient
(J. S. G.)
shaving-brushes
Glasgow
two years.
D.P.H.
OFFICER, PUBLIC
"
as a case
EPIDEMIOLOGY OF A SMALL OUTBREAK OF ANTHRAX
Glasg.,
"
At this time there was in of anthrax.
Public Health
M.B.
AUSTIN MELFORD, of the National Adoption reiterated the doubts often felt as to whether the motives for adoption were the right ones. It was important to make a wise choice of adopters, and to avoid unhealthy, highly strung, or elderly couples. Still greater care was necessary in placing a second child with the same family, and there was more risk of failure where adopters had a child of their own. In the last session, Prof. A. V. NEALE pleaded for the removal of the " iron curtain" between preventive and curative medicine and for greater knowledge of the normal child. Undergraduates in particular should examine normals’’ because later they would encounter more normalcy than disorder. The training in hospitals might lead to wrong views, for hospitals were filled with medical failures." Students should have more teaching in the homes of the people. Mrs.
Society,
or hair-brushes. The patient’s place of work and his duties were investigated (A. T. D.), and these did not appear to bring him into contact with any known or likely source of anthrax-infected material. The vans were all motor-driven. His main duties were to carry trays of foodstuffs from the bakery to his van and then deliver these. The goods handled were almost all cooked or baked and seldom contained meat, although on occasion he had to collect meat from a butcher.
reasonably certain that case 1 was infected indirectly in the barber’s shop, by contaminated instruments or finger-nails, or both. It also seems permissible It
seems
to assume that this infection was introduced into the barber’s shop on or about May 16 by a tannery employee whose hair or clothing was contaminated by infected dust, but who himself was not suffering, and did not later suffer, from anthrax. The assumed path of infection, then, is from the infected hides by means of dust to the hair or clothing of an unaffected worker, thence to the barber’s instruments or finger-nails, and finally to the affected person. The facts supporting these conclusions are as follows : (1) a certain batch of hides in the tannery was proved to be infected with B. anthracis, which was also present in the dust arising from this batch ; (2) a considerable
number of employees at the a
nearby hairdresser ; (3)
tannery habitually patronised having no other known,
a man
1012 contact with infected material received a wound the neck while having his hair cut at the same hairdresser’s, and a malignant pustule developed at the site of the wound ; (4) two cases of anthrax occurred in the third week after this incident in tannery employees who had contact with the infected hides, but had not patronised the hairdresser’s shop.
or on
likely,
Children in Glasgow The average weights and heights of Glasgow schoolchildren have increased steadily in the last 18 years. The following figures for 19501show the average increases for the different age-groups since 1932 :
Medicine and the Law Parent’s Refusal to allow Operation IN a recent case which must have given the hospital authorities a distressing anxiety a mother persistently refused permission for an operation to be performed upon her infant daughter. At the inquest2 the coroner told the jury that they might have to consider returning a verdict of manslaughter or even murder. The jury’s verdict was " death by misadventure"; they added the comment : "We feel that the mother did not sufficiently understand what was being asked of her." In recording the verdict the coroner observed that death was accelerated by lack of adequate treatment owing to the mother’s refusal to consent to an operation. The deceased baby, born in June last year, was admitted to the Ipswich Isolation Hospital (on transfer from the Borough General Hospital) with whoopingcough. Gastro-enteritis developed. Efforts were made to obtain the mother’s permission for intravenous injection ; she was told that the medical authorities said that the child’s only chance of survival was by an operation. She had herself undergone two operations in hospital and had said that she would never have consented to them had she known how severe they would be. Since that experience she had dreaded operations. There was some conflict of evidence as to whether she had or had not, at one point, assented to the operation she maintained at the inquest that she on the child ; had at all times said " no." The doctor in charge of the case, being informed that verbal consent had been given, started the intravenous drip ; the operation was not complete when the mother arrived at the hospital and made it clear that she refused to allow it. The wound the was closed and the operation was abandoned ; infant died next day. Medical witnesses could not say that the operation would have saved the child’s life, but they considered that it would at least have prolonged it. The mother was told that the chances of survival in
hospital, if the operation were performed, fifty-fifty ; without it they were nil. At the inquest the pathologist’s evidence was that the recommended treatment was the only useful course ; it was not always were
successful, but in
many
cases
it gave the sole chance of
recovery.
