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19
The chief points of interest are:- The occurrence of an extensive
epidemic of tonsilitis of anomalous character, the epidemic being
limited to a particular part of the borough and to a neighbouring
sanitary district; its almost fortuitous discovery, in the absence of
any marked rise in the number of cases of frank scarlet fever, and owing
also to the fact that ordinary tonsilitis, the most common condition found,
is not a notifiable disease; the relation to a particular supply of unpasteurised
milk; the rapidity with which the outbreak ceased when appropriate measures
were taken in connection with this milk supply; and the problem as to
whether the disease was a mild form of true scarlet fever, a variant of
this disease, or a separate entity.
On Wednesday, June 4th, I saw in South Croydon, in consultation with
a medical practitioner, a somewhat anomalous case of illness, with a history
of acute sore throat, shivering, and some fever, and showing a peeling red
tongue with enlarged papillae suggestive of scarlet fever, but with a nonpunctate
rash so delayed in onset, and so localised and aberrant in type, as
to make the diagnosis not completely certain. I gathered that similar cases
had occurred in this doctor's practice within the previous two or three weeks.
On June 5th another medical practitioner invited me to see, in a private
boys' school (A), receiving both boarders and day-boys, five boys who, within
the previous twenty-four hours, had developed sore throat, headache, shivering,
and a temperature of 100 to 103 deg. F., without vomiting or rash.
Previous cases, in no instance showing any rash, had been observed during the
preceding ten days. These five boys were kept isolated in the sick bay,
as had been the previous cases. On June 7th three appeared well, with a
clean and normal tongue, and no rash; two had red smooth tongues with
enlarged papillae, suggestive of scarlet fever, with an indefinite non-punctate
rash on the trunk. A sixth boy (E) on this day developed a sore throat,
commencing—according to his statement—on the 6th, with engorged fauces,
yellow exudate on the tonsils, and a bright red rash, slightly coarser and
more patchy in outline than in typical scarlet fever. A seventh boy (Y)
had a sore throat, developing on the 6th June, and on the 7th showed
engorged fauces, a furred tongue, moderate pyrexia, but no rash. In view
of their anomalous character, these cases were kept isolated and under
observation. No notable change was seen on the 8th, except that the rash
shown by the boy E appeared more typical of scarlet fever, and on the
9th this case was regarded as one of mild scarlet fever. On that day, i.e.,
three days after the onset, the boy Y developed for the first time a pale pink
rash, faintly punctate on trunk and arms, and also showed a peeling tongue,
very suggestive of scarlet fever. This case similarly was regarded as suffering
from scarlet fever, although there had been delay in the appearance of the
rash.
While these cases were under observation at school A, I was asked,
on June 7th, to see at a private school (B) a girl boarder, who, with six
other boarders, developed a sore throat, with shivering, headache, and fever
of 100 to 103 deg. F., on the 5th June, while an eighth developed the same
condition on the 6th. All showed engorged fauces, some had yellow patches
of exudate on the tonsils. All had normal tongues, not suggestive of scarlet
fever. Only the one whom I had been invited to examine had developed a
slight, scattered, and indeterminate rash on the trunk. The rash was not
characteristic of scarlet fever.
When the cases at school A were diagnosed as scarlet fever, it was felt
wise to regard the causes of tonsilitis at both these schools as being also
scarlet fever in modified form. The various abnormalities in the date of
onset, and the nature of rashes, and the occurrence of batches of cases in
two schools at the same time, suggested a possible milk infection common
to both. Enquiry showed that both schools obtained their milk from a particular
dairy X, and that in both it had been possible for pupils to drink
the milk without previous boiling, though only in small quantities, e.g., with