This memorandum by Dr James Macrae was circulated locally in 1969, but was never formally published. A copy is kept in the stack room of Bristol University Medical Library. It is a fascinating document, dealing not just with the development of an intensive care ward , but also with the changes in medical practice and administration in the first 70 years of the 20th century. Incidentally, it tells an interesting story of providing anaesthesia in the 1950s for routine T's and A's, and the bleeding tonsil.
A MEMORANDUM ON INFECTION
James Macrae TD MD FRCP DPH
Problems of infection as exemplified in Bristol
1.Purpose / 2. Prologue / 3.History - The Bristol example / 4. The years between (1948-1969) / 5. The present situation / 6. Thoughts for the future
Appendix A - Scarlatina and Diphtheria / Appendix B - Intensive Care: comparative results / Appendix C- decennial admissions
Ham Green House, built in Queen Anne's reign, birthplace of Dr. Richard Bright
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.
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.
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 each 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 medico-social 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 cross-infection. 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.
The practical use of these apparently futuristic techniques has been practised since 1938 at Ham Green Hospital. During that year new cubicle wards were built for both fever patients and cases of pulmonary phthisis, and these wards still serve us well. During the year 1949 an "open" ward, providing dormitory accommodation for 20 male and 20 female cases of scarlatina, admitted some 200 patients but was constantly being closed on account of other infection introduced or scarlatinal complications reproduced throughout the ward. An adjacent cubicle ward of 28 beds cared for over 600 patients during the same period: there was no cross-infection, although a great variety of infective and non-infective diagnoses were confirmed and the ward was never closed for admissions. Now, in 1969, I use cubicle accommodation only, in the infectious department of Ham Green Hospital, an aggregate of approximately 75 beds.
In 1948 Ham Green was a Fever Hospital and a Sanatorium with an extra 100 beds at Charterhouse-on-Mendip. Fifty of the beds at Charterhouse were of the chalet type and patients virtually lived out of doors at an elevation of nearly 1000ft. At that time these conditions were regarded as eminently suitable for the treatment of pulmonary tuberculosis. Although not quite as Spartan, the Sanatorium at Ham Green provided the rest, good food and fresh air considered correct for these patients. The waiting list time was about two years and a patient considered suitable for thoracoplasty usually had to wait about eighteen months for such surgery. Diphtheria had disappeared, scarlatina was waning in severity and was easily controlled by penicillin, the first of the annual poliomyelitis epidemics had occurred and the necessity for more artificial ventilators was obvious. The most important changes in 1948 were that we accepted cases from a much wider area than merely the City of Bristol and in some respects, as the largest fever hospital in the South Western Regional board area, we took on certain regional responsibilities. We were no longer bound to take only cases of notifiable infectious disease and thus, officially, we accepted, diagnosed and treated the whole field of disease with an infective content, in effect all that acute medicine offers and a proportion of chronic disease, too.
Affairs remained thus until 1950 when the first diversification of the hospital came with the appointment of consultant chest physicians to care for the sanatorium patients. Since then the flood tide of useful antibiotics and preventive antigens continued so that tuberculosis has ebbed away to feature low in the list of differential diagnosis which every medical student knows. It astonishes me to remember that in 1948 there were 500 beds available for pulmonary phthisis occurring in Bristol; the waiting list was a disgrace; the problem was part of a national disaster. Now, a score of years later, there are fewer than 20 cases of pulmonary tuberculosis in hospital and that from a population more than twice the size of the City of Bristol. The efficacy of the new treatments brought problems. I continued as before to admit cases of tuberculosis meningitis. Prior to 1947 all died within a very few weeks. New therapy, especially the advent of isotinic acid hydrate in 1951, transformed the prognosis so that our death rate in this disease is now about 10%. But in the 1950s we accumulated 47 cases being treated simultaneously, a heavy load since the treatment lasts about nine months in hospital and two years supervision altogether. (For a most interesting account from a patient's point of view, click here). Since then the meningitis complication of tuberculosis has diminished to vanishing point. We have not seen a child with this disease for many years and the possible diagnosis is so easily forgotten that our most fruitful source of the few cases we now see is the neurosurgical department of Frenchay Hospital.
Until 1958 the fever department embraced 140 beds and cots, about half of each. This number tended to expand annually to 200 for a few months as poliomyelitis came, but still there were empty wards. For twelve years a 25-bedded ward with a small theatre, once used for tracheotomy, was fitted out for the routine removal of tonsils and adenoids. Mr. Gordon Scarff and Mr. Elwin Harris arranged this for the Regional Hospital Board and left the day to day running of the ward in my hands. Being able to stitch up bleeding tonsils and give simple anaesthetics, and being resident, I was able to help in a practical way. In all 15,000 patients had their T's and A's removed; for a time the Bristol waiting list was reduced to a negligible week or two. I gave perhaps 2,000 anaesthetics and stitched up 300 "bleeders". This work eased in 1960 when I no longer lived at Ham Green and the new Ear, Nose and Throat Department became fully operational at Southmead Hospital, but it served to show what could be done, safely, efficiently and cheaply. At times this work came to a halt in the face of poliomyelitis epidemics: the nursing staff became magnificently adept and trustworthy, and, at its zenith, 50 children were operated on cheerfully, expeditiously and safely each week. This was not strictly fevers, but it was an exercise in limiting infection and gave me an opportunity to study methods of ventilation to reduce the respiratory type of cross-infection which is the bane of every dormitory-type ward. These and other practical experiments persuade me now that an adequately moving current of fresh air diluting the potential dose of infection is an almost complete deterrent to respiratory cross-infection. The British Public abhors draughts and has plenty of respiratory infection.
For several years a 25 bedded ward was usefully reserved for the antibiotic treatment of cases of tuberculosis infection which did not eassily fit in elsewhere. Professor Gordon Lennon was able to divert a remarkable number of cases of genital tuberculosis involving tubes or uterus; urological surgeons, especially Mr. Norman Slade, sent us cases of renal or bladder tuberculosis. Tuberculous peritonitis, cervical glands infected from tuberculous tonsils, and occasional cutaneous lesions kept this ward busy, but as treatment becomes generally more effective the supply of such cases dropped off so that the ward closed for lack of work in 1955. It is strange for me to remember that in a general hospital in 1935 I was responsible for a large out-patient clinic devoted entirely o the treatment of "tuberculous" glands of the neck. It is almost an unknown disease now.
