248 Public Health Services. CONTINUED HIGH SCOTTISH DEATH-RATE. THE death-rate in the principal towns of Scotland recorded in the return of the Registrar-General for the week ending Jan. 28th remains high, being 0’4 more than that of the previous week already reported in THE LANCET, and actually higher than it has been for 47 years. Deaths attributed to influenza number 476, 97 more than in the previous week, while those from respiratory diseases show a decline of 25 to 656. -- THE MEDICAL LIST. In an address on Medical Benefit under the National Health Insurance Acts, read before the National Federation of Employees’ Approved Societies at the London Chamber of Commerce on Jan. 24th, Mr. David Davis made a proposal to limit the right of admission to the Medical List, and the suggestion comes with some authority from the chairman of the Medical Service Sub-Committee of the London Insurance Committee. The process, Mr. Davis said, by which a doctor could become an insurance practitioner was too easy. He would like to see a committee of selection appointed for each area for the purpose of considering applications from practitioners for admission to the list. This raises the whole question of what has been called the open panel. The regulations as they stand provide that the Insurance Committee shall prepare a list, to be called the " Medical List," of the prac- titioners .... who have notified the Committee that they have accepted service upon the terms of service offered by the Committee and approved by the Minister. And in the schedule which sets out the terms of service for practitioners the clause runs (the italics are ours) :- Every practitioner, other than a practitioner disqualified from taking service by reason of his name having been removed, after an inquiry, from any medical list in Great Britain, who gives notice to the Committee that he accepts service upon the terms for the time being in operation in the Committee’s area will have his name included in the Committee’s Medical List. In other words, any practitioner who is on the Medical Register must be accepted for inclusion in the Medical List and will remain on the list until his name is removed, owing to unprofessional conduct of’such a degree as to merit this extreme penalty, after two inquiries, one locally by the insurance committee and the other centrally by the special tribunal of the Ministry. The panel is open to all, but the list is purged after complaints have been received and inquired into. This process is cumbrous and tedious, too slow in the serious cases and much too cumbrous in the majority of cases which are of a trivial nature. With the open panel is associated the principle of free choice for the insured person, and the extent of that choice depends partly upon the size of the panel and partly upon the initiative of the insured person. Free choice has been limited in the past both by the unwillingness of certain practitioners to accept service and the reluctance of insured persons to change their doctor. But if the right to admission to the Medical List is limited, then free choice must go and insured persons will take the doctors provided for them by the proposed selection committee. Those who designed the panel system were wise in providing free choice with an open panel, so that the best type of practitioner could accept service and the conditions of service might approximate to those of general practice. The only alternative would appear to be a whole-time salaried service, and this is probably the ultimate aim of those who suggest the limitation of the right of admission to the list. The question was raised in an interesting way at a recent meeting of the Burnley Insurance Committee, where certain members desired to refuse admission to a foreigner, presumably a Chinaman. But, as the medical secretary of the B.M.A. pointed out, " there is nothing to prevent a Chinaman or a native of any other country, whether he be yellow or black, practising in Great Britain if he takes a British degree .... We have," he added, " several Chinese who are members of the Association. The question of nationality does not arise." In practice " free choice " is important because it cuts both ways and enables practitioners to make a choice as well as the insured person. The difficulty is to provide for the unreasonable patients whom no practitioner desires to treat. The failure of allocation schemes emphasises the embarrassment which arises when the right of free choice is interfered with. Approved society officials might be expected to help in preserving the liberty of their members and in encouraging them to place their names on the list of a practitioner at an early date before onset of illness. Hitherto the efforts of insurance committees in this direction have been unavailing, but the approved societies should be able to influence their adherents. Societies would perform a very useful part in ex- plaining to their members the nature of their duties as well as of their privileges under the insurance scheme. ____ INFANT MORTALITY AND THE BUDGET. The provisional figures for infant mortality in England and Wales during 1921, published in our last issue, must be regarded as satisfactory. The rate of 83 per 1000 births is only three points higher than the best ever recorded-viz., 80 in the year 1920. The hot summer of 1921 was, however, much more conducive to a high diarrhoea mortality than the preceding summer, and the Registrar-General’s figures, given in his last quarterly return, show that the summer quarter of 1921 was the worst for diarrhcea since 1915, although not approaching the figures of 1911. The mean temperature recorded by the four-foot earth thermometer at Greenwich was 58.6° F. during the third quarter of 1921, whereas it was only 56’1°F. during the corresponding quarter of 1920-sufficient evidence of the very different climatic conditions prevailing in the two years. We have good reason, then, to be satisfied