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It seems to me that to make a diagnosis of a boneor joint injury without the X rays is rather likediagnosing cardiac disease without a stethoscope. Itcan be done sometimes, and in an age before theapparatus was invented it had to be done ; but itwas guesswork as compared with precision. Therewas a time when gynaecological diagnosis had to bemade without vaginal examination, and a catheterpassed for the female without removing the bed-clothes, but now we know that it is much better to" look and see " than to " fumble and guess," and soit is in the matter of fractures and the X rays, andcertainly the general public, judges, and juries are fullyaware of the fact.A very real difficulty does, however, exist in small

towns, villages, and country districts in dealing withinjuries which keep the patient bedridden, andparticularly when the patient has only moderatemeans. Efficient portable X ray plant ought to beavailable wherever it may be needed, and it couldbe taken about by the ambulance service. The chiefdifficulty exists in the matter of personnel. It oughtto be possible to have a technical expert, not aqualified doctor, in charge of such X ray plant whowould work under the direction of a qualified radio-logist, exactly as is done at every large hospital.In this way when a patient cannot afford a consultant’sfee an X ray examination could be obtained at amoderate cost.An exact analogy for this procedure exists in

the kindred subject of pathological examinations.Sputum, urine, or tumours are sent by the doctorto a clinical investigation laboratory, and a reportobtained for from 2s. 6d. to 10s. 6d. Probablythe ultimate development of this idea of a cheapmobile X ray outfit will require some form of subsidyby the county health authorities.

Adverse Criticism.Quite apart from this X ray problem, there remains

about 10 per cent. of these legal cases in which thechief factor which menaces the medical man’s peaceof mind and reputation is the accusation or condemna-tion pronounced against him by another practitioner.Sometimes this accusing colleague is - a man of noprofessional standing, who has nothing to lose andeverything to gain by posing before the public asone who is prepared to point out and correct otherpeople’s mistakes. But too often he is a man ofposition, who in an unguarded moment allowed him-self to criticise his colleague’s conduct without havinghad any opportunity of hearing that colleague’sstatement of the case. Having once made this pro-nouncement he is forced to abide by it, and to fortifyit at a later stage when the matter becomes one forlitigation. There may be occasions when it becomesthe duty of one medical man to make adverse criti-cisms of another practitioner’s diagnosis and treatment,but it surely ought to be regarded as a rule of medicalethics never to make such a criticism without firstinviting the accused colleague to some form of writtenor verbal consultation. Against this menace of anunscrupulous or indiscreet colleague I fear therenever can be any protection beyond that affordedby the defence societies. These may guard our pockets,but they cannot ensure either our reputations or ourpeace of mind.

It is a part of the onerous responsibility of ourcalling that we have to face dangers and " to su "let’the slings and arrows of outrageous fortune." Theman who treats fractures must be prepared to risk

Ithis every day. He should be no more deterred frompursuing this branch of his work by the menace ofungrateful patients, or unmerited litigation, than theabdominal surgeon should be by the danger he runsof maiming his hands or losing his life by the prickof an infected needle. It ought, I think, to be amatter of consolation to us on those rare occasionswhen we meet ingratitude and unjust accusation toreflect how many times we really have deserved

censure, but have instead received unmerited

gratitude.

An AddressON THE

RELATIONS OF THE

PUBLIC HEALTH SERVICE AND THE

PRIVATE PRACTITIONER.Delivered before the Manchester Medico-Ethical

SocietyBY FREDERICK E. WYNNE, M.B. DUB., D.P.H.,PROFESSOR OF PUBLIC HEALTH IN THE UNIVERSITY OF SHEFFIELD,

AND MEDICAL OFFICER OF HEALTH FOR SHEFFIELD.

