821 organism is liable to be distributed round the ward either by the pans themselves or by the hands and clothing of the nurse ; secondly, student nurses who will not tolerate such dirty practices, and possible recruits who revolt from the mere account of them, are lost to nursing. Those who think the disposal of excreta in hospital an unimportant detail should bear these facts in mind. What alternative methods offer Good sluice- rooms have been designed and installed in some hospitals; yet there are modern hospitals erected just before the war which have the old ineffectual equipment. In the United States, Canada., South Africa, and a few British hospitals the tipper system is in use. The nurse presses a pedal with her foot, a flap in the wall drops open, she puts the bedpan in, closes the flap, turns a handle, and the pan is flushed with water and sterilised with steam. Some such system must of course become universal, but in the present state of the building industry many years will pass before all our hospitals are so equipped. Short- term measures must be less revolutionary. Clearly there should be enough bedpans in a ward for every patient to have one marked with his name or bed number. Enamel pans, whose chipped and cratered surfaces harbour organisms, should be scrapped in favour of pans made of aluminium or other light metal. These should be designed by anatomists. The Anatomy Department at Oxford was successful in designing a chair for a ship’s gunner directing fire at an approaching aircraft : here is an equally difficult but more universal problem which needs solving at once. Besides being easy to clean, the pan should be easy to slip under the helpless patient and so shaped that he is comfortable and able to use the necessary muscles during defsecation. The pan could be lightly filmed with an appropriate deodorant. Such measures will reduce the objections, but not abolish them. The aim should be to make the use of a bedpan an occasional rather than a routine ordeal. Dr. McCLFAN makes the thoroughly practical sugges- tion that light metal-framed commodes with movable receptacles could be brought to the bedside. Few surgical patients need complete rest in bed for more than a few days, and many medical patients are up daily ; even for the patient with coronary thrombosis moving on to a commode would surely be less risky than wriggling and straining on the bedpan. Paraplegic patients, if able to sit up, find a commode specially helpful, since the action of gravity helps the paretic bowel. The commode receptacle should be made of light metal and should be deep enough to hold some deodorant fluid, which would simplify cleaning besides keeping the ward pleasant. All bedpans and commode receptacles should be boiled immediately after cleans- ing, and all sluice-rooms should contain a steriliser for this purpose ; even a zinc bath on a gas-ring is better than nothing. Wooden fittings in sluice-rooms should be removed without delay, and the sterilised pans should be placed in a metal rack till needed. These racks might carry hot pipes, so that the pans are always warmed and ready ; at present nurses warm them with hot water before giving them out. Another plan would be to distribute pans from a heated trolley. They should certainly be collected on a trolley ví’Íth shelves and doors ; there can be no good reason why patients should have to watch. nurses running through the ward, pan in hand, or why the nurse should have to make twenty journeys to the sluice when one would suffice. The cleansing of pans without proper equipment presents a much more serious problem-an example of the need for nursing research. Scientifically minded matrons and sisters, in collaboration with surgeons and bacteriologists, must devise a non-touch technique which can be taught to junior nurses. Properly taught this should give the student nurse an insight into aseptic technique which will stand her in good stead throughout her training, besides turning a nauseating job into a piece of technical virtuosity. We should welcome suggestions. Annotations THE INTERNATIONAL OFFICE OF PUBLIC HEALTH THE first meeting of the permanent committee of the Office International dHygi6ne Publique since April, 1939, was held in Paris from April 24 to May 2. Con- sidering the unsettled political state of the world, the difficulties of travel, and the threat of- absorption by the new World Health Organisation, an attendance of delegates from about 40 member countries-out of 59-and the presentation of some 20 communications on medical and quarantine subjects was highly creditable, although a number of countries were represented by diplomats rather than doctors and Russia was again conspicuously absent. At the first session, Dr. M. T. Morgan (representing the British colonies outside Africa) was unanimously elected president on the proposal of Surgeon General Hugh Cumming (U.S.A.), who had been acting as president ad interim. Perhaps the most important work of the meeting was that of its legal commission, under the chairmanship of Dr. M. Gaud (Morocco), which produced a report setting out the juridical status of the Paris Office and the international sanitary conventions, in the light of the resolution of the Economic and Social Council and the recommendations of the preparatory committee of experts,l and discussing the legal and technical difficulties which might arise through the consequent absorption of the Paris Office. It seems clear that, legally, the Office must continue to function indefinitely for any member countries who do not agree to its termination or absorption, and it is thus likely that there must be a period during which two international health organisa- tions will exist, since it may be some time before all countries, including the neutrals, are sufficiently assured that their quarantine interests will be adequately safeguarded by the new World Health Organisation. In that case it is important that a working agreement be concluded between the W.H.O. and the Paris Office, similar to that now operating successfully between the Paris .Office and UNRRA. If, however, virtually unani- mous agreement can be obtained, there are four possible solutions (1) the Paris Office could be dissolved and its functions transferred to the W.H.O. ; (2) it might itself be transformed into the W.H.O. ; (3) it might be absorbed into the W.H.O. as a functional quarantine office for the application of the7international sanitary con- ventions ; or (4) it might be absorbed as a regional office. The last proposal seems to have been most in favour with the experts of the preparatory committee, but there is perhaps even more to be said for the third, since the Paris Office would then carry on the work for which it was designed and which it has performed so successfully in the past. The quarantine commission, presided over by Dr. P. G. Stock (United Kingdom), noted with satisfaction 1. See Lancet, April 20, p. 577.
