794

INTESTINAL OBSTRUCTION AFTERGASTRO-ENTEROSTOMY.

Editors of THE LANCET.

Sms,-In THE LANCET of August 20th, p. 526, Mr.H. M. W. Gray records a case of intestinal obstruction aftergastro-enterostomy. The obstruction was caused by thesmall intestine having insinuated itself through the ringformed by the under layer of the transverse colon above andthe jejunal loop with its mesentery below. In his commentMr. Gray remarks that he can find no record in the literatureon gastro-enterostomy of such a condition. May I point outthat a similar case is recorded by Dr. W. J. Mayo of

Rochester, Minnesota, in the Annals of Surgery for August,1902 ? The details of this case are reported in the secondedition of "Diseases of the Stomach" (p. 257) by Mr. MayoRobson nnr) mvRflf -T nm Sirs vnnrc faithfully

Leeds, August 30th, 1904. B. G. A. MOYNIHAN.

THE SERUM TREATMENT OF EXOPH-THALMIC GOITRE.

70 the Editors of THE LANCET.

SIRS,-I have read with much interest Dr. G. R. hTurrav’snote on this subject in THE LANCET of August 27th, p. 583,as for some months past I have been trying to produce asatisfactory thyreolytic serum. One objection to Dr. Murray’smethod occurs to me. These antibodies are usually quitespecific. Thus a sheep injected with ox’s blood developsan antibody for the blood of an ox and not for that of anyother animal. Portis injected emulsions of dog’s thyroidsinto goats and produced a serum which was cytolytic fordogs. Probably, therefore, it will be necessary to emplo.vemulsions of human thyroids for injection into the selectedanimal to produce a satisfactory serum for Graves’s disease.

T ::J.m Sirs vnnr.c fnithfn11v

nfFinsburv-square. E.C., August 29th, 1904.W. LANGDON BROWN.

THE UTILITY OR OTHERWISE OF FEVERHOSPITALS : THE NEED FOR AN

INQUIRY.To the Editors of THE LANCET.

SIRS,-It is now becoming generally recognised that theresults which are being achieved by fever hospitals-erectedand maintained entirely out of public funds-are not nearlyso great as we were wont to believe. It is not surprising,therefore, that a strong feeling is growing up that the sub-ject calls for full investigation by some specially appointedtribunal.

In the leading article on this subject in your issue of

August 27th you, Sirs, say : " The issues raised are complex,but we think that a case is made out for inquiry, and hopethat that inquiry, if instituted, will be conducted without anyintroduction of personalities."

" The British Medical Journal,in an editorial on Feb. 27th, wrote as follows : " The factsand arguments advanced ...... are sufficiently cogent to affordjustification for the suggestion that the advantages and dis-advantages of hospitals in which cases of infectious diseaseare aggregated would be a suitable subject for investiga-tion for a Select Committee, if not by a Royal Commis-sion." Another weekly medical journal, the Medical Press,Dec. 30th, 1903, wrote: "Three questions suggest themselves.Are isolation hospitals effecting the purpose for which theywere introduced ? Are the drawbacks to the system inherentor capable of being removed ? Are the enormous sums whichthese hospitals cost justified or could the money be betterapplied? These are grave matters and fully warrant thedemand for combined inquiry by some representative body inthe profession." The Medical Magazine, March, 1904, wrotein reference to fever hospitals : " It is a question of nationalgravity as to their continuance on the present system and inany case an official inquiry seems to be demanded....... Inview of the enormous cost of these hospitals to the countrywe can only repeat our conviction that a searching inquiryappears to be necessary."A resolution calling for an inquiry was passed in October,

1903, by the Southern Branch of the Society of MedicalOfficers of Health and more recently by the Congress of the

Royal Institute of Public Health held at Folkestone last

July. The demand for an inquiry being, therefore, clearlyestablished it remains to be considered what form the inquiry

should take. The subject is admittedly a highly complexone, and it is one of national importance for it concerns

almost every sanitary district throughout the country.Moreover, the annual charge on the rates entailed by feverhospitals is, when compared with other items of preventivemedicine expenditure, very heavy indeed. The plea whichis now being put forward that these institutions are a greatconvenience to the public is not sufficient alone to justify thisexpenditure.

It is not unreasonable to claim that the subject is ofsufficient importance to justify the appointment of a reallyauthoritative tribunal, preferably a Royal Commission. Thesecond point on which I wish strongly to insist is thatthe tribunal, whatever else its qualifications, must be animpartial one. This is all important. This question of theutility of fever hospitals has, as is well known, become akeenly controversial one. It is unfortunate that it shouldbe so, but the fact remains. Those who have takenan active part in this controversy, on either side, are

disqualified to sit in judgment, however well qualifiedthey mav otherwise be. So also those sanitarians whohave been actively instrumental in securing the provisionof fever hospitals in the past cannot be regarded as

impartial or unprejudiced observers, though I am wellaware that this will exclude many of our older and mostable officers of health. There are, however, plenty of menavailable well qualified both as regards training and experi-ence to investigate such a subject as this and without beinghandicapped by long-standing convictions or preconceptions.There is no necessity that the commission should be com-posed entirely of medical men ; indeed, it would be betterthat it should contain some laymen. It should be the dutyof this commission to receive witnesses and to collectevidence from every source and I venture to predict thatwhen all available evidence has been obtained it will not be

impossible for impartial judges to arrive at some definiteconclusion. I am, Sirs, yours faithfully,

Leicester, Sept. 7th, 1904. C. KILLICK MILLARD.