Dr. Peters was very interested in diarrhoea and vomiting of infants during the 1940s. His main interest was chemical and he was able to show that these children consistently displayed a difficulty in digesting cow milk fats resulting in an excess of neutral soaps in the diarrhoeal stools. An obvious cure is to feed the baby on human milk which needs no digestion and accordingly he developed a small but remarkably effective Human Breast Milk Bank This venture was taken over by Southmead Hospital in 1949and remains in operationstill, though few will remember that Dr. Peters originated the scheme.
Since the main feature of the immediate treatment of diarrhoea and vomiting of infants is rapid replacement of fluid, salts and nutriment, the early, (1950's), methods using metal intravenous needles were not always entirely successful but the value of the intravenous drip for these babies gained general credence. With the introduction of thin, nylon, pre-sterilized intravenous catheters able to reach deep into the central venous well, the modern intravenous drip is a reliable instrument and the technique so life saving that deaths from dehydration virtually do not occur in the course of modern therapy, another miracle compared with experience in the 1930's.
Before antibiotics were available bacterial meningitis was almost certainly fatal: with our present range of antibiotics the mortality of almost any variety is about 8-10%, which means the patients who arrive too late for treatment or have an overwhelmingly virulent disease. This situation gives us enormous responsibility to recognise, identify and treat correctly such cases with the utmost speed. A delay of only a very few hours can mean the difference between death and complete cure. Knowing this we have endeavoured to maintain a drill which results in accurate antibiotic treatment within an hour of the admission of the patient. Of recent years rapid local laboratory work has not always been as readily available as I would have wished and I sometimes yearn for the days when the hospital laboratory was open to my own uses. We see some 20-30 cases of bacterial meningitis each year; it is vital that our delay should not prejudice the recovery of any of them. The intensity of our search for cases of bacterial meningitis has served to uncover a host of relatively harmless cases of viral infections of the brain and the occasional severe virus encephalitis serves to show up our therapeutic impotence by comparison with our newly found confidence in the treatment of the formerly deadly bacterial case.
In 1938 the last major building programme added greatly to Ham Green's potential. Part of this was the provision of a Smallpox Hospital on ground set apart. This consists of an acute ward, a convalescent or contact ward, a cleansing station, a large steam steriliser and a mortuary. Making due allowance for staff accommodation, the Smallpox Hospital would accommodate 35 patients. It has never been used for this purpose, the beds are in constant every day use but could be emptied within twenty-four hours. In another smaller ward 6 beds are kept always ready with necessary ancillary rooms and equipment for any real or possible case of smallpox. This "every-ready" ward is used perhaps once a year to investigate a doubtful case. We have a pool of volunteer nurses and domestic workers always available and the system works well. Dr. H. R. Cayton, Director of the Public Health Laboratory Service, (P.H.L.S.), in Bristol, is, in my company, a member of the Ministry of Health's smallpox consultant panel. This is a very convenient arrangement for me, since Dr. Cayton can so readily arrange laboratory work needed for the confirmation of smallpox. He has already been able to identify chicken-pox virus, using an electron microscope, within an hour of taking specimens. There are statutory rules laid down to control and treat smallpox and we maintain smallpox accommodation to serve a very large area. I very much doubt if these statutory instruments are necessary. Smallpox will continue to be introduced occasionally into the United Kingdom. Responsible vaccination programmes and the nursing of patients in ordinary cubicles, with good isolation nursing techniques are all that is necessary, and I feel sure that some day we will be brave enough to put this into effect.
In 1958 the administration of Ham Green was taken over by Southmead Hospital Group Management Committee. The original Ham Green administration proved well meaning but rather parochial and operated in very small circles when faced with the progressive disintegration of the original conception of the Hospital as Fevers, Sanatorium and Charterhouse annexe. Perhaps it would have been more sensible in 1958 to have amalgamated Southmead and Ham Green hospitals, administratively, clinically and in a nursing sense, too. The fever component shrinks, there is no pulmonary tuberculosis problem and venereal disease beds and a paediatric ward have been costly farces for a long time. Only gynaecology, urology and intensive care flourish, allied to a large and increasing number of geriatric beds which upsets any balanced economy of bed utilization we could ever hope to have. The hospital is marking time and its whole future is due for re-consideration. Its most valuable asset is its land, well positioned in relation to obvious future developments of roads, docks and industry in the neighbourhood.
Although I have mentioned the geriatric content of the hospital, I must remind that these old fever wards were designated for this use as very temporary cover for patients moved from Snowdon Road Hospital, therefore being accommodated in new wards at Southmead. The fruition of this plan is now clearly moonshine and it is rumoured that more fever wards are marked out for old feeble people. These purposes should be clearly stated in order to stop the general anxiety that Ham Green is fated to suffer from a species of undefined, creeping geriatric paralysis. The general medical wards and the chest wards gather an inordinate number of elderly patients and the fever department is plagued by old people sent in to die because they have "diarrhoea" which "might be infective". When this happens I seldom find myself able to transfer such cases to the real geriatric beds in Ham Green far less to another geriatric unit. It would seem that we are gaining a reputation of being a suitable and defenceless refuge available for housing old people unable to look after themselves. Apart from children and young adults suffering from infectious conditions, it is increasingly noticeable that the Bed Bureau seldom offers us a patient under the Biblical limit of three score years and ten.
Traditionally large fever hospitals have been associated with excellent bedside nursing, flexibility in use of beds and accurate quick laboratory facilities. Originally the usual laboratory was almost wholly bacteriological in nature. With advances in diagnostic and therapeutic practice demands on the laboratory have multiplied and biochemistry has become an empire of truly imperial size. A great deal of this demand is very necessary: a noticeable fraction is the routine request for a multiplicity of tests which could be reduced by sense and intelligence. Many clinicians have a touching trust in the figures supplied by the laboratory, but the most serious development I have noted is the dissociation of laboratory staff, both technical and medical, from the wards, and, therefore, the patient. This tends to create strife, since the technical staff think of specimens in bottles for testing, while the clinician awaits results which might be critical for patients, but which he cannot assess or criticize because he has little or no laboratory training and technicians, being in short supply must not be annoyed by clinical carping. The clinician, working on a twenty-four hour per day demand, finds it difficult to accept cheerfully the laboratory attitude of 9 to 5 and every weekend free. This is the new situation which the last generation of pathologists would regard as impossible.
