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THE RIGHT TO AN OPINION
138 and Trencher,8 on four patients actually under treatment with cortical extract. It was found possible to withhold the extract when salt was given, though its use had to be resumed in one The authors make the pertinent suggestion case. that the withdrawal of salt from the diet should be used to confirm the presence of Addison’s disease. Needless to say this test should only be made if large amounts of potent cortical extract are available, for the condition of the patient may be very alarming after 24 or 48 hours of a low salt diet. If, however, he is no worse for the deprivation of salt it is extremely unlikely that he has Addison’s disease. Clearly this work is of the utmost importance to sufferers from this grave disorder. The treatment should not be regarded as curative, since the sodium chloride administered only replaces that which is being lost in the urine. At the present time it is not certain for how long salt therapy will continue to be effective, as LoEB’s first case has only been treated for 16 months. It is possible that this patient will later on require cortical extract, but even then the dose is likely to be much smaller than if no additional salt were given. The biochemical aspect of this work is no less important. It has long been known that one of the inorganic bases, calcium, and one acid radicle, iodine, are controlled in the body respectively by the parathyroid and thyroid glands. Now another base, sodium, is shown to have an intimate connexion with a third ductless gland, the adrenal cortex, and it seems at least possible by analogy that still other bases and acid radicles are also regulated by some ductless gland. The loss of potassium or magnesium, for example, or of the sulphate (SO 4) radicle may also be associated with dysfunction of a gland. Now that the artificial barriers between pathological
SOFFER,
and inorganic chemistry are there is hope of a fertile their exponents in this field.
rapidly disappearing, cooperation between
THE RIGHT TO AN OPINION
public repudiation by a hospital board of expressed in good faith by one of its prominent members seems to us an act of little Whether the chairman of an appeal grace. THE views
<0
committee is wise in setting out at a festival dinner his reasons for believing that hospitals will sooner or later have to accept grants from the State is a matter of opinion. It is clear that Sir EUSTACE FIENNES had not reached this conclusion lightly. For a year he has been making great personal efforts to further an appeal which has in fact brought 16000 to Queen Mary’s Hospital for the East End, and he has himself visited 30 factories to collect donations. He finds that the difficulty of raising funds increases every year, while the hospitals are needing more and more money for scientific research and special departments. Unlike some of his former colleagues on the board of management he has had the opportunity of studying State-aided hospitals in the colonies and he does not share their horror of this arrangement. 8 Jour. Amer. Med. Assoc., 1933, c., 1850.
Is his heresy so likely to endanger the institution he has been trying to serve that its expression called for stern rebuke ? The basis of the objection to any measure of State support for voluntary hospitals is the desire for unfettered freedom of administration in the interests of the sick poor. Each of our great, hospitals takes pride in an individual tradition of service, accepting not unwillingly changes of procedure dictated by the growth of medical knowledge, but quick to resent any scheme of coordination which might involve detailed criticism from without. The smaller hospitals are no less jealous of their autonomy. That some degree of emulation or even rivalry in competing for public support leads to progress can hardly be doubted ; the maintenance of solvency at all costs does not pay. A hospital board which carries on in unsuitable buildings with an inadequate staff is suspected of a lack of efficiency as well as of enterprise and does not easily get support even for essential development; but one which takes the risk of erecting a new building with proper accommodation for patients and nurses and then demands money seems to get it. Apart from capital expenditure, there are variations in the manner of distributing income which may not concern a significant proportion of it and give to a hospital its special character. One may label as wise economy what another would regard as extravagance, for example, a team of qualified almoners, cooked breakfasts for patients, fresh fruit for nurses. Since 1927 participation in a scheme for the superannuation of nurses has become fairly general; but at least a third of the voluntary hospitals in the country have not yetjoined it, and of the rest few assume responsibility for the welfare of senior nurses whose retirement is due before the scheme can give them substantial benefit. Taking only these few examples, if every hospital accepted the highest of the current standards of feeding patients and nurses and of promoting their after-care, its annual maintenance expenses would rise appreciably. Everyone with intimate knowledge of the practice of many hospitals could easily select from each a feature which merits general adoption but for the cumulative expense. The liberty and independence of hospital authorities may thus mean progress in some respects or backwardness in others. So far the charitable public has not been disposed to criticise their actions or even, it appears, to study such details of administration as are accessible before deciding whether to support a particular hospital; and this is an expression of the confidence felt in the judgment of hospital boards throughout the country. It is generally recognised that the level of administration is high, and few subscribers to hospitals would welcome’ State grants if their acceptance implied State control; for example of admissions (see p. 166). But for institutions which set a high value on freedom of action to exhibit such fear of freedom of speech argues little faith in the stability of the system of hospital management which they uphold, and is not likely to increase
yet
its
prestige.
