623 PARIS. (FROM OUR OWN CORRESPONDENT.) Increase of Syphilis. Dr. Jeanselme, professor of syphilography in the Paris Faculty of Medicine, has recently remarked that the number of cases of fresh syphilitic infection presenting themselves at the Hopital St. Louis has definitely increased during the past year. His colleagues have made the same observation, and it seems that the total number of patients with recent syphilis treated in the six dispensaries of the hospital has risen from 1955 in 1924 to 2445 in 1925-that is to say, there has been an increase of 20 per cent. The Hopital St. Louis draws its patients from every quarter of the capital and its outskirts, and it is reasonable to conclude that syphilis is making definite headway at present amongst the working classes. A provincial inquiry suggests that this state-of affairs is true of the rest of France also. Two reasons are put forward to explain the recrudescence. First of all there is the invasion of foreign immigrants. In one of the big manufacturing works on the outskirts of Paris there are over 10,000 foreigners, besides 2000 natives from the colonies, amongst the 30,000 employees-that is, nearly 36 per cent. of the total number are not French. Of 250 syphilitic patients in the Hopital St. Louis, about one-fifth are foreigners or colonial natives : and really the proportion is higher than this suggests, because the males amongst them account for over 34 per cent. of the inmates of the male wards.. Again, amongst 451 cases of recent syphilis treated at the dispensary in 1925, there were 260 French, 140 foreigners, and 51 North Africans. And the propor- tion of foreign patients is just as high in the other big industrial centres and ports as it is in Paris. The second cause of the recrudescence of syphilis in France is undoubtedly the general use of bismuth just now, not only as a secondary treatment, but as the means of attack against the disease. This is due to the discredit into which the intravenous use of arsenobenzol has unfortunately and unjustifiably fallen. Physicians’ Compensation. An interesting case has just been decided by the Paris courts. A physician, summoned in an emergency by a friend of the patient, later presented a bill which the patient’s family considered too large. On the refusal of the family to pay more than one-third of it, the physician attacked the friend who had sum- moned him. The courts held that to do so would only have been justifiable if the family had refused to make any payment whatever. As they had not done this the claim made against the intermediary was thrown out of court, and it was decided that the physician must still negotiate with the family. Mechanical milking. Dr. Henri de Rothschild, who for 18 months has been trying mechanical milking amongst some 30 dairy cows at his establishment at Vaux-de-Cernay, has recently given the Academic de Medecine an account cf his experience. From the practical point of view there is economy of both time and labour, and neither filtering nor pasteurisation is needed after milking. The milk obtained mechanically keeps longer, especially in summer, and can be taken over long distances without there being any danger of it turning. From the scientific standpoint it cannot be regarded, strictly speaking, as aseptic, as has some- times been claimed, and in spite of the most elaborate precautions it always contains a large number of organisms. But whereas a sample obtained- in the usual way by hand anti collected in ordinary receptacles washed out in cold water has about 270,000 colonies per c.cm. after four days’ incubation at 370 C., a sample from the machine shows not more than 30 -70,000. The difference is considerable, and even if this milk cannot be called aseptic, it can at least be called clean. Blood Transfusion in hafa7ats. Dr. Gucniot, who has been studying blood transfusion, as a treatment of debility in the new-born and m premature births, has found that the method is not without difficulty, and should be adopted only in cases- not responding to the usual methods of care and feeding. ’ It has been pointed out that many laboratories in France are really incompetent to make the more complicated and delicate biological tests often required. The Académie de Médecine is heartily supporting a movement to institute rigid supervision of laboratories, advertising publicly. At the Faculte de Medecine Prof. Roussy has just closed a series of impressive conferences on cancer. The directors of cancer service at Marseilles and at the- Curie Institute of Indo-China have just been added to the committee appointed by the French Government in 1922 for coordinating methods of study and treatment. Easter vacation courses from March 29th to April 10th are offered at the Faculté de Medecine. These include a course in criminology, to be given at the Palais de Justice, obstetrical courses, and a revision course on laboratory diagnosis at the Hotel Dieu. A valuable course on occupational accidents is being continued by Balthazard, Lhermitte, Claude, Dervieux, Duvoie, Laignel-Lavastine, Terrien, and others. All sections of the subject are thus ably covered. ’ Prof. Thiery, well known for his surgical work in different hospitals at Paris, was on March l4th presented with a medal by his pupils, who wished thus to express their appreciation of his work and- teaching. UNITED STATES OF AMERICA. (FROM AN OCCASIONAL CORRESPONDENT.) The Control of N arcotic8. THE federal control of narcotic drugs is exercised through the Harrison Act. The constitutional validity of this Act was challenged in 1919 and was upheld in the Supreme Court by a majority of only 5 to 4. A strong hint has now, however, been dropped by the Court that its decision might be reversed if the subject again came up for review. To understand the constitu- tional position it should be realised that the Federal Government can exercise only those powers which are specifically granted to it under the constitution. In the absence of definite instructions the right to legislate is presumed to lie with the State Government-a presumption exactly opposite to that which obtains. under the Canadian constitution. The fathers who drew up the constitution of the United States foresaw a good deal, but some things they overlooked, and among them the growth of health legislation. There is no provision for control of health by the Federal Government. In passing laws under these limitations. Congress has shown from time to time a good deal of ingenuity. Not having power to protect certain migratory birds, for example, it took advantage of its constitutional right to make treaties with foreign powers, and concluded a treaty with Canada in which the protection of certain birds was ensured on both sides of the frontier. In public health legislation advantage has constantly been taken of the right of Congress "to regulate commerce with foreign powers and among the several States." The Pure Food and Drugs Act is an example of successful legislation under this head. The Harrison Narcotic Act depends on the right of Congress to raise taxes. Under the Act every physician who wishes to prescribe narcotics has to pay a tax- a tax which is held by many physicians to be quite unnecessarily severe, since the clear intention of the Act is not to raise revenue, but to control the distribu- tion of certain drugs. The Child Labor Tax Law, approved in 1919, was found by the Supreme Court- in 1922 to be unconstitutional, and the argument.
