No. 3676.

FEBRUARY 10, 1894.

An AddressON

SOME SUBJECTS OF PUBLIC AND PROFES-SIONAL INTEREST.

Delivered before the South-West London Medical Society onFeb. 8th, at Bolingbroke House, Wandsworth Common,

BY THOMAS BRYANT, M.CH. R.U.I.,F.R.C.S. ENG. & IREL.,

SURGEON TO THE INSTITUTION AND CONSULTING SURGEON TOGUY’S HOSPITAL.

MR. PRESIDENT AND GENTLEMEN,—Allow me to con-

,gratulate you upon the birth of the South-West LondonMedical Society and to express the pleasure I feel at being.allowed to do something in the way of help towards its start’on what, I hope, will prove to be a successful career. Permitme also, as one of the acting staff of this very excellent,local institution, to welcome you within its walls, for herepractical work based on scientific knowledge is our, as itds yonr, study. I am quite sure that you have done a wise,thing in forming this society, and particularly in estab-lishing it as an independent concern; for, being free and,unattached to any association, you are your own masters.and have no need to trouble yourselves with either the

Ipolitics of the profession or the government of public,bodies and corporations, but can leave these importantmatters in the hands of those to whom, from circumstances.{lr liking, their management has been consigned, and confinejour attention, primarily, to the everyday professional workwe are all engaged in, and, secondarily, to the subjects of I,common public and professional interests which we all’have so much at heart; for I take it that it was for,the consideration of these two branches of professional’work and professional interests that this society has been,established. It is clearly unnecessary for rue to dwell upon’the advantages which follow upon the social gatherings of’medical men who in a neighbourhood like this are by theirwork much separated ; or upon the good which follows the- discussion of difficult cases or of set papers on professionalsubjects, for the foundation of this society is a proof of yourappreciation of the value of such a practice, and any words’of mine would only tend to emphasise your views. I would,however, like to add that in discussing a case when you.can have the patient before you -for under such circum.stances accuracy is helped-discussion is encouraged and mademore valuable, and the patient’s interest may be enhanced.Let us never forget that our patients’ interests are those weshould always primarily consider, and that in all our practicaland scientific professional work the public good is its ulti-mate object; but at the same time let us bear in mind thatin order to realise this leading purpose it is all-important forthe interests of the public as well as for the due exercise and’dignity of our profession that every practitioner of medicineshould hold a perfectly independent but responsible position,and that in his professional work he should be left perfectlyfree from lay control, although amenable to lay censure. Itis also equally necessary that he should be adequately paidfor his professional services by all classes according to theirmeans. Under these circumstances all measures, whether under’the guise of charity or called " provident," and all hospitals,general, special, or private, which encourage the public toseek professional advice for little or nothing, are to be dis-couraged as helping to pauperise and degrade the public atlarge; and all members of our profession who induce ortempt the public so to do by means of private hospitals,competing private dispensaries, touting clubs and associa-tions, or who are ready to accept at a reduced figure, over theheads of their neighbours, appointments which have been putup by laymen, as it were, to auction or competition, adoptthe surest means within their power to lower the position oftheir profession in the estimation of the public and at thesame time do injustice to the profession and public bynot giving to the latter the best services the former can isupply, whilst they must, in addition, lose their own self-respect, even if they happen to gain cash by their un- 1worthy actions. For let me ask, How is it possible for a ]man who is ill-paid or overworked, or both, either to give, in 1the interests of the public, the professional attention it is Iessential for him to bestow on every case he has undertaken

to attend; or to maintain, in the interests of the profession,the position to which he is entitled and his own self-respect fWe all know that any measure which encourages, either in

a profession or trade, underpay and overwork leads to badwork. In our profession such deficiencies are no less harm-ful-nay, they are more so, as its issues to the public areeither life or death, health or ill-health, and to the professioneither a position of pleasure, honour, and respect or one ofdegradation and unrequited labour. With these leadingthoughts before us, let us approach the consideration of someof the more important subjects of public professional interests,and particularly those which have a bearing upon the mutualinterests of the public and profession-although I hope I havealready made it clear that the interests of the public and pro-fession are in a great measure identical, and that, whilstanything which lowers the status of the medical professionis most injurious to public interests, everything which tendsto raise it is beneficial.The questions I propose briefly to bring before you, and

upon which I would invite your consideration, are thefollowing : the working of public provident dispensaries ; ;the conditions under which private dispensaries should beworked and sanctioned ; the conditions under which countryand town clubs should be worked; the good or evil influencesof medical aid associations worked by laymen for their ownprofit; the duties of unqualified assistants; and how midwives,or, what seems a better term, "nurse midwives," are to beeducated and utilised for the public good. All these questions,with many others, are well worthy of the attention of yoursociety-one might be taken up each session and well threshedout; for let me say that the solution of most, if not of all, thesequestions must rest in the hands of the general practitionersof this country; and I must also express my conviction thatclearly formed opinions upon each and all of these subjects,formulated after due discussion by such societies as this,would do more to mould the minds of the professional andlay public for good, and form a better basis for future corpo-rate action, than any opinions emanating from the GeneralMedical Council or the two Royal Medical Corporations.

