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A CATALOGUE OF SUFFERING.
358 to benefit before April 14th, 1913, who should have been allocated at that date. This view of the case is supported by the statement on p. 7 of that delightful pamphlet addressed to the profession by the Commissioners in December, 1912, which says that this method of calculating the remuneration will only apply " when the system is in full working." This pamphlet may not have the legal force of the Regulations, but at any rate shows the intentions of the Commissioners. Again, Circular 29 IC (vide THE LANCET, Oct. 4th, 1913, p. 1032) recommending a distribution of unallotted persons quarter by quarter would also show that the Commissioners realised that remuneration according to the schedule would only be equitable provided there were no accumulated funds from
the
preceding quarters. certainly took Mr.
puerperium. Your correspondent speaks of the maternity benefit, while I refer to unallotted funds for medical benefit-in my opinion two distinct things. These funds are no doubt still accumulating. In considering my suggestion no one could say that the doctors would not be earning the money, which is a point raised by those who object to the whole unallotted funds being divided up amongst the doctors on the panel who have not been chosen by the insured people whose contributions are
under consideration. ir
--
Sir
yours" faithfully .;+t. "i.
JANET EWART ST. CLAIR, Honorary Secretary,
Fulham Association of Midwives.
I repealed *** I
Miss St. Clair is no doubt right as to the effect of the section in practice ; and the Insurance Com. missioners would relieve poor women in childbirth from a difficulty which often presses hardly upon them if they could see their way to fall in with her suggestion.-ED.L.
I Masterman’s statement in the House of Commons on July 14th last to refer to this particular difficulty, and regarded it as an assurance that we should receive payment at the rate of 7s. a year for each of our acceptances during the year for whom CHILLEY v. BRADFORD. 7s. was payable, though doubtless it also had To the Editor of THE LANCET. reference to deductions for the Central Fund, about which the Commissioners were discreetly SiR,-In the above case the jury held that a silent in the pamphlet of December, 1912. The nurse was negligent because, on giving a sedative, Commissioners have made arrangements for us to she did not remove from the bed, or otherwise receive full remuneration for the coming year, protect the patient from, a covered indiarubber hotsubstituting the acquisition of powers of telepathy water bag, which had been placed there about an by the Panel Committee in place of the hard work hour and a half previously, and with which the previously demanded of the staff of the Insurance patient subsequently before his operation burnt Committee, and I have no doubt will see that the himself. remuneration for the past year is equitably divided The sedative in question I understand to have consisted of 1/6 grain of morphia and 1/120 grain of amongst us. Individual actions against the committee should atropine given hypodermically, but, of course, the be a last resort, but if all other means fail it is only finding of the jury includes all sedatives and affects fair that, if the committee were liable to be the ordinary practice and routine of hospitals, surcharged if they distributed our remuneration, private or otherwise, and raises a question of some they should also be liable as a surcharge to importance to the medical profession, as in the recompense any medical man who can prove that he above case, though I was not held to have been has suffered loss through their neglect to make personally negligent, I was held responsible for adequate provision for securing an allocation of the the alleged negligence of my nurse. residue in April. I am, Sir, yours faithfully, I am, Sir, yours faithfully, ANTHONY BRADFORD, M.D. Durh. Henrietta-street, W., Jan. 24th, 1914. J. M. TWENTYMAN. Wells-street, W., Jan. 19th, 1914.
* >B<
The
case
is elsewhere dealt with.-ED. L.
To the Editor of THE LANCET.
SIR,-Your legal correspondent says, in answer suggestion that a part at any rate of the
to my
unallotted insurance funds should be held in reserve for payment of doctors who, having gone to the aid of a midwife, are unable to get their fees from very poor patients, that " this hardly seems possible in view of the fact that the National Insurance Act, 1913, repeals the portion of Section 18 of the original Act, which permitted the fee of the medical practitioner in the circumstances indicated to be ’recoverable as part of the maternity benefit."’ This repeal was made at the instance of the Midwives Institute, backed up by 55 affiliated associations of midwives in different parts of the country, for the wording of the old clause made it appear as if the societies would be responsible for the " recovery " of the doctor’s fee as part of the maternity benefit, resulting in the societies holding back, in very many instances until the woman was up and about, the whole or part of the benefit from midwives’ cases. This naturally prejudiced midwives and inflicted a great hardship on the poorest of insured persons, for whom the benefit was devised, and who most needed it during the "
A CATALOGUE OF SUFFERING. To the Editor of THE LANCET.
