405 payment. There is no cost of collection and there are no bad debts. There is also the important difference that the doctor does not dispense for his insurance patient, whereas in industrial practice he ordinarily has to provide medicine for his private patient, and his fee in the case of the private patient, therefore, covers that as well as the attendance. Persons Who Do Not Choose a Doctor. The number of persons for whom the doctors collectively are paid depends, it will be seen, upon an estimate of the whole insured population made by the Government Actuary, and not on the number who actually get on to doctors’ lists. (Q. 1452.) The doctors are paid for all such persons because they are at risk in respect of them, and have to give them treat- ment when they fall ill. For this reason no great importance is attached to the question of the actual number of such persons, which probably corresponds very closely with the number of fresh persons (about half a million) entering insurance each year. In the case of younger entrants particularly there is a tendency not to take any steps in the direction of getting on the list of a doctor until his services are needed. Mileage Payment for Country Doctors. (Q. 1463.) I see that the mileage grants have increased from .826,000 for England in 1913 to ;/3250,000 in 1924, though apparently the latter figure covers Wales also. Can you indicate why such a large increase was made ?- A. Because the whole basis on which mileage was calculated had to be revised. We started on the assumption that it was only necessary to make provision for areas of very special sparsity and difficulties of locomotion.... It was agreed at the beginning of 1920 that a mileage fund should be set up in order to pay the rural practitioner both for his expense in getting to the patient and also for the time spent in travelling over and above the time that would on the average be spent by the town doctor. The mileage fund, as from the beginning of 1920, had therefore to provide additional payments for all rural practitioners, and not only, as in 1913, for those practising in exceptionally difficult districts. (Q. 1465.) In the distribution of the Central Mileage Fund between areas the Minister has the advice of the Distribution Committee referred to above. The distribution of the local pool is based mainly on the number of persons on the lists of the doctors who claim mileage, and their distances from those doctors, with extra provisions for areas in which there are special difficulties-for example, where a man lives in the middle of a moor and has to be reached by footpath instead of by car. - Town v. Country. (Q. 1514-17.) Questions elicited the general view from the witnesses that the town doctor has profited more by the Insurance Acts than the country doctor. The country doctor is less well off-- partly because now he only gets the insurance capitation rate in respect of a number of people-indoor and outdoor servants of the squire, for instance-for whom before the Insurance Act he used to be paid at a pretty liberal rate. It is difficult to say how far that is due to the Act or how far the doctor is suffering from the impoverishment of the class that used to keep up big country places. Also the country doctor is suffering from the increased mobility of the town doctor. ROYAL COMMISSION ON LUNACY AND MENTAL DISORDER. FURTHER SITTINGS. (Continued from p. 301.) THE Commission resumed its sittings on Monday, I Feb. 9th, when Mr. Montgomery Parker continued his I evidence, speaking on behalf of the National Society for Lunacy Reform. He said that when patients were too poor to pay for the services of medical men from outside, the Society considered that financial l assistance should be granted, perhaps annually. As to the discharge of lunatics, it was thought by his Society that the petitioner’s arbitrary power to either discharge or not led to frequent abuse; sometimes members of the family shrank from the trouble attendant on the return of the patient, and occasionally there was a fear of legal action being taken. Additional power of discharge, he insisted, should be vested in a judicial authority, without the right of veto now enjoyed by individual authorities ; for licensed houses and hospitals the judicial authority should have the right of discharge. Licensed houses, Mr. Parker thought, should not be conducted with the object of making profit; some of them made larger profits than the public had any knowledge of. Their number should not be increased, and in that he was opposed to the British Medical Association. There might be a financial motive for detaining patients in these institutions. He also objected to what he termed the autocratic powers of medical superintendents of mental hospitals ; he stated that long periods sometimes intervened without a patient seeing the medical superintendent at all. He agreed with the suggestion contained in a question by Lord Russell, that the