Practical questions of the kind enumerated should beprimarily settled by the great body of the profession in apractical manner, and it is through these local societies thatthe matured and independent opinion of the profession shouldbe expressed. When the profession has spoken, extraneousaid may be sought. The press is always ready to give helpto any movement, but for the profession to leave importantquestions such as these for the press to solve is a mistake, forremember that what is called the press is but the product of ahandful of active men, and that the great " we

" in type is toooften identical in life with a little I. " It is likewise a mistaketo look to the General Medical Council or Royal Corporationsto give, under existing circumstances, judicial opinions uponthese and other complicated questions, as it is urging thesebodies to seek for powers, since they do not possess them, toenforce their views when formed ; for these important bodieshave enough to do to carry out their respective registra-tion, educational, and examination duties, as well as to purgetheir registers of men who have openly and unquestionablyoffended against the laws of their country or their corpora-tion. To ask these bodies to consider and solve ethicalquestions connected with professional work and professionaladvancement, and, having solved them, to seek powers toenforce their views, is too much to expect, even if it weredesirable ; or even if in this free country, in which self-government is still prized, and patent medicines, good, bad,and indifferent, are made a source of public profit, andquackery in all its forms is permitted, and at the same timebetter protected than are registered practitioners of medi-cine, there would be the smallest chance for such full powersto be granted. When the profession as a body has, however,spoken upon any of these questions greater powers may beobtained ; for I must tell you that six years ago, when theRoyal College of Surgeons applied to the Privy Council forsome enlargements of its disciplinary powers, its requestswere refused-not, however, on account of any objectionswhich were raised by the Privy Council to the powers askedfor, but on account of the opposition of certain Fellows andill-informed Members of our own body, who had placed them-selves in an antagonistic position to the action of their Collegeand had made a great noise about the matter by means ofthe press and other ways. If this opposition had not takenplace the disciplinary powers of the College would have beennow enlarged to the advantage of the profession generallyas well as of the public. I would, however, wish to remindyou that the General Medical Council has done, and is now

316 MR. BRYANT ON SUBJECTS OF PUBLIC AND PROFESSIONAL INTEREST.

doing, good work in putting down the serious public offenceof "covering " and of giving false certificates, more particu-

larly of death, by unqualified practitioners. It does good alsoin expressing decided opinions upon gross ways of adver-tising and other professional delinquencies as brought beforetheir notice, and I feel sure that the report upon medicalaid associations which was issued last summer will helpthe public and profession to come to a definite conclusionas to the merits or demerits of these new trading bodies.I would also assure you that my own College, the RoyalCollege of Surgeons of England, with its present limiteddisciplinary powers, has not been, and is not, idle in the samedirection, for there are few meetings of the Council beforewhich some complaint of undue modes of advertising, andof the employment of secret remedies, with other illegiti-mate methods of carrying on the "medical trade," is notbrought; and if the offence charged is not serious enoughto justify the name of the offender being taken off the

College books a serious expression of opinion on the part of,the Council upon the nature of the act complained of, anda decision that the misdemeanour is inconsistent with thedeclaration made by the delinquent, when he was admitted aMember of the College, "that he would demean himselfhonourably in the practice of his profession and do hisutmost to maintain the dignity and welfare of the College,"are often enough to induce him to mend his ways and adopt"more legitimate means of carrying on his work. At anyrate, of this 1 am sure, that these expressions of opinionupon the part of the Council do great good and tend tostop ways which lead downwards ; and I likewise believethat if the attention of the Council were drawn more fre-

