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It will be noted that the age distribution reveals an exceptional proportion of adolescents
and adults. This is not necessarily an indication of the age distribution of scarlet fever in the
community, but is probably connected with the problem of finding accommodation for older
patients during the measles epidemic.
(ii) Serum rashes.—These occurred in 28.9 per cent, of the series, an incidence which is
somewhat high in the case of concentrated serum in the dosage employed, but which is in part
explicable by the high proportion of adults.
(iii) Post - tonsillectomy and surgical scarlet fever.—In the series analysed there were 4 cases
of post-tonsillectomy scarlet fever, and 4 cases of surgical scarlet fever. Although both conditions
arise as the result of infection of wounds, surgical or otherwise, it is interesting to note that in
the post-tonsillectomy cases, as in ordinary scarlet fever, pure cultures of the hsemolytic
streptococcus are recovered from the throat; in the surgical cases cultures from the throat are
negative, but pure cultures are obtained from the surface of the wound. This was true in each
of the 4 cases of surgical scarlet fever here recorded. Otherwise surgical scarlet fever is clinically
indistinguishable from scarlet fever arising from a naso-pharyngeal focus.
(iv) Complications.-—The percentage incidence of the main complications was as follows
(since exactly 1,000 cases were included the actual numbers need not be stated):—
Otitis media.
5-8
Adenitis.
5
Albuminuria.
2-8
Acute nephritis.
0-8
Polyarthritis.
0-8
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The few cases of polyarthritis occurred amongst adults and were, with little doubt, " rheumatic."
A previous history of rheumatic manifestations, either arthritis, carditis, or chorea was
obtained in 1-7 per cent, of the series.
Clinically and administratively otitis media may be considered as the most important
complication of scarlet fever at the present time. The incidence at all ages in the series analysed
was low (5'8 per cent.), and might in part be attributed to the high proportion of adult patients.
But an analysis of the incidence of this complication in the various age groups shows that this is
not an adequate explanation, since the incidence in all groups is low. Thus :—
Age. Scarlet fever. Otitis. Percentage incidence.
0—5 years 381 33 8.6
5—10 284 16 5.6
10—15 122 6 4.9
Over 15 213 3 1.4
All ages 1,000 58 5.8
The low incidence of otitis media in each age group is to be ascribed to several factors :
(a) the mild clinical type of scarlet fever; (&) the possible influence of scarlet fever antitoxin;
(c) maintenance of adequate bed-spacing, 12 feet between bed centres being adhered to throughout;
(d) prompt barrier nursing of all patients with grossly infective foci, e.g., suppurative adenitis,
paronychia, impetigo and otitis media. Cases of impetigo and otitis media were removed as soon
as possible either to cubicles or special ear wards.
As to the relative importance of each of these factors the following observations may be
made:—
(а) Clinical type.—In the series under review there were only 5 examples of the septic type
of disease.
(б) Scarlet fever antitoxin.—Probably most observers are agreed that scarlet fever antitoxin
does tend to diminish the incidence of complications, but the complication which is least likely to
be affected by this measure is otitis media, which is the result of extension of either the primary
upper respiratory tract infection, so often seen in the septic type of the disease, or of a re-infection
of the upper respiratory tract.
Since the serum is purely antitoxic, the specific effect can only be indirect, and it is notable
that scarlatinal otitis media, save in the septic type, tends to be a late manifestation when the
acute phase is at an end.
(c) Bed-spacing.-—With a space of 12 feet between bed centres it is true that viral infections
such as the common cold and allied influenzal conditions, measles in the early catarrhal stage and
chickenpox in its earliest stages, may, with great probability, be transmitted from bed to bed by
droplet spray. But it cannot be seriously contended that bacterial infections of the upper
respiratory tract are transmitted in effective dosage by droplet spray through this distance.
Droplet spray as a mode of dissemination of streptococcal infections from bed to bed being
eliminated, there remain for practical purposes two modes of transmission of an upper respiratory
tract infection from one patient to another, viz., close personal contact when the patients are
in the convalescent stage and are up and about, and mediate transference either upon the fingers
of the attendants or upon utensils. In the case of younger children especially, given adequate
bed spacing, the latter is undoubtedly the common mode of infection; as exemplified in the
case of impetigo, when it spreads to another child.