R E T U R N CASES OF SCARLATINA.

By JOHN MARSHALL DAY, M.D. UNIV. DUBL. ;

Medical Superinteadent of the ttouse of Recovery and Fever llospital, Gork S~reeŸ Dublin.

[Read in Ÿ Sec~ion of S~ate M:edicine, April 11, 1913.]

FOR many years a controversy has been carried on as regards this disease, some considering that if a case occur in a household within six weeks after a case of scarlatina has been discharged from hospital it is a return case, and is due to some problematical neglect on the part of Ÿ hospital authorities, and in some cases the parents h~ve received damages in law against the doctor.

The following cases illustrate this point : C. M., aged five a n d a half years, was admitted on the

26th of October, 1912, suffering from scarlatin~. On the 1st of November she developed rheumatic fever with cardiac complications and otorrhoea later on. She improved con- siderably, and on December 26th she was removed out of the scarlatina into the non-infectious ward. Five days later her father, contrary to our advice, took her home; her otorrhoea had then ceased. He was advised to keep the other children away from her, and to call in his own doctor to attend her, owing to the condition of her he~rt.

He told me that she occupied a room to herself, but that often the other children ran in and out of ir. On the 10th of January, being then four days fil, her brother, aged two a n d a half years was admitted with scarlatina. Now, the question is, Was he a return case ? ir being two months

By DR. J. M. D.aY. 469

sŸ the commencement of the first child's illness, and she having been isolated for tire days before leaving

hospital. The second case was that of a boy who had been seven

weeks in hospital, of which three weeks had been spent in

the convalescent department of the hospital, after scarla- tina, and who afterwards was transferred to the non-in- fectious department of the hospital, where he was de- tained for five days. He was discharged, being, in our opinion, quite free from infection, having no discharge

from his ears. His sister was admitted on the 26th of December, and he was also sent back, having slight otorrhoea, which ceased in a few days. But was the otorrhoea the cause of the infection of bis sister ?

A converse case is as follows : ~ L a s t year I wrote to a lady to take home her child, convalescent after scarla- tina, on a Wednesday. On the Tuesday she brought in a child with scarlatina.

I discharged a child who had had scarlatina. A week afterwards another came in, and I though• ir was a return

case until I was told the first child had gone straight away to Kingstown, and had never been in contact with the other child.

What are return cases? I think you must lay down some limit, for one can scarcely be held responsible for cases which occur a f t e ra week or ten days unless one can

exclude all other sources of infection (a thing difficult to do in a city during epidemic times). I believe that if you admit that the poison may lurk in clothes, that often a child contracts scarlatina on a Sunday, is sent to hospital later in the week, and the week-day clothes are disin-

fected, not the Sunday clothes. They are puf on the child when he or she Ieaves hospital, and they are the source

47(} I:teturn Cases o/ ScarlatŸ

of infection. This question is of the more importance from the view of discharging from hospital, because one has to certify children as being safe to return to school and persons to their business, and, therefore, to determine when a patient is free from infection is very important to most medical men.

I remember a case where a boy was leaving hospital; his boots had got too small for hito, and the nurse (wrongly) gave him his brother 's boots to wear g, oing home, he also being a patient at the time. Another member of the family wore the boots afterwards and con- tracted scarlatina.

Dr. Cosgrave relates a case in which the parents, who kept the child at home, and being most anxious to prevent infection, disinfected the patient carefully. He chanccd to call j u s t a t the critical moment, and saw the little child, after her bath, run across to a non-infectious room to be dressed, but she was carrying a favourite doll with her which the doctor pointed out was full of infection. The people had never thought of this!

One has to consider very carefully in what way a clfild who has recovered from scarlatina may be infectious, a.nd what precautions should be taken before discharge from hospital. At one time we all equipped discharge depart- ments in which a child entered a room, was stripped there, entered a bath-room, was thoroughly bathed with some antiseptic in the water, and then handed over to another n u r s e (non-infectious), who dressed the child and handed her over to her parents. This procedure was objection- able, because, in the cold weather, the child was liable to cold b y being brought out in to the open air after a hot bath, orden with her hair not quite dry; also, ir necessi- tated two nurses being present to bathe and dress each

B y DR. J. M. DAy. 471

patient, and, lasfly, the child often developed a slight

nasal discharge which might become the nidus of fresh

infection. The next improvement was to subject the hair, nose,

ears, and throat to vigorous disinfection for a week before discharge.

I hold the view that the chief source of infection in scarlatina lies in the throat and nose, and, to a certain extent, in the otorrhcea which so frequently follows severe cases; a l s o - a n d on this point I may say I lay great s t ress~in the breath for about a wcek after discharge from the infectious wards.

When one considers that the nurses and attendants on scarlatina and diphtheria patients may often be the con- veyors of infection in their breath, although being them- selves quite well, one must lay great stress on this a s a source of infection. I was at one time looking after some children suffering from scarlatina belonging to a medical friend of reine; several of the family had escaped infec- tion, and were away in the country. One day I missed the governess who had been helping to nurse the sick ones, and was informed that she had been sent down to take charge of the other children. I said I was afraid she would c•rry infection, but the mother informed me that she had had a bath, washed her hair, and changed everything. I said her breath is infectious. The other children contracted the disease in a few days.

