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The Practices of Absentee Medical Officers.
66
THE PRACTICES OF ABSENTEE MEDICAL OFFICERS.
also. As Mr. PRIEST points out, there are discoveries which have no marketable value and for the production of which, therefore, patent rights provide no incentives, and yet these discoveries may reveal knowledge of incalculable value. Such are the discoveries, for example, which promote the public health, and it is a question whether the incentive of a substantial reward would not attract a much larger number of workers into the field of research and lead to a bigger harvest of results. That, at all events, is what has happened in Germany, and the man who will not learn from the enemy is a pedant, not a patriot.
whatsoever nature arising between the absentee and the deputy in regard to any question affecting the absentee’s practice, or the carrying on of the same by the deputy, the decision of the local committee being binding on both parties. Any medical man deciding to take a commission, or being called up for ordinary military service, could thus give notice to the local committee, stating whether he has made arrangements with a medical practitioner or practitioners to carry on his practice in his absence, and if so giving To the the necessary names and addresses. various parties to such arrangements an agreement would then be submitted as forming a basis which the practice of the absentee The Practices of Absentee Medical could upon be carried on and restored to him upon Officers. return with, it is hoped, some approach to integrity. THE fate of the practices of members of the Under t the proposed agreement the practitioner, on d medical profession who have accepted, or are departing, definitely appoints his deputy or deputies, c for the faithful and diligent discharge accepting, commissions in the Royal Army Medical contracts Corps has not received the amount of practical cof the requirements of the practice, and provides attention which the importance of the subjectpayment for the substituted service on a scale of demands. The fact that the practices of the absent rremuneration judged by the gross receipts of the and capable of readjustment every six medical men must in many cases suffer severely bypractice, I The deputy undertakes to keep strict the call which the needs of the country are making imonths. :: and accurate entries of all moneys has often been insisted upon, but nothing definiteaccounts has been done. as yet to remedy what may received, and to be responsible for the working ( incidental to the practice, which as far as become a widespread trouble and lead to fre- costs should be carried on at the chief surgery and infinite It must, however, possible ] quent hardship. of the be clearly stated that the neglect, which on practice ; he also admits liability for all acts of the face of it appears to have been grave, cannot negligence brought home to him. The scope be attributed as an actual blame to anyone. and intentions of the scheme and the draft legal It is true that no local committees have been agreement are in accordance with the above formed with the exact intention of watching over summary; the Central Medical War Committee the interests of the absentee practitioners, but has the details under consideration. It is quite clear that no scheme can exactly fit the British Medical Association has made definite and strongly-worded pronouncements on the neces- all kinds of practices. It may indeed be said that sity of those who remain safeguarding the property every medical man’s practice is to some extent an and professional and pecuniary look-out of those individual affair requiring individual treatment if who depart. It is the individual practitioners thempreservation and cultivation are to be of the selves who have with extraordinary light hearted- best. On the other hand, all medical practices have ness disregarded the situation. They have accepted certain things in common, for with regard to them commissions and in a large number of instances all there is a common need that when the principal have gone from their homes without making, and is away some one should do his work for him, and without attempting to make, any provision for prevent the practice from disappearing. Assuredly the abandoned patients. This is tantamount to one difficulty about any scheme must be that saying that, while no machinery has been erected the public cannot be ordered to accept the for protecting the interests of the temporary officers services of Dr. A because Dr. B is absent ; a certain of the Royal Army Medical Corps, there has been proportion of a medical man’s clientèle will transfer themselves willingly to a nominated successor, but no general demand for such machinery from the direction where it might have been anticipated. others will always prefer to choose a different The Central Medical War Committee has now the practitioner. Each man who deputises under the whole matter under consideration, and the inter- suggested agreement for an absent colleague may ference of this statutory body in a very difficult and find that he has also to look after a certain number of patients belonging to other doctors not parties important matter should be welcomed. A scheme has been laid before the Central Medical to the agreement, and complications may arise here War Committee under which local committees can requiring some exhibition of judgment and skill be instituted, to whom there may be submitted the, if they are to be met with any uniform pattern agreement which it is suggested should be entered of remedy. Undoubtedly other objections, more or into by an absentee medical practitioner with his less valid, will be forthcoming when the whole deputy. The local committee is to be comprisedt scheme is in the hands of those concerned, but we of the practitioners of the district (if thoughtj cannot think that any criticisms will conceal advisable the Local Medical War Committee; the value of instituting a general plan for can itself discharge the functions), and there; dealing with the situation: the urgency of some would be relegated to it by the proposed1 action is admitted, and some action should be taken. agreement powers to deal with all disputes off The scheme, which is now under the consideration of
its
.