quently by the Members of the College to methods whichweak men adopt from their weakness, and which strongermen know are injurious both to the profession and the public,the actions of the Council for good would be more frequentlyrepeated to the great advantage of the profession and the.suppression of bad ways. It might be well for you to con-sider whether duties of this nature should not be part of thework of such societies as your own. A society could well dowhat individual men might shrink from. I may, however,tell you that during the last six years-besides all Membersof the College who have been convicted of criminal offences-five Members have been removed from the list of Membersfor issuing advertisements which the Council regarded asprejudicial to the interests " and derogatory to the honourof the College," as well as " disgraceful to the profession of.surgery"; and four others who had offended against ourby-laws in the same way have simply been let off afterthey had made "declarations" that they would not so ioffend again ; whilst one other Member was removed for Ibeing associated with a disreputable museum. Thus tenMembers have been brought before the Council in sixyears for having seriously offended against the by-lawsof the College, besides many others who have been satis-factorily dealt with by the President for minor offences. Butlet me beg of you not to rely upon the royal corporations forthe help which, to be effective, must come from yourselves.Let the great body of the profession pronounce with no un-certain voice, through local societies, county associations,and private societies, that this, that, and the othe’J’ rnethod ofseeking or obtaining practice and noteriety is unprofessional,derogatory to the interests of the profession, and injuriousto those of the public. Let such societies as yours, and allothers like it, exclude men who do such wrongs from theirlists of members, and let the excluded members know thereason why they are so excluded. The tone of the professionwill then begin to improve, and men who enter it saturatedsvith the "spirit of trade" will become alarmed and be ledto think ; but, above all, let the united voice of the professionexpress the opinion that only men of high culture should beadmitted within its portals, that a broad preliminary educa-tion should be deemed to be essential for every man to enjoybefore he enters upon the special study of medicine, and that.at this stage of his medical career a carefully conductedexamination should be required; we may then with someconfidence feel assured that the "professional spirit" willgrow and acquire a force which will relegate the "tradespirit " to its proper place-which is secondary to the pro-fessional-and that then all may be expected to go well.For my own part I believe that public provident dispensariesmay be made of great value both to the public and profes-sion : to the public, by helping a large number of the wage-earning and poorer members of the community from fallinginto the pauper class, as well as by encouraging in theseclasses the spirit of thrift and independence which is so

essential for national prosperity ; and to the profession byenlarging the field of observation for the local practitioners.and by securing for them reasonable remuneration for their pro.fessional services, with many other secondary advantages. Butin order to secure these desirable ends it is all-important thatonly such members should be admitted to the advantages ofthe dispensary as are of the wage-earniNg and poorer classes,and that the scale of admission charges should be calculatedin single persons as upon a percentage of their wages, and infamilies upon the aggregate wages of the family or house-hold and not upon that of the member only in whose namethe dispensary ticket may have been taken out.

I should like to see in every district one or more pub:icprovident dispensaries for the "well-to-do poorer classes"as we now see dispensaries for the pauper class. I wouldhave these dispensaries managed by a committee of laymen,medical men, and representatives of the classes in whoseinterests they exist. Their doors should be open to registeredmembers, but their rules should be such as to allow of anyof the "well-to-do poorer classes" being able to obtainspeedy help and relief upon well-defined terms from any oneof the medical men of the district in the event of any suddeaillness or accident taking place.With parish dispensaries and provident dispensaries of the

kind alluded to, the poor, and "well-to-do poor," would bewell looked after, and the medical officers of both would befairly treated, for any applicant to one or other of the dis-pensaries of the wrong class could be passed over. A:medical man in a dispensary district should have the powirof placing a poor patient upon his dispensary list and ofattending him as a dispensary patient, and any poor patientshould have the power of consulting any medical man of hisdistrict upon dispensary terms. With the existence of thesepublic provident dispensaries so-called private dispensary@would not be needed, and consequently should not be allowed,since such dispensaries are too often the mere speculativeadventures of needy men who trade upon the poor for theirown ends, and certainly not for the poor’s advantage, whilstthey degrade the profession in public estimation and doubt-less degrade the dispensary medical officer to the level of zsmall and unscrupulous tradesman.Town and country clubs are institutions to be encouraged,

for the same reasons that have been adduced in favour of

public provident dispensaries ; but it seems to me that thescale of payments now required should be somewhat higherthan that which has been demanded in past years, for wageshave been much raised, and the medical club charge shouldbe a percentage rate upon wages. With the adoption of thissuggestion I regard club work, when honestly carried out, Pabeneficial to the public and valuable to the medical prac-titioner, who not only obtains fair remuneration for his work,but carries out his responsible duties untrammelled by layinterference. As to what are now called "medical aidassociations, " I am at a loss to know where, in most of them,good is to be found ; for it is clearly degrading for anyqualified medical man to do professional work as the paidservant of a committee of illiterate or even educated lay.men, and consequently to work under their control ; and it iscertainly injurious both to the public and profession that thismedical servant should be required to look after any numberof members admitted by a lay committee to the supposedadvantages of the association, upon terms concerning whichthe medical officer has no voice, and when he knows that heis often called upon to treat many more patients than caspossibly be treated with due care and proper skill.

