The Future of Medicine 6 Could Medicine Do More?

The alchemist who devoted himself to the search, for the elixir of life had the spirit which should actuate the physician. The doctor who takes a vital interest in his profession is always seeking new ways of alleviating; illness, and few professions could show such a high proportion of men with minds that are always ready to try new methods. There is undoubtedly something paradoxical about the medical profession, for in certain directions it is conservative in spirit, while in others it is sometimes in danger of accepting new and untried methods too hastily. Conservatism has always been a feature, for every writer on the history of Medicine refers to long periods during which too much dependence was placed on the opinions of the best-known physicians of an earlier age, and new views were often met by prejudice, influenced by religious and other beliefs quite unconnected with the treatment of the sick. To some extent, this conservatism was forced on the profession by the accuracy and brilliance of very early descriptions of disease, such as those of Hippocrates.

If the authoritative nature of these older descriptions of disease slowed up the progress of Medicine, the authoritative statements of modern discoverers and particularly of manufacturers of possible remedies— sometimes take an unfair advantage of the average doctor’s recognition that Medicine is a growing subject. It should be possible, as Lord Horder has put it, for the general practitioner so to inform his patients that the quack medicine seller would be put out of business. But, he adds, the doctor “would also do well to resist more than he often does the blandishments of the wholesale chemists, decline their dictation, and so provide a less easy market for purely commercial enterprise.”

This readiness of the doctor to accept views put before him by manufacturers, who may or may not be as intent on serving the sick as on selling large quantities of their products, is an indication of the doctor’s own recognition of the difficulty that exists in keeping abreast of modern developments. There is always an immense amount of medical research going on, and at any moment someone may publish results leading to new forms of treatment. Suppose such a form of treatment requires a new drug or combination of drugs which any chemical firm can manufacture and on which there are no awkward patent rights, any manufacturer may place his own brand ,of this substance on the market and may flood the post-bag of the medical profession with literature upon it, enlarging on the virtues of the product in such a way as to lead the doctor who is not personally in touch with the original research to use this preparation in large numbers of cases for which in fact it may be quite unsuitable.

One of two things may then happen, neither of which is to the advantage of Medicine nor of the patient. If the doctor attains successes he may use the drug to excess. If he fails to get results he may discard for all cases a preparation which in some of them would have produced the desired cure. Working in isolation and without scientific methods of testing new drugs or training in the assessment of their value the average doctor may never learn to utilise modern discoveries in the best way.

It should be noted that there is in this country no official way in which new medicines can be tested or can obtain an official recommendation or condemnation. There is a limited range of biological products for which the Therapeutic Substances Committee of the Medical Research Council considers the evidence, and if satisfied that the substances should be available to the public, fixes minimum standards to which all brands offered to the public must conform. This applies particularly to sera for the treatment of bacterial diseases, and many of the standards set up are, in peace-time, accepted internationally. The range of substances so controlled, however, is small, and this form of test applies only to those substances named in the Act or which the manufacturers them selves ask to be tested.

The ordinary line of development of a therapeutic advance is that some research worker or group of workers makes a fundamental discovery and publishes this so that others may check the claims by making tests under conditions which the new investigators think likely to lead to the confirmation or otherwise of the first results. If the preliminary investigation proves successful others begin to apply the new substance to actual cases, and quite soon the medical press begins to carry articles from all over the country describing the varied experiences of those who are in a position to do this type of investigation. The general practitioner who follows medical literature closely becomes aware that something new is likely to be available, but he usually has to wait until the product is offered to him by a commercial firm before he, in his turn, can apply it under the conditions of general practice. If he finds difficulties or if he is disappointed with the results obtained, there is no official or impartial body of opinion to which he can turn for advice or to which he can submit his opinion. It is therefore quite possible for a large number of substances of doubtful potency to reach the stage of being ordered by doctors, and therefore apparently having an official blessing. Manufacturers have not been slow to take advantage of this, and it is no exaggeration to say that many doctors use substances which either have no medicinal value at all or of which there are brands on the market which are inert; and some manufacturers can be judged in inverse proportion to the number of free samples which they give away to doctors.

