376 ’

normally and their weight is artificial. Most patientslose weight after sanatorium treatment even if thedisease is arrested. Having reached the normalweight for the stem length and chest measurementthey maintain this weight if the disease is arrested,and then the relationship between weight and V.C. isfound. During the loss of weight owing to increasingdisease or the gain of weight during forced feeding andrest, however, there is no reliable relationship withV.C. The significance of weight is seen when patientsafter treatment have returned to their normal lives ;a normal weight maintained is a good omen, butsteady loss of weight indicates that the disease isspreading. C’c:o.The conclusions at which we arrived in 1920 seem

more than justified now after a further two yearsstudy of the cases.6

1. In cases of pulmonary tuberculosis there is adefinite decrease in V.C. But after treatment theV.C. may improve, and as in one of our cases (No. 304)actually become normal, in spite of the fact that thedisease later broke out again and proved fatal.

2. An improvement in the clinical condition of thepatient is found to be accompanied by an increasedV.C., whilst an advance of the disease results in adecreased V.C.

3. The determination of the V.C. is useful forthe classification of cases of pulmonary tubercu-losis, because it is possible by this means numericallyto express the injury to health (e.g., degree oftoxaemia and amount of lung diseased) which other-wise would depend on the individual interpretationof physical signs by different observers. In thisconnexion it should be noted that classification byphysical signs alone may place a patient nearing deathfrom an acute lesion in a high category, whilst anotherpatient, with satisfactory fibrosis and extepsivecavitation, likely to live for several years, maybe placed in the lowest category. Dr. Cameron5criticises this conclusion and rightly points out thatthe V.C. may be low, not only because of toxsemia,but also because of extensive fibrosis, and thinks thatV.C. alone is of very restricted value and should betaken in conjunction with physical signs. We agreewith Dr. Cameron if one reading alone is taken, andare of opinion that one reading alone is always ofrestricted value. The importance lies in takingrepeated readings, as Dr. Cameron himself shows. Forinstance, one of us (L. S. T. B.) from London used tovisit at Oxford the other (G. D.) who knew nothingwhatever about the condition of the patient. If thepercentage readings presented to him were say:- 40, - 39-6, - 41, - 40-4, - 39-8, - 40-8, over aperiod of six months, he would at once say, " Chroniccase holding his own " ; on the other hand, if the read-ings were - 26, - 30, - 29, - 38, - 46, - 48 hewould say: " U7i3is patient is dying." So impressedwere we by the accuracy of these findings that one ofus (L. S. T. B.) published a classification based largelyon V.C.

4. As an aid to diagnosis even a single, but moreparticularly a repeated examination of the V.C. ofdoubtful cases will also prove useful. If a normalV.C. is found, this patient is most unlikely to besuffering from pulmonary tuberculosis, whereas if theV.C. is much decreased this patient should be sus-pected, though it must always be borne in mind thatother diseases may also cause a lowering of the V.C.

5. Finally a systematic study of the V.C. in itsproper relationship to body size has given importantinformation as to the beneficial effects of differenttreatments of pulmonary tuberculosis.

After many thousand observations we have seenno ill-effect from taking V.C. We note that Dr.Cameron after 6000 readings has found no ill-effect,and we fail to see why it should be harmful. It is, inour opinion, far less strain to the patient than even amild attack of coughing.

6 Since this report was prepared a paper by J. A. Myers withsimilar conclusions, entitled

" Comparison of Vital CapacityReadings and X Ray Findings in Pulmonary Tuberculosis," hasappeared. Amer. Rev. Tub., 1922, v., 884.

THE BED ISOLATION OF CASES OFINFECTIOUS DISEASE.

I. FURTHER EXPERIENCE AT FAZAKERLEY.

BY C. RUNDLE, O.B.E., M.D. LOND., D.P.H.,MEDICAL SUPERINTENDENT, FAZAKERLEY CITY HOSPITALS

AND SANATORIUM, LIVERPOOL.

