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wards will have to be closed, or maintained entirely bypart-timers.

STATUS AND REWARDS OF NURSING

What are the incentives to take up mental-deficiencynursing ? ‘ Are they adequate ’? The answer seems tobe clearly " no." Nursing, we know (and are continuallytold by successful general nurses), is a vocation ; materialrewards should not be required ; the satisfaction ofservice is enough. But medicine is also (surely) a voca-tion ; yet the Spens scales and the Danckwerts awardwere regarded as necessary. The rewards for nursingin fact do not seem to attract or to hold enough recruits.Here are the views on wastage of two able and devotednurses who have spent their lives in Darenth Park:

" One of the chief reasons is hours of duty, and the factthat the student nurse comes to realise that while it is possibleto qualify as staff nurse in three years, it will be a furtherseven years before the maximum salary for this grade isreached. Added to weekend, evening, and night duty this istoo much, and in spite of reasons for resignation given onthe forms these are usually the real causes for the nurseleaving. As for male students, the young married men whoare stable and responsible folk cannot afford to take uptraining : their future is uncertain, they have various Servicecommitments, and even after their National Service periodthey require the wherewithal to set up house. If forced tolive in, they leave promptly, because it is financially impossiblefor them to exist. Cases have been known, where the youngwife was willing and able to continue to work until the husbandqualified ; but not infrequently this has been terminated bythe arrival of offspring. At other times the wife has pointedout that the husband of the young wife next door is free

every evening, on Saturday afternoons and Sundays, andon bank holidays, never has to do night duty and, in addition,is in receipt of several pounds more wages.

" The basic fault is that both salaries and conditions havefailed to conform to the pattern of improvement to be foundin other occupations and, more especially, to the rapid risein the cost of living since the war. Those responsible for therecruitment of nurses must realise that they are now competingwith industry and trade interests in the labour market, andthat the nursing profession must offer opportunities ofremuneration which are equal to, if not better than, thosein other fields of employment. Furthermore, the greaternumber of male nurses in recent years means that the wagesmust be such that they can support and educate a family."

Recognition by the public and by the whole nursingprofession of the special difficulties of the mental hospitaland mental-deficiency colony nurse seems long overdue.Its absence has caused resentment.

SOLUTIONS ?

It has been said in some quarters that the only solutionis euthanasia. Others suggest compulsory nursing servicefor all. To both of these the objections on ethical,professional, and practical grounds are sufficiently obvious.It appears to us that this grave problem could be partlysolved if the profession of mental-deficiency nursing wasaccepted by leaders of the nursing profession and thegeneral public as one which entails great skill, and isof great social value, thus deserving appropriate rewardsand prestige.Attempts are already being made to form local associa-

tions of " Friends of the Hospital " for mental-deficiencycolonies, and the more the people who take part in these,and help the work of any colony in its area, the betterit will be for all concerned. Newspaper publicity givento " escapes " often does the reverse, by exciting fearand suspicion. Attempts have been made in this regionand elsewhere to get the public interested and responsible,and we believe that in the long run this is one of the mostprofitable lines of approach.

SUMMARY

Work on training defectives has shown that with

patience and skill much can be done to make many

defectives socially useful, stable, and happy people.Many of them do not need permanent institutionalcare.

Existing facilities for training are not being usedto the best advantage. The reason for this is shortage’of staff.

The shortage of student nurses is getting worse andthere are indications that it will continue to do so in thenext few years.

There are still enormous numbers of defectives awaitinginstitutional care. Many of these present most tragicproblems for their families. Some have been waitingfor years already, and the waiting time is likely toincrease as the nursing shortage grows.

Local improvements can be made by regional hospitalboards and hospital management committees. Butthe problem is really a national one and only achange of official policy towards mental-deficiencynursing, and a change in public opinion about theimportance of the work, will bring any permanentimprovement.

Points of View

MEDICINE AND THE WELFARE STATE*

H. M. C. MACAULAYM.D., B.Sc. Lond. D.P.H.

SENIOR ADMINISTRATIVE MEDICAL OFFICER, NORTH WEST

METROPOLITAN REGIONAL HOSPITAL BOARD

* From the John Tate memorial lecture delivered before theMiddlesex County Medical Society on July 21, 1953.