SOFFER,
and inorganic chemistry are there is hope of a fertile their exponents in this field.
rapidly disappearing, cooperation between
THE RIGHT TO AN OPINION
public repudiation by a hospital board of expressed in good faith by one of its prominent members seems to us an act of little Whether the chairman of an appeal grace. THE views
<0
committee is wise in setting out at a festival dinner his reasons for believing that hospitals will sooner or later have to accept grants from the State is a matter of opinion. It is clear that Sir EUSTACE FIENNES had not reached this conclusion lightly. For a year he has been making great personal efforts to further an appeal which has in fact brought 16000 to Queen Mary’s Hospital for the East End, and he has himself visited 30 factories to collect donations. He finds that the difficulty of raising funds increases every year, while the hospitals are needing more and more money for scientific research and special departments. Unlike some of his former colleagues on the board of management he has had the opportunity of studying State-aided hospitals in the colonies and he does not share their horror of this arrangement. 8 Jour. Amer. Med. Assoc., 1933, c., 1850.
Is his heresy so likely to endanger the institution he has been trying to serve that its expression called for stern rebuke ? The basis of the objection to any measure of State support for voluntary hospitals is the desire for unfettered freedom of administration in the interests of the sick poor. Each of our great, hospitals takes pride in an individual tradition of service, accepting not unwillingly changes of procedure dictated by the growth of medical knowledge, but quick to resent any scheme of coordination which might involve detailed criticism from without. The smaller hospitals are no less jealous of their autonomy. That some degree of emulation or even rivalry in competing for public support leads to progress can hardly be doubted ; the maintenance of solvency at all costs does not pay. A hospital board which carries on in unsuitable buildings with an inadequate staff is suspected of a lack of efficiency as well as of enterprise and does not easily get support even for essential development; but one which takes the risk of erecting a new building with proper accommodation for patients and nurses and then demands money seems to get it. Apart from capital expenditure, there are variations in the manner of distributing income which may not concern a significant proportion of it and give to a hospital its special character. One may label as wise economy what another would regard as extravagance, for example, a team of qualified almoners, cooked breakfasts for patients, fresh fruit for nurses. Since 1927 participation in a scheme for the superannuation of nurses has become fairly general; but at least a third of the voluntary hospitals in the country have not yetjoined it, and of the rest few assume responsibility for the welfare of senior nurses whose retirement is due before the scheme can give them substantial benefit. Taking only these few examples, if every hospital accepted the highest of the current standards of feeding patients and nurses and of promoting their after-care, its annual maintenance expenses would rise appreciably. Everyone with intimate knowledge of the practice of many hospitals could easily select from each a feature which merits general adoption but for the cumulative expense. The liberty and independence of hospital authorities may thus mean progress in some respects or backwardness in others. So far the charitable public has not been disposed to criticise their actions or even, it appears, to study such details of administration as are accessible before deciding whether to support a particular hospital; and this is an expression of the confidence felt in the judgment of hospital boards throughout the country. It is generally recognised that the level of administration is high, and few subscribers to hospitals would welcome’ State grants if their acceptance implied State control; for example of admissions (see p. 166). But for institutions which set a high value on freedom of action to exhibit such fear of freedom of speech argues little faith in the stability of the system of hospital management which they uphold, and is not likely to increase
yet
its
prestige.