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typical scarlet fever rash, with no sore throat, and the rash was followed by desquamation; the gentleman declared himself absolutely well, and it was with great incredulity that he received the diagnosis of scarlet fever. The difficulty of secluding the above cases is obvious; it is the slight ambulatory cases of scarlet fever which baffle diagnosis, obscure effectually the sequence from case to case, and act as insidious carriers of the disease from person to person. So far as is practical, the Medical Officer of Health should consider every case of sore throat in times of scarlet fever epidemic as likely to propagate scarlet fever, in short to be slight cases of the disease. This recommendation must not be taken to mean the exercise of compulsory powers of removal, for such powers must never be exercised unless the diagnosis is clear, but the recommendation refers to measures of isolation undertaken voluntarily on the advice of the health officer, and especially to the management of schools and public institutions.

(291) Seasonal Prevalence of Scarlet Fever.

The prevalence of scarlet fever is distinctly governed by season. The curve given in Buchan and Mitchell's paper,1 shows that the death-rate begins to rise in the first week of September, attains its maximum in October, commences to decline in December, and is the lowest in March, April, and May. The curve showing the admissions of scarlet fever patients to the Asylums Board Hospitals (see Plate, opposite) gives very similar results: during seventeen years the admissions fell to the minimum four times in February, four times in March, five times in April, twice in June, once in September, and once in December. The maximum number was attained once in January (1888), once in July, three times in September, seven times in October, three times in November, and twice in December.

(292) Mortality of Scarlet Fever.

This varies much in different years. During the seventeen years, from 1855-71, the total number of deaths was returned as 321,892, or on an average 18,934 yearly. 672 per cent. of these deaths were of children under five years of age.

1

Op cit. see page 369 for methods employed by the authors.

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The case and age mortality of scarlet fever can be gathered from the following Table 1 :—

TABLE XL.

SCARLET FEVER.-TABLE SHOWING MORTALITY AT VARIOUS AGES OF 25,788 CASES ADMITTED INTO THE ASYLUMS BOARD HOSPITALS.

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N.B.-The above table includes deaths within 48 hours after admission as well as deaths from intercurrent maladies.

Hence, if the deaths from scarlet fever be multiplied by 11, there is a fair probability that the number obtained will approximate to the number of cases occurring in a district.

(293) Sex and Age.

The following extract from the Forty-ninth Annual Report of the Registrar-General will show the incidence of scarlet fever on sex and age:

"In the course of the 27 years, 1859-85, nearly half a million deaths from scarlet fever were registered in England and Wales. These deaths form the basis of the following Table, which gives the mean annual mortality per million living at successive age-periods, for each sex.

1 Metropolitan Asylums Board. Annual Report of Statistical Committee, 1888.

TABLE XLI.

MEAN ANNUAL MORTALITY FROM SCARLET FEVER PER MILLION LIVING AT SUCCESSIVE AGE-PERIODS, 1859-85.

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It will be seen that in each sex the mortality from scarlet fever rises to a maximum in the third year of life, and then falls, at first slowly, but afterwards rapidly, becoming smaller and smaller with each successive age-period, to the end of life.

Further it will be noted that from birth to the end of the tenth year of life, that is to say, throughout that portion of life in which by far the greater part of the deaths from scarlet fever occur, the male mortality is considerably higher than the female mortality, but that after this period the reverse is the case, the excess being in each later age-period on the side of the female sex.

Seeing on what a very large basis these rates have been calculated, both as regards number of deaths and number of years over which they were spread, we may feel assured that the differences here pointed out between successive age-periods and the two sexes are not accidental or transitory, but fixed and permanent; and the question next to be considered is whether

1 The very variable severity of scarlet fever in different outbreaks makes it necessary, for any trustworthy statistics, to take a long series of years into account.

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