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1920
34
It is generally conceded that these mild cases constitute
a greater danger from the public health point of view than the
severer and more pronounced forms, for they are more likely to
escape detection and hence are mainly instrumental in keeping
alive an outbreak.
It is too frequently assumed that in every instance someone
is to blame for the failure to recognise the mild cases. Even
if it be granted that the virus of the disease, whatever it may
be, is certainly present in the blood, and that this presence is always
manifested by a characteristic rash, it is certain that the rash is
frequently present for a very short period.
I have examined many patients almost immediately on
their admission to the hospital, and there has been no sign of a
rash at the time of my examination. The other symptoms of
scarlet fever are present, and I have subsequently seen the doctor
in attendance, who informed me that there was a typical rash
when he examined the case a few hours previously. In some of
the milder cases, I can easily believe that the rash has made its
appearance and disappearance within less than 24 hours.
Possibly a larger percentage of these mild cases are detected
in Acton than in some other districts, as a careful examination
is made of each contact before he resumes school attendance.
When a case of scarlet fever occurs, all the other children of school
age in the house are examined at the end of the quarantine period,
before they resume attendance at school. If the contact gives
a history of sore throat since the occurrence of scarlet fever in
the house, or exhibits any suspicious symptoms, he is excluded from
school and kept under observation.
It is unfortunate that we have as yet no definite means of
determining where the infection of scarlet fever resides, how long
it persists, and in what circumstances it can live apart from the
human body.
There are good clinical grounds for believing that the
throat is the primary site of infection, and hence it is reasonable
to suppose that all exudate from that part of the body, whether
discharged through the mouth, nose, or by way of the eustachian
tube from a running ear, is virulent and capable of conveying the
disease to a susceptible-person. It is also probable that the
occurrence of "return" cases is dependent upon some abnormal
condition of the mucous membrane of the upper respiratory
passages. The condition of the skin is not now regarded as an
important index of the infection or non-infection of the patient.
If we regard the rash as evidence of blood infection, and that the
skin is performing its function as an excretory organ in common
with the kidneys, there is nothing inherently absurd in the