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Bed isolation of infectious diseases in fever hospitals
PUBLIC H E A L T H .
i28
MAY,
BED ISOLATION OF INFECTIOUS D I S E A S E S IN F E V E R H O S P I T A L S .
bacteriological l a b o r a t o r y was a t t a c h e d to the f e v e r hospital.
BY
An e m i n e n t F r e n c h Savant, Dr. Seguin, entitted to priority in the m a t t e r of i n a u g u r a t i n g e poch-mald,tg efforts in the a m e l i o r a t i o n of the m e n t a l l y defective, m o d e s t l y w r o t e : - - At certain t i m e s and eras, the whole r a c e of man as r e g a r d s the d i s c o v e r y of t r u t h Seems to a r r i v e at once at a certain point so that it is hard to say who is the d i s c o v e r e r . " W h e n i,t the yeas" 1910 Dr. F. O. Crookshanl~ w r o t e his i n t e r e s t i n g contribution on B e d Isolation, I was r a t h e r Surpt'ised to find that a p r i o r contribution I of mine on " S c a r l e t F e v e r and D i p h t h e r i a f r o m a Public H e a l t h P o i n t o~ V i e w " published in the " P r a c t i t i o n e r " of J a n u a r y , 1909, waS appat'ently a pioneer m o d e s t e x p r e s s i o n of an idea t h a t was in 1910 exciting a t t e n t i o n as a new idea.
P r i o r to m y tatting o v e r the a p p o i n t m e n t , and for a few weeks t h e r e a f t e r , cases of fsostscarlatinal d i p h t h e r i a were o c c u r r i n g in the f e v e r hospital which exercised my mind and induced me to e x a m i n e swabs f r o m the t h r o a t s of e v e r y s c a r l e t f e v e r patient on admission. This led to the d i s c o v e r y that a small p e r c e n t a g e of s c a r l e t f e v e r patients w e r e a d m i t t e d who were also c a r r i e r s o f diphtheria bacilla. Thts was in t h e y e a r 1901. This d i s c o v e r y induced me to carefully inst['uct the n u r s e s that e v e r y patient a d m i t t e d to hospital as suffering fi'om a c e r t a i n disease (and g e n e r a l l y obviously so) was invariably to be nursed as if suffering f r o m a second f o r m of infection also. In o t h e r words, although by fot;ce o f a d m i n i s t r a t i v e c i r c u m s t a n c e s a p a t i e n t was a d m i t t e d on the notification of s c a r l e t f e v e r itlto the acute s c a r l e t f e v e r ward, yet he was to be isolated itl bed, a n d the n u r s e was to take e v e r y c a r e that his utensils, bedclothes, etc., etc., w e r e kept a b s o l u t e l y distinct fi'om the others, and that she was to c a r e f u l l y disinfect her h a n d s a f t e r a t t e n d i n g to the r e q u i r e m e n t s of each individual patient.
In t h a t p a p e r I clearly and unequivocally e n u n c i a t e d the principles of " B e d Isolation " at least a cleat' y e a r before the a p p e a r a n c e of Dr. C r o o h s h a n k ' s p a p e r - - b u t I had t h o u g h t at the time t h a t p e r h a p s I was m e r e l y laying a little e x t r a s t r e s s on principles which w e r e already largely acted upon ; and y e t , ' 0 n reflection, I could not but a d m i t t h a t the principles I had e n u n c i a t e d had been based chiefly on m y own individual experiences, c o n t e m p l a t i o n s , and deductions while holding the triple appointm e n t s of Medical Offices- of H e a l t h , B a c t e r iologist, aqd Medical S u p e r i n t e n d e n t of the F e v e r Hospital in c o n n e c t i o n with a large, rapidly growing, sea-side resort. T h i s sea-side town is exceptionally exposed to the i m p o r t a t i o n of infectious diseases f r o m L o n d o n and the g r e a t e x t r a m e t r o p o l i t a n u r b a n districts e a s t of the Metropolis, and when I took up my duties it had a tong-sustained r e p u t a t i o n f o r i n d i g e n o u s typhoid and d i p h t h e r i a endemicity~ This triple c o m b i n a t i o n of offices e n a b l e d me to devote my attention to m a n y i n t e r e s t i n g problems, the m o r e easily tactded since m y
Soon a f t e r this a d m i n i s t r a t i v e p r o c e d u r e was introduced and e n f o r c e d cases o f post-scarlatinal d i p h t h e r i a ceased to occur, and this h a p p y s t a t e of things continued for two y e a r s ; thorn there was a r e c u r r e n c e of two or t h r e e c a s e s of p o s t - s c a r l a t i n a l d i p h t h e r i a in a c o m p a r a t i v e l y n e w ward. I t h e r e f o r e enquired closely into the m a t t e r to a s c e r t a i n the reason. I found that the n u r s e s were keeping strictly to the injunctions laid upon them, so I d e t e r m i n e d to e x a m i n e the t h r o a t s by s w a b b i n g of e v e r y n u r s e arid a t t e n d a n t in the ward. I n this t~¢ay I d i s c o v e r e d a w a r d m a i d with- efilarged tonsils full of diphtheria bacilli w h o I f o u n d ~had occasionally been left in the ward while the n u r s e was at a meal, and t h a t she a t f e n d e d to the w a n t s of a n y child d u r i n g t h e n u r s e ' s absence. F u r t h e r enquiries t'evealed a bi'each of the discipline I had laid "do wm in t h r e e directions, (a) this g i r l had: been t r a n s f e F r e d f r o m the d i p h t h e r i a block t o t h e s c a r l e t f e v e r block b y the Matbon without the p r e l i m i n a r y s w a b b i n g which it was my c u s t o m to e n f o r c e ; (b) she had not r e p o r t e d a slight sore, tSroa.t
a. T. C. NASH, M.D. (Edin.), D . P . H . (Camb.), Fellow (late Memb. of Council and E x - P r e s . E. Counties Branch), I n c o r p o r a t e d Society of Medical Officers of Health, C o u n t y Medical Officer of H e a l t h for Norfolk, etc., etc.