Transcript
821
organism is liable to be distributed round theward either by the pans themselves or by the handsand clothing of the nurse ; secondly, student nurseswho will not tolerate such dirty practices, and possiblerecruits who revolt from the mere account of them,are lost to nursing. Those who think the disposal ofexcreta in hospital an unimportant detail shouldbear these facts in mind.What alternative methods offer Good sluice-
rooms have been designed and installed in some
hospitals; yet there are modern hospitals erectedjust before the war which have the old ineffectualequipment. In the United States, Canada., SouthAfrica, and a few British hospitals the tipper systemis in use. The nurse presses a pedal with her foot, aflap in the wall drops open, she puts the bedpan in,closes the flap, turns a handle, and the pan is flushedwith water and sterilised with steam. Some such
system must of course become universal, but in thepresent state of the building industry many years willpass before all our hospitals are so equipped. Short-term measures must be less revolutionary. Clearlythere should be enough bedpans in a ward for everypatient to have one marked with his name or bednumber. Enamel pans, whose chipped and crateredsurfaces harbour organisms, should be scrapped infavour of pans made of aluminium or other lightmetal. These should be designed by anatomists.The Anatomy Department at Oxford was successfulin designing a chair for a ship’s gunner directing fireat an approaching aircraft : here is an equally difficultbut more universal problem which needs solving atonce. Besides being easy to clean, the pan should beeasy to slip under the helpless patient and so shapedthat he is comfortable and able to use the necessarymuscles during defsecation. The pan could be lightlyfilmed with an appropriate deodorant.Such measures will reduce the objections, but not
abolish them. The aim should be to make the use ofa bedpan an occasional rather than a routine ordeal.Dr. McCLFAN makes the thoroughly practical sugges-tion that light metal-framed commodes with movablereceptacles could be brought to the bedside. Few
surgical patients need complete rest in bed for morethan a few days, and many medical patients are updaily ; even for the patient with coronary thrombosismoving on to a commode would surely be less riskythan wriggling and straining on the bedpan. Paraplegicpatients, if able to sit up, find a commode speciallyhelpful, since the action of gravity helps the pareticbowel. The commode receptacle should be made oflight metal and should be deep enough to hold somedeodorant fluid, which would simplify cleaning besideskeeping the ward pleasant. All bedpans and commodereceptacles should be boiled immediately after cleans-ing, and all sluice-rooms should contain a steriliserfor this purpose ; even a zinc bath on a gas-ring isbetter than nothing. Wooden fittings in sluice-roomsshould be removed without delay, and the sterilisedpans should be placed in a metal rack till needed.These racks might carry hot pipes, so that the pansare always warmed and ready ; at present nurseswarm them with hot water before giving them out.Another plan would be to distribute pans from aheated trolley. They should certainly be collectedon a trolley ví’Íth shelves and doors ; there can beno good reason why patients should have to watch.
nurses running through the ward, pan in hand, orwhy the nurse should have to make twenty journeysto the sluice when one would suffice. The cleansingof pans without proper equipment presents a muchmore serious problem-an example of the need fornursing research. Scientifically minded matronsand sisters, in collaboration with surgeons and
bacteriologists, must devise a non-touch techniquewhich can be taught to junior nurses. Properlytaught this should give the student nurse an insightinto aseptic technique which will stand her in goodstead throughout her training, besides turning a
nauseating job into a piece of technical virtuosity.We should welcome suggestions.
