DESIGN OF DRESSING STATIONS - BMJ

DESIGN OF DRESSING STATIONSAND CONTROL OF. WOUND. INFECTION

BY

WILLIAM GISSANE, A. A. MILES and R. E. 0. WILLIAMS

From the Clinical Staffand Medical Research Council Unit, Birmingham Accident Hospital

IntroductionIn spite of the recent advances in the treatment

of wounds by antiseptic and chemotherapeuticagents, the aseptic treatment of wounds still remainsthe most effective way of controlling the infectionthat may occur during treatment. Aseptic tech-nique is seen in greatest elaboration in the operatingtheatre, but theatre technique is obviously im-practicable in wards, out-patient departments andfactory surgeries, where asepsis is nevertheless ofequal importance. Simple and practicable pre-cautions can be devised for these places. However,recent surveys in wards and out-patient departmentshave revealed a high incidence of wound infectiondue to defects in the aseptic dressing of the wounds(see M.R.C. War Memo. No. 6). The defects are

not altogether due to the difficulties of surgicalpractice or the greater frequency of dirty anddamaged wound tissue in war-time; defectiveaseptic techniques can also be found in civilianpractice where peace-time conditions prevail.The appearance of gross and sometimes fatal

sepsis can be traced in many instances to infectionof the wound during its treatment. In industrythese cases are .referred to hospital, with the resultthat sepsis of industrial wounds looms large inhospital practice, but does not strike the factorystaff as anything more than a rare occurrence.Many wounds are already septic when first seen inthe factory surgery, but a proportion of open

wounds become septic during treatment. It hasbeen argued that this latter sepsis is not due to any

gross breaches in aseptic precautions, but to acci-dents whose prevention could be achieved only byimpracticable elaboration of the routine of treat-ment. The argument is, we think, invalid, becausethe incidence of sepsis can be reduced by simplerevision of dressing technique. But even if it were

valid, there would still be a strong case for a carefulreview of existing methods, for obvious sepsis is notthe only result of cross-infection of wounds. Ourrecent bacteriological survey of wounds in factorysurgeries and out-patient departments (unpublished)has shown that from 30 to 40 per cent. of all clini-cally clean wounds more than one day old are

'silently' infected, usually with Staph. aureus and

sometimes with Str. pyogenes. The results ofsepsis are well recognized: quite apart from frequentpermanent disabilities, the sepsis is responsible forprolonged attendance at hospital and prolongedabsence from work. Similarly, but to a lesserdegree, silent infection prolongs the period of treat-ment of the wound. For example, the mean durationof hospital treatment of 188 minor sutured woundsof the hand, classified into clean, silently infected,and clinically septic, was as follows:

Clinically and bacteriologically clean(80 cases) .. .. .. .. 15 6 days

Clinically clean, with 'silent' infection(58 cases) . .. .. 182 days

Clinically septic (50 cases) .. .. 25-4 days

Taking these small wounds as an example, it isobvious that the time, both patient's and hospital's,that would be saved by elitninating silent infectionof a wound is not great (about 18 per cent.). Butthe saving, even in patients with such wounds,becomes highly significant when we consider theincidence of silent infection and the total number ofwounds which may be silently infected. The silentinfection rate may be as high as 40 per cent. and,as an example of the number of wounded personstreated, we may quote figures from a group oflarge factories employing 103,000 workers, where,in 1942, no less than 430,310 first dressings and615,333 redressings were performed. (Dr. DonaldStewart, personal communication.)

Silent infections occur in all kinds of wounds andmay have other consequences beside that of delayedhealing. For example, in our view it is not un-reasonable to attribute to it a common feature ofmany wounds said to have healed by first intention.These wounds, after a period of healing unaccom-panied by sepsis, develop a scar which remains redand swollen, and which may for months be sotender as to constitute a prolonged disability. It ishighly probable that this scar represents a reactionto silent infection; the point is under investiga-tion.

There is another important aspect of silentlyinfected wounds. They are particularly dangerousin a dressing station, whether of factory surgery orout-patient department, because they are unrecog-

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DESIGN OF DRESSING STATIONSnized sources of large numbers of pathogenicbacteria. By definition, they cannot be recognizedclinically, and are consequently treated as cleanwounds. It is a matter of frequent observation thatmedical and nursing staff will treat a series ofapparently clean wounds with no more than themost perfunctory aseptic and antiseptic precautionsfor each patient, and with none whatsoever toprevent the spread of hypothetical infected materialfrom one patient to the next.The rapid succession of patients with silently

infected wounds in a busy dressing station meansthat a large reservoir of infection is constantlypresent. A good dressing technique must thereforeminimize the incidence of clinical sepsis, which maybe small, and of the silent infection, which con-stitutes, numerically at least, a bigger problem.