Apart for
a
1933 ,
from
any
common-law
obligations
to
care
child, the Children and Young Persons Act of (replacing section 12 of the Children Act of 1908)
makes it
offence to neglect a child in a manner likely unnecessary suffering or injury to health, and specifically states that it is neglect if the parent fails to provide medical aid. The Act declares that injury to
an
cause
Corporation of Glasgow. Education Health Service : Report on the Medical Inspection and Treatment of School Children for the Year ended July 31, 1950. 2. East Anglian Times, April 19, 1951, p. 5. 1.
’to health includes injury to, or loss of, sight -or hearing or limb or organ of the body ; these words, as Mr. Justice Darling-pointed out in Oakey . Jackson in 1914, indicate that Parliament contemplated that medical aid might include surgical operation. In Oakey v. Jackson the alleged neglect was the failure to allow an operation upon a 13-year-old child for removal of adenoids. There was evidence that she suffered from mental dullness, impaired breathing, deafness, and some anaemia, and that, though it probably involved anaesthesia, the operation was not a dangerous one. The magistrates took the view that there was no legal compulsion upon the parent to allow the operation. The High Court held that the facts might amount to a failure to provide medical aid and that, if the facts justified it, the magistrates should have convicted the accused. Two points have arisen in this class of prosecution. The fact that parents are poor and could not ordinarily afford to pay professional fees has been no defence to the charge ; the medical aid could -be obtained through public assistance and today through the National Health Service. Secondly, the intention of the accused person The word " wilfullywas needs to be considered. explained in 1899 by Lord Russell of Killowen, L.C.J., in R. v. Senior, where the parent had belonged to the sect known as the Peculiar People and had objected on religious grounds to calling in medical aid or the use of medicine. Neglect," said Lord Russell, " is the want of reasonable care, that is, the omission of such steps as a reasonable parent would take-such as are usually taken in the ordinary experience of mankind." Mr. Justice Avory, concurring in those observations, tersely added that one matter the justices -ought to whether the person who consider in such a case is advises the operation is a qualified medical practitioner "
"
or
merely
some
irresponsible person."
Parliament The Health Service Charges THE debate on the second reading of the National Health Service Bill swung between those who regarded the proposed charges for spectacles and dentures as safeguards of the whole service and those who regarded them as a breach of faith and principle. Mr. HrLABY MARQUAND in his lucid review of the Budget proposals declared that the new charges were not a tax on the service but a of its finances to enable it to meet rising costs. Nor were these the first adjustments to be made. For instance, economies involving cuts in the remuneration of dentists, opticians, and chemists had already been made ; and patients’ travelling expenses to hospitals had been curtailed. The Secretary of State for Scotland took a similar view, defending what he described as modest charges on the very periphery of the
readjustment
service. Dr. SANTO JEGER,
on the other hand, firmly denounced the new charges. They were, he said, deterrents rather than money-raisers. They would be a counterblast to health propaganda. Spectacles and dentures were not inessentials but an important part of treatment. If economies had to be made, could not old spectacle frames be used ? Could not the patient be asked to provide his own bottle for his medicine ? What about further adjustments of dental fees ?P Were not the sums paid to medical specialists rather inflated compared with those to other members of the medical profession ?’.P Dr. CHARLES HILL joined Dr. Jeger in the defence of dentures and spectacles. He deprecated any suggestion that the word cosmetic should be applied to them, for they were of real importance to health. On the other hand he accepted the need to fix a ceiling for our health service if other less glamorous but also important social services were not to suffer. But an over-all ceiling should also mean a series of ceilings within the service for the component parts. At present hospitals claimed twothirds of the health service expenditure, and if this