SiR,-The system of election to the benefits of certain charities by a poll of subscribers has some obvious drawbacks as well as some advantages. One of the latter is the contact which it establishes between the subscribers and the nature of the work which is carried on by their money. The Hospital for Incurables at Putney, for instance, sends out twice a year a voting paper, revealing an amount of human misery calculated to appal far more callous persons than those who subscribe to that splendid charity. Medically speaking, the column headed disease or Disability"is full of interest. At first sight it is surprising to find among the 192 candidates for the benefits of the society at the recent election not a single case diagnosed as malignant disease or as pulmonary tuberculosis. The explanation is probably to be found in the delay which necessarily ensues before a patient can be accepted ; it always takes months. and generally years, to reach this much coveted haven of refuge, either as an in-patient or as a pensioner. Heart disease, again, is less prominent
359 than might be expected; and in most of them
alone appear, condition is Bright’s disease
seven cases
some
other
one
year. This is to take exceed 26.
place
when the
penalty
arrears
____
Aneurysm and absent from the list altogether. Turning THE INSURANCE MEDICAL SERVICE IN LONDON. to the common causes of disability, "rheumatoid It was noted at the meeting of the London arthritis" is diagnosed in 58 cases, and chronic Insurance Committee on Jan. 22nd that in the case rheumatism, osteo-arthritis, and rheumatic gout of practitioners who have accepted service on the account for another 14-an eloquent proof of panel for a limited number of persons the clause our therapeutic helplessness for these intractable will be omitted from the agreements which states The other main group is that of that doctors will treat disorders. persons who have been the paralyses, which includes at least 73 cases, assigned to them by the committee. It was The diagnoses of these decided to issue a circular letter to the medical and probably more. disorders are so confused that in the majority of profession emphasising this point, Dr. H. H. Mills cases it is impossible to identify the extent and (chairman of the Medical Benefit Subcommittee) nature of the disease. In a few cases disseminated that a fear of having patients assigned remarking sclerosis, locomotor ataxia, myelitis, and paralysis to them had prevented many doctors from coming agitans are specified ; but " paralysis"is the only on the panel. There were about 1000 doctors label attached to the bulk of the cases. The point whose practices were amongst the insured classes is of minor importance, no doubt, because who had so far remained outside the Act, and it most subscribers do not trouble themselves would be advantageous if a proportion of them about the complaint of the candidate they could be attracted to the panel. On a motion does vote for; but it occasionally happen by Dr. Mills, seconded by Dr. B. A. Richmond, that a medical man is asked to advise upon the Medical Benefit Subcommittee was instructed the relative disabilities attaching to various to report as to the sufficiency of the arrangements diseases. for medical benefit in the various boroughs of There are further instances of unsatisfactory dia- London. Allusion was made to the criticisms of gnosis on the list. "Internal trouble"appears the panel service made by Sir John Collie, and two or three times; not, by the way, from a false noted in the last issue of THE LANCET (p. 280). delicacy, for " "fibrous tumours" are specified in Mr. F. Coysh (chairman of the General Purposes another case. Debility after surgical operation Subcommittee) observed that too much general may be a euphemism for something more tangible, abuse of the panel system had been indulged in especially as the candidate is in her sixth year of upon the committee. The time had come for application; but it is ambiguous and therefore practical suggestions for its improvement. Some objectionable. Graves’s disease as a qualification criticism was also passed upon waiting-room and for an incurables’ charity may be a slight shock lavatory accommodation