An Address ON SOME GENERAL CONSIDERATIONS REGARDING THE RELATIONS OF THE MEDICAL PROFESSION AND THE PUBLIC.

An Address ON SOME GENERAL CONSIDERATIONS REGARDING THE RELATIONS OF THE MEDICAL PROFESSION AND THE PUBLIC.

APRIL 12, 1913. An Address ON SOME GENERAL CONSIDERATIONS REGARDING THE RELATIONS OF THE MEDICAL PROFESSION AND THE PUBLIC. Delivered to the Ulster ...

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APRIL 12, 1913.

An Address ON

SOME GENERAL CONSIDERATIONS REGARDING THE RELATIONS OF THE MEDICAL PROFESSION AND THE PUBLIC. Delivered to the Ulster Medical

BY

Society on March 6th. 1913, JAMES ALEXANDER LINDSAY, M.D.

R.U.I., F.R.C.P. LOND.

good a right to practise medicine as any legally qualified practitioner, and that it was persecution and rank professional jealousy for the medical profession to refuse recoghition and professional courtesies to such persons. The reply to this contention is very simple. The possession of a medical qualification is a guarantee that its possessor has spent several years in the studies of his profession, that he has some knowledge of the ancillary sciences, that his acquaintance with anatomy, physiology, chemistry, and materia medica will go far to preserve him from elementary errors, and that he has observed disease in hospital sufficiently long and sufficiently well to have a fair knowledge of the true nature, the probable course, the and the suitable management of the Under none of these maladies entrusted tc his care.

