- Email: [email protected]
FRENCH MEDICAL OPINION ON THE BRITISH INSURANCE BILL.
404 The centre of the the size of a small marble was found. growth showed the usual stroma, but at the growing edge the cells were losing their round shape and were becoming elongated. Further away they had their usual round formation, exactly like the cells of chronic inflammation. Is it not reasonable to assume that this elongation is taking place at the seat of least resistance, and that these elongated cells will ultimately form the stroma of the cancer as it extends? At the time of the formation of the abscess the inflammatory cells were present, and doubtless were not all removed in the subsequent treatment. These, though not malignant then, developed malignancy later. I am convinced that if all the cell-ridden area had been excised there would have been no cancer. It seems that in any tissue the continued presence of these leucocytes which the tissue is unable to rid itself of makes for malignancy. When does the pre-malignant stage of cancer cease2 I should say when these chronic inflammation cells are losing their round shape and becoming elongated. Resistance on the part of the tissues has become feeble or entirely ceased, and malignancy, The posior at any rate the commencement, has developed. tion may be stated thus : after remaining in the tissues for an indefinite period these cells, if not removed, elongate and become malignant. Repeated attacks of inflammation are not sufficient to produce this-they must be attended by retention of the cells in the tissue and gradual loss of resistFor instance, even after repeated attacks of ance thereof. gastritis in the drunkard cancer is rare, because probably these cells are absorbed without any delay. Showing the intimate relationship between cancer and chronic inflammation, if any source of irritation be removed before malignancy has set in the parts involved will most probably recover. I am, Sir, yours faithfully,
113 cases of their own. In 26 it was not possible to make a pneumothorax owing chiefly to extensive adhesions, but of the other 87 patients, all having severe disease and going downhill before the operation, 65 per cent. were very favour-
ably influenced by the operations, and in each case the prognosis is now either good or very good. The technique needs great care on the part of the operator and his assistant, but there seems little doubt that the induction of an artificial pneumothorax is of the greatest use in the treatment of some apparently hopeless cases of advanced pulmonary tuberculosis. I am, Sir, yours faithfully, HERBERT RHODES. Brechin-place, S.W.’, July 24th, 1911.
,
ST. JOHN’S HOSPITAL FOR DISEASES OF THE SKIN. To the Editor of THE LANCET. SIR,-Owing to certain difficulties arising out of the management of this hospital, and the manner in which the grievances in respect of such were dealt with by the board of management, we, the undersigned members of the medical staff, felt compelled, acting under legal advice, to take a
certain course. As a result of this action we were called upon to resign our appointments by the board within seven days, and, declining to do so, we have received imperative notice of dismissal, and have ceased to have any connexion with the said hospital. We shall take steps to lay the facts of the disabilities under which we suffered before the profession, and also before certain medical and lay hospital authorities, and in the meantime trust that, should the vacancies upon the medical staff be sought to be filled by the board, would-be candidates, before applying for our late H. LYLE, Senior Surgeon to the Liverpool Hospital for Cancer appointments, will make themselves cognisant of the conand Skin Diseases. Liverpool, July 26th, 1911. ditions which prevail, and have prevailed, at this hospital both now and in previous years. We are, Sir, yours faithfullv, ALFRED EDDOWES. ARTIFICIAL PNEUMOTHORAX IN TREATAGNES SAVILL. MENT OF TUBERCULOSIS. G. W. DAWSON. To the Editor of THE LANCET. L. F. KNUTHSEN. July 17th, 1911. SIR,-I was very much interested in the important communications by Dr. 0. Lillingston, Dr. L. Colebrook, and Dr. S. V. Pearson and Dr. A. de W. Snowden printed in FRENCH MEDICAL OPINION ON THE THE LANCET of Jaly 15th. The paper by Dr. Lillingston BRITISH INSURANCE BILL. was most complete, and he seems to have mentioned almost all the possible misfortunes as well as the methods (FROM OUR SPECIAL COMMISSIONER.) of safeguarding the patient, while the treatment is being carried out according to Saugman’s technique. Bat I should Paris, July 26th, 1911. like to discuss one point which surprised me not a little. THE members of the medical profession in France, and He describes rather contemptuously the method of Brauer and Spengler as either obsolete or at any rate almost useless. especially those who are members of militant medical unions, About five years ago I spent nearly two years at Davos- are watching with great interest and not a little anxiety the Platz and Davos-Clavadel and heard much of this wonderful fate of Mr. Lloyd George’s Insurance Bill. To them the operation of Brauer’s and saw some of his cases, and they paramount question is the free choice of the doctor. There seemed surprisingly successful. must, they say, be no State medical functionaries, and no Hearing, as Dr. Lillingston remarks, that the English cases monopolies created for disposal by the politician who has in Davos could not return home last summer because there was influence over voters. It is as a medical practitioner and not as a successful canvasser at election times that patients should no one in England capable of carrying on the treatment, I, at the request of sundry patients and