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of the seasonal wave, as well as that of the major "waves" of epidemic periods, is consistent witl
the hypothesis that the susceptible stock becomes more rapidly exhausted in the denser areas.
Report by
Dr. R.
Armstrong
on catarrhal
sore throat
or glandular
fever in
Fulham and
Hammersmith.
Intercurrent with the outbreak of scarlet fever there was a heavy incidence of epidemic sore
throat which greatly complicated matters and added to the difficulties of prevention in school. Dr.
Richard Armstrong made a special investigation into certain outbreaks of catarrhal sore-throat in
the North-Western division, and reported as follows :—
"As assistant school medical officer, I carried out, during the months of November and December
last, a number of routine enquiries into the occurrence of cases of scarlet fever and diphtheria in
schools in the Fulham and Hammersmith districts.
Whereas the cases of scarlet fever and diphtheria were apparently sporadic and infected from
external sources, there have been a very large number of cases of catarrhal sore-throat in the schools,
particularly in the Infants' Departments and there seems reason to believe that this disease, from
whatever source primarily derived, has spread from child to child and class to class within the schools.
The Infants' Department of Flora-gardens school has suffered very heavily in respect of absence
due to sore-throat, " colds," etc.—approaching 50 per cent. of children in attendance—and in addition
cases accepted as scarlet fever have also arisen.
The occurrence in all scarlet fever epidemics of mild or abortive cases suggested that there
might be some relationship between the large number of cases of sore throat and the cases notified
as scarlet fever.
The observation that haemolytic streptococci constitute a characteristic infection of the
throat during scarlet fever suggested that these micro-organisms afford a means of detecting the
possible presence of scarlet fever virus in cases otherwise clinically atypical.
Having sought and obtained permission to investigate the epidemic at Flora-gardens school
from this standpoint I have undertaken the following experiments.
(1). Bacteriological examination of material from the tonsils of three selected groups of children
at Flora-gardens school, namely, (a) children acutely ill, about to be excluded by the head teacher;
(b) children returned after exclusion, having suffered from sore throat; (c) children regularly in
attendance during the outbreak.
(2) As a control test, similar examination of children from (a) a school which has been quite free
from throat illness ; (b) a school slightly affected in which no further cases had recently occurred.
(3) As a further control, the results are recorded of the examination of material from the fauces
of ten typical cases of scarlet fever at the South Western Metropolitan Asylums Board hospital, during
the first week of the disease, carried out by Dr. M. H. Gordon, C.M.G., C.B.E., at the same time as
the above, in the laboratory of St. Bartholomew's Hospital.
As a result of the investigation it has been found:—
(1) That the fauces of infants examined at Flora-gardens school are almost all heavily infected
with micrococcus catarrhalis, haemolytic streptococci being absent. This holds not only for infants
who developed symptoms but also in others of the same school who escaped illness.
(2) That infants from the control unaffected school are free from M. catarrhalis, the flora of the
fauces consisting mainly of streptococci, pneumococci, diphtheroids, etc., the streptococci present
being non-heemolytic. By far the greater number of organisms found in the throat in health and
disease normally belong to the above mentioned non-hsemolytic groups.
(3) That children from the school in which the epidemic has run its course fall into two groups ;
(x) Those showing persistent signs of illness e.g., enlargement of tonsils, etc. (about 60 per cent). Such
have yielded cultures in which M. catarrhalis predominates. ; (y) those in all respects in good health
(about 40 per cent.) Such yield cultures from the fauces of streptococci, diphtheroids, etc.
(4) That the scarlet fever cases at an early stage of the disease uniformly show heavy infection
with hemolytic streptococci.
So far as these observations go they suggest—
(1) That the outbreak of catarrhal sore throat which has prevailed recently at Flora-gardens school
and to a greater or less extent in other schools in the Fulham area, has no relationship with scarlet
fever.
(2) That the cases of catarrhal sore throat, etc., are apparently the result of infection with Micrococcus
catarrhalis.
(3) That the carrier rate of catarrhalis corresponds with the incidence of this disorder, since
the micro-organism was present in over 90 per cent, of the children affected with the disease or in
contact with it, while the same micro-organism was absent in approximately 90 per cent, of the children
examined at the control school where no such outbreak of illness had taken place.
(4) That the outbreak has the characters of a true epidemic in that it presents a recognisable
disease symptom-complex constantly associated with a definite infecting agent, the distribution of which
corresponded with that of the disease.
A summary of the clinical features of the epidemic, the experimental observations on which the
above conclusions are based, a reference to literature and certain observations with regard to treatment,
follow. Owing to the limited facilities for studying cases presented by the brief examination which is
all that school conditions permit, a complete survey cannot be given. The following are salient symptoms
and signs.
(1) Onset usually sudden, with (2) lassitude ; (3) malaise ; (4) thickly furred tongue ; (5) dysphagia.
(6) Marked and persistent tonsillar enlargement. Injection of the fauces is seldom marked—
dilated venules are conspicuous over the tonsils which are swollen, hard and often (as commonly
described) of " gristly" appearance, no exudate on surface nor in crypts. I suggest the name
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