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394 S .A . M ED IC AL JO UR NA L 19 May 1962found distributed in al l organs - particularly in liver andin kidneys, the only ones to show histological abnormality.2. The animals excreted in th e urine a mixture of normalerum albumin and ,low"molecular proteins; !the low-molecular proteins as found in human cadmium poisoning.3. Changes in the blood were found, consistent withthe p resence of abnormal serum globulins.4. Radio-isotopic studies with glycine an d lysine ar edescr ibed which suggest th at the low-molecular protein ismetabolized more rapidly t han norma l serum proteins, an dis eliminated promptly t hr ough the renal glomerul i.5. Quantitation of th e disorder of protein metabolismp re ent in cadmium poi soning i s discussed.We wish to acknowledge our indebtedness to Dr . R. A.Kcl..wiok for th e ultracentrifugal measurements, to Drs. E. W.Emery and H. G. B. Slack for their invaluable guidance inthe i o topic experiments , and to Dr . I. P. Smith fo r histological reports on the tissues of the experimental animals.We are grateful to Profs. R. E. Lane, C.B.E., and A. C. P.Campbell, University of Manchester, for advice and the facilities of their departments. The Medical Research Council,London, has generously supported these studies with grants

to A.R.W. and I.C.S. and with a gift of the CH-labelledamino acids.REFERE 'CES

1. Friberg, L. (1950): Acta med. Scand., 138, suppl. 240.2. Baade r, E. W. (1951): Dtseh. m ~ d . Wscbr., 76, 484 .3. Bnnnell , J . A . (1955): Brit. J. Indust r. Med . J2 , 181.4. Smith. J. C . Kencb, J. E. and Lane, R. E. (1955): Biocbem. J. ,61, 698.5. Smitb. J. C. and Kench, J. E. (1957): Brit. J . I ndus tr . Med., 14, 240.6. Lan e, R . E. and Campbel l, A . C. P. (1954): Ibid., 11, 118.7. Smitb. J. C. , Kencb , J . E. and Smi tb , J . P. (1957): Ibid . 14, 246.8. Clarkson, T. W. and Kench, J. E. (1956): Biocbem. J. , 62, 361.9. Bonnell, J. A. , Ross, J. H. and King, E. (1960): Brit. J. Industr. Med.,17, 69.10. Bonnell, J. A. , Kazantis, G. and King, E. (1959): Ibid., 16, 135 .11. Kekwick, R. A. (1955): Ibid., 12, 196.12. Smi th . J . C. . Wel ls , A. R. and Keocb, J. E. (1961): Ibid., 18, 70.13. Webb, R. , Rose, B. and Sehon, A. H. (1958): Canad. J. Biocbem.,36, 1159.14. Idem (195 ): Ibid., 36, 1167 .15. Rowe, D. S. (1957): Biocbem. J. , 67, 435 .16. Smitb, J. C. and Wells, A. R. (1960): Brit. J. Industr. Med., 17 , 205.17. McFarlane, A. S. Dovey. A. , Slack, H. G. B. and Papastamatis, S. C.(1952): J. Path. Bact., 64, 335.I . Porath, J. (1960): Biocbim. biopbys. Acta (Amst .) , 39, 193.19. Bruce, A. M. and Parkes, A . S. (1947): J. Hyg. (Lond. ). 45, 70.20. Hiller, A., Mclmosh , J. F. and va n Sl yke , D. D. (1927): J. Clin.Invest.. 4, 235.21. Neube rger , A. , Per rone, J. C. and Slack, H. G. B. (1951): Biochem. J. ,~ I .22. Henriques, O. B., Henriques , S. B. and Neuberger, A. (1955): Ibid.,60, 409 .23. Gitlin, D. , Janeway, C. A. and Farr, L. E. (1956): J. Clin. Invest.,35,44.

