980 NUFFIELD COLLEGE OF SURGICAL SCIENCES--HYPNAGOGIC HALLUCINATIONS

microscopic ; treatment (medical and surgical) ; finaldiagnosis ; progress notes ; condition on discharge ;autopsy findings ?Who is head of the medical record department ?

Is the head (a) Registered ? (b) Trained but not regis-tered ? P (c) Provided with sufficient assistants ?Are records written promptly after admission of the

patient and are they signed ? (24-48 hours is consideredlimit of promptness.) ,

Is there an active record committee of the medicalstaff? (a) If active, does it control the calibre of therecords ? (b) Are all records examined by the committeebefore filing ?

It is tempting to go on picking out questionswhich here as in America touch some sensitive spots :

X-ray department.-Are the reports of interpretationsin writing or dictated ; and signed by the radiologist ? PAre requisitions for X-ray examinations in writing ?

’Medical department.-Do the records justify thediagnosis and treatment (a) By a sufficiently completehistory and physical examination ? (b) By sufficientlaboratory and other diagnostic tests ?

Are consultations required, under the medical staff,rules and regulations, in all serious cases ; and are theyalways recorded ? PHas the department (a) An electrocardiograph, with

a member of the medical staff qualified to inter-pret electrocardiograms ? Name ? Qualifications ? (b)Equipment for the estimation of basal metabolic rates ? i

Surgical deþartment.- Is sterilisation of surgical suppliesand water adequately tested by any of the followingmethods ? : (a) recording thermometer on the dischargeline ; (b) fusion tubes, such as Diack controls ; (e) colourindicators, such as sterilometer ; (d) periodic cultures :how often ? (Diack controls in each batch plus frequentculture checks at least monthly, should be made.Recording thermometer, either lag or clock, is consideredthe best check.)Do the surgical records justify the diagnosis and

operation by (a) Sufficient recorded evidence of pre-operative study ? (b) Record of surgen’s preoperativediagnosis ? (c) An operation report, signed by the opera-ting surgeon, of the findings and technique, written ordictated immediately following the operation ?Are all infections of clean surgical cases routinely:

Recorded and reported to administration ? Listed ?

Where ? Investigated ? By whom ?

Enough has perhaps been quoted to show that asystematic review of this kind by an independentauthority can be a real stimulus to progress, andthat members and officers of the regional boardswould find it useful to have a copy of this scoringsheet in their pocket as they are going round theregions. Indeed they might go further, and themselvescompile a modified list of questions more directlyapplicable to conditions in hospitals in this country.In the United States the attention concentrated bythe American College of Surgeons on a definitemedical staff organisation for each hospital, on thekeeping of accurate clinical records, and on the

provision of diagnostic facilities, has done nothingbut good. But the merits of the system should notblind us to its limitations, and it might be improvedso as to cover better those aspects of hospital lifethat are of less immediate concern to the medicalprofession. Note has been taken of the slight emphasisplaced by the system on the nursing services ; andit is surprising to see that such a question as

Is the general atmosphere of the hospital (a) Pleasantwith cheerful wards ? (b) Suggestive of a reasonableamount of interest in the patient ?is awarded only 5 points in a total of 1000.The system of hospital visiting introduced in

London by King Edward’s Hospital Fund, with itsemphasis primarily on the lay and administrative

aspects (not forgetting the amenities for the patientsand for the staff) has been a potent factor in raisingstandards not only in London but indirectly through-out the country. Among the subjects to which theKing’s Fund has given attention in recent years areseveral which have led to widespread changes. Itswell-known reports on hospital catering were initiatedby inquiries made to visitors, as also were the reporton the supervision of nurses’ health, and the healthrecord forms now used by many hospitals for theirstaff. Among the latest examples is a movementfor ,the provision of a modern type of interior-springor rubber mattress for the comfort of patients ; and" comfort of patients " is a heading that has appearedrepeatedly in the handbooks used by the Fund’svisitors. In these and similar respects the Americansystem is deficient. But a combination of the twosystems might well give us an entirely satisfactoryscheme of approach for all those now responsiblefor maintaining or improving hospital services.Furthermore, periodic surveys of the hospitals onthese lines-possibly conducted by some non-officialbody sponsored by the Royal Colleges-might providematerial for comprehensive reports to the -CentralHealth Services Council and to the public. These

reports would show how far the hospitals are ableto realise current ideas of what they ought to be.