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which by one of the printed rules it was i n c u m b e n t on' her to do; (c) she had been allowed to see to the wants of the children in the nurse's t e m p o r a r y absence without having been cautioned as to the p r o c e d u r e which was in force. Apart from disciplinary measures, the git'l was r e m o v e d from the scarlet f e v e r block, and no f u r t h e r cases of diphtheria occm'red in the block.
before proceeding w i t h the next, even in a ward labelled for one recognised z y m o t i c disease, say, scarlet fever. T h e r e is much to be Said for glass partitions between beds, but I am satisfied that the main point is to have each patient dealt with as if he or she might infect or receive infection f r o m a n o t h e r . " - (" P r a c t i t i o n e r , " No. 487, Vol, lxxxii., No. I, aanttary, 1909.)
Tt£is f u r t h e r incidental experience confirmed me in the c o r r e c t n e s s of my practice of bedisolation, and no f u r t h e r case of post-scarIatinal diphtheria ever o c c u r r e d again in t h a t hospital during the remaining y e a r s I was in charge of it.
T h e s e being my views I n a t u r a l l y read with gt'eat interest and sympathetic appreciation an address delivered before the Epidemiological Section of the Royal Society of Medicine, on J a n u a r y 28th, 1910, by Dr. F. G. Crookshank, in which he raised the question whether, in s m a l l hospitals at any rate, cases of scarlet fever, and diphtheria, and measles, etc., might not be safely t r e a t e d Side by side. At his hospital at /Vlortlake he had treated cases of diphtheria, typhoid fever, erysipelas, and puerperal fever in one ward, and he had not t r a n s f e r r e d doubtfttl cases of scarlet f e v e r or diphtheria adnlitted to the wards nominally allotted to those diseases even a f t e r the diagnosis had been f o u n d . e r r o n e o u s . His method of dealing with the cases closely c o r r e s p o n d e d with that which I, had outlined in the " P r a c t i t i o n e r " a y e a r previously by a ritual observance, isolating each patient in bed, the only s a f e g u a r d being mimtte attention to cleanliness by a competent, carefully-trained nurse.
In the y e a r 1908 I embodied my experience i n :a paper which appeared in the special number" of the " P r a c t i t i o n e r , " on " Scarlet F e v e r and Diphtheria," of J a n u a r y , 1909. I wrote as follows, inter alia : - " A v e r y i m p o r t a n t point in the administration o f the f e v e r hospital, if it is to prove a really p r e v e n t i v e m e a s u r e instead of a possible danger, is the strict limitatiot~ of the mtmbers admitted. T h e Local G o v e r n m e n t B o a r d Wisely insist on a cubic space provision o f 2,000 cubic feet for each pa*ient in a f e v e r hospital . . . . . . I n a common ward each patient, to a certain extent, is a source of ~bossible det/imeut to the others. Thus, if a child suffering from scarlet f e v e r is admitted with a profuse nasal discharge, there is a risk of the g e r m s a c c o u n t i n g for that d i s c h a r g e being t r a n s f e r r e d to o t h e r patienta in the ward unless at least 2,000 Cubic feet pet' patient is insisted upon. O t h e r points of internal administration are also of i m p o r t a n c e in determining w h e t h e r a fever hospital is of real use or the r e v e r s e ; particttlarly in regard to the supervision a n d i)~struetion of the nurses with reference to their dtities. " A p 0 i n t to be constantly urged until the n u r s e s a c t almost atttomatically on the idea is that each [2atient shouht be loohed uDon as 15ossibly harbourhzg some form of iufectim~ which might be transferred to attother. This idea involves not only separate articles of linen food, crockery, and plate, but also, which is m o r e i m p o r t a n t still, that the nurse, should c a r e f u l l y soak her hands in a suitable disinf e c t a n t solution a f t e r attending each .tSatient
In America, about the same time, Dr, Chapin, of R h o d e Island, U.S.A., advocated the t r e a t m e n t of scarlet f e v e r in general fever wards o n m u c h the same lines. E a r l y in 1912 a paper" on the " Bed Isolation of cases of Infectious Diseases," by Drs. Runc!le and B u r t o n , appeared in " T h e L a n c e t " (Vol. 2, p. 720)insisting again on the one main fact0v essential to s u c c e s s - - s u r g i c a l cleanliness; and this was followed in April, 1912, by an address delivered by Dr. Rundle before the Epidemiological Section of the Royal Society of Medicine on the same subject. This is the most i m p o r t a n t and detailed contt'ibution which has yet been made to this subiect. T h e m e a s u r e s employed by Dr. Rundle at the F a z a k e r l e y Hospital, L i v e r p o o l , are thus described : - -
