- Email: [email protected]
THE MEDICAL PROFESSION AND THE NATIONAL INSURANCE ACT.
555
V. 4H. Symons, E. L. Moss, M. J. Cromie, and E. T. Potts. Captain W. Mitchell has been transferred from the Military
Hospital at Ambala Cantonment to Subathu, Simla Hills. Captain T. Scatchard, on return from a tour of service at Ranikhet, India, has been appointed for duty as Medical Officer in Charge at Ad Fines Camp. Captain C. W. O’Brien has taken up duty at Kilbride on transfer from Dublin. Captain W. F. H. Vaughan has been selected for appointment as Specialist in Operative Surgery to the Cork District, Irish Command, in succession to Captain R. M. Ranking, whose tenure of the appointment has expired. Captain R. D. O’Connor has joined for duty at Cliffden on return from a tour of service in India. Captain E. Ryan has been placed under orders to proceed to India for a tour of duty with the Southern Army during the ensuing trooping
Lancashire Field Ambulance, Royal Army Medical be Lieutenant (dated August 17th, 1912).
Royal Army
Medical
Corps)
to
Corps.
Yorkshire Mounted Brigade, Field Ambulance, Royal Army Medical Corps : Lieutenant John Hepple to be Captain
(dated July lst, 1912). 3rd West Lancashire Field Ambulance, Royal Army Medical Corps : Captain Norman S. Jeffrey resigns his c-ommission (dated August 17th, 1912). 3rd South Midland Field Ambulance, Royal Army Medical
season.
Lieutenant O. W. J. Wynne has been appointed to the London District for duty at the Queen Alexandra Military Hospital, Grosvenor-road. Lieutenant G. H. Dive has embarked for a tour of service in North China. Lieutenant A. G. Jones and Lieutenant F. R. Laing have been placed under orders to proceed to India for a tour of duty with the Northern Army during the ensuing trooping season. Lieutenant W. Stewart has been transferred from the Military Hospital at Bedford to Colchester, on relief by Lieutenant-Colonel A. P. Poynder.
Corps : Lieutenant Cyril July 15th, 1912).
C.
Lavington
to be
Captain (dated
2nd Northern General Hospital, Royal Army Medical The undermentioned officers, from the list of officers whose service will be available on mobilisation, to be Captains in the permanent personnel (dated May lst, 1912) Captain Joseph F. Dobson and Captain James A. Coupland. The undermentioned Captains to be Majors (dated May lst, 1912) : Joseph F. Dobson and James A. Coupland. 3rd Scottish General Hospital, Royal Army Medical Corps : Major Archibald G. Hay to be Lieutenant-Colonel
Corps :
(dated
April 19th, 1912).
2nd London Army Medical
(City of London) Field Ambulance, Royal Corps : Robert Eric Barnsley (late Cadet, Cambridge University Contingent, Senior Division, Officers Training Corps) to be Lieutenant (dated July 22nd, 1912).
INDIAN MEDICAL SERVICE. Attached to Units other than Medical Units.-Lieutenant Colonel J. Smyth, principal medical officer of the Secun- Robert Thornton to be Captain (dated Feb. 3rd, 1906). derabad Brigade, Southern Army in India, has been Captain John F. F. Parr to be Major (dated May 28th, 1912). appointed to officiate as Surgeon-General with the Govern- Godfrey Kindersley Maurice to be Lieutenant (dated William Thomas Briscoe to be Lieument of Madras Presidency during the absence on leave of June 23rd, 1912). Surgeon-General W. B. Bannerman. Lieutenant-Colonel S. tenant (dated July 8th, 1912). Lieutenant Leonard B. Cane Henderson has been selected for the increased rate of pay in to be Captain (dated May 22nd, 1912). Captain Andrew the list of advanced Lieutenant-Colonels, in succession to Fowler to be Major (dated June 22nd, 1912). James Arthur Lieutenant-Colonel P. Hehir, promoted to the rank of Morris to be Lieutenant (dated July llth, 1912). Por Attachment to Units other than Medical Units.Colonel. Lieutenant-Colonel B. B. Grayfoot has been appointed Civil Surgeon at Karachi, in succession to Major H. John Francis Edmiston to be Lieutenant (dated June 3rc1, Bennett, placed on special duty. Lieutenant-Colonel C. H. 1912). Robert Glover Wills to be Lieutenant (dated July 27th, James, medical adviser to Patiala State, has taken up duty 1912). ROYAL ARMY MEDICAL COLLEGE. as Offciating Civil Surgeon at Simla West. Colonel Bruce M. Skinner, M.V.O., to be Commandant and Major .R:. U. MacLeod, civil surgeon at Dacca. has been granted combined leave of absence home from India for nine Director of Studies, vice Colonel E. J. E. Risk (dated months. Major F. A. L. Hammond, civil surgeon at August 15the,1912). Maymyo, Burma, has been appointed to officiate as a Firstclass Civil Surgeon. Major L. P. Stephen has been permitted to extend his furlough by the Secretary of State for India. Major E. F. G. Tucker has been appointed to officiate as Professor of Pathology and Morbid Anatomy at the Grant Medical College, Bombay. Major W. Selby has taken up Audi alteram partem." duty as Principal and Professor of Surgery at King George’s Medical College, Lucknow. THE MEDICAL PROFESSION AND THE The services of Captain F. P. Wernicke have been placed NATIONAL INSURANCE ACT. at the disposal of the Government of the Central Provinces. Captain W. J. Fraser has been selected for appointment as To the Editor of THE LANCET. Civil Surgeon at Chindwara. Captain S. C. Pal, senior SIR,-I should be obliged if you will publish in medical officer at Farrukhabad, has been appointed to hold civil medical charge of the station in addition to his military THE LANCET the enclosed reply to a letter received from the duties during the absence on leave of Captain F. W. Sumner. Medical Secretary of the British Medical Association, rethe medical members of the Advisory Committee to Captain H. Watts has been appointed Civil Surgeon at questing their seats on that committee. resign Wardha, Central Provinces. Captain R. D. MacGregor has , I am, Sir, yours faithfullv, been granted an extension of his leave of absence for six C. J. BOND. 1912. 