THE subject of this lecture appealed to me becausemy professional life has been divided almost equallybetween the experience of a general practitioner andthat of a whole-time medical officer of health.Without the former experience, or most of it, I shouldhave found it impossible to fulfil the functions of myofficial position with any measure of success. Eventhough he may have no direct clinical functions (thoughno member of the public health service can be com-pletely divorced from such functions), it is essentialthat the administrator of municipal medical servicesshould have an intimate knowledge of the outlook,the difficulties, and the ultimate value to the publicof the private practitioner. The period over whichmy professional memory extends has witnessed anextraordinary development in our conception, notonly of medicine and surgery in the purely scientificand technical sense, but in the relations of membersof the profession to each other and to the public.After the academic calm of the university and someresident hospital appointments, my first experienceof the rough and tumble of general practice was asassistant to a practitioner in a colliery district ofNottinghamshire. It sounds a terrible confession, butthis was in the last century. My principal was totallyignorant of what was then modern medicine andsurgery; he was also brutal, mannerless, andavaricious. My colleague was an " unqualifiedassistant " who told me that he had adopted themedical career after an apprenticeship to the" walking-stick and umbrella trade." He did allthe midwifery; and the patients loved him. In fact,several victims of puerperal sepsis would have likedto have had his name on their tombstones. He wasa nice little man, and when I got the sack, after asomewhat acute difference of opinion with myprincipal, he urged me to " go into business on myown " and, above all, to develop " a clap and poxconnexion." These reminiscences illustrate some ofthe conditions of private practice in industrial districtsin those days. My colleague must have been one of thelast of the "unqualified assistants," but he was amuch better doctor " than his so-called " principal."He had sympathy and imagination, and I fear hemust have been reduced to " travelling " in drugs ordisinfectants. In those days, and for some yearsafterwards, at all events in working-class practice,doctors in the same districts were not colleagues.They were " opponents," not merely technically butactually. The only good mark I ever earned as anassistant was when I most unprofessionally, but quiteunconsciously, " pinched " the patient of one of myprincipal’s " opponents." She was the wife of theprincipal butcher in the village, and therefore veryimportant. My self-esteem was greatly flattered, andit was only afterwards I learned that their usualattendant had been abandoned because his debitfor joints and sausages had long since ceased tobalance his contra-account for bottles of medicine.I might add that in that particular practice mid-wifery fees had been reduced to 9s., and there was a"

private club " organised by my principal who con-tracted to attend whole families for 3s. 6d. a year tThis was, of course, the " reductio ad absurdum "of " general practice," and resulted in atrocities to

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which no normally constituted doctor could endureto be a party.

THE NEW SPIRIT IN MEDICAL PRACTICE.

It was some years afterwards in Leigh that I firstwitnessed the breaching of the new spirit, when" opponents " became colleagues, when we formed amedical society, which very soon amalgamated withthe Wigan Medical Guild, and subsequently becamethe Wigan and Leigh Division of the British MedicalAssociation, which I had the honour of representingfor some seven years at the representative meetingof the Association.

Medical practice of the type I refer to was in thosedays a very sordid form of shopkeeping, a ruthlessscramble for patients on terms that rendered them,even from the commercial point of view, unremunera-tive, - and made the doctor’s claim to professionalstatus simply farcical.. Any of the younger generationwho would take the trouble to look up the files of theBritish Medical Journal and read IJhe articles andcorrespondence on the subject of " contract practice,"even in the early years of the present century, wouldobtain an insight into the conditions under which hisfather or uncles practised which would be a startlingrevelation, and I hope would enable him to appreciatethe fate from which the British Medical Associationhas saved him.

NATIONAL HEALTH INSURANCE AND THE MISCHIEVOUS" EIGHT-OUNCE BOTTLE."

The reconstitution of the Association was decidedat the historic Cheltenham meeting in 1903, whenthe Representative Body was formed, and by 1911it was strong enough to fight, and very greatly tomodify, what is now the National Health InsuranceAct. Had the Bill gone through in its original formit would have meant the enslavement of the professionand a perpetuation of the very conditions I havedescribed, the recognition of which was the real4 1 vis a tergo " that forced the popular demand forreform in the medical treatment of the wage-earningclasses of the community. But I think it is nowadmitted that with all its faults the Act has raisedthe standard of medical practice of this class andimproved the status of the doctor. PersonallyI think the main objection to it is that it has failedto free the doctor from the tyranny of the " bottle ofmedicine " habit. It has done nothing to educate thepublic in this respect, and the panel doctor who doesnot prescribe or dispense a bottle of medicine willfind his list of insured patients dwindling; as certainlyas I found my private practice evaporating whenI tried to educate my patients to abandon thisparticular form of vice. Unfortunately, we are nowspending some three-quarters of a million poundsannually on " drugs and appliances " under theInsurance Act, and I am convinced that probablyhalf a million of that amount is waste, and much ofit mischievous. I expect our ancestors who resortedto universal bleeding did more good and less harm totheir patients than we do by encouraging or main-taiair.g the superstition whose outward and visiblesign is the eight-ounce bottle.

TEAM-WORK IN MEDICAL PRACTICE.

There are other factors which tend profoundly tomodify the conditions of private practice, and one ofthem is our modern and inevitable dependence on thepathological laboratory for diagnosis. It is a develop-ment of this that causes many of the well-to-doclasses to resort to places where they obtain not onlydiagnosis but treatment, not from a doctor, as ofyore, but from a team of specialists. It is quitecertain that as this form of medical treatment becomesfashionable for the wealthy its provision, more or lessat the public expense, will be demanded by and forthe poorer classes of the community. In fact, alreadysome of our voluntary hospitals are being reorganisedmore or less on these lines. Already we have hospitalswith a " surgical section " presided over by a chief

who coordinates the work of a " team " of specialists,and is paid a salary for doing so.