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" A highty-tralned sister is in charge of the w a r d part[ion with special surgical and fever experience. Each ward, male and female, is incharge, utide;r the sister, of a general hospitaltrained n/wse with some fex~er experience. One probationer is also allocated to each ward. The night staff consists of two nurses, one o f w h o m h-as frequently had three years' general training. " E a c h c a s e of puerperal fever is placed on admission in a side ward. . As long as active tl;eatment, such. as douching, is requit'ed, the nui'se in .charge i s 'not allowed to assist in t h e dressing of any. cas e of erysipelas or ceb lulitis. C o a t s are worn by the doctor a n d nurse when attending to the ~case, and rubber gloves if douching o r dressing i s n e e d e d . , . . . EVentually the case is transferred to themain W:at+d. : ' " T h e cases :of erysipelas' and cellulitis are treated ~with' o r d i n a r y cleanliness only, no special tsol/~tion measures being adopte& ".With cases of varicell a, pertussis, and d0ubtful o r genuine cases o f Scarlet fever or diplqth~ria mot;~ rigid measures are adopted. T~yo 10.ng c o a t s I}ept for eac h c a s e are worn, op~ b y the d0ct0r,.the other by the nuyse. '"Drinkifig vessels; knife,: fork; spoon, and spitting inug are boiied afteruse; and separate sanitary, utensils, :bowl and brush for washing , and bath blankets are reserved for the use of each :of t h e s e patients. NO inter;change :of t o j s o r books is permitted. After"removing the c o a t worn in attending to the case, the doctor or nurse Washes his or her hands before l~roceeding to another patient. " T h e d i s e a s e s which are admitted to the ward ,,are as follows ::--(i) All cases of puerpet;ai fever and erysipelas, and most cases of pertussis; rubella, and varice!la. (2) Atl cases: (though notified) found on admission to have no infectious conditions: (8) Cases in which the dlagffosisis doubtful. (4) Cases from other: wards requiring operative treatment in which the a'fter treatment may be prolonged. .(5) Cases of diphtheria or-measles when the wards receiving these patients are pressed by a sudden rise in the incidence of the disease. (6) Cases of epidemic diarrhoea when these are few in n tln:lber."
MAy,
It will be noted that the wards are well-staffed with a number of experienced nurses. A n interesting account of the evolution of the bed-isolation ward is given b y Dr. Rundle which was originally utitised for convalescent transfers: from t h e Scarlet feveG diphtheria, and measles wards 0f the h o s p i t a l . Later, v a c a n t Feds were used f o r t h e reception of doubtful cases on admission. The absence of cross infection ted on to the inclusion of definite cases of the acute-infectious diseases-for which there was no accommodation elsewhere. F . o r t h e taking of temperature a separate ~tlermometer is k e p t for each case Of enteric fever or varicelta, otherwise the thermometers are washed in lysol solution after u s e . -" The patten* is allowed to get Up when-all signs of acute disease likely to prove infectious have subsided." " Special precautions a r e of course adopted in dealing :wi'th nose 0r e a r discharges." Of 741 patients admitte d to the pa.vJlion during 1 9 i 0 and.19111 t w o only deveiop,ed in£ectious disease whil'st under treatment. A poifft requiring einphas]s is that a large proportion of the patients in the wa.rd were childrep,, though the practice was to take no unnecessary risks., and t h e high percentage of adtdts admitted was" ufilised a s , f a r as Possible in the separation of prime infections OCCurring a m o n g s t "children. " W i t h r e s p e c t to the possibility, Of mriet convection of infectious ~tiseases, I anl one of those who believe. ~ctaat. if a proper :~mount Of cubic space (not less t h a n 2,00b ic. f t . ) b e allowed t o e a c h be d in an adequately ventilated ward, the risk of Such. convection is almost negligible. I agree with Dr. Rundle that the experiments of C o r n e t (Verhand d Berl reed Oeselisch, 1899) were conducted .under conditions too far removed from the natural to be of much help in determining this point, It is a common experience inthe management of a fever hospital that varicella is a most infectious complaint--a case occurring in One corner of a ward frequently being followed by another in the.fat" dorner of the opposite Side of the ward--many have attributed this to mriel convection. My own view is (and always has been) that the infection is carried by the nurse as a rule--though in the fly season, when flies
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invade the wards, a r e a d y method of c o n v e y a n c e of' infection has to my mind always been obvious, which might e x o n e r a t e the n u r s e .
quite a young nurse (provided she was properly trained, t r u s t w o r t h y and c o m p e t e n t ) in c h a r g e of a typhoid block.
