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icida, and " found dead" . The Irish disease was some-

thing different. It killed a large number of the fish in anaffected river and no-one had seen the like of it. It wascharacterised by haemorrhagic or ulcerated patches onthe skin, mostly on the upper surfaces of the body andoften covered with a layer of fungal growth due to

Saprolegna sp. Pseudomonas spp. and Aeromonas lique-faciens were found in many of these lesions, but theseorganisms are not uncommon on healthy fish of all

sorts, and they probably play no part in causing salmondisease.

The diseases of game animals have had more attentionin the United States than here. The traditions of thefrontier are not extinct, and the pursuit of mammals orfish is a major national interest in which a lot of moneyis involved. It was almost fifty years ago that Davisdescribed a lethal disease of game fish associated with abacterium which he could not grow in vitro but which,in suspension, arranged itself in a palisade of parallelorganisms. Because of this habit he labelled it Bacilluscolumnaris. Later workers have devised a medium whichwill support its growth, but the systematists are still

debating whether it belongs to the genus Chondrococcusor Cytophaga. This organism has been isolated frommany of the diseased salmon during the recent outbreakand, later, from coarse fish in various parts of England.Ajmal and Hobbs 2 give clear directions for its cultivationand recognition, and this should encourage a more exactdefinition of the disease. As a sideline to this inquiry,two other bacteria which seem to cause disease in fishhave been identified.3 One is either a Corynebacterium ora Listeria, the other is allied to Pasteurella.

A knowledge of the causal organism is obviouslythe first step towards some understanding of the pathologyand epidemiology of this disease, but the difficulties areforbidding. The pioneers who studied anthrax couldcount both the dead and the survivors. Some animals

reported dead of anthrax died of other causes, but theycould be distinguished without difficulty. Healthy andinfected animals could be kept in a controlled environ-ment. Materia morbis could be inoculated and theeffects observed. The problems of the piscine pathologistare not so easy. Dead fish are likely to be carried awayby stream or tide, and estimates of mortality must beguesswork. There is seldom a laboratory handy to asalmon river, and postmortem material in a state ofmoderate decay is not satisfactory. Technical difficultiesmake experimental work on salmon almost impossible,but the discovery that the disease may attack perch anddace offers some hope.The first need is to find out how the disease may be

passed from fish to fish and how it spreads in Nature.Will the infection pass through the intact skin or isprevious traumatic damage necessary? Physical contactcannot be excluded as a means of infection, as anyoneknows who has watched the shoals of salmon under thebridge at Galway. That the disease first appeared almostsimultaneously in several adjacent rivers in Co. Kerrysuggested that the infection had begun when the fishwere still at sea. Salmon return to the river where theywere spawned-but not invariably and a few eccentricsseem to try one or more other rivers before they begintheir ascent. Did some of these carry the disease fromriver to river? The almost simultaneous appearance of

3. Ajmal, M., Hobbs, B. C. ibid. p. 142.

the disease among coarse fish in rivers so far apart as theTrent and the Parrett is more difficult to explain. A fewsalmon try to make their way up both these unprofitablerivers, and it is known that birds such as a mallard cancarry weed and aquatic snails from river to river; butsuch guesses do not hold much promise. The epidemi-ology of the disease, so far as we know it, almost suggeststhat a spread from fish to fish may be only a secondaryfactor in its distribution. In the United States thisdisease was associated with especially hot weather: thisdoes not hold good here, but a search for some environ-mental cause is overdue. The specialised methodsneeded to isolate C. columnaris have been applied to

few fish without evidence of this disease. Perhaps it isa not uncommon organism.

