INSTRUMENT PACKS FOR THEATRE

1115

Letters

to

the Editor

exhibited obstructive jaundice, a bleeding tendency, and the other signs common to neonatal hepatitis.

While it would be foolish to suggest that all neonatal SURVEY OF CONTRACEPTIVES SiR,ńThe Consumers’ Association has carried out a nationwide survey of contraceptives on sale to the general public. Many interesting facts have emerged, some of which give cause for concern. I should like to draw the attention of doctors to the

discovery that there are over a hundred chemical contraceptives on the market. They are available as creams, jellies, pastes, suppositories (soluble pessaries), foaming tablets, and aerosol foam. Of these, almost half failed all tests for spermicidal activity (the international agreed test for total spermicidal power 1960 of the International Planned Parenthood Federation). In addition, since they are not required to do so by the 1941 Pharmacy and Medicines Act, only thirty-seven-about one in threedeclared their

contents on the container. from those on the approved lists of the F.P.A. Apart and the schedule of tested products of the I.P.P.F., there are no records of toxicity tests and not enough evidence to show that they do not produce vaginal irritation and are not

carcinogenic.

We feel that this is a serious state of affairs and urge that legislation should be introduced to cover this type of " " ilM10’

PHYLLIS M. FRASER Medical Consultant, Consumers’ Association. London, W.C.2. yrhe survey is discussed in an annotation on p. 1107

- ED. L. NEONATAL HEPATITIS SIR,-Your annotation of Oct. 26 drew attention to the interesting study of neonatal hepatitis by Danks and Bodian.1 Their findings confirm that, frequently, more than one sibling may have this disease while no other close relations are affected.

They martial the evidence against a virus aetiology, in particular pointing out that the affected children in a family may be interspersed amongst healthy sibs. Next, they show that these infants are of low birthweight for length of gestation, suggesting that there has been a profound disturbance during foetal life. On the basis of 4 consanguineous unions among the parents of their 45 cases, they suggest that the disease is caused by a mutant autosomal gene in the homozygous form. As they admit, one objection to this theory is the observation that up to half these children recover fully. This paradox-that of an apparently genetically determined disease acting principally in utero-could be quite simply explained in terms of an antibody-antigen reaction similar, if not identical, to that taking place in haemolytic disease of the newborn. Paternal heterozygosity for the antigen would account for the alternation of affected with unaffected sibs. There is considerable evidence to show that hasmolytic disease of the newborn may cause liver damage and a condition which, both clinically and pathologically, mimics neonatal

hepatitis.

The sensitising antigen may be Rh,2 AB0,3 or one of the rarer groups such as Kell.4 It is as well to remember that some of the rarer groups may not yet have been identified. Although Danks and Bodian do not report their haematological findings, they state that 3 of their index cases did have hamolytic disease. Further, a sister of case 40 died as a result of Rh incompatibility. Her very low cord-blood hxmoglobin (2-9 g. per 100 ml.) is significant in that, in my experience, levels of this order are almost always accompanied by liver damage. Had she lived, it is probable that she would have 1 2. 3. 4.

Danks, D., Bodian, M. Arch. Dis. Childh. 1963, 38, 378. Dunn, P. M. ibid. p. 54. Harris, R. C., Andersen, D. H., Day, R. L. Pœdiatrics, 1954, 13, 293. Ivemark, B. I., Hogman, C., Rudert, P. O., Andersen, B. Acta path. microbiol. Scand. 1959, 45, 193.

hepatitis is attributable to haemolytic disease of the newborn, it seems likely that this cause of liver damage receives less attention than it deserves. PETER DUNN. INSTRUMENT PACKS FOR THEATRE SIR,-The excellent article by Mr. Taylor and Dr. Seward (Nov. 16) and your annotation call for some comment. "

