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In England NowA Running Commentary by Peripatetic CorrespondentsMANY of us, I fancy, will deplore the curtailing of the

medical curriculum even as an emergency measure.This may, in part, be mere envy because no such privilegewas accorded to us of a previous generation of medicalstudents ; but I suspect that it goes deeper than that.GP’s will recall how ignorant they were, when firstqualified and how slowly and laboriously knowledge ofthe treatment and above all of the management of sickpersons (and their relatives) had to be acquired. Thebest books on medicine are the patients themselves and36 months is little enough in all conscience to give toclinical work; even then it has to be packed in witha great deal of extra clinical activity. If some abridg-ment was necessary it would, I think, have been infinitelywiser to have made it during the preclinical stage.The detailed study of anatomy, for example, is at besta mere feat of memory and at worst a stultifying experi-ence. Most of it is soon forgotten and quite useless ingeneral practice and I have heard even surgeons admitthat its importance is grossly exaggerated.

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Not long ago I had the ill luck to be sent for a shortperiod of rest, so called, to a hospital in the throes of aquiet spell. All the casualities of the last blitz were bythen discharged or required only occasional attention.The garrison troops in the area were temporarily with-drawn and things had come to a virtual standstill. Asa result I was for the first time reduced to studying theart of killing time. By rising late and prolonging one’selevenses the semblance of working in the morning couldbe maintained. In the afternoon, when the chronicinclemency of the weather permitted it, the custom wasto walk to the village about four miles away ; on wetafternoons one read or slept according to inclination.During those dreadful hours between tea and dinner aspirit of restlessness seemed to possess everybody. Toadd to this uncertainty the afternoon mail might failto arrive if the office boy was too busy drawing aero-planes to sort it. If the musician of the staff receivedno letters he became of all men the most miserable andproceeded to hammer out the most melancholy ofChopin’s preludes on the sitting-room piano in the hopethat he would succeed in making others as depressed ashe was. Like all true artists he was impervious aliketo criticism and witticism but he knows now that it ishopeless to try to compete with the wireless turned fullon.. I even managed to convince him that the set wascapable of switching itself on without human aid.In the evening after the best meal of the day and in

front of a comfortable fire feelings mellowed and eventhe musician became good enough company, providedhe would leave his wretched piano alone. This part ofthe day was customarily employed by the staff in gamesof skill and chance,-bridge, draughts and (tell it not inGath) vingt-et-un. I never cared much for gamblingand consequently was the proper prey of the chessenthusiast of the company. He would have made apleasant opponent if he could have dissociated businessand pleasure, but he was a pathologist and insisted onan exhaustive post-mortem analysis of every game.The more severely he was beaten the longer was theautopsy, and since I usually emerged victorious I soonfound it unbearable. I once asked the junior physicianwhere the billiard-table was, only to be told that neitherhe nor his colleagues had had time to loaf around theUnion in their undergraduate days. After that rebuffI dared not unpack the dart-board I had brought withme. They would never have believed that I acquiredproficiency in the game while on a voyage for my health.For some reason table-tennis was considered eminently

respectable and was played in season and out by alland sundry. When the medical superintendent playedagainst the surgeon we all pretended to an appreciativeinterest in the decorous but herculean struggle betweentwo master minds, but when the residents began to playthere was an immediate exit of all the other occupantsof the room. I used to think that this rush for safetywas uncourteous if not undignified on the part of thepermanent staff until one day I surprised the messsecretary in some abstruse calculations which involved

the use of a slide-rule. He told me he was workingout the bonuses due to his colleagues for prowess atping-pong; it appeared that some system of extra

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points was allowed on the following basis : For doingviolence to the person or propefty of anyone in the room,2 points. For a bull’s eye registered on the bald spoton the back of the surgeon’s head, 5 points. For up-setting the pathologist’s chess board 10 points. Forknocking off the physician’s pince-nez 20 points. Asthe residents played with abandon it is small wonderthat their seniors considered discretion the better partof valour and retired on the commencement of hostilities.

I don’t expect there is much time for recreation in thathospital now, for they received a train-load of casualtiesafter the last blitz in the neighbourhood. I enjoyedmy stay there and am grateful to those people forbeginning a hitherto neglected side of my education.

