205

THE LANCET.

LONDON: SATURDAY, JANUARY 24, 1920.

INSURANCE PRACTICE SETTLEMENT.—DIVERTICULITIS.

The Insurance Practice Settlement.AFTER strenuous exertion on both sides a settle-

ment was reached late on Wednesday evening,Jan. 14th, between the representatives of the

Ministry of Health responsible for administeringthe Insurance Acts and the representatives of thepractitioners who provide the medical benefit, anda letter embodying the terms of this settlementreached the secretary of the Insurance Acts Com-mittee of the British Medical Association in timefor insertion in the supplement to last week’sBritish Medical Journal. It is now generallyknown that the increased capitation fee of l1s.,offered by the Government in place of the 13s. 6d.claimed by the Conference of Panel Committees,was at first refused by the Insurance Acts Com-mittee, and then, in accordance with the discretiongiven to the Committee at the Panel Conference,referred to arbitration. The reference to the

arbitrators, who will, we understand, include a

medical man, an actuary, and a lawyer, will be toadvise the Government what capitation rate willafford to insurance practitioners fair remunerationfor the services required under the new MedicalBenefit Regulations for 1920. The arbitration is tobe confined to this single issue, it is to be completedwithin four weeks, and the award is to be bindingupon both sides. On the part of the practitionersthe condition is attached that panel committeeswill do all in their power to secure a full and

efficient medical service, with good will, under thesettlement as a whole.Whatever the award may be, and it is important

in the interests both of the insured populationand the medical service that this should approachthe figure desired by the medical profession,it will have the element of immediate finality.The capitation basis of 11s. comes into force as

from Jan. Ist, the basis as settled by arbitra-tion on April lst, and it is part of the pledgegiven by the Insurance Acts Committee, on behalfof insurance practitioners, that their work will bedone with good will on this financial basis. Itwas obviously necessary to fix some basis to

enable both parties in a huge cooperative concernto carry on during a transitional period. But

the settlement also contains the element of future

flexibility. The Government has elected not to enterupon any arrangement binding for a term of years,but, in view of further legislation affecting the wholeworking of the Insurance Acts, to leave open thepath to readjustment after consultation with therepresentatives of panel practice. Changes, as theybecome inevitable, will be made step by step aftermutual counsel between the contracting parties.and with the increasing confidence of honest inten-

tion which is always the result of familiar inter-course. The ground is now being laid for a moreinformed, and therefore a fairer and easier readjust-ment, when the time comes to discuss again thebasis of remuneration.Another aspect of the conversations between the

Ministry and the Insurance Acts Committee is of

equal or greater importance. In most cases, it is

stated, the Ministry met the desires of the PanelConference, and the new Regulations which comeinto force on April lst represent a very largeamount of give and take. Only in regard to theclause dealing with the transfer of practices is theconcession obtained less than had been hoped for.But here, it is to be remembered, the Regulationsallow a large liberty in administration, and as theclause now stands the possibility is not excludedof Insurance Committee and Panel Committtee

arranging for the allocation of patients in a

manner best adapted to local needs, with

proper consideration both for the rights of the

patient and of the doctor. No one who looks beyondthe conditions of present-day insurance practiceinto the future possibilities of prevention of diseasecan postulate the goodwill of a practice as an

unalterable and inalienable attribute. Wise fore-

sight suggests the adoption of some pensionscheme which should gradually free the practi-tioner from dependence upon his patients as goodsand chattels. Relief from carking anxiety, a mainobject of the Insurance Acts, is just as desirablefor the practitioner as for the insured person.

