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and families which resulted from "missed" cases are sufficient
proof of the necessity of Hospital Isolation.
Another factor which militates against the complete success of
Isolation Hospitals is the occurrence of what are called "return"
cases. Whether isolated at home or in the hospital, the patient
should have recovered perfectly before he is cleaned and discharged
from seclusion, but we have no means of ascertaining whether the
patient is absolutely free from infection or not. In Diphtheria, the
conditions are different; the germ has been isolated, and a bacteriological
examination can always be made before the patient is
discharged from the Hospital. It is this difficulty which gives rise
to the second group of cases of Scarlet Fever, viz. those that occur in
a house soon after the discharge of a member of the family from the
Hospital. Probably this group of cases is more closely related to
the third group (where cases recur in houses after a prolouged period)
than we have hitherto recognised, but it will at the present time be
convenient to treat the occurrence of cases in the two groups as
separate phenomena.
For this purpose, an arbitary period of one month has been
fixed, and cases occurring within one month have been included
either in groups one or two, and those over in group three.
Twenty-seven cases discharged from the Hospital were followed
within one month by the occurrence of other cases of Scarlet Fever
in the same house. Twenty-two of these were discharged from the
Council's Hospital and five from the London Fever Hospital.
Many authorities believe that the phenomenon of return cases
is essentially due to imperfections in Hospital management, and that
there is reason to believe that recent association of discharged patients
with acute cases is responsible for most, if not all return cases.
It has been found in some districts that by placing patients in a
convalescent ward for about a fortnight before their discharge, and
systematically disinfecting the skin, nose and auditory canals, not a
single return case had occurred. This statement is probably true,
but it certainly will not explain everything in connection with return
cases. Return cases are not unknown after home isolation. There
was one such instance in this district last year. A case was notified
on September 14th. The case was nursed at home, certified as free