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explained; it is possible that it is not true dyspnoea, of the type seen with congested lungs, which you get in left-sided heart failure, but dyspnoea in the sense that the effort of breathing in the face of a low cardiac output on exertion is such that the respiratory muscles become tired, and therefore breathing becomes uncomfortable. This is a very unscientific explanation, but I think something of this sort might explain dyspnoea without pulmonary congestion. Dr. FLETCHER: When you observe these patients, they don't in fact hyperventilate but become, as you say, uncomfortable, and they sometimes faint, rather than hyperventilating as this lady definitely did. McIlroy and Apthorp2 studied a number of these cases, and in most of them they did not find gross hyperventilation. Dr. GOODWIN: I think that is true, but on the other hand Davison et al.3 showed some years ago that patients with cyanotic congenital heart disease, usually those with the tetralogy of Fallot, did hyperventilate all the time. They thought this might be related to the reduced arterial saturation. This might explain it. RESPONSE TO GUANETHIDINE Could I raise two more points about the endocardial fibrosis ? First, can this occur simply as a result of heart failure? Second, she was treated with guanethidine, which is a drug which tends to cause a rise in venous pressure and can sometimes apparently put patients into heart failure for inadequately known reasons. I wonder if this could possibly be a factor in causing endocardial fibrosis ? Professor McMicHAEL: I do not think we have any answer to the drug question; certainly hypertensive patients on guanethidine sometimes seem to react in an unusual way, with further exacerbation of cardiac failure. I think Dr. Dollery told me the other day that he thought they were mainly the nephritic ones, or uraemic ones. Dr. SHILLINGFORD: Yes, that is so. The few we have observed have all had a high blood urea. Dr. H. GARLICK (Melbourne): May I ask you, please, what is the connexion ? The other blocking agent, bretylium, has been shown in fact to raise pulmonary artery pressure, and I am just. wondering whether it is known if guanethidine has the same effect. I rather suspect it might. Professor MCMICHAEL: According to the Edinburgh workers, guanethidine intravenously does not raise pulmonary artery pressure.
LocAL PERITONITIS Dr. C. C. BooTH: Could I ask Professor Harrison just one thing about the gut ? You did not show us the mesenteric vessels; were they all right ? Professor HARRISON: I have sections and they were normal. Dr. BooTH: The appendix looks surprisingly uninflamed in the section that you showed us. Professor HARRISON: It was the peritoneal tissues that were immediately adjacent to it. The one I showed you with active fibrin exudate was in fact the mesoappendix. It was on the same section. Dr. BooTH: You are quite sure it was the appendix that was at fault, are you ? Professor HARRISON: And not the tube ? The tube was even more innocent-looking.

Dr. BOOTH: It just seems odd that she should have had a peritonitis due to appendicitis when the appendix seems to have been normal. It is also odd that you could not grow anything on culturing the pus. FOcAL MYOCARDIAL FIBROSIS Dr. J. P. D. MOUNSEY: May I ask Professor Harrison about one point that he raised and indicated he might discuss further-namely, the cause of the small foci of fibrosis that were scattered about within the muscle of the heart ? Were these rather like the scattered fibrosis you sometimes see in the right ventricular hypertrophy of long-standing congenital heart disease ? Were they in any way tied up with the widespread inversion of the T wave, which, Dr. Goodwin has pointed out, is such a constant feature in these cases of pulmonary hypertension, and to thrombo-embolism ? Or were they in some way tied up with fibroelastosis ? Professor HARRISON: I do not know. Professor MCMICHAEL: No obvious coronary artery narrowing ? Professor HARRISON: We positively excluded narrowing of the dissectable levels of the coronary vasculature. We are grateful to Dr. J. P. Shillingford and Dr. B. E. Heard for assistance in preparing this report, and to Mr. W. Brackenbury for the photographs.
REFERENCES

Davies, J. N. P., Amer. Heart J., 1960, 59, 600. Mcllroy, M. B., and Apthorp, G. H., Brit. Heart J., 1958, 20, 397. Davison, P. H., Armitage, H., and Arnott, W. M., ibid., 1953, 15, 221.

