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ACADEMIC FREEDOM AND THE HEALTH ACT

SIR,—Dr. Russell Brain’s letter in your issue ofMarch 12 trails several red herrings. My objections to thepresent Act are to the monopoly which it confers on theState and to the tremendous powers it hands over tothe Minister. Once admit that this monopoly and thesepowers are good, then all further argument about theAct is futile. Personally, I am entirely sceptical about thetotal planning of the medical profession, and more thanalarmed when its educational institutions and organisa-tions become closely identified with the State. A briefdefinition of the State is impossible, but it is certainlynot " the medical officers and lay officials of the Ministryof Health," as suggested by Dr. Brain. I must leaveothers to decide whether the president of the RoyalCollege of Physicians of London is now the head of acorporation of physicians or whether his position as

chairman of the Distinction Awards Committee makeshim a State servant.

I have no doctrinaire views about the running of themedical services, but I believe that the quality andconditions of independent medical practice outside anyState scheme will in the long run be the factors determin-ing the quality and conditions inside any State scheme.Medicine has functions towards the community whichare not co-extensive with those of the State, and I amanxious that the colleges and the universities should notmerely become identified with the State because of officialpressure.Academic freedom is the apex of the pyramid based on

many other freedoms throughout the community. Thesituation regarding academic freedom within medicine iscompletely altered now that the Government has themonopoly of_ the medical educational institutions, forthere can be no clinical teaching outside the Governmentservice. The University Grants Committee has bufferedthe academic worker from the activities of the politicianand the official, and a comparable method of bufferingall undergraduate and postgraduate institutions from theactivities of the Ministry of Health is imperative. Inthe issue of your journal which contains Dr. Brain’sletter, the signatories of a letter dealing with the NationalForynulary wrote :

" It is realised, however, that the staffs of teachinghospitals may have some misgivings about placing itwithout comment in the hands of medical students, since itcontains preparations which can justifiably be criticised."In the interests of administrative convenience an

approved National Formulary is published. Such a

formulary may be valuable and its employment inacademic medicine may be a relatively minor matter,but the extension of such processes may graduallyproduce a set of conditions imposed from without, whichslowly and successfully limit the real independence ofthought and action of the academic worker.

Dr. Brain’s citation of the Medical Research Councilto support his argument is completely irrelevant. Myobjection is to the situation produced by a Governmentmonopoly. The Medical Research Council performs avery specialised function in relation to scientific medicine,and its founders had the good sense to put it under thePrivy Council, which is at least a good deal quieter thanthe Ministry of Health ! My letter contained no referenceto civil servants. but the modern hybrid employe thatis being produced has neither the advantages of the civilservant, nor the real advantages of being independent.The only real analogy for Dr. Brain is that of the hospitalservice of the Ministry of Pensions. This service isdesigned for a specific purpose. It has obligations to thepensioners, to the Treasury, and to the taxpayer, but Ishould certainly not be prepared to hand over to such anorganisation the guardianship of academic freedom inmedicine since the obligations to the Treasury are tooimmediate and too direct. Dr. Brain’s letter is a testi-mony to his belief that the extension of State activitywill promote academic freedom. Contemporary evidencehardly suggests this. In Czechoslovakia all studentshave just been subjected to " reliability tests,"

" norms "have been established, and the unsuitable studentsexpelled.

Dr. Bourne in his letter of April 9 discusses economics,while I am concerned primarily with the relationship of

medicine and the State, particularly as affecting educa-tion. Dr. Bourne will be aware that in the past theRoyal Colleges have got into difficulties as the result oftheir monopolistic claims. At the present time thecolleges have allowed their interest in medical monopolyto become fused with the interest of politicians whofavour State monopoly. The taste, standards, anddecisions of official academies are not always correctand should not be beyond criticism, and the recentexhibition of the Chantrey Bequest has been an inter-esting commentary on this. The Royal Colleges haveweathered storms before and will weather the presentone. Meanwhile, the real need is to protect Medicineand the colleges from the politicians. Thomas Wakley,-the founder of THE LANCET, wrote in your columns ofthe Royal College of Surgeons as " the vile cave inLincoln’s Inn," and of the Royal College of Physiciansas

" the old dowagers of Pall Mall East." If such invec-tive is no longer permitted to the editorial pen, at leastcriticism may still be called for and may still provesalutary.

London, «’.1. REGINALD T. PAYNE.

A PLAN FOR THE AGED

SIR,—I read with great interest the article byDr. Boucher in your issue of April 30 under .the abovetitle.

