Download Problems of infection as exemplified in Bristol

Problems of infection as exemplified in Bristol
1. Purpose
To write a personal memorandum concerning communicable disease remembering past
history and present situations; to try to gauge future developments and suggest
a reasonable organization to provide medical and nursing care for current cases
of infectious disease and be capable of expansion to deal with any epidemic
situation. The execution of this purpose is important and may be disregarded at
serious peril.
This memorandum is largely based on Bristol history and experience, but must
have a wider application since this city and its hinterland represents a fairly
standard sample area in the United Kingdom.
2. Prologue
Throughout history humanity has been at serious risk to the vagaries of
infectious disease. The influence of these infections has been remarkable,
sometimes changing a human group, sometimes decimating it; sometimes destroying
it utterly. It might be said that no other influence has had such a consistent
and devastating effect on humanity until the advent of the 20th century. Only
the shining example of Edward Jenner (1798) denies this generalization.
Roman armies, despite all the brilliance of Latin civilization, could conduct
campaigns for only a few months and then into hibernation to recover from
routine infection casualties. The merchant princes of Venice considered it cold
economic sense to hold argosies from the East to anchor and incommunicado for
forty days to be sure that bubonic plague was not included in the precious
cargoes; there remains as a reminder in our modern vocabulary the word
"quarantine", a ghostly memory of the mediaeval nightmare. Wealthy Romans fled
to the Alban hills to escape the annual malarial plague, perhaps to listen to
the tales of Boccaccio, but certainly not to the therapeutic advantage of their
poorer brethren who remained in Rome, lazy and apathetic with chronic anaemia,
the result of anopheline attack from the Pontine marshes. The Great Crusade left
Constantinople a million strong but could muster only ten thousand at Lydda for
the final assault on Jerusalem. Malaria, in he river valleys, around Antioch and
in the marshes of the Orontes, consumed the crusading host more than any other
single influence. The Black Death in England destroyed the close knit society of
feudalism by killing so many people that a serf's labour could not be locally
controlled in a greatly more expensive labour market.
Typhus in gaol killed many more West Countrymen than died at Sedgemoor or on
Judge Jeferies' gibbets. Work on the Panama Canal was stopped in confusion and
bankruptcy by Yellow fever; and the same disease, aided by malaria, worms and
amoebiasis created the White Man's Grave in West Africa, no doubt adding
fractionally to the black man's graves. Typhoid fever was the real enemy in the
South African War even if Smuts, Kruger and Baden Powell held the political and
romantic fields. It might be true to say that neither of the Great Wars of he
20th century would have been possible but for Almoth Wright's work in St Mary's
Hospital in the development of a useful typhoid-paratyphoid vaccine. Even as
recently as 1918-1919 millions died in a pandemic due to an influenza virus
mutant ably assisted by the ubiquitous staphylococcus and, the astonishing
episode of encephalitis lethargica (1918-1928) is a recent demonstration of the
possible mutation of a pathogenic organism from a previously harmless stock
still unidentified.
Since the days of Louis Pasteur and continuing at an ever increasing speed into
our own generation, knowledge of micro-organisms and of the former mystery
surrounding their pathogenic activities, is available to our use. This, and our
improving standard of living, has led to a situation in 1969 in which many
people, lay and medical, think that communcable disease is no longer a problem
in our sort of society. To a large degree this is true but many poorer nations
still face uncontrolled infection and the pathogens that have existed from time
immemorial remain and may erupt anywhere with devastating effect: We have just
built a dyke and the limitless sea of infection still lies just beyond. It is
worth remembering that at least five million peple died from typhus in the Volga
region when Stalin and the "Kulaks" came to grips in the early 1920s. Bubonic
plague took some hold in Palestine on 1941 and the beinning of a great typhus
epidemic was dramatically aborte by the forcible and energetic use of DDT in
Naples in 1943-44.
It would be easy enough to paint an even more lurid picture; we have great
reason to be thankful to live in this generation; we have a duty to continue to
reduce damage due to infection and we shoukd try to regard the treatment on
infection, even with wonderfully effective antibiotics, as an occasional
necessity due to failed prevention.
