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THE PUBLIC CONTROL OF WATER-SUPPLIES.

To the Editors of THE LANCET.SiRS,-For some six months past we have had the subject

.of "Public Water Analysis" before the Tunbridge WellsBorough Improvement Association for consideration, andin March we took some action with a view to moving in- the direction which your able article upon the samematter touched upon. We have arranged with Maid-: stone, Crowborough, and other associations to form a

- deputation and to urge upon the Government the desirability- of an Act being passed to carry out such an important pro-iposal. Mr. Cornwallis (the Member for Maidstone) has beeninterviewed upon the matter and the result you may have- seen. Mr. A. S. Griffith-Boscaiven, M.P. for Tonbridgedivision, has also been assisting, and I should think if wecould form a strong deputation it might have some weight inhelping on the idea. I shall be glad if you could kindly.again draw further attention to what is being done and.state that the honorary secretary of the Tunbridge WellsBorough Improvement Association would be glad to hearfrom any society interested in the question, or from any.1l’ldividual prepared to support or willing to join as a repre-sentative to assist in augmenting the deputation beingformed so as to make it as important as possible. Arrange-jnents are in hand in order that some public and definiteexpression of opinion may be placed before the proper.quarters.—I am, Sirs, yours faithfully,

D. G. CORNWELL, Hon. Sec.Grove Hill-road, Tunbridge Wells.

D. G. CORNWELL, Hon. Sec.

THE NATIONAL DEPOSIT FRIENDLYSOCIETY.

To the Editors of THE LANCET.

SIRS,-The following is a copy of a letter addressed to theGeneral Secretary of the National Deposit Friendly Society- In answer to an application for observations on the medical’tariff of the Society.

I am, Sirs, yours faithfully,Cardiff, Aug. 6th, 1898. T. GARRETT HORDER.

To F. Letchfield, Esq.. General Secretary, NationalDeposit Friendly Society.

DEAR SiB,&mdash;In accordance with your wish I have examined the,pamphlets, &c., you were good enough to send me some little time since.1 may remark before I enter into details that I have had considerable’experience with friendly societies, and that long since I came to the<conclusion that it would be a good plan to pay the medical officers ofsuch societies for actual work done in attendance on the sick members.Of course, in arranging the fees to be paid, two things had to be takentnto consideration-namely, the proper and sufficient remuneration of-the medical officers and the position in life of the members of the.society. I freely admit that it is not an easy matter to settle the.amount of the fees to the entire satisfaction of both these parties.

According to your rules the following are the fees paid for medical- caaes in your society

s. d.One visit with medicine for two days ......... 2 6Ditto beyond three miles, extra per mile ...... 0 6Members entitled to over 5s. daily sick pay, extra forevery ls. above 5s. per visit ............ 0 6

Intermediate visits in dangerous cases, extra pervisit ........................ 1 0

Attendance at surgery and medicines for two days ... 1 6Fresh supply of medicine for two days......... 1 0

I notice that some alterations have been made in the above and thatnow an extra fee of 6d. is allowed for cases outside the two-miles radius,.!that Is. extra is allowed for visits paid between the hours of 9 P.M. and.8 A.M., and that 6d. extra is allowed for attendance at the surgerybetween these hours.

I candidly confess that I do not think the terms offered are

sufficiently liberal. To ask a medical man to travel four miles, ancsupply medicines in addition for a fee of 2s. 6d., is hardly reasonable o).fair. Neither is the allowance of 6d. per mile for visits paid outside th<two miles radius nearly sufficient. Again, the extra allowance for nigh1visits and night attendances is far too small. Supposing a member senifor the medical officer in the middle of the night, and the member live:nearly two miles from the doctor’s house, do you think the fee of 3s. 6dwould be a fair and reasonable one for such a journey ? With respecto " intermediate visits in dangerous cases " it is not quite clea:to me whether the medical officer would receive 3s. 6d. or Is. fo:such visits. If it is the latter sum, then I must say it is altogetheinadequate.As it is of the highest importance that candidates should be properl

examined by the doctors before being admitted I would suggest that thfee for such an examination should be raised from ls. to 2s. 6d. That istricter examination is more necessary in your society than in thordinary friendly societies is evident from the fact that you admimembers up to fifty-five years of age.