Without going into this question in great detail it is impossible to indicate all the ways in which doctors are assailed by, and even the best may be taken in by, exaggerated claims made by manufacturers. In America there exists an official body— the Council of Pharmacy— which has the duty of studying every drug arid chemical used by or offered to the medical profession, and the doctor there who is guided by its reports published yearly as New and Non-official Remedies cannot go far wrong in assessing the value of new products, whatever their source. Such a committee could only be set up in this country and given official authority by the Government, and it is in matters like these that the conservatism of the profession is seen. The doctors themselves should demand the setting-up of such an organisation, and the general public should be ready to give it every support.

We say that the general public should give such a move support because it follows naturally that if there was in exist­ence an impartial scientific body which had the legal right to investigate and report on every medical product offered for sale, almost the whole of the quack remedy and proprietary medicine businesses in this country would be at once con­demned. The public does not yet realise how easy it is for useless or even harmful drugs to be sold to it without any check on either their value or their purity. In the words of the Select Committee of the House of Commons which reported on this matter as long ago as 1914: “British law is powerless to prevent any person from procuring any drug whether, potent or without any therapeutical activity whatever (so long as it does not contain a scheduled poison) and advertising it in any decent terms as a cure for any disease or ailment, recommending it by books, testimonials  and the invented opinions of fictitious physicians, and selling it under any name he chooses for any price he can persuade a credulous public to pay.” The result of this has been the flooding of the market with an almost infinite variety of preparations guaranteeing to relieve or cure almost every real and imaginary disease.

In addition, it is open to anyone to rename a simple remedy and offer it for sale as a panacea. Aspirin, for example, is not only sold under that name in a great variety of brands, but is also sold under other names and appears as the principal ingredient of a wide range of tablets arid powders whose proprietary names give no indication that aspirin is a large constitutent. P.E.P. says : “It cannot be in the consumer’s interest that, where a simple remedy or drug can be mass-produced in one or two forms suitable for a wide range of purposes, it should be marketed under a bewildering variety of trade names with the aid of rival advertising, and sales campaigns, making claims which often cannot be substantiated and adding to the costs which the consumer has to bear.” Nor, we might add, can it be to the consumer’s interests that a manufacturer should be able to change the formula of a “remedy” overnight without any intimation to the public and without any alteration in the wording of newspaper advertisements. We mentioned in an earlier chapter how amidopyrine was used very widely :until the discovery that it might in certain cases destroy the white blood-cells and sometimes cause death. Prior to this discovery there were on the British market a very large number of proprietary, remedies containing amidopyrihe. When this substance was placed on the schedule of dangerous drugs the manufacturers of these remedies changed the formula but continued to make the same claims for the new and probably less potent pills arid powders that they had made for the old. Changes of formula are of course, nothing new to the manufacturer of a proprietary medicine, for there are some which have long found favour with the British public but which today may have no resemblance chemically to the form in which they were first sold.

The public may also be injured by having to pay an excessive price where it is tempted by advertising to purchase a simple drug at an inflated cost. “Each shilling spent on a preparation perhaps worth 2d. is a drag on the national health effort,” P.E.P. remarks. Even more serious is the fact that in attempting self-medication the public is tempted to delay seeking proper medical advice. If the general practitioner is to be expected to preserve the health of the individual or of the family, his work should not be made more difficult by the constant barrage of advertising put out by manufacturers of proprietary medicines or by the attempts of the public to treat themselves.

It cannot be said that the attitude of the Government now or in the past has been of particular assistance to the doctors or to the community in this matter. For nearly one hundred and fifty years a certain amount of revenue has been obtained by means of the Medicine Stamp Duties, under which a manufacturer who did not wish to reveal the formula of a medical preparation or who wished to make certain claims in regard to its action was required to pay a tax according to the price of the remedy, and a stamp representing the amount paid was fastened to the preparation. This source of taxation the Chancellor of the Exchequer abolished in his 1941 Budget, so that there is no longer any restriction of any kind on the sale of patent and proprietary remedies.

There is much speculation in the trade as to the possible effects of this, and it has, already been forecast that large increases in sales may be expected after the war, and that many more millions of pounds every year may be spent on advertising them.

We may in, passing note that even more important than the control of medicines and medical products may be the need for the control of food. The whole question of nutrition is one in which the medical profession has not yet taken a strong enough stand, and sooner or later doctors will have to make it clear that neither they nor Medicine as a whole can do much more than they do at present unless a completely adequate diet is ensured to every individual. In addition to this, however, it is vitally important that all our laws relating to the composition of food, the presence of adulterants and deleterious substances, and the advertising of food products in unscientific terms, must all be taken in hand and, wherever possible, standards set up by which the public can judge exactly what they are getting for the money they pay and by which doctors can be certain that their patients, whether in health or in sickness, are obtaining everything that is necessary to maintain bodily perfection.