Diverticulitis.DIYERTICULITIS is a comparatively new disease,

if we hold that a disease is born by being given aname. The first classification of cases of the diseasewas made in 1908 by Dr. W. H. MAXWELL TELLING,who opened the recent discussion on the subjectbefore the Proctological Subsection of the RoyalSociety of Medicine, and since 1908 the conditionhas received more and more notice, until at thepresent time its importance and its frequency arebeing fully recognised. The condition, unnamed,was identified as far back as 1885 by Sir ARBUTHNOTLANE. By the term diverticulum is meant a patho-logical sacculation proceeding from some portion ofthe large intestine, and chiefly seen in relationwith the sigmoid flexure. The walls of thesediverticula are formed not by all the coats ofthe bowel, for the muscular coat is wanting. As to

their aetiology there is nearly general agreementthat they must be explained as caused by someform of increased pressure within the bowel, butthere is evidence that this is not the whole truth,for in some cases many are present and in othersthey are few in number. In some there seems to

be a special weakness of the involuntary musclefibres of the body, for cases have been describedin which diverticula of the bladder were found toco-exist with diverticula of the colon. By certainwriters stress has been laid on venous congestion

206 MEDICAL EDUCATION AND THE POOR-LAW INFIRMARIES.

as a cause of the existence of diverticula, but ina series of bodies examined by Mr. HAMILTON

DRUMMOND, many of them were those of elderlypeople with chronic heart disease and markedback pressure, yet in none were diverticula found.Evidence of intestinal obstruction was present inonly 10 per cent. of the cases of diverticulitis,but this does not preclude the possibility ofincreased pressure within the bowel in the othercases. LANE, in a paper written for the Guy’sHospital Reports, and quoted from elsewhere inthis issue of THE LANCET, described a case of

multiple diverticula from the colon, and expressedthe opinion that the two factors in the productionof the saccules were the action of tension andthe presence of fat. The suggestion that thesediverticula are congenital in origin was putforward before the Subsection by Mr. G. GREY

TURNER, but this idea did not find favour withMr. ERNEST MILES, who regarded an increasein the intracolic pressure as the essential cause.It will be best at present to confess that we have nocertain knowledge of the mode of production ofthese protrusions, but, as they have been describedalmost exclusively in those over middle life, theprobability of their being truly congenital in originis but small.

Except to those who have devoted special attentionto the large bowel the structure of diverticula maybe unknown. For the most part they are small and !,,almost invisible from the exterior of the bowel ; andeven when the mucous membrane is examined the

apertures may easily escape notice unless search isspecially made for them. These openings are oftenvery small; they may be as minute as a sixteenthof an inch in diameter; rarely do they exceed athird of an inch, and often they are completelyconcealed by the rugous mucous membrane. As

the diverticula pass outwards they may enter theappendices epiploicæ, and they are then entirelyinvisible from the exterior. So long as a diver-ticulum is not inflamed no harm seems to follow itsexistence, but, as in the case of the vermiform

appendix, when faecal matter collects within it,inflammation is very liable to arise, and from thatinflammation several results may follow. The

simplest is the formation of adhesions to the

surrounding structures, but it is seldom that the

consequences are limited to this. The faecalcontents form a reservoir of bacteria andtheir toxins. The mucous membrane of the

diverticulum ulcerates, and this may lead to

perforation with extravasation of the con-

tents into the peritoneal cavity, with all the

symptoms and results of peritonitis, or the

adhesions which have previously formed may

prevent the more serious consequences of per-foration. If the diverticulum has become adherentto a hollow viscus a fistulous communication willbe established between the colon and the other

viscus, and in this way may arise colo-vesical orcolo-vaginal fistulae. Again, inflammation of a

diverticulum may result in an extensive infiltration

of the tissues around the colon with the formationof many adhesions, so that a mass is formed, andto this condition the name of peridiverticularfibrous hyperplasia has been given ; this oftentimesleads to narrowing of the gut, with more or lessobstruction. Many of these cases have been mis-taken, and excusably mistaken, for instances of

carcinoma of the bowel, and have been treated

by colostomy or colectomy, as appeared best. Peri-diverticulitis forms a solid mass in the wall of thebowel with obvious narrowing of the lumen, andthe diagnosis between it and malignant diseasemay be very difficult indeed. Here the X rays mayafford assistance. Dr. IvENS SPRIGGS at the recentdebate showed that even small diverticula no largerthan a currant could be clearly recognised on anX ray plate ; but the diverticula which admitted thebarium meal were permeable and probably healthy.The presence of healthy diverticula is suggestive ofothers which may be inflamed, and therefore theX ray plate may be helpful.’ The treatment was summed up by Mr. R. P.ROWLANDS in the course of the debate, when heurged that every surgeon, in operating for obstruc-tion of the colon, should keep in mind the possiblepresence of diverticulitis. Early resection of thewhole of the affected portion of the colon withend-to-end anastomosis is the operation of choice,but in late or complicated cases temporary colostomymay be advisable. Sometimes, indeed, it may bedesirable to make a short circuit, leaving the