THE Welfare State is the name given to an arrange-ment of the nation’s social and economic resources

whereby the community, out of funds contributed byeach member according to his means, supplies a widerange of services for the bodily and intellectual needsof any member of the community desiring them.There is nothing novel in the conception of the

stronger brethren helping the weaker: it has beena tenet of the Christian faith for nearly two thousandyears ; indeed, it goes back far beyond that and hasbeen dignified by the noble but now unpopular nameof charity-or love of one’s fellow men. To this attributemany of our hospitals and other benevolent institutionsowe their foundation and their strength. Nor is there

anything very novel in the conception that the richshould be taxed to provide for the needs of the poor,for the first Act of Parliament to this effect was placedupon the statute-book in the reign of Elizabeth I. Whatis new in the modern Welfare State is the principlethat rich and poor alike contribute directly or indirectlythe funds which finance it ; and the concept that theState is in a better position than the individual to provide,for the individual, a very wide range of services andbenefits.

These include education from the infant school tothe university ; care of the body from conception to

cremation, including a comprehensive medical service;an income during illness, incapacity, unemployment,widowhood, and old age. Included also are a large numberof benefits or concessions to classes of the communitywhich have claims for particular consideration in thenational interest or on grounds of compassion, such asexpectant mothers, infants, school-children, the blind,and those disabled in industry. All these benefits are

bestowed wholly or largely without regard to the meansof the beneficiary-they are paid for by all and aretherefore enjoyed by all. Some paradoxes occur hereand there ; thus many of those who contribute mostto the Welfare State expect least from it, and vice versa;and the poorer man may realise that he is subsidising

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the rent of the council house, occupied by his more By " medicine " I mean not only the men and womenwell-to-do neighbour.

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engaged in the profession of medicine but its tradition,Although its name is comparatively new, the Welfare its science, and its warm humanistic art.

State has been growing rapidly in this country since Apart from the possibility of political interference,the first world war, though its roots, even in its modern there must always be in a great national service whichconception, go deeper than that. There is no doubt that is directly answerable to Parliament, a measure ofsince that time the poor have become markedly less departmental control from the Government departmentpoor. Able as I am to look back a good many years, I concerned-in this case the Ministry of Health. Thecan see a tremendous change for the better in the health, nature and extent of this will depend upon the wisdomappearance, and habits of the poorer members of the and experience of the senior Civil Servants concernedcommunity. Perhaps the most striking index of this and the source to which they turn for expert advice.improvement is the infantile-mortality rate which it Control is also exercised by regional hospital boards,would not be too inaccurate to describe as varying by boards of governors, by hospital management com-directly with the product of poverty and ignorance. As mittees, and by executive councils, on all of which thethe poor have become less poor and more enlightened medical profession is well represented.there has been a spectacular fall in infantile mortality The type of administrative structure which has beensince the early years of the century in spite of two world evolved by regional boards and hospital managementwars. These matters are not without effect on the committees is based largely on local-authority practicepractice of our profession. -that is to say, tiers of committees and subcommittees.During this century there have been many variations This has the advantage of bringing many minds to bear

in what might be termed the natural history of disease upon any given problem and allows many people towhich affect our daily clinical work. When I was a comment upon any given proposal. To this extent it ismedical student chlorosis and rickets, though not nearly democratic. It was devised, however, to suit the needsso commonplace as they were in my father’s practice, of local authorities whose problems on the whole arewere by no means rare. Of all micro-organisms the far more static than those with which the National Healthstreptococcus was looked on as the chief enemy of man Service has to deal. The hospital service in particularand the most dreaded of the killing infectious fevers is intensely dynamic, and problems of quite a majorwere scarlet fever, diphtheria, and typhoid. Tubercu- character which call for speedy action are apt to ariselosis, both of the lungs and of the bones and joints, was at short notice. The present administrative machinefar more common, and its results more serious, than they is far too slow and cumbersome for much of the workare today. In some of the changes in the face of it has to do. At present the service is tending to stranglemedicine, the Welfare State in its widest sense can itself with red tape of its own weaving. Moreover,claim to have played a part. So far as the practice of on the administrative side of any great organisationmedicine is concerned, however, the changes have not there are minds, among members and officers alike, whichall been in one direction. The Welfare State, by pro- pav more heed to the correct procedural working of thelonging life, now calls upon doctors to treat more of the administrative machine than to the results achieved. Indegenerative conditions of old age, and indeed more of this way the machine can quite easily become morethe diseases of middle life such as malignant disease and important than the job it has been created to perform-coronary tbrombosis-though I do not for a moment a phenomenon which at various times in my life I havesuggest that mere prolongation of life is more than a witnessed to my sorrow and anger.minor factor in the increase of these diseases recorded inrecent decades. The Medical DirectorThe Welfare State has come to stay. As I have tried Any control involves some infringement of personalto show, it has been slowly coming into existence for a liberty but the alternative to some measure of controlnumber of years ; and today, as all the great political is anarchy. This brings me to a matter of internal