dangers,

me puoiio any guaraut,ee as regarus tue Natural dexterity or happy chance may enable him to reduce a dislocation or set a fracture which has baffled GENTLEMEN,—Our secretary has laid upon me the onerous the surgeon, but he is even more likely to do harm. He may task of submitting to you some general considerations make a lucky hit in the field of medicine, but as he is regarding the relations of the medical profession and the ignorant ef pathology, and his diagnosis is mainly guesspublic, a task which I would not have. ventured to undertake work, it is evident that his intervention may be fraught with unsolicited, and to which I address myself with unfeigned serious risk to the patient. The British laws are very difedence. I am informed that some of our members think tolerant of irregular medical practice, much more tolerant that the present time of conflict and uncertainty, when our than the laws of most civilised countries. In the field of profession is the object of so much ill’-informed and medical practice there still lingers in the public mind someungenerous criticism, is a suitable opportunity for recon- thing of the laisser-faire spirit of the now discredited Man- sidering our responsibilities, duties, and privileges. It is chester school of politicians. Caveat emptor is a favourite sometimes salutary to hark back to first principles and to maxim with the British people. The vague idea that, as we inquire what help they afford in dealing with the difficulties are a free nation, it is an infringement of public liberty .of the hour. to check irregular medical practice is widespread. But it THE ITATIOBTtl7. INSURANCE ACT. is a shallow and short-sighted conception. The State which The Insurance Act, which is now the law of the land, and protects us against adulterated foods has no right to permit not likely to be abrogated, has had a difficult nativity and its the sale of powerful and often poisonous drugs under some - share of infantile disorders. Whether it will ever attain to a specious and high-sounding designation. Granting the right thoroughly healthy maturity I shall not attempt to predict. of the public to :drug itself at its own option, the State in .Experience upon the point in Germany is not altogether this country should follow the example of most other reassuring. But one thing is certain. The Insurance Act is civilised states and insist that the public shall know what it ’bound to have far-reaching effects for good or for ill upon is buying. the status, dignity, and usefulness of the medical profession. It is however, to such obvious matters that I con.A large majority of our brethren have become, or are about to ceive I am requested to direct your attention, but rather to become, State servants, in receipt of State pay, and owing some of those ultimate principles which must regulate the obligations to the State. In future they will have to acknow- relations of our profession to the public, if those relations ledge a threefold obligation-to their patients, an obligation are to be mutually satisfactory, if the prevention and which is primary and fundamental for us all ; to their profession cure of disease are to be successfully promoted, and if and their medical brethren ; and to the State in its corporate the interests of medical science are to be conserved. Just ,capacity. The controversies which have raged round the as the wise administration of the law is a matter not of mere Insurance Act have been to many of us painful and dis- professional interest but of fundamental national importance, quieting. They have too often shown a singular lack of so the cultivation and successful practice of medical science appreciation of professional rights and professional honour, is a matter which concerns not the medical profession only, and a niggardly recognition of the value of medical services. not our nation only, but our common humanity. For life, The’T ’ork of safeguarding the public health and fighting the work, and happiness nothing is more essential than health. as honourable and No interest is more vital to the State than the physical batf, against disease-a work certainly indispensable as that of administering our laws or providing well-being of its inhabitants. If the practice of medicine for the national safety-has been the object of much mis- is not wisely regulated, if it is not accorded due recognition representation and ill-timed satire. Our critics have not and adequate reward, if it is harassed by unwise legislation, always stopped to inquire whether their own contribu- if it ceases to attract the best minds to its service, it tion to the labours of the nation will bear comparison is the public, the nation, which in the long run will suffer. with that which they have belittled and impugned. A GLAXCE AT This, HISTORY OF MEDICINE. Politicians have argued as if you could contract for medical service as you contract for the supply of milk or potatoes, It may not be amiss to begin our survey by a glance at forgetting that the one indispensable thing in a medical the past. The history of medicine, which is far too little .’contract is to-secure the good-will of the doctor and to have studied, is full of instruction for us. We are apt to underan assurance that the best that is in him, the best of his rate the achievements of our remote predecessors in the field knowledge, energy, -and skill, will be ungrudgingly devoted of medicine, and to imagine that where there was little -to his patients’ welfare. A reluctant medical service will science there could be no successful art. But the history of always be .a bad medical service. Men smarting under the medicine in Mesopotamia, in Persia, in Egypt, and, above all, - sense of compulsion or injustice oannot in the nature of in Greece, shows with what zeal and insight the phenomena things be expected to give their best to duties which are of disease were studied in early ages, and how many wise believed’ to involve unnecessarv hardship. I do not affirm and successful methods of treatment were in operation. The that all sense of injustice may not yet .be removed, but I do history of medicine may be compared to two parallel currents. eon&dently affirm that if the -State wishes to be well served One current begins in magic and sorcery, passes through by the doctors it must treat them with respect and con- priesteraft, and ends in science. The other current is that sMeration, and not only secure but deserve their cordiai of empiricism, which flows parallel to the first current, and - ’cooperation. sometimes rivals or surpasses it in volume and in strength. UNQUALIFIED MEDICAL PRACTICE. Primitive man attributed disease to demonic power ; treatAnother disquieting sign of these ’days was afforded by ment was conceived as a contest between opponents, each ,>3,. recent oontroversy in the columns of the lintes on the wielding the weapons of sorcery ; magic had to be encountered .subject of quackery. In the course -of that correspondence by magic. In this stage of development the medicine man iit was laid down by various authorities, more’or less eminent, and the witch doctor represented the art of healing. At a ’that if anyone could prove his capacity to cure, whether as later stage the conceptions of sacrifice, propitiation, purificaa bone-setter ’cr the possessor of some new drug, he had as tion, fumigation, fasting, &c., make their appearance, and the rtnrna

PROFESSOR OF MEDICINE IN THE

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1008 doctor becomes identical with the priest. This combination and over-ridden. Whence come our present confusions. of medical and sacerdotal functions had a wide range and a and discontents ?7 Why is there so much unsettlement, long vogue, and seems to have attained its maximum develop- apprehension, and insecurity2 Why are we compelled, ment in Egypt about 2000 years B. o. The physician often reluctantly, to be so much upon our defence ? The belonged to the priesthood, medicine was taught in the answer, I think, is that we are passing through a period of temple schools, the god Thoth was the patron of our transition, that many of the old landmarks are submerged art, medical practice was largely theurgical, great stress while the new landmarks are not yet visible, that the present being laid upon elaborate ritual, charms, ablutions, and age is critical of the doctors as it is critical of the politicians various hypnotic or suggestive devices. Greece, to which we and even of the theologians-in a word, to employ a useful owe so much that is best in our civilisation, seems to evolutionary figure, that we are not yet adapted to our new deserve the honour of being the first to evolve the lay environment. Let us ask and strive to answer two elementary questions physician-the man devoted to the study and cure of disease, specially trained for the task, and accorded -viz., (1) What is the true function of the doctor in the social consideration and substantial reward. It is true that modern state ? and (2) what are the indispensable conditions in Greece the sacerdotal conception of medicine lingered of satisfactory medical practice at the present day?7