20th, Leicester, August months on medical certificate. The services of Captain A. W. been at have the of the Greig placed disposal Punjab ENCLOSURE.J Administration by the Government of India for employment To the slledical Secretary of the British Medical Association. as Superintendent of the Central Jail at Montgomery. Captain DEAR SIR,-I beg to acknowledge the receipt of your R. B. Lloyd has been appointed probationer in the Chemical letter of to-day conveying the wish of the British Medical Examiners’ Department, and has been posted for duty to the Association that I should resign my seat on the Advisory Chemical Laboratory at Calcutta. The services of Captain Committee in connexion with the National Insurance Act. W. a. Collinson, medical officer of the 63rd (Palamcotta) In answer I should like to point out that I was appointed Light Infantry, have been placed at the disposal of the by the Commissioners to advise in regard to matters affectGovernment of India, Department of Education, for employing the interests of county hospitals without medical schools. ment on Plague Prevention duty in the United Provinces of In view of the important relationships between these Agra and Oudh. , interests and those of the medical profession and the TERRITORIAL FORCE. public, and bearing in mind that in all probability agreements, requiring the approval of the Insurance CommisYeomanry.
Correspondence. "
Lincolnshire Yeomanry: Surgeon-Lieutenant
Purves to be
Robert B.
14th, 1910). Surgeon-Captain (dated Infantry. 5th Battalion, The King’s Own (Royal Lancaster Regiment) : Norman Stuart Jeffrey (late Captain 3rd West Nov.
sioners, will
be entered into between Insurance Committees and the boards of general hospitals, especially in regard to the treatment of non-pulmonary cases of tuberculosis, I have, after very careful consideration, and with a full sense of responsibility, formed the opinion that it is my duty to remain at present a member of the Advisory Committee.
556
May I add that I am in full accord with the desire on the part of the profession to obtain adequate remuneration and
who are all for professional unity but have an innate dislike for trades unionism. It seems to me that the British Medical Association, fair conditions of service, and it is because I believe that these objects can be best obtained, and the interests to having decided to place itself outside the Act so long as the which I have alluded can be best safeguarded by further Act is unacceptable to the profession, could not reasonably let efforts at negotiation with the Commissioners that I have its nominees stay upon the Advisory Committee. The other medical members of that committee were not in the same decided to take this course of action. Ynilr- fmhhfn11v position, and I respect both those who resigned at the request J. BOND. of the Association and those who could not see their way to do C. 1912. Leicester, August 3rd, so. If the Association were still represented officially upon the Advisory Body of the Commissioners, that would surely show To the Editor of THE LANCET. that the breaking off of negotiations was a mere tactical SIR,-As one of the rank and file, practising in an move and not a serious step taken with a definite intention. industrial district, I should like through the medium ofThe Advisory Committee is a statutory body for helping in THE LANCET to pay a tribute to the public-spirited, wise, and the administration of the Act. The Association has, at courageous course of action of the 14 gentlemen who have least for the present, washed its hands of the Act ; how, resisted the request of the British Medical Association to therefore, could it remain officially represented in the resign their seats on the Advisory Committee. The reasons administration of that Act ? adduced by Dr. Addison and Dr. Harford, published in your It is nonsense to talk as party papers do about medical last issue, are, in my opinion, weighty and unanswerable. the law." They are not refusing to pay men be dubbed will Doubtless these men potential blacklegs by their"disobeying contributions or to lick stamps ; they are personal extremists, but they can afford to treat such nomenclatures merely refusing the Government’s invitation to help in the I feel confident that their conduct with contempt. administration of a law so long as that law fails to meet will meet with the approval of a large section of the medical requirements. profession who place citizenship before selfishness and If the Commissioners cannot produce satisfactory regulapolitical partisanship. It is idle to deny the fact that a tions they will have to pay over the medical benefit money to considerable amount of the unreasonable opposition to the insured, for they cannot at present create a whole-time a settlement must be attributed to the bias of a faction, medical service. The British Medical Association, so I whose motive is the downfall of the Chancellor and foresaw this when it broke off negotiations, and understand, not the interest of the general practitioner. Personally, I it is getting ready to provide a proper public medical service decline to participate in this unworthy endeavour. The outside the Act, which insured persons will have to make use Chancellor desires to treat us fairly, consistent with his posiof if medical benefit is The task of preparing a tion as guardian of the public purse. I think the time has general scheme which cansuspended. be adapted throughout the country come when reasonable counsels should prevail, and that the to suit varying local requirements is, of course, very difficult, moderate section of the profession must insist on a settlebut I see no reason why it should not be accomplished, ment without delay, in spite of the fatuous resolution we all work together and believe in ourselves. passed at Liverpool. If a card vote of the whole profession provided I do not by any means approve of everything that the were taken, one may with confidence predict that a majority British Medical Association has done, but, as you have would be in favour of a settlement upon a fair basis-i. e., a said, it is the only organisation through which the capitation fee of 7s. 6d., including medicine, for ordinary profession can express its demands or administer a domiciliary attendance. It may safely be stated that a great scheme of public medical service outside the Act. I many prospectiveoccupants of the ultimate trench are not think it is our duty, members and non-members