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epidemics of Scarlet Fever and Diphtheria last year were not on so great a scale. Tracing the prevalence
of Scarlet Fever and Diphtheria in Willesden backwards it is not till we come to the consecutive
years 1901 and 1902 that we again find Diphtheria and Scarlet Fever in epidemic form
at the same time.
So far as the present epidemics are concerned and judging by previous years and past experience,
it is likely that they will die down towards the end of the year. If we could be sure that
no similar epidemic or concurrence of epidemics would occur again, anxiety need not arise, but we
have to remember that Scarlet Fever and Diphtheria, like all other epidemic diseases, are specially
liable to considerable fluctuations both in prevalence and fatality. Scarlet Fever shews a tendency
so far as Willesden is concerned to assume epidemic proportions in cycles of about 6 years and of
course both Scarlet Fever and Diphtheria shew a seasonal prevalence every autumn. It is further
noteworthy that Scarlet Fever, like all epidemic diseases, appears in conditions of increased activity
after longer or shorter periods of quiescence. Scarlet Fever was at a low ebb in Willesden in the
years 1917 and 1918. In those two years together, fewer cases of Scarlet Fever occurred than in
any single year during the past 25 years. In 1919 and 1920, however, we got as it were compensating
epidemics of considerable magnitude. The epidemic disease which shows this tendency of recrudescence
after quiescence most characteristically is Influenza. There was a great epidemic of Influenza
in 1889-92, which was followed by a long period of quiescence during which only a few cases of the
disease occurred. Then in 1918 and 1919 Influenza appeared again in Great Britain as an epidemic
of unparalleled magnitude and now once more has lapsed into quiescence.
The Utility of Isolation Hospitals.
It may properly be asked what steps have been taken to prevent the spread of Scarlet Fever,
and of Diphtheria in Willesden. The measures taken have included the establishment of an Isolation
Hospital and the isolation of cases therein, the Disinfection of bedding and clothing and the Quarantine
of contacts, i.e., the isolation for a period of persons who have been in contact with others suffering
from these diseases. It would have been reasonable to expect that with a greater amount of isolation
of Scarlet Fever and Diphtheria cases there would have been a diminished prevalence of Scarlet
Fever and Diphtheria in Willesden, but an examination of the available statistics for the past 28
years fails to establish this fact. In 1894, Scarlet Fever cases occurred at the rate of 3.6 per thousand
of the population in Willesden when only 31 per cent. of cases were removed to Hospital; in the
year 1914, the number of cases of Scarlet Fever per thousand of the population was 4.6, when as
many as 89 per cent. of cases were isolated in Hospital. Similarly with Diphtheria, in 1894, Diphtheria
cases occurred at the rate of 17 per thousand of the population when only 6.2 per cent. of cases.
were removed to Hospital; in 1914, Diphtheria cases occurred at the rate of 1.8 per thousand of
the population when no less than 85 per cent. of the cases were taken into Hospital. Similarly we
would expect that fewer secondary cases would occur in households after the first case was removed
to Hospital, but an examination of the available statistics between the years 1910 and 1919 shews
no change in this respect. Again as a result of the removal to Hospital of a high percentage of cases
we would expect that the number of houses with two or more cases of Scarlet Fever occurring in
them would have diminished but an examination of the statistics during the years 1910-19 again
shews practically no change. Having regard to all these facts we are forced to conclude that Isolation
Hospitals which were established with the intention of the prevention of the spread of Scarlet
Fever and Diphtheria have failed in that object. There are reasons however, why isolation has
failed in its primary object. For example there is the unrecognised case in a household, a mild case
perhaps, in which the child is thought to have a cold or to be merely out of sorts, and in which the
doctor is often not called in, but subsequent to the occurrence of which other members of the family
are stricken down with Scarlet Fever or Diphtheria as the case may be. Again there is the case
which comes to knowledge too late for isolation to be of much, if any, avail. Such a case is that
in which a member of a household is thought to be suffering from say Influenza before the appearance
of the Scarlet Fever rash. In this interval before the correct diagnosis is made he has, however,
often infected other members of the family. Another reason why Isolation has failed to prevent
the spread of disease is because cases of Scarlet Fever and Diphtheria are intermittently infectious
for an indefinite period. Take the so-called return case of Scarlet Fever, infected by a case discharged
from Hospital well with healthy mucous membranes, no glandular enlargements and no discharges
of any kind. Shortly after such a case returns home it develops a cold and with the development
of a cold becomes infectious again and infects other members of the family. A case of Diphtheria,
too, may often be negative so far as the existence of the Diphtheria bacillus in the upper respiratory
passages is concerned on discharge from the hospital, but after a shorter or longer period extending
in my own experience to eleven months, the bacillus reappears in the throat and again renders the
person infectious and dangerous to others.
But while these various causes have operated to make Hospital Isolation as a means of the
prevention of Scarlet Fever and Diphtheria ineffective, it must not be understood that Isolation
Hospitals are of no value or of no use. Isolation Hospitals are wanted for the treatment of severe
or complicated cases of Scarlet Fever or Diphtheria or other Infectious Diseases. They are wanted
where the person suffering is without suitable lodging or accommodation for treatment at home and
this applies to the large bulk of cases which occur. They are wanted in cases where if the patient
remains at home some other member or members of the family would suffer pecuniary loss and above
all they have been of great value to the community by reducing the fatality rate of the diseases
specially admitted. In 1894. the fatality rate from Scarlet Fever in Willesden was at the rate of
26 per thousand cases, in 1914, the fatality rate had fallen to 7 per thousand cases. Similarly in
Diphtheria, the fatality rate in 1894 was 126 per thousand cases, while in 1914, it was only 79 per
thousand cases. It is open to argument that the fall in the fatality rate in Diphtheria has been due
to the use of Diphtheria Anti-toxin.