1127

THE LANCET.

LONDON: SATURDAY, APRIL 23, 1898.

UNQUALIFIED ASSISTANTS AND THE GENERAL MEDICAL COUNCIL.

IT is impossible to deny that the action of the General a

Medical Council in November last in formulating a Notice t

to registered medical practitioners in advance, as respects t

clearness and stringency, of previous notices of the sort has c

been generally regarded by the profession and the public with 1

satisfaction. Even unqualified assistants themselves have

not ventured to question the abstract justice and reasonable-ness of such action on the part of the Council. No doubt

‘

to many men of this class it has come as a severe if some- ‘

what belated reminder that they were in a false and un- satisfactory position. The Council for many years connived

almost completely at the use of unqualified assistants until reminded by the Home Secretary of the day that it was responsible for scandals which arose out of their em-

ployment and that it had the power to deal in a disciplinary way with registered practitioners whose countenance alonekept the class of unqualified assistants in existence. For

many years more, down indeed to the present time, theCouncil has acted with remarkable leniency and tolerationtowards the class of unqualified assistants and has virtuallyonly punished the practitioner for using such in very grosscases-for the most part in cases of covering, where the

unqualified assistant was left practically in complete chargeof patients or in the management of a branch practicewith little or no supervision by his principal. It is notorious

that until very lately it was not uncommon for several largeseparate practices under the name of one registered practi-tioner to be practically conducted by unqualified assistants.The fact is that the sense of hardship produced by therecent action of the Council has been occasioned mainlyby its past slackness in regard to this great evil, so

that unqualified assistants came to think themselves

an indispensable and almost a recognised class. The

slackness of the General Medical Council in this matter was

injurious alike to the public and the profession and it hasbeen cruel in its operation on the unqualified assistants, whohave come to regard themselves almost as having rights andclaims similar to those which practitioners before the year1815 had when the Apothecaries Act came into force. This

view is quite untenable. The Medical Acts would be stulti-

fied if under the thin cover of supervision by a registeredpractitioner unqualified assistants were to be foisted on

the public. The public would be defrauded and very greatinjustice would be done to young practitioners who attaina place in the Medical Register by years of hard studyand after undergoing the ordeal of many examinations.

Accordingly, the action of the Council has been generallyapproved and will, doubtless, be steadily maintained.Our readers will have seen that a movement is on

1 THE LANCET, April 9th, 1898, p. 1013.

foot in favour of a strictly limited section of the class

of unqualified assistants. It is proposed to petition theGeneral Medical Council to authorise the examiningbodies, or certain of them, to hold, if they please,one or more special examinations, during the presentyear alone, for the benefit of such unqualified assistants

as, firstly, are over forty years of age, secondly, havecompleted the medical curriculum, and, thirdly, are

of satisfactory moral character. It is essential that in

sanctioning any such accommodation to unqualified assist-ants the Council should stipulate for conditions which implythat the non-qualification of men has arisen rather from

their misfortune than from their fault. It is easily con-ceivable that there are not a few men who have been

hindered by little fault of their own from obtainingdiplomas which would have entitled them to registration.Want of health, want of means, failure of parental help atan inconvenient stage of their career, and such like things,are only too common and happen often to students of

good character and of good ability. It cannot be to

the interest of the profession to throw these men adriftinto the ranks of illegitimate practice and if any

reasonable plan can be adopted for legalising their posi-tion few will object to its adoption. It is significantof the impression that such a step would be consistentwith justice that it is approved and promoted by registeredmedical men. It is not asked that such an exceptionalgate of entrance to the profession should be kept openfor more than the present year. It would be no kindness

to the class whose legalisation is contemplated to keep it

open for any length of time. They must clearly realise thatthe profession is to be closed quickly and completely to allwho have not complied with the requirements of the

examining bodies and the General Medical Council. But

it does seem to us that the petition in favour of this limitedclass of unqualified assistants may be seriously entertainedby the Council without detriment to the public or the

profession.

