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THE MODERN FEVER HOSPITAL

THE LANCET

LONDON: SATURDAY, FEBRUARY 12, 1938

THERE was a time when people with typhoidor scarlet fever had to be removed from theirhomes by stealth or wile. Now the public is

coming to demand the hospitalisation of infectiouscases, and the list of diseases admitted to the largefever hospitals grows steadily longer. This has

brought with it increasingly the danger of a patientadmitted for one disease being infected with another,and the avoidance of cross-infection has taxed theadministration of fever hospitals and has led tothe trial of new methods of construction. Thedifficulties are formidable. In the first place byno means all the patients notified as suffering fromthis or that disease are actually found to be sosuffering when the ambulance reaches the hospital.On p. 97 of the recent report on L.C.C. hospitalsfor 1936 is a table showing errors in the notifieddiagnosis of cases admitted to acute hospitals ;revision was required in .24 per cent. of the totalnotifications of diphtheria, in 34 per cent. of theenteric group, 7 per cent. of measles, 10 per cent.of scarlet fever and whooping-cough. In fact outof some 35,000 arrivals more than 4000 could notfor this reason alone be admitted to open wardsreserved for specific infections. When to this hasbeen added the large number of patients who onadmission were found to be suffering from morethan one infection, or known to have been exposedto a second infection, it is obvious that the feverhospital must dispose of a large number of bedsfor the segregation of such cases.But patients in fever hospital wards do not only

run risk from the introduction and spread ofextraneous specific infections. Though these mayclog the administrative machinery they are of

secondary importance, for they endanger life butlittle, whereas an outbreak of broncho-pneumoniain a measles ward may be deadly ; commonlyregarded as one of the inevitable perils of hospitali-sation it may really be a cross-infection by hsemo-lytic streptococci, although of type other than thatcausing scarlet fever. Until lately no steps weretaken to remove from the general ward suchreservoirs of infection as cases of broncho-

pneumonia, otitis media, impetigo, and enteritis inthe course of measles. If these patients remainin the open ward without precaution of any sort

1 Annual Report of the London County Council, Vol. IV(Part 1). London : P. S. King and Son. No. 3308.2s. 6d.

there exists a perpetual state of cross-infection.Even in a scarlet fever ward where the primaryinfection is the haemolytic streptococcus theretention of patients with such complications leadsto the occurrence of late complications of septictype, whether due to reinfection with the samestrain or with another strain of streptococcus.Adequate spacing of beds does much to minimisethe danger. To overcrowd a ward is to invite a

high rate of septic complications and, to put it atits lowest, is false economy. An overcrowdedward means an overworked staff, and hard pressednurses will from time to time inevitably cutcorners. Even in the well-spaced ward the deviceof barrier nursing should be regarded as a tem-porary measure unless the staff is speciallyexperienced ; otherwise a false sense of securitymay result. Bed-isolation, where every patient isnursed in barrier, may make it possible to segregatewithin a single ward any acute specific infection(other than early measles and chicken-pox), all

types of extraneous non-specific conditions (suchas broncho-pneumonia and otitis), and patientsunder observation pending diagnosis, but it is

extremely exacting for the staff and the addedstress may readily lead to physical breakdownamong the nurses. Bed-isolation therefore cannotbe regarded as a normal state of things unless thehospital can rely upon a succession of nurses welltrained in general surgical work and especially in.the methods of asepsis. Such a staff is not easyto recruit and retain in these days ; it was mucheasier twenty years ago.

So far we have considered segregation basedupon the invisible barrier. It is now generallyaccepted that the big open undivided ward isobsolete. During the transition the movablescreens devised by HUTINEL many years ago arecoming into use again ; they afford ready meansof establishing conditions resembling a partialcubicle around any bed. A convincing expressionof the modern tendency may be seen in the newblocks approaching completion at the North-Eastern Hospital (L.C.C.), Tottenham, where themain wards are subdivided by glass screens intofive sections each of which accommodates four beds

spaced in parallel. The idea of grouping by fixedscreens in these new wards is not so much to

prevent the transference of specific infections asthe non-specific infections of the upper respiratorytract arising from droplet spray. The ideal methodof segregation is seen in the wardlet containingone or two beds with complete structural separa-tion from the next in the series. Provided the

aseptic technique, for which every facility exists,is rigidly carried out, diseases of any descriptionmay be nursed in them without spread. Suchwardlets are available at the North-Eastern Hos-

pital both in the form of annexes to the mainward blocks and as two large chamber blocks

providing 112 single-bedded wardlets. Whenreconstruction is complete nearly 40 per cent. ofthe total accommodation at this hospital will bein the form of these one- or two-bedded cells. Ithas often been objected that children nursed in

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single chambers become bored and depressed.Whether this occurs or not depends largely uponthe lay-out ; surrounded by brick walls of the oldside-ward type the children soon became dejected.It is not the experience in the new chamber blockswhere glass walls afford a wide prospect for thepatient as well as adequate supervision for thenurse. With these new types of ward life hasbecome immeasurably more desirable both for thepatients and those who attend on them, and it islamentable that just when the conditions of fevernursing have become so attractive there should bea grave difficulty in recruiting enough nurses tomake full use of the hospitals. This has now ledto the restriction in the admission of scarlet fever,measles, whooping-cough, and dysentery to casesin which the severity of the disease and the con-dition of the home make hospital treatmentessential. One cannot help feeling that a visit toone of the new fever wards on a bright morningwould turn the scale in the decision to trainas a nurse and we hope that municipal authori-ties will take every care to put their fever

hospitals on the map.

