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35
1920
position that the desquamated skin is, or can be, infectious. As
a matter of experience the period of six to eight weeks which elapses
before desquamation is complete usually covers the time in which
most of the complications of scarlet fever occur, and it is also well
beyond the average time taken to clear the throat of diphthiritic
infection. Unfortunately, though, the period of infection cannot
be said to coincide with the period of desquamation. Probably
the most infectious period is in the earl stage of the disease before
desquamation has commenced; frequently the patient can, without
risk, be discharged as free from infection, although he has not
finished peeling on the soles of his feet and palms of his hands.
More unfortunate still is the fact that in a small percentage of
cases the infection persists long after desquamation has finished,
and these are the ones which give rise to "return cases." The
controversy concerning" return cases "which took place some
years ago did much good in focussing attention on some of the
conditions which were likely to give rise to "return cases." It
is now known that patients suffering from enlarged tonsils and adenoids
are likely to give rise to "return cases," and removal of the
tonsils and adenoids are attempted before the patients are discharged
from hospital, or at any rate before the resumption of
school attendance. A sore in or around the orifice of the nose
is another condition in which the affection is likely to persist,
and as much attention is paid to this condition as was formerly
paid to a discharge from the ears. Sometimes a post-nasal catarrh,
or an ulceration of the nose or a discharging ear starts after the
patient has been discharged from the hospital, and these are the
patients which usually give rise to "return cases." Occasionally
a "return case" occurs, and no abnormal condition whatsoever
exists in the supposed infecting case. Whether these cases are
dependent upon the persistence of the infection in the patient
discharged from isolation cannot be ascertained until the germ of
scarlet fever has been isolated. At present we reckon every case
that occurs within two months of the discharge of a patient from
hospital as a " return case," and last year we had 9 " return cases."
Encephalitis Lethargica.
There were two cases of Encephalitis Lethargica notified,
and in one instance the patient died and the other patient recovered.
In one of the cases the circumstances were peculiar, as it
was the second case that occurred in the same house. Probably
there was no connection between the first and the second case.
The first case in the house occurred in May, 1919, and the patient
died of the disease. Generally, the degree of infectivity from
person to person is of a low order, and cases of the disease usually
appear to be isolated or sporadic. Multiple cases of the disease