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The Use of Isolation Hospitals.
THE USE OF ISOLATION HOSPITALS.
397
of medical and nursing skill in the saving of individual life, which is observed particularly in severe measles and whooping-cough. From the administrative standpoint, difficulties arise from increasing the variety of infectious cases admitted to the hospital. Under the present system these difficulties are already very considerable, as a large number of patients reach the receiving room when diagnosis is in doubt, and a carrier may at any time start a secondary infection in a ward carefully set apart for one type of disease. For these reasons the ideal to be aimed at is the isolation of the patient not only from susceptible persons outside the hospital, but also., so far as may be necessary, to prevent the spread of contagion to other patients in the hospital, even if supposed to be suffering from the same disease. The various means of putting this in practice are set forth in an admirable chapter entitled Measures for the Prevention of Cross-infection in the second edition of Parsons’s " Isolation Hospitals,"partially rewritten by Dr. R. BRUCE Low, who, like his predecessor, did not live to see the completion of his labours. An attractive method of solving this difficulty of cross-infection is that of so-called bedisolation, introduced in the first instance at Fazakerley Hospital by Dr. CLAUDE RUNDLE, and we print this week a record of his recent experience along with similar results obtained at Plaistow Hospital where Dr. DONALD MACINTYRE has carried on the work started by the late Dr. J. BIERNACKI in 1912. The conditions under which bed-isolation is successful are carefully set out in these articles. The essential point is, that while patients can talk to each other there is no other communication of any kind between them. The precautions may sound rigorous and even harsh from the patients’ point of view, and for this reason only children under 12 years of age are admitted at Plaistow to the ward. But in practice the children do not appear to feel the lack of toys, and the lively conversation from one end of the ward to the other testifies to their contentment. On the part of the nursing staff the precautions are simple. The nurse works with bare arms and covered hair, wearing a gown hanging by the patient’s bed whilst attending to that patient, and thereafter straightway washing hands and forearms in running water. Dr. Low remarks in his book that one of the conditions of success in bed-isolation is a specially trained staff of nurses. Dr. RuNDLE and Dr. MACINTyRE make it quite clear that in their experience
advantage
THE
LANCET.
LONDON: SATURDAY, AUGUST 19, 1922.
The Use of Isolation Hospitals. THERE are now in England and Wales over 1000 fever hospitals with an aggregate of more than 37,000 beds, the vast majority of which are allotted to cases of scarlet fever and diphtheria. Typhoid and cerebrospinal fever cases are admitted as they occur, and the beds reserved for small-pox are sometimes used for tuberculosis or convalescing scarlet fever, but practically speaking, nearly one-quarter of urban public health expenditure is on hospital treatment for scarlet fever and diphtheria. To take the most recent figures, last week’s return from the M.A.B. Fever Hospitals gives a total of 4619 patients, classified as follows : diphtheria 2357, enteric 22, measles 138, puerperal 14, scarlet 2046, whooping-cough 13, other diseases 29. Now to keep a child, whether ill or not, in weeks costs something
severely
hospital over
for
a
period
of four
:S12, and the ratepayer
may quite properly inquire whether’he is well served by an expenditure of Is. 4d. a head per annum on simple isolation of all cases of scarlet fever, when mortality of scarlet fever in the metropolitan hospitals has gone down from 10 per cent. in the 70’s to less than 1 per cent. at the present time, the actual mortality being only 38 per million in 1920. Were -this reduction in death-ra,te attributable to the the
case
isolation, it has been well worth the expense in the
past, but for the present there are other and more urgent claims on beds. The question whether the best use is now being made of hospitals for isolating fevers was the subject of a suggestive communication to the recent Congress of the Royal Sanitary Institute by Dr. W. ALLEN DALEY, medical officer of health for Blackburn. The influence of these hospit als on preventing the spread of scarlet fever is presumably small, for children have generally infected other members of the household before removal to hospital. In regard to diphtheria the position is different, for the value of the hospital lies in treatment rather than administration presents no difficulty. Success isolation. Diphtheria remains a grave disease and assumes a highly trained and enthusiastic sister, but hospital treatment is necessary for it, as