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classification already given, and, since this seems tobe generally recognised by American doctors, it servesas a convenient shorthand, as well as providingcomparable data for research purposes. When itcomes to settling the patient in a job the doctor isurged to take special trouble. It is useless for him to

say : " You could do light work now," and think nomore about it ; he must advise the patient, andadvise him intelligently, on the work he should do.This means that he must take a detailed occupationalhistory, including the names and addresses of

employers, the types of job held, the hours worked,the pay, the patient’s educational background andspecial skills, the aspects of his work he found a strain,the aspects he found easy, the daily travel needed andthe method of transport, and the stair-climbing,entailed in getting from home to job and back again.It is not unknown for a patient to take a light industrialjob which on paper appears to be satisfactory in everyway-until someone learns, after his death, that thefactory was at the top of a steep hill. The patient cananswer most of the necessary questions on a form, butif the doctor is going to find out clearly how muchenergy the job demands he will have to have a talkwith him about it. The same sort of close inquiryis needed when the patient is a housewife, for it hasbeen shown that " managing a household withoutassistance is the physical equivalent of a full-timeindustrial job." Nevertheless the average womanwith cardiac disease can continue to run her home ifshe is taught to limit the time she spends on her feetand to change her methods so as to reduce her physicaloutput. One of the association’s booklets 2 tells herhow to set about it.The doctor’s final prescription for activity is based

on all the information collected. The associationrecommends that he should then fill in a detailed"work capacity report," which can be used as a

guide by social workers and industrial employers.The amount of travelling needed is taken into account ;and the doctor, besides giving an opinion on causation,lesion, functional and therapeutic classification, cardiacanxiety, emotional status, and work tolerance, alsoindicates, by ticks against a list, exactly what physicalactivities and working conditions are forbidden orlimited. The booklet notes that most cardiac patientsclassed as IB, IIB, and lie can work 40 hours a week inclerical and sales jobs and in most skilled and semi-skilled occupations ; and that many mc patients cando sedentary and part-time jobs. Most patients arehappier if they can return to their former jobs ; butif the job must be changed the doctor ought to beable to suggest alternatives. With a good confidentpatient, however, reassurance and explanation are

often all the help that is needed : he will then go andfind an appropriate job for himself. When he is backin work the doctor should see him regularly and assesshis capacity afresh.

This is an exacting programme for doctors, but fromthe point of view of the public as well as the patientit would be well worth achieving. As the association

point out in a booklet addressed to employers,3 theskills of workers with heart-disease can be an asset to

industry ; but when they are not used the workerhimself becomes a liability.

2. The Heart of the Home.3. These Hands are Able.

Economy in Hospital StaffingAN important memorandum from the Ministry of

Health (summarised on a later page) asks boards andcommittees to reduce further their man-power. Thisreasonable request for economy is in line with nationalpolicy ; but unfortunately it has been made theoccasion for a serious retrograde step-namely, theimposition of central control of hospital establishments,by making it necessary for any increase in staff to beapproved by regional boards in the case of staff

employed by management committees and by theMinistry in the case of staff employed by regionalboards. Neither the need nor the possibility of economycan be disputed. In hospitals there is still scope forthe introduction of labour-saving devices and of modernmethods -of business efficiency. Many hospital com-mittees, -however, have already gone as far as theycan with direct economies ; and further saving inmaintenance costs will call for expensive new equip-ment, the rebuilding of out-of-date laundries andkitchens, or extensive structural alterations, such asmay be needed, for example, to introduce a cafeteriasystem.The aim of the Ministry’s approach may easily be

defeated by the antagonism it will create amongstmany who have worked hard in the best interestsof the service ; for central control is feared anddetested by those who work at the periphery. If theMinistry had ruled that all staff increases must bebalanced by savings under any other headings, hospitalauthorities would no doubt have cooperated readily;instead it has specified a group of non-medical pro-fessional staff and of technical and other staff for a5% cut. This must cause restlessness, ill-feeling, anddistrust not only among individual workers but alsoamong the committee members who are doing theirbest to provide a good service with limited resources.It may easily lead to friction between managementcommittees and boards, and between boards and theMinistry. Apparently the Ministry has not yetrealised that a big peripheral hospital cannot be

regarded in the same light as, for example, a postoffice, which year after year provides the same serviceand in which the staff can readily be classified.A hospital medical service is constantly remouldedby the rapid changes in knowledge ; and manyservices are related to particular skills which happento be available at a particular time and place. The

peripheral committees should have latitude in makingthe best use of their resources without having tofritter away time, energy, and temper in referringdetails to -a central authority.

This memorandum naively suggests that applica-tions for increases in staff may conveniently be sentup with the annual budget, although some applicationsmay have to be made as the year proceeds. Yet in

hospitals opportunities have to be taken as theyarise ; and a delay of six or nine months is usuallyunthinkable. On the day when the staff returns aremade, a matron may have only ten nurses (belowthe average number) in her preliminary training school,whereas twenty-five may present themselves nexttime. Henceforth she must seek permission to takeher normal number. Who will investigate her case,and how quickly will it be done ? Regional boardsare having to cut their own staff and yet take on a

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heavy new load of responsibility which properlybelongs to the management committees, whosemembers have been hand-picked for their sense of

public duty and knowledge of local affairs.A proper spirit of economy throughout the health

service must be based on mutual trust. There is noreason why a sense of trust and of service to thecommunity should not be infused down the line fromthe Minister to the ward-orderly, by personal contactand transference of a sense of individual responsibilityfrom the centre towards the periphery. The Ministry’saction, by checking this trend, will cause damage atall levels.

