" ARE HOSPITALS TO BECOME MEDICAL CLUBS ? "

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practical benefit. In former times it was quit exceptional to find the results of cancer surgery so full reported that we can show them to have been disappointin by exact statistical records ; yet no one doubts that the were bad, and the increasing severity of modern operation

has been of

is based upon

DIPHTHERIA AND ITS PROPAGATION BY MEANS OF SCHOOLS. To t7te Editors

conviction of the worthlessness of th earlier surgical procedure. In the present day there is muc greater operative activity ; yet there is the same lack c statistics. Quite recently Mr. Arbuthnot Lane1 of Guy Hospital published "A Case illustrating a very Effectua Method of treating Extensive Malignant Disease of th Breast" from a single woman aged twenty-nine, wh had developed carcinoma of the right breast only fiv months previously. He removed the middle third of th clavicle, tied the subclavian artery and vein, and made clean sweep of the subclavian triangle, though its glands wer not obviously affected. Then he made an incision nine inche in length along the middle line of the sternum and extende, the incision at what seemed a safe distance from the growth to the posterior fold of the axilla, and thence to the oute end of the clavicle. In order to cover this enormou wound, more than nine inches in diameter, he mad a large and sufficient flap from the skin over th deltoid. Next, he amputated the arm at the shoulder joint, and, lastly, he dissected all the soft parts fron the sternum, clavicle, ribs, cartilages, intercostal muscles serratus magnus, and posterior wall of the axilla No one has commented upon an operation of such nove magnitude except Mr. Rutherford Morison of Newcastle-on Tyne, who, it appears,2 had forestalled Mr. Lane upon tw occasions. It is the logical outcome of our increased know ledge of the lymphatic anatomy of the breast, and now tha a lead has been given it is likely to be followed more o less extensively. Comment, therefore, is almost obli gatory. In Mr. Lane’s patient the new growth was foun( to involve the greater pectoral muscle-a common occurrence and one which absolutely prevents assurance of complet, eradication of the disease, for it is impossible to remove the mediastinal glands which drain the pectoral muscles. It migh be argued that as the mediastinal glands had to be left the glands of the neck, which were not obviously diseased might as well have been left also ; but the practical answe is that one must do what one can. There are, however, . statistics to show the results of the recent surgical treatmen of cancer of the breast. The operations have increased ir severity, but there is a suspicion that the results in pro longation of life are no better. It would, perhaps, b( invidious to refer particularly to the many papers upoi cancer surgery which have appeared during the pas decade. Availing myself of the meagre statistics t( hand, I endeavoured to show, in a paper which i lately read before the Liverpool Medical Institution that we possess no evidence such as would convince mer of ordinary business capacity that life is prolonged by the numerous and heroic operations which are now performed upon patients with cancer of the breast, uterus, or alimentary canal. Events clearly show that malignant disease is constitutional, yet we act as if it had been con, elusively proved to be a mere local affection. Sir James Paget has said that cancer of the breast does not fail tc return after amputation more than once in 500 cases. Of course, as Mr. Bryant has recently pointed out, simple cysts of the breast are sometimes mistaken for cancer, and these, one need scarcely say, never return after removal. Chronic mastitis has also been mistaken for cancer. In rare and exceptional instances patients live for many years without recurrence of their disease, which appeared to be cancerous, and ultimately die from something else. But it is freely admitted that in the large majority of cases death after operation for malignant disease is an affair of a few months. It is only by a serial and methodic investigation that these discrepant results can be explained. Such inquiry would be of the highest value to the profession, and I hope soon to take some part in promoting it. Even though the inquiry should prove unfavourable to the surgical measures which &re now in vogue we shall not be content to sit helpless, with folded hands, for pathological research already gives promise of another and perhaps more scientific mode of treatment. I am, Sirs, yours respectfully, E. T. DAVIES, Assistant Surgeon to the Hospital for Women, Liverpool. Jan. 5th, 1896. our

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1

THE LANCET, Oct. 12th, 1895. Oct. 19th, 1895.

