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were subsequent to it ? What, then, of these remarks

by Mr. Alexander Wilson? "The symptoms in thesecases indicate that the primary lesion is a paralysisof the circulation." "The first warning of danger isa change in the circulation." "The practical pointis that in these cases the first warning of danger isexhibited by a change in the circulation." " It cannot betoo much insisted on that as the primary lesion is in thecirculation to the circulation must we look for the first signsof danger and to the improvement of- the circulation musttreatment be directed." They are all entirely pointless.Since the first sign of danger was in this case abnormal

respiration it is scarcely worth while to pay any more atten-tion to the remarks based on the opposite supposition.With regard to treatment, the indications are plain :

maintain absolutely regular respiration from beginning toend of the anæsthesia; do not early in the anaesthesia givethe vapour in such concentration that the patient holds hisbreath ; remember that a strength of vapour which one manwill breathe with ease will so irritate the laryngeal mucousmembrane of another that there will follow spasmodicadduction of his vocal cords and holding of the breath ;and remember, too, that during all this time the chloroformimprisoned in his lungs is being absorbed with perhaps fataleffect. Later, too, be equally careful to maintain regularbreathing, remembering that irregular breathing may mean

either too much or too little chloroform (a point to bedetermined by other signs), and that either condition is oneof considerable danger. With regard to the giving ofammonia vapour bear in mind that it equally with chloro-form vapour may produce laryngeal spasm in the first

stage of chloroform anaesthesia and plunge a patient froma condition of comparative safety into one of imminent

danger. Seeing that Mr. Alexander Wilson has publishedseveral chloroform fatalities in his own practice, and that hemakes a special point of the danger from syncope due tochloroform poisoning, and therefore presumably takes specialpains to note the state of the circulation during his chloro-form administration, would it not be worth his while in thefuture to direct his attention to merely maintaining regularrespiration ? The result, should he do so, can scarcely failto be satisfactory to all concerned.

I am, Sirs, yours faithfully,CLAYTON A. LANE, M.D. Lond.,

Mussooree, Oct. 19th, 1898. Lieutenant, I. M.S.CLAYTON A. LANE, M.D. Lond.,

Lieutenant, I.M.S.

"A DEFENCE OF THE MIDWIFE."To the Editors of THE LANCET.

SIRS,—In your annotation under the above headingin THE LANCET of Nov. 12th, pp. 1283-84, you say: "NoMidwives Bill which we have yet seen contains any provisionfor ensuring that in every serious case a lying-in woman,however poor, shall have the benefit of qualified medicalattendance, and without such provision no MidwivesBill should pass." In my Sick and Obstetric NursesBill, already reviewed in your columns, special pro-vision is made for this very thing and by Clause 3:"It shall be unlawful for any person (male or female)to assume the title of midwife, or to practise as such,or to act as a sick or obstetric nurse for gain or other-wise, without the supervision and control of a fully-qualifiedand registered medical practitioner. Any person infringingthis provision and neglecting or refusing to send for medicalor surgical aid at or immediately after a confinement shallbe liable to a fine of £10 or imprisonment for a month indefault." Surely this is strong enough and the modllsoperandi is worked out in the schedules to the Bill. TheBill is printed in full in the Medical Magazine for March,1898. I am, Sirs, yours faithfully,East Sheen, Nov. 14th, 1898. ALEXANDER MCCOOK WEIR.ALEXANDER MCCOOK WEIR.

" THE ETHICS OF CLUB PRACTICE."To the Editors of THE LANCET.

SIRS,-I have read with interest and fellow-sympathy theletter re the above in THE LANCET of Oct. 15th. Leavingthe possible legal obligation to pay the bill out of thequestion, should " Beta" pay it he will find that thesmoothness and friendly feeling which have characterisedhis relations with the club members for thirty yearswill speedily disappear and that it will only be the

eage or me weuge anu me signai ior omer malcontentsto be on the war-path, and that he will very soon bepestered with similar bills from quite unexpected quarters onaccount of some fancied neglect, and if he makes the dangerousprecedent he will find a large hole made in the receipts fromhis clubs. So long as clubs exist so long will like cases crop.up. There are always so many malcontents who are neversatisfied, and very often it is those who get the most attendance-who are the first to turn round and accuse you of neglectand will frequently tell you quite straight that because your-money is sure you just do as you like. Then the medical

practitioner, on the other hand, is called out over and over

again, often at night and at unreasonable hours, to cases.that are quite trivial, and if he dares to demur he is told that11 hue will be reported" or "he must come," or " he will be-made to come or someone else will be called, and he will bemade to pay the bill."One knows when a message comes to attend a private case