We have thus suggested that Medicine as a whole could do much more for the people if there were control of all new remedies discovered by medical science and made available to every doctor, drastic changes in the degree of freedom at present enjoyed by commercial exploiters of simple remedies and of man’s gullibility, and the setting up of standards for nutrition and for the quality of foodstuffs. There are other ways in which Medicine as a whole could do more for the health of the people, but before considering them we must discuss whether the general practitioner himself could  do more. Since we have suggested that the general practitioner must be the first link of the chain of health services, it is obviously important to discover the full capabilities of the average practitioner.

The answer unquestionably is that with, the present form of medical education, with the method of purchasing an interest in the sickness of the population with money borrowed from financial sources, and with the necessity for building up a practice and an income in competition instead of in cooperation with his colleagues, the general practitioner would find it very difficult to do more for his patients than he does at present. Of all the branches of Medicine on which he might be expected to give advice that of health preservation is the one in which he is least able to do more than at present. The general practitioner sees his patients only when they are sufficiently ill to come to his surgery or are confined to bed and call him to their home, and it is not to be wondered at therefore that Lord Horder should say that in this respect “there are some criticisms of the doctor which are by no means ungrounded. Too often he visualises the Health Services as Sickness Services, and granting that it is his traditional function to cure and alleviate disease, there is today a need for him to orientate towards the care of those who are not diseased and yet are not fit; in other words to raise the standard of health. He should be the health ‘man rather than the ‘medicine’ man.”

Preservation of health must be the keynote of the medical service of the future. The general practitioner as he exists today can play only a very minor part in this work. For its complete success it requires an organisation so operated that every individual can use the service for the discovery of variations in his own state of health and, when the variation has been discovered, for putting info operation the necessary machinery for treatment. The general practitioner, for example, who on his daily round sees walking on the pavement someone suffering from an obvious anaemia might make a correct diagnosis of pernicious anaemia but would hardly improve his standing with the rest of the profession in his area, and might not be thanked even by the sufferer, if he jumped from his car and advised the obviously sick man to go to have a blood test done at once. In an organised medical service such a blood test would be done at sufficiently regular intervals (and be as easily obtainable at all times) that the disease would be detected long before it had reached the stage of compelling the sufferer to visit his doctor.

Apart from changes in the method of organisation of the medical services very much more could be done by Medicine as a whole. One of the most important developments would be in the control of infections. Everyone knows that certain diseases are infectious, that is to say, they are caused by an agent which can pass from a sufferer to a healthy person who then develops the same disease. The general public are also aware that a certain time, which varies with the disease, must elapse between the contact of a healthy person with an infected individual and the first appearance of symptoms. Advantage has been taken of this latent period to prevent too rapid and too widespread dissemination of infectious illnesses by segregating known sufferers and by placing contacts in quarantine. By these methods and by sanitary methods generally the incidence of certain infections has been lowered and may be still further lessened. While some diseases such as cholera, seem to have disappeared from this country, we have occasional outbreaks of other diseases which remind us of the dangers that would arise if there was a serious breakdown in our sanitary arrangements. An example which will spring to the mind of everybody is that of the epidemic of typhoid fever in the town of Croydon in 1937. The accidental contamination of part of the water supply by an unsuspected ”carrier” caused a rapid spread of typhoid germs, with the result that 344 people contracted the disease and 43 died.

On the outbreak of war it was feared that interruption of sanitary services and water-supply mains might produce many such epidemics, but the fact that in two years of war no major epidemic has occurred shows the strength of our sanitary arrangements just as the Croydon outbreak demonstrated the need for constant vigilance even in time of peace.

The need today, however, is for more definite methods of prevention, and already we know that some diseases can be completely prevented by the application of the correct im­munising agent. The great search in medical laboratories today is for methods of immunisation which will give com­plete protection for the longest possible period. The greatest success has been obtained in typhoid fever, tetanus, and diphtheria. For this latter disease immunising agents now available, if given by the proper method and adequately controlled, can produce, an immunity which lasts for many years and gives over that period almost complete protection. Yet it is possible for the Chief Medical Officer of the Ministry of Health, Sir Wilson Jameson, to declare that “the diphtheria figures are really an absolute disgrace to us all.” He said that during 1940 we had over 46,000 cases of this disease, but there are many examples that could be quoted of towns and districts where immunisation has been so efficient that the disease has practically disappeared altogether.