At Ham Green, for very many years Dr. Peters used a system of teleo-pathology, sending all specimens to a Bristol laboratory. Work at Ham Green was entirely limited to organic chemical research which was at times quite abstruse. I felt the need for local laboratory services and in 1947 started certain bacteriological work myself, particularly connected with the rapid diagnosis of such as bacterial meningitis, diphtheria, malaria, glandular fever and the identification and culture of tubercle bacilli. The amount of work I could do alone was limited but it merited the establishment of a minor laboratory with one technician in 1948. This expanded so that a respectable amount of useful work was being done by 1958, and an accurate biochemical section was established. The laboratory and medical staff were fully integrated and technicians often knew patients by Christian name. A human as well as a scientific atmosphere prevailed between doctors, technicians and patients. Although Dr. A. L. Taylor could not devote much time to us at Ham Green he was a mediating influence and a ready and authoritative opinion which we valued and missed when he retired. Since then the laboratory, from a clinical view point, had deteriorated; the greater part of the formerly local work is now done at Southmead Laboratory and contact is difficult and distant. Fortunately, wehave retained our connection with the P.H.L.S. and Dr. Cayton now supervises the bacteriology done at Ham Green and our liaison with the P.H.L.S. in Bristol is excellent in both the bacteriological and virological sections of this work. Such an arrangement is vital when working with infections and I am greatly comforted when compared with the service which was disintegrating before my eyes some two years ago. We still miss Dr. Taylor's enthusiasm and authority in histological opinion, but this is less important than the rapidly developing lack of belief in the bacteriological work. All is well again and the continual support of Dr. Frank Lewis in haematological problems is a useful and happy part of our work.
Our work nowadays does not result in a large volume of morbid anatomy but the autopsies that are necessary are the more important. This service continues: the mass of work increases, mainly as more and more coroner's cases come in from outside to be dealt with in hospital accommodation not designed for such a number of bodies and might increase to a level which could be to the detriment of hospital needs for histopathology on hospital cases. The real and continued dissociation between some laboratory and clinical workers serves to help nobody, least of all the patients, and has been one of the major disappointments of my recent years.
During twenty-two years at Ham Green the most signal development has been the establishment of our Neuro-Respiratory Unit which is now an Intensive Care Ward with departments of acute and chronic haemo-dialyses added since 1962. The early epidemics of poliomyelitis, especially that of 1950 when we had over 350 paralytic cases, showed all too clearly how deficient the hospital was in artificial respirators and how ignorant we all were about the management of these machines. We worked in cubicle wards where nursing attention was divided with other types of cases; we designed, developed and brought into use a new type of positive pressure respirator to be used in conjunction with a cuffed tracheostomy tube and at the same time persuaded the Bristol Aeroplane Company to build an ideal type of cabinet respirator. The "peak" year of 1953 decided that the better treatment was by positive pressure and marked the decline of the tank respirator. While we devoted time to the development of these mechanical aids, more and more interest was shown in the management of artificial respiration and we developed accurate means of measuring ventilation and its end result, normal blood gases. These investigations held much of Dr. R. V. Walley's attention; he wrote an excellent thesis on his work and laid the foundations of our present well tried, accurate and reliable methods of assessing respiratory needs and providing means to monitor the mechanics of an artificial respirator. It was also obvious that a different environment should be provided for the nursing of patients needing artificial ventilation and a special ward unit was designed using one of the old 1899 fever wards for adaptation. This ward was opened in 1957, provided 18 beds in a variety of small wards, including two large single rooms. We used the same equipment, the same methods, the same sort of patients suffering from poliomyelitis and the same nurses. All that was different was the special environment, the undivided attention of the nurses and perhaps, for all of us, an extra year's experience. But even having said this, the results bettered by far any experience hitherto, and Appendix C. shows how artificial respiration quite suddenly became a relatively safe procedure in our hands. In 1959, poliomyelitis disappeared as the result of active immunization, but by that time our expertise in artificial respiration attracted other varieties of disease. The meticulous quality of nursing which had been developed and continual work on patient monitoring gave us a reputation with many other hospitals who sent us their problem cases. In 1962 we first used an artificial kidney, and since then have been able to provide a complete intensive care service with a sufficiency of beds to see patients through to convalescence, and provide an almost complete regional service in the special treatment of tetanus. In ten years we have treated 120 cases of severe tetanus, possibly the biggest series in England in recent years.
Inevitably the use of the artificial kidney for acute conditions led to chronic dialysis and this is now so well established and expanding that nephrology is being hived off to Southmead Hospital to a special unit in the care of a consultant nephrologist working in close concert with Mr. Humphry White, who has already successfully transplanted cadaver kidneys into several of our patients. Both Dr. Walley and I are glad to have laid the foundation of this work, albeit almost accidentally. We are happy to surrender it to a nephrologist able to devote his whole time to the many problems that renal work now implies, not least the ethical and practical decisions that arise day and night.
Before leaving the whole subject of our intensive care unit it is notably that we, physicians, have done some of our own surgery, tracheostomies, femoral catheterisations, arterio-venous shunts and cardiac catherisation. It may be difficult in future to provide for the urgent tracheostomy when the present generation of physicians disappears. We have shown that meticulous nursing reliability is the real secret of intensive care and we have been especially blessed in having our ward in the firm and capable hands of Mr. Ronald Dix. He contrives to make an intensive care unit tranquil and controlled; a vastly different atmosphere from many other intensive care units I have seen. It is odd but true that many of our cured patients admit to nostalgia for the days they spent in intensive care.
Having found accurate methods of managing artificial respiration, the same equipment can be used to assess pulmonary function. Dr. Walley has developed this work so thoroughly that he is able to give an accurate opinion based on recorded facts, on any patient who might have a pulmonary pathology tending to interfere with lung function. This self imposed task has made him an authority in this field and his opinion is valued and much sought by physicians in and beyond the limits of Bristol. The steady development of respiratory and renal work which has gone on over the years has invited attention and we have been very glad to pass on the knowledge and techniques we have acquired. This teaching has meant that we do less routine work than we used to do, and because of this, many other hospitals perform artificial respiration and can do at least peritoneal dialysis when formerly they sent their patents to us. Our intensive care unit might be one of the oldest in the country: it has served well and give us great satisfaction. We must, however, admit that it is in the wrong place in Ham Green and that, logically it should be moved to a bigger centre so that greater use can be made of the virtues we have learned to value.