WE remember holding a conversation some years ago witha distinguished American in which allusion was made to thewant of friendly feeling exhibited by the newspaper pressof the United States towards this country, the reason ofwhich was inexplicable to us. The feeling of England tothe United States, we urged, has always seemed to be most

friendly; the official representatives of that country were

very popular in London society, and Americans were every-where received in England on terms of the frankest friend-

ship. Our American friend in effect replied: "Never mindthese surface exhibitions of apparent hostility, for they arebut apparent, not real. If your people were in a great straitand were making a hard fight-which you would-againstany big coalition against you there would be no holding mypeople; there would be such a flood of feeling in your favouras would sweep everything before it." We believed that at

the time and we believe it now. There is, and always hasbeen, an underlying conviction on this side of the Atlanticthat, in spite of all our differences and diversities and

methods of procedure, the Anglo-American race is one; thatin our love of a just and law-abiding rule, in our love of

freedom, independence, and progress we recognise and are

1128 THE AMERICAN AND SPANISH CRISIS.—SANITATION f. SOCIALISM.

working up to the same standards; and that, in fact, bloodis thicker than water.

As we have so often said we have happily nothingwhatever to do as medical and scientific j oournalists with

politics, but it is ’difficult to prevent a subject that

meets the eye in every newspaper at the present momentfrom obtruding itself into our thoughts and influencingour sentiments. It is also impossible for people in

this country not to feel some sorrow and sympathy withSpain, with all her historical traditions and past power,placed as she now is in the most difficult and tryingsituation possible. But looking to the future good of

humanity, and believing, as we do, that the sincerest andbest people, at any rate, in the United States, are movedby a spirit of unselfish indignation at the protracted mis-rule of Spain in Cuba, we cannot withhold our sympathywith them and the cause they are championing, or avoidperceiving that it is for the good of the world that suchcruel misrule should be brought to an end. If Spain had

long ago spontaneously adopted the course she is now pre-pared to accept the case would have been different, buther concessions come too late. Oar contemporary, the

Spectator, correctly hit off the situation, we think, when itsaid that Spain has some supporters in this country becauseshe is thought to be so weak and the States so strong." The real test of public opinion, however, is the admitted

fact that the Government, even if they wanted to,

which they certainly do not, could not show the slightesthostility to the States without creating an opposition sostrong that it would bring them to ruin." What pre-

cipitated matters, no doubt, was the Maine disaster andthe belief in the United States that its cause was not

purely accidental but attributable to the culpability or

negligence of the Spaniards-a view which has not been

proved and which the Spanish Government scornfullyrepudiates. It is, we think, easy to trace one of the causesof the somewhat tentative and contradictory lines of policyput forward in the United States, They have never relin-quished the object in view-namely, the complete evacuationof the island of Cuba by Spain, but the hope has neverthe- I,less been entertained that this object might be somehow attained without war. Mr. MCKINLEY has made that much

apparent. While it was very important to guard againstthe idea that it was only a case of NABOTH’S vineyard-acase of land-grabbing-it was also necessary to protectthe United States Government against being entangled inthe meshes of a doubtful Cuban Republic constituted byinsurgents.From 1823 to the present time the history of Cuba has

been one of chronic discontent and periodical insurrectionagainst Spanish rule, and it was, we repeat, inevitable thatthe United States would intervene to put an end to theterrible state of things there if the Spanish Governmentcould not pacify its Cuban subjects. It is scarcely likelythat Spain under existing circumstances could now submitto give up Cuba altogether and withdraw her forces fromthe island (by which alone war could have been averted), forsuch a course would probably give rise to a revolution andendanger the present dynasty, but she may be glad to do sounder cover of a defeat. We can only hope, so long as thefinal step remains to be taken and war between the United

States and Spain has not been actually declared, that it

nay yet be averted, but the bare hope is all that remains.All the indications, it must be confessed, point in one

direction only-that of war ; and we suspect that it will

prove a very grave undertaking for even so powerful,but unprepared, a nation as the United States. Military andnaval experts are already busying themselves with con.