with the lowness of the infant mortality rate. How to allot credit for the recent great.improvement in infant mortality is a real difficulty which has nowhere been set forth better than in the report of the Medico-Sociological Committee of the B.M.A. Clearly it is not due to improvement in habitation, for the simple reason that housing conditions have recently become worse. It is more difficult to rebut the contention that the improvement in infant mortality, extending as it does to the pre-school period of life, is largely due to better and more intelligent feeding. Infant welfare centres have not confined their activities to the provision of advice ; most of them make it possible for the mothers to secure safe milk. ’The mothers who attend the centres as a matter of course get milk for their infants if they cannot nurse them, but they also-and this is the important point-purchase milk for their other children up to 5 years of age. Thus milk now finds its way into urban households in which its use was often unknown in the old days. The Government Committee on the production and distribution of milk showed how inadequate is the consumption of milk per head in this country, while research work on vitamins has emphasised its value as a food. Reckless gratuitous distribution of milk may have taken place in a few towns, but a Government concerned for its child-life will hesitate before taking steps to reduce still further the consumption of milk at early ages. Circular 267 of the Ministry of Health seems to suggest that the gratuitous supply of milk should be limited to infants under 12 months. Experience has shown that in large towns it is the years between babyhood and school entrance which are starved of milk. To stop the gratuitous issue may benefit the national budget by a sum of £200,000, but it would prove an
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248
Public Health Services.CONTINUED HIGH SCOTTISH DEATH-RATE.
THE death-rate in the principal towns of Scotlandrecorded in the return of the Registrar-General forthe week ending Jan. 28th remains high, being0’4 more than that of the previous week alreadyreported in THE LANCET, and actually higher thanit has been for 47 years. Deaths attributed toinfluenza number 476, 97 more than in the previousweek, while those from respiratory diseases show adecline of 25 to 656.
--
THE MEDICAL LIST.
In an address on Medical Benefit under the NationalHealth Insurance Acts, read before the NationalFederation of Employees’ Approved Societies at theLondon Chamber of Commerce on Jan. 24th, Mr.David Davis made a proposal to limit the right ofadmission to the Medical List, and the suggestion comeswith some authority from the chairman of the MedicalService Sub-Committee of the London InsuranceCommittee. The process, Mr. Davis said, by which adoctor could become an insurance practitioner wastoo easy. He would like to see a committee of selectionappointed for each area for the purpose of consideringapplications from practitioners for admission to thelist. This raises the whole question of what has beencalled the open panel. The regulations as they standprovide that the Insurance Committee shall preparea list, to be called the " Medical List," of the prac-titioners .... who have notified the Committee thatthey have accepted service upon the terms of serviceoffered by the Committee and approved by theMinister. And in the schedule which sets out the termsof service for practitioners the clause runs (the italicsare ours) :-
Every practitioner, other than a practitioner disqualifiedfrom taking service by reason of his name having beenremoved, after an inquiry, from any medical list in GreatBritain, who gives notice to the Committee that he acceptsservice upon the terms for the time being in operation inthe Committee’s area will have his name included in theCommittee’s Medical List.
In other words, any practitioner who is on the MedicalRegister must be accepted for inclusion in the MedicalList and will remain on the list until his name isremoved, owing to unprofessional conduct of’such adegree as to merit this extreme penalty, after twoinquiries, one locally by the insurance committee andthe other centrally by the special tribunal of theMinistry. The panel is open to all, but the list ispurged after complaints have been received andinquired into. This process is cumbrous and tedious,too slow in the serious cases and much too cumbrousin the majority of cases which are of a trivial nature.With the open panel is associated the principle offree choice for the insured person, and the extent ofthat choice depends partly upon the size of the paneland partly upon the initiative of the insured person.Free choice has been limited in the past both by theunwillingness of certain practitioners to accept serviceand the reluctance of insured persons to change theirdoctor. But if the right to admission to the MedicalList is limited, then free choice must go and insuredpersons will take the doctors provided for them by theproposed selection committee.Those who designed the panel system were wise in
providing free choice with an open panel, so thatthe best type of practitioner could accept service andthe conditions of service might approximate to thoseof general practice. The only alternative would appearto be a whole-time salaried service, and this is probablythe ultimate aim of those who suggest the limitationof the right of admission to the list. The question wasraised in an interesting way at a recent meeting of theBurnley Insurance Committee, where certain membersdesired to refuse admission to a foreigner, presumably
a Chinaman. But, as the medical secretary of theB.M.A. pointed out, " there is nothing to prevent aChinaman or a native of any other country, whetherhe be yellow or black, practising in Great Britain ifhe takes a British degree .... We have," he added," several Chinese who are members of the Association.The question of nationality does not arise."
