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already shed light on the aetiology and management of the so-called disorders of civilisation—eg, diverticular disease and atherosclerosis. Likewise, for some diseases that are common in tropical countries but almost unknown elsewhere, collaborative work has yielded very useful results. Examples are Madura foot,4 Burkitt’s lymphoma,5 and portal hypertension due to schistosomiasis.5 Many other diseases common in each of these societies lend themselves to collaborative studies. Moreover, clinical and applied research might yield innovative ideas about the extension and improvement of surgical care in the third world. Sister British departments might then act as agents or catalysts and, together with other interested organisations, both inside and outside the tropics, could offer help in the implementation and evaluation of these plans. Unquestionably it is better to train a surgeon in the environment in which he or she is going to function. Consequently, many developing countries have started their own training programmes. Departments who run these programmes have to strike a balance between the continuous and acute demand by their societies for more surgeons and the desire by the profession and trainees for international standards. To avoid the possibility that these programmes may become too inward looking and of an entirely local nature, it is expected that sister British departments, headed by professors of tropical surgery, will open their doors for these budding tropical surgeons. The trainees from the tropics will then have the benefit of being exposed to surgery practised outside their environment and of exchanging their experiences with their British colleagues. They may find opportunities to extend their training in areas badly needed in their own countries, and make use of the facilities and technical skills available in these departments. Conversely, trainees from British surgical departments could be encouraged to take up recognised posts in the tropics via such departmental links. A lone chair of tropical surgery in Britain or in every country of the EC is not going to solve the problems of surgery world wide. Nevertheless, it is a step in the right direction, and should help surgeons from developed and developing countries to improve surgical care and research in both societies. 1. Holcombe C. The need for a chair of tropical surgery. Br J Surg 1990; 77: 3-4. 2. Efem SEF. A chair of tropical surgery. Br J Surg 1990; 77: 834. 3. Craven JL. A chair of tropical surgery. Br J Surg 1990; 77: 954. 4. Lynch JB. Mycetoma in the Sudan. Ann R Coll Surg 1964; 35: 319-40. 5. Burkitt D, O’Connor GT. Malignant lymphoma in African children: a clinical syndrome. Cancer 1961; 14: 258-69. 6. Homeida M, Saad A, Dafalla A, et al. Morbidity associated with Schistosoma mansoni infection as determined by ultrasound: a study in Gezira, Sudan. Am J Trop Med 1988; 39: 196-201.

HOUSES OF RECOVERY Last year, in New York city, a Mayor’s task force on AIDS recommended the establishment of two special institutions exclusively for the treatment of human immunodeficiency virus (HIV) infection.1 The implicit suggestion, that the best way to deal with a difficult health issue may be the creation of a special institution, raises the interesting question of the origin, role, and advantages (if any) of

specialist hospitals. In Britain, through the eighteenth century, the steady growth of voluntary general hospitals was accompanied by that of specialist institutions established for various reasons.

Some of these institutions came into being because the disease they dealt with aroused fear or disgust-eg, the sinister-sounding lock hospitals for venereal disease, or the early fever hospitals that were named "houses of recovery" to avoid scaring the neighbours. Others were established because the early rules of the general hospitals excluded certain groups of patients-pregnant women, children, and those with fevers, cancer, insanity, and "the itch". Nevertheless, the nineteenth century saw an enormous growth of specialist hospitals. No fewer than 169 were founded in the UK (excluding psychiatric institutions) 2 In the first half of that century it was often said they were established by medical men who failed to obtain an appointment at a general hospital and so created a special institution solely to advance their career. Specialisation, initially despised by most physicians and surgeons as a form of opportunism, only became respectable in the late nineteenth century. From their beginning special hospitals had an advantage over general hospitals when it came to soliciting subscriptions. That the public have always identified more easily with a disease or group of diseaseseg, with blindness and deafness, consumption and cancer, childbirth and children-than with the whole spectrum of hospital medicine largely explains the number and success of special institutions. However, in the early years of this century there were powerful arguments against such separate institutions and in favour of incorporating specialties as departments of general hospitals. Whilst specialisation had become inevitable (it was now certain that the sum total of medical knowledge was beyond the grasp of any single doctor), most doctors recognised the intellectual as well as the practical benefits of close contact with colleagues. Radiology departments and laboratories, centred in general hospitals, were essential for most specialties; and with all branches of medicine under one roof teaching was easier. So why do so many specialist hospitals survive today? One reason is that they are monuments to the high status of specialisation in twentieth-century medicine, a feature not always shared by other professions. In the law, the civil service, and the armed forces, for example, the need for specialists is recognised, but the highest offices are occupied by generalists. The reputation of special hospitals allows them to attract the best young doctors and the most challenging patients, and to provide unrivalled teaching, research, and experience. Their high status is thereby perpetuated with both the public and the profession. Who would dare to pull them down? However, to establish new special hospitals would be a very different matter. The dangers of stigmatisation, divorce from community care, and "isolation of staff from mainstream medicine and colleagues" outweigh the advantages of concentrating special skills and knowledge. With respect to AIDS, proposals for special institutions may resurrect some of the fever hospital mentality-a plan in Los Angeles to turn an old tuberculosis sanatorium into an HIV institution had to be abandoned after community protests. If any are established, it may prove necessary to reinvent the euphemism houses of recovery. 1. Rothman

DJ, Tynan EA. Advantages and disadvantages of special hospitals for patients with HIV infection. A report by the New York City task force on single-disease hospitals. N Engl J Med 1990; 323: 764-68.

2.

Kershaw J. Special hospitals. Their origin, development and relationship to medical education: their economic aspects and relative freedom from abuse. London: Pulman, 1909.

Houses of recovery.

1354 way have already shed light on the aetiology and management of the so-called disorders of civilisation—eg, diverticular disease and ather...
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