884 "DEATHS UNDER CHLOROFORM."—NOTES FROM INDIA.

district, Kent, has paid, a fee of 10s. 6d. for each

report. Sequent to 1897 this fee has been disallowed bythe Kentish County Council, and medical men thereby burkedof their legitimate dues. My professional brethren shouldnote that in dealing with a coroner who refuses to pay forsuch reports not to furnish him or his officer with any ex-pression of a professional opinion as to the cause of deathwithout a subpcena.-I am, Sirs, yours faithfully,

CLARENCE A. WRIGHT, F.F.P.S. Glasg., 1’.R.C.S. Edin.Leytonstone.CLARENCE A. WEIGHT, F.F.P.S. Glasg., F.R.C.S. Edin.

"DEATHS UNDER CHLOROFORM."

To the -Editors of THE LANCET.

SiRS,—With reference to the letter of Lieutenant ClaytonLane, I.M.S.. at page 731 of THE LANCET of March 10thwill you permit me to draw attention to a few points whichhe has apparently overlooked ? I quite admit that my opinion,or "guess" " as he prefers to call it, is based on purely cir-cumstantial evidence ; that is perhaps unavoidable in suchcases. Lieutenant Lane assumes that the respirationbegan to fail first, but why he should do so is somewhatdifficult to conceive since the report states that " the breath-ing continued being slow and stertorous " some time afterthe appearance of dangerous symptoms.

Again, as the medulla is one of the last parts of the brainto become affected by chloroform, respiratory paralysis onlycomes on in the late stages of ansesthesia; in the case inquestion the dangerous symptoms appeared in the second orexcitement stage, while even the superficial reflexes were stillactive. While agreeing and sympathising with LieutenantLane in his regrets at the incompleteness frequently observedin the reports of deaths under chloroform, a little reflectionconfirms one in the belief that many of the defects areunavoidable so long as the patient’s life is considered ofmore importance than the solution of a purely scientificproblem.-I am, Sirs, yours faithfully,

GEORGE MOWAT, M.B., Ch.B. Aberd.Royal Infirmary, Wigan, March 19th, 1900.

GEORGE MOWAT, M.B., Ch.B. Aberd.

NOTES FROM INDIA.

(FROM OUR SPECIAL CORRESPONDENT.)

Famine and Plague in India Foll’1’ Millions of People UnderRelief. - Tlte -Reer2ideseenee of Plague in Calcutta. -The General Mortality in Bombay, 170 per 1000 perMMMM.&mdash;&mdash;2%C Enormous Plag1te L’xpenditure.-T7te Ter-rible Mortality in B01Jlhay.-Increase of Plague in<7&MM.

FAMINE and plague are the two chief factors of medicalinterest at the present time. The famine is of almost

unparalleled magnitude and is very widespread. The numbersin receipt of relief have now approached four millions andincreases are weekly reported from several provinces. Nosuch number of persons has ever before been simultaneouslyrelieved by any Government in the world. Unfortunatelythere is every likelihood of these totals being still furtherincreased during the spring and summer months. In

Western Rajputana 90 per cent. of the cattle have been lost.Except in some native states mortality from famine has beenalmost completely suppressed. There are not now, as onformer occasions, the poor emaciated wastrels, the livingskeletons, whose pitiful likenesses nearly broke our heartswhen they appeared in the illustrated papers three yearsago." Public charity has been called for and the call hasbeen grandly answered. Some of the native princes havegiven liberally. The distributers of the famine fund makeno discrimination between the claims of native States andBritish India. Is is perhaps only in this famine that

organised relief in native territory has been carried out, asin 1897 such relief was experimental. The famine is nowmost severe in the native States.

Points of interest about the plague epidemic continuallyarise. The disease has now taken hold of Bengal and isspreading fast. As I predicted there is a recrudescence inCalcutta. The plague mortality has been rising steadilysince the end of January and the returns for last week show199 deaths. The outbreak in Calcutta has not yet alarmed

the native mind and large numbers still refuse to believe thatthe disease is plague at all, but comfort themselves with thetitle of bubonic fever, milder forms of which they thinkthey have known in Bengal for many years. The regulationsbeing so mild there is no ground for any complaints againstthe authorities. Should plague really develop seriously, asin Bombay and Poona, the organisation must show itself ashelpless as it is insufficient. The rate of general mortalitynow exceeds 50 per 1000 per annum, the normal being about37. There is every indication of a very serious development.The outbreak in the Patna district has much increased but.it does not seem to have attracted much public attention.Nearly 1000 deaths occurred last week. The people refuseto follow the traditional plan of evacuation which hasproved so successful in Dacca, Faridpur, Backergunge, and inDarbhanga. Someone appears to have poisoned their mindsjust in the same way as someone poisoned the minds of thepeople of Calcutta with regard to inoculation. The con-sequence is that the disease has spread rapidly and is nowthreatening South Behar.Of Bombay city the record is terrible, no less than 2701

deaths having occurred during the past week. The numberof those dying from plague is greater than has ever beenknown. The death-rate is over 170 per 1000 per annum.The official returns only give the small number of 641deaths from plague. Small-pox is still raging but probablydoes not account for more than 300 deaths in the week.The plague expenditure in Bombay has been very large.,