jectures about its probable course and results. It is quitepossible that some decisive naval action may take place atits commencement, but if, the result of it were even adverse

to the States it could not end the war. Be all this as it may,

however, there is a medical aspect of the question which

may turn out to be a most important factor. All pastexperience testifies and everybody knows how much dependsupon the season at which war is waged in hot countries.Cuba has the reputation of being a hot, unhealthy, malariousisland, where yellow fever may be said to be endemic andoccasionally to prevail with epidemic violence. The un-

healthy season is notoriously the hot and rainy one,

and the healthy is that of the colder months of the

year. The losses from fever and dysentery, from the timeof ALBEMARLE’s naval expedition in 1762 to that of the

large Spanish expedition against the Cuban insurgents ofquite recent times, have been excessive. We all know that

the death-rate among the large Spanish force was

great, although we do not know statistically how great itwas; but it was as nothing compared with the total

inefficiency caused by sickness, or with the number of sicksoldiers in the military hospitals in the island during thehot and rainy season and the large amount of invalidingwhich followed. We do not, of course, know what is the size

of the military force which the United States contemplatelanding in Cuba, but there is already a large Spanisharmy present in the island, and any expeditionary forcesent from America, or army of occupation required for

holding Cuba until peace and good government have becomeestablished, will presumably have to be large. There is no

doubt that the United States Government will take all pos-sible care of its soldiers as far as sanitary precautions andthe provision of excellent hospitals are concerned, but wefear that the sickness and loss of life will in any case be

large and that it may, on the outbreak, and in the presenceof any epidemic disease, be excessive.

0

THE March issue of the Sanitary Tournal, contains acharacteristic article by Dr. J. B. RUSSELL, entitled "PublicHealth and Social Problems." It appears to have been de-

livered as an address to a students’ society in Glasgow Uni-versity, and though we fully recognise the ability of under-graduates to appreciate a good thing, it almost seems thatthe lecturer might have found at least a larger and a wider,if not a more appreciative, audience. But when we recollect

that that gem of public health literature, the address on" Life in one Room," was originally given to some local

mutual improvement society, we begin to see that the

question of an audience is a secondary one with Dr. RUSSELL,even when he has something very particular to say. Briefly,the thesis of the present paper is that sanitation is doing agreat deal to remove the chief causes of discontent on

. which modern socialism is founded, that it is carable

1129THE CONTROL OF PUBLIC WATER-SUPPLIES.

of doing still more, and that it is at least a more

practical if not essentially a better remedy. "The differ.

ence," says Dr. RUSSELL, "between all those social architectsand the sanitarian is this : the sanitarian is like the lifeboat

or the lifebelt to the drowning man—’ a very present help ’ ;the theorist is like the lecturer on the art of swimming-any good he may do is in the future. He certainly will not

help the drowning man." As to the causes of increased

population in certain parts of the country we read that" Glamorganshire presents the most remarkable illustrationin the country of a purely rural county, slumbering, so to

speak, over untold wealth, entirely unconscious of its

existence, and transformed by its discovery into a swelteringland of coal-mines, ironworks, copper- tin- and lead-

smelting works, its shores lined with docks and bristlingwith the masts of ships. Such is the wondrous tale,

excelling all the marvels of Aladdin’s lamp, which is

hidden in the dry bones of this bit of statistics, that

between 1801 and 1891 the population of Glamorganshireincreased 835 per cent." Having shown how largely thepopulation of Great Britain has migrated from the countryto the town Dr. RUSSELL points out what this migrationmeans socially and politically as well as sanitarily :-"As I look at these percentages creeping up from decade

to decade they become not merely sanitarily but sociallyand politically eloquent. They mark the emancipation ofthe people from obscurity.

Not kings and lords, but nations, ’

Not thrones and crowns, but men. !