Order and quiet around the operating-theatre " are not, you suggest, confined to the world of Walter Mitty and Dr. Kildare, but are commonplace in all operating suites where pre-packed sterilisation is in use. Indeed, so peaceful is the atmosphere that some planners in the U.S.A. look on preansesthetic rooms as an unnecessary luxury. Your comment on pre-packed sterilisation that " The idea is not entirely new " is a masterpiece of understatement; for it has been almost universal practice in the U.S.A. for at least 10 years and I saw it in French hospitals more than 10 years ago. But the remark does illustrate how far behind we have fallen in this country in operating-theatre administration and design. Ignorance of modern practice is all the more disturbing when we are now embarking on an ambitious scheme of hospital construction all over the country. Yet planning of operatingsuites is proceeding in almost complete ignorance of how the system of pre-packed sterilisation works, or what modifications in planning it demands. To suggest that reduction of the risk of airborne infection is one of its main purposes misses the whole point. (Indeed, far too much weight is being given to the problem of airborne infection in current theatre planning. Two-thirds of the operating-suites in this country have no ventilation system or depend on an extractor fan which draws all the corridor dust into the operating area; yet the figures for infection in these suites are often lower than those in the more fortunate suites with a plenum system.) It is true, however, that this system permits considerable economies in floor space and can reduce capital costs-e.g., it would no longer be necessary to equip each theatre with large autoclaves. Economies in staff are also possible; for cleansing and re-packing can mostly be done by unskilled labour. Criticism of the system is mainly theoretical or based on lack of knowledge of theatre procedures. Surgeons do not normally have their " own set of tools " as Taylor and Seward point out. The general sets are common to all surgeons, most of whom do nevertheless have a few special instruments. Preparation of small individual packs for them should present no difficulty. Personal observation of this system for a year confirms the assertion of Taylor and Seward that the dropped instrument is uncommon, probably because nurses no longer have to fish them out of steaming kettles with clumsy Cheatle’s forceps, but there is an advantage in having a small " nash " three-minute autoclave to sterilise any instrument which may be needed. Rather than wait for our new hospitals to appear, only to discover that our operating-suites are incorrectly planned, there are strong grounds for a country-wide modernisation of all operating-suites to include the introduction of pre-packed instrument sterilisation. A recent survey which Miss Reeder, S.R.N., and I have carried out confirms our impression that most operating-suites in this country are substandard and outdated ; they are deficient in ventilation, heating, changing-room, and sterilisation practice, and recovery-rooms and resuscitation units are virtually non-existent. Most management committees and theatre superintendents would welcome steps towards modernisation, but the average management committee could not afford to buy the instruments, let alone embark on a modernisation programme. The only solution is a special Treasury grant for modernisation up to a minimum standard. as

We cannot wait another twelve years whilst new are being built. If we do, it means that many

hospitals

1116

of us will complete our working life in operating-suites that we know are outdated and inefficient, and whose ventilation systems would probably not pass for, the average factory or office worker. If the sterilising equipment is removed from the operating area it is surprising how much extra space becomes available, and ventilation becomes relatively simple. This and intelligent use of prefabricated structures could bring all our operatingsuites up to a reasonably civilised standard and provide working conditions more in keeping with the times and to which the nurses and others who spend their working days in operating-suites are entitled. D. A. BUXTON HOPKIN. HOSPITALS FOR THE SUBNORMAL

SiR,—Dr. Pilkington (Nov. 9) has endorsed my remarks1 on the functions of a hospital for the mentally retarded. As very much in the melting-pot at the moment, should have some idea where we are going. A hospital for the mentally retarded should fulfil three functions.

things I feel

are

we

Firstly, it should provide a high standard of care for those patients who are unsuitable, for one reason or another, to be maintained in the community; similarly beds should be available for short-term care to enable the relatives to have some respite, or to tide them over some crisis (it must be remembered that in dealing with the retarded one has to consider the family as much as the patient). Secondly, the hospital should provide modern diagnostic facilities for all the mentally retarded in its catchment area. This means there should be a good consultant staff covering all the various disciplines of medicine. It should be stated here that it is not possible in an outpatient interview to properly assess a patient-one needs to admit such patients for observation under life situations and school, &c. We here have an active outpatient department and are prepared to admit patients I think outpatient visits for a limited period for diagnosis, &c. are important, since they provide rapport between patient, relatives, and hospital. This also means a close liaison between the local health authority and the hospital service. Thirdly, because research should be undertaken at hospitals for the retarded-because this attracts better staff and promotes the right attitude in all staff-one must not perpetuate unquestioningly the established routine without searching for better methods. South Ockendon Hospital, GORDON DUTTON. Romford, Essex.