In practice " free choice " is important because itcuts both ways and enables practitioners to make achoice as well as the insured person. The difficultyis to provide for the unreasonable patients whom nopractitioner desires to treat. The failure of allocationschemes emphasises the embarrassment which ariseswhen the right of free choice is interfered with.Approved society officials might be expected to helpin preserving the liberty of their members and inencouraging them to place their names on the listof a practitioner at an early date before onset of illness.Hitherto the efforts of insurance committees in thisdirection have been unavailing, but the approvedsocieties should be able to influence their adherents.Societies would perform a very useful part in ex-plaining to their members the nature of their dutiesas well as of their privileges under the insurancescheme.
____
INFANT MORTALITY AND THE BUDGET.
The provisional figures for infant mortality inEngland and Wales during 1921, published in ourlast issue, must be regarded as satisfactory. Therate of 83 per 1000 births is only three points higherthan the best ever recorded-viz., 80 in the year 1920.The hot summer of 1921 was, however, much moreconducive to a high diarrhoea mortality than thepreceding summer, and the Registrar-General’s figures,given in his last quarterly return, show that thesummer quarter of 1921 was the worst for diarrhceasince 1915, although not approaching the figures of1911. The mean temperature recorded by thefour-foot earth thermometer at Greenwich was
58.6° F. during the third quarter of 1921, whereas itwas only 56’1°F. during the corresponding quarter of1920-sufficient evidence of the very different climaticconditions prevailing in the two years. We havegood reason, then, to be satisfied with the lowness ofthe infant mortality rate.How to allot credit for the recent great.improvement
in infant mortality is a real difficulty which hasnowhere been set forth better than in the report of theMedico-Sociological Committee of the B.M.A. Clearlyit is not due to improvement in habitation, for thesimple reason that housing conditions have recentlybecome worse. It is more difficult to rebut thecontention that the improvement in infant mortality,extending as it does to the pre-school period of life,is largely due to better and more intelligent feeding.Infant welfare centres have not confined theiractivities to the provision of advice ; most of themmake it possible for the mothers to secure safe milk.’The mothers who attend the centres as a matter ofcourse get milk for their infants if they cannotnurse them, but they also-and this is the importantpoint-purchase milk for their other children up to5 years of age. Thus milk now finds its way intourban households in which its use was often unknownin the old days. The Government Committee on theproduction and distribution of milk showed howinadequate is the consumption of milk per head inthis country, while research work on vitamins hasemphasised its value as a food. Reckless gratuitousdistribution of milk may have taken place in a fewtowns, but a Government concerned for its child-lifewill hesitate before taking steps to reduce still furtherthe consumption of milk at early ages. Circular 267of the Ministry of Health seems to suggest that thegratuitous supply of milk should be limited to infantsunder 12 months. Experience has shown that inlarge towns it is the years between babyhood andschool entrance which are starved of milk. To
stop the gratuitous issue may benefit the nationalbudget by a sum of £200,000, but it would prove an
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expensive economy to check the wonderful progressrecently made in child welfare.