Annotations

NUFFIELD COLLEGE OF SURGICAL SCIENCES

Lord Nuffield’s gift of 250,000 to the Royal Collegeof Surgeons, which was announced last week, has beenmade " for the promotion of research and education inthe surgical sciences, and in order to increase facilitiesfor young surgeons from the Dominions, the UnitedStates, and other countries, who come to Britain foradvanced studies." These general terms Lord Nuffieldhas translated into more concrete suggestions for aresidential college to be attached to the Royal College,where students will have easy access to museums,

library, and laboratories, and in their collegiate life

opporturtities to meet their teachers and seniors outsidethe operating-theatre and the lecture-room. Here, too,distinguished visitors from abroad will find a congenialcentre. Though the foundations of the new Nuffield

College have yet to be laid, it will soon have at leasta partial existence, for the scheme is an extension ofthe experiment which the college are making in theNew Yeat of providing in an adjacent house residentialaccommodation and common-rooms for 20 postgraduatestudents. Through the Sims travelling professor thecollege have already made fresh contacts among theircolleagues abroad, and this gift will enable them toreceive hospitably their new and old friends who cometo pay a return visit. In welcoming Lord Nuffield totheir honorary fellowship the college have recognised hismany stimulating services to medicine, of which thislatest gift is yet another example.

HYPNAGOGIC HALLUCINATIONS

SiNcE the Pharaohs, and especially since Freud,dreams have been studied by soothsayers and psychia-trists. The similarity between dreaming and madnesshas often been pointed out ; less attention has been paidto the peculiar states that characterise the transitionbetween sleeping and waking. Familiar as they are to amajority of people, the " hallucinations

" of the hypna-gogic state, and the other normal disturbances of thinkingand sensation which occur in falling asleep or in waking

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up, are sometimes misconstrued by doctors, who mistakethem for symptoms. They are also, as a letter from acorrespondent elsewhere in this issue shows, sometimesalarming to the patient.Hypnagogic hallucinations have been pretty widely

recognised and investigated since Maury’s report of.1861. Disturbances of the body image, however, duringthe hypnagogic or hypnopompic transition, have seldombeen studied. They occur fairly often, and as good adescription as any was provided by Paul Federn, thepsychoanalyst. The body, he pointed out, seems tobecome flat and two-dimensional, and its surface may bedistorted in many directions. The distance between

symmetrical parts can appear enormously increased, ascan many other bodily proportions. Parts of the bodymay seem normal while the rest becomes a vague mass,either much diminished or much enlarged. Sometimesthe body seems to end at the bottom of the trunk, or atthe knees ; on the other hand, parts of the middle of thebody may disappear. The borderline of the body in onedirection may become blurred, and may seem to movein this direction. The face and head are usually sparedfrom any distortion, as are also those parts of the bodywhich are fully supported on the bed. Paul Schilder like-wise described such phenomena ; for example, one ofhis patients felt, as she was falling asleep, that she becamesmaller and smaller, until she was only a few centi-metres long. Schilder drew attention to the similarityof this experience to those which may occur in dreamsand in the first stages of hypnosis. The similarity tocertain intoxications from mescaline is also striking.Not everyone would be disposed to go as far as Schilderin interpreting these phenomena in psychoanalyticalterms, and relating them to the libidinal structure ofthe body image. Few, however, would contest theirrelevance to the problems of self-perception which areof such interest to neurologists and psychiatrists alike.

INCIDENCE OF DIPHTHERIAIN his report for 1947 on the Seacroft Hospital, Leeds,

Dr. E. C. Benn records that of 121 patients admittedwith a notified diagnosis of diphtheria only 42 hadclinical attacks (36 faucial and 6 simple nasal infections),while another 10 proved to be healthy carriers. In the17 confirmed cases (including carriers) with a history ofimmunisation recovery was rapid and uncomplicated.Ten years ago the medical superintendent of a large

fever hospital could not have reported such modest

figures. Without doubt the main agent in the declinehas been mass immunisation, though even now thesuccess achieved years ago in many American andCanadian cities is not paralleled here. Martin pointsout that diphtheria mortality began to fall at the

beginning of this century. This was due mainly toimproved hygiene and treatment, and particularly tothe introduction, in 1895, of antitoxin-which has sincebeen improved and is now administered more intensively.Nevertheless, considering that the aetiology of thedisease had long been known, the downward trendwas disappointingly slight until 1940 when, withthe start of mass immunisation the fall quickened ;in 1946 mortality was less than a fifth of whatmight have been expected with the previous slowerdecline. The number of cases notified each yearhas fallen from an average of 60,000 (uncorrected) inthe pre-immunisation years to 10,500 (corrected) in 1947.The decline in mortality has been still more rapid,partly owing, as Martin says, to the better chance ofsurvival of the previously protected when they contractclinical diphtheria. As a cause of death the disease hasfallen from third to sixth place in the 1-5 years age-group, and from first to third place in the 5-10 age-group.