at surgeries in East both to some physicians and to some surgeons. London. The committee passed a further resoluCreeping paralysis"is a curious phrase in a list tion instructing a subcommittee to report as to the presumably derived from medical certificates, and adoption of a scheme for the nursing of insured nervous debility" is equally vague and meaning- persons. less. Heemophilia, myxoedema, and anaemia with enlarged spleen are some of the more uncommon INSTITUTIONAL TREATMENT OF TUBERCULOSIS IN and interesting diagnoses put forward. Doubtless LONDON. the investigations of the society’s officers exclude The cost of institutional treatment of tuberall except really urgent and deserving cases; but culosis in the metropolis appears, from a report there is room for improvement in the system of to the London Insurance Committee on presented setting forth the diagnosis and in the information Jan. 22nd, to have been considerably increased by thereby supplied to the electors. the decision of the London County Council to rely I am, Sir, yours faithfully, upon such temporary accommodation as the chiefly M.D. CANTAB. Jan. 17th, 1914. Metropolitan Asylums Board could provide. The rate per head works out at 40s. 2½d., against the more usual 30s elsewhere. Restricted accommodaTHE NATIONAL INSURANCE ACT. tion prevents the reception of a sufficient number of cases to effect more economical working. The Insurance Committee, whilst fully appreciating the PENALTIES FOR ARREARS OF CONTRIBUTIONS. assistance of the Metropolitan Asylums Board (but AT a joint meeting of the Insurance Advisory for whose readiness in emergency institutional Committees for England, Scotland, Wales, and treatment would be almost a dead letter in Ireland draft regulations were considered fixing London), has pointed out to the London County penalties for those falling into arrears with their Council the unsatisfactory and expensive nature contributions. The scheme proposed by the Com- of the present temporary arrangements, and has missioners was submitted by their actuary, Mr. urged the importance of securing permanent At the same At accommodation at an early date. A. W. Watson, and was unanimously approved. the end of each contribution year-i.e., in June- meeting of the Insurance Committee a resolution each member’s net arrears, if any, are to be ascer- was passed expressing regret that the County tained, certain credit allowances being made, and Council had let slip the opportunity of acquiring he is to have the opportunity of paying them off for tuberculosis treatment the Mount Vernon before Oct. lst. If on that date he is still behind- Hospital, Hampstead, which has now been purhand the arrears then found will be his " penalty chased by the Medical Research Committee arrears"" for the benefit year beginning Nov. lst, formed under the Insurance Act. Mr. D. E. and reductions of his benefit will follow upon a Warburg, a prominent member of the County scale depending upon the number of payments Council, in defending the inaction of that body, which he has failed to make, and having as its made the announcement that in regard to the treat extreme penalty the suspension of all benefits for ment of tuberculosis the Council adopts the same
superadded.
are
"
"
____
the
preceding quarters. certainly took Mr.
puerperium. Your correspondent speaks of the maternity benefit, while I refer to unallotted funds for medical benefit-in my opinion two distinct things. These funds are no doubt still accumulating. In considering my suggestion no one could say that the doctors would not be earning the money, which is a point raised by those who object to the whole unallotted funds being divided up amongst the doctors on the panel who have not been chosen by the insured people whose contributions are
under consideration. ir
--
Sir
yours" faithfully .;+t. "i.
JANET EWART ST. CLAIR, Honorary Secretary,
Fulham Association of Midwives.
I repealed *** I
Miss St. Clair is no doubt right as to the effect of the section in practice ; and the Insurance Com. missioners would relieve poor women in childbirth from a difficulty which often presses hardly upon them if they could see their way to fall in with her suggestion.-ED.L.