alike, paid at the above rate at present by their private patients. to do all in our power to help the Association to One’s experience of meetings is that a considerable number such a service, and I feel strongly that success of men are cowed, and vote against their consciences : organise will follow if THE LANCET encourages loyalty to the ’’ peaceful persuasion"" looms ahead and saps their inde- Association whilst this business is in hand. There are pendence. moderate men like myself within and without the Unfortunately, the British Medical Association has, by the many and the line you take up will, I believe, Association, Liverpool resolution, put itself out of court, and forfeited its make all the difference between failure and success. I right to continue negotiations ; therefore, apparently, the think that if we all stand together now such a service function of intermediary must devolve upon some other body. could be set up and worked satisfactorily. Let us conMr. Masterman, speaking on behalf of the Government, has If we succeed in establishing an centrate on that. explicitly stated that the Association’s decision would be efficient service adaptable to local requirements and fair regarded as final. If the gentlemen now ruling the Asso- to profession and public alike, we shall be in a very it is in their irreconcilable ciation persist attitude, perfectly and I have little doubt that in the clear that a schism of the utmost magnitude will inevitably strong position; course of time the Commissioners or the Government in result, ending in the disruption of the Association and the power would feel obliged to save the medical side of the Act ruin of many practitioners. the Association with a view to taking over by approaching As to the alternative, Public Medical Service Scheme, it is its public medical service as a going concern and dovedoubtful whether Parliament would tolerate a scheme dealing tailing it into the Act ; whether by the issue of new with the national health which savoured of syndicalism. regulations or by the passing of an amending Act matters I am. Sir. vours faithfully. little to us. W. OWEN WILLIAMS. Mile End, August 20th, 1912. I put these disconnected views before you, Sir, in the hope that you will deal with them on their merits, and, in so far To the Editor of THE LANCET. as they appeal to you, will make them your own. I am. Sir. vours faithfullv. SIR,-From the beginning I have read the leading articles TELEMACHUS. in THE LANCET which have dealt week by week with the August 20th, 1912. position of our profession under the National Insurance *** We must all await the issue of the regulations with scheme, and have followed closely your reviews of the patience we can.-ED. L. changing situation and your words of guidance and of warnas each critical the ing phase arose. I think that profession owes much to THE LANCET for the judicial and independent I To the Editor of THE LANCET.. attitude which it has maintained through this long and anxious period, and for constantly bringing its readers back SIR,-During the long and arduous fight to which the to the main issues. I can well understand the pressure that medical profession has been committed in Great Britain, must have been brought to bear upon you to lean towards since Mr. Lloyd George launched his Insurance measure, it one extreme view or another and support some policy which has been interesting to read the comments which have been could not be maintained in the light of later events. made from time to time by the leading medical journalists But, although I see that clear leadership is difficult when of America, and not a little comforting to find that they are everything is still so chaotic and uncertain, I think the in sympathy with the principles underlying the claims, of present moment is one at which we must ask for more their British colleagues. The New lor74 3-redical Record, guidance from you. I belong to the large body of medical August 3rd, 1912, has a leading article entitled "The men
-
,
’
what
.
557 Medical Revolution in Great Britain." The actual subject of the article is the recent refusal of the Representative Meeting of the British Medical Association to accept the Act as it stands. The writer, standing at some distance from the conflict, perceives the fact which is in danger of being lost sight of by the protagonists, that the chief defect in the medical service proposed by the Government is not the rate or method of payment, but the control of the profession by Friendly Society officials. He rightly says that it is this feature of the medical benefit section of the Act which is most bitterly resented by the profession. The capitation fee of "two dollars and ten cents," not including extras and medicine, is regarded as reasonable, and the writer says that when the cost of the medical man’s education and the responsibilities of practice are taken into account the assurance of Mr. Lloyd George in expecting him to become absolutely the servant of the public at a remuneration of less than$1500 a year is nothing less than remarkable ; especially in view of the sum of$2000 per annum paid to each member of the House of Commons for services requiring no special education and to a great extent perfunctory. One of his comments is particularly gratifying. He says that a notable feature of the situation is the sane, temperate, and dignified manner in which the question has been discussed by the leading medical journals of Great Britainin striking contrast to the heated appeals to party and class prejudice made by politicians responsible for the measure and by the lay journals interested in popularising their statements." The fact that the struggle for reasonable conditions of service is being watched by our colleagues in America with close attention should heighten the sense of responsibility with which the British profession is carrying on its controversy with the Government ; for it is a reminder that whatever the organisation of medical service issuing finally from the struggle, it will stand as a precedent to be copied more or less closely in other countries where hitherto no such organisation has been set up.
