THE NATIONAL INSURANCE SCHEME AND MEDICAL FEES.

1306

ON THE SUPRAPUBIC TRANSVERSE FASCIAL INCISION.

year in all but one child, and in two cases four years was recorded as the length of history. It will surely be conceded that where chronic sinuses have been present for any length of time the disease ceases to be a true tuberculous arthritis, and, especially in children, amyloid disease is apt a

To the Editor of THE LANCET. whose practice of transverse abdominal to develop. SiR,-To It is the onset of amyloid degeneration in patients suffer. incisions extends over a period of about eight years, Dr. T. Wilson’s interesting paper in your issue of May 6th, adds ing from joint and bone disease with persistent sinuses welcome support to a method of procedure which is as truly which determines the incurability of the condition, and, advantageous as it is anatomically correct. But I should oftentimes, the fatal issue of the case. Now it is clear that like to lead Dr. Wilson to still further improvements, and in Case 4 of Mr. Chapple’s series this condition was present, that is, in the first place, by suggesting to him to make his as the boy had hectic fever, diarrhoea, and albuminuria, and final incision into the peritoneal cavity also transversely, and I think most authorities will agree that such are the late so follow out logically the correct reasoning he employs for symptoms of this disease. What are the early symptoms of adopting the transverse division of the aponeurosis in front amyloid disease ? The answer to this question is difficult, of the recti. Some years ago Dr. J. Oleland, then professor of for there are none which can be described as characteristic of anatomy in the University of Glasgow, pointed out that very the early stages unless constipation and staining of the skin, frequently the posterior sheaths of the recti did not terminate present in nearly all Mr. Chapple’s cases, can be so regarded. midway between the umbilicus and the pubes in the fold of I venture to suggest that the benefits of Mr. Lane’s operation Douglas but extended down to the pubes, so that there of excluding the colon may be in the direction of arresting or existed both in front and behind the recti muscles preventing amyloid degeneration of the viscera, and I should an enveloping sheath of transversely disposed fibres. be glad if Mr. Chapple would give some further details as This disposition I have frequently observed and pointed to the presence or absence of "amyloid symptoms," both out to those assisting me at operations. If, there- before and after operation, in his series of cases. Enlargefore, the reason for cutting the aponeurosis transversely in ment of the liver and spleen are doubtless late signs of front of the rectus is to avoid cross division of the tendinous amyloid disease, but their condition might well have been fibres, equally should the cut be carried in the same direc- recorded, together with a report on the urine. tion when the deeper or final incision is made into the Experimentally, amyloid disease has been produced by reperitoneal cavity. In the second place, may I also suggest, peated inoculation of cultures of the staphylococcus pyogenes as furthering the claims which Dr. Wilson otherwise so well aureus and of the bacillus pyocyaneus. Is it not possible advances, that freer access to the deeper seats of operation that in the human subject the toxins which cause this as well as greater expeditiousness in execution may, when degeneration of the viscera are absorbed from the large desirable, be safely attained by dividing, in part or wholly, intestine ? It is certainly the abdominal organs which In making this exhibit demonstrable amyloid change more commonly than the muscle fibres of one or both recti. somewhat bold suggestion in the face of a practice which other viscera. Another fact, which, if my theory is correct, has been hitherto all but religiously condemned I do so is easily comprehended, is that Mr. Chapple appears to be advisedly. Not only do I know that free access facilitates less certain as to the cure of those cases where sinuses were greatly the rapidity and safety with which an abdominal not present. In these probably there were no beginnings of operation can be performed, and that expeditiousness in amyloid disease. If, therefore, Mr. Lane has hit upon abdominal work is an all-important factor regarding the a satisfactory method of treatment for amyloid disease, nature of recovery, immediate or remote, but that a perfectly great progress has been made, and I think this suggestion firm cicatrix can be obtained secure against any future appears more rational than that tuberculous arthritis can be development of hernia. The acquisition of the latter is not cured by exclusion of the colon. I am, Sir, yours faithfully, dependent,on the union of the divided muscle fibres, but on J. E. ADAMS. the close and accurate coaptation of the divided sheaths Wimpole-atreet, W., May 2nd, 1911. both in front and behind the recti. Although Dr. Wilson has not done me the honour of referring, amidst his many useful references, to my own pubOF THE ROYAL INSTITUTE OF lished work, I think he will not deem my suggestions more PUBLIC HEALTH. DUBLIN. 1911. than warranted if I ask him, at his leisure, to refer to an exhaustive contribution on the subject which I delivered To the Editor of THE LANCET. before the Surgical Section of the British Medical Associawe, through the medium of your journal, request tion at Exeter in 1907, and published in extenso in the allSIR,-May those who intend to contribute papers to the Congress of Association’s Journal for October of the same year, p. 895. the Royal Institute of Public Health (to be held August 15th My main argument was then, and is still, that the reasons to August 21st, 1911) to send in the titles to the honorary for the selection of any particular course for an abdominal secretaries of the section or to the undersigned at their very incision, whether above or below the umbilicus, should be earliest convenience.-We are, Sir, yours faithfully, based on sound physiological and anatomical grounds ; and HENRY CAMPBELL, that the more this aspect of the question is exclusively conCHARLES A. Hon. Sees. sidered, the more will it be found that transverse and not E. MAGENNIS, vertical incisions are the true lines of election. Offices: Municipal Buildings, Cork Hill, Dublin, I am, Sir, yours faithfully, May 9th, 1911. A. ERNEST MAYLARD. Glasgow, May 8th, 1911. one

