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47
Scarlet fever
in relation
to "social
condition."
Glasgow,
1898-1902.
Dr. Brownlee took as his index of the various social conditions the number of persons per room,
and he arranged the districts of Glasgow in order accordingly, beginning with a group containing .5-1
persons per room and ending with a group having 2.5-2.75 persons per room. He also gave the
scarlet fever attack rates for the corresponding groups of districts and for the five year period 1898-1902;
these rates ranged from 388'2 to 1384 per 10,000 children per annum. It should be especially noted
that he took the total numbers of scarlet fever cases and applied these totals to the populations at ages
under 10 years. The result is a very striking one, the group of least crowded districts had the highest
scarlet fever incidence rate (388'2), and, passing from group to group of the districts, as the crowding
increased, the scarlet fever rates steadily diminished (to 1384). Dr. Brownlee hints that this paradoxical
result may be in part due to failure to notify in the more crowded districts, but he thinks it cannot
thus be wholly explained away. Apart from this consideration, however, the application of the scarlet
fever cases at all ages to the numbers of children under 10, materially affects the value of the rates for
comparative purposes in the Glasgow districts, for some of the richer and less overcrowded districts
contain quite a small proportion of children, and these are contrasted with the poorer crowded districts
which have an abnormally large proportion of children. Thus the method of calculating the rates
adopted goes at least a considerable part of the way in explaining the results obtained. Over and
above this, moreover, it appears that two milk outbreaks occurred in Glasgow during the years 18981902,
and one of these, if not both, affected the least crowded districts in question. It is recorded by
Dr. Chalmers, the Medical Officer of Health, that only adults were attacked in one of these outbreaks;
it was a small one and the populations upon which the rates are calculated were quite small too. The
arrangement of sanitary areas in Glasgow was altered shortly after 1902, but on testing the now existing
sanitary areas of Glasgow, for more recent years, results such as those yielded in 1898-1902 arc, as a rule,
no longer obtainable. Despite these drawbacks Dr. Brownlee's Table illustrates in a particularly striking
manner the undoubted fact that, at certain times and in certain places, the incidence of scarlet
fever is more heavy upon the less poor than upon the poor; and, indeed, Dr. Robertson of Birmingham,
remarks (Annual Report for 1913) that "scarlet fever is less a disease of the squalid areas than it is of
the suburbs." It should be added that Dr. Brownlee observes "In some towns it is quite true, it (scarlet
fever) is more common in the lower than in the upper class districts, but this is by no means the
rule."
The Glasgow rates in 1898-1902 have been referred to in detail not so much on account of the
use made of them by Dr. Brownlee as because there is some risk that, appearing where they do, the
figures may be cited as a typical instance of the natural behaviour of scarlet fever, although it is obvious
that Dr. Brownlee does not so regard them.
Mr. J. Netten Radcliffe many years ago (Epidem. Trans. 1864-5, p. 262) went to the root of the
whole matter. He observes, "Once let it be determined that there are constant foci of scarlatinal
infection and half the battle of preventive medicine is won." He then describes the 20 great
"scarlatina fields" in the England of the time, and he advocates application of means of prevention
" to the great foci of infection—the crowded courts of great towns." Again, referring to the cases in the
poor home, he says, "These cases, which always exist more or less in great towns, are the persistent
sources of infection in the Kingdom." In Mr. Radcliffe's experience scarlet fever was a terrible scourge,
causing upwards of 15,000 deaths in England annually. Thanks to the preventive measures and
particularly to isolation and cleansing, first advocated from 60 to 80 years ago, this mortality has been
reduced to below 3,000 deaths annually; the corresponding rates being approximately 1,200 per
million in 1840 and 77 per million in 1914.
The epidemiologists of the middle of the last century did not live to witness the carrying into
full effect of the preventive measures which they advocated. Their followers have, however, seen that
practically pari passu with the carrying out of these measures, scarlet fever has declined. The course of
events, indeed, justifies in large measure Mr. Radcliffe's far sighted prophecy that if cases of the disease
could be" weeded out of the denser masses of population as they occur "it would be" to the incalculable
gain of the people." In the light of all the facts it is clear that too great stress must not be laid upon
the observation that "in the best parts of the city (Glasgow)," during a particular five years, there was
" nearly three times as much scarlet fever as in the worst."
Comparison
of scarlet
fever and
diphtheria
case rates in
London.
With the object of studying the question on a broad basis, the rates of scarlet fever and diphtheria
incidence, in London boroughs during a series of 18 years, have been used for purposes of comparison
in three different ways.
The accompanying diagram B is divided into three sections. In the first the shaded squares above
the line indicate, for any given year, a scarlet fever case rate exceeding by more than 10 per cent. the
London case rate for that year; the black squares below the line indicate diphtheria case rates for any
given year exceeding the London case rate of that year by 12 per cent. These percentages have been
so selected as to make the total number of shaded squares and black squares equal, i.e., 147.
The second section of the diagram serves to exhibit the years during which the case rate in any
given borough is high as compared with the average for that borough during the 18 years shown. The
shaded squares indicate a scarlet fever case rate exceeding by more than 24 per cent. the 18 year average
and the black squares diphtheria case rates exceeding this average by more than 14 per cent. The
shaded squares number 146 and the black 144, the numbers being thus almost the same.
In the third section of the diagram the London average case rate for the 18 years is taken as the
standard for each borough; the shaded squares indicate scarlet fever case rates exceeding this standard
by more than 10 per cent. and the black squares diphtheria case rates more than 13 per cent. in excess,
The shaded squares number 148 and the black 149.