I write this prologue to remind that
all the pathogens are still "just round the corner", that new ones may appear at
any time and that a physician needs training, experience and an uninhibited
understanding of infection if he is going to be the immediate value tpo the
community that epeidemic cpnditions demaqnd in terms of care, control and
treatment. It is not enough to assume that any good physician can function with
usefulness and without panic; equally, too, trained and experienced nurses can
be the only useful assistants of the experienced doctor. This memorandu1m is
devoted largely to problems of infection relaqting to the Bristol area, but
obviously cn have some national meaning. We must think broadly about these
matters and not just in terms of certain notorious or notifiable diseases. Thus
it is salutary to remember that but for Pasteur, Lister and the consequent
development of a "good surgical technique" the simple appendicitis of today
would still be the deadly perityphlitis of the past, and some of us would not be
alive to discuss modern medicine.
3. History
The story of infection in Bristol is much the same as any similar city in
England. Although knowledge and Public Health Acts followed each other in the
second half of the last century, it is the 20th century practice that has
brought us to the stage where many people say that infection is no longer worthy
of consideration.
During the latter years of the 19th century a hulk anchored in the River Avon
provided accommodation for fever cases and there was a small smallpox pest house
in Bedminster. The majority of severe cases of various infections were admitted
to the general hospitals. In 1899, Ham Green Hospital, (76 beds) was opened as
an isolation hospital, mainly to take care of typhoid cases. It is interesting
that these patients were carried to Ham Green by river boat and the landing
stages still exist. The hospital was built by Bristol Corporation as part of
their Public Health Duty, and in accordance with plans and precepts generally
accepted at that time. Accordingly the hospital was built as a multiplicity of
wards, each separate in space and occupying a considerable acreage OF GOOD
AGRICULTURAL LAND. Isolation of infectious cases from the community was the
prime consideration, applied only to the official list of notifiable diseases
and only to such cases, as occurred within the bounds of the City and County of
Bristol. The provision made BY Bristol proved to be excellent by current
standards and good treatment was added to isolation accommodation. the hospital
grew, developed a sanatorium for pulmonary tuberculosis and an annexe at
Charterhouse-on-Mendip. By 1948 there were available 360 infectious diseases
beds, 200 pulmonary tuberculosis beds and a 100 on Mendip for assorted cases
meriting country convalescence. The last building extensions in 1938 gave the
hospital the inestimable benefit of many single and double rooms both in the
fever wards and the sanatorium.
IN 1948 the fever hospital was surrounded by a high wooden wall emphasising the
dreary concept of isolation when, in reality, the hospital's work concentrated
more and more on modern diagnosis and treatment, while newer knowledge of
transfer of infection in the community reduced the role of isolation to that of
the control of cross-infection. These more reasonable ideas started during the
v1930s and have been augmented steadily until now the former fever hospital has
become a small efficient unit treating all aspects of acute medicine bearing any
r elation to infection, and practising isolation nursing techniques using, from
preference, single room accommodation. The high wooden wall is gone and visiting
so developed as to be practically unrestrained among family groups. The old
sanatorium has occasional patients suffering from pulmonary tuberculosis. in the
field of common infections there has been an unbelievable transformation. my own
professional experience has covered this magical time, starting in 1934and,
during the War years, I saw for myself many exotic and tropical; diseases not
occurring in England.
In 1939 I could be almost certain of seeing up to 6 cases of diphtheria e ach
day; scarlatina was common enough,
, not severe but with many septic
complications, but I worked with seniors who had attempted treatment of the
"Fever", (Scarlet fever), At the beginning of the century when virulence was
high and the death rate tragic. Now scarlatina is the mild disease as first
described by Sidenham in the 18th century. Mutation, not treatment or
prevention, has mastered scarlatina. On the other h and, in 1921 the basic
method of preventing diphtheria was thoroughly known; apathy and poor medicosocial communication allowed this disease to continue for over twenty years. The
pressures of the War forced on the population the [preventive measure that has
made diphtheria one of the rarest infections of this day. (Appendix A). I last
saw a case of diphtheria in 1949.