that it is necessary, but to attend a club case out of hours is.in a great many cases unnecessary. The members pay somuch and they must have their pound of flesh. Who of club-doctors has not experienced the big strong man come to the-surgery and after untying several large handkerchiefs holdout a slightly abraded finger, or slight crush, or small cut.from a pocket-knife, &c., &c. ? Who has not seen his surgeryfilled on a fine summer evening chiefly by women, who have,just been passing the surgery during a walk and justdropped in to see what the medical man says aboutsome very trivial matter, not only trivial in the doctor’s.estimation, but one which would be trivial also in a privatepatient’s eyes ? The private patient would not waste a fee-on such a small matter, but the club patient has nothingmore to pay no matter how often he consults his surgeon, so,he abuses his privileges. All this is very degrading, but willexist so long as clubs exist-and I suppose that will be untilthe end of time. If one could get club members to under-stand, as you point out in your leading article in THE LANCETof Oct. 22nd, that the medical man must himself, and he-only, be the judge as to the urgency of the cases and the-order in which they are to be seen things would go more-smoothly. I think the great majority of club doctors willagree that I have in nowise overstated, in fact have under-stated, the annoyances attached to club practice. Clubs are-

pernicious for both sides-they take from the doctor his.dearest possession, his independence, and very often put the-club member in a false position.

I have never seen a club yet, and that may seem a sweep-ing statement, which did not possess its malcontents-some-fewer, some more-and it is from them that bills for attend-ance emanate. " Beta" should strenuously resist payingThe matter will be brought before a meeting of the com-mittee and he will probably find that it will decide in his.favour, though most likely, so as to mollify the malcontent,with a rider or suggestion, if not actually a warning, to be-more particular in future. "Beta" is singularly fortunate-in having been thirty years without such an experience.

I do not wish to seem at all to class the whole of themembers of clubs as so inconsiderate-quite the reverse..The great majority are grateful for your attention and willithank you for coming during the night or at inconvenient.hours and will express regret at having to trouble you, and itis a pleasure to attend such people, for who does not appre-ciate gratitude ? The mere monetary consideration is not

everything. I hope I have not trespassed too much on your-space. I am, Sirs, yours faithfully,

Oct. 29th, 1898. CONSTANT READER.CONSTANT READER.

THE FEE FOR THE REGISTRATION OFDIPLOMAS IN PUBLIC HEALTH.

To the Editors of THE LANCET.

SIRS,-In the "Abstract of the Principal Laws Affectingthe Medical Profession contained in a recent edition of the-Medical Directory I read under I I Registration that "a.registered practitioner who obtains a recognised diploma for-proficiency in sanitary science, public health, or state-medicine after special examination in the United Kingdomis entitled to have such diploma entezed in the Register,"’and further that " any registered person who obtains-

any ...... of the qualifications mentioned above other than,the qualification in respect of which he was registered isentitled to have such ...... additional qualifications insertedin the Register ...... on payment of a fee of 5s." Recently

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I wished to register a diploma in public health and went to’the Registrar’s office expecting to have to pay 5s. as usual,%ut to my dismay I was informed that the fee was £ 2.

Will you kindly enlighten me as to any reason there maybe for thus taxing one particular branch of medical know-’iiedge’1 On the face of it to me it certainly seems unfair.

I am, Sirs, yours faithfully,Nov. 14th, 1898. D.P.H.

*** We sympathise with our correspondent in having to/pay a fee of £ 2 for the registration of his diploma in publichealth instead of 5s. Five shillings used to be the fee in’accordance with the rule that additional qualifications might’be registered for that sum. But the fee was increased in.1893.1 There is some reason, too, for the larger fee. The

diploma is of a different kind from others and confers

altogether a new qualification. Also in 1893 inspections of’the examinations were instituted and these, of course, costanoney, which it was thought, perhaps, should be provided;for in this way.-ED. L.

A POINT UNDER THE PUBLIC HEALTHACT.

To the Editors of THE LANCET.

SIRS,—Will you kindly help me as to the following ? 1(Section 124 of the Public Health Act, 1875, says " Anyttperson who is suffering from a dangerous infectious disorder;and is without proper lodging or accommodation, &c.," "may’be removed, &c." Does the word " accommodation " in thatsection justify the removal of a child or person who cannotibe sufficiently isolated (say for diphtheria) from the rest ofthe family (the patient being one of the same family) ? 1Perhaps you will kindly refer me to some cases on the

,point. I am, Sirs, yours faithfully,Nov. 15th, 1898. M.O.H.

