454 ROYAL COMMISSION ON NATIONAL HEALTH INSURANCE.

Careful watch should be kept for signs of right-sided failure-e.g., an increasing cyanosis, weakeningof the second pulmonic sound, slight venous stasisin the vessels of the neck, oedema of the lung bases,or a fall in the tension of the pulse and of the bloodpressure. Digitalis is the most generally usefuldrug, and it should be used early before the signsof circulatory failure are present. Tincture of digitalismay be added to the diaphoretic mixture, or pre-ferably given separately in 5 to 7 minim dosesthree times a day from the onset of the disease,increased to 10 to 15 minims, according to thenecessities of the case. In cases of known cardiacdisease, the larger doses are used from the onset ; wherecardiac failure is severe, digitalin gr. 1/100 shouldbe used hypodermically or intramuscularly. Stro-phanthin gr. 1/100 may also be used hypodermicallyor intravenously, but only with caution in patientsalready under the influence of digitalis.

Falling blood pressure is always an ominous sign,and calls for more energetic stimulation of thecardiovascular system. Numerous drugs have beenrecommended-strychnine hydrochloride or sulphategr. 1/60 to 1/30, camphor gr. iii. in olive oil,or caffeine gr. v. hypodermically every four or sixhours. Strychnine has rather fallen but of fashionas a

" cardiac stimulant," and is perhaps more usefulin threatened respiratory failure. Latterly I haveused adrenalin in preference to any other drug,giving it hypodermically in doses of TR v. to x. of1 : 1000 solution every six hours for 24 to 48 hoursbefore the crisis. Adrenalin is not recommendedas a routine in all cases, but only as an emergencyin those cases which show a falling pulse tension.Pituitrin c.cm. may be used in place of or withthe adrenalin.

- 8. 7 . 77 . m

M’iscellaneous Points.Where there are signs of cedema of the bases of

the lungs, or where there is excessive sweating atthe crisis, atropine is of very great value. It shouldbe given hypodermically in doses of gr. 1/120 to1/100, repeated if necessary once or twice. Atropine,like adrenalin, is an emergency remedy and shouldbe used with caution.The use of alcohol as a stimulant is still much in

dispute, but the general tendency seems to be to useit less and less frequently. It seems to be beneficialin certain cases, particularly elderly and debilitatedpatients and in those habituated to its use, and maybe prescribed in doses of 4 to 6 oz. in 24 hours.In young robust people one seldom has recourse

to alcohol.Oxygen has a considerable effect in relieving the

cyanosis, but generally has little effect on thedyspnoea. Its use is indicated in those cases whereearly and marked cyanosis is present. In privatepractice it is usually given by means of a wide filterfunnel, held close to the nose and mouth of the patient,or by means of an ordinary gas-bag, and the patientis allowed to breathe the oxygen for 10 or 15 minutesat a time, repeated every hour or so.

Venesection is frequently recommended but seldompractised. In the obese plethoric individual, witha full bounding pulse and marked cyanosis, the with-drawal of 15 to 20 oz. of blood at the beginning ofthe illness gives considerable relief to the symptoms.Later on in the disease it is indicated in any casepresenting signs of right-sided cardiac failure. Amild delirium is not uncommon in many patients,preceding the crisis, but an active, noisy deliriumoccurring early in the illness adds greatly to the i

responsibilities of those in attendance on the case.Paraldehvde in doses of 2 to 4 drachms, repeatedas may be necessary, should be tried. Constantobservation is essential in all cases of delirium.

Specific Therapy.Specific therapy has been successful so far only in

cases infected with pneumococci belonging to GroupNo. 1. An anti-serum has been prepared againstGroup No. 2 pneumococcus, but has not been success-ful. The results, even against Group No. 1 infections,

are much inferior to those obtained by the use ofanti-sera in diphtheria. A specimen of sputum shouldbe sent to the laboratory in order that the group tawhich the infecting organism belongs may be deter-mined. A minute dose of the serum, 0’02 c.cm. ofa 1 : 10 dilution is injected intradermically, in orderto determine the patient’s sensitiveness to serum.