SCHOOL CLOSURE FOR INFECTIOUS DISEASE.The recent influenza epidemic appears to be respon-
sible for school closure on a wholesale scale throughoutthe country, although Dr. Maxwell Williamson has setout in full in the Edinburgh papers his reasons fornot closing the schools there. In cases where theteaching staff is so seriously depleted as to make itimpossible to carry on, or where, as in certain ruraldistricts, intercommunication is difficult and theschools are to some extent a distributing centre fordisease, we agree that closure is unavoidable or, atleast, excusable. But in urban districts and in themajority of rural areas school closure suggests that thehealth authority is shelving its responsibility ratherthan dealing with the problem on its own ground.Once the school is closed the authority has shut itselfoff from all knowledge of what is happening to thechildren, and as far as these are concerned the authority ’,might as well be non-existent. The only centre forthe control of infectious disease among children of ’,school age is the school. Absentees are noted, andchildren sickening in school are promptly dealt with. ’,The home can then be visited and arrangements madefor adequate nursing. When the schools are closedthe children are in the street, and if, as so often happensin an influenza epidemic, the parents are stricken, thechildren have no one to look after.them. Moreover,since many of the mothers are out at work, they areunable to exercise any real supervision over theirchildren, such as they get in school, and so the chancesof infection are seriously increased. It is well knownthat influenza does not attack children in such anacute manner as its does adults ; during the severeepidemic of 1918 it was not found necessary to closea single school in London. The recent epidemic hasassumed a milder form, lasting not much more thana week in a given district, and thus even if schoolclosure were defensible on general grounds it is boundto come too late. Measles is an almost uncontrollabledisease whether in school or out of it, but it is possiblewith school supervision by teachers, nurses, and doctorsto forecast very accurately the course of a measlesepidemic, and by noting and following up the casesconsiderably to reduce the mortality rate. Class closuremay have to be resorted to where the number ofunprotected children is high, but contact infection inschool is limited, and far too large a proportion ofcases have been ascribed to school infection. In thecase of scarlet fever and diphtheria school control,involving a systematic inspection of absentees, whichgenerally reveals a missed case of a mild degree, isthe only method of checking the spread of infection.The school medical officer is not always to blame for
school closure ; in many cases he has to submit topublic clamour, or his own views are overridden by ’,the health authority. But over 12 years ago the ’,advantages of school control of infectious disease were ’,accepted by the leading authorities on school hygiene,and a determined effort should be made to educatepublic opinion on these lines.
THE DEVELOPMENT OF PUBLIC HEALTH SERVICES IIN AMERICA.
A valuable store of information on publichealth problems and practice is contained in theJubilee Historical Volume 1 of the American PublicHealth Association, which in 461 pages deals withmany aspects of American public health from adevelopmental point of view.The editor-in-chief, Dr. M. P. Ravenel, writes inter-
estingly on the history of the American Public HealthAssociation and its share in the marvellous progressin nublic health administration which has ta.ken
1 A Half Century of Public Health. Jubilee HistoricalVolume of the American Public Health Association. Mazyck P.Ravenel, Editor-in-Chief. Pp. 461-xl. New York : AmericanPublic Health Association, 370, Seventh-avenue. Cloth, $5.25 ;stiff paper cover, $3.75.
place. He may be congratulated on the variouscontributions to the volume, and on the fact thatthough 19 hygienists are concerned in its compilation,there is but little redundancy, and so far as we haveseen, no evidence of essential differences in policy.The article by Dr. Stephen Smith, the centenarianfirst President of the American Public Health Associa-tion, gives interesting peeps into the past, and inciden-tally may be assumed to convey the author’s secret oflongevity, for he quotes, apparently with approval,the remark of a recent American authority, " Ikeep my stomach and brain busy." Dr. PeterBryce, of Ottawa, tells the story of public health inCanada, and Professor F. P. Gorham, of the BrownUniversity, gives a fairly exhaustive history of bacteri-ology and its contribution to public health work.He quotes the pioneer work of Burdon-Sanderson,who in 1871 demonstrated the presence of bacteria inwater, and attributes the first use in 1897 of chlorinefor disinfecting drinking water to the late Sir SimsWoodhead. It is noted that the first municipallaboratory in the States was established in 1888 inProvidence, R.I., where Dr. Charles V. Chapin was,and happily still is, the chief health officer.
S’tati.stical Progress.—The statistical progress of theStates is described by Dr. Frederick L. Hoffman insmall space. The account is necessarily somewhatincomplete, but what is given is interesting and learned,and makes one wish that Dr. Hoffman, who is masterof his subject, would give a complete statistical accountof progress during the last 50 years. He describes anearly life-table made by Dr. E. Wigglesworth in 1789,dealing with the experience of Massachusetts and NewHampshire. This table, like that of Dr. Price forNorthampton, was based on deaths alone, and thereforeits results are somewhat misleading. It is noteworthythat for four cities, New York, Philadelphia, Boston.and New Orleans, mortality statistics are available fora nearly unbroken hundred years. Dr. Hoffman’s reviewdoes not extend to the date of issue of the importantlife-tables, based on the experience of 1909 and 1910,which were published by the Federal Census Office in1916. His concluding remarks are worthy of quotation,for they place statistical evidence, especially when thisinvolves difficult mathematical calculations, in its place:" In the final analvsis, observational experience is asessential to sound judgment as statistical and mathe-matical calculations. The latter merely reduce to ameasurable basis conclusions otherwise vague andindefinite, but nevertheless accurate, if used withrestraint and caution, for practical purposes."
