- Email: [email protected]
Return cases of scarlet fever
7 54
Correspondence
[rubric Hoan~
The British 2~ledical Journal has published an article upon chewinggum, in which the following passage occurs: " A few days ago an inquest was held at Lincoln on a child eight years of age, who died from the effects of eating a pellet o f t h e substance. The symptoms preceding death were those of gastritis, and at the post-mortem examination it was found that the mucous membrane of the stomach was inflamed, and that there was much local peritonitis. The coroner pointed out that the distribution of such dangerous stuff to young children was a very improper proceeding, and the jury, in endorsing his remarks, added that in their opinion its sale should be absolutely prohibited. The danger seems to us to be in the fact that children who buy sweets are often too young to read, and cannot be made to understand something bought at a sweetstuff shop, and having all the appearance of a candy, is ' not to be eaten." A bolus . . . of indiarubber . . . would remain undissolved in the stomach, and would undoubtedly act as an irritant."--British Food #ournal.
CORRESPONDENCE. "RETURN
CASES
OF
SCARLET
FEVER."
To THE EDITOR OF " PUBLIC HEALTH." D E A R SIR,
I n the June number of PuBntC HEALTH there appeared a very interesting paper on the above subject by Dr. J. Niven. In this he expresses the opinion that one chief cause for the occurrence of "return eases" is the recent association of the discharged patient with acute cases, and he points out the advantage which he believes has been obtained at the Monsall Fever Hospital by adopting the method of treating the patients in convalescent wards for the last ten or fourteen days of their stay in hospital. From a theoretical point of view, this method is one which will probably commend itself to many. I t is not so easy, however, in practice to observe that any good really results from it, and though I do not wish to be thought to decry the method, I should like to point out a possible fallacy in Dr. Niven's deductions to which he does not refer. The procedure adopted at ~ o n s a l l appears to have been very similar to what has been tried at the Birmingham City Hospital and, I have no doubt, at many other similar institutions. Briefly stated, the patients are detained in the acute wards for five or six weeks, and then transferred to a separate convalescent ward for the remaining two or three weeks of their stay in hospital. To make the experiment really satisfactory, only those patients who are free from such complications as otorrhcea and rhinorrhcea, and are apparently free or nearly free from infection, should be transferred; and any patient subsequently developing such complications after being transferred must at once be sent back again. Dr. Niven states that it was only during a part of the time that the experiment was being tried that i t w a s found possible to observe this obvious precaution. I t appears, however, that some selection of the cases was made, and it is here where the possibility of a fallacy comes in. Dr. Niven bases his deductions purely upon a comparison between the percentage of return cases occurring from those patients discharged direct from the acute wards and the per-
August, 1 8 9 9 ]
Correspondence
75 5
centage occurring from those discharged from the convalescent wards. I t is my contention that if any such selection was exercised in the way of retaining the bad cases complicated with rhinorrhcea and otorrhcea in the acute w a r d s - - a n d we ar0 told that it was so during part of the t i m e - - t h e n that this selection m a y quite account for the difference in the percentage of return cases. Moreover, Dr. Niven specially emphasizes the fact that the greatest difference was observed during the months when the selection of the cases was most rigidly enforced. I have myself tried the experiment, with similar results-i.e., I found that fewer return cases occur from a " c l e a n " ward (in which there are no patients suffering from complications) than from an acute ward which contains an undue proportion of chronic and complicated cases. I attribute it, however, chiefly to the difference in the type of cases in the two wards, and I believe if the experiment were reversed--i.e., if the chronic and complicated cases were sent to the convalescent ward, and the mild, simple cases were retained in the acute w a r d - - t h a t then the result would also be reversed. To make the experiment fairly, all cases should be transferred, so that there could be no selection exercised, though the " c l e a n " and "complicated" convalescents could be treated in separate convalescent wards. The total return cases occurring could then be compared with the proportion occurring during the same period in other wards in which the experiment was not being tried. Three years ago, when scarlet fever was very prevalent in Birmingham, and the accommodation at the Lodge Road Hospital was insufficient, the practice was adopted of sending scarlet fever convalescents to the branch hospital at Little Bromwich after they had been at Lodge Road for three or four weeks. No acute cases were sent there ; and though m a n y of the patients were undoubtedly infectious, it was essentially a convalescent hospital, and I had hoped that this, combined with the fact that the hospital was in the country, with very extensive grounds round, would have resulted in a lessened percentage of return eases. This, unfortunately, was not the case, though the average stay in hospital was not diminished. This is only negative evidence, but is of value as far as it goes. I have ventured to write to you at this length, not because I am not in favour of the principle of separating acute from convalescent cases, but because I doubt if it has much influence in the prevention of return cases, and I do not think that Dr. Niven's figures, unless they were specially guarded against the fallacy I have pointed out, are quite as conclusive as might appear on casually reading his paper. Yours faithfully, City Hospital, Birmingham. C. I~ILLICK MILLARD, July 19th, 1899. Medical Superintendent.
APPOINTYIENTS. Angove, W. T., M.B.C.S, L.S.A., appointed M.O.H. for Tea Tree Gully, South Australia. Collins, H. Beale, M.R.G.S. Eng., D.P.H., R.C.P.S. Lond., reappointed M.O.H. for the Borough of Kingston-on-Thames. Dingan, C. B., L.2~.C.P., ~5.2~.C.B. Edin., appointed M.O.H. for the Borough of Carisbrook, Victoria, Australia. Donaldson, J. B., JL.R.C.P., L.R.C.S. Edln., L.F.P.8. Glasg., appointed M.O.H. for the Shire of Hampden, Parishes of CarraubaUac, South Barriyallock, and Skipton, New Zealand.