for the many probationers soon pick up the method. Judging by cases of measles and whooping-cough which develop the results at Fazakerley and Plaistow, a high degree serious complications. From the Registrar-General’s of precision has been achieved. Of 482 cases treated recent return we learn that for the year 1920 the at the latter during the past three years, crossdeath-rate per million living was 191 in the case of infection resulted in seven cases only. At Fazakerley, measles and 117 in the case of whooping-cough, out of a total of nearly 600 infectious cases of all compared with 150 for diphtheria and 38 for scarlet kinds only one cross-infection with chicken-pox fever. The subject was before the recent annual developed. Free ventilation is an important factor. meeting of the Metropolitan Branch of the Society of Windows are kept widely open and both patients and M.O.H.’s, who decided to memorialise the M.A.B. nurses must be warmly clothed. But a high standard on its traditional policy of admitting mild scarlet of ventilation and of conscientiousness in nursingin preference to severe measles and whooping-cough, are of value in themselves, and the extra time and when accommodation is not sufficient to receive all the attention required seem but a small price to pay forpatients. We do not suggest that the sanitary a system which makes it possible for any sanitary authority should or could undertake the isolation of authority to treat within small compass all theall infectious disease in its area, but that its utility infectious cases in the area which need special care. would be greatly enhanced if it undertook to deal with The experimental stage is past, and the time has selected cases of all kinds, putting in the forefront those come for general reform along the same lines. from institutions and very poor homes, the new cases 1 Isolation Hospitals. By H. Franklin Parsons. Second in a locality, and all those of severe type. Apart from edition. Revised and partly rewritten by R. Bruce Low. the question of segregation there is the indisputable Cambridge University Press. 1922. Pp. 281. 25s.
398
DIABETES: SUCCESSFUL RESULTS OF NEW RESEARCHES.
Diabetes: Successful Results of New Researches. I
sugar
THE fact that the pancreas is connected with metabolism cannot well be doubted, since the extirpa. tion of the whole gland, as was first shown by v. MERING and MINKOWSKI, always causes the death of an experimental animal from severe diabetes in a very few days. Further, it is known that the amount of pancreas which is required is very small, since F. M. ALLEN has shown that it is necessary to remove seven-eighths of the gland in order to produce even a mild form of diabetes mellitus. The evidence that the pancreas is a double gland with an internal and external secretion is not so good. The relation of the islands of Langerhans to diabetes mellitus is one which has been much discussed. These are thought by some observers to be mere continuations of the acinous portion of the gland and not definite entities ; but the work of E. L. OPIE, A. WEICHSELBAUM, and the recent studies of M. A. LANE, R. R. BENSLEY, and ALLEN are all strongly in favour of their autonomy. The introduction of better staining methods has shown that the cells of the islands are of two kinds, the so-called a and (3 cells. These cells contain granules which stain differently from those of the acinous portion of the gland. Numerous blood-vessels have, moreover, been traced to the islands, which thus have an abundant blood-supply. Further, when a dog which has only one-eighth of its pancreas intact is overfed with starch or sugar the granules disappear from the &bgr; cells and a vacuole (hydrops of the cell) develops. The nucleus is displaced to one side and finally the whole cell breaks up. ALLEN thinks that, if the process is not pushed too far, the cell may recover. If the cells break up, the island decreases in size but does not disappear because the a cells remain intact and apparently unaffected by the overfeeding with Although this evidence convinces many sugar. observers, it has not convinced all. Thus, SWALE VINCENT, in his recent Arris and Gale lecture,speaking of the internal secretions of the reproductive organs and pancreas, says: " in the pancreas I am not prepared to admit that the islets are organs sui generis, nor am I persuaded that the internal secretion of the gland is furnished solely by these structures." Hitherto the experimental evidence in favour of any internal secretion of the pancreas has not been very conclusive. A. H. CLARK showed that sugar could be metabolised if the heart of the diabetic animal was perfused with a fluid which had passed through the pancreas of a non-diabetic animal, and E. H. STARLING and C. A. LOVATT EvANS produced some effect with extracts of From the clinical side no good results pancreas. have been reported with any kind of pancreatic extract.
