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A SIDELIGHT ON CONTRACT PRACTICE
The advantages of this method are : 1. The incision does a minimum amount of damage to the abdominal wall. If it is carefully sutured in layers there is little risk of a ventral 2. It allows a transperitoneal exposure of the hernia. whole length of both ureters, and an extraperitoneal exposure of the pelvic portions of both ureters. In one case I removed eight stones from the right ureter and explored the pelvic portion of the left at one sitting. By any other method this would have necessitated two incisions. 3. Should the stone at the time of the operation be found to be in the intramural portion of the ureter the bladder can be immediately opened and the stone cut down on and removed from within. This point was illustrated by one of my cases. The patient had a small stone in his right ureter which he failed to pass after about six weeks’ almost continuous colic. I exposed the ureter by means of this incision, but failed to locate the stone. After a few minutes’ search I noticed a small, hard nodule in the bladder wall. I then opened the bladder, fpund that the stone was impacted in the intramural portion of the ureter, cut down on it and removed it. The advantage of removing such stones from within the bladder is obvious. Any other method of exploring the ureter would have necessitated a fresh incision for the cystotomy in this case. I am. Sir. vours faithfullv. J. SWIFT JOLY.
also as a citizen of a country which prides itself on thefactthat everyone who is accused is entitled to know at onceexactly what charges are made against him with a view tobeing enabled to reply to them should he wish to do so. I also wrote to Mr. McKenna making the same requestHe also, while admitting that he had lodged charges. against me, declined to inform me of the nature and detail of his accusations. It appears to me to be extraordinary for a Minister of the Crown to make a complaint concerning a professional man’s reputation without giving him notice, and further for thePresident of our College to refrain in his turn from informing the professional man thus complained against that such charges had been made and to refuse to disclose the nature of them when asked to do so. I mention this incident as evidencing the pressing need for reform in the present constitution of the Royal College: of Surgeons. I am, Sir, yours faithfully, VICTOR HORSLEY. The this letter alludes werecircumstances to which * made the subject of questions and replies in the House of on Tuesday last (see p. 1709).-ED. L.
Commons
TUBERCULIN TESTS.
INSANITY AND DIVORCE. To the Editor of THE LANCET.
SIR,-Dr. Batty Tuke’s question is simple enough, and I will endeavour to
it as simply. It is impossible to for the granting of divorce from a purely eugenic point of view. One is forced to take other things into consideration. Terrible as is the sorrow and suffering entailed upon humanity by the spread of tuberculosis, often owing, it is true, to the injudicious marrying of tuberculous persons, yet it would prove well-nigh impossible either to prevent such marriages or to grant divorce for any bodily sickness only, whereas in insanity the I think, case is utterly different, and few persons will, be found who will not concede its greater terrors and A healthy mind, although clogged by a sick horror. and suffering body, may yet prove a very efficient and beloved companion through life. A body in which the soul and mind are sick, smitten of the dread disease of insanity, can prove nothing but a curse to the unhappy man or woman who finds himself or herself tied to it for life with no hope in all the lonely years to come of ever forming fresh ties and
regard
a.
the
answer
reasons
hanniar home -T
am
Rir
vrmrs
faithfully
A. HAMILTON, Organising Secretary, Divorce Law Reform Union.
SIR VICTOR HORSLEY AND MR. McKENNA. To the Editor of THE LANCET.
SIR,-A constitutional position of interest, especially to the members of our profession, has just been created by the Mr. McKenna, the Home Secretary, and Sir Rickman J. Godlee, the President of the Royal College of action of
Surgeons
I
To tke Editor of THE LANCET. SIR,-May I point out that the percentage rates which you quote from the Royal Commission Report on Tuberculosis in your leading article, " Tuberculin Tests," of May 31st, are subject to a very wide error, as the number of is animals under consideration much too small to. justify percentage deductions. For example, 31 percent. of animals infected with bovine bacilli and suffering from severe and progressive tuberculosis failed to react. The actual number -of animals tested was 16;. 11 reacted, 5 did not. The possibilities of failure lie between 1 per cent. and 64 per cent. Again, 9.8per cent. suffering from general tuberculosis, not severe and not progressive, failed to react. The number of animals tested was 61; 55reacted, 6 did not. The possibilities of failure lie between 1 per cent. and 19 per cent. Lastly, ° in cases of minimal or local tuberculosis the percentage of failures was 8’5.’ Here 47 animals were inoculated ; 43 were positive, 4 negative. The possibilities of failure lie between 2 per cent. and 21 per cent. The fact should be mentioned that there were 6 animals in the class " cases of general tuberculosis, not of the greatest severity but progressive, in which the reaction was always positive." As there is danger that these statistics. appearing in a Royal Commission Report, and supported by THE LANCET, may be used outside to the detriment of the’ tuberculin reaction, would it not be well to point out. the smallness of the numbers upon which they are based? I am, Sir, yours faithfully, R. STENHOUSE WILLIAMS.
