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tendency to refer patients wholesale to the part-time Poor-law medical officers would not proveacceptable to these practitioners, who are also withoutexception on the panel. The hardship would fallrather on individual doctors, especially the com-

paratively few who are dependent solely for theirexistence upon a large panel. Although no doubtthe individual fee per patient would be higher--for in the Manchester scheme practitioners are

actually paid only some three-fourths of the sums towhich they are entitled on the basis of the model fees-yet attendances would certainly drop off in greater orless degree, young people of both sexes generallywould be loath to come if a fee was to be charged,minor ailments would remain unattended, and in factall the early preventive work which has been growingup unobtrusively under the Acts would drop out.How long would such a struggle last ? Manchester

is not optimistic in regard to the Minister yieldingforthwith, even when evidence of the determinationof the medical profession is submitted. But insuredpersons will, no doubt, bring pressure upon theirfriendly societies to come into line, even beforethe seriousness of the position is brought home tothem in the New Year, for the doctors’ case alreadyhas widespread sympathy among insured patients," Surely, Doctor, you are not going to take less thanyou do now," being frequently heard. The difficultyis realised in stating an issue which cannot readily beexplained in popular terms. No doubt 8s. 6d. isregarded in the Manchester area as an insufficient sumfor services rendered. So much is this the case that,as was to be feared, a number of the practitioners withsmaller panels-men whose presence on the lists isparticularly valuable in proof of the all-round qualityof service-have decided in any case not to renew theiragreement with the Insurance Committee ; but it isnot easy, in an area where feeling is friendly all round,to evaluate the fear of central interference from theapproved society representatives, which Manchester is theas sensible to as practitioners in less organised districts.Can the resistance be effective ? There is, I gather, (

a large local relief fund quite apart from the NationalInsurance Trust Fund, from which the hard cases 4

would be relieved, and on the financial side it is felt gthat the Minister of Health is unaware of the strength 1of the position. Experience has shown that it is not 1difficult to keep up a loyal standard of a minimumfee per visit or surgery attendance, although more diffi- 1cult to do so in the case of any contract arrangement. 1A curious difficulty arises in enlisting the sympathy i

of the women for the insurance principle, for, even in Ian area where the serious aspect and determination of ithe Mancunian at once strike the southerner, women 1are found not readily comprehending that principle. principle.

When in health they are apt to resent the payment of iinstalments which do not seem to them to result inany material return. At any rate, the domestic <

servants in Manchester-for there still appear to be (

some-are hostile to medical benefit under the Act,and this spirit has been in evidence often and else- Iwhere. But these comprise the only section of the 1community, it would seem, who desire to " scrap {

the Acts." In Manchester the medical men and the <public alike accept the insurance principle, the <

medical men only wanting to have proper conditions }of service. _____________ (

SCOTLAND.(FROM OUR OWN CORRESPONDENT.)

Cameron Prize Leetzere The Story of Insulin.Prof. McLeod, of Toronto, delivered the first of

two lectures on Oct. 16th in the University NewBuildings, Edinburgh. He said that he proposed togive a review of the investigations which had led tothe introduction of insulin as a recognised therapeuticagent. The problem with which they were concernedwas the nature of the fundamental factors which controlcarbohydrate metabolism. Prof. McLeod brieflyoutlined the well-known facts of the breaking up of