DURING the period February, 1920, to June, 1922,the following cases of infectious disease have beentreated in one bed-isolation ward of 26 beds at theFazakerley Isolation Hospital :-

Of this total one case only developed a secondaryinfection-namely, a patient admitted with whooping-cough on Dec. 8th, 1921, who developed chicken-poxon Jan. 29th, 1922. The circumstances under whichthese patients were admitted to a bed-isolation wardwere similar to those laid down in a previous report.lThe cases were admitted in all stages of infection,

they were chiefly of susceptible ages, and they includeunder the group " other diseases " a large number ofconditions not commonly included amongst the acuteinfections-e.g., tonsillitis, pneumonia, and tuber-culosis.The routine observed for the avoidance of secondary

infection is shown in the following transcript from theprinted notice hung up in the ward :-

BED ISOLATION AT THE CITY HOSPITAL,FAZAKERLEY.

Precautions to be Observed.

COATS to be worn for every purpose, and hands washed(using nail-brush) after their removal.

Feeding and drinking utensils to be rinsed and placed,immediately after use, into the kitchen steriliser. Theymust not be laid down in the sinks in the kitchen or elsewhere.Coats must not be worn in the kitchen, but the nurse shouldreturn to the bedside bowl for washing purposes after takingout the feeding utensils, &c.

In wards, other than " G " and " C," bed-isolation crockerymust be distinctive, or separately marked.

Separate and marked sanitary utensils, lavatory cloths,bath blankets.

Coat must be worn when removing clothing, bedding,sanitary utensils, &c., to the lavatories ; the coat to besubsequently removed at the bedside and hands disinfected.

Separate washing-bowl, towel, nail-brush, and thermometerto be used in cases of chicken-pox, measles, enteric fever, andin any case where the treatment is likely to be frequent orprolonged.

Patients not to be allowed to mix with other patients, sitat common table, or use lavatories.

Bedside bowls to be immediately emptied and refilled afteruse. For this purpose the nurse must not wear coat tolavatory. The coat must be removed and hands washed,using nail-brush, before refilling bowl.

All temperatures to be taken in axilla, and thermometerwashed in lysol after use.No toys, books, or papers to be allowed.The doctor will decide which patients are to undergo bed

isolation, but all patients admitted to the bed isolationwards are to be so dealt with from the moment of admissionuntil the doctor has visited the wards and given his instruc-tions in the case. The only exception to this rule iserysipelas, which is to be treated with ordinary cleanlinessonly. -

No nurse engaged in the active treatment of puerperalfever is to attend, in any way, upon a case of erysipelas orscarlet fever. Rubber gloves (reserved for the purpose) mustbe used in vaginal douching.

1 C. Rundle and A. H. G. Burton : THE LANCET, 1912, i., 720.

377

Precautions to be Taken When Patient Dies or isDischarged.

Bedding, personal clothing, towels, bath blankets, coats,&c., to be at once placed in bundle and labelled for disinfector.

Patient’s soap, flannel, and tooth-brush to be destroyed.Brush and comb to be washed in lysol.Bed mackintoshes, bedside locker, bedstead, temperature

chart-holder, and bedboard to be washed with soap andwater.

Precautions to be Observed When Coats are Omitted froma Case.

These must vary according to the nature of the case, andthe nurse must take the instructions of the doctor.

It is of interest to note that only one of the pre-warnursing staff has been available for this work-viz.,the sister-in-charge-the remaining members of theward staff being wholly without previous experiencein this branch of nursing. A second bed-isolationward has been in operation at the Sparrow Hallsection of the Fazakerley Hospital for a period ofone year. The figures for this ward have not yetbeen collated, but so far no case of cross infectionhas occurred, although no member of the staff ofthis section (other than the matron) has had previousexperience of bed-isolation work.A necessary and obvious reservation in the presen-

tation of the results of any method of hospital isolationarises from the possibility of secondary infectionsdeveloping after the patients’ discharge from theinstitution. It is not considered probable, however,that such an event would escape notice under theconditions of public health administration obtainingin a provincial area.

Bed-isolation work at this hospital has been underthe observation of visitors interested in infectioushospital administration for a number of years, andan inspection of the wards and case-records has madeit very clear that the incidence of secondary infectionis considerably less than that commonly observed ina one-disease ward. The administrative and economicadvantages are equally obvious.

,

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II. EXPERIENCE AT PLAISTOW.

BY DONALD MAcINTYRE, M.C.,M.D. GLASG., D.P.H.,

MEDICAL SUPERINTENDENT, PLAISTOW HOSPITAL, LONDON, E.