A. T. DOIG M.D. St. And., D.P.H. H.M. MEDICAL INSPECTOR OF FACTORIES
J. S. GEMMILL SENIOR MEDICAL
HEALTH
DEPARTMENT,
GLASGOW
IN
early summer, 1950, three cases of anthrax occurred Glasgow. The first patient, who sickened in May, was a motor-van driver employed by a firm of purveyors and caterers in a southern area of Glasgow some four in
miles distant from his home in the east end. On May 16, 1950, the patient, aged 35, returned from work, and, before entering his home had his hair cut at the local
barber’s shop. While a towel was being adjusted he received scratch on the back of his neck which made him wince, and he remonstrated with the barber. Before leaving he felt the same spot again painful when having his hair brushed. On the following day there was a small pimple at the site of the injury which he covered with an adhesive dressing; the area, however, continued to itch for some days. On May 21 he suffered from anorexia, headache, generalised pains, and malaise, to which sweating was added on the 22nd, when he stayed in bed. On the 23rd his doctor visited him and treated him for influenza and a boil, the dressing having now been removed for the first time. On the 24th he had pain in his left shoulder and, now very ill, he was seen by another doctor who suspected anthrax from the appearance of the neck lesion and took a smear, in which the presence of anthrax bacilli was confirmed by animal inoculation. Penicillin treatment was begun and was at once effective. a
The
no
other
patient
notified
A visit to the hairdresser’s shop showed this to be of a low order of hygiene and management. The equipment was modern but the premises were generally dirty and untidy. Scissors, clippers, brushes, combs, &c., were said to be sterilised by heat every night. They were certainly not sterilised between each customer; the proprietor freely admitted that this was not practicable and was never done. He had not recently bought any new brushes; his present stock of shaving-brushes had been in use for a year, and of hair-brushes for
was seen at home on the 31st by one of us and was found to be convalescent. The lesion consisted of a healing ulcer on the left side of the back of the neck just above collar level ; the crater was covered by a dry black eschar which measured 1 in. horizontally by 3/4 in. vertically. The appearance was typical of a malignant pustule in the stage of resolution. There was also firm discrete adenitis of the posterior triangle and supraclavicular region on the left side, but none of the left axilla or on the right side anywhere. He had not recently bought or used any new
Many of this hairdresser’s regular customers were known to be employed at a nearby tannery ; and on June 1 two men employed at the tannery-neither of whom was a customer of this hairdresser-fell ill with anthrax. These two patients, aged 47 and 50, were seen by us several days after the onset of their illness. In one the lesion was on the left arm and was extremely severe, while in the other it consisted of a typical malignant pustule at the angle of the right jaw ; anthrax bacilli were isolated from both lesions. Both patients recovered. The severe case appeared to be penicillinresistant but began to make slow progress under treatment with anti-anthrax serum and ’Aureomycin’; the other case responded well to penicillin alone. On June 6 one of us (J. S. G.) visited the tannery and took samples for bacteriological examination. These were : (1) floor-sweepings from an area of the store on which a batch of suspected East African hides had been stacked since their arrival in the factory in February and March, 1950 ; (2) a sample of dry East African hide cut from the edge ; (3) a sample of dry East African hide cut from the centre. Sample 2 was negative for Bacillus anthracis, the guineapig having died of an intercurrent intoxication (Clostridium welchii). Samples 1 and 3 were both positive for B. anthracis on guineapig inoculation. Another batch of East Indian hides from the same cargo was responsible for a fourth case of anthrax occurring in another town. COMMENT
patient
(J. S. G.)
shaving-brushes
Glasgow
two years.
D.P.H.
