553NOTES FROM INDIA.

This tonic contraction with its concurrent shortening wouldbe quite enough to produce the rigidity necessary for syphonaction, and it cannot be denied that the large intestine withits short ascending and long descending tube fulfils in otherrespects the conditions of a syphon.One of my points was that, on completely filling the

colon by injection from the cut ileum, the 20-inchtransverse colon leaves its nine-inch bed and becomeselongated and tortuous ; the same thing must happen insigmoid obstruction. Thus the question arises: Is the

V-shaped colon sometimes a post-mortem change ? When a

person is found dead in a sitting position, therefore,I should like the maker of the necropsy to noticewhether the transverse colon has dropped from itsusual site. If empty perhaps this could not be expected.Again, I have a suspicion that the constipation and colic oflead poisoning are due to paralysis of the longitudinal bandswith the consequent elongation, kinking, and loss of rigidityof the.bowel. This should not be very difficult to determine.Further, since I have shown that hydraulic power is a factorin the propulsion of the intestinal contents, I should like toknow with what average force the stream from the ileumenters the cascum.

I am, Sirs, yours faithfully,R. W. LEFTWICH, M.D.

Buckingham-gate, S.W., Feb. 9th, 1903.

THE UNIVERSITY OF LONDON AND THE ENGLISH ROYAL COLLEGES OF PHYSICIANS AND SURGEONS.

To the Editors of THE LANCET.

SiRS,-I would like to make a few remarks upon"Africander’s" letter in THE LANCET of Feb. 7th, p. 399.He states that: " Hitherto the whole crux of the question hasbeen taken to be not a matter of personal ability but of

opportunity," and I quite agree with him. I contend thatopportunity should exist in London, as in other universitytowns. It seems anomalous that out of 60 entries at aLondon hospital only four should contemplate taking adegree. I submit that out of the same number of students

entering, say, at Edinburgh, a very much larger percentagewould contemplate and, as a matter of fact, take the degree.Further, however judicial the mind of South Africa is in

respect to the practitioner of medicine (a country by thebye just now perturbed by political and racial hatred),there is I submit a very great advantage in possessing adegree in the old country, and the opportunity to obtain thesame in London would be forthcoming were the RoyalColleges to join the University for examination purposesunder the Act of Parliament which contemplated the possibledesirability of such a union.

I am, Sirs, yours faithfully,FREDK. W. COLLINGWOOD.

Devonshire-street, W., Feb. 7th, 1903.

NOTES FROM INDIA.

(FROM OUR SPECIAL CORRESPONDENT.)

Mr. Jonathan Hutohinson’s Leprosy Tour.-The Jamsetjee IJejeebhoy Native Hospital in Bombay.-The Government IGrant to the Pasteur Institute at Kasa-itli.-The Plagueepidemic.THE advent of Mr. Hutchinson to the principal cities of

India is announced by letters in the local papers. Besidesasking for information and promising to attend meetingsMr. Hutchinson gives a résumé of his views upon leprosy. IHe holds that the disease is caused by a bacillus which gainsaccess to the body through the stomach, that there is great idanger in eating food directly from the hands of a leper, thatin the majority of grown-up lepers the disease is caused byeating badly-cured fish, and that a long period is necessarybefore results will be observed. It remains to be seen howthe profession in India will receive these opinions whichmany consider are advanced on very imperfect scientificdata.The public appeal for money in aid of the nursing estab-

lishment of the Jamsetjee Jejeebhoy Native Hospital in

Bombay is accompanied by the announcement of an extra-ordinary condition of the nursing staff. Here we have the

largest native hospital in Bombay of no less than 460 bedswhich are always full, with 15 wards totally unnursedand seven others only nursed during the day. There is nocomplaint about the buildings and the staff is for the mostpart drawn from the Indian Medical Service. Treatmentcan hardly be conducted with much satisfaction to themedical men and the patients are without one of the mainadvantages of a hospital. It is stated that the BombayGovernment is prepared to assist to the extent of half theexpenditure necessary.The increase in the Government of India grant to the

Pasteur Institute at Kasauli is not marked by excessiveliberality. Hitherto Rs. 9500 have been contributed, but infuture Rs. 12,000 have been promised. Considering that 119European and 33 native military patients were treated lastyear and that if the institute had not been established avery much larger sum than the above would have beenincurred in sending British soldiers to Paris, the apparentgenerosity is in reality a sharp stroke of business. Theinstitute is dependent in part upon private subscriptions andis necessarily hampered in its work by uncertainty in in-come. As other scientific work than the treatment ofrabies is conducted at this institute it is of the highest im-portance that its expenses should be completely covered andRs. 20,000 at least should be the annual grant made from theGovernment of India alone.Every week now records rapidly rising figures in the plague

mortality throughout India. Last week 22,954 deaths wererecorded, as compared with 19,231 for the previous sevendays and with 11,445 for the corresponding week last year.In the Bombay Presidency 10,747 deaths were returned, inBombay city 495, in the Madras Presidency 848, in the