THE isolation of individual cases in main wardswas first put into practice at Plaistow Hospital by thelate Dr. J. Biernacki in 1906, when he introduced the" barrier system of nursing. By this method alimited number of cases with " mixed " infections canbe nursed in the common wards. Each barrieredbed is supplied with a complete outfit of everythingrequired in the treatment of. the case, so that thepatient is practically in a separate ward except asregards the common air-supply. Separate gowns areworn by the medical officer and nurses while attendingthe case, and the hands are dipped in disinfectantlotion before touching the patient or any of hisequipment and again on leaving the bedside. As thestrict observance of all the details means a good dealof extra work for the nursing staff, not more than twocases are isolated in this manner in a main ward at onetime. Such diseases as diphtheria, mumps, whooping-cough, rubella, typhoid, erysipelas, and general septicinfections are controlled by the barrier system, but ithas failed in the case of three diseases-viz., chicken-pox, measles, and scarlet fever. This method is stillused at Plaistow, and has been found most valuable,especially for patients admitted with septic dischargesand spreading skin infections ; its employment keepsthe main wards clean and saves the transferring of suchcases to side-wards or isolation blocks.Following the successful work of Dr. Claude Rundle

at the Fazakerley Hospital, a bed-isolation ward wasopened by Dr. Biernacki at Plaistow in the autumn of1912. This ward is a modern one of 12 beds, well

lighted, well ventilated, and having 12 feet of wallspace and 156 feet of floor space for each bed. Acovered balcony for two beds opens off one side of theward, and annexed to the entrance corridor is a side-ward for one bed, thus giving accommodation for15 patients in all. Cots are placed along one side ofthe ward and beds on the other, including the balconyand side-ward. The sanitary annexe opens from theside of the ward. Placed in the centre of the floor is awash-basin with hot and cold spray, fitted with elbowtaps. A steam steriliser is fixed in the ward at theside of the entrance for boiling all feeding utensils.There is another steriliser in the sluice room forboiling wash-basins, bed-pans, urine bottles, &c. Thegeneral furniture of the ward is reduced to a minimum.A better idea of the disposition of the beds, &c., will

be obtained from the accompanying sketch (Fig. 1).

FIG. 1.-Sketch Plan of Bed-Isolation Ward.

The nursing staff of the ward consists of one sisterwith general and fever training, one senior and twojunior probationers for day duty, and one seniorprobationer for night duty. The day staff relievethemselves for off-duty time, but the night nurse isrelieved by another probationer who has hadexperience in the ward. The probationers are notspecially chosen for the work, and many of themobtain several months’ experience in this ward duringtheir two years’ period of training. When a nursefirst goes on duty in the ward the nature of the workand the reason for all the precautions are explainedto her by the sister. She is kept under the sister’sclose observation until she understands the meaningof surgical cleanliness and has grasped all the details.

Nursing Routine.The following is a very brief description of the

nursing routine : The ward has a common stock offeeding and nursing utensils which are boiledimmediately after use. Of other nursing articles,a complete outfit is reserved for each bed; forexample, bath-towel, bath-blanket, soap, bib, duster,hair-comb are kept in each bed.locker. On the bed-board, at the head of the bed, are hung the patient’scharts, treatment sheet and history sheets in metalcases, also gowns for doctor and nurse (see Fig. 2).Each patient has his own thermometer, kept in asmall glass container on the bed-board. A half-minute sandglass in a metal case is used for taking thepulse, and the charting is done with a lead pencilwhich is afterwards burned ; the pencil and sandglassare tied together and hung on the bed-board. A cardis placed on each bed-board stating the regulardisease and any secondary infection from which thepatient is suffering, also the position of the bed in theward and the diseases treated in each of the otherbeds at the time. Should cross-infection occur theparticulars are all noted down on this card.When a patient is discharged his bedding is sent to

the laundry and all the other nursing utensils areeither boiled or steeped in strong disinfectant. Thebedstead, bed-locker, and bed-board are thoroughlywashed and scrubbed with soap and water containing1 in 200 lysol, and the floor in that area is polished.The nurse works with her arms bare to the elbows andhas her hair completely covered by her cap. On