Quarantine Systems.—Tbe chapter by Surgeon-General Cummings on the United States quarantinesystem brings out clearly the differences between theEnglish and the American systems. The Americansystem is " unique in the maintenance of a doubleline of sanitary defence." Perhaps it is not wellknown that it includes land quarantine, especially asregards Mexico, whence there is risk of the introductionof a highly virulent strain of small-pox, as well as oftyphus ; for, as Dr. Cummings says, the typhuscondition in Mexico during several years past has beeneven more serious than the menace from Europe.
State and Municipal Control of Disease.- As mightbe anticipated, Dr. Chapin’s contribution on thehistory of State municipal control of disease is freshand original. He pursues his well-known thesis thatit is not dirt, but dirt carrying human excretions,which is dangerous, and illustrates this by the actionof the Federal Government even so late as 1898.Waring was then sent to Havana to stamp out yellow-fever by cleansing the city, and though his untiringenergy made Havana the cleanest city in the westernworld, yellow-fever continued. He points out thatthe acme of the filth theory was the sewer-gas bogey.Dr. Chapin bears eloquent testimony to the value ofvital statistics but adds that " figures do not measurethe terror of epidemics, nor the tears of the motherat her baby’s grave, nor the sorrow of the widow whosehelpmate has been snatched away in the prime oflife. To have prevented these not once, but a milliontimes, justifies our half-century of public health work."
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Prof. G. C. Whipple gives a review of 50 years of waterpurification ; Mr. R. Hering writes on the removal ofsewage and solid refuse ; Mr. E. P. Phelps on streampollution by industrial wastes ; Dr. C. A. Alsberg onprogress in Federal food control ; and Prof. S. C.Prescott, of the Massachusetts Institute of Technology,gives an admirable review of food conservation. The
chapter on milk and its relation to public health, byDr. C. E. North, gives in 52 pages a good account ofthe one branch of public health work in which Americais far ahead of Britain. Dr. P. Van Ingen reviews thehistory of child welfare work in the United States.Mr. L. Veiller writes on housing. Other chapters dealwith ventilation, public health nursing, and the historyof medical entomology ; and the veteran Prof. G. M.Kober, of Washington, D.C., contributes a valuablehistory of industrial hygiene.
It is clear that the review of 50 years covers a largeshare of the public health field, but there are strikingomissions. The control of epidemic diseases, of tuber-culosis, and of venereal diseases receives scant or nomention, the last named perhaps because of the recent-ness of its initiation. The important inter-relationbetween general social work and public health nursingis not developed, and consideration of the problems ofpoverty and hospital service are omitted, although muchvaluable work has been done towards their solution, andstill more is being done as the solidarity of social andpublic health work becomes more fully realised. Buton the subjects touched on the volume is extremelyinteresting, and will enable the public health workerin this country to institute useful comparisons and toacquire valuable suggestions for improved work.
The Services.ROYAL ARMY MEDICAL COLLEGE.
Maj. ancl Bt. Lt.-Col. W. P. MacArthur, R.A.M.C., has beenappointed Professor, vice Lt.-Col. T. C. Kennedy, R.A.M.C.
ARMY MEDICAL SERVICE.Col. H. S. Thurston. late R.A.M.C., retires on ret. pay.
ROYAL ARMY MEDICAL CORPS.Lt.-Col. and Bt.-Col. P. S. Lelean retires on ret. pay.Maj. J. Fairbairn retires on ret. pay and is granted the
rank of Lt.-Col.Maj. and Bt. Lt.-CoI. W. P. MacArthur relinquishes the
acting rank of Lt.-CoI.Temp. Capt. E. G. D. Milsom relinquishes his commn.
and is granted the rank of Maj.Temp. Capt. G. 11’. Woodroffe relinquishes his commn.
and retains the rank of Capt.ARMY UENTAL CORPS.
Lt. (temp. Capt.) A. B. H. Cole to be Capt.TERRITORIAL ARMY.