For a hospital containing so many pulmonary tuberculosis beds Ham Green had primitive x-ray facilities at the end of the War. In 1946 one room, containing a rather old and inefficient machine, served as both x-ray room and dark room. Any available doctor took the processed the films. At this time the late Dr. Sparks gave attention to the service at Ham Green and arranged for the archaic set to be transferred to Charterhouse for screen purposes only and installed a new machine at Ham Green with a modest, but separate, dark room. These improvements, although important, remained sketchy on account of costs but Dr. Sparks was also able to persuade Mr. W. Stillwell to come out of recent retirement and work at Ham Green as radiographer. Mr. Stillwell was a character of great notability. He had helped to wire up the very first x-ray machine used in Bristol and possessed such charming abilities that he could produce perfect radiography with the minimum of equipment or fuss and endeared himself to everybody he met. I regard it a privilege to have worked in Bill Stillwell's company.
With the coming of the National Health Service in 1948 and the political implication of tuberculosis at that time, it was not difficult to press for an extension of the radiological services. Although the accommodation has never been ideal, a department has been created and staffed with remarkable smoothness through the years. Now we can boast of a quick, accurate service which has kept pace with the steadily increasing demands of the hospital as its bed usage has changed. We have a very full consultant coverage of the highest standard and it is now quite exceptional for a patient to be sent to any other hospital for any radiological service not now available at Ham Green.
For some years there was an amicable arrangement for radiologists from the Bristol Royal Infirmary to provide part of consultant work but now the department is integrated on consultant level with the larger radiological department at Southmead Hospital. Without doubt we owe regular improvement in our X-Ray Unit to the active work and long term planning of Dr. Graham Airth whose positive decisions have proved so right during these many years. Without this quality of x-ray service the Neuro-Respiratory Unit could not have developed.
Although only incidental to the story of infection at Ham Green it is strange to look back 23 years and realise what did not exist then. There was no physiotherapy department, no occupational therapy, no nurses' surgery, no record department and no telephone switchboard. The pharmacy made up bottles of medicine on order and there was only one small refrigerator for the whole hospital. Pathological specimens were stored in an ice box and the only centrifuge was hand driven. So much that we regard as essential today just simply was not there and the development of each new department to its present stature would provide a series of sagas more historical than relevant to the ebb and flow of the fever work.
But it might be worth recording how physiotherapy came to Ham Green. With hundreds of cases of chest disease, small babies with whooping cough and an annual poliomyelitis epidemic the Management Committee cautiously appointed Miss Ruth Skinner in 1949. Her labours served mainly to emphasize a crying need and soon an arrangement was made to amalgamate the physiotherapy requirements of Ham Green with those of Winford Orthopaedic Hospital. This was a particularly satisfactory arrangement for the poliomyelitis cases, many of whom were transferred to Winford for further treatment anyway. Miss Saywell, senior physiotherapist supervised the work at both hospitals and some of our patients were able to help initiate the pony riding therapy which Miss Saywell developed so successfully at Winford.
In 1958 this rather happy arrangement came to an end and poliomyelitis ceased at the same time. Mr. Hancock arranged for a proper department to be built and ever since then it has expanded in work and dexterity and has made possible the management of the most difficult respiratory cases using respirators apart from all sorts of other work including a steadily increasing out-patient section.
When I came to Ham Green there was an active nursing class being trained for the Fever Register of the General Nursing Council. Within three years local nursing opinion and the implied opinion of the General Nursing Council allowed nurse recruitment to wither away and eventually the hospital was declared unsuitable for the training of candidates for the Fever Register. For some years this deficiency in junior nurses was made up by the secondment of student nurses from other hospitals, notably the Bristol Royal Infirmary, which sent groups of 30 years for three months at a time. Unfortunately, very few of these excellent nurses returned to us after obtaining their S.R.N. qualification and eventually the whole secondment scheme petered out to be replaced by the establishment of our S.E.N. nursing school to serve the whole hospital, now vastly diversified, although short of surgery and long in geriatrics.
Now we have the strange experience of having to second our S.E.N. pupils for part of their surgical training, that no specialist nurse training in fevers is given and practice of control of infection becomes more tenuous as knowledge diminishes among our nurses. We depend on a few fever trained sisters and nurses to pass on vital knowledge and methods; without the cubicles we use, cross-infection would be rife. It is strange for me to give a course of fever tuition to Bristol Royal Infirmary student nurses but not to Ham Green pupils. Having taught nurses fever methods since 1937, I now feel a gap in my duties in my own department. Fever nursing expertise is the only asset we should retain and value from "the good old days of fevers". There is a fair chance that this asset will be lost to the nation during the next decade and this loss may be a sorrow for the future. The ideal solution would be the incorporation of basic isolation nursing technique into the training of all nurses.
For most of his time as medical superintendent, Dr. Peters had two junior doctor assistants. During the 1939-45 war he had a junior medical officer of health seconded to help with the Sanatorium and a junior doctor, if obtainable, at Charterhouse when that annexe was opened in 1941. When I was appointed as Dr. Peters' deputy in January, 1947, there was an embarrassingly large medical staff, all ex-service doctors appointed hurriedly to obtain some clinical experience. In 1948, when I became resident consultant physician, there were two S.H.M.O. "assistants", one fever and one sanatorium, and a very doubtful and occasional supply of more junior doctors, as medical staff to the whole hospital.
At first denied, Bristol University later allowed the fever department two pre-registration medical posts and the Management Committee and the Regional Hospital Board allotted a deputy (S.H.M.O.), a registrar and an S.H.O. This establishment remains except that the Registrar rotates with Southmead Hospital and a Medical Assistant has been appointed to the developing Renal Unit: and things have been made more balanced by raising the S.H.M.O. appointment to Consultant Physician, (Dr. R. V. Walley), making possible two teams to serve alternate days each comprising consultant, junior and pre-registration medical officer.
As time passes and the fever commitment changes we must review this establishment, especially when the whole of the renal work moves to Southmead Hospital in 1970. It might well be convenient to amalgamate the Fever Department with the rest of acute medicine in Ham Green. We have operated separately so far, but I think integration is not far off. The major worry in my mind is the replacement of myself and Dr. Walley, consultant physicians with special knowledge and experience in infection. At the very least, a proportion of medical registrars or senior registrars should have the opportunity of a reasonably long serve, say twelve months, in a fever unit such as we still represent. Thus might the fever units of the future be doctored, as doctored they must be, for fevers will stay with us as a permanent but probably manageable problem.