THE SWEAT GLANDS

THE chief function of perspiration is to assistin regulating the temperature of the body ; the heatlost by the skin is increased many fold by evapora-- tion, particularly at high temperatures and duringmuscular exercise. Secretion of sweat, however,is not the only mechanism by which water is givenoff from the skin. WIEIITEHOUSE, HANCOCK, andHALDANE found that during rest under ordinary- conditions of temperature practically the wholeof the moisture given off from the skin passedthrough by osmosis or diffusion, the osmotic

passage of water increasing rapidly as the skintemperature rose and playing a large part in heatregulation. Osmotic transference is, actually, theonly available mechanism of water loss from theskin for individuals with congenital absence ofthe sweat glands, of which a few cases have beeninvestigated. The glands are not in fact essentialfor life, though their absence may be a serious

handicap, especially when associated with defectiveregulation of the skin circulation. On the otherhand excessive sweating, if combined with free

drinking of water, may produce water-intoxication,either in the common form of undue fatigue or

the acute form of muscle cramps. Between theextremes of total suppression and excessive lossthere are many features of sweat secretion whichdeserve closer study. Some years ago Dr. YASKuNo, the Japanese physiologist, drew attention 2to something which had previously been almostoverlooked-namely, sweating in response to

emotion, mental effort, or sensory stimulation,with a peculiar limitation to the palm, the sole,and the axilla. In our last issue KuNo recountedfurther investigations of sweat secretion by himselfand his associates ; the results are no less surprising,

1 Whitehouse, A. G. R., Hancock, W., and Haldane, J. S.,Proc. roy. Soc. B. 1932, 111, 412.

2 Lancet, 1930, 1, 912.

though perhaps less readily susceptible of explana-tion, than the facts of mental sweating. It seemsthat a considerable number of sweat glands,although morphologically fully developed, donot secrete even under conditions which call formaximal activity. Accordingly KiTNO dividesthe sweat glands into active and inactive. Theinactive glands cannot be thrown into activityby intense body warming, even when this stimulusis repeated frequently, or by local injection of

pilocarpine which acts directly on the gland cellswithout the intervention of nervous mechanisms.Some observations suggest that a limited activationof such inactive glands may occur during earlychildhood, but in the adult there are many glandswhich are never in action under physiologicalconditions, and which are therefore useless as a

reserve’-force to be called upon when the need is

urgent. It is possible that activation of inactiveglands may occur under stimulation by other

pharmacological agents or during the abnormal

sweating responses which arise in certain patho-logical states of the central nervous system,and we hope that Dr. Kurro will continue this study.More data on the ratio of inactive to active glandsin different situations would be valuable, and

investigation would be facilitated by improvedmethods of recording ’activity of the sweat

glands.

THE PROGNOSIS OF SCHIZOPHRENIA

IN another part of this issue two papers will befound, one of which briefly describes the use ofCardiazol to evoke convulsions in the treatment ofa dozen cases of schizophrenia, while the otherreviews the respective merits of this form of

therapy and of induced hypoglycaemia, which arealready the subject of temperate disputed Theuse of convulsions and coma to overcome theresistances of mental disorder is exceedinglydramatic and these two papers, with the discussion

reported on p. 378, well illustrate what is beingattempted and done. It is evident that favourableresults have been reported by many competentworkers, yet it is still advisable, perhaps, to

approach the subject with reserve. Prima facie,it is probable that a remedy so startling, for adisease so severe, will arouse hopes and generateclaims that, however sincere, have little to dowith the actual efficacy of the method under trial.(The history of tuberculosis gives us plenty of

examples.) Study of the natural prognosis of thecondition under treatment provides some safe-

guard, as Dr. PULLAR STRECKER and others haverecognised, against exaggerating or underrating thevalue of a new remedy. Yet sometimes thisessential is deliberately ignored. Thus in recordingtheir observations on the treatment of schizo-phrenia CAMERON and HOSKINS 2 say : 14 Noattempt was made to select on the basis of

reaction-type or on probability of recovery. Our

experience in the latter regard has been that the

1 J. Amer. med. Ass. 1937, 109, 1470.2 Cameron. D. E., and Hoskins, R. G., J. Amer. med. Ass.

1937, 109, 1246.