carbohydrates into carbon dioxide and water, andhow this was influenced and controlled by an internalsecretion of the pancreas, to which Sir EdwardSchafer gave the name insulin. He told how he andhis co-workers had eventually managed to obtain thissubstance free from proteolytic enzymes by the processof acid-alcohol extraction of fractional precipitation.The next step was to study the effects of insulin onexperimental animals. In depancreatised dogs insulinreplaced something which was absent and controlledover-production of sugar, so preserving the balance inthe blood. In normal animals it was a toxic agent,having, as it were, the effect of an overdose. Theadvantage of using depancreatised dogs rather thanexperimenting on diabetics was that the latter arenot completely depancreatised and consequently anunknown factor is involved. Best and Banting in theirfirst experiment obtained a definite fall in blood-sugarand this was accompanied by a lower output of sugarin the urine, so that the sugar was used by the animal.They next set to work to find out by comparing intakewith output how much glucose a unit of insulin couldcause to be metabolised. Thus, if a dog on an intakeof 145 g. of sugar used 105 g. with 20 units of insulinand 135 g. with 30 units, the additional insulin haspresumably accounted for the extra 30 g. of sugar used,and the glucose equivalent, as it is called, would be 3.It was important from the clinical standpoint todetermine this glucose equivalent. It was not constantin any one case, and was found to be considerablylower in diabetics than in the experimental animals.It became progressively smaller as the dose of insulinincreased according to a definite curve, so that insulinin this respect behaved as an enzyme. This observa-tion suggested that clinically a slow absorption of smallamounts as from inunction or the alimentary tract wasmore desirable in obtaining the maximum effect thanthe present hypodermic method. The glucose derivedfrom carbohydrates was apparently more easilymetabolised than that from other sources, whichpossibly accounted for the lower glucose equivalent indiabetics who derived their supply to a considerableextent from protein. Insulin also acted on the otherend of the chain, bringing about the deposition ofglycogen in the liver and muscles. It acted, too, onboth ends of the fat metabolism chain, reducing thelipsemia and fat excess in the liver at the one end andat the other bringing about the complete oxidation ofbutyric acid. The lecturer pointed out that thislatter action was indirect and quoted the well-knownillustration of the fats being burnt up in the carbo-hydrate fire. The ketone bodies in diabetes might beregarded as the poisonous smoke of incomplete com-bustion. The influence of the pancreas on fatmetabolism was a problem of great interest andimportance.

In the second lecture Prof. McLeod began bydiscussing the effect of insulin on experimental formsof hyperglycsemia. These he classified in threegroups : (1) nervous, (2) asphyxial, (3) pharmaco-logical. Claude Bernard’s classical experiment of

puncturing the floor of the fourth ventricle furnishedan excellent example of the group (1). There wasalso in this group sympathetic stimulation, eitherdirect electrical or indirect by adrenalin. Ether andphloridzin respectively were examples of the groups(2) and (3). Insulin controlled all these forms ofhyperglycsemia. That this was not a simple reactionin the blood was indicated by the fact that much moreglycogen was recovered from the liver of an animalto which insulin had been given along with epinephrinthan from that of one which had had epinephrinalone. An interesting and at present inexplicablefact was that only 60 per cent. of injected glucosewas recovered in the body 15 minutes later. It wouldseem that insulin brought about the formation of anintermediary substance between glucose and theend-products, carbon dioxide and water, which withour present analytical methods we are unable to detect.Prof. McLeod went on to deal with the effect ofinsulin on normal animals. In well-fed animals, inwhich there was a plentiful store of glycogen, the

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blood-sugar curve returned in about three hours toits normal level, whereas in starved animals, whichlacked this store, the return was very much slower.This had a practical bearing in indicating a possibledanger in the insulin treatment of severe diabetics.The two curves corresponded in the first half-hour,which might seem to indicate that the process takesplace in the blood. But in vitro the glycolysis curvewas unaffected by insulin. The effect would seem,therefore, to be produced in the tissues, and this wassupported by the fact that insulin greatly increasedthe rate of glycolysis of the perfused mammalianheart. It was as if a vacuum were created in thecell and filled up again from the blood. This" vacuum" was in all probability the result ofincreased carbohydrate metabolism, though theexperimental evidence of this was not absolutelyunimpeachable. Non-insulin normal rabbits showedhigher storage of glycogen than insulin ones. Theincreased carbohydrate metabolism resulting frominsulin led to a sparing of protein metabolism. Thelecturer went on to speak of the source of insulin. Hereviewed the known facts concerning the islets ofLangerhans. In the lower animals, such as the skate,the islet tissue is definitely arranged along the ductsand appears to be an outgrowth of the epithelium ofthe ducts, whilst in some fishes the islet and zymo-genous tissues are quite separate. In these the islettissue was present as a number of small glands, oneof which, larger than the rest, was known as theprincipal islet. As much as 25 units of insulin had beenobtained from one of these islets. The cod and thehalibut were providentially provided with large Iprincipal islets, and, as these could be quite easilycollected by fishermen when cleaning the fish, therewould seem to be every hope of a substantial reductionin the cost of production of insulin.

University of Edinburgh: Retirement ofProfessor Alexis Thomson.

