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and has a protruding chest. His belly is well drawn ; thesexual parts large and strongly developed ; the vertebralcolumn rather long and resembling in its arched form that

of the ape when walking upright; the thighs are well drawn,but the femur is very short ; the lower part of the leg andthe foot are regular and well formed ; the head is slightlythrown backwards, and the face has a joyful expression."This description by Elie Massénat is quoted on page 297 ofJoly’s "Man before Metals," 1887. In Laugerie Basse wasfound also a figure of "a species of immodest Venus," andone of a pregnant woman. This last, too, belongs to the"reindeer age," which may have been that of the CerneAbbas giant.

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ACUTE PULMONARY ŒDEMA.

IN another place we publish an article by Dr. A. E.

Carver on "Acute or Paroxysmal Pulmonary (]}lems." The

cases he records are interesting, and, as he says, are

apparently identical in nature with those described in a

recent paper by Dr. Stengel of Philadelphia. In this countrya prominent symptom of acute pulmonary oedema has alwaysbeen considered to be a copious flow of thin, wateryexpectoration which is frothy from admixture with air. This

phenomenon was absent from the cases recorded by Dr.Stengel and also in those now described by Dr. Carver. As

the latter writer points out, it is difficult to feel confidentthat the underlying pathological processes are essentiallythe same. Acute pulmonary cedema may ensue in

death by asphyxia brought about by pneumonia and

acute bronchitis, also in acute nephritis and in certain

cases of heart failure; it also occasionally occurs after

the administration of an anaesthetic. Authorities differas to the exact manner of its production, many, however,favouring the view that owing to obstruction of the pul-monary circulation, due to cardiac failure or other causes,there is some interference with the proper circulation throughthe lymph channels, and exudation accordingly ensues. In

the cases referred to by Dr. Carver and Dr. Stengel therewere obvious signs of temporary heart failure, but althoughthere were indications of a profound degree of congestion ofthe lungs, the typical symptom of oedema of the lungs, asthat condition is generally supposed to manifest itself, wasabsent. It may be that such difference as exists betweenthese cases and those previously described under the

diagnosis of acute pulmonary oedema is, as Dr. Carver

remarks, "one merely of degree," but further clinicaland pathological experience is necessary before a definiteanswer can be given.

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AIR EMBOLISM DURING OPERATION UNDERAIR-INFLATION URETHROSCOPY.

AT a meeting of the American Urological Association

recently held in Chicago Dr. Ernest G. Mark of Kansas

reported the following remarkable case, which has beenrecorded in the Boston Medical and S1lrgical Tozornal. A

man had a small band-like stricture on the floor of the

urethra just anterior to the peno-scrotal junction. The

stricture was divided under air-inflation urethroscopy, and anemphysematous condition was then seen in its neighbour-hood. Almost immediately the patient complained of painsin the epigastrium and began to cough. He became rapidlycyanotic and the pulse became imperceptible. Auscultationover the cardiac area revealed the "whirr" " of what was

apparently considerable quantities of air passing through theheart. The heart sounds ceased and the respiration graduallystopped. The pupils dilated, the eyes became fixed, the jawdropped, and the patient apparently died. But under artificialrespiration and the hypodermic injection of whisky he wasresuscitated and slowly recovered consciousness. For about

a week he complained of a feeling of depression in the-epigastrium. The local emphysema was not marked and’seemed to involve only the cellular tissue of the pendulousurethra. There was no emphysema of the scrotal tissues.

On the following day the patient complained of tendernessin the hypogastrium, especially on the left side. On eaamina

tion extensive emphysema of the abdominal wall was found.This slowly disappeared in about a week. The amount of air

which was forced into the circulation without producing afatal issue is astonishing. Mr. Hurry Fenwick has statedthat in air-inflation urethroscopy of a stricture, complicatedby a recent false passage, he has observed the occurrence oiran emphysematous condition.

THE NATIONAL INSURANCE BILL.

WE epitomise below the action that is being taken and the:opinions that have been expressed by bodies qualified itsvarious respects to speak for the medical profession.

