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a very serious drawback in its slow and sometimesvery irregular absorption, which may in some casesproduce severe intoxication, and in other cases a

feeble therapeutic effect. Treatment by inunctionspossesses the advantage of being reliable, effective,and painless. To obtain a rapid saturation of the body,the author suggests that it may be of advantage to giveat the beginning of the inunction treatment an injectionof the soluble salt of mercury, or simply a dose of 0’5 g.of calomel per os. The daily dose of ointment to beused should vary from 3 to 5 g. according to the size,&c., of the patient. The injection of soluble com-

pounds of mercury is not employed very muchnowadays owing to the necessity of daily treatment,but it is specially indicated in idiosyncrasia mercurialis,where a tendency to " hydrargyria cutanea " preventsthe use of inunctions.

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LONDON PANEL PRACTICE.

THERE are just over 1 million insured persons onthe lists of insurance practitioners in London. Ofthese 4060, or 1 in 380, gave notice at the New Yearthat they were desirous of making a change of doctor.The names of 207 insured persons were removed from

practitioners’ lists at request of the latter. During thethird quarter of last year just over 1 million pre-scriptions were given to insured persons, an average of0’67 a head at a cost of 9’64d. each prescription, theexpense being almost equally divided between the costof ingredients and the fee for dispensing. One practi-tioner, whose prescriptions for the first quarter of theyear averaged I’ll (instead of 0’92) a head at a costof 11’91d. (instead of 9’25d.) each prescription, was sur-charged X2 4s. 8d. by the Insurance Committee on theground that the drugs ordered were in excess of what wasreasonably necessary for adequate treatment. Severalof his patients received 25 or more mixtures each

during this period. Only 47 insured persons applied tobe allowed to make their own arrangements for medicalbenefit. Over 1,650,000 cards were issued for the newform of medical record which came into operation onJan. 1st. The current issue of the London Panel Com-mittee Gazette replies to certain general questionswhich have arisen as to the use of these cards.Practitioners are only required to record such clinicalnotes as they consider will be of use to them or to anypractitioner who may subsequently have the care of aninsured person. Where an independent record is keptof visits or attendances available for inspection by theregional medical officer it is allowed that after the firstvisit, or first three attendances, the total number ofthese may be entered weekly or monthly ; the date ofthe first (or initial) certificate and that of the last(or final) certificate only require to be recorded.

THE CONCENTRATING ACTIVITY OF THEGALL-BLADDER.

IT has long been recognised that the gall-bladdermust have a concentrating function, since bile from thegall-bladder is more concentrated or inspissated thanthat in the bile-ducts of the same animal. Previous

experiment 1 has shown that the fluid which collectsin bile-ducts artificially obstructed is an inspissatedtarry bile when the ducts communicate with the gall-bladder, whereas in ducts unconnected with thisviscus the fluid is thin and soon becomes free from

pigments and bile salts. Mr. P. Rous and Mr. P. D.McMaster, of the Rockefeller Institute, takingadvantage of the disposition of the bile-ducts in thedog, have sought to determine the rate of concentration.There are three hepatic ducts in the dog, whichunite to form a common bile-duct, with the cysticduct opening high up into the central one. Throughan opening near the lower end of this last a

catheter was pushed into the neck of the gall-bladder, which was emptied and washed with saltsolution, the duct being ligated after the catheter waswithdrawn. The bile from the middle lobes of theliver thus had no escape save into the gall-bladder,while that from the lobes to either side still reached

1 THE LANCET, 1920, ii., 864.

the common duct. From this it was collected into a,

rubber balloon placed in the peritoneal cavity, theabdominal cavity being then closed. A control experi-ment was made by substituting a similar balloon forthe gall-bladder, which showed that the separatedportions of bile differed little in their pigment content,which was taken as the index of concentration. After24 hours the gall-bladder, still undistended, wasregularly found to contain only one-sixth to one-

tenth as much fluid as was shown on calculationto have reached it, but this, thick and dark,was six to ten times as concentrated in pigmentas the control specimen in the rubber balloon. Theresults were the same when, without other varia-tions in the experiment, the gall-bladder was fllled tothe normal distension with sterile bile of knowncharacter prior to withdrawal of the catheter. At the

autopsy the branches of the hepatic duct always con-tained a thin bile like that in the balloon, a directproof that the thick contents of the gall-bladder hadnot come as such from the liver. It is thereforeevident that the gall-bladder can concentrate bile withvery great rapidity, and this raises the questionwhether concentration of the bile in periods of inter-mittent or partial stasis may not be an importantfavouring element in the formation of gall-stones.

FRIEDMANN’S VACCINE.