THE HOSPITAL ADMINISTRATOR*SAMUEL DISLER, M.B., CH.B. (CAPE Tow'), President , atal Coastal Branch (M.A.SA.), 1961

'The hospi ta l' , said Abernethy , 'i s the only proper college inwhioh to rear a true disciple of Aesculapius'.But how much does this true disciple of Aesculapius knowof the vast ramifications of the hospital, t ha t need efficientand smooth oroganization so that he may practise and improvehis profession, treat and heal his patients, test and try hiscience?There i a side of medicine that receives scant attentionfrom the average doctor and little con ideration from theaverage patient; possibly the nursing profession give t!his

aspect of medicine better recognition. I re fer to th at importantpa n of medicine which is calledmanagement - good medicineneeds good management.The general practit ioner, thesurgeon, the physician , or thedoctor practising anyone o f t hepecialties, depends as much ongood management of his practice to give of his best as hedoes on his medical knowledgeand skill .HOSPITAL MANAGEMENTThere cannot be good medicinewithout good managementwhether thi management isconducted by the doctor him-self, as is the case in privatepractice, or whether it is con-Dr. Dis le r ducted for him, as in hospitalpractice.Before the surgeon can wa h up and pu t on his sterile gown,let a lone open an abdomen, a hundred ervices have to becoord inated and t imed. The patient musl be delivered safelyon to the operating table, the surgeon must be given facilitiesto begin his operation, his assistants must be ready to servehis every need. These services have to be provided for himby the hospital administrator who has to see to the exact timingof al l the services.The patient's life and health depend on the skill of theurgeon; the urgoon's skill is wonhless if every fac ili ty is

Valedictory address delivered in Durban on 15 February 1962.

no t provided for him. Behind the surgeon (and the physician orany other doctor who uses the hospi ta l) s tands the adminis trator, who is to the other hospital doctors wha t th e general isto hi s fighting units.The pat ient 's l ife and health and much of hi s futurehappiness depend on skilled nursing; behind the nurse standsthe adminis trator as well.The patient's life and health and much of his future happinessdepend on how he is t re at ed in hospital: the food he eats,

the way people talk to him, t he s leep he gets, his visitors,t he at tit ude of the hospital doct or s and nurses and stafftowards him - and towards his people and his own familydoctor. The patient's future hea lth and happiness depend ineffect on the att itude of 'the hospital' to him, to his relatives,t o his friends, to his own family doctor. And make no mistake:a hospital is as good as its head - or as good as the hospitalhead is allowed to be.The Doctor-administratorAnd make no mistake either; a hospi ta l administrator mustbe first, last and al l the time - a doctor. A layman with agood business head can undoubtedly be trained to do al l theadministrative work of a hospi tal- as he could be trainedto do al l the administrative work of an army - but one thin-gno such training will t each h im is to be a doctor. The generalof an army must be pr imar ily a soldier; dIe hospi ta l administrator must be primarily a doctor with the whole tradition

of medicine behind him - from Imhotep and Hippocratesand Luke to Cosmos and Damian; from Linacre and Sydenhamto OsIer.We doctors are a peculiar people with a particular outlook.Humbly (yet proudly) we say, too: we are a chosen people.

R. L. Stevenson wrote: 'Vhere are men and classes of menthat stand above t he common herd: the soldier, the sailorand the hepherd no t infrequeIl!tly; the artist rarely; .rareliersWl the cleJ1gyman; the physician almost as a rule. He is thef lower (such as it is) of our civilization'.Medicine i not learned out of a book- though rich is theheritage of medical book: cientific, philosophic, l iterary,poetic, dramatic, historical . . . iledicine is no t learned inthe lecture room - though the l ec turer p lays an importantpart in the doctor's education and training, and ou r great

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19 Mei 1962 S.A. TYDSKRIF VIR GEN EESK UND E 395lecturers' words are passed f rom mouth to mouth, generationafter generation, down the arches of the years. Medicine is no teven learned at the bedside! - though this is one of t he mos timpoctant places in the training of the doctor.Medicine is learned in the total environment in which tihepre- and postgraduate student lives and moves and has hisbeing: in the laboratory and lib rary, in the l ectur e room andon the campus, at t he bedside and in the home, and in thetotality of all the actDvities of the community and culture towhich he ,belongs or in whioh he lives.

Medicine - l i ke man - is psycho-somatic-indDvidual-social.The hospital administrator must not only function, and function efficiently, in eaoh of these worlds; he must do his workas a doc to r and from the point of view of a doctor. He mustnot only drink of the water of knowledge; he must partakeof the wine of understanding. The l ayman may know, andknow a good deal, about the importance of the doctor/patientrelatiollS'hip; only the doctor can experience it. And no mm,however efficient, can head the vast opganization and oroganizethe tremendous teamwork that const itutes a hospi ta l, unJessmedicine is ingrained in his bones by tradition, training,eXiperience and practice.Every doctor brings to his work his own indDvidualcharacteristics that have been moulded in him by heritageand upbringing. Each specialty bears and breeds special typespeculiar to itself: the surgeon, the physician, the pathologist,

the general practitioner, the otOl'hinolaryngologist, theanaesthetist, and so on.QUALITIES OF A HOSPITAL ADMINISTRATOR