If the patient is sensitive, or if he has alreadyreceived injections of serum for some other disease,.he should be desensitised by repeated small dosesgiven at intervals of half an hour, 0’01 c.cm. ; 0’1 c.cm.and 1 c.cm. hypodermically. The serum should thembe diluted 1 : 10 with normal saline solution raisedto body temperature, and injected slowly. Inordinary cases the serum should be diluted withequal parts of normal saline solution. Large dosesare necessary, as much as 100 c.cm. in the first24 hours, and 40 to 50 c.cm. on subsequent days.A dose of 30 to 40 c.cm. of serum should be injectedand repeated at eight-hour intervals. Serumtreatment in this as in other diseases should becommenced as soon as the diagnosis and the type ofinfecting organism are established. The necessityfor very large doses and for the intravenous routeare serious drawbacks to the routine use of serumin private practice. Vaccines, whether autogenousor stock, do not appear to have any very beneficialresult except in cases of delayed resolution.

In ordinary cases where cardiac or other complica-tions have been absent, the patient should be allowedto sit up in bed a week after the crisis, and after anotherweek may be allowed to get up. If feasible, he shouldbe sent to the country for two or three weeks beforereturning to work.

A. GREIG ANDEBSON, M.D. Aberd., M.R.C.P. Lond.,Assistant Physician, Royal Infirmary, Aberdeen.

Special Articles.PROCEEDINGS OF THE

ROYAL COMMISSION ON NATIONALHEALTH INSURANCE.*

(Continued from p. 405.)

I IN the three previous articles a summary hasbeen given of the official evidence on MedicalBenefit, except in so far as it relates to the work of theRegional Medical Staff of the Ministry of Healthand the Certification Rules. These affect both thedoctors and the Approved Societies, and a summarywill be given later before the evidence given byApproved Societies is dealt with. At this stage theofficial evidence on financial provisions and on

Scottish questions is inserted.

FINANCIAL PROVISIONS OF THE ACT.

The official account of the financial structure andresources of the Act and of the accounting arrange-ments (Section D of the Appendix) was supplementedby the oral evidence of Mr. E. J. Strohmenger, C.B.

(App. D. 2.) The moneys, consisting of accumula-tions of contributions, which constitute the permanentbalances in the National Health Insurance Fund,belong in the main to Approved Societies, some98 per cent. of the insured population being membersof Approved Societies. In general the summary ofthe evidence which has been extracted will, therefore,relate to the funds of Approved Societies, the evidenceas to the small percentage appertaining to theDeposit Contributors’ Fund, the Navy and ArmyFund, &c., not being of general interest.

* References to the official statement which has been issuedas an appendix in four sections are given thus : Section A,para. 69, is shown as " App. A. 69," and references to the oralevidence thus—Q. 1369.

455ROYAL COMMISSION ON NATIONAL HEALTH INSURANCE.

(Q.2133-4.) The National Health Insurance Fundacts as banker for the societies, and also acts as ageneral clearing house for all financial transactionsinvolved in the scheme. The disposal of all moneysin the National Health Insurance Fund is fixed by.statute, and there are no funds which are availablefor other purposes. (App. D. 6-9.) The receipts ofthe N.H.I. Fund consist of the contributions paidby employers and employed, the State grants, whichconsist of two-ninths of the cost of all benefits andof administration, and the interest on investments.The payments out of the fund consist of (1) the sumsnecessary to pay cash benefits and to pay doctorsand chemists and expenses of administration, and(2) the sums issued from time to time to societiesfor investment.

Contributions and Reserze Values.

2137, 2374-81.) The flat rate of weekly contribu-tions under the Act is the rate required for the ordinarybenefits in the case of a boy (or girl) of the age of16 on entering into insurance. If there is addedthe contribution of the State, the value of the 10d.paid by the boy of 16 and by his employer exceedsthe value of his benefits ; the State contributionin respect of all insured persons is really requiredin order to make everybody 16.

(Q.2154-8.) A " Reserve Value " is a paper creditin respect of every person admitted to insuranceover the age of 16. These paper sums are creditedin the accounts of the Approved Societies and willbe- gradually liquidated over a long term of yearsout of the margin available from the contributions.and interest on investments. The amount of thesepaper reserve values originally created was 65millions, and when the contributions and benefitswere increased by the Act of 1920 further reservevalues, estimated to amount to 48 millions, werecreated.

7M).’weM.

(App. D. 17.) The balances in the National HealthInsurance Fund are in the first place temporarilyinvested with the National Debt Commissioners.Subsequently, one-half of any sum ascertained tobe available for permanent investment by an

Approved Society is transferable to the N.H.I.Fund Investment Account and is placed to the creditof the society in that account. As regards theremaining half the society may take one of threecourses-viz., it may request the Department:(1) to pay over the amount to the society for invest-ment in the names of its trustees ; (2) to invest theamount in specified securities in the name of theMinister (in the case of England and Wales) onbehalf of the society ; or (3) to transfer the amounttogether with the other half, to the InvestmentAccount in the N.H.I. Fund.

