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The influence of hospital isolation upon scarlet fever
Ootober, m 0 4 ]
Correspondence
59
CORRESPONDENCE. THE
INFLUENCE
OF HOSPITAL ISOLATION SCARLET FEVER.
UPON
To the Editor o/Public Health. SIIL As the greater part of Dr. Walford's paper on the above subject, published in your issue for August, is a criticism of the paper published by me three and a half years ago, kindly allow me to reply, especially as no opportunity was afforded me o{ being present at the reading of the paper. There are severalpoints in the paper which I am pleased to note. Thus, Dr. WMford endorses the view, which so many now hold, that return cases are a serious evil and are " certainly not the result of a too early discharge from hospital, but, on the contrary, seem to occur usually amongst those patients who have been detained ior the longest periods." He condemns the " promiscuous aggregation" of acute and chronic cases, and recognizes that " s e c o n d a r y septic sore throats and post-scarlatinal diphtheria seem to be complications peculiar to hospital." He also states, referring to Cardiff, that " so far as the fatality of scarlet fever is concerned, no marked advantage can be shown in the case of hospital patients as compared with those treated at home." Dr. Walford recognizes that there is room for improvement in the administration of hospitals, and he thinks that "possibly a better seIeetion of cases removed to hospital might be made. The wholesale removal of rich and poor, regardless of their opportunities of home isolation, should be checked, and the tendency to make these hospitals a personal convenience is an abuse rather on the increase." Also, " I t seems quite likely that we have been detaining cases an unnecessarily long time." So far, Dr. Walford appears to be on sound progressive lines, but there are other parts of his paper which, I think, are open to exception. To follow Dr. Walford through all his statistical points would occupy much more space than I can reasonably expect you to allow me. I will, therefore, confine myself to one or two. He objects to my comparing groups of towns (although these groups were made as large as possible, without selection, and were taken over as long a period as possible), and then he himself proceeds to compare a selected town, Cardiff, with another selected " town," The Rhondda Valley (not a town in the ordinary sense, but rather a collection of districts). Moreover, he only takes the short period of five years, and follows this up by taking single years. I leave it to others to decide which is the fairer method. Then, on page 682, he gives the following table : - Year.
Proportion Isolated in Hospital
I I
Attack-rate.
Death-rate.
1884 1892 1905
13"0
,,
f
,,
!
28 per I000 13 ,, 8 ,,
1"36 per 1000 0"65 ,, 0"21 ,,
48"0
0"0 per cent
-
This table, on the surface, may appear to be highly satisfactory evidence of the value of hospital isolation. But let us examine it. The periods
60
Correspondence
[public Health
taken for comparison are single selected years, no indication being given of the prevalence of scarlet fever in the intervals between these years. I t is true that they are selected as being epidemic years, but it is quite possible and, indeed, probable that one effect of hospital isolation is to reduce the height of epidemic peaks by spreading an epidemic over a longer period. Next consider the extraordinary attack-rate (28 per 1,000) given for the year 1884. On referring to the previoL~spage we learn that this is only an estimated attack-rate, and the method adopted for the estimation is open to most serious objection. He first assumes that the fatality of the 1884 epidemic was no greater than in the following epidemic, quite forgetting, apparently, that the tendency of scarlet fever everywhere has been for each successive epidemic to become less and less fatal. Indeed, the difference between the fatality of two consecutive epidemics, especially just at the period in question, was often great. Then, on the basis of this imaginary fatality, he calculates the attack-rate from mot~ality--searcely a very reliable method ! In the third column of the table we have the mortality from scarlet fever in Cardiff in each epidemic. As we should expect, for the reason just stated, this shows a progressive decrease. If Dr. Walford wishes to seriously suggest that this is due to the increase of hospital isolation in Cardiff, he will find himself in conflict with such an authority as the late Sir Thorne Thorne, who stated emphatically that he could discover no evidence that the decrease in scarlet fever mortality was the result of hospital isolation. On page 68~ Dr. Walford compares the number of secondary cases occurring in houses where patients are left at home with the number of return cases* in houses where patients are removed to hospital. I have never heard of such a comparison being made before, and to me the two sets of facts appear quite incomparable. Dr. Walford takes no cognizance of the secondary cases occurring in houses