CHOICE OF ANTIBIOTIC

RECENT leading articles on chloramphenicol 1 havebeen followed by further correspondence on the use ofthis controversial drug. Its efficacy as a broad-spectrumantibiotic is unchallenged, but there is considerable dis-agreement on its indications and toxicity. While the Foodand Drug Administration in the U.S.A. and the Commit-tee on Safety of Drugs in the United Kingdom havewarned of its serious effects on the bone-marrow, it con-tinues to be widely used abroad. Last year, in a sym-posium on the chemotherapy of infections with specialemphasis on chloramphenicol,3 Italian workers in par-ticular spoke of its value in a wide variety of circumstances,and claimed that bone-marrow depression was not a

significant hazard in their experience. Similarly, Sheba 4has described its wide use in Israel with an apparent lackof serious blood dyscrasias. He suggests that differencesin formulation or dose may be responsible for regionaldifferences in toxicity, or that genetic and racial factorsmay be important. These questions are at presentunresolved. We do realise, however, as Freston hasemphasised,5 that chloramphenicol probably gives rise totwo forms of bone-marrow toxicity. One is an acuteeffect which is found commonly at blood-levels above25 ;jLg. per 100 ml. The white-blood-cell count falls, andthe platelet and red-cell count may also be depressed.Vacuolisation and inhibition of cellular respiration occur.These changes are readily and rapidly reversed when thedrug is discontinued. Secondly chloramphenicol maygive rise to aplastic anaemia, which is usually, if not

always, fatal; and it may become manifest several weeksafter discontinuation of the drug. While we would repeatthat chloramphenicol should not be withheld because ofpossible toxicity when the clinical indications for its useare unequivocal and there is no suitable alternative, it mustbe restricted to such cases. Its prescription for upper-respiratory-tract infections, particularly when no bacterio-logical studies have been carried out, can hardly bedefended.One attraction of chloramphenicol is its effectiveness

over a wide spectrum of bacterial activity, with only arelatively small proportion of resistant strains. This hasoften made it the drug of choice where the severity of an1. Lancet, 1967, i, 32.2. Br. med. J. 1967, i, 649.3. Postgrad. med. J. 1967, 43. Supplement: The Chemotherapy of In-

fections.4. Sheba, C. Lancet, 1967, i, 1007.5. Freston, J. Postgrad. med. J. 1967, 43. Supplement: The Chemotherapy

of Infections.

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infection has demanded the initiation of therapy beforeisolation and detailed sensitivity studies of the organismhave been completed. Gantner and Laskowski 6 describea system whereby statistical information is kept of allprevious bacterial sensitivities in their laboratory. Whenan infectious case presents, immediate information on thesource of the specimen, and gram-staining and morpho-logical characterisation of the organism, permit a predic-tion of its sensitivity. This prediction is based on currentexperience in that laboratory and reflects new changes insensitivity patterns. Special sorting procedures allow thebest antibiotic combinations to be predicted when com-bined therapy is desirable.

Computer programs may be devised to provide moredetailed information, but in smaller hospitals reasonablysimple punched-card systems would suffice for the

majority of infections. Such an approach might lead tomore rational immediate treatment of infections, and itmight help to obviate the indiscriminate use of potentiallydangerous drugs such as chloramphenicol.

ST. CHRISTOPHER’S HOSPICE

IN the days when the death of children and young adultswas commonplace, most people had contact with deathduring their earlier and impressionable years; and

perhaps a simpler and more generally acknowledgedreligious framework also made it easier to accept the idea.Doctors, with less powerful therapeutic tools, seemed lessanxious to protect patients from awareness of impendingdeath-and perhaps more ready to recognise their ownimpotence. Whatever the complex underlying reasons,attitudes have changed. Many doctors now hold sincerelythat their patients (and even sometimes the patients’relatives) must not be told that their illness may be mortal.With this attitude has come a reluctance to face the

problems of the dying; young doctors and nurses are leftalone to cope with their patients’ needs with insufficientteaching and support; research concentrates on lifesavingissues; and some at least of the incurable are made to feelrejected and even guilty (a patient entering a hospital forterminal care said to the doctor " will you turn me out ifI cannot get better ? "). The family doctor, living amonghis patients and with primary responsibility for their deathas well as life, has for the most part retained his concernand skill in their case, though even he may welcomeguidance in the use of drugs and symptomatic treatment.It is the hospital service that needs to look at its resources;and about half of all deaths in Britain take place inhospital.