A HOSPITAL COLOUR SCHEME

BY

Senior Medical

D. W. A. McCREADIE, L.R.C.P.&S.Ed. Officer, Department of Health, Kuwait

Prior to 1918 colour schemes in hospitals were limited to whitewashed walls above dado height and dark brown below. In the 1920's the introduction of washable paints did not produce any real variation of colour in hospitals, but instead of whitewash a white gloss paint was used, and below dado height some sombre dirtconcealing colour-a dark green or brown. In the early 1930's all-white became a vogue and in the more progressive hospitals white-tiled walls to dado height replaced the sombre colours. The idea behind the earlier scheme was to show up dirt above dado height and so have it removed, and to conceal the dirt below dado height and hope that it would be removed. The report by the Nuffield Provincial Hospitals Trust (1955) devoted a few pages in a comparatively large book to colour and described some limited but successful experiments. Now, as repainting is undertaken, real attempts to make wards and hospitals more colourful are being carried out. The objects of colour in hospitals are: (1) To make the hospital a bright and cheerful place to which the patient can come in confidence, remain in cheerful surroundings, and leave without thoughts of escaping from a dark and difficult period in his life. This aspect of hospital administration was realized in the 1930's, when new hospitals had day-rooms and sun loggias built for the benefit of ambulant patients. (2) To make the

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hospital a pleasant place in which staff can work. Industry has accepted the principle that colour is effective in bettering staff relations and increasing staff efficiency. (3) To ensure that dirt can be seen. It is axiomatic that if dirt cannot be seen it will be allowed to accumulate. The bacteriologist can easily prove the disadvantages of drab colours. A Modern Colour Scheme In 1958, in Kuwait, a modern general hospital was completely repainted inside and outside in modern colour schemes. The hospital is of the pavilion type and has five blocks. It is situated in the desert in its own grounds. The immediate hospital area is well planted for Kuwait, where water is not plentiful, and these small gardens give a welcome relief from the desert sand. The hospital consists of a steel framework with asbestos roofing. The outside walls are of roughcast on cement blocks and bricks. The floors are tiled and the ceilings are of acoustic tiles. Almost all the inside walls and partitions are made of metal panels. There is a long communicating corridor between all the pavilions. The pavilions are 40 ft. (12 metres) wide and have a 10-foot (3-metre) roof overlap on each side. In this type of hospital in this part of the world good day lighting is available throughout thz year. Almost all the work done on colour in hospitals has been associated with mentally ill patients. Since this hospital is used by patients with temporary illness of a physical nature it was not necessary to consider the effects of colour on the psychologically disturbed person. So it was concluded that, if the architect, the engineer, and the doctor agreed, it could be taken that their visual judgments would be compatible with those of the patients. It was decided at an early stage to use a variety of colours in each ward. If complementary colours were used then each would absorb the spectrum components reflected by the other. If contrasting colours were used a better effect would be achieved. The colours for building and decorative paints as accepted by the Royal Institute of British Architects are in common terminology and understood by contractor, doctor, and architect. In the end the subjective type of colour system based on the cards of this colour range was fouLnd to be the best method of attacking the problem. The next problem was the choice of colours. Colour therapy per se has not been considered. Birren (1950), who looked at the problem from the psychologist's viewpoint, found that, in general, potential extroverts prefer exciting colours while potential introverts prefer cool colours. N. A. Wells attempted to determine the moods which people associate with colour-as examples he found that deep orange is the most exciting colour and green the most tranquillizing. In a Massachusetts mental hospital experiments with coloured lights showed that blue, magenta, and yellow in that order had a quieting effect on disturbed patients (Warner, 1949). If the results of these experiments have general application then green and blue and yellow seem to be most satisfactory for hospitals. The principle of brighter wards must be applied to the ten-day patient in a general hospital as well as to the long-term patient, and it needs no psychological
training to realize that drab
colours are depressing and