1. Martin, W. J. Mon. Bull. Min. Hlth P.H.L.S. 1947, 7, 232.

Improvement, however, is not uniformly good ; duringthe last year or two there have been small localisedoutbreaks in the North and in Wales, due either to localvariations in the extent of immunisation or to real

regional differences of the sort that was recognised inpre-war years. The decline in the attack-rate has beenmost rapid in- London ; whereas in 1937-38 the ratehere was 28% above the rate for the whole country,in 1946-47 it was 12% below the general rate. In

nearly all " density areas " incidence was considerablylower in 1947 than in 1946. Martin observes that, asmight be expected, the preschool child and the adultwere relatively more often attacked in 1947 than in1944 ; the greatest fall in the attack-rate has been inchildren aged 10-15, among whom the rate in 1947was only a fifth of that in 1944. This is a reversal ofthe previous pattern throughout this century. As tosex incidence, the attack-rate is still much higher in-adult females, but the difference is now less than it was,especially at age 25 or over. -

The aim is to increase the percentage of immunisedchildren to at least 75, and efforts should be concentratedparticularly on the protection of infants under one year.With a larger initial dose of the prophylactic (0-5 ml.A.P.T.) and reinforcing doses (0-2 ml. A.P.T. or 1 ml.

T.A.F.) midway between infancy and school age and

again at school entry, diphtheria’ is likely to becomestill more rare.

BLOOD-PRESSURE AND THE SUPRARENALCORTEX

MANY years ago, when it first became clear that thesuprarenal had some part in the production of hyper-tension, the association seemed fairly straightforward.French workers, for instance, claimed that hypertensionwas accompanied by hypertrophy of the gland. Thiswas not confirmed, and attention shifted to adrenalineitself. Then it emerged that the simplicity of the

problem was illusory ; for some twenty years ago thereports of Rogoff and Stewart and of Hartman and hiscolleagues 2 revealed the vital rôle of the cortex, andwithin ten years the brilliant research of American 3 andSwiss 4 workers culminated in the isolation and synthesisof a series of cortical hormones. Of these the most

important was desoxycorticosterone with its specificaction in raising the blood-pressure.5 5 ’ The intensive workon Addison’s disease prompted by observation of the

potent action iof cortical extracts in this previously fatalcondition, brought to light the prime importance of thesodium and potassium ions ; and it was immediatelyasked whether the blood-pressure changes in Addison’sdisease were due directly to lack of cortical hormones orto disturbance in the electrolyte pattern of the tissues.This question was almost immediately’ overshadowed bythe experimental observations of Goldblatt and hisassociates on the effect of renal ischemia in producinghypertension.

Probably what we vaguely describe as essential hyper-tension is a collection of conditions. Four factors clearlytake leading parts-adrenaline ; one or more of thehormones of the suprarenal cortex ; the sodium andpotassium ions ; and renin-but how these factorscombine in any one case no-one can tell. Perera and his

colleagues 6 have reported the development of hyper-tension in 8 out of 24 patients with Addison’s diseaseunder protracted treatment with desoxycorticosterone1. Rogoff, J. M., Stewart, G. N. Science, 1927, 66, 327.2. Hartman, F. A., MacArthur, C. G., Hartman, W. E. Proc.

Soc. exp. Biol., N.Y. 1927, 25, 69.3. Mason, H. L., Myers, C. S., Kendall, E. C. J. biol. Chem. 1936,

116, 267.4. Steiger, M., Reichstein, T. Helvet. chem. Acta, 1937, 29, 1164.5. Soffer, L. J. Diseases of the Adrenals. London, 1946; p. 215.6. Perera, G. A.. Knowlton, A. I., Lowell, A., Loeb, R. F. J. Amer.

med. Ass. 1944, 125, 1030.