long, that the temples of Esculapius were practically hospitals, and that temple practice and superstitious ideas played a large part in the life of the people. But the spirit of Greece was essentially a lay spirit ; the scientific instinct awoke early, and it was the great good fortune of Greek medicine to find in Hippocrates one of the greatest minds of all time. His works still repay study. He was a close observer, an acute clinician, and a practical therapeutist. His views upon the importance of diet, exercise, gymnastics, massage, and hygiene were sound and wise. In the great days of Greece the physician seems to have enjoyed a position of considerable repute and affluence, and the Hippocratic tradition was held in just honour. Amongst the Romans the position of medicine was less honourable. Medical practice was largely in the hands of Greeks, who were

i

WHAT

IS THE

TRUE FUNCTION OF THE DOCTOR IN THE MODERN STATE?7

The time is past when it would have been sufficient to that it is the sole business of the doctor to cure, or relieve, suffering and disease. The importance of preventive medicine is now universally recognised. The public are fully aware that prevention is not only better but cheaper than cure. We are all sorrowfully alive to the fact that a good deal of our time and energy is absorbed, both in hospital and private practice, by the wrecks of humanity, by cases where a good result is in the nature of things impossible. Plato advised physicians not to waste time over cases which they could not cure, but that is not a possible position to-day. Now, it is one of the anomalies often freedmen and slaves, and it shared in the general dis- of the present day that preventive medicine is so largely credit attaching to these classes. But there were exceptions. handed over to a special class amongst our profession, and The great Galen, whose writings were destined to dominate one relieved from the cares and responsibilities of ordinary medical thought and practice for a thousand years, enjoyed practice. But we are beginning to hear a demand that the an immense repute, and had emperors for his friends and ordinary practitioner of medicine should recognise preventive patients. Amongst the Arabs, both in the East and in work as part of his habitual duty. The compulsory inspection Spain, medicine held a high place, and in particular of school children, which England in somewhat belated pharmacy made great progress. It is not, however, until fashion has adopted and Ireland, to her sorrow, still neglects, the tenth or the eleventh century that at Salerno we seem is a step in this direction. The result of such inspection has to mark the beginnings of modern medicine. Here there been to throw a lurid light upon the amount of disease and was a flourishing medical school, of which the origin is very defect which was previously neglected. In round numbers obscure, a recognised course of study, and something of the 90 per cent. of school children have dental defects, 30 per nature of a diploma or testamur. Medicine won its way to cent. have adenoids or enlarged tonsils, 10 per cent. have recognition slowly in the mediaeval universities. The Uni- visual defects, and 1 per cent. are feeble-minded. It is versities of Bologna, Paris, and Oxford devoted themselves an interesting subject for speculation as to what results almost exclusively to the study of theology, philosophy, and would emerge if the adult population were subjected to a law. The conception of science-i.e., of the orderly interro- similar examination. But how is the practitioner to exercise any preventive gation of nature and the systematic employment of observation and experiment, which was familiar to Aristotle- function ?7 How can he give his advice until it is asked was almost lost’in the Middle Ages, although we detect its for ?7 At present it is very seldon asked for except A good many obscure strivings in the writings of that enigmatical figure, in case of real, or imagined, illness. the great Franciscan monk of Oxford, Roger Bacon, whose people visit their dentist once a year as a matter of fame has been unjustly dimmed by that of his better-known routine to be assured that their teeth are in order or namesake. The repute of medicine grew but slowly as the to have any necessary repairs effected in good time. modern epoch advanced. Even Harvey’s great discovery How many people visit their doctor once a year, or even at Moliere’s comedies show the much longer intervals, to ascertain whether organs more was imperfectly appreciated. low esteem in which the medical practitioner was held in one important even than the teeth are bearing the stress and Nor is strain of existence ?7 of the most brilliant periods of French history. How many cardiac valves go their this surprising. Medical practice remained crude and un- way to complete inefficiency when a little timely warning scientific ; there was no sound pathology ; blood-letting was might have stayed the process of disorganisation?7 How the universal panacea; surgery was a mere mechanical art. many cases of incipient phthisis are allowed to drift on from Jenner’s discovery opened a new era, and henceforward the curable to the incurable stage ?7 How many livers proprogress was rapid and continuous. The great discoveries of gress to incurable cirrhosis when a hint in time from the the nineteenth century in the physical and biological sciences doctor might at least have delayed the hardening process ?7 had their counterpart in the field of medicine. A long array of How many cases of Bright’s disease or of diabetes are famous names, culminating in those of Pasteur and Lister, are allowed to become formidable when early treatment the landmarks of a progress which has revolutionised medicine might have been efficacious ?7 The subject opens up and surgery and opened up new hopes for humanity. And vast vistas. In some of the German cities it is bethis progress in discovery has had as its natural correlative a coming usual for persons to obtain a health schedule, higher repute and an improved status for the medical prac- filled up by some qualified practitioner, setting forth the titioner and for medical science. Yet that status still leaves state of the various organs and of the general health. much to be desired. We are still much under-represented These schedules are not obtained necessarily for the purpose in Parliament. The House of Lords, where the law, the of life assurance, but on general grounds, and are found Church, the army, and the navy are so generously repre- useful in many ways. Even candidates for matrimony somesented, contains at the moment no representative of medicine. times find the possession of such a schedule advantageous. We have no Cabinet Minister entrusted, as in Japan, with It is clear that those persons who think that at present the the oversight of the public health, although we have a medical practitioner does too little in the way of prevention Minister to look after our letters and another to supervise have the matter largely in their own hands. If they will but our farmers. We are very inadequately represented in the give him the opportunity, it is probable that it will often be lay press, which pronounces upon medical questions with a in his power to give warnings or to suggest cautions which confidence not always founded on knowledge. Recent con- may prevent much mischief. Especially does the periodic troversies have shown that medical opinion can be flouted j examination of children suggest itself as a necessary and answer