It seems to me that the approach so far to the problemsof the old has been too much from the angle of morbidityand the treatment of disease, and too little from the aspectof maintaining as long as possible their health andhappiness. In his suggestion that, the name of thespecialist concerned should be " gerocomist " ratherthan " geriatrician," Dr. Boucher evidently appreciatesthis fact, but his article is still dominated by that questionof hospital treatment that seems to underlie so muchplanning arising from the National Health Service-Act.

I would venture to suggest that the analogy amongexisting welfare services for a welfare service for the oldis rather with maternity and child welfare than withtuberculosis. Old age is not in itself a disease, and theremust be a normal old age--and for that matter a normaldeath-just as there is a normal childhood and a normalbirth. It should be the aim of the Health Service to aidin the provision of circumstances conducive to thesenormalities at the one as at the other extreme of life.Childhood and a large number of births take place athome, and so should old age and a large number of deaths.The regional hospital boards are therefore concernedbut incidentally, and the statutory bodies mainlyinterested should be the local health authorities. Ipersonally regard the whole field of care of the old asthe next great province of development of public health,as maternity and child welfare was between the twoworld wars.

Darlington.JOSEPH V. WALKERMedical Officer of Health.

CHILDREN IN HOSPITAL

SIR,—Whenever I read that the answer to somecommon problem in human relations " must come fromresearch, from pooling of experience, from cooperationamong the professions ..." I am reminded of Shaw’sBlack Girl, who knew, long before she had heard ofPavlov, that when a dog sees his dinner his mouthwaters. Miss Anna Freud, with her gift of vivid illus-tration, did well to rub in what we all recognise withouttroubling to.act on it-that a child and his mother areill parted. Studies have shown what this separationdoes to the young child ; but there are also those olderchildren who spend as much as six or seven years, oreven their- whole childhood, in an orthopaedic ward.Like children in other institutions, they grow up withoutclose personal love ; and they have two added rriis-fortunes-they cannot get emotional release in physicalaction, and their education is often perfunctory. Suchexperiences harm not only emotional growth buteconomic prospects. Surely the answer is not to hopefor some formula, distilled from research, which willteach every nurse to be a mother-who-is-not-the-mother,a beloved regent but never a usurper. The notion is

unprofitable; one woman in twenty might achieve itafter half a lifetime of training and self-discipline.

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Spence has solved the problem for the infant byaccepting him and his mother as a unit, and taking bothinto hospital together. But the unit does not resolve atthe end of the second year ; it is slowly exchanged for aflexible partnership which lasts till the child’s adolescence,and sometimes beyond. A lesson now being learned bythe geriatricians might be followed. Children in

orthopaedic hospitals often have long intervals betweenoperations. Would it not be possible to give suchchildren the essentials of hospital care in their homes,anyhow for a substantial part of each year ? A well-organised home service could arrange physiotherapy forthose who needed it, or provide nursing care for those whowere bedridden or in plaster. The child would get his shareof home life and affection ; and even if his schooling stillhad to be given during his terms in hospital, at least hewould be gaining, while at home, that practical experienceof life which the institutional child so greatly needs andcovets.

CANDIDA.

DECAMETHONIUM IODIDE

SIR,—In their article last week Dr. Davies and Pro-fessor Lewis give a valuable account of the use ofdecamethonium iodide and d-tubocurarine chloride inelectroconvulsive therapy.The relative duration of the recovery period in these

cases merits further consideration. The effects of acurarising dose of d-tubocurarine persist on average for30-40 minutes ; in the case of decamethonium iodidethe average duration of action. is 15 minutes. Sincerapid recovery from the effects of the drug is obviouslydesirable in these cases, decamethonium iodide would atfirst seem to be preferable. It has been observed,lhowever, that the effects of d-tubocurarine pass off twiceas rapidly in patients submitted to an electricallyinduced convulsion as in subjects receiving the samedose without a convulsion. I have observed no suchde-curarising effect where decamethonium iodide hasbeen used in electroconvulsive therapy, and it wouldseem that there is little to choose between the twodrugs on the ground of duration of action.

It has been suggested that electrical stimulation leadsto the liberation of increased amounts of acetylcholineat the neuromuscular junction and that this neutralisesthe effect of the d-tubocurarine ; in the case of deca-methonium iodide it is known that neostigmine is notan effective antagonist ; so it is not surprising thatelectrically induced convulsions do not reduce itsaction.