CONGRESS

CAMERON,

A CONSIDERATION OF SOME CASES OF ADVANCED TUBERCULAR JOINTS TREATED BY ILEO-COLOSTOMY.

THE NATIONAL INSURANCE SCHEME AND MEDICAL FEES.

To the Editor of THE LANCET. SIR,-The proposed insurance against sickness, invalidity, To the Editor of THE LANCET. and unemployment is the inevitable result of the fact brought SIR,-No one, I think, who reads the article under the out by the recent Royal Commission that there is a large above title by Mr. Harold Chapple in THE LANCET of class of the community in the position of potential pauperism April 29th can fail to be deeply interested, and the excellent and in need of assistance when the thin line of independence records of this operation must evoke admiration for the work has been crossed. Sickness is responsible for a third of this of Mr. Arbuthnot Lane. A careful scrutiny of the eight poverty, and has been called recently "the bedrock of cases described, however, raises the question as to whether pauperism." Bound up with the cost of sickness is the the operation performed can be regarded as a therapeutic expense of medical attendance, which, in the interests of the remedy for tuberculous arthritis. In the first place, all the nation as well as the individual, should be adequate and patients were children, the oldest being only 12 years of efficient. Hitherto, it has been slipshod from no fault of the age; secondly, suppuration was present in five out of the profession, but from the inability of the patients to pay eight cases, and of these five, four had chronic discharging reasonable fees, without which medical men could not exist. sinuses ; thirdly, the disease had been in existence for over Sooner or later the provision of medical attendance must be

1307 made in connexion with the insurance scheme, and the

cent., servants’ wages

increased 1UU per

cent., purchasing

community, as is just, be asked to contribute to this power of the rupee decreased 50 per cent., a longer necessary part of the project, the burden of which has been and more specialised medical course, practically no private borne hitherto by the profession alone until it has proved practice outside large towns, and even these getting too heavy. The time has come for a reasonable scale of fees gradually less, and pay increased on the average by 10 per to be fixed for medical work, as has long been done for the oent. These are bald facts which require no proving. In the other Indian services, owing to paucity of comlegal profession, and the present scandalous standard must not be taken as the model on which it has to be built. petition, the pay has been substantially increased and the Employees, employers, and even public corporations have conditions of service improved, so much so that a casual succeeded in beating down a disunited and overcrowded pro- glance into any provincial civil list will show that in some fession to starvation rates, and these must not be recognised as cases officers of 25 years of age in those services draw as anything else than sweating terms. On the other hand, the much as officers 10 years their senior in age in the Indian profession should not be guilty of the folly of making Medical Service. In view of the above it is difficult to understand why anydemands which cannot be accepted by the Government, and which would be looked upon as extortionate by the public. one elects to enter the Indian Medical Service when much However valuable it is or may think itself it cannot afford to force its demands on an unwilling nation, for there are plenty of needy men in its own ranks who would readily face the ostracism of their brethren if they could be assured of the sympathy of the public, and there are hosts of people, such into whose hands much medical work is as midwives, &c., even now passing, ready to absorb more of it. The idea that the State is at the back of the scheme and has an unlimited purse is tempting some medical societies to make larger claims than they would otherwise do. This is rank Socialism and in no way differs from the Social Democratic Party and Independent Labour Party in their demands for State bounties. We cannot without loss of dignity and independence ask our neighbours to pay us fees greater than we would otherwise demand from people of narrow means. The guinea fee for a confinement becomes two or even three for a working man’s wife ; a dislocation or fracture is to cost £5 ; vaccination 5s. ; and the capitation rate per man, woman, and child 15s., and so forth. It will not do. The intentions of the Government being now disclosed, possibly in a tentative form, will be a disappointment to those who are responsible for advancing such claims as I have referred to. above. The plea that it is necessary to make greater demands than were meant to be accepted savours too much of commercialism. Since the scheme suggests a uniform rate of contribution at all ages, and only slightly reduces the benefits between 50 and 65, the heavy initial cost admitted by the Chancellor will press hardly on the profession in increased attendance at the older ages, and the capitation rate of 4s. is grossly inadequate. It will also come as a blow that the friendly societies, however carefully selected, are to administer the benefits. The profession must have an adequate share in the administration of those funds which affect medical attendance, or the old friction with the friendly societies will continue as heretofore. I will not presume as an individual to criticise so complicated a scheme, but trust that a conciliatory attitude will be maintained on both sides in carrying out this great reform. I am, Sir, yours faithfully, M.D. 1911. May 10th,