Recently F. G. BANTING and C. H. BEST,2 working in Prof. J. J. R. McLEOD’S laboratory in Toronto, have adopted an ingenious method of preparing, the pancreatic extracts. It is wellknown that if the ducts of the pancreas are tied the acinous portion of the gland dies and is gradually replaced by fibrous tissue. The islands, on the contrary, do not seem to be affected at all by this procedure and the animal does not show any signs of diabetes. Similar effects occur when the pancreatic duct is injected with lamp-black and can also be seen in cases of chronic pancreatitis occurring in human beings. BANTING and BEST took advantage of this change in the following way. They tied the 1 THE LANCET, August 12th, p. 313. Jour. of Laboratory and Clinical Medicine, St. Louis, 1922, vii., 1.
ducts of the pancreas of dogs and after an interval of seven to ten weeks removed the pancreas and made an extract of the chilled gland with a neutral solution. This extract, when injected into the veins of a dog whose pancreas has been completely removed, always causes a fall in the blood-sugar and a decrease in the amount of sugar excreted. The extract had to be given every four hours in order to keep the blood-sugar at the normal level, and was effective only when injected intravenously, being apparently inert when given per rectum. No mention is made of its action when given by mouth. The extract can be kept in cold storage without harm for about seven days and is not affected by a weak acid solution. But an alkaline solution, boiling, or incubation with a tryptic extract destroys its action. The action of fresh pancreatic extracts was then compared with those in which the acinous portion of the gland was atrophied. It was found that the fresh extracts also had the effect of lowering the blood-sugar and diminishing the sugar output, but always caused many symptoms of toxicity in the animals and also thrombosis of the veins; and the same unpleasant effects followed injections of pancreatic extracts prepared from the pancreas of animals which had been exhausted as much as possible by secretin injections. Quite recently they have prepared a pancreatic extract from a 5-month bovine faetus and were able therewith to keep a depancreatised dog alive This experimental work thus offers a for 70 days. convincing proof of the existence of an internal secretion coming from the islands of-Langeshans and should serve to satisfy those who doubted the microscopic evidence. The question at once arises whether these extracts of the islands can be used for the treatment of diabetes and thus score a brilliant success such as occurred in the case of myxcedema. BANTING and BEST, together with J. B. COLLIP, W. R. CAMPBET,L, and A. A. FLETCHER,3 have already used the extract on seven cases of diabetes and report a definite improve. ment clinically. So far the details published have been meagre and only one case is given in any detail, The extract caused a fall in the blood-sugar and a decrease in the amount of sugar excreted. Although the extract was given twice a day intravenously for ten days the urine still contained sugar in amounts which varied from 7’5 to 45 g. in the day, in comparison with over 100 g. before the injections were given. The aceto-acetic acid in the urine, however, which was never large in amount, disappeared altogether. As soon as the injections ceased the blood- and urine-sugar increased again. Thus the results on human being with diabetes confirm those obtained in animal experimentation. But the difficulties to be overcome before the treatment can be at all widely used must not be overlooked. The process of preparation from an animal whose duct has been tied some seven weeks earlier and the fact that such an extract only suffices for the treatment of one completely diabetic dog for two to three days makes its preparation in sufficiently large amounts a hard problem. Moreover, since the extract must be given intravenously two or three times a day in order to keep the blood-sugar at its normal level the widespread application of the treat-ment in its present form is not very practicable. Mere problems of technique should, however, be amenable to solution by patient effort. The authors are to be congratulated on making a first-rate contribution to the correct understanding of the pathology of diabetes which may ultimately solve the treatment of the disease.