THE SIGNIFICANCE OF THE AMINO-ACIDS.
67
the Central Medical War Committee, has been drawn of the different molecular groups in the protein We could then determine, as Dr. up with particular regard to urban practices. In molecule. out, whether in any particular Hopkins points for the old of districts, instance, country question case the withdrawal of individual amino-acids will occur and ask for mileage separate treatment; the animal of something essential, or but otherwise in country districts the arrangements deprives the removal from the food of whether, perhaps. for a deputy must naturally be far simpler than they any particular amino-acid under study may have ever can be in town communities, for in the country little effect, because the animal can synthesise it the public is limited by geography in its choice of for itself or dispense with it altogether. We may A method of payment in proportion to thus gain a further insight into the question of a doctor. a certain maximum and minimum weekly deficiency diseases. It should be pointed out, howreceipts, sum being laid down, is clearly a fair proposal, but ever, that during the use of the synthetic diets some ingenuity will be required to meet the case suggested as a basis of inquiry, Dr. Hopkins has where the deputy seeks cash payment and the found that it is always essential to supply the "at mysterious vitamine or food hormone patients are always used to being given credit. present factor." The results of the experiments are very But assuredly such matters can be dealt with by remarkable. Thus when an animal is fed on food competent local committees. containing only tryptophan, histidine, tyrosine, lysine, and cystine, that is, five out of the 18 aminoacids of protein, there is a remarkably slow loss of weight, and long maintenance of apparent health. On the other hand, when the five amino-acids mentioned are replaced by another five of "Ne quid nimis." simpler aliphatic type, when leucine, valine, alanine, and glycine, together with glutamic THE SIGNIFICANCE OF THE AMINO-ACIDS. acid form the sole nitrogen supply, loss of THE interesting group of bodies known as the weight is rapid and the animal soon succumbs. amino-acids is disclosing facts of the utmost im- A familiar case of a non-nutritional protein is portance in connexion with nutrition. It is well gelatin, and, significantly enough, this substance known that on hydrolysis proteins break down on hydrolysis yields neither tyrosine nor tryptophan. by resolution of the polypeptide linkings in the The entire absence of tryptophan from its molecule molecule into an assembly of a-amino-acids, of which stamps it at once, says Dr. Hopkins, as a deficient Dr. Hopkins goes even so far as to say some 18 have been separated. Enquiry is now being foodstuff. he feels it quite possible that further experithat in directions that of which show each developed these substances possesses its own significance- ment will show that life can be maintained on a sometimes greater, sometimes less-in the processes mixture from which many of the amino-acids are of nutrition. Inasmuch as the proteins do not all lacking. This suggests that if nutrition can be alike resolve into the same amino-acids, it is clear guaranteed on a quite limited number of aminothat their metabolic value will depend upon the acids, the solution of the problem of artificially synkind of amino-acid produced. In an interesting thesisingour food-supply is brought within the region and lucid lecture upon the subject delivered before of possibility. On all fours with this are the indethe Chemical Society on May 18th by Dr. F. pendent conclusions of Professor Underhill in the Investigations of this Gowland Hopkins, and now published in the work already referred to. character promise ultimately, he suggests, to lead June number of the society’s journal, these to the of more or less specific functions assignment " newer standpoints in the study of nutrition"the title of the lecture-are carefully discussed. to the various amino-acids, and hence will inThe starting point of this study is that when a directly indicate the relative efficiency of this or mixture of all the free amino-acids obtainable from that protein in bringing about a desired result in The whole story is a triumph of bioprotein has entirely replaced the normal intact nutrition. chemical research. protein of their food, an adult animal maintains itself and a young animal grows. In his own expeTHE TRYPANOSOMES OF SLEEPING SICKNESS. rience Dr. Hopkins records that scores of young animals grow steadily during experimental periods THE South African Institute for Medical Research when no trace of intact protein, and no other source has recently issued a pamphlet1 prepared by Mr. of flesh-forming material save amino-acids, was G. D. Maynard, statistician and clinician to the passing their mouths. In a brief and excellent out- Institute, on the Trypanosomes of Sleeping line1 of the salient features