THE INDIAN MEDICAL SERVICE.To the Editors of THE LANCET.

SIRS,-In THE LANCET of July 23rd, 1904, p. 254,"Lieutenant-Colonel, I.M.S.," writes with reference to anorder which is called the latest order of Lord Curzon’sGovernment, dealing with the relations between officers ofthe Indian Medical Service and certain of their native

patients." He further states with reference to this orderthat it " will make such medical officer liable to havehis name removed from the Medical Register for conductinfamous in a professional respect " for the reasons given-viz., for betraying confidence to a third person-a civilpolitical officer, &c. In THE LANCET of Sept. 3rd, p. 724,in dealing with the present position of the Indian MedicalService and comparing it with the Royal Army MedicalCorps you say: "The blots on the present regulationsfor the Indian Medical Service are as follows," andunder paragraph 3 you state: "The order of the presentGovernment of India that an officer of the IndianMedical Service must refer the question of the amount of hisfees when above a certain low limit to the civil authority.The recent orders might necessitate the violation of pro-fessional secrecy." The order mentioned is, as will beobserved from the under-mentioned printed order No. 437,Home Department (Medical), dated Simla, July 26th, 1893,a modification of the same and in supersession of the notifica-tion of the order No. 813 of the Home Department, datedDec. 8th, 1888 :-

No. 457.

Home Department, Medical, Simla, July 26th, 1893.In supersession of the notification of this Department No. 813, dated

the 8th December, 1888, the Governor-General in Council is pleased tomake the following rules regarding the remuneration of medical officersfor attendance on native chiefs and nobles and native gentlemen of highposition in a Native State.

2. When a native chief or noble or gentleman of high position desiresthe professional attendance of any medical officer of Government thelatter will be at liberty to attend him, provided that such attendancedoes not interfere with the due performance of his ordinary duties. Thespecial permission of the local government will, however, be necessarywhen such attendance involves the absence of the officer from thoseduties for any substantial time.

3. The native chief, noble, or gentleman may offer any medical officer

795

of Government attending him such fee as he things 1it. The offermade will he reported by the medical officer through the politicalagent or other officer of Government exercising political functionsin the state of which the said chief, noble, or gentleman is a residentfor the consideration of the local government within w liose jurisdictionthe native state is situated. In reporting the offer the medical officerwill state, so far as he is able to do so consistently with his position asa medical adviser, the nature and the extent of relief afforded, the

importance of the case from a professional point of view, and the cir-cumstances under which he attended the patient. The political agentor officer forwarding the report will submit it, with such remarks as lieconsiders necessary. The local government will have authority tosanction the acceptance of any fee so reported unless the amountappears to be out of proportion to the relief afforded and to the circum-stances of the case, in which event the matter will be submitted withthe local governments opinion for the consideration and orders of theGovernment of India.

4. The report prescribed in the preceding paragraph will not berequired from a medical ofHcer in the following cases: (1) when theofficer names his own charges in accordance w ith a scale which lie hasfixed for his patients generally who are not native princes, or chiefs,and when such charge is accepted by the patients ; and (2) when theofficer and patient reside in the same station and the fee does notexceed Us. 50 for each visit or Ills. 1000 in the aggregate for repeatedvisits during the course of a year.

5. For the purpose of this notification the term Local Government"will be held to include an agent to the Governor-General and aresident of the first class.

No. 438-439.

ForeignCopy forwarded to the Foreign Department for information inMilitary

continuation of the indorsement from this Department.814

No. 816 -Date,l the 18th December, 1888.By Order

(Sd.) P. G. MELLITUS,Deputy Secy. to the Government of India.

Circular No. 33 of 1893.Dated Lucknow, the 18th December, 1893.

Copy forwarded to the Civil Surgeon at Bijnour for his informationand guidance.

(Sd.) J. G. PILCHER, F.R.C.S., Surgeon-Colonel,Offg. Inspector-General, Civil Hospitals, N.-W. P. and Oudh.

I am sure that the question of fees to medical officers inIndia from native chiefs, nobles, and gentlemen is one whichit would be wise not to interfere with, for it is in manycases a religious institution among some of the families ofthe chiefs and nobles in that country, and it would beregarded as i,nfra dig. for a rajah that his medical attendantshould receive his fee doled out in so many rupees per visitas prescribed. While I was civil surgeon of the Prince ofWales’s Hospital and superintendent of the Ishwair Hospitalin Benares a rajah paid me in " gold mohur fees (the goldmohur being the sum in professional and commercial trans-actions which is still current) and in tending me the goldcoin he gave familv reasons and asked me to accept thesame as it was an old family custom not to fee in rupees.Would it not be wise to encourage such a custom, whichgives pleasure to the donor, who feels proud to maintainwhat has been handed down by his forefathers, to one whohas saved the life of a child or cured it of epilepsy andplaced him in a position to inherit the throne instead of

being consigned to a lunatic asylum ? The educated nativesof India are educated enough to perceive a want of "fellow-countrymanism " in the social atmosphere, hence the orderhas an element of danger about it, since it savours of a

selfishness and doubts the integrity as well as the honestyof the donor and receiver of the fee.