parties are committed in principle to the Welfare State, hospital administration about which I feel very keenly.with the National Health Service as one of its main It is the denigration of the medical director. Since thesupports, it may safely be regarded as a permanent part Appointed Day many medical directors of hospitals haveof the social and economic structure of this country. been slighted, ignored, and in some cases eliminated-We shall do well, then, to consider the influence this fact a state of affairs for which our own profession is veryis having and is likely to have upon medicine. largely responsible. The passing of the medical director

Politics and Control has been greeted with acclamation by many consultantsPolitics and Control and specialists of this country, by which they have

The National Health Service costs a great deal of shown themselves to be suffering from an alarmingmoney. Any Chancellor of the Exchequer would be degree of myopia. By their action they are permittingsomething more than human if he did not sometimes hospitals, which are the most essentially medical ofcast covetous eyes upon the substantial proportion of institutions, to pass under lay control.the total national expenditure which is being devoted It is almost always forgotten that when the mightyto the health service in all its branches and to other have been put down from their seats and the humblesocial services such as housing which affect the health and meek have been duly exalted, the humble andof the people. Although the political parties agree on meek in their turn become the mighty and may indeedthe principle of the National Health Service there are become more severe taskmasters than their predecessors.differences of opinion on its detail. It seems that there We experienced this as a nation when we tried our briefis a real risk that the service, and indeed medicine, experiment in dictatorship in the time of the Stuartmay become the sport of party politics. I am one of kings, and we learned our lesson 300 years ago. The samethose who believe that medicine, like religion, should thing happened in the French Revolution and in thebe kept as far from politics as possible, and that the Hitler dictatorship in Germany. It has happened timesolution of medical problems should be sought by a and time again in the affairs of the South Americanscientific and objective approach without reference to republics ; it is happening before our eyes today inthis or that party line. Medicine should transcend party certain of the countries in the Middle East, to say nothingpolitics. One can only hope that politicians will be of Eastern Europe.wise and statesmanlike enough to recognise that - to A vacuum is being created in our hospitals which thebring medicine into the political cockpit would be to do lay administrator is being rapidly and superficiallyit, and the public, the greatest possible disservice. trained to fill. I have nothing against the lay adminis-

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trator who is often an able man with a keen intelli- The Need for Planninggence and a good business head ; and no reasonable

.

-...

man will deny that the business side of a hospital can The National Health Service within the Welfarebe looked after just as well by a well-trained layman State was devised as a planned service within a plannedas by a doctor-and perhaps better. The error which national economy. One of the strongest arguments ill

has been made is in the confusion of thought which favour of its introduction was the need to bring an elementmixes the business side of a hospital with the hospital of planning into a service which, as a service, had hithertoitself. Good as a lay administrator may be, there are been almost completely incoordinated. As a result theredaily problems of medical administration arising in a were gaps here and overlaps there with consequenthospital with which only a doctor can effectively deal. inefficiency and waste of effort. Since the health service

Every medical director knows this. It is no doubt pleasing came into existence five years ago, rational planning,to a consultant to feel that he possesses not only clinical very largely empirical, has effected enormous improve-autonomy-which is essential-but also administrative ments and has greatly raised the standard of service to theautonomy over his own department as well. But the sick population of this country as a whole. Effort hasresult, so far as concerns the medical administration largely, and I believe properly, been concentrated on theof the hospital as a whole, is anarchy-and that is the more backward areas so that some of the more efficientcondition in many hospitals today. A consultant who elements in the health service have very largely markedjoins the staff of a hospital joins a team, and a team time.

