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THE DRUG TARIFF UNDER THE NATIONAL INSURANCE ACT.
715 Dr. Saleeby point out that their observations have a great revision of the conditions of payment. distinct bearing upon the etiology of beri-beri, and Even the report of the committee, to which are in accord with the broad proposition that this we referred last week, fails to give satisfaction The Pharmadisease results primarily from a poor dietary, one to the pharmaceutical members. that is deficient, more particularly, in specific sub- ceutical Journal states that the three members stances of the nature of the vitamine described by specifically dissent from the view taken by the Casimir Funk. The fact that all types of beri-beri majority of their colleagues on the question of respond in greater or less degree to the same an adequate establishment charge, while two of treatment would seem to indicate that they are in the members dissociate themselves from other points of detail. With such divergence of opinion reality one and the same disease. from those who have had full opportunity of investigation, it is to be hoped that further THE DRUG TARIFF UNDER THE NATIONAL discussion of the matter may be shelved until after INSURANCE ACT. the war. ____
IN
our
last issue we
published
a
resume of the
of the Departmental Committee on the Drug Tariff under the National Insurance Act, from which it will have been seen that there is some prospect of an early revision of the payments to be made to chemists. In the early days, when the subject was first under discussion, there appeared to be considerable satisfaction with the plan by which doctors were to prescribe and chemists to dispense. This satisfaction has shown signs of waning with further experience. There have been many indications that the dispensing chemists think they have been induced to make a hard bargain, and they have frequently charged members of the medical profession with wilfully prescribing expensive drugs. In all probability this accusation could rarely be substantiated ; but even when the prescriptions have been kept within the legitimate bounds of routine practice adopted in out-patient departments of hospitals, there has been some hardship during the past year owing to the great increase in the cost price of many drugs. In addition it must be remembered that the difficulties of work have been greater owing to the number of assistants who have entered some branch of the army. This reduction of establishment might have been accompanied by a proportionate reduction of working expenses, but, as in every other branch of work, we believe that assistants, knowing they are badly wanted, demand higher wages. It may be assumed, probably, that payments, which were perhaps barely adequate before the war, leave no margin of profit under present conditions. So far, therefore, there would appear to be some justification for reopening the whole subject of the payment to be made to the chemists under the Insurance Act. Before yielding to such charitable impulses, with regard to one side of the question, the rights of the panel doctors must be considered. Sir Robert Morant, in a letter dated August 23rd, 1915, has indicated that the Commissioners, in the present exceptional circumstances, when so many members of the profession are inaccessible, would be most reluctant to make any substantial modifications of the terms of service of medical practitioners under the Insurance Act unless they could feel assured that such modifications were desirable in the view of all concerned. The plain fact appears to be that the amount available for medical benefit is a fixed sum, war or no war, and that if chemists are to receive something more than hitherto, then doctors must receive less. With every sympathy with the difficulties of the chemists, we fear that a similar account of falling income and increased expanses might be heard from panel doctors, and as so many are at present inaccessible, to repeat Sir Roberb Morant’s term, we cannot but think that this is a most inopportune moment for any
report
EPIDIDYMOTOMY FOR ACUTE EPIDIDYMITIS.
Dr. A. H. Crosbie and Dr. A. Riley have called attention in the Boston Medical and Surgical Journal to the value of epididymotomy in acute epididymitis. The operation appears to have been first practised by Pirogoff in 1852, and in this country by the late Mr. Henry Smith in 1864. But it was subsequently neglected until it was revived by an American surgeon, F. P. Hagner, in 1906. Up to a year ago Dr. Crosbie and Dr. Riley used to treat cases of gonorrhoeal epididymitis at the Boston Dispensary by the usual method of local applications, strapping, and rest in bed. Finding this treatment far from satisfactory they began to perform epididymotomy in the very acute cases. The results were so gratifying that now they operate even in the milder cases. At first they operated under ether, but they found that local anaesthesia is quite satisfactory and enables the operation to be performed as an out-patient procedure. They use from 20 to 30 c.c. of a 1 per cent. solution of novocaine to which has been added 3 to 6 drops of adrenal solution 1 in 1000. The best syringe is a 10 c.c. glass one with The first step is to infiltrate a 2-inch needle. the cord, which is done by grasping it where it emerges from the external ring between the leftthumb and forefinger. The needle is inserted into the cord, and from 5 to 10 c.c. of solution are injected in all directions. It is well before removing the needle to point upwards and inwards and inject a little solution into the inguinal canal, so as to block completely all the nerves to the cord. The needle is then pushed downwards through the same point of entry along the cord to the region of the globus major and a little more is injected. The scrotum is then injected on the side of operation all the way to the perineum in the line of junction with the thigh. Finally, a little novocain is injected along the line of incision. In order to get perfect anaesthesia it is well to wait 10 or 15 minutes. The incision is made laterally so that the tunica, vaginalis is opened near the epididymis. In very acute cases there is always considerable hydrocele fiuidy so that it is easy to cut through the tunica vaginalis, but after some days the fluid disappears and the tunica becomes adherent, so that care has to be taken not to cut the testicle. The fluid may be clear and straw-coloured or turbid. Adhesions are freed with the blunt end of the knife or with a, scissors and the testicle is delivered through the incision. The inflammation is usually most severe at the globus minor. Where the inflammation is worst the epididymis is hard and indurated. Occasionally minute abscesses can be seen. Multiple punctures are made deeply in the indurated area. with a tenotome, whether there is visible pus or
.