I

1009 the common incidents of childhood which often escape recognition until irreparable mischief is done we might signalise the slighter manifestations of rheumatism, obscure affections of the throat, incipient spinal caries, ill-marked chorea, defects of sight and hearing. Another complaint which is sometimes preferred against our profession in these days is that it does too little in the way of instructing the public in the laws of health. The word "doctor," we are reminded, means "teacher," but the medical practitioner, it is affirmed, does little or nothing in the way of teaching. He practises and heals, but he does not teach. He is supposed to regard medical knowledge as the province and perquisite of his profession, not to be properly or usefully shared with the laity. I think there is some truth in these allegations, but it may be replied that there never was a time when medical men, often at the cost of much inconvenience and even some material loss, gave so much attention to educational work. If the public remains ignorant of the elementary laws of health and the primary precautions against disease, it is not from lack of popular lectures, articles in the magazines, and the circulation of cheap literature, often good of its kind. Our profession does much at the present day to inform the public and to spread enlightened views, and does it often at the cost of But this some misunderstanding and misrepresentation. work must go on, and is undoubtedly destined to assume larger proportions. The public press is more interested than ever before in questions of hygiene and public health. The great work of preventive medicine accomplished in Uganda, Western Africa, Cuba, and Panama has captured the public imagination. Now it may be fairly asked, how far is this process of popularising medicine to be carried ? Does it not involve some risk both to the public and to the medical profession ? Can the line be drawn between discussions and contributions which are likely to be fruitful and wholesome and those which may be mischievous both to the public and to ourselves ? I think that line can be drawn. The natural functions of the body, the laws of physiological health, sanitation, hygiene, the regulation of trades, the inspection of schools, the dangers of city life, the means of rendering first aid in the case of accident or sudden illness-all these may be safely and rightly taught to the public. But when it comes to be a matter of the diagnosis and treatment of disease the lay press should be warned off from a field where it can have no real competence and where its intervention is sure to be mischievous. Let me pass on to the second question which I have propounded for your consideration-viz.:

prudent step. Amongst

WHAT In

an

ARE THE INDISPENSABLE PRIMARY CONDITIONS OF SATISFACTORY MEDICAL PRACTICE ?

article which

I

contributed to the

September "

number, 1911, of "The Nineteenth Century and After"

I propounded three principles to which medical practice should conform. These three principles were as follows :(1) The patient, or his responsible relatives, should be free to select a practitioner in whose character and skill he or they have confidence ; (2) the practitioner should give the case adequate time and attention at a scale of remuneration which satisfies him ; (3) the relation of patient and doctor should be terminable on either side for adequate cause and subject to certain easily-defined limitations. These three principles seem to me to contain the pith of the whole matter, and we might get some assistance in dealing with our present difficulties by inquiring how far any proposed arrangements conform to them or to fail to conform to them. It is evident that over considerable areas of practice these conditions are fairly fulfilled. The patient gets the doctor of his choice, he pays him fees on some recognised scale, and he dispenses with his services when those services have ceased to be acceptable to him. But in contract practice these conditions are subject to some inevitable limitations. The patient’s choice of doctor is not absolutely free, the scale of remuneration too often gives just cause for dissatisfaction, and the severance of professional relations, when those have become strained, is not immediately practicable. My point is that in so far as contract practice approximates to the three specified conditions just to that degree it will work smoothly and successfully. In so far as it departs from them will it be a failure, and a failure, be it noted, just as much from the point of view of the patient as from that of the doctor. How far the National Insurance Act

be worked to secure these three conditions it is, perhaps, to express any opinion. It is certain that our legislators would have acted more wisely if, before launching this great scheme, they had taken the precaution of ascertaining whether the conditions which they were prepared to offer were likely to be generally acceptable to the members of the medical profession. can

premature

CONSIDERATION OF PROPOSED NATIONAL MEDICAL SERVICE. In the course of recent controversies there has emerged for the first time in any definite or concrete form the proposal for the nationalisation of the medical profession. It is suggested that doctors should be formed into a State Civil Service, that they should be distributed locally on some definite principle, receive a fixed salary and suitable pension, and discharge certain clearly defined duties. It is claimed that by such a system many existing evils would be mitigated or removed, that the labours of practice would be more evenly distributed, remuneration more fairly adjusted, a uniform standard for entrance into the profession secured, and unhealthy competition obviated. If these ends could be secured without serious dangers and sacrifices, the gain would undoubtedly be great. But the subject is surrounded by enormous practical difficulties. We have no precedents to guide us to prove the possibility of such a scheme. That all classes in any single area would consent to be served by the same doctor is an improbable assumption. Her ladyship might, without undue snobbishness, hesitate to discuss her ailments with the doctor who was in attendance upon her cook or her footman. The social difficulty looms large in view of any scheme for nationalising the medical profession, and we have no evidence that it could be successfully overcome. Further, we might reasonably entertain doubts where the large diminution of the element of competition which would be inevitable under such a scheme might not react injuriously upon professional competence and energy. Then there might be a serious question whether a State service, offering only moderate financial rewards and only a few great prizes, would attract men of the first intellectual capacity, who might probably aspire to a more brilliant career in other professions. Grave as are these difficulties and objections, it is not certain that they are absolutely final, and the whole question of a National Medical Service is one upon which it might be advisable to keep an open mind. I do not believe, however, that such a service will come in our day. HOSPITAL ADMINISTRATION. The last question to which I wish to direct your attention is the present state of our hospitals and the probable effect of the National Insurance Act upon that position. It must be admitted that our present system of hospital administration is in many respects most unsatisfactory. Magnificent work is being done, and our hospitals are one of the greatest glories of the age, but there is lack of definite and intelligent organisation, serious abuses exist, serious wrongs are inflicted both upon the medical practitioner and the charitable public, and efforts at reform have so far proved almost wholly futile. It is worth inquiring why this should be so. Our hospitals fall into five categories, viz. : (1) hospitals supported wholly or mainly by charitable contributions or investments from former benefactions. In this class are included the great general and special hospitals of our cities and cottage and other small hospitals scattered over the country. 2. Poor-law hospitals, rate-supported. 3. Municipal fever hospitals, rate-supported. 4. Lunatic asylums, rate-supported. 5. Consumption sanatoriums, supported partly by grants from Government and municipal contributions and partly by