regarded as anaphylaxis did not follow any undue exertion (as Dr. Berry suggests), but occurred at a time when the patient was being confined rigidly to bed. 3. The sudden onset of a series of symptoms and signs, which faithfully
accorded with what has been described as anaphylaxis, whether occurring in man or in animals. On May 29th, after some 50 grains of thyroidectin had been taken in the course of several weeks, we found the patient suddenly confronted with intense distress in her breathing, which was shallow, irregular, and quick, numbering 90 per minute. There were intense lividity of the skin, acute pain in the epigastrium, marked tenderness over the region of the liver, intense icteric staining of the conjunctivas, and persistent vomiting and diarrhoea. In addition all the signs of severe shock were present. There was great coldness of the periphery, an anxious expression of the face, and a marked fall in the peripheral blood pressure. The pulse was very irregular and quick, numbering 160 per minute. The condition suggested to all her friends, to us, and to the patient herself, that death was imminent. Dr. Berry suggests that the condition was one of simple heart failure. We think there is evidence in support of our diagnosis of anaphylaxis. According to Schulz and Jordan this grave condition is caused by the liberation of toxic proteins in the blood. These proteins produce spasm of the muscle fibres in the walls of the bronchi and by folding of the mucosa the lumen comes to be partially or completely occluded, with resulting asphyxia. In like manner (as a recent annotation in THE LANCET suggests) the proteins cause spasm in the larger arteries, which leads to a marked fall in the peripheral blood pressure. The condition of our patient showed evidence of such a series of events. The most marked features present were the sudden onset of respiratory embarrassment and the great fall in the blood pressure in the peripheral vessels. With regard to the treatment we instituted with complete success, we consider that it goes far in supporting our T Sir. vours faithfullv. diagnosis. The reduction of the toxicity of the blood that BRISTOLIAN. occurs in cases of uraemia and eclampsia after venesection, and the marked increase in the agglutinative power of the To t7te Editor of THE LANCET. serum seen in typhoid patients after small hemorrhages, SIR,-One aspect of the many schemes put forward for led us to try venesection as the most efficient means in dealing with tuberculosis under the National Insurance Act our power of reducing the toxicity of the blood in our has struck me very forcibly. In almost every case-in anaphylactic patient. The significant fact is that not more than 6 oz. of blood counties, at any rate-the medical officers of health (and, were withdrawn from the vein. The almost instantaneous to the the absence of medical men on Insurance owing Committees, they are having things all their own way) relief that followed was, in our opinion, greater than can that they be appointed be explained by the mere mechanical effect exercised recommend, with sublime modesty, " chief tuberculosis officers."" The plea they urge-and how on an engorged right heart by the withdrawal of such It seemed more likely that well they know their councils !—is economy. The result a small quantity of blood. will be that in tuberculosis work, as in school medical work, it acted. by reducing the toxicity of the blood to an the junior appointments will be blind-alley appointments for extent sufficient to relieve bronchial and arterial spasm. whoever takes them up. The medical officer of health is to The administration of adrenalin chloride solution subsebe not only medical officer of health, but also chief tuber- quently quite efficiently raised the peripheral blood pressure. culosis officer and chief school medical officer, and neither of We are glad to have Dr. Berry’s assurance that further The condition is now apthe latter will be held qualified to be a medical officer of venesection was not required. health. parently that of uncomplicated exophthalmic goitre. We The best class of men, are content to leave to your readers the decision as to Further comment is needless. however, will hardly take up these appointments, or, having whether our diagnosis of anaphylaxis was justifiable. The been induced to accept them, will be unlikely to retain line of treatment we have suggested may, in any case, stand them when they realise the facts as to the prospects of as worthy of trial in cases of anaphylaxis ; and we think it advancement to a responsible post. Cooperation can be might with profit be made the subject of experiment on secured without making a demi-god of the medical officer of animals. We are, Sir, yours faithfully, JOHN R. O’BRIEN, M.D., health (who cannot be an expert in all things) and inciH. M. WILSON, M.B. dentally increasing his salary at the expense of those Glasgow, August 14th, 1912. actually doing the work. I am, Sir, yours faithfully, D. P. H. August 13th, 1912. PRE-OPERATIVE THE DIAGNOSIS OF ’’
-
-
--
I
THE TREATMENT OF ANAPHYLACTIC SHOCK.
APPENDICITIS AND THE DORSAL METHOD OF EXAMINATION.
To the Editor of THE LANCET. SIR,-Our attention has been drawn to Dr. T. P. Berry’s criticism of our letter in your issue of June 8th. We still think wewere justified in regarding as 1, anaphylaxis the grave condition our subject of Graves’s disease suffered from after treatment with thyroidectin. May we refer briefly to the following significant features in the case ? 1. Dr. Berry’s admission that the patient exhibited marked intolerance to thyroidectin from the first. Hefound it necessary to reduce the dose by one-half." 2. The condition we
To the Editor of THE LANCET.
"
SIR,-Will you permit me to dispel any misconception which might arise from the short notice given of the subject on p. 448 of your last issue ? The dorsal method does not profess to be an alternative for, or to be independent of, the present routine of diagnosis ; it is merely complementary to it. It is specially concerned with those cases which have been so far diagnosed as to raise the question of operation, because they call for all " the evidence and therefore render The following points a dorsal examination indispensable.