appointment of a medical superintendent should not be permanent until he had occupied the post three years. Allegations of Physical Violence. Mr. Parker said numerous statements which his Society had received from patients did not allow of any doubt that on occasions physical violence was practised on patients. It was, he said, a feature of the age to substitute chemical violence for physical, and that was more difficult of detection. Some explanation of the use in these institutions of hyoscine was, he submitted, called for ; also croton oil, the most painful and powerful purgative known. The Commission should inform itself of the purchases of croton oil over a definite period at all mental institutions. The Board of Control could deniind this. Mr. Parker was again in the witness-chair on Tuesday, when he continued his statements con- cerning the use of drugs in asylums, his main conten- tion being that the disciplinary measures now usual were cruel. Environment, he said, had the greatest influence in the progress of a patient towards normal health, and so should receive close scrutiny. He alleged, in regard to treatment, that often the con- trolling factor was not the interest of the patient. but finance. It was a pity that the Board of Control had only recently pressed for a more extended use of open-air treatment ; and there should be freer facilities for exercise. Private asylums should be required to render returns of recoveries to the Board of Control. It was not now necessary. A further point which Mr. Parker made was that the medical staffs in these institutions must be considerably augmented. In some asylums there was practically no trained nursing staff. He pleaded also for more facilities for recreation and amusement and the use of small libraries. ’ The meeting was adjourned to Feb. 24th. NOTES FROM INDIA. (BY AN OCCASIONAL CORRESPONDENT.) - Medical Relief in Rural Areas. THE problem of bringing medical relief within easy reach of the rural population has been engaging the attention of the authorities for some time. The existing facilities in this respect are extremely inade- quate. The great mass of the village populations have hitherto had no opportunity of coming into intimate daily touch with qualified doctors and have had to be content to a great extent with the services of unqualified men. Schemes for dealing with the diffi- cult situation have been drafted by both the Bombay and Madras Governments. In the latter the only solu- tion possible with the funds at present at the disposal of the Government seems to be on one of the three following alternative lines-namely, (1) the opening of a large number of Ayurvedic and Unani dispensaries, (2) the starting of a large number of itinerating or travelling dispensaries, and (3) the encouragement of
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payment. There is no cost of collection and there are nobad debts. There is also the important difference that thedoctor does not dispense for his insurance patient, whereasin industrial practice he ordinarily has to provide medicinefor his private patient, and his fee in the case of the privatepatient, therefore, covers that as well as the attendance.
Persons Who Do Not Choose a Doctor.The number of persons for whom the doctors
collectively are paid depends, it will be seen, upon anestimate of the whole insured population made by theGovernment Actuary, and not on the number whoactually get on to doctors’ lists. (Q. 1452.) Thedoctors are paid for all such persons because they are atrisk in respect of them, and have to give them treat-ment when they fall ill. For this reason no greatimportance is attached to the question of the actualnumber of such persons, which probably correspondsvery closely with the number of fresh persons (abouthalf a million) entering insurance each year. In thecase of younger entrants particularly there is a
tendency not to take any steps in the direction ofgetting on the list of a doctor until his services areneeded.
Mileage Payment for Country Doctors.(Q. 1463.) I see that the mileage grants have increased
from .826,000 for England in 1913 to ;/3250,000 in 1924,though apparently the latter figure covers Wales also.Can you indicate why such a large increase was made ?-A. Because the whole basis on which mileage was calculatedhad to be revised. We started on the assumption that it wasonly necessary to make provision for areas of very special sparsity and difficulties of locomotion.... It was agreed at the beginning of 1920 that a mileage fund should be set upin order to pay the rural practitioner both for his expensein getting to the patient and also for the time spent intravelling over and above the time that would on the averagebe spent by the town doctor. The mileage fund, as from thebeginning of 1920, had therefore to provide additionalpayments for all rural practitioners, and not only, as in1913, for those practising in exceptionally difficult districts.