’" >B0 This question has received various interpretations by- different magistrates, but it has never been finally decided- en appeal. Some have held that since the section is one,of a group under the heading Provisions against Infection",it has primarily to do with the protection of the healthy.But others have maintained that since one of the conditions- named in the section under which compulsory removal of aninfectious patient to a hospital is permitted relates to a sick,person" lodged in a room occupied by more than one family’- interference of the sort referred to was not intended where’the patient was in a room occupied by members of his ownfamily, provided that the sick person had " proper lodging and.accommodation " for his own treatment and recovery. Owingto the differences of opinion which exist on this point it is z’

generally deemed expedient in ordinary cases to rely rather- on persuasion than on compulsion.-ED. L.

THE VACCINATION OF CLUB PATIENTS.To the Editors of THE LANCET.

SIRS,&mdash;May I ask the courtesy of space in your columns to<;all the attention of my professional brethren holding postsas medical officers to friendly societies to the question of theadmission of unvaccinated candidates to the medical benefitsof these societies. When the older-the parent-societieswere founded, from which juvenile branches have for themost part sprung, vaccination, more or less compulsory, wasgeneral throughout the country. Underneath the contractbetween medical officer and club lay, therefore, at thistime the tacit assumption that the majority of the members.entering the different lodges would be vaccinated. Circum-- stances are now altered. Not only has legal vaccination’been for several years neglected but under the new Act it- seems probable that primary vaccination among the unedu-cated classes will fall very largely into abeyance.We must expect, therefore, from this time forward an

increasing proportion of unvaccinated candidates, bothjuvenile and adult, for admission to the membership of these

1 See Minutes, vol. xxx., p. 154.

societies. Under these circumstances the conditions ofcontract between the societies and their medical officers areno longer what they were before the abandonment ofvaccination, and it behoves each medical officer to endeavourto protect himself under the altered conditions. He has nowlaid upon his shoulders the increased responsibility, risk,and liability to expenditure arising from the presence amonghis club patients of a large body of members unvaccinatedand therefore peculiarly susceptible to small-pox in itsseverest form. What that susceptibility is among un-

vaccinated children, both as to attack and as to a fatal issuewhen attacked, need not be argued here.The report of the Royal Commission (Final Report, p. 58,

par. 217) shows that among children between the ages of oneyear and ten, and counting as vaccinated all doubtful cases,the average fatality-rate in six carefully observed epidemicswas fifteenfold higher among the unvaccinated attacked thanamong the vaccinated attacked. It is desirable, therefore,that those who hold positions as medical officers to thesesocieties should decide, and if possible decide unanimously,as to the course which they will adopt in dealing withthis matter. Several courses appear to be open: 1.Where medical officers are in a position to make theirown terms they may refuse to accept unvaccinated candi.dates. 2. In less favourable circumstances they might acceptthem, but at an increased subscription adequate to the extrarisk involved. 3. They might accept them, but with a savingclause, which should appear in writing, that the unvaccinatedmembers when suffering from small-pox shall have no claimon the gratuitous services of the medical officer.

I shall be glad if this communication calls forth an

expression of opinion from others who have considered thismatter. I am, Sirs, yours faithfully,Nov. 14th, 1898. A CLUB DOCTOR.

NOTES FROM INDIA.

(FROM OUR SPECIAL CORRESPONDENT.)

The Progress of the Plague.-The Three Ontbrealts inBombay.-Concealment of Plague Cases.

A FEW odd cases of plague continue to occur in Karachibut Calcutta remains apparently free. The epidemic appearsto be extending towards Madras, where some doubtfulcases of fever have already been reported. In the Dharwardistrict and in Bangalore it is now raging with greatvirulence. When I reported that for some months pastplague in Bombay city had been allowed practically to takeits own course I referred to the comparatively mild stepswhich are now being taken, compared with the rigorousmeasures adopted by the late committee. There being nowno compulsion patients are allowed to remain in theirown homes and to have their friends around them. Acertain number of dirty houses are cleaned or emptied and acertain amount of disinfection is employed, but as far asinfection goes it may be said that plague has a clear field.Notwithstanding the confidence restored by these con-

siderate measures the number of reported cases of plaguefalls very far short of the excess in the total mortality, whichis probably the only true guide to any estimate of the pre-valence of the disease. But the lesson I want to point out isthat plague did not increase with the abandonment of thestrict repressive measures but rapidly went down, and thatnow during the third outbreak, which has already lastedthirteen weeks, we are exreriencing a mild attack comparedwith the two preceding developments. The following tableshows the total mortality for each week since July 5th :-

The general mortality is about 500 a week, and it stood atabout this figure during the early part of July. Any excess