Between 1947 and 1958 poliomyelitis ran a stormy course with annual
epidemics and a peak of paralysed patients, (350), in 1950. As a result we
developed an efficient artificial respiration department which has since become
an intensive care ward, providing also for acute and chronic renal failure.
There is now no poliomyelitis, again the happy result of efficient active
immunization, special nursing care remains. (Apendix B)
Each year has seen a smaller number of infectious cases, a quicker
turnover of patients as a result of modern treatment and a very different
variety of admission diagnoses. We tend to receive problem cases, many not
infectious at all, and many suffering from relatively newly identified viral
diseases. We see few cases of "normal" common diseases like measles, chickenpox
and mumps, and the efficient immunization techniques practised in Bristol have
further reduced our potential admissions. It is odd that we have treated 120
cases of severe tetanus during the last ten years, not because we are an
infectious diseases hospital, but because we have a reliable artificial
respiration unit at our disposal.
Although we treat numbers of babies with diarrhoea and vomiting, few of them are
actually infected but many are very sick infants, biochemically very upset and
highly vulnerable to infection of any sort. Our accommodation and fever nursing
techniques combined with a considerable practical knowledge of the treatment of
biochemical disorders, give these infants protection and care such as makes the
death of a child an almost forgotten event. This gives infinite satisfaction
compared to my memory of similar infants in the 1930s who almost invariably died
from what was learnedly termed "marasmus". As I remember, the only treatment
consisted of an attitude of prayer and hope in despair. Yet such children are
now easily managed and returned to health by the swift, practical use of an
intravenous drip to provide appropriate replacement of fluid, salts and
nourishment. "Drips" are so much a part of medical life today that we forget
that they are comparatively new and seldom stop to realize that they are life
saving.
In 1935 the bacteriological diagnosis of any bacterial meningitis was
almost an academic exercise. I remember delaying diagnostic lumbar puncture for
a day or two so that I could identify the organism the more easily! There was no
effective treatment and death was the usual result. It was with awe that I saw a
16 year old boy recovered and walking around after pneumococcal meningitis,
treated by sulphapyridine (M&B 963). At this time small babies and the elderly
all died when stricken by bacterial pneumonia; young adults stood a one in four
chance of survival. By using the same drug the death rate of pneumonia fell to
some 2% and I came to identify a baby dying from pneumonia as suffering from
staphylococcal infection. These were exciting therapeutic times still important
in my memory but made more commonplace by the antibiotic revolution which
started with the advent of penicillin in 1941. Nowadays public opinion tends to
think somebody is to blame if anybody dies as a result of any infection, and
some part at least of what can be called the "geriatric crisis" is due to the
liberal use of antibiotics in the presence of respiratory infection of any kind
in the elderly.
Of course, medicine and surgery have advanced on other fronts, too, and the
steadily rising standards of living is predicated by a low infant mortality and
the strange sight of paediatricians and public health doctors seeking new fields
of work. We now hear much of "infant salvage", (meningomyelocoele and other
congenital deformities), and even mental health gets a hearing against the rival
attractions of transplant surgery and coronary resuscitation. The new epidemic
diseases are trauma on the highways, vascular occlusive disease, and the
neuroses reputedly created by the good, fast life we lead.
The medical history of the past half-century is almost unbelievable but it
parallels other scientific developments that have placed new knowledge in human
hands. None of this has altered the human personality, and brutal wars,
political and industrial strife, depreciation of real spiritual values exist
today as they did in Biblical times. Indeed, the title of the book by Desmond
Morris, "The Naked Ape", is not a bad description of humanity and it is this
inherent defect, which shows no sign of rectification, that may yet bring to
chaos man's bright new world; the same old bacteria and viruses await such an
event to plunge humanity back into a Dark Age of the future if we do not control
our aggressive personalities and make war an unacceptable method of solving
problems.
