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(iv) W.C.s, bed-pans, and chambers should be

regarded as possible sources of infection, more

particularly those with high seats which involve

climbing, and should be thoroughly cleansed with asuitable antiseptic.

(v) No infant or child should, in any circumstances,be allowed upon another’s cot.

UNITED STATES OF AMERICA

A CHALLENGE TO THE A.M.A.

AN unmistakable challenge to the present leader-ship of the American Medical Association was utteredin the presidential address of Prof. James H. Meansto the American College of Physicians meetingyesterday (April 6th) in New York City. " Thebehaviour of the Association," Prof. Means said,"is political. It is partisan behaviour. It championsa cause. At the present time the cause is somethingclose to standpatism." But the policy could be

changed at any time, if the membership willed it.At present the electorate of the Association wasapathetic and inarticulate because it had no issues, noplatforms set up to vote for. " It is allowing themedical politicians to run things about as theyplease, and official spokesmen, like Jove on highOlympus, to hurl their thunderbolts of wrath at allwho differ with orthodox doctrine." There was needof " medical statesmen, men of intellectual honesty,breadth of vision, courage, nobility of purpose, andthe qualities of leadership, who can find the way tothe solution of some of the problems of medicalservice which now baffle both the profession and thepublic." The development of enlightened oppositionwithin the democracy of the national association wasone way of bringing to light such leaders. There wasno place for "

yes-men " in a truly learned society,

nor was there place for political manoeuvring, or

reprisal for the expression of honest opinion.Among the orthodox concepts Prof. Means attacked

were the " sacrosant doctor-patient relationship,"the attitude of organised medicine toward grouppractice, the question of a third party determiningthe physician’s fee, and the free treatment of the

indigent patient."We hear a great deal," he said, " about the

sacrosant doctor-patient relationship. No thirdparty can be allowed to come between the twoinvolved. This has been used as an argument againstall attempts to improve the efficiency of medicalservice through group practice. When it is suggestedthat a disinterested outside person could with greaterequity than the doctor determine what might be aproper fee for services rendered in any given case,there are storms of protest from the conservativewing of the profession. Yet a philosopher mightrecognise such an arrangement as an ideal one, and,as a matter of fact, it is actually working success-fully in more than one place.... I submit thathaving a third party determine the size of and evencollect the fee from the patient for the doctor is notonly not an intrusion into the holy doctor-patientrelationship, but actually increases the likelihood ofthe patient’s receiving from the doctor the best andwisest treatment the doctor is capable of giving."Another thing that stimulated the doctor to do

his best by his patient was to have his work overseenby his critical colleagues. If this was an intrusioninto the holy relationship, then it was to the patient’sbest interest to have an intrusion. The place wherea patient was most likely to have his case diagnosed

and treated correctly was in the public wards of ateaching clinic. This was not because the doctorsare necessarily any wiser there, but because if onemade a mistake another would observe and correct it.If one had some new information about diagnosis ortreatment that applied to a given case, he would tellhis colleagues about it.Turning finally to the question whether physicians

and surgeons should give their professional servicesto the care of the indigent, Prof. Means said it mustbe admitted that if the profession abandoned itstraditional custom of giving its service freely to thepoor, something of an mtangible or spiritual naturewould be lost.

"

However, we have to face the realities of our ownday, and it is not unlikely that in many instances atleast the indigent will get better medical service if thecommunity pays for it. It may be proper to add thateven if the doctor is paid for caring for the indigent,he still has the opportunity to exercise his generosity,as does any other citizen, by giving of his substanceto the most that he is able to the worthy causes ofhis community. Let him show the world that thedoctor can be as good a citizen as any. Let him also,in rendering the service for which he is paid, add toit those qualities of spirit and purpose which cannotbe bought with gold. Therein lies his chance topreserve the ancient values in the face of modernadaptations. "Unorthodox views had been expressed on April 4th,the first day of the conference, by Prof. John P.Peters of Yale University, who is the secretary ofthe committee of physicians which propounded a

year ago certain Principles and Proposals now becomefamous, or infamous, according to the points of viewof the 770 signators or of Dr. Fishbein (editor of theJournal of the American Medical Association), andthe trustees of the A.M.A. Without referring directlyto these principles and proposals Dr. Peters said thatat present most of the advances in medicine whichthe rich enjoyed were developed in hospitals andinstitutions through the instrumentality of theindigent patients. The fees which the rich paid,however, did not as a rule return to the support ofthese institutions or the patients, but went to thepractitioner who was exploiting the medical dis-coveries. It was his impression that governmentalone could assume the burden of providing, main-taining, and correlating the necessary medicalresources.

" Such a suggestion immediately arouses cries ofbureaucracy and corruption, as if these were inevit-able attributes of our political system. The medicalprofession should be the first to deny such allegations.It is its proud boast that the public health services ofthis country have been free from corruption andpolitics. But, in any case, there is no good reasonto believe that government direction would be worsethan the whims and vagaries of philanthropists orthe publicists and promoters who have the dispositionof large funded fortunes. Nor are the subsidies fromthe manufacturers of proprietary foods, drugs, andmedical instruments likely to direct education,investigation, and practice into the most desirablechannels. It is my opinion, further, that cost musteventually be collected by general taxation. Thosewho can pay for their own care and prefer to patronisephysicians of their own choice should not escape thegeneral tax on this account; because this will not beimposed to pay for personal services but for theproductive work that makes these services valuable."