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We badly need a proverb to sum up the fact that theobvious, unless it has actually been thought about,can still surprise us. " You never miss the water tillthe well runs dry " is about as near as we get, but thisreflects only one aspect of the whole. Recently I haveseen something of veterinary surgeons at work, and heremany of the surprises were really quite obvious implica-tions of the differences between their patients and ours.For example, if one had thought about the doses ofsulphonamides needed for cattle, obviously one wouldhave expected them to be large. But I had never givenit a thought and consequently the sight of 7 lb. drums /of the drugs on the shelves astonished me no less thanthe instructions to " Give him two ounces right away."Similarly with midwifery ; remembering the manualstrength that is often required did not prepare me forthe sight of ropes and pulleys, and the request that allthe available man-power should heave hard. One objectthat baffled me completely was a long tube of very hardleather about the thickness of the handle of a tennisracket. This turned out to be a stomach-tube, and laterI saw it used with something like the result that Iimagine would follow a direct hit on a barrage balloon.These qualitative differences, however, were small com-pared with one difference in kind which filled me withapprehension at the thought that it might ever beapplied in human medicine. An aspect of treatmentthat I had never considered is the relative value of theanimal and the treatment. Nobody is going to givetreatment worth 95 to an animal worth ;&bgr;l; but howawful a thought that one might have to decide whetheror not Mr. A’s usefulness to the community justifiedremoval of his appendix.__

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It is high time that someone called the bluff on thepresent craze for extolling the young. The wholesuggestion seems to be that if only " the young " werein control how different everything would be. Who areincluded in this exclusive group ? Physiologically westart growing old from the moment we are conceived.We are probably at our physical prime in the earlytwenties. When are we at our mental prime ? I wasbrought up by a chief who never tired of pointing outthat a man’s best work was done before he was 30. Atthe time (in my early twenties). I found this ratherdepressing, but I have no doubt now that, like many ofhis opinions, there is a great deal of truth in it, especiallyin the modified form that unless a man has shown promiseand produced some good work before he is 30 he is notlikely to be outstanding. This of course applies particu-larly to research. In other spheres the story may bedifferent. Some men, for instance, mature late butnevertheless turn out better than the scintillating youngman of the early twenties who is unable to maintain thepace. The real clinician may be born and not bred but formost of us clinical acumen is the result of long and oftenbitter experience, and the same applies to the statesman.The young may have more generous impulses, be less

bound by conventions and have more imagination, butthey have not the experience of life which’is essentialin handling men and women. When short sharp burstsof energy and initiative are required they are undoubtedlysupreme, but in long-sustained efforts such as leadinga community they can only supply some of the energy,the actual leadership requires other attributes whichonly come with experience. One only needs to study

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the painfully inadequate attempts which certain groupsof medical students have made to produce memorandaon the subject of medical education. Catch-words, thefashions of the nioment--all these are incorporated.And worst of all there i a nagging insistence on theirown importance and a complete lack of appreciation ofwhat their seniors have accomplished.

Since the introduction of universal suffrage the. citizen has been considered capable of recording a voteat 21. What difference has this tremendous influxof the young to the electoral roll made to the member-ship of the House of Commons ? What percentage haveever troubled to record their votes ? Or, to take anexample nearer home, what part do the junior membersof the honorary staffs play in running our teaching a

hospitals ? How many of them are prepared to settledown to the task of producing a reasoned scheme whichwill prove practical ? How many have been content toproduce some novel idea and then collapse like a pricked

balloon as soon as any criticism was offered ? Modernyouth is no better and no worse than preceding genera-tions, but I wish someone would take them in hand,reintroduce a little discipline into our life and silencetheir querulous whimperings. Let youth pull itselftogether, get down to a.little hard thinking and chatterless. Let them realise, and their elders as well, that weare all part of a whole. The ripe experience of age incooperation with,the initiative and energy of youth will’ ‘

go far, but youth alone will only land us in unpredict-able, instead of known, dangers. The present positionin Germany should be an ample warning of the purgatoryin which misguided youth can land a nation.

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Coming over in the ship I met a captain of signals,whose hobby had become his job-pigeons. He had adozen with him and liberated them when six miles fromshore. They circled round for ten minutes before beinglost to sight. " Funny if they refused to leave you," Isaid. ’* They do home back to their basket sometimesif they’re flighted too often," he answered. He said, and Iput it in my " awaits confirmation" box, that pigeonsnever flight in the dark, they come down wherever they are.He also said there were too many peregrines about.