OFFICER, PUBLIC
"
as a case
EPIDEMIOLOGY OF A SMALL OUTBREAK OF ANTHRAX
Glasg.,
"
At this time there was in of anthrax.
Public Health
M.B.
AUSTIN MELFORD, of the National Adoption reiterated the doubts often felt as to whether the motives for adoption were the right ones. It was important to make a wise choice of adopters, and to avoid unhealthy, highly strung, or elderly couples. Still greater care was necessary in placing a second child with the same family, and there was more risk of failure where adopters had a child of their own. In the last session, Prof. A. V. NEALE pleaded for the removal of the " iron curtain" between preventive and curative medicine and for greater knowledge of the normal child. Undergraduates in particular should examine normals’’ because later they would encounter more normalcy than disorder. The training in hospitals might lead to wrong views, for hospitals were filled with medical failures." Students should have more teaching in the homes of the people. Mrs.
Society,
or hair-brushes. The patient’s place of work and his duties were investigated (A. T. D.), and these did not appear to bring him into contact with any known or likely source of anthrax-infected material. The vans were all motor-driven. His main duties were to carry trays of foodstuffs from the bakery to his van and then deliver these. The goods handled were almost all cooked or baked and seldom contained meat, although on occasion he had to collect meat from a butcher.
reasonably certain that case 1 was infected indirectly in the barber’s shop, by contaminated instruments or finger-nails, or both. It also seems permissible It
seems
to assume that this infection was introduced into the barber’s shop on or about May 16 by a tannery employee whose hair or clothing was contaminated by infected dust, but who himself was not suffering, and did not later suffer, from anthrax. The assumed path of infection, then, is from the infected hides by means of dust to the hair or clothing of an unaffected worker, thence to the barber’s instruments or finger-nails, and finally to the affected person. The facts supporting these conclusions are as follows : (1) a certain batch of hides in the tannery was proved to be infected with B. anthracis, which was also present in the dust arising from this batch ; (2) a considerable
number of employees at the a
nearby hairdresser ; (3)
tannery habitually patronised having no other known,
a man
1012 contact with infected material received a wound the neck while having his hair cut at the same hairdresser’s, and a malignant pustule developed at the site of the wound ; (4) two cases of anthrax occurred in the third week after this incident in tannery employees who had contact with the infected hides, but had not patronised the hairdresser’s shop.
or on
likely,
Children in Glasgow The average weights and heights of Glasgow schoolchildren have increased steadily in the last 18 years. The following figures for 19501show the average increases for the different age-groups since 1932 :
Medicine and the Law Parent’s Refusal to allow Operation IN a recent case which must have given the hospital authorities a distressing anxiety a mother persistently refused permission for an operation to be performed upon her infant daughter. At the inquest2 the coroner told the jury that they might have to consider returning a verdict of manslaughter or even murder. The jury’s verdict was " death by misadventure"; they added the comment : "We feel that the mother did not sufficiently understand what was being asked of her." In recording the verdict the coroner observed that death was accelerated by lack of adequate treatment owing to the mother’s refusal to consent to an operation. The deceased baby, born in June last year, was admitted to the Ipswich Isolation Hospital (on transfer from the Borough General Hospital) with whoopingcough. Gastro-enteritis developed. Efforts were made to obtain the mother’s permission for intravenous injection ; she was told that the medical authorities said that the child’s only chance of survival was by an operation. She had herself undergone two operations in hospital and had said that she would never have consented to them had she known how severe they would be. Since that experience she had dreaded operations. There was some conflict of evidence as to whether she had or had not, at one point, assented to the operation she maintained at the inquest that she on the child ; had at all times said " no." The doctor in charge of the case, being informed that verbal consent had been given, started the intravenous drip ; the operation was not complete when the mother arrived at the hospital and made it clear that she refused to allow it. The wound the was closed and the operation was abandoned ; infant died next day. Medical witnesses could not say that the operation would have saved the child’s life, but they considered that it would at least have prolonged it. The mother was told that the chances of survival in
hospital, if the operation were performed, fifty-fifty ; without it they were nil. At the inquest the pathologist’s evidence was that the recommended treatment was the only useful course ; it was not always were
successful, but in
many
cases
it gave the sole chance of
recovery.