needs a captain if coordinated effort is to be achieved. It might here be desirable to give a little thoughtI think it matters little whether the medical leader is to what might be the hospital of the future. The publicappointed or elected, whether he serves for life or for has been encouraged to expect bigger and better hospitala term of years. What is essential is that he should services, and there is likely to be no slackening of theenjoy the confidence of the staff, should have time to demand in the years to come. Up to the present ourdevote to his medical administrative duties, be suitably principal method of meeting the demand has been therewarded for the heavy additional responsibility he is provision of hospital beds. The bed, in fact has becomecalled upon to bear, and be endowed with sufficient the chief unit of measurement of the importance of apower and authority, and no more than sufficient, to hospital, and a high percentage occupation is regardedenable him to carry out his duties. as an index of efficiency. In the present state of theAs matters are moving, it looks very much as though nation’s health and social habits this condition of affairs

hospitals will pass completely under lay domination is inevitable ; but to project this conception into the-medical advice on technical matters being sought future is surely illogical, for our aim should be to keeponly as thought desirable by the lay administrator. patients out of hospital. The admission of a patientIf this happens, the loss to medicine and to the public to hospital is in a sense an admission of failure-anwill be very great. acknowledgment that our preventive measures have

Rights and Responsibilities broken down. I am using the word " preventive :’

Rights and Responsibilities .

here in its widest possible meaning, including the preven.I have referred to the danger of the administrative tion of accidents at home, at work, or on the roads;

machine coming to be regarded as of more importance the prevention of serious and chronic illness by recognitionthan the work it has to do. A comparable danger is and treatment of its early manifestations, as well as thethat of the worker coming to regard himself as of more eradication of many diseases which assail us and about

importance than the work he does. This is a state of which our knowledge as regards preventive measures isaffairs which may occur in any circumstances, but as yet absent or incomplete. Today many patients areexperience shows that the larger and more highly admitted to hospital for investigation because facilitiesorganised an industry or service becomes, the greater in too many of our outpatient departments are lackingis this tendency. Today the vast majority of all workers and conditions unsatisfactory for investigations of anyin the field of health-professional, technical, and magnitude, so that it is far simpler for the consultant

manual-acknowledge one employer-the State-an to admit the patient to one of his beds. Many otherorganism with no body to kick and no soul to damn. patients are admitted because of failure to diagnoseSince the National Health Service was first mooted, sufficiently soon a condition which at all earlier stage

it has been most noticeable how vociferous have been might have been treated at home.the various groups of workers in the health service in The continual expansion of our hospital beds in responsetheir demands for their personal betterment. Granted to insatiable demand would ultimately break the Welfarethat this clamour is by no means confined to the health State through sheer force of economic circumstances.service but represents a sign of the times in which we live. For this reason and also to avoid the disruption of familyGranted that the demands were sincerely regarded as life which hospital admission entails, should we not

justified. Nevertheless one cannot but deplore the direct our efforts to keeping a patient in the hands of histendency to rank rights as higher than responsibilities family doctor rather than admit him to hospital ? Thisor to seek to take more out of life than one puts in. would involve a fairly drastic reorientation of thought,Amid the strident brass of rights and the clanging especially on the part of those who are responsible forcymbals of privilege, the soft overtones of duty and the the education of the medical student ; it would involvegentle harmonics of responsibility may pass unheard putting aids to diagnosis and home treatment more andor unheeded. If medicine is to reach its greatest heights more at the disposal of the general practitioner andit must contain a large vocational component, and planning our new hospitals with outpatient departmentsit would be a sad day if work of any kind in the health or policlinics on a far more generous scale than hasservice were to be regarded merely as a job to be done hitherto been contemplated in this country. Hospitalat so much an hour ; if staff were to consider themselves beds of course are necessary, for many acutely ill patientsentitled to privileges not accorded to those who provide will need admission however perfect our preventivethe service ; or if a hospital came to be looked upon measures may ultimately become ; and, as for chronicas a pleasant place if it were not for the patients. As illness, no prophylaxis can indefinitely postpone themen and women of education and holding the most degenerative changes which are the concomitants of

privileged and therefore the most responsible place in advancing years. I do submit, however, that in thethe country’s health service, it behoves us doctors by decades ahead the slant of thought in the hospitalprecept and example in our daily work to foster the world should be away from the bed and towards thespirit of vocation. policlinic.