In the train I sat opposite a young man who had comedown to see his sick father. Pain over the heart anddown the left arm, dyspnoea at night, sounded badenough. The doctor had warned him for anything, butwisely had not branded it with a name. He himselfwas an asthmatic, but I think I might have deduced thatfrom the shoulders and keen, anxious eyes. In 50 mileshe gave me a brief resume of all the treatments he’d hadsince boyhood. The best one was living in London. Hewas a designer and has turned over to precision instru-ment making and is on night-work. He is very struckby the immutable methodicalness of the professionals ; ;everything has to be in its exact place on the bench.He said that their union meetings for which they hadtime off generally resolve themselves into personalwrangles between the elder men as to who had the mostexperience and so on. His hobby is painting and he hasliterary aspirations. We changed trains together andgot into a darkening carriage with five sailors. Theyhad been torpedoed and were longing to tell us moreabout it, but didn’t. Expansion is so much commonerwith the English than repression. They’d switched offthe light, so that they could have the curtain up and the.window open-a touch of claustrophobia here. Expan-sion and claustrophobia are, I suppose, mental stateswhich protect the herd against the individual ; repressionand agoraphobia protect the individual against the herd;most of us keep an uneasy balance. The carriage grewdarker. My first friend’s head rested on my shoulderand I could feel his troubled breathing-his father’sillness, his work to-night, his untidiness, his writing. Asailor’s leg touched mine, but changed position often,restlessly, almost angrily. Mankind has lost nine-tenthsof his tactile sensibility. If I were a cat, I could probablytell what they are dreaming about. My dog alwayssleeps with a bit of him touching me. Children have afair tactile sense. When they are going to have a mealthey think of it in terms of the taste and the feel of it intheir mouths ; when they’re going to swim they feel thewater round them hours before ; they love nakedness ;clothes can be a torture ; hair-cutting purgatory.

What’s that up on the rack ? 0, the Cheshire Cat ! I" Of course, my dear boy, I think entirely as smell, tasteand touch, at any rate for present use. When I want todo a little future thinking, I may throw a picture or twobut it’s an effort. Words, those obscene noises you make,how can you possibly think in those ! Don’t be absurd "Snore-kick-rattle. " That’s why I enjoy the sun somuch, and being stroked and prolonged nocturnalpropagation." He chuckled and faded. Snort-jolt." Gawd, what’s that ? " Dawn and Paddington.

A NATIONAL MEDICAL SERVICE SCHEME

JLiliM lVtbInlVlldl l3.Cdllnll LSSOCiatjiOIl, wmcil 1121.’ its

headquarters in Tunbridge Wells, advocates the forma-tion of a National Medical Service based on democraticprinciples and under the control of the local governmentadministration and insurance committees.They have drawn up the following scheme. A national

medical service should extend over the widest possiblearea, including, in particular, rural districts. It shouldbe administrated by joint health advisory boards,which would advise units in their respective areas on theimplementation of improvements in institutional, in-dustrial and domiciliary services.. The boards wouldcover the areas as defined by local government. Theservice would thus work as a compact unit for thepreservation of health and the prevention of ill health,as well as to secure early diagnosis and provide the mostmodern facilities for medical treatment under centraladvisory direction.Under the Local Government Act 1929, authorities are

empowered to unite and form joint boards, having advisoryand executive powers. These authorities include countycouncils, county boroughs, and municipal, urban and ruralauthorities. Machinery thus already exists for the establish-ment of joint health advisory boards. These would act in con-

junction with already established medical authorities. Com-

plete coordination of institutional, industrial and domiciliary’medical services should be assured by these boards without inter-fering with the executive powers of local government bodies.An efficient national medical service should be divided into

institutional, industrial and domiciliary services. Institu-tional services, in the main impersonal, can be administeredwith efficiency by local authorities under the existing PublicHealth Acts. Institutional medical services, consisting ofhospitals, clinics (diagnostic and treatment), rehabilitationcentres, specialist services (accident, blind and deaf, ortho-psedic, dental, infectious diseases, maternity and child-welfare,mental deficiency, ophthalmic, nursing, pathology), poor-lawservices, school medical services, tuberculosis, and venerealdisease services, and such others as may be found necessaryor desirable. They would in the main be administered byappropriate public-health authorities, which would be

responsible through the joint health advisory board to theMinister of Health.

Industrial medical services are administered in factories in

peace-time by the Factory Department of the Home Office,but in war-time by the Minister of Labour and NationalService ; in mines by the Minister of Mines ; on railways bythe Minister of Transport ; and in merchant shipping by thePresident of the Board of Trade. Such division of authorityis inconsistent with an efficient national medical service.Local authorities are the most appropriate bodies to administerthe scheme.

Domiciliary services comprise medical and pharmaceuticalservices in collaboration with facilities for specialist diagnosisand treatment in clinics under the institutional service. Freechoice of medical attendant and free acceptance by a medicalpractitioner are matters of fundamental importance for ademocratic medical service. A capitation scheme of paymentcoupled with a basic salary for the medical practitioner isessential. Domiciliary service should be administered throughinsurance committees in the respective district of each author-ity, and these committees would be responsible through thejoint health advisory board to the Minister of Health.

Ninety-five per cent. of the population is in receipt ofincomes of under E500 a year ; it is proposed that theyand their dependants should be covered by insurance formedical benefit, but without prejudice to their right to beprivately attended by a doctor of their own choice. Thecost of institutional, industrial and domiciliary servicescould be covered by contributory insurances withExchequer grants in aid.