doctors, went out last be able to select their medical attendant. The new Health winter to Clavadel and there learnt all I could of these new Committees that are to decide how to carry out the legisladevelopments of the artificial pneumothorax treatment. I tive provisions are not likely in French opinion to be neutral have both assisted at and performed the initial operation in politics. Theoretically, all elected administrative bodies and the after-fillings a good many times now, and from my in England, except the two Houses of Parliament, are supposed comparatively small personal experience and the very con- to have no politics. A municipality is constituted merely for siderable number of cases whose notes I have studied I have local purposes, though it is often elected now on the lines of the political parties; and this is also the case with less come to the conclusion that the initial open operation as performed by Brauer is not very dangerous, and that the important bodies, such as, in England, the boards of dangers of pleural reflex, air embolism, sepsis, and so on guardians. What, then, is going to be the politics of the proare greater at the time of the earlier after-fillings, especially posed Health Committees seems to our French neighbours a when Saugman’s needle is used, as it invariably is used by vital point. Are they likely to be free from all political Spengler, Frey, Neumann, Noble, and the other practitioners bias ? Are there, indeed, administrative bodies anywhere at Davos. that can be considered as free from political bias ? Medical If this conclusion of mine is true, it seems to me that men are not themselves absolutely free from political predia combination of Brauer’s initial operation, with the use lections, and their full representation on the committees of a fine trocar and cannula fitted to Saugman’s needle- would not alter this danger. When, in answer to these mount for the after-fillings, should make the procedure in the curious criticisms, I confessed that it seemed to me possible majority of cases free from the risks mentioned in Dr. that the medical profession in England, if polled, would Lillingston’s paper. I had such a needle made for me by the show a Conservative majority-a view which I knew many Holborn Instrument Supply Company. Dr. Brauer and Dr. medical men would not agree with-the retort was immeSpengler in their latest work on this subject describe some diately made that this might account for some of the -
405 I protested to my questioners tbalupon a sick man, instead of waiting until, as a consequence to the Bill. every effort had been made, on the contrary, to exclude of the honourable exercise of his profession, the sick man is politics from the discussion of the Bill, and that thes inspired with confidence in him and voluntarily sends for Conservative party, by the voice of its leaders and inhim. On one side we have the medical practitioner who has. its journals, had expressed its approval of the generalacquired a practice by his own skill, science, and hard work ; principles of the Bill. The idea of political bias was firmlyron the other is a practitioner who owes his practice to the rooted in their minds, and they continued to point out that fact that he was appointed by a lay committee, and was a medical adviser must not be imposed on a patient willing to violate the fundamental principles of the profesbecause he had found favour in the eyes of some authority, sion of medicine. Where rests the vested interest ? Does it or other. If such authority is not guided in its choice by, rest with the independent practitioner or with the practipolitical motives, it is likely to be influenced by family or tioner who has sold himself ? personal interests ; in fact, by any number of considerations Proposed International Action in Regard to the Bill. save the one and only reason that should govern the choice of Mr. Lloyd George, on more than one occasion, has the medical attendant. his approval of the principle of free choice’ of expressed The French TTiEw of Vested Interests in ClubPractice.1 medical attendant by the patient. But if the wage limit is The only means of excluding influences that should not be, to be maintained at £160 a year and the payment is not to seems quite obvious brought to bear was, from the French viewpoint, to allow be much higher than 6s. a year, then it and suffer severely, will that suffer, many the medical practitioner to appoint himself. I expractitioners This, in their pockets. In fact, their vested interests will be plained, was exactly what would happen in the majority of affected. cases. Any fully qualfied practitioner who was willing to The French practitioners with whom I discussed this do the work could inscribe his name on the panel, but there remained a minority of cases where the patient would matter viewed the prospect of British legislation setting not be free to send for the practitioner he might prefer. such an example with little short of terror. Such a bad There were the medical men at present employed at regular precedent, they said, would be extremely injurious to salaries by the Friendly Societies, and these salaries were their British colleagues, and would check the campaign now successfully in progress in France against similar abuses. likely to be treated as vested interests which must not be Would it not be possible, I was eagerly asked, for some disturbed. The same difficulty has arisen in France, British and French medical men to meet and though the term " vested interests " does not exist there. It representative The entente cordiale, surely, is replaced by the very appropriate expression acquired draw up a joint manifesto ? Aituations "(sit iiatiog?s