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massage and manipulation and various forms of localtreatment.

J5<eoe?’ap.&mdash;Water may have various importantreactions upon the body-mechanically by its invalu-able support in exercising stiff and wasted muscles ;by the stimulus of its impact, as in douches or

whirlpool baths, or by an action attributable tosubstances which it holds in solution or suspension,

salt, sulphur, CO2, But its main therapeutic effectsin chronic arthritis are those which depend upon itstemperature. Hot baths, like protein shock, have alocal reaction and a general reaction. The localreaction is a hyperaemia, whilst the general reaction isa rise in the temperature of the skin, an increase inthe peripheral circulation, owing to enlargement of thecalibre of the surface blood-vessels, and a quickeningof metabolism. Many patients cannot take generalbaths, and are sufficiently treated by local heat andmanipulation. Heat applied to a limb as in thewhirlpool bath, at 4&deg; C., very greatly increases thelocal circulation, and the blood capillaries may be sodilated that the venous blood becomes arterial incharacter. The application of cold following theapplication of heat (thermal contrast) is anothermethod of stimulating reabsorption of arthriticexudates.Balneotherapy is of great service in almost all

forms of chronic arthritis for the following purposes :-1. For stimulating the immunising mechanism and for

aiding the absorption of inflammatory products-actionresembling to some extent that of protein shock.

2. For the restoration of the cutaneous reaction, and forpromoting elimination through the skin (diaphoresis), andin through the kidneys (diuresis).

3. For the relief of pain.4. For aiding (by the relief of muscular spasm and by

obviating gravity) the re-education of function in jointsand muscles stiffened or deformed by previous inflammation.

The second of these functions-the restoration ofcutaneous reaction-is of great importance.A healthy skin has many functions besides its protective

action. By the ingenious mechanism of its capillarycirculation (in which it is said one-third of the blood canbe accommodated when fully dilated) it is the principalorgan for regulating temperature, and for the conservationor loss of heat ; it is an important agent in elimination ofwaste and toxic substances, and, in addition, recent workhas made it appear in the new light of a great gland withan internal as well as an external secretion. The skin hasa hard time in civilised life, and in patients with rheumatoidarthritis obvious signs of defective skin action are seen ;beauty is lost, the skin is pale, sallow (or even pigmented)and unattractive, the mechanism of heat regulation seemsjammed on the " off " side (to borrow a railway carriagemetaphor), the surface temperature is low, the skin feelscold, and unnatural sweat comes from palms and soles. iThe patient has lost the glow of health and feels miserablycold with the shiveriness of toxaemia. Balneotherapyattempts to encourage and re-educate the patient’s skinback to the " full flush " of health.

Balneotherapy is rather an art than a science, andit is almost impossible to give precise indications forits use. In general, however, baths and other forms ofphysical treatment are contra-indicated in the activefebrile stages of any arthritis, whilst if a patient hasa removable focus of infection it is bad practice tocommence balneotherapy or physical treatmentbefore that focus be removed, save only perhaps forthe relief of pain, and in certain somewhat rare caseswhere it is judged that the patient’s resistance hasbeen so lowered that physical treatment should comefirst, with a view to increasing the resistance suffi-

ciently to allow the focus to be safely removed. Twoor more forms of phvsical treatment administeredtogether are more likely to do good than if they aregiven separately.Diathermy is a form of heat which is of great service,

and is increasingly applied both to the joints them-selves and in treating foci of infection.

’

Facilities for Treatment.Hydrological methods have their best hope of

success when the patient can devote his whole timeto the treatment in favourable surroundings-e.g.,

at a. spa-with the advantages of change of air andregimen, and sometimes with the additional assistanceto be obtained from natural mineral waters. Manvforms of hydrological treatment can, however, be

I given with great benefit to patients using ordinarvwaters at hospitals other than those at the spas, andat out-patient clinics. Their employment requiresspecial experience, a specially trained staff, andsuitable equipment.The report concludes, after references to surgical

measures, with a section on the facilities for treatingadult rheumatic disorders in this country, includinga brief account of the spa hospitals. The need forfurther provision is emphasised, and recommendationsare made concerning the establishment of physicaltreatment centres and " arthritis units." An appen-dix on the treatment of rheumatism by physicalmethods in Germany is contributed by Dr. FortescueFox and Dr. Margarethe Mautner.

IRELAND.

(FROM OUR OWN CORRESPONDENT.)