The emphasis is changing and the care and management of infections is passing into the hands of community health teams where the District Nurse sees a surprising volume of infection. One report, (H.M.J. 21 Sept. 1968, p. 734), shows that one such nurse paid 434 visits to chronic geriatric patients. In general practice the care of infection still commands a very considerable amount of doctor and nurse time thereby relieving the infectious disease units. The hospital deals more and more with complicated and difficult fever work using fewer beds but well able to apply advances in medical progress as these develop.
5. The Present Situation
There is no doubt but the demand for infectious disease beds shows a steadily diminishing trend and this has been so emphatic during the past year that 28 bed children's ward has been closed and 10 adult beds have been temporarily changed to geriatric use. The six first line smallpox beds remain empty but always ready. This does not mean that we have not been busy because such patients as are now admitted are difficult cases each engendering a considerable work load. In addition, the Intensive Care Ward with acute and chronic renal failure makes for continual responsibility, activity at all hours and with a decision-making content which can be considerably exhausting for everybody concerned.
We no longer use any dormitory wards and at present plan to transform our double cubicles into singles, for the future economics of fever management dictates single bed-rooms. At present we have a unit consisting of two cubicle wards, one of 28 beds, (10 single, 9 double cubicles), plus a small theatre; the other of 30 beds (10 single, 10 double cubicles). There are 8 other single cubicles available not counting the 6 stand-by smallpox beds. The intensive care ward provides 14 bed spaces and a chronic dialysis unit of 3 beds. Thus during the past year the infectious diseases department has managed reasonably comfortably using 28 single and 19 double cubicles. If the doubles were subdivided into singles I have no doubt but that the provision would be ample indeed with a total of 66 rooms to be put to any use at any time for any disease occurring in either sex.
Special arrangements exist for smallpox. We do not admit a questionable case unless seen by a consultant to assess the probability. The suspect is possibly admitted to the first line accommodation where an accurate diagnosis is established as rapidly as possible. The need to open our second line Smallpox Hospital has never arisen but plans to do so within twenty-four hours could become reality at any time.
Our wards are staffed by a mixture of State Registered, Fever Registered, State Enrolled and auxiliary nurses. There are a few male nurses. As is common, the complement of nurses on day duty is larger and generally more alive than the night nurses. We depend on married women, with nursing qualifications and domestic demands, as part-time nurses and get along remarkably well. As usual, Matron's job is no sinecure and she has to satisfy many nursing requirements besides the fever wards which have become a relatively small section of the hospital, getting less each year. Undoubtedly the generous number of cubicles we can use limits cross-infection problems, since respiratory spread is totally controlled, but I would like to see more active nurse training in the knowledge and prevention of cross-infection. At present only a few sisters and nurses of the "old school" pass on the tradition and this will soon fail as, indeed, I am seeing signs already.
The present medical staff consists of two consultant physicians, one medical registrar, who rotates on an eight monthly basis with Southmead Hospital, one medical S.H.O. and two pre-registration house officers. These doctors run the department, including the Intensive Care Unit, and have no assistance from any of the other medical officers working in Ham Green. We are a separate clinical entity, providing our own duty rotas.
There is an immediate prospect of a nephrologist taking over our renal responsibilities and a medical assistant is already appointed to help him. Eventually, probably in 1970, all the renal work will be undertaken in Southmead Hospital in new premises. Our Intensive Care work goes on, but since an intensive care unit of some sort has become a status symbol, fewer patients are referred to us by other hospitals. We are, however, sometimes flattered to have cases sent to our intensive care ward from other intensive care units. At present our geographical position and the unfortunate planning instability of Ham Green will tend to reduce our intensive care wok and logically what we have developed would be better employed in a more central hospital like Southmead. Exactly the same comments must apply to the Pulmonary Assessment work done by Dr. Walley; this is important and must not be lost.
There remains the present state of organized teaching of infectious diseases: until this year all students studying for the Diploma of Public Health at Bristol Universityh attended a course of clinical teaching. Similarly University nursing students working for the Health Visitor's Certificate attended Ham Green for regular fever teaching. These courses have been chopped from each syllabus on the presumed assumption that fevers no longer matter. Undergraduate teaching goes on as before, but it is becoming a problem in providing proper clinical material for demonstration since our cases tend to either by atypical or very severely ill, giving students an entirely wrong impression of the average case of disease in question. This year we are handling nearly eighty undergraduates, half on each of two mornings per week of a term. These numbers, combined with the fact that our cases are treated in cubicles, can often making teaching doubtfully useful. We know that within two years the numbers will rise to one hundred and twenty making it imperative to reconsider the methods of conveying some knowledge of common infections to future undergraduates. Dr. Walley and I have already discussed the problem with the Professor of Medicine.
The fever department does not teach fevers to nurses at Ham Green but we do run short courses on Artificial Respiration and the modern management of renal diseases. We trust this will continue and I wish fervently that we could contribute some knowledge of fevers to the S.E.N. pupils.
There is a strong feeling that we stand at a cross roads, and seek rational methods of using hospital beds which have largely become redundant by the great success in controlling the diseases which formerly and traditionally filled these beds. In other words, our disarray is due to recent preventive and therapeutic success.
6. Thoughts for the Future
I speak mainly for the future of fevers, but must mention that Ham Green Hospital possesses 160 acres of ground strategically sited for a new district hospital very close to the M5, adjacent to inevitably dock expansion, associated industry and increased population north of the river Avon. These considerations could well lie behind any valid hospital planning for the Bristol and North Somerset area.
It should not need Sir James Howie, Director of the Public Health Laboratory Service, to emphasize that infection still exists in this country and in the world and that we should maintain an aggressive and knowledgeable attack on these diseases led by the Medical Officer of Health, the microbiologist and the fever physician. (Public Health, Sept. 1968). In hospital this can best be achieved in an environment of single cubicles with associated ancillary work places and convalescent rest rooms used with discretion in accordance with the physician's knowledge of the infectivity and danger of each treated disease. Such accommodation for the Bristol area and for all age groups in the foreseeable future should not require more than fifty rooms properly staffed.
Better still, if a new hospital were built, say on Ham Green estate and every bed was in a separate room and simple barrier nursing practised as routine, all the problems of cross-infection, introduced infection, "hospital" infection the provision of special accommodation for infectious disease patients would be obviated. Indeed, the infectious disease physician would be a true consultant available to all staff and maintaining the "infective security" of the hospital. Apart from this, the patients would have privacy when ill and vulnerable and would get better the more quickly: there would be no problems of male and female wards or even medical and surgical. We could, as it were, have an "open plan" hospital. A recent reading of "The Falkirk Ward", (Edinburgh, H.M.S.P. 1969), points the way to exactly the ideal conditions I have outlined above.