resection for a subsequent operation, but this

procedure can be required only in late and seriouscases. As Sir JOHN BLAND-SUTTON well said, themost important point about diverticulitis is its

mimicry of cancer of the colon. Of the manycases that have been recorded of the spontaneousdisappearance of an abdominal tumour some weredoubtless instances of diverticulitis ; there are

patients who have refused operation for what theywere assured by physicians and surgeons of greatrepute was cancer of the colon, and yet haverecovered to the surprise of their medical advisers.It must never be forgotten that an apparentcarcinoma, causing chronic obstruction of the largebowel, may be after all diverticulitis, demandingsimilar treatment, but with a vastly better

prognosis. The discussion at the Royal Societyof Medicine has been a valuable one. Many towhom diverticulitis was little more than a namewill in future have clear ideas of its nature andbe on the look-out for its appearance.

Medical Education and the Poor-law Infirmaries.

SIGNS are not wanting of a new attitude on thepart of the public towards medical education.

This, they begin to see, is no longer the affair ofthe schools of medicine only; it has become amatter of public interest. That new standpoint isa legacy of the war, the natural outcome of publicinterest in recruiting and in pensioning boards,

207MEDICAL EDUCATION AND THE POOR-LAW INFIRMARIES.

and more generally in the work and methods ofthe profession in war-time. The General Medical

Council, the State authority upon medical educa-tion, has long seen and anxiously discussed theproblems ahead, and it is conceivable that in the

wider diffusion of experience that now exists someof the difficulties will disappear. The new agree-ment between St. Mary’s Hospital and the

Paddington Board of Guardians, by which the clinicalmaterial of the Paddington Infirmary will becomeavailable for the instruction of the medical studentsof St. Mary’s Hospital, is an excellent example ofrecognition by the public of scientific needs. The

idea is not new, but now that it has been put intopractice it should follow that other medical schoolswill seek to make similar arrangements, whenthe departure will be seen to constitute a con-

siderable event in the history of medical educa-tion and in the life of the Poor-law infirmaries.

During the war the Paddington Infirmary was

used as a military hospital. When it reopensin February there will be no workhouse, andthe infirmary will provide accommodation for600 beds.- The possibilities of undergraduate instruction in

infirmaries are not generally appreciated. In

1913 some 25 per cent. of the total admissions tothe Paddington Infirmary were under ten yearsof age, and in the same year more than half

the cases remained in the infirmary for less

than one month, over three-quarters for less

than two months, and less than 5 per cent.

for more than six months. There is there-

fore no foundation for the widely prevalent viewthat the wards of these institutions are filled

with chronic and incurable disease in aged subjects.The infirmary, in fact, contains about equal numbersof two types of case. In the first group, the natureof the patient’s illness and its severity in no waydiffer from the clinical material in the wardsof a general hospital; the majority of cases are

children, or patients requiring surgical treatment.The second group is largely made up of a

type and stage of disease that is not generallyfound in the wards of those hospitals, and providesvaluable material for investigation and instructionin every form and phase of chronic illness, butespecially in diseases of the respiratory tract andin chronic heart disease. In particular this istrue of pulmonary tuberculosis. The out-patientdepartment for that disease at a general hos-

pital does not at present meet the need for

undergraduate instruction; accommodation inthe wards for cases in both the early and late

phases of the malady is necessary, but it isnot provided, or is insufficiently provided. Thisthe infirmary supplies. The cases received therefall into two groups: firstly, those which arE

detained pending arrangements for sanatorium

treatment; secondly, those which are too advancedto profit by such a course, and which are kepiindefinitely. Here indeed is fine material for

medical instruction.

