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27
control the incidence of the disease, and the reasons are fanmily
to every epidemiologist. A doctor will not notify a case unless the
classical symptoms are present, and especially the rash, but ther
are reasons for thinking that the number of cases of streptococe
fever and sore throats notified represents but a minority; the more
numerous, and, because unrecognised, more dangerous, sufferer
from sore throats caused by the same organism, and the carrier
remain at large. But, though we recognise that hospitalisation will
not solve the problem of the epidemicity or endemicity of Scarlet
Fever, the percentage of cases treated in hospital continues and
will continue to be a high one; the public insists upon institutional
treatment as a social sen-ice, and it should be recognised as such.
Scarlet fever is a disease which requires, in the majority of cases,
skilled treatment; medical, nursing, dietetic, &c., and the sequelae
and complications require prompt treatment. Apart from the
treatment, it is an infectious disease, and for three or four weeks
at least the patient is infectious; so that, even if there are facilities
in the home for isolation and nursing, a case nursed at home places
a good deal of restriction on the movements of the rest of the
family.
It is doubtful if hospitalisation is responsible entirely for
the "return" case. After the patient's return home from hospital,
scarlet fever occurs in some other member of the household
in 2 to 4 per cent. of cases. Last year in the case of three patients
discharged from hospital, other cases occurred in the household. These
return cases always cause annoyance, and occasionally complaints
are made that the infecting case has been prematurely discharged
from hospital. In inter-epidemic years, this, of course, would be
obviously incorrect; last year there was not at any time any pressure
upon our accommodation. One of the cases had been in hospital
four weeks, one four weeks and four days, and the third five weeks.
In 1927, a memorandum was issued by the Ministry of Health, as
a result of evidence obtained from all over the country. The opinion
was expressed that there was no good evidence for prescribing a
routine period of detention in hospital of more than four weeks in
uncomplicated cases, and the old six-weeks period which was based
on the now exploded belief in the infectivity of pealing, has long
been abandoned by most fever authorities. In a number of hospitals,
uncomplicated cases are discharged under 3 weeks, and the shortened
period of detention has not increased the percentage of return
cases, probably it has decreased it. This may sound paradoxical,
but the explanation probably lies in the fact that a shortened period
of detention in uncomplicated cases has diminished overcrowding of
wards.