Annotations
THE INTERNATIONAL OFFICE OF PUBLIC HEALTH
THE first meeting of the permanent committee of theOffice International dHygi6ne Publique since April,1939, was held in Paris from April 24 to May 2. Con-
sidering the unsettled political state of the world, thedifficulties of travel, and the threat of- absorption bythe new World Health Organisation, an attendanceof delegates from about 40 member countries-outof 59-and the presentation of some 20 communicationson medical and quarantine subjects was highly creditable,although a number of countries were represented bydiplomats rather than doctors and Russia was againconspicuously absent. At the first session, Dr. M. T.Morgan (representing the British colonies outsideAfrica) was unanimously elected president on the proposalof Surgeon General Hugh Cumming (U.S.A.), who hadbeen acting as president ad interim.-
Perhaps the most important work of the meetingwas that of its legal commission, under the chairmanshipof Dr. M. Gaud (Morocco), which produced a reportsetting out the juridical status of the Paris Office andthe international sanitary conventions, in the lightof the resolution of the Economic and Social Counciland the recommendations of the preparatory committeeof experts,l and discussing the legal and technicaldifficulties which might arise through the consequentabsorption of the Paris Office. It seems clear that, legally,the Office must continue to function indefinitely for anymember countries who do not agree to its terminationor absorption, and it is thus likely that there must bea period during which two international health organisa-tions will exist, since it may be some time before allcountries, including the neutrals, are sufficiently assuredthat their quarantine interests will be adequatelysafeguarded by the new World Health Organisation.In that case it is important that a working agreementbe concluded between the W.H.O. and the Paris Office,similar to that now operating successfully between theParis .Office and UNRRA. If, however, virtually unani-mous agreement can be obtained, there are four possiblesolutions (1) the Paris Office could be dissolved and itsfunctions transferred to the W.H.O. ; (2) it mightitself be transformed into the W.H.O. ; (3) it mightbe absorbed into the W.H.O. as a functional quarantineoffice for the application of the7international sanitary con-ventions ; or (4) it might be absorbed as a regional office.The last proposal seems to have been most in favour withthe experts of the preparatory committee, but thereis perhaps even more to be said for the third, since theParis Office would then carry on the work for which itwas designed and which it has performed so successfullyin the past.
-
The quarantine commission, presided over by Dr.P. G. Stock (United Kingdom), noted with satisfaction
1. See Lancet, April 20, p. 577.
822
that the Mecca pilgrimage had again been free from
epidemic disease and decided to defer for furtherconsideration the request of the Egyptian delegate torevise the pilgrimage clauses of the 1926 convention.Discussions were also held on the surveillance of air
passengers, the so-called " immunity reaction " to
smallpox vaccination, and the great value of dried
lymph in hot countries. Noteworthy among the generalcontributions were papers on tuberculosis in Denmarkand France, by Prof. Th. Madsen and Dr. E. Aujaleu ;on an epidemic of smallpox in Arras, by Prof. A.
Lemierre ; and on the control of transmissible diseasesin the British colonies during the war, by Dr. W. H.Kauntze. Finally the finance commission reviewedthe financial position of the Office, which seems to havemet its obligations adequately during the war yearsdespite the lapse of contributions. Indeed the healthand vigour generally shown by this prospective corpseproved quite remarkable.
THE COMMON COLD
THE study of several important human diseases hasbeen hampered because the infection cannot be trans-mitted to laboratory animals or because its effect onanimals is quite different from its effects on man. Thisis true especially of viruses. The discovery that influenzacould be transmitted to ferrets was a big step forward,and the story of the ferret, nearly 200th in the chainof infection, which gave a man influenza by sneezing inhis face has passed into the history of bacteriology.Unhappily the only animal so far found to contract thecommon cold is the chimpanzee, which is unsuitablefor tests on a large scale. For the new investigation whichbegins in July volunteers will therefore be used. Thework will be done by a common-cold research unitestablished by the Medical Research Council and theMinistry of Health at the Harvard Hospital, near Salis-bury, which was built and equipped in 1941 and was
given to the Ministry by Harvard University and theAmerican Red Cross for research into communicablediseases. Volunteers from the universities, who willbe isolated in pairs, -will have their noses sprayed withmaterial to test for the presence of the virus. Organisedobservations of this kind have been going on for manyyears 2 and it is high time that whatever outstandingquestions they_ can answer were answered definitely.Conclusive experiments necessitate rigorous quarantine,but every effort will be made to mitigate the irksomenessof isolation, and there will be no lack of volunteers forany serious attempt at investigating one of the majorafflictions of these islands. The unit will make new effortsto find a susceptible animal " or, better still, some otherlaboratory technique which will permit a scientificapproach to the problem."