Unfortunately, the reduction of silent infectioncan be demonstrated only by a bacteriological studyover a long period. But wherever we have madethese studies we have found a high incidence ofadded silent infection, a fact which suggests thataseptic routines as generally practised could begreatly improved in this respect.The possible sources from which a wound may

become infected with Staphylococcus aureus andStreptococcus pyogenes are: the nose, throat andskin of the patient himself or of the nurses anddoctors who attend to his wound, and, in thefactory surgery and hospital particularly, infectedwounds of other patients. The occurrence ofwound to wound infection has been attested byseveral recent reports (Miles et al., 1940; Spooner,1941; McKissock, et al. 1941) and McKissock et al.were able to show that it could be controlled bythe introduction of a dressing technique designedto minimize the transference ofpathogenic organismsfrom one wound to another. We have been ableto confirm these observations (Williams, Clayton-Cooper, Howat and Miles, unpublished).We recognize that the maintenance of a com-

pletely sterile wound is an unattainable ideal.Infection depends both on the susceptibility of thetissues and the dosage of pathogenic bacteria intro-duced into them. The treatment of the woundhelps to reduce its susceptibility to infection.Aseptic measures, by eliminating several of themore important sources of infection, reduce theinfecting bacteria to numbers that the tissues canovercome.

Routine of Wound DressingThe best general method of reducing added

infection is by revision of the dressing technique.We use the word 'revision' rather than ' improve-ment ' or ' elaboration ' because, from observationof a large number of dressing stations, it is clearthat though some preventive measures are inade-quate, others (e.g. ' scrubbing-up' instead of theuse of dry hands and a ' no-touch' technique) areunnecessarily elaborate. In many cases, the routinecan with advantage be ' rationalized ' and the time

thereby saved is more than enough for takingadditional aseptic precautions.For the most part dressings are, from a bacterio-

logical point of view, either carelessly or very badlydone. A careful scrutiny of any routine will yielda list of preventable breaches in the anti-bacterialprotection that it is supposed to afford. But tooffer a list of remedies to a busy medical staff is, onthe face of it, to offer an additional burden of work.The minutiae of the aseptic routine and the thera-peutic manipulations are already reduced to apracticable minimum. The staff is not prepared tospend time on improvements whose value only along-term application will reveal.The problem, therefore, is to introduce a dressing

routine which respects silent infection as well asobvious sepsis without increasing the time spent oneach patient, and its solution lies in the analysis ofexisting routines from the standpoint of functionalefficiency. Most dressing stations are no morethan rooms furnished with a number of medicalappliances-trolley, sink and perhaps sterilizer-placed without much regard to their function. Ifthe wash-basin is 12 feet from the patient anddressing trolley. the wash-basin tends to drop outof use. If the sterilizer is relatively inaccessible,either the sterilization is omitted or it is done badlyon the trolley with far too dilute antiseptic.The main routes of added infection. are: (a) the

hands and pocket scissors of the dressers; (b) thetrolley instruments; and (c) 'clean' dressings,lotions and their containers, all of which may havebeen contaminated in bulk when portions areremoved by contaminated, hands and instrumentswhile a dressing is in progress. Carriage of infec-tion on the hands can be prevented by washing aftereach dressing, and contamination on scissors bykeeping them in antiseptic.

Contamination of clean dressings in bulk can beavoided in many ways. The single-handed dressermay use packets containing enough material for onewound, though this method is time-consuming forlarge numbers of small wounds. Alternatively,before each dressing the requisite amount of materiaIcan be gathered in a sterile bowl with sterile instru-ments from the clean store. This we term the' cafeteria' method. The required aseptic con-ditions can also be achieved by the provision ofcontainers for bulk dressing material that allowwithdrawal under sterile conditions without lid-lifting, etc.-' safe-sampling' containers. Thedesign of such a container is under consideration.Two nurses may act as dresser and server. The-

server hands to the dresser everything required fromclean stocks, and never comes into contact withinfected material. She also looks after the trolleysupplies for each dressing and supervises thesterilization of instruments, etc. One server cansupply two or perhaps three dressets in a dressingstation working to full capacity.We will consider first the single-handed dresser,

and later the modifications required for dressingteams of two or more. The ideal dressing routine