A SIDELIGHT ON CONTRACT PRACTICE To the Editor of THE LANCET. short while ago the subject of payment according SIR,-A to work done as distinguished from payment per capita, which is theoretically a payment according to the estimated work to be done, the amount being collected by an equal
of England. On March 18th, 1913, Mr. McKenna made a personal attack upon me by name in the House of Commons. On assessment from all members of a group instead of from the May lst I wrote to him asking him to publicly withdraw his individuals for whom the work has been done in proportion statements, they being from evidence in my possession to their respective liabilities, was greatly to the fore. Of inaccurate in several respects, and at the same time giving course, it does not matter one iota to the medical man if he him the proofs of these inaccuracies. Further correspondence is paid a fair fee for the 100 visits he pays whether the ensued but without any material result. sum comes out of the pockets of those to whom he While this correspondence was still proceeding it came to has paid the visits or by an average weekly payfrom a whole group who have pooled their my knowledge that Mr. McKenna had lodged a complaint against me at the Royal College of Surgeons without liabilities. But it does matter if he is called upon informing me that he was doing so or had done so. On to face an unknown quantity of work for a strictly discovering this I at once wrote to the President (Sir R. J. limited payment, which may quite likely recoup him Godlee) and requested that a copy of the document or on a totally inadequate scale of payment for the actual It was the knowledge that when the documents containing the Home Secretary’s charges be work done. furnished to me so that I might deal with them. receipts obtained under contract practice in the past were Sir R. J. Godlee, who did not reply until he received a averaged against the items of service rendered they were letter from, my solicitor, declined to accede to my request. always found to be absurdly inadequate that roused the This request I made, not only as a Fellow of the College, but antagonism of the profession at large to the per capita,
ment
method of payment. An interesting sidelight on this ques- tion is thrown by what has recently happened in the Barnstaple Poor-law District. In THE LANCET of Jan. 4th it was reported that the medical officer for the Ilfracombe rural district had resigned the appointment on account of the inadequacy of his salary and that no application had been received for the post. The ex-medical officer offered to continue to attend the patients until another medical man could be appointed at the remuneration of 2s. 6d. per visit and medicine, and Is. 6d. for consultation and medicine at his surgery. This seems a very by many reasonable offer, and indeed was so considered of the guardians at the time. Now comes the sequel. At the last meeting of the board this medical officer rendered his account for the quarter, which amounted to .6130 19s. 6d. for 761 visits and 478 surgery consultations (including medicine, of course, in both cases). Some of the guardians took exception to the account, but it was eventually settled. The interesting point, however, is that one of the guardians remarked that it would be hardly pleasant for the newly appointed officer to find that his salary was only one-eighth of the amount paid on the scale fixed for work done. But if that scale was only reasonable payment for the work involved, as many would maintain it was (myself among them), and as was generally agreed by the board when it was settled, the obvious corollary is that the salary is very greatly below what it should be, for it entails doing eight times the work for which reasonable payment is made. And that has been the trend of contract practice in the past, and in most cases the aim of those who have been responsible for it. Will there be any difference in the
who, led by nothing but greed, gulls the public ; but is there no
’
a
communication from
one
of your Western of
County correspondents that the Barnstaple board guardians are still unable to fill their appointment. I am, Sir, yours faithfully,
INTERESTED.
June 9th, 1913. __________________
THE NATIONAL INSURANCE ACT: FIRST DAY CERTIFICATES. To the Editor
of THE LANCET.
open meeting on June 6th of practitioners on the panel resident in the boroughs of Hackney and Stoke Newington the following resolution was framed :-
SIR,-At
an
That, in the opinion of practitioners on the panel in the boroughs of Hackney and Stoke Newington, we refuse to grant insurance certificates on the first day of illness. The chairman was asked to send a copy of the resolution to every practitioner on the panel in the said boroughs, which has duly been done. I am, Sir, yours faithfully, C. WYNDHAM GITTENS, Honorary Secretary, Hackney Medical Society.