1. Public Health Lectures. By K. EVANG, J. E. GORDON, andR. G. TYLER. Boston, Mass. Unitarian Service CommitteeInc. 1952. Pp. 122. $1

Annotations

PREVENTION AND CURE

PREVENTIVE medicine in this country has alreadypassed through three phases, and the form that thefourth will take is in the balance. The fire and furyof Chadwick and his followers ecreated a new specialty- public health-from among the clinicians, and the

driving force of his " sanitary idea," the quality of themen it attracted, and the prosperity of the mid-19thcentury combined to give us world leadership in thenew ’science of prevention. At the beginning of the20th century the practitioners of this science were ableto extend their sway, first to a wide group of personalpreventive services, and after 1929, to a hospital servicewhich rapidly rivalled the old voluntary system. Thenin 1948, in the interests of a comprehensive and integratedhospital system, public health was shorn of its hospitals-even of the fever hospitals which it had controlledfor nearly a century-and of a number of its other func-tions, leaving many of its exponents confused and

frustrated, as they were for a time in 1854 whenChadwick’s Board of Health ceased to exist. Recentlythere have been signs of a new pattern evolving, and itis instructive to have the views of a distinguishedforeigner familiar with this problem in many parts ofthe world.

In the course of some lectures given during a medicalteaching mission to Israel,1 Dr. Karl Evang, director-general of the public-health service in Norway, distin-guished three basic systems of public health : (1) thecontinental European, originating in Germany and at itsinception a great advance, but now too legalistic andbureaucratic; (2) the Anglo-Saxon, more flexible, prag-matic, and crusading ; and (3) the Slav or Russian, whichhas attempted a more complete combination of curativeand preventive medicine but which, alas, can seldom bestudied except at second hand. The field he allots to

public health is comprehensive : it should, he thinks,not only be a specialty in its own right but also beresponsible for over-all planning and coordination of thewhole system, including curative medicine. In hisopinion neglect of curative medicine by the public-healthservices has been as unfortunate as the similar neglectby the clinicians of such preventive services as maternityand child welfare and tuberculosis. The central govern-ment should give centralised direction, but activityshould be decentralised : the division of health functionsbetween different government departments is largelyhistorical, and the trend is now towards concentration.On hospitals, Evang feels that the approach to efficient

administration must not be like the approach to a

mathematical problem—there are no " right answers."Nor should those who appropriate money for hospital

services demand the obvious advantages of " stabilisationof budgets," which inevitably leads to stagnation. Onthe open versus closed hospital, he favours the closed,with safeguards covering provision of diagnostic facilitiesfor surrounding practitioners and a system of efficientreporting on their patients ; selection of staff should beobviously impartial, and there must be flexibility in theallocation of beds. Rigid allocation of beds to specialtiesis on the way out, as are specialised hospitals-e.g., fortuberculosis and infectious disease. " The modern trendis away from very large hospitals " and a general teachinghospital, including psychiatric, tuberculosis, and infec-tious-disease departments, should not exceed 700-1200beds. An administrator with a medical degree, otherthings being equal, is to be preferred to a layman, andEvang quotes Goldwater as saying that " a stalwartmedical superintendent can protect his hospital from theexuberance of the reckless medical enthusiast more

effectively than can a non-medical superintendent," aswell as guarding clinical medicine from ill-informed laycontrol. While this does not imply that one of theclinicians at a large hospital should take full responsibilityfor the administration, he pleads for more clinicians tointerest themselves in administration.

" To my mind this is a vital point : when medical activitiesproliferate, as they do in modern society, medical men musttake administrative responsibility. If they do not, if theylimit themselves to clinical work, others, ignorant as to allthe medical factors involved, will organize the institutionsin which medical men will be invited to work. This appliesnot only to hospital medicine, but also to all other formsof medical activity. This calls for education in healthadministration, a field which has been neglected in mostcountries."

While rejecting the complete integration of hospitaland health services as being at present impossible andinadvisable in most countries, Evang emphasises the needfor " bringing the student and the teaching hospital outof their present clinical isolation,’ " quoting Newsholme’sdictum that " the treatment and prevention of diseasecannot administratively be separated without injuringthe possibilities of success of both." ,

1. Chu, C. M., Andrewes, C. H., Gledhill, A. W. Bull. World HlthOrg. 1950, 3, 187.

THE MASKS OF A VIRUS

THE influenza virus can assume a bewildering varietyof antigenic forms ; and, so far, the particular strainwhich causes an epidemic in any year has been recognis-ably different from all the strains found before. It hasbeen suggested that this continual antigenic novelty,allied to changes in virulence, is of great importance inthe annual renascence of the virus ; for if it returnedto us each year in the same form we would have builtup too strong a barrier of immunity to allow it to troubleus again. These are, at the moment, merely speculations,but it is fortunate that the techniques for studying theinfluenza virus have reached so sophisticated a stagethat it is possible to set about testing the truth of thisand other hypotheses.The World Influenza Centre of the World Health

Organisation has, since 1947, been making a special studyof the origin and spread of influenza epidemics. Althoughinformation is obtained from many parts of the world,attention is for the moment focused mainly on Europe.Here the work is grievously handicapped by the IronCurtain, which forms an effective barrier to the exchangeof news about the virus, though the virus itself brushesit aside easily enough. But despite the difficulties andthe fact that relatively few people are collecting strains,a brilliant start has been made and information of the

greatest interest is beginning to appear. The first report,on influenza in 1948 and 1949, was published two yearsago,l and now comes the report on the European epidemic