The e x p e r i e n c e of F a z a k e r l e y Hospital as r e g a r d s varicelta was t h e r e f o r e a m a t t e r of great interest to me, and one which [ would look upon as of the first i m p o r t a n c e in adjudicating On the merits of the bed-isolation system as t h e r e applied. W h a t then were the results ? D r . R t m d l e states that no fewer than fortyone Cases of Varicella received t r e a t m e n t in the bed-isolatlon ward in the y e a r s 1910 and 1911 .withoz~t a si,;gle itlstanee of cross-infection occz*rring. On ,the o t h e r hand, varieella was aeeldently introdtfced into the o r d i n a r y wards of the hospital On twenty-one occasions during t h e , s a m e period o f time, and cross-itafection
My own experience confirms Dr. Rundle's s t a t e m e n t that the controlling f a c t o r in " bedi s o l a t i o n " is nndoubtedly that of a d e q u a t e nursing with i n t e l l i g e n t supervision on the part of the medical officer. S o m e think that small-pox would afford a test of value. S u r e l y varicella is quite as infectious as small-pox though f o r t u n a t e l y a disease a l m o s t devoid of danger, I am quite satisfied t h a t Dr. R u n d l e ' s r e c o r d e d e x p e r i e n c e with varicella is quite as valuable and convincing a t e s t as small-pox would be.
occurred
in
e v e r y instc~nce: exc@ting
o~e.
Precisely the same o p p o r t u n i t i e s for m r i e l infection were present in each group of cases .... but not 0 n l y direct but als0 i n t e r m e d i a t e contact infection Was excluded i n o n e series of cases only, and that was of c o u r s e the series where c r o s s d n f e c t i o n did not occur. I v e n t u r e to a s s e r t t h a t in all h o s p i t a l s ' w h e r e bedisolation is not practised, the usual, if not invariable experience, is that of the o t h e r series of cages r e c o r d e d by Dr. Rundle, w h e r e crossinfection o c c u r r e d in practically e v e r y occasion (20 out of 21). Dr. R u n d l e touches o n the question of flies, and confesses to some anxiety in this respect during the s u m m e r months. Comparing Dr. Crookshank's and Dr. Rundle's m e t h o d s with my own met~hod at" S o u t h e n d - o n - g e a F e v e r Hospital, I find t h a t Dr. R u n d l e ' s m e t h o d more closely c o r r e s p o n d s with mine as r e c o r d e d i n 1909 (" Practiti~0ner ") more particularly in impressing the n u r s i n g staff with t h e i r individual responsibility. Indeed, I went so far .as to tell my nurses that if a n y o n e of them c o n t r a c t e d typhoid f e v e r in the hospital I should dismiss her on recovery, =as I should feel certain that she had not s t r i c t l y a d h e r e d to the minutiae Of bet" instructions, P r o v i d e d the nurse had learnt t h o r o u g h l y the i m p o r t a n c e Of disinfecting her hands directly a f t e r a t t e n d i n g t o the wants o f ' a typhoid patient, even to the m e r e smoothing of the bed-sheets, I had no c o m p u n c t i o n in putting
A point of difference b e t w e e n my own m e t h o d and that of Dr. Rundte: was that although I put on an overall to p r o t e c t my own clothes, I wore the same Overall while seeing to e v e r y patient in the hospital, ianless I had reason to think it: had b e c o m e i n f e c t e d b y discharge or Saliva. B u t my invariable practice w a s to be a t t e n d e d by two n u r s e s ' one c a r r y i n g two b o w l s of disinfectant ~olution (Lysol 0r Izal or Cyllin), o n e o f which was used by me a f t e r each individual case. W a s h i n g with s o a p and Wa~er was carried out at the:concluSion of the visit t~0 each ward. The nurses were e n c o u r a g e d to work with a r m s bared to the elbow, and they also had to soak the hands in disinfectant solution a f t e r any attention to each individual 6atient. Sufficient evidence is now available on t h e question of " bed isolation," t o w a r r a n t extensive enquiry into the m a t t e r - - b e a r i n g in mind as much as possible---all epidemiological factors such as age, sex, season, day of disease, period of epidemic prevalence, intensification or recession of the disease as a whole, and so forth. The main essentials for successful enquiry and administration are- (1) a well-equipped e x p e r t medical s u p e r i n t e n d e n t ; (2) nurses specially trained in the method. In my opinion the nurses need not alt be n u r s e s o f t h r e e years' general hospital t r a i n i n g - - t h e essential being that they should u n d e r s t a n d the why and .wherefore of the m e t h o d s of " bedisolation," and the adequate disinfection of theirown hands between a t t e n t i o n to each patient.
i28
MAY,
BED ISOLATION OF INFECTIOUS D I S E A S E S IN F E V E R H O S P I T A L S .
bacteriological l a b o r a t o r y was a t t a c h e d to the f e v e r hospital.
