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It will be seen from the foregoing table that the scarlet fever death-rate was in the period 1901—4
highest in Bermondsey (0.20) and lowest in Hampstead (005), and in the year 1905 was highest in
Shoreditch (0.24) and lowest in Lewisham (0.03). The scarlet fever death-rates obtaining in London
during the four quarters of the year 1905 were as follows:— first quarter, 0.11; second quarter,
0.10; third quarter, 0.11; and fourth quarter, 0.15 per 1,000 persons living.
Scarlet fever appears to have manifested greater infectivity during the year, but the fatality
still remained low, both the number of cases and of deaths having been some 50 per cent. greater than
in the preceding year of 1904. Only one outbreak of scarlet fever was attributed to the distribution
of an infected milk supply. This outbreak occurred in Wandsworth, mainly in the early part of the
month of April, and involved the attack of 20 persons. A child of one of the men employed in distributing
the milk was among the sufferers and Dr. Caldwell Smith found no other cause to which he
could attribute the outbreak. The annual reports give account of local prevalences due to communication
of infection from one person to another, the mildness of the disease giving opportunity
for Cases of scarlet fever to remain undetected. In these circumstances it is not matter for surprise
that much difficulty was experienced in finding the source of infection of many cases. In Finsbury, Dr.
Newman was able to discover the source of infection in 265 of 456 cases brought to his knowledge;
in Battersea, Dr. McCleary was able to find the source of infection of 144 out of 801 cases, and in
Bermondsey, Dr. Brown in 120 cases out of 768. In Battersea, in 144 cases there was history of
exposure to infection from a previous case, in 55 cases there was good reason for suspecting school
infection, and 23 were "return cases." The sources of infection of the Bermondsey cases were
attributed in 47 cases to previous cases in the house or family, in eight cases to friends (visiting), in
four cases to infection in hospital where they were sent for other reasons, in thirty-five cases to infection
in school, and twenty-six were " return cases."

In a number of the annual reports "return cases" are discussed. This subject was reported
upon in 1904 by Dr. A. G. R. Cameron, and is still being investigated by Dr. F. M. Turner on behalf of
the Metropolitan Asylums Board. The results are not finally conclusive and it is interesting to note
that the observations of Dr. Cameron cast suspicion especially, as sources of infection, upon children
who developed rhinorrhoea, while Dr. Turner has not found evidence of infectivity above the average
in such cases after ten weeks detention in hospital. A notice as to the precautions to be observed
on the return home of a child discharged from hospital is now communicated to parents whose
children have suffered from scarlet fever in the hospitals of the Board.
Scarlet fever and elementary schools.
The summer holiday of the London County Council schools began in 1905 on Thursday, the
27th July, i.e., the latter part of the 30th week, and the schools re-opened on Monday, the 28th
August, i.e., at the beginning uf the 35th week. If the number of cases notified in the four weeks,
which would be most subject to holiday influence, be compared with the number of cases notified in
the four preceding and four subsequent weeks, the results shown in the following table are obtained:—

It is interesting to note that the year 1905 is the first year since the question has been considered
that the number of cases of scarlet fever among children at school age has in the summer holiday month
exceeded that of the preceding month. This increase has been due in the main to exceptional prevalence
in St. Pancras, where an outbreak occurred during the month of August, involving in that and the
subsequent period the attack of some 140 persons, and to exceptional prevalence in Stepney in the
neighbourhood of Montague-street and Wentworth-street, apparently due to infection from a boy,
the nature of whose illness had not been recognised and whom Dr. Thomas found to be suffering from
desquamation of the skin. Dr. Kerr (see Appendix II.), states that in only three instances were
school departments (infants.) closed during the year ended March, 1906, on account of the occurrence
of scarlet fever among the scholars, while in nine instances classes were closed on this account, seven
of the classes being in infants. departments.
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