acquises). Dr.M.Vimontrecentlv pub- was not a mere empty sound-a pretty sentiment with nothing lished an eloquent nrotest against the excess of consideration practical about it. Here, in France, the economical diffishown situations"under the contract system. In culties besetting the medical profession were almost Would it the Concours M6dicol he explains that he has himself served as identical with those obtaining in England. the medical officer of various Friendly Societies and quite not lend greater weight to the demands brought forward understands the anxieties of these poorly paid practitioners. if they were simultaneous and similar in both countries. Nevertheless, he questions whether their position as the An Opportunity for Reform. salaried medical officers of mutualist organisations or The great benefit of the proposed law is the panel, but Friendly Societies can be considered as a vested interest. only, my French friends say, if it is universally applied. He draws a picture of the young practitioner remaining at It is bad enough that medical monopolies should have home, depriving himself of holidays for fear of losing a been created by Friendly Societies and medical aid clubs patient, devoting himself with the utmost assiduity to the of all sorts, acting as private organisations established by few patients who send for him, till at last, after much privaprivate enterprise. Against such a procedure medical tion and many efforts he wins a good name and establishes a men have formed militant unions and have collected strike practice. This, indeed, is an"acquired situation," and is due funds, and there have been many medical strikes throughentirely to personal effort and merit. But by-and-bye, though out Europe. The Governments may plead that where he has in no wise modified his manner of treatment and has freedom of association exists they are not responsible for been and is just as successful, his patients leave him one by one. what these associations may do. But Governments are They leave him because they join the Friendly Society of the responsible for the laws they present to Parliament. industry in which they are engaged. At first, however, he If, under private enterprise, a mischievous and bad system continues to attend to wives and children, but in course of has grown up, a system that has been condemned by at least time even that fails him, for the Friendly Society extends its nine out of every ten medical practitioners in England, field of action and takes in the women and children as well. France, Germany, Belgium, and in fact throughout Europe, Here, then, is a vested interest destroyed by a Friendly it surely is not the role of any Government, seeking to Society, which imports a medical officer and makes him legislate for the public good, to give legal sanction to abuses. attend patients on charity terms with the aid of an elaborate The Friendly Societies and medical aid clubs must no longer system of advertising and touting. Then, as a climax, when be allowed to impose upon their members such medical men a reform is proposed, it is urged with due solemnity that as their managing committees may choose to appoint, or to respect must be shown for the vested interest of the Friendly oppress their medical officers. The Health Committees to Society’s medical officer ; the vested interest of the very be created under the proposed law will be able to see that man who has destroyed by unfair competitive methods the the is open to all who are properly qualified. The best, the most worthy, form of vested interest that can club panel doctors of good professional repute should not lose anypossibly exist. thing by the abolition of their function as club doctors. They The "Medical Monopoliser." have only to put their name on the panel and their patients The medical monopoliser,"as he is called in France, is will continue to send for them just as before. If, on the one who acquires a vested interest in medical practice not other hand, they have not been acceptable to the patients, by reason of his personal efforts and successful experience the law should have no right to interfere with the liberty of among the sick and the suffering, but by going about the patient and force him to accept medical attendance he hat in hand soliciting a post, bringing outside influ- does not wish to have. In Germany and in France, where ences to bear, getting people who have nothing to strenuous resistance is being organised against such an abuse, do with medical practice to recommend him to the its legal sanction by a British law would be looked upon as He sur- a retrograde measure likely to have an injurious moral effect lay committee managing a Friendly Society. renders his personal independence, he consents to become throughout the continent, the salaried servant of a number of persons who know nothing about the medical profession or medical matters, he SEVENTH INTERNATIONAL CONGRESS OF DERMATaccepts payment that is much below the prevailing custom, and thus damages not only his own interests-which Dr. OLOGY AND SYPHILOLOGY. -This congress will be postponed Vimont holds him at liberty to do-but also the interests of from September, 1911, to the middle of April, 1912. This all his colleagues, which is most unfair and most repre- delay is due to the fact that many of the foreign committees hensible. He allows himself to be imposed, to be forced, have found the month of September very unsuitable for their members. Previous references to this congress were made in 1 The article was written, of course, before the agreement was come to in the House of Commons on Clause 13 of the National Insurance THE LANCET of May 20th, 1911 (p. 1395) and Sept. 17th, 1910 (p. 921). Bill.