better prospects at about one-third the initial expenditure in both money and time are offered in the other Indian

services. The facts seem to be overlooked that Indian Medical Service officers enter the service on the average later in life than officers in any other Indian service, that the expenses of their education are greater than any other, not even excluding the Indian Civil Service, and that they are still spending money on their education while their school contemporaries who have entered other services are earning it. It is to be hoped that the time has come for the Indian Government to substantially increase the emoluments of Indian Medical Service officers if they wish the service to maintain its glorious traditions. I am, Sir, yours faithfully, M.B. April 9th, 1911. ’" * We comment elsewhere upon this letter.-ED. L.

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EMOLUMENTS IN THE INDIAN MEDICAL SERVICE. To the Editor of THE LANCET. SIR,-The profession in England is apparently beginning to realise at last that the prospects of a career in the Indian Medical Service are not what they used to be. It seems, at any rate, that this is the case from the paucity of candidates that have appeared at the last three examinations. That there is much discontent in the service there is no doubt, but as long as candidates can be induced to appear for examination, even in small numbers, there appears to be very little hope of redress. There will always be candidates, even with the conditions as they are at present, as there will always be a large number of natives of India ready and willing to enter the service, as gazetted rank gives them a standing which they otherwise would not have. For the European, however, the service has none of the attractions that it used to have. In the past these attractions were: cheap living, cheap sport, small wages to servants, a rupee of large purchasing power, a shorter and less expensive medical course, and for those in the civil branch of the service private practice and good fees. What a contrast do we find now: cost of living increased 100 per

CONGRESS OF THE GERMAN SURGICAL ASSOCIATION. (FROM OUR BERLIN CORRESPONDENT.) THE German Surgical Association held its annual in Berlin from April 19th to 22nd, Professor REHN fort) being in the chair.

meeting (Frank-

Disinfection of the Hands and of the Field of Operation. Professor KVTTNER (Breslau) had made a collective investigation in 210 clinics and hospitals of Germany on the methods used for disinfection. A reliable disinfection was difficult of attainment for three reasons : first, because the bacteria penetrated to the deeper layers of the skin, to the hair-follicles, and sweat glands; secondly, because they were embedded in fat, so that the action of disinfectants became inefficacious ; and thirdly, because the time available for disinfection was too small to destroy the germs. There were three ways to improve disinfection. 1. More efficacious chemical compounds must be found. The modern mercurial preparations, such as iodide of mercury, oxycyanide of mercury, and sublamin, were by no means preferable to sublimate ; and the same was the case with formalin; phenol, kresol, and chloride compounds gave relatively the best results. 2. The mechanical methods of disinfection of the hands must be made more reliable; the use of sand, marl, soap, &c., proved to have no advantages. It was tried to fix the bacteria to their place by tanning the skin with alcohol, and it was found that the disinfection by pure alcohol was as efficacious as the former complicated methods. A solution of soap in spirit gave bad results. 3. To avoid the hands coming in contact with the wound impermeable covers were used, especially rubber gloves; they were efficacious, but very expensive, and had the additional drawback that they often burst. They must be sterilised by steam. The disinfection of the field of operation had made the greatest progress by the method of Dr. Grossich-viz., painting the skin with tincture of iodine; it had become nearly the standard method, being in use in 187 out of 210 clinics and hospitals.l Eczema could be avoided by using a 5 per cent. instead of a 10 per cent. tincture and only a fresh preparation and abstaining from the use of other compounds with the iodine. Dr. N6TZEL (Saarbrucken) spoke on the disinfection of 1

THE LANCET, 1910, vol. i., p. 336.