(Q. 1465.) In the distribution of the Central MileageFund between areas the Minister has the advice ofthe Distribution Committee referred to above. Thedistribution of the local pool is based mainly on thenumber of persons on the lists of the doctors whoclaim mileage, and their distances from those doctors,with extra provisions for areas in which there arespecial difficulties-for example, where a man livesin the middle of a moor and has to be reached byfootpath instead of by car.
-
Town v. Country.(Q. 1514-17.) Questions elicited the general view
from the witnesses that the town doctor has profitedmore by the Insurance Acts than the country doctor.The country doctor is less well off--partly because now he only gets the insurance capitationrate in respect of a number of people-indoor and outdoorservants of the squire, for instance-for whom before theInsurance Act he used to be paid at a pretty liberal rate.It is difficult to say how far that is due to the Act or how farthe doctor is suffering from the impoverishment of the classthat used to keep up big country places.
Also the country doctor is suffering from theincreased mobility of the town doctor.
ROYAL COMMISSION ON LUNACYAND MENTAL DISORDER.
FURTHER SITTINGS.(Continued from p. 301.)
THE Commission resumed its sittings on Monday, IFeb. 9th, when Mr. Montgomery Parker continued his Ievidence, speaking on behalf of the National Societyfor Lunacy Reform. He said that when patients were too poor to pay for the services of medical men from outside, the Society considered that financial lassistance should be granted, perhaps annually.As to the discharge of lunatics, it was thought byhis Society that the petitioner’s arbitrary power to either discharge or not led to frequent abuse;sometimes members of the family shrank from the
trouble attendant on the return of the patient,and occasionally there was a fear of legal actionbeing taken. Additional power of discharge, heinsisted, should be vested in a judicial authority,without the right of veto now enjoyed by individualauthorities ; for licensed houses and hospitals thejudicial authority should have the right of discharge.Licensed houses, Mr. Parker thought, should not beconducted with the object of making profit; some
of them made larger profits than the public hadany knowledge of. Their number should not beincreased, and in that he was opposed to the BritishMedical Association. There might be a financialmotive for detaining patients in these institutions.He also objected to what he termed the autocraticpowers of medical superintendents of mental hospitals ;he stated that long periods sometimes intervenedwithout a patient seeing the medical superintendentat all. He agreed with the suggestion contained ina question by Lord Russell, that the appointmentof a medical superintendent should not be permanentuntil he had occupied the post three years.
Allegations of Physical Violence.Mr. Parker said numerous statements which his
Society had received from patients did not allowof any doubt that on occasions physical violencewas practised on patients. It was, he said, a featureof the age to substitute chemical violence for physical,and that was more difficult of detection. Someexplanation of the use in these institutions of hyoscinewas, he submitted, called for ; also croton oil, themost painful and powerful purgative known. TheCommission should inform itself of the purchasesof croton oil over a definite period at all mentalinstitutions. The Board of Control could deniind this.
Mr. Parker was again in the witness-chair onTuesday, when he continued his statements con-
cerning the use of drugs in asylums, his main conten-tion being that the disciplinary measures now usualwere cruel. Environment, he said, had the greatestinfluence in the progress of a patient towards normalhealth, and so should receive close scrutiny. Healleged, in regard to treatment, that often the con-trolling factor was not the interest of the patient.but finance. It was a pity that the Board of Controlhad only recently pressed for a more extended useof open-air treatment ; and there should be freerfacilities for exercise. Private asylums should berequired to render returns of recoveries to the Boardof Control. It was not now necessary.A further point which Mr. Parker made was that
the medical staffs in these institutions must beconsiderably augmented. In some asylums therewas practically no trained nursing staff. He pleadedalso for more facilities for recreation and amusementand the use of small libraries.
’
The meeting was adjourned to Feb. 24th.