2
3 Jour. Canadian Medical
Association, March, 1922.
397
of medical and nursing skill in the saving of individual life, which is observed particularly in severe measles and whooping-cough. From the administrative standpoint, difficulties arise from increasing the variety of infectious cases admitted to the hospital. Under the present system these difficulties are already very considerable, as a large number of patients reach the receiving room when diagnosis is in doubt, and a carrier may at any time start a secondary infection in a ward carefully set apart for one type of disease. For these reasons the ideal to be aimed at is the isolation of the patient not only from susceptible persons outside the hospital, but also., so far as may be necessary, to prevent the spread of contagion to other patients in the hospital, even if supposed to be suffering from the same disease. The various means of putting this in practice are set forth in an admirable chapter entitled Measures for the Prevention of Cross-infection in the second edition of Parsons’s " Isolation Hospitals,"partially rewritten by Dr. R. BRUCE Low, who, like his predecessor, did not live to see the completion of his labours. An attractive method of solving this difficulty of cross-infection is that of so-called bedisolation, introduced in the first instance at Fazakerley Hospital by Dr. CLAUDE RUNDLE, and we print this week a record of his recent experience along with similar results obtained at Plaistow Hospital where Dr. DONALD MACINTYRE has carried on the work started by the late Dr. J. BIERNACKI in 1912. The conditions under which bed-isolation is successful are carefully set out in these articles. The essential point is, that while patients can talk to each other there is no other communication of any kind between them. The precautions may sound rigorous and even harsh from the patients’ point of view, and for this reason only children under 12 years of age are admitted at Plaistow to the ward. But in practice the children do not appear to feel the lack of toys, and the lively conversation from one end of the ward to the other testifies to their contentment. On the part of the nursing staff the precautions are simple. The nurse works with bare arms and covered hair, wearing a gown hanging by the patient’s bed whilst attending to that patient, and thereafter straightway washing hands and forearms in running water. Dr. Low remarks in his book that one of the conditions of success in bed-isolation is a specially trained staff of nurses. Dr. RuNDLE and Dr. MACINTyRE make it quite clear that in their experience
advantage
THE
LANCET.
LONDON: SATURDAY, AUGUST 19, 1922.
The Use of Isolation Hospitals. THERE are now in England and Wales over 1000 fever hospitals with an aggregate of more than 37,000 beds, the vast majority of which are allotted to cases of scarlet fever and diphtheria. Typhoid and cerebrospinal fever cases are admitted as they occur, and the beds reserved for small-pox are sometimes used for tuberculosis or convalescing scarlet fever, but practically speaking, nearly one-quarter of urban public health expenditure is on hospital treatment for scarlet fever and diphtheria. To take the most recent figures, last week’s return from the M.A.B. Fever Hospitals gives a total of 4619 patients, classified as follows : diphtheria 2357, enteric 22, measles 138, puerperal 14, scarlet 2046, whooping-cough 13, other diseases 29. Now to keep a child, whether ill or not, in weeks costs something
severely
hospital over
for
a
period
of four
:S12, and the ratepayer
may quite properly inquire whether’he is well served by an expenditure of Is. 4d. a head per annum on simple isolation of all cases of scarlet fever, when mortality of scarlet fever in the metropolitan hospitals has gone down from 10 per cent. in the 70’s to less than 1 per cent. at the present time, the actual mortality being only 38 per million in 1920. Were -this reduction in death-ra,te attributable to the the
case
isolation, it has been well worth the expense in the
past, but for the present there are other and more urgent claims on beds. The question whether the best use is now being made of hospitals for isolating fevers was the subject of a suggestive communication to the recent Congress of the Royal Sanitary Institute by Dr. W. ALLEN DALEY, medical officer of health for Blackburn. The influence of these hospit als on preventing the spread of scarlet fever is presumably small, for children have generally infected other members of the household before removal to hospital. In regard to diphtheria the position is different, for the value of the hospital lies in treatment rather than administration presents no difficulty. Success isolation. Diphtheria remains a grave disease and assumes a highly trained and enthusiastic sister, but hospital treatment is necessary for it, as for the many probationers soon