V. 4H. Symons, E. L. Moss, M. J. Cromie, and E. T. Potts. Captain W. Mitchell has been transferred from the Military
Hospital at Ambala Cantonment to Subathu, Simla Hills. Captain T. Scatchard, on return from a tour of service at Ranikhet, India, has been appointed for duty as Medical Officer in Charge at Ad Fines Camp. Captain C. W. O’Brien has taken up duty at Kilbride on transfer from Dublin. Captain W. F. H. Vaughan has been selected for appointment as Specialist in Operative Surgery to the Cork District, Irish Command, in succession to Captain R. M. Ranking, whose tenure of the appointment has expired. Captain R. D. O’Connor has joined for duty at Cliffden on return from a tour of service in India. Captain E. Ryan has been placed under orders to proceed to India for a tour of duty with the Southern Army during the ensuing trooping
Lancashire Field Ambulance, Royal Army Medical be Lieutenant (dated August 17th, 1912).
Royal Army
Medical
Corps)
to
Corps.
Yorkshire Mounted Brigade, Field Ambulance, Royal Army Medical Corps : Lieutenant John Hepple to be Captain
(dated July lst, 1912). 3rd West Lancashire Field Ambulance, Royal Army Medical Corps : Captain Norman S. Jeffrey resigns his c-ommission (dated August 17th, 1912). 3rd South Midland Field Ambulance, Royal Army Medical
season.
Lieutenant O. W. J. Wynne has been appointed to the London District for duty at the Queen Alexandra Military Hospital, Grosvenor-road. Lieutenant G. H. Dive has embarked for a tour of service in North China. Lieutenant A. G. Jones and Lieutenant F. R. Laing have been placed under orders to proceed to India for a tour of duty with the Northern Army during the ensuing trooping season. Lieutenant W. Stewart has been transferred from the Military Hospital at Bedford to Colchester, on relief by Lieutenant-Colonel A. P. Poynder.
Corps : Lieutenant Cyril July 15th, 1912).
C.
Lavington
to be
Captain (dated
2nd Northern General Hospital, Royal Army Medical The undermentioned officers, from the list of officers whose service will be available on mobilisation, to be Captains in the permanent personnel (dated May lst, 1912) Captain Joseph F. Dobson and Captain James A. Coupland. The undermentioned Captains to be Majors (dated May lst, 1912) : Joseph F. Dobson and James A. Coupland. 3rd Scottish General Hospital, Royal Army Medical Corps : Major Archibald G. Hay to be Lieutenant-Colonel
Corps :
(dated
April 19th, 1912).
2nd London Army Medical
(City of London) Field Ambulance, Royal Corps : Robert Eric Barnsley (late Cadet, Cambridge University Contingent, Senior Division, Officers Training Corps) to be Lieutenant (dated July 22nd, 1912).
INDIAN MEDICAL SERVICE. Attached to Units other than Medical Units.-Lieutenant Colonel J. Smyth, principal medical officer of the Secun- Robert Thornton to be Captain (dated Feb. 3rd, 1906). derabad Brigade, Southern Army in India, has been Captain John F. F. Parr to be Major (dated May 28th, 1912). appointed to officiate as Surgeon-General with the Govern- Godfrey Kindersley Maurice to be Lieutenant (dated William Thomas Briscoe to be Lieument of Madras Presidency during the absence on leave of June 23rd, 1912). Surgeon-General W. B. Bannerman. Lieutenant-Colonel S. tenant (dated July 8th, 1912). Lieutenant Leonard B. Cane Henderson has been selected for the increased rate of pay in to be Captain (dated May 22nd, 1912). Captain Andrew the list of advanced Lieutenant-Colonels, in succession to Fowler to be Major (dated June 22nd, 1912). James Arthur Lieutenant-Colonel P. Hehir, promoted to the rank of Morris to be Lieutenant (dated July llth, 1912). Por Attachment to Units other than Medical Units.Colonel. Lieutenant-Colonel B. B. Grayfoot has been appointed Civil Surgeon at Karachi, in succession to Major H. John Francis Edmiston to be Lieutenant (dated June 3rc1, Bennett, placed on special duty. Lieutenant-Colonel C. H. 1912). Robert Glover Wills to be Lieutenant (dated July 27th, James, medical adviser to Patiala State, has taken up duty 1912). ROYAL ARMY MEDICAL COLLEGE. as Offciating Civil Surgeon at Simla West. Colonel Bruce M. Skinner, M.V.O., to be Commandant and Major .R:. U. MacLeod, civil surgeon at Dacca. has been granted combined leave of absence home from India for nine Director of Studies, vice Colonel E. J. E. Risk (dated months. Major F. A. L. Hammond, civil surgeon at August 15the,1912). Maymyo, Burma, has been appointed to officiate as a Firstclass Civil Surgeon. Major L. P. Stephen has been permitted to extend his furlough by the Secretary of State for India. Major E. F. G. Tucker has been appointed to officiate as Professor of Pathology and Morbid Anatomy at the Grant Medical College, Bombay. Major W. Selby has taken up Audi alteram partem." duty as Principal and Professor of Surgery at King George’s Medical College, Lucknow. THE MEDICAL PROFESSION AND THE The services of Captain F. P. Wernicke have been placed NATIONAL INSURANCE ACT. at the disposal of the Government of the Central Provinces. Captain W. J. Fraser has been selected for appointment as To the Editor of THE LANCET. Civil Surgeon at Chindwara. Captain S. C. Pal, senior SIR,-I should be obliged if you will publish in medical officer at Farrukhabad, has been appointed to hold civil medical charge of the station in addition to his military THE LANCET the enclosed reply to a letter received from the duties during the absence on leave of Captain F. W. Sumner. Medical Secretary of the British Medical Association, rethe medical members of the Advisory Committee to Captain H. Watts has been appointed Civil Surgeon at questing their seats on that committee. resign Wardha, Central Provinces. Captain R. D. MacGregor has , I am, Sir, yours faithfullv, been granted an extension of his leave of absence for six C. J. BOND. 1912. 