LIBERTY AND THE NATIONAL INSURANCE ACT. To the Editor of THE LANCET. SIR,-If carry our memories back to one of those nights of our student days when two or three friends sat over the fire, pipe in mouth, and talked out the greater and lesser problems of the cosmos, love and liberty, medicine and marriage, shall we not remember that general practice came in also for consideration ? And we may recall that there seldom lacked some instance of error in diagnosis amongst the newly admitted patients to give a text to hold forth upon the imagined methods of the ’’—— G.P." Then, was there not always one among us who with pity mixed with scorn would ask what is to be expected from those who work for such miserable fees, or rather from the medical profession, unless we rally to the ideals of medicine that nothing but the best in thought and pains is good enough to give ? And did we not conceive of liberty as that state in which all conduces most perfectly to the complete fulfilment of ideals, that state in which the physician is most free to exercise his art to the best of his ability ? For is not medicine an art, and are we not artists ? What say our brothers of the brush ? They have but scorn for him
in the studio for the
hunger-stricken
canvas-the
We write, we talk about the battle of the clubs" ; but many medical men have heard the scratching of the wolf at the door. The National Insurance Act has come, and it remains for us to work within it ; but our art may yet be free to give her best to those who need it most. The old club rates have been improved; and if the mass of writing work is really to be taken from our hands, there is, I would submit, no doubt that our patients should get improved service. Already we no longer treat a score of those diseases that our fathers took in hand. These are fevers, some of which no longer need be reckoned with, having been gathered in to isolation hospitals ; and provision is being made for the tuberculous in all their stages; the epileptic, too, will doubtless soon be cared for ; and every year the net is wider spread to catch the mentally deficient and diseased. The general practitioner has a definite place in the treatment of these conditions, but it cannot be denied that as far as club patients are concerned our responsibilities have been lightened. Hygiene and better housing will reduce the sickness among those who are called the insured ; and when the nation’s teeth receive attention a host of ailments, great and small, will flee. Surely the way to sweep away the type of practice that we must admit is not conducive to that state of liberty we have demanded for our art’s welfare is to support amendments to"the Act" which shall sweep in within its scope all those who hitherto have formed the class of club patient (and their dependents too) and those who patronised the sixpenny and shilling consultation with a bottle of medicine. For wives and children of the insured class to-day are getting treatment (of a kind) at even lower rates than that of male club patients in bygone days with their 4s. 4d. yearly. There are those among us who eagerly take on to their books the uninsured club members (old, infirm, or not "employed") at the old rates and so keep up the former state of things, knowing full well they cannot afford to give their best in treatment at the remuneration. In a small town not far from where I write eight doctors practise, and not one of them but will accept a wife and any number of her children for treatment at 10s. paid per annum. We must educate the insured themselves that competent doctoring " is not simply the pouring of potions down their greedy gullets, and this sort of things will cease. The provision of a state pathologist working in close conjunction with the public health authority of the area is required. If we keep our faces set against the forms of practice that we all deplore (because they neither grant our art the proper place that sheshould hold, nor bring the artist aught but degradation, nor give the sick man aught but ill-placed hopes) I submit that the National Insurance Act may yet be made to serve its high purposes and our calling yet more closely conform to the principles of truth and liberty. I am, Sir, yours faithfully, J. R. R. T. June 7th, 1913.
future ? I note from
pity
"pot-boiler"?‘! Greed they consider the ruin of their art, but the pot-boiler only suggests the question whether the poor public will ever learn to love good work enough to line poor painters’ bellies.
we
THE MEDICAL GOLFING SOCIETY.-The annual was held on June 5th on the Oxhey golf Play was 18 holes against bogey under handicap, the handicap limit being 18. In Class I. (handicaps 10 and under) G. A. Sutherland (2) was first with 4 down, L. A. Lawrence (8) being second with 5 down, and F. A. Rose (10) gained a prize for the best last 9 holes with 1 down. In Class II. (handicaps over 10) P. P. Cole (18) made the best net score of the day, being all square, thus winning the Henry Morrischallenge cup, the Medical Golfing Society’s gold medal, and the first prize. A. Eddowes (11) was awarded the second prize after tying with J. F. O’Malley (12). No player being permitted to take two prizes, J. F. O’Malley was awarded
tournament course.