4. The Years Between (1948 - 1969)
Situations develop, they seldom happen suddenly; thus the present state of
infectious problems in Bristol shows best as the end result of a trend seen in
Appendix C. This series of ten year samples of diagnoses and admissions to Ham
Green Fever Hospital demonstrates clearly that in the "good old days of fever",
as represented in the 1920s, the hospital really treated only scarlatina and
diphtheria. It should be remembered, too, that patients came from within the
local authority limits of the County and City of Bristol. During the 1930s a
gradual relaxation of admission diagnoses took place, although even in 1946 the
rule was that only cases suffering from one of the notifiable diseases be
admitted. A certain amount of of subterfuge in admission labelling, as for
example accepting infantile diarrhoea and vomiting as dysentery, broadened the
clinical scope of work, but the real cause of change from the old established
order was the disappearance of diphtheria. This had been the "bread and butter"
disease for so long, occupying constantly at least five wards at Ham Green, that
the work of the hospital in terms of nursing training, equipment, ancillary
departments and even diets all revolved round the care of cases of diphtheria.
The teaching of undergraduates tended to be demonstrations of a succession of
children with various degrees and types of diphtheric infection and tracheotomy
was a fairly common operation offering some drama in an otherwise hum-drum
routine.
The fever hospital, seen in retrospect, was an unusual phenomenon. The
administrative principle of the medical superintendent left a great deal to
chance but on the whole was an economical method of running a hospital. The
success or failure of the method depended entirely on the enthusiasm, energy and
personality of the superintendent. None had any training in economics,
management or diplomacy, and it is surprising that relative success rather than
failure was the common result. A very few domineering or lazy men spoilt the
image of the medical superintendent so that he is credited with few virtues
today. However he did have values: unification, immediate decision and
unquestioned command gave him the qualities of the captain of the ship. Things
could be done quickly and reliably without argument, to suit the twists and
turns of epidemic demands and, being resident, the medical superintendent was
virtually always available. There is no doubt but that he had ultimate control
of nursing policy usually amicably arranged with his matron, and the standard of
bedside nursing achieved in major fever hospitals during the 20s and 30s,
especially in the details of the prevention of cross-infection, set a high
standard usual in any other hospital. Admittedly this standard was of an
automatic variety: without question nurses did exactly as they were told,
discipline was absolute and elements of changelessness, childishness and useless
precision spoiled the otherwise excellent bedside nurse training. Matrons of
general hospitals welcomed and set special value on girls who had already
completed the fever training. Quite simply this type of bedside nursing does not
exist today.
Unfortunately, the medical superintendent lived in medical isolation and the job
possibly attracted an austere type of man. Many held such a lonely job too long
so that methods and practices tended to gel, especially since local authority
finances did not allow for much expansion of work or scope for experiment. The
hospitals lagged behind in basic matters like plumbing, telephones, kitchen
equipment and even electrical and water supply. Superintendents lived in a world
apart from the main stream of medicine, continuing to do the work year after
year without change, even if with sincerity and devotion.
Ham Green hospital had three medical superintendents: of these Dr. B.A.I. Peters
was pre-eminent. He was appointed in 1908 as sole resident doctor, rapidly took
over the hospital care of cases of pulmonary tuberculosis as well as the
original fever work and for forty years administered a growing hospital with
usually only two medical assistants, supervised a large market garden and a 700
acre farm and still found time for his own hobby of organic chemistry. When he
retired in 1948, the previous year's budget for the hospital had been £80,000*
and the notable pedigree pigs on the farm had earned a profit of £4,000. (*Ham
Green's probable budget figure is about £800,000 for 1969). It was marvellous
that a man like Dr. Peters could produce such a successful result with such an
economy of staff, equipment and buildings.
The system ran almost on military lines, at least a paternalistic dictatorship
but gave flexibility of reaction well suited to the varying demands of infection
especially in epidemic conditions. This command structure has disappeared
entirely from medicine but it is still maintained and even strengthened in the
Nursing division of hospital work so that now a Matron has more real power than
anybody else, even the governing body. If the Salmon Report goes into full use,
the practical governance of our hospitals will be in the hands of matrons,
perhaps not an improvement on the so recently execrated medical superintendent.
I have emphasise these matters because, with the creation of the National Health
Service in 1948, medical superintendents started to disappear in England and I
myself was appointed as a consultant physician in General Medicine in July 1948.