2 THE LANCET,

of THE LANCET. many points in the reports of

the various SIRS,-There medical officers of health which are considered of trifling importance at the time and yet in the light of subsequent experience are proved to be of great value. The question in sanitary science which is occupying our minds most at the present time is as to the influences which are mostly at work in the production of diphtheria. One important observation has been made by Mr. Shirley Murphy, medical officer of health of the London County Council-viz., that an epidemic often breaks out when children meet together in the schools after the holidaysbut another, equally important, has been made by Mr. Biddle-viz., that the cases fall off as the term goes on. And in order, if possible, to reconcile these apparently irreconcilable facts I have suggested that the cause of these school outbreaks may be due to imperfect flushing of drains during the holidays. In support of this contention I would cite a case which was told me by Dr. Gibbes, medical officer of health for the Kingston rural sanitary district, and no doubt put forward in one of his annual reports. Some time ago he said he had two or three outbreaks in the schools of a neighbouring village, and that, in spite of their being closed on more than one occasion, fresh outbreaks occurred immediately on their being reopened. At last he had the drain thoroughly well flushed with a strong solution of corrosive sublimate, and the epidemics then completely stopped. Of course this may have been a mere coincidence, but there could not possibly be any harm in having the drains thoroughly flushed with some strong antiseptic before each term commenced. I am, Sirs, your obedient servant, F. P. ATKINSON. Surbiton, Jan. 6th, 1896. are

" ARE HOSPITALS TO BECOME MEDICAL CLUBS ? " To the Editors of THE LANCET. SIRS,-In your issue of the 28th ult. (page 1671) you have article on a meeting of the committee of the Swansea Hospital to discuss a report of the medical staff on this subject, in which you warn the working men not to be led by me save on military matters. However indifferent anyone may be to the smiles or frowns of public opinion, yet it is not pleasant to find your article repeated in the local papers. I see myself in the not very enviable position of being held up to the working men as one whose counsels are to be avoided, as if I had really been guilty of some crime in the opinion of others than THE LANCET ; but if you think you had cause to warn them against me I had, I consider, better and more just reason for warning them not to be led by a report in THE LANCET of a meeting of a hospital committee, more especially at Swansea, and I do protest against the unfair way you have placed the matter before the public." You state: "Colonel Morgan said in his opinion working men had a right to their admission, and the benefit need not necessarily be a charity. Where can right come in when, as everyone knows, the hospital was for serious cases which cannot be accommodated at home or paid for without straining a working man ? As the chairan

said, There are the rules-we cannot alter them." Now, who reading this would suppose that Colonel Morgan man

and the chairman were one and the same person ? The only charitable conclusion I can arrive at is that you likewise did not realise it, and so unwittingly you made the same mistake as did Balaam the son of Beor some thousands of years ago. As regards the first part, from the way you put it it means one thing ; but, had you not omitted to state that the only rights I claim for them are to select or nominate their cases the same as any other subscribers, it would then have meant something different. You ask, "Where can the right come?" I reply, because we have promised it, and we ought to keep I enclose a letter I wrote to the Cambrian on this our word. subject on Dec. 20th, in which you will see exactly what my ideas are, and if you will do me the honour to criticise them I am quite prepared to meet you as regards the conclusion arrived at by the hospital committee that 11 subscribes be requested to investigate the cases they recommend." I thought it answered all the requirements, and believe it is

134 the only solution of the question, so I much regret that in acted likewise, but without knowing what I had done; a my opinion we have been dragged into this Battle of the third, I regret to say, utterly disregarded the dignity of the Clubs " quite unnecessarily. I am, Sirs, yours faithfully, profession. ÆSCULAP. I am, Sirs, your obedient servant, Jan. 8th, 1896. W. LL. MORGAN, Lieut.-Colonel, late Royal Engineers; Chairman, GRADES OF ______________

Swansea Hospital. Brynhiallu, Swansea. Colonel find from We Morgan’s letter to us and his ** letter to the Cambrian that we have misunderstood his position in the hospital and in regard to the question of hospital abuse. Colonel Morgan does not, we are glad to point out, allow the right of admission to working men to the use of,

hospitals, unless in their opinion, and in that of the hospital’ committee, the cases are suitable. He remarks in the letter to our contemporary that " the whole remedy lies with the subscribers, who should see that they only recommend suitable cases, and they ought to remember the charity of the medical staff in so kindly and generously giving their services, and see that their goodness be not abused and used to their detriment." We could not state the case better in any language of our own. We trust to the good sense of the working men to appreciate the distinction between the hospital as an institution for severe and exceptional cases and a medical club where ordinary disease has to be treated. They and their families have the exclusive use of the hospitals. These institutions are chiefly supported by the wealthier members of the community, and cheerfully so. But the subscriptions of the working men are most gratefully received and much nppreciated, so long as they are not used so as to alter the whole conception of the hospital as an institution officered by medical men who give their services gratuitously in extreme .

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PROMOTION IN THE SENIOR THE ARMY MEDICAL STAFF AND INDIAN MEDICAL SERVICE, AND ITS PRESENT EFFECT ON THE SISTER SERVICES. To the Editors

of

THE LANCET.