(Q. 2400.) Why is it that only one moiety of tre money.available for permanent investment is allowed to beinvested by the Approved Society. The Act has fixed amoiety ?-That is roughly the share of the contributionspaid by the insured person.

(Q. 2288-2291.) The total cash resources of thescheme for England, Scotland, and Wales as exist-ing on Dec. 31st, 1923, were 2107,000,000. Of thissum ;S88,700,000 is the immediate property ofApproved Societies, made up of 38,000,000 Invest-ment Account, 240,000,000 their own investments,9,700,000 in their current accounts, and about1,000,000 working balance in societies’ own hands.

A irH.(Q. 2189-94.) The witness explained that in the

.account of stamps sold there were accumulations,in excess of the sum paid over to the ApprovedSocieties, which had gradually mounted up to 5!millions. The greater part of this amount hedescribed as a windfall. It is paid into a specialfund called the Central Fund, and under the Insur-ance (Cost of Medical Benefit) Act, 1924, there is aspecial charge on that fund for certain liabilitiesin respect of the cost of medical benefit. Part of

the excess cost of medical benefit in the years 1924,1925, and 1926 will be charged to that fund. Atthe end of 1926, when all the charges on the fundhave been met, it will stand at 21,500,000 with, inaddition, interest from the end of 1923, and iscertainly adequate to meet its liabilities (that is,in the way of helping societies having deficiencies).

Q. If this special liability for medical benefit had notarisen and been thrown on the Central Fund, a problemas to the amount of that fund would have arisen later on.with which, I suppose, Parliament would have had to deal ?that is so. This large sum of money is wholly a windfallin any case. Q. In your view, have Approved Societiesany proper claim upon it ?-Practically none whatever.Q. It is absolutely a windfall ?-It is absolutely a windfall.

An Impression of Considerable Complication.(Q. 2129, 2351.) The Chairman at the outset had

stated that the financial arrangements appeared tobe highly technical and complicated. As to this, Mr.Strohmenger said that some of the arrangementswere made in the interests of sound financial adminis-tration, but the whole scheme was really the schemewhich Parliament had itself laid down.

(Q.2360.) Asked whether the societies understoodthe essential features of the financial arrangements,the witness said :-

I think they know all things that they need know inthe interests of their members. I should not like to saythat every society really understands the whole of thefinancial structure of National Health Insurance.... Theofficials of the large societies of course have understood itperfectly, but I do not suppose the great bulk of ApprovedSociety offiçials have a very intimate knowledge of all thesemysteries, and I do not think they need have. The ordinaryworking Approved Society secretary who looks after hisinsured people and protects his funds knows, I think, quiteas much as he need know. (Q.2361.) And no great degreeof simplification in the central finance of the scheme couldbe said to be necessary for the proper and intelligentadministration of benefits by the agencies concernedI say that quite clearly.

(Q. 2437-8.) To those to whom ledgers are profoundmysteries, there is an interesting piece of evidencewith regard to the ledger work of the ApprovedSocieties. The officials, especially of small societies,are in effect keeping a ledger without really knowingit.

We devised a scheme under which a book was given tothem, arranged according to subject in columns. Therewas a specific instruction on each advice as to which columneach entry should go into. The book really is a ledger ;but instead of having a separate opening for each account,it has got columns in which the entries go. It helps thesociety, which has simply to look at its advices saying thata certain item should be posted in column 20, line 10, forinstance. At the end of the year they simply add up thetotal of their entries and thus get their ledger balances.

This book gives all the material to enable a societyto make up its benefit fund and to get the auditor’scertificate.

The Cost of Medical Benefit.(App. C. 142.) The cost of medical benefit has

varied from time to time with the agreements enteredinto with the doctors’ representatives with regardto the amount of the capitation fee and the sumsto be allowed for mileage and with the arrangementsin force in regard to the supply of drugs. The pro-visions of the Act at present in force (the NationalHealth Insurance Cost of Medical Benefit Act,1924) fix the charge for medical benefit at 11s. 10.per insured person. The total amount required inaddition to the sum of 9s. 6d. provided by the Actof 1920 is 2s. 4’d., and this is provided as follows :-

s. d.(1) Out of the funds of Approved Societies, &c... 0 2(2) Out of moneys in the Central Fund (as explained

above) derived from the unclaimed balance ofsums received from sale of National HealthInsurance stamps 1 8