Bengal Presidency 3060, in Calcutta 76, in the United Pro-vinces 2954, in the Punjab 2627, in the Central Provinces850, in the Hyderabad State 446, and in Berar 596. For someextraordinary reason the Poona figures are not included inthe published returns, but local papers show that it is ragingin this town with extraordinary virulence, over 100 deathsoccurring daily. The disease is still severe in Karachi andis also severe in Allahabad, Meerut, Benares, and Lucknow,while the Cawnpore district continues to suffer very badly.In Bombay city the rate of mortality is about 90 per 1000per annum. In Calcutta the recrudescence is rapidlydeveloping. Madras has shown some indigenous cases andother cases are reported from Simla.The mass of poor humanity which assembled in Calcutta

upon the large Maidan to be fed in celebration of the King’sCoronation numbered probably 50,000. The wretchedphysique of the majority of these beggars was painfullyevident and the collection offered many opportunities ofseeing external diseased conditions. Skin diseases werevery common, especially the different forms of parasiticorigin, and numerous lepers moved amongst the crowd.Deformities, paralytic states, and conditions produced bychronic diseases such as malaria and elephantiasis were every-where evident. The Hindu portion consisted largely of pro-fessional beggars. A few years ago such a gathering wouldhave been condemned as conducive to the spread of plague,but subsequent knowledge has shown that a plague patientwould be either too ill to go or not in a stage of contagion.Jan. 30th.

LITERARY INTELLIGENCE.-The Scientific Press,Limited, announces the publication of a cheap edition, price10s. 6d. net, of Dr. R. Sisley’s work, The London Water-Supply." Messrs. W. B. Saunders and Co. announce

the immediate publication of two new volumes in"Saunders’s Medical Hand Atlas Series "-viz., "Atlasand Epitome of Diseases of the Mouth, Pharynx, andNose," by Dr. L. Grunwald of Munich, edited, with

additions, by Dr. J. E. Newcomb ; and Atlas and

Epitomeof Human Histology and Microscopical Anatomy,"by Professor Dr. J. Sobotta of Wiirzburg, edited, withadditions, by Dr. G. C. Huber. Messrs. Saunders and Co.have in preparation for early publication two new volumesin their English edition of Nothnagel’s Practice-viz," Diseases of the Pancreas, Suprarenal Capsules,,and Liver,"and "Diseases of the Stomach." - Mr. Henry Frowdeannounces the approaching publication by the OxfordUniversity Press of Dr. A. J. Ewart’s treatise on "ThePhysics and Physiology of Protoplasmic Steaming inPlants," of which an abstract was communicated to the

Royal Society.

554 THE ORGANISATION OF THE PROFESSION.

THE

ORGANISATION OF THE PROFESSION.

(FROM OUR SPECIAL COMMISSIONER.)

(Continued from p. 480.)The Swansea Single Men pay for Medical Attendance on the

Wives and Children of the Married Men.-Figuresdemonstrate the Charitable Aspect of Club Practice.-Complaints against the Medical Officers.

IT has been seen that at Swansea the custom is that men

only pay for medical aid. Their wives and children have

to be attended without the member of the club or societybeing called upon to make any extra payment on theiraccount. A member who has no wife or child pays thesame subscription as the member who has a large family.This is a strange and unusual arrangement, but whenviewed from the workmen’s standpoint it has a beautiful, lia poetical, and altruistic appearance. Are we not told, !Ithey say, to bear each other’s burdens ? and who can better Iafford to pay for the married man’s family than the bachelor ’,In his turn, if a married man has only two children shouldhe not contribute something for the man who has half a IIdozen children ? With such principles there should be nodecrease in the birth-rate, but the medical practitionerobjects to these theories, however beautiful they may be, ’,when they are not put into practice except at his ’,expense. If the bachelors will pay for married men’schildren, well and good, but then they should pay and not ’,merely talk about it. It is not an average of 6s. 6d. permember that will cover the cost of attending numerous I,families. But the workmen challenge these figures and havetried to demonstrate that the single men pay enough tomake up for the acknowledged insufficiency of the paymentseffected by the married men. One case, for instance,is cited of a married man who pays 6s. a year to his

lodge but has two unmarried sons who subscribe to two othersocieties, and altogether his household pays about ;6113s. 4d.per annum. It is obvious that no argument can be based onsuch a case as this. No one desires that any individualfamily should contribute too much, but what were the pay-ments of this family before the children had grown up andwhat will happen when they marry ? Again, the workmensay that they often belong to several societies and that theytherefore pay for several medical men. This unsatisfactorystate of affairs is not, however, desired by the members ofthe profession ; they would wish that only one medical manshould be engaged but that he should be properly re-

munerated. Besides, this simply means that the most

popular medical man has the most work to do and does notget proportionate pay. Dr. John D. Davies has calculated thatthe medical profession is overworked at Swansea. He saysthat there are 44 practitioners in the town and this means, inround numbers, the population being 97,000, one practitionerfor every 2000 persons. At Cardiff there are 113 practi-tioners and this is equal to one for every 1143 persons andat Newport there is one practitioner for every 1800 of thepopulation. To make a decent living from club practicealone at the old Swansea rate of payment it would be

necessary, Dr. Davies reckons, to see about 100 patientsper day and this is not possible short of defrauding thepatient and converting the practitioner into a mere machine.

