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than full responsibility. The Royal Commission said: 3"it must be accepted that the standards of the professionand the interests of the public require that such doctorsshould be appointed only to posts in which guidance andsupervision are available." This is the painful heart ofthe matter.

Annotations

ACUTE POST-PARTUM RENAL FAILURE:A NEW SYNDROME?

UNEXPECTED post-partum acute renal failure is withinthe occasional experience of many physicians, but fewcan be familiar with this disaster. Robson and his col-

leagues 4 in Edinburgl-- have performed a useful servicetherefore by identifying features common to four suchcases. In no patient was there any apparent precipitatingcause. A normal pregnancy, with no evidence of signifi-cant hypertension or renal disease, was followed by thedelivery of a normal infant. Two to five weeks later, symp-toms of acute renal failure developed, including bothuraemia and fluid retention. The blood-pressure roseappreciably in two cases, but the malignant phase did notsupervene. The hypertension was mild, and clearly theresult rather than the cause of the renal disease. Evidenceof associated heart-disease was always present, and onepatient died in cardiac failure with only moderate urxmia.In the other cases the renal failure developed rapidly, butthen remained almost stationary. One of the two survivorsnow requires regular hxmodialysis, and the other is inchronic cardiac and renal failure.The commonest causes of acute renal failure are prob-

ably acute tubular necrosis and acute glomerulonephritis,but in none of these four cases was there any obvious pre-cipitating cause of either condition. The histologicalfindings in renal biopsy specimens were not characteristicof either disease. All four had thickening of the basementmembrane, proliferation of endothelial cells, focal

glomerular necrosis, and glomerular infiltration with

leucocytes. Red cells were seen in the lumen of thetubules. Electron microscopy showed similar glomerularabnormalities in all cases. The foot processes of the epi-thelial cells were much reduced, but the cause of theglomerular failure seemed to be capillary obstruction bythe deposition of an irregular layer of abnormal materiallying between the basement membrane and the endo-thelial cells. In many places this material, which wasunlike that seen in other renal diseases, had a fibrillarstructure: it seemed to reflect a basement-membranedisorder. A contributing cause of the renal failure wasprobably occlusion by fibrous tisuse in interlobulararteries and in arterioles, presumably the result oforganisation of fibrin.

In two cases there was evidence of haemolysis, and manyof the renal features were reminiscent of the " hsemolyticuraemic syndrome " in children with acute gastroenteri-tis.5 This syndrome may possibly be the result of virusinfection, and the associated myocarditis of the post-partum urxmic patients, together with the acute onset and3. Royal Commission on Medical Education 1965-66; para. 162. H.M.

Stationery Office, 1968.4. Robson, J. S., Martin, A. M., Ruckley, A., Macdonald, M. K. Q. Jl

Med. 1968, 37, 423.5. Gasser, C., Gautier, E., Steck, A., Siebenmann, R. E., Oechslin, R.

Schweiz. med. Wschr. 1955, 85, 905. See Lancet, 1965, i, 588.

apparent arrest, are also perhaps best explained by a virusinfection. Search for evidence of such an infection, how-ever, was negative. An acute immunological disorderseems unlikely, since the renal disease does not progress.The unique association of the highly specific renal lesion

with delivery suggests some common factor of a differentkind. Robson et al. point out that in three of the four cases,and possibly in all four, the patient had had a mixtureof ergometrine and oxytocin (’ Syntometrine ’). These

drugs have been widely used, and adverse reactions mustbe rare; but clinicians who see similar situations in as-sociation with these drugs should report the events aspossible adverse drug reactions. Only thus can the possi-bility of some rare but catastrophic reaction be brought tolight.

HOSPITAL BUILDING: A CASE-REPORT

" To plan a hospital, first take the back of an envelope."This has never, to our knowledge, appeared as the openingsentence of an official directive on hospital planning, buteach hospital building scheme in the United Kingdomhas started from such a baseline. Even within one regionalboard it is almost impossible for one planning group to betotally informed on other, and possibly similar, projectsundertaken by that board. Until the day when standardplanning is agreed and becomes effective, each planningteam will have to face each problem in isolation, backedonly by the personal experience and contacts of themembers. When a new hospital is officially opened, ittakes its place in the statistics of the hospital service, andusually no more is heard of its conception, planning, andbuilding. Subsequent evaluation, if any, is played close tothe chest and is carried out according to the whims of theevaluation-team leader. He, in turn, has had in the past toassess what he found without full reference to what was inthe minds of the planners, for an official brief to thearchitects has only lately become an essential part ofhospital planning procedure. To arrive at worth-whileconclusions on a study of design in use, the evaluationteam must be fully informed of what has gone before.To help combat planning isolation and to ease the burdenof evaluation teams, the King’s Fund has published adescription of the first phase of Wycome General Hospitaldevelopment. 1 The Fund’s aim has been to provide amodel for future descriptions of new hospitals and to en-courage the establishment of a standard reference libraryof hospital planning information. The book gives a shorthistory of the development, followed by a " brief thatnever was ", constructed retrospectively from officialminutes and associated documents. Written by an archi-tect in association with a hospital administrator, and withthe encouragement of the Ministry of Health and thebacking of the Oxford Regional Hospital Board, this workis, indeed, a model. The vital statistics it contains rangefrom the 16,166 spent on work below ground-level in theresidential accommodation to an honourable mention forone gas-heated tilting shallow fryer on a cooking island inthe kitchen. Construction techniques are described insome detail, and the staffing establishment is shown. Thebook contains pictures, plans, illustrations, and maps.Despite the wealth of information, the publication is

eminently readable. Perhaps a breakaway from the

1. Hospital Description: Wycombe General Hospital, Phase One, byJOHN GAINSBOROUGH, A.R.I.B.A., in association with R. E. LINGARD,F.H.A. Published by King Edward’s Hospital Fund for London. 1968.Pp. 131. 17s. 6d.