It is likewise a clear wrong both to the public and pro>fession that members should be admitted to these associa-tions who are not of the wage-earning or allied classes, andwho are well able to pay the limited charges of a privatepractitioner. This medical aid association is a developmentof the medical club, but it is a growth of a diseased nature,and it ought to be either brought into line with public provi-dent dispensaries or club practice, as sanctioned by andbased upon the Friendly Societies Act, or it ought to be-rooted out of professional public work.As to the duties of unqualified assistants, I believe all will

agree with me that they should be reserved to home duties;not far beyond those of a dispensing assistant. No visitingand dispensary or outside club work ought to be entrusted tothem, beyond a visit of inquiry ; nor ought they to havepower to sign professional certificates of any kind. If theyare employed beyond these limits harm is certain to ensue.And, lastly, let me say a few words upon the burning ques-

tion of midwives, for we all must admit that midwives ar9necessary, since in some districts they divide the midwife

317DR. W. HOWSHIP DICKINSON ON THE TREATMENT OF RENAL DISEASE.

work between them, and in all districts they hold an importantposition in the social scale. If, then, midwives are necessary,st is equally evident that they should be efficient, for if theyare not efficient they are dangerous assistants and hadbetter be away, and if they are to be efficient the conclusionis certain that they must not only be made so, but that theirknowledge should be tested by competent examiners beforethey are allowed to embark on the responsible and seriousduties they have undertaken. With respect to the questionof their education, it goes without saying that the teachingmust be practical, although based upon a certain amount ofanatomical knowledge, and that this practical knowledgeis only to be acquired at lying-in hospitals which are

sufficiently well officered to afford a guarantee that theteaching will be enough, but no more than enough, toensure competency to attend a natural labour and to knowwhen true professional assistance is required, on accountof the many difficulties and dangers which may arise.For I would wish " midwives, " as they are now called, to beregarded as "nurse midwives," and even to be named such,since the term carries with it the meaning that they are reallynothing but skilled nurses educated for special work andthat they are always acting either directly under medical-supervision or under the clearest instruction that they are tocall in medical professional assistance in every case of sus-pected or real difficulty or danger. Finally let me ask, How"is this exumnation work to be conducted, and who is to con-duct it? For my own part, I feel strongly that such im-portant public work should not be entrusted to any private"society or institution, however eminent, but that it should,be placed and left in the hands of some responsible public’body. I do not mean such a one as a county council or.allied body; but I would wish it to be undertaken underthe direction of the two royal medical colleges of England-the Royal College of Physicians and the Royal College ofi3urgeons-by means of examining boards, central or district,composed of either specialists or general practitioners, or ofwhat would be preferable, both combined, as may after fullctllsideration be deemed best, the curriculum of study aswell as scope of examination resting entirely with the twoSoyal Colleges.

I must now bring these somewhat desultory remarks to aconclusion. The subjects I have brought before you are allof importance, and my views upon them have not beenformed hastily; for I have been called upon to consider themwith care when President of the Royal College of Surgeonsand as a Member of the General Medical Council. Whetherthese views are right or wrong I leave to you to decide ; fortheir full consideration is well worthy of the attention ofthis and other allied societies. Whatever solution you mayfind for the different problems which I have brought beforeyou, of this I am sure-that the conclusions you come to willhelp the final solution of them all and so tend to the advan-tage of our profession and the welfare of the public.

PLACES AND COMMONPLACES IN THETREATMENT OF RENAL DISEASE.BY W. HOWSHIP DICKINSON, M.D. CANTAB.,

F.R.C.P. LOND.,CONSULTING PHYSICIAN TO ST. GEORGE’S HOSPITAL AND TO THE

HOSPITAL FOR SICK CHILDREN.

I PROPOSE to bring together, perhaps in a somewhatunconnected manner, some of the impressions which have beenleft upon my mind as the results of experience in regard torenal disease, taking those especially which would seem, Iwill not say to have practical value, but at least to have apractical bearing. I shall introduce some considerations withregard to climate which may furnish useful guidance in the’treatment of the granular kidney and the more chronicvarieties of nephritis in persons who belong to what may becalled the movable classes.