opposition
to "acquired
113 cases of their own. In 26 it was not possible to make a pneumothorax owing chiefly to extensive adhesions, but of the other 87 patients, all having severe disease and going downhill before the operation, 65 per cent. were very favour-
ably influenced by the operations, and in each case the prognosis is now either good or very good. The technique needs great care on the part of the operator and his assistant, but there seems little doubt that the induction of an artificial pneumothorax is of the greatest use in the treatment of some apparently hopeless cases of advanced pulmonary tuberculosis. I am, Sir, yours faithfully, HERBERT RHODES. Brechin-place, S.W.’, July 24th, 1911.
,
ST. JOHN’S HOSPITAL FOR DISEASES OF THE SKIN. To the Editor of THE LANCET. SIR,-Owing to certain difficulties arising out of the management of this hospital, and the manner in which the grievances in respect of such were dealt with by the board of management, we, the undersigned members of the medical staff, felt compelled, acting under legal advice, to take a
certain course. As a result of this action we were called upon to resign our appointments by the board within seven days, and, declining to do so, we have received imperative notice of dismissal, and have ceased to have any connexion with the said hospital. We shall take steps to lay the facts of the disabilities under which we suffered before the profession, and also before certain medical and lay hospital authorities, and in the meantime trust that, should the vacancies upon the medical staff be sought to be filled by the board, would-be candidates, before applying for our late H. LYLE, Senior Surgeon to the Liverpool Hospital for Cancer appointments, will make themselves cognisant of the conand Skin Diseases. Liverpool, July 26th, 1911. ditions which prevail, and have prevailed, at this hospital both now and in previous years. We are, Sir, yours faithfullv, ALFRED EDDOWES. ARTIFICIAL PNEUMOTHORAX IN TREATAGNES SAVILL. MENT OF TUBERCULOSIS. G. W. DAWSON. To the Editor of THE LANCET. L. F. KNUTHSEN. July 17th, 1911. SIR,-I was very much interested in the important communications by Dr. 0. Lillingston, Dr. L. Colebrook, and Dr. S. V. Pearson and Dr. A. de W. Snowden printed in FRENCH MEDICAL OPINION ON THE THE LANCET of Jaly 15th. The paper by Dr. Lillingston BRITISH INSURANCE BILL. was most complete, and he seems to have mentioned almost all the possible misfortunes as well as the methods (FROM OUR SPECIAL COMMISSIONER.) of safeguarding the patient, while the treatment is being carried out according to Saugman’s technique. Bat I should Paris, July 26th, 1911. like to discuss one point which surprised me not a little. THE members of the medical profession in France, and He describes rather contemptuously the method of Brauer and Spengler as either obsolete or at any rate almost useless. especially those who are members of militant medical unions, About five years ago I spent nearly two years at Davos- are watching with great interest and not a little anxiety the Platz and Davos-Clavadel and heard much of this wonderful fate of Mr. Lloyd George’s Insurance Bill. To them the operation of Brauer’s and saw some of his cases, and they paramount question is the free choice of the doctor. There seemed surprisingly successful. must, they say, be no State medical functionaries, and no Hearing, as Dr. Lillingston remarks, that the English cases monopolies created for disposal by the politician who has in Davos could not return home last summer because there was influence over voters. It is as a medical practitioner and not as a successful canvasser at election times that patients should no one in England capable of carrying on the treatment, I, at the request of sundry patients and doctors, went out last be able to select their medical attendant. The new Health winter to Clavadel and there learnt all I could of these new Committees that are to decide how to carry out the legisladevelopments of the artificial pneumothorax treatment. I tive provisions are not likely in French opinion to be neutral have both assisted at and performed the initial operation in politics. Theoretically, all elected administrative bodies and the after-fillings a good many times now, and from my in England, except the two Houses of Parliament, are supposed comparatively small personal experience and the very con- to have no politics. A municipality is constituted merely for siderable number of cases whose notes I have studied I have local purposes, though it is often elected now on the lines of the political parties; and this is also the case with less come to the conclusion that the initial open operation as performed by Brauer is not very dangerous, and that the important bodies, such as, in England, the boards of dangers of pleural reflex, air embolism, sepsis, and so on guardians. What, then, is going to be the politics of the proare greater at the time of the earlier after-fillings, especially posed Health Committees seems to our French neighbours a when Saugman’s needle is used, as it