Consideration of two infectious diseases in which up to the present no immunological method is possible will indicate that, very radical changes both in the practice of Medicine and in the attitude of the State towards disease are urgently required. We segregate cases of typhoid fever, which on medical grounds usually require hospital treatment but can be treated with perfect safety in an ordinary hospital ward, – yet we make no attempt to separate from the rest of the population cases of tuberculosis or of venereal disease. These conditions are caused by recognised germs which can pass from one person to another, but despite this infectious nature sufferers are left free to mix with the general public and spread the disease as they will. In the case of syphilis not only is the disease passed from one individual to another but may be conveyed to the next generation. This disease is one which is usually dealt with in clinics and cannot legally be treated except by a qualified medical man, so that the discovery and control of cases is already in the hands of the medical profession. There is, however, no attempt to segregate cases and no power to compel them to submit to treatment until they have got beyond the stage of being infectious to others.

Tuberculosis is more than an infection. In all its forms it is caused by the presence in the body of tubercle bacilli, but an examination of the way in which these ;germs invade the body, of the variations of resistance to the bacilli among different classes of the population, and of the results obtain­able by various methods of treatment, all lead to considera­tions of wide social and economic importance. So far as the community is concerned every case of tuberculosis should be treated as an infection and should be segregated for as long as there is evidence that the disease is at a stage at which the germs can be conveyed to others.    For the individual sufferer, however, the disease has another importance, for it is rarely a disease which kills quickly and the patient has therefore, whatever the ultimate result, to face a long and often serious illness.   All efforts have failed to discover a method of treatment which gives a high proportion of complete cures, but by a combination of all the available methods a very large proportion of cases reach a stage at which the disease is quiescent and in which they live a fairly full life. Tuberculosis is, however, a disease which, because of environmental conditions affects industrial workers more than others, and they can never face the economic difficulties which this disease involves. In a case of tuberculosis of the lungs it is possible for a patient to be sent to a sanatorium where he will be given treatment lasting for many months costing some £5 per week and including a generous diet. At the end of this period, if he is sufficiently well he leaves the sanatorium but is expected to return to the environment in which he developed the disease and to the few shillings a week allowed him by the National Health Insurance or by the Public Assistance Committee. He is unlikely to be able to return to his own trade or profession and if he finds work it is very doubt­ful whether he would receive an income which would yield him that generous diet which he was given in the sanatorium. In a recent article (Medicine: Today & TomorrowJune 1941) it was stated that “the struggle for existence of the tuberculous worker is well known among the working class and is a major cause of the delay in reporting sick, persistence in carrying on as long as possible, and, premature return to work.”

The medical profession knows that in this matter much, more could be done., So far as tuberculosis is conveyed by milk a certain number of deaths could be avoided by universal pasteurisation; so far as it is conveyed from one human being to another, more rigorous segregation would soon have an effect. This must, however, be linked with early diagnosis, and most tuberculosis officers advocate the application to all industrial workers and to large bodies of men such as the armed forces of methods of mass radiography, which, using miniature X-ray films, is proving a cheap and practical proposition.

There is a close relationship between tuberculosis and industrial employment, particularly in young people and especially in time of war. Statistics show that during the 1914-18 period there were in England and Wales 25,000 more deaths from tuberculosis than would have occurred had the 1913 death-rate continued; In Germany it has been calculated that there were 280,000 deaths between 1914 and 1927 which would not have occurred but for the effects of the war and subsequent economic depression. In this war the same tendency has already developed and in the first half of 1940 there were 1200 more deaths in England and Wales than in the first half of 1939. In the last war the risk of tuberculosis was particularly great among young people, and especially women in industry.

Against this menace we have this new method of detection but have still to devise methods of prevention and treatments. The method of detection by mass radiography makes it possible to take X-ray photographs of the lungs of large numbers of people quickly and cheaply. Photographs are first taken on a miniature camera, and all cases which show any suspicioussigns are then re-examined and photographs on the full scale taken.