charity. Now these five groups of institutions, all aiming at dealing with disease or mental incapacity, are practically independent of each other. Very different degrees of efficiency are attained. These institutions have no necessary bond of union, no combination for any form of cooperation, no system to secure mutual aid or prevent injurious competition or It is true that the differentiation of conflict of interests. function between these different types of institution follows to a large extent natural and inevitable lines, partly medical, partly economic. But it does seem extraordinary that so loosely articulated a system should still survive. It has grown up through the accident of circumstance, and has never undergone readjustment to the needs of the present

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Perhaps the lack of intelligent and coherent system questions which have not yet received any definite, or largely explains how it comes about that hospital abuse has satisfactory reply. It would seem almost inevitable that proved so intractable and perplexing a problem. We have the State should be compelled to provide its own institutions had committees of inquiry innumerable, some of the ablest for the hospital treatment of insured persons, and pay the men of the day have given willing assistance, but very little staffs of such institutions-a solution which I confess I conhas been effected. May the explanation not be that we have template with not a little apprehension, especially from the never thoroughly thought out what hospitals should do and point of view of medical education. should not do, what their proper and equitable relation is to It is much to be desired that the present crisis should find the sick, the charitable public, and the medical profession? some solution consistent with the maintenance of the just Here, if anywhere, we need the guidance of first principles. rights of the medical profession—rights which are often These principles might, perhaps, be formulated somewhat as infringed both in hospital administration and in private follows. Hospitals, and in particular our great general and practice-without the sacrifice of its reputation as a special hospitals, in connexion with which the main diffi- benevolent and unselfish profession, a reputation which it, culties arise, are intended to meet the medical and surgical upon the whole, enjoys, and which, we may humbly hope, it, needs of that large class which, not being paupers, is unable upon the whole, deserves. But my time is exhausted and I to bear the cost of treatment either in their own homes or in must bring these discursive observations to a close. They private nursing institutions. Hospitals are further intended are designed less to express my individual opinions than to to deal with such medical and surgical cases as the general stimulate thought and initiate discussion. practitioner cannot treat satisfactorily in their own homes. Two indications clearly arise from this definition of function. First, there should be an adequate investigation of the THE EFFECT OF GENERAL CONTRACpatient’s means-that is the economic problem. Secondly, TION OF THE PERIPHERAL BLOODthe general practitioner should not be deprived of patients whom he can treat to his own and the patient’s satisfaction VESSELS UPON MOUSE CANCERS. at their own homes-that is the professional problem. There BY CHARLES WALKER, D.SC. LIVERP., M.R.C.S. ENG., can be no question that these two indications are at present L.R.C.P. LOND., very inadequately fulfilled. They are not even always AND clearly realised. But hard experience shows how great are the difficulties surrounding this subject. Even with the best HAROLD WHITTINGHAM, M.B., CH.B. GLASG. intentions, an adequate inquiry into the means of patients (From the Research Department, Royal Cancer Hospital, presenting themselves for hospital treatment is a task of Glasgow.) great difficulty. The pressure of work is great ; the means of getting trustworthy information are not always readily Wassermannand Neuberg, Caspari and Lohe22 describe or easily available. The almoner system is the best device the liquefaction and final disappearance of tumours proso far suggested, and it should be universally adopted when possible. The second indication-viz., that the general duced by inoculation in mice. This result is obtained by the practitioner should have more influence than he at present intravenous injection of various highly toxic materials. In exercises in deciding who are suitable subjects for hospital Wassermann’s case the " compound " is one of selenium and treatment-should not be incapable of solution, although it eosin. The theory of the treatment is based upon Ehrlich’s undoubtedly involves delicate professional questions. On statement that tumour cells possess a much greater avidity the one hand, hospital authorities have no right to do work for oxygen and nourishment than do the cells of normal which can be equally well done at the patient’s house, and tissue. Neuberg and his collaborators have worked with for which the patient can afford to pay. On the other hand, compounds of cobalt, silver, copper, platinum, gold, and the general practitioner should not overlook the needs of the tin, obtaining the best results with the two first. The theory clinical teacher and the just claims of medical education, of in this case is that the cells of malignant growths possess He should remember that the peculiar characters of rapid growth and degeneration, which he is himself the product. hospitals fulfil one of their noblest functions in providing a which characters are due to the presence of certain abnormal enzymes. The substances used are supposed to act only in training ground for the doctor of the future. How far it would be possible or equitable to introduce the presence of these abnormal enzymes, and to increase generally into these countries the practice which prevails the degenerative process to such an extent that the tumour widely elsewhere-viz., that a patient of any rank of society cells are destroyed. In the case of all these experiments the useful dose of the should have aecess to our hospitals and be at liberty to command the services at the usual fees, either of a member "compound"is nearly as great as that which kills the animal of the staff of such hospitals or of his own private medical outright, and must be injected directly into the circulation. attendant-is a question upon which medical opinion seems So nearly the lethal dose must be used that the mortality is to be much divided. Our cottage hospitals already recognise as high as 70 per cent. None of these investigators have this principle, and in their case it seems to work successfully given any definite information as to the constitution or and without friction. There seems no clear or final reason manner of preparing the compounds"they have used. why this principle should not be made more widely applicable. The compounds are, however, generally stated to be It would certainly meet the needs and gain the approval of a unstable. ine immediate eirecc or me "compounds injected oy considerable section of the public, who at present are somewhat puzzled to see all the splendid administration of our Neuberg and his collaborators is described as a contraction great hospitals at the service of their iliousemaids or men of the blood-vessels of the body and a dilatation of those of servants, but withheld from themselves, even when they are the tumour. The animal’s body is generally blanched, but in the tumour the dilatation is so great that extravasations quite prepared to pay the full price for such benefits.