I
that for the best last 9 holes, being all square with bogey. The foursomes sweepstakes was won by J. Cunning and F. A. Rose (3 down), J. C. Clayton and J. F. O’Malley being second, with 4 down. The Medical Golfing Society owe a debt of gratitude to the Oxhey Golf Club for their
hospitality.
also as a citizen of a country which prides itself on thefactthat everyone who is accused is entitled to know at onceexactly what charges are made against him with a view tobeing enabled to reply to them should he wish to do so. I also wrote to Mr. McKenna making the same requestHe also, while admitting that he had lodged charges. against me, declined to inform me of the nature and detail of his accusations. It appears to me to be extraordinary for a Minister of the Crown to make a complaint concerning a professional man’s reputation without giving him notice, and further for thePresident of our College to refrain in his turn from informing the professional man thus complained against that such charges had been made and to refuse to disclose the nature of them when asked to do so. I mention this incident as evidencing the pressing need for reform in the present constitution of the Royal College: of Surgeons. I am, Sir, yours faithfully, VICTOR HORSLEY. The this letter alludes werecircumstances to which * made the subject of questions and replies in the House of on Tuesday last (see p. 1709).-ED. L.
Commons
TUBERCULIN TESTS.
INSANITY AND DIVORCE. To the Editor of THE LANCET.
SIR,-Dr. Batty Tuke’s question is simple enough, and I will endeavour to
it as simply. It is impossible to for the granting of divorce from a purely eugenic point of view. One is forced to take other things into consideration. Terrible as is the sorrow and suffering entailed upon humanity by the spread of tuberculosis, often owing, it is true, to the injudicious marrying of tuberculous persons, yet it would prove well-nigh impossible either to prevent such marriages or to grant divorce for any bodily sickness only, whereas in insanity the I think, case is utterly different, and few persons will, be found who will not concede its greater terrors and A healthy mind, although clogged by a sick horror. and suffering body, may yet prove a very efficient and beloved companion through life. A body in which the soul and mind are sick, smitten of the dread disease of insanity, can prove nothing but a curse to the unhappy man or woman who finds himself or herself tied to it for life with no hope in all the lonely years to come of ever forming fresh ties and
regard
a.
the
answer
reasons
hanniar home -T
am
Rir
vrmrs
faithfully
A. HAMILTON, Organising Secretary, Divorce Law Reform Union.
SIR VICTOR HORSLEY AND MR. McKENNA. To the Editor of THE LANCET.
SIR,-A constitutional position of interest, especially to the members of our profession, has just been created by the Mr. McKenna, the Home Secretary, and Sir Rickman J. Godlee, the President of the Royal College of action of
Surgeons
I
To tke Editor of THE LANCET. SIR,-May I point out that the percentage rates which you quote from the Royal Commission Report on Tuberculosis in your leading article, " Tuberculin Tests," of May 31st, are subject to a very wide error, as the number of is animals under consideration much too small to. justify percentage deductions. For example, 31 percent. of animals infected with bovine bacilli and suffering from severe and progressive tuberculosis failed to react. The actual number -of animals tested was 16;. 11 reacted, 5 did not. The possibilities of failure lie between 1 per cent. and 64 per cent. Again, 9.8per cent. suffering from general tuberculosis, not severe and not progressive, failed to react. The number of animals tested was 61; 55reacted, 6 did not. The possibilities of failure lie between 1 per cent. and 19 per cent. Lastly, ° in cases of minimal or local tuberculosis the percentage of failures was 8’5.’ Here 47 animals were inoculated ; 43 were positive, 4 negative. The possibilities of failure lie between 2 per cent. and 21 per cent. The fact should be mentioned that there were 6 animals in the class " cases of general tuberculosis, not of the greatest severity but progressive, in which the reaction was always positive." As there is danger that these statistics. appearing in a Royal Commission Report, and supported by THE LANCET, may be used outside to the detriment of the’ tuberculin reaction, would it not be well to point out. the smallness of the numbers upon which they are based? I am, Sir, yours faithfully, R. STENHOUSE WILLIAMS.