Local Appointments.THE medical profession in the Irish Free State is;

much interested in the Local Authorities (Officers andEmployees) Bill introduced to the Dail last week bvMr. de Valera. The object of the Bill is to amend theLocal Authorities (Officers and Employees) Act of 1926in one particular. That Act provided that appoint-ments under local authorities should be made on thenomination of a central board set up by the Govern-ment, the Local Appointments Board, only one

nomination being made in each case. Mr. de Valeraproposes that instead of naming one person to beappointed the Board should submit a panel of namesfrom which the local authority should choose one.

His argument was that the local authority should notbe deprived of all power of choice in the selection oftheir officers. In opposing the Bill Mr. W. Cosgrave,President of the Executive Council, said that the Acthad been introduced for one main purpose-to securein the appointment the best qualified persons.Under the Bill now before the House local authoritieswere to be invited to ask for a panel of not less thanthree. This would mean that canvassing and localinfluence would be resurrected. The purpose of

sending down more than one name could only be to-invite the local authorities to appoint someone otherthan the best qualified candidate. He further statedthat the standard of applicants for the various postshad been good. Mr. T. J. O’Connell, the leader of theLabour Party, also opposed the Bill. He said thatappointments, whether made under the centralgovernment or under local authorities, and themethod of making them, should be above party. Heasked that there should be an inquiry into theworking of the original Act, subsequent to which theremight be, if necessary, agreed legislation. Mr. E.Blythe, Minister for Finance, agreed that an inquiryinto the working of the Act might be extremely useful.One of the results of the present system was thatthere had been great numbers of candidates comingforward, which showed that they had confidence in themethods by which they could be appointed. He sawno reason why officials should be chosen by a localauthority which they had to serve under, just as hesaw no reason why civil servants should be chosen bya Minister, because officials were no more the servantsof council or local authority than civil servantswere the servants of the Minister. Dr. T. Hennessvsaid that before the passing of the Act it oftenhappened that a candidate-a medical candidate-passed his final examination one day, had his degreeconferred, and then went down the day afterwardsand got elected to a position. Professional experiencehad mattered little so long as he had influentialfriends enough on the local board. Dr. Ward saidthat the corruption practised by public bodies in the

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country had been put to shame by the corruptionpractised at headquarters. The difference was thatwhen there was a big case of corruption in thecountry it was exposed, but the corruption practisedat headquarters did not see the light of day. To whichMr. R. Mulcahy, Minister for Local Government andPublic Health, replied that if there were details tosubstantiate the charge that the work of the LocalAppointments Commission was tinged with corruption,those details should be given.

Medical opinion in Ireland is strongly against anyweakening of the Act of 1926. In the opinion ofmany that Act was the greatest reform in localadministration in the history of the countrv. Itensured that the appointment of local officials shouldbe made by an independent body, assisted by experts,and thereby it ensured the gradual establishment ofan efficient local government service. Medical menrealise that appointments are now given on meritand not on grounds of family or political influence, andthere is no doubt that the standard of entrants to thepublic medical service is improving. The only furtherchange desired by medical opinion is one suggested inthe debate by Mr. O’Reilly, an Opposition Member,- namely, the conversion of the local governmentservice with a civil service. The medical professionhas long been asking for a National Medical Service.

Royal College of Stirgeons in Ireland.The annual election of officers and council of the

Royal College of Surgeons in Ireland took place lastweek. Mr. T. E. Gordon, who has been elected

President, is professor of surgery in Trinity Collegeand senior surgeon to the Adelaide Hospital. Heserved in the war at the " Dublin " (83) Hospital,with the rank of Lieut.-Colonel. Mr. R. A. Stoney, thenew Vice-President, is senior surgeon to the RoyalCity of Dublin Hospital. He served in the war in theFrench army, with the rank of Medecin Majeur, and

Iis a Chevalier of the Legion of Honour.

" FINCLURE."

" Finclure, Cent. London " is the telegraphic addressof the Surgical and Medical Protection Union ofLondon. Ltd., a body which is seeking the support ofthe medical profession on grounds which are set outin the following circular, placed in our hands by acorrespondent :-

May, 1928.DEAR Sin,&mdash;The attention of all Surgical and Medical

Practitioners is urgently directed to the great risks whichthey incur by remaining outside the Union. The number ofclaims is greatly increasing, and it cannot be too clearlyemphasised that any member of these professions who failsto enrol as a subscriber is assuming very serious risks, whichno prudent person would accept. The annual subscriptionis 21 per annum, and to practitioners tcho are tran8ferrinqfrom another Defence Society, the subscription is 15s., and willbe retained at that sum for at least three years. iNo entrancefee is payable on admission. The subscription includes aninsurance, unlimited in amount, and all costs, in cases whichmay be raised against a Subscriber, in which he may befound liable in damages. In view of the verdicts of juries Iin such cases as Harnett v. Bond and Adanzs, it is essentialthat full protection should be given against any awardwhich may be made. This Union undertakes to defend theirSubscribers against all claims which may be made againstthem, in respect of their professional work, including liability,not only for the acts of the Subscriber himself, but of allassistants and dispensers in his employment, and of otherpractitioners acting on his behalf. A separate indemnitycontract is delivered to each Subscriber in his own favour.