-

I am, dear Sir, faithfully yours,Cardin, Aug. 5th. T. GARRETT HORDER.T. GARRETT HORDER.

1 THE LANCET, April 23rd, 1898.

"THE ALLEGED DEARTH OF QUALIFIEDASSISTANTS."

To the Editors of THE LANCET.SiRS,-I have read with great interest the correspondence

Ln THE LANCET under the above title. Now, Sirs, I3.m sure that anyone who has read the correspondence cannotfail to see that there is something seriously wrong withgeneral practice, as undoubtedly the letters represent theopinions of the majority of general practitioners. Speakingpersonally, although a young man I have had experience asan assistant in several practices and have a father and twobrothers all in separate practices as well as having beenintimately associated for many years with general practi-tioners. The result is that I have never yet known onewho caeteris paribu.s, and presuming that he fulfils his dutiesproperly, has not what" Practitioner "1 describes so

aptly as "a life of hardship, a scanty income, constantharass," &c., and I am so disgusted with the life of the

ordinary medical man that had I the opportunity I wouldeven now make a fresh start at another calling, althoughI love the work per se and the study of medicine.As regards the question of employer and assistant I thinkthere is a lot to be said on both sides. My first assistantshipproduced &pound; 80 per annum, indeed, and was not a happy one.Although well treated as far as board and lodging andcourtesy went, the life was wretched, as I was so tied down-always on duty, except perhaps for an hour in the day andafter 8 P.M., when one was just as likely to be called out asnot; no opportunity for games, and as my employer gene-rally went out every night I had to be in, and if allowed afew hours to run up to town once a month to visit atheatre it was considered sufficient. But I do not thinkthe salary was inadequate, as I am sure the expenses ofa practice at present are so heavy, owing to poorfees, clubs, and underpaid appointments, that any practitionerdoing less than Z1000 a year cannot afford to pay more to anassistant than &pound; 100 a year indoor, if he wants to put byanything at all, although the average salary of a qualifiedassistant, which I should put as Z70 per annum, is indeedwhat one would pay a first-class butler. And now let meconsider why the general practitioner is so hard pushed andif a remedy can be pointed out.

In the first place, thousands of pounds which ought togo to medical men go to quacks-i.e., herbalists and bone-setters-and prescribing chemists. And, as "Assistant" 2

says, the General Medical Council ought, in the interests ofthe public as well as in those of the general practitioner, toimmediately suppress them, and I am glad to see the HomeSecretary promised recently in Parliament to give the matterhis attention. Let us hope he will do so. And here I maymention that in Denmark at any rate prescribing bychemists is illegal.

Secondly, we have medical fees, and, as "M.B.,B.Ch. Dubl."3 suggests, these should be fixed by law. I

daresay this would be difficult, but suppose that the GeneralMedical Council obtained powers to - maintain a properstandard of professional etiquette. I take it that to attend

people at starvation fees is or ought not to be etiquette. TheCouncil can erase a man from the Register for advertising,why not for taking halfpenny fees, as this is degrading? 2Supposing they enacted that any man who took mid-

wifery under .elks. ahead, and who visited under 2s., andsupplied medicine and prescribed under 2s. a head, and whoengaged to attend anyone in a club under 7s. 6d. per annum-which is only lid. per week-would be guilty of unpro-fessional conduct what a difference it would make.And I consider that all men earning over 15s. a week areable to pay lid. per week for medical attendance. All thosewho could not afford to pay this should be treated by theparish or hospital and consequently the Local GovernmentBoard would have to raise their salaries. These, again, are agreat grievance, as all the Poor-law medical appointments

: are underpaid. My father, for example, has five parishes, under him with a total of about 100 paupers some five miles.

