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THE SINGLE-SITE HOSPITAL
416 related to one group of antidepressants, it does not seem to have been used on its own to treat depression. Depression is associated not only with anxiety but also with ideas of unworthiness, of hopelessness, of futility. It has been described as aggression redirected to the self, as self-punishment. If the rat were to have rudimentary equivalents of these symptoms, then depression would also account for the results of the conditioned-avoidance work. Chlorpromazine need not reduce fear of the shock, sometimes referred to as punishment -it increases acceptance. Imperial Chemical Industries Ltd., Industrial Hygiene Research Laboratories, A. P. SILVERMAN. Alderley Park, Nr. Macclesfield, Cheshire.
THE SINGLE-SITE HOSPITAL SIR,-Mr. McGavin’s thesis, outlined in his letter last week (p. 365), in support of large hospitals seems to depend upon the basic assumption that a hospital is " an organisation run by doctors in the interests of their own greater technical efficiency ". This assumption is valid for some of the facilities required for the treatment of damaged human machinery, and would be a good basis for designing such things as an operatingtheatre, a pathology laboratory, and perhaps an intensive-care unit. But a sick person, rightly or wrongly, enters hospital with the assumption that the institution will enable him to " become whole ", and this implies a rather different basis for
planning. Both assumptions-those of patient
as well as doctor-need When hospitals grow larger than 500 beds, the risk of their becoming " impersonal " grows rapidly. No doubt an outstanding administrator, whether medical, nursing, or lay, can do much to minimise this, but such people are rare, and it is not sensible to plan as if they were to be had for the advertising. University hospitals, which have no difficulty in recruiting medical and nursing staff, are not a good guide to hospital planning elsewhere. The availability of part-time married women for nursing duties is likely to be a major consideration in most regional hospitals, and it is wrong to give a hospital more beds than can be staffed: the fact that in a large hospital " cover for shortages caused by holidays, illnesses, and unfilled vacancies ... is less difficult to arrange " merely means that in a large hospital it is easier to pretend you are giving a first-rate service when you
to be taken into account.
are not.
It does not seem reasonable to plan in such a way that patients, who are sick, should have to cope with travelling difficulties, while doctors, who are supposedly healthy, should not. Is it really true that doctors’ time is more valuable than patients’ time ? I think that what may prove to be desirable in the long run is a two-tier hospital system-i.e., a concentration of technical facilities in an " intensive care hospital " with an absolute minimum of beds, surrounded (not on the same site) by a ring of " general care " satellites, which will be designed and administered to meet the personal needs of patients, with technical considerations taking second place. There are plenty of objections to such a scheme from a hospital doctor’s viewpoint, of course. Perhaps it is just a patient’s pipe-dream. Patients would be near their homes and in familiar surroundings. Visiting would be easier, the part-time nurses and domestic staff would be members of their own community. Their family doctors might even be able to drop in to see them, or to have a word with the hospital doctors who were caring for them. But considerations of this kind, which bear upon patients’ morale and thus affect the speed of their recovery, should not be totally left out of account in planning. JAMES R. MATHERS. Birmingham, 31.
SiR,—In advocating single-site hospitals Mr. McGavin has important disadvantages. Firstly, there may be
overlooked two 1.
Main,
T. F. Bull.
Menninger Clin. 10,
no. 3.
overall loss of trained and proficient nursing staff. Our local general-practitioner hospital is mostly staffed by married women who have returned to nursing on a part-time basis. Matron always has several applicants for every vacancy and the standard is very high. These nurses would be reluctant to travel relatively long distances to work and the closing of a local hospital would mean the loss of their services. Secondly, the only hope of ending the present boycott and atrophy of general practice is to establish the principle of free and open access of every practising doctor to the local hospital-but to ensure that
an
this is practicable the hospital
must
be local.
Church Hill,
Camberley, Surrey.