IN
our
last issue we
published
a
resume of the
of the Departmental Committee on the Drug Tariff under the National Insurance Act, from which it will have been seen that there is some prospect of an early revision of the payments to be made to chemists. In the early days, when the subject was first under discussion, there appeared to be considerable satisfaction with the plan by which doctors were to prescribe and chemists to dispense. This satisfaction has shown signs of waning with further experience. There have been many indications that the dispensing chemists think they have been induced to make a hard bargain, and they have frequently charged members of the medical profession with wilfully prescribing expensive drugs. In all probability this accusation could rarely be substantiated ; but even when the prescriptions have been kept within the legitimate bounds of routine practice adopted in out-patient departments of hospitals, there has been some hardship during the past year owing to the great increase in the cost price of many drugs. In addition it must be remembered that the difficulties of work have been greater owing to the number of assistants who have entered some branch of the army. This reduction of establishment might have been accompanied by a proportionate reduction of working expenses, but, as in every other branch of work, we believe that assistants, knowing they are badly wanted, demand higher wages. It may be assumed, probably, that payments, which were perhaps barely adequate before the war, leave no margin of profit under present conditions. So far, therefore, there would appear to be some justification for reopening the whole subject of the payment to be made to the chemists under the Insurance Act. Before yielding to such charitable impulses, with regard to one side of the question, the rights of the panel doctors must be considered. Sir Robert Morant, in a letter dated August 23rd, 1915, has indicated that the Commissioners, in the present exceptional circumstances, when so many members of the profession are inaccessible, would be most reluctant to make any substantial modifications of the terms of service of medical practitioners under the Insurance Act unless they could feel assured that such modifications were desirable in the view of all concerned. The plain fact appears to be that the amount available for medical benefit is a fixed sum, war or no war, and that if chemists are to receive something more than hitherto, then doctors must receive less. With every sympathy with the difficulties of the chemists, we fear that a similar account of falling income and increased expanses might be heard from panel doctors, and as so many are at present inaccessible, to repeat Sir Roberb Morant’s term, we cannot but think that this is a most inopportune moment for any
report
EPIDIDYMOTOMY FOR ACUTE EPIDIDYMITIS.
Dr. A. H. Crosbie and Dr. A. Riley have called attention in the Boston Medical and Surgical Journal to the value of epididymotomy in acute epididymitis. The operation appears to have been first practised by Pirogoff in 1852, and in this country by the late Mr. Henry Smith in 1864. But it was subsequently neglected until it was revived by an American surgeon, F. P. Hagner, in 1906. Up to a year ago Dr. Crosbie and Dr. Riley used to treat cases of gonorrhoeal epididymitis at the Boston Dispensary by the usual method of local applications, strapping, and rest in bed. Finding this treatment far from satisfactory they began to perform epididymotomy in the very acute cases. The results were so gratifying that now they operate even in the milder cases. At first they operated under ether, but they found that local anaesthesia is quite satisfactory and enables the operation to be performed as an out-patient procedure. They use from 20 to 30 c.c. of a 1 per cent. solution of novocaine to which has been added 3 to 6 drops of adrenal solution 1 in 1000. The best syringe is a 10 c.c. glass one with The first step is to infiltrate a 2-inch needle. the cord, which is done by grasping it where it emerges from the external ring between the leftthumb and forefinger. The needle is inserted into the cord, and from 5 to 10 c.c. of solution are injected in all directions. It is well before removing the needle to point upwards and inwards and inject a little solution into the inguinal canal, so as to block completely all the nerves to the cord. The needle is then pushed downwards through the same point of entry along the cord to the region of the globus major and a little more is injected. The scrotum is then injected on the side of operation all the way to the perineum in the line of junction with the thigh. Finally, a little novocain is injected along the line of incision. In order to get perfect anaesthesia it is well to wait 10 or 15 minutes. The incision is made laterally so that the tunica, vaginalis is opened near the epididymis. In very acute cases there is always considerable hydrocele fiuidy so that it is easy to cut through the tunica vaginalis, but after some days the fluid disappears and the tunica becomes adherent, so that care has to be taken not to cut the testicle. The fluid may be clear and straw-coloured or turbid. Adhesions are freed with the blunt end of the knife or with a, scissors and the testicle is delivered through the incision. The inflammation is usually most severe at the globus minor. Where the inflammation is worst the epididymis is hard and indurated. Occasionally minute abscesses can be seen. Multiple punctures are made deeply in the indurated area. with a tenotome, whether there is visible pus or
.