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Infectious Diseases, Discussion on Isolation And Meeting III.?December 3, 1913 Dr William Russell, Vice-President, in the Chair II. Original Communications DISCUSSION ON ISOLATION AND QUARANTINE PERIODS IN THE MORE COMMON INFECTIOUS DISEASES Opened by Claude B. Ker, M.D., F.R C.P., Medical Superintendent, Edinburgh City Hospital It has occurred to me that the time has arrived when we may with profit investigate the rules usually laid down for the isolation and quarantine periods of the more common infectious diseases. Tradi' tions are handed down to us, we accept them, and they not only become the routine of our own practice, but are also regarded as almost sacred by the general public. And yet our views of the infectivity of certain diseases are undergoing modification, and in this subject, as in others, we are surely to -be permitted to criticise the opinions of our predecessors. That is why I think that an occasional stocktaking, if I may call it so, of our regulations regarding infectious diseases might be undertaken with great advantage. But first I wish to make it perfectly clear that, as things are at present, I totally disclaim any desire to find fault with the regula- tions laid down by public health departments and by schools. 1 have had a hand in drawing up many, and I have always felt myself tied by the views accepted by the profession at large. I do not think either a it reasonable to expect public health authority or a school BY DR CLAUDE B. KER 43 *? take the initiative in relaxing generally accepted rules which aPpear to some of us unnecessarily strict or irksome. Speaking as a Public official, if I translated into practice at once all the opinions ^vhich I have formed after long experience, I know well that not only Av?uld I cause considerable alarm and disquiet among the general Public, but that I could not count on the support of the profession. ls . by the conversion of the profession that progress will come, and l* *s f?r that reason that the subject should be thoroughly ventilated. I am prepared to admit that when we go fully into the question ^Ve find that, as regards certain diseases, it is largely an academic 0lle- An infectious case is after all confined in a room or in a hospital for two reasons?firstly, infectivity, and secondly, disability. In s?uie conditions the infectivity, as we know, lasts very much longer ^an the disability, whereas in others the disability caused by the lllness may be prolonged far beyond the usual period of infectivity. .n the latter case the patient of course undergoes far less hardship, 1 the views held regarding the duration of his infection are mistaken, ^?han he would suffer physically if he were allowed to be up and about |?? soon. But even here, so far as the home is concerned, a r&- .axation of the rules for excluding visitors and maintaining rigid ls?lation might conceivably be to his own advantage, as it would Undoubtedly be to that of the household. In boarding-schools, par- ticularly, much trouble might be saved. Still, in the diseases to ^hich I allude, the time of detention in hospital is not likely to be CUrtailed. Scarlet Fever.?Probably the most important and most trouble- ^?nie of the infectious diseases which I propose to consider is scarlet Ver. The normal minimum isolation recommended for this disease six |s weeks, a period which in my own opinion may be either much ,?? short or unnecessarily long, according to the condition of the dividual case. The six weeks' tradition is not limited to this c?untry. Xhe most recent German book on the subject (Escherich and Schick) recommends such an isolation period, and a period of 4? days, or practically the same thing, is laid down by Wurtz and by Moizard, the two French authorities whose articles I have Consulted. M'Collom, whom we may regard as a representative ^rican authority on this subject, does not give any specified but talks of an "average" of 50 days; and we learn ^uirrium,0rtl . Chapin that a six weeks' isolation is, if not invariable, usual though that country is making advances in the direction 0f^ -America, Shorter period. 