Capt. T. H. Richmond to be Maj.Capts. G. Adam and R. W. Smith (late R.A.M.C.) to be
Capts.Officers relinquishing their commns. : Majs. P. G.
Williamson (granted the rank of Lt.-CoI. with permissionto wear the prescribed uniform) and L. P. Gamgee (1stS. Genl. Hosp.), and Capts. C. C. Fitzgerald, U. Watts-Taylor (retains the rank of Capt.), and F. H. C. Watson(granted the rank of Maj.). -
WOMEN’S MEDICAL SERVICE OF INDIA.Dr. F. Hamilton Browne has been transferred from the Lady
Elgin Hospital, Jubbalpore, to the charge of the Dufferin Hos-pital, Calcutta. Dr. C. Cuthbert on arrival in India has beenposted as resident medical officer of the Dufferin Hospital,-and Dr. Millicent Webb has been transferred from the chargeof that hospital to the office of principal of the Women’sMedical School, Agra. Dr. D. D’Abreu has been appointedtemporarily to the charge of the Lady Elgin Hospital,Jubbalpore, Dr. C. Constance Hart to the charge of theDufferin Hospital, Karachi, and Dr. Alice O’Reilly to thecharge of the Lady Aitchison Hospital, Lahore. Dr. GertrudeCampbell has been appointed principal and professor ofobstetrics, and Dr. Grace Stapleton, professor of medicine inthe Lady Hardinge Medical College for Women, Delhi. Onarrival in India Dr. Marguerite Stewart has been postedtemporarily to the Government Victoria Hospital, Madras. I
Correspondence.
EPITHELIOMA IN KASHMIR.
"
Audi alteram partem."
To the Editor of THE LANCET.
SiR,-An annotation in your issue of last week" On Keeping Warm " refers to epithelioma of theabdominal wall that occurs in Kashmiris fromrepeated burning by the kangri. The conditionoccurs in other parts of the body from the samecause. When I last visited the Kashmir MissionHospital, Srinagar (September, 1918), the seniorsurgeon of that institution showed me six cases, fromall of whom he had removed epithelioma of the upperanterior and (mostly) inner part of the thigh. Intwo other cases the cancer had been removed fromthe lower abdominal wall. The braziers or earthenpots are partly filled with live charcoal, and placedbetween the thighs while the victim is squatting, thechaddar or outer body covering enclosing bothbrazier and body. The sides and rim of the heatedcharcoal container come into contact with the skinand inflict burns resulting in scars from whichcancerous growths develop. There could be no betterdemonstration of cause and effect ; it reminds oneof the same form of growth occurring in the lower lipfrom the clay pipe and in the scrotum of chimneysweeps. I was informed that in a very high per-centage of these cases there is no recurrence afterexcision. The condition is exceedingly common inKashmir.You refer in the same note to the splendid work
being done by the Rev. C. E. Tyndale-Biscoe, of theC.M.S., in his endeavours to inculcate the athleticspirit into the young Kashmiri as a means of main-taining the warmth of the body in winter, and Ican speak with personal knowledge of his laudableefforts in this direction. But those who mostly sufferfrom the growths under reference are the poorestclass, who are ill-fed and scantily clothed, and findthemselves obliged to resort to the form of artificialheating described.
I would ask you to allow me to say a few wordsabout the Kashmir Mission Hospital at Srinagar, inwhich there is a large amount of benevolent work ofa very high standard done quietly and without showby a devoted staff of medical officers and nurses. Itis an ideal institution, located on a knoll below theSuliman-i-Takht. having the glorious Dal lake onone side and the city on the other, the stately Jhelumflowing close to its base. What struck me most wasthat its wonderful efficiency is attained in an extra-ordinarily economical way. One special direction inwhich the cost is kept down is by having a large partof the hospital equipment, medical appliances, andsurgical instruments made in Kashmir, where labouris comparatively cheap. Medical administrators fromIndia visiting Kashmir might with advantage goover this hospital ; they will meet with the utmostcivility from the staff.
To the Editor of THE LANCET.SIR,—I am much interested in Mr. W. B. Gabriel
and Dr. A. Neave Kingsbury’s communication in THELANCET of Jan. 28th, having described a similar case(with illustrations) in the Lettsomian lectures for1920, published in the Transactions of the MedicalSociety of London and separately.l -
1 Tumours Complicating Pregnancy, Labour, and thePuerperium. Harrison and Sons. 1920.
