187

THE LANCET.

LONDON: SATURDAY, JANUARY 17, 1914.

SOME POINTS WITH REGARD TO A STATE MEDICAL SE]TVICE.

Some Points with Regard to a StateMedical Service. I

THE difficulties which have arisen in working thepanel system under the National Insurance Act mayhave been magnified, but are none the less real; andthe financial conditions which are affecting ApprovedSocieties, owing to the calls upon their resourcesfor sickness benefit, have contributed to bring intosome prominence before the general public the

question of a State Medical Service. Whether the

public has been aroused to any great degree ofinterest or no, does not alter the fact that

-,we have here a question which affects it no

less closely than it does the medical profes-sion. Frequent opportunities have been affordedrecently to read observations upon the subjectin the lay press, and we may refer here

to a temperate and clearly written articlewhich has appeared in the om!</ Post as

indicating the points with which the publicmust concern itself, if any change in present con-ditions should come within the scope of practicalpolitics. At the present time there appears to besome misunderstanding of the subject on the

part of the public, or the institution of a

State Medical Service would hardly have beenput forward at meetings of the managers of

certain Friendly Societies, with the suggestionthat in some manner there would follow upon thisdrastic revolution of existing procedures a diminu-tion of expenditure upon sickness benefit. This

might indeed be brought about by placing all

medical treatment in the hands of medical officer,

appointed by the societies, but we do not conceivEthat the officers of a State Medical Service woulc

occupy any such position. Their responsibility to]the welfare of their patients would be enforced bthe superior officers of their own service, and thei]competency would be tested by the efficient performance of their professional duties, and woul(not be considered proved by economical advice upo]pecuniary matters. This we take to be the view als.of Sir JOHN COLLIE, who on Monday last at Caxto]Hall argued in favour of a State Medical Service aa substitute for the panel system. In all the circumstances it is not surprising that at the recent corference of Friendly Societies a proposal that thershould be a State Medical Service was rejected ba substantial majority.The establishment of such a service would

affect a very much wider public, and one more

likely to be critical of the possible medical

advantages than those responsible for FriendlySociety finance. The members of the societies’

at present, in contradistinction to the managersof the societies, seem to be well contented,as a rule, with the medical service providedunder the National Insurance Act; they do notfind fault with the increased expenditure on sick-ness benefit as long as they are its recipicmts, andthey are also willing to avail themselves of thatwhich the medical profession unanimously declaredthey ought to have-namely, the free choice ofdoctor. It is true that this freedom of choice onlyexists to a limited extent, and it is true also thatin some localities it is being threatened, as our

Special Commissioner has shown in more than oneof the articles in which for the past year he hasbeen reviewing the working of the Acts ; but indistricts where most of the medical practitionersare on the panel it does exist in a; substantial

degree. In London, where the number of medicalmen on the panel is relatively small, and was at onetime smaller still, the desire of the working man tochoose his medical man for himself is proved by theaccumulation of a fund in respect of unallotted

patients so large that its bulk has created a difficultyin disposing of it, a difficulty which we cannot helpthinking has been much exaggerated. While, then,the public and the medical profession are largely atone, as far as the working of the existing NationalInsurance Act is concerned, in maintaining the

principle of permitting to all sick persons the rightto choose their medical attendants, it will be

necessary for those who advocate the establishmentof a State Medical Service to show how under anyscheme of the sort a similar discretion could be

given to a far greater public. The development ofnational health insurance which many expect, andwhich some consider inevitable, is the extension ofmedical benefit to the dependents of those now

insured. We have seen it estimated that this would

bring under the State medical treatment providedby insurance about 40 million out of 45 million

inhabitants of Great Britain, and without doubtthe numbers would be so large that a scheme

of medical service to meet their wants would be

almost equivalent to a State Medical Service. But whyshould these women, on behalf of themselves andof their children, be less tenacious of the right of

. free choice than their husbands are already’? In

fact, we should say they would be much more so,l and that men being in many conditions of life

l accustomed to be attended by, and to obey, the) particular medical officer appointed for them arel familiar in a way which women are not with; the principles of regimented service. As matters. now stand freedom of choice is enjoyed in- different degrees by the whole population. It3 is exercised most absolutely by the rich, who

y can go wherever they like in order to consultwhomsoever they like; and in great degree bythose many others who are, however, restrained bypecuniary considerations from exercising their

selection except in their immediate neighbourhood.