Dr. T. D. Griffiths, who is to preside over the next meet-ing of the British Medical Association, is of opinion thatthere should be one medical practitioner for every 1100persons. According to figures derived from the Order ofForesters the average number of members on the clubfunds at a time amounts to 3 per cent. of the total

membership. So if there are 1100 members this meansthat there would be an average of 33 patients per dayto attend. To do such work properly and includingthe time required to go from house to house it is not possibleto see more than four patients per hour and this means 32patients in a day of eight hours. But this calculationunder-estimates the position, for it is based on the health ofmembers of a friendly society-that is to say, of adult males-and it may well be estimated that for one member whorequires medical attendance there are at least two womenor children who are also ill. Dr. Griffiths makes, how-ever, another calculation. He says if 100 members pay 4s.a year each this yields .620, or .E6 13s. 4d. for each of the

three members who are ill all the year round, and thisamounts to 2s. 6d. per week for attending a patient. Thechief registrar of friendly societies has based the sick pay tobe allowed on calculations extending over some millions ofmembers and he concludes that the average amount ofsickness equals 12 days per annum per member. Thisconfirms the previous estimate, for the 4s. annual sub-

scription divided by the 12 days of sickness does amountto about 2s. 6d. per week for attending the patients.These figures are taken from the statistics of the friendlysocieties themselves.

Though the insufficiency of the pay is thus very clearlydemonstrated the members of the friendly societies foundit difficult to believe that their medical officers had goodcause for dissatisfaction. Why, they urged, was such workaccepted and why, when a vacancy occurred, were thereso many applicants for the vacant post ? At Swansea ananswer was made, or was said to have been made, that

greatly startled-not to say shocked-the members ofthe friendly societies. It has been admitted that someclub medical officers merely gave value for value; inother words, they did not do as much for patientswho, on on average, only paid from 3d. to 6d. per consulta-tion as they did for those who paid 2s. 6d. This frankadmission has caused quite a scandal. Some local leaderspromptly replied that if this was the case they would dismissall their medical officers, they would amalgamate all theirclubs, and found a large medical institute, where they wouldemploy their own medical officers who should be entirely attheir service. Furthermore, they would buy their own drugsand thus insure that they should be of the best quality. A

lengthy circular was issued to this effect. It states, amongother things :-That the grievance is that under existing conditions club patients

do not get the proper attendance and medicine which they have arightto expect. In saying this we only state what is a well-known fact tomost friendly society members. How often do we hear the complaintfrom our members as to the indifference and inattention of doctors toclub patients. Is it infrequent that we hear of members protestingthat, rather than go to a club doctor, to whom they pay theircontributions ungrudgingly, they go to another and pay him feeswhich in many cases they can ill afford to pay? Why, these com-plaints have become so common that the name of club doctor is a

reproach among the members..

This is an important statement and perhaps was con-

sidered by its author as an attack against the medical

profession, but it, on the contrary, confirms the argu-ments so frequently brought forward in these columns.The circular containing the above passage is addressed tothe friendly societies and the opening paragraph explainsthat-In pursuance of a resolution passed at a general meeting of dele-

gates representing the various branches of the friendly societies ofSwansea and district, held at the lodge room of the Bird-in-HandHotel, High-street, on Friday evening, Nov. 28th, we beg to submit thefollowing for your consideration.

The circular is therefore and in its way an officialdocument and it distinctly proclaims what has always beenurged in these columns that club practice must inevitablytend to degrade the profession. Undoubtedly, patients donot always obtain proper attendance and medicine, but theyhave only the "right" to expect this on one of two condi-tions. They must pay for it or else they must be consideredfit and proper subjects for the receipt of charity. But themembers of the friendly societies seek to avoid both theseissues ; they do not subscribe enough to constitute a pay-ment and yet they are very indignant when told that theyare in receipt of charity. Nevertheless, the fact remains thatwhenever a club patient is properly attended he is in receiptof charity, but as medical men cannot spend all their livesand substance in works of charity the complaints made inthe circular are sometimes based on fact.

Dr. Griffiths has explained that when he first commencedto practise at Swansea he took a club and its members

paid him 5s. a year. He contracted with a druggist todispense for him at the average charge of 6d. per bottleof medicine and 2d. per box of pills. At the end of his firstyear Dr. Griffiths found that his drug bill exceeded by £11the amount he had received from the club. Was not thischarity to the amount of £11 in cash and all the labour ofattending the patients ? The practical upshot is that to makethe 5s. subscription yield some small remuneration the drugbill must be reduced from an average of 6d. to about ld. perbottle. This club met at the Adam and Eve" in High-street and Dr. Griffiths promptly resigned his position as

their medical officer. He then received a deputation froma club that met at the " Bird-in-Hand and had about