pick up the method. Judging by cases of measles and whooping-cough which develop the results at Fazakerley and Plaistow, a high degree serious complications. From the Registrar-General’s of precision has been achieved. Of 482 cases treated recent return we learn that for the year 1920 the at the latter during the past three years, crossdeath-rate per million living was 191 in the case of infection resulted in seven cases only. At Fazakerley, measles and 117 in the case of whooping-cough, out of a total of nearly 600 infectious cases of all compared with 150 for diphtheria and 38 for scarlet kinds only one cross-infection with chicken-pox fever. The subject was before the recent annual developed. Free ventilation is an important factor. meeting of the Metropolitan Branch of the Society of Windows are kept widely open and both patients and M.O.H.’s, who decided to memorialise the M.A.B. nurses must be warmly clothed. But a high standard on its traditional policy of admitting mild scarlet of ventilation and of conscientiousness in nursingin preference to severe measles and whooping-cough, are of value in themselves, and the extra time and when accommodation is not sufficient to receive all the attention required seem but a small price to pay forpatients. We do not suggest that the sanitary a system which makes it possible for any sanitary authority should or could undertake the isolation of authority to treat within small compass all theall infectious disease in its area, but that its utility infectious cases in the area which need special care. would be greatly enhanced if it undertook to deal with The experimental stage is past, and the time has selected cases of all kinds, putting in the forefront those come for general reform along the same lines. from institutions and very poor homes, the new cases 1 Isolation Hospitals. By H. Franklin Parsons. Second in a locality, and all those of severe type. Apart from edition. Revised and partly rewritten by R. Bruce Low. the question of segregation there is the indisputable Cambridge University Press. 1922. Pp. 281. 25s.
398
DIABETES: SUCCESSFUL RESULTS OF NEW RESEARCHES.
Diabetes: Successful Results of New Researches. I
sugar
THE fact that the pancreas is connected with metabolism cannot well be doubted, since the extirpa. tion of the whole gland, as was first shown by v. MERING and MINKOWSKI, always causes the death of an experimental animal from severe diabetes in a very few days. Further, it is known that the amount of pancreas which is required is very small, since F. M. ALLEN has shown that it is necessary to remove seven-eighths of the gland in order to produce even a mild form of diabetes mellitus. The evidence that the pancreas is a double gland with an internal and external secretion is not so good. The relation of the islands of Langerhans to diabetes mellitus is one which has been much discussed. These are thought by some observers to be mere continuations of the acinous portion of the gland and not definite entities ; but the work of E. L. OPIE, A. WEICHSELBAUM, and the recent studies of M. A. LANE, R. R. BENSLEY, and ALLEN are all strongly in favour of their autonomy. The introduction of better staining methods has shown that the cells of the islands are of two kinds, the so-called a and (3 cells. These cells contain granules which stain differently from those of the acinous portion of the gland. Numerous blood-vessels have, moreover, been traced to the islands, which thus have an abundant blood-supply. Further, when a dog which has only one-eighth of its pancreas intact is overfed with starch or sugar the granules disappear from the &bgr; cells and a vacuole (hydrops of the cell) develops. The nucleus is displaced to one side and finally the whole cell breaks up. ALLEN thinks that, if the process is not pushed too far, the cell may recover. If the cells break up, the island decreases in size but does not disappear because the a cells remain intact and apparently unaffected by the overfeeding with Although this evidence convinces many sugar. observers, it has not convinced all. Thus, SWALE VINCENT, in his recent Arris and Gale lecture,speaking of the internal secretions of the reproductive organs and pancreas, says: " in the pancreas I am not prepared to admit that the islets are organs sui generis, nor am I persuaded that the internal secretion of the gland is furnished solely by these structures." Hitherto the experimental evidence in favour of any internal secretion of the pancreas has not been very conclusive. A. H. CLARK showed that sugar could be metabolised if the heart of the diabetic animal was perfused with a fluid which had passed through the pancreas of a non-diabetic animal, and E. H. STARLING and C. A. LOVATT EvANS produced some effect with extracts of From the clinical side no good results pancreas. have been reported with any kind of pancreatic extract.