SIR9 The article by Dr. Pilkington raises many issues. If we can follow Dr. Pilkington’s argument he advocates the establishment in general hospitals of centres for the investigation and treatment, for a year or two, of the mentally retarded. It is difficult to see the purpose and value of such a centre. If it is for the investigation of patienis, then investigations that are of value can be carried out in an outpatient department, general or psychiatric; only for air-studies and prolonged metabolic studies need a patient be admitted. If the centre is for treatment, then what is Dr. Pilkington doing but setting up another hospital that is likely to have the faults of the hospitals he condemns and few of their virtues ? Such an establishment would but downgrade existing hospitals. statements made by Dr. Pilkington are inThe Mental Health Act, 1959 (which is presumably the one he means), according to him " shifted the emphasis from restrictive custodial care to active treatment based on increased clinical knowledge It did nothing of the sort: it gave the local authorities a few powers and then went on, for the rest of the

Many of the

accurate.

1. Dutton, G. J.

ment.

Subnorm. 1963, 9, 34.

to deal almost exclusively with the compulsory patient’s detention in hospital or under guardianship. We had admitted patients informally long before the Act. It is not true that the large hospitals are usually in remote parts of the country; hospitals of this kind are not found in the centre of cities, but the many hospitals that serve London, Birmingham, Bristol, Leeds, Sheffield (to mention some known to us) are within twenty miles of the city centre, and others are in, or close to, thriving communities. It is not true that " little of the present forward-looking research emanates from these institutions", and writing from a hospital which has departments for research in cytogenetics, biochemistry, neuropathology, and psychology and knowing other hospitals that have similar departments, we can but think that Dr. Pilkington is not fully aware of what is being done elsewhere. Dr. Pilkington’s article might lead one to suspect that his experiences may have been unfortunate ; he is presumably speaking of hospitals he knows; but in condemning the poor he does harm to the better. Had Dr. Pilkington chosen to describe in detail the present work he is doing in Offerton House, the kind of patients he admits, the facilities he provides, the results he has achieved, his article might have commanded more consideration. But he has not done this. His last sentence could be regarded as a sneer at anyone who does not think as he does, and should have been neither penned nor published. We have each a vested interest-a vested interest that the best, according to our lights, is done for our patients.

Act,

JOHN GIBSON St. Lawrence’s

Hospital, Caterham, Surrey.

A. W. GRIFFITHS P. E. SYLVESTER.

DOCTORS FOR NIGERIA

SiR,—Iwas amazed and perhaps just a little hurt when I read Mr. Walker’s article of Aug. 24 to learn that I might be considered to be an expensive luxury. I am the present orthopaedic registrar at Kano, Nigeria, having been seconded by the Royal National Orthopaedic Hospital for a period of fifteen months. Whilst I agree that the secondment scheme provides invaluable experience in orthopxdics, I cannot agree with some of his suggestions and conclusions. of work is such that much of the time the is registrar acting at a consultant level. The Nigerian Government therefore gets a man with training in a specialty at an adequate but not overpaid rate, and I think that it would be nearer the mark to regard it as cheap labour than as an The

amount

expensive luxury. As is well known by all those training in the specialties at home, the competition to sit at the feet of the Masters is excessive. If the would-be specialists from the developing countries are also to join in the rat race, the situation would appear to be insoluble. Whilst a year in Nigeria to

someone

with

an

orthopxdic

background provides a fascinating addition to his experience and training, the same cannot be said for a Nigerian wishing to be trained in orthopxdics in the United Kingdom. In the U.K. he may receive excellent instruction in backache, bunions, osteoarthritis, c.D.H., fractured femoral necks, &c., but he can forget all this when he returns home to lament his lack of knowledge of the treatment of gross deformities, infections of bones and joints, and innumerable other problems, such as prosthetic requirements. I would agree with Dr. Ampofo (Sept. 7) and Professor Field (Sept. 14) that the greatest progress would be made by setting up institutions and professorial units in these countries and by the development of those already in existence. These units should receive all the help that Britain can give both in funds and in the secondment of consultants and registrars for adequate periods. They could then provide, at a relatively small cost, good basic postgraduate training for prospective surgeons and physicians, and instruction in the care of those local conditions which will form the bulk of their practice for the

rest

of their lives.