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An Academy of Medicine

41"

THE LANCET-L6NDON: SATURDAY, JANUARY 27, 1945

. THE profession is invited to consider two venturesin post-war medical development which have nothingto do with the white-paper on a National HealthService. Both have been mooted under the title ofAn Academy of Medicine. The first is the gatheringtogether of the buildings of the Royal Colleges ofPhysicians, Surgeons, and Obstetricians, along withthe headquarters of many of the larger specialties ;for which purpose the surgeons propose their site inLincoln’s Inn Fields. On this plan the academywould presumably be formed by the voluntary-association of its constituent bodies, each retainingits identity and independence, and all sharing acommon meeting-house. The second proposal is themuch more ambitious one sketched by Sir STEWARTDUKE-ELDER in our columns two years ago.2 Hisacademy would be " a corporation with a statutorybasis, of compact size, authoritatively selected, andwholly divorced from politics. It should be sup-ported by and work intimately with the State, beaffiliated to the Privy Council, and thus responsiblethrough a minister to Parliament." He places underit half a dozen councils : a Council of Civil and SocialMedicine; an Imperial Medical Council; an Inter-national Medical Council;’ the Medical ResearchCouncil; a group of Professional Councils (includingthe Royal Colleges) ; and a Council of MedicalEducation, whose postgraduate hospital in Londonwould stand in the same relation to the teachinghospitals as these do to their associated sector

hospitals. The functions he allots to these councilsare some advisory and some executive. Sir STEWARThas now commended 3 association of the three RoyalColleges in Lincoln’s Inn Fields as a first step towardsthe creation of the statutory academy he has in mind.The assumption that the first proposal is an instal.

ment of the second may be too readily accepted. Anexamination of the purpose in view, and of the likeli-hood that the suggested organisation will serve thatpurpose, should come first. The object of SirSTEWART’S academy is threefold : to advise the State,with a single authoritative voice, on how it shoulddirect and administer its medical services ; to estab-lish British medicine, in place of German, as a leadingcultural and political influence in post-war Europe ;and to be the channel of medicine’s contribution to theinvigoration of our own national life. Are thesefunctions best served by bodies under governmentcontrol or by bodies independent of government ?The advice given to government should be purelyprofessional and scientific, leaving political considera-tions out of account ; but Sir STEwART’s academy,subvented by large sums of government money,and designed as a pyramidal structure with a ministerat its apex, might be subject to political andbureaucratic influence. Situations might even arise

1. Lancet, 1944, ii, 605. 2. Ibid, 1942, ii, 686.3. Times, Jan. 10, p. 5.

where the only way to elicit a "

single authoritativevoice" from medicine would be to exert pressure on itfrom above. The leadership of European medicine isa worthy aim, but it should be sought for its own sake,not as support to British political influence abroad ;and it should rest on the excellence of British medi-cine, not on the strength of government-sponsoredsalesmanship. The zeal of medicine in the national

peace effort might be sapped if all its professionalbodies were over-organised under high direction. Tothese doubts it may be objected that Sir STEWART’sacademy is to be affiliated with the Privy Council, asdistinct from a ministerial department, and is to be" wholly divorced from politics " ; and the presentMedical Research. Council may be quoted as an

example of a professional body enjoying both freedomand government finance. But the MRC’s annual.

quarter of a million is a small sum. The academywould need many times that, and as an organisationand its cost grow large, government control isliable to become more close and detailed. Theinternational role of the academy’is a particularlydelicate one. ’Sir STEWART almost admits that itschief aim may become political, when he urges thatBritish influence should replace that of Berlin, which" was exploited for political ends." Such exploita-

tion of British medicine might prove tempting to agovernment finding itself in close control of most of theorganisation; and while at the moment the professionmay find itself at one with the government and thecountry on its foreign policy this may not alwaysbe so.With socialisation, and its almost inevitable instru-

ment, bureaucracy, steadily and quietly transformingthe structure of our society, it is well to distinguishthose functions of society well served by socialismfrom those that are hampered by its cumbrous anduniform machinery. Among the former are mechani-cal offices, like delivering letters or making munitions,and in general all large tasks which can be simplyand precisely formulated in advance. Among thelatter are most of the activities of man which we callcultural or creative. For these the utmost freedom of =

individuals or of groups is a first essential-completefreedom of expression and reasonable liberty of action.They cannot be administratively integrated. Thetask of medicine is neither purely mechanical andcomputable, nor purely creative. It is something ofeach. So while it may be proper that its routine workshould be tied up in an organised health service-albeitwith pink elastic rather than with red tape-it isessential that its philosophy and its search for truthshould be free, and that the bodies that give expres-sion to these should be independent. The principle iseasily stated; but putting it into practice requiresmoney; and, with the levelling of incomes thatsocialism involves, independent financial support forthe " higher " activities of the human spirit shrinks :already the State supports art galleries, though not yetopera-houses. It is a problem of the socialised Statethat it must find ways of paying for these things,without exercising close control ; for close controlis the expression of the average mind, and these arethe activities of the gifted. As things are, it had betterpay smaller sums to chosen bodies and trust them withthe spending, rather than organise a ministry of finearts or a government Academy of Medicine.