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BRITISH JOURNAL OF INDUSTRIAL MEDICINE

for an open wound is briefly: setting of the dressingtrolley; removal and safe discard of soiled dressings;inspection and toilet of the wound; dressing of thewound with clean material; cleaning and steriliza-tion of instruments, bowls, etc., used in the dressing;washing of the hands; and, finally, recording thetreatment of the patient. In practice, the routineis often: unbandaging and inspection of thewound; selection of material; toilet and dressingof the wound; recording of treatment; clearing upof soiled and unused dressings; and, finally, pro-ceeding to the next patient.The requirements for the ideal procedure are

briefly as follows:1. Trolley, with sterile or 'clean' (where 'clean'

means 'free from pathogenic bacteria ') dressingmaterials, preferably in safe sampling containersfrom which portions can be taken without con-taminating the whole store.

2. A near-by deep and capacious discard bin.3. Sink for washing instruments.4. Sterilizer.5. Wash-basin (may be the same as No. 3).6. Records desk.7. Cupboard or shelves for spare dressing stores,

etc.In factory surgeries a good deal of dirty material

on wounds might be removed by the patient him-self, and a separate patients' wash-basin and discardbin, to facilitate preliminary cleansing of the partssurrounding the wound, might be added to the list.

Lay-out of the Dressing StationThe awkwardness of the design of existing dressing

stations, for the purposes we have outlined, isexemplified in Plans I-VI, which are based on someof the surgeries we have visited. They are self-explanatory. The seven essential pieces of furni-ture are indicated, where they exist, by the numbersgiven in the above list of requirements. The orderis that in which the different pieces of equipmentwould be used during a wound dressing properlycarried out in the way outlined above. The bin,No. 2, will not be found in most of the diagrams;soiled dressings were usually discarded into ashallow bowl kept on the lower shelf of the trolley,of such capacity that it was filled to overflowingafter half an hour's continuous work. In the plansthe path followed by the nurse is shown by thecontinuous line with arrows, that followed by thepatient by the broken line.

Surgery I is shown twice. In Ia the path takenby the dresser during her routine is plotted; in Ib,the path she would have taken if following the'ideal' routine. In II, III, IV, V and VI the pathsare those necessary for carrying out the 'ideal'technique. The path in most instances includes avisit to the store cupboard. In practice, the pathsusually lay between the dressing trolley and therecords desk (1 and 6), and a glance at the plans ofthese surgeries shows that even for the practice ofan inadequate dressing technique, the lay-out is notefficient. In the treatment of 40 patients in one

morning, a nurse might walk at least an unnecessaryhalf mile.

Plan VII represents a hypothetical small surgery(12 feet by 12 feet) where this movement is reducedto a minimum. The principles of its layout are:

1. The essential pieces of furniture are gatheredaround the dresser, in the best light, and away fromthe door. They are placed so th4t the dresser,when standing ready to deal with a patient, has totake a maximum of one or two paces to reach thetrolley, the records desk or the wash-basin andsterilizer respectively.

2. Where movement about the surgery is essentialthe patient, rather than the dresser, does the walking.But the plan is so arranged that at no point doesthe track taken by the patient from door to waitingbench, to his wash-basin, to the dressing chair andout of the room again, cross that taken by the nursein carrying out her duties as a dresser.A second wash-basin is provided for patients. A

third is placed near the couch, so that if dressingsare to be done on a recumbent patient, a bacterio-logically safe unit is constituted by moving thetrolley over to the couch side. The line around thecouch indicates the position of an overhead trolleyrail from which depends a curtain that can be drawnat will around the couch.

Plans VIII and IX show respectively an out-patient dressing station and a ward side-room atthe Birmingham Accident Hospital, which weredevised by the application of the principles outlinedabove. Plan VIII was designed to accommodate adoctor and his secretary, four nurses (two acting asdressers and two as servers) and two patients atone time. Each member of the staff has readyaccess to his work and to a wash-basin. Theservers work outside the low walls WW (5 feethigh), passing clean material through one hatch,and taking soiled instruments, etc., through another.The dressers work from a fixed dressing bench.Dressings are discarded into a bin in an enclosedcupboard under dressing slab. The bin is removedfor emptying through a door outside the dressingstation. The doctor sees each patient with nomore movement than the turning of a swivel chair.Should he handle a wound, the wash-basin is imme-diately behind him for his use. The paths taken bythe dressers and by the patients are plotted in theplan.

