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35
At about the same date the possibility that even a prejudicial influence might be exerted by
hospital isolation was mooted, and this subject was very fully investigated by Mr. T. W. Thompson
(Trans. Epidem. Soc., Lond., 1895.6; and Report Local Gov. Board, 1896). He examined certain
instances in which return cases had been ascribed to hospital influence, and he says,"In a certain
proportion of instances, though by no means in all, a returned hospital patient is found upon examination
to exhibit some evidence of desquamation, or to be suffering from discharge from the nose or from
the ears, a discovery which is naturally held to strengthen the belief in his having reintroduced infection
into the household."On the other hand, as Mr. Thompson pointed out, the occurrence of the fresh
case may have been a mere coincidence, or have been due to failure to disinfect the dwelling, or may
have"probably owed its origin to the unpacking, in preparation for the home.coming of the hospital
patient, of some garment which had been worn by that patient prior to his removal to hospital, and
which had, upon his departure from home, been packed away in a drawer or box out of reach of any
aerial disinfection which might have been subsequently employed."
He concluded that while"the occurrence of a further case of scarlatina in a household shortly
after the return of a patient from hospital is sometimes merely a coincidence ... a proportion
of alleged cases are really due to infection in some way re.introduced into the dwelling by the patients
themselves."He doubted whether such patients operated merely as mechanical carriers of infection;
he questioned the sufficiency of the"infected breath"theory; and he thought the influence of
desquamation required"very careful study,"as also that of"the influence of catarrhal conditions
of the nose, ear and throat."His enquiry elicited, however, the important fact that there was a special
incidence of secondary invasion"upon the hospital class of households"; there was a suggestion that
milk outbreaks may sometimes play a part; or, again,"that one factor of the kind in question had
perhaps been furnished by attendance at particular schools"; and on the whole it appeared probable"that some unknown proportion of the so.called return cases had in this instance been due, not to
the return of the patients from hospital, but to the cause or causes which had contributed to the excessive
incidence of secondary invasion generally upon households of the hospital isolation class."He decided,
therefore, that in connection with the occurrence of return cases there are in all probability some
obscure factors at work,"/actors perhaps closely bound up with the natural history of scarlatina."
A like appreciation of the complex character of the problem is shown in the annual reports of
Dr. Niven. In 1901 he suggested that the autumnal wave of scarlet fever must be associated with"a growth of the specific germ in the soil"; he was, moreover, impressed then with the importance
of"overlooked cases,"and he said"it is impossible not to be roused to a strong suspicion that in the
more insanitary parts of the City, where the people are poorest, there is a considerable proportion of
such cases"; he referred too to the"possibility of scarlet fever receiving a reinforcement from growth
of the infection outside the body."In the following year he recurs to this, and suggests that"flies
or some other medium of communication may be more active in one year than another."In 1903
he questioned the infectivity of particles of skin and was already at that time in doubt about mucous
discharges; he noted that the disease may"reach considerable proportions in one department of a
school yet not spread to another having a separate playground and offices,"and that it"does not
spread aerially from scarlet fever wards to others in the same grounds."He surmises that the vehicle
of infection"must be comparatively heavy,"and that the infection may"actually multiply in clothing
under certain conditions."Then later, in 1907, he says"instances arise when it seems to be carried
by an intermediate agent not affected with the disease,"and adds,"a collection of such cases might
throw considerable light on what happens when return cases occur"; further, he now declares, concerning
mucous discharges, that there is no evidence that they"materially add to the infectiousness of discharged
cases."These deductions and speculations of Dr. Niven are profoundly interesting when
regarded in the light of the hypothesis of flea communication of scarlet fever, and they would certainly
for the most part be justified if the truth of that hypothesis were firmly established.
The questions raised by the important papers of Dr. Wilson and Mr. Thompson and by the
writings of Dr. Niven and others were much discussed. As regards the supposed malefic influence of
hospitals, the evidence collected in the last'20 years has certainly not proved convincing; no doubt
the criticisms made have been, in quite a minor degree, beneficial, but despite the most rigid precautions
return cases continue to occur. As regards desquamation, opinion has steadily veered in the direction
of discrediting altogether the view that the powdered cuticle is itself the vehicle of infection. For
example, a striking table, on p. 60 of Dr. Ken's Annual Report for 1909, gives the outcome of an
enquiry concerning 26 children found to be peeling in school; harm resulted in only 3 instances, and
it is thus clear that"secondary cases seldom occur in school, even although the affected child has been
in constant attendance."Careful study has, moreover, been made, particularly in the last 10 yeaTs.
of the infectivity of mucous discharges, and here again the result by no means always accords with
popular belief. Professor Simpson suggested that these discharges may act as the vehicle of infection,
but are not specifically infectious. This view has not, however, been materially supported by later
observations. Newsholme held that such discharges might not infrequently be at fault, but agreed
that though the proportion of cases"in which there are no mucous discharges is smaller, their occurrence
is undoubted."Cameron attached importance to these discharges, but pointed out that the figures
relating to occurrence of return cases, ir metropolitan boroughs, seemed to suggest that home environment
was largely concerned as well as the condition of the patient. This question was carefully followed
up in the"Observations on Dr. Cameron's Report bv the Medical Superintendents of the Board's Fevei
Hospitals,"and the conclusion was reached that"it is even possible that home conditions are more important
tha i hospital conditions in determining the infectivity rate."Dr. F. M. Turner's carefully collected statistics
(see Annual Report of M.A.B.. p. 265) throw considerable doubt upon the serious character
43316 £ 2
The return
case problem.