A. M. W. PORTER
THROMBOSIS AND SUPPRESSION OF LACTATION SIR,-You write (Aug. 5, p. 295): " Hitherto, no-one has thought to link these deaths with cestrogen therapy in the puerperium." Four years ago Scott tentatively ascribed one puerperal pulmonary embolism to "intramuscular hexoestrol propionate given to inhibit lactation, as a possible clue to the way to lower maternal mortality figures".’ In calculating the risks of oral contraceptives it is necessary to deduct from attributable deaths the maternal mortality that users would have suffered without oral contraceptives. If puerperal thromboembolism, the cause of 10% of maternal mortality,3 is itself partly due to like medication, the equation alters against both types of hormone preparation considered
together. Oral contraception has to be resumed at some interval after delivery. Three weeks after delivery high-dose but not lowdose oral contraception inhibits lactation 4 ; five weeks has recently been recommended.5 However, 11 out of 71 cases of fatal puerperal pulmonary embolism in 1961-63 occurred at day 28 or later,3 and in a full study the time-relationships between use of lactation suppressants, and use of oral contraceptives should be considered together. As you write, Other groups of patients may be at risk." The first U.K. case of thromboembolism in an oral-contraceptive user was in a patient with endometriosis 6; and four deaths have been reported in the U.K. from thromboembolism in women using oral contraceptives for indications other than (later found to be pregnancy),’7 contraception—amenorrhoea " " menstrual disorder ",9 and fertility.lo ",8 haemorrhage (The third death had a contraindication-varicose veins undergoing injection.") The fourth death calls to mind another group at risk: those taking gonadotrophins for fertility, with one reported death (in Israel).12 Summerfield Hospital, ROBERT J. HETHERINGTON. Birmingham 18.
thromboembolism, "
ŒDEMA IN PREGNANCY
SIR,-Mr. Sophian’s suggestion (Aug. 5, p. 309) that there is excessive sodium retention in pre-eclampsia and that findings to the contrary are fallacious might not have been made if he had consulted my recent publication.13 Briefly this shows that patients with severe pre-eclampsia (hypertension and proteinuria), but without clinical oedema, have an average total body-water much the same as those with a normal pregnancy. 1. Scott, J. G. Br. med. J. 1963, ii, 558. 2. ibid. 1967, ii, 327. 3. Rep. publ. Hlth med. Subj., Lond. 1966, 115, 20. 4. Garcia, C. R., Pincus, G. Int. J. Fertil. 1964, 9, 95. 5. Sharman, A. Lancet, 1967, i, 1163. 6. Jordan, W. M. ibid. 1961, ii, 1146. 7. Baines, C. F. Br. med. J. 1965, i, 189. 8. Birmingham Post, October 26, 1965. 9. Jones, H. O., Townsend, J. C. F., Roberts, J. T. Br. med. J. 1967, ii, 637. 10. Sun, March 3, 1967. 11. Br. med. J. 1965, i, 778. 12. Mozes, M., Bogokowsky, H., Antebi, E., Lunenfeld, B., Rabau, E., Serr, D. M., David, A., Salomy, M. Lancet, 1965, ii, 1213. 13. MacGillivray, I. Scott. med. J. 1967, 12, 237.
THE SINGLE-SITE HOSPITAL SIR,-Mr. McGavin’s thesis, outlined in his letter last week (p. 365), in support of large hospitals seems to depend upon the basic assumption that a hospital is " an organisation run by doctors in the interests of their own greater technical efficiency ". This assumption is valid for some of the facilities required for the treatment of damaged human machinery, and would be a good basis for designing such things as an operatingtheatre, a pathology laboratory, and perhaps an intensive-care unit. But a sick person, rightly or wrongly, enters hospital with the assumption that the institution will enable him to " become whole ", and this implies a rather different basis for
planning. Both assumptions-those of patient
as well as doctor-need When hospitals grow larger than 500 beds, the risk of their becoming " impersonal " grows rapidly. No doubt an outstanding administrator, whether medical, nursing, or lay, can do much to minimise this, but such people are rare, and it is not sensible to plan as if they were to be had for the advertising. University hospitals, which have no difficulty in recruiting medical and nursing staff, are not a good guide to hospital planning elsewhere. The availability of part-time married women for nursing duties is likely to be a major consideration in most regional hospitals, and it is wrong to give a hospital more beds than can be staffed: the fact that in a large hospital " cover for shortages caused by holidays, illnesses, and unfilled vacancies ... is less difficult to arrange " merely means that in a large hospital it is easier to pretend you are giving a first-rate service when you
to be taken into account.
are not.