Plan IX is of a side-room of a ward used mainlyfor patients with septic wounds of the hand, adaptedto the needs of a four-nurse team dressing technique.The team consists of two dressers, a server and arunner. The dressers share one trolley. Here thefunction of the dressers is simpler than in a factory,since there are no records to be written during thedressings. This arrangement has been in use for14 months, and, once the nurses had learnt theirrespective duties in the team, proved to be generallyas well as bacteriologically efficient.

Factors Determining DesignThe factors that must be considered in designing

a dressing station comprise those which are common

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PLAN Ia. PLAN lb.

PLAN II.

FEET:-

PLAN III.

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PLAN IV.

RECORDS srOCK FOOT SINK,6 BOTTLES, BATH 3, S

I.

CURTAIN

COUCH

PLAN V.

PLANS I-VI.-Sketch Plans of Factory Surgeries.Broken line shows path followed by patient. Con-tinuous line shows path of nurse doing one dressingwith the ' ideal ' routine described in the text (exceptin la, where it shows the path that she actuallyfollowed). Surgeries shown in I, II, V and VI were

staffed by one nurse only; III and IV by two to threenurses. Lighting was artificial in I1, IV and VI; Ihad a skylight; III and V had windows. Forkey to numbers, see text.

WINDOW WINDOW

.FEEr -

PLAN VII.-Plan of suggested lay-out for surgery, staffedby one nurse, based on principles discussed in text.

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DESIGN OF DRESSING STATIONS

TO DRESSING STATIONS FOR MORE COMPLICATED?I ORESSINGSI /

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IPLAN VIII.-Part of the New Out-Patient Department, Birmingham Accident Hospital.

to works surgeries and to hospital departments, andthose which are, for the most part, peculiar toworks. The list that follows is not intended to becomprehensive in respect of works factors; we donot as yet know enough about them.

1. Geographical.-The dressing station must bereadily accessible. The number of injuries per

WINDOW WINDOW

H- HAND-REST I

PLAN 1X.-Ward Dressing Station, Birmingham Acci-dent Hospital, for two dressers working simulta-neously.

person per month reported in a works surgery thatwas not more than 50 yards from the remotestworker, was 4-5 times the number in a comparableroom (in a factory doing similar work, under thesupervision of the same medical officer) where someof the workers had to walk 10 minutes to get to it.(Dr. E. H. Capel, personal communication.)Stairs, and a walk in the open air, are also said todiscourage attendance.

2. Structural.-The rooms should be spaciousenough for the staff and work intended. Daylighting is preferable, but good artificial lighting,especially fluorescent tubular lighting, is satisfactoryfor minor surgical manipulations.The position of the doors and windows in the

room is usually fixed. The dressing area, wherethe essential furniture (1-6 in the list above) will bedisposed, should be as remote as possible from thedoor, and placed so that the path taken by theingoing and outgoing patients does not cross thepath taken by the nurses. In larger dressingstations, designed for more than one dresser withservers, the design must ensure that the paths ofthe servers and dressers do not intersect more thanis necessary. If the dressing area can be placedunder a window, so much the better; but day-lighting should be sacrificed to drainage. Thesacrifice is often necessary, for water points anddrains, being expensive to alter or-extend, oftendefine the position of the sinks and wash-basins,

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and it is part of our thesis that awkwardly placedbasins frequently determine that omission of handwashing and instrument cleansing which consti-tutes the largest gap in the defence against surgicalinfection. In general, the wash-basin and sinkshould be close together, and in the middle of thewall along which the supply of drainage and Waterpoints is most convenient. From that fixed pointthe remainder of the dressing area may be planned.The table with the sterilizer adjoins the sink againstthe wall. A shallow stock cupboard hangs at facelevel above the basin and sink. The dresser willwork with her back to the hand-basin and sink,with the dressing trolley, discard bin and recordsdesk conveniently disposed at one side or the other.The patient's chair is immediately in front of thedresser. The records desk should be at standingheight (a foot rest for leg injuries is convenientlystored under it). The records desk accommodatesthe day sheet, special sheets, certificates, etc. Inlarger surgeries there may be a single records deskor office, in charge of a clerk, and here it is moreconvenient to give each patient a small card uponwhich all his notes are written. In such a case onlya small records desk is needed, or a small hingedflap may be added to the dressing trolley to accom-modate the individual cards.The trolley should be on wheels, so that it can be

moved, if necessary, to a couch in the cubicle. Thecurtained cubicle, if it is far from the hand-basin,should be provided with a separate hand-basin. Ifpossible, the curtains should run on suspendedtrolley rails, so that the floor is not encumberedwith upright rail supports.