Transcript
623
PARIS.
(FROM OUR OWN CORRESPONDENT.)
Increase of Syphilis.Dr. Jeanselme, professor of syphilography in the Paris
Faculty of Medicine, has recently remarked that thenumber of cases of fresh syphilitic infection presentingthemselves at the Hopital St. Louis has definitelyincreased during the past year. His colleagues havemade the same observation, and it seems that thetotal number of patients with recent syphilis treatedin the six dispensaries of the hospital has risen from1955 in 1924 to 2445 in 1925-that is to say, therehas been an increase of 20 per cent. The HopitalSt. Louis draws its patients from every quarter ofthe capital and its outskirts, and it is reasonable toconclude that syphilis is making definite headwayat present amongst the working classes. A provincialinquiry suggests that this state-of affairs is true of therest of France also. Two reasons are put forward toexplain the recrudescence. First of all there is theinvasion of foreign immigrants. In one of the bigmanufacturing works on the outskirts of Paris thereare over 10,000 foreigners, besides 2000 natives fromthe colonies, amongst the 30,000 employees-that is,nearly 36 per cent. of the total number are not French.Of 250 syphilitic patients in the Hopital St. Louis,about one-fifth are foreigners or colonial natives : andreally the proportion is higher than this suggests,because the males amongst them account for over34 per cent. of the inmates of the male wards.. Again,amongst 451 cases of recent syphilis treated at thedispensary in 1925, there were 260 French, 140foreigners, and 51 North Africans. And the propor-tion of foreign patients is just as high in the other bigindustrial centres and ports as it is in Paris.The second cause of the recrudescence of syphilis
in France is undoubtedly the general use of bismuthjust now, not only as a secondary treatment, butas the means of attack against the disease. This isdue to the discredit into which the intravenous useof arsenobenzol has unfortunately and unjustifiablyfallen.
Physicians’ Compensation.An interesting case has just been decided by the
Paris courts. A physician, summoned in an emergencyby a friend of the patient, later presented a bill whichthe patient’s family considered too large. On therefusal of the family to pay more than one-third ofit, the physician attacked the friend who had sum-moned him. The courts held that to do so would onlyhave been justifiable if the family had refused to makeany payment whatever. As they had not done thisthe claim made against the intermediary was thrownout of court, and it was decided that the physicianmust still negotiate with the family.
Mechanical milking.Dr. Henri de Rothschild, who for 18 months has
been trying mechanical milking amongst some 30dairy cows at his establishment at Vaux-de-Cernay,has recently given the Academic de Medecine anaccount cf his experience. From the practical pointof view there is economy of both time and labour, andneither filtering nor pasteurisation is needed aftermilking. The milk obtained mechanically keepslonger, especially in summer, and can be taken overlong distances without there being any danger of itturning. From the scientific standpoint it cannot beregarded, strictly speaking, as aseptic, as has some-times been claimed, and in spite of the most elaborateprecautions it always contains a large number oforganisms. But whereas a sample obtained- in theusual way by hand anti collected in ordinary receptacleswashed out in cold water has about 270,000 colonies
per c.cm. after four days’ incubation at 370 C., asample from the machine shows not more than30 -70,000. The difference is considerable, and evenif this milk cannot be called aseptic, it can at leastbe called clean.
Blood Transfusion in hafa7ats.Dr. Gucniot, who has been studying blood transfusion,
as a treatment of debility in the new-born and mpremature births, has found that the method is notwithout difficulty, and should be adopted only in cases-not responding to the usual methods of care andfeeding.