Recently F. G. BANTING and C. H. BEST,2 working in Prof. J. J. R. McLEOD’S laboratory in Toronto, have adopted an ingenious method of preparing, the pancreatic extracts. It is wellknown that if the ducts of the pancreas are tied the acinous portion of the gland dies and is gradually replaced by fibrous tissue. The islands, on the contrary, do not seem to be affected at all by this procedure and the animal does not show any signs of diabetes. Similar effects occur when the pancreatic duct is injected with lamp-black and can also be seen in cases of chronic pancreatitis occurring in human beings. BANTING and BEST took advantage of this change in the following way. They tied the 1 THE LANCET, August 12th, p. 313. Jour. of Laboratory and Clinical Medicine, St. Louis, 1922, vii., 1.
ducts of the pancreas of dogs and after an interval of seven to ten weeks removed the pancreas and made an extract of the chilled gland with a neutral solution. This extract, when injected into the veins of a dog whose pancreas has been completely removed, always causes a fall in the blood-sugar and a decrease in the amount of sugar excreted. The extract had to be given every four hours in order to keep the blood-sugar at the normal level, and was effective only when injected intravenously, being apparently inert when given per rectum. No mention is made of its action when given by mouth. The extract can be kept in cold storage without harm for about seven days and is not affected by a weak acid solution. But an alkaline solution, boiling, or incubation with a tryptic extract destroys its action. The action of fresh pancreatic extracts was then compared with those in which the acinous portion of the gland was atrophied. It was found that the fresh extracts also had the effect of lowering the blood-sugar and diminishing the sugar output, but always caused many symptoms of toxicity in the animals and also thrombosis of the veins; and the same unpleasant effects followed injections of pancreatic extracts prepared from the pancreas of animals which had been exhausted as much as possible by secretin injections. Quite recently they have prepared a pancreatic extract from a 5-month bovine faetus and were able therewith to keep a depancreatised dog alive This experimental work thus offers a for 70 days. convincing proof of the existence of an internal secretion coming from the islands of-Langeshans and should serve to satisfy those who doubted the microscopic evidence. The question at once arises whether these extracts of the islands can be used for the treatment of diabetes and thus score a brilliant success such as occurred in the case of myxcedema. BANTING and BEST, together with J. B. COLLIP, W. R. CAMPBET,L, and A. A. FLETCHER,3 have already used the extract on seven cases of diabetes and report a definite improve. ment clinically. So far the details published have been meagre and only one case is given in any detail, The extract caused a fall in the blood-sugar and a decrease in the amount of sugar excreted. Although the extract was given twice a day intravenously for ten days the urine still contained sugar in amounts which varied from 7’5 to 45 g. in the day, in comparison with over 100 g. before the injections were given. The aceto-acetic acid in the urine, however, which was never large in amount, disappeared altogether. As soon as the injections ceased the blood- and urine-sugar increased again. Thus the results on human being with diabetes confirm those obtained in animal experimentation. But the difficulties to be overcome before the treatment can be at all widely used must not be overlooked. The process of preparation from an animal whose duct has been tied some seven weeks earlier and the fact that such an extract only suffices for the treatment of one completely diabetic dog for two to three days makes its preparation in sufficiently large amounts a hard problem. Moreover, since the extract must be given intravenously two or three times a day in order to keep the blood-sugar at its normal level the widespread application of the treat-ment in its present form is not very practicable. Mere problems of technique should, however, be amenable to solution by patient effort. The authors are to be congratulated on making a first-rate contribution to the correct understanding of the pathology of diabetes which may ultimately solve the treatment of the disease.
2
3 Jour. Canadian Medical
Association, March, 1922.