(3) Out of interest earned on the proportion of -

insurance funds retained in the National HealthInsurance Fund (Investment) Account beyondthe prescribed rate credited on sums standingin that account .......... 0 6

2 41

456 ROYAL COMMISSION ON NATIONAL HEALTH INSURANCE.

It would appear (Q. 1435-7) that this provisionof 2s. 4id. is a temporary provision, and that for thecost of medical benefit in the future in the absence offresh legislation 9s. 6d. only will be available atthe end of 1926. With regard to these provisions,Mr. Strohmenger said :-

(Q. 2238.) These financial provisions as regards medicalbenefit are, so far as the Ministry is concerned, extremelyunsatisfactory. They constitute a serious defect in thegeneral financial arrangements. Here you have what isreally a limited provision for the payment of medical benefitand an unlimited liability. It is true that the paymentto the doctors is fixed for a period of years from time to time,but there is always the risk that the time may come to reviewthe bargain with the doctors, and to have a further liabilityfor which you have no provision.... For the years1924, 1925, and 1926, the Department made what theyconsidered to be a very full estimate of the cost of drugs,but owing to the epidemic this spring the cost exceededthat estimate, and although I hope that, during the threeyears for which the Act of 1924 will run, the cost will bewithin the provision, at the same time it may not be, andit will be an acute embarrassment to the Department if itis not.

EVIDENCE OF THE SCOTTISH BOARD OF HEALTH.

A careful reading of the evidence given by SirJames Leishman, the chairman of the insurance sideof the Scottish Board of Health, and the other officialScottish witnesses, fails to reveal any peculiarlyScottish problems which would appear to necessitatea separate Scottish administration. The contribu-tions and benefits are the same throughout GreatBritain, and Approved Societies operate in bothcountries. (Q. 1544.) Generally there is constantcommunication by letter, by telephone, by wireeven, with the English Ministry; practically alldocuments are exchanged between the two depart-ments ; and there is a considerable measure ofcooperation through the operations of the JointCommittee.

’

(Q. 1556.) The question whether a good deal ofmachinery was not thus required for the purposesof coordination, and also whether a certain amountof difficulty did not result from movements of thepopulation, especially with regard to statistics,accounts, and valuation, Sir James Leishman said :-

Yes, there is some, but it is part of the price you have topay for separate administration, and in my judgment theprice is fully justified.

(Q. 1573.) Apart from the question of national suscepti-bility, do you think on the grounds of efficiency alone thereis a case for separate administration in Scotland ?-I thinkso, but I may be prejudiced.

Separate Valuation.The witness was asked why Scotland insisted on

having a separate valuation for the Scottish membersof societies, and he replied that it was an indicationof what might be called the " Home Rule " position.

(Q. 1894.) Has anything been gained in these internationalsocieties by having a dual system of valuation ?-It isvery difficult to answer that question. What we do know isthat, putting the objection to uniformity on the highestplane, Scotland, on the whole, stands fairly well, and that,at all events, we have not lost anything while we havegained a certain element in our own self-respect.

The Friendly Society Jlovemeitt.(Q. 1764.) Before the days of the Insurance Act the

Friendly Society movement, especially in the purelycountry districts, had not got such a firm grip inScotland as it had in England. This appears toaccount in part for the fact that there are relativelynot so many small societies in Scotland administeringthe Act as separate units. Although, as stated,not many problems peculiarly Scottish are dealtwith in the evidence, the views of Sir James Leishmanwere ascertained upon various matters, of commoninterest on both sides of the Border, from which wemake a selection.

’

AfKHMyerM.—(Q. 1617.) Are you satisfied now thatmalingering or over-generous certification is not a sub-stantial financial danger ?-It is a serious part of the

administration, but, as far as I can see, there is not asubstantial financial danger.

Delay in Paying Benefits.-(Q. 1fi19.) While some

societies are probably not so good as others, we couldhardly say, viewing the position as a whole, and havingregard to the fact that societies are spread all over thecountry, and to the fact that members are often ininaccessible places, that there could be any serious chargemade of undue delay in paying benefits.

Insurance of Married Women.(Q. 1663-1729.) Sir James Leishman was questioned

at great length with regard to his opinion that marriedwomen were not an insurable proposition. Heexpressed himself as in favour, on the grounds ofsimplicity, of the view that a woman on marriageshould be given some sort of surrender value. SirAlfred Watson pointed out that a similar proposalwhen the Bill of 1918 was before Parliament wasstoutly opposed by the representatives of Women’sSocieties.