invariably is used by vital point. Are they likely to be free from all political Spengler, Frey, Neumann, Noble, and the other practitioners bias ? Are there, indeed, administrative bodies anywhere at Davos. that can be considered as free from political bias ? Medical If this conclusion of mine is true, it seems to me that men are not themselves absolutely free from political predia combination of Brauer’s initial operation, with the use lections, and their full representation on the committees of a fine trocar and cannula fitted to Saugman’s needle- would not alter this danger. When, in answer to these mount for the after-fillings, should make the procedure in the curious criticisms, I confessed that it seemed to me possible majority of cases free from the risks mentioned in Dr. that the medical profession in England, if polled, would Lillingston’s paper. I had such a needle made for me by the show a Conservative majority-a view which I knew many Holborn Instrument Supply Company. Dr. Brauer and Dr. medical men would not agree with-the retort was immeSpengler in their latest work on this subject describe some diately made that this might account for some of the -
405 I protested to my questioners tbalupon a sick man, instead of waiting until, as a consequence to the Bill. every effort had been made, on the contrary, to exclude of the honourable exercise of his profession, the sick man is politics from the discussion of the Bill, and that thes inspired with confidence in him and voluntarily sends for Conservative party, by the voice of its leaders and inhim. On one side we have the medical practitioner who has. its journals, had expressed its approval of the generalacquired a practice by his own skill, science, and hard work ; principles of the Bill. The idea of political bias was firmlyron the other is a practitioner who owes his practice to the rooted in their minds, and they continued to point out that fact that he was appointed by a lay committee, and was a medical adviser must not be imposed on a patient willing to violate the fundamental principles of the profesbecause he had found favour in the eyes of some authority, sion of medicine. Where rests the vested interest ? Does it or other. If such authority is not guided in its choice by, rest with the independent practitioner or with the practipolitical motives, it is likely to be influenced by family or tioner who has sold himself ? personal interests ; in fact, by any number of considerations Proposed International Action in Regard to the Bill. save the one and only reason that should govern the choice of Mr. Lloyd George, on more than one occasion, has the medical attendant. his approval of the principle of free choice’ of expressed The French TTiEw of Vested Interests in ClubPractice.1 medical attendant by the patient. But if the wage limit is The only means of excluding influences that should not be, to be maintained at £160 a year and the payment is not to seems quite obvious brought to bear was, from the French viewpoint, to allow be much higher than 6s. a year, then it and suffer severely, will that suffer, many the medical practitioner to appoint himself. I expractitioners This, in their pockets. In fact, their vested interests will be plained, was exactly what would happen in the majority of affected. cases. Any fully qualfied practitioner who was willing to The French practitioners with whom I discussed this do the work could inscribe his name on the panel, but there remained a minority of cases where the patient would matter viewed the prospect of British legislation setting not be free to send for the practitioner he might prefer. such an example with little short of terror. Such a bad There were the medical men at present employed at regular precedent, they said, would be extremely injurious to salaries by the Friendly Societies, and these salaries were their British colleagues, and would check the campaign now successfully in progress in France against similar abuses. likely to be treated as vested interests which must not be Would it not be possible, I was eagerly asked, for some disturbed. The same difficulty has arisen in France, British and French medical men to meet and though the term " vested interests " does not exist there. It representative The entente cordiale, surely, is replaced by the very appropriate expression acquired draw up a joint manifesto ? Aituations "(sit iiatiog?s acquises). Dr.M.Vimontrecentlv pub- was not a mere empty sound-a pretty sentiment with nothing lished an eloquent nrotest against the excess of consideration practical about it. Here, in France, the economical diffishown situations"under the contract system. In culties besetting the medical profession were almost Would it the Concours M6dicol he explains that he has himself served as identical with those obtaining in England. the medical officer of various Friendly Societies and quite not lend greater weight to the demands brought forward understands the anxieties of these poorly paid practitioners. if they were simultaneous and similar in both countries. Nevertheless, he