Consider the offence such an order would give the wholeof society, and particularly the English nobleman, ifthe Premier of England prescribed so many shillingsper visit, and limited a fee to £200 in the yearfor the Duke of Westminster or Baron Rothschild to

present as a mark ot his gratitude to his medicalattendant for saving his or his child’s life, and also that theHome Secretary required a report of the case if the feeexceeded the prescribed amount, with the full particulars ofthe case from a " professional point of view"! A medicalman is not to be feed according to his skill, experience, 01his devotion to his duties, but purely to satisfy the curiosityof a Home Secretary in India from the views of a laymember and not the liberality and large-heartedness of hisdonor. Why conceal such enlightened selfishness under thecloud of an order to give it a different rainbow hue of purityto receive any colour which it pleases the Home Secretary tcpaint his donor and the receiver in and consign to the sealeccover of Confidential Reports under lock and key? Lord Curzorwould do India, his countrymen and women, as well as alHis Majesty’s subjects-white, brown, or black-in India andthe British dominions throughout the world a lasting benefiif he removed the blot which now exists by inquiring full;

ito the merits of every case, for this would ever live in theearts of people and cause the British nation and empire toe loved and admired by all right-thinking people. Such anrder in its present construction neither appeals to Britishonour, large-heartedness, nor sense of justice, and I writehis with no desire to make it private or coniidential butwith the object of raising the breeze of healthy publicpinion about the question and in the interests of fair playnd justice T am Sirs voiir.,; faithfully

Sept. 6th,1904. MAJOR, I.M.S. (retired).

THE SALE OF MEDICAL PRACTICES.l’o the Editors of THE LANCET.

SIRS,-In THE LANCET of August 27th, p. 629, you reportthe case of a medical man who had sold no less than 29 or30 practices during the same space of years and you givesome wise words of warning anent the buying of practices.Now it has been my unfortunate experience to meet anotherclass of medical man who seems to have made his livelihoodor at least added to his income by taking in (!) partners.His own son when writing to me on hearing of the dis-solution described his "governor as a regular Bluebeard asregards partners," and so I have since heard from othermedical men. I believe my late partner actually has hadnearly 20 partners in about 30 years. Unfortunatelymen in the position I was never learn these factsuntil it is too late, and if only some association could beformed for would-be buyers to obtain advice from, or whichcould privately make inquiries and keep records for theprotection of would-be buyers, it would doubtless fill awant. None at present exists, and I beg to suggest thatyou open your columns to receiving the experiences of menwho have been " done " and thus give an opportunity for thedrawing up a series of rules whereby the inexperienctd buyerwould avoid the pitfalls dug by such men as my late partr erand the over-frequent vendor of practices to whom youalluded recently.-I am, Sirs, yours faithfully,

Sept. 4th, 1904. A LATE PARTNER OF BLUEBEARD.

NOTES FROM INDIA.

(FROM OUR SPECIAL CORRESPONDENT.)

The Simla Improvement Scheme.-English Medical Men forIiccbu,l.-The Uselessness of " Ocimum Viride " againstMosquitoes.-Items of Plague News.-The Re-marriage of1Hclows in India.

THE many who know Simla will be glad to hear of theactive steps which are being taken for its extension and

improvement. Fresh land has been acquired in the vicinityof Simla by exchange of land at Kotkai with the Rani ofKoti. The installation for the electric lighting of thisstation is to be commenced shortly. The proposals forcertain broad driving roads are being pushed along and theSanjauli tunnel is to be widened. This latter scheme isestimated to cost Rs.50.000 and will be commenced at theend of the season. Very naturally the Government of Indiais taking a prominent part in all matters connected withthe improvements and on the return of certain Governmentofficials accelerated progress may be anticipated, more

particularly during the next few months.It was hardly to be expected after the skilled surgical

assistance rendered to the Amir of Afghanistan for his recentaccident that he would be content to rely on his own

Afghan medical men in the future and it is now reportedthat he has intimated his desire for expert English medicalmen to be stationed at Kabul. The staff suggested is onemedical officer, one lady doctor, and three hospital assist-ants with a small compounding staff. The Government ofIndia has the matter under consideration.The vaunted value of the plant ’’ocimum viride" for

keeping off mosquitoes and as an effective destroyer ofthese insects has been put to the test at the Lucknowhorticultural gardens. The plant is found in East Africaand some seed was imported last year. Numerous plantswere raised and experiments conducted, but it is very clearthat the plant is valueless for the purpose stated. It

possesses a strong aromatic odour, especially when bruised.. The plant belongs to the Casir or Tulsi family, several

species of which, particularly ocimum sanctum, are wellknown in India.