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More thought, too, should be devoted to the develop- arfid mortar and derives from the minds and hearts of

ment of the day hospital and the night hostel as less those in authority in a hospital, and also from tradition.expensive alternative means of providing the equivalent Planning can deal only with material things, the structure,of hospital inpatient treatment. The day hospital is functioning, equipment and staffing of a hospital. Oneuseful for those patients who need protracted and cannot plan a spirit into a hospital; but by over-

intensive forms of treatment but who are ambulant and centralised direction and by planned over-concentrationhave satisfactory home conditions. Examples are centres upon detail one can by interference drive the spiritfor certain forms of psychotherapy, centres for rehabilita- out of a hospital.tion after injury or illness, and geriatric clinics. At all Planning, applied to medicine, if carried too far canof these, treatment of patients individually or in groups be very frustrating. Apart from our lack of precisemay go on all day ; patients are given a midday meal knowledge, we have to deal in applied medicine with aand return home at the end of the day. They correspond host of variables-movements of populations, theto the day pupils of a public school. The night hostel changing tastes and habits of society, changes in birthon the other hand caters for patients, again ambulant, and death rates, the ageing population, variations in thepossibly even fit to be at work of some kind, but whose pattern of disease, and discoveries in medicine. Thehome conditions are either responsible for their illness effects of some of these trends are to some extent predict-(as in certain neuroses), or militate against their effective able, others are incalculable. Planning in the healthtreatment (as in some cases of pulmonary tuberculosis). service is therefore largely a matter of empiricism and

Too Much Planning to think of it as a scientific process is merely self-deception.

Planning in the sense of looking ahead, trying to fore- The Irresponsible Litiganttell future trends and making provision to meet them is ..

wise and prudent, as is a measure of experimentation in There is one other impact of the Welfare State uponall fields of health work. But planning, as other good medicine on which I would like to touch. Formerly athings, can be overdone-it has its uses and abuses. patient receiving treatment in hospital regarded his

Since the National Health Service came into being five care and attention as a gift of grace and accepted with

rears ago, planning on the whole has been very successful ; thankfulness what was offered. Today he realises thatand herein lies a danger, for the success is an encourage- the hospital service is something for which he has paidment to the planner, situated perhaps somewhat remotely and he expects it to be at his disposal. and if resultsfrom the point of contact between patient and doctor, expects not only treatment but results ; and if resultsto proceed to further and more detailed efforts. More- are not up to expectation, or through some accidentover there is a large body of opinion which holds that or human error are unfavourable, he is becoming moreevery part of the health service must have intense and and more prone to seek satisfaction in the courts of law.detailed planning if it is to be effective and efficient. Two further factors have aggravated this trend. One is

The great institutions, however, which are part of our the tendency during the last three or four years for theBritish heritage and way of life were not the result of courts to ascribe to negligence unforeseen consequencesdeliberate planning. The British Constitution, unwritten of treatment and mishaps which formerly would notand illogical, has been evolved through the centuries- have been so ascribed. The principle of res loquiturand it works. The French are said to be the most logical has been followed rather strictly by the courts-that

people in the world. They have within the last few years is to say, if there is some untoward consequence of treat-laid down a new, planned constitution-and a Frenchman nlellt in hospital, negligence may be presumed unless thewould be the first to admit it does not work. British hospital can otherwise explain the untoward consequencejustice which is respected throughout the world is based to the satisfaction of the court.upon common law which is unwritten and unplanned but The other factor which has latterly brought medicineis a product of evolution ; and flexible enough to be into the law-courts is that in certain circumstances the

moulded in conformity with the changes of thought Welfare State now provides prospective litigants with abegotten by changing conditions. To turn to homelier free legal service. Whilst no-one would wish justiceinstances of equally British institutions : I should find to be denied to the poor, there can be no doubt that a

it hard to believe that a century or two ago a sporting combination of free medicine and free law has broughtplanner with the tools of his trade sat down and produced about a sense of irresponsibility in litigation, in that