3. Social Considerations.-In many factories,especially those that in peace-time employed women,there is a strong tradition of segregation of the sexesin a surgery. In others, the practice is similar tothat of hospital out-patient departments, wherethere is no segregation. The manipulations thatrequire exposure of the covered parts are carriedout in a cubicle. The cubicle method, however, isoften inconvenient, for either the whole parapher-nalia of trolley, etc., must be taken over to thecubicle, or the dressing done by an imperfecttechnique. It seems to us that the principle of adependent curtain rail, suspended at a height of6 feet 6 inches along the periphery of the dressingarea nearest to the waiting patients, round which aneasily running curtain might be drawn to secludethe seated patient deserves trial as a convenient andtime-saving device. It has the advantage that insmall surgeries, the cubicle, which usually containsthe couch, is left free for patients suffering fromfaints, shock and other medical conditions needingrelatively long treatment.The provision of a basin at which the work-soiled

patient can give himself a preliminary wash workedwell in one factory surgery we inspected, but its usemust be carefully supervised and individual towelsmust be provided; otherwise it might become apotent source of cross-infection of wounds.

4. Technical Considerations.-In the small surgery,

where simplicity of procedure is essential to a rapidturnover of patients without too great a lag at therush hours, several technical improvements on theusual procedure are possible. Among these wemay note:

(a) The provision of readily sterilizable liddedbowls in which dry, sterile instruments anddressings may be stored.

(b) The provision of safe-sampling containers forsterile dressings, gauze, lint and wool.

(c) The provision of vessels delivering requiredquantities of sterile fluids, i.e. 'safe-sampling' fluid containers.Both (b) and (c) are required for the

cafeteria technique.(d) Reduction of the multiplicity of cleansing

lotions, antiseptics and therapeutic sub-stances, applied to the wound. The averagedressing trolley would be large enough forthe proper practice of aseptic rituals, if itwere not crowdedwith bottles and ointments.Most trolleys resemble a well-stocked cock-tail bar.

(e) The provision of easily applied, flexible, oc-clusive dressings that do not require renewal.A man at work with a hand wound, whichrequires elaborate dressing, may return tothe surgery every two hours for rebandaging,especially if he is working with fluids.

In collaboration with the hospital staff, industrialmedical officers and nurses, we have attempted someof these technical improvements, but more investi-gation is required to define the most satisfactorymaterials for the initial cleansing of the wound, foruse as an antibacterial dressing, and for the immo-bilization and cover of the wound.As an example of the application of the principles

enunciated above we may describe in some detailthe reorganization of a temporary dressing stationat the Birmingham Accident Hospital used for out-patients with established sepsis of wounds (Plans Xand XI). Between 9 a.m. and 1 p.m. some 60-80patients are seen and treated in the dressing station.In all cases the wound has to be inspected by adoctor; treatment may be simply a dressing, or mayinvolve a preliminary soaking in a bath.

Plan X shows the original lay-out of the station.The general arrangements were as follows:

1. Patients entered by the door and sat on thebench (A) where they removed their dressings andput them in a large bin.

2. Patients were seen by the doctor (B) at a tablenear the middle of the room, and remote from awash-basin and the light.

3. Having seen the doctor and had a temporarydressing, in the form of a piece of gauze, put ontheir wounds, the patients waited for their dressingson the other bench (C).

