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time, and may therefore as well, if not preferably, have it at once. The results, however, to which our statistical inquiry has led us, are completely subversive of such a position. They show-independently of the plain fact that a very large proportion of persons go through life without ever contracting this diseasethat the longer an attack is deferred, the less likely it is to occur at all; and not only so, but that, even supposing it to occur eventually, the less likely it is to end fatally."

(294) Sequela and Complications of Scarlet Fever.

Of late years the relative frequency of different complications of scarlet fever has been studied on a large scale in the hospitals connected with the Asylums Board, and the various reports of the Statistical Committee constitute a veritable mine of information. A curious circumstance about these reports is however the undoubted fact that scarlatina derived from one part of the Metropolitan area does not present the same percentage of complications as another; for instance, in the 1887 epidemic, in the Eastern Hospital, albuminuria complicated the cases in the proportion of 49 per cent. of the attacks, while in the Western Hospital, in the same year and the same epidemic, albuminuria prevailed in the proportion of 35.6 per cent.; it may be suggested that the staff of the one hospital more diligently examined the urine than of the other, but there are similar differences with other diseases; take, for example, otorrhea in 1887 the Eastern Hospital records show, in over 1,000 cases, that otorrhea prevailed in the proportion of 43 per cent., in the Western 11:0 per cent. Hence it is impossible to be dogmatic with regard to the relative frequency of particular complications: it may however be useful to give the following percentages observed, compiled from 1,115 cases of scarlet fever admitted into the Western Hospital in 1887

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To this may be added a long list of less frequent complications, such as hæmaturia, pyæmia, convulsions, dropsy, peri and endocarditis, laryngitis, cystitis, and others. It must be specially noted that the complications mentioned above rarely occur simply, they are for the most part compound, that is, a person will suffer at once from albuminuria, otorrhea, and abscess, or other combinations.

Dr. Sweeting has observed the remarkable fact that albuminuria has been on the increase in the Western Hospital in successive epidemics, due, as he considers to decreasing cubic space, the wards becoming in successive years more crowded with patients. He gives the following table:

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The same increase of albuminuria has been noted by Dr. Thorne, late physician to the London Fever Hospital, who says,1 "There have been occasions when, owing to repairs or otherwise, it has been found necessary as a temporary measure to exceed the number of patients properly allotted to one or other ward, and when this has been the case the practice has almost invariably been followed by an increase in the number of patients exhibiting albumen in the urine."

It may well form the subject of inquiry whether the curious. odour given off by lungs and skin in the worst form of scarlet 1 Practitioner, December, 1887.

fever is not some volatile toxic matter producing albuminuria, if so, it would be a reasonable explanation of the above facts. Whatever the cause of the increase, such observations are additional arguments for the amplest cubic space in infectious hospitals.

(295) Period during which it is necessary to isolate Scarlet
Fever Patients.

It is to be hoped that accurate observations based upon experimental data will ere long be forthcoming, so as to enable us to know when a patient ceases to be contagious; at present we have to rely solely upon the length of desquamation or discharges. That in the prolonged "peeling" of some cases of scarlet fever the debris contains the scarlatinal infection is more a inatter of inference than actual proof, but until the question is settled, it will be safest to take the period of seven weeks from the beginning of the illness as a rule for ordinary cases, provided the desquamation is finished, and this is the opinion of Dr. Gayton,1 the superintendent of the North-Western Hospital, whose observations may be quoted verbatim :-"The variableness of desquamation, or peeling, is by all medical men admitted. Occasionally a long period elapses before the whole of the cuticle has separatedsix weeks, two months, and longer; indeed, that on the soles of the feet may often be seen peeling long after the desquamation on the rest of the body has ceased, when the patient is perfectly well, and has been walking about, perhaps, for a long time. Again, it may be so slight as to be perceptible about the roots of the nails only, or so considerable as to cover the whole place with dust every time the patient shakes himself, during the whole of which time, however, it would be utterly wrong-nay, criminal-to sanction any inter-communication with the healthy. Enforced isolation, after a time at least, is no doubt very hard, especially in cases where the disease is slight, where there is no sense of illness, and but slight or no appearance of desquamation, but, nevertheless, it is sound doctrine; the precaution may appear needlessly excessive, but the case is one for great caution. As a matter, therefore, of sanitary precaution against the dissemination of infection, it is,