distant, and others two or three, and he is expected to attend. and provide them with medicine for about .630 a year. This, is disgraceful, and why should it be so seeing that solicitorsholding Poor-law appointments are at any rate fairly paid 1

I cannot think the Local Government Board can be aware,

how underpaid these posts are or they would try to

remedy the evils. And medical officers to clubs should all

1 THE LANCET, July 9th, 1898, p. 104. 2 THE LANCET, July 2nd, 1898, p. 53.3 THE LANCET, July 23rd, 1898, p. 229.

435

unite in seeing that the clubs are not abused by people wellable to be private patients. Lastly, there is the questionof hospital abuse, which is assuming alarming proportions anddemands immediate legislation.To sum up, who is responsible for this state of

affairs 7 The answer is apparent-the General MedicalCouncil. Why do they not adopt more stringent remedies ? 7Because that body consists almost entirely of consultantswith scarcely any general practitioners and these mendo not know and cannot understand what. hardships thegeneral practitioner has to contend with and remain satisfiedwith a few trifling reforms. I am sure that if they had anequal number of consultants and general practitioners ontheir staff a great deal more would be done for professionaletiquette. I commend their recent action with regard to

unqualified men, hard though it may be on some, for is itnot a case of "the survival of the fittest and we are thefittest.Our only chance is to immediately agitate to get the same

number of general practitioners on the Council as there areconsultants, or even more, as we are undoubtedly the bodyof the profession and therefore ought most certainly to haveour own representatives in sufficiency, and then the Councilwill obtain from Parliament more extensive powers to enablethem to raise the standard of, to mitigate the evils affecting,and to remunerate more properly the body of the profession.

I call therefore on all those who have written on this

subject recently and all those who are interested inand approve of this scheme to join with me and at onceenrol ourselves into an alliance of general practitioners,call it what you will, and to invite all other medical improve-ment associations to join us in one great body and let usstart a journal devoted to the subject or ask permission toinaugurate our society in the columns of THE LANCET-that journal which has already done so much to raise thedignity of the profession; and, in the first place, petitionthe General Medical Council to allow us to be more fitlyrepresented on their rolls and then urge upon our representa-tives to take immediate action to reform the state of theprofession. I am, Sirs, yours faithfully,

ASPIRATOR.

ADDRESSES AT MEDICAL CONGRESSES.To t7te Editors of THE LANCET.

SIRS,-The Presidential Address of Sir Thomas GraingerStewart at the recent meeting of the British Medical Asso-ciation in Edinburgh was more than a r&eacute;s1lm&eacute; of medicalprogress during modern times, but not so much more thatit would be very unfair so to describe it. Professor Fraser,in his Address in Medicine, gave a brief history of puremedicine during the twenty-three years which had elapsedsince the last meeting of the Association in Edinburgh.Professor Annandale recorded the advances of modern

surgery in the first part of his Address in Surgery.All three learned gentlemen gave thoughtful and informatoryaddresses, but I question whether their hearers wouldnot have preferred that a more personal note shouldhave been struck. It has lately become the invariablecustom for the addresses at medical congresses-I refer inparticular to those delivered in plenary assembly, but thePresidents of Sections often do exactly the same--to assumethe form of stocktaking. This sort of address is disappoint-ing to the general practitioner. Eminent physicians andsurgeons are wasted in delivering such speeches, for thesubject matter lies within the ken of their audience before-hand. What the medical public desires to get from itsleaders is a personal expression of opinion upon something ;they seek a sign, not a summary. It must not be supposedthat I do not recognise the pains and the erudition whichhave gone to the making of the addresses which youpublished last week and the week before. I recognise theirvalue, but, the speakers being the men that they are, Icannot but regret that their audience did not have fromthem something more distinctive.

I am, Sirs, your obedient servant,Aug. 8th.

________

M. B.

VENESECTION IN CHRONIC BRIGHT’SDISEASE.