. a complete blueprint of cricket or football. whatever the result of an action the costs will be paid

. Admittedly some of the evils from which our country out of the bottomless purse of the State. A litigant may; suffers have been brought upon us by lack of intelligent thus be in the happy position of

" heads I win, tails youa planning, for example our slums and our atmospheric lose," and today many actions of an almost frivolous

pollution-evils which it is now very difficult to remedy. nature are being settled out of court sooner than that

r Nevertheless planning can easily be overdone. The the State should incur the possibility of damages and, health service is yet in its infancy ; our knowledge the certainty of costs.t of many of the problems with which we are confronted All this is bad for medicine. Doctors are not infre-

in a preventive and curative health service on a national quently joined as defendants with governing bodies ofscale is rudimentary, and some of the premises on which hospitals, with the result that there is a tendency,planning is being attempted are very dubious. We either privately or in court, for each defendant to trydo not even know how many beds per thousand of the and throw the responsibility upon the other, thus impair-population are needed for a given community, and until ing the mutual trust and respect which should exist

many field experiments have filled some of the gaps in between a hospital and its staff. There is also theour knowledge it seems that planning should proceed possibility that the public will suffer through doctorsin the light of such commonsense as may have been becoming unwilling to take possible risks in the interestsvouchsafed to us and that it should deal with outlines, of their patients if legal action is likely to be a con-leaving the detail to be filled in by the man on the spot sequence. In justice to the ideals of my own professionwho would thereby work out his own salvation and that I would say I am certain that we are far from such a sorryof the department which he served. state of affairs ; but I have myself seen in recent timesEvery hospital has a spirit-something it is extremely on the part of governing bodies in the health service

difficult to define, but something which all of us who have the safeguarding of a public authority against possible[ worked or been a patient in hospitals have experienced legal consequences becoming the dominant consideration

and can recognise. It is quite independent of bricks in the formulation of policy. No profession can put

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its best foot forward if it is continually looking over itsshoulder to guard its posterior against a kick from therear.

The Task and the OpportunityIn the course of this address I have posed a number of

problems, the answers to which I do not pretend toknow. I have also pointed out a number of unfavourableinfluences which need to be guarded against if medicalscience and art are not to be impaired. The NationalHealth Service in this country is the greatest experimentin social medicine which the world has ever seen. Itis yet in a very early stage in its development andflaws in its structure are bound to appear. That thesewill be corrected in the light of experience I have not theleast doubt, for of the great nations of the world we arethe most politically mature and have a flair for improvisa-tion, compromise, and the application of common sense.There is a great task before us all ; but if we play ourparts with patience and wisdom I firmly believe weshall have a health service which will be the wonder andthe envy of the world, and this new Elizabethan agewill see British medicine surpassing even its proudrecords of the past in promoting the health of the

people.

1. The National Insurance (Industrial Injuries) (Prescribed Diseases)Amendment Regulations, 1954, S.I. 1954, no. 5. H.M.Stationery Office. 4d.

Public Health

Prevention of AccidentsA PAMPHLET dealing with accidents to children and old

folk has been sent to general practitioners in Ilford byDr. I. Gordon, medical officer of health for the borough.The advice about children is largely based on materialprepared by the committee on accident prevention ofthe American Academy of Pediatrics. One aim is toencourage doctors to keep a sharper look-out, on theirrounds, for conditions that could readily lead to accidentsin the home.