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or most of the objects Sir STBWABT’DUKE-ELDERhas in view, the Royal Colleges, by virtues of theirtradition and their independence, are bodies wellsuited to the task. In research they can play a partcomplementary to that of the universities and thehospitals. In some degree they are perhaps too

narrowly centred on London ; a reorganisation of theequivalent bodies in Scotland into one or two Scottishcolleges would do much to compensate for that. In

presenting British medicine to the world, they arehandicapped by their isolation and the inadequacy oftheir buildings. Undoubtedly their own life and theirwider contribution would be enriched by rehousingthem in propinquity, and it will be a disappointmentand a missed opportunity if the Lincoln’s Inn Fieldsplan, or a better, does not materalise. If Govern-ment support is necessary it might be given as pay-ment for services rendered in connexion with higherqualifications and their examinations. And if the

group of colleges take for themselves the name

Academy, they should do so as a free association ofindependent bodies, cooperating for their own andtheir common ends, after a fashion already familiar inthe British Commonwealth of Nations.

Keep Moving PleaseWE are all familiar with the patient after an

abdominal operation who lies painfully still, fearingto move limb or muscle. And with his joy when heis told : " You can move about, run if you like-there isn’t the slightest risk of your bursting." Weare largely to blame for his over-cautious attitude,for we do not always impress on the nursing staff theimportance of encouraging early movements ; fromhis first awakening from the ansesthetic the patienthears the nurse calling on him to keep still. It is a

pity that in many hospitals the surgical nursinglectures and the orders for postoperative treatmentare the tasks of junior house-officers, and the surgeonis rarely invited to talk to the nurses. ROWLANDS of

Guy’s used to tell his patients, with assumed dignity,"I confer on you "the freedom of the bed," and itwent down well. Early movement is one of ourmost powerful counter-measures against pulmonaryembolism or massive collapse of the lung. Its localvalue we also know ; the muscle contraction callsfor and brings more blood, while the squeezing oflymphatics scavenges debris and prevents the

stagnation and organisation of pools of lymphglue.

w

We know that the moving face muscles heal well ;so does the tongue, and so does the ever-moving chestwall. We have not so much faith in the abdominalwall. Yet many surgeons get their patients aftersimple abdominal operations out of bed by the 4thday, and one at least insists that his abdomino-

perineals meet him in the corridor. by the 7th day.Particularly in America there is a trend to getpatients up even earlier-walking within the first24 hours after operation-the contention being thatthe 3rd day is too late if lung complications or venousthrombosis are to be avoided. NELSON 2 has reportedon 426 abdominal operations treated by early ambula-tion, and has been impressed by their more rapidand smooth convalescence. Within a few hours of

1. Neuberger, B. Surgery, 1943, 14, 14z.2. Nelson, H. Arch. Surg. 1944, 49, 1.

the operation he asks them to walk to the bathroom(no-one is unduly urged to do this) ; they then situp in a chair for a time before returning to bed. Theabdominal wound hurts slightly at first, but withfurther movement becomes less painful. Most sur.

geons will agree with this observation, and un-

doubtedly the " moving " patient is rarely troubledby painful stitches. ’ NELSON also points out that,despite their bawlings and struggles, wound dis.

ruption is almost unknown after operations on infants;and in animals, even with their vigorous movements,experimental wounds heal firmly. But catgut was notused at any of NELSON’S operations; indeed herecommends that only if cotton or nylon has beenused should early ambulation be allowed. LOCALIO,CASALE, and HINTON 3 have shown experimentallythat the tensile strength of a wound sutured withcatgut is at its weakest on the 3rd or 4th day, andMASON 4 maintains that any motion during this lagperiod will stretch the forming scar. With cotton,nylon, or wire the minimal strength of the woundis at all times far above that with catgut. In Britaincatgut is still on the whole favoured, although thereis a growing tendency to use non-absorbable suturematerial. Such very early rising may for’ thisreason-and others too-not be advisable afterabdominal section, at any rate in this country.Moreover, NELSON’S figures indicate that 317 out ofhis 426 abdominal operations were appendicectomies ;although the 79 hernia wounds healed well, the

follow-up results are not described, and these arethe real test. The appendicectomy wound is usuallyvalvular and does not necessitate a long convalescence.South Africans will recall an international ruggermatch where the New Zealand full back played 3weeks after an emergency appendicectomy (and hehad done some training first). But to get a soldierfit for duty takes longer. DiVELY 5 found that afterappendicectomy an average of 61 days’ rehabilitationwas needed for the US soldier to be able to march17 miles a day with full kit.Our attitude towards head injuries too has changed

in recent years. We no longer insist that the patientwith concussion or a fractured skull must lie. still ina room with drawn blinds and darkened lamps,while all around, with tiptoe and whispering, gloomyfaces tell him to keep quite still. That is a sure wayto convince him that his brain has been damaged,that he will be abnormal and unable to competefully in his future life. Emphasis is now laid on thenear-certainty that there will be no permanentdamage-he is got out of bed early, rapidly rehabi-litated, and by trial brought back to normal life.If he gets headaches or dizziness he may be put backtemporarily, but only for a day or so. How satis-factory this may -be is shown by CADE’S extensiveexperience of head injuries in the Royal Air Force.He has enunciated a new all-or-none law : "If acase of head injury escapes death, the injury is suchthat return to full flying duties can confidently beanticipated." .

There are two important contra-indications to

very early movement after operation-when infection3. Localio, S. A., Casale, W., Hinton, J. W. Surg. Gynec. Obstet.

1943, 77, 376. Ibid (Int. Abstr. Surg.), p. 369.4. Mason, M. L. Ibid, 1939, 69, 303.5. British Orthopaedic Association meeting, London, Dec. 15, 1944.6. Cade, S. Brit. J. Surg. 1944, 32, 12.