BY
An e m i n e n t F r e n c h Savant, Dr. Seguin, entitted to priority in the m a t t e r of i n a u g u r a t i n g e poch-mald,tg efforts in the a m e l i o r a t i o n of the m e n t a l l y defective, m o d e s t l y w r o t e : - - At certain t i m e s and eras, the whole r a c e of man as r e g a r d s the d i s c o v e r y of t r u t h Seems to a r r i v e at once at a certain point so that it is hard to say who is the d i s c o v e r e r . " W h e n i,t the yeas" 1910 Dr. F. O. Crookshanl~ w r o t e his i n t e r e s t i n g contribution on B e d Isolation, I was r a t h e r Surpt'ised to find that a p r i o r contribution I of mine on " S c a r l e t F e v e r and D i p h t h e r i a f r o m a Public H e a l t h P o i n t o~ V i e w " published in the " P r a c t i t i o n e r " of J a n u a r y , 1909, waS appat'ently a pioneer m o d e s t e x p r e s s i o n of an idea t h a t was in 1910 exciting a t t e n t i o n as a new idea.
P r i o r to m y tatting o v e r the a p p o i n t m e n t , and for a few weeks t h e r e a f t e r , cases of fsostscarlatinal d i p h t h e r i a were o c c u r r i n g in the f e v e r hospital which exercised my mind and induced me to e x a m i n e swabs f r o m the t h r o a t s of e v e r y s c a r l e t f e v e r patient on admission. This led to the d i s c o v e r y that a small p e r c e n t a g e of s c a r l e t f e v e r patients w e r e a d m i t t e d who were also c a r r i e r s o f diphtheria bacilla. Thts was in t h e y e a r 1901. This d i s c o v e r y induced me to carefully inst['uct the n u r s e s that e v e r y patient a d m i t t e d to hospital as suffering fi'om a c e r t a i n disease (and g e n e r a l l y obviously so) was invariably to be nursed as if suffering f r o m a second f o r m of infection also. In o t h e r words, although by fot;ce o f a d m i n i s t r a t i v e c i r c u m s t a n c e s a p a t i e n t was a d m i t t e d on the notification of s c a r l e t f e v e r itlto the acute s c a r l e t f e v e r ward, yet he was to be isolated itl bed, a n d the n u r s e was to take e v e r y c a r e that his utensils, bedclothes, etc., etc., w e r e kept a b s o l u t e l y distinct fi'om the others, and that she was to c a r e f u l l y disinfect her h a n d s a f t e r a t t e n d i n g to the r e q u i r e m e n t s of each individual patient.
In t h a t p a p e r I clearly and unequivocally e n u n c i a t e d the principles of " B e d Isolation " at least a cleat' y e a r before the a p p e a r a n c e of Dr. C r o o h s h a n k ' s p a p e r - - b u t I had t h o u g h t at the time t h a t p e r h a p s I was m e r e l y laying a little e x t r a s t r e s s on principles which w e r e already largely acted upon ; and y e t , ' 0 n reflection, I could not but a d m i t t h a t the principles I had e n u n c i a t e d had been based chiefly on m y own individual experiences, c o n t e m p l a t i o n s , and deductions while holding the triple appointm e n t s of Medical Offices- of H e a l t h , B a c t e r iologist, aqd Medical S u p e r i n t e n d e n t of the F e v e r Hospital in c o n n e c t i o n with a large, rapidly growing, sea-side resort. T h i s sea-side town is exceptionally exposed to the i m p o r t a t i o n of infectious diseases f r o m L o n d o n and the g r e a t e x t r a m e t r o p o l i t a n u r b a n districts e a s t of the Metropolis, and when I took up my duties it had a tong-sustained r e p u t a t i o n f o r i n d i g e n o u s typhoid and d i p h t h e r i a endemicity~ This triple c o m b i n a t i o n of offices e n a b l e d me to devote my attention to m a n y i n t e r e s t i n g problems, the m o r e easily tactded since m y
Soon a f t e r this a d m i n i s t r a t i v e p r o c e d u r e was introduced and e n f o r c e d cases o f post-scarlatinal d i p h t h e r i a ceased to occur, and this h a p p y s t a t e of things continued for two y e a r s ; thorn there was a r e c u r r e n c e of two or t h r e e c a s e s of p o s t - s c a r l a t i n a l d i p h t h e r i a in a c o m p a r a t i v e l y n e w ward. I t h e r e f o r e enquired closely into the m a t t e r to a s c e r t a i n the reason. I found that the n u r s e s were keeping strictly to the injunctions laid upon them, so I d e t e r m i n e d to e x a m i n e the t h r o a t s by s w a b b i n g of e v e r y n u r s e arid a t t e n d a n t in the ward. I n this t~¢ay I d i s c o v e r e d a w a r d m a i d with- efilarged tonsils full of diphtheria bacilli w h o I f o u n d ~had occasionally been left in the ward while the n u r s e was at a meal, and t h a t she a t f e n d e d to the w a n t s of a n y child d u r i n g t h e n u r s e ' s absence. F u r t h e r enquiries t'evealed a bi'each of the discipline I had laid "do wm in t h r e e directions, (a) this g i r l had: been t r a n s f e F r e d f r o m the d i p h t h e r i a block t o t h e s c a r l e t f e v e r block b y the Matbon without the p r e l i m i n a r y s w a b b i n g which it was my c u s t o m to e n f o r c e ; (b) she had not r e p o r t e d a slight sore, tSroa.t
a. T. C. NASH, M.D. (Edin.), D . P . H . (Camb.), Fellow (late Memb. of Council and E x - P r e s . E. Counties Branch), I n c o r p o r a t e d Society of Medical Officers of Health, C o u n t y Medical Officer of H e a l t h for Norfolk, etc., etc.