What are the particular qualities required of the hospitaladministrator?He must be a whole man wDth a hol is tic out look. He mustpractise ,his profession and adminis te r his pract ice (which is hishospital) in toto; psycho/ somaticaJly j.indirvidually/ socially.The nospital administrator is f irst ly a general pract it ioner,secondly a special ist - w ith the ability to opganize, administerand control a vast under taking s ta ffed by some of t he mostdifficult people on earth to deal with: doctors and nurses!The direct influence of the hospita l adminis trator not onlywit:hirn, bu t also outside his hospital can be most important; hisind irect inf luence can be even greater.I t may be bu t throwing a pebble in the pond for thehospital to take the trouble to keep in touch with the patient'sprivate practitioner, bu t it is a pebble whose ripples ofinfluence spread wider and wider outside the hospDtal. I t is,for instance, my contention that no t only should a patientbe given a note to his prDvate pvactitioner when he leaves thehospital, but thlllt the pr ivate p ract it ioner should also betelephoned at critical moments of his patient's treatment.After an operation, for example, he should be told: 'Doctor,your pat ient , Mrs . X, was operated on by Mr. So-and-So thismorning. The appendix was acute ly inf lamed and lying retrocaecally, etc. etc.' .Such policy by a hospi ta l would sure ly enhance the practiceof medicine in anyone town. I t wouJd also encourage privatepraotitioners to write adequate letters when sending the irpatients to hospital: either for outpatient consultation or treatment or for admission.What then a re some of the qualities that go into the makingof this whole man, the hospital administrator?.I t is easy to pu t :these qualities into words; no t so easy toassimilate their fundamental meaning.A better understanding may be obtained by briefly outliningthe main organs that go into making up that vital organism,the hospi ta l, a lways bearing in mind 3 things:Firstly, that the nel"Ve centre, the head, as well as the vitalspark in the soul of that opganism is the administrator.Secondly, iliat jus t as the hospi ta l is a medical oliganism,so must its head be a doctor, not a layman.Thirdly, that medicine without management is like b loodwi thout haemoglobin : anaemic. Good medicine no t only

deserves good management; good medicine needs good man'agemen!.Like Gaul, the hospital administrator is divided into 3 par ts ,or rather he has 3 dis tinc t yet interrelated functions:1. His work within the hospital.2. His wonk outside the hospital .3. His association with his colleagues.

1lhis third aspect of the hospital adminis trator ' work empha-sizes once more that he should be a doctor , not a layman.Throughout every field of the hospi ta l administrator's workruns the golden thread (as indeed it runs through the fieldof every man's work) of 'personal relationshrp'. llhis inoludesthe following relationships:1. W i ~ h i n the hospital, from his most senior surgeon to hismost junior domestic.2. H is as sociat ion outside the hospital may range f rom thePresident of th e Republic or the Prime Minister or theAdministrator of the Province to the little sel"V'ant girl whoenquires: 'How is my boy friend in the Special Clinic?'3. His association with his colleagues: from me administrating Director of Hospitals or the President of the MedicalAssociation of South Mrica, to his most recen t house surgeonin the hospital, not only is the hospital superintendent me

hub of tha t univer se which is the hospital itself, but, mostimportant of all, he is the link b e ~ w e e n the patlient and thedoctor. He is also the hUlb around which the medical worldrotates with regard to hospital work. Therefore, once again , ahospital administrator must be first and foremost a doctor.Moreover, he must be well versed in the modern ar t andscience of medicine. He must keep abreast of a ll t rends :medical, surgical, all the specialties, public health, epidemiology,etc. He m.ust bring to the tradition of the pa st t he knowledgeof the present. .DIVISION OF HOSPITAL ADMINISTRATION

A hospital should be divided administ ra tively into 3 sections:the medical services, the nursing services, and the generalseITVices, coordinated under the hospital administrator.I shall t ake them brief ly in turn, bu t in reverse.