Already the word " revolt " has reappeared in theheadlines. It is perhaps better justified on thisoccasion than it was at the time of the publication ofthe Principles and Proposals. But it must be

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correctly interpreted. The revolt is not a movementto found a new organisation or a new system of

government. The dissident group considers that ithas had undue difficulty in securing a hearing for itsproposals and has been treated with intolerance, anditasks that the American Medical Association shouldbe made " safe for democracy."To-day (April 7th) the newly installed president of

the College of Physicians, Dr. William J. Kerr, indi-cates that he endorses the position of his predecessor.On the other hand, in Chicago, Dr. Fishbein has toldthe Associated Press that Prof. Means is typical ofthose who stand outside and criticise without them-selves putting a shoulder to the wheel to help, andadds that " his ignorance of what is going on is

actually lamentable." Dr. Fishbein has also rebukedNezus-Week for reporting that the number of signatorsto " principles and proposals " has grown to 770. The

report, however, is correct. The sponsoring committeehas also been enlarged and now consists of the

following: Russell L. Cecil (New York), Hugh Cabot(Rochester), Milton C. Winternitz, John P. Peters,and George Blumer (New Haven), Alan M. Butler(Boston), Louis Casamajor (New York), Thomas B.Cooley (Detroit), J. Rosslyn Earp (Albany), ChanningFrothingham (Boston), L. Emmett Holt (Baltimore),William S. Ladd (New York), William S. McCann(Rochester), George R. Minot (Boston), Hugh J.Morgan (Nashville), Robert B. Osgood and Richard M.Smith (Boston), John H. Stokes (Philadelphia),Borden S. Veeder (St. Louis), James J. Waring(Denver), Soma Weiss (Boston), and William J. Kerr(San Francisco).

AUSTRALASIA

(FROM OUR OWN CORRESPONDENT)

THE STATE AND THE MEDICAL PROFESSION

IN QUEENSLAND

CHANGES in the social structure of the communityare everywhere being reflected in similar changes inthe relation between the medical profession and thepublic. Queensland, like many other countries, isfaced with the problem of adjusting this relationship.The State government tends towards a hospitalisa-

tion programme, and in endeavouring to counterthis tendency the Queensland branch of the BritishMedical Association has been urging a scheme of itsown. In September, 1935, it published proposals fora national medical service for the State, based on theprovision of a general practitioner for every family.The Association proposed that this should be financedby contributions through the friendly societies, andby government subsidy for unemployed and chronicinvalids. The aim was to build the existing systemof private practice and the friendly societies’ medicalservice into a national medical service. The Asso-ciation was opposed to full-time nationalisation andwas emphatic that the patient’s right of free choiceof a doctor should be preserved. The Minister forHealth’s comment in 1935 was that the scheme was

vague and indefinite, that it had not been supportedby actuarial evidence, and that the Governmentwould not commit itself without obtaining the fullestinformation. In the following February the BritishMedical Association asked for a joint committee toexamine the policy for a general medical service, butthe Minister replied that the Association shouldformulate a definite plan showing exactly what con-tributions would be required from the public, and

what benefits contributors would receive. For two

years no further progress was made.The Commonwealth Government is now seriously

considering a national insurance scheme which willinclude all States, and in this it has the support, inprinciple, of the federal council of the British MedicalAssociation. The position in Queensland, however,has been further complicated by the appearance inthe daily press on Jan. 12th of an " open letter "to medical men from the director-general of healthand medical services. This " open letter " purportedto be a request for cooperation with the QueenslandGovernment, and shortly after its publication a

questionnaire was sent to all practitioners in Queens-land, in which they were asked to signify whetherthey were willing, if called upon, to enrol with theDepartment of Health, for various types of hospital,insurance, or preventive medical work, on a full-time or a part-time basis. As the Queensland branchof the British Medical Association had been com-

plaining for some time that it had been unable tomake contact with the Department of Health, muchless cooperate with it, the appeal from the director-general was greeted with surprise. It is taken tomean that the Government proposes shortly toextend its activities to the provision of public medicalservices. ’

Two possibilities may be inferred from the letter-either that the Government would retain a limitednumber of doctors who would be wholly paid frompublic funds, or that a large number of doctors wouldbe paid to devote part of their time to public medicalservice. It is not known to what extent any suchscheme would be affected by the federal insuranceplans. Presumably they would bear a portion ofthe cost of such a scheme. By the time the Common-wealth proposals can be put into effect the Queenslandscheme would, it may be supposed, be well developed.The letter refers to the increased demand by the

poorer sections of the community for medical care,for which, under existing conditions, they are incapableof paying, and states that, without true cooperationand the establishment of a proper compromise, theproblem as to how both curative and preventive needscan be met for people on the lower income rangeswill grow continually more serious. "When itbecomes sufficiently acute, it is obvious that theGovernment will intervene, and it will take itsaction in terms of the great masses of the populationwho require the service, irrespective, also, of whetherits action interferes with the personal relation betweenmedical men and the patient or does not."Members of the Queensland branch have been

advised by the branch council that they might replyin the affirmative to all the questions in the circularletter, with the proviso added : " the acceptance issubject to the qualification that the conditions ofservice are satisfactory, and have the approval ofthe branch." It is felt by practitioners in Queenslandthat no helpful advance has been gained by means ofthis step of the director-general, for the Governmentstill is not committed to any future in particular.A frank discussion between the department andaccredited representatives of the profession wouldhave been a much more fruitful method of exploringpossibilities for future cooperation.

AUSTRALASIAN COLLEGE OF PHYSICIANS

The legal incorporation of the Australasian Collegeof Physicians will soon be completed. The college, itwill be recalled, is a development from the Asso-ciation of Physicians of Australia, a private society;