THE controversy over the merits of Friedmann’svaccine appears to be raging as vehemently as ever inthe German medical press and at medical meetings,the discussions at which are marked rather byheated partisanship than a judicial preference fortruth. In the Deutsche medizinische Wochenschrift forJan. 6th Professor W. Kruse, of Leipzig, complainsbitterly of the open hostility with which his addresson the subject of Friedmann’s vaccine at the MedicalSociety of Berlin was greeted by his audience. Hefound it most galling, while voicing his conviction thatthis vaccine is of incalculable importance both as aprophylactic and as a remedy for tuberculosis in theearly stages, to be constantly interrupted by cries of" Keep to the point." Professor J. Schwalbe’s answerto this complaint in the same number of thisjournal is to the effect that when a provincialprofessor comes to Berlin to teach his colleagueswisdom he should not exasperate them by mouthingplatitudes. The audience at the meeting of the BerlinMedical Society had come to hear what the director ofthe Hygienic Institute of the University of Leipzig hadto tell them of his experimental investigations into theaction of Friedmann’s vaccine, and only after they hadlistened for some time to such truisms as "...... thegerm of tuberculosis is evidently widely distributedand easily transmitted " had silent attention givenplace to interruptions. To outsiders unfamiliar withthe petulant atmosphere in which the Friedmann con-troversy has been enveloped for several years, it mustseem strange that after more than eight years’ trialthe remedy should still hold such an equivocal positionin the medical world.

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CARCINOMA OF THE PROSTATE.

Dr. H. C. Bumpus,1 of Rochester, Minnesota, hasmade a study of 362 cases of carcinoma of the prostateobserved at the Mayo clinic from 1914 to 1919 inclusive,with special reference to metastases. He considersthat metastasis to the glands occurs more frequentlythan is demonstrable clinically-in his series it wasfound in only 37, or 10’2 per cent.-because of theinaccessibility of the glands first involved. He statesthat clinically and microscopically carcinoma of the

prostate presents two fairly distinct types of enlarge-ment. In the first and more malignant type the glandis so slightly enlarged, and gives rise to so few localsymptoms, that the condition is often only recognisedby the symptoms produced by metastasis. In the morecommon type of carcinomatous prostate urinary sym-ptoms are more pronounced, and metastases occur later

1 Surgery, Gynecology, and Obstetrics, January, 1921.

292

than in the first type. Owing to its lesser degree ofmalignancy this type is more amenable to radium-

therapy. Dr. Bumpus estimates that one-third of thepatients with carcinoma of the prostate have osseousmetastases demonstrable by X rays, the most frequentsites being the pelvis, vertebrae, and femora. Pulmonaryinvolvement is rare and occurs late in the disease,probably never without metastases elsewhere. In Dr.

Bumpus’s three patients in whom metastases werefound in the lungs there was also pelvic and spinalinvolvement, and in two the ribs, and in one the femorawere also affected. Spinal cord involvement whichoccurred in eight of his cases closely simulates primaryspinal cord tumours, and is apt to occur when the

prostate is only slightly enlarged, giving rise to painsimulating intracostal neuralgia or aneurysmal pains.Owing to the absence of urinary symptoms in a con-siderable proportion of all cases with metastases-11’5 per cent. in the present series-the possibility ofcarcinoma of the prostate should always be consideredin men above middle age who complain of neuralgiaand rheumatic pain, even in the absence of urinarysymptoms. ___

MEDICAL PROVIDENT SCHEMES.

THE Sussex Provident Scheme for Hospital Benefitsand Additional Medical Services, of which we wereable to give the details in our issue of Jan. 15th, hasnot only gained the approval of all branches of themedical profession in the county of its origin, but isattracting a good deal of attention elsewhere. Andrightly, for, given a comprehensive medical servicedebarring no one from obtaining every known means ofdiagnosis and treatment, it does not much matterwhether it is paid for by a subscription or premiumaccording to means, or by a tax or rate. The essentialaim in either case is to organise a service which thepatients can afford and which will at the same timeafford fair remuneration to the doctors. The claimsmade on behalf of the Sussex Provident Scheme maybe briefly summarised thus :-

1. That it calls for no capital expenditure and entails noexpense either to the State, the rates, or the hospitals, nordoes it ask for charitable contributions.

2. That it provides the hospitals with a new source ofrevenue which has great financial possibilities and may helpto.save the voluntary system.

3. That it does not materially interfere with the presentwork or the established routine of the hospital.

4. That, although not offering general practitioner attend-ance, it supplies its members with all those facilities whichmay be necessary for their efficient treatment in illness, andwhich are not provided under the National Health InsuranceActs.

5. That the ready access to these facilities must tend tothe prevention and early arrest of disease, and so to animprovement in the standard of national health.

6. That it benefits the general practitioner by giving himwider facilities for diagnosis and treatment ; by keeping inhis hands many patients whom he would otherwise lose inhospital; and inasmuch as the members of the scheme canonly obtain its benefits through their doctor, by giving hima position of greater influence and prestige.