of the problem Dr. Frank Sickness, being a study of the grounds for the P. Underhill, professor of pathological chemistry, alleged identity of T. brucei with those causing Yale University, makes similar observations. His disease in man in Nyasaland. The Sleeping Sickconclusion is that the amino-acids must be regarded ness Commission of the Royal Society in their as foodstuffs capable of supplying the nitrogenous sixteenth report seem to have satisfied themselves needs of the organism, and that the chief factors that the form of the malady met with in Nyasaland to be taken into account with regard to the nutri- and Rhodesia was caused by a trypanosome believed tive value of any protein or proteins are the to be common to all " fly country," and that it was character and the extent of the amino-acids containedL spread from wild animals to man. It was theretherein. Since it is mainly, if not entirely, in the fore recommended that efforts should be made to form of free amino-acids, and not in complex asso- diminish as far as possible the number of wild ciations of these, that our nitrogenous food begins animals in fly areas, and it was urged that every its proper metabolism, it is obviously valuable to be 1 Memoirs of the South African Institute for Medical Research, able to measure the relative nutritive importance No. VI. The Trypanosomes of Sleeping Sickness, being a Study of
Annotations.
I,
____
-
,
.
.
the Grounds for the Alleged Identity of T. Brucei with those The Physiology of the Amino-acids. By Frank P. Underhill, Ph.D.,Causing Disease in Man in Nyasaland. By G. D. Maynard, F.R.C.S. Published by the Institute, Professor of Pathological Chemistry, Yale University. London: Edin., Statistician and Clinician. Oxford University Press. 1915. Pp. 169. Price 6s. net. Johannesburg, December, 1915. Pp. 39, with 26 charts. Price 5s. 1
THE PRACTICES OF ABSENTEE MEDICAL OFFICERS.
also. As Mr. PRIEST points out, there are discoveries which have no marketable value and for the production of which, therefore, patent rights provide no incentives, and yet these discoveries may reveal knowledge of incalculable value. Such are the discoveries, for example, which promote the public health, and it is a question whether the incentive of a substantial reward would not attract a much larger number of workers into the field of research and lead to a bigger harvest of results. That, at all events, is what has happened in Germany, and the man who will not learn from the enemy is a pedant, not a patriot.
whatsoever nature arising between the absentee and the deputy in regard to any question affecting the absentee’s practice, or the carrying on of the same by the deputy, the decision of the local committee being binding on both parties. Any medical man deciding to take a commission, or being called up for ordinary military service, could thus give notice to the local committee, stating whether he has made arrangements with a medical practitioner or practitioners to carry on his practice in his absence, and if so giving To the the necessary names and addresses. various parties to such arrangements an agreement would then be submitted as forming a basis which the practice of the absentee The Practices of Absentee Medical could upon be carried on and restored to him upon Officers. return with, it is hoped, some approach to integrity. THE fate of the practices of members of the Under t the proposed agreement the practitioner, on d medical profession who have accepted, or are departing, definitely appoints his deputy or deputies, c for the faithful and diligent discharge accepting, commissions in the Royal Army Medical contracts Corps has not received the amount of practical cof the requirements of the practice, and provides attention which the importance of the subjectpayment for the substituted service on a scale of demands. The fact that the practices of the absent rremuneration judged by the gross receipts of the and capable of readjustment every six medical men must in many cases suffer severely bypractice, I The deputy undertakes to keep strict the call which the needs of the country are making imonths. :: and accurate entries of all moneys has often been insisted upon, but nothing definiteaccounts has been done. as yet to remedy what may received, and to be responsible for the working ( incidental to the practice, which as far as become a widespread trouble and lead to fre- costs should be carried on at the chief surgery and infinite It must, however, possible ] quent hardship. of the be clearly stated that the neglect, which on practice ; he also admits liability for all acts of the face of it appears to have been grave, cannot negligence brought home to him. The scope be attributed as an actual blame to anyone. and intentions of the scheme and the draft legal It is true that no local committees have been agreement are in accordance with the above formed with the exact intention of watching over summary; the Central Medical