’
It has been pointed out that many laboratories inFrance are really incompetent to make the morecomplicated and delicate biological tests often required.The Académie de Médecine is heartily supporting amovement to institute rigid supervision of laboratories,advertising publicly.At the Faculte de Medecine Prof. Roussy has just
closed a series of impressive conferences on cancer.The directors of cancer service at Marseilles and at the-Curie Institute of Indo-China have just been added tothe committee appointed by the French Government in1922 for coordinating methods of study and treatment.
Easter vacation courses from March 29th toApril 10th are offered at the Faculté de Medecine.These include a course in criminology, to be givenat the Palais de Justice, obstetrical courses, and arevision course on laboratory diagnosis at the HotelDieu. A valuable course on occupational accidentsis being continued by Balthazard, Lhermitte, Claude,Dervieux, Duvoie, Laignel-Lavastine, Terrien, andothers. All sections of the subject are thus ablycovered.
’
Prof. Thiery, well known for his surgical work indifferent hospitals at Paris, was on March l4thpresented with a medal by his pupils, who wishedthus to express their appreciation of his work and-teaching.
UNITED STATES OF AMERICA.
(FROM AN OCCASIONAL CORRESPONDENT.)
The Control of N arcotic8.THE federal control of narcotic drugs is exercised
through the Harrison Act. The constitutional validityof this Act was challenged in 1919 and was upheld inthe Supreme Court by a majority of only 5 to 4. Astrong hint has now, however, been dropped by theCourt that its decision might be reversed if the subjectagain came up for review. To understand the constitu-tional position it should be realised that the FederalGovernment can exercise only those powers which arespecifically granted to it under the constitution. Inthe absence of definite instructions the right to legislateis presumed to lie with the State Government-apresumption exactly opposite to that which obtains.under the Canadian constitution. The fathers whodrew up the constitution of the United States foresawa good deal, but some things they overlooked, andamong them the growth of health legislation. Thereis no provision for control of health by the FederalGovernment. In passing laws under these limitations.Congress has shown from time to time a good dealof ingenuity. Not having power to protect certainmigratory birds, for example, it took advantage of itsconstitutional right to make treaties with foreignpowers, and concluded a treaty with Canada in whichthe protection of certain birds was ensured on bothsides of the frontier. In public health legislationadvantage has constantly been taken of the right ofCongress "to regulate commerce with foreign powersand among the several States." The Pure Food andDrugs Act is an example of successful legislation underthis head.
The Harrison Narcotic Act depends on the right ofCongress to raise taxes. Under the Act every physicianwho wishes to prescribe narcotics has to pay a tax-a tax which is held by many physicians to be quiteunnecessarily severe, since the clear intention of theAct is not to raise revenue, but to control the distribu-tion of certain drugs. The Child Labor Tax Law,approved in 1919, was found by the Supreme Court-in 1922 to be unconstitutional, and the argument.
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is of sufficient historical importance to be quotedat length :-
" Taxes are occasionally imposed in the discretion of thelegislature on proper subjects with the primary motive ofobtaining revenue from them and with the incidental motiveof discouraging them by making their continuance onerous.They do not lose their character as taxes because of theincidental motive. But there comes a time in the extensionof the penalising features of the so-called tax when it loses itscharacter as such and becomes a mere penalty with thecharacteristics of regulation and punishment. Such is thecase in law before us."-Child Labor Tax Case, 259 U.S. 20,decided May 15th, 1922.
It will be seen that with this precedent anotheronslaught on the constitutionality of the Harrison Actis likely to prove successful. The Journal of theAmerican Medical Association (Feb. 27th, 1926,p. 627), reviewing the situation, expresses no regret atthe danger in which this Act is found. " No satisfac-tory evidence has yet been adduced," it remarks,
" toshow that the Harrison Narcotic Act has accomplishedor is accomplishing its purpose, the suppression of thenarcotic habit." Too little is known about theunderground traffic, and apparent regulation byfederal action may merely be blinding people to aserious state of affairs. An international conferenceon narcotic addiction is being planned with some energy iand is to be held this summer in Philadelphia. No ’,doubt the importance of international control of thesources of production will be taken up at this confer-ence, but it is difficult to see any possibility of effectiveaction without the close cooperation and machinery ofthe Health Section of the League of Nations.