In less degree still it is enjoyed by those whounless they choose to pay twice over, as insured

188

persons and as private patients, have to consultmedical men on the panel of their district, revisingtheir choice at stated periods only. The inhabi-

tants of any district can, however, do for

themselves to some extent that which under

a State Medical Service would be out of their

power. They can by giving general proof of

their confidence retain the services of a medical

attendant whom they esteem.A man who has built up and is increasing his

practice with marked success is not likely to leaveit readily. But under a State Medical Service a

medical officer enjoying a fixed salary for the

performance of a stated amount of service, wouldfrom time to time earn promotion and be anxiousto obtain the emoluments of a new and better post.He might be deservedly esteemed by his patients,but his success in treating them would, if any-thing, conduce to shorten his stay among them, andhis removal to a superior position elsewhere wouldlead to the appointment of another officer, selected, nodoubt, with some care for their benefit, but selectedentirely by others. The exercise of free choice ofa medical adviser is valued in different degreesby different individuals and by different classes,but we can hardly conceive that the large body ofthose now affected by the Insurance Act who beforewere not members of Friendly Societies, or who asmembers conditionally exercised that right, willacquiesce without protest in any attempt to deprive ethem of it. Moreover, it may be pointed out thatmembers of the legislature are as free to select theirmedical advisers as they are to select their legal orspiritual advisers, and that they would find it difficultto justify the application to others of a compulsionwhich they would resent if applied to themselves.The free choice of a doctor is the matter uponwhich everything turns. That a State Medical

Service might offer an alluring prospect to manyyoung men entering the medical profession cannotbe denied. The prospect of the possible institutionof such a service is a matter of grave importance tothe profession and to the public, and its discussionfrom every point of view is desirable. For thisreason we have dwelt upon what we conceive to becertain important practical points; the acceptanceor rejection of any innovation by the public whenexpressed through the ballot-box will probably beinfluenced by considering the same points. Some

form of State Medical Service may arrive, but thedifficulties ahead are solid.

Radium and Cancer.

RADIUM AND CANCER.

PERIODICALLY the influence of radium over

cancer comes under public attention in some formor another through the agency of the lay press,as well as in the columns of medical journals,and the reasons for the enormous attractionof the subject for laymen are clear. On the

one hand, we have a fatal disease with sucha prevalence that a large proportion of the

population have first-hand knowledge of its ravages

t while in some directions that prevalency seems to5 be increasing. On the other is a newly discovered- element having remarkably fascinating properties,r not the least of which is that of inhibiting the

r growth and development of living cells. About the

r working of radium we know a good deal. Abnormalf cells are more susceptible to its influence than1 normal ones, so that what may be destructive to

the one class is no more than a stimulant to the; other. These are the principles which form the) basis of the radium treatment of cancer, and theyL have been known to radiologists for some time past.B Take the instance of a small superficial epithelioma;l there are now numerous cases of such being cured! by a few properly adjusted applications of radium,. and there has been no recurrence after some years, in cases where but one application was made. Thismuch may be definitely stated, but we are on less

. safe ground if we say further that all such cases

. may be cured by the same means. Some carcino-I matous conditions arising on a moist mucous mem-. brane, as that of the mouth and tongue, have so far. given very poor results from radium or X ray treat.ment. Furthermore, it may be assumed that theaction of radium and the X rays is almost, if notentirely, local, and it is only the malignant cells

receiving efficient radiation that are destroyed. Thesuccessful treatment of a malignant tumour requiresa sufficiency of radium so disposed as to irradiateeffectively all the cells of the growth, particularlythe advancing margin; it is necessary also that

metastasis ;should not have commenced, for at nostage will radium or the X rays give us controlover this unfortunate property of most malignantneoplasms.Now everything about radium in connexion with

the treatment of cancer, that we can as yet be

reasonably sure of, has been known to radiologistsfor a considerable time, and in view of the widepublicity that is suddenly being given to the sub-ject it is inevitable that medical men should ask

whether the facts have been multiplied, or whetherany new principles have been discovered. The

answer is, we think, in the negative, and we there-fore find it regrettable that medical men should

encourage the publication of a contrary view in thelay press in the absence of any advances that havestood an adequate test of time. No one but a

medical man, or, a man with considerable know-

ledge of physics, can properly assess the value ofthe statements which have recently been made

public, and the tendency of the layman has been,we fear, to read into these communications thatwhich he wishes to believe. In many instances

grievous disappointment and serious financialembarrassment have been needlessly added to thesufferings of the victims of malignant disease bythe publication of ill-understood medical evidence,and deeply interested as we are in the splendidwork now being done by radiologists and surgeonswith the new machinery at their disposal, weshould much deplore this happening in con-

nexion with such work. The crucial question is,

189RADIUM AND CANCER

How many cases of undoubted and inoperablemalignant disease have been completely relievedby radium treatment, and have remained appar-ently cured sufficiently long to give reasonable

hopes of permanent relief :’ The number must be

small, we think, and the permanent relief

probably only occurs where the circumstances areunusually favourable. Up to the present radiumhas brought us little, if any, nearer to the dis-

covery of a definite curc for malignant disease,and we feel that our science is not benefited byallowing enthusiasm to outrun discretion. At the