20th, Leicester, August months on medical certificate. The services of Captain A. W. been at have the of the Greig placed disposal Punjab ENCLOSURE.J Administration by the Government of India for employment To the slledical Secretary of the British Medical Association. as Superintendent of the Central Jail at Montgomery. Captain DEAR SIR,-I beg to acknowledge the receipt of your R. B. Lloyd has been appointed probationer in the Chemical letter of to-day conveying the wish of the British Medical Examiners’ Department, and has been posted for duty to the Association that I should resign my seat on the Advisory Chemical Laboratory at Calcutta. The services of Captain Committee in connexion with the National Insurance Act. W. a. Collinson, medical officer of the 63rd (Palamcotta) In answer I should like to point out that I was appointed Light Infantry, have been placed at the disposal of the by the Commissioners to advise in regard to matters affectGovernment of India, Department of Education, for employing the interests of county hospitals without medical schools. ment on Plague Prevention duty in the United Provinces of In view of the important relationships between these Agra and Oudh. , interests and those of the medical profession and the TERRITORIAL FORCE. public, and bearing in mind that in all probability agreements, requiring the approval of the Insurance CommisYeomanry.
Correspondence. "
Lincolnshire Yeomanry: Surgeon-Lieutenant
Purves to be
Robert B.
14th, 1910). Surgeon-Captain (dated Infantry. 5th Battalion, The King’s Own (Royal Lancaster Regiment) : Norman Stuart Jeffrey (late Captain 3rd West Nov.
sioners, will
be entered into between Insurance Committees and the boards of general hospitals, especially in regard to the treatment of non-pulmonary cases of tuberculosis, I have, after very careful consideration, and with a full sense of responsibility, formed the opinion that it is my duty to remain at present a member of the Advisory Committee.
556
May I add that I am in full accord with the desire on the part of the profession to obtain adequate remuneration and
who are all for professional unity but have an innate dislike for trades unionism. It seems to me that the British Medical Association, fair conditions of service, and it is because I believe that these objects can be best obtained, and the interests to having decided to place itself outside the Act so long as the which I have alluded can be best safeguarded by further Act is unacceptable to the profession, could not reasonably let efforts at negotiation with the Commissioners that I have its nominees stay upon the Advisory Committee. The other medical members of that committee were not in the same decided to take this course of action. Ynilr- fmhhfn11v position, and I respect both those who resigned at the request J. BOND. of the Association and those who could not see their way to do C. 1912. Leicester, August 3rd, so. If the Association were still represented officially upon the Advisory Body of the Commissioners, that would surely show To the Editor of THE LANCET. that the breaking off of negotiations was a mere tactical SIR,-As one of the rank and file, practising in an move and not a serious step taken with a definite intention. industrial district, I should like through the medium ofThe Advisory Committee is a statutory body for helping in THE LANCET to pay a tribute to the public-spirited, wise, and the administration of the Act. The Association has, at courageous course of action of the 14 gentlemen who have least for the present, washed its hands of the Act ; how, resisted the request of the British Medical Association to therefore, could it remain officially represented in the resign their seats on the Advisory Committee. The reasons administration of that Act ? adduced by Dr. Addison and Dr. Harford, published in your It is nonsense to talk as party papers do about medical last issue, are, in my opinion, weighty and unanswerable. the law." They are not refusing to pay men be dubbed will Doubtless these men potential blacklegs by their"disobeying contributions or to lick stamps ; they are personal extremists, but they can afford to treat such nomenclatures merely refusing the Government’s invitation to help in the I feel confident that their conduct with contempt. administration of a law so long as that law fails to meet will meet with the approval of a large section of the medical requirements. profession who place citizenship before selfishness and If the Commissioners cannot produce satisfactory regulapolitical partisanship. It is idle to deny the fact that a tions they will have to pay over the medical benefit money to considerable amount of the unreasonable opposition to the insured, for they cannot at present create a whole-time a settlement must be attributed to the bias of a faction, medical service. The British Medical Association, so I whose motive is the downfall of the Chancellor and foresaw this when it broke off negotiations, and understand, not the interest of the general practitioner. Personally, I it is getting ready to provide a proper public medical service decline to participate in this unworthy endeavour. The outside the Act, which insured persons will have to make use Chancellor desires to treat us fairly, consistent with his posiof if medical benefit is The task of preparing a tion as guardian of the public purse. I think the time has general scheme which cansuspended. be adapted throughout the country come when reasonable counsels should prevail, and that the to suit varying local requirements is, of course, very difficult, moderate section of the profession must insist on a settlebut I see no reason why it should not be accomplished, ment without delay, in spite of the fatuous resolution we all work together and believe in ourselves. passed at Liverpool. If a card vote of the whole profession provided I do not by any means approve of everything that the were taken, one may with confidence predict that a majority British Medical Association has done, but, as you have would be in favour of a settlement upon a fair basis-i. e., a said, it is the only organisation through which the capitation fee of 7s. 6d., including medicine, for ordinary profession can express its demands or administer a domiciliary attendance. It may safely be stated that a great scheme of public medical service outside the Act. I many prospectiveoccupants of the ultimate trench are not think it is our duty, members and non-members alike, paid at the above rate at present by their private