THE FRAMEWORK OF MEDICINE IN INDIA

933 the chest without suffering necrosis. must reduce the covering skin with as few and as inconspicuous scars as possible. A contribution by Sir Harold Gillies was the use of a double pedicle, which was made by an external and an internal tube pedicle carrying the nipple on the apex of the V, the central portion being excised. That gave a sound blood-supply and was an excellent method of shifting the nipple to its normal position ; it enabled a very even breast to be made--a disadvantage sometimes was that too much was left in the axilla. The double pedicle was still being used. The next phase was Wiesenberger’s introduction of the internal pedicle. If this was made correctly, the blood-supply to the nipple was never in danger ; it must not be tied tightly to the chest wall. A single upper flap obviated a scar from the nipple to the submammary incision. Mr. McIndoe favoured operating in two stages, as he did not think one stage safe enough in a large series of cases of gross hypertrophy. After many single operatiQns the surgeon had the feeling that if a little had been left for a second attempt a more satisfactory result could have been achieved. For moderate ptosis where a single upper flap was impossible, the internal pedicle was used, or possibly a double pedicle together with the typical Weisenberger operation. When the single upper flap was used there were 7 cases of mild necrosis of the skin edge. Partial necrosis of the pedicles resulted from maladjustment of the upper pedicle. One of the curses of these operations was haematoma formation ; there were 15 cases in the series, 5 of which became infected, resulting in a delayed convalescence ; 6 of the patients had stitch abscesses, and in all of these chromic catgut had been used, the complication disappearing when the material was given up. There All these were 4 cases of deep-seated abscess. operations should be done with every care, and under the most stringent aseptic precautions.

position on Secondly, he

(Marseilles) aescrioea a metnoa of rapid dilatation for cicatricial stenosis after laryngotracheostomy. Usually, he said, this was a slow and thankless task, and he demonstrated a tube designed to shorten the procedure ; it consisted of two hinged half-tubes, furnished with a double spring to keep it open. The degree of elasticity of the spring could be altered to regulate the dilating force. It caused a rapid destruction of the scar tissue, hence its action must be closely watched. It must be removed after being in position a few days, and could later be replaced if necessary. It must not be retained in the presence of pain or a rise of temperature. Dr. A. GALLASSI (Bologna) with the aid of drawings and radiograms described an operation for congenital anorectal atresia. The case on which the contribution was based was that of a child aged 6 years. Besides the congenital atresia she had a double vagina. The intestines emptied by an abnormal opening in the vestibule between urethra and vagina. At the operation it was found that the intestine was too high and too far forward to allow it to be brought directly to the surface near the anus. A new rectum was made from the right vagina, which thus conducted faeces from the intestine to the anal region. He demonstrated the passage of barium from the intestine to the vestibule before the operation, and to the anal region after the reconstruction. Dr. JACK THEVENIN (Paris), discussing the causes of intolerance to cartilage grafts, said that notwithstanding the careful precautions taken when these had been used, especially in their after-care, there would always remain some risk that the grafts would fr.

M.

YREVOT

not take and would be expelled. Failures he classified into three groups : those due to the general condition of the patient, those due to a poor condition of the tissue in the locality, and those attributable to extrinsic factors. He reviewed the accidents that might happen after or during the use of grafts taken from another person ; blood-groups were important in this.

Sir HAROLD GILLIES exhibited a film of a case with extensive destruction of the nasal contour due to syphilitic erosion. The film showed his method and the good results he had obtained from intranasal

skin-grafting.

’

THE FRAMEWORK OF MEDICINE INDIA

IN

TiiE members of the British Medical Association who visited Bombay on their way to the Melbourne meeting in 1935 were impressed by the need for reorganisation of the profession in India, and the council decided to send the secretary of the association, Dr. G. C. Anderson, to investigate conditions there on its behalf. The secretary therefore spent three months of the winter 1936-37 in an extensive tour of the country, visiting the principal medical colleges and schools, civil and medical hospitals, maternity and child welfare centres and so on, and interviewing and collecting the opinions of representative medical men and others. The council have now published his report,l summarised below, with a view to obtaining the comments and suggestions of the Indian branches of the association and of others interested before deciding upon action. EXISTING SERVICES