First, as to acute nephritis or acute renal dropsy. The,disease has a tendency to recovery qualified, especially whenscarlatinal, by a tendency to fibrosis. To assist recoverywarmth in bed and liquid diet are essential. The food shouldconsist not only of milk, but should also comprise thin beef-,tea or light animal broths. Water and aqueous drinks- should be given freely; alcohol prohibited. Bread-and-butterday be generally permitted, and farinaceous food in somevariety may be early introduced. After a calomel purge it will- often affice to give z lle alka-lising saline such as potassio-

tartrate of soda (a great favouiite with me) or tartrate orcitrate of potash. These are laxative and mildly diureticand beneficially reduce the acidity of the urine, which in suchcases is apt to be excessive. If anything more is needed tokeep the bowels moderately loose a morning potion of

sulphate of magnesia should be superadded. Digitalisought to be given only if there is dropsy or if theurine is very scanty. With the exception of digitalisand such mild salines as have been mentioned the wholeclass of diuretics may be avoided as either useless or

injurious. Preeminent among the latter are cantharides.Though the urine may contain blood it is seldom advisableto give medicines with the object of stopping the discharge,which depletes the kidney, generally to its advantage. Ifthe loss is profuse and persistent and there is much anaemiawith it some astringent form of iron, the sulphate or theperchloride, may be given with an aperient, such as a littlesulphate of magnesia, or in an extreme case iron alum inthe same company. Should the cerebral indications ofursemia present themselves they ought to be treated on prin-ciples to which I shall presently refer.

Next, with regard to chronic albuminuria I will put asidefor the present that of lardaceous origin and speak withreference only to the granular or fibriotic kidney. Many arethe reminiscences which testify to the lengthy and almostindefinite quiescence of the disease. A man may suffer fromit for a quarter of a century and be practically none the worse,though such cases are not common. The heart will be hyper-trophied as a salutary adjustment, and the dropsy which sooften marks the beginning of the end may be indefinitelypostponed. For tens of years there may be no obtrusive sym-ptoms or anything to prevent the patient, if he be one, frompursuing his usual way of life, presuming that this is one ofordinary moderation and care, and that he does not whollyignore his disease. It may even be better for him to remainin ignorance of it than to be over-treated or over-restricted.The physiological agencies, diet and climate, first presentthemselves for consideration. As to diet, in a quiescent case1 commonly advise temperance rather than austerity-onemeat meal, one fish meal, and one meal without meat orfish. Farinaceous and vegetable food without restriction,milk without stint but without insistence, watery drinksfreely, and the less alcohol the better. I believe a purelymilk diet is not generally advantageous. One of the hardestpulses I ever felt belonged to a man who conscientiouslyrestricted himself to a milk diet and ultimately died fromapoplexy. It is a matter of importance, and even of life,that in certain forms of renal insufficiency the free drinkingof aqueous liquids should be permitted and even encouraged.When the urine is of low specific gravity and poor in qualityit can provide sufficient exit only when it is in large amount.It is a condition of life that quantity should make up forquality. The quantity is maintained by that of the waterintroduced as drink. In such a case as I am supposing thesolid food should be light and the liquid abundant. I haveseen fatal consequences follow the reversal of this rule inthe treatment of the advanced granular kidney.As long ago as 18671 I took upon myself to advocate the

employment of a warm climate in the treatment of chronicrenal disease-a therapeutical measure which has since beenwidely resorted to. If it be said that the results are dis-appointing, this must be taken as implying no more thanthat too much is expected. No climate can turn fibrous tissueinto tubes or a granular kidney into a healthy one ; butthe crippled organ may be relieved of work, the insufficientgland may be made sufficient, and the easily irritated struc-ture may be saved from inflammatory attacks by the influenceof some place where cold winds cease from troubling andthe kidneys are at rest. The desiderata may be said to bewarmth, uniformity of temperature, and dryness of air. Ithink that the first consideration should be the temperature,regulating as it does the action of the skin and of the kidneys.The mean temperature, as expressing broadly the generalattitude of this over-ruling physiological influence, is perhapsthe most important guide in the choice of a climate. Thedaily range, or variability within each twenty-four hours, isof obvious importance, but probably less so than is the dailymean temperature. A great daily range implies a corre-sponding fall in some part of the twenty-four hours, whichmust be of paramount importance to persons exposed. Butseekers after health are not like shepherds who watchtheir flocks by night, nor need they be much out of doorsafter sunset. The low temperatures are at night, or

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1 Pathology and Treatment of Albuminuria, first edition.