age.

of blood visible to the naked eye are numerous. In HOSPITALS AND INSURED PERSONS. Wassermann’s experiments the injection of the seleniumThe relation of insured persons under the Act to hospitals eosin is described as turning the mouse pink all has raised the most difficult question with which our pro- over preparation but the immediately, pink coloration disappears rapidly fession has been confronted in our time, and we see how from the and is concentrated in the tumour. These body much perplexity it has caused. And here, as throughout facts seem to suggest that the action of the preparations this address, I suggest that we should refer a temporary under consideration may possibly be to some extent problem to first principles. The State has made a bargain mechanical and not due to any selective action upon the with insured persons to guarantee treatment for them in tumour cells. There is no nerve-supply to malignant It will be forced to interpret case of sickness or injury. and in these mouse tumours the vessels generally growths, this bargain so as to include hospital treatment, and the possess walls of a single layer of cells. Even in the larger problem is whether such treatment can be given by our vessels it is highly improbable that the nerve-supply is as voluntary hospitals as at present organised. Will the efficient as it is in normal blood-vessels. charitable public continue to subscribe funds for the treatment of insured persons-treatment for which the State 1 Beiträge zum Problem: Geschwülste von der Blutbahn aus therahas made itself responsible? Will the medical staffs of peutisch zu beeinflussen, Deutsche Medicinische Wochenschrift, 1911. such hospitals feel bound to give gratuitous service to December, 2 Weiteres über Heilverserch an Geschwülstranken Tieren mittels the beneficiaries of the State ?2 These are most anxious tumeraffiner Substanzen, Berliner Klinische Wochenschrift, July, 1912.