Correspondence
[rubric Hoan~
The British 2~ledical Journal has published an article upon chewinggum, in which the following passage occurs: " A few days ago an inquest was held at Lincoln on a child eight years of age, who died from the effects of eating a pellet o f t h e substance. The symptoms preceding death were those of gastritis, and at the post-mortem examination it was found that the mucous membrane of the stomach was inflamed, and that there was much local peritonitis. The coroner pointed out that the distribution of such dangerous stuff to young children was a very improper proceeding, and the jury, in endorsing his remarks, added that in their opinion its sale should be absolutely prohibited. The danger seems to us to be in the fact that children who buy sweets are often too young to read, and cannot be made to understand something bought at a sweetstuff shop, and having all the appearance of a candy, is ' not to be eaten." A bolus . . . of indiarubber . . . would remain undissolved in the stomach, and would undoubtedly act as an irritant."--British Food #ournal.
CORRESPONDENCE. "RETURN
CASES
OF
SCARLET
FEVER."
To THE EDITOR OF " PUBLIC HEALTH." D E A R SIR,
I n the June number of PuBntC HEALTH there appeared a very interesting paper on the above subject by Dr. J. Niven. In this he expresses the opinion that one chief cause for the occurrence of "return eases" is the recent association of the discharged patient with acute cases, and he points out the advantage which he believes has been obtained at the Monsall Fever Hospital by adopting the method of treating the patients in convalescent wards for the last ten or fourteen days of their stay in hospital. From a theoretical point of view, this method is one which will probably commend itself to many. I t is not so easy, however, in practice to observe that any good really results from it, and though I do not wish to be thought to decry the method, I should like to point out a possible fallacy in Dr. Niven's deductions to which he does not refer. The procedure adopted at ~ o n s a l l appears to have been very similar to what has been tried at the Birmingham City Hospital and, I have no doubt, at many other similar institutions. Briefly stated, the patients are detained in the acute wards for five or six weeks, and then transferred to a separate convalescent ward for the remaining two or three weeks of their stay in hospital. To make the experiment really satisfactory, only those patients who are free from such complications as otorrhcea and rhinorrhcea, and are apparently free or nearly free from infection, should be transferred; and any patient subsequently developing such complications after being transferred must at once be sent back again. Dr. Niven states that it was only during a part of the time that the experiment was being tried that i t w a s found possible to observe this obvious precaution. I t appears, however, that some selection of the cases was made, and it is here where the possibility of a fallacy comes in. Dr. Niven bases his deductions purely upon a comparison between the percentage of return cases occurring from those patients discharged direct from the acute wards and the per-
August, 1 8 9 9 ]
Correspondence
75 5
centage occurring from those discharged from the convalescent wards. I t is my contention that if any such selection was exercised in the way of retaining the bad cases complicated with rhinorrhcea and otorrhcea in the acute w a r d s - - a n d we ar0 told that it was so during part of the t i m e - - t h e n that this selection m a y quite account for the difference in the percentage of return cases. Moreover, Dr. Niven specially emphasizes the fact that the greatest difference was observed during the months when the selection of the cases was most rigidly enforced. I have myself tried the experiment, with similar results-i.e., I found that fewer return cases occur from a " c l e a n " ward (in which there are no patients suffering from complications) than from an acute ward which contains an undue proportion of chronic and complicated cases. I attribute it, however, chiefly to the difference in the type of cases in the two wards, and I believe if the experiment were reversed--i.e., if the chronic and complicated cases were sent to the convalescent ward, and the mild, simple cases were retained in the acute w a r d - - t h a t then the result would also be reversed. To make the experiment fairly, all cases should be transferred, so that there could be no selection exercised, though the " c l e a n " and "complicated" convalescents could be treated in separate convalescent wards. The total return cases occurring could then be compared with the proportion occurring during the same period in other wards in which the experiment was not being tried. Three years ago, when scarlet fever was very prevalent in Birmingham, and the accommodation at the Lodge Road Hospital was insufficient, the practice was adopted of sending scarlet fever convalescents to the branch hospital at Little Bromwich after they had been at Lodge Road for three or four weeks. No acute cases were sent there ; and though m a n y of the patients were undoubtedly infectious, it was essentially a convalescent hospital, and I had hoped that this, combined with the fact that the hospital was in the country, with very extensive grounds round, would have resulted in a lessened percentage of return eases. This, unfortunately, was not the case, though the average stay in hospital was not diminished. This is only negative evidence, but is of value as far as it goes. I have ventured to write to you at this length, not because I am not in favour of the principle of separating acute from convalescent cases, but because I doubt if it has much influence in the prevention of return cases, and I do not think that Dr. Niven's figures, unless they were specially guarded against the fallacy I have pointed out, are quite as conclusive as might appear on casually reading his paper. Yours faithfully, City Hospital, Birmingham. C. I~ILLICK MILLARD, July 19th, 1899. Medical Superintendent.
APPOINTYIENTS. Angove, W. T., M.B.C.S, L.S.A., appointed M.O.H. for Tea Tree Gully, South Australia. Collins, H. Beale, M.R.G.S. Eng., D.P.H., R.C.P.S. Lond., reappointed M.O.H. for the Borough of Kingston-on-Thames. Dingan, C. B., L.2~.C.P., ~5.2~.C.B. Edin., appointed M.O.H. for the Borough of Carisbrook, Victoria, Australia. Donaldson, J. B., JL.R.C.P., L.R.C.S. Edln., L.F.P.8. Glasg., appointed M.O.H. for the Shire of Hampden, Parishes of CarraubaUac, South Barriyallock, and Skipton, New Zealand.