The surgical wards of the infirmary are enrichedby the inability of general hospitals to take intotheir beds the number who require admission.

Every year a considerable proportion of patients,whose names are added to the waiting list by theout-patient surgeons, have to be subsequently in-formed that there is no prospect of their beingadmitted to the hospital. Accordingly, in the

compilation of the in-patient waiting list this

shortage of beds is kept in mind, with the resultthat patients whose disease is not likely to be curedby a short stay in hospital are only added to thelist with reluctance or for some particular scientificreason. The selection goes farther, for patientssuffering from septic infections, such as cellulitis,are referred to the infirmary, and it has becomenecessary, in some general hospitals at least,practically to exclude all fractures from the wardsexcept such as require an open surgical operationfor their reduction. Hence a very large proportionof fractures of the lower limb are passed on tothe infirmaries by these hospitals, and the modernstudent has less opportunity than his predecessors ofbecoming acquainted with the treatment of frac-

tures. It has been possible for him in the past togo through his course only rarely seeing the treat-ment of such diseases as tuberculosis of the spineand hip, chronic septic osteomyelitis, the pallia-tive treatment of malignant disease, and some acuteinflammatory and orthopaedic conditions. Further,a hitherto distinct hiatus in medical educationshould be filled by the provision of psychiatricclinics for incipient mental disease, while if theseclinics are established in the infirmaries there isneed for a recognised authority on psychiatry .todirect the treatment, and for workers in pathologyto take part in scientific investigation. In an

agreement between a general hospital and an

infirmary these needs should be met, and the

student have an opportunity of seeing the earlymanifestations of mental disorder.The arrangements between St. Mary’s Hospital

and the Paddington Infirmary will result in some-thing more than an addition of 600 beds to those atSt. Mary’s. They will provide facilities fo*r instruc-tion and investigation which do not at presentexist in general hospitals. It is probable, too, asthe outcome of the provision of a wealth of clinicalmaterial, that out-patient teaching at the generalhospital will devote itself more to the beginningsof disease, and to a type of case in which the

malady is not sufficiently advanced to provide grossphysical signs. When the student’s preoccupa-tion of mastering signs is safeguarded elsewhere, hewill be encouraged to follow an illness throughout itscourse and to interpret the first warning symptomsin the light of subsequent events. The public gaindirectly by the conversion of a Poor-law infirmaryinto a modern hospital, equipped with the sameresources as those of a general hospital, and, like it,

able to enlist the services of a large staff. Theygain indirectly in that greater facilities for becomingefficient are placed in the hands of those who in the

208 UNSTABLE HYDROGEN PEROXIDE AND ITS STABLE SIMILARS.

future will become responsible for the health of Ithe country; and it is in the recognition bythe guardians of this indirect gain that the real Isignificance of the change is to be found.While the cottage hospital exists for the care ofthe sick poor and for the provision of local

benefits, the general hospital to which a teachingschool is affiliated has a larger mission. A teachingschool exists to set up a standard of efficiencythroughout the country, to add to knowledge, andto secure the common good by sending out from its

’

walls graduates fully equipped to take their part inthe work of medicine, preventive as well as curative.The success of that work is brought a little nearerby the action of the Paddington Board of Guardians.

Annotations.UNSTABLE HYDROGEN PEROXIDE AND ITS

STABLE SIMILARS.

"IrTe quid nimis."

THE announcement by the War Office in an ArmyCouncil. Instruction issued recently that the supplyof hydrogen peroxide to military hospitals will belimited to very special cases which cannot betreated satisfactorily by some other antiseptic willbe viewed with dismay by those who have cause toappreciate the application of this cleansing andhealing agent. We understand that this action hasbeen taken in view of the unstable nature of

hydrogen peroxide solution, the difficulty of

obtaining and cost of suitable containers, theexcessive loss by bursting and leakage, the greatbulk of the liquid, and the high cost of transport.The virtue of peroxide of hydrogen in medicalpractice lies in its profuse oxygen content-a fact,of course, which gives rise to its instability.Were the compound stable, medicine would prob-ably have a very limited use for it. But the