Fortunately, the past few years have seen a revival ofinterest in the handling of dying patients, both in theU.S.A. and in this country.’-11 Here there have long beensmall specialised units, both voluntary and within theNational Health Service, where dying patients receive thegood nursing and medical and spiritual support they need.Valuable work has been done by the Marie Curie Founda-tion, but it has been clear for some time that there wasneed for a new foundation where the fulfilment of patients’needs could be combined with research and with the

teaching of all concerned in their care.6. Gantner, G. E., Laskowski, L. F. J. Am. med. Ass. 1967, 200, 431.7. Hinton, J. M. Q. Jl Med. 1963, 32, 1.8. Exton-Smith, A. N. Lancet, 1961, ii, 305.9. Saunders, C. M. Care of the Dying. London, 1959. Proc. R. Soc. Med.

1963, 56, 195.10. Hinton, J. M. Dying. London, 1967.11. Yudkin, S. Lancet, 1967, i, 37.

St. Christopher’s Hospice, Beckenham, which was

opened by Princess Alexandra on July 24, has these aims.The concept began from the experience of its founder,Dr. Cicely Saunders, who was successively hospital nurse,almoner, and then medical officer to a terminal-care home,and from her conviction that the needs of those withsevere and chronic pain, whether dying or not, neededmore study and consideration than they could receive in abusy hospital ward. They needed too, she maintained, thesolid basis of a religious faith, though both staff and

patients at St. Christopher’s are drawn from those of manycreeds and of none.

The Hospice (the word means a place of shelter on the road) hasbeen built with grants from a number of Trusts, as well as with giftsfrom private well-wishers. The first stage contains 54 beds and a wingfor 16 old people, whose interest and help is proving of remarkablemutual benefit. The cost of building and equipment is some

E480,000, of which E418,000 has so far been raised. The impressivebuilding, designed by Messrs. Stewart, Hendry and Smith, is full oflight and brings the -life of the world outside right into the wards.The second stage plans to transfer staff and teaching accommodationto a site two doors away, thus releasing 13 single rooms for patients;and a third stage would add another 23 beds. But first the existingbuilding must be paid for.The intention is to take terminal cases (mainly cancer, with an

estimated expectation of life of not more than three months) intoabout three-quarters of the beds, admitting to the remaining quarterlong-stay patients with special nursing or other problems. Experiencehas shown that such a propcrtion of stable and continuing patientsis an important encouragement and respite for the staff. The South-East Metropolitan Regional Hospital Board has contracted to acceptresponsibility for 40 beds for National Health Service patients fromthe four Metropolitan Regions, leaving 14 beds for others, for whomthe charge is expected to be of the order of E25 a week. It is hopedto build up an endowment fund for patients for whom this sumcannot be raised.

The Ministry of Health has contributed both capital andrevenue grants for research. Clinical trials of new drugsand of improved methods of handling old ones are planned.Another aspect of research will be the emotional and

psychological reactions to dying and bereavement, and thestaff includes a part-time social psychiatrist and a psycho-therapist. A novel feature is an outpatient clinic, wherepatients whose symptoms have been sufficiently con-

trolled to enable them to go home can be seen regularlyand support provided for them and their families; somemay also be able to attend here either before admissionbecomes necessary or, while awaiting admission, for assess-ment and advice on control of pain. Finally, the teachingfunction will be developed as soon as St. Christopher’s isfully open and running smoothly. It has already been shownthat, with cooperation from selected patients, teachingcan be carried out without detriment to them and even totheir benefit; and medical and nursing students andgraduates, as well as social workers and ministers andpriests of all denominations, can be shown how much canbe done for these patients-and how much needs to bedone.

Those concerned with St. Christopher’s have beenheartened by the welcome. and help extended by localhospitals, by teaching and regional hospital board, and bythe local community, whose offers of voluntary service areto be fully accepted. Help of all kinds, by relatives as wellas by local well-wishers, is to be an important part of thisinformal and friendly institution. Perhaps the greatestgift that it will give to its staff is time-time to listen topatients, time to seek to discover their needs, and time tothink about their problems. In Dr. Saunders’ words," You don’t need to tell the patients; if you wait andlisten, they tell you, and tell you what they need."