patients. to do all in our power to help the Association to One’s experience of meetings is that a considerable number such a service, and I feel strongly that success of men are cowed, and vote against their consciences : organise will follow if THE LANCET encourages loyalty to the ’’ peaceful persuasion"" looms ahead and saps their inde- Association whilst this business is in hand. There are pendence. moderate men like myself within and without the Unfortunately, the British Medical Association has, by the many and the line you take up will, I believe, Association, Liverpool resolution, put itself out of court, and forfeited its make all the difference between failure and success. I right to continue negotiations ; therefore, apparently, the think that if we all stand together now such a service function of intermediary must devolve upon some other body. could be set up and worked satisfactorily. Let us conMr. Masterman, speaking on behalf of the Government, has If we succeed in establishing an centrate on that. explicitly stated that the Association’s decision would be efficient service adaptable to local requirements and fair regarded as final. If the gentlemen now ruling the Asso- to profession and public alike, we shall be in a very it is in their irreconcilable ciation persist attitude, perfectly and I have little doubt that in the clear that a schism of the utmost magnitude will inevitably strong position; course of time the Commissioners or the Government in result, ending in the disruption of the Association and the power would feel obliged to save the medical side of the Act ruin of many practitioners. the Association with a view to taking over by approaching As to the alternative, Public Medical Service Scheme, it is its public medical service as a going concern and dovedoubtful whether Parliament would tolerate a scheme dealing tailing it into the Act ; whether by the issue of new with the national health which savoured of syndicalism. regulations or by the passing of an amending Act matters I am. Sir. vours faithfully. little to us. W. OWEN WILLIAMS. Mile End, August 20th, 1912. I put these disconnected views before you, Sir, in the hope that you will deal with them on their merits, and, in so far To the Editor of THE LANCET. as they appeal to you, will make them your own. I am. Sir. vours faithfullv. SIR,-From the beginning I have read the leading articles TELEMACHUS. in THE LANCET which have dealt week by week with the August 20th, 1912. position of our profession under the National Insurance *** We must all await the issue of the regulations with scheme, and have followed closely your reviews of the patience we can.-ED. L. changing situation and your words of guidance and of warnas each critical the ing phase arose. I think that profession owes much to THE LANCET for the judicial and independent I To the Editor of THE LANCET.. attitude which it has maintained through this long and anxious period, and for constantly bringing its readers back SIR,-During the long and arduous fight to which the to the main issues. I can well understand the pressure that medical profession has been committed in Great Britain, must have been brought to bear upon you to lean towards since Mr. Lloyd George launched his Insurance measure, it one extreme view or another and support some policy which has been interesting to read the comments which have been could not be maintained in the light of later events. made from time to time by the leading medical journalists But, although I see that clear leadership is difficult when of America, and not a little comforting to find that they are everything is still so chaotic and uncertain, I think the in sympathy with the principles underlying the claims, of present moment is one at which we must ask for more their British colleagues. The New lor74 3-redical Record, guidance from you. I belong to the large body of medical August 3rd, 1912, has a leading article entitled "The men
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557 Medical Revolution in Great Britain." The actual subject of the article is the recent refusal of the Representative Meeting of the British Medical Association to accept the Act as it stands. The writer, standing at some distance from the conflict, perceives the fact which is in danger of being lost sight of by the protagonists, that the chief defect in the medical service proposed by the Government is not the rate or method of payment, but the control of the profession by Friendly Society officials. He rightly says that it is this feature of the medical benefit section of the Act which is most bitterly resented by the profession. The capitation fee of "two dollars and ten cents," not including extras and medicine, is regarded as reasonable, and the writer says that when the cost of the medical man’s education and the responsibilities of practice are taken into account the assurance of Mr. Lloyd George in expecting him to become absolutely the servant of the public at a remuneration of less than$1500 a year is nothing less than remarkable ; especially in view of the sum of$2000 per annum paid to each member of the House of Commons for services requiring no special education and to a great extent perfunctory. One of his comments is particularly gratifying. He says that a notable feature of the situation is the sane, temperate, and dignified manner in which the question has been discussed by the leading medical journals of Great Britainin striking contrast to the heated appeals to party and class prejudice made by politicians responsible for the measure and by the lay journals interested in popularising their statements." The fact that the struggle for reasonable conditions of service is being watched by our colleagues in America with close attention should heighten the sense of responsibility with which the British profession is carrying on its controversy with the Government ; for it is a reminder that whatever the organisation of medical service issuing finally from the struggle, it will stand as a precedent to be copied more or less closely in other countries where hitherto no such organisation has been set up.