Apart for
a
1933 ,
from
any
common-law
obligations
to
care
child, the Children and Young Persons Act of (replacing section 12 of the Children Act of 1908)
makes it
offence to neglect a child in a manner likely unnecessary suffering or injury to health, and specifically states that it is neglect if the parent fails to provide medical aid. The Act declares that injury to
an
cause
Corporation of Glasgow. Education Health Service : Report on the Medical Inspection and Treatment of School Children for the Year ended July 31, 1950. 2. East Anglian Times, April 19, 1951, p. 5. 1.
’to health includes injury to, or loss of, sight -or hearing or limb or organ of the body ; these words, as Mr. Justice Darling-pointed out in Oakey . Jackson in 1914, indicate that Parliament contemplated that medical aid might include surgical operation. In Oakey v. Jackson the alleged neglect was the failure to allow an operation upon a 13-year-old child for removal of adenoids. There was evidence that she suffered from mental dullness, impaired breathing, deafness, and some anaemia, and that, though it probably involved anaesthesia, the operation was not a dangerous one. The magistrates took the view that there was no legal compulsion upon the parent to allow the operation. The High Court held that the facts might amount to a failure to provide medical aid and that, if the facts justified it, the magistrates should have convicted the accused. Two points have arisen in this class of prosecution. The fact that parents are poor and could not ordinarily afford to pay professional fees has been no defence to the charge ; the medical aid could -be obtained through public assistance and today through the National Health Service. Secondly, the intention of the accused person The word " wilfullywas needs to be considered. explained in 1899 by Lord Russell of Killowen, L.C.J., in R. v. Senior, where the parent had belonged to the sect known as the Peculiar People and had objected on religious grounds to calling in medical aid or the use of medicine. Neglect," said Lord Russell, " is the want of reasonable care, that is, the omission of such steps as a reasonable parent would take-such as are usually taken in the ordinary experience of mankind." Mr. Justice Avory, concurring in those observations, tersely added that one matter the justices -ought to whether the person who consider in such a case is advises the operation is a qualified medical practitioner "
"
or
merely
some
irresponsible person."
Parliament The Health Service Charges THE debate on the second reading of the National Health Service Bill swung between those who regarded the proposed charges for spectacles and dentures as safeguards of the whole service and those who regarded them as a breach of faith and principle. Mr. HrLABY MARQUAND in his lucid review of the Budget proposals declared that the new charges were not a tax on the service but a of its finances to enable it to meet rising costs. Nor were these the first adjustments to be made. For instance, economies involving cuts in the remuneration of dentists, opticians, and chemists had already been made ; and patients’ travelling expenses to hospitals had been curtailed. The Secretary of State for Scotland took a similar view, defending what he described as modest charges on the very periphery of the
readjustment
service. Dr. SANTO JEGER,
on the other hand, firmly denounced the new charges. They were, he said, deterrents rather than money-raisers. They would be a counterblast to health propaganda. Spectacles and dentures were not inessentials but an important part of treatment. If economies had to be made, could not old spectacle frames be used ? Could not the patient be asked to provide his own bottle for his medicine ? What about further adjustments of dental fees ?P Were not the sums paid to medical specialists rather inflated compared with those to other members of the medical profession ?’.P Dr. CHARLES HILL joined Dr. Jeger in the defence of dentures and spectacles. He deprecated any suggestion that the word cosmetic should be applied to them, for they were of real importance to health. On the other hand he accepted the need to fix a ceiling for our health service if other less glamorous but also important social services were not to suffer. But an over-all ceiling should also mean a series of ceilings within the service for the component parts. At present hospitals claimed twothirds of the health service expenditure, and if this