In addition to the great security which is afforded byjoining the Union, various advantages are offered, theparticulars of which are attached hereto.A form of application is sent herewith.

Yours faithfully,W. h’I1DL3Y.

Secretary and Treasztrer.This circular letter emanates from Atlantic House,

45, Holburn Viaduct, London, E.C., and apparentlyfrom a small office on an elevated floor of thebuilding, but there is a second address on the letter,

indicating that the Union has a Scottish departmentlocated at 86, St. Vincent-street, Glasgow, where theaccommodation may be more in keeping with thepromises of the secretary and treasurer of the newactivity. We do not know if Mr. W. Findlay isor is not the same person who has figured in the" Handbook for Recently Qualified Medical Practi-tioners " as secretary of the Medical and DentalDefence Union of Scotland, Ltd., 155, St. Vincent-street, Glasgow.The following are the particulars of the advantages

of joining this movement which are set out in thecircular :-

1. Subscribers have an unlimited cover for damageswhich may be awarded, and an individual IndemnityContract is delivered to each Subscriber when joining.

2. All cases in which the Subscriber is attacked profes-sionally are taken up by the Union and defended, icithoiitany discretionary power to refuse defence.

3. Special " Surgical and Medical" Insurance Policiescan be obtained through the Union for life, personal accident,motor car, sickness, and other risks. Special Insurancearrangements are offered making provision for the Widowsand Children of Surgical and Medical Practitioners in theevent of death. The Insurance offered is by one of thebest Insurance Companies. The terms offered are excep-tionally favourable, and, owing to the privileges which 3,Union is able to obtain, much more advantageous than canbe obtained otherwise. These " Surgical and MedicalPolicies can only be issued to Subscribers to this Union.

4. Subscribers are entitled to obtain legal advice on allmatters relating to their professional work direct from theSolicitors and Counsel, and complete confidentiality is thussecured. Subscribers may rely on the fact that their privateaffairs on the matters regarding which they desire to beguided will be entirely free from the knowledge of anyonebut the Solicitors and Counsel (where the latter require tobe employed).

I There are also set out in this communicative circular" other facilities available to subscribers," the terms-for which can be obtained on application to lTr.

Findlay. These include the buying and selling ofpractices and houses, with arrangement for financialhelp, the drawing up of agreements for partnershipsand assistancies, the preparation of income-taxreturns, the audit of professional books, and adviceon investments.Upon the advantages set out above the following

comments seem fair :-(1) An individual indemnity contract is of no use

if he who offers it cannot fulfil the terms. (2) Withouta discretionary power to refuse defence, Mr. Findlaywill be compelled to mediate legally in cases where hewill be forced to meet damages and costs in actionswhich should never have been undertaken-often forprofessional reasons. (3) The Medical InsuranceAgency is already in a position to obtain favourableterms for insurance of all sorts for medical men.while paying substantial sums in support of medicalcharities. (4) It will be noted that solicitors otherthan Mr. Findlay are going to give legal advice on theconduct of medical practice with complete confi-dentiality ; is this funny promise a suggestion thatsolicitors and counsel are going to give their assist-ance gratuitously, or what is implied by the word" entitled " ?The medical profession may wish to be guided

in their decisions as to reply. The title of the newassociation is very reminiscent of the titles of the twowell-known and substantial medical defence societiesalready discharging with increasing efficiency many ofthe responsibilities which Mr. Findlay is ready toassume. The offer to do the work of these societiesand much more than their work for 15s. per annuminstead of 21 per annum can only be worth consideringif Mr. Findlay can prove the present command oflarge capital. No directors are mentioned and notrustees, and there is no guarantee that Mr. Findlaypossesses any resources from which to meet liabilitiesrightly described by himself as " unlimited inamount." Thus " the great security ... afforded byjoining the Union " is obviously absent, and we cannotrecommend our subscribers either to pay an annual feeof Bl in response to Mr. Findlay’s invitation. or todesert either of the well-known medical defence