The Chirgwin Correspondence
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Fluck, D. C., Taubman, J. O., Cleland, W. P., Mounsey, J. D. (1966)Lancet, ii, 1052.
Goodwin, J. F. (1958) ibid. i, 16.— (1961) Clin. Obstet. Gynœc. 41, 645.— (1963) Lancet, i, 464.— Hollman, A., Cleland, W. P., Teare, D. (1960) Br. Heart J. 22, 403.— Hunter, J. D., Cleland, W. P., Davies, L. G., Steiner, R. E. (1955)
Br. med. J. ii, 573.— Stanfield, C. A., Steiner, R. E., Bentall, H. H., Sayed, H. M.,Bloom, V. R., Bishop, M. B. (1962) Thorax, 17, 9.
Green, L., Oakley, C. M., Davies, D. M., Cleland, W. P. (1965) Lancet, ii,984.
Hallidie-Smith, K. A., Cleland, W. P., Bentall, H. H., Hollman, A., Good-win, J. F. (1968) Br. Heart J. (in the press).
— Dulake, M., Wong, M., Oakley, C. M., Goodwin, J. F. (1967) ibid.29, 533.
— Oakley, C. M., Goodwin, J. F. (1967) ibid. p. 634.Hollman, A., Hamed, M. (1965) ibid. 27, 274.Kerr, W. F., Wilken, D., Steiner, R. E. (1961) ibid. 23, 88.Kulbertus, H., Kirk, A. R. (1968) Br. med. J. (in the press).Melrose, D. G. (1952) Med. Illus. 6, 591.
— Bentall, H. H., McMillan, I. K. R., Flege, J. B., Alvarez Diaz, F. R.,Nahas, R. A., Fautley, R., Carson, J. (1964) Lancet, ii, 623.
— Dreyer, B., Bentall, H. H., Baker, J. B. E. (1955) ibid. ii, 21.Miller, G. A. H., Saunders, K. B. (1968) Unpublished.Morgan, J., Pitman, R., Goodwin, J. F., Steiner, R. E., Hollman, A. (1962)
Br. Heart J. 24, 279.Oakley, C. M. (1968) ibid. (in the press).
— Braimbridge, M. V., Bentall, H. H., Cleland, W. P. (1964) ibid.26, 662.
— Hallidie-Smith, K. A. (1967) ibid. 29, 367.Raftery, E. B., Oakley, C. M., Goodwin, J. F. (1966) Lancet, ii, 360.Smith, D. R., Effat, H., Hamed, M. A., Al-Omeri, M. (1965) Br. Heart J.
27, 604.Smith, B., Umapathy, A., Bentall, H. H., Cleland, W. P. (1965) ibid. p. 618.Wilcken, D. E. L. (1960) Br. med. J. i, 681.
The Chirgwin Correspondence
THIS is the last instalment of the Chirgwin correspondence,which has been extracted from the files of an imaginary regionalhospital board which for many years has been planning theChirgwin District General Hospital.*
22nd December, 1963.To: Oliver Tidy, M.A., F.H.A.,
R.H.B. Secretary.From: Alistair de P. Shacklingbody, A.R.I.B.A.,
Messrs. Coldpotch, Rubble, and Associates,Consultant Architects.
Dear Mr. Tidy,I enclose the sketch plans of Chirgwin District General Hospital.
So that the timetable may not be allowed to fall further behind, 1should be grateful if you could obtain the agreement of your Boardto these plans by lst January.
Yours sincerely,This has been known to happen. The sketch plans have
appeared weeks late and, to make up time, the regional hospitalboard has been asked to agree them in a very short time.Members of the board cannot be assembled overnight and,
as they are the guard dogs of public expenditure, they mus1satisfy themselves, generally through the advice of their seniotofficers, that the sketch plans agree with previous proposals andthe estimated cost is within the limit agreed by the Ministry oiHealth.