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

from my point of view, utterly wrong to permit any scarlet fever patient whatever to mingle with persons susceptible to the disease until the expiration of seven weeks from the beginning of the illnesss, and in those cases where the desquamation is of late appearance, until the process is completed, and for a fortnight afterwards, nor then, unless there is entire absence of discharge from the nose and ears, and the clothes worn on discharge are clean and thoroughly disinfected."

(296) The Connexion of Scarlatina with Disease in Milch Cows.

That in some way or other milk conveys the cause of scarlet fever has been many times noticed, but it was not until the inquiry by Mr. Power into an epidemic of scarlet fever (1882) in St. Giles and St. Pancras, that there were sufficient grounds for believing that the cow itself may secrete milk which, independent of human agency, is an infectious fluid, and will give those drinking such milk, who are susceptible of the poison, scarlet fever. To quote Buchanan, in this epidemic "two facts could be affirmed; the one, that a cow recently come into milk at a particular farm had been suffering from some ailment, seemingly from the time of her calving, of which loss of hair in patches was the most conspicuous manifestation; the other, that there existed no discoverable means by which the milk, which had coincided with scarlatina in its distribution, could have received infective quality from the human subject." The facts, although imperfect, were so far suggestive that, at the instance of the Local Government Board, Dr. Klein made some experimental observations as to the concern of animals with human scarlatina, and it was found that, particularly when a cow was in milk, a definite disease was producible in the animal by means of scarlatina infection, the disease was capable of being communicated from one animal to another by inoculation.

In 1885 new light was thrown upon the subject, by what is known as the Marylebone epidemic. The author reported to the Local Government Board a sudden and extensive outbreak of scarlet fever that was evidently connected with a particular milk supply. The retailer obtained his supply from two farms, and the coincidence of the retail milk distribution with scarlatina. was limited to one portion of the milk, which portion only was

derived from a certain farm at Hendon. Mr. Power was deputed to investigate the matter, and he found that milk had been distributed by retail in St. John's Wood, in St. Pancras, in Hampstead, and at Hendon, and in these districts only, and from every one of these districts, except from St. John's Wood, the same general story was forthcoming. "Until the end of November or beginning of December, 1885, the district had been for some months exceptionally free from scarlatina; about this date scarlatina had undergone a sudden and notable increase in the district, and then and thenceforward a strikingly large proportion of the recorded cases had occurred among persons who proved, upon inquiry, to be customers of the milk retailer dealing in the particular Hendon milk." A very strict inquiry at the Hendon farm seemed to put beyond a doubt, that the milk had not been contaminated there by human agency.

By a series of facts amply detailed in Mr. Power's report, among which the exemption of the St. John's Wood customers occupied an important link in the chain of evidence, the infected milk was traced to a particular cowshed, and to particular cows. In the end it was demonstrated beyond a reasonable doubt that in December these cows suffered from an eruptive disease of the udder and teats, a condition first introduced there in the previous month by some cows newly arrived from Derbyshire.

Products derived from the affected animals were studied by Dr. Klein, and two of the cows were purchased and conveyed to the Brown Institution.

Dr. Klein 2 made a series of researches with this material, and the results of which up to the present are as follows:

The cow disease is characterised by closely similar anatomical features to the disease in man. From the diseased tissues and organs of man and cow alike a streptococcus can be separated which has the following characters. The streptococcus grows on gelatin in opaque white colonies, and it does not liquify the gelatin. It is slower of growth than most micrococci. After a long time (several weeks) it has a fairly distinct but slightly irregular and crenate outline here and there, beset

1 Fifteenth Annual Report of the Local Government Board (Supplement), 1885-6. 2 Seventeenth Annual Report of the Local Government Board (Supplement), 1887-8, p. xiii.

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