Insurance against PneumoconiosisThe Minister of Pensions and National Insurance has

made regulations which provide extended insurancecover against pneumoconiosis. At present, benefit forpneumoconiosis under the National Insurance (IndustrialInjuries) Acts is available only for persons who, sinceJuly 5, 1948, have worked in occupations which havebeen scheduled because they are known to be capableof giving rise to the disease. Under the new regulationsbenefit will also be available to those who have neverworked in a scheduled occupation but who are sufferingfrom pneumoconiosis which is attributable to the natureof their work since July 5, 1948, in some other dustyoccupation. Before being referred to the pneumoconiosismedical panels, however, claimants from unscheduledoccupations must provide a medical certificate or someother evidence to show that there is reasonable causefor suspecting that they are suffering from pneumo-coniosis. This provision was recommended by theIndustrial Injuries Advisory Council to protect thepanels, with their limited resources, from having to carryout needless examinations. The new regulations alsoprovide disablement benefit of 5s. 6d. a week in caseswhere disablement from pneumoconiosis is assessed atbetween 1% and 10%. Hitherto, no benefit has beenpayable on pneumoconiosis assessments of less than 5 %.The regulations came into effect on Jan. 11 ; and fromthat date benefit will also be available, under the Pneumo-coniosis and Byssinosis Benefit Scheme, 1952, to personstotally disabled by pneumoconiosis who have never

worked in a scheduled occupation and whose last workin any other dusty occupation was before July 5, 1948.The Industrial Diseases (Benefit) Bill, now beforeParliament, would enable the Minister to extend thePneumoconiosis and Byssinosis Benefit Scheme to covercases of partial disablement.

Management of Burns

* The members of the subcommittee are : Mr. R. J. V. BATTLE,Mr. PATRICK CLARKSON, Mr. RAINSFORD MOWLEM, Mr. ROWLANDOSBORNE, and Mr. A. B. WALLACE. They are glad toacknowledge assistance from Mr. A. D. R. BATCHELOR andMr. R. L. G. DAWSON.

A series of six articles prepared by a subcommittee of theBritish Association of Plastic Surgeons * .

III. NUTRITIONAL CARE OF THE BURNED

PATIENT

AFTER a severe burn, profound alterations occur in thephysiological balance of the patient. Certain of thesechanges affect particularly the nutritional state.The metabolic-rate rises rapidly following a severe

burn, and may remain elevated for several months.The " reaction to injury " occasions an increased lossof nitrogen in the urine, and this loss is greatest inpreviously healthy adults. Nitrogen is also lost from theburned surface, particularly in extensive infected burns.Lastly, the demands of the body for protein are increased.by the processes of repair and healing.

At the present time, hard and fast figures for thevarious nutritional elements cannot be stated with anyconfidence. A diet for a seriously burned patient must,obviously, contain a balanced mixture of protein, fat,carbohydrate, accessory food factors, and minerals,as well as an adequate total of calories and water.

BALANCING THE DIET

Protein

The incr-eased demand for, and loss of, proteinnecessitates an intake well above the normal require.ment. Should this not be provided, the serious sequelae ofprotein deficiency will appear. The extent of the bum,and the age, sex, and previous nutritional state of thepatient must all be considered in gauging the ideal intake.The normal daily protein intake in health varies from4 g. per kg. in the infant to 1-5 g. per kg. in the adult.A moderate intake for the burned patient would givea 50% increase in the child, and a 100% increase in theadult. Considerably higher levels may be needed for theseverely burned patient.

In assessing the efficacy of a particular intake,accurate nitrogen balances are rarely feasible in clinicalpractice, and reliance must be placed on simpler clinicaltests. Variations in a patient’s weight, the plasma.protein level, the haemoglobin, and the rate of healingare valuable pointers.Caloric IntakeThe raised metabolism and the high-protein intake

combine to necessitate a high caloric intake if tissuedepletion is to be minimised. Caloric requirementsin health vary from 100 calories per kg. in the infant to45 calories per kg. in the adult. For burned patients,an increase of at least one-third above this normal isrequired.Fat and Carbohydrate

These two components provide most of the caloriesneeded. Individuals vary considerably in their toleranceto fat, and its proportion in the diet must be adjustedaccordingly. Many burned patients will tolerate fat

up to 30% of the total caloric intake, some up to 50%.Its high energy value per unit weight makes fat a usefulaid in producing a diet high in calories without excessivebulk.

Carbohydrate metabolism may be deranged followingsevere burns, and hyperglycaemia and glycosuria maybe present. Anything more than a mild degree of hyper-glycaemia and glycosuria would be an indication for

decreasing the carbohydrate load.