REVIEW — TROPICAL MEDICINE, ETC. 123 



that is not easy to establish the supposed role of the cat as a carrier. He asks what Measles- 

 are the causes of the failure to stamp out measles, and replies : — coniiimed 



In the first place, though its infectivity is evanescent, yet while it lasts, measles is one of the most infectious 

 of all diseases. It is a very rare thing to see a single case of measles. Nearly every first case produces a crop of 

 others. In the second place, it is very infectious before the eruption appears, and therefore before the disease is 

 recognised as measles. When a medical man is called in, the presence on the buccal mucous membrane of 

 Koplik's spots, which often appear a day or two before the rash, may aid diagnosis, but the difficulty is that very 

 many cases are not seen by a doctor at this stage. Thirdly, parents look on measles as of no consequence, and 

 often do not send for a doctor. Fourthly, very few local authorities apply to the disease the powers of the 

 Compulsory Notification Act. Fifthly, epidemics come on so quickly and so extensively that hardly any authority 

 has a staff sufficient to cope with tliem. Sixthly, as compared with small-pox, there is no vaccine to protect 

 individuals against attack. Seventhly, school attendance gives the infection every facility for spreading, and 

 countries where education is compulsory are correspondingly liable to measles. 



To the question, Is hospital isolation the remedy ? the reply is in the negative owing 

 to the nature of the disease and the prohibitive cost. Notification is useless if no action 

 follows it. It is noteworthy, however, that broadly speaking, the disease is decidedly 

 dangerous up till the beginning of the fifth year of life ; is very little dangerous frotn 

 that time to the end of the tenth year, and afterwards is free from danger to life. The 

 policy, therefore, is to delay attack by measles — and measles is spread mainly by schools. 

 What is all-important is to receive early information of its occurrence. A couple of useful 

 pages on the vexed question of school closure are here inserted in full as likely to be of 

 value, for in Khartoum there are both Government and mission schools, and much might be 

 done by prompt action to avert or mitigate a measles epidemic : — 



With reference to the circumstances under which there is reason to hope that closure of a school, or of the 

 infant department of a school, will be effective in arresting the spread of measles, the general dictum may be 

 taken to be closure on account of the first case present in school during the infective stage. If it should so 

 happen that a first case is detained at home by parents from the on.set of catarrhal symptoms, or if a first case 

 develop catarrhal symptoms on a weekly holiday and does not return to school thereafter, the child may be 

 regarded as not having been in school during the infective phase, and a medical officer may correctly stay his hand 

 from closure. But if a first case has been present, say, in the infant department, red-eyed and sneezing, that first 

 case is an indication for closure of the department. 



In determining the time for which a school, or part of a school, should be closed, with the object of checking 

 measles, the medical officer will again be guided by circumstances ; but his ultimate criterion will be the reputed 

 incubation limit of measles, which may, for practical purposes, be taken as ten to fourteen days. It follows that 

 the beginning of closure cannot be delayed without risk much longer than a week from the date of the last 

 presence in the school of an infective case, for the case may have been infective for two days or three before it 

 ceased attendance. It follows also that the end of closure need not be carried beyond fifteen days from the same 

 date, which allows a margin of safety. It may occur in actual practice, more frequently than not, and especially 

 in the absence of notification, that a case of measles escapes the notice of the medical officer of health during its 

 earlier days. Alertness on the part of school officials may effect much towards obviating this omission, but in 

 most instances a few days will have passed before the data for closure are before the medical officer. 



Under these conditions, the medical officer will observe, in the first place, that, despite the lapse of a few 

 days, he may still have a day or two in hand before closure need take effect. Incubating measles is not infectious, 

 and these few days of grace will give him time to make the necessary arrangements, or to explain to incredulous 

 officials the benefits which will follow the step proposed. It is not essential that he should justify the scientific 

 faith that is in him by postponing closure to the limit of safety, but the knowledge that closure need not in aU 

 cases instantly follow the discovery of an infective child may prove helpful to him at a time of stress. 



The medical officer will observe, in the second place, as suggested above, that is is not necessary to continue 

 closure beyond fifteen days from the last exposure of the infant department to infection. An example will make 

 these general statements plain. On 3rd June, the medical officer becomes aware that the child is at home with 

 measles. Now the earliest date at which a case is probable will be ten days from the first exposure of the school 

 children on 29th May, that is to say, 8th June, and the latest date at which a case is probable will be fourteen 

 days from the last exposure of the school on 31st May, that is to say, 14th June. The medical officer decides on 

 closure. He closes the department on the 5th or 6th of June, with two or three safe days in hand, and he keeps 

 it closed from the 5th or 6th to the 15th June, a period of nine or ten days in all. 



At present it is not very often that the disease is heard of early enough to make this system of dealing with 

 it practicable. And, even where notification is compulsory, parents frequently do not send for a doctor at all, so 

 that medical notification is a broken reed, while notification by parents is almost entirely neglected. But much 

 more is likely to be done in the future than has been attempted hitherto for prevention of spread of measles 

 by schools. 



M'Vail remarks, however, that the introduction of regular medical inspection of school 

 children is the likeliest way to prevent the spread of measles by means of schools, and that 

 great assistance is to be expected from an intelligent and painstaking teacher, as the latter 

 has an excellent opportunity of observing the case in catarrhal stage. Naturally school 

 closure is of much less value in towns than in the country, for in the latter case there are 

 less opportunities for close intercourse out of school hours. Valuable notes on school 

 ventilation complete an able paper, which has attached to it an appendix in the form of a 

 type of an informative pamphlet, which we reproduce, as it is excellent. 