* * ’If’
7th February, 1965.To: Dr. R. B. Amos,
From: Mr. A. Urquhart Terrace, M.B., F.R.C.O.G., F.R.C.S.E.,Consultant Obstetrician and Gynaecologist, Royal Infirmary.
Dear Dr. Amos,When speaking yesterday to Mr. Black, the project secretary oj
Chirgwin, I was alarmed to see that the obstetric house-officers anto be accommodated in the general residence. By my measuring-scale, this residence is nearly 400 yards from the maternit)department and is too far away to be acceptable.As you are aware, an obstetric emergency requiring a doctor needs
immediate attention. There should be living accommodation fo]medical staff within the department.The first three instalments appeared on Jan. 6 (p. 39), Jan. 13 (p. 85), anc
Jan. 20 (p. 137).
I do not know if any of my colleagues in other specialties have seenthese plans, but I observe that the surgical wards are 300 yards fromthe residence and the medical wards are 500 yards away. Pity thepatient requiring cardiac resuscitation!Mr. Black suggested that the houseman on call could sleep on a
divan in the doctor’s office. Why should he ? I have two housemenand they take alternate nights and weekends on duty. Why shouldthey be asked to " bunk down " for half their nights ?And if this is to be the Board’s policy for the housemen, how about
my registrar ? Last year, Dr. Koo Whatta would have been able tobe on call from 400 yards away, but he represented his country in theOlympic Games: not all registrars are as athletic.My medical staff must live in, or very near to, the department.
Quite right. The administrators, who go horne at 5.30 P.M.,and the consultants (4.30 ?), must not forget that, in a lineardevelopment, the hospital may well stretch for nearly half a mile.Housemen may argue that they do not wish to live on top of
their work because, inter alia, a mess party can disturb thepatients, but, against this, no one wants to walk (or run)hundreds of yards through the hospital to treat a patient atthree in the morning.
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17th December, 1966.Memo. to Mr. A. Black, A.H.A., Project Secretary.From: Miss Carrie Round, S.R.N.,
Regional Nursing Officer.Please pay particular attention to the siting of electric power points.
Although there appear to be plenty of them on the plans, I want tobe certain that they are all easily accessible and at a convenient height.We do not want to have nurses crawling under beds to plug inequipment. Neither do we want to have to recruit a special race ofgiantesses capable of reaching plugs 8 feet off the ground.Well done, Miss Round. This is a very simple thing to over-
look when one examines plans because, on seeing a plugmarked, one is inclined to believe that it will end up in theright place: a naive assumption. The fault may not be with thebuilding side of the organisation. They may not have beentold the type of equipment which will eventually be in therooms.
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1st April, 1967.To: Dr. R. B. Amos, Senior Administrative Medical Officer.From: Dr. D. Mort-Beet, Consultant Pathologist.Dear Dr. Amos,
I have seen a copy of the architect’s plans for the new post-mortemroom.
I must bring to your notice most forcibly the undesirability ofhaving a w.c. in the dissecting-room. This would be far better placedin the changing-rooms which should, I feel, be placed on the eastside of the department, facing the car park, rather than on the westside by the hearse entrance.So that the undertakers will not need to walk through the changing-
rooms, the hearse entrance could be moved to the north-east corner.This would mean reducing the size of the histology laboratory, but
this loss could be offset by having a split-level room extending above thedissecting-room. This, in turn, would allow more students to attend.
Incidentally, I feel it is ethically wrong to allow members of thehospital management committee into the department, even thoughit is only into a small room marked on the plan by the back door.
Yours sincerely,To: Dr. D. Mort-Beet, Consultant Pathologist.From: Dr. R. B. Amos, S.A.M.O.