It is difficult for an agricultural population to realise its strength. But in cities the numerical superiority of those who are employed over those who employ cannot be hidand must suggest thoughts. Physical aggregation promotesmoral association. Following Watt’s discovery there comesa period of English history which the historian demarcatesas I The Conflict with Democracy, 1789-1827.’ .’ We are nothere and now concerned with politics, but multitudes havea profound, even a pathetic, interest to the sanitarian, andas I consider them from my point of view I cannot shut myeyes to their fortunes and misfortunes, their virtues andtheir vices. I see them wakened up by the Revolutionin France, then becoming definitely visible through theI hurricane eclipse’ of the Napoleonic wars ; fighting for

their country as vigorously in the factory and workshop,with the help of steam, as their brothers under arms in thePeninsula or afloat with Nelson ; starving when the peacethey had helped to win left the Continent free to competewith them in the arts of peace ; in the blindness of despair,burning mills, clamouring for the suffrage, rioting, riddendown by the cavalry at Peterloo; gradually gaining theprotection of the Factory Acts and emancipation from thenew slavery of the apprenticeship system, secured fromstarvation by the abolition of the Corn Laws and the

adoption of free trade ; finally, struggling through Chartistriots towards political enfranchisement and the Ballot Act.There, masters of their own destinies, we may leave theDemocracy." "

Another fine passage begins as follows :—

"What is the fulness of the meaning of a lowered death-rate How can I bring it home to you? Marshal all thephysical facts which constitute the scientific conception ofsummer and winter, and how much nearer are you to

knowing what they are A few hours more or less of sun-

light, a few degrees more or less of heat, a few inches moreor less of rain; a mile or two of velocity, a pound or two ofpressure more or less of the wind, and a point of change in

the direction from which it comes, that is all the difference,and yet summer is life and laughter, winter is death andtears. It is much the same with the statistical expression ofthe movements of public health-a unit or two or only adecimal fraction of a unit more or less, that is all, whetherwe adhere to the simplicity of a death-rate or resort to theintricacies of a life-table."

Space prevents us from quoting further, but we trust thatDr. RUSSELL or the publishers of the Sanitary Jawrnal’ willbe so inundated with requests for copies that it will benecessary to reprint the lecture for general circulation. It

should have been given as the opening address of a SocialScience Congress or from the presidential chair of the

British Association for the Advancement of Science.

Annotations.

THE CONTROL OF PUBLIC WATER-SUPPLIES.

" Ne quid nimis."

Is it not time that the quality of public water-suppliesthroughout the country should be placed under the samelegislative control and check which obtain at the present’’time in regard to food and drugs ? A short yet very compre-hensive Act involving but little need of additional organisa" -tion would appear to be all that is required. Big supplies like’-the metropolitan supply are, as is well known, periodically --and minutely examined, but the public water-supply of the ,majority of provincial towns is not as a rule subject to the’ °

same officially conducted examinations. Yet if such a.

scheme were established throughout the country we should-undoubtedly possess in it a power to prevent as far as is

humanly possible the occurrence of epidemics of water-borne disease. Is not this the lesson which we oughtseriously to take to heart from the great epidemics art -

Maidstone, Lynn, and elsewhere. The purity of a water--supply is one of the most vital matters concerned

..

with the health of the community and, oddly enough,the community in this matter has but feeble protec-tion afforded to it by its own specific laws. Howfar under the present régime protection is secured may be’gathered from the utterly incongruous state of affairs which’is brought to view when cases of dispute as to the purity ofcertain supplies come before public notice. First and fore-most there is the totally erroneous idea frequently hara-boured by town councillors and others in authority thatSomerset House is the tribunal in such cases. It is true

that the Somerset House laboratory is for the presentthe place of reference for disputed samples taken underthe provisions of the Food and Drugs Act, but the

officials at Somerset House are widely deviating fromtheir proper sphere and function when they take uponthemselves to give a final decision as to the fitness or unfit-ness of a given source of.water-supply. And if these officers

go upon the lines which they have evidently adopted inrecent cases they may produce endless mischief and undomuch of the excellent work undertaken at great painsby our sanitary officers. To take one example. In THELANCET of March 26th we referred to the extraordinaryopinions expressed by the members of a certain towncouncil as to the action of their surveyor who, whensubmitting a sample of water to the analyst, afforded himcertain information upon the source of the water and

upon the probability of contamination. The majority

1 Wm. Hodge and Co., Glasgow.