Vital Statistics of New York State.The report on the vital statistics of New York State
for 1925 shows a very satisfactory state of affairs.The Milbank Foundation is at present financing threehealth demonstrations in this State, and although it isnot possible to estimate quantitatively the influence ofthese demonstrations, there can be no doubt that theyhave contributed to the success of the health depart-ment’s work. The general death-rate (12-7 per 1000)has been lower only once-in 1921. Except for minorvariations this rate has declined steadily since 1890,when it stood at 21 -4. If the 1900 death-rate hadprevailed last year there would have been 60,000 moredeaths. The infant mortality is 68 per 1000 live births,and is the lowest on record. Among the causes ofdeath tuberculosis (all forms) has dropped into fifthplace with a rate of 90-9 per 100,000. It is exceeded Iby diseases of the cardio-vascular system, pneumonia,cancer, and external causes, whose importance is inthe order named. The death-rate from alcoholism is7-9, which is five times the rate from this cause in i1920.
ROYAL COMMISSION ON LOCAL GOVERNMENT.——ThisCommission, of which Lord Onslow is chairman, will notbegin before ’BVhitsuntide to hear evidence on the relationsbetween local sanitary authorities and their constitution,areas, and functions. The postponement is to give time toconsider the proposals for Poor-law reform, which are underdiscussion between the Minister of Health and the localauthorities.
COMPLIMENTARY DINNER TO PROF. T. G. MOORHEAD.Prof. Moorhead was recently put to the trouble of defendingan action for damages brought against him by a patientwhom he had examined in the course of his duty as consultingphysician to a suburban hospital in Dublin. The actionwas unsuccessful, none of the charges being established ;but his professional brethren in Dublin have thought ita suitable opportunity to express their entire confidence inhim and their sympathy with him in the annoyance towhich he had been subjected. Accordingly a complimentarydinner was given to him last Saturday night in the dininghall of Trinity College, Dublin. The chair was taken bythe Provost of Trinity College (Most Reverend Dr. J. H.Bernard), in his capacity as an Honorary Fellow of the RoyalCollege of Physicians of Ireland, and some 120 hosts satdown to dinner. Only four or five laymen, personal friendsof Dr. Moorhead, were present. The staff of every hospitalin Dublin, general and special, was represented, and amongthose present were teachers from all the schools in Dublin.The gathering was a remarkable exhibition of respect andaffection for Dr. Moorhead.
Correspondence.
THE CONSTITUTION AND DUTIES OF THEGENERAL MEDICAL COUNCIL.
..Audi alteram partem."
To the Editor of THE LANCET.
SIR,-The exposition of the functions of the GeneralMedical Council given by its Registrar in THE LANCETof Feb. 6th clearly indicates the prime services itrenders. In his words the two prime services are
first, to prevent the unfit (in education and training)from gaining access to the Register, and seco7tdly, toremove the unworthy from it. The Council is thesole arbiter in each situation. but its action is subjectto the ruling of the Privy Council.
Evolution of the Council.When the Council came into being in 1858 it found
the entry into the medical profession was by meansof training under an apprenticeship system supple-mented by education tested by examination underthe control of the medical corporations and the univer-sities. The supplementary education was entirely inthe hands of the different educational bodies and inconsequence it varied with each. The result was thatthe value of the diplomas granted and the degreesconferred also varied, a high standard being main-t,ained at some places and a low one reached at others.The difference between the education given at theuniversities and that at the medical schools laymainly in the scope and in the inclusion at the univer-sities of a greater number of the subjects upon whichthe science and art of medicine are based.The Council soon standardised the examinations,
and after a time widened the scope of medical educa-tion in those medical schools and universities whichwere below the level of the best. While the Councilwas standardising the medical examinations it atthe same time created uniformity in medical educa-tion. All the schools came to imitate one another,and to-day, it may be said, variety has been replacedby dull uniformity. The education of the doctorwas improved by standardisation of the examinations,but education tends to deteriorate under the deadweight of uniformity established by insistence onstereotyped curricula. Variety is needed to-day togive elasticity once more to the education, and toafford each centre scope to grow in directions favour-able to the widening of the outlook of the doctor.It matters not in the least that the doctor is bettereducated at one school in chemistry, at another inphysics ; but it does matter that he gets a wide, ifnot a particular, education in each subject so thathe may in practice be able to apply his intelligenceand make good use of principles. Again, it is of noconsequence if he is unacquainted with minutedetails in anatomy and physiology, provided he shallhave sufficient education in each of them to be ableto turn to his knowledge of them for fundamentalinformation when in difficulties.
’
In all the subjects, which form the basis uponwhich medicine rests, the Council need not now,so it appears to me, interfere with the medical schools,whether of universities or constituent colleges ofuniversities ; and it would be well to leave theeducation and the choice of those subjects entirelyin their hands provided the standard attained attheir examinations is such as to warrant the Councilin accepting a certificate that the student is fit toenter upon his clinical and other studies. In thatway freedom in the choice of subjects and in the scopeof education would be restored to the medical schools,the beneficial effects of which, would, I believe, be,very great.
If it be advisable for the Council to accept degreesfrom universities as evidence of sufficient educationto entitle a graduate to enter upon clinical studies,