A SIDELIGHT ON CONTRACT PRACTICE To the Editor of THE LANCET. short while ago the subject of payment according SIR,-A to work done as distinguished from payment per capita, which is theoretically a payment according to the estimated work to be done, the amount being collected by an equal
of England. On March 18th, 1913, Mr. McKenna made a personal attack upon me by name in the House of Commons. On assessment from all members of a group instead of from the May lst I wrote to him asking him to publicly withdraw his individuals for whom the work has been done in proportion statements, they being from evidence in my possession to their respective liabilities, was greatly to the fore. Of inaccurate in several respects, and at the same time giving course, it does not matter one iota to the medical man if he him the proofs of these inaccuracies. Further correspondence is paid a fair fee for the 100 visits he pays whether the ensued but without any material result. sum comes out of the pockets of those to whom he While this correspondence was still proceeding it came to has paid the visits or by an average weekly payfrom a whole group who have pooled their my knowledge that Mr. McKenna had lodged a complaint against me at the Royal College of Surgeons without liabilities. But it does matter if he is called upon informing me that he was doing so or had done so. On to face an unknown quantity of work for a strictly discovering this I at once wrote to the President (Sir R. J. limited payment, which may quite likely recoup him Godlee) and requested that a copy of the document or on a totally inadequate scale of payment for the actual It was the knowledge that when the documents containing the Home Secretary’s charges be work done. furnished to me so that I might deal with them. receipts obtained under contract practice in the past were Sir R. J. Godlee, who did not reply until he received a averaged against the items of service rendered they were letter from, my solicitor, declined to accede to my request. always found to be absurdly inadequate that roused the This request I made, not only as a Fellow of the College, but antagonism of the profession at large to the per capita,
ment
method of payment. An interesting sidelight on this ques- tion is thrown by what has recently happened in the Barnstaple Poor-law District. In THE LANCET of Jan. 4th it was reported that the medical officer for the Ilfracombe rural district had resigned the appointment on account of the inadequacy of his salary and that no application had been received for the post. The ex-medical officer offered to continue to attend the patients until another medical man could be appointed at the remuneration of 2s. 6d. per visit and medicine, and Is. 6d. for consultation and medicine at his surgery. This seems a very by many reasonable offer, and indeed was so considered of the guardians at the time. Now comes the sequel. At the last meeting of the board this medical officer rendered his account for the quarter, which amounted to .6130 19s. 6d. for 761 visits and 478 surgery consultations (including medicine, of course, in both cases). Some of the guardians took exception to the account, but it was eventually settled. The interesting point, however, is that one of the guardians remarked that it would be hardly pleasant for the newly appointed officer to find that his salary was only one-eighth of the amount paid on the scale fixed for work done. But if that scale was only reasonable payment for the work involved, as many would maintain it was (myself among them), and as was generally agreed by the board when it was settled, the obvious corollary is that the salary is very greatly below what it should be, for it entails doing eight times the work for which reasonable payment is made. And that has been the trend of contract practice in the past, and in most cases the aim of those who have been responsible for it. Will there be any difference in the
who, led by nothing but greed, gulls the public ; but is there no
’
a
communication from
one
of your Western of
County correspondents that the Barnstaple board guardians are still unable to fill their appointment. I am, Sir, yours faithfully,
INTERESTED.
June 9th, 1913. __________________
THE NATIONAL INSURANCE ACT: FIRST DAY CERTIFICATES. To the Editor
of THE LANCET.
open meeting on June 6th of practitioners on the panel resident in the boroughs of Hackney and Stoke Newington the following resolution was framed :-
SIR,-At
an
That, in the opinion of practitioners on the panel in the boroughs of Hackney and Stoke Newington, we refuse to grant insurance certificates on the first day of illness. The chairman was asked to send a copy of the resolution to every practitioner on the panel in the said boroughs, which has duly been done. I am, Sir, yours faithfully, C. WYNDHAM GITTENS, Honorary Secretary, Hackney Medical Society.