Medical care in India is provided by the Indian Medical Service, the Royal Army Medical Corps, the Indian Medical Department, the provincial medical service, the civil surgeons, the independent medical profession, the public health services, the medical missionary and railway services, and a voluntary women’s medical service. The I.M.S. is primarily military but has a civil branch of 220 officers, of whom 166 are British, which comprises civil surgeons, specialists at teaching hospitals, and research workers, appointed from those who have completed 2-5 years’ service on the military side. The R.A.M.C is concerned solely with the care of the British troops stationed in India. The I.M.D. supplies the subordinate personnel for the army and consists of military assistant surgeons and sub-assistant surgeons who have mostly been trained at government expense and act as house surgeons, clerks, storekeepers, &c., and are responsible for hospital discipline. The assistant surgeons are usually Anglo-Indians and serve with the British troops under the R.A.M.C., whereas the sub-assistant surgeons are Indians working with the Indian troops under I.M.S. officers, and both may be selected for civil employment. Each province has a civil medical department under a surgeon-general, who is responsible for the superintendence of hospitals, asylums, and other institutions, for public health administration, and for medical education and the regulation of medical qualifications in the province. His staff, the provincial medical service, is recruited from the I.M.S. or the I.M.D. or appointed directly from among candidates holding Indian qualifications. The civil surgeons are 1

Brit. med. J. Suppl. Oct.

9th, 1937, p. 221.

934

appointed from the provincial medical service in a proportion of about 4 to 1, and are generally responsible for medical administration and for all government hospitals in their districts, in addition to which they act as medico-legal advisers to the government and as superintendents of the district jails, attend the local government servants, examine recruits, and engage in private practice. They have suitable number of assistant and sub-assistant surgeons under them. The independent medical profession, which has greatly increased in recent years, includes a number of men who have received post-graduate instruction in England. The conditions in rural areas are so poor that private practice is practically confined to the towns, and the market has now been so flooded by licentiates of inferior training that there is difficulty in making a livelihood even in the more populous areas. Fees everywhere are necessarily very low and the standard of medical ethics is even lower. No legal restrictions are placed upon unqualified practice, and the population shows a preference for the indigenous systems of medicine as practised by the Hakims and the Vaids, and also supports so-called homoeopaths and quacks of all kinds. The public health service is administered both by the central federal government, which deals with questions affecting India as a whole, such as emigration and the census, and the provincial governments, which are responsible for local matters, hospitals, registration of births and deaths, water-supplies, and the like. The work of the federal government is superintended by the public health commissioner, a member of the I.M.S., and that of the provincial governments by their directors of public health, each with from 2 to 4 assistant directors. The municipal authorities deal with administration in the towns and the district boards in the rural areas. Their staffs are similar, comprising whole- or part-time medical officers of health, vaccination officers, school medical officers, sanitary officers, and so on. In spite of this imposing organisation Dr. Anderson formed the opinion that even elementary sanitation is largely deficient, and that there is a considerable need for general coordination. a

SOME GRIEVANCES

condiconcentrated upon those common to most provinces. In the I.M.S. itself the Indian officers hold that they are unfairly treated as compared with Europeans. For example the gratuity payable to those of them who are retired after five years’ service is Rs.4500 (337 10s.), compared with £ 1000 allowed to Europeans after six years, and although the basic rates of pay are the same in both categories, the Europeans receive a substantial addition of overseas pay. Further, they complain that the civil posts reserved for Indian I.M.S. officers are markedly less than those for Europeans, and that no specialist posts in the teaching centres are reserved for them. The purpose of the civil branch of the I.M.S. is to ensure a reserve of trained men for emergencies and adequate medical attention for European government servants by those of their own race. Indians hold that such a reserve could easily be built up in India and that greater opportunities for Indians would produce men of sufficient standing and education to satisfy the needs of the community. As regards the teaching posts, some hold that these should be filled by the best men obtainable regardless of race, while others consider that the presence of at In

a few European officers is essential if the latest English teaching is to reach the Indian colleges. The competition of the members of the I.M.S. and the provincial medical service is a perpetual source of grievance to private practitioners, in whose view government subsidised surgeons and specialists should be limited to attending government servants and their families and to strictly consulting practice, except where this would cause hardship to the community, and an honorary or part-time paid staff should replace the members of the I.M.S. at hospitals.