It is a matter of great regret that Prof. AlexisThomson, C.M.G., has been compelled through ill-health to retire from the Chair of Systematic Surgery,tor which he was appointed in 1909. In appreciationof the place he held in the estimation of the under-graduate a former pupil writes in The Student, theofficial students’ magazine of the University :&mdash;" Some of us will long remember the strange feeling of

despondency we felt on hearing that Prof. Thomson mightretire from the Chair of Surgery. He has filled, and willcontinue to do so, a very conspicuous place in the traditionof the Edinburgh school, and in the conversation andmemories of undergraduates. Never has any lectureroccupied a more affectionate and familiar place in thememories of his students.... Although severed to his intenseregret, from the detail of teaching surgery, his name willlong remain as an impulse to progress. One of the greatestbenefits students have derived from Prof. Thomson’slectures, and one which he was never tired of emphasising,was his conception of the evolutionary nature of surgery.His teaching was valuable, not for the number of factsthat he enunciated, but for the angle from which he regardedsurgery, not as an abstract collection of immutable rules,but the practical art of relieving disease based on

physiological principles."

Royal Medical Society of Edinburgh.The inaugural address of the 187th session of the

Society was delivered in the Society’s Hall, Melbourne-place, on the evening of Oct. 19th by Sir WilliamLeishman, K.C.M.G., Director-General of MedicalServices.

Royal College of Physicians of Edinburgh.At a dinner given by Prof. George M. Robertson

in connexion with the Morison lectures, Prof. Robertsonspoke on the Centenary of the Delivery of Specia]Courses of Lectures on Mental Disease.

WEST RIDINIG ASSOCIATION OF GRADUATES OF THEUNIVERSITY OF EDINBURGH.-The annual dinner will bEheld in the Great Northern Hotel, Leeds, on Nov. 9that 7 P.M. It will be preceded by the annual generameeting at 6.30 P.M. Further information may be obtainecfrom the hon. secretary, 103, Manningham-lane, Bradford.

Public Health Services.REPORTS OF MEDICAL OFFICERS OF HEALTH.THE following table gives some of the principal

health statistics for three cities during 1922. It willbe noted that Sheffield compares favourably with theother two for the death-rate from respiratory diseasesand influenza, probably for the reason given by Dr.Wynne, that influenza was prevalent in the last quarterof 1921 in Sheffield and not in the first quarter of 1922.

. The figure in brackets gives the undivided infant mortality rate.

Sheffield.Dr. Fred. E. Wynne reports that the general death-

rate and the infant mortality-rate were the lowestever recorded. The Sheffield death-rate was for thefirst time lower than that for England and Wales.This is partly due to the fact that the influenza andpneumonia epidemic occurred in Sheffield during thelast quarter of 1921, whereas in most parts of thecountry it occurred in the first quarter of 1922.Eleven cases of small-pox were notified during theyear, all of the mild type characteristic of recentoutbreaks in the Midlands. All the patients made agood recovery. The war increase in tuberculosis deathsamongst both males and females has disappeared.The lowest death-rate from tuberculosis was in 1920,and the two subsequent years show a slight increase.Thus the deaths in 1920 were 590, in 1921 619, and in

, 1922 636. Dr. Wynne combats the suggestion thatthe reduction in infant mortality merely postponesl the deaths of infants to a slightly later period of lifel by showing that the mortality at ages 1-5 has declinedl pari passu with the mortality during the first year of- life. He further shows that, owing to the decreased numbers of deaths of infants from diarrhoeal and

&iacute; respiratory diseases, the number of deaths of weaklyt or degenerate infants with a bad heredity, included in the congenital causes group of prematurity, debility,, &c., now form a greater proportion of the total. infant deaths. This indicates that the infants who are

being saved are not the weekly and degenerate ones.The number of houses erected during the year was

979, of which 801 formed part of a municipal scheme.Overcrowding is still deplorable and the citytreasurer has 4000 families on the waiting list formunicipal houses. Owing to the shortage, there has

e been much sub-letting by tenants of the corporation- and endeavours are being made to check this and1 to prevent undesirable conditions arising on the" corporation housing estates. Much attention hasbeen given during the year to the repaving of back-yards, and Dr. Wynne emphasises the fact that

1. " when an unpaved and dirty back-yard is put in1. good condition the effect is to improve the sanitaryj condition and cleanliness of the whole interior of the

houses using such yard." As the cost falls entirely_ on the owner, the progress of this work is difficult

- in many cases at the present time. A scheme is under

E consideration by which, when necessary, the corpora-e tion would do the work and recover the cost from the

i owner in instalments. Dr. Wynne believes that suchd an arrangement would constitute, without cost tothe rates, an important sanitary reform.