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79
strain, and that what we know as "relapses" or "second attacks"
are really new infections by streptococci of different types.
It is generally agreed that a definite correlation exists between
overcrowding of wards and increased incidence of complications.
Like an axiom of Euclid, the association of cause of effect appears
to have been accepted as a self-evident truth requiring no proof.
Experienced Medical Superintendents have given their opinion
that complications become more common whenever the standards of
bed-spacing and nursing efficiency were reduced during epidemics;
but I have never been able to find any published results of the
comparative incidence rates of complications in wards which
were, and those which were not, overcrowded during the same
epidemic.
In the estimation of complication incidence rates much depends
on the standard accepted by the observer, for one will accept and
schedule as a complication a slight departure from normal which
would be disregarded by another; and for that reason such rates
are not strictly comparable unless their estimation is carried out by
the same observer.
In a recent investigation of 808 cases in a large, well-equipped
hospital with modern facilities for isolation and treatment, Brown
and Allison found that 243 patients (i.e., 30 per cent.) showed
complications during their stay in hospital. It is of interest to
compare that rate with the complication incidence rate of a small
temporary isolation hospital in which the total accommodation and
facilities for isolation are inadequate (e.g., of the total accommodation,
only 5.8 per cent. is in the form of separate cubicles). During
1934 the incidence of scarlet fever in Leyton was very high and, as
measles and diphtheria were both prevalent, the available number
of hospital beds was insufficient to meet the demand. Even after
the most rigorous selection of cases for admission, the number of
patients in hospital was in excess of the standard accommodation
during the whole year. My colleague, Dr. F. W. Gavin, undertook
a detailed analysis of the incidence of complications during that
year, and found that of 387 scarlet fever patients treated in hospital
as many as 199 (i.e.,. 51.4 per cent.) suffered from one or more of the
recognised complications during their stay in hospital. That is an
alarmingly high figure even when allowance is made for the fact
that some 23 per cent. of the complications were present on
admission.