questions whether their position as the An Opportunity for Reform. salaried medical officers of mutualist organisations or The great benefit of the proposed law is the panel, but Friendly Societies can be considered as a vested interest. only, my French friends say, if it is universally applied. He draws a picture of the young practitioner remaining at It is bad enough that medical monopolies should have home, depriving himself of holidays for fear of losing a been created by Friendly Societies and medical aid clubs patient, devoting himself with the utmost assiduity to the of all sorts, acting as private organisations established by few patients who send for him, till at last, after much privaprivate enterprise. Against such a procedure medical tion and many efforts he wins a good name and establishes a men have formed militant unions and have collected strike practice. This, indeed, is an"acquired situation," and is due funds, and there have been many medical strikes throughentirely to personal effort and merit. But by-and-bye, though out Europe. The Governments may plead that where he has in no wise modified his manner of treatment and has freedom of association exists they are not responsible for been and is just as successful, his patients leave him one by one. what these associations may do. But Governments are They leave him because they join the Friendly Society of the responsible for the laws they present to Parliament. industry in which they are engaged. At first, however, he If, under private enterprise, a mischievous and bad system continues to attend to wives and children, but in course of has grown up, a system that has been condemned by at least time even that fails him, for the Friendly Society extends its nine out of every ten medical practitioners in England, field of action and takes in the women and children as well. France, Germany, Belgium, and in fact throughout Europe, Here, then, is a vested interest destroyed by a Friendly it surely is not the role of any Government, seeking to Society, which imports a medical officer and makes him legislate for the public good, to give legal sanction to abuses. attend patients on charity terms with the aid of an elaborate The Friendly Societies and medical aid clubs must no longer system of advertising and touting. Then, as a climax, when be allowed to impose upon their members such medical men a reform is proposed, it is urged with due solemnity that as their managing committees may choose to appoint, or to respect must be shown for the vested interest of the Friendly oppress their medical officers. The Health Committees to Society’s medical officer ; the vested interest of the very be created under the proposed law will be able to see that man who has destroyed by unfair competitive methods the the is open to all who are properly qualified. The best, the most worthy, form of vested interest that can club panel doctors of good professional repute should not lose anypossibly exist. thing by the abolition of their function as club doctors. They The "Medical Monopoliser." have only to put their name on the panel and their patients The medical monopoliser,"as he is called in France, is will continue to send for them just as before. If, on the one who acquires a vested interest in medical practice not other hand, they have not been acceptable to the patients, by reason of his personal efforts and successful experience the law should have no right to interfere with the liberty of among the sick and the suffering, but by going about the patient and force him to accept medical attendance he hat in hand soliciting a post, bringing outside influ- does not wish to have. In Germany and in France, where ences to bear, getting people who have nothing to strenuous resistance is being organised against such an abuse, do with medical practice to recommend him to the its legal sanction by a British law would be looked upon as He sur- a retrograde measure likely to have an injurious moral effect lay committee managing a Friendly Society. renders his personal independence, he consents to become throughout the continent, the salaried servant of a number of persons who know nothing about the medical profession or medical matters, he SEVENTH INTERNATIONAL CONGRESS OF DERMATaccepts payment that is much below the prevailing custom, and thus damages not only his own interests-which Dr. OLOGY AND SYPHILOLOGY. -This congress will be postponed Vimont holds him at liberty to do-but also the interests of from September, 1911, to the middle of April, 1912. This all his colleagues, which is most unfair and most repre- delay is due to the fact that many of the foreign committees hensible. He allows himself to be imposed, to be forced, have found the month of September very unsuitable for their members. Previous references to this congress were made in 1 The article was written, of course, before the agreement was come to in the House of Commons on Clause 13 of the National Insurance THE LANCET of May 20th, 1911 (p. 1395) and Sept. 17th, 1910 (p. 921). Bill.
opposition
to "acquired