LIBERTY AND THE NATIONAL INSURANCE ACT. To the Editor of THE LANCET. SIR,-If carry our memories back to one of those nights of our student days when two or three friends sat over the fire, pipe in mouth, and talked out the greater and lesser problems of the cosmos, love and liberty, medicine and marriage, shall we not remember that general practice came in also for consideration ? And we may recall that there seldom lacked some instance of error in diagnosis amongst the newly admitted patients to give a text to hold forth upon the imagined methods of the ’’—— G.P." Then, was there not always one among us who with pity mixed with scorn would ask what is to be expected from those who work for such miserable fees, or rather from the medical profession, unless we rally to the ideals of medicine that nothing but the best in thought and pains is good enough to give ? And did we not conceive of liberty as that state in which all conduces most perfectly to the complete fulfilment of ideals, that state in which the physician is most free to exercise his art to the best of his ability ? For is not medicine an art, and are we not artists ? What say our brothers of the brush ? They have but scorn for him
in the studio for the
hunger-stricken
canvas-the
We write, we talk about the battle of the clubs" ; but many medical men have heard the scratching of the wolf at the door. The National Insurance Act has come, and it remains for us to work within it ; but our art may yet be free to give her best to those who need it most. The old club rates have been improved; and if the mass of writing work is really to be taken from our hands, there is, I would submit, no doubt that our patients should get improved service. Already we no longer treat a score of those diseases that our fathers took in hand. These are fevers, some of which no longer need be reckoned with, having been gathered in to isolation hospitals ; and provision is being made for the tuberculous in all their stages; the epileptic, too, will doubtless soon be cared for ; and every year the net is wider spread to catch the mentally deficient and diseased. The general practitioner has a definite place in the treatment of these conditions, but it cannot be denied that as far as club patients are concerned our responsibilities have been lightened. Hygiene and better housing will reduce the sickness among those who are called the insured ; and when the nation’s teeth receive attention a host of ailments, great and small, will flee. Surely the way to sweep away the type of practice that we must admit is not conducive to that state of liberty we have demanded for our art’s welfare is to support amendments to"the Act" which shall sweep in within its scope all those who hitherto have formed the class of club patient (and their dependents too) and those who patronised the sixpenny and shilling consultation with a bottle of medicine. For wives and children of the insured class to-day are getting treatment (of a kind) at even lower rates than that of male club patients in bygone days with their 4s. 4d. yearly. There are those among us who eagerly take on to their books the uninsured club members (old, infirm, or not "employed") at the old rates and so keep up the former state of things, knowing full well they cannot afford to give their best in treatment at the remuneration. In a small town not far from where I write eight doctors practise, and not one of them but will accept a wife and any number of her children for treatment at 10s. paid per annum. We must educate the insured themselves that competent doctoring " is not simply the pouring of potions down their greedy gullets, and this sort of things will cease. The provision of a state pathologist working in close conjunction with the public health authority of the area is required. If we keep our faces set against the forms of practice that we all deplore (because they neither grant our art the proper place that sheshould hold, nor bring the artist aught but degradation, nor give the sick man aught but ill-placed hopes) I submit that the National Insurance Act may yet be made to serve its high purposes and our calling yet more closely conform to the principles of truth and liberty. I am, Sir, yours faithfully, J. R. R. T. June 7th, 1913.
future ? I note from
pity
"pot-boiler"?‘! Greed they consider the ruin of their art, but the pot-boiler only suggests the question whether the poor public will ever learn to love good work enough to line poor painters’ bellies.
we
THE MEDICAL GOLFING SOCIETY.-The annual was held on June 5th on the Oxhey golf Play was 18 holes against bogey under handicap, the handicap limit being 18. In Class I. (handicaps 10 and under) G. A. Sutherland (2) was first with 4 down, L. A. Lawrence (8) being second with 5 down, and F. A. Rose (10) gained a prize for the best last 9 holes with 1 down. In Class II. (handicaps over 10) P. P. Cole (18) made the best net score of the day, being all square, thus winning the Henry Morrischallenge cup, the Medical Golfing Society’s gold medal, and the first prize. A. Eddowes (11) was awarded the second prize after tying with J. F. O’Malley (12). No player being permitted to take two prizes, J. F. O’Malley was awarded
tournament course.
I
that for the best last 9 holes, being all square with bogey. The foursomes sweepstakes was won by J. Cunning and F. A. Rose (3 down), J. C. Clayton and J. F. O’Malley being second, with 4 down. The Medical Golfing Society owe a debt of gratitude to the Oxhey Golf Club for their
hospitality.