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which by one of the printed rules it was i n c u m b e n t on' her to do; (c) she had been allowed to see to the wants of the children in the nurse's t e m p o r a r y absence without having been cautioned as to the p r o c e d u r e which was in force. Apart from disciplinary measures, the git'l was r e m o v e d from the scarlet f e v e r block, and no f u r t h e r cases of diphtheria occm'red in the block.
before proceeding w i t h the next, even in a ward labelled for one recognised z y m o t i c disease, say, scarlet fever. T h e r e is much to be Said for glass partitions between beds, but I am satisfied that the main point is to have each patient dealt with as if he or she might infect or receive infection f r o m a n o t h e r . " - (" P r a c t i t i o n e r , " No. 487, Vol, lxxxii., No. I, aanttary, 1909.)
Tt£is f u r t h e r incidental experience confirmed me in the c o r r e c t n e s s of my practice of bedisolation, and no f u r t h e r case of post-scarIatinal diphtheria ever o c c u r r e d again in t h a t hospital during the remaining y e a r s I was in charge of it.
T h e s e being my views I n a t u r a l l y read with gt'eat interest and sympathetic appreciation an address delivered before the Epidemiological Section of the Royal Society of Medicine, on J a n u a r y 28th, 1910, by Dr. F. G. Crookshank, in which he raised the question whether, in s m a l l hospitals at any rate, cases of scarlet fever, and diphtheria, and measles, etc., might not be safely t r e a t e d Side by side. At his hospital at /Vlortlake he had treated cases of diphtheria, typhoid fever, erysipelas, and puerperal fever in one ward, and he had not t r a n s f e r r e d doubtfttl cases of scarlet f e v e r or diphtheria adnlitted to the wards nominally allotted to those diseases even a f t e r the diagnosis had been f o u n d . e r r o n e o u s . His method of dealing with the cases closely c o r r e s p o n d e d with that which I, had outlined in the " P r a c t i t i o n e r " a y e a r previously by a ritual observance, isolating each patient in bed, the only s a f e g u a r d being mimtte attention to cleanliness by a competent, carefully-trained nurse.
In the y e a r 1908 I embodied my experience i n :a paper which appeared in the special number" of the " P r a c t i t i o n e r , " on " Scarlet F e v e r and Diphtheria," of J a n u a r y , 1909. I wrote as follows, inter alia : - " A v e r y i m p o r t a n t point in the administration o f the f e v e r hospital, if it is to prove a really p r e v e n t i v e m e a s u r e instead of a possible danger, is the strict limitatiot~ of the mtmbers admitted. T h e Local G o v e r n m e n t B o a r d Wisely insist on a cubic space provision o f 2,000 cubic feet for each pa*ient in a f e v e r hospital . . . . . . I n a common ward each patient, to a certain extent, is a source of ~bossible det/imeut to the others. Thus, if a child suffering from scarlet f e v e r is admitted with a profuse nasal discharge, there is a risk of the g e r m s a c c o u n t i n g for that d i s c h a r g e being t r a n s f e r r e d to o t h e r patienta in the ward unless at least 2,000 Cubic feet pet' patient is insisted upon. O t h e r points of internal administration are also of i m p o r t a n c e in determining w h e t h e r a fever hospital is of real use or the r e v e r s e ; particttlarly in regard to the supervision a n d i)~struetion of the nurses with reference to their dtities. " A p 0 i n t to be constantly urged until the n u r s e s a c t almost atttomatically on the idea is that each [2atient shouht be loohed uDon as 15ossibly harbourhzg some form of iufectim~ which might be transferred to attother. This idea involves not only separate articles of linen food, crockery, and plate, but also, which is m o r e i m p o r t a n t still, that the nurse, should c a r e f u l l y soak her hands in a suitable disinf e c t a n t solution a f t e r attending each .tSatient
In America, about the same time, Dr, Chapin, of R h o d e Island, U.S.A., advocated the t r e a t m e n t of scarlet f e v e r in general fever wards o n m u c h the same lines. E a r l y in 1912 a paper" on the " Bed Isolation of cases of Infectious Diseases," by Drs. Runc!le and B u r t o n , appeared in " T h e L a n c e t " (Vol. 2, p. 720)insisting again on the one main fact0v essential to s u c c e s s - - s u r g i c a l cleanliness; and this was followed in April, 1912, by an address delivered by Dr. Rundle before the Epidemiological Section of the Royal Society of Medicine on the same subject. This is the most i m p o r t a n t and detailed contt'ibution which has yet been made to this subiect. T h e m e a s u r e s employed by Dr. Rundle at the F a z a k e r l e y Hospital, L i v e r p o o l , are thus described : - -
