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the 7th, and one on the 9th. The men engaged in the London dairy supplying the milk were in
good health, but it was found that the sister of a lad who attended to the refrigerator on one of five
farms supplying the daily with milk was suffering from scarlet fever. The supply of milk from
this farm was stopped until the Kith September. When it was again supplied scarlet fever again
appeared among the consumers, viz., two cases on the 25th September, three cases on the 28th,
two on the 29th and two on the 30th. Dr. Caldwell Smith then advised the milk seller to
Pasteurise the milk, keeping it separate from other supplies, after which no further cases
occurred.
In March of 1902 the Metropolitan Asylums Board, at the request of the Society of Medical
Officers of Health, made arrangements for communicating to London medical officers of health
immediately before their discharge from hospital the names of patients who had been received from
these officers' districts. In this way medical officers of health are able to keep under observation the
households which thus receive the patients, and note whether subsequent cases occur. This
system is especially desirable in view of a proposition to detain patients in the hospitals
for shorter periods than has hitherto been the practice. The results will be awaited with interest.
As in previous years, " return " cases from time to time occurred, i.e., persons developed
the disease within a short period of the return to their homes of patients discharged from the
hospitals. Some of the annual reports show such cases to have occurred as follows: In Fulham
there were 20 such cases within 14 days of the return of the first cases ; in Stoke Newington
there were 3 such cases ; in Finsbury the relatives attributed 14 cases to the return home of
antecedent scarlet fever or diphtheria patients ; in Shored itch there were 12 cases, in G of
which the evidence was very strong that the returned patient was the cause of the infection, in
the remaining 6 the evidence was doubtful ; in Stepney 15 primary cases, on their return home,
gave rise to 24 return cases; in Bermondsey, Dr. Brown states, the proportion of return cases to
cases admitted was, in 1901, 3 per cent., in 1902, 2.2 per cent., in 1903,1.5 per cent.; in Wandsworth
there were 50 return cases; in Greenwich 8; in Lewisham 41; and in Woolwich 10 cases,
due to the return home of 4 cases. Some of the patients who were believed to have given rise to
subsequent cases were observed to have discharge from nose or ears or some amount of
desquamation.
Scarlet fever and elementary schools.
The summer holiday of the London School Board schools began in 1903 on Thursday, the
23rd July, i.e., the latter part of the 29th week, and the schools re-opened on Monday, the 24th
August, i.e., at the beginning of the 34th 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 will be seen that the decrease during the period of holiday influence is most marked
at ages 3—13—

The effect of school closure during the summer holidays in interrupting the autumnal rise
of the disease in London is conspicuously shown in diagram IV., page 13, which may well be
compared with the corresponding diagram for enteric fever, in which this interruption is absent.
Proportion of cases of scarlet fever removed to hospital.
It will be seen from diagram VIII. that the proportion of cases of scarlet fever admitted
to the hospitals of the Metropolitan Asylums Board was slightly greater in 1903 than in the
preceding year.
Scarlet fever—Age and sex distribution.
The following table shows the cases, deaths, case-rates, death-rates and fatality of scarlet
fever at the several ages and for each sex in London during the year 1903. It will be seen that
the case-rate, death-rate and fatality were higher among males at "all ages" than among females.
In the age groups adopted for the purposes of this table the greatest incidence of attack was
upon both males and females of four years of age. The greatest incidence of death was upon
males of two, and upon females of three years of age. The fatality was greatest among males
of one year of age, and among females under one year of age—