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Owing to the increase in the number of cases of scarlet fever in 1893 the hospital accommodation
available for this disease in London proved inadequate, and as a result a smaller proportion of the
total cases was received into and a smaller proportion of the total deaths occurred in the hospitals
of the Metropolitan Asylums Board than in the preceding three years. (See diagram VII.) Sir Edwin
Galsworthy states that it has been estimated that had sufficient accommodation existed when the
number of scarlet fever patients was at its maximum as many as 6,000 patients, or almost double the
actual number, would not improbably have been under treatment in the Board's hospitals at one and
the same time.
With a view to showing the number of cases in each week in relation to the mean of the year,
diagrams VIII. and IX. for the years 1892 and 1893 respectively have been prepared. It will be
observed that in the " all age " curves for these years there is a depression in that part of the curve
which relates to the month of August, the August depression in the curve for 1893 being much greater
than the August depression in the curve for the year 1892. The curve for the year 1893 deserves,
therefore, closer examination. If for this purpose the cases of scarlatina notified in that year be
divided into three classes, (a) those occurring in children from 0-3 years of age, (b) those occurring in
children from 3-13 years of age, and (c) those occurring in persons above 13 years of age, the cases
may be considered in relation to school operations, these three groups representing practically (a)
those who are too young to attend school, (b) those at the school age period of life, and (c) those who
have in great part left school. If curves be constructed with the cases included in these three groups
it will be seen that the August depression is much accentuated in the curve relating to children from
3-13 years of age, and that the depression in the curve relating to infants from 0-3 years occurs a
little later. This striking diminution of scarlet fever in the month of August, occurring especially
among children at the school age period of life, necessarily raises the question whether disease had
been spreading in schools and whether the summer holiday has arrested the spread of disease due to
this cause.
At this season of the year there is, however, another condition which deserves consideration.
Coincident with the closing of schools, children in considerable numbers migrate from London, and it
may be that the diminution in the number of cases of scarlet fever in August is in some part
attributable to this migration. Such inquiry as I have been able to make does not, however, lead
me to the conclusion that this circumstance affords sufficient explanation of the reduction of scarlatina
during the month of August. School operations must therefore be further considered. I am not able
to show for each week the number of children in London who are attending school, but so far as the
operations of the schools of the London School Board are concerned the dates at which the schools
generally close and re-open can be given. It is probable that the times of the closing and re-opening
of many other London schools correspond with the times of the closing and re-opening of the schools
of the Board.
In 1892 the schools of the London School Board generally closed for the summer holidays on
the 21st of July, i.e., towards the end of the 29th week, and re-opened on the 22nd of August, i.e., the
beginning of the 34th week. If time is allowed for the period of incubation and a little delay in
notification, any effect of school closure on the number of scarlatinal cases notified might be expected to
be manifested in the returns for the 31st, 32nd, 33rd, and 34th weeks, and the diagram shows that the
August depression corresponds with these weeks. Comparison between the number of cases in three
periods of four weeks, (1) the 27th—30th week, (2) the 31st—34th week, and (3) 35th—38th week at
several ages gives the following results—
Under 3—13 13 years
3 years. years. and above.
Increase or decrease per cent, of number
of cases in 2nd period in relation to
that of 1st +25 —9« +9
Increase per cent, of number of cases in
3rd period in relation to that of 2nd Nil. +52 +15
In the diagram for the year 1893 the August depression is still more marked. In this year the
schools generally closed on the 27th July, i.e., nearly the end of the 30th week, and reopened on the
28th of August, i.e., the beginning of the 35th week. Diminution in the number of cases notified
might be expected therefore in the 32nd, 33rd, 34th and 35th weeks, and the August depression in the
diagram corresponds with these weeks.
If comparison be again made between three periods of four weeks, i.e., 28th-31st, 32nd-35th,
and 36th-39th, the following results are obtained—
Under 3-13 13 years
3 years. years. and above.
Decrease per cent, of number of cases in
2nd period in relation to that of 1st —1 -26 -17
Increase per cent, of cases in 3rd period in
relation to that of 2nd +9 +65 +26
There appears, therefore, to be a very close relation between the August holidays and the
diminution in the amount of scarlatina.
The cases notified, and the deaths which occurred in 1893, are sufficiently numerous to be
deserving of comment with regard to the question of age distribution. A study of the following table
shows that the greater incidence of both disease and death was on males. At the several ages, the
greatest incidence of disease was in this year on males and females who were 4 to 5 years of age, the
greatest incidence of death was on males of 3 to 4 years and females of 2 to 3 years of age. The fatality
(case mortality) of males was greater than that of females. At the several ages the greatest fatality
occurred among males under 1 year of age, and among females from 1 to 2 years of age.
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