So efficacious is this method of detection that it has been adopted by the British Navy, and every entrant to that service will be X-rayed before he joins a ship and will be re-examined  every two or three years. Tuberculosis has always been a problem in naval circles. To the landsman a sea-going life seems a very healthy one. But the amount of space, available in the crews quarters is so small that the spread of tuberculosis is almost inevitable if there are susceptible people in contact with those already suffering, even in a mild form, from the disease. Among the men the invaliding rate of tuberculosis has for many years been 2 per cent, more than double the rate for the Army.

Now the Navy is X-raying every man, and in the first 20,000 something like 4 per cent were found to have signs of tuberculosis, The medical officers in charge of this work, have reason to hope that by this method the spread of this disease in the Navy will be rapidly reduced and may ultimately be completely prevented.

The same method could  be applied to workers in industry and methods devised for treatment that might save many lives and greatly assist in cutting down the incidence of tuberculosis. It is mentioned here, however, as an example of scientific method not only outside the skill and experience of the ordinary doctor but quite impossible of attainment within the present structure of Medicine based on personal service between the doctor and the already sick.

But while it is essential to secure early identification of cases of the disease it is also imperative to enforce safeguards against victimisation of sufferers by unsympathetic em­ployers, to provide immediate institutional treatment, and to ensure an adequate diet and suitable social conditions when sanatorium treatment has been completed. Special arrangements must also be made for the employment  of those who have been successfully treated for tuberculous conditions. Another disease which has important social repercussions is rheumatism, a term which in the lay mind covers a wide variety of conditions associated with joint and muscular pains and disabilities. From the point of view of the State this is one of the most expensive of all diseases, and it is estimated that it costs in sick pay, lost wages, medical treatment, etc., no less than £25,000,000 a year. To the individual, rheumatic disease may mean anything from occasional twinges of muscular pain to disease of the heart causing permanent disability, and sometimes death. The chronic sufferer from the ordinary joint type of the disease may suffer considerable pain for many years and become more or less a permanent cripple. The number of adult sufferers in Britain is almost incalculable; it is certainly well over a million, and there are probably 200,000 cases among children.  In a recent book the Empire Rheumatism Council says : “War against rheumatism is the most urgent of the campaigns against the enemies of man­kind’s well-being  -the agencies of preventable disease— and considerations of humanity, national safety, and true economy plead for some immediate effort to check it.”

One difficulty is that in spite of an enormous amount of investigation our knowledge of the exact causes of rheumatism is still far from complete. An additional factor is that rheumatism is one of the diseases which the public believes itself capable of treating without the assistance of the doctor, and one that lends itself particularly to the art of the patent medicine vendor. A disease which fluctuates so much in its attacks as rheumatism, which everyone will agree may be intensely painful and crippling one day and comparatively mild on the next, is ideal for those who wish to sell a remedy which is either useless or at best a palliative. The  position with regard to the popular remedies is summed up in the book already quoted in the following passage: “It is mainly commercial speculators. in the fruitful field of popular gullibility who claim to have infallible ‘cures,’ by panaceas applicable to all forms and all its sufferers; there have to be, added to these panacea-merchants others who may have seemingly nothing to sell yet who profess faith in a single universal remedy.” Medical opinion may be summarised in the statement that all cases of rheumatic disease treated at the earliest possible moment under conditions which will allow ample time and the use of all available methods will always show some degree of improvement and the disease will very often be completely arrested. There is, however, no single method of treatment which will produce results in all cases. Since pain is such a prominent feature of the disease, anyone who sells to a sufferer a mixture of the pain-killing drugs will always appear to produce a certain amount of benefit in some cases. It is these cases which give rise to the widely-publicised testimonials, which are, of course, never withdrawn when the condition of the patient relapses and he is compelled to seek  proper advice. The medical profession itself is not entirely blameless in its use of remedies of  doubtful efficiency, but when a doctor falls into the trap laid for him by a commercial firm he does so because he sees so many cases he would like to assist and he is willing to try even the most unlikely forms of treatment.

In no other disease is the need for widespread changes in our medical arrangements so obviously necessary.  The principle on which this must be based is that it must be made possible for every sufferer from rheumatism to consult at the earliest possible moment doctors who are particularly expert in this disease. While they continue the methods of diagnosis, investigation, and treatment at present in use, a research campaign covering, the whole country should be initiated and might very well reveal the exact nature of the rheumatic condition. At the same time the public should be taught that rheumatism is not only a crippling and economically disastrous condition but can be a deadly disease of which the first symptom must be regarded very seriously. The popular attitude that “a touch of the screws” is one of the ills which all of us must expect to suffer sooner or later is entirely false and has led to serious disease in many otherwise healthy individuals.