extemporaneous preparation of hydrogen peroxidesolution is by no means difficult, and we bring thesuggestion forward to the notice of those who maysuffer from a curtailment of supplies. It is wellknown that there are per-salts-as, for example,the per-borates and the per-carbonates-whichreadily yield available oxygen. All these are

obtainable in the dry state, and therefore thedrawbacks raised by the War Office as regardsinstability, loss of oxygen, difficulty of safe trans-port of hydrogen peroxide, do not obtain. Asan example it may be quoted that 170 g. ofsodium per-borate dissolved in a litre of water

containing 60 g. of citric acid will give the

equivalent of a litre of peroxide of hydrogen of" 10-volume strength." The ingredients should beavailable in tablet form. Then there is per-carbonate of sodium, now made in commercial

quantities, which can be similarly treated for theproduction of peroxide of hydrogen. It may indeedbe an advantage to use these salts without theaddition of an acid at all, for they practically ’,present the oxidising power of peroxide of hydrogenin the presence, of course, of the alkaline salts

respectively, borax and carbonate of soda. Thesepoints may be well worth considering where,though the need of peroxide of hydrogen may not beurgent, the active antiseptic and healing agency ofits nascent oxygen is indicated or preferred.

THE NEED FOR ISOLATION HOSPITALS.

THE seasonal wave of the more common acuteinfectious diseases has by its unwonted volumedrawn attention to the need for greater facilitiesfor isolation. The daily press has brought embar-rassing publicity to a number of highly respectabledistricts in the throes of scarlet fever, or diph-theria, or measles ; while many others, probably noless implicated, have rejoiced to be able to blushunseen by the relentless eye of the reporter. Thisattention on the part of press and public, whilerather fortuitous and undiscriminating in the choiceof district to be pilloried, nevertheless serves amost useful purpose in awaking the communalconscience to the necessity for further means ofisolation. For it must be recognised that althoughour cities and larger towns are second to none inthe world in their provision of isolation hospitals,the small urban districts and a considerable pro-portion of the rural districts have notoriouslyfailed to meet their responsibilities in this respect.Moreover, for two other, and very different,reasons there is some danger of a slackening ofpace in the provision of isolation hospitals. In thefirst place, it was becoming somewhat of a fashionbefore the war to look coldly on the spread ofisolation hospitals, to ask whether they were infact a serious influence in diminishing the preva-lence of infectious diseases, or whether they shouldnot now be regarded as a not altogether necessaryluxury in view of the decrease in virulence of mostof the diseases with which they had happened to beconcerned. In the second place, there has of latebeen a danger-perhaps as yet rather potential thanactual-that the enthusiastic administrator of

to-day, seeing that preventive medicine is now

emerging from the lower plane of supervision ofthe environment to the higher one of care of theindividual, may, in looking upwards, be obliviousof the many and huge gaps in that supervision.The chief difficulty, however, is naturally that

of the purse. Even before the war it was morethan difficult for the average ’rural authority toprovide its own isolation hospital. With the presentenhanced prices it becomes almost impossible.From all points of view the intervention of thecounty council to exercise its powers of combiningrural and the smaller urban authorities into

hospital districts becomes the wise solution ofthe difficulty. Not only are the hospitals of a

combined hospital district more likely to beeconomical in construction than the individualdiminutive hospitals of separate authorities, butthey can be better staffed and more efficientlymanaged, while the introduction of the motorambulance has abolished one of the maindifficulties in the practical utility of such hos-pitals for a wide area. Even under the Isola-tion Hospitals Acts of 1893 and 1901 countycouncils had wide powers in this respect, and couldtake action either on a petition by a district councilor by 25 ratepayers, or on a report by the countymedical officer of health. The procedure involvedin the holding of an inquiry and the subsequentdefinition of a hospital district and formation of ahospital board was sluggish in the extreme. Astimulus to speedy action was given in 1913 by thePublic Health (Prevention and Treatment of Disease)Act. which made provision for the recognition ofcounty councils as local authorities for the purposeof erecting isolation hospitals. By obtaining anOrder from the Ministry of Health, a county council-