7. That it benefits the consultant by providing remunera-tion for those members of the honorary staffs of hospitalswho are willing to carry out its provisions with regard toconsultations, whether personal or by correspondence, atthe hospital; and by giving full fees for consultations at thepatient’s house, instead of the reduced fees which are nowso often accepted. It is also obvious that these consultationsare likely to be much more numerous when the generalpractitioner knows that they will entail no expense to hispatient.

8. That it gives an opportunity of profiting by hospitaltreatment to people of many classes whose circumstancesare really as necessitous as those of the manual worker, butwho have hitherto felt themselves debarred from accepting I

charity, and have shrunk from the publicity of a hospital.These ends are to be attained in the Sussex scheme

by bringing in all the nine cooperating general andspecial hospitals on a uniform basis. Urgent cases willbe admitted to hospitals as at present, other casesrequiring operation or other hospital treatment will,after consultation, be admitted to hospital, or be placedupon the waiting list of the hospital until there is avacant bed, but a member will not take precedence

over more urgent cases, and the ordinary hospitalroutine will not be disturbed. In all the cooperatinghospitals in which private beds are reserved at presentfor paying patients, members will be admitted to thesebeds if available, should they desire it, at a uniformreduction of 1 guinea a week from the usual price of thebed. The specific rules, which have been very carefullythought out for local needs, are as follows :-

1. No one will be accepted as a single member except an un-

married man or woman, or a widower or widow without childrenunder the age of 16. The subscription for a single member will beae1 per annum

2. Married people without children, or a widower or widow withonly one child under the age of 16 years, may only subscribe jointly ,

at a rate of ae11Os. per annum for the two, although each shall beaccounted a member.

3. Married people with a child or children under the age of 16, or awidower or widow with children under the age of 16 years, mayonly subscribe at a family rate of ae2 per annum, which shall includethe whole family, however large, except children over the age of 16,who must be accepted as single members, although each individualin the family shall be accounted a member. N.B.-These rates aresubject to revision by the cooperating hospitals after due notice.

4. All candidates for membership must be approved by theCommittee of Reference" formed by the cooperating hospitals.except in the case of those insured under the National HealthInsurance Acts, who will produce their medical card. In the eventof the eligibility of any member being questioned, the matter willbe submitted to the "Committee of Reference," whose decisionshall be final.

5. Cards of membership, bearing the date, will be issued on thefirst day of each month to those who have become members duringthe preceding month, and the benefits will begin on the date of thecard, and continue for one calendar year. These cards can beproduced as evidence of membership.

6. At the end of one year from the date of issue of the member-ship card the benefits will cease unless the subscription has beenrenewed. Fourteen days grace will be given for renewal (duringwhich no benefit will be available), but, after this, renewedmembership will only be possible from the beginning of the nextquarter.

7. When the number of members has reached the limit of thecapacity of the cooperative hospitals the list will be closed.

8. When a member is leaving the county within the first sixmonths of membership, and in consequence wishes to resign, one-half of the subscription will be repayable upon application’.

Consultation fees are to be drawn from a pool formedby deducting 25 per cent. of the moneys allotted to eachhospital, and it is obvious that the plan can be

similarly applied to the conditions ruling in other areas.It should be carefully noted that the Sussex scheme doesnot include general practitioner services and is restrictedto a maximum yearly income limit at present fixed atj6260 for single members and 500 for a family. Wepublish this week for comparison a scheme for a Londoncooperative polyclinic drawn up by Mr. C. A. Parker,honorary secretary of the State Medical Service Asso-ciation, which is of a still more inclusive nature and isintended also to cover the general practitioner service,and is not limited as regards maximum income. Ineach case the principle of assurance is the same, thefortunate by their annual contributions helping theirless fortunate brethren, adhesion being on a voluntarybasis.

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THE ACTION OF SUPRARENAL TOXIC SERUMON ATHEROMA.

THERE are two theories which hold the field withreference to the pathology of arterio-sclerosis, one

which regards hypertension as the principal factor inthe arterial lesions, the other which considers theselesions to be directly toxic in nature. Josue foundthat intravenous injections of adrenalin were followedby increase of arterial pressure, and subsequentlyproduced atheromatous lesions in the arteries. Certainobservers explain this experimental atheroma by thevasomotor, others by the toxic, action of the adrenalin,while others again, such as Lucien and Thevanot,hold that this substance acts simply through an

atheromatogenous action independent of the two

preceding. Observations by Etionne and Parisot,who, by submitting animals to intravenous injec-tions of adrenalin and at the same time of vaso-

dilatory substances, such as iodine and trinitrin,invariably obtained atheromatous lesions of theaorta, seem to indicate that increase of arterialpressure is not a necessary condition to the pro-duction of atheroma, and that this is, on the con-

trary, due to the atheromatogenous action of theadrenalin. Dr. Fabio Marabotto 1 has lately undertaken

1 Annali dell’ Istituto Maragliano, vol. viii., Fasc. 4, August, 1916.