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" A highty-tralned sister is in charge of the w a r d part[ion with special surgical and fever experience. Each ward, male and female, is incharge, utide;r the sister, of a general hospitaltrained n/wse with some fex~er experience. One probationer is also allocated to each ward. The night staff consists of two nurses, one o f w h o m h-as frequently had three years' general training. " E a c h c a s e of puerperal fever is placed on admission in a side ward. . As long as active tl;eatment, such. as douching, is requit'ed, the nui'se in .charge i s 'not allowed to assist in t h e dressing of any. cas e of erysipelas or ceb lulitis. C o a t s are worn by the doctor a n d nurse when attending to the ~case, and rubber gloves if douching o r dressing i s n e e d e d . , . . . EVentually the case is transferred to themain W:at+d. : ' " T h e cases :of erysipelas' and cellulitis are treated ~with' o r d i n a r y cleanliness only, no special tsol/~tion measures being adopte& ".With cases of varicell a, pertussis, and d0ubtful o r genuine cases o f Scarlet fever or diplqth~ria mot;~ rigid measures are adopted. T~yo 10.ng c o a t s I}ept for eac h c a s e are worn, op~ b y the d0ct0r,.the other by the nuyse. '"Drinkifig vessels; knife,: fork; spoon, and spitting inug are boiied afteruse; and separate sanitary, utensils, :bowl and brush for washing , and bath blankets are reserved for the use of each :of t h e s e patients. NO inter;change :of t o j s o r books is permitted. After"removing the c o a t worn in attending to the case, the doctor or nurse Washes his or her hands before l~roceeding to another patient. " T h e d i s e a s e s which are admitted to the ward ,,are as follows ::--(i) All cases of puerpet;ai fever and erysipelas, and most cases of pertussis; rubella, and varice!la. (2) Atl cases: (though notified) found on admission to have no infectious conditions: (8) Cases in which the dlagffosisis doubtful. (4) Cases from other: wards requiring operative treatment in which the a'fter treatment may be prolonged. .(5) Cases of diphtheria or-measles when the wards receiving these patients are pressed by a sudden rise in the incidence of the disease. (6) Cases of epidemic diarrhoea when these are few in n tln:lber."
MAy,
It will be noted that the wards are well-staffed with a number of experienced nurses. A n interesting account of the evolution of the bed-isolation ward is given b y Dr. Rundle which was originally utitised for convalescent transfers: from t h e Scarlet feveG diphtheria, and measles wards 0f the h o s p i t a l . Later, v a c a n t Feds were used f o r t h e reception of doubtful cases on admission. The absence of cross infection ted on to the inclusion of definite cases of the acute-infectious diseases-for which there was no accommodation elsewhere. F . o r t h e taking of temperature a separate ~tlermometer is k e p t for each case Of enteric fever or varicelta, otherwise the thermometers are washed in lysol solution after u s e . -" The patten* is allowed to get Up when-all signs of acute disease likely to prove infectious have subsided." " Special precautions a r e of course adopted in dealing :wi'th nose 0r e a r discharges." Of 741 patients admitte d to the pa.vJlion during 1 9 i 0 and.19111 t w o only deveiop,ed in£ectious disease whil'st under treatment. A poifft requiring einphas]s is that a large proportion of the patients in the wa.rd were childrep,, though the practice was to take no unnecessary risks., and t h e high percentage of adtdts admitted was" ufilised a s , f a r as Possible in the separation of prime infections OCCurring a m o n g s t "children. " W i t h r e s p e c t to the possibility, Of mriet convection of infectious ~tiseases, I anl one of those who believe. ~ctaat. if a proper :~mount Of cubic space (not less t h a n 2,00b ic. f t . ) b e allowed t o e a c h be d in an adequately ventilated ward, the risk of Such. convection is almost negligible. I agree with Dr. Rundle that the experiments of C o r n e t (Verhand d Berl reed Oeselisch, 1899) were conducted .under conditions too far removed from the natural to be of much help in determining this point, It is a common experience inthe management of a fever hospital that varicella is a most infectious complaint--a case occurring in One corner of a ward frequently being followed by another in the.fat" dorner of the opposite Side of the ward--many have attributed this to mriel convection. My own view is (and always has been) that the infection is carried by the nurse as a rule--though in the fly season, when flies
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invade the wards, a r e a d y method of c o n v e y a n c e of' infection has to my mind always been obvious, which might e x o n e r a t e the n u r s e .
quite a young nurse (provided she was properly trained, t r u s t w o r t h y and c o m p e t e n t ) in c h a r g e of a typhoid block.