(Q. 1679.) There was substituted for it the presentarrangement under which a woman gets something equivalentto that surrender value in the shape of maternity benefitand a small weekly allowance for a short period of sickness ?-

Yes, and also medical benefit.(Q. 1702.) Is it really the considered view of ApprovedSocieties responsible for administering the insurance schemethat rather than have the trouble ... of administeringthese benefits they would offer the woman a bribe to getout ?-I would not put it in that way, not so bluntly as that.So far as I know the mind of Approved Societies-and Iwould rather this question was pressed home with them-... they would prefer that.

Sir James Leishman said that he was all forsimplicity. A series of further questions, however,led to the following :-

(Q. 1729.) If you take an able-bodied young man, if he isat home you assume something is wrong, but in the case ofa married woman you would not know whether it wasanything more than spring-cleaning. Does it come to any-thing more than those two propositions ?-I think youhave stated the case very well, if I may say so.

Maternity Benefit in Scotland.(Q. 1965.) Maternity benefit in Scotland has been

highly popular. Positive evidence is abundant thatit has greatly helped mother and child, and there hasbeen very little misapplication of this benefit.Complaints, however, have been received that in manycases too much of the money has gone to the doctoror midwife, but, even so, the mother and child havebenefited by the skill and care thus obtained.

Mledical Benefit.Medical benefit has been found to work well, even

under the severe difficulties and the restricted servicemade necessary by the war, and very little reliableevidence has emerged of neglect of duty on the partof insurance practitioners, or of any real ground forloose general charges of inefficiency. Dissatisfactionwith a limited service and agitation for an extendedand complete medical and institutional service mustnot be fastened on as a condemnation of the workingof the Insurance scheme, but rather as an indi-cation that it has resulted in increased appreciationof the importance of a further great developmentof medical services in the interests of national welfare.

Early Diagnosis.An American critic has alleged that insurance

doctors are mainly occupied in dealing with trivialailments. In so far as that is the case it is testimonyto the worth of the present scheme. The facilitiesfor treatment which the Act presents to the insuredhave resulted in the insurance practitioner seeingdisease in its earliest and most curable stages, whenthere is frequent opportunity to prevent the onsetof disabling or fatal illness.

Need for Specialist Advice.The witness quoted from the Fifth Annual Report

of the Scottish Board of Health, 1923, as follows :There is a great diversity in the range of treatment given

to their insurance patients by practitioners. The work done

457REX v. BATEMAN.

’by many practitioners is of the very highest quality, some-times comparing not unfavourably with that of specialistsattached to hospitals.... There is an urgent need forincreased hospital accommodation for the insured. Thefullest advantage is not always taken by the practitionersof the availability of specialist advice at these institutions.

Nicmhers of Doctors on the Panel.

(Q. 1972.) Out of 2175 general practitioners inScotland 1790 are panel doctors. In the county ofFife all the general practitioners are on the panel.In Glasgow 401 out of 670 are on the panel. InDundee Burgh the proportion is 95 per cent. Inrural areas, it may be assumed that most of the doctors

are on the panel, and, indeed, in a single practice areait is almost inevitable that the doctor should go onthe panel. In Edinburgh the figures are 160 doctorsout of about 230 in general practice. Edinburgh,said the witness, was the place where the reaction inconnexion with the agitation was felt most keenlyin the medical profession owing to the number of.consultants who were there.

Vaccination.

(Q. 1976.) The question of preventive treatmenthad been the subject of an interesting decision inScotland by referees, who had come to the conclusionthat treatment should cover-

all treatment of every kind which a person is entitled toreceive from any general practitioner attending him in theordinary way ; in ordinary general practice prophylactictreatment for the prevention of sickness is given, and theonly change effected by the Act is that the practitioner,instead of being recompensed by fees, is recompensed by thecapitation grant.

The referees, having regard to the rapid advance inmedical science, added a rider that the panel doctoris not bound to undertake prophylactic treatmentof any kind which has not become a matter ofordinary treatment by competent general prac-titioners ; with regard to the particular case sub-mitted to them, they had no hesitation in holdingthat any general practitioner was able to revaccinateagainst small-pox.

S’izes of Doctors’ Lists in Scotland.