The Aim in General Prior to painting, some general decisions were reached. In the ophthalmic unit brightness and cleanliness was to be achieved by the use of clean muted complementary colours on the walls and ceilings, and cheerfulness was to be obtained by the use of strong primary colours for the bedside lockers, linen bedscreens and bed-covers, and by painting the shades of over-bed lights in a colour contrasting with the walls. In this unit it was felt that the general effect should be subdued but yet capable of being stimulating to patients in the late convalescent stage. In the medical and surgical units bright primary colours were used on the walls and ceilings and the contrasting colours were supplied by the lockers, linen bed-screens, bed-covers, and over-bed light-shades as before. In general, a stimulating effect was aimed at throughout the patient's stay in hospital. The technical medical services departments, the outpatient department, the main corridors, and the medical administration offices-all virtually public areas-were to be reassuring and stimulating but not disturbing. Clean, clear-cut contrasting colours were used to obtain the desired effects. The architectural idea was to have a light colour on the dark walls appropriate for any combination of contrasting colours for use on the light walls. The whole effect was tied in with the ceiling colour, which, because of the clear-story lighting, increased the sense of spaciousness. The rectangular panel components of the steel partitions invited the use of coloured murals composed of symmetrical and asymmetrical coloured rectangles. This latter effect was used in the children's ward, the main corridors, the laboratory, the pharmacy, and the main office. Throughout the hospital all sanitary annexes and all services rooms and ward treatment rooms have been painted ivory white. All skirtings, where present, have been painted light grey. The frames of all the windows and French windows have been painted white, as have all sanitary fittings. The floors of the hospital are of marled red tiles except in the technical medical services departments, offices, and out-patient departments, where the tiles are marled white. It was decided that bed-frames, bed-screens, over-bed tables, and under-bed chairs in all wards should be repainted in light grey, in case redistribution might be necessary. The lockers were painted in six colours and distributed in proportion to the wards. Linen bedscreens are in several colours, and these, along with the coloured bed-covers and chair-covers, have also been distributed proportionately. To obtain real colour effects one must depend on contrasts, and it is the method of applying the colours, and not the colours themselves, which creates the effect. In general, the advice on the use of brilliant colours in waiting-rooms is good, but it is not so in the out-patient rooms. Patients are there for only a short time, and the staff must be considered: a profusion of primary colours that may be architecturally satisfactory and striking can be more disconcerting than stimulating to the latter. The hospital staff were in general highly critical while the painting was in progress. Fortunately, either their
adaptation to colour was very rapid or the general

light, cheerful colours stimulating.

e.ffect

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was so pleasing that criticism was stilled by the time the project was finished. The colours must be decided by an architect or colour consultant, with a doctor to advise on any necessary adjustments. Considerable latitude is required, since it was found that colours on a small area may be perfect but when used on an extensive wall surface the required effect was lost. The use of different-coloured lockers, linen screens, bed-covers, and chair-covers is the easiest and most satisfactory way of varying the colour scheme in the ward without complete repainting. When the staff tire of one arrangement a simple reshuffling of the lockers, bed-covers, etc., gives a completely different effect. This experiment has shown that a multicoloured system is probably the most effective one for the decoration of hospitals. Pale pastel complementary colours can only be regarded as a sop to modernity and are used by those who are timidly modern. The contrasting element is essential for success.
I thank Mr. B. Hogan, B.Arch., A.R.I.B.A., Chief Architect, Design Section of the Kuwait Public Works Department, who was colour consultant, and the Director of Health and Mr. E. Parry, O.B.E., F.R.C.S., Chief Medical Officer, for permission to publish this paper.
REFERENCES

described a double blind controlled trial of vitamin A carried out by a group of practitioners in Scotland. There was no evidence of benefit from the vitamin. It was decided to forward the following recommendations to the Medical Science Committee for consideration:
(i) The Association should encourage and promote research in those fields not yet covered. (ii) Under the direction of a Steering Committee, a survey should be undertaken and inquiries made: (1) Among general practitioners on the family history and social background of patients attending for treatment for acne, and successful treatment used. (2) Among school medical officers and factory doctors on the incidence of acne in those attending for examination.

ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE

[FROM A SPECIAL CORRESPONDENT]

Birren, F. (1950). Colour Psychology and Colour Therapy. Nuffield Provincial Hospitals Trust (1955). Studies in Function and Design of Hospitals. Warner, S. J. (1949). Psychological Monographs, N301. American Psychological Association.

CONFERENCE ON ACNE
A congress on acne vulgaris was held at B.M.A. House on May 9 under the auspices of the Committee on Medical Science, Education, and Research. It was the result of some observations on the importance of acne in the B.M.A. report " The Adolescent " and the resolution of the Winchester and South Bedfordshire Divisions at the Annual Representative Meeting, 1961. The chairman was Dr. W. N. LEAK (Winsford, Cheshire). After welcoming the members Dr. Leak began by emphasizing that one of the objects of the Association was to " promote the medical and allied sciences." He then pointed out the importance of acne from a psychological point of view, which was quite out of proportion to its severity as a medical condition. He hoped that this meeting might be the origin of some constructive recommendations on the treatment of acne which could be put to the Medical Science Committee. Professor J. T. INGRAM (Newcastle) then discussed the aetiology of the condition both as regards constitutional factors and secondary bacterial infection. Dr. A. J. ROOK (Cambridge) outlined some current research on the structure and metabolism of the pilo-sebaceous follicle and the factors which influenced them. He mentioned work in progress on the acne bacillus which possibly might produce breakdown products of sebum which were themselves irritant to the tissues. In animals it had also been shown that severe dietary deficiency led to profound changes in the metabolism of the sebaceous gland. During further discussion the high incidence of acne in schoolchildren was emphasized, and also the importance of " therapeutic ablution " with soap and water, graded according to the person's skin, in removing excess sebum and keratinous material. Dietary instructions and a suitable local application were also important. Dr. E. v. KUENSSBERG (Edinburgh)

The zoonoses-the infections of man naturally acquired from other vertebrates-become increasingly interesting as their complexity is unfolded, and this complexity is particularly evident in those tropical infections in which not only vertebrate hosts but also arthropod-transmitting agents take part in the seemingly improbable cycles in which Nature indulges. In his address to this Society, at Manson House on May 17, Dr. R. B. HEISCH (Nairobi), who has done so much research to elucidate the zoonoses of East Africa, described his recent work in Kenya on the rickettsiae of tick typhus (Rickettsia conori), murine typhus (R. mooseri) and Q fever (R. burneti), and their hosts. The results were interesting, and in solving some problems they raised others. Complement-fixing antibodies to tick typhus and Q fever, or both, were found in 12 species of rodents and nine species of other wild animals, sometimes in high titre, and both infections were found in ticks, even in the same species of ticks. Wild rodents were obviously important hosts for both these infections, and Dr. Heisch thought that other animals were probably infected secondarily from this rodent source. The cycles in rodents and domestic animals seemed to be rather distinct. Murine typhus, however, presented a different picture. It was an infection of urban domestic rats, and there was little evidence of it in rats from rural areas or in wild rodents. Clinical Significance Sir PHILIP MANSON-BAHR (London) emphasized the importance of these zoonoses as a constant potential menace to man, and, from the point of view of the clinician, stressed the importance of bearing them in mind. He quoted a case in which a probable double infection, partly with a filaria of animals and partly with Q fever, which had long baffled diagnosis, was eventually recognized and treated with
Dr. C. E. GORDON SMITH (London) recalled the position in Malaya, where antibodies to Q fever had been found in 2% of house rats and 9% of forest rodents, and murine typhus in house rats. Tick typhus was transmitted by bite, and murine by inhalation or ingestion of infected flea faeces; this might provide a reason for the different natural history of these diseases. But much remained unknown; it was difficult to estimate flea populations; we did not know the different excretion rates of rickettsiae by the different
success.