least

It seems, however, that frequent transfers prevent I.M.S. officers from acquiring extensive private practices, and that these proposals would admit the less well qualified to important institutional posts. At present many of the appointments which offer the more attractive fields of work, for example in the district civil hospitals, and in public health and research work, are held by government medical officers, and this undoubtedly acts as an incentive for Indians to do post-graduate work and attain higher qualifications. The independent practitioners suggest that if these posts were open to competition this incentive would be at least as great, and they claim that the position in the large presidency towns and in certain provinces, where many posts are open to independents, should be extended to the whole of India. HOSPITALS AND RURAL AREAS

The majority of the hospitals and dispensaries are maintained out of public funds and are free. There is no adequate almoner system so that the middle classes flock to these institutions, which thus deprive private practitioners of their livelihood and are unable to give sufficient attention to the legitimate poor. All hospitals -are short of nursing staff as custom forbids Indian women generally from adopting nursing as their profession. While medical men swarm in the towns they are a rarity in the rural areas, where the pay offered is very small-Rs. 70-100 a month or less-and there is no opportunity for adding to it by private practice, and where there are no social amenities and sanitary and housing conditions are prohibitive. It has been suggested that a lower grade of first-aid " men should be trained for these districts, but it is likely that they also would take the first opportunity of migrating to the towns. "

considering complaints against existing

MEDICAL EDUCATION

tions, Dr. Anderson

men trained in India are divided into and licentiates. The former attend one of the medical colleges such as Bombay, Calcutta, Madras, or Lahore, whose standard has been much improved in recent years, and whose degrees are now recognised by the General Medical Council. The licentiates are trained at one of the many medical schools, some of which maintain a deplorably low standard, particularly in the preliminary education demanded and in the class from which their students are drawn. The licentiates undoubtedly serve a useful purpose where they work under the supervision of more highly qualified men, as in the plantation hospitals in Assam, but they are not now contented with such subordinate posts and are engaging in general practice for which they are often unsuited. Post-graduate instruction may be said to be non-existent in India. There is no organised profession of pharmacy and in most provinces no restriction whatever upon the dispensing of medicines. The manufacture of drugs is also quite uncontrolled, and adulterated and inferior preparations are specially made for the Indian market.

Medical

graduates

935

by the

PROFESSIONAL ORGANISATIONS

There

are

three main

professional organisations,

the

Indian Medical Association, the All-India Licentiates’ Medical Association, and the British Medical Association. The I.M.A., with a membership of 2000, Indian graduates, is a medico-political body aim is at limiting the competition of the main whose The A.-I.L.M.A. comprises men. medical government 3000 of the 30,000 existing licentiates, and is working for an improved and uniform standard of medical education throughout India, and for the placing of their members upon an equal footing with the graduates. The B.M.A. has a membership of 1500, with a strong service element, but its branches, except in Assam, have been largely inactive and its subscription rates prohibitive for licentiates, even in those branches where they were eligible for admission. A representative meeting of the association, which Dr. Anderson attended at Bombay, proposed to admit Indian graduates and licentiates to all branches and to set up a central office with a part-time paid secretary to improve the association’s

mostly

organisation. MEDICINE AND THE LAW Precautions against Puerperal Infection use of masks and gloves by nurses attending confinements in hospitals was a matter of discussion a few months ago 1 in the Ashby de la Zouch hospital case (Heafield v. Crane and Hart). It was again discussed at a recent inquest at Burton-on-Trent. The deceased woman, Mrs. Shepherd, had given birth to a child in the Burton Nursing Institution on May llth. Four days later it was suspected that she had contracted scarlet fever ; she and her child were therefore moved to the Isolation Hospital. Subsequently her husband was told by the medical officer of health that Mrs. Shepherd was suffering from. puerperal septicaemia. On the 21st she died. The body was exhumed in July. Sir Bernard Spilsbury conducted a post-mortem examination and expressed to the coroner his opinion that the cause of death THE

