333

is appended full references to their own work on the subjectas well as to the work of many other observers. The

difficulties connected with the study of anaphylactic feverare well known, and we do not attempt here to make allusionto them, confining ourselves to commenting upon infection

experiments in which not only post-mortem lesions but

demonstrable capsule formation can be adduced in supportof conclusions. Accurate post-mortem examinations alwayscommand attention, whilst the significance of capsuleformation becomes evident from the recent careful work

of PREISZ, GRUBER, and FUTAKI.

Annotations.

MEDICAL SERVICE IN THE HIGHLANDS ANDISLANDS.

" Ne quid nimis,"

"IT is clear, however, ...... that a primary step in the

direction of rendering medical service adequate should be toplace a doctor in such a position of financial competenceand professional security as would enable him to carry outthe highly responsible duties of his post with the fullest

efficiency, zeal, and contentment." To find a committee

appointed by Government expressing such an opinion as thatwhich we have quoted is no less surprising than it is

gratifying, yet the words in question are found upon p. 16of Vol. I. of the Report of the Highlands and Islands

Medical Service Committee, appointed July llth, 1912, andissued as a Blue-book on Dec. 24th of the same year.Vol. 1. contains the report; Vol. II. the minutes ofevidence and the index. The matter of the report is,if saddening reading, at the same time of extraordinaryinterest; the patience and fortitude with which the

greater part of the population in question bear sickness

and death is only exceeded by the gallant struggles underalmost overwhelming difficulties which are time after timeexhibited by the medical man in endeavouring to bring aidto the sick. The physical characters of the district are suchas to make the provision of medical attendance a matterof exceeding difficulty. To quote the report: I I The country ’,is rugged, roadless, and mountainous, and where not com-posed of islands is very largely peninsular on the seaboard,and inland is broken up by lakes and rivers. The weather

conditions, too, and particularly in the winter time, addenormously to the difficulties of travel." It appears fromthe report that by far the greater number of medical prac-titioners in the districts under review are parish medicalofficers appointed by the parish council nominally to attendto the registered sick poor, but as a matter of fact theseofficers are appointed to attend to the whole popula-tion of the parish, their fees for such as are not paupersbeing often fixed by the parish council at a much lowerrate than ordinary charges. The result of medical men

working under such unfavourable conditions is that there isa constant change of doctors ; in one parish, for instance,there were "ten doctors and as many locum tenentes in

twenty-two years." The general recommendation of the com-mittee is that the existing public medical services should beconsolidated, and should work under a central authoritytogether with a special local authority. Further, the com-mittee " express their opinion in a general way that forpublic and private medical service (in single practice areas)a. minimum income of £300 per annum, with travelling

1 See THE LANCET, Jan. 25th, 1913, p. 278.

allowance, should be secured to every medical practitionerrecognised by the central authority." We are thus apparentlyin view of a State Medical Service for, at all events, a portionof the kingdom. The report of the committee shows thatits members recognise the necessity for a contented medicalservice; it remains to be seen whether the Government willlook at the matter in the same light.

SURGEONS ON ANÆSTHESIA: THE USE OFNITROUS OXIDE AND OXYGEN.

ANÆSTHETISTS see so mucn or operative proceaures tnat

they often become keen and competent surgical critics,though for obvious reasons they seldom voice their opinions.Surgeons, in their turn, are largely dependent on satisfactoryanaesthesia for comfort and even for success in operating,and thus tend to be good judges of the administration. Eachclass is prone to belittle the critical faculty of the other ;and it would be difficult to say whether surgeons resent

suggestions from anæsthetists in respect of their operationsmore than do anaesthetists from surgeons about the anxs-

thetic. At the twenty-fifth annual meeting of the AmericanAssociation of Obstetricians and Gynæcologists severalsurgeons indulged in plain speaking about various methodsof anaesthetisation which are just now in favour with

American anaesthetists. The whole discussion is interestingin view of the present divergence between British andTransatlantic practice in this specialty, although apparentlybut one anaesthetist took part in it. In the United States

several of the leading authorities upon anaesthesia have

during the last few years employed nitrous oxide and

oxygen very extensively in major surgery, and have

published their conviction that this combination is superiorto all others in safety and range of application. Pre-

ceded by morphine, scopolamine, and similar narcotics,nitrous oxide and oxygen are administered for the most

extensive laparotomies as well as for operations demandinga less profound relaxation of muscles. In averting shock,toxic symptoms, asphyxial complications, and troublesomeafter-effects of all kinds, the method is said to be far

superior to any other. In this country, on the other hand,where the possibilities of nitrous oxide and oxygen were

originally investigated by Sir Frederic Hewitt many yearsago, the general sentiment is that the method has seriouslimitations, especially imperfect relaxation, difficult and

complicated technique, and expense. According to Dr.

Skeel, who read a paper at the meeting in question, andseveral of his surgical colleagues, hesitation in acceptingthe glowing accounts of American administrators is dis-

tinctly to be justified. Dr. Skeel asserts that for the

majority of abdominal operations nitrous oxide is neitherthe most comfortable nor the safest " anæsthetic. He holds

that in thus producing narcosis sufficiently profound formajor operations, as opposed to dental extractions, there is avery distinct danger of asphyxiation, even in the most experthands. Once the deepest possible anaesthesia has beenattained the danger disappears, but is succeeded by another.Either the oxygen in the mixture, says Dr. Skeel, or the

carbon dioxide stimulation keeps the patient in such

apparently good condition that there is sometimes a tempta-tion, to prolong unduly an operation which might have beenhastened, with the result that dangerous shock comes onimmediately after the anaesthetic is withdrawn. The exactlyopposite danger of failing to survey thoroughly the entirefield of operation on account of troublesome rigidity is alsomentioned as a drawback, and Dr. Skeel says that unjustifi-able force and manipulation are often required, "since

abdominal rigidity and protruding gut are always in

1 American. Journal of Obstetrics and Gynæcology, January, 1913,p. 102.