[DR. SAUNDBY requests us to publish the following letterwhich he has addressed to Professor Ewald.]DEAR PROFESSOR EwALD,&mdash; the Section of Pharmaco-

l logy and Therapeutics at Edinburgh, during your speech on-L the treatment of chronic Bright’s disease you expressedl surprise that in the last edition of my lectures on Renal and

Urinary Diseases I had omitted all reference to the value of, bleeding in uraemia. I could only reply that if that were the-L case it was an undoubted omission, although it was rare forI me now to have recourse to bleeding in these cases. Ont returning home, however, I have turned to the place in my. book and find you were mistaken, as on page 177, under thei heading " Treatment of Uraemia," are these words : "In. obstinate convulsions 12 to 16 ounces of blood may be taken. from the arm. Hemiplegia and coma call for bleeding to the. like amount, but the hot-air bath recovered one patient from. coma after the attempt to bleed had failed."

I am sending this correction to the press.. Yours faithfully,! ROBERT SAUNDBY.

Edmund-street, Birmingham, Aug. 6th.ROBERT SAUNDBY.

NOTES FROM INDIA.

(FROM OUR SPECIAL CORRESPONDENT.)

The Probable Ditration of the Plag1fe Epidemie.-LessoMfrom History.-Hope front further Scientific Investiga-tions.

Now that the plague has so greatly subsided in nearly everyplace which has been attacked speculation is rife not only asto the recurrence of further outbreaks but as to the probable.duration of the plague. That its apparent extinction in adistrict is no guarantee against a re-importation or a recru-descence has unfortunately been proved by many instances.The gradual spread of plague over a larger and largerarea is also an additional source of danger for the-

perpetuation of the scourge. The clearest indication as-

to its further continuance seems to be derived from thehistory of plague in former times. It is generally recorded-to have attacked districts or towns for a number of years inmore or less regular succession. In Central India it existedfrom 1813 to 1821, in Kathiawar from 1816 to 1821, inGharwal from 1849 to 1854, again from 1875 to 1877,and a third time from 1884 to 1897. In Hong-Kong-it has lasted since 1894. Older writers describe whatwas probably plague as existent in the Punjaub from1618 for eight years, in Ahmedabad from 1683 to 1689,and in Surat from 1684 to 1690. Short intervals of apparentfreedom have characterised nearly all these outbreaks. In-most cases it appears that the larger the population of a townor village the greater seems to be the virulence and intensityof the outbreak and the longer its duration. The older records,while obviously incomplete, seem to show that a much larger-proportion of the population was carried off by the disease informer epidemics than has been recorded anywhere during-the present visitation of plague. While there is some comfortfrom the latter observation there is very little hope of

escaping from a further series of outbreaks for perhaps manyyears to come. On this point Dr. Roux has expressed hisopinion that plague in India "would remain with us in-

Bombay for a long time." He affirmed his belief that itwould be several years before we should see the last of it.Dr. Yersin has also stated that plague would be a recurring-epidemic for many years. It must be admitted that allour sanitary measures have failed to eradicate the disease.While we stick to all sorts of repressive sanitary measureswhich were exceedingly difficult and almost impossible to-apply, and have proved over and over again almost complete-failures, we have amongst us several foreign savants whoare working on quite different lines - for prophylactic-inoculation, M. Haffkine ; for curative serum, Dr. Simond,as representing Professor Roux and the Pasteur Institute ;-and Dr. Gallioti, representing Professor Lustig of Florence.As there is no difficulty in the manufacture of either the pro-phylactic fluid or the various kinds of curative serum, and asboth offer some hope of success, it seems extraordinary thatthe Government does not engage English men of scienceto pursue further investigations in these directions. Both

systems are capable of very considerable improvement. It is

impossible that the expensive methods of sanitary controlas hitherto adopted can go on for years. Every city wouldbe bankrupt and perhaps India in insurrection, so that

either plague will have to be left almost entirely to take its.own course or experimental science must step in and supply