44 ISOLATION AND QUARANTINE PERIODS Obviously the origin of this arbitrary regulation is the fact that in a very large number of patients desquamation may be expected to be complete in that time. The question of detention to a great extent resolves itself into this?Is desquamation infectious ? ^ it is not, and much evidence has been collected in the last 20 years which favours such a view, the revision of our traditional ideas and regulations is overdue. If it is, it is high time that satisfactory evidence be produced to establish that fact. Now we know that scarlet fever is infectious before desquama' tion begins, and we know also that it may persist for a long time after desquamation has ceased. I have never been able to con1' prehend, therefore, why a source of infectivity which precedes and survives desquamation should not be allowed to be responsible f?r infection during the desquamative period, without such infection being attributed as a matter of course to the exfoliated skin. may justly suspect the desquamated scales in the same way as a$ suspect fomites, for an infectious patient may infect his skin easily as he infects his clothes. But once he has ceased to be in' fectious he can no longer infect either his skin or his clothes, and when the one has been cleansed and the other disinfected, I see no reason to dread a convalescent, even if he still is desquamating. The experience of Priestley, who during an outbreak of smallp0* discharged 120 desquamating children from the Leicester Fever Hospital without causing a single secondary case, did much to dra^ the attention of hospital workers to this subject. Millard, raising the question at a meeting of the Epidemiological Society in 1902' reported that of 21 medical officers of health and superintendent of fever hospitals whom he had consulted, no less than 16 disbelieve^ or doubted the infectiousness of desquamation. He himself reduced his minimum period of isolation to 4 weeks without increa5 his ing percentage of return cases. Shortly afterwards Laudef that repoited he had actually reduced his percentage of return caseS< although entirely disregarding desquamation and adopting 4 week5 as his mimimum period of detention in hospital. Moore, at Hudder5 field, was able to reduce 44 his average period of detention from 0 to 29 days without increasing his return-case rate. The reports Camei on and Turner to the Metropolitan Asylums Board also thi?NV doubt on the great infectivity of, at any rate, late desquamation' in his " Finally, Goodall, well-known book, says that clinical dence goes to show that after the fourth week the scales are n0^ infectious." BY DR CLAUDE B. KER 45 The idea of the infectivity of desquamation doubtless arose from fact that scarlet fever was considered analogous to small-pox, ln which disease it is of course certain that the infective agent is Present in the skin lesions and resulting crusts. But the rash and esquamation of scarlet fever are almost certainly due to the toxins the unknown micro-organism which causes the disease and not to e germ itsdf. It is much better to regard scarlet fever as analogous ^ 0 diphtheria, which, as has been pointed out by Pugh, Chapin, d, and others, considerable resemblances in its mode Qx presents mfection and persistence of infectivity. We have the advantage re of being able to put the infectivity, as it were, under the micro- and to determine, by obtaining negative examinations, the scope,e at which the patient is no longer capable of causing infection. eikle, working at the Edinburgh City Hospital, found the average ration of infection to be three weeks ; Graham Smith has collected bUres which point to 66 per cent, of convalescents being germ free 5 Weeks; and of course all observers have noted cases of long of the bacilli in the throat. It is noteworthy, however, Persistencet in many of these prolonged cases the germs are non-virulent, ikle emphasises the fact that in all his cases of persistence of f?6rm ?"L ms the patient had large and ragged tonsils. Now, we know that in scarlet fever, morbid conditions of the n?Se and throat and discharges from the ears are found, in an u*duly high proportion, associated with the production of return 'ases. It is fairly obvious that the throat in scarlet fever is in- lQus from the first, and remains so in some cases for extremely periods. I have seen infection carried home by a patient ^longed? ained over 20 weeks. But it does seem reasonable to assume that in a considerable proportion of cases the patient becomes, as in I " " uheria, free from infectivity within 3 weeks, and that clean es> with normal tonsils and no ^ mucopurulent discharges, might re^ease^ with before the six weeks have ela safety long statutory ^ 1*?*' aS a ma^er Patients who are dis- ch^Se^'arged after short detentions who ^ comparatively carry infection a^lle' ^ is those who, on account of some ear or nose complication, f detained longer than the normal time in hospital who do the nief. j Mere length of detention, though not the cause of in- l0n> will never by itself prevent return cases, which I fear we expect in a greater or smaller percentage until we know what tlia|.CaUSa^ve micro-organism of scarlet fever is, and can put it, like diphtheria, under the microscope.
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