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Adequate bed spacing, the maintenance of 12 feet between bed centres, the minimum standard
of the Ministry of Health for infectious diseases hospitals, ensures two things : (i) the elimination of
the factor of droplet spray in the dissemination of bacterial infections from bed to bed and a
fortiori amongst patients more remote from the potential focus of infection, (ii) the limitation of
t he number of patients in the ward and therefore of the potential foci of infection which renders
manual transference less likely by a staff which is not overworked, and is thus in a position to
take essential precautions in passing from one patient to the next. It is clear that if the total
load of infective material in the ward is limited the likelihood of transference by any means is
much diminished.
(d) Barrier nursing of certain cases.—If as an additional precaution any patients with
obvious and gross foci of infection are strictly barrier nursed, or, preferably removed from the
ward altogether, the likelihood of transference of infection is still further diminished.
Considerable evidence has been produced by other observers in the Council's infectious
diseases service that relapses and the extraneous septic type of complications in scarlet fever are
the result of re-infection, possibly by hemolytic streptococci of different types or strains, and
it is perhaps significant that in the series of 1,000 cases analysed, in spite of the fact that all were
treated with serum, which has been held by some to hinder the production of active immunity
as the result of the attack, there were only 4 instances (- 4 per cent.) of relapse of disease.
Consideration of these various factors leads to the conclusion that, other things being equal,
adequate bed spacing and segregation or removal of patients with gross potential foci of infection
are of the utmost importance in securing a low incidence of complications, e.g., otitis media, which
may be brought about in part, at least, by re-infection of the upper respirator}- tract.
It may well be that the disparity in the effects upon the complication rate in serum-treated
cases of scarlet fever recorded by different workers depends not only upon such factors as age
distribution, variability of clinical type, potency, dosage and route of administration of antitoxin
but upon bed spacing and the prompt segregation of those patients who may constitute the
reservoirs from which extraneous infection is derived and disseminated by one means or another.
The removal of cases of otitis media from main wards to special wards is infinitely preferable
to allowing them to remain as reservoirs of infection, but is not ideal unless each patient in the
ear ward is rigorously " barrier nursed." If this is not done, re-infection of the upper respiratory
tract, not necessarily with the streptococcus, may take place in exactly the same way as in
ordinary open wards.
In one such ear ward, nursed as an open ward, it was observed that the introduction of a fresh
case of otitis media was liable to be followed by the lighting up of other cases which were either
actually quiescent, or were becoming so. The only feasible explanation is to be found in reinfection
of the upper respiratory tract, the most likely mode of transference, under the conditions
obtaining, being manual. There seems to be no escape from the conclusion that patients with
gross potential foci of infection should, on medical and administrative grounds, be nursed either
in separate chambers or in very small wards with the most rigorous aseptic nursing technique if
the likelihood of re-infection of the upper respiratory tract is to be reduced to minimal proportions.
What has been written above about scarlet fever applies with even greater force to measles,
because younger children suffer risk from infections and re-infections of the upper respiratory
tract which may result not only in otitis media, which has been found more difficult to treat
successfully than the corresponding complication in scarlet fever, but in bronchopneumonia.*
When the new isolation blocks are constructed at this hospital it will be possible to segregate
scarlatinal and measles otitis media to an extent which is not at present feasible.
The medical superintendent of the North-Western hospital (Dr. Joe) states
that, at that hospital, scarlet fever appeared on the death certificates in seven cases.
The salient features of the fatal cases are given below and in only four (cases 3, 4,
5 and 6) can the death be directly attributable to scarlet fever, as in the other cases
some other serious condition was already present at the onset, or developed late in
convalescence and played a predominating part in producing the fatal result. Corrected
in this way, therefore, the case fatality rate is 4 per cent. The details are
as follows:—
(1) A.P., aged 4, male. Mongolian idiot. Was suffering from bronchopneumonia
for some time before contracting scarlet fever, and died within 24 hours of admission.
(2) G.W.C., aged 2, male. Death due to measles bronchopneumonia following scarlet
fever.
(3) I.B., aged 2, female. Death due to scarlatina anginosa and enteritis.
(4) O.W., aged 2, female. Death due to endocarditis following scarlet fever.
(5) F.W., aged 86, female. Death due to chronic bronchitis and scarlet fever. Patient
very enfeebled owing to age.
(6) K.H., aged 3, male. Death due to scarlatina maligna.
(7) D.P., aged 10 months, male. Death due to acute miliary tuberculosis, intercurrent
scarlet fever and nasal diphtheria.
* This point was alluded to in the special report upon the Measles Epidemic of 1933-34, together
with other observations upon measles.