In the meantime the health services organised bythe State through the local authorities have undergonean enormous change, and in a direction which causesthem to encroach more and more on the sphere of theprivate practitioner and the consultant.The result of the " industrial revolution " was to

create unheard-of wealth, and an enormous increaseof population. What had been mainly an agriculturalpopulation distributed over the country and dependenton villages and country towns for markets and craftssuddenly underwent a process of clotting. Industrialtowns grew up like foul weeds. The demand forcheap labour, and even child-labour, was inexhaustible.Anyone who owned a few square yards of land in theneighbourhood of any industry built a house on it.There were no restrictions on the exploitation ofpoverty by wealth. People prated about the " sanctityof human life " well knowing that men, women, andchildren were much cheaper than turnips, and a cropthat raised itself without any trouble to anybodyelse. By the middle of the nineteenth century con-ditions had become so appalling and death-rates soalarming that the nation awoke to the necessity oftaking this problem seriously in hand.

PUBLIC HEALTH LEGISLATION FOLLOWING THEINDUSTRIAL REVOLUTION.

The great Lord Shaftesbury had already won hisbattle over the first Factory Act and had at leastemancipated infancy from one of the most ghastlyforms of slavery. Chadwick began to preach sanita-tion, and the Towns Improvement Clauses Act waspassed in 1847. It was the forerunner of muchpublic health legislation. In 1870 the-Education Actwas passed, and five years later a great deal of scrappypublic health legislation was consolidated in thegreat Public Health Act of 1875. Unfortunately, bythat time the mischief was done. We had created amess which we have by no means cleared up yet.The Act of 1875 very naturally and properly dealtalmost altogether with the environment of the people.Only in the case of " dangerous infectious disease "was the individual considered, and even then he wasnot considered as an individual but as a possibledanger to the rest of the community. It enabled,and in fact compelled, local authorities to provideadequate water-supplies, to make and cleanse roadsand streets, to compel the " abatement of nuisances,"and to make at least a beginning of clearing up theAugean stables bequeathed to us by the " industrialrevolution." It was followed by a bewildering massof legislation, various amending Acts, the Food andDrugs Acts, new Factory Acts, Acts dealing with theNotification and Prevention of Infectious Diseases,and all the housing legislation that began with theAct of 1890. There was a flood of legislation, andParliament even concerned itself with details of theconditions under which rag flock was produced andhandled I

ACTIVITY IN THE TWENTIETH CENTURY.At the end of the century the work was certainly

not half done. We may perhaps claim that it was" well begun," but we can certainly claim no more.Nevertheless, with the beginning of the presentcentury a very marked change came over the spiritof the public health movement, and the publicdemanded that the municipalities should turn theirattention more and more to the direct care of theindividual. By that time the campaign againsttuberculosis had been in existence for a considerablenumber of years, but the problem of the infantilemorcality-rate had not been seriously tackled, andthis mortality had not at all followed the generalmortality-rate in its downward career. It was notuntil the beginning of the century that child welfarework was generally established on the lines withwhich we are now so familiar, which have resultedin so startling a reduction in infant mortality. Its

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proper corollary, the study and care of prenatalconditions, is the most recent growth of publicactivities. It is since the war that the public consciencehas been aroused to the terrible havoc that was beingwrought in the present generation and the threat tothe future of the race involved in the prevalence ofvenereal disease. The control of these diseases alsohas been " municipalised " mainly, I regret to say,on a curative and not on a preventive basis. Again.it was towards the close of the first decade of thecentury that the Education (AdministrativeProvisions) Act was passed which established theschool medical service, with all its enormous influencefor good. Of course, our environmental work hasnot been neglected. Enormous arrears in the matterof housing have had to be overtaken at a time whenthe financial burden of the nation is greater thananything ever contemplated by our forefathers, andit should be remembered that in this matter ofhousing we are doing much more than overtakingarrears. We are aiming at a standard of health andamenity that would have seemed not merely Utopianbut insane to the makers of the industrial revolution.We limit our municipal housing schemes to 12 housesper acre, and in some cases we are displacing peoplefrom slums where houses are huddled together at therate of 200 per acre I Every civilised community isnow rapidly eliminating such abominable relics ofthe Middle Ages as the " conservancy " system ofdisposal of excreta, while we are insisting thatbackyards shall be paved and existing houses main-tained in a state of reasonable repair. Nevertheless,it is quite true, as Sir George Newman said some sixyears ago, that the centre of gravity of public healthadministration has shifted from the environmenttowards the individual, and in this shifting I thinkthere has sometimes been a tendency to concentrateon the cure of end-results at tne cost of prevention.Recent results in our antituberculosis campaign havebeen most remarkable, but in the early enthusiasmfor " sanatorium " treatment in elaborate and costlyinstitutions there was an enormous expenditure ofpublic funds without any commensurate result.Education and rational preventive measures would intime make many of our venereal disease clinics ananachronism. Our failure to eliminate rickets is duenot to want of knowledge of its cause or of themethods of prevention, but to our inability to get Ithis knowledge home to the very class of people whomost require it.