1. The General ServicesThese illustrate tha t not only must the hospitllll administratorbe a doctor, bu t he must also be 'all things to all men'.Tillough his secretary, the hospital administrator controlsfinance, stores, wopkshops, gr ounds, l aundry, s taf f, andkitohen. In passing I may ay t ha t t he control of the dieteticside of hospital orgarrization differs in different hospitals. Inmy opinion the die te tic s ide is a medical problem and shouldbe under the direct supervision of the superintendent.Therefore, the hospital administrator must, apart from beinga doctor, be something of a financier, an elect ric ian , agardener, a mechan ic, a plumber - a 'whatever exists' in theworking world. The hospital adminis trator must delegateauthority to his secretary W1ho controls specific organs of thehospital organism. At the same time a good hospital administra

tor knows at l east the heads of each of his working depart-ments, and as much as possible about eaoh member o f thesevarious departments.2. Nursing Staff

Of this second grea t o rgan within our tripartite Oliganism,the hospital , I need say very little. To the matron is delegatedcontrol of her staff, and the good adminis trator will Dotinterfere with her supervision. However, one thing I say, andI say quite clearly, that a hospi ta l, like a ship, can have onlyone captain: the hospital administrator.I f the captain is indecisive or unfair or dictatorial or tootemperamental, he will upset his sen ior staff and they cannotbe blamed if they quarrel with him. On the other hand, hissenior staff must recognize when they have a good leader anda good captain, and abide by his direction.

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396 S .A. MEDICAL JOURNAL 19 May 19623. Medical Staff

While the superintendent delegates authority to the secretaryand .the matron with regard to the working organ and theDursrng OI1gan of this ongan ism, the hospital, he himselfassumes direct responsibility with regard to the medical side,although he may work through a medical deputy or medicalassistant.In this connection I shall mention only a few of the factors

which should exist in modern hospital practice.FACTORS IN MODERN HOSPITAL PRACTICE

CentralizationTwo things which , when centralized, can greatly improve

~ h efficiency and economy of hospital praotice, are centralsterilization and a central resuscitation unit.With regard to central sterilization, I envisage the collection,preparation, and distribution of that equipment which is of anessentially sterile nature to the ward'S, outpatient departments,casualty and theatres.The equipment embraces everyth ing that has to be sterilizedin the hospital, from a yringe and needle to a glove andgown. The amount of organization needed in running acentral sterilization department can be envisaged when I

state that it means preparing, for instance, basic laparotomyinstrument sets, separate specialist (urological, gynaecologicaland such-1j'ke) sets, plus mall sets to meet me specific demandsof individual sUI1geons.The central resuscitation unit must be distinguished fromt he theat re recovery room. The central resuscitation unit isessentially the unit to which all acutely il l patients needingurgent resuscitation are sent, whether they a re f rom the wardsas inpatients, or are acu te ly ill patients admitted direct fromthe outpatient department. Having been resusci ta ted thepatient is either re-admitted to the ward whence he came, or

i f he has come directly from outpatients, he is admitted to anappropJi.ate ward.Special Units

The second feature of a modern ho sp ital includes, inaddition to th e accepted units, the following 5 special units:accident ward, burns ward, geriatric unit, psychiatric ward, andteenagers' unit.

I have not the time to enlange on the value and use of allthese units. I should, however, l ike to say a little more withregard to the impor ta nt p ar t t ha t a t eenage rs ' hospi ta l unitcould pJ.ay in the treatment and subsequent happy recoveryof !!hat group of people who are neither children no r adults.Such a ward will obvi'ate the mental t rauma and subsequentpsychopathology that flows from a girl of 15 recoveringhappily from an appendicectomy in a hed next to an oldwoman dying of carcinoma of the breast or rectum. This isbu t one example of the many advantages that acc rue f romnursing age groups among their own kind.There are of course disadvantages, but these can be large lyoveI1come by an intelligent and humane system of better facili-ties for visitors. .

Visiting HoursThis brings me to ano!!her advance in modern hospitalpractice. The old system of restrioted visiting hours (Wednesdays, Saturdays and Sundays - 2 - 4 p.m. and 6.30 -7.30 p.m.- when visitors ar e barely tolerated) no longer applies.Today, hospital visitors are welcomed and encouraged totake part in the overall therapy and the promotion of healthand recovery of the patients.

Outpatient Department'J1he third trend of hospital practice is in th e outpatientdepa11tment and demonst ra te s once aga in the hospital's greaterconsciousness of th e patient as a person and no t merely as a'case' or a statistical cy;pher. The hospital i n fact is d evelop ingwhat has long been a prime consideration in private practice:

the doctor/patient relationship (you could say the hospi ta l!patient relationship). Such a concept ma:k.es ~ the hospi ta l aliving opgarusm, as I have alrea