regarded as anaphylaxis did not follow any undue exertion (as Dr. Berry suggests), but occurred at a time when the patient was being confined rigidly to bed. 3. The sudden onset of a series of symptoms and signs, which faithfully
accorded with what has been described as anaphylaxis, whether occurring in man or in animals. On May 29th, after some 50 grains of thyroidectin had been taken in the course of several weeks, we found the patient suddenly confronted with intense distress in her breathing, which was shallow, irregular, and quick, numbering 90 per minute. There were intense lividity of the skin, acute pain in the epigastrium, marked tenderness over the region of the liver, intense icteric staining of the conjunctivas, and persistent vomiting and diarrhoea. In addition all the signs of severe shock were present. There was great coldness of the periphery, an anxious expression of the face, and a marked fall in the peripheral blood pressure. The pulse was very irregular and quick, numbering 160 per minute. The condition suggested to all her friends, to us, and to the patient herself, that death was imminent. Dr. Berry suggests that the condition was one of simple heart failure. We think there is evidence in support of our diagnosis of anaphylaxis. According to Schulz and Jordan this grave condition is caused by the liberation of toxic proteins in the blood. These proteins produce spasm of the muscle fibres in the walls of the bronchi and by folding of the mucosa the lumen comes to be partially or completely occluded, with resulting asphyxia. In like manner (as a recent annotation in THE LANCET suggests) the proteins cause spasm in the larger arteries, which leads to a marked fall in the peripheral blood pressure. The condition of our patient showed evidence of such a series of events. The most marked features present were the sudden onset of respiratory embarrassment and the great fall in the blood pressure in the peripheral vessels. With regard to the treatment we instituted with complete success, we consider that it goes far in supporting our T Sir. vours faithfullv. diagnosis. The reduction of the toxicity of the blood that BRISTOLIAN. occurs in cases of uraemia and eclampsia after venesection, and the marked increase in the agglutinative power of the To t7te Editor of THE LANCET. serum seen in typhoid patients after small hemorrhages, SIR,-One aspect of the many schemes put forward for led us to try venesection as the most efficient means in dealing with tuberculosis under the National Insurance Act our power of reducing the toxicity of the blood in our has struck me very forcibly. In almost every case-in anaphylactic patient. The significant fact is that not more than 6 oz. of blood counties, at any rate-the medical officers of health (and, were withdrawn from the vein. The almost instantaneous to the the absence of medical men on Insurance owing Committees, they are having things all their own way) relief that followed was, in our opinion, greater than can that they be appointed be explained by the mere mechanical effect exercised recommend, with sublime modesty, " chief tuberculosis officers."" The plea they urge-and how on an engorged right heart by the withdrawal of such It seemed more likely that well they know their councils !—is economy. The result a small quantity of blood. will be that in tuberculosis work, as in school medical work, it acted. by reducing the toxicity of the blood to an the junior appointments will be blind-alley appointments for extent sufficient to relieve bronchial and arterial spasm. whoever takes them up. The medical officer of health is to The administration of adrenalin chloride solution subsebe not only medical officer of health, but also chief tuber- quently quite efficiently raised the peripheral blood pressure. culosis officer and chief school medical officer, and neither of We are glad to have Dr. Berry’s assurance that further The condition is now apthe latter will be held qualified to be a medical officer of venesection was not required. health. parently that of uncomplicated exophthalmic goitre. We The best class of men, are content to leave to your readers the decision as to Further comment is needless. however, will hardly take up these appointments, or, having whether our diagnosis of anaphylaxis was justifiable. The been induced to accept them, will be unlikely to retain line of treatment we have suggested may, in any case, stand them when they realise the facts as to the prospects of as worthy of trial in cases of anaphylaxis ; and we think it advancement to a responsible post. Cooperation can be might with profit be made the subject of experiment on secured without making a demi-god of the medical officer of animals. We are, Sir, yours faithfully, JOHN R. O’BRIEN, M.D., health (who cannot be an expert in all things) and inciH. M. WILSON, M.B. dentally increasing his salary at the expense of those Glasgow, August 14th, 1912. actually doing the work. I am, Sir, yours faithfully, D. P. H. August 13th, 1912. PRE-OPERATIVE THE DIAGNOSIS OF ’’
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THE TREATMENT OF ANAPHYLACTIC SHOCK.
APPENDICITIS AND THE DORSAL METHOD OF EXAMINATION.
To the Editor of THE LANCET. SIR,-Our attention has been drawn to Dr. T. P. Berry’s criticism of our letter in your issue of June 8th. We still think wewere justified in regarding as 1, anaphylaxis the grave condition our subject of Graves’s disease suffered from after treatment with thyroidectin. May we refer briefly to the following significant features in the case ? 1. Dr. Berry’s admission that the patient exhibited marked intolerance to thyroidectin from the first. Hefound it necessary to reduce the dose by one-half." 2. The condition we
To the Editor of THE LANCET.
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SIR,-Will you permit me to dispel any misconception which might arise from the short notice given of the subject on p. 448 of your last issue ? The dorsal method does not profess to be an alternative for, or to be independent of, the present routine of diagnosis ; it is merely complementary to it. It is specially concerned with those cases which have been so far diagnosed as to raise the question of operation, because they call for all " the evidence and therefore render The following points a dorsal examination indispensable.