EFFECT OF PUBLIC HEALTH ENTERPRISE ONPRIVATE PRACTICE.

In the meantime all this public work has made the Imost terrible inroads on the work and the earningcapacity of the private practitioner. He has verylargely lost his attendance on the expectant mother,and his maternitv practice is now largely in the handsof highly qualified midwives. He has lost the infantsand the school-children ; the tuberculous and thesuilerers from venereal disease. There is now a

tendency, which becomes more marked every year, to (demand the isolation, and theretore the municipalisa- Ition, of pneumonia, of measles, and of whooping-cough.Very soon we may acquire some accurate knowledgeof the causes of that enormous group of more or lesscrippling conditions now lumped together in themeaningless mediaeval category of " rheumatism,"and still absurdly classified in the " internationallist " as " diseases of the organs of locomotion " 1Some of these, if not all of them, will certainly cometo be regarded as " preventable diseases," and to thatextent the doctor’s purse will again be depleted.A deep resentment against this encroachment on

the part of men who have gone through an arduousand expensive training seems to me quite natural,but not necessarily wise. As we have seen, theconditions of medical practice have changed. The

majority of members of the public still want theirown doctor, wno

" knows their constitution." Theywant his friendly manner, his sympathy, and, aboveall, his bottle of medicine-if possible," the same as

they had last time." With the possible exceptionof the bottle of medicine, all these are good things,and I daresay when my time comes I shall welcomethe presence at my bedside of the successor ofTrollope’s Dr. Fillgrave, without whose sanction no-one could die respectably. But the custodians ofthe people, their politicians, the insurance companies,and the so-called " friendly societies " will not, ifthey can help it, permit the perpetuation of theseluxuries. The statesman sees that under modernconditions the nation can no longer afford avoidableinvalidity, even though the medical profession maystill have a vested interest in disease.

It is useless for us to protest against these economictendencies or to attempt to oppose them. I believethat with the lessened incidence of disease, and theincrease of " team work " in the profession, thenation will not be able in future to support as manydoctors as it has dope in the past, and that we shouldendeavour to limit the entries of medical students bydemanding a much higher standard of preliminarygeneral education than we have done in the past. Ithink that some experience of " general practice "should be compulsory before any form of specialisationis permitted, and that the profession should at leasttry to reorganise itself from within so as to giveevery member an interest in the preventive side of hiswork. In Sheffield, since I have been responsiblefor it, the clinical part of our prenatal and childwelfare work has been carried out entirely by a staffof general practitioners working on a part-time basis;and, judging by our results and the smoothness of theadministrative working, I see no reason to wish tochange it. Our venereal disease clinics are operatedby part-time specialists, and I think the future ofpreventive work may, if they choose, be largely inthe hands of private practitioners, provided they areprepared to maintain the value of public work bythe standard of their private practice.

UNRECOGNISED TOXIC SUBSTANCES INHUMAN FÆCES.*

BY DOUGLAS CHALMERS WATSON,M.D., F.R.C.P. EDIN.,

PHYSICIAN TO THE ROYAL INFIRMARY, EDINBURGH.

With an Account of Experiments byP. DE, M.B., B.SC. CALCUTTA,

ASSISTANT PROFESSOR OF PHARMACOLOGY, SCHOOL OFTROPICAL MEDICINE, CALCUTTA.

communication is intended to be franklyprovocative and suggestive ; to provoke thoughtand commentary from teachers of clinical medicineon the correctness of the views expressed, andto suggest to practitioners the necessity in theinterests of medical progress of their independentthought and observation on facts which come dailyunder their own notice. The late Sir James Mackenziedivided clinicians into two groups-those who do notknow, and know that they do not know, f1nd thosewho do not know, and do not know that they do notknow. I write franklv as a member of the first group.Stated shortly, my thesis is : the urgent necessityat the present time of clinicians directing theirattention to the teaching of Bouchard, Metchnikoff,Arbuthnot Lane, and William Hunter. Few will denythe present unsatisfactory state of our knowledge ofthe aetiology of most common medical disorders thatfill our hospital wards to-day, our comparative help-lessness in curing them, or our too limited endeavouralong lines of preventive treatment. Much attentionhas been directed for many years, and with markedsuccess, to making more complete our knowledge ofthe physical signs of disease, to refinement in diagnosis,and to research work, both clinical and laboratory,dealing with the end-products of disease. Too little

* A paper read at the Medico-Chirurgical Society ofEdinburgh on Jan. 18th.