A recent return shows that up to Dec. 31st, 1899, thetotal expenditure was Rs. 4,081,208 (equal roughly to.about .6270,000). During the past year, that is, sincethe dissolution of the Plague Committee, the expenseshave been much reduced, but, still, during this periodsomething like 35,000 have been spent on plague adminis-tration. The returns for the whole of India give 2597 deathsfrom plague. It would probably not be far wrong to doublethis estimate. In the Jullunder district of the Punjab morevillages are being attacked. The recrudescence at Karachihas aborted and the plague mortality has now sunk to verysmall dimensions. These abortive attacks have occurred atother places, but there seems no explanation to account forthem. Though not serious in themselves they keep thedisease slumbering ready to awaken to renewed activity ata future period. I am afraid that they form no indicationof a decadence of the epidemic.The latest weekly plague statement for India ending

Feb. 24th shows a marked increase in the number of deathsand the week closes with 3184 fatal cases, against 2597 inthe previous week. The increase is due to the further develop-ment in Bombay and in the Bengal Presidency. In Bombaycity the general mortality again surpassed the previousmaximum and 2831 deaths were recorded. Of this number263 were attributed to small-pox, but the official figures onlyreturn 768 deaths as due to plague. If the truth were known

probably 2000 deaths occurred from plague alone. Thisterrible general mortality very nearly touches a rate of 180per 1000 per annum. In Calcutta the outbreak is developingvery rapidly and now after only five weeks’ increase theplague mortality is double what it amounted to during theworst week of last year. ’

I regret to say that the rapid increase and the discoveryof more living cases foreshadow a still further developmentof the outbreak. The general mortality at the present timeexceeds the average by just about the number of the plaguedeaths and there is no other epidemic to account for theexcess. In the Patna district the disease has spread con-siderably and 1444 deaths were returned for last week. I

regret to have to record a renewed activity at Karachi, freshoutbreaks in the Punjab, and that six fatal cases have beenreported from Aden.

Feb. 26th.

UNIVERSITY OF DURHA1I FACULTY OF MEDICINE.-Dr. Percival Davidson is now in South Africa with the5th Battalion Imperial Yeomanry (including Northumberlandand Durham and Shropshire Companies), to which he is

surgeon. Dr. Davidson is a graduate of Durham Universityand was for some time senior house physician at NewcastleRoyal Infirmary. Dr. W. L. W. Walker, a graduate ofDurham University, who was mentioned in THE LANCET ofMarch 10th (p. 739) as being attached to one of the SouthAfrican Companies of the Northumberland Yeomanry, isattached to a hospital on the lines of communication.

885THE ORGANISATION OF THE PROFESSION.

THE

ORGANISATION OF THE PROFESSION.NORWICH.&mdash;ABORTIVE ATTEMPTS TO DEAL WITH CLUB

PRACTICE.&mdash;GOOD RULES THAT ARE NOT APPLIED.&mdash;THEROLE OF THE MEDICO-CHIRURGICAL SOCIETY.

(FROM OUR SPECIAL COMMISSIONER.)

THE position of affairs at Norwich is certainly not en--couraging. This town may serve as a typical example of- difficulties that have not been overcome and yet where some,efforts have been made to deal with the existing grievances.So far back as the month of April, 1897, a meeting of allthe members of the medical profession was held in the

library of the Norwich Medico-Chirurgical Society. Most of

the practitioners of the county belong to this association andit meets once a month for the purpose of reading scientificpapers. When, however, ethical questions became prominentthey were also discussed. Some of the members urged thatenergetic measures should be taken, others were opposed toany such action, and during the year 1896 so many heateddiscussions occurred that some fears were expressed thatthe association would be broken up. However, the reformparty was so far successful that at the annual meeting forthe year 1896 a new rule was accepted and worded asfollows :-Any registered medical practitioner who shall be adjudged guilty of,

and persist in, unprofessional conduct as defined by the code of rulesadopted by this society shall be ineligible to be a member of thissociety. ,

It was, however, easier to adopt rules than to enforce theirapplication. Some of the local practitioners were receivingincomes from the medical aid organisations. In one casesuch income was said to amount to about 300 annually andit was stated that paid canvassers were employed. In reply itwas urged that the canvassers were only collectors and did nottout. Indeed, as the discussion continued, it seemed as if theapplication of the new rule would involve the expulsion of thegreater part of the members of the Medico-Chirurgical Society.Many practitioners had also private penny clubs of theirown. Others had commenced practice in Norwich as thesalaried officers of the Friendly Societies’ Institute and thenhad taken some of the patients away from this instituteand thus built up for themselves a private practice.They were therefore not very anxious to abuse the bridge onwhich they had crossed. Others complained that the FriendlySocieties’ Institute had been the means of introducing a lowclass of medical men into the town and this accusation didnot tend to sweeten the acerbities that arose. Thus, it wasfound that while most of the practitioners were readyenough to throw stones each had his own particularskeleton which he was anxious to conceal.’ If the ruleswere strictly applied terrible ruptures would ensue, oldwell-established social ties would be broken; and thereseemed to be no leader, no organised force, to give adirection and to indicate a policy that could unite the pro-fession and bring about an attack on the line of leastresistance.