In view of this difference in the action of the twodrugs on the neuromuscular junction, one awaits withkeen interest the results of a test of the effects ofdecamethonium iodide on a myasthenic subject ; suchan experiment may indicate whether idiosyncrasyto this drug is likely to be encountered in clinicalpractice.Department of Anæsthetics, Westminster

Hospital, London, S.W.1.C. F. SCURR.

RISK FROM ASPIRIN PREPARATION

SIR,—In his letter last week, Dr. Forster would seemto refer to our product Magsilate,’ since we use thephrase can be eaten like a sweet."

This tablet can be taken pleasantly and requires nowater ; and it offers other advantages such as completedisintegration before swallowing, the inclusion of antacidsto prevent gastric irritation, and the sealing of the

aspirin as a centre core to prevent deterioration.

Incidentally, magsilate, which was evolved in our ownlaboratories, is entirely British. The only commentsreceived from doctors have been of congratulationupon presenting aspirin in a palatable and convenientform.

Apparently Dr. Forster has overlooked the fact thatthe tablets are distinctively wrapped and in a packagewhich bears a caution to keep them in a safeplace.Westminster Laboratories Ltd.,

London, N.W.1.E. W. GODDING.

1. Hobson, J. A., Prescott, F. Brit. med. J. 1947, i, 445.

Parliament

Nurses Bill

Lord SHEPHERD, in moving the second reading of thisBill, defined it as a finely balanced document, trying to’please as many as possible of the parties interested. Itincreased the status and strength of the General NursingCouncil, and put it on a more widely representative basis.The new statutory committee relating to mental nurseswould have referred to it without question all mattersconcerning mental nursing that come before the council.In all probability the medical and other professionswould receive notice of the members to be appointed bythe Minister to this committee, and they would certainly beconsulted in respect of the appointments. How far thestudent nurse could be given fall student status remainedto be seen, but the Bill created the conditions in whichthe answer might be evolved by trial and experiment. Itprovided for regional committees, independent of thehospital authorities, whose main duty it would be to °

coordinate training arrangements, and it provided for ’

the expense of training to be separated from the expensesof hospital administration. The General Nursing Councilwas also given power to introduce experimental training.Lord AMULREE suggested that it would greatly-

strengthen the General Nursing Council if there was

medical representation on it. He thought that thecontinuing deficiency of nurses, in spite of the increasingnumber of student nurses compared with before the war,was due to the fact that they now worked in shifts, andhad a 96-hour fortnight, in place of. the much longerhours that formerly applied, and that it was unlikelythat this gap would ever be filled entirely. He was noteven sure that it was a good thing that it should be,because the type of young women now being taken inwere well trained and educated, and he was not sure /

that we could afford to have a great number of thesepeople taking care of the sick. The new council shouldmake up its mind what functions a nurse should performand keep her firmly to those functions, and not let herwaste her time doing things which were not strictlynursing matters. He questioned putting the entireresponsibility for the training of nurses on the nurse-training committees. Although a great deal should bedone by them the final charge must be that of the manoge-ment committees and boards of governors of the varioushospitals. Some medical opinion should be given aboutthe kind of training that was necessary.Lord MoftAN said the crux of the Bill was that for the

first time the funds for nurse training were separated fromthe general hospital budget. In those few words nurseshad been given a charter of freedom in regard to theirtraining. Another provision almost equally importantwas that for bringing the standard of efficiency of thesmaller hospitals up to the level of the best. Everyonewould welcome the fact that there had been a bridgeput between the teaching hospitals and the smallerhospitals in the shape of the standing nurse-trainingcommittees, and that financial powers had been givento them. But it was another story when they came tothe other executive function of these committees, thatof examining. The central State examination establishedin 1919 had done a great deal to raise the minimumstandards everywhere. From now onwards he was afraidthey would have to admit that there would be no nationalminimum standard. The more they were driven to shiftsand expedients to meet the shortage of nurses, the moreessential it was that they should preserve the standardthey had known in the past. That was why he and othersfelt concern that the teaching hospitals were put into theregional machinery for this purpose of training nurses.This was- the first departure from the principle laid downby the Minister in the National Health Service Act thatteaching hospitals should be kept outside the regions,so that the " growing edge " of medicine should not beblunted.Lord WEBB-JOHNSON also welcomed the introduction

of a measure providing for the independent financing ofthe training of nurses, but he was disappointed that theGeneral Nursing Council should have been selected asthe body for the general control of funds for this purpose.