NOTES FROM INDIA.(BY AN OCCASIONAL CORRESPONDENT.) -
Medical Relief in Rural Areas.THE problem of bringing medical relief within easy
reach of the rural population has been engaging theattention of the authorities for some time. Theexisting facilities in this respect are extremely inade-quate. The great mass of the village populationshave hitherto had no opportunity of coming intointimate daily touch with qualified doctors and havehad to be content to a great extent with the servicesof unqualified men. Schemes for dealing with the diffi-cult situation have been drafted by both the Bombayand Madras Governments. In the latter the only solu-tion possible with the funds at present at the disposalof the Government seems to be on one of the threefollowing alternative lines-namely, (1) the openingof a large number of Ayurvedic and Unani dispensaries,
(2) the starting of a large number of itinerating ortravelling dispensaries, and (3) the encouragement of
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private medical practitioners (allopathic) to settledown in villages for practice by the grant of moneysubsidies and supply of medicines from public funds.The first alternative, though it is likely to find favourwith the public, is impracticable and unrealisable atpresent on account of the lack of a sufficient numberof duly qualified and accredited practitioners of theindigenous systems of medicine. As regards thesecond alternative, the starting of itinerating dis-pensaries has been tried on a small scale but the resultshave not been encouraging. The third alternative-namely, that of subsidising private practitionerswho agree to settle down in villages-appears to be thecheapest and at the same time the best from manypoints of view. The idea is to divert to the villagesthe large number of unemployed medical men whonow congregrate in the towns for private practice.This third scheme is put forward as a practicalproposition by the Government, and its working isoutlined in a recent order.1 For the present, onlyregistered medical practitioners will be admitted tothe benefits of this scheme. The subsidy to be givenwill be low enough to compel the medical men to exertthemselves and earn the confidence of their neighboursand high enough to serve as an attraction in the initialstage until they are able to build up a practice. Thegrant of the subsidy will be subject to the conditionthat the recipients agree to settle down in specifiedvillages and treat the necessitous poor free. They willotherwise have complete liberty to accept such feesfor medical attendance and treatment as they can get.The actual working out of the scheme will be entrustedto the respective local boards ; the villages will beselected by them and the medical men by theirpresidents. The cost of the subsidies will be metentirely by the Government and will be paid as acontribution to the local boards concerned, and theywill be disbursed monthly by the presidents concerned.The subsidy of medical men in order to induce themto settle in rural areas is a somewhat novel experimentand is one of the results of which will be watched withgreat interest by those who believe that the realpeople of India are the great masses of agriculturistswho never leave their fields.
King Institute of Preventive Medicine, Madras.The report of the King Institute for 1923-24 is a
document full of interest to all medical men in thePresidency, and it contains material which shouldattract the attention of many who are working in thetropics. In spite of the cessation of routine vaccina-tion for four months during the hot weather, thenumber of cases of vaccine lymph issued rose from2,079,915 to 2,184,590, the largest issue on recordsince the Institute was founded. Concurrent with thisincrease in issue there was a decrease of 25 per cent.in the amount of lymph unaccounted for. The newarrangements made with the Public Health Depart-ment for the distribution of lymph to vaccinatorshave also ensured the use of fresh lymph andeffected considerable saving in the cost of packing.In their review of this part of the report theGovernment emphasise that success in combatingthe factors which combine to keep the standard ofsuccessful vaccination on a low level will hereafterdepend upon the vigilance of the district health staffs.The field of scientific research has been widely
explored by Colonel J. Cunningham and his staffduring the year. Interesting and important results arereported to have been achieved by research into variousaspects of relapsing fever. The scheme of travellinglaboratories for examination of water-supplies at
railway stations in the Presidency has been droppedfor the present, but the appointment of a travellinginspectorate for examination of water-supplies in thePresidency is under the consideration of Government. IThe question of experiments on sewage disposal plantat the Engineering College, Guindy, depends on thebudget proposals for 1925-26.
1 Government of Madras Local Self-Government Department(Public Health), Order, No. 1522, P.H., Oct. 22nd, 1924.
The staff of the Institute took a very active part inpublic health propaganda by preparing the materialissued by the Madras Health Council for the Healthand Baby Week, and by preparing and deliveringlectures. In notes such as these it is difficult to giveany detailed description of a report so full of excellentmaterial, and the Government rightly congratulateColonel Cunningham and his staff on the excellentachievements of the year and on the high standard ofefficiency maintained in the Institute.