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correlation between prognosis recorded at the timeof admission and subsequent progress is almost

negligible." Most psychiatrists are certainly notof this opinion 3 : the factors entering into

judgment are no doubt complicated, but an

expert’s forecast is much more often right than

wrong.A careful study made in Norway recently and

reviewed in our columns 4 reaffirms that to assess

prognosis in schizophrenia is by no means a

deceptive e exercise like casting a horoscopeor reading the entrails of a sacrificial beast.LAKGFELDT studied the subsequent fate of a

hundred cases of undoubted schizophrenia admittedbetween 1926 and 1929 to the University PsychiatricClinic in Oslo : he made personal investigations,being rightly convinced that it is inadmissible to

speak of the recovery or partial recovery of anypatient on the strength merely of statements madein letters from the patient or his family. As theresult of his inquiry, he concludes that the boun-daries of schizophrenia are now set so generouslywide that several conditions, with very differentprospects of recovery, may be covered by theterm. The proportions in which the doomed andthe atypical, more hopeful, varieties are mixed inany selection of material will determine how many" recoveries,"

"

spontaneous remissions," "

cures,".are reported a,s characteristic of schizophrenia as awhole. LANGFELDT considers that the more

optimistic results reported as obtained with insulin,say, or psychotherapy, rest on this diagnosticlaxity : where there is a stricter interpretation ofschizophrenia no such triumphs are recorded. Itis too much to hope for the same degree of precisionin the initial diagnosis of schizophrenia as is

attained, for instance, with tuberculosis. Thereare no tangible proofs of the disease, great experi-ence and judgment are necessary, and there isroom for wide latitude of usage. It is well knownthat some clinics like to use independent standardsand categories while clinging to the accepted names,and that diagnoses by poorly trained and inexpertpsychiatrists are worthless to a much greaterdegree than in other branches of medicine. Hencethe foolish statement is sometimes made that

diagnoses in psychiatry are futile labels, not worththe affixing. Diagnosis is indeed of the first

importance. Some of the most lamentable dis-

appointments, and even tragedies, in the history ofpsychiatric treatment have been due to carelessnessin diagnosis, and ignorance or contempt of the

accepted canons. LANGFELDT’s strictures on theuselessness of bare reports of such-and-such a

percentage of " cured schizophrenics

" are therefore

appropriate. Until this state of affairs has beenremedied by the better training of psychiatristsor the discovery of some less complex and intangiblecriteria of diagnosis than the patient’s talk andbehaviour, it will be necessary for each country,and perhaps for each clinic, to work out thestatistical prognosis for the cases which it has

agreed to classify as "

schizophrenia." In England3 See Lancet, "Prognosis," Vol. I, p. 265; Faurby, A., Nord.

med. Tidskr. 1937, 13, 206.4 Lancet, 1937, 2, 1434.

relatively little work of this kind has as yet beenpublished-a good thing, on the whole, since ifthere were a host of such studies they could

scarcely be trustworthy, but would be more likelyto darken counsel bv their contradictions. Areliable prognostic study requires such full recordsand uniformity in diagnosis, so much skill, time,trained help, and personal visiting (in their homesor elsewhere) of all the patients concerned, yearsafter they were first seen, that it cannot be carriedout wholesale. LANGFELDT was fortunate enoughto be able to trace all his patients. In Englandthis is a more difficult task than in Norway,though we have here in the records of the Boardof Control an invaluable centralised storehouse ofmaterial about each of the patients who mayhave had a relapse after discharge from hospital :failure to include individual details about such

cases, which experience has shown are especiallyapt to evade notice in an inquiry, can make theresearch of very little value. *

A careless investigation does nothing but harm.Careful ones go further than merely to providecomparative data for assessing the value of a newmethod of treatment : LANGFELDT, for example,believes that he can now distinguish in his series ofcases the features which would have made it

possible in the beginning confidently to tell the

group of progressive cases from those in whichthe environmental factor was stronger than the

hereditary, and outlook for more or less " spon-taneous " recovery good. But wisdom after theevent is justly suspect. Moreover, " spontaneousrecovery " is so often used to mean recovery underfavourable circumstances of care, without the useof any novel or supposedly specific method, thatthe efficacy of undramatic but rational measuresis less regarded than it should be. All thesefactors must be weighed in any inquiry into thelater history of schizophrenic patients. " Catam-nestic " studies are difficult and, unless expertlymade, deceptive : but without them the clinical

psychiatrist is at the mercy of arbitrary notions,with none of those checks upon his wisdom whichother doctors find, or submit to, in the autopsyroom and the operating theatre.

PRESENTATION TO SIR ARTHUR KEITH

0 Monday next at 5 P.M. Sir Arthur Keith, F.R.S.,will deliver a lecture at the Royal College of Surgeonsof England on the Prehistoric People of Palestine.He will summarise the results of the investigationswhich he and Mr. T. McCown have been conductingon the anatomical characters of the Mousterian

peoples discovered near Mount Carmel in 1931 and1932. Before the lecture a bronze bust of himselfwill be presented to him by the president of the RoyalCollege of Surgeons on behalf of a large number ofhis friends and admirers in commemoration of his

twenty-five fruitful years as conservator of the

museum. Executed by Miss Kathleen Parbury, thebust is of real merit and recalls one of Sir Arthur’sfamiliar attitudes. Admission to the lecture is byticket to be had from the secretary, R.C.S., Lincoln’sInn-fields, W.C.2.