War Committee the interests of the absentee practitioners, but has the details under consideration. It is quite clear that no scheme can exactly fit the British Medical Association has made definite and strongly-worded pronouncements on the neces- all kinds of practices. It may indeed be said that sity of those who remain safeguarding the property every medical man’s practice is to some extent an and professional and pecuniary look-out of those individual affair requiring individual treatment if who depart. It is the individual practitioners thempreservation and cultivation are to be of the selves who have with extraordinary light hearted- best. On the other hand, all medical practices have ness disregarded the situation. They have accepted certain things in common, for with regard to them commissions and in a large number of instances all there is a common need that when the principal have gone from their homes without making, and is away some one should do his work for him, and without attempting to make, any provision for prevent the practice from disappearing. Assuredly the abandoned patients. This is tantamount to one difficulty about any scheme must be that saying that, while no machinery has been erected the public cannot be ordered to accept the for protecting the interests of the temporary officers services of Dr. A because Dr. B is absent ; a certain of the Royal Army Medical Corps, there has been proportion of a medical man’s clientèle will transfer themselves willingly to a nominated successor, but no general demand for such machinery from the direction where it might have been anticipated. others will always prefer to choose a different The Central Medical War Committee has now the practitioner. Each man who deputises under the whole matter under consideration, and the inter- suggested agreement for an absent colleague may ference of this statutory body in a very difficult and find that he has also to look after a certain number of patients belonging to other doctors not parties important matter should be welcomed. A scheme has been laid before the Central Medical to the agreement, and complications may arise here War Committee under which local committees can requiring some exhibition of judgment and skill be instituted, to whom there may be submitted the, if they are to be met with any uniform pattern agreement which it is suggested should be entered of remedy. Undoubtedly other objections, more or into by an absentee medical practitioner with his less valid, will be forthcoming when the whole deputy. The local committee is to be comprisedt scheme is in the hands of those concerned, but we of the practitioners of the district (if thoughtj cannot think that any criticisms will conceal advisable the Local Medical War Committee; the value of instituting a general plan for can itself discharge the functions), and there; dealing with the situation: the urgency of some would be relegated to it by the proposed1 action is admitted, and some action should be taken. agreement powers to deal with all disputes off The scheme, which is now under the consideration of
its
.
THE SIGNIFICANCE OF THE AMINO-ACIDS.
67
the Central Medical War Committee, has been drawn of the different molecular groups in the protein We could then determine, as Dr. up with particular regard to urban practices. In molecule. out, whether in any particular Hopkins points for the old of districts, instance, country question case the withdrawal of individual amino-acids will occur and ask for mileage separate treatment; the animal of something essential, or but otherwise in country districts the arrangements deprives the removal from the food of whether, perhaps. for a deputy must naturally be far simpler than they any particular amino-acid under study may have ever can be in town communities, for in the country little effect, because the animal can synthesise it the public is limited by geography in its choice of for itself or dispense with it altogether. We may A method of payment in proportion to thus gain a further insight into the question of a doctor. a certain maximum and minimum weekly deficiency diseases. It should be pointed out, howreceipts, sum being laid down, is clearly a fair proposal, but ever, that during the use of the synthetic diets some ingenuity will be required to meet the case suggested as a basis of inquiry, Dr. Hopkins has where the deputy seeks cash payment and the found that it is always essential to supply the "at mysterious vitamine or food hormone patients are always used to being given credit. present factor." The results of the experiments are very But assuredly such matters can be dealt with by remarkable. Thus when an animal is fed on food competent local committees. containing only tryptophan, histidine, tyrosine, lysine, and cystine, that is, five out of the 18 aminoacids of protein, there is a remarkably slow loss of weight, and long maintenance of apparent health. On the other hand, when the