For two or three years, since there is an inevitable momentum in these affairs,
I took over Dr Peter's work and was automatically granted his powers. Thus I am
able to compare the administrative capabilities of a medical superintendent with
the influence of a single physician member of a medical advisory committee. To
give a single example, in 1949 a large maternity and baby unit was infected with
paratyphoid fever. The disease was spreading apparently out of control. A
conference was called and I attended. It was imperative that the booked
maternity work should not stop and, therefore, I offered to take all cases,
contacts, nursing staff and even doctors involved by the infection to Ham Green.
After a telephone discussion with my Deputy Matron, wards were opened, or re-
arranged, and twelve hours later over 200 extra souls were installed at Ham
Green. The limiting factor proved to be an insufficiency of ambulances; the full
bed space was available in four hours. This sort of manoeuvre could not be done
today; there are too many interested parties, there would be too many committee
meetings convened; it is almost a principle of life now that nobody is allowed
executive power to take such actions, to be responsible for them and to suffer
if they prove wrong or inadequate. And yet if serious infection strikes the
population in future these sort of powers will be necessary and it appears we
have nobody experienced to be calmly serious in the exercise of such discipline.
In 1969 a consultant physician has no executive powers to control or modify the
environment of his patients; a solemn thought.
When talking about fever hospitals and infection, the control of epidemics would
seem to be absolutely important. Yet, in my still growing experience, the
popular idea of an epidemic does not now occur. One must always be prepared for
a small rush of cases, seldom exceeding twenty, mostly in the order of half a
dozen. This sort of demand occurs perhaps eight or ten times in a year and is
likely to be a feature of the work perpetually. Then there is the "expected"
epidemic; for example we "expected" poliomyelitis every year in August and so
prepared to receive cases until December; we expected measles every second year;
we expected an excess f respiratory infections in February and a little burst
pof assorted infections immediately schools re-open after holidays. This pattern
is becoming lost. Immunization has eliminated poliomyelitis as it has made
diphtheria only a difficult word to spell; measles is going the same way and the
intelligent use of antibiotics in an area with an excellent practitioner and
public health service has reduced our admissions almost to a steady flow,
showing little seasonal change and delivering to our care problem cases or
ordinary infections which have developed serious complications. There is a
general appreciation of the value of early diagnosis and since, for example, a
stiff neck might mean nothing, it might also be the earliest sign of bacterial
meningitis. We, therefore, see a considerable number of such cases sent in for
diagnosis.
Paradoxically we are seldom invited to help diagnosis in the home at domiciliary
consultation, although it is obvious and perhaps flattering to see how much the
general practitioners and other hospital doctors respect our judgement on the
cases they send to us in hospital. Thus, to a surprising extent, we have become
a diagnostic sorting station: not all cases of jaundice are infective; patients
with diarrhoea produce a satisfactory multiplicity of diagnoses and the possible
case of meningitis van have any variety of central nervous disease imaginable.
The Department of Fevers becomes more and more a department of acute medicine,
with some surgery, principally in the diagnostic field. It is a department which
covers all age groups and forces the physician to look at the patient as a whole
man, living in a variable environment.
The turnover is rapid. We are dissociated from the old image of infection,
isolation, scarlatina and diphtheria, and the pattern of the future emerges as a
unit within a general hospital accommodated entirely in single bedrooms with
appropriate public rest rooms and ancillary spaces. Indeed, if all hospital
accommodation was planned in the same way and managed by an understood and
reasonable isolation nursing technique, there would be no need for special fever
accommodation: indeed there would be no need for differentiation between male
and female wards, or medical and surgical departments. The special parts of the
future hospital could be mostly associated with complicated equipment and the
care of small noisy children. Privacy and quiet would be available and we would
at last get away from mediaeval dormitories and the ever-present risk of crossinfection. In this country hospital cross-infection occurs at night, is
respiratory in type and our population is not yet educated to appreciate free
ventilation. With a population mostly working to achieve the social status of a
private bedroom at home it is a strange anomaly that we still persist in
providing dormitory wards for our sick when they are most vulnerable to strange
smells, noises and the forced company of total strangers, in accommodation not
unlike a railway station platform.