The General Medical Council.Sir Donald MacAlister, President of the General Medical Council, in,

his opening address to the Council in session on Tuesday said that-"This far-reaching measure touches at so manv points the conditions-of professional efficiency in this country that it is difficult withoutclose and prolonged study to estimate its effects, immediate andremote,on ordinary medical practice, on clinical hospitals, on public healthadministration, and on professional education. The Chancellor has-admitted this difficulty, and has intimated his willingness to considersuch suggestions and criticisms as he may receive from the medical pro-fession of this country. From the nature of its statutory functionsthe General Medical Council is necessarily concerned with certainaspects of each of the questions I have indicated; and in virtue’of its statutory constitution it includes representatives of all depart-ments of medical practice, and of all registered practitioners,incorporate or unincorporate, within the United Kingdom. I suggest,therefore, that it will be proper for the Council to respond to the’Chancellor’s invitation, and to offer him advice and assistance in rela-

tion to matters within its province which appear to be involved in theproposals of the Bill.I We are extremely glad to learn that the General Medical Council’has appointed an active committee which will be prepared to-advise the Council upon professional lines. We are certain thatit will be a great source of satisfaction to the medical pro-fession to know that the General Medical Council has realised’how vital are the professional interests at stake. The committee is.

already meeting, so that it will be able to report to the Council,before the end of the session.

The British Medioal Association.For 12 months the Association has been considering the various ways,

in which this subject might be dealt with, and in March last issued tothe divisions a report including questions on all the points which mightbe raised in any insurance scheme. The divisions have been urged to’hold meetings to discuss the report and invite non-members of the-Assooiation. This has been done, and the meetings are reported to havebeen more largely attended and more enthusiastic than any of which we-have record. The Medical Secretary and the Deputy Medical Secretaryhave attended many of these meetings. As a result of the answers of:the divisions to the questions contained in the report, the Association,has been able to form a general idea of what the profession wishes, and-their views have been laid before Mr. Lloyd George and several otherMembers of the Government. The Chancellor of the Exchequer is-receiving another deputation from the Association next week. Alarge number of Members of Parliament have been interviewed and’some of them are in constant communication with the central office of-the Association. The feelings of the profession have been laid beforecommittees of both Liberal and Unionist parties, and several Members.have undertaken to raise the points put to them in the second reading.of the Bill.A special representative meeting is being held on May 31st and,

June 1st finally to lay down the policy of the Association and on thispolicy a plan of campaign will be formed. The plan of campaign will"in all probability include a canvass of every member of the profession,in the United Kingdom, in order to secure that members will notundertake any individual contract under the Bill, but will insist uponsuch terms as are approved of by the local profession, the local pro--fession in its turn to take the policy laid down by the representative-meeting for its guidance.

The Poor-la7v Medical Officers’ Association of England and’Wales.

At a meeting of the council of this association on May 17th the-National Insurance Bill came under consideration. The honorarysecretary said that the injury likely to be done thereby to the whole-profession reduced to insignificance any special injury to their service.He might add that as far as he could discover after a careful searchthrough the Bill there were only two direct references to the Poor-lawservice: 1. It is provided that boards of guardians in giving relief to.applicants insured under this Act are not to take into account any sick-ness allowance not exceeding 5s. a week. So that in such cases Poor--law medical officers may be required to afford medical services to those.who are entitled to State medical attendance. 2. In Ireland it would

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<seem that the doctors who are to work the Government scheme areessentially the Poor-law Medical Service of that country.

Medical Defenoe Union.At the annual general meeting of the above society on May 18th, the

chairman, in opening the proceedings, gave an address upon the dis-abilities of the profession in relation to the proposed scheme of nationalsickness insurance. The disadvantages of the suggested legislation andits interference with the existing general practice were dealt with fully,and a hope was expressed that strenuous and united resistance wouldbe made to the scheme by the profession.