It does not seem reasonable to plan in such a way that patients, who are sick, should have to cope with travelling difficulties, while doctors, who are supposedly healthy, should not. Is it really true that doctors’ time is more valuable than patients’ time ? I think that what may prove to be desirable in the long run is a two-tier hospital system-i.e., a concentration of technical facilities in an " intensive care hospital " with an absolute minimum of beds, surrounded (not on the same site) by a ring of " general care " satellites, which will be designed and administered to meet the personal needs of patients, with technical considerations taking second place. There are plenty of objections to such a scheme from a hospital doctor’s viewpoint, of course. Perhaps it is just a patient’s pipe-dream. Patients would be near their homes and in familiar surroundings. Visiting would be easier, the part-time nurses and domestic staff would be members of their own community. Their family doctors might even be able to drop in to see them, or to have a word with the hospital doctors who were caring for them. But considerations of this kind, which bear upon patients’ morale and thus affect the speed of their recovery, should not be totally left out of account in planning. JAMES R. MATHERS. Birmingham, 31.
SiR,—In advocating single-site hospitals Mr. McGavin has important disadvantages. Firstly, there may be
overlooked two 1.
Main,
T. F. Bull.
Menninger Clin. 10,
no. 3.
overall loss of trained and proficient nursing staff. Our local general-practitioner hospital is mostly staffed by married women who have returned to nursing on a part-time basis. Matron always has several applicants for every vacancy and the standard is very high. These nurses would be reluctant to travel relatively long distances to work and the closing of a local hospital would mean the loss of their services. Secondly, the only hope of ending the present boycott and atrophy of general practice is to establish the principle of free and open access of every practising doctor to the local hospital-but to ensure that
an
this is practicable the hospital
must
be local.
Church Hill,
Camberley, Surrey.
A. M. W. PORTER
THROMBOSIS AND SUPPRESSION OF LACTATION SIR,-You write (Aug. 5, p. 295): " Hitherto, no-one has thought to link these deaths with cestrogen therapy in the puerperium." Four years ago Scott tentatively ascribed one puerperal pulmonary embolism to "intramuscular hexoestrol propionate given to inhibit lactation, as a possible clue to the way to lower maternal mortality figures".’ In calculating the risks of oral contraceptives it is necessary to deduct from attributable deaths the maternal mortality that users would have suffered without oral contraceptives. If puerperal thromboembolism, the cause of 10% of maternal mortality,3 is itself partly due to like medication, the equation alters against both types of hormone preparation considered
together. Oral contraception has to be resumed at some interval after delivery. Three weeks after delivery high-dose but not lowdose oral contraception inhibits lactation 4 ; five weeks has recently been recommended.5 However, 11 out of 71 cases of fatal puerperal pulmonary embolism in 1961-63 occurred at day 28 or later,3 and in a full study the time-relationships between use of lactation suppressants, and use of oral contraceptives should be considered together. As you write, Other groups of patients may be at risk." The first U.K. case of thromboembolism in an oral-contraceptive user was in a patient with endometriosis 6; and four deaths have been reported in the U.K. from thromboembolism in women using oral contraceptives for indications other than (later found to be pregnancy),’7 contraception—amenorrhoea " " menstrual disorder ",9 and fertility.lo ",8 haemorrhage (The third death had a contraindication-varicose veins undergoing injection.") The fourth death calls to mind another group at risk: those taking gonadotrophins for fertility, with one reported death (in Israel).12 Summerfield Hospital, ROBERT J. HETHERINGTON. Birmingham 18.
thromboembolism, "
ŒDEMA IN PREGNANCY
SIR,-Mr. Sophian’s suggestion (Aug. 5, p. 309) that there is excessive sodium retention in pre-eclampsia and that findings to the contrary are fallacious might not have been made if he had consulted my recent publication.13 Briefly this shows that patients with severe pre-eclampsia (hypertension and proteinuria), but without clinical oedema, have an average total body-water much the same as those with a normal pregnancy. 1. Scott, J. G. Br. med. J. 1963, ii, 558. 2. ibid. 1967, ii, 327. 3. Rep. publ. Hlth med. Subj., Lond. 1966, 115, 20. 4. Garcia, C. R., Pincus, G. Int. J. Fertil. 1964, 9, 95. 5. Sharman, A. Lancet, 1967, i, 1163. 6. Jordan, W. M. ibid. 1961, ii, 1146. 7. Baines, C. F. Br. med. J. 1965, i, 189. 8. Birmingham Post, October 26, 1965. 9. Jones, H. O., Townsend, J. C. F., Roberts, J. T. Br. med. J. 1967, ii, 637. 10. Sun, March 3, 1967. 11. Br. med. J. 1965, i, 778. 12. Mozes, M., Bogokowsky, H., Antebi, E., Lunenfeld, B., Rabau, E., Serr, D. M., David, A., Salomy, M. Lancet, 1965, ii, 1213. 13. MacGillivray, I. Scott. med. J. 1967, 12, 237.