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in another class. The origin of the infectious sore throat was not clear, but may have been from " out
of school " association with a girl excluded on account of infection at home who subsequently developed
scarlet fever herself. In the case of each sister the girls sitting next in class were infected with scarlatina.
The second sister attended school for two days with her throat " wrapped up." None of the secondary
cases showed any symptoms in school or gave rise to further cases.
An example of a different method of spread may be given from Chequer-street School, where 27
cases occurred between April and the end of the year. The origin of the first case could not be detected.
There was no source of infection found in school. Seven further cases occurred in the summer term, but
no single case could be traced to school infection. Four cases occurred in one block of Peabody-buildings
in two families, another in the next block was contracted during a six weeks' absence, and the seventh
was also an " out of school" case. A number of " out of school" cases affecting children above or
below school age living in the same blocks were probably links. During the Michaelmas term 20 cases
occurred. The connection with the previous cases was not at school but extended over the holiday
period by means of out of school " cases. Seven of these were in five rooms of the girls' department,
two in two rooms of the boys', and 11 in five rooms in the infants'. The only suspicion of school spread
was four in one room of the infants', but they were spread over three months. Possibly only two of
these twenty were secondar}' in school, but even there the probability seemed more to be the home
contact. Fourteen of the cases came from the same, or neighbouring, blocks of buildings, whilst the only
remaining one was either infected in school as a secondary case or imported from a neighbouring borough
This explanation, even as it stands, of home and street contact, seems more reasonable than the hypothetical
infection in school, especially as after the careful kind of investigation detailed above no mild
cases were detected and practically no sore throats, nor were any missed cases revealed later. Further,
twelve different foci are needed to account for cases in twelve separate classrooms in three separate
departments and no secondary cases resulting. On the other hand, a continuous series of cases at
short intervals in neighbouring blocks of buildings favour the out of school dissemination. It is to be
remembered also that out of school there is no knowledge of, or control over, the cases of sore throat
which so often disseminate scarlatina.
Missed cases, or carriers which revive infection, of the type which Newsholme described as chronic
scarlatina, may cause trouble. In a small non-provided girls' and infants' school in Hampstead there
were four cases last summer. The first was an isolated case and was infected from a resident in the
same street. The others were three sisters attending three different classrooms. No secondary cases
occurred. In the Michaelmas term in the infants' classes three further cases occurred. One of the
previous cases had a period of indisposition after return to school and apparently affected two others,
and one suspicious case. During her absence no further case occurred, but they broke out again five
weeks later. Several were affected with sore throats and four children who were sitting together appeared
to have been mild cases of scarlet fever. After their exclusion no further cases occurred. Among the girls
the outbreak was confined to two classes. The first was possibly infected by one of the infant cases, but
apparently gave rise to no secondary case in school. A fortnight later in a girl with a sore throat the
diagnosis was missed until three weeks later her sister developed scarlatina. This girl meanwhile infected
a friend at school, and probably also another girl in the same room. Three Weeks later three suspicious
cases were discovered, and these gave rise to two others. All these children were sitting together. After
their exclusion there were no further cases. Of the 15 cases in this whole outbreak 12 showed no signs
of illness in school. Only one of the three others, and that a missed case with a doctor in attendance,
gave rise to secondary cases. The secondary cases were almost certainly due to mild cases thought at
the time to have sore throat only. The real significance of these cases would not have been discovered
had there been no school enquiry on the spot. If the school or classroom had been simply closed the
result might have been an extensive outbreak of scarlet fever in the neighbourhood.

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