same time, we are glad to be able to record con-siderable advances in practical radium therapy.With layer supplies of radium, and greater expe-rience in applying it where it can do the most good,an increasing number of cases are being relieved andremaining well for a longer time. Far more progresswould have been made if all malignant growths ofany given variety reacted to radium in a similarmanner. But cases apparently alike may give oppositeresults to the same treatment, and though this maybe overcome by improved technique the difficultyis a serious one. It serves to show as much as any-

thing else how very imperfect is our knowledge oithis mysterious disease. And could there be a

better reason why workers in a promising fielc

should be guarded in their public utterances? AV( (want, before anything is said in public that maylead to bitter disappointment, far more clinica

records than we yet possess. The results o

cases must be collated and methods must b

compared, for which time is required. Thi

we understand to be the feeling also of th

Radium Institute, where wards will shortly b

opened in extended premises, and where the be,of additional opportunities for observation wibe afforded.

Regarding the results reported from the cancerresearch department of the Middlesex Hospital,no stress should be laid upon Dr. LAZARUS-BARLOW’S

recent statement. It is that of a pathologist havingno responsibility for the treatment of any patients,the figures given are incorrect, and the statementhas been repudiated by the surgical staff of the

Middlesex Hospital in the columns of the Times.

With an adequate supply of radium and a series ofcases accessible and susceptible to its action, goodresults are easy to understand, although highlycreditable to those who carry out the treatment. Butthe time has not come for any public announcement,however guarded, pointing to radium as a CKre foicancer, while any statement of results obtained at a

hospital should clearly come from the medical stafwho carry out the treatment and watch the resultsThe rarity of radium limits the number of casesand for a time all public utterance that is no

very carefully worded may be harmful. Tlu

present price of radium is probably artificiallintlated, but we must remember that the con

ditions are unusual, and, as anyone who hahad much experience of metallurgical chemistrwill understand, the isolation of a grain c

precious metal from two or three tons of ore isof necessity a prolonged, expensive, and tedious

operation. For example, it will require -,i, methodof separation very different from that in use at

present to enable radium to be sold for a few

shillings per milligramme, as has been suggestedby Dr. LA7;AHUH-BAHLOW. Also, when we considerthat manufacturers can dispose of all they can makefor months in advance, and the absence of anyreason why the law of supply and demand shouldnot apply in this as in any other commodity, it isdifficult to see how the present price can be

materially altered until the sources of supplyhave been extended, and methods of extraction

greatly simplified and accelerated. It is note-

worthy that an English firm was prepared to

supply pure radium bromide at less than &pound; 15

per milligramme to some London hospitals. Theoffer was not accepted and the whole amount,

. including the output for several months ahead, has: been disposed of to Germany at the currentr rate of about .t20 per milligramme. Already we are, promised more extensive supplies from Cornwall- and simpler methods of extraction are said to havef been discovered. If these prospects materialisez the outlook for a larger and cheaper supply1 becomes very bright. In the meantime, we shoulde not allow our enthusiasm for radium to make us

y forget what we owe to the X rays. In the treat-jl ment of accessible growths it is doubtful if radiumIf has any advantage over the X rays properlye applied; indeed, it is a question if the X ray tubeLS has yet been used to its full advantage for theLe treatment of malignant disease. We appear to be)e on the eve of some radical improvements in thest construction of X ray tubes, and if these give11 us the complete control over the quantity and

quality of the radiation that is promised we

may confidently look for important advances in

radio-therapeutics.

FOREIGN UNIVERSITY INTELLIGENCE.-Baltimore (J?hns Hopkins University) : An arrangement hasbeen made with the University of Breslau for a temporaryexchange of teachers, Dr. Felix Landois coming for a

semester as assistant to one of the professors (Dr. Halsted),while Dr. Geo. Heuer, who holds that position, goes to

Breslau to fill a similar post.&mdash;2M: Dr. Eugen Bernoullihas been recognised as privat-docent of Pharmacology.-Berlin Dr. L. Lesser, professor of dermatology, has beenappointed Professor in the Kaiser Wilhelm Post-Graduate

Academy ; Dr. George Arndt, prizat-docent of Dermatology,,

has been granted the title of Professor, -Breslau Dr. Karl, Ludloff, surgeon to the orthopaedic department of the

Surgical Clinic, has been promoted to an Honorary Pro-fessorship ; Dr. Julius Schmidt, privat-docent of medicine,

b has been granted the title of Professor.&mdash;.B’M<pe.’ Dr,Hari, privat-docent of medical chemistry, has been appointed

" Extraordinary Professor.&mdash;JMos Aires : Dr. C. Bonorino

Udaondo has been appointed Extraordinary Professor of- Semeiology. - Copen7tagen: Dr. V. Schaldemose, Extraordinarys Professor of Surgery, has been promoted to Ordinaryy Professor.-Florence. : Dr. Francesco Casagli has been

f recognised as privat.docent of Surgical Pathology.