SIRS,-It is not long since those officers of the Indian Staff Corps who are either in command or second in command of the native regiments obtained a wise concession from the Secretary of State granting them brevet rank in consequence of the constant supersession to which they were subjected owing to the greater celerity of promotion in the British regiments over that obtaining in the Staff Corps. I am desirous to direct attention to the present position of the officers of the Army Medical Staff serving in India, contrasting it with that of the officers of the Indian Medical

Service, and to call the notice of the authorities to the condition which now obtains and to ask if some. method cannot be devised to equalise the rank among thesenior medical officers of the two services in India and prevent the supersedure of the officers of the home"by those of the India Service, which is now and must be the prevalent condition for a long time to come, unless means be devised to do away with the injustice. One measure which might possibly be of avail would, as in the case of the senior officers in native regiments, be the granting of brevet rank to the administrative officers of the Army Medical Staff while serving in India, but as the tendency in these days is to reduce brevet steps, and as its introduction might be productive of many complications, itcases.-ED. L. would be well if the only real remedy for the evil-a remedy which would moreover, in my opinion, have a far-reaching beneficial effect-were at once applied : I refer to selection CORONERS AND INQUESTS. for merit in the higher grades of the Army Medical Staff. 2o the Editors of THE LANCET. The causes which have led to the present state of affairs in SlRS,-A matter has arisen recently to which I should India are two in number, but it is only with the second that like to draw your attention. On Christmas Day I met a I intend to deal here, as the first is an accidental one. messenger with a note, in which it was stated that a certain They are : (1) the circumstance that between the years 1860 person was dangerously ill. On going to the house I found that and 1865 no officers were admitted to the Indian Medical the patient had been dead some hours. I then learnt from the Service, which has had a material influence in quickening registrar that the coroner had directed him to register the the promotion of those joining the Indian army in and after death. I could not communicate with the coroner until the latter year ; and (2) the method of regulating promotion yesterday, and I presume the friends and the registrar to the senior grades which obtains in the so-calledhome "’ between them managed to satisfy the coroner. Should an and in the Indian Service. With reference to the latter and inquest not have been held in this case, as the deceased had more important cause I should like to point out that,. not been medically treated for years ? When called I expressed while in the Indian Service a judicious use is made of the to a relative the belief that apoplexy would probably regulation permitting selection for merit when filling the have been the cause of death, and I have been thinking higher ranks, this most beneficial order is practically a they have made use of that information. Would a fee of dead letter where the officers of the Army Medical Staff are 7s. 6d. be too much to charge for the visit, the place being concerned. It is true that men who are not deemed fit for three miles from my house, although I was going there when promotion from physical causes are occasionally made to I met the messenger ? I was in the house half an hour after retire, but I have long noticed the decided bias against meeting the messenger, or about an hour after the note passing men over and in favour of allowing promotion to mentioned above was written, so that the person who wrote the higher grades to go by seniority alone without any due the note knew at the time of writing that the patient was regard to fitness for administrative duties. I have drawn up a table showing that, taking the six then dead. I shall probably have a reply from the coroner seniors of the grade in the Army Medical Staff and in I am, Sirs, yours truly, to-morrow. the medical services of the three presidencies, the rank WM. WALLACE. Crick, Rugby, Dec. 27th, 1895. of surgeon-lieutenant -colonel has been attained *** In our opinion, given on the facts stated, an inquest by brigade the officers of the Army Medical Staff after thirty should most certainly have been held. The fee mentioned is years’ service, by those of the Bengal service after quite reasonable.-ED. L. twenty-six years, and by the officers of the Bombay and Madras services after twenty-seven and twenty-eight years of service respectively. It should also be observed that three of the surgeon-colonels now serving in the "LIFE INSURANCE OFFICES AND THE Bengal army attained the rank, one in twenty-six and two PROFESSION." after only twenty-seven years’ service, and that the surgeonTo the Editors of THE LANCET. major-generals of the Indian Service in Bengal were gazetted cannot SIRS,-I help admiring the conduct of "M.D." to this, the highest rank in the department, after only thirty with regard to a certain life assurance society. I say a years of service, that now, while enjoying this rank, they arecertain," because the society is probably well known to most the contemporaries of the brigade- surgeon-lieuten ant-colonels. members of the profession who have been in practice for of the Army Medical Staff, and thus supersede many officers some years. But there is another aspect to which I of the Army Medical Staff with much longer service to their may be permitted now to refer. I allude to half-fees. Well credit. Thus Surgeon-Colonel T. Maunsell, A.M.S., has been may "M.D." say that "we should present an unbroken serving under Surgeon-Major-General Harvey, I.M.S., while front." Quite recently I was asked to examine a patient for the former has nearly five years’ more service than the latter. half a fee (10s. 6d.) and refused; a brother practitioner In Madras, Surgeon-Colonel Churchill, A.M.S., is serving