The Medico-Legal Society.At a meeting of the Medico-Legal Society held at the society’s rooms,

11, Chandos-street, W., on May 23rd. Sir John Tweedy presiding, Mr.J. Smith Whitaker, medical secretary to the British Medical Associa-tion, gave an address setting forth very clearly the medical objections,o the National Insurance BillMr. SMITH WHITAKER traced through the reports of Royal Com-

missions, &c., evidences of a growing feeling in recent years that somebetter provision was necessary for dealing with sickness amongst a verylarge proportion of the population so that the vicious circle of diseaseand destitution might be broken. It was very important that the.medical profession should realisethat the essence of the present Bill,which was based, of course, on German models, was that the working.man should be assigned as important a part as possible in the administra-tion, through societies of which he was a member. The clauses dealingwith the employment of medical men were very indefinite andapparently left the door open for any system that could be conceived.Methods might be adopted-such as the employment by societies incombination of doctors at fixed salaries&mdash;which would have the effect ofexploiting the doctor and makiog a profit out of his services. Theobjections of the medical profession to the scheme were several. In thefirst place, an objection was entertained by a large number which.applied to the scheme as a whole or any modification of it-namely,,public intervention between doctor and patient. This interference,however, was recognised as inevitable if the necessary public objects ofthe Bill were to be secured, but doctors said, " Let there be no moreinterference than is absolutely necessary." One of the objections to the- scheme was that it did carry intervention far beyond what theybelieved to be needful. Many would be included as employed contri-butories who were perfectly well able to provide out of their ownresources the cost of the medical benefits allowed under the Bill. Theworking man earning 35s. to &pound;2 a week could, and did, employ a doctorto attend him privately. The necessity for providing medical benefitsfor voluntary contributors whose incomes exceeded 2160 was cei tainlynot demonstrated. The Bill gave them what they did not need-ordi-B ary medical attendance; but did not give them what they did need-viz.,institutional treatment. The scheme, it was feared, would tend to theemployment of selected doctors; the private practitioner would find aconsiderable proportion of his patients practically compelled to transfer.themselves to doctors officially employed. There was also unwilling--ness to trust the administration of the scheme to the friendly-societies., which had shown themselves in the past shortsighted inthe way they had employed their doctors. Medical men wanted awage limit for medical benefits, free choice of doctor by patient-the gain being that patients would have more confidence inthe doctor, and the danger would be avoided of dividing the pro-fession into two factions. Seeing that it was practically agreed by Mr.Lloyd George that the friendly societies were not to appoint thedoctor, fix his payment or his patients, and that the terms of em-ployment were to be subject to the Insurance Commissioners, whatwas there left ’for the approved societies to administer ? It wouldbe better to place the whole respon,.ibility in the hands of thelocal health committees which already had to deal with institu-tional treatment, and where home treatment ended and institutional.treatment began it would be difficult to say. He believed themedical profession would secure adequate representation on centraland local administrative organisations ; they wanted also the powerto elect in every district a medical committee which should

play a recognised part in the administration of the service. The

.question of payment could not be discussed definitely because the dutieswere undefined, but the work could not be adequately paid for by anysum in sight at present. In conclusion, Mr. Smith Whitaker spoke ofthe magnitude of this experiment, and said the profession would reco-gnise that it owed a service to the public, whose interests must be the-first consideration. But in return they were entitled to ask the public,to bear in mind that it was in the public interest that doctors should be-satisfactorily treated.

In the courS3 ofa discussion some interesting points were raised.Dr. MORISON remarked that if doctors were to serve anyone in the

way proposed in the Bill it must be the State and not middlemen. Thenthey would have some prospect of an intelligent directorate, which,could not be expected from the majority of friendly societies.

Dr. MAJOR GREENWOOD predicted that unless a wage limit wasgranted the medical profession had a serious time ahead. Alreadythe sale of piaetices had absolutely gone-no one could sell or transferone.

Dr. TlRARD cJaime,1 that the Bill would do much to raise the-status of the p ofession by establishing, as it did, the principle thatadvice should be paid for, and that advice and medicine were twodifferent things. It was a great s’epin advance in the education ofthe public.Dr. LAURISTON SHAW urged that it should be made clear to the public

what the terms were on which individual doctors had been willing toaccept capitation grants from friendly societies. There was a danger’that the charity of doctors in the past would be their ruin in the future.’The reason doctors accepted 4s. a head was that years ago it was a pointof charitable honour to do what they could for struggling institutionsjust started to help the working man. Doctors would have treated a.great many of these cases for nothing in the ordinary way, and whenworking men tried to help themselves by their societies themedical profession lent a hand and accepted a nominal capitationfee. Now they were told because they had treated these people formext to nothing they should be willing to treat the whole communityfor a few pounds more. The profession should join in absolutelyrefusing to do any work under the scheme unless properly paid, not

f:om any sordid motive, but because they were trustees of the pro-fession. It was their duty to see that the profession was properlyremunerated, so that an adequate number of men might be secured tcoit in the future.