five amino-acids mentioned are replaced by another five of "Ne quid nimis." simpler aliphatic type, when leucine, valine, alanine, and glycine, together with glutamic THE SIGNIFICANCE OF THE AMINO-ACIDS. acid form the sole nitrogen supply, loss of THE interesting group of bodies known as the weight is rapid and the animal soon succumbs. amino-acids is disclosing facts of the utmost im- A familiar case of a non-nutritional protein is portance in connexion with nutrition. It is well gelatin, and, significantly enough, this substance known that on hydrolysis proteins break down on hydrolysis yields neither tyrosine nor tryptophan. by resolution of the polypeptide linkings in the The entire absence of tryptophan from its molecule molecule into an assembly of a-amino-acids, of which stamps it at once, says Dr. Hopkins, as a deficient Dr. Hopkins goes even so far as to say some 18 have been separated. Enquiry is now being foodstuff. he feels it quite possible that further experithat in directions that of which show each developed these substances possesses its own significance- ment will show that life can be maintained on a sometimes greater, sometimes less-in the processes mixture from which many of the amino-acids are of nutrition. Inasmuch as the proteins do not all lacking. This suggests that if nutrition can be alike resolve into the same amino-acids, it is clear guaranteed on a quite limited number of aminothat their metabolic value will depend upon the acids, the solution of the problem of artificially synkind of amino-acid produced. In an interesting thesisingour food-supply is brought within the region and lucid lecture upon the subject delivered before of possibility. On all fours with this are the indethe Chemical Society on May 18th by Dr. F. pendent conclusions of Professor Underhill in the Investigations of this Gowland Hopkins, and now published in the work already referred to. character promise ultimately, he suggests, to lead June number of the society’s journal, these to the of more or less specific functions assignment " newer standpoints in the study of nutrition"the title of the lecture-are carefully discussed. to the various amino-acids, and hence will inThe starting point of this study is that when a directly indicate the relative efficiency of this or mixture of all the free amino-acids obtainable from that protein in bringing about a desired result in The whole story is a triumph of bioprotein has entirely replaced the normal intact nutrition. chemical research. protein of their food, an adult animal maintains itself and a young animal grows. In his own expeTHE TRYPANOSOMES OF SLEEPING SICKNESS. rience Dr. Hopkins records that scores of young animals grow steadily during experimental periods THE South African Institute for Medical Research when no trace of intact protein, and no other source has recently issued a pamphlet1 prepared by Mr. of flesh-forming material save amino-acids, was G. D. Maynard, statistician and clinician to the passing their mouths. In a brief and excellent out- Institute, on the Trypanosomes of Sleeping line1 of the salient features of the problem Dr. Frank Sickness, being a study of the grounds for the P. Underhill, professor of pathological chemistry, alleged identity of T. brucei with those causing Yale University, makes similar observations. His disease in man in Nyasaland. The Sleeping Sickconclusion is that the amino-acids must be regarded ness Commission of the Royal Society in their as foodstuffs capable of supplying the nitrogenous sixteenth report seem to have satisfied themselves needs of the organism, and that the chief factors that the form of the malady met with in Nyasaland to be taken into account with regard to the nutri- and Rhodesia was caused by a trypanosome believed tive value of any protein or proteins are the to be common to all " fly country," and that it was character and the extent of the amino-acids containedL spread from wild animals to man. It was theretherein. Since it is mainly, if not entirely, in the fore recommended that efforts should be made to form of free amino-acids, and not in complex asso- diminish as far as possible the number of wild ciations of these, that our nitrogenous food begins animals in fly areas, and it was urged that every its proper metabolism, it is obviously valuable to be 1 Memoirs of the South African Institute for Medical Research, able to measure the relative nutritive importance No. VI. The Trypanosomes of Sleeping Sickness, being a Study of
Annotations.
I,
____
-
,
.
.
the Grounds for the Alleged Identity of T. Brucei with those The Physiology of the Amino-acids. By Frank P. Underhill, Ph.D.,Causing Disease in Man in Nyasaland. By G. D. Maynard, F.R.C.S. Published by the Institute, Professor of Pathological Chemistry, Yale University. London: Edin., Statistician and Clinician. Oxford University Press. 1915. Pp. 169. Price 6s. net. Johannesburg, December, 1915. Pp. 39, with 26 charts. Price 5s. 1