(Q. 2023.) In counties 66 per cent., and in burghs36 per cent. of the panel doctors have less than 500insured persons each on their lists ; 18’5 per cent. incounties and 16-4 per cent. in burghs have from 500to 1000 insured persons ; and 13’8 in counties and 34’2per cent. in burghs have from 1000 to 2000 insuredpersons. Those with over 2000 number 1’8 per cent.in counties and 13’4 per cent. in burghs.

Cost of Drugs.(Q. 2024-2062.) The Scottish chemists are paid

at higher rates than those paid in England, but thetotal expenditure on drugs is about 3d. per insuredperson less. This was explained as being due todifferences in the prescribing habits of the doctors inthe two countries. Mixtures are renewed in England5 times to 4 in Scotland; powders 6 to 4 andpills nearly 7 to 4. The dosages are different,and it does not necessarily seem to imply that moremedicine is consumed in England. (Q. 2038.) Theextra cost in England is explained by the fact thateach renewal carries a separate dispensing fee andseparate payment for the chemist’s establishmentcharges.

(App. II. C. 19.) The chemists in Scotland haveproved more difficult in regard to terms of remunera-tion because, unlike the English chemists, they hadnot so much new business under the Insurance Act.Generally speaking, in Scotland, before the InsuranceAct, the doctor had dispensed his own medicinesonly in country districts in which there was nochemist. In England, on the other hand, dispensingby doctors had been widely prevalent and in certaindistricts it was the almost universal rule. The

t The figures which are quoted were given in a note to Q. 1997.

Insurance Act, by prohibiting doctors from dispensingmedicines for insured persons, except in specialcircumstances, thus diverted into the hands ofEnglish chemists an increased volume of trade withoutconferring upon Scottish chemists an equal or corre.sponding advantage.

Medical Service in the Highlands.(Q. 2119.) It is claimed that there exists in the

Highlands and Islands of Scotland a combination ofdifficulties not to be found in any other part of thecountry. By means of a special Exchequer Grant-the Board have been able to make considerable improvementsin the medical service, not merely in supplying surgeons andspecialists, but also in raising the status of the ordinarypractitioner, for example, by providing him with a livingwage and helping him with a motor-car to reach his patients.The total of the grant is about £42,000 a year, but ... thatcovers payments for services rendered to other classes in theHighlands besides insured persons.

Extra Payments to Medical Men in the Lowlands.(App. II. C. 25-34.) An Exchequer Grant of £65,000

is available for the Lowlands of Scotland for mileageand also to include special grants for necessitousdistricts. These special grants are paid under ascheme which provides funds for maintenance ofdoctors in isolated areas, for the maintenance of amotor-car, for dispensary provision, removal ofpatients to hospital and even, in a limited numberof cases, for expenses incurred by the doctor in takingleave for the purpose of a short course of post-graduatestudy.

REX v. BATEMAN.

ALL our readers know the successful issue of Dr.Bateman’s appeal against his conviction last December,which resulted in the quashing of the sentence andthe immediate release of the wrongfully convictedman. Most of us also know that these devastatingoccurrences in the life of a practising doctor bring withthem both a train of heavy expenses and a temporaryloss in professional earnings. Through representa-tions made to us it has been found that the advocacy,from the first extended to Dr. Bateman’s case in thesecolumns, has met with the approval of the medicalprofession at large, and we may here say that theattitude of THE LANCET in the matter was entirelydictated by great professional motives. In our opinionfrom the first-and it was strongly supported by goodauthorities-Dr. Bateman’s conviction was an exampleof the neglect in a court of law to give value to clinicalevidence ; and in a court of law, when malpraxis isin question, clinical evidence must always receive thegreatest respect if injustice is not to be done. Thusjuries have the right to expect that their attention willbe directed, and directed prominently, to the placeswhere clinical evidence might be expected to influencetheir opinion. This was not done in the case of Dr.Bateman, and the result of that case must lead tobetter things.

It has been felt that material assistance ought to beoffered to Dr. Bateman in the present circumstances,when he has to meet the legal expenses of the appealand to make good the deficits in his professionalincome. With that view we shall be happy toannounce in these columns any subscriptions thatmay be received towards a " Bateman Fund,"designed to defray the expenses which he hasincurred and to assist him in temporary but veryreal need.

Remittances should be forwarded to the Manager ofTHE LANCET, 423, Strand, W.C.2, and made payableto the " Bateman Fund Account."

We have received :-£ s. d.

The Proprietors of THE LANCET.. 250 0 0Lieut.-Colonel Henry Smith, C.I.E., I.M.S. 5 0 0Dr. J. Bright Banister...... 5 0 0