THE REAL VALUE OF CONTRACT

PRACTICE.

BY Two PRACTITIONERS.

WE have prepared a few statistics illustrating the clubwork done in a mixed practice in London which may be ofuse in the present critical juncture in the history of our pro-fession, and from these a fair estimate may be made of ourposition as a profession in the future.

In the first place it is clear that the friendly societiesbenefit largely at the expense of the more wealthy patients ofa practice-where, as here, they are treated just like any otherpatients-no account being taken in their drugs or dressingsof the fact that they are contract patients. The figures showclearly that they are getting for &pound;318 a year what the otherpatients pay &pound;636 for, and, further, that the contract pay-ments, should they be applied to the whole practice, wouldshow a salary divisible among two partners of &pound;249&mdash;&pound;124 10s. each, or much less than one-half a taxi-driver’searnings.The figures taken are consultations-no account having

been taken of visits-but on investigation we find roughlythat 1 in 4 were domiciliary visits, and taking Group J., fourtimes 7d. 9-lOths, or say 8d. for convenience = 2s. 8d. ;take 2s. away for the visit and this will leave 8d. for threeconsultations at the surgery, or if ls. 6d. is taken as a feefor the visits it will leave ls. 2d., or 42/3d. each consultationother than visits. Again, take the average of the OJdfellowsat 4s., and we get 3s. 6d. for three visits at the surgery andone at home, and taking 2s. for the visit, it will show 6d.each other consultation.

Seeing 65 people a day we find hard work for two men,the distance limit for visits being mostly three miles-in afew cases two miles; taken at the above rates the Odd-fellows will show payments of &pound; 12s. for 16 visits and&pound;1 4s. 6d. for surgery consultations-total &pound;2 16s. 6d. perday, or &pound;1 8s 3d. each partner, plua 6s. 7d. each for Sundays.Total i&456 12s. 6d. per annum each partner in place of thepresent return of &pound;1412 gross.We have endeavoured to take the average payment as

received at present from friendly societies where the membersare selected.

Careful estimate has been made of the likely effect of theBill if passed in its present form (4s. for the doctor as fore-shadowed in Clause 38). We find about 2-9ths will still remain,being work practically outside the limit of the Bill ; one-ninth are now clubs, and if the 6s. rate is reduced to 4s. weshall lose &pound;650 a year on this section ; the remaining 6-9ths =&pound;1882, will be reduced at once to one-half, namely, &pound;941;thus the loss will be &pound;991 per annum. Against this therewill be a saving of about &pound;100 a year on drugs, &c., showinga net loss of &pound;891, or &pound;445 each partner. About one-fourthof this loss may be recovered if the work is taken back ascontract work.Now as to the balance-sheet of work we find, as the Bill

now stands, the following are an additional burden. 1.Diseases owing to the patient’s own fault-this is now a fairsource of income and will be completely wiped away. 2.All the chronic cases-the refuse of the friendly societieswill come in for free medical benefit almost at once.

3. Loss of all fees for attendance on workmen injured byaccident.On the other side we are promised relief from some

attendance on tuberculous cases, and this we fear is a delu-sion and a snare, as Clause 15 (3) clearly indicates that onlycases likely to benefit will be so treated-what a farce to besure. The old chronic cases-the tubercle carriers, if wemay so call them, will be with us still-and do not a greatnumber of the other cases get away for treatment now *!Most assuredly they do.

If this Bill passes, as it promises to do, it will be thegreatest blow any profession has received in history ; it willmean ruin to thousands of the hardest worked class in thekingdom, and, as far as it is possible to see, the Chancellor