I Masterman’s statement in the House of Commons on July 14th last to refer to this particular difficulty, and regarded it as an assurance that we should receive payment at the rate of 7s. a year for each of our acceptances during the year for whom CHILLEY v. BRADFORD. 7s. was payable, though doubtless it also had To the Editor of THE LANCET. reference to deductions for the Central Fund, about which the Commissioners were discreetly SiR,-In the above case the jury held that a silent in the pamphlet of December, 1912. The nurse was negligent because, on giving a sedative, Commissioners have made arrangements for us to she did not remove from the bed, or otherwise receive full remuneration for the coming year, protect the patient from, a covered indiarubber hotsubstituting the acquisition of powers of telepathy water bag, which had been placed there about an by the Panel Committee in place of the hard work hour and a half previously, and with which the previously demanded of the staff of the Insurance patient subsequently before his operation burnt Committee, and I have no doubt will see that the himself. remuneration for the past year is equitably divided The sedative in question I understand to have consisted of 1/6 grain of morphia and 1/120 grain of amongst us. Individual actions against the committee should atropine given hypodermically, but, of course, the be a last resort, but if all other means fail it is only finding of the jury includes all sedatives and affects fair that, if the committee were liable to be the ordinary practice and routine of hospitals, surcharged if they distributed our remuneration, private or otherwise, and raises a question of some they should also be liable as a surcharge to importance to the medical profession, as in the recompense any medical man who can prove that he above case, though I was not held to have been has suffered loss through their neglect to make personally negligent, I was held responsible for adequate provision for securing an allocation of the the alleged negligence of my nurse. residue in April. I am, Sir, yours faithfully, I am, Sir, yours faithfully, ANTHONY BRADFORD, M.D. Durh. Henrietta-street, W., Jan. 24th, 1914. J. M. TWENTYMAN. Wells-street, W., Jan. 19th, 1914.
* >B<
The
case
is elsewhere dealt with.-ED. L.
To the Editor of THE LANCET.
SIR,-Your legal correspondent says, in answer suggestion that a part at any rate of the
to my
unallotted insurance funds should be held in reserve for payment of doctors who, having gone to the aid of a midwife, are unable to get their fees from very poor patients, that " this hardly seems possible in view of the fact that the National Insurance Act, 1913, repeals the portion of Section 18 of the original Act, which permitted the fee of the medical practitioner in the circumstances indicated to be ’recoverable as part of the maternity benefit."’ This repeal was made at the instance of the Midwives Institute, backed up by 55 affiliated associations of midwives in different parts of the country, for the wording of the old clause made it appear as if the societies would be responsible for the " recovery " of the doctor’s fee as part of the maternity benefit, resulting in the societies holding back, in very many instances until the woman was up and about, the whole or part of the benefit from midwives’ cases. This naturally prejudiced midwives and inflicted a great hardship on the poorest of insured persons, for whom the benefit was devised, and who most needed it during the "
A CATALOGUE OF SUFFERING. To the Editor of THE LANCET.
SiR,-The system of election to the benefits of certain charities by a poll of subscribers has some obvious drawbacks as well as some advantages. One of the latter is the contact which it establishes between the subscribers and the nature of the work which is carried on by their money. The Hospital for Incurables at Putney, for instance, sends out twice a year a voting paper, revealing an amount of human misery calculated to appal far more callous persons than those who subscribe to that splendid charity. Medically speaking, the column headed disease or Disability"is full of interest. At first sight it is surprising to find among the 192 candidates for the benefits of the society at the recent election not a single case diagnosed as malignant disease or as pulmonary tuberculosis. The explanation is probably to be found in the delay which necessarily ensues before a patient can be accepted ; it always takes months. and generally years, to reach this much coveted haven of refuge, either as an in-patient or as a pensioner. Heart disease, again, is less prominent
359 than might be expected; and in most of them
alone appear, condition is Bright’s disease
seven cases
some
other
one
year. This is to take exceed 26.