The Services.ROYAL ARMY MEDICAL CORPS.
Capts. to be Majs.: H. N. Sealy, A. Jackson (Prov.), E. C.Beddows, J. Rowe (Prov.), W. P. Croker (Prov.), A. B. H.Bridges, A. G. Brown, and R. Hemphill.
Capt. T. Parr and Lt. T. W. Davidson are seed. for dutywith Sudan Defence Force.
Lt. (on prob.) M. A. Graham-Yooll resigns his commn.TERRITORIAL ARMY.
Lt.-Col. D. T. Graham to be Bt. Col.Maj. T. A. Hindmarsh to be Lt.-Col. and to command
50th (1st Northern) Casualty Clearing Station.Lt. D. Ross to be Capt. -
INDIAN MEDICAL SERVICE.W. Aitchison and R. W. H. Miller to be C apts.D. McD. Fraser to be Lt. -
ROYAL AIR FORCE.The undermentioned are granted short service commis-
sions as Flying Officers for three years on the active list:C. G. J. Nicholls and B. Pollard.
DEATHS IN THE SERVICES.Col. Robert Isaac Dalby Hackett, C.B.E., M.A., M.D.
R.U.I., died on Feb. 15th at Cheltenham in his sixty-eighth year. He was a son of W. Thomas Hackett, J.P.,of Castletown, King’s County, Ireland, and a youngerbrother of the present Dean of Limerick, the VeryRev. T. Aylmer P. Hackett D.D. Born in 1857, hewas educated at Chesterfield College and Queen’s Uni-versity of Ireland, where he graduated M.A. and M.D.,with honours. He joined the R.A.M.C. in 1881, waspromoted surgeon-major in 1893, lieutenant-colonel in1901, and colonel in 1911, retiring at the end of 1912.In 1914 he rejoined the army for the period of the latewar and served to its close. Early in his army careerhe served in Cyprus and Egypt, and took part in theSudan Campaign of 1885, for which he received the medaland clasp and the Khedive’s Star. The following yearhe was transferred to Nova Scotia, but went to SouthAfrica in 1888 to serve in the Zululand operations againstDinizulu. He was again in South Africa for the war of1899 to 1902 as principal medical officer of the GeneralHospital, and was with the expedition that relieved Lady-smith, subsequently serving in later operations in Nataland Cape Colony. For these services he had the Queen’smedal and clasp, and the King’s medal with two clasps.After the war was over he had further periods of serviceat the Cape, and during 1911-12 was in India as adminis-trative officer of the Sialkote and Abbotabad Brigades.For his services in the late war he received the C.B.E.In 1895 he married Miss Evelyn Mary Wynne-Jones, bywhom he had one son and one daughter.
JOHNS HOPKINS HOSPITAL, BALTIMORE : MEMORIALTO THE LATE SIR WILLIAM OsLER.-A large memorialplaque showing the late Sir William Osler at work in hislaboratory was recently unveiled and dedicated in themedical amphitheatre of Johns Hopkins Hospital. Theplaque was modelled by Dr. R. Tait Mackenzie, of Phil-adelphia, and was presented on behalf of a group of formerassociates and friends of Dr. Osler by another Philadelphiaphysician, Dr. Thomas McCrae. The amphitheatre wascrowded to overflowing when Mrs. McCrae, a niece of Dr.Osler, unveiled the tablet, Dr. William H. Welch gavehis recollections of early association with Dr. Osler in theearly days of the hospital. Other speakers were Dr. RufusCole, director of the hospital of the Rockefeller Instituteof New York, who spoke of Sir William Osler as not merely agreat teacher but also " learned historian, classicist, wisecounsellor and able physician," and Dr. Henry M. Hurd,who was introduced as having known Sir William Oslerprobably before anyone else there present. A message wassent from the meeting to Lady Osler in Oxford informingher of the memorial.