where the first case is removed to hospital ! I would commend to the notice of Dr. Walford, and of all who attempt to make comparisons between home-treated and hospital-treated cases, the method adopted by Dr. James Niven, Medical Officer of Health for Manchester, as detailed in his Annual Report just published, pp. 96-102. Dr. Niven very properly adds return cases to secondary cases and records the number of susceptible persons under fifteen years of age in the home. But he also takes a most important precaution, which too many observers have neglected, and without which any comparison is likely to be fallacious. He excludes all unrecognized cases. Obviously, all such cases must necessarily fall into the home-treated group, and, the number of secondary cases resulting from these being, as we should expect, much above the average, they unfairly " weight " the home-treated group. Having taken this precaution, Dr. Niven finds that the proportion of secondary plus return cases in the hospital-treated group, is nearly equal to the proportion of secondary cases in the home treated group, and he states, p. 102, " We must conclude that the Hospital shows no saving so jar as in]ection in the same house is concerned." I t is true that he still thinlrs that hospital isolation must be of benefit outside the home, but, if his first conclusion is right, it marks an important advance and will necessitate considerable modification of existing belief. Finally, Dr. Walford dismisses the very important financial aspect of the question--whether the results achieved are proportionate to the great expense--by leaving it " f o r accountants and others to decide." * Moreover he limils re~urn cases to ~hose occurring within one week of the ~eturn home.
Octaber, 1 9 0 4 ]
Correspondence
61
I would ask how it is possible for outsiders to correctly decide this so long as they retain the very optimistic views they have learnt from us to hold as to the magnitude of the results ? I certainly think Dr. Walford is to be congratulated for having approached this difficult subject and for having added his quota to its solution. I t is greatly to be hoped that before long the whole subject will receive much fuller and more complete investigation than it has yet received. At present it is impossible to disguise the fact that very great uncertainty and difference of opinion exists as to the value of hospital isolation in the case of scarlet fever, and it is not surprising, therefore, that at the recent Health Congress at Folkestone the following resolution was passed by a large majority: "That as the hospital isolation of scarlet fever has now been tried on a large scale for many years, and as some doubt exists as to whether the results obtained are commensurate with the cost, it is desirable, in the public interest, that a full and authoritative inquiry into the subject should be made." C. KILLICK MILLARD. LEICESTER, August 13th, 1904. THE LEICESTER
METHOD OF DEALING W I T H SMALL-POX. To the Editor of Public Health.
SIR, I t is with some surprise that I have read the letter of Dr. Armstrong in the August number of Public Health. Dr. Millard is perfectly able to defend, with courtesy and with temper, the views which he has expressed, and with which I for one may not wholly agree. But in whatever reply Dr. MillaM may make to his critics, obstetrical allusions of doubtful taste will, I am sure, find no place. As one, however, who was present at the meeting in March, I beg to protest against the suggestions that Dr. Millard claimed for his town, as new and original, a " method of dealing with epidemic small-pox which is neither the one nor the other" ; and advocated " t h e general abandonment of a preventive measure in which he owns a firm and implicit faith." Dr. Millard did neither of these things. He described the results at Leicester of a method which has been generally identified with Leicester by those who have prophesied, as a result of its adoption, catastrophes which have not yet occurred: And he stated facts which, in his opinion, rendered worthy of consideration the question of the value to the community of vaccination under existing sanitary circumstances as a compulsorily enforced State institution. At the meeting in March many things were said about the dignity of the Society. I t is, I trust, not incompatible with that dignity to consider, temperately and courteously, and without misrepresentation, views which are logically and intelligently put forward. I believe as firmly as does either Dr. Armstrong or Dr. Millard in the protective value to the individual o~ vaccination. But I cannot, ]mowing the history of inoculation, declare, with Dr. Millard's opponents, that benefit to an individual is always a benefit to the community of which the individual is a member. Nor can I hold that at all times, and under all circumstances, whatever the epidemic prevalence or case mortality of smali-pox may be, and however perfect sanitary mechanism may become, vaccination and re-vaccination should be compulsorily enioreed by the State.