",
PREDIGESTED PROTEIN
THE importance of enough protein in the diet, bothfor maintaining health and for speeding recovery fromdisease, has been emphasised by the present world
shortage of food. In the care of sick infants paediatricianshave long been faced with the dilemma of choosingbetween the risks of food intolerance and those of starva-tion, while physicians responsible for older patientsnow -,recognise the dangers of former " light " diets,.which were often insufficient to keep the body in nitrogenbalance. Predigested protein is now increasingly usedto provide easily assimilable nourishment for those whocannot tolerate ordinary food : after hydrolysis mostof the protein is reduced to amino-acids which are solublein water. The main objection to these products is theirbitter taste, which is unpalatable to all humans, otherthan premature or very young babies. There are, how-1. Smith, W., Andrewes, C. H., Laidlaw, P. P. Lancet, 1933, ii, 66.2. E.g., Dochez, A. R., Mills, K. C., Kneeland, Y. Ibid, 1931, ii, 547.
ever, ways of disguising this flavour, and these may beexpected to improve. _-
The raw material has usually been the casein of cows’milk or raw beef, but Dormer 1 in South Africa announcesa proposal to prepare protein digests on a large scalefrom whale flesh, a substance not at present used forhuman consumption. Concentrates are made up in twoforms, both of which are reported to be stable ; the firstis a water-soluble syrup or powder containing mostlyamino-acids, and the second an insoluble powder con-taining amino-acids, polypeptides, and peptones. It issaid that the products can be processed without difficultyon shore or at sea, and that the cost of production willprobably be a quarter that of concentrates from othersources. Chemical analysis is proceeding, and successfulclinical trials have already been made. Protein biscuitsmight, it is suggested, be issued to school-children inareas where the diet is deficient ; and the concentrate,which lends itself to easy transportation and protractedstorage, might be kept in depots throughout the worldas a reserve against times of war and famine.
THE DOCTOR’S DISEASE ?
THE Registrar-General’s Decennial Supplement for1931 was largely responsible for the widespread beliefthat doctors are more liable to coronary thrombosisthan any other section of the community ; the death-ratefrom coronary disease and angina pectoris among 25,000physicians and surgeons was found to be 3-68 times theaverage for all occupations. In 1941, Willius, a distin-guished American cardiologist,2 expressed the view thatthe cardiac death-rate among physicians today isappalling." This Anglo-American shroud of gloom wasrudely rent by Hope Gosse,3 who not only indicatedanomalies in both the Registrar-General’s returns andthe American figures but also produced new figures ofhis own contradicting the claim that doctors were par-ticularly liable to coronary thrombosis. He pointed outthat during the period covered by the Registrar-General’sreturns the diagnosis of coronary thrombosis was notyet in general use in this country, the condition probablyoften being certified as myocardial degeneration. Afairer comparison, he maintained, was to take the totalof deaths due to " heart diseases," which showed, thatphysicians and surgeons had a mortality 1-38 times thatof the average for the community. Vrillius’s figures werebased on those deaths, reported in the Journal of theA’/nerican Jledical Association, in which the cause ofdeath was stated. Since this was not stated in all cases,the statistical value of the figures was doubtful. As partof an analysis of morbidity and mortality among 8884medical men between the ages of thirty and sixty-five,Hope Gosse found that among 100 consecutive deathsonly 27 were due to cardiovascular causes. He summedup the position in Great Britain as being that I doctorin 4 dies before he reaches the age of sixty-five ; 1 in40 dies from coronary thrombosis : and less than 1 in10 up to sixty-five years of age dies from cardiovascularand cerebrovascular degeneration, including coronarythrombosis. ’
’
This comforting conclusion is now supported byAmerican workers.4 Working on the principle that, ifthe age at death from a particular disease is distinctlylower in one occupational group than in the generalpopulation the occupation must play a part in theaetiology of the disease, they have compared the averageage at death from coronary-artery disease among doctorsand among the general population. In two differentseries (215 and 253 cases) of doctors dying 6f coronary-artery disease the average age at death was 66-0 and-65°81. Dormer, B. A. Report to the Red Cross Society, Natal, on an
Experiment with Predigested Protein.2. Willius, F. A. Proc. Mayo Clin. 1941, 16, 714.3. Gosse, A. H. Brit. med. J. 1942, ii, 567.4. Levine, S. A., Hindle, J. A. New Engl. J. Med. 1945, 233, 657.
