View report page

88
Actually at the Brook hospital, in the early part of 1934, there were two main wards full of
patients suffering from the combination of scarlet fever and diphtheria.
Referring back to the first table, it is interesting to note that the percentage incidence of
otitis media in the non-serum group is double that in the serum group (10 per cent, against 5
per cent.). Also the number of so-called relapses is greater in the non-serum group. This is
in accord with expectation, as research work suggests that most of them are really re-infections
with a different type of streptococcus, and it would seem that the non-serum treated case, owing
to the fact that it usually has a more prolonged illness, would therefore be more susceptible to
secondary infections.
There is also a definite difference in the incidence of nephritis in the two groups, it being much
higher in the non-serum group. The part of the table devoted to intercurrent diseases, shows that
diphtheria, measles and chickenpox between them accounted for the bulk of the cases.
The fact that the intercurrent diseases raised the average length of stay in the serum group
from 35-8 days to 40-3 days, and in the non-serum group from 36-8 days to 46-2 days, in a series
of over 1,000 cases, is enough to show what a serious factor intercurrent diseases can be in the
treatment of scarlet fever in open wards.
The general conclusion which I have drawn during 1934 as regards the treatment of scarlet
fever by serum is that serum is definitely efficacious. It should, however, be given as far as
possible to every case, as (1) the practice of having wards containing both serum and non-serum
cases is not satisfactory and (2) the arbitrary selection of cases for serum treatment results in
many cases not receiving it who should (or, as often happens if a mild case gets worse after
admission, it receives serum late when its action is very doubtful). As to whether the dose of
serum should be larger or whether the intravenous route is better than the intramuscular, I am
unable from the year's work to draw any definite conclusions, but I feel that either of these factors
might still further reduce the morbidity of scarlet fever and is worth a trial.
Research
work.
A paper by Dr. W. A. Brown, senior assistant medical officer, Brook hospital,
and Dr. V. D. Allison, medical officer of the Ministry of Health, on "An investigation
into the relationship between discharge and return cases in scarlet fever from the
bacteriological and serological point of view " appeared in the Journal of Hygiene
for June. 1935.
They will shortly publish a further paper on " the bacteriological examination
of doubtful cases of scarlet fever with a view to determining whether negative
findings might allow of such cases being discharged from hospital more rapidly."
The findings in this paper are now being applied at the Brook hospital, and doubtful
cases of scarlet fever are being discharged early if two cultures negative to hemolytic
streptococci are obtained from nose and throat.
Dr. Brown and Dr. Allison are also carrying out (i) an investigation into the
effect of intravenous serum on the infectivity of scarlet fever and (ii) a bacteriological
investigation of wards in quarantine for scarlet fever in order to decide the minimum
quarantine period required.
Type of
disease.
Diphtheria.
The medical superintendent of the North-Western hospital (Dr. Joe) has
reported as follows :—
Whilst it cannot be said that, when estimated by case fatality rates, diphtheria has shown a
phenomenal increase in severity, the tendency to more severe forms of the disease noted in
1933 continued during 1934. Diphtheria, including bacteriological diphtheria, appeared in the
death certificates of 36 cases, but in 7 it played little or no part in producing the fatal result, and
the " corrected " case fatality rate therefore on 666 discharges, transfers and deaths works out
at 4.35 per cent. Of the 29 deaths, 1 received antitoxin on the 1st day, 3 on the 2nd day, 9 (3)
on the 3rd day, 6 (2) on the 4th day, 5 on the 5th day, and 5 on or after the 6th day. The
figures in brackets represent the number of cases in which bacteriological confirmation of the
diagnosis was awaited before notification. It should be stated that no great accuracy is claimed
for the day on which antitoxin was first given. The reasons for this have been discussed in
previous reports, but it can always be assumed that the time interval between the onset of
disease and the administration of serum is never overstated. It is consequently somewhat
depressing to report once again that more than half the fatal cases did not receive antitoxin
until the 4th day or after. The age periods in which these deaths occurred bring out the usual
features, 3 occurring at the period 1 to 2, 3 at 2 to 3, 4 at 3 to 4, 5 at 4 to 5, 11 at 5 to 10 years,
and 1 each in the periods 10 to 15, 15 to 20, and 20 to 30 years. Only two of the fatal cases
were of the hemorrhagic type, and so far as my observation goes, this form of the disease has
not become more prevalent among the cases admitted to the North-Western hospital during
the past two years when the clinical severity as a whole was on the up-grade. Two of the deaths
resulted from respiratory paralysis. The Bragg Paul pulsator, which was supplied to the