4. Dressings were done by two nurses working ata table near the window and wash-basin (E). Theyused the 'cafeteria' method. As will be seen fromthe plan, there was great congestion at this end ofthe. room, in part because there were so many

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DESIGN OF DRESSING STATIONS

WI NDOW

PLANS X and XI.-Part of a temporary Out-Patient Department, Birmingham Accident Hospital, beforeand after reorganization. For key to letters, see text.

people congregated in a small area, and in partbecause the route taken by the patients crossed thatfollowed by the nurses in taking instruments to thebasin and sterilizer. The congestion was accen-tuated by the practice of having a runner to helpwith the bandaging, so that when the wound toiletwas finished the patient had to move to anotherseat for bandaging.The disadvantages of the plan may be summarized

as, firstly, that the doctor saw the patients in asituation where the light was bad and whence, toget to a wash-basin, he had to go right through thecollection of nurses and patients at the dressingtable; and secondly, that the dressings were done,though near a wash-basin, in an area which madecongestion inevitable. The result was that thenurses were unable to keep pace with the flow ofpatients, and a queue formed in the middle of theroom.The principles set out for the model factory

surgery had to be modified somewhat in this case,since all patients were to be seen by a doctor beforethe wounds were dressed by the nurses. Neverthe-less, the requirements were similar: all who haveto handle wounds must be near a wash-basin; thedressings must be done near to the sterilizer; thepaths followed by the patients and nurses must notcross; and inspection and treatment of woundsshould be done in a good light.The alterations made in the dressing station are

shown in Plan XI. New wash-basins were insertedat (F) and (G) and the sterilizer was transferred toa table between them. This was then made thefocal point for the dressers, a table being arrangedH

at (H), so that the nurses had access to basins andsterilizer, while the patients could easily reach theirchairs. The team method of dressing, with a server,was introduced. The doctor's desk was transferredto the position (L) where he was under the windowand near a wash-basin. Patients waiting to seehim had plenty of space at (M), while those whohad seen him and were waiting for dressings, couldsit along the bench (N). A comparison of theroutes followed by patients and staff on the Plans Xand XI demonstrates the simplification achieved onpaper, and this had been borne out in practice; thenurses are able to follow the safer dressing techniquewhile taking less time over each patient.

Summary and ConclusionsAdded infections during the treatment of wounds

in a factory surgery produce manifest sepsis in afew cases and silent (clinically inapparent) infectionsin a much larger number of cases. Silent infection,which may be present in up to 40 per cent. of thewounds treated, not only delays healing but alsocreates a large reservoir of organisms capable ofinfecting clean wounds treated in the same surgery.Aseptic technique must therefore be designed toprevent cross-infection of wounds from thosealready septic or silently infected. Relative freedomfrom manifest sepsis is not a safe indication thatthe aseptic routine in use is fully efficient.

Aseptic techniques are often defective because theplan of the dressing station makes the practice of acompletely safe routine unduly laborious. Arevision of the technique usually implies a redesignof the dressing station.

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We have discussed the requirements of a dressingstation which would allow the easy performance ofa safe routine. The plan should be such that thedresser works conveniently close to the patient, thewash-basin and sterilizer, and the records desk, andthat all unnecessary movements of the dresser are

~eliminated. Reorganization of a hospital dressingstation along these Iines enabled the staff to carry

-out a revised and safer dressing technique, with a

decrease in the average time spent on each dressing.Our detailed recommendations are, for the most

part, trite, but we have so frequently observed theinconveniences which they are intended to remove

that we have no hesitation in making them explicitly.We have also borne in mind that the factory surgery

is used for other purposes beside wound dressing.The application of the principles of dressing stationdesign need not interfere with-other functions ofthe factory surgery.

It should perhaps be emphasized that we considerthe proper design of dressing stations to be a pre-

liminary step in the control of wound infection.Only when added infection is minimized can theoptimum methods of treatment of both clean andinfected wounds be assessed with any confidence.

AcknowledgementsWe are greatly indebted to the medical officers

and nursing staffs of a large number of factorysurgeries for co-operation in our survey and formuch practical advice; and to our colleagues at theBirmingham Accident Hospital for their help.

REFERENCESMcKissock, W., Wright, Joyce, and Miles, A. A. (1941).

Brit. med. J., 2, 375.Medical Research Council. War Memo. No. 6. 'The

Prevention of Hospital Infection.' London,H.M.S.O. 1942.

Miles, A. A., Schwabacher, Herta, Cunliffe, A. C., Ross,J. P., Spooner, E. T. C., Pilcher, R. S., and Wright,Joyce (1940). Brit. med. J., 2, 855, 895.

Spooner, E. T. C. (1941). J. Hyg., Camb., 51, 320.

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DESIGN OF DRESSING STATIONS - BMJ