Dear Dr. Mort-Beet,I will deal with the main points in your letter.There is not a w.c. in the dissecting-room. Lavatory is the
architects’ word for a wash-hand basin.The present hearse entrance is sited so that it is out of sight of the
rest of the hospital. Were it to be moved to the north-east corner ofthe building, it would be in the direct line of vision of patients waitingin the antenatal clinic and this should be avoided.The histology laboratory cannot be altered to a split-level room as
this will result in the office accommodation above having a ceilingheight of 4 feet.The H.M.C. to which you refer on the plan does not mean
" hospital management committee ", but is a recognised abbreviationfor " housemaid’s cupboard "-in other words, a broom cupboard.
Although I appreciate your anxiety to attain perfection in theplanning of the new post-mortem department, I must remind you
that the architects have now reached the stage where alterations andadditions can only be made at great expense and by loss of valuabletime.
Yours sincerely,Here we have the embarrassing position of a doctor, most
anxious to get the best for himself, who is not completely athome with architects’ plans-an understandable fault, notalways understood by the person concerned. There is, in thisconsultant’s letter, the planner’s nightmare of late suggestionswhich, on the back of an envelope, are simple, but which to theproject team will cause literally months of additional delay, tosay nothing of increased cost.The Senior Administrative Medical Officer has dealt cor-
rectly with the letter.
Extract from the Chirgwin Recorder, dated‘uly 4,1967.TOWN’S NEW HOSPITAL
Dense crowds assembled this morning at the site of the new
Chirgwin District General Hospital to witness Mr. N. 0. Money,the constituency’s jovial M.P., cut the first sod.Mr. Money said what a great honour it was to be present on such
a famous occasion. " I am sure I speak for all Chirgwin," he wenton,
" when I say that we have been looking forward earnestly to thisday. We are," he said,
" I know, grateful to Her Majesty’s Govern-ment for the foresight in allowing this magnificent pile to be builthere in our own backyard, as it were."Mr. Money went on to thank Sir Peter Coldpotch, the consultant
architect, for his finely executed plans which were soon to be con-verted to bricks and mortar. He also wished to acknowledge thelong hours of fine work put in by the local consultants who had givenunstintingly of their precious time to the planning considerations." We are," Mr. Money continued,
proud of our medical servicesin Chirgwin, and this new hospital will make us even more prouder."To applause from the assembled crowd, Mr. Money then formally
cut the first sod.(See Leader: Our Proud Heritage, p. 3, and pictures on p. 8.)
Medicine and the Law
Treatment for Drug Addicts in PrisonON June 11, 1967, a young man of 20 broke into a chemist’s
shop and stole heroin, cocaine, morphine, opium, and six boxesof hypodermic needles. He was a drug addict with one findingof guilt and six previous convictions, including one in July,1966, when he was fined E25 for possessing dangerous drugs.He pleaded guilty at quarter sessions to shop-breaking andlarceny. In his report, the probation officer said that it was
tragic that nothing could be done to help this man, who fullyrealised that he faced a severe sentence which held no hopewhatsoever of a cure when he was finally released, and themedical officer of the remand home said that the only hope ofa cure was long-term detention. He was sentenced to fouryears’ imprisonment, and applied for leave to appeal against it.Lord PARKER, the Lord Chief Justice, said that it was the
kind of case which the court might see on a number of occasions.The applicant was a drug addict, now aged 21, with a numberof previous convictions. It was an alarming case because of thatand because of the views expressed by the probation officerand the medical officer. The recorder had said that borstal
training was not long enough for this offence or for hope of apossible cure, and the court agreed that a long sentence wasinevitable. But the court would like to say that they regrettedthe view taken that nothing could be done for a young man inthese circumstances. They hoped that it would be possible forthe new drug-addiction units now being formed to collaboratewith prison authorities, or for one to be attached to prisonswhere addicts such as this were sent, because it was only rightthat modern knowledge should help to cure such a man, evenif the prognosis was not cheerful. The application for leave toappeal against sentence would be refused.Regina v. Molyneaux. Court of Appeal, Criminal Division: Lord Parker,
C.y., Sacks, L.J., and Ashworth, y. Jan. 17, 1968. The applicant did notappear and was not represented.