Correspondence
59
CORRESPONDENCE. THE
INFLUENCE
OF HOSPITAL ISOLATION SCARLET FEVER.
UPON
To the Editor o/Public Health. SIIL As the greater part of Dr. Walford's paper on the above subject, published in your issue for August, is a criticism of the paper published by me three and a half years ago, kindly allow me to reply, especially as no opportunity was afforded me o{ being present at the reading of the paper. There are severalpoints in the paper which I am pleased to note. Thus, Dr. WMford endorses the view, which so many now hold, that return cases are a serious evil and are " certainly not the result of a too early discharge from hospital, but, on the contrary, seem to occur usually amongst those patients who have been detained ior the longest periods." He condemns the " promiscuous aggregation" of acute and chronic cases, and recognizes that " s e c o n d a r y septic sore throats and post-scarlatinal diphtheria seem to be complications peculiar to hospital." He also states, referring to Cardiff, that " so far as the fatality of scarlet fever is concerned, no marked advantage can be shown in the case of hospital patients as compared with those treated at home." Dr. Walford recognizes that there is room for improvement in the administration of hospitals, and he thinks that "possibly a better seIeetion of cases removed to hospital might be made. The wholesale removal of rich and poor, regardless of their opportunities of home isolation, should be checked, and the tendency to make these hospitals a personal convenience is an abuse rather on the increase." Also, " I t seems quite likely that we have been detaining cases an unnecessarily long time." So far, Dr. Walford appears to be on sound progressive lines, but there are other parts of his paper which, I think, are open to exception. To follow Dr. Walford through all his statistical points would occupy much more space than I can reasonably expect you to allow me. I will, therefore, confine myself to one or two. He objects to my comparing groups of towns (although these groups were made as large as possible, without selection, and were taken over as long a period as possible), and then he himself proceeds to compare a selected town, Cardiff, with another selected " town," The Rhondda Valley (not a town in the ordinary sense, but rather a collection of districts). Moreover, he only takes the short period of five years, and follows this up by taking single years. I leave it to others to decide which is the fairer method. Then, on page 682, he gives the following table : - Year.
Proportion Isolated in Hospital
I I
Attack-rate.
Death-rate.
1884 1892 1905
13"0
,,
f
,,
!
28 per I000 13 ,, 8 ,,
1"36 per 1000 0"65 ,, 0"21 ,,
48"0
0"0 per cent
-
This table, on the surface, may appear to be highly satisfactory evidence of the value of hospital isolation. But let us examine it. The periods
60
Correspondence
[public Health
taken for comparison are single selected years, no indication being given of the prevalence of scarlet fever in the intervals between these years. I t is true that they are selected as being epidemic years, but it is quite possible and, indeed, probable that one effect of hospital isolation is to reduce the height of epidemic peaks by spreading an epidemic over a longer period. Next consider the extraordinary attack-rate (28 per 1,000) given for the year 1884. On referring to the previoL~spage we learn that this is only an estimated attack-rate, and the method adopted for the estimation is open to most serious objection. He first assumes that the fatality of the 1884 epidemic was no greater than in the following epidemic, quite forgetting, apparently, that the tendency of scarlet fever everywhere has been for each successive epidemic to become less and less fatal. Indeed, the difference between the fatality of two consecutive epidemics, especially just at the period in question, was often great. Then, on the basis of this imaginary fatality, he calculates the attack-rate from mot~ality--searcely a very reliable method ! In the third column of the table we have the mortality from scarlet fever in Cardiff in each epidemic. As we should expect, for the reason just stated, this shows a progressive decrease. If Dr. Walford wishes to seriously suggest that this is due to the increase of hospital isolation in Cardiff, he will find himself in conflict with such an authority as the late Sir Thorne Thorne, who stated emphatically that he could discover no evidence that the decrease in scarlet fever mortality was the result of hospital isolation. On page 68~ Dr. Walford compares the number of secondary cases occurring in houses where patients are left at home with the number of return cases* in houses where patients are removed to hospital. I have never heard of such a comparison being made before, and to me the two sets of facts appear quite incomparable. Dr. Walford takes no cognizance of the secondary cases occurring in houses where the first case is removed to hospital ! I would commend