The spectre of an epidemic is possibly more of a bogy that a reality in present conditions in this country. But the very complexity of our sophisticated living makes breakdown the more possible. Therefore, it is prudent to have plans for the unexpected epidemic. This means that beds and medical and nursing staff must be tentatively allocated based on the nucleus of the fever unit, to provide a skilled cadre for any necessary expansion. It is always difficult to define epidemic conditions because nobody wants to admit an imminent catastrophe. The best information lies in the records of the Public Health Laboratory Service. Therefore, the development of a real epidemic, not the modern mass communication wishful scare, can probably best be plotted by Public Health Laboratory Service observers. On this sound advice the local fever physicians should have reasonable executive powers to set expansion under way quickly and without too much argument from the inevitable conflicting interests whose beds might be used and whose ordinary programmes might be upset.
Modern travel reduces the size of the world and we are already experiencing exotic disease borne swiftly through the skies from countries formerly too distant to influence our medical scene. But Bristol recently saw three cases of cerebral malaria in three months and a child of fourteen took Bilharzia back with her after a holiday in Tanzania. Each summer we tend to regard a history of a bus tour in Spain as being almost synonymous with a diagnosis of enteric fever. We must take histories, including travel itineraries, and we must make ourselves acquainted with the incidence of global infection and be wary of the traveller who has developed an unusual series of symptoms.
From the view point of a physician working on the diagnosis and treatment of infection, with an eye to epidemiological effects, I find that the rock of my defence from all varieties of pathogen increasingly becomes the Public Health Laboratory Service. I would like to believe that this service cannot be bettered and it certainly remains a worthy memorial of the 1939-45 War. The local authority health services take less and less interest in community infection and exhibit a complacency so widespread as to be a little unbelievable. Social science is in the air, the welfare state reduces Ministry to Department and adds Social Security to dubious Health, and I hope all goes well. The infective killers of the not so distant past can still operate: at best e have but swept them under the carpet.
A hospital without nurses is like a ship without a crew. There is now no specialized fever nursing training. I do not believe this necessary but do believe that all nurse training should contain a realistic element of isolation nursing technique with proper explanation. An intelligent nurse, with some basic knowledge of bacteriology, can master what is required in a very few hours. If she practised this knowledge throughout her nursing career the problem of infection in hospital would be controlled automatically, given good hospital design, not forgetting proper provision of good ventilation.
When we consider the further training of doctors in this field great difficulties arise. In an arbitary sense, a consultant specialist in any branch of medicine is a person armoured with a variety of academic "labels" and possessing very considerable experience of his chosen specialty, usually vindicated by recorded work done. The old concept of the fever specialist as having vast experience of the common infections in their usual clinical variety no longer holds good. In hospital we deal with deviations from the normal disease: we investigate problems: we concern ourselves a great deal with diseases of doubtful infective basis, for example diarrhoea and vomiting of infants, and the total volume of our experience covers only a fraction of the known infections. The former medical superintendent always had a deputy to take his place; there was an accepted hierarchy adjoined to the Public Health Department.
The present day physician, interested in fevers, has nobody assigned to take his place and there are few candidates with experience because there is no training ladder as in other branches of medicine. Fevers has always been an orphan department of medicine, poorly recognised because of the unwarranted stigma given to the Medical Superintendent and the lonely routine of the work under the aegis of the Local Authority. As far as I know, no influential suggestion has been made concerning the training of consultant physicians specially interested in infection except the report of June 1966 produced by the Scottish Standing Joint Committee on Training for Consultant Physicians. The following quotes the Joint Committee's requirements for senior registrar training for the individual aspiring to be a consultant in medicine specialising in Infectious Diseases possibly including Venereal Diseases.
"Infectious Diseases (Including Venereology)
During the period of Senior Registrar training it is essential that experience be gained in one of the major infectious diseases hospitals of units. The duration should be two years.
Experience of a practical nature is desirable in microbiology. This period could often be co-incidental with the period of clinical training, for in association with the major units, there are the necessary laboratories suitably staffed.
Since clinical work in Infectious Diseases covers all age groups and may produce complications involving different systems, there would be advantage in the spending of time in such special units as Cardiology, Neurology, and Paediatrics. In the same way it would be valuable to acquire experience in Epidemiology.
With increasing interchange between this country and continents such as India and Africa, considerable advantage would be gained from clinical experience in these countries. Where possible, this might occupy a period of six months to one year.
The training required for the Physician in Charge of Infectious Diseases beds does not differ from that required for the general physician. In future some of the posts will almost certainly be filled by Senior Registrars who have completed training but have had no formal training in Infectious Diseases. In certain areas the component of Infectious Diseases will be part of a general Medical responsibility. We would suggest that when this does occur, the new consultant should be attached to the major Regional Unit for the first two years of the consultant appointment.
In some areas there may not be sufficient employment to justify the appointment of a Consultant Venereologist. In such circumstances a Consultant in Infectious Diseases may be the best person to undertake the care of Venereal Diseases. At Senior Registrar status the prospective consultant can receive adequate training and experience. Alternatively on appointment as Consultant in Infectious Diseases he can attend a large V. D. Department for about one month: with his previous background this period would be enough."
These criteria are admirable but difficult to achieve in practice, especially when the consultant posts in fevers are diminishing in number and already it is almost fashionable to consider that any general physician can do the work without extra training or experience. This dangerous and nobody should be allowed to take over an infectious diseases department without at least a year's experience in such a unit, with laboratory and epidemiological experience which could be best provided by the Public Health Laboratory Service during a minimum period of 6 months. This problem, crystallized locally as the future replacement of myself, has worried me a lot. We give six months experience to four pre-registration housemen each year. Similarly a Senior House Officer obtains at least a year's experience each year and recently an arrangement has been made with Southmead Hospital so that we have the services of a Medical Registrar rotating every eight months. None of this really corresponds to the sort of experience I had myself at home, abroad and in the laboratory. I would really like to see the fever department integrated with the departments of general medicine in Ham Green and Southmead, (i.e. one large medical department), with senior registrars available and capable of choosing a speciality in medicine including Infectious Diseases. Thus fevers would not necessarily always have a Senior Registrar, but, over the years, sufficient numbers would gain experience and be attracted to quality for posts becoming vacant. Such a candidate would be a trained general physician, entitled to apply for any consultant post in general medicine but especially those with an infectious diseases content. Something of this sort will have to be done or nobody will be left in the country of sufficient calibre to keep watch with the Public Health laboratory Service, as the Public Health Departments concentrate more and more on social science and even dare ask seriously : "Infectious Disease - Does it still matter?" (Public Health No. 6 Sept. 1968).