Letters to the Editor
BACTERIOLOGY IN THE SURGERY
SIR,-Dr. Clymo and Dr. Hurley (Jan. 13, p. 94), in theirplea for antibiotic treatment of Sonne dysentery and for delay-ing patients’ return to work until they are bacteriologically freefrom infection, voice a widely held view which we think is duefor re-examination.
There is little evidence that antibiotics alleviate the symp-toms of Sonne dysentery or shorten its course. Many physiciansbase their views on experience gained during and after the1939-45 war, often in countries where shigellse other thanShigella sonnei were more common and dysentery was often amore severe form than that currently encountered.l 2 Somemore recent studies 3 4 indicated that antibiotics were of value,but these were in North America where again the patternof shigellosis was different and the infecting organisms werepredominantly Sh. flexneri. In this country, for the past 10
years, 98% of cases diagnosed bacteriologically have been dueto Sh. sonnei and the majority were mild or subclinical infec-tions.
If antibiotics are to be used, several important implicationsmust be considered. Firstly, many current strains of Sh. sonneiisolated in this laboratory are resistant to sulphonamides,streptomycin, and ampicillin, and resistance to tetracyclines isbecoming more common. The choice may therefore berestricted to antibiotics which have not been evaluated in thisrole. Tetracycline is probably the most effective of the thera-pies for which evaluation has been reported, but even if thestrain is sensitive this treatment is not without risk. Hay,5reviewing the side-effects of oxytetracycline therapy in 603patients, recorded 2 deaths from enterocolitis-a death-rate ofabout 3 per 1000. This figure obviously cannot be extrapolatedto patients in general practice, although the two fatal cases werea 2-year-old boy with dysentery and a 6-year-old symptomlesscarrier of Salmonella typhimurium. The death-rate from Sh.sonnei infection is less than 1 per 1000 notified cases, and thetrue death-rate must be much lower than this. Secondly, thereis the danger of inducing transferable drug-resistance, whichmight well be a greater danger to the community than Sonnedysentery. Finally, the cost of treating all cases of Sonne infec-tion with antibiotics would be enormous, and in view of the
present financial difficulties of the N.H.S. we must try to assessin terms of cost-effectiveness the many ways open to us of
preventing death and disease.The other important aspect of the problem is the treatment
of symptomless excretors. The minimal infective dose of Sh.sonnei is very small and it seems likely that symptomlessexcretors will sometimes infect others. However, there is con-siderable evidence suggesting that symptomless excretors con-tribute little to the spread of infection during outbreaks.Davies 6 reported an epidemic in Oxford in which no preven-tive measures were imposed on adult symptomless excretorsother than personal hygiene and found no subsequent generalspread. Ross 7 studied 207 families, each including a positivecase, and found that symptomless excretors played an insignifi-cant part in production of further cases. In a later study Ross 8found that allowing junior and secondary schoolchildren toreturn to school when symptom-free but still positive did notproduce any recognised clinical cases. Even if the symptomlessexcretor is considered dangerous, it is still necessary to knowwhether treatment will curtail the period of excretion, or indeedprolong it by interfering with natural defence mechanisms, as1. Garfinkel, B. T., Martin, G. A., Payne, F. J., Mason, R. P., Hardy,
A. V. J. Am. med. Ass. 1953, 151, 1157.2. Taylor, P. J. Br. med. J. 1959, ii, 9.3. Haltalin, K. C., Nelson, J. D., Ring, R., Sladoje, M., Hinton, L. V.,
J. Pediat. 1967, 70, 970.4. O’Connell, C. J., Kunz, M. L., Hoffman, P. J. Curr. ther. Res. 1967, 9,
468.5. Hay, P., McKenzie, P. Lancet, 1954, i, 945.6. Davies, J. B. M. Br. med. J. 1952, ii, 191.7. Ross, A. I. Mon. Bull. Minist. Hlth, 1955, 14, 16.8. Ross, A. I. ibid. 1957, 16, 175.