to the notice of Dr. Walford, and of all who attempt to make comparisons between home-treated and hospital-treated cases, the method adopted by Dr. James Niven, Medical Officer of Health for Manchester, as detailed in his Annual Report just published, pp. 96-102. Dr. Niven very properly adds return cases to secondary cases and records the number of susceptible persons under fifteen years of age in the home. But he also takes a most important precaution, which too many observers have neglected, and without which any comparison is likely to be fallacious. He excludes all unrecognized cases. Obviously, all such cases must necessarily fall into the home-treated group, and, the number of secondary cases resulting from these being, as we should expect, much above the average, they unfairly " weight " the home-treated group. Having taken this precaution, Dr. Niven finds that the proportion of secondary plus return cases in the hospital-treated group, is nearly equal to the proportion of secondary cases in the home treated group, and he states, p. 102, " We must conclude that the Hospital shows no saving so jar as in]ection in the same house is concerned." I t is true that he still thinlrs that hospital isolation must be of benefit outside the home, but, if his first conclusion is right, it marks an important advance and will necessitate considerable modification of existing belief. Finally, Dr. Walford dismisses the very important financial aspect of the question--whether the results achieved are proportionate to the great expense--by leaving it " f o r accountants and others to decide." * Moreover he limils re~urn cases to ~hose occurring within one week of the ~eturn home.
Octaber, 1 9 0 4 ]
Correspondence
61
I would ask how it is possible for outsiders to correctly decide this so long as they retain the very optimistic views they have learnt from us to hold as to the magnitude of the results ? I certainly think Dr. Walford is to be congratulated for having approached this difficult subject and for having added his quota to its solution. I t is greatly to be hoped that before long the whole subject will receive much fuller and more complete investigation than it has yet received. At present it is impossible to disguise the fact that very great uncertainty and difference of opinion exists as to the value of hospital isolation in the case of scarlet fever, and it is not surprising, therefore, that at the recent Health Congress at Folkestone the following resolution was passed by a large majority: "That as the hospital isolation of scarlet fever has now been tried on a large scale for many years, and as some doubt exists as to whether the results obtained are commensurate with the cost, it is desirable, in the public interest, that a full and authoritative inquiry into the subject should be made." C. KILLICK MILLARD. LEICESTER, August 13th, 1904. THE LEICESTER
METHOD OF DEALING W I T H SMALL-POX. To the Editor of Public Health.
SIR, I t is with some surprise that I have read the letter of Dr. Armstrong in the August number of Public Health. Dr. Millard is perfectly able to defend, with courtesy and with temper, the views which he has expressed, and with which I for one may not wholly agree. But in whatever reply Dr. MillaM may make to his critics, obstetrical allusions of doubtful taste will, I am sure, find no place. As one, however, who was present at the meeting in March, I beg to protest against the suggestions that Dr. Millard claimed for his town, as new and original, a " method of dealing with epidemic small-pox which is neither the one nor the other" ; and advocated " t h e general abandonment of a preventive measure in which he owns a firm and implicit faith." Dr. Millard did neither of these things. He described the results at Leicester of a method which has been generally identified with Leicester by those who have prophesied, as a result of its adoption, catastrophes which have not yet occurred: And he stated facts which, in his opinion, rendered worthy of consideration the question of the value to the community of vaccination under existing sanitary circumstances as a compulsorily enforced State institution. At the meeting in March many things were said about the dignity of the Society. I t is, I trust, not incompatible with that dignity to consider, temperately and courteously, and without misrepresentation, views which are logically and intelligently put forward. I believe as firmly as does either Dr. Armstrong or Dr. Millard in the protective value to the individual o~ vaccination. But I cannot, ]mowing the history of inoculation, declare, with Dr. Millard's opponents, that benefit to an individual is always a benefit to the community of which the individual is a member. Nor can I hold that at all times, and under all circumstances, whatever the epidemic prevalence or case mortality of smali-pox may be, and however perfect sanitary mechanism may become, vaccination and re-vaccination should be compulsorily enioreed by the State.