In one respect Norwich was in a much less favourableposition than the neighbouring town of Yarmouth. At thelatter town the medical practitioners had with great una-nimity constituted a medical union before the friendlysocieties established their medical institute. At Norwich,on the contrary, a similar institute had been in existence forabout a quarter of a century. Some 25 years ago the medicalpractitioners only received 3s. per annum from the membersof the benefit societies and for this small sum they had togive medical attendance and medicine. A movement leadingup to a sort of strike was then started among the members ofthe profession, but there was a lack of unity. Still, theagitation, though not sufficiently unanimous to obtain thedesired reforms, nevertheless seriously alarmed the friendlysocieties and led them to form an amalgamation by whichthe Friendly Societies’ Medical Institute was created, andhere they employed two medical men at fixed salaries. Mostof the clubs oi henent societies went over to this institute,but some of them agreed to pay more and retain the servicesof their medical officers. Now that this institute has existedso long and has acquired well-established vested interests itcannot be combated with the same facility as could the newly

established institute at Yarmouth. The Norwich FriendlySocieties’ Medical Institute has probably some 10,000 mem-bers. It employs two medical officers and one of them liveson the premises. Sir Peter Eade and Mr. Cadge were theconsultants, but when all the grievances were exposed andthe evils of the system were made manifest both theconsultants sent in their resignations, so that the effortsmade have not been altogether futile.There is also the Norwich Free and Provident Dispensary

which is a semi-charitable institution, being supported partlyby the subscriptions of the members and partly by donations.It employs seven medical officers who are paid according tothe number of members on their list, the highest paymentbeing &pound;300 and the lowest .B80 per annum. The questionnaturally arose as to whether this dispensary could beconsidered as an organisation worthy of support by themedical profession. This was soon brought to a test. Seeinghow deeply the practitioners of Norwich are involved in thesystem of contract work it seemed impossible suddenly toput an end to the clubs or medical aid organisations.Therefore at the general meeting held by the professionin April, 1897, an attempt was made to meet thesedifficulties, not by abolishing contract work but by substitut-ing for the existing institution a provident medical serviceorganised and managed exclusively by the medical profession.In a word, Norwich sought to imitate the example set byEastbourne and Coventry. Previously to this a committeehad met on six different occasions to draft a scheme.

According to this proposal a dispensary was to be established with the title of the Norwich Public Medical Service.There was to be a central office where patients could attendto obtain advice and medicine. At Coventry and at East-bourne it may be noted that there is no such office and somedoubts may well be entertained as to the wisdom of havingsuch a central office or dispensary. It adds considerably tothe working expenses and compels the medical officers toabsent themselves from their own surgeries so as to attend atthe dispensary. The patients on their side have to go greaterdistances and have to crowd together in a waiting-roomwhere they may lose a considerable amount of time. As arule the patients prefer going to the private surgery of amedical practitioner living in their immediate neighbour-hood. However, this is only a practical question and not amatter of principle. The Public Medical Service, of course,was to be self-supporting and was to be governed by an electedcommittee. All qualified medical practitioners, not practisingas homoeopaths and having resided 12 months in Norwich,might become members of the medical staff if they signedan undertaking not to accept in future any club offering lessremuneration. Further, they were to have no professional inter-course whatsoever with any practitioner who was connectedwith medical aid societies or similar institutions if the lattercanvassed for members in the interests of individual practi-tioners, had not imposed a wage limit, and virtually sweatedtheir medical officers by making a profit out of their workand paying them inadequately. The Public Medical Servicewas to accept as members artisans and their families andothers who might be considered suitable by the committeeif they made correct statements as to their income or weeklywage and if this did not exceed the sum of 35s. per week.The candidates were to be medically examined and, if

accepted, charged 6d. entrance fee and 2d. for their cards.After that adult males and females would have to subscribe 4d.per month and children under 14 years of age 2d. per month.A family, however numerous, would not be charged morethan Is. per month. Several practitioners protested that thepayment for adult females should be 6s. per annum as theyrequired more attendance than males. Members more than60 years old or actually in ill-health when joining were to becharged an entrance fee of 5s. Domestic servants were notto claim attendance at their employers’ houses. If a member’sincome increased and exceeded the wage limit he was to bestruck off the books. The fee for confinements would be 20s.payable in advance, miscarriages 10s., and vaccinations2s. 6d. There was to be also a special scale for surgicaloperations. Of course, the members were free to select theirmedical attendant. The committee that prepared thisscheme consisted of 14 practitioners and it was adopted atthe general meeting of the profession held in April, 1897.

Unfortunately the iron was not struck while it was hot.

Shortly after this meeting a deputation went up to Londonto discuss the entire question with the General MedicalCouncil, the Royal College of Surgeons of England; and theRoyal College of Physicians of London. Much time elapsed