Following these lines, our present procedure is to pay no attention to the peeling, but to rely altogether on the condition of the nose, throat, and ears. As long as there is any redness of the throat or nasal discharge a child is not safe to be discharged. If the tonsils be enlarged we have them removed, unless the parents object; in which

472 Return Cases o~ ScarlatŸ

case we decline to take the responsibiIRy of guaranteeing freedom from infectŸ

When we think the child is ready we write to the parents to know if they can isolate the child for a week from the other children, and if they cannot do so we arrange ~o puf the child in a separate non-infectious ward for that period. I may relate a story here which illustrates my position. I was treating several children from ah insti- tution near Dublin, and the authorities arranged, as the, children went back, to keep them apart from the others for a week. The last child went back, and lo and behold ! another child carne in a few days later ; in fac~, the sister of the last case. The authorities blamed me very much, but on inquiry I found that as the child who was just dis- charged was going through the pla.yground of the school the sister ran over to her and kissed her; she alone got scarlatina.

As regards otorrhcea, which may become chronic, their stay in hospital is at least two months, c]uring which time careful antiseptic t reatment is carried out, and in the

few cases that do not cease after that time we detain them longer if the parents will permit, at the same time remov- ing them ou~ of the infec~ious wards.

THE CHAIRMAN, DR. KIRKPATRICK, said that the paper w~s one of impor~ance to every physician who had charge of cases of scarlatina.

The form of scarlatina experienced in Dublin recently was mfld, and there appeared to be a cer~ain amount of laxi~y wi~h regard to the trea~ment and management of pa~ients as compared with ~wen~y years ago, yet~ the seriousness of ~he disease is often brough~ home to us through its many eompliea~ions, and the problem of the treatment and management of i~ mus~ always remain of first importante s inze ir, incapacRa~es t, he individual for a considerable

By DI~. J. M . DA]:. 473

period. Personally, he had always experienced the greatest difficul~y in forming any estimation as to when a patient was free from the disease, and he did not think that this question would ever be satisfac~rily settled until the specific c~use of the disease can be ascertained.

The rule that he usually acted upon was to isolate pa~ients for at least six weeks, no matter how well they appeared, and ir a~ the end of that time there was any abnormal dis- charge from any part of the body he would consider the patient i¡ as long as the discharge continued. The old idea that ~he desquamated epithelium was infectious he though~ was not correct, as after the patient had been treated with antiseptics he considered ir unlikely that any in~ection would remain in the epidermis.

DR. DELAHOYDE did not agree with Dr. Day that the breath conveyed infection, and he considered six weeks scarcely sufficient to free a patient from infection.

Da. COPE recalled a case of a littIe boy, a patient of his, who had been in hospital for six or seven weeks, and after being discharged wen~ away to friends f o r a fortnigh~ before re~urning to bis family; ye~ on bis retul~~ home his little sister developed scarlatina. He had ascertained that the lit~le boy and girl had slept in the one bed on one occasion some two mon~hs after the boy's discharge from hospital. Whe~her this might be looked upon as a return case he did not know. He also gave another instance of a doubtful return case of which he had experience.

DR. CRO~TOS said tha~ when practising in England he had experienced two severe epidemics of scarlet rever, and the rules carried out were somewhat similar to those indicated by Dr. Kirkpatrick, and he did not meet with a single return case.

DR. MATSON said that the great trouble me~ with in cases of scarlatina was that ir there was any sort of peeling going on when the patient was discharged ir would be interpreted by the layman a s a source of infection, and the result was that patients had to be kept in hospital often as long as ~wo and a hall months.

He considered that there was a great deal in what Dr. Day said regarding infection by the breath.

47~ Return Cases of ScarlatŸ

I)R. WINTER referred to a repor~ by Dr. Milne, the Medical Omcer of Dr. Barnardo 's Homes, who was a very s~rong advocat,e of local treatmen~, bis me~hod being b carefully swab t,he ~hroat and syringe t,he nose with anti- sep~ics and to anoint' the body with either carbolic or euca- lyp~us oil, and he claimed t, hat, none of the patients so treated ever conveyed the infec~ion to others. So confident was the Medical Officer of Dr. Barnardo's Homes as to the emciency of this t rea tment that, he was wont to have his opera~ion cases side by side with his scarlatina cases in hospital, and he claimed that, the infection never spread. Dr Winter said that, he had opportunities of trying this treab ment wit,h apparent success.

:DR. O'FARRELL said the question about discharge inter- ested him, as he had recently met with two cases of diph- theria in which he got bacilli from the nose and ear. I~ occurred to hito tha~ two monbhs seemed a long time to keep a person in for discharge from the ear. He inquired if Dr. Day had experience of vaccine treat,ment in cases of dis- charge from the ears. He did not consŸ that the ordinary case of scarla~ina carried infecbion in the breath.

DR. Y)Au replying to the remarks, said he never believed in the early infection theory. There was little doubt tha~ persons working in diphtheria wards carried infection in their breath. He thought ir probable that those breathing a dipht, heria or scarla~ina •tmosphere are likely to suck in a certain amount of infect,ion to the lungs. He did not place much reliance on the six weeks' isolation. He tried a good m~ny tases wi~h wccines, and in some cases the method ac~ed wonderfully, but in others i~ did no~ seem to make the slightest improvement. He considered that scarlatina was not a mono-infection. He had always held that a great many of the cases meb with have diphtheria mixed with scarlatina. The reason for keeping children in hospital so long for ear discharge is tha~ they may be properly treated.