1724

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

Protracted and Reorudescent Infeotion in Diphtkeria andScarlet Fever.

A MEETING of this society was held on June 14th, SirR. DOUGLAS POWELL, Bart., the President, being in thechair.

Dr. ARTHUR NEWSHOLME read a paper on Protractedand Recrudescent Infection in Diphtheria and ScarletFever. He first detailed instances of cases of each ofthese diseases illustrating the occurrence of protractedor recrudescent infection in different circumstances :when there had been (a) contact or (b) no contact withother acute cases of the same disease ; (o) when therehad been several weeks’ interval between the occurrenceof the "return" case and the latest exposure of theinfecting patient to the infection of other patients ; and(d) when the patient had been treated alone at home.The various explanations of "return" cases were con-

sidered, including, besides the ordinary ones of failureof disinfection or a true "return" of infection, thepossibility of a relapse of the original disease, of latent

microbism, or of missed cases. Instances were given ofdiphtheria of infectivity continuing over 110 days or evenlonger. Instances of the somewhat neglected infectivity ofear discharges in diphtheria were given. The following con-siderations were emphasised : 1. "Return" cases are rela-tively rare and do not seriously invalidate the utility ofisolation hospitals. 2. These cases occur generally, but notalways, in connexion with rhinorrhoea and otorrhœa. 3. Accu-rate hospital records of complications are needed. 4. Post-isolation supervision of both home-treated and hospital-treatedcases of scarlet fever and diphtheria is required. 5. Therhinorrbcea, which is the main index of protracted infectivity,is oftenest already present when isolation is commenced.6. In some instances dormant infection is again roused intoactivity by catarrhs and the like. The close analogy betweendiphtheria and scarlet fever, as regards both protracted andrecrudescent infection, was urged. The conception of pro-tracted infection in diphtheria had been stated by Greenhowand Gresswell, but in scarlet fever it had not been re-

cognised until recently. There could, however, be littledoubt that it had occurred long before the period of isola-tion hospitals and that it explained the persistent belief inthe infectioumess of late desquamation. The bearing ofthese considerations on the hospital treatment of thesediseases was next discussed and the proposition was based onthe foregoing facts that "in scarlet fever, as in diphtheria,the occasional persistence of infection is a phenomenon in thenatural history of the disease, irrespective of, and in the mainuninfluenced by, the external conditions to which patients areordinarily subjected." This view was not, in Dr. Newsholme’sopinion, contradicted by the apparent statistical excess of"return" cases in hospital experience. No statistics makingdue allowance for varying conditions of age and susceptibilityhad hitherto been made on a sufficiently large scale. The

possibility of non ceteris paribus had not been borne in mind.It was reasonable to believe that the scarlatinal germsmultiplying in the patient himself and collecting on therhinorrhoeal lesion with which the patient was usuallyadmitted would be in large numbers and be more efficientto produce secondary infection than the relatively minutenumber that could obtain ingress from other patients. Thenotion that increased infectivity was caused by hospitalaggregation was borrowed from the like theory for small-poxand in both instances was a theory to support a theory. Thebearings of relapses of scarlet fever on this theory were dis-cussed and the analogy of enteric fever, in which suchrelapses could not be caused by fresh external infection,was pointed out.

Dr. E. W. GOODALL said that he could cite many cases ofprotracted infection in diphtheria and scarlet fever andbelieved that it was well known that a patient who developedscarlet fever during convalescence from diphtheria was veryliable to a relapse of his primary disease. He agreed thatthe protraction of infection was not due to hospitalism andthat there were more instances of the kind in cases treated at

fhome than was generally supposed-. He laid stress on’the

part played by "secondary throats" as well as by mucous dis-charges in producing "return" cases and was of the opinionthat desquamation was not a dangerous source of infection.Rhinorrhcea sometimes occurred for the first time after thepatients had returned to their homes and in these cases wasoften responsible for the infection of others. It was not

proved that complications in scarlet fever and diphtheriawere more common in hospital than in private practice.

Dr. P. CALDWELL SMITH said that in his district he hadhad in 1902 4-5 per cent. and in 1903 6-5 per cent. of" return" cases and he believed that something would have tobe done in order to reassure the public feeling in the matter.

Dr. W. J. R. SIMPSON did not agree with Dr. Newsholmethat protracted infection was a part of the naturalhistory of the pathology of these diseases. At a hospital inconnexion with the Pasteur Institute in Paris patientssuffering from various infectious fevers were separated incubicles with glass partitions and one nurse attended severaldifferent cases, taking very careful measures in the way ofdisinfection. He was of the opinion that the ward systemwas in some degree responsible for "return cases.

Dr. W. BUTLER did not think that hospitalism was aloneresponsible for I return " cases and stated that there was noevidence of medical men, nurses, or attendants carryinginfection outside fever hospitals. He had had considerableexperience of home-treated cases carrying infection forprotracted periods and had found that convalescent homesto which only uncomplicated cases had been sent were asgreat, or greater, sources of secondary infection as hospitalswhere acute and complicated cases were aggregated.

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Mr. D. L. THOMAS in investigating outbreaks of diphtheriafor the late London School Board had come to the- same con-clusion as Dr. Newsholme as regards the part played by pro-tracted infection and urged the more continuous supervisionand bacteriological examination of cases.

Dr. C. K. BOND argued against the present hospital systembut thought that the importance of "return" cases was

exaggerated.Dr. NEWSHOLME replied.

OPHTHALMOLOGICAL SOCIETY.

Primary Optic Atrophy due to Lead.-Optic Atrophy afterPostpartum Hœmorrhage. - Optic Ulioma. -Microph-thal,ntos.-Exhibition of Cases and Specimens.AN ordinary meeting of this society was held on June 9th,

Mr. JOHN TWEEDY, the President, being in the chair.Mr. SIMEON SNELL (Sheffield) related a case of Primary

Optic Atrophy due to Lead occurring in a boy aged 16 years.The sight had commenced to fail for rather more than a yearbefore the patient was first seen in October, 1903, and hadrapidly become worse during the past three months. Thevision was : right, 2/60;and left, both optic papillae werewhite and atrophic but did not suggest preceding neuritis.The family and personal histories were good. For two orthree years the boy had worked as a file-cutter whichexposed him to the influence of lead and he had the ordinarysymptoms of lead poisoning. The optic atrophy was, in Mr.Snell’s opinion, due to this cause and all other causes hadbeen eliminated. Mr. Snell, after mentioning a similar case,stated that among file-cutters he had observed severalinstances in which the optic nerves were affected eitherdirectly by the lead or in association with kidney or braindisease.Mr. SNELL related the following case of Optic Atrophy

after Post-partum Haemorrhage in a woman, aged 28 years,who was seen last February a few days after recovery frompuerperal mania. Both papillae were atrophied but therewas no evidence of past neuritis. There was no perceptionof light and the pupils were dilated and motionless. OnOct. 3rd, 1903, she was delivered of her first child at fullterm, but an hour afterwards she had haemorrhage andalthough the amount lost was not very great yet shehad never seemed really to have recovered from it. Itwas doubtful when the failure of sight had commenced butit had been suspected for some time. She had probably notseen at all for two months. There was no albumin northroughout the pregnancy anything to suggest kidneydisease. Mr. Snell referred to a previous case he had seenin which the sight was greatly affected by the same causeand he also alluded to cases collected by Chevallereau.

Mr. SNELL also narrated the following case of OpticGlioma. A baby, aged one year and ten months, was