It is worthwhile remembering in connection with rheumatism that this is one of those diseases in which the housewife may be incapacitated or crippled to an extent which does not require a stay in hospital but which makes housework and the duty of looking after a family very difficult. Here is another matter in which the medical profession has failed to make a stand which on medical grounds, as well as those of ordinary humanity they should have made long ago. Every doctor must have seen over and over again that the home conditions of his patients were such that without adequate assistance the wife and mother could not maintain any standard of efficiency in the home. Here are the kind of problems the general practitioner has been up against many times. He is called to see a patient who complains only of a feeling of general fatigue. He finds a woman of about middle age who has to do all the housework, cooking, and mending for a family of five or six with a total income which gives her every reason and excuse for neglecting her own food in order that the others may have the maximum she can provide. His examination discloses that the patient is in no fit condition to be up and about, but every suggestion that she should rest or go to bed is met with a reminder that the claims of the family come first. Having formed the opinion that she is probably very anaemic he arranges for a blood test, which shows that this wife and mother is struggling along with less than 30 per cent of the normal amount of blood. He may be in a position to treat the case in a completely satisfactory manner, but he is powerless to give the help in the home which should be the first stage in treatment. The same problem but with other aspects arises where the mother enjoys normal health but where another member of the family is so ill that if any nursing is to be done the housework must necessarily be neglected.  In other words, a serious defect in present arrangements is the failure to provide home helps.

At the moment all the help that is available is that given by the district nurses, more than 8000 of whom are employed by voluntary nursing associations principally in country areas. The work done by these nurses cannot be too highly praised, and yet their conditions of employment are in no way commensurate with the work that they do. They receive salaries and allowances which range from £180 to £250 inclusive, and are liable to be called upon at all hours of the day and night and to perform a large proportion of normal midwifery. They also do a considerable amount of visiting of chronic invalids and bed-ridden patients, and are of considerable assistance to the general practitioners. To a large extent the nursing associations which employ these nurses are “voluntary,” but a considerable proportion of their income is now drawn from local authorities, more particularly in respect of the work done by their nurses as midwives. The district nurses have very often to do work for their patients which is really outside the scope of their duties as trained nurses. Their employment not only needs co-ordinating but would be made much easier by the provision of other forms of assistance.

This question of help in the home involves many wider issues for it raises the whole subject of home conditions. To the doctor who has considered the relation between disease and environment the astonishing thing is not that so many people become afflicted with this or that disease but that so many escape.   Medical examination of an individual should always include a survey of the home conditions, but this factor is never taken into consideration in hospital cases, and rarely so even by the general practitioner.   Methods of investigating home conditions in their medical relation have been worked out in America, where certain doctors always include a summary of them, made by an experienced health visitor, in their notes on the case. But the question has always been avoided in this country because the accumulation of official accounts  of insanitary  and  disease-producing homes combined with an income-level which could not provide an adequate food supply, would soon be so great that social changes of very great significance would be demanded jointly by the medical profession and by the patients themselves.

Despite these social and economic difficulties it will be generally agreed that when our health services really settle down, to the problem of health preservation the home conditions must be taken into consideration.   Many significant facts may be revealed by a study of the conditions under which families live when the results obtained from periodic  health-examinations become known.   One speaks of periodic health examinations without any large-scale experience in this country, upon which to judge.   Nevertheless the work done by the Peckham Pioneer Health Centre indicates that it is possible, by means of a complete medical examination backed up by a suitable range of laboratory investigations, to discover many minor departures from normal and some quite serious defects in people who have not yet reached a stage at which they would seek medical advice. The exact range which these investigations should cover, the frequency with which they should be done, and the relation between clinical examination and scientifically accurate laboratory results, are matters which the medical profession has yet to work out. For our purpose it is enough to note that under existing circumstances such a conception cannot be made a reality. The general practitioner of today neither has the time nor the facilities for such an examination, his patients have neither the stimulus nor the money to submit to such investigations, and the machinery that would be necessary can only be provided by some form of medical organisation other than that which now exists.