acute blood poisoning consequent on puerperal fever following childbirth. Asked if, in his view, every precaution had been taken in the nursing-home to avoid infection, the witness replied that the fact of the infection was the answer. In other words he thought that there had been want of care. Though it was always difficult to find the source, he considered that the infection had been set up in the nursing-home. There had been evidence that Mrs. Shepherd was attended by a nurse who had previously been attending another woman who had a high temperature. The nurse had put on a clean apron before going to Mrs. Shepherd but did not wear gloves or a mask. Sir Bernard Spilsbury said he could not help feeling that it was a mistake that a nurse recently in attendance on a patient with a high temperature, which might have meant a septic condition, should have attended the labour of another woman. It was, he said, a wise precaution for nurses to wear gloves, especially at confinements, and also masks. Coughirig or sneezing could spread infection ; the mask would protect the patient ; infection could also come from the nurse’s hair ; it was important to wear headgear fully covering the hair. Evidence was given on the other hand by the doctor who, on seeing the rash on Mrs. Shepherd, had originally diagnosed scarlet fever. He told the coroner that he was as confident now as he was then that the illness was scarlet fever. Asked was

1

Lancet, August 14th,

p. 398.

if he thought it would be wiser for in this institution to wear gloves, he replied, I don’t, frankly." The coroner, in his summing-up, said that he could not see any flagrant negligence. He told the jurors that, if they thought Mrs. Shepherd died from scarlet fever, the only possible verdict was death from natural causes ; if they thought death was due to puerperal fever, the correct verdict would be death by misadventure. The jury’s verdict was " Death by misadventure, no blame attaching to the nursing institution, the isolation hospital, or the medical profession." With this verdict the coroner expressed his own concurrence. Without challenging the merits of this particular case, one may suggest to hospital committees that the views attributed to Sir Bernard Spilsbury represent an accepted standard of prudent practice. the

coroner

nurses "

Voluntary Mental Patient An interesting paper, read at the quarterly meeting of the Royal Medico-Psychological Association last May, has been reprinted in the Journal of Mental Science (vol. 83, p. 461). It raises the question of the power to retain a voluntary patient in a mental hospital if he walks out without giving the statutory notice of 72 hours. Dr. K. K. Drury, medical of the Leicestershire and Rutland superintendent Mental Hospital, outlined the facts of a particular A man aged 66, who had retired on pension case. The

from office work as a clerk six years before, signed a form of request incorporating the requirements of Section 1 (1) (5) of the Mental Treatment Act and was admitted as a voluntary patient. He was found to be depressed and worried, and there was a previous history of rather crude but not serious attempts at suicide. Kept at first under constant supervision, he was allowed a gradually increasing measure of parole as he improved. After two months he seemed to have become normal. Then one morning he was seen and spoken to in the ward garden, where he was permitted to walk without special supervision ; but a few minutes later he was missing. He somehow climbed a 6-foot railing, found his way to the main road, and There was no other traffic was run over by a lorry. on the road. The lorry-driver, the sole witness of the affair, said that the deceased attempted to run across the road in front of the lorry. The jury at the inquest found a verdict of " suicide while of unsound mind." The dead man’s widow brought an action against the mental hospital for negligence, breach of contract, and breach of warranty. She went, however, to America and did not return. The court eventually ordered that, if she did not proceed diligently with her claim and deposit E25 towards the costs, her action would be struck out. As she failed to proceed or to deposit the money, the case was automatically struck out of the lists. It had raised various legal points which were dealt with by Mr. C. E. J. Freer, clerk to the Hospital Committee, in collaboration with Dr. Drury. The patient, of course, had broken his bargain in not giving 72 hours’ notice before leaving. But, as it is reasonable to suppose that persons admitted as voluntary patients are abnormal, the written undertaking has a doubtful value. Mr. Freer threw out the suggestion that the undertaking of voluntary patients ought to be fortified by an indemnity from the patient’s relations against possible This patient was a penactions for negligence. sioner ; if his widow could have established negligence in the supervision of his movements, damages might be awarded on a calculation of his normal expectation of life. Alternatively Mr. Freer thought Parliament should be asked to enact a definite indemnity