place
when the
penalty
arrears
____
Aneurysm and absent from the list altogether. Turning THE INSURANCE MEDICAL SERVICE IN LONDON. to the common causes of disability, "rheumatoid It was noted at the meeting of the London arthritis" is diagnosed in 58 cases, and chronic Insurance Committee on Jan. 22nd that in the case rheumatism, osteo-arthritis, and rheumatic gout of practitioners who have accepted service on the account for another 14-an eloquent proof of panel for a limited number of persons the clause our therapeutic helplessness for these intractable will be omitted from the agreements which states The other main group is that of that doctors will treat disorders. persons who have been the paralyses, which includes at least 73 cases, assigned to them by the committee. It was The diagnoses of these decided to issue a circular letter to the medical and probably more. disorders are so confused that in the majority of profession emphasising this point, Dr. H. H. Mills cases it is impossible to identify the extent and (chairman of the Medical Benefit Subcommittee) nature of the disease. In a few cases disseminated that a fear of having patients assigned remarking sclerosis, locomotor ataxia, myelitis, and paralysis to them had prevented many doctors from coming agitans are specified ; but " paralysis"is the only on the panel. There were about 1000 doctors label attached to the bulk of the cases. The point whose practices were amongst the insured classes is of minor importance, no doubt, because who had so far remained outside the Act, and it most subscribers do not trouble themselves would be advantageous if a proportion of them about the complaint of the candidate they could be attracted to the panel. On a motion does vote for; but it occasionally happen by Dr. Mills, seconded by Dr. B. A. Richmond, that a medical man is asked to advise upon the Medical Benefit Subcommittee was instructed the relative disabilities attaching to various to report as to the sufficiency of the arrangements diseases. for medical benefit in the various boroughs of There are further instances of unsatisfactory dia- London. Allusion was made to the criticisms of gnosis on the list. "Internal trouble"appears the panel service made by Sir John Collie, and two or three times; not, by the way, from a false noted in the last issue of THE LANCET (p. 280). delicacy, for " "fibrous tumours" are specified in Mr. F. Coysh (chairman of the General Purposes another case. Debility after surgical operation Subcommittee) observed that too much general may be a euphemism for something more tangible, abuse of the panel system had been indulged in especially as the candidate is in her sixth year of upon the committee. The time had come for application; but it is ambiguous and therefore practical suggestions for its improvement. Some objectionable. Graves’s disease as a qualification criticism was also passed upon waiting-room and for an incurables’ charity may be a slight shock lavatory accommodation at surgeries in East both to some physicians and to some surgeons. London. The committee passed a further resoluCreeping paralysis"is a curious phrase in a list tion instructing a subcommittee to report as to the presumably derived from medical certificates, and adoption of a scheme for the nursing of insured nervous debility" is equally vague and meaning- persons. less. Heemophilia, myxoedema, and anaemia with enlarged spleen are some of the more uncommon INSTITUTIONAL TREATMENT OF TUBERCULOSIS IN and interesting diagnoses put forward. Doubtless LONDON. the investigations of the society’s officers exclude The cost of institutional treatment of tuberall except really urgent and deserving cases; but culosis in the metropolis appears, from a report there is room for improvement in the system of to the London Insurance Committee on presented setting forth the diagnosis and in the information Jan. 22nd, to have been considerably increased by thereby supplied to the electors. the decision of the London County Council to rely I am, Sir, yours faithfully, upon such temporary accommodation as the chiefly M.D. CANTAB. Jan. 17th, 1914. Metropolitan Asylums Board could provide. The rate per head works out at 40s. 2½d., against the more usual 30s elsewhere. Restricted accommodaTHE NATIONAL INSURANCE ACT. tion prevents the reception of a sufficient number of cases to effect more economical working. The Insurance Committee, whilst fully appreciating the PENALTIES FOR ARREARS OF CONTRIBUTIONS. assistance of the Metropolitan Asylums Board (but AT a joint meeting of the Insurance Advisory for whose readiness in emergency institutional Committees for England, Scotland, Wales, and treatment would be almost a dead letter in Ireland draft regulations were considered fixing London), has pointed out to the London County penalties for those falling into arrears with their Council the unsatisfactory and expensive nature contributions. The scheme proposed by the Com- of the present temporary arrangements, and has missioners was submitted by their actuary, Mr. urged the importance of securing permanent At the same At accommodation at an early date. A. W. Watson, and was unanimously approved. the end of each contribution year-i.e., in June- meeting of the Insurance Committee a resolution each member’s net arrears, if any, are to be ascer- was passed expressing regret that the County tained, certain credit allowances being made, and Council had let slip the opportunity of acquiring he is to have the opportunity of paying them off for tuberculosis treatment the Mount Vernon before Oct. lst. If on that date he is still behind- Hospital, Hampstead, which has now been purhand the arrears then found will be his " penalty chased by the Medical Research Committee arrears"" for the benefit year beginning Nov. lst, formed under the Insurance Act. Mr. D. E. and reductions of his benefit will follow upon a Warburg, a prominent member of the County scale depending upon the number of payments Council, in defending the inaction of that body, which he has failed to make, and having as its made the announcement that in regard to the treat extreme penalty the suspension of all benefits for ment of tuberculosis the Council adopts the same
superadded.
are
"
"
____