The change in fever hospital patient population means that the average undergraduate does not have an opportunity to see the common infections such as mumps, whooping cough, chickenpox and measles. He has never had a real chance of assessing the myriad minor infective episodes, mostly upper respiratory or alimentary, which have always punctuated general practice. I feel the future student's syllabus should provide more time with competent general practitioners to cover these deficiencies in hospital experience, and I would go further to suggest that the pre-registration student who intends to do general practice should have the chance of spending at least one of his two pre-registration posts assisting in the practice of a good family doctor. If it is considered necessary, arbitary teaching of fevers could be integrated into the general medical course of lectures and be conducted by the infectious disease physician.
The future has a habit of overtaking present predictions and these suggestions of mine may become unnecessary or irrelevant but they are made sincerely and relevant to the situation as I see it. Perhaps, at least, these pages can serve as a record of Ham Green Hospital, especially during these latter years of rapid change, conditioned by the War, Antibiotics, New Knowledge, and a Higher Standard of Living.
The influence of scarlatina and diphtheria on the work of a Fever Hospital
and the result of the disappearance of these diseases.
When Dr Peters came to Ham Green he found 185 infectious disease beds and an institution with almost a decade of work behind it. The records for 1907 showed that 370 cases of scarlet fever and 445 cases of diphtheria had been treated out of a total of 889 patients admitted. Thus 92% of the clinical work was concentrated on two diseases.
Successive annual reports of the Medical Officer of Health of Bristol show that this trend continued so that as recently as five years before the war the following figures were recorded:
Bed occupation was influenced because it was believed implicitly that no case of scarlatina or diphtheria could leave hospital in less than six weeks. This was probably necessary enough in many cases of diphtheria but scarlet fever has been mild for the last forty years. I have never seen a patient die directly from this disease and during Dr. Peter's period of office (1908 - 1948) the mortality of scarlatina never exceeded 2%. Even diphtheria produced an average annual death rate of 2.7% with a maximum of 8.7%. Thus, even in terms of severity, the two commonest diseases in the heyday of fever hospitals could not have provided much nursing responsibility and allowed nurses little enough experience in the knowledge of other diseases.
In 1949 three cases of diphtheria were treated and we have seen no more since then. Indeed, the organism seems to have virtually disappeared from the throats of the population around Bristol and sometimes I wonder if I could recognise the characteristic membrane of diphtheria after a lapse of 20 years.
Scarlatina is now properly regarded as a variety of streptococcal tonsillitis: only five patients were diagnosed as suffering from scarlatina in 1968 in our hospital admissions.
For 45 years Ham Green Fever Hospital bent to its task of treating two diseases and it is no wonder that such a narrow task influenced profoundly the work, methods, requirements and thinking of both the medical and nursing staff during those long years. Also in the external medical and public imagination of the fever hospital was set in a frame of diphtheria, scarlatina, medical superintendent and a minatory, high, surrounding wall.
After the War, the two "bread and butter" diseases had gone, the National Health Service provided wider horizons of clinical experience and population served, and gave the fever department an open niche in the main field of general medicine. Old habits die slowly and our new functions are not always understood; occasionally, even now, I am addressed as medical superintendent. The following graph has been constructed to illustrate the influence scarlatina and diphtheria formerly wielded, the actual expansion of work subsequent to 1947, partly due to the annual explosions of poliomyelitis and the decline of work with the disappearance of that diseases in 1959. There are indications that the workload is now settling at about 1,000 patients per year managed in about 50 working beds, gathered from a mixed urban and rural population of about one and a half million people.
Intensive Care as illustrated by comparative results in two environments within Ham Green Hospital.
For 12 years after 1947 we treated about 1500 cases of acute anterior poliomyelitis demonstrating various degrees of paralysis. This was an evocative disease in every sense and, apart from public concern, these patients required maximum medical and nursing care. If the old fever hospital developed anything it did evolve an exceedingly high level of personal bedside nursing in a ward environment affording plenty of room between beds. This nursing background and the demands of a dreaded disease continued to allow us to give these patients the very best of nursing care. Such a high proportion of patients needed artificial respiration that a new and complex discipline was added to both the medical and nursing management.
Initially these patients were treated in isolation wards which catered for many patients with other diseases. Even before the advent of positive pressure respiration in 1953, it was becoming painfully obvious that severe cases of poliomyelitis required separate accommodation. But it was not until the 15th of August 1957 that a ward with special rooms and facilities was taken into use. Without knowing it, we had evolved an intensive care unit and the transformation was extraordinary. This was especially evident among the nurses who were able to concentrate on their duties to individual patients each with individual problems. Quite suddenly the whole business of artificial respiration took on a calmness never experienced in a mixed ward. Incredibly, small but vital items of equipment no longer got lost; the machines worked more smoothly and we ceased to improvise or be dependent on somewhat inefficient equipment often borrowed from other wards. Patients and staff developed a new morale: mor patients survived and we came to regard the reliability of our nursing care and management of machines as having reached such a high level that we could expand the work.
Thus patients needing very special nursing, apart from cases of poliomyelitis, came to be treated and we took on the care of tetanus treated with curare. This is probably one of the greatest exercises in nursing care demanding at least 350 separate acts of nursing service each day and each act vital.
This ward remained in steady use and has provided care for an infinite variety of patients who are really dangerously ill. Even if proper mechanical aids and good medical care are necessary it has been proved to my entire satisfaction that intensive care means the very best nursing and in some senses the success of an intensive care ward is a reflection on the general standard of nursing in a hospital.
I have extracted some figures of work done in an ordinary cubicle mixed ward, during the period 15th August 1956 - 14th August 1957, and similar work in our special ward during the next year 15th August 1957 - 14th August 1958. These were all patients who would have died without artificial respira6tion: the only differences in management were a new ward environment and concentrated nursing care.
Not only do these figures speak of improvement among patients who were deadly ill, but they reflect, in the poor fashion that figures do, the real spiritual satisfaction engendered by work well done from start to finish. This standard remains, and is the real jewel in the therapeutic crown of Ham Green Hospital.