The e x p e r i e n c e of F a z a k e r l e y Hospital as r e g a r d s varicelta was t h e r e f o r e a m a t t e r of great interest to me, and one which [ would look upon as of the first i m p o r t a n c e in adjudicating On the merits of the bed-isolation system as t h e r e applied. W h a t then were the results ? D r . R t m d l e states that no fewer than fortyone Cases of Varicella received t r e a t m e n t in the bed-isolatlon ward in the y e a r s 1910 and 1911 .withoz~t a si,;gle itlstanee of cross-infection occz*rring. On ,the o t h e r hand, varieella was aeeldently introdtfced into the o r d i n a r y wards of the hospital On twenty-one occasions during t h e , s a m e period o f time, and cross-itafection
My own experience confirms Dr. Rundle's s t a t e m e n t that the controlling f a c t o r in " bedi s o l a t i o n " is nndoubtedly that of a d e q u a t e nursing with i n t e l l i g e n t supervision on the part of the medical officer. S o m e think that small-pox would afford a test of value. S u r e l y varicella is quite as infectious as small-pox though f o r t u n a t e l y a disease a l m o s t devoid of danger, I am quite satisfied t h a t Dr. R u n d l e ' s r e c o r d e d e x p e r i e n c e with varicella is quite as valuable and convincing a t e s t as small-pox would be.
occurred
in
e v e r y instc~nce: exc@ting
o~e.
Precisely the same o p p o r t u n i t i e s for m r i e l infection were present in each group of cases .... but not 0 n l y direct but als0 i n t e r m e d i a t e contact infection Was excluded i n o n e series of cases only, and that was of c o u r s e the series where c r o s s d n f e c t i o n did not occur. I v e n t u r e to a s s e r t t h a t in all h o s p i t a l s ' w h e r e bedisolation is not practised, the usual, if not invariable experience, is that of the o t h e r series of cages r e c o r d e d by Dr. Rundle, w h e r e crossinfection o c c u r r e d in practically e v e r y occasion (20 out of 21). Dr. R u n d l e touches o n the question of flies, and confesses to some anxiety in this respect during the s u m m e r months. Comparing Dr. Crookshank's and Dr. Rundle's m e t h o d s with my own met~hod at" S o u t h e n d - o n - g e a F e v e r Hospital, I find t h a t Dr. R u n d l e ' s m e t h o d more closely c o r r e s p o n d s with mine as r e c o r d e d i n 1909 (" Practiti~0ner ") more particularly in impressing the n u r s i n g staff with t h e i r individual responsibility. Indeed, I went so far .as to tell my nurses that if a n y o n e of them c o n t r a c t e d typhoid f e v e r in the hospital I should dismiss her on recovery, =as I should feel certain that she had not s t r i c t l y a d h e r e d to the minutiae Of bet" instructions, P r o v i d e d the nurse had learnt t h o r o u g h l y the i m p o r t a n c e Of disinfecting her hands directly a f t e r a t t e n d i n g t o the wants o f ' a typhoid patient, even to the m e r e smoothing of the bed-sheets, I had no c o m p u n c t i o n in putting
A point of difference b e t w e e n my own m e t h o d and that of Dr. Rundte: was that although I put on an overall to p r o t e c t my own clothes, I wore the same Overall while seeing to e v e r y patient in the hospital, ianless I had reason to think it: had b e c o m e i n f e c t e d b y discharge or Saliva. B u t my invariable practice w a s to be a t t e n d e d by two n u r s e s ' one c a r r y i n g two b o w l s of disinfectant ~olution (Lysol 0r Izal or Cyllin), o n e o f which was used by me a f t e r each individual case. W a s h i n g with s o a p and Wa~er was carried out at the:concluSion of the visit t~0 each ward. The nurses were e n c o u r a g e d to work with a r m s bared to the elbow, and they also had to soak the hands in disinfectant solution a f t e r any attention to each individual 6atient. Sufficient evidence is now available on t h e question of " bed isolation," t o w a r r a n t extensive enquiry into the m a t t e r - - b e a r i n g in mind as much as possible---all epidemiological factors such as age, sex, season, day of disease, period of epidemic prevalence, intensification or recession of the disease as a whole, and so forth. The main essentials for successful enquiry and administration are- (1) a well-equipped e x p e r t medical s u p e r i n t e n d e n t ; (2) nurses specially trained in the method. In my opinion the nurses need not alt be n u r s e s o f t h r e e years' general hospital t r a i n i n g - - t h e essential being that they should u n d e r s t a n d the why and .wherefore of the m e t h o d s of " bedisolation," and the adequate disinfection of theirown hands between a t t e n t i o n to each patient.