A study of confirmed diagnoses at 10 yearly intervals admitted to Ham Green Fever Hospital,
with reference to bed utilization when dealing with infectious diseases
It is not possible to discuss the use of hospital beds for infectious cases in the same way as one can consider utilzation of beds for non-infectious patients. In fever work there is no waiting list, every patient comes to hospital as an emergency and sometimes patients arrive in groups - the epidemic group, however small. Thus beds must be kept empty within reason, and, therefore, a high percentage of bed use cannot be expected. Often enough an infectious case can block an empty bed in a double cubicle and non-infectious patients, usually forlorn unwanted infants, mental defective children or feeble old people, lie in fever beds for considerable periods before the beds can be put to their proper purpose.
For many years I carefully assessed the accuracy of admission diagnosis among my fever patients. The diagnosis usually needs to be changed in one of each two admissions. This statement is not derogatory: indeed, it means that family doctors send their patients to hospital at a very early stage of the disease and, using very modest facilities, do very well to be 50% correct on initial diagnosis without the many aids available in hospital. However, knowing this, it is wise to nurse each new patient in a private room until his diagnosis is made absolute, thus putting a premium on these single cubicles I value so much.
At present I command the use of 68 beds for fever patients; of these 6 are permanently empty smallpox beds and I reckon to try to have some 12 beds available for emergency use. There are always a few beds blocked in double cubicles. Thus I can at very best fill 50 beds at any one time, which in the statistical report reads as 73% bed occupancy.
Another way of studying the use of hospital beds can be the yearly turn-over of patients per staffed and equipped bed. Rembering the awkwardness of fever cases, and more especially in the past when dormitory wards were used, the following table may be of some interest. It is noticeable that the increased use of cubicles has speededup the use of beds dn I would expect a further improvemet if we had only single cubicles.
Patients per bed per year
In 1957 the General Nursing Council still added to the Register of Fever trained nurses who suscribed to an approved syllabus of instruction. This included a considerable list of infectious diseases and on the general basis of this list I have compiled a table showing the appropriate diseases as figuring among Ham Green Hospital's fever admissions at ten yearly intervals. Only since 1947 has the list of diseases approximated the approved list. Of course, other diseases were admitted, some infective and many straight forward general medicine. Some had mixtures of diseases, evenmixed sirgical and infectious as, for example, acute appendicitis with measles or chicken pox.
The future use of beds for infectious patients should be on a much more rational basis founded on the use of single rooms allied to a proper knowledgeable use of isolation nursing technique practised as routine.
D & V (gastro-enteritis of infants)
Food poisoning (bacterial)
Note: Encephalitis (virus) includes "aseptic meningitis". Food Poisoning usually refers to enteritis due to Salmonella spp.. Laryngitis includes so called laryngo-tracheo-bronchitis. Meningitis (bacterial) includes tuberculous meningitis. Many non-infectious conditions were admitted but not included in this table.
Note by JP: In the above table the incidence of scarlet fever for 1917 was originally given as 799. As this did not add up correctly I have checked it in the Annual Reports of the MOH for City and County of Bristol 1917, and find the figure should have been 99, so I have put the correct number into the table. The photo of Ham Green House is not the one that appeared in Macrae's original manuscript. An excellent history of the Ham Green locality, and its hospital, has been written (1990) by Gerald S Hart. It is titled HAM GREEN and is published by Crockerne Books, 95 Westward Drive, Pill, North Somerset (IBSN 0 9516074 0 5). After 1969 there followed periods of both expansion and decline, as various specialities came or left (nephrology, general medicine, exotic diseases, gynaecology, urology, geriatrics and mental health). The hospital was finally closed in 1993.
The following obituary appeared in the Bristol Medical Chirurgical Journal in 1987:
James Macrae TD, MD, FRCP (Glas), DPH
Dr James Macrae, who was Physician Superintendent of Ham Green Hospital, Bristol from 1948 to 1976 died on 5th February 1987 aged 75 years.
He was born on 24th February at Kyle of Lochalsh and was educated at Dingwall Academy and Glasgow University where he qualified in 1934. During the following 5 years he held junior hospital posts in virtually every medical and surgical speciality and in 1939 was appointed Deputy Medical Superintendent of Lanarkshire County Hospital in Motherwell. In February 1940 he joined the Royal Army Medical Corps but shortly before leaving for the Middle East he married Phyl whom he had met in Guernsey in 1939 during his first real holiday since qualification. He served continuously for 4½ years in Palestine, the Western Desert, Italy and Jugoslavia before returning to the UK in 1945 with the rank of Lieutenant Colonel. Subsequently he served in the Territorial Army for a further 20 years.
After demobilisation he became Deputy Medical Superintendent in Weston-Super-Mare and in 1948 was appointed Consultant General Physician to Ham Green Hospital and worked there continuously until his retirement in 1976.
With the wide experience he had had before, during and after the war Jimmy was a classic example of the devoted whole time Medical Superintendent who could turn his skills to practically every branch of clinical medicine and surgery. His appointment to Ham Green coincided with the effective chemotherapy for most of the major infectious diseases and he had the thrill and pleasure of taking a major part in the virtual eradication of these previously dreaded conditions. But other challenges arose and Jimmy tackled them with skill and ingenuity; not only was he a wise physician but he had a remarkable mechanical aptitude.
In the 1950s with the upsurge of poliomyelitis he pioneered the development of assisted positive pressure respiration and built most of the early apparatus himself with the help of a local garage engineer. In 1959 he published in the Lancet the second account of such treatment in the UK- the first having appeared in the same journal only the week previously from Oxford. He personally performed nearly 250 tracheotomies for diphtheria, poliomyelitis and other forms of respiratory failure and in 1962 he carried out the first renal dialysis to be performed in the Bristol Clinical Area on a patient with renal failure due to drinking antifreeze. The first patient to be accepted for maintenance dialysis is still alive and in 1968 Humphrey White performed the first renal transplant in Bristol on one of his patients.
During his years at Ham Green Jimmy was virtually never off duty by day or by night and was an inspiration to his junior staff for his dedication and the standard of medicine which he set. He was greatly admired by all for his modesty and his devotion to his patients and his opinion was eagerly sought by consultants and general practitioners alike. For 17 years he was treasurer of the Bristol Medical Chirurgical Society and his Presidential Address in 1972 was on "Edward Jenner - a great Englishman". It was very appropriate that he was a founder member if the Jenner Trust set up in Bristol in 1967.
In 1968 Jimmy had a stroke from which he made a reasonable recovery but in 1982 is wife Phyl also suffered a stroke, and thereafter they lived quietly in retirement until his peaceful end. He is survived by Phyl and their daughter Judy.
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